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Mullis CE, Goldberg AJ, Avila K, Hall B, Golub SA, Keller MJ. Understanding Attitudes of Postpartum Cisgender Women Toward Integration of HIV Prevention Services into Routine Prenatal and Postpartum Sexual Health Discussions. AIDS Patient Care STDS 2024; 38:185-193. [PMID: 38656218 DOI: 10.1089/apc.2023.0307] [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] [Indexed: 04/26/2024] Open
Abstract
Oral pre-exposure prophylaxis (PrEP) is an effective, user-controlled method for HIV prevention. However, awareness, uptake, and adherence to PrEP remain low among cisgender women (CGW). The prenatal and postpartum periods present an opportunity for delivery of comprehensive sexual health services that include HIV prevention education and services. However, little is known about postpartum CGW's attitudes toward integration of HIV prevention education and services into obstetric care in the US. We conducted semistructured interviews with 20 postpartum CGW in the Bronx, NY from July to November 2022 to explore their experiences with prenatal and postpartum sexual health care, examine their attitudes toward integration of HIV prevention services into obstetric sexual health care, and identify components of future implementation strategies. Transcripts were analyzed thematically using a framework approach. Among CGW interviewed, fewer than half reported prior knowledge of PrEP. Ten participants preferred long-acting injectable PrEP relative to six who preferred daily oral PrEP. Most participants reported no discussion of sex with their provider during pregnancy, and when discussions occurred, they focused on permission or prohibition of sexual activity. Participants described a reliance on providers to lead prenatal sexual health discussions. Even when not perceived as personally relevant, most respondents valued education on HIV prevention and PrEP services. In the postpartum period, sexual health discussions were similarly limited despite participants describing complex experiential sexual health concerns. This study supports the potential for integration of HIV prevention education and services into routine prenatal and postpartum sexual health discussions in an area of high HIV prevalence in the US.
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Affiliation(s)
- Caroline E Mullis
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Alison J Goldberg
- Department of Psychology, Hunter College of the City University of New York, New York, New York, USA
| | - Karina Avila
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Bianca Hall
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sarit A Golub
- Department of Psychology, Hunter College of the City University of New York, New York, New York, USA
- PhD Program in Basic and Applied Social Psychology, Graduate Center of the City University of New York, New York, New York, USA
| | - Marla J Keller
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
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Mullis CE, Marlow KA, Maity A, Fazzari M, Zingman BS, Keller MJ, Meyerowitz EA. Clinical Presentations and Treatment Outcomes of Mycoplasma genitalium Infections at a Large New York City Health Care System. Sex Transm Dis 2024; 51:199-205. [PMID: 38100794 PMCID: PMC10922512 DOI: 10.1097/olq.0000000000001911] [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: 12/17/2023]
Abstract
BACKGROUND Mycoplasma genitalium (MG) is an emerging sexually transmitted infection. Treatment of MG is complicated by increasing resistance to primary treatment regimens, including macrolides and fluoroquinolones. Understanding the various clinical presentations and relative effectiveness of treatments for MG is crucial to optimizing care. METHODS Patients with a positive MG nucleic acid amplification test between July 1, 2019, and June 30, 2021, at a large health system in New York City were included in a retrospective cohort. Demographics, clinical presentations, coinfections, treatment, and follow-up microbiologic tests were obtained from the electronic medical record. Associations with microbiologic cure were evaluated in bivariate and multivariable logistic regression models. RESULTS Five hundred two unique patients had a positive MG nucleic acid amplification test result during the study period. Male individuals presented predominantly with urethritis (117 of 187 [63%]) and female individuals with vaginal symptoms (142 of 315 [45%]). Among patients with follow-up testing who received a single antibiotic at the time of treatment, 43% (90 of 210) had persistent infection and 57% (120 of 210) had microbiologic cure. Eighty-two percent of patients treated with moxifloxacin had microbiologic cure compared with 41% of patients receiving azithromycin regimens ( P < 0.001). In multivariable analysis, treatment with moxifloxacin was associated with 4 times the odds of microbiologic cure relative to low-dose azithromycin (adjusted odds ratio [aOR], 4.18; 95% confidence interval, 1.73-10.13; P < 0.01). CONCLUSIONS Clinical presentations of MG vary, with urethritis or vaginal symptoms in most cases. Among patients who received a single antibiotic, only treatment with moxifloxacin was significantly associated with microbiologic cure relative to low-dose azithromycin.
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Affiliation(s)
- Caroline E. Mullis
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
| | - Kerry A. Marlow
- Albert Einstein College of Medicine, Bronx, New York, United States
| | - Aloke Maity
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
| | - Melissa Fazzari
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
| | - Barry S. Zingman
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
| | - Marla J. Keller
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
| | - Eric A. Meyerowitz
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
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Murphy K, Gromisch M, Srinivasan S, Wang T, Wood L, Proll S, Liu C, Fiedler T, Valint DJ, Fredricks DN, Keller MJ, Herold BC. IgA coating of vaginal bacteria is reduced in the setting of bacterial vaginosis (BV) and preferentially targets BV-associated species. Infect Immun 2024; 92:e0037323. [PMID: 38099624 PMCID: PMC10790818 DOI: 10.1128/iai.00373-23] [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] [Received: 09/11/2023] [Accepted: 11/29/2023] [Indexed: 01/17/2024] Open
Abstract
Immunoglobulin (Ig) bacterial coating has been described in the gastrointestinal tract and linked to inflammatory bowel disease; however, little is known about Ig coating of vaginal bacteria and whether it plays a role in vaginal health including bacterial vaginosis (BV). We examined Ig coating in 18 women with symptomatic BV followed longitudinally before, 1 week, and 1 month after oral metronidazole treatment. Immunoglobulin A (IgA) and/or immunoglobulin G (IgG) coating of vaginal bacteria was assessed by flow cytometry, and Ig coated and uncoated bacteria were sorted and characterized using 16S rRNA sequencing. Despite higher levels of IgG compared to IgA in cervicovaginal fluid, the predominant Ig coating the bacteria was IgA. The majority of bacteria were uncoated at all visits, but IgA coating significantly increased after treatment for BV. Despite similar amounts of uncoated and IgA coated majority taxa ( >1% total) across all visits, there was preferential IgA coating of minority taxa (0.2%-1% total) associated with BV including Sneathia, several Prevotella species, and others. At the time of BV, we identified a principal component (PC) driven by proinflammatory mediators that correlated positively with an uncoated BV-associated bacterial community and negatively with an IgA coated protective Lactobacillus bacterial community. The preferential coating of BV-associated species, increase in coating following metronidazole treatment, and positive correlation between uncoated BV-associated species and inflammation suggest that coating may represent a host mechanism designed to limit bacterial diversity and reduce inflammatory responses. Elucidating the role of Ig coating in vaginal mucosal immunity may promote new strategies to prevent recurrent BV.
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Affiliation(s)
- Kerry Murphy
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Matthew Gromisch
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sujatha Srinivasan
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Tao Wang
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Lianna Wood
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sean Proll
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Congzhou Liu
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Tina Fiedler
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - D. J. Valint
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - David N. Fredricks
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Marla J. Keller
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Betsy C. Herold
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
- Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine, Bronx, New York, USA
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Yoon H, Li Y, Goldfeld KS, Cobb GF, Sturm-Reganato CL, Ostrosky-Zeichner L, Jayaweera DT, Philley JV, Desruisseaux MS, Keller MJ, Hochman JS, Pirofski LA, Ortigoza MB. COVID-19 Convalescent Plasma Therapy: Long-term Implications. Open Forum Infect Dis 2024; 11:ofad686. [PMID: 38269049 PMCID: PMC10807994 DOI: 10.1093/ofid/ofad686] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/27/2023] [Indexed: 01/26/2024] Open
Abstract
Background The long-term effect of coronavirus disease 2019 (COVID-19) acute treatments on postacute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC) is unknown. The CONTAIN-Extend study explores the long-term impact of COVID-19 convalescent plasma (CCP) therapy on postacute sequelae of SARS-CoV-2 infection (PASC) symptoms and general health 18 months following hospitalization. Methods The CONTAIN-Extend study examined 281 participants from the original CONTAIN COVID-19 trial (CONTAIN-RCT, NCT04364737) at 18 months post-hospitalization for acute COVID-19. Symptom surveys, global health assessments, and biospecimen collection were performed from November 2021 to October 2022. Multivariable logistic and linear regression estimated associations between the randomization arms and self-reported symptoms and Patient-Reported Outcomes Measurement Information System (PROMIS) scores and adjusted for covariables, including age, sex, race/ethnicity, disease severity, and CONTAIN enrollment quarter and sites. Results There were no differences in symptoms or PROMIS scores between CCP and placebo (adjusted odds ratio [aOR] of general symptoms, 0.95; 95% CI, 0.54-1.67). However, females (aOR, 3.01; 95% CI, 1.73-5.34), those 45-64 years (aOR, 2.55; 95% CI, 1.14-6.23), and April-June 2020 enrollees (aOR, 2.39; 95% CI, 1.10-5.19) were more likely to report general symptoms and have poorer PROMIS physical health scores than their respective reference groups. Hispanic participants (difference, -3.05; 95% CI, -5.82 to -0.27) and Black participants (-4.48; 95% CI, -7.94 to -1.02) had poorer PROMIS physical health than White participants. Conclusions CCP demonstrated no lasting effect on PASC symptoms or overall health in comparison to the placebo. This study underscores the significance of demographic factors, including sex, age, and timing of acute infection, in influencing symptom reporting 18 months after acute hypoxic COVID-19 hospitalization.
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Affiliation(s)
- Hyunah Yoon
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Yi Li
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Keith S Goldfeld
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Gia F Cobb
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | | | - Luis Ostrosky-Zeichner
- Division of Infectious Diseases, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Dushyantha T Jayaweera
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
- Miami Clinical and Translational Science Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Julie V Philley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Tyler, UTHealth East Texas, Tyler, Texas, USA
| | - Mahalia S Desruisseaux
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Marla J Keller
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
- Harold and Muriel Block Institute for Clinical and Translational Research, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Judith S Hochman
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Liise-anne Pirofski
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Mila B Ortigoza
- Division of Infectious Diseases, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
- Department of Microbiology, NYU Grossman School of Medicine, New York, New York, USA
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Kim M, Marantz P, Suadicani S, Milman S, Keller MJ. Challenges in catalyzing and sustaining research in translational science. J Clin Transl Sci 2023; 7:e217. [PMID: 38028357 PMCID: PMC10643932 DOI: 10.1017/cts.2023.651] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/03/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Advancing the new field of translational science and developing innovative solutions to overcome translational roadblocks are key priorities of the Clinical and Translational Science Awards (CTSA) Program of the National Center for Advancing Translational Science (NCATS). However, interpreting this emerging concept of "translational science" (TS) as a field of inquiry distinct from "translational research" (TR) and developing real-world investigations in TS can be challenging. The goal of this paper is to share the obstacles the Einstein-Montefiore CTSA hub has faced in generating institutional interest and research in TS and to present potential strategies for addressing them. The aim is to stimulate dialog within the wider CTSA community and beyond about the need to systematically examine how TS should be efficiently and effectively pursued, that is, the science of translational science. The collective sharing of experiences and innovative approaches to overcoming TS challenges that arise at CTSA hubs is critical if the field is to grow and gain wider recognition and acceptance by the scientific and broader communities.
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Affiliation(s)
- Mimi Kim
- Harold and Muriel Block Institute for Clinical and Translational Research, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Paul Marantz
- Harold and Muriel Block Institute for Clinical and Translational Research, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sylvia Suadicani
- Harold and Muriel Block Institute for Clinical and Translational Research, Albert Einstein College of Medicine, Bronx, NY, USA
- Departments of Urology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sofiya Milman
- Harold and Muriel Block Institute for Clinical and Translational Research, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marla J. Keller
- Harold and Muriel Block Institute for Clinical and Translational Research, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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Fong V, Hunte R, Keller MJ, Herold B, Herold B. 510. Secretory IgA in the Vaginal Mucosa Inhibits Herpes Simplex Virus Infection. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Abstract
Background
HSV2 increases HIV risk and is twice as common among women. We previously showed that cervicovaginal secretions exhibit innate anti-HSV2 activity that was lower in adolescents and women with HIV-- conditions associated with vaginal dysbiosis and increased HSV shedding. Our current study aims to test the hypothesis that vaginal dysbiosis is associated with low anti-HSV activity and to explore the molecules and mechanisms that contribute.
Methods
Cervicovaginal lavage (CVL) (10 ml normal saline wash) was collected from 20 women who presented with clinical bacterial vaginosis (BV) (Day 0) and then 1 and 4 weeks after completing a 7-day oral metronidazole course; parent study results were reported (PMID 34003290). Anti-HSV2 activity of CVL (diluted 1:4) was determined by plaque reduction assay. CVL IgG, IgA, cytokines and antimicrobial peptides were quantified by ELISA or multiplex Luminex and select microbiota by quantitative real-time PCR. CVL was enriched for IgA and IgG using protein L (binds all Ig) and Protein G (binds only IgG). HSV-specific antibodies in CVL were assessed by ELISA. Statistical analyses including Spearman correlation coefficients (SCC) were performed with GraphPad Prism version 9.1.2 software.
Results
Anti-HSV2 activity of CVL was highly variable at Day 0 (mean 18.6% SD 36.7) and trended to increase after treatment (mean 22.56% SD 33.8). The anti-HSV2 activity correlated positively with Nugent scores (SCC= -0.28, p= 0.03) and qPCR levels of BV-associated microbes (SCC = -0.2 to -0.3, p< -0.1) but positively with IgA (r= 0.49, p< 0.01) and IgG (r= 0.33, p= 0.01). IgA and IgG were isolated from pools of CVL with high inhibitory activity greater than 40% (n= 8). The anti-HSV2 activity mapped to the IgA fraction (56.5% inhibition) compared to the IgG or non-Ig fraction (0% inhibition) even though, as expected, the CVL concentration of IgG was higher than IgA (8.3μg/mL vs 4.9 μg/mL). The anti-HSV2 activity did not correlate with HSV-specific Ig in CVL.
Conclusion
Our findings suggest that secretory vaginal IgA contributes to innate anti-HSV2 activity and may trap viral particles to prevent viral entry. We speculate that sialidases, which cleave IgA and are elaborated by BV-associated microbiota, contribute to the low anti-HSV2 activity observed in high-risk cohorts.
Disclosures
Betsy Herold, MD, Viracor (Eurofins): Advisor/Consultant|X-Vax, Technologies: Advisor/Consultant|X-Vax, Technologies: Grant/Research Support|X-Vax, Technologies: Serve on Scientific Advisory Board for X-Vax, Technologies and receiving reserach funding for related worl. Betsy Herold, MD, Viracor (Eurofins): Advisor/Consultant|X-Vax, Technologies: Advisor/Consultant|X-Vax, Technologies: Grant/Research Support|X-Vax, Technologies: Serve on Scientific Advisory Board for X-Vax, Technologies and receiving reserach funding for related worl.
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Affiliation(s)
- Valerie Fong
- Albert Einstein College of Medicine , Bronx, New York
| | - Richard Hunte
- Albert Einstein College of Medicine , Bronx, New York
| | | | - Betsy Herold
- Albert Einstein College of Medicine , Bronx, New York
| | - Betsy Herold
- Albert Einstein College of Medicine , Bronx, New York
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Ortigoza MB, Yoon H, Goldfeld KS, Troxel AB, Daily JP, Wu Y, Li Y, Wu D, Cobb GF, Baptiste G, O'Keeffe M, Corpuz MO, Ostrosky-Zeichner L, Amin A, Zacharioudakis IM, Jayaweera DT, Wu Y, Philley JV, Devine MS, Desruisseaux MS, Santin AD, Anjan S, Mathew R, Patel B, Nigo M, Upadhyay R, Kupferman T, Dentino AN, Nanchal R, Merlo CA, Hager DN, Chandran K, Lai JR, Rivera J, Bikash CR, Lasso G, Hilbert TP, Paroder M, Asencio AA, Liu M, Petkova E, Bragat A, Shaker R, McPherson DD, Sacco RL, Keller MJ, Grudzen CR, Hochman JS, Pirofski LA, Parameswaran L, Corcoran AT, Rohatgi A, Wronska MW, Wu X, Srinivasan R, Deng FM, Filardo TD, Pendse J, Blaser SB, Whyte O, Gallagher JM, Thomas OE, Ramos D, Sturm-Reganato CL, Fong CC, Daus IM, Payoen AG, Chiofolo JT, Friedman MT, Wu DW, Jacobson JL, Schneider JG, Sarwar UN, Wang HE, Huebinger RM, Dronavalli G, Bai Y, Grimes CZ, Eldin KW, Umana VE, Martin JG, Heath TR, Bello FO, Ransford DL, Laurent-Rolle M, Shenoi SV, Akide-Ndunge OB, Thapa B, Peterson JL, Knauf K, Patel SU, Cheney LL, Tormey CA, Hendrickson JE. Efficacy and Safety of COVID-19 Convalescent Plasma in Hospitalized Patients: A Randomized Clinical Trial. JAMA Intern Med 2022; 182:115-126. [PMID: 34901997 PMCID: PMC8669605 DOI: 10.1001/jamainternmed.2021.6850] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE There is clinical equipoise for COVID-19 convalescent plasma (CCP) use in patients hospitalized with COVID-19. OBJECTIVE To determine the safety and efficacy of CCP compared with placebo in hospitalized patients with COVID-19 receiving noninvasive supplemental oxygen. DESIGN, SETTING, AND PARTICIPANTS CONTAIN COVID-19, a randomized, double-blind, placebo-controlled trial of CCP in hospitalized adults with COVID-19, was conducted at 21 US hospitals from April 17, 2020, to March 15, 2021. The trial enrolled 941 participants who were hospitalized for 3 or less days or presented 7 or less days after symptom onset and required noninvasive oxygen supplementation. INTERVENTIONS A unit of approximately 250 mL of CCP or equivalent volume of placebo (normal saline). MAIN OUTCOMES AND MEASURES The primary outcome was participant scores on the 11-point World Health Organization (WHO) Ordinal Scale for Clinical Improvement on day 14 after randomization; the secondary outcome was WHO scores determined on day 28. Subgroups were analyzed with respect to age, baseline WHO score, concomitant medications, symptom duration, CCP SARS-CoV-2 titer, baseline SARS-CoV-2 serostatus, and enrollment quarter. Outcomes were analyzed using a bayesian proportional cumulative odds model. Efficacy of CCP was defined as a cumulative adjusted odds ratio (cOR) less than 1 and a clinically meaningful effect as cOR less than 0.8. RESULTS Of 941 participants randomized (473 to placebo and 468 to CCP), 556 were men (59.1%); median age was 63 years (IQR, 52-73); 373 (39.6%) were Hispanic and 132 (14.0%) were non-Hispanic Black. The cOR for the primary outcome adjusted for site, baseline risk, WHO score, age, sex, and symptom duration was 0.94 (95% credible interval [CrI], 0.75-1.18) with posterior probability (P[cOR<1] = 72%); the cOR for the secondary adjusted outcome was 0.92 (95% CrI, 0.74-1.16; P[cOR<1] = 76%). Exploratory subgroup analyses suggested heterogeneity of treatment effect: at day 28, cORs were 0.72 (95% CrI, 0.46-1.13; P[cOR<1] = 93%) for participants enrolled in April-June 2020 and 0.65 (95% CrI, 0.41 to 1.02; P[cOR<1] = 97%) for those not receiving remdesivir and not receiving corticosteroids at randomization. Median CCP SARS-CoV-2 neutralizing titer used in April to June 2020 was 1:175 (IQR, 76-379). Any adverse events (excluding transfusion reactions) were reported for 39 (8.2%) placebo recipients and 44 (9.4%) CCP recipients (P = .57). Transfusion reactions occurred in 2 (0.4) placebo recipients and 8 (1.7) CCP recipients (P = .06). CONCLUSIONS AND RELEVANCE In this trial, CCP did not meet the prespecified primary and secondary outcomes for CCP efficacy. However, high-titer CCP may have benefited participants early in the pandemic when remdesivir and corticosteroids were not in use. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04364737.
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Affiliation(s)
- Mila B Ortigoza
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York.,Department of Microbiology, NYU Grossman School of Medicine, New York, New York
| | - Hyunah Yoon
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Keith S Goldfeld
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Andrea B Troxel
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Johanna P Daily
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Yinxiang Wu
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Yi Li
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Danni Wu
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Gia F Cobb
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Gillian Baptiste
- Department of Surgery, NYU Grossman School of Medicine, New York, New York
| | - Mary O'Keeffe
- Department of Medicine, NYU Long Island School of Medicine, Mineola, New York
| | - Marilou O Corpuz
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Luis Ostrosky-Zeichner
- Division of Infectious Disease, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Amee Amin
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Ioannis M Zacharioudakis
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Dushyantha T Jayaweera
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida.,Miami Clinical and Translational Science Institute, University of Miami Miller School of Medicine Miami, Florida
| | - Yanyun Wu
- Department of Pathology, University of Miami Miller School of Medicine, Miami, Florida
| | - Julie V Philley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Tyler, UTHealth East Texas, Tyler
| | - Megan S Devine
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Tyler, UTHealth East Texas, Tyler
| | - Mahalia S Desruisseaux
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Alessandro D Santin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Shweta Anjan
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Reeba Mathew
- Division of Critical Care, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Bela Patel
- Division of Critical Care, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Masayuki Nigo
- Division of Infectious Disease, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Rabi Upadhyay
- Department of Medicine, NYU Grossman School of Medicine, New York, New York.,Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York, New York
| | - Tania Kupferman
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Andrew N Dentino
- Department of Internal Medicine, The University of Texas Rio Grande Valley, Edinburg
| | - Rahul Nanchal
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David N Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Kartik Chandran
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Jonathan R Lai
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, New York
| | - Johanna Rivera
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Chowdhury R Bikash
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, New York
| | - Gorka Lasso
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Timothy P Hilbert
- Department of Pathology, NYU Grossman School of Medicine, New York, New York
| | - Monika Paroder
- Department of Pathology, Albert Einstein College of Medicine, Bronx, New York
| | - Andrea A Asencio
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Mengling Liu
- Department of Population Health, NYU Grossman School of Medicine, New York, New York.,Department of Environmental Health, NYU Grossman School of Medicine, New York, New York
| | - Eva Petkova
- Department of Population Health, NYU Grossman School of Medicine, New York, New York.,Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York.,Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York
| | - Alexander Bragat
- Clinical Research Information Technology and Informatics, NYU Grossman School of Medicine, New York, New York
| | - Reza Shaker
- Clinical and Translational Science Institute of Southern Wisconsin, Medical College of Wisconsin Milwaukee
| | - David D McPherson
- Center for Clinical and Translational Sciences, Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Ralph L Sacco
- Miami Clinical and Translational Science Institute, University of Miami Miller School of Medicine Miami, Florida
| | - Marla J Keller
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Harold and Muriel Block Institute for Clinical and Translational Research, Albert Einstein College of Medicine and Montefiore Medical Center Bronx, New York
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York.,NYC Health and Hospitals Corporation Clinical and Translational Science Institute, NYU Grossman School of Medicine, New York, New York
| | - Judith S Hochman
- NYC Health and Hospitals Corporation Clinical and Translational Science Institute, NYU Grossman School of Medicine, New York, New York.,Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Liise-Anne Pirofski
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | | | - Lalitha Parameswaran
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Anthony T Corcoran
- Department of Urology, NYU Long Island School of Medicine, Mineola, New York
| | - Abhinav Rohatgi
- Department of Medicine, NYU Long Island School of Medicine, Mineola, New York
| | - Marta W Wronska
- Department of Medicine, NYU Long Island School of Medicine, Mineola, New York
| | - Xinyuan Wu
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Ranjini Srinivasan
- Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Fang-Ming Deng
- Department of Pathology, NYU Grossman School of Medicine, New York, New York
| | - Thomas D Filardo
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Jay Pendse
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Simone B Blaser
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Olga Whyte
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | | | - Ololade E Thomas
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Danibel Ramos
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | | | - Charlotte C Fong
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Ivy M Daus
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | | | - Joseph T Chiofolo
- Department of Pathology, NYU Long Island School of Medicine, Mineola, New York
| | - Mark T Friedman
- Department of Pathology, NYU Long Island School of Medicine, Mineola, New York
| | - Ding Wen Wu
- Department of Pathology, NYU Grossman School of Medicine, New York, New York
| | - Jessica L Jacobson
- Department of Pathology, NYU Grossman School of Medicine, New York, New York
| | - Jeffrey G Schneider
- Department of Medicine, NYU Long Island School of Medicine, Mineola, New York
| | - Uzma N Sarwar
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Pfizer Vaccine Clinical Research and Development, Pfizer Inc, Pearl River, New York
| | - Henry E Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston.,Department of Emergency Medicine, The Ohio State University, Ohio
| | - Ryan M Huebinger
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Goutham Dronavalli
- Division of Critical Care, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Yu Bai
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Carolyn Z Grimes
- Division of Infectious Disease, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Karen W Eldin
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Virginia E Umana
- Division of Infectious Disease, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Jessica G Martin
- Department of Internal Medicine, The University of Texas Rio Grande Valley, Edinburg
| | - Timothy R Heath
- Department of Internal Medicine, The University of Texas Rio Grande Valley, Edinburg
| | - Fatimah O Bello
- Department of Internal Medicine, The University of Texas Rio Grande Valley, Edinburg
| | - Daru Lane Ransford
- Miami Clinical and Translational Science Institute, University of Miami Miller School of Medicine Miami, Florida
| | - Maudry Laurent-Rolle
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Sheela V Shenoi
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Oscar Bate Akide-Ndunge
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Bipin Thapa
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Jennifer L Peterson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Kelly Knauf
- Clinical and Translational Science Institute of Southern Wisconsin, Medical College of Wisconsin Milwaukee
| | - Shivani U Patel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Laura L Cheney
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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8
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Teleshova N, Keller MJ, Fernández Romero JA, Friedland BA, Creasy GW, Plagianos MG, Ray L, Barnable P, Kizima L, Rodriguez A, Cornejal N, Melo C, Cruz Rodriguez G, Mukhopadhyay S, Calenda G, Sinkar SU, Bonnaire T, Wesenberg A, Zhang S, Kleinbeck K, Palmer K, Alami M, O’Keefe BR, Gillevet P, Hur H, Liang Y, Santone G, Fichorova RN, Kalir T, Zydowsky TM. Results of a phase 1, randomized, placebo-controlled first-in-human trial of griffithsin formulated in a carrageenan vaginal gel. PLoS One 2022; 17:e0261775. [PMID: 35051209 PMCID: PMC8775213 DOI: 10.1371/journal.pone.0261775] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [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: 07/09/2021] [Accepted: 11/01/2021] [Indexed: 12/13/2022] Open
Abstract
HIV pre-exposure prophylaxis (PrEP) is dominated by clinical therapeutic antiretroviral (ARV) drugs. Griffithsin (GRFT) is a non-ARV lectin with potent anti-HIV activity. GRFT’s preclinical safety, lack of systemic absorption after vaginal administration in animal studies, and lack of cross-resistance with existing ARV drugs prompted its development for topical HIV PrEP. We investigated safety, pharmacokinetics (PK), pharmacodynamics (PD), and immunogenicity of PC-6500 (0.1% GRFT in a carrageenan (CG) gel) in healthy women after vaginal administration. This randomized, placebo-controlled, parallel group, double-blind first-in-human phase 1 study enrolled healthy, HIV-negative, non-pregnant women aged 24–45 years. In the open label period, all participants (n = 7) received single dose of PC-6500. In the randomized period, participants (n = 13) were instructed to self-administer 14 doses of PC-6500 or its matching CG placebo (PC-535) once daily for 14 days. The primary outcomes were safety and PK after single dose, and then after 14 days of dosing. Exploratory outcomes were GRFT concentrations in cervicovaginal fluids, PD, inflammatory mediators and gene expression in ectocervical biopsies. This trial is registered with ClinicalTrials.gov, number NCT02875119. No significant adverse events were recorded in clinical or laboratory results or histopathological evaluations in cervicovaginal mucosa, and no anti-drug (GRFT) antibodies were detected in serum. No cervicovaginal proinflammatory responses and no changes in the ectocervical transcriptome were evident. Decreased levels of proinflammatory chemokines (CXCL8, CCL5 and CCL20) were observed. GRFT was not detected in plasma. GRFT and GRFT/CG in cervicovaginal lavage samples inhibited HIV and HPV, respectively, in vitro in a dose-dependent fashion. These data suggest GRFT formulated in a CG gel is a safe and promising on-demand multipurpose prevention technology product that warrants further investigation.
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Affiliation(s)
- Natalia Teleshova
- Center for Biomedical Research, Population Council, New York, New York, United States of America
- * E-mail:
| | - Marla J. Keller
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - José A. Fernández Romero
- Center for Biomedical Research, Population Council, New York, New York, United States of America
- Science Department, Borough of Manhattan Community College, New York, New York, United States of America
| | - Barbara A. Friedland
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - George W. Creasy
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Marlena G. Plagianos
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Laurie Ray
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Patrick Barnable
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Larisa Kizima
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Aixa Rodriguez
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Nadjet Cornejal
- Science Department, Borough of Manhattan Community College, New York, New York, United States of America
| | - Claudia Melo
- Science Department, Borough of Manhattan Community College, New York, New York, United States of America
| | - Gearoff Cruz Rodriguez
- Science Department, Borough of Manhattan Community College, New York, New York, United States of America
| | - Sampurna Mukhopadhyay
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Giulia Calenda
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Shweta U. Sinkar
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Thierry Bonnaire
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Asa Wesenberg
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Shimin Zhang
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Kyle Kleinbeck
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Kenneth Palmer
- University of Louisville, Louisville, Kentucky, United States of America
| | - Mohcine Alami
- Center for Biomedical Research, Population Council, New York, New York, United States of America
| | - Barry R. O’Keefe
- Division of Cancer Treatment and Diagnosis, Molecular Targets Program, Center for Cancer Research and Natural Products Branch, Developmental Therapeutics Program, National Cancer Institute, Frederick, Maryland, United States of America
| | - Patrick Gillevet
- George Mason University, Manassas, Virginia, United States of America
| | - Hong Hur
- Rockefeller University, New York, New York, United States of America
| | - Yupu Liang
- Rockefeller University, New York, New York, United States of America
| | - Gabriela Santone
- Harvard Medical School, Boston, Massachusetts, United States of America
| | | | - Tamara Kalir
- Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Thomas M. Zydowsky
- Center for Biomedical Research, Population Council, New York, New York, United States of America
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9
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Kuriakose S, Singh K, Pau AK, Daar E, Gandhi R, Tebas P, Evans L, Gulick RM, Lane HC, Masur H, Aberg JA, Adimora AA, Baker J, Kreuziger LB, Bedimo R, Belperio PS, Cantrill SV, Coopersmith CM, Davis SL, Dzierba AL, Gallagher JJ, Glidden DV, Grund B, Hardy EJ, Hinkson C, Hughes BL, Johnson S, Keller MJ, Kim AY, Lennox JL, Levy MM, Li JZ, Martin GS, Naggie S, Pavia AT, Seam N, Simpson SQ, Swindells S, Tien P, Waghmare AA, Wilson KC, Yazdany J, Zachariah P, Campbell DM, Harrison C, Burgess T, Francis J, Sheikh V, Uyeki TM, Walker R, Brooks JT, Ortiz LB, Davey RT, Doepel LK, Eisinger RW, Han A, Higgs ES, Nason MC, Crew P, Lerner AM, Lund C, Worthington C. Developing Treatment Guidelines During a Pandemic Health Crisis: Lessons Learned From COVID-19. Ann Intern Med 2021; 174:1151-1158. [PMID: 34125574 PMCID: PMC8252833 DOI: 10.7326/m21-1647] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The development of the National Institutes of Health (NIH) COVID-19 Treatment Guidelines began in March 2020 in response to a request from the White House Coronavirus Task Force. Within 4 days of the request, the NIH COVID-19 Treatment Guidelines Panel was established and the first meeting took place (virtually-as did subsequent meetings). The Panel comprises 57 individuals representing 6 governmental agencies, 11 professional societies, and 33 medical centers, plus 2 community members, who have worked together to create and frequently update the guidelines on the basis of evidence from the most recent clinical studies available. The initial version of the guidelines was completed within 2 weeks and posted online on 21 April 2020. Initially, sparse evidence was available to guide COVID-19 treatment recommendations. However, treatment data rapidly accrued based on results from clinical studies that used various study designs and evaluated different therapeutic agents and approaches. Data have continued to evolve at a rapid pace, leading to 24 revisions and updates of the guidelines in the first year. This process has provided important lessons for responding to an unprecedented public health emergency: Providers and stakeholders are eager to access credible, current treatment guidelines; governmental agencies, professional societies, and health care leaders can work together effectively and expeditiously; panelists from various disciplines, including biostatistics, are important for quickly developing well-informed recommendations; well-powered randomized clinical trials continue to provide the most compelling evidence to guide treatment recommendations; treatment recommendations need to be developed in a confidential setting free from external pressures; development of a user-friendly, web-based format for communicating with health care providers requires substantial administrative support; and frequent updates are necessary as clinical evidence rapidly emerges.
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Affiliation(s)
- Safia Kuriakose
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, Bethesda, Maryland (S.K.)
| | - Kanal Singh
- National Institutes of Health, Bethesda, Maryland (K.S., A.K.P., H.C.L., H.M.)
| | - Alice K Pau
- National Institutes of Health, Bethesda, Maryland (K.S., A.K.P., H.C.L., H.M.)
| | - Eric Daar
- Harbor-University of California, Los Angeles Medical Center, Torrance, California (E.D.)
| | - Rajesh Gandhi
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (R.G.)
| | - Pablo Tebas
- University of Pennsylvania, Philadelphia, Pennsylvania (P.T.)
| | - Laura Evans
- University of Washington, Seattle, Washington (L.E.)
| | - Roy M Gulick
- Weill Cornell Medicine, New York, New York (R.M.G.)
| | - H Clifford Lane
- National Institutes of Health, Bethesda, Maryland (K.S., A.K.P., H.C.L., H.M.)
| | - Henry Masur
- National Institutes of Health, Bethesda, Maryland (K.S., A.K.P., H.C.L., H.M.)
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10
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Strickler HD, Keller MJ, Hessol NA, Eltoum IE, Einstein MH, Castle PE, Massad LS, Flowers L, Rahangdale L, Atrio JM, Ramirez C, Minkoff H, Adimora AA, Ofotokun I, Colie C, Huchko MJ, Fischl M, Wright R, D'Souza G, Leider J, Diaz O, Sanchez-Keeland L, Shrestha S, Xie X, Xue X, Anastos K, Palefsky JM, Burk RD. Primary HPV and Molecular Cervical Cancer Screening in US Women Living With Human Immunodeficiency Virus. Clin Infect Dis 2021; 72:1529-1537. [PMID: 32881999 DOI: 10.1093/cid/ciaa1317] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Primary human papillomavirus (HPV) screening (PHS) utilizes oncogenic human papillomavirus (oncHPV) testing as the initial cervical cancer screening method and typically, if positive, additional reflex-triage (eg, HPV16/18-genotyping, Pap testing). While US guidelines support PHS usage in the general population, PHS has been little studied in women living with HIV (WLWH). METHODS We enrolled n = 865 WLWH (323 from the Women's Interagency HIV Study [WIHS] and 542 from WIHS-affiliated colposcopy clinics). All participants underwent Pap and oncHPV testing, including HPV16/18-genotyping. WIHS WLWH who tested oncHPV[+] or had cytologic atypical squamous cells of undetermined significance or worse (ASC-US+) underwent colposcopy, as did a random 21% of WLWH who were oncHPV[-]/Pap[-] (controls). Most participants additionally underwent p16/Ki-67 immunocytochemistry. RESULTS Mean age was 46 years, median CD4 was 592 cells/µL, 95% used antiretroviral therapy. Seventy WLWH had histologically-determined cervical intraepithelial neoplasia grade 2 or greater (CIN-2+), of which 33 were defined as precancer (ie, [i] CIN-3+ or [ii] CIN-2 if concurrent with cytologic high grade squamous intraepithelial lesions [HSILs]). PHS had 87% sensitivity (Se) for precancer, 9% positive predictive value (PPV), and a 35% colposcopy referral rate (Colpo). "PHS with reflex HPV16/18-genotyping and Pap testing" had 84% Se, 16% PPV, 30% Colpo. PHS with only HPV16/18-genotyping had 24% Colpo. "Concurrent oncHPV and Pap Testing" (Co-Testing) had 91% Se, 12% PPV, 40% Colpo. p16/Ki-67 immunochemistry had the highest PPV, 20%, but 13% specimen inadequacy. CONCLUSIONS PHS with reflex HPV16/18-genotyping had fewer unnecessary colposcopies and (if confirmed) could be a potential alternative to Co-Testing in WLWH.
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Affiliation(s)
- Howard D Strickler
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Marla J Keller
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Nancy A Hessol
- University of California, San Francisco, California, USA
| | | | | | - Philip E Castle
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | | | - Lisa Flowers
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Lisa Rahangdale
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jessica M Atrio
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Catalina Ramirez
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Adaora A Adimora
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Igho Ofotokun
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christine Colie
- Georgetown University, Washington, District of Columbia, USA
| | - Megan J Huchko
- University of California, San Francisco, California, USA
| | - Margaret Fischl
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rodney Wright
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Gypsyamber D'Souza
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Olga Diaz
- Jacobi Medical Center, Bronx, New York, USA
| | | | | | - Xianhong Xie
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Xiaonan Xue
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Kathryn Anastos
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | | | - Robert D Burk
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
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11
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Sultan JS, Wang T, Hunte R, Srinivasan S, McWalters J, Tharp GK, Bosinger SE, Fiedler TL, Atrio JM, Murphy K, Barnett R, Ray LR, Krows ML, Fredricks DN, Irungu E, Ngure K, Mugo N, Marrazzo J, Keller MJ, Herold BC. Differences in vaginal microbiota, host transcriptome and proteins in women with bacterial vaginosis are associated with metronidazole treatment response. J Infect Dis 2021; 224:2094-2104. [PMID: 34003290 DOI: 10.1093/infdis/jiab266] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/17/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Bacterial vaginosis (BV) treatment failures and recurrences are common. To identify features associated with treatment response, we compared vaginal microbiota and host ectocervical transcriptome before and after oral metronidazole therapy. METHODS Women with BV (Bronx, NY and Thika, Kenya) received 7 days of oral metronidazole at enrollment (Day 0) and underwent genital tract sampling of microbiome (16S rRNA gene sequencing), transcriptome (RNAseq), and immune mediator concentrations on Day 0, 15 and 35. RESULTS Bronx participants were more likely than Thika participants to clinically respond to metronidazole (19/20 vs 10/18, respectively, p=0.0067) and by changes in microbiota composition and diversity. After dichotomizing the cohort into responders and non-responders by change in alpha diversity between Day 35 and Day 0, we identified transcription differences associated with chemokine signaling (q=0.002) and immune system process (q=2.5e-8) that differentiated responders from non-responders were present at enrollment. Responders had significantly lower levels of CXCL9 in cervicovaginal lavage on Day 0 (p< 0.007) and concentrations of CXCL9, CXCL10 and MCP-1 increased significantly between Day 0 and Day 35 in responders versus non-responders. CONCLUSIONS Response to metronidazole is characterized by significant changes in chemokines and related transcripts suggesting that treatments that promote these pathways may prove beneficial.
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Affiliation(s)
- Joyce Serebrenik Sultan
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Tao Wang
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Richard Hunte
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sujatha Srinivasan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jessica McWalters
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Gregory K Tharp
- Yerkes Genomics Core Laboratory, Yerkes National Primate Research Center, Atlanta, GA, USA
| | - Steven E Bosinger
- Yerkes Genomics Core Laboratory, Yerkes National Primate Research Center, Atlanta, GA, USA.,Emory University School of Medicine, Department of Pathology & Laboratory Medicine, Atlanta, GA, USA.,Emory Vaccine Center, Emory University, Atlanta,GA, USA
| | - Tina L Fiedler
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jessica M Atrio
- Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kerry Murphy
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rebecca Barnett
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Laurie R Ray
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Meighan L Krows
- Department of Global Health, University of Washington, Seattle WA, USA
| | - David N Fredricks
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Elizabeth Irungu
- Department of Medicine, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kenneth Ngure
- Department of Medicine, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly Mugo
- Department of Medicine, Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jeanne Marrazzo
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Marla J Keller
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Betsy C Herold
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
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12
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Pierce CA, Sy S, Galen B, Goldstein DY, Orner E, Keller MJ, Herold KC, Herold BC. Natural mucosal barriers and COVID-19 in children. JCI Insight 2021; 6:148694. [PMID: 33822777 PMCID: PMC8262299 DOI: 10.1172/jci.insight.148694] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/31/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is more benign in children compared with adults for unknown reasons. This contrasts with other respiratory viruses where disease manifestations are often more severe in children. We hypothesize that a more robust early innate immune response to SARS coronavirus 2 (SARS-CoV-2) protects against severe disease. METHODS Clinical outcomes, SARS-CoV-2 viral copies, and cellular gene expression were compared in nasopharyngeal swabs obtained at the time of presentation to the emergency department from 12 children and 27 adults using bulk RNA sequencing and quantitative reverse-transcription PCR. Total protein, cytokines, and anti–SARS-CoV-2 IgG and IgA were quantified in nasal fluid. RESULTS SARS-CoV-2 copies, angiotensin-converting enzyme 2, and TMPRSS2 gene expression were similar in children and adults, but children displayed higher expression of genes associated with IFN signaling, NLRP3 inflammasome, and other innate pathways. Higher levels of IFN-α2, IFN-γ, IP-10, IL-8, and IL-1β protein were detected in nasal fluid in children versus adults. Children also expressed higher levels of genes associated with immune cells, whereas expression of those associated with epithelial cells did not differ in children versus adults. Anti–SARS-CoV-2 IgA and IgG were detected at similar levels in nasal fluid from both groups. None of the children required supplemental oxygen, whereas 7 adults did (P = 0.03); 4 adults died. CONCLUSION These findings provide direct evidence of a more vigorous early mucosal immune response in children compared with adults and suggest that this contributes to favorable clinical outcomes. FUNDING NIH grants R01 AI134367, UL1 TR002556, T32 AI007501, T32GM007288, P30 AI124414; an Albert Einstein College of Medicine Dean’s COVID-19 Pilot Research Award; and the Eric J. Heyer, MD, PhD Translational Research Pilot Project Award.
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Affiliation(s)
- Carl A Pierce
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sharlene Sy
- Department of Pediatrics, the Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Doctor Y Goldstein
- Department of Pathology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Erika Orner
- Department of Pathology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Kevan C Herold
- Departments of Immunobiology and Internal Medicine, Yale University, New Haven, Connecticut, USA
| | - Betsy C Herold
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA.,Department of Pediatrics, the Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York, USA
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13
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Tomer Y, Ng Gong M, Keller MJ, Southern W, Kitsis EA, Kajita GR, Shapiro LI, Jariwala SP, Epstein EJ. Teamwork and Leadership Under Fire at the Epicenter of the COVID-19 Epidemic in the Bronx. Front Med (Lausanne) 2021; 8:610100. [PMID: 33816518 PMCID: PMC8012527 DOI: 10.3389/fmed.2021.610100] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 02/23/2021] [Indexed: 11/13/2022] Open
Abstract
The first Covid-19 patient was admitted to Montefiore Medical Center (MMC) on March 10, 2020. Soon thereafter there was a rapid and exponential surge of Covid-19 admissions to MMC that could have resulted in catastrophic consequences if MMC had been overwhelmed, as happened in Europe. To adjust to this crisis our institution, under the inspiring leadership of Dr. Philip Ozuah, President and CEO of Montefiore Medicine, adopted an "all hands on deck" approach, mobilizing our entire workforce to expand our units to accommodate the growing number of patients being admitted. Given that the internal medicine (IM) and ICU units are part of the department of medicine (DOM), the DOM was at the center of this mobilization. The DOM is the largest department at MMC and mobilizing it required careful planning, seamless teamwork, and strong leadership. To achieve that goal, we applied a framework that we designate the "3C framework," denoting Coordination, Communication, and Collaboration. In this report we describe the many initiatives the Montefiore Einstein DOM implemented during the Covid-19 pandemic using the 3C framework. These included establishing the Medicine Covid-19 Taskforce to lead our efforts, starting a daily newsletter for up-to-date communications, rapidly expanding the ICU and IM units, converting most specialty inpatient consults to eConsults, coordinating research studies, and more. The goal of this report is to serve as a guide on how the 3C framework helped us organize, mobilize, and energize the department of medicine effectively and efficiently during this unprecedented crisis.
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Affiliation(s)
- Yaron Tomer
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Michelle Ng Gong
- Divisions of Critical Care Medicine and Pulmonary Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Marla J Keller
- Division of Infectious Diseases, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - William Southern
- Division of Hospital Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Elizabeth A Kitsis
- Division of Rheumatology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Grace R Kajita
- Division of General Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Lauren I Shapiro
- Division of General Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Sunit P Jariwala
- Division of Allergy and Immunology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Eric J Epstein
- Division of Endocrinology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
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14
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Pierce CA, Preston-Hurlburt P, Dai Y, Aschner CB, Cheshenko N, Galen B, Garforth SJ, Herrera NG, Jangra RK, Morano NC, Orner E, Sy S, Chandran K, Dziura J, Almo SC, Ring A, Keller MJ, Herold KC, Herold BC. Immune responses to SARS-CoV-2 infection in hospitalized pediatric and adult patients. Sci Transl Med 2020; 12:scitranslmed.abd5487. [PMID: 32958614 PMCID: PMC7658796 DOI: 10.1126/scitranslmed.abd5487] [Citation(s) in RCA: 249] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/16/2020] [Indexed: 12/16/2022]
Abstract
Compared to adults, young people with COVID-19 have milder disease. Pierce et al. compared immune responses in hospitalized adult and young patients with COVID-19 to identify potential contributing mechanisms. In the first week after hospitalization, circulating IL-17A and IFN-γ concentrations were inversely related to age. More than 3 weeks later, CD4+ T cell responses to viral spike protein were higher in adult compared to younger patients. Neutralizing antibody titers were also higher in adults and correlated positively with age and negatively with IL-17A and IFN-γ. These findings suggest that the poor outcome in adults is not caused by a failure to generate adaptive immune responses. Children and youth infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have milder disease than do adults, and even among those with the recently described multisystem inflammatory syndrome, mortality is rare. The reasons for the differences in clinical manifestations are unknown but suggest that age-dependent factors may modulate the antiviral immune response. We compared cytokine, humoral, and cellular immune responses in pediatric (children and youth, age <24 years) (n = 65) and adult (n = 60) patients with coronavirus disease 2019 (COVID-19) at a metropolitan hospital system in New York City. The pediatric patients had a shorter length of stay, decreased requirement for mechanical ventilation, and lower mortality compared to adults. The serum concentrations of interleukin-17A (IL-17A) and interferon-γ (IFN-γ), but not tumor necrosis factor–α (TNF-α) or IL-6, were inversely related to age. Adults mounted a more robust T cell response to the viral spike protein compared to pediatric patients as evidenced by increased expression of CD25+ on CD4+ T cells and the frequency of IFN-γ+ CD4+ T cells. Moreover, serum neutralizing antibody titers and antibody-dependent cellular phagocytosis were higher in adults compared to pediatric patients with COVID-19. The neutralizing antibody titer correlated positively with age and negatively with IL-17A and IFN-γ serum concentrations. There were no differences in anti-spike protein antibody titers to other human coronaviruses. Together, these findings demonstrate that the poor outcome in hospitalized adults with COVID-19 compared to children may not be attributable to a failure to generate adaptive immune responses.
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Affiliation(s)
- Carl A Pierce
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | | | - Yile Dai
- Department of Immunobiology, Yale University, New Haven, CT 06520, USA
| | - Clare Burn Aschner
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Natalia Cheshenko
- Department of Pediatrics, The Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Benjamin Galen
- Department of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
| | - Scott J Garforth
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Natalia G Herrera
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Rohit K Jangra
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Nicholas C Morano
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Erika Orner
- Department of Pathology, Montefiore Medical Center, Bronx, NY 10467, USA
| | - Sharlene Sy
- Department of Pediatrics, The Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Kartik Chandran
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - James Dziura
- Department of Emergency Medicine and Biostatistics, Yale University, New Haven, CT 06520, USA
| | - Steven C Almo
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Aaron Ring
- Department of Immunobiology, Yale University, New Haven, CT 06520, USA
| | - Marla J Keller
- Department of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
| | - Kevan C Herold
- Department of Immunobiology, Yale University, New Haven, CT 06520, USA. .,Department of Emergency Medicine and Biostatistics, Yale University, New Haven, CT 06520, USA
| | - Betsy C Herold
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY 10461, USA. .,Department of Pediatrics, The Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY 10461, USA
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15
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Keller MJ, Kitsis EA, Arora S, Chen JT, Agarwal S, Ross MJ, Tomer Y, Southern W. Effect of Systemic Glucocorticoids on Mortality or Mechanical Ventilation in Patients With COVID-19. J Hosp Med 2020; 15:489-493. [PMID: 32804611 PMCID: PMC7518134 DOI: 10.12788/jhm.3497] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [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] [Received: 05/07/2020] [Accepted: 06/30/2020] [Indexed: 01/20/2023]
Abstract
The efficacy of glucocorticoids in COVID-19 is unclear. This study was designed to determine whether systemic glucocorticoid treatment in COVID-19 patients is associated with reduced mortality or mechanical ventilation. This observational study included 1,806 hospitalized COVID-19 patients; 140 were treated with glucocorticoids within 48 hours of admission. Early use of glucocorticoids was not associated with mortality or mechanical ventilation. However, glucocorticoid treatment of patients with initial C-reactive protein (CRP) ≥20 mg/dL was associated with significantly reduced risk of mortality or mechanical ventilation (odds ratio, 0.23; 95% CI, 0.08-0.70), while glucocorticoid treatment of patients with CRP <10 mg/dL was associated with significantly increased risk of mortality or mechanical ventilation (OR, 2.64; 95% CI, 1.39-5.03). Whether glucocorticoid treatment is associated with changes in mortality or mechanical ventilation in patients with high or low CRP needs study in prospective, randomized clinical trials.
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Affiliation(s)
- Marla J Keller
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
- Corresponding Author: Marla J Keller, MD; ; Telephone: 718-430-3240; Twitter: @MarlaJKeller
| | - Elizabeth A Kitsis
- Division of Rheumatology, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Shitij Arora
- Division of Hospital Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Jen-Ting Chen
- Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Shivani Agarwal
- Division of Endocrinology, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Michael J Ross
- Division of Nephrology, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Yaron Tomer
- Division of Endocrinology, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - William Southern
- Division of Hospital Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
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Marantz PR, Keller MJ, Meagher EA. A counterpoint to "training the translational workforce: expanding beyond translational research to include translational science". J Clin Transl Sci 2020; 4:363-364. [PMID: 33244419 PMCID: PMC7681116 DOI: 10.1017/cts.2020.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 11/07/2022] Open
Affiliation(s)
- Paul R. Marantz
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Marla J. Keller
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Emma A. Meagher
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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17
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Keller MJ, Huber A, Espinoza L, Serrano MG, Parikh HI, Buck GA, Gold JA, Wu Y, Wang T, Herold BC. Impact of Herpes Simplex Virus Type 2 and Human Immunodeficiency Virus Dual Infection on Female Genital Tract Mucosal Immunity and the Vaginal Microbiome. J Infect Dis 2019; 220:852-861. [PMID: 31111902 PMCID: PMC6667798 DOI: 10.1093/infdis/jiz203] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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] [Received: 01/15/2019] [Accepted: 04/22/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Mechanisms linking herpes simplex virus type 2 (HSV-2) with human immunodeficiency virus (HIV) are not fully defined. We tested the hypothesis that HSV-2 and HIV dual infection is associated with cervicovaginal inflammation and/or vaginal dysbiosis. METHODS Genital tract samples were obtained weekly over a 12-week period from 30 women seropositive (+) for HIV and HSV-2 and 15 women each who were seropositive for one or seronegative (-) for both viruses. Immune mediators, antimicrobial activity, and microbial composition and diversity were compared. RESULTS Significant differences in the concentrations of interferon-γ (P = .002), tumor necrosis factor-α (P = .03), human beta defensin 1 (P = .001), secretory leukocyte protease inhibitor (P = .01), and lysozyme (P = .03) were observed across the 4 groups (Kruskal-Wallis). There were also significant differences in vaginal microbial alpha diversity (Simpson index) (P = .0046). Specifically, when comparing HIV-1+/HSV-2+ to HIV-1-/HSV-2- women, a decrease in Lactobacillus crispatus and increase in diverse anaerobes was observed. The number of genital HSV outbreaks was greater in HIV+ versus HIV- women (39 versus 12) (P = .04), but there were no significant differences when comparing outbreak to non-outbreak visits. CONCLUSIONS Increased microbial diversity and cervicovaginal inflammation in HIV and HSV-2 dually infected women may adversely impact genital health and, in the absence of antiretroviral therapy, facilitate HIV shedding.
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Affiliation(s)
- Marla J Keller
- Departments of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Ashley Huber
- Departments of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
- Present Affiliation: Department of Obstetrics, Gynecology and Reproductive Medicine, Stony Brook University School of Medicine, Stony Brook, New York
| | - Lilia Espinoza
- Departments of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Myrna G Serrano
- Department of Microbiology and Immunology, Virginia Commonwealth University, Richmond
- Center for Microbiome Engineering and Data Analysis, Virginia Commonwealth University, Richmond
| | - Hardik I Parikh
- School of Medicine Research Computing, University of Virginia, Charlottesville
| | - Gregory A Buck
- Department of Microbiology and Immunology, Virginia Commonwealth University, Richmond
- Center for Microbiome Engineering and Data Analysis, Virginia Commonwealth University, Richmond
- Computer Science Department, Virginia Commonwealth University, Richmond
| | - Jeremy A Gold
- Departments of Medicine, Albert Einstein College of Medicine, Bronx, New York
- Present Affiliation: Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Yiqun Wu
- Departments of Epidemiology and Population Health, Bronx, New York
- Present Affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Tao Wang
- Departments of Epidemiology and Population Health, Bronx, New York
| | - Betsy C Herold
- Departments of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
- Department of Pediatrics, Albert Einstein College of Medicine and Children’s Hospital at Montefiore, Bronx, New York
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18
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Keller MJ, Wood L, Billingsley JM, Ray LL, Goymer J, Sinclair S, McGinn AP, Marzinke MA, Frank B, Srinivasan S, Liu C, Atrio JM, Espinoza L, Mugo N, Spiegel HML, Anderson PL, Fredricks DN, Hendrix CW, Marrazzo J, Bosinger SE, Herold BC. Tenofovir disoproxil fumarate intravaginal ring for HIV pre-exposure prophylaxis in sexually active women: a phase 1, single-blind, randomised, controlled trial. Lancet HIV 2019; 6:e498-e508. [PMID: 31320290 DOI: 10.1016/s2352-3018(19)30145-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/28/2019] [Accepted: 04/18/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND An intravaginal ring that releases the tenofovir prodrug, tenofovir disoproxil fumarate, provided 100% protection in macaques against simian HIV and was safe in a 14-day clinical trial in sexually abstinent women. We aimed to assess the safety and pharmacokinetics of this intravaginal ring over 90 days in sexually active women. METHODS We did a phase 1, single-blind, randomised, placebo-controlled trial to assess safety, pharmacokinetics, and acceptability of a tenofovir disoproxil fumarate intravaginal ring used continuously with monthly ring changes for 3 months. Sexually active women who were HIV negative were randomly assigned (3:1) to a tenofovir disoproxil fumarate ring or placebo ring. Primary safety endpoint was the proportion of women who had grade 2 or higher genitourinary adverse events judged related to study product and any grade 2 or higher adverse event as defined by the Division of AIDS Table for Grading the Severity of Adult and Pediatric Adverse Events. We quantified tenofovir disoproxil fumarate and tenofovir concentrations in cervicovaginal fluid, tenofovir in plasma, and tenofovir diphosphate, the active metabolite, in cervical tissue and dried blood spots 1 month after each ring insertion. We compared changes over time in cervicovaginal fluid cytokine and chemokine concentrations and vaginal microbiota. The study was electively stopped early and is registered with ClinicalTrials.gov, number NCT02762617. FINDINGS Between Feb 24 and July 20, 2017, 17 women were enrolled before study termination. 12 were assigned to receive the tenofovir disoproxil fumarate ring and five were assigned to receive the placebo ring. Two participants in the tenofovir disoproxil fumarate ring group completed 3 months of continuous ring use; eight were asked to discontinue ring use early because of ulcerations (grade 1) near the ring; in the remaining two women, rings were electively removed by study staff on day 20 and day 23. Ulcers were detected a mean of 32 days after ring use (range 23-56). Four of eight participants with ulcers were symptomatic with vaginal discharge; four had ulcers identified when examined; three had two ulcers; all ulcers resolved after ring removal. No participants in the placebo group developed ulcers. No grade 2 product-related adverse events were reported in either group and four non-product-related grade 2 adverse events were reported in the tenofovir disoproxil fumarate ring group. Cervicovaginal fluid tenofovir concentrations did not differ at day 14 (p=0·14) comparing the eight patients who did (median 1·0 × 105 ng/mL [IQR 9·1 × 104-1·1 × 105]) with the four who did not (6·0 × 104 ng/mL [5·6 × 104-1·1 × 105]) develop ulcers. No significant changes in vaginal microbiota were detected in either group. Concentrations of multiple inflammatory cytokines and chemokines were significantly higher at days 14 and 28 compared with baseline in the tenofovir disoproxil fumarate ring group but not the placebo group. INTERPRETATION Future studies are needed to establish whether the unanticipated finding of ulcerations is specific to this tenofovir disoproxil fumarate ring or generalisable to other sustained topical release formulations of tenofovir or its prodrugs. FUNDING National Institutes of Health.
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Affiliation(s)
- Marla J Keller
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Lianna Wood
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Laurie L Ray
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jessica Goymer
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Shada Sinclair
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aileen P McGinn
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mark A Marzinke
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Sujatha Srinivasan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Congzhou Liu
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jessica M Atrio
- Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Lilia Espinoza
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nelly Mugo
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Hans M L Spiegel
- Division of AIDS, Kelly Government Solutions, Contractor to National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Rockville, MD, USA
| | - Peter L Anderson
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - David N Fredricks
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Craig W Hendrix
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeanne Marrazzo
- Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | | | - Betsy C Herold
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA.
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19
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Murphy K, Keller MJ, Anastos K, Sinclair S, Devlin JC, Shi Q, Hoover DR, Starkman B, McGillick J, Mullis C, Minkoff H, Dominguez-Bello MG, Herold BC. Impact of reproductive aging on the vaginal microbiome and soluble immune mediators in women living with and at-risk for HIV infection. PLoS One 2019; 14:e0216049. [PMID: 31026271 PMCID: PMC6485713 DOI: 10.1371/journal.pone.0216049] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 10/10/2018] [Accepted: 04/12/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Reproductive aging may impact the vaginal microbiome and genital tract mucosal immune environment and contribute to genital tract health in women living with and at-risk for HIV infection. METHODS A cross-sectional study of 102 HIV+ (51 premenopausal, 51 postmenopausal) and 39 HIV-uninfected (HIV-) (20 premenopausal, 19 postmenopausal) women was performed in Bronx and Brooklyn, NY. Cervicovaginal lavage (CVL) was collected for quantification of innate antimicrobial activity against E. coli, HSV-2 and HIV and immune mediators by Luminex and ELISA. Microbiome studies by qPCR and 16S rRNA sequencing were performed on vaginal swabs. RESULTS HIV+ postmenopausal compared to premenopausal participants had lower median E. coli bactericidal activity (41% vs. 62%, p = 0.001), lower median gene copies of Lactobacillus crispatus (p = 0.005) and Lactobacillus iners (p = 0.019), lower proportions of Lactobacillus iners, higher proportions of Gardnerella and Atopobium vaginae and lower levels of human beta defensins (HBD-2, HBD-3) and secretory leukocyte protease inhibitor (SLPI), p<0.001. HSV-2 inhibitory activity was higher in HIV+ postmenopausal compared to premenopausal participants (37% vs. 17%, p = 0.001) and correlated with the proinflammatory molecules interleukin (IL) 6, IL-8, human neutrophil peptide (HNP) 1-3, lactoferrin and fibronectin. Similar trends were observed in HIV- postmenopausal compared to premenopausal participants. HIV inhibitory activity did not differ by reproductive status in the HIV+ participants but was significantly higher in HIV- postmenopausal compared to premenopausal participants and in participants with suppressed plasma viral load, and inversely correlated with gene copies of G. vaginalis and BVAB2. A significant proportion of HIV+ participants on ART exhibited HIV enhancing activity. CONCLUSIONS HIV+ postmenopausal compared to premenopausal participants have less CVL E. coli bactericidal activity, reflecting a reduction in Lactobacilli and a greater proportion of Gardnerella and A. vaginae, and more HSV-2 inhibitory activity, reflecting increased mucosal inflammation. The effect of menopause on mucosal immunity was greater in HIV+ participants, suggesting a synergistic impact. Promotion of a lactobacillus dominant vaginal microbiome and reduced mucosal inflammation may improve vaginal health and reduce risk for shedding of HIV and potential for HIV transmission in HIV+ menopausal women.
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Affiliation(s)
- Kerry Murphy
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Marla J. Keller
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Kathryn Anastos
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Shada Sinclair
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - J. Cooper Devlin
- Department of Medicine, New York University School of Medicine, New York, New York, United States of America
| | - Qiuhu Shi
- School of Health Sciences and Practice, New York Medical College, Valhalla, New York, United States of America
| | - Donald R. Hoover
- Rutgers University, Piscataway, New Jersey, United States of America
| | - Brian Starkman
- State University of New York/Downstate Medical Center School of Medicine, Brooklyn, New York, United States of America
| | - Jamie McGillick
- Cincinnati Children’s Medical Center, Cincinnati, Ohio, United States of America
| | - Caroline Mullis
- Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Howard Minkoff
- Department of Obstetrics and Gynecology, Maimonides Medical Center, and State University of New York/Downstate Medical Center, Brooklyn, New York, United States of America
| | - Maria Gloria Dominguez-Bello
- Department of Biochemistry and Microbiology, and Department of Anthropology, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, United States of America
| | - Betsy C. Herold
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, United States of America
- * E-mail:
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20
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Taneva E, Sinclair S, Mesquita PM, Weinrick B, Cameron SA, Cheshenko N, Reagle K, Frank B, Srinivasan S, Fredricks D, Keller MJ, Herold BC. Vaginal microbiome modulates topical antiretroviral drug pharmacokinetics. JCI Insight 2018; 3:99545. [PMID: 29997295 PMCID: PMC6124523 DOI: 10.1172/jci.insight.99545] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [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] [Received: 12/28/2017] [Accepted: 05/31/2018] [Indexed: 01/04/2023] Open
Abstract
Tenofovir gel and dapivirine ring provided variable HIV protection in clinical trials, reflecting poor adherence and possibly biological factors. We hypothesized that vaginal microbiota modulates pharmacokinetics and tested the effects of pH, individual bacteria, and vaginal swabs from women on pharmacokinetics and antiviral activity. Tenofovir, but not dapivirine, uptake by human cells was reduced as pH increased. Lactobacillus crispatus actively transported tenofovir leading to a loss in drug bioavailability and culture supernatants from Gardnerella vaginalis, but not Atopobium vaginae, blocked tenofovir endocytosis. The inhibition of endocytosis mapped to adenine. Adenine increased from 65.5 μM in broth to 246 μM in Gardnerella, but decreased to 9.5 μM in Atopobium supernatants. This translated into a decrease in anti-HIV activity when Gardnerella supernatants or adenine were added to cultures. Dapivirine was also impacted by microbiota, as drug bound irreversibly to bacteria, resulting in decreased antiviral activity. When drugs were incubated with vaginal swabs, 30.7% ± 5.7% of dapivirine and 63.9% ± 8.8% of tenofovir were recovered in supernatants after centrifugation of the bacterial cell pellet. In contrast, no impact of microbiota on the pharmacokinetics of the prodrugs, tenofovir disoproxil fumarate or tenofovir alafenamide, was observed. Together, these results demonstrate that microbiota may impact pharmacokinetics and contribute to inconsistent efficacy.
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Affiliation(s)
| | | | | | | | - Scott A. Cameron
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Kerry Reagle
- Particle Sciences, Inc., Bethlehem, Pennsylvania, USA
| | - Bruce Frank
- Particle Sciences, Inc., Bethlehem, Pennsylvania, USA
| | - Sujatha Srinivasan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
| | - David Fredricks
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
| | - Marla J. Keller
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Betsy C. Herold
- Department of Microbiology & Immunology
- Department of Pediatrics, and
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21
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Abstract
Vaginal rings for pre-exposure prophylaxis are a female-initiated HIV prevention method that does not require daily or coitally-dependent dosing. As part of a randomized placebo-controlled trial of a tenofovir disoproxil fumarate intravaginal ring, we assessed product acceptability through in-depth interviews with 18 women during and after 14 days of continuous use. Women reported that the ring was comfortable with few side effects, regardless of experimental arm. However, interest in future use by this cohort was modest for several reasons including: low self-perceived HIV risk; concern that use implied promiscuity; potential for interference with relationship formation and trust; concern for interference with menstruation and cleanliness; and worries about partners' acceptability and sexual pleasure. Potential issues were raised with duration of use prior to ring exchange. Future studies should continue to identify and address individual and relationship factors that influence acceptability, early in the product development process.
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Affiliation(s)
- Dana Watnick
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.
- Montefiore Medical Center, Bronx, NY, USA.
| | - Marla J Keller
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Montefiore Medical Center, Bronx, NY, USA
| | - Kimberly Stein
- Cummings School of Veterinary Medicine, Tufts University, Medford, MA, USA
| | - Laurie J Bauman
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
- Montefiore Medical Center, Bronx, NY, USA
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22
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Mesquita PMM, Preston-Hurlburt P, Keller MJ, Vudattu N, Espinoza L, Altrich M, Anastos K, Herold KC, Herold BC. Role of Interleukin 32 in Human Immunodeficiency Virus Reactivation and Its Link to Human Immunodeficiency Virus-Herpes Simplex Virus Coinfection. J Infect Dis 2017; 215:614-622. [PMID: 28007920 DOI: 10.1093/infdis/jiw612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/08/2016] [Indexed: 01/12/2023] Open
Abstract
Background Herpes simplex virus type 2 (HSV-2; herpes) exacerbates human immunodeficiency virus type 1 (HIV) by unclear mechanisms. These studies tested the impact of HSV-2 on systemic T-cells and HIV reservoirs. Methods Peripheral blood mononuclear cells from HIV-infected women on antiretroviral therapy who were HSV-2 seropositive or seronegative and HIV-uninfected controls were analyzed by flow cytometry. Cell-associated HIV DNA and RNA were quantified in the absence or presence of activating stimuli, recombinant interleukin 32γ (IL-32γ), and a RUNX1 inhibitor. RNA was assessed by nanostring. Results CD4, but not CD8, T-cell phenotypes differed in HIV+/HSV-2+ versus HIV+/HSV-2- (overall P = .002) with increased frequency of CCR5+, CXCR4+, PD-1+, and CD69+ and decreased frequency of CCR10+ and CCR6+ T-cells. The changes were associated with higher HIV DNA. Paradoxically, IL-32, a proinflammatory cytokine, was lower in subpopulations of CD4+ T-cells in HSV-2+ versus HSV-2- women. Recombinant IL-32γ blocked HIV reactivation in CD4+ T-cells and was associated with an increase in RUNX1 expression; the blockade was overcome by a RUNX1 inhibitor. Conclusions Herpes is associated with phenotypic changes in CD4+ T-cells, including a decrease in IL-32, which may contribute to increased HIV reservoirs. Blocking IL-32 may facilitate HIV reactivation to improve shock and kill strategies.
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Affiliation(s)
- Pedro M M Mesquita
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Marla J Keller
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Nalini Vudattu
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, USA
| | - Lilia Espinoza
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Kathryn Anastos
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Kevan C Herold
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT, USA.,Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Betsy C Herold
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
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23
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Robbins HA, Massad LS, Pierce CB, Flowers L, Darragh TM, Minkoff H, Rahangdale L, Keller MJ, Milam J, Fischl M, Shrestha S, Colie C, Strickler H, D’Souza G. Abstract 2580: Optimizing cervical cancer screening for HIV-infected women: A risk-based approach. Cancer Res 2016. [DOI: 10.1158/1538-7445.am2016-2580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Women living with HIV (WLHIV) have increased cervical cancer risk. Guidelines suggest screening WLHIV with negative cervical cytology annually, and managing WLHIV with ASC-US cytology by general population (GP) guidelines (1 year return if HPV testing unavailable).
Methods: We used risk benchmarking to compare cervical precancer risk in WLHIV to the GP. For WLHIV ages 21-65 years in the Women's Interagency HIV Study (WIHS), we evaluated the first cytology result from 2000 or later. We used parametric survival models to calculate HSIL risks after negative or ASC-US cytology, overall and by CD4 cell count. Separately, we synthesized HSIL risk estimates among GP women in 13 published studies using mixed-effects models. We then benchmarked risks in WLHIV to the 3-year GP risks, which for negative cytology represent the threshold for re-screening.
Results: Among 2,653 WLHIV, 1,982 (75%) had negative cytology and 377 (14%) had ASC-US cytology. Most WLHIV with negative (72%) and ASC-US (52%) cytology had CD4≥350 cells/μL. We observed 95 cases of HSIL (CIN2+; 44 were CIN3+ including 1 cancer) within 5 years of cytology. After negative cytology, 3-year GP risk “benchmarks” were 0.83% (CIN2+) and 0.60% (CIN3+). WLHIV with CD4≥350 met both benchmarks by 2 years (1.1% and 0.68% respectively), while WLHIV with CD4<350 exceeded the CIN2+ benchmark at only 1 year (1.1%). After ASC-US cytology, 3-year GP benchmarks were 8.7% (CIN2+) and 4.4% (CIN3+). For WLHIV with CD4≥350, 3-year risks were similar to the benchmarks (9.4% and 4.0%), but WLHIV with CD4<350 approximated these risks at only 1 year (8.8% and 3.9%).
Conclusions: For WLHIV with CD4≥350, these data suggest that the interval for re-screening after negative cervical cytology can be lengthened from 1 to 2 years, and that inclusion in GP guidelines for managing ASC-US cytology is appropriate. In contrast, WLHIV with CD4<350 remain at increased risk and should be screened annually after negative cervical cytology and referred to colposcopy after ASC-US. Cervical precancer risk after normal or ASC-US cytology in WLHIV compared to the general populationHSIL (CIN2+) risk,%HSIL (CIN2+) risk,%HSIL (CIN2+) risk,%HSIL (CIN3+) risk,%HSIL (CIN3+) risk,%HSIL (CIN3+) risk,%1 year2 years3 years1 year2 years3 yearsNEGATIVE CYTOLOGY:General population benchmark0.830.60HIV+, overall (N = 1,982)0.621.32.00.330.681.0HIV+, CD4≥350 (N = 1,393)0.471.11.70.380.680.96HIV+, CD4<350 (N = 542)1.12.02.80.240.651.1ASC-US CYTOLOGY:General population benchmark8.74.4HIV+, overall (N = 377)7.310.112.23.24.35.2HIV+, CD4≥350 (N = 191)5.57.89.42.53.34.0HIV+, CD4<350 (N = 175)8.812.815.93.95.56.8
Citation Format: Hilary A. Robbins, L. Stewart Massad, Christopher B. Pierce, Lisa Flowers, Teresa M. Darragh, Howard Minkoff, Lisa Rahangdale, Marla J. Keller, Joel Milam, Margaret Fischl, Sadeep Shrestha, Christine Colie, Howard Strickler, Gypsyamber D’Souza. Optimizing cervical cancer screening for HIV-infected women: A risk-based approach. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2580.
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Affiliation(s)
| | | | | | - Lisa Flowers
- 3Grady Memorial Hospital and Emory University School of Medicine, Atlanta, GA
| | | | | | - Lisa Rahangdale
- 6University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Joel Milam
- 8University of Southern California, Los Angeles, CA
| | | | - Sadeep Shrestha
- 10University of Alabama at Birmingham School of Public Health, Birmingham, AL
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Keller MJ, McGinn AP, Lo Y, Huber A, Espinoza L, Minkoff H, Colie C, Nowicki MJ, D'Souza G, Anastos K. Longitudinal Assessment of Systemic and Genital Tract Inflammatory Markers and Endogenous Genital Tract E. coli Inhibitory Activity in HIV-Infected and Uninfected Women. Am J Reprod Immunol 2016; 75:631-42. [PMID: 27145926 DOI: 10.1111/aji.12518] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 04/07/2016] [Indexed: 11/30/2022] Open
Abstract
PROBLEM Stability over time of systemic and mucosal immunity and their associations with bacterial vaginosis (BV) and HIV-specific parameters were assessed. METHOD OF STUDY Immune mediators and HIV viral load in plasma and cervicovaginal lavage (CVL), E. coli inhibition, and Nugent score were measured at three semiannual visits among 94 participants in the Women's Interagency HIV Study. Mixed models identified the factors associated with immune mediators. RESULTS There was higher E. coli inhibition and lower inflammation over time in the genital tract and systemically. BV was consistently associated with higher CVL inflammatory mediators and lower CVL E. coli inhibition. HIV-infected women with higher CD4 counts had lower systemic and genital inflammatory mediators, and genital HIV shedding was associated with higher CVL inflammatory mediators. Use of antiretroviral therapy (ART) was associated with lower plasma and CVL mediators, but higher E. coli inhibition. CONCLUSION HIV and BV are linked to inflammation, and ART may be associated with improved vaginal health.
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Affiliation(s)
| | | | - Yungtai Lo
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ashley Huber
- Albert Einstein College of Medicine, Bronx, NY, USA
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Nakra NA, Madan RP, Buckley N, Huber AM, Freiermuth JL, Espinoza L, Walsh J, Parikh UM, Penrose KJ, Keller MJ, Herold BC. Loss of Innate Host Defense Following Unprotected Vaginal Sex. J Infect Dis 2015; 213:840-7. [PMID: 26464206 DOI: 10.1093/infdis/jiv488] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 10/06/2015] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Multiple host defense mechanisms protect the female genital tract from pathogens, but the impact of sexual intercourse on defense is unknown. METHODS As part of a hypothesis-generating study, 17 women provided cervicovaginal lavage (CVL) specimens at baseline (all had abstained from sexual intercourse, masturbation, and vaginal product use for 72 hours prior to screening), 2-6 hours and 10-14 hours after vaginal intercourse with a male condom, and 2-6 hours and 10-14 hours after vaginal intercourse without a male condom (5 visits total, including the baseline visit). Vaginal pH, concentrations of immune molecules, and antimicrobial activity at postcoital visits were compared to baseline values. RESULTS Vaginal pH and the transforming growth factor β1 level increased, but human beta-defensin 2 (HBD-2), HBD-3, and interleukin 8 levels decreased after unprotected sex. Median Escherichia coli inhibitory activity in CVL specimens decreased significantly from baseline at the visit 2-6 hours after unprotected sex (63% [range, -34% to 99%] vs 5% [range, -51% to 100%]; P = .02) and remained low at the visit 10-14 hours after unprotected sex (6% [range, -19% to 92%]; P = .02). Pooled human seminal plasma enhanced E. coli growth in vitro in a dose-dependent manner and, when added to CVL samples with high anti-E. coli activity, reversed the inhibition. CONCLUSIONS Unprotected vaginal sex results in a reduction in endogenous anti-E. coli activity, which may reflect, in part, enhancement of bacterial growth by seminal plasma. This finding may contribute to the risk of E. coli vaginal colonization following sexual intercourse.
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Affiliation(s)
| | | | | | | | | | - Lilia Espinoza
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Jennifer Walsh
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Urvi M Parikh
- Department of Medicine, University of Pittsburgh, Pennsylvania
| | - Kerri J Penrose
- Department of Medicine, University of Pittsburgh, Pennsylvania
| | - Marla J Keller
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
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Keller MJ. Screening for Human Papillomavirus-Associated Cervical Disease in HIV-Infected Women. Top Antivir Med 2015; 23:142-145. [PMID: 26713504 PMCID: PMC6148917] [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] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
HIV-infected women have higher rates of persistence of human papillomavirus (HPV) infection, of abnormal cervical cytology results, and of cervical cancer than uninfected women. It is currently recommended that HIV-infected, sexually active women have a Papanicolaou (Pap) test performed at the time of initial diagnosis of HIV infection, followed by annual Pap testing if the previous test result is normal. Women whose test results show abnormalities greater than atypical squamous cells of undetermined significance (ASCUS) should be referred for colposcopy. Those with ASCUS should undergo immediate colposcopy or repeat cervical cytology in 6 months to 12 months, and those whose repeat cervical cytology results show ASCUS or greater abnormalities should undergo colposcopy. Recent findings indicate that screening intervals can be lengthened for HIV-infected women whose Pap test results are persistently normal and who are engaged in routine care, and that HPV DNA testing may have a role in screening. This article summarizes a presentation by Marla J. Keller, MD, at the IAS-USA continuing education program, Improving the Management of HIV Disease, held in Atlanta, Georgia, in March 2015.
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Affiliation(s)
- Marla J Keller
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
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27
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Keller MJ, Burk RD, Massad LS, Eltoum IE, Hessol NA, Castle PE, Anastos K, Xie X, Minkoff H, Xue X, D'Souza G, Flowers L, Levine AM, Colie C, Rahangdale L, Fischl MA, Palefsky JM, Strickler HD. Cervical Precancer Risk in HIV-Infected Women Who Test Positive for Oncogenic Human Papillomavirus Despite a Normal Pap Test. Clin Infect Dis 2015; 61:1573-81. [PMID: 26187020 DOI: 10.1093/cid/civ569] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 06/24/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Determining cervical precancer risk among human immunodeficiency virus (HIV)-infected women who despite a normal Pap test are positive for oncogenic human papillomavirus (oncHPV) types is important for setting screening practices. METHODS A total of 2791 HIV-infected and 975 HIV-uninfected women in the Women's Interagency HIV Study were followed semiannually with Pap tests and colposcopy. Cumulative risks of cervical intraepithelial neoplasia grade 2 or greater (CIN-2+; threshold used for CIN treatment) and grade 3 or greater (CIN-3+; threshold to set screening practices) were measured in HIV-infected and HIV-uninfected women with normal Pap tests, stratified by baseline HPV results, and also in HIV-infected women with a low-grade squamous intraepithelial lesion (LSIL; benchmark indication for colposcopy). RESULTS At baseline, 1021 HIV-infected and 518 HIV-uninfected women had normal Pap tests, of whom 154 (15%) and 27 (5%), respectively, tested oncHPV positive. The 5-year CIN-2+ cumulative risk in the HIV-infected oncHPV-positive women was 22% (95% confidence interval [CI], 9%-34%), 12% (95% CI, 0%-22%), and 14% (95% CI, 2%-25%) among those with CD4 counts <350, 350-499, and ≥500 cells/µL, respectively, whereas it was 10% (95% CI, 0%-21%) in those without HIV. For CIN-3+, the cumulative risk averaged 4% (95% CI, 1%-8%) in HIV-infected oncHPV-positive women, and 10% (95% CI, 0%-23%) among those positive for HPV type 16. In HIV-infected women with LSIL, CIN-3+ risk was 7% (95% CI, 3%-11%). In multivariate analysis, HIV-infected HPV16-positive women had 13-fold (P = .001) greater CIN-3+ risk than oncHPV-negative women (referent), and HIV-infected women with LSIL had 9-fold (P < .0001) greater risk. CONCLUSIONS HIV-infected women with a normal Pap result who test HPV16 positive have high precancer risk (similar to those with LSIL), possibly warranting immediate colposcopy. Repeat screening in 1 year may be appropriate if non-16 oncHPV is detected.
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Affiliation(s)
| | - Robert D Burk
- Albert Einstein College of Medicine, Bronx, New York
| | | | | | | | | | | | - Xianhong Xie
- Albert Einstein College of Medicine, Bronx, New York
| | | | - Xiaonan Xue
- Albert Einstein College of Medicine, Bronx, New York
| | | | - Lisa Flowers
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Lisa Rahangdale
- University of North Carolina School of Medicine, Chapel Hill
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Baxi SM, Greenblatt RM, Bacchetti P, Jin C, French AL, Keller MJ, Augenbraun MH, Gange SJ, Liu C, Mack WJ, Gandhi M. Nevirapine Concentration in Hair Samples Is a Strong Predictor of Virologic Suppression in a Prospective Cohort of HIV-Infected Patients. PLoS One 2015; 10:e0129100. [PMID: 26053176 PMCID: PMC4460031 DOI: 10.1371/journal.pone.0129100] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [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: 02/03/2015] [Accepted: 05/05/2015] [Indexed: 01/03/2023] Open
Abstract
Effective antiretroviral (ARV) therapy depends on adequate drug exposure, yet methods to assess ARV exposure are limited. Concentrations of ARV in hair are the product of steady-state pharmacokinetics factors and longitudinal adherence. We investigated nevirapine (NVP) concentrations in hair as a predictor of treatment response in women receiving ARVs. In participants of the Women’s Interagency HIV Study, who reported NVP use for >1 month from 2003–2008, NVP concentrations in hair were measured via liquid-chromatography-tandem mass-spectrometry. The outcome was virologic suppression (plasma HIV RNA below assay threshold) at the time of hair sampling and the primary predictor was nevirapine concentration categorized into quartiles. We controlled for age, race/ethnicity, pre-treatment HIV RNA, CD4 cell count, and self-reported adherence over the 6-month visit interval (categorized ≤ 74%, 75%–94% or ≥ 95%). We also assessed the relation of NVP concentration with changes in hepatic transaminase levels via multivariate random intercept logistic regression and linear regression analyses. 271 women contributed 1089 person-visits to the analysis (median 3 of semi-annual visits). Viral suppression was least frequent in concentration quartile 1 (86/178 (48.3%)) and increased in higher quartiles (to 158/204 (77.5%) for quartile 4). The odds of viral suppression in the highest concentration quartile were 9.17 times (95% CI 3.2–26, P < 0.0001) those in the lowest. African-American race was associated with lower rates of virologic suppression independent of NVP hair concentration. NVP concentration was not significantly associated with patterns of serum transaminases. Concentration of NVP in hair was a strong independent predictor of virologic suppression in women taking NVP, stronger than self-reported adherence, but did not appear to be strongly predictive of hepatotoxicity.
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Affiliation(s)
- Sanjiv M. Baxi
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- School of Public Health, Division of Epidemiology, University of California, Berkeley, California, United States of America
- * E-mail:
| | - Ruth M. Greenblatt
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Peter Bacchetti
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Chengshi Jin
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Audrey L. French
- CORE Center and Division of Infectious Diseases, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois, United States of America
| | - Marla J. Keller
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
- Department of Obstetrics and Gynecology and Women’s Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Michael H. Augenbraun
- Division of Infectious Diseases, State University of New York, Downstate Medical Center, Brooklyn, New York, United States of America
| | - Stephen J. Gange
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Chenglong Liu
- Department of Medicine, Georgetown University Medical Center, Washington DC, United States of America
| | - Wendy J. Mack
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Monica Gandhi
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
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Dominguez-Villar M, Gautron AS, de Marcken M, Keller MJ, Hafler DA. TLR7 induces anergy in human CD4(+) T cells. Nat Immunol 2014; 16:118-28. [PMID: 25401424 DOI: 10.1038/ni.3036] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 10/20/2014] [Indexed: 02/06/2023]
Abstract
The recognition of microbial patterns by Toll-like receptors (TLRs) is critical for activation of the innate immune system. Although TLRs are expressed by human CD4(+) T cells, their function is not well understood. Here we found that engagement of TLR7 in CD4(+) T cells induced intracellular calcium flux with activation of an anergic gene-expression program dependent on the transcription factor NFATc2, as well as unresponsiveness of T cells. As chronic infection with RNA viruses such as human immunodeficiency virus type 1 (HIV-1) induces profound dysfunction of CD4(+) T cells, we investigated the role of TLR7-induced anergy in HIV-1 infection. Silencing of TLR7 markedly decreased the frequency of HIV-1-infected CD4(+) T cells and restored the responsiveness of those HIV-1(+) CD4(+) T cells. Our results elucidate a previously unknown function for microbial pattern-recognition receptors in the downregulation of immune responses.
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Affiliation(s)
- Margarita Dominguez-Villar
- Department of Neurology and Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anne-Sophie Gautron
- Department of Neurology and Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Marine de Marcken
- Department of Neurology and Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Marla J Keller
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - David A Hafler
- Department of Neurology and Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, USA
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Watnick DL, Keller MJ, Espinoza L, Herold BC, Bauman LJ. Acceptability of a Polyurethane Tenofovir Disoproxil Fumarate (TDF) Intravaginal Ring for HIV Prevention. AIDS Res Hum Retroviruses 2014. [DOI: 10.1089/aid.2014.5284.abstract] [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: 11/12/2022] Open
Affiliation(s)
- Dana L. Watnick
- Albert Einstein College of Medicine, Bronx, NY, United States
| | - Marla J. Keller
- Albert Einstein College of Medicine, Bronx, NY, United States
| | - Lilia Espinoza
- Albert Einstein College of Medicine, Bronx, NY, United States
| | - Betsy C. Herold
- Albert Einstein College of Medicine, Bronx, NY, United States
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31
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Watnick DL, Keller MJ, Espinoza L, Herold BC, Bauman LJ. Using Mixed-methods to Understanding Trial Adherence to a Polyurethane Tenofovir Disoproxil Fumarate Intravaginal Ring in Low-risk US Women. AIDS Res Hum Retroviruses 2014. [DOI: 10.1089/aid.2014.5364.abstract] [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: 11/13/2022] Open
Affiliation(s)
- Dana L. Watnick
- Albert Einstein College of Medicine, Bronx, NY, United States
| | - Marla J. Keller
- Albert Einstein College of Medicine, Bronx, NY, United States
| | - Lilia Espinoza
- Albert Einstein College of Medicine, Bronx, NY, United States
| | - Betsy C. Herold
- Albert Einstein College of Medicine, Bronx, NY, United States
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Preza GC, Keller MJ, Ochoa MT, Herold B. HIV-1 +/HSV-2 + Co-infection Is Associated with Persistence of CD14 + and DC-SIGN +Antigen Presenting Cells at the Mucosa Independent of HSV Recurrences. AIDS Res Hum Retroviruses 2014. [DOI: 10.1089/aid.2014.5636.abstract] [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: 11/12/2022] Open
Affiliation(s)
- Gloria C. Preza
- University of Southern California, School of Medicine, Los Angeles, CA, United States
| | - Marla J. Keller
- Albert Einstein College of Medicine, Pediatric Infectious Diseases, Bronx, NY, United States
| | - Maria T. Ochoa
- University of Southern California, School of Medicine, Los Angeles, CA, United States
| | - Betsy Herold
- Albert Einstein College of Medicine, Pedriatic Infectious Diseases, Bronx, NY, United States
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Keller MJ, Espinoza L, Marzinke MA, Mesquita PM, Huber AM, Rabe LK, Frank B, McConnell J, Mitchnick M, Hendrix CW, Kiser PF, Herold BC. Phase 1 Safety & Pharmacokinetic Trial of a Polyurethane Tenofovir Disoproxil Fumarate Intravaginal Ring in Healthy, Low-risk U.S. Women. AIDS Res Hum Retroviruses 2014. [DOI: 10.1089/aid.2014.5059.abstract] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Marla J. Keller
- Albert Einstein College of Medicine, Bronx, NY, United States
| | - Lilia Espinoza
- Albert Einstein College of Medicine, Bronx, NY, United States
| | - Mark A. Marzinke
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | | | - Ashley M. Huber
- Albert Einstein College of Medicine, Bronx, NY, United States
| | - Lorna K. Rabe
- Magee-Womens Research Institute, Pittsburgh, PA, United States
| | - Bruce Frank
- Particle Sciences Inc., Bethlehem, PA, United States
| | | | | | - Craig W. Hendrix
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | | | - Betsy C. Herold
- Albert Einstein College of Medicine, Bronx, NY, United States
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Subramaniam K, Plank RM, Lin N, Goldman-Yassen A, Ivan E, Becerril C, Kemal K, Heo M, Keller MJ, Mutimura E, Anastos K, Daily JP. Plasmodium falciparum Infection Does Not Affect Human Immunodeficiency Virus Viral Load in Coinfected Rwandan Adults. Open Forum Infect Dis 2014; 1:ofu066. [PMID: 25734136 PMCID: PMC4281786 DOI: 10.1093/ofid/ofu066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 07/01/2014] [Indexed: 12/03/2022] Open
Abstract
In contrast to prior studies, mild malaria infection had no impact on HIV Viral Loads(VL) in Rwanda. Over fifty percent of patients prescribed ARV had detectable VL; 25% had genotypic resistance. Eleven percent of patients with mild malaria were newly diagnosed with HIV. Background Plasmodium falciparum infection has been reported to increase human immunodeficiency virus (HIV) viral load (VL), which can facilitate HIV transmission. We prospectively studied the impact of mild P falciparum coinfection on HIV VL in Rwanda. Methods We measured plasma HIV VL at presentation with malaria infection and weekly for 4 weeks after artemether-lumefantrine treatment in Rwandan adults infected with HIV with P falciparum malaria. Regression analyses were used to examine associations between malaria infection and HIV VL changes. Samples with detectable virus underwent genotypic drug-resistance testing. Results We enrolled 28 HIV-malaria coinfected patients and observed 27 of them for 5 weeks. Three patients (11%) were newly diagnosed with HIV. Acute P falciparum infection had no significant effect on HIV VL slope over 28 days of follow-up. Ten patients with VL <40 copies/mL at enrollment maintained viral suppression throughout. Seventeen patients had a detectable VL at enrollment including 9 (53%) who reported 100% adherence to ARVs; 3 of these had detectable genotypic drug resistance. Conclusions Unlike studies from highly malaria-endemic areas, we did not identify an effect of P falciparum infection on HIV VL; therefore, malaria is not likely to increase HIV-transmission risk in our setting. However, routine HIV testing should be offered to adults presenting with acute malaria in Rwanda. Most importantly, we identified a large percentage of patients with detectable HIV VL despite antiretroviral (ARV) therapy. Some of these patients had HIV genotypic drug resistance. Larger studies are needed to define the prevalence and factors associated with detectable HIV VL in patients prescribed ARVs in Rwanda.
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Affiliation(s)
| | - Rebeca M Plank
- Division of Infectious Diseases , Brigham and Women's Hospital, Harvard Medical School , Boston, Massachusetts
| | - Nina Lin
- Department of Medicine, Division of Infectious Disease , Massachusetts General Hospital, Harvard Medical School , Boston
| | | | - Emil Ivan
- Women's Equity in Access to Care and Treatment (WE-ACTx) and Kigali Health Institute , Rwanda
| | - Carlos Becerril
- Department of Medicine, Division of Infectious Disease , Massachusetts General Hospital, Harvard Medical School , Boston
| | | | - Moonseong Heo
- Epidemiology and Population Health , Albert Einstein College of Medicine , Bronx, New York
| | | | - Eugene Mutimura
- Women's Equity in Access to Care and Treatment (WE-ACTx) and Kigali Health Institute , Rwanda
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Sun M, Peipert JF, Zhao Q, Wilson TE, Weber KM, Sanchez-Keeland L, DʼSouza G, Young M, Watts DH, Keller MJ, Cohan D, Massad LS. Trends in contraceptive use among women with human immunodeficiency virus. Obstet Gynecol 2013; 120:783-90. [PMID: 22996095 DOI: 10.1097/aog.0b013e318269c8bb] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate trends in contraceptive use, especially long-acting reversible contraceptives (LARCs) and condoms, among human immunodeficiency virus (HIV)-seropositive and HIV-seronegative women. METHODS Human immunodeficiency virus-seropositive and HIV-seronegative women in a multicenter longitudinal cohort were interviewed semiannually between 1998 and 2010 about sexual behaviors and contraceptive use. Trends in contraceptive use by women aged 18-45 years who were at risk for unintended pregnancy but not trying to conceive were analyzed using generalized estimating equations. RESULTS Condoms were the dominant form of contraception for HIV-seropositive women and showed little change across time. Less than 15% of these women used no contraception. Between 1998 and 2010, LARC use increased among HIV-seronegative women from 4.8% (6 of 126) to 13.5% (19 of 141, P=.02), but not significantly among seropositive women (0.9% [4 of 438] to 2.8% [6 of 213], P=.09). Use of highly effective contraceptives, including pills, patches, rings, injectable progestin, implants, and intrauterine devices, ranged from 15.2% (53 of 348) in 1998 to 17.4% (37 of 213) in 2010 (P=.55). Human immunodeficiency virus-seronegative but not HIV-seropositive LARC users were less likely than nonusers to use condoms consistently (hazard ratio 0.51, 95% confidence interval [CI] 0.32-0.81, P=.004 for seronegative women; hazard ratio 1.09, 95% CI 0.96-1.23 for seropositive women). CONCLUSION Although most HIV-seropositive women use contraception, they rely primarily on condoms and have not experienced the increase in LARC use seen among seronegative women. Strategies to improve simultaneous use of condoms and LARC are needed to minimize risk of unintended pregnancy as well as HIV transmission and acquisition of sexually transmitted infections. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Mengyang Sun
- Division of Gynecology, Washington University in St. Louis School of Medicine, St. Louis, Missouri 63110, USA
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Kalyoussef S, Nieves E, Dinerman E, Carpenter C, Shankar V, Oh J, Burd B, Angeletti RH, Buckheit KW, Fredricks DN, Madan RP, Keller MJ, Herold BC. Lactobacillus proteins are associated with the bactericidal activity against E. coli of female genital tract secretions. PLoS One 2012. [PMID: 23185346 PMCID: PMC3501525 DOI: 10.1371/journal.pone.0049506] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [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] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Female genital tract secretions are bactericidal for Escherichia (E.) coli ex vivo. However, the intersubject variability and molecules that contribute to this activity have not been defined. METHODS The bactericidal activity and concentration of immune mediators in cervicovaginal lavage (CVL) collected from 99 healthy women were determined. RESULTS CVL reduced the number of E. coli colonies by 68% [-26, 100] (median [range]). CVL were active against laboratory and clinical isolates of E. coli, but were inactive against Lactobacillus species. Bactericidal activity correlated with the concentration of protein recovered (p<0.001), but not with cytokines, chemokines or antimicrobial peptides. Four CVL with>90% inhibitory activity (active) and two with<30% activity were subjected to MS/MS proteomic analysis. 215 proteins were identified and six were found exclusively in active samples. Four of these corresponded to Lactobacillus crispatus or jensenii proteins. Moreover, culture supernatants from Lactobacillus jensenii were bactericidal for E. coli. CONCLUSION Both host and commensal microbiota proteins contribute to mucosal defense. Identification of these proteins will facilitate the development of strategies to maintain a healthy vaginal microbiome and prevent colonization with pathogenic bacteria such as E. coli that increase the risk for urinary tract infections, preterm labor and perinatal infection.
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Affiliation(s)
- Sabah Kalyoussef
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Edward Nieves
- Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, Bronx, New York, United States of America
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Ellen Dinerman
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Colleen Carpenter
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Viswanathan Shankar
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Jamie Oh
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Berta Burd
- Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Ruth H. Angeletti
- Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, Bronx, New York, United States of America
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | | | - David N. Fredricks
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Rebecca P. Madan
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Marla J. Keller
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Betsy C. Herold
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
- Department of Microbiology-Immunology, Albert Einstein College of Medicine, Bronx, New York, United States of America
- * E-mail:
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Keller MJ, Carpenter CA, Lo Y, Einstein MH, Liu C, Fredricks DN, Herold BC. Phase I randomized safety study of twice daily dosing of acidform vaginal gel: candidate antimicrobial contraceptive. PLoS One 2012; 7:e46901. [PMID: 23056520 PMCID: PMC3466198 DOI: 10.1371/journal.pone.0046901] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [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: 06/16/2012] [Accepted: 09/05/2012] [Indexed: 11/19/2022] Open
Abstract
Background Acidform gel, an acid-buffering product that inactivates spermatozoa, may be an effective topical non-hormonal contraceptive. This study was designed to evaluate the safety of vaginal dosing and effects of Acidform on mucosal immune mediators, antimicrobial properties of genital secretions, and vaginal microbiota. Methods Thirty-six sexually abstinent U.S. women were randomized to apply Acidform or hydroxyethylcellulose (HEC) placebo gel twice daily for 14 consecutive days. Safety was assessed by symptoms and pelvic examination. The impact of gel on mucosal immunity was assessed by quantifying cytokines, chemokines, antimicrobial proteins and antimicrobial activity of genital secretions collected by cervicovaginal lavage (CVL) at screening, 2 hours after gel application, and on days 7, 14 and 21. Vaginal microbiota was characterized at enrollment and day 14 using species-specific quantitative PCR assays. Results The median vaginal and cervical pH was significantly lower 2 hours after application of Acidform and was associated with an increase in the bactericidal activity of CVL against E. coli. However, 65% of women who received Acidform had at least one local adverse event compared with 11% who received placebo (p = 0.002). While there was no increase in inflammatory cytokines or chemokines, CVL concentrations of lactoferrin and interleukin-1 receptor antagonist (IL-1ra), an anti-inflammatory protein, were significantly lower following Acidform compared to HEC placebo gel application. There were no significant changes in Lactobacillus crispatus or Lactobacillus jensenii in either group but there was a decrease in Gardnerella vaginalis in the Acidform group (p = 0.08). Conclusions Acidform gel may augment mucosal defense as evidenced by an increase in bactericidal activity of genital secretions against E. coli and a decrease in Gardnerella vaginalis colonization. However, Acidform was associated with more irritation than placebo and lower levels of antimicrobial (lactoferrin) and anti-inflammatory (IL-1ra) proteins. These findings indicate the need for additional safety studies of this candidate non-hormonal contraceptive. Trial Registration ClinicalTrials.gov NCT00850837
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Affiliation(s)
- Marla J Keller
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States of America.
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Keller MJ, Burk RD, Xie X, Anastos K, Massad LS, Minkoff H, Xue X, D'Souza G, Watts DH, Levine AM, Castle PE, Colie C, Palefsky JM, Strickler HD. Risk of cervical precancer and cancer among HIV-infected women with normal cervical cytology and no evidence of oncogenic HPV infection. JAMA 2012; 308:362-9. [PMID: 22820789 PMCID: PMC3556987 DOI: 10.1001/jama.2012.5664] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
CONTEXT US cervical cancer screening guidelines for human immunodeficiency virus (HIV)-uninfected women 30 years or older have recently been revised, increasing the suggested interval between Papanicolaou (Pap) tests from 3 years to 5 years among those with normal cervical cytology (Pap test) results who test negative for oncogenic human papillomavirus (HPV). Whether a 3-year or 5-year screening interval could be used in HIV-infected women who are cytologically normal and oncogenic HPV-negative is unknown. OBJECTIVE To determine the risk of cervical precancer or cancer defined cytologically (high-grade squamous intraepithelial lesions or greater [HSIL+]) or histologically (cervical intraepithelial neoplasia 2 or greater [CIN-2+]), as 2 separate end points, in HIV-infected women and HIV-uninfected women who at baseline had a normal Pap test result and were negative for oncogenic HPV. DESIGN, SETTING, AND PARTICIPANTS Participants included 420 HIV-infected women and 279 HIV-uninfected women with normal cervical cytology at their enrollment in a multi-institutional US cohort of the Women's Interagency HIV Study, between October 1, 2001, and September 30, 2002, with follow-up through April 30, 2011. Semiannual visits at 6 clinical sites included Pap testing and, if indicated, cervical biopsy. Cervicovaginal lavage specimens from enrollment were tested for HPV DNA using polymerase chain reaction. The primary analysis was truncated at 5 years of follow-up. MAIN OUTCOME MEASURE Five-year cumulative incidence of cervical precancer and cancer. RESULTS No oncogenic HPV was detected in 369 (88% [95% CI, 84%-91%]) HIV-infected women and 255 (91% [95% CI, 88%-94%]) HIV-uninfected women with normal cervical cytology at enrollment. Among these oncogenic HPV-negative women, 2 cases of HSIL+ were observed; an HIV-uninfected woman and an HIV-infected woman with a CD4 cell count of 500 cells/μL or greater. Histologic data were obtained from 4 of the 6 clinical sites. There were 6 cases of CIN-2+ in 145 HIV-uninfected women (cumulative incidence, 5% [95% CI, 1%-8%]) and 9 cases in 219 HIV-infected women (cumulative incidence, 5% [95% CI, 2%-8%]). This included 1 case of CIN-2+ in 44 oncogenic HPV-negative HIV-infected women with CD4 cell count less than 350 cells/μL (cumulative incidence, 2% [95% CI, 0%-7%]), 1 case in 47 women with CD4 cell count of 350 to 499 cells/μL (cumulative incidence, 2% [95% CI, 0%-7%]), and 7 cases in 128 women with CD4 cell count of 500 cells/μL or greater (cumulative incidence, 6% [95% CI, 2%-10%]). One HIV-infected and 1 HIV-uninfected woman had CIN-3, but none had cancer. CONCLUSION The 5-year cumulative incidence of HSIL+ and CIN-2+ was similar in HIV-infected women and HIV-uninfected women who were cytologically normal and oncogenic HPV-negative at enrollment.
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Affiliation(s)
- Marla J Keller
- Department of Medicine, Albert Einstein College of Medicine, 1300 Morris Park Ave, Mazer Bldg, Room 512, Bronx, NY 10461, USA.
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Madan RP, Carpenter C, Fiedler T, Kalyoussef S, McAndrew TC, Viswanathan S, Kim M, Keller MJ, Fredricks DN, Herold BC. Altered biomarkers of mucosal immunity and reduced vaginal Lactobacillus concentrations in sexually active female adolescents. PLoS One 2012; 7:e40415. [PMID: 22808157 PMCID: PMC3393710 DOI: 10.1371/journal.pone.0040415] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [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: 03/13/2012] [Accepted: 06/07/2012] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Genital secretions collected from adult women exhibit in vitro activity against herpes simplex virus (HSV) and Escherichia coli (E. coli), but prior studies have not investigated this endogenous antimicrobial activity or its mediators in adolescent females. METHODOLOGY/PRINCIPAL FINDINGS Anti-HSV and anti-E.coli activity were quantified from cervicovaginal lavage (CVL) specimens collected from 20 sexually active adolescent females (15-18 years). Soluble immune mediators that may influence this activity were measured in CVL, and concentrations of Lactobacillus jensenii and crispatus were quantified by PCR from vaginal swabs. Results for adolescents were compared to those obtained from 54 healthy, premenopausal adult women. Relative to specimens collected from adults, CVL collected from adolescent subjects had significantly reduced activity against E. coli and diminished concentrations of protein, IgG, and IgA but significantly increased anti-HSV activity and concentrations of interleukin (IL)-1α, IL-6 and IL-1 receptor antagonist. Vaginal swabs collected from adolescent subjects had comparable concentrations of L. crispatus but significantly reduced concentrations of L. jensenii, relative to adult swabs. CONCLUSIONS/SIGNIFICANCE Biomarkers of genital mucosal innate immunity may differ substantially between sexually active adolescents and adult women. These findings warrant further study and may have significant implications for prevention of sexually transmitted infections in adolescent females.
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Affiliation(s)
- Rebecca Pellett Madan
- Department of Pediatrics, Albert Einstein College of Medicine, New York, New York, United States of America.
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Keller MJ, Malone AM, Carpenter CA, Lo Y, Huang M, Corey L, Willis R, Nguyen C, Kennedy S, Gunawardana M, Guerrero D, Moss JA, Baum MM, Smith TJ, Herold BC. Safety and pharmacokinetics of aciclovir in women following release from a silicone elastomer vaginal ring. J Antimicrob Chemother 2012; 67:2005-12. [PMID: 22556381 DOI: 10.1093/jac/dks151] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Systemic aciclovir and its prodrug valaciclovir are effective in treating and reducing recurrences of genital herpes simplex virus (HSV) and reducing transmission. Local aciclovir delivery, if it can achieve and maintain comparable intracellular genital tract levels, may be equally effective in the treatment and suppression of genital HSV. Intravaginal ring (IVR) delivery of aciclovir may provide pre-exposure prophylaxis against HSV acquisition. METHODS Tolerability and pharmacokinetics were evaluated in six HIV-negative women with recurrent genital HSV who switched their daily oral valaciclovir suppression to an aciclovir IVR for 7 days (n = 3) or 14 days (n = 3). Blood and cervicovaginal lavage (CVL) were collected after oral and IVR dosing to measure aciclovir concentrations and genital swabs were obtained to quantify HSV shedding by PCR. RESULTS The rings were well tolerated. Median plasma aciclovir concentrations were 110.2 ng/mL (IQR, 85.9-233.5) 12-18 h after oral valaciclovir. Little or no drug was detected in plasma following IVR dosing. Median (IQR) CVL aciclovir levels were 127.3 ng/mL (21-660.8) 2 h after oral valaciclovir, 154.4 ng/mL (60.7-327.5) 12-18 h after oral valaciclovir and 438 ng/mL (178.5-618.5) after 7 days and 393 ng/mL (31.6-1615) after 14 days of aciclovir ring use. Median CVL aciclovir levels 2 h after oral dosing were similar to levels observed 7 (P = 0.99) and 14 (P = 0.75) days after ring use. HSV DNA was not detected in genital swabs and there was no significant change in inflammatory mediators. CONCLUSIONS This first-in-human study demonstrated that an IVR could safely deliver mucosal levels of aciclovir similar to oral valaciclovir without systemic absorption. More intensive site-specific pharmacokinetic studies are needed to determine whether higher local concentrations are needed to achieve optimal drug distribution within the genital tract.
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Affiliation(s)
- M J Keller
- Department of Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA.
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Abstract
Strategies to protect against sexual transmission of HIV include the development of products formulated for topical application, which limit the toxicities associated with systemic oral pre-exposure prophylaxis. Following several clinical trial failures, attention is now focused on antiretroviral (ARV) agents. Highly potent ARV topical formulations provide a female-controlled, targeted, and feasible option for HIV prevention. A recently completed tenofovir gel trial was the first to demonstrate significant protection against HIV acquisition. Topical ARVs have the advantage of delivering high concentration of drug at the site of transmission of HIV, with low systemic absorption. Sustained-release formulations, such as intravaginal rings, will likely improve adherence and can be designed to provide controlled and continuous delivery of ARV combinations. Further studies to test alternative dosing strategies and pharmacokinetic/pharmacodynamic relationships in the genital tract will provide valuable information as the field strives to improve upon the promising tenofovir gel trial results.
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Affiliation(s)
- Natasha A Verma
- Department of Pediatrics, Division of Infectious Diseases, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Forchheimer Building, Room 702, Bronx, NY 10461, USA.
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Keller MJ, Madan RP, Torres NM, Fazzari MJ, Cho S, Kalyoussef S, Shust G, Mesquita PMM, Louissaint N, Chen J, Cohen HW, Diament EC, Lee AC, Soto-Torres L, Hendrix CW, Herold BC. A randomized trial to assess anti-HIV activity in female genital tract secretions and soluble mucosal immunity following application of 1% tenofovir gel. PLoS One 2011; 6:e16475. [PMID: 21283552 PMCID: PMC3026837 DOI: 10.1371/journal.pone.0016475] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [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: 08/16/2010] [Accepted: 12/30/2010] [Indexed: 01/08/2023] Open
Abstract
Background Preclinical and early phase clinical microbicide studies have not consistently predicted the outcome of efficacy trials. To address this gap, candidate biomarkers of microbicide pharmacodynamics and safety were evaluated in a double-blind, placebo-controlled trial of tenofovir gel, the first microbicide to demonstrate significant protection against HIV acquisition. Methods 30 women were randomized to apply a single daily dose of tenofovir or placebo gel for 14 consecutive days. Anti-HIV activity was measured in cervicovaginal lavage (CVL) on Days 0, 3, 7, 14 and 21 by luciferase assay as a surrogate marker of pharmacodynamics. Endogenous activity against E. coli and HSV-2 and concentrations of immune mediators were quantified in CVL as candidate biomarkers of safety. Tenofovir levels were measured in CVL and blood. Results A significant increase in anti-HIV activity was detected in CVL from women who applied tenofovir gel compared to their endogenous anti-HIV activity in genital tract secretions on Day 0 and compared to activity in CVL from women in the placebo group. The activity correlated significantly with CVL concentration of tenofovir (r = 0.6, p<0.001) and fit a sigmoid Emax pharmacodynamic model. Anti-HIV activity in CVL from women who applied tenofovir persisted when virus was introduced in semen, whereas endogenous anti-HIV activity decreased. Tenofovir did not trigger an inflammatory response or induce sustained loss in endogenous antimicrobial activity or immune mediators. Conclusions Tenofovir gel had no deleterious impact on soluble mucosal immunity. The increased anti-HIV activity in CVL, which persisted in the presence of semen and correlated with tenofovir concentration, is consistent with the efficacy observed in a recent clinical trial. These results promote quantified CVL anti-HIV activity as a surrogate of tissue pharmacodynamics and as a potential biomarker of adherence to product. This simple, feasible and inexpensive bioassay may promote the development of models more predictive of microbicide efficacy. Trial Registration ClinicalTrials.gov NCT00594373
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Affiliation(s)
- Marla J Keller
- Department of Medicine, Albert Einstein College of Medicine, New York, New York, United States of America.
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Herold BC, Mesquita PM, Madan RP, Keller MJ. Female genital tract secretions and semen impact the development of microbicides for the prevention of HIV and other sexually transmitted infections. Am J Reprod Immunol 2010; 65:325-33. [PMID: 21143689 DOI: 10.1111/j.1600-0897.2010.00932.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Pharmacologic strategies for the prevention of HIV include vaccines, post-exposure prophylaxis with antiretroviral therapy, and topical microbicides. Vaginal microbicides have the potential to augment innate defenses in the genital tract but may also disrupt endogenous protection and increase HIV acquisition risk, as observed in clinical trials of nonoxynol-9. The initially disappointing results of microbicide clinical trials stimulated the development of more sensitive and comprehensive pre-clinical safety studies, which include dual-chamber culture systems to model the epithelial barrier and post-coital studies to evaluate the effects of semen and sexual intercourse on microbicide efficacy. This review discusses the key factors that contribute to a healthy female genital tract environment, the impact of semen on mucosal defense, and how our understanding of these mediators informs the development of effective vaginal microbicides.
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Affiliation(s)
- Betsy C Herold
- Department of Pediatrics, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10467, USA.
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Shust GF, Cho S, Kim M, Madan RP, Guzman EM, Pollack M, Epstein J, Cohen HW, Keller MJ, Herold BC. ERRATUM: Female Genital Tract Secretions Inhibit Herpes Simplex Infection: Correlation with Soluble Mucosal Immune Mediators and Impact of Hormonal Contraception. Am J Reprod Immunol 2010. [DOI: 10.1111/j.1600-0897.2010.00857.x] [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: 11/28/2022] Open
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Jang JJ, Schwarcz AI, Amaez DA, Woodward M, Olin JW, Keller MJ, Schecter AD. Elevated osteoprotegerin is associated with abnormal ankle brachial indices in patients infected with HIV: a cross-sectional study. J Int AIDS Soc 2010; 13:12. [PMID: 20307322 PMCID: PMC2859852 DOI: 10.1186/1758-2652-13-12] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Accepted: 03/22/2010] [Indexed: 11/26/2022] Open
Abstract
Background Patients infected with HIV have an increased risk for accelerated atherosclerosis. Elevated levels of osteoprotegerin, an inflammatory cytokine receptor, have been associated with a high incidence of cardiovascular disease (including peripheral arterial disease, or PAD), acute coronary syndrome, and cardiovascular mortality. The objective of this study was to determine whether PAD is prevalent in an HIV-infected population, and to identify an association with HIV-specific and traditional cardiovascular risk factors, as well as levels of osteoprotegerin. Methods One hundred and two patients infected with HIV were recruited in a cross-sectional study. To identify the prevalence of PAD, ankle-brachial indices (ABIs) were measured. Four standard ABI categories were utilized: ≤ 0.90 (definite PAD); 0.91-0.99 (borderline); 1.00-1.30 (normal); and >1.30 (high). Medical history and laboratory measurements were obtained to determine possible risk factors associated with PAD in HIV-infected patients. Results The prevalence of PAD (ABI ≤ 0.90) in a young HIV-infected population (mean age: 48 years) was 11%. Traditional cardiovascular risk factors, including advanced age and previous cardiovascular history, as well as elevated C-reactive protein levels, were associated with PAD. Compared with patients with normal ABIs, patients with high ABIs had significantly elevated levels of osteoprotegerin [1428.9 (713.1) pg/ml vs. 3088.6 (3565.9) pg/ml, respectively, p = 0.03]. Conclusions There is a high prevalence of PAD in young HIV-infected patients. A number of traditional cardiovascular risk factors and increased osteoprotegerin concentrations are associated with abnormal ABIs. Thus, early screening and aggressive medical management for PAD may be warranted in HIV-infected patients.
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Affiliation(s)
- James J Jang
- Zena and Michael A Wiener Cardiovascular Institute and Marie-Joseìe and Henry R Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, New York, USA.
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Wilson SS, Cheshenko N, Fakioglu E, Mesquita PMM, Keller MJ, Herold BC. Susceptibility to genital herpes as a biomarker predictive of increased HIV risk: expansion of a murine model of microbicide safety. Antivir Ther 2010; 14:1113-24. [PMID: 20032541 DOI: 10.3851/imp1463] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND A crucial gap in the development of microbicides for HIV prevention is the absence of models predictive of safety. Previous studies have demonstrated an increased susceptibility to genital herpes in mice following repeated applications of nonoxynol-9 (N-9). This study was designed to explore the underlying mechanisms, focusing on the effects that N-9 has on genital tract epithelium and to apply this expanded model to evaluate the safety of microbicides that have been advanced to clinical trials. METHODS Mice were treated intravaginally with formulated 3.5% N-9, 1% tenofovir, 0.5% or 2% PRO 2000, hydroxyethylcellulose (HEC) placebo or no treatment and the effect on herpes simplex virus 2 (HSV-2) susceptibility, epithelial cell architecture, junctional proteins and inflammation were assessed. RESULTS Mice treated with seven daily doses of N-9, but not tenofovir, PRO 2000 or HEC, were significantly more susceptible to challenge with low doses of HSV-2; confocal microscopy demonstrated increased numbers of viral particles deep within the genital tract. N-9 disrupted the epithelium with loss of tight and adherens junctional proteins. By contrast, the epithelium was relatively preserved following tenofovir, PRO 2000 and HEC exposure. Additionally, N-9, but not the other microbicides, triggered a significant inflammatory response relative to untreated mice. CONCLUSIONS These findings indicate that disruption of the epithelium contributes to increased HSV-2 susceptibility and might provide a biomarker predictive of increased risk for HIV acquisition. The results are consistent with the safety outcomes of the recently completed Phase IIb clinical trial with 0.5% PRO 2000 gel, and predict that tenofovir gel will not adversely affect the genital tract.
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Affiliation(s)
- Sarah S Wilson
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
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Keller MJ, Mesquita PMM, Torres NM, Cho S, Shust G, Madan RP, Cohen HW, Petrie J, Ford T, Soto-Torres L, Profy AT, Herold BC. Postcoital bioavailability and antiviral activity of 0.5% PRO 2000 gel: implications for future microbicide clinical trials. PLoS One 2010; 5:e8781. [PMID: 20107502 PMCID: PMC2809740 DOI: 10.1371/journal.pone.0008781] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [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: 09/30/2009] [Accepted: 12/30/2009] [Indexed: 12/20/2022] Open
Abstract
Background The pharmacokinetics and pharmacodynamics of vaginal microbicides are typically assessed among sexually abstinent women. However, the physical act of sex may modulate gel distribution, and preclinical studies demonstrate seminal plasma interferes with the antiviral activity of several microbicides. This study compared the biological activity and concentration of PRO 2000 in cervicovaginal lavage (CVL) collected in the absence or following coitus. Methods CVL samples were collected from ten heterosexual couples at baseline, after sex, after a single dose of 0.5% PRO 2000 gel and sex, and after gel application without sex. The impact of CVL on HIV-1 infection of TZM-bl cells and HSV-2 infection of CaSki cells was monitored by luciferase and plaque assay, respectively. PRO 2000 concentrations were measured by fluorescence. Results CVL collected after PRO 2000 application significantly inhibited HIV-1 and HSV-2 (p = 0.01). However, the antiviral activity was reduced following sex and no significant protective effect was observed in postcoital CVL obtained in the presence compared to the absence of PRO 2000 for HIV (p = 0.45) or HSV-2 (p = 0.56). Less PRO 2000 was recovered in postcoital CVL, which, in conjunction with interference by seminal plasma, may have contributed to lower antiviral activity. Conclusions Postcoital responses to PRO 2000 differ from precoital measures and the results obtained may provide insights into the clinical trial findings in which there was no significant protection against HIV-1 or HSV-2. Postcoital studies should be incorporated into clinical studies before embarking on large-scale efficacy trials.
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Affiliation(s)
- Marla J. Keller
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
- Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Pedro M. M. Mesquita
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - N. Merna Torres
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Sylvia Cho
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Gail Shust
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Rebecca P. Madan
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Hillel W. Cohen
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Julie Petrie
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Tara Ford
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Lydia Soto-Torres
- Division of AIDS, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Albert T. Profy
- Endo Pharmaceuticals, Chadds Ford, Pennsylvania, United States of America
| | - Betsy C. Herold
- Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, New York, United States of America
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, United States of America
- Department of and Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, United States of America
- * E-mail:
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Shust GF, Cho S, Kim M, Madan RP, Guzman EM, Pollack M, Epstein J, Cohen HW, Keller MJ, Herold BC. Female genital tract secretions inhibit herpes simplex virus infection: correlation with soluble mucosal immune mediators and impact of hormonal contraception. Am J Reprod Immunol 2009; 63:110-9. [PMID: 20015330 DOI: 10.1111/j.1600-0897.2009.00768.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PROBLEM Female genital tract secretions inhibit herpes simplex virus (HSV) infection, however, the intra- and inter-subject variability, contribution of specific mediators, and impact of reproductive hormones have not been defined. METHOD of study Cervicovaginal lavage (CVL) (n = 89) obtained from nine cyclers and seven women on hormonal contraception (HC), who completed between three and eight weekly visits, were examined for anti-herpes simplex virus activity and concentrations of mediators. RESULTS The CVL inhibited HSV infection by a mean value of approximately 57% during the follicular or luteal phase, but only by 36% in hormonal contraceptive users. Human neutrophil peptides 1-3 (HNP1-3) (P = 0.03), IL-8 (P = 0.003), lactoferrin (P = 0.005), lysozyme (P = 0.003), IgA (P = 0.002), and IgG (P = 0.02) correlated with antiviral activity. Intra-subject and inter-subject variability was observed, suggesting that factors other than hormones contribute to innate defense. CONCLUSION Endogenous antimicrobial activity may provide a biomarker of healthy mucosal immunity and may be reduced in the setting of HC. However, larger prospective studies are needed.
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Affiliation(s)
- Gail F Shust
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY 10467, USA
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Mesquita PMM, Cheshenko N, Wilson SS, Mhatre M, Guzman E, Fakioglu E, Keller MJ, Herold BC. Disruption of tight junctions by cellulose sulfate facilitates HIV infection: model of microbicide safety. J Infect Dis 2009; 200:599-608. [PMID: 19586414 DOI: 10.1086/600867] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The lack of biomarkers that are predictive of safety is a critical gap in the development of microbicides. The present experiments were designed to evaluate the predictive value of in vitro models of microbicide safety. METHODS Changes in the epithelial barrier were evaluated by measuring transepithelial electrical resistance (TER) after exposure of human epithelial cells to candidate microbicides in a dual-chamber system. The significance of observed changes was addressed by challenging cultures with human immunodeficiency virus (HIV) and measuring the ability of virus to cross the epithelium and infect target T cells cultured in the lower chamber. RESULTS Exposure to nonoxynol-9 (N-9) or cellulose sulfate (CS), but not 9-[2-(phosphonomethoxy)propyl]adenine (also referred to as tenofovir) or PRO2000, resulted in a rapid and sustained reduction in TER and a marked increase in HIV infection of T cells cultured in the lower chamber. Moreover, CS triggered nuclear factor kappaB activation in peripheral blood mononuclear cells and increased HIV replication in chronically infected U1 cells. CONCLUSIONS Epithelial barrier disruption and enhanced viral replication may have contributed to the increased risk of HIV acquisition observed in phase 3 trials of N-9 and CS. Expansion of in vitro safety testing to include these models would provide a more stringent preclinical assessment of microbicide safety and may prove to be more predictive of clinical outcomes.
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Affiliation(s)
- Pedro M M Mesquita
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York 10461, USA
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Jones S, Restrepo D, Kasowitz A, Korenstein D, Wallenstein S, Schneider A, Keller MJ. Risk factors for decreased bone density and effects of HIV on bone in the elderly. Osteoporos Int 2008; 19:913-8. [PMID: 18071649 DOI: 10.1007/s00198-007-0524-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Accepted: 10/19/2007] [Indexed: 10/22/2022]
Abstract
UNLABELLED Most studies of bone density in HIV-infected individuals focus on young men. This study compares differences in bone density in elderly HIV positive men and women to HIV negative controls. Bone density was lower in the lumbar spine and hip in the HIV-infected group. Antiretrovirals may be associated with decreased bone mineralization. INTRODUCTION Individuals with human immunodeficiency virus (HIV) may be at increased risk for osteoporosis. Prolonged exposures to HIV and/or antiretroviral therapy are possible causes for this association. This study compares differences in bone mineral density (BMD) in elderly HIV positive men and women to HIV negative controls. METHODS A cross-sectional study was conducted among 57 HIV-infected and 47 HIV negative subjects over age 55. BMD at the lumbar spine and total hip and markers of bone turnover were compared. RESULTS BMD was borderline lower in the lumbar spine and significantly lower in the hip in the HIV-infected group. Controlling for age, sex, race and body mass index, differences between the groups were significant at both sites. There was no difference in markers of bone turnover between the groups. Tenofovir use was significantly associated with decreased BMD at the spine while protease inhibitor use was significantly associated with decreased BMD at the hip. CONCLUSION Elderly men and women with HIV have lower bone mass than HIV negative controls. Decreased body mass index was the most important risk factor associated with decreased BMD. Bone demineralization was observed among HIV-infected subjects receiving either tenofovir or a protease inhibitor.
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Affiliation(s)
- S Jones
- Department of Medicine, Weill Medical College of Cornell University, New York, NY, USA
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