Past and future of HIV infection. A document based on expert opinion

HIV infection is now almost 40 years old. In this time, along with the catastrophe and tragedy that it has entailed, it has also represented the capacity of modern society to take on a challenge of this magnitude and to transform an almost uniformly lethal disease into a chronic illness, compatible with a practically normal personal and relationship life. This anniversary seemed an ideal moment to pause and reflect on the future of HIV infection, the challenges that remain to be addressed and the prospects for the immediate future. This reflection has to go beyond merely technical approaches, by specialized professionals, to also address social and ethical aspects. For this reason, the Health Sciences Foundation convened a group of experts in different aspects of this disease to discuss a series of questions that seemed pertinent to all those present. Each question was presented by one of the participants and discussed by the group. The document we offer is the result of this reflection.

Factors associated with seminal impairment in HIV-infected men under antiretroviral therapy

STUDY QUESTION

How do semen parameters of HIV-infected men under antiretroviral treatment compare with WHO parameters of normal semen, and what factors are associated with any differences?

SUMMARY ANSWER

Semen quality in most HIV-infected patients under antiretroviral treatment exceeds WHO limits, but the number falling below them is higher than would be expected in a healthy population. Exposure to efavirenz has a significant association with dysmotility.

WHAT IS KNOWN ALREADY

Dysmotility is the most frequently described sperm alteration related to HIV infection, and it has recently been linked to treatment with non-nucleoside reverse transcriptase inhibitors, particularly to efavirenz.

STUDY DESIGN, SIZE, DURATION

Prospective cohort study. Between March 2002 and December 2013, 139 HIV-infected men undergoing antiretroviral therapy were enrolled.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were male members of serodiscordant couples who attended a clinic for sexually transmitted infections (STIs) in Madrid and requested reproductive counselling. Sociodemographic, behavioural and clinical data were collected. CD4⁺ lymphocyte count, HIV viral load, serology/viral load of hepatitis B and C viruses, syphilis serology and other STIs diagnosis were performed. Semen parameters were assessed through standard sperm analysis and were compared with WHO 2010 reference values. Factors associated with impaired semen parameters were evaluated by bivariate and multivariate analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

The median values of all assessed semen parameters were within a normal range, but in up to 19% of HIV-positive males, at least one parameter of semen quality was below the normal range. A significant association between treatment with efavirenz and the presence of dysmotility was detected in the multivariate analysis.

LIMITATIONS, REASONS FOR CAUTION

Our results cannot demonstrate a causal relationship between exposure to efavirenz and impaired motility. We do not have a real comparison group as the WHO cohort is international and may not reflect local variations in semen characteristics. Subjects who requested reproductive counselling might not be representative of HIV-positive men in general.

WIDER IMPLICATIONS OF THE FINDINGS

Since efavirenz is still widely used in current therapeutic regimens may be affecting fertility in seropositive men who desire procreation.

STUDY FUNDING/COMPETING INTERESTS

No external funding was used for this study. The authors have no conflict of interest to declare.

Cause-Specific Mortality in HIV-Positive Patients Who Survived Ten Years after Starting Antiretroviral Therapy

OBJECTIVES

To estimate mortality rates and prognostic factors in HIV-positive patients who started combination antiretroviral therapy between 1996-1999 and survived for more than ten years.

METHODS

We used data from 18 European and North American HIV cohort studies contributing to the Antiretroviral Therapy Cohort Collaboration. We followed up patients from ten years after start of combination antiretroviral therapy. We estimated overall and cause-specific mortality rate ratios for age, sex, transmission through injection drug use, AIDS, CD4 count and HIV-1 RNA.

RESULTS

During 50,593 person years 656/13,011 (5%) patients died. Older age, male sex, injecting drug use transmission, AIDS, and low CD4 count and detectable viral replication ten years after starting combination antiretroviral therapy were associated with higher subsequent mortality. CD4 count at ART start did not predict mortality in models adjusted for patient characteristics ten years after start of antiretroviral therapy. The most frequent causes of death (among 340 classified) were non-AIDS cancer, AIDS, cardiovascular, and liver-related disease. Older age was strongly associated with cardiovascular mortality, injecting drug use transmission with non-AIDS infection and liver-related mortality, and low CD4 and detectable viral replication ten years after starting antiretroviral therapy with AIDS mortality. Five-year mortality risk was <5% in 60% of all patients, and in 30% of those aged over 60 years.

CONCLUSIONS

Viral replication, lower CD4 count, prior AIDS, and transmission via injecting drug use continue to predict higher all-cause and AIDS-related mortality in patients treated with combination antiretroviral therapy for over a decade. Deaths from AIDS and non-AIDS infection are less frequent than deaths from other non-AIDS causes.

Evidence for lipids-calcium ions interactions using fluorescent probing in paediatric nutrition admixtures

The aim of this work was to envisage a new analytical fluorescent method to study the molecular interactions between cations and negatively charged lipid droplets contained in total parenteral nutrition (TPN) admixtures. For this purpose, two fluorescent probes were tested: 9-diethylamino-5H-benzo[alpha]phenoxazine-5-one, commonly named nile red (NR), and 2-(p-toluidinyl)-naphthalene-6-sulfonate (TNS). NR, a neutral molecule, and TNS, an anionic one, are both polarity probes. Their fluorescence emission was enhanced in an apolar environment. They were used at 1 and 2.5 muM, respectively. Results showed that scattered light was very intense in weak aqueous dilution (1/10 vv(-1)) of fat emulsion and appeared as an experimental constraint. The sensitivity of fluorescence measurement in fat emulsion samples was constantly higher for NR than for TNS. When calcium addition occurs, as in pharmaceutical practice, a dramatic increase of fluorescence emission signal was showed for TNS, but no effect was observed for NR. As a conclusion, it was pointed out that the interactions between lipid droplets and calcium ions were likely to take place at the interface of the droplet and that TNS was a more appropriate probe than NR to prove it. Thus, fluorescent probing appeared to be a convenient new analytical tool for the investigation of lipid-cations interactions in TPN mixtures.

Effect of long-term administration of cross-sex hormone therapy on serum and urinary uric acid in transsexual persons

BACKGROUND

Transsexual persons afford a very suitable model to study the effect of sex steroids on uric acid metabolism.

DESIGN

This was a prospective study to evaluate the uric acid levels and fractional excretion of uric acid (FEUA) in a cohort of 69 healthy transsexual persons, 22 male-to-female transsexuals (MFTs) and 47 female-to-male transsexuals (FMTs). The subjects were studied at baseline and 1 and 2 yr after starting cross-sex hormone treatment.

RESULTS

The baseline levels of uric acid were higher in the MFT group. Compared with baseline, uric acid levels had fallen significantly after 1 yr of hormone therapy in the MFT group and had risen significantly in the FMT group. The baseline FEUA was greater in the FMT group. After 2 yr of cross-sex hormone therapy, the FEUA had increased in MFTs (P = 0.001) and fallen in FMTs (P = 0.004). In MFTs, the levels of uric acid at 2 yr were lower in those who had received higher doses of estrogens (P = 0.03), and the FEUA was higher (P = 0.04). The FEUA at 2 yr was associated with both the estrogen dose (P = 0.02) and the serum levels of estradiol-17beta (P =0.03). In MFTs, a correlation was found after 2 yr of therapy between the homeostasis model assessment of insulin resistance and the serum uric acid (r = 0.59; P = 0.01).

CONCLUSIONS

Serum levels of uric acid and the FEUA are altered in transsexuals as a result of cross-sex hormone therapy. The results concerning the MFT group support the hypothesis that the lower levels of uric acid in women are due to estrogen-induced increases in FEUA.

Clusters of travel-associated Legionnaires’ disease in Italy, Spain and France, July 2002 - June 2006

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Oral complication risks after invasive and non-invasive dental procedures in HIV-positive patients

BACKGROUND

Limited published scientific evidence is available to provide guidance to clinicians on possible increased risks of invasive oral procedures associated with the human immunodeficiency virus (HIV) status of the patient. The aim of this study was to assess post-procedural complications in patients infected with HIV.

MATERIAL AND METHODS

This was a retrospective cross-sectional study of the records of 101 consecutive HIV patients treated at the School of Dentistry of Madrid Complutense University and Sandoval STD Clinic in Madrid between January 2003 and February 2005. Data were gathered by an experienced dental practitioner using a structured epidemiological questionnaire for information on gender, age, HIV transmission category, medical history, hepatitis B virus (HBV) or hepatitis C virus (HCV) coinfection and other diseases, TCD4+ and TCD8+ count, HIV viral load (VL), platelet count, neutrophil count, international normalized ratio and haemoglobin level; tobacco and alcohol intake, highly active antiretroviral treatment and presence of oral lesions. Information was also collected on complications related to dental treatment (invasive or non-invasive) during the previous 6 months. Chi-squared test and Fisher's exact test were used to establish statistical significance.

RESULTS

Data were gathered on 314 dental procedures in 101 patients. The overall complication rate was 2.2% (7/314); in 147 invasive procedures, seven complications (4.8%) were documented (one persistent pain, two prolonged bleeding, three infections, one bone sequestrum) including extractions, periodontal scaling, endodontic treatment and biopsy. No differences were found in TCD4+, TCD8+, platelet count, HBV or HCV co-infections or HIV VL between patients with and/or without complications. Patients with complications were mainly in B stage of HIV disease (P=0.020). Oral lesions and smoking habit>20 cig day-1 were documented in 83.3% (P=0.086) and 50% (P=0.060), respectively, of patients with complications.

CONCLUSIONS

The complication rate was 2.2% overall and 4.8% after invasive dental procedures. Presence of oral lesions, smoking habit or HIV clinical stage B may be predictive factors for oral complications in HIV patients. No relationship was found between complications and virological, immunological or other laboratory values. Studies with wider samples and negative control group are warranted to confirm the absence of an association between HIV positivity and higher risk of oral complications.

Oral transmission of HIV, reality or fiction? An update

Human immunodeficiency virus (HIV) and many other viruses can be isolated in blood and body fluids, including saliva, and can be transmitted by genital-genital and especially anal-genital sexual activity. The risk of transmission of HIV via oral sexual practices is very low. Unlike other mucosal areas of the body, the oral cavity appears to be an extremely uncommon transmission route for HIV. We present a review of available evidence on the oral-genital transmission of HIV and analyse the factors that act to protect oral tissues from infection, thereby reducing the risk of HIV transmission by oral sex. Among these factors we highlight the levels of HIV RNA in saliva, presence of fewer CD4+ target cells, presence of IgA antibodies in saliva, presence of other infections in the oral cavity and the endogenous salivary antiviral factors lysozyme, defensins, thrombospondin and secretory leucocyte protease inhibitor (SLPI).

[Women who are partners of a man infected by HIV: description of their characteristics and appraisal of risk]

OBJECTIVE

To describe the situations of risk and the prevalence of HIV in women with a heterosexual partner infected by HIV.

DESIGN

Cross-sectional descriptive study.

SETTING

Out-patient HIV diagnosis centre in Madrid.

PATIENTS

229 women seen for the first time between 1993 and 2002 because they had a stable heterosexual partner diagnosed with HIV, and who were exposed to no other risk.

MAIN MEASUREMENTS

Social and personal details, reproduction history, sexual conduct, clinical, and analytic data of both partners.

RESULTS

66% of couples had maintained sexual relations for over a year. Women were on average younger (29.6 years old) than the men. 29% of the women had children and 5.2% were pregnant. 82% of men had injected drugs, but only 13% still did. 73% had been diagnosed with HIV for over 6 months, 16% had AIDS criteria, and 35% were taking retroviral treatment. 60% of the men who knew of their infection had systematically avoided sex without condoms, against 33% of those who did not know they were infected (P<.001). 19% had had accidents in use of the condom. HIV seroprevalence in the women was 6.1% (95% CI, 3.5%-10.3%).

CONCLUSIONS

Health care of people with HIV must include care of their sexual partner, involving information, psychological support, preventive and reproductive advice, as well as diagnosis of HIV or other sexually transmitted diseases.

Absence of hepatitis C virus transmission in a prospective cohort of heterosexual serodiscordant couples

OBJECTIVE

To analyse hepatitis C virus (HCV) transmission in a cohort of heterosexual couples who are discordant both for HIV and for HCV.

METHODS

We followed an open cohort of 171 people, 152 women and 19 men, who were not initially infected by either HIV or HCV, and whose steady heterosexual partner presented antibodies to both viruses (index case). Other risk exposures were excluded. Every 6 months clinical, epidemiological, and risk behaviour information was collected, and antibodies to both viruses were determined.

RESULTS

During 529 person years of follow up more than 40 000 vaginal or anal penetrations were recorded. 74 partners (43.3%) had vaginal and/or anal intercourse without condoms with the index case; another 15.8%, who always used condoms, declared breaking or slipping episodes during intercourse; and another 22.2% had unprotected orogenital exposures. During the follow up, over 5800 unprotected vaginal and anal contacts with the index case were estimated, as well as more than 25 000 unprotected orogenital contacts. 31 women became pregnant (two were index cases), and seroconversion to HIV occurred for one woman (1.7 per 10 000 unprotected contacts; 95% CI, 0 to 9.5), but there was no seroconversion to HCV (95% CI, 0-6.3 per 10 000 unprotected contacts).

CONCLUSION

These results are consistent with a low or null transmissibility of HCV in heterosexual relations, even when the index case is HIV co-infected.

Quantitative determination of fat emulsion using 1,6-diphenyl-1,3,5-hexatriene as fluorescence probe: application to the compounding of all-in-one parenteral nutrition admixtures

The potential contamination of binary bags by traces of fat emulsion stemmed from ternary bags prepared just before, led us to determine traces of lipids into the line set of the automated compounder MM23. Diphenylhexatriene (DPH) was chosen as fluorescence probe due to its strong fluorescence enhancement in a lipid environment. Optimization of experimental conditions (i.e. DPH amounts, pH of fat emulsion samples, ultrasounds use, light, temperature and contact duration) for fluorescence measurement and validation of analytical method were performed. This method was linear over 0.5-8.0 mg l(-1) (r=0.999) of fat emulsion. The intra-day and inter-day precisions were inferior to 2% for the 2.0 and 8.0 mg l(-1) standards. Under optimized conditions, the detection limit and quantitation limit were 0.10 and 0.29 mg l(-1) of lipids respectively. Compared to the colorimetric method using sodium dichromate, it is at least 100 times more sensitive. The proposed method permitted to rapidly measure fat emulsion traces in automated compounder line set for parenteral nutrition solutions and thus, to assess the risk of contamination of binary bags by lipids. At last, this method was shown to be conveniently applied to the analysis of fat emulsion in the final total parenteral nutrition bag.

Prevalence of epilepsy in northeast Madrid

During a period of 42 months, we studied the prevalence of epilepsy in a specific health district, composing by four towns with 98,405 inhabitants older than 10 years. This has been accomplished by a two-phase cross-sectional study. The prevalence rate observed was 4.12/1000 inhabitants for all types of epilepsy. No significant differences were found between the sexes. Sixty-three per cent of affected individuals had partial seizures, with a confirmed cause in 45%. Fifty-five patients with single unprovoked seizures, were also identified but not included in the prevalence rate.

Reproducibility of skin prick test results in epidemiologic studies: a comparison of two devices

The reproducibility of skin prick tests under field conditions is essential for comparing prevalences between centers in epidemiologic multicenter studies. This study aimed to evaluate and compare the reproducibility of two widely used skin prick test devices: the Multi-Test and the ALK lancet. The subjects were 28 children, aged 6-14 years, with known sensitivities to Dermatophagoides pteronyssinus (D. pter.). Both devices were applied to each subject on two occasions, 1 week apart, by different, randomly assigned fieldworkers, using histamine, negative control, and the D. pter. allergen extract. For all three tested solutions, mean wheal sizes were larger for the Multi-Test than for the ALK lancet. The coefficient of variation for histamine was 21.8% for the Multi-Test and 17.3% for the ALK lancet. The coefficients of variation for the allergen D. pter. amounted to 47.4% for the Multi-Test and to 24.6% for the ALK lancet. The percentage of concordant test results was 92.6% for the Multi-Test and 100.0% for the ALK lancet for a cutoff point of wheal size equal to or greater than 1 mm. The results of this study suggest that the single ALK lancet performs slightly better than the Multi-Test device with respect to reproducibility under conditions of epidemiologic field studies.