Drug-naive Individuals Research Articles

Immunological aspects of drug hypersensitivity—from molecule to man

ImmuNologICal aSpeCTS of drug hyperSeNSITIVITy—from moleCule To maN K. Park Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom Summary: Drug-induced liver injury (DILI) accounted for > 50% of cases of acute liver failure and 15% of patients undergoing liver transplantation between 1990 and 2002. One of the biggest fears is unpredictable idiosyncratic drug-induced liver injury (IDILI), which is a major contributor to the failure of a drug to process through development and is a major cause of withdrawal and black box warnings. Due to the low concordance of the hepatotoxicity of drugs in animals and humans, a fundamental understanding of the mechanistic basis from novel human-relevant in vitro models and biomarkers is critical for the development of effective strategies to prevent and predict DILI. Hepatocellular activation of drugs has been widely implicated in immune-mediated DILI with concomitant activation of the adaptive immune system. Consistent with this hypothesis, a number of HLA alleles that are associated with DILI have been identified. Studies with patient PBMC and PBMC from drug-naive donors carrying HLA risk alleles have shown that drugs form specific associations with HLA risk alleles generating T-cell antigens and hence provide the immunogenetic basis for the reaction. The identification of HLA alleles as predisposing factors for IDILI suggests that the adaptive immune system also participates in reactions targeting the liver. Furthermore, the release of damage-associated molecular pattern molecules (DAMPs), such as high mobility group box-1, may serve to activate cells of the innate immune system. Certain mediators produced by innate immune cells may cause liver injury, but other factors are actually important to promote tissue repair and regeneration. However, to fully define cause and effect (bioactivation vs liver failure), an integrated approach based on clinical studies, in vitro experiments, and animal models will be required, underpinned by appropriate bioanalysis. We have been able to characterize covalent protein adducts in man formed by reactive drug metabolites (nevirapine, diclofenac) using techniques developed for β -lactam antibiotics that associate with various types of drug hypersensitivity. We have also developed in vitro models to look at the interplay between, genetic, chemical, and immunologic factors using cells from both hypersensitive and drug-naive individuals. Such techniques and concepts should enable us to elucidate various mechanistic pathways and thus define both chemical and biological variables that underpin this rare but serious form of DILI. Disclosure of Interest: None declared.

Transmission Patterns of HIV-Subtypes A/AE versus B: Inferring Risk-Behavior Trends and Treatment-Efficacy Limitations from Viral Genotypic Data Obtained Prior to and during Antiretroviral Therapy

BackgroundHIV subtypes A and CRF01_AE (A/AE) became prevalent in Israel, first through immigration of infected people, mostly intravenous-drug users (IVDU), from Former Soviet-Union (FSU) countries and then also by local spreading. We retrospectively studied virus-transmission patterns of these subtypes in comparison to the longer-established subtype B, evaluating in particular risk-group related differences. We also examined to what extent distinct drug-resistance patterns in subtypes A/AE versus B reflected differences in patient behavior and drug-treatment history.MethodsReverse-transcriptase (RT) and protease sequences were retrospectively analyzed along with clinical and epidemiological data. MEGA, ClusalX, and Beast programs were used in a phylogenetic analysis to identify transmission networks.Results318 drug-naive individuals with A/AE or patients failing combination antiretroviral therapy (cART) were identified. 61% were IVDU. Compared to infected homosexuals, IVDU transmitted HIV infrequently and, typically, only to a single partner. 6.8% of drug-naive patients had drug resistance. Treatment-failing, regimen-stratified subtype-A/AE- and B-patients differed from each other significantly in the frequencies of the major resistance-conferring mutations T215FY, K219QE and several secondary mutations. Notably, failing boosted protease-inhibitors (PI) treatment was not significantly associated with protease or RT mutations in either subtype.ConclusionsWhile sizable transmission networks occur in infected homosexuals, continued HIV transmission among IVDU in Israel is largely sporadic and the rate is relatively modest, as is that of drug-resistance transmission. Deviation of drug-naive A/AE sequences from subtype-B consensus sequence, documented here, may subtly affect drug-resistance pathways. Conspicuous differences in overall drug-resistance that are manifest before regimen stratification can be largely explained in terms of treatment history, by the different efficacy/adherence limitations of older versus newer regimens. The phenomenon of treatment failure in boosted-PI-including regimens in the apparent absence of drug-resistance to any of the drugs, and its relation to adherence, require further investigation.

High Rate of Non-detectable HIV-1 RNA Among Antiretroviral Drug Naive HIV Positive Individuals in Nigeria.

Plasma HIV-1 RNA concentration, or viral load, is an indication of the magnitude of virus replication and largely correlates with disease progression in an infected person. It is a very useful guide for initiation of therapy and monitoring of response to antiretroviral drugs. Although the majority of patients who are not on antiretroviral therapy (ART) have a high viral load, a small proportion of ART naive patients are known to maintain low levels or even undetectable viral load levels. In this study, we determined the rate of undetectable HIV-1 RNA among ART naive HIV positive patients who presented for treatment at the University College Hospital (UCH), Ibadan, Nigeria from 2005 to 2011. Baseline viral load and CD4 lymphocyte cell counts of 14,662 HIV positive drug naive individuals were determined using the Roche Amplicor version 1.5 and Partec easy count kit, respectively. The detection limits of the viral load assay are 400 copies/mL and 750,000 copies/mL for lower and upper levels, respectively. A total of 1,399 of the 14,662 (9.5%) HIV-1 positive drug naive individuals had undetectable viral load during the study period. In addition, the rate of non-detectable viral load increased over the years. The mean CD4 counts among HIV-1 infected individuals with detectable viral load (266 cells/μL; range = 1 to 2,699 cells/μL) was lower than in patients with undetectable viral load (557 cells/μL; range = 1 to 3,102 cells/μL). About 10% of HIV-1 infected persons in our study population had undetectable viral load using the Roche Amplicor version 1.5.

The primary HIV drug resistance in partial region of Henan province

To study the prevalence of primary HIV drug resistance in antiretroviral therapy (ART) areas of Henan province. A total of 121 drug-naive long-term infected individuals and 154 patients with newly diagnosed from January 2011 to March 2012 were recruited, the questionnaires were surveyed and whole blood were collected to analyze the CD4(+)T cell counts and viral load. In-house method for genotypic resistance test was determined in those with viral load > 1000 copies/ml samples, the differences of demographic characteristics, immunological parameters and primary drug resistance were compared between the two groups. A total of 121 cases of long-term individuals who had infected (12.50 ± 3.21) years were mainly previous paid blood donors, and the age was (46.61 ± 9.32) years old. The infection route of the newly diagnosed were diversity, including blood, sexual transmission and others, the cases were 73, 73, 8, respectively, the confirmatory year was (0.91 ± 0.28) years, and average age was (22.21 ± 3.11) years old. The difference were statistically significant in the route of transmission, age and infection time from demographic analysis of the two groups (P < 0.05). The absolute M(P(25)-P(75)) counts of CD4(+)T lymphocytes of long-term group was 322 (217 - 422) cell/µl, which was lower than the newly diagnosed was 434(308 - 578) cell/µl (P < 0.05), and viral load was 4.0 (2.96 - 4.64) copies/ml, 3.77 (2.94 - 4.53) copies/ml, the difference was not significant (P > 0.05). The prevalence of primary drug resistance in long-term group and newly diagnosed was 5.79% (7/121), 9.09% (14/154), respectively, and the difference was statistically different (P < 0.05), and one PI-resistant strain was found in the newly diagnosed group. The primary drug resistant strains in untreated patients were found in Henan province of ART areas, and there was difference in degree of resistance between long-term infected individuals and newly diagnosed.

Highly efficient neutralization of human immunodeficiency viruses by plasma from antiretroviral drug treated patients is mediated by IgG fractions

Background Little is known about the neutralizing activity in patients on antiretroviral therapy (ART), as most recent studies have focused on drug naive individuals. ART may lead to a significant increase in B cell numbers and normalization of B cell subpopulations, providing a possible explanation for improved B cell responses after ART. Methods Thirty-four HIV-1 seropositive patients on ART (25 males and 9 females) within the age range of 20-55 years were recruited in this study. The patients had a median CD4 count and viral load of 283 cells and 178 RNA copies respectively, and were on treatment for a few days up to two years. Heat inactivated plasma samples were tested for neutralization against a panel of 14 subtype-A, B and C tier 1 and tier 2 viruses in TZM-bl assay. Results Of the 34 plasma samples, remarkably all the plasma samples were able to neutralize at least one virus while 32 (94%) samples were found to neutralize ≥50% viruses tested. Clustering analysis revealed that AIIMS253 (a clade-C virus) was the most sensitive while RHPA4259.7 (a clade-B isolate) was most resistant to antibody neutralization. The Immunoglobulin-G fractions from two representative samples AIIMS221 and AIIMS265 were shown to mediate neutralization exclusively. The IgG fractions retained binding to subtype-A, B and C recombinant gp120 proteins. We did not find any association of mean reciprocal ID50 neutralization titers with the plasma levels of ART drugs and clinical and immunological variables like CD4 count (p=0.35), viral load (p=0.37) and plasma total IgG (p=0.46). However we observed a positive association of neutralization with duration of ART (p=0.02) with a similar trend in two follow up patient samples. Conclusion

Low Drug Resistance Levels Among Drug-Naive Individuals with Recent HIV Type 1 Infection in a Rural Clinical Cohort in Southwestern Uganda

To investigate the prevalence of transmitted drug resistance (TDR) among individuals with recent HIV-1 infection between February 2004 and January 2010 in a rural clinical cohort, samples from 72 participants were analyzed. Results from the 72 participants showed no protease inhibitor and nucleoside reverse transcriptase inhibitor-associated mutations. One participant (1.4%, 95% CI: 0.04-7.5%) had two nonnucleoside reverse transcriptase inhibitor mutations (G190E and P225H). HIV-1 subtype frequencies were A 22 (30.6%), D 38 (52.8%), and C 1 (1.4%); 11 (15.3%) were A/D unique recombinant forms. Seven years after the scale up of antiretroviral therapy (ART) in a rural clinical cohort in Uganda, the prevalence of TDR among recently HIV-1-infected individuals was low at 1.4%. Since our findings from an HIV study cohort may not be generalizable to the general population, routine TDR surveys in specific populations may be necessary to inform policy on the magnitude and prevention strategies of TDR.

No Increase of Drug-Resistant HIV Type 1 Prevalence Among Drug-Naive Individuals in Northern Vietnam

We reported previously that the prevalence of drug-resistant HIV-1 among antiretroviral therapy (ART)-naive individuals in Northern Vietnam was 2.9% in 2007 and 6.2% in 2008. To investigate the continuing trend of prevalence, we collected plasma samples from 958 individuals in Hai Phong and Hanoi in 2009, extracted viral RNA from HIV-1 antibody-positive samples, and analyzed them genetically. HIV-1 antibody prevalence was 26.8% in injecting drug users (n=302), 13.4% in female sex workers (n=284), 0.5% in blood donors (n=206), and 0.6% in pregnant women (n=166). All HIV-1 strains were CRF01_AE. Nonnucleoside reverse-transcriptase inhibitor resistance mutations were found in two (2.0%) of the 102 successfully analyzed cases (one case with the Y181C and one with the K101E). No nucleoside reverse-transcriptase inhibitor resistance or protease inhibitor resistance mutations were detected. The prevalence of circulating ART-resistant HIV-1 in Northern Vietnam did not increase from 2007 to 2009, although the rate of ART coverage did increase.

Predicting HIV treatment response in Romania – Comment

In recent years mathematical modeling has become a valuable tool in the analysis of infectious disease dynamics at both individual and population level. Mathematical models allow us to extrapolate from current information about the natural history of a disease, therapy/intervention outcome, state and progress of an outbreak, to predict the future and, most importantly, to quantify the uncertainty in these predictions, thus, increasingly gaining the ability to perform as a link between basic science, clinical medicine and public health. With the current technological and computational power it is tempting to build very complex models in order to fit the data the most. However, models are only as good as the data they are trained on and supplied with, making predictions based on limited information very difficult and unreliable.1 The study presented by Revell et al. actually manages to overcome lack of information and still provide plausible predictions.2 This does seem very promising for countries with limited resources, such as the case is with Serbia. The time of the initial identification of the HIV-1 epidemics in Serbia is comparable to that in West European countries, and so is the timeline of introduction of antiretroviral therapy (ART) use.3 However, the healthcare system and infrastructure in the country have been severely challenged during the last decades, suffering from the lack of financial resources, equipment and supplies, which is particularly reflected in the field of HIV treatment. Thus, supply of drugs was periodically irregular and unreliable, introduction of new ARV drugs rather late and inefficient, as was the access to state of the art laboratory monitoring. HIV-1 epidemics in Serbia is largely caused by subtype B, thus the issue of viral subtype is not as relevant as in Romania, however, important clinical parameters such as CD4 cell count or viral load are lacking. In Serbia, there are 4 centers for the management and treatment of HIV/AIDS patients. The largest Serbian center where over 915 HIV/AIDS patients (over 85% of the total patient population in Serbia) are being treated is situated at the University Infectious Diseases Hospital in Belgrade. In those centers, especially in the one in Belgrade, doctors are facing with long periods of time with no completely available HAART monitoring tools. 4 Precisely, CD4 cell count has been not available, and less often plasma viral load could not be measured. HIV resistance testing has not become an everyday routine yet. Our prospective follow-up study of all HIV positive, drug-naive individuals who started antiretroviral treatment between January 1st 2003 and June 1st 2011 has shown that among patients with over 9 months of follow-up, the frequency of CD4 monitoring had a median (IQR) of 1 (IQR 1, 2) measurements in the first year of ART with an average of 2 (IQR 1, 3) CD4 tests per year. The frequency of plasma viral load monitoring had a median (IQR) of 1 (IQR 0, 2) measurements in the first year of ART with an average of 1 (IQR 1, 2) plasma viral load tests per year (unpublished data). For those patients who experience virological failure and when resistance testing is not available, doctors relay on the standard of care practice. That means considering all possible antiretroviral drugs cross-resistance and changing the combination accordingly. Having in mind these circumstances, it would be very useful to test the reliability of HIV Resistance Response Database Initiative (RDI) method to assess the current Serbian practice using only baseline viral load and the viral load after the change of antiviral combination, regardless of the CD4 cell count.

Prevalence of Drug Resistance-Related Polymorphisms in Treatment-Naive Individuals Infected with Nonsubtype B HIV Type 1 in Cameroon

Mutations associated with the use of protease (PR) and reverse transcriptase (RT) inhibitors have been mostly mapped for HIV-1 subtype B. The prevalence of these mutations in drug-naive HIV-1 subtype B-infected individuals is low but occurs at high frequencies in treated individuals. To determine the prevalence of treatment-associated mutations in non-B viruses, we analyzed a 1613-bp pol region of specimens collected from 57 HIV-1-infected treatment-naive individuals from Cameroon. Of the 57 HIV-1 sequences, 43 belonged to CRF02-AG, two to CRF11-cpx, six to subtype A, one to subtype D, and five were unclassifiable. Of the 57 PR sequences, 100% contained at least one codon change giving substitutions at positions 10, 11, 16, 20, 33, 36, 60, 62, 64, 69, 77, and 89. These substitutions gave the following prevalence pattern, 36I/L (100%, 57/57) >89M/I (98%, 56/57)>69K/R (93%, 53/57)>20I/R (89%, 51/57)>16E (16%, 9/57)>64M (12%, 7/57)>10I (11%, 6/57)>11V (5%, 3/57)=62V (5%, 3/57)=77I (5%, 3/57)>233F/V (4%, 2/57)=60E (4%), which differed significantly from subtype B at positions 20, 36, 69, and 89. All but one (98%) of the 57 RT sequences (438 amino acid residues) carried substitutions located at codons 39A (7%), 43E (7%), 122E (7%), 312Q (2%), 333E (2%), 335C/D (89%), 356K (89%), 358K (14%), 365I (2%), 371V (81%), 376S (11%), or 399D (4%); the frequency of these substitutions ranged from <0.5% to 4% in RT of subtype B. The high prevalence of minor mutations associated with protease inhibitors (PI) and reverse transcriptase inhibitors (RTI) represents natural polymorphisms. HIV-1 PR and RT sequences from antiretroviral (ARV)-naive HIV-infected persons in Cameroon are important for monitoring the development of resistance to PIs and RTIs as such mutations could lead to treatment failures in individuals undergoing ARV therapy.

Access to a running wheel inhibits the acquisition of cocaine self-administration

Physical activity decreases cocaine self-administration in laboratory animals and is associated with positive outcomes in substance abuse treatment programs; however, less is known about its efficacy in preventing the establishment of regular patterns of substance use in drug-naive individuals. The purpose of the present study was to examine the effects of access to a running wheel on the acquisition of cocaine self-administration in experimentally naive rats. Male, Long–Evans rats were obtained at weaning and assigned to sedentary (no wheel) or exercising (access to wheel) conditions immediately upon arrival. After six weeks, rats were surgically implanted with intravenous catheters and placed in operant conditioning chambers for 2h/day for 15 consecutive days. Each session began with a noncontingent priming infusion of cocaine, followed by a free-operant period in which each response on the active lever produced an infusion of cocaine on a fixed ratio (FR1) schedule of reinforcement. For days 1–5, responding was reinforced with 0.25mg/kg/infusion cocaine; for days 6–15, responding was reinforced with 0.75mg/kg/infusion cocaine. In addition, all rats were calorically restricted during days 11–15 to 85% to 95% of their free-feeding body weight. Compared to sedentary rats, exercising rats acquired cocaine self-administration at a significantly slower rate and emitted significantly fewer active lever presses during the 15days of behavioral testing. These data indicate that access to a running wheel inhibits the acquisition of cocaine self-administration, and that physical activity may be an effective intervention in substance abuse prevention programs.

Relative reactivity of HIV-1 polyclonal plasma antibodies directed to V3 and MPER regions suggests immunodominance of V3 over MPER and dependence of high anti-V3 antibody titers on virus persistence

Antibodies to two crucial regions, the third variable loop (V3) of gp120 and the membrane-proximal external region (MPER) of gp41 are important for HIV-1 neutralization. We here evaluated the relative binding of polyclonal plasma antibodies from 99 HIV-1-infected individuals from India to the consensus-C V3 and MPER peptides and observed immunodominance of V3 over MPER (p<0.0001). We further examined the V3- and MPER-specific antibody correlates with clinical parameters. Our results revealed that anti-V3 antibody titers are significantly lower in patients on ART compared to drug-naive individuals (p<0.0001), most likely due to a decrease in plasma viral load, irrespective of their CD4 counts and total IgG. No such association was observed for MPER, with a similar trend in four follow-up patients. These findings strongly suggest that high titers of V3-specific antibodies are dependent on persistence of virus in circulation, while antibodies to MPER are probably not.

Reduced Dorsal Prefrontal Gray Matter After Chronic Ketamine Use

Use of ketamine as a recreational drug is spreading rapidly among young people all over the world. Epidemiological studies have linked chronic ketamine use with a number of problems, including cognitive impairments, bladder dysfunction, and ketamine-related death. However, little is known about the long-term effects of ketamine use on brain structure and function. We used voxel based morphometry in conjunction with statistical parametric mapping on the structural magnetic resonance images of ketamine-dependent (n = 41) and drug-naive control individuals (n = 44) to assess differences in gray matter volume between the two groups. We observed significant decreases in gray matter volume in bilateral frontal cortex (left superior frontal gyrus and right middle frontal gyrus) of ketamine users in comparison with control subjects (p < .05 corrected for multiple comparisons at cluster-level). Duration of ketamine use was negatively correlated with gray matter volume in bilateral frontal cortex, whereas the estimated total lifetime ketamine consumption was negatively correlated with gray matter volume in left superior frontal gyrus. We have demonstrated a reduction in frontal gray matter volume in patients after chronic ketamine use. The link between frontal gray matter attenuation and the duration of ketamine use and cumulative doses of ketamine perhaps suggests a dose-dependent effect of long-term use of the drug. Our results have important connotations for the clinical picture that is likely to emerge with the growing recreational use of ketamine and is also relevant to the status of the drug as a model for schizophrenia.

Drug Resistance Mutations in Drug-Naive HIV Type 1 Subtype C-Infected Individuals from Rural Malawi

In this preliminary study we show that in 2008, 3 years after antiretroviral therapy was introduced into the Karonga District, Malawi, a greater than expected number of drug-naive individuals have been infected with HIV-1 subtype C virus harboring major and minor drug resistance mutations (DRMs). From a sample size of 40 reverse transcriptase (RT) consensus sequences from drug-naive individuals we found five showing NRTI and four showing NNRTI mutations with one individual showing both. From 29 protease consensus sequences, again from drug-naive individuals, we found evidence of minor DRMs in three. Additional major and minor DRMs were found in clonal sequences from a number of individuals that were not present in the original consensus sequences. This clearly illustrates the importance of sequencing multiple HIV-1 variants from individuals to fully assess drug resistance.

Natural Polymorphisms Associated with Resistance to New Antivirals against HCV in Newly Diagnosed HIV–HCV-Coinfected Patients

Direct acting antivirals (DAA) targeting the HCV serine protease and RNA polymerase have recently entered clinical development. Information about primary resistance to these compounds in HIV-HCV-coinfected patients is scarce. All individuals newly diagnosed with HIV-1 at several clinics in Madrid between 2000 and 2010 were tested for serum HCV antibody and HCV RNA. The NS3 protease and NS5B polymerase genes were sequenced in all HCV viraemic patients with genotype 1 (G1). From 1,684 individuals newly diagnosed with HIV-1 during the 10-year study period, 141 (8.4%) were positive for serum HCV RNA. Overall, 58% were infected with G1, being 1a in 64.2% of them. Altogether, 62% of G1a and 30% of G1b harboured HCV drug-resistant changes, with the most common being prQ80K (n=9), prV55A (n=2), polC316Y/N (n=3) and polV499A (n=24). Although no primary resistance mutations were identified for HCV protease inhibitors or nucleoside analogues, mutations C316Y/N and V499A conferring resistance to some non-nucleoside analogues were found in 6% and 51% of G1 patients, respectively. Natural DAA resistance-associated mutations are frequently seen in HIV-HCV-coinfected individuals. Changes polV499A and prQ80K seem to be natural polymorphisms and their effect on treatment outcomes warrants further examination. However, drug resistance testing in HCV drug-naive individuals coinfected with HIV currently does not seem to be warranted before using HCV protease inhibitors and nucleoside analogues. More information is needed for HCV non-nucleoside analogues.

Primary Antiretroviral Drug Resistance among HIV Type 1-Infected Individuals in Brazil

Infection with drug-resistant human immunodeficiency virus type 1 (HIV-1) has been documented in all countries that have surveyed for it and may result in an unfavorable response to therapy. The prevalence and characteristics of individuals with transmitted resistance to antiretroviral drugs have been scarcely described in Brazil. We performed antiretroviral resistance testing prior to initiation of therapy in 400 subjects enrolled from 20 centers in 13 Brazilian cities between March and September 2007. Genotyping was conducted using PCR-amplified HIV pol products by automated sequencing, and genotype interpretation was done according to the IAS-USA consensus. Of 400 eligible participants, 387 (95.8%) were successfully tested. Seven percent of antiretroviral-naive patients carried viruses with one or more major mutation associated with drug resistance. The prevalence of these mutations was 1.0% for protease inhibitors, 4.4% for nonnucleoside reverse transcriptase inhibitors, and 1.3% for nucleoside reverse transcriptase inhibitors. The frequency of multidrug resistance among the resistant strains was 13.6%. Among subjects infected with drug-resistant virus, the majority were infected with subtype B viruses (91%). Subjects from the city of São Paulo had higher transmitted resistance mutations compared to the rest of the country. Reporting a partner taking antiretroviral medications was associated with a higher chance of harboring HIV variants with major drug resistance mutations [odds ratio = 2.57 (95% confidence interval, 1.07-6.16); p = 0.014]. Resistance testing in drug-naive individuals identified 7% of subjects with mutations associated with reduced susceptibility to antiretroviral drugs. Continued surveillance of drug-resistant HIV-1 in Brazil is warranted when guidelines for HIV prophylaxis and treatment are updated. Resistance testing among drug-naive patients prior to treatment initiation should be considered, mainly directed at subjects whose partners are already on antiretroviral therapy.

Lack of Primary Mutations Associated With Integrase Inhibitors Among HIV-1 Subtypes B, C, and F Circulating in Brazil

Antiretroviral drugs targeting integrase (IN) have recently been approved for use in combined and salvage therapeutic interventions. To evaluate the presence of natural polymorphisms and resistance mutations associated with IN inhibitors among HIV-1 subtypes B, C, and F samples obtained from drug-naive individuals and patients failing highly active antiretroviral therapy in Brazil. Proviral DNA was obtained from blood samples of 105 HIV-1-positive drug-naive patients infected by B, C, or F subtypes and plasma viral RNA from 30 subtype B-infected individuals failing highly active antiretroviral therapy. The IN region was amplified by nested polymerase chain reaction and automatically sequenced for subtype determination. Translated amino acid sequences were inspected for IN mutations associated with antiretroviral resistance. Eleven mutations described as conferring in vitro resistance to IN strand transfer inhibitors were detected among the HIV-1 Brazilian samples. V72I and V201I were considered as polymorphisms. Major mutations associated with elvitegravir or raltegravir in vivo resistance (Q148K/H/R, N155H) were not detected. Although some naturally occurring polymorphisms were observed, the absence of major resistance mutations for the current IN inhibitors provides a good rationale for the introduction of these drugs in Brazil. These results highlight the importance of the continuous surveillance of IN genetic diversity.

The Combined Effect of Modern Highly Active Antiretroviral Therapy Regimens and Adherence on Mortality Over Time

To characterize the impact of longitudinal adherence on survival in drug-naive individuals starting currently recommended highly active antiretroviral therapy (HAART) regimens. Eligible study participants initiated HAART between January 2000 and November 2004 and were followed until November 2005 (N = 903). HAART regimens contained efavirenz, nevirapine, or ritonavir-boosted atazanavir or lopinavir. Marginal structural modeling was used to address our objective. The all-cause mortality was 11%. Individual adherence decreased significantly over time, with the mean adherence shifting from 79% within the first 6 months of starting HAART to 72% within the 24- to 30-month period (P value <0.01). Nonadherence over time (<95%) was strongly associated with higher risk of mortality (hazard ratio: 3.13; 95% confidence interval (CI): 1.95 to 5.05). Nonadherent (<95%) patients on nonnucleoside reverse transcriptase inhibitor (NNRTI)-based and boosted protease inhibitor-based regimens were, respectively, 3.61 times (95% CI: 2.15 to 6.06) and 3.25 times (95% CI: 1.63 to 6.49) more likely to die than adherent patients. Within the NNRTI-based regimens, nonadherent individuals on efavirenz were at a higher risk of mortality. Incomplete adherence to modern HAART over time was strongly associated with increased mortality, and patients on efavirenz-based NNRTI therapies were particularly at a higher risk if nonadherent. These results highlight the need to develop further strategies to help sustain high levels of adherence on a long-term basis.

Neutralization Patterns and Evolution of Sequential HIV Type 1 Envelope Sequences in HIV Type 1 Subtype B-Infected Drug-Naive Individuals

To design a vaccine that will remain potent against HIV-1, the immunogenic regions in the viral envelope that tend to change as well as those that remain constant over time must be identified. To determine the neutralization profiles of sequential viruses over time and study whether neutralization patterns correlate with sequence evolution, 12 broadly neutralizing plasmas from HIV-1 subtype B-infected individuals were tested for their ability to neutralize sequential primary HIV-1 subtype B viruses from four individuals. Three patterns of neutralization were observed, including a loss of neutralization sensitivity by viruses over time, an increase in neutralization sensitivity by sequential viruses, or a similarity in the sensitivity of sequential viruses to neutralization. Seven to 11 gp160 clones from each sequential virus sample were sequenced and analyzed to identify mutational patterns. Analysis of the envelope sequences of the sequential viruses revealed changes characteristic of the neutralization patterns. Viruses that evolved to become resistant to neutralizing antibodies also evolved with diverse sequences, with most of the changes being due to nonsynonymous mutations occurring in the V1/V2, as well as in the constant regions (C2, C3, C4), the most changes occurring in the C3. Viruses from the patient that evolved to become more sensitive to neutralization exhibited less sequence diversity with fewer nonsynonymous changes that occurred mainly in the V1/V2 region. The V3 region remained constant over time for all the viruses tested. This study demonstrates that as viruses evolve in their host, they either become sensitive or resistant to neutralization by antibodies in heterologous plasma and mutations in different envelope regions account for these changes in their neutralization profiles.

The Relationship Between Resistance and Adherence in Drug-Naive Individuals Initiating HAART Is Specific to Individual Drug Classes

To investigate the relationship between HIV-1 drug resistance and adherence and the accumulation rate of resistance mutations in 1191 HIV-infected, antiretroviral-naive adults initiating highly active antiretroviral therapy in British Columbia, Canada. Plasma samples with plasma viral load >1,000 copies per milliliter collected within 30 months of follow-up were genotyped for drug resistance. Adherence was estimated using prescription refills and plasma drug levels. The primary outcome measure was time to detection of drug resistance. Cox proportional hazard regression was used to calculate hazard ratios (HRs) associated with baseline variables. The accumulation rates of multiple primary and secondary mutations were similar in patients initiating highly active antiretroviral therapy with protease inhibitor versus nonnucleoside reverse transcriptase inhibitor (NNRTI). Rates decreased approximately 50% per additional mutation. At 80%-90% adherence based on refills, there was greater risk of detecting lamivudine (3TC) [HR 3.0, 95% confidence interval (CI): 1.9 to 4.7; P < 0.0001] and NNRTI mutations (HR 6.0, 95% CI: 3.3 to 10.9; P < 0.0001) compared with the >or=95% refill reference group. In a multivariate model, individuals with <95% refills and consistently detectable plasma drug levels were at increased risk for 3TC (HR 4.5, 95% CI: 2.6 to 7.9; P = 0.0001) and NNRTI resistance (HR 7.0, 95% CI: 3.4 to 14.5; P = 0.0001) compared with the reference group of >or=95% refills with consistently detectable drug levels. Adherence-resistance relationships were much weaker for protease inhibitors and nucleoside reverse transcriptase inhibitors as there was little variance in HRs among the different adherence strata compared with 3TC and NNRTIs. The relationships between resistance, adherence, and mutation accumulation differ between HIV drug classes.

Simultaneous EEG‐fMRI in drug‐naive children with newly diagnosed absence epilepsy

In patients with idiopathic generalized epilepsy (IGE), blood oxygen level dependent (BOLD) EEG during functional MRI (EEG-fMRI) has been successfully used to link changes in regional neuronal activity to the occurrence of generalized spike-and-wave (GSW) discharges. Most EEG-fMRI studies have been performed on adult patients with long-standing epilepsy who were on antiepileptic medication. Here, we applied EEG-fMRI to investigate BOLD signal changes during absence seizures in children with newly diagnosed childhood absence epilepsy (CAE). Ten drug-naive children with newly diagnosed CAE underwent simultaneous EEG-fMRI. BOLD signal changes associated with ictal EEG activity (i.e., periods of three per second GSW) were analyzed in predefined regions-of-interests (ROIs), including the thalamus, the precuneus, and caudate nucleus. In 6 out of 10 children, EEG recordings showed periods of three per second GSW during fMRI. Three per second GSW were associated with regional BOLD signal decreases in parietal areas, precuneus, and caudate nucleus along with a bilateral increase in the BOLD signal in the medial thalamus. Taking into account the normal delay in the hemodynamic response, temporal analysis showed that the onset of BOLD signal changes coincided with the onset of GSW. In drug-naive individuals with CAE, ictal three per second GSW are associated with BOLD signal changes in the same striato-thalamo-cortical network that changes its regional activity during primary and secondary generalized paroxysms in treated adults. No BOLD signal changes in the striato-thalamo-cortical network preceded the onset of three per second GSW in unmediated children with CAE.