Plasma HIV-1 RNA Load Research Articles

Outcomes of switch to atazanavir-containing combination antiretroviral therapy in HIV-1-infected patients with hyperlipidemia

Prolonged exposure to combination antiretroviral therapy (CART) may result in hyperlipidemia and other metabolic complications. This study aimed to evaluate the clinical, virologic, and immunologic outcomes in HIV-infected patients with hyperlipidemia whose CART was switched to atazanavir-containing antiretroviral regimens. In this 48-week prospective, observational study that was conducted at designated hospitals for HIV care in Taiwan, HIV-infected patients aged 18 years or older who had developed hyperlipidemia after receiving CART that did not contain atazanavir were enrolled. Antiretroviral regimens were switched to regimens containing two nucleoside reverse-transcriptase inhibitors plus atazanavir 400 mg once daily or atazanavir 300 mg boosted with ritonavir 100 mg once daily. The lipid profiles, including total triglycerides, total cholesterol, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, CD4+ lymphocyte counts, and plasma HIV RNA load were determined every 3 months. Sixty-six patients with hyperlipidemia were enrolled. At the end of the study, triglyceride levels declined by 49.0% (p = 0.0002) and total cholesterol levels by 18.1% from baseline (p < 0.0001), whereas there were no significant changes observed for low-density lipoprotein- and high-density lipoprotein-cholesterol levels. Mean CD4 lymphocyte count increased from 465 cells/μL at baseline to 498 cells/μL at the end of the study, whereas the proportion of patients with undetectable plasma HIV RNA load increased from 73.1% to 81.7%. The regimens were well tolerated. Switch to atazanavir-containing regimens that were well tolerated resulted in significant improvement of hyperlipidemia and maintenance of clinical, immunologic, and virologic responses to CART.

Intraocular and plasma HIV-1 RNA loads and HIV uveitis

The objective of this study was to analyze human immunodeficiency virus (HIV) dynamics across the blood-retinal barrier and to determine whether the high levels of HIV in the eye are associated with any ocular disorders in HIV-infected patients. This study included a prospective case series of 40 HIV-positive patients with uveitis. Clinical and laboratory examinations included plasma and intraocular HIV-1 RNA loads as well as the clinical manifestations of uveitis. Intraocular HIV-1 RNA was detected in 32% (13/40) of HIV-positive patients with uveitis. Intraocular HIV-1 RNA loads were associated with high HIV-1 RNA plasma loads (P < 0.001) and not being on HAART therapy (P = 0.005). In addition, detectable intraocular HIV-1 RNA levels were higher in patients with the absence of retinal lesions (P = 0.008). In three patients, the HIV load in the eye largely exceeded that of plasma. These three patients had all bilateral anterior uveitis and/or vitritis without retinal lesions and exhibited no evidence of other intraocular infectious agents causing uveitis than HIV itself. The eye can form a sanctuary where HIV might replicate and cause an inflammatory reaction.

No selection of nucleoside reverse transcriptase inhibitor resistance associated mutations by acyclovir suppressive therapy in herpes simplex virus-2/HIV-1 dually infected persons

Genital herpes simplex virus type 2 (HSV-2) shedding has been associated with increased concentrations of HIV-1 in the genital tract and plasma [1,2]. Recent data from randomized controlled trials suggest that daily HSV-2 suppressive therapy with acyclovir (ACV) or valacyclovir over periods of up to 3 months may reduce plasma and genital HIV RNA load by 0.3–0.5 log10 copies/ml among HIV/HSV-2 coinfected individuals not receiving antiretroviral therapy (ART) [3–7]. However, a recent trial of suppressive therapy [ACV 400 mg twice daily (b.i.d.)] delivered to the HIV/HSV-2 seropositive partner in HIV discordant couples found no decrease in the rate of HIV transmission to the HIV negative partner [8]. ACV is an acyclic guanosine analog that inhibits HSV DNA polymerase after conversion to its triphosphate form. As the first phosphorylation is synthesized selectively by HSV thymidine kinase [9], ACV is mainly active in HSV-infected cells and was therefore thought to have no or poor antiretroviral activity. The postulated mechanism of impact on HIV is that herpes suppressive therapy is able to prevent HIV replication by disrupting direct HSV-2/HIV-1 interaction and, indirectly, by reducing the systemic and local immune activation induced by HSV-2 [10]. However, recent in-vitro experiments have suggested that ACV may directly inhibit HIV replication and induce the selection of mutations in the HIV reverse transcriptase known to confer resistance to nucleoside reverse transcriptase inhibitors (NRTIs) [11,12]. ACV has been shown to select the mutation V75I, associated with the reverse transcriptase multidrug resistance complex, and also, to a lesser extent, T69N and M184I, which typically precedes the emergence of the M184V mutation that confers a high level of resistance to lamivudine/emtricitabine. These results suggest that the use of ACV may select HIV variants harboring mutations associated with resistance to NRTI. If confirmed in vivo, this may impact the choice and efficacy of antiretroviral regimens among HIV patients who have previously been treated with ACV, and would suggest that the use of ACV in ART-naïve HIV-positive patients should be carefully considered. To determine the impact of ACV suppressive therapy on the selection of mutations in the HIV reverse transcriptase gene in vivo, we analyzed plasma samples from dually HIV/HSV-2-infected women receiving ACV suppressive therapy who were enrolled in a randomized placebo-controlled trial of ACV 400 mg b.i.d. for HSV suppression in Tanzania [13,14]. The detection of mutations was performed by HIV reverse transcriptase gene sequence analysis on plasma samples selected from women with a reported high-ACV adherence (defined as taking >90% tablets by tablet counts) and HIV RNA load more than 3 log10 copies/ml after 12 months of ACV suppressive therapy, and who were not on ART. Among 21 selected samples, none of the mutations V75I, T69N and M184I were detected. No other mutations known to confer resistance to NRTI were detected in the reverse transcriptase gene. In four samples, mutations at the codon 69 (69A n = 2, 69P n = 1, T69S n = 1) were detected. T69A and T69P are not known to be associated with NRTI resistance, but T69S in combination with other mutations may be associated with tenofovir resistance. This mutation may have been selected owing to ACV exposure or owing to natural polymorphism. These results suggest that b.i.d. HSV-2 suppressive therapy with a standard dose of 400 mg of ACV for 12 months did not induce the selection of NRTI resistance mutations in HIV-infected women not receiving ART. Because the threshold of resistant variant detection with sequence analysis is above 20%, we cannot completely rule out the presence of minor populations containing NRTI resistance mutations. However, we selected samples from women with high-ACV adherence to guarantee the highest selective pressure of ACV, and restricted the laboratory analyses to those who had been on ACV therapy for 12 months in order to be able to detect late emergence of ACV-associated NRTI resistance mutations. Thus, the selection of mutations in the reverse transcriptase gene by ACV exposure seems unlikely in our population. Considering the bioavailability of oral ACV, plasma concentrations after 400 mg b.i.d. should not exceed 1 μmol/l, five-fold lower than the half maximal inhibitory concentration for HIV [12] and such concentrations might not be sufficient to achieve antiretroviral activity. Our results do not confirm the in-vitro data obtained studies using high-dose ACV [12], but corroborate results recently presented on patients receiving ACV or valacyclovir for periods of 8–24 months [15]. These reassuring results for the use of 400 mg b.i.d. ACV in HSV-2/HIV coinfected patients deserve further confirmation especially if higher dosage of ACV is used in HIV-infected individuals.

Factors associated with isolated anti‐hepatitis B core antibody in HIV‐positive patients: impact of compromised immunity

In regions that are hyperendemic for chronic hepatitis B virus (HBV) infection, prevalence of and risk factors associated with isolated anti-hepatitis B core antibody (anti-HBc) in HIV-positive patients are less well described. HIV-positive patients who were tested for hepatitis B surface antigen (HBsAg), anti-hepatitis B surface antibody (anti-HBs) and anti-HBc at designated hospitals for HIV care in Taiwan were included for analysis. HBV DNA was detected by real-time polymerase chain reaction in patients with and without isolated anti-HBc. Of 2351 HIV-positive patients, 450 (19.1%) were HBsAg positive, 411 (17.5%) were anti-HBc positive alone and 963 (41.0%) for both anti-HBs and anti-HBc. Compared with patients who were positive for both anti-HBs and anti-HBc, patients with isolated anti-HBc were older, less likely to have anti-hepatitis C virus antibody (anti-HCV), had lower CD4 lymphocyte counts and higher plasma HIV RNA loads. Older age (adjusted odds ratio, 1.029; 95% confidence interval, 1.015-1.043) and CD4 <100 cells/microL (adjusted odds ratio, 1.524; 95% confidence interval, 1.025-2.265) were independently associated with isolated anti-HBc by logistic regression, while presence of anti-HCV and injecting drug use were not. HBV DNA was detectable in 8.3% of 277 patients with isolated anti-HBc and 14.3% of 56 patients with both anti-HBs and anti-HBc (P = 0.160). In a country hyperendemic for HBV infection, HIV-positive patients at older age and with CD4 <100 cells/microL were more likely to have isolated anti-HBc, suggesting that compromised immunity plays a role in the presence of this marker.

Risk of pneumocystosis after early discontinuation of prophylaxis among HIV-infected patients receiving highly active antiretroviral therapy

BackgroundRisk of pneumocystosis after discontinuation of primary or secondary prophylaxis among HIV-infected patients before CD4 counts increase to ≧200 cells/μL (early discontinuation) after receiving highly active antiretroviral therapy (HAART) is rarely investigated.MethodsMedical records of 660 HIV-infected patients with baseline CD4 counts <200 cells/μL who sought HIV care and received HAART at a university hospital in Taiwan between 1 April, 1997 and 30 September, 2007 were reviewed to assess the incidence rate of pneumocystosis after discontinuation of prophylaxis for pneumocystosis.ResultsThe incidence rate of pneumocystosis after HAART was 2.81 per 100 person-years among 521 patients who did not initiate prophylaxis or had early discontinuation of prophylaxis, which was significantly higher than the incidence rate of 0.45 per 100 person-years among 139 patients who continued prophylaxis until CD4 counts increased to ≧200 cells/μL (adjusted risk ratio, 5.32; 95% confidence interval, 1.18, 23.94). Among the 215 patients who had early discontinuation of prophylaxis after achievement of undetectable plasma HIV RNA load, the incidence rate of pneumocystosis was reduced to 0.31 per 100 person-years, which was similar to that of the patients who continued prophylaxis until CD4 counts increased to ≧200 cells/μL (adjusted risk ratio, 0.63; 95% confidence interval, 0.03, 14.89).ConclusionsCompared with the risk of pneumocystosis among patients who continued prophylaxis until CD4 counts increased to ≧200 cells/μL after HAART, the risk was significantly higher among patients who discontinued prophylaxis when CD4 counts remained <200 cells/μL, while the risk could be reduced among patients who achieved undetectable plasma HIV RNA load after HAART.

Couples at risk for HIV infection in Southern India: characteristics of HIV-infected patients in concordant and discordant heterosexual relationships

The aim of the article is to compare the clinical and behavioural characteristics of HIV-infected South Indian patients in concordant and discordant heterosexual relationships. A cross-sectional analysis of married couples in concordant and discordant relationships was carried out. Demographic and clinical characteristics, sexual behaviours, CD4 cell count and plasma HIV-1 RNA loads were assessed. A total of 839 concordant patients and 996 discordant patients were included in this analysis. Significantly more men were in discordant than concordant relationships (97% versus 59%; P = 0.002). More discordant patients had never initiated highly active antiretroviral treatment (HAART) than concordant patients (14.1% versus 8.5%; P = 0.004). Concordant patients had significantly higher CD4 cell counts than discordant patients at the time of enrolling to care (205 versus 139 cells/microL; P = 0.001). Discordant patients had significantly higher plasma viral loads than concordant patients (100,000 copies/mL versus 89,154 copies/mL; P = 0.002). Discordant patients were more likely to use condoms with their spouses than concordant patients (49% versus 28.8%; P = 0.01). In conclusion, couples-based interventions and the provision of HAART could substantially decrease behavioural and clinical correlates of HIV transmission among discordant South Indian married couples. The spouses of HIV-infected index patients are at increased risk for HIV infection, and further preventive measures are needed.

Risk factors for HIV transmission among heterosexual discordant couples in South India*

To assess the risk factors associated with heterosexual HIV transmission among South Indian discordant couples enrolled in clinical care. A nested matched case-control study of serodiscordant couples in which the HIV-infected partner (index case) was enrolled in care. Demographic and clinical characteristics, sexual behaviours, CD4 cell count and plasma HIV-1 RNA loads were measured at enrollment and longitudinally over 12 months of follow-up. The study included 70 cases who seroconverted during study follow-up and 167 matched controls who remained persistently serodiscordant. The incidence of HIV infection among the initially seronegative partners was 6.52 per 100 person-years. Persistently discordant patients were more likely to have initiated highly active antiretroviral therapy (HAART) than patients in seroconverting relationships (62.9%vs. 42.9%) (P=0.001). Patients in seroconverting relationships had significantly higher plasma viral loads (PVLs) than patients in discordant relationships at enrolment, at 6 months and at 12 months (P<0.05). Patients in seroconverting relationships were less likely to use condoms with their primary partners than patients in discordant relationships (P<0.05). Patients in relationships that seroconverted between 6 and 12 months were diagnosed more often with genital Herpes simplex than patients in discordant relationships (P=0.001). In the univariate and multivariate logistic regression, the following variables were associated with seroconversion: PVL >100,000 [odds ratio (OR): 1.82; 95% confidence interval (CI): 1.1-2.8], non-disclosure of HIV status (OR: 5.5; 95% CI: 4.3-6.2) and not using condoms (OR: 2.8; 95% CI: 2.4-3.6). Couples-based intervention models are crucial in preventing HIV transmission to seronegative spouses. Providing early treatment for sexually transmitted infections, HAART and enhancing condom use and disclosure could potentially decrease the risk of HIV transmission within Indian married couples.

Factors associated with unprotected anal intercourse between HIV-positive men and regular male partners in a Sydney cohort

Blood plasma HIV-RNA load (BPVL) is the strongest predictor of HIV-1 transmission during sex. Unprotected anal intercourse (UAI) is the highest risk activity for transmission among men who have sex with men (MSM). Awareness of BPVL may influence rates of UAI. We assessed whether optimism towards antiretroviral therapy (ART) and/or biomedical factors influenced sexual activities with regular partners. Questionnaires were administered to 109 HIV-positive MSM participating in a cross-sectional study of BPVL and seminal viral load. The survey assessed HIV transmission beliefs and sexual practices with regular male partners in the past three months. Sixty-nine of 109 (63.3%) had been in a regular relationship and 42 reported having had anal sex. Unprotected receptive anal intercourse without ejaculation (URAI - e) was associated with awareness that their most recent BPVL was detectable (>50 RNA copies/mL) and not taking ART. Receptive UAI with ejaculation (URAI + e) was associated with not taking ART, having a sexually transmissible infection and having an HIV-positive partner; the latter was also associated with insertive UAI with ejaculation (UIAI + e). Treatment optimism was not associated with UAI. In this cohort, sexual practices were based more upon knowledge of biomedical factors rather than attitudes regarding transmission risks.

Viable strategies to facilitate liver transplantation for human immunodeficiency virus coinfection

The morbidity and mortality associated with human immunodeficiency virus (HIV) have dramatically decreased as a result of highly active antiretroviral therapy (HAART). Although people infected with HIV are no longer dying from the progression of HIV to acquired immune deficiency syndrome, end-stage liver disease secondary to the viral copathogens hepatitis B virus (HBV) and hepatitis C virus (HCV) has become a major cause of mortality in developed countries. As infection with HIV has evolved into a chronic disease, an increasing number of coinfected people are being referred for liver transplantation in the United States and Europe. Although many transplant centers still consider HIV infection a relative contraindication to transplantation, those with early experience in coinfected recipients with well-controlled HIV have reported excellent results following liver transplantation for hepatitis B and poorer but acceptable results following liver transplantation for hepatitis C. At the same time, transplant centers that have been proceeding with liver transplantation in coinfected patients have reported significantly shorter pretransplantation survival in HIV-positive recipients listed for liver transplantation in comparison with HIVnegative subjects. With this background, Murillas et al. in this issue of Liver Transplantation report on the natural history and prognostic factors of end-stage liver disease in HIV-coinfected patients following their first clinical decompensation of liver disease. The findings from this prospective study by Murillas et al. are highly relevant and noteworthy, in that only 14% (15/104) of the coinfected patients in the Spanish cohort experiencing their first documented liver decompensation met the acceptance criteria for liver transplantation and were placed on a waiting list. Furthermore, only 33% (5/15) of the listed patients underwent liver transplantation, and the other 10 (67%) died while on the waiting list for a median survival time of 5 months. It is of equal importance that the Model for End-Stage Liver Disease (MELD) score and the inability to achieve an undetectable plasma HIV-1 RNA load were independent risk factors for death. For those patients listed for liver transplantation, the calculated mortality rate for a given MELD score in HIV-infected patients was similar to the mortality rate in non–HIVinfected patients with a MELD score that was roughly 10 points higher. Although the MELD score correlated with death on the waiting list for the HIV-infected patients, the absolute value of the MELD score was associated with poorer survival rates in comparison with HIV-negative monoinfected patients. The dismal rates of listing (14%) HIV-coinfected patients for transplant, as well as the extremely high death rates on the waiting list, are important observations in this prospective study and deserve further discussion. A significant discrepancy between the US trials and this prospective Spanish trial is related to the inclusion trial for transplantation. Murillas et al. report that a previous history of opportunistic infection (with the exception of tuberculosis) was an exclusion criterion for activation on the waiting list. This exclusion criterion was the reason that a very high percentage of patients (55/89) were precluded from the transplant list. Some

Impact of Combined Anti-Retroviral Therapy on HIV-Associated Non-Hodgkin-Lymphoma - a Prospective European Multi-Cohort Study on Behalf of the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) Study Group

Background: Following its introduction in 1996, combination antiretroviral therapy (cART) has led to a substantial reduction in HIV-associated morbidity and mortality. The decline has, however, been less pronounced for non-Hodgkin lymphoma (NHL) than for other HIV-related complications, and NHL has become the most common cancer associated with HIV. Within the framework of a large prospective European multi-cohort project, the Collaboration of Observational HIV Epidemiological Research Europe (COHERE), we studied the incidence and risk factors for the development and survival of NHL in HIV-infected patients in the cART era.Methods: We analyzed the data of HIV- infected adult patients (aged >16 years) who were cART naïve at inclusion and started cART after 01.01.1998, at a time when cART had become well established and widely used in Europe. cART was defined as a regimen of at least 3 antiretroviral drugs. Patients had to have CD4 count measurements available before the start of cART and the diagnosis of NHL. Patients developing NHL before receiving cART (“not on cART”) and patients developing NHL while receiving cART (“on cART”) were analyzed separately. Both patients with Primary Brain Lymphoma (PBL) and systemic NHL were included in the analysis. Incidence rates were calculated based on the Poisson distribution; risk factors were estimated using crude and adjusted Weibull models, with random effects to account for heterogeneity between cohorts. Models with time varying covariates were used to explore the effects of CD4 cell counts and plasma HIV-RNA loads over time. Survival was estimated using Kaplan-Meier life table probabilities, with 95% confidence intervals (95% CI).Results: For the incidence analysis 56,305 patients from 22 cohort studies across Europe with 212,042 person-years at risk were evaluated. The incidence for NHL (both systemic NHL and PBL) in patients not on cART was 519 (95% CI 448 to 602) per 100,000 personyears compared to 229 (95% CI 208 to 252) per 100,000 person-years in those on cART. The corresponding rates for PBL were 57 (95% CI 36 to 89) per 100,000 person-years and 24 (95% CI 18 to 33) per 100,000 person years. In cART naïve patients risk factors for NHL were older age and low CD4 cell count nadirs. When included as time up-dated variables, high plasma HIV-1 RNA loads and low CD4 cell counts emerged as important risk factors. In patients receiving cART risk factors included low CD4 cell count nadirs, older age, and groups associated with HHV-8 infection, i.e. men having sex with men and patients with a previous diagnosis of Kaposi Sarcoma. Time up-dated HIV-1 RNA plasma concentration and CD4 cell count were also associated with developing NHL while on cART. For the survival analysis 847 NHL patients were eligible. Of those, 364 (43%) were cART naïve at diagnosis of NHL. After one year 66% (95% CI 63%–70%) of patients with systemic NHL and 54% (95% CI 43%–65%) of patients with PBL were alive. Risk factors for death were diagnosis of PBL, low CD4 cell count nadir and history of injection drug use.Conclusions: Combined anti-retroviral therapy reduces the risk of developing NHL. In the era of cART more advanced immunodeficiency is the dominant risk factors for developing NHL both in patients receiving and not receiving cART. Two thirds of patients diagnosed with HIV-related NHL other than PBL survive for longer than one year after diagnosis. Survival is poorer in patients diagnosed with PBL.

Detection of low-frequency K103N mutants after unstructured discontinuation of efavirenz in the presence of the CYP2B6 516 TT polymorphism

To measure antiretroviral drug plasma levels in newly diagnosed HIV-1 seropositive persons who presented with an undetectable plasma HIV-1 RNA load but gave no history of antiretroviral drug exposure and to determine the impact of interrupting undisclosed or unknown antiretroviral therapy on the emergence of drug resistance. Five newly diagnosed, reportedly drug-naive HIV-1 seropositive persons were included in the study. Drug resistance was determined by population and clonal sequencing of reverse transcriptase and protease. CYP2B6 polymorphisms were assayed by real-time PCR allelic discrimination on pre-amplified exons. Efavirenz was detected in the plasma of one of the five persons coinciding with a viral load <40 copies/mL by two different assays. When efavirenz became undetectable, the viral load rebounded. The patient was CYP2B6-516T homozygous. Population sequencing showed wild-type subtype D virus, whereas clonal sequencing detected low-frequency (2%) K103N. The patient firmly denied antiretroviral exposure but described the use of Ugandan remedies. In migrating populations seeking HIV testing, careful and compassionate counselling is required to facilitate the disclosure of previous diagnosis and therapy. The use of remedies of dubious content should also be discussed and investigated.

Seroprevalence of Viral Hepatitis and Sexually Transmitted Disease Among Adults with Recently Diagnosed HIV Infection in Southern Taiwan, 2000–2005: Upsurge in Hepatitis C Virus Infections Among Injection Drug Users

The purpose of this study was to compare the seroprevalence of viral hepatitis and sexually transmitted disease (STD) co-infections among three populations at risk recently diagnosed with HIV infection. A retrospective review of medical records was performed to determine the prevalence of several co-infections among adults recently diagnosed with HIV infection between 2000 and 2005 at National Cheng Kung University Hospital in Tainan, Taiwan. Among a total of 484 adults, 124 (25.6%) were men having sex with men (MSM), 105 (21.7%) were heterosexual adults, and 255 (52.7%) were injection drug users (IDUs). The case number of adults with recently diagnosed HIV infection increased annually, from 27 in 2000 to 142 in 2005 (p < 0.001). This trend appeared to be attributable to the upsurge in HIV infection among IDUs beginning in 2003. At the time of HIV diagnosis, mean CD4+ counts were significantly higher and plasma HIV-1 RNA loads were lower in the IDU group than the MSM or heterosexual groups. The hepatitis B virus (HBV) carrier rate was similar in all three groups, with an average rate of 16.5%. The prevalence of treponemal antibody and Entamoeba histolytica indirect hemagglutination antibody was higher in MSM (37.5% and 9.4%, respectively) than in heterosexuals (19.6% and 7.3%, respectively) or IDUs (3.2% and 2.1%). The seroprevalence of hepatitis A virus infection increased with age, with 94.2% (97/103) of patients who were older than 40 years. Hepatitis C virus (HCV) or HBV-HCV co-infections were noted more often in IDUs (97.9% and 16.9%, respectively) than in heterosexuals (10.9% and 2.2%, respectively) and MSM (5.3% and 3.6%, respectively). There was a recent upsurge in HIV-HCV co-infected IDUs in southern Taiwan. A higher rate of co-infection with STDs among HIV-infected MSM highlights the need for integrated STD control efforts in current HIV prevention programs.

A Randomized Study to Evaluate Injection Site Reactions using Three Different Enfuvirtide Delivery Mechanisms (the OPTIONS Study)

The antiretroviral enfuvirtide (ENF) is injected subcutaneously using a 27-gauge needle. Injection site reactions (ISRs) can affect long-term ENF tolerability. Alternative ENF delivery methods may ameliorate ISRs. We conducted a multicentre, open-label, randomized controlled trial in which patients receiving ENF were randomized to continue receiving ENF by a 27-gauge needle, a shorter 31-gauge needle or a gas-powered, needle-free injection device (NFID). The primary study endpoint was the proportion of participants with < grade 2 ISR induration at week 12. Sixty patients received treatment and were included in the intention-to-treat population. The cohort was predominantly male (95%) with a mean age of 49.1 (SD +/- 7.7) years who had injected ENF for a mean of 821 (SD +/- 561) days. Response rates for ISR induration at week 12 were 38%, 25% and 42% for the 27-gauge, 31-gauge and NFID groups, respectively (all pairwise treatment comparison P-values > 0.2). There was no significant between-group difference for any ISR endpoint, except for changes in the composite ISR score (that is, no ongoing pain of > grade 1 or ISR for ongoing pain > or = grade 1 with induration ISR < grade 3 and for nodules < grade 2), which favoured the 27-gauge needle and NFID groups over the 31-gauge group (P = 0.012 and 0.047, respectively). Plasma HIV RNA load was unaffected. There were seven adverse events related to the delivery system: five attributed to the NFID. At week 12, 85% of participants elected to use the NFID. Needle-free ENF injection offers a reasonable, reliable alternative to needle-based injecting in this population, at least in the short term.

Toll-like receptor expression and responsiveness are increased in viraemic HIV-1 infection

Toll-like receptors (TLR) are important in pathogen recognition and may play a role in HIV disease. We evaluated the effect of chronic untreated and treated HIV-1 infection on systemic TLR expression and TLR signalling. Two hundred HIV-infected and uninfected women from a Kenya cohort participated in the studies. TLR1 to TLR10 messenger RNA expression was determined by quantitative reverse transcriptase polymerase chain reaction in peripheral blood mononuclear cells (PBMC). TLR ligand responsiveness was determined in or using ex-vivo PBMC by cytokine production in culture supernatants. Chronic, untreated HIV-1 infection was significantly associated with increased mRNA expression of TLR6, TLR7, and TLR8 and when analysis was limited to those with advanced disease (CD4 cell count < 200 cells/ml) TLR2, TLR3, and TLR4 were additionally elevated. TLR expression correlated with the plasma HIV-RNA load, which was significant for TLR6 and TLR7. In vitro HIV single-stranded RNA alone could enhance TLR mRNA expression. PBMC of HIV-infected subjects also demonstrated profoundly increased proinflammatory responsiveness to TLR ligands, suggesting sensitization of TLR signalling in HIV. Finally, viral suppression by HAART was associated with a normalization of TLR levels. Together, these data indicate that chronic viraemic HIV-1 is associated with increased TLR expression and responsiveness, which may perpetuate innate immune dysfunction and activation that underlies HIV pathogenesis, and thus reveal potential new targets for therapy.

Plasma Viral Load Threshold for Sustaining Intrahost HIV Type 1 Evolution

The objective of the present study was to determine if natural suppression of plasma viremia below the detection limit of commercial assays (50-80 copies HIV-1 RNA/ml) can contain the HIV-1 evolution. HIV-1 quasispecies complexity in PBMC DNA was assessed in the env gene at two time points in 14 long-term nonprogressors (LTNPs). Sequence changes consistent with viral evolution was found in all patients with a median plasma RNA viral load >100 copies/ml. Evidence of low-level viral evolution was detected in two of four patients with intermittent viremia and a median plasma HIV-1 RNA load of >80 copies/ml. No significant evolution was observed in the three LTNPs with persistent viral suppression below the detection limit. Overall, a significant positive correlation (p < 0.001) was observed between viral evolution and plasma RNA viral load in the LTNPs analyzed. These results suggest that the detection limit of ultrasensitive viremia assays could represent an important threshold below which intrahost HIV-1 evolution does not occur.

Response to region of difference 1 (RD1) epitopes in human immunodeficiency virus (HIV)-infected individuals enrolled with suspected active tuberculosis: a pilot study

Tuberculosis is the most frequent co-infection in human immunodeficiency virus (HIV)-infected individuals, and which still presents diagnostic difficulties. Recently we set up an assay based on interferon (IFN)-gamma response to region of difference 1 (RD1) peptides selected by computational analysis which is associated with active Mycobacterium tuberculosis replication. The objective of this study was to investigate the response to RD1 selected peptides in HIV-1-infected individuals in a clinical setting. The mechanisms of this immune response and comparison with other immune assays were also investigated. A total of 111 HIV-infected individuals with symptoms and signs consistent with active tuberculosis were enrolled prospectively. Interferon (IFN)-gamma responses to RD1 selected peptides and recall antigens were evaluated by enzyme-linked immunospot assay. Results were correlated with CD4(+) T cell counts, individuals' characteristics, tuberculin skin test, QuantiFERON-TB Gold and T-SPOT.TB. Results from 21 (19%) individuals were indeterminate due to in vitro cell anergy. Among 'non-anergic' individuals, sensitivity for active tuberculosis of the assay based on RD1 selected peptides was 67% (24 of 36), specificity was 94% (three of 54). The assay also resulted positive in cases of extra-pulmonary and smear-negative pulmonary active tuberculosis. The response was mediated by CD4(+) effector/memory T cells and correlated with CD4(+) T cell counts, but not with plasma HIV-RNA load. Moreover, the RD1 selected peptides assay had the highest diagnostic odds ratio for active tuberculosis compared to tuberculin skin test (TST), QuantiFERON-TB Gold and T-SPOT.TB. RD1 selected peptides assay is associated with M. tuberculosis replication in HIV-infected individuals, although T cell anergy remains an important obstacle to be overcome before the test can be proposed as a diagnostic tool.

Predictors of Virological Outcome and Safety in Primary HIV Type 1-Infected Patients Initiating Quadruple Antiretroviral Therapy: QUEST GW PROB3005

Initiation of antiretroviral therapy during primary human immunodeficiency virus (HIV)-1 infection may confer long-term benefit. After initiation of zidovudine, lamivudine, abacavir, and amprenavir therapy in patients in the QUEST cohort, predictors of virological outcome, virological and immunological changes, and adverse events were evaluated over 48 weeks. One hundred forty-eight patients started antiretroviral therapy during primary HIV-1 infection with < or =3 bands on Western Blot (median plasma HIV-1 RNA load, 5.4 log copies/mL; median CD4 cell count, 517 cells/mm(3)). By week 48, 36% of patients had stopped treatment or were lost to follow-up. Among the 115 patients receiving follow-up care at week 48 (102 of whom were receiving antiretroviral therapy), the median viral load decrease was -5.4 log copies/mL (interquartile range [IQR], -6.4 to -3.9 log copies/mL), and the median increase in CD4 cell count was 147 cells/mm(3) (IQR, -1 to 283 cells/mm(3)); 84.2% of patients had a viral load < or =50 copies/mL, and 44.7% of patients had a viral load < or =3 copies/mL. The median cell-associated RNA level decreased from 3.4 log copies/million PBMCs (IQR, 2.9-4.1 log copies/million PBMCs) to 0.8 log copies/million PBMCs (IQR, 0.5-1.4 log copies/million PBMCs), and the median cell-associated DNA level decreased from 2.8 log copies/million PBMCs (IQR, 2.4-3.0 log copies/million PBMCs) to 1.6 log copies/million PBMCs (IQR, 1.2-1.9 log copies/million PBMCs); 33.3% of patients had an undetectable RNA level, and 9.5% of patients had an undetectable cell-associated DNA level. The median CD8(+)/CD38(++) T cell count decreased from 459 cells/mm(3) (IQR, 208-974 cells/mm(3)) to 33 cells/mm(3) (IQR, 19-75 cells/mm(3)). Baseline CD8(+)/CD38(++) T cell count and cell-associated DNA level were independent inverse predictors for reaching a viral load < or =3 copies/mL. Eighty-three patients experienced a serious adverse event (median duration of an adverse event, 15 days).Conclusions. Initiation of antiretroviral therapy during primary HIV-1 infection was associated with very significant antiretroviral activity and a decrease in immune activation. Lower baseline CD8(+)/CD38(++) T cell count and cell-associated DNA level were predictive of achieving a viral load < or =3 copies/mL.

Clinical Impact of GB Virus C Viremia on Patients with HIV Type 1 Infection in the Era of Highly Active Antiretroviral Therapy

The influence of GB virus C (GBV-C) viremia on clinical outcomes of patients with human immunodeficiency virus type 1 (HIV-1) infection remains controversial in the era of highly active antiretroviral therapy (HAART). A prospective observational study was conducted to describe the epidemiology of GBV-C viremia and assess its clinical impact on treatment responses to HAART in 385 HIV-1-infected patients during the period from January 1999 through June 2004. A total of 59 patients (15.3%) had detectable GBV-C RNA viremia during a median observation of 3.6 years (range, 1.0-7.0 years); 47 patients (12.2%) had GBV-C viremia at enrollment, and 12 (3.1%) acquired GBV-C infection during follow-up. Thirty-two (68.1%) of the 47 patients with baseline GBV-C viremia had persistent GBV-C viremia. Compared with patients with clearance of GBV-C viremia (n=15) and patients without detectable GBV-C viremia (n=326), patients with persistent GBV-C viremia were more likely to be men who have sex with men (81.3% vs. 60.4%; P=.02), tended to have lower baseline plasma HIV RNA load (HIV RNA load > or =5 log(10) copies/mL, 31.3% vs. 49.4%; P=.05), and had a higher proportion of isolated anti-hepatitis B core antibody (37.5% vs. 17.2%; P=.005). There was no statistically significant difference in terms of virologic, immunologic, and clinical responses to HAART; occurrence of hepatic events; and mortality among the 3 groups. Persistent GBV-C viremia is significantly associated with male-male sex in HIV-infected patients with advanced immunodeficiency, and persistent GBV-C viremia does not confer short-term benefit in patients receiving HAART.

Phenotypic Susceptibility to Didanosine Is Associated with Antiviral Activity in Treatment‐Experienced Patients with HIV‐1 Infection

We investigated the relationship between human immunodeficiency virus (HIV) phenotypic susceptibility to didanosine and the antiviral activity of didanosine (ddI) in the JAGUAR study. Baseline plasma HIV phenotypic susceptibility to ddI was assessed using a phenotype assay of patients randomized to receive ddI or placebo for 4 weeks in addition to their current regimen. Phenotypic susceptibility scores (PSSs) were then calculated for each sample. Associations between PSS and week 4 reductions in plasma HIV-1 RNA load or virologic response were assessed using linear regression and Jonckherre's test and the Wilcoxon and Cochran-Armitage tests, respectively. In the ddI arm, a significant association between reduction in viral load and continuous PSS was observed (P<.0001). Using distinct categories, an increasing fold change (FC) in susceptibility to ddI was strongly associated with smaller reductions in plasma HIV-1 RNA load (P<.0001). The proportion of virologic responders was 83% (15/18) for patients with a ddI FC < or =1.3, 50% (33/66) for patients with an FC of 1.3-2.2, and 29% (4/14) for patients with an FC > or =2.2 (P=.0008). After we determined these findings, 3 ddI FC categories were defined using 1.3 and 2.2 as thresholds. The relationship between phenotypic susceptibility to ddI and reduction in plasma HIV-1 RNA load describes a continuum. The establishment of a lower clinical cutoff at 1.3 and an upper clinical cutoff at 2.2 are clinically relevant.

Rate of Viral Evolution and Risk of Losing Future Drug Options in Heavily Pretreated, HIV-Infected Patients Who Continue to Receive a Stable, Partially Suppressive Treatment Regimen

Many treatment-experienced, HIV-infected patients who have limited therapeutic options for complete viral suppression continue to receive a partially suppressive treatment regimen pending the availability of at least 2 new antiretroviral drugs. The major risk of this approach is ongoing viral evolution and the loss of future drug options. Antiretroviral-treated subjects with incomplete viral suppression were sampled from a clinic-based cohort. Inclusion criteria were receipt of a stable treatment regimen for > or = 120 days, a plasma HIV RNA load of > 500 copies/mL, and > or = 1 resistance mutation. Phenotypic and genotypic resistance testing was performed every 4 months. The 106 patients who were eligible for the study had a median of 3 observations during a median of 11.3 months. An estimated 23% and 18% developed at least 1 new nucleoside analogue and 1 new protease inhibitor mutation at 1 year, respectively. An estimated 30% lost the phenotypic equivalent of 1 susceptible drug at 1 year. A lower number of total mutations at baseline was a significant predictor of developing a new nucleoside analogue mutation (P=.01). At 1 year, the probability that an existing mutation would become undetectable using population-based sequencing was 32%. There was a higher rate of change at nonresistance codons than at codons known to be associated with drug resistance. Heavily pretreated patients with HIV infection who remain on a partially suppressive regimen have a measurable risk of losing future drug options, particularly those patients who have few baseline mutations. Resistance mutations vary over time, which suggests that the results of any single resistance test may not be representative of all mutations selected by a given treatment regimen.