Global epidemiology of HIV:

Fasting blood glucose and insulin sensitivity are unaffected by HAART duration in Cameroonians receiving first-line antiretroviral treatment

AIMS

This study assessed the relationship between highly active antiretroviral therapy (HAART) duration and cardiometabolic disorders in HIV-infected Cameroonians.

METHODS

HIV-infected Cameroonians aged 21 years or above were cross-sectionally recruited at the Yaoundé Central Hospital, a certified HIV care centre, and their anthropometry, body composition (impedancemetry), fasting blood glucose (FBG) and lipid levels, and insulin sensitivity (IS; short insulin tolerance test) were measured.

RESULTS

A total of 143 participants with various durations of HAART [treatment-naïve (n=28), 1-13 months (n=44), 14-33 months (n=35) and 34-86 months (n=36)] were recruited. They were mostly women (72%), and had a mean age of 39.5 (SD: 9.8) years. Half (52%) were using a stavudine-containing regimen. There was a significant trend towards a positive change in body mass index and waist-to-hip ratio with increasing duration of HAART (all P=0.02). Systolic (P=0.04) and diastolic (P=0.03) blood pressure, total cholesterol (P=0.01), prevalence of hypertension (P=0.04) and hypercholesterolaemia (P=0.007) were also significantly increased with HAART duration, whereas triglycerides, FBG and IS were unaffected. Clustering of metabolic disorders increased (P=0.02 for ≥1 component of the metabolic syndrome and P=0.09 for ≥2 components) with HAART duration.

CONCLUSION

HAART duration is associated with obesity, fat distribution, blood pressure and cholesterol levels in HIV-infected Cameroonians, but does not appear to significantly affect glucose metabolism.

An assessment of the likely acceptability of vaginal microbicides for HIV prevention among women in rural Ghana

BACKGROUND

The findings of the CAPRISA tenofovir studies have raised expectations that soon an approved microbicide would be available. However it is in only a limited number of countries in sub-Saharan Africa that the acceptability of microbicides has been evaluated. We conducted a study to assess the acceptability of vaginal microbicides among women in rural Ghana.

METHODS

The study employs a mixed method design, using cross-sectional survey and focus group discussions to further understand issues related to awareness and attitudes towards microbicide development, acceptability and perceived partner attitudes among pregnant women attending antenatal clinic in two health facilities in the Kintampo North municipality of Ghana. We used logistic regression to identify possible predictors of microbicide acceptability among the women surveyed.

RESULTS

Although only 2% of the 504 women were aware of the development of microbicides, 95% were willing to use one when it became available. The cost of a microbicide that will be considered affordable to 50% of women was US$0.75. Although there were concerns about possible wetting effect, gel or creams were the most preferred (68% of women) formulation. Although 71% thought their partners will find microbicide acceptable, apprehensions about the feasibility of and consequences of failed discreet use were evident. 49% of women were concerned about possible negative effect of microbicide on sexual pleasure. Perceived partner acceptability (O.R. =17.7; 95%C.I. 5.03-62.5) and possibility of discreet use (O.R. =8.9 95%C.I. 2.63-30.13) were the important predictors of microbicide acceptability.

CONCLUSION

Achieving microbicide acceptability among male partners should be made a part of the promotive interventions for ensuring effective use among women in rural Ghana.

Animal models in virus research: their utility and limitations

Viral diseases are important threats to public health worldwide. With the number of emerging viral diseases increasing the last decades, there is a growing need for appropriate animal models for virus studies. The relevance of animal models can be limited in terms of mimicking human pathophysiology. In this review, we discuss the utility of animal models for studies of influenza A viruses, HIV and SARS-CoV in light of viral emergence, assessment of infection and transmission risks, and regulatory decision making. We address their relevance and limitations. The susceptibility, immune responses, pathogenesis, and pharmacokinetics may differ between the various animal models. These complexities may thwart translating results from animal experiments to the humans. Within these constraints, animal models are very informative for studying virus immunopathology and transmission modes and for translation of virus research into clinical benefit. Insight in the limitations of the various models may facilitate further improvements of the models.

Viral targets of acylguanidines

Acylguanidines are a new class of antiviral compounds with the unique ability to target both RNA polymerase and transmembrane proteins of viruses from different families. Importantly, they inhibit proteins which are not targeted by existing antiviral therapies, for example, Vpu of HIV type 1, p7 of hepatitis C virus, E of severe acute respiratory syndrome coronavirus and RNA-dependent RNA polymerase of coxsackievirus B3. BIT225, developed by Biotron Limited, is the first acylguanidine in clinical trials against HIV type 1 and hepatitis C virus. In this article we focus on the mechanisms of inhibition of viral proteins by acylguanidines.

The HIV Epidemic: High-Income Countries

The HIV epidemic in higher-income nations is driven by receptive anal intercourse, injection drug use through needle/syringe sharing, and, less efficiently, vaginal intercourse. Alcohol and noninjecting drug use increase sexual HIV vulnerability. Appropriate diagnostic screening has nearly eliminated blood/blood product-related transmissions and, with antiretroviral therapy, has reduced mother-to-child transmission radically. Affected subgroups have changed over time (e.g., increasing numbers of Black and minority ethnic men who have sex with men). Molecular phylogenetic approaches have established historical links between HIV strains from central Africa to those in the United States and thence to Europe. However, Europe did not just receive virus from the United States, as it was also imported from Africa directly. Initial introductions led to epidemics in different risk groups in Western Europe distinguished by viral clades/sequences, and likewise, more recent explosive epidemics linked to injection drug use in Eastern Europe are associated with specific strains. Recent developments in phylodynamic approaches have made it possible to obtain estimates of sequence evolution rates and network parameters for epidemics.

Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Female sex workers are a population who are at heightened risk of HIV infection secondary to biological, behavioural, and structural risk factors. However, three decades into the HIV pandemic, understanding of the burden of HIV among these women remains limited. We aimed to assess the burden of HIV in this population compared with that of other women of reproductive age.

METHODS

We searched PubMed, Embase, Global Health, SCOPUS, PsycINFO, Sociological Abstracts, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Science, and POPLine for studies of female sex workers in low-income and middle-income countries published between Jan 1, 2007, and June 25, 2011. Studies of any design that measured the prevalence or incidence of HIV among female sex workers, even if sex workers were not the main focus of the study, were included. Meta-analyses were done with the Mantel-Haenszel method with a random-effects model characterising an odds ratio for the prevalence of HIV among female sex workers compared with that for all women of reproductive age.

FINDINGS

Of 434 selected articles and surveillance reports, 102 were included in the analyses, representing 99,878 female sex workers in 50 countries. The overall HIV prevalence was 11·8% (95% CI 11·6-12·0) with a pooled odds ratio for HIV infection of 13·5 (95% CI 10·0-18·1) with wide intraregional ranges in the pooled HIV prevalence and odds ratios for HIV infection. In 26 countries with medium and high background HIV prevalence, 30·7% (95% CI 30·2-31·3; 8627 of 28,075) of sex workers were HIV-positive and the odds ratio for infection was 11·6 (95% CI 9·1-14·8).

INTERPRETATION

Although data characterising HIV risk among female sex workers is scarce, the burden of disease is disproportionately high. These data suggest an urgent need to scale up access to quality HIV prevention programmes. Considerations of the legal and policy environments in which sex workers operate and actions to address the important role of stigma, discrimination, and violence targeting female sex workers is needed.

FUNDING

The World Bank, UN Population Fund.

Design and synthesis of a bivalent ligand to explore the putative heterodimerization of the mu opioid receptor and the chemokine receptor CCR5

The bivalent ligand approach has been utilized not only to study the underlying mechanism of G protein-coupled receptors dimerization and/or oligomerization, but also to enhance ligand affinity and/or selectivity for potential treatment of a variety of diseases by targeting this process. Substance abuse and addiction have made both the prevention and the treatment of human immunodeficiency virus (HIV) infection more difficult to tackle. Morphine, a mu opioid receptor (MOR) agonist, can accelerate HIV infection through up-regulating the expression of the chemokine receptor CCR5, a well-known co-receptor for HIV invasion to the host cells and this has been extensively studied. Meanwhile, two research groups have described the putative MOR-CCR5 heterodimers in their independent studies. The purpose of this paper is to report the design and synthesis of a bivalent ligand to explore the biological and pharmacological process of the putative MOR-CCR5 dimerization phenomenon. The developed bivalent ligand thus contains two distinct pharmacophores linked through a spacer; ideally one of which will interact with the MOR and the other with the CCR5. Naltrexone and Maraviroc were selected as the pharmacophores to generate such a bivalent probe. The overall reaction route to prepare this bivalent ligand was convergent and efficient, and involved sixteen steps with moderate to good yields. The preliminary biological characterization showed that the bivalent compound 1 retained the pharmacological characteristics of both pharmacophores towards the MOR and the CCR5 respectively with relatively lower binding affinity, which tentatively validated our original molecular design.

Vitamin E deficiency in developing countries

In addition to its role as a potent antioxidant, vitamin E is involved in a wide range of physiological processes, ranging from immune function and control of inflammation to regulation of gene expression and cognitive performance. Results from multiple studies suggest that poor nutritional status and higher prevalence of other oxidative stressors such as malaria and HIV infection predispose populations in developing countries for vitamin E deficiency. Although direct comparison between study outcomes is complicated by varied definitions of vitamin E deficiency, data trends indicate that children and the elderly are more vulnerable age groups and that men may be at higher risk for deficiency than women. Public health initiatives aimed at improving the vitamin E status of high-risk populations in developing countries would be prudent to counteract oxidative stress, improve immune function, and protect against neurologic and cognitive deficits. Additional research is needed to establish dose-response relationships of various interventions and to develop cost-effective, culturally-appropriate, and targeted programs.

Drosophila as a genetic model for studying pathogenic human viruses

Viruses are infectious particles whose viability is dependent on the cells of living organisms, such as bacteria, plants, and animals. It is of great interest to discover how viruses function inside host cells in order to develop therapies to treat virally infected organisms. The fruit fly Drosophila melanogaster is an excellent model system for studying the molecular mechanisms of replication, amplification, and cellular consequences of human viruses. In this review, we describe the advantages of using Drosophila as a model system to study human viruses, and highlight how Drosophila has been used to provide unique insight into the gene function of several pathogenic viruses. We also propose possible directions for future research in this area.

Molecular characterization of HIV-1 CRF01_AE in Mekong Delta, Vietnam, and impact of T-cell epitope mutations on HLA recognition (ANRS 12159)

Background

To date, 11 HIV-1 subtypes and 48 circulating recombinant forms have been described worldwide. The underlying reason why their distribution is so heterogeneous is not clear. Host genetic factors could partly explain this distribution. The aim of this study was to describe HIV-1 strains circulating in an unexplored area of Mekong Delta, Vietnam, and to assess the impact of optimal epitope mutations on HLA binding.

Methods

We recruited 125 chronically antiretroviral-naive HIV-1-infected subjects from five cities in the Mekong Delta. We performed high-resolution DNA typing of HLA class I alleles, sequencing of Gag and RT-Prot genes and phylogenetic analysis of the strains. Epitope mutations were analyzed in patients bearing the HLA allele restricting the studied epitope. Optimal wild-type epitopes from the Los Alamos database were used as reference. T-cell epitope recognition was predicted using the immune epitope database tool according to three different scores involved in antigen processing (TAP and proteasome scores) and HLA binding (MHC score).

Results

All sequences clustered with CRF01_AE. HLA class I genotyping showed the predominance of Asian alleles as A*11:01 and B*46:01 with a Vietnamese specificity held by two different haplotypes. The percentage of homology between Mekong and B consensus HIV-1 sequences was above 85%. Divergent epitopes had TAP and proteasome scores comparable with wild-type epitopes. MHC scores were significantly lower in divergent epitopes with a mean of 2.4 (±0.9) versus 2 (±0.7) in non-divergent ones (p<0.0001).

Conclusions

Our study confirms the wide predominance of CRF01_AE in the Mekong Delta where patients harbor a specific HLA pattern. Moreover, it demonstrates the lower MHC binding affinity among divergent epitopes. This weak immune pressure combined with a narrow genetic diversity favors immune escape and could explain why CRF01_AE is still predominant in Vietnam, particularly in the Mekong area.

The type I interferon response during viral infections: a "SWOT" analysis

The type I interferon (IFN) response is a strong and crucial moderator for the control of viral infections. The strength of this system is illustrated by the fact that, despite some temporary discomfort like a common cold or diarrhea, most viral infections will not cause major harm to the healthy immunocompetent host. To achieve this, the immune system is equipped with a wide array of pattern recognition receptors and the subsequent coordinated type I IFN response orchestrated by plasmacytoid dendritic cells (pDCs) and conventional dendritic cells (cDCs). The production of type I IFN subtypes by dendritic cells (DCs), but also other cells is crucial for the execution of many antiviral processes. Despite this coordinated response, morbidity and mortality are still common in viral disease due to the ability of viruses to exploit the weaknesses of the immune system. Viruses successfully evade immunity and infection can result in aberrant immune responses. However, these weaknesses also open opportunities for improvement via clinical interventions as can be seen in current vaccination and antiviral treatment programs. The application of IFNs, Toll-like receptor ligands, DCs, and antiviral proteins is now being investigated to further limit viral infections. Unfortunately, a common threat during stimulation of immunity is the possible initiation or aggravation of autoimmunity. Also the translation from animal models to the human situation remains difficult. With a Strengths-Weaknesses-Opportunities-Threats ("SWOT") analysis, we discuss the interaction between host and virus as well as (future) therapeutic options, related to the type I IFN system.

Genomic detection of human immunodeficiency virus (HIV) by nucleic acid amplification test in a frequent platelet donor during the pre-seroconversion period

Since serological donor-screening tests for HIV were introduced in 1985, the safety of donated blood components has improved dramatically. However, these tests do not completely prevent the risk of transfusion-associated HIV infection related to the use of blood donated during the pre-seroconversion window period. Testing based on nucleic acid amplification is being implemented to screen for HIV-infected blood donated during this period, which has reduced the probability of transmitting HIV through transfusion by shortening the window period. This article describes a case of acute HIV-1 infection, detected using a nucleic acid amplification test (NAT) in a repeat blood donor who donated during the pre-seroconversion window period and whose antigen and anti-HIV antibody expression was observed after molecular marker detection. In addition, the possible route of infection is discussed based on the patient's history, and finally, the need for NAT technology for blood donor screening is emphasized.

Anti-AIDS agents 86. Synthesis and anti-HIV evaluation of 2',3'-seco-3'-nor DCP and DCK analogues

In a continuing study of novel anti-HIV agents with drug-like structures and properties, 30 1'-O-, 1'-S-, 4'-O- and 4'-substituted-2',3'-seco-3'-nor DCP and DCK analogues (8-37) were designed and synthesized. All newly synthesized seco-compounds were screened against HIV-1(NL4-3) and a multiple reverse transcriptase (RT) inhibitor-resistant (RTMDR) strain in the TZM-bl cell line, using seco-DCK (7) and 2-ethyl-DCP (4) as controls. Several compounds (14, 18, 19, 22-24, and 32) exhibited potent anti-HIV activity with EC(50) values ranging from 0.93 to 1.93 μM and therapeutic index (TI) values ranging from 20 to 39. 1'-O-Isopropoxy-2',3'-seco-3'-nor-DCP (12) showed the greatest potency among the newly synthesized compounds with EC(50) values of 0.47 and 0.88 μM, and TI of 96 and 51, respectively, against HIV-1(NL4-3) and RTMDR strains. The seco-compounds exhibited better chemical stability in acidic conditions compared with DCP and DCK compounds. Overall, the results suggested that seco-DCP analogues with simplified structures may be more favorable for development as novel anti-HIV candidates.

In-hospital mortality rates and HIV: a medical ward review, Lilongwe, Malawi

In order to determine inpatient hospital mortality rates, causes of mortality and characteristics of inpatients at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, we conducted a prospective observational study of all patients admitted to KCH medical ward from 20 September 2008 to April 2, 2009. All admission diagnoses, HIV status and antiretroviral therapy (ART) use were recorded. Patients' vital status was determined at discharge. A descriptive analysis and two logistic regression models were used for the analysis. Of the 1895 enrolled patients, the overall hospital mortality rate was 14.6%, substantially higher among known HIV-infected patients (24.2% versus 10.8%, P = 0.0009) and men (17.1% versus 12%, P = 0.033). Patients with multiple diagnoses had significantly higher mortality (odds ratio [OR] 2.33; 95% confidence interval [CI] 1.47, 3.71). Most patients (62.3%) had unknown HIV status at admission. Among HIV-infected patients, ART use did not reduce hospital mortality or alter the spectrum of diseases. The majority of diagnoses were infectious (63.4%). The high inpatient mortality rate, especially among HIV-infected patients combined with the limited spectrum of diagnoses, emphasizes the need for improved inpatient management and diagnostic services. Expansion of HIV testing is warranted. Despite the rollout of ART, there remains a significant need for treatment of HIV-infected individuals.

Use of respondent-driven sampling to enhance understanding of injecting networks: a study of people who inject drugs in Sydney, Australia

BACKGROUND

Respondent-driven sampling (RDS) is a method for recruiting hidden populations, such as people who inject drugs (PWID). In RDS, participants recruit their peers into the study; who recruited who into the study is tracked, and thus information is gathered on the population's social networks. The purpose of this study was to use information collected from an RDS study of PWID to determine the size and structure of injecting networks and whether network characteristics are associated with sharing injecting equipment.

METHODS

A study was launched in Sydney, Australia in 2009 with five seeds, who were asked to recruit three participants each into the survey. This process was repeated until the target sample size was reached. The median size of injecting networks and the homophily (a measure of in-group affiliation) of different subgroups were calculated. Participants' information was linked with that of their recruiter to form dyads, and multivariate analysis was conducted to determine whether dyad and injecting network characteristics were associated with sharing injecting equipment within the dyads.

RESULTS

The injecting networks were large, the lowest median subgroup network size being 12. Homophily estimates indicated a lack of strong ties both within and across groups. In the multivariate analysis, factors significantly associated with sharing injecting equipment within dyads were feeling very close to their recruiter and having one or both members of the dyad identify as Aboriginal or Torres Strait Islander and one or both members having not been tested for hepatitis C in the previous year.

CONCLUSION

RDS provided valuable information on injecting networks in Sydney. PWID were shown to be socially connected with a large number of other injectors, and affiliations were formed without regard to demographic or drug use characteristics. Linking information from the recruits with that of their recruiter was a useful way of organizing information to gain a more complete understanding of risk behaviour.

HIV and tuberculosis trends in the United States and select Sub-Saharan Africa countries

Tuberculosis (TB) and Human Immunodeficiency Virus (HIV) are two catastrophic diseases affecting millions of people worldwide every year; and are considered to be pandemic by the World Health Organization. This study aims to compare the recent trends in TB and HIV in the United States and Sub-Saharan African Countries. Data (incidence, prevalence and death rates of HIV and TB) for the United States, Cameroon, Nigeria, and South Africa were collected from The Joint United Nations Programme for HIV/AIDS (UNAIDS), US Census Bureau and World Health Organization (WHO) databases and analyzed using Statistical Analysis Software (SAS v 9.1). Analysis of Variance (ANOVA) was performed to compare the variables of interest between the countries and across time. Results showed that percent rates of TB cases, TB deaths, HIV cases and HIV deaths were significantly different (P < 0.001) among these countries from 1993 to 2006. South Africa had the highest rates of HIV and TB; while US had the lowest rates of both diseases. Tuberculosis and HIV rates for Cameroon and Nigeria were significantly higher when compared to the United States, but were significantly lower when compared to South Africa (P < 0.001). There were significant differences (P < 0.001) in the prevalence of TB and HIV between the United States and the Sub-Saharan African countries, as well as differences within the Sub-Saharan African countries from 1993 to 2006. More analysis needs to be carried out in order to determine the prevalence and incidence of HIV and TB among multiple variables like gender, race, sexual orientation and age to get a comprehensive picture of the trends of HIV and TB.

Sexual orientation and mortality among US men aged 17 to 59 years: results from the National Health and Nutrition Examination Survey III

OBJECTIVES

We investigated associations between minority sexual orientation and mortality among US men.

METHODS

We used data from a retrospective cohort of 5574 men aged 17 to 59 years, first interviewed in the National Health and Nutrition Examination Survey III (NHANES III; 1988-1994) and then followed for mortality status up to 18 years later. We classified men into 3 groups: those reporting (1) any same-sex sexual partners (men who have sex with men [MSM]; n = 85), (2) only female sexual partners (n = 5292), and (3) no sexual partners (n = 197). Groups were then compared for all-cause mortality, HIV-related mortality, suicide-related mortality, and non-HIV-related mortality.

RESULTS

Compared with heterosexual men, MSM evidenced greater all-cause mortality. Approximately 13% of MSM died from HIV-related causes compared with 0.1% of men reporting only female partners. However, mortality risk from non-HIV-related causes, including suicide, was not elevated among MSM.

CONCLUSIONS

In the United States, the HIV epidemic continues to be the major contributing factor for premature death rates among MSM. Cohorts such as the NHANES III offer a unique opportunity to track the effects of the HIV epidemic on this population.

Vaginally administered PEGylated LIF antagonist blocked embryo implantation and eliminated non-target effects on bone in mice

Female-controlled contraception/HIV prevention is critical to address health issues associated with gender inequality. Therefore, a contraceptive which can be administered in tandem with a microbicide to inhibit sexually transmitted infections, is desirable. Uterine leukemia inhibitory factor (LIF) is obligatory for blastocyst implantation in mice and associated with infertility in women. We aimed to determine whether a PEGylated LIF inhibitor (PEGLA) was an effective contraceptive following vaginal delivery and to identify non-uterine targets of PEGLA in mice.

Vaginally-applied ¹²⁵I-PEGLA accumulated in blood more slowly (30 min vs 10 min) and showed reduced tissue and blood retention (24 h vs 96 h) compared to intraperitoneal injection in mice. Vaginally-applied PEGLA blocked implantation. PEGLA administered by intraperitoneal injection inhibited bone remodelling whereas vaginally-applied PEGLA had no effect on bone. Further, PEGLA had no effect in an animal model of multiple sclerosis, experimental auto-immune encephalomyelitis, suggesting PEGLA cannot target the central nervous system.

Vaginally-administered PEGLA is a promising non-hormonal contraceptive, one which could be delivered alone, or in tandem with a microbicide. Vaginal application reduced the total dose of PEGLA required to block implantation and eliminated the systemic effect on bone, showing the vagina is a promising site of administration for larger drugs which target organs within the reproductive tract.

Diverse peptide presentation of rhesus macaque major histocompatibility complex class I Mamu-A 02 revealed by two peptide complex structures and insights into immune escape of simian immunodeficiency virus

Major histocompatibility complex class I (MHC I)-restricted CD8(+) T-cell responses play a pivotal role in anti-human immunodeficiency virus (HIV) immunity and the control of viremia. The rhesus macaque is an important animal model for HIV-related research. Among the MHC I alleles of the rhesus macaque, Mamu-A 02 is prevalent, presenting in ≥20% of macaques. In this study, we determined the crystal structure of Mamu-A 02, the second structure-determined MHC I from the rhesus macaque after Mamu-A 01. The peptide presentation characteristics of Mamu-A 02 are exhibited in complex structures with two typical Mamu-A 02-restricted CD8(+) T-cell epitopes, YY9 (Nef159 to -167; YTSGPGIRY) and GY9 (Gag71 to -79; GSENLKSLY), derived from simian immunodeficiency virus (SIV). These two peptides utilize similar primary anchor residues (Ser or Thr) at position 2 and Tyr at position 9. However, the central region of YY9 is different from that of GY9, a difference that may correlate with the immunogenic variance of these peptides. Further analysis indicated that the distinct conformations of these two peptides are modulated by four flexible residues in the Mamu-A 02 peptide-binding groove. The rare combination of these four residues in Mamu-A 02 leads to a variant presentation for peptides with different residues in their central regions. Additionally, in the two structures of the Mamu-A 02 complex, we compared the binding of rhesus and human β(2) microglobulin (β(2)m) to Mamu-A 02. We found that the peptide presentation of Mamu-A 02 is not affected by the interspecies interaction with human β(2)m. Our work broadens the understanding of CD8(+) T-cell-specific immunity against SIV in the rhesus macaque.

Ignoring the group in group-level HIV/AIDS intervention trials: a review of reported design and analytic methods

OBJECTIVES

Studies evaluating the efficacy of HIV/AIDS interventions often involve the random assignment of groups of participants or the treatment of participants in groups. These studies require analytic methods that take within-group correlation into account. We reviewed published studies to determine the extent to which within-group correlation was dealt with properly.

DESIGN

We reviewed group-randomized trials (GRTs) and individually randomized group treatment (IRGT) trials published in HIV/AIDS and general public health journals 2005-2009.

METHODS

At least two of the authors reviewed each article, recording descriptive characteristics, sample size estimation methods, analytic methods, and judgments about whether the methods took intraclass correlation into account properly.

RESULTS

Of those articles including sufficient information to judge whether analytic methods were correct, only 24% used only appropriate methods for dealing with the intraclass correlation. The percentages differed substantially for GRTs (41.7%) and IRGT trials (8.0%). Most of the articles (69.2%) also made no mention of a priori sample size estimation.

CONCLUSION

A majority of the articles in our review reported analyses ignoring the intraclass correlation. This practice may result in underestimated variance, inappropriately small P values, and incorrect conclusions about the effectiveness of interventions. Previous trials that were analyzed incorrectly need to be re-analyzed, and future trials should be designed and analyzed with appropriate methods. Also, journal reviewers and editors need to be aware of the special requirements for design and analysis of GRTs and IRGT trials and judge the quality of articles reporting on such trials according to appropriate standards.

Systemic preexposure prophylaxis for human immunodeficiency virus infection

Antiretroviral therapy has significantly improved the typical course of human immunodeficiency virus (HIV) infection in industrialized nations, and life expectancies associated with the infection have increased. However, infection rates have generally remained unchanged, with increases noted among certain subpopulations. The use of systemic preexposure prophylaxis for HIV infection has been proposed as an intervention to reduce the risk of disease transmission in at-risk individuals. The basis of this prophylaxis involves the orchestrated use of antiretrovirals in uninfected individuals either continuously or just before high-risk situations, such as perinatal and occupational exposure to HIV, in order to reduce the likelihood of successful HIV infection. Data from the use of antiretrovirals to prevent HIV infection in these scenarios support the concept of preexposure prophylaxis. Preliminary animal studies have focused on the use of antiretrovirals to prevent simian immunodeficiency virus infection in macaque monkeys, and these data have provided support for the potential efficacy of preexposure prophylaxis for HIV in humans. Limited human data are available, however, but studies are ongoing. Clinical trials have focused on the use of tenofovir disoproxil fumarate either alone or in combination with emtricitabine. Tenofovir-emtricitabine-based regimens may be ideal, given the drugs' pharmacodynamic and pharmacokinetic properties. Some investigators have surveyed at-risk individuals to assess their knowledge of preexposure prophylaxis and whether they used or intended to use this prevention strategy. Routine use of preexposure prophylaxis and even knowledge of its existence appear to be very limited. If efficacy is proved, use of preexposure prophylaxis faces several ethical issues. Ultimately, its success will depend on proof of cost-effectiveness. Until the many questions concerning optimal use of preexposure prophylaxis for HIV are answered, however, its use should be limited to research-related clinical investigations.

Genetic characteristics, coreceptor usage potential and evolution of Nigerian HIV-1 subtype G and CRF02_AG isolates

HIV-1 CRF02_AG and subtype G (HIV-1G) account for most HIV infections in Nigeria, but their evolutionary trends have not been well documented. To better elucidate the dynamics of the epidemic in Nigeria we characterised the gag and env genes of North-Central Nigerian HIV-1 isolates from pregnant women. Of 28 samples sequenced in both genes, the predominant clades were CRF02_AG (39%) and HIV-1G (32%). Higher predicted proportion of CXCR4-tropic (X4) HIV-1G isolates was noted compared to CRF02_AG (p = 0.007, Fisher's exact test). Phylogenetic and Bayesian analysis conducted on our sequences and all the dated available Nigerian sequences on the Los Alamos data base showed that CRF02_AG and HIV-1G entered into Nigeria through multiple entries, with presence of HIV-1G dating back to early 1980s. This study underlines the genetic complexity of the HIV-1 epidemic in Nigeria, possible subtype-specific differences in co-receptor usage, and the evolutionary trends of the predominant HIV-1 strains in Nigeria, which may have implications for the design of biomedical interventions and better understanding of the epidemic.

Multicultural challenges in epilepsy

Epilepsy is a common neurological condition throughout the world. Its care involves medical expertise, but may also bring different cultural challenges. We discuss clinical, social and psychological outcomes in different cultural settings. We point out differences and similarities in epilepsy epidemiology (etiology and risk factors, prognosis, and natural history), disparities in care and health services, and cultural influences and traditional beliefs, with special respect to practical issues and possible transcultural misunderstandings. We also discuss the relevance of multicultural issues to clinicians working in developed countries.

Why HIV/AIDS should be treated as exceptional: arguments from sub-Saharan Africa and Eastern Europe

The idea that HIV and AIDS gets too much attention and funding emerged in 2008 with a call to end 'AIDS exceptionalism.' This article outlines a short history of AIDS exceptionalism - the idea that HIV and AIDS require a response above and beyond 'normal' health interventions and is privileged in terms of attention and resources when compared with other diseases - and the reasons for the backlash to this idea. We argue that in some settings HIV and AIDS must be treated as exceptional. These are the hyperendemic countries of southern Africa, where HIV epidemics have shown substantial and lasting demographic and social impact, and parts of Eastern Europe where the epidemic is augmenting troubling demographic changes, such as declines in fertility rates and population growth, and impacting society in nuanced ways. Also included are resource-poor settings, mostly in Africa, where the combination of the high number of HIV infections and the cost of treatment have created issues concerning donor dependency and sustainable responses. An HIV epidemic must be seen as a long-wave event, with complex challenges to both HIV prevention and treatment responses. The article reviews the available data and literature to provide evidence for our arguments. We conclude that the perception that AIDS exceptionalism is outdated ignores the complexity of different HIV epidemics and obfuscates the challenges to effective responses.

Use of cervicovaginal fluid for the identification of biomarkers for pathologies of the female genital tract

Cervicovaginal fluid has an important function in the homeostasis and immunity of the lower female genital tract. Analysis of the cervicovaginal fluid proteome may therefore yield important information about the pathogenesis of numerous gynecological pathologies. Additionally, cervicovaginal fluid has great potential as a source of biomarkers for these conditions.

This review provides a detailed discussion about the human cervicovaginal proteome and the proteomics studies performed to characterize this biological fluid. Furthermore, infection-correlated pathological conditions of the female genital tract are discussed for which cervicovaginal fluid has been used in order to identify potential biomarkers. Recent years, numerous studies have analyzed cervicovaginal fluid samples utilizing antibody-based technologies, such as ELISA or Western blotting, to identify biomarkers for preterm birth, premature preterm rupture of membranes, bacterial vaginosis and cervical cancer. The present article will discuss the importance of proteomic technologies as alternative techniques to gain additional meaningful information about these conditions. In addition, the review focuses on recent proteomic studies on cervicovaginal fluid samples for the identification of potential biomarkers. We conclude that the use of proteomic technology for analysis of human cervicovaginal fluid samples is promising and may lead to the discovery of new biomarkers which can improve disease prevention and therapy development.

Drug treatment as HIV prevention: a research update

Drug use continues to be a major factor fueling the global epidemic of HIV infection. This article reviews the current literature on the ability of drug treatment programs to reduce HIV transmission among injection and noninjection drug users. Most data come from research on the treatment of opiate dependence and provide strong evidence on the effectiveness of medication-assisted treatment for reducing the frequency of drug use, risk behaviors, and HIV infections. This has been a consistent finding since the epidemic began among diverse populations and cultural settings. Use of medications other than methadone (such as buprenorphine/naloxone and naltrexone) has increased in recent years with promising data on their effectiveness as HIV prevention and as new treatment options for communities heavily affected by opiate use and HIV infection. However, few treatment interventions for stimulant abuse and dependence have shown efficacy in reducing HIV risk. The cumulative literature provides strong support of drug treatment programs for improving access and adherence to antiretroviral treatment. Drug users in substance abuse treatment are significantly more likely to achieve sustained viral suppression, making viral transmission less likely. Although there are challenges to implementing drug treatment programs for maximum impact, the scientific literature leaves no doubt about the effectiveness of drug treatment as an HIV prevention strategy.

Phosphorothioate 2' deoxyribose oligomers as microbicides that inhibit human immunodeficiency virus type 1 (HIV-1) infection and block Toll-like receptor 7 (TLR7) and TLR9 triggering by HIV-1

Topical microbicides may prove to be an important strategy for preventing human immunodeficiency virus type 1 (HIV-1) transmission. We examined the safety and efficacy of sequence-nonspecific phosphorothioate 2' deoxyribose oligomers as potential novel microbicides. A short, 13-mer poly(T) phosphorothioate oligodeoxynucleotide (OPB-T) significantly inhibited infection of primary peripheral blood mononuclear cells (PBMC) by high-titer HIV-1(Ba-L) and simian immunodeficiency virus mac251 (SIV(mac251)). Continuous exposure of human vaginal and foreskin tissue explants to OPB-T showed no toxicity. An abasic 14-mer phosphorothioate 2' deoxyribose backbone (PDB) demonstrated enhanced anti-HIV-1 activity relative to OPB-T and other homo-oligodeoxynucleotide analogs. When PDB was used to pretreat HIV-1, PDB was effective against R5 and X4 isolates at a half-maximal inhibitory concentration (IC(50)) of <1 μM in both PBMC and P4-R5 MAGI cell infections. PDB also reduced HIV-1 infectivity following the binding of virus to target cells. This novel topical microbicide candidate exhibited an excellent in vitro safety profile in human PBMC and endocervical epithelial cells. PDB also retained activity in hydroxyethylcellulose gel at pH 4.4 and after transition to a neutral pH and was stable in this formulation for 30 days at room temperature. Furthermore, the compound displayed potent antiviral activity following incubation with a Lactobacillus strain derived from normal vaginal flora. Most importantly, PDB can inhibit HIV-1-induced alpha interferon production. Phosphorothioate 2' deoxyribose oligomers may therefore be promising microbicide candidates that inhibit HIV-1 infection and also dampen the inflammation which is critical for the initial spread of the virus.

Anti-AIDS agents 79. Design, synthesis, molecular modeling and structure-activity relationships of novel dicamphanoyl-2',2'-dimethyldihydropyranochromone (DCP) analogs as potent anti-HIV agents

In a continued study, 23 3'R,4'R-di-O-(-)-camphanoyl-2',2'-dimethyldihydropyrano[2,3-f]chromone (DCP) derivatives (5-27) were synthesized, and screened for anti-HIV activity against both a non-drug-resistant NL4-3 strain and multiple reverse transcriptase (RT) inhibitor-resistant (RTMDR-1) strain, using 2-EDCP (4) and 2-MDCP (35) as controls. New DCP analogs 5, 9, 14, and 22 exhibited potent anti-HIV activity against HIVNL4-3 with EC50 and therapeutic index (TI) values ranging from 0.036 microM to 0.14 microM and from 110 to 420, respectively. Compounds 5 and 9 also exhibited good activity against RTMDR-1 (EC50 0.049 and 0.054 microM; TI 310 and 200, respectively), and were twofold more potent than the leads 4 and 35 (EC50 0.11 and 0.19 microM; TI 60 and 58, respectively). Evaluation of water solubility showed that 5 and 22 were 5-10 times more water soluble than 4. Quantitative structure-activity relationship (QSAR) modeling results were first performed on this compound type, and the models should aid in design of future anti-HIV DCP analogs and potential clinical drug candidates.

An overview of the relative risks of different sexual behaviours on HIV transmission

PURPOSE OF REVIEW

Sexual intercourse represents the majority of HIV transmission and is preventable. Overall, the risk of HIV transmission following a single sexual exposure is low especially in comparison with other sexually transmitted infections (STIs), with estimates of the average probability of male-to-female HIV transmission only 0.0005-0.0026 per coital act. The risk of acquiring HIV from a single contact varies enormously and is dependant upon the infectiousness of the HIV-positive individual and the susceptibility to HIV of their sexual partner.

RECENT FINDINGS

Of concern, unprotected sex among men who have sex with men (MSM) has increased in recent years and HIV incidence in both MSM and heterosexuals remains a considerable public health concern. Sexual practices and health optimism about HIV have changed, which have significantly impacted HIV risk behaviour.

SUMMARY

In this review article we summarize the current evidence regarding the observed relative risks of HIV transmission for each different types of sex act, relationship type and the strategies that have been tested to interrupt transmission.

Are HIV epidemics among men who have sex with men emerging in the Middle East and North Africa?: a systematic review and data synthesis

BACKGROUND

Men who have sex with men (MSM) bear a disproportionately higher burden of HIV infection than the general population. MSM in the Middle East and North Africa (MENA) are a largely hidden population because of a prevailing stigma towards this type of sexual behavior, thereby limiting the ability to assess infection transmission patterns among them. It is widely perceived that data are virtually nonexistent on MSM and HIV in this region. The objective of this review was to delineate, for the first time, the evidence on the epidemiology of HIV among MSM in MENA.

METHODS AND FINDINGS

This was a systematic review of all biological, behavioral, and other related data on HIV and MSM in MENA. Sources of data included PubMed (Medline), international organizations' reports and databases, country-level reports and databases including governmental and nongovernmental organization publications, and various other institutional documents. This review showed that onsiderable data are available on MSM and HIV in MENA. While HIV prevalence continues at low levels among different MSM groups, HIV epidemics appear to be emerging in at least few countries, with a prevalence reaching up to 28% among certain MSM groups. By 2008, the contribution of MSM transmission to the total HIV notified cases increased and exceeded 25% in several countries. The high levels of risk behavior (4-14 partners on average in the last six months among different MSM populations) and of biomarkers of risks (such as herpes simplex virus type 2 at 3%-54%), the overall low rate of consistent condom use (generally below 25%), the relative frequency of male sex work (20%-76%), and the substantial overlap with heterosexual risk behavior and injecting drug use suggest potential for further spread.

CONCLUSIONS

This systematic review and data synthesis indicate that HIV epidemics appear to be emerging among MSM in at least a few MENA countries and could already be in a concentrated state among several MSM groups. There is an urgent need to expand HIV surveillance and access to HIV testing, prevention, and treatment services in a rapidly narrowing window of opportunity to prevent the worst of HIV transmission among MSM in the Middle East and North Africa. Please see later in the article for the Editors' Summary.

Influence of HLA class I and HLA-KIR compound genotypes on HIV-2 infection and markers of disease progression in a Manjako community in West Africa

Overall, the time to AIDS after HIV-2 infection is longer than with HIV-1, and many individuals infected with HIV-2 virus remain healthy throughout their lives. Multiple HLA and KIR gene products have been implicated in the control of HIV-1, but the effect of variation at these loci on HIV-2 disease is unknown. We show here for the first time that HLA-B*1503 is associated significantly with poor prognosis after HIV-2 infection and that HLA-B*0801 is associated with susceptibility to infection. Interestingly, previous data indicate that HLA-B*1503 is associated with low viral loads in HIV-1 clade B infection but has no significant effect on viral load in clade C infection. In general, alleles strongly associated with HIV-1 disease showed no effect in HIV-2 disease. These data emphasize the unique nature of the effects of HLA and HLA/KIR combinations on HIV-2 immune responses relative to HIV-1, which could be related to their distinct clinical course.

Suspicious axillary lymph nodes in patients with unremarkable imaging of the breast

OBJECTIVE

The aim of this study was to evaluate the pathological findings and the method of tissue harvesting in those patients who have both suspicious axillary lymph nodes and normal imaging of the breast.

STUDY DESIGN

From January 2005 to June 2008 all female patients who underwent opportunistic screening mammography and ultrasound examination of the breast and the axilla, and who were found to have suspicious axillary lymph nodes seen on ultrasound examination, were retrospectively analysed. Tissue harvesting was done by fine needle aspiration, core needle biopsy, or open biopsy.

RESULTS

Out of approximately 7500 screened patients, 51 were found to have suspicious axillary lymph nodes on ultrasound with unremarkable breast ultrasound and mammography. Histopathology and/or cytology of these lymph nodes showed 33 benign and 18 malignant results. Of the malignant results only 1 case was an occult invasive lobular breast carcinoma detected afterwards on breast magnetic resonance imaging. Eleven cases were non-Hodgkin lymphomas, 4 were malignant melanomas, and 2 were metastases from the lower genital tract. Diffuse cortical thickening and complete loss of echo texture were the only features on ultrasound predicting malignancy. Palpation and mean size of the evaluated lymph nodes had no predictive value for malignancy. In the 33 cases of non-malignant pathology 9 patients showed patterns of specific infectious disease, including 4 patients with tuberculosis.

CONCLUSION

Suspicious lymph nodes of the axilla seen on ultrasound rarely indicate occult breast cancer but show a variety of other malignancies and generalised infectious disease requiring further treatment. Fine needle aspiration and/or core needle biopsy are both sufficient methods for clarification in the majority of cases.

Characterization of a single-cycle rabies virus-based vaccine vector

Recombinant rabies virus (RV)-based vectors have demonstrated their efficacy in generating long-term, antigen-specific immune responses in murine and monkey models. However, replication-competent viral vectors pose significant safety concerns due to vector pathogenicity. RV pathogenicity is largely attributed to its glycoprotein (RV-G), which facilitates the attachment and entry of RV into host cells. We have developed a live, single-cycle RV by deletion of the G gene from an RV vaccine vector expressing HIV-1 Gag (SPBN-DeltaG-Gag). Passage of SPBN-DeltaG-Gag on cells stably expressing RV-G allowed efficient propagation of the G-deleted RV. The in vivo immunogenicity data comparing single-cycle RV to a replication-competent control (BNSP-Gag) showed lower RV-specific antibodies; however, the overall isotype profiles (IgG2a/IgG1) were similar for the two vaccine vectors. Despite this difference, mice immunized with SPBN-DeltaG-Gag and BNSP-Gag mounted similar levels of Gag-specific CD8(+) T-cell responses as measured by major histocompatibility complex class I Gag-tetramer staining, gamma interferon-enzyme-linked immunospot assay, and cytotoxic T-cell assay. Moreover, these cellular responses were maintained equally at immunization titers as low as 10(3) focus-forming units for both RV vaccine vectors. CD8(+) T-cell responses were significantly enhanced by a boost with a single-cycle RV complemented with a heterologous vesicular stomatitis virus glycoprotein. These findings demonstrate that single-cycle RV is an effective alternative to replication-competent RV vectors for future development of vaccines for HIV-1 and other infectious diseases.

HIV-1 and HCV detection in dried blood spots by SYBR Green multiplex real-time RT-PCR

Dried blood spot (DBS) is a reliable method of blood collection used for the diagnosis of several human diseases. DBS is particularly useful for diagnosing children and for the screening of high-risk populations especially in countries where health facilities are not readily accessible. This report describes a qualitative SYBR Green-based real-time multiplex RT-PCR for the simultaneous detection of hepatitis C virus (HCV) and human immunodeficiency virus type 1 (HIV-1) genomes in DBS. Specific viral amplicons were identified in the same sample by their distinctive melting temperatures. The analysis of scalar concentrations of the reference samples indicated that this multiplex procedure detects at least 2500 copies/ml of HCV and 400 copies/ml of HIV-1. HIV-1 and HCV viral loads in 20 patients infected with HIV-1 and/or HCV and in 5 healthy blood donors were also tested, confirming the sensitivity and specificity of the assay. This method may represent a reliable alternative for the detection of HIV-1/HCV co-infection, in rapid and relatively inexpensive screening programmes.

The implications of pharmacogenomics in the treatment of HIV-1-infected patients of African descent

One of the great advances in the treatment of HIV-1 infection was the development of the highly active antiretroviral therapy (HAART). Although this treatment strategy is highly effective in many individuals, interpatient variability of drug response and high incidences of short- and long-term toxicities remain significant problems associated with this treatment. Logically, pharmacogenetic differences among HIV-1-infected individuals are thought to represent important factors contributing to antiretroviral drug response. Studies have identified polymorphisms in drug-metabolizing enzymes, drug transporters, and most recently the human leukocyte antigen locus that appears to have significant effects on the clinical outcomes of antiretroviral therapy. Furthermore, some studies have shown that many of these crucial polymorphisms are more likely or less likely in certain populations. This review investigates the potential role of pharmacogenomics in the management of HIV-1 infection in people of African descent.

Adult combination antiretroviral therapy in sub-Saharan Africa: lessons from Botswana and future challenges

Numerous national public initiatives offering first-line combination antiretroviral therapy (cART) for HIV infection have commenced in sub-Saharan Africa since 2002. Presently, 2.1 million of an estimated seven million Africans in need of cART are receiving treatment. Analyses from the region report favorable clinical/treatment outcomes and impressive declines in AIDS-related mortality among HIV-1-infected adults and children receiving cART. While immunologic recovery, virologic suppression and cART adherence rates are on par with resource-rich settings, loss to follow-up and high mortality rates, especially within the first 6 months of treatment, remain a significant problem. Over the next decade, cART coverage rates are expected to improve across the region, with attendant increases in healthcare utilization for HIV- and non-HIV-related complications and the need for expanded laboratory and clinical services. Planned and in-progress trials will evaluate the use of cART to prevent primary HIV-1 infection with so-called 'test and treat' expansions of coverage and treatment. Education and training programs as well as patient-retention strategies will need to be strengthened as national cART programs are expanded and more people require lifelong monitoring and care.