Low serum thiol levels predict shorter times-to-death among HIV-infected injecting drug users

Food supplementation among HIV-infected adults in Sub-Saharan Africa: impact on treatment adherence and weight gain

Sub-Saharan Africa has the highest proportion of undernourished people in the world, along with the highest number of people living with HIV and AIDS. Thus, as a result of high levels of food insecurity many HIV patients are also undernourished. The synergism between HIV and undernutrition leads to poor treatment adherence and high mortality rates. Undernutrition has a debilitating effect on the immune system due to key nutrient deficiencies and the overproduction of reactive species (oxidative stress), which causes rapid HIV progression and the onset of AIDS. Therapeutic food supplementation used in the treatment of severe acute malnutrition is being applied to HIV palliative care; however, little biochemical data exist to highlight its impact on oxidative stress and immune recovery. In addition, as most food supplements are imported by donor agencies, efforts are being put into local therapeutic food production such as the Food Multi-Mix concept to ensure sustainability. The purpose of this review is to highlight studies that examine the effectiveness of food supplementation in undernourished HIV patients in Sub-Saharan Africa; noting the parameters used to measure efficacy, as well as the long-term feasibility of supplementation.

Existing and potential therapeutic uses for N-acetylcysteine: the need for conversion to intracellular glutathione for antioxidant benefits

N-acetyl-l-cysteine (NAC) has long been used therapeutically for the treatment of acetaminophen (paracetamol) overdose, acting as a precursor for the substrate (l-cysteine) in synthesis of hepatic glutathione (GSH) depleted through drug conjugation. Other therapeutic uses of NAC have also emerged, including the alleviation of clinical symptoms of cystic fibrosis through cysteine-mediated disruption of disulfide cross-bridges in the glycoprotein matrix in mucus. More recently, however, a wide range of clinical studies have reported on the use of NAC as an antioxidant, most notably in the protection against contrast-induced nephropathy and thrombosis. The results from these studies are conflicting and a consensus is yet to be reached regarding the merits or otherwise of NAC in the antioxidant setting. This review seeks to re-evaluate the mechanism of action of NAC as a precursor for GSH synthesis in the context of its activity as an "antioxidant". Results from recent studies are examined to establish whether the pre-requisites for effective NAC-induced antioxidant activity (i.e. GSH depletion and the presence of functional metabolic pathways for conversion of NAC to GSH) have received adequate consideration in the interpretation of the data. A key conclusion is a reinforcement of the concept that NAC should not be considered to be a powerful antioxidant in its own right: its strength is the targeted replenishment of GSH in deficient cells and it is likely to be ineffective in cells replete in GSH.

Social and structural factors associated with HIV disease progression among illicit drug users: a systematic review

OBJECTIVE

To systematically review factors associated with HIV disease progression among illicit drug users, focusing on exposures exogenous to individuals that likely shape access and adherence to HIV treatment.

DESIGN

A systematic review of peer-reviewed English-language studies among HIV-seropositive illicit drug users with at least one of these endpoint of interest: a diagnosis of AIDS; death; changes/differences in CD4 cell counts; or changes/differences in plasma HIV-1 RNA levels.

METHODS

Articles were included if they reported factors associated with an outcome of interest among a group of illicit drug users. Studies were identified, screened and selected using systematic methods.

RESULTS

Of 2668 studies matching the search criteria, 58 (2%) met the inclusion criteria, all but one from North America or western Europe. Overall, 41 (71%) studies contained significant individual-level clinical characteristics or behaviors (e.g. illicit drug use) associated with disease progression. Fifteen studies (26%) identified significant social, physical, economic or policy-level exposures, including incarceration, housing status or lack of legal income.

CONCLUSION

Although past studies demonstrate important environmental exposures that appear to shape access to care and subsequent disease progression, the limited literature to examine these factors demonstrates the need for future research to consider risk environment characteristics and the role they may play in shaping health outcomes from HIV infection among drug users through determining access and adherence to evidence-based care.

The role of phase II antioxidant enzymes in protecting memory T cells from spontaneous apoptosis in young and old mice

Aging is associated with a functional decline and change in the phenotypic distribution of T cell subsets. The free radical theory of aging is widely promoted as the mechanistic basis for cellular senescence, including the immune system. Although the exact molecular explanation for the role of oxidative stress in cellular senescence is unclear, there is a connection to altered mitochondrial function, both as a contributor and as a target of oxidative stress. In this study we demonstrate that splenic T lymphocytes from old C57BL/6 mice exhibit a significant decline in mitochondrial membrane potential (deltapsi(m)). However, despite this change, there is a lower rate of withdrawal apoptosis in the memory CD4+ and CD8+ T cells. To explain the survival of these long-lived cells against a background of increased oxidative stress, we demonstrate increased glutathione production and phase II enzyme expression, which combine to protect memory T cells against oxidative stress, mitochondrial dysfunction, and cell death. The accumulation of memory T cells with aging explains higher phase II enzyme expression in CD4+ and CD8+ T cells from old mice. Compared with wild-type mice, mice lacking the expression of NF-E2-related factor-2, the transcription factor that regulates phase II enzyme expression, had a significantly enhanced rate of apoptosis in the presence of an oxidative stress stimulus. NF-E2-related factor-2-deficient T cells exhibit a bigger decline in deltapsi(m) and increased reactive oxygen species production than cells from wild-type animals. Taken together, we suggest that phase II enzyme expression and the accompanying increase in intracellular thiol levels protect memory T cells from mitochondrial dysfunction and spontaneous apoptosis.

Glutathione in defense and signaling: lessons from a small thiol

The mechanisms of thiol metabolism and chemistry have particular relevance to both cellular defenses against toxicant exposure and to redox signaling. Here, we will focus on glutathione (GSH), the major endogenous low- molecular-weight nonprotein thiol synthesized de novo in mammalian cells. The major pathways for GSH metabolism in defense of the cell are reduction of hydroperoxides by glutathione peroxidases (GSHPx) and some peroxiredoxins, which yield glutathione disulfide (GSSG), and conjugation reactions catalyzed by glutathione-S-transferases. GSSG can be reduced to GSH by glutathione reductase, but glutathione conjugates are excreted from cells. The exoenzyme gamma-glutamyltranspeptidase (GGT) removes the glutamate from extracellular GSH, producing cysteinyl-glycine from which a dipeptidase then generates cysteine, an amino acid often limiting for de novo GSH synthesis. Synthesis of GSH from the constituent amino acids occurs in two regulated, enzymatically catalyzed steps. The signaling pathways leading to activation of the transcription factors that regulate these genes are a current area of intense investigation. The elucidation of the signaling for GSH biosynthesis in human bronchial epithelial cells in response to 4-hydroxynonenal (4HNE), an end product of lipid peroxidation, will be used as an example. GSH also participates in redox signaling through the removal of H(2)O(2), which has the properties of a second messenger, and by reversing the formation of sulfenic acid, a moiety formed by reaction of critical cysteine residues in signaling proteins with H(2)O(2). Disruption of GSH metabolism will therefore have major a impact upon function of cells in terms of both defense and normal physiology.

Cellular glutathione and thiols metabolism

Low molecular weight thiol-containing compounds have an essential role in many biochemical and pharmacological reactions due to the ease with each they are oxidized, and the rapidity with which they can be regenerated. Thioredoxin and glutathione (GSH) are two of the major small molecular weight thiol-containing compounds synthesized de novo in mammalian cells that participate in those functions. Understanding the mechanisms of thiol metabolism has special relevance to understanding the cell's defense against toxicant exposure and as the focal point in redox signaling. This commentary will, however, focus on GSH consumption and synthesis, and the role of thiols in signaling. The chemical reactions of GSH, including conjugation reactions mediated by glutathione S-transferases (GST) and oxidation reactions mediated by glutathione peroxidases will be described. The regulation of GSH synthesis will be illustrated from a compilation of studies designed to understand the various levels at which enzymatic GSH biosynthesis is controlled, and the signaling pathways that mediate them. The response of the cell to 4-hydroxynonenal (4HNE), a reactive aldehyde produced physiologically in response to inflammation and various air pollutants, will be explored in detail. Finally, the direct role of thiols as signaling molecules will be addressed, with particular attention given to "redox state." It is our aim that this commentary will lead the reader to appreciate that studies investigating the signaling for and regulation of thiol metabolism must never be generalized, and that perturbations in any of step of thiol metabolism may have etiological roles in genetically, virally, and environmentally borne pathologies.

[Oxidative metabolism of HIV-infected macrophages: the role of glutathione and a pharmacologic approach]

Oxidative stress and glutathione deficiency seem to play a major role in the pathogenesis of HIV infection, as suggested by the increased survival of HIV-infected patients treated with N-acetylcysteine, a prodrug of glutathione. However, beneficial effects of GSH-replenishing drugs are restricted in vivo by the high concentrations needed to obtain biological effects and their low bioavailability. In this study, we evaluated the antiretroviral and antioxidant activities of new more lipophilic GSH-replenishing molecules, in macrophages infected in vitro with HIV-1. In these experimental conditions, a prodrug of N-acetylcystéine and beta-mercaptoethylamine, I-152 demonstrated a potent anti-HIV activity, increased intracellular GSH level, and decreased TNF-alpha production. Altogether, these results suggest that I-152 could be beneficial as adjuvant therapy of antiretrovirals in HIV-infected patients, especially in those with damages to the central nervous system or with mitochondrial damages associated with highly active antiretroviral therapy.

N-acetylcysteine replenishes glutathione in HIV infection

BACKGROUND

Glutathione (GSH) deficiency is common in HIV-infected individuals and is associated with impaired T cell function and impaired survival. N-acetylcysteine (NAC) is used to replenish GSH that has been depleted by acetaminophen overdose. Studies here test oral administration of NAC for safe and effective GSH replenishment in HIV infection.

DESIGN

Oral NAC administration in a randomized, 8-week double-blind, placebo-controlled trial followed by optional open-label drug for up to 24 weeks.

SUBJECTS

HIV-infected, low GSH, CD4 T cells < 500 micro L(-1), no active opportunistic infections or other debilitation; n = 81. Study conducted prior to introduction of protease inhibitors.

RESULTS

Whole blood GSH levels in NAC arm subjects significantly increased from 0.88 mM to 0.98 mM, bringing GSH levels in NAC-treated subjects to 89% of uninfected controls (P = 0.03). Baseline GSH levels in the placebo group (0.91) remained essentially the same during the 8 week placebo-controlled trial. T cell GSH, adjusted for CD4 T cell count and beta2-microglobulin levels, also increased in the NAC-treated subjects (P = 0.04). Adverse effects were minimal and not significantly associated with NAC ingestion.

CONCLUSION

NAC treatment for 8 weeks safely replenishes whole blood GSH and T cell GSH in HIV-infected individuals. Thus, NAC offers useful adjunct therapy to increase protection against oxidative stress, improve immune system function and increase detoxification of acetaminophen and other drugs. These findings suggest that NAC therapy could be valuable in other clinical situations in which GSH deficiency or oxidative stress plays a role in disease pathology, e.g. rheumatoid arthritis, Parkinson's disease, hepatitis, liver cirrhosis, septic shock and diabetes.

Oxidative stress in HIV-1-infected injection drug users

Low serum antioxidant levels observed in many HIV-infected populations could be largely due to an increase in oxidative stress (defined as a disturbance in the equilibrium status of prooxidant/antioxidant systems of intact cells). In HIV infection, oxidative stress may be caused by both overproduction of reactive oxygen intermediates (ROIs) and a simultaneous deficiency of antioxidant defenses. Furthermore, injection drug use has been associated with increased levels of oxidative stress in animal models. Currently, there is widespread use of self-prescribed antioxidant supplementation among the HIV-infected population and a prevailing belief that high-dose supplementation is beneficial, or at the very least, not harmful. Data from our studies show that HIV-positive injection drug users (IDUs) who are on antiretroviral combination therapies including a protease inhibitor have significantly higher mean serum levels of several antioxidants, independent of dietary and supplemental intake, compared with both HIV-negative IDUs and HIV-positive IDUs not taking protease inhibitors. This suggests that oxidative stress may be reduced in patients taking protease inhibitors. Preliminary data suggest that the future of antioxidant supplementation therapy, if any, will be one in which different doses of supplements are recommended for HIV-infected patients on the various antiretroviral treatment regimens. More research is needed to determine the interactions among injection drug use, oxidative stress, antiretroviral therapy, and the use of antioxidant supplements in HIV infection. Until more is known, caution should be exercised when using or recommending high-dose antioxidant supplementation in HIV-infected individuals, particularly in those on protease inhibitors, since moderate levels of oxidative stress are involved in a number of useful physiologic processes.

Nutrition, HIV, and drug abuse: the molecular basis of a unique role for selenium

HIV-infected injection drug users (IDUs) often suffer from serious nutritional deficiencies. This is a concern because plasma levels of micronutrients such as vitamin B12, zinc, and selenium have been correlated with mortality risk in HIV-positive populations. Injection drug use also increases lipid peroxidation and other indicators of oxidative stress, which, combined with antioxidant deficiencies, can stimulate HIV-1 replication through activation of NF-kappaB transcription factors, while weakening immune defenses. As detailed herein, these prooxidant stimuli can also increase the pathogenic effects of HIV-1 by another mechanism, involving viral selenoproteins. Overlapping the envelope coding region, HIV-1 encodes a truncated glutathione peroxidase (GPx) gene (see #6 in reference list). Sequence analysis and molecular modeling show that this viral GPx (vGPx) module has highly significant structural similarity to known mammalian GPx, with conservation of the catalytic triad of selenocysteine (Sec), glutamine, and tryptophan. In addition to other functions, HIV-1 vGPx may serve as a negative regulator of proviral transcription, by acting as an NF-kappaB inhibitor (a known property of cellular GPx). Another potential selenoprotein coding function of HIV-1 is associated with the 3' end of the nef gene, which terminates in a conserved UGA (potential Sec) codon in the context of a sequence (Cys-Sec) identical to the C-terminal redox center of thioredoxin reductase, another cellular regulator of NF-kappaB. Thus, in combination with known cellular mechanisms involving Se, viral selenoproteins may represent a unique mechanism by which HIV-1 monitors and exploits an essential micronutrient to optimize its replication relative to the host.

Massive loss of sulfur in HIV infection

Skeletal muscle tissue from SIV-infected macaques was previously found to contain abnormally high sulfate and low glutathione levels indicative of an excessive cysteine catabolism. We now confirm the peripheral tissue as a site of massive cysteine catabolism in HIV infection and have determined the urinary loss of sulfur per time unit. The comparison of the sulfate concentrations of the arterial and venous blood from the lower extremities of 16 symptomatic HIV+ patients and 18 HIV- control subjects (study 1) revealed (1) that the peripheral tissue of HIV+ patients with or without highly active antiretroviral therapy (HAART) releases large amounts of sulfate and (2) that plasma sulfate, thioredoxin, and interleukin-6 levels are elevated in these patients. A complementary investigation of 64 asymptomatic HIV+ patients and 65 HIV- subjects (study 2) revealed increased plasma sulfate levels in the asymptomatic patients. The analysis of the daily urinary excretion of sulfate and urea of another group of 19 HIV+ patients and 22 healthy HIV- subjects (study 3) confirmed (1) that HIV+ patients experience a massive loss of sulfur and (2) that this loss is not ameliorated by HAART. The sulfur loss of asymptomatic patients was equivalent to a mean loss of about 10 g of cysteine per day. If extrapolated, this would correspond to an alarming negative balance of approximately 2 kg of cysteine per year under the assumption that the normal sulfate excretion equivalent to approximately 3 g of cysteine per day is balanced by a standard Western diet. The abnormally high sulfate/urea ratio suggests that this process drains largely the glutathione pool.

Molecular mechanism of decreased glutathione content in human immunodeficiency virus type 1 Tat-transgenic mice

Human immunodeficiency virus (HIV) progressively depletes GSH content in humans. Although the accumulated evidence suggests a role of decreased GSH in the pathogenesis of HIV, significant controversy remains concerning the mechanism of GSH depletion, especially in regard to envisioning appropriate therapeutic strategies to help compensate for such decreased antioxidant capacity. Tat, a transactivator encoded by HIV, is sufficient to cause GSH depletion in vitro and is implicated in AIDS-associated Kaposi's sarcoma and B cell lymphoma. In this study, we report a decrease in GSH biosynthesis with Tat, using HIV-1 Tat transgenic (Tat+) mice. A significant decline in the total intracellular GSH content in liver and erythrocytes of Tat+ mice was accompanied by decreased gamma-glutamylcysteine synthetase regulatory subunit mRNA and protein content, which resulted in an increased sensitivity of gamma-glutamylcysteine synthetase to feedback inhibition by GSH. Further study revealed a significant reduction in the activity of GSH synthetase in liver of Tat+ mice, which was linearly associated with their GSH content. Therefore, Tat appears to decrease GSH in vivo, at least partially, through modulation of GSH biosynthetic enzymes.

The role of oxidative imbalance in progression to AIDS: effect of the thiol supplier N-acetylcysteine

In this study we investigate the redox profile of HIV+ patients at different stages of disease with regard to immunological parameters, i.e., the number of circulating CD4+ and CD8+ lymphocytes. For this purpose, peripheral blood mononuclear cells (PBMCs) obtained from healthy donors, HIV+ patients in the asymptomatic phase, long-term nonProgressors (LTNPs), and AIDS patients have been considered. Cells have been exposed in vitro to the prooxidizing agent menadione, which is able to induce superoxide anion formation, and the susceptibility of the cells to the induced oxidative stress was estimated. Moreover, the possibility that the susceptibility of the cells to oxidative stress might be reduced by preexposing them to the antioxidizing agent N-acetylcysteine (NAC) has also been analyzed. The results obtained can be summarized as follows: (1) treatment with the prooxidant agent is capable of inducing massive morphological alterations in PBMCs. In particular, a significant correlation was found between the decrease in number of CD4+ lymphocytes in patients at different stages of disease and the susceptibility of their PBMCs to oxidative stress; (2) preincubation with NAC was able to preserve partially the ultrastructural characteristics of PBMCs isolated from HIV+ patients. In particular, a direct relationship was found between the efficacy of NAC protection and CD4 counts; (3) evaluation of the plasma index of peroxidation and the number of circulating CD4 lymphocytes indicates the existence of a positive correlation between "systemic" oxidative imbalance and stage of the disease; and (4) cells from LTNPs display either oxidative susceptibility or oxidative markers similar to those of healthy donor cells. Our study suggests that the redox profile of patients may be considered a predictive marker of AIDS progression and that the acute infection and the asymptomatic phase of the disease may represent a useful period in which the combined use of antiretroviral and antioxidant drugs may be beneficial.

Dietary oxidative stress and the potentiation of viral infection

Oxidative stress is implicated in the pathogenesis of several viral infections, including hepatitis, influenza, and AIDS. Dietary oxidative stress due to either selenium or vitamin E deficiency increases cardiac damage in mice infected with a myocarditic strain of coxsackievirus B3. Such dietary oxidative stress also allows a normally benign (i.e., amyocarditic) coxsackievirus B3 to convert to virulence and cause heart damage. This conversion to virulence is due to a nucleotide sequence change in the genome of the benign virus, which then resembles more closely the nucleotide sequence of virulent strains. Although it has been known for many years that poor nutrition can affect host response to infection, this is the first report of host nutrition affecting the genetic sequence of a pathogen. Further research is needed to determine whether poor host nutrition plays any role in the emergence of new viral diseases via alterations in he genotype of an infectious agent.