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Promer K, Karris MY. Current Treatment Options for HIV Elite Controllers: a Review. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018; 10:302-309. [PMID: 30344450 DOI: 10.1007/s40506-018-0158-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Opinion statement Initiating antiretroviral therapy (ART) in human immunodeficiency virus (HIV) elite controllers remains controversial, because current evidence does not definitively demonstrate that the benefits of ART outweigh risk in this patient population. However, it is the opinion of the authors that in developed countries, where first-line ART regimens have minimal toxicities, treatment of elite controllers should be strongly considered. Treatment of elite controllers has the potential to minimize the size of the HIV reservoir, which benefits elite controllers who choose to pursue future cure, dampen immune activation, diminish risk of transmission, and encourage linkage and engagement in care allowing HIV providers the opportunity to address HIV-associated non-AIDS conditions and other co-morbidities. Purpose of review This review aims to summarize literature relevant to the management of elite controllers for clinicians caring for patients living with HIV. Key topics include timing of antiretroviral therapy (ART) and ART in the unique populations of elite controllers with concomitant cardiovascular disease and hepatitis C co-infection, and undergoing immunosuppressive therapy for other co-morbidities. Recent findings The persistent HIV reservoir in elite controllers has two main implications. First, increased immune activation appears to adversely impact clinical outcomes in elite controllers, but the role of ART in addressing this effect remains unclear. Second, elite control duration can be limited, but certain factors may help to predict disease progression with implications on timing of ART. Summary Initiation of ART during elite control remains controversial, although there are multiple theoretical benefits. Elite controllers comprise a heterogeneous population of patients living with HIV, and optimal management involves weighing the risk and benefit of ART as well as monitoring of clinical consequences of increased immune activation.
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Affiliation(s)
- Katherine Promer
- Department of Medicine, University of California San Diego, 200 West Arbor Drive #8681, San Diego, CA, 92103, USA
| | - Maile Y Karris
- Department of Medicine, University of California San Diego, 200 West Arbor Drive #8681, San Diego, CA, 92103, USA
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Benito JM, Ortiz MC, León A, Sarabia LA, Ligos JM, Montoya M, Garcia M, Ruiz-Mateos E, Palacios R, Cabello A, Restrepo C, Rodriguez C, Del Romero J, Leal M, Muñoz-Fernández MA, Alcamí J, García F, Górgolas M, Rallón N. Class-modeling analysis reveals T-cell homeostasis disturbances involved in loss of immune control in elite controllers. BMC Med 2018; 16:30. [PMID: 29490663 PMCID: PMC5830067 DOI: 10.1186/s12916-018-1026-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 02/13/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Despite long-lasting HIV replication control, a significant proportion of elite controller (EC) patients may experience CD4 T-cell loss. Discovering perturbations in immunological parameters could help our understanding of the mechanisms that may be operating in those patients experiencing loss of immunological control. METHODS A case-control study was performed to evaluate if alterations in different T-cell homeostatic parameters can predict CD4 T-cell loss in ECs by comparing data from EC patients showing significant CD4 decline (cases) and EC patients showing stable CD4 counts (controls). The partial least-squares-class modeling (PLS-CM) statistical methodology was employed to discriminate between the two groups of patients, and as a predictive model. RESULTS Herein, we show that among T-cell homeostatic alterations, lower levels of naïve and recent thymic emigrant subsets of CD8 cells and higher levels of effector and senescent subsets of CD8 cells as well as higher levels of exhaustion of CD4 cells, measured prior to CD4 T-cell loss, predict the loss of immunological control. CONCLUSIONS These data indicate that the parameters of T-cell homeostasis may identify those EC patients with a higher proclivity to CD4 T-cell loss. Our results may open new avenues for understanding the mechanisms underlying immunological progression despite HIV replication control, and eventually, for finding a functional cure through immune-based clinical trials.
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Affiliation(s)
- José M Benito
- IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos, 2, 28040, Madrid, Spain. .,Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain.
| | | | - Agathe León
- Hospital Clinic-IDIBAPS, HIVACAT, Universidad de Barcelona, Barcelona, Spain
| | | | - José M Ligos
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | - María Montoya
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | - Marcial Garcia
- IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos, 2, 28040, Madrid, Spain.,Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | | | - Rosario Palacios
- Unidad de E. Infecciosas. Hospital Virgen de la Victoria e IBIMA, Málaga, Spain
| | - Alfonso Cabello
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Clara Restrepo
- IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos, 2, 28040, Madrid, Spain.,Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | - Carmen Rodriguez
- Centro Sanitario Sandoval, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Jorge Del Romero
- Centro Sanitario Sandoval, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | | | - María A Muñoz-Fernández
- Laboratory of Molecular Immuno-Biology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - José Alcamí
- AIDS Immunopathology Unit, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Felipe García
- Hospital Clinic-IDIBAPS, HIVACAT, Universidad de Barcelona, Barcelona, Spain
| | - Miguel Górgolas
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Norma Rallón
- IIS-Fundación Jiménez Díaz, UAM, Av. Reyes Católicos, 2, 28040, Madrid, Spain. .,Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain.
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Kerkerian G, Alimohammadi A, Raycraft T, Conway B. Repeated spontaneous clearance of hepatitis C virus infection in the setting of long-term non-progression of HIV infection. Infect Dis Rep 2017; 9:7142. [PMID: 29071045 PMCID: PMC5641653 DOI: 10.4081/idr.2017.7142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 07/07/2017] [Accepted: 07/08/2017] [Indexed: 12/28/2022] Open
Abstract
Hepatitis C Virus (HCV) and human immunodeficiency virus (HIV) are global pandemics that affect 170 million and 35 million individuals, respectively. Up to 45% of individuals infected with HCV clear their infections spontaneously – correlating to factors like aboriginal descent and some host specific immune factors. HIV, however, establishes true latency in infected cells and cannot be cured. In the setting of longterm non-progressors (LTNPs) of HIV, a state of immune preservation and low circulating viral load is established. Regarding HIV/HCV co-infection, little is known about the relationship between spontaneous clearance of HCV infection and long-term control of HIV infection without medical intervention. We describe a case of a HIV-infected female defined as a LTNP in whom spontaneous clearance of HCV was documented on multiple occasions. Similar cases should be documented and identified in an effort to develop novel hypotheses about the natural control of these infections and inform research on immune-based interventions to control them.
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Affiliation(s)
- Genevieve Kerkerian
- Vancouver Infectious Diseases Center.,Department of Medicine, University of British Columbia, Vancouver, Canada
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Dominguez-Molina B, Leon A, Rodriguez C, Benito JM, Lopez-Galindez C, Garcia F, Del Romero J, Gutierrez F, Viciana P, Alcami J, Leal M, Ruiz-Mateos E. Analysis of Non-AIDS-Defining Events in HIV Controllers. Clin Infect Dis 2016; 62:1304-1309. [PMID: 26936669 DOI: 10.1093/cid/ciw120] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 02/17/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV) controllers have the striking ability to maintain viremia at extremely low or undetectable levels without antiretroviral treatment. Even though these patients have been widely studied, information about clinical outcomes, especially concerning to non-AIDS-defining events (nADEs), is scarce. We have analyzed the frequency and rate of nADEs and their associated factors in a large multicenter HIV controller cohort. METHODS Data on nADEs were recorded for 320 HIV controllers within the multicenter Spanish AIDS Research Network HIV Controllers Cohort (ECRIS). Percentages and crude incidence rates (CIRs) per 100 person-years of follow-up (PYFU) were calculated for the entire follow-up period and for 2 separate periods: the period under control and the period after loss of control. These rates were compared with those for 632 noncontrollers. Demographic and immunological data collected from the controllers were included in a multivariate model to assess factors that were independently associated with nADEs in HIV controllers. RESULTS HIV controllers experience nADEs, albeit at lower rates than patients who do not spontaneously control the virus (1.252 [95% confidence interval {CI}, .974-1.586] per 100 PYFU and 2.481 [95% CI, 2.153-2.845] per 100 PYFU, respectively; P < .001). Hepatitis C virus (HCV) coinfection was the main factor associated with nADEs in all of the studied periods. Although hepatic events were the most prevalent, they represented only approximately 30% of the total events. CIRs of cardiovascular events increased in the post-loss-of-control period. CONCLUSIONS HCV/HIV coinfection was the main factor associated with hepatic and extrahepatic nADEs in HIV controllers. The eradication of HCV infection may ameliorate the presence of comorbidities in these patients.
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Affiliation(s)
- Beatriz Dominguez-Molina
- Laboratory of Immunovirology, Clinic Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville, Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital
| | - Agathe Leon
- Infectious Diseases Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona
| | - Carmen Rodriguez
- Centro Sanitario Sandoval, Instituto de Investigacion Sanitaria San Carlos (IdISSC)
| | - Jose M Benito
- Instituto de Investigacion Sanitaria-Fundacion Jimenez Díaz (IIS-FJD), Universidad Autonoma de Madrid (UAM)
| | | | - Felipe Garcia
- Infectious Diseases Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona
| | - Jorge Del Romero
- Centro Sanitario Sandoval, Instituto de Investigacion Sanitaria San Carlos (IdISSC)
| | - Felix Gutierrez
- Hospital General de Elche and Universidad Miguel Hernández, Alicante
| | - Pompeyo Viciana
- Laboratory of Immunovirology, Clinic Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville, Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital
| | - Jose Alcami
- AIDS Immunopathology Unit, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Manuel Leal
- Laboratory of Immunovirology, Clinic Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville, Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital
| | - Ezequiel Ruiz-Mateos
- Laboratory of Immunovirology, Clinic Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville, Institute of Biomedicine of Seville (IBiS), Virgen del Rocío University Hospital
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BenMarzouk-Hidalgo OJ, Torres-Cornejo A, Gutierrez-Valencia A, Ruiz-Valderas R, Viciana P, López-Cortés LF. Higher Activation in CD4(+) T Cells But Similar Viral Control Among HIV/Hepatitis C Virus-Coinfected Patients on a Simplification Monotherapy. AIDS Res Hum Retroviruses 2016; 32:6-11. [PMID: 26414169 DOI: 10.1089/aid.2014.0299] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The aim of this study was to assess whether hepatitis C virus (HCV) coinfection would affect the clinical and immunological outcome of HIV-infected patients following a simplification strategy. A prospective cohort of HIV-infected patients starting a ritonavir boosted darunavir monotherapy (mtDRV/rtv) was followed for 24 months. HCV infection was evaluated by HCV viremia and hepatic fibrosis. Immune activation was studied as HLA-DR CD38 coexpression on CD4(+) and CD8(+) T cells and also the quantification of plasma sCD14 levels. Microbial translocation was studied by the plasma levels of 16S rDNA and lipopolysaccharide (LPS). A total of 150 HIV-infected patients were enrolled in this study, including 46 individuals also infected with HCV (30.6%). HIV/HCV coinfection did not decrease mtDRV/rtv efficacy, since similar rates of HIV-1 intermittent viremia (HCV: 26.6% vs. no-HCV: 34.7%) and episodes of virological failure (HCV: 22.2% vs. no-HCV: 11.2%, p-value = 0.381) were found. No major differences were found between both groups at baseline, although higher HLA-DR(+)CD38(+)CD4(+) T cell counts were found in the coinfected group (HCV: 6.65% vs. no-HCV: 4.55%, p-value = 0.032); this difference was maintained in the 24 months of follow-up. After the 24-month follow-up, both groups, HIV-monoinfected patients and HIV/HCV-coinfected patients, presented similar immune activation and microbial translocation profiles. In conclusion, the use of a simplified mtDRV/rtv strategy compromises neither HIV nor HCV viremic control in coinfected patients, although a higher immune activation of CD4(+) T cells was found.
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Affiliation(s)
- Omar J. BenMarzouk-Hidalgo
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Almudena Torres-Cornejo
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Alicia Gutierrez-Valencia
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Rosa Ruiz-Valderas
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Pompeyo Viciana
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Luis F. López-Cortés
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
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Mitchell RM, Schukken Y, Koets A, Weber M, Bakker D, Stabel J, Whitlock RH, Louzoun Y. Differences in intermittent and continuous fecal shedding patterns between natural and experimental Mycobacterium avium subspecies paratuberculosis infections in cattle. Vet Res 2015; 46:66. [PMID: 26092571 PMCID: PMC4474556 DOI: 10.1186/s13567-015-0188-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 03/14/2015] [Indexed: 11/17/2022] Open
Abstract
The objective of this paper is to study shedding patterns of cows infected with Mycobacterium avium subsp. paratuberculosis (MAP). While multiple single farm studies of MAP dynamics were reported, there is not large scale meta-analysis of both natural and experimental infections. Large difference in shedding patterns between experimentally and naturally infected cows were observed. Experimental infections are thus probably driven by different pathological mechanisms. For further evaluations of shedding patterns only natural infections were used. Within such infections, the transition to high shedding was studied as a proxy to the development of a clinical disease. The majority of studied cows never developed high shedding levels. Those that do, typically never reduced their shedding level to low or no shedding. Cows that eventually became high shedders showed a pattern of continuous shedding. In contrast, cows with an intermittent shedding pattern had a low probability to ever become high shedders. In addition, cows that start shedding at a younger age (less than three years of age) have a lower hazard of becoming high shedders compared to cows starting to shed at an older age. These data suggest the presence of three categories of immune control. Cows that are intermittent shedders have the infection process under control (no progressive infection). Cows that start shedding persistently at a young age partially control the infection, but eventually will be high shedders (slow progressive infection), while cows that start shedding persistently at an older age cannot effectively control the infection and become high shedders rapidly.
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Affiliation(s)
- Rebecca M Mitchell
- Centers for Disease Control and Prevention, Atlanta, Georgia. .,Department of Population Medicine and Diagnostic Sciences, Cornell University, Ithaca, NY, USA.
| | - Ynte Schukken
- Department of Bacteriology and TSE, Central Veterinary Institute part of Wageningen UR, Lelystad, The Netherlands. .,GD Animal Health, Deventer, The Netherlands.
| | - Ad Koets
- GD Animal Health, Deventer, The Netherlands. .,Central Institute for Animal Disease Control, Lelystad, The Netherlands.
| | | | - Douwe Bakker
- Central Institute for Animal Disease Control, Lelystad, The Netherlands.
| | - Judy Stabel
- National Animal Diseases Center Ames, 2300 Dayton Avenue, Ames, IA, 50010, USA.
| | - Robert H Whitlock
- Department of Clinical Studies, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Yoram Louzoun
- Gonda Brain Research Center and Department of Mathematics, Bar-Ilan University, Ramat Gan, Israel.
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