Timing of antiretroviral therapy for HIV in the setting of TB treatment

Insights to the HIV-associated visceral leishmaniasis clinical outcome: lessons learned about immune mediated disorders

Most cases of visceral leishmaniasis (VL) and human immunodeficiency virus (HIV) co-infection (VL/HIV) in the Americas occur in Brazil, and the prevalence of VL/HIV has been increasing since 2019, reaching 19% in 2023. This association presents a challenge for the management of VL, since both VL and HIV infection share immunopathogenic characteristics that can reciprocally affect co-infected patients. Thus, VL may contribute to the immunosuppression and other immunological disturbances associated with the rapid progression to acquired immunodeficiency syndrome (AIDS), whereas HIV infection accelerates the development of active VL and reduces the probability of a successful response to anti-Leishmania therapy, resulting in an increase in the relapse and lethality rates of VL. In this synergistic impairment, one of the most critical hallmarks of VL/HIV co-infection is the enhancement of immunosuppression and intense chronic immune activation, caused not only by each infection per se, but also by the cytokine storm and translocation of microbial products. Thus, co-infected patients present with an impaired effector immune response that may result in inefficient parasitic control. In addition, the chronic activation environment in VL/HIV patients may favor progression to early immunosenescence and exhaustion, worsening the patients' clinical condition and increasing the frequency of disease relapse. Herein, we review the immunological parameters associated with the immunopathogenesis of VL/HIV co-infection that could serve as good biomarkers of clinical prognosis in terms of relapse and severity of VL.

The cause-effect relation of tuberculosis on incidence of diabetes mellitus

Tuberculosis (TB) is one of the oldest human diseases and is one of the major causes of mortality and morbidity across the Globe. Mycobacterium tuberculosis (Mtb), the causal agent of TB is one of the most successful pathogens known to mankind. Malnutrition, smoking, co-infection with other pathogens like human immunodeficiency virus (HIV), or conditions like diabetes further aggravate the tuberculosis pathogenesis. The association between type 2 diabetes mellitus (DM) and tuberculosis is well known and the immune-metabolic changes during diabetes are known to cause increased susceptibility to tuberculosis. Many epidemiological studies suggest the occurrence of hyperglycemia during active TB leading to impaired glucose tolerance and insulin resistance. However, the mechanisms underlying these effects is not well understood. In this review, we have described possible causal factors like inflammation, host metabolic changes triggered by tuberculosis that could contribute to the development of insulin resistance and type 2 diabetes. We have also discussed therapeutic management of type 2 diabetes during TB, which may help in designing future strategies to cope with TB-DM cases.

Determinants of adverse reactions to first-line antitubercular medicines: a prospective cohort study

BACKGROUND

The success of tuberculosis treatment relies on patients adhering to their medication regimen consistently. However, adherence levels tend to decrease among patients who experience adverse drug reactions to antitubercular medications, leading to suboptimal treatment outcomes. Hence, this study aimed to examine the types, incidence rates, and severity of adverse reactions caused by first-line antitubercular drugs. Additionally, it aimed to identify factors associated with the development of these reactions. By doing so, the study aimed to facilitate the provision of personalized and effective treatment to patients, ultimately improving treatment outcomes.

METHODS

Newly diagnosed patients with active tuberculosis were monitored from the start of their treatment until the completion of therapy. Any adverse reactions to anti-TB drugs that they encountered were carefully recorded. The collected data were analyzed using appropriate statistical methods such as analysis of variance, Chi-squared test, Fisher's exact test, and independent t-tests. Logistic regression was employed to assess the association between adverse drug reactions and various socio-demographic and clinical factors of the patients, using odds ratios as a measure of association.

RESULTS

Among the 378 patients included in the study, 181 individuals (47.9%) reported experiencing at least one adverse drug reaction, with an incidence rate of 1.75 events per 100-person months. The majority of these reactions occurred during the intensive phase of treatment. The gastrointestinal tract was the most commonly affected system, followed by the nervous system and skin. Patients aged over 45 years (OR = 1.55, 95% CI 1.01-2.39, p = 0.046) and those with extrapulmonary tuberculosis (OR = 2.41, 95% CI 1.03-5.64) were more likely to develop gastrointestinal reactions. Female gender was a significant predictor of both skin (OR = 1.78, 95% CI 1.05-3.02, p = 0.032) and nervous system (OR = 1.65, 95% CI 1.07-2.55, p = 0.024) reactions. Additionally, alcohol use and HIV infection were identified as independent predictors of adverse drug reactions affecting all three systems.

CONCLUSION

Significant risk factors for developing antitubercular drug adverse reactions include alcohol consumption, cigarette smoking, being HIV positive, female gender and extrapulmonary tuberculosis.

Tuberculosis and HIV Coinfection–the Challenge in the Prevention, Detection and Treatment of Tuberculosis

Background:

Tuberculosis (TB) is still a major public health concern world-wide. The increasing global burden of TB is linked to HIV infection. HIV-TB coinfection has also conditioned clinical aspects of the TB. Since the HIV is beginning in the 1980s, the HIV infection poses a significant challenge in global TB control.

Objective:

In this review we focused on the challenges of epidemiological and clinical feature of tuberculosis presented by the HIV coinfection.

Method:

The article consists of a summary of the most important effects presented by the HIV coinfection on epidemiological and clinical feature of tuberculosis. The article analyzes and summary the causes for these challenges.

Results:

The major challenges to strategy of TB control and clinical feature of TB-HIV coinfection are presented in this paper.

Conclusion:

HIV/TB co-infection is synergic, interactive and reciprocal with significant impact. The infection of HIV and Mtb affect each other and the breakdown the immune function in TB/HIV coinfected individual. HIV infection has changed the strategy of TB control, however HIV increases global burden of TB, the reduction in the TB incidence rate is far from sufficient. Atypically clinical manifestations in TB/HIV co-infected patients and increased MDR-TB and XDR-TB contribute to the challenges in the diagnosis and treatment. Increased complexity of managing patients requires expertise in the clinical m knowledge. The focused efforts to control HIV-related TB are of great urgency. These findings will provide insight into the prevention, detection and treatment of tuberculosis and will guide advances towards tuberculosis control.

Challenges to tuberculosis control in Angola: the narrative of medical professionals

Background

There is a tuberculosis (TB) epidemic in Angola that has been getting worse for more than a decade despite the active implementation of the DOTS strategy. The aim of this study was to directly interrogate healthcare workers involved in TB control on what they consider to be the drivers of the TB epidemic in Angola.

Methods

Twenty four in-depth qualitative interviews were conducted with medical staff working in this field in the provinces of Luanda and Benguela.

Results

The healthcare professionals see the migrant working poor as a particular problem for the control of TB. These migrants are constructed as 'Rural People' and are seen as non-compliant and late-presenting. This is a stigmatized and marginal group contending with the additional stigma associated with TB infection. The healthcare professionals interviewed also see the interruption of treatment and self-medication generally as a better explanation for the TB epidemic than urbanization or lack of medication.

Conclusions

The local narrative is in contrast to previous explanations used elsewhere in the developing world. To be effective policy must recognize the local issues of the migrant workforce, interruption of treatment and the stigma associated with TB in Angola.

The twin epidemics: Prevalence of TB/HIV co-infection and its associated factors in Ethiopia; A systematic review and meta-analysis

BACKGROUND

Tuberculosis and HIV/AIDS are the major public health problems in many parts of the world particularly in resource limited countries like Ethiopia. Although studies have been conducted on the prevalence and associated factors of TB / HIV co-infection in Ethiopia, there is no comprehensive data on the magnitude and risk factors at a national and regional levels. Therefore, this review is aimed to summarize the prevalence of TB /HIV co-infection in Ethiopia using meta-analysis based on a systematic review of published articles & grey literatures.

METHODS

To conduct this systematic review and meta-analysis, major databases such as Pub Med, Google scholar, CINAHL, Africa Journals Online and Google were systematically searched using search terms. PRISMA guideline was followed in the study. Two authors extracted all necessary data using a standardized data extraction format, and analysis was done using STATA version 11. A Statistical heterogeneity across the studies was evaluated by using Cochran's Q test and I2 statistic. The pooled effect size was conducted in the form of prevalence and associations were measured using odds ratio. Moreover, the univariate meta regression was performed by considering the sample size to determine potential sources of heterogeneity. The Egger's weighted regression and Begg's rank correlation tests were used to assess potential publication biases.

RESULTS

This meta-analysis included 21 studies with a total of 12,980 participants. The pooled prevalence of TB / HIV Co-infection was 25.59% (95% CI (20.89%-30.29%). A significant association was found between low CD4 counts (OR: 3.53; 95% CI: 1.55, 8.06), advanced WHO stage (OR: 6.81; 95% CI: 3.91, 11.88) and TB/ HIV/AIDS Co-infection.

CONCLUSION

This finding revealed that the magnitude of TB /HIV co-infection in Ethiopia is increasing and deserves special attention. Low CD4 count and advanced WHO stage are contributing factors for dual infection. Establishing mechanisms such as Conducting surveillance to determine HIV burden among TB patients and TB burden among HIV patients, and intensifying the three I's (Intensive case finding, INH Preventive Therapy and Infection control) should be routine work of clinicians. Moreover, early screening & treatment should be provided to those patients with low CD4 count and advanced WHO stage.

Synthesis of substrate analogues as potential inhibitors for Mycobacterium tuberculosis enzyme MshC

Mycothiol cysteine ligase (MshC) is a key enzyme in the mycothiol (MSH) biosynthesis and a promising target for developing new anti-mycobacterial compounds. Herein, we report on the synthesis of substrate analogues, as potential inhibitors, for the MshC enzyme. The target molecules were synthesized employing a Schmidt glycosylation strategy using an enantiomerically pure inositol acceptor and 2-deoxy trichloroacetimidate glycosyl donors with glycosylation yields greater than 70% and overall yields >5%. The inositol acceptor was obtained via chiral resolution of (±)-myo-inositol.

Dual-targeted anti-TB/anti-HIV heterodimers

HIV and M. tuberculosis are two intersecting epidemics making the search for new dual action drugs against both pathogens extremely important. Here, we report on the synthesis and suppressive activities of five dual-targeted HIV/TB compounds. These compounds are heterodimers of AZT, as anti-HIV molecules, and 5-substituted uracil derivatives, as anti-TB molecules. We found that these compounds inhibit the growth of M. tuberculosis and suppress the replication of HIV in human cell cultures and human lymphoid tissues ex vivo. We identified one particular heterodimer that inhibited both HIV and the drug-resistant TB strain MS-115 most potently. This compound demonstrated low toxicity and had no cytostatic effect on cells in culture, constituting an ideal candidate for future development and further in vivo testing.

Tuberculosis Infection: Occurrence and Risk Factors in Presumptive Tuberculosis Patients of the Serengeti Ecosystem in Tanzania

Background

Cross-species tuberculosis (TB) transmission between humans and animals has been reported for quite a long time in sub-Saharan Africa. Because humans and animals coexist in the same ecosystem, exploring their potential for cross-species transmission and the impact the disease may have on the health of humans, animals, and their products is critical.

Objectives

This study aimed to identify risk factors for transmission of TB (Mycobacterium tuberculosis) and to assess the potential for zoonotic TB (Mycobacterium bovis) transmission in the Serengeti ecosystem where humans and animals are in intense contact. Our aim is to create a base for future implementation of appropriate control strategies to limit infection in both humans and animals.

Methodology

We administered a semi-structured questionnaire to 421 self-reporting patients to gather information on risk factors and TB occurrence. In a parallel study, researchers screened sputum smears using Ziehl-Neelsen staining and confirmed by mycobacterial culture. We then performed descriptive statistics (Pearson's chi-square test) and logistic regression analysis to establish frequencies, association, and quantification of the risk factors associated with TB cases.

Results

Our findings showed 44% (95% confidence interval [CI], 0.40-0.49) of the results were positive from sputum samples collected over a 1-year duration in areas with a high TB burden, particularly the Bunda district, followed by the Serengeti and Ngorongoro districts. Of the culture-positive patients who also had infections other than TB (43/187 patients), 21 (49%) were HIV positive. Contact with livestock products (odds ratio [OR] 6.0; 95% CI, 1.81-19.9), infrequent milk consumption (OR 2.5; 95% CI, 1.42-4.23), cigarette smoking (OR 2.9; 95% CI, 1.19-7.1.2), and alcohol consumption (OR 2.3; 95% CI, 1.22-4.23) were associated with a higher likelihood of TB infection.

Conclusion

There was no evidence of direct cross-species transmission of either M tuberculosis or M bovis between humans and animals using the study methods. The absence of cross-species TB transmission could be due to limited chances of contact rather than an inability of cross-species disease transmission. In addition, not all people with presumptive TB are infected with TB, and therefore control strategies should emphasise confirming TB status before administering anti-TB drugs.

The prevalence and associated factors for delayed presentation for HIV care among tuberculosis/HIV co-infected patients in Southwest Ethiopia: a retrospective observational cohort

Background

A delay presentation for human immunodeficiency virus (HIV) patient’s care (that is late engagement to HIV care due to delayed HIV testing or delayed linkage for HIV care after the diagnosis of HIV positive) is a critical step in the series of HIV patient care continuum. In Ethiopia, delayed presentation (DP) for HIV care among vulnerable groups such as tuberculosis (Tb) /HIV co-infected patients has not been assessed. We aimed to assess the prevalence of and factors associated with DP (CD4 < 200 cells/μl at first visit) among Tb/HIV co-infected patients in southwest Ethiopia.

Methods

A retrospective observational cohort study collated Tb/HIV data from Jimma University Teaching Hospital for the period of September 2010 and August 2012. The data analysis used logistic regression model at P value of ≤ 0.05 in the final model.

Results

The prevalence of DP among Tb/HIV co-infected patients was 59.9 %. Tb/HIV co-infected patients who had a house with at least two rooms were less likely (AOR, 0.5; 95 % CI: 0.3–1.0) to present late than those having only single room. Tobacco non-users of Tb/HIV co-infected participants were also 50 % less likely (AOR, 0.5; 95 % CI: 0.3–0.8) to present late for HIV care compared to tobacco users. The relative odds of DP among Tb/HIV co-infected patients with ambulatory (AOR, 1.8; 95 % CI, 1.0–3.1) and bedridden (AOR, 8.3; 95 % CI, 2.8–25.1) functional status was higher than with working status.

Conclusions

Three out of five Tb/HIV co-infected patients presented late for HIV care. Higher proportions of DP were observed in bedridden patients, tobacco smokers, and those who had a single room residence. These findings have intervention implications and call for effective management strategies for Tb/HIV co-infection including early HIV diagnosis and early linkage to HIV care services.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0193-y) contains supplementary material, which is available to authorized users.

Pleuropulmonary Kaposi Sarcoma in the Setting of Immune Reactivation

We present a case of a 26 year with history of HIV/AIDS who presented with a pleural effusion. Serial radiography, pleural fluid analysis as well as clinical symptoms revealed development of Kaposi Sarcoma related immune reconstitution inflammatory syndrome (KS-IRIS) in the setting of initiation of effective anti- retroviral therapy.

Outcomes of highly active antiretroviral therapy and its predictors: a cohort study focusing on tuberculosis co-infection in South West Ethiopia

BACKGROUND

In this study, we hypothesized that TB co-infection independently increases the risk of poor treatment outcomes in such patients even if they are on antiretroviral therapy (ART). Therefore, this study was aimed at investigating this hypothesis among cohort of adult PLWHs in South West Ethiopia.

METHODOLOGY

Cohort study comparing the immunologic and clinical outcomes of 130 HIV/TB co-infected and 520 only HIV patients starting ART was enrolled. Chi square and student t test were used to compare outcome variables and logistic regression was used to assess the effect of TB on treatment failure.

RESULTS

In this study, TB co-infection didn't increase immunologic failure even in univariate analysis at both 6 [OR, 1.10 (0.59-1.69), P = 0.85] and 12 months [OR, 1.06 (0.58-1.93), P = 0.89] of ART initiation. However, it increased the risk of clinical failure at both 6 [Adjusted Odd Ratio (AOR), 2.90 (1.41-6.09), P = 0.028] and 12 months [AOR, 2.93 (1.41-6.09), P = 0.004] of ART initiation.

CONCLUSION

This study showed that TB co-infection didn't adversely affect the immunologic outcomes, weight and hemoglobin responses even though it increased the risk of clinical failure nearly three times. Therefore, beside the concern given for TB prevention and treatment, several patient and policy related factors need to be addressed to maximally benefit from highly active antiretroviral therapy rollout in resource limited settings.

The Effect of Early Initiation of Antiretroviral Therapy in TB/HIV-Coinfected Patients: A Systematic Review and Meta-Analysis

BACKGROUND

The importance of early initiation of antiretroviral therapy (ART) for tuberculosis (TB) and HIV-coinfected patients is controversial. We conducted a systematic review and meta-analysis to assess the effect of early initiation of ART (within 2-4 weeks of TB treatment) on several treatment outcomes among TB/HIV-coinfected patients.

METHOD

A systematic search of clinical trials was performed in PubMed, Embase, Google Scholar, Science Direct, Medscape, and the Cochrane library. Clinical trials which were published in any language before the last date of search (March 31, 2015) were included. The qualities of the studies were assessed using criteria from the Cochrane Library. Heterogeneity test was conducted to assess the variations among study outcomes. For each study outcome, the risk ratio (RR) with 95% confidence interval (CI) was calculated as a measure of intervention effect. The Mantel-Haenszel method was used to estimate the RR using a fixed-effects model.

FINDINGS

A total of 2272 study participants from 6 trials were included in the meta-analysis. Early ART initiation during TB treatment was associated with reduced all-cause mortality (RR = 0.78; 95% CI = 0.63-0.98) and increased rate of TB-associated immune reconstitution inflammatory syndrome (TB-IRIS; RR = 2.19; 95% CI = 1.77- 2.70) and death related to TB-IRIS (RR = 6.94; 95% CI = 1.26-38.22). However, the time of ART initiation has no association with TB cure rate (RR = 0.99; 95% CI = 0.81-1.07), rate of drug toxicity (RR = 1.00; 95% CI = 0.93-1.08), death associated with drug toxicity (RR = 0.40; 95% CI = 0.14- 1.16), rate of low viral load (less than 400 copies/mL; RR = 1.00; 95% CI = 0.96-1.04), and rate of new AIDS-defining illness (RR = 0.84; 95% CI = 0.60-1.18). Immunological response in early ART arms of study participant in different trials showed a greater or equal response compared with late ART arms.

CONCLUSION

This systematic review presents conclusive evidence on the reduction of all-cause mortality as a result of early initiation of ART. However, this study also confirms the high rate of TB-IRIS and death associated with it. Operational and implementation research are required to maintain the benefit of early ART initiation and proper management of TB-IRIS. Studies on the timing of ART in extrapulmonary and multidrug-resistant TB are recommended.

Optimal Timing of Antiretroviral Therapy Initiation for HIV-Infected Adults With Newly Diagnosed Pulmonary Tuberculosis: A Systematic Review and Meta-analysis

BACKGROUND

Initiation of antiretroviral therapy (ART) during tuberculosis (TB) treatment remains challenging.

PURPOSE

To assess evidence from randomized, controlled trials of the timing of ART initiation in HIV-infected adults with newly diagnosed pulmonary TB.

DATA SOURCES

PubMed, EMBASE, Cochrane Central Register of Controlled Trials, conference abstracts, and ClinicalTrials.gov (from January 1980 to May 2015).

STUDY SELECTION

Randomized, controlled trials evaluating early versus delayed ART initiation (1 to 4 weeks vs. 8 to 12 weeks after initiation of TB treatment) or deferred ART initiation (after the end of TB treatment).

DATA EXTRACTION

Three reviewers independently extracted data and assessed risk of bias. The main outcome measures were all-cause mortality and the TB-associated immune reconstitution inflammatory syndrome (TB-IRIS).

DATA SYNTHESIS

The 8 included trials (n = 4568) were conducted in Africa, Asia, and the United States and were generally at low risk of bias for the assessed domains. Overall, early ART reduced mortality compared with delayed ART (relative risk [RR], 0.81 [95% CI, 0.66 to 0.99]; I2 = 0%). In a prespecified subgroup analysis, early ART reduced mortality compared with delayed ART among patients with baseline CD4+ T-cell counts less than 0.050 × 109 cells/L (RR, 0.71 [CI, 0.54 to 0.93]; I2 = 0%). However, a mortality benefit from early ART was not found among those with CD4+ T-cell counts greater than 0.050 × 109 cells/L (RR, 1.05 [CI, 0.68 to 1.61]; I2 = 56%). Early ART was associated with a higher incidence of TB-IRIS than delayed ART (RR, 2.31 [CI, 1.87 to 2.86]; I2 = 19%).

LIMITATION

Few trials provided sufficient data for subgroup analysis.

CONCLUSION

Early ART in HIV-infected adults with newly diagnosed TB improves survival in those with CD4+ T-cell counts less than 0.050 × 109 cells/L, although this is associated with a 2-fold higher frequency of TB-IRIS. In patients with CD4+ T-cell counts greater than 0.050 × 109 cells/L, evidence is insufficient to support or refute a survival benefit conferred by early versus delayed ART initiation.

PRIMARY FUNDING SOURCE

None. (PROSPERO registration: CRD42012001884).

Early versus Delayed Antiretroviral Therapy for HIV and Tuberculosis Co-Infected Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To compare important clinical outcomes between early and delayed initiation of antiretroviral therapy (ART) in adults who had a co-infection of human immunodeficiency virus (HIV) and tuberculosis (TB).

METHODS

We performed a systematic search for relevant publications on PubMed, EMBASE, and the International Clinical Trials Registry Platform. We included randomized controlled trials (RCTs) that compared early ART initiation (within four weeks after anti-TB treatment starting) and delayed ART initiation (after eight weeks but less than twelve weeks of anti-TB treatment starting) in the course of TB treatment. Pooled estimates with corresponding 95% confidence interval (95%CI) were calculated with random-effects model. Sensitivity analysis was performed to investigate the stability of pooled estimates.

RESULTS

A meta-analysis was evaluated from six RCTs with 2272 participants. Compared to delayed ART initiation, early ART initiation significantly reduces all-cause mortality in HIV-positive patients with TB [incidence rate ratio (IRR) 0.75, 95%CI 0.59 to 0.95; I2 = 0.00%; p = 0.67], even though there is an increased risk for IRD [IRR 2.29, 95%CI 1.81 to 2.91; I22 = 0.00%; p = 0.56]. Additionally, early ART initiation was not associated with an increased risk for grade 3-4 drug-related adverse events [IRR 0.99, 95%CI 0.83 to 1.18; I2 = 0.00%; p = 0.56].

CONCLUSIONS

Although limited evidence, our results provide support for early ART initiation in the course of anti-TB treatment. However, more well-designed cohort or intervention studies are required to further confirm our findings.

Modelling HIV and MTB co-infection including combined treatment strategies

A new host-pathogen model is described that simulates HIV-MTB co-infection and treatment, with the objective of testing treatment strategies. The model includes CD4+ and CD8+ T cells, resting and activated macrophages, HIV and Mycobacterium tuberculosis (MTB). For TB presentation at various stages of HIV disease in a co-infected individual, combined treatment strategies were tested with different relative timings of treatment for each infection. The stages were early HIV disease, late HIV disease and AIDS. The main strategies were TB treatment followed by anti-retroviral therapy (ART) after delays of 15 days, 2 months and 6 months. ART followed by TB treatment was an additional strategy that was tested. Treatment was simulated with and without drug interaction. Simulation results were that TB treatment first followed by ART after a stage-dependent delay has the best outcome. During early HIV disease a 6 month delay is acceptable. During late HIV disease, a 2 month delay is best. During AIDS it is better to start ART after 15 days. However, drug interaction works against the benefits of early ART. These results agree with expert reviews and clinical trials.

Alcohol consumption effect on antiretroviral therapy and HIV-1 pathogenesis: role of cytochrome P450 isozymes

INTRODUCTION

Alcohol consumption, which is highly prevalent in HIV-infected individuals, poses serious concerns in terms of rate of acquisition of HIV-1 infection, HIV-1 replication, response to highly active antiretroviral therapy (HAART) and AIDS/neuroAIDS progression. However, little is known about the mechanistic pathways by which alcohol exerts these effects, especially with respect to HIV-1 replication and the patient's response to HAART.

AREAS COVERED

In this review, the authors discuss the effects of alcohol consumption on HIV-1 pathogenesis and its effect on HAART. They also describe the role of cytochrome P450 2E1 (CYP2E1) in alcohol-mediated oxidative stress and toxicity, and the role of CYP3A4 in the metabolism of drugs used in HAART (i.e., protease inhibitors (PI) and non-nucleoside reverse transcriptase inhibitors (NNRTI)). Based on the most recent findings the authors discuss the role of CYP2E1 in alcohol-mediated oxidative stress in monocytes/macrophages and astrocytes, as well as the role of CYP3A4 in alcohol-PI interactions leading to altered metabolism of PI in these cells.

EXPERT OPINION

The authors propose that alcohol and PI/NNRTI interact synergistically in monocytes/macrophages and astrocytes through the CYP pathway leading to an increase in oxidative stress and a decrease in response to HAART. Ultimately, this exacerbates HIV-1 pathogenesis and neuroAIDS.

Early versus delayed initiation of antiretroviral therapy for Indian HIV-Infected individuals with tuberculosis on antituberculosis treatment

Background

For antiretroviral therapy (ART) naive human immunodeficiency virus (HIV) infected adults suffering from tuberculosis (TB), there is uncertainty about the optimal time to initiate highly active antiretroviral therapy (HAART) after starting antituberculosis treatment (ATT), in order to minimize mortality, HIV disease progression, and adverse events.

Methods

In a randomized, open label trial at All India Institute of Medical Sciences, New Delhi, India, eligible HIV positive individuals with a diagnosis of TB were randomly assigned to receive HAART after 2-4 or 8-12 weeks of starting ATT, and were followed for 12 months after HAART initiation. Participants received directly observed therapy short course (DOTS) for TB, and an antiretroviral regimen comprising stavudine or zidovudine, lamivudine, and efavirenz. Primary end points were death from any cause, and progression of HIV disease marked by failure of ART.

Findings

A total of 150 patients with HIV and TB were initiated on HAART: 88 received it after 2-4 weeks (early ART) and 62 after 8-12 weeks (delayed ART) of starting ATT. There was no significant difference in mortality between the groups after the introduction of HAART. However, incidence of ART failure was 31% in delayed versus 16% in early ART arm (p = 0.045). Kaplan Meier disease progression free survival at 12 months was 79% for early versus 64% for the delayed ART arm (p = 0.05). Rates of adverse events were similar.

Interpretation

Early initiation of HAART for patients with HIV and TB significantly decreases incidence of HIV disease progression and has good tolerability.

Trial registration

CTRI/2011/12/002260

Identification of common biological pathways and drug targets across multiple respiratory viruses based on human host gene expression analysis

BACKGROUND

Pandemic and seasonal respiratory viruses are a major global health concern. Given the genetic diversity of respiratory viruses and the emergence of drug resistant strains, the targeted disruption of human host-virus interactions is a potential therapeutic strategy for treating multi-viral infections. The availability of large-scale genomic datasets focused on host-pathogen interactions can be used to discover novel drug targets as well as potential opportunities for drug repositioning.

METHODS/RESULTS

In this study, we performed a large-scale analysis of microarray datasets involving host response to infections by influenza A virus, respiratory syncytial virus, rhinovirus, SARS-coronavirus, metapneumonia virus, coxsackievirus and cytomegalovirus. Common genes and pathways were found through a rigorous, iterative analysis pipeline where relevant host mRNA expression datasets were identified, analyzed for quality and gene differential expression, then mapped to pathways for enrichment analysis. Possible repurposed drugs targets were found through database and literature searches. A total of 67 common biological pathways were identified among the seven different respiratory viruses analyzed, representing fifteen laboratories, nine different cell types, and seven different array platforms. A large overlap in the general immune response was observed among the top twenty of these 67 pathways, adding validation to our analysis strategy. Of the top five pathways, we found 53 differentially expressed genes affected by at least five of the seven viruses. We suggest five new therapeutic indications for existing small molecules or biological agents targeting proteins encoded by the genes F3, IL1B, TNF, CASP1 and MMP9. Pathway enrichment analysis also identified a potential novel host response, the Parkin-Ubiquitin Proteasomal System (Parkin-UPS) pathway, which is known to be involved in the progression of neurodegenerative Parkinson's disease.

CONCLUSIONS

Our study suggests that multiple and diverse respiratory viruses invoke several common host response pathways. Further analysis of these pathways suggests potential opportunities for therapeutic intervention.

Survival outcomes and effect of early vs. deferred cART among HIV-infected patients diagnosed at the time of an AIDS-defining event: a cohort analysis

Objectives

We analyzed clinical progression among persons diagnosed with HIV at the time of an AIDS-defining event, and assessed the impact on outcome of timing of combined antiretroviral treatment (cART).

Methods

Retrospective, European and Canadian multicohort study.. Patients were diagnosed with HIV from 1997–2004 and had clinical AIDS from 30 days before to 14 days after diagnosis. Clinical progression (new AIDS event, death) was described using Kaplan-Meier analysis stratifying by type of AIDS event. Factors associated with progression were identified with multivariable Cox regression. Progression rates were compared between those starting early (<30 days after AIDS event) or deferred (30–270 days after AIDS event) cART.

Results

The median (interquartile range) CD4 count and viral load (VL) at diagnosis of the 584 patients were 42 (16, 119) cells/µL and 5.2 (4.5, 5.7) log₁₀ copies/mL. Clinical progression was observed in 165 (28.3%) patients. Older age, a higher VL at diagnosis, and a diagnosis of non-Hodgkin lymphoma (NHL) (vs. other AIDS events) were independently associated with disease progression. Of 366 patients with an opportunistic infection, 178 (48.6%) received early cART. There was no significant difference in clinical progression between those initiating cART early and those deferring treatment (adjusted hazard ratio 1.32 [95% confidence interval 0.87, 2.00], p = 0.20).

Conclusions

Older patients and patients with high VL or NHL at diagnosis had a worse outcome. Our data suggest that earlier initiation of cART may be beneficial among HIV-infected patients diagnosed with clinical AIDS in our setting.