Association of hepatitis B infection in patients with HIV Encephalopathy

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1 Romanian Biotechnological Letters Vol. 17, No.6, 2012 Copyright 2012 University of Bucharest Printed in Romania. All rights reserved ORIGINAL PAPER Association of hepatitis B infection in patients with HIV Encephalopathy Received for publication, August 20, 2012 Accepted, December 15, 2012 PAUL MARINESCU 1, LOREDANA SABINA CORNELIA MANOLESCU 2*

2 There are people living with HIV/AIDS in Romania, according to the data provided by Compartment for Monitoring and Evaluation of HIV/AIDS Data, National Institute of Infectious Diseases Prof. Dr. Matei Bals, as of 31 st of December Currently, Romania has a large number of survivors, integrated in the age group, who belong to the cohort (>6000). Almost 10% of them are currently living in the same region, the Giurgiu County (CNLAS [8]). Here, we assessed the degree of association between hepatitis B virus infection and prognosis of HIV encephalopathy in a large cohort of HIV-infected patients with common epidemiological particularities which have experienced multiple therapeutic schemes over time. We undertook a critical review of the available evidence concerning whether the nadir CD4 cell count predicts neurocognitive impairment in HIV infected patients after several changes in antiretroviral therapy schemes. 2. Materials and methods 2.1. Ethics. This research was approved by the ethical review board of the Infectious Disease Hospital from Giurgiu County Study participants. Data from a cohort of 462 HIV infected individuals from Giurgiu County, Romania, was retrospectively analyzed at different points in time. These patients were born in poor families or abandoned in foster care during the period from 1987 to 1990 and were probably infected in the same way and probably during the same period of time, parenterally, by horizontal route. The main inclusion criteria for selecting these patients from Giurgiu Infectious Diseases Hospital s database were HIV infection and the year of birth, making our cohort very homogeneousness. The majority of patients were HIV diagnosed from 1989 to 1999 but there were 35 patients that were diagnosed later between 2000 and The HBV diagnosis was performed from 1996 to The patients were clinically evaluated in day clinic from Giurgiu Infectious Disease Hospital. First CD4 and HIV RNA evaluations were performed in 1995 for those already diagnosed and which started at that time antiretroviral (ARV) therapy. Patients diagnosed after 1995 have been evaluated at the time of HIV diagnose and if eligible they started ARV therapy. As ARV drugs developed worldwide they were administered to Romanian patients so their ARV therapy changed along with the improvement of those drugs and according with the need of the patients. From the initial group 33.76% patients died until Quantitative CD4 and HIV RNA Parameters. HIV RNA and absolute CD4cell count were measured in all the participants enrolled in the study. Absolute CD4 cell count has been performed at least twice a year and HIV RNA once a year up to now starting with From 1995 and until 2005 absolute CD4 cell count was determined from fresh whole blood samples using the TRITEST three-color reagent CD4/CD8/CD3 with TRU-COUNT tubes (BECTON & DICKINSON, USA). Plasma HIV RNA levels were measured from fresh blood specimens using the ROCHE AMPLICOR, version 1.5 (dynamic range, copies/ml), manufactured by ROCHE DIAGNOSTIC CORPORATION, USA.

3 Starting with 2005 absolute CD4 cell count was determined from fresh whole blood samples on a 4-color flow cytometer. Plasma HIV RNA levels were measured from fresh blood specimens using the the COBAS AMPLIPREP/COBAS TAQMAN HIV-1 TEST (dynamic range, copies/ml), manufactured by ROCHE DIAGNOSTIC CORPORATION, USA. The tests were conducted in Professor Dr. Victor Babes Infectious Diseases Hospital from Bucharest. Because the dynamic ranges of these assays differed, for

4 2.6. Statistical Analyses Differences in HIV RNA levels and absolute CD4 cell count was evaluated by Fisher's exact test analysis of contingency tables and chi-square test, using GraphPad Prism 5.0. Twotailed P values were reported. P <.05 was considered statistically significant. Mean values were compared using unpaired t test. For scientific significance confidence intervals (CI) were

5 There were a total of 462 analyzed HIV infected patients. Out of them 156 deceased, median age at death 10 years (limits 7-16). These patients were not treated with any ARV regimen. 197 patients, median age at last investigation 17 years (limits 15-18), were followed up only until 2006 due to several reasons such as: change of residence, lack of adherence or enrollment in other AIDS centers. 109 patients, median age at last investigation 23 years (limits 21-24), were followed up until the end of 2011 (Table 1). All laboratory investigations presented in Table 1 are from their last visit in Giurgiu Day Clinic.

6 regard to level of immune status and age. In the deceased group the majority, 62.87% were male participants. Many of the ARV treated patients have begun therapy since1995 and experimented between one and six antiretroviral regimens until the end of The therapeutic regimens prescribed over time were: 2NRTIs (for at least 24 months), 3NRTIs (6 months), 2NRTIs+1NNRTI

7 Table 1. Cohort characteristics at last investigation Characteristics Total of patients 462 Deceased ARV naive 156 Lost from evidence ARV treated 197 ARV treated 109 Females, no (%) 204 (48%) 58 (37.1%) 112 (56.8%) 61 (55.9%) Age (years) 17 (7-24) 10 (7-16) 17 (15-18) 23 (21-24) Follow up period HIV diagnose date CD4 count (cells/µl) a 242 (0-1652) 73 (0-1040) 379 (5-1652) (3-1250) HIV RNA Level Log 10 (copies/ml) a b 3.31 ( ) 5.5 ( ) 2.9 ( ) 2.6 ( )

8 STATISTICAL ANALYSES OF IMMUNE STATUS AND PROGRESSION TO AIDS IN NAIVE HIV INFECTED CHILDREN FROM GIURGIU COUNTY, ROMANIA LOREDANA MANOLESCU*, P. MARINESCU**

9 This research was approved by the ethical review board of the Infectious Disease Hospital from Giurgiu County. STUDY PARTICIPANTS Data from an initial large cohort of 600 HIV infected individuals from Giurgiu County, Romania was analyzed. These patients were born in poor families or abandoned in foster care in the period from 1987 to 1990 and were probably infected in the same way and probably at the same period of time by horizontal route. The majority of patients were HIV diagnosed from 1989 to All

10 3 CD4 and progression to AIDS in Giurgiu 43 patients were clinically evaluated in day clinic from Giurgiu Infectious Disease Hospital. From this large cohort, 150 patients, 25%, had died in between years These patients were admitted in day clinic evidence since 1995 up to

11 compared using the Wilcoxon match-pairs signed rank test. Median values were used in all tables due to the fact that they are less affected by the presence of an outlier and are better and more reliable measures of central tendency. For scientific significance confidence intervals (CI) were established. The chi-square test was used for comparisons of categorical variables, with Fisher s two-tailed exact test used when the sample was small. Linear regression models were developed with GraphPad Prism 5.0. A Kaplan Meier analysis of the time from HIV diagnosis to AIDS according to sex was performed; the significance of the difference between the curves was assessed with the log-rank test. Analyses of baseline characteristics were performed with either a t-test for categorical variables or an F test for continuous variables, to determine whether there were sex differences. These analyses were performed separately for two groups, namely, HIV-infected naive

12 COHORT CHARACTERISTICS The group of 150 analyzed HIV infected patients was split into two subgroups: 56 girls and 94 boys (Table 1). All laboratory investigations presented in Table 1 are from their last visit in Giurgiu Day Clinic.

13 Our cohort is representative because the participants are from the same region, are probably infected in the same way and were subjected to the same behavioral and epidemiologic risk factors or socioeconomic disparities. The majority of patients came from HIV/AIDS uninfected parents. They were HIV infected by horizontal way of transmission.

14 Does Patient Sex Affect Human Immunodeficiency Virus Levels? Monica Gandhi, 1 Peter Bacchetti, 1 Paolo Miotti, 2 Thomas C. Quinn, 3,4 Fulvia Veronese, 2 and Ruth M. Greenblatt 1

15 We undertook a critical epidemiological review of the available evidence concerning whether women have lower levels of human immunodeficiency virus (HIV) RNA than do men at similar stages of HIV infection. The 13 studies included in this analysis reported viral load measurements in HIV-infected men and women at a single point in time (cross-sectional studies) or over time (longitudinal studies). Seven of the 9 crosssectional studies demonstrated that women had log 10 ( 2-fold) lower levels of HIV RNA than do men, despite controlling for CD4 + cell count. Four longitudinal studies revealed that women had log 10 (2- to 6-fold) lower levels of HIV RNA than do men, even when controlling for time since seroconversion. Downloaded from

16 values for the men, contrary to observation. Longitudinal studies. Because CD4 cell count serves as a limited surrogate for disease stage, longitudinal studies allow comparisons between sex groups while controlling for duration of infection. Four of the studies [31 34] were longitudinal in jectories of men and women crossing 5.8 years after infection. Therefore, the rate of viral load increase over time in the 6 years after seroconversion was greater for women than for men, as women began with lower HIV RNA levels. In the second report by Sterling et al. [34], none of the p://cid.oxfordjournals.

17 Indian J Med Res 134, December 2011, pp Paediatric HIV - trends & challenges S.N. Mothi *, S. Karpagam **, V.H.T. Swamy +, M. Lala Mamatha ++ & S.M. Sarvode

18 Abnormalities include fat maldistribution and body habitus changes, hyperlipidaemia, hyperglycaemia, insulin resistance, diabetes mellitus, osteopenia, osteoporosis and osteonecrosis. Allergic reactions: including skin rashes and hypersensitivity reactions. These are more common Virological criteria: Virological failure is recognized if the child is adherent to first-line ART regimen for more than 24 wk from initiation, and has a persistent viral load over 5000 copies/ml. In resource-limited settings it may not be feasible to perform viral load testing. Availability of viral load is not a prerequisite

19 Copyright, 1995, by the Massachusetts Medical Society Volume 332 JANUARY 26, 1995 Number 4 VIROLOGIC AND IMMUNOLOGIC CHARACTERIZATION OF LONG-TERM SURVIVORS OF HUMAN IMMUNODEFICIENCY VIRUS TYPE 1 INFECTION YUNZHEN CAO, M.D., LIMO QIN, M.D., LINQI ZHANG, PH.D., JEFFREY SAFRIT, PH.D., AND DAVID D. HO, M.D.

20 Abstract Background. In most subjects infected with human immunodeficiency virus type 1 (HIV-1), clinical or laboratory evidence of immunodeficiency develops within 10 years of seroconversion, but a few infected people remain healthy and immunologically normal for more than a decade. Studies of these subjects, termed long-term survivors, may yield important clues for the development of prophylactic and therapeutic interventions against the acquired immunodeficiency syndrome. another subject with use of a CD8-depleted culture. The other six subjects had no detectable infectious virus in their PBMC. A quantitative polymerase-chain-reaction assay revealed that all subjects had detectable but low titers of viral DNA in PBMC. Overall, the viral burden in the plasma and PBMC of long-term survivors was orders of magnitude lower than that typically found in subjects with progressive disease. There was no in vitro evidence of resistance by host

21 Sex Differences in HIV RNA Level and CD4 Cell Percentage During Childhood Theodore D. Ruel, 1 Brian C. Zanoni, 2,3 Isaac Ssewanyana, 4 Huyen Cao, 5 Diane V. Havlir, 5 Moses Kamya, 6 Jane Achan, 7 Edwin D. Charlebois, 5 and Margaret E. Feeney 1,2,3,8

22 8 Division of Experimental Medicine, Department of Medicine, University of California, San Francisco, California Background. HIV-infected women have lower HIV RNA levels and higher CD4-cell counts than do men. This observation has been attributed to the immunomodulatory effects of sex steroid hormones, such as estrogen and progesterone. Limited data exist regarding potential sex differences in HIV RNA level and CD4 parameters among prepubertal children with untreated HIV infection. Methods. We examined the relationship of sex to HIV RNA level and CD4 parameters among 670 perinatally

23 across all observed ages. Levels of T-cell activation did not differ between the sexes. Conclusions. Significant sex differences in HIV RNA levels and CD4 parameters are present in HIV-infected children before the onset of puberty. These data suggest that intrinsic genetic differences between male and female individuals, unrelated to sex steroid hormone levels, influence HIV RNA level and CD4 parameters in HIV-infected individuals.

24 men and correlates with plasma progesterone levels has been suggested to be a potential biological mechanism for the observed sex differences in HIV load [13, 14]. Comparison of HIV RNA levels between prepubertal boys and girls provides a means to uncouple the impact of sex hormones from other sex-specific genetically determined effects. Two small studies in the United States and Europe described lower HIV RNA levels among girls than among boys [15, 16], but the majority of children in both cohorts were receiving combination antiretroviral therapy (ART). One study of ARTnaive Kenyan infants detected no sex difference in viral load but included only a small number of participants [17]. Here, we assessed HIV RNA levels, CD4 parameters, and T-cell activation markers in a large cohort of HIV-infected children before the (dynamic range, copies/ml) or the NucliSENS easymag (biomérieux; dynamic range, IU/mL) was used. Because the dynamic ranges of these assays differed, for combined analyses, we assigned all HIV RNA measurements copies/ml as a value of copies/ml, and we assigned measurements,400 copies/ml as a value of 399 copies/ml. Log-transformed HIV RNA levels were used for all analyses. CD4 and CD8 Activation Markers For the participants in cohort 3, the proportions of CD41 and CD81 lymphocytes coexpressing the activation markers CD38 and HLA-DR were measured in freshly isolated peripheral blood mononuclear cells with use of the following antibodies: CD3

25 Quantitative CD4 and HIV RNA Parameters CD4-cell counts and percentages were determined from fresh whole blood samples on a 4-color flow cytometer. Plasma HIV RNA levels were measured from fresh blood specimens. For cohort 3, all plasma HIV RNA levels were measured using the Roche Amplicor, version 1.5 (dynamic range, copies/ml). For cohorts 1 and 2, the Roche Amplicor, version 1.5, assay was used for most viral load determinations, but for some, the COBAS AmpliPrep/COBAS TaqMan HIV-1 Test counting for repeated measures was developed using longitudinal data from cohort 3. Mean changes in HIV RNA level with age were examined graphically by plotting observed measurements for each individual as a function of age. Mean trends for female and male children were estimated using locally linear regression smooths to allow visual inspection of observed differences without specifying a parametric model. Differences in age-related changes in HIV RNA level between sexes were evaluated using linear mixed effect regression models, accounting

26 All statistical tests were 2-tailed, with a P value,.05 considered to be statistically significant, and were performed using Stata statistical software (release 11.1; StataCorp) and R (version ; R Foundation for Statistical Computing). RESULTS Cohort Characteristics A total of 670 ART-naive HIV-infected African children aged 1 day to 18 years (median, 4.8 years) were studied. The cohorts were balanced with regard to sex but differed substantially with regard to age and level of immune compromise (Table 1) be- Sex Differences in CD4 Parameters In cross-sectional analysis, female children had significantly higher CD4 cell percentages than male children (median, 18% vs 15%; P,.0001, Figure 3) and a trend toward higher absolute CD4 cell counts (median, 602 vs 531 cells/ll; P 5.053, Table 2). When stratified by age, CD4 cell percentages were significantly higher among female children.2 yearsofage(p,.0001), but no difference was seen among younger children (Table 4). When stratified by HIV RNA level, there was a pronounced sex difference in CD4 cell percentages among children with HIV RNA levels in the quantifiable range (,5.7 log copies/ml; P,.0001), but no difference was observed among children with HIV RNA levels

27 Sex Differences in HIV RNA Levels In cross-sectional analysis, HIV RNA levels were significantly lower in female than in male children (P 5.001) (Table 2). This difference was most pronounced among older children and those with higher CD4 percentages and absolute counts (Table 3). In multivariable regression analysis, sex remained a significant predictor of HIV RNA level (P 5.026) after adjustment for age percentage among male children, but a 2.7% decrease among female children. Longitudinal Analyses To further evaluate the effect of sex on age-related changes in HIV RNA level, we developed a multilevel mixed-effects linear regression model with use of longitudinal data from cohort 3. A total of 188 HIV-infected children with a median of 10 HIV

28 ( ) 5.5 ( ).10 $ ( ) 5.1 ( ).004 CD4 Count (cells/ll) c, ( ) 5.3 ( ) ( ) 5.3 ( ).80 $ ( ) 5.7 ( ).001 of infections, but the relative contribution of sex hormones to this disparity has been unclear. Here, we revealed basic biologic differences in HIV load and CD4 cell dynamics between male and female individuals that are evident during early childhood, when levels of the major sex steroid hormones estrogen, progesterone, and testosterone do not appreciably differ between

29 Figure 1. Loess-smoothed regression lines showing the relationship of mean HIV RNA levels (log 10 copies/ml) to age for male and female children followed longitudinally in cohort 3. HIV RNA levels were lower among female children across all observed ages. Figure 2. Loess-smoothed regression lines showing the relationship of CD4 cell percentage to age for male and female children followed longitudinally in cohort 3. CD4 cell percentages were higher among female individuals across all observed ages.

30 antiviral immune response and potential implications for treatment guidelines. Sex differences in HIV RNA levels among adults have been well established. During early HIV infection, plasma HIV RNA levels are 0.5 log lower in adult women than in men, but this One study of children receiving ART found HIV RNA levels to be 0.38 log lower in girls than in boys, with no difference in CD4 cell count or percentage [15]. Another group reported that HIV RNA levels were higher in girls at the peak of viremia but consistently lower after 4 years of age [16]. Of note, this group

31 HIV RNA levels between male and female individuals [17]. For our study, we drew data from a large cohort of children, none of whom had received prior ART. Multiple factors likely contribute to sex differences in the course and clinical manifestations of infectious diseases, including behavioral and epidemiologic risk factors, socioeconomic disparities, differences in gene expression, and levels of sex steroid hormones. Our data suggest that sex hormones are unlikely to be the major driver of the sex disparity in HIV RNA

32 immune functions, including those encoding TLR7, TLR8, IRAK, CD40L, and FoxP3, reside on the X chromosome and could be subject to gene dosage effects [8]. The mechanisms by which sex-biased gene expression might ultimately result in plasma HIV RNA differences are not clear, but could include differences in target cell availability or perneeded to optimize outcomes. Our analysis has several limitations. HIV RNA levels were truncated at 5.7 log copies/ml in more than one-third of study participants, limiting our ability to accurately quantify the effect size of sex at high HIV RNA levels. This limitation would be expected to conservatively bias our analysis toward the null

33 changes in T-cell activation do not underlie the sex differences in plasma HIV RNA levels in children. These results have potential implications for pediatric HIV treatment guidelines. HIV RNA levels and CD4 cell parameters are currently the key laboratory measures used to guide initiation and monitoring of ART. In our study, fewer girls would be eligible for ART on the basis of WHO pediatric guidelines, and other studies have suggested similar discrepancies for adult portion was 50%. Furthermore, the fact that sex differences were stable over time in the longitudinal data analysis makes the influence of such bias less likely. Another potential limitation of our analysis is that data were combined from 3 cohorts that differed by age, stage of disease, and HIV RNA assay used; however, each cohort was balanced with regard to sex, and inclusion of cohort in the multivariate models did not alter the results.

34 In summary, we found substantial differences in HIV RNA level and CD4 cell percentages between HIV-infected boys and girls throughout childhood and before the onset of puberty. These data suggest that sex-specific mechanisms other than steroid hormones are important in the immunologic development and control of HIV infection in children. Our findings have broad implications for the understanding of sex differences in immune function and highlight the need for further study of the molecular mechanisms underlying this sexual dimorphism. 12. Hel Z, Stringer E, Mestecky J. Sex steroid hormones, hormonal contraception, and the immunobiology of human immunodeficiency virus-1 infection. Endocr Rev 2010; 31: Meier A, Chang JJ, Chan ES, et al. Sex differences in the Toll-like receptor-mediated response of plasmacytoid dendritic cells to HIV-1. Nat Med 2009; 15: Berghofer B, Frommer T, Haley G, Fink L, Bein G, Hackstein H. TLR7 ligands induce higher IFN-alpha production in females. J Immunol 2006; 177: Foca M, Moye J, Chu C, et al. Gender differences in lymphocyte populations, plasma HIV RNA levels, and disease progression in a cohort of children born to women infected with HIV. Pediatrics 2006; 118:

35 ANTIRETROVIRAL THERAPY FOR HIV INFECTION IN INFANTS AND CHILDREN: TOWARDS UNIVERSAL ACCESS Recommendations for a public health approach

36 treatment failure. Viral load is the most sensitive way to detect viral replication. However, individual viral load values do not directly correlate with clinically relevant outcomes (death or disease progression). Virological failure is recognized if the child is adherent to their (first-line) ART regimen, more than 24 weeks from initiation of ART, and has a persistent viral load over copies/ml. In resource-limited settings it may not be feasible to perform viral load testing. The availability of viral load is not a prerequisite for initiation of ART or for the determination of treatment failure.

37 Children with clinical failure and/or immunological failure may not all have virological failure, and may not need to switch to second-line therapy. However, a delay in switching therapy in a child with high levels of viral replication may lead to greater development of resistance and compromise the virological activity of standard second-line regimens. It is unclear whether this translates to compromised clinical outcomes. Therefore, in the context of accurately identifying treatment failure, measurement of viral load is useful. Currently, there are insufficient data to inform programmes on the

HIV-HBV coinfection in HIV population horizontally infected in early childhood between

UNIVERSITY OF MEDICINE AND PHARMACY OF CRAIOVA FACULTY OF MEDICINE HIV-HBV coinfection in HIV population horizontally infected in early childhood between 1987-1990 Supervising professor: Prof. Cupşa Augustin