Better Pregnancy Birth Infant

What does the marriage of Open Access with online publication bring?

2009-07-20T17:59:00.003-07:00

Open Access online publishing is the trend of the future for unrestricted rapid and international dissemination of knowledge. Several journals are published on acquired immune deficiency syndrome (AIDS) research, but none of them appear to be Open Access. To eliminate or to abate the scourge of AIDS, it is important that the knowledge acquired through research be disseminated as soon as possible. The Open Access journal, AIDS Research and Therapy, is intended to fill this knowledge gap by online publication of basic, preclinical, and clinical research articles.

Lentiviral transduction of Tar Decoy and CCR5 ribozyme into CD34+ progenitor cells and derivation of HIV-1 resistant T cells and macrophages

2009-07-20T17:59:00.001-07:00

Background
RNA based antiviral approaches against HIV-1 are among the most promising for long-term gene therapy. These include ribozymes, aptamers (decoys), and small interfering RNAs (siRNAs). Lentiviral vectors are ideal for transduction of such inhibitory RNAs into hematopoietic stem cells due to their ability to transduce non-dividing cells and their relative refractiveness to gene silencing. The objective of this study is to introduce an HIV-1 Tar aptamer either alone or in combination with an anti-CCR5 ribozyme into CD34+ hematopoietic progenitor cells via an HIV-based lentiviral vector to derive viral resistant progeny T cells and macrophages.
Results
High efficiency and sustained gene transfer into CD34+ cells were achieved with lentiviral vector constructs harboring either Tar decoy or Tar decoy in combination with CCR5 ribozyme. Cells transduced with these constructs differentiated normally into T-lymphocytes in vivo in thy/liv grafts of SCID-hu mice, and into macrophages in vitro in the presence of appropriate growth factors. When challenged in vitro, the differentiated T lymphocytes and macrophages showed marked resistance against HIV-1 infection.
Conclusions
Viral resistant transgenic T cells and macrophages that express HIV-1 Tar aptamer either alone or in combination with an anti-CCR5 ribozyme could be obtained by lentiviral gene transduction of CD34+ progenitor cells. These results showed for the first time that expression of these anti-HIV-1 transgenes in combination do not interfere with normal thymopoiesis and thus have set the stage for their application in stem cell based gene therapy for HIV/AIDS.

Expanding access to HIV prevention

2009-07-20T17:58:00.056-07:00

Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a cohort of HIV patients

2009-07-20T17:58:00.055-07:00

Background
Although highly active antiretroviral therapy (HAART) reduces mortality in the developed world, it remains undocumented in resource-poor settings. We assessed the effect of HAART on patient mortality and tuberculosis incidence rate under routine clinical care conditions in Ethiopia. The objective of this study was to assess the effect of HAART on patient mortality and tuberculosis incidence rate under routine clinical care conditions in a resource-limited setting in south Ethiopia. Starting in January 2003, we followed all consecutive adult HIV infected patients who visited the HIV clinic. Since August 2003, we treated patients with HAART. Only basic laboratory services were available.
Results
We followed 185 patients in the pre-HAART cohort and 180 patients in the HAART cohort. The mortality rate was 15.4 per 100 person-years of observation (PYO) in the HAART group and tuberculosis incidence rate was 3.7 per 100 PYO. In the pre-HAART group, the mortality rate was 58.1 per 100 PYO and the tuberculosis incidence rate was 11.1 per 100 PYO. HAART resulted in a 65% decline in mortality (adjusted hazard ratio [95%CI] = 0.35 [0.19–0.63]; P < 0.001). Tuberculosis incidence rate was lower in the HAART group (adjusted hazard ratio [95%CI] = 0.11 [0.03–0.48]; P < 0.01). Most of the deaths occurred during the first three months of treatment.
Conclusion
HAART improved survival and decreased tuberculosis incidence to a level similar to that achieved in the developed countries during the early years of HAART. However, both the mortality and the tuberculosis incidence rate were much higher in terms of absolute figures in this resource-limited setting. Attention should be paid to the early weeks of treatment when mortality is high. The high tuberculosis incidence rate, when coupled with the improved survival, may lead to increased tuberculosis transmission. This highlights the need for strengthening tuberculosis prevention efforts with the scale-up of treatment programmes

Vitamin supplementation for prevention of mother-to-child transmission of HIV and pre-term delivery: a systematic review of randomized trial including more than 2800 women

2009-07-20T17:58:00.054-07:00

Background
Observational studies have suggested that low serum vitamin levels are associated with increased mother-to-child transmission (MTCT) of HIV and increased preterm delivery. We aimed to determine the efficacy of vitamins on the prevention of MTCT and preterm delivery by systematically reviewing the available randomized controlled trials [RCTs]. We conducted systematic searches of 7 electronic databases. We extracted data from the RCTs independently, in duplicate.
Results
We included 4 trials in our review. Of the three trials on Vitamin A, two suggested no difference in MTCT, while the third and largest trial (n = 1078) suggested an increased risk of MTCT (Relative Risk 1.35, 95% Confidence Interval [CI], 1.11–1.66, P = 0.009). Two of the vitamin A trials addressed the impact of supplementation on pre-term delivery; one suggested a benefit (RR 0.65, 95% CI, 0.44–0.94) and the other no difference. All three vitamin A trials found no significant effect on infant mortality at 1 year. Of the two trials that looked at multivitamin use, only one addressed the prevention of MTCT, and found a non-significant RR of 1.04 (95% CI, 0.82–1.32). Two of the multivitamin trials found no significant effects on pre-term delivery. The single multivitamin trial examining children's mortality at 1 year yielded a non-significant RR of 0.91 (95% CI, 0.17–1.17).
Conclusion
Randomized trials of vitamins to prevent MTCT have yielded conflicting results without strong evidence of benefit and have failed to exclude the possibility of harm.

Absence of seroreversion in 80 HAART-treated HIV-1 seropositive patients with at least five-years undetectable plasma HIV-1 viral load

2009-07-20T17:58:00.053-07:00

Partial or complete seroreversion for HIV-1, or incomplete antibody evolution are relatively rare events that have so far only been described in patients treated with HAART early after virus infection. Whether seroreversion is seen in patients treated effectively with HAART years after their acute infection has not been investigated so far. Therefore we have investigated anti-HIV antibody levels in 80 patients treated with HAART during chronic HIV-1 infection, who had an undetectable HIV-1 plasma viral load for at least five years. In none of the patients we observed seroreversion, and there was also no significant decrease or increase in antibody levels in this group of patients. So, successful HAART treatment during chronic HIV-1 infection does not induce seroreversion.

Cerebrospinal fluid signs of neuronal damage after antiretroviral treatment interruption in HIV-1 infection

2009-07-20T17:58:00.052-07:00

Background
The neurofilament is a major structural component of myelinated axons. Increased cerebrospinal fluid (CSF) concentrations of the light chain of the neurofilament protein (NFL) can serve as a sensitive indicator of central nervous system (CNS) injury. To assess whether interrupting antiretroviral treatment of HIV infection might have a deleterious effect on the CNS, we measured NFL levels in HIV-infected subjects interrupting therapy.
We identified subjects who had CSF HIV RNA concentrations below 50 copies/mL at the time combination antiretroviral therapy was interrupted, and for whom CSF samples were available before and after the interruption.
Results
A total of 8 subjects were studied. The median (range) CSF NFL level at baseline was <125 (<125–220) ng/L (normal <250 ng/L). All 8 subjects exhibited an increase in CSF and plasma HIV RNA after stopping therapy, accompanied by intrathecal immunoactivation as evidenced by CSF lymphocytic pleocytosis (7/8 patients) and increased CSF neopterin concentration (5/6 patients). Three subjects showed a consistent increase in CSF NFL, rising from <125 ng/L to a maximum of 880 (at day 148), 1,010 (day 58) and 10,930 ng/L (day 101). None exhibited new neurological symptoms or signs, or experienced functional deterioration during the period off treatment; of 5 who underwent brief quantitative neurological testing, none showed worsening performance.
Conclusion
These findings suggest that resurgence of active HIV replication may result in measurable, albeit subclinical, CNS injury. Further studies are needed to define the frequency and pathobiological importance of the increase in CSF NFL.

Evaluation of the proficiency of trained non-laboratory health staffs and laboratory technicians using a rapid and simple HIV antibody test

2009-07-20T17:58:00.051-07:00

In Cambodia, nearly half of pregnant women attend antenatal care (ANC), which is an entry point of services for prevention of mother-to-child transmission of HIV (PMTCT). However, most of ANC services are provided in health centres or fields, where laboratory services by technicians are not available. In this study, those voluntary confidential counselling and testing (VCCT) counsellors involved in PMTCT were trained by experienced laboratory technicians in our centre on HIV testing using Determine (Abbot Laboratories) HIV1/2 test kits through a half-day training course, which consisted of use of a pipette, how to process whole blood samples, and how to read test result. The trained counsellors were midwives working for ANC and delivery ward in our centre without any experience on laboratory works. The objective of this study was to assess the feasibility of the training by evaluating the proficiency of the trained non-laboratory staffs. The trained counsellors withdrew blood
sample after pre-test counselling following ANC, and performed the rapid test. Laboratory technicians routinely did the same test and returned reports of the test results to counsellors. Reports by the counsellors and the laboratory technicians were compared, and discordant reports in two groups were re-tested with the same rapid test kit using the same blood sample. Cause of discordance was detected in discussion with both groups. Of 563 blood samples tested by six trained VCCT counsellors and three laboratory technicians, 11 samples (2.0%) were reported positive in each group, however four discordant reports (0.7%) between the groups were observed, in which two positive reports and two negative reports by the counsellors were negative and positive by the laboratory technicians, respectively. Further investigation confirmed that all the reports by the counsellors were correct, and that human error in writing reports in the laboratory was a cause of these discordant reports
. These findings lead us the conclusion that the half-day training using the rapid and simple test was feasible for non-laboratory staffs to attain enough proficiency to implement VCCT services for PMTCT in resource-limited settings, and that human error was more likely to occur in laboratory before giving reports to counsellors.

Monitoring processed, mature Human Immunodeficiency Virus type 1 particles immediately following treatment with a protease inhibitor-containing treatment regimen

2009-07-20T17:58:00.050-07:00

Protease inhibitors (PIs) block HIV-1 maturation into an infectious virus particle by inhibiting the protease processing of gag and gag-pol precursor proteins. We have used a simple anti-HIV-1 p24 Western blot to monitor the processing of p55gag precursor into the mature p24 capsid immediately following the first dosage of a PI-containing treatment regimen. Evidence of PI activity was observed in plasma virus as early as 72 hours post treatment-initiation and was predictive of plasma viral RNA decrease at 4 weeks.

HIV-1 resistance conferred by siRNA cosuppression of CXCR4 and CCR5 coreceptors by a bispecific lentiviral vector

2009-07-20T17:58:00.049-07:00

Background
RNA interference (RNAi) mediated by small interfering RNAs (siRNAs) has proved to be a highly effective gene silencing mechanism with great potential for HIV/AIDS gene therapy. Previous work with siRNAs against cellular coreceptors CXCR4 and CCR5 had shown that down regulation of these surface molecules could prevent HIV-1 entry and confer viral resistance. Since monospecific siRNAs targeting individual coreceptors are inadequate in protecting against both T cell tropic (X4) and monocyte tropic (R5) viral strains simultaneously, bispecific constructs with dual specificity are required. For effective long range therapy, the bispecific constructs need to be stably transduced into HIV-1 target cells via integrating viral vectors.
Results
To achieve this goal, lentiviral vectors incorporating both CXCR4 and CCR5 siRNAs of short hairpin design were constructed. The CXCR4 siRNA was driven by a U6 promoter whereas the CCR5 siRNA was driven by an H1 promoter. A CMV promoter driven EGFP reporter gene is also incorporated in the bispecific construct. High efficiency transduction into coreceptor expressing Magi and Ghost cell lines with a concomitant down regulation of respective coreceptors was achieved with lentiviral vectors. When the siRNA expressing transduced cells were challenged with X4 and R5 tropic HIV-1, they demonstrated marked viral resistance. HIV-1 resistance was also observed in bispecific lentiviral vector transduced primary PBMCs.
Conclusions
Both CXCR4 and CCR5 coreceptors could be simultaneously targeted for down regulation by a single combinatorial lentiviral vector incorporating respective anti-coreceptor siRNAs. Stable down regulation of both the coreceptors protects cells against infection by both X4 and R5 tropic HIV-1. Stable down regulation of cellular molecules that aid in HIV-1 infection will be an effective strategy for long range HIV gene therapy.

Scutellaria baicalensis decreases ritonavir-induced nausea

2009-07-20T17:58:00.048-07:00

Background
Protease inhibitors, particularly ritonavir, causes significant gastrointestinal disturbances such as nausea, even at low doses. This ritonavir-induced nausea could be related to its oxidative stress in the gut. Alleviation of drug-induced nausea is important in effectively increasing patients' compliance and improving their quality of life. Conventional anti-emetic drugs can only partially abate the symptoms in these patients, and their cost has also been a concern. Rats respond to nausea-producing emetic stimuli by increasing consumption of non-nutritive substances like kaolin or clay, a phenomenon known as pica. In this study, we used this rat pica model to evaluate the effects of Scutellaria baicalensis, a commonly used oriental herbal medicine, on ritonavir-induced nausea.
Results
Rats treated with 20 mg/kg ritonavir significant caused increases of kaolin consumption at 24 to 48 hr (P < 0.01). Pretreatment with 0.3 and 3 mg/kg Scutellaria baicalensis extract significantly decreased ritonavir-induced kaolin intake in a dose-related manner (P < 0.01). Compared to vehicle treatment, the extract completely prevented ritonavir-induced kaolin consumption at dose 3 mg/kg. The area under the curves (AUC) for kaolin intake from time 0 to 120 hr for vehicle only, ritonavir only, SbE 0.3 mg/kg plus ritonavir, and SbE 3 mg/kg plus ritonavir were 27.3 g•hr, 146.7 g•hr, 123.2 g•hr, and 32.7 g•hr, respectively. The reduction in area under the curves of kaolin intake from time 0 to 120 hr between ritonavir only and SbE 0.3 mg/kg plus ritonavir, ritonavir only and SbE 3 mg/kg plus ritonavir were 16.0% and 77.7%, respectively.
Conclusion
Scutellaria baicalensis significantly attenuated ritonavir-induced pica, and demonstrated a potential in treating ritonavir-induced nausea.

HIV-1 reverse transcriptase mutations that confer decreased in vitro susceptibility to anti-RT DNA aptamer RT1t49 confer cross resistance to other anti-RT aptamers but not to standard RT inhibitors

2009-07-20T17:58:00.047-07:00

RNA and DNA aptamers specific for HIV-1 reverse transcriptase (RT) can inhibit reverse transcription in vitro. RNA aptamers have been shown to potently block HIV-1 replication in culture. We previously reported mutants of HIV-1 RT with substitutions N255D or N265D that display resistance to the DNA aptamer RT1t49. Variant viruses bearing these mutations singly or in combination were compromised for replication. In order to address the wider applicability of such aptamers, HIV-1 RT variants containing the N255D, N265D or both (Dbl) were tested for the extent of their cross-resistance to other DNA/RNA aptamers as well as to other RT inhibitors. Both N265D and Dbl RTs were resistant to most aptamers tested. N255D mutant displayed mild resistance to two of the DNA aptamers, little change in sensitivity to three and hypersensitivity to one. Although all mutants displayed wild type-like ribonuclease H activity, their activity was compromised under conditions that prevent re-binding
. This suggests that the processivity defect caused by these mutations can also affect RNase H function thus contributing further to the replication defect in mutant viruses. These results indicate that mutants conferring resistance to anti-RT aptamers significantly affect many HIV-1 RT enzymatic activities, which could contribute to preventing the development of resistance in vivo. If such mutations were to arise in vivo, our results suggest that variant viruses should remain susceptible to many existing anti-RT inhibitors. This result was tempered by the observation that NRTI-resistance mutations such as K65R can confer resistance to some anti-RT aptamers.

Microbicides 2006 conference

2009-07-20T17:58:00.046-07:00

Current HIV/AIDS statistics show that women account for almost 60% of HIV infections in Sub-Saharan Africa. HIV prevention tools such as male and female condoms, abstinence and monogamy are not always feasible options for women due to various socio-economic and cultural factors. Microbicides are products designed to be inserted in the vagina or rectum prior to sex to prevent HIV acquisition.
The biannual Microbicides conference took place in Cape Town, South Africa from 23–26 April 2006. The conference was held for the first time on the African continent, the region worst affected by the HIV/AIDS pandemic. The conference brought together a record number of 1,300 scientists, researchers, policy makers, healthcare workers, communities and advocates. The conference provided an opportunity for an update on microbicide research and development as well as discussions around key issues such as ethics, acceptability, access and community involvement.
This report discusses the current status of microbicide research and development, encompassing basic and clinical science, social and behavioural science, and community mobilisation and advocacy activities.

Human immunodeficiency virus type-1 episomal cDNA in semen

2009-07-20T17:58:00.045-07:00

Background
Episomal 2-long terminal repeat (LTR) HIV-1 cDNA, a by-product of HIV-1 infection, is used in clinical trials as a marker for ongoing viral replication. It would be useful to employ 2-LTR cDNA to monitor cryptic HIV-1 infection in the genital tract of men on antiretroviral therapy (ART) to predict the evolution of sexually transmissible drug-resistant HIV-1, but studies thus far have failed to detect this marker in semen. The objectives of this study were: 1) to use a technique that maximizes DNA recovery from HIV-1 infected white blood cells in semen to determine if episomal 2-LTR cDNA is detectable in semen of ART-naïve men with other evidence of genital tract HIV-1 infection, and 2) to compare levels of HIV-1 2-LTR cDNA, RNA, and proviral DNA in semen from HIV-1+ men on ART.
Results
Using a somatic cell DNA extraction technique, 2-LTR cDNA was detected by PCR/ELISA in 4 out of 8 semen samples from ART-naïve men selected for other signs of seminal HIV-1 infection (positive controls). Southern blot and DNA sequencing confirmed that the amplified sequences were HIV-1 2-LTR cDNA; copy numbers ranged from 55 to 504 copies/sample. Two semen samples from a cohort of 22 HIV-1-infected men on dual nucleoside therapy, one with and one without detectable seminal HIV-1 RNA, were 2-LTR cDNA positive (336 and 8,560 copies/sample). Following addition of indinavir to the therapy regimen, no semen samples from 21 men with controlled peripheral and seminal viral loads were 2-LTR cDNA positive at 1 and 6 month time points, despite the persistence of HIV-1 proviral DNA+ semen cells and seminal cytomegalovirus (CMV) shedding in some cases. However, one individual who failed indinavir therapy and later developed distinct protease inhibitor (PI) drug resistance mutations
in semen, maintained elevated levels of HIV-1 RNA and 2-LTR cDNA in semen.
Conclusion
2-LTR HIV-1 cDNA is detectable in semen of HIV-1-infected men. Two men on ART had 2-LTR HIV-1 cDNA in semen, suggesting that this marker may prove to be useful to monitor HIV-1 infection in the genital tract of men on ART to predict the evolution of drug resistance mutations in semen.

The effect of different combination therapies on oxidative stress markers in HIV infected patients in cameroon

2009-07-20T17:58:00.044-07:00

The study assessed the effect of some highly active antiretroviral therapies (HAART), used in the management of HIV/AIDS in Cameroon, on oxidative stress markers such as malondialdehyde (as TBARs), albumin, protein carbonyl content and protein sulfhydryls groups. 85 HIV positive patients (34.8 ± 9.3 years) were on three different highly active antiretroviral therapies (HAART patients). 65 HIV positive patients (32.2 ± 10.9 years) on no treatment (Pre-HAART patients), and 90 non-HIV infected patients (32.6 ± 9.3 years), were the control groups. Plasma TBARs as well as carbonyl levels were significantly higher in HIV patients on HAART compared to pre-HAART patients or non-HIV infected controls. On the other hand, the protein sulfhydryl group content was not different for patients on HAART compared to pre-HAART patients, but both were significantly lower than non-HIV infected controls (P < 0.0001, 0.001). The combination treatment Therapy I [stavudin (80 mg) +
Lamivudin (600 mg) + Nevirapin + (400 mg) zidovudin (600 mg)] brought about a significant (p < 0.05) reduction in the plasma concentration of protein sulfhydrl groups as well as TBARs compared to Therapy II [stavudin (80 mg) + Lamivudin (300 mg) + nevirapin (400 mg)] or with combination Therapy III of [zidovudine (600 mg) + lamivudin(300 mg) with efavirenz (600 mg)] (P < 0.05). The content of the antioxidant, Vitamin C was lower in the plasma of patients on Therapy I compared to those on Therapy II (P < 0.01) and Therapy III (P < 0.001).
HIV infection therefore increases the oxidative stress process, while antiretroviral combination therapy increased protein oxidation as well as the level of oxidative stress already present in HIV infection.

Aboriginal status is a prognostic factor for mortality among antiretroviral na?ve HIV-positive individuals first initiating HAART

2009-07-20T17:58:00.043-07:00

Background
Although the impact of Aboriginal status on HIV incidence, HIV disease progression, and access to treatment has been investigated previously, little is known about the relationship between Aboriginal ethnicity and outcomes associated with highly active antiretroviral therapy (HAART). We undertook the present analysis to determine if Aboriginal and non-Aboriginal persons respond differently to HAART by measuring HIV plasma viral load response, CD4 cell response and time to all-cause mortality.
Methods
A population-based analysis of a cohort of antiretroviral therapy naïve HIV-positive Aboriginal men and women 18 years or older in British Columbia, Canada. Participants were antiretroviral therapy naïve, initiated triple combination therapy between August 1, 1996 and September 30, 1999. Participants had to complete a baseline questionnaire as well as have at least two follow-up CD4 and HIV plasma viral load measures. The primary endpoints were CD4 and HIV plasma viral load response and all cause mortality. Cox proportional hazards models were used to determine the association between Aboriginal status and CD4 cell response, HIV plasma viral load response and all-cause mortality while controlling for several confounder variables.
Results
A total of 622 participants met the study criteria. Aboriginal status was significantly associated with no AIDS diagnosis at baseline (p = 0.0296), having protease inhibitor in the first therapy (p = 0.0209), lower baseline HIV plasma viral load (p < 0.001), less experienced HIV physicians (P = 0.0133), history of IDU (p < 0.001), not completing high school (p = 0.0046), and an income of less than $10,000 per year (p = 0.0115). Cox proportional hazards models controlling for clinical characteristics found that Aboriginal status had an increased hazard of mortality (HR = 3.12, 95% CI: 1.77–5.48) but did not with HIV plasma viral load response (HR = 1.15, 95% CI: 0.89–1.48) or CD4 cell response (HR = 0.95, 95% CI: 0.73–1.23).
Conclusion
Our study demonstrates that HIV-infected Aboriginal persons accessing HAART had similar HIV treatment response as non-Aboriginal persons but have a shorter survival. This study highlights the need for continued research on medical interventions and behavioural changes among HIV-infected Aboriginal and other marginalized populations.

Assessment of HIV-1 entry inhibitors by MLV/HIV-1 pseudotyped vectors

2009-07-20T17:58:00.042-07:00

Background
Murine leukemia virus (MLV) vector particles can be pseudotyped with a truncated variant of the human immunodeficiency virus type 1 (HIV-1) envelope protein (Env) and selectively target gene transfer to human cells expressing both CD4 and an appropriate co-receptor. Vector transduction mimics the HIV-1 entry process and is therefore a safe tool to study HIV-1 entry.
Results
Using FLY cells, which express the MLV gag and pol genes, we generated stable producer cell lines that express the HIV-1 envelope gene and a retroviral vector genome encoding the green fluorescent protein (GFP). The BH10 or 89.6 P HIV-1 Env was expressed from a bicistronic vector which allowed the rapid selection of stable cell lines. A codon-usage-optimized synthetic env gene permitted high, Rev-independent Env expression. Vectors generated by these producer cells displayed different sensitivity to entry inhibitors.
Conclusion
These data illustrate that MLV/HIV-1 vectors are a valuable screening system for entry inhibitors or neutralizing antisera generated by vaccines.

Glutathione and growth inhibition of Mycobacterium tuberculosis in healthy and HIV infected subjects

2009-07-20T17:58:00.041-07:00

Intracellular levels of glutathione are depleted in patients with acquired immunodeficiency syndrome in whom the risk of tuberculosis, particularly disseminated disease is many times that of healthy individuals. In this study, we examined the role of glutathione in immunity against tuberculosis infection in samples derived from healthy and human immunodeficiency virus infected subjects. Our studies confirm that glutathione levels are reduced in peripheral blood mononuclear cells and in red blood cells isolated from human immunodeficiency virus-infected subjects (CD4>400/cumm). Furthermore, treatment of blood cultures from human immunodeficiency virus infected subjects with N-acetyl cysteine, a glutathione precursor, caused improved control of intracellular M. tuberculosis infection. N-acetyl cysteine treatment decreased the levels of IL-1, TNF-α, and IL-6, and increased the levels of IFN-γ in blood cultures derived from human immunodeficiency virus-infected subje
cts, promoting the host immune responses to contain M. tuberculosis infection successfully.

Novel multi-component nanopharmaceuticals derived from poly(ethylene) glycol, retro-inverso-Tat nonapeptide and saquinavir demonstrate combined anti-HIV effects

2009-07-20T17:58:00.040-07:00

Background
Current anti-AIDS therapeutic agents and treatment regimens can provide a dramatically improved quality of life for HIV-positive people, many of whom have no detectable viral load for prolonged periods of time. Despite this, curing AIDS remains an elusive goal, partially due to the occurrence of drug resistance. Since the development of resistance is linked to, among other things, fluctuating drug levels, our long-term goal has been to develop nanotechnology-based drug delivery systems that can improve therapy by more precisely controlling drug concentrations in target cells. The theme of the current study is to investigate the value of combining AIDS drugs and modifiers of cellular uptake into macromolecular conjugates having novel pharmacological properties.
Results
Bioconjugates were prepared from different combinations of the approved drug, saquinavir, the antiviral agent, R.I.CK-Tat9, the polymeric carrier, poly(ethylene) glycol and the cell uptake enhancer, biotin. Anti-HIV activities were measured in MT-2 cells, an HTLV-1-transformed human lymphoid cell line, infected with HIV-1 strain Vbu 3, while parallel studies were performed in uninfected cells to determine cellular toxicity. For example, R.I.CK-Tat9 was 60 times more potent than L-Tat9 while the addition of biotin resulted in a prodrug that was 2850 times more potent than L-Tat9. Flow cytometry and confocal microscopy studies suggest that variations in intracellular uptake and intracellular localization, as well as synergistic inhibitory effects of SQV and Tat peptides, contributed to the unexpected and substantial differences in antiviral activity.
Conclusion
Our results demonstrate that highly potent nanoscale multi-drug conjugates with low non-specific toxicity can be produced by combining moieties with anti-HIV agents for different targets onto macromolecules having improved delivery properties.

Randomized controlled trial of Hepatitis B virus vaccine in HIV-1-infected patients comparing two different doses

2009-07-20T17:58:00.039-07:00

Background
Co-infection with hepatitis B virus (HBV) and human immunodeficiency virus (HIV) is not infrequent as both share same route of exposure. The risk of developing chronic hepatitis B virus is 6%, in general population but can reach 10–20% in HBV/HIV co-infected patients. When compared to general population, the response rate to HBV vaccine in HIV-infected patients is diminished, so previous studies have tried to improve this response using variety of schedules, doses and co-administration of immunomodulators. The purpose of this study was to evaluate two doses of recombinant HBV vaccine (10 or 40 μg), IM at 0, 1 and 6 months. Vaccination response was measured 30–50 days after last dose; titers of >9.9 IU/L were considered positive.
Results
Seventy-nine patients were included, 48 patients (60.7%) serconverted. Thirty-nine patients (49.3%) received 10 μg vaccine dose, 24 patients (61.5%) seroconverted. Forty patients (50.7%) received 40 μg vaccine dose, 24 (60%) seroconverted. There were no differences between two doses. A statistically significant higher seroconversion rate was found for patients with CD4 cell counts at vaccination ≥ 200 cel/mm3 (33 of 38 patients, 86.8%), compared with those with CD4 < 200 cel/mm3 (15 of 41, 36.6%), [OR 11.44, 95% IC 3.67–35.59, p = 0.003], there were no differences between two vaccine doses. Using the logistic regression model, CD4 count <200 cel/mm3 were significantly associated with non serologic response (p = 0.003). None other variables such as gender, age, risk exposure for HIV, viral load, type or duration of HAART or AIDS-defining illness, were asociated with seroconversion.
Conclusion
In this study, an increase dose of HBV vaccine did not show to increase the rate of response in HIV infected subjects. The only significant findings associated to the response rate was that a CD4 count ≥ 200 cel/mm3, we suggest this threshold at which HIV patients should be vaccinated.

Assessing the effect of HAART on change in quality of life among HIV-infected women

2009-07-20T17:58:00.038-07:00

Background
The impact of highly active antiretroviral therapy (HAART) on health-related quality of life (QOL) of HIV-1 infected individuals in large prospective cohorts has not been well studied.
Objective
To assess the effect of HAART on QOL by comparing HIV-infected women using HAART with HIV-infected women remaining HAART naïve in the Women's Interagency HIV Study (WIHS), a multicenter prospective cohort study begun in 1994 in the US.
Methods
A 1:1 matching with equivalent (≤ 0.1%) propensity scores for predicting HAART initiation was implemented and 458 pairs were obtained. HAART effects were assessed using pattern mixture models. The changes of nine QOL domain scores and one summary score derived from a shortened version of the MOS-HIV from initial values were used as study outcomes.
Results
The background covariates of the treatment groups were well-balanced after propensity score matching. The 916 matched subjects had a mean age of 38.5 years and 42% had a history of AIDS diagnosis. The participants contributed a total of 4,292 person visits with a median follow-up time of 4 years. In the bivariate analyses with only HAART use and time as covariates, HAART was associated with short-term improvements of 4 QOL domains: role functioning, social functioning, pain and perceived health index. After adjusting for demographic, socioeconomic, biological and clinical variables, HAART had small but significant short-term improvements on changes in summary QOL (mean change: 3.25; P = 0.02), role functioning (6.99; P < 0.01), social functioning (5.74; P < 0.01), cognitive functioning (3.59; P = 0.03), pain (6.73; P < 0.01), health perception (3.67; P = 0.03) and perceived health index (4.87; P < 0.01). These QOL scores typically remained stable or declined over
additional follow-up and there was no indication that HAART modified these trends.
Conclusion
Our study demonstrated significant short-term HAART effects on most QOL domains, but additional use of HAART did not modify long-term trends. These changes could be attributed to the direct effect of HAART and indirect HAART effect mediated through clinical changes.

A nucleolar localizing Rev binding element inhibits HIV replication

2009-07-20T17:58:00.037-07:00

The Rev protein of the human immunodeficiency virus (HIV) facilitates the nuclear export of intron containing viral mRNAs allowing formation of infectious virions. Rev traffics through the nucleolus and shuttles between the nucleus and cytoplasm. Rev multimerization and interaction with the export protein CRM1 takes place in the nucleolus. To test the importance of Rev nucleolar trafficking in the HIV-1 replication cycle, we created a nucleolar localizing Rev Response Element (RRE) decoy and tested this for its anti-HIV activity. The RRE decoy provided marked inhibition of HIV-1 replication in both the CEM T-cell line and in primary CD34+ derived monocytes. These results demonstrate that titration of Rev in the nucleolus impairs HIV-1 replication and supports a functional role for Rev trafficking in this sub-cellular compartment.

Review of "HIV Chemotherapy: a Critical Review" by Salvatore T. Butera

2009-07-20T17:58:00.036-07:00

Efavirenz use during pregnancy and for women of child-bearing potential

2009-07-20T17:58:00.035-07:00

Background
Efavirenz is the preferred non-nucleoside reverse transcriptase inhibitor for first-line antiretroviral treatment in many countries. For women of childbearing potential, advantages of efavirenz are balanced by concerns that it is teratogenic. This paper reviews evidence of efavirenz teratogenicity and considers implications in common clinical scenarios.
Findings
Concerns of efavirenz-induced fetal effects stem from animal studies, although the predictive value of animal data for humans is unknown. Four retrospective cases of central nervous system birth defects in infants with first trimester exposure to efavirenz have been interpreted as being consistent with animal data. In a prospective pregnancy registry, which is subject to fewer potential biases, no increase was detected in overall risk of birth defects following exposure to efavirenz in the first-trimester.
Discussion
For women planning a pregnancy or not using contraception, efavirenz should be avoided if alternatives are available. According to WHO guidelines for resource-constrained settings, benefits of efavirenz are likely to outweigh risks for women using contraception. Women who become pregnant while receiving efavirenz often consider drug substitution or temporarily suspending treatment. Both options have substantial risks for maternal and fetal health which, we argue, appear unjustified after the critical period of organogenesis (3–8 weeks post-conception). Efavirenz-based triple regimens, initiated after the first trimester of pregnancy and discontinued after childbirth, are potentially an important alternative for reducing mother-to-child transmission in pregnant women who do not yet require antiretroviral treatment.
Conclusion
Current recommendations for care for women who become pregnant while receiving efavirenz may need to be re-considered, particularly in settings with limited alternative drugs and laboratory monitoring. With current data limitations, additional adequately powered prospective studies are needed.

Body image in women with HIV: a cross-sectional evaluation

2009-07-20T17:58:00.034-07:00

Background
HIV lipodystrophy syndrome is a recognized complication of potent antiretroviral therapy and is characterized by often dramatic changes in various body fat stores, both central and peripheral. Given prior findings of heightened body image dysphoria among HIV-infected men with lipodystrophy as compared to HIV-infected men without lipodystrophy, we sought to determine body image among HIV-infected and HIV-negative women and to determine the relationship of HIV and lipodystrophy with body image. Our a priori hypothesis was that women with HIV and lipodystrophy would have significantly poorer body image as compared to women without HIV and to women with HIV without lipodystrophy.
Results
116 women responded to two previously validated self-report instruments (Body Image Quality of Life Index (BIQLI) and the Situational Inventory of Body-Image Dysphoria – Short Form (SIBID-S)) on body image. 62 (53% subjects) HIV-infected women were recruited at the university-based HIV clinic. 54 (47% subjects) HIV-negative female controls were recruited from another study evaluating bone density in otherwise healthy controls. 96% identified their sexual orientation as women having sex with men. Among the HIV-infected group, 36 reported the presence of lipodystrophic characteristics and 26 reported no lipodystrophic changes. Agreement regarding the presence of lipodystrophy between physician and subject was 0.67 as measured by the kappa coefficient of agreement. Compared to HIV-negative women, HIV-positive women demonstrated poor body image as measured by BIQLI (p = 0.0009). Compared with HIV-infected women who denied lipodystrophy, HIV-infected women with self-reported
lipodystrophy demonstrated poor body image as measured by BIQLI (p = 0.02) and SIBID-S scales (p = 0.001).
Conclusion
We demonstrate that HIV and lipodystrophy status among women is associated with poor body image. Universal efforts should be made in the HIV medical community to recognize body image issues particularly among persons affected by lipodystrophy so that appropriate intervention and support may be provided.

Phase I safety study of 0.5% PRO 2000 vaginal Gel among HIV un-infected women in Pune, India

2009-07-20T17:58:00.033-07:00

Background
The objective of this study was to evaluate the safety of twice daily, intra-vaginal use of 0.5% PRO 2000 Gel for fourteen days in HIV un-infected women at lower as well as higher risk for HIV acquisition, in Pune, India.
Methods
Forty-two eligible volunteers (30 low-risk and 12 high-risk) were given 0.5% PRO 2000 Gel for intra-vaginal application twice daily for 14 consecutive days.
Results
Twenty-four participants (57%, 95% CI 41%–72%) experienced at least one adverse event (AE) judged to be possibly related to the product use. There were 17 (40%, 95% CI 26%–57%) mild AEs and 7 (17%, 95% CI 7%–31%) moderate AEs. There were no serious adverse events and no AEs judged probably or definitely related to product use. Genitourinary discomfort was reported by 2/30 (6.67%) participants in the low-risk cohort as compared to 4/12 (33.3%) women in the high-risk cohort (p = 0.03). Intermenstrual bleeding was reported in 2/30 (6.7%, 95% CI 1.0–22.1) women from the low risk cohort and 3/12 (25%, 95% CI 5.5–57.2) women from the high-risk cohort. One participant showed mild elevation of blood gamma glutamyl transferase and two showed mild elevations in total bilirubin. None of the participants showed detectable PRO 2000 in their blood after 14 days of product use.
Conclusion
0.5% PRO 2000 Gel appeared to be safe when used twice-daily by sexually active HIV-uninfected women from Pune, India. Although genitourinary discomfort and metrorrhagia were more common in the high-risk cohort, ongoing Phase II/IIb trial would provide data for generalization of this finding.

Inhibition of highly productive HIV-1 infection in T cells, primary human macrophages, microglia, and astrocytes by Sargassum fusiforme

2009-07-20T17:58:00.032-07:00

Background
The high rate of HIV-1 mutation and increasing resistance to currently available antiretroviral (ART) therapies highlight the need for new antiviral agents. Products derived from natural sources have been shown to inhibit HIV-1 replication during various stages of the virus life cycle, and therefore represent a potential source of novel therapeutic agents. To expand our arsenal of therapeutics against HIV-1 infection, we investigated aqueous extract from Sargassum fusiforme (S. fusiforme) for ability to inhibit HIV-1 infection in the periphery, in T cells and human macrophages, and for ability to inhibit in the central nervous system (CNS), in microglia and astrocytes.
Results
S. fusiforme extract blocked HIV-1 infection and replication by over 90% in T cells, human macrophages and microglia, and it also inhibited pseudotyped HIV-1 (VSV/NL4-3) infection in human astrocytes by over 70%. Inhibition was mediated against both CXCR4 (X4) and CCR5 (R5)-tropic HIV-1, was dose dependant and long lasting, did not inhibit cell growth or viability, was not toxic to cells, and was comparable to inhibition by the nucleoside analogue 2', 3'-didoxycytidine (ddC). S. fusiforme treatment blocked direct cell-to-cell infection spread. To investigate at which point of the virus life cycle this inhibition occurs, we infected T cells and CD4-negative primary human astrocytes with HIV-1 pseudotyped with envelope glycoprotein of vesicular stomatitis virus (VSV), which bypasses the HIV receptor requirements. Infection by pseudotyped HIV-1 (VSV/NL4-3) was also inhibited in a dose dependant manner, although up to 57% less, as compared to inhibition of native NL4-3, indicatin
g post-entry interferences.
Conclusion
This is the first report demonstrating S. fusiforme to be a potent inhibitor of highly productive HIV-1 infection and replication in T cells, in primary human macrophages, microglia, and astrocytes. Results with VSV/NL4-3 infection, suggest inhibition of both entry and post-entry events of the virus life cycle. Absence of cytotoxicity and high viability of treated cells also suggest that S. fusiforme is a potential source of novel naturally occurring antiretroviral compounds that inhibit HIV-1 infection and replication at more than one site of the virus life cycle.

A placebo-controlled pilot study of intensification of antiretroviral therapy with mycophenolate mofetil

2009-07-20T17:58:00.031-07:00

Purpose
We studied the safety, tolerability, virologic, and immunologic effects of mycophenolate mofetil (MMF) added to a stable antiretroviral therapy (ART) in the setting of low-level viremia.
Methods
MMF 500 mg BID or placebo was given to patients thought to be adherent on stable ART with plasma viremia between 200 and 4000 copies/mL. At week 4 unblinding was performed and patients on placebo were offered open-label MMF.
Results
Six patients were enrolled. At entry mean plasma HIV-1 RNA (VL) was 2.98 log10 copies/mL; mean CD4 count was 523. All subjects randomized to placebo elected to cross over to open label MMF. No significant adverse events were observed during MMF therapy. Three patients on MMF achieved VL < 50 copies/mL by week 4; a fourth had VL decline of > 0.5 log. Two patients on placebo had declines of VL. One of these had further decline on open label MMF. Cell surface markers of apoptosis, activation, and proliferation on CD4+ and CD8+ cells declined modestly or remained low. CD4 counts were stable at week 24. All but one subject had rebound of viremia by week 24, universally associated with missed doses of medication by pill count.
Conclusion
MMF appears to be safe, and its administration lead to decreased T cell activation. During periods of adherence to therapy, the use of MMF was correlated with declines in viremia, but this small pilot study could not prove this association. Further study of MMF in patients with viremia should be considered for whom additional or alternative antiretrovirals are impractical.

HIV in semen: Still more to be learned

2009-07-20T17:58:00.030-07:00

Barriers to the implementation of programs for the prevention of mother-to-child transmission of HIV: A cross-sectional survey in rural and urban Uganda

2009-07-20T17:58:00.029-07:00

Background
Implementation of programs for the prevention of mother-to-child transmission (PMTCT) of HIV faces a variety of barriers and challenges. The assessment of these challenges has generally been conducted in large urban health facilities. As programs expand into rural areas, the potential barriers that may be encountered there also need to be assessed. This study examines potential barriers that might affect the acceptability of interventions for PMTCT in rural and urban settings.
Results
Four hundred and four women at a large urban hospital and three rural clinics that had recently started implementing PMTCT were interviewed. Level of knowledge of MTCT and preference for rapid HIV testing were equally high in both areas, but rural women had a higher tendency to think that they should consult their husbands before testing, with borderline statistical significance (72% vs. 64% p = 0.09). Health facility-based deliveries were significantly lower among mothers in rural areas compared to those in the urban setting. Overall, significant predictors of willingness to test for HIV were post-primary education (OR = 3.1 95% CI 1.2, 7.7) and knowledge about rapid HIV tests (OR = 1.8, 95% CI 1.01, 3.4). The strongest predictor of willingness to accept an HIV test was the woman's perception that her husband would approve of her testing for HIV. Women who thought their husbands would approve were almost six times more likely to report a willingness to be tested compared to
those who thought their husbands would not approve (OR = 5.6, 95% CI 2.8, 11.2).
Conclusion
Lessons learned in large urban hospitals can be generalized to rural facilities, but the lower proportion of facility-based deliveries in rural areas needs to be addressed. Same-day results are likely to ensure high uptake of HIV testing services but male spousal involvement should be considered, particularly for rural areas. Universal Primary Education will support the success of PMTCT programs.

Clade, Country and Region-specific HIV-1 Vaccines: Are they necessary?

2009-07-20T17:58:00.027-07:00

Today, scientists are often encouraged to custom-design vaccines based on a particular country or clade. Here, we review the scientific literature and then suggest that the overwhelming endeavor to produce a unique vaccine for every world region or virus subtype may not be necessary.

Use of taste-masking product, FLAVORx, to assist Thai children to ingest generic antiretrovirals

2009-07-20T17:58:00.025-07:00

We evaluated whether FLAVORx helped thirty Thai children take opened capsule, crushed tablets and liquid generic ARVs with more ease. All children had excellent adherence, evaluated by PACTG Standard International Questionnaire and interviewing, before and after one month of FLAVORx. Eighty percent took ARV with more ease and wish to continue FLAVORx. Strawberry was the most popular flavor.

Post-exposure prophylaxis for SIV revisited: Animal model for HIV prevention

2009-07-20T17:58:00.023-07:00

Background
A 4-week, uninterrupted treatment with 9-(2-phosphonyl-methoxypropyly)adenine (PMPA, commonly called tenofovir) completely prevents simian immunodeficiency virus (SIVmne) infection in cynomolgus macaques if treatment begins within 24 hours after SIVmne inoculation, but is less effective if treatment is delayed or duration of treatment is shortened. Critical factors for efficacy include timing and duration of treatment, potency of antiretroviral drug and a contribution from antiviral immune responses. Therefore, we evaluated the impact of one or more treatment interruptions plus SIVmne re-exposures on efficacy of PMPA treatment to prevent SIVmne infection in cynomolgus macaques. We also evaluated whether macaques with pre-existing SIV immune responses show increased efficacy of treatment. Eight PMPA-treated, virus-negative and seronegative macaques, and five PMPA-treated, virus-negative but weakly or strongly seropositive macaques were re-inoculated with SIVmne and treated wit
h PMPA starting 24 hr post inoculation. Thereafter, they received either a 5-week treatment involving one interruption plus one SIVmne challenge or a 10-week treatment involving six interruptions plus six SIVmne challenges early during treatment. Parameters measured were plasma SIV RNA, SIV-antibody response, CD4+ T lymphocyte subsets and in vivo CD8+ cell-suppression of virus infection.
Results
All seronegative macaques developed persistent antibody response beginning 4 to 8 weeks after stopping PMPA-treatment in absence of viremia in a majority of macaques and coinciding with onset of intermittent viremia in other macaques. In contrast, all weakly or strongly seropositive macaques showed immediate increase in titers (> 1600) of SIV antibodies, even before the end of PMPA-treatment, and in absence of detectable viremia. However, in vivo CD8+ -cell depletion revealed CD8 cell-suppression of viremia and persistence of virus in the macaques as long as 2 years after PMPA-treatment, even in aviremic macaques. Unlike untreated macaques, a treated macaque controlled viral replication and blocked CD4+ T cell depletion when challenged with a heterologus chimeric SIV/HIV-1 virus called SHIV89.6P.
Conclusion
A single interruption plus one SIVmne challenge was as sufficient as six interruptions plus six SIVmne challenges in reducing efficacy of PMPA, but results in long-term persistence of virus infection suppressed by CD8+ cells. Efficacy of PMPA treatment was highest in macaques with pre-existing SIV immune responses.

Review of Anton A. Niekerk and Loretta M. Kopelman (eds.) Ethics and AIDS in Africa: The Challenge to our Thinking

2009-07-20T17:58:00.021-07:00

HIV among pregnant women in Moshi Tanzania: the role of sexual behavior, male partner characteristics and sexually transmitted infections

2009-07-20T17:58:00.019-07:00

Background
Women continue to be disproportionately affected by HIV in Tanzania, and factors contributing to this situation need to be identified. The objective of this study was to determine social, behavioral and biological risk factors of HIV infection among pregnant women in Moshi urban, Tanzania. In 2002 – 2004, consenting women (N = 2654), attending primary health clinics for routine antenatal care were interviewed, examined and biological samples collected for diagnosis of HIV and other sexually transmitted/reproductive tract infections.
Results
The prevalence of HIV was 6.9%. The risk for HIV was greater among women whose male partner; had other sexual partners (adjusted odds ratio [AOR], 15.11; 95% confidence interval [CI], 8.39–27.20), traveled frequently (AOR, 1.79; 95% CI, 1.22–2.65) or consumed alcohol daily (AOR, 1.68; 95% CI, 1.06–2.67). Other independent predictors of HIV were age, number of sex partners, recent migration, and presence of bacterial vaginosis, genital ulcer, active syphilis and herpes simplex virus type 2.
Conclusion
Development of programs that actively involve men in HIV prevention is important in reducing transmission of HIV in this population. Further, interventions that focus on STI control, the mobile population, sexual risk behavior and responsible alcohol use are required.

Comparison of capillary based microflurometric assay for CD4+ T cell count estimation with dual platform Flow cytometry

2009-07-20T17:58:00.017-07:00

The CD4+ T cell count estimation is an important monitoring tool for HIV disease progression and efficacy of anti-retroviral treatment (ART). Due to availability of ART at low cost in developing countries, quest for reliable cost effective alternative methods for CD4+ T cell count estimation has gained importance. A simple capillary-based microflurometric assay (EasyCD4 System, Guava Technology) was compared with the conventional flow cytometric assay for estimation of CD4+ T cell counts in 79 HIV infected individuals. CD4+ T cell count estimation by both the assays showed strong correlation (r = 0.938, p < 0.001, 95% CI 0.90 to 0.96). The Bland Altman plot analysis showed that the limits of variation were within agreeable limits of ± 2SD (-161 to 129 cells/mm3). The Easy CD4 assay showed 100% sensitivity for estimating the CD4+ T cell counts < 200 cells/mm3 and < 350 cells/mm3 and 97% sensitivity to estimate CD4+ T cell count < 500 cells/mm3. The specificity
ranged from 82 to 100%. The Kappa factor ranged from 0.735 for the CD4+ T cell counts < 350 cells/mm3 to 0.771 for < 500 cells/mm3 CD4+ T cell counts. The system works with a simple protocol, is easy to maintain and has low running cost. The system is compact and generates minimum amount of waste. Hence the EasyCD4 System could be applied for estimation of CD4+ T cell counts in resource poor settings.

HLA-G DNA sequence variants and risk of perinatal HIV-1 transmission

2009-07-20T17:58:00.015-07:00

Background
HLA-G gene is a non-classical MHC class 1 molecule that is highly expressed in the trophoblast at the maternal-fetal interface. In an attempt to elucidate possible immunological mechanisms facilitating protection of infants born to human immunodeficiency virus type (HIV-1) infected mothers, we have been studying genetic variations in the coding and untranslated regions of HLA-G antigen between HIV-1-infected mothers and their infected or uninfected infants. This study investigated whether HLA-G DNA sequence variants are associated with perinatal HIV-1 transmission.
Results
Genomic DNA samples were obtained from a nested case-control study of 34 mother-child pairs co-enrolled in a cohort of the Perinatal AIDS Collaborative Transmission Study in New York. The samples were from two groups predominantly of African-American and Hispanic origin: In the first group, both mother and child were HIV-1-infected; in the second group, only the mother was infected while the child remained uninfected. Genotyping of HLA-G gene were performed on the extracted DNA from peripheral blood mononuclear cells using PCR based sequencing and restriction fragment-length polymorphism analyses.
Among the studied HLA-G exons, dissimilarities in HLA-G DNA sequence variants between the HIV-1 non-transmitting mother child pairs were mostly observed in exon 8-3'-untranslated region at nucleotide positions T3742A, C3743T, G3777C (P = 0.001). Non-transmitting HIV-1 mother child pairs exhibited dissimilarities at nucleotide position C3743T allele with decreased risk of perinatal HIV-1 transmission, compared with HIV-1 transmitting mother-child pairs carrying this allele (odds ratio 0.02 [95% confidence interval 0.00–0.15] P = 0.00001). In addition, heterozygous dissimilarities at nucleotide positions C634G and 714 insT/G in the 5'-upstream regulatory region were observed between the mother child pairs of the HIV-1-non-transmitting group while homozygous similarities of C634C, and either 714insG/G or mother-child pairs with similar 714insT/G were observed among the transmitting group in the same region.
Conclusion
This study identified new variants in the HLA-G gene and provides further evidence that dissimilarities in the HLA-G DNA sequence variants could influence the transmission of HIV-1 from infected mothers to their infants.

Cytotoxic T cell recognition of an HIV-1 reverse transcriptase variant peptide incorporating the K103N drug resistance mutation

2009-07-20T17:58:00.013-07:00

During HIV-1 infection, cytotoxic T cell (CTL) responses exert strong selective pressure on the replicating virus population. Here we report evidence for T cell activity against the drug resistant K103N region of viral reverse transcriptase in three HIV-1 infected patients exposed to NNRTI antiretroviral drugs. We further characterize the response in one patient by ELISPOT analysis. A nine amino acid peptide incorporating 103N was recognized by patient T cells whereas the wild type was not. The RT K103N mutation is selected by the NNRTI class of HIV drugs. We hypothesize that, in certain individuals, CTL responses against 103N-containing epitopes may protect against NNRTI drug resistance. Characterizing such responses in the context of HLA subtypes could lead to tailored HIV drug therapy or to the design of therapeutic vaccines.

Partial protective effect of CCR5-Delta 32 heterozygosity in a cohort of heterosexual Italian HIV-1 exposed uninfected individuals

2009-07-20T17:58:00.011-07:00

Despite multiple sexual exposure to HIV-1 virus, some individuals remain HIV-1 seronegative (exposed seronegative, ESN). The mechanisms underlying this resistance remain still unclear, although a multifactorial pathogenesis can be hypothesised. Although several genetic factors have been related to HIV-1 resistance, the homozigosity for a mutation in CCR5 gene (the 32 bp deletion, i.e. CCR5-Delta32 allele) is presently considered the most relevant one. In the present study we analysed the genotype at CCR5 locus of 30 Italian ESN individuals (case group) who referred multiple unprotected heterosexual intercourse with HIV-1 seropositive partner(s), for at least two years. One hundred and twenty HIV-1 infected patients and 120 individuals representative of the general population were included as control groups. Twenty percent of ESN individuals had heterozygous CCR5-Delta 32 genotype, compared to 7.5% of HIV-1 seropositive and 10% of individuals from the general population, respe
ctively. None of the analysed individuals had CCR5-Delta 32 homozygous genotype. Sequence analysis of the entire open reading frame of CCR5 was performed in all ESN subjects and no polymorphisms or mutations were identified. Moreover, we determined the distribution of C77G variant in CD45 gene, which has been previously related to HIV-1 infection susceptibility. The frequency of the C77G variant showed no significant difference between ESN subjects and the two control groups.
In conclusion, our data show a significantly higher frequency of CCR5-Delta 32 heterozygous genotype (p = 0.04) among the Italian heterosexual ESN individuals compared to HIV-1 seropositive patients, suggesting a partial protective role of CCR5-Delta 32 heterozygosity in this cohort.

Prevention for those who have freedom of choice � or among the choice-disabled: confronting equity in the AIDS epidemic

2009-07-20T17:58:00.009-07:00

With the exception of post-exposure prophylaxis for reported rape, no preventive strategy addresses the choice disabled – those who might like to benefit from AIDS prevention but who are unable to do so because they do not have the power to make and to act on prevention decisions. In southern African countries, where one in every three has been forced to have sex by the age of 18 years, a very large proportion of the population is choice disabled. This group is at higher risk of HIV infection and unable to respond to AIDS prevention programmes; they represent a reservoir of infection. Reduction of sexual violence would probably decrease HIV transmission directly, but also indirectly as more people can respond to existing AIDS prevention programmes.

Predicting AIDS-related events using CD4 percentage or CD4 absolute counts

2009-07-20T17:58:00.007-07:00

Background
The extent of immunosuppression and the probability of developing an AIDS-related complication in HIV-infected people is usually measured by the absolute number of CD4 positive T-cells. The percentage of CD4 positive cells is a more easily measured and less variable number. We analyzed sequential CD4 and CD8 numbers, percentages and ratios in 218 of our HIV infected patients to determine the most reliable predictor of an AIDS-related event.
Results
The CD4 percentage was an unsurpassed predictor of the occurrence of AIDS-related events when all subsets of patients are considered. The CD4 absolute count was the next most reliable, followed by the ratio of CD4/CD8 percentages. The value of CD4 percentage over the CD4 absolute count was seen even after the introduction of highly effective HIV therapy.
Conclusion
The CD4 percentage is unsurpassed as a parameter for predicting the onset of HIV-related diseases. The extra time and expense of measuring the CD4 absolute count may be unnecessary.

IL-2 production correlates with effector cell differentiation in HIV-specific CD8+ T cells

2009-07-20T17:58:00.005-07:00

Background
Diminished IL-2 production and lack of effector differentiation have been reported for HIV-specific T cells. In this study, we examined the prevalence of these phenomena using 8-color cytokine flow cytometry, and tested the hypothesis that these two findings were causally related. We analyzed cytokine profiles and memory/effector phenotypes of HIV-specific and CMV-specific T cells using short-term in vitro stimulation with HIV or CMV peptide pools. Nineteen HIV-positive subjects with progressive disease and twenty healthy, HIV-negative subjects were examined.
Results
Among HIV-infected subjects, there were significantly fewer CD8+ IL-2+ T cells responding to HIV compared to CMV, with no significant difference in CD4+ IL-2+ T cells. The majority of CMV-specific T cells in both HIV-negative and HIV-positive subjects appeared to be terminally differentiated effector cells (CD8+ CD27- CD28- CD45RA+ or CD8+ CD27- CD28- CD45RA-). In HIV-positive subjects, the most common phenotype of HIV-specific T cells was intermediate in differentiation (CD8+ CD27+ CD28- CD45RA-). These differences were statistically significant, both as absolute cell frequencies and as percentages. There was a significant correlation between the absolute number of HIV-specific CD8+ IL-2+ T cells and HIV-specific CD8+ CD27- CD28- CD45RA+ terminal effector cells.
Conclusion
IL-2 production from antigen-specific CD8+ T cells correlates with effector cell differentiation of those cells.

LMP-420, a small-molecule inhibitor of TNF-alpha, reduces replication of HIV-1 and Mycobacterium tuberculosis in human cells

2009-07-20T17:58:00.003-07:00

Background
Co-infections of human immunodeficiency virus (HIV) and Mycobacterium tuberculosis (M. Tb) are steadily increasing and represent a major health crisis in many developing countries. Both pathogens individually stimulate tumor necrosis factor-alpha (TNF) release from infected cells and TNF, in turn, enhances the replication of each. A recent report on a Phase I clinical trial suggested that etanercept (soluble TNF receptor) might be beneficial in treating HIV/M. Tb co-infected patients. We sought to determine if a small molecule inhibitor of TNF synthesis and activity could block replication of either organism and thus be a potential adjunct to existing drugs targeting these agents.
Results
LMP-420, a novel anti-inflammatory agent that inhibits TNF, was tested for HIV-1 inhibition both alone and in combination with AZT (3' -azido-3-deoxythymidine). LMP-420 alone was tested against M. Tb. HIV-1 infected human peripheral blood mononuclear cells (PBMC) or M. Tb-infected human alveolar macrophages (AM) were treated with a single dose of LMP-420 and viral or bacterial replication determined after 7 or 5 days respectively. Viral replication was determined from supernatant p24 levels measured by ELISA. M. Tb replication was determined by bacterial culture of macrophage lysates. LMP-420 alone inhibited HIV replication over 7 days with an IC50 of ~300 nM. Combination of LMP-420 with AZT doubled the level of HIV inhibition observed with AZT alone. LMP-420 alone inhibited the replication of virulent M. Tb by >80%, more than that observed with anti-TNF antibody alone.
Conclusion
Inhibition of TNF with inexpensive, small-molecule, orally-active drugs may represent a useful strategy for enhancing the activity of currently-available antiviral and anti-M. Tb agents, particularly in those areas where co-infections with these pathogens act to synergistically enhance each other.

Review of "The Twelfth West Coast Retrovirus Meeting" and "The Twenty-third Annual Symposium on Nonhuman Primate Models for AIDS"

2009-07-20T17:58:00.001-07:00

Two recent meetings held on the west coast of the USA highlighted current work being done in the field of retrovirology and AIDS. The meetings, "The Twelfth West Coast Retrovirus Meeting" (Palm Springs CA; October 6–8, 2005), and the "Twenty-third Annual Symposium on Nonhuman Primate Models for AIDS" (Portland OR; September 21–24) covered a broad range of topics. The highlights covered here are not meant to be inclusive but reflect presentations of interest in the identification and development of new HIV therapies and the role played by animal models in their development.

Acceptability of Carraguard, a candidate microbicide and methyl cellulose placebo vaginal gels among HIV-positive women and men in Durban, South Africa

2009-07-19T18:00:00.027-07:00

Background and Methods
When on the market, microbicides are likely to be used by individuals who do not know their HIV status. Hence, assessment of safety and acceptability among HIV positive men and women is important. Acceptability of Carraguard, the Population Council's lead microbicide candidate was assessed in a Phase I safety study among healthy HIV-positive sexually abstinent women and men, and sexually active women (20 per group), in Durban, South Africa. Participants were randomized to use Carraguard gel, placebo gel, or no product. All women in the gel arms applied 4 ml gel vaginally every evening for 14 intermenstrual days (women in the sexually active group inserted gel within 1 hour prior to sex on days when sex occurred), and sexually abstinent men applied gel directly to the penis every evening for 7 days. Acceptability was assessed by face-to-face structured questionnaires and semi-structured in-depth interviews with all participants. Gel use questions were applicable to participant
s in the gel arms only (13 sexually abstinent women, 14 sexually active women, and 13 abstinent men).
Results
Overall, 93% of the women liked the study gel (Carraguard or placebo) very much, 4% disliked it somewhat, and 4% were neutral. 15% of men and women disliked the gel's color, smell, or packaging. Most women and men reported never experiencing pain or irritation during or after gel application. Although over two thirds of the women preferred some lubrication during sex, some of the women felt that the gel was frequently too wet. Twenty-one percent of women and 42% of men said they felt covert use of a microbicide would be acceptable. Over 60% of women and men would prefer to use a microbicide alone instead of using it with a condom.
Conclusion
Acceptability of Carraguard among HIV-positive women and men in Durban was good. The wetness experienced by the women may be attributed to the delivery of gel volume. The applicator was designed to deliver 4 mls whereas in fact between 4 ml to 5 mls were actually dispensed. Condom migration in the event of a partially effective product is of concern.

Impact of drug classes and treatment availability on the rate of antiretroviral treatment change in the TREAT Asia HIV Observational Database (TAHOD)

2009-07-19T18:00:00.026-07:00

Background
It is critical to understand the pattern of antiretroviral treatment (ART) prescription in different regions of the world as ART procurement needs to be anticipated. We aimed at exploring rates and predictors of ART combination changes in clinical practice in Treat Asia HIV Observational Database (TAHOD).
Methods
Rates of ART changes were examined in patients who started first line triple or more ART combination in TAHOD, and had at least one follow-up visit. Rates of ART changes were summarised per follow-up year, and factors associated with changes assessed using random-effect Poisson regression. The Kaplan-Meier method was used to determine durations of patients in their first, second and third regimen.
Results
A total of 1846 patients initiated an ART combination with at least three drugs. Median follow up time for the first treatment was 3.2 years. The overall rate of ART change was 29 per 100-person-year.
In univariate analyses, rate of treatment change was significantly associated with exposure category, the country income category, the drug class combination, calendar year and the number of combinations. In multivariate analysis, compared to d4T/3TC/NVP, starting ART with another NNRTI-containing regimen, with PI only or with a triple NRTI regimen was associated with a higher risk of combination change (relative risk (RR) 1.6 (95% CI 1.64 – 1.96), p < 0.001, RR 3.39 (2.76 – 4.16) p < 0.001, RR 6.37 (4.51 – 9.00), p < 0.001). Being on a second or a third combination regimen was also associated with a decreased rate of ART change, compared with first ART combination (RR 0.82 (0.68 – 0.99), p = 0.035, RR 0.77 (0.61 – 0.97), p = 0.024). Sites with fewer than 12 drugs used had an increased rate of treatment changes (1.31 (1.13 – 1.51), p < 0.001). Injecting drug users, and other/unknown exposure was found to increase rate of treatme
nt change (1.24 (1.00 – 1.54), p = 0.055). Percentages of patients who stopped treatment due to adverse events were 31, 27 and 32 in 1st, 2nd and 3rd treatment combinations, respectively.
Conclusion
Our study suggests that drug availability impacts on ART prescription patterns. Our data, reflecting real clinic use in Asia, suggest that around half of all patients require second combination ART by 3 years after treatment initiation.

Immune reconstitution inflammatory syndrome in association with HIV/AIDS and tuberculosis: Views over hidden possibilities

2009-07-19T18:00:00.025-07:00

Gut immune components are severely compromised among persons with AIDS, which allows increased translocation of bacterial lipopolysaccharides (LPS) into the systemic circulation. These microbial LPS are reportedly increased in chronically HIV-infected individuals and findings have correlated convincingly with measures of immune activation. Immune reconstitution inflammatory syndrome (IRIS) is an adverse consequence of the restoration of pathogen-specific immune responses in a subset of HIV-infected subjects with underlying latent infections during the initial months of highly active antiretroviral treatment (HAART). Whether IRIS is the result of a response to a high antigen burden, an excessive response by the recovering immune system, exacerbated production of pro-inflammatory cytokines or a lack of immune regulation due to inability to produce regulatory cytokines remains to be determined. We theorize that those who develop IRIS have a high burden of proinflammatory cytokin
es produced also in response to systemic bacterial LPS that nonspecifically act on latent mycobacterial antigens. We also hypothesize that subjects that do not develop IRIS could have developed either tolerance (anergy) to persistent LPS/tubercle antigens or could have normal FOXP3+ gene and that those with defective FOXP3+ gene or those with enormous plasma LPS could be vulnerable to IRIS. The measure of microbial LPS, anti-LPS antibodies and nonspecific plasma cytokines in subjects on HAART shall predict the role of these components in IRIS.

Gender-specific effects of HIV protease inhibitors on body mass in mice

2009-07-19T18:00:00.024-07:00

Protease inhibitors, as part of highly active anti-retroviral therapy (HAART), have significantly increased the lifespan of human immunodeficiency virus (HIV) infected patients. Several deleterious side effects including dyslipidemia and lipodystrophy, however, have been observed with HAART. Women are at a higher risk of developing adipose tissue alterations and these alterations have different characteristics as compared to men. We have previously demonstrated that in mice the HIV protease inhibitor, ritonavir, caused a reduction in weight gain in females, but had no effect on male mice. In the present study, we examined the potential causes of this difference in weight gain. Low-density lipoprotein receptor (LDL-R) null mice or wild-type C57BL/6 mice, were administered 15 μg/ml ritonavir or vehicle (0.01% ethanol) in the drinking water for 6 weeks. The percent of total body weight gained during the treatment period was measured and confirmed that female LDL-R gained si
gnificantly less weight with ritonavir treatment than males. In wild type mice, however, there was no effect of ritonavir treatment in either sex. Despite the weight loss in LDL-R null mice, ritonavir increased food intake, but no difference was observed in gonadal fat weight. Serum leptin levels were significantly lower in females. Ritonavir further suppressed leptin levels in (p < 0.05). Ritonavir did not alter serum adiponectin levels in either gender. To determine the source of these differences, female mice were ovariectomized remove the gonadal sex hormones. Ovariectomy prevented the weight loss induced by ritonavir (p < 0.05). Furthermore, leptin levels were no longer suppressed by ritonavir (p < 0.05). This study demonstrates that gonadal factors in females influence the hormonal control of weight gain changes induced by HIV protease inhibitors in an environment of elevated cholesterol.

Rapid CD4 decline after interruption of non-nucleoside reverse transcriptase inhibitor-based antiretroviral therapy in a resource-limited setting

2009-07-19T18:00:00.023-07:00

Background
Non-nucleoside reverse transcriptase inhibitor (NNRTI) with stavudine and lamivudine is widely used as the first-line antiretroviral therapy (ART) in resource-limited settings. Lipodystrophy is common and options for switching ART regimen are limited; this situation can lead to patients' poor adherence and antiretroviral resistance. Treatment interruption (TI) in patients with high CD4 cell counts, lipodystrophy, and limited options may be an alternative in resource-limited settings. This study aimed to determine time to resume ART after TI and predictors for early resumption of ART in a resource-limited setting.
Methods
A prospective study was conducted in January 2005 to December 2006 and enrolled HIV-infected patients with HIV-1 RNA <50 copies/mL, CD4 > 350 cells/mm3, and willing to interrupt ART. CD4 cell count, HIV-1 RNA, lipid profile, and lipodystrophy were assessed at baseline and every 3 months. ART was resumed when CD4 declined to <250 cells/mm3 or developed HIV-related symptoms. Patients were grouped based on ART regimens [NNRTI or protease inhibitor (PI)] prior to TI.
Results
There were 99 patients, 85 in NNRTI group and 14 in PI group. Mean age was 40.6 years; 46% were males. Median duration of ART was 47 months. Median nadir CD4 and baseline CD4 were 151 and 535 cells/mm3, respectively. Median CD4 change at 3 months after TI were -259 (NNRTI) and -105 (PI) cells/mm3 (p = 0.038). At 13-month median follow-up, there was no AIDS-defining illness; 38% (NNRTI) and 29% (PI) of patients developed HIV-related symptoms. ART was resumed in 51% (NNRTI) and 36% (PI) of patients (p = 0.022). By Kaplan-Meier analysis, median time to resume ART was 5.5 (NNRTI) and 14.2 (PI) months (log rank test, p = 0.026). By Cox's regression analysis, NNRTI-based ART (HR 4.9; 95%CI, 1.5–16.3), nadir CD4 <100 cells/mm3 (HR 2.7; 95%CI 1.4–5.3) and baseline CD4 <500 cells/mm3 (HR 1.6; 95%CI, 1.2–3.1) were predictors for early ART resumption.
Conclusion
TI of NNRTI-based ART leads to rapid CD4 decline and high probability of early ART resumption and should be avoided. It is necessary to scale-up the options for HIV-infected patients with lipodystrophy in resource-limited settings.

Provider-initiated HIV testing in rural Haiti: low rate of missed opportunities for diagnosis of HIV in a primary care clinic

2009-07-19T18:00:00.021-07:00

As HIV treatment is scaled-up in resource-poor settings, the timely identification of persons with HIV infection remains an important challenge. Most people with HIV are unaware of their status, and those who are often present late in the course of their illness. Free-standing voluntary counseling and testing sites often have poor uptake of testing. We aimed to evaluate a 'provider-initiated' HIV testing strategy in a primary care clinic in rural resource-poor Haiti by reviewing the number of visits made to clinic before an HIV test was performed in those who were ultimately found to have HIV infection. In collaboration with the Haitian Ministry of Health, a non-governmental organization (Partners In Health) scaled up HIV care in central Haiti by reinforcing primary care clinics, instituting provider-initiated HIV testing and by providing HIV treatment in the context of primary medical care, free of charge to patients. Among a cohort of people with HIV infection, we assessed
retrospectively for delays in or 'missed opportunities' for diagnosis of HIV by the providers in one clinic. Of the first 117 patients diagnosed with HIV in one clinic, 100 (85%) were diagnosed at the first medical encounter. Median delay in diagnosis for the remaining 17 was only 62 days (IQR 19 – 122; range 1 – 272). There was no statistical difference in CD4 cell count between those with and without a delay. 3787 HIV tests were performed in the period reviewed. Provider-initiated testing was associated with high volume uptake of HIV testing and minimal delay between first medical encounter and diagnosis of HIV infection. In scale up of HIV care, provider-initiated HIV testing at primary care clinics can be a successful strategy to identify patients with HIV infection.

Immune Restoration Syndrome with disseminated Penicillium marneffei and Cytomegalovirus co-infections in an AIDS patient

2009-07-19T18:00:00.019-07:00

Background
Penicillium marneffei is a dimorphic fungus, endemic in South-east Asia. The fungus causes severe disease in immunocompromised patients such as AIDS. However, no case of immune restoration disease of Penicillium marneffei is reported in literature from a non-endemic area.
Case Presentation
We report the first case of Penicillium marneffei and Cytomegalovirus infection manifesting as a result of immune restoration one month after initiating HAART. This severely immunocompromised patient had presented with multiple lymphadenopathy, massive hepatosplenomegaly, visual impairment and mild icterus, but no skin lesions. Penicillium marneffei was isolated from lymph node fine-needle aspirates and blood cultures.
Conclusion
In order to diagnose such rare cases, the clinicians, histopathologists and microbiologists alike need to maintain a strong index of suspicion for making initial diagnosis as well as for suspecting immune reconstitution syndrome (IRS) with Penicillium marneffei.

Utilization and spending trends for antiretroviral medications in the U.S. Medicaid program from 1991 to 2005

2009-07-19T18:00:00.017-07:00

Background
HIV/AIDS incidence and mortality rates have decreased in the U.S. since 1996. Accompanying the longer life spans of those diagnosed with the disease, however, is a tremendous rise in expenditures on medication. The objective of this study is to describe the trends in utilization of, spending on, and market shares of antiretroviral medications in the U.S. Medicaid Program. Antiretroviral drugs include nucleoside reverse transcriptase inhibitors (NRTIs), protease inhibitors (PIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), and fusion inhibitors (FIs).
Methods
Utilization and payment data from 1991 to 2005 are provided by the Centers for Medicare & Medicaid Services. Descriptive summary analyses were used to assess quarterly prescription numbers and amounts of payment.
Results
The total number of prescriptions for antiretrovirals increased from 168,914 in 1991 to 2.0 million in 1998, and 3.0 million in 2005, a 16.7-fold increase over 15 years. The number of prescriptions for NRTIs reached 1.6 million in 2005. Prescriptions for PIs increased from 114 in 1995 to 932,176 in 2005, while the number of prescriptions for NNRTIs increased from 1,339 in 1996 to 401,272 in 2005. The total payment for antiretroviral drugs in the U.S. Medicaid Program increased from US$ 30.6 million in 1991 to US$ 1.6 billion in 2005, a 49.8-fold increase. In 2005, NRTIs as a class had the highest payment market share. These drugs alone accounted for US$ 787.9 million in Medicaid spending (50.8 percent of spending on antiretrovirals). Payment per prescription for each drug, with the exception of Agenerase®, increased, at least somewhat, over time. The relatively expensive drugs in 2005 included Trizivir® ($1040) and Combivir® ($640), as well as Reyataz® ($7
50), Lexiva® ($700), Sustiva® ($420), Viramune® ($370), and Fuzeon® ($1914).
Conclusion
The tremendous growth in antiretroviral spending is due primarily to rising utilization, secondarily to the entry of newer, more expensive antiretrovirals, and, finally, in part to rising per-prescription cost of existing medications.

Instability of retroviral vectors with HIV-1-specific RT aptamers due to cryptic splice sites in the U6 promoter

2009-07-19T18:00:00.015-07:00

Background
Internal polymerase III promoters in retroviral vectors have been used extensively to express short RNA sequences, such as ribozymes, RNA aptamers or short interfering RNA inhibitors, in various positions and orientations. However, the stability of these promoters in the reverse orientation has not been rigorously evaluated.
Results
A series of retroviral vectors was generated carrying the U6+1 promoter with 3 different HIV-1 RT-specific RNA aptamers and one control aptamer, all in the reverse orientation. After shuttle packaging, the CD4+ cell line CEMx174 was transduced with each vector, selected for expression of GFP, and challenged with HIV-1. We did not observe inhibition of HIV-1 replication in these transduced populations. PCR amplification of the U6+1 promoter-RNA aptamer inhibitor cassette from transduced CEMx174 cells and RT-PCR amplification from transfected Phoenix (amphotropic) packaging cells showed two distinct products: a full-length product of the expected size as well as a truncated product. The sequence of the full-length PCR product was identical to the predicted amplicon sequence. However, sequencing of the truncated product revealed a 139 bp deletion in the U6 promoter. This deletion decreased transcriptional activity of the U6 promoter. Analysis of the deleted sequences from the U6
promoter in the antisense direction indicated consensus splice donor, splice acceptor and branch point sequences.
Conclusion
The existence of a cryptic splice site in the U6 promoter when expressed in a retroviral vector in the reverse orientation generates deletions during packaging and may limit the utility of this promoter for expression of small RNA inhibitors.

Trends in the HIV related hospital admissions in the HAART era in Barbados, 2004�2006

2009-07-19T18:00:00.013-07:00

Background
To investigate the reasons for hospitalizations and its outcome in the era of HAART in Barbados. This report also describes the profile of the HIV infected persons who are hospitalized in the HAART era.
Methods
This is a retrospective study of HIV related admissions in this country. We examined the admission case notes of all the adult admissions to the Queen Elizabeth Hospital where one of the discharge diagnosis was HIV infection during the April 2004 through March 2006. Data collected included patients' profile, including the date of diagnosis of HIV infection, outcome of the current admission in term of discharge or death and the final diagnosis at the time of discharge or death.
Results
Over the 24 months period there were 431 adult admissions to the medical wards of the Queen Elizabeth Hospital where one of the discharge diagnosis was HIV infection and this accounted for 5.9% of all medical admissions. 258(60%) admissions were in persons who were known to be HIV infected prior to the current admission, where as diagnosis of HIV infection was made for the first time during the current admission in case of remaining 76(47.5%) cases. Nearly half of those hospitalized, had a CD 4 cell counts of < 200/μL. Over all, opportunistic infection was the commonest (35%) discharge diagnosis, followed by serious bacterial infections, anemia and HIV nephropathy. The outcome of these admissions was death in 30 (14.2%) cases where as patient was discharged out in the remaining 181 (85.8%) cases. Of the medical admissions with HIV as one of the discharge diagnosis during the period April 04 through March 05, 43% were newly diagnosed HIV infection and the corresponding
figure for the period April 05 through March 06 was 35% (P = 0.54). During the April 05 through March 04 significantly higher proportion of HIV infected adults had Anemia with a Hemoglobin less than 10 g/dL (P = 0.044), HIV related nephropathy (P = 0.0003), HAART toxicity (P = < 0.0001) and a Non-AIDS related conditions (P = 0.043) as one of the final discharge diagnosis.
Conclusion
A significant proportion of patients admitted with HIV infection were the newly diagnosed and severely immuno-supressed. An opportunistic infection continues to be the commonest discharge diagnosis, although there was a growing trend in the proportion of the discharge diagnosis being HAART toxicity and Non-AIDS related conditions. Over all hospitalization of HIV infected persons still carries a significant risk of mortality.

HIV-associated adipose redistribution syndrome (HARS): definition, epidemiology and clinical impact

2009-07-19T18:00:00.011-07:00

A segment of the HIV infected population develops abnormal and excessive accumulation of adipose tissue in the trunk, including accumulation of visceral (deep abdominal) adipose tissue. This condition, known as HIV-related adipose redistribution syndrome (HARS), may also be accompanied by fat accumulation in the upper back/neck (dorsocervical region) and/or depletion of subcutaneous adipose tissue from the abdomen, face, limbs, or buttocks. HARS is estimated to occur in up to 32% of patients and is associated with health risks similar to those of metabolic syndrome. Techniques to detect and measure HARS include physician and patient assessments and radiologic or anthropometric methods.

Protease inhibitor associated mutations compromise the efficacy of therapy in human immunodeficiency virus � 1 (HIV-1) infected pediatric patients: a cross-sectional study

2009-07-19T18:00:00.009-07:00

Background
Although the introduction of combined therapy with reverse transcriptase and protease inhibitors has resulted in considerable decrease in HIV related mortality; it has also induced the development of multiple drug-resistant HIV-1 variants.
The few studies on HIV-1 mutagenesis in HIV infected children have not evaluated the impact of HIV-1 mutations on the clinical, virological and immunological presentation of HIV disease that is fundamental to optimizing the treatment regimens for these patients.
Results
A cross sectional study was conducted to evaluate the impact of treatment regimens and resistance mutation patterns on the clinical, virological, and immunological presentation of HIV disease in 41 children (25 male and 16 female) at the Robert Wood Johnson Pediatric AIDS Program in New Brunswick, New Jersey. The study participants were symptomatic and had preceding treatment history with combined ARV regimens including protease inhibitors (PIs), nucleoside reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs). Fifteen (36.6%) children were treated with NRTI+NNRTI+ PI, 6 (14.6%) with NRTI+NNRTIs, 13 (31.7%) with NRTI+PIs, and the remaining 7 (17.1%) received NRTIs only.
Combined ARV regimens did not significantly influence the incidence of NRTI and NNRTI associated mutations. The duration of ARV therapy and the child's age had no significant impact on the ARV related mutations. The clinico-immunological presentation of the HIV disease was not associated with ARV treatment regimens or number of resistance mutations. However, primary mutations in the protease (PR) gene increased the likelihood of plasma viral load (PVL) ≥ 10,000 copies/mL irrespective of the child's age, duration of ARV therapy, presence of NRTI and NNRTI mutation. Viremia ≥ 10,000 copies/mL was recorded in almost all the children with primary mutations in the PR region (n = 12/13, 92.3%) as compared with only 50.0% (n = 14/28) of HIV infected children without (PR-), P < 0.008. However, CD-4 T cells were not affected by the mutations in the PR gene of the HIV-1 isolates.
Conclusion
Primary PR resistance mutations significantly increase the likelihood for high viral replication in pediatric patients with moderate/severe HIV-1 infection, which may affect the long-term clinical prognosis of the HIV infected children.

Immune reconstitution inflammatory syndrome (IRIS): review of common infectious manifestations and treatment options

2009-07-19T18:00:00.007-07:00

The immune reconstitution inflammatory syndrome (IRIS) in HIV-infected patients initiating antiretroviral therapy (ART) results from restored immunity to specific infectious or non-infectious antigens. A paradoxical clinical worsening of a known condition or the appearance of a new condition after initiating therapy characterizes the syndrome. Potential mechanisms for the syndrome include a partial recovery of the immune system or exuberant host immunological responses to antigenic stimuli. The overall incidence of IRIS is unknown, but is dependent on the population studied and its underlying opportunistic infectious burden. The infectious pathogens most frequently implicated in the syndrome are mycobacteria, varicella zoster, herpesviruses, and cytomegalovirus (CMV). No single treatment option exists and depends on the underlying infectious agent and its clinical presentation. Prospective cohort studies addressing the optimal screening and treatment of opportunistic infectio
ns in patients eligible for ART are currently being conducted. These studies will provide evidence for the development of treatment guidelines in order to reduce the burden of IRIS. We review the available literature on the pathogenesis and epidemiology of IRIS, and present treatment options for the more common infectious manifestations of this diverse syndrome and for manifestations associated with a high morbidity.

Perceptions of vaginal microbicides as an HIV prevention method among health care providers in KwaZulu-Natal, South Africa

2009-07-19T18:00:00.005-07:00

Background
The promise of microbicides as an HIV prevention method will not be realized if not supported by health care providers. They are the primary source of sexual health information for potential users, in both the public and private health sectors. Therefore, the aim of this study was to determine perceptions of vaginal microbicides as a potential HIV prevention method among health care providers in Durban and Hlabisa, South Africa, using a combination of quantitative and qualitative methods.
Results
During 2004, semi structured interviews with 149 health care providers were conducted. Fifty seven percent of hospital managers, 40% of pharmacists and 35% of nurses possessed some basic knowledge of microbicides, such as the product being used intra-vaginally before sex to prevent HIV infection. The majority of them were positive about microbicides and were willing to counsel users regarding potential use. Providers from both public and private sectors felt that an effective microbicide should be available to all people, regardless of HIV status. Providers felt that the product should be accessed over-the-counter in pharmacies and in retail stores. They also felt a need for potential microbicides to be available free of charge, and packaged with clear instructions. The media was seen by health care providers as being an effective strategy for promoting microbicides.
Conclusion
Overall, health care providers were very positive about the possible introduction of an effective microbicide for HIV prevention. The findings generated by this study illustrated the need for training health care providers prior to making the product accessible, as well as the importance of addressing the potential barriers to use of the product by women. These are important concerns in the health care community, and this study also served to educate them for the day when research becomes reality.

Baseline resistance to nucleoside reverse transcriptase inhibitors fails to predict virologic response to combination therapy in children (PACTG 338)

2009-07-19T18:00:00.003-07:00

Background
The association between baseline drug resistance mutations and subsequent increase in viral failure has not been established for HIV-infected children. We evaluated drug resistance mutations at 39 codon sites (21 protease inhibitor (PI) resistant codons and 18 nucleoside reverse transcriptase inhibitor (NRTI) resistant codons) for 92 clinically stable NRTI-experienced, PI-naive HIV-infected children 2 to 17 years of age who were initiating new therapy with ritonavir plus zidovudine (ZDV) and lamivudine or plus stavudine. The association between baseline drug resistance mutations and subsequent viral failure after 12 and 24 weeks of highly active antiretroviral therapy (HAART) was studied.
Results
There were few primary PI associated mutations in this PI-naïve population, but 84% had NRTI mutations – codons 215 (66%), 41 (42%), 67 (37%), 210 (33%) and 70 (32%). None of the specific baseline drug resistance mutations were associated with a higher rate of virologic failure after 12 or 24 weeks of HAART. Median week 12 viral load decreased as the total number of NRTI mutations at baseline increased (P = 0.006). Specifically, a higher level of baseline ZDV resistance mutation was associated with a decrease in viral failure after 12 weeks on a ZDV-containing HAART regimen (P = 0.017).
Conclusion
No increase was seen in the rate of viral failure after HAART associated with the presence of resistance mutations at baseline. This paradoxical result may be due to adherence, replicative capacity, or ZDV hypersusceptibility to the new regimen.

Determining eligibility for antiretroviral therapy in resource-limited settings using total lymphocyte counts, hemoglobin and body mass index

2009-07-19T18:00:00.001-07:00

Background
CD4+ T lymphocyte (CD4) cell count testing is the standard method for determining eligibility for antiretroviral therapy (ART), but is not widely available in sub-Saharan Africa. Total lymphocyte counts (TLCs) have not proven sufficiently accurate in identifying subjects with low CD4 counts. We developed clinical algorithms using TLCs, hemoglobin (Hb), and body mass index (BMI) to identify patients who require ART.
Methods
We conducted a cross-sectional study of HIV-infected adults in Uganda, who presented for assessment for ART-eligibility with WHO clinical stages I, II or III. Two by two tables were constructed to examine TLC thresholds, which maximized sensitivity for CD4 cell counts ≤ 200 cells μL, while minimizing the number offered ART with counts > 350 cells μL. Hb and BMI values were then examined to try to improve model performance.
Results
1787 subjects were available for analysis. Median CD4 cell counts and TLCs, were 239 cells/μL and 1830 cells/μL, respectively. Offering ART to all subjects with a TLCs ≤ 2250 cells/μL produced a sensitivity of 0.88 and a false positive ratio of 0.21. Algorithms that treated all patients with a TLC <2000 cells/μL, excluded all patients with a TLC >3000 cells/μL, and used Hb and/or BMI values to determine eligibility for those with TLC values between 2000 and 3000 cells/μL, marginally improved accuracy.
Conclusion
TLCs appear useful in predicting who would be eligible for ART based on CD4 cell count criteria. Hb and BMI values may be useful in prioritizing patients for ART, but did not improve model accuracy.

Traditional Indian medicine and homeopathy for HIV/AIDS: a review of the literature

2009-07-19T17:55:00.029-07:00

Background
Allopathic practitioners in India are outnumbered by practitioners of traditional Indian medicine and homeopathy (TIMH), which is used by up to two-thirds of its population to help meet primary health care needs, particularly in rural areas. India has an estimated 2.5 million HIV infected persons. However, little is known about TIMH use, safety or efficacy in HIV/AIDS management in India, which has one of the largest indigenous medical systems in the world. The purpose of this review was to assess the quality of peer-reviewed, published literature on TIMH for HIV/AIDS care and treatment.
Results
Of 206 original articles reviewed, 21 laboratory studies, 17 clinical studies, and 6 previous reviews of the literature were identified that covered at least one system of TIMH, which includes Ayurveda, Unani medicine, Siddha medicine, homeopathy, yoga and naturopathy. Most studies examined either Ayurvedic or homeopathic treatments. Only 4 of these studies were randomized controlled trials, and only 10 were published in MEDLINE-indexed journals. Overall, the studies reported positive effects and even "cure" and reversal of HIV infection, but frequent methodological flaws call into question their internal and external validity. Common reasons for poor quality included small sample sizes, high drop-out rates, design flaws such as selection of inappropriate or weak outcome measures, flaws in statistical analysis, and reporting flaws such as lack of details on products and their standardization, poor or no description of randomization, and incomplete reporting of study results.
Conclusion
This review exposes a broad gap between the widespread use of TIMH therapies for HIV/AIDS, and the dearth of high-quality data supporting their effectiveness and safety. In light of the suboptimal effectiveness of vaccines, barrier methods and behavior change strategies for prevention of HIV infection and the cost and side effects of antiretroviral therapy (ART) for its treatment, it is both important and urgent to develop and implement a rigorous research agenda to investigate the potential risks and benefits of TIMH and to identify its role in the management of HIV/AIDS and associated illnesses in India.

Stable gene transfer of CCR5 and CXCR4 siRNAs by sleeping beauty transposon system to confer HIV-1 resistance

2009-07-19T17:55:00.028-07:00

Background
Thus far gene therapy strategies for HIV/AIDS have used either conventional retroviral vectors or lentiviral vectors for gene transfer. Although highly efficient, their use poses a certain degree of risk in terms of viral mediated oncogenesis. Sleeping Beauty (SB) transposon system offers a non-viral method of gene transfer to avoid this possible risk. With respect to conferring HIV resistance, stable knock down of HIV-1 coreceptors CCR5 and CXCR4 by the use of lentiviral vector delivered siRNAs has proved to be a promising strategy to protect cells from HIV-1 infection. In the current studies our aim is to evaluate the utility of SB system for stable gene transfer of CCR5 and CXCR4 siRNA genes to derive HIV resistant cells as a first step towards using this system for gene therapy.
Results
Two well characterized siRNAs against the HIV-1 coreceptors CCR5 and CXCR4 were chosen based on their previous efficacy for the SB transposon gene delivery. The siRNA transgenes were incorporated individually into a modified SB transfer plasmid containing a FACS sortable red fluorescence protein (RFP) reporter and a drug selectable neomycin resistance gene. Gene transfer was achieved by co-delivery with a construct expressing a hyperactive transposase (HSB5) into the GHOST-R3/X4/R5 cell line, which expresses the major HIV receptor CD4 and and the co-receptors CCR5 and CXCR4. SB constructs expressing CCR5 or CXCR4 siRNAs were also transfected into MAGI-CCR5 or MAGI-CXCR4 cell lines, respectively. Near complete downregulation of CCR5 and CXCR4 surface expression was observed in transfected cells. During viral challenge with X4-tropic (NL4.3) or R5-tropic (BaL) HIV-1 strains, the respective transposed cells showed marked viral resistance.
Conclusion
SB transposon system can be used to deliver siRNA genes for stable gene transfer. The siRNA genes against HIV-1 coreceptors CCR5 and CXCR4 are able to downregulate the respective cell surface proteins and thus confer resistance against viral infection by restricting viral entry. These studies have demonstrated for the first time the utility of the non-viral SB system in conferring stable resistance against HIV infection and paved the way for the use of this system for HIV gene therapy studies.

Determinants of late disease-stage presentation at diagnosis of HIV infection in Venezuela: A case-case comparison

2009-07-19T17:55:00.027-07:00

Background
Although Venezuela has a National Human Immunodeficiency Virus (HIV) Program offering free diagnosis and treatment, 41% of patients present for diagnosis at a later disease-stage, indicating that access to care may still be limited. Our study aimed to identify factors influencing delay in presenting for HIV-diagnosis using a case-case comparison. A cross-sectional survey was performed at the Regional HIV Reference Centre (CAI), Carabobo Region, Venezuela. Between May 2005 and October 2006 225 patients diagnosed with HIV at CAI were included and demographic, behavioural and medical characteristics collected from medical files. Socio-economic and behavioural factors were obtained from 129 eligible subjects through interviews. "Late presentation" at diagnosis was defined as patients classified with disease-stage B or C according to the 1993 Centers for Disease Control and Prevention (Atlanta, USA) classification, and "early presentation" defined as diagnosis in disease-stage A.
Results
Of 225 subjects, 91 (40%) were defined as late presenters. A similar proportion (51/129) was obtained in the interviewed sub-sample. Older age (>30 years), male heterosexuality, lower socio-economic status, perceiving ones partner to be faithful and living ≥ 25 km from the CAI were positively associated with late diagnosis in a multivariate model. Females were less likely to present late than heterosexual males (odds ratio = 0.23, P = 0.06). The main barriers to HIV testing were low knowledge of HIV/AIDS, lack of awareness of the free HIV program, lack of perceived risk of HIV-infection, fear for HIV-related stigma, fear for lack of confidentiality at testing site and logistic barriers.
Conclusion
Despite the free Venezuelan HIV Program, poverty and barriers related to lack of knowledge and awareness of both HIV and the Program itself were important determinants in late presentation at HIV diagnosis. This study also indicates that women; heterosexual, bisexual and homosexual men might have different pathways to testing and different factors related to late presentation in each subgroup. Efforts must be directed to i) increase awareness of HIV/AIDS and the Program and ii) the identification of specific factors associated with delay in HIV diagnosis per subgroup, to help develop targeted public health interventions improving early diagnosis and prognosis of people living with HIV/AIDS in Venezuela and elsewhere.

Relationship between Total Lymphocyte count (TLC) and CD4 count among peoples living with HIV, Southern Ethiopia: a retrospective evaluation

2009-07-19T17:55:00.026-07:00

Background
CD4 count is a standard measure of immunodeficiency in adults infected with HIV to initiate and monitor highly active antiretroviral therapy; however, it may not be feasible in resource poor countries. There is a need to have another marker of immunodeficiency that is less resource demanding.
Objective
The objective of this study was to assess the relationship between total lymphocyte count and CD4 count in one of the resource poor countries, Ethiopia.
Methods
This was a retrospective evaluation. A total of 2019 cases with total lymphocyte and CD4 counts from three hospitals (Yirgalem, Hossana and Arba-Minch) were included in the study. Pearson correlation, linear regression and Receiver Operating Characteristic (ROC) were used.
Result
For adults, the sensitivity, specificity, positive and negative predictive values of TLC < 1200 cells/mm3 to predict CD4 count < 200 cells/mm3 were 41%, 83.5%, 87.9% and 32.5%, respectively. For subjects aged less than 18 years, these values were 20.2%, 87%, 82% and 27.1%, respectively. A TLC ≤ 1780 cells/mm3 was found to have maximal sensitivity (61%) and specificity (62%) for predicting a CD4 cell count of < 200 cells/mm3. Meanwhile, a TLC ≤ 1885 cells/mm3 would identify only 59% of patients with CD4 count of < 350 cells/mm3(sensitivity, 59%; and specificity, 61%). The combined sensitivity and specificity for patients above 40 years of age was greater.
Conclusion
Our data revealed low sensitivity and specificity of TLC as a surrogate measure for CD4 count.

Use of WHO clinical stage for assessing patient eligibility to antiretroviral therapy in a routine health service setting in Jinja, Uganda

2009-07-19T17:55:00.025-07:00

In a routine service delivery setting in Uganda, we assessed the ability of the WHO clinical stage to accurately identify HIV-infected patients in whom antiretroviral therapy should be started.
Among 4302 subjects screened for ART, the sensitivity and specificity (95% CI) of WHO stage III, IV against a CD4 count < 200 × 106/l were 52% (50, 54%) and 68% (66, 70%) respectively. Plasma viral load was tested in a subset of 1453 subjects in whom ART was initiated. Among 938 subjects with plasma viral load of 100,000 copies or more, 391 (42%, 95% CI 39, 45%) were at WHO stage I or II.
In this setting, a large number of individuals could have been denied access to antiretroviral therapy if eligibility to ART was assessed on the basis of WHO clinical stage. There is an urgent need for greater CD4 count testing and evaluation of the utility of plasma viral load prior to initiation of ART to accompany the roll-out of ART.

A feasibility study of immediate versus deferred antiretroviral therapy in children with HIV infection

2009-07-19T17:55:00.024-07:00

Objective
To evaluate the feasibility of a large immediate versus deferred antiretroviral therapy (ART) study in children.
Methods
We conducted an open-label pilot randomized clinical trial study in 43 Thai children with CD4 15 to 24% of starting generic AZT/3TC/NVP immediately (Arm 1) or deferring until CD4 < 15% or CDC C (Arm 2). Primary endpoints were recruitment rate, adherence to randomized treatment and retention in trial. Secondary endpoints were % with CDC C or CD4 < 15%. Children were in the trial until the last child reached 108 weeks. Intention to treat and on treatment analyses were performed.
Results
Recruitment took 15 months. Twenty-six of 69 (37.7%) were not eligible due mainly to low CD4%. Twenty four and 19 were randomized to arms 1 and 2 respectively. All accepted the randomized arm; however, 3 in arm 1 stopped ART and 1 in arm 2 refused to start ART. Ten/19 (53%) in arm 2 started ART. At baseline, median age was 4.8 yrs, CDC A:B were 36:7, median CD4 was 19% and viral load was 4.8 log. All in arm 1 and 17/19 in arm 2 completed the study (median of 134 weeks). No one had AIDS or death. Four in immediate arm had tuberculosis. Once started on ART, deferred arm children achieved similar CD4 and viral load response as the immediate arm. Adverse events were similar between arms. The deferred arm had a 26% ART saving.
Conclusion
Almost 40% of children were not eligible due mainly to low CD4% but adherence to randomized treatment and retention in trial were excellent. A larger study to evaluate when to start ART is feasible.

Pre-clinical development as microbicide of zinc tetra-ascorbo-camphorate, a novel terpenoid derivative: Potent in vitro inhibitory activity against both R5- and X4-tropic HIV-1 strains without significant in vivo mucosal toxicity

2009-07-19T17:55:00.023-07:00

Background
Terpenoid derivatives originating from many plants species, are interesting compounds with numerous biological effects, such as anti-HIV-1 activity. The zinc tetra-ascorbo-camphorate complex (or "C14"), a new monoterpenoid derivative was evaluated in vitro for its anti-HIV-1 activity on both R5- and X4-HIV-1 infection of primary target cells (macrophages, dendritic cells and T cells) and on HIV-1 transfer from dendritic cells to T cells.
Results
The toxicity study was carried out in vitro and also with the New Zealand White rabbit vaginal irritation model. C14 was found to be no cytotoxic at high concentrations (CC50 > 10 μM) and showed to be a potential HIV-1 inhibitor of infection of all the primary cells tested (EC50 = 1 μM). No significant changes could be observed in cervicovaginal tissue of rabbit exposed during 10 consecutive days to formulations containing up to 20 μM of C14.
Conclusion
Overall, these preclinical studies suggest that zinc tetra-ascorbo-camphorate derivative is suitable for further testing as a candidate microbicide to prevent male-to-female heterosexual acquisition of HIV-1.

The feasibility of preventing mother-to-child transmission of HIV using peer counselors in Zimbabwe

2009-07-19T17:55:00.022-07:00

Background
Prevention of mother-to-child transmission of HIV (PMTCT) is a major public health challenge in Zimbabwe.
Methods
Using trained peer counselors, a nevirapine (NVP)-based PMTCT program was implemented as part of routine care in urban antenatal clinics.
Results
Between October 2002 and December 2004, a total of 19,279 women presented for antenatal care. Of these, 18,817 (98%) underwent pre-test counseling; 10,513 (56%) accepted HIV testing, of whom 1986 (19%) were HIV-infected. Overall, 9696 (92%) of women collected results and received individual post-test counseling. Only 288 men opted for HIV testing. Of the 1807 HIV-infected women who received posttest counseling, 1387 (77%) collected NVP tablet and 727 (40%) delivered at the clinics. Of the 1986 HIV-infected women, 691 (35%) received NVPsd at onset of labor, and 615 (31%) infants received NVPsd. Of the 727 HIV-infected women who delivered in the clinics, only 396 women returned to the clinic with their infants for the 6-week follow-up visit; of these mothers, 258 (59%) joined support groups and 234 (53%) opted for contraception. By the end of the study period, 209 (53%) of mother-infant pairs (n = 396) came to the clinic for at least 3 follow-up visits.
Conclusion
Despite considerable challenges and limited resources, it was feasible to implement a PMTCT program using peer counselors in urban clinics in Zimbabwe.

Barriers to access prevention of mother-to-child transmission for HIV positive women in a well-resourced setting in Vietnam

2009-07-19T17:55:00.021-07:00

Background
According to Vietnamese policy, HIV-infected women should have access at least to HIV testing and Nevirapine prophylaxis, or where available, to adequate counselling, HIV infection staging, ARV prophylaxis, and infant formula. Many studies in high HIV prevalence settings have reported low coverage of PMTCT services, but there have been few reports from low HIV prevalence settings, such as Asian countries. We investigated the access of HIV-infected pregnant women to PMTCT services in the well-resourced setting of the capital city, Hanoi.
Methods
Fifty-two HIV positive women enrolled in a self-help group in Hanoi were consulted, through in-depth interviews and bi-weekly meetings, about their experiences in accessing PMTCT services.
Results
Only 44% and 20% of the women had received minimal and comprehensive PMTCT services, respectively. Nine women did not receive any services. Twenty-two women received no counselling. The women reported being limited by lack of knowledge and information due to poor counselling, gaps in PMTCT services, and fear of stigma and discrimination. HIV testing was done too late for optimal interventions and poor quality of care by health staff was frequently mentioned.
Conclusion
In a setting where PMTCT is available, HIV-infected women and children did not receive adequate care because of barriers to accessing those services. The results suggest key improvements would be improving quality of counselling and making PMTCT guidelines available to health services. Women should receive early HIV testing with adequate counselling, safe care and prophylaxis in a positive atmosphere towards HIV-infected women.

Microbicides 2008 conference: From discovery to advocacy

2009-07-19T17:55:00.020-07:00

Recently revised statistics show the number of individuals living with HIV at over 33 million worldwide, with 68% being in sub-Saharan Africa. Current HIV prevention methods, such as condom use, monogamy and abstinence, are not always feasible. The need for improved HIV preventative technologies remains urgent. Of these, microbicides represent a promising female-initiated preventative method. Microbicides are designed to be applied vaginally to prevent HIV and STI acquisition. Research is also being undertaken to assess the safety of the product during rectal application.
The biannual Microbicides conference took place in New Delhi, India from 24–27 February 2008. The conference was open to delegates from the scientific and medical fields, as well as communities and advocates. In addition to microbicide research and development, the conference afforded the opportunity for the discussion of key issues such as ethics, acceptability, access, and community involvement.
In this conference report we provide brief summaries of recent advancements made and challenges experienced in microbicide research and development, including updates on basic and clinical science, social and behavioural science, and community mobilisation and advocacy activities pertaining to clinical trials.

Effect of HIV-1-related protein expression on cardiac and skeletal muscles from transgenic rats

2009-07-19T17:55:00.019-07:00

Background
Human immunodeficiency virus type 1 (HIV-1) infection and the consequent acquired immunodeficiency syndrome (AIDS) has protean manifestations, including muscle wasting and cardiomyopathy, which contribute to its high morbidity. The pathogenesis of these myopathies remains partially understood, and may include nutritional deficiencies, biochemical abnormalities, inflammation, and other mechanisms due to viral infection and replication. Growing evidence has suggested that HIV-1-related proteins expressed by the host in response to viral infection, including Tat and gp120, may also be involved in the pathophysiology of AIDS, particularly in cells or tissues that are not directly infected with HIV-1. To explore the potentially independent effects of HIV-1-related proteins on heart and skeletal muscles, we used a transgenic rat model that expresses several HIV-1-related proteins (e.g., Tat, gp120, and Nef). Outcome measures included basic heart and skeletal muscle morphology, glut
athione metabolism and oxidative stress, and gene expressions of atrogin-1, muscle ring finger protein-1 (MuRF-1) and Transforming Growth Factor-β1 (TGFβ1), three factors associated with muscle catabolism.
Results
Consistent with HIV-1 associated myopathies in humans, HIV-1 transgenic rats had increased relative heart masses, decreased relative masses of soleus, plantaris and gastrocnemius muscles, and decreased total and myosin heavy chain type-specific plantaris muscle fiber areas. In both tissues, the levels of cystine (Cyss), the oxidized form of the anti-oxidant cysteine (Cys), and Cyss:Cys ratios were significantly elevated, and cardiac tissue from HIV-1 transgenic rats had altered glutathione metabolism, all reflective of significant oxidative stress. In HIV-1 transgenic rat hearts, MuRF-1 gene expression was increased. Further, HIV-1-related protein expression also increased atrogin-1 (~14- and ~3-fold) and TGFβ1 (~5-fold and ~3-fold) in heart and plantaris muscle tissues, respectively.
Conclusion
We provide compelling experimental evidence that HIV-1-related proteins can lead to significant cardiac and skeletal muscle complications independently of viral infection or replication. Our data support the concept that HIV-1-related proteins are not merely disease markers, but rather have significant biological activity that may lead to increased oxidative stress, the stimulation of redox-sensitive pathways, and altered muscle morphologies. If correct, this pathophysiological scheme suggests that the use of dietary thiol supplements could reduce skeletal and cardiac muscle dysfunction in HIV-1-infected individuals.

Predictive validity of a brief antiretroviral adherence index: Retrospective cohort analysis under conditions of repetitive administration

2009-07-19T17:55:00.018-07:00

Background
Newer antiretroviral (ARV) agents have improved pharmacokinetics, potency, and tolerability and have enabled the design of regimens with improved virologic outcomes. Successful antiretroviral therapy is dependent on patient adherence. In previous research, we validated a subset of items from the ACTG adherence battery as prognostic of virologic suppression at 6 months and correlated with adherence estimates from the Medication Event Monitoring System (MEMS). The objective of the current study was to validate the longitudinal use of the Owen Clinic adherence index in analyses of time to initial virologic suppression and maintenance of suppression.
Results
278 patients (naïve n = 168, experienced n = 110) met inclusion criteria. Median [range] time on the first regimen during the study period was 286 (30 – 1221) days. 217 patients (78%) achieved an undetectable plasma viral load (pVL) at median 63 days. 8.3% (18/217) of patients experienced viral rebound (pVL > 400) after initial suppression. Adherence scores varied from 0 – 25 (mean 1.06, median 0). The lowest detectable adherence score cut point using this instrument was ≥ 5 for both initial suppression and maintenance of suppression. In the final Cox model of time to first undetectable pVL, controlling for prior treatment experience and baseline viral load, the adjusted hazard ratio for time updated adherence score was 0.36score ≥ 5 (95% CI: 0.19–0.69) [reference: <5]. In the final generalized estimating equations (GEE) logistic regression model the adjusted odds ratio for time-updated adherence score was 0.17score ≥ 5 (0.05&#82
11;0.66) [reference: <5].
Conclusion
A brief, longitudinally administered self report adherence instrument predicted both initial virologic suppression and maintenance of suppression in patients using contemporary ARV regimens. The survey can be used for identification of sub-optimal adherence with subsequent appropriate intervention.

Two specific drugs, BMS-345541 and purvalanol A induce apoptosis of HTLV-1 infected cells through inhibition of the NF-kappaB and cell cycle pathways

2009-07-19T17:55:00.017-07:00

Human T-cell leukemia virus type-1 (HTLV-1) induces adult T-cell leukemia/lymphoma (ATL/L), a fatal lymphoproliferative disorder, and HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP), a chronic progressive disease of the central nervous system after a long period of latent infection. Although the mechanism of transformation and leukemogenesis is not fully elucidated, there is evidence to suggest that the viral oncoprotein Tax plays a crucial role in these processes through the regulation of several pathways including NF-κB and the cell cycle pathways. The observation that NF-κB, which is strongly induced by Tax, is indispensable for the maintenance of the malignant phenotype of HTLV-1 by regulating the expression of various genes involved in cell cycle regulation and inhibition of apoptosis provides a possible molecular target for these infected cells. To develop potential new therapeutic strategies for HTLV-1 infected cells, in this present study
, we initially screened a battery of NF-κB and CDK inhibitors (total of 35 compounds) to examine their effects on the growth and survival of infected T-cell lines. Two drugs namely BMS-345541 and Purvalanol A exhibited higher levels of growth inhibition and apoptosis in infected cell as compared to uninfected cells. BMS-345541 inhibited IKKβ kinase activity from HTLV-1 infected cells with an IC50 (the 50% of inhibitory concentration) value of 50 nM compared to 500 nM from control cells as measured by in vitro kinase assays. The effects of Purvalanol A were associated with suppression of CDK2/cyclin E complex activity as previously shown by us. Combination of both BMS-345541 and Purvalanol A showed a reduced level of HTLV-1 p19 Gag production in cell culture. The apparent apoptosis in these infected cells were associated with increased caspase-3 activity and PARP cleavage. The potent and selective apoptotic effects of these drugs suggest that both BMS-345541 and Pur
valanol A, which target both NF-κB and CDK complex and the G1/S border, might be promising new agents in the treatment of these infected patients.

The prognostic significance of facial lymphoedema in HIV-seropositive subjects with Kaposi sarcoma

2009-07-19T17:55:00.016-07:00

Background
Kaposi Sarcoma (KS) is a multifocal angioproliferative neoplasm characterized by inflammation, oedema, neoangiogenesis and spindle cell proliferation. The pathogenesis of human immunodeficiency virus (HIV)-associated KS (HIV-KS) is multifactorial. HHV-8 is an essential factor but not in itself sufficient to cause HIV-KS, the development of which is influenced by HIV, by increased production of cytokines and by growth factors. Whether HIV-KS is a true malignancy or a reactive hyperplastic inflammatory condition is debatable.
Results and Conclusion
Oedema of the face, legs and hands is a prominent feature of HIV-KS and is probably caused by lymphoedema related to the HIV-KS lesions. The cases of two HIV-seropositive subjects with KS-associated facial lymphoedema are reported. Extensive oral HIV-KS in association with facial oedema in the absence of anti-retroviral treatment appears to be an indication of a poor prognosis.

Fosamprenavir or atazanavir once daily boosted with ritonavir 100 mg, plus tenofovir/emtricitabine, for the initial treatment of HIV infection: 48-week results of ALERT

2009-07-19T17:55:00.015-07:00

Background
Once-daily (QD) ritonavir 100 mg-boosted fosamprenavir 1400 mg (FPV/r100) or atazanavir 300 mg (ATV/r100), plus tenofovir/emtricitabine (TDF/FTC) 300 mg/200 mg, have not been compared as initial antiretroviral treatment. To address this data gap, we conducted an open-label, multicenter 48-week study (ALERT) in 106 antiretroviral-naïve, HIV-infected patients (median HIV-1 RNA 4.9 log10 copies/mL; CD4+ count 191 cells/mm3) randomly assigned to the FPV/r100 or ATV/r100 regimens.
Results
At baseline, the FPV/r100 or ATV/r100 arms were well-matched for HIV-1 RNA (median, 4.9 log10 copies/mL [both]), CD4+ count (mean, 176 vs 205 cells/mm3). At week 48, intent-to-treat: missing/discontinuation = failure analysis showed similar responses to FPV/r100 and ATV/r100 (HIV-1 RNA < 50 copies/mL: 75% (40/53) vs 83% (44/53), p = 0.34 [Cochran-Mantel-Haenszel test]); mean CD4+ count change-from-baseline: +170 vs +183 cells/mm3, p = 0.398 [Wilcoxon rank sum test]). Fasting total/LDL/HDL-cholesterol changes-from-baseline were also similar, although week 48 median fasting triglycerides were higher with FPV/r100 (150 vs 131 mg/dL). FPV/r100-treated patients experienced fewer treatment-related grade 2–4 adverse events (15% vs 57%), with differences driven by ATV-related hyperbilirubinemia. Three patients discontinued TDF/FTC because their GFR decreased to <50 mL/min.
Conclusion
The all-QD regimens of FPV/r100 and ATV/r100, plus TDF/FTC, provided similar virologic, CD4+ response, and fasting total/LDL/HDL-cholesterol changes through 48 weeks. Fewer FPV/r100-treated patients experienced treatment-related grade 2–4 adverse events.

The impact of HIV-associated lipodystrophy on healthcare utilization and costs

2009-07-19T17:55:00.014-07:00

Background
HIV disease itself is associated with increased healthcare utilization and healthcare expenditures. HIV-infected persons with lipodystrophy have been shown to have poor self-perceptions of health. We evaluated whether lipodystrophy in the HIV-infected population was associated with increased utilization of healthcare services and increased healthcare costs.
Objective
To examine utilization of healthcare services and associated costs with respect to presence of lipodystrophy among HIV-infected patients.
Methods
Healthcare utilization and cost of healthcare services were collected from computerized accounting records for participants in a body image study among HIV-infected patients treated at a tertiary care medical center. Lipodystrophy was assessed by physical examination, and effects of lipodystrophy were assessed via body image surveys. Demographic and clinical characteristics were also ascertained. Analysis of healthcare utilization and cost outcomes was performed via between-group analyses. Multivariate modeling was used to determine predictors of healthcare utilization and associated costs.
Results
Of the 181 HIV-infected participants evaluated in the study, 92 (51%) had clinical evidence of HIV-associated lipodystrophy according to physician examination. Total healthcare utilization, as measured by the number of medical center visits over the study period, was notably increased among HIV-infected subjects with lipodystrophy as compared to HIV-infected subjects without lipodystrophy. Similarly, total healthcare expenditures over the study period were $1,718 more for HIV-infected subjects with lipodystrophy than for HIV-infected subjects without lipodystrophy. Multivariate modeling demonstrated strong associations between healthcare utilization and associated costs, and lipodystrophy score as assessed by a clinician. Healthcare utilization and associated costs were not related to body image survey scores among HIV-infected patients with lipodystrophy.
Conclusion
Patients with HIV-associated lipodystrophy demonstrate an increased utilization of healthcare services with associated increased healthcare costs as compared to HIV-infected patients without lipodystrophy. The economic and healthcare service burdens of HIV-associated lipodystrophy are significant and yet remain inadequately addressed by the medical community.

Sub-optimal CD4 reconstitution despite viral suppression in an urban cohort on Antiretroviral Therapy (ART) in sub-Saharan Africa: Frequency and clinical significance

2009-07-19T17:55:00.013-07:00

Background
A proportion of individuals who start antiretroviral therapy (ART) fail to achieve adequate CD4 cell reconstitution despite sustained viral suppression. We determined the frequency and clinical significance of suboptimal CD4 reconstitution despite viral suppression (SO-CD4) in an urban HIV research cohort in Kampala, Uganda
Methods
We analyzed data from a prospective research cohort of 559 patients initiating ART between 04/04–04/05. We described the patterns of SO-CD4 both in terms of:- I) magnitude of CD4 cell increase (a CD4 count increase < 50 CD4 cells/μl at 6 months, <100 cells/μl at 12 months; and <200 cells/μl at 24 months of ART) and II) failure to achieve a CD4 cell count above 200 cells/μl at 6,12 and 24 months of ART. Using criteria I) we used logistic regression to determine the predictors of SO-CD4. We compared the cumulative risk of clinical events (death and/or recurrent or new AIDS-defining illnesses) among patients with and without SO-CD4.
Results
Of 559 patients initiating ART, 386 (69%) were female. Median (IQR) age and baseline CD4 counts were 38 yrs (33–44) and 98 cells/μl (21–163) respectively; 414 (74%) started a d4T-based regimen (D4T+3TC+NVP) and 145 (26%) a ZDV-based regimen (ZDV+3TC+EFV). After 6, 12 and 24 months of ART, 380 (68%), 339 (61%) and 309 (55%) had attained and sustained HIV-RNA viral suppression. Of these, 78 (21%), 151 (45%) and 166 (54%) respectively had SO-CD4 based on criteria I), and 165(43%), 143(42%) and 58(19%) respectively based on criteria II). With both criteria combined, 56 (15%) and 129 (38%) had SO-CD4 at 6 and 12 months respectively. A high proportion (82% and 58%) of those that had SO-CD4 at 6 months (using criteria I) maintained SO-CD4 at 12 and 24 months respectively. There were no statistically significant differences in the incidence of clinical events among patients with [19/100PYO (12–29)] and without SO-CD4 [23/100PYO (19–28)].
Conclusion
Using criteria I), the frequency of SO-CD4 was 21% at 6 months. Majority of patients with SO-CD4 at 6 months maintained SO-CD4 up to 2 years. We recommend studies of CD4 T-cell functional recovery among patients with SO-CD4.

Substitution of the Rev-response element in an HIV-1-based gene delivery system with that of SIVmac239 allows efficient delivery of Rev M10 into T-lymphocytes

2009-07-19T17:55:00.012-07:00

Background
Human immunodeficiency virus type 1 (HIV-1)-based gene delivery systems are popular due to their superior efficiency of transduction of primary cells. However, these systems cannot be readily used for delivery of anti-HIV-1 genes that target constituents of the packaging system itself due to inimical effects on vector titer. Here we describe HIV-1-based packaging systems containing the Rev-response element (RRE), of simian immunodeficiency virus (SIV) in place of the HIV-1 RRE. The SIV RRE-containing packaging systems were used to deliver the anti-Rev gene, Rev M10, into HIV-1 susceptible target cells.
Results
An HIV-1 based packaging system was created using either a 272- or 1045-nucleotide long RRE derived from the molecular clone SIVmac239. The 1045-nucleotide SIV RRE-containing HIV-1 packaging system provided titers comparable to that of the HIV-1 RRE-based one. Moreover, despite the use of HIV-1 Rev for production of vector stocks, this packaging system was found to be relatively refractory to the inhibitory effects of Rev M10. Correspondingly, the SIV RRE-based packaging system provided 34- to 130-fold higher titers than the HIV-1 RRE one when used for packaging a gene transfer vector encoding Rev-M10. Jurkat T-cells, gene modified with Rev M10 encoding HIV-1 vectors, upon challenge with replication defective HIV-1 in single-round infection experiments, showed diminished production of virus particles.
Conclusion
A simple modification of an HIV-1 gene delivery system, namely, replacement of HIV-1 RRE with that of SIV, allowed efficient delivery of Rev M10 transgene into T-cell lines for intracellular immunization against HIV-1 replication.

Imbalanced effector and regulatory cytokine responses may underlie mycobacterial immune restoration disease

2009-07-19T17:55:00.011-07:00

Background
Immune restoration disease (IRD) is an adverse consequence of antiretroviral therapy, where the restored pathogen-specific response causes immunopathology. Mycobacteria are the pathogens that most frequently provoke IRD and mycobacterial IRD is a common cause of morbidity in HIV-infected patients co-infected with mycobacteria. We hypothesised that the excessive effector immune response in mycobacterial IRD reflects impaired regulation by IL-10.
Results
We studied two patients who experienced mycobacterial IRD during ART. One patient developed a second episode of IRD with distinct clinical characteristics. Findings were compared with patients 'at risk' of developing IRD who had uneventful immune recovery. Peripheral blood mononuclear cells (PBMC) from all subjects were stimulated with mycobacterial antigens in the form of purified protein derivative (PPD). Supernatants were assayed for IFNγ and IL-10. In response to PPD, PBMC from IRD patients generated IFNγ during the first IRD episode, whilst cells from non-IRD controls produced more IL-10.
Conclusion
We present preliminary data from two HIV-infected patients showing an imbalance between IFNγ and IL-10 responses to mycobacterial antigens during mycobacterial IRD. Our findings suggest that imbalanced effector and regulatory cytokine responses should be investigated as a cause of IRD.

The Iranian female high school students' attitude towards people with HIV/AIDS: a cross-sectional study

2009-07-19T17:55:00.010-07:00

Background
Acquired Immunodeficiency Syndrome (AIDS) has become an important public health hazard in Iran. It is believed that AIDS-related knowledge does not necessarily translate into behavior modification. Hence, it has been suggested that culturally appropriate educational campaigns should be implemented to obtain satisfactory outcomes. Here, we evaluated the female high school students' attitude towards HIV/AIDS in Tabriz, Iran to assess the cultural needs for the related educational programs and to discover sources of information about AIDS.
Results
Anonymous, self-administered questionnaires were filled by the young female students. Among 300 students, 91% agreed that being an HIV carrier should not be an obstacle to obtaining education and employment. Moreover, 72.5% of the students declared that the community should be informed of HIV-positive people. In addition, one-tenth declared that they would feel extremely uncomfortable towards their HIV infected classmate. In addition, only 16% of the students stated that they would continue to shop at HIV infected grocer's store. The mass media and the experts were the major source and the most reliable source of information about AIDS, respectively.
Conclusion
Tabrizian female students have overall negative attitudes towards HIV/AIDS. HIV/AIDS related educational campaigns should target the students, society and the families with emphasizing the leading roles of health staff.

Prevalence of reverse transcriptase and protease mutations associated with antiretroviral drug resistance among drug-na?ve HIV-1 infected pregnant women in Kagera and Kilimanjaro regions, Tanzania

2009-07-19T17:55:00.009-07:00

Background
Access to antiretroviral drugs for HIV-1 infection has increased in sub-Saharan Africa (SSA) during the past few years. Mutations in the HIV-1 genome are often associated with treatment failure as indicated by viral replication and elevated levels of virus in the blood. Mutations conferring resistance to antiretroviral drugs are based on comparing gene sequences with corresponding consensus sequences of HIV-1 subtype B that represents only 10% of the AIDS pandemic. The HIV pandemic in SSA is characterized by high viral genetic diversity. Before antiretroviral drugs become more widely available, it is important to characterize baseline naturally occurring genetic mutations and polymorphisms associated with antiretroviral drug resistance among circulating HIV-1 subtypes.
Methods
The prevalence of mutations associated with antiretroviral drug resistance in protease (PR) and reverse transcriptase (RT) regions among antiretroviral treatment-naïve HIV-1 infected pregnant women was investigated in Bukoba (Kagera) and Moshi (Kilimanjaro) municipalities, Tanzania, between September and December 2005. The HIV-1 pol gene was amplified using primers recognizing conserved viral sequences and sequenced employing BigDye chemistry from 100 HIV-1 seropositive treatment-naïve pregnant women and 61 HIV-1 seropositive women who had received a single dose of Nevirapine (sdNVP). Positions 1–350 of the RT and 1–99 of the PR genes were analyzed for mutations based on the Stanford University HIV Drug Resistance Database.
Results
HIV-1 subtypes A, C, D, CRF10_CD and Unique Recombinant Forms (URF) were detected. Primary mutations associated with NRTI and NNRTI resistance were detected among 3% and 4% of treatment-naïve strains, respectively. Primary mutations associated with NRTI and NNRTI resistance were detected in 1.6% and 11.5% of women who had received sdNVP, respectively. None of the primary mutations associated with PI resistance was found. Polymorphisms detected in RT and PR sequences were mainly mutations that are found in the consensus sequences of non-B subtypes
Conclusion
Based on the WHO HIV Drug Resistance Research Network Threshold of less than 5%, the baseline prevalence of primary mutations among treatment-naïve HIV-1 infected pregnant women in Kagera and Kilimanjaro regions was low. The significance of HIV-1 subtype B polymorphic positions with respect to antiretroviral resistance identified among the prevalent HIV-1 subtypes is unknown. More studies addressing the correlation between polymorphic mutations, antiretroviral resistance and clinical outcome are warranted in regions where non-B subtypes are prevalent.

The intracellular detection of MIP-1beta enhances the capacity to detect IFN-gamma mediated HIV-1-specific CD8 T-cell responses in a flow cytometric setting providing a sensitive alternative to the ELISPOT

2009-07-19T17:55:00.008-07:00

Background
T-cell mediated immunity likely plays an important role in controlling HIV-1 infection and progression to AIDS. Several candidate vaccines against HIV-1 aim at stimulating cellular immune responses, either alone or together with the induction of neutralizing antibodies, and assays able to measure CD8 and CD4 T-cell responses need to be implemented. At present, the IFN-γ-based ELISPOT assay is considered the gold standard and it is broadly preferred as primary assay for detection of antigen-specific T-cell responses in vaccine trials. However, in spite of its high sensitivity, the measurement of the sole IFN-γ production provides limited information on the quality of the immune response. On the other hand, the introduction of polychromatic flow-cytometry-based assays such as the intracellular cytokine staining (ICS) strongly improved the capacity to detect several markers on a single cell level.
Results
The cumulative analysis of 275 samples from 31 different HIV-1 infected individuals using an ICS staining procedure optimized by our laboratories revealed that, following antigenic stimulation, IFN-γ producing T-cells were also producing MIP-1β whereas T-cells characterized by the sole production of IFN-γ were rare. Since the analysis of the combination of two functions decreases the background and the measurement of the IFN-γ+ MIP-1β+ T-cells was equivalent to the measurement of the total IFN-γ+ T-cells, we adopted the IFN-γ+ MIP-1β+ data analysis system to evaluate IFN-γ-based, antigen-specific T-cell responses. Comparison of our ICS assay with ELISPOT assays performed in two different experienced laboratories demonstrated that the IFN-γ+ MIP-1β+ data analysis system increased the sensitivity of the ICS up to levels comparable to the sensitivity of the ELISPOT assay.
Conclusion
The IFN-γ+ MIP-1β+ data evaluation system provides a clear advantage for the detection of low magnitude HIV-1-specific responses. These results are important to guide the choice for suitable highly sensitive immune assays and to build reagent panels able to accurately characterize the phenotype and function of responding T-cells. More importantly, the ICS assay can be used as primary assay to evaluate HIV-1-specific responses without losing sensitivity in comparison to the ELISPOT assay.

HIV-2 diagnosis and quantification in high-risk patients

2009-07-19T17:55:00.007-07:00

Current diagnostic assays for HIV-1 do not always test for the presence of HIV-2 in the United States. We present the case of a patient from Cape Verde, who was admitted to our hospital with rapidly deteriorating neurological function and multiple white matter lesions on MRI likely secondary to progressive multifocal leukoencephalopathy (PML). Initially, the patient had a positive EIA for HIV, but a negative HIV-1 Western Blot and no viral load detected on a branched-DNA assay. A repeat viral load by reverse transcriptase methodology (RT-DNA) detected 121,000 copies and an HIV-2 Western Blot was positive. The case highlights an extremely rare presentation of HIV-2 with severe neurological disease. We discuss the different tests available for the diagnosis and monitoring of HIV-2 in the United States.

Significant improvements in self-reported gastrointestinal tolerability, quality of life, patient satisfaction, and adherence with lopinavir/ritonavir tablet formulation compared with soft gel capsules

2009-07-19T17:55:00.005-07:00

Background
The tablet formulation of ritonavir-boosted lopinavir (LPV/r; Kaletra®) has many advantages over the soft gel capsule (SGC) formulation, including lower pill count, no refrigeration requirement, and no dietary restrictions. These advantages may help improve patient compliance and therefore increase adherence to treatment. However, there are limited data regarding patient preferences and only recently was the comparative efficacy and tolerability data of LPV/r SGC versus tablet formulation presented at an international conference. To address this deficit, we conducted a market research survey to assess potential tolerability benefits, patient satisfaction, changes in adherence, and formulation preference in patients switching from SGCs to the tablet formulation. Data from 332 patients who switched from LPV/r SGCs twice-daily (BID) to tablets BID and 41 patients who switched from LPV/r SGCs BID or once daily (QD) to tablets QD were analyzed.
Results
Switching from SGCs to a tablet formulation of LPV/r was associated with increased patient satisfaction, tolerability and self-reported adherence to treatment; gastrointestinal side effects were reduced. In addition, respondents indicated that they preferred the tablet formulation to the SGC.
Conclusion
The LPV/r tablet formulation provides HIV-infected patients with multiple benefits over the SGC in terms of tolerability and convenience. Additional assessments to further define the tolerability profile of the LPV/r tablet, including studies using once-daily dosing, are warranted.

Human embryonic stem cell (hES) derived dendritic cells are functionally normal and are susceptible to HIV-1 infection

2009-07-19T17:55:00.003-07:00

Background
Human embryonic stem (hES) cells hold considerable promise for cell replacement and gene therapies. Their remarkable properties of pluripotency, self-renewal, and tractability for genetic modification potentially allows for the production of sizeable quantities of therapeutic cells of the hematopoietic lineage. Dendritic cells (DC) arise from CD34+ hematopoietic progenitor cells (HPCs) and are important in many innate and adaptive immune functions. With respect to HIV-1 infection, DCs play an important role in the efficient capture and transfer of the virus to susceptible cells. With an aim of generating DCs from a renewable source for HIV-1 studies, here we evaluated the capacity of hES cell derived CD34+ cells to give rise to DCs which can support HIV-1 infection.
Results
Undifferentiated hES cells were cultured on S17 mouse bone marrow stromal cell layers to derive CD34+ HPCs which were subsequently grown in specific cytokine differentiation media to promote the development of DCs. The hES derived DCs (hES-DC) were subjected to phenotypic and functional analyses and compared with DCs derived from fetal liver CD34+ HPC (FL-DC). The mature hES-DCs displayed typical DC morphology consisting of veiled stellate cells. The hES-DCs also displayed characteristic phenotypic surface markers CD1a, HLA-DR, B7.1, B7.2, and DC-SIGN. The hES-DCs were found to be capable of antigen uptake and stimulating naïve allogeneic CD4+ T cells in a mixed leukocyte reaction assay. Furthermore, the hES-DCs supported productive HIV-1 viral infection akin to standard DCs.
Conclusion
Phenotypically normal and functionally competent DCs that support HIV-1 infection can be derived from hES cells. hES-DCs can now be exploited in applied immunology and HIV-1 infection studies. Using gene therapy approaches, it is now possible to generate HIV-1 resistant DCs from anti-HIV gene transduced hES-CD34+ hematopoietic progenitor cells.

Summary of presentations at the NIH/NIAID New Humanized Rodent Models 2007 Workshop

2009-07-19T17:55:00.001-07:00

It has long been recognized that a small animal model susceptible to HIV-1 infection with a functional immune system would be extremely useful in the study of HIV/AIDS pathogenesis and for the evaluation of vaccine and therapeutic strategies to combat this disease. By early 2007, a number of reports on various rodent models capable of being infected by and responding to HIV including some with a humanized immune system were published. The New Humanized Rodent Model Workshop, organized by the Division of AIDS (DAIDS), National Institute Allergy and Infection Diseases (NIAID), NIH, was held on September 24, 2007 at Bethesda for the purpose of bringing together key model developers and potential users. This report provides a synopsis of the presentations that discusses the current status of development and use of rodent models to evaluate the pathogenesis of HIV infection and to assess the efficacy of vaccine and therapeutic strategies including microbicides to prevent and/or tr
eat HIVinfection.

Prescribing and using self-injectable antiretrovirals: How concordant are physician and patient perspectives?

2009-07-19T17:40:00.009-07:00

Background
The selection of agents for any treatment regimen is in part influenced by physician and patient attitudes. This study investigated attitudinal motivators and barriers to the use of self-injectable antiretroviral agents among physicians and patients and measured the degree of concordance between physician and patient perspectives.
Methods
Attitudes toward prescribing and usage of self-injectable antiretroviral therapy (SIAT) were assessed by structured interview in 2 cohorts sampled from the European Union and the USA: 499 HIV-treating physicians and 603 treatment-experienced HIV-infected patients. Motivators and barriers to prescribing SIAT were identified from statistical analysis of the associations between physicians' ratings of enfuvirtide-based therapy compared to standard oral-based therapy and 2 indicators of enfuvirtide prescribing behavior. Patients' attitudes were assessed by their responses to a written profile of enfuvirtide and their ratings of the likelihood of accepting a treatment offer.
Results
Both indicators of SIAT prescribing behavior were predicted by the same pattern of physician beliefs. Nonprescribing was associated with: (1) the belief that offering enfuvirtide would be perceived negatively by patients, leading to treatment refusal and nonadherence; (2) the belief that prescribing enfuvirtide is harder to justify in terms of time/resources; and (3) a lack of confidence in the efficacy and use of enfuvirtide in practice (all p < 0.05). However, physicians' beliefs were not in concordance with patients' views. After reading a profile of enfuvirtide, 76% patients said that they would be moderately or highly likely to accept a treatment offer, although most (72%) had not discussed enfuvirtide with their doctor. Patients' beliefs predicted the likelihood of accepting enfuvirtide.
Conclusion
Physician and patient beliefs about SIAT influence prescribing behavior and compliance yet may not be concordant, with patients having more positive attitudes towards SIAT than anticipated by physicians.

Comparative study of the persistence of anti-HIV activity of deoxynucleoside HIV reverse transcriptase inhibitors after removal from culture

2009-07-19T17:40:00.008-07:00

Background
Most in vitro assays of drug potency may not adequately predict the performance in vivo. Methods to assess the persistence of antiviral activity of deoxynucleoside analogs, which require intracellular activation to the active metabolites that can persist in cells, will be important for designing dosages, combination regimens, and assessing treatment compliance. Using an HIV-IIIB/TZM-bl indicator cell culture system, we assessed the ability of an inhibitor to protect cells from infection and to delay viral rebound after removal of inhibitor from culture.
Results
The order of protection of cells from HIV-infection was 4'-Ed4T > LFD4C > DDI > D4T > 3TC > AZT > FTC > NVP. The fold-increase in EC50 to delay viral rebound was DDI < 4'-Ed4T < LFD4C < FTC < D4T < 3TC < NVP < AZT. The ranking of persistence of anti-HIV activity of the inhibitors based on the two-component assay was DDI > 4'-Ed4T > LFD4C > FTC = D4T > 3TC > NVP > AZT.
Conclusion
The persistence ranking was derived from assays based on measures of single viral replication-cycle and cumulative inhibition at multiple time-points. Therefore, a better indicator of the pharmacodynamic property of an inhibitor. The persistence of anti-HIV activity assay may complement in vitro potency assays to better predict in vivo performance of nucleoside analogs.

Adherence to anti-retroviral therapy among HIV patients in Bangalore, India

2009-07-19T17:40:00.007-07:00

Introduction
Human Immunodeficiency Virus (HIV) has an estimated prevalence of 0.9% in India (5.2 million). Anti-retroviral drugs (ARV) are the treatments of choice and non-adherence is an important factor in treatment failure and development of resistance, as well as being a powerful predictor of survival. This study assesses adherence to ARV in HIV positive patients in Bangalore, India, a country where only 10% of those who need therapy are receiving it.
Methods
A cross-sectional anonymous questionnaire survey of 60 HIV antibody positive patients was carried out with patients attending HIV outpatient services at two centres: The Chest and Maternity Centre, Rajajinagar, and Wockhardt Hospital and Heart Institute, Bangalore. Consent was obtained. Translation was done by a translator and doctors where required. Data was analysed using SPSS statistical analysis.
Results
A response rate of 88% (53/60) was achieved. The mean patient age was 39.98 years, with 50% aged 30–40, and 73.6% of participants being male. Mean family size was 4.8 (1–13). 21% lived less than 50 kms and 21% greater than 400 kms from clinic.
60% reported they were fully adherent. Adherence was statistically significantly linked to regular follow-up attendance (70.5%, p = 0.002). No other results were statistically significant but trends were found. "100% adherence" trends were seen in older patients, male gender, those from larger families, those who had a previous AIDS defining illness, those taking fewer tablets, and without food restrictions. Commonest side-effects causing non-adherence were metabolic reasons (66%) and GI symptoms (50%). No trends were seen for education level, family income, distance travelled to clinic, time since diagnosis, or time on ART.
Conclusion
Regular attendance for follow up was statistically significant for 100% lifetime adherence. Positive trends were seen in those in larger families, older, those who had AIDS defining illness, simple regimes, and without side-effects. Education, income, distance travelled and length of time diagnosed or treated had no effect on adherence.

Fat distribution and longitudinal anthropometric changes in HIV-infected men with and without clinical evidence of lipodystrophy and HIV-uninfected controls: A substudy of the Multicenter AIDS Cohort Study

2009-07-19T17:40:00.006-07:00

Background
Fat abnormalities are common among HIV-infected persons, but few studies have compared regional body fat distribution, including visceral fat, in HIV-infected and HIV-uninfected persons and their subsequent trajectories in body composition over time.
Methods
Between 1999 and 2002, 33 men with clinical evidence of lipodystrophy (LIPO+), 23 HIV-infected men without clinical evidence of lipodytrophy (LIPO-), and 33 HIV-uninfected men were recruited from the four sites of the Multicenter AIDS Cohort Study (MACS). Participants underwent dual-energy x-ray absorptiometry, quantitative computerized tomography of the abdomen and thigh, and circumference measurements of the waist, hip and thigh. Circumference measurements at each semi-annual MACS visit between recruitment and 2008 were used to compare average annual anthropometric changes in the 3 groups.
Results
Body mass index (BMI) was lower in LIPO+ men than in the LIPO- men and the HIV- uninfected controls (BMI: 23.6 ± 0.4 vs 26.8 ± 1.5 vs 28.7 ± 0.9 kg/m2, respectively, p < 0.001). The average amount of visceral adipose tissue (VAT) was similar in all three groups (p = 0.26), but after adjustment for BMI, VAT was higher in the LIPO+ group (169 ± 10 cm2) compared to the LIPO- men (129 ± 12 cm2, p = 0.03) and the HIV-uninfected group (133 ± 11 cm2, p = 0.07). Subcutaneous adipose tissue (thigh, abdomen) and total extremity fat were less in the HIV-infected men (LIPO+ and LIPO-) than in the HIV-uninfected men. Over an average of 6 years of follow-up, waist circumference increased at a faster rate in LIPO+ group, compared to the LIPO- men (0.51 cm/year vs 0.08 cm/year, p = 0.02) and HIV-uninfected control men (0.21 cm/year, p = 0.06). The annual changes in hip and thigh circumferences were similar in all three groups
Conclusion
Subcutaneous lipoatrophy was observed in HIV-infected patients, even those without clinical evidence of lipodystrophy, compared to age-matched HIV-uninfected men. Despite markedly lower BMI, HIV-infected men with lipodystrophy had a similar amount of VAT as HIV-uninfected men and tended to have more rapid increases in waist circumference over 6 years of follow-up. These longitudinal increases in waist circumference may contribute to the development of cardiovascular risk in HIV-infected patients with lipodystrophy.

HIV-1 transgene expression in rats causes oxidant stress and alveolar epithelial barrier dysfunction

2009-07-19T17:40:00.005-07:00

Background
HIV-infected individuals are at increased risk for acute and chronic airway disease even though there is no evidence that the virus can infect the lung epithelium. Although HIV-related proteins including gp120 and Tat can directly cause oxidant stress and cellular dysfunction, their effects in the lung are unknown. The goal of this study was to determine the effects of HIV-1 transgene expression in rats on alveolar epithelial barrier function. Alveolar epithelial barrier function was assessed by determining lung liquid clearance in vivo and alveolar epithelial monolayer permeability in vitro. Oxidant stress in the alveolar space was determined by measuring the glutathione redox couple by high performance liquid chromatography, and the expression and membrane localization of key tight junction proteins were assessed. Finally, the direct effects of the HIV-related proteins gp120 and Tat on alveolar epithelial barrier formation and tight junction protein expression were determin
ed.
Results
HIV-1 transgene expression caused oxidant stress within the alveolar space and impaired epithelial barrier function even though there was no evidence of overt inflammation within the airways. The expression and membrane localization of the tight junction proteins zonula occludens-1 and occludin were decreased in alveolar epithelial cells from HIV-1 transgenic rats. Further, treating alveolar epithelial monolayers from wild type rats in vitro with recombinant gp120 or Tat for 24 hours reproduced many of the effects on zonula occludens-1 and occludin expression and membrane localization.
Conclusion
Taken together, these data indicate that HIV-related proteins cause oxidant stress and alter the expression of critical tight junction proteins in the alveolar epithelium, resulting in barrier dysfunction.

Is vitamin D deficiency involved in the immune reconstitution inflammatory syndrome?

2009-07-19T17:40:00.004-07:00

Background
About 20–30% of persons with HIV infection, especially those living in countries with limited resources, experience an immune reconstitution inflammatory syndrome (IRIS) after starting antiretroviral treatment. The active form of vitamin D, 1,25-dihydroxyvitamin D, is a key player in the clearance of pathogens and influences the level of inflammation and macrophage activation.
Presentation of the hypothesis
We hypothesize that low availability of 1,25-dihydroxyvitamin D, either due to vitamin D deficiency or due to polymorphisms in the vitamin D receptor or in its activating/inactivating enzymes, contributes to the appearance of IRIS. Furthermore, drug interactions with the enzymatic pathways of vitamin D could favour the development of IRIS.
Testing the hypothesis
Our hypothesis could be explored by a case-control study to assess the prevalence of vitamin D deficiency in HIV-infected patients on antiretroviral treatment who develop and do not develop IRIS.
Implications of the hypothesis
If the role of vitamin D in IRIS is confirmed, we would be able to screen patients at risk for IRIS by screening for vitamin D deficiency. After confirmation by means of a clinical trial, vitamin D supplementation could be a cheap and safe way to reduce the incidence of IRIS.

A randomized, controlled trial of initial anti-retroviral therapy with abacavir/lamivudine/zidovudine twice-daily compared to atazanavir once-daily with lamivudine/zidovudine twice-daily in HIV-infected patients over 48 weeks (ESS100327, the ACTION Study)

2009-07-19T17:40:00.003-07:00

Background
Traditional first line regimens containing a non-nucleoside reverse transcriptase inhibitor or protease inhibitor may not be suitable for a subset of antiretroviral-naïve patients such as those with certain co-morbidities, women of child-bearing potential, and intolerability to components of standard first line therapy. This study was conducted to determine if alternate treatment options may meet the needs of both general and special patient populations. The ACTION study was a randomized, open-label, multicenter, 48-week trial that compared the safety and efficacy of a triple nucleoside regimen versus a protease inhibitor plus a dual nucleoside regimen in HIV-1 treatment-naïve subjects.
Results
279 HIV-infected subjects with HIV-1 RNA (VL) >5000 but < 200,000 copies/mL (c/mL) and CD4+ count ≥ 100 cells/mm3 were randomized (1:1) to receive abacavir sulfate/lamivudine/zidovudine (ABC/3TC/ZDV) twice-daily or atazanavir (ATV) once-daily plus lamivudine/zidovudine (3TC/ZDV) twice-daily. Protocol-defined virologic failure was based on multiple failure criteria.
Non-inferiority of ABC/3TC/ZDV to ATV+3TC/ZDV was established with 62% vs. 59% of subjects achieving a VL < 50 c/mL at week 48, [ITT(E), M/S = F, 95% CI: -5.9, 10.4]. Similar results were observed in the 230 (82%) subjects with baseline VL<100,000 c/mL (ABC/3TC/ZDV vs. ATV+3TC/ZDV), 66% vs. 59%; 95% CI: -5.6, 19.5. However, ABC/3TC/ZDV did not meet the non-inferiority criterion compared to ATV+3TC/ZDV in the 48 subjects with baseline VL ≥ 100,000 c/mL, 39% vs. 60%; 95% CI: -49.2, 7.4, respectively. Protocol-defined virologic failure was similar between groups.
Conclusion
ABC/3TC/ZDV demonstrated comparable virologic efficacy to ATV+3TC/ZDV in this population over 48 weeks. In those with a baseline VL ≥ 100,000 c/mL, subjects in the ATV+3TC/ZDV showed better virologic efficacy. Both regimens offer benefits in select therapy-naïve subjects.
Trial Registration
[Clinical Trials Identifier, NCT00082394].

Ankle-brachial index in HIV infection

2009-07-19T17:40:00.001-07:00

Prognosis for patients with the human immunodeficiency virus (HIV) has improved with the introduction of highly active antiretroviral therapy (HAART). Evidence over recent years suggests that the incidence of cardiovascular disease is increasing in HIV patients. The ankle-brachial index (ABI) is a cheap and easy test that has been validated in the general population. Abnormal ABI values are associated with increased cardiovascular mortality. To date, six series of ABI values in persons with HIV have been published, but none was a prospective study. No agreement exists concerning the risk factors for an abnormal ABI, though its prevalence is clearly higher in these patients than in the general population. Whether this higher prevalence of an abnormal ABI is associated with a higher incidence of vascular events remains to be determined.

Recommendations on the use of recombinant activated factor VII as an adjunctive treatment for massive bleeding – a European perspective

2009-07-14T22:05:00.003-07:00

Abstract
Introduction
Our aim was to develop consensus guidelines for use of recombinant activated factor VII (rFVIIa) in massive hemorrhage.

Methods
A guidelines committee derived the recommendations using clinical trial and case series data identified through searches of available databases. Guidelines were graded on a scale of A to E (with A being the highest) according to the strength of evidence available. Consensus was sought among the committee members for each recommendation.

Results
A recommendation for the use of rFVIIa in blunt trauma was made (grade B). rFVIIa might also be beneficial in post-partum hemorrhage (grade E), uncontrolled bleeding in surgical patients (grade E), and bleeding after cardiac surgery (grade D). rFVIIa could not be recommended for use in the following: in penetrating trauma (grade B); prophylactically in elective surgery (grade A) or liver surgery (grade B); or in bleeding episodes in patients with Child–Pugh A cirrhosis (grade B). Efficacy of rFVIIa was considered uncertain in bleeding episodes in patients with Child–Pugh B and C cirrhosis (grade C). Monitoring of rFVIIa efficacy should be performed visually and by assessment of transfusion requirements (grade E), while thromboembolic adverse events are a cause for concern. rFVIIa should not be administered to patients considered unsalvageable by the treating medical team.

Conclusion
There is a rationale for using rFVIIa to treat massive bleeding in certain indications, but only adjunctively to the surgical control of bleeding once conventional therapies have failed. Lack of data from randomized, controlled clinical trials, and possible publication bias of the case series data, limits the strength of the recommendations that can be made.

Introduction
This study is endorsed by the European Society of Anaesthesiology (ESA), the European Society of Intensive Care Medicine (ESICM), the European Society for Emergency Medicine (EuSEM), the European Resuscitation Council (ERC), the European Haematology Association (EHA) and the European Association of Trauma and Emergency Surgery (EATES).

Uncontrolled massive hemorrhage is an important cause of morbidity and mortality. In patients with traumatic injury, it is second only to injuries to the central nervous system as the most common cause of death in the prehospital setting [1,2], and is the primary cause of early in-hospital (first 48 hours) mortality due to trauma [3]. In patients with liver disease, severe upper gastrointestinal (UGI) bleeding is fatal in about 30% of cases [4], whereas in patients undergoing open heart surgery, coagulopathic bleeding has been shown to increase both morbidity and mortality [5].

Massive hemorrhage is often characterized by a surgical or vascular component and a coagulopathic component. The surgical/vascular component can be corrected by surgical intervention or embolization. However, coagulopathic bleeding is more difficult to control. Coagulopathy arises through several interrelated mechanisms, which include the consumption of coagulation factors and platelets through repeated attempts to form clots during massive hemorrhage, the dilution of coagulation factors as a result of fluid resuscitation, and metabolic disorders (hypothermia or acidosis), which can affect the coagulation process [6]. Together with acidosis and hypothermia, coagulopathy forms the so-called 'lethal triad' in trauma, because of associated high mortality rates [7].

Conventional treatment options for coagulopathic/diffuse bleeding include fluid replacement (crystalloids and colloids) to maintain circulating volume, and the use of blood products such as red blood cells (RBCs), fresh frozen plasma (FFP), cryoprecipitate or fibrinogen, and platelets to replace the blood components lost during hemorrhage. However, attempts at resuscitation with large volumes of intravenous fluids can lead to an exacerbation of coagulopathy and may fail to arrest bleeding [8]. Furthermore, the use of blood products is associated with an increase in the risk of infections [9] and complications such as multiple organ failure and acute respiratory distress syndrome [10], which may result in increased mortality and morbidity [11,12].

The limitations of replacement therapy suggest the need for additional approaches to the treatment of coagulopathic bleeding. Hemostatic agents offer some promise as adjunctive therapy to be used with current treatments, but there are limited clinical trial data. Recombinant activated factor VII (rFVIIa, NovoSeven®; Novo Nordisk, Copenhagen, Denmark) may be useful in the treatment of coagulopathic bleeding. However, rFVIIa is currently approved worldwide only for the treatment of bleeding in patients with hemophilia A or B with inhibitors to coagulation factors VIII or IX [13]. In Europe, it is also approved for factor VII deficiency and Glanzmann's thrombasthenia in patients who are refractory to platelet transfusions, but it is not currently approved as an adjunctive treatment for massive or coagulopathic bleeding in any country.

In cases of injury, tissue factor (TF) is brought into contact with naturally occurring FVIIa, which is normally present in minute quantities, to initiate the coagulation pathway [14,15]. At pharmacological, supraphysiological doses, rFVIIa is able to bind to activated platelets at the site of injury and activate factors IX and X directly, leading to a thrombin burst [16]. As platelets are activated only at sites of TF exposure, it is believed that the action of rFVIIa is therefore localized to these sites. Nevertheless, a primary concern of treatment with rFVIIa is the possibility of an increased incidence of thrombotic adverse events, arising from a systemic activation of the coagulation pathway or from TF exposure at sites not associated with tissue injury, such as unstable coronary plaques [17].

rFVIIa is increasingly being used on a compassionate use basis [18]. However, there is no clear guidance on which patients are suitable for treatment, the appropriate timing of rFVIIa administration, and the most appropriate dose of rFVIIa to use. Although there are several ongoing Phase III clinical trials (see Additional file 1), the results will not be available for several years. Guidelines might therefore help to ensure that physicians receive appropriate guidance on the use of rFVIIa. This might be important when considering the potential costs, safety concerns and the risk of unpredictable adverse events, as well as the risks of overuse or inappropriate use associated with this treatment. In addition, published guidelines may help to protect physicians from the suggestions of substandard care when opting not to use rFVIIa in massive bleeding because of the lack of formally approved indications, and may also offer help with reimbursement when linked to the appropriate use of drugs not currently available on the open market.

Active management of the third stage of labour without controlled cord traction: a randomized non-inferiority controlled trial

2009-07-14T22:05:00.001-07:00

Abstract
Background
The third stage of labour refers to the period between birth of the baby and complete expulsion of the placenta. Some degree of blood loss occurs after the birth of the baby due to separation of the placenta. This period is a risky period because uterus may not contract well after birth and heavy blood loss can endanger the life of the mother. Active management of the third stage of labour (AMTSL) reduces the occurrence of severe postpartum haemorrhage by approximately 60–70%. Active management consists of several interventions packaged together and the relative contribution of each of the components is unknown. Controlled cord traction is one of those components that require training in manual skill for it to be performed appropriately. If it is possible to dispense with controlled cord traction without losing efficacy it would have major implications for effective management of the third stage of labour at peripheral levels of health care.

Objective
The primary objective is to determine whether the simplified package of oxytocin 10 IU IM/IV is not less effective than the full AMTSL package.

Methods
A hospital-based, multicentre, individually randomized controlled trial is proposed. The hypothesis tested will be a non-inferiority hypothesis. The aim will be to determine whether the simplified package without CCT, with the advantage of not requiring training to acquire the manual skill to perform this task, is not less effective than the full AMTSL package with regard to reducing blood loss in the third stage of labour.

The simplified package will include uterotonic (oxytocin 10 IU IM) injection after delivery of the baby and cord clamping and cutting at approximately 3 minutes after birth. The full package will include the uterotonic injection (oxytocin 10 IU IM), controlled cord traction following observation of uterine contraction and cord clamping and cutting at approximately 3 minutes after birth. The primary outcome measure is blood loss of 1000 ml or more at one hour and up to two hours for women who continue to bleed after one hour. The secondary outcomes are blood transfusion, the use of additional uterotonics and measure of severe morbidity and maternal death.

We aim to recruit 25,000 women delivering vaginally in health facilities in eight countries within a 12 month recruitment period.

Management
Overall trial management will be from HRP/RHR in Geneva. There will be eight centres located in Argentina, Egypt, India, Kenya, Philippines, South Africa, Thailand and Uganda. There will be an online data entry system managed from HRP/RHR. The trial protocol was developed following a technical consultation with international organizations and leading researchers in the field.

Expected outcomes
The main objective of this trial is to investigate whether a simplified package of third stage management can be recommended without increasing the risk of PPH. By avoiding the need for a manual procedure that requires training, the third stage management can be implemented in a more widespread and cost-effective way around the world even at the most peripheral levels of the health care system. This trial forms part of the programme of work to reduce maternal deaths due to postpartum haemorrhage within the RHR department in collaboration with other research groups and organizations active in the field.

Trial Registration
ACTRN12608000434392

Background
The third stage of labour refers to the period between birth of the baby and complete expulsion of the placenta. Some degree of blood loss occurs after the birth of the baby due to separation of the placenta. This period is a risky period because uterus may not contract well after birth and heavy blood loss can endanger the life of the mother.

The third stage of labour is managed differently around the world. Over the years two management packages, known as 'active management' and 'expectant management' emerged. The primary aim of active management is to reduce postpartum blood loss as a preventive intervention. In active management (AMTSL) a number of interventions are applied in combination while the expectant management represents a more hands-off style with those interventions used in AMTSL withheld. AMTSL has been defined in various ways and current international definition comprises three components: administration of an uterotonic soon after delivery of the baby; controlled cord traction; and uterine massage after delivery of the placenta [1]. Active management of the third stage of labour (AMTSL) reduces the occurrence of severe postpartum haemorrhage by approximately 60–70% [2].

In previous active versus expectant trials the cord was clamped as soon as possible usually within one minute. However, trials of cord clamping timing have shown beneficial effects on newborn haematological indices leading to the recommendation to clamp the cord at around 3 minutes although the effects on the mother are unknown [3].

The WHO PPH Prevention Guidelines published in 2007 recommended AMTSL defined as the use of oxytocin 10 IU IM/IV after birth, cord clamping at around 3 minutes when the uterus contracts and controlled cord traction. There were no recommendations related to the use of uterine massage in this guideline.

Unfortunately, the relative contribution of the components of AMTSL to the overall reduction in blood loss is not clearly known. Understanding the contribution of the components of AMTSL to the overall effect in reducing the incidence of haemorrhage could have major programmatic significance since some components require training while others require an efficient drug procurement and utilization system [4]. At the same time the probability of interaction between AMTSL components should be kept in mind.

These considerations led to a technical consultation of scientists working in the field of postpartum haemorrhage research in December 2007 to discuss work on a research project to evaluate the effects of different components of AMTSL. Such research is important and timely because some components such as the uterotonic and controlled cord traction may not be feasible in all settings and it is worthwhile evaluating a more simple package with fewer components.

Systematic reviews of effects of AMTSL components
Uterotonic
The uterotonic component of AMTSL seems to be important for the reduction in blood loss after delivery [5]. Two trials compared oxytocin to nothing without other active management components practiced [6,7] and one trial compared oxytocin to nothing with other active management components practiced in both groups [8]. Oxytocin used at 5–10 IU seemed to reduce the risk of severe postpartum haemorrhage although the other components were not well described.

Controlled cord traction
Cord traction was introduced into obstetric practice by Brandt (1933) and Andrews (1940) by the so-called Brandt-Andrews maneuver. The aim is to facilitate the delivery of a placenta that is already separated. In 1962 the term controlled cord traction (CCT) was introduced which aims to facilitate the separation of the placenta once the uterus contracts [9]. In performing CCT placental separation is not waited and once the uterus contracts the CCT is initiated. The third stage is usually completed in less than 10 minutes when CCT is used.

There is concern by clinicians, based on teachings from their pre-service education that traction on the cord prior to placental separation may lead to maternal complications such as separation of the cord from the placenta and uterine inversion. There is not a large body of direct evidence for or against effects of controlled cord traction in isolation [10].

CCT requires training to acquire this manual skill. Evaluation of CCT component is important because if it does not add any beneficial effects it can be dropped from the AMTSL package with important programmatic implications.

Uterine massage
Uterine massage is used following delivery in various forms. Between delivery of the baby and the placenta a birth attendant will often put his/her hand over the uterus to ensure that there is no undiagnosed twin, to assess if the uterus is contracting and may rub the uterus to stimulate contraction. The Cochrane review on active versus passive management does not refer to the use of uterine massage as part of AMTSL whereas the FIGO/ICM statement on AMTSL does include uterine massage as part of AMTSL. Evidence that massage contributes to a reduction in blood loss would provide evidence to support the use of this intervention with simple instructions.

The National Institute for Health and Clinical Excellence of the United Kingdom published comprehensive guidelines on intrapartum management on 26 September 2007 http://www.nice.org.uk/nicemedia/pdf/IPCNICEGuidance.pdf webcite and has made no reference to uterine massage.

A small pilot trial (n = 200) conducted in Assiut, Egypt, used 'sustained uterine massage' started after delivery applied every 10 minutes and continued for 60 minutes. The findings are promising, since women receiving massage had less blood loss > 500 ml and received less additional uterotonics than women not receiving uterine massage [11]. In the two surveys conducted by Prevention of Postpartum Hemorrhage Initiative (POPPHI) massage before placental delivery was practiced in about one third of all deliveries. In the same surveys massage after placental delivery was used in 80–90% of women although it was not possible to observe how long after delivery the massage was continued [12].

Williams Obstetrics states "massage is not employed but the fundus is frequently palpated to make certain that the organ does not become atonic and filled with blood from placental separation". In the United States and some other countries, palpating the uterus and massaging if "soft" for the first few hours after childbirth is considered standard of care [13]. In many countries however, no well-defined massage protocol exists. A systematic review to evaluate the effects of sustained uterine massage from the time of birth of the baby currently contains very little evidence to guide practice [14].

Other interventions
One intervention that has recently been included in AMTSL package is delayed cord clamping. There is evidence that delayed cord clamping increases newborn haematological indices in the short term and also has beneficial effects of reduced intraventricular haemorrhage when applied to preterm infants. However, there is almost no evidence on maternal effects especially whether it increases the blood loss.

Other third stage interventions include squeezing the uterus from the fundus to expel the placenta (Credé maneuver) [15], placental cord drainage, umbilical vein injection and variations in timing, dose, and route of above discussed components.

Rationale for selecting the experimental intervention
An important aspect of AMTSL components is that one cannot assume that each component has no interaction with others. Such interactions could occur for single, double or triple components. The implication is that even if an intervention may not be (as) effective when individually applied it may have effect together with another component. For example, oxytocin and massage could act synergistically.

The relative importance of all of these uncertainties and the feasibility of evaluating the effects of one or more of the components were discussed in detail at the technical consultation referred above in December 2007. The evaluation of two components namely CCT and uterine massage after placental delivery was given priority. The feasibility of evaluating both interventions in one trial was discussed in detail. Different epidemiological designs such as three-arm and 2 × 2 factorial design were considered. Evaluating more than one component in a single trial posed particular difficulties. Such difficulties originated from the nature of the intervention(s) (manual procedures being difficult to mask) and the low incidence of the primary outcome measure. The implications of these two factors were resorting to cluster or cross-over cluster designs with added complexity and large sample sizes. At the end of the consultative process evaluation of a package that does not include controlled cord traction was regarded as the highest priority research question among all discussed. The main reason for this conclusion is that currently, the global scale up of AMTSL is limited to those settings where skilled birth attendants are available largely because controlled cord traction (CCT) requires clinical skills training. Considerable training investments are needed to enable health providers to do CCT correctly and safely.

The presence of a skilled birth attendant is essential in every childbirth. Birth attendants are required for not only basic care during the first and second stage of labour but also in the third stage when haemorrhage risk is greatest and also for the immediate care of the newborn. We aim to identify the relative effect of one component that requires manual skill training. In the most peripheral points of the health system the availability of health personnel with skills to implement the full AMTSL package may be more difficult to ensure in some settings. Therefore, evaluation of whether a simplified package without CCT is non-inferior to the full AMTSL package has both clinical and public health importance. The simplified package is also less intrusive for the mother.

If it were possible to demonstrate the non-inferiority of a simplified form of AMTSL, dispensing with CCT, it would greatly reduce programme costs associated with training, and enable the intervention to be used by lower level providers, especially in out-of-hospital settings.

We therefore put forward the hypothesis that a simplified package comprising oxytocin 10 IU IM/IV (with or without uterine massage) is as effective as the full AMTSL package.

Objective
The primary objective is to determine whether the simplified package of oxytocin 10 IU IM/IV, without CCT, is not less effective than the full AMTSL package with regard to reducing blood loss ≥ 1000 ml in the third stage of labour. The hypothesis will be that of non-inferiority within a margin of 0.45 to 0.50%. If this hypothesis is demonstrated, the simplified package without CCT could be adopted, with the advantage of not requiring training to acquire the manual skill to perform this task.

Study design
This will be a hospital-based, multicentre, individually randomized non-inferiority controlled trial.

Each woman will be randomized to receive either the full (AMTSL) package or the simplified package. The blinding of the intervention will not be possible because the comparison includes a manual procedure.

Interventions
In order to overcome the variations in the actual practice of AMTSL a working definition was discussed and agreed upon during the technical consultation.

Experimental arm: Simplified package
The simplified package will include;

• Uterotonic
Oxytocin 10 IU IM. Oxytocin will be administered as soon as possible after birth preferably within one minute. If a woman has an IV line oxytocin can be administered through the IV line by slow injection.

• Cord clamping
Cord will be clamped following observation of a uterine contraction either manually or visually. For practical purposes this is estimated to be around 1–3 minutes. It is recommended to clamp the cord close to the perineum.

• Placental delivery
Cord traction is omitted. Placenta should be delivered passively by aid of gravity and maternal effort. The caregiver should observe the placental separation and as the placenta delivers it should be held in two hands and gently turned so that the membranes do not tear off.

• Uterine massage
No uterine massage is recommended before placental delivery. After placental delivery the uterus will be rubbed and any clots expressed. For a period of two hours the uterus will be massaged gently until it contracts and this procedure will be repeated every 15 minutes. It is acknowledged that not all centres will be able to implement this component. Each centre will decide before the trial begins whether the uterine massage component will be implemented or not.

Standard intervention arm: Full AMTSL package
The full package will include:

• Uterotonic
Oxytocin 10 IU IM. Oxytocin will be administered as soon as possible after birth preferably within one minute. If a woman has an IV line oxytocin can be administered through the IV line by slow injection.

• Cord clamping
Cord will be clamped following observation of a uterine contraction either manually or visually. For practical purposes this is estimated to be around 1–3 minutes. It is recommended to clamp the cord close to the perineum.

• Placental delivery
Placenta will be delivered by controlled cord traction immediately after cord clamping and cutting. The cord will be gently pulled while applying counter traction to the uterus with the other hand. As the placenta delivers it should be held in two hands and gently turned so that the membranes do not tear off.

• Uterine massage
No uterine massage is recommended before placental delivery. After placental delivery the uterus will be rubbed and any clots expressed. For a period of two hours the uterus will be massaged gently until it contracts and this procedure will be repeated every 15 minutes. It is acknowledged that not all centres will be able to implement this component. Each centre will decide before the trial begins whether the uterine massage component will be implemented or not.

The two intervention packages will differ only in placental delivery technique. If the umbilical cord has been clamped early because of newborn indication cord traction should be applied only after the uterus has contracted as above.

Outcome measures
The primary outcome measure is blood loss of 1000 ml or more at one hour and up to two hours for women who continue to bleed after one hour. Blood collection will be made using the calibrated drape BRASSS-V® and measured from delivery to one hour following delivery or up to two hours if bleeding continues [16].

Secondary outcomes are;

• blood transfusion,

• the use of additional uterotonics to treat PPH

• blood loss 500 ml or more

• postpartum maternal haemoglobin (in centres where feasible)

• maternal death

• manual removal of placenta,

• additional surgical procedures (e.g. hysterectomy, ligation of vessels)

• composite outcome of maternal death or severe morbidity (admission to intensive care unit, hysterectomy, blood loss of two liters or more, uterine inversion, near miss event as defined in the manual of operations)

• initiation of breastfeeding

• side effects such as nausea and abdominal pain

Once the cord is clamped and cut the drape will be placed under the woman's buttocks and blood loss measurement will begin. The blood loss measurement will continue for one hour regardless of whether the woman is kept in the delivery room or moved elsewhere. If the bleeding continues beyond one hour the blood loss measurement will continue until two hours postpartum.

Side effects will be recorded by the researcher. Any side effect requiring treatment will be regarded as an adverse event and a separate form will be filled.

Serious adverse events will be recorded in special forms and will be returned by the local investigators to the trial coordination unit within 24 hours.

Study population
All women expecting to deliver vaginally at the participating hospitals will be potentially eligible. Women will be approached primarily during antenatal care and early labour for consent for participation except under the following circumstances;

1. Advanced first stage of labour (> 6 cm cervical dilatation)

2. Women who are too distressed to give consent regardless of cervical dilatation or phase of labour. Such evaluation will be made by the clinician in charge of the care of the woman.

3. Minors without a guardian

4. Planned caesarean section

5. If the birth is considered an abortion according to local limits

6. Women with twins or higher order multiple gestations

7. Women who are not capable of giving consent due to other health problems such as obstetric emergencies (e.g. eclampsia) or mental disorder.

Women receive AMTSL regardless of whether they are at high or low-risk for haemorrhage. Therefore all women will be eligible for participation according to the exceptions mentioned above.

Methods
Generation of allocation sequence
The random allocation sequence will be generated centrally at WHO Headquarters using computer generated random numbers. Randomization will be to two groups and stratified by country. Blocking with randomly varying groups of 6–8 will be used to restrict randomization within the strata.

Random allocation technique and allocation concealment
Allocation of the random generated sequence will be by consecutively numbered envelopes. Allocation concealment will be achieved by using sealed opaque envelopes. Allocation will take place during second stage when vaginal delivery is imminent. Once the envelope is opened the name of the woman will be entered on the log file with the envelope number and that woman is enrolled in the trial.

Rationale for the non-inferiority hypothesis and for sample size estimation
The objective of this trial is to show 'non-inferiority' of the simplified package' compared to the full AMTSL package. As such, while superiority would be an added bonus it is not expected and is probably not plausible since the experimental intervention has fewer interventions.

In the conventional superiority trial, the aim is to determine whether one intervention is superior to another, for example, whether uterotonic is superior to nothing. By contrast, in a non-inferiority trial, the aim is to determine whether an alternative intervention with certain advantages is similar to a gold standard. The full AMTSL package represents the gold standard management strategy for reducing blood loss in the third stage of labour. In order to evaluate the effectiveness of a simplified package with fewer components that package has to be compared to the full package to see whether t is "non-inferior" to the gold standard [17].

Because proof of exact equality is impossible, a pre-stated margin of non-inferiority (Δ) for the difference in effectiveness has to be defined. The choice of the non-inferiority margin can be made using clinical assessment, which is to a certain extent arbitrary, and needs consensus among different stakeholders. A technique which has been proposed [17] to establish the non-inferiority margin is to look at the effect of the gold standard, in this case the full AMTSL, compared with placebo in historical (past) trials, in this case the expectant management. A reasonable criterion is to preserve 80% of the benefit of the full AMTSL package (considered as 100%) over expectant management (considered as 0%). Preserving a higher percentage (say 90%) will push the sample size calculations very high while a smaller percentage (say 50%) may not be considered acceptable.

Estimates of blood loss ≥ 1000 ml (severe PPH – sPPH) with active and passive management were taken from the literature. In addition, unpublished data from several ongoing WHO studies where postpartum blood loss is measured were obtained. Based on those data, a 1.5% risk of blood loss of 1000 ml with full active management was considered realistic and appropriate.

The expectant management sPPH rate was more difficult to estimate because the data was only available from earlier published trials and blood loss estimation methods and the actual expectant management method differed between trials. Values between 3.0 to 4.0% are considered realistic and used for sample size estimations.

Table 1 includes different scenarios for the calculation of sample size, obtained by varying the sPPH rate with expectant management (3.0 to 4.0%) and varying the % retained effect (70% to 80%), assuming a fixed 1.5% sPPH rate for the full AMTSL package. These different scenarios result in different choices of the margin of non-inferiority Δ. The total sample size required for a non-inferiority test at the 2.5% level using a two-sided 95% confidence interval and a power of 80% is shown, as well as the power obtained for fixed sample sizes of 20,000 and 25,000.

A woman with late postpartum hemorrhage and placenta accrete

2009-07-14T22:04:00.003-07:00

I read with interest the case reported by S. Akhavan
published in the recent issue of the
Journal of Research in Medical Sciences 1. I
would like to declare my opinion about it. For
screening hemostasis disorders before invasive
procedures or surgery, we usually test APTT,
PT, INR, BT, and Platelet Count to detect relevant
abnormalities. Although these tests may
be sufficient for major hemostasis disorders,
some hemostasis disorders such as factor XIII
deficiency may be overlooked. The PT, APTT,
and thrombin time are normal in factor XIII
deficiency. In these patients, bleeding following
trauma or surgery may be delayed for 12 to
36 hours, while in other patients immediate
bleeding occurs 2.
Although the final diagnosis for the cited
patient was placenta accrete, it is useful to consider
factor XIII deficiency as a differential diagnosis
in similar conditions. Factor XIII (fibrin
stabilizing factor) catalyzes lysine bonds between
various protein substrates such as fibrin
monomers, α2-plasmin inhibitor, fibronectin,
and collagen. These intermolecular crosslinking
reactions between various plasma and
extracellular matrix proteins contribute to hemostasis,
wound healing, and maintenance of
pregnancy 3. A screening test for the presence
or absence of factor XIII consists of observing
clot solubility or insolubility in 5 M urea or 1%
monochloroacetic acid 4.
H. Mansouri Torghabeh*
*Experimental Hematology and Blood Banking Group, Tarbiat Modarres University, Tehran, Iran. e-mail: mansouritorghabe@mums.ac.ir
References
1. Akhavan S. A woman with late post partum hemorrhage and placenta accrete. J Res Med Sci 2005; 10(5): 322.
2. Beutler E, Litchman MA, Coller BS, Kipps TJ, Seligsohn U. Williams Hematology. 6th ed. New York: McGraw-Hill,
2000: 123.
3. Colman RW, Hirsh J, Marder VJ, Clowes AW, George JN. Hemostasis and Thrombosis: Basic Principles and Clinical
Practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2000: 43.
4. Bick RL. Disorder of thrombosis and hemostasis. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2002: 129.
In Response
Factor XIII is a transglutaminase that stabilizes
fibrin clots by forming å-amino-ã glutamil
cross-links between adjacent á and ã chains of
fibrin. Factor XIII deficiency is an extremely
rare inherited syndrome. Patients usually
bleed in neonatal period from their umbilical
stump or circumcision. In addition to hemorrhage,
these patients may have poor wound
healing, a high incidence of infertility among
males and abortion among affected females,
and a high incidence of intracerebral hemorrhage.
These observations suggest that the enzyme
may be important in other physiologic
processes beyond hemostasis, including placental
implantation, spermatogenesis, and
wound healing. Several drugs including isoniazid,
may bind to cross-linking sites on fibrinogen
and mimic factor XIII deficiency by
blocking enzyme activity. Normal hemostasis
requires only 1% of normal enzyme activity; a
single effusion of fresh frozen plasma or a purified
factor XIII-rich product derived from
human placenta called fibrogammin is effective.
The reported case was a woman with normal
hemostasis in past medical history and her
post-operative condition was normal.

Misoprostol in addition to routine treatment of postpartum hemorrhage: A hospital-based randomized-controlled trial in Karachi, Pakistan

2009-07-14T22:04:00.001-07:00

Abstract
Background
Postpartum hemorrhage (PPH) remains a major killer of women worldwide. Standard uterotonic treatments used to control postpartum bleeding do not always work and are not always available. Misoprostol's potential as a treatment option for PPH is increasingly known, but its use remains ad hoc and available evidence does not support the safety or efficacy of one particular regimen. This study aimed to determine the adjunct benefit of misoprostol when combined with standard oxytocics for PPH treatment.

Methods
A randomized controlled trial was conducted in four Karachi hospitals from December 2005 – April 2007 to assess the benefit of a 600 mcg dose of misoprostol given sublingually in addition to standard oxytocics for postpartum hemorrhage treatment. Consenting women had their blood loss measured after normal vaginal delivery and were enrolled in the study after losing more than 500 ml of blood. Women were randomly assigned to receive either 600 mcg sublingual misoprostol or matching placebo in addition to standard PPH treatment with injectable oxytocics. Both women and providers were blinded to the treatment assignment. Blood loss was collected until active bleeding stopped and for a minimum of one hour after PPH diagnosis. Total blood loss, hemoglobin measures, and treatment outcomes were recorded for all participants.

Results
Due to a much lower rate of PPH than expected (1.2%), only sixty-one patients were diagnosed and treated for their PPH in this study, and we were therefore unable to measure statistical significance in any of the primary endpoints. The addition of 600 mcg sublingual misoprostol to standard PPH treatments does, however, suggest a trend in reduced postpartum blood loss, a smaller drop in postpartum hemoglobin, and need for fewer additional interventions. Women who bled less overall had a significantly smaller drop in hemoglobin and received fewer additional interventions. There were no hysterectomies or maternal deaths among study participants. The rate of transient shivering and fever was significantly higher among women receiving misoprostol

Conclusion
A 600 mcg dose of misoprostol given sublingually shows promise as an adjunct treatment for PPH and its use should continue to be explored for its life-saving potential in the care of women experiencing PPH.

Trial Registration
Clinical trials.gov, Registry No. NCT00116480

Spontaneous acute subdural hematoma as an initial presentation of choriocarcinoma: A case report

2009-07-14T22:03:00.001-07:00

Abstract
Introduction
Diverse sequelae of central nervous system metastasis of choriocarcinoma have been reported, including infarction, intra or extra axial hemorrhages, aneurysm formation and carotid-cavernous fistula. Here we report a case of subdural hematoma as the first presentation of choriocarcinoma.

Case presentation
The patient is a 34-year-old woman whose initial presentation of widely metastatic choriocarcinoma was an acute subdural hematoma, requiring decompressive craniectomy. Histopathologic examination of the tissue showed no evidence of choriocarcinoma, but the patient was found to have diffuse metastatic disease and cerebrospinal fluid indices highly suggestive of intracranial metastasis.

Conclusion
Choriocarcinoma frequently metastasizes intracranially. We review the diverse possible manifestations of this process. In addition, the cerebrospinal fluid:serum beta-human chorionic gonadotropin ratio is an important factor in diagnosing these cases. Finally, the role of the neurosurgeon is discussed.

Introduction
Choriocarcinoma is a rare gestational trophoblastic disease that complicates approximately 1 in 50,000 term pregnancies and 1 in 30 hydatidiform moles[1]. Among confirmed cases of choriocarcinoma, 45% occur after molar pregnancy, 24% after normal term pregnancy, 25% after spontaneous abortion, and 5% after ectopic pregnancy[2]. Prognosis of this disease is generally good, 80–90% long-term survival with chemotherapy, radiotherapy, and surgical excision in appropriate cases[3]. One of the indicators of a poor prognosis is intracranial metastases, which complicate between 3 and 28% of gestational choriocarcinoma[1]. Here we report a case of subdural hematoma as the first presentation of choriocarcinoma and present a review of the literature pertaining to subdural hematoma in this setting.

Case Presentation
The patient is a 34-year-old woman who had an acute episode of excruciating headache and was later found obtunded. She had a history of a normal pregnancy three years prior to presentation. She then had an abnormal pregnancy requiring dilation and evacuation at 10–12 weeks that was found to be a molar pregnancy. She became pregnant again 9 months after the dilation and evacuation of the molar pregnancy. This ended in a spontaneous, uncomplicated delivery 5 months prior to her presentation. There was no history of trauma, recent or remote.

Upon arrival to Emergency Department, she had fixed, dilated pupils and displayed extensor posturing. Computerized tomography of the head without contrast (Figure 1) showed a 10-mm left hemispheric subdural hematoma causing significant midline shift and uncal herniation. The patient was then taken to the operating room for emergency decompression via frontotemporal craniectomy. A thick, clotted subdural hematoma was removed. Fresh bleeding from one of the cortical arteries was encountered and controlled with bipolar coagulation. Inspection under microscope magnification revealed no obvious vascular or neoplastic lesion. The coagulated part of the small cortical artery was divided and sent for histopathologic examination along with the evacuated hematoma.

Intrahepatic cholestasis of pregnancy

2009-07-14T22:02:00.002-07:00

Abstract
Intrahepatic cholestasis of pregnancy (ICP) is a cholestatic disorder characterized by (i) pruritus with onset in the second or third trimester of pregnancy, (ii) elevated serum aminotransferases and bile acid levels, and (iii) spontaneous relief of signs and symptoms within two to three weeks after delivery. ICP is observed in 0.4–1% of pregnancies in most areas of Central and Western Europe and North America, while in Chile and Bolivia as well as Scandinavia and the Baltic states roughly 5–15% and 1–2%, respectively, of pregnancies are associated with ICP. Genetic and hormonal factors, but also environmental factors may contribute to the pathogenesis of ICP. Intrahepatic cholestasis of pregnancy increases the risk of preterm delivery (19–60%), meconium staining of amniotic fluid (27%), fetal bradycardia (14%), fetal distress (22–41%), and fetal loss (0.4–4.1%), particularly when associated with fasting serum bile acid levels > 40 μmol/L. The hydrophilic bile acid ursodeoxycholic acid (10–20 mg/kg/d) is today regarded as the first line treatment for intrahepatic cholestasis of pregnancy. Delivery has been recommended in the 38th week when lung maturity has been established.

Disease name and synonyms
Intrahepatic cholestasis of pregnancy

Obstetric cholestasis Recurrent jaundice of pregnancy

Pruritus gravidarum

Icterus gravidarum

Idiopathic jaundice of pregnancy

Definition
Intrahepatic cholestasis of pregnancy (ICP) is a cholestatic disorder characterized by pruritus, elevated serum aminotransferases and bile acid levels with onset in the second or third trimester of pregnancy, and spontaneous relief of signs and symptoms within two to three weeks after delivery [1,2].

In the first description of ICP in 1883, Ahlfeld described maternal pruritus and jaundice in the last trimester of pregnancy disappearing after delivery [3].

Epidemiology
ICP has been observed in almost all ethnic groups, but there is relevant geographical variation in the incidence of ICP [1,4]. The incidence of ICP was highest in Bolivia and Chile several decades ago (up to 14% of all pregnancies before 1975), particularly among the Araucanos Indians of Chile (27.6%) and the Aimara Indians of Bolivia (13.8%) [5-8], but has considerably decreased in these countries more recently to less than 2% of all births today [7]. In Scandinavian and Baltic countries, ICP occurs in up to 2% of all pregnancies, while in other regions of Europe, Asia, North America and Australia the reported incidence is less than 1% [1,7,9]. While the incidence has recently decreased in the high-incidence regions, it increased in low-incidence areas, possibly reflecting the raising awareness of the disease [4,7]. ICP is more common in the winter months in Chile and Scandinavia [10,11], and in twin and multiple pregnancies [12].

Clinical manifestations and biochemical tests
Pruritus is the primary clinical symptom of ICP. Pruritus may be mild and tolerable for some patients, but may also be very severe and disabling. It may considerably impair the patient's quality of life causing sleep deprivation, psychological suffering and even suicidal thoughts. Pruritus is most severe in the evening, with a predilection for the palms of the hands and soles of the feet, and is not associated with any specific skin lesions. It usually presents in the third trimester, after 30 weeks of gestation, but rare cases developing as early as 6 to 10 weeks have been described [9,13,14]. Mild jaundice with serum levels of conjugated bilirubin only moderately elevated occurs in 10 to 15% of cases [9,15]. Jaundice typically develops 1–4 weeks after the onset of pruritus, but occasionally can be the initial symptom [16,17]. Subclinical steatorrhea may be seen along with fat malabsorption, which may lead to vitamin K deficiency resulting in a prolonged prothrombin time and postpartum hemorrhage [18,19]. The incidence of gallstone formation and cholecystitis (rate ratio 3.7) is higher in women with a history of ICP (as well as in their first degree relatives) than in the normal population [20]. Abdominal pain, malaise and other constitutional symptoms are uncommon.

The main biochemical alterations are elevations of serum bile acids and aminotransferase activities [21]. Serum total bile acid levels may increase 10–100 times above the normal range and higher fetal complications rates were observed with maternal fasting bile acid levels exceeding 40 μmol/L [22-25]. In ICP, cholic acid is raised more than chenodeoxcholic acid with an increase in the usual molar ratio of serum cholic to chenochenodeoxcholic acid, whereas the ratio of glycine- to taurine-conjugated bile acids decreases [13,26-28]. Of interest, a subgroup of asymptomatic healthy pregnant women with total serum bile acids above the upper normal limit of 11 μM in late gestation and normal serum liver tests has recently been defined as asymptomatic hypercholanemia of pregnancy (AHP) [29,30]. The serum bile acid composition of women with ICP revealed a shift towards a more hydrophobic pattern with higher levels of lithocholic acid and unconjugated serum bile acids, suggesting that these alterations could be additional useful parameters in the differential diagnosis of ICP and AHP [30]. Serum aminotransferases are also elevated 2–10-fold above normal in 20–60% of patients with pruritus, and may exceed 1000 U/L in exceptional cases [1,9,10,16,31]. Serum aminotransferases may allow better to follow patients with ICP after start of UDCA treatment than total fasting serum bile acid levels which initially increase due to an increase in ursodeoxycholic acid (UDCA) serum levels. Serum concentrations of gamma glutamyl transpeptidase are normal or modestly elevated in half of the patients, reaching up to four times the upper normal limits [9,13]. Serum levels of alkaline phosphatase may rise up to 7–10 times normal, but are difficult to interpret due to elevation of the placenta isoenzyme [32].

Maternal outcome
Maternal prognosis is good and symptoms resolve rapidly after delivery, accompanied by normalization of serum liver tests [28]. Persistent abnormalities should prompt reconsideration of other underlying chronic liver diseases like primary biliary cirrhosis, primary sclerosing cholangitis, or chronic hepatitis C which all may be associated with development of pruritus during late pregnancy. ICP recurs during subsequent pregnancies in 45–70% with varying severity of recurrent episodes [9].

Fetal outcome
ICP increases the risk of preterm delivery (up to 19–60%) [9,33,34], meconium staining of amniotic fluid (up to 27%) [35], fetal bradycardia (up to 14%) [35], fetal distress (up to 22–41%) [11,33,36], and fetal loss (up to 0.4–4.1%) [33,37,38], particularly when associated with fasting serum bile acid levels > 40 μmol/L [25]. Fasting serum bile acid levels and severity of pruritus at diagnosis were independent predictors of preterm delivery in a recent analysis (Kondrackiene et al., submitted). Interestingly, most recent data show a marked decrease in fetal complications [25,39-42] possibly in part due to greater awareness for the disease, closer follow-up and experienced management in specialized centers. Autopsies of the stillborns show signs of acute anoxia with serosal and pulmonary petechial bleeding without intrauterine growth retardation [18,35,43]. The pathogenesis of the fetal complications is still poorly understood, although a role for bile acids or toxic metabolites of bile acids has been suggested [4]. Bile acids were shown to induce contraction of the chorionic veins of the placenta, and myometrial sensitivity of healthy women to oxytocin was increased after incubation with cholic acid [44,45]. The infusion of cholic acid in fetal lambs stimulates colonic motility increasing the incidence of meconium passage [46]. In a prospective study of ICP in patients with bile acid levels > 40 μmol/L the frequency of meconium passage was 44% compared to 22% in a group with only mild ICP [25].

Etiology and pathogenesis
The etiology of ICP is not completely understood and is still under discussion. Genetic and hormonal factors, but also environmental factors may contribute to the pathogenesis of ICP [1]. Familial clustering, ethnic and geographic variation, and the high rate of reoccurrence in subsequent pregnancies support a genetic predisposition for ICP [1,47]. Mutations in the hepatocellular phospholipid transporter, ABCB4 (MDR3), that mediates secretion of the major human phospholipid, phosphatidylcholine (lecithine) into bile, have been estimated to account for up to 15% of all ICP cases [21,48,49]. Available molecular genetic analysis suggests that other major ABC transporters of liver cells, the bile salt export pump (BSEP), ABCB11, and the aminophospholipid transporter (FIC1), ATP8B1, are less likely to be implicated in the pathogenesis of ICP [21,50-52].

Clinical evidence supports an etiologic role for estrogens in the initiation of ICP [1,53,54]. ICP most commonly occurs in the last trimester, when estrogen levels reach their maximum. ICP has been associated with twin and triplet pregnancies with higher estrogen levels than single gestations. Finally, estrogen oral contraceptive use among women with a personal or family history of ICP could result in clinical features of ICP particularly when former high-dose preparations were used [1,4,32]. Progesterone and associated metabolites may also be involved in the pathogenesis of ICP. Patients with ICP have significantly increased plasma levels of mono- or disulfated progesterone metabolites and an increased ratio of 3α-hydroxylated steroids to 3β-hydroylated steroids [47,55,56]. Some estrogens, in particular 17β-D-glucuronide, and sulfated progesterone metabolites have been shown to cause cholestasis [57], but the molecular mechanism is still under discussion. Impairment of the function of major hepatocellular ABC transporters like the bile salt export pump (BSEP), ABCB11, or the phospholipid transporter, ABCB4 (MDR3), by high levels of estrogen glucuronides and progesterone, respectively, at the posttranscriptional level has been demonstrated in vitro [58-60]. In addition, estrogens impaired basolateral as well as canalicular bile acid transporter expression of liver cells in vitro by transcriptional mechanisms [61].

Thus, mutations in genes encoding hepatobiliary transport proteins as well as abnormal metabolites impairing hepatobiliary carriers may be involved in the pathogenesis of ICP.

The seasonal variation, the incomplete recurrence in subsequent pregnancies, as well as the decrease in the prevalence of ICP in high-incidence regions in association with improved nutritional supply suggest that exogenous factors such as nutritional factors like selenium deficiency may contribute to ICP [62,63].

Diagnosis
The diagnosis of ICP is based on (i) pruritus of cholestasis, (ii) elevated fasting serum bile acids > 10 μmol/L (and elevated serum transaminases), (iii) spontaneous relief of signs and symptoms within two to three weeks after delivery and (iv) absence of other diseases that cause pruritus and jaundice. Liver biopsy is not necessary for the diagnosis and histopathology is not diagnostic, showing centrilobular cholestasis without inflammation and bile plugs in hepatocytes and caniculi without bile duct dilatation or injury [16,64].

Differential diagnosis
A number of other disorders may erroneously be interpreted as ICP during pregnancy, making exclusion of diseases associated with pruritus without cholestasis or with pruritus with cholestasis important. The differential diagnosis of ICP with pruritus (and elevation of serum bile acid levels) only includes skin diseases and specific dermatoses of pregnancy, allergic reactions, renal pruritus and hematological disorders such as Hodgkin's disease and polycythemia rubra vera. ICP with elevation of serum liver tests should be distinguished in the late 1st trimester from hyperemesis gravidarum, in the 3rd trimester from acute fatty liver of pregnancy, HELLP (a syndrome characterized byHemolysis, Elevated Liver enzyme levels and a Low Platelet count), pre-eclampsia, eclampsia, and in all trimesters from viral hepatitis, alcoholic hepatitis, drug-induced hepatitis, biliary obstruction, hyperbilirubinemic states, primary biliary cirrhosis and primary sclerosing cholangitis [13,47].

Management
Pharmacologic treatment
The primary objective of pharmacologic treatment in ICP is to alleviate maternal symptoms and improve fetal outcome. Antihistamines, benzodiazepines, phenobarbital, opioid antagonists, dexamethasone, epomediol, S-adenosyl-L-methionine and cholestyramine have been used but not introduced into clinical practice because of limited efficacy and/or tolerability [1,32,39].

Currently, the hydrophilic bile acid ursodeoxycholic acid (UDCA) is the most effective treatment for ICP. In an open, randomized, parallel group study, 84 symptomatic patients with ICP were randomized to either UDCA, 8–10 mg/kg body weight per day, or cholestyramine, 8 g per day, for 14 days. Relief of pruritus was significantly more pronounced in the UDCA group and serum alanine and aspartate aminotransferase activities and endogenous serum bile acid levels were more effectively lowered after UDCA therapy. In addition, delivery occurred closer to term in patients treated with UDCA [40]. A second double-blind, placebo-controlled trial comparing UDCA (1 g per day for three weeks) and dexamethasone (12 mg per day for one week) in 130 women with ICP demonstrated significant improvement of serum alanine aminotransferase and bilirubin levels irrespective of disease severity in the UDCA group only and significant improvement of pruritus in the subgroup of women in the UDCA group with bile acid levels = 40 μmol/L at study entrance. In contrast, dexamethasone did not alleviate pruritus, and serum bile acids and bilirubin were less effectively reduced compared to the UDCA group. However, no differences in fetal complications were detected, possibly due to the fact that fetal complications were less frequently observed in the whole study population than in previous studies [39]. In a retrospective, non-randomized analysis of a 12-year observation period, 32 patients with ICP were treated with UDCA (15 mg/kg/day) for three or more weeks before delivery and compared with 16 historical untreated controls with similar clinical and biochemical characteristics. UDCA treatment significantly improved pruritus intensity and some biochemical markers of ICP and resulted in a higher proportion of deliveries at term with a higher birth weight compared with historical controls [21,41]. A recent randomized prospective comparative study of UDCA (750 mg per day) and S-adenosyl-L-methionine (1000 mg per day intravenously) of 78 patients with ICP suggested that both regimens improved pruritus, but the combined therapy had no additive effect on pruritus as compared to UDCA monotherapy [42]. UDCA seems to be well tolerated by pregnant women and no adverse effects in mothers or newborns have been observed [39-42]. The mechanisms underlying the beneficial effects of UDCA in ICP are not entirely clear. UDCA has been shown to improve impaired hepatocellular secretion by mainly posttranscriptional stimulation of canalicular expression of key transport proteins like the conjugate export pump, MRP2 (ABCC2), or the bile salt export pump, BSEP (ABCB11) [65,66]. In particular, targeting and insertion of these transporter proteins into the canalicular membrane by UDCA conjugates has been demonstrated in experimental models of cholestasis, which led to enhanced elimination of bile acid metabolites and other organic anions as well as steroid mono- and disulfates [65,66]. This mechanism might be crucial for the understanding of the beneficial effect of UDCA in ICP.

In addition to effects of UDCA on the maternal liver, UDCA restores the impaired maternal-placental bile acid transport across the trophoblast. This could be mediated by enhanced expression of plasma membrane transporters involved in the excretory role of the placenta and would prevent structural alterations of the trophoblast induced by maternal cholestasis [15,21].

Delivery
Since conventional antepartum testing does not reliably predict fetal mortality and induction of labor in the 38th week of gestation has been observed to reduce fetal risk, delivery has been recommended in the 37th to 38th week in ICP. In most severe cases (before the era of UDCA treatment), delivery has been initiated even at 36 weeks gestation as soon as lung maturity had been established [28,34,67]. As clearly stated by the UK Guideline for Obstetric Cholestasis 2006, "there are insufficient data to support or refute the popular practice of 'early' (37 weeks of gestation) induction of labour aimed at reducing late stillbirth. The timing and risks of delivery should, therefore, be discussed on an individual basis."

References
Lammert F, Marschall HU, Glantz A, Matern S: Intrahepatic cholestasis of pregnancy: molecular pathogenesis, diagnosis and management.

J Hepatol 2000, 33:1012-1021. PubMed Abstract | Publisher Full Text

Return to text

Beuers U, Pusl T: Intrahepatic cholestasis of pregnancy--a heterogeneous group of pregnancy-related disorders?

Hepatology 2006, 43:647-649. PubMed Abstract | Publisher Full Text

Return to text

Ahlfeld F: Berichte und Arbeiten aus der geburtshilflich-gynaekologischen Klinik zu Giessen 1881-1882.. Leipzig, Grunow FW; 1883:148.

Return to text

Germain AM, Carvajal JA, Glasinovic JC, Kato CS, Williamson C: Intrahepatic cholestasis of pregnancy: an intriguing pregnancy-specific disorder.

J Soc Gynecol Investig 2002, 9:10-14. PubMed Abstract | Publisher Full Text

Return to text

Reyes H, Gonzalez MC, Ribalta J, Aburto H, Matus C, Schramm G, Katz R, Medina E: Prevalence of intrahepatic cholestasis of pregnancy in Chile.

Ann Intern Med 1978, 88:487-493. PubMed Abstract

Return to text

Reyes H, Taboada G, Ribalta J: Prevalence of intrahepatic cholestasis of pregnancy in La Paz, Bolivia.

J Chronic Dis 1979, 32:499-504. PubMed Abstract | Publisher Full Text

Return to text

Reyes H: Review: intrahepatic cholestasis. A puzzling disorder of pregnancy.

J Gastroenterol Hepatol 1997, 12:211-216. PubMed Abstract

Return to text

Riely CA, Bacq Y: Intrahepatic cholestasis of pregnancy.

Clin Liver Dis 2004, 8:167-176. PubMed Abstract | Publisher Full Text

Return to text

Bacq Y, Sapey T, Brechot MC, Pierre F, Fignon A, Dubois F: Intrahepatic cholestasis of pregnancy: a French prospective study.

Hepatology 1997, 26:358-364. PubMed Abstract | Publisher Full Text

Return to text

Berg B, Helm G, Petersohn L, Tryding N: Cholestasis of pregnancy. Clinical and laboratory studies.

Acta Obstet Gynecol Scand 1986, 65:107-113. PubMed Abstract

Return to text

Laatikainen T, Ikonen E: Fetal prognosis in obstetric hepatosis.

Ann Chir Gynaecol Fenn 1975, 64:155-164. PubMed Abstract

Return to text

Gonzalez MC, Reyes H, Arrese M, Figueroa D, Lorca B, Andresen M, Segovia N, Molina C, Arce S: Intrahepatic cholestasis of pregnancy in twin pregnancies.

J Hepatol 1989, 9:84-90. PubMed Abstract | Publisher Full Text

Return to text

Fagan EA: Intrahepatic cholestasis of pregnancy.

Clin Liver Dis 1999, 3:603-632. PubMed Abstract | Publisher Full Text

Return to text

Brites D, Rodrigues CM, Cardoso MC, Graca LM: Unusual case of severe cholestasis of pregnancy with early onset, improved by ursodeoxycholic acid administration.

Eur J Obstet Gynecol Reprod Biol 1998, 76:165-168. PubMed Abstract | Publisher Full Text

Return to text

Serrano MA, Brites D, Larena MG, Monte MJ, Bravo MP, Oliveira N, Marin JJ: Beneficial effect of ursodeoxycholic acid on alterations induced by cholestasis of pregnancy in bile acid transport across the human placenta.

J Hepatol 1998, 28:829-839. PubMed Abstract | Publisher Full Text

Return to text

Knox TA, Olans LB: Liver disease in pregnancy.

N Engl J Med 1996, 335:569-576. PubMed Abstract | Publisher Full Text

Return to text

Nichols AA: Cholestasis of pregnancy: a review of the evidence.

J Perinat Neonatal Nurs 2005, 19:217-225. PubMed Abstract

Return to text

Mullally BA, Hansen WF: Intrahepatic cholestasis of pregnancy: review of the literature.

Obstet Gynecol Surv 2002, 57:47-52. PubMed Abstract | Publisher Full Text

Return to text

Reyes H, Radrigan ME, Gonzalez MC, Latorre R, Ribalta J, Segovia N, Alvarez C, Andresen M, Figueroa D, Lorca B: Steatorrhea in patients with intrahepatic cholestasis of pregnancy.

Gastroenterology 1987, 93:584-590. PubMed Abstract

Return to text

Ropponen A, Sund R, Riikonen S, Ylikorkala O, Aittomaki K: Intrahepatic cholestasis of pregnancy as an indicator of liver and biliary diseases: a population-based study.

Hepatology 2006, 43:723-728. PubMed Abstract | Publisher Full Text

Return to text

Poupon R: Intrahepatic cholestasis of pregnancy: from bedside to bench to bedside.

Liver Int 2005, 25:467-468. PubMed Abstract | Publisher Full Text

Return to text

Heikkinen J, Maentausta O, Ylostalo P, Janne O: Changes in serum bile acid concentrations during normal pregnancy, in patients with intrahepatic cholestasis of pregnancy and in pregnant women with itching.

Br J Obstet Gynaecol 1981, 88:240-245. PubMed Abstract

Return to text

Brites D, Rodrigues CM, van Zeller H, Brito A, Silva R: Relevance of serum bile acid profile in the diagnosis of intrahepatic cholestasis of pregnancy in an high incidence area: Portugal.

Eur J Obstet Gynecol Reprod Biol 1998, 80:31-38. PubMed Abstract | Publisher Full Text

Return to text

Brites D: Intrahepatic cholestasis of pregnancy: changes in maternal-fetal bile acid balance and improvement by ursodeoxycholic acid.

Ann Hepatol 2002, 1:20-28. PubMed Abstract

Return to text

Glantz A, Marschall HU, Mattsson LA: Intrahepatic cholestasis of pregnancy: Relationships between bile acid levels and fetal complication rates.

Hepatology 2004, 40:467-474. PubMed Abstract | Publisher Full Text

Return to text

Brites D, Rodrigues CM, Oliveira N, Cardoso M, Graca LM: Correction of maternal serum bile acid profile during ursodeoxycholic acid therapy in cholestasis of pregnancy.

J Hepatol 1998, 28:91-98. PubMed Abstract | Publisher Full Text

Return to text

Heikkinen J: Serum bile acids in the early diagnosis of intrahepatic cholestasis of pregnancy.

Obstet Gynecol 1983, 61:581-587. PubMed Abstract

Return to text

Bacq Y: Intrahepatic cholestasis of pregnancy. In UpToDate. Edited by: Rose and BD . Waltham, MA; 2006.

Return to text

Pascual MJ, Serrano MA, El Mir MY, Macias RI, Jimenez F, Marin JJ: Relationship between asymptomatic hypercholanaemia of pregnancy and progesterone metabolism.

Clin Sci (Lond) 2002, 102:587-593. PubMed Abstract

Return to text

Castano G, Lucangioli S, Sookoian S, Mesquida M, Lemberg A, Di Scala M, Franchi P, Carducci C, Tripodi V: Bile acid profiles by capillary electrophoresis in intrahepatic cholestasis of pregnancy.

Clin Sci (Lond) 2006, 110:459-465. PubMed Abstract

Return to text

Lunzer M, Barnes P, Byth K, O'Halloran M: Serum bile acid concentrations during pregnancy and their relationship to obstetric cholestasis.

Gastroenterology 1986, 91:825-829. PubMed Abstract

Return to text

Palmer DG, Eads J: Intrahepatic cholestasis of pregnancy: a critical review.

J Perinat Neonatal Nurs 2000, 14:39-51. PubMed Abstract

Return to text

Fisk NM, Storey GN: Fetal outcome in obstetric cholestasis.

Br J Obstet Gynaecol 1988, 95:1137-1143. PubMed Abstract

Return to text

Rioseco AJ, Ivankovic MB, Manzur A, Hamed F, Kato SR, Parer JT, Germain AM: Intrahepatic cholestasis of pregnancy: a retrospective case-control study of perinatal outcome.

Am J Obstet Gynecol 1994, 170:890-895. PubMed Abstract

Return to text

Reid R, Ivey KJ, Rencoret RH, Storey B: Fetal complications of obstetric cholestasis.

Br Med J 1976, 1:870-872. PubMed Abstract | PubMed Central Full Text

Return to text

Shaw D, Frohlich J, Wittmann BA, Willms M: A prospective study of 18 patients with cholestasis of pregnancy.

Am J Obstet Gynecol 1982, 142:621-625. PubMed Abstract

Return to text

Alsulyman OM, Ouzounian JG, Ames-Castro M, Goodwin TM: Intrahepatic cholestasis of pregnancy: perinatal outcome associated with expectant management.

Am J Obstet Gynecol 1996, 175:957-960. PubMed Abstract | Publisher Full Text

Return to text

Williamson C, Hems LM, Goulis DG, Walker I, Chambers J, Donaldson O, Swiet M, Johnston DG: Clinical outcome in a series of cases of obstetric cholestasis identified via a patient support group.

BJOG 2004, 111:676-681. PubMed Abstract | Publisher Full Text

Return to text

Glantz A, Marschall HU, Lammert F, Mattsson LA: Intrahepatic cholestasis of pregnancy: a randomized controlled trial comparing dexamethasone and ursodeoxycholic acid.

Hepatology 2005, 42:1399-1405. PubMed Abstract | Publisher Full Text

Return to text

Kondrackiene J, Beuers U, Kupcinskas L: Efficacy and safety of ursodeoxycholic acid versus cholestyramine in intrahepatic cholestasis of pregnancy.

Gastroenterology 2005, 129:894-901. PubMed Abstract | Publisher Full Text

Return to text

Zapata R, Sandoval L, Palma J, Hernandez I, Ribalta J, Reyes H, Sedano M, Toha D, Silva JJ: Ursodeoxycholic acid in the treatment of intrahepatic cholestasis of pregnancy. A 12-year experience.

Liver Int 2005, 25:548-554. PubMed Abstract | Publisher Full Text

Return to text

Binder T, Salaj P, Zima T, Vitek L: Randomized prospective comparative study of ursodeoxycholic acid and S-adenosyl-L-methionine in the treatment of intrahepatic cholestasis of pregnancy.

J Perinat Med 2006, 34:383-391. PubMed Abstract | Publisher Full Text

Return to text

Rodrigues CM, Marin JJ, Brites D: Bile acid patterns in meconium are influenced by cholestasis of pregnancy and not altered by ursodeoxycholic acid treatment.

Gut 1999, 45:446-452. PubMed Abstract

Return to text

Sepulveda WH, Gonzalez C, Cruz MA, Rudolph MI: Vasoconstrictive effect of bile acids on isolated human placental chorionic veins.

Eur J Obstet Gynecol Reprod Biol 1991, 42:211-215. PubMed Abstract | Publisher Full Text

Return to text

Germain AM, Kato S, Carvajal JA, Valenzuela GJ, Valdes GL, Glasinovic JC: Bile acids increase response and expression of human myometrial oxytocin receptor.

Am J Obstet Gynecol 2003, 189:577-582. PubMed Abstract | Publisher Full Text

Return to text

Campos GA, Guerra FA, Israel EJ: Effects of cholic acid infusion in fetal lambs.

Acta Obstet Gynecol Scand 1986, 65:23-26. PubMed Abstract

Return to text

Kroumpouzos G: Intrahepatic cholestasis of pregnancy: what's new.

J Eur Acad Dermatol Venereol 2002, 16:316-318. PubMed Abstract | Publisher Full Text

Return to text

Pauli-Magnus C, Lang T, Meier Y, Zodan-Marin T, Jung D, Breymann C, Zimmermann R, Kenngott S, Beuers U, Reichel C, Kerb R, Penger A, Meier PJ, Kullak-Ublick GA: Sequence analysis of bile salt export pump (ABCB11) and multidrug resistance p-glycoprotein 3 (ABCB4, MDR3) in patients with intrahepatic cholestasis of pregnancy.

Pharmacogenetics 2004, 14:91-102. PubMed Abstract | Publisher Full Text

Return to text

Jacquemin E, Cresteil D, Manouvrier S, Boute O, Hadchouel M: Heterozygous non-sense mutation of the MDR3 gene in familial intrahepatic cholestasis of pregnancy.

Lancet 1999, 353:210-211. PubMed Abstract | Publisher Full Text

Return to text

Painter JN, Savander M, Sistonen P, Lehesjoki AE, Aittomaki K: A known polymorphism in the bile salt export pump gene is not a risk allele for intrahepatic cholestasis of pregnancy.

Scand J Gastroenterol 2004, 39:694-695. PubMed Abstract | Publisher Full Text

Return to text

Painter JN, Savander M, Ropponen A, Nupponen N, Riikonen S, Ylikorkala O, Lehesjoki AE, Aittomaki K: Sequence variation in the ATP8B1 gene and intrahepatic cholestasis of pregnancy.

Eur J Hum Genet 2005, 13:435-439. PubMed Abstract | Publisher Full Text

Return to text

Savander M, Ropponen A, Avela K, Weerasekera N, Cormand B, Hirvioja ML, Riikonen S, Ylikorkala O, Lehesjoki AE, Williamson C, Aittomaki K: Genetic evidence of heterogeneity in intrahepatic cholestasis of pregnancy.

Gut 2003, 52:1025-1029. PubMed Abstract | Publisher Full Text

Return to text

Reyes H, Simon FR: Intrahepatic cholestasis of pregnancy: an estrogen-related disease.

Semin Liver Dis 1993, 13:289-301. PubMed Abstract

Return to text

Kreek MJ: Female sex steroids and cholestasis.

Semin Liver Dis 1987, 7:8-23. PubMed Abstract

Return to text

Meng LJ, Reyes H, Palma J, Hernandez I, Ribalta J, Sjovall J: Profiles of bile acids and progesterone metabolites in the urine and serum of women with intrahepatic cholestasis of pregnancy.

J Hepatol 1997, 27:346-357. PubMed Abstract | Publisher Full Text

Return to text

Laatikainen T, Karjalainen O: Excertion of progesterone metabolites in urine and bile of pregnant women with intrahepatic cholestasis.

J Steroid Biochem 1973, 4:641-648. PubMed Abstract | Publisher Full Text

Return to text

Reyes H, Sjovall J: Bile acids and progesterone metabolites in intrahepatic cholestasis of pregnancy.

Ann Med 2000, 32:94-106. PubMed Abstract

Return to text

Stieger B, Fattinger K, Madon J, Kullak-Ublick GA, Meier PJ: Drug- and estrogen-induced cholestasis through inhibition of the hepatocellular bile salt export pump (Bsep) of rat liver.

Gastroenterology 2000, 118:422-430. PubMed Abstract | Publisher Full Text

Return to text

Huang L, Smit JW, Meijer DK, Vore M: Mrp2 is essential for estradiol-17beta(beta-D-glucuronide)-induced cholestasis in rats.

Hepatology 2000, 32:66-72. PubMed Abstract | Publisher Full Text

Return to text

Debry P, Nash EA, Neklason DW, Metherall JE: Role of multidrug resistance P-glycoproteins in cholesterol esterification.

J Biol Chem 1997, 272:1026-1031. PubMed Abstract | Publisher Full Text

Return to text

Simon FR, Fortune J, Iwahashi M, Gartung C, Wolkoff A, Sutherland E: Ethinyl estradiol cholestasis involves alterations in expression of liver sinusoidal transporters.

Am J Physiol 1996, 271:G1043-G1052. PubMed Abstract

Return to text

Reyes H, Baez ME, Gonzalez MC, Hernandez I, Palma J, Ribalta J, Sandoval L, Zapata R: Selenium, zinc and copper plasma levels in intrahepatic cholestasis of pregnancy, in normal pregnancies and in healthy individuals, in Chile.

J Hepatol 2000, 32:542-549. PubMed Abstract | Publisher Full Text

Return to text

Ribalta J, Reyes H, Hernandez I, Fuentes O, Baez M, Gonzalez M, Palma J: [Can a selenium deficiency affect the pathogenesis of cholestasis in pregnancy?].

Gastroenterol Hepatol 1995, 18:114-120. PubMed Abstract

Return to text

Rolfes DB, Ishak KG: Liver disease in pregnancy.

Histopathology 1986, 10:555-570. PubMed Abstract | Publisher Full Text

Return to text

Paumgartner G, Beuers U: Ursodeoxycholic acid in cholestatic liver disease: mechanisms of action and therapeutic use revisited.

Hepatology 2002, 36:525-531. PubMed Abstract | Publisher Full Text

Return to text

Beuers U: Drug insight: Mechanisms and sites of action of ursodeoxycholic acid in cholestasis.

Nat Clin Pract Gastroenterol Hepatol 2006, 3:318-328. PubMed Abstract | Publisher Full Text

Return to text

Heinonen S, Kirkinen P: Pregnancy outcome with intrahepatic cholestasis.

Obstet Gynecol 1999, 94:189-193. PubMed Abstract | Publisher Full Text

Return to text

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