Anna Degli Antoni

Evolution of proviral DNA HIV-1 tropism under selective pressure of maraviroc-based therapy

OBJECTIVES To evaluate the evolution of HIV-1 coreceptor tropism in proviral DNA of patients during maraviroc-based therapy. METHODS Fourteen heavily high active antiretroviral therapy (HAART)-treated patients with a CCR5 Trofile profile were monitored over a 24 month period from the start of maraviroc therapy. Whole-blood samples were obtained at different timepoints, and coreceptor tropism was determined for proviral DNA from the V3-loop region sequence using the Geno2Pheno algorithm [false positive rate (FPR): 20%]. RESULTS At the start of maraviroc treatment, 13/14 patients were viraemic (median: 4.33 log copies/mL). Concordance in R5 tropism (R5/R5) was observed between circulating HIV-RNA (Trofile) and HIV-DNA provirus in 10/14 patients (median FPR = 54.0%), while 4 patients showed a CXCR4-tropic R5/X4 variant in their provirus (FPR: 5.8%, 5.7%, 16.6% and 1.1%, respectively). All R5/R5 patients showed a stable HIV-1 DNA coreceptor usage. Two out of four R5/X4 patients showed a tropism shift in their archived provirus and, after 6 months a prevalence of R5-tropic virus was detected in DNA. The other two R5/X4 patients harboured the 11/25 genotype, and maintained X4 tropism in provirus during the study. Virological response did not reveal differences in RNA decay and CD4+ cell recovery in patients with discordant tropism. CONCLUSIONS A relatively good correlation between RNA and DNA tropism was observed at baseline. Proviral DNA tropism remained stable over 24 months of maraviroc-based therapy, indicating that determination of proviral DNA V3 sequence could be used in tropism prediction in clinical practice. The data also confirm the importance of the 11/25 rule in predicting viral tropism.

Atazanavir and lopinavir profile in pregnant women with HIV: tolerability, activity and pregnancy outcomes in an observational national study

BACKGROUND Atazanavir and lopinavir represent the main HIV protease inhibitors recommended in pregnancy, but comparative data in pregnant women are limited. METHODS Women from a national observational study, exposed in pregnancy to either atazanavir or lopinavir, were compared for glucose and lipid profiles, liver function tests, CD4 count, HIV RNA and main pregnancy outcomes. Statistical methods included univariate and multivariable analyses. RESULTS The study population included 428 pregnancies (lopinavir, 322; atazanavir, 106). The lopinavir group was characterized by higher rates of HIV diagnosis in pregnancy and treatment indication for maternal health, lower CD4 counts, higher HIV RNA levels, less frequent antiretroviral treatment at conception and shorter duration of drug exposure during pregnancy. No differences in pregnancy outcomes, glucose metabolism and weight gain were observed. The two groups also showed in a multivariable analysis similar odds for detectable HIV RNA in the third trimester (adjusted OR 0.85, 95% CI 0.35-2.10, P = 0.730). Total lipid levels were significantly higher in the lopinavir group (median values in the third trimester 239 versus 221 mg/dL for total cholesterol and 226 versus 181 mg/dL for triglycerides; P < 0.001 for both comparisons) and bilirubin levels were significantly higher in the atazanavir group (1.53 versus 0.46 mg/dL, P < 0.001). CONCLUSIONS In this observational study atazanavir and lopinavir showed similar safety and activity in pregnancy, with no differences in the main pregnancy outcomes. Atazanavir use was associated with a better lipid profile and with higher bilirubin levels. Overall, the study findings confirm that these two HIV protease inhibitors represent equally valid alternative options.

Relationship Between Health-Related Quality of Life Measures and High HIV Viral Load in HIV-Infected Triple-Class-Experienced Patients

Abstract Background: Health-related quality of life (HRQoL) has been recognized as a central measure of the overall health status in HIV patients. With the availability of different highly effective drug combinations, maximizing quality-adjusted survival has become a major target of HIV treatment. Although the association of HIV RNA and CD4 cell count with clinical HIV progression has been well established, the relation between these markers and HRQoL measures is still unclear. Method: This cross-sectional study investigated the relationship linking HIV RNA and CD4 to HRQoL measures in 181 triple-class-experienced patients with advanced HIV disease. The instrument used was the ISSQoL, a self-administered and HIV-specific HRQoL questionnaire. Results: Data showed no correlation between HRQoL measures and CD4 counts. Higher HIV RNA levels were, however, associated with poor HRQoL scores in 3 out of 9 scales of social functioning, depression and anxiety, and satisfaction with quality of life. In multivariable analyses, only the satisfaction with quality of life mean score remained significantly lower for the HIV RNA >100,000 copies/mL group compared to the HIV RNA 50 to 10,000 copies/mL group. Conclusions: Although other determinants of HRQoL in people with HIV should also be considered, this finding suggests a negative impact of high viral load on perceived HRQoL that adds to other described determinants of lower quality of life in people with HIV, such as lower social support and self-reported symptoms.

Response to raltegravir-based salvage therapy in HIV-infected patients with hepatitis C virus or hepatitis B virus coinfection

OBJECTIVES To define the impact of coinfection with hepatitis B virus (HBV) or hepatitis C virus (HCV) on viroimmunological response to raltegravir-based salvage regimens that also include new HIV inhibitors such as maraviroc, darunavir and etravirine. METHODS We used data from a national observational study of patients starting raltegravir-based regimens to compare virological suppression and CD4 cell change from baseline in patients with and without concomitant HBV or HCV infection. RESULTS Overall, 275 patients (107 coinfected and 168 non-coinfected) were evaluated. Coinfected patients were more commonly former intravenous drug users and had a longer history of HIV infection and higher baseline aminotransferase levels. Both HIV-RNA and CD4 response were similar in the two groups. Mean time to first HIV-RNA copy number <50 copies/mL was 4.1 months (95% CI 3.5-4.6) in non-coinfected patients and 3.9 months (95% CI 3.3-4.5) in coinfected patients (hazard ratio 1.039, 95% CI 0.761-1.418, P = 0.766, log-rank test). The risk of developing new grade 3-4 hepatic adverse events was significantly higher in coinfected patients (hazard ratio 1.779, 95% CI 1.123-2.817, P = 0.009). The two groups of coinfected and non-coinfected patients had similar rates of interruption of any baseline drug (hazard ratio 1.075, 95% CI 0.649-1.781, P = 0.776) and of raltegravir (hazard ratio 1.520, 95% CI 0.671-3.447, P = 0.311). Few AIDS-defining events and deaths occurred. CONCLUSIONS Viroimmunological response to regimens based on raltegravir and other recent anti-HIV inhibitors is not negatively affected by coinfection with HBV or HCV. Liver toxicity, either pre-existing or new, is more common in coinfected patients, but with no increased risk of treatment interruption.

HTLV-II does not adversely affect the natural history of HIV-1 infection in intravenous drug users

The influence of the human T cell leukaemia virus type II (HTLV-II) on the natural history of HIV-1 infection in coinfected subjects has not yet been clarified. Weiss et al. [1] reported a higher mortality and Page et al. [2] found a significantly increased risk for the development of AIDS in intravenous drug users (IVDUs) coinfected with HTLV-II and HIV-1,.compared to individuals infected with HIV-1 alone. In contrast, Visconti et al. [3] recently described less immunological impairment and a delayed HIV-1 disease progression in coinfected subjects. In order to address this debated issue, we compared the immunological and clinical outcome of HIV-1 seropositive IVDUs, with and without HTLV-II coinfection. From January 1986 to December 1988, serum samples from a cohort of 437 IVDUs followed in the Drug Dependency Unit of the Hospital of Parma (Italy) have been collected and tested for HIV-1 and HTLV-I/II . The presence of anti-HIV-1 antibodies was determined by commercial enzyme immune assays (ELISA) (Abbott Laboratories, North Chicago, USA) and confirmed by Western blot analysis (Du Pont de Nemours, Milan, Italy). Initially, presence of HTLV-I/II antibodies was determined by agglutination assay (Fujirebio, Tokyo) and ELISA (Diagnostic Biotechnology, Ltd., Singapore). Ant i -HTLV:I/ I I positivity was confirmed by Western blot (Diagnostic Biotechnology, Ltd., Singapore), according to the manufacturer s instructions. To confirm further HTLV infection and to differentiate between HTLV-I and HTLV-II infection, polymerase chain reaction (PCR) was performed on lymphocyte samples of subjects with HTLV positivity using a tax gene primer pair, recognizing both HTLV-I and HTLV-II sequences; specific probes were then used to distinguish the two viruses [4]. Three hundred and sixty six patients tested seropositive for HIV1 antibodies, with an overall seroprevalence of 83.7%. The incidence of anti-HTLV antibodies was 2.05%, with a similar distribution among HIV-1 infected and uninfected subjects (2.1% and 1.4%, respectively). Al l subjects with confirmed HTLV seropositivity showed HTLV-II infection by PCR. Five HTLV-II and HIV-1 coinfected patients (group 1, two men and three women, aged 33:0 _+ 4.4 years; two on antiretroviral therapy for 3.0 + 1.4 years), and 44 with HIV-1 infection alone (group 2, 31 men and 13 women, aged 31.7 _+ 3.8 years; 37 on antiretroviral therapy for 3.5 _+ 1.3 years) with similar CDC entry stage, drug history and serology for other viral infections (cytomegalovirus, herpes simplex, Epstein Barr and hepatitis B viruses) were studied. Clinical and immunological data were derived retrospectively from the individual clinical records of patients of both groups (6.0 _+ 1.8 and 6.0 + 1.0 years of observation, respectively). According to a well-defined protocol used in our department for HIV-1 positive individuals, all patients underwent a clinical and laboratory control at least every 3-4 months. The progression rate from asymptomatic conditions (CDC group II A or B) to persistent generalised lymphadenopathy (group III A or B), AIDS-related complex (group IV A), overt AIDS and death from AIDS was calculated as a progression step. Patients in group 2 showed a faster staging progression (93 steps observed, 184 expected) than those in group 1 (four steps observed, 20 expected; chi-square = 6.747, p <0.01). No statistical difference was found in the cumulative survival between the two groups (Kaplan Meier curves estimating the difference in the progression rate by Cox test) even though the progression rate was lower in patients of group 1 (p = 0.23), Overall evaluation, at 12month intervals, of immunological parameters (testing the parallelism hypothesis by analysis of variance) showed a similar decrease per year in the mean number of total lymphocytes (group 1, r = -0.419 vs. group 2, r = -0.958, p = 0.695) and CD8+ (r = -0.681 vs. r = -0.345, p = 0.120) in the two groups; in contrast, a more rapid decrease of CD4+ mean number (r = -0.142 vs. r = -0.927, p = 0.033) and CD4+/CDs+ ratio (r = 0.829 vs. r = -0.660, p = 0.008) was observed in group 2. Although the limited number of the patients in the group coinfected by HIV-1 and HTLV-II may represent a statistical limit , our findings confirm the results of Visconti et al. [3] suggesting that HTLV-II , in contrast to HTLV-I [5], does not adversely affect the natural history of HIV-1 infection. A slower HIV-1 disease progression has indeed been recorded i n some of our HTLV-II coinfected subjects. The lack of a negative influence of HTLV-II on the clinical outcome of HIV-1 disease might be explained by its tropism for CD8+ [6]; in contrast, HTLV-I, which preferentially infects CD4+ lymphocytes, could transactivate HIV-1 and broaden the spectrum of HIV-1 cellular tropism [7].

HIV‐1 DNA dynamics and variations in HIV‐1 DNA protease and reverse transcriptase sequences in multidrug‐resistant patients during successful raltegravir‐based therapy

There is limited information on the variations of HIV‐1 DNA mutation profile in reverse transcriptase (RT) and protease (PR) genes during suppressive antiretroviral treatment (plasma HIV‐1 RNA continuously <50 copies/ml) with raltegravir (RAL)‐based regimens in patients with baseline RT/PR resistant HIV. Twelve multidrug resistant (RT: 12/12, PR: 8/12) HIV‐infected patients were followed during effectively suppressive RAL‐based therapy. Total and integrated HIV‐1 DNA were assessed by real time PCR at baseline and every 6 months. Ultrasensitive (threshold: 2.5 copies/ml) plasma HIV‐1 RNA and genotypic analysis of RT and PR in proviral DNA were performed at baseline and at 24 months. Half of the patients had full viral suppression (plasma HIV‐RNA < 2.5 copies/ml) at month 12. Total HIV‐1 DNA declined significantly after 12 months of therapy (from 249.2 to 145.7 copies/106 cells, P = 0.023), and remained stable until 24 months, when total HIV‐1 DNA levels raised, concomitantly with a less stringent suppression of HIV‐1 RNA (81.8% of patients with >2.5 copies/ml). Integrated HIV‐1 DNA did not show fluctuations during the study period. Sequencing of the PR and RT regions from HIV‐1 DNA revealed changes in the resistance mutation profile in five patients. Total HIV‐1 DNA declined after the introduction of RAL‐based therapy, with a rebound after 2 years. No changes were observed in levels of integrated DNA, suggesting limited effect on archived HIV. The RT and PR sequence changes in archived HIV‐1 DNA suggest that variation of the mutation profile can occur even in the absence of detectable HIV‐1 RNA. J. Med. Virol. 88:2115–2124, 2016.

Impact of Highly Active Antiretroviral Therapy on the Natural History of Cervical Precancerous Lesions: A 17-Year Institutional Longitudinal Cohort Study

We performed an observational cohort study in order to assess the correlation between precancerous cervical lesions (cervical intraepithelial neoplasia [CIN]) and immunological state in human immunodeficiency virus (HIV)-positive women treated by highly active antiretroviral therapy (HAART). We analyzed 194 HIV-infected women referred to the Parma-Universitary Hospital for early detection of human papilloma virus–induced CINs. We analyzed cytology, colposcopy, and CIN degree according to HAART: group A untreated and group B treated. We compared the CD4+ count and viral load at the time of CIN onset and the time interval between diagnosis of HIV and the onset of CIN. Group A and group B showed homogeneous results for general features, CD4+ count, viral load, and Papanicolaou test features. Differences were not found in terms of histology and CD4+ value, viral load count, pharmacological treatment, years since the diagnosis of HIV, age, smoking, sexual promiscuity, previous intravenous narcotics abuse, prostitution, sexually transmitted diseases, ethnicity, and age at diagnosis. Histology and the clinical stage of HIV showed significant concordances between the high degree of cervical dysplasia and advanced stage of HIV disease.

Pregnancy Outcomes in HIV-Infected Women of Advanced Maternal Age

Abstract Background: There is limited information on pregnancy outcomes in women with HIV who are of a more advanced maternal age.Methods: Data from a national observational study in Italy were used to evaluate the risk of nonelective cesarean section, preterm delivery, low birthweight, major birth defects, and small gestational age-adjusted birthweight according to maternal age (<35 and ≥35 years, respectively).Results: Among 1,375 pregnancies with live births, 82.4% of deliveries were elective cesarean sections, 15.8% were nonelective cesarean sections, and 1.8% were vaginal deliveries. Rates of nonelective cesarean section were similar among mothers ≥35 and <35 years (odds ratio [OR], 1.22; 95% CI, 0.90–1.65;P = .19). Preterm delivery and low birthweight were significantly more common among women ≥35 years in univariate but not in multivariate analyses. Newborns from women ≥35 and <35 years showed no differences inZ scores of birthweight, with a similar occurrence of birthweight <10th percentile (12.1% vs 12.0%; OR, 1.02; 95% CI, 0.71–1.46;P = .93). The overall rate of birth defects was 3.4% (95% CI, 2.4–4.4), with no differences by maternal age (≥35 years, 3.5%; <35 years, 3.3%; OR, 1.05; 95% CI, 0.56–1.98;P = .88).Discussion: In this study of pregnant women with HIV, older women were at higher risk of some adverse pregnancy outcomes, such as preterm delivery and low birthweight. The association, however, did not persist in multivariable analyses, suggesting a role of some predisposing factors associated with older age.

Clinical features of hepatitis delta virus infection in a northern Italian area.

SummaryExpression of hepatitis delta virus (HDV) markers was investigated in sera from 310 patients with acute hepatitis, 63 chronic hepatitis B surface antigen (HBsAg) carriers and 76 drug addicts positive for at least one serological hepatitis B virus (HBV) marker. Acute HDV infection occurred in 17.1% of the patients with acute hepatitis. Among 40 cases of coinfection, hepatitis was severe in ten and fulminant in three. Only two of the 13 superinfected patients showed a severe hepatitis, but a high percentage (78%) of them developed chronic hepatitis one year after HDV infection. Also in our area parenteral drug addiction represents the main factor of risk for HDV infection. The high prevalence of HDV infection in our area points to the necessity for serological screening for HDV markers in patients with acute and chronic hepatitis.ZusammenfassungDie Expression von Markern des Hepatitis Delta Virus (HDV) wurde in Seren von 310 Patienten mit akuter Hepatitis, 63 chronischen Trägern des Hepatitis B Virus-Oberflächenantigen (HBSAg), und 76 Drogenabhängigen mit mindestens einem serologischen Marker für eine Hepatitis B Virus-(HBV-)Infektion untersucht. Bei 17,1% der Patienten mit akuter Hepatitis trat eine akute HDV-Infektion auf. Unter 40 Fällen von HBV-HDV-Koinfektion kam es zehnmal zu einer schweren und dreimal zu einer fulminanten Hepatitis. Bei 13 Fällen von Superinfektion trat nur zweimal eine schwere Hepatitis auf; der Übergang in eine chronische Hepatitis ein Jahr nach der HDV-Infektion war jedoch häufig (78% der Fälle). Auch in unserer Region stellt der parenterale Drogenabusus den Hauptrisikofaktor für die HDV-Infektion dar, und die hohe Prävalenz von HDV-Infektionen unterstreicht die Notwendigkeit eines serologischen Screening auf HDV-Marker bei Patienten mit akuter und chronischer Hepatitis.

No evidence of autoimmune disorders in antiretroviral-experienced HIV-1-infected individuals after long-term treatment with raltegravir

BACKGROUND The HIV integrase inhibitor raltegravir (RAL) can exacerbate autoimmune diseases in genetically predisposed mice. To evaluate whether this may occur in clinical practice, we clinically monitored HIV-positive patients treated with RAL and measured a panel of autoantibodies (auto-Abs) during the first year of RAL treatment. METHODS This was a longitudinal study in 109 antiretroviral-experienced patients who started a RAL-based regimen and were followed up for more than 2 years. A total of 45 patients were tested at baseline (before starting RAL) and after 12 months for the presence of the following auto-Abs: anti-nuclear antibodies, anti-double-stranded DNA, anti-smooth-muscle antibodies, anti-thyreoglobulin and anti-thyroid peroxidase antibodies, anti-cardiolipin immunoglobulin G and immunoglobulin M and anti-nuclear extractable antigens, including anti-SM ribonucleoprotein antigen, anti-Ro antigen and anti-La antigen. RESULTS A low rate of clinically relevant autoimmune diseases was observed at study entry (3/109; 2.8%; 95% CI 0.004, 0.059). No exacerbations were observed during follow-up. During the second year of RAL-based therapy a previously healthy patient developed psoriasis. At baseline, 17/45 (37.8%) patients tested for the presence of auto-Abs were positive. Most patients (n=13) were positive for anti-cardiolipin. After 12 months of RAL exposure, 9/45 patients were positive (20%; P=0.063). A positive correlation was found between HIV-1 RNA and anti-cardiolipin antibody concentration (P=0.010). CONCLUSIONS According to these results, RAL does not promote antibody-mediated immune disorders, at least not in the mid-term. A prolonged follow-up and an extension of the panel of auto-Abs are recommended to support these results.