Cécile Poggi

Effects of a Combination of Zidovudine, Didanosine, and Lamivudine on Primary Human Immunodeficiency Virus Type 1 Infection

A combination of zidovudine, didanosine, and lamivudine was used to treat 10 patients with primary human immunodeficiency virus type 1 (HIV-1) infection 5-28 days after the onset of symptoms. When therapy began, the mean plasma HIV-1 RNA level was 5.31 +/- 0.33 log10 copies/mL and the mean CD4 T cell count was 630 +/- 112 x 10(6)/L. The plasma HIV-1 RNA level decreased rapidly, and levels dropped below the cutoff in each case after 108 +/- 32 days. Lymph nodes from 5 patients were biopsied before therapy and during follow-up. Infectious HIV-1 could not be cultivated from any lymph node mononuclear cells taken on day 90, and HIV-1 RNA was at very low levels in lymph nodes after 1 year. In some cases, waning of the antibody response to HIV-1 was shown by Western blot after several months of undetectable plasma RNA. These data demonstrate that triple-drug therapy has a potent antiviral effect during primary HIV-1 infection.

Residual human immunodeficiency virus type 1 RNA in lymphoid tissue of patients with sustained plasma RNA of <200 copies/mL.

Human immunodeficiency virus type 1 (HIV-1) RNA was measured in lymph node (LN) mononuclear cells of 50 patients with sustained plasma RNA of <200 copies/mL with therapy. Six patients had received a combination of three reverse transcriptase inhibitors (RTIs) since primary infection, 11 received this same combination during chronic disease, 21 received a combination of two RTIs plus a protease inhibitor (PI), and 12 received three RTIs plus a PI. The mean overall duration of therapy was 8.9 +/- 0.5 months (range, 5-24), with no significant difference between groups. LN HIV-1 RNA levels varied from undetectable to 1.7 million copies/10(6) cells according to cases. The mean LN HIV-1 RNA level was 2.99 +/- 0.42 log10 copies/10(6) cells in the 17 patients receiving three RTIs compared with 1.93 +/- 0.25 log10 copies/10(6) cells in the 33 patients receiving a PI (t test, P = .02). These data demonstrate that highly active antiretroviral regimens have unequivalent effects on LNs and invite redefinition of suboptimal therapy at this level.

Quantification of HIV-1 viral load in lymphoid and blood cells: assessment during four-drug combination therapy.

Objective: To assess the antiretroviral effect of a combination of zidovudine, didanosine, lamivudine and saquinavir in plasma, peripheral blood mononuclear cells (PBMC) and lymph‐node mononuclear cells (LNMC) after 8 weeks. Methods: Ten HIV‐1 antiretroviral therapy‐naive patients were given a combination of oral zidovudine (200 mg three times daily), oral didanosine (200 twice a day), oral lamivudine (150 mg twice a day) and oral saquinavir (600 mg three times daily). HIV‐1 plasma RNA was measured by quantitative reverse transcriptase (RT)‐polymerase chain reaction (PCR). Infectious HIV‐1 in PBMC and LNMC was measured by a coculture technique. HIV‐1 RNA in PBMC and LNMC was quantified by RT‐PCR. Proviral DNA titres in PBMC and LNMC were measured by endpoint dilution PCR. CD4 T‐cells were analysed by flow cytometry. Results: CD4 cell counts rose in all patients (mean increase of 125 ± 71 CD4 cells × 106/l) and the benefit was greater for patients with fewer than 350 CD4 cells × 106/l (mean increase of 159 ± 74 CD4 cells × 106/l). Plasma HIV‐1 RNA decreased exponentially in all patients (mean decrease of 3.1 log10 after 8 weeks with a mean half‐life of 2.2 ± 0.6 days). HIV‐1 RNA showed a decrease of 3.07 log10 in PBMC and of 2.1 log10 in LNMC. The decrease in plasma HIV‐1 RNA was consistently associated with the decrease in LNMC. These data were supported by a concomitant drop of HIV‐1 infectious titres in PBMC (mean decrease of 1.41 log10) and in LNMC (mean decrease of 2.54 log). Conclusions: These data show a significant antiretroviral effect of this four‐drug combination in blood and lymphoid tissues. However, a greater decrease in HIV‐1 RNA was observed in PBMC and in plasma than in lymph node cells.

Hepatitis E virus in HIV-infected patients.

Objectives:Many cases of acute autochthonous hepatitic E virus (HEV) hepatitis have been reported in France, mainly from the south. Chronic HEV infection has recently been described in immunosuppressed patients. Although a potential risk of chronicity exists in HIV-infected patients, no survey has been conducted in this population. The aim of this study was to assess the sero-virological prevalence of HEV in French HIV-infected patients. Methods:Two hundred and forty-five HIV-infected patients followed at two Infectious Diseases Departments (one in the south, one in the north) were included from January to March 2009. Sera were collected from all patients and tested using anti-HEV IgG and IgM kits. HEV RNA was systematically amplified in the ORF2 region with an in-house method. The IgG avidity index of all IgG-positive samples was determined. Results:Three of the 133 southern patients showed both anti-HEV IgG and IgM positivities, along with cytolysis and biological cholestasis; HEV RNA was amplified in two of these cases, whereas a low IgG avidity index was observed in all three samples. Twelve of the 130 remaining southern patients (9%) showed anti-HEV IgG positivity. The serological prevalence in the 112 northern patients was 3%, which was significantly lower than in the southern patients (P = 0.04). No case of acute hepatitis was reported in the north, whereas the prevalence of patients with biochemical liver abnormalities was similar in both areas (P = 0.22). Conclusions:In France, HIV-infected patients are at risk of HEV infection with a serological north-to-south gradient. No case of chronic HEV infection was detected in this study.

Pilot study of a combination of highly active antiretroviral therapy and cytokines to induce HIV-1 remission.

Summary: A pilot study of a combination of highly active antiretroviral therapy (HAART) and cytokines in early HIV‐1 infection has been undertaken to test the hypothesis that HIV‐1 remission can be reached with this strategy by flushing latently infected viral reservoirs. Ten previously antiretroviral naive patients have received a combination of zidovudine, lamivudine, didanosine, saquinavir, and ritonavir for 72 weeks. Between weeks 12 and 48, three courses of interleukin (IL)‐2 (7.5 millions of international units [MUI] twice a day for 5 consecutive days) and 2 courses of &ggr;‐interferon (IFN) (100 &mgr;g every other day during 2 weeks) were administered subcutaneously. All patients reached plasma HIV‐1 RNA levels < 20 copies/ml within 12 ± 4 weeks. Transient increases in plasma levels (<120 copies/ml) were observed during administration of IL‐2, but less frequently during &ggr;‐IFN administration. HIV‐1 RNA decreased in lymph node cells by ˜ 4 log, then remained stable after week 24. A mean drop of ‐0.8 log in peripheral blood mononuclear cell (PBMC) proviral DNA was observed during the trial. Isolation of potentially infectious HIV‐1 was successful in each case by coculture of CD4+ T cells taken at week 72. The 2 patients who stopped therapy at the end of the trial showed rebounding plasma HIV‐1 RNA levels within a few weeks. No additional mutations were selected in comparison with those present at baseline in 8 patients. In addition, 2 patients developed new mutations in the reverse transcriptase or protease gene and in 1 case, resistance selection was found in lymphoid tissue HIV‐1 RNA but not in latently infected cells. In all cases, a rapid increase in both naive and memory CD4+ T cells was observed, with a reduction in activation markers and preservation of the CD8+CD28+ subset. Consequently, an aggressive regimen of HAART and cytokines administered in early stage disease is associated with a positive effect in terms of proviral load reduction and immune reconstitution but is unable to induce HIV‐1 remission, allowing low levels of viral replication to persist in lymphoid reservoirs.

Predictors of Plasma Human Immunodeficiency Virus Type 1 RNA Control after Discontinuation of Highly Active Antiretroviral Therapy Initiated at Acute Infection Combined with Structured Treatment Interruptions and Immune-Based Therapies

Thirty patients with acute human immunodeficiency virus (HIV) type 1 infection received a combination of 3 antiretroviral drugs (n=15) or 4 antiretroviral drugs plus hydroxyurea and interleukin-2 (n=15) for 24 months, followed by 1-3 structured therapeutic interruptions (STIs). Viral control, defined as maintaining plasma viremia <5000 copies/mL without therapy, was achieved in 14 cases. Lymphocyte subsets, plasma HIV-1 RNA loads, proviral DNA loads in peripheral blood mononuclear cells (PBMCs), residual HIV-1 RNA loads in PBMCs and in lymph node cells, and anti-p24 lymphoproliferative response were measured. In the multivariate analysis, proviral DNA loads in PBMCs and anti-p24 lymphoproliferative response assessed at 24 months were independently correlated with viral control after STI. These results enabled us to define a subgroup of patients for whom safe discontinuation of therapy initiated at acute infection was suitable and contributed to ascertaining priority for biological parameter assessment in future clinical trials.

Correlation between plasma levels of cytokines and HIV-1 RNA copy number in HIV-infected patients

SummaryThe plasma levels of HIV-1 RNA, tumor necrosis factor alpha (TNF-α), soluble receptors type II of TNF-α (sTNF-α RII), soluble receptors of interleukin-4 (sR IL-4), interleukin-6 (IL-6), soluble receptors of interleukin-6 (sR IL-6), granulocyte macrophage colony stimulating factor (GM-CSF), soluble receptors of GM-CSF (sR GM-CSF), RANTES, MIP-1α and MIP-1β were measured in 80 HIV-infected patients. All patients had not been treated previously with antiretroviral drugs and did not present a recent history of opportunistic infection. A statistically significant correlation was found between HIV-1 RNA and TNF-α (p=0.005) or sTNF-α RII levels (p<0.001). RANTES and MIP-1α levels did not correlate with HIV-1 RNA. MIP-1β levels were correlated with plasma RNA titers in patients with CD4+ T cells <200 × 106/l (p=0.03). MIP-1α and sR IL-4 levels were significantly different according to the CD4+ T cell range (p=0.003 and p=0.0002, respectively). GM-CSF and sR GM-CSF were undetectable in each case. These data confirm that HIV-1 replication in the plasma is correlated with TNF-α levels, but do not show a clear correlation with levels of the chemokines studied.

Antiretroviral effect of zidovudine-didanosine combination on blood and lymph nodes.

Objective:To evaluate the antiretroviral effect of a combination of zidovudine (ZDV) and didanosine (ddI) on plasma, peripheral blood mononuclear cells (PBMC) and lymph nodes after 24 weeks. Methods:Eight patients naive of antiretroviral therapy were followed by monthly blood samples and two surgical lymph-node biopsies taken at baseline and after 24 weeks. CD4+ T cells were counted monthly by flow cytometry. Plasma HIV-1 RNA was measured monthly by polymerase chain reaction (PCR). Infectious cellular viraemia was measured monthly by a culture technique. Proviral DNA titres in PBMC were measured by endpoint dilution PCR at baseline and 24 weeks. Infectious HIV-1 and proviral DNA titres were measured in the lymph-node mononuclear cells (LNMC). The total HIV-1 RNA content of lymph nodes was measured by PCR. In some cases, phenotypic resistance to ZDV was measured, and codon 215 and 74 mutations in PBMC and LNMC were analysed. Results:A mean increase in CD4 cell count of 122 × 106/l, a mean decrease in HIV-1 RNA of 1.47 log10 in plasma and a mean decrease in HIV-1 DNA titre of 0.63 log10 were found after 24 weeks of therapy. Nevertheless, there were no statistically significant changes in the mean infectious HIV-1 titre in PBMC and LNMC, in the HIV-1 DNA titre in LNMC or in the total lymph-node HIV-1 RNA burden at week 24. Phenotypic or genotypic markers of drug resistance were rarely found in PBMC at week 24, although they were detected in LNMC from some patients. Conclusion:A discrepancy in the therapeutic effect can be observed between lymphoid organs and blood after 24 weeks of therapy with ZDV and ddI. This difference could be explained by the insufficient antiretroviral potency of this combination facing the significant viral burden present in lymph nodes. Development of drug resistance in this compartment prior to blood can be demonstrated in some cases, although other mechanisms remain to be investigated in future studies to explain this difference.

Long-term evaluation of triple nucleoside therapy administered from primary HIV-1 infection

OBJECTIVE To study the long-term effect of triple-drug therapy initiated at the time of primary HIV-1 Infection and to evaluate the persistance of replication-competent virus in responding patients. METHODS Prospective open-label pilot study. Patients received a combination of zidovudine, didanosine and lamivudine. Viral sequencing of the reverse transcriptase gene was performed before therapy and during follow-up. HIV-1 RNA and DNA as well as CD4 and CD8 T lymphocyte subsets were measured in blood and in lymph node biopsies during therapy. Isolated blood CD4 T cells were cultured in conditions that improved HIV isolation. Three patients received in vivo interleukin-2 and gamma-interferon in order to try to identify intracellular pools of replication-competent virus. SETTING A tertiary care general hospital. PATIENTS Fifteen patients observed within 28 days following the acute retroviral syndrome. RESULTS After a mean follow-up of 27.5+/-2.9 months, plasma RNA remained < 20 copies/ml (four patients), fluctuated between 20 and 120 copies/ml (six patients) or rebounded (five patients). M184V and/or T215Y mutations were demonstrated in two of these last five patients. Proviral DNA in peripheral blood mononuclear cells (PBMC) decreased by an average of -1 log after 16+/-3 months, reaching undetectable levels in three patients. The culture of isolated CD4 T cells yielded virus in all but two patients. These last were characterized by a waning antibody reactivity on the Western blot, undetectable proviral DNA in PBMC and undetectable RNA in lymph nodes. Cytokine administration in vivo had no effect in one patient and unmasked plasma RNA in the other. Stopping therapy in the first patient led to a rebound in plasma RNA. CONCLUSION Despite a lack of detectable plasma viral activity in some patients after 3 years of triple nucleoside therapy administered since the acute retroviral syndrome, replication-competent virus can still be demonstrated.

Human Immunodeficiency Virus Type 1 Dynamics in Different Lymphoid Tissue Compartments

Human immunodeficiency virus type 1 (HIV-1) RNA was measured in total lymph node (LN) tissue and isolated LN mononuclear cells (LNMC) in sequential LN biopsy samples from 1 patient with primary HIV-1 infection and from 5 previously untreated patients with chronic disease. HIV-1 RNA levels were an average of 210-fold higher in total LN tissue compared with levels in LNMC, even during primary infection, when circulating antibodies were absent. After the patients were treated with a three- or four-drug regimen, total HIV-1 RNA decreased exponentially in total LN tissue and in LNMC (mean half-lives of 8.5 +/- 1.8 and 7.9 +/- 2.2 days, respectively). In addition, the evolution of the infectious virus in LNMC was analyzed for the 5 patients with chronic disease: Titers decreased, with a mean half-life of 7.5 +/- 2.3 days. Extracellular virions are the most important virus compartments in LNs; however, they exhibit the same dynamics as virions situated in LNMC, with a mean virus decay half-life of approximately 1 week.