Chantal Maurice

Efficacy of trimethoprim-sulphamethoxazole prophylaxis to decrease morbidity and mortality in HIV-1-infected patients with tuberculosis in Abidjan, Côte d'Ivoire: a randomised controlled trial

BACKGROUND There is a high incidence of opportunistic infection among HIV-1-infected patients with tuberculosis in Africa and, consequently, high mortality. We assessed the safety and efficacy of trimethoprim-sulphamethoxazole 800 mg/160 mg (co-trimoxazole) prophylaxis in prevention of such infections and in decrease of morbidity and mortality. METHODS Between October, 1995, and April, 1998, we enrolled 771 HIV-1 seropositive and HIV-1 and HIV-2 dually seroreactive patients who had sputum-smear-positive pulmonary tuberculosis (median age 32 years [range 18-64], median CD4-cell count 317 cells/microL) attending Abidjans four largest outpatient tuberculosis treatment centres. Patients were randomly assigned one daily tablet of co-trimoxazole (n=386) or placebo (n=385) 1 month after the start of a standard 6-month tuberculosis regimen. We assessed adherence to study drug and tolerance monthly for 5 months and every 3 months thereafter, as well as rates of admission to hospital. FINDINGS Rates of laboratory and clinical adverse events were similar in the two groups. 51 patients in the co-trimoxazole group (13.8/100 person-years) and 86 in the placebo group (25.4/100 person-years) died (decrease In risk 46% [95% CI 23-62], p<0.001). 29 patients on co-trimoxazole (8.2/100 person-years) and 47 on placebo (15.0/100 person-years) were admitted to hospital at least once after randomisation (decrease 43% [10-64]), p=0.02). There were significantly fewer admissions for septicaemia and enteritis in the co-trimoxazole group than in the placebo group. INTERPRETATION In HIV-1-infected patients with tuberculosis, daily co-trimoxazole prophylaxis was well tolerated and significantly decreased mortality and hospital admission rates. Our findings may have important implications for improvement of clinical care for such patients in Africa.

Cervicovaginal Secretory Antibodies to Human Immunodeficiency Virus Type 1 (HIV-1) that Block Viral Transcytosis through Tight Epithelial Barriers in Highly Exposed HIV-1–Seronegative African Women

Antibodies to human immunodeficiency virus (HIV) of the IgA, IgG, and IgM isotypes and high levels of the HIV suppressive beta-chemokine RANTES (regulated on activation, normally T cell expressed and secreted) were found in the cervicovaginal secretions (CVSs) of 7.5% of 342 multiply and repeatedly exposed African HIV-seronegative female sex workers. The antibodies are part of a local compartmentalized secretory immune response to HIV, since they are present in vaginal fluids that are free of contaminating semen. Cervicovaginal antibodies showed a reproducible pattern of reactivity restricted to gp160 and p24. Locally produced anti-env antibodies exhibit reactivity toward the neutralizing ELDKWA epitope of gp41. Study results show that antibodies purified from CVSs block the transcytosis of cell-associated HIV through a tight epithelial monolayer in vitro. These findings suggest that genital resistance to HIV may involve HIV-specific cervicovaginal antibody responses in a minority of highly exposed HIV-seronegative women in association with other protecting factors, such as local production of HIV-suppressive chemokines.

Sensitivity and Specificity of Human Immunodeficiency Virus Rapid Serologic Assays and Testing Algorithms in an Antenatal Clinic in Abidjan, Ivory Coast

ABSTRACT To evaluate serologic testing algorithms for human immunodeficiency virus (HIV) based on a combination of rapid assays among persons with HIV-1 (non-B subtypes) infection, HIV-2 infection, and HIV-1–HIV-2 dual infections in Abidjan, Ivory Coast, a total of 1,216 sera with known HIV serologic status were used to evaluate the sensitivity and specificity of four rapid assays: Determine HIV-1/2, Capillus HIV-1/HIV-2, HIV-SPOT, and Genie II HIV-1/HIV-2. Two serum panels obtained from patients recently infected with HIV-1 subtypes B and non-B were also included. Based on sensitivity and specificity, three of the four rapid assays were evaluated prospectively in parallel (serum samples tested by two simultaneous rapid assays) and serial (serum samples tested by two consecutive rapid assays) testing algorithms. All assays were 100% sensitive, and specificities ranged from 99.4 to 100%. In the prospective evaluation, both the parallel and serial algorithms were 100% sensitive and specific. Our results suggest that rapid assays have high sensitivity and specificity and, when used in parallel or serial testing algorithms, yield results similar to those of enzyme-linked immunosorbent assay-based testing strategies. HIV serodiagnosis based on rapid assays may be a valuable alternative in implementing HIV prevention and surveillance programs in areas where sophisticated laboratories are difficult to establish.

Genetic Analysis of Human Immunodeficiency Virus in Abidjan, Ivory Coast Reveals Predominance of HIV Type 1 Subtype A and Introduction of Subtype G

To better understand the molecular epidemiology of HIV genetic diversity in Abidjan, Ivory Coast, we performed a genetic analysis of 170 HIV-1-seropositive specimens representing newly diagnosed tuberculosis patients (n = 143) and women monitored in a mother-to-child transmission cohort study (n = 27). Preliminary screening with RFLP presumptively classified 162 (95.3%) of these as subtype A. The envelope region of 108 specimens was subtyped by sequence analysis: 102 (94.4%) were subtype A, 2 (1.9%) were subtype D, and 4 (3.7%) were subtype G. Subtyping gag and env regions of the genome suggested that five of the six nonsubtype A isolates exhibited a potentially mosaic structure. A comparative phylogenetic analysis of HIV-1 subtype A C2V3 from 27 Ivory Coast and 21 Ugandan sequences revealed a striking clustering among Ivory Coast variants, and an independent segregation from Ugandan subtype A. Despite independent clustering with other subtype A specimens, limited variability of the V3 loop apex was observed; the globally predominant V3 motif, GPGQ, represented 90.1% of the HIV-1 strains. This study demonstrates that clade A is the predominant HIV-1 subtype in HIV-seropositive individuals in Abidjan, Ivory Coast and that these strains are phylogenetically distinct from other subtype A strains observed in East Africa.

Dual infection with human immunodeficiency virus type 1 and type 2: impact on HIV type 1 viral load and immune activation markers in HIV-seropositive female sex workers in Abidjan, Ivory Coast.

To determine the impact of dual infection with HIV-1 and HIV-2 on HIV-1 viral load and markers of immune activation among HIV-seropositive FSWs in Abidjan, we analyzed blood samples obtained from consenting HIV-seropositive FSWs attending a confidential clinic between September 1996 and June 1997 in Abidjan. Among HIV-1 and HIV-2 dually seropositive FSWs, polymerase chain reaction (PCR) testing with HIV-1 and HIV-2 primers was used to differentiate between FSWs who were PCR positive only for HIV-1 and those positive for both HIV-1 and HIV-2 (dually infected). Of the 203 FSWs, 151 (74%) were HIV-1 seropositive only (median age, 26 years), 4 (2%) were HIV-2 seropositive, and 48 (24%) were dually seropositive (median age, 30 years). Of the 48 dually seropositive FSWs, 33 (69%) were dually infected and 15 (31%) were dually seropositive. Median CD4+ T cell counts per microliter were not significantly different among the three groups (525 for HIV-1 positive only, 502 for dually infected, and 416 for dually seropositive) (p = 0.14). Median viral load (log10 copies/ml) was not significantly different among the HIV-1-only FSWs (4.8 log10 copies/ml) compared with the 32 dually infected FSWs (4.6 log10 copies/ml) and 14 dually seropositive FSWs (4.7 log10 copies/ml; p = 0.95). Median levels of HLA-DR immune activation were increased in both CD4+ and CD8+ T cells for the dually infected (n = 27) FSWs compared with those infected with HIV-1 only (n = 123) (p = 0.019 and p = 0.01, respectively). Dual infection does not appear to influence levels of HIV-1 viral load in vivo. However, levels of HLA-DR are higher among FSWs dually infected with HIV-1 and HIV-2 than among those infected with HIV-1 only.

Suppressed cellular alloimmune responses in HIV-exposed seronegative female sex workers

Particular human leucocyte antigen (HLA) polymorphisms have been associated with a reduced risk of HIV transmission. However, protective alloimmune responses expected to result from such a genetic predisposition have not been demonstrated. To this end, we analysed and compared cellular and humoral alloimmune responses in a cohort of female sex workers who remained human immunodeficiency virus (HIV)‐seronegative despite more than 3 years of high‐risk sexual activity (ESN FSWs) with those of low‐risk HIV‐seronegative female blood donors in Abidjan, Côte d’Ivoire. ESN FSWs showed significantly lower allostimulated CD69 expression and secretion of interferon‐γ, macrophage inflammatory protein (MIP)‐1β and RANTES (regulated upon activation, normal T‐cell expressed and secreted) by lymphocytes than controls. In contrast, ESN FSWs showed significantly higher mitogen‐stimulated CD69 expression and secretion of tumour necrosis factor‐α and MIP‐1β than controls. Suppression of cellular alloimmune responses among ESN FSWs was associated with a higher self‐reported frequency of unprotected sex. Levels of anti‐HLA class I alloantibodies in plasma were not significantly different between ESN FSWs and controls. These findings indicate that frequent sexual exposure to multiple partners results in suppression rather than activation of cellular alloimmune responses. Our data support the hypothesis that suppressed cellular alloimmune responses may play a role in protection against HIV infection.

Cellular Human Immunodeficiency Virus (HIV)–Protective Factors: A Comparison of HIV-Exposed Seronegative Female Sex Workers and Female Blood Donors in Abidjan, Côte d’Ivoire

Cellular factors that may protect against human immunodeficiency virus (HIV) infection were investigated in 27 HIV-exposed seronegative (ESN) female sex workers (FSWs) and 27 HIV-seronegative female blood donors. Compared with blood donors, ESN FSWs had significantly decreased expression levels of C-X-C chemokine receptor 4 (CXCR4), but not of C-C chemokine receptor 5, on both memory (P<.001) and naive (P=.041) CD4(+) T cells. CXCR4 down-regulation was associated with prolonged duration of commercial sex work by ESN FSWs. CD38 expression on CD8(+) T cells was significantly increased among ESN FSWs, compared with that among blood donors (P=.017). There were no differences in HLA-DR and CD62L expression between blood donors and ESN FSWs. Proportions of T cells producing the beta-chemokines RANTES (regulated on activation, normally T cell-expressed and -secreted), macrophage inflammatory protein (MIP)-1alpha, and MIP-1beta or the cytokines interleukin (IL)-2, IL-4, interferon-gamma, and tumor necrosis factor-alpha, were similar in the 2 groups. These data indicate that ESN FSWs differ from HIV-seronegative female blood donors with respect to immunological factors that have no clear protective potential against HIV transmission.

Polymorphism in protease and reverse transcriptase and phenotypic drug resistance of HIV-1 recombinant CRF02_AG isolates from patients with no prior use of antiretroviral drugs in Abidjan, Côte d'Ivoire.

To the Editor: Access to antiretroviral drug therapy (ART) is increasing in Africa. For instance, today about 3200 HIVinfected patients have initiated ART in Côte d’Ivoire as part of the UNAIDS Drug Access Initiative. Because most drugs were designed, tested, and validated against HIV-1 subtype B viruses, a wider implementation of ART in Africa requires evaluation of the role of drug resistance since limited data exist regarding resistance profiles of HIV-1 non-B strains. In Côte d’Ivoire and most of West Africa, about 75% of HIV-1 strains are CRF02_AG, which is a complex mosaic with subtypes A or G in the pol region. Limited studies of naive persons infected with HIV-1 non-B subtypes have examined mutational resistance profiles in the protease region or protease and reverse transcriptase regions of HIV-1. However, only limited phenotypic testing, which is a direct measure of resistance in the presence of drugs, has been done. Here we describe baseline polymorphism and phenotypic antiretroviral drug-resistant mutational profiles of patients infected with HIV-1 CRF02_ AG recombinant forms in Abidjan, Côte d’Ivoire. We analyzed ART drug resistance among a consecutively enrolled subset of 20 ART-naive HIV-1-infected patients who participated in the UNAIDS Drug Initiative (DAI). For sequencing of the Pol genes, we have used the TrueGene HIV-1 genotyping assay (version 2.5) (Visible Genetics, Toronto, Ontario, Canada). Amino acid sequences obtained were compared with a reference HIV-1 sequence HXBr2, using the ADRA program from Los Alamos, New Mexico. Mutations were classified as primary or secondary and associated or not associated with ARV drug resistance, according to the consensus statement on ARV drug resistance. The Bioedit (www. mbio.nesu.edu) program was used to align the 20 HIV pol sequence with the HXBr2 HIV-1 reference sequence. For identification of secondary HIV-1 resistance mutations or baseline polymorphisms we used the ADRA program from www.hiv.lanl.gov site. Phenotypic resistance was performed by a recombinant virus assay technology (Antivirogram, Virco NV, Mechelen, Belgium) as described previously. Of the 20 patients, 8 (40%) were men; all the patients were infected with the HIV-1 CRF02_AG strains. Median age was 38 years (interquartile range [IQR] 30–40], median CD4 T-cell count was 84 cells/μL (IQR, 13–137), and median viral load was 5.0 log10 RNA copies/mL (IQR, 5.0–6.0). We successfully sequenced all 20 protease and 19 RT regions. Compared with the HIV-1 subtype B (HXBr2) amino acid sequence, the RT gene was less conserved than protease gene. No primary genotypic resistance mutation was observed in any of the 20 protease or 19 RT sequences. Baseline polymorphisms were restricted to the following positions in the protease: M36I (n = 20, 100%), K20I (n = 19, 95%), L63P/H/L/S (n = 6, 30%), L10I/V (n = 4, 21%). Secondary mutations for the RT were at positions: L214F (n = 16, 84%), I135V (n = 12, 60%), R211K (n = 6, 31.6%), L283I (n = 2, 10.5%), V189I (n = 1, 5.3%), and W88S (n = 1, 5.3%) for the RT. Of the 20 patients’ viruses, 12 (60%) had 2 protease mutations, and 8 (45%) had >2 mutations. Of the 19 RT sequences, 3 (15.8%) had a single mutation, 9 (47.4%) had 2 mutations, and 7 (36.8%) >2 mutations. We observed polymorphisms at positions not yet described to be genotypic resistance mutations in the protease and in the RT deduced amino acids. Of the 19 HIV-1 patients’ viruses tested for phenotypic resistance, we observed low-level phenotypic resistance in 4 patients (21%) (Table 1). No correlation was observed between any secondary genotypic mutations and phenotypic resistance, as not all patients with the R211K, L214F, I135V, and L210M mutations had phenotypic resistance (Table 1). One patient had a 5.1-fold resistance to delarvidine (DLV) and had the I135V, the R211K, and L214F mutations. One patient had a 4.4fold resistance to DLV but no sequence information was available for the RT gene. Lastly, one patient’s virus had a 6-fold resistance to EFV and had the L214F and I135V mutations. Our results show that none of the 20 patients infected with the recombinant virus CRF02_AG had primary genotypic resistance mutations; however, low levels of phenotypic resistance were found in 4 patients’ viruses. The high proportion of M36I (100%) and K20I (94%) in the protease region is comparable with what others have reported with other HIV-1 non-B subtypes. We found a high percentage of the R211K (31.6%), L214F (84%), and I135V (60%) mutations in the 19 HIV-1 RT sequences analyzed. The R211K mutation has also been shown to be present in high percentage in non-B subtype. The 135 and 283 RT positions have been strongly associated with reduced susceptibility to efavirenz, nevirapine, and delavirdine. In the present study these mutations are observed in 13 samples but reduced susceptibility to drugs was observed in only 3 samples. Our findings that 4 ART-naive HIV-1 patients had low levels of phenotypic resistance are not clear. However, natural resistance to nevirapine (NVP) has been reported in HIV-1 ART-naive patients. Taken together, our results suggest that persons infected with the CRF02_AG

Quantification of RNA in HIV Type 1 Subtypes D and G by NucliSens and Amplicor Assays in Abidjan, Ivory Coast

We have compared the performance of the NucliSens and the standard and modified HIV Monitor assays to quantify HIV-1 RNA plasma viral load in 12 tuberculosis patients infected with HIV-1 env subtype D (n = 3) and env subtype G (n = 9) in Ivory Coast. RNA was quantified in all nine subtype G specimens by the modified Amplicor HIV Monitor (mean, 4.6 log10 copies/ml; range, 3.1-6.3 log10/ml), in seven specimens by NucliSens (mean, 4.4 log10 copies/ml; range, 2.7-5.5 log10 copies/ml), and in 6 specimens by the standard Amplicor HIV Monitor assay (mean, 4.2 log10 copies/ml; range, 3.5-5.0 log10 copies/ml). All three subtype D samples were amplified by both the modified Amplicor HIV Monitor (mean, 4.5 log10 copies/ml; range, 3.8-5.1 log10 copies/ml) and NucliSens (mean, 3.8 log10 copies/ml; range, 2.8-5.0 log10 copies/ml); two samples were quantified by the standard Amplicor HIV Monitor assay (mean, 3.0 log10 copies/ml; range, 2.4-3.6 log10 copies/ml). Our preliminary results suggest that the modified Amplicor HIV Monitor can accurately quantify HIV-1 RNA viral load in persons infected with subtype D and G strains.