Flavia Lillo

Human Papillomavirus Infection and Associated Cervical Disease in Human Immunodeficiency Virus-Infected Women: Effect of Highly Active Antiretroviral Therapy

To determine the effect of highly active antiretroviral therapy (HAART) on high-risk human papillomavirus (HR-HPV) infections and related cervical lesions, the virologic and cytologic markers of HPV infection were prospectively studied in 163 human immunodeficiency virus (HIV)-infected women, including 27 untreated, 62 treated with reverse transcriptase inhibitors, and 74 treated with HAART. A high prevalence of both infections with HR-HPV types (68%) and squamous intraepithelial lesions (SILs; low grade, 20.2%; high grade, 6.2%) was observed. The risks of infection and disease were inversely correlated with CD4 cell counts (P=.015 and P=.022, respectively). During the observation period (mean, 15.4 months; range, 6-24 months), CD4 cell counts increased significantly only in subjects receiving HAART (P<.001). Persistence of HR-HPV infection and progression of SILs were comparable in the 3 groups. These results indicate that, even in the era of HAART, HIV-infected women should be monitored carefully for the emergence of high-grade SILs and cervical cancer.

HIV, human papillomavirus, and cervical neoplasia and cancer in the era of highly active antiretroviral therapy.

The objective of this study was to review the literature on the epidemiological association between human papillomavirus (HPV), HIV, and cervical neoplasia, and the impact of highly active antiretroviral therapy (HAART) on this association. MEDLINE was searched using the terms ‘human papillomavirus’, ‘HPV’, ‘HIV’, ‘cervix’, ‘neoplasm’, and ‘antiretroviral’ to identify articles published before December 2006. HIV-infection was strongly associated with a higher prevalence, incidence, and persistence of HPV infection and correlated with prevalence, incidence, persistence, and progression of squamous intraepithelial lesions. The association between HIV and invasive cervical carcinoma has been more difficult to establish, but is now fully recognized. HAART seems to have little, if any, beneficial effect on the natural history of intraepithelial lesions in HIV-positive women. Despite this fact, HAART, does increase the life expectancy of HIV-positive women. Therefore, it remains important to closely monitor HPV-related disease in women with HIV who are receiving HAART, particularly in regions of the world where cervical screening is not available routinely.

Plasma levels of soluble CD30, tumour necrosis factor (TNF)-α and TNF receptors during primary HIV-1 infection : correlation with HIV-1 RNA and the clinical outcome

Objectives: The immunological and virological events associated with primary HIV‐1 infection have a major impact on the course of HIV‐1 disease, and the identification of early predictors during primary HIV infection is critical for the therapeutic stratergy. Design and methods: Eighteen consecutive patients with primary HIV infection were followed for a median of 398 days. Clinical status, CD4+ T‐cell counts, and plasma samples were obtained weekly from enrolment until week 6, then at weeks 12, 24 and 52, and every 6 months thereafter. Seroconversion was assessed by anti‐HIV‐1/2 antibodies and Western blot analysis. HIV‐1 RNA in plasma was quantified by Amplicor HIV Monitor test. Samples were assayed for immune complex‐dissociated p24 antigen, tumour necrosis factor (TNF)‐&agr;, soluble TNF receptor (sTNFR)‐1, sTNFR‐II, sCD30 and sCD8 by enzyme immunoassays. Outcome was defined as entering clinical category B or C according to the Centers for Disease Control and Prevention criteria. As a control group, we included 23 HIV‐1‐negative healthy blood donors. Results: Plasma levels of sCD30, TNF‐&agr; and sTNFR were significantly higher in HIV‐1‐infected patients than in controls, and were positively correlated with each other and with values of HIV‐1 RNA. Patients who developed an outcome (n = 4) had significantly higher levels of sCD30, TNF‐&agr; and sTNFR compared with those who did not. Multivariate logistic regression analysis showed that sCD30 and TNF‐&agr; were the best predictors of outcome independently of CD4+ T‐cell counts. Conclusions: During primary HIV infection, a persistent immune activation may be associated with a poor clinical outcome. The identification of sCD30 and TNF‐&agr; levels in plasma as early predictors of outcome in primary HIV infection, may direct the implementation of early therapeutic strategies in patients with elevated risk of disease progression.

Viral load and burden modification following early antiretroviral therapy of primary HIV-1 infection.

OBJECTIVE The aim of this study was to monitor the effect on viral DNA and RNA of early treatment with highly aggressive antiretroviral therapy (HAART), in comparison with zidovudine (ZDV) monotherapy or no treatment in subjects with primary HIV-1 infection (PHI). DESIGN AND METHODS Of the 28 patients selected, four were untreated, four received ZDV alone, 10 received a triple combination (ZDV, lamivudine (3TC) and saquinavir (SQV)) and 10 received a quadruple combination (ZDV, 3TC, SQV and ritonavir (RTV)). Seroconversion was monitored by means of Western blot profile analysis. A quantitative polymerase chain reaction (PCR) assay in the HIV gag region was used to monitor viral DNA and the nucleic acid sequence based amplification (NASBA) system for viraemia (HIV-RNA). RESULTS There was a certain level of heterogeneity in the baseline values of HIV-DNA and RNA. Early HAART led to a rapid recovery in the number of CD4 cells and the CD4/CD8 cell ratio and a reduction in HIV-RNA to undetectable levels, which was significantly greater than in the untreated patients or those treated with ZDV. Although a reduction in DNA levels was also observed in the HAART-treated subjects, this variation was not significant. CONCLUSIONS The parameters of viral replication and CD4 cell recovery were only slightly better in the patients receiving ZDV monotherapy than in the untreated patients, thus confirming that the course of the infection is hardly affected by the monotherapy. The early introduction of HAART greatly reduces plasma viraemia and restores the number of CD4 cells for up to 1 year. HIV-DNA remains detectable, although at low levels, thus confirming that the early established reservoir of infected cells is little affected. Longer periods of observation and the introduction of complementary approaches, such as immunomodulatory therapies, will provide further information concerning the possibility of radically interfering with the natural evolution of the disease.

Determination of Human Papillomavirus (HPV) Load and Type in High-Grade Cervical Lesions Surgically Resected from HIV-Infected Women during Follow-up of HPV Infection

BACKGROUND The role of human papillomavirus (HPV) load and the importance of multiple-strain HPV infections as biomarkers for the development of cervical disease were evaluated in human immunodeficiency virus (HIV)-positive women. METHODS A total of 108 samples were analyzed, 64 of which were obtained from 16 HIV-positive women who underwent surgical resection of the cervical cone for treatment of a histologically confirmed high-grade cervical intraepithelial neoplasm (cases) and 44 of which were obtained from 22 HIV-positive women who had high-risk HPV but a negative colposcopy result (controls). Each patient underwent periodic examinations at 6-12-month intervals that included colposcopy, Papanicolaou testing, biopsy (if indicated), and cervical brushing for HPV testing. Viral typing was performed by reverse dot-blot hybridization and quantification of viral load by in-house real-time PCR and commercial assays. RESULTS Analysis of the cervical-brush samples collected when high-grade squamous intraepithelial lesions were diagnosed revealed that all cases had HPV loads that were significantly higher than those of controls (P=.0004 and P=.0003, by PCR and the Hybrid Capture 2 index [Digene], respectively). Decreasing concentrations of HPV load were observed when comparing samples obtained before and after treatment (P<.0001). The number and type of HPV strains that were detected were not statistically different between cases and controls. CONCLUSIONS The significantly higher HPV load detected in women with high-grade cervical dysplasia, as well as the dramatic decrease in the load after surgical removal of the lesion, suggest that HPV load is a possible prognostic marker of high-grade SIL.

Cytomegalovirus Pneumonia in AIDS Patients: Value of Cytomegalovirus Culture From BAL Fluid and Correlation With Lung Disease

OBJECTIVES To verify the value of cytomegalovirus (CMV) cultures of BAL fluid vs postmortem lung histopathology in detecting CMV pneumonia, and to correlate the BAL viral dose with the number of CMV inclusion bodies (CMV-IB) in the lung tissue of AIDS patients. DESIGN Retrospective analysis of 434 BALs and 40 autopsies involving 307 AIDS patients; clinical follow-up lasted 10 months. PATIENTS AND METHODS The 40 patients who died within 20 days of undergoing BAL were divided on the basis of histopathologic findings into subjects with and without CMV-IB in the lung tissue. The relationship between the BAL viral dose and CMV lung infection was evaluated by counting the early antigen (CMV-EA) positive cells/200 microL of BAL and the number of CMV-IB/mm2 of lung tissue. RESULTS The predictive value of BAL virus isolation for the diagnosis of CMV pneumonia was 61% for positive and 100% for negative results. The patients with the largest number of CMV-IB had CMV-EA counts from 2 to 840; in those with a moderate and small number, the CMV-EA counts were, respectively, from 11 to 700 and 2 to 300. Among the patients surviving up to 10 months after the BAL index sample, the frequency of recurrent extrapulmonary CMV abnormalities was 27% in those with positive and 7% in those with negative cultures. CONCLUSIONS BAL CMV cultures from AIDS patients have a very high negative and relatively low positive predictive value for CMV pneumonia. The presence and replication of CMV in the lung may lead to systemic dissemination as suggested by the higher probability of CMV extrapulmonary diseases. Viral titers do not seem to be related to the degree of lung damage.

IFN-γ Produced by Human Papilloma Virus-18 E6-Specific CD4+ T Cells Predicts the Clinical Outcome after Surgery in Patients with High-Grade Cervical Lesions

Cervical neoplastic lesions are associated with infection by high-risk human papilloma viruses (HPVs). HPV-16 and HPV-18 are the most common genotypes. It has been proposed that development of HPV-16-positive cervical lesions is associated with impaired CD4+ T cell immunity against early Ags. The aim of the study was to evaluate whether this impairment also applies to HPV-18. We investigated the presence and the quality of anti-HPV-18 E6 CD4+ T cell responses in the blood of 37 consecutive patients with high-grade cervical lesions, 25 normal donors, and 20 cord bloods. The immune infiltrate in the cervical lesions was also evaluated. The characteristics of the responses were correlated to the clinical outcome. We found that one or more HPV-18 E6 peptides, containing naturally processed epitopes, were able to induce a response in 40–50% of the patients, depending on the effector function tested. Importantly, these percentages rose to 80–100% when HPV-18-positive patients were considered. HPV-18 E6-specific CD4+ T cells produced mixed Th1/Th2 responses and statistical analysis of the cytokines produced revealed that the amount of IFN-γ released could predict infection persistence and/or disease relapse after surgery. Finally, we found that a higher number of infiltrating CD4+ and T-bet+ T cells in the lesions correlated with a favorable clinical outcome. Our results strongly suggest a relevant role for CD4+ T cells in the control of the HPV-18 compared with HPV-16 infections in patients with high-grade cervical lesions and identify an immunologic parameter potentially useful for patients’ stratification.

HIV AND HTLV INFECTIONS IN 1305 TRANSFUSION DEPENDENT THALASSAEMICS IN ITALY

ConclusionsAntibodies to HIV-1, HIV-2, HTLV-I and HTLV-II were detected in 2.76, 0, 0.23 and 0.08% of patients, respectively. The residual risk of HIV-1 infection through blood transfusion after the implementation of anti-HIV-1 screening in blood donors in Italy was approximately 1:50 000 blood units; this is based on an approximate number of 200000 blood units administered to our group of patients during 1986–1990 and the occurrence of four new anti-HIV-1 seroconversions. Seroconversions to HTLV-I/II suggest that these viruses are present in Italian blood donors.

Anti-CD4 antibodies in exposed seronegative adults and in newborns of HIV type 1-seropositive mothers : A follow-up study

In this work, an ELISA for the quantitative determination of IgG anti-CD4 autoantibodies was validated and utilized in the follow-up of two cohorts of HIV-1-exposed seronegative subjects. A serum with an arbitrarily assigned concentration of 100,000 units/ml was used as a reference, and the detection limit, inter- and intraassay variability, and analytical recovery were calculated. The study subjects included adults sexually exposed to HIV-1-infected partners and the newborns of HIV-1+ mothers who seroreverted by 18 months of age. Some of these individuals were studied over an 18- to 24-month period. The detection limit of the assay was 2000 AU/ml. Intra- and interassay variability was, respectively, 3.92 and 3.90%. Analytical recovery in an assay in which a fixed amount of anti-CD4 antibodies was added to different samples was 98%. A proportion of adults (16 of 47, 34.0%) and babies (12 of 27, 44.4%) had significantly higher concentrations of anti-CD4 antibodies. Among them, 8 adults maintained the same concentration as that found in the first determination; on the other hand, 12 babies born to seronegative mothers showed a significant increase in the concentration of anti-CD4 antibodies during their first months of life. In conclusion, anti-CD4 antibodies can be measured using a validated ELISA. They represent a serologic trait that is quantitatively conserved in HIV-1-exposed seronegative adult individuals and is actively acquired by newborns to HIV+ mothers.

Role of CD4 and CCR5 Levels in the Susceptibility of Primary Macrophages to Infection by CCR5-Dependent HIV Type 1 Isolates

Macrophages are a preferred target for sexually transmitted human immunodeficiency virus type 1 (HIV-1) isolates that use CCR5 as a coreceptor in combination with CD4. To assess whether the susceptibility of MDMs to infection by an R5 isolate was influenced by CD4 and/or CCR5 expression, levels of membrane CD4 or CCR5 transcripts at the time of infection and ID50 values 15 days postinfection were measured in cultures of primary macrophages infected with HIV-1(10005). To analyze the data, subjects were divided so as to maximize differences in the levels of CD4 or CCR5 expression between groups. Indeed, the difference in CD4 expression between the CD4high (MFI, 16.7 +/- 2.2) and CD4low (MFI, 6.7 +/- 0.7) groups attained high significance (p < 0.005). Of note, susceptibility to infection of MDMs isolated from CD4high donors was strikingly enhanced as compared with CD4low subjects, as shown by a fourfold increase in ID50 titers at day 15 postinfection (p < 0.002). In contrast, no significant difference in ID50 was apparent when the subjects were grouped according to the levels of CCR5 transcripts, even though CCR5 expression in the two groups differed significantly (p = 0.01). These results suggest that, regardless of variations among individuals, the intensity of CD4 expression in macrophages is such that CCR5 levels are above the threshold required for efficient HIV-1 infection. Consistent with this hypothesis, macrophages from three additional donors selected for high CD4 expression and low CCR5 transcripts were found to be highly susceptible to HIV-1 infection.