Kailapuri G. Murugavel

High Prevalence of Hiv, Hiv/hepatitis C Virus Coinfection, and Risk Behaviors Among Injection Drug Users in Chennai, India: A Cause for Concern

Objective:To estimate the prevalence of HIV and hepatitis C virus (HCV) and hepatitis B virus (HBV) coinfections and current risk behaviors among HIV-positive and -negative injection drug users (IDUs) in Chennai, India. Methods:Cross-sectional analysis of a convenience sample of 912 IDUs recruited between March 2004 and April 2005. Specimens were tested for HIV, HBV, and HCV. Adjusted prevalence ratios (PRs) were estimated using Poisson regression with robust variance estimates. Results:The prevalence of HIV, hepatitis B surface antigen, and anti-HCV were 29.8%, 11.1%, and 62.1%, respectively. Among HIV-infected IDUs, prevalence of coinfection with anti-HCV and hepatitis B surface antigen/anti-HCV were 86% and 9.2%, respectively. In multivariate analysis, injecting at a dealers place (PR: 1.57) and duration of injection drug use ≥11 years (PR: 3.02) were positively associated with prevalent HIV infection. Contrastingly, alcohol consumption ≥1 per week (PR: 0.55) was negatively associated with HIV. HIV-positive IDUs were as or more likely compared with HIV-negative IDUs to report recent high-risk injection-related behaviors. Conclusions:There is a high burden of HIV, HCV, and HBV among IDUs that needs to be addressed by improving access to therapies for these infections; furthermore, preventive measures are urgently needed to prevent further spread of HIV, HBV, and HCV in this vulnerable population.

A reliable and inexpensive EasyCD4 assay for monitoring HIV-infected individuals in resource-limited settings.

Summary: Serial measurements of absolute CD4+ T-lymphocyte counts are required to initiate and gauge response to therapy and monitor disease progression. Hence, there is an urgent need to evaluate the accuracy and validity of low-cost CD4+ T-cell count assays. Tripotassium EDTA blood specimens from HIV-infected individuals were studied using a novel flow cytometric assay (EasyCD4 assay; Guava Technologies, Hayward, CA) in comparison with standard flow cytometry (FACSCount; Becton Dickinson Immunocytometry Systems, San Jose, CA). The sensitivity, specificity value by EasyCD4 assay in enumerating absolute CD4+ T-cell counts of less than 200 cells/&mgr;L were 95% and 100%, respectively. Bland-Altman analysis showed close agreement, with the EasyCD4 assay yielding CD4+ T-cell counts a mean difference of −26 cells/&mgr;L (95% confidence interval, −96 to 44 cells/&mgr;L) higher than by flow cytometry. Our data suggest that EasyCD4 assay could be a useful alternative assay to conventional flow cytometry, may be appropriate for use in resource-limited settings.

Changes in antioxidant profile among HIV-infected individuals on generic highly active antiretroviral therapy in southern India

OBJECTIVE The role of oxidative stress in disease progression has been shown to be more complicated in HIV-infected individuals receiving highly active antiretroviral therapy (HAART) compared to those who remain treatment-naïve. This study examined the changes in the antioxidant profile of HIV-infected subjects who remained HAART-naïve due to a high CD4 cell count and HIV-negative controls, over a 12-month follow-up period at YRG CARE, a tertiary HIV referral centre in southern India. METHODS We prospectively studied 35 HIV-infected participants (18 on d4T+3TC+EFV (stavudine+lamivudine+efavirenz), eight on AZT+3TC+EFV (zidovudine+lamivudine+efavirenz), and nine who were antiretroviral therapy-naïve) and 20 HIV-negative controls. Antioxidant profile (total antioxidant status, glutathione reductase, glutathione peroxidase, uric acid, ceruloplasmin, zinc, and albumin), CD4 cell count, plasma viral load, dietary intake, and history of smoking and alcohol use were determined at baseline and at twelve months. RESULTS At 12 months, participants on HAART showed a significant increase in glutathione peroxidase (baseline: 1765 vs. 12 months: 2850U/l; p<0.001) and albumin (3.6 vs. 4.4g/dl; p<0.001), and a significant decrease in glutathione reductase (52.6 vs. 50.5U/l; p=0.054) and uric acid (5.4 vs. 4.8mg/dl; p=0.027) compared to baseline. Also HAART-naïve participants had a significant increase in albumin (baseline: 3.7 vs.12 months: 4.3g/dl; p=0.023) and a significant decrease in zinc levels (baseline: 79.0 vs.12 months: 74.5microg/dl; p=0.052) from baseline to 12 months. HIV-negative subjects had a significant increase in glutathione reductase at 12 months from baseline (baseline: 37 vs.12 months: 39U/l; p=0.002). No significant difference in total antioxidant status, ceruloplasmin, and zinc levels were observed in HAART-experienced subjects and negative controls over the 12-month follow-up period. CONCLUSION This study documents changes in antioxidants over a period of time in HAART-experienced subjects in a southern India setting.

HIV rates and risk behaviors are low in the general population of men in southern India but high in alcohol venues: Results from 2 probability surveys

Background:As the HIV epidemic continues to expand in India, empiric data are needed to determine the course of the epidemic for high-risk populations and the general population. Methods:Two probability surveys were conducted in Chennai slums among a household sample of men and alcohol venue patrons (“wine shops”) to compare HIV and other sexually transmitted disease (STD) prevalence and to identify STD behavioral risk factors. Results:The wine shop sample (n = 654) had higher rates of HIV and prevalent STDs (HIV, herpes simplex virus 2 [HSV-2], syphilis, gonorrhea, or chlamydia) compared with the household sample (n = 685) (3.4% vs. 1.2%, P = 0.007 and 21.6% vs. 11.8%, P < 0.0001, respectively). High-risk behaviors in the household sample was rare (<4%), but 69.6% of wine shop patrons had >2 partners, 58.4% had unprotected sex with a casual partner, and 54.1% had exchanged sex for money in the past 3 months. A multivariate model found that older age, ever being married, ever being tested for HIV, and having unprotected sex in the past 3 months were associated with STD prevalence in wine shop patrons. Conclusions:Prevalent HIV and STDs, and sexual risk behaviors are relatively low among the general population of men. We found that men who frequent alcohol venues practice high-risk behaviors and have high rates of STDs, including HIV, and may play an important role in expanding the Indian epidemic.

The intersection between sex and drugs: a cross-sectional study among the spouses of injection drug users in Chennai, India

BackgroundIt is estimated that there are up to 1.1 million injection drug users (IDUs) in India; the majority are likely married. We characterize HIV, hepatitis B (HBV) and hepatitis C (HCV) prevalence and the risk environment of a sample of spouses of IDUs.MethodsA cohort of 1158 IDUs (99% male) was recruited in Chennai, India from 2005-06. A convenience sample of 400 spouses of the male IDUs in this cohort was recruited in 2009. A risk assessment questionnaire was administered and a blood sample collected. Logistic regression was used to identify factors associated with prevalent HIV.ResultsMedian age was 31 years; thirteen percent were widowed and 7% were not currently living with their spouse. Only 4 (1%) reported ever injecting drugs; Twenty-two percent and 25% reported ever using non-injection drugs and alcohol, respectively. The majority had one lifetime sexual partner and 37 (9%) reporting exchanging sex. Only 7% always used condoms with their regular partner. HIV, HBV and HCV prevalence were 2.5%, 3.8% and 0.5%, respectively; among spouses of HIV+ IDUs (n = 78), HIV prevalence was 10.3%. The strongest predictor of HIV was spousal HIV status (OR: 17.9; p < 0.001). Fifty-six percent of women had ever experienced intimate partner violence; Eight-six percent reported sexual violence.ConclusionsOur finding of a 10-fold higher HIV prevalence among spouses of IDUs compared with general population women indicates their vulnerability; prevalence is likely to increase given the context of low condom use and frequent sexual violence. Prevention efforts directed at IDUs should also include programs for spouses.

Does CD4+CD25+foxp3+ cell (Treg) and IL-10 profile determine susceptibility to immune reconstitution inflammatory syndrome (IRIS) in HIV disease?

HIV-specific T-lymphocyte responses that underlie IRIS are incomplete and largely remain hypothetical. Of the several mechanisms presented by the host to control host immunological damage, Treg cells are believed to play a critical role. Using the available experimental evidence, it is proposed that enormous synthesis of conventional FoxP3- Th cells (responsive) often renders subjects inherently vulnerable to IRIS, whereas that of natural FoxP3+ Treg cell synthesis predominate among subjects that may not progress to IRIS. We also propose that IRIS non-developers generate precursor T-cells with a high avidity to generate CD4+CD25+FoxP3+ Tregs whereas IRIS developers generate T-cells of intermediate avidity yielding Th0 cells and effector T-cells to mediate the generation of proinflammatory cytokines in response to cell-signaling factors (IL-2, IL-6 etc.). Researchers have shown that IL-10 Tregs (along with TGF-β, a known anti-inflammatory cytokine) limit immune responses against microbial antigens in addition to effectively controlling HIV replication, the prime objective of HAART. Although certain technical limitations are described herein, we advocate measures to test the role of Tregs in IRIS.

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

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 cytokines 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.

Alpha-fetoprotein as a tumor marker in hepatocellular carcinoma: investigations in south Indian subjects with hepatotropic virus and aflatoxin etiologies

OBJECTIVES The prevalence of hepatitis B virus (HBV) is reportedly the main cause of hepatocellular carcinoma (HCC) in India, where hepatitis C virus (HCV)-associated HCC is believed to be relatively less prevalent. We verified the usefulness of alpha-fetoprotein (AFP) as a tumor marker and analyzed the influence of viral etiology on AFP levels in HCC. METHODS Of a total of 1012 cases with liver disease, 202 were investigated for the presence of AFP (142 HCC cases, 30 cirrhosis cases, and 30 chronic liver disease (CLD) cases). In addition, serum samples from 30 healthy patients, 30 hepatitis B surface antigen (HBsAg) carriers, and 30 acute viral hepatitis cases were included as controls. AFP was quantitatively determined using a commercial ELISA (Quorum Diagnostics, Canada). Out of the 142 HCC cases screened for AFP, aflatoxin B1 (AFB1) detection was carried out in 38 HCC cases using an in-house immunoperoxidase test. RESULTS In HBV and HCV co-infected HCC cases, the AFP positivity was 85.7%. In HBV alone-associated HCC, the positivity was 62.9%, and 54.5% of AFB1 positive HCC cases showed AFP positivity. In HBV and HCV negative HCC cases, the positivity was 20.5%, and in HCV-associated HCC it was 17.6%. The HBV/HCV co-infected group and HBV alone positive HCC cases had significantly elevated levels of AFP. When AFP positivity was analyzed based on the marker profile of HBV, 89.7% of AFP positive cases were HBV-DNA positive. CONCLUSIONS The overall positivity pattern of AFP in HCC does indicate that higher levels of AFP are observed with hepatitis virus positivity, especially with HBV. Further studies must be carried out to correlate the serum levels of AFP with the size, number, and degree of differentiation of HCC nodules.

Ethnic variation in certain hematological and biochemical reference intervals in a south Indian healthy adult population

BACKGROUND We established the biochemical and hematological reference intervals among a south Indian healthy adult population attending an HIV referral centre in Chennai, southern India. METHODS In a cross sectional study, 213 study subjects (129 male and 84 female) were studied between March and August 2005. All of the parameters were analyzed using standard hematological and biochemical techniques. RESULTS Certain biochemical (viz. total bilirubin, alanine transaminase, albumin, creatinine, total protein, lipid profile, creatine phosphokinase, uric acid and lactate) and hematological (mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration and lymphocyte levels) parameters presented higher upper limits. In addition, the upper limits of white blood cell count, platelet count, hematocrit, red blood cell count and hemoglobin level were low in comparison to the currently reported ranges. CONCLUSION Ethnic variation in reference intervals was observed in certain biochemical and hematological analytes in a south Indian adult population.

TB-IRIS after initiation of antiretroviral therapy is associated with expansion of preexistent th1 responses against mycobacterium tuberculosis antigens

Background:The role of T-cell responses against Mycobacterium tuberculosis antigens in tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) is unclear. Methods:Peripheral blood mononuclear cells from 45 HIV patients with treated TB, of whom 12 developed TB-IRIS, were collected at weeks 0, 2, and 6 of antiretroviral therapy (ART). Production of interferon-gamma (IFN-&ggr;) and interleukin-2 by T cells after stimulation with purified protein derivative (PPD) or early secretory antigenic target-6 (ESAT-6) and T-cell expressions of CCR5 and CXCR3 were assessed by flow cytometry. IFN-&ggr; and CXCL10 were assayed by enzyme-linked immunosorbent assay. Results:TB-IRIS patients had higher proportions of PPD- and ESAT-6–reactive IFN-&ggr;+CD4+ and CD3+CD4− T cells at weeks 0, 2, and 6. IFN-&ggr; levels were also higher in peripheral blood mononuclear cell culture supernatants at all times with PPD but only at weeks 2 and 6 with ESAT-6. There were few differences for interleukin-2. CXCL10 levels in supernatants after PPD and ESAT-6 stimulation were only higher at week 6. CXCR3+/CCR5+CD4+ T cells were higher at week 2, and CCR5+CD4+ T cells were higher at week 6. Conclusions:TB-IRIS is associated with Th1 responses against M. tuberculosis antigens by CD4+ and CD3+CD4− T cells that are present before ART and amplified afterward. It is unclear if these cause immunopathology or reflect a high pathogen load.