Mark Atkins

Transmission of hepatitis C virus among HIV-positive homosexual men and response to a 24-week course of pegylated interferon and ribavirin.

Objective:To evaluate treatment outcome of acute hepatitis C virus (HCV) in HIV-positive individuals. Design:Open-label, prospective study conducted in London, January 1997-December 2003. Methods:Patients in whom acute HCV infection had been diagnosed had sequential HCV RNA levels measured at 0, 4, 12, 24, 32, and 48 weeks. If HCV RNA positive at 12 weeks, patients were offered pegylated interferon α-2b 1.5 μg/kg/wk and ribavirin 800-1200 mg/d for 24 weeks. Patients with increasing HCV RNA titers were offered treatment earlier. Results:Fifty male homosexuals with a mean age 37 years were identified: 44 from abnormal liver function test results, 4 from sexual contact with an HCV-positive partner, and 2 at HIV seroconversion. Overall, 12 individuals became HCV RNA negative spontaneously. This was significantly associated with high baseline median CD4+ count (P = 0.029), CD4+ count >500 cells/mm3 (P = 0.017), and lower HCV RNA titers (P = 0.017). Only 27 patients accepted treatment, 16 (59%) of whom reached sustained virologic response. This was associated with higher peak mean alanine aminotransferase (P < 0.001) and higher baseline CD4% (P = 0.041). Conclusions:Sustained virologic response rates in HIV-positive patients treated for acute HCV infection are lower than in HIV-negative subjects. Because a high percentage of individuals seroconvert spontaneously, treatment should be delayed until after 12 weeks.

HIV testing in non-traditional settings--the HINTS study: a multi-centre observational study of feasibility and acceptability.

Background UK guidelines recommend routine HIV testing in healthcare settings if the local diagnosed HIV prevalence >2/1000 persons. This prospective study assessed the feasibility and acceptability, to patients and staff, of routinely offering HIV tests in four settings: Emergency Department, Acute Care Unit, Dermatology Outpatients and Primary Care. Modelling suggested the estimated prevalence of undiagnosed HIV infection in attendees would exceed 1/1000 persons. The prevalence identified prospectively was not a primary outcome. Methods Permanent staff completed questionnaires assessing attitudes towards routine HIV testing in their workplace before testing began. Subsequently, over a three-month period, patients aged 16–65 were offered an HIV test by study staff. Demographics, uptake, results, and departmental activity were collected. Subsets of patients completed questionnaires. Analyses were conducted to identify factors associated with test uptake. Findings Questionnaires were received from 144 staff. 96% supported the expansion of HIV testing, but only 54% stated that they would feel comfortable delivering testing themselves, with 72% identifying a need for training. Of 6194 patients offered a test, 4105 (66·8%) accepted (61·8–75·4% across sites). Eight individuals were diagnosed with HIV (0–10/1000 across sites) and all transferred to care. Younger people, and males, were more likely to accept an HIV test. No significant associations were found between uptake and ethnicity, or clinical site. Questionnaires were returned from 1003 patients. The offer of an HIV test was acceptable to 92%. Of respondents, individuals who had never tested for HIV before were more likely to accept a test, but no association was found between test uptake and sexual orientation. Conclusions HIV testing in these settings is acceptable, and operationally feasible. The strategy successfully identified, and transferred to care, HIV-positive individuals. However, if HIV testing is to be included as a routine part of patients’ care, additional staff training and infrastructural resources will be required.

Routine HIV testing in the emergency department: tough lessons in sustainability

Routine HIV testing in nonspecialist settings has been shown to be acceptable to patients and staff in pilot studies. The question of how to embed routine HIV testing, and make it sustainable, remains to be answered.

Non-hepatitis virus associated mixed essential cryoglobulinemia

CASE PRESENTATION A 42-year-old Indo-Asian woman presented to her local emergency department with a 1-week history of joint pains, fatigue, and episodic macroscopic hematuria. She was prescribed oral cephalexin and analgesia for a presumed urinary tract infection. Subsequently, she developed a skin rash, leg edema, and recurrent epistaxis, prompting withdrawal of her antibiotics. Her condition failed to improve over the ensuing week, and on return to the emergency department, she was found to have developed progressive edema, hematuria, and proteinuria on urine dipstick testing. Blood tests showed a rise in the serum creatinine over 1 week from 114 to 240 μmol/l. The patient was transferred to our renal unit for further investigation and management.

The significance of Epstein–Barr virus detected in the cerebrospinal fluid of people with HIV infection

Epstein–Barr virus (EBV) is detected in the cerebrospinal fluid (CSF) in people with HIV infection who develop primary cerebral lymphoma (PCL). However, EBV may also be detected in the CSF of patients without PCL, and here the significance is uncertain.

Automatic oral fluid-based HIV testing in HIV screening programmes: automatic for the people.

UK guidelines recommend routine HIV testing in general clinical settings when the local HIV prevalence is > 0.2%. During pilot programmes evaluating the guidelines, we used laboratory‐based testing of oral fluid from patients accepting tests. Samples (n = 3721) were tested manually using the Bio‐Rad Genscreen Ultra HIV Ag‐Ab test (Bio‐Rad Laboratories Ltd, Hemel Hempstead, UK). This was a methodologically robust method, but handling of samples was labour intensive. We performed a validation study to ascertain whether automation of oral fluid HIV testing using the fourth‐generation HIV test on the Abbott Architect (Abbott Diagnostics, Maidenhead, UK) platform was possible.

Clearance of hepatitis C virus RNA from serum in HIV/hepatitis C virus coinfection indicates eradication from peripheral blood mononuclear cells.

Objectives:The objectives of this study are to determine the frequency of hepatitis C virus (HCV) RNA persistence in peripheral blood mononuclear cells (PBMCs) of HIV-positive patients with clearance of the virus from serum and to identify the presence of any ongoing replication. Design:This is a prospective cross-sectional study. Methods:HIV antibody-positive individuals with previous exposure to HCV, but not current infection with HCV, were recruited. Blood was taken to allow identification of HCV RNA in both serum and PBMCs. Intracellular HCV was extracted using the QIAamp RNA Blood MiniKit. Reverse transcriptase-PCR was performed using a modification of the COBAS TaqMan HCV Test for use with the high pure system. Results:Twenty-six HIV-positive individuals were recruited to the study. All had previously been infected with HCV. Six individuals had spontaneously cleared HCV, 10 had achieved sustained virological response following 24 weeks of pegylated interferon and ribavirin for acute HCV, and 10 had achieved sustained virological response following standard pegylated interferon and ribavirin therapy for chronic HCV. None demonstrated HCV RNA persistence in either serum or PBMCs. Conclusion:Our findings lend support to the view that clearance of HCV RNA from serum in HIV/HCV coinfection indicates eradication from PBMCs. Thus, absence of serum HCV RNA 6 months after the end of therapy can be used as a marker of treatment success for interferon-based therapies. However, the advent of small molecule HCV inhibitors may require us to rethink our definitions of response and cure.

A Randomised, Placebo-Controlled, First-In-Human Study of a Novel Clade C Therapeutic Peptide Vaccine Administered Ex Vivo to Autologous White Blood Cells in HIV Infected Individuals

Background Preclinical studies of overlapping 15mer peptides, spanning SIV, SHIV or HIV, pulsed on autologous PBMC ex vivo have demonstrated high level, virus-specific T cell responses and viral suppression in non-human primates (NHP). Opal-HIV-Gag(c) consists of 120 synthetic 15mer peptides spanning Clade C, consensus Gag, manufactured to current good manufacturing practice; having been evaluated in a good laboratory practice toxicology study in Macaca mulatta. We evaluated the safety and preliminary immunogenicity of such peptides administered intravenously after short-duration ex vivo incubation, to HIV-positive adults on suppressive antiretroviral therapy. Methods and Findings A first-in-human, placebo-controlled, double-blind, dose escalation study was conducted. Twenty-three patients with virus suppressed by antiretroviral therapy were enrolled in four groups 12 mg (n = 6), 24 mg (n = 6), 48 mg (n = 2) or matching placebo (n = 8). Treatment was administered intravenously after bedside enrichment of 120 mL whole blood for white cells using a closed system (Sepax S-100 device), with ex vivo peptide admixture (or diluent alone) and 37°C incubation for one hour prior to reinfusion. Patients received 4 administrations at monthly intervals followed by a 12-week observation post-treatment. Opal-HIV-Gag(c) was reasonably tolerated at doses of 12 and 24 mg. There was an increased incidence of temporally associated pyrexia, chills, and transient/self-limiting lymphopenia in Opal-HIV-Gag(c) recipients compared to placebo. The study was terminated early, after two patients were recruited to the 48 mg cohort; a serious adverse event of hypotension, tachycardia secondary to diarrhoea occurred following a single product administration. An infectious cause for the event could not be identified, leaving the possibility of immunologically mediated product reaction. Conclusions A serious, potentially life-threatening event of hypotension led to early, precautionary termination of the study. In the absence of a clearly defined mechanism or ability to predict such occurrence, further development of Opal-HIV-Gag(c) will not be undertaken in the current form. Registration ClinicalTrials.gov NCT01123915; EudraCT: 2008-005142-23

Non-Immunogenicity of Overlapping Gag Peptides Pulsed on Autologous Cells after Vaccination of HIV Infected Individuals

Background HIV Gag-specific CD4+ and CD8+ T-cell responses are important for HIV immune control. Pulsing overlapping Gag peptides on autologous lymphocytes (OPAL) has proven immunogenic and effective in reducing viral loads in multiple pigtail macaque studies, warranting clinical evaluation. Methodology We performed a phase I, single centre, placebo-controlled, double-blinded and dose-escalating study to evaluate the safety and preliminary immunogenicity of a novel therapeutic vaccine approach ‘OPAL-HIV-Gag(c)’. This vaccine is comprised of 120 15mer peptides, overlapping by 11 amino acids, spanning the HIV Gag C clade sequence proteome, pulsed on white blood cells enriched from whole blood using a closed system, followed by intravenous reinfusion. Patients with undetectable HIV viral loads (<50 copies/ml plasma) on HAART received four administrations at week 0, 4, 8 and 12, and were followed up for 12 weeks post-treatment. Twenty-three people were enrolled in four groups: 12 mg (n = 6), 24 mg (n = 7), 48 mg (n = 2) or matching placebo (n = 8) with 18 immunologically evaluable. T-cell immunogenicity was assessed by IFNγ ELIspot and intracellular cytokine staining (ICS). Results The OPAL-HIV-Gag(c) peptides were antigenic in vitro in 17/17 subjects. After vaccination with OPAL-HIV-Gag(c), 1/6 subjects at 12 mg and 1/6 subjects at 24 mg dose groups had a 2- and 3-fold increase in ELIspot magnitudes from baseline, respectively, of Gag-specific CD8+ T-cells at week 14, compared to 0/6 subjects in the placebo group. No Gag-specific CD4+ T-cell responses or overall change in Rev, Nef, Tat and CMV specific responses were detected. Marked, transient and self-limiting lymphopenia was observed immediately post-vaccination (4 hours) in OPAL-HIV-Gag(c) but not in placebo recipients, with median fall from 1.72 to 0.67 million lymphocytes/mL for active groups (P<0.001), compared to post-placebo from 1.70 to 1.56 lymphocytes/ml (P = 0.16). Conclusion/Significance Despite strong immunogenicity observed in several Macaca nemestrina studies using this approach, OPAL-HIV-Gag(c) was not significantly immunogenic in humans and improved methods of generating high-frequency Gag-specific T-cell responses are required. Name of Registry ClinicalTrials.gov, Registry number: NCT01123915, URL trial registry database: http://www.clinicaltrials.gov/ct2/results?term=OPAL-HIV-1001&Search=Search

JC – a forgotten foe or a foe to be forgotten?

Progressive multifocal leucoencephalopathy (PML) is an opportunistic infection caused by JC virus (JCV) in immunodeficient individuals. The pathological hallmark is irreversible white matter demyelination. The diagnosis is supported by the clinical presentation (subacute motor deficits, ataxia and cortical visual symptoms), characteristic findings on magnetic resonance imaging (MRI) of the brain (bilateral, asymmetric, well-demarcated, T2 hyperintense white matter lesions with no oedema) and JCV detection by polymerase chain reaction (PCR) in the cerebrospinal fluid (CSF). We obtained retrospective data for all JCV PCR test results performed on CSF samples between March 2002 and November 2011 from HIV-seropositive patients at Chelsea & Westminster Hospital NHS Trust. In total, 564 CSF samples from HIV-positive patients were tested for JCV during 117 months, of which seven (1.24%) were positive. Contemporaneous MRI imaging of the brain was performed in 360 of 564 patients (63.8%) (Table 1). The gold standard for diagnosis of PML is brain biopsy. However, this is often unsafe, unethical or unnecessary. The combination of an appropriate clinical presentation and typical findings on brain MRI is often sufficient to make the diagnosis, for which highly active antiretroviral therapy (HAART) is the evidence-based treatment[1]. The utility of JCV PCR testing in the CSF of HIV-seropositive individuals is under question (sensitivity for MRI-proven PML = 24–89.5% [2,3]). Unsurprisingly, the use of HAART has been shown to reduce the sensitivity of this test (57.5% vs. 89.5% in patients not on HAART [3]). JCV was infrequently detected in the CSF of HIVpositive individuals over a 9-year period. Although JCV was more frequently found in the CSF of patients with MRI findings suggestive of PML, the detection rate was still <5%, suggesting a very high false negative rate for this test. CSF JCV testing should not be performed routinely when MRI of the brain is normal or suggestive of a noninfectious pathology. Even when PML is suspected on MRI of the brain, JCV CSF is unlikely to be positive. We conclude that many of these tests are unnecessary, offering a potential to significantly reduce costs without compromising patient care.