Roel A. Coutinho

Macrophage-tropic variants initiate human immunodeficiency virus type 1 infection after sexual, parenteral, and vertical transmission.

Macrophage-tropic, non-syncytium-inducing, HIV-1 variants predominate in the asymptomatic phase of infection and may be responsible for establishing infection in an individual exposed to the mixture of HIV-1 variants. Here, genotypical and phenotypical characteristics of virus populations, present in sexual, parenteral, or vertical donor-recipient pairs, were studied. Sequence analysis of the V3 domain confirmed the presence of a homogeneous virus population in recently infected individuals. Biological HIV-1 clones were further characterized for syncytium inducing capacity on the MT2 cell line and for macrophage tropism as defined by the appearance of proviral DNA upon inoculation of monocyte-derived macrophages. Both sexual and parenteral transmission cases revealed a selective outgrowth in the recipient of the most macrophage-tropic variant(s) present in the donor. In three out of five vertical transmission cases, more than one highly macrophage-tropic virus variant was present in the child shortly after birth, suggestive of transmission of multiple variants. In three primary infection cases, homogeneous virus populations of macrophage-tropic, non-syncytium-inducing variants were present prior to seroconversion, thus excluding humoral immunity as the selective pressure in favour of macrophage-tropic variants. These observations may have important implications for vaccine development.

T cell telomere length in HIV-1 infection: No evidence for increased CD4(+) T cell turnover

Progression to acquired immunodeficiency syndrome (AIDS) has been related to exhaustion of the regenerative capacity of the immune system resulting from high T cell turnover. Analysis of telomeric terminal restriction fragment (TRF) length, a marker for cellular replicative history, showed that CD8+ T cell TRF length decreased but CD4+ T cell TRF length was stable during the course of human immunodeficiency virus type-1 (HIV-1) infection, which was not explained by differential telomerase activity. This observation provides evidence that turnover in the course of HIV-1 infection can be increased considerably in CD8+ T cells, but not in CD4+ T cells. These results are compatible with CD4+ T cell decline in HIV-1 infection caused by interference with cell renewal.

Full participation in harm reduction programmes is associated with decreased risk for human immunodeficiency virus and hepatitis C virus: evidence from the Amsterdam Cohort Studies among drug users

Objectives To investigate the impact of harm-reduction programmes on HIV and hepatitis C virus (HCV) incidence among ever-injecting drug users (DU) from the Amsterdam Cohort Studies (ACS). Methods The association between use of harm reduction and seroconversion for human immunodeficiency virus (HIV) and/or hepatitis C virus (HCV) was evaluated using Poisson regression. A total of 714 DU were at risk for HIV and/or HCV during follow-up. Harm reduction was measured by combining its two most important components—methadone dose and needle exchange programme (NEP) use—and looking at five categories of participation, ranging from no participation (no methadone in the past 6 months, injecting drug use in the past 6 months and no use of NEP) to full participation (≥ 60 mg methadone/day and no current injecting or ≥ 60 mg methadone/day and current injecting but all needles exchanged). Results Methadone dose or NEP use alone were not associated significantly with HIV or HCV seroconversion. However, with combination of these variables and after correction for possibly confounding variables, we found that full participation in a harm reduction programme (HRP) was associated with a lower risk of HIV and HCV infection in ever-injecting drug users (DU), compared to no participation [incidence rate ratio 0.43 (95% CI 0.21–0.87) and 0.36 (95% CI 0.13–1.03), respectively]. Conclusions In conclusion, we found that full participation in HRP was associated with a lower incidence of HCV and HIV infection in ever-injecting DU, indicating that combined prevention measures—but not the use of NEP or methadone alone—might contribute to the reduction of the spread of these infections.

Increase in HCV incidence among men who have sex with men in Amsterdam most likely caused by sexual transmission

We retrospectively screened 1836 men who have sex with men (MSM) participating in the Amsterdam Cohort Studies (1984-2003) for hepatitis C virus (HCV) antibodies. HCV incidence was 0.18/100 person-years (PY) in human immunodeficiency virus (HIV)-positive MSM (8/4408 PY [95% confidence interval {CI}, 0.08-0.36]) but was 0/100 PY in MSM without HIV (0/7807 PY [95% CI, 0.00-0.05]). After 2000, HCV incidence among HIV-positive men increased 10-fold to 0.87/100 PY (5/572 PY [95% CI, 0.28-2.03]). Additional hospital cases (n=34) showed that MSM in Amsterdam who acquired HCV infection after 2000 reported high rates of ulcerative sexually transmitted infections (59%) and rough sexual techniques (56%), denied injection drug use, and were infected mainly with the difficult-to-treat HCV genotypes 1 (56%) and 4 (36%). Phylogenetic analysis showed 3 monophyletic clusters of MSM-specific HCV strains. The emergence of an MSM-specific transmission network suggests that HIV-positive MSM with high-risk sexual behaviors are at risk for sexually acquired HCV. Targeted prevention and routine HCV screening among HIV-positive MSM is needed to deter the spread of HCV.

Hepatitis C virus infections among HIV-infected men who have sex with men: an expanding epidemic.

Background:Since 2000 outbreaks of sexually transmitted hepatitis C Virus (HCV) infections have been reported among HIV-infected men who have sex with men (MSM). We studied the prevalence and determinants of HCV-infection among MSM attending a large sexually transmitted infection (STI) clinic in the Netherlands. Methods:In 2007–2008, 3125 attendees of the STI clinic Amsterdam, including 689 MSM, participated in an anonymous biannual crosssectional survey. Participants were interviewed and screened for HIV and HCV antibodies. Additionally, all anti-HCV positive and HIV-infected individuals were tested for HCV RNA. Using phylogenetic analysis, HCV strains of the STI clinic attendees were compared with those isolated from MSM with acute HCV in 2000–2007. Determinants of HCV-infection were analysed using logistic regression. Results:Two of 532 (0.4%) HIV-negative MSM and 28 of 157 (17.8%) HIV-positive MSM were infected with HCV. Over the study period, HCV prevalence among HIV-infected MSM increased (14.6%–20.9%). Seven of 28 (25.0%) HIV/HCV coinfected MSM had acute HCV infection. Only five of 28 (17.9%) HIV/HCV coinfected MSM ever injected drugs (IDU). HIV-infection, IDU, fisting and gamma hydroxy butyrate (GHB)-use were significantly associated with HCV-infection. Phylogenetic analyses revealed a high degree of MSM-specific clustering. Conclusion:We found a high and increasing HCV prevalence in HIV-infected MSM. Though not statistically significant, this trend, and the relatively large proportion of acute infections suggest ongoing transmission of HCV in HIV-positive MSM. Regardless of IDU, rough sexual techniques and use of recreational drugs were associated with HCV-infection; phylogenetic analysis supported sexual transmission. Targeted prevention, like raising awareness and routine testing, is needed to stop the further spread among HIV-infected MSM, and to prevent possible spillover to HIV-negative MSM.

Seroconversion for human herpesvirus 8 during HIV infection is highly predictive of Kaposi's sarcoma.

Background:The finding of antibodies against human herpesvirus 8 (HHV-8) is associated with the occurrence of Kaposis sarcoma in persons infected with HIV. However, the predictive value of HHV-8 antibodies for Kaposis sarcoma in HIV infection is unknown. Methods:The Amsterdam Cohort Studies on HIV infection and AIDS started in 1984 for homosexual men and in 1985 for injecting drug users. Serum samples from 1459 homosexual men and 1167 drug users were tested for antibodies to recombinant HHV-8 lytic-phase capsid (ORF65) antigen and latent-phase nuclear (ORF73) antigen. Individuals were retrospectively identified as HHV-8-positive or HHV-8-negative at enrolment or HHV-8 seroconverter during the study. Kaposis sarcoma-free survival time was compared between HIV-infected men who were positive for HHV-8 at enrolment and those who later seroconverted for HHV-8. Hazard ratios were estimated for Kaposis sarcoma, lymphoma, and opportunistic infection according to the HHV-8 serostatus. Results:The incidence of HHV-8 seroconversion among drugs users was 0.7 per 100 person-years based on 31 seroconversions, whereas an incidence of 3.6 was found among homosexual men based on 215 seroconversions. The hazard ratio for Kaposis sarcoma was 3.15 (95% CI: 1.89–5.25) in HIV-infected individuals if HHV-8 antibodies were present either at enrolment or at HIV seroconversion. In HIV-infected persons who later seroconverted to HHV-8, Kaposis sarcoma developed more rapidly: hazard ratio of 5.04 (95% CI: 2.94–8.64), an additional risk of 1.60 (95% CI: 1.01–2.53; P = 0.04). Time-dependent adjustment for CD4+ cell count and HIV RNA had no impact on the additional risk, although the CD4+ cell count was an independent risk factor for Kaposis sarcoma. HHV-8 infection did not increase the risk of AIDS-related lymphoma or opportunistic infections. Conclusions:The incidence of HHV-8 infection is higher in homosexual men than in drug users. The presence of HHV-8 antibodies in HIV-infected persons increases the risk of Kaposis sarcoma. Among HIV-infected persons, those who subsequently seroconvert for HHV-8 are at highest risk. These results strongly confirm the causal role of HHV-8 in Kaposis sarcoma and emphasize the clinical relevance of HHV-8 seroconversion before and after the HIV infection.

A resurgent HIV-1 epidemic among men who have sex with men in the era of potent antiretroviral therapy

Objective:Reducing viral load, highly active antiretroviral therapy has the potential to limit onwards transmission of HIV-1 and thus help contain epidemic spread. However, increases in risk behaviour and resurgent epidemics have been widely reported post-highly active antiretroviral therapy. The aim of this study was to quantify the impact that highly active antiretroviral therapy had on the epidemic. Design:We focus on the HIV-1 epidemic among men who have sex with men in the Netherlands, which has been well documented over the past 20 years within several long-standing national surveillance programs. Methods:We used a mathematical model including highly active antiretroviral therapy use and estimated the changes in risk behaviour and diagnosis rate needed to explain annual data on HIV and AIDS diagnoses. Results:We show that the reproduction number R(t), a measure of the state of the epidemic, declined early on from initial values above two and was maintained below one from 1985 to 2000. Since 1996, when highly active antiretroviral therapy became widely used, the risk behaviour rate has increased 66%, resulting in an increase of R(t) to 1.04 in the latest period 2000–2004 (95% confidence interval 0.98–1.09) near or just above the threshold for a self-sustaining epidemic. Hypothetical scenario analysis shows that the epidemiological benefits of highly active antiretroviral therapy and earlier diagnosis on incidence have been entirely offset by increases in the risk behaviour rate. Conclusion:We provide the first detailed quantitative analysis of the HIV epidemic in a well defined population and find a resurgent epidemic in the era of highly active antiretroviral therapy, most likely predominantly caused by increasing sexual risk behaviour.

Diagnostic and clinical implications of anorectal lymphogranuloma venereum in men who have sex with men: a retrospective case-control study.

BACKGROUND Recently, outbreaks of anorectal lymphogranuloma venereum (LGV) have occurred among men who have sex with men (MSM). This study identifies risk factors and clinical predictors of LGV to determine the implications for clinical practice. METHODS The Chlamydia trachomatis serovars for all MSM who had anorectal chlamydia diagnosed at a sexually transmitted infection clinic in Amsterdam, The Netherlands, in 2002 and 2003 were retrospectively typed; 87 persons were infected with C. trachomatis serovar L2b and received a diagnosis of LGV. MSM infected with C. trachomatis serovars A-K and who thus had non-LGV anorectal chlamydia (n = 377) and MSM who reported having receptive anorectal intercourse but who did not have anorectal chlamydia (n = 2677) served as 2 separate control groups. Risk factors and clinical predictors were analyzed by multivariate logistic regression. Receiver operating characteristic curves were used to determine clinical relevance. RESULTS HIV seropositivity was the strongest risk factor for LGV (odds ratio for patients with LGV vs. those with non-LGV chlamydia, 5.7 [95% confidence interval, 2.6-12.8]; odds ratio for patients with LGV vs. control subjects without chlamydia, 9.3 [95% confidence interval, 4.4-20.0]). Proctoscopic findings and elevated white blood cell counts in anorectal smear specimens were the only clinically relevant predictors for LGV infection (area under the curve of the receiver operating characteristic curve, > 0.71). Use of these 2 parameters and HIV infection status provided the highest diagnostic accuracy (for MSM with anorectal chlamydia, the area under the curve was > 0.82; sensitivity and specificity were 89% and 50%, respectively). CONCLUSIONS LGV testing is recommended for MSM with anorectal chlamydia. If routine LGV serovar typing is unavailable, we propose administration of syndromic LGV treatment for MSM with anorectal chlamydia and either proctitis detected by proctoscopic examination, > 10 white blood cells/high-power field detected on an anorectal smear specimen, or HIV seropositivity.

Predictors of rapid progression to AIDS in HIV-1 seroconverters.

OBJECTIVE To determine whether at the time of HIV-1 seroconversion rapid progressors to AIDS and a low CD4+ count can be distinguished by the clinical presentation of primary HIV-1 infection and serological and immunological characteristics. DESIGN Prospective cohort study on HIV-1 infection in homosexual men. SETTING The Municipal Health Service, Amsterdam, The Netherlands. SUBJECTS One hundred and eight men who seroconverted for HIV-1 during follow-up. MAIN OUTCOME MEASURES Progression to AIDS and progression to a CD4+ lymphocyte count < 200 x 10(6)/l. RESULTS Symptomatic primary HIV infection with fever and skin rash, absence of anti-HIV core and transient HIV p24 antigenemia were independent predictors of progression to AIDS at the time of HIV-1 seroconversion. A low CD4+ count immediately after seroconversion and the calendar year were independent predictors of progression to a low CD4+ count at the time of HIV-1 seroconversion. CONCLUSIONS Even in the earliest stage of HIV-1 infection a small group of individuals at high risk for rapid progression to AIDS can be recognized by the clinical presentation of primary HIV infection, the presence of HIV p24 antigenaemia and the absence of a serological response to HIV core protein.

HIV incidence on the increase among homosexual men attending an Amsterdam sexually transmitted disease clinic: using a novel approach for detecting recent infections.

ObjectiveDramatic increases have occurred in sexually transmitted diseases (STD) and in sexual risk behaviour among homosexual men in Amsterdam and internationally. We investigated whether these trends indicate a resurgence of the HIV epidemic. MethodsHIV incidence was determined among homosexual attendees of an STD clinic in Amsterdam, who had participated in semi-annual anonymous unlinked cross-sectional HIV prevalence studies from 1991 to 2001. Stored HIV-seropositive samples were tested with a less-sensitive HIV assay and, if non-reactive, were further tested for the presence of antiretroviral drugs, indicative of the use of highly active antiretroviral therapy. Seropositive men who tested non-reactive on the less-sensitive assay and had not used antiretroviral drugs were classified as recently infected (< 170 days). Annual HIV incidence and its changes were examined. ResultsAmong 3090 homosexual participants (median age 34 years), 454 were HIV infected, of whom 37 were recently infectioned. From 1991 to 2001 the overall incidence was 3.0 infections/100 person-years. Incidence increased over time (P = 0.02) and, strikingly, the increase was evident in older (⩾ 34 years) men (P < 0.01), but not in the young. Of men recently infected, 84% (n = 31) were unaware of their infection and 70.3% (n = 26) had a concurrent STD. These 26 men reportedly had sex with a total of 315 men in the preceding 6 months. ConclusionHIV incidence is increasing among homosexual attendees of an STD clinic. It is imperative to trace recently infected individuals, because they are highly infectious, and can thus play a key role in the spread of HIV.