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A healthy 40-year-old woman was diagnosed with necrotizing fasciitis 2 days after her husband's death from the same infectious process. Prompt identification and immediate surgical intervention prevented a similar result in this patient. Additional investigation into both patients' medical records found the inciting organism to be group A streptococcus. Although the exact mechanism of inoculation is unknown, the spread of this infection within a household prompts the question of whether antibiotic prophylaxis should be given among close contacts in future cases of necrotizing fasciitis.

BACKGROUND: MK-0518 is a novel HIV-1 integrase strand transfer inhibitor with potent in vitro activity against HIV-1 (95% inhibitory concentration [IC95] = 33 nM in 50% human serum) and good bioavailability in uninfected subjects. This study explored the antiretroviral activity and safety of MK-0518 versus placebo for 10 days as monotherapy in antiretroviral therapy-naive HIV-1-infected patients with plasma HIV-1 RNA levels of at least 5000 copies/mL and CD4 T-cell counts of at least 100 cells/mm. METHODS: This was a multicenter, double-blind, randomized, placebo-controlled 2-part study, with the first part using MK-0518 in 1 of 4 doses (100, 200, 400, and 600 mg) versus placebo (randomized 1:1:1:1:1) given twice daily for 10 days of monotherapy. Patients were monitored for safety, pharmacokinetic parameters, and antiretroviral effect. RESULTS: Thirty-five patients were enrolled (6-8 patients per treatment group) and completed 10 days of therapy; the mean baseline log10 HIV RNA level ranged from 4.5 to 5.0 copies/mL in each group. On day 10, the mean decrease from baseline in the log10 HIV RNA level was -0.2 copies/mL for the placebo group and -1.9, -2.0, -1.7 and -2.2 log10 copies/mL for the MK-0518 100-, 200-, 400-, and 600-mg treatment groups, respectively. All dose groups had superior antiretroviral activity compared with placebo (P < 0.001 for comparison of each dose with placebo). At least 50% of patients in each MK-0518 dose group achieved an HIV RNA level

Summary Background Two randomised, placebo-controlled trials—BENCHMRK-1 and BENCHMRK-2—investigated the efficacy and safety of raltegravir, an HIV-1 integrase strand-transfer inhibitor. We report final results of BENCHMRK-1 and BENCHMRK-2 combined at 3 years (the end of the double-blind phase) and 5 years (the end of the study). Methods Integrase-inhibitor-naive patients with HIV resistant to three classes of drug and who were failing antiretroviral therapy were enrolled. Patients were randomly assigned (2:1) to raltegravir 400 mg twice daily or placebo, both with optimised background treatment. Patients and investigators were masked to treatment allocation until week 156, after which all patients were offered open-label raltegravir until week 240. The primary endpoint was previously assessed at 16 weeks. We assessed long-term efficacy with endpoints of the proportion of patients with an HIV viral load of less than 50 copies per mL and less than 400 copies per mL, and mean change in CD4 cell count, at weeks 156 and 240. Findings 1012 patients were screened for inclusion. 462 were treated with raltegravir and 237 with placebo. At week 156, 51% in the raltegravir group versus 22% in the placebo group (non-completer classed as failure) had viral loads of less than 50 copies per mL, and 54% versus 23% had viral loads of less than 400 copies per mL. Mean CD4 cell count increase (analysed by an observed failure approach) was 164 cells per μL versus 63 cells per μL. After week 156, 251 patients (54%) from the raltegravir group and 47 (20%) from the placebo group entered the open-label raltergravir phase; 221 (47%) versus 44 (19%) completed the entire study. At week 240, viral load was less than 50 copies per mL in 193 (42%) of all patients initially assigned to raltegravir and less than 400 copies per mL in 210 (45%); mean CD4 cell count increased by 183 cells per μL. Virological failure occurred in 166 raltegravir recipients (36%) during the double-blind phase and in 17 of all patients (6%) during the open-label phase. The most common drug-related adverse events at 5 years in both groups were nausea, headache, and diarrhoea, and occurred in similar proportions in each group. Laboratory test results were similar in both treatment groups and showed little change after year 2. Interpretation Raltegravir has a favourable long-term efficacy and safety profile in integrase-inhibitor-naive patients with triple-class resistant HIV in whom antiretroviral therapy is failing. Raltegravir is an alternative for treatment-experienced patients, particularly those with few treatment options. Funding Merck Sharp & Dohme.

Background Many HIV databases and applications focus on a limited domain of HIV knowledge. Since even a “simple” organism like HIV represents a very complex system with many interacting elements, the fractured structure of existing databases and applications likely limits our ability to investigate and understand HIV. To facilitate research, therefore, we have built HIVToolbox, which integrates much of the knowledge about HIV proteins and presents the data in an interactive web application. HIVToolbox allows quick and convenient hypotheses generation, experiment interpretation, and potential new drug structure creation. Methods HIVToolbox was built as a standard three-tier J2EE web application, consisting of 1) an underlying relational MySQL database, 2) a set of standard Java data access objects that pull data from the database, and 3) a set of dynamic web pages the user interacts with. HIV-1 data from external sources such as the Protein Data Bank, NCBI, Los Alamos, etc. was collected, curated, and stored in the HIVToolbox database. Additional data, such as homology and position statistics matrices, was generated from existing data. Since version 1, drug binding site and drug resistant mutation data has also been added. Results HIVToolbox was used to create several new hypotheses about HIV-1 integrase, including predicting the location of a CK2 phosphorylation site, which was later confirmed by experiment. A new version of HIVToolbox support display of the 3D locations of drug resistant mutations on surface plots of HIV proteins and the drug binding sites for structures of complexes of HIV proteins with drugs. Conclusion HIVToolbox is an open-access web application that allows virologists and structural biologists to access detailed information about HIV-1 proteins, such as sequence, structure, functional sites and relationships, homology, drug binding sites, and drug resistant mutations, and to immediately see the relationships between any or all of them. Weblink: [http://hivtoolbox.bio-toolkit.com], Background Analysis of human monoclonal antibodies (mAbs) developed from HIV-1 infected donors have enormously contributed to the identification of neutralization sensitive epitopes on the HIV-1 envelope glycoprotein. The third variable region (V3) is a crucial target on gp120, primarily due to its involvement in co-receptor (CXCR4 or CCR5) binding and presence of epitopes recognized by broadly neutralizing antibodies. Methods Thirty-three HIV-1 seropositive drug naive patients (18 males and 15 females) within the age range of 20-57 years (median=33 years) were recruited in this study for mAb production. The mAbs were selected from EBV transformed cultures with conformationally constrained Cholera-toxin-B containing V3C (V3C-CTB) fusion protein. We tested the mAbs for their binding with HIV-1 derived proteins and peptides by ELISA and for neutralization against HIV-1 viruses by TZM-bl assays. Results We isolated three anti-V3 mAbs, 277, 903 and 904 from the cells of different individuals. The ELISA binding revealed a subtype-C and subtype-A specific binding of antibody 277 and 903 while 904 exhibited cross reactivity also with subtype-B V3. Epitope mapping of mAbs with overlapping V3 peptides showed exclusive binding to V3 crown. The antibodies displayed high and low neutralizing activity against 2/5 tier 1 and 1/6 tier 2 viruses respectively. Overall, we observed a resistance of the tier 2 viruses to neutralization by the anti-V3 mAbs, despite exposure of the epitopes recognized by these antibodies on the native viruses, as determined by intact virion binding assay with two representative subtype-C and B viruses (Du156.12 and JRFL). Conclusion Our study suggests that the anti-V3 antibodies derived from subtype-C infected Indian patients display neutralization potential against tier 1 viruses. Defining the epitope specificities of these mAbs and further experimental manipulations will be helpful in identification of epitopes, unique to clade C or shared with non-clade C viruses, for immunogen design., Background One major obstacle to induce bNAbs resides in the high variability of the viral envelope and structural mechanisms hiding crucial epitopes. Besides, maturation of bNAbs against HIV represents a difficult process that can be impaired by the immunodeficiency associated with HIV infection. We have explored the hypothesis that preserved B cell function in LTNPs could result in the production of bNAbs at higher frequency and increased affinity in comparison with HIV progressors. Methods Samples (142) from the cohort of LTNPs (median RNA copies/ml: 87, median CD4+: 802 cells/µl) were kindly provided by the HIV BioBank integrated in the Spanish AIDS Research Network (RIS). A control population of 191 untreated patients (median RNA copies/ml: 10,241, median CD4+: 567 cells/µl) from Hospital Clinic, Barcelona, was analyzed. Sera at 1/200 and 1/2000 dilutions were preincubated with Env recombinant viruses harboring a luciferase gene and then added to U87.CD4.CXCR4/CCR5. bNAbs specificities were studied by ELISA using mutated gp120 that abrogates antibody binding, competition ELISA with biotinylated antibodies, neutralization assays with mutated viruses and peptide competition neutralization assays. Results The percentage of elite neutralizers was higher in the LTNPs (9.3%) than in the control population (3.7%). Broadly neutralizing sera were screened for the presence of epitope-specific antibodies. CD4 binding site antibodies were detected in several sera. To determine whether these antibodies were responsible for broad neutralization, competition neutralization assays using RSC3 (antigenically resurfaced glycoprotein containing the CD4bs) were performed. RSC3 addition inhibited neutralization mediated by 16.7% of sera in LTNPs and 12.5% sera of the control population. Anti-MPER antibodies were detected in 50% individuals of both populations, including several sera with 4E10-like antibodies. Glycan-dependent HIV-1 NAbs were more abundant in LTNPs (66%) than in control population (37%). Conclusion Broad humoral immune responses against HIV-1 were more common among LTNP than a control population of untreated HIV-1-infected donors., Background HIV/SIV primarily infect activated CD4+ T cells, but can infect macrophages. Because of the relatively small percentage of infected macrophages, the interaction between antigen-specific CD8+ T cells and infected macrophages in HIV/SIV infection has been poorly studied. We, therefore, sought to determine whether SIV-specific CD8+ T cells could control viral replication in infected macrophages. Methods We wanted to ascertain whether ex vivo tetramer-sorted SIV-specific CD8+ T cells could suppress viral replication in SIVmac239/316e- and SIVsmE660-infected macrophages using a recently developed 48-hour viral suppression assay. We reasoned that freshly sorted CD8+ T cells might be more representative of the in vivo properties of CD8+ T cells than in vitro cultured cell lines and clones. Results Surprisingly, both ex vivo tetramer-sorted SIV-specific CD8+ T cells and bulk CD8+ T cells that eliminated and suppressed viral replication in SIV-infected CD4+ T cells were inefficient at controlling viral replication in SIV-infected macrophages. Our data suggest that macrophages may be an important reservoir for SIV because it may be difficult for SIV-specific CD8+ T cells to suppress viral replication in this particular cell type. Conclusion It is possible, therefore, that while AIDS virus-infected macrophages only constitute a small percentage of all virus-infected cells, they may be relatively resistant to CD8+ T cell-mediated lysis and continue to produce virus over long periods of time. Thus, macrophages could actually be contributing significantly to viral production. Induction of HIV/SIV-specific CD8+ T cells capable of killing infected macrophages or preventing establishment of the macrophage reservoir HIV might be critical for controlling viral replication., Background The potential role of ADCC in prevention of infection is suggested by the RV144 HIV vaccine trial where non-neutralizing antibodies contributed to protection against infection with HIV. Studies from Kenya showed that HIV specific IgA in cervical fluid was present in uninfected sex workers. We aimed to analyze cervicovaginal lavage fluid(CVL) from 2 seroconverters (SC) and 10 highly exposed seronegative women who had unprotected sex with known positive partners. Methods A 51Cr-release assay with natural killer cells or monocytes as effectors was used to measure IgG or IgA mediated ADCC against clade specific gp120 coupled target cells. We analyzed CVL from ESN at one visit, and SC at intervals from one yr pre-seroconversion (PSC) to 6.5 yr after seroconversion (ASC). We evaluated activity at 4, 10 fold serial dilutions starting with a 1/10 dilution. Results Figure 1 (top)shows shows minimal to no activity of IgG mediated ADCC in the CVL of 10 ESN. Figure 1(bottom) shows IgA mediated ADCC in the CVL of the same 10 ESN. 4 patients show significant activity above background activity. At the peak dilution, patient 4 shows 27.3% Specific Release (SR), patient 6 shows 14.5 %SR, patient 8 shows 17.9 %SR and patient 10 shows 17.6 %SR. Figure 2 and 3 shows no IgA mediated ADCC activity in CVL of 2 seroconverters from PSC to 6.5 years ASC even while IgG activity is present in later visits. Conclusion HIV IgA in CVL samples was associated with ADCC and lack of HIV infection in exposed women, indicating that genital HIV IgA may contribute to protection from infection. Further studies need to be done to determine if IgA mediated ADCC antibodies may be protective in ESN., Background CD4+ T-cells from gut-associated lymphoid tissues (GALT) are major HIV-1 targets. Recruitment of excess effector CD8+ T-cells in the proximity of target cells is critical for the control of viral replication. We investigated the colocalization potential of HIV-specific CD8+ and CD4+ T-cells into the GALT and explored the role of retinoic acid (RA) in regulating this process in a cohort of HIV-infected subjects with slow disease progression (SP). Methods Five SP subjects were available for this study: median CD4 counts 670 cells/µl, plasma viral load 3.27 log10 HIV-RNA copies/ml, and 15 years of infection. PBMC were exposed to HIV peptides or CMVpp-65 protein in the presence or absence of all-trans RA (ATRA) or the RA antagonist LE540. The expression of trafficking molecules on antigen specific T-cells was analyzed by flow cytometry using the CFSE assay. Results The expression of the gut-homing molecules integrin β7, CCR6, and CXCR3 was identified as a “signature” for HIV-specific but not CMV-specific CD4+ T-cells, thus providing a new explanation for their enhanced permissiveness to infection in vivo. HIV-specific CD8+ T-cells expressed high levels of integrin β7 and CXCR3; however CCR6 was detected at superior levels on HIV-specific CD4+ versus CD8+ T-cells. ATRA upregulated the expression of integrin β7 but not CCR6 on HIV-specific T-cells. Conclusion HIV-specific CD8+ T-cells may colocalize in excess with CD4+ T-cells into the GALT via integrin β7 and CXCR3, but not CCR6. Considering our previous findings that CCR6+CD4+ T-cells are major HIV targets, a limited ability of CD8+ T-cells to migrate in the vicinity of CCR6+CD4+ T-cells may facilitate HIV dissemination at mucosal sites. In addition to other previously described T-cell features (e.g., antiviral properties, poly-functionality, and exhaustion), the colocalization potential of CD4+ and CD8+ T-cells represents a new parameter to consider for predicting the efficacy of anti-HIV responses., Background An attractive approach for restoring CTL activity to HIV-1 infected individuals is the adoptive transfer of autologous CD8 T cells that have been transduced with an HIV-1 specific TCR. Previously, we described an HLA-A2-SL9 specific TCR that when introduced into CD8 T cells could control HIV-1 replication in an in vitro suppression assay. Given that the success of HAART is based, in part, on attacking multiple targets, we isolated an additional HLA-A2 restricted, HIV-1 specific TCR targeting the HIV-1POL sequence YQYMDDLYV. This epitope is of great clinical relevance because it lies within the active site of Pol and is a target of many reverse transcriptase inhibitors. Methods By surface plasmon resonance, we defined the Kd of this wild type TCR to be 6.7µM and t1/2 to be 2.7s. Using phage display, a panel of affinity enhanced A2-YV9 TCRs were obtained with Kd values ranging from 5.1 to 0.3µM. Results When introduced into CD8 T cells by lentiviral vectors, the A2 YV9 specific TCRs were highly specific for the wild type epitope. In contrast to what we previously determined for CD8 T cells transduced with the wild type A2-SL9 specific TCR, we observed that the A2-YV9 specific T cells could respond in a polyfunctional manner by simultaneously producing TNF-α, IFN-γ, IL-2, and MIP1-β when presented with a wide range of peptide concentrations. Moreover, affinity enhanced A2-YV9 specific CD8 T cells were able to recognize and respond to several variants of the wild type sequence, including those responsible for resistance to NNRTI and NRTI such as Nevirapine, Didanosine and Efavirenz. Conclusion Together, our data suggest that adoptive transfer of these A2-YV9 specific CD8 T cells presents great potential for augmenting available treatments and imparting additional control to HIV-1 infected individuals experiencing drug resistance., Background HIV Controllers are rare individuals who spontaneously control HIV replication in the absence of antiretroviral therapy. To identify parameters of the CD4 response that may contribute to viral control, rather than merely reflect a persistently low viremia, we compared the T helper profile in two groups of patients with more than 10 years of viral suppression: HIV Controllers from the ANRS CO18 cohort (n=26) and efficiently treated patients (n=16). Methods Cells specific for immunodominant Gag and CMV peptides were evaluated for the production of 10 cytokines and cytotoxicity markers, and were also directly quantified ex vivo by MHC class II tetramer staining. Results HIV Controller CD4+ T cells were characterized by a higher frequency of IFN-γ production, perforin+/CD107a+ expression, and polyfunctionality in response to Gag peptides. While IL-4, IL-17, and IL-21 production did not differ between groups, treated patients cells produced more IL-10 in response to Gag and CMV peptides, pointing to persistent negative immunoregulation after long-term antiretroviral therapy. Gag293 tetramer-positive cells were detected at high frequency (0.15%) and correlated positively with IFN-γ producing CD4+ T cells in the Controller group (R=0.84; P=0.01). Tetramer-positive cells were fewer in the HAART group (0.04%) and did not correlate with IFN-γ production, supporting the notion of a persistent immune dysfunction in HIV-specific CD4+ T cells of treated patients. Conclusion HIV Controllers maintained a population of highly efficient Th1 effectors directed against Gag in spite of a persistently low antigenemia, while patients treated in the long-term showed a loss of CD4 effector functions. We previously reported that HIV Controllers harbored a unique population of CD4+ T cells expressing high avidity TCRs directed against Gag293. We propose that high avidity drives continuous Th1 effector differentiation in response to low antigen concentrations and explains the persistence of an activated antiviral response in HIV Controllers., Background Natural control of HIV infection is associated with CD8+ T cell responses to HIV core antigens, encoded by Gag, restricted by ‘protective’ HLA-B alleles (HLA-B27, -57, -58). Slower progression of HIV infection is associated with antibodies to HIV core proteins but mechanisms are unclear. Antibody responses that have isotype switched to IgG2 may be particularly effective. We have investigated this further. Methods Plasma from 32 HIV controllers (HIV RNA2SD of non-HIV sera for rp55 antibodies. Antibodies to rgp140 were titred. Controllers were HLA typed by sequenced-based typing using genomic DNA. Results Controllers had a positive IgG1 or IgG2 antibody response to one or more core protein (p17, p24) on WB more often than non-controllers (75% vs 28.6%, p=0.0016 and 22% vs 0, p=0.034, respectively). Also, 12.5% of controllers but no non-controllers had a positive IgG2 antibody to rp55 (p=0.14). When results of WB assays and ELISA were combined, 34% of controllers but no non-controllers had positive IgG2 antibodies to core antigens (p=0.04). Positive IgG2 antibodies to core antigens were more common in patients without ‘protective’ HLA-B alleles (57%) than patients with these alleles (16.5%) (p=0.026). Positive IgG1 antibodies to Pol-encoded proteins were also more common in controllers (p=0.0003) but IgG2 antibodies were not detected. IgG1 and IgG2 antibodies to envelope antigens showed few differences. Conclusion An isotype switched IgG antibody response to HIV core antigens is associated with control of HIV infection in patients without ‘protective’ HLA-B alleles., Background A recent genome-wide association study (GWAS) of host determinants for HIV-1 disease revealed that single nucleotide polymorphisms (SNPs) near genes HLA-C and ZNRD1 were associated with setpoint HIV-1 viral load and disease progression. ZNRD1 has also been identified as a host protein required by HIV-1 life cycle in a genome-wide functional genomic study. Methods We investigated the effects of 13 SNPs in the ZNRD1 region on HIV-1 infection and progression in five U.S-based treatment-naive HIV-1 longitudinal cohorts consisting of homosexuals, hemophiliacs and injection drug users (IDUs) (n=1028). Allelic frequencies were compared between HIV-1 seronegatives (SN) and seroconverters (SC) with further analysis focusing on high-risk exposed HIV-1-uninfected individuals (HREU) compared to HIV-1 seroconverters (SC). Among HIV- 1 seroconverters, variation in time to clinical AIDS was assessed by haplotype. Electrophoretic mobility shift assay (EMSA) was used to assess the associated SNP's potential to alter DNA-protein interactions. Results A haplotype in the ZNRD1 gene showed significant association with decreased risk of HIV-1 acquisition (OR=0.65, 95% CI 0.47-0.89), independent of the effect of HLA-C rs9264942. The tag SNP allele in the ZNRD1 promoter region causes a loss of nuclear factor binding, as revealed by EMSA. This differential binding was further shown to be cell-specific, occurring in Hela epithelial cells instead of Jurkat T-cells (stimulated or unstimulated), suggesting its regulatory role in mucosal epithelial barriers influence HIV-1 transmission. Indeed, this infection effect was not observed in HIV-1 infected IDUs (OR=0.82, 95% CI, 0.44-1.54). On the other hand, SNPs and haplotypes for ZNRD1 modestly affect progression rate to AIDS. Conclusion This study provided novel evidence supporting a direct role of ZRND1 in modulating HIV and identified a ZNRD1 allele as a host resistant factor to HIV-1 acquisition. (Funded by NCI HHSN26120080001E), Background Understanding the early events during heterosexual HIV transmission at the genital mucosa is necessary to develop a safe and efficacious HIV microbicide or vaccine. A recent workshop highlighted the benefits of studying Highly Exposed Seronegative (HESN) individuals in order to identify and describe correlates of HIV protection. In an HESN cohort of commercial sex workers in Nairobi, Kenya, we have described a state of reduced systemic T cell immune activatio termed Immune Quiescence. However, the extent of Immune Quiescence at the genital mucosal is not known. This study characterized the female genital mucosal profile of cells, cytokines and chemokines involved in immune activation and lymphocyte recruitment among HESN. Methods CVL and plasma from commercial sex workers from the Majengo clinic in Nairobi, Kenya (57 HIV- followed for7 years) were analysed for the presence of 22 cytokines/chemokines and five antiproteases previously associated with resistance to HIV infection. Activation of cervico vaginal cells was analysed by multiparametric flow cytometry. Results HESN women have a unique pattern of mucosal chemokine/cytokine expression. HESN subjects showed lower expression of MIG, IP-10 and IL-1a as well as higher levels of antiproteases. Among the HESN women there was a distinct chemokine gradient between the blood and genital mucosa relative to control women. Conclusion MIG and IP-10 are important regulators of T cell trafficking to the genital mucosa while IL-1a is an indicator of immune activation. The reduced levels of these cytokines/chemokines together with the unique correlations observed with antiprotease expression among HESN women suggest that the Immune Quiescent phenotype extends to the female genital tract. Reducing the number of activated CD4+ T cells in the FGT could limit cellular targets for HIV infection and may be an important component to resisting HIV infection., Background For 26 years a group of HESN women from Nairobi, Kenya who can be epidemiologically described as relatively resistant to HIV infection have provided clues towards the identification of natural correlates of protection against HIV-1 infection. Studies of these HIV-1-resistant women suggest they posses a unique mucosal environment which includes the overexpression of specific antiproteases and a unique proinflamatory cytokine expression patern. Here we describe how these factors contribute to protection against HIV infection during mucosal transmission. Methods Cervical lavage fluid (CVL) from 277 women were collected from 76 HIV-1-resistant, 120 HIV-1 uninfected, and 97 HIV-1 infected women. CVL protein was analyzed both independently by SELDI-TOF MS and as pooled groups by 2D-LC-FTICR MS. Of the more than 350 unique proteins identified 29 proteins were differentially expressed (> 2-fold cutoff) between HIV-1-resistant women and controls. These findings were confirmed by traditional ELISA and quantitative Western Blot (WB) analysis. Results The majority of overexpressed proteins were serpins, their breakdown products (p=2.2 x 10−8), and other antiproteases, as well as innate factors with known anti-HIV-1 activity. The overexpression of specific serpins and an epithelial-derived antiproteases was confirmed by ELISA and WB (p=0.004, p=0.05, and p=0.02). Underexpressed proteins in HIV-resistant women included inflammatory proteases and immune response factors. Cytokine/chemokine analysis revealed that antiprotease expression correlated with pro-inflammatory cytokines (p, Background Herpes simplex virus type 2 (HSV-2), the most frequent cause of genital ulcer disease (GUD), has been shown to play a more important role than any other sexually transmitted infections (STIs) in driving HIV prevalence in Africa. In turn, HIV-1 infection leads to more frequent HSV-2 reactivations and shedding. The exact immune mechanisms involved in this virological negative immuno-synergy are unknown. In the present study we sought to assess whether HIV co-infection would affects HSV-specific T cell immunity. Methods Nineteen HSV peptides, derived from HSV-2 glycoproteins gB and gD, were used to analyze the frequency and the magnitude of HSV-2-specific IFN-γ-producing CD4+ and CD8+ T cell responses in 30 HSV-2 seropositive patients and 17 HSV-2 seronegative individuals in a cohort of heterosexual Senegalese HIV-discordant couples, using ELISpot assay. HIV RNA viral load has been run for HIV infected subjects and CD4 count ran for all subjects using a flow cytometry method. Results The magnitude and frequency HSV-2-specific T cell responses was compared between 21 HSV-2 co-infected with HIV-1 and 9 HSV-2 mono-infected individuals. A significantly higher magnitude of IFN-γ-producing T cell responses were observed in HSV-2 infected patients compared to seronegative individuals (median, 61 vs. 0 spots/106 PBMC, P=0.001). Moreover, twenty-four (80%) out of 30 HSV-2 seropositive patients showed significant HSV-2-specific IFN-γ-producing T cell responses compared with only 6 (35%) out of 17 HSV-2 negative subjects (P, Background HIV-infection leads to GALT CD4+ T-cell depletion that persists despite prolonged antiretroviral therapy (ART). SBI is a medical food that neutralizes bacterial antigens and reduces gut inflammation in animal models. Methods Subjects on ART with diarrhea and a thorough negative GI-workup received SBI (EnteraHealth, Ankeny,IA,USA) 2.5 grams BID for 8 weeks. 4-hour urine disaccharide gut permeability and absorption test and duodenal biopsies were obtained before and at 8-weeks. Immunohistochemistry for CD3/CD4 was performed on biopsies and flow cytometry was performed on duodenal single-cell suspensions and PBMCs for lymphocyte subsets. Markers of bacterial translocation and cytokine levels were measured in plasma. Stool was collected for 16S rDNA quantification and sequencing. Median values (interquartile ranges) and nonparametric analysis are reported. Results All 8 subjects experienced resolution of GI-related symptoms. D-xylose absorption increased in 7/8 subjects and in those with improvement, the absorption levels increased from 31.4 mgs (28.5, 38.8) to 41.5 mgs (33.7, 45.2)(p=0.016). Gut permeability was normal before [0.024% (0.0, 0.048)] and after [0.032% (0.0, 0.047)] intervention (normal, Background Interleukin (IL)-21 regulates three immunological functions - Th17 cell homeostasis, differentiation of memory B cells and antibody-secreting plasma cells, and long-term maintenance of functional CD8+T-cells - that are compromised in pathogenic HIV and SIV infections. Since IL-21 availability is reduced during infection, we hypothesized that in vivo administration of IL-21 might be beneficial for HIV infected humans. Methods We infected 12 rhesus macaques with SIVmac239 (i.v.), and then treated 6 of them with rhesus rIL-21-IgFc (50mg/kg, s.c., once weekly for 5 weeks) during the early infection (from day 14 to 42 post-infection). Effects of IL-21 on viral load, immune activation, homeostasis of T-cells and their main subsets as well as T-cell cytotoxic potential have been evaluated in blood and mucosa by q-PCR, IHC, and flow cytometry up to 6 months post-infection. Mann-Whitney test and Spearman correlation were used for statistical analyzes. Results IL-21 treatment was safe and did not increase plasma viral load or systemic immune activation. Compared to untreated animals, IL-21 treatment resulted in (i) increased expression of Perforin and GrB in total and virus specific CD8+T-cells of various anatomical sites (P, Background The majority of new HIV infections are acquired via heterosexual transmission. Certain individuals remain seronegative despite repeated high-risk exposure to HIV. The correlates of protection in exposed seronegative(ESN) individuals remain unclear. The purpose of this study was to determine the breadth and persistence of HIV-specific CTL responses in blood and cervical mucosa of ESN women. Methods The ESN cohort included 30 female partners of antiretroviral naïve HIV+ men. ESN women were followed longitudinally for 3-6 months. Controls included sero-concordant couples (n=17) and low-risk seronegative women (n=30). PBMC and mucosal mononuclear cells (MMC) from cervical cytobrush were stimulated with HIV Gag and Env (Clade C) peptide pools; IFN-g production was measured by intracellular cytokine staining. IFN-g production by>0.1% of cells after background subtraction was considered positive. Samples with, Background A characteristic feature of the early phase of mammalian cells to metabolic stress is an increase in the rate of glucose uptake and metabolism. Glucose transporter 1 (Glut1) is the major glucose transporter in T cells and its expression is increased on CD4+T cells during chronic HIV-1 infection in vivo (Palmer et al., Abstract 1, IAS, 2012). We therefore seek to determine the impact of increased Glut1 expression on glucose metabolism in CD4+T cells from HIV-1-infected subjects. Methods The cell surface expression of Glut1 and glucose uptake (2-NBDG) was monitored in CD4+T cells from HIV-1 infected treatment naïve or HIV- controls subjects by flow cytometry. Hexokinase and glycolytic activity was measured by the intracellular concentrations of Glucose-6-phosphate (G-6-P) and L-lactate, respectively. Intracellular PTEN, pAkt (T308) and pAkt (S473) levels determined PI3K-mTOR activity. In vitro HIV-1 infection was performed on PBMCs activated with anti-CD3/CD28 microbeads and IL-7 and incubated with the CXCR4-using NL4.3-GFP virus. Results Basal glucose uptake, G-6-P, L-lactate, intracellular p-Akt (T308) and p-Akt (S473) were significantly higher in CD4+Glut1+ vs CD4+Glut1- cells. This corresponded with an overall increased glucose uptake and glycolysis and lower levels of PTEN expression in CD4+T cells from HIV-1+subject vs seronegative individuals. Anti-CD3/CD28-induced Glut1 expression on CD4+ T cells was sensitive to specific inhibition of the Class1B PI3K-y and mTORC1 pathways which also blocked HIV-1 infection of CD4+T cells in vitro. Conclusion CD4+T cells from HIV-1 infected patients have increased glucose uptake and glycolytic activity mediated at least in part by the PI3k-y-mTORC1 pathway. Increased Glut1 cell surface expression and glycolysis in CD4+T cells may increase their susceptibility to HIV-1 infection and foster their depletion due to hypermetabolism. Approaches to normalize Glut1 expression or glycolysis in CD4+T cells may offer a platform for interventions to slow HIV-1 disease progression., Background Progressive depletion of CD4 T cells is a hallmark of AIDS yet the underlying mechanism remains poorly understood. In human lymphoid cultures, most of the dying cells correspond to abortively infected resting CD4 T cells (Cell 143:789-901,2010). We have now studied how these cells die. Methods Human lymphoid aggregated cultures (HLACs) prepared with human tonsil and spleen were used to recapitulate many of the conditions encountered by HIV in vivo. CD4 T cell death is prominent in HLAC following viral infection. Results >95% human lymphoid CD4 T cells that die in HLAC are abortively, not productively, infected. These nonpermissive resting cells accumulate incomplete cytosolic viral transcripts that trigger an innate immune response resulting in interferon-beta production and activation of caspase-3 and caspase-1. Most cells die as a consequence of caspase-1-mediated pyroptosis, an intensely inflammatory form of programmed cell death where cytoplasmic contents and pro-inflammatory cytokines (IL-1b) are released. Unexpectedly, HIV-induced CD4 T-cell death and release of inflammatory mediators can be blocked by addition of certain oral sulfonylureas like glimepiride that inhibit P2X7 ion channels, and are FDA-approved for the treatment of type II diabetes. Conclusion 1. Abortively infected lymphoid CD4 T cells do not die due to the action of an HIV virulence factor(s), but rather because of host innate immune response launched against viral DNA produced in these cells. 2. This response likely evolved to protect the host from spread of infection, but the involvement of pyroptosis appears to trigger additional rounds of cell recruitment, infection, cell death, and inflammation. 3. CD4 T-cell depletion is blocked by P2X7 inhibitors that may interfere with pyroptosis. Such agents might be clinically useful in combination with classical antiretrovirals, particularly in HIV-infected subjects displaying rapid progression of disease or broad drug resistance., Background Increased Tryptophan (Trp) catabolism into kynurenine (Kyn) and/or 3-hydroxykynurenine (3OH-kyn) by indoleamine 2,3 dioxygenase (IDO), contributes significantly to the persistent immune activation during HIV infection and plays a detrimental role in T cell responses in advanced AIDS. We herein studied Trp catabolism in elite controllers comparing to other well established groups of HIV patients with different disease outcomes. Methods Plasma samples from elite controllers (EC) (n=21), ART-naive (n=96), ART-successfully treated (ST) (n=18), and healthy controls (n=51) were collected. All these groups were standardized for nutritional status (albumin levels and body mass index). Levels of Trp, Kyn and 3OH-kyn were measured using isotope dilution tandem mass spectrometry and the markers of Trp catabolism (Kyn/Trp and 3OH-kyn/Trp ratios) were correlated to clinical data. Results In ART-naive patients, viral load was positively associated with Kyn, 3OH-kyn levels and the markers of Trp catabolism (p, Background In view of the role interleukin (IL)-7 plays in T-cell survival, homeostasis and function it is no surprise expression of the IL-7 receptor alpha-chain (CD127) is tightly regulated. We previously showed that expression of CD127 is suppressed on CD8 T-cells in HIV+ patients and that this suppression is mediated by both IL-7 and the HIV Tat protein. IL-7 down-regulates CD127 transcripts and surface protein through two distinct mechanisms. In this study we examine the mechanism by which IL-7 down-regulates the CD127 gene at the level of transcription. Methods CD8 T-cells from HIV-negative volunteers were treated with IL-7 (0.1−10 ng/ml) in the presence or absence of various inhibitors. CD127 transcripts were quantified by qPCR. STAT-5 phosphorylation was measured by flow cytometry. Nuclear run-on assays were utilized to measure the rate of CD127 gene transcription. Candidate CD127 repressors were identified using PCR arrays, qPCR, Western and siRNA-mediated gene knock-down assays. Results IL-7 attenuates levels of CD127 transcripts in CD8 T-cells in a time- and dose-dependent manner. Both the full-length transcript and the splice-variant encoding the secreted isoform of CD127 are suppressed by IL-7. We show by nuclear run-on assay that IL-7 suppresses the rate of transcription of the CD127 gene and found no evidence that IL-7 affects the stability of CD127 mRNA. Further, the suppression of CD127 transcripts is dependent on JAK kinase activity and phosphorylation of STAT-5 but not STAT-3. Notably, cycloheximide blocked IL-7's ability to down-regulate CD127 transcripts suggesting IL-7 stimulates the de novo synthesis of a transcriptional repressor which in turn suppresses CD127 gene transcription. We recently identified several candidate repressors using PCR arrays and are currently examining their involvement in the transcriptional suppression by siRNA-mediated knockout experiments. Conclusion Upon binding to its receptor, IL-7 activates the JAK/STAT-5 signaling and induces the expression of a transcriptional repressor which suppresses CD127 gene transcription., Background Interleukin (IL)-7 plays essential roles in T-cell development, homeostasis and activation. Disruption of this cytokine pathway likely contributes to HIV-induced immune deficiency. We previously showed that IL-7 and the HIV Tat protein reduce the half-life of the IL-7 receptor alpha-chain (CD127) in human CD8 T-cells but the mechanism directing CD127 to the proteasome is not yet understood. In this study we examined roles of SOCS proteins in regulating CD127 expression. Methods CD8 T-cells isolated from healthy HIV-negative volunteers were treated with IL-7 (0.1–10 ng/ml) in the presence or absence of various inhibitors. SOCS1-7 and CIS transcripts were examined by qPCR and protein expression was measured by Western. The interaction of SOCS proteins with CD127 was examined by Co-IP. Surface CD127 protein expression was measured by flow cytometry. Intracellular localization of SOCS and CD127 protein was examined by confocal microscopy. Results IL-7 induces the expression of SOCS1-3 and CIS transcripts in CD8 T-cells via the JAK/STAT-5 signaling pathway in a time- and dose-dependent manner with SOCS2 transcripts increasing 300-fold within 3 hours. While induction of SOCS2 and SOCS3 mRNA was transient, SOCS1 and CIS transcripts remained elevated over baseline for at least 48 hours. Western blot analysis confirmed increased protein expression of the induced SOCS genes. Preliminary data on CD8 T-cells isolated from HIV+patients indicate that the IL-7-mediated up-regulation of SOCS transcripts is significantly decreased compared to healthy controls. IL-7 induces rapid phosphorylation and internalization of CD127 followed by proteasomal degradation. By Co-IP we show SOCS proteins induced by IL-7 physically interact with CD127 and study their cellular localization by confocal microscopy. We hypothesize this interaction directs the receptor to the proteasome. Conclusion IL-7 induces the expression of SOCS1-3 and CIS genes through the JAK/STAT-5 pathway. Through physical interaction with CD127, SOCS proteins may direct CD127 to the proteasome for degradation., Background Nonhuman primate natural hosts for simian immunodeficiency viruses (SIV) develop a non-resolving chronic SIV infection, but do not develop AIDS. While several hypotheses, such as down-modulation of immune activation and differential surface expression of SIV receptors, have been suggested as putative mechanisms to explain the nonprogressive nature of SIV infection in natural hosts, mechanisms underlying high and maintained levels of plasma viremia without apparent loss of target cells in natural hosts remain unclear. Methods Here, we have used flow cytometric sorting, quantitative real-time PCR, immunohistochemistry, and in situ hybridization to study viral infectivity and production within subsets of peripheral blood and lymph node-resident CD4+ T cells in cohorts of chronically SIVsmm-infected sooty mangabeys and SIVsmE53-infected rhesus macaques. Results We find: (1) infection frequencies among PB and LN-resident CD4+ T cells in chronically SIVsmE543-infected RM are significantly higher than those in SIVsmm-infected SM; (2) differential virus targeting is observed among anatomical LN niches and among individual CD4+ T cell subsets in SIV-infected RM and SM; (3) lymph node resident TFH cells are preferentially SIV-infected in RM, but these cells are not preferentially infected in SM and; (4) infectivity of central and effector memory CD4+ T cells is associated with plasma viremia in RM while infectivity of only effector memory CD4+ T cell infectivity is associated with plasma viremia in SM. Conclusion These data provide mechanistic insights into the maintenance of immunological function among chronically SIV-infected natural hosts for SIV, provide an explanation as to how natural hosts are able to maintain high levels of plasma viremia without apparent loss of target cells, and may lead to novel gene therapy interventions to recapitulate the natural host phenotype to animals that are susceptible to SIV-induced disease., Background Transcription of the HIV-1 genome yields an initial pre-mRNA which undergoes complex alternative splicing to produce over multiple spliced mRNAs. Analysis of host cell factors important for HIV replication by genome-wide siRNA screens has emphasized that HIV replication is extremely sensitive to the complement of available splicing factors, suggesting that HIV splicing may be an attractive target for therapeutic intervention. Here, we have used single molecule amplification and third generation sequencing to characterize splice patterns for the patient isolate HIV89.6 under different conditions. Methods We infected HOS cells or primary T-cells and carried out single molecule PCR in emulsionsto minimize competition among amplicons. We then used Pacific Biosciences single molecule sequencing to analyze message populations. Results Primary sequence read lengths averaged 1.6 Kb, and 5% of reads were over 3.8 Kb. Over 100 different messages was documented, more than doubling the previous number. The HIV sequence reads confirmed all of the known major splice junctions and identified new splice junctions, which create new ORFs in the 89.6 isolate. The presence of these new transcripts was confirmed using RT-PCR. The ORFs encode a novel form of Tat with an altered carboxy terminus and a Rev-Nef fusion (dubbed “Ref”) containing the amino terminal helix of Rev and the carboxy terminal portion of Nef. Using this assay, we found that HIV splicing differed between different cell types, differed between different human donors, and changes over time after infection. Conclusion These data illustrate how the diversity and promiscuity of splicing in HIV allows the virus to respond to different cellular environments and provides a continuous supply of evolutionary novelty that can potentially serve as a substrate for natural selection., Background HIV-1 infected cells have evolved strategies to delay apoptosis but the exact mechanism is unknown. One explanation could be the enhancement of Bcl-2 levels. MicroRNAs (miRNAs) are small non-coding RNAs that participate in the innate immune response. Several cellular miRNAs target viral mRNAs, leading to a decreased viral replication, but viruses may also counteract this effect. In the case of HIV-1, Tat has been described as an RNAi suppressor, although this statement remains controversial. To get better insight into this issue and into the effect of Tat in protection to apoptosis, we have analyzed the miRNA expression pattern in Jurkat cells expressing different forms of Tat. Methods The miRNA expression profile of Jurkat cells with stable expression of HIV-1 full-length Tat101 (two-exon protein) or Tat72 (exon 1 isoform) was analyzed with a two color-based array of miRNAs (Exiqon). Differences in miRNA expression were then confirmed by qRT-PCR. Results Global down-regulation of cellular miRNAs due to the expression of Tat was not observed. Instead, several specific miRNAs were dis-regulated due to the expression of Tat101 or Tat72, although the expression of the second exon granted a higher modification. We confirmed that cellular miR-21 and miR-222 were up-regulated in Jurkat Tat101 cells. miR-21 plays an important role in apoptosis. Since a higher resistance to FasL-mediated apoptosis was observed in Jurkat Tat101, we established a correlation between this protection and the increased levels of Bcl-2 in Jurkat Tat101. Regarding miR-222, it regulates cell cycle progression. In agreement with this, Jurkat Tat101 cells showed less proliferation capacity than control cells. Conclusion HIV-1 Tat does not show a general RNAi suppressor activity but it increases specifically several human miRNAs, conferring cells protection to apoptosis. This phenomenon was dependent on the expression of full-length Tat., Background Throughout the years many labs have discovered important factors that contribute to the transcription of HIV-1. Most of these factors have been well characterized and their significance has been validated. Some of the critical factors involved in Tat activated transcription include RNA Pol II (associated with LTR), chromatin remodeling complexes (i.e. SWI/SNF), acetyltransferases (i.e. CBP, p300, pCAF), NFκB and components of pTEF-b. Surprisingly, almost none of the published literature has focused on finding these factors as complexes from genuine HIV-1 infected cells. Here we show presence of undiscovered complexes unique to HIV-1 infected cells which may serve as targets of inhibition. Methods We utilized a combination of HIV infected cell lines and primary latent cells (both T-cells and monocyte/macrophages) to define changes of protein complexes in infected cells. We utilized large quantities of infected cell lysates for size-exclusion chromatography to find novel kinases (i.e. cdk9/T complexes), and chromatin remodeling complexes, among others in presence of high salt (500 mM). Results We found that there are novel cdk9/T complexes ranging from 2 MDa to ~300 KDa present only in T-cells that produce virus. Other components of the pTEF-b are also examined and found to be mostly unchanged in infected vs uninfected cells. Other novel complexes present only in infected cells included kinases for the NFkB pathway and SWI/SNF proteins. Many of these proteins are extremely stable and are targets of drug inhibition. Using a small panel of drugs, we find that many of the kinases utilized for transcription of HIV-1 have varying IC50s depending on the size of the complex and their protein partners. Conclusion HIV-1 infected cells contain many novel protein complexes that are yet to be discovered. Here we use a simple method of size exclusion to discover novel complexes that could potentially be used as targets of inhibition in therapeutics., Background Latently-infected resting CD4+ T-cells are a major barrier to the eradication of HIV infection. These cells are enriched in lymphoid tissue compared to blood. We hypothesized that interactions between dendritic cells (DC) and resting CD4+ T-cells are critical for the establishment and maintenance of HIV latency. Methods Resting CD4+ T-cells labelled with eFluor670 were cultured alone or with syngeneic DC for 24h prior to infection with a CCR5-tropic, EGFP-reporter virus. Non-proliferating (eFluor670hi), non-productively-infected (EGFP-) CD4+ T-cells were sorted on day 5 post-infection. Latent infection was re-activated and amplified by co-culturing sorted cells with mitogen stimulated PBMC. Results Infection of resting CD4+ T-cells in the presence of myeloid (m)DC significantly increased latent infection of non-proliferating CD4+ T-cells compared to infection of T-cells cultured alone (p=0.0005, n=11). Latent infection was not increased in resting CD4+ T-cells co-cultured with plasmacytoid DC (n=11) or monocyte-derived-dendritic-cells (n= 2). Co-culture of mDC with memory (CD45RO+) CD4+ T-cells but not naïve (CD45RO-) CD4+ T-cells resulted in latency (n=6). eFluor670hiEGFP- CD4+ T-cells that had been co-cultured with mDC showed a significant increase in the expression of CD69 (p=0.01, n=8) and PD-1 (p=0.007, n=10), but did not express HLA-DR or Ki67. Treatment of the mDC-T-cell co-cultures with blocking antibodies to the chemokines CCL19 and CXCL10 (shown to induce latent infection in resting CD4+ T-cells); the chemokine receptor CXCR3; or the adhesion molecule LFA-1 (binds to ICAM) led to no changes in the frequency of latently-infected CD4+ T-cells (n=5). When mDC-T-cell contact was prevented using transwells the number of latently-infected CD4+ T-cells was reduced (n=3). Conclusion mDC play a key role in the establishment and/or maintenance of HIV latency in resting memory CD4+ T-cells. Our results suggest this is likely to be mediated through DC-T-cell contact via alternative pathways to ICAM-LFA-1 binding., Background HIV-1 penetrates the central nervous system (CNS) during early infection, establishing a viral reservoir. While macrophages and microglia represent the sites of productive HIV-1 infection, astrocytes undergo a restricted/latent infection. We recently demonstrated that astrocytes are extensively infected and may therefore constitute a significant potential reservoir of HIV-1 within the CNS. Here, we analyzed HIV-1 promoters (LTR) from matched CNS and non-CNS compartments to determine their role in virus restriction within CNS-derived cells. Determining the regulatory mechanisms of CNS-derived LTRs is essential to understanding the CNS as a HIV-1 viral reservoir, and in developing strategies aimed at HIV-1 eradication. Methods HIV-1 LTR sequences from a cohort of HIV-1 autopsy subjects consisting of matched CNS- and non-CNS-derived isolates were examined and their activity was determined in T-cells and SVG astrocyte cells. Electrophoretic mobility shift assays (EMSA) were used to analyze transcription factor binding activity within the core and basal promoter regions of the LTR. Results CNS-derived LTRs demonstrated restricted basal transcriptional activity in both T-cells and SVG cells, and non-CNS-derived LTRs showed decreased activity in SVG cells. Restricted basal activity mapped to the three Sp binding motifs, previously shown to be essential for both Tat-independent and Tat-dependent activation of the LTR in T-cells. Further repression in astrocytes was observed due to elevated levels of the repressor Sp3 in SVG cells. Conclusion The reduced transcriptional activity observed for CNS-derived HIV-1 promoters was found to correlate with a reduction in Sp1 binding, which mapped to mutations within the core Sp binding motif. Transcriptional activity in SVG cells was further regulated by Sp3, which outcompeted Sp1 for Sp-motif binding. These data suggest that CNS-derived viruses have a reduced capacity to initiate viral transcription in astrocytes and highlights that unique transcriptional mechanisms exist within the CNS, ultimately affecting the fate of viral infection and the development of latency., Background Latent reservoirs of HIV-1 consist of cells harboring dormant, stably integrated viral genomes that can be reactivated after cell stimulation. Latent HIV-1 evades immune responses and resists anti-retroviral therapy. CD4+ T cells are the major reservoir of latent HIV-1. These cells are very rare and lack distinctive markers, which has hindered their characterization. Methods We developed an in vitro model suitable to investigate HIV-1 latency in CD4+ T cells. In our system CD4+ T cells are activated with dendritic cells and antigen, infected in vitro with HIV-1, and then brought back to quiescence through a resting phase in the presence of interleukin-7. During the resting phase, the latently infected cells generated with our system lack expression of activation markers; do not undergo cellular proliferation and do not sustain viral replication. We sorted latently infected and uninfected cells from the same cell culture at the end of the resting phase, and profiled their entire transcriptome. Results The results of this microarray analysis revealed profound differences between latently infected and uninfected cells derived from the same culture. First, a number of genes involved in all major cellular metabolic pathways are down-modulated in latently infected cells. Second, several messengers involved in gene expression (including chromatin organization, transcription, translation, post-translational modification, transport and assembly) are also down-regulated in latently infected cells. Third, genes involved in signal transduction, cell activation, cell proliferation and cell cycle progression are down-modulated in latently infected cells. Finally, several genes encoding cell surface molecules are differently expressed in latently infected vs. uninfected cells. Conclusion The establishment of HIV-1 latency does not simply entail suppression of HIV-1 expression, and the return to cell quiescence. Rather, HIV-1 appears to exploit and/or promote suppression of all cellular functions, leading to cell quiescence and viral latency. These results may have therapeutic implication for viral eradication., Background HIV-1 cure remains elusive despite HAART due to the reservoirs of proviral DNA integrated into the human genome. Efforts to cure HIV-1 therefore need to aim at eliminating proviral DNA from cellular reservoirs. The first epigenetic signal identified in virus infected and uninfected cells has been promoter methylation. Compelling evidence confirms that specific promoter methylation can lead to gene silencing. Previous studies have examined HIV-1 epigenetics mostly in vitro. Methods We determined methylation patterns in HIV-1 proviral genomes from PBMCs obtained from 21 individuals with a spectrum of disease progression. The CpGs in the long terminal repeats (LTRs) of proviral DNA were investigated by bisulfite sequencing in up to 85 genomic variants per individual. This approach facilitates the study of the full range of CpG methylation and sequence variability of HIV-1 proviruses under conditions of natural selection in human populations. Results In patients with advanced disease, the HIV-1 proviruses remained essentially unmethylated in their LTRs. In one long-term nonprogressor, the percentage of methylated proviruses varied from 0–77% at different times after infection. More important and unexpected was the detection of three specific LTR-located CpG dinucleotides that had been selectively mutated to TpAs in>20 out of the 32 samples analyzed. Comparison to 11 HIV-1 LTR sequences in the Los Alamos HIV database demonstrated that mutations in the sites identified by our study occurred more frequently than at other locations, although the mutations were different from TpAs. Conclusion These specific CpGs, possibly including their abutting sequences, might indicate weak spots in the proviral genomes whose sacrifice by mutation to TpAs could enhance the HIV-1 potential for long-term proviral survival. These data suggest that the sites of the mutated CpGs occurring at conserved sites may serve as potential targets for therapeutic interventions to eliminate integrated proviruses. Grants: DFG-DO165/28-1; NIH-UO1-AI35004, Background We have demonstrated that HIV latency can be established in resting CD4+ T-cells infected after incubation with the CCR7 ligand, CCL19. The aim of this study was to identify the sites of viral integration in this model and to determine the relationship of integration sites to transcription factor binding sites and cellular gene expression. Methods Resting CD4+ T-cells were incubated with either IL2/PHA, CCL19, or in media alone (unactivated). After 2 days, cells were infected with NL4.3 and the presence of integrated DNA was confirmed at day 4. Total cellular DNA was purified and provirus-host junctions cloned and sequenced and mapped on the human genome using the UCSC Genome Browser. Gene expression in each cell type was determined using Illumina microarrays. Comparisons were made between these in vitro conditions and CD4 T-cells from HIV-infected patients on antiretroviral therapy (ART). Gene ontology was analysed using ClueGo. Results We identified unique integration sites in infected CCL19-treated (n=247), IL2/PHA (n=432) and unactivated (n=133) T-cells. Integration occurred in transcriptionally active genes and most were involved in cellular housekeeping and cell signalling pathways. Integration sites were a similar distance from CpG islands, CTCF, pol II and histone methylation and acetylation sites. Compared to IL2/PHA-activated and unactivated cells, integration in CCL19-treated cells was further away from regions with high transcriptional activity (including transcriptional start sites (TSS); (p< 0.0001)) and closer to Long Interspersed Nuclear Elements (p< 0.0001), H4K20me3 (p< 0.0001) (a methylation site mapped to heterochromatin) and H4R3me2 (p< 0.0001; involved in priming gene expression). CCL19 treated cells and patient derived cells were similar in some but not all integration site patterns. Conclusion HIV integration occurred in transcriptionally active genes in all culture conditions although integration patterns in CCL19-treated latently infected cells were distinct. The significance of unique integration site selection in the setting of latency warrant further investigation., Background SIVagm infection of rhesus macaques (RMs) provides a model of functional cure: initial high level viremia (108 copies/ml) and massive mucosal CD4+ T cell depletion are followed by durable control of SIVagm replication, complete recovery of CD4+ T cells, normalization of T-cell activation and seroreversion. The advantage of this model is that the functional cure occurs in all SIVagm-infected RMs. Immune control of SIVagm replication can be temporary reversed by experimental CD8-cell depletion. Methods Our objectives were to further characterize the RM/SIVagm model of functional cure by: (i) assessing the level of persistent chronic SIVagm viremia using qPCR with single copy sensitivity (SCA); (ii) determining whether rebounding virus after CD8-cell depletion is replication-competent by inoculation of uninfected RMs; and (iii) characterizing the diversity of rebounding virus using single genome sequencing (SGS). Results SCA revealed low level viremia, averaging 20 copies/ml (range 10–30), in RMs 9 month after viremia became undetectable by conventional qPCR. Inoculation of new RMs with plasma collected during virus rebound after CD8 cell depletion resulted in peak viremia of 108–109 SIVagm RNA copies/ml, followed by control of viremia with kinetics similar to that following infection with high titer SIVagm stock virus. SGS of rebound plasma virus after CD8 cell depletion revealed sequence homogeneity consistent with clonality. Rebound virus was genetically similar to unpassaged SIVagm used to infect RMs, suggesting that the viral reservoirs that were the source of the rebounding virus were seeded early after infection. Conclusion These findings further validate SIVagm-infected RMs as a model of functional cure of replication-competent retrovirus infection. Deciphering the mechanisms of control may identify new strategies to achieve functional cure. This model is well suited to assess new therapeutic strategies to deplete viral reservoirs without the complexity of multidrug antiretroviral therapy., Background Integration into host cell chromosomal DNA is considered an essential step in the replication of retroviruses, yet HIV-1 replication in vivo or in vitro generates one to two orders of magnitude more copies of unintegrated viral DNA (uDNA) than successfully integrated proviruses (iDNA). These extrachromosomal species are reported to possess limited capacity for gene expression and to be a replicative dead end. Resting CD4+ cells are the major targets of early infection following mucosal transmission, and resting memory CD4+ T cells constitute the major reservoir of latent infection. The cytokine environment in mucosal and lymphoid compartments facilitates HIV-1 infection of CD4+ T cells in the absence of TCR mediated activation. Methods We employed a combination of HIV-1 reporter viruses, flow cytometry and quantitative PCR to analyze HIV-1 early and late gene expression and virus production in purified peripheral blood CD4+ T cells. Results We find that resting CD4+ T cells rendered permissive to HIV-1 replication by cytokines IL-2, IL-4, IL-7 or IL-15 provide a reservoir for the persistence of unintegrated HIV-1 DNA. Nonproliferating cells containing uDNA could generate de novo HIV-1 and transmit virus efficiently to uninfected cells, resulting in recombination between viruses. uDNA generated an order of magnitude less virus than integrated proviruses, but cells generating virus from uDNA survived and produced virus longer. Vpr packaged in virions was necessary for initial gene expression from uDNA. Subsequent T cell receptor/coreceptor-mediated activation substantially increased early viral gene expression from uDNA, but an increase in virus production was observed only when activation-induced cell proliferation was inhibited by de novo Vpr generated from the uDNA template. Activation through the T cell receptor or HDAC inhibitors in combination with Prostratin efficiently activated latent uDNA several weeks after infection of resting T cells. Conclusion We propose unintegrated HIV-1 as a potential reservoir of inducible virus., Background A thorough understanding of the molecular mechanisms governing HIV-1 latency is essential in the development of rational therapeutics for the eradication of the virus. Evidence is accumulating that histone methylation regulates HIV latency. The multi-domain protein UHRF1 (ubiquitin-like, containing PHD and RING finger domains 1), a key epigenetic regulator for maintaining DNA methylation patterns, has also been reported to interact with histone 3 lysine 9 methylated histones. This study investigates the role of UHRF1 in the transcriptional silencing of latent HIV-1 provirus. Methods 293T cells were co-transfected with wild type HIV-1 long terminal repeat (LTR) and either with constructs encoding wild type or mutant forms of human UHRF1, treated with tumor necrosis factor alpha (TNF-α) and the promoter activity was determined by the dual luciferase assay. The presence of UHRF1 at the LTR was assessed by chromatin immunoprecipitation assay using sheared chromatin lysates from latently infected cells, ACH-2 and J-Lat 6.3. Small interfering RNA (siRNA) experiments were conducted using TZM-bl cells, which contain a chromatin-integrated HIV-1 LTR, to confirm the influence of UHRF1 on the HIV-1 LTR. Results We observed that UHRF1 inhibited both basal and the induced HIV-1 gene expression by TNF-α. Chromatin immunoprecipitation assay revealed the presence of UHRF1 at the vicinity of the HIV-1 LTR and UHRF1 occupancy was reduced upon activation. Meanwhile, knockdown of UHRF1 expression modestly increased basal LTR activity. Conclusion Results suggest that UHRF1 contributes to the transcriptional silencing of latent HIV-1 provirus and further elucidate the underlying molecular mechanisms that maintain latency., Background Replication-competent HIV persists in patients who are treated with highly active antiretroviral therapy (HAART). One significant reservoir of this persistent virus is within rare latently infected CD4+ T cells. However, the infrequent nature of these cells makes them challenging to study directly in infected patients, and clinical attempts to completely eliminate this viral reservoir have not been successful. Therefore improved models for HIV latency and eradication strategies are needed. The humanized bone marrow-liver-thymus (BLT) mouse provides robust multi-lineage immune reconstitution with human cells. When infected with HIV, these mice can also serve as an in vivo model for investigating HIV latency. Methods BLT mice were infected with HIV and assessed for the presence of latently-infected cells. Cells were stimulated ex vivo with a variety of canonical and novel latency activators. Infected mice were also treated with HAART and then assessed for the presence of activation-inducible virus. Results Up to 3% percent of human cells in spleen, peripheral blood, and thymus/liver implants in HIV-infected BLT mice harbored latent HIV. This virus was integrated, activation-inducible, and replication competent. The latently-infected cells were also responsive to stimulation with protein kinase C activators and latency-activating nanoparticles. Furthermore, activation-inducible virus was detectable in HAART-treated mice, although at lower frequencies than in untreated mice. Conclusion The humanized BLT mouse provides a versatile system for ex vivo and in vivo investigation of HIV latency., Background In a previous ART intensification study with MVC we detected episomal 2-LTR-DNA in all patients at week 24, while undetectable at baseline (Gutierrez C, et al. PLoS ONE, 2011). A residual agonistic effect of MVC on CCR5 receptor through calcium flux has been discarded. Activation of CCR5 intracellular signaling pathways leading to transcription factors activation, including NFkB, could promote HIV-1 transcription in resting CD4 T cells. We aimed to study if MVC could trigger this effect. Methods TROPISMVC (NCT01060618) is a clinical trial of 10 days MVC monotherapy in naïve HIV-1-infected patients. Blood samples were drawn at baseline, after 10 days of MVC and 18 days after MVC withdrawal (day 28). PBMCs were isolated from nine patients, bearing CCR5 (n=6) and D/M (n=3) tropic viruses. Resting CD4+ T cells were separated by MACS® Technology and aliquots of 5 million cells were frozen. Nuclear proteins were obtained using the Actif Motif Nuclear Extract Kit. NFkB activation was detected by ELISA plates coated with oligonucleotides mimicking the specific consensus binding sites (TransAMTM NFkB family, Actif Motif), following the manufacturer's instructions. NFkB activity was estimated measuring target genes' expression by real-time PCR of the extracted RNA. Results NFkB activity was detected in 4/6 patients with R5 tropic viruses and in 2/3 patients with D/M tropic viruses; results expressed in fold change (FC) compared to baseline according to HIV-1 tropism. The presence of MVC increased NFkB activity consistently, as summarized in the following table. Upregulation of at least one NFkB targeted gene was observed in all but one cases with available RNA sample. Conclusion MVC can activate NFkB, and the expression of targeted genes, in resting CD4 T cells from HIV-infected patients regardless of the viral tropism. Through this pathway, MVC could trigger HIV-1 transcription in resting cells thus accelerating the decay of the HIV-1 cell reservoir., Background Children have large populations of naive CD4+ T-cells that characteristically express high levels of CXCR4 and low levels of CCR5, compared to memory CD4+ T-cells. We hypothesized that HIV+ Ugandan children infected with CXCR4-tropic virus would exhibit larger HIV-DNA reservoirs in naïve CD4+ T-cells, compared to children infected with CCR5-tropic (R5) virus. Methods Cryopreserved PBMC from a convenience sample of 12 HIV+ Ugandan children receiving antiretroviral therapy (ART) with undetectable plasma HIV-RNA (< 400 copies/ml, Amplicor, Roche) were sorted into naïve (CD27+CD45RA+) and memory (CD27-CD45+ and CD45-CD27±) CD3+CD4+ T-cells. HIV-DNA levels were determined using a Taqman assay targeting gag, normalized to cellular-DNA content (tert, ABI). Co-receptor tropism was determined using a commercial phenotypic assay (Trophile, Monogram). We calculated 1) the ratio of the prevalence of infection (copies per 106 cells) in naïve to the prevalence in memory CD4+ T-cells and 2) the proportion of the total peripheral CD4+ T-cell HIV-reservoir that is contained in naïve CD4+ T-cells, and compared them between children with R5- and dual/mixed(CXCR4/CCR5, DM)-tropic virus using non-parametric statistics. Results Median age was 4.9 (interquartile range 3.5-8.1) years, CD4+T-cell number 743 cells/ul (565-1089), CD4+ T-cell percentage 25 (21-29), and ART duration 95 days (95-147), with 6 subjects each with HIV-envelope-subtypes A and D. R5 virus was identified in 8 and DM virus in 4 children. Conclusion In ART-treated adults, the vast majority of persistently infected CD4+ T-cells are memory cells. By contrast, we found that a significant proportion of the reservoir resides in the naïve CD4+ T-cells among Ugandan HIV+ ART-treated children. Infection with DM virus was associated with preferential naïve T-cell infection. In developing strategies to eradicate HIV, it will be important to take into account the high levels of naïve T-cell infection in children, particularly among those with DM virus., Background Functional HIV-1 cure has been described in the setting of myeloablative allogeneic stem cell transplant (alloSCT) with ccr5▵32/ ccr5▵32 donor cells, but the effects of alloSCT on viral reservoirs are largely unknown. We studied the longitudinal effects of reduced-intensity conditioning (RIC) alloSCT on HIV-1 peripheral blood reservoirs in two infected male patients with hematologic malignancies who previously underwent autologous SCT. Methods Analysis of peripheral HIV-1 reservoirs was performed on banked samples (1 pre- and 3 post-RIC-AlloSCT) for both patients, including: 1) quantification of HIV-1 DNA from peripheral blood mononuclear cells (PBMCs), 2) quantification of 2-LTR circles from PBMC episomal DNA, 3) full-length envelope amplification and phenotypic coreceptor usage prediction from proviral DNA, 4) quantification of plasma viremia by a single-copy assay, 5) flow cytometric characterization of lymphocyte subsets and coreceptor expression, and 6) CCR5 genotyping. Results No HIV-1 DNA was detected 8 to 17 months after alloSCT in PBMC from both patients despite presence of modest levels of total PBMC-associated HIV-1 DNA prior to and 2-3 months after SCT (87–271 copies/106 PBMCs). 2-LTR circles were not detected at any time-point despite excellent recovery of episomal mitochondrial DNA. Both patients were heterozygous for ccr5▵32 mutation prior to transplant; a transient reduction in CXCR4 expression was observed following transplant. Pseudoviruses incorporating envelopes from early time-points used predominately CCR5 for entry. Both patients remained virologically suppressed on ART, but were either started on prednisone or continued on tacrolimus/sirolimus immunosuppressive therapy for chronic graft-versus-host disease (GVHD) near the time of loss of HIV-1 reservoir detection. Conclusion PBMC HIV-1 DNA became undetectable 8 months after RIC-alloSCT. This finding may be due to a dilutional effect of donor cell engraftment in the setting of protective ART, the additive effect of cytotoxic therapies, and/or GVHD. Confirmation of results by sampling large-volume blood collections and other tissue compartments is warranted., Background Nonhuman primate (NHP) models are needed for evaluation of proposed but unproven, and potentially dangerous strategies targeting residual virus and latent reservoirs in AIDS virus-infected subjects receiving suppressive antiretroviral drug treatment (ART), but such models have proven challenging to develop. Methods We treated a cohort of 6 Indian rhesus macaques with a novel three class (NRTI, PI, IN-STI) six drug (PMPA/FTC/DRV-RTV/L-870812/L-870564) ART regimen beginning at 4 weeks post-infection with SIVmac239. Peripheral blood CD4+ T cells from ART-treated animals with suppressed viremia were evaluated ex vivo for responses to SAHA, including changes in histone acetylation patterns and induction of expression of SIV. Beginning approximately 26 weeks post infection, animals received four 21 day courses of daily treatment with SAHA, with each course of SAHA separated by an approximately 3 week interval, with continuous ART throughout and longitudinal sampling of blood and lymph nodes for immunological, virological, and pharmacodynamic evaluations. Animals were euthanized and necropsied after the final SAHA dose, while still on ART, and tissues studied virologically. Results The ART regimen was feasible, safe and well tolerated over one year of treatment and allowed suppression of plasma viremia to, Background The “Berlin patient” is the first patient functionally cured of HIV. He received stem cell transplantation from a homozygote CCR5-Δ32 donor. The reconstituted CD4+ T-cell population should be susceptible to infection with CXCR4-using viruses. According to gp120-V3 deep sequencing analysis of plasma-derived variants present before transplantation, the patient harbored a minority (2.9%) of viruses predicted to be CXCR4-tropic (geno2phenocoreceptor FPR 10%). It remains puzzling why these variants failed to emerge post-transplant. We hypothesize that these CXCR4-predicted variants depend on CCR5 for replication. Methods Patient-derived viral constructs were generated by cloning V3-sequences of the CXCR4-predicted viruses (pX1-pX7) and the dominant CCR5-predicted strain (pR5) into HXB2-ΔV3. As controls V3-sequences of HXB2 (cHXB2; CXCR4-tropic) and BaL (cBaL; CCR5-tropic) were cloned. Co-receptor preference was investigated in U-373-MAGI-cells expressing CD4+CCR5+ or CD4+CXCR4+, PBMCs from healthy donors and patient-derived post-transplant CCR5-Δ32 PBMCs. Results Three pre-transplant CXCR4-predicted strains had an amino acid substitution in the V3 glycosylation-motif and one had a lysine at position 25, all associated with CXCR4-tropism. Five of the 7 viral clones were infectious. As expected cHXB2 infected CD4+CXCR4+-MAGI-cells and was inhibited by AMD-3100 (CXCR4-inhibitor) in donor PBMCs. Remarkably, the CXCR4-predicted viruses (FPR 2.7–9.3) depended on CCR5 for replication in MAGI-cells and were inhibited by maraviroc (CCR5-inhibitor) in donor PBMCs similar to pR5 and cBaL. As an ultimate proof it was shown that CXCR4-predicted strains could not replicate in the post-transplant derived CCR5-Δ32 PBMCs, whereas cHXB2 replication was observed. Conclusion The minority population of CXCR4-predicted viral strains which the patient harbored pre-transplant were fully dependent on CCR5 for replication in vitro. This could explain lack of rebound after treatment discontinuation. This provides a strong rationale for the further development of CCR5-targeted gene therapy and suggests that successful reconstitution of CCR5-depleted immune system may work, even if there is some evidence of CXCR4-predicted variants., Background Although HIV-infected individuals can suppress plasma viremia to undetectable levels with antiretroviral therapy, infected cells remain in the body and can contribute to viremia when therapy is discontinued. Macaque models allow investigators to more easily characterize viral reservoirs. Methods Twelve male macaques were infected with RT-SHIV, an SIV virus containing HIV-1 reverse transcriptase, and monitored for plasma viremia and CD4 counts. After 10-14 weeks post-infection, 6 animals were not treated and 6 animals were treated for 17–20 weeks with 3 drugs (tenofovir, lamivudine, and efavirenz) or 4 drugs (tenofovir, lamivudine, efavirenz, and an integrase inhibitor). Viral RNA and viral DNA were measured longitudinally in the blood and at necropsy in over 20 different tissues by quantitative PCR and normalized for cellular RNA and DNA. Results In untreated and treated animals, RT-SHIV DNA was highest in lymphoid and gastrointestinal tissues and very low to absent in the brain, genital tract, and kidney. The amount of viral DNA detected in multiple lymphoid tissues correlated with the level of plasma viremia 1 week post-infection. RT-SHIV RNA was abundant in the lymphoid tissues of untreated macaques with detectable viremia, but was detected variably in different regions of the gastrointestinal tract. Little or no viral RNA was detected in the tissues from animals after 17-20 weeks of therapy. There was no obvious difference in RT-SHIV RNA levels between animals treated with 3 or 4 drugs. Conclusion Our results suggest that the majority of virally-infected cells are located in lymphoid tissues with variable levels in the gastrointestinal tract. The number of infected cells in these reservoirs correlates with viremia one week after infection, suggesting that viral reservoirs are seeded within days of infection. Little viral RNA is evident in tissue after suppressive therapy with either 3 or 4 antiretroviral drugs., Background The role of ongoing virus replication in HIV persistence during long-term antiretroviral therapy is unknown. Since residual replication should result in detectable evolution, we investigated the degree of sequence evolution in blood-derived and rectal tissue-derived CD4+ T cells. Methods Using single-genome and single-proviral sequencing techniques, we obtained 20-50 single viral genomes from pre-therapy plasma samples from 5 subjects who initiated therapy during acute infection and 3 subjects who initiated therapy during chronic infection. Pre-therapy plasma viral sequences were compared to single proviral HIV-1 genomes derived from HIV-1-infected T-cells (naïve, memory, central- and effector-memory) from peripheral blood (PB) and gut-associated lymphoid tissue (GALT) samples collected after 4-12 years of suppressive therapy. Maximum likelihood phylogenetic trees were constructed using the general time reversible model incorporating rate variation among sites. Evolutionary divergence was explored using root-to-tip analysis (Path-O-Gen). Results The geometric mean infection frequency of memory and naïve CD4+ T-cells in the PB was 13- and 24-fold higher respectively in subjects treated during chronic compared to acute infection. This was also true for effector memory CD4+ T-cells from the GALT (6-fold higher). Phylogenetic analysis revealed clear evidence against any substantial evolution between the pre-therapy plasma-derived HIV RNA sequences and on-therapy intracellular HIV DNA sequences. Numerous intracellular HIV sequences identified after long-term therapy contained replication-incompetent virus. One patient had a predominant intracellular clone in both memory and effector memory T-cells containing a 380bp deletion after >9 years of therapy. Conclusion Early initiation of effective therapy results in substantially lower reservoir size in blood and gut. The lack of HIV-1 genetic evolution in the HIV-1 infected CD4+ T-cell populations after years of therapy argues against virus replication as a major cause of persistence in these cell populations. The role of replication in other tissues and cell types however remains to be defined., Background HIV-1-infected individuals who control viremia to below the limit of detection without antiviral therapy have been termed elite controllers (EC). Functional attenuation of some HIV-1 proteins has been reported in EC. However, little is known about role of the HIV-1 accessory protein Vif function in EC, which enhances HIV-1 infectivity through APOBEC3G degradation. In this study, the anti-APOBEC3G function of Vif was compared between EC, chronic progressors (CP) and individuals with acute infection (AI). Methods Forty-nine EC, 49 CP and 44 AI were studied. vif genes were amplified by nested RT-PCR using concentrated plasma. To compare anti-APOBEC3G activity of Vif proteins among those groups, VSV-G-pseudotyped viruses were generated by co-transfecting 293T cells with expression plasmids encoding patient-derived Vif, APOBEC3G, VSV-G, together with a vif/env-deficient HIV-1 proviral DNA clone carrying a luciferase reporter gene. VSV-G-pseudotyped viruses were normalized for p24 antigen and used to infect 293T cells and luciferase activity was measured at 48 h postinfection. Results Anti-APOBEC3G activity of Vif from EC was significantly reduced compared to those from CP or AI (Figure 1). These results remained significant after excluding individuals expressing protective HLA alleles B*27 and/or B*57. No significant difference was observed between CP and AI. Significant differences in amino acid usage in vif genes were found at 7 residues between CP and EC, and at 13 residues between AI and EC. However, there were no common polymorphisms (away from consensus B) that could explain reduced anti-APOBEC3G activity of Vif derived from EC. Conclusion Anti-APOBEC3G activity of Vif proteins derived from EC was reduced. This reduced activity was independent of presence or absence of known protective HLA alleles. Common Vif mutations in EC unlikely explain the observed reduction; rather it might be attributable to unique mutations to each EC Vif protein., Background Repressive epigenetic modifications have been shown to induce and maintain HIV latency; however underlying molecular mechanisms are not yet clear. We have previously demonstrated the critical role of CBF-1 (Latency-C-promoter binding factor 1) in establishing repressive chromatin structures at HIV LTR during latency establishment. The knockdown of CBF-1 results in the reactivation of latent proviruses and overexpression of CBF-1 facilitates latency establishment. Here we extend these studies to show that multiple repressive epigenetic modifications that CBF-1 induces are the result of recruitment of Polycomb Group (PcG) corepressor complex at HIV LTR by CBF-1. Methods Both transformed and primary T cells were infected with lentiviral vectors expressing Tat in cis to study the underlying molecular mechanisms regulating HIV latency and via running various molecular assays, including Chromatin Immunoprecipitation (ChIP) assays. Results In this study, we demonstrate that CBF-1 induces repressive chromatin structures at HIV LTR by recruiting Polycomb Group (PcG) corepressor complex at HIV LTR. The knockdown of endogenous CBF-1 results in the dissociation of PcG complex components from HIV LTR. Furthermore, knockdown of the individual components of PcG complex leads to the reactivation of latent HIV proviruses demonstrating the direct role of PcG complex in establishing HIV latency. Overall our results demonstrate that the CBF-1 induced various epigenetic modifications are the result of recruitment of Polycomb Group (PcG) corepressor complex at HIV LTR, which carry a variety of epigenetic factors that repress HIV gene expression via generating several layers of repressive epigenetic modifications. Conclusion We have established that analogous to the transformed T cell lines in primary T cells CBF-1 induced repressive chromatin structures play important role in establishing HIV latency. Additionally by recruiting PcG corepressor complex at LTR, CBF-1 not only facilitates HIV latency establishment also play critical role in maintaining and stabilizing the latent proviruses., Background Virological and Immunological Studies in CONtrollers after Treatment Interruption (VISCONTI) are required to understand the benefits of an early treatment at acute HIV-1 infection on the HIV reservoir. We studied the distribution, magnitude and inducibility of the HIV reservoir in VISCONTI patients. Methods The prospective VISCONTI study included twelve patients controlling HIV for a median of 76[IQR:67.5–84.5] months after interruption of a 3[IQR:1.7–5.9] years long HAART initiated within 10 weeks post-infection. Circulating resting CD25-CD69-HLADR- CD4+T cell subsets were sorted as naive (TN), central-memory (TCM), transitional-memory (TTM) and effector-memory cells (TEM) for further cell-associated HIV-DNA quantification by ultrasensitive real-time-PCR, and viral inducibility by culture with anti-CD3/anti-CD28/IL-2/IL-7. Reservoir distribution was compared to the one observed in 8 untreated Elite-Controllers for whom 90% of HIV-RNA measures was undetectable (below 200 copies) over 12[9–14] years. Results In the VISCONTI group, activated CD4+T cells had significantly higher HIV-DNA levels than resting ones (median 2.7[IQR:2.4–3.4] and 2[IQR:1.8–2.5] log copies/million cells, p=0.005). HIV-DNA was detected in all subsets from all patients except for 8 out of 12 TN-sorted cells, which were 10 fold less infected than all memory subsets (median TN:1.5[IQR:1.2–1.6], TCM:2.5[IQR:1.8–2.9], TTM:2.6[IQR:2.2–2.8] and TEM:2.4[IQR:2–2.8] log copies/million cells, p< 0.007). TTM was the major subset contributing to 56% of this reservoir. The same HIV reservoir characteristics were observed in Elite-Controllers in term of magnitude and distribution, except that both TCM and TTM equally contributed to the Elite-Controllers HIV reservoir. The VISCONTI HIV reservoir was inducible after TCR-stimulation in all sorted memory subsets from all patients, except in TN where no virus was recovered in 6 out of 8 patients. Conclusion In VISCONTI patients, treatment initiated at primary HIV-1 infection leads, after treatment interruption, to a low -but inducible- durable HIV reservoir distributed mainly in short-lived memory CD4+T cells that mimicks the natural distribution observed in Elite-Controllers., Background A major hurdle toward curing HIV is the establishment of long-lived latent reservoirs such as the CNS. Using an SIV model of HIV infection we examined the effect of combination antiretroviral therapy (cART) on immune and inflammatory gene expression in the periphery and CNS that leads to virus downregulation. Methods To examine the effect of cART on acute and long-term systemic and CNS immunopathogenesis, groups of SIV-infected macaques were untreated and euthanized at 21 postinoculation (dpi) or end stage disease, or treated with cART starting at 4 or 12 dpi and euthanized at 21 or 175 dpi, respectively. RNAs for immune and inflammatory genes were quantified in the spleen and brain by non-amplification Nanostring technology or by qRT-PCR. SIV replication and viral DNA were also measured. Results cART initiation at 4 or 12 dpi did not prevent SIV seeding of the brain; brain viral DNA levels were the same as in untreated animals. cART treatment initiated at 4 dpi had little effect on peripheral and CNS immune and inflammatory gene expression profiles as compared to responses mounted in untreated macaques after acute infection, as indicated by similar levels of IL17A, IL17F, and CCL5 in the periphery and IL-6, IFNß, and TNFa in the CNS. Conclusion The CNS is a latent reservoir for SIV that is seeded early after infection regardless of cART initiation at 4 or 12 dpi. The innate and adaptive immune responses are nearly as effective as early cART treatment at returning the host to peripheral and CNS immune homeostasis by 21 dpi. However, at the same time those responses likely promote the establishment of latent reservoirs by suppressing viral replication, not eliminating the reservoir., Background Toll-like receptors (TLRs) are critical proteins of the innate immune system. We evaluated association of single nucleotide polymorphisms (SNPs) in 6 TLR and 2 TLR-associated genes with infant HIV-1 acquisition and progression. Methods HIV-outcomes were assessed from birth to 1-year of age among infants from a Kenyan perinatal cohort in which HIV-infected women were enrolled during pregnancy and received short-course zidovudine. Infants were genotyped for 6 candidate and 118 haplotype-tagging polymorphisms in TLRs 2, 3, 4, 7, 8, and 9, MyD88 and TIRAP, and 144 ancestral informative markers. Cox proportional hazards and linear regression were performed to assess TLR polymorphism associations with HIV-1 acquisition, peak HIV-1 RNA levels, and infant mortality. Sex-stratified analyses of TLR7 and TLR8 were conducted due to their X-chromosome location. Results Among 368 mother-infant pairs, 56 (15%) infants acquired HIV-1 by month 1 and 17 (4.6%) between 1 and 12 months. Infants with the TLR9 1635A (rs352140) variant were more likely to acquire HIV by 1 month (HR=1.49, 95% confidence interval [CI] =1.04–2.38, p=0.028) and by month 12 (HR=1.40, CI=1.02–1.92, p=0.038) in additive models adjusted for maternal plasma HIV-1 viral load (VL) and genetic ancestry. Among 56 HIV-1 infected infants infected at, Background The Toll-like receptor (TLR) genes mediate the innate response to viral infections and may impact HIV-1 pathogenesis. We evaluated TLR polymorphisms for association with plasma HIV-1 RNA set-point in HIV-1 infected individuals from East and Southern Africa. Methods Analyses included prospective data and DNA from 500 Africans with heterosexually-acquired HIV-1 (125 incident, 375 prevalent). For incident HIV-1, set-point was defined as the median plasma HIV-1 RNA level ≥4 months after the estimated infection date. For prevalent HIV-1, set-point was the average of ≥2 consecutive plasma HIV-1 RNA measurements before ART initiation or CD4 decline to, Background Human cyclophilin A (CypA) encoded by peptidyl prolyl isomerase A gene (PPIA), is an important cellular co-factor for efficient human immunodeficiency virus type 1 (HIV-1) infection. In this study we investigated the effect of genetic variation in the regulatory region of PPIA on HIV-1 disease progression and CypA mRNA expression levels in HIV-1 South African cohorts. Methods A total of 603 black South African participants from these cohorts were genotyped for single nucleotide polymorphism (SNP) A1650G in the regulatory region of CypA using PCR-RFLP. 247 (195 HIV-1 seronegative participants [SNs] and 52 primary infected participants [SPs]) participants were from the CAPRISA acute infection (AI) 002 cohort and 356 HIV-1 chronically infected participants were from the Sinikithemba cohort. CypA mRNA expression was quantified in 30 SNs and 28 SPs from the CAPRISA AI 002 cohort by real-time RT-PCR. Lastly, we assessed the effect of SNPA1650G on viral (NL4.3) replication in PBMCs isolated from HIV-1 negative individuals. Results The minor allele (G) of SNP A1650G (referred to as 1650G) was significantly associated with higher viral load (p, Background Class I Human Leukocyte Antigens (HLA) play an important role in the adaptive immune response by presenting antigens to CD8+ T-cells. Previous studies have reported multiple HLA associations with rates of disease progression in HIV infected individuals, while few class I associations with resistance or susceptibility to HIV-1 infection have been reported. Methods HLA-A, -B, and -C were typed for more than 1000 women enrolled in the Pumwani sex worker cohort using a sequence-based typing method. Kaplan-Meier analysis was used to identify alleles influencing seroconversion and disease progression to AIDS (CD4+ decline to, Background We have recently shown that the IFN-inducible Tripartite motif-containing protein 22 (TRIM22) suppresses basal HIV-1 LTR-mediated transcription through a Tat-and NF-κB-independent mechanism [Kajaste-Rudnitski et al., J Virol 2011, 85(10):5183–96]. In the absence of Tat/TAR RNA complex, HIV-1 transcription can occur through the positive elongation factor (P-TEF) b function and Sp1. We have here investigated whether TRIM22 interferes with Sp1-mediated transcriptional activation of the HIV-1 LTR. Methods 293T cells, devoid of endogenous TRIM22, were transfected with increasing amounts of a TRIM22-expressing plasmid together with a fixed amount of an HIV-1 LTR reporter construct that contains a TAR sequence unresponsive to Tat and two tet-O motifs that bind to rtTA in the presence of doxycycline (Dox). Constructs containing the deletion of one, two or three Sp1 sites were also tested. Results TRIM22 efficiently inhibited Dox-induced WT HIV-1 LTR transcription. Interestingly, this inhibitory effect was progressively lost with the LTR reporters lacking one, two or all three Sp1 binding sites, respectively. In line with these observations, addition of three Sp1 sites into a reporter construct based on a CMV-derived promoter element, normally insensitive to TRIM22, renders it susceptible to TRIM22 transcriptional repression, indicating that TRIM22 could have a broader regulatory role in Sp1-mediated gene expression. Although TRIM22 does not alter overall Sp1 expression levels when transfected into 293T cells, immunoprecipitation experiments performed on 293T cells transfected with a FLAG-tagged TRIM22 revealed that TRIM22 directly interacts with Sp1. Conclusion These results suggest that TRIM22 may inhibit HIV-1 LTR-driven transcriptional initiation through interference with the Sp1-mediated signaling and activation of early HIV-1 gene expression, rendering it an attractive candidate for novel therapeutic approaches., Background We hypothesized that APOBEC3G (A3G) was associated with provirus burden in resting memory CD4+ T cells, and infectivity of HIV produced from them. Methods Cells from antiretroviral-naïve, long-term non-progressor (LTNP, n=7) and HAART-suppressed (HS, n=11) subjects were negatively selected from PBMCs (Robo-Sep). Sorting (FACS Aria, BD) separated activated cells (CD25+, CD69+, CD38+ and HLA-DR+) from resting central memory (Tcm: CCR7+, CD45RO+), resting effector memory (Tem: CCR7-, CD45RO+, which includes resting transitional memory) and resting naïve (CCR7+, CD45RO) T cells. A3G was quantified by immunoblotting (Odyssey, Li-Cor). Provirus was quantified by alu-PCR. Reactivated HIV was recovered from cells treated ex vivo with anti-CD3,8 bispecific monoclonal antibody and IL2. Virus p24 levels in culture supernatants were quantified by ELISA. Infectivity of virus produced from ex vivo activated cells was assessed using TZM-bl indicator cells. Results Tcm and Tem from LTNP had less provirus in vivo than the same cell type from HS subjects (p= 0.01 for Tcm and 0.02 for Tem). A3G protein levels were higher in Tcm and Tem from the LTNP, in comparison to Tcm and Tem from the HS, subjects (p=0.02 for Tcm and p=0.02 for Tem). Virions were recovered from ex vivo activated Tcm from 5 of the HS subjects. Infectivities of normalized virion amounts were inversely associated with the A3G levels in virions produced from them (Spearman r=-0.99, p=0.01) Conclusion Resting central and effector memory CD4+ T cells from LTNP had less provirus and higher levels of A3G protein than the same cell types from HS subjects. Infectivity of HIV reactivated ex vivo from Tcm of HS subjects was inversely associated with virion A3G levels. A3G appears able to restrict viral spread from proviruses reactivated from resting memory CD4+ T cells, suggesting that improving this restriction may contribute to 'curing' HIV., Background The immediate and early dynamic cellular response to an HIV virion entering the cell is not well understood, particularly at the post-transcriptional level where known rapid immune responses occur. Several RNA-binding proteins (RBPs) are known to be important in infection, including HuR, which is known to bind to and regulate the mRNA transcripts of several of the known early entry co-factors such as PPIA, TRIM5, APOBEC3G and CUL5. Methods We have previously integrated three global methods to measure post-transcriptional regulation in Jurkat T cell activation and examine relationships between ribonucleoprotein (RNP) interactions, transcription, RNA stability and translation. Dynamic changes in association with HuR caused measurable effects on RNA stability and translation of mRNAs. Transcripts that increased in association with HuR during activation showed increased stability and translation while those that decreased show decreased stability and translation. Furthermore, these changed transcripts fell into relevant functional groups, where cell cycle regulators were largely decreased in association, stability and translation, and DNA/RNA regulators were largely increased in association, stability and translation. Results To test the effect of post-transcriptional regulation in HIV infection, we used the C8166 T cell line for a near complete and synchronous infection and measured global changes in RNA stability and rates of transcription using 4-thiouridine stability profiling at five time points over the initial 24 hours of infection. Simultaneously, we measured dynamic changes in mRNA association with HuR during the same infection time points. Comparing the two datasets, we observed several mRNA transcripts, including myc mRNA, a known target of HuR, showing dynamic regulation at the level of stability during the infection time course. Conclusion Elucidation of these events supports the involvement of the post-transcriptional response early in HIV infection and suggests that potentially modifying or amplifying the post-transcriptional response may be able to reduce the efficiency of infection., Background Semen, the most common vector for HIV transmission, enhances HIV infection in vitro. We recently identified amyloid fibrils comprised of fragments from semenogelins, the predominant component of the semen coagulum. Semenogelin amyloids interact with virions (Figure 1) and potently enhance HIV infection of target cells. During semen liquefaction, semenogelins are fragmented and eventually completely degraded by PSA. We hypothesized that if semenogelins are important for the viral enhancing activity of semen, then the change in the levels of these proteins during liquefaction should affect the ability of semen to enhance infection. Methods Seminal fluid liquefied for different amounts of time were assayed for viral enhancing activity and semenogelin levels in the absence or presence of PSA inhibitors. We also tested the effect of purified PSA on the activity of amyloids formed from chemically-synthesized semenogelin peptides. Results The viral enhancing activity of semen decreases with increasing liquefaction time in a manner that parallels the degradation of semenogelins. Semenogelin degradation and loss of viral enhancing activity in semen are both prevented in the presence of a PSA inhibitor. Finally, PSA specifically cleaves and inhibits the viral enhancing activity of semenogelin fibrils. Conclusion Seminal fluid's viral enhancing activity is retained for several hours and then progressively decreases during prolonged liquefaction. We found a correlation between activity and semenogelin levels during liquefaction. These findings underscore the importance of semenogelins for the viral enhancing activity of semen. We also provide evidence that PSA directly regulates the activity of semenogelin fibrils, suggesting that these amyloids are regulated by liquefaction. As such, mechanisms to enhance the natural liquefaction process may be a useful approach to limit the ability of semen to enhance viral transmission., Background The relationship between exogenous contraceptive hormones and permissiveness of the female genital tract to human immunodeficiency virus type 1 (HIV-1) remains the subject of intense debate, due to a recent study showing a two-fold increase in the rate of acquisition and transmission in serodiscordant couples using depot medroxyprogesterone acetate (DMPA)[1]. In order to better characterize the effect of DMPA on the vagina, we compared the leukocyte populations and density of epithelial junction proteins in vaginal tissue biopsies of women at baseline (during both the follicular and luteal phases of the menstrual cycle) and 12 weeks after receiving one DMPA injection. Methods Vaginal biopsies were obtained from 20 healthy women in the follicular and luteal phases of the menstrual cycle, and approximately 12 weeks after receiving a 150 milligram intramuscular injection of DMPA. Leukocyte populations, activation phenotype and epithelial thickness and tight junction and adherens proteins were measured by immunohistochemistry and integrated optical density. Statistical analyses were performed using Wilcoxon signed rank tests. Results After DMPA administration, CD3, CD8, CD45, CD68, HLA-DR and CCR5 bearing lymphocytes were all significantly (p0.05). Epithelial thickness and tight junction and adherens proteins were not statistically different between sampling times (p>0.05). Conclusion After exposure to DMPA, vaginal leukocyte populations significantly increase in the vaginal mucosa. In absence of changes in epithelial integrity, the increase in vaginal T cells, activation markers, and HIV-1 receptors point to a possible immunological basis for the observed effects of DMPA on HIV-1 acquisition and transmission in women., Background Semen is the main carrier of sexually transmitted viruses, including HIV-1. However, semen of HIV-infected men is not merely a passive transporter of HIV-1 but, because of its richness in biologically-active compounds, including chemokines, may facilitate HIV-1 transmission. To test this hypothesis and to study HIV-1 transmission under controlled conditions, we evaluated HIV-1 loads and the cytokine milieu in semen and blood from infected men as well as, the role of these cytokines in HIV transmission to cervicovaginal tissue ex vivo. Methods We measured 21 cytokines/chemokines with a multiplex bead assay and evaluated the loads of HIV-1 in seminal and blood plasmas from 50 HIV-1-infected and 28 uninfected Indian men. Results We found that semen and blood are two separate immunological compartments, in which concentrations of cytokines and loads of coinfecting herpesviruses are profoundly different. Upon HIV infection, the levels of blood and semen cytokines were significantly altered, thus facilitating cytokine network compartmentalization. HIV-1 infection changes the seminal cytokine spectrum by upregulating 16 of the 21 measured cytokines, while in blood 2 cytokines were downregulated and 7 were upregulated. One of the most prominent cytokine in semen was IL-7, which was significantly upregulated in semen of HIV-1-infected individuals. IL-7 in concentrations similar to that in semen of HIV-1-infected individuals facilitates HIV-1 infection in cervicovaginal tissue ex vivo. This facilitation is associated with a suppression of apoptosis of infected CD4 T cells. Conclusion HIV-1 infection results in an aberrant production of cytokines, changing the seminal cytokine network. The altered seminal milieu is an important determinant of HIV-1 sexual transmission: Cytokines altered by seminal infection facilitate HIV-1 transmission to cervicovaginal tissue ex vivo. Cervicovaginal tissue infected ex vivo provides a platform to study the mechanisms of this phenomenon and to develop new preventive strategies by targeting the seminal microenvironment., Background Male circumcision has been shown to decrease rates of HIV acquisition in African men. The STEP vaccine trial also demonstrated that vaccinated, uncircumcised men were at increased risk for HIV acquisition. We sought to identify the mode(s) by which HIV infection may occur in uncircumcised men. Methods Foreskins were obtained from consenting male donors receiving prophylactic male circumcision in Rakai, Uganda. Whole penile specimens were obtained from tissue donation organizations (ScienceCare and NDRI). Using fluorescent immunohistochemistry, foreskin keratin layers were labeled with filaggrin and involucrin markers. Penile tissues were incubated with ex vivo with photo-activatable GFP-linked-Vpr HIVBal for 4 hours, snap-frozen, and cryosections stained for target cells and keratin. Images were obtained with epifluorescent microscopy and analyzed for keratin thickness, viral particles, and viral penetration into penile epithelia. Results We found no significant differences between inner and outer foreskin keratin layers from 19 foreskin samples obtained in Uganda, indicating that reduced keratin thickness is not likely to make the inner foreskin more susceptible to HIV. Preliminary data from whole penile specimens (uncircumcised n=7, circumcised n=7) shows no significant difference in number of visualized virions per image captured, but more virions entering uncircumcised as compared to circumcised glans tissue (uncircumcised:circumcised=2:1). Virions were found at distances from the epithelial surface (mean±SD=33.5±22.3 µm) in the range where CD4+ cells are also localized (mean±SD=53.6 ±32.3 µm), in the absence of trauma to the epithelium. Finally, we visualize virions interacting with the male urethral pseudo-stratified columnar epithelia, though to a lesser degree than seen with stratified squamous epithelia (n=5, glans:urethra=2:1). Conclusion These preliminary results suggest preferential routes by which HIV-1 may enter the male genital tract in female-to-male HIV sexual transmission., Background Our laboratory previously reported that HIV binds and signals through Integrin-α4β7, the gut homing receptor, on the surface of CD4+ T-cells. This interaction may be critical during the earliest events of HIV transmission, when the virus rapidly homes to the gut and a massive depletion of gut CD4+ T cells ensues. Understanding the precise manner by which the virus engages α4β7 may therefore provide insights into the earliest events in HIV infection and the design of novel therapeutics. Both its natural ligands (MAdCAM and VCAM) and gp120 bind α4β7 in a cation-dependent manner. In each case a divalent cation bound to the integrin coordinates an aspartic acid (Asp) residue in the ligand. We previously described a highly conserved Asp in the V2-loop of gp120 that mimics the natural ligands of α4β7, and plays a critical role in this interaction. However, MAdCAM and VCAM utilize a second Asp residue and a second coordinating cation to mediate recognition of both α4 and β7 chains in a complex way. Our data suggests that gp120 interactions with α4β7 are similarly complex. Methods To identify critical residues in HIV-gp120 that mediate α4β7-reactivity we designed site-directed Asp mutants in recombinant gp120s, and measured the binding of each mutant to α4β7. Results By this approach, we identified two sites that mediate gp120-α4β7 interactions. A single Asp mutant at either position reduced reactivity with α4β7 by~2-fold relative to the wildtype, while the double Asp mutants diminished α4β7 binding to near-undetectable levels. Conclusion This observation reveals the discontinuous nature of the gp120-a4 7 epitope and suggests gp120 interactions with a4 7 closely mimic MAdCAM and VCAM. These results advance upon our previous understanding of the molecular basis of α4β7-gp120 interactions and lay the groundwork for further structural studies., Background Highly exposed seronegative (HESN) individuals have had repeated exposures to HIV-1 yet remain virus and antibody negative. We evaluated HIV-1 specific NK cell responses in men who have sex with men (MSM) defined as HESN based on high-risk sexual activities engaged in the early 1980's. Methods Fresh, whole blood samples from HIV-1 seropositives on ART (HIVpos), HIV-1 seronegatives (HIVneg), and HESN subjects in the Multicenter AIDS Cohort Study were cultured with overlapping 15-mer peptide pools representing consensus sequences of HIV-1 Gag, Env, and Reg (Tat, Rev, Vif, Vpu, Vpr), or peptide diluent (Tiemessen, et al., JID 2010). The cultures were analyzed for CD3-CD56+ NK cell and CD3+CD8+ T cell responses by flow cytometry. Results HIV-1 peptide-specific NK cell IFN-g and TNF-a responses were present in 19/23 (83%) HIVpos, 6/13 (46%) HESN and 4/21 (19%) HIVneg (P< 0.001 and P=0.07 compared to HIVpos and HESN, respectively). The IFN-g response magnitudes ranged from 1% to 20% of all NK cells: HIVpos=5.6±1.1%, HESN=1.5±0.7%, and HIVneg=0.47±0.1% (P< 0.001 and P=0.065 compared to HIVpos and HESN, respectively). HIVpos NK cells predominately responded to Env peptides, whereas HESN NK cells responded to both Env and Reg peptides. While both HIVpos and HESN demonstrated CD8+ T-cell responses to Env and Reg, only HESN had CD8+ T-cell IFN-g reactivity to Reg in association with NK cell responses. Conclusion We show for the first time that contemporaneous blood samples from MSM defined as HESN exhibit relatively robust, innate NK cell immunity, and less common CD8+ T cell immunity, specific for HIV-1 proteins. These presumably long lasting, NK cell responses to Env and Reg peptides could be due to prior exposure to HIV-1, or to an inherited genetic resistance. In-depth assessment of these virus-specific NK cell responses could be important in designing effective HIV-1 therapeutics and vaccines., Background Marked differences are seen in individuals’ susceptibility to HIV infection. Inflammation and immune activation are critical factors contributing to initial infection with HIV. The objective of this study was to define serum levels of cytokines and biomarkers of inflammation in participants in the Multicenter AIDS Cohort Study (MACS) who were at high risk for acquiring HIV infection but remained HIV seronegative (HESN), and in those at lower risk who did (LRSC), or did not (LRSN), subsequently undergo HIV seroconversion. Methods Serum levels of cytokines, and biomarkers for inflammation were quantified using Luminex multiplexed assays, in 188 HESN, 125 LRSC, and 197 LRSN. LRSC were tested at a study visit preceding HIV seroconversion. HESN were defined as persistently seronegative participants who were multiply-exposed (>45 anal sexual partners in the 2.5 years prior to MACS visit 2). The LRSC and LRSN groups had, Background Mother-to-infant transmission (MTIT) of HIV results in ~400,000 infected children each year, with a transmission rate of 35–40%. In contrast, nonhuman primate species that are naturally infected with SIV in the wild (“natural hosts”, including sooty mangabeys, SMs) rarely transmit SIV from mothers to infants. The mechanisms underlying this protection are unknown. In this study we tested the hypothesis that limited target cell availability protects SMs from MTIT. Methods The availability of target cells (CD4+CCR5+ and CD4+Ki67+ T-cells) for SIV infection in seven uninfected SM infants was measured by flow cytometry among naïve and memory T-cell subsets obtained from tissues (lymph nodes, spleen, tonsil, and multiple sites along the gastrointestinal tract) at necropsy. Results We found that, in infant SMs, the median percentage of CD4+Ki67+ T-cells ranged from 3.2%-10.3% depending on the anatomic site analyzed, with lower values found in CD95-CD28+ naïve CD4+ T-cells. In contrast, the CD95+CD28+CCR7+ central memory and CD95+CD28+CCR7- transitional memory CD4+ T-cells displayed higher median levels of Ki67 (10.4%-49.3%). The percentage of Ki67+CD95+CD28-CCR7- effector memory CD4+ T-cells tended to be between that of the naïve cells and other memory subsets. Despite this increased level of proliferation (compared to adult SMs), CCR5+T-cells comprised, Background Current HIV-1 integrase inhibitors target the catalytic activity, which is vital for sustained viral infection. Integrase mediates the critical step of proviral DNA integration. Efficient integration also requires a crucial cellular co-factor of HIV-1 integrase, LEDGF/p75, that tethers the viral DNA to the host chromatin. LEDGINs, small molecules designed to bind to the LEDGF/p75 interaction site on IN and to disrupt the interaction, have recently been shown to act as potent inhibitors of HIV replication in cell culture. Methods We have now analyzed the detailed mode of action of LEDGINs, dissecting the allosteric nature of inhibition in vitro and analyzing phenotypically their activity in cell culture. Mechanistic studies and combination experiments shed light on potential synergy of LEDGINs with known integration inhibitors. Analysis of the inhibition of a broad spectrum of HIV strains allows predictions on combinations with other drugs such as entry, RT and protease inhibitors. Results Biochemical evaluation of LEDGINs demonstrates in addition to a potent inhibition of the integrase-LEDGF/p75 interaction, a block of the catalytic integrase activities. This allosteric inhibition is promoted by the stabilization of the dimer-interface of IN upon LEDGIN binding most likely by affecting interaction with viral DNA. These properties of LEDGINs result in potent inhibition of HIV replication in both MT2 and PBMC cells. Moreover, LEDGINs are active across a broad range of HIV clades. LEDGINs retained full activity against a panel of viruses containing mutations that confer resistance to integrase strand transfer inhibitors. Combining LEDGINs with strand transfer inhibitors demonstrates a synergistic effect of these classes of integration inhibitors. Conclusion The biochemical data together with the lack of cross resistance and the observed synergistic effects of LEDGINs in combination with strand transfer inhibitors support the potential for combined use of LEDGINs with strand transfer inhibitors in HIV therapy., Background Tenofovir (TFV) is the only microbicide antiretroviral that has shown clinical effectiveness when dosed pericoitally in a vaginal gel. There remains a need to improve TFV delivery by providing long-lasting, coitally-independent, effective drug levels. Intravaginal rings (IVRs) offer this capability; however TFV is hydrophilic and demonstrates inadequate delivery from conventional IVR technologies. Our objective was to develop a novel IVR technology capable of releasing ≥10 mg/d TFV for ≥90 days, alone or co-delivered with 10 or 20 µg/d of the contraceptive levonorgestrel (LNG). Methods IVRs were designed using single (TFV-only) or dual (TFV-LNG) reservoir-type polyurethane (PU) segments. TFV segments comprised water-swellable PU tubing filled with a high density TFV paste. LNG segments comprising a LNG-loaded non-swellable PU core with a rate controlling membrane were cut to 1 and 2 cm lengths to obtain target release rates of 10 and 20 µg/d, respectively. In vitro release testing (IVRT) and 3-month pharmacokinetic (PK) studies in rabbits and sheep evaluated device performance. Results IVRT revealed time-independent and tunable TFV and LNG release rates which were optimized to achieve our target 10 mg/d TFV and 10 or 20 µg/d LNG. In sheep, TFV and LNG release rates were estimated at ~12–17 mg/d and ~14–31 µg/d, respectively. TFV vaginal tissue and fluid levels were ~104 and 106 ng/g, respectively, similar to levels reported after clinical dosing of TFV 1% gel. In rabbits, LNG PK demonstrated 2-fold differences in plasma and cervical tissue concentrations between the two dose groups, as predicted by in vitro release. Conclusion We developed a unique IVR technology that met our target product profile delivering a high flux of a hydrophilic antiretroviral (TFV) alone or with a low flux of a hydrophobic drug (LNG) in a controlled, time-independent manner. PK results are highly encouraging and warrant a Phase I clinical study. [Picture of prototype TFV and TFV/LNG IVRs], Background HIV-1 integrates into the host chromosome and persists as a provirus flanked by long terminal repeats (LTR). To date, treatment regimens primarily target the virus enzymes or virus entry, but not the integrated provirus. Therefore, HAART requires lifelong treatment which is frequently accompanied by the occurrence of substantial side effects and/or the development of drug-resistant viruses. Previously, we engineered a LTR-specific recombinase (Tre-recombinase) that effectively excises integrated HIV-1 proviral DNA from infected human cell cultures, suggesting that customized enzymes might someday help to eradicate HIV-1 from the body. Therefore, we here analyzed the potential of Tre-recombinase to reverse HIV-1 infection in vivo. Methods We constructed an advanced lentiviral self-inactivating (SIN) vector that expresses Tre-recombinase conditionally in HIV-infected cells. We monitored Tre functionality and potential Tre-related cytopathic effects over time in tissue cultures. Moreover, the effect of Tre activity on HIV-1 infection was investigated in humanized mice. Results It is shown that Tre-recombinase is efficiently delivered into cells and accurately excises HIV-1 proviral DNA from chromosomal integration sites. Apparently, prolonged overexpression of Tre-recombinase does not induce undesired cytopathic effects in the transduced cells. Finally, we demonstrate pronounced antiviral activity of Tre-recombinase in HIV-1 infected Rag2−/−?c−/− mice, which were either engrafted with Tre-transduced human CD4+ T cells or with Tre-transduced human CD34+ hematopoietic stem cells (HSC). Conclusion The presented data suggest that Tre-recombinase may be a valuable component of future antiretroviral therapies of the post HAART era that aim at virus eradication, thereby providing a cure for AIDS., Background In HIV infection, the HIV-specific cytotoxic T lymphocyte (CTL) response is a critical component in controlling viral replication that ultimately fails in its ability to eradicate the virus from the body. Our primary aim is the development of a way to enhance the HIV-specific CTL response to allow long-term viral suppression or viral clearance. Methods In our approach, we sought to genetically manipulate human hematopoietic stem cells (HSCs) such that they differentiate into mature CTLs that will kill HIV infected cells. To perform this, we utilized molecularly cloned HIV-specific T cell receptors (TCRs) derived from CD8+ T cells. These TCRs were used to genetically transduce HSCs that were introduced into a humanized mouse and were allowed to differentiate into mature human CD8+ CTLs. Mice expressing the transgenic HIV-specific TCR and, separately, control mice were then infected with HIV-1 and functional cellular responses, viral suppression, and viral and T cell dynamics were assessed. Results We found that genetic modification of human HSCs with a cloned TCR allows proper differentiation of the cells to occur in vivo and these cells migrate to multiple anatomic sites, mimicking what is seen in humans. We observed that the genetically modified HIV-specific CTLs form a functional antiviral response in vivo that results in the significant suppression of HIV replication in multiple organs. In addition, we found significant correlations between the levels of reconstitution with cells bearing the HIV-specific TCR, antigen-driven T cell expansion, and the control of viral replication. Conclusion We have developed a system to closely characterize the engineering of antiviral immunity and HIV-specific CTL responses. Our results strongly suggest that stem cell based gene therapy may be a feasible approach in the treatment of chronic viral infections and provide a foundation towards the development of this type of strategy., Background Treatment of HIV infection by antiretroviral therapy is effective but costly and often associated with numerous side effects. The key to a permanent treatment to chronic HIV infections is to elicit potent host resistance to viral infection and to restore immune functions. The prolonged incubation period of HIV-1 provides a good opportunity for applying non-conventional interventions such as gene therapy. For HIV gene therapy to be effective, the combination of an efficient gene transfer vector and a powerful anti-HIV strategy is necessary. Methods HIV resistance will be established in patients′ hematopoietic stem cells (HSCs) by lentivector (LV) transduction of (i) a microRNA to block endogenous CCR5 expression, (ii) a sequence-modified CCR5Δ32 gene to interfere with the function of native CCR5 and CXCR4 and (iii) effective multiple anti-HIV shRNAs to target viral RNAs. Results We generated LVs encoding the native and a codon-optimized CCR5Δ32 gene. Ectopic expression of CCR5Δ32 in HOS-R5 and Magi-R5 cells established protection against R5-HIV-1 infection. Unexpectedly, we observed severe cytotoxicity in HOS-R5 cells and primary CD4 T cells when CCR5Δ32 was expressed. In a second approach, we generated a LV expressing an H1-promoter driven CCR5 miRNA and demonstrated marked protection against R5-HIV-1 infection. In a third approach, we generated a novel LV expressing three miRNA intronic cassettes (miR155-19a-30a) targeting HIV-1 pol, int and vpu, respectively, and demonstrated marked protection against HIV-1 infection. LV transduction of adult CD34+ HSCs had no adverse effect on hemopoiesis for dendritic cell development but T cell development appeared to be impaired based on an in vitro assay. Conclusion We conclude that ectopic expression of CCR5Δ32 in adult CD34+ HSCs using a constitutive expression promoter is cytotoxic because the CCR5Δ32 transgene can activate uncontrollable intracellular T cell signaling. However, miRNAs targeting endogenous CCR5 and multiple HIV sequences is highly effective against HIV infection without cytotoxicity., Background The transition from native to receptor-bound and eventually to the fusion-competent conformation of HIV-1 envelope glycoprotein (Env) Env requires a tightly choreographed interaction among highly conserved structures within the viral envelope glycoprotein. Recent structural information has revealed that these conformational transitions are regulated by three conserved but highly mobile layers stacked between the receptor-binding domain (gp120) and the fusion arm (gp41) of Env. We hypothesized that limiting the mobility of these layers by artificially insertion of covalent bonds will capture Env in a conformation where conserved sites are stably exposed. Methods We scanned residues that lie at the interface of gp120 layers (layers 1, 2 and 3) and identified targets that are predicted to form disulfide bonds if substituted with paired cysteines. We substituted a pair of residues between layers 1 and 2 with cysteine & expressed and purified the disulfide-stabilized gp120 (and gp140) antigens and analyzed them using Surface Plasmon Resonance (SPR) assay. Following in vitro analysis, we immunized rabbits with both the wild-type and disulfide-stabilized gp120 (and gp140) antigens, adjuvanted with Carbopol+MF59, and evaluated serum antibodies for binding, neutralization and epitope-specificity. Results A single disulfide bond inserted between the highly conserved layers 1 and 2 led to enhanced stability of the receptor bound conformation of gp120. This was revealed by lower dissociation constant (Kd) of the mutant gp120 binding to 17b antibody, which recognized a conserved CD4 induced (CD4i)-epitope on gp120. Upon immunization in rabbits, the disulfide-stabilized gp120 (and gp140) antigens, in comparison to wild-type antigens, elicited higher level of antibodies directed to CD4-binding site and CD4i-site. Conclusion We demonstrate that structure guided stabilization of inter-layer interactions within Env can be used to improve and stabilize the exposure of conserved epitopes on the antigen and elicit improved antibody response, with the aid of a potent adjuvant, upon immunization., Background The limited success of vaccines targeting the MPER of HIV-1 gp41, we hypothesize, may in part reflect the difficulty of mimicking its neutralization-competent structure (NCS). We have developed DNA-vaccine candidates meant to emulate the NCS of the MPER, and report on their ability to elicit MPER-specific, neutralizing (Nt) antibodies (Abs). Methods DNA vaccines encoding various gp41 ectodomain fragments, and the transmembrane region (TM) of either the platelet-derived growth factor receptor (PGDFR), or that of gp41 were engineered, transiently expressed in COS-7 cells, and tested for antigenicity. Rabbits were immunized with plasmid DNA of select candidates; sera were collected and tested for MPER reactivity. Results Work with the protein products of these vaccines has shown they mimic the NCS of the MPER by several criteria, including the ability to be bound tightly by well-characterized Nt MAbs, but weakly by their non-neutralizing mutant-MAb counterparts. Immunizations with plasmids expressing the MPER tethered to the PDGFR-TM elicited MPER-specific Abs that targeted the epitope of the 2F5 NtAb. Immunization with DNA vaccines encoding the MPER and gp41 TM, elicited low-titre Abs that cross-reacted weakly with the MPER, and strongly with regions outside the MPER. Both sets of immunizations failed to produce Abs that cross-reacted with the 4E10 epitope, or neutralized pseudoviruses bearing HIV-1 Env. We found that the presence of the PGDFR-TM significantly reduced MPER-binding to 4E10 MAb, but not by 2F5. Putative models suggest that in the PDGFR-TM fusions, the 4E10 epitope faces into the lipid bilayer, thereby altering its exposure. Conclusion Our work reveals key structural features involved in promoting the NCS of the MPER. While the gp41 TM is vital in properly exposing neutralizing epitopes on the MPER, it was also found to elicit Abs against sites outside the MPER. Current work is focused on engineering the gp41 TM to optimally expose MPER epitopes., Background The classical vaccine approach for combating other viruses has failed so far in dealing with HIV-1, a virus infecting a key component of immune system and with greater diversity and rapid mutation. New approaches are needed to develop a preventative vaccine. The protease of HIV-1 is a small 99-amino acid aspartic enzyme mediating the cleavage of Gag, Gag-Pol and Nef precursor polyproteins. The process is highly specific, temporally regulated and essential for the production of infectious virions. A total of 12 proteolytic reactions are required to generate a viable virion. Therefore, a vaccine targeting the 12 protease cleavage sites(PCS) could be effective. The PCS of HIV-1 are highly conserved, direct immune responses against these sites would yield several advantages. First, the immune response could destroy the virus before its establishment in the host. Second, it could force the virus to accumulate mutations eliminating the normal function of the HIV protease. Third, restricting the immune responses to these sites can avoid distracting immune responses that often generate unwanted inflammatory responses, induce excess immune activation, and attract more targets for HIV-1 infection, establishment and spread. Methods We conducted a pilot study to investigate the feasibility and effectiveness of this approach. The recombinant VSV-peptides were used to immunize cynomolgus macaques and nanopackaged peptides were used to boost the immune response to the 12 PCS of SIVmac239. The controls and immunized macaques were repeatedly challenged intrarectally with an increased dosage of SIVmac239. Results Antibody and T cell responses to the 12 PCS can protect macaques against higher dosage of SIVmac239 challenge (p=0.0005, R=0.8005) and the vaccine group maintains significantly higher CD4+ counts (p=0.0002) than the controls weeks after being infected. Population coverage analysis showed that this approach can be applied to >95% populations in the world. Conclusion Targeting 12 PCS of HIV-1 is a viable approach., Background A strategy combining Canarypox based vaccine, ALVAC-HIV with gp120 protein has resulted in limited but significant protection from HIV infection in The RV144 vaccine efficacy trial. We have previously tested a similar strategy in the non-human primate model of HIV infection obtaining a similar efficacy to what observed in humans. Methods To study the contribution of innate immune responses as correlate of protection, we have performed microarray analysis in the blood collected from 6 macaques at 16, 24 48 and 72 hours after the first two immunizations with ALVAC (V1 and V2 respectively) and the 3rd immunization with ALVAC/gp120 protein (V3). Results Our results show that 1) 24h after the 1st immunization with ALVAC-SIV (V1) genes with antiviral activity were up regulated (MX1, HERC-5, CD79b), but interestingly inflammatory genes where down regulated (IL1, IL18RAP, IFNR1), suggesting a reciprocal regulation of genes for IFN type I and II; 2) similar patterns of gene expression where observed earlier, at 16h from V2, suggesting the presence of "memory -innate" anti viral responses; 3) the 3rd boost with ALVAC, given simultaneously to the gp120 protein adjuvanted in Alum (V3), resulted in significant changes in the gene expression profile when compared to the first two vaccinations. At 24h from this immunization there were a far less number of IFN-related genes that were significantly up regulated (V3=3) when compared to the first and second immunization (V1= 17; V2=27), and the IFN-responses still up regulated were associated with NK cells, B cell- (CD79B) and T cell- (PKC, CD28 TCR) responses. Conclusion These results suggest that each component of vaccination could have contributed to the protection from infection underscored the ALVA/gp120 strategy. Understanding how to induce different types of immune responses that are protective for HIV may be relevant for the generation of more effective vaccine strategies., Background One of the most frequent complications associated with antiretroviral therapy (ART) in HIV-tuberculosis (TB) co-infected patients is the Immune Reconstitution Inflammatory Syndrome (IRIS). While monocytes/macrophages play a major role in both HIV- and TB-infection individually, the putative contribution of monocytes to the development of TB-IRIS remains uncharacterized. We therefore applied a parallel approach of genome-wide microarray analysis and focused gene expression profiling in monocytes from Ugandan HIV-TB co-infected patients before and shortly after ART initiation, to investigate the possible functional contribution of monocytes to the development of IRIS. Methods Monocyte gene expression of TB-IRIS patients and non-TB-IRIS patients was analyzed by Affymetrix GeneChip® Human Gene 1.0 ST Arrays and was confirmed using the nCounter system; datasets were analyzed for overrepresented pathways using Ingenuity Pathway Analysis. Expression levels of and enzymatic activities of proteins of interest were characterized in the isolated monocyte fractions and in the plasma of IRIS patients. Results Pathway analysis indicated that the complement system was significantly modulated in monocytes of TB-IRIS patients, both before initiation of therapy (baseline) and after two weeks of therapy. At baseline, expression of both C1q and C1-inhibitor was higher in TB-IRIS patients. After two weeks, the C1q mRNA levels in the majority of TB-IRIS patients increased, whereas C1-inhibitor mRNA levels decreased pronouncedly. Additionally, the inhibitory activity of C1-inhibitor was significantly higher in TB-IRIS patients compared with non-TB-IRIS patients at baseline but reduced to the level of C1-inhibitor activity in non-TB-IRIS patients at week 2. Conclusion For the first time, we provide evidence that monocytes at least partially contribute to the development of TB-IRIS, probably through the complement system response. An intriguing possibility is that the relative balance between C1q and C1-inhibitor may be affecting the inflammatory function of C1q in the complement cascade., Background We have shown that leishmaniasis contributes to heightened T-cell activation in HIV-1/Visceral leishmaniasis (AVL) patients. Now we investigate whether lipopolysaccharide (LPS) has a crucial role in the pathogenesis of this co-infection. Methods 10 healthy volunteers, 17 AVL/HIV-1 and 16 HIV-1/AIDS patients were recruited. CD4+T counts and CD8+T cells expressing CD38 were analyzed by flow cytometry. LPS and sCD14 levels were measured by enzymatic assays. Plasmatic pro-inflammatory cytokines (IL-1/IL-6/IL-8/IL-17/IFN-γ/TNF-a) were assessed by multiplex analysis. The macrophage migration inhibition factor (MIF) and intestinal fatty acid binding protein (IFABP) were quantified by ELISA. Mann-Whitney and Spearman correlation test were employed for statistical analysis. Multivariate linear regression was used to determine influence of intervenient factors over T-cell activation. Results AVL/HIV-1 patients in leishmaniasis remission presented equal CD4+T counts or T-cell activation levels in comparison to patients in the active phase of leishmaniaisis. Higher levels of CD8+/CD38+ were seen independently of leishmaniasis clinical phase when compared to HIV/AIDS cases (p< 0.05). Viral load levels had no influence in CD8+/CD38+ levels. Co-infected and HIV+ patients presented similar LPS and IFABP levels, but higher than healthy donors (p< 0.001). Pro-inflammatory cytokines levels, but not MIF were significantly augmented in co-infected cases. LPS levels were positively correlated with MIF (r=0.40;p< 0.05). We found positive correlation between LPS levels and CD38 on CD8+ T lymphocytes(p, Background The incidence of HPV-associated lesions is higher in HIV-infected than in HIV-uninfected individuals. Oral and anogenital mucosal epithelia of HIV/AIDS-positive individuals contain infiltrating HIV-infected immune cells that express viral tat and gp120, and proinflammatory cytokines TNF-a and IFN-g. These proteins may disrupt tight junctions (TJ) of mucosal epithelium, facilitating HPV penetration. Our aims were to investigate how HIV-associated disruption of mucosal epithelium promotes HPV infection. Methods Polarized oral and cervical epithelial cells and tissue explants from HIV-uninfected individuals were treated with recombinant HIV-1 tat, gp120, TNF-a and IFN-g independently and together. The cells and tissue explants were exposed to HPV 16 pseudovirions labeled with fluorescent dyes. Paracellular HPV penetration through disrupted epithelium was evaluated by confocal microscopy. Results Treatment of oral and cervical epithelial cells with tat, gp120, TNF-a, or IFN-g independently for 24 h did not induce significant disruption of TJ but the combination of all 4 proteins caused disruption of TJ in about 90% of cells. Prolonged treatment of cells with these proteins independently for 5 days also induced substantial disruption of TJ. Epithelial disruption mediated by these proteins facilitated paracellular PsV passage through polarized cells-30-45% of apically applied virions were detected in the basolateral compartment. Treatment of oral epithelial explants with HIV tat, gp120, TNF-a, and IFN-g led to disruption of epithelial TJ with paracellular HPV penetration into epithelium and entry of HPV into basal cells. Conclusion Our data indicate that HIV tat, gp120, TNF-a, and/or IFN-g in the epithelial microenvironment disrupt epithelial TJ in a time-dependent manner. Alone or together, they potentiate HPV penetration into basal epithelial cells where HPV infection is initiated. Interference with the effects of these proteins may be useful to reduce the risk of HPV infection when applied topically to at-risk genital mucosal epithelium prior to sexual exposure., Background TT virus is genetically variable and widespread among the general population without apparent pathological effects. It has been detected in the peripheral blood and a variety of body fluids such as semen and cervical fluids. Studies from North America and Europe have reported that TTV infection is more prevalent in HIV-1-infected individuals than in healthy control, but its prognostic significance has been controversial. No study has been reported for TTV co-infection in HIV-1-infected Asian people. This study was aimed to demonstrate prevalence, genotypic variability and prognostic significance of TTV coinfection in northern Thailand HIV cohort. Methods A total of 756 HIV-1-infected adults were enrolled in the Lampang HIV cohort in northern Thailand, and their blood samples were collected. HIV-1 plasma viral loads and CD4 counts were measured at enrollment, and their clinical courses had been monitored. 40 healthy Japanese adults were also tested as controls. DNA of 5 TTV genogroups (G1 to G5) was detected by PCR using genogroup-specific primer pairs. Results 753 (99.9%) of 754 HIV-1-infected adults were infected with any genogroup of TTV: G1 (700/754, 93%), G2 (0/754, 0%), G3a (740/754, 98%), G3b (732/754, 97%), G4 (601/754, 80%) and G5 (562/754, 75%). On the other hand, 38 (95%) of 40 healthy Japanese adults were infected with any TTV genogroup: G1 (63%), G2 (3%), G3a (70%), G3b (68%), G4 (63%) and G5 (20%). Infection with more than one genogroup is more common in HIV-1-infected adults (99%) than in controls (68%). 62% HIV-1-infected and only 13% healthy adults were infected with all of G1, G3a, G3b, G4 and G5. Conclusion TTV infection is highly prevalent in both HIV-1-infected and uninfected Asian adults; however, mixed genogroups were much more common in the former. Correlations between certain TTV genogroup or TTV loads and CD4 counts or HIV-1 load will be determined., Background Secreted proteins play an important role in intercellular interactions, especially between cells of the immune system. Infection of human lymphoid tissues by HIV-1 may alter secretion patterns. Here, we describe a novel, easy, inexpensive, and versatile method, which allows the identification and isolation of a living cell actually secreting any protein of interest. Methods We coupled carboxylated magnetic iron oxyde nanoparticles (IONPs) or quantum dots to polyclonal goat anti-mouse IgG(H+L) antibodies (GAM) and used them as a platform to bind a cell-specific antibody, conferring cell targeting, and an antibody specific for a secreted protein. Purified complexed IONPs form an affinity matrix on the cell surface and capture the cell-secreted product, which can then be detected on the surface of the secreting cell by another secreted-protein-specific labeled antibody. Results GAM-IONPs complexed with anti-CD45 antibody and either anti-IL-2 or anti-IFNgamma. This capture assay was as efficient as a commercial assay and intracellular cytokine staining in identifying cells that secrete IL-2 and IFNg. Respectively, these assays detected IL-2 secretion on 16.9±4%, 14.7±1.8% and 16.3±1.4% of T cells (N=6, P, Background Monitoring of antiretroviral treatment (ART) with human immunodeficiency virus (HIV) viral loads, is rarely available in resource-limited settings because of the high costs, stringent requirements for storage and transport of plasma. Monitoring of antiretroviral therapy (ART) with HIV-1 viral load assays to determine virological treatment failure and to decide when to change to second line therapy is highly recommended. Requirements for -80 degrees Celsius freezers for sample storage prohibit implementation of this level of care in resource poor settings. Dried blood spots (DBS) can be used as an alternative to plasma, but the use of DBS for HIV-1 assays has not been assessed in Zimbabwe. This study investigates the performance of DBS for HIV viral load monitoring of patients on ART in Zimbabwe. Methods Parallel forty eight (48) plasma samples and 48 DBS samples were used in this study. They were selected from samples stored at Flow Cytometry Laboratory, Zimbabwe, collected from patients with ART failure and who were being monitored for HIV drug resistance. Viral load assays were performed on 48 samples using plasma and dried blood spots methods. Plasma was separated and frozen at -80 degrees Celsius and DBS were kept at room temperature for 30days. Results The correlation between plasma and DBS viral load was high (R2=0.75). Mean difference was 0.05 log10 copies/mL (SD 0.58), and only 8 samples showed >1 log10 difference. Sensitivity and specificity of DBS to detect virological failure (plasma viral load >400 copies/mL) was 82.5 and 93.1%, respectively. Conclusion There was a very good correlation between DBS stored at room temperature for 30 days and plasma viral load assays. The evaluation shows that DBS can be a feasible and reliable method for virological monitoring of patients on ARVs in rural areas with transport facilities for referring samples to a central laboratory. Abstract Coding GuideExample: MOAA01=(Weekday) MO – (Session type) AA – (Session order) 01 Weekdays: SU (Sunday), MO (Monday), TU (Tuesday), WE (Wednesday), TH (Thursday), FR (Friday) Session types: oral abstract sessions – AA (Track A), AB (Track B), AC (Track C), AD (Track D), AE (Track E), AX (Cross-Track), LBA (Late Breaker Track A), LBB (Late Breaker Track B), LBC (Late Breaker Track C), LBD (Late Breaker Track D), LBE (Late Breaker Track E), LBX (Late Breaker Cross-Track); oral poster discussions sessions – PDA (Track A), PDB (Track B), PDC (Track C), PDD (Track D), PDE (Track E) PDX (Cross-Track) Session order: 01, 02, 03, 04, etc.

Background Toll-like receptors (TLRs) are transmembrane receptors that activate cells of the innate immune systems upon recognition of pathogen-associated molecular patterns. The TLR4 is an essential component of the innate immune response to various microorganisms. We investigated the impact of TLR4 polymorphism on development of opportunistic diseases in HIV-infected patients. Methods The presence of TLR4 Asp299Gly single nucleotide polymorphisms (SNPs) was determined in a cohort of 180 antiretroviral treatment-naive HIV-1 infected patients and evaluated in relation to the occurrence of opportunistic infections. TLR4 genotyping was performed by real-time PCR. Results One hundred sixty-five patients were homozygous for the wild-type genotype (AA); 15 patients (8,3%) were heterozygous for the Asp299Gly SNP (AG). TLR4 polymorphism was associated with more frequent development of the opportunistic infections, such as active tuberculosis (OR=3.27; 95% CI [1.21–10.29]), herpes zoster (OR=4.15; 95% CI [1.24–7.29]) and toxoplasmosis (OR=6.23; 95% CI [1.19–18.67]) compared with genotype AA. In addition, TLR4 SNP was associated with development of opportunistic diseases among individuals with CD4 cell count of>100 cells/mm3, compared with homozygous HIV-infected patients (OR, 5.25; 95%, CI [2.28–10.47]). Conclusion This study suggests a greater risk of developing of active tuberculosis and other opportunistic infections in patients with the Asp299Gly TLR4 polymorphism., Background Diagnosis of acute HIV infection (AHI) is uncommon in resource limited settings. This abstract describes acute HIV infection in women in three East African countries. Methods Women at high risk of infection were recruited from ‘hot spots’ in Kericho (rural Kenya), Kampala (urban Uganda) and Mbeya (rural Tanzania). HIV negative eligible women were prospectively screened twice a week using HIV nucleic acid testing. A positive test led to entry into an intensive one-month diagnostic verification phase to definitively establish HIV infection status. Clinical and laboratory assessments were performed semiweekly. Supportive care and symptomatic treatment was provided. Results Overall, 1197 high-risk volunteers have enrolled to date with 37 cases of AHI identified (31 prior to detectable antibodies). Mean age at HIV acquisition was 24.4 years (range 18–34). Only six reported unprotected sex with a known HIV positive partner. Crude incidence was 2.77/100 PY (95% CI:±0.87). Of the 37 AHI cases; 14 presented with malaria-like symptoms (all smear negative), 7 flu-like symptoms while 16 had 1–2 mild complaints (8) or no symptoms (8). Overall, AHI cases were evaluated at 302 visits and at least one symptom was reported in only 75 visits (24.8%). Pregnancy did not increase the frequency of symptoms but dehydration due to vomiting resulted in 2 of the 3 hospitalizations observed. Conclusion Identification of AHI is feasible in East Africa. Young, rural, females are most vulnerable. Individuals with clinical syndromes suggestive of malaria, but excluded by microscopy, should raise index of suspicion for AHI. The majority of cases had few or no symptoms or brief non-specific symptoms not requiring medical intervention. Screening protocols based on malaria syndromic presentation would not identify the majority of AHI cases., Background The use of combination antiretroviral therapy (cART) has resulted in dramatic reductions in HIV-related mortality and morbidity. Nevertheless, despite sustained suppression of viral replication there remains evidence of increased levels of immune activation, particularly in patients initiating treatment during late-stage infection. We asked whether early initiation of therapy could potentially ameliorate this apparent limitation of cART. Methods 40 subjects identified as acutely or early HIV-1 infected were treated with either 3-drug cART (N=14) which included TDF/FTC, a ritonavir-boosted protease inhibitor (atazanavir or darunavir) or 5-drugs (N=26) cART as above with raltegravir and maraviroc. CD38 and HLA-DR expression on CD8+ T cells were determined by flow cytometry at baseline and weeks 48 and 96. Levels of sCD14 by ELISA were measured at weeks 48 and 96. These results were compared to values in 13 healthy, HIV-1 uninfected volunteers. Results A total of 29 subjects, 11 on 3-drugs and 18 on 5-drugs remained on therapy, suppressed and were available for analysis at 48 weeks. After 96-weeks 25 subjects, 9 on 3-drugs and 16 on 5-drugs were similarly analyzed. There are no statistically significant differences (Mann-Whitney, p, Background HIV controllers, maintaining low plasma HIV RNA levels (, Background HIV+ individuals in care with access to ART may experience a wider range of non-AIDS-related complications than previously. It is important to accurately classify causes of death, and monitor trends over time. Ratio ratio (95% CI) for underlying cause of death over calender time (reference=1999/2000)2001/20022003/20042005/20062007/20082009–2011 Total deaths Unadjusted0.98 (0.85–1.12)0.91 (0.79–1.04)0.69 (0.60–0.80)0.58 (0.50–0.67)0.48 (0.41–0.55)Adjusteda 1.06 (0.92–1.23)1.03 (0.89–1.18)0.80 (0.69–0.93)0.71 (0.61–0.83)0.66 (0.56–0.77) AIDS Unadjusted0.91 (0.71–1.16)0.88 (0.69–1.12)0.56 (0.43–0.72)0.44 (0.34–0.57)0.31 (0.24–0.42)Adjusteda 1.11 (0.87–1.43)1.20 (0.94–1.54)0.86 (0.66–1.11)0.82 (0.62–1.07)0.85 (0.64–1.13) Liver-related Unadjusted0.96 (0.67–1.37)0.71 (0.50–1.03)0.63 (0.43–0.90)0.46 (0.32–0.68)0.28 (0.18–0.42)Adjusteda 1.02 (0.70–1.47)0.80 (0.55–1.17)0.73 (0.49–1.07)0.59 (0.39–0.88)0.39 (0.25–0.61) Non-AIDS malignancyb Unadjusted1.18 (0.74–1.89)1.34 (0.84–2.11)1.16 (0.73–1.84)1.16 (0.73–1.83)1.09 (0.69–1.72)Adjusted1.10 (0.68–1.78)1.19 (0.75–1.90)0.95 (0.59–1.52)0.91 (0.57–1.46)0.83 (0.52–1.35) CVD-related Unadjusted1.07 (0.69–1.66)0.97 (0.63–1.51)0.77 (0.50–1.20)0.69 (0.44–1.07)0.46 (0.29–0.74)Adjusteda 0.99 (0.64–1.55)0.84 (0.54–1.32)0.62 (0.39–0.98)0.51 (0.32–0.82)0.31 (0.19–0.51) Other/Unknownc Unadjusted0.97 (0.76–1.25)0.90 (0.70–1.15)0.71 (0.55–0.92)0.59 (0.45–0.76)0.59 (0.45–0.76)Adjusteda 1.05 (0.82–1.36)1.00 (0.77–1.29)0.82 (0.63–1.07)0.71 (0.55–0.93)0.75 (0.57–0.99)Results from Poisson Regression Model.aAdjusted for (fixed) gender, age, ethnicity, riskgroup, HBV status, HCV status, smoking, diabetes, hypertension, (time-updated) viral load, BMI and CD4 count.bIncludes lung, prostate, anal, primary liver, GI, breast, uterus, testicular and bladder cancers, leukemias and Hodgkin's lymphomas.cAlt deaths that do not meet criteria for other categories. Methods Individuals from a large prospective cohort collaboration (D:A:D) were followed starting from 1999 until death, loss-to-follow-up or February 2011, whichever came first. Underlying causes of death were attributed based on the Coding of causes of Death (CoDe) system. Results 3,802 deaths occurred in 49,734 individuals followed for 304,695 person-years (rate=12.5/1000 person-years [95% CI 12.1–12.9]). Leading underlying causes were: AIDS-related (29%), non-AIDS-defining malignancies (NADM; 14%), liver disease (LD; 13%), cardiovascular disease (CVD; 11%), invasive bacterial infection (7%), drug overdose (3%), accidents (2%), renal disease (1%) and unknown (7%). Decreases over time occurred in rates of all-cause (17.4/1000 person-years in 1999–2000 to 8.3 in 2009–2011), AIDS-related (5.9−1.9), LD (2.7−0.8) and CVD-related (1.8−0.8) mortality. However, the rate of NADM deaths remained stable (1.5−1.6). After accounting for factors including current CD4 count (Table), there was still evidence of decreases over time in LD and CVD deaths, but not AIDS-related. The proportion of all deaths attributed to AIDS (34% in 1999–2000 to 22% in 2009–2011), NADM (9%–20%) and LD (16%–9%) changed over time. Conclusion Underlying causes of death have changed markedly over the last 12 years. AIDS remains the leading cause. Although there have been marked reductions over time in AIDS-related deaths, this effect is removed when accounting for current CD4 and other factors. NADMs are now the leading non-AIDS cause. Rates of LD and CVD-related deaths have decreased substantially, even after accounting for the factors listed below, suggesting other improvements in patient management during the study period. No trends in emerging causes of unexpected deaths were observed. Collection of specific causes of deaths is important to allow earlier interventions in HIV case management., Background US CDC guidelines recommend at least annual HIV testing for those at high risk. Nonadherence to testing guidelines and late diagnosis of infection may contribute to HIV transmission. Methods HPTN 061 is a feasibility study of a multi-component HIV prevention intervention for at-risk black MSM in 6 US cities. At enrollment, participants were offered HIV testing. Participants reporting past HIV-uninfected or unknown status at enrollment and no HIV testing within the prior 12 months were considered nonadherent to HIV testing guidelines. Participants with newly diagnosed HIV and CD4, Background Recent data showing a high incidence of HIV infection among men who have sex with men (MSM) who had been tested during the past year suggest that MSM might benefit from more frequent HIV screening (e.g., every 3 to 6 months). We assessed the cost-effectiveness of HIV screening at 3 and 6 month intervals compared with annual screening. Methods We used a published mathematical model of HIV transmission to evaluate screening intervals for a cohort of 10,000 MSM ages 14–64. We incorporated HIV transmissions averted due to serostatus awareness for each screening interval (e.g. 3, 6, 12 months), as well as HIV testing costs and treatment costs for averted transmissions. We assumed an HIV incidence of 1.27% for MSM and conducted threshold analyses on incidence. We assumed conventional testing with a 3rd generation antibody test and 75% receipt of results. In sensitivity analyses, we investigated the impact of all rapid testing and 100% receipt of results. We valued each HIV transmission averted using lifetime treatment costs of $367,134. Results Compared to annual screening, conventional HIV testing every 3 months and 6 months averted 2.04 and 1.36 HIV transmissions, respectively, and both were cost-saving. The incremental cost-effectiveness of 3-month versus 6-month screening also was cost-saving. Threshold values for HIV incidence at which screening was cost-saving were 0.3% and 0.5% at the 3-month and 6-month screening intervals, respectively. Screening with a rapid test was cost-saving at both 3- and 6-month intervals compared to annual screening. The incremental cost-effectiveness of 3-month versus 6-month screening was $813 per QALY saved. Every 6 months compared to annually Every 3 months compared to annually Every 3 months compared to every 6 months HIV Screening Costs$97,340$284,574$187,233HIV Transmissions Averted1.362.040.68QALYs Saved8.7613.144.38HIV Treatment Costs Saved$500,149$750,223$250,074Incremental Cost-effectiveness RatioCost-savingCost-savingCost-savingCost-effectiveness of HIV Screening for MSM. Conclusion HIV screening with either conventional or rapid testing as frequently as every 3 months is cost-saving or very cost-effective. Reexamination of HIV screening intervals for MSM should be considered on the basis of the economic evidence., Background Pooling techniques have been advanced to improve the cost effectiveness of nucleic acid testing for diagnosis of serologically undetectable acute HIV infections in resource limited settings. Previously reported methods have relied on serum samples. The goal of this study is to develop and apply a novel dried blood spot (DBS) based RT-PCR pooling technique to facilitate household sample collection, efficient diagnosis, and treatment-as-prevention strategies in Mochudi, Botswana. Methods Laboratory-prepared DBS samples with plasma viral load >50,000 copies/mL are diluted with HIV negative DBS samples to generate estimates of sensitivity for pool sizes of 5, 10, 25, 50, and 100 samples. RT-PCR is performed using the Abbott RealTime HIV-1 assay. This analysis will inform the development of an acute HIV case detection pooling algorithm to be applied to all seronegative samples collected as part of a large prevention study cohort.Table 1Sensitivities of DBS pooled RT-PCR Mean copies per mL (95% CI) Pool size % Sensitivity 38680.96 (28170.00, 49191.91)510019965.30 (15020.37, 24910.23)1094.18735.91 (6800.21, 10671.61)2571.44992.78 (3579.63, 6405.93)5070.63121.21 (1676, 4566.20)10027.8 Results Preliminary findings based on 9 HIV positive samples used to create 90 pools, reflected sensitivities ranging from 27.8% for pools at 1/100 dilution to 100% for 1/5. We were able to detect the presence of an HIV positive sample in pools of 10 with a sensitivity of 94.1%. The difference in sensitivity between pool sizes of 25 and 50 was minimal. Conclusion We have demonstrated the feasibility of using DBS pooling for acute HIV diagnosis. Because acute HIV infection involves high viral loads, we can reasonably expect to detect acute cases >50,000 copies/mL in pools of 10 with 94.1% sensitivity. Although increasing pool size decreases sensitivities, the false negative rate during the acute window period could be significantly reduced even with the use of larger pools. Because secondary HIV transmission in acute and recent HIV infection may contribute significantly to the epidemic in Botswana, the potential for a treatment-as-prevention strategy would be facilitated by screening methods to detect acute HIV cases., Background In Kenya, HIV-1 viral load (VL) monitoring is commonly performed with the COBAS Amplicor using plasma specimens, but interest is growing in transitioning to real-time PCR (RT-PCR), including the COBAS Ampliprep/COBAS Taqman (CAP/CTM), using dried blood spots (DBS). RT-PCR has several advantages including full automation, lower detection limit, and broader measuring range. Benefits with DBS include sample collection via finger or heel stick, low biohazard risk, and specimen transportation under ambient conditions. Prior to implementation, a direct evaluation of the two assays using DBS field specimens is required. Methods This analysis compares sensitivity, specificity, negative (NPV) and positive (PPV) predictive values, concordance correlation, and agreement, as evaluated with Bland Altman analyses, between HIV-1 VL measurements using paired plasma and DBS specimens obtained from 512 HIV-1 infected treatment-naive pregnant women enrolled in the Kisumu Breastfeeding Study, and tested with the COBAS Amplicor and CAP/CTM assays. Results The sensitivity and NPV of VL detection in DBS specimens were higher with CAP/CTM (sensitivity: 100%, 95% CI: 99.1–100.0; NPV: 100%, 95% CI: 59.0–100.0) than COBAS Amplicor (sensitivity: 96.6%, 95% CI: 94.3–98.1; NPV: 58.8%, 95% CI: 40.7–75.4), with comparable PPV; 99.5%, 95% CI: 98.3–99.9 and 99.6%, 95% CI: 98.6–100.0 for the respective assays. The specificity of VL detection in DBS specimens was lower with CAP/CTM (77.8%, 95% CI: 40.0–97.2) than COBAS Amplicor (95.2%, 95% CI: 76.2–99.9). Good concordance and agreement were observed when testing paired plasma and DBS specimens (Figures 1 and 2).Figure 1 Concordance correlation analyses of HIV-1 viral load quantification among plasma and DBS specimens collected from patients enrolled in Kisumu Breastfeeding Study and tested with COBAS Amplicor and CAP/CTM. COBAS Amplicor plasma viral loads were used as reference group for comparison: a)vs. COBAS Amplicor DBS viral loads; b) vs. CAP/CTM plasma viral loads; c) vs. CAP/CTM DBS viral loads [Correlation plots]. Figure 2 Bland-Altman analyses to evaluate agreement in HIV-1 viral load quantification among plasma and DBS specimens collected from patients enrolled in Kisumu Breastfeeding Study and tested with COBAS Amplicor and CAP/CTM. COBAS Amplicor plasma viral loads were used as reference group for comparison. The difference between the reference and the comparision assay/specimen type were plotted against the average of the reference group and the comparision assay/specimen type o; a)COBAS Amplicor DBS viral loads; b) CAP/CTM plasma viral loads; c) CAP/CTM DBS viral loads [Bland-Altman plots]. Conclusion There was good correlation between DBS and plasma viral loads as well as between COBAS Amplicor and CAP/CTM. However, CAP/CTM had a better sensitivity compared to COBAS Amplicor. Our findings show that DBS may be an alternative sample type to plasma for viral load measurement, which could increase access to viral load monitoring in resource limited settings. Disclaimer The content and views in this abstract are solely the responsibility of the authors and do not necessarily represent the official views of the affiliated organizations, United States Government, or Government of Kenya., Background Routine viral load (VL) testing is not available or recommended for patients on HAART in India. The implications of not having routine VL testing are not known in this setting. Methods As part of a longitudinal adherence study, participants on first-line HAART in Bangalore, India were monitored every six months, for 24 months, with CD4 cell count, HIV VL, and genotype, if VL>1000copies/ml. Participants with virologic failure (VF) often continued on first line therapy due to local resource constraints. We compared the incidence of WHO-defined criteria for immunologic failure (IF) to VF, defined as two consecutive VL >1000 copies/ml or VL>10,000 copies/ml for those who had only one VL available. Results Five hundred nine participants were included in the study (63% male, median age 36, median duration on HAART at start of study 14 months). Forty (7.8%) experienced VF, 25 (6.1%) IF and 10 (2.0%) both VF and IF. The sensitivity of immunologic criteria to detect VF was 20%, specificity 95% and positive-predictive value 29%. Of the 40 participants with VF only, 18 developed new thymidine analogue mutations over the follow-up period during which they continued on first line therapy; 11 of 18 developed high- level NRTI resistance, which would preclude subsequent tenofovir use. In addition, six participants developed NNRTI mutations, which confer genotypic resistance to etravirine and rilpivirine. Conclusion WHO IF criteria have low sensitivity for detecting VF and presence of IF poorly predicts VF. Relying on CD4 count data alone would lead a substantial number of unnecessary switches to second-line therapy. A notable proportion of patients would be continued on first line therapy that they are already failing, jeopardizing future HAART options. Universal access to VL monitoring would avoid costly switches to second line therapy and preserve future therapeutic options., Background Rapid scale-up of antiretroviral therapy (ART) in Southern Africa has put enormous strain on health systems. Information about acquired drug resistance in treated individuals is important to monitor quality of programmes and to ensure that ART policies remain appropriate. The majority of resistance data so far have come from urban, hospital-based programmes; limited data have been reported from rural treatment programmes. Methods Adult (≥16 years) HIV-infected individuals with virological failure (2×VL>1000 copies/ml) on first-line NNRTI-based ART were enrolled from all 17 primary health care clinics of the Hlabisa ART Programme. Genotypic resistance testing was performed using the in-house SATuRN/Life Technologies system. Sequences were analysed and genotypic susceptibility scores (GSS) were calculated using RegaDB and Stanford HIVDB 6.0.5 algorithms. Results 187 adults enrolled between Dec 2010 and Dec 2011; median age 37 years (IQR 31–45); 70% female. Median time on ART 41 months (IQR 31–53); median time on failing regimen 30 months (IQR 20–42). 120 (64%) had never achieved full virological suppression (VL≤50 copies/ml). 160 (86%) individuals had ≥1 drug resistance mutation; 149 (80%) and 153 (82%) respectively had NRTI and NNRTI mutations. 72 (38%) had at least one thymidine analogue mutation (TAM) and 32 (17%) had ≥3 TAMs. 14 (7%) had other NRTI mutations that might impact on second-line therapy (K65R-12 (6%); Q151M-3 (2%)). The standard second-line regimen was substantially compromised (defined as GSS≤1.5) in 33 (18%) individuals. Conclusion There are high levels of acquired drug resistance associated with prolonged virological failure in this rural primary health care programme. Standard second-line regimens would be significantly compromised in almost one in five adults. This suggests a role for genotypic resistance testing in routine care but, more importantly, it highlights the need for increased attention to quality of care and adherence to virological monitoring guidelines., Background In assessing the cost-effectiveness of CD4 versus viral load (VL) monitoring strategies, the “resistance cost” associated with delays in identifying non-suppression must be considered, and would likely favor a VL strategy. Here we examined the extent of protease (PR) mutation accumulation according to duration of 2nd-line (2L) failure. Methods Since 2004, the Harvard PEPFAR/APIN Program has provided ART to over 85,000 people in Nigeria. Approximately 8% of patients have received protease inhibitor (PI)-based 2L therapy (mostly LPV/r). A subset of patients with VL failure, defined as 2 consecutive VLs >1000cpm after ≥6 months on 2L, underwent genotypic resistance testing. Accumulation of PR mutations according to time on failing regimen was determined. Results Of 6714 patients who received PI-based ART, 661 (9.8%) met virologic failure criteria. Genotypes were performed on 53 samples (median CD4 183; VL 30150 at 2L failure). Time on Failing 2nd-line Regimen Characteristic 0–12 months (n=15) 13–24 months (n=27) >24 months (n=11) Total (n=53) Age (years), median (IQR)43 (34–47)40 (34–43)42 (32–51)42 (33–46)% Female33%48%55%45%# ARVs previously used, median (range)6 (4–7)6 (4–8)6 (5–9)6 (4–9)Duration on 1L (months), median (IQR)23 (19–37)28 (16–37)16 (14–23)24 (15–35)Duration on 2L (months)12 (8–20)20 (18–22)36 (34–50)20 (16–34)Time Failing 2L Regimen (months)8 (6–11)18 (16–20)34 (32–40)17 (12–22)2L Adherence (%), median (IQR)89 (79–98)96 (87–100)91 (78–100)92 (84–100)Characteristics of Patients Failing 2L ART. Patients on non-suppressive 2L therapy for ≤12 months prior to genotype testing had a median of 3 (IQR, 1–5) International AIDS Society (IAS) PR mutations, compared with 6 (IQR, 0–6.5) among patients failing for >24 months. Patients developed a median of 1.1 (IQR, 0–2.3) IAS PR mutations per 6 months on failing 2L therapy. In 30% of failing patients no PR mutations were present, suggesting non-adherence; when these patients were excluded, the median number of IAS PR mutations/6 months increased to 1.8 (IQR, 1.1–2.8). For patients failing >24 months, high- or intermediate-level resistance to LPV/r and ATV/r was present in 64%, with 9% to DRV/r. Time on Failing 2L Regimen Protease Resistance 0–12 months (n=15) 13–24 months (n=27) >24 months (n=11) Total (n=53) Total # PR mutations, median (IQR)3 (1–5)2 (0–5)6 (0–6.5)3 (0–5)Major PR mutations0 (0–1.5)0 (0–3)3 (0–4)1 (0–3)Minor PR mutations2 (0.5–3.5)2 (0–2)2 (0–3)2 (0–2)High- or Intermediate-level PI Resistance, # (%)Lopinavir (LPV/r) and Atazanavir (ATV/r)4 (27%)12 (44%)7 (64%)23 (43%)Darunavir (DRV/r)0 (0%)4 (15%)1 (9%)5 (9%)# PR mutations/6 mo. on Failing 2L, median (IQR)2.7 (0.5–3.7)0.9 (0–1.8)0.8 (0–1.1)1.1 (0–2.3)# PR mutations/6 mo. on Failing 2L (No PR mutations excluded)3.4 (2.6–4)1.4 (0.8–2.3)1.1 (0.9–1.2)1.8 (1.1–2.8)Protease Mutation Accumulation by Time Failing. Conclusion This is the first report assessing the impact of duration of non-suppressive 2L therapy on the accumulation of PR resistance in a resource-limited setting. This information provides insight into the “resistance cost” associated with failing to switch non-suppressive 2L regimens, and highlights the issue of 3rd-line access., Background In the USA, CD4 cell counts and HIV-1 viral load (VL) have been tested concomitantly 2–4 times/year for persons receiving antiretroviral therapy (ART). With the advancement of effective HIV care, many individuals now have viral suppression and higher CD4 cell counts. After therapy is initiated, the CD4 cell count is used to monitor the need for prophylaxis against opportunistic infections and immunologic response to ART. We assessed whether CD4 cell counts may be performed less frequently after viral suppression of, Background Cryptococcal meningitis (CM) is a leading cause of death in AIDS patients in sub-Saharan Africa. Cryptococcal antigen (CRAG) can be detected weeks before symptom onset, and those who are asymptomatic but CRAG+ have a high risk of subsequent CM and mortality. A new CRAG point-of-care immunochromatographic lateral flow assay (LFA) is available that is remarkably easy to administer without laboratory infrastructure or expertise and has excellent sensitivity and specificity. Methods We assessed the cost-benefit of targeted CRAG screening for patients with CD4, Background Penicillium marneffei is an emerging dimorphic mycosis endemic in South and Southeast Asia, and a leading cause of mortality among HIV-infected people in the region. Factors governing the seasonal incidence of P. marneffei infection have yet to be identified, and may yield critical insights into possible reservoirs or modes of transmission. We used P. marneffei incidence data from Ho Chi Minh City (HCMC), Vietnam from 2004–2010, as well as high-resolution weather data, to identify climactic factors that could account for the observed seasonality of P. marneffei infection. Methods This study included all P. marneffei, Cryptococcus neoformans, and HIV-related admissions to the Hospital for Tropical Disease (HTD) in HCMC from 2004–2010, as well as temperature, humidity, wind, and precipitation data for the corresponding period. We used logistic regression modeling to identify factors significantly associated with P. marneffei and C. neoformans admissions. We also estimated the P. marneffei incubation period by incorporating different exposure-to-admission delays in our models. Results This analysis included 719 HIV-infected patients presenting with penicilliosis. P. marneffei admissions were closely associated with humidity (P, Background RIF upregulates CYP 450 isoenzymes and can lower EFV exposure, particularly if weight ≥50 kg, However, clinical data have not shown reduced HIV virologic suppression with 600 mg EFV+RIF. We conducted a nested PK study to evaluate EFV concentrations and virologic suppression in A5221 patients on EFV(600 mg) and RIF-based TB treatment. Table 1 Weight (kg) 4) compared to Whites(22.9% vs 3.9%;p=0.002). Conclusion Overall, RIFcoadministration was not associated with lower EFV trough concentrations; patients weighing ≥50 or ≥60 kg had lower EFV Cmin, but there was no association with subtherapeutic Cmin nor virologic suppression. These data from a multinational, predominantly non-White population do not support guidelines for weight-based dosing of EFV with RIF., Background HIV is the strongest risk factor for progressing from latent M. tuberculosis infection to tuberculosis (TB). 9 months of daily self-administered INH (9H) is efficacious but has low completion rates and may cause hepatotoxicity. PREVENT TB demonstrated that 3 months of once-weekly rifapentine 900 mg+INH 900 mg under direct observation (3HP) was at least as effective as 9H, but only 3% of the participants were HIV+, so enrollment of HIV+ persons was extended to adequately assess tolerability. Methods HIV+ persons ≥2 years old who were either tuberculin skin test positive or close contacts of TB cases were randomized to 3HP or 9H. Persons could not receive antiretroviral therapy (ART) for 90 days after enrollment. Participants were enrolled from the U.S., Brazil, Spain, Peru, and Canada between June 2001 and December 2010. Follow-up for TB continues through 2013. Results Of 4,128 participants enrolled with known HIV status and who received ≥1 dose of study therapy, 393 were HIV +: 207 in the 3HP and 186 in the 9H arm. In the MITT analysis (enrolled participants who were eligible), 178/201 (89%) HIV+ persons completed 3HP vs. 125/193 (65%) on 9H (P< 0.001). The proportion of participants with a serious adverse event (SAE), ≥1 AE, or hepatotoxicity was lower in 3HP than 9H (4 vs. 11%; P=0.006; 22 vs. 40%; P=0.004; 2 vs. 6%; P=0.03). Compared to 1,888 HIV-negative participants treated with 3HP, HIV+ persons were less likely to permanently discontinue treatment for any reason (11 vs. 20%; P, Background HIV and TB are threats to pregnant women and infants. Treatment with rifampin can reduce ART concentrations and increase risk of treatment failure and vertical transmission. We describe the pharmacokinetics (PK) and pharmacodynamics of EFV among pregnant HIV-infected women. Methods Prospective cohort of HIV-infected pregnant women with and without TB in Soweto. Women taking ART with EFV 600 mg had PK sampling at 37 weeks’ gestation or at delivery and then six weeks post-partum. EFV concentrations were measured in cord blood at delivery and in infants at 7 days. Post-hoc Bayesian estimates of PK parameters from nonlinear mixed-effects modeling with allometric scaling are reported. Results Among 41 HIV-infected pregnant women taking EFV ART, 19 received rifampin (TB/HIV) and 22 ART alone. Median age and weight were 29 years and 70 kg. For 35 women with pre-/peripartum EFV PK, median (IQR) estimated EFV trough (Cmin) was 1.31 (0.84, 1.86)mg/L, apparent oral clearance (CL/F) 13.62 (10.67, 18.44)L/h, and volume of distribution (Vd/F) 516 (440, 591)L. 31% had Cmin20 copies/mL (one had TB/HIV). Median cord blood EFV concentration was 1.09 (0.46, 2.38)mg/L. EFV concentrations were BLQ in 6/24 cord blood and 25/30 infant 7-day samples; both correlated with maternal concentrations. 0/35 infants were HIV-infected at 6 weeks. In mothers 6 weeks postpartum, median EFV Cmin was 1.75mg/L, CL/F 10.79L/h, and Vd/F 433L; 30% had Cmin, Background TMC207 (bedaquiline) (B) is a diarylquinoline in Phase 2 development to treat drug-sensitive and drug-resistant tuberculosis. It is being evaluated in novel combination regimens with an aim to minimize adverse interactions with antiretroviral therapy (ART). This study investigated the effect of enzyme inducers rifapentine (P) or rifampicin (R) on TMC207 pharmacokinetics.Geometric LS Means of Bedaquiline Confidence IntervalsTreatment GroupParameterWith InducerAloneMean Ratio90% ConfidenceRifapentine Group 1Cmax 2077333962.2(53.4, 72.5)AUC(0–1) 276126453142.3(37.8, 48.5)Rifampicin Group 2Cmax 2240371860.2(52.0, 69.8)AUC(0–1) 253146120941.4(37.7, 45.4)Results Table. Methods This was a 2-period, single-sequence drug interaction study performed in 2 groups of healthy subjects. Period 1 examined the PK of B and its M2 metabolite after a single 400 mg dose of B. Period 2 examined the effects of repeated doses of either P or R on the PK of B and M2. Subjects took P 600 mg (Group 1) or R 600 mg (Group 2) q.d. for 22 days. A single 400 mg dose of B was administered on Study Day 10 of period 2 followed by PK sampling for 14 days. Results 32 subjects were enrolled and 29 completed; B, alone, and in combination with P or R, was generally well tolerated. P and R both reduced the Cmax and AUC of B greater than M2. Conclusion Both P and R reduce the Cmax and AUC of single doses of B by approximately 58%. Future regimens with B to treat TB should avoid the inclusion of P or R. The development of B with R sparing regimens is ongoing., Background PA-824 (Pa) and bedaquiline (B) (TMC) are novel compounds in phase 2 development with established Early Bactericidal Activity (EBA) over 14 days. The study presented is an EBA study that evaluated these drugs alone or in combination with each other and with moxifloxacin (M) and pyrazinamide (Z) to identify a regimen with the potential to shorten treatment of TB in patients without the use of rifamycins or other drugs that interact adversely with antiretroviral Therapy (ART). Methods 83 participants enrolled (26% F, 74% M, including 6 HIV+) as five cohorts of 15 TB patients, each who received daily dosages of B alone, B with Z, B with Pa, Pa with Z and Pa with M and Z. A cohort of 8 patients received daily standard TB treatment (isoniazid, rifampin, Z and ethambutol: HRZE) as a control for the EBA quantitative mycobacteriology. The primary efficacy endpoint was the rate of change in number of colony forming units (CFU) of Mycobacterium tuberculosis per ml of sputum incubated on agar plates from serial sputum collections over the period Day 0 to Day 14. Results All cohorts had decreases in logCFU counts/ml of sputum from Days 0 to 14 that ranged from 1.2–2.7 over 14 days. While Z potentiated the activity of both B and Pa and compared favorably with the HRZE standard regimen, the cohort with the combination Pa-M-Z had numerically the greatest effect on CFU reduction. Conclusion The combination regimen of Pa-M-Z has potent bactericidal activity over 14 days in patients with pulmonary TB and has the potential to treat both Drug Sensitive- and Drug Resistant-TB (contains no INH or rifampicin) without adverse clinical interactions with ART. This regimen has been taken into an 8 week trial to treat DS- and DR-TB in patients with and without HIV infection., Background The impact of HIV on MDR-TB treatment outcomes in sub-Saharan Africa remains unclear where extensive rollout of highly active antiretroviral therapy (HAART) has occurred. We therefore compared the time to initial culture conversion among patients with and without HIV infection in a setting of individualized, ambulatory MDR-TB care in Botswana. Methods We performed a prospective cohort study of MDR-TB patients receiving ambulatory care at two public clinics in Botswana. The time to culture conversion and proportion converting were compared by HIV status using Cox proportional hazard ratios (HRs). Results 40 HIV-infected and 30 HIV-uninfected patients with MDR-TB and follow up cultures were identified. The median CD4+T-lymphocyte count of those with HIV was 215 cells/mm3 (IQR 129–347), and 36 (90%) were on HAART. 85% of HIV-infected and 83% of HIV-uninfected achieved culture clearance. The median time to initial culture conversion was 78 days (IQR 42–186) for HIV-infected and 95 days (IQR 70–133)for HIV-uninfected individuals [log rank p=0.62; unadjusted HR=0.9 (95% CI: 0.5 to 1.5)]. Adjusting for age, gender, TB treatment history and number of active antitubercular drugs used did not change this result [adjusted HR=0.8 (95% CI: 0.4 to 1.4)]. Toxicity was frequent in all subjects: ototoxicity occurred in 53% and 70%, neuropathy in 40% and 10%, and nephropathy in 25% and 7% of HIV-infected and uninfected patients, respectively. Neuropathy (p=0.005) & nephropathy (p=0.044) were significantly associated with HIV infection. Conclusion We found no difference in the proportion or time to initial sputum culture conversion between an HIV-infected and non-infected cohort of MDR-TB patients in Botswana. These results suggest that microbiologic outcomes among those with HIV can be comparable to those without HIV in similar settings with access to individualized TB treatment and HAART., Background Tuberculosis, the leading cause of death among HIV patients, is difficult to diagnose with smear microscopy. Xpert MTB/RIF, a near point-of-care, fully automated, nucleic acid amplification test for TB and for the detection of rifampin resistance, has been endorsed by WHO. Xpert has increased sensitivity compared with smear microscopy; however its cost-effectiveness and affordability in resource limited settings is still controversial. Methods Between August and December 2011, Partners in Hope integrated Xpert MTB/RIF alongside fluorescence microscopy for TB evaluation.Attribute of LaboratoryMicroscope typeTechnician experience and expertiseLaboratory staff workloadQuality of AFB MicroscopyPartners in HopeFluoroscenceAdvancedUsually manageableGoodStandard Malawian AFB laboratoryConventionalUsually limitedUsually overburdenedUsually poorAttributes of study laboratory and standard lab. All HIV-TB suspects were evaluated with spot AFB smear, morning Xpert and another spot smear. Patients were classified as smear-positive, indeterminate (only one scanty smear) or smear-negative based on Malawi TB Guidelines. Smear and Xpert results were compared to determine the number of excess cases detected by Xpert. Cost per excess case detected was calculated. Results 436 clinical samples were tested using Xpert. 417 were sputum samples and 19 extrapulmonary samples. Of 64 samples which tested positive by Xpert, 61 were sputum samples and 3 extrapulmonary samples. Corresponding smear results were available for 58 sputum samples. Table 1 shows a comparsion of Xpert and smear results. AFB smear Positive AFB smear indeterminate AFB smear negative Xpert positive (Total 58 with smears available)35158% of total positive60%26%14%Comparsion of Xpert and Smear results. 14% of the Xpert positive samples were smear negative and only diagnosed by Xpert testing. Another 26% of samples were indeterminate and Xpert helped confirm the diagnosis. No sputum yielded a positive smear and negative Xpert. Xpert increased detection by 16% if scanty smears are considered positive, or 65% if scanty smears are considered negative. Cost per smear negative case detected is shown in Table 2 (note the two calculations based on how scanty smears classified). Total smear negative sputum samples Smear negative with positive Xpert NNT to detect one smear negative Cost per test cartridge Total cost to detect one smear negative case with Xpert “Scanty” smears considered positive367846$20$920“Scanty” smears considered negative3822317$20$340Cost to detect one smear negative case. Conclusion Xpert MTB/RIF increased TB detection by 16%-65% compared to fluorescence microscopy in a well-equipped laboratory. The Xpert may perform differently in a less sophisticated laboratory. However, cost per case detected was high and not affordable in Malawi., Background Xpert® MTB/RIF is a new molecular diagnostic tool, developed to increase detection and shorten time to diagnosis of sputum-smear-negative (SSN) tuberculosis (TB). In April 2011, Médecins Sans Frontières (MSF) in collaboration with the Zimbabwean Ministry of Health and Child welfare implemented two Xpert® MTB/RIF systems in a rural district in Zimbabwe serving two hospitals and 26 decentralised primary care clinics. Methods From May to October 2011, parallel testing with both smear microscopy and Xpert® MTB/RIF was performed on specimens from all TB suspects. We used information abstracted from clinical and laboratory records to compare the number of laboratory-confirmed TB cases, number of TB notifications, and the time to diagnosis among HIV/TB co-infected patients with sputum-smear-negative TB during 6 months before and after Xpert® MTB/RIF implementation. Results A total of 1672 sputum specimens were processed, of which 184 (11.0%) were smear-positive. Mycobacterium tuberculosis was detected by Xpert® MTB/RIF in 116 (7.8%) of the 1488 remaining smear-negative specimens. Comparing the period after implementing Xpert® with the period before, the proportion of TB notifications that were smear positive (33% versus 27%), smear-negative (48% versus 49%), sputum not tested (11% versus 12%), and extra-pulmonary (8% versus 12%) was unchanged. The median time to TB treatment initiation among HIV/TB co-infected patients with sputum-smear-negative TB, decreased at decentralised sites (from 18.5 days to 7 days), but remained constant at the hospital level (5.5 days before and 6 days after). Conclusion Xpert® MTB/RIF increased the number of laboratory-confirmed TB cases in rural Zimbabwe, enabling further task shifting of TB management. In settings where access to chest X-Ray and trained doctors is lacking the impact on TB notifications may be greater. Time-to-initiation of TB treatment at the decentralized clinics was reduced, which has the potential to reduce morbidity in individuals and reduce the risk of TB transmission to others., Background Recently, WHO recommended that GeneXpert MTB/RIF be used as first line diagnostic to test for TB in HIV positive individuals. Most patients initiating ART lack the classical symptoms for TB resulting in missed diagnosis. The role of symptom screen in predicting a positive GeneXpert result among pre-ART patients was studied. Methods This was a nested cohort study within a GeneXpert impact evaluation trial in pre-ART patients. TB symptomatic and asymptomatic adults (>18 yrs) at an ART initiation clinic in Harare were recruited between October 2011 and February 2012. For each patient, two spot sputum samples were collected and induction with 6% hypertonic NaCl performed in those who could not expectorate. Sputum samples were tested with GeneXpert (Cepheid) Test. Participants were followed-up for 3months. Results 150 participants were recruited and 126 produced specimens and were tested for TB using GeneXpert. Median CD4 count was 165cells/ul (IQR 79–256). Fifty-four percent of the participants had a cough (68/126). Induction was carried out in 19 participants and of these, 47% (9/19) were coughers and 53% (10/19) non-coughers. TB was diagnosed in 10% of participants (13/126; 95% CI 4–16); with an additional 2 cases diagnosed on second GeneXpert test. Significant predictors of disease were cough of any duration (p=0.019), night sweats (p=0.03) and weight loss (p=0.04). Of those induced, 16% (3/19) had a positive GeneXpert result. Notably, induced samples accounted for 23% (3/13) of the TB cases detected. Three percent (2/58) of the non-coughers were GeneXpert positive. Seven participants (5%) with negative GeneXpert results were started on TB treatment based on clinical suspicion. Conclusion TB testing using GeneXpert in pre-ART patients, with sputum induction, should be carried out routinely regardless of patient TB symptom status. A two step screening test and Xpert testing algorithm is needed for scale-up of universal TB testing in pre-ART patients., Background PNU-100480 is a linezolid analog with superior bactericidal activity against Mycobacterium tuberculosis in the hollow fiber, whole blood and mouse models that is time-dependent and unaffected by resistance mutations for standard TB drugs. PNU-100480 neither induces nor inhibits CYP3A4. This study is its first in TB patients. Methods Sputum AFB smear positive South African patients (incl. HIV+ not requiring ART) were randomly assigned to PNU-100480 600 mg BID (N=25) or 1200 mg QD (N=25), or standard 4-drug therapy (HREZ, N=9) for the first 14 days of treatment. Sputum mycobacterial burden was monitored both as log CFU/ml and time to detection (TTP) in automated liquid culture system (MGIT). Results 20% of subjects were women; 7% were HIV+. All subjects completed assigned treatments. There were no treatment-related serious adverse events nor any permanent discontinuations or dose reductions due to laboratory abnormalities. There was no effect on the QT interval. At baseline, the mean log CFU/ml and TTP were 6.95 and 116 hrs, respectively. Changes in mycobacterial burden during treatment are shown below. Lines indicate estimates by mixed-effect model repeated measures (MMRM) analysis; shading indicates 90% CI. MMRM analysis revealed that the 90% CI after the full treatment period excluded zero for all 3 treatments and for both monitoring methods. Seven PNU-treated patients (14%) had transient, asymptomatic ALT elevations on day 14 to 2–3x ULN that subsequently returned promptly to normal; none met Hy's law criteria. Conclusion Treatment with PNU-100480 600 mg BID or 1200 mg QD reduced the mycobacterial burden in sputum during 14 days of treatment. Both treatments were safe and reasonably well tolerated. Further studies of PNU-100480 in tuberculosis are warranted. EBA., Background More than 80% of patients with multidrug-resistant tuberculosis (MDR-TB) in Tugela Ferry, South Africa are co-infected with HIV. Concomitant treatment for both diseases is recommended, but concern about severe and additive toxicities of MDR-TB therapy and ART has slowed acceptance of community-based treatment. Methods Confirmed MDR-TB patients were treated at home by an injection team and returned to the clinic monthly where they were screened for common adverse events (AEs). Severity was graded using the DAIDS toxicity table. Safety labs were drawn monthly and TSH was drawn every 3 months. We reviewed clinical and laboratory AEs for all patients between November 2008 and April 2011. We examined the incidence of each AE in 6-month time blocks and the within-patient trend of each AE over time. We compared those who received concomitant MDR-TB/ART treatment to those who received MDR-TB treatment alone. Results Of 91 MDR-TB patients, 55% were female; median age was 34 (IQR 29–41); and 84% were HIV co-infected. 74 patients (97% of HIV+) were receiving ART and median baseline CD4 cell count was 207 cells/mm3 (IQR: 89–411). Ninety-nine percent of patients reported at least one AE during treatment, but most were mild and did not require therapy modification. The most common AEs were peripheral neuropathy (73%), injection site pain (66%), and arthralgia (43%). The most common severe AEs (grade=3) were psychosis (10%) and hypothyroidism (29%). Patients receiving concurrent ART did not experience AEs more frequently than those on MDR-TB therapy alone. Patients were significantly less likely to report most AEs later in their treatment course (Figure 1).Figure 1 AEs by 6-month time blocks. Conclusion Home-based treatment of MDR-TB and HIV is associated with high rates of mild AEs which are not increased by concurrent ART and can be managed symptomatically without changing MDR-TB therapy or ART. Treatment can be safely administered in a home-based care setting., Background The effect of chronic hepatitis B (HBV) on HIV outcomes is relatively unknown in sub-Saharan Africa (SSA) where a high burden of HIV-HBV co-infection exists. Methods Clinical and immunologic outcomes in response to ART were compared longitudinally between HIV mono- (HIV+) and HIV-HBV co-infected (HIV&HBV+) adults enrolled between November 2004-December 2010 at 18 Management and Development for Health (MDH)-PEPFAR supported HIV clinics in Tanzania. Inclusion criteria were: tested ≥×1 for HbsAg (DIMA), age ≥15, no prior ART. Results The prevalence of HBV was 837/13,107 (6.4%).Compared to HIV+ patients, HIV&HBV+ patients were more likely to be male, older, have lower median CD4+ cell counts, and higher ALT's (p values 120IU/L [38/813 (4.7%) vs. 303/12,136 (2.5%); HR 1.76 (1.25, 2.49), p200IU/l [20/831 (2.4%) vs. 102/12,236 (0.8%); HR 2.74, (1.66, 4.05), p, Background Few studies have examined the natural history of chronic hepatitis C virus (HCV) infection among HIV-infected persons in the era of combination antiretroviral therapy (cART). Our objectives were to: 1) compare the incidence of hepatic decompensation between cART-treated HIV/HCV-coinfected and HCV-monoinfected patients, and 2) evaluate determinants of decompensation among coinfected patients on cART. Methods We performed a cohort study among 4,286 cART-treated HIV/HCV-coinfected and 6,639 HCV-monoinfected patients in the Veterans Aging Cohort Study Virtual Cohort (1997–2010). All patients had HCV viremia and were HCV treatment-naïve. Coinfected patients received cART for at least one year and had an HIV RNA result >500 copies/mL within 180 days prior to starting cART (to identify new cART initiators). Hepatic decompensation events (defined by diagnoses of ascites, spontaneous bacterial peritonitis, variceal hemorrhage, or hepatocellular carcinoma) and death were evaluated. Cox regression was used to determine the adjusted hazard ratio (aHR) of hepatic decompensation associated with cART-treated coinfection and evaluated baseline risk factors for decompensation (alcohol abuse, non-black race, diabetes mellitus, FIB-4 >3.25, hemoglobin3.25 (aHR=7.18 [5.12−10.07]), and baseline hemoglobin, Background HIV-1/HCV coinfected patients respond poorly to pegylated interferon(PEG-IFN) and weight-based ribavirin(WBR), with sustained virologic response(SVR) of 27% in genotype 1 HCV treatment-naïve subjects (ACTG 5178 results). Nitazoxanide(NTZ) plus PEG-IFN and WBR has demonstrated improved efficacy in HCV monoinfected subjects. We hypothesized that addition of NTZ to PEG-IFN/WBR would improve HCV virologic responses in HIV-1/HCV co-infected persons. Methods HIV-1/HCV genotype 1 co-infected subjects naïve to HCV treatment received 4-week lead-in of NTZ(1000 mg/day) followed by 48 weeks of NTZ, PEG-IFN alfa-2a(180 µg/week) and WBR(1000–1200 mg/day). SVR was defined as undetectable serum HCV RNA (, Background The objective of this study was to examine the immunogenicity of the HPV-6, -11, -16, -18 vaccine in HIV-infected young women. Methods This phase II, open-label, multi-center trial was conducted through the Adolescent Trials Network for HIV/AIDS Interventions. Participants were 16-23 year-old women behaviorally infected with HIV. Two groups were enrolled: Group A (ART naÿ or had not received HAART for at least six months prior to study entry) and Group B (had received HAART for at least 6 months, with two HIV-1 RNA plasma viral loads, Background HIV-infected women are disproportionately affected by human papillomavirus (HPV)-related anogenital disease. A5240 is a clinical trial of 319 HIV-infected women at US, Brazil and South Africa sites to determine immunogenicity and safety of the quadrivalent HPV vaccine. Methods Safety and serostatus of HPV types 6, 11, 16, and 18 were examined in 222 women. The vaccine was administered at 0, 8, 24 weeks in 3 strata based on screening CD4: >350 (A), 201-350 (B), ≤200 cells/mm3 (C). HPV serotyping was performed using competitive Luminex Immuno-Assay (HPV-4 cLIA). HPV type-specific seroconversion analysis was on participants seronegative for the given type at baseline. Seroconversion was defined by: ≥20, ≥16, ≥20, ≥24 mMU/mL for types 6, 11, 16, 18 respectively. Two-sided 95% CIs are provided. Results We report preliminary safety and week 28 seroconversion results from A and B. At baseline, median age was 37 years (range 19–45), 13% were white, 57% black, and 29% Hispanic. Median nadir CD4 was 262 cells/mm3, 41% had undetectable HIV-1 viral load, 13% from non-US sites. No safety issues were identified; none of the grade ≥3 AEs was thought to be vaccine-related. Proportion of Women who Seroconverted 4 weeks After the Vaccination Series: HPV Type Baseline seronegatives 6 11 16 18 Stratum A CD4>350N=50N=79N=62N=73>Seroconversion proportion (95% CI)96% (86–99%)97% (91–100%)98% (91–100%)90% (81–96%)Geometric Mean Titers (95% CI)425 (289–627)454 (337–611)1088 (777–1524)160 (114–225)Stratum B 200200., Background Antiretroviral therapy (ART) reduces the risk of tuberculosis, but the incidence still exceeds that in HIV-uninfected people. Retrospective cohort studies suggest an additive benefit of isoniazid preventive therapy (IPT) in patients on ART, but there are no controlled data on the efficacy and safety of IPT for patients on ART. Methods Using a pragmatic randomized double-blind placebo-controlled study design, we evaluated the efficacy of IPT among HIV-infected participants established on ART or newly starting ART in Khayelitsha, South Africa. Participants were randomized to daily isoniazid or matching placebo for twelve months, and followed for up to four years. Tuberculosis was excluded at screening by sputum culture. Development of incident tuberculosis was the primary endpoint. Secondary endpoints included toxicities and deaths. Results 1,329 participants contributed 3227 person-years (PY) of follow-up in the modified intention to treat analysis; 662 on placebo and 667 on IPT, with comparable CD4+count and proportion starting ART. Overall there were 95 incident tuberculosis cases: 3.6 (95% CI 2.8–4.7) versus 2.3 (95% CI 1.6–3.1) per 100 PY in the placebo and IPT arms respectively (HR 0.63, 95% CI 0.41–0.94, p=0.026). Study drug was discontinued due to pre-specified toxicity in 2.5% in the placebo arm and 4.1% in the IPT arm (logrank p=0.13). The number of deaths was similar between arms (3.0% and 2.1 respectively, logrank p=0.29). Conclusion Under field conditions, twelve months of IPT reduced the incidence of TB without causing excess harm in HIV-infected individuals established on ART or newly starting ART. It is feasible to implement IPT in busy ART clinics in settings with high HIV/TB co-morbidity., Background With improved survival of HIV-infected children, neurocognition is an important area to address. We examined the effects of HIV infection on cognitive, neurological, and behavioral functioning on perinatally-infected children. Methods HIV-infected children (4–15yrs) were recruited from a tertiary-care center in India, along with age-gender-and-income-matched HIV-negative children. Assessment tools included (i) soft neurological signs: Physical and Neurological Examination for Soft Signs (PANESS); (ii) neurocognition: culturally-adapted Wechsler Preschool and Primary Scales of Intelligence (WPPSI), Wechsler Intelligence Scale for Children (WISC-III); (iii) adaptive behaviour: Vineland Adaptive Behaviour Scales (VABS). Results We studied 167 children, (82 HIV-infected, 85 HIV-uninfected) with 56% males and mean age 8.6 yrs. Total IQ scores were lower among HIV-infected children compared to HIV-uninfected children (74.9 12.9 versus 87.915.4, p20%, (IQ 77.112.8, p=0.03). Viral load and ART status has no effect on IQ scores. Multivariate regression revealed that HIV status, weight-for-age Z-score and hemoglobin were independent factors that affected IQ scores (adjusted r2=0.25, p=0.006). The presence of HIV infection independently decreased IQ scores by 9.22 units. PANESS scores were higher among HIV-infected children compared to uninfected children (HIV-positive: 7.5, [3, 13.3]; HIV-negative: 4, [1.5, 9.5], p=0.02) suggesting higher degree of subtle neurological abnormalities in this group. Adaptive behaviour scores were similar for both HIV-infected and uninfected children irrespective of age and sex. Conclusion HIV-infected children had lower IQ scores and higher prevalence of soft neurological signs compared to HIV-uninfected children, indicating that subtle neurocognitive impairment is an important feature of perinatally-acquired HIV infection, particularly those with poor nutritional status. We recommend routine neurocognitive assessment and suggest that early intervention with initiation of ART before the onset of severe immunosuppression may improve outcomes in these children., Background HIV infected patients receiving combination antiretroviral therapy are at higher risk of cardiovascular morbidity and have accelerated aging notably of cognitive functions. The link between cardiovascular risk factors and cognition has rarely been investigated in HIV-infected cohorts. In a large hospital-based cohort, we explored whether cardiovascular risk factors are associated with cognitive performances. Methods The ANRS-CO3 Aquitaine Cohort recruits patients through a hospital-based information system on HIV-1 infection in the Bordeaux University Hospital in the Aquitaine region, South Western France. Between 2007 and 2009, 403 patients participated in a sub-study and had a thorough assessment of several cognitive domains. Cognitive performances were analyzed using both the raw test scores and the presence of neurocognitive impairment (NCI), based on the most recent definition of HIV-associated neurocognitive disorders. Selected cardiovascular risk factors were type 2 diabetes, hypertension, hypercholesterolemia, smoking status and BMI. Covariance analyses were computed to investigate the association between cardiovascular risk factors and raw cognitive test scores, adjusting for potential confounders. Logistic regression with the same covariates was used to analyse NCI as dependent variable. Results Mean age was 47.3 years and 79% were male. The prevalence of cardiovascular risk factors ranged from 9.7% for diabetes to 49.6% for current smoking, and 37.7% of participants had NCI. Lower performances in all cognitive tests were related to older age and lower education. Among cardiovascular risk factors, diabetes was significantly associated with lower performances in all cognitive tests after adjusting for potential confounders. By contrast, no such consistent associations were noted for any other cardiovascular risk factors. Diabetes prevalence did not significantly differ by NCI status (p=0.44). Conclusion In this hospital-based cohort, diabetes, but not the other cardiovascular risk factors, is associated with lower performances in all assessed cognitive domains. The mechanisms underlying our findings remain to be clarified but could involve inflammation and microcirculation., Background Current literature indicates that infection with HIV contributes to an increased risk of acute stroke. The goal of this study is to compare clinical and epidemiological characteristics of stroke patients with and without HIV infection. Methods We performed a retrospective chart review of stroke patients who were admitted to the stroke unit between January of 2005 and June of 2011. We identified 43 patients with known HIV infection at the time of admission for acute stroke. 101 controls were randomly selected from non-HIV patients who had acute stroke within the same time period. Clinical and epidemiological characteristics of two groups were compared. Results Of 1679 admissions with acute stroke, 43 (2.6%) were in HIV-infected patients (32 males, 11 females) and 101 in non-HIV infected patients (45 males, 56 females). Mean age was 57.8 years and 72.6 years, respectively. All 144 patients had acute ischemic stroke confirmed by imaging. Significant difference was identified in age, race, blood pressure on admission, National Institute of Health Stroke Scale (NIHSS) on admission, and HDL level (Table 1). The presence of co-morbidities (HTN, DM, hyperlipidemia), body mass index (BMI), homocysteine level, LDL, and coagulation profiles were not statistically different between two groups. In the HIV+ group, 30 patients (83%) were taking HAART prior to stroke onset. CD4 count was available in 37 patients; 21 had CD4 >200 cells/mm3 and 16 had CD4< 200 cells/mm3 (mean CD4 count=329.7 cells/mm3).Table 1Results of Significant CharacteristicsCharacteristicHIV Positive Group(N = 43)HIV Negative Group (N = 101)P ValueAge-Mean (Range)57.8 (41–80)71.6 (34–99)0.001Male sex-no (%)32 (74.4%)45 (44.6%)0.007Race0.001Caucasian11 (45.8%)72 (72.7%)African American13 (54.2%)14 (14.1%)Asian0 (0%)13 (13.1%)NIHSS on admission5.399.090.03Systolic Blood Pressure on Admission142.18158.190.018HDL (mg/dl)40.7247.710.043 Conclusion HIV infection increases the risk of stroke in younger patients. They have lower blood pressure, HDL and NIH stroke scale on admission compared to HIV negative stroke patients. Prevalence of DM, HTN, hyperlipidemia and other metabolic factors were not significantly different in the two groups, although the relatively small sample size and retrospective nature of the study represent limiting factors., Background To further our understanding of anal lesions in relationship to HPV genotypes in HIV-infected men who have sex with men (MSM), we analyzed HPV genotype distribution in anal disease categories based on cytology and histology results. Knowledge of HPV genotype attribution can allow estimation of the preventable fraction of anal intraepithelial neoplasia (AIN) and may indicate disease misclassification. Methods 363 HIV-infected MSM underwent anal cytology and high-resolution anoscopy/biopsy at an anal cancer screening clinic. Anal disease categories were determined by combining histology and anal cytology results. We evaluated presence of HPV genotypes by Linear Array and estimated preventable fractions of anal lesions based on attribution to genotypes included in bivalent, quadrivalent, and nonavalent HPV vaccines. We explored classification of histology-cytology disease groups based on distribution of carcinogenic HPV genotypes using unsupervised hierarchical clustering. Results The proportion of carcinogenic HPV infections increased from 51.4% in MSM without AIN to 98.2% in those with AIN3. HPV16 was the most common HPV genotype overall (28.1%) and among MSM with AIN2/3 lesions (51.8%). The attribution fractions of AIN2/3 to genotypes included in HPV vaccines ranged from 56.4% (95% CI: 47.0–65.3) for the bivalent vaccine to 89.1% (95% CI: 81.9–93.7) for the nonavalent vaccine. (Table) In the exploratory clustering analysis, the disease group of normal histology/HSIL cytology and AIN1histology/HSIL cytology clustered with AIN2/AIN3 on histology based on the distribution of carcinogenic HPV types. (Figure).Figure 1 Unsupervised hierarchical clustering of AIN disease categories (various cytology-histology combinations) by distribution of carcinogenic HPV gentypes. Table 1Potential range of vaccine protection in a cross-sectional study of n=363 HIV-infected MSM: attribution schemes for AIN2/3* lesions to HPV genotypes in prophylactic HPV vaccines Prevalence of HPV vaccine genotypes in AIN2/3 lesions Cases with single carcinogenic HPV type1 Cases with any HPV type2 Hierarchical attribution fraction of AIN2/3 to HPV vaccine genotypes3 Genotypes in bivalent HPV vaccine: HPV16/18 36.7% (95% CI: 21.9–54.5) 61.8% (95% CI: 52.5–70.3) 56.4% (95% CI: 47.0–65.3) Genotypes in quadrivalent HPV vaccine: HPV16/18/6/11 40.0% (95% CI: 24.6–57.7) 70.0% (95% CI: 60.9–77.8) 56.4% (95% CI: 47.0–65.3) Genotypes in nonavalent HPV vaccine: HPV16/18/6/11/31/33/45/52/58 86.7% (95% CI: 70.3–94.7) 92.7% (95% CI: 86.3–96.3) 89.1% (95% CI: 81.9–93.7)*AIN2/3: refers to a diagnosis using a combined cytologic-histologic endpoint of AIN2 (AIN2 histology or HSIL-AIN2/ ASC-H cytology) or AIN3 (AIN3 histology or HSIL-AIN3 cytology); this does not refer to a histologic classification of “AIN2/3” (or moderate to severe dysplasia) which would be classified as AIN3 (based on automatic default to the more severe disease category in case of dual/intermediate disease classification).1Genotypes from cases in whom only a single carcinogenic type is detected, irrespective of additional possible/non/unknown carcinogenic types (n=30 cases of HO cases of AIN2/3).2Genotypes from cases in whom arty HPV type was detected (n=l09 cases of 110 cases of AIN2/3).3in ‘Hierarchical attribution’, HPV genotypes are attributed proportionally to the case by the most frequent type (according to hierarchical frequencies in the AIN2/3 category), This allows attribution of HPV genotypes to the disease category regardless of multiplicity of infections.. Conclusion A substantial fraction of high grade AIN can be prevented by prophylactic HPV vaccines. Both anal cytology and high resolution anoscopy followed by anal biopsy and histology have limited sensitivity for prevalent anal precancer. We demonstrate that combined histology-cytology disease categories can improve misclassification in cross-sectional studies. Our analytical framework can be useful to compare attribution of anal disease categories to HPV genotypes across various populations and to estimate the extent of disease misclassification., Background Maraviroc (MVC) is a CCR5 antagonist approved for the treatment of CCR5-tropic (R5) HIV-1. This study evaluated a once-daily (QD), dual-therapy regimen of MVC plus atazanavir/ritonavir (ATV/r) in treatment-naïve patients; 96-week outcomes are presented. Methods In this Phase 2b, randomized, open-label study, 121 R5 HIV-1-infected patients received either MVC 150 mg QD (n=60) or tenofovir/emtricitabine (TDF/FTC) 200/300 mg QD (n=61) with ATV/r 300/100 mg QD for 48 weeks, later extended to 96 weeks. The primary endpoint was the proportion of patients with HIV-1 RNA500 copies/mL at failure or study discontinuation; virologic analyses detected no resistance, change in tropism or loss of susceptibility relevant to treatment in either arm. At Week 48, there was a greater reduction in immune activation on CD4+ cells in patients receiving MVC versus TDF/FTC. Markers of bone formation were significantly different between arms at both 48 and 96 weeks. Conclusion Durable virologic activity of MVC 150 mg QD+ATV/r was demonstrated through 96 weeks, with no differences between the arms in the rates of virologic failure, no resistance or change in tropism seen, and with most of the treatment difference due to low-level transient viremia. Differences between the arms in immune activation and bone markers require further investigation., Background Cobicistat is a novel investigational pharmacoenhancer with no anti-HIV activity. Methods An international, randomized, double-blind, double-dummy, active controlled trial was conducted to evaluate the efficacy and safety of cobicistat vs ritonavir as pharmacoenhancers of atazanavir (ATV/co vs ATV/r group) in combination with tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) in treatment-naïve patients. Key eligibility criteria were HIV-1 RNA ≥5,000 copies/mL, estimated glomerular filtration rate by Cockcroft-Gault formula (eGFR) ≥70 mL/min. Primary endpoint was HIV-1 RNA 100,000 copies/mL, the response rates were similar (86 vs 86%). Two subjects in ATV/co and none in ATV/r group developed resistance mutations to study drugs; both were M184V/I. Similar percentages of subjects in both groups (ATV/co vs ATV/r) had serious adverse events (AEs) (11 vs 7%), discontinued study drug due to any AEs (7 vs 7%), or had bilirubin-related AEs (4 vs 3%). Median increases in total bilirubin at Week 48 in ATV/co and ATV/r group were 1.9 and 1.7 mg/dL. Median increases in serum creatinine were 0.13 and 0.09 mg/dL. Median increases in total cholesterol were 4 and 10 mg/dL; increases in triglycerides were 16 and 24 mg/dL. Plasma exposures of ATV (steady state mean Ctau [ng/mL]) were comparable (796.1 vs 853.4). Conclusion ATV/co was noninferior to ATV/r in combination with TDF/FTC at Week 48. Both regimens achieved high rates of virologic success. Safety and tolerability profiles of the two regimens were comparable. ATV/co (n=344) ATV/r (n=348) Age (years), median3637Male83%83%Race-White58%62%HIV-1 RNA (log10copies/mL), median4.784.84HIV-1 RNA >100,000 copies/mL38%41%CD4 count (cells/mm3), median348341CD4 count ≤200 cells/ mm3 17%16%Baseline Characteristics. ATV/co (n=344) ATV/r (n=348) Snapshot Analysis85%87%Snapshot Analysis (Per Protocol)98%98%Time to Loss of Virologic Response83%85%Missing=Failure89%90%Missing=Excluded97%96%Efficacy at Week 48 (HIV-1 RNA, Background Antiretroviral regimen simplification improves both quality of life, and long-term medication adherence while reducing the risk of HIV virologic failure (VF) and long-term drug-related toxicities. FTC/RPV/TDF is a well-tolerated, once daily STR treatment option. This is the first study to evaluate the efficacy and safety of switching from boosted Protease Inhibitor (PI) based HAART to a simplified regimen of FTC/RPV/TDF STR. Methods A randomized, open-label, multi-center, international, 48 week study to evaluate the safety and efficacy of switching from ritonavir-boosted PI regimens to FTC/RPV/TDF in virologically-suppressed (HIV RNA, Background Once-daily elvitegravir (EVG) was noninferior in efficacy and well-tolerated relative to twice-daily raltegravir (RAL) in combination with a fully active ritonavir-boosted protease inhibitor (PI/r) and another second agent in a phase 3 study of treatment-experienced patients (GS-US-183-0145) at Week 48. We present the blinded 96-week results. Methods Randomized, double-blinded, active-controlled, 96-week noninferiority trial. Key eligibility criteria were HIV-1 RNA ≥1,000 copies/mL, any CD4 cell count, and resistance to and/or 6 months’ experience with at least two classes of antiretroviral drugs. Primary endpoint was achievement and maintenance of HIV-1 RNA 5×ULN) were less common on EVG vs. RAL (2.3 vs. 5.9%; 1.7 vs. 5.3%). No other differences in graded laboratory abnormalities were seen. Conclusion At Week 96, once-daily EVG in combination with a fully active PI/r and another second agent in treatment-experienced patients continue to be noninferior to twice-daily RAL in efficacy with excellent tolerability. These data support the long-term use of EVG in treatment-experienced patients. TLOVR EVG (n=351) RAL (n=351) Virologic response47.6%45.0%Virologic failure22.8%27.4%Death0.6%2.6%Drug discontinuation26.5%20.8%Adverse events2.6%4.3%Lack of efficacy3.7%2.0%Lost to follow-up5.4%6.8%Other reasons17.4%12.0%Emerging major INSTI resistance6.6%7.4%Efficacy at Week 96 (HIV-1 RNA, Background The integrase inhibitor, Dolutegravir (DTG; S/GSK1349572), has shown rapid and durable antiviral response, with a favorable tolerability profile. Methods In this multicenter, double-dummy-blinded, Phase III, non-inferiority study, HIV-1 infected ART-naive adults with HIV-1 RNA ≥1000 c/mL and no evidence of viral resistance were randomized 1:1 to receive DTG 50 mg QD or RAL 400 mg BID, in addition to investigator-selected backbone NRTIs of either TDF/FTC or ABC/3TC. Subjects were stratified by screening HIV-1 RNA (≤ and >100,000 c/mL) and backbone NRTI selection. The primary endpoint was proportion of subjects with HIV-1 RNA100,000 c/mL, 41% ABC/3TC. Proportion of subjects meeting the primary endpoint was 88% for DTG and 85% for RAL; difference (2.5%; 95% CI: −2.2% to 7.1%) met 10% non-inferiority criteria. For subjects with HIV-1 RNA >100,000 c/mL, response rate was 82% for DTG vs 75% for RAL. Secondary analyses supported non-inferiority: HIV-1 RNA, Background AZT/3TC/NVP and TDF/3TC/NVP BID have been recommended 1st-line ART regimens in Rwanda. TDF/3TC/NVP is the least well studied of the WHO-recommended 1st-line regimens. We compared the efficacy of this regimen with AZT/3TC/NVP. Methods Between 2009 and 2011, we enrolled ART-naive patients. CD4 counts (cells/ul) and viral load (VL) were collected before ART and at 26 and 52 weeks. The primary endpoint was a VL 1000 copies/ml. Results 1,072 HIV+ ART-naive patients were enrolled: 521 (48.6%) received AZT/3TC/NVP (AZT), 551 (51.4%) received TDF/3TC/NVP (TDF). Median age was 37; 64% were women. Median baseline CD4 count was similar 260, VL was >100,000 copies/ml in 43% (AZT) vs. 32% (TDF) (p< 0.001). The AZT versus TDF, 5.4% vs. 3.8% transferred to others health facilities, 3.6% vs. 4.0% were lost to follow-up, and 1.9% vs. 2.7% died. 10%(AZT) vs 4%(TDF) of discontinued therapy due to adverse effects (p=0.001). The primary endpoint were: 80% (441/551) TDF and 78% (410/521) receiving AZT attained a VL < 200 copies/ml by week 52. The median CD4 count increase was 88 in the AZT and 50 in the TDF groups (p=0.034). However, in patients with baseline VL >100,000 copies/ml, 44% (133/351) in the TDF vs. 56% (170/351) in the AZT group attained the primary endpoint (p= 0.001). 11.8% (TDF) and 7.7% (AZT) underwent GRT. 58% had >=1 NNRTI-resistance mutation: most commonly Y181C (34%) and K103N (16%). 53% had >=1 NRTI-resistance mutation: most commonly M184V (48%) and K65R (29%). K65R emerged exclusively in the TDF group. Conclusion TDF/3TC/NVP was as effective as AZT/3TC/NVP at attaining, Background In the ECHO and THRIVE studies (HIV-1 treatment-naive patients), rilpivirine (RPV) 25mg qd and efavirenz (EFV) 600mg qd plus background N(t)RTIs resulted in a 78% response rate (viral load [VL], Background In 2009, South Africa's National AIDS Council recommended TDF access to HIV+ adults and ABC to HIV+ infants/children. We analyzed the effects of these guideline changes on NRTI-resistance mutations in ART virological failure (VF) and analyzed the effect of the cumulative second-line LPV/r use on emerging PI resistance. Methods HIV RT and PR sequences were obtained from plasma samples submitted for genotypic resistance testing to the Tygerberg National Health Service Laboratory between 2006 and 2011 from patients experiencing ART VF. Demographic and ART treatment data were obtained from the physicians submitting samples. Results Between 2006 and 2011, 1,525 plasma samples were obtained from 1,293 patients, of whom 57% were female and 42% =1 of the following major PI-resistance mutations: V32I, M46I, I47A, I50V, I54V, L76V, V82A/F, I84V, and L90M. 17 (4%) of 42 LPV/r recipients had major DRV/r resistance mutations (V32I, I50V, and L76V). Conclusion The increased use of TDF and ABC since 2009 has been associated with a markedly increased frequency of TDF-resistance (K65R) and ABC-resistance (L74V). Compared with TDF/3TC/EFV recipients, the risk of developing K65R was higher in patients with TDF/3TC/NVP VF (88% vs 31%; p=0.002) and lower in patients with TDF/3TC/LPV/r VF (7% vs 31%; p=0.008). Among 439 LPV/r recipients, 42 (10%) had LPV/r resistance and 17(4%) DRV/r cross-resistance., Background Since the availability of viral load (VL) assay with a threshold of 20 copies/mL, some patients display VL values between 20 and 50 copies/mL. The aims of our study were to: (i) identify factors associated with low level viremia (LLV) in patients receiving stable suppressive antiretroviral therapy (cART); and (ii) assess virological outcome during the year following LLV detection. Methods Retrospective study among the 4820 patients followed in our institution fulfilling the inclusion criteria: (i) stable cART for at least 6 months; (ii) all VL 50 copies/mL)/(number of VL determinations) before study inclusion. Results Among the 656 patients included, 5.8% were in group LLV+. The nature of the ongoing cART did not differ between LLV- and LLV+ groups. In the multivariate analysis, only CDC clinical stage B/C at study inclusion (OR=2.9; 95% CI=1.4–5.9; P=0.003) and a higher “Blip Ratio” before study inclusion (OR=0.9; 95% CI=0.9–1.0; P=0.001) were independently associated with LLV. During the follow-up, the proportion of patients experiencing virological failure (2 consecutive VL >50 copies/mL) was not different between LLV- and LLV+ groups (4% vs 8%, respectively; P=0.32); and 40% of patients shifted from LLV+ to LLV- status. Conclusion LLV was infrequent in our series and the one-year follow-up did not evidence a higher rate of virological failure than in patients always fully-suppressed. LLV seems to be a transient phenomenon that might be driven by residual ongoing viral replication and/or viral release and/or accuracy of VL assay in lower values., Background Alternatives to EFV for the treatment of HIV-infection in patients with TB are warranted. Rifampin decreases RAL exposure in healthy volunteers. We estimated the safety and efficacy of two doses of RAL and EFV in HIV-1-infected adults receiving rifampin for TB. Methods Multicentre, open-label, randomized, phase II trial. Antiretroviral naïve HIV-1-infected adults were randomized to receive RAL (400 or 800 mg bid) or EFV (600 mg qd), in combination with TDF and 3TC, after starting rifampin. The primary efficacy end-point was the proportion of patients with plasma HIV-RNA level50cp/ml was the main reason for failure and occurred in 6, 11 and 16 patients in RAL800, RAL400 and EFV, respectively. There was a trend towards more RAL, 3TC, and TDF resistance in the RAL400 than RAL800 arm. Safety of the three regimens was good with only 1, 1 and 3 grade 3/4 ALT elevations in RAL800, RAL400 and EFV arms, respectively. Conclusion At week 24, RAL800 mg bid provided the highest success rate in HIV-1-infected patients receiving a rifampin-based therapy for TB and should be considered for further evaluation., Background A5202 was a randomized equivalence study of four daily regimens of efavirenz (EFV) or atazanavir/ritonavir (ATV/r) with double-blinded tenofovir and emtricitabine or abacavir and lamivudine. Previous findings from A5202 reported women assigned ATV/r had higher-risk of virologic failure (VF) than women assigned EFV; also, women on ATV/r had higher risk of VF than men on ATV/r. This analysis relates ATV clearance (CL) to treatment efficacy and safety. Methods The associations between ATV CL and times to VF and safety event (first increased grade 3/4 sign, symptom, or laboratory abnormality), while on ATV/r (as-treated), were estimated with hazard ratios (HR) from Cox proportional hazards models, adjusted for screening HIV-1 RNA (105 copies/mL) and NRTIs. Additionally adjusted models included race-ethnicity (RE), age, baseline CD4 count, and body mass index. Interactions between ATV CL and sex, RE, and NRTIs were evaluated. A 1-compartment pharmacokinetic (PK) model including 815 subjects (88% of 928 randomized to ATV/r) was used to estimate subject-specific ATV CL. Atazanavir CL was categorized by overall sample tertiles (slow:¯9 L/hr). Analyses were restricted to 768 subjects of white, black, or Hispanic RE. Results Atazanavir CL association with time to VF differed significantly by sex (p=0.003, Table 1). The association between ATV CL and time to VF did not differ significantly by NRTIs (p=0.6) or RE (p=0.085); additionally adjusted model results were similar. There was no significant association between ATV CL and time to safety event (rapid vs. intermediate: HR 1.06; 95% confidence interval (0.79, 1.43); slow vs. intermediate: HR 1.28 (0.95, 1.72), p=0.22), nor a significant interaction with sex, NRTIs or RE for this outcome (p≥0.31). ATV Clearance Association with time to VF N=768: 131 females (28 VFs), 655 males (78 VFs) Comparison Hazard Ratio (95% Confidence Interval) Rapid (n=38) vs. Intermediate (n=29) among Female3.49 (1.24–9.84)Slow (n=64) vs. Intermediate among Female0.82 (0.26–2.54)Rapid (n=249) vs. Intermediate (n=210) among Male1.50 (0.82–2.71)Slow (n=196) vs. Intermediate among Male2.10 (1.16–3.77)*ATV CL by Sex Interation: p=0.003. Conclusion The differential in CL association with time to VF by sex may reflect PK/pharmacodynamic reasons for failure, and will require further investigations., Background Nevirapine (NVP) is metabolized by cytochrome P450 (CYP) 2B6. We investigated associations between single nucleotide polymorphisms (SNPs), haplotypes, and pharmacokinetics (PK) following SD NVP to prevent mother-to-child transmission (MTCT). Methods Protocol A5207 evaluated strategies to prevent NVP resistance following intrapartum SD NVP. At onset of labor, participants received SD NVP (200 mg) and were randomized to lamivudine/zidovudine, emtricitabine/tenofovir, or lopinavir/ritonavir (LPV/r), for 7 or 21 days. Plasma for NVP assay was obtained at post-partum day 1 and week 1, 3 and 5. Derived PK parameters included the NVP elimination constant estimated using linear mixed effect models based on natural logarithm of NVP measured between day 1 and week 3. We assayed 214 SNPs in ABCB1, CYP2B6, CYP2C19, CYP3A4, CYP3A5 and NR1I2. CYP2B6 metabolizer status was based on *6/*18 haplotypes. SNP and CYP2B6 haplotype associations were based on parametric regression models adjusted for body mass index and treatment arm as indicated. Results In A5207, 422 women in Haiti, India, Malawi, South Africa, Tanzania, and Uganda received SD NVP at onset of labor. This analysis includes 304 women (217 and 87 of African and Indian descent, respectively) with suitable NVP assay and genotype data. Among individuals of African descent, CYP2B6 metabolizer status was associated with slower NVP elimination (p =0.045), but not with week 5 NVP BLQ (below limit of quantification). Median elimination constants were −0.0105 (*6/*6 6/*18 or *18/*18*), −0.0108 (*6/− or *18/−), and −0.0113 (−/−) h−1. Among these individuals on LPV/r, an ABCB1 SNP (rs7787082) was associated with slower NVP elimination (p=0.0046). Among Indians, an NR1I2 SNP (rs2472682) was associated with increased likelihood of week 5 NVP BLQ (p=0.0061). Conclusion Slow metabolizer CYP2B6 genotypes were associated with slower elimination following SD NVP. This association appeared less pronounced than that described at steady state, suggesting effects on gene inducibility. Non-CYP2B6 SNP associations may be spurious., Background Prior studies investigating pharmacogenomics and efavirenz exposure use single plasma drug levels, which are limited by marked day-to-day variability. The Women's Interagency HIV Study (WIHS) performed 24 hour pharmacokinetics (PK) studies in a large number of HIV-infected women on efavirenz and calculated areas-under-the-curve (AUC) as measures of short-term exposure; concentrations in hair assessed long-term exposure. We typed 183 single nucleotide polymorphisms (SNPs) in 9 candidate genes known to influence efavirenz absorption, distribution, metabolism and elimination (ADME) and examined them in relation to AUC and hair levels in multivariate models. Methods Intensive PK studies were conducted in 111 women (74% African American; 17% Hispanic; 9% white). SNPs (n=183) with a minor allele frequency of >0.05 were analyzed in CYP2B6, CYP2C19, CYP3A4/A5, ABCB1, ABCC2, CYP2D6, SCL22A6, UDP, and UGT1A, along with other factors that could influence PK (race, age, menstrual status, diet, liver and renal function, weight). Hair efavirenz levels were measured in 84 women. Variables were examined with log-transformed EFV AUC and hair levels via linear regression; multivariable models were constructed by forward stepwise selection, including non-genetic predictors with p-values< 0.05 and genetic predictors with p-values< 0.001. Results Non-genetic factors, such as transaminase levels and orange juice consumption, were associated with EFV AUCs, but the most significant predictors associated with exposure were CYP2B6 516G>T, CYP2B6 983T>C and a p-glycoprotein transporter (ABCB1) haplotype (Table). CYP2B6 516TT (12.6% prevalence) was associated with 3.5-fold (95% CI 2.7–4.5, p=8.6x10−19) increases in AUC and 3.2-fold (2.1–4.7, p=1.3x10−11) increases in hair concentrations.Genetic and non-genetic factors associated with short-term EFV exposure (AUC, n=111) FactorEffect on AUC (±95% CI)p-valueDistribution of factorOranges or orange juice in preceding 5 days1.26 (1.05–1.50) 0.0119 76 (68.5%)For every doubling of ALT level1.23 (1.11–1.36) 0.0001 Median ALT (range) 23 (8–117) IU/LCYP2B6 983 T > C (rs28399499) 2.2×10 −10 0 doses of minor allele (TT)1.0095 (85.6%)–0 dose 1 or 2 doses of minor allele (TC/CC)1.96 (1.54–2.5)16(14.4%)–1 doseCYP2B6 516 G > T (rs3745274) 1.4×10 −18 0 or 1 dose of minor allele (GG, GT)1.0097 (87.4%)–0/1 dose 2 doses of minor allele (TT) 3.5 (2.7–4.5) 14(12.6%)–2 dosesABCB1 hdplotype (2SNPs:rs7779562 &rs4148745) 0.0004 0 doses of the haplotype1.0014 (12.6%)–0 dose 1 or 2 doses of the haplotype1.60 (1.24–2.1)97 (87.4%)–1/2 doses Factors associated with long-term exposure (hair levels, n = 84) -models include adherence Factor Effect on hair (±95% CI) p-value Distribution of factor ALT, Orange juice, ABCB1 haplotype, and adherence (below) not significantly associated with hair levelsCYP2B6 983 T > C ( rs28399499)0.021 0 doses of minor allele (TT)1.0074 (88.1%) –0 dose 1 or 2 doses of minor allele (TC/CC)1.70 (1.09–2.7)10 (11.9%)–1/2 dosesCYP2B6 516 G > T (rs3745274)1.0×10−10 0 or 1 dose of minor allele (GG, GT)1.0071 (84.5%) –0/1 dose2 doses of minor allele (TT) 3.2 (2.1–4.7) 13 (15.5%)–2 dosesSelf-reported adherence ≤74%1.004 (4.8%)75–94%0.94 (0.45–1.96)0.8813 (15.4%)≥95%1.10 (0.56–2.2)0.7767 (79.8%)Hair EFV PG table. Conclusion A comprehensive search for SNPs in genes associated with efavirenz ADME demonstrated that CYP2B6 516TT was associated with >3-fold increases in short-term (AUC) and long-term (hair) EFV exposure. The effect of this SNP on exposure over the prolonged duration represented by hair levels is reported for the first time. Genetic testing may allow optimization of EFV dosing., Background The pharmacokinetics of raltegravir in HIV-1 infected subjects is characterized by high inter/intra-patient variability. We investigated the potential contribution of the drug pharmaceutical formulation on raltegravir pharmacokinetics. Methods We firstly compared in vivo the pharmacokinetics of raltegravir from 50 patients given the drug by swallowing with those obtained from 10 HIV-infected patients that chewed raltegravir due to swallowing difficulties. Subsequently we evaluated in vitro the dissolution of raltegravir tablets under different conditions (pH 1, pH 6.8 buffer and water). Dissolution tests were performed comparing raltegravir whole tablets with tablets crushed by grinding in mortar and pestle. Results In the in vivo study we found that the raltegravir pharmacokinetic profiles in patients given the drug by swallowing were highly variable, characterized in some cases by multiple peaks and irregular/limited absorption. Conversely, patients given raltegravir by chewing presented regular pharmacokinetic profiles, characterized by single sharp drug peak and higher raltegravir absorption compared with patients given the drug by swallowing (Figure 1).Figure 1 Raltegravir time-concentration profiles in HIV-patients given the drug by swalling or chewing. The in vitro studies showed that the whole tablets presented relatively slow release profiles due to lacking disintegration. Crushed tablets tested in water and pH 6.8 buffer exhibited prompt and complete dissolution of raltegravir. For whole tablets tested in the acidic medium the raltegravir concentrations were very low, reaching less the 10% of the dose after 2h, owing to well-known poor solubility of raltegravir at low pH. However, when crushed tablets were tested in acid the profiles presented significantly higher concentrations of raltegravir (Figure 2)Figure 2 In vitro dissolution profiles of whole tabletes versus crushed tablets of raltegravir at different pH. . Conclusion HIV-infected patients given raltegravir by chewing showed higher drug absorption compared with patients given the drug by swallowing. This may be depends to problems related to the tablets disintegration leading to erratic drug release. The improvement of the raltegravir pharmaceutical formulation could reduce variability of raltegravir pharmacokinetics, eventually contributing to increase the response of HIV-infected patients., Background To inform optimal timing of ART initiation, we analyzed clinical outcomes during follow-up of HPTN 052 incorporating both AIDS and non-AIDS events related to HIV and ART. 052 WTS LB-K-M and table. Methods HIV+ adults (CD4+350 550/µL) from Africa, Asia, and South America were randomized to ART immediately or after CD4+, Background Nigeria's population of over 150 million and HIV prevalence of 3.8% ranks it among the top 5 countries with the highest HIV burden. Since 2004, HRSA has provided PEPFAR support to Harvard/APIN to develop a HIV prevention, care and treatment program at 32 hospitals in Nigeria. Methods ART eligibility in the adult program is consistent with the Nigerian and WHO ART guidelines. Enrolled patients that gave written informed consent with greater than 6 months of ART were included in this study. Patients had clinical exams and laboratory tests, at baseline, month 3, 6, and every 6 months thereafter. All patient data was collected and stored electronically. Treatment failure was defined as 2 consecutive viral loads > 1000 copies/mL following 6 months on ART. Results As of December 2010, 76,269 adult patients were enrolled on ART, 60,600 (79.5%) of which were ARV-naïve at baseline. Nine tertiary hospitals accounted for the majority of patients (53,406; 88.4%) with the remainder at 23 secondary. Female patients were more common (64.3%) and younger compared to men (median age 32 versus 39 years). Median baseline CD4 was 143 cells/mm3 and VL was 68,731 copies/mL. First-line ART for treatment-naïve patients included zidovudine (AZT) (51.6%), tenofovir (TDF) (35.3%) or stavudine (d4T) (7.5%) plus lamivudine/emtricitabine (3TC/FTC) plus an NNRTI - nevirapine (NVP) (68.4%)/efavirenz (EFV) (26%). The cumulative virologic failure rate for naïve patients was 21.4%, with the majority of failures occurring in the first year (56.9%). Applying the revised 2010 WHO recommendation defining virologic failure at > 5000 copies/mL, the cumulative failure rate was 13.6%, with 55.8% of failures in the first year. Virologic failure by time on ART. Conclusion Virologic failure rates were highest in the first year of ART and decreased with duration of ART. Particular emphasis on drug adherence and retention in care during the first year of ART may optimize patient outcomes., Background The second-line ART was rolled out in India in 2009 at 10 centers. Patients meeting immunologic/clinical failure criteria were evaluated by an expert panel and underwent viral load testing. Those found to have a confirmed virologic failure (VL> 5,000c/mL) were started on second-line ART (zidovudine/tenofovir/lamivudine/ lopinavir/ritonavir). We evaluated 18-month outcomes of patients started on second-line treatment. Methods Patients seen monthly and CD4 was performed every 6 months. VL testing was conducted 6 months after second-line ART initiation. We performed multivariable logistic regression modeling to determine factors associated with 6-month virologic suppression (, Background A large proportion of individuals enter health care very late in the course of their HIV-infection, these individuals have a poor clinical prognosis. This analysis aims to investigate trends in the percentage of individuals presenting late for care and identify factors associated with late presentation. Methods Individuals enrolled in the Collaboration of Observational HIV Epidemiological Research Europe (COHERE), which includes 33 cohorts from across Europe, who presented for care for the first time after 1st January 2000 were included. Late presentation was defined, as a person presenting for care with a CD4 count, Background Lipoprotein Lipase (LPL) is a key enzyme in lipid metabolism, especially for plasma circulating triglycerides (TG). Genetic variants of LPL have been associated to lipid levels in healthy individuals, cardiovascular disease, obesity and diabetes. Our aim was to evaluate the influence of three polymorphisms: Hind III (intron 8), Pvu II (intron 6) and S447X (exon 9) in plasma TG levels in HIV-1 infected children under HAART. Methods 52 children (28 girls and 24 boys) diagnosed with HIV-1 between 2005 and 2009, were retrospectively selected with at least one plasma TG level assessment. Also, 86 seronegative blood donors were randomly selected to estimate allelic frequencies in Argentinean population. TG levels were examined before and after one-year of HAART. Hypertriglyceridemia was defined as TG>150 mg/dL. Hind III (H+/H−), Pvu II (P+/P−) and S447X (S/X) were determined by PCR-RFLP. Wilcoxon sum rank test was used to compare median plasma TG among groups. Results Allelic frequencies for HIV-1 infected children were: H-,0.21 P-, 0.53 and X: 0.05, with no significant difference to controls. After one year of HAART, median TG levels were significantly lower in P+/P− (144 mg/dL) and P−/P− (95 mg/dL) compared to P+/P+ (180 mg/dL) (p=0.03 and p= 0.0002, respectively). A gene dose-dependent effect was observed for P- allele, and its presence was associated with a 7-fold lower risk of hypertriglyceridemia. Additionally, when H-is accompanying P-, the risk diminished to 15-fold (p=0.008, OR=0.06, 95% CI=, Background There are limited data on the pharmacokinetics (PK) of tenofovir (TFV) administered to pregnant women during labor or to newborns. Methods HPTN 057 is a phase I trial of tenofovir disoproxil fumarate (TDF) in HIV-infected pregnant women and their neonates in Malawi and Brazil. In the current cohort, women received 600 mg TDF at labor onset or 4 hours prior to C section (C/S) and newborns received 6 mg/kg TDF suspension daily ×7 doses. Plasma samples were obtained from mothers at delivery, from cord blood and from infants before and 2, 10 and 24 hours after the 1st, 4th and 7th doses. TFV concentration (conc) was determined by HPLC/MS/MS; lower limit of quantitation was 5 ng/mL. The PK target was to keep infant TFV conc >50 ng/ml (mean trough conc in nonpregnant adults) for the first week of life. Data are presented as median (range) or geometric mean (%CV). Results 33 mother-infant pairs were studied (21 vaginal deliveries, 12 C/S). Delivery occurred median of 4.5 (0.6–11.4) hours after dosing. Mean maternal TFV conc at delivery was 108 (76.1%) ng/mL. Mean cord blood TFV conc was 61 (69.3%) ng/mL. Cord blood TFV conc was>50 ng/mL in 24/31 (77%). Mean ratio of cord blood to maternal delivery TFV conc was 0.55 (64.0%). Infant 24 hr postdose conc was>50 ng/mL in 28/31 (90.3%) after the first dose, in 27/28 (96.4%) after the 4th dose and in 22/30 (73.3%) after the 7th dose. All infant TFV conc were >30 ng/mL. All mothers and infants tolerated TDF well. Mean (CV%) infant PK parameters are presented below: Dose Cmax(ng/mL) C24h(ng/mL) AUC(ng*hr/mL) t½ (hrs) 1288 (49.9%)104 (47.9%)3939 (37.6%)13.2 (80.1%)4336 (40.5%)112 (52.1%)4413 (37.4%)14.5 (45.0%)7221 (66.1%)69.7 (45.7%)3060 (49.0%)14.6 (96.1%)Mean (CV%) infant PK parameters. Conclusion This regimen provides TFV exposure similar to adults receiving 300 mg daily doses and is appropriate for use in neonates in studies of TDF used for HIV prophylaxis or treatment., Background P1093, is an ongoing, Phase 1/2 open-label PK, safety dose finding study of DTG plus optimized background regimen (children 6 wks to, Background Pharmacokinetics, safety and antiviral activity of fosamprenavir (FPV)/ritonavir (RTV) twice daily were evaluated in protease inhibitor (PI)-naive and -experienced HIV-1-infected children aged 6 months to48 weeks. PK parameters and comparisons with historical adult data are shown in the table. Historical healthy adult 6 months to, Background Etravirine has demonstrated efficacy and safety in treatment-experienced, HIV-1-infected adults. Pediatric development is ongoing. Methods PIANO (TMC125-C213; NCT00665847) is a 48-week, Phase II, open-label trial of the safety, efficacy and pharmacokinetics of etravirine 5.2 mg/kg (maximum dose 200mg) bid in HIV-1-infected, treatment-experienced children (6–95% adherent; 70% were >80% adherent. The most common drug-related AE was rash (18%) (Table). Four percent discontinued due to rash. Serious AEs were seen in 5% of patients while 14% experienced a grade 3/4 AE. Laboratory toxicities were predominantly grade 1/2. At W48, 56% of patients achieved VL10% of patients overallzgrouped term including rash not further specified, rash macula-papular, rash generalized, rash erythematous, rash macular rash papular and rash puritic¶occurnng in >5% of patients overall; AE, adverse event NC = F, non-completer equals failure; SE standard error; TLOVR, time-to-loss of virologic response algorithm. Conclusion The efficacy, safety and resistance profiles of etravirine 5.2 mg/kg bid plus OBR in this difficult-to-treat, antiretroviral-experienced pediatric population were comparable to those observed in treatment-experienced adults (DUET trials). Responses were better in children than adolescents, most likely due to less advanced disease, better adherence and less previous NNRTI use., Background New antiretrovirals are needed for HIV+ children. IMPAACT P1066 is a Phase I/II open label multicenter trial to evaluate pharmacokinetics (PK), safety, tolerability, and efficacy of multiple RAL formulations in treatment experienced HIV+ youth. RAL was given with an optimized background regimen. Dose selection was based upon intensive PK and safety data: 400 mg BID of RAL film-coated tablet (6–18 years) and weight-based dosing (~6mg/kg BID) of RAL chewable tablet (2 to, Background In Kenya, an estimated 7,000-10,000 children are HIV infected yearly. National targets for 10% of all HIV clinic patients registered being pediatric are often difficult to reach or fall behind adult uptake. In addition, concerns exist regarding retention of children in HIV/AIDS clinics. Such challenges are often magnified in rural settings due to frequent changes in caregivers,distances away from pediatric clinics, and extremes in poverty. Methods In 2004, HIV/AIDS care and treatment programs began developing under the President's Emergency Plan for AIDS Relief (PEPFAR) program in the SRV Province of Kenya, a largely rural population. Effort has been made to decentralize care, making more clinics closer to rural populations available. In addition, initiatives such as the “Mwangalizi” (“care givers”, often HIV positive adults linked with children to assure they come to HIV clinics) project have been implemented, and pediatric HIV support groups have been established. We describe aggregate program level data for the development of/uptake in HIV pediatric clinics. Results Between 2004 and 2011, 17,572 children received HIV testing through both voluntary counseling and testing (VCT) and diagnostic testing and counseling (DTC) initiatives. 5,310 children (mean age 10.0 +/− 3.3 years, 50.6% female) were enrolled in 57 pediatric HIV clinics. Of those enrolled, 44.3% started first line ART, 2.5% switched to 2nd line ART, and 1 has advanced to 3rd line ART. In 2005, 7.0% of HIV clinic attendees were children on ART, which increased to 10.5% in 2011 (p, Background Lipid abnormality is a common long-term complication in HIV-infected children. This study aimed to compare lipid profiles in children randomized to immediate versus deferred nevirapine-based antiretroviral therapy (ART). Methods This was a substudy of PREDICT (NCT00234091), a 144-week randomized trial of immediate ART (at CD4 15–24%) versus deferred ART (at CD4200 mg/dl, Triglyceride > 130 mg/dl, LDL>130 mg/dl, HDL≤40 mg/dl. Conclusion After 3 years, children randomized to immediate nevirapine-based ART had less dyslipidemia and lower TC/HDL ratio than the deferred ART group. This supports earlier nevirapine-based initiation to achieve favorable lipid profile in children with mild to moderate HIV-associated immune deficiency., Background Metabolic abnormalities, common among perinatally HIV-infected children (HIV+), may be caused by mitochondrial dysfunction that is induced by antiretroviral therapy (ARV) or chronic viral infection. We compared mitochondrial function [oxidative phosphorylation (OXPHOS) enzyme activities and lactate levels] of HIV+ and HIV-exposed, uninfected (HEU) children and, among HIV+, determined associations with fasting glucose, insulin, and homeostatic model assessment of insulin-resistance (HOMA-IR). Methods HIV+ and HEU were enrolled from the PHACS Adolescent Master Protocol. Children with known, non-HIV-associated mitochondrial disorders were excluded. Demographic and BMI [all] and CD4, HIV viral load, ARV exposures, and fasting insulin/glucose [HIV+ only] were collected. Main outcomes included venous and point-of-care (POC) lactate, venous pyruvate, and PBMC NADH dehydrogenase (CI) and cytochrome c oxidase (CIV) enzyme activities. A Wilcoxon test was used to compare outcomes between HIV+ and HEU; Spearman correlations were determined between insulin/glucose and OXPHOS activity in HIV+. Results 112 HIV+ and 66 HEU children were enrolled as of December 2011. HIV+ were older than HEU (15.8yr vs 12.4yr) with similar gender and racial distributions. BMI-Z was lower in HIV+ (0.41SD vs 0.54SD). Among HIV+, 45% were CDC stage B/C and 74% had CD4 >500 cell/mm3 with 60% having viral load, Background Peripheral neuropathy is a well-recognised and common condition in HIV-infected adults and may be related to use of antiretroviral therapy (ART) as well as be directly caused by HIV infection. Data on the prevalence, manifestations and risk factors of neuropathy in children are limited. Only few tools are available for clinical screening for peripheral neuropathy in children. We used the neuropathy symptom score (NSS) and neuropathy disability score (NDS) to screen for peripheral neuropathy in a cohort of children on ART. Methods In this cross-sectional study we included 182 children aged 5-15 years attending to healthcare facilities for ART collection in rural Mopani District, South Africa. Subjective and objective assessment of neuropathy was done using the NSS respectively NDS. These scores are feasible for resource-poor and skills-limited settings and only require a reflex hammer, cotton butt, tooth pick, and cold water. A definite diagnosis of peripheral neuropathy was defined by NSS≥3 or NDS≥ 2. Results Neuropathy screening was completed for 174/182 (96%) of children as 8 children did not fully cooperate. Median age was 9 years old and time on ART 2.0 years (2 months-6.4 years) with 86% on a stavudine-containing regimen. Symptoms related to neuropathy were reported by 49 children (27%) while NDS was positive for 25 children (14%). Forty-one (24%) of children fulfilled the criteria of peripheral neuropathy. Co-trimoxazole use was negatively associated with neuropathy presentation (OR 0.42, 95% CI 0.20–0.88; p=0.019) while there were tendencies for peripheral neuropathy to be associated with older age (p=0.09) and longer time on ART (p=0.06). Conclusion Peripheral neuropathy is a common condition in children collecting ART at healthcare facilities in rural Mopani District. The NSS and NDS can be used to screen for this condition in resource-poor settings., Background Antiretroviral (ARV) administration to HIV positive pregnant women and neonates reduces perinatal HIV transmission to less than 2% worldwide. However, concerns have been raised about potential toxicity in some neonates following gestational ARV exposure. Precise quantification of ARV exposure by history is difficult. Quantitative meconium analysis may better reflect fetal exposure during the third and perhaps second trimesters than history alone. Therefore, we developed and validated the first liquid chromatography-tandem mass spectrometry (LC-MS/MS) assay for ARVs and metabolites in meconium. Methods Blank meconium (0.25g) was fortified with 16 ARVs and 4 metabolites, chosen based on prevalence of use by HIV-infected mothers in the SMARTT (Surveillance Monitoring of ART Toxicities) Study of PHACS. Samples were homogenized in methanol and subjected to solid phase extraction prior to quantification by LC-MS/MS. Tenofovir (TDF), lamivudine (3TC), emtricitabine (FTC), abacavir (ABC) and its carboxylate (CABC) and glucuronide (GABC) metabolites, nevirapine (NVP), raltegravir (RAL), saquinavir (SQV), amprenavir (AMP), darunavir (DRV), atazanavir (ATV), ritonavir (RTV), lopinavir (LPV), nelfinavir (NFV) and its bioactive hydroxyl (M8) metabolite were quantified with positive ionization; stavudine (d4T), efavirenz (EFV), zidovudine (AZT) and its glucuronide (GAZT) metabolite were quantified with negative ionization. Results Chromatographic separation was achieved with gradient elution; two injections were required due to the need for both positive (35 min) and negative (18 min) ionization modes. Extraction efficiencies were greater than 60% for all analytes except GABC (30%), and TDF, 3TC, GAZT and CABC (50%). Linear calibration curves employing 1/x2 weighting ranged from 10–2500ng/g (TDF, FTC, ABC, GABC, NVP, RAL, SQV, ATV, RTV, LPV, NFV, and M8), 50–2500ng/g (3TC), 75–2500ng/g (CABC), 100–25,000ng/g (AMP, DRV, AZT, EFV) and 500–25,000ng/g (d4T, and GAZT). Conclusion We developed a selective and sensitive LC-MS/MS method to detect antiretroviral medications and metabolites in meconium, which may be useful in quantifying the in utero ARV exposure for children of HIV-infected women., Background Mechanisms for increased cardiovascular risk in HIV-infected adults are incompletely understood, but heighted inflammation leading to a pro-thrombotic state has been proposed as a major contributor. In vitro platelet aggregation has been studied as a robust biological marker of coronary events and mortality. Methods We studied platelet aggregation in 25 HIV-infected subjects on ART with undetectable plasma HIV-1 RNA, median CD4 537 cells/mm3 (73.9%men) and 29 healthy HIV seronegative controls (44.4%men) in response to submaximal adenosine diphosphate (ADP, 0.4uM), arachidonic acid (AA, 0.15mM), or without agonist (spontaneous platelet aggregation [SPA]). The effects of one week of aspirin 81mg daily on activation markers, as measured by flow cytometry, and platelet aggregation were investigated. Two-tailed paired t tests and non-parametric Mann-Whitney U test tests were used for statistical analyses, with results given as medians with interquatile ranges. Results Compared to controls, HIV subjects on ART had increased platelet aggregation in response to ADP (10.8% [6.5, 42.3] vs 7.6% [3.3, 10.2], p=0.02), AA (54.9% [8.7, 89.9] vs 11% [2.5, 77.6], p, Background Limited data exist regarding the relationship between dysfunctional HDL (dys-HDL) and the osteoprotegerin (OPG)/receptor activator of the NF-kB ligand (RANKL) in HIV infection. Oxidized HDL (dys-HDL) has been shown to activate the NF-kB pathway in vitro. In view of this observation and the important role of biomarkers of activation of the NF-kB pathway (RANKL/OPG axis) in systemic inflammatory conditions, we used a novel assay that measures oxidation of HDL to explore possible associations between dys-HDL with RANKL/OPG and parameters that may predict these biomarkers. Methods We used cryopreserved serum samples from a prospective study (A5078) where subjects were enrolled as risk factor-matched triads of HIV-infected subjects (n=55) and HIV-uninfected individuals (n=36). Relationships between HIV infection, RANKL, OPG, RANKL/OPG, and dys-HDL were assessed using Wilcoxon tests and mixed effects linear regression analysis. The baseline covariates considered in the analysis are shown in Table 1 and also included fasting glucose and lipids, insulin, use of statins, anthropometric parameters of obesity, years of protease inhibitors (PI) use, and nadir CD4+ T cells. Significant (p, Background The association of inflammatory biomarkers with clinical events after ART initiation is unclear. Methods A5202 randomized 1857 treatment-naive subjects to abacavir/lamivudine or tenofovir DF/emtricitabine with efavirenz or atazanavir/ritonavir. Substudy A5224s measured inflammatory biomarkers on all substudy subjects with available plasma from baseline and weeks 24 or 96. The association of hsCRP, IL-6, sTNF-RI, sTNF-RII, TNF-a, sVCAM-1, and sICAM-1 with times to AIDS and non-AIDS defining events was analyzed with Cox proportional hazards models, with adjustment by ART assignment, and HIV-1 RNA or CD4. Time-updated analyses used the most current value. Results Analysis included 244 subjects; 85% male, 48% white non-Hispanic, with median age 39 years, HIV-1 RNA 4.6 log10 copies/mL, and CD4 240 cells/µL. A total of 13 AIDS-defining events (9 opportunistic infections; 3 AIDS-cancers, 1 recurrent bacterial pneumonia) and 18 non-AIDS defining events (6 diabetes, 4 cancers, 3 cardiovascular, 5 pneumonias) occurred. Higher baseline IL-6, sTNF-RI, sTNF-RII, and sICAM-1 were significantly associated with increased risk of AIDS-defining events. Adjustment for baseline HIV-1 RNA did not change results, while adjusting for CD4 count left sTNF-RI and sICAM-1 significantly associated with increased AIDS-defining events risk. Time-updated values of these biomarkers were also associated with increased risk of AIDS-defining events, even after adjusting for ART assignment, baseline and changes in CD4 and HIV-1 RNA. For non-AIDS events, only baseline hsCRP was significantly associated with increased risk; after adjustment for baseline CD4 count, IL-6 became significantly associated with higher risk. Analyses of time-updated biomarker value showed TNF-a to be significantly associated with increased risk of non-AIDS-defining events, even after adjustment for ART, baseline and changes in CD4 and HIV-1 RNA.Table 1Baseline and Time-Updated Biomarker Association with AIDS-Defining Events Unadjusted Baseline CD4, NRTI and NNRTI/PI Adjusted Time-Updated CD4, NRTI and NNRTI/PI Adjusted Biomarker HR (95% CI) p-value HR (95% CI) p-value HR (95% CI) p-value Baseline hsCRP (per 1 log, ug/ml higher)1.21 (0.80, 1.83)0.361.26 (0.84, 1.88)0.26Time-updated hsCRP (per 1 log, ug/ml higher)1.17 (0.78, 1.77)0.441.17 (0.78, 1.75)0.441.18 (0.78, 1.76)0.43Baseline IL-6 (per l log, pg/ml higher)1.98 (1.06, 3.69)0.0321.79 (0.96, 3.34)0.066Time-updated IL-6 (per 1 log, pg/ml higher)2.06 (1.12, 3.77)0.0201.88 (1.02, 3.47)0.0421.92 (1.04, 3.55)0.037Baseline sICAM-1 (per 1 log, ng/ml higher)8.28 (1 93, 35.59)0.0046.13 (1.51, 24.78)0.011Time-updated sICAM-1 (per 1 log, ng/ml higher)4.45 (1.18, 16.68)0.0273.66 (1.03, 13.08)0.0463.55 (0.98, 13.56)0.053Baseline sTNF-RI (per 1 log, pg/ml higher)10.24 (2.08, 50.32)0.0046.25 (1.17, 33.36)0.032Time-updated sTNF Rl (per 1 log, pg/ml higher)18.14 (2.94, 112.01)0.00211.58 (1.81, 73.92)0.01012.83 (1.99, 82.59)0.007Baseline sTNF-RII (per 1 log, pg/ml higher)3.45 (1.28, 9.33)0.0152.89 (0.99, 8.46)0.052Time-updated sTNF-RII (per 1 log, pg/ml higher)3.51 (1.27, 9.67)0.0152.98 (1.03, 8.60)0.0443.03 (1.04, 8.79)0.041Baseline sVCAM 1 (per 1 log, ng/ml higher)2.29 (0.59, 8.92)0.231.92 (0.47, 7.75)0.36Time-updated sVCAM 1 (per 1 log, ng/ml higher)1.77 (0.41, 7.64)0.4515.9 (0.36, 6.98)0.541.47 (0.34, 6.43)0.51Baseline TNF-a (per 1 log, pg/ml higher)2.28 (0.67, 7.78)0.192.17 (0.61,7.79)0.23Time-updated TNF-a (per 1 log, pg/ml higher)1.94 (0.54, 6.98)0.311.78 (0.47, 6.74)0.401.76 (0.47, 6.62)0.40Biomarker Association with AIDS-Defining Events. Conclusion Higher levels of several inflammatory biomarkers were associated independently of CD4 count with increased risk of AIDS and non-AIDS events. Larger and longer studies should investigate the use of these markers as predictors of clinical endpoints.Table 2Baseline and Time-updated Biomarker Association with Non-AIDS-Defining Events Unadjusted Baseline CD4, NRTI and NNRTI/PI Adjusted Time-Updated CD4, NRTI and NNRTI/PI Adjusted Biomarker HR (95% CI) p-value HR (95% CI) p-value HR (95% CI) p-value Baseline hsCRP (per 1 log, ug/ml higher)1.66 (1.15, 2.41)0.0071.66 (1.14, 2.43)0.008Time-updated hsCRP (per 1 log, ug/ml higher)1.15 (0.81, 1.64)0.441.16 (0.81, 1.67)0.411.16 (0.81, 1.65)0.42Baseline IL-6 (per l log, pg/ml higher)1.68 (0.96, 2.93)0.0681.81 (1.01, 3.25)0.047Time-updated IL-6 (per 1 log, pg/ml higher)0.96 (0.51, 1.83)0.911.01 (0.53, 1.93)0.970.99 (0.52, 1.87)0.97Baseline sICAM-1 (per 1 log, ng/ml higher)0.81 (0.53, 1.24)0.330.79 (0.51, 1.22)0.28Time-updated sICAM-1 (per 1 log, ng/ml higher)0.89 (0.55, 1.44)0.640.88 (0.55, 1.42)0.610.89 (0.55, 1.44)0.65Baseline sTNF-RI (per 1 log, pg/ml higher)1.31 (0.24, 7.26)0.751.69 (0.27, 10.69)0.58Time-updated sTNF Rl (per 1 log, pg/ml higher)2.58 (0.34, 19.84)0.363.06 (0.36, 25.89)0.312.55 (0.31, 20.76)0.38Baseline sTNF-RII (per 1 log, pg/ml higher)1.66 (0.69, 4.01)0.261.98 (0.81, 4.87)0.14Time-updated sTNF-RII (per 1 log, pg/ml higher)2.07 (0.76, 5.61)0.152.32 (0.84, 6.40)0.112.14 (0.77, 5.97)0.15Baseline sVCAM 1 (per 1 log, ng/ml higher)1.03 (0.32, 3.32)0.951.16 (0.35, 3.85)0.81Time-updated sVCAM 1 (per 1 log, ng/ml higher)2.14 (0.60, 7.55)0.242.22 (0.62, 7.95)0.222.14 (0.59, 7.83)0.25Baseline TNF-a (per 1 log, pg/ml higher)2.33 (0.80, 6.76)0.122.35 (0.83, 6.66∣0.11Time-updated TNF-a (per 1 log, pg/ml higher)3.75 (1.31, 10.77)0.0144.01 (1.39, 11.55)0.0103.87 (1.34, 11.18)0.012Biomarker Association with NONAIDS-Defining Events., Background HIV-positive patients may be at increased risk of premature onset of age-associated non-communicable comorbidity (AANCC). Methods Comprehensive assessment for AANCC in an ongoing prospective cohort study of HIV-1-infected patients ≥45 years from a tertiary care HIV-outpatient clinic, and concurrently recruited HIV-uninfected public sexual health clinic-attendants, comparable regarding age, gender, ethnicity and risk-behavior. Baseline data on AANCC (blood pressure ≥140/90 mmHg, FEV1/FVC, Background The report of a successful HIV cure after allogeneic bone marrow transplant for acute leukemia has generated major interest in HIV eradication. We examined the efficacy, cost, and relapse rate combinations that would make ‘cure’ cost-effective compared with antiretroviral therapy (ART). Methods We used a Monte Carlo simulation of HIV disease (CEPAC model) to assess the impact of suppressive ART either continued indefinitely, or followed by one of three hypothetical strategies for HIV eradication: gene therapy (GeneRx), chemotherapy to activate the latent viral reservoir (Chemo), and an allogeneic bone marrow transplant (BMT). Patients eligible for inclusion in the model were virologically suppressed on first-line ART for one year. Patients who relapsed after a cure strategy restarted on ART. For each strategy we examined combination rates of cure, upfront cost, and monthly relapse rates to determine benchmarks for which the eradication strategies would compare favorably to ART. Model outcomes included projected life expectancy in months (LMs), cost, and discounted (3%) cost-effectiveness (C-E) in $US/QALY using a C-E threshold of

BACKGROUND: We conducted a Phase I dose escalation trial of ADVAX, a DNA-based candidate HIV-1 vaccine expressing Clade C/B' env, gag, pol, nef, and tat genes. Sequences were derived from a prevalent circulating recombinant form in Yunnan, China, an area of high HIV-1 incidence. The objective was to evaluate the safety and immunogenicity of ADVAX in human volunteers. METHODOLOGY/PRINCIPAL FINDINGS: ADVAX or placebo was administered intramuscularly at months 0, 1 and 3 to 45 healthy volunteers not at high risk for HIV-1. Three dosage levels [0.2 mg (low), 1.0 mg (mid), and 4.0 mg (high)] were tested. Twelve volunteers in each dosage group were assigned to receive ADVAX and three to receive placebo in a double-blind design. Subjects were followed for local and systemic reactogenicity, adverse events, and clinical laboratory parameters. Study follow up was 18 months. Humoral immunogenicity was evaluated by anti-gp120 binding ELISA. Cellular immunogenicity was assessed by a validated IFNgamma ELISpot assay and intracellular cytokine staining. ADVAX was safe and well-tolerated, with no vaccine-related serious adverse events. Local and systemic reactogenicity events were reported by 64% and 42% of vaccine recipients, respectively. The majority of events were mild. The IFNgamma ELISpot response rates to any HIV antigen were 0/9 (0%) in the placebo group, 3/12 (25%) in the low-dosage group, 4/12 (33%) in the mid-dosage group, and 2/12 (17%) in the high-dosage group. Overall, responses were generally transient and occurred to each gene product, although volunteers responded to single antigens only. Binding antibodies to gp120 were not detected in any volunteers, and HIV seroconversion did not occur. CONCLUSIONS/SIGNIFICANCE: ADVAX delivered intramuscularly is safe, well-tolerated, and elicits modest but transient cellular immune responses. TRIAL REGISTRATION: Clinicaltrials.gov NCT00249106., published_or_final_version

BENCHMRK-1 and -2 are ongoing double-blind phase III studies of raltegravir in patients experiencing failure of antiretroviral therapy with triple-class drug-resistant human immunodeficiency virus infection. At week 96 (combined data), raltegravir (400 mg twice daily) plus optimized background therapy was generally well tolerated, with superior and durable antiretroviral and immunological efficacy, compared with optimized background therapy alone.

Background: Raltegravir (MK-0518) is an inhibitor of human immunodeficiency virus type 1 (HIV-1) integrase active against HIV-1 susceptible or resistant to older antiretroviral drugs. Methods: We conducted two identical trials in different geographic regions to evaluate the safety and efficacy of raltegravir, as compared with placebo, in combination with optimized background therapy, in patients infected with HIV-1 that has triple-class drug resistance in whom antiretroviral therapy had failed. Patients were randomly assigned to raltegravir or placebo in a 2:1 ratio. Results: In the combined studies, 699 of 703 randomized patients (462 and 237 in the raltegravir and placebo groups, respectively) received the study drug. Seventeen of the 699 patients (2.4%) discontinued the study before week 16. Discontinuation was related to the study treatment in 13 of these 17 patients: 7 of the 462 raltegravir recipients (1.5%) and 6 of the 237 placebo recipients (2.5%). The results of the two studies were consistent. At week 16, counting noncompletion as treatment failure, 355 of 458 raltegravir recipients (77.5%) had HIV-1 RNA levels below 400 copies per milliliter, as compared with 99 of 236 placebo recipients (41.9%, P

Background: We evaluated the efficacy of raltegravir and the development of viral resistance in two identical trials involving patients who were infected with human immunodeficiency virus type 1 (HIV-1) with triple-class drug resistance and in whom antiretroviral therapy had failed. Methods: We conducted subgroup analyses of the data from week 48 in both studies according to baseline prognostic factors. Genotyping of the integrase gene was performed in raltegravir recipients who had virologic failure. Results: Virologic responses to raltegravir were consistently superior to responses to placebo, regardless of the baseline values of HIV-1 RNA level; CD4 cell count; genotypic or phenotypic sensitivity score; use or nonuse of darunavir, enfuvirtide, or both in optimized background therapy; or demographic characteristics. Among patients in the two studies combined who were using both enfuvirtide and darunavir for the first time, HIV-1 RNA levels of less than 50 copies per milliliter were achieved in 89% of raltegravir recipients and 68% of placebo recipients. HIV-1 RNA levels of less than 50 copies per milliliter were achieved in 69% and 80% of the raltegravir recipients and in 47% and 57% of the placebo recipients using either darunavir or enfuvirtide for the first time, respectively. At 48 weeks, 105 of the 462 raltegravir recipients (23%) had virologic failure. Genotyping was performed in 94 raltegravir recipients with virologic failure. Integrase mutations known to be associated with phenotypic resistance to raltegravir arose during treatment in 64 patients (68%). Forty-eight of these 64 patients (75%) had two or more resistance-associated mutations. Conclusions: When combined with an optimized background regimen in both studies, a consistently favorable treatment effect of raltegravir over placebo was shown in clinically relevant subgroups of patients, including those with baseline characteristics that typically predict a poor response to antiretroviral therapy: a high HIV-1 RNA level, low CD4 cell count, and low genotypic or phenotypic sensitivity score. (ClinicalTrials.gov numbers, NCT00293267 and NCT00293254.)