Trends and predictors of HIV-1 acquired drug resistance in Minas Gerais, Brazil: 2002-2012

Abstract Several studies show that the prevalence of multidrug-resistant HIV-1 virus is declining over time. A retrospective cohort study was carried out to evaluate the trends of drug resistance in antiretroviral treatment-exposed individuals in a state of a middle-income country, Minas Gerais, southeast region of Brazil. We analyzed 2115 HIV-1 sequences from 2002 up to 2012, from 52 cities of Minas Gerais. The groups were analyzed according to the definitions: "IAS – 3 class mutations", if ≥1 drug resistance mutation from IAS 2015 list (DRM) was present in each class; "No fully susceptible drugs" as the absence of any fully susceptible drug in Stanford algorithm; and "GSS ≥ 2″, when a maximum calculated GSS (genotypic susceptibility score) was ≥2 or ≥3, counting only drugs available in Brazil and USA at given calendar years. Time trends of resistance were analyzed by Cochran–Armitage test. We observed a decrease in the rate resistance mutations for PI, NRTI, "IAS – 3 class mutations", and "No fully susceptible drugs" over these 11 years, from 69.2% to 20.7%, 92.3% to 90.2%, 46.2% to 22.5%, and 12.8% to 5.7%, respectively (p < 0.05). Resistance to NNRTI increased from 74.4% to 81.6%, mainly because of K103N mutation. The GSS score ≥2 increased during the years from 35.9% to 87.3% (p < 0.001). We demonstrate that resistance to PI and to the three main classes simultaneously are declining, although the number of patients on of antiretroviral therapy has doubled in the last ten years in Brazil (125,000 in 2002 to 400,000 in 2014). Broader resistance testing and the availability of more therapeutic options might have influenced this decline. The increase in NNRTI resistance can limit this class as first line treatment in Brazil in the future.

PCR interna con ADN extraído directamente de portaobjetos positivos para confirmar o excluir el diagnóstico de tuberculosis: enfoque en la bioseguridad / In-house PCR with DNA extracted directly from positive slides to confirm or exclude the diagnosis of tuberculosis: focus on biosafety

The possibility to obtain DNA from smears is a valuable alternative to remedy the lack of samples when they are totally used for bacilloscopy; this technique solves the biosafety problem related to a possible accident with the transportation of flasks containing potentially transmissible clinical samples. Hence, the purpose of this study was to utilize the insertion sequence IS6110 for amplification of DNA from a smear-positive sample for tuberculosis (TB) diagnosis. Among the 52 positive bacilloscopies, sensitivity, specificity, positive predictive value and negative predictive value were 52.3%, 100%, 100% and 89.7%, respectively whereas accuracy was 90.7%. The IS6110-based PCR for TB diagnosis developed in DNA extracted from a positive smear is a fast, simple, specific, and safe method

La posibilidad de obtener ADN a partir de frotis es una valiosa alternativa para remediar la falta de muestras cuando estas son totalmente utilizadas para la baciloscopia; esta opción soluciona, además, el problema de bioseguridad asociado a la posibilidad de accidente al transportar frascos que contienen muestras clínicas potencialmente infectivas. Por lo tanto, el propósito de este estudio fue utilizar para el diagnóstico de la tuberculosis la secuencia de inserción IS6110 para amplificación del ADN a partir de frotis que resultaron positivos por baciloscopia. Del análisis de 52 baciloscopias positivas surge que la sensibilidad, la especificidad, el valor predictivo positivo y el valor predictivo negativo de esta técnica fueron, respectivamente, del 52,3%, del 100%, del 100% y del 89,7%; y la precisión fue del 90,7%. La PCR IS6110 para el diagnóstico de tuberculosis, desarrollada con ADN extraído de frotis positivos, es un método rápido, simple, específico y seguro

Social and immunological differences among uninfected Brazilians exposed or unexposed to human immunodeficiency virus-infected partners

Understanding the social conditions and immunological characteristics that allow some human immunodeficiency virus (HIV)-exposed patients to remain uninfected represents an on-going challenge. In this study, the socio-demographic and sexual behaviour characteristics and immune activation profiles of uninfected individuals exposed to HIV-infected partners were investigated. A confidential and detailed questionnaire was administered and venous blood was tested using HIV-1/enzyme immunoassays, plasma HIV-1 RNA levels/bDNA and immunophenotyping/flow cytometry to determine the frequencies of CD4 and CD8 T cells expressing activation markers. The data analysis showed significant differences (p < 0.05) for immune parameters in individuals who were uninfected, albeit exposed to HIV-infected partners, compared with unexposed individuals. In particular, the exposed, uninfected individuals had a higher frequency (median, minimum-maximum) of CD4+HLA-DR+ (4.2, 1.8-6.1), CD8+HLA-DR+ (4.6, 0.9-13.7), CD4+CD45RO+ (27.5, 14.2-46.6), CD4+CD45RO+CD62L+ (46.7, 33.9-67.1), CD8+CD45RA+HLA-DR+ (12.1, 3.4-35.8) and CD8+CD45RO+HLA-DR+ (9.0, 3.2-14.8) cells, a decreased percentage of CD8+CD28+ cells (11.7, 4.5-24.0) and a lower cell-surface expression of Fcγ-R/CD16 on monocytes (56.5, 22.0-130.0). The plasma HIV-1 RNA levels demonstrated detectable RNA virus loads in 57% of the HIV-1+ female partners. These findings demonstrate an activation profile in both CD4 and CD8 peripheral T cells from HIV-1 exposed seronegative individuals of serodiscordant couples from a referral centre in Belo Horizonte, state of Minas Gerais.

Transmitted human immunodeficiency virus-1 drug resistance in a cohort of men who have sex with men in Belo Horizonte, Brazil - 1996-2012

The presence of transmitted human immunodeficiency virus (HIV)-1 drug-resistance (TDR) at the time of antiretroviral therapy initiation is associated with failure to achieve viral load (VL) suppression. Here, we report TDR surveillance in a specific population of men who have sex with men (MSM) in Belo Horizonte, Brazil. In this study, the rate of TDR was evaluated in 64 HIV-infected individuals from a cohort of MSM between 1996-June 2012. Fifty-four percent had a documented recent HIV infection, with a seroconversion time of less than 12 months. The median CD4+T lymphocyte count and VL were 531 cells/mm3and 17,746 copies/mL, respectively. Considering the surveillance drug resistance mutation criteria, nine (14.1%) patients presented TDR, of which three (4.7%), five (7.8%) and four (6.2%) had protease inhibitors, resistant against nucleos(t)ide transcriptase inhibitors and against non-nucleoside reverse-transcriptase inhibitors mutations, respectively. Two of the patients had multi-drug-resistant HIV-1. The most prevalent viral subtype was B (44, 68.8%), followed by subtype F (11, 17.2%). This study shows that TDR may vary according to the population studied and it may be higher in clusters of MSM.

Analysis of correlation between cerebrospinal fluid and plasma HIV-1 RNA levels in patients with neurological opportunistic diseases / Análise da correlação entre os níveis de RNA do HIV-1 no líquido cefalorraquidiano e plasma em pacientes com doença neurológica oportunista

The question of whether HIV-1 RNA in cerebrospinal fluid (CSF) is derived from viral replication in the central nervous system or simply reflects the transit of infected lymphocytes from the blood compartment has long been a matter of debate. Some studies found no correlation between CSF and plasma viral load, whereas others did. The lack of a correlation between the two compartments suggests that the presence of HIV-1 RNA is not simply due to the passive passage of the virus from blood to CSF but rather due to intrathecal replication. To evaluate the correlation between plasma and CSF HIV-1 RNA levels and to identify situations in which there is no correlation between the two compartments, seventy patients were prospectively studied. The association between CSF and plasma viral load was evaluated in the total population and in subgroups of patients with similar characteristics. A correlation between the CSF and plasma compartments was observed for patients undergoing highly active antiretroviral therapy (HAART), those with a CD4 T lymphocyte count lower than 200 cells/mm³, and those with increased CSF protein content. On the other hand, no correlation was observed for patients without adequate virological control, who had a CD4 count higher than 200 cells/mm³ and who did not use HAART. The correlation between the two compartments observed in some patients suggests that CSF HIV-1 RNA levels may reflect plasma levels in these subjects. In contrast, the lack of a correlation between the two compartments in patients who were not on HAART and who had normal CSF proteins and a poor virological control possibly indicates compartmentalization of the virus in CSF and, consequently, plasma-independent intrathecal viral replication.

Tem sido objeto de debate a questão se o RNA do HIV-1 no líquido cefalorraquidiano (LCR) é derivado da replicação viral no sistema nervoso central ou simplesmente reflete o tráfego de linfócitos infectados do compartimento sanguíneo. Alguns estudos não mostraram correlação entre a carga viral do plasma e LCR, mas outros sim. A falta de correlação entre os dois compartimentos sugere que a presença de RNA do HIV-1 não é simplesmente devido à passagem do vírus do plasma para o LCR, mas sim a uma replicação intratecal. Para avaliar a correlação entre os níveis de RNA do HIV-1 no plasma e no LCR e tentar identificar situações, na qual, não existe a correlação entre os dois compartimentos avaliaram-se setenta pacientes prospectivamente. A associação entre a carga viral do LCR e plasma foi avaliada na população total e em subgrupos de pacientes com características similares. A correlação entre os dois compartimentos foi observada em pacientes que estavam em uso da terapia antiretroviral (HAART), naqueles que tinham contagem de linfócitos CD4 menor que 200 céls/mm³ e naqueles com aumento da concentração de proteínas no LCR. Por outro lado, não houve correlação para os pacientes que não tinham um controle virológico adequado, os que tinham contagem de CD4 maior que 200 céls/mm³ e aqueles que não estavam usando HAART. A correlação entre os dois compartimentos observada em alguns pacientes sugere que os níveis de RNA do HIV-1 no LCR podem refletir os níveis plasmáticos nestes pacientes. E a falta de correlação ente os dois compartimentos em pacientes que não usavam HAART, nos que tinham uma concentração de proteínas no LCR normal, e nos que não apresentavam bom controle virológico, indica provavelmente a compartimentalização do vírus no LCR e consequentemente replicação viral intratecal independente da do plasma.

HIV-1 RNA detection in the amniotic fluid of HIV-infected pregnant women

This study is aimed at evaluating the potential to detect human immunodeficiency virus (HIV) in amniotic fluid (AF) collected at delivery from 40 HIV-positive pregnant women. Thirty patients had a plasma viral load (VL) below 1,000 copies/mL at delivery. VL was positive in three AF samples. No significant association was found between the HIV-1 RNA in AF and the maternal plasma samples. There was no HIV vertical transmission detected.

Treatment switch guided by HIV-1 genotyping in Brazil

We assessed the performance of HIV-1 genotyping tests in rescue therapy. Patients were divided into two groups: group 1 (genotyped), included those switching to new antiretroviral drugs based on HIV-1 genotyping data, and group 2 (standard of care -SOC), comprised those in rescue therapy who had not used this test. This was an open and non-randomized study, with 74 patients, followed up for a mean period of 12 months, from February 2002 to May 2003. The groups differed in the duration of antiretroviral use, experience with diverse drug classes (non-nucleoside reverse transcriptase inhibitors and protease inhibitors) and viral load <2.6 log10 copies/mL at any time during treatment. In 23 patients (group 1), the switch in antiretroviral (ARV) regimen was based on genotyping data; this test was not used for 51 patients (group 2). Two CD4 + lymphocyte counts and viral load counts were made for each patient during the study. Data from the pharmacy where patients received antiretroviral agents, medical charts, and direct interviews with patients to assess compliance to treatment, were analyzed. In the genotyped group, the average drop in viral load was 2.8 log10, compared with a 1.5 log10 difference in group 2; the difference was significant in the first assessment performed six months after switching (p=0.001). Considering the patients with viral load < 2.6 log10 (400 copies/mL) after switching, the patients in group 1 had a better performance in the first assessment (73.9 percent versus 31.1 percent in groups 1 and 2, respectively); this difference was significant (p=0.001). In multivariate analysis, the variables associated with a greater drop in viral load in the first assessment were the patients whose switching was based on genotyping (group 1), those with a past history of viral load < 2.6 log10 and correct use of antiretroviral agents. In conclusion, the genotyping test and adherence were found to be independent factors for success in the management of patients who failed treatment.

HIV-1 RNA levels in cerebrospinal fluid and plasma and their correlation with opportunistic neurological diseases in a Brazilian AIDS reference hospital

INTRODUÇÃO: Os níveis de RNA do HIV-1 no plasma refletem a replicação viral sistêmica e a replicação no sistema nervoso central pode ocorrer independentemente da infecção sistêmica, mas a utilidade da medida destes níveis no líquido cefalorraqueano (LCR) permanece indefinida. OBJETIVO: Comparar os níveis de RNA do HIV-1 no LCR e plasma de pacientes sem doenças neurológicas e com diferentes doenças neurológicas, bem como correlacionar estes níveis com a sua evolução e o uso de antiretrovirais. MÉTODO: Foram avaliados 97 pacientes com suspeita de doença neurológica que realizaram punção lombar e que foram divididos em dois grupos: sem doenças neurológicas (23) e com doenças neurológicas (74). Metodologia NASBA foi usada para quantificação do RNA do HIV-1. RESULTADOS: A mediana da carga viral do LCR foi maior em pacientes com neurotoxoplasmose, neurocriptococose, demência pelo HIV e doença neurológica sem etiologia definida quando comparada aos pacientes sem doenças neurológicas. Não houve diferença da carga viral do plasma entre os pacientes com e sem doença neurológica. A mediana da carga viral do plasma e LCR foi maior nos pacientes que faleceram em relação aos tratados com sucesso. A carga viral do LCR e plasma foi menor nos pacientes com doenças oportunísticas que usavam HAART em relação aos que não a usavam. CONCLUSÃO: A carga viral no LRC foi maior nos pacientes com qualquer doença neurológica em relação aos sem doenças neurológicas, mas isto não ocorreu no plasma, sugerindo que doença neurológica influencia mais o compartimento do LCR que o do plasma, mas não foi possível diferenciar as doenças neurológicas pelos níveis de RNA do HIV-1 do LCR.

HIV-1 genotypes related to failure of nelfinavir as the first protease inhibitor treatment

Combined antiretroviral therapy results in sustained viral suppression and a decrease in mortality and morbidity due to HIV infection. Intrinsic strength, durability and absence of cross-resistance are key factors in the selection of antiretrovirals. Failure with nelfinavir has been associated with two protease gene mutations, D30N and L90M. The D30N mutation does not result in cross-resistance with other protease inhibitors, and it decreases viral fitness. In order to check for this mutation after failure with nelfinavir, the 246 HIV-1 genotyping test was performed on virus samples from 55 patients with failure of nelfinavir as the first protease inhibitor. Most (84 percent) of the viral strains were of subtype B. Nucleosides associated with mutations (NAM) were observed in 80 percent of the tests; no INS69, complex 151, K65R and L74V mutations, which give multi-resistance to nucleoside analogue reverse transcriptase inhibitors to tenofovir and DDI, respectively, were observed. In the tests for protease gene mutations, the D30N mutation was found in 57 percent, L90M in 18 percent and the wild-type virus in 25 percent. These data are similar to published reports, showing that alternative therapies used after failure with nelfinavir may be more successful, as the D30N mutation does not cause cross-resistance to other protease inhibitors.

Associação entre a carga viral e os linfócitos T CD4+ com as lesões intra-epiteliais do colo uterino em mulheres infectadas pelo vírus da imunodeficiência humana / Association between viral load and CD4+ T lymphocyte count and cervical intraepithelial lesions in HIV-infected women

OBJETIVOS: verificar se a contagem de linfócitos T CD4+ e a carga viral do HIV têm influência na presença de lesões intra-epiteliais cervicais (SIL). MÉTODOS: estudo transversal, no qual foram selecionadas 134 mulheres HIV-positivas, todas submetidas à biópsia do colo uterino, quantificação da carga viral do HIV e contagem de linfócitos T CD4+. Os valores laboratoriais da quantificação da carga viral e da contagem de linfócitos T CD4+ foram obtidos antes da realização da biópsia, tendo sido estabelecidos cortes para o estudo da carga viral (<400 cópias/mL; 401 a 50.000 cópias/mL; >50.000 cópias/mL) e contagem de linfócitos T CD4+ (<200 células/mm ; 200 a 350 células/mm ; >350 células/mm ). Foram realizados os testes chi2, chi2 de tendência linear, chi2 de Mantel-Haenszel e análise de variância. Estabeleceu-se significância estatística para p<0,05 e intervalo de confiança a 95 por cento. RESULTADOS: não houve tendência de risco para as mulheres HIV-positivas apresentarem SIL com o aumento da carga viral ou diminuição dos linfócitos T CD4+. Comparando-se a carga viral com a presença ou ausência de SIL, estratificada pelo tempo em que foi quantificada, houve diferença significante para valores acima de 400 cópias/mL (OR: 3,17; IC 95 por cento: 1,02-9,93; p=0,048). Nenhuma associação foi encontrada para a contagem de linfócitos T CD4+ com a presença da SIL. CONCLUSAO: as pacientes com carga viral do HIV maior que 400 cópias/mL, quantificada antes da biópsia do colo uterino, apresentaram chance 3,17 vezes maior de desencadear SIL. A contagem de linfócitos T CD4+ não influenciou no aparecimento da SIL.

Carga viral do HIV como fator de risco das lesões intra-epiteliais escamosas cervicais / HIV viral load as a risk fator for cervical squamous intraepithelial lesions

A Infecção pelo vírus da imunodeficiência humana (HIV)atinge, anualmente, milhões de mulheres em todo o mundo. A quantificação da carga viral do HIV pode ser feita pelas modernas técnicas de biologia molecular, sendo usada rotineiramente na prática clínica para avaliar a eficácia terapêutica e predizer o risco para a progressão da doença. São inúmeros os estudos em busca de fatores de risco que justifiquem a alta prevalência das lesões intra-epiteliais escamosas cervicais (SIL) em mulheres portadoras do HIV. Aborda-se a importância da carga viral, os métodos de quantificação e a associação entre a carga viral e os vários fatores relacionados ao aparecimento dessas lesões. Incluiu-se, nessa análise, a possível interferência da terapia anti-retroviral potente (HAART) no aparecimento das SIL. Concluiu-se que, até o presente momento, não existem dados na literatura que demonstrem associação direta entre a quantificação da carga viral do HIV e a evolução das SIL