Successful application of laboratory tools for the detection of HIV drug resistance in routine clinical care in Georgia.

Since 2004, Georgia the first among Eastern European countries ensured universal access to highly active antiretroviral therapy (HAART). Laboratory monitoring of HAART using CD4 count, viral load (VL) and HIV genotypic resistance testing was carried out in according with National HIV/AIDS Treatment Guidelines. Georgia the first among former Soviet Union countries implemented HIV genotypic resistance testing in HIV clinical care. The present paper reports on successful application of laboratory tools in routine clinical care for the early detection of HIV drug resistance. For genotypic resistance testing the TruGene HIV-1 Genotyping Kit (Bayer HealthCare LLC, Tarrytown, NY) was used according to manufacturer's instructions. Analysis included 45 patients with virologic failure. Of them 34 (75.5%) had at least one resistant mutation. Dual-class drug resistance was found in 30 (66.7%) patients. One (2.2%) patient carried triple-class resistance mutations. Median number of resistant mutations was 2. Most commonly detected NRTI mutation was M184/V/I (68.9%). G190S/A was the most frequent NNRTI mutation (42.2%), followed by K103N (28.9%). All patients with drug resistance mutations were switched to a second line regimens. Analysis of virologic and immunological outcomes among 23 patients who had at least two follow-up measurements of CD4 and VL after resistance test, showed statistically significant decrease in VL by 2.5 log(10) and mean gain of 181 cells/mm(3) in CD4 count by the last available measurement. Routine monitoring of VL and subsequent use of HIV drug resistance testing allowed for early identification of HIV drug resistance, reducing the opportunity for mutations to accumulate. Routine use of sophisticated laboratory methods for HAART monitoring has beneficial impact on clinical outcomes and should be used as part of the strategy to combat resistance.

Distribution of HIV-1 resistant polymorphisms among HIV infected patients in Georgia.

Host genetic factors are believed to play an important role in the pathogenesis and natural history of HIV disease along with determining the rate and severity of HIV epidemic in a particular country. CCR5, CCR2 and SDF1 genes are known to influence the susceptibility to HIV-1 infection and to be involved in the rate of disease progression. Unlike CCR5 Delta32 mutation, mutations in CCR2-64I and SDF1-3A do not provide full protection against HIV-1 acquisition, however, they are believed to delay the onset of AIDS defining illness. The objectives of this study were to evaluate the prevalence of host genetic factors among HIV infected patients in Georgia in order to define the correlations between CCR5Delta32, CCR-64I and SDF1-3A genotypes and HIV disease progression in our country. 120 HIV infected individuals were enrolled in the study. Mutations were detected by the polymerase chain reaction/restriction fragment length polymorphism method. We have studied the DNA polymorphisms at the loci that encode these proteins in 120 HIV infected individuals. As expected, no CCR5 homozygous 32 base pair mutation was found among HIV infected persons, however 6 heterozygous patients produced allele frequency 2.5%. Allele frequency of CCR2 and SDF1 allele was equal to 10.75% and 32% respectively. The overall frequency of CCR2 and CCR5 mutations is comparable to their frequency among European populations. However, to our knowledge, the frequency of SDF1-3A allele frequency in Georgians is higher than has been reported in European countries. We found a delay in the progression of HIV infection among persons who were between heterozygous for the CCR5 Delta32 mutation. In order to explore the impact of host genetic factors on the HIV epidemic in Georgia, host genetic studies involving different groups would be of interest.

IFN/RBV treatment induced neutropenia and its correction with neupogen in patients with hepatitis C.

The aim of the study was to observe the frequency of neutropenia during Pegylated Interferon/Ribavirin therapy in patient with chronic hepatitis C; to compare the efficacy of two strategies of management of neutropenia--with Interferon dose modification and with Neupogen administration; to compare the effectiveness rate of sustained viral response (SVR) in patients with Pegylated Interferon dose modification and in patients treated by using granulocyte colony-stimulating factor G-CSF-filgrastim. (Neupogen). Study enrolled 47 patients with chronic active hepatitis C, aged 23-64. (38 male and 9 female). All patients had HCV genotype 1b. Significant neurtopenia (ANC<750 mm3) and severe neurtopenia (ANC<500 mm3) developed in 41 of 47 patients (87%). 41 patients with neurtopenia were randomized into two groups. The first group--22 patients who received granulocyte colony-stimulating factor (G-CSF, or filgrastim) 300 mcg s/c weekly for correction of neutropenia and the second group--19 patients treated either with Interferon dose reduction or temporarily inhibit of Interferon treatment. In all 22 patients of the first group neutropenia was normalized without reduction and/or inhibit of Pegylated interferon. Neupogen was well tolerated and in all 22 patients the improvement of quality of life (QOL) was observed. It was concluded that dose reduction or temporary inhibit of Pegylated Interferon in the second group negatively acts on antiviral treatment response in patients with HCV genotype 1. In patients with PEG-IFN/RBV therapy Neupogen effectively manages neutropenia and gives opportunity to maintain interferon dose (without reduction). Neupogen has the potential to improve adherence rates, which may in turn improve SVR.

Prion diseases--mysterious persistent infections.

The group of persistent viral infections includes latent, chronic and slow infections. The latter can be caused by: conventional viruses (e.g. polyomavirus JC - causative agent of the Progressive Multifocal Leucoencephalopathy (PML)); defective forms of conventional viruses (e.g. defective measles virus, causing Subacute Sclerosing Panencephalitis (SSPE)) and non-conventional infectious agents - prions (proteinaceous infectious particles), causative agents of transmissible spongiform encephalopathies of humans and different animal species. Prion Diseases are unique in that the same pathologic substrate may cause infectious , genetic and sporadic disease. The primary signs of prion diseases are cognitive impairment and ataxia. On histologic analysis of tissue, spongiform degeneration of the brain accompanied by activated astrocytes and microglia is observed. Prion diseases are the least frequent of all persistent infections. However, there is a big scientific interest in these diseases aimed to solve many open questions related to these mysterious diseases. Emergence of the variant Creutzfeldt-Jakob disease in 1996 in Europe manifested a new threat - prions may cross a species barrier, humans may get infection from diseased animals. According to some authors, the list of prion diseases may grow to include several neurodegenerative disorders. The present review discusses current scientific concepts and peculiarities of prion diseases.

Ifn/Rbv treatment induced anemia and its correction with epoetin alpha in patients with hepatitis C.

The aim of the 18 months follow up study was to assess the frequency of anemia during IFN/RBV therapy in patients with chronic hepatitis C; to manage anemia either with recombinant human erythropoietin (rHuEPO)--epoetin alpha or with RBV dose reduction and to compare the rate of SVR in patients with RBV dose reduction and with administration of epoetin alpha. Study enrolled 61 patients with chronic active hepatitis C aged 33-61 years. All patients had HCV genotype 1b. Out of them 41 were male and 20 female. Anemia (Hb <10 or >2 g/dL Hgb drop from baseline) developed in 41 patients out of 61 (67,21%) during the therapy. These 41 patients were randomized into two groups: 21 patients who received 40 000 IU epoetin alpha weekly (I group) and 20 patients in whom for managing anemia we used standard of care (SOC) or RBV dose reductions from 1000/1200 to 800/600 mg (II group). In all 21 patients of the I group the Hb level normalized without reduction of RBV dose. In this group of patients SVR at 6 months after completion of full course of treatment was achieved in 17 (66%) patients. Improvement of quality of life (QOL) was observed in all 21 patients. Out of 20 patients of II group with standard of care (SOC) 5 patients developed symptomatic anemia with fatigue and dyspnoea; RBV was stopped temporarily. In 15 patients RBV dose was reduced from 1200 mg to 600 mg for correction of anemia. In this group of patients SVR at 6 months after treatment completion was achieved in 7 (25%) patients. Lower RBV doses yield a lower treatment response in patients with HCV genotype 1. In anemic HCV-infected patients on RBV/PEG-IFN therapy, EPO maintains RBV dose and significantly improves anemia and QOL. EPO has the potential to improve adherence rate, which may in turn improve SVR.

Hiv prevalence among high risk behavior group persons with herpes zoster infection.

The aim of the two year (2003-2005) study was to study the HIV prevalence among high risk behavior groups of persons with Herpes Zoster infection. For this purpose we have investigated the high risk group patients: 1257 prisoners (1st group), 1543 IDUs (2nd group) and 1350 persons including: homosexuals, persons with history of frequent unprotected sex and persons with hepatitis B and C (3rd group). We revealed the persons with current or previous history of Herpes Zoster, and studied HIV prevalence among them. Besides, we have studied the immune status of revealed HIV positive persons, relationship between disease (Herpes Zoster) severity and CD4 count. Herpes Zoster infection was diagnosed based on clinical symptoms, anamnesis and by detection of VZV specific IgM and IgG by ELISA. HIV infection was diagnosed by ELISA method and was confirmed by Western Blot. CD4 count was detected by immunophenotyping technique and was analyzed using a FACSCalibur flow cytometer. The total prevalence of HIV infection among high risk behavior group persons with Herpes Zoster infection was 18,9% (31 HIV cases out of 164). The disease (Herpes Zoster) severity and duration was associated with decreased rate of cellular immunity, CD4 count. Herpes Zoster has a positive predictive value for HIV infection, predominantly recurrent Herpes Zoster. Herpes Zoster should be recognized as a marker condition indicating the necessity of screening for HIV, especially in Georgia, the region where the problem of IDU exists.

Peculiarities of herpes zoster in immunocompetent and immunocompromised hosts.

The aim of five years (2000-2005) study was to investigate the peculiarities of Herpes Zoster in immunocompromised and immunocompetent patients. For this purpose we have investigated the clinical course of Herpes Zoster, disease duration, complications of disease, as in acute phase as well as postherpetic neuralgia in 74 HIV positive (1st group) and 74 HIV negative (2nd group) groups of patients. In both group of patients we have studied the prevalence of the following complications: 1. Acute complications of Herpes Zoster: a) Neurological: motor neuropathy, cranial neuritis, meningoencephalitis, transverse myelitis. b) Ophthalmic: keratitis, iritis, retinitis, visual impairment c) Cutaneous: bacterial superinfection, scarring, disfigurement. d) Visceral: pneumonitis, hepatitis. e) Multidermatomal. 2. The complications of after resolution of infection: a) Postherpetic neuralgia and various duration of pain associated with postherpetic neuralgia such as : < month, 1-6 months, 6-12 months and >1 year durations. b) Recurrent herpes zoster. Herpes Zoster infection was diagnosed based on clinical symptoms and by detection of VZV specific IgM and IgG by ELISA. HIV infection was diagnosed by ELISA method and was confirmed by Western Blot. We found that Herpes Zoster may develop as in HIV positive as well as HIV negative population. Study showed that severe cases of disease (Herpes Zoster), long duration and rate of complications are much higher in HIV/AIDS than in HIV negative group patients. Rate of hospitalization is also higher in HIV/AIDS patients with Herpes Zoster than in HIV negative patients with Herpes Zoster. Frequency of recurrent Herpes Zoster is much higher in HIV/AIDS patients than in HIV negative patients. The postherpetic neuralgia is very frequent complication for both group (HIV positive and HIV negative) Herpes Zoster patients, but its duration longer in HIV/AIDS patients in comparison HIV negative group. There were no significant difference in disease severity, duration and complications among male and female patients.

Relationship of neurological manifestations, CD4+ lymphocyte count and plasma viral load in HIV infected patients.

The aim of the study was to assess the relationship between the neurological manifestations of HIV infection, CD4+ lymphocyte count and the levels of HIV-1 RNA (viral load) in plasma. A total of 62 adult antiretroviral naïve HIV infected patients were enrolled in the study. Among them 26 had neurological complications of HIV infection (1st group), 16 patients had symptomatic disease without neurological involvements (2nd group) and 20 were asymptomatic patients (control group). Measurement of CD4 count was performed by indirect immunofluorescent assay by using the monoclonal antibodies and viral load (VL) in plasma--by RT PCR method. CD4 count was significantly lower in the 1st and 2nd group compared to the control group. There was correlation between the level of CD4 count and type of neurological manifestation. VL was comparable between the 1st and 2nd groups and was higher than in control group. There is a significant correlation between the level of CD4 count and type of neurological manifestation of HIV infection. Presence of neurological complication as well as other clinical manifestations is associated with decreased CD4 count and increased VL. Level of CD4 count can serve as an indicator for initiation of prophylaxis treatment of certain opportunistic pathogens.