MOLECULAR TRACING OF HETEROSEXUAL HIV-1 TRANSMISSION IN GEORGIA.

HIV epidemic in Georgia has entered a new phase with number of heterosexually acquired infections rising each year. Epidemiological data indicates that this switch in epidemic trends is largely due to HIV positive male IDUs transmitting the virus to their female sexual partners. However, no genetic studies confirming linkage between IDUs and their sex partners were done in Georgia before. The objective of our study was to investigate molecular epidemiology of HIV-1 transmission events between heterosexual couples. Viral genotypes were obtained from plasma specimens of 36 heterosexual HIV-1 positive antiretroviral treatment (ART) naive persons representing 18 epidemiologically linked transmission events were genotyped and phylogenetic analyses were done on HIV pol sequences. HIV infection among all women was attributed to heterosexual transmission from their partners. None of 18 women had history of IDU. Fourteen pairs had subtype A virus, three - subtype B and one - subtype G viruses. Phylogenetic analysis confirmed the existing epidemiological link in 16 pairs with bootstrap values ranging from 88% to 100%. Of these 16 events, viruses from 14 pairs had genetic distance less than 0.015.Mutation A62V was seen in samples from 5 pairs, of them samples from 4 pairs additionally had V77I mutation. All 5 pairs were infected with the subtype Avirus. Women, who are sexual partners of IDUs or other men with high risk heterosexual behaviors, are at increased risk of HIV acquisition. HIV epidemic in Georgia has not spread to general population and remains concentrated around key populations at risk. Our work confirms that female sexual partners can serve as a bridge between key affected populations and general community, such as heterosexually active adults. Therefore, prevention efforts targeting key populations at risk and their sexual partners need to be expanded to avoid the spread of the infection within specific communities and beyond.

Distinct drug resistance profile of HIV-1 subtype A strain circulating in Georgia.

Emergence of HIV-1 drug resistance limits effectiveness of antiretroviral therapy (ART). Since 2004 Georgia provides free ART to all patients in need. We aimed to evaluate drug resistance patterns of Georgian HIV-1 variants among patients with virologic failure. Study included adult HIV-1 patients, who experienced virologic failure and were found to carry drug resistant strains based on genotypic resistance testing in 2005-2013. HIV-1 pol gene sequences were examined for the presence of resistance-associated mutations. Stanford HIV Sequence Database was used for interpretation of resistance data. A total 193 patients were included in the study. Among them majority (86.5%) carried subtype A virus and nearly 80% were on Efavirenz-based regimen. The most common nucleoside reverse transcriptase inhibitor (NRTI) mutation was M184V - 86.0% (n=166). The most frequent non-nucleoside reverse transcriptase inhibitor (NNRTI) mutation was G190S, found in 105 (54.4%) of samples. Other significant NNRTI mutations included K101E (31.6%, n=61), K103N (30.1%, n=58) and Y181CI (26.9%, n=52). The prevalence of G190S was 62.3% in subtype A viruses compared to 3.8% in non-A variants (p<0.0001). Frequency of K101E was also significantly higher in subtype A (36.5% vs. 0%, p<0.0001). ). In 69 samples G190S co-occurred with either K101E or Y181C or with both: 39 genotypes G190S/K101E; 10 genotypes G190S/Y181CI and 20 genotypes G190S/K101E/Y181CI. High prevalence of G190S and K101 mutations suggests subtype A specific response to currently approved first-line NNRTIs. Frequent co-occurrence of G190S with Y181C and K101E may limit the use of novel generation NNRTIs in subtype A infected patients with previous exposure to this drug class.

High seroprevalence of Chlamydia trachomatis in newly diagnosed human immunodeficiency virus patients in georgia.

Due to the shared routes of transmission, co-infection with Human Immunodeficiency Virus (HIV) and other sexually transmitted infections (STIs) is common. There is strong evidence of bidirectional interactions between HIV and ulcerative STIs. Recent studies have also shown importance of non-ulcerative inflammatory STIs in the acquisition of HIV. The incidence of HIV and Chlamydia in Georgia has risen every year. We explored the extent of the problem of co-infection with C. trachomatis in HIV patients in the country. Study included 234 consecutive patients diagnosed with HIV from September 2008 through May 2009. Of them, approximately two-thirds were male 162 (69.23%), up to 44% (102) of patients had more than one lifetime sexual partner and one fifth of patients reported prior history of STIs. The seroprevalence of C. trachomatis in our study was 23.93% (95% CI: 18.61%-29.92%). In multivariate analysis the strongest predictors of C. trachomatis infection were history of STI (PR 1.94, 95% CI: 1.22-3.07) and female gender (PR 1.79, 95% CI: 1.11-2.87), while younger age and not being in marriage showed borderline significance. Findings of our study have important public health and clinical implications. Data suggest that STIs may play important role in increasing heterosexual transmission of HIV in Georgia. Efforts should be made to expand HIV screening programs. Further research is needed to better understand the role of inflammatory STIs in spreading HIV.

HLA-B*5701 genetic screening prior to abacavir prescription in Georgia.

A hypersensitivity reaction to abacavir develops in approximately 2-8% of HIV patients receiving this drug and is strongly associated with presence of the human leukocyte antigen (HLA)-B*5701. Screening for HLA-B*5701 reduces the risk of developing an abacavir hypersensitivity reaction. The carriage rate of HLA-B*5701 has not been studied in Georgia before 2009. Objective of the study was to determine HLA-B*5701 prevalence in HIV-infected patients in Georgia. One hundred and sixty HIV positive patients attending Georgian Infectious Diseases, AIDS and Clinical Immunology Research Center in 2009 were recruited for the study. None of the patients had previously been treated with abacavir. Blood samples were collected and screened for HLA-B*5701 prior to abacavir prescription. Of 160 patients recruited 9 tested HLA B*5701 positive - 5.6% (95% CI: 2.6-10.4%). Of these nine patients 7 were males (male prevalence: 6.5%, 95% CI: 2.6-12.9 %) and 2 females (female prevalence: 4.8%, 95% CI: 0.6-16.2%). The first prospective study of HLA-B*5701 prevalence in Georgia show similar results to the results of other studies. Abacavir still remains one of the key drugs of antiretroviral regimens in Georgia and other countries. Therefore, prospective HLA-B*5701 screening should be implemented in all settings where abacavir is widely used to guide selection of ART regimens and to reduce the risk of potentially life threatening hypersensitivity reaction.

Antiretroviral treatment in Georgia.

HIV infection is the major public health, social and economic problem in Georgia. The aim of this study is to evaluate effectiveness of ARV treatment system in Georgia. Study included 1052 people living with HIV/AIDS in Georgia registered at Infectious Disease, AIDS and Clinical Immunology Research Center since 2004. To ensure universal access to ARV therapy all HIV/AIDS individuals included in the study were investigated by special algorithm, all identified patients requiring ARV therapy were offered treatment and monitored during therapy on treatment effectiveness and side effects. Detection of HIV antibodies was performed by ELISA with further confirmation by Western Blot Assay. HIV-1 RNA in plasma was measured by quantitative Polymerase Chain Reaction. For determination of percentages and absolute count of T lymphocyte subpopulations single-platform immunophenotyping technique using the Becton-Dickinson FACSCalibur flow cytometer was applied. For resistance testing TRUGENE HIV-1 Genotyping Kit with the OpenGene DNA Sequencing System (Siemens) was used. Treatment was offered to 595 HIV/AIDS patients. 594 patients started treatment, 1 patient refused. Out of treated 594 HIV/AIDS patients 22 patients discontinued, 111 patients died and 461 patients are currently on ARV treatment. Out of treated patients 406 adults and 21 children are receiving first-line treatment, 31 adults and 2 children are on second-line treatment and 1 adult is receiving salvage regimen. Treatment failure was defined in 55 cases. Among them immunological failure was observed in 7 cases, clinical failure in 1 case and virologic failure in 47 cases. Prevalence of drug resistance among virologic failure cases accounted for 72% and inadequate adherence for 28% cases. Majority of death cases among ARV treated patients was due to non-AIDS related or incurable conditions, while deaths due to AIDS related conditions mainly were associated to the delayed referral of patients in already advanced stage of disease. It's worth to mention that highest number of death cases was due to liver failure in HIV/HCV and/or HBV co-infected patients.

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.