Discrepancy between HCV structural and non structural genes in Georgian genotype two patients.

Correct identification of hepatitis C genotypes is an important diagnostic tool, which guarantees further selection of adequate treatment regimen and correct duration. Ideal approach for accurate genotyping is amplification of both structural and non structural parts of HCV genome. As different methods, which use either one or another region for HCV genotyping sometimes lead to indeterminate genotype and subtype results. Therefore, it is of importance to compare HCV genotyping results based on two different genomic regions. As part of this study, remnant 108 specimens, with previous history of successful genotype identification by 5'UTR/core Versant HCV genotyping kit, were retrospectively analyzed. "In house" HCV real time PCR based method that amplifies parts of NS5B region was used for this purpose. Based on our data, genotyping calls were concordant between genotype one and genotype three specimens group in both regions. However, discrepancy was evident among genotype 2 group. Of 25 specimens originally typed as genotype 2 in structural region, only 7 was confirmed in non structural region, remaining 18 specimens were typed as 1b. Therefore, the discordance rate between structural and non structural regions for genotyping call among genotype two was 72%. Our data showed highly discordant structural and non structural genome for genotype two identification in our specimens. We propose that this phenomenon might be due to the recombination event between genotype two and genotype one. Possible circulation of this strain in Georgia stresses the need for detailed sequencing and phylogenetic analyses of these specimens in both structural and non structural parts of HCV genome.

Occurrence of occult HCV infection among Hiv infected patients in Georgia.

Occult hepatitis C (OCI) infection has been known as detectable HCV-RNA in the liver or peripheral blood mononuclear cells (PBMCs) in the absence of detectable serum or plasma HCV-RNA. OCI has been detected among different patients groups worldwide, it has been found not only in chronic hepatitis patients of unknown origin, but also among several groups at risk for HCV infection (hemodialysis patients or family members of patients with occult HCV). This occult infection has been reported also in healthy populations without evidence of liver disease. Prevalence of occult Hepatitis C virus has not been investigated in Georgian population, where a rate of HCV infection is highest (6.7%) among Eastern European Countries. The aim of this study was to investigate the occurrence of occult HCV infection among HIV infected individuals in Georgia. As a pilot study, we have selected three groups of HIV infected patients for analyses: Group 1- HIV infected patients without evidence of liver disease (n=98), group 2- HIV infected patients with cryptogenic liver disease (n=34) and group 3- HIV/HBV co infected patients (n=29). HCV RNA was tested in PBMCs samples by real-time polymerase chain reaction. HCV genotyping was performed by Line-probe assay based on reverse-hybridization technology. Liver fibrosis was evaluated by transient elastography (FibroScan®). HCV-RNA was detected in PBMCs specimens among 2 (2%) subjects from group 1, 4 (12%) subjects from group 2, and 9 (31%) subjects from group 3. HCV genotypes were determined for 14 of 15 OCI subjects resulting following genotype distribution: 6 (46%) - 1b, 3 (23%) - 2a/2c and 5 (38%) - 3a. One samples failed to be genotyped due to extremely low HCV viral load. Our data revealed the occurrence of occult HCV infection in HIV infected patients. No single HCV genotype was predominant in the present study. Liver fibrosis was found more frequently and the fibrosis score was significantly higher in OCI patients versus negative ones, suggesting that undiagnosed OCI might impact on the liver damage. The study demonstrated that testing only for HCV antibody fails to identify the true prevalence of HCV co-infection among HIV infected patients. We propose that in the absence of liver biopsy specimens, analysis of PBMC sample for HCV-RNA would be informative for detection of occult HCV.

Safety and efficacy of systematic administration of Filgrastim to prevent neutropenia and infections in patient with hepatitis C.

The aim of 36 months follow up study was to assess the safety and efficacy of Filgrastim (Neupogen) for preventing neutropenia and bacterial infection during combination therapy of chronic HCV infection with pegilated interferon alfa and ribavirin. Study enrolled 64 patients with chronic active hepatitis C, aged 20-65. Among them 49 were male and 15 female). Among 64 patients: 5 patients had HCV genotype 1a, 24 patients HCV genotype 1b, 17 patients HCV genotype 2a/2c and 18 patients HCV genotype 3a. Treatment regimen for chronic hepatitis C patients was as follows: Pegylated interferon alfa 2a (Pegasys) 180 micro kg or alfa 2b (PegIntron) 1,5 micro g/kg. and ribavirin (RBV). RBV daily dose was adjusted by body weight- 1000/1200 mg. Treatment duration was 48 weeks for HCV genotype 1 patient and 24 weeks for HCV non 1 genotype accordingly. The patients were divided into two groups: 29 patients (1st group) besides combination antiviral therapy (pegilated interferon alfa plus ribavirin) systematically received Filgrastim and other 35 patients (2nd group) - same antiviral therapy without administration of Filgrastim. Selection of patients was performed by computerized randomization method. HCV antibodies were detected by ELISA and RIBA. HCV RNA by Real time PCR. HCV genotype- by Inno-Lipa. Among 2nd group 35 patients (without Filgrastim administration) during antiviral therapy 8 patients (22.8%) developed different bacterial infections.(3 patients- urinary tract infection, 2 patients- pneumonia, 1 patient- bronchitis, 1 patients - sinusitis and 1 patient-gingivitis/stomatitis). 7 patients required interferon dose modification (dose reduction) and in 5 patients treatment stopped due to severe neutropenia. Among 1st group patients (with filgrastim administration) only one patient developed bacterial infection (urinary tract infection). None of patients, due to neutropenia, required neither stoppage of therapy, nor interferon dose reduction. The quality of life of 1st group patients was better in comparison of 2nd group patients. Filgrastim was safe and effective for prevention neutropenia and bacterial infections in Hepatitis C patients with Peg-INF/RBV combination antiviral therapy. Filgrastim was well tolerated by patients. It gives possibility to maintain interferon dose during treatment period and significantly improves the patient's quality of live.

Prevailing HCV genotypes and subtypes among hiv infected patients in Georgia.

Recent analysis of antiretroviral treatment (ART) program data in Georgia showed that end-stage liver disease was a leading cause of death among HIV/HCV co infected patients in 2005. The objective of this retrospective study was to study prevailing genotypes and subtypes of HCV virus in a cohort of HIV infected patients. The investigation revealed that of 1490 patients, 879 (59%) were hepatitis C antibody positive. Detectable HCV RNA was found among 91% of patients. Median liver HCV RNA level was higher than among mono-infected patients. The most prevalent genotypes were genotype 1 (41.6%), followed by genotype 3 (34.7%) and genotype 2 (17.6%), inter (mix) genotype recombinants were found among 5.8 % of patients. The genotype distribution in our study is slightly different from what was seen in Georgia in 2000. The differences of prevailing HCV genotypes among general population and HIV co infected group was probably attributed to the different methods for sample selection used within our study or possible influence of diverse transmission networks among HIV infected group. Another explanation can be the possible shift from predominance of genotype 1 to non 1 genotypes. The higher number intergenotype recombinant forms might be the result of continues parenteral exposure to different HCV genotypes during drug injection paraphernalia. Our study demonstrated high prevalence of HCV infection among HIV-infected patients and revealed 1b as predominant genotype. IDUs were less likely to spontaneously clear the virus than homosexual man and heterosexually infected woman. A greater HCV RNA levels were associated with a greater chance to be infected with HCV genotypes 1. Possible shift from predominance of genotype 1 to non 1 genotypes can be of option. This shift may have a major and beneficial impact on treatment schedules and costs. The higher number intergenotype recombinant forms might be the results of continues parenteral exposure to different HCV genotypes during drug injection paraphernalia. Study results highlights and strengthens the need for careful follow-up of HCV/HIV co infected patients, effective management and therapies against HCV in order to reduce liver related death rates in patients on ART.

Neurological complications in patients with HIV/AIDS.

The aim of the study was to determine the prevalence of HIV-related neurological disorders in HIV positive patients and its relationship to CD4 cell counts in Georgia. This study included 388 HIV/AIDS patients (302 men and 86 women), who have been admitted to the in-patient Department of Infectious Diseases, AIDS and Clinical Immunology Research Center (IDACIRC) of Georgia since 2006. Diagnosis of neurological disorders was made based on clinical symptoms and instrumental-laboratory investigations. CNS Neurological complications were detected in 76 patients; 13 patients had two or more neurological complications. Tuberculosis meningitis were the most common neurological disorders 26 (34%), followed by CNS toxoplasmosis 17 (22%), cryptococcal meningitis 11 (15%), presumed CMV encephalitis 5 (7%), PML 4 (5%), primary CNS lymphoma 4 (5%) and bacterial meningitis 3 (4%). AIDS related dementia was detected in 18 patients (24%). The median CD4+ T lymphocyte count was 47 cells/mm(3) (range: 2-183 cells/mm(3)) in HIV patients with neurological complications. There was correlation between the CD4 T lymphocyte count and type of neurological manifestation. Namely, in the patients with HIV related dementia median CD4 T lymphocyte count was 164 cells/mm(3), in the patients with CNS toxoplasmosis median CD4 count was 83 cells/mm(3), in the patients with cryptococcal meningitis median CD4 T lymphocyte count was 34 cells/mm(3) and in the patients with CMV encephalitis median CD4 T lymphocyte count was 26 cells/mm(3). Some neurological disorders such as TB meningitis and bacterial meningitis can occur at any CD4 level. PML and primary CNS lymphoma occurred when CD4 T lymphocyte count < 50 cells/mm(3). The most common clinical manifestations of neurological disorders in HIV infected patients were headache (91%), fever (75%), focal neurological deficits (61%), speech disturbances (42%), cognitive dysfunction (41%), visual disturbances (36%), impaired coordination (29%) and seizures (15%). The study provide convincing evidence that neurological disorders with HIV infection might serve as an indicator for advanced HIV infection, immunosuppression and decreased CD4 cell counts. Our data have shown correlation between the type of neurological manifestations of HIV infection and CD4 T lymphocyte count.

Prevalence of hepatitis B and C among HIV positive patients in Georgia and its associated risk factors.

The aim of the study was to determine the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) co-infection among HIV positive patients, to identify most relevant risk factors of co-infection and develop preventive interventions. Study participants were voluntary individuals 18 years of age or older recruited from AIDS Center VCT unit in Tbilisi, Georgia. Eligibility criteria of participants were: HIV positive result confirmed by western blot; age; and voluntary participation. Total 175 patients undergo interview with specially designed questionnaires. Most of the participants were male (71.4%), age range of HIV positives varied from 20 to 77 years old. Prevalence of HCV among HIV positive patients is high. Almost half (48.57%) HIV positive patients are co-infected with HCV. Men were more likely than women co-infected with HCV (60.80% and 18% accordingly). Major risk factor of male co-infection was related to drug use, needle and injection equipment sharing. Prevalence of HCV among injecting drug users was (73.40%). Drug users had 3.25 times more risk (PR 3.25; 95%CI; CL--1.89-5.26; p<0.01) to be infected with HCV compare non IDUs. Prevalence of being infected with HBV (Anti-HBc) among HIV positives was 43.42% (76/175) and the prevalence of Chronic HBV (HBsAg positive) was 6.86% (12/175). Prevalence rate of HBsAg among IDUs was 8.51% and among non IDU participants 5.26%. Triple infection (HIV, Hepatitis C and chronic form of Hepatitis B--HBsAg) was among 9 patients (5.14%). Infections were associated with injection drug use (88.88%) and mostly were related to share of needles/syringes and other injecting medical equipment. Transmission of HBV and HCV by sexual contact was not observed among those 9 participants. High risk behavior among HIV positive participants mostly related to drug use and unprotected sex with non regular partners. Other risk factors for Hepatitis transmission were associated with invasive medical manipulations, blood transfusion, surgery, abortions and etc. None of cases of HIV, or Hepatitis (B, C) transmission through medical manipulations can be documentary proved based on those research data.

Overview of HIV epidemiological situation in Georgia.

Georgia still belongs to low HIV epidemic countries and by December 1st, 2008 there are 1825 HIV/AIDS cases registered at the IDACIRC with estimated number 3500 (estimated prevalence 0.09%). Majority of HIV/AIDS patients are male (75%). Four hundred and sixty one patients are under the Antiretroviral (ARV) treatment, including 23 children. Despite of HIV low prevalence, Georgia is considered to be at risk for an imminent epidemic spread of HIV mainly due to wide spread drug use with high risk practices (needle-sharing) and high rate of STIs. The major route of HIV transmission is associated with IDU. At the moment approximately 60% of all reported HIV cases are due to drug injection. However over the last several years heterosexual route of transmission is gaining importance, and increased from 29.1% to 36.1% for last five years. First significant increase of HIV incidence rate was observed from 1999 to 2000 (2.24 times) and 2003 to 2004. From 2004 stabile, but slight increase of incidence rate is presented. Most HIV positive patients are diagnosed at the age from 25 to 45. The highest HIV prevalence rates are found in Western Georgia, particularly Black Sea coast regions--Megrelia and Adjara (with prevalence of 131.11 and 132.03 among adult HIV cases per 100,000 adult population). Enlarging educational activities, prevention interventions, better financing of HIV programs and improvement of capacity building will help the country to keep HIV epidemic in a low prevalence and give country possibility to achieve "Universal Access to HIV Prevention, Treatment, Care and Support" for 2010 year.

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.