Long term follow-up of uterine fibroids treated with microwave ablation: an up to 3-year observational study of volume, regrowth, and symptoms.

OBJECTIVE: To study long-term effects in patients treated with microwave ablation (MWA) for symptomatic uterine fibroids and investigate fibroid characteristics predictive of successful treatment. METHOD: Women who received MWA treatment for uterine fibroids in a previous study were included. A total of 16 patients underwent contrast enhanced MRI before treatment, postoperatively at 6 months and at long-term follow-up, to assess volumes of treated fibroids (n = 42). Long-term MRI was performed between 16 and 36 months after treatment [median 22 months, interquartile range (IQR) 18.5-27]. Validated questionnaires for evaluation of uterine fibroid symptoms and menstrual bleeding (UFS-QoL and PBAC) were used to assess long-term effects on symptoms. The degree of shrinkage was correlated to vascularization and T2 signal intensity (SI) at preoperative MRI and location of fibroids according to the FIGO classification, using the Mann-Whitney U test. RESULTS: Most patients (82%) reported improvement up to 3 years after treatment. Out of 42 treated fibroids, 35 (83%) continued to shrink over time with median relative volume reduction of 77% (IQR 39-95). For eight fibroids (19%) which showed low vascularization on the pretreatment MRI, there was less shrinkage compared to well-vascularized fibroids (p = 0.01). Most fibroids (79%) showed iso- to hyperintense T2 signal on preoperative MRI and showed a higher grade of shrinkage than hypointense fibroids (p = 0.02). CONCLUSION: After microwave treatment improvement is maintained for most patients up to 36 months and most fibroids showed continuous shrinkage. Preoperative vascularization, high T2 SI and submucosal location predicted continuous volume reduction. However, to confirm this, larger studies are needed.

Ultrasound guided microwave ablation compared to uterine artery embolization treatment for uterine fibroids - a randomized controlled trial.

OBJECTIVE: To evaluate the efficacy, feasibility and acceptability of microwave ablation (MWA) compared to uterine artery embolization (UAE) as treatment for uterine fibroids. METHOD: A randomized controlled superiority trial, including premenopausal women 30-55 years, with symptomatic uterine fibroids without any single fibroid exceeding mean diameter of eight centimeters. Patients were randomized to receive microwave ablation, performed abdominally or vaginally, or to uterine artery embolization. The primary outcome was volume difference of the three largest fibroids at 6 months post treatment evaluated by magnetic resonance imaging (MRI) by a blinded radiologist analyzed by Mann-Whitney U-test. Secondary outcomes included symptom severity score (SSS), health related quality of life (HR-QoL), amount of menstrual bleeding, postoperative pain, length of hospitalization, need for additional treatment, adverse events and if patients would recommend the treatment to a friend. RESULTS: Patients were recruited from 30 January 2017 to 12 September 2019, with a total of 17 patients treated in each group from May 2017 to December 2019. Superiority of MWA could not be established. The volume reduction was 41.8% (Interquartile range, IQR, 14-63) in the MWA group compared to 62.2% (IQR 34.9-80.1) in the UAE group (p = 0.29). Effects on symptoms, HR-QoL and acceptability did not differ between groups. Days of hospitalization and sick leave were significantly fewer in the MWA group (p < 0.001 and p = 0.001). CONCLUSIONS: Although superiority of MWA could not be established, it is a promising technique for treating uterine fibroids. It was well tolerated and associated with lower use of health care resources. Trial registration: NCT02942537, www.clincialtrials.gov.

Investigating the loss of work productivity due to symptomatic leiomyoma.

INTRODUCTION: Leiomyoma affects up to 50% of fertile women, leading to morbidity such as bleeding or pain. The effect of symptomatic leiomyoma on the productivity of employed women is understudied. The present study investigates productivity loss in a Swedish setting in women with symptomatic leiomyoma compared to healthy women. MATERIAL AND METHODS: Women seeking care for leiomyoma and heavy menstrual bleeding (HMB) were recruited at nine Swedish sites. Healthy controls with self-perceived mild to normal menstruation were recruited at routine visits. Cases and controls were employed without option to work from home. After recruitment, all women reported the work productivity and activity impairment (WPAI) questionnaire, the pictorial blood assessment chart (PBAC) and pain on the visual analog scale (VAS). RESULTS: Women with symptomatic leiomyoma (n = 88) missed more working time during menses compared to asymptomatic controls (n = 34): 7.6 vs 0.2% p = 0.003. The proportion of impairment while working was also significantly higher in women with symptomatic leiomyoma (43.8 vs 12.1% p<0.001). Moreover, cases reported greater activity impairment outside office hours (43.9 vs 12.1%, p<0.001). Among healthy controls, 69.5% reported symptoms of HMB (PBAC>100). CONCLUSIONS: Symptomatic leiomyoma leads to loss of working hours as well as loss of productivity during working hours, and affects women in other daily activities. Increased awareness of the impact of leiomyomas on women's lives is needed, and timely and appropriate management of the symptomatic leiomyomas could improve work productivity and quality of life.

The vaginal microbiome amplifies sex hormone-associated cyclic changes in cervicovaginal inflammation and epithelial barrier disruption.

PROBLEM: Susceptibility to HIV is associated with the menstrual cycle and vaginal microbiome, but their collective impact on vaginal inflammation remains unclear. Here, we characterized the cervicovaginal proteome, inflammation, and microbiome community structure and function during the menstrual cycle. METHOD OF STUDY: Cervicovaginal secretions were collected from regularly cycling women (n = 16) at median day 10, 16, and 24 of each menstrual cycle and analyzed by mass spectrometry, 16S rRNA gene sequencing, and a multiplex bead array immunoassay. Follicular, ovulatory, and luteal phases were defined by serum sex hormone levels. RESULTS: Ovulation showed the largest mucosal proteome changes, where 30% and 19% of the 406 human proteins identified differed compared to the luteal and follicular phases, respectively. Neutrophil/leukocyte migration pathways were lowest during ovulation and peaked in the luteal phase, while antimicrobial and epithelial barrier promoting proteins were highest during ovulation. Vaginal microbial community structure and function did not vary significantly during the menstrual cycle, with the majority consistently Lactobacillus-dominant (63%) or non-Lactobacillus-dominant (25%). Fluctuations in the epithelial barrier protein RPTN between the ovulatory and luteal phase were amplified in women with Gardnerella vaginalis and anaerobic bacteria and reduced when Lactobacillus was dominant. CONCLUSION: This small study demonstrates that sex hormones modulate neutrophil/leukocyte inflammation, barrier function, and antimicrobial pathways in the female genital tract with the strongest changes occurring during ovulation. The data further suggest a microbiome context for hormone-driven changes in vaginal immunity which may have implications for HIV susceptibility.

A comparative proteomic analysis of the soluble immune factor environment of rectal and oral mucosa.

OBJECTIVE: Sexual transmission of HIV occurs across a mucosal surface, which contains many soluble immune factors important for HIV immunity. Although the composition of mucosal fluids in the vaginal and oral compartments has been studied extensively, the knowledge of the expression of these factors in the rectal mucosa has been understudied and is very limited. This has particular relevance given that the highest rates of HIV acquisition occur via the rectal tract. To further our understanding of rectal mucosa, this study uses a proteomics approach to characterize immune factor components of rectal fluid, using saliva as a comparison, and evaluates its antiviral activity against HIV. METHODS: Paired salivary fluid (n = 10) and rectal lavage fluid (n = 10) samples were collected from healthy, HIV seronegative individuals. Samples were analyzed by label-free tandem mass spectrometry to comprehensively identify and quantify mucosal immune protein abundance differences between saliva and rectal fluids. The HIV inhibitory capacity of these fluids was further assessed using a TZM-bl reporter cell line. RESULTS: Of the 315 proteins identified in rectal lavage fluid, 72 had known immune functions, many of which have described anti-HIV activity, including cathelicidin, serpins, cystatins and antileukoproteinase. The majority of immune factors were similarly expressed between fluids, with only 21 differentially abundant (p<0.05, multiple comparison corrected). Notably, rectal mucosa had a high abundance of mucosal immunoglobulins and antiproteases relative to saliva, Rectal lavage limited HIV infection by 40-50% in vitro (p<0.05), which is lower than the potent anti-HIV effect of oral mucosal fluid (70-80% inhibition, p<0.005). CONCLUSIONS: This study reveals that rectal mucosa contains many innate immune factors important for host immunity to HIV and can limit viral replication in vitro. This indicates an important role for this fluid as the first line of defense against HIV.

Broad and potent cellular and humoral immune responses after a second late HIV-modified vaccinia virus ankara vaccination in HIV-DNA-primed and HIV-modified vaccinia virus Ankara-boosted Swedish vaccinees.

We have previously shown that an HIV vaccine regimen including three HIV-DNA immunizations and a single HIV-modified vaccinia virus Ankara (MVA) boost was safe and highly immunogenic in Swedish volunteers. A median 38 months after the first HIV-MVA vaccination, 24 volunteers received 10(8) plaque-forming units of HIV-MVA. The vaccine was well tolerated. Two weeks after this HIV-MVA vaccination, 18 (82%) of 22 evaluable vaccinees were interferon (IFN)-γ enzyme-linked immunospot (ELISpot) reactive: 18 to Gag and 10 (45%) to Env. A median minimal epitope count of 4 to Gag or Env was found in a subset of 10 vaccinees. Intracellular cytokine staining revealed CD4(+) and/or CD8(+) T cell responses in 23 (95%) of 24 vaccinees, 19 to Gag and 19 to Env. The frequency of HIV-specific CD4(+) and CD8(+) T cell responses was equally high (75%). A high proportion of CD4(+) and CD8(+) T cell responses to Gag was polyfunctional with production of three or more cytokines (40% and 60%, respectively). Of the Env-specific CD4(+) T cells 40% were polyfunctional. Strong lymphoproliferative responses to Aldrithiol-2 (AT-2)-treated subtype A, B, C, and A_E virus were demonstrable in 21 (95%) of 22 vaccinees. All vaccinees developed binding antibodies to Env and Gag. Neutralizing antibodies were detected in a peripheral blood mononuclear cell (PBMC)-based assay against subtype B and CRF01_AE viruses. The neutralizing antibody response rates were influenced by the vaccine dose and/or mode of delivery used at the previous HIV-MVA vaccination. Thus, a second late HIV-MVA boost induced strong and broad cellular immune responses and improved antibody responses. The data support further exploration of this vaccine concept.

Feasibility and safety of cervical biopsy sampling for mucosal immune studies in female sex workers from Nairobi, Kenya.

BACKGROUND: There is an urgent need to improve our understanding of the mucosal immuno-pathogenesis of HIV acquisition in the female genital tract, particularly in high-risk women such as female sex workers (FSWs). Cervical biopsy samples offer technical advantages over cytobrush sampling, but there are concerns that this might increase HIV acquisition, particularly if healing is slow and/or women do not abstain from sex during healing. METHODOLOGY/PRINCIPAL FINDINGS: Cervical biopsy samples and cervico-vaginal swabs for co-infection diagnostics, prostate specific antigen (PSA) and immune studies were collected from 59 women, including HIV seropositive and HIV-exposed seronegative (HESN) FSWs as well as lower risk women from Nairobi, Kenya. A clinical-demographic questionnaire was administered and women were instructed to avoid sexual intercourse, douching and the insertion of tampons for 14 days. All participants underwent a repeat exam to assess healing within the 14 days, and had HIV diagnostics at six months. Cervical sampling was well tolerated, and 82% of participants had healed macroscopically by 5 days. Both self-report and PSA screening suggested high levels of compliance with pre- and post-procedure abstinence. Delayed healing was associated with vulvovaginal candidiasis (VVC) and HESN status. At six-month follow up all low-risk and HESN participants remained HIV seronegative. CONCLUSION: Cervical biopsy sampling is a safe and well-tolerated method to obtain cervical biopsies in this context, particularly if participants with VVC are excluded. As healing could be delayed up to 11 days, it is important to support (both financially and with rigorous counseling) a period of post-procedure abstinence to minimize HIV risk.

Salivary basic proline-rich proteins are elevated in HIV-exposed seronegative men who have sex with men.

OBJECTIVE: Innate mucosal factors are associated with protection in HIV-exposed seronegative (HESN) individuals, but studies of MSM have been very limited. We performed proteomic analysis of saliva from a cohort of HESN MSM who have regular unprotected oral receptive intercourse with their HIV-infected partner. METHODS: Saliva samples from HESN (n = 25) and non-exposed male controls (n = 22) were analyzed by 2D-LC mass spectrometry. An overexpressed innate protein factor was further characterized by immunoblot, and compared with CC-chemokine expression, HIV-neutralizing activity, clinical factors, and sexual behavior. RESULTS: Of 337 total proteins, seven were identified as differentially abundant in the HESN group. The five overabundant proteins (Basic salivary proline-rich proteins (bPRP) 2 and 3, Histatin-3, Lysozyme C, and SLPI) have known antimicrobial activity. bPRP2 showed the highest overabundance (>six-fold) in HESN individuals compared with controls (P = 0.009), including multiple isoforms. Salivary bPRP2 correlated with CC-chemokine levels in HESN individuals including RANTES (P = 0.02), MIP-1-alpha (P = 0.01), MIP-1-beta (P = 0.0002), MCP-1 (P = 0.005) and Eotaxin (P = 0.003) but not with frequency of HIV neutralizing activity, oral sexual practices, or viral load of the sexual partner. CONCLUSION: This study identifies salivary bPRP2 as a novel soluble factor elevated in the oral compartment of HIV-exposed MSM.

HIV-1 exposed uninfected men who have sex with men have increased levels of salivary CC-chemokines associated with sexual behavior.

OBJECTIVES: To determine whether soluble molecules with known anti-HIV-1 activity are increased in saliva of HIV-1 exposed uninfected individuals of discordant couples of men who have sex with men (MSM), and whether the levels of these molecules are associated with genetic polymorphisms, sexual behavior and/or HIV-1 neutralizing capacity. METHODS: Saliva and PBMC were collected from exposed uninfected individuals (n=25), and low-risk controls (n=22). Levels of CCL2, CCL3, CCL4, CCL5 and CCL11 were detected by Luminex, and SLPI, LL-37, alpha-defensins and IgA2 were detected by ELISA. Single nucleotide polymorphisms (SNPs) were investigated using mass spectrometry or PCR-sequencing. HIV-1 neutralizing activity was assessed using PBMCbased neutralization assays. Self-reported questionnaires described sexual behavior. RESULTS: Exposed uninfected individuals had significantly higher levels of salivary CCL2, CCL4, CCL5 and CCL11 as compared with controls although genetic polymorphisms within the corresponding regions were equally distributed. IgA2 was also increased in exposed uninfected individuals, whereas neither CCL3, SLPI, LL-37 nor alpha-defensins differed between exposed uninfected individuals and controls. The HIV-1 neutralizing capacity of saliva was associated with higher levels of CC-chemokines (but not SLPI, LL-37, alpha-defensins or IgA2) in both exposed uninfected individuals and controls. The increased levels of CC-chemokines were associated with a higher frequency of unprotected oral sex and/or additional casual sex partners. CONCLUSION: HIV-1 exposed uninfected MSM had higher levels of salivary CC-chemokines compared with controls, this finding associated with sexual behavior rather than with genetic polymorphisms. The increased levels of CC-chemokines associated with HIV-1 neutralizing capacity in saliva.

Induction of systemic HIV-1-specific cellular immune responses by oral exposure in the uninfected partner of discordant couples.

OBJECTIVES: Previous studies have identified HIV-specific T-cell responses in HIV-exposed uninfected individuals (EUI). However, so far no study has investigated exposure through oral sex. Our aim was to investigate whether oral exposure is enough to induce a systemic HIV-specific T-cell response. DESIGN: Peripheral blood mononuclear cells were collected from 25 EUI living with a HIV-positive partner. Sexual behavior was described by the EUI in self-reported questionnaires. All clinical data of the infected partners were well documented. METHODS: Peripheral blood mononuclear cells were stimulated with five different HIV peptide pools and HIV-specific T-cell responses were detected using the interferon-[gamma] enzyme-linked immunospot assay. Multiple cytokine production was studied longitudinally using flow cytometry intracellular cytokine assay. RESULTS: The majority of the discordant couples reported having protected anal intercourse but unprotected oral sex. Three of the 23 tested EUI with evaluable results had HIV-Gag or Nef-specific T-cell responses. Two of the responders reported unprotected oral sex as the only route of exposure. The HIV-specific CD4+ and CD8+ T cells in the Gag-responder showed production of multiple cytokines. The magnitude of the responses decreased over time when the level of exposure, determined by the viral load in the partner, declined. CONCLUSION: HIV exposure through oral sex is sufficient to induce systemic HIV-specific CD4+ and CD8+ T-cell immune responses in some uninfected individuals. Further investigation is needed to determine whether these responses have any protective role against HIV infection, or are merely evidence of exposure.

Orally exposed uninfected individuals have systemic anti-HIV responses associating with partners' viral load.

OBJECTIVES: To determine whether oral HIV-1 exposure incites a persistent systemic anti-HIV-1 response in exposed uninfected individuals of discordant couples of men who have sex with men, and whether this response associates with HIV-1 exposure measured by viral load in the HIV-positive partners. METHODS: Plasma were collected from exposed uninfected individuals (n = 25), HIV-positive partners (n = 25) and low-risk controls (n = 22). A peripheral blood mononuclear cells-based neutralization assay was used to test these samples against three primary HIV-1 isolates. Self-reported questionnaires described routes of HIV-1-exposure, and clinical records documented viral loads in HIV-positive partners. RESULTS: At enrollment, plasma samples from seven of 25 exposed uninfected individuals neutralized at least two of the three HIV-1 isolates. No samples from the 22 controls neutralized any HIV-1 isolate (P = 0.01). Of these seven exposed uninfected individuals, six retained neutralization capacity during follow-up. Neutralization capacity among exposed uninfected individuals associated with the highest measured viral load of their respective partners (P = 0.01) and also time since highest viral load (P = 0.02). Purified plasma immunoglobulin (Ig) A1-mediated neutralization was observed in six of the seven samples, whereas none of the IgA1-depleted plasma samples neutralized HIV-1. The neutralizing IgA1 was not HIV envelope specific as detected by ELISA and western blot. CONCLUSION: Orally exposed uninfected men who have sex with men can mount neutralizing anti HIV-1 activity in plasma, mediated primarily by non-HIV envelope-specific IgA1. Neutralization was associated with previous measured highest viral load in the HIV-positive partner, as well as time elapsed since the peak viral load. Neutralization also persisted over time in spite of a continuous low viral exposure.

Genital and oral mucosal immune response against HIV-1 in exposed uninfected individuals.

Epidemiologic reports routinely indicate that the high rate of HIV-1 transmission via mucosal exposure has been relatively stable since the epidemic began. Unfortunately, research on mucosal immune responses to HIV-1 has not been done in proportion to its importance. Most knowledge about immune responses against HIV-1 in humans comes from studies limited to the use of peripheral blood cells and plasma. Consequently, T-cell-based HIV-1 vaccines have long been considered a primary end point of preventive therapeutic strategies. The interest in HIV-1 exposed uninfected individuals has intensified because of the lessons to be learned about a natural immunologic response that promotes opposition to the infection. Such information has useful applications in the clinical setting. This review describes the current status of research on mucosal immune responses to HIV-1 from examining mucosal fluids and tissues of sexually exposed uninfected adults.

Oral HIV-exposure elicits mucosal HIV-neutralizing antibodies in uninfected men who have sex with men.

OBJECTIVE: To determine whether oral sexual exposure to HIV-1 (HIV) results in HIV-neutralizing activity in saliva of uninfected men who have sex with infected men? DESIGN: Saliva samples were collected from HIV IgG seronegative men (n = 25) whose male partners were HIV infected and from low-risk healthy controls (n = 22) and analyzed for HIV-neutralizing capacity. METHODS: The presence of neutralizing activity in saliva was tested in a peripheral blood mononuclear cell-based assay using primary HIV isolates. Self-reporting questionnaires described the individuals' sexual behaviors and routes of possible HIV exposure. RESULTS: Of 25 exposed, uninfected individuals (EUI), 21 reported receptive unprotected oral intercourse, whereas three of the 25 reported unprotected anal receptive intercourse. Whole saliva from both EUI and low-risk healthy controls contained HIV-neutralizing activity. However, a significant difference was seen when analyzing the salivary IgA1 fraction: 13 of 25 EUI neutralized HIV, whereas none of the 22 controls had this capacity. The neutralizing capacity of the EUI males persisted during 2 years of follow-up. CONCLUSION: Unprotected oral sex evokes a salivary IgA1-mediated HIV-neutralizing response that persists over time during continuous exposure in uninfected male partners of infected men.

HIV-neutralizing immunoglobulin A and HIV-specific proliferation are independently associated with reduced HIV acquisition in Kenyan sex workers.

OBJECTIVES: HIV-neutralizing immunoglobulin A (IgA) and HIV-specific cellular immunity have been described in highly exposed, persistently seronegative (HEPS) individuals, but well controlled studies have not been performed. We performed a prospective, nested case-control study to examine the association of genital IgA and systemic cellular immune responses with subsequent HIV acquisition in high-risk Kenyan female sex workers (FSWs). DESIGN AND METHODS: A randomized trial of monthly antibiotic prophylaxis to prevent sexually transmitted disease/HIV infection was performed from 1998 to 2002 in HIV-uninfected Kenyan FSWs. After the completion of trial, FSWs who had acquired HIV (cases) were matched 1: 4 with persistently uninfected controls based on study arm, duration of HIV-seronegative follow-up, and time of cohort enrolment. Blinded investigators assayed the ability at enrolment of genital IgA to neutralize primary HIV isolates as well as systemic HIV-specific cellular IFNgamma-modified enzyme-linked immunospot and proliferative responses. RESULTS: The study cohort comprised 113 FSWs: 24 cases who acquired HIV and 89 matched controls. Genital HIV-neutralizing IgA was associated with reduced HIV acquisition (P = 0.003), as was HIV-specific proliferation (P = 0.002), and these associations were additive. HIV-specific IFNgamma production did not differ between case and control groups. In multivariable analysis, HIV-neutralizing IgA and HIV-specific proliferation each remained independently associated with lack of HIV acquisition. Genital herpes (HSV2) was associated with increased HIV risk and with reduced detection of HIV-neutralizing IgA. CONCLUSION: Genital HIV-neutralizing IgA and systemic HIV-specific proliferative responses, assayed by blinded investigators, were prospectively associated with HIV nonacquisition. The induction of these immune responses may be an important goal for HIV vaccines.

HIV-1 neutralizing activity is correlated with increased levels of chemokines in saliva of HIV-1-exposed uninfected individuals.

AIM: Mucosal HIV-1 exposure stimulates a variety of mucosal immune responses, including IgA1-mediated virus neutralization, even in the absence of an established infection. We hypothesized that other immune molecules might also contribute to the HIV-1 neutralizing activity observed in the mucosal secretions of HIV-1 exposed uninfected individuals. METHODS: Saliva samples were collected from HIV-1 seronegative high-risk female sex workers (FSW) from Nairobi. Samples were also collected from HIV-1 IgG positive FSW and HIV-1 IgG negative low-risk women from the same geographical area. In all samples, IgA2, secretory leukocyte protease inhibitor (SLPI), regulated on activation, normal T-cell expressed and secreted (RANTES), macrophage inflammatory protein 1 alpha and beta (MIP-1alpha and -beta) and monocyte chemoattractant protein-1 (MCP-1) were quantified. The IgA1-depleted saliva samples were subsequently tested for neutralizing capacity in a PBMC-based neutralization assay using a primary HIV-1 clade A isolate to determine biological relevance of the measured molecules. RESULTS: HIV-1 specific neutralization was present in the IgA1-depleted fraction from saliva of both HIV-1 seropositive (9 of 10) and high-risk individuals (36 of 45) but not in HIV-1 IgG-negative control subjects (0 of 8). In the high-risk individuals, higher levels of CC-chemokines were seen in those that could neutralize HIV-1 as compared with those that could not (P<0.05). CONCLUSION: The HIV-1 neutralizing activity in saliva of HIV-1-exposed high-risk individuals is not only mediated by IgA1, but is also present in IgA1-depleted fractions and is associated with increased levels of CC-chemokines. Such innate immune factors may be important in limiting HIV-1 mucosal transmission.