Role of the laboratory in ensuring global access to ARV treatment for HIV-infected children: consensus statement on the performance of laboratory assays for early infant diagnosis.

A two day meeting hosted by the World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC) was held in May 2006 in Entebbe, Uganda to review the laboratory performance of virologic molecular methods, particularly the Roche Amplicor DNA PCR version 1.5 assay, in the diagnosis of HIV-1 infection in infants. The meeting was attended by approximately 60 participants from 17 countries. Data on the performance and limitations of the HIV-1 DNA PCR assay from 9 African countries with high-burdens of HIV/AIDS were shared with respect to different settings and HIV- subtypes. A consensus statement on the use of the assay for early infant diagnosis was developed and areas of needed operational research were identified. In addition, consensus was reached on the usefulness of dried blood spot (DBS) specimens in childhood as a means for ensuring greater accessibility to serologic and virologic HIV testing for the paediatric population.

Drosophila AP-1: lessons from an invertebrate.

In recent years, studies in the model organism Drosophila melanogaster have contributed significant insights into the molecular and developmental biology of the AP-1 transcription factors Jun and Fos. Powerful genetic and biochemical approaches uncovered a baffling complexity and variability of the signaling connections to and from AP-1. The range of biological processes that Jun and Fos regulate in this organism is equally multi-faceted. Regulatory interactions between AP-1 and JNK, ERK, TGFbeta, Notch or other signaling systems have been implicated in the control of a multitude of embryonic and adult events, including tissue closure processes, patterning of eye, gut and wing, as well as apoptosis. Here we review the information that has been gathered on Drosophila AP-1 in signal transduction and on the developmental and cellular functions controlled by AP-1-mediated signals in the fly. Lessons learned from the studies on AP-1 in Drosophila may contribute to our general understanding, beyond species boundaries, of this fundamental class of transcriptional regulators.

Evaluating herbal medicine for the management of Herpes zoster in human immunodeficiency virus-infected patients in Kampala, Uganda.

OBJECTIVE: This study was carried out to evaluate the potential effectiveness of herbal treatments used for herpes zoster (HZ) by a great number of people living with acquired immunodeficiency syndrome (PLWAs) in Uganda. SETTING: Kampala, Uganda. Clinics of indigenous traditional healers, at the Department of Medicine of Mulago Hospital, Makerere University, and at The AIDS Support Organization (TASO) Clinic, providing primary care to people living with HIV and AIDS. DESIGN, PATIENTS, AND PARTICIPANTS: Nonrandomized, nonplacebo controlled, observational study in two phases. Inclusion criteria included HIV seropositivity and a recent HZ attack. In phase 1, 52 patients were enrolled, treated, and followed for up to 3 months at three healers' clinics, and compared to 52 TASO Clinic controls receiving ambulatory care. Phase 2 was similar in design to phase 1, but lasted longer (6-month follow-up) and involved 154 hospital outpatients treated with herbal medicine and 55 TASO controls. In both phases, healer patients were given herbal treatment according to healers' prescriptions, while controls received either symptomatic treatment or acyclovir. RESULTS: Healer patients and controls experienced similar rates of resolution of their HZ attacks. Fewer healer patients than controls experienced superinfection in phase 1 (18% versus 42%, p < 0.02) and fewer healer patients showed keloid formation in either phase. This difference was not statistically significant. In both phases, zoster-associated pain resolved substantially faster among healer patients with a higher degree of significance in phase 2 where the progression of pain over time could be seen because of the longer follow-up (phase 1: maximum p value (pmax) < pmax < 0.02 at 1 month, pmax < 0.005 at 2 months, pmax < 0.0001 at 3 months). CONCLUSION: Herbal treatment is an important local and affordable primary care alternative for the management of HZ in HIV-infected patients in Uganda and similar settings.

Involving traditional healers in AIDS education and counselling in sub-Saharan Africa: a review.

PIP: Traditional healers are the preferred and most accessible care providers in Africa. The AIDS epidemic in sub-Saharan Africa has stimulated interest on the part of modern biomedical health practitioners in collaboration with these traditional healers. The literature includes numerous studies of healers' perceptions of HIV/AIDS and other sexually transmitted diseases. On the basis of study findings, healers have been trained as educators and counselors to disseminate HIV/AIDS information and prevention practices among their peers and communities. This article reviews the initial outcomes and challenges of such new initiatives in Zambia, Uganda, Botswana, Malawi, Mozambique, South Africa, and Central African Republic. None of the projects has completed a comprehensive evaluation of the different approaches used and their real impact on the population served. Overall, however, the case studies indicate that traditional healers are capable of performing at least as well as their biomedical counterparts as AIDS educators and counselors. Of concern is the failure of many projects to provide systematic follow-up to healers after their initial training. Such follow-up is essential to support healers in dealing with unfamiliar issues such as condom use and death and dying.^ieng

The role of traditional healers in HIV / AIDS counselling in Kampala, Uganda. Key issues and debates: traditional healers.

PIP: Traditional medicine is the most widely established and available health care system in Uganda. The emergence of AIDS has presented traditional healers with a substantial challenge. The Traditional and Modern Health Practitioners Together Against AIDS Project was established in 1992 to create a framework for respectful collaboration between traditional healers and medical doctors. Project activities have included comparative clinical trials of herbal treatments for specific HIV/AIDS symptoms for which few modern treatment regimens are available and training to empower traditional healers in STD/HIV counseling and education for women. The training emerged from administration of a baseline survey on AIDS to 55 healers. On the basis of community recognition as a healer, inclusion in their client population of women with AIDS, use of herbal treatments, and interest in the project, 17 of the interviewed healers were selected to participate in the initial training. The 15-month AIDS training (3 days/month), developed with input from healers and community women, covers areas such as counseling, leadership, cultural beliefs and practices, sexuality, and gender relations. Since traditional counseling is largely dependent on the spiritual medium on which the healer bases the treatment, counseling was conceptualized broadly as "a helping relationship aimed at empowering an individual to take action to cope with whatever problem he or she may be confronted with." Over time, trained healers became able to discuss AIDS with all clients, without concerns of offending them. Interviews with 180 female clients of 9 of the trained healers documented changes in the knowledge, attitudes, and practices of both healers and patients. Especially notable was a new willingness on the part of traditional healers to demonstrate and offer condoms.^ieng

Village-based AIDS prevention in a rural district in Uganda.

OBJECTIVE: To design, implement and evaluate a village-based AIDS prevention programme in a rural district in north-western Uganda. A baseline KAP survey of the general population was carried out to design a district-wide information campaign and condom promotion programme. Eighteen months later the impact achieved was measured through a second KAP survey, using the same methodology. METHODS: Anonymous structured interviews were conducted in March 1991 and October 1992 with 1486 and 1744 randomly selected individuals age 15-49, respectively. RESULTS: At 18 months, 60% of respondents had participated in an information session in the past year (47% women, 71% men) and 42% had received a pamphlet about AIDS (26% women, 58% men). Knowledge about AIDS, high initially (94%), reached 98%. More respondents knew that the incubation period is longer than one year (from 29% to 40%), and were willing to take care of a PWA (from 60% to 77%). Knowledge about condoms increased from 26 to 63% in women and 57 to 91% in men. Ever use of condoms among persons having engaged in casual sex in the past year increased from 6 to 33% in women, and 27 to 48% in men. Fifty per cent of condom users criticized lack of regular access to condoms. CONCLUSIONS: This is the first documented example of the impact a village-based AIDS prevention programme can achieve in a rural African community. Critical areas to be improved were identified, such as: women must be given better access to information, more attention must be paid to explain the asymptomatic state of HIV infection in appropriate terms, and condom social marketing must be developed.

PIP: A population-based knowledge, attitude and practice (KAP) survey was carried out as the first step in designing and implementing an AIDS prevention program. The design and implementation of an AIDS information campaign and condom promotion program following the results of the first KAP survey is described. Anonymous interviews on knowledge, attitudes, and practices related to AIDS were conducted in February-March 1991 on a representative sample of the adult population of the district. A 3-stage cluster sampling procedure (parish, village, household) was applied to 800 randomly selected households. In each household 1 man and 1 woman in the 15-49 age range were randomly selected and interviewed. A total of 1486 interviews (753 women, 733 men) were completed. More than 90% of respondents had heard of AIDS, and of these 90% knew that the disease is sexually transmitted and not curable. During September 1991-January 1992 of the information campaign, an estimated 50,000 people attended the village-based information sessions, and 45,000 pamphlets and 40,000 condoms were distributed. A second KAP survey was carried out during September-October 1992 to evaluate the impact of the AIDS prevention program. A total of 1744 questionnaires (874 women, 870 men) were completed and analyzed. Knowledge about the prevention of AIDS had improved substantially, from 40% to almost 70% of the respondents. Overall 39% of respondents knew that the time between infection and disease is more than one year, as compared to 26% at baseline. The proportion of respondents willing to take care of a family member suffering from AIDS had increased from 60% to 77% (p 0.001) between 1991 and 1992. In addition, the proportion of respondents who had ever used condoms increased from 23% to 46% among those who had engaged in casual sex in the past year. However, the overall proportion of respondents who had ever used a condom had remained at 3%. About half of the condom users complained about lack of access to condoms.

Country watch. Uganda.

PIP: In 1991, Medecins sans Frontieres initiated an HIV/AIDS prevention program in Moyo District, Uganda, with the goal of gradually transferring responsibility for it to local people through the training of AIDS control advisors (ACA). Informational pamphlets were developed along with an action plan for a village-based information campaign, followed by the insertion of 8 women and 22 men into a two-week training course in Moyo Town on prevention measures and communication. The ACAs were evaluated monthly both qualitatively and quantitatively with an overall evaluation conducted in January 1992. All villages had been visited several times in the first five months, with the ACAs meeting 50,000 people and distributing 45,000 pamphlets and 40,000 condoms. Community collaboration was excellent, although condoms were distributed to only adults and older teenagers in response to local cries that condom distribution encouraged immorality. Some language difficulties were also encountered. ACAs continued to distribute condoms upon request over the period February-August 1992, but concentrated upon drivers, beer brewers and their customers, traders, musicians, soldiers, barmaids, fishermen, teachers and school children, traditional healers and birth attendants, and religious leaders. Subsequent to this period, the advisors received a week of training on conducting KAP surveys. Refinements were made later in the program with the Ugandan assistant manager ultimately taking over field responsibility in May 1993. Although the ACA team was reduced from 30 to 10 people, it continues to work closely with all district authorities.^ieng

HIV-1 expression in chimpanzees can be activated by CD8+ cell depletion or CMV infection.

CD8+ cell antiviral activity and cytomegalovirus (CMV) were investigated in vivo as possible cofactors influencing the outcome of HIV-1 infection. The role of CD8+ cell suppression of HIV replication was evaluated by depleting CD8+ cells in two infected chimpanzees by inoculation with monoclonal anti-CD8 antibodies. Two other infected animals were injected with chimpanzee CMV (CCMV)-infected human fibroblasts to determine if exposure to this virus would induce HIV replication. Treatment with anti-CD8 antibody resulted in recovery of virus from the CD4+ lymphocytes of one animal at 1, 4, and 6 months, and from a second animal at 1 month postinoculation. In contrast, virus had been recovered only once or not at all from these infected chimpanzees for 4 years prior to treatment. Similarly, HIV was recovered from the CD4+ cells of the two animals 2 to 3 months after inoculation of CCMV-infected fibroblasts but not after inoculation of control uninfected fibroblasts. These studies suggest that CD8+ cell-mediated suppression and the presence of other viruses (such as CMV) could act as cofactors in influencing the extent of HIV-1 replication in vivo and, possibly, progression to disease.

Mother-to-infant transmission of human immunodeficiency virus by breast milk: presumed innocent or presumed guilty?

This article reviews the virological and epidemiological data available on transmission of the human immunodeficiency virus type 1 (HIV-1) by breast milk. Colostrum and breast milk are considered major modes of transmission for many animal retroviruses as well as human T-cell leukemia virus, mainly as the consequence of ingestion of infected cells. Several cases that strongly suggest transmission of HIV-1 through breast-feeding have now been reported. In addition, recent evidence suggests that postpartum HIV-1 seroconversion of a mother may be associated with a high risk of postnatal transmission to offspring via breast milk. Preventive measures such as pasteurization of breast milk have not been fully examined. While the World Health Organization continues to promote breast-feeding in areas where no safe alternative exists, the Centers for Disease Control recommends that American women who are infected by HIV-1 not practice breast-feeding if a safe alternative is available. Large-scale, carefully controlled, prospective studies of the risk of HIV-1 infection associated with breast-feeding are of the utmost priority. Feasible and ethically acceptable feeding alternatives should be developed for countries where formula feeding has a strong negative effect on child morbidity and mortality.

Corneal and conjunctival/scleral penetration of p-aminoclonidine, AGN 190342, and clonidine in rabbit eyes.

The ocular penetration pathways of three alpha 2-adrenergic agents (p-aminoclonidine, AGN 190342, and clonidine) were investigated in rabbits both in vitro and in vivo. The corneal permeabilities of the compounds correlated positively with their octanol/water distribution coefficients. The ocular drug absorption via corneal and conjunctival/scleral penetration routes was evaluated separately after drug perfusion in vivo. In most cases, the corneal route was the major pathway for the intraocular drug absorption. However, the conjunctival/scleral penetration pathway was the predominant pathway for the delivery of p-aminoclonidine, the least lipophilic compound among the three drugs, to the ciliary body. The drug concentration in the iris was contributed mainly by the corneal route and correlated well with drug lipophilicity.

Serum enhancement of human immunodeficiency virus (HIV) infection correlates with disease in HIV-infected individuals.

The sera from 16 individuals infected with the human immunodeficiency virus (HIV) at different clinical stages were evaluated for antibody-dependent neutralization and/or enhancement of infectivity by HIV. The HIV isolate from each individual (homotypic) and established laboratory strains showing broad cellular host range and cytopathicity were used. All sera could neutralize one of the laboratory-passaged isolates, whereas only two could neutralize the corresponding homotypic strain. Seven homotypic isolates were enhanced by serum from the respective individual. This activity was primarily observed in patients with acquired immune deficiency syndrome. Moreover, the tropism for macrophages of four of these seven viral isolates was found to be enhanced by the homotypic sera. Finally, sequential pairs of HIV and sera obtained from five HIV-infected individuals with different clinical progression were studied over time. The enhancing activity of three of the five sera appeared to increase over time, indicating changes in both the host virus population and the type of antibodies produced. These results suggest that enhancing antibodies contribute to the spread and pathogenesis of HIV in vivo. They emphasize the necessity of studying further the association of enhancing antibodies and disease progression in infected individuals.

The Fc and not CD4 receptor mediates antibody enhancement of HIV infection in human cells.

Antibodies that enhance human immunodeficiency virus (HIV) infectivity have been found in the blood of infected individuals and in infected or immunized animals. These findings raise serious concern for the development of a safe vaccine against acquired immunodeficiency syndrome. To address the in vivo relevance and mechanism of this phenomenon, antibody-dependent enhancement of HIV infectivity in peripheral blood macrophages, lymphocytes, and human fibroblastoid cells was studied. Neither Leu3a, a monoclonal antibody directed against the CD4 receptor, nor soluble recombinant CD4 even at high concentrations prevented this enhancement. The addition of monoclonal antibody to the Fc receptor III (anti-FcRIII), but not of antibodies that react with FcRI or FcRII, inhibited HIV type 1 and HIV type 2 enhancement in peripheral blood macrophages. Although enhancement of HIV infection in CD4+ lymphocytes could not be blocked by anti-FcRIII, it was inhibited by the addition of human immunoglobulin G aggregates. The results indicate that the FcRIII receptor on human macrophages and possibly another Fc receptor on human CD4+ lymphocytes mediate antibody-dependent enhancement of HIV infectivity and that this phenomenon proceeds through a mechanism independent of the CD4 protein.

Long-term observation of baboons, rhesus monkeys, and chimpanzees inoculated with HIV and given periodic immunosuppressive treatment.

Baboons, rhesus monkeys, and chimpanzees were injected with the human immunodeficiency virus (HIV) and monitored for up to 4 years. Various immunosuppressive regimens were used during this time in attempts to induce development of the acquired immune deficiency syndrome (AIDS). No infectious virus was recovered or anti-HIV antibodies detected in the baboons and rhesus monkeys. Virus has been recovered from lymphocyte cultures of all five of the chimpanzees at intermittent periods following inoculation. The chimpanzees developed anti-HIV antibodies from 1 to 5 months after virus inoculation and had circulating antibodies that neutralized HIV. All the infected animals were capable of in vitro lymphocyte blastogenic responses to recombinant envelope and core HIV antigens. Despite immunosuppressive therapies and evidence of some immunologic abnormalities, none of the five chimpanzees has yet developed AIDS or a related disorder.

Lymphocyte proliferative responses to human immunodeficiency virus antigens in vitro.

All HIV seronegative (HIV Ab-) and most HIV seropositive (HIV Ab+) individuals' lymphocytes failed to proliferate in primary cultures in response to purified HIV or to recombinant envelope and core antigens of HIV, even in the presence of recombinant interleukin 2 (rIL-2). Most HIV Ab- and HIV Ab+ individuals' lymphocytes, however, could proliferate or be induced by rIL-2 to proliferate in response to lysates of Escherichia coli or Saccharomyces cerevisiae. These findings indicate selective defects in lymphocyte proliferative responses to HIV antigens before the development of AIDS in which lymphocytes are unable to proliferate in response to any antigens. These defects in cell-mediated immune responses to HIV antigens are likely to play an important role in the pathobiology of HIV infections. Although intact HIV or glycosylated gp120 envelope protein of HIV are involved in these defects, a non-glycosylated recombinant form of the HIV gp120 envelope (ENV2-3) and p25 core proteins did not inhibit antigen- or mitogen-driven lymphocyte proliferation.