PEPFAR support of alcohol-HIV prevention activities in Namibia and Botswana: a framework for investigation, implementation and evaluation.

BACKGROUND: The association between harmful use of alcohol and HIV infection is well documented. To address this dual epidemic, the US President's Emergency Plan for AIDS Relief (PEPFAR) developed and implemented a multi-pronged approach primarily in Namibia and Botswana. We present the approach and preliminary results of the public health investigative and programmatic activities designed, initiated and supported by PEPFAR to combat the harmful use of alcohol and its association as a driver of HIV morbidity and mortality from 2008 to 2013. APPROACH: PEPFAR supported comprehensive alcohol programming using a matrix model approach that combined the socio-ecological framework and the Alcohol Misuse Prevention and Intervention Continuum. This structure enabled seven component objectives: (1) to quantify harmful use of alcohol through rapid assessments; (2) to develop and evaluate alcohol-based interventions; (3) to promote screening programs and alcohol abuse resource services; (4) to support stakeholder networks; (5) to support policy interventions and (6) structural interventions; and (7) to institutionalize universal prevention messages. DISCUSSION: Targeted PEPFAR support for alcohol activities resulted in several projects to address harmful alcohol use and HIV. Components are graphically conceptualized within the matrix model, demonstrating the intersections between primary, secondary and tertiary prevention activities and individual, interpersonal, community, and societal factors. Key initiative successes included leveraging alcohol harm prevention activities that enabled projects to be piloted in healthcare settings, schools, communities, and alcohol outlets. Primary challenges included the complexity of multi-sectorial programming, varying degrees of political will, and difficulties monitoring outcomes over the short duration of the program.

Development of Combination HIV Prevention Programs for People Who Inject Drugs through Government and Civil Society Collaboration in the Russian Federation.

Population Services International (PSI) has worked collaboratively with several government institutions of the Russian Federation to develop and implement a model program to access health services for individuals who are opioid dependent, including those with HIV infection. Through the development of partnership agreements between government organizations (GOs) and non-government organizations (NGOs), a model of the continuum of care has been developed that identifies a Recommended Package of HIV Prevention Services for Injecting Drug Users (RPS-IDU). The implementation of the RPS-IDU in the Russian Federation offers a model for other countries with HIV epidemics associated with injection drug use. This paper will describe the model program and its implementation in one of the pilot program regions.

Hepatic drug delivery and gene therapy.

On September 21-22, 1995, an international meeting entitled "Targeting of Novel Therapeutics to the Liver and GI Tract" was held at the Natcher Conference Center on the campus of the National Institutes of Health. The conference was sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases through the Division of Digestive Diseases and Nutrition and Digestive Diseases Interagency Coordinating Committee (DDICC). Section 440A of Public Law 94-562 in 1976 created the DDICC for the purpose of coordinating the digestive disease-related research activities of relevant federal health agencies into a coordinated program aimed at combating digestive diseases. As part of this federal effort, an assessment of the "state of the art" for targeted drug therapeutics to the liver and gene therapy was undertaken through the conference, cochaired by Dr. Mark Zern (Thomas Jefferson Medical College) and Dr. Flossie Wong-Staal (University of California, San Diego, CA). The conference was divided into four sessions: Session I was Vectors and Techniques; Session II was Liver and Metabolic Diseases; Session III was Hepatitis and GI Disease; and Session IV was Approaches for HIV Infection. This summary focuses on the new technologies and the studies directly pertaining to liver disease. Table 1 lists the techniques and their applications. Table 2 describes viral vectors that have been employed for the purpose of hepatic gene therapy. Table 3 summarizes the studies presented as posters at the conference.

Function and expression of a human idiotypic network in Schistosomiasis japonica.

The cross-reactive idiotype (Hu-SJ-CRIM) is defined by polyclonal human anti-idiotypic antibodies derived from chronically S. japonicum infected patients. The present study shows that serum levels of Hu-SJ-CRIM expressed by antibodies to S. japonicum soluble egg antigen (SEA) are associated with acute infection and hepatosplenic disease. Xenogeneic anti-idiotypic antisera (anti-Hu-SJ-CRIM) suppressed human lymphocyte blastogenesis to SEA in vitro by 47-82% (P < 0.05). These anti-idiotypic antibodies also suppressed in vitro granuloma formation induced by SEA coated heads in a dose dependent manner. This immunosuppression was antigen specific in that mitogen (PHA) or non-related antigen (PPD) induced blastogenic responses were not suppressed. Surprisingly, anti-idiotypic antibodies (anti-SJ-CRIM), which describe the mouse correlate CRIM were not suppressive in the human blastogenesis or in vitro granuloma formation assays. These data indicate a dichotomy in the function and specificity of the idiotype/anti-idiotype human and murine immune networks in S. japonicum infection. Thus, only the patient derived molecules and serology form the basis for an immunoregulatory network in Schistosomiasis japonica.

Hepatic fibrogenesis.

Hepatic fibrogenesis may be the end result of chronic alcohol abuse, viral or parasitic infection, heavy metal overload, bile duct obstruction, or autoimmune disease. The sinusoidal hepatic stellate cell (or Ito cell or lipocyte) is the major effector cell that proliferates during fibrogenesis and produces abnormal amounts of extracellular matrix proteins as well as matrix-degrading enzymes. This article summarizes the known matrix proteins and the putative regulatory cytokines, cytoplasmic kinases, and transcription factors involved in this process.

Induction of protective immunity to schistosomiasis with immunologically cross-reactive Lumbricus molecules.

Immunologically cross-reactive molecules of Schistosoma japonicum and Lumbricus terrestris were identified by antibodies derived from human and rodent sera. Pooled IgG from schistosomiasis patients but not uninfected individuals bound multiple antigens of identical molecular weight in both soluble S. japonicum worm antigen preparations (SWAP) and soluble earthworm preparations (SEWP). These antigens had molecular weights corresponding to 18, 40, 62, 64, 74, 97, and > 110 kDa. Three of these antigens of 74, 97 and > 110 kDa were immuno-affinity purified using antibodies derived from schistosomiasis patients' sera. Vaccination of mice with SEWP produced murine antibodies which bound parasite molecules of 40, 74, 97, and > 110 kDa and induced 36% protection from S. japonicum infection (P < 0.05). Antibody production to S. japonicum paramyosin, a molecule previously shown to induce protection from schistosome infection, was prominently expressed in the protected murine immune sera. The study shows that Lumbricus sp. represent a potential source for paramyosin and other candidate vaccine molecules for schistosomiasis.

The extramural exocrine pancreas program of the U.S. National Institutes of Health.

The National Institutes of Health (NIH) is the major agency in the federal government that supports both biomedical research and training in the digestive diseases as it relates to health maintenance, human development throughout life, disease prevention, and disease treatment. The present article summarizes the exocrine pancreas program in the context of digestive diseases expenditures of the NIH. This article is a follow-up review of the Pancreas Program as originally described by Roussos (Pancreas 1986;1:74-79). The period covered in this review is fiscal year (FY) 1987 to present. Data presented for FY 1987 to 1992 were provided by the NIH Data Book (U.S. Public Health Service, 1993). Fiscal data for FY 1993-FY 1994 are compiled from institutional databases. FY 1995 figures are presented from the President's budget request submitted to the Congress of the United States.

Gene expression of transforming growth factor beta 1 and extracellular matrix proteins in murine Schistosoma mansoni infection.

BACKGROUND/AIMS: The study of Schistosoma-induced hepatic fibrosis in murine Schistosoma mansoni infection has elucidated the nature of hepatic fibrosis in humans. In the present study, fibrogenic gene expression was determined in murine S. mansoni infection during primary infection, after chemotherapy with praziquantel, and during secondary infection. METHODS: Both histomorphometric analysis and Northern blot profiles were performed. RESULTS: Histomorphometric analysis of granulomatous inflammation showed smaller hepatic fibrotic granulomata after chemotherapy and during secondary infection. Albumin gene expression remained relatively constant throughout primary infection, chemotherapy, and secondary infection. Fibronectin gene expression in primary infection was comparable with the level observed in noninfected mice and was reduced by chemotherapy. Reinfection resulted in augmented expression levels equal to primary infection levels. Osteonectin gene expression was active in primary infection, was reduced by chemotherapy, and was actively reexpressed in secondary infection. Interstitial matrix macromolecules, types I and III collagen, and basement membrane collagen showed high levels of gene expression in primary infection, were virtually terminated by chemotherapy, and were reexpressed on reinfection. The gene expression of transforming growth factor beta 1, a major, fibrogenic cytokine, paralleled collagen expression. CONCLUSIONS: Chemotherapy of schistosomiasis initiated a dramatic decrease in steady-state messenger RNA levels of major proteins associated with fibrosis; reinfection resulted in a reexpression of these genes.

Induction of hepatic pathology in SCID-Hu mice engrafted with peripheral blood lymphocytes of patients with Schistosomiasis japonica.

SCID mice were engrafted with peripheral blood lymphocytes (PBL) derived from persons currently or previously infected with Schistosoma japonicum. After immunization with soluble worm antigenic preparation, the SCID-Hu mice were analyzed for a human immune response. ELISA revealed a low titer of human antibody recognizing soluble egg antigens in 2 of 10 mice. One mouse had detectable levels of interleukin (IL)-2 and gamma-interferon, TH1 phenotype cytokines. All mice had elevated levels of IL-4, a TH2 phenotype cytokine. The human cytokine profile of the mice paralleled the patient's serum profile at clinical examination. In addition, all mice had substantial hepatic pathology, including inflammatory cell infiltrates and macrovesicular fat deposition. The data indicate that activation of PBL from patients with a history of schistosomiasis japonica infection can result in focal hepatic pathology, which may be driven by specific cytokines.

Human monoclonal antibodies heterogeneously express a human cross-reactive idiotype associated with immune function in Schistosoma japonicum infection.

Hybridomas secreting human monoclonal antibodies (hMAb) were derived from Epstein Barr Virus (EBV) transformed lymphocytes of a patient with acute Schistosoma japonicum infection. Three IgG1 hMAb SJ-D, SJ-E, and SJ-F bind soluble egg antigens (SEA) as determined by ELISA. These hMAb exhibit identical western blot profiles, recognizing an epitope(s) of multiple antigens with apparent molecular weights between 42 and 75 kDa. Serological analysis of these hMAb revealed a heterogeneity in their expression of a specific human S. japonicum anti-SEA associated cross reactive idiotype designated Hu SJ-CRIM. The differential expression of idiotypy by these hMAb correlates with immunosuppression of blastogenesis of lymphocytes from schistosomiasis patients. The level of suppression mediated by hMAb expressing high levels of Hu SJ-CRIM ranged from 41% to 52% (p < 0.05) for antigen and 36% to 43% for mitogen. In contrast, hMAb SJ-D which expressed over two fold lower levels Hu SR-CRIM, on a per weight basis showed no suppressive immune function. The data show the heterogeneous expression of human idiotype associated with S. japonicum infection and the correlation of idiotype expression with immune function.

Hepatic fibrosis and gene expression changes induced by praziquantel treatment during immune modulation of Schistosoma japonicum infection.

In the present study fibrogenic gene expression was determined in murine Schistosoma japonicum infection during the progression of immune modulation of infection and following chemotherapy during the course of immune modulation. Histomorphometric analysis of granuloma size and collagen deposition revealed peak granuloma size in acute infection (5 weeks) and peak hepatic collagen content at 16 weeks of infection. Peak Type I collagen gene expression was concomitant with TGF-beta 1 gene expression at 8-11 weeks. Chemotherapy during either acute (9 weeks) or chronic (24, 28 weeks) infection resulted in increased collagen deposition and increased gene expression of Type I collagen and TGF-beta 1. However, chemotherapy at 14-16 weeks resulted in decreased levels of TGF-beta 1 gene expression and essentially minimal change in Type I collagen deposition and gene expression. These data indicate that chemotherapy of schistosomiasis japonica does not reverse hepatic fibrogenesis when administered in acute infection-when granuloma size is maximal-or in chronic infection. However, a beneficial effect on hepatic fibrogenesis is seen when chemotherapy is administered at 14-16 weeks post-infection, a time of decreasing granuloma size and maximal hepatic collagen content. Thus the ability to reverse schistosomal-induced hepatic fibrogenesis by chemotherapy may depend on disease stage.

Human EBV-transformed lymphocytes of patients with Schistosoma japonicum infection secrete idiotypically related immunoregulatory antibodies.

Lymphocytes derived from the peripheral blood of individuals infected with Schistosoma japonica were transformed in vitro with Ebstein-Barr virus (EBV). Serological characterization of antibody molecules revealed both antigen reactive (idiotypic) and anti-idiotypic transformants. One idiotypic EBV transformant, LO2C2, describes a major cross-reactive idiotype associated with anti-antigen binding molecules. Other antibody populations expressing idiotypic cross-reactivity were derived from separate individuals showing shared idiotypy in S. japonicum field study populations in the Republic of Philippines. Both idiotypic and anti-idiotypic molecules suppressed parasite antigen-driven blastogenesis of heterologous human peripheral blood lymphocytes. The data show a serologically related immunoregulatory immune network in patients in the Republic of the Philippines which is serologically distinct from idiotypy expressed in other selected S. japonicum endemic areas in the Far East.

Human hybridoma generation by hypo-osmolar electrofusion: characterization of human monoclonal antibodies to Schistosoma mansoni parasite antigens.

Human monoclonal antibodies which bind Schistosoma mansoni worm and egg antigens were identified and characterized from hybridomas generated using the hypo-osmolar electrofusion technique of somatic cell fusion. Splenocytes from S. mansoni infected individuals were mitogen-activated in vitro and subsequently fused by electrofusion. The greatest number of HAT resistant hybridomas per helical fusion chamber was obtained with unfrozen splenocytes cultured for 4-6 days after introduction of mitogen. Hybridomas secreting IgG antibodies recognizing parasite antigens were identified by ELISA. Twenty-one cloned cell lines secreting IgG antibody were maintained for at least 6 months. Characterization of antigen reactivity by Western blot analysis of nien cloned cell lines revealed antibodies which bound stage specific parasitic antigens. The data show that the technique of hypo-osmolar electrofusion produces stable, antibody producing hybridomas. The human monoclonal antibodies screened represent candidate molecules useful in the investigations of the human pathogen S. mansoni.