Long-Term Benefits from Early Antiretroviral Therapy Initiation in HIV Infection.

BACKGROUND: For people with HIV and CD4+ counts >500 cells/mm3, early initiation of antiretroviral therapy (ART) reduces serious AIDS and serious non-AIDS (SNA) risk compared with deferral of treatment until CD4+ counts are <350 cells/mm3. Whether excess risk of AIDS and SNA persists once ART is initiated for those who defer treatment is uncertain. METHODS: The Strategic Timing of AntiRetroviral Treatment (START) trial, as previously reported, randomly assigned 4684 ART-naive HIV-positive adults with CD4+ counts .500 cells/mm3 to immediate treatment initiation after random assignment (n = 2325) or deferred treatment (n= 2359). In 2015, a 57% lower risk of the primary end point (AIDS, SNA, or death) for the immediate group was reported, and the deferred group was offered ART. This article reports the follow-up that continued to December 31, 2021. Cox proportional-hazards models were used to compare hazard ratios for the primary end point from randomization through December 31, 2015, versus January 1, 2016, through December 31, 2021. RESULTS: Through December 31, 2015, approximately 7 months after the cutoff date from the previous report, the median CD4+ count was 648 and 460 cells/mm3 in the immediate and deferred groups, respectively, at treatment initiation. The percentage of follow-up time spent taking ART was 95% and 36% for the immediate and deferred groups, respectively, and the time-averaged CD4+ difference was 199 cells/mm3. After January 1, 2016, the percentage of follow-up time on treatment was 97.2% and 94.1% for the immediate and deferred groups, respectively, and the CD4+ count difference was 155 cells/mm3. After January 1, 2016, a total of 89 immediate and 113 deferred group participants experienced a primary end point (hazard ratio of 0.79 [95% confidence interval, 0.60 to 1.04] versus hazard ratio of 0.47 [95% confidence interval, 0.34 to 0.65; P<0.001]) before 2016 (P=0.02 for hazard ratio difference). CONCLUSIONS: Among adults with CD4+ counts >500 cells/mm3, excess risk of AIDS and SNA associated with delaying treatment initiation was diminished after ART initiation, but persistent excess risk remained. (Funded by the National Institute of Allergy and Infectious Diseases and others.).

Mucosal immunity and antibody anergy in COVID-exposed Covishield vaccinees

Knowledge is limited on mucosal immunity induction and longitudinal responses to vaccination against SARS-CoV2. Here, we determined serum/salivary antibodies and cytokines after three Covishield vaccine doses. Sera from 205 healthcare workers (HCWs) one-month after first- dose; one-, three- and six-months after second-dose; paired sera and stimulated whole mouth fluid (SWMF) from 10 HCWs one-, three- and six-months after third-dose were tested for anti- spike SARS-CoV2 antibodies by ECLIA and for cytokines by ELISA/cytokine bead arrays. One-month after second-dose, antibodies had increased significantly (6-fold) in COVID-naive group, but declined (1.5-fold) in those previously exposed to COVID. At one-month after first- dose, IL-10 levels were statistically higher in the previously COVID-exposed group compared to COVID-naive group (p<0.02). Breakthrough infections were 44% in COVID-naive group, while re-infections were 27% in COVID-exposed group (p<0.02). Proinflammatory cytokines-IL- 17/IL-21 at one-month after first- and second-doses, and memory cytokines-IL-7/IL-15 at three- and six-months after second-dose were minimal. Antibodies spiked at one-month after third- dose and declined by three- and six-months after third-dose similar to post-second-dose. Paired sera and SWMF at one- and six-months after third-dose lacked adaptive immunity cytokine expression. Innate immunity cytokines (MIG, MCP-1, IL-8, TNF-, IL-6, IL-1{beta}) showed a declining trend in serum, but were sustained in SWMF. Thus, our findings suggest that first-dose acts as an antibody boost, while second-dose induces antibody anergy in the previously COVID- exposed group. Rapidly declining antibodies and minimal T cell cytokines raises concerns over their durability in subsequent virus exposures. Sustained innate cytokines emanating from the oral mucosa warrant further in-depth explorations.

Povidone iodine, hydrogen peroxide and chlorhexidine mouthwashes reduce SARS-CoV2 burden in whole mouth fluid and respiratory droplets

SARS-CoV2 is transmitted primarily through oral mouth secretions and respiratory droplets. Commercial mouthwashes, povidone iodine (PI), hydrogen peroxide (HP) and chlorhexidine (CHX) have been tested in cell culture and RT-PCR studies for their efficacy to reduce SARS-CoV2 burden. Here, we evaluated SARS-CoV2 burden in whole mouth fluid (WMF) and respiratory droplets (RD) samples before and after the use of PI, HP or CHX mouthwashes in hospitalized COVID-19 patients using RT-PCR and rapid antigen test (RAT). Thirty-six SARS-CoV2 RT-PCR-positive in-patients were randomly assigned to one of the four groups: 20 and 60 minutes after 1% w/v PI or 1.5% HP; 90 and 180 minutes after 1.5% HP or 0.2% w/v CHX. WMF and RD samples were collected concurrently at baseline and after the two different time points. RD (92%) showed a higher reduction in SARS-CoV2 burden than WMF samples (50%; p=0.008). SARS-CoV2 burden was statistically lower at both 20 minutes (p=0.02) and 60 minutes (p=0.03) with PI; at 20 minutes with HP (p=0.0001); and 90 minutes with CHX (p=0.04). The overall and individual mean logarithmic reductions in the WMF and RD samples were greater than 1.0 at 20, 60 and 90 minutes after PI, HP or CHX. RAT-positive patients at 90 minutes post-treatment (n=3) demonstrated a one log increase in virus copies. Among the three RAT-negative post-treatment patients, SARS-CoV2 burden declined by one log in two while the third patient had a slight increase in RNA copies. In conclusion, we have shown for the first time that the mouthwashes, PI, HP and CHX can reduce the SARS-CoV2 burden in the concurrently collected RD and WMF samples. RAT is more appropriate than RT-PCR to evaluate the efficacy of the mouthwashes.

Implications in the quantitation of SARS-CoV2 copies in concurrent nasopharyngeal swabs, whole mouth fluid and respiratory droplets

ImportanceThe nasopharyngeal swab (NPS) is considered the ideal diagnostic specimen for Covid-19, while WMF is recently promoted due to collection simplicity and importance in disease transmission. There is limited knowledge on the relative viral load in these samples - NPS, whole mouth fluid (WMF) and respiratory droplets (RD; another important source in transmission), on how the loads vary with disease severity and on how much virus is shed. ObjectiveTo quantify and compare SARS-CoV2 copies in the NPS, WMF and RD samples, and correlate with disease severity. DesignCross sectional study. SettingTertiary care multi-speciality hospital with limited resources in a low-to-middle income country. ParticipantsEighty suspected COVID-19 patients were recruited from the COVID-19 out-patient clinic and hospital isolation wards. InterventionConcurrent NPS, WMF and RD samples were collected from all the recruited patients and tested for SARS-CoV2 copies by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR). Main outcomes and measuresThe main outcome was COVID-19 measured by SARS-CoV2 quantitative RT-PCR in NPS samples. COVID-19 disease severity was determined according to NIH criteria. Virus shedding was defined as the presence of SARS-CoV2 copies in the WMF and RD samples. ResultsSARS-CoV2 was detected in 55/80 (69%) of the NPS samples. Of these 55, WMF and RD samples were positive in 44 (80%) and 17 (31%), respectively. The concordance of WMF with NPS was 84% (p=0.02). SARS-CoV2 copy numbers were comparable in the NPS (median: 8.74x10^5) and WMF (median: 3.07x10^4), but lower in RD samples (median: 3.60x10^2). Patients with mild disease had higher copies in the NPS (median: 3.46x10^6), while patients with severe disease had higher copies in the WMF (median: 1.34x10^6) and RD samples (median: 4.29x10^4). The 25-75% interquartile range of NPS SARS-CoV2 copies was significantly higher in the WMF (p=0.0001) and RD (p=0.01) positive patients. Conclusion and relevanceSARS-CoV2 copies are highest in NPS samples. WMF is a reliable surrogate sample for diagnosis. High copy numbers in the NPS imply initial virological phase and higher risk of virus shedding via WMF and RD. Key pointsO_ST_ABSQuestionC_ST_ABSHow the numbers of SARS-CoV2 copies in nasopharyngeal swab (NPS) samples might reflectvirus shedding from the whole upper aerodigestive tract and indicatedisease severity? FindingsIn this cross-sectional study involving 80 suspected COVID-19 patients, the data indicate higher SARS-CoV2 copies in NPS samples of patients with mild disease,and in the whole mouth fluid (WMF) and respiratory droplet (RD) samples of patients with severe disease. Patients with higher SARS-CoV2 copies in the NPS shed the virus in the WMF and RD samples at statistically higher levels. MeaningHigh SARS-CoV2 copies in NPS samples imply initial virological phase withhigh levels of shedding through both WMF and RD.

Detection of SARS-CoV2 antigen in human saliva may be a reliable tool for large scale screening

IntroductionSARS-CoV2, the aetiological agent of the current COVID-19 pandemic, has been detected in saliva and recently implicated in several oral diseases. Collection of nasopharyngeal swabs (NPS) and detection by reverse transcriptase-polymerase chain reaction (RT-PCR) requires medical / technical expertise. A reliable and easy to handle point-of-care (POC) test is highly desirable, especially to curb transmission. Therefore, in this study, we evaluated a commercially available POC rapid antigen test (RAT) for the detection of SARS-CoV2 antigens in the saliva of RT-PCR confirmed positive and negative patients. MethodsThirty saliva samples of 10 saliva RT-PCR negative and 20 saliva RT-PCR positive patients were tested by RAT. ResultsRAT was negative in 10/10 (100%) RT-PCR-negative samples; positive in 9/20 (45%) RT-PCR-positive samples; concordance was 63% (p=0.001). Patients with positive RAT had higher virus copies in their NPS samples compared to the RAT-negative patients. This difference was also statistically significant (p=0.01). ConclusionThus, the POC RAT may be used to detect SARS-CoV2 as a reliable tool for self-testing, large-scale population screening and emergency medical/dental screening. Patients negative by RAT should be confirmed by RT-PCR.

Oral candidal carriage, salivary lysozyme levels, and their relationship with CD4 count in HIV-infected patients.

AIM: The aim of the present study was to compare the lysozyme concentration and candidal count in saliva between HIV-seropositive and HIV-negative individuals, and to correlate the relationship between lysozyme concentrations, candidal count, and CD4 count in HIV patients. METHODS: A study was conducted in 90 HIV-seropositive patients (subgroups: 1 [CD4 ≥ 500 cells/µL], 2 [CD4 200-499 cells/µL], and 3 [CD4 ≤ 200 cells/µL] and 30 HIV-negative individuals. A total of 6 mL unstimulated saliva was collected and stored at -80°C. Samples were centrifuged and divided into two portions of 600 µL each. One portion was used for the candidal assay and the other for the lysozyme assay using ready-made kits. Student's independent t-test and Karl Pearson correlation coefficient were used for the statistical analysis. RESULTS: There was a significant increase (P < 0.001) in lysozyme levels and the candidal count in the saliva of HIV-positive individuals compared with the HIV-negative individuals. A significant increase (P < 0.004) in the salivary candidal count was observed in the HIV subgroups 1-3. There was a significant negative correlation (P < 0.01) between the CD4 and candidal counts in subgroup 1 (P < 0.02) and between the lysozyme concentration and CD4 count in subgroup 3. There was no correlation between the lysozyme concentration and oral candidal carriage. CONCLUSIONS: An association exists between the lysozyme concentration and specific immunity. Yeast colonization serves as a marker of immunodeficiency in HIV disease progression.

Analysis of selection pressure and mutational pattern of HIV type 1 reverse transcriptase region among treated and nontreated patients.

Variation of the HIV-1 subtype C reverse transcriptase region (RT) resulting in response to the selective pressures of drug therapy remains poorly characterized. Here, we compared the genetic variation resulting in the presence and absence of antiretroviral drug selective pressures on HIV-1 subtype C RT among nontreated and treated patients. The nucleotide variability, nonsynonymous and synonymous ratio, and the positively selected mutations were determined by comparing the RT sequences isolated at two time points among nontreated (baseline and follow-up) and treated patients (baseline and treatment failure). Compared to the nontreated patients, the intrapatient nucleotide variability, the number of nonsynonymous and synonymous substitutions was significantly higher among the treated patients. Among the mutations positively selected, the frequency of D121Y, I135R, and Q207E increased and the frequency of mutation S48T decreased significantly during treatment failure. Further studies are essential to discover the role of these mutations during treatment in HIV-1 subtype C.

Short communication: Nucleotide variation and positively selected sites in HIV type 1 reverse transcriptase among heterosexual transmission pairs.

Mutations in the env gene of HIV-1 have been the primary focus in most epidemiologically related cohort studies of virus evolution and very limited studies have focused on the reverse transcriptase (RT) region, the primary target of antiretroviral therapy (ART). Hence, we measured the selection pressure and searched for the positively selected sites in the RT sequences amplified from HIV-1-infected heterosexual transmission pairs. Married couples (n = 10) who were ART naive were included in this study. Phylogenetic analysis, the measurement of synonymous and nonsynonymous ratio (dN/dS) and the interpatient nucleotide variation, was done. Phylogenetic analysis demonstrated distinct subclusters of the RT sequences from heterosexual transmission pairs and the median (IQR) nucleotide variation between the epidemiologically related transmission pairs was significantly (p < 0.001) lower [0.01% (0.01-0.02%)] compared to the epidemiologically unrelated transmission pairs [0.04% (0.03-0.04%)]. The ratio of dN/dS was <1 and codons 135, 162, 166, 207, and 211 were positively selected in >50% of the donor and recipient RT sequences. Purifying selection pressure and low nucleotide variation in the RT sequences between epidemiologically related transmission pairs highlight its essential role in HIV-1 replication. The effect of the RT positively selected mutations that persist over time following transmission between individuals needs to be studied to determine the fitness cost of the mutations in vivo, which may possibly represent good targets for inclusion in HIV-1 vaccines.

HIV-I reverse transcriptase variation in plasma and genital secretion of antiretroviral-naive females.

The reverse transcriptase (RT) enzyme of HIV type 1 (HIV-1) is largely targeted by the host immune selection pressure and would differ in the anatomical compartments, thereby having a drastic impact on viral quasi-species evolution. The HIV-1 RT region sequenced from plasma and genital secretions of 8 antiretroviral treatment (ART)-naive females was analyzed for the pattern of amino acid mutations and the ratio of synonymous and nonsynonymous substitutions to determine whether it is under different selection pressure in both the compartments. Phylogenetic and mutational analysis of the HIV-1 RT in plasma and genital secretions of HIV-1-infected ART-naive females showed limited variation likely reflecting the absence of differential selection pressure and therefore genetic variation in these compartments.

Atypically distributed cutaneous lesions of Norwegian scabies in an HIV-positive man in South India: a case report.

INTRODUCTION: Immune-compromised subjects, especially those with underlying HIV disease, are prone to be infected with Norwegian scabies, where the cutaneous lesions are classically distributed over the extremities. CASE PRESENTATION: We report the case of an HIV-positive 16-year-old man with severe crusted Norwegian scabies initially misdiagnosed as a dermal fungal infection. The patient had extensive, generalized, thick, hyperkeratotic, crusting, yellowish papule lesions distributed on the entire body from his scalp to his toes.The patient was started with Ivermectin and topical Permethrin, which eventually resulted in complete resolution. Interestingly, despite quarantining efforts, one of the patient's acquaintances and a healthcare worker acquired the symptoms of itching. CONCLUSION: This atypical presentation of Norwegian scabies emphasizes the need to include scabies in the differential diagnosis when HIV-infected patients present with crusted, generalized cutaneous lesions.

Oral Candida species in healthy and HIV-infected subjects in Chennai, South India

Objective: Candidiasis is the most common fungal infection in human immunodeficiency virus (HIV) - infected individuals. As there is sparse data on the oral <I>Candida</I> species in HIV- infected individuals in India, we characterized <I>Candida</I> species from the oral cavity in two cohorts - with and without HIV infection and with presence or absence of clinical oral candidiasis, in Chennai, South India.<br>Methods: Saliva samples were collected from 147 consecutive study participants by the oral rinse technique. <I>Candidal</I> species were isolated by culturing specimens on Sabouraud‘s dextrose agar. The pure cultures so derived were speciated using the commercially available ID32C system, and the results were interpreted using APILAB plus software.<br>Results: In the HIV seropositive group, the most commonly isolated candida species was <I>C.albicans</I> (86%) followed by <I>C.tropicalis</I> (23%), <I>C.guilliermondi</I> (6%), <I>C.krusei</I> (5%) and others (4%). In the healthy cohort without clinical candidiasis, C.tropicalis was the most commonly isolated species.<br>Conclusion: There appears to be a marked variation in oral <I>Candida</I> species found in HIV-seropositive and seronegative individuals in India. To our knowledge, this is the first attempt to identify oral Candida species in a South Indian population.