Expression Level and Significance of Tim-3 in CD4+ T Lymphocytes in Peripheral Blood of Patients with Coronary Heart Disease

Abstract Objective: To investigate the expression level and significance of T cell immunoglobulin and mucin-domain containing molecules-3 (Tim-3) and interleukin-7 (IL-7) in CD4+ T lymphocytes in peripheral blood of patients with coronary heart disease (CHD). Methods: 75 patients with CHD treated at our hospital were selected and classified as mild group (25 cases), moderate group (25 cases) and severe group (25 cases), according to the severity of illness. Twenty-five healthy volunteers who underwent a physical examination at our hospital during the same period were selected as the control group. The expression level of Tim-3 in CD4+ T lymphocytes in peripheral blood of patients in four groups was detected by flow cytometry and quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR). The expression level of IL-7 in peripheral blood serum was measured by enzyme-linked immunosorbent assay (ELISA). Correlation analyses of Tim-3 and IL-7, Tim-3 and disease severity and IL-7 and disease severity were performed, respectively. Results: Flow cytometry and qRT-PCR demonstrated that the expression of Tim-3 in CD4+ T lymphocytes in peripheral blood of patients with CHD increased with the aggravation of the disease. ELISA showed that the tendency of IL-7 expression in peripheral blood serum was consistent with the expression of Tim-3, and the expression of Tim-3 had a positive correlation with IL-7. The expression levels of both Tim-3 and IL-7 were positively correlated with the Gensini score. Conclusion: The expression of Tim-3 and IL-7 in peripheral blood of patients with CHD was upregulated and increased with the aggravation of CHD.

Expression Level and Significance of Tim-3 in CD4+ T Lymphocytes in Peripheral Blood of Patients with Coronary Heart Disease.

OBJECTIVE: To investigate the expression level and significance of T cell immunoglobulin and mucin-domain containing molecules-3 (Tim-3) and interleukin-7 (IL-7) in CD4+ T lymphocytes in peripheral blood of patients with coronary heart disease (CHD). METHODS: 75 patients with CHD treated at our hospital were selected and classified as mild group (25 cases), moderate group (25 cases) and severe group (25 cases), according to the severity of illness. Twenty-five healthy volunteers who underwent a physical examination at our hospital during the same period were selected as the control group. The expression level of Tim-3 in CD4+ T lymphocytes in peripheral blood of patients in four groups was detected by flow cytometry and quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR). The expression level of IL-7 in peripheral blood serum was measured by enzymelinked immunosorbent assay (ELISA). Correlation analyses of Tim-3 and IL-7, Tim-3 and disease severity and IL-7 and disease severity were performed, respectively. RESULTS: Flow cytometry and qRT-PCR demonstrated that the expression of Tim-3 in CD4+ T lymphocytes in peripheral blood of patients with CHD increased with the aggravation of the disease. ELISA showed that the tendency of IL-7 expression in peripheral blood serum was consistent with the expression of Tim-3, and the expression of Tim-3 had a positive correlation with IL-7. The expression levels of both Tim-3 and IL-7 were positively correlated with the Gensini score. CONCLUSION: The expression of Tim-3 and IL-7 in peripheral blood of patients with CHD was upregulated and increased with the aggravation of CHD.

Avaliação do perfil bioquímico, hematológico e imunológico em pacientes com diagnóstico recente para HIV de um Centro de Referência em Santarém, Pará, Brasil / Evaluation of the biochemical, hematological and immunological profile in patients with a recent diagnosis of HIV in Santarém Reference Center, Pará, Brazil

Introdução: Alterações hematológicas, bioquímicas e imunológicas podem estar presentes no paciente infectado pelo HIV, no momento do diagnóstico, antes ou depois de iniciar com os antirretrovirais. Objetivo: Analisar o perfil bioquímico, hematológico e imunológico de pacientes com diagnóstico recente para HIV. Método: O estudo avaliou 321 prontuários de pacientes recém diagnosticados com a infecção pelo HIV. A coleta de dados envolveu informações sociodemográficas (data de nascimento, idade, sexo, escolaridade, estado civil, vínculo empregatício e procedência), clínicas (data do diagnóstico para a infecção pelo HIV, situação de imunodeficiência e tipo de exposição), bioquímicas (glicose, triglicerídeos, colesterol total e frações), hematológicas (hemoglobina e plaqueta) e imunológicas (linfócitos T CD4+ e carga viral). Os dados foram analisados por estatística descritiva e inferencial, adotando-se p<0,05. Resultados: Notou-se predominância do sexo masculino (67%), faixa etária de 18-27 anos (39,9%), solteiros (58,6%) e com 32% dos pacientes apresentando Aids. Das variáveis analisadas, o sexo masculino apresentou, em relação às mulheres, maior quantidade de hemoglobina e menores valores para contagem de linfócitos T CD4+, glicose e colesterol total (p<0,05). Além disso, ressalta-se que 69% da amostra apresentou alguma alteração lipídica, 96% tinha carga viral detectável e 29% apresentou linfócitos T CD4+ <200 cel/mm3. Conclusão: Pessoas vivendo com o HIV, no momento do diagnóstico, podem apresentar alterações imunológicas, hematológicas e bioquímicas, tornando imprescindível a avaliação, acompanhamento e orientação multiprofissional, tanto antes como posterior introdução dos antirretrovirais, a fim de evitar futuros agravos a saúde. [au]

Introduction: Hematological, biochemical, and immunological alterations may already be present in HIV-infected patients at the time of diagnosis or before, or after starting antiretroviral therapy. Objective: Analyze the biochemical, hematological, and immunological profile of patients with a recent diagnosis of HIV. Method: The study evaluated 321 medical records of patients newly diagnosed with HIV infection. Data collection involved sociodemographic (date of birth, age, gender, education, marital status, employment relationship, and origin), clinical (date of diagnosis for HIV infection, immunodeficiency status, and type of exposure), biochemical (glucose, triglycerides, total cholesterol, and fractions), hematological (hemoglobin and platelet) and immunological (CD4+ T lymphocytes and viral load) information. Data were analyzed by descriptive and inferential statistics, adopting p<0.05. Results: There was a predominance of males (67%), aged 18-27 years (39.9%), single (58.6%), and 32% of patients had AIDS. Of the variables analyzed, males presented higher amounts of hemoglobin and lower values for CD4+ T lymphocyte count, glucose, and total cholesterol in relation to females (p<0.05). In addition, it is noteworthy that 69% of the sample presented a lipid alteration, 96% had a detectable viral load, and 71% had CD4+ T lymphocytes <200 cells/mm3. Conclusion: People living with HIV, at the time of diagnosis, may present immunological, hematological, and biochemical alterations, making multidisciplinary evaluation, follow up, and guidance essential, both before and after the introduction of antiretroviral therapy, in order to avoid future health problems. [au]

High CD4 + T-Cell/B-Cell Ratio in the Paranasal Sinus Mucosa of Patients with Eosinophilic Chronic Rhinosinusitis.

Introduction Chronic rhinosinusitis (CRS) is commonly classified based on the presence or absence of nasal polyps (NPs). Eosinophil infiltration is observed in NPs of patients in Western countries. In contrast, in East Asian countries, including Japan, CRS with NPs (CRSwNP) is subdivided based on the presence (eosinophilic CRS [ECRS]) or absence (non-eosinophilic CRS [NECRS]) of eosinophils in NPs. However, detailed analyses of other immune cells, such as lymphocytes, in NPs have not been performed. Therefore, clarification of the types of cells that infiltrate NPs is important to understand CRS pathogenesis. Objectives We analyzed the lymphocytes that infiltrate the paranasal sinus mucosa of ECRS and NECRS patients. Methods Eighteen patients with CRSwNP participated in this study, out of whom 6 were NECRS patients, and 12 were ECRS patients. The mucosa specimens, collected from patients during sinus surgeries, were subjected to collagenase treatment to prepare single cell suspensions. Then, mononuclear cells were isolated, and CD4 + T, CD8 + T, and CD20 + B-cell populations were examined using flow cytometry. Results In both NECRS and ECRS patients, CD8 + T-cells were dominant over CD4 + T-cells. Notably, CD4 + T-cell/B-cell ratio, but not CD8 + T-cell/B-cell or CD4 + T-cell/CD8 + T-cell ratios, was significantly higher in ECRS patients than in NECRS patients. Conclusion The CD4 + T-cell/B-cell ratio can be used as a potential indicator to differentiate between ECRS and NECRS.

The role of T Cells in SARS-CoV-2 Infection. / El papel de los linfocitos T en la infección por SARS-CoV-2.

T lymphocytes (or T cells) are characterized by having an essential role in the control of acute viral infections. SARS-CoV-2 infection is an acute viral infection that mainly affects the respiratory tract causing COVID-19 disease, which presents with mild, moderate and critical symptoms that can lead to the death of the patient. The induction of populations of CD4+ and CD8+ T cell with a functional memory phenotype could be decisive in the control of viral replication and therefore be determinants in the course of the disease. In this opinion article, we will review the reported evidence regarding the presence, phenotype, and function of circulating T cell populations and the site of infection to understand their possible role in controlling viral replication, in the severity of the disease, and the importance of T-cell-mediated protection in the development of vaccines against SARS-CoV-2 infection.

Los linfocitos T se caracterizan por tener un papel esencial en el control de infecciones virales agudas. La infección por SARS-CoV-2 es una infección viral aguda que afecta principalmente el tracto respiratorio y causa la enfermedad COVID-19, la cual cursa con síntomas leves, moderados y críticos que pueden llevar a la muerte del paciente. La inducción de poblaciones de linfocitos T CD4+ y CD8+ con fenotipos de memoria funcionales podrían ser esenciales en el control de la replicación viral y, por lo tanto, determinantes en el curso de la enfermedad. En este artículo de opinión revisaremos las evidencias reportadas en cuanto a la presencia, fenotipo y función de las poblaciones de linfocitos T en circulación y en el sitio de infección para entender su posible papel en el control de la replicación viral, en la severidad de la enfermedad y la importancia de la protección mediada por linfocitos T en el desarrollo de vacunas contra la infección por SARS-CoV-2.

Caracterización de las manifestaciones otorrinolaringológicas en pacientes con infección por VIH/Sida en la ciudad de Cartagena / Characterization of the otorrinolaringological manifestations in patients with HIV/AIDS infection in the city of Cartagena

Introducción: en Colombia, la incidencia por virus de inmunodeficiencia humana (VIH) ha ido en aumento; la ciudad de Cartagena tiene una de las más altas del país. Las manifestaciones otorrinolaringológicas en personas con VIH se estiman entre un 20%-80%, lo que genera un gran impacto en la calidad de vida. Objetivo: determinar las características epidemiológicas y las manifestaciones otorrinolaringológicas en un grupo de personas con VIH/Sida de la ciudad de Cartagena. Metodología: diseño observacional descriptivo de corte transversal y prospectivo. Se recolectó información de pacientes con VIH de la ciudad de Cartagena, que asistieron a dos centros médicos. Se les aplicó un cuestionario para obtener datos epidemiológicos, signos y síntomas otorrinolaringológicos, así como un examen físico otorrinolaringológico completo. Resultados: se incluyeron 150 pacientes en el estudio, con una media de edad de 31 años, 59,3% del género masculino y 40,7% del femenino. El antecedente patológico no otorrinolaringológico más frecuente fue la coinfección por sífilis en un 10%; el otorrinolaringológico fue la sinusitis y la candidiasis oral, cada uno con un 3,3%. El 73% de los pacientes manifestó alteración otorrinolaringológica en el momento de la evaluación. Las más frecuentes fueron las otológicas, con el 39,9% de los pacientes. Además, se observó una relación estadísticamente significativa entre los conteos de CD4 y hallazgos como disfonía en laringe (p = 0,045). Conclusiones: las manifestaciones otológicas fueron las más frecuentes en nuestro medio y se encontró una relación entre el conteo de CD4 y las manifestaciones laríngeas de la enfermedad.

Introduction: In Colombia, the incidence of the disease has been increasing and Cartagena has the highest numbers of the country. Otorhinolaryngological manifestations in people with HIV/AIDS are estimated between 20%-80% generating a great impact on quality of life. Objective: To determine the epidemiological characteristics and otorhinolaryngological manifestations in a group of people with HIV / AIDS in the city of Cartagena. Methodology: Observational, descriptive, cross-sectional and prospective design. Information was collected from patients with HIV from the city of Cartagena who attended 2 medical centers, a questionnaire was applied to obtain epidemiological data, otorhinolaryngological signs and symptoms, as well as a complete otorhinolaryngological physical examination. Results: 150 patients were included in the study, with a mean age of 31 years, 59.3% male and 40.7% female. The most frequent non-otorhinolaryngological pathological antecedent was syphilis coinfection in 10% and otorhinolaryngological, sinusitis and oral candidiasis each with 3.3%. 73% of the patients at the time of the evaluation manifested otorhinolaryngological alteration, the otological ones being the most frequent with 39.9% of the patients. Furthermore, a significant relationship was observed between CD4 counts and findings such as laryngeal dysphonia (p = 0.045). Conclusions: The otological manifestations were the most frequent in our environment and a relationship was found between the CD4 count and the laryngeal manifestations of the disease.

Liver cirrhosis in HIV/HCV-coinfected individuals is related to NK cell dysfunction and exhaustion, but not to an impaired NK cell modulation by CD4+ T-cells.

INTRODUCTION: HIV worsens HCV-related liver disease by accelerating fibrosis progression; however, progression rates are extremely variable among HIV/HCV-coinfected individuals. NK cells are associated with modulation of liver fibrosis and are profoundly altered during HCV and HIV infections. CD4+ T-cells modulate NK cell function, and are also affected by HIV infection. Here, we aim to characterize the association of hepatic fibrosis with both the phenotype and function of peripheral NK cells and their regulation by CD4+ T-cells, in HIV/HCV-coinfected individuals. METHODS: Thirty-four HIV/HCV-coinfected individuals with minimal (n = 16) and advanced (n = 18) fibrosis (METAVIR F0/F1 and F4 scores respectively) and 20 healthy volunteers were enrolled. PBMC were obtained from peripheral blood samples and NK and CD4+ T-cells were isolated and analysed. NK cell phenotype (CD25, CD69, Nkp46, NKG2D, PD-1), degranulation (CD107a) and IFN-γ and TNF-α production, as well as CD4+ T-cell activation (CD69, CD25 and CD38) were measured by flow cytometry. CD4+ T-cell conditioned medium (CM) derived from F0/F1 or F4 individuals was assessed for IL-2 levels by ELISA. Modulation of NK cell functionality by these CMs was also analysed. RESULTS: When comparing to NK cells from individuals with minimal fibrosis, degranulation and cytokine secretion by NK cells from subjects with F4 scores was significantly impaired, while PD-1 expression was augmented. On the one hand, neither the expression of activation markers nor IL-2 secretion was distinctly induced in CD4+ T-cells from subjects with F0/F1 or F4 METAVIR scores. Finally, NK cell degranulation and cytokine secretion were not differentially modulated by CD4+ T-cell CM, whether CD4+ T-cells derived from subjects with minimal or advanced fibrosis. CONCLUSIONS: Low levels of NK and CD4+ T-cells in HIV/HCV-coinfected individuals with advanced liver fibrosis have been previously described. Here, we show that advanced liver fibrosis in coinfected individuals is associated to a defective function of NK cells and an increased expression of the exhaustion/senescence marker PD-1. This NK signature could not be attributed to changes in the ability of CD4+ T-cells to modulate NK cell function.

Relationships between phenotype and function of blood cd4+ t-cells and ascending thoracic aortic aneurysm: an experimental study

Abstract Introduction: Non-familial ascending thoracic aorta dilation and aneurysms (TAAs) are silent diseases in elderly patients. Histopathology revealed that functionally polarized infiltrating CD4+ T-cells play a key role in aortic wall weakening. Objective: To evaluate the possible associations between phenotype and cytokine production of circulating CD4+ T-lymphocytes and the presence of TAA in patients with aortic valve disease (AVD). Methods: We studied blood samples from 10 patients with TAA and 10 patients with AVD. Flow cytometry was used to quantify: a) CD4+ T-lymphocytes surface expression of CD25, CD28, and chemokine receptors (CCR5, CXCR3, CX3CR1); b) fractions of in vitro stimulated CD4+ T-cells producing cytokines (interferon gamma [IFN-γ], interleukin [IL]-17A, IL-21, IL-10); c) CD4+CD25highFoxP3+ regulatory T-cells (Treg) fraction. Enzyme-linked immunosorbent assays (ELISA) were performed for cytokines (IFN-γ, IL-6, IL-10, IL-17A, IL-23, transforming growth factor beta [TGF-β]) and chemokines (RANTES, CX3CL1). Results: The total CD4+CD28±CD4+/CX3CR1+ T-cells fraction was higher (P=0.0323) in AVD (20.452±4.673) than in TAA patients (8.633±2.030). The frequency ratio of CD4+ T-lymphocytes producing IFN-γ vs. IL-17A+IL-21 cytokine-producing CD4+ T-cells was higher (P=0.0239) in AVD (2.102±0.272) than in TAA (1.365±0.123) patients. The sum of CD4+CD28±CD4+/CX3CR1+ T-cells correlated positively with values of the previous cytokine ratio (P=0.0002, R=0.732). The ratio of CD4+CD28±CD4+/CX3CR1+ T-cells vs. Treg was higher (P=0.0008) in AVD (20.859±3.393) than in TAA (6.367±1.277) patients. Conclusion: Our results show that the presence of TAA in subjects with AVD is associated with imbalance between phenotypic and cytokine-producing subsets of circulating CD4+ T-lymphocytes, prevalently oriented towards a pro-fibrotic and IFN-γ counteracting effect to functional polarization.

Perfil clínico e epidemiológico das alterações bucais em portadores do HIV / Clinical and epidemiological profile of oral changes in HIV patients / Perfil clínico y epidemiológico de las alteraciones bucales en portadores del VIH/SIDA

Introdução: Pacientes portadores do vírus da imunodeficiência humana apresentam susceptibilidade a desenvolver alterações bucais, em que estas estão intimamente relacionadas ao grau de carga viral e consequentemente a contagem de células linfocitárias. Objetivo: Traçar um perfil clínico-epidemiológico de alterações bucais em pacientes portadores do HIV. Material e Método: Realizou-se uma revisão onde foram analisados artigos científicos obtidos da base de dados PubMed. Foram incluídos os estudos do período de 2000 a 2017, de acordo com os descritores: HIV; Linfócitos T CD4-positivos; Doenças da boca, bem como a associação dos termos. Totalizando-se 19 estudos para realização da pesquisa. As pesquisas que não se enquadraram a esses critérios foram excluídas. Os dados foram analisados a partir de estatística descritiva. Conclusão: Conclui-se que a cavidade oral é a área de maior frequência para manifestações do HIV/AIDS sendo a candidose, leucoplasia pilosa e as doenças periodontais as lesões mais ocorrentes em todo o mundo. Em relação ao sexo, conclui-se que a maior prevalência varia de acordo com a população estudada, sendo o sexo masculino o mais prevalente no Brasil, porém o sexo feminino quando afetado possuíam idade mais precoce(AU)

Introduction: Patients with human immunodeficiency virus are susceptible to develop oral alterations, in which they are closely related to the viral load and consequently the lymphocyte count. Objective: To establish a clinical-epidemiological profile of oral alterations in patients with HIV. Material and Method: A review was carried out, where scientific articles were retrieved from the PubMed database. We included studies from the period 2000 to 2017, according to the descriptors: HIV; CD4-positive T lymphocytes; Diseases of the mouth, as well as the association of terms. A total of 19 studies were carried out to carry out the research. Searches that did not meet these criteria were excluded. Data were analyzed from descriptive statistics. Conclusion: It is concluded that the oral cavity is the area of greatest frequency for manifestations of HIV / AIDS being candidosis, hairy leukoplakia and periodontal diseases the most frequent lesions worldwide. Regarding sex, it was concluded that the highest prevalence varies according to the population studied, being the male sex the most prevalent in Brazil, but the female sex when affected had an earlier age(AU)

Introducción: Los pacientes portadores del virus de la inmunodeficiencia humana son susceptibles a desarrollar alteraciones bucales, que están íntimamente relacionadas al grado de carga viral y al recuento de células linfocitarias. Objetivo: Trazar un perfil clínicoepidemiológico de alteraciones bucales en pacientes portadores del VIH. Material y Método: Se realizó una revisión bibliográfica, fueron analizados artículos científicos obtenidos de la base de datos PubMed. Se incluyeron los estudios del período 2000 a 2017, de acuerdo con los descriptores: VIH; Linfocitos T CD4-positivos; Enfermedades de la boca, así como la asociación de los términos. En un total de 19 estudios para la realización de la investigación. Las encuestas que no se relacionaron a estos criterios, se excluyeron. Los datos analizados a partir de estadística descriptiva. Conclusión: Se concluye que la cavidad oral es el área de mayor frecuencia para manifestaciones del VIH/SIDA siendo la candidiasis, leucoplasia pilosa y las enfermedades periodontal las lesiones más frecuentes en todo el mundo. En cuanto al sexo, se concluye que la mayor prevalencia varía de acuerdo con la población estudiada, siendo el sexo masculino el más prevalente en Brasil, pero el sexo femenino cuando afectado poseía edad más precoz(AU)

Parámetros hematológicos y recuento de células T-CD4+ en pacientes VIH con síntomas digestivos en Bucaramanga, Colombia / Haematological parameters and T-CD4+ cells count in HIV patients with digestive symptoms in Bucaramanga, Colombia

Introducción: La anemia, las citopenias y la sintomatología digestiva son hallazgos frecuentes en la población con infección por el virus de la inmunodeficiencia humana, VIH. Objetivo: Describir los parámetros hematológicos y el recuento de linfocitos T- CD4 en pacientes con VIH hospitalizados por síntomas digestivos a los que se realizaron estudios endoscópicos. Métodos: Se realizó un estudio observacional y descriptivo en 54 pacientes con VIH que se consultaron por síntomas digestivos y que requirieron procedimientos endoscópicos digestivos altos o bajos durante el año 2014 en un Hospital Universitario de tercer nivel en Bucaramanga, Colombia.Se tomaron datos sociodemográficos, se indagó sobre el uso de terapia antirretroviral altamente efectiva (TARAE), se registró la sintomatología digestiva, el tipo de procedimiento realizado, los datos del hemograma, el recuento de linfocitos T-CD4, la realización de mielograma, biopsia de médula ósea y la mortalidaddurante la estancia hospitalaria. Resultados: La prevalencia de anemia, leucopenia y trombocitopenia fue de 83.3 por ciento, 37 por ciento y 20.3 por ciento, respectivamente. Se encontró bicitopenia y pancitopenia en 25.9 por ciento y 14.8 por ciento.De los pacientes con bicitopenia y pancitopenia se les realizó estudio de médula ósea a 57.1 por ciento y 87.5 por ciento, respectivamente. Se encontró una tendencia de conteo de linfocitos T-CD4 menor en aquellos pacientes con anemia. Conclusiones: Las alteraciones hematológicas son frecuentes en pacientes con VIH y síntomas digestivos, con alta prevalencia de anemia. Los recuentos de linfocitos T-CD4 encontrados fueron notoriamente bajos(AU)

Introduction: Anemia, cytopenias and gastrointestinal symptoms are common findings in the population that are infected by the HIV. Objective: To describe hematological parameters and the T-CD4 cell counts in HIVpatients hospitalized for gastrointestinal symptoms that were taken to endoscopy. Methods: A descriptive study in 54 HIV patients who consulted for digestive symptoms and requiring high or low digestive endoscopy during 2014 in a third level University Hospital of Bucaramanga, Colombiawas carried out. Sociodemographicdata were questioned, it was the use of highly active antiretroviral therapy (HAART), it was registered digestive symptoms, type of procedure, data from blood count, T-CD4 count, myelogram, bone marrow biopsy and mortality during hospital stay were recorded. Results: The prevalence of anemia, leucopenia and thrombocytopenia were 83.3 percent, 37 percent and 20.3 percent, respectively. Bicytopenia and pancytopenia were found in 25.9 percent and 14.8 percent. Bicytopenia patients with pancytopenia and underwent bone marrow study to 57.1 percent and 87.5 percent, respectively. A trend of lower T-CD4 lymphocyte count was found in patients with anemia. Conclusions: Hematological disorders are common in patients with HIV and digestive symptoms, with high prevalence of anemia. T-CD4 counts were found notoriously low(AU)

A transcriptome-based model of central memory CD4 T cell death in HIV infection.

BACKGROUND: Human central memory CD4 T cells are characterized by their capacity of proliferation and differentiation into effector memory CD4 T cells. Homeostasis of central memory CD4 T cells is considered a key factor sustaining the asymptomatic stage of Human Immunodeficiency Virus type 1 (HIV-1) infection, while progression to acquired immunodeficiency syndrome is imputed to central memory CD4 T cells homeostatic failure. We investigated if central memory CD4 T cells from patients with HIV-1 infection have a gene expression profile impeding proliferation and survival, despite their activated state. METHODS: Using gene expression microarrays, we analyzed mRNA expression patterns in naive, central memory, and effector memory CD4 T cells from healthy controls, and naive and central memory CD4 T cells from patients with HIV-1 infection. Differentially expressed genes, defined by Log2 Fold Change (FC) ≥ |0.5| and Log (odds) > 0, were used in pathway enrichment analyses. RESULTS: Central memory CD4 T cells from patients and controls showed comparable expression of differentiation-related genes, ruling out an effector-like differentiation of central memory CD4 T cells in HIV infection. However, 210 genes were differentially expressed in central memory CD4 T cells from patients compared with those from controls. Expression of 75 of these genes was validated by semi quantitative RT-PCR, and independently reproduced enrichment results from this gene expression signature. The results of functional enrichment analysis indicated movement to cell cycle phases G1 and S (increased CCNE1, MKI67, IL12RB2, ADAM9, decreased FGF9, etc.), but also arrest in G2/M (increased CHK1, RBBP8, KIF11, etc.). Unexpectedly, the results also suggested decreased apoptosis (increased CSTA, NFKBIA, decreased RNASEL, etc.). Results also suggested increased IL-1ß, IFN-γ, TNF, and RANTES (CCR5) activity upstream of the central memory CD4 T cells signature, consistent with the demonstrated milieu in HIV infection. CONCLUSIONS: Our findings support a model where progressive loss of central memory CD4 T cells in chronic HIV-1 infection is driven by increased cell cycle entry followed by mitotic arrest, leading to a non-apoptotic death pathway without actual proliferation, possibly contributing to increased turnover.

Periodontal Conditions in Human Immunodeficiency Virus-Positive Patients Under Highly Active Antiretroviral Therapy From a Metropolitan Area of Rio De Janeiro.

BACKGROUND: The aim of this study is to evaluate the periodontal status and the presence of opportunistic oral lesions in human immunodeficiency virus-positive (HIV+) patients under highly active antiretroviral therapy (HAART) and their association with cluster of differentiation (CD)4+ and CD4+ nadir T-cell counts and viral load levels. METHODS: Clinical periodontal parameters and the presence of opportunistic oral lesions along with records of CD4+ counts and viral load levels were evaluated in 29 individuals (16 females; mean age: 42.7 years) with previous serologic diagnosis of HIV, from the acquired immunodeficiency syndrome program of the Health Center of Duque de Caxias, Rio de Janeiro, Brazil. RESULTS: All individuals presented gingivitis or periodontitis. A higher non-significant prevalence of periodontitis was found in smokers (93.8%) compared with non-smokers (76.9%). A significant weak positive correlation was observed between CD4+ counts and missing teeth (ρ = 0.380, P <0.05), CD4+ nadir and periodontal diagnosis (ρ = 0.418, P <0.005), and CD4+ nadir and moderate probing depth (PD) (ρ = 0.424, P <0.05). When only non-smokers were analyzed, a significant moderate positive association was found between viral load and moderate clinical attachment level (CAL) (ρ = 0.638, P <0.05), CD4+ nadir and diagnosis (ρ = 0.586, P <0.05), and CD4+ nadir and moderate CAL (ρ = 0.680, P <0.05). Analysis considering only smokers found no correlations between serologic parameters and demographic or clinical parameters. CONCLUSIONS: The current investigation demonstrates that HIV+ individuals under HAART presents a high prevalence of mild to moderate periodontal disease. Viral load levels, CD4+ nadir, and CD4+ counts may present a weak to moderate correlation to the number of missing teeth, periodontal diagnosis, moderate PD, and moderate CAL, which may also reflect some effect of these systemic conditions on the periodontal status.

Aerobic training modulates T cell activation in elderly women with knee osteoarthritis

Osteoarthritis of the knee (kOA) is a disease that mainly affects the elderly and can lead to major physical and functional limitations. However, the specific effects of walking, particularly on the immune system, are unknown. Therefore, this study aimed to analyze the effect of 12 weeks of walking (3×/week) on the leukocyte profile and quality of life (QL) of elderly women with kOA. Sixteen women (age: 67±4 years, body mass index: 28.07±4.16 kg/m2) participated in a walking program. The variables were assessed before and after 12 weeks of training with a progressively longer duration (30–55 min) and higher intensity (72–82% of HRmax determined using a graded incremental treadmill test). The QL was assessed using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36), and blood samples were collected for analysis with a cell counter and the San Fac flow cytometer. Walking training resulted in a 47% enhancement of the self-reported QL (P<0.05) and a 21% increase in the VO2max (P<0.0001) in elderly women with kOA. Furthermore, there was a reduction in CD4+ cells (pre=46.59±7%, post=44.58±9%, P=0.0189) and a higher fluorescence intensity for CD18+CD4+ (pre=45.30±10, post=64.27±33, P=0.0256) and CD18+CD8+ (pre=64.2±27, post=85.02±35, P=0.0130). In conclusion, the walking program stimulated leukocyte production, which may be related to the immunomodulatory effect of exercise. Walking also led to improvements in the QL and physical performance in elderly women with kOA.

Depressão em pacientes HIV positivos: a realidade de um hospital português / Depression in HIV-positive patients: the reality of a Portuguese hospital

Objetivos: A depressão constitui a mais frequente perturbação psiquiátrica entre indivíduos infectados pelo HIV. Este trabalho pretende caracterizar a população de doentes HIV positivos da clínica de infectologia do Hospital de Joaquim Urbano do Porto quanto ao perfil de sintomas depressivos e verificar se estes se correlacionam com os parâmetros analíticos mais frequentemente avaliados no contexto da infecção por este vírus: carga viral do HIV, contagem e percentagem de linfócitos CD4+. Métodos: Foi realizado um estudo observacional descritivo e analítico. Os níveis de sintomas depressivos dos participantes foram avaliados com o Inventário Depressivo de Beck. Os antecedentes patológicos, psiquiátricos e os valores analíticos da carga viral, contagem e percentagem de CD4+ foram obtidos através de consulta aos respectivos processos clínicos. Resultados: Foi encontrada uma prevalência de 65,5% de sintomas depressivos, com uma percentagem considerável (32,7%) dos indivíduos apresentando sintomas graves. Não se verificaram associações entre os níveis de sintomas depressivos e a contagem de CD4+, percentagem de CD4+ ou carga viral. Foram, no entanto, demonstradas associações entre sintomas depressivos, toxicodependência e grau de escolaridade. Conclusões: A elevada prevalência de sintomas depressivos encontrada neste estudo reforça a importância da vigilância desse tipo de sintomatologia em indivíduos HIV positivos. O fato de não se terem verificado associações entre sintomas depressivos e os parâmetros analíticos avaliados está em conformidade com estudos anteriores.

Aims: Depression is the most common psychiatric disorder among people infected with HIV. This study aims to characterize the Hospital of Joaquim Urbano population of HIV-infected patients' profile regarding depressive symptoms and whether they correlate with the analytical parameters most frequently evaluated in the context of infection by this virus ­ HIV viral load, CD4+ count and CD4+ percentage. Methods: We conducted an observational descriptive and analytical study. The participants' level of depressive symptoms was assessed with the Beck Depression Inventory. The medical and psychiatric history and the analytical values of viral load, CD4+ count and CD4+ percentage were obtained by consulting the participants' clinical processes. Results: A prevalence of 65.5% in HIV-infected patients' depressive symptoms was found, with a considerable high percentage of subjects presenting with severe symptoms (32.7%). No associations between the depressive symptoms' levels and CD4+ count, CD4+ percentage or viral load were found. However, depressive symptoms were associated with substance abuse and education level. Conclusions: The high prevalence of depressive symptoms found in this study reinforces the importance of monitoring this type of symptoms in HIV-infected subjects. The fact that there have been no associations between depressive symptoms and the analytical parameters evaluated is in line with previous studies.

Perfil de risco imunológico de idosas com câncer de mama: os primeiros 37 casos / Immune risk profile of elderly women with breast cancer: the first 37 cases

Objetivos: Avaliar o perfil imunológico de risco em idosas com câncer de mama e testar se este pode ser um fator preditivo confiável para determinar tipos de tratamento e seguimento oncológico.Métodos: Foram pesquisadas a relação das células T CD4+/CD8+ e a sorologia para citomegalovírus no sangue periférico de mulheres com 60 anos ou mais de idade no momento do diagnóstico da neoplasia mamá¡ria, que realizaram tratamento cirúrgico no Centro de Mama da Pontifí­cia Universidade Católica do Rio Grande do Sul pelo Sistema Único de Saúde. Foram excluí­das da pesquisa pacientes com sorologia positiva para HIV, com imunossupressão após transplante de órgãos e as que realizaram quimioterapia neoadjuvante. Os dados foram comparados em grupos conforme o comprometimento axilar, o tamanho tumoral, o perfil imunohistoquí­mico do tumor e a ocorrência de eventos adversos (recidiva axilar, recidiva local do tumor e/ou metástases). Nos casos de eventos adversos, foi realizada uma nova contagem de CD4+ e CD8+.Resultados: Foram incluídas 37 pacientes, entre as quais 10 tiveram metástases axilares. As pacientes com axila positiva para metástases apresentaram uma relação CD4+/CD8+ maior que nos casos de axila negativa para metástases (p=0,04). Não foi encontrada diferença estatisticamente significativa em relação ao tamanho e perfil imunohistoquí­mico do tumor. No seguimento médio de 14,3 meses, ocorreram dois eventos adversos (uma recidiva axilar e um caso de metástases ósseas), quando se observou um aumento na relação das células T pesquisadas.Conclusões: A relação das células T CD4+/CD8+ parece aumentar nos casos de câncer de mama de pior prognóstico. Tanto quanto foi possível pesquisar na literatura, estes são os primeiros dados sobre células T CD4+ e CD8+ no sangue periférico de mulheres idosas com câncer de mama. Um seguimento maior poderá determinar o valor destas células como fator prognóstico e/ou preditivo.

Aims: To evaluate the immune risk profile of elderly women with breast cancer and to assess whether this can be a reliable predictor to determine types of treatment and oncologic follow-up.Methods: We assessed the CD4+/CD8+ ratio in peripheral blood cell, as well as serology for cytomegalovirus, of 37 women who were aged 60 years or more at the time they were diagnosed with breast cancer/. They all had surgical treatment at the Breast Center from Pontificia Universidade Catolica do Rio Grande do Sul. Those with positive serology for HIV, or immuno suppressed due to organ transplant, as well as those who had neoadjuvant chemotherapy. Data was analyzed according to axillary involvement, tumor size, tumor immunohistochemical profile and occurrence of adverse events (axillary relapse, local relapse and/or metastases).Results: The mean value of CD4+/CD8+ ratio was 1.72 (min. 1.1, max. 2.32) and cytomegalovirus serology was positive in all subjects. Comparing the groups, patients with positive axillary metastases (n=10) had a CD4+/CD8+ ratio greater than in those with negative axillary metastases (p=0.04). No statistically significant difference was detected regarding the size and immunohistochemical profile of the tumor. Two adverse events occurred at a mean follow-up of 14 months (one axillary relapse and one bone metastasis), when an increase in the CD4+/CD8+ ratio was observed.Conclusions: The CD4+/CD8+ ratio appear to increase in cases of breast cancer with worst prognosis. As far as was possible to search, these are the first data on CD4+ and CD8+ peripheral blood of elderly women with breast cancer. A longer follow-up will determine the value of these cells as a prognostic and/or predictive marker.

The influence o hiv-1 subtypes c, crf31_bc andb on disease progression and innitial virologic response to haart in a southern Brazilian cohort / A influência dos subtipos C, CRF31_BC e B do vírus HIV-1 na progressão da infecção e resposta virológica inicial a terapia antirretroviral em uma coorte no sul do Brasil

Background: Although most HIV-1 infections in Brazil are due to subtype B, Southern Brazil has a high prevalence of subtype C and recombinant forms, such as CRF31_BC. This study assessed the impact of viral diversity on clinical progression in a cohort of newly diagnosed HIV-positive patients. Methods: From July/2004 to December/2005, 135 HIV-infected patients were recruited. The partial pol region was subtyped by phylogeny. A generalized estimating equation (GEE) model was used to examine the relationship between viral subtype, CD4+ T cell count and viral load levels before antiretroviral therapy. Hazard ratio (Cox regression) was used to evaluate factors associated with viral suppression (viral load < 50 copies/mL at six months). Results: Main HIV-1 subtypes included B (29.4%), C (28.2%), and CRF31_BC (23.5%). Subtypes B and C showed a similar trend in CD4+ T cell decline. Comparison of non-B (C and CRF31_BC) and B subtypes revealed no significant difference in the proportion of patients with viral suppression at six months (week 24). Higher CD4+ T cell count and lower viral load were independently associated with viral suppression. Conclusion: No significant differences were found between subtypes; however, lower viral load and higher CD4+ T cell count before therapy were associated with better response.

Introdução: Embora a maioria das infecções de HIV-1 no Brasil seja devido ao subtipo B, o Sul do Brasil apresenta uma alta prevalência do subtipo C e formas recombinantes, como CRF31_BC. Este estudo avaliou o impacto da diversidade viral na evolução clínica em uma coorte de pacientes HIV-positivos recém diagnosticados. Métodos: De julho/2004 a dezembro/2005, 135 pacientes anti-HIV reagentes foram recrutados. A região pol parcial foi subtipada por filogenia. Um modelo de equação de estimativa generalizada (GEE) foi utilizado para examinar a relação entre subtipo viral, contagem de células CD4 e níveis de carga viral pré-terapia antirretroviral. Hazard ratio (regressão de Cox) foi utilizada para avaliar os fatores associados à supressão viral (carga viral < 50 cópias/mL em seis meses). Resultados: Os principais subtipos de HIV-1 incluíram B (29,4%), C (28,2%) e CRF31_BC (23,5%). Os subtipos B e C apresentaram uma tendência semelhante no declínio de células CD4. Quando comparados os subtipos não B (C e CRF31_BC) e B, não houve diferença significativa na proporção de pacientes com supressão viral aos seis meses (24 semanas). CD4 mais alto e carga viral mais baixa demonstraram associação independente com supressão viral. Conclusão: Não houve diferença significativa entre os subtipos; entretanto, viremia mais baixa e CD4 mais alto pré-terapia mostraram associação com melhor resposta.

Treatment of HIV-associated facial lipoatrophy: impact on infection progression assessed by viral load and CD4 count / Tratamento da lipoatrofia facial associada ao HIV/AIDS: o impacto sobre a progressao da infeccao avaliada pela contagem de CD4 e carga viral

BACKGROUND: HIV/AIDS-Associated Lipodystrophy Syndrome includes changes in body fat distribution, with or without metabolic changes. The loss of fat from the face, called facial lipoatrophy, is one of the most stigmatizing signs of the syndrome. OBJECTIVES: To evaluate the effect of FL treatment using polymethylmethacrylate (PMMA) implants on disease progression, assessed by viral load and CD4 cell count. METHODS: This was a prospective study of 44 patients treated from July 2009 to December 2010. Male and female patients, aged over 18 years, with clinically detectable FL and who had never been treated were included in the study. PMMA implantation was done to fill atrophic areas. Laboratory tests were conducted to measure viral load and CD4 count before and after treatment. RESULTS: Of the 44 patients, 72.72% were male and 27.27% female, mean age of 44.38 years. Before treatment, 82% of patients had undetectable viral load, which increased to 88.6% after treatment, but without statistical significance (p = 0.67). CD4 count before treatment ranged from 209 to 1293, averaging 493.97. After treatment, the average increased to 548.61. The increase in CD4 count after treatment was statistically significant with p = 0.02. CONCLUSION: The treatment of FL with PMMA implants showed a statistically significant increase in CD4 count after treatment, revealing the impact of FL treatment on disease progression. Viral load before ...

FUNDAMENTOS: A Síndrome Lipodistrófica Associada ao HIV/AIDS compreende alterações na distribuição da gordura corporal, acompanhada ou não de alterações metabólicas. A perda da gordura facial, chamada lipoatrofia facial, é dos sinais mais estigmatizantes da síndrome. OBJETIVOS: Avaliar o impacto do tratamento dalipoatrofia facial com implante de polimetilmetacrilato sobre a progressão da doença, avaliada pela contagem da carga viral e a contagem de células CD4. MÉTODOS: Estudo prospectivlipoatrofia facial clinicamente detectável e sem tratamento prévio. Foi realizado implante de polimetilmetacrilato para preenchimento das áreas atróficas. Foram realizadas contagem da carga viral e células CD4 antes e após o tratamento. RESULTADOS: Dos 44 pacientes, 72,72% eram do sexo masculino e 27,27% do feminino, e idade média de 44,38 anos. Antes do tratamento, 82% dos pacientes apresentavam carga viral indetectável, que aumentou para 88,6% após o tratamento, mas sem significância estatística (p=0,67). A contagem de CD4 antes do implante variou de 209 a 1293, com média de 493,97. Após o tratamento, essa média aumentou para 548,61. O aumento do CD4 após o tratamento foi estatisticamente significativo, com p=0,02. CONCLUSÃO: O tratamento dalipoatrofia facial com implante de polimetilmetacrilato ...

Comparación de linfocitos CD4 de pacientes con VIH procesadas en un centro de derivación de la Provincia de Buenos Aires de 2005 hasta 2010 / Comparison of CD4 lymphocyte recount among HIV carriers processed in a derivation center of Buenos Aires Province from 2005 up to 2010

En el laboratorio del HIGA Eva Perón se procesaron entre 2005 y 2010 8354 muestras para el dosaje del linfocitos TCD4 de 19 centros asistenciales de la zona Sanitaria V. Los objetivos buscados en este estudio fueron: conocer la distribución de edades, sexo, procedencia y status inmunológico de la población VIH positiva que se atendió entre 2005 y 2010. La medición se hizo por citometría de flujo utilizando un citómetro Coulter para los años 2005-2006 y un Becton-Dickinson los restantes años. En los resultados obtenidos se observa una mejoría general en las poblaciones asistentes a través de los años en estudio ya que en más del 90% de los casos hay un aumento de las células CD4 blanco de la infección y una franca disminución de los porcentajes que caen por debajo de las 200 células/mm3, que reflejan la presencia de enfermedades oportunistas Se observó que la distribución de sexo se mantuvo en un 50%. Durante todos los años en estudio la franja etaria más numerosa fue la nacida en la década del 70. Seguida por los de la década del 60, pero los nuevos casos parecen corresponder a poblaciones más jóvenes nacidos en las décadas de los 80 y 90 Los hallazgos parecen mostrar que la población afectada es cada vez más joven y que la incidencia en el sexo femenino fue en aumento hasta igualar los casos masculinos

From 2005 to 2010 8354 blood samples of patients with VIH were tested by flow citometry to count the number of CD4 T lymphocytes. The specimens were sent to this laboratory by 19 health centers belonging to sanitary Zone V. The aims of this study were to know the age, geographical and sex distribution as well as the immunology status of their bearers. General and progressive improvement in the studied groups were verified during the above mentioned years. There was an increased number of CD4 T cells and a remarkable decrease of samples with less than 200 cell/mm3 and the concurrent appearance of pointer diseases. The group of patients which were more numerous were born during the seventies followed by those born during the sixties. New cases seem to be among the youngest. The distribution of samples remains equal in both sexes

No laboratório do HIGA Eva Perón, processaram-se, entre 2005 e 2010, 8354 amostras para a dosagem dos linfócitos TCD4 de 19 centros assistenciais da zona Sanitária V. Os objetivos procurados neste estúdio foram: conhecer a distribuição de idade, sexo, procedência e status imunológico da população HIV positiva que se atendeu entre 2005 e 2010. A medição se fez por citometria de fluxo utilizando um citômetro Coulter para os anos 2005 - 2006 e um Benton Dickinson, nos restantes anos. Nos resultados obtidos, observase uma melhora geral nas popu lações assistentes através dos anos em estudo, já que mais de 90% dos casos háum acréscimo das células CD4, alvo da infecção, e una franca/ampla diminuição das percentagens, que diminuem a menos de 200 células/mm3, e refletem a presença de doenças oportunistas. Observouse que a distribuição de sexo se manteve em 50%. A faixa etária mais numerosa dos anos de duração do estudo foi a dos nascidos na década de 70. Seguida pela nascida na década de 60. Todavia, os novos casos parecem corresponder a populações mais jovens, nascidas nas décadas de 80 e 90 Os achados parecem mostrar que a população afetada é a cada vez mais jovem e que a incidência no sexo feminino foi crescendo até igualar os casos masculinos

Glutamine or whey-protein supplementation on alloxan-induced diabetic rats. Effects on CD4+ and CD8+ lymphocytes / Efeitos da oferta de glutamina ou de proteína do soro de leite sobre os linfócitos CD4+ e CD8+ em ratos diabéticos aloxano induzidos

PURPOSE: To evaluate the effects of glutamine (L-Gln) or whey-protein supplementation on CD4+ and CD8+ lymphocytes in alloxan-induced diabetic rats. METHODS: Thirty-two healthy male Wistar rats were used in the experiment. Eight rats served as baseline controls (G-1). The remaining 24 animals received alloxan 150mg/Kg intraperitonially dissolved in buffer solution and were equally distributed in 3 subgroups, upon induction of diabetes mellitus, and treated as follows: (G2): saline, 2.0ml; (G3): glutamine solution (0.7g/kg), 2.0 ml; and (G4): whey-protein (WPS) solution (0.7g/kg), 2.0 ml. All solutions were administered by daily 7:00 AM gavages during 30 days. Next, arterial blood samples (3.0 ml) were collected from anesthetized rats for CD4+ and CD8+ lymphocyte count through flow cytometry technology. RESULTS: CD4+ and CD8+ counts decreased significantly in all groups compared with baseline values (G1). G2 rats CD4+/CD8+ ratio decreased significantly compared with G1. CD4+/CD8+ ratio increased significantly (>260 percent) in L-Gln treated group (G3) compared with saline-treated rats (G2). There were no statistical differences in lymphocyte counts (CD4+ and CD8+) between L-Gln (G3) and saline-treated (G2) groups. There was a significant reduction in CD8+ cell count compared with CD4+ cell count in L-Gln treated rats (G3). CONCLUSION: The offer of L-Gln to experimental diabetic rats enhances the immunologic response to infection.(AU)

OBJETIVO: Avaliar os efeitos da suplementação de glutamina ou proteína do soro de leite ( PSL) sobre os linfócitos CD4+ e CD8+ em ratos diabéticos aloxano induzidos. MÉTODOS: Trinta e dois ratos Wistar machos, saudáveis, foram utilizados no estudo. Oito ratos foram usados como controles basais (G1). Os 24 animais remanescentes foram equitativamente distribuídos em 3 subgrupos, após indução do diabetes mellitus por injeção intraperitonial de aloxano (150mg/Kg) e tratados como se segue: (G2): salina; (G3): 2,0 ml de solução de glutamina (0,75g/Kg);(G4): PSL, (0,7g/Kg), 2,0ml. Todas as soluções foram administradas por gavagem, diariamente, cada 7:00 h, durante 30 dias. Após esse período, foram coletadas amostradas de sangue arterial para contagem de linfócitos CD4+ e CD8+ por citometria de fluxo. RESULTADOS: A população de linfócitos CD4+ e CD8+ diminuiu significantemente em todos os grupos em comparação aos valores encontrados no grupo G1. A razão CD4+/CD8+ foi significantemente maior (>260 por cento) nos ratos tratados com L-Gln que nos ratos tratados com salina (G2). Não se observaram diferenças significantes na população de linfócitos CD4+ e CD8+ entre os grupos G3 e G2. Houve redução significante do número de células CD8+ quando comparado ao número de células CD4+ nos ratos tratados com L-Gln (G3). CONCLUSÃO: A oferta de L-Gln em ratos diabéticos aloxano-induzidos melhora a resposta imunológica à infecção.(AU)

Cryptosporidium SP in HIV-infected individuals attending a Brazilian University Hospital

The aim of the current work was to evaluate the occurrence of Cryptosporidium sp in AIDS patients in a region of São Paulo State, Brazil. Patients were divided into groups according to CD4+ T lymphocyte count and use of potent antiretroviral treatment. Two hundred and ten fecal samples from 105 patients were fixed in 10% formalin and subjected to centrifuge formol-ether sedimentation. Slides were stained with auramine and confirmed by modified Ziehl-Neelsen. Cryptosporidiosis occurrence was 10.5% with no relationship among gender, age or the presence of diarrhea. The number of oocysts in all samples was small, independent of CD4+ T lymphocyte count, HIV plasma viral load, and presence of diarrhea. These results may be due to the reduced prevalence of opportunistic infections in AIDS individuals after the advent of highly active antiretroviral therapy.