Epidemiological and evolutionary consequences of different types of CRISPR-Cas systems.

Bacteria have adaptive immunity against viruses (phages) in the form of CRISPR-Cas immune systems. Currently, 6 types of CRISPR-Cas systems are known and the molecular study of three of these has revealed important molecular differences. It is unknown if and how these molecular differences change the outcome of phage infection and the evolutionary pressure the CRISPR-Cas systems faces. To determine the importance of these molecular differences, we model a phage outbreak entering a population defending exclusively with a type I/II or a type III CRISPR-Cas system. We show that for type III CRISPR-Cas systems, rapid phage extinction is driven by the probability to acquire at least one resistance spacer. However, for type I/II CRISPR-Cas systems, rapid phage extinction is characterized by an a threshold-like behaviour: any acquisition probability below this threshold leads to phage survival whereas any acquisition probability above it, results in phage extinction. We also show that in the absence of autoimmunity, high acquisition rates evolve. However, when CRISPR-Cas systems are prone to autoimmunity, intermediate levels of acquisition are optimal during a phage outbreak. As we predict an optimal probability of spacer acquisition 2 factors of magnitude above the one that has been measured, we discuss the origin of such a discrepancy. Finally, we show that in a biologically relevant parameter range, a type III CRISPR-Cas system can outcompete a type I/II CRISPR-Cas system with a slightly higher probability of acquisition.

Pathogen diversity drives the evolution of generalist MHC-II alleles in human populations.

Central players of the adaptive immune system are the groups of proteins encoded in the major histocompatibility complex (MHC), which shape the immune response against pathogens and tolerance to self-peptides. The corresponding genomic region is of particular interest, as it harbors more disease associations than any other region in the human genome, including associations with infectious diseases, autoimmune disorders, cancers, and neuropsychiatric diseases. Certain MHC molecules can bind to a much wider range of epitopes than others, but the functional implication of such an elevated epitope-binding repertoire has remained largely unclear. It has been suggested that by recognizing more peptide segments, such promiscuous MHC molecules promote immune response against a broader range of pathogens. If so, the geographical distribution of MHC promiscuity level should be shaped by pathogen diversity. Three lines of evidence support the hypothesis. First, we found that in pathogen-rich geographical regions, humans are more likely to carry highly promiscuous MHC class II DRB1 alleles. Second, the switch between specialist and generalist antigen presentation has occurred repeatedly and in a rapid manner during human evolution. Third, molecular positions that define promiscuity level of MHC class II molecules are especially diverse and are under positive selection in human populations. Taken together, our work indicates that pathogen load maintains generalist adaptive immune recognition, with implications for medical genetics and epidemiology.

Behavioral changes before lockdown and decreased retail and recreation mobility during lockdown contributed most to controlling COVID-19 in Western countries.

BACKGROUND: The COVID-19 pandemic has prompted a lockdown in many countries to control the exponential spread of the SARS-CoV-2 virus, hereby reducing the time-varying basic reproduction number (Rt) to below one. Governments are looking for evidence to balance the demand of their citizens to ease some of the restriction, against the fear of a new peak in infections. In this study, we wanted to quantify the relative contribution of mobility restrictions, and that of behavioral changes that occurred already before the lockdowns, on the reduction of transmission during lockdowns in Western countries in early 2020. METHODS: Incidence data of cases and deaths from the first wave of infections for 35 Western countries (32 European, plus Israel, USA and Canada) were analyzed using epidemiological compartment models in a Bayesian framework. Mobility data was used to estimate the timing of changes associated with a lockdown, and was correlated with estimated reductions of Rt. RESULTS: Across all countries, the initial median estimate for Rt was 3.6 (95% IQR 2.4-5.2), and it was reduced to 0.78 (95% IQR 0.58-1.01) during lockdown. 48% (18-65%) of the reduction occurred already in the week before lockdown, with lockdown itself causing the remaining drop in transmission. A lower Rt during lockdown was independently associated with an increased time spent at home (0.21 per 10% more time, p < 0.007), and decreased mobility related to retail and recreation (0.07 per 10% less mobility, p < 0.008). CONCLUSIONS: In a Western population unaware of the risk, SARS-CoV-2 can be highly contagious with a reproduction number R0 > 5. Our results are consistent with evidence that recreational activities (including restaurant and bar visits) enable super-spreading events. Exiting from lockdown therefore requires continued physical distancing and tight control on this kind of activities.

Dissecting HIV Virulence: Heritability of Setpoint Viral Load, CD4+ T-Cell Decline, and Per-Parasite Pathogenicity.

Pathogen strains may differ in virulence because they attain different loads in their hosts, or because they induce different disease-causing mechanisms independent of their load. In evolutionary ecology, the latter is referred to as "per-parasite pathogenicity". Using viral load and CD4+ T-cell measures from 2014 HIV-1 subtype B-infected individuals enrolled in the Swiss HIV Cohort Study, we investigated if virulence-measured as the rate of decline of CD4+ T cells-and per-parasite pathogenicity are heritable from donor to recipient. We estimated heritability by donor-recipient regressions applied to 196 previously identified transmission pairs, and by phylogenetic mixed models applied to a phylogenetic tree inferred from HIV pol sequences. Regressing the CD4+ T-cell declines and per-parasite pathogenicities of the transmission pairs did not yield heritability estimates significantly different from zero. With the phylogenetic mixed model, however, our best estimate for the heritability of the CD4+ T-cell decline is 17% (5-30%), and that of the per-parasite pathogenicity is 17% (4-29%). Further, we confirm that the set-point viral load is heritable, and estimate a heritability of 29% (12-46%). Interestingly, the pattern of evolution of all these traits differs significantly from neutrality, and is most consistent with stabilizing selection for the set-point viral load, and with directional selection for the CD4+ T-cell decline and the per-parasite pathogenicity. Our analysis shows that the viral genotype affects virulence mainly by modulating the per-parasite pathogenicity, while the indirect effect via the set-point viral load is minor.

Network topology dynamics of circulating biomarkers and cognitive performance in older Cytomegalovirus-seropositive or -seronegative men and women.

BACKGROUND: Cytokines are signaling molecules operating within complex cascade patterns and having exceptional modulatory functions. They impact various physiological processes such as neuroendocrine and metabolic interactions, neurotrophins' metabolism, neuroplasticity, and may affect behavior and cognition. In our previous study, we found that sex and Cytomegalovirus (CMV)-serostatus may modulate levels of circulating pro- and anti-inflammatory cytokines, metabolic factors, immune cells, and cognitive performance, as well as associations between them. RESULTS: In the present study, we used a graph-theoretical approach to investigate the network topology dynamics of 22 circulating biomarkers and 11 measures of cognitive performance in 161 older participants recruited to undergo a six-months training intervention. For network construction, we applied coefficient of determination (R 2 ) that was calculated for all possible pairs of variables (N = 33) in four groups (CMV- men and women; CMV+ men and women). Network topology has been evaluated by clustering coefficient (CC) and characteristic path length (CPL) as well as local (E local ) and global (E global ) efficiency, showing the degree of network segregation (CC and E local ) and integration (CPL and E global ). We found that networks under consideration showed small-world networks properties with more random characteristics. Mean CC, as well as local and global efficiency were highest and CPL shortest in CMV- males (having lowest inflammatory status and highest cognitive performance). CMV- and CMV+ females did not show any significant differences. Modularity analyses showed that the networks exhibit in all cases highly differentiated modular organization (with Q-value ranged between 0.397 and 0.453). CONCLUSIONS: In this work, we found that segregation and integration properties of the network were notably stronger in the group with balanced inflammatory status. We were also able to confirm our previous findings that CMV-infection and sex modulate multiple circulating biomarkers and cognitive performance and that balanced inflammatory and metabolic status in elderly contributes to better cognitive functioning. Thus, network analyses provide a useful strategy for visualization and quantitative description of multiple interactions between various circulating pro- and anti-inflammatory biomarkers, hormones, neurotrophic and metabolic factors, immune cells, and measures of cognitive performance and can be in general applied for analyzing interactions between different physiological systems.

Teams on the same wavelength perform better: Inter-brain phase synchronization constitutes a neural substrate for social facilitation.

Working together feels easier with some people than with others. We asked participants to perform a visual search task either alone or with a partner while simultaneously measuring each participant's EEG. Local phase synchronization and inter-brain phase synchronization were generally higher when subjects jointly attended to a visual search task than when they attended to the same task individually. Some participants searched the visual display more efficiently and made faster decisions when working as a team, whereas other dyads did not benefit from working together. These inter-team differences in behavioral performance gain in the visual search task were reliably associated with inter-team differences in local and inter-brain phase synchronization. Our results suggest that phase synchronization constitutes a neural correlate of social facilitation, and may help to explain why some teams perform better than others.

HIV competition dynamics over sexual networks: first comer advantage conserves founder effects.

Outside Africa, the global phylogeography of HIV is characterized by compartmentalized local epidemics that are typically dominated by a single subtype, which indicates strong founder effects. We hypothesized that the competition of viral strains at the epidemic level may involve an advantage of the resident strain that was the first to colonize a population. Such an effect would slow down the invasion of new strains, and thus also the diversification of the epidemic. We developed a stochastic modelling framework to simulate HIV epidemics over dynamic contact networks. We simulated epidemics in which the second strain was introduced into a population where the first strain had established a steady-state epidemic, and assessed whether, and on what time scale, the second strain was able to spread in the population. Simulations were parameterized based on empirical data; we tested scenarios with varying levels of overall prevalence. The spread of the second strain occurred on a much slower time scale compared with the initial expansion of the first strain. With strains of equal transmission efficiency, the second strain was unable to invade on a time scale relevant for the history of the HIV pandemic. To become dominant over a time scale of decades, the second strain needed considerable (>25%) advantage in transmission efficiency over the resident strain. The inhibition effect was weaker if the second strain was introduced while the first strain was still in its growth phase. We also tested how possible mechanisms of interference (inhibition of superinfection, depletion of highly connected hubs in the network, one-time acute peak of infectiousness) contribute to the inhibition effect. Our simulations confirmed a strong first comer advantage in the competition dynamics of HIV at the population level, which may explain the global phylogeography of the virus and may influence the future evolution of the pandemic.

Gag-Pol processing during HIV-1 virion maturation: a systems biology approach.

Proteolytic processing of Gag and Gag-Pol polyproteins by the viral protease (PR) is crucial for the production of infectious HIV-1, and inhibitors of the viral PR are an integral part of current antiretroviral therapy. The process has several layers of complexity (multiple cleavage sites and substrates; multiple enzyme forms; PR auto-processing), which calls for a systems level approach to identify key vulnerabilities and optimal treatment strategies. Here we present the first full reaction kinetics model of proteolytic processing by HIV-1 PR, taking into account all canonical cleavage sites within Gag and Gag-Pol, intermediate products and enzyme forms, enzyme dimerization, the initial auto-cleavage of full-length Gag-Pol as well as self-cleavage of PR. The model allows us to identify the rate limiting step of virion maturation and the parameters with the strongest effect on maturation kinetics. Using the modelling framework, we predict interactions and compensatory potential between individual cleavage rates and drugs, characterize the time course of the process, explain the steep dose response curves associated with PR inhibitors and gain new insights into drug action. While the results of the model are subject to limitations arising from the simplifying assumptions used and from the uncertainties in the parameter estimates, the developed framework provides an extendable open-access platform to incorporate new data and hypotheses in the future.

Hyper-brain hyper-frequency network topology dynamics when playing guitar in quartet.

Ensemble music performance is a highly coordinated form of social behavior requiring not only precise motor actions but also synchronization of different neural processes both within and between the brains of ensemble players. In previous analyses, which were restricted to within-frequency coupling (WFC), we showed that different frequencies participate in intra- and inter-brain coordination, exhibiting distinct network topology dynamics that underlie coordinated actions and interactions. However, many of the couplings both within and between brains are likely to operate across frequencies. Hence, to obtain a more complete picture of hyper-brain interaction when musicians play the guitar in a quartet, cross-frequency coupling (CFC) has to be considered as well. Furthermore, WFC and CFC can be used to construct hyper-brain hyper-frequency networks (HB-HFNs) integrating all the information flows between different oscillation frequencies, providing important details about ensemble interaction in terms of network topology dynamics (NTD). Here, we reanalyzed EEG (electroencephalogram) data obtained from four guitarists playing together in quartet to explore changes in HB-HFN topology dynamics and their relation to acoustic signals of the music. Our findings demonstrate that low-frequency oscillations (e.g., delta, theta, and alpha) play an integrative or pacemaker role in such complex networks and that HFN topology dynamics are specifically related to the guitar quartet playing dynamics assessed by sound properties. Simulations by link removal showed that the HB-HFN is relatively robust against loss of connections, especially when the strongest connections are preserved and when the loss of connections only affects the brain of one guitarist. We conclude that HB-HFNs capture neural mechanisms that support interpersonally coordinated action and behavioral synchrony.

Lower theta inter-trial phase coherence during performance monitoring is related to higher reaction time variability: a lifespan study.

Trial-to-trial reaction time (RT) variability is consistently higher in children and older adults than in younger adults. Converging evidence also indicates that higher RT variability is (a) associated with lower behavioral performance on complex cognitive tasks, (b) distinguishes patients with neurological deficits from healthy individuals, and also (c) predicts longitudinal cognitive decline in older adults. However, so far the processes underlying increased RT variability are poorly understood. Previous evidence suggests that control signals in the medial frontal cortex (MFC) are reflected in theta band activity and may implicate the coordination of distinct brain areas during performance monitoring. We hypothesized that greater trial-to-trial variability in theta power during performance monitoring may be associated with greater behavioral variability in response latencies. We analyzed event-related theta oscillations assessed during a cued-Go/NoGo task in a lifespan sample covering the age range from middle childhood to old age. Our results show that theta inter-trial coherence during NoGo trials increases from childhood to early adulthood, and decreases from early adulthood to old age. Moreover, in all age groups, individuals with higher variability in medial frontal stimulus-locked theta oscillations showed higher trial-to-trial RT variability behaviorally. Importantly, this effect was strongest at high performance monitoring demands and independent of motor response execution as well as theta power. Taken together, our findings reveal that lower theta inter-trial coherence is related to greater behavioral variability within and across age groups. These results hint at the possibility that more variable MFC control may be associated with greater performance fluctuations.

Superinfection with drug-resistant HIV is rare and does not contribute substantially to therapy failure in a large European cohort.

BACKGROUND: Superinfection with drug resistant HIV strains could potentially contribute to compromised therapy in patients initially infected with drug-sensitive virus and receiving antiretroviral therapy. To investigate the importance of this potential route to drug resistance, we developed a bioinformatics pipeline to detect superinfection from routinely collected genotyping data, and assessed whether superinfection contributed to increased drug resistance in a large European cohort of viremic, drug treated patients. METHODS: We used sequence data from routine genotypic tests spanning the protease and partial reverse transcriptase regions in the Virolab and EuResist databases that collated data from five European countries. Superinfection was indicated when sequences of a patient failed to cluster together in phylogenetic trees constructed with selected sets of control sequences. A subset of the indicated cases was validated by re-sequencing pol and env regions from the original samples. RESULTS: 4425 patients had at least two sequences in the database, with a total of 13816 distinct sequence entries (of which 86% belonged to subtype B). We identified 107 patients with phylogenetic evidence for superinfection. In 14 of these cases, we analyzed newly amplified sequences from the original samples for validation purposes: only 2 cases were verified as superinfections in the repeated analyses, the other 12 cases turned out to involve sample or sequence misidentification. Resistance to drugs used at the time of strain replacement did not change in these two patients. A third case could not be validated by re-sequencing, but was supported as superinfection by an intermediate sequence with high degenerate base pair count within the time frame of strain switching. Drug resistance increased in this single patient. CONCLUSIONS: Routine genotyping data are informative for the detection of HIV superinfection; however, most cases of non-monophyletic clustering in patient phylogenies arise from sample or sequence mix-up rather than from superinfection, which emphasizes the importance of validation. Non-transient superinfection was rare in our mainly treatment experienced cohort, and we found a single case of possible transmitted drug resistance by this route. We therefore conclude that in our large cohort, superinfection with drug resistant HIV did not compromise the efficiency of antiretroviral treatment.

Risk Factors of Severe COVID-19: A Review of Host, Viral and Environmental Factors.

The clinical course and outcome of COVID-19 are highly variable, ranging from asymptomatic infections to severe disease and death. Understanding the risk factors of severe COVID-19 is relevant both in the clinical setting and at the epidemiological level. Here, we provide an overview of host, viral and environmental factors that have been shown or (in some cases) hypothesized to be associated with severe clinical outcomes. The factors considered in detail include the age and frailty, genetic polymorphisms, biological sex (and pregnancy), co- and superinfections, non-communicable comorbidities, immunological history, microbiota, and lifestyle of the patient; viral genetic variation and infecting dose; socioeconomic factors; and air pollution. For each category, we compile (sometimes conflicting) evidence for the association of the factor with COVID-19 outcomes (including the strength of the effect) and outline possible action mechanisms. We also discuss the complex interactions between the various risk factors.

Intra- and interbrain synchrony and hyperbrain network dynamics of a guitarist quartet and its audience during a concert.

Playing music in a concert represents a multilevel interaction between musicians and the audience, where interbrain synchronization might play an essential role. Here, we simultaneously recorded electroencephalographs (EEGs) from the brains of eight people during a concert: a quartet of professional guitarists and four participants in the audience. Using phase synchronization analyses between EEG signals within and between brains, we constructed hyperbrain networks, comprising synchronized brain activity across the eight brains, and analyzed them using a graph-theoretical approach. We found that strengths within and between brains in the delta band were higher in the quartet than in the public. Within-brain strengths were higher and between-brain strengths were lower in the music than in the applause condition, both particularly in the quartet group. These changes in coupling strength were accompanied by corresponding changes in the hyperbrain network topology, which were also frequency-specific. Moreover, the network topology and the dynamical structure of guitar sounds showed specific guitar-brain, guitar-guitar, and brain-brain directional associations, indicating multilevel dynamics with upward and downward causation. Finally, the hyperbrain networks exhibit modular structures that were more stable during music performance than during applause. Our findings illustrate complex hyperbrain network interactions in a quartet and its audience during a concert.

Dynamics in interbrain synchronization while playing a piano duet.

Humans interact with each other through actions that are implemented by sensory and motor processes. To investigate the role of interbrain synchronization emerging during interpersonal action coordination, electroencephalography data from 13 pairs of pianists were recorded simultaneously while they performed a duet together. The study aimed to investigate whether interbrain phase couplings can be reduced to similar bottom-up driven processes during synchronous play, or rather represent cognitive top-down control required during periods of higher coordination demands. To induce such periods, one of the musicians acted as a confederate who deliberately desynchronized the play. As intended, on the behavioral level, the perturbation caused a breakdown in the synchronization of the musicians' play and in its stability across trials. On the brain level, interbrain synchrony, as measured by the interbrain phase coherence (IPC), increased in the delta and theta frequency bands during perturbation as compared to non-perturbed trials. Interestingly, this increase in IPC in the delta band was accompanied by the shift of the phase difference angle from in-phase toward anti-phase synchrony. In conclusion, the current study demonstrates that interbrain synchronization is based on the interpersonal temporal alignment of different brain mechanisms and is not simply reducible to similar sensory or motor responses.

Intra- and inter-brain coupling and activity dynamics during improvisational music therapy with a person with dementia: an explorative EEG-hyperscanning single case study.

Objective: Real-life research into the underlying neural dynamics of improvisational music therapy, used with various clinical populations, is largely lacking. This single case study explored within-session differences in musical features and in within- and between-brain coupling between a Person with Dementia (PwD) and a music therapist during a music therapy session. Methods: Dual-EEG from a music therapist and a PwD (male, 31 years) was recorded. Note density, pulse clarity and synchronicity were extracted from audio-visual data. Three music therapists identified moments of interest and no interest (MOI/MONI) in two drum improvisations. The Integrative Coupling Index, reflecting time-lagged neural synchronization, and musical features were compared between the MOI and MONI. Results: Between-brain coupling of 2 Hz activity was increased during the MOI, showing anteriority of the therapist's neural activity. Within-brain coupling for the PwD was stronger from frontal and central areas during the MOI, but within-brain coupling for the therapist was stronger during MONI. Differences in musical features indicated that both acted musically more similar to one another during the MOI. Conclusion: Within-session differences in neural synchronization and musical features highlight the dynamic nature of music therapy. Significance: The findings contribute to a better understanding of social and affective processes in the brain and (interactive) musical behaviors during specific moments in a real-life music therapy session. This may provide insights into the role of such moments for relational-therapeutic processes.

Mutations in HIV-1 gag and pol compensate for the loss of viral fitness caused by a highly mutated protease.

During the last few decades, the treatment of HIV-infected patients by highly active antiretroviral therapy, including protease inhibitors (PIs), has become standard. Here, we present results of analysis of a patient-derived, multiresistant HIV-1 CRF02_AG recombinant strain with a highly mutated protease (PR) coding sequence, where up to 19 coding mutations have accumulated in the PR. The results of biochemical analysis in vitro showed that the patient-derived PR is highly resistant to most of the currently used PIs and that it also exhibits very poor catalytic activity. Determination of the crystal structure revealed prominent changes in the flap elbow region and S1/S1' active site subsites. While viral loads in the patient were found to be high, the insertion of the patient-derived PR into a HIV-1 subtype B backbone resulted in reduction of infectivity by 3 orders of magnitude. Fitness compensation was not achieved by elevated polymerase (Pol) expression, but the introduction of patient-derived gag and pol sequences in a CRF02_AG backbone rescued viral infectivity to near wild-type (wt) levels. The mutations that accumulated in the vicinity of the processing sites spanning the p2/NC, NC/p1, and p6pol/PR proteins lead to much more efficient hydrolysis of corresponding peptides by patient-derived PR in comparison to the wt enzyme. This indicates a very efficient coevolution of enzyme and substrate maintaining high viral loads in vivo under constant drug pressure.

Lifespan differences in nonlinear dynamics during rest and auditory oddball performance.

Electroencephalographic recordings (EEG) were used to assess age-associated differences in nonlinear brain dynamics during both rest and auditory oddball performance in children aged 9.0-12.8 years, younger adults, and older adults. We computed nonlinear coupling dynamics and dimensional complexity, and also determined spectral alpha power as an indicator of cortical reactivity. During rest, both nonlinear coupling and spectral alpha power decreased with age, whereas dimensional complexity increased. In contrast, when attending to the deviant stimulus, nonlinear coupling increased with age, and complexity decreased. Correlational analyses showed that nonlinear measures assessed during auditory oddball performance were reliably related to an independently assessed measure of perceptual speed. We conclude that cortical dynamics during rest and stimulus processing undergo substantial reorganization from childhood to old age, and propose that lifespan age differences in nonlinear dynamics during stimulus processing reflect lifespan changes in the functional organization of neuronal cell assemblies.

Neural Synchrony and Network Dynamics in Social Interaction: A Hyper-Brain Cell Assembly Hypothesis.

Mounting neurophysiological evidence suggests that interpersonal interaction relies on continual communication between cell assemblies within interacting brains and continual adjustments of these neuronal dynamic states between the brains. In this Hypothesis and Theory article, a Hyper-Brain Cell Assembly Hypothesis is suggested on the basis of a conceptual review of neural synchrony and network dynamics and their roles in emerging cell assemblies within the interacting brains. The proposed hypothesis states that such cell assemblies can emerge not only within, but also between the interacting brains. More precisely, the hyper-brain cell assembly encompasses and integrates oscillatory activity within and between brains, and represents a common hyper-brain unit, which has a certain relation to social behavior and interaction. Hyper-brain modules or communities, comprising nodes across two or several brains, are considered as one of the possible representations of the hypothesized hyper-brain cell assemblies, which can also have a multidimensional or multilayer structure. It is concluded that the neuronal dynamics during interpersonal interaction is brain-wide, i.e., it is based on common neuronal activity of several brains or, more generally, of the coupled physiological systems including brains.

Probing associations between interbrain synchronization and interpersonal action coordination during guitar playing.

Playing music in an ensemble is a highly coordinated human action involving musicians' brain-body interactions at different levels of physical and cortical organization in time and space. It has been suggested that interbrain phase synchronization plays an essential role in musical interaction. In this study, we aimed to explore associations between interbrain synchronization and interpersonal action coordination, using electroencephalographic recordings of the brain activity of guitarists playing in a duet as well as the acoustic recordings of their music. By applying phase synchronization algorithms to the musicians' brain activities and the sounds produced during guitar playing, we show that synchronous brain activity is strongly related to instrument sounds and behavioral play-onset synchrony, as indicated by phase alignment in relation to the time differences in play onsets and an angular-linear correlation between phase and time differences across trials and guitarist pairs. Interestingly, this correlation was especially strong in the first part of the music piece, when the guitarists seem to adjust their coordinated play onsets and brain rhythms actively. This suggests that the methods capturing intra- and interbrain synchronization and its relations to coordinated playing provide crucial information about the underlying mechanisms of interpersonal action coordination.

The Impact of Genital Ulcers on HIV Transmission Has Been Underestimated-A Critical Review.

In the early 1990s, several observational studies determined that genital ulcer disease (GUD), in either the index or the exposed person, facilitates HIV transmission. Several meta-analyses have since presented associated risk ratios (RR) over the baseline per-act transmission probability (PATP) usually in the range of 2-5. Here we review all relevant observational studies and meta-analyses, and show that the estimation of RRs was, in most cases, biased by assuming the presence of GUD at any time during long follow-up periods, while active genital ulcers were present in a small proportion of the time. Only two studies measured the GUD co-factor effect in PATPs focusing on acts in which ulcers were present, and both found much higher RRs (in the range 11-112). We demonstrate that these high RRs can be reconciled with the studies on which currently accepted low RRs were based, if the calculations are restricted to the actual GUD episodes. Our results indicate that the effect of genital ulcers on the PATP of HIV might be much greater than currently accepted. We conclude that the medical community should work on the assumption that HIV risk is very high during active genital ulcers.