High frequency of dolutegravir resistance in patients failing a raltegravir-containing salvage regimen

OBJECTIVES: Dolutegravir is a second-generation integrase strand transfer inhibitor (InSTI) that has been recently approved by the FDA to treat antiretroviral therapy-naive as well as treatment-experienced HIV-infected individuals, including those already exposed to the first-generation InSTI. Despite having a different mutational profile, some cross-resistance mutations may influence its susceptibility. The aim of this study was to evaluate the impact of a raltegravir-containing salvage regimen on dolutegravir activity. PATIENTS AND METHODS: Blood samples of 92 HIV-infected individuals with virological failure (two or more viral loads >50 copies/mL after 6 months of treatment) using raltegravir with optimized background therapy were sequenced and evaluated according to the Stanford University HIV Drug Resistance Database algorithm. RESULTS: Among the 92 patients analysed, 32 (35%) showed resistance to dolutegravir, in most cases associated with the combination of Q148H/R/K with G140S/A mutations. At genotyping, patients with resistance to dolutegravir had viral load values closer to the highest previously documented viral load. CONCLUSIONS: Changes in viraemia during virological failure may indicate the evolution of raltegravir resistance and may predict the emergence of secondary mutations that are associated with a decrease in dolutegravir susceptibility. Early discontinuation of raltegravir from failing regimens might favour subsequent salvage with dolutegravir, but further studies are necessary to evaluate this issue.

Transmission of a multidrug-resistant HIV-! from an accupational exposure, in São Paulo, Brazil

We documented the first transmission of a multidrug-resistant HIV from an occupational exposure in Sao Paulo, Brazil, albeit with antiretroviral prophylaxis instituted within 1 h after the accident. A 27-year-old female healthcare worker (HCW) sustained an index finger needle stick injury with a 20-gauge needle while puncturing the forearm of an HIV-infected patient. The putative source (index) patient was a 44-year-old homeless female, on irregular use of zidovudine (AZT), lamivudine (3TC) and ritonavir boosted lopinavir(LPV/r). She was hepatitis C virus (HCV) coinfected and had been prescribed different regimens including nucleos(t)ide reverse transcriptase inhibitors (NRTI), non-nucleos(t)ide reverse transcriptase inhibitors (NNRTI) or protease inhibitors since 2011. Around the time of the accident, she had a HIV viral load of 4.56 log10, HCV viral load of 5.9 log10 (Abbott Real Time HIV and HCV, USA) and CD4+ cell count (BD Biosciences FACSCalibur Flow Cytometer, USA) of 143 cells/µl. After the HCW tested negative by rapid test, AZT/3TC/LPV/r was instituted, as suggested by current guidelines [1,2], within 1 h of the accident.

Serotyping HIV-1 with V3 peptides: detection of high avidity antibodies presenting clade-specific reactivity

The main objective of the present study was to assess the specificity and sensitivity of a modified assay using short synthetic peptides of the V3 region of HIV-1 gp120, which is the main target for neutralizing antibodies. Results from an enzyme immunoassay (EIA) employing a panel of synthetic peptides of HIV-1 subtypes and using urea washes to detect high avidity antibodies (AAV3) were compared with those obtained by the heteroduplex mobility assay and DNA sequencing. The EIA correctly typed 100 percent of subtype B (sensitivity = 1.0; specificity = 0.95), 100 percent of HIV-1 E samples (sensitivity = 1.0; specificity = 1.0), and 95 percent of subtype C specimens (sensitivity = 0.95; specificity = 0.94). In contrast, only 50 percent of subtype A (sensitivity = 0.5; specificity = 0.95), 60 percent of subtype D (sensitivity = 0.6; specificity = 1.0), and 28 percent of subtype F samples (sensitivity = 0.28; specificity = 0.95) were correctly identified. This approach was also able to discriminate in a few samples antibodies from patients infected with B variants circulating in Brazil and Thailand that reacted specifically. The assays described in this study are relatively rapid and simple to perform compared to molecular approaches and can be used to screen large numbers of serum or plasma samples. Moreover, the classification in subtypes (genotypes) may overestimate HIV-1 diversity and a classification into serotypes, based on antigenic V3 diversity or another principal neutralization domain, may be more helpful for vaccine development and identification of variants

Two variants of HIV-1 B serotype are transmitted heterosexually in Säo Paulo, Brazil

HIV-1 variability may have an important impact on transmission and pathogenicity. Better characterization of the HIV epidemic in Brazil is necessary for the development of vaccine trials in this country. We analyzed sera from 108 HIV-1-infected volunteers from Säo Paulo City to determine serotype and reactivity for V3 motifs of HIV in this population, and the relationship to transmission mode. We concluded that the HIV-1 B serotype is frequent among heterosexually infected women, even in the absence of anal sex, and that two major V3 motifs, GPGR and GWGR, had similar prevalence among women (48 per cent and 52 per cent, respectively) and men (56 per cent and 44 per cent, respectively). We also observed an equal distribution of these strains regardless of their CD4+ T cell counts, clinical status, and mode of transmission. Even though V3 serology for HIV-1 subtyping is an inexpensive tool for use in developing countries, additional methods, such as heteroduplex mobility assay and direct DNA sequencing, should be included to determine HIV-1 genetic diversity.

Human immunodeficiency virus grown in CD4-expressing cells is associated with CD4.

Using a CD4-capture immunoassay for gp120, several strains of human immunodeficiency virus type 1 (HIV-1) grown in CD4-expressing T lymphoblastoid cells were found to contain little CD4-reactive gp120 (0.3-1.0 ng/ml) relative to virus titre (10(3.2)-10(5.0) TCID50/ml) and p24 antigen (80-1000 ng/ml). The measured CD4-reactive gp120 concentrations of HIV-1 suspensions grown in CD4-negative human neuroblastoma cells were 100- to 10,000-fold greater than those of HIV-1 grown in CD4-positive lymphoblastoid cells, even though both virus suspensions contained abundant viral gp120 as shown by immunoblot assay. It was postulated that CD4 derived from host cells might be associated with virions, concealing the binding domains of gp120. CD4 association with HIV-1 virions grown in CD4-positive cells was demonstrated directly by immunoblot assay of sucrose gradient-purified virus suspensions and by specific co-sedimentation of 125I-labelled OKT4 with virions propagated in CD4-expressing cells. CD4 coating of primary HIV-1 isolates grown in peripheral blood mononuclear cells was also observed. The biological significance of CD4 coating of HIV particles remains to be determined.

[Common variable immunodeficiency (hypogammaglobulinemia of late onset or acquired hypogammaglobulinemia): initial follow-up of 11 cases]. / Imunodeficiência comum variável (hipogamaglobulinemia de início tardio ou hipogamaglobulinemia adquirida): seguimento inicial de 11 casos.

The present paper describes the clinical and laboratory follow-up of 11 patients with the diagnosis of common variable immunodeficiency. Their age varied from 8 to 45 years. The mean disease time was 12.6 years and mean diagnosis time 4.3 years. Infectious manifestations, mainly of the respiratory and digestive tracts, occurred in all patients. Polyadenomegaly was noted in seven, hepatomegaly in six, splenomegaly in five and arthralgia in four patients. All of them presented serum IgG less than 250 mg/dl. IgA less than 33 mg/dl and IgM less than 31 mg/dl, except one with IgM = 176 mg/dl. The isohaemagglutinin titers were less than 1/20 in all but one patient. The determination of the number of B lymphocytes in the peripheral blood revealed normal counts in three, elevated in one and decreased in five patients. The CD-4/CD-8 ratio was less than 1 in 8 and greater than 1 in three of them. Five patients had positive cutaneous late reactions to at least one of the following antigens: PPD, SK-SD (Varidase), Trichophytin and Levedurin (Candidin). A decrease of the proliferative activity of peripheral blood mononuclear cells stimulated by lectins (PHA, Con-A, PWM) was also noted. Natural killer function was decreased. The association a possible role of regulatory lymphocytes in the immunopathogenesis of this disease. The data presented here emphasize the diversity of clinical and immunological manifestations of this disease, which could be noted between diverse patients and in the follow-up of a single one. In our cases the disease had an evolutive character, with a primarily humoral dysfunction followed by cellular immunity disturbances that determined poorer prognosis and progressive difficulties in the therapeutics. We suggest a conceptual reevaluation of this condition and a new denomination, for instance "Late-Onset Combined Immunodeficiency". The long delay between the initial clinical manifestations of the disease and its diagnosis was a handicap for an adequate treatment. Early intervention could certainly decrease the morbidity and mortality of the disease.

[Immunologic changes associated with human immunodeficiency virus (HIV)]. / Alterações imunológicas associadas ao vírus da imunodeficiencia humana (HIV).

Infection by HIV usually leads to dysfunction of the immune system which, facilitates the development of opportunistic infections or neoplasia in which almost always are fatal. The pathological process associated with this infection involves, characteristically, the destruction or malfunction of helper T lymphocytes (CD4+), due to, besides other factors, direct parasitism of the virus or to the secondary immune response, which seems to include autoimmune mechanisms. These pathological changes, along with the action of the virus on other components of the immune system, disturb the production of trophic factors and also the proliferation, differentiation and effector ability of different cells of the immune system. The long latent period, when a large number of infected individuals remain asymptomatic or with only minor clinical and/or laboratory disturbances suggest the possible role of some as yet uncharacterized cofactors, either inherent to the host or to other environmental agents; these cofactors may play a role in the modulation of the progression to this syndrome (AIDS).