Clinical challenges and controversies in the management of HIV/HCV-coinfected individuals

The natural history of HIV infection has been dramatically changed by the highly active antiretroviral therapies, reducing complications, morbidity and mortality of the disease. Approximately 25% of persons infected with HIV are co-infected with hepatitis C, and some high risk populations have a prevalence of HCV of more than 75%. Liver disease has become one of the principal causes of morbidity and mortality in this population. Co-infection increases viremia of hepatitis C, with increase in fibrosis progression, cirrhosis and death related to hepatitis C. The permanent state of chronic immune activation related to the persistent hepatitis C virus favors transcription of HIV in infected cells and causes a more rapid destruction of T4 and absolute lymphocytes. In addition, the immunologic response after the start of highly active antiretroviral therapy for HIV is less than in mono-infected patients. The role of liver biopsy in the management of co-infected patients is controversial. Many of these patients, even with normal transaminases, show fibrosis in liver biopsy. Predictive factors for advanced fibrosis include male sex, alcohol consumption in excess of 50 grams per day, age over 35, and HIV infection of more than 15 years with CD4 lymphocytes less than 400/ mm3. The treatment of hepatitis C is limited and sustained viral response is less than 30% for genotypes 1 and 4. This response is even less in the more advanced stages of HIV and hepatitis C. The determination of when to start treatment and the increased toxicity when combining pegylated interferon plus ribavirin and antiretroviral medications makes the management of these patients more difficult. The development of more potent, safe and tolerated medications is required. Management strategies for patients unresponsive to conventional therapy are geared towards improving liver histology and delaying progression to cirrhosis, hepatocellular cancer and liver transplantation.

Intracellular studies of the nucleoside reverse transcriptase inhibitor active metabolites: a review.

Nucleoside reverse transcriptase inhibitors (NRTIs) plasma concentrations do not correlate with clinical efficacy or toxicity. These agents need to be phosphorylated to become active against HIV-infection. Thus, the characterization of the NRTIs intracellular metabolite pharmacological parameters will provide a better understanding that could lead to the development of more rational dose regimens in the HIV-infected population. Furthermore, intracellular measurements of NRTIs may provide a better marker with respect to clinical efficacy and toxicity than plasma concentrations. Thus, in this article we review the latest information regarding the intracellular pharmacological parameters of zidovudine (ZDV) and lamivudine (3TC) active metabolites in HIV-infected patients including the results from our recent clinical studies. We will start the discussion with ZDV and 3TC clinical efficacy, followed by systemic pharmacokinetics studies. We will then discuss the in vitro and in vivo intracellular studies with particular emphasis in the method development to measure these metabolites and we will conclude with the most current data from our clinical trials.

Increased chitin synthesis in response to type II myosin deficiency in Saccharomyces cerevisiae.

We reported previously that the chitin content in cell walls of type II myosin-deficient Saccharomyces cerevisiae strains is increased relative to wild-type cells suggesting that increased chitin synthesis is induced in these strains. In the present study, we have performed enzyme activity assays for chitin synthases 1, 2, and 3 to determine the enzyme isoform(s) involved. To determine if transcriptional regulation is involved, we conducted quantitative mRNA assays of the corresponding chitin synthase genes. We show that the enzyme activities of all three chitin synthases increase substantially over the wild-type strain while eight- and twofold increases in the mRNA levels for chitin synthases 1 and 3 were detected. Increases in enzyme activities and mRNA levels were not proportional. We conclude that the enzyme activities for all three chitin synthases are elevated in this strain and that this increase is mediated mainly by a posttranslational mechanism(s). The heightened sensitivity to osmotic stress and the corresponding increase in cell wall chitin content reported in these strains are consistent with a compensatory "stress response" mechanism induced by abnormal cell wall assembly.

Plasma glutathione concentrations in non-infected infants born from HIV-infected mothers: developmental profile.

Glutathione (GSH) is the primary antioxidant in humans. Oxidative cellular injury is postulated to be centrally involved in diverse processes including aging, cancer, cardiovascular disease, and Human Immunodeficiency Virus (HIV) disease progression. Normal plasma GSH concentrations have been well characterized in healthy children and adults, but not during infant development. The objectives of this study were to: a) measure plasma GSH concentrations in non-infected infants born from HIV-infected mothers, to b) assess the developmental variations with age and gender, and c) evaluate for possible associations with growth, anemia, and other maternal and infant variables. One hundred and seventy (170) plasma samples from 44 HIV-uninfected infants (birth to 18 mos.) born to HIV-infected mothers from the Women and Infant Transmission Study (Puerto Rico site) were analyzed. The total plasma GSH geometric mean concentration for all samples analyzed was 1.94 (1.06) mumoles/L. A developmental effect of age was seen with lower concentrations in younger infants (0-2 months) than in older infants 4-18 months. There was no significant effect of gender, anemia, zidovudine exposure, maternal age, maternal CD4 cell percent, or infant growth, although a trend towards increasing GSH concentration was seen with increasing weight for height z-score. These findings have multiple clinical ramifications including prediction of capacity to detoxify oxidants at different ages, and partial explanation for the increased viral loads seen in HIV-infected infants.