Ellagic acid inhibits HIV-1 infection in vitro: Potential role as a novel microbicide.

OBJECTIVE: To investigate the in vitro effects of ellagic acid on HIV-1 replication. METHODS: Anti-HIV-1 activity of ellagic acid was determined in vitro using X4-tropic HIV-1NPO3 and R5-tropic pBaL Env-recombinant virus. Anti-HIV-1NPO3 activity of ellagic acid was investigated at a multiplicity of infection (MOI) of 0.01. Anti-HIV-1 integrase and protease activities of ellagic acid were tested using in vitro integration and proteolytic cleavage assays. RESULTS: Ellagic acid, added either before or after HIV-1NPO3 exposure, suppressed replication of the virus in C8166 cells up to 34%. Ellagic acid showed an anti-integrase IC50 of 8.7 µM. No cytotoxicity of ellagic acid at concentrations ranging from 12.5 to 100 µM was observed. CONCLUSION: We conclude that ellagic acid can inhibit HIV-1 infection without cytotoxicity. Thus, it may be a new effective agent that has potential to be developed as a novel microbicide against HIV-1.

Oral fungi in HIV: challenges in antifungal therapies.

Oral candidiasis (OC) caused by Candida species is a common fungal infection among HIV-infected individuals. Despite the wide use of antiretroviral therapy (ART) resulting in a declined prevalence, OC remains the most common oral lesions seen in those living with HIV/AIDS. Various topical and systemic antifungal drugs are available to treat OC. However, due to the patients' immunodeficiency and the nature of OC as biofilm-associated infection, relapse is frequently observed after cessation of antifungal therapy. In addition, long-term antifungal therapy may lead to drug resistance. This review article addressed three major challenges in the treatment of OC in HIV infection including antifungal drug resistance, biofilm-associated infection of OC, and the host underlying immunodeficiency. To reduce the risks of antifungal drug resistance, the author recommends that future studies should focus on herbal plant-derived compounds with antifungal activity that may be used in combination with the drugs. Also, it is recommended that more research should be carried out to explore how to enhance the host innate immunity against oral Candida.

Oral mycoses and other opportunistic infections in HIV: therapy and emerging problems - a workshop report.

Oral mycoses and other opportunistic infections are recognized features of HIV infection even after four decades of the epidemic. The therapeutic options, challenges of therapy, and evolving patterns of opportunistic infections were evaluated by the workshop. It was observed that high Candida counts and infection are still more prevalent in HIV-positive individuals even in the era of antiretroviral therapy. Furthermore, one or more non-Candida albicans are present in some HIV-positive individuals. While Candida species are more virulent in HIV infection, similar virulence may be present in other states of immunosuppression. Consequently, the interplay between host factors and virulence ultimately determines the clinical outcomes. Adverse clinical outcomes such as candidemia and other deep fungal infections are on the increase in HIV infection. Disseminated histoplasmosis and penicilliosis have been reported, especially with low CD4 counts. Even with advances in antifungal therapy, mortality and morbidity from deep fungal infections have not changed significantly. In addition, long-term exposure to common antifungal drugs such as fluconazole has led to the development of antifungal resistance in 6% to 36%. Development of new antifungal therapeutic agents and the use of alternative therapies may offer breakthrough. In addition, effective strategies to enhance the host immune status are being explored.

Innate immunity in HIV-1 infection: epithelial and non-specific host factors of mucosal immunity- a workshop report.

The interplay between HIV-1 and epithelial cells represents a critical aspect in mucosal HIV-1 transmission. Epithelial cells lining the oral cavity cover subepithelial tissues, which contain virus-susceptible host cells including CD4(+) T lymphocytes, monocytes/macrophages, and dendritic cells. Oral epithelia are among the sites of first exposure to both cell-free and cell-associated virus HIV-1 through breast-feeding and oral-genital contact. However, oral mucosa is considered to be naturally resistant to HIV-1 transmission. Oral epithelial cells have been shown to play a crucial role in innate host defense. Nevertheless, it is not clear to what degree these local innate immune factors contribute to HIV-1 resistance of the oral mucosa. This review paper addressed the following issues that were discussed at the 7th World Workshop on Oral Health and Disease in AIDS held in Hyderabad, India, during November 6-9, 2014: (i) What is the fate of HIV-1 after interactions with oral epithelial cells?; (ii) What are the keratinocyte and other anti-HIV effector oral factors, and how do they contribute to mucosal protection?; (iii) How can HIV-1 interactions with oral epithelium affect activation and populations of local immune cells?; (iv) How can HIV-1 interactions alter functions of oral epithelial cells?

Houttuynia cordata modulates oral innate immune mediators: potential role of herbal plant on oral health.

OBJECTIVE: Epithelial cells play an active role in oral innate immunity by producing various immune mediators. Houttuynia cordata Thunb (H. cordata), a herbal plant found in Asia, possesses many activities. However, its impacts on oral innate immunity have never been reported. The aim of this study was to determine the effects of H. cordata extract on the expression of innate immune mediators produced by oral epithelial cells. MATERIALS AND METHODS: Primary gingival epithelial cells (GECs) were treated with various concentrations of the extract for 18 h. The gene expression of hBD2, SLPI, cytokines, and chemokines was measured using quantitative real-time RT-PCR. The secreted proteins in the culture supernatants were detected by ELISA or Luminex assay. Cytotoxicity of the extract was assessed using CellTiter-Blue Assay. RESULTS: H. cordata significantly induced the expression of hBD2, SLPI, IL-8, and CCL20 in a dose-dependent manner without cytotoxicity. The secreted hBD2 and SLPI proteins were modulated, and the levels of IL-2, IL-6, IL-8, and IFN-γ were significantly induced by the extract. CONCLUSIONS: Our data indicated that H. cordata can modulate oral innate immune mediators. These findings may lead to the development of new topical agents from H. cordata for the prevention and treatment of immune-mediated oral diseases.

Expression of oral cytokines in HIV-infected subjects with long-term use of antiretroviral therapy.

OBJECTIVES: The objectives of this study were to determine (i) the expression of oral pro-inflammatory cytokines in HIV-infected subjects compared with non-HIV individuals, (ii) the cytokine expression in the subjects with antiretroviral therapy (ART) compared with those without ART, and (iii) factors associated with the expression of the cytokines. MATERIALS AND METHODS: Oral examination was performed and saliva samples were collected and analyzed for the expression of pro-inflammatory cytokines using ELISA. Logistic regression analysis was performed to determine the association between HIV/ART status and the cytokine expression. RESULTS: One hundred and fifty-seven HIV-infected subjects with and without ART, and 50 non-HIV individuals were enrolled. TNF-α and IL-6 in saliva were significantly decreased, while IL-8 was significantly increased in HIV infection (P < 0.05). Changes in the expression of IL-8 were also observed between HIV-infected subjects who were and were not on ART (P < 0.05). Duration of HIV infection and smoking was significantly associated with the expression of pro-inflammatory cytokines in saliva (P < 0.05). CONCLUSION: Oral innate immunity is affected by HIV infection and use of ART. IL-8 may be the useful biomarker to identify subjects at risk of infection and malignant transformation due to HIV infection and long-term use of ART.

Urban legends series: oral manifestations of HIV infection.

Human immunodeficiency virus-related oral lesions (HIV-OLs), such as oral candidiasis (OC) and oral hairy leukoplakia (OHL), have been recognized as indicators of immune suppression since the beginning of the global HIV epidemic. The diagnosis and management of HIV disease and spectrum of opportunistic infection has changed over the past 30 years as our understanding of the infection has evolved. We investigated the following controversial topics: (i) Are oral manifestations of HIV still relevant after the introduction of highly active antiretroviral therapy (HAART)? (ii) Can we nowadays still diagnose HIV infection through oral lesions? (iii) Is the actual classification of oral manifestations of HIV adequate or does it need to be reviewed and updated? (iv) Is there any novelty in the treatment of oral manifestations of HIV infection? Results from extensive literature review suggested the following: (i) While HAART has resulted in significant reductions in HIV-OLs, many are still seen in patients with HIV infection, with OC remaining the most common lesion. While the relationship between oral warts and the immune reconstitution inflammatory syndrome is less clear, the malignant potential of oral human papillomavirus infection is gaining increasing attention. (ii) Effective antiretroviral therapy has transformed HIV from a fatal illness to a chronic manageable condition and as a result expanded screening policies for HIV are being advocated both in developed and in developing countries. Affordable, reliable, and easy-to-use diagnostic techniques have been recently introduced likely restricting the importance of HIV-OLs in diagnosis. (iii) The 1993 EC-Clearinghouse classification of HIV-OLs is still globally used despite controversy on the relevance of periodontal diseases today. HIV-OL case definitions were updated in 2009 to facilitate the accuracy of HIV-OL diagnoses by non-dental healthcare workers in large-scale epidemiologic studies and clinical trials. (iv) Research over the last 6 years on novel modalities for the treatment of HIV-OLs has been reported for OC and OHL.

Changes in oral cytokeratin expression in HIV-infected subjects with long-term use of HAART.

OBJECTIVES: The objectives of this study were to determine (i) the expression of oral cytokeratins (CKs) among human immunodeficiency virus (HIV)-infected subjects compared with non-HIV controls, (ii) the oral CK expression in the subjects with highly active antiretroviral therapy (HAART) compared with those without HAART, and (iii) factors associated with the expression of oral CKs. MATERIALS AND METHODS: Oral tissues from buccal mucosa were obtained by punched biopsy in HIV-infected subjects with and without HAART, and non-HIV individuals. The samples were processed for immunohistochemical studies of CK1, CK13, CK14, CK16, and involucrin. The staining intensity was scored and recorded. Logistic regression analysis and multi-way ANOVA test were performed. RESULTS: The expression of CK13, CK14, and CK16 was found to be significantly different between HIV-infected subjects and non-HIV individuals (P < 0.05). The expression of those CKs was also significantly different between those who were and were not on HAART (P < 0.05). No significant difference between the groups was observed regarding CK1 and involucrin. CONCLUSIONS: Oral epithelial cell differentiation as marked by the CK expression is affected by HIV infection and use of HAART. CKs may be the useful biomarkers to identify HIV-infected subjects who are at risk of malignant transformation of the oral mucosa because of HIV infection and HAART.

Clinical markers of immunodeficiency and mechanism of immune reconstitution inflammatory syndrome and highly active antiretroviral therapy on HIV: workshop 3A.

Antiretroviral therapy (ART) has improved survival and changed the disease pattern of HIV infection. However, ART may cause serious side effects, such as metabolic and cardiovascular complications. In addition, immune reconstitution inflammatory syndrome (IRIS) is being increasingly reported in relation to ART. The article presents the consensus of a workshop around 4 key issues: (1) the differences in the response of adults and children to highly active antiretroviral therapy, (2) the mechanism of the new HIV entry inhibitors and its effect on oral markers, (3) the pathogenesis of IRIS and the contradictory findings of the possible oral lesions related with IRIS, (4) and the benefits and barriers associated with using ART in the developing and developed world. The consensus of the workshop was that there is a need for future studies on the oral manifestations of HIV in individuals treated with new ARTs-especially, children. IRIS was considered a promising field for future research; as such, workshop attendees recommended formulating an IRIS-oral lesions case definition and following strict criteria for its diagnosis.

Mode of HIV transmission associated with risk of oral lesions in HIV-infected subjects in Thailand.

BACKGROUND: The aim of this study was to determine if route of human immunodeficiency virus (HIV) transmission is associated with the risk of oral lesions in HIV-infected subjects in Thailand. METHODS: A cross-sectional study was performed in 186 HIV-infected heterosexuals (aged 21-65 years, mean 32 years), and 82 HIV-infected intravenous drug users (IVDUs) (aged 16-50 years, mean 30 years). The following information was recorded: route of HIV transmission, total lymphocyte cell counts, weight, smoking habit, alcohol consumption, medications, presence of denture, plaque index, and presence of oral lesions. The association between mode of HIV transmission and the risk of oral lesions among the subjects was determined by multiple logistic regression analysis. RESULTS: Oral lesions were found in 138 HIV-infected heterosexuals (75%) and in 37 HIV-infected IVDUs (46%). Oral candidiasis (OC) was the most common lesion among both groups (44% vs. 28%), followed by hairy leukoplakia (HL) (33% vs. 10%). Multiple logistic regression analysis showed a significant association between mode of HIV transmission and the risk of oral lesions after controlling for the total lymphocyte cell counts and other confounding factors [OR 3.1; 95% CI 1.5-6.4; P = 0.002]. OC was significantly associated with heterosexual route of HIV transmission [OR 2.4; 95% CI 1.2-4.7; P = 0.014]. Similar association was also observed with HL [OR 3.7; 95% CI 1.5-9.1; P = 0.004]. CONCLUSIONS: Mode of HIV transmission is associated with the risk of oral lesions in HIV-infected subjects in Thailand. Further studies should be performed to determine if the risk of oral lesions is associated with differences in HIV-subtypes.

A randomized clinical trial of chlorhexidine in the maintenance of oral candidiasis-free period in HIV infection.

OBJECTIVE: To determine if chlorhexidine can be used as an intervention to prolong the time to relapse of oral candidiasis. SUBJECTS AND METHODS: A double-blinded randomized clinical trial was performed in 75 HIV/AIDS subjects with oral candidiasis. Clotrimazole troche was prescribed, and the subjects were re-examined every 2 weeks until the lesions were completely eradicated. The subjects were then randomly divided into two groups; 0.12% chlorhexidine (n = 37, aged 22-52 years, mean 34 years) and 0.9% normal saline (n = 38, aged 22-55 years, mean 38 years). They were re-examined every 2 weeks until the next episode was observed. RESULTS: The time to recurrence of oral candidiasis between the chlorhexidine and the saline group was not statistically significant (P > 0.05). The following variables were significantly associated with the time of recurrence; frequency of antifungal therapy (P = 0.011), total lymphocyte (P = 0.017), alcohol consumption (P = 0.043), and candidiasis on gingiva (P = 0.048). The subjects with lower lymphocyte showed shorter oral candidiasis-free periods (P = 0.034). CONCLUSIONS: Chlorhexidine showed a small but not statistically significant effect in maintenance of oral candidiasis-free period. This lack of significance may be due to the small sample size. Further study should be performed to better assess the size of the effect, or to confirm our findings.

(A3) HIV Phenotypes, oral lesions, and management of HIV-related disease.

Workshop participants discussed: the role of HIV subtypes in disease; the treatment of oral candidiasis; the relationship between and among viral load, CD4+ counts, oral candidiasis and oral hairy leukoplakia, pigmentation; and the development of a reliable oral index to predict disease progression. Regarding HIV, the literature revealed that Type I (HIV-I), in particular group M, is involved in the majority (90%) of documented infections, and groups N and O to a lesser extent. Viral envelope diversity led to the subclassification of the virus into nine subtypes, or clades-A-D, F-H, J, and K-each dominating in different geographical areas. HIV-2, currently occurring mostly in West Africa, appears to be less virulent. No evidence could be produced of any direct impact of type, subtype, or clade on oral lesions, and participants believed that further research is not feasible. Oral candidiasis in patients from resource-poor countries should be prevented. When the condition does occur, it should be treated until all clinical symptoms disappear. Oral rinsing with an antimicrobial agent was suggested to prevent recurrence of the condition, to reduce cost, and to prevent the development of antifungal resistance. Lawsone methyl ether, isolated from a plant (Rhinacanthus nasutus leaves) in Thailand, is a cost-effective mouthrinse with potent antifungal activity. Evidence from a carefully designed prospective longitudinal study on a Mexican cohort of HIV/AIDS patients, not receiving anti-retroviral treatment, revealed that the onset of oral candidiasis and oral hairy leukoplakia was heralded by a sustained reduction of CD4+, with an associated sharp increase in viral load. Analysis of the data obtained from a large cohort of HIV/AIDS patients in India could not establish a systemic or local cause of oral melanin pigmentation. A possible explanation was a dysfunctional immune system that increased melanin production. However, longitudinal studies may contribute to a better understanding of this phenomenon. Finally, a development plan was presented that could provide a reliable prediction of disease progression. To be useful in developing countries, the index should be independent of costly blood counts and viral load.

Changing knowledge, attitudes, and practices of Thai oral health personnel with regard to AIDS: an evaluation of an educational intervention.

OBJECTIVE: This study evaluated the effect of an educational intervention in improving Thai oral health personnel's (OHP) knowledge, attitudes and practices (KAP) regarding HIV/AIDS. RESEARCH DESIGN: The study used a pre-test/post-test design with study and control groups. RESULTS: of the pre-test questionnaire were used to design the intervention. Three months after the study group received the intervention, the same questionnaire was given to both groups. INTERVENTION: A three-day workshop was conducted using a variety of teaching methods: lectures, videos, role-plays, interviews with HIV infected persons, and demonstrations. SETTING: The study was conducted in rural government dental clinics in three provinces in southern Thailand. One hundred and three OHP in 23 dental clinics were in the study group while 46 OHP in II dental clinics were in the control group. OUTCOME MEASURES: The outcomes were knowledge and attitudes regarding HIV/AIDS, perception of occupational risk, willingness to treat HIV infected persons and adherence to recommended infection control procedures. RESULTS AND CONCLUSIONS: The educational intervention resulted in significant improvement in many domains of KAP in the study group, while there was little change in the control group. The post-test questionnaire showed that further improvements are needed in attitudes towards HIV/AIDS and practices regarding accidental needle stick injury. The intervention was both effective and appropriate and should be considered for national use.

Oral lesions in Thai heterosexual AIDS patients: a preliminary study.

OBJECTIVE: To study the types of oral lesions in Thai heterosexual AIDS patients. DESIGN: Cross-sectional study and single centre. SETTING: Medical ward of the Prince of Songkla University Hospital, Thailand, from June 1994 to May 1995. SUBJECTS: Heterosexual AIDS patients who had been admitted because of opportunistic infections and/or neoplasms. MAIN OUTCOME MEASURES: Types of oral lesions, opportunistic systemic diseases present and drugs in use, as well as the lymphocyte count, were recorded in each patient. Mycological investigations by the oral rinse technique were also performed. RESULTS: 41 patients were examined (32 male, 9 female; aged 19-53 years, median 29 years). Oral lesions were found in 35 (85%) patients as follows: oral candidiasis (31), hairy leukoplakia (3), aphthous ulcer (3), linear gingival erythema (2), non-Hodgkin's lymphoma (2) and histoplasmosis (2). CANDIDA ALBICANS: was isolated in 31 patients. There was correlation between the clinical signs of oral candidiasis and the colony-forming units of Candida (Mann-Whitney U test; two-tailed P = 0.0007). CONCLUSIONS: Oral candidiasis was the most common lesion. It is of interest that non-Hodgkin's lymphoma was the only neoplasm detected. We conclude that oral lesions among Thai heterosexual AIDS patients may differ from those in other countries.

AIDS-related non-Hodgkin's lymphoma presenting as delayed healing of an extraction wound.

Non-Hodgkin's lymphoma (NHL) of the oral cavity frequently occurs in patients infected with human immunodeficiency virus (HIV). This report describes a lesion presenting as delayed healing of an extraction wound with hyperaemic swollen gingivae and ulceration in an apparently healthy 34-year-old Thai fisherman. The lesion was the first evidence of his HIV-positivity. It is, therefore, imperative that clinicians should consider a diagnosis of HIV infection in cases of non-healing extraction wounds in patients in high risk categories.

Oral histoplasmosis associated with candidiasis in HIV-infected patients: a report of two cases.

Oral histoplasmosis, a rare condition, is reported in two HIV-infected patients. The lesions showed different characteristics. One was an ulcerative lesion presenting as the only manifestation of the disease. The other was nodular, with disseminated histoplasmosis. In both cases infection with Candida was also noted within the lesions.

Penicilliosis marneffei: another AIDS defining illness in Southeast Asia.

Penicilliosis marneffei, a common mycosis among AIDS patients living in Southeast Asia, has been recently suggested for inclusion in the AIDS surveillance case definition. Infections with Penicillium marneffei were rare in the past, but infections with this dimorphic fungus have increased with the endemic of AIDS in the region. The reservoir of P. marneffei in nature is still unknown, although it seems likely that inhalation may be the route of entry of the organism leading to infection in humans. P. marneffei can cause two clinical types of the disease; focal and fatal progressive, disseminated infections, characterized by a variety of symptoms which can mimic those of other diseases. Oral P. marneffei lesions usually occur in patients with disseminated infections, presenting as shiny papules, as erosions or as shallow ulcers covered with whitish yellow, necrotic slough which may be found on the palate, gingiva, labial mucosa, tongue and oropharynx. Biopsy and culture provide definitive diagnoses, while serologic tests for both antibody and antigen are useful in rapid presumptive diagnoses as well as in surveillance studies of the prevalence and latency of the infection. Penicilliosis marneffei is a treatable disease, but late diagnosis and treatment may be fatal. Itraconazole and ketoconazole are the drugs of first choice for mild to moderately severe forms of the disease, whereas parenteral therapy with amphotericin B may be required for seriously ill patients. Recurrence of the disease is common, therefore maintenance is recommended. As reported, prophylaxis generating resistant strains are likely to develop.

Prevalence of Candida species in AIDS patients and HIV-free subjects in Thailand.

The purpose of this study was to examine the prevalence of Candida species among groups of HIV-infected and HIV-free subjects in Thailand and to ascertain whether particular Candida species were associated with HIV infection. Oral rinse specimens were collected from 45 AIDS patients (CDC stage IV), 74 HIV-free healthy subjects, and 42 HIV-free patients who had clinical candidiasis. Yeasts recovered in culture were identified and quantified. The mean ages of the cohorts were 30.75+/-8.19 years (AIDS group), 28.50+/-7.98 (HIV-free healthy group) and 41.83+/-12.25 years (HIV-free candidiasis group). Yeasts were isolated from 30/45 (66.66%, range 6.6x10(2)-5.7x10(6) CFU/ml) of the AIDS group, 8/74 (10.81%, range 8.0x10(1)-3.5x10(4) CFU/ml) of the HIV-free healthy group, and 24/42 (57.14%, range 1.0x10(2)-1.1x10(5) CFU/ml) of the HIV-free candidiasis group. There were statistically significant differences in the Candida colony counts between the AIDS group without oral candidiasis and the healthy group (P=0.0078) and between the AIDS group with candidiasis and the HIV-free, oral candidiasis group (P=0.0003). Candida albicans was the most common species recovered from AIDS patients (29 out of 30; 96.66%).

PIP: The association between Candida species and HIV serostatus in Thailand was compared in 45 patients hospitalized with AIDS-related conditions, 74 HIV-negative blood donors, and 42 HIV-negative individuals with clinical signs of oral candidiasis. Pseudomembranous and erythematous lesions were the most common clinical findings. After collection of oral rinse specimens by a single clinician, yeasts recovered in culture were identified and quantified. Yeasts were isolated from 30 AIDS patients (66.6%), 8 HIV-negative blood donors (10.81%), and 24 individuals in the HIV-free candidiasis group (57.14%). Both the number of subjects who yielded Candida species and the mean number of Candida colonies were significantly higher in the AIDS group than in the HIV-free candidiasis group. C. albicans was the isolated yeast in 96.66% of AIDS patients, 79.16% of HIV-free candidiasis patients, and 100% of those in the healthy carrier group. Although C. albicans is a common and harmless commensal of the mucous membranes, it can cause severe mucosal or invasive disease in immunodeficient patients. It has been postulated that Candida strains that are nonpathogenic in healthy persons become pathogenic in HIV-infected individuals due to impaired host defense mechanisms.

Oral lesions in a group of Thai people with AIDS.

OBJECTIVES: The objectives of the study were to assess the prevalence of oral lesions present in Thai people with AIDS and to determine whether gender influences the occurrence of oral lesions. SUBJECTS AND METHODS: Extra- and intra-oral examinations were performed on 124 AIDS patients (90 men, aged 19-62 years, median 30 years; and 34 women, aged 19-41 years, median 28 years). RESULTS: Oral lesions were found in 102 patients (82%). Pseudomembranous candidiasis was the most common lesions, (n = 67; 54%) followed by erythematous candidiasis (n = 31; 25%), and hairy leukoplakia (n = 16; 13%). Other lesions were atypical ulcers (n = 14; 11%), periodontal disease (n = 9; 7%), angular cheilitis (n = 8; 6%), and infection with herpes simplex virus (n = 6; 5%). Non-Hodgkin's lymphoma was the only detected neoplasm (n = 5; 4%). Other lesions caused by fungi were histoplasmosis (n = 5; 4%) and penicilliosis (n = 2; 2%). Xerostomia was also found to be a common condition (n = 79; 63%). Most patients had a total number of lymphocytes of less than 1000 cell mm-3 (n = 85; 68%). CONCLUSIONS: The types of oral lesions observed in AIDS patients in Thailand show some similarities with studies from other countries. The prevalence of oral lesions did not appear to be influenced by gender.