The relationship between HIV and fertility in the era of antiretroviral therapy in sub-Saharan Africa: evidence from 49 Demographic and Health Surveys.

OBJECTIVES: To describe regional differences in the relative fertility of HIV-positive vs. HIV-negative women and changes as antiretroviral treatment (ART) is scaled up, to improve estimates of predicted need for and coverage of prevention of mother-to-child transmission services at national and subnational levels. METHODS: We analysed 49 nationally representative household surveys in sub-Saharan Africa between 2003 and 2016 to estimate fertility rate ratios of HIV-positive and HIV-negative women by age using exponential regression and test for regional and urban/rural differences. We estimated the association between national ART coverage and the relationship between HIV and fertility. RESULTS: Significant regional differences exist in HIV and fertility relationships, with less HIV-associated subfertility in Southern Africa. Age patterns of relative fertility are similar. HIV impact on fertility is weaker in urban than rural areas. For women below age 30, regional and urban/rural differences are largely explained by differences in age at sexual debut. Higher levels of national ART coverage were associated with slight attenuation of the relationship between HIV and fertility. CONCLUSIONS: Regional differences in HIV-associated subfertility and urban-rural differences in age patterns of relative fertility should be accounted for when predicting need for and coverage of PMTCT services at national and subnational level. Although HIV impacts on fertility are somewhat reduced at higher levels of national ART coverage, differences in fertility between HIV positive and negative remain, and fertility of women on ART should not be assumed to be the same as HIV-negative women. There were few data in recent years, when ART has reached high levels, and this relationship should continue to be assessed as further evidence becomes available.

Fibrin(ogen) mediates acute inflammatory responses to biomaterials.

Although "biocompatible" polymeric elastomers are generally nontoxic, nonimmunogenic, and chemically inert, implants made of these materials may trigger acute and chronic inflammatory responses. Early interactions between implants and inflammatory cells are probably mediated by a layer of host proteins on the material surface. To evaluate the importance of this protein layer, we studied acute inflammatory responses of mice to samples of polyester terephthalate film (PET) that were implanted intraperitoneally for short periods. Material preincubated with albumin is "passivated," accumulating very few adherent neutrophils or macrophages, whereas uncoated or plasma-coated PET attracts large numbers of phagocytes. Neither IgG adsorption nor surface complement activation is necessary for this acute inflammation; phagocyte accumulation on uncoated implants is normal in hypogammaglobulinemic mice and in severely hypocomplementemic mice. Rather, spontaneous adsorption of fibrinogen appears to be critical: (a) PET coated with serum or hypofibrinogenemic plasma attracts as few phagocytes as does albumin-coated material; (b) in contrast, PET preincubated with serum or hypofibrinogenemic plasma containing physiologic amounts of fibrinogen elicits "normal" phagocyte recruitment; (c) most importantly, hypofibrinogenemic mice do not mount an inflammatory response to implanted PET unless the material is coated with fibrinogen or the animals are injected with fibrinogen before implantation. Thus, spontaneous adsorption of fibrinogen appears to initiate the acute inflammatory response to an implanted polymer, suggesting an interesting nexus between two major iatrogenic effects of biomaterials: clotting and inflammation.

Hypohaptoglobinemia associated with familial epilepsy.

In select kindreds afflicted with familial idiopathic epilepsy, most individuals suffering seizures also have low levels of the plasma hemoglobin-binding protein, haptoglobin. This hypohaptoglobinemia may be causally associated with a tendency to develop epilepsy. Our experimental results indicate that artificially-induced hypohaptoglobinemia in mice causes retarded clearance of free hemoglobin from the central nervous system, and that such free hemoglobin may engender the peroxidation of brain lipids. We hypothesize that hypohaptoglobinemia, either inherited, or acquired via traumatic processes, may prevent efficient clearance of interstitial hemoglobin from the central nervous system, thereby predisposing these people to encephalic inflammation and the appearance of seizure disorders.

Cerebral ischemia enhances polyamine oxidation: identification of enzymatically formed 3-aminopropanal as an endogenous mediator of neuronal and glial cell death.

To elucidate endogenous mechanisms underlying cerebral damage during ischemia, brain polyamine oxidase activity was measured in rats subjected to permanent occlusion of the middle cerebral artery. Brain polyamine oxidase activity was increased significantly within 2 h after the onset of ischemia in brain homogenates (15.8 +/- 0.9 nmol/h/mg protein) as compared with homogenates prepared from the normally perfused contralateral side (7.4 +/- 0.5 nmol/h/mg protein) (P <0.05). The major catabolic products of polyamine oxidase are putrescine and 3-aminopropanal. Although 3-aminopropanal is a potent cytotoxin, essential information was previously lacking on whether 3-aminopropanal is produced during cerebral ischemia. We now report that 3-aminopropanal accumulates in the ischemic brain within 2 h after permanent forebrain ischemia in rats. Cytotoxic levels of 3-aminopropanal are achieved before the onset of significant cerebral cell damage, and increase in a time-dependent manner with spreading neuronal and glial cell death. Glial cell cultures exposed to 3-aminopropanal undergo apoptosis (LD50 = 160 microM), whereas neurons are killed by necrotic mechanisms (LD50 = 90 microM). The tetrapeptide caspase 1 inhibitor (Ac-YVAD-CMK) prevents 3-aminopropanal-mediated apoptosis in glial cells. Finally, treatment of rats with two structurally distinct inhibitors of polyamine oxidase (aminoguanidine and chloroquine) attenuates brain polyamine oxidase activity, prevents the production of 3-aminopropanal, and significantly protects against the development of ischemic brain damage in vivo. Considered together, these results indicate that polyamine oxidase-derived 3-aminopropanal is a mediator of the brain damaging sequelae of cerebral ischemia, which can be therapeutically modulated.

Membrane-associated phosphoproteins in Plasmodium berghei-infected murine erythrocytes.

Normal and Plasmodium berghei (NYU-2 strain)-infected murine erythrocytes display substantially different patterns of plasma membrane phosphoproteins phosphorylation. Intact erythrocytes (normal and parasite infected) incubated with 32Pi and isolated washed erythrocyte plasma membranes incubated with gamma-32P-ATP were analyzed for phosphoproteins by SDS PAGE and autoradiography. Two new phosphoproteins of molecular weight 45,000 (pp45) and 68,000 (pp68), which are absent in normal erythrocyte membranes, are associated with the membranes of infected erythrocytes subjected to both intact-cell and isolated-membrane phosphorylation conditions. Two-dimensional gel electrophoresis indicates that pp45 and pp68 are of parasite origin. Partial or complete proteolytic digestion reveals that pp45 is phosphorylated at similar amino acid residues both in intact cells and in isolated membranes. The pp45 phosphoprotein can be detected at as low as 3% parasitemia and its phosphorylation is not affected by 10 microM cAMP, 1 mM Ca2+, or 5 mM EGTA. Extraction of isolated washed plasma membranes with 0.5% Triton X-100 or 0.1 M NaOH indicates that pp45 is detergent insoluble and only partially extractable with NaOH, suggesting that pp45 is closely associated with the host erythrocyte plasma membrane.

Erythrocyte metabolism: interaction with oxygen transport.

Studies of the interactions between the metabolism and the function of the red cell have shown the importance of the red cell's metabolism in contributing to the maintenance of adequate oxygen delivery. Some of the phosphorylated intermediates of glycolysis, especially DPG, are now known to reduce the affinity of hemoglobin for oxygen. Current evidence indicates that this phenomenon is due to the effects of the binding of DPG to the , beta-chains of deoxyhemoglobin. It appears that increases in red cell concentrations of DPG commonly occur during hypoxia, and that these increases (as well as normal physiological variation) significantly enhance oxygen transport. Artificial manipulation of erythrocyte metabolism may soon prove to be of great clinical usefulness in the treatment of a great variety of disorders which limit oxygen transport.

Survival at extreme altitude: protective effect of increased hemoglobin-oxygen affinity.

Decreased hemoglobin-oxygen affinity is thought to be of adaptive value to humans and nonindigenous animals at high altitude. To test this, hemoglobin-oxygen affinity was modified by carbamoylation of hemoglobin in rats. Exposure of control (low oxygen affinity) and experimental (high oxygen affinity) animals to a pressure equivalent to high altitude revealed that increased, rather than decreased, hemoglobin-oxygen affinity will permit survival at greatly reduced environmental oxygen pressures.

Skin color and nutrient photolysis: an evolutionary hypothesis.

Human populations native to areas of intense sunlight tend to be heavily melanized. Previous explanations for this relationship have invoked only weak selective pressures. To test the hypothesis that dark pigmentation may protect against photolysis of crucial light-sensitive vitamins and metabolites by ultraviolet light, folate was used as a model. It was found that exposure of human plasma in vitro to simulated strong sunlight causes 30 to 50 percent loss of folate within 60 minutes. Furthermore, light-skinned patients exposed to ultraviolet light for dermatologic disorders have abnormally low serum folate concentrations, suggesting that photolysis may also occur in vivo. Deficiency of folate, which occurs in many marginally nourished populations, causes severe anemia, fetal wastage, frank infertility, and maternal mortality. Prevention of ultraviolet photolysis of folate and other light sensitive nutrients by dark skin may be sufficient explanation for the maintenance of this characteristic in human groups indigenous to regions of intense solar radiation.

Phagocyte impotence caused by an invasive bacterial adenylate cyclase.

For unknown reasons, humans infected with the bacterium Bordetella pertussis are exceptionally vulnerable to secondary infections. Bordetella species elaborate a soluble, heat-stable, and highly active adenylate cyclase. This enzyme is internalized by phagocytic cells and catalyzes the unregulated formation of adenosine 3',5'-monophosphate (cyclic AMP), thereby disrupting normal cellular function. This unusual phenomenon may explain Bordetella-induced aphylaxis and may prove to be useful for investigating a variety of cyclic AMP-governed processes.

Malaria parasites adopt host cell superoxide dismutase.

Aerobic organisms depend on superoxide dismutase to suppress the formation of dangerous species of activated oxygen. Intraerythrocytic stages of the malaria parasite exist within a highly aerobic environment and cause the generation of increased amounts of activated oxygen. Plasmodium berghei in mice was found to derive a substantial amount of superoxide dismutase activity from the host cell cytoplasm. Plasmodia isolated from mouse red cells contained mouse superoxide dismutase, whereas rat-derived parasites contained the rat enzyme. This is believed to be the first example of the acquisition of a host cell enzyme by an intracellular parasite.

Haptoglobin: a natural bacteriostat.

The combination of bacteria and blood in a wound can have lethal consequences, probably because hemoglobin iron supports prolific bacterial growth. Rats inoculated intraperitoneally with pathogenic Escherichia coli and small amounts of hemoglobin die. Simultaneous administration of haptoglobin, a naturally occurring hemoglobin-binding protein, fully protects against lethality. Therefore, haptoglobin may not only accelerate the clearance of free hemoglobin, but also limit its utilization by adventitious bacteria. Haptoglobin may have therapeutic potential in the treatment of life-threatening, hemoglobin-driven bacterial infections.

Chlorinated urban water: a cause of dialysis-induced hemolytic anemia.

Unexplained acute hemolytic anemia is sometimes seen in uremic patients undergoing hemodialysis. Chloramines, which are oxidant compounds made up of chlorine and ammonia and are widely used as bactericidal agents in urban water supplies, have been found responsible for two recent epidemics, in dialyzed uremic patients, of acute hemolytic anemia characterized by Heinz bodies. Chloramines produce denaturation of hemoglobin, both by their direct oxidizing capacity and their ability to inhibit red cell reductive (hexose monophosphate shunt) metabolism.

LHRH receptor targeted therapy for breast cancer.

Breast cancer remains the most common cancer among women, with an estimated 212,920 new cases and 40,970 deaths in the United States in 2006. The present work extends the studies of nanoparticles targeted to the luteinizing hormone-releasing hormone (LHRH) receptor which is overexpressed in breast, ovarian, endometrial and prostate cancer cells. In contrast, LHRH receptors are not expressed, or expressed at a low level in most visceral organs. In our studies, we conjugated Fe3O4 nanoparticles (20-30 nm) with [D-Trp6]LHRH (Triptorelin), a decapeptide analog of LHRH currently used for treatment of sex-hormone-dependent tumors. Conjugation of [D-Trp6]LHRH to Fe3O4 particles retained its binding affinity and biological activity for the LHRH receptor. Treatment of two separate breast tumor cell lines (MCF-7 and MDA-MB231) with these conjugated nanoparticles resulted in 95-98% cell death and loss of viability within 24 h whereas no change in cell proliferation or cell apoptosis was observed in cells treated with equal amounts of either [D-Trp6]LHRH or unconjugated Fe3O4 nanoparticles. These studies provide critical and important information regarding use of LHRH receptor targeted therapy for breast cancer.

Ras transformation requires metabolic control by 6-phosphofructo-2-kinase.

Neoplastic cells transport large amounts of glucose in order to produce anabolic precursors and energy within the inhospitable environment of a tumor. The ras signaling pathway is activated in several cancers and has been found to stimulate glycolytic flux to lactate. Glycolysis is regulated by ras via the activity of 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatases (PFK2/FBPase), which modulate the intracellular concentration of the allosteric glycolytic activator, fructose-2,6-bisphosphate (F2,6BP). We report herein that sequential immortalization and ras-transformation of mouse fibroblasts or human bronchial epithelial cells paradoxically decreases the intracellular concentration of F2,6BP. This marked reduction in the intracellular concentration of F2,6BP sensitizes transformed cells to the antimetabolic effects of PFK2/FBPase inhibition. Moreover, despite co-expression of all four mRNA species (PFKFB1-4), heterozygotic genomic deletion of the inducible PFKFB3 gene in ras-transformed mouse lung fibroblasts suppresses F2,6BP production, glycolytic flux to lactate, and growth as soft agar colonies or tumors in athymic mice. These data indicate that the PFKFB3 protein product may serve as an essential downstream metabolic mediator of oncogenic ras, and we propose that pharmacologic inhibition of this enzyme should selectively suppress the high rate of glycolysis and growth by cancer cells.

Hemoglobin-mediated oxidant damage to the central nervous system requires endogenous ascorbate.

Hemorrhage within the central nervous system (CNS) may be associated with subsequent development of seizure states or paralysis. Prior investigations indicate that hemoglobin, released from extravasated erythrocytes, may be toxic to the CNS by promoting peroxidation of lipids and inhibition of Na,K-ATPase. These deleterious effects are blocked both in vitro and in vivo by the Fe3+ chelator, desferrioxamine, indicating the involvement of free iron derived from hemoglobin. We now report that the Fe2+ chelator, ferene, also inhibits methemoglobin- and ferric iron-mediated CNS lipid oxidation, reflecting the reduction of Fe3+ by some component of the CNS. This reduction is apparent in the accumulation of the highly chromophoric ferene: Fe2+ chelate after the addition of Fe3+ salts to supernatants of murine brain homogenates. Because large amounts of ascorbic acid occur in mammalian CNS, we suspected that this reducing substance might be responsible. Indeed, the peroxidative effects of hemoglobin and iron on murine brain are blocked by washing of CNS membranes or by preincubation of crude homogenates with ascorbate oxidase. Furthermore, the addition of ascorbate to washed CNS membranes fully restores hemoglobin/iron-driven peroxidation. We conclude that posthemorrhagic CNS dysfunction may stem from damaging redox reactions between hemoglobin iron, ascorbic acid, and oxidizable components of the nervous system.

Hypoxic ventilatory response in subjects with normal and high oxygen affinity hemoglobins.

It has still not been shown unequivocally whether a decrement of arterial oxygen content or tension governs the ventilatory response to hypoxia. In an attempt to discriminate between the two possibilities, we have measured the ventilatory response to isocapnic progressive hypoxia in two healthy children with a high oxygen affinity hemoglobin (Hb Andrew-Minneapolis) and in their age- and sex-matched normal siblings. Hypoxic ventilatory response was identical in all subjects, there being no difference in minute ventilation at PAo2 = 40 mm Hg or in k (decrement of PO2 required to increase ventilation by a factor of 2.718). In contrast, at PAo2 = 40 mm Hg, hemoglobin oxygen saturation decreased markedly in controls but only slightly in high affinity subjects. Furthermore the increase in heart rate at PAo2 = 40 mm Hg was significantly less in high affinity subjects, suggesting a concomitant difference in oxygen delivery. Thus, with identical decrements in PAo2 but widely divergent changes in arterial oxygen content and oxygen delivery, controls and high affinity subjects showed virtually identical ventilatory response to hypoxia. We conclude that decrements of oxygen tension are the major stimulus for hypoxic ventilatory response.

Degradation of biomaterials by phagocyte-derived oxidants.

Polymers used in implantable devices, although relatively unreactive, may degrade in vivo through unknown mechanisms. For example, polyetherurethane elastomers used as cardiac pacemaker lead insulation have developed surface defects after implantation. This phenomenon, termed "environmental stress cracking," requires intimate contact between polymer and host phagocytic cells, suggesting that phagocyte-generated oxidants might be involved. Indeed, brief exposure of polyetherurethane to activated human neutrophils, hypochlorous acid, or peroxynitrite produces modifications of the polymer similar to those found in vivo. Damage to the polymer appears to arise predominantly from oxidation of the urethane-aliphatic ester and aliphatic ether groups. There are substantial increases in the solid phase surface oxygen content of samples treated with hypochlorous acid, peroxynitrite or activated human neutrophils, resembling those observed in explanted polyetherurethane. Furthermore, both explanted and hypochlorous acid-treated polyetherurethane show marked reductions in polymer molecular weight. Interestingly, hypochlorous acid and peroxynitrite appear to attack polyetherurethane at different sites. Hypochlorous acid or activated neutrophils cause decreases in the urethane-aliphatic ester stretch peak relative to the aliphatic ether stretch peak (as determined by infrared spectroscopy) whereas peroxynitrite causes selective loss of the aliphatic ether. In vivo degradation may involve both hypohalous and nitric oxide-based oxidants because, after long-term implantation, both stretch peaks are diminished. These results suggest that in vivo destruction of implanted polyetherurethane involves attack by phagocyte-derived oxidants.

Molecular determinants of acute inflammatory responses to biomaterials.

The frequent inflammatory responses to implanted medical devices are puzzling in view of the inert and nontoxic nature of most biomaterials. Because implant surfaces spontaneously adsorb host proteins, this proteinaceous film is probably important in the subsequent attraction of phagocytes. In fact, earlier we found that acute inflammatory responses to experimental polyethylene terephthalate implants in mice require the precedent adsorption of one particular host protein, fibrinogen. The present investigations were aimed at defining the molecular determinants of fibrinogen-mediated acute inflammatory responses to implanted biomaterials. We find: (a) plasmin degradation of purified fibrinogen into defined domains reveals that the proinflammatory activity resides within the D fragment, which contains neither the fibrin cross-linking sites nor RGD sequences; (b) the major (and, perhaps, exclusive) proinflammatory sequence appears to be fibrinogen gamma 190-202, previously shown to interact with CD11b/CD18 (Mac-1). The chemically synthesized peptide, cross-linked to albumin (which itself does not promote inflammatory responses), mimics the proinflammatory effect of adsorbed native fibrinogen; and (c) this sequence probably promotes inflammatory responses through interactions with Mac-1 because phagocyte accumulation on experimental implants is almost completely abrogated by administration of recombinant neutrophil inhibitory factor (which blocks CD11b-fibrin(ogen) interaction). We conclude that improved knowledge of such surface-protein-phagocyte interactions may permit the future development of more biocompatible implantable materials.

Spontaneous oxygen radical generation by sickle erythrocytes.

Since the various membrane abnormalities of sickle erythrocytes might result from excessive accumulation of oxidant damage, we have measured the generation of superoxide, peroxide, and hydroxyl radical by normal and sickle erythrocytes using assays involving reduction of cytochrome c, aminotriazole inhibition of catalase, and methane evolution from dimethyl sulfoxide, respectively. Compared with normal erythrocytes, sickle erythrocytes spontaneously generate approximately twice as much superoxide, peroxide, and hydroxyl radical. One possible source of hydroxyl radical generation was identified as hemichrome, excessive amounts of which are bound to sickle erythrocyte membranes. Hemichrome did not generate hydroxyl radical when exposed to superoxide alone or peroxide alone. However, in the presence of both superoxide and peroxide, hemichrome greatly facilitated hydroxyl radical generation. Supporting this, normal erythrocyte membranes induced to acquire sickle hemichrome concomitantly acquired an enhanced ability to mediate hydroxyl radical generation. Finally, sickle erythrocyte membranes greatly enhanced superoxide/peroxide-driven hydroxyl radical generation as compared with normal erythrocyte membranes. These data suggest that an excessive accumulation of oxidant damage in sickle erythrocyte membranes might contribute to the accelerated membrane senescence of these cells. They further indicate that accumulation of oxidant damage could be a determinant of normal erythrocyte membrane senescence.

Erythrocyte catalase. A somatic oxidant defense?

Mammalian erythrocytes have large amounts of catalase, an enzyme which catabolizes hydrogen peroxide (H2O2). Because catalase has a low affinity for H2O2, others have suggested that glutathione peroxidase clears most H2O2 within the erythrocyte and that catalase is of little import. We hypothesized that erythrocyte catalase might function to protect heterologous somatic cells against challenge by high levels of exogenous H2O2 (e.g., in areas of inflammation). We find that, whereas nucleated cells (L1210 murine leukemia) are readily killed by an enzymatically generated flux of superoxide (and, therefore, H2O2), the addition of human and murine erythrocytes blocks lethal damage to the target cells. Inhibition of erythrocyte superoxide dismutase, depletion of glutathione, and lysis of the erythrocytes do not diminish this protection. However, inhibition of erythrocyte catalase abrogates the protective effect and the addition of purified catalase (but not superoxide dismutase) restores it. Furthermore, erythrocytes derived from congenitally hypocatalasemic mice (in which other antioxidant systems are intact) do not protect L1210 cells. Our results raise the possibility that the erythrocyte may serve as protection against by-products of its own cargo, oxygen.