Acyclovir and transmission of HIV-1 from persons infected with HIV-1 and HSV-2.

BACKGROUND: Most persons who are infected with human immunodeficiency virus type 1 (HIV-1) are also infected with herpes simplex virus type 2 (HSV-2), which is frequently reactivated and is associated with increased plasma and genital levels of HIV-1. Therapy to suppress HSV-2 reduces the frequency of reactivation of HSV-2 as well as HIV-1 levels, suggesting that suppression of HSV-2 may reduce the risk of transmission of HIV-1. METHODS: We conducted a randomized, placebo-controlled trial of suppressive therapy for HSV-2 (acyclovir at a dose of 400 mg orally twice daily) in couples in which only one of the partners was seropositive for HIV-1 (CD4 count, > or = 250 cells per cubic millimeter) and that partner was also infected with HSV-2 and was not taking antiretroviral therapy at the time of enrollment. The primary end point was transmission of HIV-1 to the partner who was not initially infected with HIV-1; linkage of transmissions was assessed by means of genetic sequencing of viruses. RESULTS: A total of 3408 couples were enrolled at 14 sites in Africa. Of the partners who were infected with HIV-1, 68% were women, and the baseline median CD4 count was 462 cells per cubic millimeter. Of 132 HIV-1 seroconversions that occurred after randomization (an incidence of 2.7 per 100 person-years), 84 were linked within couples by viral sequencing: 41 in the acyclovir group and 43 in the placebo group (hazard ratio with acyclovir, 0.92, 95% confidence interval [CI], 0.60 to 1.41; P=0.69). Suppression with acyclovir reduced the mean plasma concentration of HIV-1 by 0.25 log(10) copies per milliliter (95% CI, 0.22 to 0.29; P<0.001) and the occurrence of HSV-2-positive genital ulcers by 73% (risk ratio, 0.27; 95% CI, 0.20 to 0.36; P<0.001). A total of 92% of the partners infected with HIV-1 and 84% of the partners not infected with HIV-1 remained in the study for 24 months. The level of adherence to the dispensed study drug was 96%. No serious adverse events related to acyclovir were observed. CONCLUSIONS: Daily acyclovir therapy did not reduce the risk of transmission of HIV-1, despite a reduction in plasma HIV-1 RNA of 0.25 log(10) copies per milliliter and a 73% reduction in the occurrence of genital ulcers due to HSV-2. (ClinicalTrials.gov number, NCT00194519.)

Down-regulation of MHC class I is a property common to papillomavirus E5 proteins.

The E5 protein family of papillomaviruses comprises small hydrophobic proteins which are associated with the cell endomembrane compartments. The functions of the E5 proteins, particularly those of HPV, are still far from clear. We have reported that the E5 proteins of BPV-1, BPV-4, HPV-16 and HPV-6 down-regulate MHC class I, potentially helping the virus evade the host immune response. Others have described MHC class I down-regulation by HPV-2 E5. We report here that another E5 protein, HPV-83 E5, likewise down-regulates MHC class I and propose that interference with expression, assembly and/or transport of MHC class I is a common property of all E5 proteins evolved by the virus to circumvent host immunosurveillance and thus establish productive infection.

Incidence of HIV infection in monocyte subpopulations characterized by CD4 and HLA-DR surface density.

OBJECTIVE: The purpose of this study was to determine any correlation between the expression of CD4 antigen on the surface of monocytes, and the frequency with which these cells are infected with HIV. DESIGN: CD4 surface expression on monocytes is significantly less than that expressed on CD4+ lymphocytes. Nevertheless, all monocytes express the HIV CD4 receptor and infected individuals have a significant decrease in the number of monocytes that express a higher density of CD4 surface fluorescence. METHODS: Three-color flow cytometric analysis was used to characterize monocyte-enriched peripheral blood mononuclear cells (PBMC) in terms of surface expression of CD4, CD14 (macrophage antigen), and class II major histocompatibility antigen (HLA-DR). HLA-DR+ monocytes from HIV-positive individuals were sorted into two subpopulations based on either 'bright' or 'dim' CD4 surface expression. A polymerase chain reaction (PCR) assay was used to detect the presence of proviral HIV sequences within the DNA from 10(5) cells from each sorted population. RESULTS: Post-sort analysis revealed that the dim CD4+ monocyte subset expressed dim HLA-DR surface antigen, while the bright CD4+ monocyte subset contained both bright and dim HLA-DR+ cells. PCR results showed that four out of eight dim CD4+ monocyte subsets contained proviral HIV DNA, compared with one out of eight bright CD4+ monocyte subsets.

Differences among mononuclear cell subpopulations in HIV seropositive or seronegative homosexual and heterosexual men as determined by four-color flow cytometry.

Four-color cell surface immunofluorescence and flow cytometry analysis was used to quantitate mononuclear cell subpopulations from HIV seropositive (HIV+) and seronegative (HIV-) homosexual men and heterosexual men. HIV+ men were divided into two groups based on peripheral blood CD4/mm3 of greater than 500 or less than 500. CD4+ cells that were simultaneously CD45R-, CDw29-, and 13- were significantly less in HIV+ men with less than 500 CD4/mm3 (17%) compared to heterosexual men (34%). This lower percentage of "CD4 only" cells in HIV+ males with less than 500 CD4/mm3 correlated with a significantly higher percentage of CD4+ cells that were CD45R+, CDw29+, and 13+ in these individuals. CD8+ cells that were CD45R+, 13+, but CD38-, were significantly less in HIV+ men with less than 500 CD4 as compared to HIV- homosexual men. In contrast, a second CD8+ subpopulation that was CD45R-, CD38+, and either 13+ or 13- was significantly greater in less than 500 HIV+ men as compared to both HIV- homosexual men and heterosexual men. A significant difference in this subpopulation was observed between the less than 500 and greater than 500 HIV+ groups and correlated with seropositivity for viral p24 antigen. Interestingly, CD8+ cells that were CD45R+, as well as CD38+, and either 13+ or 13- were significantly greater in the less than 500 HIV+ group compared to the greater than 500 HIV+ group, and did not correlate with p24 seropositivity. The percentage of monocyte/macrophages that were CD4- or expressed dim CD4 immunofluorescence, but were 13+, was significantly greater in HIV+ men (43%) compared to HIV- homosexual men (27%). In summary, we have identified previously undescribed mononuclear cell subpopulations that were altered with HIV infection and, in some cases, correlated with the stage of disease.

The safety and efficacy of combination N-butyl-deoxynojirimycin (SC-48334) and zidovudine in patients with HIV-1 infection and 200-500 CD4 cells/mm3.

We conducted a double-blind, randomized phase II study to evaluate the safety and activity of combination therapy with N-butyl-deoxynojirimycin (SC-48334) (an alpha-glucosidase I inhibitor) and zidovudine versus zidovudine alone. Patients with 200 to 500 CD4 cells/mm3 who tolerated < or = 12 weeks of prior zidovudine therapy received SC-48334 (1000 mg every 8 h) and zidovudine (100 mg every 8 h) or zidovudine and placebo. Sixty patients received combination therapy and 58, zidovudine and placebo. Twenty-three patients (38%) and 15 (26%), in the combination and zidovudine groups, respectively, discontinued therapy (p = 0.15). The mean SC-48334 steady-state trough level (4.04 +/- 0.99 micrograms/ml) was below the in vitro inhibitory concentration for human immunodeficiency virus (HIV). The mean increase in CD4 cells at week 4 was 73.8 cells/mm3 and 52.4 cells/mm3 for the combination and zidovudine groups, respectively (p > 0.36). For patients with prior zidovudine therapy, the mean change in CD4 cells in the combination and zidovudine groups was 63.7 cells/mm3 and 4.9 cells/mm3 at week 8 and 6.8 cells/mm3 and -45.1 cells/mm3 at week 16, respectively. The number of patients with suppression of HIV p24 antigenemia in the combination and zidovudine groups was six (40%) and two (11%) at week 4 (p = 0.10) and five (45%) and two (14%) at week 24 (p = 0.08), respectively. Diarrhea, flatulence, abdominal pain, and weight loss were common for combination recipients.(ABSTRACT TRUNCATED AT 250 WORDS)

Genital herpes simplex virus infections.

Genital HSV infection is an important sexually transmitted disease that is becoming more common. The primary infection typically is associated with systemic signs and symptoms and painful genital lesions, with a high rate of complications. Recurrences are much milder, with less frequent complications. Although many rapid diagnostic tests for genital herpes are now available, none is as sensitive or reliable as tissue culture. Dilemmas still exist regarding the best management strategy for the expectant mother at risk for transmitting HSV to the neonate, in part because of limitations in current diagnostic techniques. Although current treatment regimens with acyclovir can effectively control most symptoms and improve healing of lesions, they appear to have no effect on decreasing the frequency of subsequent recurrences. Short-term chronic suppression with acyclovir is effective in preventing symptomatic recurrences and appears to be relatively free of toxicity, but long-term studies are only now in progress. Asymptomatic viral shedding associated with either primary or recurrent infections and its contribution to sexual transmission of the disease are just now being fully appreciated, and the effect of therapy on subsequent transmission of disease remains to be determined. HSV genital infection in the immunocompromised host can produce a more severe and prolonged illness than in the normal host, but reactivation of the infection can be prevented with acyclovir suppression. Further research is needed on many aspects of the host-HSV interaction, especially regarding the factors involved in recurrences and the importance of the host's immune response to the manifestations of disease.

Human papillomavirus infections of the genital tract.

Infection of the genital tract by HPV is a sexually transmitted disease of increasing prevalence. The association of HPV infection with genital tract malignancies is of great concern, and further studies are needed to clarify this association. Few investigators believe at this time that proof of a direct causative role exists for HPV in these cancers, but indirect evidence of such a role is abundant. There are many clinical forms of HPV infection of the genital tract, and few clinicians can easily recognize them all. Treatment of condyloma acuminatum is difficult and frustrating. Cryotherapy with liquid nitrogen is the safest and most effective therapy for most forms of condyloma acuminatum. Recurrence of condyloma acuminatum is common with all presently used forms of therapy, probably owing to latent HPV infection in normal-appearing skin. No form of treatment is ideal for all forms of condyloma acuminatum, but without continued efforts to find better therapeutic modalities and preventative measures, the epidemic of genital HPV infection will continue unchecked.

Association of human papillomavirus type 11 DNA with squamous cell carcinoma of the tongue.

A 47-year-old man with a history of a benign papilloma of the tongue 5 years earlier was treated for a squamous cell carcinoma of the tongue with surgical resection. An analysis of the tumor DNA using several methods showed the presence of human papillomavirus (HPV) type 11 sequences that migrated with the high molecular weight cellular DNA, suggesting integration of viral DNA into the cellular genome. A segment of the HPV DNA was cloned from the lesion and shown to be similar to prototype HPV 11 DNA, except for some variability in the viral long control region. The proviral DNA contained part of the L1 region, all of the viral long control region, the entire E6 and E7 open-reading frames, and at least a portion of the E1 region; the E4 region appeared to be deleted. The integration sites of the HPV DNA could not be specifically identified. An analysis of the p53 tumor suppressor gene region of the tumor DNA showed no evidence of mutation. These results suggest that the HPV 11 DNA may have had a role in the origin of the cancer in this patient.

Cytomorphologic correlates of human papillomavirus infection in the "normal" cervicovaginal smear.

OBJECTIVE: To determine if cytologic abnormalities less striking than those usually considered diagnostic could predict the presence of human papillomavirus (HPV). STUDY DESIGN: Cervical scrapings were obtained from 403 women and examined by conventional Papanicolaou staining and for the presence of low- and high-risk human HPV DNA. The cytologic smears from 63 HPV DNA-positive and 63 matched HPV DNA-negative patients whose smears were initially read as normal or inflammatory were reviewed by a single cytotechnologist and a cytopathologist, who were blind to the HPV result. RESULTS: The cytologic diagnosis was upgraded to atypical squamous cells of undetermined significance (ASCUS) in nine cases and to low grade squamous intraepithelial lesion in one. All 10 upgraded cases were from the HPV DNA-positive group. A review diagnosis of ASCUS was significantly associated with both HPV in general and the presence of high-risk HPV DNA. Partial koilocytosis and multinucleation were associated with the detection of high-risk HPV DNA, while only partial koilocytosis was associated with the presence of low-risk HPV DNA. CONCLUSION: Because infection with high-risk HPV types is associated with cervical neoplasia, partial koilocytosis and multinucleation should be viewed with greater concern and possibly added to the ASCUS definition.

The psychosocial impact of serological diagnosis of asymptomatic herpes simplex virus type 2 infection.

OBJECTIVES: To evaluate the impact of a positive herpes simplex virus type 2 (HSV-2) serological test on psychosocial functioning among people with no known history of genital herpes. METHODS: Individuals (age 14-30 years) without a history of genital herpes were recruited from an urban university setting and sexually transmitted diseases (STD), primary care, and adolescent clinics. Participants completed a questionnaire addressing psychological functioning, psychosocial adjustment, and perceived quality of sex and were offered free HSV-2 antibody testing. 33 HSV-2 positive people and 60 HSV-2 negative people demographically matched from the same source of recruitment were re-evaluated at a 3 month follow up visit. HSV-2 positive participants also completed a genital herpes quality of life (GHQOL) measure. RESULTS: Of the 33 who were HSV-2 seropositive, four did not recall their diagnosis. In comparing those who were HSV-2 positive with those who were negative, repeated measures analysis of variance indicated there were no significant differences over time on any of the measures. None the less, many HSV-2 positive individuals indicated that the diagnosis had a notable impact on their quality of life. Also, among the HSV-2 positive people, lower GHQOL at the 3 month follow up was predicted by higher interpersonal sensitivity (r = -0.44, p<0.05), lower social support (r = 0.40, p<0.05), and quality of sex (r = 0.62, p<0.01) at baseline. CONCLUSIONS: A diagnosis of asymptomatic HSV-2 infection does not appear to cause significant lasting psychological difficulties. Those for whom the diagnosis had the greatest impact were interpersonally vulnerable before the diagnosis. These results suggest that assessment of interpersonal distress may be important to include as part of pretest and post-test counselling.

Human papillomavirus vaccine development.

The greatest successes in combating important viral infections have been achieved using vaccines. A vaccine to prevent genital tract human papillomavirus (HPV) infections, especially those types associated with genital tract malignancy, could significantly reduce morbidity and mortality from cervical and other genital tract cancers. However, several barriers currently stand in the way of HPV vaccine development. The immunological response to natural HPV infection is incompletely understood and there is uncertainty about which viral antigen(s) should be included in a candidate vaccine. It is clear that immunization of several animal species with the L1 major capsid protein (usually in the form of virus-like particles) spurs the production of anti-HPV antibodies that are neutralizing in several assay systems. However, it is not clear if neutralizing antibody will be present in the genital tract in sufficient quantities to block infection. A second problem is the lack of a reliable serological assay for HPV. This is a major problem for clinical trials in which the identification of susceptible individuals, and incident infections, usually relies on serological diagnosis. Finally, there is also interest in the development of a vaccine that is used to treat individuals who are already infected--a therapeutic vaccine. It is likely that a therapeutic vaccine will need to target different or additional antigens to those comprising a prophylactic vaccine.

Human papillomaviruses: are we ready to type?

The issue of determining which human papillomavirus (HPV) is present in a clinical specimen (typing specimens for HPVs) is receiving attention because HPVs cause condyloma acuminata and are associated with the continuum of disease which ranges from dysplasia to invasive genital cancer. Morphological inspection of precancerous lesions is not sufficient to determine which lesions will progress and which will not. A number of research tools based primarily on deoxyribonucleic acid hybridization have been developed. These permit identification and typing of HPV in genital tract scrapings or biopsies. Some HPV types (e.g., HPV-16 and HPV-18) have been identified in high-grade dysplasias and carcinomas more commonly than other types (e.g., HPV-6) and have been designated "high risk" types for cervical cancer. Thus, the question arises whether HPV typing would improve patient management by providing increased sensitivity for detection of patients at risk or by providing a prognostic indicator. In this review, the available typing methods are reviewed from the standpoint of their sensitivity, specificity, and ease of application to large-scale screening programs. Data implicating HPVs in the genesis of genital tract cancers are reviewed, as is the association of specific HPV types with specific outcomes. We conclude that there is currently no simple, inexpensive assay for HPV types, although such assays may be developed in the future. Analysis of the typing data indicates that, while HPV types can be designated high risk and low risk, these designations are not absolute and thus the low-risk group should not be ignored. In addition, interpretation of the data is complicated by finding high-risk types in individuals with no indication of disease. Insufficient data exist to indicate whether knowledge of the presence of a given HPV type is a better prognostic indicator than cytological or histological results. Thus, more research is needed before it can be determined whether typing information will augment the method currently in use for deciding treatment regimen and whether it warrants widespread use.

Lack of evidence for intertypic recombinants in the pathogenesis of recurrent genital infections with herpes simplex virus type 1.

Clinical observations indicate that herpes simplex virus type 1 (HSV-1) is significantly less likely than herpes simplex virus type 2 (HSV-2) to establish latency in (or reactivate from) sacral ganglionic tissue. In an effort to identify viral functions associated with latency, we analyzed HSV-1 isolates from three patients with established recurrent genital herpes and sought evidence of DNA sequences and proteins similar to those found in HSV-2. By restriction endonuclease cleavage patterns and by DNA hybridization analysis using either whole HSV-2 DNA or several cloned segments of HSV-2 DNA as probes, we found that the three HSV-1 isolates from patients with recurrent genital herpes showed no unusual homology to HSV-2 as compared with other HSV-1 isolates. Similarly, the proteins of these isolates could not be distinguished from those of other HSV-1 isolates and were distinct from those of HSV-2. At this level of resolution, there was no evidence to suggest that these recurrent genital HSV-1 isolates were intertypic recombinants, nor did they show any other unusual similarity to HSV-2.

Symptomatic and asymptomatic cervical infections with human papillomavirus during pregnancy.

The prevalence of human papillomavirus (HPV) infection of the cervix was determined in an unselected population of pregnant women presenting to an inner-city Obstetrics Clinic in the first trimester. Cervical scrape specimens were screened for the presence of HPV types 6, 11, 16, 18, and 31 DNA by using three different blot hybridization methods. Specimens from 26 (11.1%) of 234 patients contained HPV DNA sequences. HPV-16 and -31 were detected in six specimens each, whereas HPV-6, -11, and -18 were each identified in three specimens. Five additional specimens contained HPV DNA sequences of undetermined type. Only two of the 26 positive specimens were obtained from patients with genital warts; an additional 12 specimens were from patients with cytological abnormalities. We conclude that cervical HPV infections in some pregnant populations are common and that many such infections are not clinically apparent.

A one-step method for detecting and typing human papillomavirus DNA in cervical scrape specimens from women with cervical dysplasia.

We studied 66 women with a previous dysplastic cervical cytological smear who were referred for colposcopy and biopsy for the presence of human papillomavirus (HPV) types 6, 11, 16, 18, and 31 DNA in cervical specimens. The specimens were analyzed by a novel hybridization method termed reverse blotting, in which cellular DNA is radiolabeled and used to probe a battery of cloned HPV DNAs immobilized on nitrocellulose. Reconstruction experiments demonstrated that this method could detect about one HPV genome equivalent per cell. HPV DNA sequences were detected in 52 (96%) of 54 patients who showed either condylomatous changes or dysplasia by cervical biopsy. HPV-16 was most commonly detected overall and was detected in 61% of moderate or severe dysplastic samples. HPV DNA was also detected in seven of 12 cervical scrapes from women with a history of dysplasia but with either normal or inflammatory changes noted on cervical biopsy. Our results indicate that the reverse-blot method can detect DNA homologous to various HPV types in a single experiment using DNA from the small numbers of cells obtained by cervical scraping.

Genomic variation of adenovirus type 5 isolates recovered from bone marrow transplant recipients.

We characterized the genomic variation of adenovirus type 5 isolates recovered from bone marrow transplant recipients in Seattle between 1976 and 1982. By restriction endonuclease analysis, we identified three new adenovirus genomic variants, each associated with a single invasive adenovirus infection. In addition, we were able to obtain suggestive evidence for a nosocomial spread of a particular group of isolates within this population. This study demonstrates that the technique of restriction endonuclease analysis is an important epidemiological tool for investigating viral infections.

Nucleotide sequence of the inverted terminal repetition in adeno-associated virus DNA.

The inverted terminal repetition in adeno-associated virus type 2 DNA has been sequenced. The terminal repetition contain 145 nucleotides of which the first 125 nucleotides can self-base pair to form a T-shaped hairpin structure. Both restriction endonuclease analysis with SmaI and BglI and direct sequence analysis of the SmaI fragments provide evidence for two sequences in the region of the terminal repetition between nucleotides 44 and 81. The two sequences represent an inversion of the first 125 nucleotides of the terminal repetition. Based on these data a model for adeno-associated virus DNA replication is presented which agrees in detail with a general model for eucaryotic DNA replication originally proposed by Cavalier-Smith (T. Cavalier-Smith, Nature [London] 18:672--684, 1976).

The intracellular expression pattern of the human papillomavirus type 11 E1--E4 protein correlates with its ability to self associate.

The function of the human papillomavirus type 11 (HPV 11) E1--E4 spliced protein is not known. E1--E4 protein in HPV-infected tissue is detected in the cytoplasm of differentiated epithelial cells and as immunoreactive bands corresponding to potential monomers, dimers and trimers in immunoblots. The yeast two-hybrid system was employed to test for self association of the HPV 11 E1--E4 protein. To confirm the results of the yeast two-hybrid experiments, coimmunofluorescence studies of a green fluorescent fusion protein (GFP-E1--E4) and a T7 epitope-tagged E1--E4 protein were performed in C33a keratinocytes. E1--E4 protein was shown to self associate in the yeast two-hybrid system, and this result was confirmed by colocalization of GFP-E1--E4 and T7-E1(wedge)E4 proteins in keratinocytes. Analysis of E1--E4 mutants established that the C-terminus was required for self association and that sequences in the N-terminus influenced the intracellular localization of E1--E4 protein. The intracellular expression patterns of GFP-E1--E4 and GFP-E1--E4 mutants were correlated with E1--E4 binding in the yeast two-hybrid system. Those E1--E4 mutants that did not self associate in the yeast two-hybrid system were detected as diffuse cellular fluorescence when expressed as GFP fusions. In contrast, GFP-E1--E4 was detected as a perinuclear aggregate. All E1--E4 mutants capable of associating with E1--E4 in the yeast two-hybrid system were detected as aggregates when expressed as GFP fusion proteins in keratinocytes.