Chronic HIV-1 Infection Frequently Fails to Protect against Superinfection

Reports of HIV-1 superinfection (re-infection) have demonstrated that the immune response generated against one strain of HIV-1 does not always protect against other strains. However, studies to determine the incidence of HIV-1 superinfection have yielded conflicting results. Furthermore, few studies have attempted to identify superinfection cases occurring more than a year after initial infection, a time when HIV-1-specific immune responses would be most likely to have developed. We screened a cohort of high-risk Kenyan women for HIV-1 superinfection by comparing partial gag and envelope sequences over a 5-y period beginning at primary infection. Among 36 individuals, we detected seven cases of superinfection, including cases in which both viruses belonged to the same HIV-1 subtype, subtype A. In five of these cases, the superinfecting strain was detected in only one of the two genome regions examined, suggesting that recombination frequently occurs following HIV-1 superinfection. In addition, we found that superinfection occurred throughout the course of the first infection: during acute infection in two cases, between 1–2 y after infection in three cases, and as late as 5 y after infection in two cases. Our results indicate that superinfection commonly occurs after the immune response against the initial infection has had time to develop and mature. Implications from HIV-1 superinfection cases, in which natural re-exposure leads to re-infection, will need to be considered in developing strategies for eliciting protective immunity to HIV-1

Young and Early Career Investigators: Report from a Global HIV Vaccine Enterprise Working Group

The scientific challenges facing HIV-1 vaccine development are unprecedented in the history of vaccinology. As a result, investigators, funders, and other stakeholders generally agree that “game-changing” ideas are required. While innovation can certainly arise from investigators at all career stages, young and early-career investigators, defined as those under 40 years of age or within 10 years of their final degree or clinical training, are especially key contributors of novel and transformative ideas. Young and early-career investigators bring energy, enthusiasm, and fresh perspectives that are unbiased by prevailing dogma and that are essential to scientific progress

Implementation of HIV Drug Resistance Testing in Kenya

Background: Testing for HIV drug resistance prior to antiretroviral therapy (ART) is standard of care in the United States but is rarely performed in Africa due to its high cost. The prevalence of HIV drug resistance is increasing in resource-limited settings (RLS). An affordable and feasible strategy is needed in RLS to identify individuals with drug resistance and prescribe effective ART. Our group developed a low-cost oligonucleotide ligation assay (OLA) that detects mutations conferring resistance. Little data exists on implementing HIV drug resistance testing in RLS. Here, we describe the implementation of OLA in one laboratory in Kenya and discuss practical aspects of executing the OLA over two years. Methods: The OLA was transferred to a research laboratory at the Coptic Hope Center in Nairobi, Kenya, as part of a randomized trial testing use of the OLA in individuals starting first-line ART to improve virologic outcome. The Seattle Lab Manager (SLM) transported equipment needed for OLA to Nairobi, set up the laboratory, and trained two Kenyan lab technicians to perform OLA. Two additional technicians were later trained. Technicians had education either as a lab technologist or lab scientist, with limited training in molecular techniques. Results: OLA was successfully performed by Kenyan lab technicians on 565 blood samples. Each week, OLA was performed on approximately 7 samples, requiring an estimated 10 hours of technician labor, and 2 hours of remote technical support, review of test results and oversight from the SLM. Some sample results were delayed during two temporary, month-long pauses in testing of specimens, due to suboptimal performance of the OLA. This required trouble-shooting by the SLM in conjunction with lab personnel. Conclusion: OLA technology was successfully transferred to the Kenyan laboratory. However, it required time-intensive technician labor and substantial oversight by the SLM. The complexity of OLA, and a paucity of lab technicians and on-site supervisors trained in molecular techniques are potential bottlenecks for implementation of the current version of OLA at a larger population-level. Research is ongoing to develop OLA Simple, a simplified kit aimed to address these challenges and serve as a point-of-care assay

Increasing HIV-1 pretreatment drug resistance among antiretroviral-naïve adults initiating treatment between 2006 and 2014 in Nairobi, Kenya

Antiretroviral-naïve adults initiating antiretroviral therapy in Nairobi, Kenya were tested for HIV-1 drug resistance at codons K103N, Y181C, G190A, M184V, and K65R using an oligonucleotide ligation assay. Prevalence of pretreatment drug resistance increased from 3.89% in 2006 to 10.93% in 2014 (P \u3c 0.001), and 95% of those with resistance had at least one nonnucleoside reverse transcriptase inhibitor mutation. Resistance to tenofovir (K65R) was found in 2014 but not in 2006

Casting a Wide Net: HIV Drug Resistance Monitoring in Pre-Exposure Prophylaxis Seroconverters in the Global Evaluation of Microbicide Sensitivity Project.

BACKGROUND: Evidence of HIV drug resistance (HIVDR) in individuals using oral pre-exposure prophylaxis (PrEP) who acquire HIV is limited to clinical trials and case studies. More data are needed to understand the risk of HIVDR with oral PrEP during PrEP rollout. Mechanisms to collect these data vary, and are dependent on cost, scale of PrEP distribution, and in-country infrastructure for the identification, collection, and testing of samples from PrEP seroconverters. METHODS: The Global Evaluation of Microbicide Sensitivity (GEMS) project, in collaboration with country stakeholders, initiated HIVDR monitoring among new HIV seroconverters with prior PrEP use in Eswatini, Kenya, South Africa, and Zimbabwe. Standalone protocols were developed to assess HIVDR among a national sample of PrEP users. In addition, HIVDR testing was incorporated into existing demonstration projects for key populations. LESSONS LEARNED: Countries are supportive of conducting a time-limited evaluation of HIVDR during the early stages of PrEP rollout. As PrEP rollout expands, the need for long-term HIVDR monitoring with PrEP will need to be balanced with maintaining national HIV drug resistance surveillance for pretreatment and acquired drug resistance. Laboratory capacity is a common obstacle to setting up a monitoring system. CONCLUSIONS: Establishing HIV resistance monitoring within PrEP programs is feasible. Approaches to drug resistance monitoring may evolve as the PrEP programs mature and expand. The methods and implementation support offered by GEMS assisted countries in developing methods to monitor for drug resistance that best fit their PrEP program needs and resources

Primary Isolates of Human Immunodeficiency Virus Type 1 Are Usually Dominated by the Major Variants Found in Blood▿

The isolation of primary strains of human immunodeficiency virus (HIV) is an invaluable tool for assessing properties of viruses replicating in HIV-infected subjects. A common method for obtaining a primary isolate is coculture of peripheral blood mononuclear cells (PBMCs) from HIV-infected subjects with PBMCs from uninfected donors. However, such in vitro expansion may disturb the composition (identities and relative proportions of constituting viral species) of the original viral population. We developed a GeneScan assay to monitor HIV populations by detecting variants that differ in the length of the V1/V2 coding region of the envelope gene. This assay was used to compare proviral DNAs from the PBMCs of eight subjects to the corresponding primary isolates. Major variants found in uncultured PBMCs usually persisted during culturing, while the minor variants frequently disappeared, resulting in a reduction in viral diversity. The outgrowth of the initial (2 to 4 days) viral population appeared to be determined by random events. However, subsequent changes in the population were deterministic, and as a result, the compositions of primary isolates from parallel cultures were often very similar. For two of three subjects studied, the source of HIV-negative PBMCs had little effect on the composition of primary isolates, while for the third subject donor-dependent effects were observed. Overall, our results show that most primary isolates accurately represent the major viruses found in a subject's blood and that rapid population-based genotyping methods are useful for detecting isolates with perturbed viral populations

Evidence for Frequent Reinfection with Human Immunodeficiency Virus Type 1 of a Different Subtype

A major premise underlying current human immunodeficiency virus type 1 (HIV-1) vaccine approaches is that preexisting HIV-1-specific immunity will block or reduce infection. However, the recent identification of several cases of HIV-1 reinfection suggests that the specific immune response generated for chronic HIV-1 infection may not be adequate to protect against infection by a second HIV-1 strain. It has been unclear, though, whether these individuals are representative of the global epidemic or are rare cases. Here we show that in a population of high-risk women, HIV-1 reinfection occurs almost as commonly as first infections. The study was designed to detect cases of reinfection by HIV-1 of a different subtype and thus captured cases where there was considerable diversity between the first and second strain. In each case, the second virus emerged ∼1 year after the first infection, and in two cases, it emerged when viral levels were high, suggesting that a well-established HIV-1 infection may provide little benefit in terms of immunizing against reinfection, at least by more-divergent HIV-1 variants. Our findings indicate an urgent need for studies of larger cohorts to determine the incidence and timing of both intersubtype and intrasubtype reinfection

Analysis of the Percentage of Human Immunodeficiency Virus Type 1 Sequences That Are Hypermutated and Markers of Disease Progression in a Longitudinal Cohort, Including One Individual with a Partially Defective Vif▿ †

Hypermutation, the introduction of excessive G-to-A substitutions by host proteins in the APOBEC family, can impair replication of the human immunodeficiency virus (HIV). Because hypermutation represents a potential antiviral strategy, it is important to determine whether greater hypermutation is associated with slower disease progression in natural infection. We examined the level of HIV-1 hypermutation among 28 antiretroviral-naive Kenyan women at two times during infection. By examining single-copy gag sequences from proviral DNA, hypermutation was detected in 16 of 28 individuals. Among individuals with any hypermutation, a median of 15% of gag sequences were hypermutated (range, 5 to 43%). However, there was no association between the level of gag hypermutation and the viral load or CD4 count. Thus, we observed no overall relationship between hypermutation and markers of disease progression among individuals with low to moderate levels of hypermutation. In addition, one individual sustained a typical viral load despite having a high level of hypermutation. This individual had 43% of gag sequences hypermutated and harbored a partially defective Vif, which was found to permit hypermutation in a peripheral blood mononuclear cell culture. Overall, our results suggest that a potential antiviral therapy based on hypermutation may need to achieve a substantially higher level of hypermutation than is naturally seen in most individuals to impair virus replication and subsequent disease progression

Correlates of HIV detection among breastfeeding postpartum Kenyan women eligible under Option B.

BackgroundThe Option B+ strategy streamlines delivery of HIV antiretroviral therapy (ART) to pregnant women, but concerns remain about ART treatment adherence and long term outcomes.MethodsWe conducted a retrospective analysis of a cohort of HIV-positive, postpartum breastfeeding women receiving ART via Option B+ in Nairobi, Kenya. The primary outcome was virologic failure in plasma (HIV RNA >1000 copies/mL), and detection in breast milk (>150 copies/mL) and endocervical secretions (>100 copies/mL) at 2 postpartum timepoints. Correlates of virologic failure were assessed using univariate tests and multivariate logistic regression.ResultsOf 42 women at 6-14 weeks postpartum, 21.4% of women had HIV RNA detected in plasma; 14.3% in breast milk, and 23.7% in endocervical secretions. At 18-24 weeks postpartum, the percentages were 21.1%, 7.1%, and 14.3%, respectively. Younger maternal age, intent to breastfeed for longer, and later ART start in pregnancy were significantly associated with plasma virologic failure (p ConclusionsDespite months of ART, nearly one-quarter of the women in our cohort did not achieve plasma virologic suppression in the postpartum period. After adjusting for time on ART, earlier ART initiation in pregnancy was significantly associated with plasma suppression. Our findings suggest that postpartum HIV RNA monitoring in Option B+ programs will be needed to achieve elimination of MTCT