Role of antiretroviral therapy exposure host genetics on cytomegalovirus infection status and association with gut microbiome profiles among pregnant black African women

Cytomegalovirus (CMV) is an important antenatal infection that is prevalent in the developing world. The disabling and potentially fatal effects of CMV acquisition or reactivation during pregnancy on the developing foetus and or neonate are known but, factors predisposing pregnant women to CMV are not well studied. CMV has a wide host cell tropism that includes gut epithelial cells. CMV infection in the gut epithelial cells results in a leaky gut and potential gut microbial dysbiosis. In this study, we set out to determine the prevalence of CMV infection as well as factors associated with CMV reactivation in a cohort of pregnant Zimbabwean women. We also aimed to determine the role of CMV infection and CMV susceptibility host genetics on gut bacterial profiles. Seroprevalence of CMV was determined using the enzyme-linked immunosorbent assay. A high prevalence of previous exposure to CMV, as denoted by the presence of anti-CMV IgG antibodies in participants' sera, was observed. Anti-CMV IgM antibodies that denote active CMV infection were detected in the sera of 4.6% (n=35/524) study participants. Prevalence of CMV was also determined using real time PCR, CMV reactivation was higher (6.7%) when using PCR than when using immunological assays (4.6%). The presence of CMV DNA was significantly associated with HIV positivity (p=0.04). PCR is the gold standard for CMV diagnosis, thus, CMV DNA positivity was used to denote CMV infection status in this thesis. The second objective was to determine if the differential effect of CMV acquisition or reactivation among HIV infected participants was due to variability in plasma efavirenz containing antiretroviral therapy (ART) exposure. Efavirenz (EFV) plasma concentrations were determined using high performance liquid chromatography (HPLC). Single nucleotide polymorphisms (SNPs) in the CYP2B6 gene, which encodes the main EFV metabolizing enzyme were genotyped. Carriers of CYP2B6 poor metaboliser (PM) genotypes (c.516T/T and c.983T/C) had significantly higher mean plasma EFV concentration compared to carriers of CYP2B6 fast metabolizer genotypes (i.e., c.516G/G and c.983T/T). CYP2B6 PM genotype carriers were significantly less likely to be positive for CMV DNA when compared with fast metabolizer genotype carriers (pC (p=0.002), TLR7 rs179008A>C (pC (p=0.003). In contrast, presence of the IL6 rs10499563T>C polymorphism was inversely correlated with CMV infection (p=0.002). The reported genetic variants are reported to modulate proteins involved in immune responses against viral infections, thus, their association with susceptibility to CMV infection. Such findings may assist in the designing of a muchneeded candidate CMV vaccine. Lastly, we set out to determine the possible role of CMV infection in shaping gut microbiota profiles. We report on a significant difference (p=0.001) in the beta diversity of gut bacterial profiles between HIV- and age-matched CMV-infected (cases) and CMVuninfected (controls) participants. Using linear discriminant analysis (LDA) effect size (LefSe), significant differences in the relative abundance of specific bacterial taxa were observed between cases and controls (p2). Significantly lower abundance of Lactobacillus reuteri and Roseburia, genera associated with lower microbial translocation was observed in cases than controls. Lower relative abundance of Lactobacillus and Roseburia, is consistent with microbial translocation and heightened inflammation, respectively, hence higher likelihood of microbial translocation and inflammation occurring in cases than controls. Furthermore, Prevotella copri, a species that has been association with cytokine release and chronic inflammation was significantly more abundant in cases than controls. CMV is a known chronic inflammatory condition, and this study provides further confirmation through the higher relative abundance of P.copri in cases than controls. Biomarker identification has proven to be a successful means of translating molecular data into clinical practice, such as vaccine development in the case of CMV infection. Overall, this study reports the possible interaction of various host factors in facilitating CMV acquisition or reactivation during pregnancy. In the setting of HIV-CMV coinfection, our findings emphasise on the need for genotype guided drug dosage to achieve therapeutic EFV so as to maintain the balance between host and coinfecting microbes in HIV management. Comprehensive genotype guided drug dosage, if taken as a once-off test should be affordable especially in resource-limited settings. This is particularly important in pregnant women who are at a risk of vertically transmitting infection to the immunologically immature foetus and or neonate. Data from this study may assist in curbing the host associated challenges in designing an effective CMV vaccine. Moreover, the biomarkers reported may assist in diagnosis and management of potential CMV acquisition or reactivation during pregnancy. However, bigger prospective, functional studies would be needed to confirm the exact roles of the biomarkers identified in this study in the diagnosis, prognosis and therapeutics of CMV infection

Genetic variation in toll like receptors 2, 7, 9 and interleukin-6 is associated with cytomegalovirus infection in late pregnancy

Background Maternal cytomegalovirus (CMV) infection and/or reactivation in pregnancy is associated with a myriad of adverse infant outcomes. However, the role of host genetic polymorphisms in modulating maternal CMV status is inconclusive. This study investigated the possible association of single nucleotide polymorphisms in toll-like receptor (TLR) and cytokine genes with maternal plasma CMV DNA status in black Zimbabweans. Methods In a cross-sectional study, 110 women in late gestation who included 36 CMV infected cases and 74 CMV uninfected, age and HIV status matched controls were enrolled. Twenty single nucleotide polymorphisms in 10 genes which code for proteins involved in immunity against CMV were genotyped using Iplex GOLD SNP genotyping protocol on the Agena MassARRAY® system. Statistical analyses were performed using Stata SE and the ‘Genetics’ and ‘SNPassoc’ packages of the statistical package R. Results The TLR7 rs179008A > T (p  C (p = 0.049) polymorphism was on the borderline for association with CMV positive (CMV+) status. In contrast, the interleukin (IL)-6 rs10499563T > C (p  T (p = 0.001) polymorphisms were associated with CMV negative (CMV-) status. Furthermore, allele frequencies of SNPs in TLR2, TLR4, TLR9, TLR7, IL-6, IL-10, IL-28B, IL-1A and interferon AR1 (IFNAR1) genes are being reported here for the first time in a Zimbabwean population. The allele frequencies in the Zimbabwean population are generally comparable to other African populations but different when compared to European and Asian populations. Conclusions Toll-like receptor and interleukin genetic polymorphisms influence CMV status in late gestation among black Zimbabweans. This is attributable to possible modulation of immune responses to CMV reactivation in a population previously exposed to CMV infection

Promoting Undetectable equals Untransmittable in sub-Saharan Africa: Implication for clinical practice and ART adherence

In the last decade, reliable scientific evidence has emerged to support the concept that undetectable viral loads prevent human immunodeficiency virus (HIV). Undetectable equals untransmissible (U = U) is a simple message that everyone can understand. The success of this concept depends on strict adherence to antiretroviral therapy (ART) and the attainment of suppressed viral loads (VLs). To achieve U = U in sub-Saharan Africa (SSA), poor adherence to ART, persistent low-level viremia, and the emergence of drug-resistant mutants are challenges that cannot be overlooked. Short of a cure for HIV, U = U can substantially reduce the burden and change the landscape of HIV epidemiology on the continent. From a public health perspective, the U = U concept will reduce stigmatization in persons living with HIV (PLWHIV) in SSA and strengthen public opinion to accept that HIV infection is not a death sentence. This will also promote ART adherence because PLWHIV will aim to achieve U = U within the shortest possible time. This article highlights challenges and barriers to achieving U = U and suggests how to promote the concept to make it beneficial and applicable in SSA. This concept, if expertly packaged by policy-makers, clinicians, health service providers, and HIV control programs, will help to stem the tide of the epidemic in SSA

Higher serum 25-hydroxyvitamin D concentrations are associated with active pulmonary tuberculosis in hospitalised HIV infected patients in a low income tropical setting: a cross sectional study

Abstract Background The inherent risk of developing tuberculosis (TB) in HIV- infected individuals is further enhanced by hypovitaminosis D. Interventions that offset HIV-associated immune deterioration potentially arrest disease progression and incidence of opportunistic infections including TB. Despite conflicting reports on association between vitamin D deficiency (VDD) and risk of TB, vitamin D (VD) supplementation remains a promising intervention. Methods We conducted a comparative cross-sectional study on 145 HIV+/pulmonary TB+ (PTB) and 139 HIV+/PTB− hospitalised patients to investigate association of vitamin D status and risk of PTB. Stratified random sampling was used to select archived serum specimens from participants enrolled in a randomised controlled trial (RCT) conducted to investigate the impact of using a point-of-care urine lipoarabinomannan strip test for TB diagnosis. PTB status was confirmed using sputum smear microscopy, culture or GeneXpert MTB/RIF. Serum 25-hydroxyvitamin D [25(OH) D] concentrations were assayed by competitive chemiluminescent immunoassay prior to commencement of anti-TB treatment. Effect of VD status on duration of hospital stay and patient outcomes on follow up at 8 weeks were also investigated. Median serum 25(OH) D concentrations were compared using Mann-Whitney test and covariates of serum VD status were assessed using logistic regression analysis. Results Overall VDD prevalence in the cohort was 40.9% (95% CI: 35.1–46.8). Median serum 25(OH)D concentrations were significantly higher in HIV+/PTB+ group (25.3 ng/ml, IQR:18.0–33.7) compared to the HIV+/PTB− group (20.4 ng/ml, IQR:14.6–26.9), p = 0.0003. Patients with serum 25(OH) D concentration ≥ 30 ng/ml were 1.9 times more likely to be PTB+ compared to those with serum 25(OH) D concentrations < 30 ng/ml (odds ratio (OR) 1.91; 95% CI 1.1–3.2). PTB-related death was associated with higher odds of having 25(OH) D levels≥30 ng/ml. Age, gender, CD4+ count, combination antiretroviral therapy (cART) status, efavirenz based cART regimen and length of hospital stay were not associated with vitamin D status. Conclusions The finding of an association between higher serum 25(OH) D concentrations and active PTB and TB-related mortality among hospitalised HIV-infected patients in the present study is at variance with the commonly reported association of hypovitaminosis and susceptibility to TB. Our findings though, are in concordance with a small pool of reports from other settings