High Epstein-Barr virus (EBV) DNA loads in HIV-infected patients: correlation with antiretroviral therapy and quantitative EBV serology

OBJECTIVE: To study Epstein-Barr virus (EBV) DNA loads in peripheral blood of HIV carriers to determine base-line values and diagnostic relevance of viral load in relation to quantitative serology; to compare EBV presence in parallel plasma and unfractionated whole blood samples; and to correlate EBV DNA load to HIV, CD4 T-cell counts and HAART. DESIGN: One-hundred and nine random patients receiving highly active antiretroviral therapy (HAART) during 1999 and 99 patients on anti-HIV monotherapy during 1993-1996 were included. METHODS: EBV DNA load was determined by quantitative competitive PCR. EBV serology was determined by immunoblot profile and quantitative enzyme-linked immunosorbent assay for responses against VCA-p18 and EBNA-1. RESULTS: Twenty-two out of 109 patients receiving HAART and 28 out of 99 of patients on anti-HIV monotherapy showed elevated EBV DNA loads in whole blood (> 2000 copies/ml), without elevated loads in parallel plasma. EBV DNA load distribution did not differ between the two groups (P = 0.78) and did not correlate with HIV or CD4 T-cell count. In three patients with high EBV DNA loads EBV RNA was virtually absent. Patients with high EBV DNA loads (3610-89 400 copies/ml) had higher anti-VCA-p18 IgG levels than patients with undetectable EBV DNA (P < 0.0001) but lower anti-EBNA-1 IgG levels (P = 0.005). CONCLUSION: Absolute values of EBV DNA load may have poor diagnostic value for defining HIV patients at risk for developing EBV-associated disease. Elevated EBV DNA loads are cell-associated and are not influenced by HAART. Increased anti-p18-VCA and decreased anti-EBNA-1 IgG levels in patients with high EBV loads indicate impaired latency control and increased lytic replication suggesting disturbed overall immunosurveillance against EBV

High Prevalence of Human Papillomavirus Infections in Urine Samples from Human Immunodeficiency Virus-Infected Men

Infection with human immunodeficiency virus (HIV) and the resulting immunosuppression are associated with an increased risk for human papillomavirus (HPV) persistence and related malignancies. In the present study we investigated the prevalence of HPV in urine samples from 104 HIV-infected men with low CD4(+) cell counts (<100 per mm(3)) and 115 urine samples from HIV-negative men. A high prevalence of HPV DNA (39.4%) was found in the HIV patients. Most of the HPV types were high risk (81.4%), with HPV 52 as the most prevalent type (12.5%), followed by HPV 18 (6.7%), HPV 35 (5.8%), and HPV 70 (4.8%). Multiple HPV genotypes were observed in 17 (41%) of the 41 HPV- and HIV-positive men. In contrast, only 11 (9.6%) HPV DNA-positive cases were observed among the 115 HIV-uninfected men, and 3 (27.3%) contained multiple genotypes. Quantitative analyses indicated that the HPV viral load, as measured in urine samples, is significantly higher in HIV-positive men compared to HIV-negative men. In the present study we show that urine samples are useful for detecting HPV DNA, there is a high prevalence of HPV in HIV-positive men, and the HPV viral load is substantially higher in HIV-positive than in HIV-negative men. More studies are needed to evaluate the risk and natural development of HPV-related malignancies in HIV-positive men

Monitoring of Epstein-Barr Virus DNA Load in Peripheral Blood by Quantitative Competitive PCR

A competitive quantitative PCR (Q-PCR) assay combined with simple silica-based DNA extraction was developed for monitoring of Epstein-Barr virus (EBV) DNA load in unfractionated peripheral blood. The Q-PCR is based on competitive coamplification of a highly conserved 213-bp region of the EBNA-1 open reading frame with an internal standard (IS), added in a known concentration. The IS has the same amplicon length and base composition as the wild-type (WT) EBNA-1 amplicon but differs in 23 internally randomized bases. Competitive coamplification yields two PCR products that are quantified by enzyme immunoassay or by electrochemiluminescence detection, with probes specific for the 23 differing internal nucleotides. The Q-PCR has a sensitivity of 10 copies of either WT or IS plasmid DNA. The Q-PCR was validated by quantification of known amounts of plasmid containing the WT EBNA-1 target. Furthermore, we determined EBV genome copy numbers in different cell lines. For EBV quantification in clinical samples, DNA was isolated from lysed whole blood by silica-affinity purification. Forty-six percent of healthy donor peripheral blood samples were positive by Q-PCR. In most of these samples, viral load was less than 2,000 EBV copies/ml of blood. In peripheral blood samples from two AIDS-related non-Hodgkin’s lymphoma patients, elevated EBV loads (up to 120,000 copies/ml) were observed, which decreased upon therapy. In Burkitt’s lymphoma patients, up to 4,592,000 EBV genome copies/ml of blood were detected. In conclusion, the EBNA-1-based Q-PCR assay provides a reproducible, accurate, and easy method for studying the relationship between EBV load and clinical parameters

Immune reconstitution after 2 years of successful potent antiretroviral therapy in previously untreated human immunodeficiency virus type 1-infected adults

Today's antiretroviral combination regimens can induce significant and sustained decreases in human immunodeficiency virus (HIV)-RNA levels, allowing the immune system to recover. To what extent immune reconstitution is possible and what factors determine the outcome have thus far not been resolved. We studied 19 subjects, treated for 2 years with protease inhibitor-containing triple therapy, who had a strong suppression of HIV-RNA levels. CD4+ T-cell numbers increased from medians of 170 to 420 x 106 cells/L, but in a number of subjects T-cell numbers did not further increase after week 72, without having reached normal values. Long-term CD4+ T-cell change was mainly caused by a slow but continuous increase in naive CD4+ T cells (CD45RA+CD62L+) and was predicted by the baseline number of these cells. Our data indicate that long-term immunological recovery is gradual, even during strong suppression of viral replication, not always complete, and dependent on the preexisting level of naive CD4+ T cells

Pharmacotherapy of Hospitalised HIV-Infected Patients in a General Hospital during 1990, 1997 and 2001

OBJECTIVE: To describe the changes over time in drug therapy (antiretroviral as well as co-administered drugs) in HIV-infected patients who required hospitalisation during the period 1990-2001. In addition, we wanted to evaluate and compare the characteristics of these patients. DESIGN/SETTING: Retrospective review of hospitalisations of HIV-infected patients in a general hospital. RESULTS: During specified periods in 1990, 1997 and 2001, 22 patients out of 130 outpatients, 29 out of 394 outpatients, and 19 out of 570 outpatients, respectively, who were treated at the outpatient clinic were admitted 30, 38 and 27 times, respectively. The mean duration of these hospitalisations was 18.8, 14.2 and 16.7 days, respectively. The percentage of women and the mean age of the hospitalised patients increased over the studied time period. AIDS-related diagnoses decreased when comparing 1997 with 2001. The type of co-administered drugs of patients who required hospitalisation was fairly stable, but the total volume (defined as the mean volume of drugs per patient per bed-day) increased dramatically from 5.3 in 1990 to 6.8 in 1997 and to 15.5 in 2001. Dual and triple antiretroviral therapy decreased and became quadruple or greater therapy when 1997 and 2001 were compared. In addition, the number of hospitalised patients not treated with antiretroviral drugs increased from 1997 to 2001. CONCLUSION: The incidence of hospital admissions decreased but the volume of co-administered drugs increased from 1990 to 2001, suggesting extensive co-morbidity in the patients who still require hospitalisation

Hepatotoxicity following nevirapine-containing regimens in HIV-1-infected individuals

To determine the incidence of hepatotoxicity and to investigate whether plasma concentrations of nevirapine, in addition to other risk factors, could predict hepatotoxicity during treatment with nevirapine-containing regimens, we conducted a retrospective analysis with data from 174 individuals infected with human immunodeficiency virus-1 (HIV-1). During regular visits to the clinic, blood samples were collected for the determination of nevirapine plasma concentrations and clinical chemistry parameters including liver enzymes (LEs) and total bilirubin (TBR). Severe hepatotoxicity was defined as a grade > or =3 elevation in at least one of the tested LEs or TBR levels while on therapy. Analysis of predictive factors was focused on increases in aspartate aminotransferase (ASAT) and/or alanine aminotransferase (ALAT) to grade > or =2. Grade > or =3 elevation developed with an incidence of 0.15 per patient year (PY); only 3.4% of the patients developed grade > or =3 values for ASAT and/or ALAT (incidence 0.03 per PY). We found that patients who use a protease inhibitor (PI) in a nevirapine-containing regimen and patients who have chronic hepatitis B (HBV) infection are at a higher risk for the development of increases in ASAT and/or ALAT to grade > or =2. In contrast, the plasma concentration of nevirapine does not appear to be a predictive factor in this study populatio

The steady-state pharmacokinetics of nevirapine during once daily and twice daily dosing in HIV-1-infected individuals

Objective: To investigate and to compare the steady-state plasma pharmacokinetics of nevirapine in a dosing regimen of 400 mg once daily versus 200 mg twice daily in HIV-1-infected individuals. Design: Open-label, randomized, cross-over study. Methods: Twenty HIV-1-infected individuals who already used nevirapine as part of their antiretroviral regimen were randomized to continue their current regimen (200 mg twice daily) or to switch to the alternate regimen (400 mg once daily). The steady-state plasma pharmacokinetics of nevirapine were assessed after 2 weeks during a 24-h period. Subsequently, patients were switched to the alternate regimen and the pharmacokinetics of nevirapine were assessed again after 2 weeks. Noncompartmental methods were used to calculate the area under the plasma concentration versus time curve (AUC([24 h])), and the maximal (C(max)) and minimal plasma concentration (C(min)), the time to C(max) (t(max)), the plasma elimination half-life (t(1/2)), the apparent oral clearance (Cl/F) and the apparent volume of distribution (V/F). Differences in these pharmacokinetic parameters for the two dosing regimens were tested using ANOVA. Results: The exposure to nevirapine, as measured by the AUC([24 h]), was not significantly different between the 400 mg once daily and 200 mg twice daily dosing regimen (P = 0.60). Furthermore, the values for t(max), t(1/2) Cl/F and V/F were not significantly different between the two dosing regimens (P ≥ 0.08). However, C(max) and C(min) were higher and lower, respectively, when nevirapine was used in the once daily regimen as compared with the twice daily regimen. The median values for C(max) and C(min) as measured for the once daily and twice daily regimens were 6.69 and 5.74 μg/ml, respectively (P = 0.03), and 2.88 and 3.73 μg/ml, respectively (P < 0.01). Conclusion: These data show that the daily exposure to nevirapine, as measured by the plasma AUC([24 h]), is not different between a 400 mg once daily and a 200 mg twice daily dosing regimen. However, C(max) and C(min) are higher and lower, respectively, for the once daily regimen as compared with the twice daily regimen. The clinical implications of these differences remain to be established. (C) 2000 Lippincott Williams and Wilkins