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BackgroundPersons living with HIV (PLHIV) who are also infected with Kaposi sarcoma-associated herpesvirus (KSHV) constitute a group among the highest risk for Kaposi sarcoma (KS). As such, understanding KSHV prevalence amongst PLHIV is important for the control of KS. To date, data on KSHV prevalence amongst PLHIV in East Africa — one of the world’s hotbeds for KS — is both sparse and variable.MethodsIn a cross-sectional design, we studied consecutive adult PLHIV identified just prior to starting antiretroviral therapy at an ambulatory HIV clinic in Mbarara, Uganda. Results from two enzyme immunoassays (with synthetic K8.1 and ORF 65 antigens as targets) and one immunofluorescence assay (using induced BCBL cells) to detect antibodies to KSHV were combined to classify KSHV antibody positivity.ResultsWe evaluated 727 PLHIV between 2005 to 2013; median age was 34 years (interquartile range (IQR): 28-40), 69% were women, and median CD4 count was 167 cells/µl (IQR: 95-260). Prevalence of KSHV antibody positivity was 42% (95% CI: 38%-46%), with little substantive change after several correction approaches, including Rogan-Gladen. Adjusted prevalence of KSHV antibody positivity was 1.6 times (95% CI: 1.3-1.9) higher in men than women; adjusted absolute prevalence difference was +0.20 (95% CI: +0.11 to +0.30). Lack of formal education (prevalence ratio=1.6 comparing no school to ≥ 4 years of secondary school; 95% CI: 1.1-2.3) was also associated with KSHV infection. We found no strong evidence for a role for age, alcohol use, or other measurements of sexual behavior, SES, or well-being in the occurrence of KSHV antibody positivity.ConclusionAmong adult PLHIV in western Uganda, KSHV prevalence is estimated at 42%, with little change after several approaches to correction for antibody detection inaccuracy. This estimate differs from several others in the region (up to 83%), highlighting need for inter-assay comparison studies using identical local specimens. To the extent HIV does not influence KSHV acquisition, the findings may also represent KSHV prevalence in the general population. The large-magnitude effect of sex and education on KSHV acquisition motivates an accelerated search for mechanisms. The sex effect, in part, may explain the higher incidence of KS among men.

BACKGROUND: Residual systemic inflammation, which is associated with non-AIDS clinical outcomes, may persist despite viral suppression. We assessed the effect of antiretroviral (ART) adherence interruptions on systemic inflammation among Ugandans living with HIV who were virally suppressed. SETTING: We evaluated adults initiating first-line ART at a regional referral hospital clinic in Mbarara, Uganda. METHODS: Plasma concentrations of interleukin-6 (IL-6), D-dimer, soluble sCD14, sCD163, the kynurenine/tryptophan (K/T) ratio, and CD8(+) T-cell activation (HLA-DR(+)/CD38(+) co-expression) were measured at baseline and 6 months following ART initiation among participants who achieved viral suppression (VL

Realization of optimal treatment and prevention benefits in the era of universal antiretroviral therapy (ART) and “U=U” (undetectable = untransmittable) requires high adherence at all stages of HIV disease. This article draws upon qualitative interview data to characterize two types of influences on ART adherence for 100 Ugandans and South Africans initiating ART during early-stage HIV infection. Positive influences are: (a) behavioral strategies supporting adherence; (b) preserving health through adherence; (c) support from others; and (d) motivating effect of adherence monitoring. “De-stabilizing experiences” (mobility, loss, pregnancy) as barriers are posited to impact adherence indirectly through intervening consequences (e.g. exacerbation of poverty). Positive influences overlap substantially with adherence facilitators described for later-stage adherers in previous research. Adherence support strategies and interventions effective for persons initiating ART later in HIV disease are likely also to be helpful to individuals beginning treatment immediately upon confirmation of infection. De-stabilizing experiences merit additional investigation across varying populations.

Single-nucleotide polymorphisms (SNPs) in CYP2B6 have been shown to predict variation in plasma efavirenz concentrations, but associations between these SNPs and efavirenz-mediated depression and viral suppression are less well described. We evaluated three SNPs in CYP2B6 (rs3745274, rs28399499, and rs4803419) in Ugandan persons living with HIV. To define exposure, we used previously published pharmacokinetic modeling data to categorize participants as normal, intermediate, and poor efavirenz metabolizers. Our outcomes were probable depression in the first 2 years after antiretroviral therapy (ART) initiation (mean score of >1.75 on the Hopkins Symptom Depression Checklist) and viral suppression 6 months after ART initiation. We fit generalized estimating equation and modified Poisson regression models adjusted for demographic, clinical, and psychosocial characteristics with or without individuals with depression at the time of ART initiation. Among 242 participants, there were no differences in the pre-ART depression or viral load by efavirenz metabolism strata (p > .05). Participants were classified as normal (32%), intermediate (50%), and poor (18%) metabolizers. Seven percent (56/242) of follow-up visits met criteria for depression. Eighty-five percent (167/202) of participants who completed a 6-month visit achieved viral suppression. CYP2B6 metabolizer strata did not have a statistically significant association with either depression [adjusted risk ratio (aRR) comparing intermediate or poor vs. normal, 1.46; 95% confidence interval (CI), 0.72-2.95] or 6-month viral suppression (aRR, 1.01; 95% CI, 0.88-1.15). However, in analyses restricted to participants without pre-ART depression, poorer CYP2B6 metabolism was associated with increased odds of depression (adjusted odds ratio, 4.11; 95% CI, 1.04-16.20). Efavirenz-metabolizing allele patterns are strongly associated with risk of incident depression. Future work should elucidate further region-specific gene-environment interactions and whether alternate polymorphisms may be associated with efavirenz metabolism.

HIV infection may increase risk of postpartum infection and infection-related mortality. We hypothesized that postpartum infection incidence and attributable mortality in Mbarara, Uganda would be higher in HIV-infected than HIV-uninfected women. We performed a prospective cohort study of 4,231 women presenting to a regional referral hospital in 2015 for delivery or postpartum care. All febrile or hypothermic women, and a subset of randomly selected normothermic women were followed during hospitalization and with 6-week postpartum phone interviews. The primary outcome was in-hospital postpartum infection. Secondary outcomes included in-hospital complications (mortality, re-operation, intensive care unit transfer, need for imaging or blood transfusion) and 6-week mortality. We performed multivariable regression analyses to estimate adjusted differences in each outcome by HIV serostatus. Mean age was 25.2 years and 481 participants (11%) were HIV-infected. Median CD4+ count was 487 (IQR 325, 696) cells/mm(3), and 90% of HIV-infected women (193/215 selected for in-depth survey) were on antiretroviral therapy. Overall, 5% (205/4231) of women developed fever or hypothermia. Cumulative in-hospital postpartum infection incidence was 2.0% and did not differ by HIV status (aOR 1.4, 95% CI 0.6–3.3, P=0.49). However, more HIV-infected women developed postpartum complications (4.4% vs. 1.2%, P=0.001). In-hospital mortality was rare (2/1,768, 0.1%), and remained so at 6 weeks (4/1526, 0.3%), without differences by HIV serostatus (P=1.0 and 0.31, respectively). For women in rural Uganda with high rates of antiretroviral therapy coverage, HIV infection did not predict postpartum infection or mortality, but was associated with increased risk of postpartum complications.

Recent ecological data demonstrate improving outcomes for HIV-infected people in sub-Saharan Africa. Recently, Uganda has experienced a resurgence in HIV incidence and prevalence, but trends in HIV-related deaths have not been well described. Data were collected through the Uganda AIDS Rural Treatment Outcomes (UARTO) Study, an observational longitudinal cohort of Ugandan adults initiating antiretroviral therapy (ART) between 2005 and 2013. We calculated cumulative incidence of death within one year of ART initiation, and fit Poisson models with robust variance estimators to estimate the effect enrollment period on one-year risk of death and loss to follow-up. Of 760 persons in UARTO who started ART, 30 deaths occurred within one year of ART initiation (cumulative incidence 3.9%, 95% confidence interval [CI] 2.7–5.6%). Risk of death was highest for those starting ART in 2005 (13.0%, 95% CI 6.0–24.0%), decreased in 2006–2007 to 4% (95% CI 2.0–6.0%), and did not change thereafter ( P = 0.61). These results were robust to adjustment for age, sex, CD4 cell count, viral load, asset wealth, baseline depression, and body mass index. Here, we demonstrate that one-year cumulative incidence of death was high just after free ART rollout, decreased the following year, and remained low thereafter. Once established, ART programs in President’s Emergency Fund for AIDS Relief-supported countries can maintain high quality care.

The impact of real-time electronic monitoring on antiretroviral therapy adherence warrants further study. We conducted an analysis of cohort participants that initially involved standard electronic adherence monitoring (EAM), followed by real-time EAM and home visits for sustained at least 48-h adherence interruptions. Immediately after switching between the two types of EAM, mean adherence among 112 participants increased from 84% to 93% and remained elevated for 6 months (P

Introduction The success of universal antiretroviral therapy (ART) access and aspirations for an AIDS‐free generation depend on high adherence in individuals initiating ART during early‐stage HIV infection; however, adherence may be difficult in the absence of illness and associated support. Methods From March 2015 to October 2017, we prospectively observed three groups initiating ART in routine care in Uganda and South Africa: men and non‐pregnant women with early‐stage HIV infection (CD4 > 350 cells/μL), pregnant women with early‐stage HIV infection and men and non‐pregnant women with late‐stage HIV infection (CD4 0.72). In South Africa, median adherence was higher in early/non‐pregnant versus early/pregnant or late/non‐pregnant participants (76%, 37%, 52%; p

HIV-1 can downregulate HLA-C on infected cells, using the viral protein Vpu, and the magnitude of this downregulation varies widely between primary HIV-1 variants. The selection pressures that result in viral downregulation of HLA-C in some individuals, but preservation of surface HLA-C in others are not clear. To better understand viral immune evasion targeting HLA-C, we have characterized HLA-C downregulation by a range of primary HIV-1 viruses. 128 replication competent viral isolates from 19 individuals with effective anti-retroviral therapy, show that a substantial minority of individuals harbor latent reservoir virus which strongly downregulates HLA-C. Untreated infections display no change in HLA-C downregulation during the first 6 months of infection, but variation between viral quasispecies can be detected in chronic infection. Vpu molecules cloned from plasma of 195 treatment naive individuals in chronic infection demonstrate that downregulation of HLA-C adapts to host HLA genotype. HLA-C alleles differ in the pressure they exert for downregulation, and individuals with higher levels of HLA-C expression favor greater viral downregulation of HLA-C. Studies of primary and mutant molecules identify 5 residues in the transmembrane region of Vpu, and 4 residues in the transmembrane domain of HLA-C, which determine interactions between Vpu and HLA. The observed adaptation of Vpu-mediated downregulation to host genotype indicates that HLA-C alleles differ in likelihood of mediating a CTL response that is subverted by viral downregulation, and that preservation of HLA-C expression is favored in the absence of these responses. Finding that latent reservoir viruses can downregulate HLA-C could have implications for HIV-1 cure therapy approaches in some individuals.

Background In sub-Saharan Africa (SSA), antiretroviral therapy (ART) can prolong life for HIV-infected patients. However, patients initiating ART, especially in routine treatment programs, commonly dropout from care either due to death or loss to follow-up. Methods In a cohort of HIV-infected patients initiating ART at a public sector clinic in Uganda, we assessed predictors of dropout from care (a composite outcome combining death and loss to follow-up). From a large set of socio-demographic, clinical, and laboratory variables routinely collected at ART initiation, we selected those predicting dropout at P

Aim It was recently found that HIV can downregulate HLA-C on infected cells. This is mediated by the viral protein Vpu, and is in addition to the downregulation of HLA-A/B by Nef. The magnitude of HLA-C downregulation varies widely between primary HIV viruses, but the selection pressures resulting in either HLA-C downregulation or preservation are not clear. Methods To better understand viral immune evasion targeting HLA-C, we have characterized HLA-C downregulation by a range of primary HIV-1 viruses. Results 100 replication competent viral isolates, from limiting dilution outgrowth assays of 20 individuals with effective anti-retroviral therapy, show a substantial minority of individuals harbor reservoir virus which strongly downregulates HLA-C. 20 longitudinal samples from 4 untreated individuals demonstrate no changes in HLA-C downregulation during acute infection, but show variation between viral quasispecies that can persist in chronic infection. 200 Vpu molecules cloned from plasma of treatment naive individuals in chronic infection, show that downregulation of HLA-C adapts to host HLA genotype. HLA-C alleles differ in the pressure they exert for viral downregulation of HLA-C, and individuals with higher levels of HLA-C expression favour greater viral downregulation of HLA-C. Studies of primary and mutant molecules show the transmembrane regions of both Vpu and HLA are responsible for their interaction when removing HLA-C from the cell surface. Conclusions Finding that reservoir virus can downregulate HLA-C could have implications for HIV cure therapy approaches in some individuals. The adaptation of HLA-C downregulation to host HLA genotype which is observed, indicates a subset of HLA-C alleles restrict HIV-specific CTL responses which are subverted by viral downregulation of HLA-C. Differential viral modulation of HLA-C, compared to HLA-A/B, can be used to understand differences in the biological roles of these HLA molecules in HIV infection.