Clade-Specific Evolution Mediated by HLA-B*57/5801 in Human Immunodeficiency Virus Type 1 Clade A1 p24

HLA-B*57-mediated selection pressure leads to a typical escape pathway in human immunodeficiency virus type 1 (HIV-1) CD8 epitopes such as TW10. Whether this T242N pathway is shared by all clades remains unknown. We therefore assessed the nature of HLA-B*57 selection in a large, observational Kenyan cohort where clades A1 and D predominate. While T242N was ubiquitous in clade D HLA-B*57⁺ subjects, this mutation was rare (15%) in clade A1. Instead, P243T and I247L were selected by clade A1-infected HLA-B*57 subjects but not by HLA-B*5801⁺ subjects. Our data suggest that clade A1 consensus proline at Gag residue 243 might represent an inherent block to T242N escape in clade A1. We confirmed immunologically that P243T and I247L likely represent escape mutations. HLA-B*57 evolution also differed between clades in the KF11 and IW9 epitopes. A better understanding of clade-specific evolution is important for the development of HIV vaccines in regions with multiple clades.Human immunodeficiency virus type 1 (HIV-1) displays extreme genetic diversity, with nine clades (subtypes) described in group M, and frequent genomic recombination among and within the clades (7, 44). HIV is also capable of rapid evolution, which can lead to mutational escape from immune control (43). Escape from CD8⁺ T-cell responses occurs frequently in HIV-1 infection through mutations that affect epitope processing, HLA class I binding, and/or T-cell receptor recognition (23). In early HIV-1 infection, the majority of amino acid substitutions are associated HLA class I alleles (1). The timing and consequences of mutational escape from CD8⁺ T-cell responses vary considerably (8, 22).HLA-B*57, and to a lesser extent HLA-B*5801, has been associated with slower progression to AIDS in several studies (18, 27, 39), and HLA-B*5701 was associated with a lower viremia set point in a genome-wide association study (16). Several attributes of HLA-B*57-restricted CD8⁺ T-cell responses may contribute to their protectiveness, including dominant responses in acute infection (2), recognition of protective epitopes in HIV-1 p24 (33), better recognition of epitope variation (45), and retention of proliferative capability in chronic infection (24).HLA-B*57/5801 also exert powerful selection pressure on HIV to avoid CD8⁺ T-cell recognition. This was first demonstrated in the HLA-B*57-restricted TW10 epitope (TSTLQEQIGW [Gag_240-249]), which accounts for >30% of overall HIV-specific CD8⁺ T-cell responses in acutely infected HLA-B*57⁺ subjects (3). Escape in this epitope usually occurs early in infection, which coincidently is when HLA-B*57 is most protective (18). In clade B and C infections, >75 to 100% of HLA-B*57/5801⁺ subjects develop the T242N escape mutation, while HLA-B*57/5701-negative subjects rarely display polymorphism at this residue (5, 9, 10, 15, 32, 35, 38, 41). When T242N is transmitted to HLA-B*57/5801-negative subjects, it rapidly reverts to the consensus, suggesting that T242N is associated with a fitness defect (32, 35).While CD8⁺ T-cell cross-clade recognition has been tested extensively (6, 11, 19, 36, 48), few studies have addressed the possibility of clade-specific escape from CD8⁺ T-cell responses. This may be especially relevant where clade consensus sequences differ in immunologically relevant epitopes. Here we demonstrate in a large Kenyan cohort substantial differences in HLA-B*57/B*5801-mediated selection among HIV clades.Participants were enrolled from a Nairobi, Kenya-based cohort, and the relevant ethical review boards approved the study. HLA typing was performed as described previously (34). CD4 counts were measured longitudinally at biannual visits. Multiple and other clade infections were excluded. The HIV-1 p24 gene was amplified from proviral HIV DNA or RNA using a nested PCR approach and sequenced, and viral subtyping was carried out as described previously (42). Previously described HLA-B*57 epitopes IW9 (ISPRTLNAW), KF11 (KAFSPEVIPMF), and TW10 (TSTLQEQIGW) and selected variants were tested in immunological assays and described where relevant. Gamma interferon enzyme-linked immunospot (ELISPOT) assays were performed as described previously (37) using blood samples from HLA-B*57⁺ and -B*5801⁺ subjects. All peptides were tested at concentrations of 10 μg, 1 μg, 0.1 μg, and 0.01 μg/ml. Responses were considered positive if they were more than two times higher than that of the negative control and were measured at ≥100 spot-forming units ml⁻¹. Fisher''s exact test and chi-square analyses were used to determine differences among groups in categorical analyses. Mann-Whitney U tests were used to compare response magnitudes and disease progression between groups.We confirmed the protective effects of HLA-B*57 in clade A1 infection (mean of 9.9 years versus 7.8 years until CD4 counts were <200, P = 0.041) (Fig. ​(Fig.1).1). Slow progressors were overrepresented in HLA-B*57⁺ clade A1⁺ subjects (52.2%) compared to both HLA-B*5801⁺ clade A1⁺ (13.3%, P = 0.02) and HLA-B*57/5801-negative clade A1⁺ (27.8%, P = 0.028) subjects (Fig. ​(Fig.1b).1b). In contrast to what has been shown for other clades (2, 27), protection was not observed for clade A1-infected HLA-B*5801⁺ subjects (mean of 6.5 years versus 7.8 years until CD4 counts were <200, P > 0.3) (Fig. ​(Fig.11).Open in a separate windowFIG. 1.HLA-B*57, but not HLA-B*5801, is associated with a lower rate of disease progression in clade A1-infected subjects than that of the overall cohort. (a) Number of years from cohort entry until sequential CD4 counts fell below 200/μl. (b) Slow progressors (>10 years with CD4 counts of >200) were also more common in HLA-B*57⁺ clade A1-infected subjects than in those expressing HLA-B*5801 or neither.Stratification of TW10 (Gag_240-249) proviral sequences on the basis of HLA allele and clade revealed several differences in selection between clades A1 and D (Fig. ​(Fig.2a).2a). We observed the expected T242N substitution in 100% of HLA-B*57⁺ clade D-infected subjects (7/7), compared to only 14.7% variability at Gag residue 242 in HLA-B*57/5801-negative subjects (13/88, P = 3.26 × 10⁻⁹) (Fig. ​(Fig.2b).2b). In contrast, T242N was found infrequently in clade A1-infected HLA-B*57⁺ subjects (15%, 5/33, P = 0.0004). Instead, variants containing the mutations P243T and I247L were more frequently observed (both observed in 11/33 subjects). Overall, variation at residues 243 and 247 was more common in HLA-B*57⁺ subjects (51% and 15%, respectively; P = 2.92 × 10⁻⁶) than in HLA-B*57/5801-negative clade A1⁺ subjects (33% and 9%, respectively; P = 0.0008). Selection at both residues 243 and 247 was observed only in 2/33 HLA-B*57⁺ subjects, suggesting that these mutations are independent. Selection at residue 248, observed in clade B infection (32), was not evident in either clade A1 or D. While I247X selection has been described in other clades at low frequencies and in elite controllers (21, 40), HLA-B*57-mediated selection at Gag residue 243 has not yet been described. In summary, the T242N mutation, which is typical of other clades, does not appear to be the primary escape mutant in clade A1.Open in a separate windowFIG. 2.HLA-B*57-mediated selection in TW10 differs between clade A1 and clade D. (a) TW10 sequences were stratified by HLA-B*57, HLA-B*5801, or other alleles (HLA-B*57/5801⁻) and compared between clades A1 and D, based on the clade B consensus TW10 sequence. Each subject is represented by one sequence, and the numbers of subjects with a given sequence are shown in parentheses. A summary of variation from the TW10 consensus at Gag residues 242, 243, 247, and 248 is shown for HLA-B*57⁺ (b) and -B*5801⁺ (c) subjects. (b and c) Clade D is shown at the top, and clade A1 is shown at the bottom. Variation is shown in dark gray, and consensus is shown in light gray. (d) The proportions of clade A1-infected subjects with selection at Gag residue 242 only, and those with selection at residues 242 and 243 in combination, are shown. *, P < 0.05; **, P < 0.005; ***, P < 0.0005.Previous studies have suggested that HLA-B*5801 places selection pressure on TW10, similar to that of HLA-B*57 (35). Similar to clades B and C, selection of T242N was evident in HLA-B*5801⁺ clade D-infected subjects (TW10 variation in 8/11 HLA-B*5801⁺ subjects versus 13/88 HLA-B*57/5801-negative subjects; P = 0.0069) (Fig. ​(Fig.2c).2c). Limited T242N selection was observed in clade A1-infected HLA-B*5801⁺ subjects, and in contrast to HLA-B*57, there were no HLA-B*5801-associated substitutions at residues 243 and 247 in clade A1 (P values of 0.75 and 0.29, respectively) (Fig. ​(Fig.2c).2c). In summary, these data suggest that in addition to HLA-B*5801 not being associated with protection in clade A1 (Fig. ​(Fig.1),1), HLA-B*5801 does not select the HLA-B*57-associated clade A1 TW10 escape mutations.Inclusion of all clade A1 sequences with T242X substitutions (regardless of the HLA allele) reveals that in every case (10/10), there is an accompanying residue 243 mutation. Polymorphisms at these sites correlate very strongly (P = 3.71 × 10⁻⁸) (Fig. ​(Fig.2d).2d). Together, these data suggest that residue 242 polymorphism in clade A1 is incompatible with proline at residue 243, which is the clade A1 consensus.We next assessed the immunological implications of novel clade A1 variants in HLA-B*57⁺ (n = 12) and -B*5801⁺ (n = 6) subjects infected primarily by clade A1. Clade A1-infected subjects commonly made anamnestic, low-avidity responses to TW10. The majority of HLA-B*57⁺ subjects who recognized clade A1 TW10 did not respond to P243T or I247L in ELISPOT assays (Fig. ​(Fig.3),3), supporting the hypothesis that these represent escape mutations. Those who did recognize P243T and I247L had lower magnitude responses than those who recognized clade A1 TW10 at the 10-μg/ml peptide concentration (P of 0.0005 for both) (Fig. ​(Fig.3a).3a). Similarly, these variants were not well recognized by CD8⁺ T cells from HLA-B*5801⁺ subjects (Fig. ​(Fig.3b).3b). For two HLA-B*57⁺ subjects, P243T and I247L responses had lower avidity than clade A1 TW10 responses (Fig. ​(Fig.3c).3c). These data support the hypothesis that P243T and I247L likely represent escape mutations.Open in a separate windowFIG. 3.Peptides with novel TW10 clade A1-selected mutations are poorly recognized in ex vivo gamma interferon ELISPOT avidity assays, suggestive of escape mutations. ELISPOT responses to TW10 and variants at 10 μg/ml peptide by HLA-B*57⁺ (a) and HLA-B*5801⁺ (b) subjects are shown. (c) The functional avidity of TW10 and variants for two HLA-B*57⁺ subjects is shown, suggesting that P243T and I247L are less recognized than TW10, particularly at lower peptide concentrations. Sequence names are described in the text. (d) Elispot responses to A1 TW10 and T242N correlated at 10 μg/ml. SFU/m, spot-forming units/million PBMCs.Recognition of the clade B/D consensus (TSTLQEQIGW) was diminished compared to that of clade A1 TW10. However, despite the presumed absence of this variant in these subjects'' autologous sequences, the clade B/D escape variant (TSNLQEQIGW [T242N]) was recognized at a magnitude similar to that of the consensus clade A1 TW10 (r = 0.71, P = 0.0099) (Fig. ​(Fig.3d).3d). No responses to T242N/G248A were observed (not shown), as described previously (32). These data suggest that clade A1 and B TW10, and their escape variants, are immunologically distinct from one another.We next assessed whether clade-specific selection was evident in other immunodominant HLA-B*57 p24 epitopes that are commonly targeted in chronic clade B infection (2). In clade D IW9 (ISPRTLNAW [Gag_147-155]), variants containing the escape variant I147L (14) were more common in HLA-B*57⁺ subjects than in HLA-B*57/5801-negative subjects (86% and 30%, respectively; P = 0.0055) (Table ​(Table1).1). However, this variant was not selected in clade A1 (variation in 30% versus 21% subjects; P value was not significant), where leucine is the consensus. Interestingly, ELISPOT data indicated substantial cross-reactivity between 147L and 147I in clade A1-infected subjects (10 μg/ml, r = 0.987, P < 0.0001) (data not shown), suggesting that infection with an escape variant from one clade (clade D) does not necessarily preclude recognition of this epitope in another one (clade A1). Other amino acids (F, M, and P) were common in HLA-B*57⁺ subjects at residue 147 (>30% versus 3% in HLA-B*57/5801-negative subjects, P = 3.85 × 10⁻⁶). Although the immunological consequences are unknown, these HLA-associated substitutions could represent novel escape variants.

TABLE 1.

p24 sequences in HLA-B*57⁺ subjects infected by clades A1 and D

HLA Class I-Mediated Control of HIV-1 in the Japanese Population, in Which the Protective HLA-B*57 and HLA-B*27 Alleles Are Absent

We investigated the effect of HLA class I alleles on clinical parameters for HIV-1 disease progression in the Japanese population, where two strongly protective alleles, HLA-B*57 and HLA-B*27, are virtually nonexistent. HLA-B alleles showed a dominant role, primarily through HLA-B*67:01 and the HLA-B*52:01-C*12:02 haplotype. Neither a rare-allele nor a heterozygote advantage was found, suggesting that the effect of HLA alleles in the Japanese population is either different from those observed in Africans and Caucasians or undetectable due to limited power.     

HLA-B57/B*5801 Human Immunodeficiency Virus Type 1 Elite Controllers Select for Rare Gag Variants Associated with Reduced Viral Replication Capacity and Strong Cytotoxic T-Lymphotye Recognition

Human immunodeficiency virus type 1 (HIV-1) elite controllers (EC) maintain viremia below the limit of commercial assay detection (<50 RNA copies/ml) in the absence of antiviral therapy, but the mechanisms of control remain unclear. HLA-B57 and the closely related allele B*5801 are particularly associated with enhanced control and recognize the same Gag_240-249 TW10 epitope. The typical escape mutation (T242N) within this epitope diminishes viral replication capacity in chronically infected persons; however, little is known about TW10 epitope sequences in residual replicating viruses in B57/B*5801 EC and the extent to which mutations within this epitope may influence steady-state viremia. Here we analyzed TW10 in a total of 50 B57/B*5801-positive subjects (23 EC and 27 viremic subjects). Autologous plasma viral sequences from both EC and viremic subjects frequently harbored the typical cytotoxic T-lymphocyte (CTL)-selected mutation T242N (15/23 sequences [65.2%] versus 23/27 sequences [85.1%], respectively; P = 0.18). However, other unique mutants were identified in HIV controllers, both within and flanking TW10, that were associated with an even greater reduction in viral replication capacity in vitro. In addition, strong CTL responses to many of these unique TW10 variants were detected by gamma interferon-specific enzyme-linked immunospot assay. These data suggest a dual mechanism for durable control of HIV replication, consisting of viral fitness loss resulting from CTL escape mutations together with strong CD8 T-cell immune responses to the arising variant epitopes.A subset of human immunodeficiency virus type 1 (HIV-1)-infected persons who control viremia to below the limit of detection (<50 RNA copies/ml plasma) without antiviral therapy has been termed elite controllers/suppressors (EC) (2, 3, 6, 13, 32). Some of these individuals have been infected in excess of 30 years, indicating prolonged containment of HIV replication, but the mechanisms associated with this extreme viremia control remain elusive (13). Among EC, certain HLA class I alleles are overrepresented, in particular HLA-B57, strongly suggesting that HIV-1-specific cytotoxic T-lymphocyte (CTL) responses restricted by these alleles may be crucial for viremia control (16, 29, 32). However, to date, there has been no clear explanation as to why some subjects can control viremia but others cannot, even when carrying the same allegedly protective HLA alleles. Moreover, the characteristics of virus-specific immune responses as well as the impact of viral escape mutations on in vitro replicative fitness in persons with different disease outcomes remain unclear.Growing numbers of studies suggest that CTL targeting Gag, particularly the p24 capsid protein, play an important role in controlling viremia (7, 15, 22, 26, 32, 33, 38). Indeed, the most protective HLA class I allele, B57, which is present in over 40% of EC (32), restricts four immunodominant CTL epitopes in the p24 capsid protein. Previous studies have failed to find differences in the recognition of Gag epitopes or in gamma interferon (IFN-γ) responses to HIV proteins between B57-positive (B57⁺) long-term nonprogressors and B57⁺ progressors (28). Other studies have shown differences in the frequency of polyfunctional CD8⁺ T cells between B57⁺ EC and B57⁺ progressors (5); likewise, differences in the frequency of IFN-γ/interleukin-2-producing CD8⁺ T cells between controllers and progressors with protective HLA alleles were reported (16). Recently, Bailey et al. reported that plasma viruses in B57⁺ EC can harbor CTL escape mutations in the Gag protein, and in some cases these autologous variants were recognized by CTL (3). However, since there were no comparisons to progressors, it is unclear whether the viral variants that were detected or the apparent de novo CTL responses to the variant viruses are characteristic features among B57⁺ persons who maintain persistent control.Of the four immunodominant Gag CTL epitopes restricted by HLA-B57, TW10 (TSTLQEQIGW [Gag residues 240 to 249]) is known to be the earliest target in acute infection (1, 11, 36), therefore likely playing an important role in defining the plasma viral load set point. This epitope is also known to be presented by the closely related B*5801 allele, which is also associated with viral control (21). One of the most frequently detected mutations within this epitope, T242N, is known to occur rapidly and almost universally after acute infection in persons expressing HLA-B57/B*5801 (11, 17, 23). The same mutation has been shown to have a negative impact on viral replication capacity (VRC) by both clinical observation and in vitro experiments (8, 23, 25). Moreover, as plasma viral load increases, compensatory mutations accumulate, restoring VRC to some extent (8). Additional studies, predominantly with children, indicated that some TW10 escape variants may be targeted by specific immune responses (17). Together, these data suggest a hypothesis to explain the diverse disease courses among B57⁺ subjects, namely, that a combination of fitness cost by CTL escape from the TW10 response, variable accumulation of compensatory mutations, and variable generation of specific CTL responses to the new variant influence plasma viral loads.In this study, we investigated plasma viral sequences and IFN-γ-specific enzyme-linked immunospot (ELISPOT) assay responses to autologous Gag TW10 sequences in HLA-B57/B*5801-positive EC and compared these data to those obtained from persons with detectable viremia. Our results indicate that the TW10 T242N mutation does not differentiate HLA-B57/B*5801 EC from those with viremia and that CTL responses to this variant epitope are frequently detected in both viremic and aviremic subjects. However, some rare variants within and flanking this epitope were observed exclusively in HIV controllers, most of which not only reduced VRC but also were recognized by specific CTL at a high magnitude. These data suggest that the additive effects of both CTL-mediated selection for less fit viral variants and CD8 T-cell responses to the variant viruses contribute to strict viremia control in HLA-B57/B*5801-positive controllers.     

Cost-Effectiveness of Long-Lasting Insecticide-Treated Hammocks in Preventing Malaria in South-Central Vietnam

Background

Despite much success in reducing the burden of malaria in Vietnam, pockets of malaria persist and eliminating them remains an important development goal. In central Vietnam, insecticide-treated hammocks have recently been introduced to help counter the disease in the highly forested, mountainous areas, where other measures have so far been unsuccessful. This study assesses the cost-effectiveness of using long-lasting insecticide-treated hammocks in this area.

Methods and Findings

This cost-effectiveness study was run alongside a randomized control trial testing the efficacy of the long-lasting insecticide-treated hammocks. Data were collected through an exit survey, a household survey, expenditure records and key informant interviews. The study estimates that under normal (non-trial) conditions the total net societal cost per malaria episode averted in using long-lasting insecticide-treated hammocks in this area was 126 USD. Cost per hammock, including insecticidal netting, sewing, transport, and distribution was found to be approximately 11.76 USD per hammock. Average savings per episode averted were estimated to be $14.60 USD for the health system and 14.37 USD for households (including both direct and indirect cost savings). The study estimates that the annual financial outlay required of government to implement this type of programme to be 3.40 USD per person covered per year.

Conclusion

The study finds that the use of a hammock intervention could represent good value for money to help prevent malaria in more remote areas, where traditional control measures such as insecticide-treated bednets and indoor residual spraying are insufficient or inappropriate to control malaria. However, the life span of the hammock–the number of years over which it effectively deters mosquitoes–has a significant impact on the cost-effectiveness of the intervention and study results should be interpreted in light of the evidence on effectiveness gathered in the years to come.     

The Bw4/Bw6 difference between HLA-B*0802 and HLA-B*0801 changes the peptides endogenously bound and the stimulation of alloreactive T cells

 HLA-B^*0801 is unique among HLA-B allotypes in having dominant amino acid anchors at positions 3 and 5 of the peptide-binding motif. HLA-B^*0802 is a variant of HLA-B^*0801 in which the Bw6 sequence motif is replaced by a Bw4 sequence motif. This change, involving substitutions at positions 77, 80, 81, 82, and 83 of the B^*08 heavy chain, is probably the result of a single evolutionary event of interallelic conversion. Moreover, the difference between B^*0802 and B^*0801 is sufficient to stimulate a cytotoxic T-cell response. To assess further the functional impact of the Bw4 motif on a B8 background, we compared the peptide-binding specificity of the B^*0801 and B^*0802 allotypes by sequencing the mixture of peptides endogenously bound to B^*0802 and 12 individual peptides purified from that mixture. The HLA-B^*0802 allotype, while able to bind some peptides bound by B^*0801, has a broader repertoire of endogenously bound peptides than B^*0801: the peptides bound by B^*0802 are more variable in length and exhibit greater diversity in the carboxyl-terminal amino acid which interacts with the F pocket. Received: 29 October 1997     

Cost-Effectiveness Analysis of Chemical Testing for Decision-Support: How to Include Animal Welfare?

Toxicity testing for regulatory purposes raises the question of test selection for a particular endpoint. Given the public's concern for animal welfare, test selection is a multi-objective decision problem that requires balancing information outcome, animal welfare loss, and monetary testing costs. This paper demonstrates the applicability of cost-effectiveness analysis as a decision-support tool for test selection in a regulatory context such as, for example, the new European chemicals legislation (REACH). We distinguish different decision-making perspectives, in particular the regulator's and chemical industry's perspectives, and we discuss how cost-effectiveness analysis can be applied to test selection from both perspectives. Furthermore, we show how animal welfare goals can be included in cost-effectiveness analyses, and we provide a three-dimensional extension to the standard cost-effectiveness analysis if animal welfare loss cannot be valued in monetary terms. To illustrate how cost-effectiveness analysis works in different settings, we apply our model to a simple case of selecting short-term tests for mutagenicity. We demonstrate that including sufficiently high values for animal welfare induces cost-effective replacements of animal testing. Furthermore, we show that the regulator and chemical companies face different tradeoffs when selecting tests. This may lead to different choices of tests or testing systems.     

Different evolutionary pathway of B*570101 and B*5801 (B17 group) alleles based in intron sequences

Two theories about MHC allele generation have been put forward: (1) point mutation diversification and/or (2) gene conversion events. A model supporting the existence of both of these mechanisms is shown in this paper; the possible evolution of the HLA-B*570101 and HLA-B*5801 alleles (which belong to the HLA-B17 serology group) is studied. The hypothesis favoured is that gene conversion events have originated these alleles, because intron sequences are also analysed. Evolution by point mutation should only be accepted if flanking introns have also been sequenced.The nucleotide sequence data (exons and introns) reported in this paper have been sequenced in our laboratory. They are in the GenBank nucleotide sequence database and have been assigned the accession numbers: B*150101—(a) exon 1, L79939; (b) exon 2 and exon 3, L48400; (c) intron 1, L76249; (d) intron 2, L42468; B*1515—(a) exon 1, exon 2 and exon 3, L49343; (b) intron 1 and intron 2, L76254; B*1539—(a) exon 2, AF033501; (b) exon 3, AF033502; (c) intron 1, AF034961; (d) intron 2 AF034962; B*350101—(a) exon 1, exon 2 and exon 3, L63544; (b) intron 1, L79921; (c) intron 2, L57505; B*510101—(a) exon 1, L77204; (b) exon 2 and exon 3, L47985; (c) intron 1, L76245; (d) intron 2, L42469; B*520102—(a) exon 1, L77205; (b) exon 2 and exon 3, L47984; (c) intron 1, L76244; (d) intron 2, L76251; B*5301—(a) exon 1, intron 1, exon 2, intron 2 and exon 3, U90566; B*1302—(a) intron 1, exon 2, intron 2, exon 3, AF196182; B*400101/02—(a) exon 2 and exon 3, L79937; (b) intron 1, L79919; (c) intron 2, L76629; B*4101—(a) intron 1, exon 2, intron 2 and exon 3, U90560; B*4102 (a) intron 1, exon 2, intron 2 and exon 3, AF 126199; B*4501—(a) intron 1, exon 2, intron 2 and exon 3, U90562; B*570101—(a) intron 1, exon 2, intron 2 and exon 3, AF196183; B*5801—(a) intron 1, exon 2, intron 2 and exon 3, AF196184All exon sequences were officially assigned as confirmatory by the WHO Nomenclature Committee in December 2003: B*1302, B*150101, B*350101, B*400101/02, B*4101, B*510101, B*570101, B*5801, B*5301, B*4501, B*520102, B*1515, B*4102 and B*1539. This follows the agreed policy that, subject to the conditions stated in the Nomenclature Report [Marsh et al. (2002) Tissue Antigens 60:407–464], names will be assigned to new sequences as they are identified. Lists of such new names will be published in the following WHO Nomenclature Report     

Comparing Cost-Effectiveness of HIV Testing Strategies: Targeted and Routine Testing in Washington,DC

BackgroundRoutine HIV testing is an essential approach to identifying undiagnosed infections, linking people to care and treatment, and preventing new infections. In Washington, DC, where HIV prevalence is 2.4%, a combination of routine and targeted testing approaches has been implemented since 2006.MethodsWe sought to evaluate the cost effectiveness of the District of Columbia (DC) Department of Health’s routine and targeted HIV testing implementation strategies. We collected HIV testing data from 3 types of DC Department of Health-funded testing sites (clinics, hospitals, and community-based organizations); collected testing and labor costs; and calculated effectiveness measures including cost per new diagnosis and cost per averted transmission.ResultsCompared to routine testing, targeted testing resulted in higher positivity rates (1.33% vs. 0.44%). Routine testing averted 34.30 transmissions per year compared to targeted testing at 17.78. The cost per new diagnosis was lower for targeted testing ($2,467 vs. $7,753 per new diagnosis) as was the cost per transmission averted ($33,160 vs. $104,205). When stratified by testing site, both testing approaches were most cost effective in averting new transmissions when conducted by community based organizations ($25,037 routine; $33,123 targeted) compared to hospitals or clinics.ConclusionsWhile routine testing identified more newly diagnosed infections and averted more infections than targeted testing, targeted testing is more cost effective per diagnosis and per transmission averted overall. Given the high HIV prevalence in DC, the DC Department of Health’s implementation strategy should continue to encourage routine testing implementation with emphasis on a combined testing strategy among community-based organizations.     

Cost-Effectiveness of HIV Testing Referral Strategies among Tuberculosis Patients in India

Background

Indian guidelines recommend routine referral for HIV testing of all tuberculosis (TB) patients in the nine states with the highest HIV prevalence, and selective referral for testing elsewhere. We assessed the clinical impact and cost-effectiveness of alternative HIV testing referral strategies among TB patients in India.

Methods and Findings

We utilized a computer model of HIV and TB disease to project outcomes for patients with active TB in India. We compared life expectancy, cost, and cost-effectiveness for three HIV testing referral strategies: 1) selective referral for HIV testing of those with increased HIV risk, 2) routine referral of patients in the nine highest HIV prevalence states with selective referral elsewhere (current standard), and 3) routine referral of all patients for HIV testing. TB-related data were from the World Health Organization. HIV prevalence among TB patients was 9.0% in the highest prevalence states, 2.9% in the other states, and 4.9% overall. The selective referral strategy, beginning from age 33.50 years, had a projected discounted life expectancy of 16.88 years and a mean lifetime HIV/TB treatment cost of US$100. The current standard increased mean life expectancy to 16.90 years with additional per-person cost of US$10; the incremental cost-effectiveness ratio was US$650/year of life saved (YLS) compared to selective referral. Routine referral of all patients for HIV testing increased life expectancy to 16.91 years, with an incremental cost-effectiveness ratio of US$730/YLS compared to the current standard. For HIV-infected patients cured of TB, receiving antiretroviral therapy increased survival from 4.71 to 13.87 years. Results were most sensitive to the HIV prevalence and the cost of second-line antiretroviral therapy.

Conclusions

Referral of all patients with active TB in India for HIV testing will be both effective and cost-effective. While effective implementation of this strategy would require investment, routine, voluntary HIV testing of TB patients in India should be recommended.     

Expanded HIV Testing in Low-Prevalence,High-Income Countries: A Cost-Effectiveness Analysis for the United Kingdom

Objective

In many high-income countries with low HIV prevalence, significant numbers of persons living with HIV (PLHIV) remain undiagnosed. Identification of PLHIV via HIV testing offers timely access to lifesaving antiretroviral therapy (ART) and decreases HIV transmission. We estimated the effectiveness and cost-effectiveness of HIV testing in the United Kingdom (UK), where 25% of PLHIV are estimated to be undiagnosed.

Design

We developed a dynamic compartmental model to analyze strategies to expand HIV testing and treatment in the UK, with particular focus on men who have sex with men (MSM), people who inject drugs (PWID), and individuals from HIV-endemic countries.

Methods

We estimated HIV prevalence, incidence, quality-adjusted life years (QALYs), and health care costs over 10 years, and cost-effectiveness.

Results

Annual HIV testing of all adults could avert 5% of new infections, even with no behavior change following HIV diagnosis because of earlier ART initiation, or up to 18% if risky behavior is halved. This strategy costs £67,000–£106,000/QALY gained. Providing annual testing only to MSM, PWID, and people from HIV-endemic countries, and one-time testing for all other adults, prevents 4–15% of infections, requires one-fourth as many tests to diagnose each PLHIV, and costs £17,500/QALY gained. Augmenting this program with increased ART access could add 145,000 QALYs to the population over 10 years, at £26,800/QALY gained.

Conclusions

Annual HIV testing of key populations in the UK is very cost-effective. Additional one-time testing of all other adults could identify the majority of undiagnosed PLHIV. These findings are potentially relevant to other low-prevalence, high-income countries.     

Interaction between HLA-B60 and HLA-B27 as a Better Predictor of Ankylosing Spondylitis in a Taiwanese Population

Objective

Ankylosing spondylitis (AS) is a form of chronic inflammatory spondyloarthritis (SpA) that causes pain and stiffness in spines or joints. Human leukocyte antigen B27 (HLA-B27) and B60 (HLA-B60) have been reported as major genetic risk factors of AS. In addition, rs13202464, located on major histocompatibility complex (MHC) region, showed high sensitivity (98.7%) and specificity (98.0%) for HLA-B27.

Design

The aim of our study is to test whether the interaction between HLA-B60 and HLA-B27 (rs13202464) can serve as a better predictor of AS. We have genotyped HLA-B60 and rs13202464 among 471 patients with AS and 557 healthy subjects. Combined risk factors were investigated to test the biological interaction.

Results

Our results indicated that the relative risk (RR) for HLA-B27+/HLA-B60− was 152 (95% CI 91 to 255) and it increased to 201 (95% CI 85 to 475) in HLA-B27+/HLA-B60+ patients (with HLA-B27−/HLA-B60− as reference). Combinational analysis of two risk factors (HLA-B27+/HLA-B60+) showed a relative excess risk due to interaction (RERI) of 46.79 (95% CI: -117.58 to 211.16), attributable proportion (AP) of 0.23 (95% CI: -0.41 to 0.88) and a synergy index (S) of 1.31 (95% CI: 0.56 to 3.04).

Conclusion

In conclusion, genetic interaction analysis revealed that the interaction between HLA-B60 and HLA-B27 is a better marker for the risk of AS susceptibility in a Taiwanese population.     

Systematic Identification and Comparative Analysis of Human Cartilage-Derived Self-peptides Presented Differently by Ankylosing Spondylitis (AS)-Associated HLA-B*27:05 and Non-AS-associated HLA-B*27:09

International Journal of Peptide Research and Therapeutics - The human leukocyte antigen B27 (HLA-B27) gene has been observed to significantly increase the risk of developing ankylosing spondylitis...     

Point-of-Care CD4 Testing to Inform Selection of Antiretroviral Medications in South African Antenatal Clinics: A Cost-Effectiveness Analysis

Background

Many prevention of mother-to-child HIV transmission (PMTCT) programs currently prioritize antiretroviral therapy (ART) for women with advanced HIV. Point-of-care (POC) CD4 assays may expedite the selection of three-drug ART instead of zidovudine, but are costlier than traditional laboratory assays.

Methods

We used validated models of HIV infection to simulate pregnant, HIV-infected women (mean age 26 years, gestational age 26 weeks) in a general antenatal clinic in South Africa, and their infants. We examined two strategies for CD4 testing after HIV diagnosis: laboratory (test rate: 96%, result-return rate: 87%, cost: $14) and POC (test rate: 99%, result-return rate: 95%, cost: $26). We modeled South African PMTCT guidelines during the study period (WHO “Option A”): antenatal zidovudine (CD4 ≤350/μL) or ART (CD4>350/μL). Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/life-year saved).

Results

In the base case, laboratory led to projected MTCT risks of 5.7%, undiscounted pediatric LE of 53.2 years, and undiscounted PMTCT plus pediatric lifetime costs of $1,070/infant. POC led to lower modeled MTCT risk (5.3%), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant). Maternal outcomes following laboratory were similar to POC (LE: 21.2 years; lifetime costs: $23,860/person). Compared to laboratory, POC improved clinical outcomes and reduced healthcare costs.

Conclusions

In antenatal clinics implementing Option A, the higher initial cost of a one-time POC CD4 assay will be offset by cost-savings from prevention of pediatric HIV infection.     

A Cost-Effectiveness Analysis of a Home-Based HIV Counselling and Testing Intervention versus the Standard (Facility Based) HIV Testing Strategy in Rural South Africa

Introduction

There is growing evidence concerning the acceptability and feasibility of home-based HIV testing. However, less is known about the cost-effectiveness of the approach yet it is a critical component to guide decisions about scaling up access to HIV testing. This study examined the cost-effectiveness of a home-based HIV testing intervention in rural South Africa.

Methods

Two alternatives: clinic and home-based HIV counselling and testing were compared. Costs were analysed from a provider’s perspective for the period of January to December 2010. The outcome, HIV counselling and testing (HCT) uptake was obtained from the Good Start home-based HIV counselling and testing (HBHCT) cluster randomised control trial undertaken in KwaZulu-Natal province. Cost-effectiveness was estimated for a target population of 22,099 versus 23,864 people for intervention and control communities respectively. Average costs were calculated as the cost per client tested, while cost-effectiveness was calculated as the cost per additional client tested through HBHCT.

Results

Based on effectiveness of 37% in the intervention (HBHCT) arm compared to 16% in control arm, home based testing costs US$29 compared to US$38 per person for clinic HCT. The incremental cost effectiveness per client tested using HBHCT was $19.

Conclusions

HBHCT was less costly and more effective. Home-based HCT could present a cost-effective alternative for rural ‘hard to reach’ populations depending on affordability by the health system, and should be considered as part of community outreach programs.     

Analysis of HLA-B*2705 peptide motif,using T2 cells and monoclonal antibody ME1

The first two authors contributed equally to this project.