Tuberculosis preventive treatment in people living with HIV—Is the glass half empty or half full?

Olivia Oxlade and co-authors introduce a Collection on tuberculosis preventive therapy in people with HIV infection.

The most recent World Health Organization Global Tuberculosis (TB) Report suggests that 50% of people living with HIV (PLHIV) newly enrolled in HIV care initiated tuberculosis preventive treatment (TPT) in 2019 [1]. TPT is an essential intervention to prevent TB disease among people infected with Mycobacterium tuberculosis—some 25% of the world’s population [2]. Without TPT, it is estimated that up to 10% of individuals will progress to TB disease. Among PLHIV, the prognosis is worse. Of the approximately 1.4 million annual deaths from TB, 200,000 occur among PLHIV [1], who experience TB at rates more than 30 times [3] higher than people living without HIV.In 2018, governments at the United Nations High-Level Meeting (UNHLM) on TB committed to rapid expansion of testing for TB infection and provision of TPT [4]. The goal was the provision of TPT to at least 24 million household contacts of people with TB disease and 6 million PLHIV between 2018 and 2022. However, by the end of 2019, fewer than half a million household contacts had initiated TPT, well short of the pace needed to achieve the 5-year target [1]. On the other hand, approximately 5.3 million PLHIV have initiated TPT in the past 2 years [1], with particularly dramatic increases in countries supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) [5]. Globally, among PLHIV entering HIV care programs, TPT initiation rose from 36% in 2017 to 49% in 2018 and 50% in 2019 [6,7].To provide insight into scaling up TPT for PLHIV, it is important to consider each of the many steps involved in the “cascade of care” for TPT. A previous systematic review of studies in several populations receiving TPT concluded that nearly 70% of all people who may benefit from TPT were lost to follow-up at cascade of care steps prior to treatment initiation [8]. To maximize the impact of TPT for TB prevention among PLHIV, the full TPT cascade of care must be assessed to identify problems and develop targeted solutions addressing barriers at each step. Until now, these data had not been synthesized for PLHIV.In order to address important research gaps related to TPT in PLHIV such as this one, we are now presenting a Collection in PLOS Medicine on TPT in PLHIV. In the first paper in this Collection, Bastos and colleagues performed a systematic review and meta-analysis of the TPT cascade of care in 71 cohorts with a total of 94,011 PLHIV [9]. This analysis highlights key steps in the cascade where substantial attrition occurs and identifies individual-level and programmatic barriers and facilitators at each step. In stratified analyses, they found that losses during the TPT cascade were not different in high-income compared to low- or middle-income settings, nor were losses greater in centers performing tests for TB infection (tuberculin skin test [TST] or interferon gamma release assay [IGRA]) prior to TPT initiation.The net benefits of TPT could potentially be increased through greater adoption of shorter rifamycin-based TPT regimens, for which there is increasing evidence of greater safety, improved treatment completion, and noninferior efficacy, compared to isoniazid regimens. Two reviews of rifamycin-based regimens in mostly HIV–negative adults and children concluded that they were as effective for prevention of TB as longer isoniazid-based regimens, with better treatment completion and fewer adverse events [10,11]. However, safety and tolerability of TPT regimens can differ substantially between people with and without HIV, and for rifamycin-based TPT regimens, safety outcomes were actually worse in people without HIV [12], plus there can be important drug–drug interactions between rifamycin-based regimens and antiretroviral drugs [13]. Reviews of studies focused on PLHIV concluded that TPT (regardless of regimen selected) significantly reduced TB incidence [14] and that the benefits of continuous isoniazid in high TB transmission settings outweighed the risks [15]. As part of this Collection, Yanes-Lane and colleagues conducted a systematic review and network meta-analysis of 16 randomized trials to directly and indirectly compare the risks and benefits of isoniazid and rifamycin-based TPT regimens among PLHIV [16]. Their findings highlight the better safety, improved completion, and evidence of efficacy, particularly reduced mortality, with rifamycin-based TPT regimens, while also noting improved TB prevention with extended duration mono-isoniazid regimens. Their review also revealed that few studies exist on some important at-risk populations, such was pregnant women and those with drug-resistant TB infection.In North America, recommendations changed in 2020 to favor shorter rifamycin-based regimens over isoniazid [17], but WHO still favors isoniazid [18], largely due to the lower drug costs. Although drug costs for rifamycins are typically higher than for isoniazid, their shorter duration and better safety profile mean that total costs for care (including personnel costs) may be lower for rifamycin-based regimens, even in underresourced settings [19]. The cost-effectiveness of different TPT regimens among PLHIV in underresourced settings remains uncertain, as well as the impact of antiretroviral therapy (ART), and the use of diagnostic tests for TB infection, such as TST or IGRA on cost efficiency. Uppal and colleagues, in the third paper in this Collection, performed a systematic review and meta-analysis of 61 published cost-effectiveness and transmission modeling studies of TPT among PLHIV [20]. In all studies, TPT was consistently cost-effective, if not cost saving, despite wide variation in key input parameters and settings considered.When comparing access to TPT among PLHIV to household contacts, many would consider the glass is half full, given that almost half of all PLHIV newly accessing care initiated TPT in 2018 and 2019, and the UNHLM goal of 6 million PLHIV initiating TPT was already nearly achieved by the end of 2020. This remarkable achievement is the result of strong recommendations from WHO for TPT among PLHIV for nearly a decade and strong donor support. These policies are, in turn, based on clear and consistent evidence of individual benefits from multiple randomized trials, plus consistent evidence of cost-effectiveness from many economic analyses as summarized in the papers in this Collection. These are useful lessons for scaling up TPT for other target populations, particularly household contacts, of whom less than half a million have initiated TPT, of the 24 million–person target set in 2018.However, the glass of TPT among PLHIV is also half empty. In contrast to the “90-90-90” targets, 50% of PLHIV newly enrolled in care do not initiate TPT, and PLHIV still bear a disproportionate burden of TB. Programmatic scale-up of TPT continues to encounter challenges that need to be overcome in order to translate individual-level success to population-level improvement. The study by Bastos and colleagues in this Collection has identified programmatic barriers including drug stockouts and suboptimal training for healthcare workers, but it also offers useful solutions, including integration of HIV and TPT services [9]. New evidence on the success of differentiated service delivery will also be invaluable to support programmatic scale-up in different settings [21]. Acting on this evidence will be essential to achieve the goal of full access to effective, safe, and cost-effective TPT for PLHIV.     

Implications of cnidarian gene expression patterns for the origins of bilaterality is the glass half full or half empty?

The past two years have seen a dramatic increase in the availabledata on gene sequence and gene expression for cnidarians andother "lower" Metazoa, and a flurry of recent papers has drawnon these to address the origins of bilaterality. Cnidarian homologsof many genes that play key roles in the specification of boththe A/P and D/V axes of bilaterians have been characterized,and their patterns of expression determined. Some of these expressionpatterns are consistent with the possibility of conservationof function between Cnidaria and Bilateria, but others clearlydiffer. Moreover, in some cases very different interpretationshave been made on the basis of the same, or similar, data. Inpart, these differences reflect the inevitable uncertaintiesassociated with the depth of the divergence between cnidariansand bilaterians. In this article, we briefly summarize the cnidariandata on gene expression and organization relevant to axis formation,the varying interpretations of these data, and where they conflict.Our conclusion is that the presently available data do not allowus to unequivocally homologize the single overt axis of cnidarianswith either of the bilaterian axes.     

Progress of a half century in the study of the Luria-Delbrück distribution

The Luria-Delbrück mutation model has been mathematically formulated in a number of ways. This review article examines four most important formulations, focusing on important practical issues closely linked with the distribution of the number of mutants. These issues include the probability generating functions, moments (cumulants), computational methods and asymptotics. This review emphasizes basic principles which not only help to unify existing results but also allow for a few useful extensions. In addition, the review offers a historical perspective and some new explanations of divergent moments.     

The Mauthner cell half a century later: a neurobiological model for decision-making?

The Mauthner (M) cell is a critical element in a vital escape "reflex" triggered by abrupt or threatening events. Its properties at the molecular and synaptic levels, their various forms of plasticity, and the design of its networks, are all well adapted for this survival function. They guarantee that this behavior is appropriately unilateral, variable, and unpredictable. The M cell sets the behavioral threshold, and, acting in concert with other elements of the brainstem escape network, determines when, where, and how the escape is executed.     

Is the hemidesmosome a half desmosome? An immunological comparison of mammalian desmosomes and hemidesmosomes

Although the mammalian epidermal basal cell hemidesmosome bears some superficial resemblance to one half of a desmosome at the ultrastructural level, examination of the structure of the electron-dense submembranous plaques of the hemidesmosome and desmosome reveals that they differ with respect to their overall morphology and dimensions. Based on these findings, we wondered whether components of the desmosome are present in the hemidesmosome. In order to determine this we prepared a number of stratified squamous epithelial tissues for indirect immunofluorescence using antibody preparations directed against known desmosome components including desmoplakin and certain glycoproteins. These antibody preparations do not show reaction with hemidesmosomes by indirect immunofluorescence criteria. We have also utilized bullous pemphigoid (BP) autoantibodies that have been shown to recognize hemidesmosomes in mammalian skin cells [Mutasim et al., J. Invest. Derm., 84:47-53, 1985]. Double label indirect immunofluorescence observations of neonatal mouse skin prepared using desmoplakin antibodies and BP autoantibodies reveal that hemidesmosomes that are stained by the BP autoantibodies are not recognized by the desmoplakin antibodies. We confirmed these findings at the ultrastructural level by indirect immunogold localization of desmoplakin antibodies and BP autoantibodies. Therefore, the hemidesmosome does not appear to be one half of a desmosome and may possess a very different molecular organization relative to the desmosome. We raise the possibility that the variability between the hemidesmosome and desmosome that we detect at the morphological and immunological level may reflect the functional differences of these two types of junctions.     

Anti-TNFα domain antibody construct CEP-37247: Full antibody functionality at half the size

We report preclinical data for CEP-37247, the first human framework domain antibody construct to enter the clinic. At approximately 11–13 kDa, domain antibodies or dAbs are the smallest antibody domain able to demonstrate the antigen-recognition function of an antibody, e.g., high selectivity and affinity for target antigen. CEP-37247 is a bivalent anti-tumor necrosis factor (TNF)α domain antibody protein construct combining the antigen-recognition function of a dAb with the pharmacological advantages of an antibody Fc region. As a homodimer, with each chain comprising V_L dAb, truncated C_H1, hinge, C_H2 and C_H3 domains, CEP-37247 has a molecular mass of approximately 78 kDa, which is about half the size of a conventional IgG molecule. Surface plasmon resonance data demonstrate that CEP-37247 possesses high selectivity and affinity for TNFα. CEP-37247 is a potent neutralizer of TNFα activity in vitro in the L929 TNF mediated cytotoxicity assay. In a human TNFα-overexpressing mouse model of polyarthritis, CEP-37247 prevents development of disease and is at least as effective as the marketed product etanercept. Fc functionality is intact—CEP-37247 is capable of mediating antibody-dependent cell-mediated cytotoxicity and has a circulating half-life of approximately 4.5 days in cynomolgus macaques. Given the favorable properties outlined above and its high expression levels (approaching 7 g/L) in a CHOK1 based-expression system, CEP-37247 is progressing into the clinic where other potential advantages, such as enhanced efficacy due to improved tissue distribution and beneficial immunogenicity profile, will be evaluated.Key words: CEP-37247, ART621, domain antibody, dAbs, anti-TNFα, Fc construct     

Stability and value of male care for offspring: is it worth only half the trouble?

Models of parental investment often assume a trade-off for males between providing care and seeking additional mating opportunities. It is not obvious, however, how such additional matings should be accounted for in a consistent population model, because deserting males might increase their fertilization success at the cost of either caring males, other deserting males or both. Here, we present a game theory model that addresses all of these possibilities in a general way. In contrast to earlier work, we find that the source of deserting males' additional matings is irrelevant to the evolutionary stability of male care. We reject the claim that fitness gains through male care are intrinsically less valuable than those through desertion, and that the former must therefore be down-weighted by 1/2 when compared with the latter.     

A half a century of measuring ungulate body condition using indices: is it time for a change?

From a literature review of five wildlife ecology journals since 1937, we document how using indices to monitor ungulate body condition is common practice, with the kidney fat index (KFI = weight of fat around the kidneys/weight of kidneys without fat × 100) as the favoured tool (82% of studies). In this context, we highlight the problems of using indices when underlying statistical assumptions are not met (isometry, parallel slopes between treatments). We show, with real and simulated data for two cervids with contrasting fat storage strategies, how results from analysis of variance of KFI values differ from analysis of covariance (ANCOVA) of raw data. We conclude that the KFI is affected by the restrictions typically associated with derived index values, and as a consequence, statistical analysis of the KFI could generate spurious results leading to erroneous interpretations concerning variation in body condition of ungulate populations. Thus, we recommend analysing fat weight as an untransformed variable in ANCOVA (kidney weight as covariate) to describe body condition variation in ungulates. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Regulation of biotechnology in the United States: One and a half years of using the ‘coordinated framework’

There are several organizations in the US with responsibilities for regulatory oversight of the planned introduction of recombinant DNA organisms into the environment. Equally, there are many kinds of projects which require assessment. The policies, recommendations and rulings of the various authorities have been integrated into a ‘Coordinated Framework’ which defines the operation of flexible case-by-case risk assessment. Additions to and revision of the guidelines are being made, a process which will continue in the light of new experience.     

Point-of-View: Arguments for conventional fisheries management and against no-take marine protected areas: only half of the story?

Recent arguments for conventional fisheries management approaches (CFMAs) and against no-take marine protected areas (NTMPAs) are reviewed, i.e. CFMAs are more effective, density-dependent factors will lead to reduced fish stock production in and around NTMPAs, rights-based approaches in combination with CFMAs will be more effective, and natural refuges from fishing already exist. It is concluded that these are largely valid but only from a fisheries management perspective. The arguments of proponents of NTMPAs and those of proponents of CFMAs are considered as contrasting storylines, the divergences between which are based on two key factors: different objectives and different science. In relation to different objectives, it is concluded that the arguments against NTMPAs based on their lack of fisheries management benefits must be considered as only applying to the secondary resource conservation objectives of such designations and not to the primary marine biodiversity conservation objectives. On this basis it is argued that it is counter-productive for NTMPAs to be ‘sold’ on a win–win basis, including their potential to deliver fisheries management benefits, as this detracts from their marine biodiversity conservation objectives and leaves such calls open to arguments that CFMAs are better able to deliver fisheries management objectives. In relation to different science, it is concluded that criticisms of NTMPAs and support for CFMAs implicitly resist the shift from Mode 1 (reductive, intra-disciplinary) to Mode 2 (holistic, trans-disciplinary) science that is inherent in calls for NTMPAs as part of an ecosystem approach. Mode 2 science attempts to accommodate both uncertainty and wider societal values and preferences, and it is argued that arguments for NTMPAs should be more explicitly focussed on this potential. It is difficult, if not impossible and inappropriate, to extend the reductive approach inherent in CFMA analyses to encompass the broader ethical and scientific concerns for the health of marine ecosystems and their component populations and habitats that arguments for NTMPAs reflect. NTMPA proponents might focus on stressing that arguments against such designations and in favour of CFMAs do not encompass such valid concerns, therefore they tell only half of the story.

Effects of a half a millennium winter on a deep lake – a shape of things to come?

Analyses of the effects of extreme climate periods have been used as a tool to predict ecosystem functioning and processes in a warmer world. The winter half‐year 2006/2007 (w06/07) has been extremely warm and was estimated to be a half‐a‐millennium event in central Europe. Here we analyse the consequences of w06/07 for the temperatures, mixing dynamics, phenologies and population developments of algae and daphnids (thereafter w06/07 limnology) in a deep central European lake and investigate to what extent analysis of w06/07 limnology can really be used as a predictive tool regarding future warming. Different approaches were used to put the observations during w06/07 into context: (1) a comparison of w06/07 limnology with long‐term data, (2) a comparison of w06/07 limnology with that of the preceding year, and (3) modelling of temperature and mixing dynamics using numerical experiments. These analyses revealed that w06/07 limnology in Lake Constance was indeed very special as the lake did not mix below 60 m depth throughout winter. Because of this, anomalies of variables associated strongly with mixing behaviour, e.g., Schmidt stability and a measure for phosphorus upward mixing during winter exceeded several standard deviations the long‐term mean of these variables. However, our modelling results suggest that this extreme hydrodynamical behaviour was only partially due to w06/07 meteorology per se, but depended also strongly on the large difference in air temperature to the previous cold winter which resulted in complete mixing and considerable cooling of the water column. Furthermore, modelling results demonstrated that with respect to absolute water temperatures, the model ‘w06/07’ most likely underestimates the increase in water temperature in a warmer world as one warm winter is not sufficient to rise water temperatures in a deep lake up to those expected under a future climate.     

Chimpanzee insectivory in the northern half of Uganda’s Rift Valley: do Bulindi chimpanzees conform to a regional pattern?

Insects are a nutritious food source for many primates. In chimpanzees, insectivory is most prevalent among communities that manufacture tools to harvest social insects, particularly ants and termites. In contrast to other long-term study sites, chimpanzees (Pan troglodytes schweinfurthii) in Budongo Forest and Kibale National Park, Uganda, rarely eat insects and have small foraging tool kits, supporting speculation that infrequent insectivory—technically aided or otherwise—characterises chimpanzees in this part of Uganda’s Rift Valley. To expand the dataset for this region, insect foraging was investigated at Bulindi (25 km from Budongo) over 19 months during two studies in 2007–2008 and 2012–2013. Systematic faecal analysis demonstrated that insectivory is a habitual foraging activity at this site. Overall levels of insect consumption varied considerably across months but were not predicted by monthly changes in rainfall or fruit intake. Unlike their Budongo and Kibale counterparts, Bulindi chimpanzees often consume ants (principally weaver ants, Oecophylla longinoda) and use sticks to dig out stingless bee (Meliponini) ground nests. In other respects, however, insectivory at Bulindi conforms to the pattern observed elsewhere in this region: they do not manufacture ‘fishing’ or ‘dipping’ tools to harvest termites and aggressive or hard-to-access ants (e.g., army ants, Dorylus spp.), despite availability of suitable prey. The Bulindi data lend support to the supposition that chimpanzees in this part of the Rift Valley rarely exploit termites and Dorylus ants, apparently lacking the ‘cultural knowledge’ that would enable them to do so most efficiently (i.e., tool use). The study’s findings contribute to current debates about the relative influence of genetics, environment and culture in shaping regional and local variability in Pan foraging ecology.     

The UPS and autophagy in chronic neurodegenerative disease: Six of one and half a dozen of the other—Or not?

In the past twenty years, evidence has accumulated to show that ubiquitinated proteins are a consistent feature of the intraneuronal protein aggregates (inclusions) that characterize chronic neurodegenerative disease. These findings may indicate that age-related dysfunction of the 26S proteasome may be central to disease pathogenesis. The aggregate-prone proteins can also be eliminated by autophagy. We have used the Cre-recombinase/loxP genetic approach to ablate the proteasomal psmc1 ATPase gene and deplete 26S proteasomes in neurons in different regions of the brain to mimic neurodegeneration. Deletion of the gene in dopaminergic neurons in the substantia nigra generates a new model of Parkinson’s disease. Ablation of the gene in the forebrain creates the first model of dementia with Lewy bodies. In both neuroanatomical regions, gene ablation causes the formation of Lewy-like inclusions together with extensive neurodegeneration. There is some evidence for neuronal autophagy in areas adjacent to inclusions. The models indicate that neuronal loss in neurodegenerative diseases can be attributed to proteasomal malfunction accompanied by Lewy-like inclusions as seen in dementia with Lewy bodies and Parkinson’s disease.     

Assessment of resolution by half distance values for tritium and radioiodine in electron microscopic radioautographs using Ilford L4 emulsion developed by “Solution Physical” or D-19b methods

Summary Half distance values for electron microscopic (EM) radioautographs with the isotopes³H and¹²⁵I were determined using Ilford L4 emulsion processed with either fine grain, solution physical development, or filamentous grain, chemical development with D-19b.³H- and¹²⁵I-line sources, obtained by cutting perpendicular sections from sections of³H-labeled methacrylate or¹²⁵I-labeled thyroid glands, were processed for EM radioautography. The distribution of silver grains around a line source was determined by measuring their distance from the source in photographs of EM radioautographs. The number of silver grains per unit distance from the line source was plotted on graphs and half distance values were calculated. With solution physical development, the half distance value was 76 nm for³H and 80 nm for¹²⁵I; whereas with D-19 b development it was 187 nm for³H and 157 nm for¹²⁵I. Since solution physical development produced a reduction of about 50% in the half distance values for both isotopes, it is concluded that the production of fine grain by this method provides better resolution for EM radioautography than filamentous grain development with D-19 b. This work was the subject of a McGill University dissertation (Levine 1977)