Triple-antiretroviral prophylaxis to prevent mother-to-child HIV transmission through breastfeeding--the Kisumu Breastfeeding Study, Kenya: a clinical trial

Background

Effective strategies are needed for the prevention of mother-to-child HIV transmission (PMTCT) in resource-limited settings. The Kisumu Breastfeeding Study was a single-arm open label trial conducted between July 2003 and February 2009. The overall aim was to investigate whether a maternal triple-antiretroviral regimen that was designed to maximally suppress viral load in late pregnancy and the first 6 mo of lactation was a safe, well-tolerated, and effective PMTCT intervention.

Methods and Findings

HIV-infected pregnant women took zidovudine, lamivudine, and either nevirapine or nelfinavir from 34–36 weeks'' gestation to 6 mo post partum. Infants received single-dose nevirapine at birth. Women were advised to breastfeed exclusively and wean rapidly just before 6 mo. Using Kaplan-Meier methods we estimated HIV-transmission and death rates from delivery to 24 mo. We compared HIV-transmission rates among subgroups defined by maternal risk factors, including baseline CD4 cell count and viral load.Among 487 live-born, singleton, or first-born infants, cumulative HIV-transmission rates at birth, 6 weeks, and 6, 12, and 24 mo were 2.5%, 4.2%, 5.0%, 5.7%, and 7.0%, respectively. The 24-mo HIV-transmission rates stratified by baseline maternal CD4 cell count <500 and ≥500 cells/mm³ were 8.4% (95% confidence interval [CI] 5.8%–12.0%) and 4.1% (1.8%–8.8%), respectively (p = 0.06); the corresponding rates stratified by baseline maternal viral load <10,000 and ≥10,000 copies/ml were 3.0% (1.1%–7.8%) and 8.7% (6.1%–12.3%), respectively (p = 0.01). None of the 12 maternal and 51 infant deaths (including two second-born infants) were attributed to antiretrovirals. The cumulative HIV-transmission or death rate at 24 mo was 15.7% (95% CI 12.7%–19.4%).

Conclusions

This trial shows that a maternal triple-antiretroviral regimen from late pregnancy through 6 months of breastfeeding for PMTCT is safe and feasible in a resource-limited setting. These findings are consistent with those from other trials using maternal triple-antiretroviral regimens during breastfeeding in comparable settings.

Trial registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00146380","term_id":"NCT00146380"}}NCT00146380 Please see later in the article for the Editors'' Summary     

Intrinsic disorder mediates the diverse regulatory functions of the Cdk inhibitor p21

Traditionally, well-defined three-dimensional structure has been thought to be essential for protein function. However, myriad biological functions are performed by highly dynamic, intrinsically disordered proteins (IDPs). IDPs often fold upon binding their biological targets and frequently show 'binding diversity' by targeting multiple ligands. We sought to understand the physical basis of IDP binding diversity and report here that the cyclin-dependent kinase (Cdk) inhibitor p21(Cip1) adaptively binds to and inhibits the various Cdk-cyclin complexes that regulate eukaryotic cell division. Using results from NMR spectroscopy and biochemical and cellular assays, we show that structural adaptability of a helical subdomain within p21, termed LH, enables two other subdomains, D1 and D2, to specifically bind conserved surface features of the cyclin and Cdk subunits, respectively, within otherwise structurally distinct Cdk-cyclin complexes. Adaptive folding upon binding is likely to mediate the diverse biological functions of the thousands of IDPs present in eukaryotes.     

A global quantitative synthesis of local and landscape effects on wild bee pollinators in agroecosystems

Bees provide essential pollination services that are potentially affected both by local farm management and the surrounding landscape. To better understand these different factors, we modelled the relative effects of landscape composition (nesting and floral resources within foraging distances), landscape configuration (patch shape, interpatch connectivity and habitat aggregation) and farm management (organic vs. conventional and local‐scale field diversity), and their interactions, on wild bee abundance and richness for 39 crop systems globally. Bee abundance and richness were higher in diversified and organic fields and in landscapes comprising more high‐quality habitats; bee richness on conventional fields with low diversity benefited most from high‐quality surrounding land cover. Landscape configuration effects were weak. Bee responses varied slightly by biome. Our synthesis reveals that pollinator persistence will depend on both the maintenance of high‐quality habitats around farms and on local management practices that may offset impacts of intensive monoculture agriculture.     

Changes in Forest Soil Properties in Different Successional Stages in Lower Tropical China

Background

Natural forest succession often affects soil physical and chemical properties. Selected physical and chemical soil properties were studied in an old-growth forest across a forest successional series in Dinghushan Nature Reserve, Southern China.

Methodology/Principal Findings

The aim was to assess the effects of forest succession change on soil properties. Soil samples (0–20 cm depth) were collected from three forest types at different succession stages, namely pine (Pinus massoniana) forest (PMF), mixed pine and broadleaf forest (PBMF) and monsoon evergreen broadleaf forest (MEBF), representing early, middle and advanced successional stages respectively. The soil samples were analyzed for soil water storage (SWS), soil organic matter (SOM), soil microbial biomass carbon (SMBC), pH, NH₄ ⁺-N, available potassium (K), available phosphorus (P) and microelements (available copper (Cu), available zinc (Zn), available iron (Fe) and available boron (B)) between 1999 and 2009. The results showed that SWS, SOM, SMBC, Cu, Zn, Fe and B concentrations were higher in the advanced successional stage (MEBF stage). Conversely, P and pH were lower in the MEBF but higher in the PMF (early successional stage). pH, NH₄ ⁺-N, P and K declined while SOM, Zn, Cu, Fe and B increased with increasing forest age. Soil pH was lower than 4.5 in the three forest types, indicating that the surface soil was acidic, a stable trend in Dinghushan.

Conclusion/Significance

These findings demonstrated significant impacts of natural succession in an old-growth forest on the surface soil nutrient properties and organic matter. Changes in soil properties along the forest succession gradient may be a useful index for evaluating the successional stages of the subtropical forests. We caution that our inferences are drawn from a pseudo-replicated chronosequence, as true replicates were difficult to find. Further studies are needed to draw rigorous conclusions regarding on nutrient dynamics in different successional stages of forest.     

Incidence and Predictors of First Line Antiretroviral Regimen Modification in Western Kenya

Background

Limited antiretroviral treatment regimens in resource-limited settings require long-term sustainability of patients on the few available options. We evaluated the incidence and predictors of combined antiretroviral treatment (cART) modifications, in an outpatient cohort of 955 patients who initiated cART between January 2009 and January 2011 in western Kenya.

Methods

cART modification was defined as either first time single drug substitution or switch. Incidence rates were determined by Poisson regression and risk factor analysis assessed using multivariate Cox regression modeling.

Results

Over a median follow-up period of 10.7 months, 178 (18.7%) patients modified regimens (incidence rate (IR); 18.6 per 100 person years [95% CI: 16.2–21.8]). Toxicity was the most common cited reason (66.3%). In adjusted multivariate Cox piecewise regression model, WHO disease stage III/IV (aHR; 1.82, 95%CI: 1.25–2.66), stavudine (d4T) use (aHR; 2.21 95%CI: 1.49–3.30) and increase in age (aHR; 1.02, 95%CI: 1.0–1.04) were associated with increased risk of treatment modification within the first year post-cART. Zidovudine (AZT) and tenofovir (TDF) use had a reduced risk for modification (aHR; 0.60 95%CI: 0.38–0.96 and aHR; 0.51 95%CI: 0.29–0.91 respectively). Beyond one year of treatment, d4T use (aHR; 2.75, 95% CI: 1.25–6.05), baseline CD4 counts ≤350 cells/mm³ (aHR; 2.45, 95%CI: 1.14–5.26), increase in age (aHR; 1.05 95%CI: 1.02–1.07) and high baseline weight >60kg aHR; 2.69 95% CI: 1.58–4.59) were associated with risk of cART modification.

Conclusions

Early treatment initiation at higher CD4 counts and avoiding d4T use may reduce treatment modification and subsequently improve sustainability of patients on the available limited options.     

Epstein–Barr Virus Genetic Variation in Lymphoblastoid Cell Lines Derived from Kenyan Pediatric Population

Epstein-Barr virus (EBV) is associated with Burkitt’s lymphoma (BL), and in regions of sub-Saharan Africa where endemic BL is common, both the EBV Type 1 (EBV-1) and EBV Type 2 strains (EBV-2) are found. Little is known about genetic variation of EBV strains in areas of sub-Saharan Africa. In the present study, spontaneous lymphoblastoid cell lines (LCLs) were generated from samples obtained from Kenya. Polymerase chain reaction (PCR) amplification of the EBV genome was done using multiple primers and sequenced by next-generation sequencing (NGS). Phylogenetic analyses against the published EBV-1 and EBV-2 strains indicated that one sample, LCL10 was closely related to EBV-2, while the remaining 3 LCL samples were more closely related to EBV-1. Moreover, single nucleotide polymorphism (SNP) analyses showed clustering of LCL variants. We further show by analysis of EBNA-1, BLLF1, BPLF1, and BRRF2 that latent genes are less conserved than lytic genes in these LCLs from a single geographic region. In this study we have shown that NGS is highly useful for deciphering detailed inter and intra-variations in EBV genomes and that within a geographic region different EBV genetic variations can co-exist, the implications of which warrant further investigation. The findings will enhance our understanding of potential pathogenic variants critical to the development and maintenance of EBV-associated malignancies.     

Anemia and Red Blood Cell Abnormalities in HIV-Infected and HIV-Exposed Breastfed Infants: A Secondary Analysis of the Kisumu Breastfeeding Study

Background

Anemia results in increased morbidity and mortality, underscoring the need to better understand its pathophysiology amongst HIV-exposed and infected children in sub-Saharan Africa, the region where most infant HIV exposure and infections occur.

Methods

This analysis used samples obtained from children in the Kisumu Breastfeeding Study (KiBS). KiBS was a longitudinal phase IIB, open-label, one-arm clinical trial, designed to investigate the safety, tolerability and effectiveness of a maternal triple-antiretroviral (ARV) regimen for prevention of mother-to-child transmission (PMTCT) of HIV, during late pregnancy and early infancy while breastfeeding. Blood samples from 482 children were obtained at birth, 2, 6, 10 and 14 weeks and 6, 9, 12, 18 and 24 months. Severity of anemia was graded using the NIH Division of AIDS (DAIDS) toxicity tables. We describe the proportion of children with anemia and anomalies in red blood cell parameters at various time points over 24 months and compare rates of anemia between HIV-infected and HIV-uninfected children and by mothers’ ARV regimen and infant malaria infection.

Results

The proportion of children with anemia significantly increased after the breastfeeding period in both HIV-infected and HIV-uninfected children with higher proportion among HIV-infected children compared to HIV-uninfected children (RR: 1.72; CI: 1.22–2.44, p = 0.002). Maternal triple-antiretroviral regimen was not associated with infant anemia (p = 0.11). There was no significant difference in mean hemoglobin between HIV-uninfected children with and without malaria at each time point except at 24 months.

Conclusion

A relatively lower proportion of children with severe anemia during the breastfeeding period suggest that exposure to mother’s triple antiretroviral combinations through breast milk, posed minimal risk of hematologic toxicity.     

Water use by a warm-temperate deciduous forest under the influence of the Asian monsoon: contributions of the overstory and understory to forest water use

The warm temperate deciduous forests in Asia have a relatively dense understory, hence, it is imperative that we understand the dynamics of transpiration in both the overstory (E _O) and understory (E _U) of forest stands under the influence of the Asian monsoon in order to improve the accuracy of forest water use budgeting and to identify key factors controlling forest water use under climate change. In this study, E _O and E _U of a temperate deciduous forest stand located in South Korea were measured during the growing season of 2008 using sap flow methods. The objectives of this study were (1) to quantify the total transpiration of the forest stand, i.e., overstory and understory, (2) to determine their relative contribution to ecosystem evapotranspiration (E _eco), and (3) to identify factors controlling the transpiration of each layer. E _O and E _U were 174 and 22 mm, respectively. Total transpiration accounted for 55 % of the total E _eco, revealing the importance of unaccounted contributions to E _eco (i.e., soil evaporation and wet canopy evaporation). During the monsoon period, there was a strong reduction in the total transpiration, likely because of reductions in photosynthetic active radiation, vapor pressure deficit and plant area index. The ratio of E _U to E _O declined during the same period, indicating an effect of monsoon on the partitioning of E _eco in its two components. The seasonal pattern of E _O was synchronized with the overstory canopy development, which equally had a strong regulatory influence on E _U.     

Functional convergence in water use of trees from different geographical regions: a meta-analysis

Functional convergence in water use of trees across species from diverse geographic locations was examined using data on tree water use parameters, with the intention of gaining an understanding on the capacity for water transport for trees with varying structural and functional traits. Wood density (ρ_w), which is reported to have a negative exponential relation with sap flow density (SFD), showed a bell-shaped curve when the daily SFD data from 101 tree species belonging to 35 angiosperm and gymnosperm families were plotted. The species came from 23 different geographical locations representing all continents. Trees were most efficient in water transport when the ρ_w was between 0.51 and 0.65 g cm^?3. When the ρ_w increased or decreased from this range, there was a gradual fall in their water transport rate as indicated by lower daily SFD. The unexpected reduction in SFD with decreasing ρ_w is explained in terms of reduced conductance in the transport pathway, which is a precaution taken by the tree for avoiding cavitation or implosion in larger conducting tubes, which is characteristic of low density wood. The development of severe leaf water potential variations, which is frequently reported in such trees, supports this notion. The SFD versus ρ_w relation has a potentially wide applicability in predicting water use by forest stands with varying ρ_w. In addition, the occurrence of a high number of tree species with ρ_w values in the range of 0.51–0.65 g cm^?3 across all continents examined points towards the importance of ρ_w in the evolutionary process as related to efficient functioning of the water transport mechanism.     

Flavonol and iridoid glycosides of Ajuga remota aerial parts

Six flavonol glycosides characterised as myricetin 3-O-alpha-rhamnosyl-(1'-->2')-alpha-rhamnoside-3'-O-alpha-rhamnoside, 5'-O-methylmyricetin 3-O-[alpha-rhamnosyl (1'-->2')][alpha-rhamnosyl (1'-->4')]-beta -glucoside-3'-O-beta-glucoside, 5'-O-methylmyricetin 3-O-alpha-rhamnosyl (1'-->2')-alpha-rhamnoside 3'-O-beta-galactoside, kaemferol 3-O-rutinoside-7-O-rutinoside, myricetin 3-O-rutinoside-3'-O-alpha-rhamnoside, myricetin 3-O-beta-glucosyl (1'-->2')-beta-glucoside-4'-O-beta-glucoside together with two iridoid glycosides identified as 6,8-diacetylharpagide and 6,8-diacetylharpagide-1-O-beta-(3',4'-di-O-acetylglucoside) have been isolated from extract of Ajuga remota aerial parts. Also isolated from the same extract were known compounds; kaempferol 3-O-alpha-rhamnoside, quercetin 3-O-beta-glucoside, quercetin 3-O-rutinoside, 8-acetylharpagide, ajugarin I and ajugarin II.