Jan Gerstoft

People with HIV (PWH) have a high risk of coronary artery disease (CAD). Cytomegalovirus (CMV) co-infection is very common in PWH, but little is known about its association with CAD. We aimed to investigate if CMV IgG serostatus and concentrations are associated with CAD in PWH. From the Copenhagen Comorbidity in HIV Infection (COCOMO) Study we included PWH with coronary CT angiography (CCTA) and quantitative CMV IgG concentration measurements. We measured the stenosis grades and plaque volumes in the coronary vessels. Using multivariable regressions adjusted for traditional CAD risk factors, we investigated if CMV IgG serostatus and concentrations were associated with any atherosclerosis, obstructive CAD, or plaque volumes. We included 620 PWH of whom 586 had positive CMV serostatus, which was not associated with any atherosclerosis, obstructive CAD, or plaque volumes. A doubling of CMV IgG concentrations was associated with any atherosclerosis (OR 1.21 [95% CI: 1.06–1.39]), obstructive CAD (OR 1.31 [95% CI: 1.07–1.59]), and higher total plaque volume (1.56 [95% CI: 1.21–2.01] fold increase), but the association did not remain significant after adjustment for traditional CAD risk factors. This indicates that CMV IgG serostatus and concentrations are not independently associated with prevalent CAD in PWH.

Background: We aimed to determine the prevalence of coronary artery disease (CAD) in persons with human immunodeficiency virus (HIV; PWH) and investigate whether inflammatory markers, including interleukin 6, IL-1β, and high-sensitivity C-reactive protein (hsCRP), were associated with CAD. Methods: From the Copenhagen Comorbidity in HIV Infection (COCOMO) study, we included virologically suppressed PWH who underwent coronary computed tomographic (CT) angiography. Any atherosclerosis was defined as >0% stenosis, and obstructive CAD as ≥50% stenosis. Results: Among 669 participants (mean age [standard deviation], 51 [11] years; 89% male), 300 (45%) had atherosclerosis, and 119 (18%) had obstructive CAD. The following risk factors were associated with any atherosclerosis and with obstructive CAD: age, male sex, hypertension, diabetes, smoking, dyslipidemia, time with HIV, and current protease inhibitor use. Interleukin 6 (IL-6) and hsCRP levels >2 mg/L were associated with any atherosclerosis and with obstructive CAD in univariable analyses but not after adjustment for traditional risk factors. IL-1β was not associated with CAD. Conclusions: In a large population of PWH without viral replication, almost half had angiographically verified atherosclerosis. High concentrations of IL-6 and hsCRP were associated with CAD in univariable analyses, but adjustment for cardiovascular risk factors attenuated the association, suggesting that inflammation may mediate the association between traditional risk factors and CAD.

HIV-1 resistance towards integrase inhibitors is a potential threat of the success of HIV-1 combination treatment. G118R is a rare drug resistance mutation conferring pan-integrase resistance. Here, we describe the occurrence of G118R in a HIV-1 subtype-B-positive individual with major compliance problems, detected while the patient was on dolutegravir-based cART. We speculate the pre-selection of M184I/V aided the occurrence of G118R in this case, and discuss the robustness of dolutegravir-based therapies.

The SARS-CoV-2 pandemic has created an urgent need for large amounts of diagnostic tests to detect viral RNA, which commercial suppliers are increasingly unable to deliver. In addition to the lack of availability, the current methods do not always fully inactivate the virus. Together, this calls for the development of safer methods for extraction and detection of viral RNA from patient samples that utilise readily available reagents and equipment present in most standard laboratories. We present a rapid and straightforward RNA extraction protocol for inactivating the SARS-CoV-2 virus that uses standard lab reagents. This protocol expands analysis capacity as the inactivated samples can be used in RT-qPCR detection tests at laboratories not otherwise classified for viral work. The method circumvents the need for commercial RNA purification kits, takes about 30 minutes from swab to PCR-ready viral RNA, and enables downstream detection of SARS-CoV-2 by RT-qPCR with very high sensitivity (~4 viral RNA copies per RT-qPCR). In summary, we present a rapid, safe and sensitive method for high-throughput detection of SARS-CoV-2, that can be conducted in any laboratory equipped with a qPCR machine.

Between 1975 and 1985 a total of 91 Danish patients with moderate and severe hemophilia (PWH) was infected with HIV constituting a major scandal in the Danish health care system. This study describes the burden of HIV infection among Danish PWH by evaluating changes from 1988 to 2012 in well-being, social function, experiencing stigma and openness about disease among Danish HIV⁺ PWH. Three anonymous surveys were conducted in 1988, 2001 and 2012 targeting all Danish patients with moderate to severe hemophilia. Survey responses were received from 53, 21 and 18 HIV⁺ PWH respectively. A matched comparison sample of HIV⁻ PWH was identified for each survey-year, using propensity score matching. Differences for each survey-year and trends over time were analyzed using ordinal logistic regression. In 1988, HIV⁺ PWH had more psychosomatic symptoms than HIV⁻ PWH, but in 2001 life satisfaction was higher among HIV⁺ PWH than among HIV⁻ PWH. Tests of differences in trend over time showed larger improvements in life satisfaction among HIV⁺ PWH than HIV⁻ PWH, while HIV⁻ PWH showed an increase in educational level compared to HIV⁺ PWH. Analysis restricted to HIV⁺ PWH showed an increase in perceived stigmatization. Differences between Danish HIV⁺ and HIV⁻ PWH regarding well-being and psychosomatic symptoms seem to have evened out between 1988 and 2012. However, results suggest that HIV⁺ PWH still experience stigmatization and lower levels of education.

Correct classification of underlying causes of death is an important outcome among transplant recipients. Deaths due to infections and adverse graft function are often misclassified. We aimed to develop and validate a system to code causes of death in hematopoietic stem cell (HSCT) and solid organ (SOT) transplant recipients and to identify characteristics that could identify deaths with a clear cause. A standardized case record form (CRF) was used to collect clinical information from consecutive recipients transplanted at a transplant hospital between 2004 and 2014, who died 2010–2013 (derivation cohort). Causes of death were determined through a centralized process involving two medical experts who independently assessed each CRF. Factors associated with independent agreement between reviewers were assessed and validated on patients who died 2013–2016 (validation cohort). All cases without agreement were adjudicated. Death causes ascertained by our system were compared with death causes in the Danish National Death Registry. 388 transplant recipients died during 2010 to 2016 (196 (51%) SOT and 192 (49%) HSCT). Using our methodology, leading underlying causes of death among SOT and HSCT were classified as cancer (20%, 48%), graft rejection/failure/graft-vs.-host-disease (35%, 28%) and infections (20%, 11%) (Figure 1). Death causes were in agreement with the Danish registry in only 37% of cases in derivation cohort. In the derivation cohort, kappa was 0.64 (95% CI 0.56–0.69) for independent agreement between the two experts (all remaining classified upon adjudication) (Figure 2). Odds for independent agreement were higher in cases with a history of cancer (aOR 3.20 (1.45–7.06)); among 174 with this characteristics, kappa was 0.71 (0.64–0.79). These findings were reproducible in the validation cohort (kappa for overall independent agreement=0.63 (0.52 – 0.73); among 54 recipients with a history of cancer, kappa = 0.71 (0.57–0.84)). We developed and validated a method able to systematically and reliably classify underlying cause of death among transplant recipients. There was a high degree of discordance between this classification and that in the National Death Registry. Our method can be applied to any cohort. All authors: No reported disclosures.

Increased risk of both cardiovascular disease (CVD) and bleeding has been found in patients with chronic hepatitis C (CHC) infection, and a re-balanced hemostasis has been proposed. The aim of this study was to investigate functional whole blood coagulation and platelet function in CHC infection. The prospective study included 82 patients with CHC infection (39 with advanced liver fibrosis and 43 with no or mild liver fibrosis) and 39 healthy controls. A total of 33 patients were treated for CHC infection and achieved sustained virological response (SVR). Baseline and post-treatment blood samples were collected. Hemostasis was assessed by both standard coagulation tests and functional whole blood hemostatic assays (thromboelastograhy (TEG), and platelet aggregation (Multiplate). Patients with CHC and advanced fibrosis had impaired platelet aggregation both compared to patients with no or mild fibrosis and to healthy controls. Patients with CHC and advanced fibrosis also had lower antithrombin, platelet count, and coagulation factors II-VII-X compared to healthy controls. In contrast, TEG did not differ between groups. In treated patients achieving SVR, post-treatment platelet count was higher than pre-treatment counts (p = 0.033) and ADPtest, ASPItest, and RISTOhightest all increased post treatment (all p < 0.05). All Multiplate tests values, however, remained below those in the healthy controls. CHC-infected patients displayed evidence of rebalanced hemostasis with only partly hemostatic normalization in patients achieving SVR. The implications of rebalanced hemostasis and especially the impact on risk of CVD and bleeding warrants further studies.

By assessing the changes in concentration of soluble receptor activator of nuclear factor κ B ligand (RANKL) and osteoprotegrin (OPG) after initiation of combination antiretroviral therapy (cART) in treatment-naïve HIV-infected patients we aimed to evaluate whether the initial accelerated bone loss could be mediated by increased soluble RANKL (sRANKL) levels associated with CD4+ T cell recovery. We used multiplex immunoassays to determine sRANKL and OPG concentrations in plasma from 48 HIV patients at baseline and 12, 24, 48 and 96 weeks after cART initiation. Soluble RANKL changed significantly over time (overall p = 0.02) with 25% decrease (95% CI: -42 to −5) at week 24 compared to baseline and stabilized at a lower level thereafter. We found no correlation between CD4+ T cell count increment and changes in sRANKL or between percentage change in BMD and changes in sRANKL. In this study there was no indication that the accelerated bone loss after cART initiation was mediated by early changes in sRANKL due to CD4+ T cell recovery. Future studies should focus on the initial weeks after initiation of cART. Clinical-Trial.gov . id NCT00135460 , August 25, 2005. The study was approved by the Danish Data Protection Agency, Danish Medicines Agency and Regional Ethics Committee.

Objective: Inflammation may contribute to an increased risk of cardiovascular disease (CVD) in HIV-1 infection. MicroRNAs (miRNAs) are involved in the regulation of inflammation. In treated HIV-1–infected individuals, we aimed to identify differentially expressed miRNAs with known roles in inflammation and CVD risk and to investigate associations between these and systemic inflammation. Methods: In a screening cohort including 14 HIV-1–infected individuals and 9 uninfected controls, microarray profiling was performed using peripheral blood mononuclear cells (PBMCs). Differentially regulated miRNAs previously related to inflammation and CVD were validated using real-time quantitative reverse-transcription polymerase chain reaction in 26 HIV-1–infected individuals and 20 uninfected controls. Validated miRNAs were measured in PBMCs, CD4⁺ and CD8⁺ T cells. Interleukin-6, tumor necrosis factor-alpha, high-sensitivity C-reactive protein, lipopolysaccharide (LPS), cytomegalovirus immunoglobulin G, lipids, and fasting glucose were measured, and associations with validated miRNAs were assessed with multiple linear regression analysis. Results: Upregulation of miR-210, miR-7, and miR-331 was found in PBMCs from HIV-1–infected individuals when compared with those from uninfected controls (P < 0.005). In contrast, miR-210 and miR-331 were downregulated in CD8⁺ T cells. In multivariate analysis, miR-210 in CD8⁺ T cells was negatively associated with LPS (P = 0.023) and triglycerides (P = 0.003) but positively associated with tumor necrosis factor-alpha (P = 0.004). MiR-7 in PBMC was positively associated with interleukin-6 (P = 0.025) and fasting glucose (P = 0.005), whereas miR-331 was negatively associated with LPS (P = 0.006). In PBMCs from HIV-1–infected individuals with low cytomegalovirus immunoglobulin G, miR-7, miR-29a, miR-221, and miR-222 were downregulated. Conclusion: In 2 independent cohorts, miR-210, miR-7, and miR-331 were differentially regulated in treated HIV-1–infected individuals and associated with markers of systemic inflammation.

Increased incidence of cardiovascular diseases (CVD) in both HIV infection and type 2 diabetes (T2D) compared to the general population has been described. Little is known about the combined effect of HIV infection and T2D on inflammation and endothelial function, both of which may contribute to elevated risk of CVD. Cross-sectional study including 50 HIV-infected persons on combination anti-retroviral therapy (cART), with HIV RNA <200 copies/mL (n = 25 with T2D (HIV + T2D+), n = 25 without T2D (HIV + T2D-)) and 50 uninfected persons (n = 22 with T2D (HIV-T2D+) and n = 28 without T2D (HIV-T2D-)). Groups were matched on age and sex. High sensitive C-reactive protein (hsCRP) was used to determine inflammation (cut-off 3 mg/L). The marker of endothelial dysfunction asymmetric dimethylarginine (ADMA) was measured using high performance liquid chromatography. Trimethylamine-N-oxide (TMAO), a microbiota-dependent, pro-atherogenic marker was measured using stable isotope dilution LC/MS/MS. The percentage of HIV + T2D+, HIV + T2D-, HIV-T2D+, and HIV-T2D- with hsCRP above cut-off was 50%, 19%, 47%, and 11%, respectively. HIV + T2D+ had elevated ADMA (0.67 μM (0.63-0.72) compared to HIV + T2D- (0.60 μM (0.57-0.64) p = 0.017), HIV-T2D+ (0.57 μM (0.51-63) p = 0.008), and HIV-T2D- (0.55 μM (0.52-0.58) p < 0.001). No differences in TMAO between groups were found. However, a positive correlation between ADMA and TMAO was found in the total population (rs = 0.32, p = 0.001), which was mainly driven by a close correlation in HIV + T2D+ (rs = 0.63, p = 0.001). Elevated inflammation and evidence of endothelial dysfunction was found in HIV-infected persons with T2D. The effect on inflammation was mainly driven by T2D, while both HIV infection and T2D may contribute to endothelial dysfunction. Whether gut microbiota is a contributing factor to this remains to be determined.