The purpose of this study was to analyze and measure the short-term and long-term impacts of a chronic disease self-management program (CDSP) for individuals living with HIV/AIDS. This study was a follow-up study on an HIV/AIDS Organization in Southern California’s (HAOSC’s) CDSP programs in 2007 and 2008 called “Newly Empowered Women” (NEW), a six (6) week CDSP for women diagnosed with HIV/AIDS which sought to promote self-efficacy through education and self-management skills. A retrospective longitudinal study on the female clients who participated with this program in 2007 and 2008 determined whether clients retained the skills taught in the CDSP and if they attained self-efficacy through improved behavioral changes in better overall self-management that were influenced as a result of their participation. Behavioral changes were examined and measured in the areas of self-rated health, anxiety and stress, social activities, communication with physicians, and the client’s overall self-confidence in managing symptoms related to the disease. The measurement of change in these areas informed the study on the effectiveness and practicality of the skills being taught in the CDSP and their effectiveness in the promotion of self-efficacy. It also highlighted which skills seem to be most helpful and impactful to clients, and if the skills they learned were retained over time. The study measured the short-term impacts from completion of the CDSP to the 6-month follow-up period and also measured the long-term impacts the CDSP had on client health outcomes three (3) and four (4) years after the initial program was implemented to see if there was a correlation between increased self-efficacy and improved health outcomes. Participant CD4 and viral load counts were analyzed, as these are determinant biological markers in measuring the immunological impacts of the disease. Measuring these variables over time for individuals that were in a CDSP gave the study insight into the CDSP’s short-term and long-term effectiveness in the promotion and sustainment of self-efficacy for individuals living with HIV/AIDS and how the effective management of their chronic illness can lead to overall better health outcomes. Additionally, this study sought to better understand the experience of the women who participated in the CDSP through incorporating a mixed methods qualitative approach, by interviewing some of the women who had participated in the CDSP to identify common themes or lessons learned, best practices of the program, and areas for improvement. Although this study was not able to show that changes in behavior and increased self-efficacy impact health outcomes, more complex analysis should be done in this area, as this study highlighted the positive impacts a CDSP can have on increasing self-management skills and promoting self-efficacy over the short-term and long-term for individuals diagnosed with HIV/AIDS.

<p>Human Papillomavirus (HPV) is a key factor in the development of cervical cancer. Out of the more than 100 known HPV types 13 are considered oncogenic. In addition to presence of the virus several other factors have been proposed to influence risk of cervical cancer. This thesis focuses on viral load and HLA class II alleles as risk factors for cervical cancer.</p><p>To enable quantification of the most common oncogenic HPV types, a real-time PCR-based assay was developed and evaluated in terms of technical sensitivity and specificity.</p><p>This assay was then employed on archival smears from 457 cases and 552 controls to assess associations between viral load and cervical carcinoma <i>in situ</i> (CIS). Whereas the data indicate a pronounced dose dependent effect of HPV 16 load on the risk of CIS, other HPV types only seem to increase CIS risk at higher viral loads. These effects were observed even when cytology indicated that cells were normal.</p><p>We then investigated viral load as a risk factor for invasive cervical carcinoma (ICC) in a retrospective study comprising 139 cases and 550 controls. Viral load contributed similarly to the risk of ICC as to the risk of CIS.</p><p>Finally, associations between HLA class II alleles, viral load and CIS were investigated. Carriers of the DRB1*1301 allele were less prone to infections and high viral loads of HPV 31 and -18/45. Moreover, DRB1*1301 had a protective effect against CIS among women infected by HPV 31 or -18/45. In contrast, carriers of DRB1*1501 and DQB1*0602 were more susceptible to infections and high viral loads of HPV 16.</p><p>These results indicate that HPV load may have HPV-type specific effects on cervical cancer risk. Furthermore, HLA class II alleles may confer either susceptibility or protection against cervical cancer by acting on the HPV infections preceding tumor development.</p>

Human Papillomavirus (HPV) is a key factor in the development of cervical cancer. Out of the more than 100 known HPV types 13 are considered oncogenic. In addition to presence of the virus several other factors have been proposed to influence risk of cervical cancer. This thesis focuses on viral load and HLA class II alleles as risk factors for cervical cancer. To enable quantification of the most common oncogenic HPV types, a real-time PCR-based assay was developed and evaluated in terms of technical sensitivity and specificity. This assay was then employed on archival smears from 457 cases and 552 controls to assess associations between viral load and cervical carcinoma in situ (CIS). Whereas the data indicate a pronounced dose dependent effect of HPV 16 load on the risk of CIS, other HPV types only seem to increase CIS risk at higher viral loads. These effects were observed even when cytology indicated that cells were normal. We then investigated viral load as a risk factor for invasive cervical carcinoma (ICC) in a retrospective study comprising 139 cases and 550 controls. Viral load contributed similarly to the risk of ICC as to the risk of CIS. Finally, associations between HLA class II alleles, viral load and CIS were investigated. Carriers of the DRB1*1301 allele were less prone to infections and high viral loads of HPV 31 and -18/45. Moreover, DRB1*1301 had a protective effect against CIS among women infected by HPV 31 or -18/45. In contrast, carriers of DRB1*1501 and DQB1*0602 were more susceptible to infections and high viral loads of HPV 16. These results indicate that HPV load may have HPV-type specific effects on cervical cancer risk. Furthermore, HLA class II alleles may confer either susceptibility or protection against cervical cancer by acting on the HPV infections preceding tumor development.

Hantaviruses can cause two severe human diseases: hemorrhagic fever with renal syndrome (HFRS) and hantavirus cardiopulmonary syndrome (HCPS). Hantaviruses are spread to humans mainly through inhalation of infectious virions, secreted from infected rodents. The human diseases are characterized by an increased capillary leakage syndrome. Hantaviruses are known to infect endothelial cells, but they are non-cytopathogenic. The mechanism behind human disease is not well understood, but an overactive immune response is implicated in the pathogenesis. The aim of my thesis has been to investigate parts of innate and adaptive immune responses in Puumala virus-infected patients. In paper I we found a sex difference in the cytokine profile during acute infection. Females had significantly higher plasma levels of IL-9, FGF-2, GM-CSF and lower levels of IL-8 and IP-10 compared to males. These differences may affect the activation and function of the immune response. In paper II we studied the phenotype and kinetics of NK cells. We observed that CD56dim NK cells were elevated during acute infection and that these, predominantly NKG2C+ NK cells, remained elevated for at least two months after symptom debut. Our novel finding of a prolonged NK cell response, implicates that NK cells may possess adaptive immunity features.  In paper III we observed a vigorous cytotoxic T cell (CTL) response during acute infection, which contracted in parallel with decrease in viral load. The CTL response was not balanced by an increase in regulatory T cells. The T cells expressed inhibitory immunoregulatory receptors, known to dampen intrinsic T cell activity.  In paper IV, we found that a low IgG response in patients was significantly associated with more severe disease, while the viral load did not affect the outcome. Our findings support the use of passive immunization as a treatment alternative for hantavirus-infected patients. In conclusion, my thesis contributes to an increased knowledge about the immune response in hantavirus-infected patients. The findings, combined with future studies, will hopefully lead to a better understanding of the pathogenesis and possible treatment alternatives.

L’histoire naturelle et la progression des infections au VPH (virus du papillome humain) sont bien décrites. Cependant, la dynamique de transmission reste faiblement documentée. Une meilleure compréhension de la dynamique de transmission ainsi que de ses facteurs de risque permettrait d’optimiser les stratégies de prévention afin de réduire la prévalence de ces infections dans la population par la vaccination et les méthodes contraceptives. Notre étude vise à déterminer si la charge virale des infections au VPH influence leur transmission entre les partenaires sexuels. Pour ce faire, l’association entre la charge virale au niveau des organes génitaux et la concordance spécifique de type des infections prévalentes au VPH a été évaluée pour 250 couples hétérosexuels récemment formés. Les charges virales de VPH16 (r = 0.30), de VPH18 (r = 0.50) et de VPH51 (r = 0.19) étaient significativement corrélées (p < 0.05) entre les deux partenaires sexuels, contrairement à celles de VPH31 (r = 0.08) et de VPH42 (r = -0.1). Lorsqu’ajusté en fonction de l’âge des participants, une charge virale élevée augmentait significativement le taux de détection du même type chez le partenaire pour les types 16, 31 et 51. Ainsi, dans les couples hétérosexuels récemment formés, des charges virales élevées sont associées à une détection accrue du même type chez le partenaire sexuel. / The natural history and progression of genital HPV infection are well understood. However, less is known about transmission dynamics of HPV between sexual partners. A better knowledge of risk factors and dynamics of HPV transmission is needed to optimize prevention strategies through vaccination and contraceptive measures. Our study aims to determine if the viral load of HPV infection affects transmission between sexual partners. The association between human papillomavirus (HPV) loads in genital swabs and type-specific concordance of prevalent HPV infection was assessed in 250 heterosexual recently-formed couples to further characterize HPV transmission. Viral loads of HPV16 (r=0.30), HPV18 (r=0.50) and HPV51 (r=0.19) were significantly correlated (p<0.05) between partners in opposite to HPV31 (r=0.08) and HPV42 (r=-0.10). A higher HPV load increased significantly the rate of detection of HPV16, 31 and 51 in sexual partners (age-adjusted odds ratios from 1.64 to 7.71). In recently-formed heterosexual couples, higher HPV16, 31 or 51 load was associated with increased detection of the same HPV type in sexual partners.

Diss. (sammanfattning) Stockholm : Karol. inst., 2006. / Härtill 4 uppsatser.

Thesis (Ph. D.)--University of Washington, 2005. / Vita. Includes bibliographical references (leaves 72-106).

Made available in DSpace on 2015-07-22T20:49:21Z (GMT). No. of bitstreams: 0 Previous issue date: 2008-10-29. Added 1 bitstream(s) on 2015-08-11T03:25:40Z : No. of bitstreams: 1 Publico-065a.pdf: 467665 bytes, checksum: 5c21c191852c281d4e2eebf6fd7a8d72 (MD5). Added 1 bitstream(s) on 2015-08-11T03:25:40Z : No. of bitstreams: 2 Publico-065a.pdf: 467665 bytes, checksum: 5c21c191852c281d4e2eebf6fd7a8d72 (MD5) Publico-065b.pdf: 1808818 bytes, checksum: ea880bd6471f0602f5add685ca9800fe (MD5) / INTRODUÇÃO: A substituição monótona de bases G → A no genoma do HIV-1 é observada desde a década de 1990, entretanto, apenas recentemente esse efeito foi atribuído às APOBECs (apolipoprotein B editing catalytic polypeptide) da imunidade inata. As APOBECs celulares atuam na deaminação de citidina a uridina na fita de DNA viral de polaridade negativa e esse efeito é verificado como excesso de adeninas na fita complementar de DNA viral resultante do processo de transcrição reversa. A presença de hipermutações ocasiona perda da capacidade replicativa da partícula do HIV-1 e pode levar populações virais à extinção. Estudos in vitro demonstraram o efeito antiretroviral das APOBECs3 baseados, principalmente, na verificação de hipermutação. Por outro lado, estudos sistemáticos in vivo são escassos e os dados da literatura são controversos com relação ao efeito da hipermutação no genoma das subpopulações de HIV-1 e na dinâmica da infecção. OBJETIVOS: Este estudo objetivou avaliar os efeitos da hipermutação em pacientes HIVpositivos não tratados correlacionando a freqüência de hipermutação com a carga viral. A carga viral é um importante indicador biológico de replicação do HIV-1 e clínico de progressão para a aids. Assim sendo, foi testado se a presença de hipermutação tem efeito protetor no controle da infecção natural pelo HIV utilizando como parâmetro de apoio a carga viral plasmática do HIV-1 nas 157 amostras de pacientes não tratados testadas para detecção de hipermutação. A integrase constitui um hot spot de hipermutação no genoma viral. MÉTODOS: Foi realizada PCR (Polymerase Chain Reaction) para amplificar um fragmento de 582 pares de bases do gene da integrase e o produto de PCR foi visualizado em gel de agarose com HA-Yellow. O corante HA-Yellow retarda a migração eletroforética de um produto de PCR proporcionalmente ao conteúdo de bases A da sequência. Nosso método de análise foi validado com base em sequências de clones e calibrado em acordo com os resultados gerados pelo programa Hypermut (disponível em http://www.hiv.lanl.gov/content/sequence/HYPERMUT/ hypermut.html). A análise dos dados realizou-se com base na estatística de K-means que permitiu agrupar as amostras clínicas de acordo com sua distância de migração no gel de agarose com HA-Yellow. RESULTADOS: Foi observada hipermutação em 31,2% (n=49/157) destas amostras e houve associação entre presença de hipermutação e maiores níveis de viremia (P=0,02, teste de Mann-Whitney). Adicionalmente, a presença de hipermutação não apresentou associação com menores níveis de linfócitos T CD4 positivos (P=0,06, Teste de Mann-Whitney), nem ao gênero ou à etnia. CONCLUSÕES: Os valores de carga viral detectados em cada indivíduo refletem a quantidade de partículas virais filtradas pelo processo de hipermutação e o substrato da hipermutação é a replicação viral. Assim sendo, nós constatamos que amostras clínicas com altos níveis de replicação viral exibiram o fenômeno de hipermutação mais frequentemente. Em resumo, a detecção de variantes provirais de HIV-1 portando hipermutação correlacionou-se com maiores níveis de carga viral nos pacientes avaliados. Assim sendo, concluímos que a hipermutação, fenômeno bioquímico de substituições G para A no HIV-1, é um processo pervasivo e está associada com níveis mais elevados de replicação viral. Palavras- Chave: HIV-1, APOBEC, imunidade inata, carga viral, hipermutação / TEDE / BV UNIFESP: Teses e dissertações

Sur le plan mondial, le nombre de patients infectés par le VIH (PVVIH) sous traitement antirétroviral (TARV) est en constante augmentation. Les pays aux ressources limitées (PRL) sont les plus touchés par l’épidémie et de fortes inégalités existent ce malgré des objectifs ambitieux fixés par les Nations Unies en 2015 (90-90-90). Le suivi biologique nécessaire des patients sous TARV est connu et les avantages de la mesure de la charge virale (CV) sont bien établis en termes de détection précoce de l'échec thérapeutique, de détection de la non-observance au TARV et de prévention de l’accumulation de résistances. Cependant, dans les PRL et notamment en zone décentralisée, l’accès à la mesure de la CV reste très restreint. Les obstacles sont divers : difficulté d’accès pour les patients à un laboratoire en capacité d’effectuer cette mesure, manque en ressources humaines et matérielles. L’utilisation des Dried Blood Spot (DBS) comme support de prélèvement permet de surmonter ces barrières notamment du fait de sa simplicité, de l’absence de nécessité de chaine de froid et de l’utilisation des machines existantes.L’objectif de ce travail de thèse est de proposer et d’évaluer une stratégie afin d’améliorer le suivi virologique des PVVIH sous TARV issus de zones décentralisées de PRL en montrant la faisabilité et la validité d’un système de collecte de DBS afin de donner accès à la mesure de la CV aux patients suivis dans des centres non dotés des machines couteuses et de la logistique nécessaire à la réalisation de celle-ci. Une méta-analyse sur le contrôle virologique en Afrique Sub-saharienne a mis en évidence un taux de succès virologique en « intention de traiter » de 65.4% [61.8_69.1] et de 56.8% [51.3-62.4] à respectivement 12 et 24 mois de TARV ainsi qu’une proportion de succès significativement plus élevée rapportées dans les essais cliniques comparativement à ceux issus des cohortes. Ensuite, plusieurs projets ont été menés afin d’obtenir des résultats dans des conditions de vie réelle dans deux zones géographiques différentes: le Cameroun et le Vietnam. Au Cameroun, une étude menée dans 12 sites décentralisés a permis d’évaluer 2215 patients dont 937 ont été évalués virologiquement. Cette étude a montré un faible taux de rétention avec 63.3%, 53.5% et 39.9% à respectivement 12, 24 et 36 mois de l’initiation du TARV. Le taux de suppression virologique était très bas avec 66.6%, 62.7% et 59.8% à respectivement 12, 24 et 36 mois de TARV. Le profil des résistances virales analysé chez les patients ayant une CV>5000 cp/mL a montré une accumulation importante des résistances virales, s’aggravant au cours du temps et hypothéquant les options. Au Vietnam, deux études incluant 198 et 203 patients, ont été menées afin d’évaluer les performances de la mesure de la CV sur DBS comparativement au plasma. Trois techniques de mesure de la CV issues de deux industriels ont été évaluées. Une sensibilité de 93.3% [81.7–98.6], 90.1% [80.7-95.9] et 54.9% [40.3–68.9] a été trouvé avec respectivement l’ancien et le nouveau protocole fournis par Abbott et le nouveau protocole fourni par Roche (FVE). La spécificité retrouvé a été respectivement de 94.8% [90.0–97.7], 96.2% [91.4-98.8] et 100% [97.5–100]. Ainsi, à travers ces travaux nous avons montré que l’utilisation des DBS est faisable, immédiatement disponible et d’un niveau de performance acceptable. Elle permet d’apporter des données précieuses tant au niveau individuel, collectif que programmatique. L’utilisation des DBS devrait être intégrée à la stratégie d’expansion de l’accès à la CV. Le suivi virologique des patients est un enjeu de Santé Publique majeur dans un contexte d’utilisation en 1ère ligne de TARV de molécules à barrière génétique faible à la résistance, d’augmentation des résistances transmises et acquises et d’un taux d’incidence encore élevé de l’infection. / Worldwide, the number of HIV-infected patients (PLWHA) on antiretroviral therapy (ART) is growing steadily. Low- and Middle-Incomes Countries (LMICs) are the most affected and strong inequalities still exist despite ambitious goals set by the United Nations in 2015 (90-90-90). The required biological monitoring of patients on ART is well known and the benefits of viral load (VL) measurement are well established, in terms of early detection of treatment failure, detection of non-adherence to ART and prevention of resistance accumulation. However, in LMICs and especially in decentralized areas, access to VL measurement remains scarce or unavailable. Barriers are various: difficulty for patients to reach a laboratory able to perform this measurement, lack of human and material resources. The use of Dried Blood Spot (DBS) as a sampling carrier allows to overcome these barriers, in particular because of its simplicity, the lack of the necessity of a cold chain and the use of existing machines. This PhD work aims at proposing and improving virological monitoring of PLWHA on ART living in decentralized areas of LMICs by demonstrating the feasibility and validity of a DBS collection system to provide access to VL measurement for patients followed in centres not equipped with costly machines and the logistics for its realization.A meta-analysis on virological success in Sub-Saharan Africa was conducted. This work showed a virological success rate in "intention to treat" analysis of 65.4%[61.8-69.1] and 56.8%[51.3-62.4] at 12 and 24 months of ART respectively, and a significantly higher proportion of success reported in clinical trials compared to cohorts. Then, several projects were conducted to obtain results in real life conditions in two different settings: Cameroon and Vietnam. In Cameroon, a study conducted in 12 decentralized sites evaluated 2215 PLWHA on ART, 937 of whom were virologically evaluated. This study showed a low retention rate with 63.3%, 53.5% and 39.9% at 12, 24 and 36 months after ART initiation, respectively. Virological suppression rate was also low with 66.6%, 62.7% and 59.8% at 12, 24 and 36 months of ART, respectively. Profiles of HIV Drug Resistance (HIVDR) in patients with VL>5000 cp/mL showed a significant accumulation of viral resistance, worsening over time and hypothecating therapeutic options. In Vietnam, two studies, involving 198 and 203 patients, were conducted to evaluate performance of VL measurement on DBS compared to plasma. Three VL techniques from two manufacturers were evaluated. Sensitivities of 93.3% [81.7-98.6], 90.1% [80.7-95.9] and 54.9% [40.3-68.9] were found with the old and optimized protocol provided by Abbott company and the new protocol provided by Roche company (FVE), respectively. Specificities were 94.8% [90.0-97.7], 96.2% [91.4-98.8] and 100% [97.5-100], respectively. Through this work, we showed that the use of DBS is feasible, immediately available and with an acceptable level of performance. It provides valuable data at the individual, collective and programmatic levels. The use of DBS should be integrated into the strategy of expanding access to VL. Virological monitoring of patients is a major public health challenge in a context of use in first line ART of molecules with a low genetic barrier to HIVDR, an increase of transmitted and acquired HIVDR and a persistently high incidence of infection.

Miami-Dade County has approximately 27,000 people living with HIV (PLWH), and the highest HIV incidence in the nation. PLWH have reported several types of sleep disturbances. Caffeine is an anorexic and lipolytic stimulant that may adversely affect sleep patterns, dietary intakes and body composition. High caffeine consumption (>250 mg. per day or the equivalent of >4 cups of brewed coffee) may also affect general functionality, adherence to antiretroviral treatment (ART) and HIV care. This study assess the relationship of high caffeine intake with markers of disease progression, sleep quality, insomnia, anxiety, nutritional intakes and body composition. A convenience sample of 130 PLWH on stable ART were recruited from the Miami Adult Studies on HIV (MASH) cohort, and followed for three months. After consenting, questionnaires on Modified Caffeine Consumption (MCCQ), Pittsburg Insomnia Rating Scale (PIRS), Pittsburg Sleep Quality Index (PSQI), Generalized Anxiety Disorder-7 (GAD-7), socio-demographics, drug and medication use were completed. CD4 count, HIV viral load, anthropometries, and body composition measures were obtained. Mean age was 47.89±6.37 years, 60.8% were male and 75.4% were African-Americans. Mean caffeine intake at baseline was 337.63 ± 304.97 mg/day (Range: 0-1498 mg/day) and did not change significantly at 3 months. In linear regression, high caffeine consumption was associated with higher CD4 cell count (β=1.532, P=0.049), lower HIV viral load (β=-1.067, P=0.048), higher global PIRS (β=1.776, P=0.046), global PSQI (β=2.587, P=0.038), and GAD-7 scores (β=1.674, P=0.027), and with lower fat mass (β=-0.994, P=0.042), energy intakes (β=-1.643, P=0.042) and fat consumption (β=-1.902, P=0.044), adjusting for relevant socioeconomic and disease progression variables. Over three months, these associations remained significant. The association of high caffeine with lower BMI weakened when excluding users of other anorexic and stimulant drugs such as cocaine and methamphetamine, suggesting that caffeine in combination, but not alone, may worsen their action. In summary, high caffeine consumption was associated with better measures of disease progression; but was also detrimental on sleep quality, nutritional intakes, BMI and body composition and associated with insomnia and anxiety. Large scale studies for longer time are needed to elucidate the contribution of caffeine to the well-being of PLWH.