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Journal of Virology, June 2003, p. 7120-7123, Vol. 77, No. 12
0022-538X/03/$08.00+0 DOI: 10.1128/JVI.77.12.7120-7123.2003
Copyright © 2003, American Society for Microbiology. All Rights Reserved.
Comparison of Human Immunodeficiency Virus Type 1 Viral Loads in Kenyan Women, Men, and Infants during Primary and Early Infection
Barbra A. Richardson,1,2* Dorothy Mbori-Ngacha,3 Ludo Lavreys,4 Grace C. John-Stewart,3,4,5 Ruth Nduati,3 Dana D. Panteleeff,6 Sandra Emery,6 Joan K. Kreiss,4,5 and Julie Overbaugh2,6
Departments of Biostatistics,1
Epidemiology,4
Medicine, University of Washington,5
Divisions of Public Health Sciences,2
Human Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington,6
Department of Paediatrics,3
University of Nairobi, Nairobi, Kenya7
Received 26 December 2002/
Accepted 12 March 2003

ABSTRACT
Steady-state levels of human immunodeficiency virus type 1 (HIV-1)
RNA in plasma reached at approximately 4 months postinfection
are highly predictive of disease progression. Several studies
have investigated viral levels in adults or infants during primary
and early infection. However, no studies have directly compared
these groups. We compared differences in peak and set point
plasma HIV-1 RNA viral loads among antiretrovirus-naive Kenyan
infants and adults for whom the timing of infection was well
defined. Peak and set point viral loads were significantly higher
in infants than in adults. We did not observe any gender-specific
differences in viral set point in either adults or infants.
However, infants who acquired HIV-1 in the first 2 months of
life, either in utero, intrapartum, or through early breast
milk transmission, had significantly higher set point HIV-1
RNA levels than infants who were infected after 2 months of
age through late breast milk transmission or adults who were
infected through heterosexual transmission.

TEXT
Primary human immunodeficiency virus type 1 (HIV-1) infection
in adults is characterized by high levels of virus replication.
This is manifested as a steep rise in plasma HIV-1 RNA levels
that reach a peak of between 10
5 and 10
6 copies/ml approximately
2 weeks after infection. Once the host defenses are mobilized
against the virus, there is a slow decline to a steady-state
viral load, or set point, of between 10
4 and 10
5 copies/ml at
approximately 4 months postinfection (
9,
21,
23). Peak viral
levels in adults are not predictive of the rate of disease progression.
However, the viral set point, which is most likely a measure
of the dynamics between the virulence of the infecting virus
strain and the ability of the host immune system to contain
the virus, is highly predictive of disease progression. This
has been exhibited in studies in which high steady-state levels
of HIV-1 RNA in plasma at 4- to 12-months postinfection translated
to significantly faster progression to AIDS (
21,
23).
The levels of viral replication during primary and early infection in infants seem to be more variable than those seen in adults. Most infants experience a peak HIV-1 RNA viral load in the first few weeks after infection (2, 5, 22). However, after this peak, some infants exhibit a decrease to a viral set point like that seen in adults while others exhibit a continued gradual decrease in viral load for several months or years (2, 5, 7, 14, 22). Because very few studies of HIV-1 RNA viral loads in infected infants have been done in the absence of antiretroviral treatment, some of the gradual decrease with increasing age reported from these studies could have been due to the effects of treatment. Finally, unlike those found in adult infections, high HIV-1 RNA viral-load levels very early in infant infections are highly predictive of disease progression (1, 4, 5, 16, 19, 20, 22, 24).
The reported levels of HIV-1 RNA viral loads in infants during primary and early infection appear to be higher than those seen in adults (2, 22). However, there are no published results directly comparing HIV-1 RNA viral-load levels during early infections in adult and infant populations for whom the timing of infection is well defined. Thus, there are no data that can be used to precisely compare the differences in peak viral-load levels and viral-load set points between these groups. To address this, we undertook a study to compare HIV-1 RNA viral loads in antiretrovirus-naive adults and infants during primary and early infection by using data obtained from studies of HIV-1 acquisition in Kenya. In addition, because the age at acquisition or the route of infection may influence viral-load peak and set point levels, we compared infants infected at different times during infancy (i.e., during the first 2 months of life due to in utero, intrapartum, or early breast milk infection or after the second month of life due to late breast milk transmission). All of the studies from which data were used for these analyses were approved by the University of Nairobi, University of Washington, and Fred Hutchinson Cancer Research Center institutional review boards, and all participants provided informed consent. The human experimentation guidelines of these institutions were followed in conducting the clinical research.
The cohorts for this study consisted of initially HIV-1-uninfected high-risk adults in Mombasa, Kenya, who were monitored through HIV-1 seroconversion, (13) and infants of HIV-1-infected mothers in Nairobi, Kenya, who were monitored from birth (15). The adult cohorts were initiated in 1993, and the infant cohort was initiated in 1992. In all of the cohorts, the participants were tested at frequent intervals for HIV-1 infection; the infants were tested by using HIV-1 DNA PCR (17), and the adults were tested by using a combination of serology and a plasma HIV-1 RNA test (11). After infection, the viral-load levels in the plasma of all the cohorts were determined by using the Gen-Probe HIV-1 RNA assay as previously described (6). The peak viral load was defined as the maximum viral load in the first 2 months after the estimated infection time. The set point viral load was defined as the first viral load measured between 4 and 12 months after the estimated infection time. Less than 1% of the subjects had viral loads below the limit of detection of the assay. For these few observations, the value for viral load was set at the midpoint between zero and the limit of detection of the assay.
The estimated time of infection in the infants was defined as the midpoint between the last negative and the first positive HIV-1 DNA PCR test for children who were uninfected at birth or had an unknown infection status at birth. The estimated time of infection for infants that tested HIV-1 DNA PCR positive at birth was set at birth. Infants that first tested HIV positive prior to 2 months of age were defined as having early infections. HIV-1 RNA viral-load assays were run on samples at and after the visit for which a child was first HIV-1 DNA PCR positive. Of the 38 HIV-infected infants available for analysis, 22 (60%) were female. Twenty-six (68%) were infected prior to 2 months of age, and 12 (32%) were infected at or after 2 months of age. Early infection occurred either in utero, intrapartum, or by breast milk transmission, while late infection was by breast milk transmission.
For adults who first tested HIV-1 RNA positive at the visit when seroconversion was first documented, the estimated time of infection was defined as the midpoint between that visit and the previous visit. The estimated time of infection for adults who had HIV-1 RNA detected at a visit prior to seroconversion was set to be 17 days prior to the detection of HIV-1 RNA, as described previously (3, 11). Of the 181 adults available for analysis, 150 (83%) were women and the remaining 31 (17%) were men. Based on the results of an independent samples t test, the average age of the men at their estimated time of infection was not significantly different from that of the women {29.6 years for the men (95% confidence interval [CI], 26.8 to 32.4 years) versus 29.9 years for the women (95% CI, 28.9 to 31.0); P = 0.8}. HIV-1 infection in the adults was assumed to be acquired through heterosexual contact, since none of the men or women reported a history of injection drug use and none of the men reported ever having had sex with a male partner.
For the infants and adults for whom there were both peak and set point viral-load measurements, these measurements were taken at very similar intervals after their estimated dates of infection (peak, a mean of 30 days for adults versus a mean of 27 days for infants; P = 0.3; set point, a mean of 209 days for adults versus a mean of 196 days for infants; P = 0.3; all means were determined by independent samples t tests). The mean peak viral load in infants was significantly higher than in adults (6.06 versus 5.07 log10 copies/ml, P < 0.001, determined by independent samples t tests), as was the mean set point plasma viral load (5.84 versus 4.60 log10 copies/ml, P < 0.001, determined by independent samples t tests) (Fig. 1). The average change in plasma HIV-1 RNA viral load per month between the peak and set points was -0.087 log10 copies/ml in adults compared to -0.042 log10 copies/ml in infants (P = 0.4; determined by independent samples t tests). In addition, there was not a significant difference in the average change in log10 HIV-1 RNA viral load per month between the viral-load set point and the first measurement 12 to 24 months after infection for adults versus that for infants (P = 0.1, data not shown; determined by independent-sample t tests). Because infants were monitored only to a maximum age of 24 months, we were unable to look at viral loads beyond 2 years postinfection. The continued high viral levels following primary HIV-1 infection for infants compared to those for adults may explain why viral loads soon after infection have been found to be highly predictive of disease progression in infants (1, 4, 5, 16, 19, 20, 21, 24).
We further subdivided the infant cohort based on the timing
of transmission. We also divided the adult cohort based on gender.
We were unable to compare peak viral levels among these groups
because of significant differences in the times of collection
of the first sample after infection among the groups. However,
we were able to examine viral levels at the set point for all
participants with set point measurements, because there were
no significant differences in the times between infection and
the times at which the sample for the viral set point was collected
for any of the four groups (Table
1).
View this table:
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TABLE 1. Number of days between estimated HIV infection date and collection of set point plasma HIV-1 RNA viral-load samples
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The effects of gender on the viral set point were examined because
some previous studies have reported differences in viral levels
between adult men and women (
23), although this observation
is not universal (
8). In our study, there was not a statistically
significant difference in the mean viral set point for men versus
that for women (Fig.
2) (
P = 0.4; determined by independent
samples
t tests) or for infants (data not shown). In addition,
we did not see a significant difference in the average levels
of change in viral loads between the set point and 12 to 24
months postinfection for female versus male adults (data not
shown). Comparisons of median viral loads among women and men
gave similar results. This is one of the few longitudinal studies
that have used the same HIV-1 RNA viral-load assay to compare
viral RNA loads in parallel cohorts of antiretrovirus-naive
adult males and females from the same city who were infected
with similar HIV-1 subtypes and whose only risk for HIV-1 infection
was through heterosexual contact. However, our study is limited
by a rather small number of male subjects (
n = 31). It is possible
that our observation of similar viral-load set points among
women and men in this study reflects the high number of women
with viral diversity at the time of infection in this cohort.
Recent studies suggest that the acquisition of multiple variants
is associated with an increased viral-load set point (M. Sagar,
L. Lavreys, J. M. Baeten, B. A. Richardson, K. Mandaliya, J.
Ndinya-Achola, J. K. Kreiss, and J. Overbaugh, submitted for
publication), while in previous studies the diversity of the
infecting virus population was not known. Thus, our results
support the need for additional studies comparing similar male
and female cohorts with known times of infection to clarify
whether observed differences in viral loads between genders
can be assumed for all populations.
Based on the results of independent samples
t tests, the mean
set point viral load was significantly higher for infants infected
early either in utero, intrapartum, or through early breast
milk transmission (6.12 log
10 copies/ml) than those for women
(4.61 log
10 copies/ml,
P < 0.001), men (4.76 log
10 copies/ml,
P < 0.001) and infants infected through breastfeeding at
or after 2 months of age (5.31 log
10 copies/ml,
P = 0.03) (Fig.
2). In addition, the average set point viral load for infants
infected through breastfeeding at or after 2 months of age was
significantly higher than that for adult women and trended towards
being higher than that for adult men (
P was 0.01 when the viral
load for infants was compared to that for women;
P was 0.1 when
the viral load for infants was compared to that for men; determined
by independent samples
t tests). There was not a significant
difference in the average changes in log
10 HIV-1 RNA viral loads
per month between the viral set point and the first measurement
12 to 24 months after infection for any of the groups in comparison
to the others (
P = 0.2, data not shown; determined by one-way
analysis of variance). Thus, the magnitude of the viral-load
set point was inversely related to the age of the host at the
time of infection, with infants infected in the first 2 months
of life having the highest set point, followed by infants infected
at or after 2 months of age through breast milk transmission
and then by adults. In addition, these differences in plasma
HIV-1 RNA viral loads were sustained through at least the first
2 years after infection. The finding of a high viral-load set
point among infants infected in the first 2 months of life compared
to that of those infected later complements and extends previous
findings for nonbreastfeeding cohorts that infants infected
in utero have a more rapid disease progression than those infected
intrapartum (
5).
The fact that average peak plasma HIV-1 viral loads are 1 log10 higher in infants than in adults indicates that the level of viral replication is higher in infants, starting at the earliest stages of infection. This difference may be a result of infants having a high concentration of circulating CD4+ T lymphocytes, which are the major target cells for HIV-1 replication, compared to that of adults (10). Alternatively, it may reflect a delayed and less robust early immune response to infection in the infants. Differences in the abilities of younger versus older infants to mount a strong immune response and/or the presence of maternal antibodies in breastfed infants may also explain the high viral set point among infants infected in the first 2 months of life compared to that of those infected later (12, 18). It is also possible that the differences in viral set points between younger and older infants is due to differences in the type of virus transmitted via breast milk versus the type of virus transmitted in utero or intrapartum. Detailed studies of both cell-free and cell-associated viral levels, as well as host immune responses in cohorts with frequent follow-ups starting at or before infection, will be useful in further dissecting the mechanisms underlying the differences in early virus replication in these groups.

ACKNOWLEDGMENTS
This research was supported by National Institutes of Health
grants AI-38518, AI-29168, and HD-23412 and an Elizabeth Glaser
Scientist Award (to J.O.).

FOOTNOTES
* Corresponding author. Present address: Harborview Medical Center, Box 359909, 325 Ninth Ave., Seattle, WA 98104-2499. Phone: (206) 731-2425. Fax: (206) 731-2427. E-mail:
barbrar{at}u.washington.edu.


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Journal of Virology, June 2003, p. 7120-7123, Vol. 77, No. 12
0022-538X/03/$08.00+0 DOI: 10.1128/JVI.77.12.7120-7123.2003
Copyright © 2003, American Society for Microbiology. All Rights Reserved.
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