Thailand Tropical Diseases Research Programme Official Website

Summary Report Meeting on The Future Directions for Supporting HIV-OI in Thailand
24 September 2003
09:00 am - 04:00 pm
Siam City hotel, Bangkok, Thailand

Welcome address:
Dr. Somsak Chunharas, the T-2 Director, addressed to participants at the meeting on the rationale and status of the T-2 Programme which will finish in December, 2003. He also explained the main purpose of the meeting that all the experts from the various fields relating to HIV-Opportunistic Infections were invited for these discussion forum in order to generate the significant suggestions and opinions. All of the results from their discussions will be gathered and recorded to be the references guiding to the research direction on HIV-Opportunistic Infections in Thailand in the future.

I. Review HIV-OI Research: Opportunistic Infection in the era of HAART
Presenter: Prof. Thira Sirisanthana
Prof. Sirisanthana informed those at the meeting that the National Institute of Health provided Anti-Retroviral Therapy (ART) to 3000 patients in fiscal year 2002. After the Government Pharmacy Organization developed GPO-VIR, the cost of ART dropped to 1,200 Baht per month for each patient. So in fiscal year 2003, 10,000 patients were treated with ART, while using the same budget as in fiscal year 2002. The hope is that in fiscal year 2004, by using the same budget, as well as money received from the Global Funds, 50,000 patients can be treated to free ART. He also mention to the 2 problems related to Opportunistic Infections in the era of Highly Active Anti-retroviral Therapy (HAART):

- When can one stop primary and secondary prophylaxis for opportunistic infection?
- Immune Reconstitution Inflammatory Syndrome (IRIS) : A paradoxical deterioration in clinical status attributable to the recovery of the immune system during HAART
The proposed criteria for IRIS are as follows:

ART and could not be explained by a newly acquired infection, expected clinical course of a previously diagnosed opportunistic infection, or side effects of treatment.
He informed us of the many kinds of IRIS that have been reported in the literature. IRIS from Mycobacterium avium complex and Mycobacterium tuberculosis were also clarified.
The following are issues that he raised for basic science research and clinical science research:
Issues for basic science research.

Last of all, he asked those who were related to this problem whether or not this was the end of the research of Opportunistic Infection in HIV/AIDS. He hoped that this topic would be discussed later.

II. Review HIV-OI Research: Opportunistic fungal infections: Cryptococcus neoformans, Pennicillium marneffei
Presenter: Prof. Nongnuch Vanittanakom

Prof. Vanittanakom informed those at the meeting that two of the Opportunistic fungal infections that AIDS patients may contract are Cryptococcus neoformans and Pennicillium marneffei.
Cryptococcus neoformans is an encapsulated budding yeast. It has 3 varieties and 4 serotypes; A, B, C and D. More research will be needed to survey animal and other natural reservoirs of C. neoformans, so that we can learn to control and prevent the transmission of cryptococcosis. For epidemiology, more study of DNA fingerprinting profiles is needed. It is also important to differentiate C. neoformans subtype A from the other two subtypes, to explain source of infection, mode of transmission and molecular epidemiology. The following are research questions that were raised about mating type, virulence and laboratory diagnosis:

She also informed those at the meeting that current research being conducted at Chiang Mai University involves "Molecular typing of clinical and environmental isolates of Cryptococcus neoformans in Chaing Mai (Sriburee et al)".

Pennicillium marneffei
Images of the mold and yeast forms of P. marneffei were presented. Its natural habitats are endemic to Southeast Asia and Southern China. P. marneffei can be isolated from Rhizomys sinesis, R. pruinosus, R. sumatrensis, Cannomys badius and soil samples.
Genotype of P. marneffei were identified as having 2 patterns with 9 subprofiles, by using the PFGE method (Trewatcharegon et al 2001). In collaboration with Dr. Fisher, UK, Dr. Vanittanakom and team have done research on the topic "P. marneffei biodiversity by microsatellite genotype".
Infection with P. marneffei is presumed to originate via the inhalation of conidia from the environment. The development of the disease may involve both host immunity and fungal virulence. Kudeken et al, found that cell media immunity plays a central role in host defense mechanisms. Dr. Vanittanakom identified its host response, fungi virulence factors and diagnosis.
The following are research topics that should be investigated:

III. Review HIV-OI Research: Opportunistic bacterial infections: Atypical mycobacterium
Presenter: Assoc. Prof. Somying Thamwasorn
The following are case reports of mycobacterium in Thailand:

Prevalence rate (%) of mycobacterial opportunistic infection in Thailand was identified. Dr. Thamwasorn also informed the meeting about clinical characteristics and survival rates and Trend in NTM infection in Thailand.

IV. Review HIV-OI Research: Opportunistic viral infections: CMV
Presenter: Prof. Pilaipan Puthawatana
Prof. Puthawatana informed the meeting about Herpes Simplex Virus, Excise Bar Virus and Cytomegalovirus (CMV).
- The prevalence rate of these three viruses is 80-90%.
- They each can cause latent infection.
- Of these three viruses, CMV is the most common opportunistic infection in AIDS.

V. Review HIV-OI Research: Opportunistic parasitic infections: Pneumocystis carinii
Presenter: Lt.Col. Dr. Mathiruth Mungthin

Lt.Col. Dr. Mathiruth Mungthin informed the meeting about Pneumocystis pneumonia (PCP), which is the most common AIDS defining opportunistic infection in the USA and Europe. It is the second most common AIDS defining opportunistic infection in Thailand. He also informed the meeting about the other AIDS defining opportunistic infections discovered in Thailand from September 1984 to June 2003. He also briefed the meeting on Pneumocystis jiroveci, formally called P. carinii f. sp. hominis. It is a typical fungi that has trophozoites and cysts. Its absence of ergosterol makes it susceptible to all antiparasitic agents except amphotericin B.
The following evidence for classification as a fungi was given:

.- rDNA and a few other sequences establish fungal taxonomy, probably between Ascomycetes and Basidomycetes.
- The presence of translation elongation factor 3 (EF3).
- The presence of thymidylate synthase (TS) and dihydrofolate reductase (DHFR) coding sequences as two distinct genes.
- The presence of cell wall glucans, especially p-glucans.
- Sensitivity to p-glucans synthase inhibitors (echinocandins).
- The resemblance of cysts to ascomycetous fungi spore cases (asci) and the formation of infracystic bodies resembling ascospores.

Genotyping of Pneumacystis was mentioned. It was sequence polymorphism of ITS, mtLSU rRNA, DHPS, 26S, b-tubulin and PCR-SSCP. Following are reactivation of transmission of Pneumocystis:
- Detected Ab in most normalchildren over 4 years old
- Characteristics consistant with long-term carriage in host
For reinfection transmission of Pneumocystis are
- Absence of Pneumocystis in immunocompetent hosts without clinical evidence of PCP
- Immunosuppression alone is not sufficient to cause PCP in animals
- Pneumocystis genotypes in patients with recurrent PCP often differ from oiginal genotype.
- Pneumocystis varies by location

The source of infection, composed of environmental exposure and person-to-person transmission, was discussed. It was explained that Giemsa, toluidine O blue, methenamine silver, Immunofluorescence and PCR are used to detect Pneumocystis. The Clinical significance of DHPS mutations is as follows:
- Patients with mutant DHPS were significantly less likely to survive for 3 months than were patients with wild-type Pneumocystis infection.
- No association has been found between mutations and either the response to therapy or survival rates.

Cryptosporidiosis
3 broad entities of cryptosporidiosis are

- Outbreak of diarrhea in mammals
- A life-threatening disease in AIDS patients
- Waterborne-related diarrhea
Characteristics of the pathogen were discussed. Other species identification in immunocompromised persons were also clarified.

Microsporidia (Microsporidiosis)
Most cases of Microsporidia are found in AIDS patients. It is the causative agent of chronic diarrhea in AIDS (10-30% in Thai HIV-positive patients). The diagnosis of Microsporidiosis was discussed. It can be done by Electron microscopy and PCR technique.

All the participants were organized into four separate groups in order to address the status of each field area in Thailand, introduce the research teams and discuss any other suggestions for a funding agency. The following fields of HIV-OI were discussed and will be documented in order to extend research progress:
1. Opportunistic fungal infections
2. Opportunistic bacterial infections
3. Opportunistic viral infections: CMV
4. Opportunistic parasitic infections

Summary of the discussions from each group

PCP

- Detect samples from

o mouthwash
o Gastric wash

- Drug resistance

Cryptosporidiosis

- Treatment

o Nitazoxanide in HIV+
o (Clinical Trial Phase I)

- Water Borne
- Zoonosis

Taxoplasmosis

- Treatment
Problem

o Stop producing
o High site effect of drug

- In vivo animal model
- Diagnosis

o Has no definite diagnosis PCR?
o Clinical Correlation

NTM
Research Question

1. Rapid detection of NTM infections

o Direct smear
o Easy to use, low cost

Available techniques

o PCR direct detection
o Others Molecular techniques

Implement where?
Epidemiology = - data of NTM in Thailand

o necessity

2. Longitudinal detection of OI in children to answer IRIS? How long? Where to be done?

3. Treatment :

o Do we need susceptibility test?
o Do we need new drugs?
o Do we need vaccine?

Cryptococcosis
Penicillosis marneffei

1. Basic research

o Virulence factors
o Ag characterization

2. Diagnostic kit

o Asymtomatic (Ag/Ab detection)
o PCR

3. Epidemiology

o Source of infection
o Typing

4. Drug

o Herb treatment
o Drug target/resistance

5. Vaccine?

Virus

Diagnosis

o Standard
o Low cost
o Virus of particular interest
"CMV"
"Center for Dx of OpportunisticViral Infection"

Drug Resistance

o Techniques to Detect Drug Resistance Strains
o HSV -Acyclonr resistance
o Genotypic Analysis, Phenotypic Analysis

Pathogenesis

o CMV
o EBV

CMV Retinitis

o No HAART
o MDR

Foscaner---> Toxic

Gancyclovir

Other Alternative

Network

Closing remark
Dr. Somsak, the T-2 director, said that the mission of this meeting is to encourage researchers to conduct discussions and connect networks with each other that will lead to them finding good research questions and producing good proposals. Since the T-2 programme currently only has a few organizers, researchers who are interested in good research questions and would like to be organizers and build a research team are encouraged to submit their name lists to T-2 secretariat. We will manage the meetings and the support facilities, send out the invitation letters, etc.. As with the Gordon conference, T-2 may invite researchers to present their work. We hope that this type of meeting will lead to the development of many new research questions.
For database purposes, those with sources are kindly requested to submit them. For future reference, the contents of today's meeting will be summarized and sent to all participants. Furthermore, updates and new information will be uploaded into the T-2's website, where a search engine will be created to provide visitors with access to the publications.
T-2 will attempt to put into action that which has been proposed today.

Reported by : Ms. Taweeporn Gedarram
Approved by: Dr. Pokrath Hansasuta, Dr. Ram Rangsin, Dr. Somsak Chunharas