1. Overview of Neglected tropical diseases and their impact on HIV: Chagas disease, Leishmaniasis and Endemic Mycoses XIX International Aids Conference, 2012 Washington, USA Maria Aparecida Shikanai Yasuda Infection on Immunosupressed Host Committee Chagas disease Out patient clinic Laboratory of Clinical Investigation in Immunology Hospital das Clínicas, Faculdade de Medicina University of São Paulo WHO Technical Group IVb on Prevention and Control of Transmission of Chagas Disease and Case Management of Non- Congenital Infection email: masyasuda@yahoo.com.br Phone 55 11 3061 7047/7048 CONFLICT OF INTEREST DISCLOSURE: NO CONFLICTS OF INTERESTS

2. HIV - parasite/host interactions: bi-directional influences HIV - parasite/host interactions: bi-directional influences I.Reactivation of parasitic disease in aids patients:  Leishmania (M  ) and  T. cruzi: blood and tissues (ID mice) II.  HIV replication by the parasite: Stimulus on lymphocytes by Leishmania LPG: Promastigote Lipophosphoglycan (surface) and Upregulation of HIV gene expression by NF-  B  HIV load Chagas disease reactivation but experimental data in restricted systems:  HIV replication by T. cruzi at placenta level/in human M  culture III. Changes in the immunopathology/ response to therapy 1.  rate of reactivation of chronic iinfection (co-infecton without React) 2.Higher severity of the Reactvation: meningoencephallitis 75%, myo- carditis 15% in Chagas disease reactivation, dissemination of dermotropic Leishmnania to visceral organs.... 3. Decreased therapeutic sucess (more recidives, lower % of cure) Increased lethality III. Changes in the natural history of both HIV and parasite infection 1. Progress in the evolution of parasite disease: severe involvement of organs/ death 2. HIV progression (?): aids and occurrence of opportunistic infection IV. Expansion of the HIV epidemic around the world + globalization of parasite infection: impact on parasite/HIV coinfections) Andreani et al, 2009, PLoS ONE 4(12): e8246, Olivier et al, An. Trop. Med. Par 2003,,97 (S 1): S79, Da Cruz et al.,.S Br.Med.Trop 39(SIII) :75, 2006

3. HIV (a)/ Trypanosoma cruzi (b), Leishmaniasis (d) co-infections Andre ani et al, Curr Op Hiv Ai ds7: 276, 2012 Epidemiology Chagas disease 1990 2000 2006 ____________________________________________ Deaths (year) > 45000 21000 12500 Human infection 10 6 cases) 30 18 15 (8) Annual Incidence 700 000 200 000 41200 Population under risk (10 6 ) 100 40 28 Distribution (countries) 21 19 18 ___________________________________________ Source: TDR/WHO, PAHO

4. T. cruzi and HIV co-infection TH2 response: Parasitemia as cofactor for reactivation 1. A. Trypanosoma cruzi: CD4< 200/μL in Chagas disease: 80% reactivated pt and  IL4/IF  ratio – co-infection SCID mice T. cruzi infected and  IF  :   parasites with low levels of myocardial inflammation but early mortality (Silva et al, 1993, Michailowsky et al, 2001).  parasites placental cultures Tc/HIV: ↓IL6,IL8, IP10 and MCP 1 (cytokines: downmodulate T. cruzi replication) 2. Higher parasitemia in coinfected T. cruzi/HIV without React. lead to > chance of reactivation (5 year prospective study) Major chance of transmission by bood and derivatives Major chance vertical transmission (1-13.8% immunocompetents vs > 50% in co-infection) No polimorfisms or innate immunity have been analyzed. 3. Mortality up to 100% on dependence of early therapy, clinical severity Usually less than 20% with 60 days of treatment Freitas et al, PLOS Neg. Trop. Dis, 2011; 5(8) e1277, Sartori et al. Ann. Trop. Med. Parasitol. 101:31-50, 2007,Scappelato et al, Rev. Soc. Bras. Med. Trop. 42:107, 2009; Freilij & Altchech 1995, 2:;551, Nisida et al, Rev. Soc. Bras. Med. Trop 41:305, 1999 Recomendações, Rev. Soc.Bras.Med.Trop., 39:392- 2006

5. 1) prevalence of T. cruzi/HIV coinfection (1.5%) (multicenter)/incidence Chagas disease reactivation(10-15%); 2) active screening to imonitor T.cruzi/HIV coinfection before the reactivation of parasitic disease (underestimate: < 300 reported cases), 3) predictive factors for disease reactivation (CD4 + parasitemia + HIV load); Ramos Jr et al. J Infect Dev Ctries 2010; 4:682, Freitas et al, PLOS Neg. Trop. Dis, 2011; 5(8) e1277, Sartori et al. Ann. Trop. Med. Parasitol. 101:31-50, 200 Brazilian (International) Network for Attention and Studies on T.cruzi/HIV coinfection (10000-15000 co-infected patients in Brazil) 4) new drugs or drugs combination: > efficacy parasitological cure, < toxicity; % of recurrence after therapy; 5) efficacy of secondary prophylaxis and its relationship with CD4+ T lymphocyte levels, HIV viral load and HAART therapy; 6) Monitoring of parasitemia and immunosupression (qPCR - pre-emptive therapy; 7) % of congenital transmission, and the morbidity-mortality rate among newborns, perinatal deaths/intervention; 8) Influence of genetic diversity of parasite (and HIV) and innate/acquired immunity in the co-infection and reactivation

6. Source: MoH /SVS -Brazil. VL-HIV co-infection cases (%) reported in Brazil and % of co-infection Cure 60-67% (glucantime/Amph B) Failures 34-40% Relapses 21-61% Lethality 17,2% (mean) Variable from 0 - 30.7% HIV  100-2320X chance of VL endemic areas In 2001 ~ 0.5% VL cases In 2010 ~ 6.5% VL cases Co-infection: Cutaneous leishmaniasis 0.1% x 2% VL Guidelines for Leishmania/ HIV-AIDS coinfection: Recommendations for diagnosis, treatment and follow- up of the patients – Secretaria de Vigilância em Saúde, Health Ministry, Brazil, Olivier et al, An. Trop. Med. Parasitol.. 2003, 97 (S 1): S79, Da Cruz et al., Rev. Soc. Bras. Med. Trop. 39(SIII) :75, 2006, Cota et al, PLOS Neg.Trop Dis 5(6):e1153, 2011 } co-infections Co-infection: ↓ CD4/μL, decreased IL15 (linked to TH1 response )  TH2 Dendritic cell as Leishmania reservoirs: infected by HIV bind to DC-SIGN, enhanced entry) CD8 T cells more activated in Leishmania co-infected than HIV + patients

7. Brazilian Network of Leishmania/HIV co-infection GAPS in Co-infection HIV/Leishmania Immunopathogenesis – Recovery of immune response against Leishmania is related to CD4 and CD8? – Differential immune response in visceral and tegumentary leishmaniasis ? Genotyping of Leishmania X Pathogenesis Diagnosis: better serologic methods for antibody detection in co-infection (Recommendation: HIV serology to all VL patients (Brazilian Health Ministry) Sensitivity Specificity Response to the treatment – Different drugs – Drugs association. Doses José Angelo Lauletta Lindoso* (email: jlindoso@usp.br) Coordinator of the Brazilian Network of Leishmania/HIV co-infection

8. Paracoccidoides brasiliensis complex Analysis of 65 isolates (8 regions in 5 nuclear loci) Matute et al. Mol. Biol. Evol. 23:65-73, 2006 S1 – 38 isolates: Argentina, Paraguai, Peru, Brazil, Venezuela PS3: 21 Colombia PS2- 5 Brazil 1 Venezuela Richini-Pereira et al., Mem Inst O Cruz 104: 636, 2009, Takayama et al, Med Mycology, 2009; 1: 9

9. A new species: Paracoccidioides lutzii : Main challenges for diagnosis, and clinical management Paracoccidioides lutzii: divergent from S1, PS2 e PS3  Rondonia (North West egion) and Mato Grosso (Central West region): Secreted Antigens from other regions: 26-45% Sensitivity X 92.3% com P. lutzii  Biological differences, clinical expression and drug susceptibility??  Role in Immunocompetent and Immunosupressed patients (HIV) Teixeira et al, Mol. Phylog. Evol. 2009; 52:273,Batista et al, ;Mycoses, 53:176, 2009, Morejon et al, Am..J Trop Med. Hyg. 2009, 80:359 1. HIV/Pbm Patients a. 1.5- 5% Paracoccidioidomycosis endemic area are HIV + b. are younger than immunocompetent patients, drug users. c. CD4 80%) d. irregular anti-retroviral therapy (Viral load >= 30 000/  l in 90%)) 2. Clinical expression: lung + lymphohematogenic dissemination: Skin,bones, liver, spleen, lymphnodes  Immunosupressed patient: Chronic form + phagocytic mononuclear system dissemination - IMMUNE PROFILE UNKNOWN Paracoccidioidomycosis/Histoplasmosis: hypergammaglobulinemia/polyclonal activation of Blymphocytes Immunocompetents: TH1 associated with protection, IF  by M 

10. Paracoccidioidomycosis and HIV infection Opportunistic disease that changes the natural history of the infection with P. brasiliensis: should be considered as condition that defines AIDS Early diagnosis and treatment 3. Treatment Co-infection % Pbmycosis %period (months) Remission or improvement 63 93.424 Relapses 18.5 2.324 (p<0.05) Deaths (pbmycosis) 12.2 6.006 Deaths (other causes) 14/45 6.0 Data from a Reference center – early diagnosis Morejon et al, Amer. J. Trop. Med. Hyg. 2009, 80:359; Marques & Shikanai-Yasuda, 1994

11. Histoplasmosis and HIV/aids infection In red: Histoplasmosis /HIV, Ferreira & Borges, Rev Soc. Bras, Med.Trop. 2009, 42:192 Without HIV: Endemic in America Less common: Europe and Asia 1.3 – 5% histoplasmosis in patients in patients with HIV infection with HIV infection Zerbe & Holland, CID 41:38, 2005, Goldman et al, CID 38:1485, 2004, Lee et al, Arth. Rheum. 46:2565, 2002

12. Histoplasmosis and aids:different clinical expressions due to genetic diversity? Variable clinical expression and high lethality in intensive care units (30%) Mortality is variable according to early diagnosis (?visceral forms:CNS) and therapeutic intervention Influence of genetic diversity in the clinical expression and outcomes of the disease? Data (%)MoraUnis Daher Chang Panamá* Badlley* ____________________________________________________________________ Skin 43.544.3 10.0 16.7 17.3 06.5 Mucosa08.814.3 1.9 > 3xHepatic Enzyme 94.762.5 Pancytopenia59.6 (mean  SD ) 34.6 (median) CD4<100/dl94.3 104  17980.0 16(2-450) Hepato/Espl66.735.7 34/18 40.042.310.9 XR Ret.Dif.Inf.61.432.948.0 (pneum) 52.3 Fungemia24.3 35.7 50.0 Dissemination 83.3 93.5 Lymphadenopathy 3.0 36.7 Mortality23.0 38.6 32.0 40.0 12.5 12.0 Unis et al, 2004, Rev SBMT 30:463,De Francesco Daher et al Trop.Med. Int. Hlth 2007,12:118, Chang et al, 2007, Rev SBMT.49:37, Mora et al, 2008, Mycoses 51:136, Balley et al,D. Mic Inf Dis 2008,62:151 Major challenges Chagas disease, Leishmaniasis, Paracoccidioidomycosis, Histoplasmosis Analysis of the Prevalence of co-infection in different countries, including population of major risk for transmission of both infections and reactivation of parasitic disease: (clinical regional aspects) Look for accessible screening sensitive methods for early diagnosis of the co-infection and reactivation to guarantee Best therapeutic approach and prophylaxis directed to special risks population (and/or preemptive therapy) Look for more efficient and less toxic drugs and drugs combination Analysis of the role of genetic diversity of parasites, and innate and acquired immunityin the clinical expression and outocmes of the disease

13. Laboratório de Imunologia LIM-48 HC-FMUSP Vera Lúcia Teixeira de Freitas Sheila Cristina Vicente da Silva Célia Regina Furuchó Paula Keiko Sato SEAP/HIV Clínica Moléstias Infecciosas e Parasitárias Ana Marli C. Sartori Maria Christina Gallafrio Noêmia Barbosa Carvalho Laboratório de Parasitologia LIM- 46 HC-FMUSP Rita Cristina Bezerra Erika Gakya Instituto de Ciências Biomédicas – USP Marta M. G. Teixeira Instituto Adolfo Lutz - Setor Parasitoses Sistêmicas Elisabeth V. Nunes Osvaldo Silva Thank you! Fundação de Amparo à Pesquisa Estado de São Paulo FAPESP Conselho Nacional de Desenvolvimento Científico e Tecnológico CNPq Ambulatório de Micoses Sistêmicas Adriana Kono Márcia Yoshida International Network for Attention and Studies on HIV/T. cruzi co-infection Brazilian Network of Leishmanaia/HIV co-infection