HIV superinfection (also called HIV reinfection) is a condition in which a person with an established human immunodeficiency virus infection acquires a second strain of HIV, often of a different subtype. These can form a recombinant strain that co-exists with the strain from the initial infection, as well as the strain from the new virus, and may cause more rapid disease progression or carry multiple resistances to certain HIV medications.
People with HIV risk superinfection by the same actions that would place a non-infected person at risk of acquiring HIV. These include sharing needles and forgoing condoms with HIV-positive sexual partners. Cases have been reported globally and studies have shown the incidence rate to be 0-7.7% per year. Research from Uganda published in 2012 indicates that HIV superinfection among HIV-infected individuals within a general population remains unknown. Further research from The Journal of Infectious Diseases indicates that there have been 16 documented cases of superinfection since 2002.
"If a person is infected with a second virus before seroconversion to the first virus has taken place, it is termed a dual infection. Infection with a second strain after seroconversion is known as superinfection."
- 1 Immunology
- 2 Causes
- 3 Mechanism
- 4 Diagnosis
- 5 Prognosis
- 6 Epidemiology
- 7 History
- 8 Implications for treatment and care
- 9 References
A study conducted in Kenya in 2007 shows that superinfection tends to occur during the course of the initial infection, that is during acute infection, or 1–5 years after initial infection, but not during the latency period. Thus, superinfection occurs after an immune response to the initial infection has already been established.
It is unknown what aspects of the natural immune response to HIV may protect someone from superinfection, but it has been shown that cytotoxic lymphocyte responses do not seem to be protective. Immune responses to initial infection with a particular strain of HIV do not provide protection against superinfection with a different strain. The effect of neutralizing antibodies (NAb) is also unknown, but it has been shown that individuals with HIV tend not to have a NAb response prior to superinfection.
In addition, it has been demonstrated that superinfection can occur in individuals that demonstrate a robust anti-HIV antibody response. The anti-HIV antibody response broadens and strengthens in individuals post-superinfection. The finding that superinfection occurs within and between HIV subtypes suggests that an immune response to initial HIV infection provide limited protection against infection by a new viral strain. This means that HIV-vaccine strategies made to replicate the host's immune response to HIV infection may not prevent new infections.
Studies indicate that superinfection causes a spike in HIV viral load and a decrease in CD4+ cell count similar to those reported during primary HIV infection. Early studies of HIV superinfection analysed these spikes to diagnose cases of superinfection. It is unclear whether superinfection causes a sustained increase in viral load. The effect of superinfection on the progression of HIV infection is unclear because of its ambiguous effects on surrogate markers for the disease, such as an increase in viral load or a decrease in CD4 cell count. The potential of superinfection to cause rapid disease progression depends on viral and host factors.
Cases of superinfection are yet to be identified in sufficient numbers to conduct detailed studies on the effect of superinfection on the host immune response.
HIV superinfection is distinct from HIV dual infection, where an individual is simultaneously infected with multiple distinct viral strains. HIV superinfection involves an individual with HIV being infected by a new, phylogenetically distinct HIV strain. Early reports of HIV superinfection were observed in cases of co-infection with HIV-1 and HIV-2.
Studies have shown that a lack of neutralizing antibodies against HIV-1 infection predisposes patients to superinfection. Additionally, the tendency of HIV-1 virions to recombine when two subtypes infect a single cell increases its susceptibility to HIV superinfection. Further evidence of superinfection stems from the fact that nearly 10% of HIV-1 infections are associated with a transmittable recombinant strain. HIV-1 virions are divided into nine subtypes, all of which are characterized by different rates of disease progression, viral load and sensitivity to assays used in detection. When a single cell is infected by two HIV-1 subtypes, they recombine, forming a new, transmittable recombinant strain.
Loss of immune control
Following initial acute HIV infection, CD8+ T-cells control viral replication and maintain it at a viral set point. Following superinfection, CD8+ T-cells lose control over replication and it deviates from the set point. The mechanism responsible for this is unknown. A weakened T-cell response against the initial virus enables the superinfecting strain to resist immune control, resulting in an increased replication rate and subsequent viremia. Increased viral load and a declining T-cell response enables the superinfecting strain to recombine rapidly, further decreasing immune control.
HIV virions each contain a double-stranded RNA genome. When superinfection occurs, cells contain 2 different HIV strains. These can exchange genetic material such that an RNA strand from each strain is contained in a single virion. As this progeny virion infects new cells, the RNA template transcribed by viral reverse transcriptase changes, resulting in a reverse transcript with genetic material from both parental viruses. Recombination results in a rapid increase in HIV viral diversity, causing quicker adaptations to host immune response and resistance to ART. Recombination tends to produce two distinct recombinant forms, the presence of which are used as evidence of dual infection. The high prevalence of interclade recombinants increases the likelihood of superinfection being more widespread than reported.
Circulating recombinant forms
Circulating recombinant forms (CRFs) are mosaic viruses - recombinants with randomly assorted genetic material from phylogenetically distinct parental viruses. They spread geographically through human propagation, for example CRF02_AG, which is found in west and central Africa, as well as South America. CRF's account for 10% of HIV infections worldwide. There are 15 known CRFs, reported on 4 continents. More recombinants are likely to arise in regions with a growing HIV epidemic and where viral clades intersect, including Africa, Southeast Asia an South America.
Unique recombinant forms
In 2004, a study by AIDS on sex workers in Nairobi, Kenya reported URF generation in a women initially infected with clade A, and then 9 years later acquired clade C, which recombined with the initial infecting virus to form a recombinant of clades A and C that fully replaced the parental clade A virions.
Initial reports solely documented interclade superinfection, where patients are infected by a virus of a different clade from the initial virus. This is because the viruses in initial cases were all subtypes of HIV-1, with at least a 30% difference in nucleotides in their envelope proteins that makes such superinfections easier to detect.
Superinfection is identified by the detection of viral recombinants for phylogenetically distinct parent strains.
Multiregion hybridisation assaysare used to identify interclade superinfection by detecting genetic differences between parental and progeny strains. Heteroduplex mobility assays can be used to sequence viral genetic material, allowing the detection of samples with a genetic difference exceeding 1.5%.
Bulk sequencing is used to amplify viral RNA to enable the identification of new phylogenetic species in a patient over time. However, this method is poor at detecting genetic differences at levels of 20% of lower.
There are no known methods to estimate the timing of superinfection.
Studies on individuals with superinfection with 2 strains of HIV showed a poorer prognosis. Superinfection is correlated with a faster progression of the HIV infection. Patients in studies have displayed a shorter lag between seroconversion and experiencing an AIDS-defining clinical conditionor death. However, it is unclear whether this rapid conversion is a direct effect of superinfection, or a result of a weaker immune response to the virus caused by superinfection.
It is difficult to gain accurate estimations of the frequency of HIV superinfection because most studies are performed on patients infected with the HIV-1 B subtype, and recombinant strains are difficult to distinguish from the original strain for this subtype.
HIV superinfection has been reported in the USA, Canada, Europe, Australia, Asia and Africa. Data on the prevalence of superinfection has been gathered from case reports and observational studies, suggesting that it is underreported.
Initial care reports and observational studies of superinfection were in men who have sex with men, intravenous drug users and female sex workers. Incidence in heterosexual populations was first reported in rural Africa.
Incidence rates have been reported as 0% to 7.7% annually, although this varies across populations and depends on the frequency of antiretroviral drug use, the length of the follow-up period, and the method used to detect superinfection. However, a study in Uganda conducted using next-generation deep sequencing assays found that the rate of superinfection was large enough to be comparable to the primary HIV infection rate.
Risk factors for superinfection are not clearly understood because of the small number of cases documented. However, the risk factors for primary infection are considered to apply to superinfection, including:
- high number of sexual partners
- limited condom use
- no anti-retroviral use
- detectable plasma viral load
- absence of male circumcision
- non-marital relationships
The results of studies modeling the effect of HIV superinfection on viral recombination have suggested that superinfection has been instrumental in spurring community recombination rates. However, these studies were based on several epidemiological assumptions that are yet to be verified. These include assumptions about the pattern of HIV-1transmission and that superinfection causes transmission to uninfected sexual partners.
1991 - HIV-1 found to superinfect HIV-2-infected cells in a study through inducing infection in cells cultured from HIV patient samples.
2003 - Intraclade infection by an immune response to one strain of HIV-1 cannot prevent superinfection with a second virus from the same clade.
2005 - The ability of HIV superinfection to cause ART resistance.
Implications for treatment and care
Because of viral recombination, superinfection patients infected with at least one drug resistant strain are likely to develop a mosaic recombinant strain with multi-drug resistance. This lowers the potential success of ART. Additionally, the existence of multiple strains of the virus in a host enhances interclade and intraclade recombination, accelerating global virus diversification for HIV.
Impact on vaccine development
Research on the development of a HIV-1 vaccine has sought to replicate virus-specific CD8+ T-cell responses, which play a role in the control of HIV-1 replication. Superinfection case reports have shown that superinfecting strains generally had different viral epitopes from the initial infecting cell. An immune response to the initial infection would therefore be ineffective against the super-infecting strain, leading to the proliferation of the superinfecting strain.
A HIV-1 vaccine designed to recognize specific viral epitopes would be ineffective as it would not provide protection against HIV-1 viruses that do not share the same epitope. Such an ineffective vaccine could also lead to faster disease progression than in unvaccinated individuals. A successful vaccine would therefore have to incorporate viral epitopes derived from several viral subtypes.
Impact on clinical care
Increasing rates of antiretroviral therapy (ART) use have led to concerns about the development of drug-resistant strains which could be transmitted though superinfection. Individuals with drug-resistant strains are vulnerable to superinfection with a susceptible strain of the virus, reversing the effect of ART's the clinical aspects of HIV infection. Individuals with HIV were found to have a sudden increase in viral load, or a decrease in CD4 count should be tested for a resistant viral strain to identify the resistance profile of the secondary strain.
Sexual practices, such as serosorting, place individuals with HIV infection at a higher risk of superinfection and other sexually transmitted diseases(STDs). HIV positive individuals engaging in unprotected sex with seroconcordant partners require counseling on the risks of superinfection and STDs, both of which are expressed more virulently because of immunosuppression in HIV patients. Counselling for HIV patients on the risk of HIV superinfection, and encouraging safe sexual and injection practices have shown an improvement in safer sexual practices, reducing the risk of superinfection.
- Smith DM, Strain MC, Frost SD, Pillai SK, Wong JK, Wrin T, Liu Y, Petropolous CJ, Daar ES, Little SJ, Richman DD (November 2006). "Lack of neutralizing antibody response to HIV-1 predisposes to superinfection". Virology. 355 (1): 1–5. doi:10.1016/j.virol.2006.08.009. PMID 16962152.
- Redd AD, Mullis CE, Serwadda D, Kong X, Martens C, Ricklefs SM, Tobian AA, Xiao C, Grabowski MK, Nalugoda F, Kigozi G, Laeyendecker O, Kagaayi J, Sewankambo N, Gray RH, Porcella SF, Wawer MJ, Quinn TC (July 2012). "The rates of HIV superinfection and primary HIV incidence in a general population in Rakai, Uganda". The Journal of Infectious Diseases. 206 (2): 267–74. doi:10.1093/infdis/jis325. PMC 3415936. PMID 22675216.
- Redd AD, Quinn TC, Tobian AA (July 2013). "Frequency and implications of HIV superinfection". The Lancet. Infectious Diseases. 13 (7): 622–8. doi:10.1016/s1473-3099(13)70066-5. PMC 3752600. PMID 23726798.
- Foley B.T. (2017). HIV and SIV Evolution. In: Shapshak P. et al. (eds) Global Virology II - HIV and NeuroAIDS. doi:10.1007/978-1-4939-7290-6_5.
- Piantadosi A, Chohan B, Chohan V, McClelland RS, Overbaugh J (November 2007). "Chronic HIV-1 infection frequently fails to protect against superinfection". PLoS Pathogens. 3 (11): e177. doi:10.1371/journal.ppat.0030177. PMC 2077901. PMID 18020705.
- Blish CA, Dogan OC, Jaoko W, McClelland RS, Mandaliya K, Odem-Davis KS, Richardsonb BA, Overbaugh J (March 2012). "Cellular immune responses and susceptibility to HIV-1 superinfection: a case-control study". AIDS. 26 (5): 643–6. doi:10.1097/QAD.0b013e3283509a0b. PMC 3511787. PMID 22210637.
- Cortez V, Odem-Davis K, McClelland RS, Jaoko W, Overbaugh J (2012). "HIV-1 superinfection in women broadens and strengthens the neutralizing antibody response". PLoS Pathogens. 8 (3): e1002611. doi:10.1371/journal.ppat.1002611. PMC 3315492. PMID 22479183.
- Smith DM, Richman DD, Little SJ (August 2005). "HIV superinfection". The Journal of Infectious Diseases. 192 (3): 438–44. doi:10.1086/431682. PMID 15995957.
- Streeck H, Li B, Poon AF, Schneidewind A, Gladden AD, Power KA, Daskalakis D, Bazner S, Zuniga R, Brander C, Rosenberg ES, Frost SD, Altfeld M, Allen TM (August 2008). "Immune-driven recombination and loss of control after HIV superinfection". The Journal of Experimental Medicine. 205 (8): 1789–96. doi:10.1084/jem.20080281. PMC 2525594. PMID 18625749.
- Altfeld M, Allen TM, Yu XG, Johnston MN, Agrawal D, Korber BT, Montefiori DC, O'Connor DH, Davis BT, Lee PK, Maier EL, Harlow J, Goulder PJ, Brander C, Rosenberg ES, Walker BD (November 2002). "HIV-1 superinfection despite broad CD8+ T-cell responses containing replication of the primary virus". Nature. 420 (6914): 434–9. doi:10.1038/nature01200. PMID 12459786.
- Smith DM, Wong JK, Hightower GK, Ignacio CC, Koelsch KK, Petropoulos CJ, Richman DD, Little SJ (August 2005). "HIV drug resistance acquired through superinfection". AIDS. 19 (12): 1251–6. doi:10.1097/01.aids.0000180095.12276.ac. PMID 16052079.
- Fang G, Weiser B, Kuiken C, Philpott SM, Rowland-Jones S, Plummer F, Kimani J, Shi B, Kaul R, Bwayo J, Anzala O, Burger H (January 2004). "Recombination following superinfection by HIV-1". AIDS. 18 (2): 153–9. PMID 15075531.
- "Method of the Year". Nature Methods. 5 (1): 1–1. January 2008. doi:10.1038/nmeth1153.
- Marcus J, McConnel JJ, Grant RM (2005). "HIV Superinfection vs Dual Initial Infection: What Clinicians and Patients Should Know". Medscape HIV/AIDS. 11 (1): 33.
- Yerly S, Jost S, Monnat M, Telenti A, Cavassini M, Chave JP, Kaiser L, Burgisser P, Perrin L (July 2004). "HIV-1 co/super-infection in intravenous drug users". AIDS. 18 (10): 1413–21. doi:10.1097/01.aids.0000131330.28762.0c. PMID 15199317.
- Campbell MS, Gottlieb GS, Hawes SE, Nickle DC, Wong KG, Deng W, Lampinen TM, Kiviat NB, Mullins JI (May 2009). "HIV-1 superinfection in the antiretroviral therapy era: are seroconcordant sexual partners at risk?". PLOS One. 4 (5): e5690. doi:10.1371/journal.pone.0005690. PMC 2684644. PMID 19479055.
- Taylor JE, Korber BT (January 2005). "HIV-1 intra-subtype superinfection rates: estimates using a structured coalescent with recombination". Infection, Genetics and Evolution. 5 (1): 85–95. doi:10.1016/j.meegid.2004.07.001. PMID 15567142.
- Fultz PN, Srinivasan A, Greene CR, Butler D, Swenson RB, McClure HM (December 1987). "Superinfection of a chimpanzee with a second strain of human immunodeficiency virus". Journal of Virology. 61 (12): 4026–9. PMID 2446009.
- Le Guern M, Levy JA (January 1992). "Human immunodeficiency virus (HIV) type 1 can superinfect HIV-2-infected cells: pseudotype virions produced with expanded cellular host range". Proceedings of the National Academy of Sciences of the United States of America. 89 (1): 363–7. JSTOR 2358537. PMID 1346069.
- Otten RA, Ellenberger DL, Adams DR, Fridlund CA, Jackson E, Pieniazek D, Rayfield MA (September 1999). "Identification of a window period for susceptibility to dual infection with two distinct human immunodeficiency virus type 2 isolates in a Macaca nemestrina (pig-tailed macaque) model". The Journal of Infectious Diseases. 180 (3): 673–84. doi:10.1086/314968. PMID 10438354.
- Ramos A, Hu DJ, Nguyen L, Phan KO, Vanichseni S, Promadej N, Choopanya K, Callahan M, Young NL, McNicholl J, Mastro TD, Folks TM, Subbarao S (August 2002). "Intersubtype human immunodeficiency virus type 1 superinfection following seroconversion to primary infection in two injection drug users". Journal of Virology. 76 (15): 7444–52. doi:10.1128/JVI.76.15.7444-7452.2002. PMC 136380. PMID 12097556.
- Koelsch KK, Smith DM, Little SJ, Ignacio CC, Macaranas TR, Brown AJ, Petropoulos CJ, Richman DD, Wong JK (May 2003). "Clade B HIV-1 superinfection with wild-type virus after primary infection with drug-resistant clade B virus". AIDS. 17 (7): F11–6. doi:10.1097/01.aids.0000060361.78202.4c. PMID 12700477.