eRapport

HIV-infected African children: Gut microbiota in relation to chronic lung disease and long-term antibiotic treatment

Prosjekt
Prosjektnummer
HNF1539-20
Ansvarlig person
Trond Flægstad
Institusjon
Universitetssykehuset Nord-Norge
Prosjektkategori
Ph.d.-stipend
Helsekategori
Infection, Inflammatory and immune system
Forskningsaktivitet
5. Treatment Development, 6. Treatment Evaluation
Rapporter
2024
Prosjektet er en del av et stort Norges Forskningsråds-finansiert prosjekt, hvor NFR bevilget ca 40 mill kr. Det ble i en placebo-kontrollert randomisert studie undersøkt om ukentlig azithromycin kunne redusere forekomsten av lungesvikt hos barn og unge med HIV-infeksjon. Pasientene ble rekruttert i Harare, Zimbabwe og Blantyre, Malawi.1. Hvilke deler av prosjektet er gjennomført og hvilke gjenstår? Trym Flygel har avlagt doktorgrad. Det er noe arbeid med hans tredje manuskript. Dette vil bli ferdiggjort i vinteren 2025. 2. Vil prosjektet kunne gjennomføres som planlagt, jf. opprinnelig søknad? Hvis ikke, hvilke endringer er påkrevd for å kunne gjennomføre prosjektet på en kvalitativ god måte slik at forventet nytte i prosjektet kan realiseres? Prosjektet er en del av et stort Norges Forskningsråds-finansiert prosjekt, hvor NFR bevilget ca 40 mill kr. Det ble i en placebo-kontrollert randomisert studie undersøkt om ukentlig azithromycin kunne redusere forekomsten av lungesvikt hos barn og unge med HIV-infeksjon. Pasientene ble rekruttert i Harare, Zimbabwe og Blantyre, Malawi. De mikrobiologiske undersøkelsene, inkludert våre prøver, der tarmens mikrobiom ble undersøkt, ble analysert i Cape Town, Sør-Afrika. De immunologiske undersøkelsene ble gjort i Harare, Zimbabwe og Oxford, Storbritannia. Pga corona-epidemien ble prosjektet betydelig forsinket 3. Ubrukte Helse Nord-midler planlegges brukt til videre undersøkelser av luftveis mikrobiom og samspill mellom tarmens og luftveis mikrobiom («the gut-lung axis») hos barn med HIV infeksjon og kronisk lungesykdom. I første omgang til mer og nyere sekvensering enn det vi hadde tilgang til tidligere. I henhold til opprinnelig søknad, er dette fortsettelse av forskningsspørsmålene vi hadde. Vi skal blant annet se på utvikling av antibiotika resistens etter gjennomgått behandling med azithromycin. 4. Prosjektet 17190 er PhD-prosjekt, og Trym Flygel har disputert etter å ha vært lønnet fra denne bevilgningen i kortere tid enn det det var søkt om. Det er godkjent å kunne bruke resterende midler til forskning relatert til mikrobiom. Vi ønsker å fortsette innsamling av avføring til mikrobiomundersøkelser fra friske barn og unge i Tromsø for å finne et godt norsk normalmateriale. Det vil komme noe utgifter til dette, bl.a. lønn til forskningsassistent/stud.med. Vi har allerede samlet gut mikrobiom data fra HIV negative friske barn fra Zimbabwe og Malawi som vi kan bruke til å studere geografiske, etniske aspekter av gut mikrobiom utvikling hos friske barn. “We will study the longterm effect of azithromycin on the respiratory microbiome in HIV-1 infected children. The study has been performed in South Africa and samples have been collected and the analysis has in part been done. Implementation may be difficult as there is a lack of alternatives to long AZM therapy in these kids This project overall aims to explore methods to treat HIV induced chronic lung disease, while keeping pathogenic infections under control. The project will explore the development of microbial resistance in a trial cohort of ~450 african children, funded by norwegian funders. “ We have all samples stored at the University of Cape Town and plan to perform DNA extractions and shotgun sequencing during the fall-winter 2024. Data analysis, interpretation of results and drafting the manuscripts will be done during winter 2024-spring 2025. I tillegg vil det påløpe utgifter til faglige reiser, driftsutgifter til lab.rekvisita, innkjøp av tjenester som sekvensering, biostatistikk osv. 5. Gi en realistisk gjennomføringsplan for fullføringen av prosjektet/tildelingen. Vi er meget godt i gang med de siste prosjektene, og det er realistisk at vi blir ferdig i løpet av 2026.

Pasientene i studien behandles fortsatt i Zimbabwe og Malawi. Inkludering og oppfølging av pasienter ble avsluttet i 2019. The participants in the project are children and adolescents. They are defined as users together with their families. The family bonds are strong in this part of the world. The user organizations are not strong, most likely less involved in user participation. Children and adolescents are normally not found in a typically user organization. Therefore, the users in the project are already involved in focus groups through the ongoing BREATHE study were the microbiome study is a substudy. The families have regular contact outpatient clinics where the sampling is implemented, and they have an ongoing discussion with the local project coordinators about the advantages, and possible problems connected to the project. Groups of families are organized locally, and they have very strict information procedures and a voluntary participation agreement, where the children and adolescents can withdraw at any stage of the study

2023
An estimated 2.50 million children aged 0-19 years are living with HIV worldwide. HIV-associated chronic lung disease (HCLD) is the most prevalent comorbidity among children and adolescents with HIV in sub-Saharan Africa, where more than half of the population with HIV in the world reside. Obliterative bronchiolitis (OB) is found to be the most prevalent cause of HCLD in sub-Saharan Africa.The exact pathogenesis of OB is multifactorial and not completely understood. Studies indicate OB to be result of immune activation and repeated injury to the lungs causing permanent damage and excessive fibroproliferation, ultimately leading to narrowing of the airways. HIV is characterized by chronic immune activation, and CD4+ T-cells are the main target for HIV infection. As the majority of CD4+ T-cells reside in the gut and gut associated lymphatic tissue, HIV is also an intestinal disease, causing a disrupted gut barrier and gut microbial dysbiosis, persisting even after initiation of antiretroviral therapy (ART). Several studies have linked gut microbial dysbiosis to a variety of diseases, but it is difficult to prove causality between dysbiosis and disease. The link between a disrupted gut barrier caused by HIV, gut microbiota and immune-related complications of HIV is yet to be determined. Aim: The overall aim of the thesis was to investigate the composition of gut microbiota of HIV infected children and adolescents with HCLD, and to study the effects of macrolide antibiotic (azithromycin) treatment on gut microbial composition and the effect on local lung inflammation in HCLD. Methods: This work was a part of the double-blinded, placebo-controlled, randomized clinical trial; BREATHE (Bronchopulmonary function in response to azithromycin treatment for chronic lung disease in HIV-infected children and adolescents). Children and adolescents aged 6-19 years with HCLD was recruited from Harare, Zimbabwe and Blantyre, Malawi. Participants were randomized to once-weekly azithromycin or placebo for one year, to investigate if it improved lung function. In addition, a control group of 103 HIV negative participants were recruited in Harare, Zimbabwe. Rectal swabs were collected at inclusion, after 48 weeks of treatment and after 72 weeks (6 months after cessation of study drug). 16s rRNA sequencing was performed to assess diversity and composition of the gut microbiota. Exhaled nitric oxide (eNO) was measured at inclusion and after 48 weeks for a subset of participants from Zimbabwe to assess local inflammation in the lungs. Results: In Paper I we demonstrated that participants with HIV had lower alpha diversity and higher beta diversity compared to participants without HIV. Prolonged ART increased richness by alpha diversity to levels comparable to that of HIV negative. We found no association between gut microbiota and airway obstruction or history of TB. Corynebacterium, Finegoldia and Anaerococcus were significantly enriched in participants with HIV compared to participants without HIV. In Paper II we showed that higher levels of eNO served as a risk factor for developing acute respiratory exacerbations. eNO was associated with proinflammatory MMPs involved in development of chronic lung disease and fibroproliferation. There was no effect of azithromycin on levels of eNO. In Paper III we demonstrated that azithromycin reduced both richness and evenness by alpha diversity after 48 weeks of treatment and that these changes resolved 6 months after cessation of study drug. Eggerthella, Blautia and Dorea was increased, whereas Bifidobacterium and Campylobacter was decreased in azithromycin group at 48 weeks. Depletion of Campylobacter persisted for at least 6 months after finishing treatment. Conclusions: This work highlights the association between HIV and gut microbial dysbiosis and the effect of long-term antibiotics on lung inflammation and composition of gut microbiota. It adds knowledge to the field of HIV-associated comorbidities and can be helpful when designing new studies on gut microbiota and potential targets for microbiome-based interventions in the future.

The participants in the project are children and adolescents. They are defined as users together with their families. The family bonds are strong in this part of the world. The user organizations are not strong, most likely less involved in user participation. Children and adolescents are normally not found in a typically user organization. Therefore, the users in the project are already involved in focus groups through the ongoing BREATHE study were the microbiome study is a substudy. The families have regular contact outpatient clinics where the sampling is implemented, and they have an ongoing discussion with the local project coordinators about the advantages, and possible problems connected to the project. Groups of families are organized locally, and they have very strict information procedures and a voluntary participation agreement, where the children and adolescents can withdraw at any stage of the study

2022
Chronic lung disease is a recognised complication in children growing up with HIV. Acute respiratory exacerbations (ARE) are common among this group and causes significant morbidity. The aethiology of HIV-associated chronic lung disease (HCLD) is not completely understood, but chronic inflammation and immune activation is thought to play a role.Immune activation associated with HIV persists despite effective ART and may play a role in in the development of chronic HIV-related comorbidities including HCLD. In adults, data show that HCLD is associated with elevated levels of systemic proinflammatory biomarkers such as CRP, IL-6, TNF-alfa and T-cell activation. Matrix metalloproteinases MMP-1, MMP-7 and MMP-10, as well as biomarkers of inflammation IFN-γ, CRP and IP-10 were associated with HCLD in children and adolescents. Exhaled nitric oxide (eNO) is by far the most widely studied biomarker of local inflammation in CLD. Elevated levels of eNO have been used as a marker of eosinophilic airway inflammation in asthma and is suggested to be useful in diagnosing and monitoring of asthmatic disease. We investigated the effect of azithromycin treatment on levels of eNO, in children and adolescents with HCLD. We also assessed the association between eNO and the risk of ARE in children with HCLD and described the association between eNO and plasma soluble biomarkers of systemic inflammation. This study was nested within the BREATHE trial; a double blinded, randomized, placebo-controlled trial of weekly weight-adjusted azithromycin for 48 weeks in individuals aged 6-19 years with HCLD in Harare, Zimbabwe and Blantyre, Malawi (BREATHE trial, clinicaltrials.gov, identifier NCT02426112). We found that participants experiencing at least one ARE during follow-up had significantly higher baseline eNO-levels compared to participants who did not [geometric mean ratio 1.13, 95%CI (1.03-1.24),p=0.015]. Matrix metalloproteinase (MMP)-3, MMP-7 and MMP-10 were associated with higher baseline eNO-levels. 48-week azithromycin treatment did not affect eNO-levels [geometric mean ratio 0.86 95%CI (0.72-1.03),p=0.103]. In conclusion, baseline eNO-levels was a risk factor for ARE. eNO was associated with proinflammatory biomarkers relevant in developing chronic lung disease. The use of eNO as an inflammatory marker and risk factor for ARE in HIV-associated chronic lung disease needs further investigation. These results are now written up as a manuscript and submitted to Journal of Infectious Diseases, awaiting editorial decision. The next part of the project is to continue to analyse the gut microbial samples, and to compare and describe changes in the gut microbial composition after 48 weeks of azithromycin treatment, and to see whether the changes persist 6 months after cessation of antibiotic treatment.

The participants in the project are children and adolescents. They are defined as users together with their families. The family bonds are strong in this part of the world. The user organizations are not strong, most likely less involved in user participation. Children and adolescents are normally not found in a typically user organization. Therefore, the users in the project are already involved in focus groups through the ongoing BREATHE study were the microbiome study is a substudy. The families have regular contact outpatient clinics where the sampling is implemented, and they have an ongoing discussion with the local project coordinators about the advantages, and possible problems connected to the project. Groups of families are organized locally, and they have very strict information procedures and a voluntary participation agreement, where the children and adolescents can withdraw at any stage of the study

2021
Chronic lung disease (CLD) is the most common manifestation of HIV among children, accounting for more than 50% of HIV-associated mortality ). Though the etiology of CLD in HIV-infected children is not completely understood, chronic inflammation and immune activation may have a distinct role in the development of this chronic condition.Systemic translocation of microbes and microbial products due to HIV-associated damage of the gastrointestinal tract (GIT) is one of the major factors contributing to persistent inflammation in HIV-infected individuals. This process is accompanied by substantial changes in the composition of the gut microbiome, and this may further contribute to disease progression and potentially the development of chronic complications. With this study we seek to investigate whether the diversity and composition of the gut microbiome is different among HIV-infected children compared to HIV-uninfected controls and to study the link between the gut microbiome and CLD. In addition, the effect of long-term azithromycin treatment on the gut microbiome will be investigated. The present study will be embedded within a randomized clinical trial of the impact of azithromycin on bronchopulmonary function in HIV‐infected children (https://clinicaltrials.gov/ct2/ show/NCT02426112, BREATHE trial). The trial is funded by GLOBVAC, the Norwegian Research council, and organized from the UiT – the Arctic University of Norway, Tromsø. The main aim of the GLOBVAC-funded project is to investigate whether adjuvant treatment with azithromycin results in improvement in lung function in HIV-infected children with CLD on antiretroviral therapy. Results: HIV infected children had significantly lower alpha-diversity and higher beta-diversity compared to HIV uninfected. No association was observed between microbiome diversity and CD4+ T-cell counts, HIV viral load or HIV-associated CLD. We found enriched levels of Corynebacterium (p<0.01), Finegoldia (p<0.01) and Anaerococcus (p<0,01) in HIV infected, and enrichment of Enterobacteriaceae (p=0.02) in participants with low CD4+ counts (<400 cells/mm3). Prolonged ART-treatment (10 years) was significantly associated with a richer gut microbiota by alpha diversity. Conclusion: HIV infected children have altered gut microbiota. Our results suggest that prolonged ART minimize the differences in gut microbiota between HIV infected and uninfected participants. The PhD project goes non with comparison of immunological biomarkers, gut microbioma, and clinical signs and symptoms.

Beskriv samarbeidet med brukerrepresentanten(e) det siste året The participants in the project are children and adolescents. They are defined as users together with their families. The family bonds are strong in this part of the world. The user organizations are not strong, most likely less involved in user participation. Children and adolescents are normally not found in a typically user organization. Therefore, the users in the project are already involved in focus groups through the ongoing BREATHE study were the microbiome study is a substudy. The families have regular contact outpatient clinics where the sampling is implemented, and they have an ongoing discussion with the local project coordinators about the advantages, and possible problems connected to the project. Groups of families are organized locally, and they have very strict information procedures and a voluntary participation agreement, where the children and adolescents can withdraw at any stage of the study

2020
Chronic lung disease (CLD) is the most common manifestation of HIV among children, accounting for more than 50% of HIV-associated mortality ). Though the etiology of CLD in HIV-infected children is not completely understood, chronic inflammation and immune activation may have a distinct role in the development of this chronic condition.Systemic translocation of microbes and microbial products due to HIV-associated damage of the gastrointestinal tract (GIT) is one of the major factors contributing to persistent inflammation in HIV-infected individuals. This process is accompanied by substantial changes in the composition of the gut microbiome, and this may further contribute to disease progression and potentially the development of chronic complications. Systemic translocation of microbes and microbial products due to HIV-associated damage of the gastrointestinal tract (GIT) is one of the major factors contributing to persistent inflammation in HIV-infected individuals. This process is accompanied by substantial changes in the composition of the gut microbiome, and this may further contribute to disease progression and potentially the development of chronic complications. With this study we seek to investigate whether the diversity and composition of the gut microbiome is different among HIV-infected children compared to HIV-uninfected controls and to study the link between the gut microbiome and CLD. In addition, the effect of long-term azithromycin treatment on the gut microbiome will be investigated. The present study will be embedded within a randomized clinical trial of the impact of azithromycin on bronchopulmonary function in HIV‐infected children (https://clinicaltrials.gov/ct2/ show/NCT02426112, BREATHE trial). The trial is funded by GLOBVAC, the Norwegian Research council, and organized from the UiT – the Arctic University of Norway, Tromsø. The main aim of the GLOBVAC-funded project is to investigate whether adjuvant treatment with azithromycin results in improvement in lung function in HIV-infected children with CLD on antiretroviral therapy. Results: HIV infected children had significantly lower alpha-diversity and higher beta-diversity compared to HIV uninfected. No association was observed between microbiome diversity and CD4+ T-cell counts, HIV viral load or HIV-associated CLD. We found enriched levels of Corynebacterium (p<0.01), Finegoldia (p<0.01) and Anaerococcus (p<0,01) in HIV infected, and enrichment of Enterobacteriaceae (p=0.02) in participants with low CD4+ counts (<400 cells/mm3). Prolonged ART-treatment (10 years) was significantly associated with a richer gut microbiota by alpha diversity. Conclusion: HIV infected children have altered gut microbiota. Our results suggest that prolonged ART minimize the differences in gut microbiota between HIV infected and uninfected participants. The PhD prosjcet goes non with comparison of immunological biomarkers, gut microbioma, and clinical signs and symptoms.

The participants in the project are children and adolescents. They are defined as users together with their families. The family bonds are strong in this part of the world. The user organizations are not strong, most likely less involved in user participation. Children and adolescents are normally not found in a typically user organization. Therefore, the users in the project are already involved in focus groups through the ongoing BREATHE study were the microbiome study is a substudy. The families have regular contact outpatient clinics where the sampling is implemented, and they have an ongoing discussion with the local project coordinators about the advantages, and possible problems connected to the project. Groups of families are organized locally, and they have very strict information procedures and a voluntary participation agreement, where the children and adolescents can withdraw at any stage of the study.

Vitenskapelige artikler
Mushunje PK, Dube FS, Olwagen C, Madhi S, Odland JØ, Ferrand RA, Nicol MP, Abotsi RE,

Characterization of bacterial and viral pathogens in the respiratory tract of children with HIV-associated chronic lung disease: a case-control study.

BMC Infect Dis 2024 Jun 26;24(1):637. Epub 2024 jun 26

PMID: 38926682

Flygel TT, Hameiri-Bowen D, Simms V, Rowland-Jones S, Ferrand RA, Bandason T, Yindom LM, Odland JØ, Cavanagh JP, Flaegstad T, Sovershaeva E

Exhaled nitric oxide is associated with inflammatory biomarkers and risk of acute respiratory exacerbations in children with HIV-associated chronic lung disease.

HIV Med 2024 Feb;25(2):223. Epub 2023 okt 7

PMID: 37804064

Hameiri-Bowen D, Yindom LM, Sovershaeva E, Bandason T, Mayini J, M Rehman A, Simms V, Gift Ngwira L, Flagestad T, Jarl Gutteberg T, McHugh G, Abbas Ferrand R, Rowland-Jones SL

"The effect of 48-weeks azithromycin therapy on levels of soluble biomarkers associated with HIV-associated chronic lung disease".

Int Immunopharmacol 2023 Mar;116():109756. Epub 2023 jan 20

PMID: 36682262

Hameiri-Bowen D, Sovershaeva E, Flaegstad T, Gutteberg TJ, Ngwira LG, Simms V, Rehman AM, McHugh G, Bandason T, Ferrand RA, Rowland-Jones S, Yindom LM

Soluble biomarkers associated with chronic lung disease in older children and adolescents with perinatal HIV infection.

AIDS 2021 09 01;35(11):1743-1751.

PMID: 34074817

Ferrand RA, McHugh G, Rehman AM, Mujuru H, Simms V, Majonga ED, Nicol MP, Flaegstad T, Gutteberg TJ, Gonzalez-Martinez C, Corbett EL, Rowland-Jones SL, Kranzer K, Weiss HA, Odland JO,

Effect of Once-Weekly Azithromycin vs Placebo in Children With HIV-Associated Chronic Lung Disease: The BREATHE Randomized Clinical Trial.

JAMA Netw Open 2020 12 01;3(12):e2028484. Epub 2020 des 1

PMID: 33331916

Flygel TT, Sovershaeva E, Claassen-Weitz S, Hjerde E, Mwaikono KS, Odland JØ, Ferrand RA, McHugh G, Gutteberg TJ, Nicol MP, Cavanagh JP, Flægstad T,

Composition of Gut Microbiota of Children and Adolescents With Perinatal Human Immunodeficiency Virus Infection Taking Antiretroviral Therapy in Zimbabwe.

J Infect Dis 2020 01 14;221(3):483-492.

PMID: 31549151 - Inngår i doktorgradsavhandlingen

McHugh G, Rehman AM, Simms V, Gonzalez-Martinez C, Bandason T, Dauya E, Moyo B, Mujuru H, Rylance J, Sovershaeva E, Weiss HA, Kranzer K, Odland J, Ferrand RA,

Chronic lung disease in children and adolescents with HIV: a case-control study.

Trop Med Int Health 2020 05;25(5):590-599. Epub 2020 feb 10

PMID: 31989731

Flygel TT., Hameiri-Bowen D., Simms V., Rowland-Jones S., Ferrand RA., Bandason T., Yindom L-M., Odland JØ., Cavanagh JP., Flægstad T., Sovershaeva E.

Exhaled Nitric Oxide is associated with inflammatory biomarkers and risk of acute respiratory exacerbations in children with HIV-associated chronic lung disease

Submitted

Doktorgrader
Trym Thune Flygel

HIV Infected African Children: Gut microbiota in relation to chronic lung disease and long-term antibiotic treatment

Disputert:
april 2024
Hovedveileder:
Trond Flægstad
Deltagere
  • Jon Øyvind Odland Prosjektleder
  • Trym Thune Flygel Doktorgradsstipendiat
  • Tore Jarl Gutteberg Prosjektdeltaker
  • Jorunn Pauline Cavanagh Prosjektdeltaker
  • Evgeniya Sovershaeva Prosjektdeltaker
  • Erik Hjerde Prosjektdeltaker
  • Rashida Ferrand Prosjektdeltaker
  • Trond Flægstad Prosjektleder

eRapport er utarbeidet av Sølvi Lerfald og Reidar Thorstensen, Regionalt kompetansesenter for klinisk forskning, Helse Vest RHF, og videreutvikles av de fire RHF-ene i fellesskap, med støtte fra Helse Vest IKT

Alle henvendelser rettes til eRapport, Helse Nord

Personvern  -  Informasjonskapsler