Mar, 2022

Determinants of B-Cell Compartment Hyperactivation in European Adolescents Living With Perinatally Acquired HIV-1 After Over 10 Years of Suppressive Therapy


Authors: Ruggiero A, Pascucci G.R, Cotugno N, Domínguez-Rodríguez S, Rinaldi S, Tagarro A, Rojo P, Foster C, Bamford A, De Rossi A, Nastouli E, Klein N, Morrocchi E, Fatou B, Smolen K.K, Ozonoff A, Di Pastena M, Luzuriaga K, Steen H, Giaquinto C, Goulder P, Rossi P, Levy O, Pahwa S, Palma P, the EPIICAL Consortium

Published in: Frontiers in Immunology 


Mar, 2022

The subphenotypes of early-treated children living with HIV-1


Authors: S Domínguez-Rodríguez, A Tagarro, C Foster, P Palma, N Cotugno, AD Rossi, A Dalzini, SG. Pahwa, E Nastouli, K Gärtner, AG Marcelin, P Rossi, C Giaquinto, P Rojo

Presented at: CROI 2022



Subphenotypes have been identified in several heterogeneous diseases. Having a specific subphenotype often has therapeutic implications or impacts disease progression. In this study, we aimed to assess if children with HIV may show subphenotypes according to clinical, virological and immunological features.

We collected data from 40 HIV+ children included in a cross-sectional multicentric study (CARMA Study, EPIICAL Consortium). All children commenced ART <2 years, suppressed (viral load (VL) <50 copies/ml) within 12 months and remained suppressed for >5 years. Immunological and virological assays were performed at a median of 12 years after ART initiation. We collected clinical and sociodemographic data, baseline VL, CD4 and CD8 data, age at ART, HIV DNA reservoir size, cell-associated RNA (CA-RNA), ultrasensitive VL, CD4 subsets (T effector CD25+, activated memory cells, Treg cells ), humoral-specific HIV response (T-bet B cells), innate response (CD56dim NK cells, NKp46+, perforin), exhaustion markers (PD-1, PD-L1, DNAM), CD8 senesence, and biomarkers for T-lymphocyte thymic output (TREC) and endothelial activation (VCAM). To build the subphenotypes, the most informative variables were selected using an unsupervised penalty selection. Hierarchical clustering was performed using Pearson correlation as distance metric and Ward.D2 as clustering method. Internal validation was applied to select the best number of clusters.

Three subphenotypes were revealed (Cluster 1 n=18, 45%; Cluster 2 n=11, 27.5%; Cluster 3 n=11, 27.5%). Cluster 1 (best controllers) consisted of early ART-treated patients with high baseline %CD4, low reservoir size, low WB score, high TREC values, and low VCAM values. In contrast, Cluster 3 (worst controller) consisted of later ART-treated patients with low baseline %CD4, high reservoir size, low TREC values, high innate response, immunosenescence markers and VCAM. Cluster 2 (low-level viremia, altered immune response) consisted of early-treated patients with low-level (10 to 50 c/mL) VL, high reservoir size but low CA-RNA, higher Treg CD4 than in the other clusters, low TREC, weak innate response and lower levels of T-bet expression.

Three subphenotypes with decreasing levels of viral control and increasing levels of immune well-being were discovered. Response to different therapies may be different across the different clusters.

View poster


Mar, 2022

2-year outcome of early treated infants in Sub-Saharan Africa


Authors: A Tagarro, S Domínguez-Rodríguez, L Kuhn, T Nhampossa, K Otwombe, AJv Rensburg, N Klein, MG Lain, AI. Maiga, C Brehin, C Giaquinto, P Rossi, P Rojo

Presented at: CROI 2022



The real-world evolution of very early treated children born with HIV in high-prevalence settings during first years of life is unclear. We assessed the probability of death, progression to AIDS, viral load (VL) suppression, immunosuppression, and continuation in care of a cohort of early treated children born with HIV.

EARTH-EPIICAL Cohort is underway at 2 rural and 4 urban sites in Mozambique, Mali, and South Africa (SA). Infants with HIV who started ART in the first 3 months of life, are followed at 2, 6 and 12 weeks, and then 6-monthly for 4 years. Hereby, we provide the probability of death, progression, suppression and continuation in care during the first 2 years of life with multivariable cox regression models were used. Backward stepwise elimination was applied to reach the final multivariable model.

212 participants were enrolled and followed during a median time of 17 [6.8;27.5] months; 84 reached 2 years of follow-up. ART started at 34 [26;74] days of life, mostly 3TC+ABC+LPV/r (65%). Adherence was suboptimal (<90%) in 56% of visits. 23 patients (10.8%) died, at a median of 2.5 [0.6;6.8] months of age. At 2 years, probability (P) of death was 12% (CI95%,7 to 17), (P) of progression was 11% (CI95%,6 to 16%), (P) of continuation in care, 80% (CI95%,74 to 86%), (P) of VL suppression was 46% (CI95%, 0.34-0.49), and (P) of severe IS, 54% (CI95%, 44 to 62). Death occurred predominantly in the first 6 months (74%); mostly due to pneumonia (43%), malnutrition (13%) or diarrhea (8.7%). (P) of death was associated with baseline VL 2.19 (1.4-3.3), and suboptimal adherence 2.88 (1.18-7.2). (P) of progression was associated with baseline VL 1.71 (CI95%,1.14-2.58), and weight for age 0.53 (CI95%,0.39-0.71). (P) of lost to follow up also was associated with baseline VL (HR, 1.60 (CI95%,1.06-2.40) and weight for age (HR, 1.67 (CI95%,1.11-2.50). (P) of suppression associated with baseline VL (HR, 0.60 (CI95%,0.51-0.71) and CD4% (HR, 1.04, (CI95%,1.01-1.06), p=0.01. (P) of severe IS was associated with baseline VL, (HR, 1.4 (CI95% 1.15-1.69), baseline CD4% (HR, 0.91 (0.88-0.93), baseline weight for age (HR, 0.86 (CI95%, 0.76-0.99), and Mozambique (HR 1.88 (CI95%, 1.16-3.1).

Despite early treatment and a close follow-up, death, progression, and severe IS remain high in children born with HIV in Africa, especially in the 6 first months. Additional strategies are required to improve the care of this population.

View poster


Dec, 2021

Size of HIV-1 reservoir is associated with telomere shortening and immunosenescence in early-treated European children with perinatally acquired HIV-1


Authors: A Dalzini, G Ballin, S Dominguez-Rodriguez, P Rojo , M.R Petrara, C Foster, N Cotugno, A Ruggiero, E Nastouli, N Klein, S Rinaldi, S Pahwa, P Rossi, C Giaquinto, P Palma , A De Rossi1, and on behalf of EPIICAL Consortium

Published in: Journal of the International AIDS Society

View publication


Dec, 2021

Characterisation of the HIV proviral and inducible reservoir in well- suppressed children on long-term ART


Authors: Gärtner K, Byott M, Heaney J, Pagliuzza A, Spyer M.J Frampton D, Rossi A.D, Palmas P, Giaquinto C, Conejo P.R, Foster C,  Rossi P, Klein N, Chomont N, Nastouli E, for the EPIICAL consortium

Presented at: Keystone symposia on molecular and cellular biology

View poster


Jul, 2021

Early ART initiation during infancy preserves natural killer cells in young European adolescents living with HIV (CARMA cohort)


Authors: M Doria, S Zicari, N Cotugno, S Domínguez-Rodríguez, A Ruggiero, GR Pascucci, A Tagarro, PR Conejo, E Nastouli, K Gärtner, M Cameron, B Richardson, Ce Foster, SL Williams, S Rinaldi, AD Rossi, C Giaquinto, P Rossi, S Pahwa, P Palma, for the EPIICAL consortium

Published in: Journal of the International Aids Society



Introduction HIV infection causes pathological changes in the natural killer (NK) cell compartment that can be only partially restored by antiretroviral therapy (ART). We investigated NK cells phenotype and function in children with perinatally acquired HIV (PHIV) and long-term viral control (five years) due to effective ART in a multicentre cross-sectional European study (CARMA, EPIICAL consortium). The impact of age at ART start and viral reservoir was also evaluated.

Methods Peripheral blood mononuclear cells (PBMCs) from 40 PHIV who started ART within two years of life (early treated patients (ET), ≤6 months; late treated patients (LT), > 6 months), with at least five years of HIV-1 suppression (<40 HIV copies/mL), were collected between November 2017 and August 2018. NK phenotype and function were analysed by flow cytometry and transcriptional profile of PBMCs by RNA-Seq. HIV-1 DNA was measured by real-time polymerase chain reaction (Data were analysed by Spearman correlation plots and multivariable Poisson regression model (adjusted for baseline %CD4 and RNA HIV viral load and for age at ART start as an interaction term, either ET or LT) to explore the association between NK cell parameters and HIV reservoir modulated by age at ART start.

Results A significantly higher frequency of CD56neg NK cells was found in LT compared with ET. We further found in LT a positive correlation of CD56neg NK cells with HIV-1 DNA. LT also displayed increased expression of the NKG2D and NKp46 activating receptors and perforin compared with ET. Moreover, CD107a+ and IFN-γ+ frequencies in non-stimulated NK were associated with HIV-1 DNA in LT patients. Finally, RNA-Seq analysis showed in LT an up-regulation of genes related to NK-activating pathways and susceptibility to apoptosis compared with ET.

Conclusions We show that early initiation of ART during infancy preserves the NK compartment and is associated with lower HIV-1 reservoir. Such condition persists over adolescence due to long-term viral control achieved through effective ART.

Read full article


Jul, 2020

The CARMA study: early infant antiretroviral therapy—Timing impacts on total HIV-1 DNA quantitation 12 years later

Tags: ,

Authors: Foster C, Domínguez-Rodríguez S, Tagarro A, et al. For the Early Treated Perinatally HIV Infected Individuals: Improving Children’s Actual Life (EPIICAL) Consortium

Published in: J Pediatr Infect Dis Soc. 2020 2020 Jul 17;piaa071

Background Strategies aimed at antiretroviral therapy (ART)–free remission will target individuals with a limited viral reser- voir. We investigated factors associated with low reservoir measured as total human immunodeficiency virus type 1 (HIV-1) DNA in peripheral blood mononuclear cells (PBMCs) in perinatal infection (PaHIV).

Methods Children from 7 European centers in the Early Treated Perinatally HIV Infected Individuals: Improving Children’s Actual Life (EPIICAL) consortium who commenced ART aged <2 years, and remained suppressed (viral load [VL] <50 copies/mL) for >5 years were included. Total HIV-1 DNA was measured by quantitative polymerase chain reaction per million PBMCs. Factors associated with total HIV-1 DNA were analyzed using generalized additive models. Age, VL at ART initiation, and baseline CD4% effects were tested including smoothing splines to test nonlinear association.

Results Forty PaHIV, 27 (67.5%) female 21 (52.5%) Black/Black African, had total HIV-1 DNA measured; median 12 (IQR, 7.3– 15.4) years after ART initiation. Eleven had total HIV-1 DNA <10 copies/106 PBMCs. HIV-1 DNA levels were positively associated with age and VL at ART initiation, baseline CD4%, and Western blot antibody score. Age at ART initiation presented a linear associ- ation (coefficient = 0.10 ± 0.001, P ≤ .001), the effect of VL (coefficient = 0.35 ± 0.1, P ≤ .001) noticeable >6 logs. The effect of CD4% (coefficient = 0.03 ± 0.01, P = .049) was not maintained >40%.

Conclusions In this PaHIV cohort, reduced total HIV-1 DNA levels were associated with younger age and lower VL at ART initiation. The impact of early-infant treatment on reservoir size persists after a decade of suppressive therapy.



Jul, 2020

The size of HIV reservoir is associated with telomere shortening and immunosenescence in early ART-treated HIV-infected children


Authors: De Rossi A, Dalzini A, Ballin G, Dominguez-Rodriuguez S, Rojo P, Foster C, Palma P, Sessa L, Nastouli E, Pahwa S, Rossi P, Giaquinto C, EPIICAL Consortium

Published in: 23rd International AIDS Conference, July 6th-10th, 2020

Background: HIV infection is linked to premature senescence, with increased risk of aging-associated illnesses. Early ART has been associated with a reduced HIV reservoir in HIV-perinatally infected children (PHIV), but its impact on the senescence process is an open question. Telomeres are critical for cellular replicative potential and their shortening is a marker of cellular senescence and aging process. We investigated the relationship between immunosenescence and HIV reservoir in PHIV enrolled in a multicenter cross-sectional study (CARMA, EPIICAL consortium).

Methods: 37 PHIV, who started ART <2 years of age and had undetectable viremia for at least 5 years, were enrolled in this study. HIV-DNA copies on CD4 cells and relative telomere length and levels of T-cell receptor rearrangement excision circle (TREC, marker of thymic output) on CD4 and CD8 cells were quantified by qPCR. Senescent and activated CD4 and CD8 cells were estimated by flow cytometry. To explore the associations between cellular parameters, HIV reservoir and age at ART initiation, data were analyzed using a multivariable Poisson regression (adjusted for baseline % CD4, plasmaviremia, age at reservoir measurement, and age at ART initiation as interaction term).

Results: HIV reservoir was significantly (p<0.001) associated with immunosenescence (1.23[1.21-1.26]) and telomere shortening (0.15[0.13-0.17]) in CD4 cells, and immune activation (3.67[3.49-3.85]) and TREC levels (1.08[1.06-1.11]) in CD8 cells. These associations decreased by 1%, 10%, 6% and 6%, respectively, for each month ART was delayed. Early treated PHIV (ART initiation ≤6 months of age) displayed significantly lower HIV-DNA level (89[56-365] vs 552[303-1001] copies/106 cells)  and % CD4 senescent cells (1.0[0.5-2.7] vs 2.9[2.0-6.3]) than late treated ones.



Jul, 2020

Aging B-cells (ABC) and anti-Env humoral responses are associated with T-bet expression in B-cells of perinatally HIV infected children (PHIV) treated within 24 months (m) of life (the CARMA cohort)


Authors: Ruggiero A, Cotugno N, Domínguez-Rodríguez S,  Zicari S, Rinaldi S, Zangari P, Tagarro A, Foster C, De Rossi A, Nastouli E, Luzuriaga K, Giaquinto C, Rossi P, Pawha S, Palma P, on behalf of the EPIICAL consortium.

Published in: 23rd Virtual International AIDS Conference, July 6th-10th, 2020

Background The role of T-bet, an immune factor involved in adaptative and innate response, has been poorly explored in B-cells. Previous studies concentrated on HIV+ and HIV- adults and T-bet was found to be associated with ABC. This work characterizes T-bet expression in B-cell (CD19+CD10-) subsets associated with aging (activated memory AM CD21-CD27+, Tissue Like Memory TLM CD21-CD27- and Double Negative DN CD27-IgD-) and with immunological memory (Resting Memory, RM CD27+CD21+IgD-) in PHIV.

Methods We studied 40 PHIV starting ART at median 4m of age (min 0m, max 22m) and ART-suppressed for >5 years (median 14 years (y) (min 5y, max 22y). Flow Cytometry was used to define B-cell phenotype and intracellular T-bet (MFI) in PHIV and in 20 age and gender-matched controls (HC). Anti-HIV serology was measured using Western blot and ELISA. Comparisons were analysed using Mann-Whitney test (MW). Associations were explored using Spearman test (rho, p) and multivariable ridge Poisson Regression model including baseline CD4, gender, and age at ART as confounders.

Results DN were expanded in PHIV compared with HC (p=0.01 MW). T-bet levels were elevated in AM, TLM and marginally DN compared to the others.  The models demonstrated a strong association between T-bet levels and time of ART start: for each month without ART T-bet increased by 3% and 2% in DN and AM, respectively (Fig.1a). Anti-Env responses were positively associated and were identified as predictors of T-bet levels in IgG+ B-cells (rho=0.35, p=0.03, Fig 1b), IgM+ B-cells (rho=0.39, p=0.01), RM IgM+ (rho=0.33, p=0.042).

Conclusions ABC are expanded in PHIV compared with HC, despite suppressive ART. Earlier ART-start preserves from premature aging of B-cell compartment. Furthermore, elevated levels of T-bet in memory B-cells was associated with anti-Env responses. Our findings add onto the previous literature by suggesting a role of T-bet in the anti-HIV B-cell response that warrant further investigation.




Jul, 2020

A machine learning approach for predicting probability of death or disease progression in an early-treated pediatric African cohort


Authors: Domínguez-Rodríguez S, Tagarro A, Serna Pascual M, Otwombe K, Violari A, Fernández S, Nhampossa T, Lain M,  Vaz P , Behuhuma NO, Danaviah S, Dobbels E, Barnabas S, Cotugno N, Zangari P, Palma P, Oletto A,  Nardone A, Nastouli E, Spyer M, Kuhn L, Rossi P, Giaquinto C, Rojo P on behalf of EPIICAL consortium.

Published in: 23rd international AIDS Conference, July 6th-10th 2020

Background In perinatally HIV infected children, mortality and morbidity are highest in the first months after ART initiation and is linked to advanced disease and late diagnosis. The random forest approach can deal with more predictors than classical models and has no model assumptions such as normality, linearity or hazard proportionality. The aim of this study was to predict the probability of death or clinical progression at a specific time of follow-up.

Methods EARTH (EPIICAL consortium) is an African multi-centre cohort enrolling HIV-infected infants treated within 3 months of life (n=151). A total of 134 infants with >1 follow-up visit were included in this analysis. The primary endpoint was the right-censored time to death or progression to AIDS. To predict the outcome, a log-rank random survival forest with imbalance correction was performed in a training subset (n=95, 70%). The algorithm was validated on the remaining 30% (n=39).

Results A total of 22 infants reached the primary endpoint with 13 (10%) patients dead and 9 (7%) with an AIDS defining condition. A total of 10000 trees were built with an error rate of 20%. The most important predictors of reaching the primary endpoint were baseline HIV viral load, age at diagnosis, weight-for-age, gender, age at ART initiation, and baseline CD4 count. In the validation, the model predicted a higher probability of reaching the primary endpoint among children who did indeed die or progress to AIDS, as compared to the group of children who did well (1-month: 14% vs. 0.01%, p-value=0.045; 6-months: 62% vs. 0.03%, p-value=0.019; 12-months: 76% vs. 16%, p-value=0.012). The AUC for predicting survival or progression was 0.83, 0.84, and 0.72 for 1-month, 6-months, and 1-year respectively.

Conclusions This model helps clinicians individualize the probability of death or progression to AIDS at time of diagnosis and may be useful for the early identification of high-risk patients.


We would like to update you on our recent activities