534

CONCISE COMMUNICATIONS

Association of Plasma Levels of Human Immunodeficiency Virus Type 1 RNA

and Oropharyngeal Candida Colonization
Magnús Gottfredsson, Gary M. Cox, Department of Medicine, Division of Infectious Diseases
Ólafur S. Indridason, Gisele M. D. de Almeida,a and International Health and Nephrology, Duke University Medical
Alison E. Heald, and John R. Perfect Center, Durham, North Carolina

The pathophysiology of oropharyngeal candidiasis in patients infected with human im-

munodeficiency virus (HIV) type 1 is poorly understood. Association between oropharyngeal
yeast carriage and various clinical factors in HIV-1–infected patients was studied in 83 patients

Downloaded from http://jid.oxfordjournals.org/ at University of North Dakota on June 2, 2015

with no clinical evidence of thrush and no recent antifungal use. Of the clinical factors mea-
sured, the only correlate of yeast colonization was with plasma HIV-1 RNA levels (P 5
.001), whereas the correlation with CD4 cell count was poor (P 5 .36). By multivariable
regression modeling, plasma HIV-1 RNA was the only parameter that correlated with the
extent of colonization with Candida infection (P 5 .003 ). These data indicate that the presence
and amount of asymptomatic oropharyngeal yeast carriage in persons with HIV-1 infection
is more significantly correlated with plasma HIV-1 RNA levels than with CD4 cell count.
Further studies on the effect of HIV-1 on oropharyngeal yeast colonization, infection, and
local immunity are warranted.

Oropharyngeal candidiasis (OPC), primarily caused by Can- 1–infected persons [5]. It is likely that most of the decrease in
dida albicans, is relatively common in persons infected with the prevalence of opportunistic infections is due to improve-
human immunodeficiency virus (HIV) type 1. The point prev- ments in immune function in patients who receive highly active
alence of OPC in HIV-1–infected persons is 2.2%–7%, and the antiretroviral therapy (HAART) [6]. The improvements in im-
lifetime risk is 190% [1]. The presence of OPC is a predictor mune function in patients responding to HAART are incom-
of poor outcome in HIV-1–infected persons [2]. A statistical pletely understood. They do not appear to be solely reflected
association exists between few CD4 cells and the development by increases in numbers of CD4 lymphocytes, since the rise in
of OPC, but this association is weak [1, 3]. In fact, some HIV- CD4 cells in patients responding to HAART lags behind other
1–infected persons with relatively high CD4 cell counts can have qualitative and quantitative measures of immunity [5].
In order to improve our understanding of how carriage of
OPC, as can some persons with acute HIV-1 infection syndrome
yeast in the oropharynx is determined in HIV-1 disease, we
[4]. Thus, the pathophysiology of OPC remains poorly under-
conducted a cross-sectional study of several clinical factors and
stood, and factors that probably play a role in this disease are
their association with yeast colonization. Our hypothesis was
yet unidentified.
that the presence and amount of yeasts would be correlated
Recent experience suggests that the prevalence of most op-
with both plasma HIV-1 RNA levels (viral load) and peripheral
portunistic infections, including OPC, are declining in HIV-
blood CD4 lymphocyte counts. Furthermore, of these two po-
tential predictors, we believed that plasma HIV-1 RNA would
Received 23 November 1998; revised 8 April 1999; electronically published most closely correlate with yeast colonization.
9 July 1999.
Presented in part: 12th World AIDS Conference, Geneva, June–July 1998
(abstract 22214).
Informed consent was obtained from all patients prior to study partici- Materials and Methods
pation, in compliance with human experimentation guidelines of the US
Department of Health and Human Services. The study was approved by
the Duke Institutional Review Board Committee.
Study design. This cross-sectional study was conducted in an
Grant support: NATO science fellowship (to M.G.). academic medical center outpatient clinic. Baseline clinical varia-
a
Present affiliation: Hospital das Clı́nicas da Faculdade de Medicina da bles and laboratory data were collected prospectively. This clinic
Universidade de São Paulo, Brazil. provides care for 11000 HIV-1–infected patients and serves as the
Reprints or correspondence: Dr. John R. Perfect, Dept. of Medicine,
primary care provider for the vast majority of its patients.
Division of Infectious Diseases and International Health, P.O. Box 3353,
Duke University Medical Center, Durham, NC 27710 ([email protected] Patient evaluations. At enrollment, the study subjects were
.edu). interviewed and examined and asked to swish 20 mL of 0.9% sterile
saline in their mouths for 15 s and to collect the contents into a
The Journal of Infectious Diseases 1999; 180:534–7
q 1999 by the Infectious Diseases Society of America. All rights reserved. sterile container. Subsequently, 1 mL was plated onto CHROM-
0022-1899/99/8002-0042$02.00 agar (Hardy Diagnostics, Santa Maria, CA). After the plates were
JID 1999;180 (August) HIV-1 RNA and Candida Colonization 535

incubated at 307C for 48 h, growth on the plates was quantitated, parametric correlation coefficient. Bivariate and multivariable lo-
and the Candida load was expressed as colony-forming units (cfu) gistic regression analyses were then used to assess these relation-
per milliliter. If a dense growth of yeast was noted after 24 h of ships further. Poisson regression analysis was performed by use of
incubation, the culture was diluted 10-fold and replated. Colonies Candida load as the dependent variable in both bivariate and mul-
with the diagnostic green appearance were assumed to be C. al- tivariable analyses. For the Poisson regression analysis, the Can-
bicans; all other organisms were speciated by use of standard dida load was categorized as follows: no growth, 1–50 cfu/mL,
growth and morphologic criteria as well as sugar assimilation pro- 51–200 cfu/mL, 201–500 cfu/mL, 501–1500 cfu/mL, and 11500 cfu/
files (API 20; BioMerieux, Hazelwood, MO). All enrolled patients mL. Goodness-of-fit was evaluated by Pearson’s x2 test for each
had recent HIV-1 RNA and CD4 cell measurements (!30 days for model, as well as by residual plots. One outlier was identified (1533
plasma HIV-1 RNA and !90 days for CD4 cell count) CD4 cells/mL, CD4/CD8 ratio of 1.13, Candida load !25); this
while on a stable antiretroviral regimen. Most of the patients (64/ subject was influential in the models in which CD4 cell count was
83) had plasma HIV-1 RNA determined by reverse transcriptase– used as an independent variable. Since no other data points were
polymerase chain reaction (Roche Diagnostics, Alameda, CA) and in this range, we chose to delete this subject from the final analysis.
CD4 lymphocyte counts determined by flow cytometry on the same Statistical analysis was performed by use of SAS software (SAS

Downloaded from http://jid.oxfordjournals.org/ at University of North Dakota on June 2, 2015

day that the culture was obtained. The following exclusion criteria Institute, Cary, NC).
were used: topical or systemic antifungal use within 30 days, clinical
evidence of OPC, poor dentition, oral prosthetic devices, including
dentures, and use of antibacterial agents other than those used for
Results
Pneumocystis carinii pneumonia (PCP) prophylaxis within 30 days.
Over an 8-month period, 83 patients were enrolled in the study. Patient characteristics. Characteristics of the 83 patients
Data on patient demographics, history of prior fungal infections, enrolled in the study are shown in table 1. In all, 58 (70%) were
antifungal treatment, and medications at the time of enrollment
colonized with yeast. The only 2 yeast species cultured were C.
were collected (table 1).
albicans (55 isolates) and C. glabrata (5 isolates); 56 patients
Statistical methods. Prior to data analysis, 5 variables were
identified as likely to be related to oropharyngeal colonization with had a single species isolated.
Candida organisms: CD4 lymphocyte counts, plasma HIV-1 RNA Association between amount of oropharyngeal Candida and
levels, history of prior fungal infections, number of antiretroviral plasma HIV-1 RNA. The relationships between colonization
agents, and PCP prophylaxis. The association of these factors with with Candida species and previously identified clinical and lab-
oropharyngeal Candida species was calculated by Spearman’s non- oratory parameters were analyzed by use of Spearman’s cor-

Table 1. Characteristics of the 83 patients participating in the study.

Colonized Not colonized
Parameter n 5 58 (%) n 5 25 (%)
Age (years), median 34 (range, 19–63) 35 (range, 27–77)
Sex
Women 25 (43) 10 (40)
Men 33 (57) 15 (60)
Pneumocystis carinii prophylaxis
Yes 17 (29) 8 (32)
No 41 (71) 17 (68)
Previous history of fungal infection
Yes 21 (36) 6 (24)
No 37 (64) 19 (76)
Current use of antiretroviral agents
Yes 42 (72) 20 (80)
No 16 (23) 5 (20)
No. of antiretroviral agents
0 16 (28) 5 (20)
1 0 (0) 1 (4)
2 13 (22) 5 (20)
3 25 (43) 14 (56)
13 4 (7) 0 (0)
Protease inhibitors 28 (48) 13 (52)
CD4 cells/mL, median 382 (range, 7–860) 381 (range, 44–876)
Plasma HIV-1 RNA (copies/mL), median 5378 (range, 76–553,090) 1298 (range, 90–100,385)
Log10 HIV-1 RNA, median 3.73 3.10
Colonization with Candida albicans 55/58 (95) 0
a
Colonization with Candida, non-albicans 5/58 (9) 0
Candida load (cfu/mL), median 60 (range, 1–1832) 0
NOTE. Data are median (range) for continuous variabled and no. of patients (%) for categorical
variables. Cfu, colony-forming units.
a
Nos. 1100% because 2 patients had mixed colonization.
536 Gottfredsson et al. JID 1999;180 (August)

relation coefficients. As shown in table 2, the only predictor of in the incidence of opportunistic infections in HIV-1–infected
Candida load was plasma HIV-1 RNA (r 5 .35, P 5 .001). persons receiving HAART suggests, however, that partial re-
When only the 58 patients who were colonized with yeasts were constitution of the immune system can result from retroviral
analyzed, the correlation with HIV-1 RNA was even stronger, suppression. We hypothesized that the yeast carriage in patients
and no other potential predictors reached statistical significance with HIV-1 infection was more closely associated with the level
(data not shown). Numbers of yeasts in the oropharynx were of retroviral replication and its effects on mucosal immunity
generally low in patients with a plasma HIV-1 RNA of !4 log10 rather than on peripheral blood CD4 lymphocyte counts. This
copies/mL, but counts rose steeply in persons with higher HIV- hypothesis was based on several observations. Some patients
1 loads (14 log10 copies/mL). can have OPC during acute HIV-1 infection syndrome, when
By bivariate logistic regression analysis, the presence of Can- virus load measurements are generally very high and CD4 cells
dida species in the oropharynx was associated with higher HIV- are usually relatively preserved [4]. Furthermore, antiretroviral
1 loads (odds ratio, 1.9 for each 1 log10 HIV-1 RNA increase; monotherapy is associated with a significant reduction in OPC,
95% confidence interval, 1.12–3.09; P 5 .016). No other patient despite minimal effects on CD4 cell counts [8]. In addition,

Downloaded from http://jid.oxfordjournals.org/ at University of North Dakota on June 2, 2015

factors, including CD4 cell count, use of PCP prophylaxis, his- recent reports showed resolution of oropharyngeal thrush after
tory of fungal infection, and number of antiretroviral agents, initiation of HAART [9, 10], even though CD4 lymphocyte
were significantly associated with yeast carriage, by multivariate counts remained low (!140 cells/mL) in all patients at the time
logistic regression (data not shown). that infection resolved [10].
Statistical modeling. After categorization of the Candida Prior to the era of HAART, the presence of yeast in HIV-
load into 6 different categories, as described in Materials and 1–infected patients predicted subsequent development of OPC
Methods, bivariate Poisson regression analysis showed that [3]. We conducted this cross-sectional study to determine
HIV-1 RNA level was the only variable significantly associated whether oropharyngeal carriage of yeast was correlated more
with Candida load (P 5 .003). Addition of other parameters to strongly with HIV-1 load than with peripheral CD4 cells. As
the model did not alter the relationship between Candida load shown in table 2, we found that the quantity of yeasts in the
and HIV-1 load (data not shown). A final model using 5 var- oropharynx was significantly associated with the level of HIV-
iables revealed HIV-1 RNA as the single significant predictor 1 RNA levels but not with the number of CD4 cells. In fact,
(P ! .001 ) of the presence and amount of Candida species in the HIV-1 load measurement was the only significantly asso-
the oropharynx (table 2). This model had good statistical fit
ciated variable among those tested. We tried to eliminate factors
(Pearson’s x2, 0.97).
that may influence the oropharyngeal cultures by excluding
persons with recent antifungal use and those who used dentures.
We also looked for correlates between the presence of yeast
Discussion
and factors such as age, sex, history of fungal infections, use
In this study, 70% of the patients were colonized with yeast, of PCP prophylaxis, and the number of antiretroviral agents
which is similar to findings studied for asymptomatic HIV-1– that the patients were receiving at the time of culture. However,
infected patients by other investigators [7]. The recent decrease none of these factors had a significant association with the

Table 2. Spearman’s rank correlation coefficients between yeast colonization

(log10 cfu/mL) and demographic and laboratory results of 83 patients, and
final model (Poisson regression modeling) using five variables to predict Can-
dida colonization.
Spearman’s rank Parameter
Parameter correlation coefficient estimate P
Spearman’s rank correlation coefficient
Age (years) 20.05 .67
Sex 0.02 .83
PCP prophylaxis 0.11 .34
History of fungal infection 0.15 .18
Any antiretroviral therapy 20.04 .75
No. of antiretroviral agents 20.10 .35
CD4 cells/mL 20.10 .36
HIV-1 RNA (log10 copies/mL) 0.35 .001
Poisson modeling
HIV RNA (log10 copies/mL) 0.409 !.001
CD4 cells/mL !.001 .27
History of previous fungal infection 0.142 .49
PCP prophylaxis 0.279 .24
No. of antiretroviral agents 0.029 .71
NOTE. Scaled Pearson’s x2 for Poisson model was 0.97. PCP, Pneumocystis carinii
pneumonia.
JID 1999;180 (August) HIV-1 RNA and Candida Colonization 537

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