HAART联合中药对云南省两县HIV/AIDS患者的干预作用
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摘要
目的：目前艾滋病流行态势依然严峻,HAART在治疗艾滋病上取得了巨大成就,但依存在局限性。临床实践表明中医药在治疗艾滋病有一定的效果,那么中医药介入艾滋病治疗的切入点何在?本文试图对"HAART持续治疗中中药治疗HIV/AIDS的切入点何在,有何优势和特点”这一问题进行初步探讨,发现HAART联合中药治疗HIV/AIDS的优势和可能作用靶点,解决HAART持续治疗过程中中药介入的关键问题。为中药治疗艾滋病研究提供思路,为阐释中药治疗HIV/AIDS的作用靶点和机制提供借鉴。为临床上更好的利用HAART联合中药的特点和优势改善HIV./AIDS患者的生活质量和延长生命提供科学依据。
方法：
首先,对云南省两县免费抗病毒治疗数据库进行回顾性研究,从HAART治疗临床证据中发现和找到中医药艾滋病治疗的切入点。探讨HAART后60个月随访过程中CD4+T细胞、CD8+T细胞、HIV-1病毒载量、血液生化免疫等指标的变化规律,运用一般线性模型多元方差分析HAART后影响CD4+T细胞恢复的影响因素,运用Kaplan-Meier检验分析HAART后发生死亡的危险因素。
其次,探讨HIV-1RNA被有效抑制下HIV/AIDS患者的T细胞亚群、HAART持续时间、HIV-1前病毒DNA三者之间的相关性,发现HAART后HIV-1前病毒DNA存在的特点以及和T细胞亚群的关系。
最后,对HIV-1RNA被有效抑制的HIV/AIDS患者进行12个月随机双盲试验,探讨HAART联合中药和HAART+安慰剂干预后免疫细胞、HIV-1前病毒DNA env、gag、pol基因相对表达量等指标的变化规律。发现HAART联合中药进行HIV/AIDS治疗的可能优势和可能的作用靶点。
结果：
1、对云南省腾冲、祥云免费抗病治疗数据库进行回顾性研究,研究发现：CD4+T细胞基线水平越高越有利于HAART后CD4+T细胞恢复和降低死亡率,HAART后24月CD4+T细胞恢复数量进入了平台期。HAART后HIV/AIDS患者免疫重建不全,部分患者病毒抑制不完全。HIV/AIDS患者在HAART治疗前、后出现不同程度的血液、肝肾、脂质代谢异常。
(1) HAART开始后0月至12月CD4+T细胞中位数增加最快；24月后CD4+T细胞恢复进入了平台期。在60个月随访过程中CD4+T细胞基线≥200个/μl的HIV/AIDS患者的CD4+T细胞中位数比CD4+T细胞基线<200个/μl组的患者高(P<0.05)。
(2)CD8+T细胞中位数在HAART后随访60个月过程中没有明显的增加或减少, CD4+T细胞基线<200个/μl和CD4+T细胞基线≥200个/μl两组的患者仅在24月、42月的差异有显著性意义外(P<0.05),其余各时间点没有差异。
(3) HAART后60个月随访过程中CD4+T细胞中位数恢复至500个/μl的百分比均低于25%,在第60个月恢复至350个/μl的百分比达到最高为62.5%。在各随访时间点CD4+T细胞基线<200个/μl组和CD4+T细胞基线≥200个/μl两组CD4+T细胞中位数恢复至350个/μl的百分比的差异有显著性意义(P<0.05),除51、54月外两组CD4+T细胞恢复至500个/μl的百分比的差异均有显著性意义(P<0.05)。
(4) HIV/AIDS患者HAART后6个月HIV-1RNA被抑制至检测限(50拷贝/ml)以下的百分比为74.4%。HAART第48个月全部患者的HIV RNA被抑制至检测限以下。CD4+T细胞基线<200个/μl和CD4+T细胞基线≥200个/μl两组的HIV RNA被抑制至检测限的百分比的差异的无显著性意义(P>0.05)。
(5)性别、CD4+T细胞基线、HIV-1RNA基线、WHO HIV感染临床分期是影响HAART治疗的CD4+T细胞恢复数量的因素(P<0.05),年龄、CD8+T细胞基线,HIV-1感染途径、是否合并HBV、HCV感染对HAART后CD4+T细胞恢复没有影响(P>0.05)。
(6)CD4+T细胞基线<100个/μl、100-199个/μl、200-299个/μl、>300个/μl各组之间生存率的差异有显著性意义(P=0.002)。WHO HIV感染临床分期、年龄是HAART后死亡的风险因素。WHO HIV感染临床分期每增加一个等级,死亡风险增加3.464倍,HAART开始时年龄超过50岁的死亡风险是HAART开始时年龄小于50岁的3.114倍。感染途径和HAART持续时间是死亡的保护因素,异性传播及其他的死亡风险是静脉吸毒的15.9%,HAART持续时间超过12月的死亡风险是HAART持续时间小于12月的7.8%。
(7) HAART后随访过程中血液指标的表现为：白细胞计数异常百分比无明显下降,接近100%；总淋巴计数异常百分比有下降趋势；血小板异常百分比有下降趋势,血小板小于正常值的百分比呈下降趋势；血红蛋白呈缓慢上升趋势,小于正常值的百分比呈下降趋势,大于正常值的百分比呈上升趋势。
(8) HAART后60个月的随访过程中生化免疫指标出现不同程度异常,表现在：血肌酐小于正常值的百分比逐渐上升,大于正常值的百分比逐渐下降；血尿素氮异常百分比没有下降趋势,最低为94.4%；甘油三酯异常百分比呈逐渐上升趋势；总胆固醇异常百分比呈逐渐上升趋势；血淀粉酶异常比在变化趋势不明；天冬氨酸转移酶和谷氨酸转移酶大于正常值的百分比呈逐渐下降趋势；总胆红素异常百分比无明显的变化趋势。
2、对HIV-1RNA被有效抑制下HIV/AIDS患者的T细胞亚群、]HAART持续时间、HIV-1前病毒DNA三者之间的相关性进行研究,研究发现：HIV-1RNA被有效抑制下时HAART持续时间与某些T细胞亚群细胞数量相关,长时间HAART治疗后HIV-1前病毒DNA仍稳定持续存在。
(1) HAART持续治疗时间与CD4+CD28+、CD4+CD45RA+、CD4+CD45RO+T细胞绝对计数呈正相关。
(2) HAART持续治疗时间与CD38+T细胞相对计数呈正相关性,与CD3+、CD8+CD38+、CD8+T细胞相对计数呈负相关。
(3)CD4+细胞绝对计数与CD4+CD28+、CD4+CD45RO+T细胞相对计数呈正相关,与CD8+CD38+表达比例呈负相关。
(4)HIV-1前病毒DNA的相对表达量与CD4+CD45RA+T细胞绝对计数呈负相关,与CD4+CD45RA+T细胞相对计数呈正相关(P<0.05),与CD38+T细胞绝对计数呈正相关(P<0.05)。
(5)HIV-1前病毒DNA相对表达量与HAART持续治疗时间无相关性(R=0.108,P=0.310)。
3、对HIV-1RNA被有效抑制的HIV/AIDS患者进行随机双盲试验,研究发现：HAART联合中药(康爱保生浓缩丸)能持续提高HIV-1RNA被有效抑制下但CD4+T细胞基线仍<200个/μl的HIV/AIDS患者的CD4+T细胞数量,推迟CD4+T细胞恢复进入平台期的时间；提高NK细胞数量,对HIV-1前病毒DNA pol基因可能有一定程度的抑制作用。
(1)在12个月各随访时间点HAART联合中药(康爱保生浓缩丸)和HAART+安慰剂的CD4+T细胞绝对计数的差异无显著性意义(P>0.05),在第12月时HAART联合中药的CD4+T细胞绝对计数高于HAART+安慰剂组的。
(2)在第3月时HAART+安慰剂和HAART联合中药(康爱保生浓缩丸)的CD4+T细胞、CD4+CD45RO+T细胞相对计数的差异有显著性意义(P=0.029,P=0.028),在第6月时两组的CD8+CD38+T细胞相对计数的差异有显著性意义(P=0.029)。
(3)HAART+安慰剂和HAART联合中药(康爱保生浓缩丸)的NK细胞绝对计数总体逐渐增长,在第12月时两组的NK细胞绝对计数细胞绝对计数的差异有显著性意义(P=0.032)。
(4)在各随访时间点HAART+安慰剂和HAART联合中药(康爱保生浓缩丸)的细胞因子IL-2、IL-10的差异无显著性意义(P>0.05)。
(5)入组时CD4+T细胞基线<200个/μl层：HAART联合康爱保生浓缩丸治疗HIV/AIDS患者在第6个月后的CD4+T细胞绝对计数增长趋势比HAART+安慰剂组明显。
(6)第3月时HAART+安慰剂和HAART联合中药组的HIV-1前病毒DNA pol基因相对表达值的差异有显著性意义(P<0.050)。入组时CD4+T细胞基线<200个/μl的HIV/AIDS患者在HAART+康爱保生丸治疗后第3个月的HIV前病毒DNA pol基因相对表达量显著低于HAART+安慰剂组(P<0.05)。
结论：
1、中医药进行艾滋病治疗可以从以下几个方面作为切入点：HAART后HIV/AIDS患者免疫重建不全和病毒抑制不完全；HIV/AIDS患者在疾病进程中出现和HAART治疗后出现不同程度的血液、肝肾、脂质代谢异常；对HIV-1RNA被有效抑制的情况下的HIV-1前病毒DNA进行干预。
2、HIV-1前病毒DNA持续存在,长期HAART不能降低HIV-1前病毒DNA表达量,CD4+T细胞数量与HIV-1前病毒DNA表达量无关。
3、HAART联合中药对HAART后HIV-1RNA被有效抑制下、CD4+T细胞<200个/μl的HIV/AIDS患者可能有优势,中医药临床治疗艾滋病作用缓慢、存在一定的不稳定因素,但能对多个作用靶点发挥作用,因此应从多角度进行中医药治疗艾滋病的作用靶点和机制研究。
Objective:At present, the AIDS epidemic situation is still grim, HAART has made great achievements, despite limitations still existed. It was proved that effect of traditional Chinese medicine (TCM) in the treatment of AIDS. What aspects we can treat AIDS by traditional Chinese medicine? What are the advantages of TCM treatment of AIDS? What effects of HAART combined with traditional Chinese medicine on HIV-1proviral DNA of HIV/AIDS individuals with HIV-1RNA suppressed? In this paper, we found fields TCM treatment of AIDS from HAART treatment database of Yunnan province. The change of immune cells and relative counts of HIV-1pro virus DNA through Randomized double-blind trial of HAART combined with TCM.
Methods:
First, the databases of HAART of Tengchong and Xiangyun counties were reviewed, including CD4+T cell counts, CD8+T cell counts, copies of HIV-1load, and et al. The general linear model multivariate analysis was applied for investigated the factors of recovery of CD4+T cell counts. T the risk factors of death after HAART were analyzed by the Kaplan-Meier analysis.
Second, we explored correlation between T absolute count and duration time of HAART and correlation between T cell and HIV-1proviral DNA in AIDS individuals with persistently undetectable plasma HIV-1RNA levels.
Finally, copies of env, gag, pol gene of HIV-1proviral DNA were simultaneously detected by GeXP multiple genetic analysis system, the average copies of3structural genes as copies of HIV-1previous DNA, thereby, the effect of HIV-1proviral DNA by HAART combined with TCM was researched.
Results:
1. The databases of HAART of Tengchong and Xiangyun counties were reviewed, we found:
(1) The median CD4+T cell count increased to287cells/μl (interquartile range,204-378cells/μl) among patients with a baseline CD4+T cell count<200cells/μl, to513cells/μl (interquartile range,469-522cells/μl) among those with a baseline CD4+T cell count>200cells/μ, the median CD4+T cell count were statistically higher in the≥200cells/μl group during the follow-up except at51months (P＜0.05), the significant increases of CD4+T cell count were seen in the first12months in each group, until24months it reached plateau.
(2) It weren't that the median CD8+T cell count hadn't significantly increase or decrease in all patients included or different groups.The median CD8+T cell count were statistically lower in the≥200cells/μl group than CD4+T cell count<200cells/μl group during the follow-up except in24and42months(P<0.05).
(3) The percentage of all patients who achieved a CD4+T cell count500cells/μl low25%, or350cells/μl after receiving60months of HAART were62.5%. The percentage who reached CD4+T cell count of500cells/μl were significant difference between CD4+T cell count<200cells/μl and CD4+T cell count≥200cells/μl groups except45months and54months (P＜0.05), and the percentage who reached CD4+T cell count of350cells/μl were significant difference between groups divided by baseline CD4+T cell count.
(4) After60months HAART initiation, the percentage of HIV-1RNA under50copies/ml was74.4%.At48months,100%of treated individuals had undetectable plasma HIV-1RNA levels The percentage of patients reaching HIV-1RNA levels below50copies/ml during0to48months was no difference between the CD4+T cell count<200cells/μl and CD4+T cell count>200cells/μl groups (P>0.05).
(5) In the multivariate model sex, the mode of HIV transmission, baseline CD4+T cell count and HIV-1RNA baseline load were correction with the recovery median count of CD4+T cell (P＜0.05). Age, HIV-1disease WTO category, baseline CD8+T cell, HCV and HBV positive were not independently associated with the was an independent factor of increase of CD4T-lymphocyte at60months (P>0.05).
(6). There were significant differences in CD4+T cell subgroups (100,101-199,200-299,>300cell/ml). Univariate and multivariate analyses using Cox proportional hazards regression showed that age and HIV-1disease WTO category were the factors associated with death after HAART. Patients50years or older at HAART initiation had more than3.114fold risk of death relative to those younger than50years of age. WHO HIV-1higher category was3.464times than lower category. HAART duration and HIV-1transmission category were protection factors, the death of heterosexual HIV-1transmission and duration of HAART exceed12months reduced to0.159and0.078, respectively.
(7) During60months of HAART follow-up, the abnormal percents of white blood cell were not significantly decreased, remained above95%, however, the percentages of less than normal were declined; the percentages less than the normal of total lymphocyte were downward trend; abnormal percentages of platelet declined, percentages of platelets less than normal also were decreased; hemoglobin were slowly increased, the percents less than normal hemoglobin were decline, the proportions greater than the normal were upward.
(8) After HAART, the biochemistry immunity appeared unusual. Druing HARRT60months follow-up, the percentages of blood CREA been smaller than normal value rised gradually, the percentages of blood CREA been higher than normal decreased gradually; the unusual percentages of BUN were not obvious change; the abnormal percentages of TGL were gradually increased; The unusual percentages of Total cholesterol TC were gradually up; the rates of abnormality of BA were unobviously; the unusual percentages of AST were gradually deceased, the unusual percentage of ALT been bigger than normal value were decreased; the change of TC were not obviously.
2. Study on correlations between T cells, duration of HAART and HIV-1proviral DNA, we found:
(1) Duration time of HAART was positive related to CD4+CD28+CD4+CD45RA+、CD4+CD45RO+T cells absolute counts.
(2) It was shown that correlation of HAART duration to frequency of CD8+CD38+CD3+, CD8+T cells were inverse correlation, however, there was positive correlation with frequency of CD38+
(3) CD4+absolute count was positively related to the frequency of CD4+CD28+CD4+CD45RO+T cells. It was inversly correlated with the proportion of CD8+CD38+T cells.
(4) Log copies of HIV-1proviral DNA was positive related to CD4+CD45RA+T cell absolute and relative counts. It was shown that correlation of Log copy of HIV-1proviral DNA to CD38+T cell was positive correlation.
(5) Duration time of HAART was no correlation to HIV-1proviral DNA.
3.126HIV/AIDS with HIV-1RNA suppressed under detection threshold undivided by HAART+placebo group and the HAART plus TCM (Kang ai bao sheng concentrated pill) group, the T lymphocyte subgroup, the NK cell, cytokine and HIV-1proviral DNA were examined during12months, the results:
(1) The differences of CD4+T cells and CD4+CD45RO+T cell relative counts of two groups were significant at3months(P=0.029, P=0.028), The differences of CD8+CD38+T cell relative counts of two groups were significant(P=0.029) at6months.
(2) From the9months, NK cell absolute counts of HAART plus TCM were higher than the HAART+placebo group, NK cell absolute counts of two groups were significant difference (P=0.032) at12months.
(3) after6months, CD4+T absolute counts of HIV/AIDS individuals with CD4+T cells baseline <200cells/μl treated by HAART combined with TCM were higher than HAART+placebo group, there is no significantly statistical difference (P=0.015).
(4) IL-1, IL-10were no significant difference between HAART combined with TCM and HAART+placebo groups.
(5)At3months,the relative counts of HIV-1proviral DNA pol gene of HAART plus TCM group were lower than HAART+placebo group (P＜0.050). HIV/AIDS CD4+T cells baseline<200cells/μl when introlled treated by HAART plus TCM, the relative counts of HIV-1proviral DNA of HAART group were significant differences than HAART+placebo group,at3months(P<0.05).
Conclusion:
1. We can choose the following aspects of TCM of treatment of AIDS:HIV/AIDS patients with not compatible with antiviral treatment standard; HIV/AIDS individuals with incompletedmmunologic reconstitution and HIV virus suppression after HAART; abnormal blood lipid metabolism, liver and kidney in HIV/AIDS individuals when infected HIV and during HAART; HIV-1proviral DNA.
2. HIV-1proviral DNA persisted exited although long-term HAART, it was no correlation with CD4+T cells and counts of HIV-1proviral DNA.
3.The advantages of HAART combined with TCM was HIV/AIDS patients with HIV-1RNA suppressed and CD4+T cells<200个/μl although HAART intitation. The advantages and characteristic are interrelated with multiple target effect, so we should study the effect target and mechanism from many angles in future.
方法：
首先,对云南省两县免费抗病毒治疗数据库进行回顾性研究,从HAART治疗临床证据中发现和找到中医药艾滋病治疗的切入点。探讨HAART后60个月随访过程中CD4+T细胞、CD8+T细胞、HIV-1病毒载量、血液生化免疫等指标的变化规律,运用一般线性模型多元方差分析HAART后影响CD4+T细胞恢复的影响因素,运用Kaplan-Meier检验分析HAART后发生死亡的危险因素。
其次,探讨HIV-1RNA被有效抑制下HIV/AIDS患者的T细胞亚群、HAART持续时间、HIV-1前病毒DNA三者之间的相关性,发现HAART后HIV-1前病毒DNA存在的特点以及和T细胞亚群的关系。
最后,对HIV-1RNA被有效抑制的HIV/AIDS患者进行12个月随机双盲试验,探讨HAART联合中药和HAART+安慰剂干预后免疫细胞、HIV-1前病毒DNA env、gag、pol基因相对表达量等指标的变化规律。发现HAART联合中药进行HIV/AIDS治疗的可能优势和可能的作用靶点。
结果：
1、对云南省腾冲、祥云免费抗病治疗数据库进行回顾性研究,研究发现：CD4+T细胞基线水平越高越有利于HAART后CD4+T细胞恢复和降低死亡率,HAART后24月CD4+T细胞恢复数量进入了平台期。HAART后HIV/AIDS患者免疫重建不全,部分患者病毒抑制不完全。HIV/AIDS患者在HAART治疗前、后出现不同程度的血液、肝肾、脂质代谢异常。
(1) HAART开始后0月至12月CD4+T细胞中位数增加最快；24月后CD4+T细胞恢复进入了平台期。在60个月随访过程中CD4+T细胞基线≥200个/μl的HIV/AIDS患者的CD4+T细胞中位数比CD4+T细胞基线<200个/μl组的患者高(P<0.05)。
(2)CD8+T细胞中位数在HAART后随访60个月过程中没有明显的增加或减少, CD4+T细胞基线<200个/μl和CD4+T细胞基线≥200个/μl两组的患者仅在24月、42月的差异有显著性意义外(P<0.05),其余各时间点没有差异。
(3) HAART后60个月随访过程中CD4+T细胞中位数恢复至500个/μl的百分比均低于25%,在第60个月恢复至350个/μl的百分比达到最高为62.5%。在各随访时间点CD4+T细胞基线<200个/μl组和CD4+T细胞基线≥200个/μl两组CD4+T细胞中位数恢复至350个/μl的百分比的差异有显著性意义(P<0.05),除51、54月外两组CD4+T细胞恢复至500个/μl的百分比的差异均有显著性意义(P<0.05)。
(4) HIV/AIDS患者HAART后6个月HIV-1RNA被抑制至检测限(50拷贝/ml)以下的百分比为74.4%。HAART第48个月全部患者的HIV RNA被抑制至检测限以下。CD4+T细胞基线<200个/μl和CD4+T细胞基线≥200个/μl两组的HIV RNA被抑制至检测限的百分比的差异的无显著性意义(P>0.05)。
(5)性别、CD4+T细胞基线、HIV-1RNA基线、WHO HIV感染临床分期是影响HAART治疗的CD4+T细胞恢复数量的因素(P<0.05),年龄、CD8+T细胞基线,HIV-1感染途径、是否合并HBV、HCV感染对HAART后CD4+T细胞恢复没有影响(P>0.05)。
(6)CD4+T细胞基线<100个/μl、100-199个/μl、200-299个/μl、>300个/μl各组之间生存率的差异有显著性意义(P=0.002)。WHO HIV感染临床分期、年龄是HAART后死亡的风险因素。WHO HIV感染临床分期每增加一个等级,死亡风险增加3.464倍,HAART开始时年龄超过50岁的死亡风险是HAART开始时年龄小于50岁的3.114倍。感染途径和HAART持续时间是死亡的保护因素,异性传播及其他的死亡风险是静脉吸毒的15.9%,HAART持续时间超过12月的死亡风险是HAART持续时间小于12月的7.8%。
(7) HAART后随访过程中血液指标的表现为：白细胞计数异常百分比无明显下降,接近100%；总淋巴计数异常百分比有下降趋势；血小板异常百分比有下降趋势,血小板小于正常值的百分比呈下降趋势；血红蛋白呈缓慢上升趋势,小于正常值的百分比呈下降趋势,大于正常值的百分比呈上升趋势。
(8) HAART后60个月的随访过程中生化免疫指标出现不同程度异常,表现在：血肌酐小于正常值的百分比逐渐上升,大于正常值的百分比逐渐下降；血尿素氮异常百分比没有下降趋势,最低为94.4%；甘油三酯异常百分比呈逐渐上升趋势；总胆固醇异常百分比呈逐渐上升趋势；血淀粉酶异常比在变化趋势不明；天冬氨酸转移酶和谷氨酸转移酶大于正常值的百分比呈逐渐下降趋势；总胆红素异常百分比无明显的变化趋势。
2、对HIV-1RNA被有效抑制下HIV/AIDS患者的T细胞亚群、]HAART持续时间、HIV-1前病毒DNA三者之间的相关性进行研究,研究发现：HIV-1RNA被有效抑制下时HAART持续时间与某些T细胞亚群细胞数量相关,长时间HAART治疗后HIV-1前病毒DNA仍稳定持续存在。
(1) HAART持续治疗时间与CD4+CD28+、CD4+CD45RA+、CD4+CD45RO+T细胞绝对计数呈正相关。
(2) HAART持续治疗时间与CD38+T细胞相对计数呈正相关性,与CD3+、CD8+CD38+、CD8+T细胞相对计数呈负相关。
(3)CD4+细胞绝对计数与CD4+CD28+、CD4+CD45RO+T细胞相对计数呈正相关,与CD8+CD38+表达比例呈负相关。
(4)HIV-1前病毒DNA的相对表达量与CD4+CD45RA+T细胞绝对计数呈负相关,与CD4+CD45RA+T细胞相对计数呈正相关(P<0.05),与CD38+T细胞绝对计数呈正相关(P<0.05)。
(5)HIV-1前病毒DNA相对表达量与HAART持续治疗时间无相关性(R=0.108,P=0.310)。
3、对HIV-1RNA被有效抑制的HIV/AIDS患者进行随机双盲试验,研究发现：HAART联合中药(康爱保生浓缩丸)能持续提高HIV-1RNA被有效抑制下但CD4+T细胞基线仍<200个/μl的HIV/AIDS患者的CD4+T细胞数量,推迟CD4+T细胞恢复进入平台期的时间；提高NK细胞数量,对HIV-1前病毒DNA pol基因可能有一定程度的抑制作用。
(1)在12个月各随访时间点HAART联合中药(康爱保生浓缩丸)和HAART+安慰剂的CD4+T细胞绝对计数的差异无显著性意义(P>0.05),在第12月时HAART联合中药的CD4+T细胞绝对计数高于HAART+安慰剂组的。
(2)在第3月时HAART+安慰剂和HAART联合中药(康爱保生浓缩丸)的CD4+T细胞、CD4+CD45RO+T细胞相对计数的差异有显著性意义(P=0.029,P=0.028),在第6月时两组的CD8+CD38+T细胞相对计数的差异有显著性意义(P=0.029)。
(3)HAART+安慰剂和HAART联合中药(康爱保生浓缩丸)的NK细胞绝对计数总体逐渐增长,在第12月时两组的NK细胞绝对计数细胞绝对计数的差异有显著性意义(P=0.032)。
(4)在各随访时间点HAART+安慰剂和HAART联合中药(康爱保生浓缩丸)的细胞因子IL-2、IL-10的差异无显著性意义(P>0.05)。
(5)入组时CD4+T细胞基线<200个/μl层：HAART联合康爱保生浓缩丸治疗HIV/AIDS患者在第6个月后的CD4+T细胞绝对计数增长趋势比HAART+安慰剂组明显。
(6)第3月时HAART+安慰剂和HAART联合中药组的HIV-1前病毒DNA pol基因相对表达值的差异有显著性意义(P<0.050)。入组时CD4+T细胞基线<200个/μl的HIV/AIDS患者在HAART+康爱保生丸治疗后第3个月的HIV前病毒DNA pol基因相对表达量显著低于HAART+安慰剂组(P<0.05)。
结论：
1、中医药进行艾滋病治疗可以从以下几个方面作为切入点：HAART后HIV/AIDS患者免疫重建不全和病毒抑制不完全；HIV/AIDS患者在疾病进程中出现和HAART治疗后出现不同程度的血液、肝肾、脂质代谢异常；对HIV-1RNA被有效抑制的情况下的HIV-1前病毒DNA进行干预。
2、HIV-1前病毒DNA持续存在,长期HAART不能降低HIV-1前病毒DNA表达量,CD4+T细胞数量与HIV-1前病毒DNA表达量无关。
3、HAART联合中药对HAART后HIV-1RNA被有效抑制下、CD4+T细胞<200个/μl的HIV/AIDS患者可能有优势,中医药临床治疗艾滋病作用缓慢、存在一定的不稳定因素,但能对多个作用靶点发挥作用,因此应从多角度进行中医药治疗艾滋病的作用靶点和机制研究。
Objective:At present, the AIDS epidemic situation is still grim, HAART has made great achievements, despite limitations still existed. It was proved that effect of traditional Chinese medicine (TCM) in the treatment of AIDS. What aspects we can treat AIDS by traditional Chinese medicine? What are the advantages of TCM treatment of AIDS? What effects of HAART combined with traditional Chinese medicine on HIV-1proviral DNA of HIV/AIDS individuals with HIV-1RNA suppressed? In this paper, we found fields TCM treatment of AIDS from HAART treatment database of Yunnan province. The change of immune cells and relative counts of HIV-1pro virus DNA through Randomized double-blind trial of HAART combined with TCM.
Methods:
First, the databases of HAART of Tengchong and Xiangyun counties were reviewed, including CD4+T cell counts, CD8+T cell counts, copies of HIV-1load, and et al. The general linear model multivariate analysis was applied for investigated the factors of recovery of CD4+T cell counts. T the risk factors of death after HAART were analyzed by the Kaplan-Meier analysis.
Second, we explored correlation between T absolute count and duration time of HAART and correlation between T cell and HIV-1proviral DNA in AIDS individuals with persistently undetectable plasma HIV-1RNA levels.
Finally, copies of env, gag, pol gene of HIV-1proviral DNA were simultaneously detected by GeXP multiple genetic analysis system, the average copies of3structural genes as copies of HIV-1previous DNA, thereby, the effect of HIV-1proviral DNA by HAART combined with TCM was researched.
Results:
1. The databases of HAART of Tengchong and Xiangyun counties were reviewed, we found:
(1) The median CD4+T cell count increased to287cells/μl (interquartile range,204-378cells/μl) among patients with a baseline CD4+T cell count<200cells/μl, to513cells/μl (interquartile range,469-522cells/μl) among those with a baseline CD4+T cell count>200cells/μ, the median CD4+T cell count were statistically higher in the≥200cells/μl group during the follow-up except at51months (P＜0.05), the significant increases of CD4+T cell count were seen in the first12months in each group, until24months it reached plateau.
(2) It weren't that the median CD8+T cell count hadn't significantly increase or decrease in all patients included or different groups.The median CD8+T cell count were statistically lower in the≥200cells/μl group than CD4+T cell count<200cells/μl group during the follow-up except in24and42months(P<0.05).
(3) The percentage of all patients who achieved a CD4+T cell count500cells/μl low25%, or350cells/μl after receiving60months of HAART were62.5%. The percentage who reached CD4+T cell count of500cells/μl were significant difference between CD4+T cell count<200cells/μl and CD4+T cell count≥200cells/μl groups except45months and54months (P＜0.05), and the percentage who reached CD4+T cell count of350cells/μl were significant difference between groups divided by baseline CD4+T cell count.
(4) After60months HAART initiation, the percentage of HIV-1RNA under50copies/ml was74.4%.At48months,100%of treated individuals had undetectable plasma HIV-1RNA levels The percentage of patients reaching HIV-1RNA levels below50copies/ml during0to48months was no difference between the CD4+T cell count<200cells/μl and CD4+T cell count>200cells/μl groups (P>0.05).
(5) In the multivariate model sex, the mode of HIV transmission, baseline CD4+T cell count and HIV-1RNA baseline load were correction with the recovery median count of CD4+T cell (P＜0.05). Age, HIV-1disease WTO category, baseline CD8+T cell, HCV and HBV positive were not independently associated with the was an independent factor of increase of CD4T-lymphocyte at60months (P>0.05).
(6). There were significant differences in CD4+T cell subgroups (100,101-199,200-299,>300cell/ml). Univariate and multivariate analyses using Cox proportional hazards regression showed that age and HIV-1disease WTO category were the factors associated with death after HAART. Patients50years or older at HAART initiation had more than3.114fold risk of death relative to those younger than50years of age. WHO HIV-1higher category was3.464times than lower category. HAART duration and HIV-1transmission category were protection factors, the death of heterosexual HIV-1transmission and duration of HAART exceed12months reduced to0.159and0.078, respectively.
(7) During60months of HAART follow-up, the abnormal percents of white blood cell were not significantly decreased, remained above95%, however, the percentages of less than normal were declined; the percentages less than the normal of total lymphocyte were downward trend; abnormal percentages of platelet declined, percentages of platelets less than normal also were decreased; hemoglobin were slowly increased, the percents less than normal hemoglobin were decline, the proportions greater than the normal were upward.
(8) After HAART, the biochemistry immunity appeared unusual. Druing HARRT60months follow-up, the percentages of blood CREA been smaller than normal value rised gradually, the percentages of blood CREA been higher than normal decreased gradually; the unusual percentages of BUN were not obvious change; the abnormal percentages of TGL were gradually increased; The unusual percentages of Total cholesterol TC were gradually up; the rates of abnormality of BA were unobviously; the unusual percentages of AST were gradually deceased, the unusual percentage of ALT been bigger than normal value were decreased; the change of TC were not obviously.
2. Study on correlations between T cells, duration of HAART and HIV-1proviral DNA, we found:
(1) Duration time of HAART was positive related to CD4+CD28+CD4+CD45RA+、CD4+CD45RO+T cells absolute counts.
(2) It was shown that correlation of HAART duration to frequency of CD8+CD38+CD3+, CD8+T cells were inverse correlation, however, there was positive correlation with frequency of CD38+
(3) CD4+absolute count was positively related to the frequency of CD4+CD28+CD4+CD45RO+T cells. It was inversly correlated with the proportion of CD8+CD38+T cells.
(4) Log copies of HIV-1proviral DNA was positive related to CD4+CD45RA+T cell absolute and relative counts. It was shown that correlation of Log copy of HIV-1proviral DNA to CD38+T cell was positive correlation.
(5) Duration time of HAART was no correlation to HIV-1proviral DNA.
3.126HIV/AIDS with HIV-1RNA suppressed under detection threshold undivided by HAART+placebo group and the HAART plus TCM (Kang ai bao sheng concentrated pill) group, the T lymphocyte subgroup, the NK cell, cytokine and HIV-1proviral DNA were examined during12months, the results:
(1) The differences of CD4+T cells and CD4+CD45RO+T cell relative counts of two groups were significant at3months(P=0.029, P=0.028), The differences of CD8+CD38+T cell relative counts of two groups were significant(P=0.029) at6months.
(2) From the9months, NK cell absolute counts of HAART plus TCM were higher than the HAART+placebo group, NK cell absolute counts of two groups were significant difference (P=0.032) at12months.
(3) after6months, CD4+T absolute counts of HIV/AIDS individuals with CD4+T cells baseline <200cells/μl treated by HAART combined with TCM were higher than HAART+placebo group, there is no significantly statistical difference (P=0.015).
(4) IL-1, IL-10were no significant difference between HAART combined with TCM and HAART+placebo groups.
(5)At3months,the relative counts of HIV-1proviral DNA pol gene of HAART plus TCM group were lower than HAART+placebo group (P＜0.050). HIV/AIDS CD4+T cells baseline<200cells/μl when introlled treated by HAART plus TCM, the relative counts of HIV-1proviral DNA of HAART group were significant differences than HAART+placebo group,at3months(P<0.05).
Conclusion:
1. We can choose the following aspects of TCM of treatment of AIDS:HIV/AIDS patients with not compatible with antiviral treatment standard; HIV/AIDS individuals with incompletedmmunologic reconstitution and HIV virus suppression after HAART; abnormal blood lipid metabolism, liver and kidney in HIV/AIDS individuals when infected HIV and during HAART; HIV-1proviral DNA.
2. HIV-1proviral DNA persisted exited although long-term HAART, it was no correlation with CD4+T cells and counts of HIV-1proviral DNA.
3.The advantages of HAART combined with TCM was HIV/AIDS patients with HIV-1RNA suppressed and CD4+T cells<200个/μl although HAART intitation. The advantages and characteristic are interrelated with multiple target effect, so we should study the effect target and mechanism from many angles in future.
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