Can HIV infection be prevented with a vaccine?

The global human immunodeficiency virus type 1 (HIV-1) epidemic is devastating many communities and a well tolerated and effective vaccine is urgently required. Several lines of evident suggest that vaccine-induced protective immunity can be achieved. This evidence includes individuals shown to have natural immunity, and the partially effective immune responses that are generated during natural infection. However, the obstacles to HIV-1 vaccine development are enormous. The only substantially effective vaccine studied in pathogenic animal models (live, attenuated vaccines) is at present far too unsafe. The only HIV-1 vaccine to proceed to efficacy trials (an envelope protein approach) has been disappointing in its immunogenicity and efficacy in preliminary trials. The antigenic variability of HIV-1 strains is also a great obstacle. Unfortunately, commercial realities also do not favour the expensive development of HIV-1 vaccines required most urgently in less developed countries. Despite these obstacles, there is cause for cautious optimism. Better tolerated HIV-1 vaccine approaches are currently showing great promise in primate models and preliminary clinical trials. Many governments and the World Bank are now providing the political will and funding necessary to fast-track HIV-1 vaccine development. Given sufficient long term scientific and commercial commitment to the HIV-1 vaccine development process, it is ultimately likely that a preventative HIV-1 vaccine will emerge.

Enhanced T-cell immunogenicity and protective efficacy of a human immunodeficiency virus type 1 vaccine regimen consisting of consecutive priming with DNA and boosting with recombinant fowlpox virus

The induction of human immunodeficiency virus (HIV)-specific T-cell responses is widely seen as critical to the development of effective immunity to HIV type 1 (HIV-1). Plasmid DNA and recombinant fowlpox virus (rFPV) vaccines are among the most promising safe HIV-1 vaccine candidates. However, the immunity induced by either vaccine alone may be insufficient to provide durable protection against HIV-1 infection. We evaluated a consecutive immunization strategy involving priming with DNA and boosting with rFPV vaccines encoding common HIV-1 antigens. In mice, this approach induced greater HIV-1-specific immunity than either vector alone and protected mice from challenge with a recombinant vaccinia virus expressing HIV-1 antigens. In macaques, a dramatic boosting effect on DNA vaccine-primed HIV-1-specific helper and cytotoxic T-lymphocyte responses, but a decline in HIV-1 antibody titers, was observed following rFPV immunization. The vaccine regimen protected macaques from an intravenous HIV-1 challenge, with the resistance most likely mediated by T-cell responses. These studies suggest a safe strategy for the enhanced generation of T-cell-mediated protective immunity to HIV-1.

A minimally replicative HIV-2 live-virus vaccine protects M. nemestrina from disease after HIV-2(287) challenge

M. nemestrina immunized with an apathogenic HIV-2 molecular clone (HIV-2KR) were protected from CD4 decline and disease upon challenge with HIV-2(287), after any immunizing virus could be detected. Higher but not lower inocula of HIV-2KR were protective against intravenous inoculation of either 10(5) or 10(1) TCID50 of HIV-2(287). Protected animals displayed substantial reductions in PBMC proviral burden (1-3 logs), viral titers (1-2 logs), and plasma viral RNA (2-4 logs) compared to unprotected or naive animals as early as 1 week postinfection. Plasma viral RNA became undetectable after 24 weeks in protected animals, but remained high in unprotected animals. No viral RNA was present in the spleen of the protected animal necropsied more than a year after challenge (though viral DNA was still present). No neutralizing responses could be demonstrated, but CTL activity was detected sooner and at higher levels after challenge in protected than in unprotected macaques. In this novel HIV-2 vaccine model, protection was clearly dose-dependent, and clearance of challenge virus RNA from the plasma did not require detectable ongoing replication of the immunizing virus at the time of challenge.

Human immunodeficiency virus type 1 (HIV-1)-specific T cell responses correlate with control of acute HIV-1 infection in macaques

Macaca nemestrina efficiently control acute human immunodeficiency virus type 1 (HIV-1) infection. The roles of helper (Th) and cytotoxic (CTL) T cells in controlling acute HIV-1 infection in both peripheral blood and lymph node mononuclear cells (PBMC and LNMC) were assessed in this model. Th and CTL responses to HIV-1 were detected within 2 weeks following HIV-1 infection, and CTL responses to HIV-1 antigens peaked at 4 weeks after infection (>100 HIV-specific CTL/10[6] PBMC), coincident with reductions of HIV-1 RNA and DNA levels in peripheral blood. HIV-1-specific Th and CTL were present in LNMC 6 weeks after infection. Although HIV-1 antibodies were detected 2 weeks after infection, maximal HIV-1 antibody responses were not generated until > 13 weeks after inoculation. Thus, T cell responses temporally correlate with control of HIV-1 in macaques. The induction of a brisk HIV-1-specific CTL response may have been facilitated by a persistent Th response.

Lymphoproliferative immune function in the Sydney Blood Bank Cohort, infected with natural nef/long terminal repeat mutants, and in other long-term survivors of transfusion-acquired HIV-1 infection

OBJECTIVES

To assess T-helper cell immune function (proliferation) in members of the Sydney Blood Bank Cohort (SBBC) compared with other individuals with transfusion- and sexually acquired HIV-1 infection and with matched HIV-negative controls.

DESIGN AND METHODS

Decreasing CD4 counts and T-helper cell function are associated with disease progression. Peripheral blood mononuclear cells (PBMC) from study subjects were assayed for in vitro proliferative responses to HIV-1-derived antigens, recall antigens and alloantigen. T-helper cell function and CD4 counts in members of the SBBC were followed longitudinally.

RESULTS

Proliferative responses and CD4 counts from members of the SBBC were similar to or better than those of other transfusion- or sexually-acquired HIV-1-positive long-term non-progressors (LTNP), including the HIV-negative matched SBBC control groups. However, individuals with disease progression had reduced or undetectable proliferative responses to recall antigens but a conserved response to alloantigen; they also had low CD4 counts and low CD4:CD8 ratios. In the SBBC, these immune parameters were usually stable over time.

CONCLUSIONS

The unique SBBC with natural nef/long terminal repeat deletions in the HIV-1 genome were genuine LTNP without showing signs of disease progression. They appeared to be a group distinct from the tail-end of the normal distribution of disease progression rates, and may remain asymptomatic indefinitely. The SBBC virus may form the basis of a live attenuated immunotherapeutic or immunoprophylactic HIV vaccine.

Antagonism of vaccine-induced HIV-1-specific CD4+ T cells by primary HIV-1 infection: potential mechanism of vaccine failure

Prior immunity to HIV-1 elicited by vaccination may modify subsequent responses upon exposure to infectious HIV-1. An HIV-1-uninfected person entered in a vaccine trial that included immunizations to HIV-1(LAI) envelope with a recombinant vaccinia vector and recombinant protein developed envelope-specific CD4+ T cell responses, including proliferative and cytolytic responses, but was not protected from a high risk HIV-1 exposure. CD4+ T cell clones derived from blood at the peak of vaccine-induced immunity recognized and lysed autologous target cells expressing four distinct regions within the HIV-1(LAI) envelope region; three of these CTL clones also recognized targets expressing envelope from a similar viral subtype, HIV-1(MN). The epitope specificity of CD4+ clone 9G8, recognizing both HIV-1(LAI) and HIV-1(MN) envelope, was within the 571-590 amino acid envelope region. Sequence analysis of the first infectious autologous strain revealed two amino acid mutations within this region. The 9G8 CTL clone induced by immunization failed to recognize targets expressing the corresponding CTL epitope from the infecting virus. Moreover, a peptide based on the epitope sequence of the infecting isolate antagonized the vaccine-induced CTL clone such that the CTL clone was no longer able to recognize the vaccine strain or HIV-1(MN) epitope. These findings suggest a potentially novel mechanism associated with vaccine failure whereby the infecting virus may not only escape from CTL activity, but also alter the ability of CTL to recognize other variants in an individual.

Antagonism of vaccine-induced HIV-1-specific CD4+ T cells by primary HIV-1 infection: potential mechanism of vaccine failure

Prior immunity to HIV-1 elicited by vaccination may modify subsequent responses upon exposure to infectious HIV-1. An HIV-1-uninfected person entered in a vaccine trial that included immunizations to HIV-1(LAI) envelope with a recombinant vaccinia vector and recombinant protein developed envelope-specific CD4+ T cell responses, including proliferative and cytolytic responses, but was not protected from a high risk HIV-1 exposure. CD4+ T cell clones derived from blood at the peak of vaccine-induced immunity recognized and lysed autologous target cells expressing four distinct regions within the HIV-1(LAI) envelope region; three of these CTL clones also recognized targets expressing envelope from a similar viral subtype, HIV-1(MN). The epitope specificity of CD4+ clone 9G8, recognizing both HIV-1(LAI) and HIV-1(MN) envelope, was within the 571-590 amino acid envelope region. Sequence analysis of the first infectious autologous strain revealed two amino acid mutations within this region. The 9G8 CTL clone induced by immunization failed to recognize targets expressing the corresponding CTL epitope from the infecting virus. Moreover, a peptide based on the epitope sequence of the infecting isolate antagonized the vaccine-induced CTL clone such that the CTL clone was no longer able to recognize the vaccine strain or HIV-1(MN) epitope. These findings suggest a potentially novel mechanism associated with vaccine failure whereby the infecting virus may not only escape from CTL activity, but also alter the ability of CTL to recognize other variants in an individual.

Managing HIV. Part 8: Controlling an epidemic. 8.3 Prospects for a preventive HIV vaccine

A safe vaccine to halt or slow the global HIV pandemic is urgently needed, yet the immediate prospects for an effective vaccine are poor. Experimental work to date suggests that live attenuated vaccines are most effective, but they raise serious safety concerns. The search for alternatives continues.

Detection of simian immunodeficiency virus (SIV)-specific CD8+ T cells in macaques protected from SIV challenge by prior SIV subunit vaccination

Vaccines for lentiviruses would ideally induce in the host complete resistance to infection of host cells. However, such sterilizing immunity may be neither readily achievable nor absolutely necessary to provide protection from exposure to the immunodeficiency viruses. To examine the nature of protective immunity to simian immunodeficiency virus (SIV), we studied three macaques that had been immunized with a recombinant vaccinia virus-based SIV subunit vaccine regimen and exhibited protection from a challenge with cell-free SIV (MNE) as determined by viral cultures, serology, and PCR for viral genomes. Peripheral blood mononuclear cells were obtained from the protected macaques and analyzed for CD8+ cytotoxic T-lymphocyte (CTL) responses to SIV proteins. CTL reactive to SIV proteins not included in the subunit vaccine, and thus to which these animals had not been exposed prior to challenge, were detected postchallenge in the vaccine-protected animals and persisted for up to 1 year. These CTL, as reflected by studies of cytolytic lines and derived T-cell clones, were CD8+, did not recognize allogeneic targets, and recognized the SIV proteins in the context of class I major histocompatibility complex molecules. The frequency of precursor CD8+ CTL reactive to SIV proteins was determined by limiting-dilution analysis and demonstrated that the responses elicited following challenge of protected animals to SIV proteins not present in the vaccine were quantitatively similar to those of animals persistently infected with SIV. The presence of these CD8+ CTL responses to SIV proteins present only in the challenge virus suggests that infection of some host cells occurred postchallenge. These results suggest that the development of a low level of SIV infection following exposure of vaccinated hosts to SIV does not preclude protection from lethal SIV disease by vaccine-induced immunity.

A monoclonal antibody to alpha 4-integrin reverses the MR-detectable signs of experimental allergic encephalomyelitis in the guinea pig

Experimental allergic encephalomyelitis (EAE) is a T cell-mediated autoimmune disease of the CNS characterized by blood-brain barrier breakdown, cerebral edema formation, lymphocyte infiltration, and demyelination, and is used as an animal model of multiple sclerosis (MS). MR imaging is important for the diagnosis of MS and for the evaluation of potential new therapies. In this study, T2-weighted and T1-weighted contrast-enhanced MR imaging was used to evaluate the effectiveness of an antiadhesion therapy in EAE. Leukocyte-endothelial adhesion at the blood-brain barrier is considered an essential step in the mediation of CNS leukocyte infiltration in EAE. AN100226m, a monoclonal antibody to alpha 4 integrin has been previously shown to reverse the clinical and histologic signs of EAE by blocking this interaction. In the present study, AN100226m treatment in acute EAE significantly decreased contrast enhancement of the CNS parenchyma indicating closure of the blood-brain barrier. The percentage of pixels due to leakage of contrast material in T1-weighted images decreased to < 4% in AN100226m-treated animals whereas it was increased to 15% in control animals (P < .05, Mann-Whitney rank sum test). A decrease in CNS abnormalities associated with cerebral edema and inflammation was also observed on T2-weighted images (P < .05, Mann-Whitney rank sum test). Thus, an antibody to alpha 4 integrin reversed the blood-brain barrier permeability changes characteristic of acute EAE. In addition, the further accumulation of inflammatory edema was prevented and preexisting edema was resolved.

A monoclonal antibody to alpha 4 integrin suppresses and reverses active experimental allergic encephalomyelitis

In experimental allergic encephalomyelitis (EAE), circulating leukocytes enter the central nervous system (CNS) producing inflammation, myelin damage and paralysis. Prevention of leukocyte infiltration by an antibody against alpha 4 integrin suppressed clinical and pathological features of EAE in the guinea pig. Rapid clearance of leukocytes from the CNS and reversal of clinical findings were observed when anti-alpha 4 treatment was administered during active disease. Clinical improvement was accompanied by a marked decrease in abnormal pathological findings, including demyelination. Therefore anti-alpha 4 is an effective treatment of EAE and may be similarly useful in the treatment of autoimmune diseases such as multiple sclerosis.

Which surgeons in a district general hospital should treat patients with carcinoma of the rectum?

There has recently been considerable media and medical interest in the apparent differences of the results of the surgical treatment of colorectal cancer by specialist and non-specialist colorectal surgeons. We have therefore audited and compared the results of the elective treatment of cancers of the rectum and distal sigmoid colon undertaken by two surgeons working in the same hospital, one a general surgeon with a vascular special interest and the other a colorectal specialist. Although our results demonstrate no difference in overall survival, the higher clinical leak rate and higher rate of palliative diversional surgery in the general surgeon's group lends some support to the argument that carcinoma of the rectum should be treated by surgeons with a special interest in colorectal surgery.

Cytotoxic and proliferative T cell responses in HIV-1-infected Macaca nemestrina

Macaca nemestrina has been described as an animal model for acute HIV-1 infection. This animal, unlike most infected humans, appears to contain HIV-1 replication. Therefore analysis of HIV-1-specific proliferative and cytotoxic T lymphocyte (CTL) responses following HIV-1 challenge of M. nemestrina may provide information into the role of such responses in both the control of acute HIV infection and protective immunity. Although CD4+ T cell responses to HIV-1 are generally difficult to detect in HIV-1-infected humans, early and persistent CD4+ T cell proliferative responses to HIV-1 antigens were detected in all HIV-1-inoculated M. nemestrina. HIV-1-specific CD8+ CTL responses were evaluated in PBMC by stimulation with autologous cells expressing HIV-1 genes, limiting dilution precursor frequency analysis, and T cell cloning. CTL reactive with gag, env, and nef were present 4-8 wk after infection, and persisted to 140 wk after infection. The presence of both CD4+ and CD8+ T cell responses before and after clearance of HIV-1 viremia is consistent with a role for these responses in the successful control of HIV-1 viral replication observed in M. nemestrina. Further studies of T cell immunity in these animals that resist disease should provide insights into the immunobiology of HIV-1 infection.

HIV infection of monocyte-derived macrophages in vitro reduces phagocytosis of Candida albicans

HIV-1 infection of peripheral blood monocyte-derived macrophages (MDMs) is unrelated to the level of CD4 expression on the surface of the cell, is associated with considerable donor variability, causes minimal cytopathology, and results in peak viral antigen production after 2 weeks of infection. Phagocytosis of opsonized Candida albicans by MDMs infected in vitro with several strains of HIV was compared with that of uninfected cells from the same donors; the proportion of MDMs containing the fluorescein isothiocyanate-labeled yeast was determined by flow cytometry and phase contrast microscopy. The intracellular localization of C. albicans was confirmed by confocal microscopy. Using paired MDMs from nine donors, 81% of uninfected and 53% of HIV-infected MDMs phagocytosed C. albicans. In addition, the number of yeast per cell was significantly higher in uninfected MDMs than in HIV-infected cells (mean 6.1 versus 2.5). These findings may partially explain the high incidence of mucocutaneous candidiasis in HIV-infected patients with advanced disease.

Analysis of cytotoxic T lymphocyte responses to SIV proteins in SIV-infected macaques using antigen-specific stimulation with recombinant vaccinia and fowl poxviruses

Methods to analyze CD8+ CTL responses to simian immunodeficiency virus (SIV)-encoded proteins are essential to understand lentivirus immunopathogenesis and protective immune responses. Recombinant infectious shuttle vectors are useful for analyzing CTL responses to many viruses, including HIV. Therefore, CTL responses in SIV-infected Macaca fascicularis to SIV env and SIV gag/pol were evaluated using specific antigen stimulation with recombinant vaccinia (rVV) and fowl poxviruses (rFPV) containing SIV genes. Peripheral blood mononuclear cells from SIV-infected animals were stimulated with autologous cells infected with rVV expressing SIV env/gag/pol, and CTLs specific for SIV env and for SIV gag/pol were detected by testing for lytic activity in target cells expressing these genes separately. Lymphocyte subset purifications from the effector population demonstrated that the CTL response was mediated by CD8+ cells, and the use of brefeldin A to selectively block antigen presentation in association with MHC class I products affirmed this cytolytic activity was class I restricted. The use of rVV to analyze responses to SIV genes is potentially problematic in hosts immunized to vaccinia. Fowl poxvirus is an alternative virus that has many of the molecular advantages of vaccinia virus but is genomically distinct. Therefore, the ability of rFPV to expand and detect SIV-specific CTLs was evaluated. Although there was no cytopathic effect following infection with rFPV, macaque cells infected with this vector did express rFPV gene products, and could be used as stimulator and target cells to detect SIV-specific CD8+ CTLs. The results suggest that these recombinant viral vectors can be used to specifically stimulate CD8+, MHC class I-restricted CTLs reactive to SIV proteins, and should facilitate evaluating CTL responses in both SIV-infected animals and animals vaccinated against SIV.

HIV-1 infection of monocyte-derived macrophages reduces Fc and complement receptor expression

Fc receptor (FcR) and complement receptor (CR) expression on HIV-infected monocyte-derived macrophages may be an important determinant of immune function. We studied the effects of HIV-1 infection of macrophages in vitro on FcR and CR expression. Macrophages were infected with HIV-1DV 7 days following isolation, and the expression of Fc gamma RI-III and CR3 were measured at intervals thereafter by flow cytometry. We found a reduction in receptor expression with the percentage of cells expressing FcRI 14 days post infection declining from 77% to 13%, FcRII fell from 96% to 85%, FcRIII from 45% to 9%, and CR3 from 91% to 67% 14 days following infection. As these receptors are important for macrophage function, their down-modulation may contribute to the pathogenesis of HIV-related disease.

Tuberculous meningitis: a 30-year review

Tuberculous meningitis remains an important illness that can be difficult to diagnose in a timely fashion and carries significant morbidity. We present a retrospective review of the cases of tuberculous meningitis diagnosed and treated at a single institution. Fifty-eight cases were identified and stratified according to stage of disease at presentation. Four patients (7%) died; three (5%) developed severe neurological sequelae. Poor outcomes were largely confined to cases presenting in an advanced stage and at the extremes of age. Corticosteroids were administered to 56 patients and may have contributed to the comparatively good outcome in these cases.

Oral dapsone versus nebulized pentamidine for Pneumocystis carinii pneumonia prophylaxis: an open randomized prospective trial to assess efficacy and haematological toxicity

OBJECTIVE

To compare the haematological toxicity and efficacy of oral dapsone and nebulized pentamidine as Pneumocystis carinii pneumonia (PCP) prophylaxis in HIV-infected patients receiving zidovudine.

DESIGN

Randomized, prospective.

SETTING

Infectious diseases hospital with participants drawn from both inpatient and outpatient departments.

PATIENTS

Those eligible were starting treatment with zidovudine, needed PCP prophylaxis (CD4+ count < 200 x 10(6)/l or < 20% total lymphocyte count or previous episode of PCP), and had a normal glucose-6-phosphate dehydrogenase screen. Of the 98 patients enrolled, 96 returned for follow-up.

INTERVENTIONS

Fifty patients received dapsone (100mg orally twice weekly) and 46 pentamidine (400 mg nebulized monthly). Follow-up was for a median of 18 months.

MAIN OUTCOME MEASURES

The development of PCP, transfusion requirements, monthly complete blood cell counts, serious adverse reactions and death were recorded.

RESULTS

Nine (18%) dapsone and eight (17%) pentamidine recipients developed PCP. There was no significant difference in number of patients transfused (12 dapsone and nine pentamidine recipients) or transfusion-free survival. At exit from the study, mean haemoglobin (11.7 versus 12.4 g/dl), white blood cell (3.9 versus 3.7 x 10(9)/l) and platelet (195 versus 184 x 10(9)/l) counts did not differ for the dapsone and pentamidine arms, respectively. There was no significant difference in the occurrence of serious adverse reactions (six in the dapsone and eight in the pentamidine arm).

CONCLUSIONS

Dapsone can be recommended in preference to pentamidine as PCP prophylaxis on the basis of equivalent efficacy, absence of excessive haematological toxicity, low cost and ease of administration.

Invasive aspergillosis in AIDS

Invasive aspergillosis (IA) is a rare infection in patients with the Acquired Immune Deficiency Syndrome (AIDS). We report the first Australian cases of histologically and microbiologically proven IA diagnosed antemortem in AIDS patients. We also describe the first case of laryngeal involvement and the unusual case of a pneumothorax due to IA. These three cases illustrate the varied clinical and pathological features of IA in AIDS and highlight some of the difficulties in diagnosis and treatment. The infections occurred in the setting of advanced immunodeficiency and multiple opportunistic infections and responded poorly to treatment.

Arterial thrombosis associated with graduated pressure antiembolic stockings

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Analysis of the potential association between noise-induced hearing loss and cardiovascular disease in USAF aircrew members

Questions have been raised concerning the possible impact on health of populations exposed to excessive noise in their work- and leisure-time environments. The purpose of this investigation was to explore the relationship between noise-induced hearing loss and cardiovascular disease by examining the medical records of 2,250 Air Force aircrew members. In this correlative analysis, high-tone hearing loss diagnosed with a high probability of being noise-induced was interpreted as an indirect indicator of noise exposure. Cardiovascular function was measured in terms of recorded systolic and diastolic blood pressure and clinical diagnoses of cardiovascular diseases. Analyses consisted of comparing cardiovascular parameters in maximum and minimum hearing loss groups including polynomial regression curves for blood pressure data, and determining relative risk and attributable risk associated with noise-induced hearing loss for development of cardiovascular disease. Our analyses consistently failed to indicate any association between the degree of noise-induced hearing loss and cardiovascular function in the aircrew population.

The value of arteriography of the hand in the Raynaud's syndrome

The hand arteriograms of 18 patients with Raynaud's syndrome are reviewed. In 17 of the patients the arteriographic abnormality consists of digital artery occlusions, collaterals and diminished vascularity of the tips of the affected fingers. These changes are non-specific and do not correlate with the clinically diagnosed underlying arterial disease. The results of upper thoracie sympathectomy are unrelated to the type or severity of the angiographic changes. It is suggested that hand arteriography has little place in the diagnosis or management of patients with Raynaud's phenomenon. Arteriography is only of value to demonstrate a proximal source of digital emboli.