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Promer K, Karris MY. Current Treatment Options for HIV Elite Controllers: a Review. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018; 10:302-309. [PMID: 30344450 DOI: 10.1007/s40506-018-0158-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Opinion statement Initiating antiretroviral therapy (ART) in human immunodeficiency virus (HIV) elite controllers remains controversial, because current evidence does not definitively demonstrate that the benefits of ART outweigh risk in this patient population. However, it is the opinion of the authors that in developed countries, where first-line ART regimens have minimal toxicities, treatment of elite controllers should be strongly considered. Treatment of elite controllers has the potential to minimize the size of the HIV reservoir, which benefits elite controllers who choose to pursue future cure, dampen immune activation, diminish risk of transmission, and encourage linkage and engagement in care allowing HIV providers the opportunity to address HIV-associated non-AIDS conditions and other co-morbidities. Purpose of review This review aims to summarize literature relevant to the management of elite controllers for clinicians caring for patients living with HIV. Key topics include timing of antiretroviral therapy (ART) and ART in the unique populations of elite controllers with concomitant cardiovascular disease and hepatitis C co-infection, and undergoing immunosuppressive therapy for other co-morbidities. Recent findings The persistent HIV reservoir in elite controllers has two main implications. First, increased immune activation appears to adversely impact clinical outcomes in elite controllers, but the role of ART in addressing this effect remains unclear. Second, elite control duration can be limited, but certain factors may help to predict disease progression with implications on timing of ART. Summary Initiation of ART during elite control remains controversial, although there are multiple theoretical benefits. Elite controllers comprise a heterogeneous population of patients living with HIV, and optimal management involves weighing the risk and benefit of ART as well as monitoring of clinical consequences of increased immune activation.
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Affiliation(s)
- Katherine Promer
- Department of Medicine, University of California San Diego, 200 West Arbor Drive #8681, San Diego, CA, 92103, USA
| | - Maile Y Karris
- Department of Medicine, University of California San Diego, 200 West Arbor Drive #8681, San Diego, CA, 92103, USA
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Sustained Viremic Control in HIV-Infected Patient: Case Report from Nepal. Case Rep Infect Dis 2018; 2018:5279595. [PMID: 29732227 PMCID: PMC5872622 DOI: 10.1155/2018/5279595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/18/2018] [Indexed: 12/02/2022] Open
Abstract
A case of human immunodeficiency virus (HIV) infection is described from Nepal with constant maintenance of CD4 count and HIV-RNA level below the lower detection threshold for more than ten years. The case was diagnosed of HIV positive in the year 2008. He had his viral load estimation performed every year since then which was always below lower detection limit and remained healthy without treatment. The patient also had not any kinds of opportunistic infection till date. He is married now and has not transmitted the disease to his wife.
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Pohlmyer CW, Bullen CK, Martin AR, Laird GM, Chioma SU, Walker-Sperling VE, Blankson JN. Characterization of Elite Suppressors Cell-Associated HIV-1 mRNA at Baseline and with T Cell Activation
. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2017; 90:331-336. [PMID: 28656019 PMCID: PMC5482309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: Elite Controllers or Suppressors (ES) are patients who control HIV replication without antiretroviral therapy. In this study, we compared baseline and inducible HIV-1 mRNA levels in CD4+ T cells from ES and chronic progressors (CPs) receiving suppressive antiretroviral therapy. Methods: We quantified basal levels of cell associated HIV-1 mRNA in CD4+ T cells isolated from CPs and ES. Additionally, we measured the fold upregulation of intracellular HIV-mRNA after stimulation of CD4+ T cells with phorbol 12-myristate 13-acetate (PMA) and ionomycin, and quantified the amount of HIV-mRNA levels released into culture supernatant. Results: ES have significantly less cell associated HIV-mRNA per 5x106 cells (p = 0.003); 8 of 10 CPs had quantifiable HIV-1 mRNA at baseline, whereas this was present in only 2 of 10 ES. Upon stimulation with PMA and ionomycin, 4 of 5 CPs and 7 of 9 ES showed increased cell associated HIV-mRNA. Interestingly, released HIV-1 mRNA could be detected in supernatants of CD4+ T cells stimulated with PMA/ionomycin from 5 of 8 ES. Conclusion: Our results demonstrate that while the baseline levels of cell associated HIV-1 mRNA are significantly lower in ES compared to CPs, stimulation of CD4+ T cells results in a comparable relative upregulation of viral transcription.
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Affiliation(s)
| | | | | | | | | | | | - Joel N. Blankson
- To whom all correspondence should be addressed: Joel Blankson, 855 N. Wolfe St, Baltimore, MD, 21205, Tel: 410-502-9920, Fax: 410-614-1159, .
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Reiss KA, Jackson DC, Piotrowski A, Grossman S, Blankson JN. Immune Control Despite Protracted Lymphopenia After Chemoradiation in an Elite Controller. Open Forum Infect Dis 2016; 3:ofw016. [PMID: 26949716 PMCID: PMC4776053 DOI: 10.1093/ofid/ofw016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 01/22/2016] [Indexed: 11/13/2022] Open
Abstract
Elite controllers are human immunodeficiency virus-1-positive individuals capable of sustaining undetectable viral loads without treatment. We present the case of an elite controller diagnosed with extensive stage small cell lung cancer who maintained a viral load of <20 copies/mL despite the development of severe treatment-related lymphopenia.
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Affiliation(s)
- Kim A Reiss
- Department of Medicine, Hematology-Oncology Division , University of Pennsylvania School of Medicine , Philadelphia
| | | | | | | | - Joel N Blankson
- Department of Medicine , Johns Hopkins University School of Medicine , Baltimore, Maryland
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HLA-B*57 elite suppressor and chronic progressor HIV-1 isolates replicate vigorously and cause CD4+ T cell depletion in humanized BLT mice. J Virol 2014; 88:3340-52. [PMID: 24390323 DOI: 10.1128/jvi.03380-13] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
UNLABELLED Elite controllers or suppressors (ES) are HIV-1-infected patients who maintain undetectable viral loads without antiretroviral therapy. The mechanism of control remains unclear, but the HLA-B*57 allele is overrepresented in cohorts of these patients. However, many HLA-B*57 patients develop progressive disease, and some studies have suggested that infection with defective viruses may be the cause of the lack of high levels of virus replication and disease progression in ES. We therefore performed a comprehensive comparative in vivo and in vitro characterization of viruses isolated from well-defined ES. For this purpose, we first performed full-genome sequence analysis and in vitro fitness assays on replication-competent isolates from HLA-B*57 ES and HLA-B*57 chronic progressors (CPs). Under our experimental conditions, we found that isolates from ES and CPs can replicate in vitro. However, since inherently these assays involve the use of unnaturally in vitro-activated cells, we also investigated the replication competence and pathogenic potential of these HIV isolates in vivo using humanized BLT mice. The results from these analyses demonstrate that virus isolates from ES are fully replication competent in vivo and can induce peripheral and systemic CD4 T cell depletion. These results provide the first direct in vivo evidence that viral fitness does not likely determine clinical outcome in HLA-B*57 patients and that elite suppressors can control replication-competent, fully pathogenic viruses. A better understanding of the immunological bases of viral suppression in ES will serve to inform novel approaches to preventive and therapeutic HIV vaccine design. IMPORTANCE Elite suppressors are HIV-1-infected patients who have undetectable levels of viremia despite not being on antiviral drugs. One of the most fundamental questions about this phenomenon involves the mechanism of control. To address this question, we isolated virus from elite suppressors and from HIV-1-infected patients who have the usual progressive disease course. We compared how well the isolates from the two groups of patients replicated in culture and in humanized mice. Our results suggest that elite suppressors are capable of controlling HIV-1 due to the possession of unique host factors rather than infection with defective virus.
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Genovese L, Nebuloni M, Alfano M. Cell-Mediated Immunity in Elite Controllers Naturally Controlling HIV Viral Load. Front Immunol 2013; 4:86. [PMID: 23577012 PMCID: PMC3620550 DOI: 10.3389/fimmu.2013.00086] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Accepted: 03/26/2013] [Indexed: 12/26/2022] Open
Abstract
The natural course of human immunodeficiency virus (HIV) infection is characterized by high viral load, depletion of immune cells, and immunodeficiency, ultimately leading to acquired immunodeficiency syndrome phase and the occurrence of opportunistic infections and diseases. Since the discovery of HIV in the early 1980s a naturally selected population of infected individuals has been emerged in the last years, characterized by being infected for many years, with viremia constantly below detectable level and poor depletion of immune cells. These individuals are classified as “elite controllers (EC) or suppressors” and do not develop disease in the absence of anti-retroviral therapy. Unveiling host factors and immune responses responsible for the elite status will likely provide clues for the design of therapeutic vaccines and functional cures. Scope of this review was to examine and discuss differences of the cell-mediated immune responses between HIV+ individuals with disease progression and EC.
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Affiliation(s)
- Luca Genovese
- AIDS Immunopathogenesis Unit, Division of Immunology, Transplantation and Infectious Diseases, San Raffaele Scientific Institute Milan, Italy
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Developing strategies for HIV-1 eradication. Trends Immunol 2012; 33:554-62. [PMID: 22867874 DOI: 10.1016/j.it.2012.07.001] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Revised: 07/05/2012] [Accepted: 07/09/2012] [Indexed: 12/26/2022]
Abstract
Highly active antiretroviral therapy (HAART) suppresses HIV-1 replication, transforming the outlook for infected patients. However, reservoirs of replication-competent forms of the virus persist during HAART, and when treatment is stopped, high rates of HIV-1 replication return. Recent insights into HIV-1 latency, as well as a report that HIV-1 infection was eradicated in one individual, have renewed interest in finding a cure for HIV-1 infection. Strategies for HIV-1 eradication include gene therapy and hematopoietic stem cell transplantation, stimulating host immunity to control HIV-1 replication, and targeting latent HIV-1 in resting memory CD4(+) T cells. Future efforts should aim to provide better understanding of how to reconstitute the CD4(+) T cell compartment with genetically engineered cells, exert immune control over HIV-1 replication, and identify and eliminate all viral reservoirs.
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Buckheit RW, Allen TG, Alme A, Salgado M, O’Connell KA, Huculak S, Falade-Nwulia O, Williams TM, Gallant JE, Siliciano RF, Blankson JN. Host factors dictate control of viral replication in two HIV-1 controller/chronic progressor transmission pairs. Nat Commun 2012; 3:716. [PMID: 22395607 PMCID: PMC3549550 DOI: 10.1038/ncomms1697] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 01/23/2012] [Indexed: 02/07/2023] Open
Abstract
Viremic controllers and elite controllers/suppressors maintain control over HIV-1 replication. Some studies have suggested that control is a result of infection with a defective viral strain, while others suggested host immune factors have a key role. Here we document two HIV-1 transmission pairs: one consisting of a patient with progressive disease and an individual who became an elite suppressor, and the second consisting of a patient with progressive disease and a viremic controller. In contrast to another elite suppressor transmission pair, virus isolated from all patients was fully competent. These data suggest that some viremic controllers and elite suppressors are infected with HIV-1 isolates that replicate vigorously in vitro and are able to cause progressive disease in vivo. These data suggest that host factors have a dominant role in the control of HIV-1 infection, thus it may be possible to control fully pathogenic HIV-1 isolates with therapeutic vaccination.
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Affiliation(s)
- Robert W. Buckheit
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 733 N. Broadway, BRB 880, Baltimore, MD 21205
| | - Tracy G. Allen
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 733 N. Broadway, BRB 880, Baltimore, MD 21205
| | - Angela Alme
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 733 N. Broadway, BRB 880, Baltimore, MD 21205
| | - Maria Salgado
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 733 N. Broadway, BRB 880, Baltimore, MD 21205
| | - Karen A. O’Connell
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 733 N. Broadway, BRB 880, Baltimore, MD 21205
| | - Sarah Huculak
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 733 N. Broadway, BRB 880, Baltimore, MD 21205
| | - Oluwaseun Falade-Nwulia
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 733 N. Broadway, BRB 880, Baltimore, MD 21205
| | - Thomas M. Williams
- Department of Pathology, School of Medicine and Tricore Reference Laboratories, University of New Mexico, Albuquerque, New Mexico
| | - Joel E. Gallant
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 733 N. Broadway, BRB 880, Baltimore, MD 21205
| | - Robert F. Siliciano
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 733 N. Broadway, BRB 880, Baltimore, MD 21205
- Howard Hughes Medical Institute. Johns Hopkins University School of Medicine. 733 N. Broadway, Baltimore MD 21205, USA
| | - Joel N. Blankson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 733 N. Broadway, BRB 880, Baltimore, MD 21205
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