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Chan P, Spudich S. Central Nervous System Effects of Early HIV Infection and Consequences of Antiretroviral Therapy Initiation during Acute HIV. Viruses 2024; 16:1082. [PMID: 39066244 PMCID: PMC11281648 DOI: 10.3390/v16071082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/03/2024] [Accepted: 07/04/2024] [Indexed: 07/28/2024] Open
Abstract
HIV infection is a multi-organ disease that involves the central nervous system (CNS). While devastating CNS complications such as HIV-associated dementia and CNS opportunistic infection typically manifest years after HIV acquisition, HIV RNA is readily detected in the cerebrospinal fluid in untreated neuroasymptomatic people with HIV, highlighting that HIV neuroinvasion predates overt clinical manifestations. Over the past two decades, increased awareness of HIV infection within the at-risk population, coupled with the accessibility of nucleic acid testing and modern HIV immunoassays, has made the detection of acute and early HIV infection readily achievable. This review aims to summarize research findings on CNS involvement during acute and early HIV infection, as well as the outcomes following the immediate initiation of antiretroviral therapy during this early stage of infection. The knowledge gap in long-term neuroprotection through early ART within the first year of infection will be discussed.
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Affiliation(s)
- Phillip Chan
- Department of Neurology, Yale School of Medicine, New Haven, CT 06510, USA
- Center for Brain and Mind Health, Yale School of Medicine, New Haven, CT 06510, USA
| | - Serena Spudich
- Department of Neurology, Yale School of Medicine, New Haven, CT 06510, USA
- Center for Brain and Mind Health, Yale School of Medicine, New Haven, CT 06510, USA
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Wahl A, Al-Harthi L. HIV infection of non-classical cells in the brain. Retrovirology 2023; 20:1. [PMID: 36639783 PMCID: PMC9840342 DOI: 10.1186/s12977-023-00616-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/02/2023] [Indexed: 01/15/2023] Open
Abstract
HIV-associated neurological disorders (HAND) affect up to 50% of people living with HIV (PLWH), even in the era of combination antiretroviral therapy (cART). HIV-DNA can be detected in the cerebral spinal fluid (CSF) of approximately half of aviremic ART-suppressed PLWH and its presence is associated with poorer neurocognitive performance. HIV DNA + and HIV RNA + cells have also been observed in postmortem brain tissue of individuals with sustained cART suppression. In this review, we provide an overview of how HIV invades the brain and HIV infection of resident brain glial cells (astrocytes and microglia). We also discuss the role of resident glial cells in persistent neuroinflammation and HAND in PLWH and their potential contribution to the HIV reservoir. HIV eradication strategies that target persistently infected glia cells will likely be needed to achieve HIV cure.
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Affiliation(s)
- Angela Wahl
- grid.10698.360000000122483208International Center for the Advancement of Translational Science, University of North Carolina at Chapel Hill, Chapel Hill, NC USA ,grid.10698.360000000122483208Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC USA ,grid.10698.360000000122483208Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Lena Al-Harthi
- grid.240684.c0000 0001 0705 3621Department of Microbial Pathogens and Immunity, Rush University Medical Center, Chicago, IL USA
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Chan P, Spudich S. HIV Compartmentalization in the CNS and Its Impact in Treatment Outcomes and Cure Strategies. Curr HIV/AIDS Rep 2022; 19:207-216. [PMID: 35536438 PMCID: PMC10590959 DOI: 10.1007/s11904-022-00605-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review focuses on the cerebrospinal fluid (CSF) findings in connection to the central nervous system (CNS) reservoir in treatment-naïve and virally suppressed PLWH, followed by the findings in CSF HIV-1 escape and analytical treatment interruption studies. RECENT FINDINGS Compared to chronic infection, initiating antiretroviral therapy (ART) during acute HIV-1 infection results in more homogeneous longitudinal benefits in the CNS. Viral variants in CSF HIV-1 escape are independently linked to infected cells from the systemic reservoir and in the CNS, highlighting the phenomenon as a consequence of different mechanisms. HIV-infected cells persist in CSF in nearly half of the individuals on stable ART and are associated with worse neurocognitive performance. Future studies should probe into the origin of the HIV-infected cells in the CSF. Examining the capacity for viral replication would provide new insight into the CNS reservoir and identify strategies to eradicate it or compensate for the insufficiency of ART.
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Affiliation(s)
- Phillip Chan
- SEARCH, Institute of HIV Research and Innovation, Bangkok, Thailand
| | - Serena Spudich
- Department of Neurology and Center for Neuroepidemiology and Clinical Neurological Research, Yale University, New Haven, CT, USA.
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Pröll J, Paar C, Taylor N, Skocic M, Freystetter A, Blaimschein A, Mayr R, Niklas N, Atzmüller S, Raml E, Wechselberger C. New aspects of the Virus Life Cycle and Clinical Utility of Next Generation Sequencing based HIV-1 Resistance Testing in the Genomic, the Proviral and the Viral Reservoir of Peripheral Blood Mononuclear Cells. Curr HIV Res 2022; 20:213-221. [PMID: 35331114 DOI: 10.2174/1570162x20666220324111418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/07/2021] [Accepted: 01/28/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Typically, genotypic resistance testing is recommended at the start of antiretroviral therapy and is even mandatory in cases of virologic failure. The material of choice is plasma viral RNA. However, in patients with low viremia (viral load < 500 copies/ml), resistance testing by population-based sequencing is very difficult. OBJECTIVE Therefore, we aimed to investigate whether next generation sequencing (NGS) from proviral DNA and RNA could be an alternative. MATERIAL AND METHODS EDTA blood samples (n = 36) from routine clinical viral load testing were used for the study. Viral loads ranged from 96 to 390,000 copies/mL, with 100% of samples having low viremia. Distribution of subtypes A (n = 2), B (n = 16), C (n = 4), D (n = 2), G (1), CRF02 AG (n = 5), CRF01 AE (n = 5), undefined/mixed (n = 4). The extracted consensus sequences were uploaded to the Stanford HIV Drug Resistance Data Base and Geno2pheno for online analysis of drug resistance mutations and resistance factors. RESULTS A total of 2476 variants or drug resistance mutations (DRMs) were detected with Sanger sequencing, compared with 2892 variants with NGS. An average of 822/1008 variants were identified in plasma viral RNA by Sanger or NGS sequencing, 834/956 in cellular viral RNA, and 820/928 in cellular viral DNA. CONCLUSIONS Both methods are well suited for the detection of HIV substitutions or drug resistance mutations. Our results suggest that cellular RNA or cellular viral DNA is an informative alternative to plasma viral RNA for variant detection in patients with low viremia, as shown by the high correlation of variants in the different viral pools. And we show that by using UDS, a plus of two DRMs per patient becomes visible and that can make a big difference in the assessment of the expected resistance behavior of the virus.
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Affiliation(s)
- Johannes Pröll
- Center for Medical Research, Medical Faculty Johannes Kepler University, Medical Faculty, Krankenhausstraße 5, A-4020 Linz, Austria
| | - Christian Paar
- Institute of Laboratory Medicine, Kepler Universitätsklinikum, Med Campus III, Krankenhausstraße 9, A-4020 Linz, Austria
| | - Ninon Taylor
- Department of Dermatology, University Hospital of the Paracelsus Medical University, Müllner Hauptstraße 48, A-5020 Salzburg, Austria
| | - Matthias Skocic
- Department of Dermatology, Kepler Universitätsklinikum, Med Campus III, Krankenhausstraße 9, A-4020 Linz, Austria
| | - Andrea Freystetter
- Institute of Laboratory Medicine, Kepler Universitätsklinikum, Med Campus III, Krankenhausstraße 9, A-4020 Linz, Austria
| | - Anna Blaimschein
- Institute of Laboratory Medicine, Kepler Universitätsklinikum, Med Campus III, Krankenhausstraße 9, A-4020 Linz, Austria
| | - Roland Mayr
- Institute of Laboratory Medicine, Kepler Universitätsklinikum, Med Campus III, Krankenhausstraße 9, A-4020 Linz, Austria
| | - Norbert Niklas
- Red Cross Transfusion Center for Upper Austria, Krankenhausstraße 7, A-4020, Austria
| | - Sabine Atzmüller
- Center for Medical Research, Medical Faculty Johannes Kepler University, Medical Faculty, Krankenhausstraße 5, A-4020 Linz, Austria
| | - Edeltraud Raml
- Center for Medical Research, Medical Faculty Johannes Kepler University, Medical Faculty, Krankenhausstraße 5, A-4020 Linz, Austria
| | - Christian Wechselberger
- Division of Pathophysiology, Institute for Physiology and Pathophysiology, Medical Faculty, Johannes Kepler University, ADM Building, Krankenhausstraße 5, A-4020 Linz, Austria
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Mbunkah HA, Bertagnolio S, Hamers RL, Hunt G, Inzaule S, Rinke De Wit TF, Paredes R, Parkin NT, Jordan MR, Metzner KJ. Low-Abundance Drug-Resistant HIV-1 Variants in Antiretroviral Drug-Naive Individuals: A Systematic Review of Detection Methods, Prevalence, and Clinical Impact. J Infect Dis 2021; 221:1584-1597. [PMID: 31809534 DOI: 10.1093/infdis/jiz650] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/04/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The presence of high-abundance drug-resistant HIV-1 jeopardizes success of antiretroviral therapy (ART). Despite numerous investigations, the clinical impact of low-abundance drug-resistant HIV-1 variants (LA-DRVs) at levels <15%-25% of the virus population in antiretroviral (ARV) drug-naive individuals remains controversial. METHODS We systematically reviewed 103 studies assessing prevalence, detection methods, technical and clinical detection cutoffs, and clinical significance of LA-DRVs in antiretroviral drug-naive adults. RESULTS In total, 14 919 ARV drug-naive individuals were included. Prevalence of LA-DRVs (ie, proportion of individuals harboring LA-DRVs) was 0%-100%. Technical detection cutoffs showed a 4 log range (0.001%-10%); 42/103 (40.8%) studies investigating the impact of LA-DRVs on ART; 25 studies included only individuals on first-line nonnucleoside reverse transcriptase inhibitor-based ART regimens. Eleven of those 25 studies (44.0%) reported a significantly association between preexisting LA-DRVs and risk of virological failure whereas 14/25 (56.0%) did not. CONCLUSIONS Comparability of the 103 studies is hampered by high heterogeneity of the studies' designs and use of different methods to detect LA-DRVs. Thus, evaluating clinical impact of LA-DRVs on first-line ART remains challenging. We, the WHO HIVResNet working group, defined central areas of future investigations to guide further efforts to implement ultrasensitive resistance testing in routine settings.
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Affiliation(s)
- Herbert A Mbunkah
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zürich, Switzerland.,Institute of Medical Virology, University of Zurich, Zürich, Switzerland.,Paul-Ehrlich-Institut, Langen, Germany
| | | | - Raph L Hamers
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Eijkman-Oxford Clinical Research Unit, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Gillian Hunt
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Seth Inzaule
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tobias F Rinke De Wit
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Roger Paredes
- Infectious Diseases Service and IrsiCaixa AIDS Research Institute for AIDS Research, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | | | - Michael R Jordan
- Division of Geographic Medicine and Infectious Disease, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Karin J Metzner
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zürich, Switzerland.,Institute of Medical Virology, University of Zurich, Zürich, Switzerland
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Drug Resistance Mutation Frequency of Single-Genome Amplification-Derived HIV-1 Polymerase Genomes in the Cerebrospinal Fluid and Plasma of HIV-1-Infected Individuals under Nonsuppressive Therapy. J Virol 2020; 94:JVI.01824-19. [PMID: 32759323 DOI: 10.1128/jvi.01824-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 07/13/2020] [Indexed: 01/05/2023] Open
Abstract
HIV-1 evolution in the cerebrospinal fluid (CSF) and plasma may result in discordant drug resistance mutations (DRMs) in the compartments. Single-genome amplification (SGA) was used to generate partial HIV-1 polymerase genomes in paired CSF and plasma samples from 12 HIV-1-positive participants in the CNS HIV Antiretroviral Therapy Effects Research (CHARTER) study who were classified as neurocognitively unimpaired or with various degrees of HIV-associated neurocognitive disorders (HAND). Subjects were viremic on combination antiretroviral therapy (cART). HIV-1 DRMs and phylogenetic characteristics were determined using the Stanford HIVdb program and phylogenetic analyses. Individual DRMs were identified more frequently in plasma than in paired CSF (P = 0.0078). Significant differences in the ratios of DRMs in CSF and plasma were found in 3 individuals with HAND (3/7 = 43%). Two HAND subjects (2/7 = 29%) demonstrated one DRM in CSF not identified in paired plasma. Longitudinal analyses (n = 4) revealed significant temporal differences in the ratios of DRMs in the compartments. Statistically significant differences in the frequency of DRMs in the CSF and plasma are readily found in those on nonsuppressive cART. While compartment-based DRM discordance was largely consistent with increased drug-selective pressures in the plasma, overrepresentation of DRMs in the central nervous system (CNS) can occur. Underlying mechanisms of HAND are complex and multifactorial. The clinical impact of DRM discordance on viral persistence and HAND pathogenesis remains unclear and warrants further investigation in larger, longitudinal cohorts.IMPORTANCE Several antiretroviral agents do not efficiently enter the CNS, and independent evolution of HIV-1 viral variants in the CNS and plasma can occur. We used single-genome amplification (SGA) in cross-sectional and longitudinal analyses to uniquely define both the identity and relative proportions of drug resistance mutations (DRMs) on individual HIV-1 polymerase genomes in the cerebrospinal fluid (CSF) and plasma in individuals with incomplete viral suppression and known neurocognitive status. Statistically significant differences in the ratio of DRMs in the CSF and plasma were readily found in those on nonsuppressive cART, and overrepresentation of DRMs in the CNS can occur. Although questions about the clinical significance of DRM discordance remain, in the quest for viral eradication, it is important to recognize that a significant, dynamic, compartment-based DRM ratio imbalance can exist, as it has the potential to go unnoticed in the setting of standard clinical drug resistance testing.
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Abstract
Purpose of Review This review focuses on the pathophysiology of acute HIV infection (AHI) and related central nervous system (CNS) pathology, the clinical characteristics of neurologic complications of AHI, and the implications of the CNS reservoir and viral escape for HIV treatment and cure strategies. Recent Findings Recent studies in newly seroconverted populations show a high prevalence of peripheral neuropathy and cognitive dysfunction in AHI, even though these findings have been classically associated with chronic HIV infection. HIV cure strategies such as the "shock and kill" strategy are currently being studied in vitro and even in small clinical trials, though the CNS as a reservoir for latent HIV poses unique barriers to these treatment strategies. Summary Limited point of care diagnostic testing for AHI and delayed recognition of infection continue to lead to under-recognition and under-reporting of neurologic manifestations of AHI. AHI should be on the differential for a broad range of neurological conditions, from Bell's palsy, peripheral neuropathy, and aseptic meningitis, to more rare manifestations such as ADEM, AIDP, meningo-radiculitis, transverse myelitis, and brachial neuritis. Treatment for these conditions involves early initiation of antiretroviral therapy (ART) and then standard presentation-specific treatments. Current HIV cure strategies under investigation include bone marrow transplant, viral reservoir re-activation and eradication, and genome and epigenetic viral targeting. However, CNS penetration by HIV-1 occurs early on in the disease course with the establishment of the CNS viral reservoir and is an important limiting factor for these therapies.
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Potential for early antiretroviral therapy to reduce central nervous system HIV-1 persistence. AIDS 2019; 33 Suppl 2:S135-S144. [PMID: 31789814 DOI: 10.1097/qad.0000000000002326] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
: Although treatment with antiretroviral therapy (ART) improves central nervous inflammation, limits viral replication detected in the cerebrospinal fluid, and prevents severe clinical neurological disease in most individuals, HIV-1 can persist in the central nervous system (CNS) despite ART. Recent observations that initiation of ART early in the course of infection limits the size of systemic HIV reservoirs, parallel clinical reports of increased rates of posttreatment viral control in early treatment cohorts, and an understanding of the dynamics of HIV-1 infection and neuropathogenesis during early infection provides rationale to consider that ART started early in the course of HIV-1 infection may have a beneficial effect on CNS HIV-1 persistence. Early ART may restrict the initial establishment of HIV-1 infection in cells of the CNS, and furthermore, may reduce levels of immune activation and inflammation that allow perpetuation of CNS infection. In this review, we consider the precedent set by studies of the impact of early treatment on systemic HIV-1 reservoirs, summarize the current understanding of early CNS HIV-1 exposure and its effects, and examine the evidence for a benefit in the CNS compartment of early treatment.
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