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Runtuwene LR, Parbie PK, Mizutani T, Ishizaka A, Matsuoka S, Abana CZY, Kushitor D, Bonney EY, Ofori SB, Kiyono H, Ishikawa K, Ampofo WK, Matano T. Longitudinal analysis of microbiome composition in Ghanaians living with HIV-1. Front Microbiol 2024; 15:1359402. [PMID: 38426062 PMCID: PMC10902004 DOI: 10.3389/fmicb.2024.1359402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/18/2024] [Indexed: 03/02/2024] Open
Abstract
Human immunodeficiency virus (HIV) 1 infection is known to cause gut microbiota dysbiosis. Among the causes is the direct infection of HIV-1 in gut-resident CD4+ T cells, causing a cascade of phenomena resulting in the instability of the gut mucosa. The effect of HIV infection on gut microbiome dysbiosis remains unresolved despite antiretroviral therapy. Here, we show the results of a longitudinal study of microbiome analysis of people living with HIV (PLWH). We contrasted the diversity and composition of the microbiome of patients with HIV at the first and second time points (baseline_case and six months later follow-up_case, respectively) with those of healthy individuals (baseline_control). We found that despite low diversity indices in the follow-up_case, the abundance of some genera was recovered but not completely, similar to baseline_control. Some genera were consistently in high abundance in PLWH. Furthermore, we found that the CD4+ T-cell count and soluble CD14 level were significantly related to high and low diversity indices, respectively. We also found that the abundance of some genera was highly correlated with clinical features, especially with antiretroviral duration. This includes genera known to be correlated with worse HIV-1 progression (Achromobacter and Stenotrophomonas) and a genus associated with gut protection (Akkermansia). The fact that a protector of the gut and genera linked to a worse progression of HIV-1 are both enriched may signify that despite the improvement of clinical features, the gut mucosa remains compromised.
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Affiliation(s)
- Lucky Ronald Runtuwene
- AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
- Graduate School of Frontier Sciences, The University of Tokyo, Kashiwa, Japan
| | - Prince Kofi Parbie
- Department of Virology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Taketoshi Mizutani
- Graduate School of Frontier Sciences, The University of Tokyo, Kashiwa, Japan
- The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Aya Ishizaka
- The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Saori Matsuoka
- AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Christopher Zaab-Yen Abana
- Department of Virology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Dennis Kushitor
- Department of Virology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Evelyn Yayra Bonney
- Department of Virology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Sampson Badu Ofori
- Department of Internal Medicine, Eastern Regional Hospital Koforidua, Ghana Health Service, Koforidua, Ghana
| | - Hiroshi Kiyono
- The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
- Institute for Global Prominent Research, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Medicine, Chiba University-University of California San Diego Center for Mucosal Immunology, Allergy and Vaccines (cMAV), University of California San Diego, San Diego, CA, United States
| | - Koichi Ishikawa
- AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - William Kwabena Ampofo
- Department of Virology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Tetsuro Matano
- AIDS Research Center, National Institute of Infectious Diseases, Tokyo, Japan
- The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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2
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Moretti S, Schietroma I, Sberna G, Maggiorella MT, Sernicola L, Farcomeni S, Giovanetti M, Ciccozzi M, Borsetti A. HIV-1-Host Interaction in Gut-Associated Lymphoid Tissue (GALT): Effects on Local Environment and Comorbidities. Int J Mol Sci 2023; 24:12193. [PMID: 37569570 PMCID: PMC10418605 DOI: 10.3390/ijms241512193] [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: 06/29/2023] [Revised: 07/20/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
HIV-1 replication in the gastrointestinal (GI) tract causes severe CD4+ T-cell depletion and disruption of the protective epithelial barrier in the intestinal mucosa, causing microbial translocation, the main driver of inflammation and immune activation, even in people living with HIV (PLWH) taking antiretroviral drug therapy. The higher levels of HIV DNA in the gut compared to the blood highlight the importance of the gut as a viral reservoir. CD4+ T-cell subsets in the gut differ in phenotypic characteristics and differentiation status from the ones in other tissues or in peripheral blood, and little is still known about the mechanisms by which the persistence of HIV is maintained at this anatomical site. This review aims to describe the interaction with key subsets of CD4+ T cells in the intestinal mucosa targeted by HIV-1 and the role of gut microbiome and its metabolites in HIV-associated systemic inflammation and immune activation that are crucial in the pathogenesis of HIV infection and related comorbidities.
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Affiliation(s)
- Sonia Moretti
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, 00162 Rome, Italy; (S.M.); (I.S.); (G.S.); (M.T.M.); (L.S.); (S.F.)
| | - Ivan Schietroma
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, 00162 Rome, Italy; (S.M.); (I.S.); (G.S.); (M.T.M.); (L.S.); (S.F.)
| | - Giuseppe Sberna
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, 00162 Rome, Italy; (S.M.); (I.S.); (G.S.); (M.T.M.); (L.S.); (S.F.)
| | - Maria Teresa Maggiorella
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, 00162 Rome, Italy; (S.M.); (I.S.); (G.S.); (M.T.M.); (L.S.); (S.F.)
| | - Leonardo Sernicola
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, 00162 Rome, Italy; (S.M.); (I.S.); (G.S.); (M.T.M.); (L.S.); (S.F.)
| | - Stefania Farcomeni
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, 00162 Rome, Italy; (S.M.); (I.S.); (G.S.); (M.T.M.); (L.S.); (S.F.)
| | - Marta Giovanetti
- Instituto Rene Rachou, Fundação Oswaldo Cruz, Belo Horizonte 30190-009, Minas Gerais, Brazil;
- Sciences and Technologies for Sustainable Development and One Health, University Campus Bio-Medico of Rome, 00128 Rome, Italy
| | - Massimo Ciccozzi
- Unit of Medical Statistics and Molecular Epidemiology, University Campus Bio-Medico of Rome, 00128 Rome, Italy;
| | - Alessandra Borsetti
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, 00162 Rome, Italy; (S.M.); (I.S.); (G.S.); (M.T.M.); (L.S.); (S.F.)
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3
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Zhang C, Zaman LA, Poluektova LY, Gorantla S, Gendelman HE, Dash PK. Humanized Mice for Studies of HIV-1 Persistence and Elimination. Pathogens 2023; 12:879. [PMID: 37513726 PMCID: PMC10383313 DOI: 10.3390/pathogens12070879] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/06/2023] [Accepted: 06/23/2023] [Indexed: 07/30/2023] Open
Abstract
A major roadblock to achieving a cure for human immunodeficiency virus type one (HIV-1) is the persistence of latent viral infections in the cells and tissue compartments of an infected human host. Latent HIV-1 proviral DNA persists in resting memory CD4+ T cells and mononuclear phagocytes (MPs; macrophages, microglia, and dendritic cells). Tissue viral reservoirs of both cell types reside in the gut, lymph nodes, bone marrow, spleen, liver, kidney, skin, adipose tissue, reproductive organs, and brain. However, despite the identification of virus-susceptible cells, several limitations persist in identifying broad latent reservoirs in infected persons. The major limitations include their relatively low abundance, the precise identification of latently infected cells, and the lack of biomarkers for identifying latent cells. While primary MP and CD4+ T cells and transformed cell lines are used to interrogate mechanisms of HIV-1 persistence, they often fail to accurately reflect the host cells and tissue environments that carry latent infections. Given the host specificity of HIV-1, there are few animal models that replicate the natural course of viral infection with any precision. These needs underlie the importance of humanized mouse models as both valuable and cost-effective tools for studying viral latency and subsequently identifying means of eliminating it. In this review, we discuss the advantages and limitations of humanized mice for studies of viral persistence and latency with an eye toward using these models to test antiretroviral and excision therapeutics. The goals of this research are to use the models to address how and under which circumstances HIV-1 latency can be detected and eliminated. Targeting latent reservoirs for an ultimate HIV-1 cure is the task at hand.
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Affiliation(s)
| | | | | | | | | | - Prasanta K. Dash
- Department of Pharmacology and Experimental Neuroscience, College of Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA (S.G.)
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Guo YT, Guo XY, Fan LN, Wang ZR, Qu MM, Zhang C, Fan X, Song JW, Yang BP, Zhang JY, Xu R, Jiao YM, Ma P, Chen YK, Wang FS. The Imbalance Between Intestinal Th17 and Treg Cells Is Associated with an Incomplete Immune Reconstitution During Long-Term Antiretroviral Therapy in Patients with HIV. Viral Immunol 2023; 36:331-342. [PMID: 37184871 DOI: 10.1089/vim.2023.0017] [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] [Indexed: 05/16/2023] Open
Abstract
Studies assessing the gut mucosal immune balance in HIV-infected patients using intestinal samples are scarce. In this study, we used intestinal mucosal specimens from the ileocecal region of seven immunological nonresponders (INRs), nine immunological responders (IRs), and six HIV-negative controls. We investigated T helper 17 (Th17) and T regulatory (Treg) cell counts and their ratio, zonula occludens-1 (ZO-1), intestinal fatty acid-binding protein (I-FABP), tumor necrosis factor-α, CD4+ T cell counts, HIV DNA, and cell-associated HIV RNA. The results showed that INRs had lower Th17 and higher Treg cell counts than IR, resulting in a significant difference in the Th17/Treg ratio between IRs and INRs. In addition, INRs had lower ZO-1 and higher I-FABP levels than IRs. The Th17/Treg ratio was positively associated with ZO-1 and negatively associated with I-FABP levels. There was a positive correlation between Th17/Treg ratio and CD4+ T cell counts and a negative correlation between the Th17/Treg ratio and HIV DNA in the intestine. Our study suggests that the imbalance of Th17/Treg in the intestine is a characteristic of incomplete immune reconstitution to antiretroviral therapy and is associated with intestinal damage.
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Affiliation(s)
- Yun-Tian Guo
- Department of Internal Medicine, The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Senior Department of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
| | - Xiao-Yan Guo
- Senior Department of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
| | - Li-Na Fan
- Department of Infectious Diseases, Tianjin Second People's Hospital, Tianjin, China
| | - Ze-Rui Wang
- Department of Gastroenterology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Meng-Meng Qu
- Senior Department of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
| | - Chao Zhang
- Senior Department of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
| | - Xing Fan
- Senior Department of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
| | - Jin-Wen Song
- Senior Department of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
| | - Bao-Peng Yang
- Senior Department of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
| | - Ji-Yuan Zhang
- Senior Department of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
| | - Ruonan Xu
- Senior Department of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
| | - Yan-Mei Jiao
- Senior Department of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
| | - Ping Ma
- Department of Infectious Diseases, Tianjin Second People's Hospital, Tianjin, China
| | - Yao-Kai Chen
- Department of Infectious Disease, Chongqing Public Health Medical Center, Chongqing, China
| | - Fu-Sheng Wang
- Department of Internal Medicine, The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Senior Department of Infectious Diseases, the Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious Diseases, Beijing, China
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5
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de Gea-Grela A, Moreno S. Controversies in the Design of Strategies for the Cure of HIV Infection. Pathogens 2023; 12:322. [PMID: 36839593 PMCID: PMC9961067 DOI: 10.3390/pathogens12020322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 02/17/2023] Open
Abstract
The cure for chronic human immunodeficiency virus (HIV) infections has been a goal pursued since the antiretroviral therapy that improved the clinical conditions of patients became available. However, the exclusive use of these drugs is not enough to achieve a cure, since the viral load rebounds when the treatment is discontinued, leading to disease progression. There are several theories and hypotheses about the biological foundations that prevent a cure. The main obstacle appears to be the existence of a latent viral reservoir that cannot be eliminated pharmacologically. This concept is the basis of the new strategies that seek a cure, known as kick and kill. However, there are other lines of study that recognize mechanisms of persistent viral replication in patients under effective treatment, and that would modify the current lines of research on the cure of HIV. Given the importance of these concepts, in this work, we propose to review the most recent evidence on these hypotheses, covering both the evidence that is positioned in favor and against, trying to expose what are some of the challenges that remain to be resolved in this field of research.
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Affiliation(s)
| | - Santiago Moreno
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigaciones Sanitarias (IRYCIS), Alcalá University, 28034 Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28034 Madrid, Spain
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6
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Kharbanda KK, Chokshi S, Tikhanovich I, Weinman SA, New-Aaron M, Ganesan M, Osna NA. A Pathogenic Role of Non-Parenchymal Liver Cells in Alcohol-Associated Liver Disease of Infectious and Non-Infectious Origin. BIOLOGY 2023; 12:255. [PMID: 36829532 PMCID: PMC9953685 DOI: 10.3390/biology12020255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023]
Abstract
Now, much is known regarding the impact of chronic and heavy alcohol consumption on the disruption of physiological liver functions and the induction of structural distortions in the hepatic tissues in alcohol-associated liver disease (ALD). This review deliberates the effects of alcohol on the activity and properties of liver non-parenchymal cells (NPCs), which are either residential or infiltrated into the liver from the general circulation. NPCs play a pivotal role in the regulation of organ inflammation and fibrosis, both in the context of hepatotropic infections and in non-infectious settings. Here, we overview how NPC functions in ALD are regulated by second hits, such as gender and the exposure to bacterial or viral infections. As an example of the virus-mediated trigger of liver injury, we focused on HIV infections potentiated by alcohol exposure, since this combination was only limitedly studied in relation to the role of hepatic stellate cells (HSCs) in the development of liver fibrosis. The review specifically focusses on liver macrophages, HSC, and T-lymphocytes and their regulation of ALD pathogenesis and outcomes. It also illustrates the activation of NPCs by the engulfment of apoptotic bodies, a frequent event observed when hepatocytes are exposed to ethanol metabolites and infections. As an example of such a double-hit-induced apoptotic hepatocyte death, we deliberate on the hepatotoxic accumulation of HIV proteins, which in combination with ethanol metabolites, causes intensive hepatic cell death and pro-fibrotic activation of HSCs engulfing these HIV- and malondialdehyde-expressing apoptotic hepatocytes.
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Affiliation(s)
- Kusum K. Kharbanda
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE 68105, USA
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Department of Biochemistry & Molecular Biology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Shilpa Chokshi
- Institute of Hepatology, Foundation for Liver Research, London SE5 9NT, UK
- Faculty of Life Sciences and Medicine, King’s College London, London SE5 8AF, UK
| | - Irina Tikhanovich
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO 66160, USA
| | - Steven A. Weinman
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, MO 66160, USA
- Research Service, Kansas City Veterans Administration Medical Center, Kansas City, MO 64128, USA
| | - Moses New-Aaron
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE 68105, USA
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Murali Ganesan
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE 68105, USA
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Natalia A. Osna
- Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE 68105, USA
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
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7
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Solis-Leal A, May AM, Mohan M, Dufour JP, Ling B. Duration of antiretroviral therapy impacts the degree of residual SIV infection in the gut in long-term non-progressing Chinese rhesus macaques. J Med Virol 2023; 95:e28185. [PMID: 36181356 PMCID: PMC9839467 DOI: 10.1002/jmv.28185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/08/2022] [Accepted: 09/26/2022] [Indexed: 01/17/2023]
Abstract
The gut is a major reservoir in HIV-infected individuals on antiretroviral therapy (ART) and in long-term non-progressors (LTNPs). Whether ART reduces gut infection and reservoirs in LTNPs is unknown. Herein, SIV-infected LTNP Rhesus macaques were treated with short- or long-term ART, and SIV envelope gp120 sequences obtained from single genome amplification were analyzed before and after ART in peripheral blood and the intestine. Although ART does not eliminate SIV in these LTNPs, a longer ART period dramatically reduces SIV infection in the gut. This study highlights the importance of long-term ART in LTNPs to minimize gut infection and prolong remission.
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Affiliation(s)
- Antonio Solis-Leal
- Host-Pathogen Interaction Program & Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Ann-Marie May
- Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Mahesh Mohan
- Host-Pathogen Interaction Program & Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA
| | - Jason P Dufour
- Tulane National Primate Research Center, Covington, LA 70433, USA
| | - Binhua Ling
- Host-Pathogen Interaction Program & Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA
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8
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Le T, Reeves RK, McKinnon LR. The Functional Diversity of Tissue-Resident Natural Killer Cells Against Infection. Immunology 2022; 167:28-39. [PMID: 35751452 DOI: 10.1111/imm.13523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 06/03/2022] [Indexed: 11/30/2022] Open
Abstract
For decades, studies of natural killer (NK) cells have focused on those found in peripheral blood (PBNK cells) as the prototype for NK cell biology. Only recently have researchers begun to explore the diversity of tissue-resident NK (tr-NK) cells. While tr-NK cells were initially identified from mice parabiosis and intravascular staining experiments, they can also be identified by tissue retention markers such as CD69, CD103, and others. More importantly, tr-NK cells have distinct functions compared to PBNK cells. Within the liver, there are diverse subsets of tr-NK cells expressing different combinations of tissue-retention markers and transcription factors, the clinical relevance of which are still unclear. Functionally, liver tr-NK are primed with immediate responsiveness to infection and equipped with regulatory mechanisms to prevent liver damage. When decidual NK (dNK) cells were first discovered, they were mainly characterized by their reduced cytotoxicity and functions related to placental development. Recent studies, however, revealed different mechanisms by which dNK cells prevent uterine infections. The lungs are one of the most highly exposed sites for infection due to their role in oxygen exchange. Upon influenza infection, lung tr-NK cells can degranulate and produce more inflammatory cytokines than PBNK cells. Less understood are gut tr-NK cells which were recently characterized in infants and adults for their functional differences. In this mini-review, we aim to provide a brief overview of the most recent discoveries on how several tr-NK cells are implicated in the immune response against infection. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Toby Le
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
| | - R Keith Reeves
- Division of Innate and Comparative Immunology, Center for Human Systems Immunology, Duke University, Durham, NC, USA.,Department of Surgery, Duke University School of Medicine, Durham, NC, USA.,Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Lyle R McKinnon
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
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Kleinman AJ, Sivanandham S, Sette P, Sivanandham R, Policicchio BB, Xu C, Penn E, Brocca-Cofano E, Le Hingrat Q, Ma D, Pandrea I, Apetrei C. Changes to the Simian Immunodeficiency Virus (SIV) Reservoir and Enhanced SIV-Specific Responses in a Rhesus Macaque Model of Functional Cure after Serial Rounds of Romidepsin Administrations. J Virol 2022; 96:e0044522. [PMID: 35638831 PMCID: PMC9215247 DOI: 10.1128/jvi.00445-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/10/2022] [Indexed: 11/20/2022] Open
Abstract
HIV persistence requires lifelong antiretroviral therapy (ART), calling for a cure. The histone deacetylase inhibitor, romidepsin, is used in the "shock and kill" approach with the goal of reactivating virus and subsequently clearing infected cells through cell-mediated immune responses. We tested serial and double infusions of romidepsin in a rhesus macaque (RM) model of SIV functional cure, which controls virus without ART. Off ART, romidepsin reactivated SIV in all RMs. Subsequent infusions resulted in diminished reactivation, and two RMs did not reactivate the virus after the second or third infusions. Therefore, those two RMs received CD8-depleting antibody to assess the replication competence of the residual reservoir. The remaining RMs received double infusions, i.e., two doses separated by 48-h. Double infusions were well tolerated, induced immune activation, and effectively reactivated SIV. Although reactivation was gradually diminished, cell-associated viral DNA was minimally changed, and viral outgrowth occurred in 4/5 RMs. In the RM which did not reactivate after CD8 depletion, viral outgrowth was not detected in peripheral blood mononuclear cells (PBMC)-derived CD4+ cells. The frequency of SIV-specific CD8+ T cells increased after romidepsin administration, and the increased SIV-specific immune responses were associated, although not statistically, with the diminished reactivation. Thus, our data showing sequential decreases in viral reactivation with repeated romidepsin administrations with all RMs and absence of viral reactivation after CD8+ T-cell depletion in one animal suggest that, in the context of healthy immune responses, romidepsin affected the inducible viral reservoir and gradually increased immune-mediated viral control. Given the disparities between the results of romidepsin administration to ART-suppressed SIVmac239-infected RMs and HIV-infected normal progressors compared to our immune-healthy model, our data suggest that improving immune function for greater SIV-specific responses should be the starting point of HIV cure strategies. IMPORTANCE HIV cure is sought after due to the prevalence of comorbidities that occur in persons with HIV. One of the most investigated HIV cure strategies is the "shock and kill" approach. Our study investigated the use of romidepsin, a histone deacetylase (HDAC) inhibitor, in our rhesus macaque model of functional cure, which allows for better resolution of viral reactivation due to the lack of antiretroviral therapy. We found that repeated rounds of romidepsin resulted in gradually diminished viral reactivation. One animal inevitably lacked replication-competent virus in the blood. With the accompanying enhancement of the SIV-specific immune response, our data suggest that there is a reduction of the viral reservoir in one animal by the cell-mediated immune response. With the differences observed between our model and persons living with HIV (PWH) treated with romidepsin, specifically in the context of a healthy immune system in our model, our data thereby indicate the importance of restoring the immune system for cure strategies.
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Affiliation(s)
- Adam J. Kleinman
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sindhuja Sivanandham
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Paola Sette
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ranjit Sivanandham
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Benjamin B. Policicchio
- Department of Infectious Diseases and Immunology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cuiling Xu
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ellen Penn
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Egidio Brocca-Cofano
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Quentin Le Hingrat
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dongzhu Ma
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ivona Pandrea
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Infectious Diseases and Immunology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cristian Apetrei
- Division of Infectious Diseases, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Infectious Diseases and Immunology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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10
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Elmahdi R, Kochhar GS, Iversen AT, Allin KH, Dulai PS, Desai A, Jess T. Development of Inflammatory Bowel Disease in HIV Patients: A Danish Cohort Study (1983–2018) With American Validation (1999–2018). GASTRO HEP ADVANCES 2022; 1:1114-1121. [PMID: 36531445 PMCID: PMC9757766 DOI: 10.1016/j.gastha.2022.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Human immunodeficiency virus (HIV) infection is associated with several immune-mediated disorders. However, the risk of inflammatory bowel disease (IBD) in people living with HIV (PLWH) remains unclear. We aimed to assess the risk of IBD among PLWH using a nationwide, population-based Danish cohort and to validate findings in a large American insurance-based database. METHODS Using Danish registries (1983-2018), we identified 8995 PLWH and age- and sex-matched them to 449,750 HIV-negative individuals. Cox regression analysis was undertaken to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) for IBD diagnosis. Results were stratified by sex, age, and year of HIV diagnosis. Using an American insurance-based cohort, Explorys (1999-2018), we assessed the prevalence odds ratio (OR) and 95% CI of IBD diagnosis in PLWH compared with HIV-negative individuals. RESULTS IBD diagnosis among PLWH in Denmark was increased (HR: 2.25, 95% CI: 1.78-2.83) compared with matched HIV-negative individuals. This was seen for both Crohn's disease (HR: 2.25, 95% CI: 1.47-3.44) and ulcerative colitis (HR: 2.24, 95% CI: 1.70-2.96) and in male (HR: 2.75, 95% CI: 2.15-3.52) but not female (HR: 0.93, 95% CI: 0.48-1.79) PLWH. Explorys analysis also showed an increased odds of IBD diagnoses among PLWH (OR: 1.41; 95% CI: 1.35-1.49). CONCLUSION This study finds an increased risk of IBD diagnosis among PLWH in both a Danish and US cohort, highlighting a need to consider IBD in PLWH with new-onset gastrointestinal symptoms. Further research into the role of antiretroviral therapy in this relationship is required.
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Affiliation(s)
- Rahma Elmahdi
- Department of Clinical Medicine, Center for the Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Aalborg University, Copenhagen, Denmark
- Department for Lung and Infectious Disease Medicine, Nordsjællands Hospital, Hillerød, Denmark
| | - Gursimran S. Kochhar
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Aske T. Iversen
- Department of Clinical Medicine, Center for the Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Aalborg University, Copenhagen, Denmark
| | - Kristine H. Allin
- Department of Clinical Medicine, Center for the Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Aalborg University, Copenhagen, Denmark
- Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Parambir S. Dulai
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Aakash Desai
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Tine Jess
- Department of Clinical Medicine, Center for the Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Aalborg University, Copenhagen, Denmark
- Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
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11
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Yukl SA, Khan S, Chen TH, Trapecar M, Wu F, Xie G, Telwatte S, Fulop D, Pico AR, Laird GM, Ritter KD, Jones NG, Lu CM, Siliciano RF, Roan NR, Milush JM, Somsouk M, Deeks SG, Hunt PW, Sanjabi S. Shared Mechanisms Govern HIV Transcriptional Suppression in Circulating CD103 + and Gut CD4 + T Cells. J Virol 2020; 95:e01331-20. [PMID: 33115867 PMCID: PMC7944458 DOI: 10.1128/jvi.01331-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/23/2020] [Indexed: 12/22/2022] Open
Abstract
Latent HIV infection is the main barrier to cure, and most HIV-infected cells reside in the gut, where distinct but unknown mechanisms may promote viral latency. Transforming growth factor β (TGF-β), which induces the expression of CD103 on tissue-resident memory T cells, has been implicated in HIV latency. Using CD103 as a surrogate marker to identify cells that have undergone TGF-β signaling, we compared the HIV RNA/DNA contents and cellular transcriptomes of CD103+ and CD103- CD4 T cells from the blood and rectum of HIV-negative (HIV-) and antiretroviral therapy (ART)-suppressed HIV-positive (HIV+) individuals. Like gut CD4+ T cells, circulating CD103+ cells harbored more HIV DNA than did CD103- cells but transcribed less HIV RNA per provirus. Circulating CD103+ cells also shared a gene expression profile that is closer to that of gut CD4 T cells than to that of circulating CD103- cells, with significantly lower expression levels of ribosomal proteins and transcriptional and translational pathways associated with HIV expression but higher expression levels of a subset of genes implicated in suppressing HIV transcription. These findings suggest that blood CD103+ CD4 T cells can serve as a model to study the molecular mechanisms of HIV latency in the gut and reveal new cellular factors that may contribute to HIV latency.IMPORTANCE The ability of HIV to establish a reversibly silent, "latent" infection is widely regarded as the main barrier to curing HIV. Most HIV-infected cells reside in tissues such as the gut, but it is unclear what mechanisms maintain HIV latency in the blood or gut. We found that circulating CD103+ CD4+ T cells are enriched for HIV-infected cells in a latent-like state. Using RNA sequencing (RNA-seq), we found that CD103+ T cells share a cellular transcriptome that more closely resembles that of CD4+ T cells from the gut, suggesting that they are homing to or from the gut. We also identified the cellular genes whose expression distinguishes gut CD4+ or circulating CD103+ T cells from circulating CD103- T cells, including some genes that have been implicated in HIV expression. These genes may contribute to latent HIV infection in the gut and may serve as new targets for therapies aimed at curing HIV.
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Affiliation(s)
- Steven A Yukl
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Shahzada Khan
- Gladstone Institutes, San Francisco, California, USA
| | - Tsui-Hua Chen
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- University of California, San Francisco, San Francisco, California, USA
| | | | - Frank Wu
- Gladstone Institutes, San Francisco, California, USA
| | - Guorui Xie
- Gladstone Institutes, San Francisco, California, USA
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Sushama Telwatte
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Daniel Fulop
- Gladstone Institutes, San Francisco, California, USA
| | | | | | | | - Norman G Jones
- Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Chuanyi M Lu
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- University of California, San Francisco, San Francisco, California, USA
| | - Robert F Siliciano
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Howard Hughes Medical Institute, Baltimore, Maryland, USA
| | - Nadia R Roan
- Gladstone Institutes, San Francisco, California, USA
- Department of Urology, University of California, San Francisco, San Francisco, California, USA
| | - Jeffrey M Milush
- Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Ma Somsouk
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California, USA
| | - Steven G Deeks
- Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Peter W Hunt
- Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Shomyseh Sanjabi
- Gladstone Institutes, San Francisco, California, USA
- Department of Microbiology and Immunology, University of California, San Francisco, San Francisco, California, USA
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12
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Fujinaga K, Cary DC. Experimental Systems for Measuring HIV Latency and Reactivation. Viruses 2020; 12:v12111279. [PMID: 33182414 PMCID: PMC7696534 DOI: 10.3390/v12111279] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 11/02/2020] [Accepted: 11/05/2020] [Indexed: 02/07/2023] Open
Abstract
The final obstacle to achieving a cure to HIV/AIDS is the presence of latent HIV reservoirs scattered throughout the body. Although antiretroviral therapy maintains plasma viral loads below the levels of detection, upon cessation of therapy, the latent reservoir immediately produces infectious progeny viruses. This results in elevated plasma viremia, which leads to clinical progression to AIDS. Thus, if a HIV cure is ever to become a reality, it will be necessary to target and eliminate the latent reservoir. To this end, tremendous effort has been dedicated to locate the viral reservoir, understand the mechanisms contributing to latency, find optimal methods to reactivate HIV, and specifically kill latently infected cells. Although we have not yet identified a therapeutic approach to completely eliminate HIV from patients, these efforts have provided many technological breakthroughs in understanding the underlying mechanisms that regulate HIV latency and reactivation in vitro. In this review, we summarize and compare experimental systems which are frequently used to study HIV latency. While none of these models are a perfect proxy for the complex systems at work in HIV+ patients, each aim to replicate HIV latency in vitro.
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Affiliation(s)
- Koh Fujinaga
- Division of Rheumatology, Department of Medicine, School of Medicine, University of California, San Francisco, CA 94143-0703, USA
- Correspondence: ; Tel.: +1-415-502-1908
| | - Daniele C. Cary
- Department of Medicine, Microbiology, and Immunology, School of Medicine, University of California, San Francisco, CA 94143-0703, USA;
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13
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Tumiotto C, Alves BM, Recordon-Pinson P, Jourdain M, Bellecave P, Guidicelli GL, Visentin J, Bonnet F, Hessamfar M, Neau D, Sanchez J, Brander C, Sajadi M, Eyzaguirre L, Soares EA, Routy JP, Soares MA, Fleury H. Provir/Latitude 45 study: A step towards a multi-epitopic CTL vaccine designed on archived HIV-1 DNA and according to dominant HLA I alleles. PLoS One 2019; 14:e0212347. [PMID: 30811489 PMCID: PMC6392325 DOI: 10.1371/journal.pone.0212347] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 01/22/2019] [Indexed: 12/26/2022] Open
Abstract
One of the approaches by which the scientific community is seeking to cure HIV is the use of therapeutic vaccination. Previous studies have highlighted the importance of the virus-specific CD8+ T cell cytotoxic responses for the immune control of HIV and have oriented research on vaccine constructs based on CTL epitopes from circulating HIV-1 strains. The clinical trials with therapeutic vaccines to date have had limited success likely due to (i) a discrepancy between archived CTL epitopes in the viral reservoir and those in circulating viruses before antiretroviral therapy (ART) initiation and (ii) the lack of strong affinity between the selected CTL epitopes and the HLA grooves for presentation to CD8+ cells. To overcome these limitations, we launched the Provir/Latitude 45 study to identify conserved CTL epitopes in archived HIV-1 DNA according to the HLA class I alleles of aviremic patients, most of whom are under ART. The near full-length genomes or Gag, Pol and Nef regions of proviral DNA were sequenced by Sanger and/or Next Generation Sequencing (NGS). The HLA-A and B alleles were defined by NGS or molecular analysis. The TuTuGenetics software, which moves a sliding window of 8 to 10 amino acids through the amino acid alignment, was combined with the Immune Epitope Data Base (IEDB) to automatically calculate the theoretical binding affinity of identified epitopes to the HLA alleles for each individual. We identified 15 conserved epitopes in Pol (11), Gag (3), and Nef (1) according to their potential presentation by the dominant HLA-A and B alleles and now propose to use the corresponding conserved peptides in a multi-epitopic vaccine (HLA-fitted VAC, HFVAC).
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Affiliation(s)
- Camille Tumiotto
- University Hospital of Bordeaux, CNRS UMR 5234, Bordeaux, France
| | | | | | - Marine Jourdain
- University Hospital of Bordeaux, CNRS UMR 5234, Bordeaux, France
| | | | | | | | - Fabrice Bonnet
- University Hospital of Bordeaux, CNRS UMR 5234, Bordeaux, France
| | - Mojdan Hessamfar
- University Hospital of Bordeaux, CNRS UMR 5234, Bordeaux, France
| | - Didier Neau
- University Hospital of Bordeaux, CNRS UMR 5234, Bordeaux, France
| | - Jorge Sanchez
- Centro de Investigationes Technologicas, Biomedicas y Madioambiantales, Lima, Peru
| | - Christian Brander
- IrsiCaixa AIDS Research Institute, Hospital Universitari Germans Trias I Pujol, Badalona, Spain
- Central University of Catalonia, Barcelona, Spain
- ICREA, Barcelona, Spain
| | - Mohammad Sajadi
- Institute of Human Virology, Baltimore, MD, United States of America
| | | | | | | | | | - Hervé Fleury
- University Hospital of Bordeaux, CNRS UMR 5234, Bordeaux, France
- * E-mail:
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14
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Telwatte S, Lee S, Somsouk M, Hatano H, Baker C, Kaiser P, Kim P, Chen TH, Milush J, Hunt PW, Deeks SG, Wong JK, Yukl SA. Gut and blood differ in constitutive blocks to HIV transcription, suggesting tissue-specific differences in the mechanisms that govern HIV latency. PLoS Pathog 2018; 14:e1007357. [PMID: 30440043 PMCID: PMC6237391 DOI: 10.1371/journal.ppat.1007357] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 09/27/2018] [Indexed: 02/07/2023] Open
Abstract
Latently-infected CD4+ T cells are widely considered to be the major barrier to a cure for HIV. Much of our understanding of HIV latency comes from latency models and blood cells, but most HIV-infected cells reside in lymphoid tissues such as the gut. We hypothesized that tissue-specific environments may impact the mechanisms that govern HIV expression. To assess the degree to which different mechanisms inhibit HIV transcription in the gut and blood, we quantified HIV transcripts suggestive of transcriptional interference (U3-U5; "Read-through"), initiation (TAR), 5' elongation (R-U5-pre-Gag; "Long LTR"), distal transcription (Nef), completion (U3-polyA; "PolyA"), and multiple splicing (Tat-Rev) in matched peripheral blood mononuclear cells (PBMCs) and rectal biopsies, and matched FACS-sorted CD4+ T cells from blood and rectum, from two cohorts of ART-suppressed individuals. Like the PBMCs, rectal biopsies showed low levels of read-through transcripts (median = 23 copies/106 cells) and a gradient of total (679)>elongated(75)>Nef(16)>polyadenylated (11)>multiply-spliced HIV RNAs(<1) [p<0.05 for all], demonstrating blocks to HIV transcriptional elongation, completion, and splicing. Rectal CD4+ T cells showed a similar gradient of total>polyadenylated>multiply-spliced transcripts, but the ratio of total to elongated transcripts was 6-fold lower than in blood CD4+ T cells (P = 0.016), suggesting less of a block to HIV transcriptional elongation in rectal CD4+ T cells. Levels of total transcripts per provirus were significantly lower in rectal biopsies compared to PBMCs (median 3.5 vs. 15.4; P = 0.008) and in sorted CD4+ T cells from rectum compared to blood (median 2.7 vs. 31.8; P = 0.016). The lower levels of HIV transcriptional initiation and of most HIV transcripts per provirus in the rectum suggest that this site may be enriched for latently-infected cells, cells in which latency is maintained by different mechanisms, or cells in a "deeper" state of latency. These are important considerations for designing therapies that aim to disrupt HIV latency in all tissue compartments.
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Affiliation(s)
- Sushama Telwatte
- San Francisco Veterans Affairs (VA) Medical Center and University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Sulggi Lee
- Zuckerberg San Francisco General Hospital and the University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Ma Somsouk
- Zuckerberg San Francisco General Hospital and the University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Hiroyu Hatano
- Zuckerberg San Francisco General Hospital and the University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Christopher Baker
- Zuckerberg San Francisco General Hospital and the University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Philipp Kaiser
- San Francisco Veterans Affairs (VA) Medical Center and University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Peggy Kim
- San Francisco Veterans Affairs (VA) Medical Center and University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Tsui-Hua Chen
- San Francisco Veterans Affairs (VA) Medical Center and University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Jeffrey Milush
- Zuckerberg San Francisco General Hospital and the University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Peter W. Hunt
- Zuckerberg San Francisco General Hospital and the University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Steven G. Deeks
- Zuckerberg San Francisco General Hospital and the University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Joseph K. Wong
- San Francisco Veterans Affairs (VA) Medical Center and University of California, San Francisco (UCSF), San Francisco, CA, United States of America
| | - Steven A. Yukl
- San Francisco Veterans Affairs (VA) Medical Center and University of California, San Francisco (UCSF), San Francisco, CA, United States of America
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