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Kutscher S, Allgayer S, Dembek CJ, Bogner JR, Protzer U, Goebel FD, Erfle V, Cosma A. MVA-nef induces HIV-1-specific polyfunctional and proliferative T-cell responses revealed by the combination of short- and long-term immune assays. Gene Ther 2010; 17:1372-83. [DOI: 10.1038/gt.2010.90] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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2
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Zhou Q, Hidajat R, Peng B, Venzon D, Aldrich MK, Richardson E, Lee EM, Kalyanaraman VS, Grimes G, Gómez-Román VR, Summers LE, Malkevich N, Robert-Guroff M. Comparative evaluation of oral and intranasal priming with replication-competent adenovirus 5 host range mutant (Ad5hr)-simian immunodeficiency virus (SIV) recombinant vaccines on immunogenicity and protective efficacy against SIV(mac251). Vaccine 2007; 25:8021-35. [PMID: 17935840 DOI: 10.1016/j.vaccine.2007.09.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Revised: 09/04/2007] [Accepted: 09/06/2007] [Indexed: 01/22/2023]
Abstract
Oral, replication-competent Ad-HIV vaccines are advancing to human trials. Previous evaluation of protective efficacy in non-human primates has primarily followed upper respiratory tract administrations. Here we compared sequential oral (O/O) versus intranasal/oral (I/O) priming of rhesus macaques with Ad5 host range mutant-SIV recombinants expressing SIV env/rev, gag, and nef genes followed by boosting with SIV gp120 protein. Cellular immune responses in PBMC were stronger and more frequent after I/O administration. Both groups developed mucosal immunity, including memory cells in bronchial alveolar lavage, and gut-homing receptors on PBMC. Following intrarectal SIV(mac251) challenge, both groups exhibited equivalent, significant protection and robust post-challenge cellular immunity. Our results illustrate the promise of oral replication-competent Ad-recombinant vaccines. Pre-challenge PBMC ELISPOT and proliferative responses did not predict protection in the O/O group, highlighting the need for simple, non-invasive methods to reliably assess mucosal immunity.
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Affiliation(s)
- Qifeng Zhou
- Vaccine Branch, National Cancer Institute, Bethesda, MD 20892, United States
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3
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Moodie Z, Huang Y, Gu L, Hural J, Self SG. Statistical positivity criteria for the analysis of ELISpot assay data in HIV-1 vaccine trials. J Immunol Methods 2006; 315:121-32. [PMID: 16959262 DOI: 10.1016/j.jim.2006.07.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2006] [Revised: 05/22/2006] [Accepted: 07/18/2006] [Indexed: 10/24/2022]
Abstract
The enzyme-linked immunospot (ELISpot) assay is one of the leading technologies used to measure cellular responses in many settings including HIV vaccine clinical trials. HIV-1-specific effector T lymphocyte responses are considered necessary in the control of infection. Accurate measurement and summary of cellular immune responses are critical to HIV research. ELISpot assay readout is often dichotomized into positive/negative responses according to some pre-specified criteria. Given the increase in the number of replicates used for each stimulation with current assay configurations in the HIV Vaccine Trials Network (HVTN) laboratories, a new approach is now possible. We propose an objective criteria based on a hypothesis-driven method that controls the false positive rate while maintaining sensitivity to each of the antigen-specific responses under study. The new approach is compared to other commonly employed criteria using real and simulated data.
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Affiliation(s)
- Zoe Moodie
- Statistical Center for HIV/AIDS Research and Prevention Fred Hutchinson Cancer Research Center Seattle, Washington 98109, USA.
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4
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Ayash-Rashkovsky M, Borkow G, Davis HL, Moss RB, Moss RB, Bartholomew R, Bentwich Z. Enhanced HIV-1 specific immune response by CpG ODN and HIV-1 immunogen-pulsed dendritic cells confers protection in the Trimera murine model of HIV-1 infection. FASEB J 2005; 19:1152-4. [PMID: 15833766 DOI: 10.1096/fj.04-3185fje] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We have recently developed a novel small animal model for HIV-1 infection (Ayash-Rashkovsky et al., http://www.fasebj.org/cgi/doi/10.1096/fj.04-3184fje; doi:10.1096/fj.04-3184fje). The mice were successfully infected with HIV-1 for 4-6 wk with different clades of either T- or M-tropic isolates. HIV-1 infection was accompanied by rapid loss of human CD4+ T cells, decrease in CD4/CD8 ratio, and increased T cell activation. HIV specific human humoral and cellular immune responses were observed in all HIV-1 infected animals. In the present study, HIV specific human immune responses, both humoral and cellular, were generated in noninfected Trimera mice, after their immunization with gp120-depleted HIV-1 antigen, presented by autologous human dendritic cells. Addition of CpG ODN to the antigen-pulsed DCs significantly enhanced (by 2- to 30-fold) the humoral and cellular HIV-1 specific immune responses. Only mice immunized with the HIV-1 immunogen and CpG were completely protected from infection with HIV-1 after challenge with high infection titers of the virus. This novel small animal model for HIV-1 infection may thus serve as an attractive platform for rapid testing of candidate HIV-1 vaccines and of adjuvants and may shorten the time needed for the development and final assessment of protective HIV-1 vaccines in human trials.
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Lichterfeld M, Kaufmann DE, Yu XG, Mui SK, Addo MM, Johnston MN, Cohen D, Robbins GK, Pae E, Alter G, Wurcel A, Stone D, Rosenberg ES, Walker BD, Altfeld M. Loss of HIV-1-specific CD8+ T cell proliferation after acute HIV-1 infection and restoration by vaccine-induced HIV-1-specific CD4+ T cells. J Exp Med 2004; 200:701-12. [PMID: 15381726 PMCID: PMC2211961 DOI: 10.1084/jem.20041270] [Citation(s) in RCA: 286] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2004] [Accepted: 08/02/2004] [Indexed: 12/12/2022] Open
Abstract
Virus-specific CD8(+) T cells are associated with declining viremia in acute human immunodeficiency virus (HIV)1 infection, but do not correlate with control of viremia in chronic infection, suggesting a progressive functional defect not measured by interferon gamma assays presently used. Here, we demonstrate that HIV-1-specific CD8(+) T cells proliferate rapidly upon encounter with cognate antigen in acute infection, but lose this capacity with ongoing viral replication. This functional defect can be induced in vitro by depletion of CD4(+) T cells or addition of interleukin 2-neutralizing antibodies, and can be corrected in chronic infection in vitro by addition of autologous CD4(+) T cells isolated during acute infection and in vivo by vaccine-mediated induction of HIV-1-specific CD4(+) T helper cell responses. These data demonstrate a loss of HIV-1-specific CD8(+) T cell function that not only correlates with progressive infection, but also can be restored in chronic infection by augmentation of HIV-1-specific T helper cell function. This identification of a reversible defect in cell-mediated immunity in chronic HIV-1 infection has important implications for immunotherapeutic interventions.
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Affiliation(s)
- Mathias Lichterfeld
- Partners AIDS Research Center, Massachusetts General Hospital, 149 13th St., Boston, MA 02129, USA
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6
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Berzofsky JA, Ahlers JD, Janik J, Morris J, Oh S, Terabe M, Belyakov IM. Progress on new vaccine strategies against chronic viral infections. J Clin Invest 2004. [PMID: 15314679 DOI: 10.1172/jci200422674] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Among the most cost-effective strategies for preventing viral infections, vaccines have proven effective primarily against viruses causing acute, self-limited infections. For these it has been sufficient for the vaccine to mimic the natural virus. However, viruses causing chronic infection do not elicit an immune response sufficient to clear the infection and, as a result, vaccines for these viruses must elicit more effective responses--quantitative and qualitative--than does the natural virus. Here we examine the immunologic and virologic basis for vaccines against three such viruses, HIV, hepatitis C virus, and human papillomavirus, and review progress in clinical trials to date. We also explore novel strategies for increasing the immunogenicity and efficacy of vaccines.
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Affiliation(s)
- Jay A Berzofsky
- Molecular Immunogenetics and Vaccine Research Section, Vaccine Branch, The Center for Cancer Research, National Cancer Institute/NIH, 10 Center Drive, Bethesda, MD 20892, USA.
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7
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Egan MA. Current prospects for the development of a therapeutic vaccine for the treatment of HIV type 1 infection. AIDS Res Hum Retroviruses 2004; 20:794-806. [PMID: 15320982 DOI: 10.1089/0889222041725244] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Michael A Egan
- Department of Immunobiology, Wyeth Vaccines Research, Pearl River, New York, 10965, USA.
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Fernandez-Cruz E, Moreno S, Navarro J, Clotet B, Bouza E, Carbone J, Peña JM, Pérez Molina J, Podzamczer D, Rubio R, Ocaña I, Pulido F, Viciana P, Maradona JA, Blazquez R, Barros C, Quereda C, Rodriguez-Sainz C, Gil J, Abad ML, Díaz L, Cantó C, Muñoz MA, Ferrer E, Jou A, Sirera G, Díaz M, Lopez F, Gatell JM, Gonzalez-Lahoz J. Therapeutic immunization with an inactivated HIV-1 Immunogen plus antiretrovirals versus antiretroviral therapy alone in asymptomatic HIV-infected subjects. Vaccine 2004; 22:2966-73. [PMID: 15297045 DOI: 10.1016/j.vaccine.2004.03.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2003] [Accepted: 03/27/2004] [Indexed: 10/26/2022]
Abstract
To determine whether the addition of an inactivated-gp120-depleted HIV-1 Immunogen to antiretrovirals (ARTs) conferred a beneficial effect on delaying time to virologic failure relative to that obtained by ARTs alone, a phase II clinical trial was performed in 243 asymptomatic, ART naïve, HIV-1 seropositive adults. The Cox model showed that HIV-1 Immunogen treatment was associated with a 34% decrease in the risk of virologic failure (P = 0.056). When the analysis incorporated baseline HIV-RNA stratification the risk of virologic failure in the HIV-1 Immunogen Arm was significantly reduced a 37% compared to the IFA placebo Arm (P = 0.034). The data suggest that therapeutic immunization plus ARTs could influence virologic control.
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Affiliation(s)
- E Fernandez-Cruz
- Division of Immunology, Hospital General Universitario "Gregorio Marañon", Dr. Esquerdo 46, 28007 Madrid, Spain.
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9
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Janetzki S, Schaed S, Blachere NEB, Ben-Porat L, Houghton AN, Panageas KS. Evaluation of Elispot assays: influence of method and operator on variability of results. J Immunol Methods 2004; 291:175-83. [PMID: 15345315 DOI: 10.1016/j.jim.2004.06.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Revised: 05/13/2004] [Accepted: 06/03/2004] [Indexed: 11/20/2022]
Abstract
In this study, a comprehensive comparative analysis of different evaluation methods of Elispot plates was performed. Three investigators using three different evaluation approaches read 50 randomly selected wells at three different time points. The methods were: (1) manual evaluation using a stereomicroscope, (2) automated evaluation using an image analysis reader system with reading parameters established by each investigator, and (3) automated evaluation using a reader system with preset reading parameters using assay-specific controls. We demonstrate that manual evaluation had the highest variability both within the same method and when comparing all methods, followed by automated evaluation with investigator-dependent parameters. The variability was low only when all investigators used the same parameters established using assay-specific controls. This variability was independent of operator or spot number per well. Based on this study, recommendations for standardization and validation procedures of Elispot assay performance and evaluation procedures are presented.
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Affiliation(s)
- S Janetzki
- ZellNet Consulting, Inc., 555 North Avenue, Suite 25-S, Fort Lee NJ 07024, USA.
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10
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Robbins GK, Addo MM, Troung H, Rathod A, Habeeb K, Davis B, Heller H, Basgoz N, Walker BD, Rosenberg ES. Augmentation of HIV-1-specific T helper cell responses in chronic HIV-1 infection by therapeutic immunization. AIDS 2003; 17:1121-6. [PMID: 12819512 DOI: 10.1097/00002030-200305230-00002] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To determine whether therapeutic immunization with a whole inactivated HIV-1 immunogen augments HIV-1-specific T helper cell responses in chronically infected individuals receiving suppressive antiretroviral therapy (ART). DESIGN An investigator-initiated, single center, double-blind, placebo-controlled, randomized trial. METHODS Subjects selected for study were HIV-1-infected adults on ART with an HIV-1-RNA plasma viral load of less than 500 copies/ml for at least 6 months, and a CD4 cell count greater than 250 cells/mm3 before starting ART. Study subjects were randomly assigned to receive either immunogen (inactivated envelope-depleted HIV-1 coupled with incomplete Freund's adjuvant; IFA), versus placebo (IFA alone). The primary outcome was significant CD4 cell lymphoproliferative responses to HIV-1 proteins. Secondary endpoints included HIV-1-specific CD8 T cell responses, CD4 cell count/percentage, HIV-1-RNA plasma viral load, and delayed-type hypersensitivity (DTH) responses. RESULTS The augmentation of HIV-1-specific T helper cell responses was achieved in five out of five vaccine recipients and none out of four controls (P = 0.008, Fisher's exact test). There were no significant changes in the breadth or magnitude of cytotoxic T lymphocyte responses, CD4 cell count/percentages, or DTH test responses. CONCLUSION HIV-1-specific T helper cell responses can be successfully increased by therapeutic immunization in individuals with chronic infection on suppressive ART. Further studies will be needed to determine whether the augmentation of these responses correlate with long-term clinical benefits.
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Affiliation(s)
- Gregory K Robbins
- Partners AIDS Research Center and Infectious Disease Division, Massachusetts General Hospital, Division of AIDS Harvard Medical School, Boston, 02114, USA
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11
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Ayash-Rashkovsky M, Weisman Z, Diveley J, Moss RB, Bentwich Z, Borkow G. Generation of Th1 immune responses to inactivated, gp120-depleted HIV-1 in mice with a dominant Th2 biased immune profile via immunostimulatory [correction of imunostimulatory] oligonucleotides--relevance to AIDS vaccines in developing countries. Vaccine 2002; 20:2684-92. [PMID: 12034094 DOI: 10.1016/s0264-410x(02)00202-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Vaccination against HIV-1 of hosts with a dominant Th2 immune profile may fail to induce essential protective Th1 immune responses. By using Schistosoma-infected mice, with a pre-existent Th2 immune background, we demonstrate that oligodeoxynucleotides (ODN) containing unmethylated cytosine-phosphate-guanosine (CpG) immunostimulatory sequences co-administered with inactivated, gp120-depleted HIV-1 viral particles (HIV-1 immunogen) lead to potent Th1 anti-HIV-1 immune responses overcoming the Th2 bias. In contrast, Schistosoma-infected mice immunized with HIV-1 immunogen in incomplete Freund's adjuvant only, induced Th2 anti-HIV-1 immune responses. These findings strongly support the advisability of using CpG ODN as a Th1 inducing adjuvant when immunizing human populations with a strong pre-existent Th2 immune profile.
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Affiliation(s)
- Mila Ayash-Rashkovsky
- Ruth Ben-Ari Institute of Clinical Immunology & AIDS Center, Kaplan Medical Center, Hebrew University Hadassah Medical School, Rehovot 76100, Israel
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12
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Vandepapelière P. Therapeutic vaccination against chronic viral infections. THE LANCET. INFECTIOUS DISEASES 2002; 2:353-67. [PMID: 12144898 DOI: 10.1016/s1473-3099(02)00289-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Chronic viral infections such as those caused by hepatitis B virus, human papilloma virus, herpes simplex virus, and HIV, in theory, present logical targets of active specific immunotherapy. Indeed, immunological mechanisms are involved in several aspects of their pathogenesis and natural course, such as virus persistence, destruction of infected cells and control of viral replication. Therapeutic vaccination could therefore be an adequate replacement for, or adjunct to, existing therapies. Almost all approaches to therapeutic vaccination have been evaluated in those four disease areas. Despite encouraging results in animals none of these attempts has, so far, been completely successful in the human setting. However, with a better understanding of the immunological mechanisms involved in the control of disease successful therapeutic vaccines, used alone or in combination with other therapies, are an achievable goal.
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Affiliation(s)
- Pierre Vandepapelière
- Clinical R&D HIV vaccines and anti-infective therapeutic vaccines, GlaxoSmithKline Biologicals, Rue de l'Institut 89, B-1330, Rixensart, Belgium.
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13
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Abstract
New HIV treatment strategies are needed. Over the past year, substantial progress has been made in the development of new antiretroviral agents, although the journey from drug discovery to wide clinical use is completed by only a small number of medications. Strategies to enhance immune control and either discontinue or decrease the need for prolonged HAART are under study. The promising preliminary results in very early PHI are in contrast with the minor successes in chronic infection.
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Affiliation(s)
- J J Eron
- Infectious Diseases Division, 547 Burnett-Womack, CB #7030, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7030, USA.
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14
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Schmitz JL, Denny TN, Garcia A, Lathey JL. Comparison of human immunodeficiency virus antigens as stimulants for lymphocyte proliferation assays. CLINICAL AND DIAGNOSTIC LABORATORY IMMUNOLOGY 2002; 9:525-9. [PMID: 11986255 PMCID: PMC119975 DOI: 10.1128/cdli.9.3.525-529.2002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CD4 proliferative responses to the human immunodeficiency virus (HIV) type 1 (HIV-1) p24 (gag) antigen inversely correlate with the plasma viral load in HIV-infected subjects who control viral replication without antiretroviral therapy. Use of a single HIV-1 protein to assess CD4 proliferative responses may not reflect the global response to this pathogen. We compared the abilities of HIV p24 and gp120 antigens from two different vendors, an inactivated whole HIV-1 MN virion preparation and an HIV-1E culture supernatant antigen, to elicit proliferative responses in HIV-seropositive and HIV-seronegative donors. Peripheral blood mononuclear cells from 12 HIV-seropositive donors (each with HIV-1 loads <4,000 copies/ml of plasma, >350 CD4 T lymphocytes/mm(3), and no antiretroviral therapy) and 15 HIV-seronegative donors were assessed with multiple concentrations of each stimulant by standard lymphocyte proliferation assays. Wide variations in response rates were found, with zero, three, five, and eight individuals demonstrating stimulation indices of >3 for the HIV culture antigen supernatant, gp120, p24, and inactivated whole-virus preparations, respectively. These results suggest that the use of the inactivated whole virus resulted in a more sensitive assay for detection of CD4 T-lymphocyte function in HIV-infected subjects.
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Affiliation(s)
- John L Schmitz
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
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15
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Abstract
The drug treatments introduced in recent years for HIV infection have enabled a marked reduction in morbidity and prolongation of life. These treatments, however, are often associated with acute and chronic toxicities, the development of resistant virus can limit their effectiveness, and they are too expensive and difficult to administer in most third world settings. A successful HIV immunotherapeutic vaccine has the potential to overcome these problems, and would be a valuable advance. The most promising approaches have induced the type of immune response found to correlate with reduced activity of HIV in man, especially cytotoxic T-cell responses, or have led to reduced HIV or SIV viral load and increased CD4 counts in non-human primates or man. The agents that have led to one or both of these effects have been selected for review, and include inactivated envelope depleted virus, recombinant envelope glycoprotein, DNA vaccines utilising HIV peptides or gene products, viral vectors, such as canarypox or attenuated vaccinia, with HIV core proteins. There are other approaches, such as alloimmunity, for which no candidate products yet exist, but which conceptually appear promising. Currently, however, only a few phase III studies of HIV therapeutic vaccines have been completed in man, and there has been a modest therapeutic effect. Further development of both existing and new candidates remains one of the key priorities in our fight against HIV.
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Affiliation(s)
- B S Peters
- Department of GU Medicine, GKT School of Medicine, Harrison Wing, St. Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, UK.
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16
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Abstract
In this short article we review the immunopathology of HIV infection and delineate the kinds of immune responses seen in acute infection and in long-term nonprogression that are understood to be necessary if the host is to maintain long-term control of the virus. In this context we discuss the potential promise of therapeutic vaccination in HIV infection.
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Affiliation(s)
- F M Gotch
- Department of Immunology, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK.
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17
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Sereti I, Lane HC. Immunopathogenesis of human immunodeficiency virus: implications for immune-based therapies. Clin Infect Dis 2001; 32:1738-55. [PMID: 11360217 DOI: 10.1086/320758] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2000] [Revised: 01/12/2001] [Indexed: 11/03/2022] Open
Abstract
Human immunodeficiency virus (HIV) infection leads to a state of CD4 lymphopenia and generalized immune activation with subsequent development of opportunistic infections and neoplasms. The use of highly active antiretroviral treatment has dramatically improved the clinical outcome for HIV-infected patients, but the associated cost and toxicity and the eventual development of drug resistance have underscored the need for additional therapeutic strategies. Immune-based therapies, such as treatment with cytokines or immunosuppressants, adoptive immunotherapy, and therapeutic immunizations, are being intensely investigated as potential supplements to antiretroviral therapy. Although much data have been generated as a result of these efforts, to date there has been little evidence of the clinical efficacy of these strategies. Randomized clinical studies remain critical in evaluating the clinical significance and the role of immune-based therapies in the therapeutic armamentarium against HIV.
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Affiliation(s)
- I Sereti
- Cellular and Molecular Retrovirology Section, Laboratory of Immunoregulation, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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