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Pinkevych M, Docken SS, Okoye AA, Fennessey CM, Del Prete GQ, Pino M, Harper JL, Betts MR, Paiardini M, Keele BF, Davenport MP. Timing of initiation of anti-retroviral therapy predicts post-treatment control of SIV replication. PLoS Pathog 2023; 19:e1011660. [PMID: 37801446 PMCID: PMC10558076 DOI: 10.1371/journal.ppat.1011660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 09/04/2023] [Indexed: 10/08/2023] Open
Abstract
One approach to 'functional cure' of HIV infection is to induce durable control of HIV replication after the interruption of antiretroviral therapy (ART). However, the major factors that determine the viral 'setpoint' level after treatment interruption are not well understood. Here we combine data on ART interruption following SIV infection for 124 total animals from 10 independent studies across 3 institutional cohorts to understand the dynamics and predictors of post-treatment viral control. We find that the timing of treatment initiation is an important determinant of both the peak and early setpoint viral levels after treatment interruption. During the first 3 weeks of infection, every day of delay in treatment initiation is associated with a 0.22 log10 copies/ml decrease in post-rebound peak and setpoint viral levels. However, delay in initiation of ART beyond 3 weeks of infection is associated with higher post-rebound setpoint viral levels. For animals treated beyond 3 weeks post-infection, viral load at ART initiation was the primary predictor of post-rebound setpoint viral levels. Potential alternative predictors of post-rebound setpoint viral loads including cell-associated DNA or RNA, time from treatment interruption to rebound, and pre-interruption CD8+ T cell responses were also examined in the studies where these data were available. This analysis suggests that optimal timing of treatment initiation may be an important determinant of post-treatment control of HIV.
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Affiliation(s)
- Mykola Pinkevych
- Infection Analytics Program, Kirby Institute for Infection and Immunity, UNSW Australia, Sydney, New South Wales, Australia
| | - Steffen S. Docken
- Infection Analytics Program, Kirby Institute for Infection and Immunity, UNSW Australia, Sydney, New South Wales, Australia
| | - Afam A. Okoye
- Vaccine & Gene Therapy Institute, and Oregon National Primate Research Center, Beaverton, Oregon, United States of America
| | - Christine M. Fennessey
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Gregory Q. Del Prete
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Maria Pino
- Division of Microbiology and Immunology, Emory National Primate Research Center, Emory University, Atlanta, Georgia, United States of America
| | - Justin L. Harper
- Division of Microbiology and Immunology, Emory National Primate Research Center, Emory University, Atlanta, Georgia, United States of America
| | - Michael R. Betts
- Department of Microbiology and Center for AIDS Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Mirko Paiardini
- Division of Microbiology and Immunology, Emory National Primate Research Center, Emory University, Atlanta, Georgia, United States of America
- Department of Pathology and Laboratory Medicine, School of Medicine; Emory University, Atlanta, Georgia, United States of America
| | - Brandon F. Keele
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Miles P. Davenport
- Infection Analytics Program, Kirby Institute for Infection and Immunity, UNSW Australia, Sydney, New South Wales, Australia
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Herbert NG, Goulder PJR. Impact of early antiretroviral therapy, early life immunity and immune sex differences on HIV disease and posttreatment control in children. Curr Opin HIV AIDS 2023; 18:229-236. [PMID: 37421384 PMCID: PMC10399946 DOI: 10.1097/coh.0000000000000807] [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] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW To review recent insights into the factors affecting HIV disease progression in children living with HIV, contrasting outcomes: following early ART initiation with those in natural, antiretroviral therapy (ART)-naive infection; in children versus adults; and in female individuals versus male individuals. RECENT FINDINGS Early life immune polarization and several factors associated with mother-to-child transmission of HIV result in an ineffective HIV-specific CD8+ T-cell response and rapid disease progression in most children living with HIV. However, the same factors result in low immune activation and antiviral efficacy mediated mainly through natural killer cell responses in children and are central features of posttreatment control. By contrast, rapid activation of the immune system and generation of a broad HIV-specific CD8+ T-cell response in adults, especially in the context of 'protective' HLA class I molecules, are associated with superior disease outcomes in ART-naive infection but not with posttreatment control. The higher levels of immune activation in female individuals versus male individuals from intrauterine life onwards increase HIV infection susceptibility in females in utero and may favour ART-naive disease outcomes rather than posttreatment control. SUMMARY Early-life immunity and factors associated with mother-to-child transmission typically result in rapid HIV disease progression in ART-naive infection but favour posttreatment control in children following early ART initiation.
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Affiliation(s)
- Nicholas G Herbert
- Peter Medawar Building for Pathogen Research, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
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3
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Harwood OE, Matschke LM, Moriarty RV, Balgeman AJ, Weaver AJ, Ellis-Connell AL, Weiler AM, Winchester LC, Fletcher CV, Friedrich TC, Keele BF, O’Connor DH, Lang JD, Reynolds MR, O’Connor SL. CD8+ cells and small viral reservoirs facilitate post-ART control of SIV replication in M3+ Mauritian cynomolgus macaques initiated on ART two weeks post-infection. PLoS Pathog 2023; 19:e1011676. [PMID: 37747933 PMCID: PMC10553806 DOI: 10.1371/journal.ppat.1011676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 10/05/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023] Open
Abstract
Sustainable HIV remission after antiretroviral therapy (ART) withdrawal, or post-treatment control (PTC), remains a top priority for HIV treatment. We observed surprising PTC in an MHC-haplomatched cohort of MHC-M3+ SIVmac239+ Mauritian cynomolgus macaques (MCMs) initiated on ART at two weeks post-infection (wpi). None of the MCMs possessed MHC haplotypes previously associated with SIV control. For six months after ART withdrawal, we observed undetectable or transient viremia in seven of the eight MCMs, despite detecting replication competent SIV using quantitative viral outgrowth assays. In vivo depletion of CD8α+ cells induced rebound in all animals, indicating the observed PTC was mediated, at least in part, by CD8α+ cells. With intact proviral DNA assays, we found that MCMs had significantly smaller viral reservoirs two wpi than a cohort of identically infected rhesus macaques, a population that rarely develops PTC. We found a similarly small viral reservoir among six additional SIV+ MCMs in which ART was initiated at eight wpi, some of whom exhibited viral rebound. These results suggest that an unusually small viral reservoir is a hallmark among SIV+ MCMs. By evaluating immunological differences between MCMs that did and did not rebound, we identified that PTC was associated with a reduced frequency of CD4+ and CD8+ lymphocyte subsets expressing exhaustion markers. Together, these results suggest a combination of small reservoirs and immune-mediated virus suppression contribute to PTC in MCMs. Further, defining the immunologic mechanisms that engender PTC in this model may identify therapeutic targets for inducing durable HIV remission in humans.
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Affiliation(s)
- Olivia E. Harwood
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Lea M. Matschke
- Department of Pathobiological Sciences, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Ryan V. Moriarty
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Alexis J. Balgeman
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Abigail J. Weaver
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Amy L. Ellis-Connell
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Andrea M. Weiler
- Wisconsin National Primate Research Center, Madison, Wisconsin, United States of America
| | - Lee C. Winchester
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Courtney V. Fletcher
- College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Thomas C. Friedrich
- Department of Pathobiological Sciences, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- Wisconsin National Primate Research Center, Madison, Wisconsin, United States of America
| | - Brandon F. Keele
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - David H. O’Connor
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- Wisconsin National Primate Research Center, Madison, Wisconsin, United States of America
| | - Jessica D. Lang
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- Center for Human Genomics and Precision Medicine, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Matthew R. Reynolds
- Department of Pathobiological Sciences, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- Wisconsin National Primate Research Center, Madison, Wisconsin, United States of America
| | - Shelby L. O’Connor
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
- Wisconsin National Primate Research Center, Madison, Wisconsin, United States of America
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4
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Zhou C, Wu Y, Zhang Y, Wang Y, Wu H, Zhang T, Chen G, Huang X. Factors associated with post-treatment control of viral load in HIV-infected patients: a systematic review and meta-analysis. Int J Infect Dis 2023; 129:216-227. [PMID: 36707043 DOI: 10.1016/j.ijid.2023.01.025] [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: 08/16/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES This study aimed to investigate the factors associated with maintenance of viral suppression after antiretroviral therapy (ART) discontinuation. METHODS Databases were searched for studies published between January 01, 2011, and July 01, 2022, that correlated the time of virus rebound with treatment interruption (TI). The corresponding data were extracted from these studies. A fixed-effects model was used to calculate pooled estimates. RESULTS Thirty-one studies were included in this analysis. Results showed that patients who started ART during acute or early infection had longer viral control than those who started ART during chronic infection. It has been reported that some broadly neutralizing HIV-1-specific antibodies can significantly prolong viral inhibition. The study also found that approximately 7.2% of patients achieved post-treatment control (PTC) approximately a year after TI. CONCLUSION ART initiation in the acute or early phases can delay viral rebound after TI. Cell-associated HIV RNA and HIV DNA have been difficult to prove as able to predict viral rebound time. Many vaccines and antibodies have also been shown to be effective in prolonging viral control in people without PTC, and more research is needed to develop alternative ART therapies that can effectively inhibit or even eliminate HIV.
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Affiliation(s)
- Chi Zhou
- Department of Dermatology, The Affiliated Hospital of Qingdao University, Qingdao, China; Clinical and Research Center for Infectious Disease, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Yaxin Wu
- Clinical and Research Center for Infectious Disease, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Yang Zhang
- Clinical and Research Center for Infectious Disease, Beijing Youan Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory for HIV/AIDS Research, Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Yingying Wang
- Department of Internal Medicine, Shenzhen Hospital of the University of Hong Kong, Shenzhen, China
| | - Hao Wu
- Clinical and Research Center for Infectious Disease, Beijing Youan Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory for HIV/AIDS Research, Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Tong Zhang
- Clinical and Research Center for Infectious Disease, Beijing Youan Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory for HIV/AIDS Research, Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China.
| | - Guanzhi Chen
- Department of Dermatology, The Affiliated Hospital of Qingdao University, Qingdao, China.
| | - Xiaojie Huang
- Clinical and Research Center for Infectious Disease, Beijing Youan Hospital, Capital Medical University, Beijing, China.
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5
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Harwood OE, Matschke LM, Moriarty RV, Balgeman AJ, Weaver AJ, Ellis-Connell AL, Weiler AM, Winchester LC, Fletcher CV, Friedrich TC, Keele BF, O'Connor DH, Lang JD, Reynolds MR, O'Connor SL. CD8+ cells and small viral reservoirs facilitate post-ART control of SIV in Mauritian cynomolgus macaques. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.03.01.530655. [PMID: 36909458 PMCID: PMC10002716 DOI: 10.1101/2023.03.01.530655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Sustainable HIV remission after antiretroviral therapy (ART) withdrawal, or post-treatment control (PTC), remains a top priority for HIV treatment. We observed surprising PTC in an MHC-haplomatched cohort of MHC-M3+ SIVmac239+ Mauritian cynomolgus macaques (MCMs) initiated on ART at two weeks post-infection (wpi). For six months after ART withdrawal, we observed undetectable or transient viremia in seven of eight MCMs. In vivo depletion of CD8α+ cells induced rebound in all animals, indicating the PTC was mediated, at least in part, by CD8α+ cells. We found that MCMs had smaller acute viral reservoirs than a cohort of identically infected rhesus macaques, a population that rarely develops PTC. The mechanisms by which unusually small viral reservoirs and CD8α+ cell-mediated virus suppression enable PTC can be investigated using this MHC-haplomatched MCM model. Further, defining the immunologic mechanisms that engender PTC in this model may identify therapeutic targets for inducing durable HIV remission in humans.
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Affiliation(s)
- Olivia E Harwood
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, WI 53711
| | - Lea M Matschke
- Department of Pathobiological Sciences, University of Wisconsin-Madison, Madison, WI 53711
| | - Ryan V Moriarty
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, WI 53711
| | - Alexis J Balgeman
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, WI 53711
| | - Abigail J Weaver
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, WI 53711
| | - Amy L Ellis-Connell
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, WI 53711
| | - Andrea M Weiler
- Wisconsin National Primate Research Center, Madison, WI, 53711
| | - Lee C Winchester
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198
| | | | - Thomas C Friedrich
- Department of Pathobiological Sciences, University of Wisconsin-Madison, Madison, WI 53711
- Wisconsin National Primate Research Center, Madison, WI, 53711
| | - Brandon F Keele
- AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, MD 21701
| | - David H O'Connor
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, WI 53711
- Wisconsin National Primate Research Center, Madison, WI, 53711
| | - Jessica D Lang
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, WI 53711
- Center for Human Genomics and Precision Medicine, University of Wisconsin-Madison, Madison, WI 53711
| | - Matthew R Reynolds
- Department of Pathobiological Sciences, University of Wisconsin-Madison, Madison, WI 53711
- Wisconsin National Primate Research Center, Madison, WI, 53711
| | - Shelby L O'Connor
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, WI 53711
- Wisconsin National Primate Research Center, Madison, WI, 53711
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6
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Abstract
Posttreatment controllers (PTCs) are rare HIV-infected individuals who can limit viral rebound after antiretroviral therapy interruption (ATI), but the mechanisms of this remain unclear. To investigate these mechanisms, we quantified various HIV RNA transcripts (via reverse transcription droplet digital PCR [RT-ddPCR]) and cellular transcriptomes (via RNA-seq) in blood cells from PTCs and noncontrollers (NCs) before and two time points after ATI. HIV transcription initiation did not significantly increase after ATI in PTCs or in NCs, whereas completed HIV transcripts increased at early ATI in both groups and multiply-spliced HIV transcripts increased only in NCs. Compared to NCs, PTCs showed lower levels of HIV DNA, more cell-associated HIV transcripts per total RNA at all times, no increase in multiply-spliced HIV RNA at early or late ATI, and a reduction in the ratio of completed/elongated HIV RNA after early ATI. NCs expressed higher levels of the IL-7 pathway before ATI and expressed higher levels of multiple cytokine, inflammation, HIV transcription, and cell death pathways after ATI. Compared to the baseline, the NCs upregulated interferon and cytokine (especially TNF) pathways during early and late ATI, whereas PTCs upregulated interferon and p53 pathways only at early ATI and downregulated gene translation during early and late ATI. In NCs, viral rebound after ATI is associated with increases in HIV transcriptional completion and splicing, rather than initiation. Differences in HIV and cellular transcription may contribute to posttreatment control, including an early limitation of spliced HIV RNA, a delayed reduction in completed HIV transcripts, and the differential expression of the IL-7, p53, and TNF pathways. IMPORTANCE The findings presented here provide new insights into how HIV and cellular gene expression change after stopping ART in both noncontrollers and posttreatment controllers. Posttreatment control is associated with an early ability to limit increases in multiply-spliced HIV RNA, a delayed (and presumably immune-mediated) ability to reverse an initial rise in processive/completed HIV transcripts, and multiple differences in cellular gene expression pathways. These differences may represent correlates or mechanisms of posttreatment control and may provide insight into the development and/or monitoring of therapeutic strategies that are aimed at a functional HIV cure.
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7
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Challenges of HIV therapeutic vaccines clinical trials design. Curr Opin HIV AIDS 2022; 17:345-351. [PMID: 36178769 DOI: 10.1097/coh.0000000000000767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF THE REVIEW To discuss main challenges of therapeutic vaccine clinical trials design, implementation and analyses in the HIV cure field. RECENT FINDINGS Therapeutic vaccines are progressively being postulated as T-cell stimulating agents to use in combination HIV cure strategies, with the addition of immunomodulators, latency reversing agents and/or broadly neutralizing antibodies. Although promising strategies are rapidly evolving in preclinical studies using nonhuman primate models, translation into human testing in randomized controlled clinical trials is more challenging and expensive to conduct. Adaptive designs, access to cohorts of early-treated individuals, consensus on how to safely conduct analytical treatment interruptions, use of alternative statistical methods, development of point-of-care/home-based testing technologies and ensuring early engagement of communities where research is being developed are some of the critical aspects to consider to facilitate clinical trial development in the HIV cure field. SUMMARY Design and development of HIV therapeutic vaccine clinical trials poses many challenges, from Phase 0/pilot studies to Phase I/II trials in which efficacy of the intervention is being tested and antiretroviral therapy cessation is needed, complexity of cure trials progressively increases. Understanding fundamental issues and careful planning of therapeutic vaccine clinical trials is crucial to minimize design flaws, reduce loss of follow-ups and missing data while ensuring participant's safety and guarantee valid and accurate analyses and thus, better contribute towards an HIV cure.
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8
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Adams P, Berkhout B, Pasternak AO. Towards a molecular profile of antiretroviral therapy-free HIV remission. Curr Opin HIV AIDS 2022; 17:301-307. [PMID: 35938464 DOI: 10.1097/coh.0000000000000749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To summarize the current status and highlight recent findings on predictive biomarkers for posttreatment HIV control (PTC) and virological remission. While historically, many studies focused on virological markers, there is an increasing tendency to enter immune and metabolic factors into the equation. RECENT FINDINGS On the virological side, several groups reported that cell-associated HIV RNA could predict time to viral rebound. Recent data hints at the possible importance of the genic location and chromatin context of the integrated provirus, although these factors still need to be assessed in relation to PTC and virological remission. Evidence from immunological studies highlighted innate and humoral immunity as important factors for prolonged HIV remission. Interestingly, novel metabolic markers have emerged, which offer additional angles to our understanding of latency and viral rebound. SUMMARY Facilitating PTC and virological remission remain top priorities for the HIV cure research. We advocate for clear and precise definitions for both phenomena in order to avoid misconceptions and to strengthen the conclusions that can be drawn. As no one-size-fits-all marker has emerged yet, more biomarkers are on the horizon, and viral rebound is a complex and heterogeneous process, it is likely that a combination of various biomarkers in cohesion will be necessary for a more accurate prediction of antiretroviral therapy-free HIV remission.
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Affiliation(s)
- Philipp Adams
- Laboratory of Experimental Virology, Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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9
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Abstract
PURPOSE OF REVIEW The quest for HIV-1 cure could take advantage of the study of rare individuals that control viral replication spontaneously (elite controllers) or after an initial course of antiretroviral therapy (posttreatment controllers, PTCs). In this review, we will compare back-to-back the immunological and virological features underlying viral suppression in elite controllers and PTCs, and explore their possible contributions to the HIV-1 cure research. RECENT FINDINGS HIV-1 control in elite controllers shows hallmarks of an effective antiviral response, favored by genetic background and possibly associated to residual immune activation. The immune pressure in elite controllers might select against actively transcribing intact proviruses, allowing the persistence of a small and poorly inducible reservoir. Evidence on PTCs is less abundant but preliminary data suggest that antiviral immune responses may be less pronounced. Therefore, these patients may rely on distinct mechanisms, not completely elucidated to date, suppressing HIV-1 transcription and replication. SUMMARY PTCs and elite controllers may control HIV replication using distinct pathways, the elucidation of which may contribute to design future interventional strategies aiming to achieve a functional cure.
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10
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Pace M, Ogbe A, Hurst J, Robinson N, Meyerowitz J, Olejniczak N, Thornhill JP, Jones M, Waters A, Lwanga J, Kuldanek K, Hall R, Zacharopoulou P, Martin GE, Brown H, Nwokolo N, Peppa D, Fox J, Fidler S, Frater J. Impact of antiretroviral therapy in primary HIV infection on natural killer cell function and the association with viral rebound and HIV DNA following treatment interruption. Front Immunol 2022; 13:878743. [PMID: 36110857 PMCID: PMC9468877 DOI: 10.3389/fimmu.2022.878743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 07/29/2022] [Indexed: 11/25/2022] Open
Abstract
Natural Killer (NK) cells play a key role in controlling HIV replication, with potential downstream impact on the size of the HIV reservoir and likelihood of viral rebound after antiretroviral therapy (ART) cessation. It is therefore important to understand how primary HIV infection (PHI) disrupts NK cell function, and how these functions are restored by early ART. We examined the impact of commencing ART during PHI on phenotypic and functional NK cell markers at treatment initiation (baseline), 3 months, 1 year, and 2 years in seven well-characterised participants in comparison to HIV seronegative volunteers. We then examined how those NK cell properties differentially impacted by ART related to time to viral rebound and HIV DNA levels in 44 individuals from the SPARTAC trial who stopped ART after 48 weeks treatment, started during PHI. NK cell markers that were significantly different between the seven people with HIV (PWH) treated for 2 years and HIV uninfected individuals included NKG2C levels in CD56dim NK cells, Tim-3 expression in CD56bright NK cells, IFN-γ expressed by CD56dim NK cells after IL-12/IL-18 stimulation and the fraction of Eomes-/T-bet+ in CD56dim and CD56bright NK cells. When exploring time to viral rebound after stopping ART among the 44 SPARTAC participants, no single NK phenotypic marker correlated with control. Higher levels of IL-12/IL-18 mediated NK cell degranulation at baseline were associated with longer times to viral rebound after treatment interruption (P=0.028). Additionally, we found higher fractions of CD56dim NK cells in individuals with lower levels of HIV DNA (P=0.048). NKG2A and NKp30 levels in CD56neg NK cells were higher in patients with lower HIV DNA levels (p=0.00174, r=-0.49 and p=0.03, r= -0.327, respectively) while CD27 levels were higher in those with higher levels of HIV DNA (p=0.026). These data show NK cell functions are heterogeneously impacted by HIV infection with a mixed picture of resolution on ART, and that while NK cells may affect HIV DNA levels and time to viral rebound, no single NK cell marker defined delayed viral rebound.
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Affiliation(s)
- Matthew Pace
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ane Ogbe
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jacob Hurst
- Etcembly Ltd, Harwell Campus, Didcot, United Kingdom
| | - Nicola Robinson
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jodi Meyerowitz
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Natalia Olejniczak
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - John P. Thornhill
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Mathew Jones
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Anele Waters
- Department of Infection, Guys and St Thomas’ National Health Service (NHS) Trust, London, United Kingdom
| | - Julianne Lwanga
- Department of Infection, Guys and St Thomas’ National Health Service (NHS) Trust, London, United Kingdom
| | - Kristen Kuldanek
- Department of HIV Medicine, St Mary’s Hospital, Imperial College Healthcare National Health Service (NHS) Trust, London, United Kingdom
| | - Rebecca Hall
- Department of HIV Medicine, St Mary’s Hospital, Imperial College Healthcare National Health Service (NHS) Trust, London, United Kingdom
| | | | - Genevieve E. Martin
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Infectious Diseases, Monash University, Melbourne, VIC, Australia
| | - Helen Brown
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nneka Nwokolo
- Department of HIV/GUM, Chelsea and Westminster Hospital, London, United Kingdom
| | - Dimitra Peppa
- Division of Infection and Immunity, University College, London, United Kingdom
| | - Julie Fox
- Department of Infection, Guys and St Thomas’ National Health Service (NHS) Trust, London, United Kingdom
| | - Sarah Fidler
- Department of HIV Medicine, St Mary’s Hospital, Imperial College Healthcare National Health Service (NHS) Trust, London, United Kingdom
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom
- National Institute for Health and Care Research (NIHR) Imperial College Biomedical Research Centre, London, United Kingdom
| | - John Frater
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health and Care Research (NIHR) Oxford Biomedical Research Centre, Oxford, United Kingdom
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11
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Zuidewind P, Cotton M, Barnabas S, Van Rensburg AJ, van Zyl G, Gordijn C. Approach to the management of paediatric HIV spontaneous controllers. S Afr J Infect Dis 2022; 37:399. [PMID: 35815221 PMCID: PMC9257930 DOI: 10.4102/sajid.v37i1.399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/22/2022] [Indexed: 11/16/2022] Open
Abstract
Paediatric HIV spontaneous controllers (HSCs) are a unique and understudied population with potential to inform alternative treatment options for patients living with HIV. As HSCs are so rare and often not recognised prior to antiretroviral treatment (ART) initiation, it can be difficult for clinicians to optimally manage this group. We describe the diagnosis, history and management of three paediatric HSCs, two girls and a boy who were followed for 2, 1.25 and 10.4 years, respectively, before starting ART. All had low but detectable viral loads throughout follow-up but mostly marginally low CD4:CD8 ratios. The reason for starting ART in all was a gradual tendency to poorer virological control. This case series should assist in recognising paediatric HSCs. Clinical dilemmas arising in the management of paediatric HSCs include arriving at a correct HIV-positive diagnosis, correct diagnosis as an HSC, as well as whether to initiate ART. Decision-making for initiation of ART in paediatric HSCs should be individualised. Factors supporting ART initiation in these patients included increased frequency of viral load blips, increasing detectable viral load, CD4 percentage and CD4:CD8 ratio. Other factors included Hepatitis C serology and highly sensitive C-reactive protein. All three patients ultimately required ART, which supports universal initiation of ART in paediatric HSCs, but further research is required.
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Affiliation(s)
- Peter Zuidewind
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Mark Cotton
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Shaun Barnabas
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Anita Janse Van Rensburg
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Gert van Zyl
- Department of Virology, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Carli Gordijn
- Department of Virology, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town, South Africa
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12
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De Clercq J, Rutsaert S, De Scheerder MA, Verhofstede C, Callens S, Vandekerckhove L. Benefits of antiretroviral therapy initiation during acute HIV infection. Acta Clin Belg 2022; 77:168-176. [PMID: 32468932 DOI: 10.1080/17843286.2020.1770413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives: In the last decade, there has been increasing scientific and legislative focus on antiretroviral treatment (ART) for all people living with HIV. Especially early ART initiation, preferably during acute HIV infection, has been named as a promising strategy, both for the individual and for the society. This article will review the benefits and possible future applications of immediate ART initiation during acute HIV infection and explore the remaining hurdles towards this strategy.Results: On an individual level, initiation of ART during acute HIV infection limits the viral reservoir, preserves immune function, and decreases systemic inflammation. In addition, obtaining viral suppression soon after infection can be beneficial for the society by decreasing the chance of onward HIV transmission. Reducing the transmission will reduce HIV incidence and can curtail HIV-related health expenditure. Furthermore, the favorable immunological and virological profile obtained by treating during acute HIV infection will form an ideal starting point for several HIV cure strategies.Conclusions: Initiation of ART during acute HIV infection has shown distinct benefits for the individual, for the society, and for future research on HIV cure. In order to implement this strategy, equal focus should be placed on early diagnosis.
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Affiliation(s)
- Jozefien De Clercq
- HIV Cure Research Center, Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
- Department of General Internal Medicine and Infectious Diseases, Ghent University Hospital, Ghent, Belgium
| | - Sofie Rutsaert
- HIV Cure Research Center, Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | | | - Chris Verhofstede
- AIDS Reference Laboratory, Ghent University Hospital, Ghent, Belgium
| | - Steven Callens
- Department of General Internal Medicine and Infectious Diseases, Ghent University Hospital, Ghent, Belgium
| | - Linos Vandekerckhove
- HIV Cure Research Center, Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
- Department of General Internal Medicine and Infectious Diseases, Ghent University Hospital, Ghent, Belgium
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13
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Zacharopoulou P, Marchi E, Ogbe A, Robinson N, Brown H, Jones M, Parolini L, Pace M, Grayson N, Kaleebu P, Rees H, Fidler S, Goulder P, Klenerman P, Frater J. Expression of type I interferon-associated genes at antiretroviral therapy interruption predicts HIV virological rebound. Sci Rep 2022; 12:462. [PMID: 35013427 PMCID: PMC8748440 DOI: 10.1038/s41598-021-04212-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 12/08/2021] [Indexed: 12/25/2022] Open
Abstract
Although certain individuals with HIV infection can stop antiretroviral therapy (ART) without viral load rebound, the mechanisms under-pinning 'post-treatment control' remain unclear. Using RNA-Seq we explored CD4 T cell gene expression to identify evidence of a mechanism that might underpin virological rebound and lead to discovery of associated biomarkers. Fourteen female participants who received 12 months of ART starting from primary HIV infection were sampled at the time of stopping therapy. Two analysis methods (Differential Gene Expression with Gene Set Enrichment Analysis, and Weighted Gene Co-expression Network Analysis) were employed to interrogate CD4+ T cell gene expression data and study pathways enriched in post-treatment controllers versus early rebounders. Using independent analysis tools, expression of genes associated with type I interferon responses were associated with a delayed time to viral rebound following treatment interruption (TI). Expression of four genes identified by Cox-Lasso (ISG15, XAF1, TRIM25 and USP18) was converted to a Risk Score, which associated with rebound (p < 0.01). These data link transcriptomic signatures associated with innate immunity with control following stopping ART. The results from this small sample need to be confirmed in larger trials, but could help define strategies for new therapies and identify new biomarkers for remission.
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Affiliation(s)
- P Zacharopoulou
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - E Marchi
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - A Ogbe
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - N Robinson
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - H Brown
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M Jones
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - L Parolini
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M Pace
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - N Grayson
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - P Kaleebu
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - H Rees
- Wits Reproductive Health and HIV Institute of the University of the Witwatersrand in Johannesburg, Johannesburg, South Africa
| | - S Fidler
- Division of Medicine, Wright Fleming Institute, Imperial College, London, UK
- Imperial College NIHR Biomedical Research Centre, London, UK
| | - P Goulder
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - P Klenerman
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- National Institute of Health Research Biomedical Research Centre, Oxford, UK
| | - J Frater
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- National Institute of Health Research Biomedical Research Centre, Oxford, UK.
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14
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McMahon J, Lewin SR, Rasmussen TA. Viral, inflammatory, and reservoir characteristics of posttreatment controllers. Curr Opin HIV AIDS 2021; 16:249-256. [PMID: 34334614 DOI: 10.1097/coh.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of studies to date that have identified posttreatment controllers (PTCs) and to explore current evidence around clinical characteristics, immune effector function, and inflammatory and viral reservoir characteristics that may underlie the control mechanism. RECENT FINDINGS PTCs are broadly defined as individuals capable of maintaining control of HIV replication after cessation of antiretroviral therapy (ART). While starting ART early after HIV infection is associated with PTC, genetic disposition or CD8+ T-cell function do not appear to explain this phenomenon, but these features have not been exhaustively analyzed in PTCs. A lower frequency of latently infected cells prior to stopping ART has been associated with achieving PTC, including a lower level of intact HIV DNA, but more studies are needed to map the genetic location, epigenetic characteristics, and tissue distribution of the intact HIV reservoir in PTCs. SUMMARY Current studies are small and heterogeneous and there is a significant need to agree on a uniform definition of PTC. Many aspects of PTC are still unexplored including whether specific features of genetic disposition, immune effector functions, and/or viral reservoir characteristics play a role in PTC. A large multisite international cohort study could aide in providing the important insights needed to fully understand PTC.
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Affiliation(s)
- James McMahon
- Department of Infectious Diseases, Alfred Hospital and Monash University
- Department of Infectious Diseases, Monash Medical Centre
| | - Sharon R Lewin
- Department of Infectious Diseases, Alfred Hospital and Monash University
- Department of Infectious Diseases, The University of Melbourne at The Doherty Institute for Infection and Immunity
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Thomas A Rasmussen
- Department of Infectious Diseases, The University of Melbourne at The Doherty Institute for Infection and Immunity
- Department of Infectious Diseases, Aarhus University Hospital, Arhus, Denmark
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15
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A Gut Reaction to SIV and SHIV Infection: Lower Dysregulation of Mucosal T Cells during Acute Infection Is Associated with Greater Viral Suppression during cART. Viruses 2021; 13:v13081609. [PMID: 34452474 PMCID: PMC8402906 DOI: 10.3390/v13081609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/31/2021] [Accepted: 08/12/2021] [Indexed: 11/27/2022] Open
Abstract
Selection of a pre-clinical non-human primate (NHP) model is essential when evaluating therapeutic vaccine and treatment strategies for HIV. SIV and SHIV-infected NHPs exhibit a range of viral burdens, pathologies, and responses to combinatorial antiretroviral therapy (cART) regimens and the choice of the NHP model for AIDS could influence outcomes in studies investigating interventions. Previously, in rhesus macaques (RMs) we showed that maintenance of mucosal Th17/Treg homeostasis during SIV infection correlated with a better virological response to cART. Here, in RMs we compared viral kinetics and dysregulation of gut homeostasis, defined by T cell subset disruption, during highly pathogenic SIVΔB670 compared to SHIV-1157ipd3N4 infection. SHIV infection resulted in lower acute viremia and less disruption to gut CD4 T-cell homeostasis. Additionally, 24/24 SHIV-infected versus 10/19 SIV-infected animals had sustained viral suppression <100 copies/mL of plasma after 5 months of cART. Significantly, the more profound viral suppression during cART in a subset of SIV and all SHIV-infected RMs corresponded with less gut immune dysregulation during acute SIV/SHIV infection, defined by maintenance of the Th17/Treg ratio. These results highlight significant differences in viral control during cART and gut dysregulation in NHP AIDS models and suggest that selection of a model may impact the evaluation of candidate therapeutic interventions for HIV treatment and cure strategies.
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16
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SenGupta D, Brinson C, DeJesus E, Mills A, Shalit P, Guo S, Cai Y, Wallin JJ, Zhang L, Humeniuk R, Begley R, Geleziunas R, Mellors J, Wrin T, Jones N, Milush J, Ferre AL, Shacklett BL, Laird GM, Moldt B, Vendrame E, Brainard DM, Ramgopal M, Deeks SG. The TLR7 agonist vesatolimod induced a modest delay in viral rebound in HIV controllers after cessation of antiretroviral therapy. Sci Transl Med 2021; 13:13/599/eabg3071. [PMID: 34162752 DOI: 10.1126/scitranslmed.abg3071] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/04/2021] [Indexed: 12/14/2022]
Abstract
Toll-like receptor 7 (TLR7) agonists, in combination with other therapies, can induce sustained control of simian-human immunodeficiency virus (SHIV) or simian immunodeficiency virus (SIV) in nonhuman primates. Here, we report the results of a randomized, double-blind, placebo-controlled phase 1b clinical trial of an oral TLR7 agonist, vesatolimod, in HIV-1-infected controllers on antiretroviral therapy (ART). We randomized participants 2:1 to receive vesatolimod (n = 17) or placebo (n = 8) once every other week for a total of 10 doses while continuing on ART. ART was then interrupted, and the time to viral rebound was analyzed using the Kaplan-Meier method. Vesatolimod was associated with induction of immune cell activation, decreases in intact proviral DNA during ART, and a modest increase in time to rebound after ART was interrupted. The delayed viral rebound was predicted by the lower intact proviral DNA at the end of vesatolimod treatment (13 days after the final dose). Inferred pathway analysis suggested increased dendritic cell and natural killer cell cross-talk and an increase in cytotoxicity potential after vesatolimod dosing. Larger clinical studies will be necessary to assess the efficacy of vesatolimod-based combination therapies aimed at long-term control of HIV infection.
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Affiliation(s)
| | | | | | | | - Peter Shalit
- Peter Shalit MD and Associates, Seattle, WA, USA
| | - Susan Guo
- Gilead Sciences Inc., Foster City, CA, USA
| | - Yanhui Cai
- Gilead Sciences Inc., Foster City, CA, USA
| | | | - Liao Zhang
- Gilead Sciences Inc., Foster City, CA, USA
| | | | | | | | | | - Terri Wrin
- Monogram Biosciences, South San Francisco, CA, USA
| | - Norman Jones
- University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey Milush
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | | | | | - Steven G Deeks
- University of California San Francisco, San Francisco, CA, USA.
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17
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Li JZ, Blankson JN. How elite controllers and posttreatment controllers inform our search for an HIV-1 cure. J Clin Invest 2021; 131:e149414. [PMID: 34060478 DOI: 10.1172/jci149414] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A small percentage of people living with HIV-1 can control viral replication without antiretroviral therapy (ART). These patients are called elite controllers (ECs) if they are able to maintain viral suppression without initiating ART and posttreatment controllers (PTCs) if they control HIV replication after ART has been discontinued. Both types of controllers may serve as a model of a functional cure for HIV-1 but the mechanisms responsible for viral control have not been fully elucidated. In this review, we highlight key lessons that have been learned so far in the study of ECs and PTCs and their implications for HIV cure research.
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Affiliation(s)
- Jonathan Z Li
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joel N Blankson
- Center for AIDS Research, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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18
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Conway JM, Meily P, Li JZ, Perelson AS. Unified model of short- and long-term HIV viral rebound for clinical trial planning. J R Soc Interface 2021; 18:20201015. [PMID: 33849338 PMCID: PMC8086917 DOI: 10.1098/rsif.2020.1015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/23/2021] [Indexed: 11/12/2022] Open
Abstract
Antiretroviral therapy (ART) effectively controls HIV infection, suppressing HIV viral loads. Typically suspension of therapy is rapidly followed by rebound of viral loads to high, pre-therapy levels. Indeed, a recent study showed that approximately 90% of treatment interruption study participants show viral rebound within at most a few months of therapy suspension, but the remaining 10%, showed viral rebound some months, or years, after ART suspension. Some may even never rebound. We investigate and compare branching process models aimed at gaining insight into these viral dynamics. Specifically, we provide a theory that explains both short- and long-term viral rebounds, and post-treatment control, via a multitype branching process with time-inhomogeneous rates, validated with data from Li et al. (Li et al. 2016 AIDS30, 343-353. (doi:10.1097/QAD.0000000000000953)). We discuss the associated biological interpretation and implications of our best-fit model. To test the effectiveness of an experimental intervention in delaying or preventing rebound, the standard practice is to suspend therapy and monitor the study participants for rebound. We close with a discussion of an important application of our modelling in the design of such clinical trials.
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Affiliation(s)
- Jessica M. Conway
- Department of Mathematics and Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA, USA
| | - Paige Meily
- University of Pennsylvania School of Arts and Sciences, Philadephia, PA, USA
| | - Jonathan Z. Li
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Alan S. Perelson
- Theoretical Biology and Biophysics, Los Alamos National Laboratory, Los Alamos, NM, USA
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19
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Bretscher PA, Al-Yassin G. Can interruption/withdrawl of anti-retroviral therapy provide personalized immunotherapy against HIV-1? Scand J Immunol 2020; 92:e12934. [PMID: 32654266 DOI: 10.1111/sji.12934] [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: 05/19/2020] [Revised: 07/03/2020] [Accepted: 07/06/2020] [Indexed: 11/26/2022]
Abstract
We propose a treatment of HIV-1+ individuals designed to harness protective immunity, lead to viral containment, and so render the individual minimally infectious. A few HIV-infected individuals, 'elite controllers', generate a stable Th1, cytotoxic T lymphocyte response that contains the virus. Most infected individuals, in the absence of therapy, first generate a similarly protective response that evolves with time a Th2 component, associated with antibody production and loss of viral control. Cessation of anti-retroviral treatment after three years results in viral rebound in most, but about one in seven individuals contains the virus, so-called post-treatment controllers. We suggest an understanding, of how the Th1/Th2 phenotype of immune responses is controlled, can explain these different outcomes and leads us to propose a non-invasive, personalized strategy of immunotherapy. We propose that monitoring the relative prevalence of HIV-1 specific IgG1 and IgG2 antibodies can provide a biomarker for deciding when to interrupt/withdraw anti-retroviral therapy to optimally harness protective immunity.
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Affiliation(s)
- Peter A Bretscher
- Department of Biochemistry, Microbiology and Immunology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Ghassan Al-Yassin
- Department of Biochemistry, Microbiology and Immunology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
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20
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Gianella S, Chaillon A, Chun TW, Sneller MC, Ignacio C, Vargas-Meneses MV, Caballero G, Ellis RJ, Kovacs C, Benko E, Huibner S, Kaul R. HIV RNA Rebound in Seminal Plasma after Antiretroviral Treatment Interruption. J Virol 2020; 94:e00415-20. [PMID: 32434884 PMCID: PMC7375368 DOI: 10.1128/jvi.00415-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/11/2020] [Indexed: 12/12/2022] Open
Abstract
If strategies currently in development succeed in eradicating HIV reservoirs in peripheral blood and lymphoid tissues, residual sources of virus may remain in anatomic compartments. Paired blood and semen samples were collected from 12 individuals enrolled in a randomized, double-blind, placebo-controlled therapeutic vaccine clinical trial in people with HIV (PWH) who began antiretroviral therapy (ART) during acute or early infection (ClinicalTrials registration no. NCT01859325). After the week 56 visit (postintervention), all participants interrupted ART. At the first available time points after viral rebound, we sequenced HIV-1 env (C2-V3), gag (p24), and pol (reverse transcriptase) regions amplified from cell-free HIV RNA in blood and seminal plasma using the MiSeq Illumina platform. Comprehensive sequence and phylogenetic analyses were performed to evaluate viral population structure, compartmentalization, and viral diversity in blood and seminal plasma. Compared to that in blood, HIV RNA rebound in semen occurred significantly later (median of 66 versus 42 days post-ART interruption, P < 0.01) and reached lower levels (median 164 versus 16,090 copies/ml, P < 0.01). Three of five participants with available sequencing data presented compartmentalized viral rebound between blood and semen in one HIV coding region. Despite early ART initiation, HIV RNA molecular diversity was higher in semen than in blood in all three coding regions for most participants. Higher HIV RNA molecular diversity in the genital tract (compared to that in blood plasma) and evidence of compartmentalization illustrate the distinct evolutionary dynamics between these two compartments after ART interruption. Future research should evaluate whether the genital compartment might contribute to viral rebound in some PWH interrupting ART.IMPORTANCE To cure HIV, we likely need to target the reservoirs in all anatomic compartments. Here, we used sophisticated statistical and phylogenetic methods to analyze blood and semen samples collected from 12 persons with HIV who began antiretroviral therapy (ART) during very early HIV infection and who interrupted their ART as part of a clinical trial. First, we found that HIV RNA rebound in semen occurred significantly later and reached lower levels than in blood. Second, we found that the virus in semen was genetically different in some participants compared to that in blood. Finally, we found increased HIV RNA molecular diversity in semen compared to that in blood in almost all study participants. These data suggest that the HIV RNA populations emerging from the genital compartment after ART interruption might not be the same as those emerging from blood plasma. Future research should evaluate whether the genital compartment might contribute to viral rebound in some people with HIV (PWH) interrupting ART.
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Affiliation(s)
- Sara Gianella
- University of California, San Diego, La Jolla, California, USA
| | | | - Tae-Wook Chun
- National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Michael C Sneller
- National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | | | | | - Gemma Caballero
- University of California, San Diego, La Jolla, California, USA
| | - Ronald J Ellis
- University of California, San Diego, La Jolla, California, USA
| | - Colin Kovacs
- Maple Leaf Medical Clinic, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Erika Benko
- Maple Leaf Medical Clinic, Toronto, Ontario, Canada
| | - Sanja Huibner
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rupert Kaul
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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21
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Virologic and Immunologic Features of Simian Immunodeficiency Virus Control Post-ART Interruption in Rhesus Macaques. J Virol 2020; 94:JVI.00338-20. [PMID: 32350073 DOI: 10.1128/jvi.00338-20] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/17/2020] [Indexed: 02/08/2023] Open
Abstract
Antiretroviral therapy (ART) cannot eradicate human immunodeficiency virus (HIV) and a rapid rebound of virus replication follows analytical treatment interruption (ATI) in the vast majority of HIV-infected individuals. Sustained control of HIV replication without ART has been documented in a subset of individuals, defined as posttreatment controllers (PTCs). The key determinants of post-ART viral control remain largely unclear. Here, we identified 7 SIVmac239-infected rhesus macaques (RMs), defined as PTCs, who started ART 8 weeks postinfection, continued ART for >7 months, and controlled plasma viremia at <104 copies/ml for up to 8 months after ATI and <200 copies/ml at the latest time point. We characterized immunologic and virologic features associated with post-ART SIV control in blood, lymph node (LN), and colorectal (RB) biopsy samples compared to 15 noncontroller (NC) RMs. Before ART initiation, PTCs had higher CD4 T cell counts, lower plasma viremia, and SIV-DNA content in blood and LN compared to NCs, but had similar CD8 T cell function. While levels of intestinal CD4 T cells were similar, PTCs had higher frequencies of Th17 cells. On ART, PTCs had significantly lower levels of residual plasma viremia and SIV-DNA content in blood and tissues. After ATI, SIV-DNA content rapidly increased in NCs, while it remained stable or even decreased in PTCs. Finally, PTCs showed immunologic benefits of viral control after ATI, including higher CD4 T cell levels and reduced immune activation. Overall, lower plasma viremia, reduced cell-associated SIV-DNA, and preserved Th17 homeostasis, including at pre-ART, are the main features associated with sustained viral control after ATI in SIV-infected RMs.IMPORTANCE While effective, antiretroviral therapy is not a cure for HIV infection. Therefore, there is great interest in achieving viral remission in the absence of antiretroviral therapy. Posttreatment controllers represent a small subset of individuals who are able to control HIV after cessation of antiretroviral therapy, but characteristics associated with these individuals have been largely limited to peripheral blood analysis. Here, we identified 7 SIV-infected rhesus macaques that mirrored the human posttreatment controller phenotype and performed immunologic and virologic analysis of blood, lymph node, and colorectal biopsy samples to further understand the characteristics that distinguish them from noncontrollers. Lower viral burden and preservation of immune homeostasis, including intestinal Th17 cells, both before and after ART, were shown to be two major factors associated with the ability to achieve posttreatment control. Overall, these results move the field further toward understanding of important characteristics of viral control in the absence of antiretroviral therapy.
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22
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Abstract
Therapeutic approaches towards a functional cure or eradication of HIV have gained renewed momentum upon encouraging data emerging from studies in SIV monkey models and recent results from human clinical studies. However, a multitude of questions remain to be addressed, including how to deal with the latent viral reservoir, how to boost the host immune response to the virus and what the hurdles are to reach relevant viral compartments in the body. Advances have been made especially with regard to identifying agents that can reactivate the latent virus in vivo and boost the cellular and humoral immunity, but it remains largely unclear whether any of these strategies can awaken a sufficiently large fraction of the viral reservoir and whether the boosted immunity can prevent rapid viral replication once antiretroviral treatments are stopped.
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Affiliation(s)
- Lucia Bailon
- Fundació Lluita contra la Sida, Infectious Disease Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Beatriz Mothe
- Fundació Lluita contra la Sida, Infectious Disease Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- IrsiCaixa AIDS Research Institute-HIVACAT, Badalona, Spain
- Faculty of Medicine, Universitat de Vic-Central de Catalunya (UVic-UCC), Vic, Spain
| | | | - Christian Brander
- IrsiCaixa AIDS Research Institute-HIVACAT, Badalona, Spain.
- Faculty of Medicine, Universitat de Vic-Central de Catalunya (UVic-UCC), Vic, Spain.
- AELIX Therapeutics, Barcelona, Spain.
- ICREA, Pg. Lluis Companys 23, Barcelona, Spain.
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23
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Namazi G, Fajnzylber JM, Aga E, Bosch RJ, Acosta EP, Sharaf R, Hartogensis W, Jacobson JM, Connick E, Volberding P, Skiest D, Margolis D, Sneller MC, Little SJ, Gianella S, Smith DM, Kuritzkes DR, Gulick RM, Mellors JW, Mehraj V, Gandhi RT, Mitsuyasu R, Schooley RT, Henry K, Tebas P, Deeks SG, Chun TW, Collier AC, Routy JP, Hecht FM, Walker BD, Li JZ. The Control of HIV After Antiretroviral Medication Pause (CHAMP) Study: Posttreatment Controllers Identified From 14 Clinical Studies. J Infect Dis 2019; 218:1954-1963. [PMID: 30085241 DOI: 10.1093/infdis/jiy479] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 07/31/2018] [Indexed: 01/09/2023] Open
Abstract
Background HIV posttreatment controllers are rare individuals who start antiretroviral therapy (ART), but maintain HIV suppression after treatment interruption. The frequency of posttreatment control and posttreatment interruption viral dynamics have not been well characterized. Methods Posttreatment controllers were identified from 14 studies and defined as individuals who underwent treatment interruption with viral loads ≤400 copies/mL at two-thirds or more of time points for ≥24 weeks. Viral load and CD4+ cell dynamics were compared between posttreatment controllers and noncontrollers. Results Of the 67 posttreatment controllers identified, 38 initiated ART during early HIV infection. Posttreatment controllers were more frequently identified in those treated during early versus chronic infection (13% vs 4%, P < .001). In posttreatment controllers with weekly viral load monitoring, 45% had a peak posttreatment interruption viral load of ≥1000 copies/mL and 33% had a peak viral load ≥10000 copies/mL. Of posttreatment controllers, 55% maintained HIV control for 2 years, with approximately 20% maintaining control for ≥5 years. Conclusions Posttreatment control was more commonly identified amongst early treated individuals, frequently characterized by early transient viral rebound and heterogeneous durability of HIV remission. These results may provide mechanistic insights and have implications for the design of trials aimed at achieving HIV remission.
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Affiliation(s)
- Golnaz Namazi
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jesse M Fajnzylber
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Evgenia Aga
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ronald J Bosch
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Radwa Sharaf
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | - Michael C Sneller
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | | | | | | | - Daniel R Kuritzkes
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Vikram Mehraj
- McGill University Health Centre, Montreal, Quebec, Canada
| | - Rajesh T Gandhi
- Massachusetts General Hospital, Harvard Medical School, Boston
| | | | | | | | | | | | - Tae-Wook Chun
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | | | | | | | - Bruce D Walker
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology, and Harvard, Cambridge
| | - Jonathan Z Li
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Levin B, Kuhn L, Leu CS, Tsai WY. Sequential tests of promise with discrete time-to-event data. Contemp Clin Trials 2019; 85:105818. [PMID: 31445172 DOI: 10.1016/j.cct.2019.105818] [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: 04/16/2019] [Revised: 07/25/2019] [Accepted: 08/04/2019] [Indexed: 11/24/2022]
Abstract
We introduce a family of sequential test procedures in the context of a futility study design, or as we prefer to call it, a formal test of promise, suitable for use with time-to-event data. The procedures are motivated by an actual trial that was undertaken to test the promise of very early antiretroviral therapy to achieve viral remission in infants with perinatally-acquired HIV. Important gains in efficiency are illustrated in terms of early stopping and statistical power compared with other methods such as Simon's two-stage design with binary outcomes. We show how to calculate the operating characteristics of the proposed sequential tests of promise and provide optimal or near-optimal boundaries for small or medium size samples which provide the typical context for the tests under consideration. The design features discussed in this article are also of immediate pertinence to trials designed to test disease cures which may require treatment interruption and small numbers of participants.
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Affiliation(s)
- Bruce Levin
- Department of Biostatistics, Columbia University, Mailman School of Public Health, 722 West 168(th) Street, New York, NY 10032, USA.
| | - Louise Kuhn
- Department of Epidemiology, Columbia University, Mailman School of Public Health, 722 West 168(th) Street, New York, NY 10032, USA.
| | - Cheng-Shiun Leu
- Department of Biostatistics, Columbia University, Mailman School of Public Health, 722 West 168(th) Street, New York, NY 10032, USA.
| | - Wei-Yann Tsai
- Department of Biostatistics, Columbia University, Mailman School of Public Health, 722 West 168(th) Street, New York, NY 10032, USA.
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Veldsman KA, Janse van Rensburg A, Isaacs S, Naidoo S, Laughton B, Lombard C, Cotton MF, Mellors JW, van Zyl GU. HIV-1 DNA decay is faster in children who initiate ART shortly after birth than later. J Int AIDS Soc 2019; 22:e25368. [PMID: 31441231 PMCID: PMC6868516 DOI: 10.1002/jia2.25368] [Citation(s) in RCA: 15] [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: 02/05/2019] [Accepted: 07/15/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION There is limited data in children on whether persistence of HIV-1 infected cells is affected by age at initiating antiretroviral therapy (ART), its duration or any subsequent ART interruption. We therefore investigated the effects of both age of ART initiation and duration of ART interruption on HIV-1 DNA decay in children. METHODS We investigated HIV-1 DNA decay in three groups of children on ART: Group-1 (n = 7) started uninterrupted ART within eight days of life; Group-2 (n = 8) started uninterrupted ART at a median of five months of age; and Group-3 (n = 23) started ART at a median age of 1.8 months for either 40 or 96 weeks, then interrupted ART (median of seven months), and restarted ART based on CD4 count and clinical criteria. Total HIV-1 DNA was assayed using a sensitive HIV-1 subtype C-adapted quantitative PCR for integrase. The duration of ART was square root transformed to fit the observed slowing of HIV-1 DNA decay rate. For each group, point estimates for decay rates were determined after six months of continuous suppressive ART in groups 1 and 2 or six months after restarting ART in Group-3. Groups-2 and 3 were combined using a mixed effect regression model to investigate covariates of HIV-1 DNA decay rate. RESULTS AND DISCUSSION At six months of continuous suppressive ART, the HIV-1 DNA t½ (95% CI) was shorter in Group-1 (n = 7): 2.7 months (2.1 to 3.8), than 9.2 months (7.4 to 12.1) in Group-2 (n = 8); and 9.6 months (7.6 to 12.6) in Group-3 (n = 23) (p < 0.01). In multivariable analyses, HIV-1 DNA before treatment (p < 0.001) and the change in HIV-1 DNA during interruption (p < 0.01) were independent predictors of slower HIV-1 DNA decay. CONCLUSIONS These data suggest that ART initiation within the first week of life can reduce the persistence of long-lived infected cells. Delaying ART is associated with slower decay of infected cells.
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Affiliation(s)
- Kirsten A Veldsman
- Division of Medical VirologyStellenbosch UniversityFaculty of Medicine and Health SciencesCape TownSouth Africa
| | - Anita Janse van Rensburg
- Department Pediatrics and Child HealthTygerberg Children's Hospital and Family Clinical Research UnitStellenbosch UniversityCape TownSouth Africa
| | - Shahieda Isaacs
- Division of Medical VirologyStellenbosch UniversityFaculty of Medicine and Health SciencesCape TownSouth Africa
| | - Shalena Naidoo
- Division of Medical VirologyStellenbosch UniversityFaculty of Medicine and Health SciencesCape TownSouth Africa
| | - Barbara Laughton
- Department Pediatrics and Child HealthTygerberg Children's Hospital and Family Clinical Research UnitStellenbosch UniversityCape TownSouth Africa
| | - Carl Lombard
- Division of Epidemiology and BiostatisticsDepartment of Global HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
- Biostatistics UnitSouth African Medical Research CouncilCape TownSouth Africa
| | - Mark F Cotton
- Department Pediatrics and Child HealthTygerberg Children's Hospital and Family Clinical Research UnitStellenbosch UniversityCape TownSouth Africa
| | - John W Mellors
- Division of Infectious DiseasesDepartment of MedicineUniversity of PittsburghPittsburghPAUSA
| | - Gert U van Zyl
- Division of Medical VirologyStellenbosch UniversityFaculty of Medicine and Health SciencesCape TownSouth Africa
- National Health Laboratory ServiceCape TownSouth Africa
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Etemad B, Esmaeilzadeh E, Li JZ. Learning From the Exceptions: HIV Remission in Post-treatment Controllers. Front Immunol 2019; 10:1749. [PMID: 31396237 PMCID: PMC6668499 DOI: 10.3389/fimmu.2019.01749] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/10/2019] [Indexed: 12/19/2022] Open
Abstract
Among the top priorities of the HIV field is the search for therapeutic interventions that can lead to sustained antiretroviral therapy (ART)-free HIV remission. Although the majority of HIV-infected persons will experience rapid viral rebound after ART interruption, there are rare individuals, termed post-treatment controllers (PTCs), who demonstrate sustained virologic suppression for months or years after treatment cessation. These individuals are considered an ideal example of durable HIV control, with direct implications for HIV cure research. However, understanding of the mechanisms behind the capacity of PTCs to control HIV remains incomplete. This is in part due to the scarcity of PTCs identified through any one research center or clinical trial, and in part because of the limited scope of studies that have been performed in these remarkable individuals. In this review, we summarize the results of both clinical and basic research studies of PTCs to date, explore key differences between PTCs and HIV spontaneous controllers, examine potential mechanisms of post-treatment control, and discuss unanswered questions and future research directions in this field.
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Affiliation(s)
- Behzad Etemad
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Elmira Esmaeilzadeh
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Jonathan Z Li
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
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Conway JM, Perelson AS, Li JZ. Predictions of time to HIV viral rebound following ART suspension that incorporate personal biomarkers. PLoS Comput Biol 2019; 15:e1007229. [PMID: 31339888 PMCID: PMC6682162 DOI: 10.1371/journal.pcbi.1007229] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 08/05/2019] [Accepted: 06/30/2019] [Indexed: 01/31/2023] Open
Abstract
Antiretroviral therapy (ART) effectively controls HIV infection, suppressing HIV viral loads. Suspension of therapy is followed by rebound of viral loads to high, pre-therapy levels. However, there is significant heterogeneity in speed of rebound, with some rebounds occurring within days, weeks, or sometimes years. We present a stochastic mathematical model to gain insight into these post-treatment dynamics, specifically characterizing the dynamics of short term viral rebounds (≤ 60 days). Li et al. (2016) report that the size of the expressed HIV reservoir, i.e., cell-associated HIV RNA levels, and drug regimen correlate with the time between ART suspension and viral rebound to detectable levels. We incorporate this information and viral rebound times to parametrize our model. We then investigate insights offered by our model into the underlying dynamics of the latent reservoir. In particular, we refine previous estimates of viral recrudescence after ART interruption by accounting for heterogeneity in infection rebound dynamics, and determine a recrudescence rate of once every 2-4 days. Our parametrized model can be used to aid in design of clinical trials to study viral dynamics following analytic treatment interruption. We show how to derive informative personalized testing frequencies from our model and offer a proof-of-concept example. Our results represent first steps towards a model that can make predictions on a person living with HIV (PLWH)'s rebound time distribution based on biomarkers, and help identify PLWH with long viral rebound delays.
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Affiliation(s)
- Jessica M. Conway
- Department of Mathematics and Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, Pennsylvania, United States of America
| | - Alan S. Perelson
- Theoretical Biology and Biophysics, Los Alamos National Laboratory, Los Alamos, New Mexico, United States of America
| | - Jonathan Z. Li
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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Abstract
PURPOSE OF REVIEW Clinical trials with an antiretroviral therapy (ART) interruption remains indispensable for assessing strategies for ART-free HIV remission. This review highlights the lessons learned from ART interruption studies so far, including the risks to the participants and implications for HIV remission. RECENT FINDINGS Historically, analytic HIV treatment interruption (ATI) studies were commonly designed with a prolonged duration of ART interruption and with viral load set point as the primary outcome. For a variety of reasons, including participant risk, recent treatment interruption trials have frequently used time to viral rebound as the primary endpoint and have restarted ART once a predetermined viral load threshold is reached. Through treatment interruption trials, investigators have tested the efficacy of therapeutic and curative strategies that showed promise in preclinical trials, including therapeutic vaccines, latency-reversing agents, and broadly neutralizing antibodies. In most populations, ATI trials have been well tolerated, with few adverse clinical events and no significant changes to the reservoir. Several reservoir predictors of HIV-rebound timing have been reported, with a subset of trials uncovering posttreatment controllers who can maintain HIV remission despite ART discontinuation. SUMMARY Treatment interruption trials are a vital tool, but their optimal design remain uncertain and must balance participant risks with scientific rigor. The ability to predict the timing or extent of HIV rebound and identify mechanisms of posttreatment control may accelerate the development of novel therapeutics for sustained HIV remission.
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Abstract
Purpose of review Several promising experimental pathways exist for long-term control of HIV in the absence of antiretroviral therapy (HIV ‘remission’) and are now being tested in early clinical studies. These studies can be invasive and pose a host of distinctive risks to participants, as well as to nonparticipants, especially to participants’ fetuses, and sexual partners. Recent findings Ethical analyses of these studies have mainly focused on the risks to study participants. They recommend, and some investigators implement, procedures to mitigate risks for participants or to offset them with direct, indirect, and nonmedical benefits. They also suggest ways to keep participants’ consent highly voluntary and informed. Rarely do ethicists propose keeping the social value of studies high. Of these recommended responses, only the latter, rarer proposals help address the risk to nonparticipants, as would some novel ways to address that risk. Summary HIV remission studies pose a number of ethical dilemmas. Many current investigative approaches put the participant at significant risk, but well established guidelines exist for mitigating this risk. Ethical issues that are not being fully addressed include risk to nonparticipants and the need to consider the societal value of studies, for example, their prospective impact on the global HIV burden. Video abstract
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Abstract
PURPOSE OF REVIEW A number studies are currently underway to develop new drugs aimed at reducing the HIV reservoir or achieving ART-free control of HIV infection. Many markers of HIV reservoirs have been proposed, each one having a different meaning. Total HIV DNA dynamics during the course of HIV infection and its predictive value are now well known. This marker allowed to estimate the size of HIV reservoir at different stages of HIV infection in blood, cell subsets and tissues. Therefore, the purpose of this review is timely and relevant, with the objective to discuss how total HIV DNA might be helpful in the clinical settings. RECENT FINDINGS Among the markers, it appears that HIV DNA is the most well studied, and recent articles confirmed that this marker is easy to use and is precise, specific, practical, robust and reproducible. All these characteristics correspond to what is expected from a helpful clinical marker. SUMMARY HIV DNA level could be considered as a global marker, and it is usually included in current clinical studies to describe the persistence and dynamics of the HIV reservoir, mainly in treated patients. HIV DNA might be helpful in designing clinical trials and personalized medication for HIV patients in the future.
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Abstract
PURPOSE OF REVIEW The aim of the current review is to explore the evidence around virological remission in ART-treated and untreated individuals living with HIV. With increasing evidence and interest in post-treatment control within the HIV-cure field, it is now increasingly important to agree on definitions to allow different 'controller' phenotypes to be clearly distinguished and mechanisms compared. RECENT FINDINGS This review explores recent data on potential predictors and mechanisms driving spontaneous and post-treatment control. We explore data on the role of the reservoir as a determinant of control and the challenges associated with its study, including the safety of treatment interruption. We explore options around deriving a consensus on how to define different forms of control and the longer term utility of achieving remission. SUMMARY Post-treatment control and remission following treatment interruption are becoming increasingly common measures of intervention efficacy in cure trials. As well as a need to show treatment interruption protocols are well tolerated and acceptable, for these measures to be robust and comparable between studies, clear and consensual definitions need to be agreed.
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Pace M, Frater J. Curing HIV by 'kick and kill': from theory to practice? Expert Rev Anti Infect Ther 2019; 17:383-386. [PMID: 31071275 DOI: 10.1080/14787210.2019.1617697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/08/2019] [Indexed: 01/06/2023]
Affiliation(s)
- Matthew Pace
- a Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine , University of Oxford , Oxford , UK
| | - John Frater
- a Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine , University of Oxford , Oxford , UK
- b Oxford NIHR Biomedical Research Centre , Oxford , UK
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Van Der Elst EM, Kombo B, Mugo P, Thiong’o A, Kanungi J, Wahome E, Chirro O, Graham SM, Operario D, Sanders EJ. Adjustment to acute or early HIV-1 infection diagnosis to prompt linkage to care and ART initiation: qualitative insights from coastal Kenya. PSYCHOL HEALTH MED 2019; 24:631-641. [PMID: 30468392 PMCID: PMC6425912 DOI: 10.1080/13548506.2018.1549736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 11/13/2018] [Indexed: 01/06/2023]
Abstract
Diagnosing and treating patients with acute or early HIV-1 infection (AEHI) is an important strategy to prevent HIV-1 transmission. We used qualitative methods to understand factors that facilitate adjustment to AEHI diagnosis, prompt linkage to care and initiation of antiretroviral treatment (ART). Twenty-three AEHI patients (12 women, 11 men) included 18 participants identified at health facilities, and 5 participants identified in a sex worker cohort. Of these, 17 participants (9 women, 8 men) participated in qualitative interviews about their AEHI status 2 weeks after diagnosis. Thirteen participants (7 women, 6 men) returned for a second interview 12 weeks after diagnosis. Interviews explored participants' experiences at the time of and following their diagnosis, and examined perceptions about ART initiation and behavior change recommendations, including disclosure and partner notification. A grounded theory framework was used for analysis, eliciting three important needs that should be addressed for AEHI patients: 1) the need to better understand AEHI and accept one's status; 2) the need to develop healthy strategies and adjust to the reality of AEHI status; and 3) the need to protect self and others through ART initiation, adherence, safer sex, and disclosure. A preliminary conceptual framework to guide further intervention and research with AEHI populations is proposed.
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Affiliation(s)
- EM Van Der Elst
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - B Kombo
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - P Mugo
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - A Thiong’o
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - J Kanungi
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - E Wahome
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - O Chirro
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - SM Graham
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Departments of Medicine, Global Health, and Epidemiology, University of Washington, Seattle, WA, USA
| | - D Operario
- Department of Behaviour and Social Sciences, Brown University School of Public Health, RI, USA
| | - EJ Sanders
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
- Centre for Topical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Pitman MC, Lau JSY, McMahon JH, Lewin SR. Barriers and strategies to achieve a cure for HIV. Lancet HIV 2019; 5:e317-e328. [PMID: 29893245 DOI: 10.1016/s2352-3018(18)30039-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/02/2018] [Accepted: 03/05/2018] [Indexed: 12/14/2022]
Abstract
9 years since the report of a cure for HIV after C-C chemokine receptor type 5 Δ32 stem cell transplantation, no other case of HIV cure has been reported, despite much research. However, substantial progress has been made in understanding the biology of the latent HIV reservoir, and in measuring the amount of virus that persists after antiretroviral therapy (ART) with increasingly sophisticated approaches. This knowledge is being translated into a long pipeline of clinical trials seeking to reduce viral persistence in participants on suppressive treatment and ultimately to allow safe cessation of ART. In this Review, we discuss the main barriers preventing the development of an HIV cure, methods used to measure HIV persistence in individuals on ART, clinical strategies that aim to cure HIV, and future directions for studies in the field of HIV cure research.
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Affiliation(s)
- Matthew C Pitman
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne, and Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jillian S Y Lau
- Department of Infectious Diseases, Monash University, Alfred Hospital, Melbourne, VIC, Australia
| | - James H McMahon
- Department of Infectious Diseases, Monash University, Alfred Hospital, Melbourne, VIC, Australia; Department of Infectious Diseases, Monash Medical Centre, Clayton, VIC, Australia
| | - Sharon R Lewin
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne, and Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Infectious Diseases, Monash University, Alfred Hospital, Melbourne, VIC, Australia.
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Defining Kinetic Properties of HIV-Specific CD8⁺ T-Cell Responses in Acute Infection. Microorganisms 2019; 7:microorganisms7030069. [PMID: 30836625 PMCID: PMC6462943 DOI: 10.3390/microorganisms7030069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 02/22/2019] [Accepted: 02/24/2019] [Indexed: 12/14/2022] Open
Abstract
Multiple lines of evidence indicate that CD8 + T cells are important in the control of HIV-1 (HIV) replication. However, CD8 + T cells induced by natural infection cannot eliminate the virus or reduce viral loads to acceptably low levels in most infected individuals. Understanding the basic quantitative features of CD8 + T-cell responses induced during HIV infection may therefore inform us about the limits that HIV vaccines, which aim to induce protective CD8 + T-cell responses, must exceed. Using previously published experimental data from a cohort of HIV-infected individuals with sampling times from acute to chronic infection we defined the quantitative properties of CD8 + T-cell responses to the whole HIV proteome. In contrast with a commonly held view, we found that the relative number of HIV-specific CD8 + T-cell responses (response breadth) changed little over the course of infection (first 400 days post-infection), with moderate but statistically significant changes occurring only during the first 35 symptomatic days. This challenges the idea that a change in the T-cell response breadth over time is responsible for the slow speed of viral escape from CD8 + T cells in the chronic infection. The breadth of HIV-specific CD8 + T-cell responses was not correlated with the average viral load for our small cohort of patients. Metrics of relative immunodominance of HIV-specific CD8 + T-cell responses such as Shannon entropy or the Evenness index were also not significantly correlated with the average viral load. Our mathematical-model-driven analysis suggested extremely slow expansion kinetics for the majority of HIV-specific CD8 + T-cell responses and the presence of intra- and interclonal competition between multiple CD8 + T-cell responses; such competition may limit the magnitude of CD8 + T-cell responses, specific to different epitopes, and the overall number of T-cell responses induced by vaccination. Further understanding of mechanisms underlying interactions between the virus and virus-specific CD8 + T-cell response will be instrumental in determining which T-cell-based vaccines will induce T-cell responses providing durable protection against HIV infection.
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In-vitro viral suppressive capacity correlates with immune checkpoint marker expression on peripheral CD8+ T cells in treated HIV-positive patients. AIDS 2019; 33:387-398. [PMID: 30702513 DOI: 10.1097/qad.0000000000002068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To determine whether viral suppressive capacity (VSC) of CD8+ T cells can be boosted by stimulation with HIV-1 peptides and whether the ability to control HIV-1 replication correlates with immunological (cytokine production and CD8+ T-cell phenotype) and viral reservoir measures (total HIV-1 DNA and cell-associated RNA) in well treated HIV-infected chronic progressors. DESIGN We compared VSC of peripheral CD8+ T cells to cytokine production profile in response to peptide stimulation, detailed phenotype (17-color flow-cytometry), reservoir size (total HIV-1 DNA), basal viral transcription (unspliced cell-associated RNA) and inducible viral transcription (tat/rev induced limiting dilution assay) in 36 HIV+ patients on cART and six healthy donors. RESULTS We found that the VSC of CD8+ T cells can be increased by prior stimulation with a pool of consensus HIV-1 gag peptides in a significant proportion of progressor patients. We also found that VSC after peptide stimulation was correlated with higher expression of immune checkpoint markers on subsets of terminally differentiated effector memory (TEMRA) CD8 T cells as well as with production of IFN-γ, TNF-α and IL-10. We did not find a correlation between VSC and viral reservoir measures. CONCLUSION These results add to a small body of evidence that the capacity of CD8+ T cells to suppress viral replication is increased after stimulation with HIV-1 peptides. Interestingly, this VSC was correlated with expression of immune checkpoint markers, which are generally considered to be markers of exhaustion. Our findings may guide further investigations into immune phenotypes correlated with viral suppression.
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Gossez M, Martin GE, Pace M, Ramjee G, Premraj A, Kaleebu P, Rees H, Inshaw J, Stöhr W, Meyerowitz J, Hopkins E, Jones M, Hurst J, Porter K, Babiker A, Fidler S, Frater J. Virological remission after antiretroviral therapy interruption in female African HIV seroconverters. AIDS 2019; 33:185-197. [PMID: 30325764 DOI: 10.1097/qad.0000000000002044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION There are few data on the frequency of virological remission in African individuals after treatment with antiretroviral therapy (ART) in primary HIV infection (PHI). METHODS We studied participants (n = 82) from South Africa and Uganda in Short Pulse Antiretroviral Treatment at HIV-1 Seroconversion, the first trial of treatment interruption in African individuals with PHI randomized to deferred ART or 48 weeks of immediate ART. All were female and infected with non-B HIV subtypes, mainly C. We measured HIV DNA in CD4+ T cells, CD4+ cell count, plasma viral load (pVL), cell-associated HIV RNA and T-cell activation and exhaustion. We explored associations with clinical progression and time to pVL rebound after treatment interruption (n = 22). Data were compared with non-African Short Pulse Antiretroviral Treatment at HIV-1 Seroconversion participants. RESULTS Pretherapy pVL and integrated HIV DNA were lower in Africans compared with non-Africans (median 4.16 vs. 4.72 log10 copies/ml and 3.07 vs. 3.61 log10 copies/million CD4+ T cells, respectively; P < 0.001). Pre-ART HIV DNA in Africans was associated with clinical progression (P = 0.001, HR per log10 copies/million CD4+ T cells increase (95% CI) 5.38 (1.95-14.79)) and time to pVL rebound (P = 0.034, HR per log10 copies/ml increase 4.33 (1.12-16.84)). After treatment interruption, Africans experienced longer duration of viral remission than non-Africans (P < 0.001; HR 3.90 (1.75-8.71). Five of 22 African participants (22.7%) maintained VL less than 400 copies/ml over a median of 188 weeks following treatment interruption. CONCLUSION We find evidence of greater probability of virological remission following treatment interruption among African participants, although we are unable to differentiate between sex, ethnicity and viral subtype. The finding warrants further investigation.
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Affiliation(s)
- Morgane Gossez
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
| | | | - Matthew Pace
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
| | - Gita Ramjee
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Anamika Premraj
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | - Pontiano Kaleebu
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Helen Rees
- Wits Reproductive Health and HIV Institute of the University of the Witwatersrand, Johannesburg, South Africa
| | - Jamie Inshaw
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology
| | - Wolfgang Stöhr
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology
| | - Jodi Meyerowitz
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
| | - Emily Hopkins
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
| | - Mathew Jones
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
| | - Jacob Hurst
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
| | | | - Abdel Babiker
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology
| | - Sarah Fidler
- Division of Medicine, Wright Fleming Institute, Imperial College, London
| | - John Frater
- Peter Medawar Building for Pathogen Research, Nuffield Department of Medicine, Oxford, UK
- The Oxford Martin School
- Oxford National Institute of Health Research Biomedical Research Centre, Oxford, UK
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Avettand‐Fenoel V, Bayan T, Gardiennet E, Boufassa F, Lopez P, Lecuroux C, Noel N, Trémeaux P, Monceaux V, Autran B, Meyer L, Saez‐Cirion A, Lambotte O, Rouzioux C. Dynamics in HIV-DNA levels over time in HIV controllers. J Int AIDS Soc 2019; 22:e25221. [PMID: 30629340 PMCID: PMC6327944 DOI: 10.1002/jia2.25221] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 12/03/2018] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION HIV controllers (HIC) maintain viraemia at low levels without antiretroviral treatment and have small HIV reservoirs. Nevertheless, they are heterogeneous regarding their risk of infection progression. The study of reservoirs can help elucidate this control. This study aimed to explore the factors implicated in the pathogenesis of HIV infection that are potentially associated with HIV reservoirs and their dynamics in HIC. METHODS Individuals living with HIV included in the ANRS-CODEX cohort with at least two HIV-DNA measurements between 2009 and 2016 were selected. The total HIV-DNA levels had been quantified prospectively from blood samples. Mixed-effect linear models estimated the HIV-DNA dynamics over time. RESULTS The median (interquartile range (IQR)) HIV-DNA level was 1.5 (1.3 to 1.9) log copies/million peripheral blood mononuclear cells at inclusion (n = 202 individuals). These low levels showed heterogeneity among HIC. Lower levels were then associated with the protective HLA-B*27/B*57 alleles and/or lower HIV-RNA level at inclusion, negative hepatitis C virus serology, lower HIV-suppressive capacity of specific CD8 T cells and lower levels of immune activation and inflammation. Interestingly, mathematical modelling of the dynamics of HIV-DNA over time (840 measurements) showed that the number of infected cells decreased in 46% of HIC (follow-up: 47.6 months) and increased in 54% of HIC. A multivariate analysis indicated that HLA-B*27/B*57 alleles, a low level of HIV-RNA and a low level of HIV-DNA at inclusion were markers independently associated with this decrease. CONCLUSIONS These results offer new insights into the mechanisms of long-term control in HIC. In half of HIC, the decrease in HIV-DNA level could be linked to tighter viral control and progressive loss of infected cells. These findings allow the identification of HIC with a low risk of progression who may not need treatment.
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Affiliation(s)
- Véronique Avettand‐Fenoel
- Université Paris DescartesSorbonne Paris CitéParisFrance
- AP‐HPLaboratoire de VirologieCHU Necker‐Enfants MaladesParisFrance
| | - Tatiana Bayan
- INSERM CESP U1018Université Paris SudLe Kremlin BicêtreFrance
| | | | | | - Pauline Lopez
- Université Paris DescartesSorbonne Paris CitéParisFrance
| | - Camille Lecuroux
- INSERM UMR 1184Immunologie des Maladies Virales et Autoimmunes (IMVA)Université Paris SudLe Kremlin BicêtreFrance
- CEADSV/iMETIDivision of Immuno‐VirologyIDMITFontenay aux RosesFrance
| | - Nicolas Noel
- INSERM UMR 1184Immunologie des Maladies Virales et Autoimmunes (IMVA)Université Paris SudLe Kremlin BicêtreFrance
- CEADSV/iMETIDivision of Immuno‐VirologyIDMITFontenay aux RosesFrance
| | - Pauline Trémeaux
- Université Paris DescartesSorbonne Paris CitéParisFrance
- AP‐HPLaboratoire de VirologieCHU CochinParisFrance
| | - Valérie Monceaux
- Institut PasteurUnité HIV inflammation et persistanceParisFrance
| | - Brigitte Autran
- Cellular Immunology LaboratoryUniversité Pierre and Marie CurieINSERMUMRS 945ParisFrance
| | - Laurence Meyer
- INSERM CESP U1018Université Paris SudLe Kremlin BicêtreFrance
| | | | - Olivier Lambotte
- INSERM UMR 1184Immunologie des Maladies Virales et Autoimmunes (IMVA)Université Paris SudLe Kremlin BicêtreFrance
- CEADSV/iMETIDivision of Immuno‐VirologyIDMITFontenay aux RosesFrance
- AP‐HP, CHU BicêtreService de Médecine Interne et Immunologie CliniqueLe Kremlin‐BicêtreFrance
- Université Paris SudUMR 1184Le Kremlin‐BicêtreFrance
| | - Christine Rouzioux
- Université Paris DescartesSorbonne Paris CitéParisFrance
- AP‐HPLaboratoire de VirologieCHU Necker‐Enfants MaladesParisFrance
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Miller WC, Rutstein SE, Phiri S, Kamanga G, Nsona D, Pasquale DK, Rucinski KB, Chen JS, Golin CE, Powers KA, Dennis AM, Hosseinipour MC, Eron JJ, Chege W, Hoffman IF, Pettifor AE. Randomized Controlled Pilot Study of Antiretrovirals and a Behavioral Intervention for Persons With Acute HIV Infection: Opportunity for Interrupting Transmission. Open Forum Infect Dis 2018; 6:ofy341. [PMID: 30648131 PMCID: PMC6329906 DOI: 10.1093/ofid/ofy341] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/18/2018] [Indexed: 01/03/2023] Open
Abstract
Background Persons with acute HIV infection (AHI) have heightened transmission risk. We evaluated potential transmission reduction using behavioral and biomedical interventions in a randomized controlled pilot study in Malawi. Methods Persons were randomized 1:2:2 to standard counseling (SC), 5-session behavioral intervention (BI), or behavioral intervention plus 12 weeks of antiretrovirals (ARVs; BIA). All were followed for 26–52 weeks and, regardless of arm, referred for treatment according to Malawi-ARV guidelines. Participants were asked to refer partners for testing. Results Among 46 persons (9 SC, 18 BI, 19 BIA), the average age was 28; 61% were male. The median viral load (VL) was 5.9 log copies/mL at enrollment. 67% (10/15) of BIA participants were suppressed (<1000 copies/mL) at week 12 vs 25% BI and 50% SC (P = .07). Although the mean number of reported condomless sexual acts in the past week decreased from baseline across all arms (1.5 vs 0.3 acts), 36% experienced incident sexually transmitted infection by 52 weeks (12% SC, 28% BI, 18% BIA). Forty-one percent (19/46) of participants referred partners (44% SC, 44% BI, 37% BIA); 15 of the partners were HIV-infected. Conclusions Diagnosis of AHI facilitates behavioral and biomedical risk reduction strategies during a high-transmission period that begins years before people are typically identified and started on ARVs. Sexually transmitted infection incidence in this cohort suggests ongoing risk behaviors, reinforcing the importance of early intervention with ARVs to reduce transmission. Early diagnosis coupled with standard AHI counseling and early ARV referral quickly suppresses viremia, may effectively change behavior, and could have tremendous public health benefit in reducing onward transmission.
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Affiliation(s)
- William C Miller
- Division of Epidemiology, The Ohio State University, Columbus, Ohio.,Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Sarah E Rutstein
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | | | - Dana K Pasquale
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Katherine B Rucinski
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jane S Chen
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Carol E Golin
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kimberly A Powers
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ann M Dennis
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mina C Hosseinipour
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joseph J Eron
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Wairimu Chege
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Irving F Hoffman
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Audrey E Pettifor
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Abstract
In this brief review and perspective, we address the question of whether the immune responses that bring about immune control of acute HIV infection are the same as, or distinct from, those that maintain long-term viral suppression once control of viremia has been achieved. To this end, we describe the natural history of elite and post-treatment control, noting the lack of data regarding what happens acutely. We review the evidence suggesting that the two clinical phenotypes may differ in terms of the mechanisms required to achieve and maintain control, as well as the level of inflammation that persists once a steady state is achieved. We then describe the evidence from longitudinal studies of controllers who fail and studies of biologic sex (male versus female), age (children versus adults), and simian immunodeficiency virus (SIV) (pathogenic/experimental versus nonpathogenic/natural infection). Collectively, these studies demonstrate that the battle between the inflammatory and anti-inflammatory pathways during acute infection has long-term consequences, both for the degree to which control is maintained and the health of the individual. Potent and stringent control of HIV may be required acutely, but once control is established, the chronic inflammatory response can be detrimental. Interventional approaches designed to bring about HIV cure and/or remission should be nuanced accordingly.
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Affiliation(s)
- Philip Goulder
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- HIV Pathogenesis Programme, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
- * E-mail:
| | - Steven G. Deeks
- Department of Medicine, University of California, San Francisco, California, United States of America
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Mendoza P, Gruell H, Nogueira L, Pai JA, Butler AL, Millard K, Lehmann C, Suárez I, Oliveira TY, Lorenzi JCC, Cohen YZ, Wyen C, Kümmerle T, Karagounis T, Lu CL, Handl L, Unson-O'Brien C, Patel R, Ruping C, Schlotz M, Witmer-Pack M, Shimeliovich I, Kremer G, Thomas E, Seaton KE, Horowitz J, West AP, Bjorkman PJ, Tomaras GD, Gulick RM, Pfeifer N, Fätkenheuer G, Seaman MS, Klein F, Caskey M, Nussenzweig MC. Combination therapy with anti-HIV-1 antibodies maintains viral suppression. Nature 2018; 561:479-484. [PMID: 30258136 PMCID: PMC6166473 DOI: 10.1038/s41586-018-0531-2] [Citation(s) in RCA: 340] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 07/30/2018] [Indexed: 11/26/2022]
Abstract
HIV-1-infected individuals require lifelong antiretroviral therapy (ART) because treatment interruption leads to rapid rebound viremia. Here we report on a phase 1b clinical trial in which a combination of 3BNC117 and 10-1074, two potent monoclonal anti-HIV-1 broadly neutralizing antibodies that target independent sites on the HIV-1 envelope spike, was administered during analytical treatment interruption. Participants received three infusions of 30 mg/kg of each antibody at 0, 3 and 6 weeks. Infusions of the two antibodies were generally well tolerated. The nine enrolled individuals with antibody-sensitive latent viral reservoirs maintained suppression for 15 to > 30 weeks (median = 21 weeks), and none developed viruses resistant to both antibodies. We conclude that the combination of anti-HIV-1 monoclonal antibodies 3BNC117 and 10-1074 can maintain long-term suppression in the absence of ART in individuals with antibody-sensitive viral reservoirs.
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Affiliation(s)
- Pilar Mendoza
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Henning Gruell
- Laboratory of Experimental Immunology, Institute of Virology, University Hospital Cologne, Cologne, Germany.,Department I of Internal Medicine, University Hospital Cologne, Cologne, Germany.,German Center for Infection Research, partner site Bonn-Cologne, Cologne, Germany
| | - Lilian Nogueira
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Joy A Pai
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Allison L Butler
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Katrina Millard
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Clara Lehmann
- Department I of Internal Medicine, University Hospital Cologne, Cologne, Germany.,German Center for Infection Research, partner site Bonn-Cologne, Cologne, Germany.,Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Isabelle Suárez
- Department I of Internal Medicine, University Hospital Cologne, Cologne, Germany.,German Center for Infection Research, partner site Bonn-Cologne, Cologne, Germany.,Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Thiago Y Oliveira
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Julio C C Lorenzi
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Yehuda Z Cohen
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Christoph Wyen
- Department I of Internal Medicine, University Hospital Cologne, Cologne, Germany.,Praxis am Ebertplatz, Cologne, Germany
| | - Tim Kümmerle
- Department I of Internal Medicine, University Hospital Cologne, Cologne, Germany.,Praxis am Ebertplatz, Cologne, Germany
| | - Theodora Karagounis
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Ching-Lan Lu
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Lisa Handl
- Methods in Medical Informatics, Department of Computer Science, University of Tübingen, Tübingen, Germany
| | | | - Roshni Patel
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Carola Ruping
- Laboratory of Experimental Immunology, Institute of Virology, University Hospital Cologne, Cologne, Germany
| | - Maike Schlotz
- Laboratory of Experimental Immunology, Institute of Virology, University Hospital Cologne, Cologne, Germany
| | - Maggi Witmer-Pack
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Irina Shimeliovich
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Gisela Kremer
- Department I of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Eleonore Thomas
- Department I of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Kelly E Seaton
- Duke Human Vaccine Institute, Duke University, Durham, NC, USA
| | - Jill Horowitz
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA
| | - Anthony P West
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Pamela J Bjorkman
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Georgia D Tomaras
- Duke Human Vaccine Institute, Duke University, Durham, NC, USA.,Department of Surgery, Duke University, Durham, NC, USA.,Department of Immunology, Duke University, Durham, NC, USA.,Department of Molecular Genetics and Microbiology, Duke University, Durham, NC, USA
| | - Roy M Gulick
- Division of Infectious Diseases, Weill Cornell Medicine, New York, NY, USA
| | - Nico Pfeifer
- Methods in Medical Informatics, Department of Computer Science, University of Tübingen, Tübingen, Germany.,Medical Faculty, University of Tübingen, Tübingen, Germany.,German Center for Infection Research, partner site Tübingen, Tübingen, Germany.,Max Planck Institute for Informatics, Saarbrücken, Germany
| | - Gerd Fätkenheuer
- Department I of Internal Medicine, University Hospital Cologne, Cologne, Germany.,German Center for Infection Research, partner site Bonn-Cologne, Cologne, Germany
| | - Michael S Seaman
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Florian Klein
- Laboratory of Experimental Immunology, Institute of Virology, University Hospital Cologne, Cologne, Germany. .,German Center for Infection Research, partner site Bonn-Cologne, Cologne, Germany. .,Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany.
| | - Marina Caskey
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA.
| | - Michel C Nussenzweig
- Laboratory of Molecular Immunology, The Rockefeller University, New York, NY, USA. .,Howard Hughes Medical Institute, The Rockefeller University, New York, NY, USA.
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Rapid decline of HIV-1 DNA and RNA in infants starting very early antiretroviral therapy may pose a diagnostic challenge. AIDS 2018; 32:629-634. [PMID: 29334551 DOI: 10.1097/qad.0000000000001739] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Birth diagnosis of HIV-1 infection offers an ideal opportunity for early antiretroviral therapy (ART) to limit HIV-1 reservoir size and limit disease progression. Although data on cellular HIV-1 DNA decay exist for children commencing treatment from 2 to 3 months of age, data are lacking for starting shortly after birth. DESIGN We studied infants who initiated ART within 8 days after birth to assess HIV-1 DNA levels longitudinally. METHODS Children were recruited from public health clinics in Cape Town where birth diagnosis of HIV-1 coupled with early ART initiation occurred. Total cellular HIV-1 DNA levels were determined using a sensitive quantitative PCR targeting a conserved region in integrase. RESULTS Of 11 infants diagnosed and beginning ART within 8 days of birth with detectable pre-ART HIV-1 DNA, three subsequently had undetectable HIV-1 DNA after 6 days, 3 months and 4 months on treatment, respectively. In seven who had virologic suppression (defined as a continuous downward trend in plasma HIV-1 RNA, and <100 copies/ml after 6 months) total HIV-1 DNA continued to decay over 12 months [mean half-life of 64.8 days (95% confidence interval: 47.9-105.7)]. CONCLUSION In infants initiated on ART within 8 days of life the combination of maternal ART, and early ART for prophylaxis and treatment contribute to rapid decline of HIV-1 infected cells to low or undetectable levels. However, rapid decline of HIV-1 RNA and DNA may complicate definitive diagnosis when confirmatory testing is delayed.
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Abstract
Research over the past decade has resulted in a much-improved understanding of how and where HIV persists in patients on otherwise suppressive antiretroviral therapy (ART). It has become clear that the establishment of a latent infection in long-lived cells is the key barrier to curing HIV or allowing for sustained ART-free remission. Informed by in vitro and ex vivo studies, several therapeutic approaches aimed at depleting the pool of latently infected cells have been tested in small-scale experimental clinical trials including studies of ART intensification, genome editing, ART during acute/early infection and latency reversal. Many studies have focused on the use of latency-reversing agents (LRAs) to induce immune- or virus-mediated elimination of virus-producing cells. These trials have been instrumental in establishing safety and have shown that it is possible to impact the state HIV latency in patients on suppressive ART. However, administration of LRAs alone has thus far not demonstrated an effect on the frequency of latently infected cells or the time to virus rebound during analytical interruption of ART. More recently, there has been an enhanced focus on immune-based therapies in the onwards search for an HIV cure including therapeutic vaccines, toll-like receptor agonists, broadly neutralising antibodies, immune checkpoint inhibitors, interferon-α and interleukin therapy. In ongoing studies immunotherapy interventions are also tested in combination with latency reversal. In this chapter, the overall results of these clinical interventions ultimately aimed at a cure for HIV are presented and discussed.
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Sneller MC, Justement JS, Gittens KR, Petrone ME, Clarridge KE, Proschan MA, Kwan R, Shi V, Blazkova J, Refsland EW, Morris DE, Cohen KW, McElrath MJ, Xu R, Egan MA, Eldridge JH, Benko E, Kovacs C, Moir S, Chun TW, Fauci AS. A randomized controlled safety/efficacy trial of therapeutic vaccination in HIV-infected individuals who initiated antiretroviral therapy early in infection. Sci Transl Med 2017; 9:eaan8848. [PMID: 29212716 PMCID: PMC11059970 DOI: 10.1126/scitranslmed.aan8848] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/13/2017] [Indexed: 12/21/2022]
Abstract
Despite substantial clinical benefits, complete eradication of HIV has not been possible using antiretroviral therapy (ART) alone. Strategies that can either eliminate persistent viral reservoirs or boost host immunity to prevent rebound of virus from these reservoirs after discontinuation of ART are needed; one possibility is therapeutic vaccination. We report the results of a randomized, placebo-controlled trial of a therapeutic vaccine regimen in patients in whom ART was initiated during the early stage of HIV infection and whose immune system was anticipated to be relatively intact. The objectives of our study were to determine whether the vaccine was safe and could induce an immune response that would maintain suppression of plasma viremia after discontinuation of ART. Vaccinations were well tolerated with no serious adverse events but produced only modest augmentation of existing HIV-specific CD4+ T cell responses, with little augmentation of CD8+ T cell responses. Compared with placebo, the vaccination regimen had no significant effect on the kinetics or magnitude of viral rebound after interruption of ART and no impact on the size of the HIV reservoir in the CD4+ T cell compartment. Notably, 26% of subjects in the placebo arm exhibited sustained suppression of viremia (<400 copies/ml) after treatment interruption, a rate of spontaneous suppression higher than previously reported. Our findings regarding the degree and kinetics of plasma viral rebound after ART interruption have potentially important implications for the design of future trials testing interventions aimed at achieving ART-free control of HIV infection.
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Affiliation(s)
- Michael C Sneller
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - J Shawn Justement
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Kathleen R Gittens
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, MD 20892, USA
| | - Mary E Petrone
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Katherine E Clarridge
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | | | - Richard Kwan
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, MD 20892, USA
| | - Victoria Shi
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Jana Blazkova
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Eric W Refsland
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Daryl E Morris
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Kristen W Cohen
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - M Juliana McElrath
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
- Department of Global Health, University of Washington, Seattle, WA 98195, USA
| | - Rong Xu
- Profectus BioSciences Inc., Tarrytown, NY 10591, USA
| | | | | | - Erika Benko
- Maple Leaf Medical Clinic, Toronto, Ontario M5G 1K2, Canada
| | - Colin Kovacs
- Maple Leaf Medical Clinic, Toronto, Ontario M5G 1K2, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario M5S 1A1, Canada
| | - Susan Moir
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Tae-Wook Chun
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA.
| | - Anthony S Fauci
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
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A pilot evaluation of whole blood finger-prick sampling for point-of-care HIV viral load measurement: the UNICORN study. Sci Rep 2017; 7:13658. [PMID: 29057945 PMCID: PMC5651802 DOI: 10.1038/s41598-017-13287-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/19/2017] [Indexed: 12/31/2022] Open
Abstract
There is a global need for HIV viral load point-of-care (PoC) assays to monitor patients receiving antiretroviral therapy. UNICORN was the first study of an off-label protocol using whole blood finger-prick samples tested with and without a simple three minute spin using a clinic-room microcentrifuge. Two PoC assays were evaluated in 40 HIV-positive participants, 20 with detectable and 20 with undetectable plasma viral load (pVL) (<20 copies/ml). Using 100 µl finger-prick blood samples, the Cepheid Xpert HIV-1 Viral Load and HIV-1 Qual cartridges were compared with laboratory pVL assessment (TaqMan, Roche). For participants with undetectable viraemia by TaqMan, there was poor concordance without centrifugation with the TaqMan platform with only 40% 'undetectable' using Xpert VL and 25% 'not detected' using the Qual assay. After a 3 minute spin, 100% of samples were undetectable using either assay, showing full concordance with the TaqMan assay. Defining a lower limit of detection of 1000 copies/ml when including a spin, there was 100% concordance with the TaqMan platform with strong correlation (rho 0.95 and 0.94; p < 0.0001 for both assays). When including a simple microcentrifugation step, finger-prick PoC testing was a quick and accurate approach for assessing HIV viraemia, with excellent concordance with validated laboratory approaches.
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Brief Report: Prevalence of Posttreatment Controller Phenotype Is Rare in HIV-Infected Persons After Stopping Antiretroviral Therapy. J Acquir Immune Defic Syndr 2017; 75:364-369. [PMID: 28394856 DOI: 10.1097/qai.0000000000001393] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Posttreatment control of HIV infection is a rare phenomenon primarily described among those initiating treatment with antiretroviral therapy (ART) during early/acute HIV infection. METHODS We examined a large, well-characterized cohort of HIV-infected Department of Defense beneficiaries for the presence of posttreatment controllers (PTCs) whom we defined as individuals with sustained viral suppression for ≥6 months after discontinuation of ART. We defined those who became viremic within 6 months of discontinuing ART as rapid viremics (RVs) and compared demographic and clinical characteristics, CD4 counts, and viral loads prior, during, and after ART discontinuation between the 2 groups. RESULTS From a cohort of 6070 patients, we identified 95 who had been treated with ART for 2 years or more who subsequently discontinued ART and had viral load assessments available after discontinuation. Four (4.2%) of these 95 met our definition of PTC. The duration of viral suppression off of ART ranged from 267 to 1058 days with 1 of the 4 restarting ART without having redeveloped a significant viremia. All 4 patients initiated ART during chronic HIV infection. Demographic and clinical characteristics of PTCs were similar to RVs. CONCLUSIONS While posttreatment control has predominantly been described among individuals who initiated ART in early/acute HIV infection, we identified 4 PTCs who started ART during chronic infection suggesting that posttreatment control also occurs among such patients. The rarity of PTCs identified in our cohort is consistent with reports from previous studies.
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