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Stam AJ, Buchholtz NVEJ, Bierman WFW, van Crevel R, Hoepelman AIM, Claassen MAA, Ammerlaan HSM, van Welzen BJ, van Kasteren MEE, van Lelyveld SFL, de Jong D, Tesselaar K, van Luin M, Nijhuis M, Wensing AMJ, Team LOWERITS. Dynamics of Low-Level Viremia and Immune Activation after Switching to a Darunavir-Based Regimen. Viruses 2024; 16:182. [PMID: 38399959 PMCID: PMC10893305 DOI: 10.3390/v16020182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 02/25/2024] Open
Abstract
There is an ongoing debate regarding whether low-level viremia (LLV), in particular persistent LLV, during HIV treatment with optimal adherence originates from low-level viral replication, viral production, or both. We performed an observational study in 30 individuals with LLV who switched to a boosted darunavir (DRV)-based therapy. In-depth virological analyses were used to characterize the viral population and the (activity) of the viral reservoir. Immune activation was examined using cell-bound and soluble markers. The primary outcome was defined as the effect on HIV-RNA and was categorized by responders (<50 cp/mL) or non-responders (>50 cp/mL). At week 24, 53% of the individuals were considered responders, 40% non-responders, and 7% could not be assigned. Sequencing showed no evolution or selection of drug resistance in the non-responders. Production of defective virus with mutations in either the protease (D25N) or RT active site contributed to persistent LLV in two individuals. We show that in about half of the study participants, the switch to a DRV-based regimen resulted in a viral response indicative of ongoing low-level viral replication as the cause of LLV before the switch. Our data confirm that in clinical management, high genetic barrier drugs like DRV are a safe choice, irrespective of the source of LLV.
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Affiliation(s)
- Arjen J. Stam
- Translational Virology Research Group, Department of Medical Microbiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Infectious Diseases, Public Health Service Amsterdam, 1018 WT Amsterdam, The Netherlands
| | - Ninée V. E. J. Buchholtz
- Translational Virology Research Group, Department of Medical Microbiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Wouter F. W. Bierman
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Reinout van Crevel
- Department of Internal Medicine, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Andy I. M. Hoepelman
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Mark A. A. Claassen
- Department of Internal Medicine, Rijnstate Hospital, 6815 AD Arnhem, The Netherlands
| | - Heidi S. M. Ammerlaan
- Department of Internal Medicine, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | - Berend J. van Welzen
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | | | | | - Dorien de Jong
- Translational Virology Research Group, Department of Medical Microbiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Kiki Tesselaar
- Department of Immunology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Matthijs van Luin
- Department of Clinical Pharmacy, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Monique Nijhuis
- Translational Virology Research Group, Department of Medical Microbiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Annemarie M. J. Wensing
- Translational Virology Research Group, Department of Medical Microbiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
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Stroffolini G, Lazzaro A, Barco A, Pirriatore V, Vai D, Giaccone C, Nigra M, Atzori C, Trunfio M, Bonora S, Di Perri G G, Calcagno A. Changes in Cerebrospinal Fluid, Liver and Intima-media-thickness Biomarkers in Patients with HIV-associated Neurocognitive Disorders Randomized to a Less Neurotoxic Treatment Regimen. J Neuroimmune Pharmacol 2023; 18:551-562. [PMID: 37906406 PMCID: PMC10770227 DOI: 10.1007/s11481-023-10086-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/27/2023] [Indexed: 11/02/2023]
Abstract
The prevalence of neurocognitive impairment in people living with HIV is estimated between 30 and 50%. The pathogenesis of HIV-associated neurocognitive disorders is complex and multifactorial. Aim of the study was to measure the change in CSF biomarkers, Fibroscan and IMT measurements in PLWH with HAND randomized to a less neurotoxic regimen, or continuing their treatment. Adult patients with HAND were screened and enrolled if presenting no major resistance associated mutations, no HIV viral replication, not on efavirenz or darunavir, with R5-tropic HIV and without major confounding conditions. Lumbar puncture, IMT and Fibroscan measurements were performed. After 1:1 randomization to a less neurotoxic regimen consisting of darunavir/cobicistat plus emtricitabine plus maraviroc, or mantaining actual care, tests were repeated after 24 weeks: CSF biomarkes (HIV RNA, tau, p-tau, Beta-amyloid1-42, S100Beta and neopterin) were included. Non-parametric tests (Mann-Whitney and Wilcoxon's) were used. 28 participants completed the study. Male and European ancestry were prevalent; median age was 55 years (51-60). All patients were virally suppressed; median CD4 + count was 626 cell/uL (469-772). Baseline characteristics were similar between the study arms. A significant decrease in CSF p-tau and an increase in CSF neopterin and NFL were observed. We observed a significant reduction in liver stiffness at W24. Despite a small sample size we observed changes in neuromarkers and in hepatic stiffness in patients randomized to the experimental arm. We observed changes in CSF biomarkers (lower phosphorylated-tau and higher neopterin and NFL) that need to be replicated in large cohorts. Subclinical neurotoxicity may be observed in patients with HAND and warrants prospective studies.
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Affiliation(s)
- Giacomo Stroffolini
- Department of Medical Sciences, Infectious Diseases Unit, University of Turin, Turin, Italy
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Alessandro Lazzaro
- Department of Medical Sciences, Infectious Diseases Unit, University of Turin, Turin, Italy
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Ambra Barco
- Department of Medical Sciences, Infectious Diseases Unit, University of Turin, Turin, Italy
- Department of Infectious Diseases, Novara Hospital, Novara, Italy
| | - Veronica Pirriatore
- Department of Medical Sciences, Infectious Diseases Unit, University of Turin, Turin, Italy
| | - Daniela Vai
- Maria Vittoria Hospital, Unit of Neurology, Asl Città di Torino, Turin, Italy
| | - Claudia Giaccone
- Maria Vittoria Hospital, Unit of Neurology, Asl Città di Torino, Turin, Italy
| | - Marco Nigra
- San Giovanni Bosco Hospital, Laboratory, Asl Città di Torino, Turin, Italy
| | - Cristiana Atzori
- Maria Vittoria Hospital, Laboratory, Asl Città di Torino, Turin, Italy
| | - Mattia Trunfio
- Department of Medical Sciences, Infectious Diseases Unit, University of Turin, Turin, Italy
| | - Stefano Bonora
- Department of Medical Sciences, Infectious Diseases Unit, University of Turin, Turin, Italy
| | - Giovanni Di Perri G
- Department of Medical Sciences, Infectious Diseases Unit, University of Turin, Turin, Italy
| | - Andrea Calcagno
- Department of Medical Sciences, Infectious Diseases Unit, University of Turin, Turin, Italy.
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Shikuma CM, Wojna V, De Gruttola V, Siriwardhana C, Souza SA, Rodriguez-Benitez RJ, Turner EH, Kallianpur K, Bolzenius J, Chow D, Matos M, Shiramizu B, Clements DM, Premeaux TA, Ndhlovu LC, Paul R. Impact of antiretroviral therapy intensification with C-C motif chemokine receptor 5 antagonist maraviroc on HIV-associated neurocognitive impairment. AIDS 2023; 37:1987-1995. [PMID: 37418541 PMCID: PMC10538417 DOI: 10.1097/qad.0000000000003650] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVES Chemokine receptor CCR5 is the principal co-receptor for entry of M-tropic HIV virus into immune cells. It is expressed in the central nervous system and may contribute to neuro-inflammation. The CCR5 antagonist maraviroc (MVC) has been suggested to improve HIV-associated neurocognitive impairment (NCI). DESIGN A double-blind, placebo-controlled, 48-week, randomized study of MVC vs. placebo in people with HIV (PWH) on stable antiretroviral therapy (ART) for more than one year in Hawaii and Puerto Rico with plasma HIV RNA less than 50 copies/ml and at least mild NCI defined as an overall or domain-specific neuropsychological z (NPZ) score less than -0.5. METHODS Study participants were randomized 2 : 1 to intensification of ART with MVC vs. placebo. The primary endpoint was change in global and domain-specific NPZ modeled from study entry to week 48. Covariate adjusted treatment comparisons of average changes in cognitive outcome were performed using winsorized NPZ data. Monocyte subset frequencies and chemokine expression as well as plasma biomarker levels were assessed. RESULTS Forty-nine participants were enrolled with 32 individuals randomized to MVC intensification and 17 to placebo. At baseline, worse NPZ scores were seen in the MVC arm. Comparison of 48-week NPZ change by arm revealed no differences except for a modest improvement in the Learning and Memory domain in the MVC arm, which did not survive multiplicity correction. No significant changes between arms were seen in immunologic parameters. CONCLUSION This randomized controlled study found no definitive evidence in favor of MVC intensification among PWH with mild cognitive difficulties.
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Affiliation(s)
- Cecilia M. Shikuma
- John A. Burns School of Medicine, University of Hawaii – Manoa, Honolulu, Hawaii
| | - Valerie Wojna
- University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Victor De Gruttola
- Wertheim School of Public Health, University of California San Diego, California
| | | | - Scott A. Souza
- John A. Burns School of Medicine, University of Hawaii – Manoa, Honolulu, Hawaii
| | | | - Emilee H. Turner
- John A. Burns School of Medicine, University of Hawaii – Manoa, Honolulu, Hawaii
| | - Kalpana Kallianpur
- John A. Burns School of Medicine, University of Hawaii – Manoa, Honolulu, Hawaii
- Kamehameha Schools - Kapalama, Honolulu, Hawaii
| | - Jacob Bolzenius
- Missouri Institute of Mental Health, University of Missouri – St. Louis, St. Louis, Missouri
| | - Dominic Chow
- John A. Burns School of Medicine, University of Hawaii – Manoa, Honolulu, Hawaii
| | - Miriam Matos
- University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Bruce Shiramizu
- John A. Burns School of Medicine, University of Hawaii – Manoa, Honolulu, Hawaii
| | - Danielle M. Clements
- John A. Burns School of Medicine, University of Hawaii – Manoa, Honolulu, Hawaii
| | | | | | - Robert Paul
- Missouri Institute of Mental Health, University of Missouri – St. Louis, St. Louis, Missouri
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Hagberg L, Gisslén M. Cohort profile: a longitudinal study of HIV infection in the central nervous system with focus on cerebrospinal fluid - the Gothenburg HIV CSF Study Cohort. BMJ Open 2023; 13:e070693. [PMID: 37197824 DOI: 10.1136/bmjopen-2022-070693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
PURPOSE In order to enable long-term follow-up of the natural course of HIV infection in the central nervous system, a longitudinal cohort study with repeated cerebrospinal fluid (CSF) analyses at intervals over time was initiated in 1985. When antiretrovirals against HIV were introduced in the late 1980s, short-term and long-term effects of various antiretroviral treatment (ART) regimens were added to the study. PARTICIPANTS All adult people living with HIV (PLWH) who were diagnosed at or referred to the Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden were asked to participate in the Gothenburg HIV CSF Study Cohort. PLWH with neurological symptoms or other clinical symptoms of HIV, as well as those with no symptoms of HIV infection, were included. Most participants were asymptomatic, which distinguishes this cohort from most other international HIV CSF studies. In addition, HIV-negative controls were recruited. These included people on HIV pre-exposure prophylaxis who served as lifestyle-matched controls to HIV-infected men who have sex with men. Since lumbar puncture (LP) is an invasive procedure, some PLHW only consented to participate in one examination. Furthermore, at the beginning of the study, several participants were lost to follow-up having died from AIDS. Of 662 PLWH where an initial LP was done, 415 agreed to continue with follow-up. Among the 415, 56 only gave permission to be followed with LP for less than 1 year, mainly to analyse the short-term effect of ART. The remaining 359 PLWH were followed up with repeated LP for periods ranging from >1 to 30 years. This group was defined as the 'longitudinal cohort'. So far, on 7 April 2022, 2650 LP and samplings of paired CSF/blood had been performed, providing a unique biobank. FINDINGS TO DATE A general finding during the 37-year study period was that HIV infection in the central nervous system, as mirrored by CSF findings, appears early in the infectious course of the disease and progresses slowly in the vast majority of untreated PLWH. Combination ART has been highly effective in reducing CSF viral counts, inflammation and markers of neural damage. Minor CSF signs of long-term sequels or residual inflammatory activity and CSF escape (viral CSF blips) have been observed during follow-up. The future course of these changes and their clinical impact require further studies. FUTURE PLANS PLWH today have a life expectancy close to that of non-infected people. Therefore, our cohort provides a unique opportunity to study the long-term effects of HIV infection in the central nervous system and the impact of ART and is an ongoing study.
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Affiliation(s)
- Lars Hagberg
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
- Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Gisslén
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
- Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
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Lau CY, Adan MA, Maldarelli F. Why the HIV Reservoir Never Runs Dry: Clonal Expansion and the Characteristics of HIV-Infected Cells Challenge Strategies to Cure and Control HIV Infection. Viruses 2021; 13:2512. [PMID: 34960781 PMCID: PMC8708047 DOI: 10.3390/v13122512] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/22/2021] [Accepted: 11/27/2021] [Indexed: 12/13/2022] Open
Abstract
Antiretroviral therapy (ART) effectively reduces cycles of viral replication but does not target proviral populations in cells that persist for prolonged periods and that can undergo clonal expansion. Consequently, chronic human immunodeficiency virus (HIV) infection is sustained during ART by a reservoir of long-lived latently infected cells and their progeny. This proviral landscape undergoes change over time on ART. One of the forces driving change in the landscape is the clonal expansion of infected CD4 T cells, which presents a key obstacle to HIV eradication. Potential mechanisms of clonal expansion include general immune activation, antigenic stimulation, homeostatic proliferation, and provirus-driven clonal expansion, each of which likely contributes in varying, and largely unmeasured, amounts to maintaining the reservoir. The role of clinical events, such as infections or neoplasms, in driving these mechanisms remains uncertain, but characterizing these forces may shed light on approaches to effectively eradicate HIV. A limited number of individuals have been cured of HIV infection in the setting of bone marrow transplant; information from these and other studies may identify the means to eradicate or control the virus without ART. In this review, we describe the mechanisms of HIV-1 persistence and clonal expansion, along with the attempts to modify these factors as part of reservoir reduction and cure strategies.
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Affiliation(s)
- Chuen-Yen Lau
- HIV Dynamics and Replication Program, NCI, NIH, Bethesda, MD 20892, USA; (C.-Y.L.); (M.A.A.)
| | - Matthew A. Adan
- HIV Dynamics and Replication Program, NCI, NIH, Bethesda, MD 20892, USA; (C.-Y.L.); (M.A.A.)
- Vagelos College of Physicians & Surgeons, Columbia University, New York, NY 10032, USA
| | - Frank Maldarelli
- HIV Dynamics and Replication Program, NCI, NIH, Bethesda, MD 20892, USA; (C.-Y.L.); (M.A.A.)
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Force G, Ghout I, Ropers J, Carcelain G, Marigot-Outtandy D, Hahn V, Darchy N, Defferriere H, Bouaziz-Amar E, Carlier R, Dorgham K, Callebert J, Peytavin G, Delaugerre C, de Truchis P. Improvement of HIV-associated neurocognitive disorders after antiretroviral therapy intensification: the Neuro+3 study. J Antimicrob Chemother 2021; 76:743-752. [PMID: 33179033 DOI: 10.1093/jac/dkaa473] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/19/2020] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES Despite the effectiveness of antiretroviral (ARV) therapy to control HIV infection, HIV-associated neurocognitive disorders (HAND) remain frequent. The Neuro+3 study assessed the cognitive improvement associated with ARV intensification based on increased CNS penetration effectiveness (CPE) scoring ≥+3 and total CPE score ≥9. METHODS Thirty-one patients, aged 18-65 years, with confirmed diagnosis of HAND and effective ARV therapy were included. The cognitive improvement was measured using Frascati three-stage classification and global deficit score (GDS) after 48 and 96 weeks of ARV intensification. Ultrasensitive HIV-RNA, neopterin, soluble CD14, CCL2, CXCL10, IL6, IL8 and NF-L were measured in plasma and cerebrospinal fluid at Day 0 (baseline), Week 48 (W48) and W96. RESULTS The intensified ARV was associated with a median (IQR) CPE score increase from 6 (4-7) at baseline to 10 (9-11). From baseline to W96, the median (IQR) GDS decreased from 1.4 (0.8-2.2) to 1.0 (0.6-2.0) (P = 0.009); HAND classification improved from 2 to 1 HIV-associated dementia, 22 to 8 mild neurocognitive disorders, 7 to 17 asymptomatic neurocognitive impairment and 0 to 5 patients without any neurocognitive alterations (P = 0.001). In multivariable linear regression analysis, GDS improvement at W96 was significantly associated with CPE score ≥9 after intensification (P = 0.014), CD4 lymphocyte increase at W48 (P < 0.001) and plasma CXCL10 decrease at W96 (P = 0.001). CONCLUSIONS In patients with HAND, a significant cognitive improvement was observed after the ARV intensification strategy, with a higher CPE score. Cognitive improvement was more often observed in the case of a switch of two drug classes, arguing for better control of CNS HIV immune activation.
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Affiliation(s)
- Gilles Force
- French-British Hospital Institute, Levallois-Perret, France
| | - Idir Ghout
- APHP Hospital Ambroise Paré, Versailles Saint Quentin en Yvelines University, Boulogne, France
| | - Jacques Ropers
- APHP Hospital Ambroise Paré, Versailles Saint Quentin en Yvelines University, Boulogne, France
| | | | - Dhiba Marigot-Outtandy
- APHP Hospital Raymond Poincaré, Paris-Saclay University, Garches, France.,Bligny Hospital, Briis sous Forges, France
| | | | - Natacha Darchy
- French-British Hospital Institute, Levallois-Perret, France
| | - Hélène Defferriere
- APHP Hospital Raymond Poincaré, Paris-Saclay University, Garches, France
| | | | - Robert Carlier
- APHP Hospital Raymond Poincaré, Paris-Saclay University, Garches, France
| | - Karim Dorgham
- Sorbonne University, Inserm, Center for Immunology and Microbial Infection, Paris, France
| | | | | | | | - Pierre de Truchis
- APHP Hospital Raymond Poincaré, Paris-Saclay University, Garches, France
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Lanman T, Letendre S, Ma Q, Bang A, Ellis R. CNS Neurotoxicity of Antiretrovirals. J Neuroimmune Pharmacol 2021; 16:130-143. [PMID: 31823251 PMCID: PMC7282963 DOI: 10.1007/s11481-019-09886-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/01/2019] [Indexed: 12/20/2022]
Abstract
The development of novel antiretroviral treatments has led to a significant turning point in the fight against HIV. Although therapy leads to virologic suppression and prolonged life expectancies, HIV-associated neurocognitive disorder (HAND) remains prevalent. While various hypotheses have been proposed to explain this phenomenon, a growing body of literature explores the neurotoxic effects of antiretroviral therapy. Research to date brings into question the potential role of such medications in neurocognitive and neuropsychiatric impairment seen in HIV-positive patients. This review highlights recent findings and controversies in cellular, molecular, and clinical neurotoxicity of antiretrovirals. It explores the pathogenesis of such toxicity and relates it to clinical manifestations in each medication class. The concept of accelerated aging in persons living with HIV (PLWH) as well as potential treatments for HAND are also discussed. Ultimately, this article hopes to educate clinicians and basic scientists about the neurotoxic effects of antiretrovirals and spur future scientific investigation into this important topic. Graphical Abstract.
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Affiliation(s)
- Tyler Lanman
- Department of Neurosciences, University of California San Diego School of Medicine, 200 W Arbor Dr, San Diego, La Jolla, CA, 92103, USA
| | - Scott Letendre
- Department of Infectious Diseases, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Qing Ma
- Pharmacotherapy Research Center, University of Buffalo, School of Pharmacy & Pharmaceutical Sciences, Buffalo, NY, USA
| | - Anne Bang
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Ronald Ellis
- Department of Neurosciences, University of California San Diego School of Medicine, 200 W Arbor Dr, San Diego, La Jolla, CA, 92103, USA.
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Kroon ED, Ananworanich J, Pagliuzza A, Rhodes A, Phanuphak N, Trautmann L, Mitchell JL, Chintanaphol M, Intasan J, Pinyakorn S, Benjapornpong K, Chang JJ, Colby DJ, Chomchey N, Fletcher JL, Eubanks K, Yang H, Kapson J, Dantanarayana A, Tennakoon S, Gorelick RJ, Maldarelli F, Robb ML, Kim JH, Spudich S, Chomont N, Phanuphak P, Lewin SR, de Souza MS. A randomized trial of vorinostat with treatment interruption after initiating antiretroviral therapy during acute HIV-1 infection. J Virus Erad 2020; 6:100004. [PMID: 33251022 PMCID: PMC7646672 DOI: 10.1016/j.jve.2020.100004] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 07/09/2020] [Accepted: 07/14/2020] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE AND DESIGN A randomized, open-label pilot study in individuals treated with antiretroviral therapy (ART) since acute HIV infection (AHI) with a regimen including a histone deacetylase inhibitor to induce HIV from latency and control HIV replication during subsequent treatment interruption (TI). METHODS Fifteen participants who initiated ART at AHI were randomized to vorinostat/hydroxychloroquine/maraviroc (VHM) plus ART (n = 10) or ART alone (n = 5). The VHM arm received three 14-day vorinostat cycles within 10 weeks before TI. ART was resumed for plasma viral load (VL) > 1,000 HIV RNA copies/mL. Primary outcome was proportion of participants on VHM + ART versus ART only with VL < 50 copies/mL for 24 weeks after TI. RESULTS Fifteen participants on ART (median: 178 weeks: range 79-295) enrolled. Two on VHM + ART experienced serious adverse events. Fourteen participants underwent TI; all experienced VL rebound with no difference in time between arms: VHM + ART (n = 9) median: 4 weeks and ART only (n = 5) median: 5 weeks. VHM induced a 2.2-fold increase in VL (p = 0.008) by single-copy HIV RNA assay after the first cycle. Neopterin levels increased significantly following the first two cycles. After VHM treatment, the frequencies of peripheral blood mononuclear cells harboring total HIV DNA and cell-associated RNA were unchanged. All participants achieved VL suppression following ART re-initiation. CONCLUSIONS Administration of VHM increased HIV VL in plasma, but this was not sustained. VHM did not impact time to viral rebound following TI and had no impact on the size of the HIV reservoir, suggesting that HIV reservoir elimination will require alternative treatment strategies.
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Affiliation(s)
| | - Jintanat Ananworanich
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- United States Military HIV Research Program, Bethesda, MD, USA
- Bill and Melinda Gates Medical Research Institute, Cambridge, MA, USA
| | - Amélie Pagliuzza
- Centre de Recherche du CHUM and Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montreal, Canada
| | - Ajantha Rhodes
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
- Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Center, Melbourne, Australia
| | | | - Lydie Trautmann
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- United States Military HIV Research Program, Bethesda, MD, USA
| | - Julie L. Mitchell
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- United States Military HIV Research Program, Bethesda, MD, USA
| | - Michelle Chintanaphol
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Department of Neurology, Yale University School of Medicine, Yale University, New Haven, CT, USA
| | - Jintana Intasan
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Suteeraporn Pinyakorn
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- United States Military HIV Research Program, Bethesda, MD, USA
| | | | - J. Judy Chang
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
- Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Center, Melbourne, Australia
| | - Donn J. Colby
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Nitiya Chomchey
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | | | - Hua Yang
- Cooper Human Systems, Nashua, NH, USA
| | | | - Ashanti Dantanarayana
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
- Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Center, Melbourne, Australia
| | - Surekha Tennakoon
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
- Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Center, Melbourne, Australia
| | - Robert J. Gorelick
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Frank Maldarelli
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Merlin L. Robb
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- United States Military HIV Research Program, Bethesda, MD, USA
| | - Jerome H. Kim
- International Vaccine Initiative, Seoul, Republic of Korea
| | - Serena Spudich
- Department of Neurology, Yale University School of Medicine, Yale University, New Haven, CT, USA
| | - Nicolas Chomont
- Centre de Recherche du CHUM and Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montreal, Canada
| | | | - Sharon R. Lewin
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
- Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Center, Melbourne, Australia
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Australia
| | | | - for the SEARCH 019 and RV254 Study Teams
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- United States Military HIV Research Program, Bethesda, MD, USA
- Bill and Melinda Gates Medical Research Institute, Cambridge, MA, USA
- Centre de Recherche du CHUM and Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montreal, Canada
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
- Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Center, Melbourne, Australia
- Department of Neurology, Yale University School of Medicine, Yale University, New Haven, CT, USA
- Cooper Human Systems, Nashua, NH, USA
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, USA
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
- International Vaccine Initiative, Seoul, Republic of Korea
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Australia
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9
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Peluso MJ, Thanh C, Prator CA, Hogan LE, Arechiga VM, Stephenson S, Norris PJ, Di Germanio C, Fuchs D, Zetterberg H, Deeks SG, Gisslén M, Price RW, Henrich TJ. Cerebrospinal fluid soluble CD30 elevation despite suppressive antiretroviral therapy in individuals living with HIV-1. J Virus Erad 2020. [DOI: 10.1016/s2055-6640(20)30006-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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10
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Hermansson L, Yilmaz A, Price RW, Nilsson S, McCallister S, Makadzange T, Das M, Zetterberg H, Blennow K, Gisslen M. Plasma concentration of neurofilament light chain protein decreases after switching from tenofovir disoproxil fumarate to tenofovir alafenamide fumarate. PLoS One 2019; 14:e0226276. [PMID: 31826005 PMCID: PMC6905536 DOI: 10.1371/journal.pone.0226276] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/18/2019] [Indexed: 01/05/2023] Open
Abstract
Background Because tenofovir alafenamide (TAF) leads to significantly lower plasma tenofovir concentrations than tenofovir disoproxil fumarate (TDF) and is a stronger substrate for P-glycoprotein (P-gp) than TDF, TAF could lead to decreased central nervous system (CNS) tenofovir exposure than TDF. We aimed to determine if switching from TDF to TAF increases the risk of neuronal injury, by quantifying plasma levels of neurofilament light protein (NfL), a sensitive marker of neuronal injury in HIV CNS infection. Methods Plasma NfL concentration was measured at baseline, week 24, and week 84 in stored plasma samples from 416 participants (272 switching to elvitegravir (E)/cobicistat (C)/emtricitabine (F)/TAF and 144 continuing E/C/F/TDF) enrolled in the randomized, active-controlled, multicenter, open-label, noninferiority Gilead GS-US-292-0109 trial. Results While plasma NfL levels in both groups were within the normal range, we found a small but significant decrease in the E/C/F/TAF arm after 84 weeks from a geometric mean of 9.3 to 8.8 pg/mL (5.4% decline, 95% CI 2.0–8.4, p = 0.002). This change was significantly different (p = 0.001) from that of the E/C/F/TDF arm, in which plasma NfL concentration changed from 9.7 pg/mL at baseline to 10.2 pg/mL at week 84 (5.8% increase, 95% CI -0.8–12.9, p = 0.085). This increase is in line with what could be expected in normal ageing. Plasma NfL concentrations significantly correlated with age. No correlation was found between plasma NfL and serum creatinine. Conclusions We found no biomarker evidence of CNS injury when switching from TDF to TAF. It is unclear whether the small decrease in plasma NfL found after switch to TAF is of any clinical relevance, particularly with plasma NfL levels in both arms remaining within the limits found in HIV-negative controls. These results indicate that switching from TDF to TAF appears safe with regard to neuronal injury.
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Affiliation(s)
- Linn Hermansson
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Infectious Diseases, Gothenburg, Sweden
| | - Aylin Yilmaz
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Infectious Diseases, Gothenburg, Sweden
| | - Richard W. Price
- Department of Neurology, University of California, San Francisco, United States of America
| | - Staffan Nilsson
- Mathematical Sciences, Chalmers University of Technology, Gothenburg, Sweden
| | - Scott McCallister
- Gilead Sciences Inc, Institute of Neuroscience and Physiology, Foster City, California, United States of America
| | - Tariro Makadzange
- Gilead Sciences Inc, Institute of Neuroscience and Physiology, Foster City, California, United States of America
| | - Moupali Das
- Gilead Sciences Inc, Institute of Neuroscience and Physiology, Foster City, California, United States of America
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, University of Gothenburg, Gothenburg, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, United Kingdom
- UK Dementia Research Institute, UCL, London, United Kingdom
| | - Kaj Blennow
- Gilead Sciences Inc, Institute of Neuroscience and Physiology, Foster City, California, United States of America
- Department of Psychiatry and Neurochemistry, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Gisslen
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Infectious Diseases, Gothenburg, Sweden
- * E-mail:
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11
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Gisslén M, Hunt PW. Antiretroviral Treatment of Acute HIV Infection Normalizes Levels of Cerebrospinal Fluid Markers of Central Nervous System (CNS) Inflammation: A Consequence of a Reduced CNS Reservoir? J Infect Dis 2019; 220:1867-1869. [PMID: 30668742 PMCID: PMC6833976 DOI: 10.1093/infdis/jiz031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 01/14/2019] [Indexed: 01/17/2023] Open
Affiliation(s)
- Magnus Gisslén
- Institute of Biomedicine, Department of Infectious Diseases, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Peter W Hunt
- Division of Experimental Medicine, Department of Medicine, University of California, San Francisco
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12
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Abstract
PURPOSE OF REVIEW Neurocognitive disorders are not uncommon in HIV-positive patients but their pathogenesis is multifactorial and incompletely understood. After excluding contributing comorbidities, several factors may impair neurocognition including severe immune suppression, incomplete antiviral efficacy, drugs' persistent immune activation, vascular abnormalities, and drugs' neurotoxicity. The effectiveness of targeted antiretroviral strategies on these risk factors is unknown. RECENT FINDINGS Recent studies support the idea that residual cerebrospinal fluid HIV RNA in the setting of plasma viral suppression is associated with compartmental immune activation but the link to neuronal damage is debated. Some authors have reported an incomplete antiviral efficacy in macrophage-derived cells but targeted antiretroviral regimen switches have not been performed. Additionally, improvements in neurocognition using drugs with better central nervous system penetration or maraviroc (associated with favorable immunological properties) have been observed in pilot studies. Trials evaluating specific interventions for cardiovascular health (including brain white matter abnormalities) and neurotoxicity of antiretrovirals are warranted. Central nervous system-targeted antiretroviral strategies are needed in patients with uncontrolled cerebrospinal HIV replication, and they may be suggested in subjects with low CD4 nadir, individuals carrying drug-resistant viruses, and those with compartmental immune activation.
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13
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Persistent central nervous system immune activation following more than 10 years of effective HIV antiretroviral treatment. AIDS 2018; 32:2171-2178. [PMID: 30005007 DOI: 10.1097/qad.0000000000001950] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Low-grade immune activation is common in people living with HIV (PLHIV), despite long-term viral suppression by antiretroviral therapy (ART). The clinical significance of this activation remains unclear. The aim of this study was to examine residual intrathecal immune activation in relation to signs of neuronal injury and neurocognitive impairment in PLHIV who had been virally suppressed on ART for more than 10 years. DESIGN/METHODS Twenty neuroasymptomatic PLHIV on suppressive ART for a median of 13.2 years were retrospectively identified from the longitudinal prospective Gothenburg HIV cerebrospinal fluid (CSF) study. HIV-RNA, neopterin, and neurofilament light protein (NFL) levels were measured in paired plasma and CSF samples. Pretreatment samples were available for 14 patients. Cognitive function was assessed by CogState at follow-up. RESULTS CSF neopterin decreased from a median (IQR) of 17.8 (10.6-29.7) to 6.1 (4.6-8.0) nmol/l during treatment (P < 0.001). In 11 out of 20 participants (55%), CSF neopterin levels were above the upper normal reference limit (5.8 nmol/l) at follow-up. Age-adjusted CSF NFL decreased to within-normal levels from a median of (IQR) 1179 (557-2707) to 415 (292-610) ng/l (P < 0.001). No significant correlations were found between CSF neopterin and CSF NFL or neurocognitive performance. CONCLUSION Although CSF neopterin decreased significantly, more than 50% of the patients had CSF concentrations above the upper normal reference value despite more than 10 years of suppressive ART. We found no correlation between CSF neopterin, CSF NFL or neurocognitive performance at follow-up, indicating that low-grade immune activation during suppressive ART may be clinically benign.
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14
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Barber TJ, Imaz A, Boffito M, Niubó J, Pozniak A, Fortuny R, Alonso J, Davies N, Mandalia S, Podzamczer D, Gazzard B. CSF inflammatory markers and neurocognitive function after addition of maraviroc to monotherapy darunavir/ritonavir in stable HIV patients: the CINAMMON study. J Neurovirol 2017; 24:98-105. [PMID: 29280108 DOI: 10.1007/s13365-017-0600-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 10/19/2017] [Accepted: 11/07/2017] [Indexed: 12/16/2022]
Abstract
CINAMMON is a phase IV, open-label, single-arm, pilot study assessing maraviroc (MVC) in the central nervous system (CNS) when added to darunavir/ritonavir monotherapy (DRV/r) in virologically suppressed HIV-infected subjects. CCR5 tropic participants on DRV/r were recruited. Participants remained on DRV/r for 12 week (w) (control phase). MVC 150 mg qd was added w12-w36 (intervention phase). Lumbar puncture (LP) and neurocognitive function (Cogstate) examinations scheduled at baseline, w12 and w36; MRI before w12, again at w36. Primary endpoint was CSF inflammatory marker changes during intervention phase. Secondary endpoints included changes in NC function and MRI parameters. CSF/plasma DRV/r concentrations measured at w12 and w36, MVC at w36. Nineteen patients recruited, 15 completed (17M, 2F). Dropouts: headache (2), knee problem (could not attend, 1), personal reasons (1). Mean age (range) 45.4 years (27.2-65.1), 13/19 white, 10/19 MSM. No changes in selected CSF markers were seen w12-w36. Overall NC function did not improve w12-w36: total age adjusted z score improved by 0.27 (weighted paired t test; p = 0.11); for executive function only, age adjusted z score improved by 0.54 (p = 0.03). MRI brain parameters unchanged. DRV plasma:CSF concentration ratio unchanged between w12 (132) and w36 (112; p = 0.577, Wilcoxon signed-rank). MVC plasma:CSF concentration ratio was 35 at w36. No changes in neuroinflammatory markers seen. In this small study, addition of 24w MVC 150 mg qd to stable DRV/r monotherapy showed possible improvement in executive function with no global NC effect. Learning effect cannot be excluded. This effect should be further evaluated.
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Affiliation(s)
- T J Barber
- Chelsea and Westminster NHS Foundation Trust and St Stephen's AIDS Trust, 4th Floor, St Stephen's Centre, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK. .,Imperial College London, London, UK.
| | - A Imaz
- Bellvitge University Hospital, Barcelona, Spain
| | - M Boffito
- Chelsea and Westminster NHS Foundation Trust and St Stephen's AIDS Trust, 4th Floor, St Stephen's Centre, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK.,Imperial College London, London, UK
| | - J Niubó
- Bellvitge University Hospital, Barcelona, Spain
| | - A Pozniak
- Chelsea and Westminster NHS Foundation Trust and St Stephen's AIDS Trust, 4th Floor, St Stephen's Centre, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
| | - R Fortuny
- Bellvitge University Hospital, Barcelona, Spain
| | - J Alonso
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - N Davies
- Chelsea and Westminster NHS Foundation Trust and St Stephen's AIDS Trust, 4th Floor, St Stephen's Centre, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK.,Imperial College London, London, UK
| | - S Mandalia
- Chelsea and Westminster NHS Foundation Trust and St Stephen's AIDS Trust, 4th Floor, St Stephen's Centre, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK.,Imperial College London, London, UK
| | | | - B Gazzard
- Chelsea and Westminster NHS Foundation Trust and St Stephen's AIDS Trust, 4th Floor, St Stephen's Centre, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK.,Imperial College London, London, UK
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15
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Elvstam O, Medstrand P, Yilmaz A, Isberg PE, Gisslén M, Björkman P. Virological failure and all-cause mortality in HIV-positive adults with low-level viremia during antiretroviral treatment. PLoS One 2017; 12:e0180761. [PMID: 28683128 PMCID: PMC5500364 DOI: 10.1371/journal.pone.0180761] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 06/21/2017] [Indexed: 01/31/2023] Open
Abstract
Objective Although most HIV-infected individuals achieve undetectable viremia during antiretroviral therapy (ART), a subset have low-level viremia (LLV) of varying duration and magnitude. The impact of LLV on treatment outcomes is unclear. We investigated the association between LLV and virological failure and/or all-cause mortality among Swedish patients receiving ART. Methods HIV-infected patients from two Swedish HIV centers were identified from the nationwide register InfCare HIV. Subjects aged ≥15 years with triple agent ART were included at 12 months after treatment initiation if ≥2 following viral load measurements were available. Patients with 2 consecutive HIV RNA values ≥1000 copies/mL at this time point were excluded. Participants were stratified into four categories depending on viremia profiles: permanently suppressed viremia (<50 copies/mL), LLV 50–199 copies/mL, LLV 200–999 copies/mL and viremia ≥1000 copies/mL. Association between all four viremia categories and all-cause death was calculated using survival analysis with viremia as a time-varying covariate, so that patients could change viremia category during follow-up. Association between the three lower categories and virological failure (≥2 consecutive measurements ≥1000 copies/mL) was calculated in a similar manner. Results LLV 50–199 copies/mL was recorded in 70/1015 patients (6.9%) and LLV 200–999 copies/mL in 89 (8.8%) during 7812 person-years of follow-up (median 6.5 years). LLV 200–999 copies/mL was associated with virological failure (adjusted hazard ratio 3.14 [95% confidence interval 1.41–7.03, p<0.01]), whereas LLV 50–199 copies/mL was not (1.01 [0.34–4.31, p = 0.99]; median follow-up 4.5 years). LLV 200–999 copies/mL had an adjusted mortality hazard ratio of 2.29 (0.98–5.32, p = 0.05) and LLV 50–199 copies/mL of 2.19 (0.90–5.37, p = 0.09). Conclusions In this Swedish cohort followed during ART for a median of 4.5 years, LLV 200–999 copies/mL was independently associated with virological failure. Patients with LLV had higher rates of all-cause mortality, although not statistically significant in multivariate analysis.
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Affiliation(s)
- Olof Elvstam
- Department of Translational Medicine, Clinical Infection Medicine Unit, Lund University, Malmö, Sweden
- * E-mail:
| | - Patrik Medstrand
- Department of Translational Medicine, Clinical Virology, Lund University, Malmö, Sweden
| | - Aylin Yilmaz
- Institute of Biomedicine, Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Magnus Gisslén
- Institute of Biomedicine, Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Björkman
- Department of Translational Medicine, Clinical Infection Medicine Unit, Lund University, Malmö, Sweden
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16
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Abstract
Combination antiretroviral treatment is associated with clear benefits in HIV-positive subjects, and is also effective in the central nervous system (CNS), meaning HIV-associated dementia is now an uncommon event. Nevertheless, a significant number of patients show symptoms of neurocognitive impairment which may negatively affect their quality of life. Although several risk factors for HIV-associated neurocognitive disorders have been identified, there is no clear recommendation for their prevention and management. In this review, the penetration of drugs into the cerebrospinal fluid/CNS is discussed as well as the viral and clinical consequences associated with higher/lower compartmental exposure. We also review the potential interventions according to the currently identified underlying mechanisms, including persistent CNS immune activation, legacy effects, low-level viral replication and escape, co-morbidities, and antiretroviral-associated direct and indirect 'neurotoxicity'. Adjunctive therapies and interventions (including neuro-rehabilitation) are then briefly discussed. The treatment of HIV infection in the CNS is a complex area of therapeutics requiring multidisciplinary interventions and further study.
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Affiliation(s)
- A Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, c/o Ospedale Amedeo di Savoia, C.so Svizzera 164, 10159, Torino, Italy.
| | - G Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, c/o Ospedale Amedeo di Savoia, C.so Svizzera 164, 10159, Torino, Italy
| | - S Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, c/o Ospedale Amedeo di Savoia, C.so Svizzera 164, 10159, Torino, Italy
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17
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Motta I, Allice T, Romito A, Ferrara M, Ecclesia S, Imperiale D, Ghisetti V, Di Perri G, Bonora S, Calcagno A. Cerebrospinal fluid viral load and neopterin in HIV-positive patients with undetectable viraemia. Antivir Ther 2017; 22:539-543. [PMID: 28198350 DOI: 10.3851/imp3140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) HIV RNA is commonly used as a marker of compartmental antiviral activity in HIV-positive patients. Undetectable CSF HIV RNA levels have been associated with low CSF neopterin levels and better neurocognitive performances. The aim of this study was to analyse the prevalence and predictors of non-detectable CSF HIV RNA using a commercial assay. METHODS In adult HIV-positive HAART-treated patients with confirmed plasma HIV RNA <50 copies/ml, CSF HIV RNA (with Roche Amplicor Assay) and neopterin were measured. RESULTS 112 adult patients were included. Plasma and CSF HIV RNA were non-detectable (target not detected [TND]) in 29 (25.9%) and 36 (32.1%) patients, respectively. CSF TND was observed more frequently in patients with plasma TND (P=0.005, OR=3.87). CSF neopterin levels were associated with age (rho =0.333, P=0.002) and current (rho= -0.272, P=0.015) and nadir (rho =-0.240, P=0.038) CD4+ T-lymphocytes; the lowest CSF neopterin concentration was observed in patients with CSF TND versus other viral load strata (0.62 mg/dl versus 0.78 mg/dl; P=0.048). CONCLUSIONS Efficaciously treated HIV-positive patients with detectable plasma HIV RNA might imperfectly control CSF viral replication. Prospective studies addressing the management and neurocognitive consequences of CSF low-level viraemia are warranted.
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Affiliation(s)
- Ilaria Motta
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Tiziano Allice
- Laboratory of Microbiology and Molecular Biology, Ospedale Amedeo di Savoia, ASL TO2, Torino, Italy
| | - Alessandra Romito
- Laboratory of Immunology, Ospedale Maria Vittoria, ASL TO2, Torino, Italy
| | - Micol Ferrara
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Sara Ecclesia
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | | | - Valeria Ghisetti
- Laboratory of Microbiology and Molecular Biology, Ospedale Amedeo di Savoia, ASL TO2, Torino, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Stefano Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
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18
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Immune activation in the central nervous system throughout the course of HIV infection. Curr Opin HIV AIDS 2016; 11:226-33. [PMID: 26760827 DOI: 10.1097/coh.0000000000000243] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Robust and dynamic innate and adaptive responses characterize the acute central nervous system (CNS) response to HIV and other viral infections. In a state of chronic infection or viral latency, persistent immune activation associates with abnormality in the CNS. Understanding this process is critical, as immune-mediated abnormality in nonrenewable CNS cells may result in long-term neurologic sequelae for HIV-infected individuals. RECENT FINDINGS In humans, immune activation is reduced by suppressive combination antiretroviral therapy, but persists at abnormally elevated levels on treatment. CNS immune activation is initiated in acute infection and progressively increases until combination antiretroviral therapy is started. Newly identified characteristics of the CNS immune surveillance network include features of homeostasis and function of brain microglial cells, lymphatic drainage from CNS to cervical lymph nodes, and cells in cerebrospinal fluid associated with neurocognitive impairment. SUMMARY More research is required to determine whether early intervention to reduce infection limits the immunopathology established by sustained immune responses that ultimately fail to resolve infection, and to unravel mechanisms of persistent immune activation during treated HIV so that strategies can be developed to therapeutically protect the brain.
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19
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Tsukrov D, McFarren A, Morgenstern A, Bruchertseifer F, Dolce E, Gorny MK, Zolla-Pazner S, Berman JW, Schoenbaum E, Zingman BS, Casadevall A, Dadachova E. Combination of Antiretroviral Drugs and Radioimmunotherapy Specifically Kills Infected Cells from HIV-Infected Individuals. Front Med (Lausanne) 2016; 3:41. [PMID: 27725930 PMCID: PMC5035742 DOI: 10.3389/fmed.2016.00041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/06/2016] [Indexed: 11/13/2022] Open
Abstract
Eliminating virally infected cells is an essential component of any HIV eradication strategy. Radioimmunotherapy (RIT), a clinically established method for killing cells using radiolabeled antibodies, was recently applied to target HIV-1 gp41 antigen expressed on the surface of infected cells. Since gp41 expression by infected cells is likely downregulated in patients on antiretroviral therapy (ART), we evaluated the ability of RIT to kill ART-treated infected cells using both in vitro models and lymphocytes isolated from HIV-infected subjects. Human peripheral blood mononuclear cells (PBMCs) were infected with HIV and cultured in the presence of two clinically relevant ART combinations. Scatchard analysis of the 2556 human monoclonal antibody to HIV gp41 binding to the infected and ART-treated cells demonstrated sufficient residual expression of gp41 on the cell surface to warrant subsequent RIT. This is the first time the quantification of gp41 post-ART is being reported. Cells were then treated with Bismuth-213-labeled 2556 antibody. Cell survival was quantified by Trypan blue and residual viremia by p24 ELISA. Cell surface gp41 expression was assessed by Scatchard analysis. The experiments were repeated using PBMCs isolated from blood specimens obtained from 15 HIV-infected individuals: 10 on ART and 5 ART-naïve. We found that 213Bi-2556 killed ART-treated infected PBMCs and reduced viral production to undetectable levels. ART and RIT co-treatment was more effective at reducing viral load in vitro than either therapy alone, indicating that gp41 expression under ART was sufficient to allow 213Bi-2556 to deliver cytocidal doses of radiation to infected cells. This study provides proof of concept that 213Bi-2556 may represent an innovative and effective targeting method for killing HIV-infected cells treated with ART and supports continued development of 213Bi-2556 for co-administration with ART toward an HIV eradication strategy.
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Affiliation(s)
- Dina Tsukrov
- Albert Einstein College of Medicine , Bronx, NY , USA
| | | | - Alfred Morgenstern
- European Commission, Joint Research Centre, Institute for Transuranium Elements , Karlsruhe , Germany
| | - Frank Bruchertseifer
- European Commission, Joint Research Centre, Institute for Transuranium Elements , Karlsruhe , Germany
| | - Eugene Dolce
- Albert Einstein College of Medicine , Bronx, NY , USA
| | | | - Susan Zolla-Pazner
- New York University School of Medicine, New York, NY, USA; Veterans Affairs New York Harbor Healthcare System, New York, NY, USA
| | - Joan W Berman
- Albert Einstein College of Medicine , Bronx, NY , USA
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20
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Haubenberger D, Clifford DB. Clinical Trials in Neurovirology: Successes, Challenges, and Pitfalls. Neurotherapeutics 2016; 13:571-81. [PMID: 27194073 PMCID: PMC4965408 DOI: 10.1007/s13311-016-0440-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Clinical trials in neurovirology illustrate the special challenges confronting investigators planning to study these conditions, as well as the contributions of successful trials in establishing appropriate management for these devastating diseases. This article reviews key examples of progress in neurovirology that have been spurred by clinical trials, emphasizing human herpes virus encephalitis, HIV, and JC virus. Clinical trials in the setting of neurovirological diseases are characterized by specific challenges, which may include small sample sizes, clinical presentations from life-threatening conditions to chronic courses of disease, regional and temporally restricted outbreaks scenarios, and the unavailability of validated diagnostic tests that can be rapidly deployed at the bedside. This review aims to highlight these methodological challenges and pitfalls in designing and executing clinical neurovirology trials, as well as to outline innovative trial designs, which could be useful in addressing common challenges.
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Affiliation(s)
- Dietrich Haubenberger
- Clinical Trials Unit, Office of the Clinical Director, NINDS Intramural Research Program, National Institutes of Health, 9000 Rockville Pike, Rm 6-5700, Bethesda, MD, 20892, USA.
| | - David B Clifford
- Departments of Neurology and Medicine, Washington University in St Louis, Box 8111, 660 S Euclid Ave, Saint Louis, MO, 63110, USA
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21
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Wayman WN, Chen L, Persons AL, Napier TC. Cortical consequences of HIV-1 Tat exposure in rats are enhanced by chronic cocaine. Curr HIV Res 2015; 13:80-7. [PMID: 25760043 DOI: 10.2174/0929867322666150311164504] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Revised: 01/22/2015] [Accepted: 02/09/2015] [Indexed: 01/25/2023]
Abstract
The life span of individuals that are sero-positive for human immunodeficiency virus (HIV) has greatly improved; however, complications involving the central nervous system (CNS) remain a concern. While HIV does not directly infect neurons, the proteins produced by the virus, including HIV transactivator of transcription (Tat), are released from infected glia; these proteins can be neurotoxic. This neurotoxicity is thought to mediate the pathology underlying HIVassociated neurological impairments. Cocaine abuse is common among HIV infected individuals, and this abuse augments HIV-associated neurological deficits. The brain regions and pathophysiological mechanisms that are dysregulated by both chronic cocaine and Tat are the focus of the current review.
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Affiliation(s)
- Wesley N Wayman
- Department of Pharmacology, Rush University Medical Center, 1735 W. Harrison Street, Cohn Research Building, Rm. 463, Chicago, IL 60612, USA.
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Neurological Response to cART vs. cART plus Integrase Inhibitor and CCR5 Antagonist Initiated during Acute HIV. PLoS One 2015; 10:e0142600. [PMID: 26555069 PMCID: PMC4640512 DOI: 10.1371/journal.pone.0142600] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 10/23/2015] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To compare central nervous system (CNS) outcomes in participants treated during acute HIV infection with standard combination antiretroviral therapy (cART) vs. cART plus integrase inhibitor and CCR5 antagonist (cART+). DESIGN 24-week randomized open-label prospective evaluation. METHOD Participants were evaluated then randomized to initiate cART (efavirenz, tenofovir, and either emtricitabine or lamivudine) vs. cART+ (cART plus raltegravir and maraviroc) during acute HIV and re-evaluated at 4, 12 and 24 weeks. We examined plasma and CSF cytokines, HIV RNA levels, neurological and neuropsychological findings, and brain MRS across groups and compared to healthy controls. RESULTS At baseline, 62 participants were in Fiebig stages I-V. Randomized groups were similar for mean age (27 vs. 25, p = 0.137), gender (each 94% male), plasma log10 HIV RNA (5.4 vs. 5.6, p = 0.382), CSF log10 HIV RNA (2.35 vs. 3.31, p = 0.561), and estimated duration of HIV (18 vs. 17 days, p = 0.546). Randomized arms did not differ at 24 weeks by any CNS outcome. Combining arms, all measures concurrent with antiretroviral treatment improved, for example, neuropsychological testing (mean NPZ-4 of -0.408 vs. 0.245, p<0.001) and inflammatory markers by MRS (e.g. mean frontal white matter (FWM) choline of 2.92 vs. 2.84, p = 0.045) at baseline and week 24, respectively. Plasma neopterin (p<0.001) and interferon gamma-induced protein 10 (IP-10) (p = 0.007) remained elevated in participants compared to controls but no statistically significant differences were seen in CSF cytokines compared to controls, despite individual variability among the HIV-infected group. CONCLUSIONS A 24-week course of cART+ improved CNS related outcomes, but was not associated with measurable differences compared to standard cART.
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Mora-Peris B, Winston A, Garvey L, Else LJ, Shattock RJ, Herrera C. HIV-1 CNS in vitro infectivity models based on clinical CSF samples. J Antimicrob Chemother 2015; 71:235-43. [PMID: 26472771 DOI: 10.1093/jac/dkv326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/08/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The concentration of antiretrovirals in CSF is often utilized as a surrogate for CNS drug exposure. This measurement does not consider pharmacodynamic or combinative effects of ART. We have developed a novel endpoint measurement to assess antiretroviral activity of CSF from subjects on ART. METHODS CSF samples were obtained from patients receiving tenofovir/emtricitabine (245/200 mg once daily) with either rilpivirine (25 mg once daily) or lopinavir/ritonavir/maraviroc (400/100/150 mg twice daily) and HIV-uninfected controls. Antiviral activity of ART-containing CSF was assessed in cell cultures using PBMCs and neuro-derived glial (U87) and astrocyte (373) cell lines. Infectivity model half-maximal inhibitory concentration (IMIC50) values were calculated and expressed as -log2IMIC50. Results were correlated with CSF antiretroviral concentrations. RESULTS Compared with controls, CSF from both ART studies demonstrated in vitro antiretroviral activity in all models. CSF antiretroviral activity of patients on lopinavir/ritonavir/maraviroc was significantly greater than that of patients on rilpivirine [-log2IMIC50 (95% CI) 4.82 (4.74-4.89) versus 3.43 (3.33-3.54) in PBMCs, 3.06 (2.98-3.15) versus 2.56 (2.46-2.65) in U87 cells and 6.00 (6.11-5.88) versus 4.90 (5.09-4.72) in 373 cells, respectively]. Positive correlations were observed for individual CSF antiretroviral activity in different cellular models with CSF concentrations of rilpivirine (P = 0.040 in 373 cells) and lopinavir (P = 0.048 in 373 cells), but not maraviroc. CONCLUSIONS Antiviral activity of CSF from patients on ART was successfully calculated and was greater with a regimen containing four active drugs compared with three active drugs. The use of neuro-derived cell lines alongside PBMCs to assess the effect of ART on CSF may act as a useful future clinical research tool.
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Affiliation(s)
- Borja Mora-Peris
- Department of Infectious Diseases and Immunity, Faculty of Medicine, Imperial College, London, UK Department of HIV and Genitourinary Medicine, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - Alan Winston
- Department of Infectious Diseases and Immunity, Faculty of Medicine, Imperial College, London, UK Department of HIV and Genitourinary Medicine, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - Lucy Garvey
- Department of Infectious Diseases and Immunity, Faculty of Medicine, Imperial College, London, UK Department of HIV and Genitourinary Medicine, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - Laura J Else
- Department of Clinical and Molecular Pharmacology, University of Liverpool, Liverpool, UK
| | - Robin J Shattock
- Department of Infectious Diseases and Immunity, Faculty of Medicine, Imperial College, London, UK
| | - Carolina Herrera
- Department of Infectious Diseases and Immunity, Faculty of Medicine, Imperial College, London, UK
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Calcagno A, Motta I, Ghisetti V, Lo Re S, Allice T, Marinaro L, Milia MG, Tettoni MC, Trentini L, Orofino G, Salassa B, Di Perri G, Bonora S. HIV-1 Very Low Level Viremia Is Associated with Virological Failure in Highly Active Antiretroviral Treatment-Treated Patients. AIDS Res Hum Retroviruses 2015; 31:999-1008. [PMID: 26165150 DOI: 10.1089/aid.2015.0102] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The aim of this study was to evaluate the impact of HIV-1 very low-level viremia (<50 copies/ml) on the 2-year risk of virological failure. A retrospective analysis including HIV-positive patients presenting two consecutive HIV RNA below 50 copies/ml (outpatient clinic in Italy, first semester of 2010) was performed. HIV RNA was measured through real time polymerase chain reaction (PCR) assay CAP/CTM HIV-1 version 2.0 (detection limit: 20 copies/ml) and stratified as undetectable RNA ("Target Not Detected", TND), <20 copies/ml, 20-50 copies/ml. After 96 weeks virological failure was defined as two consecutive viral loads above 50 copies/ml. Log-rank tests and a multivariate Cox proportional hazard model were used for univariate and multivariate analysis. A total of 1,055 patients (71.4% male, 87.4% white, aged 46.7 years) were included: nadir and current CD4 cell counts were 203 cells/mm(3) (106-292) and 554 cells/mm(3) (413-713.5). HIV RNA was undetectable in 781 patients (74%), <20 copies/ml in 190 patients (18%) and 20-50 copies/ml in 84 patients (8%). Virological failure was observed in 81 patients (7.7%); at multivariate analysis detectable RNA at baseline (p=0.017), HCV infection (p=0.020), more than three pills in the regimen (p=0.003), and duration of HIV RNA <50 copies/ml below 2 years (p<0.001) were independently associated with virological failure. In 14 patients newly selected resistance-associated mutations were observed. Undetectable HIV RNA by real-time PCR is significantly associated with a lower 2-year risk of virological failure along with Ab HCV negativity, longer viral control, and lower pill burden. Studies investigating the management of residual viremia under antiretroviral treatment are warranted.
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Affiliation(s)
- Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Ilaria Motta
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Valeria Ghisetti
- Laboratory of Microbiology and Molecular Biology, Ospedale Amedeo di Savoia, Torino, Italy
| | - Salvatore Lo Re
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Tiziano Allice
- Laboratory of Microbiology and Molecular Biology, Ospedale Amedeo di Savoia, Torino, Italy
| | - Letizia Marinaro
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Maria Grazia Milia
- Laboratory of Microbiology and Molecular Biology, Ospedale Amedeo di Savoia, Torino, Italy
| | - Maria C. Tettoni
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Laura Trentini
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Giancarlo Orofino
- Unit of Infectious Diseases, “Divisione A,” Ospedale Amedeo di Savoia, Torino, Italy
| | - Bernardino Salassa
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Stefano Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
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Calcagno A, Di Perri G, Bonora S. Pharmacokinetics and pharmacodynamics of antiretrovirals in the central nervous system. Clin Pharmacokinet 2015; 53:891-906. [PMID: 25200312 DOI: 10.1007/s40262-014-0171-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
HIV-positive patients may be effectively treated with highly active antiretroviral therapy and such a strategy is associated with striking immune recovery and viral load reduction to very low levels. Despite undeniable results, the central nervous system (CNS) is commonly affected during the course of HIV infection, with neurocognitive disorders being as prevalent as 20-50 % of treated subjects. This review discusses the pathophysiology of CNS infection by HIV and the barriers to efficacious control of such a mechanism, including the available data on compartmental drug penetration and on pharmacokinetic/pharmacodynamic relationships. In the reviewed articles, a high variability in drug transfer to the CNS is highlighted with several mechanisms as well as methodological issues potentially influencing the observed results. Nevirapine and zidovudine showed the highest cerebrospinal fluid (CSF) to plasma ratios, although target concentrations are currently unknown for the CNS. The use of the composite CSF concentration effectiveness score has been associated with better virological outcomes (lower HIV RNA) but has been inconsistently associated with neurocognitive outcomes. These findings support the CNS effectiveness of commonly used highly antiretroviral therapies. The use of antiretroviral drugs with increased CSF penetration and/or effectiveness in treating or preventing neurocognitive disorders however needs to be assessed in well-designed prospective studies.
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Affiliation(s)
- Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, c/o Ospedale Amedeo di Savoia, C.so Svizzera 164, 10159, Torino, Italy,
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26
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A comparative study of neurocognitively impaired patients receiving protease inhibitor monotherapy or triple-drug antiretroviral therapy. J Acquir Immune Defic Syndr 2015; 67:419-23. [PMID: 25197825 DOI: 10.1097/qai.0000000000000337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In a cross-sectional study of aviremic neurocognitively impaired patients receiving protease inhibitors as triple-drug therapy (n = 30) or as monotherapy (n = 22), we found no statistically significant differences in the types of cognitive domains involved or severity of cognitive deficit. Cerebrospinal fluid concentrations of total proteins, total tau, myelin basic protein, neuron-specific enolase, β2 microglobulin, S100B protein, or prevalence of cerebrospinal fluid HIV-RNA detection by standard (6.3% vs 7.1% P = 1) or ultrasensitive assays (50% vs 71.4%, P = 0.28) were similar in both groups. These results do not suggest important differences in the pattern of neurocognitive impairment between groups receiving very different antiretroviral strategies.
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Vera JH, Garvey LJ, Allsop JM, Kaye S, McClure MO, Back D, Taylor-Robinson SD, Winston A. Alterations in Cerebrospinal Fluid Chemokines Are Associated With Maraviroc Exposure and In Vivo Metabolites Measurable by Magnetic Resonance Spectroscopy. HIV CLINICAL TRIALS 2015; 13:222-7. [DOI: 10.1310/hct1304-222] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Low levels of HIV-1 RNA detected in the cerebrospinal fluid after up to 10 years of suppressive therapy are associated with local immune activation. AIDS 2014; 28:2251-8. [PMID: 25022595 DOI: 10.1097/qad.0000000000000400] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE AND DESIGN Though combination antiretroviral therapy reduces the concentration of HIV-1 RNA in both plasma and cerebrospinal fluid (CSF) below the detection limit of clinical assays, low levels of HIV-1 RNA are frequently detectable in plasma using more sensitive assays. We examined the frequency and magnitude of persistent low-level HIV-1 RNA in CSF and its relation to the central nervous system (CNS) immune activation. METHODS CSF and plasma HIV-1 RNA were measured using the single-copy assay with a detection limit of 0.3 copies/ml in 70 CSF and 68 plasma samples from 45 treated HIV-1-infected patients with less than 40 copies/ml of HIV-1 RNA in both fluids by standard clinical assays. We also measured CSF neopterin to assess intrathecal immune activation. Theoretical drug exposure was estimated using the CNS penetration-efficacy score of treatment regimens. RESULTS CSF HIV-1 RNA was detected in 12 of the 70 CSF samples (17%) taken after up to 10 years of suppressive therapy, compared to 39 of the 68 plasma samples (57%) with a median concentration of less than 0.3 copies/ml in CSF compared to 0.3 copies/ml in plasma (P < 0.0001). CSF samples with detectable HIV-1 RNA had higher CSF neopterin levels (mean 8.2 compared to 5.7 nmol/l; P = 0.0085). Patients with detectable HIV-1 RNA in CSF did not differ in pretreatment plasma HIV-1 RNA levels, nadir CD4 cell count or CNS penetration-efficacy score. CONCLUSION Low-level CSF HIV-1 RNA and its association with elevated CSF neopterin highlight the potential for the CNS to serve as a viral reservoir and for persistent infection to cause subclinical CNS injury.
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Churchill MJ, Cowley DJ, Wesselingh SL, Gorry PR, Gray LR. HIV-1 transcriptional regulation in the central nervous system and implications for HIV cure research. J Neurovirol 2014; 21:290-300. [PMID: 25060300 DOI: 10.1007/s13365-014-0271-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 06/25/2014] [Accepted: 06/27/2014] [Indexed: 12/15/2022]
Abstract
Human immunodeficiency virus type-1 (HIV-1) invades the central nervous system (CNS) during acute infection which can result in HIV-associated neurocognitive disorders in up to 50% of patients, even in the presence of combination antiretroviral therapy (cART). Within the CNS, productive HIV-1 infection occurs in the perivascular macrophages and microglia. Astrocytes also become infected, although their infection is restricted and does not give rise to new viral particles. The major barrier to the elimination of HIV-1 is the establishment of viral reservoirs in different anatomical sites throughout the body and viral persistence during long-term treatment with cART. While the predominant viral reservoir is believed to be resting CD4(+) T cells in the blood, other anatomical compartments including the CNS, gut-associated lymphoid tissue, bone marrow, and genital tract can also harbour persistently infected cellular reservoirs of HIV-1. Viral latency is predominantly responsible for HIV-1 persistence and is most likely governed at the transcriptional level. Current clinical trials are testing transcriptional activators, in the background of cART, in an attempt to purge these viral reservoirs and reverse viral latency. These strategies aim to activate viral transcription in cells constituting the viral reservoir, so they can be recognised and cleared by the immune system, while new rounds of infection are blocked by co-administration of cART. The CNS has several unique characteristics that may result in differences in viral transcription and in the way latency is established. These include CNS-specific cell types, different transcription factors, altered immune surveillance, and reduced antiretroviral drug bioavailability. A comprehensive understanding of viral transcription and latency in the CNS is required in order to determine treatment outcomes when using transcriptional activators within the CNS.
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Affiliation(s)
- Melissa J Churchill
- Center for Biomedical Research, Burnet Institute, 85 Commercial Rd, Melbourne, 3004, Victoria, Australia,
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30
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Klatt NR, Chomont N, Douek DC, Deeks SG. Immune activation and HIV persistence: implications for curative approaches to HIV infection. Immunol Rev 2014; 254:326-42. [PMID: 23772629 DOI: 10.1111/imr.12065] [Citation(s) in RCA: 298] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Despite complete or near-complete suppression of human immunodeficiency virus (HIV) replication with combination antiretroviral therapy, both HIV and chronic inflammation/immune dysfunction persist indefinitely. Untangling the association between the virus and the host immune environment during therapy might lead to novel interventions aimed at either curing the infection or preventing the development of inflammation-associated end-organ disease. Chronic inflammation and immune dysfunction might lead to HIV persistence by causing virus production, generating new target cells, enabling infecting of activated and resting target cells, altering the migration patterns of susceptible target cells, increasing the proliferation of infected cells, and preventing normal HIV-specific clearance mechanisms from function. Chronic HIV production or replication might contribute to persistent inflammation and immune dysfunction. The rapidly evolving data on these issues strongly suggest that a vicious cycle might exist in which HIV persistence causes inflammation that in turn contributes to HIV persistence.
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Affiliation(s)
- Nichole R Klatt
- Department of Pharmaceutics, Washington National Primate Research Center, University of Washington, Seattle, WA, USA
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31
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Clifford DB, Ances BM. HIV-associated neurocognitive disorder. THE LANCET. INFECTIOUS DISEASES 2014; 13:976-86. [PMID: 24156898 DOI: 10.1016/s1473-3099(13)70269-x] [Citation(s) in RCA: 435] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Neurological involvement in HIV is often associated with cognitive impairment. Although severe and progressive neurocognitive impairment has become rare in HIV clinics in the era of potent antiretroviral therapy, most patients with HIV worldwide have poor outcomes on formal neurocognitive tests. In this Review, we describe the manifestations of HIV-associated neurocognitive disorder in the era of effective HIV therapy, outline diagnosis and treatment recommendations, and explore the research questions that remain. Although comorbid disorders, such as hepatitis C infection or epilepsy, might cause some impairment, their prevalence is insufficient to explain the frequency with which it is encountered. HIV disease markers, such as viral load and CD4 cell counts, are not strongly associated with ongoing impairment on treatment, whereas cardiovascular disease markers and inflammatory markers are. New cerebrospinal fluid and neuroimaging biomarkers are needed to detect and follow impairment. Ongoing research efforts to optimise HIV therapy within the CNS, and potentially to intervene in downstream mechanisms of neurotoxicity, remain important avenues for future investigation. Ultimately, the full control of virus in the brain is a necessary step in the goal of HIV eradication.
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Affiliation(s)
- David B Clifford
- Department of Neurology and Medicine, Washington University in St Louis, St Louis, MO, USA.
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32
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Affiliation(s)
- Marie F Grill
- Department of Neurology, Division of Hospital Neurology, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Richard W Price
- Department of Neurology, School of Medicine, University of California San Francisco, San Francisco, CA, USA.
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Titanji BK, Aasa-Chapman M, Pillay D, Jolly C. Protease inhibitors effectively block cell-to-cell spread of HIV-1 between T cells. Retrovirology 2013; 10:161. [PMID: 24364896 PMCID: PMC3877983 DOI: 10.1186/1742-4690-10-161] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 12/11/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Human Immunodeficiency Virus type-1 (HIV-1) spreads by cell-free diffusion and by direct cell-to-cell transfer, the latter being a significantly more efficient mode of transmission. Recently it has been suggested that cell-to-cell spread may permit ongoing virus replication in the presence of antiretroviral therapy (ART) based on studies performed using Reverse Transcriptase Inhibitors (RTIs). Protease Inhibitors (PIs) constitute an important component of ART; however whether this class of inhibitors can suppress cell-to-cell transfer of HIV-1 is unexplored. Here we have evaluated the inhibitory effect of PIs during cell-to-cell spread of HIV-1 between T lymphocytes. RESULTS Using quantitative assays in cell line and primary cell systems that directly measure the early steps of HIV-1 infection we find that the PIs Lopinavir and Darunavir are equally potent against both cell-free and cell-to-cell spread of HIV-1. We further show that a protease resistant mutant maintains its resistant phenotype during cell-to-cell spread and is transmitted more efficiently than wild-type virus in the presence of drug. By contrast we find that T cell-T cell spread of HIV-1 is 4-20 fold more resistant to inhibition by the RTIs Nevirapine, Zidovudine and Tenofovir. Notably, varying the ratio of infected and uninfected cells in co-culture impacted on the degree of inhibition, indicating that the relative efficacy of ART is dependent on the multiplicity of infection. CONCLUSIONS We conclude that if the variable effects of antiviral drugs on cell-to-cell virus dissemination of HIV-1 do indeed impact on viral replication and maintenance of viral reservoirs this is likely to be influenced by the antiviral drug class, since PIs appear particularly effective against both modes of HIV-1 spread.
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Affiliation(s)
| | | | | | - Clare Jolly
- Division of Infection and Immunity, University College London, Cruciform Building, Gower St, London WC1E 6BT, United Kingdom.
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Dahl V, Gisslen M, Hagberg L, Peterson J, Shao W, Spudich S, Price RW, Palmer S. An example of genetically distinct HIV type 1 variants in cerebrospinal fluid and plasma during suppressive therapy. J Infect Dis 2013; 209:1618-22. [PMID: 24338353 DOI: 10.1093/infdis/jit805] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
We sequenced the genome of human immunodeficiency virus type 1 (HIV-1) recovered from 70 cerebrospinal fluid (CSF) specimens and 29 plasma samples and corresponding samples obtained before treatment initiation from 17 subjects receiving suppressive therapy. More CSF sequences than plasma sequences were hypermutants. We determined CSF sequences and plasma sequences in specimens obtained from 2 subjects after treatment initiation. In one subject, we found genetically distinct CSF and plasma sequences, indicating that they came from HIV-1 from 2 different compartments, one potentially the central nervous system, during suppressive therapy. In addition, there was little evidence of viral evolution in the CSF during therapy, suggesting that continuous virus replication is not the major cause of viral persistence in the central nervous system.
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Affiliation(s)
- Viktor Dahl
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet and Swedish Institute for Communicable Disease Control, Stockholm
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Kelly KM, Beck SE, Metcalf Pate KA, Queen SE, Dorsey JL, Adams RJ, Avery LB, Hubbard W, Tarwater PM, Mankowski JL. Neuroprotective maraviroc monotherapy in simian immunodeficiency virus-infected macaques: reduced replicating and latent SIV in the brain. AIDS 2013; 27:F21-8. [PMID: 24051706 PMCID: PMC4235167 DOI: 10.1097/qad.0000000000000074] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 09/12/2013] [Accepted: 09/12/2013] [Indexed: 12/05/2022]
Abstract
OBJECTIVE HIV-associated neurocognitive deficits remain a challenge despite suppressive combined antiretroviral therapy. Given the association between HIV-induced central nervous system (CNS) disease and replication of HIV in immune-activated macrophages, CCR5 antagonists may attenuate CNS disease by modulating inflammatory signaling and by limiting viral replication. DESIGN To establish whether initiating CCR5 inhibition during early infection altered CNS disease progression, outcomes were compared between simian immunodeficiency virus (SIV)-infected macaques treated with maraviroc (MVC) versus untreated SIV-infected macaques. METHODS Six SIV-infected rhesus macaques were treated with MVC monotherapy for 5 months beginning 24 days postinoculation; 22 SIV-infected animals served as untreated controls. SIV RNA levels in plasma, cerobrospinal fluid, and brain, and CNS expression of TNFα and CCL2 were measured by qRT-PCR. Immunostaining for CD68 and amyloid precursor protein in the brain was measured by image analysis. Plasma sCD163 was measured by ELISA. RESULTS SIV RNA and proviral DNA levels in brain were markedly lower with MVC treatment, demonstrating CCR5 inhibition reduces CNS replication of SIV and may reduce the CNS latent viral reservoir. MVC treatment also lowered monocyte and macrophage activation, represented by CNS CD68 immunostaining and plasma sCD163 levels, and reduced both TNFα and CCL2 RNA expression in brain. Treatment also reduced axonal amyloid precursor protein immunostaining to levels present in uninfected animals, consistent with neuroprotection. CONCLUSION CCR5 inhibitors may prevent neurologic disorders in HIV-infected individuals by reducing inflammation and by limiting viral replication in the brain. Furthermore, CCR5 inhibitors may reduce the latent viral reservoir in the CNS. Adding CCR5 inhibitors to combined antiretroviral regimens may offer multiple neuroprotective benefits.
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Affiliation(s)
- Kathleen M Kelly
- aDepartment of Molecular and Comparative Pathobiology bDepartment of Pharmacology and Molecular Sciences cDivision of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland dDepartment of Biostatistics, Texas Tech University School of Medicine, El Paso Texas eDepartment of Neurology fDepartment of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Dynamics of the HIV-1 latent reservoir after discontinuation of the intensification of antiretroviral treatment: results of two clinical trials. AIDS 2013; 27:2081-8. [PMID: 24384589 DOI: 10.1097/qad.0b013e328361d0e1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Antiretroviral therapy (ART) intensification has been shown to reduce the reservoir of latently infected CD4 T cells. However, it is currently unknown whether this effect is maintained after discontinuation of the intensifying drug. DESIGN The effect of ART intensification during 48 weeks with maraviroc or raltegravir in chronically HIV-1-infected patients was assessed in two previous clinical trials. In this study, we analysed this effect at week 24 after discontinuation of the intensifying drugs, at baseline and 48 weeks of intensification. METHODS We measured the latently infected memory CD4 T cells carrying replication-competent virus, 2-long terminal repeat (2-LTR) circles and CD4/CD8 T cells activation. RESULTS Fifteen patients were evaluated. After 48 weeks of intensification, HIV-1 reservoir size significantly decreased from 1.1 to 0.0 infectious units per million (IUPM) (P=0.004). After 24 weeks of drug discontinuation, the median size of the reservoir was still significantly lower than at baseline (P=0.008). 2-LTRs were undetectable in all individuals at baseline and after 48 weeks of intensification, continuing undetectable in all patients except two at week 24 after discontinuation (P=0.1). CD4 and CD8 T-cell activation significantly decreased at 48 weeks after intensification, without further increase after discontinuation. CONCLUSION The effects of ART intensification with maraviroc or raltegravir persist at least 24 weeks after discontinuation of the drug. In a global strategy, ART intensification should be considered as part of a combination approach to achieve a functional cure or HIV eradication.
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Taiwo B, Barcena L, Tressler R. Understanding and controlling chronic immune activation in the HIV-infected patients suppressed on combination antiretroviral therapy. Curr HIV/AIDS Rep 2013; 10:21-32. [PMID: 23225316 DOI: 10.1007/s11904-012-0147-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Combination antiretroviral therapy (cART) has resulted in tremendous gains in survival among HIV-infected patients, but as a group those who achieve undetectable viral loads on cART experience a greater degree of immune activation and inflammation than the general population. HIV-infected patients continue to experience premature immune senescence with earlier and more frequent non-AIDS events compared to HIV-uninfected individuals. Chronic immune activation during suppressive cART derives from a variety of sources mediated by cytokines, chemokines, coagulation, microbial translocation, immune regulators and T(effector) cell activation abnormalities, among others. Current investigational strategies to control immune activation target potential causes of persistently heightened immune activation during cART such as microbial translocation, co-infections, and comorbidities or mediators along a common final pathway. Although several interventions have shown promise in vitro or in preliminary clinical trials, no intervention has sufficient evidence for routine use, making control of immune activation during cART an unmet need.
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Affiliation(s)
- Babafemi Taiwo
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, 645 North Michigan Avenue, Suite 900, Chicago, IL 60611, USA.
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Van Lint C, Bouchat S, Marcello A. HIV-1 transcription and latency: an update. Retrovirology 2013; 10:67. [PMID: 23803414 PMCID: PMC3699421 DOI: 10.1186/1742-4690-10-67] [Citation(s) in RCA: 237] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 05/29/2013] [Indexed: 12/11/2022] Open
Abstract
Combination antiretroviral therapy, despite being potent and life-prolonging, is not curative and does not eradicate HIV-1 infection since interruption of treatment inevitably results in a rapid rebound of viremia. Reactivation of latently infected cells harboring transcriptionally silent but replication-competent proviruses is a potential source of persistent residual viremia in cART-treated patients. Although multiple reservoirs may exist, the persistence of resting CD4+ T cells carrying a latent infection represents a major barrier to eradication. In this review, we will discuss the latest reports on the molecular mechanisms that may regulate HIV-1 latency at the transcriptional level, including transcriptional interference, the role of cellular factors, chromatin organization and epigenetic modifications, the viral Tat trans-activator and its cellular cofactors. Since latency mechanisms may also operate at the post-transcriptional level, we will consider inhibition of nuclear RNA export and inhibition of translation by microRNAs as potential barriers to HIV-1 gene expression. Finally, we will review the therapeutic approaches and clinical studies aimed at achieving either a sterilizing cure or a functional cure of HIV-1 infection, with a special emphasis on the most recent pharmacological strategies to reactivate the latent viruses and decrease the pool of viral reservoirs.
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Affiliation(s)
- Carine Van Lint
- Université Libre de Bruxelles (ULB), Service of Molecular Virology, Institute of Molecular Biology and Medicine, 12, Rue des Profs Jeener et Brachet, 6041, Gosselies, Belgium.
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40
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Abstract
The neurological outcome of HIV infection has changed dramatically in the era of HAART. Despite effective suppression of plasma viral load and a substantial decrease in the incidence of HIV-associated dementia, neurocognitive impairment and peripheral neuropathy remain widespread. The neurotoxic side effects of antiretroviral (ARV) agents are among several contributing factors to this continued prevalence. Effective penetration of the CNS by ARV agents is paramount to treating neurological symptoms as well as systemic infection, but may also exacerbate the severity of drug-related neurotoxicity. The neurotoxic side effects of ARV agents vary widely between and within drug classes. The risks and benefits of combination regimens continue to evolve as more effective treatment protocols are developed.
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Affiliation(s)
- Charles T Upton
- University of North Carolina at Chapel Hill, Physicians Office Building 2195C, Chapel Hill, NC 27599, USA
| | - Babafemi Taiwo
- Northwestern University, 645 N Michigan Ave, Suite 900, Chicago, IL 60611, USA
| | - Kevin R Robertson
- University of North Carolina at Chapel Hill, Physicians Office Building 2127, Chapel Hill, NC 27599, USA
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41
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Shan L, Siliciano RF. From reactivation of latent HIV-1 to elimination of the latent reservoir: the presence of multiple barriers to viral eradication. Bioessays 2013; 35:544-52. [PMID: 23613347 DOI: 10.1002/bies.201200170] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The discovery of a stable latent reservoir for HIV-1 in resting memory CD4(+) T cells provides a mechanism for lifelong persistence of HIV-1. The long-lived latently infected cells persist in spite of prolonged highly active antiretroviral therapy and present a major barrier to a cure of HIV-1 infection. In this review, we discuss the current understanding of HIV-1 persistence and latent viral infection in the context of effective antiretroviral therapy and the recent progress in purging latent viral reservoirs. Recent studies demonstrate that reactivation of latent HIV-1 is a promising strategy for the depletion of these viral reservoirs. A thorough evaluation of the anti-latency activity of drug candidates should include the measurement of changes in intracellular viral RNA, plasma virus levels, and the size of latent viral reservoirs, as well as potential adverse effects. Currently, there are several technical barriers to the evaluation of anti-latency drugs in vivo. We also discuss these challenging issues that remain unresolved.
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Affiliation(s)
- Liang Shan
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Tyagi M, Bukrinsky M. Human immunodeficiency virus (HIV) latency: the major hurdle in HIV eradication. Mol Med 2012; 18:1096-108. [PMID: 22692576 DOI: 10.2119/molmed.2012.00194] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 06/07/2012] [Indexed: 12/11/2022] Open
Abstract
Failure of highly active antiretroviral therapy to eradicate the human immunodeficiency virus (HIV), even in patients who suppress the virus to undetectable levels for many years, underscores the problems associated with fighting this infection. The existence of persistent infection in certain cellular and anatomical reservoirs appears to be the major hurdle in HIV eradication. The development of therapeutic interventions that eliminate or limit the latent viral pools or prevent the reemergence of the viruses from producing cells will therefore be required to enhance the effectiveness of current antiretroviral strategies. To achieve this goal, there is a pressing need to understand HIV latency at the molecular level to design novel and improved therapies to either eradicate HIV or find a functional cure in which patients could maintain a manageable viral pool without AIDS in the absence of antiretroviral therapy. The integrated proviral genome remains transcriptionally silent for a long period in certain subsets of T cells. This ability to infect cells latently helps HIV to establish a persistent infection despite strong humoral and cellular immune responses against the viral proteins. The main purpose of this report is to provide a general overview of the HIV latency. We will describe the hurdles being faced in eradicating latent HIV proviruses. We will also briefly discuss the ongoing strategies aimed toward curing HIV infection.
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Affiliation(s)
- Mudit Tyagi
- National Center for Biodefense and Infectious Disease, George Mason University, Manassas, Virginia 20109, United States of America.
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Gisslén M, Fuchs D, Hagberg L, Svennerholm B, Zetterberg H. Cerebrospinal fluid viral breakthrough in two HIV-infected subjects on darunavir/ritonavir monotherapy. ACTA ACUST UNITED AC 2012; 44:997-1000. [PMID: 22776013 PMCID: PMC3507278 DOI: 10.3109/00365548.2012.690526] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Darunavir/ritonavir monotherapy maintains HIV suppression in most patients who have achieved an undetectable viral load on combination antiretroviral treatment, and is increasingly used in the clinic. However, concerns have been raised about the effectiveness of ritonavir-boosted protease inhibitor (PI/r) monotherapy in the prevention of HIV replication in the central nervous system (CNS). Here we report the cases of 2 patients on darunavir/r maintenance monotherapy with cerebrospinal fluid viral breakthrough together with increased immunoactivation and biomarker signs of neuronal injury. These 2 cases raise concerns about the effectiveness of darunavir/ritonavir monotherapy in HIV CNS infection. Thus, we recommend caution with protease inhibitor monotherapy until CNS results have been obtained from clinical studies.
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Affiliation(s)
- Magnus Gisslén
- Department of Infectious Diseases, University of Gothenburg, Sweden.
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Johnston R, Barré-Sinoussi F. Controversies in HIV cure research. J Int AIDS Soc 2012; 15:16. [PMID: 22424402 PMCID: PMC3334674 DOI: 10.1186/1758-2652-15-16] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 03/16/2012] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Antiretroviral therapy significantly reduces HIV viral burden and prolongs life, but does not cure HIV infection. The major scientific barrier to a cure is thought to be the persistence of the virus in cellular and/or anatomical reservoirs. DISCUSSION Most efforts to date, including pharmaco, immuno or gene therapy, have failed to cure patients, with the notable exception of a stem cell transplant recipient commonly known as the Berlin patient. This case has revived interest in the potential to cure HIV infection and has highlighted the need to resolve critical questions in the basic, pre-clinical and clinical research spheres as they pertain specifically to efforts to eradicate HIV from the body of an infected person (a sterilizing cure) or at least render the need for lifelong antiretroviral therapy obsolete (functional cure). This paper describes ongoing debates in each of these research spheres as they were presented and discussed at a satellite session that took place at the 6th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in Rome in July 2011. SUMMARY The resolution of these debates may have important implications for the search for a cure, the most efficient ways to identify and test promising interventions, and ultimately the availability of such a cure to diverse groups of HIV patients around the world.
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Affiliation(s)
- Rowena Johnston
- amfAR, The Foundation for AIDS Research, 120 Wall St, 13th Floor, New York, NT 10005, USA
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Gutiérrez C, Díaz L, Vallejo A, Hernández-Novoa B, Abad M, Madrid N, Dahl V, Rubio R, Moreno AM, Dronda F, Casado JL, Navas E, Pérez-Elías MJ, Zamora J, Palmer S, Muñoz E, Muñoz-Fernández MÁ, Moreno S. Intensification of antiretroviral therapy with a CCR5 antagonist in patients with chronic HIV-1 infection: effect on T cells latently infected. PLoS One 2011; 6:e27864. [PMID: 22174752 PMCID: PMC3234247 DOI: 10.1371/journal.pone.0027864] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 10/26/2011] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE The primary objective was to assess the effect of MVC intensification on latently infected CD4(+) T cells in chronically HIV-1-infected patients receiving antiretroviral therapy. METHODS We performed an open-label pilot phase II clinical trial involving chronically HIV-1-infected patients receiving stable antiretroviral therapy whose regimen was intensified with 48 weeks of maraviroc therapy. We analyzed the latent reservoir, the residual viremia and episomal 2LTR DNA to examine the relationship between these measures and the HIV-1 latent reservoir, immune activation, lymphocyte subsets (including effector and central memory T cells), and markers associated with bacterial translocation. RESULTS Overall a non significant reduction in the size of the latent reservoir was found (p = 0.068). A mean reduction of 1.82 IUPM was observed in 4 patients with detectable latent reservoir at baseline after 48 weeks of intensification. No effect on plasma residual viremia was observed. Unexpectedly, all the patients had detectable 2LTR DNA circles at week 24, while none of them showed those circles at the end of the study. No changes were detected in CD4(+) or CD8(+) counts, although a significant decrease was found in the proportion of HLA-DR(+)/CD38(+) CD4(+) and CD8(+) T-cells. LPS and sCD14 levels increased. CONCLUSIONS Intensification with MVC was associated with a trend to a decrease in the size of the latent HIV-1 reservoir in memory T cells. No impact on residual viremia was detected. Additional studies with larger samples are needed to confirm the results. TRIAL REGISTRATION ClinicalTrials.gov NCT00795444.
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Affiliation(s)
- Carolina Gutiérrez
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, and IRYCIS, Madrid, Spain
| | - Laura Díaz
- Inmunobiology Laboratory, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Alejandro Vallejo
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, and IRYCIS, Madrid, Spain
| | - Beatriz Hernández-Novoa
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, and IRYCIS, Madrid, Spain
| | - María Abad
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, and IRYCIS, Madrid, Spain
| | - Nadia Madrid
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, and IRYCIS, Madrid, Spain
| | | | - Rafael Rubio
- Infectious Diseases Unit, Hospital General Universitario Doce de Octubre, Madrid, Spain
| | - Ana M. Moreno
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, and IRYCIS, Madrid, Spain
| | - Fernando Dronda
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, and IRYCIS, Madrid, Spain
| | - José Luis Casado
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, and IRYCIS, Madrid, Spain
| | - Enrique Navas
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, and IRYCIS, Madrid, Spain
| | - María Jesús Pérez-Elías
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, and IRYCIS, Madrid, Spain
| | - Javier Zamora
- Biostatistics Department, Hospital Universitario Ramón y Cajal, and IRYCIS, Madrid, Spain
| | | | - Eduardo Muñoz
- Immunology Department, Universidad de Córdoba, Córdoba, Spain
| | | | - Santiago Moreno
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, and IRYCIS, Madrid, Spain
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Abstract
Recent studies demonstrate that suppressive therapy can drive HIV-1 RNA levels to less than 50 copies mL(-1) in patient plasma. Yet, ultrasensitive assays show that most patients continue to harbour low-level persistent viremia. Treatment intensification studies indicate that low-level viremia could arise from several different sources. These sources include: (i) long-lived HIV-infected cells that replicate and produce virus; (ii) ongoing replication cycles in cells located in sanctuary sites where drug levels are suboptimal; and/or (iii) proliferation of latently infected cells with regeneration of a stable reservoir of slowly dividing infected cells. A well-defined latent reservoir of HIV is memory CD4+ T-cells where latency is established when an activated CD4+ T-cell becomes infected by HIV, but transitions to a terminally differentiated memory cell before it is eliminated. This review examines the dynamics and possible reservoirs of persistent HIV in patients on suppressive therapy, the mechanisms promoting viral latency and strategies to purge latent viral reservoirs. The promising research described here takes a number of steps forward to seriously address HIV remission and/or eradication.
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Affiliation(s)
- S Palmer
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Solna, Sweden.
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Boulassel MR, Chomont N, Pai NP, Gilmore N, Sékaly RP, Routy JP. CD4 T cell nadir independently predicts the magnitude of the HIV reservoir after prolonged suppressive antiretroviral therapy. J Clin Virol 2011; 53:29-32. [PMID: 22019250 DOI: 10.1016/j.jcv.2011.09.018] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 09/12/2011] [Accepted: 09/20/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND The level of HIV-1 integrated DNA in CD4 T cells was reported to predict the evolution of untreated HIV-1 infection independently of CD4 cell counts or plasma HIV-1 RNA levels. However, the relevance of reservoir level while on efficient antiretroviral therapy (ART) is still unknown. OBJECTIVES To evaluate factors that may contribute to the establishment and maintenance of HIV-1 reservoir size in ART-treated HIV-1-infected adults with complete suppression of viremia. STUDY DESIGN 35 subjects receiving ART with plasma HIV-1 RNA below the limit of detection for an average duration of 3.2 years were studied. A highly sensitive PCR was used to assess HIV-1 integrated DNA levels in sorted CD4 T cells. RESULTS The mean HIV-1 integrated DNA was 300±7copies/10(6) CD4 cells (range 10-1408). In univariate analysis, the levels of HIV-1 proviral DNA appeared to be independent of duration of HIV-1-infection, duration on ART, time since HIV-1 viral load was undetectable, delay between HIV-1 infection and starting ART, or viral load before starting ART. Conversely, CD4 T cell nadir, CD4/CD8 ratio and, to lesser degree, CD4 T cell counts were inversely associated with HIV-1 proviral DNA levels. In multivariate analysis, only CD4 T cell nadir significantly predicted levels of HIV-1 proviral DNA (P=0.025). CONCLUSIONS CD4 T cell nadir strongly predicted reservoir size independently of other factors in HIV-1-infected adults with complete suppression of viremia. Collectively, these results indicate that the extent of CD4 T cell depletion before ART drives the size of the viral reservoir after prolonged therapy.
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Affiliation(s)
- Mohamed-Rachid Boulassel
- Division of Hematology, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
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Dahl V, Lee E, Peterson J, Spudich SS, Leppla I, Sinclair E, Fuchs D, Palmer S, Price RW. Raltegravir treatment intensification does not alter cerebrospinal fluid HIV-1 infection or immunoactivation in subjects on suppressive therapy. J Infect Dis 2011; 204:1936-45. [PMID: 22021620 DOI: 10.1093/infdis/jir667] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Despite suppression of plasma human immunodeficiency virus type 1 (HIV-1) RNA by antiretroviral therapy to levels below clinical assay detection, infection and immune activation may persist within the central nervous system and possibly lead to continued brain injury. We hypothesized that intensifying therapy would decrease cerebrospinal fluid (CSF) infection and immune activation. METHODS This was a 12-week, randomized, open-label pilot study comparing addition of the integrase inhibitor raltegravir to no treatment augmentation, with an option for rollover to raltegravir. CSF and plasma were analyzed for HIV-1 RNA using a single-copy assay. CSF and blood immune activation was assessed by neopterin concentrations and CD4(+) and CD8(+) T-cell surface antigen expression. RESULTS Primary analysis compared 14 intensified (including rollovers) to 9 nonintensified subject experiences. Median HIV-1 RNA levels in all samples were lower in CSF (<.3 copies/mL) than in plasma (<.9 copies/mL; P < .0001), and raltegravir did not reduce HIV-1 RNA, CSF neopterin, or CD4(+) and CD8(+) T-cell activation. CONCLUSIONS Raltegravir intensification did not reduce intrathecal immunoactivation or alter CSF HIV-1 RNA levels in subjects with baseline viral suppression. With and without raltegravir intensification, HIV RNA levels in CSF were very low in the enrolled subjects. Clinical Trials Registration. NCT00672932.
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Affiliation(s)
- Viktor Dahl
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet and Swedish Institute for Infectious Disease Control, Stockholm, Sweden
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del Palacio M, Alvarez S, Muñoz-Fernández MÁ. HIV-1 infection and neurocognitive impairment in the current era. Rev Med Virol 2011; 22:33-45. [PMID: 21990255 DOI: 10.1002/rmv.711] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 08/05/2011] [Accepted: 08/09/2011] [Indexed: 01/18/2023]
Abstract
Brain HIV-1-infection may result in a syndrome of profound cognitive, behavioral and motor impairment known as AIDS dementia complex (ADC) in adults and HIV-related encephalopathy in children. Although the introduction of highly active antiretroviral therapy (HAART) has prolonged and improved the lives of infected individuals, it is clear that HAART does not provide complete protection against neurological damage in HIV/AIDS. HIV-1 associated dementia is a complex phenomenon, which could be the result of several mechanisms caused by those players using different intracellular signaling pathways. Understanding the causes of neurodegeneration during HIV-1 infection and the factors which certain individuals develop disease can provide researches on new therapeutic targets to positively affect disease outcomes. Controlling CNS viral replication with HAART is an essential primary approach, but it should be complemented with adjunctive CNS-directed therapeutics. Understanding the nature of HIV-1 infection within the CNS as well as inflammatory responses will ultimately lead to the elimination of HIV-associated neurocognitive disorders.
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Affiliation(s)
- María del Palacio
- Laboratorio Inmunobiología Molecular, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Targeting viral reservoirs: ability of antiretroviral therapy to stop viral replication. Curr Opin HIV AIDS 2011; 6:49-56. [PMID: 21228755 DOI: 10.1097/coh.0b013e32834134ea] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW HIV infection is controlled but not cured by combination antiretroviral therapy. HIV may persist for a number of reasons, including ongoing cycles of HIV infection or viral persistence as latent, or HIV replication in long-lived cells containing HIV proviruses. Therapeutic consequences of these alternative mechanisms are significant and distinct. If ongoing replication remains during current antiretroviral therapy, then improvements in potency will be useful in eradication strategies. Alternatively, long-lived cells with integrated proviruses will not be affected by improvements in therapy directed against active infection, and new strategies will be necessary for HIV eradication. Technologic advances have made it possible to carry out a series of drug intensification protocols in well suppressed patients; these and other analyses for HIV replication have been useful to elucidate the nature of HIV persistence on therapy. RECENT FINDINGS A number of clinical studies intensifying antiretroviral therapy carried out in the last several years have yielded new findings regarding the ability to detect the presence of ongoing replication. Decreases in persistent viremia have not been consistently detected in individuals on potent combination antiretroviral therapy. Evidence for persistent replication has been reported in patients using sensitive assays of cell-associated HIV. SUMMARY HIV viremia persists despite combination antiretroviral therapy. Antiretroviral drug intensification does not lower the level of HIV measured in plasma, suggesting current therapy arrests active virus replication. HIV eradication will most likely require therapy in addition to potent antiretroviral therapy.
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