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Slide 1 of 10 Immune Activation, HIV Persistence, and the Cure Daniel C. Douek, MD, PhD Bethesda, Maryland From DC Douek, MD, at Atlanta, GA: April 10, 2013, IAS-USA. IAS–USA Slide 2 of 10 Causes Of Chronic Immune Activation • Raised cytokine and chemokine levels are a consequence of immune activation • HIV-induced activation of innate immune system (N. Bhardwaj) – When virus load decreases after acute phase, immune activation remains elevated – Virus load alone is a poor predictor of disease progression (Rodriguez JAMA 2006) – Measures of immune activation predict disease progression independent of viral load (Giorgi, Deeks...) – Elite controllers who progress have increased activated CD38+ T cells (Hunt JID 2008) – When virus load is suppressed with ART immune activation still persists and predicts progression • Increased antigen load, bacterial overgrowth, herpes viruses (S. Deeks, P. Hunt) • Translocation of proinflammatory mediators across mucosae From DC Douek, MD, at Atlanta, GA: April 10, 2013, IAS-USA. Slide 3 of 10 Consequences of HIV Infection in GI Tract Loss of tight junctions Mucus CD4 T cell loss Microbial products Enterocyte apoptosis Healthy Gut •Tight epithelial junctions, mucus •Anti-microbial peptides, Abs, cells •Majority of CD4 T cells in body •Cross-talk between microbes and epithelial cells and immune cells HIV-Infected Gut •Massive loss of CD4 T cells •Enteropathy •2-10x increased permeability •Translocation of microbial products •Systemic immune activation From DC Douek, MD, at Atlanta, GA: April 10, 2013, IAS-USA. Slide 4 of 10 immune deficiency gut CD4 depletion enteropathy ART HIV Tem Tem immune activation Tcm Tem Tcm low thymic output LT fibrosis T/B cell dysfunction inflammation non-AIDS morbidity tissue damage and mortality coagulopathy From DC Douek, MD, at Atlanta, GA: April 10, 2013, IAS-USA. CMV ??? Slide 5 of 10 Ongoing HIV Replication During ART? Although complete inhibition of viral replication is unlikely to be curative, all cure strategies are based on first having achieved complete suppression • Evidence against ongoing HIV replication on ART • Increasing evidence in favor of ongoing replication • Evidence it is associated with immune activation • The source of the sample is key (blood vs tissues) • The assay used to measure virus is critical From DC Douek, MD, at Atlanta, GA: April 10, 2013, IAS-USA. Slide 6 of 10 HIV-Specific Immunity and HIV Persistence Immune activation adversely affects HIVspecific T cell responses Immune activation adversely affects CD4 T cell immune reconstitution What is relationship between HIV-specific T cell immunity and the HIV reservoir? From DC Douek, MD, at Atlanta, GA: April 10, 2013, IAS-USA. Slide 7 of 10 CD8 1.0 r = - 0.56, P = 0.01 0.5 0.0 0 1 2 % Gag-specific IFNg+ IL2+ CD4+ T cells (GALT) % Gag-specific IFNg+ IL2+ CD8+ T cells (GALT) HIV-Specific Immunity and HIV Persistence CD4 6 r = - 0.37, P = 0.12 5 4 3 2 1 0 0 log10 Proviral DNA (per mil PBMC) 1 2 log10 Proviral DNA (per mil PBMC) Hatano JID 2011 On suppressive ART, strong HIV specific T cell responses in the gut mucosa are associated with lower levels of PBMC viral DNA From DC Douek, MD, at Atlanta, GA: April 10, 2013, IAS-USA. Slide 8 of 10 target cell generation infected cell proliferation virus transcription virus production low thymic output immune activation new infection events From DC Douek, MD, at Atlanta, GA: April 10, 2013, IAS-USA. lymphoid fibrosis poor CD4 T cell renewal T/B cell dysfunction mucosal damage Slide 9 of 10 Therapeutic Interventions in Development • Chemokine receptor inhibitors: • Anti-inflammatory drugs: – maraviroc, TB-652 • Anti-infective therapy: – CMV, EBV, HSV, HCV/HBV • Microbial translocation: – sevelamer, colostrum, rifaximin • Enhance T cell renewal: – Growth Hormone, IL-7 • Anti-fibrotic drugs: – pirfenidone, ACEi, ARBs, KGF • Anti-aging: – caloric restriction, sirtuin activators, vitamin D, omega-3 fatty acids, rapamycin, diet, exercise – – – – – – Chloroquine, HCQ Minocycline NSAIDs (COX-2i, aspirin) Statins Methotrexate Thalidomide, lenalidomide, pentoxyfylline (weak TNF inhibitors) – Biologics (e.g., TNF inhibitors, IL-6 inhibitors, anti-IFNa, anti-PD1 • Anti-coagulants: - low dose warfarin, dabigatran, aspirin, clopidogrel Combination therapy may be necessary From DC Douek, MD, at Atlanta, GA: April 10, 2013, IAS-USA. Slide 10 of 10 In The Context of The Cure • Multiple mechanisms account for HIV persistence, all of which are being addressed therapeutically • The unifying theme is to reduce HIV reservoir size – Reduce inflammation – Increase immune function – Early ART and ART intensification – Gene therapy to reduce reservoir size – Stem cell transplants can reduce reservoir size – Drugs with biologic activity against latent virus exist – Vaccines may enhance host-clearance mechanisms Combination therapy may be necessary From DC Douek, MD, at Atlanta, GA: April 10, 2013, IAS-USA.