acute hiv infection studies in african women reveal...
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Thumbi Ndung’u, BVM, PhDAfrica Health Research Institute and
HIV Pathogenesis Programme (HPP), University of KwaZulu-Natal
International Workshop on HIV Transmission Rockville, MD, USA 12 December 2019
Acute HIV infection studies in African women reveal opportunities and challenges for prevention and cure strategies
High HIV prevalence and incidence
Wong et al, in preparation
Lessons from acute HIV-1 infection
Key questions:• Characteristics of the transmitted/founder virus• Immune responses in acute HIV-1 infection• Impact of early treatment• Ultimate goal: immune-based prevention or cure of HIV
Year 1
Fiebig I/II Fiebig III-VI
Fiebig I/II: anti-HIV humoral immune responses undetectable, viral load on upward trajectory
≥ Fiebig III: humoral immune responses detectable, peak viremia or past
FRESH study cohort
• FRESH: Females Rising through Education, Support and Health
• Recruit women 18 to 23 at very high risk of HIV infection
– Provide an intensive HIV prevention (including PrEP and POC viral load testing), empowerment, life-skills and job readiness curriculum that coincides with the sample collection protocol (Ndung’u et al, Sci Imm, 2018).
• Empowerment and training program coincides with twice per week HIV RNA testing for 9 months. Serial pre- and post-infection samples (blood, FGT and lymph nodes) are collected.
• Study host and viral factors associated with acquisition and disease progression
PrEP experience among young women in Durban
64% - PrEP uptake13 groups (~500 women)1 year (May 2018 – Apr 2019)
83 acute infections detected
As of June 2019:
• 2,053 enrollees• Incidence 7.9 (95% CI=5.8-12.0) per 100 p/y• 14 untreated, 69 treated early• 81% Fiebig I• Median 4 days since last negative HIV RNA • ART started within median 1 day
cART started in Fiebig stage I blunts peak viremia and preserves CD4 T cells
Dong et al, Lancet HIV, 2018
Participants treated in Fiebig stage I do not seroconvert*
*WB- BioRad GS kit
-500 0 50 10
015
020
025
030
035
050
0
1000
1500
2000
4241403938373635343332313029282726252423222019181716151413121110
987654321
Days after detection of plasma viremia
Acu
te P
ati
en
t N
um
ber
Late-treated
Early-treated
*
#
*
##
Negative
Impact of immediate ART on western blot after detection of AHI
Indeterminate
Positive*#
Fiebig III
Fiebig V
-500 0 50 10
015
020
025
030
035
050
0
1000
1500
2000
4241403938373635343332313029282726252423222019181716151413121110
987654321
Days after detection of plasma viremia
Acu
te P
ati
en
t N
um
ber
Late-treated
Early-treated
*
#
*
##
Negative
Impact of immediate ART on western blot after detection of AHI
Indeterminate
Positive*#
Fiebig III
Fiebig V
-500 0 50 10
015
020
025
030
035
050
0
1000
1500
2000
424140393837363534333231302928272625242322201918171615
1413121110
987654321
Days after detection of plasma viremia
Acu
te P
ati
en
t N
um
ber
Late-treated
Early-treated
*
#
*
##
Negative
Impact of immediate ART on western blot after detection of AHI
Indeterminate
Positive*#
Fiebig III
Fiebig V
Almost all Fiebig I treated individuals developed low magnitude but highly functional HIV-specific CD8+ T cell responses
Treated Untreated0
5
10
15p=0.01
Fre
quency o
f sin
gle
tetr
am
er+
cells
(%of to
tal C
D8+
PB
MC
)
Treated Untreated0
20
40
60
80
100p=0.002
% o
f te
tram
er+
IFN
-g+
HIV
-specific
CD
8+
T c
ells
Frequency of HIV-specific T-cells IFN-γ+ HIV-specific T-cells
Overall, almost all participants who started treatment in Fiebig I developed CTL responses:• 69% by IFN-γ ELISPOT• 80% by tetramer staining• 90% by CFSE proliferation
Ndhlovu et al, Sci Trans Med, 2019
Early cART preserves proliferation of HIV-specific CD4 T cells20180916 Workspace.jo Layout
9/16/18 2:35 PM Page 1 of 1 (FlowJo v9.9.4)
0 102
103
104
105
0
102
103
104
105
5.4
0 102
103
104
105
0
102
103
104
105
21.8
0 102
103
104
105
0
102
103
104
105
15.1
0 102
103
104
105
0
102
103
104
105
24.6
0 102
103
104
105
0
102
103
104
105
3.6
0 102
103
104
105
0
102
103
104
105
0.1
Tx Fiebig I
Untreated
CFSE dilution
Day 28 Day >250
Fiebig
I-II
Fiebig
III-V
Un
-Tx
0
20
40
60
80
% p
rolif
era
ting C
D4
+ T
cells
of th
e tota
l C
D4
+ T
cells
P=0.005
P=0.03
P=NS
Day>250
Fiebig
I-II
Fiebig
III-V
Un
-Tx
0
20
40
60
80
% p
rolif
era
ting C
D4
+ T
cells
of th
e tota
l C
D4
+ T
cells
P=0.05
P=NS P=NS
Day 14-42
20180916 Workspace.jo Layout
9/16/18 2:35 PM Page 1 of 1 (FlowJo v9.9.4)
0 102
103
104
105
0
102
103
104
105
5.4
0 102
103
104
105
0
102
103
104
105
21.8
0 102
103
104
105
0
102
103
104
105
15.1
0 102
103
104
105
0
102
103
104
105
24.6
0 102
103
104
105
0
102
103
104
105
3.6
0 102
103
104
105
0
102
103
104
105
0.1
CD
4
Day 28 Day >250
0 1 4 36 0 1 4 36
0
10
20
30
Weeks from detection
IP-1
0 (
pg
/ml)
Untreated Early-treated
******
***
00.
5 2 4 12 00.
5 2 4 12
0
200
400
600
Weeks from detection
CX
CL
13 (
pg
/ml)
Untreated Early-treated**
********
Treatment in Fiebig stage I abrogates the cytokine* storm
*11 of 11 cytokines with post-infection significant change Muema et al, submitted
0.0
0.2
0.4
0.6
0.8
1.01.0
1.5
Mo
no
cyte
s (
*10
9/L
)
P<0.001 P=0.004
P<0.001
Pre-infection
Fiebig I-II Fiebig III-V Chronic HIV
Acute HIV
0.0
0.1
0.2
0.3
0.4
2
Eo
sin
op
hils (
*10
9/L
)
P=0.003
P<0.001
P=0.009 P=0.005
Pre-infection
Fiebig I-II Fiebig III-V Chronic HIV
Acute HIV
HIV infection is associated with immune cell subset changes even in FiebigI treated participants
• Eosinophils, basophils and neutrophils significantly reduced post-infection
Muema et al, submitted
What about sensitivity of transmitted/founder virus to bNAbs?
V1V2 (glycan dependent) – PG9, PG16, PGT141-145,
CH01-04, CAP256-VRC26, PGDM1400CD4 binding site
b12, VRC01, 3BNC117, HJ16, NIH45-46, CH31, CH103, 12A12
MPER – 4E10, 2F5,
z13, 10E8
C3/V3 (glycan dependent) –
2G12, PGT128, PGT121,PGT135, 1010-74
Adapted from Burton et al, Science, 2012
gp120-gp41 interface (glycan dependent)
PGT151, 35O22,
CAP248 30.2B
Clonal sequenceSGA sequence
Most env viral sequences are identical indicative of a single transmitted/founder virus
BDA1
A2A2
036
079
186
208
268
267
271
318
0.03
VRC07-523LS and CAP256 show excellent coverage of T/F clade C viruses
T/F Env pseudotyped viruses were assayed in the TZM-BL luciferase assay
T/F virus PGT151 10E8 CAP256.VRC26.08VRC01 PGDM1400 PGT121 3BNC117 10-1074 VRC07-523LS
093 0,06 0,64 0,01 0,59 0,09 <0.005 >10 0,01 0,02
208 0,02 1,31 0,46 >10 0,3 0,04 0,06 0,23 0,13
268 0,03 0,51 >10 >10 9,29 0,06 >10 nd nd
079 0,02 1,4 <0.005 2,18 <0.005 >10 >10 nd nd
318 0,2 0,52 <0.005 0,92 >10 0,02 0,06 <0.005 0,05
036 <0.005 0,91 5,48 0,23 <0.005 <0.005 0,07 <0.005 0.01
271A 0,06 1,05 0,19 0,32 >10 >10 0,55 >10 0,01
271B 0,04 2,43 <0.005 6,37 <0.005 >10 >10 >10 <0.005
267 1,52 0,17 <0.005 1,33 <0.005 0,09 0,14 >10 0,03
186 0,01 0,5 <0.005 0,4 0,01 0,02 0,1 nd nd
198 0,01 0,76 <0.005 0,85 0,02 0,02 0,06 0,06 <0.005
201 2,12 1,72 <0.005 >10 0,08 0,05 >10 0,02 >10
498 >10 5,11 0,16 >10 1,36 >10 >10 >10 0,26
499 >10 0,96 0,95 3,30 0,81 >10 0,67 >10 0,05
559 >10 0,17 0,67 0,55 0,12 >10 >10 >10 <0.005
1388 0.03 >10 0.01 0.9 1.14 0.02 >10 0.02 0.01
1439 0.02 3.39 <0.005 5.01 0.01 >10 0.17 >10 0.02
% Breadth (10ug/ml) 82% 94% 94% 71% 88% 59% 53% 50% 94%
% Breadth (0.1ug/ml) 65% 0% 59% 0% 53% 59% 29% 35% 71%
IC50 Titers (µg/ml)
<0,1 µg/ml
0,9 - 0,1
3,0 - 0,91
10,0 -3,1
>10
nd not done
An opportunity to identify the most effective bNAbs against transmitted/founder viruses
Early treatment blunts peak viral load (HIV RNA) but not peak total HIV DNA
U n t r e a t e d T r e a t e d
1 02
1 03
1 04
1 05
1 06
1 07
1 08
Pe
ak
V
ir
al
Lo
ad
(
co
pi
es
/m
l)
p = 0 . 0 0 3
U n t r e a t e d T r e a t e d
1 0
1 0 0
1 0 0 0
1 0 0 0 0
Pe
ak
T
ot
al
H
IV
D
NA
(c
op
ie
s/1
06
c
el
ls
)
p = 0 . 4
Total cellular DNA Plasma HIV RNA
Early treatment blunts peak viral load (HIV RNA) but not peak total HIV DNA
U n t r e a t e d T r e a t e d
1 02
1 03
1 04
1 05
1 06
1 07
1 08
Pe
ak
V
ir
al
Lo
ad
(
co
pi
es
/m
l)
p = 0 . 0 0 3
U n t r e a t e d T r e a t e d
1 0
1 0 0
1 0 0 0
1 0 0 0 0
Pe
ak
T
ot
al
H
IV
D
NA
(c
op
ie
s/1
06
c
el
ls
)
p = 0 . 4
Total cellular DNA Plasma HIV RNA
Early treatment has much more profound suppression of viral load(HIV RNA) compared to total DNA at 12 months post-infection
Plasma viral load Total DNA reservoir
HIV Gagp24 staining of a LN
tissue from an early treated
subject
19
Gag p24
Nuclei
-500101
102
103
104
105
106
107
108
0 50 100 150 200 250 300 3500
200
400
600
800
1000
1200
1400
1600
1800V
iral lo
ad (
copie
s/m
l)
CD
4 c
ounts
(cells
/µL)
Days since detection
LN excision
Gagp24
Nuclei
BCL-6
Prolonged HIV persistence in lymph nodes despite early treatment
DAPI Nuclei HIV Gagpol RNACD4
HIV RNA persistence in lymph nodes
Baiyegunhi, Mann et al, submitted
Sequence evolution and minor variant populations may shape the reservoir in PBMCs and lymph nodes
Pt 1Pt 2Pt 3
Pl day 0/1 Pl day 0/1 bulkPl day 7Pl day 7 bulkP2 day 14Pl day 14 bulkP3 day 19 bulkLN >1 year bulkPBMC >1 year bulk
Gag SGA, bulk and deep sequencing approaches
Pt 3: No evidence of virus evolution Pt 2: LN sequences identical to T/F minor variant Pt 1: Seq evolution in LN and PBMC
Pt 1
Pl day 0/1 Pl day 0/1 bulkPl day 7Pl day 7 bulkPl day 14Pl day 14 bulkPl day 19 bulkLN >1 year bulkPBMC >1 year bulk
0 100 200 300 400 500
Plasma Day 1
Plasma Day 7
PBMC Day 415
LN Day 403
M – Pt 1
20RLRPGGKKRY20--------L-
76RSLYNTIAVLF76-----I----S
76RSLYNTIAVLF76-----I----S
RY10 (A*30) RY11 (A*30) RY11 (A*30)
Evidence of sequence evolution despite suppressive ART
Conclusions
• Acute HIV infections- novel insights into characteristics of T/F virus, immune responses and reservoir characteristics.
• Early treatment results in incomplete antibody seroconversion, low magnitude but highly functional CD8 T cell immune responses, modulates transcriptional profile of CD8 T cells and abrogates the cytokine storm- more functional responses?
• HIV persists in lymph nodes long after viral suppression in early treated individuals and some patients show evidence of virus evolution on ART
• A unique platform to inform, test and implement HIV prevention and curative strategies
AcknowledgementsHPP/UKZN and AHRI• FRESH study participants• FRESH study team• Krista Dong• Amber Moodley• Zaza Ndhlovu• Kavidha Reddy• Omolara Baiyegunhi• Jaclyn Mann• Jenn Mabuka• Bongiwe Ndlovu• Kamini Gounder• Daniel Muema• Keshni Hiramen• Nasreen Ismael• Denis Chopera
Prince Mshiyeni Hospital• Johann Pansegrouw
Funding
• Bill and Melinda Gates Foundation
• IAVI
• NIH
• South African DST/NRF
• HHMI
• Gilead Sciences, Inc.
• Wellcome Trust
Thai Red Cross/MHRP
• Merlin Robb
• Jintanat Ananworanich
• Eugene Kroon
Harvard/MGH/Ragon
• Bruce Walker
• Douglas Kwon
• Galit Alter
• Mathias Lichterfeld
• Guinevere Lee
• Musie Ghebremichael
• Sam Kazer
• Alex Shalek
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