Patogenesis Del VIH

11th Conference on Retroviruses and Opportunistic Infections
Pathogenesis of HIV Infection CME/CE
Contents of This CME/CE Activity
1. HIV Immunopathogenesis and Correlates of Protection

Michael Lederman, MD
2. Virus and Host Factors in HIV Pathogenesis

Mario Stevenson, PhD
3. Sexual Transmission of HIV

Myron S. Cohen, MD
HIV Immunopathogenesis and Correlates of Protection
Introduction
In the more than 20 years since the recognition of AIDS and HIV, substantial progress has been
made both in understanding the mechanisms of HIV replication and in designing treatment
strategies that have decreased HIV-related mortalities substantially. Nevertheless, the
pathogenesis of immune deficiency in HIV infection is incompletely understood, and the
determinants (as opposed to the correlates) of protection against and endogenous control of
HIV replication are poorly understood. It is clear that an understanding of the determinants of
protection will be critical to the design of prevention strategies, while an understanding of host
determinants of virologic control may help in the design of strategies to suppress HIV
replication.
New Data on HIV Immunopathogenesis
Speelmon and colleagues[1] from the University of Washington in Seattle examined the
susceptibility to HIV replication of CD4+ T cells obtained from exposed HIV-seronegative
persons to support in vitro HIV replication. Although the group as a whole did not show
differential susceptibility to HIV replication, a small number of subjects had cells that were
reproducibly less capable of supporting HIV replication. The mechanisms that underlie these
effects remain to be elucidated.
Very recently, a subset of CD4+ T cells that provide regulatory (inhibitory) function has been
described in both mice and humans. These T regulatory (Treg) CD4+ cells express the alpha
chain of the interleukin (IL)-2 receptor (CD25), although they are distinguishable from the
CD25+ CD4+ T cells that are expanded by treatment with high levels of IL-2. In healthy
conditions, these cells are thought to play key roles in the prevention of autoreactivity; in a
number of infectious diseases, these cells may attenuate the magnitude of immune responses.
Audrey Kinter and colleagues[2] from the National Institutes of Health and Department of Health
and Human Services in Bethesda, Maryland, reported increased numbers of these cells in HIV-
infected persons; by depleting these cells, both the cytokine responses and the proliferation
responses of CD4+ and CD8+ T-cell responses to HIV antigens were enhanced. This
enhancement appeared to be specific for HIV responses and not for responses to Candida.
These findings confirm and extend findings of other groups who have studied this cell
population in HIV disease.[3] Both the genesis of these cells and their role in HIV disease are not
well understood. Do they contribute to the immune deficiency of HIV disease, or does their
presence attenuate the heightened immune activation that is likely central to the pathogenesis
of cell losses in HIV infection?
Is the immunopathogenesis of HIV infection in men and women really different? Although this
question is not easily resolved and is hotly debated, increasing evidence from earlier work and
studies presented at this meeting suggest that differences are likely to exist. Earlier studies
have indicated that women tend to present for HIV care with lower plasma HIV RNA levels, yet
their rates of disease progression appear to be comparable to those experienced by men, and
mortalities have seemed comparable. Garcia de la Hera and colleagues[4] of University Miguel
Hernandez in Alicante, Spain, reported their findings concerning the risk for disease progression
and death among Spanish male and female intravenous-drug users with comparable durations
of known infection. Risk for both AIDS and death was apparently lower in women than in men.
Correction for confounding differences in these groups must be done since most other groups
have not been able to show an enhanced disease risk in men. Another report by Lisgaris and
colleagues[5] of Case Western Reserve University in Cleveland, Ohio, found that, overall, HIV-
infected women experienced opportunistic infections at lower CD4+ cell counts and at higher
levels of HIV replication than did men. If these interesting observations are confirmed
independently in other datasets, then we must ask if CD4+ cells are better helpers on a per-cell
basis, if effector cells are greater in number or activity, or if other nonadaptive defenses are
more active in women -- and why these differences exist.
Two studies examined immune mechanisms in sooty mangabeys, monkeys that are susceptible
to infection with SIV but that do not develop SIV-related immune deficiency. Wang and
colleagues[6] of the New England Regional Primate Research Center, Harvard Medical School,
Southborough, Massachusetts, demonstrated that these animals were capable of recognizing
and generating cytokines in response to SIV peptides. This finding suggests that it is not the
failure of immune recognition (as some had suggested) that protects these animals from the
consequences of SIV infection. Ribeiro and colleagues[7] of University of Oxford, Oxford, United
Kingdom, showed that the turnover of T cells as measured by incorporation of
bromodeoxyuridine was not increased in SIV-infected mangabeys when compared with T-cell
turnover in uninfected animals. This finding strongly supports current concepts in HIV disease
pathogenesis that suggest that immune activation is a critical determinant of the immune
deficiency that is the source of morbidity in HIV infection.
New Data on Anti-HIV Immune Responses: Mechanisms and Viral Control
The determinants of successful survival with HIV infection are poorly understood. Studies of so-
called long-term nonprogressors (LTNPs) may help to identify correlates or determinants of
virologic control. Addo and colleagues[8] from Partners AIDS Research Center, Massachusetts
General Hospital, Boston, Massachusetts, studied a group of 73 LTNPs and found that neither
the breadth nor the magnitude of CD4+ or CD8+ T-cell responses to HIV distinguished these
patients from patients with progressive disease. Of note, LTNPs with very low levels of HIV
replication (viral load < 50 copies/mL) tended to have lesser HIV-specific CD4+ and CD8+ T-cell
responses than did LTNPs with viral loads between 50 and 2000 copies/mL. In these patients
and at this time in the course of disease, it appears that these readouts of immune
responsiveness likely reflect more the consequence of viral replication than the determinants of
its control.
More details on the relationships among host genetics, adaptive immune responses, and
virologic control were provided by Simon Mallal[9] from the Center for Clinical Immunology and
Biomed Statistics at the Royal Perth Hospital, Perth, Australia. Dr. Mallal has been studying
these issues in a large cohort of HIV-infected Australians. A balance between the advantage of
viral evolution to escape peptide binding by class I MHC -- or possibly even intracellular
processing of these sequences -- vs a replicative cost of this mutation have been modeled to
determine the ultimate effect of viral evolution on control of viral replication. At a time when
some vaccine researchers are uncertain about the host determinants of virologic control in HIV
infection, these studies support the importance of peptide recognition by CD8+ T cells in the
control of HIV replication. This approach was proposed as a model to predict the design of HIV
vaccines.
New Data on Immune-Based Therapies
Kinloch and colleagues[10] from the Royal Free and University College Medical School, London,
United Kingdom, presented the results of the QUEST study. This international collaborative trial
included persons who had been recognized very shortly after acute HIV infection and who were
started immediately on a combination antiretroviral regimen. After an average of approximately
2 years of virologic control, 79 patients were randomized to received immunization with ALVAC
VcP1452, ALVAC plus Remune, or placebo. Median CD4+ cell counts in these groups exceeded
700 cells/mcL at the start of immunizations. After the 24-week immunization period, antivirals
were stopped and patients were observed for evidence of virologic rebound. There was no
difference between the 3 groups in the levels of plasma HIV RNA at 24 weeks after treatment
discontinuation or in the timing of virologic rebound. Of note, approximately half of the patients
in each group maintained plasma HIV RNA levels < 10,000 copies/mL and 20% had plasma HIV
RNA levels < 1000 copies/mL. These findings suggest the possibility that early treatment of HIV
infection permits the restoration or retention of the ability to better control HIV replication but that
these immunization strategies were futile in this setting. Of course this study was not designed
to ask the first question, and therefore there was no control group that did not receive antivirals
early in the course of infection. Controlled studies are needed to determine whether
administration of highly active antiretroviral therapy (HAART) early in the course of acute HIV
infection affects subsequent virologic control.
David Cooper and colleagues[11] from the National Centre in HIV Epidemiology and Clinical
Research, Sydney, Australia, reported the results of another smaller vaccine trial that also
studied persons who were treated with HAART shortly after acquisition of HIV infection. After an
average of 4 years of antiviral therapies, 35 persons with controlled HIV replication were
randomized to vaccination with a fowlpox vector containing no HIV sequences, a vector
containing HIV gag/pol sequences, or a vector containing HIV gag/pol and a gene encoding
human interferon gamma. Surprisingly, there was not much difference among the groups in
terms of ELISPOT cell responses or cytolytic responses after vaccination and before treatment
discontinuation, and 10 immunized subjects did not enter the treatment discontinuation phase of
the study. Nonetheless, there was no difference in the degree of virologic control between the
control group and the group immunized with the HIV gag/pol constructs. Still, the subjects
immunized with the HIV gag/pol and human interferon gamma sequences seemed to
experience better control of HIV replication, with average plasma HIV RNA levels about 0.8 log10
lower than levels in the other groups. The absence of detectable immune responses to the
immunization is disappointing, and the responses in the interferon groups are surprising. Does
this represent an effect of interferon alone or of host defenses? And if so, is the effector cell
within the T-cell compartment or a component of the innate immune defense?
Garcia and colleagues[12] of Barcelona University, Barcelona, Spain, presented a final dataset on
a controlled study examining the use of monocyte-derived dendritic cells pulsed with plasma-
derived autologous virus as a therapeutic vaccine strategy in persons with established HIV
infection. Although there were no clinically significant effects on control of HIV replication, there
were tantalizing hints of nominally significant activity, such as a delay in virologic rebound in the
group and an apparent and marginally better control of HIV replication in the vaccinated
subjects. The use of autologous sequences in established infection was an important piece of
this well-designed study, yet this approach was limited by the availability of antigen with which to
pulse the ex vivo matured dendritic cells. It will be very interesting to see whether higher doses
of autologous antigen will provide greater immunogenicity and antiviral activity.
IL-15 is a cytokine that is capable of expanding memory CD8+ T-cell populations in vitro and
enhancing effector function without enhancing HIV replication. Petrovas and colleagues[13] from
Drexel University College of Medicine, Philadelphia, Pennsylvania, reported that IL-15
administered twice weekly for 4 weeks to SIV-infected cynomolgus macaques increased the
proliferation and expansion of CD8+ T cells without affecting levels of SIV replication. No
increases in the frequency of gag-reactive interferon-gamma-producing cells were observed, but
no note was made as to whether the absolute numbers of these cells were increased.
Henry and colleagues[14] from the University of Minnesota, Minneapolis, reported the results of a
pilot study (ACTG 5102) that asked whether intermittent treatment with high doses of IL-2 while
on HAART could prolong the period off antiretroviral therapy after treatment interruption. Using
defined criteria for the resumption of antiretroviral therapies, Dr. Henry's group found that IL-2-
treated patients maintained higher CD4+ cell counts and similar plasma HIV RNA levels after
treatment interruption, and were less likely to "require" treatment reinitiation. Numbers are small
to date, and the study is ongoing. While this strategy may permit longer treatment-free intervals
after IL-2 administration, it should be recognized that irrespective of prolonging the treatment-
free interval in this setting, it remains uncertain as to whether IL-2 administration confers clinical
benefit. Nonetheless, this team has taken an interesting approach to exploring potential utilities
of this strategy and the concept of treatment interruption enhanced by IL-2-mediated CD4+ T-
cell expansion as a means to spare exposure to antiretroviral therapies and their consequences.
Conclusion
We are at an early stage in learning how to harness host mechanisms to treat HIV infection and
its consequences. That said, host-targeted strategies (eg, targeting CD4 and CCR5) will
undoubtedly prove to be clinically useful approaches to attenuating HIV replication. However,
we have only the most limited understanding of the mechanisms that protect persons from
acquisition of HIV infection and only modest understanding of the mechanisms and best
measures of virologic control and immune deterioration. Taken together with our inability (at
least to date) to generate broadly cross-reactive neutralizing antibodies against HIV after
immunization, it is fair to conclude that we are, at this point, far from having an effective
protective vaccine strategy. Likewise, the therapeutic vaccine successes to date have been
modest. In the face of these findings, we must redouble our efforts to understand better the
fundamental determinants of protection from infection, virologic control, and immune
deterioration. This likely means a more detailed examination of innate defenses, intrinsic and
virus-induced mechanisms of cellular activation and turnover, and a broader exploration of novel
approaches to virus neutralization.
References
1. Speelmon E, Desbien A, Livingston-Rosanoff D, McElrath MJ. Diminished CD4+.

Program and abstracts of the 11th Conference on Retroviruses and Opportunistic
Infections; February 8-11, 2004; San Francisco, California. Abstract M215.
2. Kinter A, Hennessey M, Bell A, et al. CD4+CD25+ Regulatory T-like cells suppress HIV-
specific CD4+ and CD8+ T cell immune responses in vitro. Program and abstracts of
the 11th Conference on Retroviruses and Opportunistic Infections; February 8-11, 2004;
San Francisco, California. Abstract M14.
3. Aandahl EM, Michaelsson J, Moretto WJ, Hecht FM, Nixon DF. Human CD4(+) CD25(+)
regulatory T cells control T-cell responses to Human Immunodeficiency Virus and
cytomegalovirus antigens. J Virol. 2004;78:2454-2459.
4. García de la Hera M, Ferreros I, del Amo J, et al. Gender differences in progression to
AIDS and death from HIV seroconversion in a cohort of intravenous drug users from
1986 to 2001. Program and abstracts of the 11th Conference on Retroviruses and
Opportunistic Infections; February 8-11, 2004; San Francisco, California. Abstract 152.
5. Lisgaris M, Rodriguez B, Yadavalli G, et al. AIDS-defining illnesses develop with lower
CD4 cell Counts and higher plasma HIV RNA levels in HIV-infected women than in men.
Infections; February 8-11, 2004; San Francisco, California. Abstract 951.
6. Wang ZC, McClure HM, Kaur A. Th1-type SIV-specific cellular immune responses
targeting structural proteins are consistently detected in naturally SIV-infected Sooty
Mangabeys. Program and abstracts of the 11th Conference on Retroviruses and
7. Ribeiro RM, Di Mascio M, McClure HM, Johnson RP, Kaur A, Perelson AS. Modeling T-
cell labeling with BrdU in SIV-infected sooty mangabeys. Program and abstracts of the
11th Conference on Retroviruses and Opportunistic Infections; February 8-11, 2004;
San Francisco, California. Abstract 129.
8. Addo MM, Rathod A, Draenert R, et al. Immunological and genetic determinants in HIV-
1 controllers and long-term non-progressors. Program and abstracts of the 11th
Conference on Retroviruses and Opportunistic Infections; February 8-11, 2004; San
Francisco, California. Abstract 11.
9. Mallal S. HLA imprinting: implications for selection of vaccine immunogens. Program
and abstracts of the 11th Conference on Retroviruses and Opportunistic Infections;
February 8-11, 2004; San Francisco, California. Abstract 60.
10. Kinloch S, Perrin L, Hoen B, et al. Evaluation of 2 therapeutic HIV vaccination regimens
in HAART-treated primary HIV infection subjects following analytical treatment
interruption: QUEST PROB3005, a randomized, placebo-controlled study. Program and
abstracts of the 11th Conference on Retroviruses and Opportunistic Infections;
11. Cooper D, Workman C, Puls R, et al. Randomized, placebo-controlled, phase1/2a
evaluation of the safety, biological activity and antiretroviral properties of an avipox virus
vaccine expressing HIV gag-pol and interferon-gamma in HIV-1 infected subjects.
12. Garcia F, Lejeune M, Climent N, et al. Final results of a phase I study of a therapeutic
vaccine using autologous dendritic cells primed with autologous virus in patients with
chronic HIV infection and CD4 T cells above 400/mm3. Program and abstracts of the
13. Petrovas C, Mueller YM, Bojczuk P, et al. IL-15 treatment of SIV-infected non-human
primates. Program and abstracts of the 11th Conference on Retroviruses and
14. Henry K, Tebas P, Cherng D, et al. Interleukin-2 prior to stopping effective antiretroviral
therapy prolongs time off treatment: initial results of a pilot study utilizing CD4+ T-cell
count <350 cells/mm3 as the threshold for restarting ART (ACTG A5102). Program and
Virus and Host Factors in HIV Pathogenesis
Pathogenic primate lentivirus infections are characterized by progressive loss of immune

function, a heightened state of immune activation, and high-level viral replication. In contrast, in
naturally infected African green monkeys, SIV infection is characterized by high viral loads, but
there is no apparent loss of immune function nor any evidence of immune system
hyperactivation. This has led to the proposal that what distinguishes pathogenic and
nonpathogenic primate lentivirus infections is the degree of immune activation, and that it is this,
rather than overt viral replication, that creates conditions for pathogenicity. However, the viral
and cellular effectors that contribute to immune activation in pathogenic HIV infection have not
been clearly elucidated.
Presentations at the 11th CROI may provide some clues as to how HIV infection induces a
chronic state of immune activation. The process of T-cell activation is suppressed by a
CD4+/CD25+ T-cell subset, also known as Treg cells. It is known that Treg cells express CD4.
Therefore, one study examined whether Treg cells were potential targets for HIV infection.[1] The
study demonstrated that Treg cells obtained from healthy seronegative individuals as well as T
cells induced to a Treg phenotype in vitro were highly susceptible to HIV infection. This supports
the notion that the infection and destruction of the Treg cell subset in HIV infection may remove
the normal control mechanisms that regulate T-cell activation, and as such, contribute to the
chronic activation state of T cells that is characteristic of pathogenic HIV infection.
Continuing in this vein, another study indicated that the difference between pathogenic and
nonpathogenic infections may relate to target-cell availability, which might affect the distribution
of viral reservoirs.[2] In pathogenic SIV infections, the gastrointestinal tract is the major site of
viral replication and lymphocyte depletion. In this reservoir, the major target cells are CD4+,
CCR5+, and CD45RA-. Therefore, the phenotype of lymphocytes from the peripheral blood and
intestinal and lymph node biopsies were examined in African green monkeys (which did not
exhibit pathogenic manifestations of SIV infection) and rhesus macaques (which do show
pathogenic manifestations of SIV infection). The study authors observed low levels of CD4+,
CCR5+, and CD45RA- cells in all compartments of African green monkeys compared with
rhesus macaques. The authors proposed that the limited availability of target cells in tissues
such as the intestine may contribute to the diminished immune responses and lack of disease
progression in this natural host. This generates a paradox because the African green monkey
still supports levels of viral replication that parallel those in pathogenic infections of rhesus
macaques, and raises questions regarding the major source of viral replication in these different
models.
In contrast to the well-characterized T-cell defects observed in HIV infection, B-cell dysfunction
-- wherein B cells undergo activation-induced terminal differentiation into a plasma cell-like
morphology -- remains a poorly explained feature of HIV pathogenesis. The same is true for the
hypergammaglobulinemia that accompanies it. Essentially, the underlying basis for the B-cell
defects in AIDS is not well understood. One study presented at the conference made a
comparison of gene-expression profiles of B cells from HIV-viremic patients and B cells from
aviremic and seronegative patients.[3] Of more than 40 genes that were found to be upregulated
in the B cells of the former group, several were associated with B-cell terminal differentiation as
well as members of the tumor necrosis factor (TNF) superfamily of receptors that regulate
apoptosis. The study authors concluded that HIV replication may trigger increased expression of
TNF superfamily receptors, making them susceptible to, for example, Fas-mediated cell death.
The mechanism through which HIV infection actually causes the changes in B-cell phenotype
awaits elucidation.
Viral Reservoirs, Replication, and Rebound
In vivo, depending upon the activation state of the cell, CD4+ T lymphocytes exhibit profound
qualitative and quantitative differences with respect to the sequelae of infection by HIV. In fully
activated lymphocytes, HIV replication is rapid and efficient and invariably leads to the death of
the infected cell. At the opposite end of the spectrum, quiescent T cells in the G0 stage of the
cell cycle harbor HIV-1 in a latent or dormant state. When that cell subsequently becomes
activated, the latent virus is activated along with it, and efficient viral replication resumes. The
ability of the virus to reside in a latent state in quiescent T cells has been proposed to be the
main obstacle to viral eradication by highly active antiretroviral therapy (HAART). A long-
standing paradox regards the mechanism through which the latently infected cell is first
established. Since quiescent lymphocytes are refractory to viral infection due to blocks early in
the viral life cycle, it has been proposed that the precursor to the latently infected cell is a
cycling cell that allows HIV entry and subsequently returns to a quiescent state after the virus is
established.
One study suggested that HIV can, in fact, establish infection in a quiescent cell and directly
enter a state of latency.[4] In their presentation, the investigators used a procedure, known as
spinoculation, in which virus-cell contact is promoted by centrifugal force, thereby increasing the
efficiency of infection. Under those conditions, the viral genome could be detected in
approximately 10% of the quiescent T cells. This observation is at odds with a number of studies
suggesting that quiescent lymphocytes do not allow the virus to establish an integrated state.
One possibility is that the spinoculation acted as a subtle stimulus which induced the
lymphocytes to enter an early stage of cell cycle; this would be consistent with the results of
other studies that have shown that lymphocytes in the G1 phase of the cell cycle and beyond
are permissive of HIV infection and integration. Nevertheless, should it be confirmed that the
infection was established in a truly quiescent cell, this has important implications for
understanding the source of latent viral reservoirs in HIV-infected individuals.
Another study attempted to distinguish the origin of virus in the context of viral rebounds
following treatment interruption.[5] Although HAART is very effective at suppressing viral
replication to below the level of detection (based on plasma viral RNA measurements), viral
replication rapidly rebounds when therapy is interrupted irrespective of the period of
suppression. The prevailing view is that the rebound virus originates from the latent reservoir.
However, other lines of evidence, such as continued viral evolution and the presence of
replication intermediates in well-suppressed patients, raises the possibility that viral replication
may persist in the face of apparently suppressive therapy. The study authors characterized
transcription patterns in order to distinguish ongoing replication in patients with high-level
replication, patients on HAART, and patients who underwent structured treatment interruptions.
Genotypically, extracellular virus was highly comparable with viruses obtained from lymph
nodes, implying that viruses are produced and sequestered locally. Furthermore, the identity of
the rebound virus was consistent with the notion that viral rebound is due to random activation
of latently infected cells, rather than ongoing, low-level replication.
HIV:Cell Interactions in the Viral Replication Cycle
Arguably, the major research theme of the conference related to the cellular forces that favor or
oppose viral replication. Primate lentiviruses such as HIV-1 have a limited armamentarium of
genes and encoded proteins with which to carry out various aspects of their replication cycle.
Therefore, it is not surprising that these viruses exploit cellular proteins in order to carry out their
respective replicative functions. Perhaps the greatest progress in terms of understanding how
cellular factors promote viral replication relates to cofactors for late steps in viral replication,
specifically virus release. The final step in the viral replication cycle is the physical detachment
of assembled virions from the surface of the infected cell, which is characteristic of type C
lentiviruses. The closest parallel to this process is the formation of multivesicular bodies (MVB)
in which membranes bud into cytoplasmic vesicles. It is now apparent that cellular proteins
which govern MVB formation also control the process of virus detachment. Several of these
proteins have now been identified and were discussed at the conference.[6-8] The proteins
identified to date belong to a family of Class E Vps proteins that have well-orchestrated roles in
formation of the MVB. These cellular proteins are recruited to sites of virus assembly through
their interaction with the structural Gag protein in the virus. It is speculated that they assist in
promoting curvature of the plasma membrane in order to wrap around structural virion proteins
during the viral budding and detachment processes.
Although, as is typical with type C lentiviruses, viruses assemble at and detach from the plasma
membrane, there are instances in which viruses assemble within cytoplasmic vacuoles of
infected macrophages. Recent studies have indicated that these cytoplasmic vesicles are, in
fact, MVBs. This unusual pattern of virus assembly can thus be reconciled with research
demonstrating that the machinery of MVB formation is exploited for HIV budding. The open
question is why virus budding is intracellular in macrophages, but extracellular in T cells. One
possibility is that the ability to bud into MVBs, which ultimately exocytose their contents after
cell/cell contact, facilitates dissemination of the virus between cells. Support of this theory was
seen in 2 presentations that indicated that viruses assemble within MVBs and MVBs are
subsequently localized to the cell surface at the point of contact between the infected cell and
the neighboring T cell.[9,10]
In the case of dendritic cells, it was demonstrated that extracellular viral particles could be
internalized into the MVB and then shunted to contact points between the dendritic cell and T
cell.[9] This is likely to provide a highly efficient mechanism for the transfer of virus particles onto
new substrate T cells. It is important to note that the virus-containing vesicles did not contain
markers characteristic of early and late endosomes, and as such are unlikely to undergo
acidification. This further suggests that these compartments may retain the virus in a stable and
infectious form. In macrophages, evidence was presented to suggest that the MVB is the
exclusive pathway for the assembly of virus and release into extracellular fluids.[10] During virus
budding and detachment, the viral membrane exhibits the same composition as the cellular
membrane from which it detached. Therefore, the viral membrane will also contain membrane
proteins common to the cellular membrane from which it originated. When the composition of
membrane proteins in viruses released from infected macrophages was analyzed, the
membrane proteins were found to be compositionally very similar to the membranes of the
MVB. Therefore, in cells such as macrophages, there is likely to be a dynamic and continuous
process of virus budding into the MVB and movement of the MVB to the plasma membrane
where MVB contents (such as virus particles) are subsequently released.
While these studies are provocative, it is too early to gauge their roles in viral persistence and
dissemination. However, if one is to speculate, it is possible that virus particles contained within
MVBs of macrophages or dendritic cells are specifically channeled to sites of contact with
neighboring T cells. This may be the favored route of viral dissemination, as opposed to the
random release of virions into the extracellular space and chance encounters with new
substrate T cells. Therefore, the immunologic synapse that occurs between an antigen-
presenting cell and a T cell may present a highly favorable environment for viral dissemination.
It is important to determine whether MVBs actually represent a stable reservoir for viral
persistence. If, as was suggested at the conference, virus-containing MVBs do not undergo
acidification, then this may represent a stable compartment for virus sequestration and as such
may provide a sanctuary site for infectious virus particles.
Although conflicting results were represented, 2 studies described another potential positive-
acting factor for HIV replication that acts at an early stage in viral replication cycle, namely at the
point of viral DNA integration.[11,12] When lentiviruses infect cells, they must synthesize their cDNA
and translocate this cDNA to the vicinity of cellular DNA where it integrates to form a provirus.
However, very little is known about the mechanisms governing the nuclear translocation of viral
cDNA or the viral and cellular factors that control it. The 2 presentations focused on a cellular
factor called lens epithelium-derived growth factor (LEDGF), which was found to form a specific
interaction with the viral integrase protein, an enzyme that catalyzes the integration of viral
cDNA with the host cell DNA. LEDGF was shown to govern the ability of the integrase protein to
localize to the nucleus. The level of expression of LEDGF in the cell was reduced using RNA
interference, and the susceptibility of those cells to infection was monitored. In one study, the
ability of the virus to integrate within cellular DNA was blocked when LEDGF was absent, while
in the other study, there was no effect. While additional work is needed to confirm the exact
importance of LEDGF in viral replication, these findings nonetheless point to a potentially new
cofactor that regulates a preintegration step in viral replication. These studies illustrate the fact
that with the advent of RNA interference, it is now possible to validate the importance of cellular
cofactors in virus biology. This will be an invaluable tool to further dissect virus-host cell
interactions that could represent future targets for drug discovery.
Cellular Antiviral Factors and Effects
While it is clear that a number of cellular proteins are positive factors for viral replication, it is
now apparent that there are cellular proteins that oppose viral infection. Research into host
defense mechanisms that counteract the replication of viruses such as HIV has focused on the
role of the humoral and cellular arms of the immune response. However, the discovery
approximately a year and a half ago, of a cellular protein called APOBEC 3G that counteracts
viral infection, has highlighted the existence of far more potent and specific defense
mechanisms that are mounted by the cell to protect itself from virus infection. APOBEC 3G is
the cellular target of the viral protein Vif, which is essential for viral replication in primary cells
such as lymphocytes and macrophages. Many presentations shed light on the mechanism by
which APOBEC 3G blocks viral replication and strategies used by the virus to counteract this
block.[13-18]
APOBEC 3G inhibits viral replications by inducing extensive deamination of cDNA as it is being

synthesized by reverse transcription. This deamination of deoxycytidine to deoxyuridine likely
promotes the degradation of the viral cDNA in the cell. It should be emphasized that this is a
very potent mechanism of viral inactivation and in fact, the antiviral activity of APOBEC 3G does
not appear to be restricted to viruses such as HIV. It also works with diverse viruses such as
hepatitis virus. Obviously, in order to establish infection in humans, HIV has come up with a way
to counteract APOBEC 3G. This is where the viral Vif protein comes in, and evidence presented
at the conference indicated that the virus uses its Vif protein to drag APOBEC 3G to the
proteosome in order to affect its degradation. This, of course, relies on the ability of Vif to
interact directly or indirectly with APOBEC 3G. It now appears that the interaction of Vif with
APOBEC 3G is species-specific. While some SIV Vif proteins interact with human APOBEC 3G,
others do not. This illustrates the fact that HIV is a zoonosis, and that the SIV ancestor to HIV
during its introduction into the human population had to evolve its Vif protein in order to interact
with the human APOBEC 3G. Therefore, the goal for the field is to find ways to block the
interaction of Vif with APOBEC 3G, using, for example, small-molecule inhibitors, thereby
rendering the host nonpermissive to viral replication.
It is also apparent that there are many new cellular resistance factors awaiting discovery. One
such factor, termed Lv1 (the identity of the actual factor is as yet unknown), protects cells such
as those from owl monkeys from HIV infection. This factor appears to act very early in the
replication cycle by targeting the Gag protein and preventing efficient reverse transcription of
viral cDNA. Studies are beginning to shed light on how these additional Gag-targeted restriction
factors operate and how viruses such as HIV may counteract them.[19-21] Cyclophilin A is a cellular
protein that was found to interact with HIV-1 Gag and promote viral infectivity. It now appears
that cyclophilin A may regulate the susceptibility of the virus to restriction factors such as Lv1.
While owl monkey cells are resistant to HIV infection because of Lv1 restriction, treating the
cells with drugs such as cyclosporin A, which blocks the interaction of cyclophilin with the viral
capsid, markedly augments HIV infection. In contrast, when interaction of cyclophilin A with
capsid is blocked in human cells, HIV infectivity is reduced. Therefore, strategies to manipulate
the virus' ability to interact with cyclophilin may restore the antiviral activities of these
endogenous restriction factors. There is likely to be a great deal of research activity in this area
in the next several years.
References
1. Oswald-Richter K, Grill SM, Shariat N, et al. HIV infection of naturally occurring and
genetically reprogrammed human regulatory T cells. Program and abstracts of the 11th
Francisco, California. Abstract 124LB.
2. Pandrea I, Apetrei C, Dufour J, et al. Lack of SIV target cells in African non-human
primate: host or virus adaptation? Program and abstracts of the 11th Conference on
Retroviruses and Opportunistic Infections; February 8-11, 2004; San Francisco,
California. Abstract 417.
3. Moir S, Malaspina A, Donoghue E, et al. Decreased survival of B cells of HIV-viremic
patients mediated by altered expression of receptors of the TNF superfamily. Program
4. O'Doherty U, Baytop C, Yu J, Swiggard W. De Novo latent infection of quiescent CD4+ T
cells in the absence of exogenous stimuli. Program and abstracts of the 11th
Francisco, California. Abstract 123LB.
5. Fischer M, Joos B, Wong JK, et al. The presence of extracellular virion-associated HIV-
RNA in lymphoid tissue reflects local productive infection: a detailed analysis of
lymphatic HIV transcription patterns in vivo. Program and abstracts of the 11th
6. Sundquist WI. Cellular factors and HIV budding. Program and abstracts of the 11th
7. Strack B, Calistri A, Popova E, Craig S, Gottlinger H. AIP1 and ESCRT-III are
components of the HIV-1 budding machinery. Program and abstracts of the 11th
8. Ono A, Freed EO. Cell-type-specific targeting of HIV-1 gag: evidence of a role for PIP2.
9. McDonald D, Hope TJ. Enhancement of HIV infection by activated dendritic cells occurs
via trafficking through a CD81 enriched compartment. Program and abstracts of the
10. Marsh M, Pelchen-Matthews A, Kramer B, et al. HIV assembly in, and release from,
primary macrophages. Program and abstracts of the 11th Conference on Retroviruses
and Opportunistic Infections; February 8-11, 2004; San Francisco, California. Abstract
46.
11. Debyser Z, Emiliani S, Van Maele B, et al. Characterization of the role of LEDGF during
HIV replication. Program and abstracts of the 11th Conference on Retroviruses and
12. Marnett A, Nomura A, Shimba N, et al. Communication between the spatially separate
active site and dimer interface of KSHV protease revealed by small molecule inhibition.
13. Neuberger M. DNA editing and host resistance factors. Program and abstracts of the
14. Mehle A, Strack B, Ancuta P, Gabuzda D. HIV-1 vif overcomes the innate antiviral
activity of APOBEC3G by promoting its degradation in the ubiquitin-proteasome
pathway. Program and abstracts of the 11th Conference on Retroviruses and
15. Yu Q, Konig R, Pillai S, et al. Characterization of mutations generated by APOBEC3G
on HIV-1 DNA. Program and abstracts of the 11th Conference on Retroviruses and
16. Landau NR. HIV vif: deactivation of a deadly deaminase. Program and abstracts of the
17. Kobayashi M, Takaori-Kondo A, Shindo K, et al. Species-specific target specificity of
APOBEC3G. Program and abstracts of the 11th Conference on Retroviruses and
18. Doehle B, Bogerd H, Wiegand H, Cullen B. A single amino acid change controls the
ability of HIV-1 vif to discriminate between human and African green monkey
APOBEC3G. Program and abstracts of the 11th Conference on Retroviruses and
19. Towers GJ. Host factors controlling species-specific replication of lentiviruses. Program
20. Hatziioannou T, Cowan S, Bieniasz PD. Mapping the restriction determinants in HIV-1
capsid and defining the role of cyclophilin A in restriction. Program and abstracts of the
21. Bobardt M, Saphire A, Gallay P. Natural resistance of HIV-1 primary isolates to ref1.
Sexual Transmission of HIV
Myron S. Cohen, MD
Introduction
Sexual transmission of HIV is dependent upon a multitude of interrelating viral, source, and host
factors that affect the efficiency of transmission. The infectiousness of the source partner's virus
is the clearest determinant of whether HIV is transmitted. Infectiousness of HIV appears to
depend primarily on the concentration of HIV in relevant body fluids (eg, semen, cervicovaginal
secretions).[1,2] Further, multiple lines of evidence support a positive correlation between plasma
viral load and HIV transmission.[3] In this regard, it is important to note that several lines of
evidence suggest that antiretroviral therapy can reduce sexual transmission of HIV by reducing
excretion of HIV in semen and female genital secretions -- an effect which is to some extent
related to the ability of individual antiviral agents to achieve suppressive concentrations in
genital secretions.[4-10]
Susceptibility of the exposed partner is the other major determinant of HIV transmission.
Susceptibility to HIV infection depends on the availability of appropriate receptive cells; local
replication of the virus; and hereditary, innate, and acquired resistance to infection. Cells
concomitantly expressing CCR5, CD4 receptors, and DC-SIGN (a dendritic cell [DC]-specific
HIV-1-binding protein that enhances transinfection of T cells) are most likely to be infected.[11]
However, not all people are equally susceptible to HIV infection. For example, approximately 1
of 100 white persons has a deletion in a portion of the CCR5 receptor, which has been found to
exert a considerable genetic resistance to HIV infection.[12] Susceptibility to HIV infection also
depends on a variety of microenvironmental factors. For example, bacterial vaginosis has been
associated with increased risk of HIV acquisition.[13]
The biology of transmission of HIV has been extensively and recently reviewed on Medscape
HIV/AIDS [http://www.medscape.com/viewprogram/2671]. The purpose of this review is to
provide an update on new information presented in the symposia, oral sessions, and posters of
the 11th Conference on Retroviruses and Opportunistic Infections.
Shedding of HIV in the Genital Tract
Sexual transmission of HIV is closely associated with the concentration of the virus in the genital
tract of the infecting partner. S. Pillai[14] of University of California, San Diego, presented
analyses of envelope sequences from blood and semen isolates derived from 12 patients.
Relative to blood HIV variants, less viral diversity was observed in semen variants, with a slower
rate of molecular evolution, and reduced potential for CXCR4 usage. The degree of HIV
glycosylation in semen and blood HIV is similar, but glycosylation sites were different.
Another study was designed to examine populations of virus in semen that persist during
therapy with a new nonnucleoside reverse transcriptase inhibitor (DM266I) and indinavir.[15] HIV
mRNA was harvested from mononuclear cells in blood and semen. Resistance mutations were
not observed, but reduced divergence after therapy in the envelope sequences suggested
considerable restriction during replication. Different mutations were observed in semen and
blood cells.
In a rather remarkable piece of work by R Coombs and colleagues[16] of the University of

Washington, Seattle, the investigators recruited 15 men who provided samples from -- in order
-- a urethral swab, first-void urine, prostate massage secretions, postmassage urine, and 6
prostate biopsies. Materials were studied for HIV-1 RNA concentration and (in the case of
biopsies) HIV-1 DNA. Five men were receiving antiretroviral therapy. The results suggest that
HIV in the urethral secretions and (likely) in semen are derived from the prostrate as well as the
urethral glands distal to the prostate.
S.T. Sadiq of the Royal Free and University College Medical School, London, United Kingdom,
and colleagues[17] measured HIV concentrations in the semen of 20 men before and after
antibiotic therapy for urethritis. Men with gonococcal and chlamydial urethritis, but not
nonspecific urethritis, had increased concentrations of HIV-1 RNA in semen relative to 35
control subjects; decreased excretion of HIV was observed after appropriate antibiotic therapy in
men with gonorrhea and chlamydia. Blood plasma HIV-1 RNA levels were not affected. The
absolute concentrations of HIV-1 RNA in semen were lower than those previously reported from
Africa.
Far less is known about shedding of HIV in the female genital tract, in part because of the
difficulty in collecting specimens in a reliable and reproducible way, without disrupting the
mucosa. M. Nowicki and coworkers[18] from the University of Southern California, Los Angeles,
measured HIV concentrations in oral and cervicovaginal lavage (CVL) secretions of 102 women.
HIV-1 RNA was detectable in 30% of oral secretions and 56% of CVL samples. Perhaps not
surprising, HIV-1 RNA concentrations were higher in the pellets derived from CVL than in the
whole (diluted) secretions.
S. Cu-Uvin[19] of Brown University in Providence, Rhode Island, and coinvestigators looked at

HIV-1 RNA levels in blood and the female genital tract over 36 months. Ninety-seven women
provided 530 paired plasma and CVL samples. At each visit, CVL HIV levels were lower than
blood plasma, but levels in the 2 compartments were associated; for example, among women
on antiretroviral therapy, HIV-1 RNA was only detected in CVL samples during blood plasma
breakthrough.
B. Sha of Rush University Medical Center in Chicago, Illinois, and colleagues[20] examined the
relationship between bacterial vaginosis (BV) and genital tract viral shedding. Of 406 samples
from 362 women, 203 had evidence of BV using a variety of techniques, including PCR. Median
HIV-1 RNA levels in blood and genital tract samples from women with BV were 4.58 and 2.88
log10 copies/mL, respectively, compared with 4.57 and 2.52 log10 copies/mL in women without
BV. CD4+ cell counts were comparable in these women. The investigators concluded that BV
flora increased HIV shedding, after correction for the plasma viral load. In addition, genital tract
infection with Candida (n = 89) and Trichomonas (n = 41) was also associated with increased
HIV shedding.
The results of a study designed to compare resistance mutations in blood and plasma HIV
isolates were presented by J. Mullen[21] of Guy 's, King 's, St. Thomas' School of Medicine in
London. Twenty-six pregnant and 15 nonpregnant women were included. As seen in other
studies, 94% of women had more HIV in blood plasma than in cervicovaginal secretions. Paired
samples sufficient for genetic analysis were recovered from 13 women. HIV-1 subtypes were
the same in both compartments. Phylogenetic analysis indicated genetic diversity between
compartments, however. Antiretroviral drug resistance reflecting past history of therapy was
observed in 3 women, and genotypes from blood and genital tract-derived virus were discordant
in 1 of 3 women.
The results of these numerous studies compliment a considerable body of literature regarding
HIV in semen, and more limited information about HIV in the female genital tract. HIV in semen
represents a heterogeneous population of HIV derived from replication by seminal cells and of
HIV from the blood, prostate, and urethral glands. The source of HIV in the female genital tract
is less well understood. Differences in concentration and genetic composition of HIV in blood
and genital secretions can be expected. Local inflammation produced by some (but not all)
sexually transmitted diseases can be expected to (reversibly) increase the concentration of HIV
in genital secretions. The selective pressures that lead to viral diversity in the genital tract
require continued study because it is the genital tract -- and not blood -- variants that will
ultimately be transmitted to the susceptible host.
Dendritic Cells, HIV Transmission, and Selection of CCR5 Variants
HIV in the genital tract must overcome all innate and acquired mucosal resistances and find a
susceptible host cell to infect. It remains unclear as to whether HIV is transmitted by cell-free
virus (as is used routinely in the macaque model) or by infected genital tract cells. The first cell
infected could be a macrophage, a dendritic cell (DC), a lymphocyte, or even a membranous
epithelial cell (M cell), although the most compelling evidence focuses on the phagocytes.
Increasingly, DCs are believed to play a critical role in the transfer of HIV to susceptible
lymphocytes, leading to HIV expansion, dissemination, and established infection. The tight
junction between cells involved in transfer may represent an "immunologic/infectious synapse,"
a popular neologism.
C-type lectin receptors (eg, DC-SIGN) facilitate HIV binding to and endosomal uptake by DCs.
Within the endosome, acid proteolytic degradation destroys some viruses, whereas others,
including CCR5-tropic viruses, remain viable, replicate, and are ultimately transferred to
susceptible T cells. A.L. Cunningham and colleagues[22] of the Centre for Virus Research in
Westmead, Australia, presented data which suggest that HIV is transferred in 2 distinct phases:
In phase 1 (ie, in the first 24 hours) HIV escapes/avoids the endolysosomal degradation and is
transferred to the DC-T-lymphocyte synapse, whereas in phase 2, HIV produced by low-level
replication within the DC is transmitted. The investigators argue that de novo CCR5-tropic
viruses may be selected in this second phase.
D. McDonald and T.J. Hope[23] of the University of Illinois, Chicago, were less sanguine about
HIV replication actually occurring within DCs, and focused on the transfer itself. They found that
lipopolysaccharide-activated DCs were best at capturing HIV and recruiting susceptible T cells.
Based on their experiments, they proposed that HIV is sequestered in multivesicular bodies
within DCs, sites normally reserved for the sequestration of intact antigens. They observed
concentrations of HIV colocalized with surface markers (CD63, CD9, DC-SIGN, HLA-DR, CD86,
and especially CD81), perhaps marking the site of transfer of HIV from DCs to lymphocytes.
The selection of CCR5-tropic HIV variants in primary infection has not been explained. In a
study presented by N. Gonzalez[24] of the Institut de Salud Carlos III in Madrid, Spain, replication
of CCR5 viruses in lymphocytes was increased 20-fold when DCs were included in the system.
This enhancement depended on the presence of DC-SIGN on DCs, as this receptor facilitates
transfer of HIV to lymphocytes. Conversely, addition of DCs decreased replication of CRCX4-
tropic HIV variants. Addition of antibodies targeting the chemokine SDF-1 (stromal cell-derived
factor-1), a natural ligand of the CRCX4 receptor, improved replication of CRCX4-tropic viruses
in this model, suggesting that SDF-1 expression by DCs represents an inhibitory antiviral
mechanism that blocks replication of CRCX4-tropic HIV variants, but not CCR5-tropic viruses.
In a study presented by M. Cavrois[25] of the Gladstone Institute of Virology and Immunology,

San Francisco, California, peripheral blood monocytes were put into culture, differentiated into
DCs (with Iinterleukin-4 and granulocyte macrophage colony-stimulating factor), and forced to
maturation with tumor necrosis factor-alpha and polyinosinic-polycytidylic acid (poly IC).
Immature DCs were found to preferentially bind to CCR5. Another group from Gladstone
compared the replication of CCR5- and CRCX4-tropic viruses in CD4+ cells.[26] After 7 days in
culture, CD4+ cells growing CRCX4 variants underwent cell death, whereas CCR5-tropic virus
replicated persistently at lower levels. In experiments conducted by S. Aquaro of the University
of Rome, Tor Vergato, Italy, and colleagues,[27] peripheral blood monocytes were incubated with
either CRCX4 or CCR5-tropic HIV. Infection of theses cells by CRCX4 viruses was abortive,
leading to increased macrophage apoptosis, whereas replication of CCR5 viruses was
sustained. Microarray analysis of macrophage gene expression demonstrated that CRCX4
variants induced proapoptotic gene expression, whereas CCR5 viruses did not.
These findings and other current evidence add to a compelling picture of initial HIV infection, in
which macrophages and DCs become infected through a combination of receptor (CCR5 and
CD4) and C-type lectin usage (DC-SIGN). Some HIV is endocytosed and destroyed in
endolysosomes while other viruses are permitted to replicate. CRCX4-tropic HIV appears to be
too toxic to monocytes and lymphocytes to survive, thus allowing for selection of CCR5-tropic
variants. Thus, CCR5-tropic HIV can cause persistent infection of CD4+ lymphocytes after they
come into close contact with infected DCs. Using this information to design novel prevention
strategies is the next great challenge.
Primary Infection: Diversity and Resistance
The study of viruses recovered from people with acute infection (ie, antibody-negative, RNA-
positive) and early infection (ie, symptomatic, antibody-positive) provides crucial information
about selective pressure and fitness. Selection of CCR5-tropic viruses has already been
reviewed, but other parameters have been examined. For example, drug resistance in HIV
recovered from untreated people indicates that drug-resistant virus has been transmitted.
Increasing resistance in drug-naive patients has attracted great attention because it emphasizes
the fragility of the antiretroviral drug arsenal currently available for therapy. In addition,
examinations of viral genetic diversity can provide insights about the degree or specifics of viral
fitness required for transmission.
J-P Routy and colleagues[28] at McGill University in Montreal, Quebec, Canada, compared
genetic analyses of HIV harvested from 585 chronically infected people with isolates from 182
recently infected patients. HIV recovered from patients with established infection had more
mutations per patient, and more patients had resistant variants. The prevalence of mutations
V1181, M184V, and K103N increased from 3% to 26%, 56% to 68%, and 14% to 33%,
respectively. Protease inhibitor mutations were found to remain stable over time. However, a
decrease has been observed in primary HIV drug resistance: from 13.4% (1996-2000) to 3.6%
(2001-2003). The prevalence of M184V and D30N is 5 times greater in patients with established
infection compared with those with recent infection. The study authors ascribed decreased de
novo resistance to reduced concentrations of HIV in blood of patients who harbor mutants (0.7-
0.8 log10 copies/mL) compared with wild-type. Similarly, in a separate study, newly infected
patients (n = 100) were identified in Amsterdam, The Netherlands, between 1994 and 2002.[29]
During the first 5 years of the study, de novo resistance was observed in 21% of subjects
compared with 6% in the past 5 years.
Ten subjects with recent HIV infection (mean, 50 days) transmitted by a total of 8 sexual
partners (donor partners) were studied.[30] All subjects had clade B infection. Three donor
subjects with drug resistance detected in blood plasma transmitted HIV to 4 partners. Genetic
divergence between donor and partners was less than 2%. Fewer glycosylation sites were
observed in the recipients than in the source partners, while HIV env sequences were either the
same length or shorter in the recipient. Neutralizing antibody responses were weak, and virus
from donors and recipients was resistant to polyclonal and monoclonal antibodies.
Diversity in the V1/V2 and V3 variable regions of HIV env was studied in 109 subjects with early
infection by K. Ritola of University of North Carolina, Chapel Hill, and colleagues.[31] Among
women who acquired HIV, 4 of 7 had multiple V1/V2 variants compared with 6 of 7 men who
had a single variant. However, 53% of men who acquired HIV through anal intercourse had
diverse V1/V2 variants. Eighty-three percent of subjects had a single V3 variant. Ninety-seven
percent of subjects were infected with CCR5 variants.
The changes observed in the prevalence of drug resistance among newly infected patients must
reflect the effects of antiretroviral therapy within the population. First, therapy that completely
suppresses HIV likely eliminates transmission, so mutations related to the most potent drugs will
only rarely be observed. Second, antiretroviral therapy that incompletely suppresses viral load in
the genital tract might reduce the efficiency of transmission, but allow detection of mutations
associated with such therapy. Third, some HIV mutants might not be fit for transfer. This latter
explanation might help to account for differences in HIV env in patients with primary infection,
an area that will receive far more attention in the future. Understanding viral characteristics
required to establish infection is required for the development of effective prevention strategies.
Microbicides for the Prevention of Sexual Transmission of HIV
Microbicides have become a "cause célèbre" in HIV prevention. This topic was emphasized in a
passionate lecture in the Opening Ceremony by Stephen H. Lewis,[32] the United Nations Special
Envoy for HIV/AIDS in Africa, in the opening plenary talk Dr. Robin Shattock[33] of St. George's
Hospital Medical School in London, and in both a poster session (#121) and a microbicide
symposium (Session 30). The microbicide symposium included 3 lectures, which are reviewed
here.
In order to identify the first-line coreceptors used by HIV to attach to and infect cells of the
cervix, H. Qu, from St. George's Hospital Medical School, and colleagues[34] used a variety of
methods to block the entry and "spread" of HIV-1 strains into an ex vivo cervical explant model.
Release of p24 antigen into the supernatant, or detection of HIV DNA in the cervical tissue, was
used to determine the occurrence of primary infection. Infection, they found, could be blocked
through inhibition of CD4 alone, or CCR5 and CXCR4 together, suggesting that primary
infection occurs in macrophages and/or lymphocytes. Spread of HIV in tissue, represented by
detection of HIV in DCs and lymphocytes in the culture supernatant, could be blocked by
inhibition of CD4 and mannose C-type lectin receptors (eg, DC-SIGN). Neutralizing antibodies
(mAB b12) and sCD4 fusion protein CD4-IgG2 blocked both localized and disseminated
infection. These results were used to relate the explant model to infection in vivo, with the
assumption that this model can be used to test microbicides. Using this model, their results
suggest initial infection of macrophages with subsequent infection of DCs, which in turn infect
lymphocytes.
Ron Veazey[35] from Tulane University in New Orleans, Louisiana, reported on the use of the
CCR5 receptor antagonist PSC-RANTES in a macaque challenge model. PSC-RANTES is a
potent amino-terminus-modified analog of the chemokine RANTES, which inhibits HIV
replication and downregulates CCR5 receptor expression. Macaques were given
medroxyprogesterone (Depo-Provera) to increase susceptibility to HIV infection through
changes in the endocervix. Animals were then treated with 1 of 3 doses of PSC-RANTES and
challenged intravaginally with 300 TCID50s (approximately 1 million copies) of SHIV162P3 15
minutes after treatment. All 5 macaques who received the highest dose (1 mM) of PSC-
RANTES remained uninfected, compared with 4 of 5 animals treated with 330-mcM PSC-
RANTES and 3 of 5 treated with 100-mcM PSC-RANTES. In a control group, 4 of 5 untreated
macaques became infected after SHIV challenge. The investigators concluded that PSC-
RANTES in high concentration is sufficient to block vaginal SHIV infection. In addition, clinical
and tissue examination of the cervix failed to reveal evidence of inflammation after RANTES
exposure.
Ron Otten[36] of the US Centers for Disease Control and Prevention in Atlanta, Georgia, reported
on the use of vaginal cellulose acetate phthalate (CAP) to prevent SHIV in a pig-tailed macaque
model. Animals (n = 12) were repeatedly exposed over 16 weeks to 3 concentrations (1.2 x 105,
1.2 x 106, or 5.8 x 106 copies/mL) of SHIV162P3. Macaques exposed to these concentrations
became infected after 3, 4-8, and 12 exposures, respectively. The higher concentration of SHIV
was then used to test the efficacy of a 2-mL application of a 13% preparation of CAP provided
15 minutes prior to SHIV exposure. Three of 4 macaques treated with CAP remained virus-free
after 8 exposures, but 1 animal became infected after 3 exposures. The peak plasma viral RNA
level in this macaque was approximately 2 logs lower than in the control animals. CAP caused
no clinical inflammation at the concentration used.
The ideal microbicide will reliably prevent sexually transmitted diseases and HIV concomitantly,
without inhibiting conception. It will be cheap to manufacture, prove simple to store and apply,
and prove palatable to women and their sexual partners. A wide range of products, including
detergents, charged compounds, acidic compounds, antibodies, antivirals, and protobiotics, are
in development. However, none of these compounds fulfills all of the criteria desired. Further, Dr.
Shattock predicted that using an optimistic timeline, no product would be clinically available
before 2010. In general, the funding stream for microbicide development has improved and
enthusiasm is high, but development of a successful product will require overcoming a variety of
major biological restrictions and conducting very large, expensive clinical trials. The models
described above, however, should facilitate the development of effective microbicides.
Challenge of animals with HIV (or SHIV) in concentrations found in human semen should help
to provide a good idea of the capacity of candidate microbicide compounds.
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3. Chakraborty H, Sen PK, Helms RW, et al. Viral burden in genital secretions determines
male-to-female sexual transmission of HIV-1: a probabilistic empiric model. AIDS. 2001;
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4. Vernazza PL, Troiani L, Flepp MJ, et al. Potent antiretroviral treatment of HIV-infection
results in suppression of the seminal shedding of HIV. The Swiss HIV Cohort Study.
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5. Coombs RW, Reichelderfer PS, Landay AL. Recent observations on HIV type-1
infection in the genital tract of men and women. AIDS. 2003;17:455-480.
6. Hart CE, Lennox JL, Pratt-Palmore M, et al. Correlation of human immunodeficiency
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7. Kashuba AD, Dyer JR, Kramer LM, Raasch RH, Eron JJ, Cohen MS. Antiretroviral-drug
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9. Reddy YS, Gotzkowsky SK, Eron JJ, et al. Pharmacokinetic and pharmacodynamic
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10. Cohen MS. Preventing sexual transmission of HIV--new ideas from sub-Saharan Africa.
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11. Greene WC, Peterlin BM. Charting HIV's remarkable voyage through the cell: Basic
science as a passport to future therapy. Nat Med. 2002;8:673-680.
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13. Taha TE, Hoover DR, Dallabetta GA, et al. Bacterial vaginosis and disturbances of
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14. Pillai S, Good B, Wong J, Strain M, Richman D, Smith D. Semen-specific genetic
characteristics of HIV-1 env. Program and abstracts of the 11th Conference on
15. Craigo K, Patterson B, Paranjpe S, et al. Persistent viral infection and sequence
evolution in semen and blood compartments in HIV-infected patients following long-term
potent antiretroviral therapy. Program and abstracts of the 11th Conference on
16. Coombs R, Deutsch L, Ross S, et al. The distal lower genitourinary tract as a source of
seminal HIV. Program and abstracts of the 11th Conference on Retroviruses and
17. Sadiq ST, Taylor S, Copas AJ, et al. The effects of gonococcal, chlamydial and non-
specific urethritis on seminal plasma HIV-1 RNA loads in the United Kingdom. Program
18. Nowicki M, Kovacs A, DeGiacomo M, Chen Z-C, Navazesh M. HIV-1 distribution in oral
and vaginal mucosa specimens. Program and abstracts of the 11th Conference on
19. Cu-Uvin S, Snyder B, Hogan J, et al. Paired plasma and cervicovaginal HIV-1 RNA
expression over 36 months. Program and abstracts of the 11th Conference on
20. Sha B, Zariffard R, Wang Q, et al. Analysis of cervical vaginal lavage fluid by
quantitative PCR for Gardnerella vaginalis, Mycoplasma hominis, and Lactobacillus is a
sensitive indicator of bacterial vaginosis and correlates with genital tract HIV viral load.
21. Mullen J, O'Shea S, Cormack I, et al. Antiretroviral drug resistance and genetic diversity
of HIV-1 in the blood and female genital tract. Program and abstracts of the 11th
22. Cunningham AL, Turville SG, Wilkonson J, et al. HIV capture and transmission by
dendritic cells. Program and abstracts of the 11th Conference on Retroviruses and
23. McDonald D, Hope TJ. Enhancement of HIV infection by activated dendritic cells occurs
via trafficking through a CD81-enriched compartment. Program and abstracts of the
24. Gonzalez N, Bermejo M, Pablos JL, Baleux F, Arenzana F, Alcami J. SDF-1/CXCL12
production by dendritic cells decreases infection of lymphocytes by X4 strains in the
immune synapsis. Program and abstracts of the 11th Conference on Retroviruses and
25. Cavrois M, Neidleman JA, Callebaut C, Kreisberg JF, Fenard D, Greene WC. Fusion
differences between R5 and X4 HIV-1 in dendritic cells: implications for selective
transmission of R5 strains. Program and abstracts of the 11th Conference on
26. Schweighardt B, Meiklejohn DA, Grace EJ III, Nixon DF. R5 HIV-1 strains replicate more
efficiently in primary CD4+ T cell cultures than X4 HIV-1 strains. Program and abstracts
of the 11th Conference on Retroviruses and Opportunistic Infections; February 8-11,
2004; San Francisco, California. Abstract 317.
27. Aquaro S, Ranazzi A, Bellocchi M, et al. HIV-1-mediated Apoptosis Occurs in
Macrophages Infected by X4, but Not by R5 Viruses. Program and abstracts of the 11th
28. Routy J-P, Machouf N, Edwardes MD, et al. Factors associated with a decrease in the
prevalence of drug resistance in newly HIV-1-infected individuals in Montreal. Program
29. Bezemer D, Jurriaans S, Prins M, et al. Limited transmission of drug resistant HIV-1 and
non-B subtypes in Amsterdam. Program and abstracts of the 11th Conference on
30. Little SJ, Liu Y, Wrin T, et al. env sequences and neutralization of HIV from transmission
partners of primary HIV infection. Program and abstracts of the 11th Conference on
31. Ritola K, Pilcher C, Little S, et al. HIV-1 V1/V2 and V3 env diversity during primary
infection suggests a role for multiply infected cells in transmission. Program and
32. Lewis SH, Sundquist W, Ho D. Opening Session. Program and abstracts of the 11th
Francisco, California.
33. Shatttock R. How close are we to an effective microbicide? Program and abstracts of
the 11th Conference on Retroviruses and Opportunistic Infections; February 8-11, 2004;
San Francisco, California. Plenary Session 6.
34. Hu Q, Watts P, Frank I, et al. Blockade of attachment and fusion receptors inhibits HIV-1
infection of human cervical tissue. Program and abstracts of the 11th Conference on
35. Veazey R, Offord R, Hartley O, et al. Intravaginal PSC-RANTES protects against
vaginal transmission of SHIV162P to macaques; implications for HIV microbicide
strategies and pathogenesis. Program and abstracts of the 11th Conference on
36. Otten R, Adams DR, Kim CN. Cellulose acetate phthalate protects macaques from
multiple, low-dose vaginal exposures with an SHIV virus: New strategy to study HIV
pre-clinical interventions in non-human primates. Program and abstracts of the 11th
Authors and Disclosures
Author
Myron S. Cohen, MD
Professor, Division Chief, Director, Center for Infectious Disease,

University of North Carolina at Chapel Hill; Chief, Division of
Infectious Disease; Director, Center for Infectious Disease, UNC
HealthCare Systems, Chapel Hill, North Carolina
Disclosure: Myron S. Cohen, MD, has no significant financial

interests to disclose. In this activity he has reported that he
discusses the use of investigational microbicidal products.
Scott R. Inkley Professor of Medicine, Case Western Reserve University School of

Medicine, Cleveland, Ohio; Director, Center for AIDS Research, Principal Investigator,
AIDS Clinical Trials Unit, Case Western Reserve University, University Hospital of
Cleveland, Cleveland, Ohio
Disclosure: Michael Lederman, MD, has disclosed that he has received research
grants from AnorMED, Berlex, Bristol-Myers Squibb, Chiron Corporation, Coley,
Merck, Triangle Pharmaceuticals, and Roche. In this activity, he reported that he does
not discuss any investigational or unlabeled uses of any commercial products.
Professor, University of Massachusetts Medical School, Worchester, Massachusetts;

Director, Center for AIDS Research, University of Massachusetts Medical School,
Worchester, Massachusetts
Disclosure: Mario Stevenson, PhD, has no significant financial interests to disclose. In

this activity, he reported that he does not discuss any investigational or unlabeled uses
of any commercial products.
Editor
Craig Sterritt
Site Editor/Program Director, Medscape HIV/AIDS, Medscape Infectious Diseases
Disclosure: Craig Sterritt has no significant financial interests or relationships to

disclose.
Registration for CME credit, the post test and the evaluation must be completed online.
To access the activity Post Test and Evaluation link, please go to:
http://www.medscape.com/viewprogram/2985_index

Patogenesis Del VIH

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Patogenesis Del VIH

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11th Conference on Retroviruses and Opportunistic Infections

Pathogenesis of HIV Infection CME/CE

Contents of This CME/CE Activity

1. HIV Immunopathogenesis and Correlates of Protection

2. Virus and Host Factors in HIV Pathogenesis

3. Sexual Transmission of HIV

HIV Immunopathogenesis and Correlates of Protection

New Data on HIV Immunopathogenesis

New Data on Anti-HIV Immune Responses: Mechanisms and Viral Control

New Data on Immune-Based Therapies

1. Speelmon E, Desbien A, Livingston-Rosanoff D, McElrath MJ. Diminished CD4+.

Virus and Host Factors in HIV Pathogenesis

Mario Stevenson, PhD

Pathogenic primate lentivirus infections are characterized by progressive loss of immune

Viral Reservoirs, Replication, and Rebound

HIV:Cell Interactions in the Viral Replication Cycle

Cellular Antiviral Factors and Effects

APOBEC 3G inhibits viral replications by inducing extensive deamination of cDNA as it is being

Shedding of HIV in the Genital Tract

In a rather remarkable piece of work by R Coombs and colleagues[16] of the University of

S. Cu-Uvin[19] of Brown University in Providence, Rhode Island, and coinvestigators looked at

Dendritic Cells, HIV Transmission, and Selection of CCR5 Variants

In a study presented by M. Cavrois[25] of the Gladstone Institute of Virology and Immunology,

Microbicides for the Prevention of Sexual Transmission of HIV

Authors and Disclosures

Professor, Division Chief, Director, Center for Infectious Disease,

Disclosure: Myron S. Cohen, MD, has no significant financial

Scott R. Inkley Professor of Medicine, Case Western Reserve University School of

Mario Stevenson, PhD

Professor, University of Massachusetts Medical School, Worchester, Massachusetts;

Disclosure: Mario Stevenson, PhD, has no significant financial interests to disclose. In

Disclosure: Craig Sterritt has no significant financial interests or relationships to

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