Immunology of HIV: What can we learn from LTNPs / Elite Controlers ? Pr Brigitte Autran Inst. of Researches Immunity, Cancer and Infection , Université Pierre et Marie Curie - Hôpital Pitié-Salpêtrière, France brigitte.autran@psl.aphp.fr Univ. Hosp Pitié-Salpétrière

HIV and Immune Deficiencies : Are CD4 defects & AIDS the only complication of the HIV infection? The collateral damages of Immune activation… Immune Responses Immune Activation CD4/mm3 Pl VL 200 AIDS Opportunistic Infections ARV 0 3-6 m 8-10 years B Autran EACS 09

Chronic Inflammation/activation plays a key role in immunopathology of HIV tat, Appay V et al, J Pathol 08

LTNPs and HIV / Elite Controllers: Models of functional Cure of HIV? Who are they ? Definition? Control of CD4 and HIV : is it stable ? Control of Immune Activation ? How do they control the virus ? : Is it the Virus or the Host ? Which virus characteristics ? Which Immunity ? Are they a model for : Vaccines ??? Cure of HIV ? EACS B Autran 2013

Which definition for LTNP and HIV / Elite Controllers ? LTNPs: 1st evidence: 1993: LTS (Long Term Survivors): SanFrancisco Cohort: S Buchbinder & J Levy (1994) Immuno/Clinical definition: > 1994: LTNPs: Seropositivity > 7-8 years No AIDS, Normal CD4 counts : >500, >600/mm3 No Treatment (VL not available) HIV / Elite Controllers (Suppressors): 1st evidences: 2000s: HIV Controlers: O. Lambotte 2005 / HIV Suppressors: J. Blanke 2005 Elite Controllers : S Deeks & B Walker 2007 Virological Definition: Seropositivity > 8-10 years Plasma Viral Load < 400 or 500 cp / mL over 90% measures +/- undetectability (AIDS symptoms or CD4 non necessary) EACS B Autran 2013

Which Epidemiology for LTNP and HIV / Elite Controllers ? Data from FHDH: LTNPs: 1993: LTS SanFrancisco Cohort: 7%? S Buchbinder (1994) Others : < 5%, <2%, …. HIV / Elite Controllers : late 90s: HIV / Elite Controlers: ??? < 1% French Hospital Data Base (FHDH): Grabar.. D Costagliola, AIDS 2009 46,880 HIV+ patients: LTNP: Sero+ >8y , CD4 nadir > 500 = 0.4% Elite LTNP: idem + CD4 nadir > 600, CD4 slope+ = 0.05% HIV Controlers: >10y , 90% VL<500cp/ml = 0.22% Elite Controllers: idem HIC + last VL<50 cp = 0.15% Elite LTNP: = 40% HIC = 32% EC = 60% detectable plVL Elite Controlers: = 46% LTNP = 12% Elite LTNP = 25% CD4 < 500/mm3 EACS: B Autran 2013

French Cohort of LTNPs: ALT –ANRS CO15: Recruitment: 1994 – 96 : Inclusion Criteria : Seropositivity known > 8 years CD4>600/mm3 for > 5 years and + CD4 slope Lack of HIV-related symptoms Lack of ARV N=71: median seropositivity: 9 y Evolution: very slow decrease in CD4 over an 18 years Follow-up:       Nb CD4>600 Number subjects Years 9 (44%) 18 2001-12 8 (33%) 24 5 12 (40%) 30 4 17 (27%) 44 3 28 (46%) 61 2 46 (65%) 71 1       EACS B Autran 2013

HIV – Elite Controllers, LTNPs The Virus or the Host? Deletions ? Evolution and escape ? What is the key parameter ? Production or Reservoir ? EACS B Autran 2013

ALT-ANRS CO15 cohort: HIV characteristics at entry: It is NOT the Virus ! Low but Heterogeneous viral production: Median plasma VL = 10 000 cp/mL at entry (20-880,000) Slow increase: Candotti et al. 1999, 2000 R5-dependent HIV Type: All isolates: NSI (Candotti J Gen Virology1999) No HIV gene deletion in: env, nef, gag, LTR but a Vif signature (Candotti, Vigne, J Virol 2000) SIMILAR FINDINGS in OTHER LTNP COHORTS 1 10 100 1000 10000 100000 1000000 HIV DNA HIV RNA Elite Controlers Viremic Slow Progressors Low Reservoir (cell associated HIV-DNA) correlated to virus production B.A.EACS 2013

Low HIV Reservoir (HIV-DNA) in PBMC : associated with a low risk of HIV disease progression HIV DNA Log copies/106 PBMC The DNA results are interesting when the different aspects of HIV infection is considered : this slide is from Pr C Rouzioux at Necker hospital You can see the DNA results fromdifferent groups of HIV infected patients A low amount of HIV DNA is associated with a low risk of HIV disease progression as you see the largest amounts of HIV DNA in patients during primary infection, then chronically infected untreated, then treated pts, then the results of the french LTNP cohorts, ALT is for asymptomatc long term who are defined according to immunological criterai and HIC with the lowest amount of HIV DNA PRIMO Progressors PRIMO LTNP HIV-controllers infection SEROCO treated ANRS Co-15 ANRS Co-18 10 S Lewin & C Rouzioux et al. AIDS 2011 10

HIV / Elite Controllers, LTNPs Do they control T-cell activation ? Low Immune Activation in Elite Controlers with undetectable plVL: CD4 activation as low as in ARV-suppressed patients, CD8 activation higher Hunt, JID 2008

HIV – Elite Controllers, LTNPs The Virus or the Host? Is it all in the Genes ? Immune Response genes Adaptive Immunity Innate Immunity Is it the anti-HIV Immunity ? EACS B Autran 2013

is the strongest Marker ImmuneGenetics and control of the HIV Reservoirs: Genome-wide analysis in Elite Controllers and LTNP HLA-B57 (HCP5) is the strongest Marker for low HIV reservoirs (Dalmasso et al.) The HLA locus in Chromosome 6 is the strongest genetic marker for: HIV controlers vs Acute infection,(Dalmasso et al.: 2009) Elite Controlers (Pereyra et al. 2010) LTNP (GISHEAL: French & Italian) vs Acute infection (Guergnon et al:2011) Lower Reservoir (HIV-DNA) in B27+/57+ vs negatives B Descours et al. Clin. Inf. Dis 2011 13 EACS B Autran 2013

It is the HOST ! ANRS-CO15 (ALT) cohort: Immune Genetics of LTNPs : A composite of HLA + chemokine /chemoreceptors gene mutations CCR5 D32(hzg) + SDF-1 wt + HLA-B27+, DR6-+ 3 of the HLA-A3, B14, B57 + DR7 Significantly predicts 80% of LTNP vs Progressors (Magierowska et al.Blood, 2000) Association HLA-B57 and low pl VL: SIMILAR FINDINGS for HLA-B57 in all LTNP / HIC & EC cohorts (M Carrington, 1999, Deeks & Walker, 2007, ….) Other genetic parameters??? Mutations of the KIRDL1 gene (M Carrington 2005), CX3CR1gene (Faure 2001) No gene polymorphisms in TRIM-5, APOBEC3G, FcgR Genome Wide Association Studies (GWAS) Protective HLA enriched during Follow-up: 59% at Year0 vs 75% at year5 Distinct influences: HLA-B57 and B14 associated to HIV control HLA-B27 associated to LTNPs Antoni G, AIDS 2013 1 2 3 4 5 TOTAL HLA B57 n=19 B27 n =14 B14 n=14 Median log10 HIV HIV-RNA Cp/mL HIV-DNA Cp/Million PBMC + - + - P=0.003 B12 n=13 P=0.01 EACS B Autran 2013

HIV – Elite Controllers, LTNPs The Virus or the Host? Is it Immunity ? T cell adaptive Immunity: CD4 T cells ? Function ? Other parameters ? CD8 T cells ? Specificity ? Gene associations ? Correlates of protection ? Is it the hen or the egg ??? EACS B Autran 2013

The ANRS Co-18 Cohort of HIV Controllers: CD8 T cells mediate a strong anti-viral activity p24 (ng/ml) 10 -1 1 2 3 4 HIC Control VIR ART CD4:CD8 1:1 Mean CD4 T cells CD8 T cells from HIC inhibit HIV production Saez-Cirion, PNAS 2008 p24 log decrease (CD4 vs CD4:CD8 1:1) 1 2 3 4 5 IFNg SFC Total /106 PBMC 2000 4000 6000 8000 10000 12000 14000 16000 Spearman 0.836 p<0.0001 Some correlation between anti-viral functions of CD8 T cells from HIC HIV inhibition and IFN-g production Saez-Cirion, JI 2009 EACS B Autran 2013

LTNP - ANRS-CO15 cohort: Robust HIV-specific CD8 T cells Strong CD8 T cells against HIV-Gag : CD8 T cells anti-Gag- but not Nef correlate with low HIV reservoirs Martinez et al. JID 2005, Jie et al. AIDS 2010 17 EACS B Autran 2013

A model for an immune control of the HIV Reservoirs in HLA-B27/57+ LTNPs HLA-B27/57pos TN TCM TTM TEM HLA-B27/57 neg Inflammation ++ Activation ++ Antigens HIV Transcriptionally active HIV Transcriptionally inactive Anti gag CD8 T cells EACS B Autran 2013

HIV – Elite Controllers, LTNPs The Virus or the Host? Is it Immunity ? Antibodies ? Neutralizing ? Others ? EACS B Autran 2013

ANRS CO-15 ALT and antibodies against HIV Env HIV-specific antibodies: against HIV-enveloppe: Neutralizing Abs:: Positively correlated to the VL: N’Go et al, AIDS Res Hum Retrov.2003 Reactivity against the MPER of gp41 Braibant et al. AIDS 2006 2F5-like et 4E10 like Abs in 60% sera Braibant et al. Virol. 2011 Reactivity against gp120: particular structural characteristics Isotype: IgG2: anti-gp41: Best correlate of protection against disease progression N’Go et al., AIDS Res Hum Retrov. 2003 Martinez et al. J Inf Dis. 2005 Inhibition of the NK cell-mediated lysis of CD4 T cells: Anti-3S (gp41): Debré et al. block NK cell lysis and correlate with disease progression Vieillard et al. AIDS 2007 DC-SIGN VIH gp41 gp120 CD4 CCR5, CXCR4 Cell Membrane EACS B Autran 2013

LTNP , HIC and EC: Robust HIV-specific CD4 T cells r = - 0,461; p= 0,0001 Proviral DNA (log cp/106 cells) 1 10 100 1,000 10,000 2 3 4 5 Anti-HIV IFNg+ SFC/million PBMC r = - 0,304 ; p= 0,026 HIV-1 RNA (log copies / ml) 6 Time from inclusion (months) 80 60 40 20 48 36 24 12 Proportion remaining LTNP (CD4>600) > 170 SFC and IgG2 (n=5) > 170 SFC, No IgG2 (n=11) < 170 SFC, and IgG2 (n=8) < 170 SFC, No IgG2 (n=29) P= 0.02 I will be brief about the CD4 T cell responses in HIC as I have shown you some of these results last time HIC have HIV specific CD4T cells as shown by the production of infg but also IL2 and mip1alpha in response to p24gag stim LTNPs: Gag-specific Th1 CD4 T cells associated with control of HIV & CD4 The best marker of protection / progression: in association with anti-gp41 IgG2 Abs Martinez et al. JID 2005 EACS B Autran 2013

HIV / Elite Controllers, LTNPs A model for HIV vaccines ? LTNPs, HIC & ECs: Strong T cell Immunity to HIV Weak Neutralizing Abs but other anti-HIV Abs associated with: low VL (IgG2) stable CD4 (anti-gp41/3S) EACS B Autran 2013

Are HIV / Elite Controllers, LTNPs a model for HIV Cure? Current AntiRetroVirals NO AIDS Persistence of HIV Reservoirs Can we decrease the HIV Reservoirs? and stop ART? Functional Cure ? or eradicate HIV Sterilizing Cure ? EACS B Autran 2013

Hot Topic in 2013: Models of Cure ? Sterilizing cure ? CCR5 defective stem cell graft ( Berlin patient ) Models of Functionnal cure Elite Controllers and Long term non progressors Infected for 10-30 years Never treated ; Genetic Background; Strong CD4 and CD8 response/HIV Preserved central-memory CD4 T cells Low immune activation Post-Treatment Controlers (Visconti) Control HIV without ARV for median 3.5 years After ARV for 5 years started at acute infection No genetic background; Immunity ??? Low Immune activation OR3 Year 98 99 00 01 02 03 04 05 06 07 08 09 GXR RNA copies/ml OR1 96 10 500 1000 1500 2000 CD4+ T cells/mm3 OR8 OR2 11 12 13 KPV JOGA MWP CXK Hoqueloux et al. AIDS 2010, J Antimicrob. Ther. 2013, Saez-Cirion et al. PLosPathogens, 2013 EACS B Autran 2013

Potential strategies to reduce HIV reservoirs: Hot Topic in Sept 2013: Potential strategies to reduce HIV reservoirs: Lessons from LTNPs and HIC /ECs Stimulate Anti-HIV immunity ??? NKT CD8 APC Immune Activation Residual Replication Reduce Systemic Inflammation HIV Reservoirs Latency What can we learn from LTNPs, HIC & ECs for Controling Latency ??? EACS B Autran 2013