1. Infection with subtype C HIV-1 of lower replicative fitness as compared to subtypes A and D leads to slower disease progression in Zimbabwean and Ugandan women Overview HIV-1 diversity in global epidemicOverview HIV-1 diversity in global epidemic Compare the replicative fitness of HIV-1 subtype A, C, and DCompare the replicative fitness of HIV-1 subtype A, C, and D Determine if disease progression differs among subtypes in a natural history cohortDetermine if disease progression differs among subtypes in a natural history cohort

2. x Gao et al., Nature, 1999 Santiago et al., Science, 2002 Corbet, J Virol, 2000 Foley & Korber HIV Database, LANL 50% 35% ~15-25% Diversity of primate lentiviruses

3. HIV-1 subtype and recombinant prevalence in the world Subtype C is dominating the epidemic

4. Has HIV-1 subtype C prevalence increased over time as compared to other HIV-1 subtypes in regional epidemics? Vidal et al. 2005. J. AIDS Rainwater et al. 2005. ARHR Li et al. 1996. Li et al. 1996. Zhonghua Liu Xing. Bing. Xue. Za Zhi Li et al. 2005. ARHR Infected population based WHO/UNAIDS reports Soares et al. 2005. AIDS Van Harmelen et al. 1999 ARHR

5. Is there a difference between subtype fitness?

6. Measurement of viral fitness Ball et al, 2003 Relative fitness: virus production in dual infection/proportion in the inoculum Fitness difference: ratio of relative fitness values = More fit/less fit

7. B vs. B C vs. C Paired T test, p > 0.5 Y axis wins X axis wins Ball et al., J. Virol. 2003 C vs. B Paired T test, p < 0.0001 B wins C wins No significant differences in intrasubtype B or C fitness Subtype C NSI/R5 HIV-1 are less fit than subtype B NSI/R5 HIV-1

8. C wins A, B, or D wins Competitions between: NSI/R5 primary HIV-1 isolates of subtypes A, B, C, and D SI/X4 primary HIV-1 isolates of subtypes A, B, C, and D Subtype C isolates are less fit than any other group M isolates, regardless of subtype Possible order in group M fitness: B = D > A >> C

9. How does subtype C fitness relate with other human lentiviruses?

10. Do HIV-1 subtype C infected individuals showed different rates of disease progression than those infected with subtype A or D? Newly infected HIV-1 women were enrolled from a cohort of 4,439 women from family planning sites from Uganda and Zimbabwe evaluating the effect of hormonal contraception on HIV-1 acquisition (quarterly HIV-1 testing) This analyses includes women recruited within three months of infection (62 Ugandan and 88 Zimbabwean). This represents a sub-set analyses of the total 275 recruited HIV-1 infected women.

11. Based on this slope of CD4 cell decline and a starting CD4 cell count of 680/ml for Uganda and 520/ml for Zimbabwe, a y intercept of 200 CD4 cells/ml would require: A mean of 8 yrs for progression to AIDS in Ugandan women 20 yrs in Zimbabwean women Analyses of CD4 cell decline following acute/early HIV-1 infection in Ugandan and Zimbabwean women

12. Mean and slope of CD4 cells per week 1 VariableNo. of women/Total N (%) No. of visits/Total N (%) Mean CD4 cells (95% CI) Slope of CD4 Cells (per week) (95% CI) Time-invariant variable Uganda62/150 (41.3)906/2048 (44.2)687.47 (629.90, 745.04)-1.09 (-1.35, -0.84) Zimbabwe88/150 (58.7)1142/2048 (55.8)521.58 (481.76, 561.41)-0.28 (-0.50, -0.06) < 25 years old at SV63/150 (42.0)851/2048 (41.6)651.09 (593.78, 708.39)-0.60 (-0.86, -0.34) ≤ 9 years education at HC Screening 76/150 (50.7)1054/2048 (51.5)590.16 (539.30, 641.02)-0.78 (-1.01, -0.55) HSV at SV128/146 (87.7)1746/2006 (87.0)588.30 (548.71, 627.89)-0.64 (-0.85, -0.43) HIV Subtype: A27/87 (31.0)423/1233 (34.3)705.22 (631.43, 779.00)-1.07 (-1.42, -0.72) C44/87 (50.6)571/1233 (46.3)498.15 (439.91, 556.39)-0.48 (-0.79, -0.16) D16/87 (18.4)239/1233 (19.4)660.91 (524.13, 797.69)-1.29 (-1.74, -0.84) 1 By GEE approach Following calculation of the CD4 decline slopes per patient and then measuring the mean (GEE approach), we estimate again that: Ugandan women will progress to AIDS in a mean of 417.4 weeks or 8.0 yrs Zimbabwean women will progress to AIDS in a mean of 1132.1 weeks or 21.8 yrs p < 0.0001 p < 0.01

13. Conclusions Ex vivo observations Subtype C “stands alone” as a less fit subtype in PBMC competitions (regardless of the ethnic source of the PBMCs) Subtype C and other group M subtypes show similar fitness in Langerhan cells, a model for HIV-1 transmission In vivo observations Women, recruited at acute/early HIV-1 infection, progress more rapidly to AIDS in Uganda than in Zimbabwe as indicated by CD4 cell decline This slower progression is not associated with age, opportunistic infections, STDs, sexual habits, and other characterized parameters Preliminary data suggest that this difference is not associated with host genetics, e.g. co- receptor genetic polymorphisms Viral load set points and viral loads at 6 and 12 months were not significantly different in Uganda and Zimbabwean women (poster MOPE0275, Morrison et al.) The only predictor of slow disease progression was infection with HIV-1 subtype C. Is this related to low subtype C virulence?

14. Acknowledgements CWRU Immaculate Nankya Korey Demers Sarah Ball Andre Marozsan Dawn Moore Courtney Walker Eric Arts Robert Salata Makerere University/JCRC Francis Mmiro Roy D. Mugerwa Peter Mugyenyi Sandra Rwambuya Fred Kyeyune Stanley Bulime University of Washington Barbra Richardson FHCRC-SCHARP Peter Cornelisse UCSF Nancy Padian IUPUI Barbara van der Pol University of Zimbabwe Tsungai Chipato Marshall Munjoma Family Health International Charles Morrison Cynthia Kwok Pai-Lien Chen NICHD, NIH Joanne Luoto Patricia Reichelderfer The entire GS/VF/HC-HIV Study Team in Uganda, Zimbabwe, Thailand, and US