1. Why may non-communicable diseases occur more often in those with HIV infection? Suzanne Crowe Co-Head Centre for Virology, Burnet Institute Consultant Infectious Diseases Physician, The Alfred Hospital Melbourne

2. Today’s presentation What do HIV and healthy ageing have in common? What is evidence of prematurely ageing of the immune system by HIV? What factors increase the risk of non-communicable diseases in HIV infection ? What role do monocytes play? The link between HIV, monocytes, immune ageing and non-communicable diseases

3. What do HIV infection and healthy ageing have in common? What do HIV infection and healthy ageing have in common?

4. Immunological and clinical manifestations shared by HIV+ and healthy elderly Immunologic characteristics Naïve T cells T cell diversity Memory cells Differentiated, senescent CD8+ T cells (eg CD28-CD57+) Telomere length CD16+ monocytes monocyte function Immunologic characteristics Naïve T cells T cell diversity Memory cells Differentiated, senescent CD8+ T cells (eg CD28-CD57+) Telomere length CD16+ monocytes monocyte function Functional immune defects Replicative capacity Tumour surveillance Pathogen protection Chronic inflammation Functional immune defects Replicative capacity Tumour surveillance Pathogen protection Chronic inflammation Clinical manifestations Vaccine responses Infections Age-associated non communicable diseases ( eg CVD, non-AIDS cancers, bone/kidney disease, frailty, neurocognitive decline) Clinical manifestations Vaccine responses Infections Age-associated non communicable diseases ( eg CVD, non-AIDS cancers, bone/kidney disease, frailty, neurocognitive decline)

5. Ageing HIV Non- communicable diseases Chronic immune activation/inflamm ation Immunologic changes : Similarities between HIV infection and normal ageing most relevant

6. Ageing HIV Non- communicable diseases Chronic immune activation/inflamm ation Immunologic changes Atherosclerosis Diabetes Cognitive decline Osteoporosis Malignancy Renal/liver disease Similar comorbidities in HIV infection and normal ageing Atherosclerosis Diabetes Cognitive decline Osteoporosis Malignancy Renal/liver disease

7. Ageing HIV Non- communicable diseases Chronic immune activation/inflamm ation Immunologic changes Shared characteristics: ↑ senescent T cells (CD28 - /CD57 + ) ↓ telomere length ↑ pro-inflammatory (CD16 + ) monocytes Brenchley, et al Nature Med 2006 ; Jiang et al J Infect Dis 2009; Hearps A et al Ageing Cell 2012 HIV infection and normal ageing: shared immune changes Shared biomarkers: ↑ inflammation Eg CRP, IL-6 ↑ coagulation Eg D-dimer

8. What evidence do we have that HIV is associated with accelerated ageing? What evidence do we have that HIV is associated with accelerated ageing?

9. Shortened telomeres in young HIV+ and in healthy elderly Hearps A et al AIDS 2012; 26: 843 Telomere length is shorter in healthy elderly and young HIV+ on cART with VL<50 Short pieces of DNA (hexonucleotide repeats) at ends of chromosomes Protect the DNA Telomeres shorten during each cell division If telomeres shorten, cells age Telomere length is a classical marker of immune ageing Median age: 28 72 29 years Range (yrs): 20-32 70-82 27-45 VL<50

10. Telomere length is maintained by telomerase reverse transcriptase (TERT) which “repairs” telomeres NRTIs inhibit TERT in vivo and in vitro NRTIs contribute to immune ageing in HIV+ on cART Calado and Young. N Engl J Med 2009:361:2353–65 TERT is inhibited by NRTIs Inhibition of TERT in vitro: TDF > 3TC=FTC=AZT > ABC Leeansyah E et al 2012; slide provided by Sharon Lewin

11. Telomere length is also significantly reduced in cART naïve HIV+ individuals: role of HIV Rickabaugh et al. Plos One 2011; Dagarag et al. J Immunol 2004 cART naïve, within 1-3 yrs of infection Young Old % telomere length in CD31+ naïve T-cells HIV negative HIV positive Why? Increased T-cell turnover Direct inhibition of telomerase RT (TERT) by HIV Slide provided by Sharon Lewin

12. What factors in HIV infection increase risk of non-communicable diseases ? What factors in HIV infection increase risk of non-communicable diseases ?

13. Ageing HIV Non- communicable diseases Chronic immune activation/inflamm ation Immunologic changes Risk for non-communicable diseases in HIV+ individuals and healthy elderly Traditional risk factors CVD, cancer, bone disease, dementia, Traditional risk factors CVD, cancer, bone disease, dementia,

14. Risk of CVD due to HIV is similar to risk from smoking Yusuf et al., Lancet 2004 364 937 Triant et al., JAIDS 2009 51 268 Cardiac events Smoking High blood pressure Diabetes Abdominal obesity Good diet & exercise 2.83 Modest EtOH High LDL/HDL ratio HIV infection 2.37 3.25 1.62 0.91 1.91 2.07 0.89

15. Ageing HIV Non- communicable diseases Chronic immune activation/inflamm ation Immunologic changes HIV+: ↑ prevalence of some traditional risk factors for eg CVD Smoking Diabetes mellitus Insulin resistance Dyslipidemia etc Risk for non-communicable diseases in HIV+ individuals and healthy elderly

16. Ageing HIV Non- communicable diseases Chronic immune activation/inflamm ation Immunologic changes : Potential drivers: Cumulative effects of lifelong antigenic stress Thymic involution Genetic role Oxidative stress Chronic endotoxemia Potential drivers: HIV viremia Microbial translocation and endotoxemia Chronic co- infections Cumulative effects of life-long antigens Thymic involution Oxidative stress Derhovanessian, et al, (2009) Curr Opin Immunol; Linton, et a., (2004) Nat Immunol; Brenchley, et a., (2006) Nature Med; Jiang et al (2009) J Infect Dis Drivers of NCDs in healthy elderly and HIV are partly similar but differently weighted, some HIV specific

17. Ageing HIV Non- communicable diseases Chronic immune activation/inflamm ation Immunologic changes : Potential drivers: Cumulative effects of lifelong antigenic stress Thymic involution Genetic role Oxidative stress Chronic endotoxemia Potential drivers: HIV viremia Microbial translocation and endotoxemia Chronic co- infections Cumulative effects of life-long antigens Thymic involution Oxidative stress Derhovanessian, et al, (2009) Curr Opin Immunol; Linton, et a., (2004) Nat Immunol; Brenchley, et a., (2006) Nature Med; Jiang et al (2009) J Infect Dis Drivers of NCDs in healthy elderly and HIV: similarities and differences

18. Chronic endotoxemia persists during HIV-1 infection Mehandru et al., J Exp Med (2004 ) HIV- HIV+ Chronic endotoxemia in elderly and HIV+, not reversed by cART (Hearps A et al AIDS 2012 Depletion of CCR5+ CD4+ T cells from gut mucosal tissue Leakage of microbial products across LP Colon lamina propria, acute/early HIV Red=CD4+ T cells Guadalupe et al JV 2003, Brenchley et al Nature Med 2006

19. HIV viremia is associated with elevated markers of inflammation and coagulation Veterans Ageing Cohort Study – n = 1525 HIV+ participants – n = 843 HIV- participants (age-matched) HIV+ VL>500 copies/ml or CD4<200 cells/ul HIV+ (OR, 95% CI)HIV- (OR, 95% CI) Elevated IL-62.25; 1/60-3.161.54; 1.14-2.09 Elevated D-dimer1.97; 1.44-2.711.68; 1.22-2.32 Armah KA Clin Infect Dis 2012 55: 126

20. Residual viremia (VL<50) linked with immune activation and non-communicable diseases? on cART – generally partial reversal of markers of immune activation – Lower levels of activated (CD38+HLA-DR+) CD4+ and CD8+ T cells compared with non-controllers 1, 2 – Higher levels of T cell activation and senescent (CD28- CD57+) T cells 3,4 – Elevated risk of sub-clinical atherosclerosis compared with HIV uninfected 5 1 Card CM et al JAIDS 2012 59:427 2 Owen RE AIDS 2010 24:1095; 3 Ruiz-Mateos E et al Curr HIV Res 2010 8:471; 4 Hsue P AIDS 2006; 5 Hsue P et al AIDS 2009 23:1059 HIV elite controllers: VL<50 in absence of ART: conflicting data On cART VL<50

21. CMV linked with immune activation and NCD – CMV induces CD8+ T cell activation that is suppressed by valganciclovir in HIV+ 4 – Activation of senescence signaling pathways in elderly patients with CMV 1 – Shortened telomere length of leukocytes in CMV infection 2 – Increased CMV IgG titre associated with atherosclerosis in HIV+ women 3 1 Henson SM et al Curr Opin Immmuol 2012; 2 Van de Berg P et al J Immunol 2010;184:3417 3 Parrinello CM et al J Infect Dis 2012 205:1788; Hunt et al JID 2011 203: 1474

22. What role do monocytes play with NCD in HIV+ ? What role do monocytes play with NCD in HIV+ ?

23. Monocyte activation is likely to be central to development of non-communicable diseases Immune ageing NCD Inflammation Immune activation Telomere shortening LPS HIV Co-infection Monocyte activation Pro-inflammatory cytokine production Altered phenotype Reduced function Altered coagulation fibrosis

24. HIV accelerates innate immune changes HIV induces age- related changes to monocytes Some (not all) changes persist despite cART – In HIV+ men 1 – In HIV+ women 2 Changes appear approx 10-14 years earlier in HIV+ than HIV- women 2. Increased pro-inflammatory CD16+ monocytes in young HIV+ and the healthy elderly 1. Hearps A et al AIDS 2012; 26: 2. Martin G et al 2012

25. “Signature of accelerated immune ageing & risk of NCD” Emerging “immune signature” to predict immune ageing and risk of age associated diseases Monocyte activation eg sCD14, CD11b, neopterin Markers of microbial translocation eg LPS Markers of altered coagulation eg D-dimer, TF Markers of T cell senescence eg CD28-CD57+ CD8+ HIV Monocyte marker of inflammation eg sCD163 GAP

26. the link between monocytes, Immune ageing and non-communicable diseases such as CVD in HIV+ the link between monocytes, Immune ageing and non-communicable diseases such as CVD in HIV+

27. Monocytes are central to pathogenesis of atherosclerosis Foam cells are lipid laden macrophages Accumulate in intima Key feature of atherosclerotic plaques Foam cells secrete inflammatory mediators that recruit more monocytes, promote plaque progression Westhorpe, Dufour, Maisa, Jaworowski, Crowe, Muller: 2012 in press

28. LDL modification dyslipidemia Endothelial activation Plaque Monocyte adherence Systemic inflammation Monocyte activation Monocyte maturation & lipid uptake Foam cell Monocyte egress Plaque regression Pro-inflammatory cytokines and Tissue factor Plaque growth destabilisation & rupture Apoptosis, necrosis MMPs Atheromatous plaque development: role of monocytes oxLDL cholesterol efflux

29. LDL modification dyslipidemia Endothelial activation Plaque Monocyte adherence Systemic inflammation Monocyte activation Monocyte maturation & lipid uptake Foam cell Monocyte egress Plaque regression Pro-inflammatory cytokines and Tissue factor Plaque growth destabilisation & rupture Apoptosis, necrosis MMPs Impact of HIV on atheromatous plaque development HIV Microbial translocation endotoxemia HIV oxLDL HIV cholesterol efflux HIV

30. Why may NCD occur more often in HIV+? multifactorial and complex Chronic immune activation and inflammation Certain ARVs An ageing population Lifestyle factors Increased risk of non-communicable age-associated diseases eg CVD HIV

31. Anthony Jaworowski Anna Hearps Genevieve Marti n Clovis Palmer Gregor Lichtfuss Tom Angelovich Yagmur Farsakoglu Wan-Jung Cheng Jingling Zhou Clare Westhorpe Centre for Population Health Tim Spelman IDU Sharon Lewin Jenny Hoy Julian Elliott Kate Cherry Janine Trevillyon Cardiovascular Medicine Anthony Dart Liz Dewar Sofie Karapanagiotidis Dmitri Sviridov Alan Landay The HaCH Study volunteers Acknowledgements “The Ageing Team” William Muller Funding from