1. HIV Induced Aging of the Immune System Dr. Tammy Rickabaugh February 4, 2013

2. Overview I. Immunological Aging in Seronegative Individuals II. Premature Aging of the Immune System in HIV-1 + Individuals: Is this the cause of AIDS? III. Implications of Premature Immunological Aging of HIV-1 + Individuals

3. Immunological Aging in Seronegative Individuals

4. Kovaiou, Grubeck-Loebenstien, 2006 General Concepts of Aging

6. Age-Associated Changes in the Immune System Elderly people are more susceptible to infections Elderly people are more susceptible to infections Less protected by vaccines Less protected by vaccines Infections in the elderly are characterized by more severe symptoms, longer duration, and poorer prognosis Infections in the elderly are characterized by more severe symptoms, longer duration, and poorer prognosis Reactivation of Varicella-Zoster, risks for pneumonia, urinary tract infections, meningitis, TB and viral gastroenteritis Reactivation of Varicella-Zoster, risks for pneumonia, urinary tract infections, meningitis, TB and viral gastroenteritis Related to age-related changes in the immune system Related to age-related changes in the immune system

7. Jamieson, BD, et al, Immunity, 1999 Adult Thymus Fetal Thymus The Human Thymus Involutes With Age

8. Significant decrease in naïve T cell number and increase in memory T cells Significant decrease in naïve T cell number and increase in memory T cells -hinders ability to respond to new infections Diversity of the naïve CD4 + T cell compartment is maintained until about 70 years of age Diversity of the naïve CD4 + T cell compartment is maintained until about 70 years of age -a dramatic and sudden collapse of diversity occurs -less diversity in T cell receptor, hinders ability to respond to new antigens Age-Associated Changes in CD4 + T Cells

9. Using cell surface markers normally used to identify naïve T cells is difficult Using cell surface markers normally used to identify naïve T cells is difficult - “naïve” cells in the elderly express receptors and functional abilities more like memory cells Signaling and cytokine secretion in naïve CD4 + T cells is altered and the activation potential of memory cells is also decreased Signaling and cytokine secretion in naïve CD4 + T cells is altered and the activation potential of memory cells is also decreased -hinders ability to mount effective immune responses to antigens Age-Associated Changes in CD4 + T Cells

10. Kovaiou, Grubeck-Loebenstien, 2006 Model for CD4 + T Cell Differentiation During Healthy Aging

11. Kovaiou, Grubeck-Loebenstien, 2006 Summary of Age-Related Changes Within the CD4 + T Cells

12. Summary of Age-related Changes Within the CD8 + T Cells Increase in terminally differentiated cells Increase in terminally differentiated cells Decrease in naïve CD8 + T cells Decrease in naïve CD8 + T cells See an increase in Type 1 (IL-2, IFN-g,TNF-a) and Type 2 (IL-4, IL-6, IL-10) cells- associated with chronic pro-inflammatory status See an increase in Type 1 (IL-2, IFN-g,TNF-a) and Type 2 (IL-4, IL-6, IL-10) cells- associated with chronic pro-inflammatory status Increase in clonal expansions Increase in clonal expansions Decrease in T cell receptor diversity Decrease in T cell receptor diversity Shortening of telomere length Shortening of telomere length

13. What are the implications of increased numbers of senescent T-cells???

14. Why Do Senescent Cells Accumulate With Age? One main reason is an age-related decrease in apoptosis One main reason is an age-related decrease in apoptosis Apoptosis is necessary to create “immunological space” for naïve cells to inhabit Apoptosis is necessary to create “immunological space” for naïve cells to inhabit This is more prominent in CD8 + T-cells This is more prominent in CD8 + T-cells Senescent cells are not susceptible to normal death signals Senescent cells are not susceptible to normal death signals

15. Mountz, JD, et al. Immunological Reviews, 2005 T-cells Become Resistant to Activation-Induced Cell Death (AICD) -Happens at a stage prior to complete senescence -AICD is a mechanism to prevent the expansion of unwanted T-cells

16. Increase in Senescent Cells Occupying “Immunological Space” Results in a Decrease in the Virus-Specific CTL Response Mountz, JD, et al. Immunological Reviews, 2005 -This can also contribute to “inflammaging”

17. Consequences of “Inflammaging” In aging there is a profound modification in the cytokine network General increase in the levels of pro- inflammatory cytokines Chronic low grade pro-inflammatory condition is called “inflammaging”

18. Inflammaging can trigger the following conditions: Franceschi, C., et al., Neuroimmunomodulation, 2008

19. Some of our data…….

20. The Proportion of Naïve T-cells Decreases Only Moderately Throughout Adulthood % of CD4+ T-cells Expressing CD45RA Participant Age Participant Age 100 90 80 70 60 50 40 30 20 10 0 202530354045505560 CD4 + CD45RA +

21. 8%48% 14% CD31 CD45RA Four CD4 + T-cell Subsets Defined by CD45RA and CD31 Naive RA+31 RA+31+ RA+31 - TREC High TREC Low Least Differentiated Differentiated

22. Maintenance of Naïve CD4 + T-cells During Aging Is Due To Stability of CD45RA + CD31 - Subset p=0.38 Participant Age (Years) 2030405060 40 50 30 20 10 0 60 50 40 30 20 10 0 2030405060 Cross Sectional Study 31 + 31 - Kilpatrick, R, Rickabaugh, T, et. al, J. Immunology, 2008 Participant Age (Years) % CD45RA+CD31- cells % CD45RA+CD31+ cells

23. Telomeres Hallmark of cellular aging Hallmark of cellular aging Region of repetitive DNA at the ends of chromosomes Region of repetitive DNA at the ends of chromosomes Protects the end of chromosome from damage Protects the end of chromosome from damage -similar to tips on shoelaces that keep it from unraveling -shortens with each replication of the cell Telomere shortening in humans can result in senescence (cells lose the ability to divide) and block cell division Telomere shortening in humans can result in senescence (cells lose the ability to divide) and block cell division Cells have a limited capacity to replicate and this appears to be partly determined by telomere length Cells have a limited capacity to replicate and this appears to be partly determined by telomere length

24. Telomeres Human chromosome is gray and telomeres are the white dots

25. Kilpatrick, R, Rickabaugh, T, et. al, J. Immunology, 2008 Evidence of Telomere Shortening in Naïve CD4 + T cells with Age

26. CD45RA + CD31 + CD45RA + CD31 -

27. Premature Aging of the Immune System in HIV-1 + Individuals: Is This the Cause of AIDS?

28. Some Causes of Clinical Immunodeficiency Not completely clear why the immune system initially controls HIV-1 infection and then ultimately fails to control viral replication Not completely clear why the immune system initially controls HIV-1 infection and then ultimately fails to control viral replication – Viral escape with mutations in epitopes recognized by cytotoxic T lymphocytes (CTLs) – Functional impairment of HIV-specific CTLs – High levels of immune activation

29. HIV-specific CD8 + T cell response: Impaired or Fully Functional? In primary HIV-1 infection there is a rapid expansion of HIV-specific effector CD8 + T cells In primary HIV-1 infection there is a rapid expansion of HIV-specific effector CD8 + T cells -phenotypically the cells appear to be at an intermediate stage of differentiation -but they are fully functional Why is the virus not cleared?? Why is the virus not cleared?? -the combination of CD4 + T cell depletion and immune escape may lead to an inability of the CD8 + T cells to respond to low levels of viral replication (around the set point) - fully functional but unable to mount an effective response

30. HIV-1 Strategies to Evade Host Immunity Appay, V and Rowland-Jones, SL, Trends in Immunology, 2002

31. HIV-1 Strategies to Evade Host Immunity Appay, V and Rowland-Jones, SL, Trends in Immunology, 2002

32. The Adaptive Immune System in Aging and HIV-1 Infection

33. Parallels Between HIV-1 Pathogenesis and Human Aging Lifespan of both CD4 + and CD8 + T cells is shortened to about a third of normal Lifespan of both CD4 + and CD8 + T cells is shortened to about a third of normal -increase of CD8 + T cells but CD4 + cannot keep up with the pace of destruction Increase in the amount of terminally differentiated T cells- consequence of immune activation Increase in the amount of terminally differentiated T cells- consequence of immune activation -leads to immunosenescence, also occurs with CMV -get an accumulation of immune cells that cannot function or replicate normally, but are more resistant to apoptosis AIDS is much more severe immune senescence than what is seen in normal aging AIDS is much more severe immune senescence than what is seen in normal aging

34. Appay, V and Rowland-Jones, SL, Trends in Immunology, 2002 Post-Thymic Development of CD8 + and CD4 + T cells

35. Appay, V, et al. Experimental Gerontology, 2007 Accumulation of Terminally Differentiated T cells in HIV infection

36. Exhaustion of Immune Resources by HIV-1 Leads to AIDS Chronic Immune Activation: Chronic Immune Activation: -In primary infection there is massive immune activation -In chronic infection still have chronic immune activation due to viral rebounds -Indirect immune activation as depletion of CD4 + T cells results in more common infections and opportunistic infections This can result in premature aging of the immune system and exhaustion of immune resources This can result in premature aging of the immune system and exhaustion of immune resources

37. Appay, V, et al. Experimental Gerontology, 2007 Exhaustion of HIV-specific CD8 + T cell Clonal Populations

38. Appay, V, et al. Experimental Gerontology, 2007 Exhaustion of HIV-specific CD8 + T cell Clonal Populations

39. Appay, V, et al. Experimental Gerontology, 2007 Exhaustion of HIV-specific CD8 + T cell Clonal Populations

40. Some of our own data regarding naïve CD4 + T cells…….

41. Individuals Early in HIV Infection Have Significantly Fewer Naïve CD4 + T-cells Rickabaugh, TM, et al., PLoS ONE 2011

42. HIV Infection Results in a Greater Loss of CD31 - T-cells Rickabaugh, TM, et al., PLoS ONE 2011

43. Naïve CD4 + T-cells of HIV Infected Men Have Shorter Telomere Lengths Rickabaugh, TM, et al., PLoS ONE 2011

44. CD31 MFI 0 1000 2000 3000 4000 5000 Progressed to AIDS within 1 year Progressed to AIDS within > 5 years * p=0.038 CD31 Expression on CD4 + T-cells is Associated with Progression to AIDS Cao, WW et al., J Acquir Immune Defic Syndr 2008

45. What is the Effect of HAART on Naïve CD4 + T-cells?

46. Reconstitution by HAART Does Not Completely Restore the CD31 - Naïve T- Cell Compartment Rickabaugh, TM, et al., PLoS ONE, 2011

47. CD31 +/Hi T-cells Increase Significantly Post-HAART Rickabaugh, TM, et al., PLoS ONE, 2011

48. Reconstitution of CD31+ T-cells appears to be better with more time on ART 0 50 100 150 200 203040506070 Age at time of analysis Seronegative 4-8 years 12-16 years CD45RA+CD28+CD31+CD4+ Absolute Cell Counts

49. Time on ART does not appear to increase CD31- naïve CD4 + T-cells 20 40 60 80 100 120 203040506070 Seronegative 4-8 years 12-16 years CD45RA+CD28+CD31-CD4+ Age at time of analysis Absolute Cell Counts

50. CD45RA + CD31 + CD45RA + CD31 -

51. Appay, V and Rowland-Jones, SL, Trends in Immunology, 2002 HIV-1 Infection Compared to Human Aging

52. Implications of Premature Immunological Aging of HIV-1 + Individuals

53. Deeks, SG, and Phillips, AN, BMJ, 2009 Evidence of Premature Aging Despite Anti-Retroviral Treatment

54. Age-Related Diseases Diagnosed in HIV + Individuals Cardiovascular Disease Cardiovascular Disease -higher in untreated versus treated -link between lower CD4 + T cells and CD -some anti-retroviral drugs are associated with CD

55. Cancer Cancer - Untreated HIV is associated with Kaposi’s Sarcoma and non-Hodgkin’s lymphoma - Even treated HIV individuals at increased risk for lung cancer, skin cancer, colorectal cancer, prostate cancer, anal cancer - Higher risk is associated with less CD4 + T cells, similar to immune compromised transplant patients Age-Related Diseases Diagnosed in HIV + Individuals

56. Older HIV + individuals are at even greater risk due to normal immunological aging coupled with aging caused by HIV-1 infection

57. Another problem….HIV infected people are getting older CDC estimates that by 2015 over 50% of all HIV infected people will be over the age of 50 in the US

58. Two reasons for this: Higher percentage of new infections in people over 50 Higher percentage of new infections in people over 50 Individuals with HIV infection are living longer on drug treatment Individuals with HIV infection are living longer on drug treatment

59. CDC

60. ~46%

61. We also see an increase in new AIDS cases in >50 year olds

62. The Search for the Immunological Fountain of Youth

63. Possible Therapies to Improve Naïve T-cell Numbers and Function The first treatment in HIV patients was IL-2 The first treatment in HIV patients was IL-2 -some evidence of efficacy -results of the trials were not consistent and there are concerns with toxicity Human growth hormone (HGH) and Insulin Growth Factor-1 (IGF1) Human growth hormone (HGH) and Insulin Growth Factor-1 (IGF1) - increased thymic volume in children with AIDS but did not affect T-cell function significantly

64. IL-7 is a very promising treatment IL-7 is a very promising treatment -cytokine that plays a key role in the thymus in lymphocyte development and survival -in the periphery it is important for T-cell homeostasis and is required for homeostatic proliferation of CD4 + and CD8 + T- cells When used in cancer patients it preferentially expanded naïve T-cells When used in cancer patients it preferentially expanded naïve T-cells In a phase I/IIa clinical trial in HIV + patients it was shown to increase naïve and central memory CD4 + and CD8 + T-cells In a phase I/IIa clinical trial in HIV + patients it was shown to increase naïve and central memory CD4 + and CD8 + T-cells The T-cells are functional and the patients had improved cell mediated immunity The T-cells are functional and the patients had improved cell mediated immunity There also seem to be very little side effects There also seem to be very little side effects Possible Therapies to Improve Naïve T-cell Numbers and Function

65. What About Telomere Length?? A screen of Chinese medicine plant extracts for telomerase inducing agents resulted in the discovery of TAT2 A screen of Chinese medicine plant extracts for telomerase inducing agents resulted in the discovery of TAT2 TAT2 has been shown to transiently increase telomerase levels in vitro in cells from HIV-, HIV+, and individuals with AIDS (highest amounts) TAT2 has been shown to transiently increase telomerase levels in vitro in cells from HIV-, HIV+, and individuals with AIDS (highest amounts) This increase was associated with longer telomere lengths, improved immune effector function, and increased ability for cellular proliferation This increase was associated with longer telomere lengths, improved immune effector function, and increased ability for cellular proliferation In vitro it has also been shown to reduce viral load and this is correlated to telomerase induction In vitro it has also been shown to reduce viral load and this is correlated to telomerase induction

66. TAT2 Can Improve Cellular Proliferation and Telomere Length Fauce, SR, et al., J Immunol, 2008

67. Summary Immune resources decline with age leading to a reduced ability to respond to new and old antigens Immune resources decline with age leading to a reduced ability to respond to new and old antigens HIV-1 infection appears to prematurely age both CD8 + and CD4 + T cells HIV-1 infection appears to prematurely age both CD8 + and CD4 + T cells - this leads to immune exhaustion and senescence - may be a significant factor in the development of AIDS HIV-1 + individuals, treated or untreated, are at a higher risk for non-AIDS related diseases seen in much older individuals HIV-1 + individuals, treated or untreated, are at a higher risk for non-AIDS related diseases seen in much older individuals There are some promising therapeutics but more work must be done to develop safe, effective, therapies to improve immune function There are some promising therapeutics but more work must be done to develop safe, effective, therapies to improve immune function