1. HIV Cellular Pathogenesis III Benhur Lee, M.D.

2. Adult v. infant (IgG v. IgA) CTL response (MHC tetramers) p24 antigenimia Ab response Viral load

3. Viral load “set-point” is a major determinant of disease progression “Set-point” determined by a balance between the virulence of the viral strain and the quality/strength of host immune response

4. Control of HIV replication and disease progression by balance of host factors

5. Viral load “set-point” is a major determinant of disease progression “Set-point” determined by a balance between the virulence of the viral strain and the quality/strength of host immune response

7. Viral Load is a stronger and more independent predictor of disease progression than CD4 count

8. Viral Load Tests Quantitative (Viral Load determination) Quantitative RT-PCR (<2x10 2 -1x10 6 ) Most sensitive for low levels of viral RNA Requires ~200  l of blood Branched chain DNA (<5x10 2 -1x10 6 ) Most accurate for high levels of viral RNA Requires ~2 ml of blood NASBA (Nucleic Acid Based Sequence Amplification) (<4x10 3 -1x10 6 ) Clinical interpretation of Viral Load must take into account the type of assay used. Inter-assay differences can differ by as much a 0.5 log.

9. Combination anti-viral Rx can reduced viral loads down to undetectable levels (<50 copies /ml) RT Pr

10. RT Inhibitors Protease Inhibitors Entry Inhibitors Synergism (Fuzeon™)

11. Log Viral Load Phase 1: Exponential Decay Phase 2: Linear Decay Phase 3: t 1/2 of this phase can be used to approximate treatment time for eradication

12. } Latently Infected Cells --turnover is very slow --relatively resistant to anti-viral Rx

13. CCR5++ CCR5+ Activation Step Is critical for recovery of virus from latent reservoir CCR5- CCR5++ Viral Eradication may require repeated “flush and kill” regimens How do we determine the number of latently infected cells if (1) Latently infected cells are so rare, and (2) Virus is not replicating in latently infected cells

14. Isolate highly purified CD4+ Naïve T-cells CD4+, CD3+, CD25-. CD69-, HLA-DR- (Activation Markers) <0.01% of resting T-cells are latently infected Limiting Dilution 5 x 10 6 1 x 10 6 2 x 10 5 4 x 10 4 8 x 10 3 Activation add PHA, add CD4+ T cells from HIV-negative donor to rescue virus Detect viral replication on day 7-9, back-calculate IUPM based on lowest dilution from which virus can be rescued

15. 5 x 10 6 1 x 10 6 2 x 10 5 4 x 10 4 8 x 10 3 ++++- IUPM 25 ++--- 1 +++++ >100 +++++ ++++- +++-- ++--- +---- ----- Time on HAART Key: (+) = virus replication detected (- ) = no virus replication detected Increasing time

16. Is Eradication Possible? Rx period>67 years

17. Mechanism for persistance of latent reservoir Stability reflects basic biology of memory T cells Long lived immunity (resting T cells) HepC and Measles specificT cells can be detected >20 years after primary infection Half life of memory T cells (>6 months) Viremia is NOT completely eliminated Undetectable viral load = No viral replication Continual low-level infection of T cells, replenishment of latent reservoir How does one determine low level of viral replication below limits of detection?

19. Eradication of Viral Reservoirs Treatment Intensification--5-drug HAART “ Flushing out” latent virus T cell activation Structured Treatment Interruptions “Autoimmunization” (no longer recommended)

20. North America

21. Challenges for an AIDS Vaccine Antibody response Elicitation of Abs towards neutralizing epitopes (conserved) Oligomeric vs monomeric Env response CTL response Conserved CTL epitopes Neutralization Escape mutants Sustaining the response (live viral vectors)