Effects of Combined CCR5/Integrase Inhibitors-Based Regimen on Mucosal Immunity in HIV-Infected Patients Na？ve to Antiretroviral Therapy: A Pilot Randomized Trial
Whether initiation of antiretroviral therapy (ART) regimens aimed at achieving greater concentrations within gut associated lymphoid tissue (GALT) impacts the level of mucosal immune reconstitution, inflammatory markers and the viral reservoir remains unknown. We included 12 HIV- controls and 32 ART-na？ve HIV patients who were randomized to efavirenz, maraviroc or maraviroc+raltegravir, each with fixed-dose tenofovir disoproxil fumarate/emtricitabine. Rectal and duodenal biopsies were obtained at baseline and at 9 months of ART. We performed a comprehensive assay of T-cell subsets by flow cytometry, T-cell density in intestinal biopsies, plasma and tissue concentrations of antiretroviral drugs by high-performance liquid chromatography/mass spectroscopy, and plasma interleukin-6 (IL-6), lipoteichoic acid (LTA), soluble CD14 (sCD14) and zonulin-1 each measured by ELISA. Total cell-associated HIV DNA was measured in PBMC and rectal and duodenal mononuclear cells. Twenty-six HIV-infected patients completed the follow-up. In the duodenum, the quadruple regimen resulted in greater CD8+ T-cell density decline, greater normalization of mucosal CCR5+CD4+ T-cells and increase of the na？ve/memory CD8+ T-cell ratio, and a greater decline of sCD14 levels and duodenal HIV DNA levels (P = 0.004 and P = 0.067, respectively), with no changes in HIV RNA in plasma or tissue. Maraviroc showed the highest drug distribution to the gut tissue, and duodenal concentrations correlated well with other T-cell markers in duodenum, i.e., the CD4/CD8 ratio, %CD4+ and %CD8+ HLA-DR+CD38+ T-cells. Maraviroc use elicited greater activation of the mucosal na？ve CD8+ T-cell subset, ameliorated the distribution of the CD8+ T-cell maturational subsets and induced higher improvement of zonulin-1 levels. These data suggest that combined CCR5 and integrase inhibitor based combination therapy in ART treatment na？ve patients might more effectively reconstitute duodenal immunity, decrease inflammatory markers and impact on HIV persistence by cell-dependent mechanisms, and show unique effects of MVC in duodenal immunity driven by higher drug tissue penetration and possibly by class-dependent effects.
References
[1]
Sandler NG, Wand H, Roque A, Law M, Nason MC, Nixon DE, et al. Plasma levels of soluble CD14 independently predict mortality in HIV infection. J Infect Dis. 2011;203: 780–90. doi: 10.1093/infdis/jiq118. pmid:21252259
[2]
Hunt PW, Sinclair E, Rodriguez B, Shive C, Clagett B, Funderburg N, et al. Gut Epithelial Barrier Dysfunction and Innate Immune Activation Predict Mortality in Treated HIV Infection. J Infect Dis. 2014;210: 1228–38. doi: 10.1093/infdis/jiu238. pmid:24755434
[3]
Tenorio AR, Zheng Y, Bosch RJ, Krishnan S, Rodriguez B, Hunt PW, et al. Soluble Markers of Inflammation and Coagulation but Not T-Cell Activation Predict Non-AIDS-Defining Morbid Events During Suppressive Antiretroviral Treatment. J Infect Dis. 2014;210: 1248–59. doi: 10.1093/infdis/jiu254. pmid:24795473
[4]
Deeks SG, Tracy R, Douek DC. Systemic Effects of Inflammation on Health during Chronic HIV Infection. Immunity. Elsevier Inc.; 2013;39: 633–45. doi: 10.1016/j.immuni.2013.10.001. pmid:24138880
[5]
Gordon SN, Cervasi B, Odorizzi P, Silverman R, Aberra F, Ginsberg G, et al. Disruption of intestinal CD4+ T cell homeostasis is a key marker of systemic CD4+ T cell activation in HIV-infected individuals. J Immunol. American Association of Immunologists; 2010;185: 5169–79. doi: 10.4049/jimmunol.1001801. pmid:20889546
[6]
Gillin JS, Shike M, Alcock N, Urmacher C, Krown S, Kurtz RC, et al. Malabsorption and mucosal abnormalities of the small intestine in the acquired immunodeficiency syndrome. Ann Intern Med. 1985;102: 619–22.
[7]
Lau K-K, Chan Y-H, Yiu K-H, Tam S, Li S-W, Lau C-P, et al. Incremental predictive value of vascular assessments combined with the Framingham Risk Score for prediction of coronary events in subjects of low-intermediate risk. Postgraduate medical journal. 2008. pp. 153–157. doi: 10.1136/pgmj.2007.064089. pmid:18372487
[8]
Li Q, Estes JD, Duan L, Jessurun J, Pambuccian S, Forster C, et al. Simian immunodeficiency virus-induced intestinal cell apoptosis is the underlying mechanism of the regenerative enteropathy of early infection. J Infect Dis. 2008;197: 420–9. doi: 10.1086/525046. pmid:18199035
[9]
Estes JD, Harris LD, Klatt NR, Tabb B, Pittaluga S, Paiardini M, et al. Damaged intestinal epithelial integrity linked to microbial translocation in pathogenic simian immunodeficiency virus infections. PLoS Pathog. 2010;6: e1001052. doi: 10.1371/journal.ppat.1001052. pmid:20808901
[10]
Vujkovic-Cvijin I, Dunham RM, Iwai S, Maher MC, Albright RG, Broadhurst MJ, et al. Dysbiosis of the Gut Microbiota Is Associated with HIV Disease Progression and Tryptophan Catabolism. Sci Transl Med. 2013;5: 193ra91. doi: 10.1126/scitranslmed.3006438. pmid:23843452
[11]
Dinh DM, Volpe GE, Duffalo C, Bhalchandra S, Tai AK, Kane A V, et al. The Intestinal Microbiota, Microbial Translocation and Systemic Inflammation in Chronic HIV Infection. J Infect Dis. 2014; doi: 10.1093/infdis/jiu409.
[12]
Vázquez-Castellano JF, Serrano-Villar S, Latorre A, Artacho A, Ferrus ML, Madrid N, et al. Altered metabolism of gut microbiota contributes to chronic immune activation in HIV-infected individuals. Mucosal Immunol. 2015;8: 760–772. doi: 10.1038/mi.2014.107. pmid:25407519
[13]
Lozupone C, Li M, Campbell TB, Flores SC, Linderman D, Gebert MJ, et al. Alterations in the gut microbiota associated with HIV-1 infection. Cell Host Microbe. Elsevier Inc.; 2013;14: 329–39. doi: 10.1016/j.chom.2013.08.006. pmid:24034618
[14]
Tenorio AR, Chan ES, Bosch RJ, Macatangay BJC, Read SW, Yesmin S, et al. Rifaximin has a marginal impact on microbial translocation, T-cell activation and inflammation in HIV-positive immune non-responders to antiretroviral therapy—ACTG A5286. J Infect Dis. 2015;211: 780–90. doi: 10.1093/infdis/jiu515. pmid:25214516
[15]
Tenorio AR, Zheng Y, Bosch RJ, Deeks SG, Rodriguez B, Krishnan S, et al. Soluble Markers of Inflammation & Coagulation, but not T-Cell Activation, Predict Non-AIDS- Defining Events During Suppressive Antiretroviral Therapy (ART). Conference of Retrovirus and Opportunistic Infections, Boston, MA. 2014.
[16]
Schuetz A, Deleage C, Sereti I, Rerknimitr R, Phanuphak N, Phuang-Ngern Y, et al. Initiation of ART during early acute HIV infection preserves mucosal Th17 function and reverses HIV-related immune activation. PLoS Pathog. 2014;10: e1004543. doi: 10.1371/journal.ppat.1004543. pmid:25503054
[17]
Jain V, Hartogensis W, Bacchetti P, Hunt PW, Hatano H, Sinclair E, et al. Antiretroviral Therapy Initiated within 6 Months of HIV Infection is Associated with Lower T-Cell Activation and Smaller HIV Reservoir Size. J Infect Dis. 2013;208: 1202–11. doi: 10.1093/infdis/jit311. pmid:23852127
[18]
Fletcher C V, Staskus K, Wietgrefe SW, Rothenberger M, Reilly C, Chipman JG, et al. Persistent HIV-1 replication is associated with lower antiretroviral drug concentrations in lymphatic tissues. Proc Natl Acad Sci. 2014;111: 2307–12. doi: 10.1073/pnas.1318249111. pmid:24469825
[19]
Chun T-W, Nickle DC, Justement JS, Meyers JH, Roby G, Hallahan CW, et al. Persistence of HIV in gut-associated lymphoid tissue despite long-term antiretroviral therapy. J Infect Dis. 2008;197: 714–20. doi: 10.1086/527324. pmid:18260759
[20]
Asmuth DM, Goodrich J, Cooper DA, Haubrich R, Rajicic N, Hirschel B, et al. CD4+ T-cell restoration after 48 weeks in the maraviroc treatment-experienced trials MOTIVATE 1 and 2. J Acquir Immune Defic Syndr. 2010;54: 394–7. doi: 10.1097/QAI.0b013e3181c5c83b. pmid:20009949
[21]
Funderburg N, Kalinowska M, Eason J, Goodrich J, Heera J, Mayer H, et al. Effects of maraviroc and efavirenz on markers of immune activation and inflammation and associations with CD4+ cell rises in HIV-infected patients. PLoS One. 2010;5: e13188. doi: 10.1371/journal.pone.0013188. pmid:20949133
[22]
Gutiérrez C, Díaz L, Vallejo A, Hernández-Novoa B, Abad M, Madrid N, et al. Intensification of antiretroviral therapy with a CCR5 antagonist in patients with chronic HIV-1 infection: effect on T cells latently infected. PLoS One. 2011;6: e27864. doi: 10.1371/journal.pone.0027864. pmid:22174752
[23]
Walker DK, Bowers SJ, Mitchell RJ, Potchoiba MJ, Schroeder CM, Small HF. Preclinical assessment of the distribution of maraviroc to potential human immunodeficiency virus (HIV) sanctuary sites in the central nervous system (CNS) and gut-associated lymphoid tissue (GALT). Xenobiotica. 2008;38: 1330–9. doi: 10.1080/00498250802447409. pmid:18853388
[24]
Wilkin TJ, Lalama CM, McKinnon J, Gandhi RT, Lin N, Landay A, et al. A pilot trial of adding maraviroc to suppressive antiretroviral therapy for suboptimal CD4+ T-cell recovery despite sustained virologic suppression: ACTG A5256. J Infect Dis. 2012;206: 534–42. doi: 10.1093/infdis/jis376. pmid:22740718
[25]
Asmuth DM, Ma Z-M, Mann S, Knight TH, Yotter T, Albanese A, et al. Gastrointestinal-associated lymphoid tissue immune reconstitution in a randomized clinical trial of raltegravir versus non-nucleoside reverse transcriptase inhibitor-based regimens. AIDS. 2012;26: 1625–34. doi: 10.1097/QAD.0b013e3283546595. pmid:22820612
[26]
Chege D, Kovacs C, la Porte C, Ostrowski M, Raboud J, Su D, et al. Effect of raltegravir intensification on HIV proviral DNA in the blood and gut mucosa of men on long-term therapy. Aids. 2012;26: 167–174. doi: 10.1097/QAD.0b013e32834e8955. pmid:22089379
[27]
Murray JM, Emery S, Kelleher AD, Law M, Chen J, Hazuda DJ, et al. Antiretroviral therapy with the integrase inhibitor raltegravir alters decay kinetics of HIV, significantly reducing the second phase. AIDS. 2007;21: 2315–21. doi: 10.1097/QAD.0b013e3282f12377. pmid:18090280
[28]
Patterson KB, Prince H a, Stevens T, Shaheen NJ, Dellon ES, Madanick RD, et al. Differential penetration of raltegravir throughout gastrointestinal tissue: implications for eradication and cure. AIDS. 2013;27: 1413–9. doi: 10.1097/QAD.0b013e32835f2b49. pmid:23945503
[29]
Critchfield JW, Lemongello D, Walker DH, Garcia JC, Asmuth DM, Pollard RB, et al. Multifunctional human immunodeficiency virus (HIV) gag-specific CD8+ T-cell responses in rectal mucosa and peripheral blood mononuclear cells during chronic HIV type 1 infection. J Virol. 2007;81: 5460–71. doi: 10.1128/JVI.02535-06. pmid:17344302
[30]
Shacklett BL, Critchfield JW, Lemongello D. Isolating mucosal lymphocytes from biopsy tissue for cellular immunology assays. Methods Mol Biol. 2009;485: 347–56. doi: 10.1007/978-1-59745-170-3_23. pmid:19020836
[31]
Sallusto F, Geginat J, Lanzavecchia A. Central memory and effector memory T cell subsets: function, generation, and maintenance. Annu Rev Immunol. 2004;22: 745–63. doi: 10.1146/annurev.immunol.22.012703.104702. pmid:15032595
[32]
Asmuth DM, Ma Z-M, Albanese A, Sandler NG, Devaraj S, Knight TH, et al. Oral serum-derived bovine immunoglobulin improves duodenal immune reconstitution and absorption function in patients with HIV enteropathy. AIDS. 2013;27: 2207–17. doi: 10.1097/QAD.0b013e328362e54c. pmid:23660579
[33]
Li Q, Duan L, Estes JD, Ma Z-M, Rourke T, Wang Y, et al. Peak SIV replication in resting memory CD4+ T cells depletes gut lamina propria CD4+ T cells. Nature. 2005;434: 1148–52. doi: 10.1038/nature03513. pmid:15793562
[34]
Vaccari M, Boasso A, Ma Z-M, Cecchinato V, Venzon D, Doster MN, et al. CD4+ T-cell loss and delayed expression of modulators of immune responses at mucosal sites of vaccinated macaques following SIV(mac251) infection. Mucosal Immunol. 2008;1: 497–507. doi: 10.1038/mi.2008.60. pmid:19079217
[35]
Chun T-W, Justement JS, Lempicki RA, Yang J, Dennis G, Hallahan CW, et al. Gene expression and viral prodution in latently infected, resting CD4+ T cells in viremic versus aviremic HIV-infected individuals. Proc Natl Acad Sci U S A. 2003;100: 1908–13. doi: 10.1073/pnas.0437640100. pmid:12552096
[36]
Brown KC, Patterson KB, Malone S a., Shaheen NJ, Prince HMA, Dumond JB, et al. Single and multiple dose pharmacokinetics of maraviroc in saliva, semen, and rectal tissue of healthy HIV-negative men. J Infect Dis. 2011;203: 1484–1490. doi: 10.1093/infdis/jir059. pmid:21502084
[37]
Thompson CG, Bokhart MT, Sykes C, Adamson L, Fedoriw Y, Luciw PA, et al. Mass Spectrometry Imaging Reveals Heterogeneous Efavirenz Distribution within Putative HIV Reservoirs. Antimicrob Agents Chemother. 2015;59: 2944–8. doi: 10.1128/AAC.04952-14. pmid:25733502
[38]
Lanoy E, Dores GM, Madeleine MM, Toro JR, Fraumeni JF, Engels E a. Epidemiology of nonkeratinocytic skin cancers among persons with AIDS in the United States. AIDS. 2009;23: 385–93. doi: 10.1097/QAD.0b013e3283213046. pmid:19114864
[39]
Serrano-Villar S, Sainz T, Lee S a., Hunt PW, Sinclair E, Shacklett BL, et al. HIV-Infected Individuals with Low CD4/CD8 Ratio despite Effective Antiretroviral Therapy Exhibit Altered T Cell Subsets, Heightened CD8+ T Cell Activation, and Increased Risk of Non-AIDS Morbidity and Mortality. Silvestri G, editor. PLoS Pathog. Public Library of Science; 2014;10: e1004078. doi: 10.1371/journal.ppat.1004078. pmid:24831517
[40]
Robbins GK, Spritzler JG, Chan ES, Asmuth DM, Gandhi RT, Rodriguez B a, et al. Incomplete reconstitution of T cell subsets on combination antiretroviral therapy in the AIDS Clinical Trials Group protocol 384. Clin Infect Dis. 2009;48: 350–361. doi: 10.1086/595888. pmid:19123865
[41]
Mudd JC, Lederman MM. CD8 T cell persistence in treated HIV infection. Curr Opin HIV AIDS. 2014;9: 500–5. doi: 10.1097/COH.0000000000000086. pmid:25010897
[42]
Deeks SG. HIV infection, inflammation, immunosenescence, and aging. Annu Rev Med. 2011;62: 141–155. doi: 10.1146/annurev-med-042909-093756. pmid:21090961
[43]
Kaech SM, Ahmed R. Memory CD8+ T cell differentiation: initial antigen encounter triggers a developmental program in na？ve cells. Nat Immunol. 2001;2: 415–22. doi: 10.1038/87720. pmid:11323695
[44]
Cho J-H, Boyman O, Kim H-O, Hahm B, Rubinstein MP, Ramsey C, et al. An intense form of homeostatic proliferation of naive CD8+ cells driven by IL-2. J Exp Med. 2007;204: 1787–801. doi: 10.1084/jem.20070740. pmid:17664294
[45]
Cho J-H, Kim H-O, Kim K-S, Yang D-H, Surh CD, Sprent J. Unique features of naive CD8+ T cell activation by IL-2. J Immunol. American Association of Immunologists; 2013;191: 5559–73. doi: 10.4049/jimmunol.1302293. pmid:24166977
[46]
Mattapallil JJ, Douek DC, Hill B, Nishimura Y, Martin M, Roederer M. Massive infection and loss of memory CD4+ T cells in multiple tissues during acute SIV infection. Nature. 2005;434: 1093–1097. doi: 10.1542/peds.2006-0900HHHH. pmid:15793563
[47]
Klatt NR, Chomont N, Douek DC, Deeks SG. Immune activation and HIV persistence: implications for curative approaches to HIV infection. Immunol Rev. 2013;254: 326–42. doi: 10.1111/imr.12065. pmid:23772629
[48]
Best BM, Koopmans PP, Letendre SL, Capparelli E V, Rossi SS, Clifford DB, et al. Efavirenz concentrations in CSF exceed IC50 for wild-type HIV. J Antimicrob Chemother. 2011;66: 354–7. doi: 10.1093/jac/dkq434. pmid:21098541
[49]
Dorr P, Westby M, Dobbs S, Griffin P, Irvine B, Macartney M, et al. Maraviroc (UK-427,857), a potent, orally bioavailable, and selective small-molecule inhibitor of chemokine receptor CCR5 with broad-spectrum anti-human immunodeficiency virus type 1 activity. Antimicrob Agents Chemother. 2005;49: 4721–32. doi: 10.1128/AAC.49.11.4721–4732.2005. pmid:16251317
[50]
Croteau D, Letendre S, Best BM, Ellis RJ, Breidinger S, Clifford D, et al. Total raltegravir concentrations in cerebrospinal fluid exceed the 50-percent inhibitory concentration for wild-type HIV-1. Antimicrob Agents Chemother. 2010;54: 5156–60. doi: 10.1128/AAC.00507-10. pmid:20876368
[51]
Cassol E, Malfeld S, Mahasha P, Bond R, Slavik T, Seebregts C, et al. Impaired CD4+ T-cell restoration in the small versus large intestine of HIV-1-positive South Africans receiving combination antiretroviral therapy. J Infect Dis. 2013;208: 1113–22. doi: 10.1093/infdis/jit249. pmid:23749968
[52]
Yukl SA, Gianella S, Sinclair E, Epling L, Li Q, Duan L, et al. Differences in HIV burden and immune activation within the gut of HIV-positive patients receiving suppressive antiretroviral therapy. J Infect Dis. 2010;202: 1553–61. doi: 10.1086/656722. pmid:20939732
[53]
Yukl SA, Shergill AK, McQuaid K, Gianella S, Lampiris H, Hare CB, et al. Effect of raltegravir-containing intensification on HIV burden and T-cell activation in multiple gut sites of HIV-positive adults on suppressive antiretroviral therapy. AIDS. 2010;24: 2451–60. doi: 10.1097/QAD.0b013e32833ef7bb. pmid:20827162
[54]
Buzón MJ, Massanella M, Llibre JM, Esteve A, Dahl V, Puertas MC, et al. HIV-1 replication and immune dynamics are affected by raltegravir intensification of HAART-suppressed subjects. Nat Med. Nature Publishing Group; 2010;16: 460–5. doi: 10.1038/nm.2111. pmid:20228817
[55]
Gutiérrez C, Hernández-Novoa B, Vallejo A, Serrano-Villar S, Abad-Fernández M, Madrid N, et al. Dynamics of the HIV-1 latent reservoir after discontinuation of the intensification of antiretroviral treatment: results of two clinical trials. AIDS. 2013;27: 2081–2088. doi: 10.1097/QAD.0b013e328361d0e1. pmid:24384589
[56]
Gandhi RT, Coombs RW, Chan ES, Bosch RJ, Zheng L, Margolis DM, et al. No effect of raltegravir intensification on viral replication markers in the blood of HIV-1-infected patients receiving antiretroviral therapy. J Acquir Immune Defic Syndr. 2012;59: 229–35. doi: 10.1097/QAI.0b013e31823fd1f2. pmid:22083073
[57]
Lafeuillade A, Assi A, Poggi C, Bresson-Cuquemelle C, Jullian E, Tamalet C. Failure of combined antiretroviral therapy intensification with maraviroc and raltegravir in chronically HIV-1 infected patients to reduce the viral reservoir: the IntensHIV randomized trial. AIDS Res Ther. 2014;11: 33. doi: 10.1186/1742-6405-11-33. pmid:25320633
[58]
Negredo E, Massanella M, Puertas MC, Buzón MJ, Puig J, Pérez-Alvárez N, et al. Early but limited effects of raltegravir intensification on CD4 T cell reconstitution in HIV-infected patients with an immunodiscordant response to antiretroviral therapy. J Antimicrob Chemother. 2013;68: 2358–62. doi: 10.1093/jac/dkt183. pmid:23677919
[59]
Puertas MC, Massanella M, Llibre JM, Ballestero M, Buzon MJ, Ouchi D, et al. Intensification of a raltegravir-based regimen with maraviroc in early HIV-1 infection. AIDS. 2014;28: 325–34. doi: 10.1097/QAD.0000000000000066. pmid:24185044
[60]
Ananworanich J, Schuetz A, Vandergeeten C, Sereti I, de Souza M, Rerknimitr R, et al. Impact of multi-targeted antiretroviral treatment on gut T cell depletion and HIV reservoir seeding during acute HIV infection. Emery S, editor. PLoS One. Public Library of Science; 2012;7: e33948. doi: 10.1371/journal.pone.0033948. pmid:22479485
[61]
Hunt PW, Shulman NS, Hayes TL, Dahl V, Somsouk M, Funderburg NT, et al. The immunologic effects of maraviroc intensification in treated HIV-infected individuals with incomplete CD4+ T-cell recovery: a randomized trial. Blood. 2013;121: 4635–46. doi: 10.1182/blood-2012-06-436345. pmid:23589670
[62]
Hatano H, Hayes TL, Dahl V, Sinclair E, Lee T- H, Hoh R, et al. A randomized, controlled trial of raltegravir intensification in antiretroviral-treated, HIV-infected patients with a suboptimal CD4+ T cell response. J Infect Dis. 2011;203: 960–8. doi: 10.1093/infdis/jiq138. pmid:21402547
[63]
Hatano H, Strain MC, Scherzer R, Bacchetti P, Wentworth D, Hoh R, et al. Increase in 2-long terminal repeat circles and decrease in D-dimer after raltegravir intensification in patients with treated HIV infection: a randomized, placebo-controlled trial. J Infect Dis. 2013;208: 1436–42. doi: 10.1093/infdis/jit453. pmid:23975885
[64]
Guan E, Wang J, Roderiquez G, Norcross MA. Natural truncation of the chemokine MIP-1 beta /CCL4 affects receptor specificity but not anti-HIV-1 activity. J Biol Chem. 2002;277: 32348–52. doi: 10.1074/jbc.M203077200. pmid:12070155
[65]
Madrid N, Hernández-Novoa B, Sastre-Turrión B, Serrano-Villar S, Salomon A, Gutiérrez C, et al. Maraviroc reverts latent HIV-1 in ART suppressed patients through NF-kB without viral load increase. Abstract #P-F8. Conference of Retrovirus and Opportunistic Infections, Boston, MA. 2014.
[66]
Pérez-Matute P, Pérez-Martinez L, Blanco JR, Oteo JA. Maraviroc, a CCR5 Antagonist, Alters Gut Microbiota Composition in a Mouse Model of Obesity. Conference on Retrovirus and Opportunistic Infections, Boston, MA. 2014.
