Limited Durability of Viral Control following Treated Acute HIV Infection

BACKGROUND: Early treatment of acute HIV infection with highly active antiretroviral therapy, followed by supervised treatment interruption (STI), has been associated with at least transient control of viremia. However, the durability of such control remains unclear. Here we present longitudinal follow-up of a single-arm, open-label study assessing the impact of STI in the setting of acute HIV-1 infection. METHODS AND FINDINGS: Fourteen patients were treated during acute HIV-1 infection and subsequently subjected to an STI protocol that required retreatment if viral load exceeded 50,000 RNA copies/ml plasma or remained above 5,000 copies/ml for more than three consecutive weeks. Eleven of 14 (79%) patients were able to achieve viral loads of less than 5,000 RNA copies/ml for at least 90 d following one, two, or three interruptions of treatment. However, a gradual increase in viremia and decline in CD4+ T cell counts was observed in most individuals. By an intention-to-treat analysis, eight (57%), six (43%), and three (21%) of 14 patients achieved a maximal period of control of 180, 360, and 720 d, respectively, despite augmentation of HIV-specific CD4+ and CD8+ T cell responses. The magnitude of HIV-1-specific cellular immune responses before treatment interruption did not predict duration of viremia control. The small sample size and lack of concurrent untreated controls preclude assessment of possible clinical benefit despite failure to control viremia by study criteria. CONCLUSIONS: These data indicate that despite initial control of viremia, durable viral control to less than 5,000 RNA copies/ml plasma in patients following treated acute HIV-1 infection occurs infrequently. Determination of whether early treatment leads to overall clinical benefit will require a larger and randomized clinical trial. These data may be relevant to current efforts to develop an HIV-1 vaccine designed to retard disease progression rather than prevent infection since they indicate that durable maintenance of low-level viremia may be difficult to achieve

HLA Alleles Associated with Delayed Progression to AIDS Contribute Strongly to the Initial CD8(+) T Cell Response against HIV-1

BACKGROUND: Very little is known about the immunodominance patterns of HIV-1-specific T cell responses during primary HIV-1 infection and the reasons for human lymphocyte antigen (HLA) modulation of disease progression. METHODS AND FINDINGS: In a cohort of 104 individuals with primary HIV-1 infection, we demonstrate that a subset of CD8(+) T cell epitopes within HIV-1 are consistently targeted early after infection, while other epitopes subsequently targeted through the same HLA class I alleles are rarely recognized. Certain HLA alleles consistently contributed more than others to the total virus-specific CD8(+) T cell response during primary infection, and also reduced the absolute magnitude of responses restricted by other alleles if coexpressed in the same individual, consistent with immunodomination. Furthermore, individual HLA class I alleles that have been associated with slower HIV-1 disease progression contributed strongly to the total HIV-1-specific CD8(+) T cell response during primary infection. CONCLUSIONS: These data demonstrate consistent immunodominance patterns of HIV-1-specific CD8(+) T cell responses during primary infection and provide a mechanistic explanation for the protective effect of specific HLA class I alleles on HIV-1 disease progression

Selection, transmission, and reversion of an antigen-processing cytotoxic T-lymphocyte escape mutation in Human Immunodeficiency Virus Type 1 infection

Numerous studies now support that human immunodeficiency virus type 1 (HIV-1) evolution is influenced by immune selection pressure, with population studies showing an association between specific HLA alleles and mutations within defined cytotoxic T-lymphocyte epitopes. Here we combine sequence data and functional studies of CD8 T-cell responses to demonstrate that allele-specific immune pressures also select for mutations flanking CD8 epitopes that impair antigen processing. In persons expressing HLA-A3, we demonstrate consistent selection for a mutation in a C-terminal flanking residue of the normally immunodominant Gag KK9 epitope that prevents its processing and presentation, resulting in a rapid decline in the CD8 T-cell response. This single amino acid substitution also lies within a second HLA-A3-restricted epitope, with the mutation directly impairing recognition by CD8 T cells. Transmission of the mutation to subjects expressing HLA-A3 was shown to prevent the induction of normally immunodominant acute-phase responses to both epitopes. However, subsequent in vivo reversion of the mutation was coincident with delayed induction of new CD8 T-cell responses to both epitopes. These data demonstrate that mutations within the flanking region of an HIV-1 epitope can impair recognition by an established CD8 T-cell response and that transmission of these mutations alters the acute-phase CD8+ T-cell response. Moreover, reversion of these mutations in the absence of the original immune pressure reveals the potential plasticity of immunologically selected evolutionary changes

The sexual pain disorders: Is the pain sexual or is the sex painful?

The concept of a sexual pain disorder is both intriguing and confusing. It is intriguing because the basic premise underlying this idea appears to be that there is a special type of pain which is sexual in nature. If this premise is true, then the study of sexual pain that becomes pleasurable or sexual pleasure that becomes painful might provide us with crucial information concerning the relationship of pain and pleasure. The nature of this relationship has intrigued philosophers, psychologists, and neuroscientists for many generations. On the other hand, the sexual pain concept is confusing because acceptance of the notion of sexual pain implies that there may be numerous other special types of pain, such as work pain and sports pain. This seems unlikely and raises doubt about whether there is a special type of sexual pain. The term, sexual pain, is also confusing because it is vague and can be understood in at least two distinct ways. Does it mean pain induced by sexual activities, thoughts, and feelings, or does it mean sexual pleasure induced by painful activities, thoughts, or feelings

Liver transplantation for alpha-1-antitrypsin deficiency in children

Alpha-1-antitrypsin (a1-AT) deficiency is an inborn error of metabolism, which can cause liver disease. The condition is one of the most common genetic disorders in the Caucasian population. Here we review our experience with 21 children suffering from end-stage liver disease due to a1-AT deficiency. All children are PIZZ homozygotes. Nineteen of them initially presented with neonatal jaundice and two with hepatosplenomegaly in childhood. Twenty-five liver transplantations were performed. All children are currently alive at a median followup of 40 months. Liver replacement provides the only definite treatment for children with end-stage liver disease associated with a1-AT deficiency. Excellent results can be achieved by reducing waiting time for transplantation and by early referral to a liver transplant centre

HLA Alleles Associated with Delayed Progression to AIDS Contribute Strongly to the Initial CD8\u3ci\u3e+\u3c/i\u3e T Cell Response against HIV-1

Background Very little is known about the immunodominance patterns of HIV-1-specific T cell responses during primary HIV-1 infection and the reasons for human lymphocyte antigen (HLA) modulation of disease progression. Methods and Findings In a cohort of 104 individuals with primary HIV-1 infection, we demonstrate that a subset of CD8+ T cell epitopes within HIV-1 are consistently targeted early after infection, while other epitopes subsequently targeted through the same HLA class I alleles are rarely recognized. Certain HLA alleles consistently contributed more than others to the total virus-specific CD8+ T cell response during primary infection, and also reduced the absolute magnitude of responses restricted by other alleles if coexpressed in the same individual, consistent with immunodomination. Furthermore, individual HLA class I alleles that have been associated with slower HIV-1 disease progression contributed strongly to the total HIV-1-specific CD8+ T cell response during primary infection. Conclusions These data demonstrate consistent immunodominance patterns of HIV-1-specific CD8+ T cell responses during primary infection and provide a mechanistic explanation for the protective effect of specific HLA class I alleles on HIV-1 disease progression

Stereotypic escape from CD8+ T-cell responses represents a major driving force of HIV-1 sequence diversity and reveals constraints on HIV-1 evolution

Background: Understanding the factors driving global HIV-1 sequence diversity is critical for vaccine development. While viral escape from CD8+ T-cell responses is well documented, it remains unclear the extent to which intra-host and global HIV-1 evolution is specifically driven by these selective pressures. Similarly, little is known regarding the extent to which sequence constraints upon protein structure affect the accumulation of mutations arising from immune selection pressures. Methods: We assessed the relationship between genome-wide viral evolution (excluding Env) and HIV-1-specific cellular immune responses in 4 patients followed longitudinally for as long as 5 years after acute infection. Ten additional chronically infected subjects expressing HLA-B57 were examined to assess reproducibility of escape mutations. Full genome population sequencing of HIV-1 was employed, and measurement of HIV-1-specific CD8+ T-cell responses using consensus, and in some cases autologous peptides, was conducted using an IFN-γ ELISpot assay. Results: A total of 98 mutations evolved in the 4 study subjects, 52 of which were associated with detectable virus-specific CD8+ T-cell responses, accounting for 48 to 60% of the mutations in each subject. In addition, 18 mutations reverted to common consensus residues, 9 of which were associated with HLA class I alleles not expressed by the respective subject, consistent with adaptations due to previous CD8+ T-cell selective pressures. Therefore, nearly two-thirds of all mutations were attributable to CD8+ T-cell selective pressures. Although the majority of CD8+ T-cell responses did not result in detectable viral evolution, targeted residues in epitopes that did mutate correlated with the most polymorphic sites in both clade B and C viruses, and selection pressure frequently resulted in identical amino acid substitutions arising in a given CD8 epitope across multiple subjects. Conclusions: These data indicate a dominant role of cellular immune responses in driving both individual and global HIV-1 evolution, and the stereotypic nature of acquired mutations provides evidence for constraints on evolution of highly variable RNA viruses

The Majority of Currently Circulating Human Immunodeficiency Virus Type 1 Clade B Viruses Fail To Prime Cytotoxic T-Lymphocyte Responses against an Otherwise Immunodominant HLA-A2-Restricted Epitope: Implications for Vaccine Design

Human immunodeficiency virus type 1 (HIV-1) mutates to escape immune selection pressure, but there is little evidence of selection mediated through HLA-A2, the dominant class I allele in persons infected with clade B virus. Moreover, HLA-A2-restricted responses are largely absent in the acute phase of infection as the viral load is being reduced, suggesting that circulating viruses may lack immunodominant epitopes targeted through HLA-A2. Here we demonstrate an A2-restricted epitope within Vpr (Vpr(59-67)) that is targeted by acute-phase HIV-1-specific CD8(+) T cells, but only in a subset of persons expressing HLA-A2. Individuals in the acute stage of infection with viruses containing the most common current sequence within this epitope (consensus sequence) were unable to mount epitope-specific T-cell responses, whereas subjects infected with the less frequent I(60)L variant all developed these responses. The I(60)L variant epitope was a stronger binder to HLA-A2 and was recognized by epitope-specific T cells at lower peptide concentrations than the consensus sequence epitope. These data demonstrate that HLA-A2 is capable of contributing to the acute-phase cytotoxic T-lymphocyte response in infected subjects, but that most currently circulating viruses lack a dominant immunogenic epitope presented by this allele, and suggest that immunodominant epitopes restricted by common HLA alleles may be lost as the epidemic matures