01/11/2015
Ariberto Fassati
What is AIDS?
Acquired ImmunoDeficiency Syndrome
First reported in 1981 in 5 North American gay men
www.cdc.gov/mmwr/PDF/wk/mm5021.pdf
Virus first isolated in France and USA
Barre-Sinoussi F, et al. Science. 1983 220: 868-71
Popovic M, Science. 1984 May 4;224(4648):497-500
CDC's definition of AIDS includes all HIV-infected people who have
fewer than 200 CD4+ T cells per cubic millimeter of blood
http://www.niaid.nih.gov/factsheets/hivinf.htm
And presents with:
Profound immune deficiency, Opportunistic infections and Kaposis Sarcoma
Lymphadenopathy, wasting, fever, pneumonia.
Very low CD4+ T cells, high CD8+ T cells (inverted T4:T8 ratio)
Acute HIV-1 infection presents as:
Asymptomatic or fever, headache, tiredness, generalised swollen glands
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HIV/AIDS: how?
Chimpanzee
Gorilla
Sooty mangabey
SIVcpz
SIVgor
SIVsm
HIV-1 M
HIV-1 O
HIV-2
Phylogenetic tree of HIVs and SIVs
Based on sequencing data
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/AIDS
Different dynamics of HIV-1 O and HIV-1 M
Faria et al. Science 2014 346: 56.
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HIV-1 variation and the pandemic
Group N: discovered in 1998 in Cameroon (rare)
Group O: outlier in West-Central Africa
Group M: major worldwide
Clade B and recombinants thereof are
dominant in North and South America,
Western Europe and Australasia
Clades A and C and recombinants are
dominant in China, India, sub-Saharan
Africa and parts of Russia.
Consequences for
1) Vaccine design
2) Diagnosis
3) Pathogenesis
HIV-1 sequence variability
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HIV/AIDS: when?
Date of origin of HIV-1: around 1920
First virus isolate available to date: 1952 from Kinshasa (DR Congo)
First retrospective case of HIV-1 seroconversion (infection): 1959
in Kinshasa.
First 5 cases reported in 1981 in USA
(Gottlieb et al. 1981 N. Engl. J. Med 305: 1425)
Number of deaths directly due to AIDS to 2007: >24 million
Number of people infected with HIV-1 at 2008: ~32 million
HIV/AIDS: where?
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Samples (from 1960) recovered from hospital in Congo showed that the epidemic probably started
around 1908
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Faria et al. Science 2014 346: 56.
II. HIV Life cycle
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HIV-1 genome organization
Approximately 9Kb
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Structure of the mature HIVHIV-1 particle
The outer envelope of
HIV consists of a lipid
bilayer with protruding
Env spikes
(heterotrimers of
SU3TM3). Inside the
envelope lie shells of
Gag proteins. In the
immature particle, Gag
itself forms a single
shell.
In the mature particle, MA associates with the membrane, CA forms the
conical capsid, and NC coats the viral RNA genome. The core contains two
genomic RNA strands (plus strand), tRNALys3, and ~50 copies of each viral
enzyme (PR, RT, and IN). Cellular proteins are also incorporated eg
Cyclophilins
Image Reconstruction of HIV-1 Cores
Li, S., C. P. Hill, W. I. Sundquist, and J. T. Finch. 2000.
Image reconstructions of helical assemblies of the HIV-1 CA protein. Nature 407:409-13.
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Robert W. Doms et al. Genes Dev. 2000; 14: 2677-2688
Major co-receptors: chemokine receptor CCR5 and CXCR4. CCR5 is essential for virus
transmission in vivo, present on T-helper lymphocytes, macrophages, microglial cells.
CXCR4 used in the late phase of the infection.
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Reverse transcription:
The RNA genome (two +strands of RNA)
is converted into a double stranded DNA
molecule by reverse transcriptase (RT), a
viral enzyme.
Reverse Transcription
5 R U5 PBS
tRNA
PPT
U3 R
AAA 3
DNA synthesis
R U5 PBS
PPT
U3 R
PPT
U3 R AAA
AAA
RNase H
PBS
R U5
First strand transfer
PBS
PPT
DNA synthesis
RNase H
PBS
PPT
PBS
DNA synthesis
RNase H
PPT
U3 R AAA
R U5
U3 R U5
U3 R U5
U3 R U5
U3 R U5
Second strand transfer
DNA synthesis
U3 R U5
U3 R U5
U3 R U5
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Visualisation of HIV-1 inside an infected cell. The RTC/PIC travels along microtubules and is
a large structure composed of viral and cellular factors. Reverse transcription takes place within
this structure.
Integration and generation of a provirus
Two bases are removed from the
3 end of both viral DNA strands
by integrase
Cellular DNA is cleaved by
Integrase leaving two 4bp
overhangs
The 3 ends of viral DNA are
Joined to the host DNA a few
bases apart
Gaps and mismatches are
Repaired by cellular enzymes
And a 4 bp duplication is
formed at the end of the provirus
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Protease
MLV
Changes in virion
morphology during maturation
MPMV
HTLV
HIV
III. HIV-1 infection
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HIV-1 cellular tropism defined by
receptor usage
R5
R5X4
X4
CD4+ T
Dendritic,
Langerhans
Macrophage
Activated/
effector memory
?
Microglia
naive
CD4
CCR5
CXCR4
Astrocyte
1) HIV may be picked up by inter-digitating
DCs and Langerhans cells (DC-SIGN or
direct infection) and shuttled to the draining
lymph nodes
2) HIV may cross the epithelial barrier
via damage to epithelium from trauma or
co-infection with other agents and directly
infect Lamina Propria CD4+ target cells
3) HIV may be able to transcytose across the
epithelial monolayer of the ecto-cervix to
access Lamina Propria
Initial seeding leads to massive
dissemination to all lymphoid tissue within
3 weeks on infection
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The natural history of HIV
infection
Average time to AIDS ~10
years post infection
Total CD4 T cells
Acute phase (1-4 weeks),
Antibodies present after 4
weeks (diagnostic).
HIV-specific CD8 T cells
HIV-specific neutralising antibody
Neutralising Abs appear
later in the course of
infection.
Viral load (RNA)
HIV-specific CD4 T cells
0
Primary
Infection
(months)
Asymptomatic (clinical latency)
(years)
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AIDS
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Anti-HIV CD8 T-cells
detected ~2 weeks after
infection, contribute to
control viral replication
V. Antiretrovirals
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Approved Antiretrovirals
Brand name
Generic name
Nucleoside reverse transcriptase inhibitors (NRTIs)
Retrovir
Zidovudine (AZT
Videx
Didanosine (ddI)
Hivid
Zalcitabine (ddC)
Zerit
Stavudine (d4T)
Epivir
Lamivudine (3TC)
Combivir
Lamivudine+Zidovudine
Ziagen
Abacavir
Trizivir
Abacavir+lamivudine+zidovudine
Videx EC
Didanosine (ddI)
Viread
Tenofovir disoproxil
Emtriva
Emtricitabine (FTC)
Epzicom
Abacavir+Lamivudine
Truvada
Emtricitabine+Tenofovir
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Viramune
Nevirapine
Rescriptor
Delavirdine (DLV)
Sustiva
Efavirenz
Intelence
etravirine
Protese Inhibitors (PIs)
Aptivus
Tipranavir (TPV)
Invirase
Saquinavir
Norvir
Ritonavir
Crixivan
Indinavir (IDV)
Viracept
Nalfinavir
Fortovase
Sequinavir Mesylate
Agenerase
Amprenavir
Kaletra
Lopinavir+Ritonavir
Reyataz
Azatavir
Lexiva
Fosemprenavir
Fusion Inhibitors
Fuzeon
Enfuvirtide (T20)
Entry inhibitors
Selzentry
Maraviroc
HIV integrase strand transfer inhibitor
Isentress
Raltagrevir
Multi-class Combination Product
Atripla
Efavirenz,emtricitabine and tenofovir
manufacturer
GlaxoSmithKline
Bristol-Meyers Squibb
Roche Pharmaceuticals
Bristol-Meyers Squibb
GlaxoSmithKline
GlaxoSmithKline
GlaxoSmithKline
GlaxoSmithKline
Bristol-Meyers Squibb
Gilead Sciences
Gilead Sciences
GlaxoSmithKline
Gilead Sciences
Boehringer Ingelheim
Pfizer
Bristol-Meyers Squibb
Tibotec Therapeutics
Boehringer Ingelheim
Roche Pharmaceuticals
Abbott Laboratories
Merck
Pfizer
Roche Pharmaceuticals
GlaxoSmithKline
Abbott Laboratories
Bristol-Meyers Squibb
GlaxoSmithKline
Hoffman-La Roche
Pfizer
Merck & Co
Brtistol MS and Gilead Sciences
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Side Effects
Lipodystrophy
Myopathy
Hepatotoxicity
Immunorestoration
Disease
Rashes
HIV-1 resistance to drugs
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Problems with antiretrovirals:
1) Latent reservoirs (memory T-cells, brain microglia).
Thus virus cannot be eradicated by therapy.
2) Emergence and spread of resistant mutants (even to
several drugs).
3) Toxicity and compliance
IV. Viral reservoirs and latency
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HIV cellular reservoirs
The major reservoirs of HIV-infected cells includes resting memory
T cells
Is a cure possible?
One case of cure known (Berlin patient)
The cured baby was not cured
Several cases of long term remission known
May depend on size of reservoir (the smaller the better)
and time of therapy. May need novel approaches.
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