Administration of vorinostat disrupts HIV-1 latency in patients on antiretroviral therapy.

Despite antiretroviral therapy, proviral latency of human immunodeficiency virus type 1 (HIV-1) remains a principal obstacle to curing the infection. Inducing the expression of latent genomes within resting CD4(+) T cells is the primary strategy to clear this reservoir. Although histone deacetylase inhibitors such as suberoylanilide hydroxamic acid (also known as vorinostat, VOR) can disrupt HIV-1 latency in vitro, the utility of this approach has never been directly proven in a translational clinical study of HIV-infected patients. Here we isolated the circulating resting CD4(+) T cells of patients in whom viraemia was fully suppressed by antiretroviral therapy, and directly studied the effect of VOR on this latent reservoir. In each of eight patients, a single dose of VOR increased both biomarkers of cellular acetylation, and simultaneously induced an increase in HIV RNA expression in resting CD4(+) cells (mean increase, 4.8-fold). This demonstrates that a molecular mechanism known to enforce HIV latency can be therapeutically targeted in humans, provides proof-of-concept for histone deacetylase inhibitors as a therapeutic class, and defines a precise approach to test novel strategies to attack and eradicate latent HIV infection directly.

HIV eradication symposium: will the brain be left behind?

On 18 July 2014, the National Institute of Mental Health in collaboration with ViiV Health Care and Boehringer Ingelheim supported a symposium on HIV eradication and what it meant for the brain. The symposium was an affiliated event to the 20th International AIDS Conference. The meeting was held in Melbourne, Australia, and brought together investigators currently working on HIV eradication together with investigators who are working on the neurological complications of HIV. The purpose of the meeting was to bring the two fields of HIV eradication and HIV neurology together to foster dialogue and cross talk to move the eradication field forward in the context of issues relating to the brain as a potential reservoir of HIV. The outcomes of the symposium were that there was substantive but not definitive evidence for the brain as an HIV reservoir that will provide a challenge to HIV eradication. Secondly, the brain as a clinically significant reservoir for HIV is not necessarily present in all patients. Consequently, there is an urgent need for the development of biomarkers to identify and quantify the HIV reservoir in the brain. Lastly, when designing and developing eradication strategies, it is critical that approaches to target the brain reservoir be included.

The differential short- and long-term effects of HIV-1 latency-reversing agents on T cell function.

Despite the extraordinary success of HIV-1 antiretroviral therapy in prolonging life, infected individuals face lifelong therapy because of a reservoir of latently-infected cells that harbor replication competent virus. Recently, compounds have been identified that can reverse HIV-1 latency in vivo. These latency- reversing agents (LRAs) could make latently-infected cells vulnerable to clearance by immune cells, including cytolytic CD8+ T cells. We investigated the effects of two leading LRA classes on CD8+ T cell phenotype and function: the histone deacetylase inhibitors (HDACis) and protein kinase C modulators (PKCms). We observed that relative to HDACis, the PKCms induced much stronger T cell activation coupled with non-specific cytokine production and T cell proliferation. When examining antigen-specific CD8+ T cell function, all the LRAs except the HDACi Vorinostat reduced, but did not abolish, one or more measurements of CD8+ T cell function. Importantly, the extent and timing of these effects differed between LRAs. Panobinostat had detrimental effects within 10 hours of drug treatment, whereas the effects of the other LRAs were observed between 48 hours and 5 days. These observations suggest that scheduling of LRA and CD8+ T cell immunotherapy regimens may be critical for optimal clearance of the HIV-1 reservoir.

Upper gastrointestinal disease in chronic renal failure. A prospective evaluation.

A prospective study was undertaken to determine the incidence of upper gastrointestinal disease in 85 chronic renal failure (CRF) patients on hemodialysis. Upper gastrointestinal x-rays were obtained for 83 patients, and enlarged gastric and duodenal folds were seen in 12% (10/83) and 42% (35/83) of the cases, respectively. Panendoscopy performed on 60 persons revealed gastritis in 22% (13/60), nodular duodenitis in 60% (35/60), and esophagitis in 13% (8/60). No peptic ulcers were identified either radiologically or endoscopically. Pathologic examination of mucosal biopsy specimens demonstrated gastritis in 46% (21/46) and duodenitis in 43% (22/51) of patients. A highly significant correlation was found between endoscopic and radiologic duodenitis (P less than .0001) and also between endoscopic and pathologic duodenitis. We have demonstrated a high incidence of mucosal inflammation but not ulcer disease in CRF patients. These lesions may predispose these individuals to gastrointestinal bleeding following renal transplantation.

Ischemic bowel disease following bilateral nephrectomy or renal transplant.

In a 2 year period five patients developed pathologically proved ischemic bowel disease (IBD) following either renal transplantation or bilateral nephrectomy in preparations for transplantation. This entity accounted for 42% of all major gastrointestinal complications in this transplant unit. Three patients presented with abdominal pain and ileus, and two patients developed massive lower gastrointestinal hemorrhage. All five patients had nonocclusive ischemic disease because obstruction of a major intestinal vessel could not be documented in any case. Each patient was treated with bowel resection and three of the five patients survived. Although sepsis, shock, and large doses of immunosuppressive drugs have been implicated in predisposing such patients to IBD, these factors were not uniformly present in our cases. Blood volume redistribution with transient episodes of hypotension, especially during postoperative hemodialysis, may be significant. IBD in uremic patients can occur in the presence or absence of renal transplantation and may be the cause of massive intestinal hemorrhage in these individuals.

In Vitro Techniques for Studies of HIV-1 Promoter Activity.

A rather unique feature of the human immunodeficiency virus type-1 (HIV-1) is the structural complexity of the regulatory sequences located in the long-terminal repeat (LTR) promoter region and the number of cellular and viral transcription factors known to interact with these sequences and modulate HIV gene expression see ref. 1). The HIV-1 LTR can be schematically divided into four functional regions: (1) the negative regulatory element (NRE) encompassing nuceotides -350 to -190 with respect to the transcription start site; (2) the enhancer (-140 to-81), containing two binding sites for the transcription factor NFκB; (3) the basal promoter (located between -80 and +1), including a typical TATAA box and three binding sites for the transcription factor Sp1; and (4) the trans-activation response (TAR) element, a bulged stem-and-loop structure present in the nascent RNA (+1 to +59) transcript that provides a binding site for Tat activation of HIV-1 transcription. In addition, a novel regulatory DNA element, named IST (Initiator of Short Transcripts), has been shown to be present in the HIV-1 LTR (position (-)5 to (+)26), encompassing the binding site for transcription factors YY1 and late SV40 transcription factor (LSF, or CP-2, or LBP-1) (see refs. 2 and 3). IST directs the RNA polymerase II to synthesize short (59-61 nt), correctly initiated, nonpolyadenylated transcripts that prematurely terminate at the TAR stem-loop structure. The function of these transcripts remains unclear (see ref. 4).

Prospects for treatment of latent HIV.

Recent advances in antiretroviral therapy (ART) have drastically improved the quality of life for people with HIV infection. However, owing to the persistence of latent HIV in the presence of therapy, patients must remain on therapy indefinitely. Currently, the solution to the HIV pandemic rests on the prevention of new infections and many decades of ART for the steadily expanding number of people infected worldwide. ART is costly, requires ongoing medical care, and can have side effects, thereby preventing its universal availability. Therefore, to escape the ironic burdens of therapy, efforts have begun to develop treatments for latent HIV infection. Current approaches propose either complete eradication of infection or induction of a state of stringent control over viral replication without ART. This review will discuss these strategies in detail and their potential for clinical development.

IL-2 receptor γ-chain molecule is critical for intestinal T-cell reconstitution in humanized mice.

Intestinal immune cells are important in host defense, yet the determinants for human lymphoid homeostasis in the intestines are poorly understood. In contrast, lymphoid homeostasis has been studied extensively in mice, where the requirement for a functional common γ-chain molecule has been established. We hypothesized that humanized mice could offer insights into human intestinal lymphoid homeostasis if generated in a strain with an intact mouse common γ-chain molecule. To address this hypothesis, we used three mouse strains (non-obese diabetic (NOD)/severe-combined immunodeficient (SCID) (N/S); NOD/SCID γ-chain(-/-) (NSG); and Rag2(-/-) γ-chain(-/-) (DKO)) and two humanization techniques (bone marrow liver thymus (BLT) and human CD34(+) cell bone marrow transplant of newborn mice (hu)) to generate four common types of humanized mice: N/S-BLT, NSG-BLT, NSG-hu, and DKO-hu mice. The highest levels of intestinal human T cells throughout the small and large intestines were observed in N/S-BLT mice, which have an intact common γ-chain molecule. Furthermore, the small intestine lamina propria T-cell populations of N/S-BLT mice exhibit a human intestine-specific surface phenotype. Thus, the extensive intestinal immune reconstitution of N/S-BLT mice was both quantitatively and qualitatively better when compared with the other models tested such that N/S-BLT mice are well suited for the analysis of human intestinal lymphocyte trafficking and human-specific diseases affecting the intestines.

Neurocognitive effects of treatment interruption in stable HIV-positive patients in an observational cohort.

OBJECTIVE: Prior studies have shown improved neurocognition with initiation of antiretroviral treatment (ART) in HIV. We hypothesized that stopping ART would be associated with poorer neurocognitive function. METHODS: Neurocognitive function was assessed as part of ACTG 5170, a multicenter, prospective observational study of HIV-infected subjects who elected to discontinue ART. Eligible subjects had CD4 count >350 cells/mm(3), had HIV RNA viral load <55,000 cp/mL, and were on ART (>or=2 drugs) for >or=6 months. Subjects stopped ART at study entry and were followed for 96 weeks with a neurocognitive examination. RESULTS: A total of 167 subjects enrolled with a median nadir CD4 of 436 cells/mm(3) and 4.5 median years on ART. Significant improvements in mean neuropsychological scores of 0.22, 0.39, 0.53, and 0.74 were found at weeks 24, 48, 72, and 96 (all p < 0.001). In the 46 subjects who restarted ART prior to week 96, no significant changes in neurocognitive function were observed. CONCLUSION: Subjects with preserved immune function found that neurocognition improved significantly following antiretroviral treatment (ART) discontinuation. The balance between the neurocognitive cost of untreated HIV viremia and the possible toxicities of ART require consideration. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that discontinuing ART is associated with an improvement in 2 neuropsychological tests (Trail-Making Test A & B and the Wechsler Adult Intelligence Scale-Revised Digit Symbol subtest) for up to 96 weeks. Resuming ART was not associated with a decline in these scores for up to 45 weeks.

A prospective evaluation of the effect of atazanavir on the QTc interval and QTc dispersion in HIV-positive patients.

BACKGROUND: Atazanavir (ATV), an HIV protease inhibitor (PI) that may be preferred for the treatment of HIV-infected patients with cardiovascular comorbidities because of its favourable effects on plasma lipids, has been associated with cardiac rhythm disturbances. OBJECTIVE: To quantify the effect of ATV on corrected QT (QTc) and QTc dispersion (QTd), markers of the potential for cardiac dysrhythmia, in patients switching from other PIs to ATV. METHODS: In this prospective, single-centre, open-label study, 12-lead electrocardiograms were performed for subjects at baseline, 2 h after the first dose of ATV, and 1 month after initiation of ATV. RESULTS: Twenty-one patients (19 received ritonavir-boosted ATV) completed the study. There was a trend towards an increase in the QTc at 2 h after the first dose [mean+/-standard deviation 3.19+/-8.0 ms; 95% confidence interval (CI) -0.47 to 6.85 ms; P=0.084]. There was no difference between QTc values at baseline and at 1 month (-1.5+/-8.75 ms; 95% CI -5.50 to 2.46; P=0.43). There was a nonsignificant decrease in the QTd between baseline and 2 h (-5.1+/-15.19 ms; 95% CI -13.22 to 2.96; P=0.197) and between baseline and 1 month (-0.61+/-15.04 ms; 95% CI -8.1 to 6.87; P=0.865). A significant increase in the PR interval (7.4+/-10.7 ms; 95% CI 2.5 to 12.25 ms; P=0.005) was observed at 1 month. CONCLUSIONS: The use of ATV did not result in increases in the QTc interval or QTd. However, PR interval monitoring may be warranted in patients with underlying heart block or those treated with atrioventricular nodal blocking agents.

Effect of the weaver (wv) mutation on cerebellar neuron differentiation. II. Quantitation of neuron behavior in culture.

Quantitative measurements of neuron behavior from time-lapse microcinematography of dissociated cultures of normal (+/+), heterozygous weaver (+/wv), and homozygous weaver (wv/wv) 7-day-old mouse cerebellum were performed to identify dose-dependent expressions of the mutant allele. Impaired neurite growth by granule cell neurons is a direct result of a dose-dependent increased frequency of neurite retraction and decreased rate of growth cone advancement. The number of retractions per neurite is 0.2, 1.0, and 2.0 for +/+, +/wv, and wv/wv neurites, respectively. Maximal rates of growth cone advancement are 1041, 443, and 250 micron/day for +/+, +/wv, and wv/wv granule cell neurites, respectively. Neurite initiation is actually increased in wv/wv cultures, though the neurites are not well sustained. The frequency of neurite initiation is 1.0, 1.7, and 2.2 for +/+, +/wv, and wv/wv neurons, respectively. Measurements of oscillations of somal position revealed that the cell center moves increasing distances over short times in proportion to the number of mutant genes. Nuclear translocation, the mode of somal migration in vivo and in vitro, occurs at the same frequency and rate in normal and mutant cultures. Weaver gene expression induces a cytopathology affecting various morphogenetic events rather than producing a block at a specific stage in granule cell differentiation. It is hypothesized that the dose-dependent impairments of cell motility reflect weaver gene action at the cell surface or cytoskeleton.

Effect of the weaver (wv) mutation on cerebellar neuron differentiation. I. Qualitative observations of neuron behavior in culture.

A mutant gene dose-dependent inhibition of cerebellar granule cell neuron survival and neurite growth in dissociated cultures of cerebellum from 7-day-old heterozygous (+/wv) and homozygous (wv/wv) weaver mutant mice (M. Willinger, D. M. Margolis, and R. L. Sidman. (1981), J. Supramol. Struc. 17, 79-86) has previously been observed. In the present phase-contrast study time-lapse microcinematography was performed between 10 and 80 hr in culture to determine which properties of neurite growth and neuron migration are affected by weaver gene expression. Neurite growth in +/+ cultures is rapid and discontinuous. Neurites are thin and cylindrical. Membrane movement occurs only at the growth cone. Growth cone contact with cell aggregates or glial somas results in the cessation of cone advancement and the induction of translocation of the neuronal soma toward the astrocyte. In cultures of +/wv and wv/wv cerebellar cells, abnormal neurite growth is characterized by frequent neurite retractions and reinitiations. Neuronal somas and neurite shafts are motile during elongation. Homozygous neurites and cones are pleomorphic. Normal, +/wv, and wv/wv neurons undergo nuclear translocation. Like +/+ neurons, +/wv neurons migrate in response to growth cone-cell soma contact. In contrast, homozygous soma frequently reverse direction and migrate independently of cell contact. Granule cell death occurs with increasing frequency with increasing gene dosage. Neurons are unusually active prior to the rapid onset of cell death. In summary, the weaver mutation impairs granule cell differentiation by affecting neurite maintenance, membrane motility, and neuron morphology. The loss of viability appears to be independent of, or secondary to, these targets of gene action.

A 74-year-old man with persistent fevers.

An elderly man with a history of extensive world travel presents with a chronic illness and fevers. The febrile illness has been present for eight years, and no diagnosis has been made despite extensive evaluation and testing. The differential diagnosis of this unusual case of fever of unknown origin is discussed.

A cutaneous lesion in a patient with AIDS: an unusual presentation of infection due to Mycobacterium avium complex.

A patient with AIDS developed a purplish, necrotic skin lesion followed by fevers, constitutional symptoms, and watery diarrhea. Stains of samples from the skin lesion and of stool and bone marrow revealed acid-fast bacilli, and Mycobacterium avium was isolated from cultures of these specimens and blood. With the initiation of multiagent oral antimycobacterial therapy, the patient's symptoms abated and the cutaneous lesion reepithelialized. We believe this lesion to be a manifestation of disseminated infection due to Mycobacterium avium complex (MAC). As the population of patients with AIDS who have CD4 cell counts of < 100/mm3 increases, new and unusual manifestations of disseminated MAC infection can be expected. New oral agents with increased activity against MAC may make early recognition and treatment of MAC infections more rewarding.

HSV-1 activation of HIV-1 transcription is augmented by a cellular protein that binds near the initiator element.

A cellular DNA binding protein, which we term Leader Binding Protein-2 (LBP-2), binds near the transcriptional initiation site of the human immunodeficiency virus type 1 (HIV-1) promoter. This protein recognizes a motif similar to that of LBP-1, a putative repressor of transcription (Kato, H., et al., Science, 251, 1476-1479, 1991). LBP-2 is associated with transcriptional activation of HIV-1 by herpes simplex virus type 1 (HSV-1). Electrophoretic mobility shift assays showed that nuclear levels of this protein increase markedly following HSV-1 infection. Mutations of the LBP binding motif eliminate LBP-2 binding and interfere with HIV-1 activation by HSV-1. When inserted into an unrelated promoter, this motif confers transcriptional responsiveness to HSV-1 infection. Proteins that bind near the initiator element may be important regulators of HIV-1 gene expression.

Human transcription factor YY1 represses human immunodeficiency virus type 1 transcription and virion production.

The transcriptional activity of human immunodeficiency virus type 1 (HIV-1) is affected by many cellular factors. Homologies near the HIV-1 initiator region to the DNA-binding sequences of YY1, a multifunctional transcription factor known to regulate diverse viral and cellular promoters, suggested that YY1 might regulate HIV-1. Antibody to YY1 blocked the formation of complexes by HeLa cell nuclear extract and a DNA oligonucleotide encoding the HIV-1 initiator region. HIV-1 long terminal repeat (LTR) expression, as measured the expression of a transfected LTR-CAT reporter gene, was repressed more than 12-fold by the cotransfection of a YY1 expression vector. HIV-1 production by both COS-1 and CEM cells after transfection of an infectious molecular HIV-1 clone was repressed 7- to 20-fold by cotransfection of a YY1 expression vector. HIV-1 production was also decreased threefold in a CD4-positive lymphocyte cell line chronically infected with HIV-1 (8E5) after transfection of YY1. In situ hybridization studies confirmed that YY1 reduced HIV-1 RNA expression. YY1 may play an important role in the regulation of HIV-1 LTR expression in vivo and virus production by infected cells.

Repression of human immunodeficiency virus type 1 through the novel cooperation of human factors YY1 and LSF.

A subpopulation of stably infected CD4+ cells capable of producing virus upon stimulation has been identified in human immunodeficiency virus (HIV)-positive individuals (T.-W. Chun, D. Finzi, J. Margolick, K. Chadwick, D. Schwartz, and R. F. Siliciano, Nat. Med. 1:1284-1290, 1995). Few host factors that directly limit HIV-1 transcription and could support this state of nonproductive HIV-1 infection have been described. YY1, a widely distributed human transcription factor, is known to inhibit HIV-1 long terminal repeat (LTR) transcription and virus production. LSF (also known as LBP-1, UBP, and CP-2) has been shown to repress LTR transcription in vitro, but transient expression of LSF has no effect on LTR activity in vivo. We report that both YY1 and LSF participate in the formation of a complex that recognizes the initiation region of the HIV-1 LTR. Further, we have found that these factors cooperate in the repression of LTR expression and viral replication. This cooperative function may account for the divergent effects of LSF previously observed in vitro and in vivo. Thus, the cooperation of two general cellular transcription factors may allow for the selective downregulation of HIV transcription. Through this mechanism of gene regulation, YY1 and LSF could contribute to the establishment and maintenance of a population of cells stably but nonproductively infected with HIV-1.

Neuronal differentiation in cultures of weaver (wv) mutant mouse cerebellum.

In the present study we report for the first time a weaver (wv) gene dose effect on neuron survival and neurite formation in vitro. Dissociated cerebellar cells from postnatal 7- and 8-day-old normal (+/+), heterozygous weaver (+/wv) and homozygous weaver (wv/wv) mice were cultured as monolayers on poly-L-lysine coated glass. Cell death occurred rapidly in wv/wv cultures. Cell counts showed that less than 20% of the total neurons and neuronal precursors (identified by "birthday" radiolabeling techniques) survived by Day 3. Cell death was less extensive in +/wv cultures with 65% of the total neurons and 80% of the precursors surviving by Day 3. In contrast to wv/wv cultures, younger neurons survive better than the total population in +/wv cultures. The impairment of neurite formation over the first week is also proportional to the number of mutant genes as shown by quantitation of (a) the percentage of cells with neurites; (b) the percentage of cells with neurites of a given length class ith time; (c) the lengths of the longest process formed per cell. The mean longest neurite lengths obtained by computer digitization at 6 days in vitro were 41.8, 26.8, and 9.0 micron for +/+, +/wv, and wv/wv granule cells, respectively.