Immune Reconstitution :

Quantitative and Qualitative aspects

B.A. Jni07

Pr Brigitte Autran, Hôpital Pitié-Salpétrière, Université Paris -VI

The 3 phases of the ART-induced immune reconstitution : the 1997-2000 years

1. Early Memory CD4 T cell Redistribution : « Fake » quantitative restoration of CD4 counts but no functionnal restoration

2. Decreased activation with virus control : allows functional restoration3. Late Naive T cell regeneration > long term CD4 T cell quantitative

expansion and Restoration of defenses against OI (Autran 97, Pakker 98, Li 98, Lederman 98, Bucy 98, Gorochov 98….)

Months3 6 9 12 18

CD4

Memory CD4+

Naive CD4+

50

100

0

150

Cel

ls/µ

l

HIV

Activation

B.A. Jni07

Quantitative and functional CD4 cell reconstitution with HAART

300 patients treated with HAART, viral loads <200 copies/ml

CD4 counts

0

200

400

600

800

0 8 16 24 32Months

Cel

ls/m

m3

Rapid CD4 counts restoration in end stage disease with high risk of CMV retinitis

0

10

20

30

40

50

60

70

0 1 3 6 9 12%

pos

itive

resp

onse

s

CMV Tuberculin

Months

Restoration of proliferative CD4 responses to CMVin end stage disease(Autran 97, Li 98, Lederman 98, Rinaldo 99,

Similar prognostic significance of CD4 counts during disease and immune reconstitution

Schematic prediction of Time to restore normal CD4 counts acording to CD4 cell depletion at time of ART initiation

(B Autran et al. 1998)

BA/11.98

8 years4

600

200

CD

4 co

unts

Normal1-22 - 3

5 - 67 - 10

> 10

2 4 6 8 10

6 - 84 - 5

HAART

Factors influencing quantitative CD4 T cell reconstitution:• Positively: - amplitude of HIV control at initiation of ART

- rapid CD4 decrease before ART initiation (Renaud et al, 1999)

• Negatively: - outbreaks of virus replication (blips, STI) (Bategay, 2006)

- HCV co-infections (Koziel 2007)

- X4 virus tropism for naive CD4 T cells (Delobel, 2006)BA JNI2007

Schematic prediction of Time to restore normal CD4 counts acording to CD4 cell depletion at time of ART initiation :

Where are we today ?

BA/11.98

8 years4

600

200

CD

4 co

unts

Normal1-22 - 3

5 - 67 - 10

> 10

2 4 6 8 10

6 - 84 - 5

HAART

BA JNI2007

Do drugs influence the quantitative CD4 T cell reconstitution:• Similar Immune restoration with PI sparing and PI

containing regimens (INITIO)(Samri et al. Antiviral Ther. 2007)

• Do new drugs generate a distinct profile of immune restoration ???• entry inhibitors ?• integrase inhibitors ?

Restoration of Immune Defenses against pathogens with ART

Restore defenses to all pathogens (Autran97; Li98, Lederman 98, Rinaldo 99,

Garcia 99, Pontesili99……

Allow arrest of prophylaxis against Opport. Inf (Furrer,99 Reiss 99,Ledereberger 01, Jouan 01..)

Months

50

100

0

150

Opp

ortu

nist

ic P

atho

gens

5

4

3

2

Plas

ma

HIV

RN

A

Memory Cells/ Opportunistic Pathogens

3 6 12 24 48

Naive Cells / Any Pathogens

B.A. Jni07

Recovery of Memory CD4+ T cell reactivity to CMV allows control of CMV viremia with HAART

1

10

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13

Months

Sti

mu

lati

on

ind

ex

anti

-CM

V

2

3

4

5

HIV

RN

A (

log

co

pie

s/m

l)

CMV viremia

HIV viral load

CD4 counts

Stimulation index anti-CMV

Positive CMV viremia

21

206

230

Li et al. AIDS Res. Retrov., 99

Restoration of a CMV-specific T cell reactivity with HAART allows to withdraw prophylaxis against

CMV retinitis in advanced disease

0

20

40

60

80

100

0 4 8 12 16 20Months

% re

spon

ses

to C

MV

0

100

200

300

400

med

ian

CD

4/m

m3

HAART

CMV prevention

47 patients:

Withprior CMV retinitis,

2 relapses after arrest of anti-CMV therapy, Jouan et al, AIDS, 2001

• Benefits from HAART: => Restoration of CD8 T cell-mediated Immune protection

against CMV retinitis:

=> Comparison of the CMV-specific CD8 T cell magnitude, repertoire breadth and differentiation in:

HN: Healthy HIV- (n=11)LTNP : HIV+HCMV+ Long Term Non Progressors (n=10), med CD4: 733/mm3

HIV+ Recovering from CMV retinitis on ART, after stopping GCV :- Short Term Recovery (18 months, n=8) : CD4:357/mm3- Long Term Recovery (>50 months, n=6) :, med CD4: 345/mm3

Acute CMV retinitis : (n=8) : med CD4:50/mm3K Sacre et al. J Exp Med 2005

Restoration of T cell-mediated immune protection against CMV disease

Short Term Recovery of strong responses against the CMV early IE1 antigens after CMV retinitis

HCMV-specific SFC/million PBMC per subject

HN LTNP STRR LTRR AHCMV

0

2000

4000

6000

8000

10000

pp65

p=0.02

0

2000

4000

6000

8000

IE1

K Sacre et al, J Exp Med 2005

HealthyCMV+

HIV-negative

HIV infectionHealthy

CMV +CMV

retinitis

Recovery from CMV retinitis

EARLY LATE

Magnitudeof HCMV-specific CD8 T cells

per target antigen

CD4 counts

Repertoire & diversity of CMV-specific CD8 T cells

against pp-65 IE1

Differentiationof HCMV-specific CD8 T cells

% CD27-28-% CD27-/+28+% CD27+28+

Naive

CMV Replication(detection threshold)

Sacre et al. , JEM 2005

Restoration of Immune Protection against CMV retinitis in HAART treated patients

HAART

Sequential Restoration of Immune protection against opportunistic pathogens

• CMV retinitis:– Loss of CD4 responses to HIV => Limited repertoire & diversity of short-

lived anti-CMV CD8 T cells => Loss of CMV control– Gancyclovir: control of CMV replication

BUT no restoration of immunity to CMV

• HAART:– Controls HIV =>Restores CD4 counts

• Restores protective Immunity against CMV:– CD4 responses to CMV– CD8 cells to CMV –IE1 antigens

» Large breadth and diversity» long-lived memory CD8 T cells

=> Restores Long Term control of CMV without gancyclovirB.A. Jni07

Reduction in morbidity / mortality (Hogg, 97, Pallella,98…

Discontinuation of prophylaxis against Opportunistic Infections: PCC. Pneumoniae, CMV retinitis (Furrer,99, Jouan 2001…)

at all stages of the disease : illustrating the lack of definitive immune alterations

BUT Induces the Immune Restoration Syndrome (IRS,.)M French , 98, 2006, Monsuez 99, Breton 2005……….

- during opportunistic infections concommitantly treated with HAART

- reactivation of pathogen-associated symptoms +/- systemic inflamatory

syndrome without microbiological relapse, or of auto-immune diseases

- particularly frequent during mycobacterial infections (MAI, TB : 40%)B.Autran, BA, 01

Rapid restoration of protective memory responses against opportunistic pathogens with HAART

B.A. Jni07

TB and VIH

IFNγ

CD4 CD4-/8-CD8 TgdTNFα

Disparition of Ag-specific responses,

= Anergy to TB antigens

Consequences of CD4 defects in HIV infection:Poor Granuloma, without caseum, poorly functionalsDisseminated pauci-symptomatic Tuberculosis

Activation macrophage

Activation CD4 Th1

IFNγIL12

• Diminution Nb activated macrophages• Diminution of intra-cellular BK lysis

A. Bourgarit 05

IRS: Hypothesis

Activation macrophage

Activation CD4 Th1

IFNγIL12

IFNγ

CD4 CD4-/8-CD8 TgdTNFα

Rapid restoration of TB Ag- spécific Th1 cells???

Rapid Restoration of CD4 counts and function with HAART=> Amplification +++ of the specific CD4 Th1 cells to Mtb => inflammatory Syndrome « cytokine Storm »

A. Bourgarit 05

TBK M0ART M1ART

M3

M6 M12BK

ConfirmationOf inclusion Declaration IRS+

TSRP TSRP+20j

Declaration IRS -

BK+ SRP

ØSRP

ANRS EP-21: PARADOX-TB:A prospective analysis of the Immunological

characteristics of the TB-associated IRS

Bourgarit et al. AIDS, 2006

IRS+ IRS- pn 11 13M/F 6/5 9/2 NSAge 38 (30-56) 36 (26-63) NSPulmonary TB 2/11 4/13 NSDisseminated TB 9/11 9/13 NS

BAAR+ 3/8 4/13 NSHIV Infection CD4 (/mm3) 26 (6-145) 54 (15-267) NS

CV (Log) 6 (4.8-6.5) 5.2 (4.3-8) NS

M0HAART Délai /TBK (j) 36 (7-77) 50 (14-111) NS

IRS Délai / M0 (j) 23 (7-85)CD4 108 (59-430) 163 (9-580)(M1) NS∆CD4 /M0 (/mm3) +54 (-1;+393) +77 (-50;+250) NS

M3 CD4 117 (58-399) 132 (49-410) NS∆CD4 /M0 (/mm3) +86 (-74;+367) +73 (-88;+354) NSCV <200 7/10 8/11 NS

ANRS EP-21: PARADOX-TB : Patients Characteristics

Bourgarit et al. AIDS, 2006

TB-IRS: Acute Exacerbation of a Th1 response to tuberculin but not to live TB (ELISpot IFN-γ) (Bourgarit, AIDS 2006)

IRS+n=11

IRS-n=13

PPD : p =0.005

CMV = NS

T BK M 0 M1 M 3 M6 M120

1000

2000

3000

4000

T BK M 0 T IRS M 3 M 6 M120

1000

2000

3000

4000 PPD CMV

SFC/

106 PB

MC

• N IFN-g producing T cells to PPD significantly stronger in IRS +• No or weak response to to live TB-associated antigens: ESAT-6, CFP-10, 85B• Mediated by CD4 T cells: up to 35% of circulating CD4 T cells

Multiplex Detection of cytokines –Chemokines in culture supernatants (Chimioluminescence)

=> Intense inflammatory response both Ag-specific (PPD) and non specific: cytokines :TNF-a, IL-6, IL-10

chemokines: RANTES, MCP1..

-10 0 10 20 30 40 500

1000

2000

3000

4000 Medium alone CMV PPD

wks

0

10000

20000

30000

40000

50000

IL-6

pg/

ml

TNF-

α an

d IL

-1β

pg/m

l

-10 0 10 20 30 40 500

1000

2000

3000

4000 Medium alone CMV PPD

wks

0

10000

20000

30000

40000

50000

TNF-

α an

d IL

-1β

pg/m

l

IL-6

pg/

ml

IRS+ IRS-

ANRS EP-21: PARADOX-TB :Non PPD-specific pro-inflammatory cytokine storm during IRS

Bourgarit et al. AIDS, 2006

Paradox-TB: A prospective study of the Immune Restoration Syndrome

associated with TB in HIV infection• A frequent syndrome :

– in 40% (9/22) TB-HIV co-infected patients with severe CD4 defects and rapid CD4 restoration within 3 months after treatment initiation

• A brutal explosion of tuberculin-specific T cells– Poorly or undetectable at baseline, – Rapidly restored and exacerbated, within a month– Mediated by activated CD4 Th1 cells + γδ T cells– with specific release of Th1 cytokines and pro-Th1 chemokines

but without deregulated Th2 response– Directed against Antigens present in tuberculin – Associated to an acute non-specific inflammatory response

Bourgarit et al. AIDS, 2006

• Paradox-TB : Pending Questions > BK-VIR-IS– Clonality of the response?– Antigens involved? And role of γ-δ T cells?– Role of regulatory T cells ?– Individual susceptibility?

• Why only 40% IRs if this corresponds to a physiological restoration of tuberculin specific T cells?

– Strains ?– Host Genetic Predisposition?

» HLA» Other Genes: Th1 pathways…,

Immune Restoration Syndrome associated with TB in HIV infection

Bourgarit et al. AIDS, 2006

ANRS and Sidaction PARADOX TB Study group :

Baakili A, Béglé A-M, Besse F, Bollens D, Bouchaud O, Bursachi P, Cadranel J, Camuset J, Chakvetadze C, Delgado J, Diemer M , Dupont B, Elmarsafy S, Fain O, Fonquernie L, Furco A, Girard P-M, Grillot-Courvalin C, Guignet A, Guilleminot MC, Herrmann J-L, Jeantils V, Grivois JF, Joly V, Jouis V, Klutse P, Lacombe K, Lahoulou R, Lavolé A, Lefebvre B, Lefort A, Letellier E, Lortholary O, Metro A TrumeauM, Meynard J-L, Meyohas M-C, Molina J-M, Obenga G , Parrinello M, Pelet O, Pintado C, Ponscarme D, Rami A, Rozenbaum W, Sahli H, Sellier P, Slama L, Courtial S, Tubiana R, Stirnemann J, Tassi S , Taulera O, Touitou H , Vacher I,., Vincent F, Yeni P

Hôpital Saint Louis, Paris FranceIntern. Med.: A Bourgarit, C. Lascoux, D SereniBactériologie: P LagrangeStatistics: V Delcey Institut Pasteur: B Gicquel

Pitié-Salpétrière, Hospital, Immunology : A Bourgarit, G. Carcelain, V Martinez, A. Samri, B. Autran

CHU Pitié-Salpétrière, Univ Pierre et Marie Curie Paris, Immunology, INSERM U543 Infect. Dis. VirologyG. Carcelain, A Samri R. Tubiana V. CalvezB Combadière K Sacre M Jouan AM FilletB. Autran H. Ait Mohand AG Marcellin

C. Katlama H. Agut Statistics : C Dalban, D. Costagliola

and the RESTIMOP study groupANRS , Sidaction and INSERM ATC Immunité anti-virale