Inflammation biomarkers in HIV infection

Laurence WEISS

Predictive biomarkers in HIV infection

1. Reflect• The extent of immune deficiency• The level of HIV replication and of HIV reservoir• The level of chronic immune activation/inflammation• The strength and quality of HIV-specific immune responses

2. Type of biomarkers• Virologic, immunologic, activation/inflammatory and genetic

biomarkers (HLA, CCR5, KIR)• Predictive biomarkers for HIV progression in untreated and/or treated

patients• Predictive biomarkers for the occurrence of co morbidities in patients

with ART-mediated viral suppression

Predictive biomarkers in HIV infection

1. Reflect• The extent of immune deficiency• The level of HIV replication and of HIV reservoir• The level of chronic immune activation/inflammation• The strength and quality of HIV-specific immune responses

2. Type of biomarkers• Virologic, immunologic, activation/inflammatory and genetic

biomarkers (HLA, CCR5, KIR)• Surrogate markers for HIV progression in untreated and/or treated

patients• Surrogate markers for the occurrence of co morbidities in patients with

ART-mediated viral suppression

- Membrane expression of the activation markersHLA-DR (MHC class II), CD38, CD25, CD70- Intranuclear expression of Ki-67 (cell cycle)

T-cell activation markers in the chronic phase of HIV infection

Giorgi, JID 99Leng et al, J.AIDS 2001Hazenberg et al, AIDS 2003

HLA-DR

CD38

CD4

CD8

Healthy donor Survival > 18 M Survival < 6 M

T-cell activation is associated with mortality

PROINFLAMMATORY CYTOKINE NETWORK

COAGULATIONTISSUEFACTOR D-dimer

T-cell activation sCD14

sCD163

Innate immunityMono/M,DC,

NK cell activation

Adaptative immunity

INFLAMMATION

PROINFLAMMATORY CYTOKINE NETWORK

COAGULATIONTISSUEFACTOR

1 2 3 4 5 60

IL-6 C-Reactive Protein

Haptoglobin

a1-glycoprotein acid

D-dimer

APP

HIVOther viruses (CMV, HCV...)Bacterial products (LPS…)

T-cell activation sCD14

sCD163

InnateImmunity

Inflammation

PROINFLAMMATORY CYTOKINE NETWORK

COAGULATIONTISSUEFACTOR D-dimer

T-cell activation sCD14

sCD163

Innate immunityMono/M,DC,

NK cell activation

Adaptative immunity

INFLAMMATION

PROINFLAMMATORY CYTOKINE NETWORK

COAGULATIONTISSUEFACTOR

1 2 3 4 5 60

IL-6 C-Reactive Protein

Haptoglobin

a1-glycoprotein acid

D-dimer

APP

HIVOther viruses (CMV, HCV...)Bacterial products (LPS…)

T-cell activation sCD14

sCD163

sCD14

sCD163…

T-cell activation

Soluble activation biomarkers

– β2- microglobulin, neopterin– hsCRP: acute phase protein– IL-6, IL-1RA, sTNFR: Cytokines and CR of innate immunity– D dimer: marker of procoagulant activity– sCD14: acute phase protein, monocyte activation– sCD163: secreted by activated monocytes/macrophages– ICAM, VCAM: endothelial activation/dysfunction– IP-10: chimiokine produced in response to IFN

Fahey, NEJM 1990, Kuller, PloS Med 2008, Sandler, JID 2011, Burdo, JID 2011

Predictive biomarkers in primary HIV infection

Deeks, Blood 2004

Immune activation set point during early HIV infection: predictive of subsequent CD4 T-cell changes independently

of viral load

CD38-MFIon CD8 T

cells

Time (weeks)

prop

ortio

n w

ith C

D4

> 35

0

Time to a CD4 T-cell count less than 350 cells/mm3

68 recently HIV-infected adults before ART

CD8 T-cell activation set point

The early level of double negative CD4-CD8- T cells predicts the level of T-cell activation at set point

R= -0.76p= 0.004

R= -0.60p= 0.035

Petitjean, Chevalier et al, AIDS 2012

DN T cells might play a role in the control of the harmful systemic immune activation

DN T cells produce anti-inflammatory cytokines

Baseline M6

plas

ma

IL-1

RA

(log

pg/m

L)

IL-1RA

An innate immune setpoint ?

plasma sCD14 at baseline(ng/mL)

plasma IL-1RA at baseline(log pg/mL)

% C

D38

+ HLA

-DR

+

CD

8 T

cells

at M

6

% C

D38

+ HLA

-DR

+

CD

8 T

cells

at M

6

% C

D38

+ HLA

-DR

+

CD

8 T

cells

at M

6

log Th17/Treg ratio at baseline

Acute HIVbaseline

Acute HIVM6

Chronic HIV

(untreated)

Sepsis(S. aureus)

n=27 n=25 n=20 n=10

plas

ma

16S

rDN

A(c

opie

s/µL

)

Chevalier, Plos Path 2013

Innate immune activation set point

plas

ma

sCD

14(n

g/m

L)Baseline M6

sCD14

Predictive biomarkers in untreated chronic infection

T-cell activation, predictive marker of AIDS progression independent of VL

Proportion of CD70+CD4+ T cells > median (—) < median (- - -)

Giorgi, JAIDS 1998Hatzenberg , AIDS 2003

Relationship between T-cell activation and HIV reservoir

• The proportion of HLA-DR+ CD38+/ CD8+ T cells before TI predicts the increase in total HIV-DNA levels between baseline and M12 of TI (ANRS 116 SALTO) (r= 0.552; p = 0.004)

Weiss, PlosOne 2010

• Positive relationship between total HIV-DNA and CD8 and CD4 T-cell activation at 12 months of TI

See poster Weiss et al MOPDA0106

Predictive values of soluble biomarkers in cohort studiesC Reactive Protein Level: associated with AIDS - free survival

Multivariate modelVariable Relative Time

(95% CI)P Value

CRP, mg/L <1.2 1.3-2.3 >2.3

1.00.86 (0.68-1.09)0.63 (0.51-0.79)

0.21<0.001

CD4+ cell count 1.12 (1.08-1.16) <0.001HIV RNA (log10) 0.34 (0.29-0.39) <0.001

Hemoglobin (g/dL) 1.14 (1.06-1.23) <0.001

Lau, Arch Intern Med 2006

N= 513 patients randomly selected from the MACS populationMedian CD4: 532 (IQR 342;721)Median HIV-RNA: 18450 (IQR 5359; 63741)62% AIDS event2709 person-years of follow-up

Fibrinogen and CRP, independent predictors of mortality in the FRAM study

Tien, JAIDS 2010

• 922 HIV-infectedparticipants > 85% on cART (past or present)• 70% with history of AIDS• 50% HIV-RNA BLD• 20% HCV+• 5-year mortality risk

Biomarker levels associated with progression in RCT

• All-cause mortality: higher for patients with CD4> 350 randomly assigned to CD4-guided interruption of ART (DC) than continuous ART (VS)

• Most common causes of death: non AIDS-malignancy, CVD• Case control study (85 cases and 170 matched controls); a study to compare DC and

VS participants for biomarker changes (249 DC and 250 VS)• Baseline IL-6, hsCRP and D-dimer associated with all cause mortality• Higher BL IL-6, D-dimer and hsCRP: related to CVD• IL-6 and D-dimer ↗ at 1 mo in the DC group. Increases related to HIV-RNA levels• BL or latest IL-6 or hsCRP: predictive of OI

• Elevated pre-ART levels of hsCRP, IL-6 and D-dimer: strongly associated with early mortality after ART initiation Ledwaba, PlosOne 2012

• Other markers associated with disease progression (case control ACTG 384 and 5015) : sTNFR-1, sCD27 and sCD40L Kalayjian, JID 2010

Kuller Plos Medicine 2008Rodger JID 2008Duprez PlosOne 2012

SMART

PHIDISA (South Africa trial)

IP10 and sCD163 levels predict subsequent CD4 counts

Predictive inflammatory biomarkers in HIV controllers

Lambotte, IAS 2014, MoAA0102

Predictive biomarkers in patients with chronic infection and ART-mediated

viral suppression

Residual immune activation and inflammation under ART

Hunt, JID, 2003Hunt, JID 2008

Persistence of residual chronic T-cell activation in ART-treated patients

n = 30 HIV+ with CV < 75 c/mL

Despite long-term viral suppression, soluble inflammatory biomarkers remain higher in patients compared to the

general population

0

25

50

75

100

125

150

175

200

IL-6 D-dimer Cystatin-C

UnadjustedAdjusted for age, gender, raceFully adjusted

UnadjustedAdjusted for age, gender, raceFully adjusted

hsCRP

% D

iff. f

rom

Gen

eral

Pop

ulat

ion

(MES

A)

Neuhaus JID 2010

Inflammationwith ongoing

viral replicationInflammation

under ARTInflammationHIV- controls

Monocytes pDCs Innate

ImmunityNK

Adaptativeimmunity

• Nested case-control study in SMART• 74 deaths + 120 CV events + 100 AIDS events (20 NA) / N= 5472• 2 controls/case• Most patients under ART with VL < 400 cp/mL• Baseline plasma sCD14, IFABP, LPS, EndoCAB

SCD14: marker of monocyte activation (acute phase protein) not necessarily indicative of microbial

translocation

Sandler, JID 2011

Plasma levels of sCD14: independent predictor of mortality in the SMART study

Can we improve prediction of mortality by adding inflammatory biomarkers?

• Veterans Aging Cohort Study: 1 302 veterans under ART; 70% with VL <500 c/mL; 154 deaths

• RI= age/CD4/VL• VACS index= RI + Hb/ FIB4 index age, transa, platelets

/HCV/eGFR: better prediction of mortality than any biomarker or than RI (p< 0.001)

• VACS+ inflammatory biomarkers (IL-6, D-dimer, sCD14)

Justice CID 2012

Cardio-VascularDiseases

Cognitive disorders

Inflammation

CANCER

CHRONIC VIRAL

INFECTIONS(HIV)

Osteoporosis

Cardiovascular comorbiditiesIn HIV infection : Alteration in biomarkers known or potentially associated with CVD in non-HIV

infected individuals• HDL cholesterol depletion• Chronic inflammation

( CRP, IL-6, sCD14)• Endothelial activation/dysfunction

( VCAM, ICAM)• Activation of coagulation

( D-dimer)

Only partially normalized during sucessfull ART

Atherosclerotic plaque

Association of soluble CD163 with arterial inflammation

Hypothesis: Arterial inflammation

- > HIV+ pts compared with non-HIV FRS-matched controls

- Correlated to mono/Mф activation (CD163)

• 81 participants. 27 HIV pts under ART (CD4 nadir 100)

• FDG-PET (activated Mф : high metabolic rate)

Variables HIV+ (N= 27) FRS-matched HIV- (N= 27)

HIV- atheroscl (N= 27)

P value

Mean FDG uptake (95% CI)

2.23 (2.07-2.40) 1.89 (1.80-1.97) 2.13 (2.03-2.23) <0.001

CAC score median (IQR)

24.4 (0.92-6) 0 (0-4.8) [N= 24] 425.2 (88.8-1234) [N= 16]

< 0.001

Subramanian JAMA 2012

Lack of association between aortic FDG uptake and CRP or D-dimer in the HIV+ population

FDG

upta

ke

Soluble markers of inflammation & coagulation, but not T-Cell activation, predict non-AIDS defining events during

suppressive ART

• Case-control study of ALLRT subjects (ACTG studies) (ART-naïve at BL and ART-suppressed during FU)

• Cases : non-AIDS death, MI, stroke, non-AIDS cancer, or serious non-AIDS bacterial infection

• Controls (2 - 3/case)

• Greater CD4 change at yr 1 associated with a decreased risk for non-AIDS event (OR per 100 cells increase= 0.81, p= 0.007)

• High T-cell activation: not consistently associated with a non-AIDS-related event

• Higher IL-6,sCD14, sTNFR-I, sTNFR-II, and D-dimer prior to ART independently associated with non AIDS events

Tenorio CROI 2013

Soluble markers of inflammation & coagulation, but not T-Cell activation, predict non-AIDS defining events during

suppressive ART• Case-control study of ALLRT subjects

(ACTG studies) (ART-naïve at BL and ART-suppressed during FU)

• Cases : non-accidental non-AIDS death, MI, stroke, non-AIDS cancer, or serious non-AIDS bacterial infection

• Controls (2 - 3/case)

• Greater CD4 change at yr 1 associated with a decreased risk of non-AIDS event (OR per 100 cells increase= 0.81, p= 0.007)

• High T-cell activation: not consistently associated with a non-AIDS-related event

• Higher IL-6,sCD14, sTNFR-I, sTNFR-II, and D-dimer prior to ART independently associated with non AIDS event

Tenorio CROI 2013

Suboptimal CD4 T-cell gains

Immune senescence

Comorbidities (Accelerated atherosclerosis, arterial inflammation, cognitive

disorders, chronic renal disease, osteoporosis: « Inflam-Aging » , cancers)

↗ Risk of mortality

Persistent Inflammation

under ART CRP, IL-6, IL-1RA, sCD14, sTNFR

D-dimer Fg

Summary

• Levels of immune activation (T-cell activation and inflammation) predict HIV disease progression in untreated patients with primary and chronic infection

• Soluble biomarkers of inflammation and coagulation, but not T-cell activation, predict non-AIDS defining events during suppressive ART

Unresolved issues• Value of these biomarkers to improve CV risk prediction in the HIV-infected

population ?• Significance: just an association or role in pathogenesis ?• Help to identify cellular pathways important in the pathogenesis of HIV

disease • Interventions that target these pathways (e.g. IL-6) and/or the mechanisms

involved in low levels of chronic activation/inflammation (e. g. ongoing low-level viral replication, MT, coinfections..) are warranted (or already in progress) with the ultimate goal to decrease the incidence of non-AIDS related morbidity in HIV-infected patients on virally suppressive ART

All the patients included in the studies

Hôpital Européen G. PompidouChristophe PikettyMaria ManeaErika Bourzam

Hôpital Saint-AntoinePierre-Marie GirardPauline CampaNelly Desplanques

Hôpital TenonLaurence SlamaGilles Pialoux

CHU Carémeau NîmesJean-Philippe LavigneCatherine Dunyach

Mathieu ChevalierGaël PetitjeanCéline DidierDaniel Scott-AlgaraFrançoise Barré-Sinoussi

…and all the physicians that included patients

INSERM U 1018Laurence MeyerChristiane DeveauFeriel Tibaoui

Remerciements

U943Dominique CostagliolaLambert Assoumou

the ANRS 116 SALTO study groupEA 3620 Christine Rouzioux