HIV and AIDS

Acquired Immunodeficiency Syndrome

• Disease caused by an infectious agent:
a retrovirus

1
 HIV and AIDS
History of an infectious agent
In Los Angeles 1967-1978: only two cases of
Pneumocystis carinii pneumonia
• 1979 - 5 cases of All Homosexual
Pneumocystis carinii
pneumonia
Dot-like intracystic
bodies of
Pneumocystis
carinii in lung

Cytologic preparation
from a bronchoalveolar
lavage – Giemsa stain

Pneumocystis
jiroveci 2
 HIV and AIDS
History of an infectious agent

Pneumocystis pneumonia

107 cases of Pneumocystis carinii pneumonia reported in the United

States before the AIDS epidemic

AIDS epidemic has resulted in 166,368 cases up to 1999

3
 HIV and AIDS

With dissemination to extrapulmonary sites, Pneumocystis

carinii tends to produce foci with prominent calcification, as
seen in the kidney 4
 HIV and AIDS
an infectious agent – Kaposi’s Sarcoma

Early 1981 MMWR: 5 cases of

Kaposi’s sarcoma
Hitherto: rare
(immunocompromization)
Elderly - Non-aggressive
1981 - 26 cases of Kaposi’s
sarcoma
• Young
• Male
• San Francisco and New
• All Homosexuals
York 5
 HIV and AIDS
an infectious agent – Kaposi’s Sarcoma

Before 1981: 40 - 120 cases per year in United States

1981-1999: 46,684 definite cases in United States

6
 HIV and AIDS
Two rare diseases in the gay community linked to

IMMUNOSUPPRESSION
OPPORTUNISTIC INFECTIONS
Also
Lymphadenopathy (diffuse, undifferentiated non-Hodgkins
lymphoma)
1977- 1980: No cases in the young male (20 - 39 years old) population
of the San Francisco area
March 1981 - January 1982: four cases within 10 months

• Gay-Related Immune Deficiency

• Acquired Immune Deficiency Syndrome (AIDS)
7
 HIV and AIDS
Little in common but:
• Young
• White
• Male
• Large towns
• Homosexual community

But not all gay men got the disease

8
 HIV and AIDS
Distinguishing characteristics
• Clusters of infected men
• Apparent concentration within sexually
interactive groups
• High numbers of sex partners

Suggests an infectious
agent
9
 HIV and AIDS
More evidence for an infectious agent
Different ways of getting a similar syndrome
• Blood transfusions
• Intravenous drug use
• Hemophilia (clotting factor)

Female sex partners of AIDS-positive IV drug

users and hemophiliacs
Not just in the Gay community
10
Haitian origin
 HIV and AIDS
1983: The 4H Club
• Homosexuality among males
• Hemophilia
• Heroin use (drug use that may involve shared needles)
• Haitian origin

11
 HIV and AIDS

Obvious agent:
A virus……that is now in the
blood supply
Primary route of
transmission: Sex
AIDS is a sexually-transmitted viral disease

12
 HIV and AIDS
The Cellular Picture
ss of one cell type throughout the course of the dise
CD4+ T4 helper cells
A fall in the CD4+ cells always precedes disease
In advanced disease: the loss of another cell
type
CD8+ cytotoxic killer cells
Suggests an infectious agent
A virus
But initially difficult to grow
13
Rapidly kills cells on which it grows
 AIDS
Definition
• AIDS is currently defined as the presence of
one of 25 conditions indicative of severe
immunosuppression
OR
• HIV infection in an individual with a CD4+ cell
count of <200 cells per cubic mm of blood

• AIDS is therefore the end point of an

infection that is continuous, progressive and
pathogenic

• With the prevalence of HIV in the developing

world, HIV and its complications will be with 14us
 AIDS Statistics

• Approximately 30,000,000 people in the

world are HIV-infected

• Approximately 14,000 new HIV infections

occur daily around the world
• Over 90% of these are in developing
countries
• 1000 are in children less than 15 years of
age 15
 AIDS Statistics

• As of December 2006, 1,106,400 Americans

have been reported with AIDS

• At least half of them have died

• 9,101 children under 15

About ONE MILLION persons in the United States are living

with HIV infection
16
HIV and AIDS

17
HIV and AIDS

Prevalaence

AIDS

Deaths

18
HIV and AIDS

Black
White
Hispanic

19
 AIDS Statistics
Sub-Saharan Africa
• About 1 million new cases of AIDS per year

• At least 20 million people with HIV infection

• AIDS is responsible for a decrease in life expectancy and

increase in child mortality. Child mortality rates in East
Africa will double by 2010 and adult life expectancy has
declined in that region

20
Impact of AIDS on life expectancy in five African countries, 1970–2010

70
65
60 Botswana
55
Life South Africa
50
expectancy
45 Swaziland
at birth
(years) 40
35 Zambia
30
Zimbabwe
25
20
1970–1975 1980–1985 1990–1995 2000–2005
1975–1980 1985–1990 1995–2000 2005–2010

Source: United Nations Population Division (2004). World Population Prospects: The 2004 Revision, database. 21
4.1
 HIV prevalence (%) in adults in Africa, 2005

Zimbabwe

Botswana
Lesotho

Swaziland 22
2.5
•Several countries in sub-Saharan Africa
report infection rates of over 25%,
especially urban areas

• Zimbabwe: 33.7% of adult population

infected

• 90% of truck drivers in Zimbabwe are

infected

• In Zambia, 1 in 5 urban girls is HIV- 23

positive by the age of 20
Human Immunodeficiency Virus

24
 HIV and AIDS
The Virus
The virus only grows on T4 cells that are proliferating
in response to an immune stimulus -- Therefore
difficult to grow in culture
Reverse transcriptase in
activated T4 cells in blood of patients
with AIDS
• Robert Gallo : HTLV-3

• Luc Montagnier and

Françoise Barré-Sinoussi: LAV
uman Immunodeficiency Human immunodeficiency viral particles are
seen at medium magnification in this electron

Virus (HIV) micrograph (CDC)

25
 HIV and AIDS
The cellular and immunological picture - The course of
the disease

virus

antibody

CD4 cells

26
 HIV and AIDS
The cellular and immunological picture - The course of
the disease

CD8 cells

27
 HIV and AIDS
The cellular and immunological
picture
The course of the disease
1. titer
• High virus Acute Infection
• Mild symptoms
• Fall in CD4+ cells but recovers
• Rise in CD8+ cells but recovers
• A high virus titer (up to 10 million viruses
per ml blood)
• Macrophages infected
Macrophages bring HIV into the body if sexually transmitted 28
 HIV and AIDS
2. A strong immune response

Virus almost disappears from

circulation
• Good cytoxic T cell response
• Soluble antibodies appear later
against both surface and internal
proteins
• Most virus at this stage comes from
recently activated (dividing) and
infected CD4+ cells
29

•
 HIV and AIDS
3. A latent state

Latency of virus and of

symptoms
• Virus persists in extra-
vascular tissues
• Lymph node dendritic cells
• Resting CD4+ memory cells
(last a very
long time - a very stable 30
population of cells) carry
 HIV and AIDS
• 10 billion HIV particles per day
• Virus half life 5.7 hours
• 100-10 million virions per ml blood (set
point)
• Small minority of T4 cells are infected
• Virus found in lymph nodes

31
 HIV and AIDS
4. The beginning of disease
Massive loss of CD4+ cells
• CD4+ cells are the targets of the virus
• Cells that proliferate to respond to the
virus are killed by it
• Dendritic cells present antigen and virus
to CD4 cells
• Epitope variation allows more and more HIV
to
escape from immune response just as response
wanes
• Apoptosis of CD4+ cells 32
 HIV and AIDS
5. Advanced disease - AIDS
CD8+ cells destroy more CD4+
cells
• CD4 cell loss means virus and
infected
cells no longer controlled
• As CD4+ cells fall below 200 per
cu mm
virus titer rises rapidly and
remaining immune response
collapses
• CD8+ cell number collapses
33
• Opportunistic infections
HIV and AIDS

Good correlation between

number of HIV particles
measured by PCR and
progression to disease

34
HIV and AIDS

Viral load predicts

survival time

35
HIV and AIDS

CD4 cell count is not a

good predictor of
progression to disease

36
 HIV and AIDS
Cofactors
Not all cases of Kaposi’s are associated
with HIV
Not all HIV infected persons suffer from
Kaposi’s
20% of homosexual HIV+ males get
Kaposi’s sarcomaKaposi’s
associated herpes virus
Few IVHuman
drug users or hemophiliacs
herpes virus-8 get
37
 HIV and AIDS
Three Views of AIDS

Gallo: Infection by HIV is sufficient to cause AIDS

Montagnier: HIV may be harmless in the

absence of other co-factors
Duesberg / Mullis: HIV is too silent to be the
etiologic agent of AIDS. It is a much maligned
by-stander
So far it seems that >50% of HIV-infected
persons have progressed to AIDS
There is NO strong evidence there is any other
infectious agent involved than HIV 38
HIV - The Virus
Retrovirus

Membrane: host derived

Three genes
GAG – POL – ENV
Three polyproteins 39
 HIV - The Virus
Retrovirus

Two glycoproteins: gp160 gp120 and

gp41
gp41 is fusogen that spans the membrane
vaccine problem
sugars
ENV gene
40
 HIV - The Virus
Retrovirus

Group-Specific Antigens

17: inner surface - myristoylated

p24: nucleocapsid
9: nucleocapsid associated with RNA

GAG gene
Polyprotein 41
 HIV - The Virus
Enzymes Retrovirus

• Polymerase (reverse
transcriptase – RNA
dependent DNA polymerase)
• Integrase
• Protease (cuts
polyproteins)
• POL gene
Polyprotein 42
 The Genome of HIV

Three structural genes

LTRs
Extra open reading frames are clue to latency
These ORFs code for small proteins - antibodies in 43
AIDS patients
HIV - The Virus

44
HIV - The Virus

Life History
A retrovirus
• Latency
• Specific destruction of
CD4+ cells

• How does the virus

45
HIV - Life History
• Fusion at ambient pH
• No need for entry
into lysosomes
• Syncytia
Profound significance
for AIDS progression:
Spread from cell to cell
Profound significance
for therapy:
Humoral antibody will
not stop spread – need
46
 HIV - Life History
Entry into the cell
T4 (CD4+) cells are major
target

Human HeLa Cell

Human transfected with
HeLa Cell CD4 antigen

NOT INFECTED INFECTED

But NOT the whole answer since this

does not happen if CD4 is transfected into a MOUSE cell 47
 HIV - Life History
Why do CD4-transfected human cells become infected
but CD4-transfected mouse cells do not?

Human cells must possess a co-factor for infection that mouse cells do not

Co-Receptors
CD8+ Cells

MIP-1 alpha MIP-1 beta RANTES

Chemokines

48
Block HIV infection of macrophages
 HIV - Life History

HIV

chemokin
e Mutant
CD4 CCR CCR5
CCR5 5 CD4
CD4

macrophage
Chemokine receptors are necessary co-receptors along with CD4 antigen
49
 HIV and AIDS
Some people do not get AIDS

Long term survivors

Exposed uninfected persons

The chemokine receptor story

50
 HIV and AIDS
Co-receptors and HIV infection
• CCR5 is a chemokine receptor
• Cells with homozygous mutant CCR5
molecules are not infected by HIV
1 in 100 Caucasians
No Africans
• Persons with heterozygous mutant CCR5
molecules progress to AIDS more slowly

51
 HIV and AIDS

Co-receptors
• 25% of long term survivors are
CCR5 or CCR2 mutants (deletions)
• The same CCR5 mutation (called
“delta 32”) is thought to be the
mutation that rendered some people
immune to the plague in the middle
• Many other chemokine
ages receptors
52
 HIV and AIDS
Long term non-progressers
• People who have been infected with HIV for
more than seven years that have stable CD4+
cell counts above 600 per cu mm with no
symptoms and no chemotherapy

• Many have produced a very good immune

response to the virus

53
 HIV and AIDS

• Nairobi prostitutes
Client infection rate more than 25%

• Rare HLA antigens

• Associations between resistance to infection
and their
class I and class II MHC (HLA) haplotypes
54
 HIV - Life History
HIV is a retrovirus
t carries with it:
• Reverse transcriptase
HIV genes
• Integrase
GAG POL ENV
• Protease
• tRNA primer

HIV has no oncogene but could still be oncogenic

vaccine problem 55
 HIV - Life History
Latency – Cellular – The problem of memory T4 cell
cel

y activated T4 cells can replicate virus

st infected T4 cells are rapidly lyzed but are replaced
me T4 cells revert to resting state as memory cells which are long-liv
mory T4 cells cannot replicate the virus unless they become activate

Clinical Latency
HIV infection is not manifested as disease for years
56
During apparent clinical latency, virus is being replicated
 Dynamics of CD4 T cells in an
Cell death
HIV infection Chronically-
apoptosis etc infected
memory T
cells with
Return provirus
Uninfecte
Infectio to
resting
d n state
activat
ed Long
T cell lived! Reactivati
on

Uninfecte Cell death Long

d immune lived!
unactivat Adapted from Saag and
ed
destruction Kilby Nat Med 5: 609, 57
1999
 Long term latent HIV

Immune response

T4 resting T4 activated
memory cell

It may be impossible to cure the patient of HIV

Even if combination therapy stops HIV replication
HIV production
58
 Inexorable decline of CD4+ T4
cells
Why do all
of the T4
cells
disappear?
At early
stages of
infection
only 1 in
10,000 cells
is infected
Late 1 in 40
59
Of great importance to therapeutic strategy
 Virus destroys the cell as a
result of budding

But few cells are infected:

Early stage of infection
1:10,000
Late 1:40

Why do all
T4 cells
1. PUNCTURED
MEMBRANE disappear?
60
 Why do all T4 cells disappear? -
2
But syncytia
not common
Infected CD4 cell Most T4 cells
Cells Fuse are not HIV+
Gp120 positive
Could “sweep
up”
uninfected
cells
Uninfected CD4
Killing of CD4 cells cell
2. Syncytium Formation Gp120 negative
61
 Why do all
T4 cells
disappear?

Cytotoxic
T cell

Killing of CD4 cells

3. Cytotoxic T cell-mediated lysis
BUT: Most cells are
not infected 62
Killing of CD4+ cells
4. Binding of free
Gp120 to CD4
antigen makes
uninfected T4 cell
look like an
infected cell
Complement-
mediated lysis
Could account for
the loss of
uninfected T4 cells
63
 Why do all T4 cells disappear?
Induction of apoptosis
CD8 cell gp120
Macrophage
(no CD4 antigen)
HIV
chemokine

G protein
CXCR4
signal
? chemokine
receptor
?

Binding to CXCR4
Binding to CXCR4
results in
results in expression of
expression of TNF- TNF-alpha on the 64
alpha receptor II cell surface
Why do all T4 cells disappear?
Induction of apoptosis

CD8 cell
CXCR4
Macrophage
Death

CD8 T cell
apoptotic
bodies 65
 Macrophages may be infected
by two routes
HIV gp12
0 CD
4 HIV gp120 binds to
macrophage CD4
antigen
Virus is opsonized by
anti gp120
antibodies which
bind to macrophage
Fc Fc receptors - an
receptor enhancing antibody
Anti-
gp120
vaccine problem
66
HIV
 Macrophages - The Trojan
Horse
Early HIV isolated during infection are macrophage
tropic (have a macrophage chemokine co-receptor
(CCR5))
Virus probably infects patient via macrophages in
semen etc
Infection by HIV leads to altered cytokine production
“slim disease”
Macrophages
Slim form
disease very a reservoir
like outside
Visna in sheep the infects
- also blood
macrophages
Carry virus into different organs (brain)
Non-proliferating mature macrophages sustain HIV
67
production for a long time without being killed by
 Population Polymorphism
HIV is a retrovirus
Retroviruses use host cell RNA polymerase II
to replicate their genome
Pol II has a high error rate 1:2,000-10,000
HIV genome 9749 nucleotides
Therefore EVERY new virus has at least one mutation!
Every possible single mutation arises daily
1% of all possible double mutations arise daily

The HIV that infects a patient is

very different from that seen by vaccine problem
68
Population Polymorphism
• Initial infecting virus is
macrophage-tropic (has CCR5
as co-receptor)
• These are non-syncytium-
inducing strains
(Note: most vaccines have
been made against syncytium-
inducing T4 cell tropic strains)
• As virus mutates, it changes
69
Population Polymorphism
Early in infection:
• Macrophage-tropic
• Non-syncytium-inducing
• Slowly replicating
Late in infection
•T4 cell tropic vaccine problem
• Syncytium-inducing
• High titer virus
70
 Population Polymorphism
• The most variable protein is gp120
• Amino acid sequence within a single patient varies
by 1-6%
• Up to 30% in population
vaccine problem
• Glycosylation masks conserved sites

vaccine problem

Co-infection may result in recombination

vaccine problem 71
 Population Polymorphism
• Variation in reverse transcriptase leads to
resistance to nucleoside analogs
drug problem

• Variation in protease leads to resistance to

protease inhibitors
drug problem
Polymorphism due to high mutation rate as
a result of lack of proof-reading in reverse
transcriptase and RNA pol II
Sub-populations arise with altered cell 72
Other cells infected by HIV
CD4-
• Epithelial cells of bowel
and vagina
• Endothelial cells of
brain
• Brains cells : Astroglia,
oligodendroglia

Galactocerebroside
73
 Anti-HIV Strategies
• Education
Sexually transmitted
Not highly infectious

• Chemotherapy
Mutation selection Resistance
but
Suppress replication No capacity for mutation74
 Anti-HIV Strategies
Highly
Active
Anti-
Retroviral
Therapy
HAART: Two nucleoside analog RT inhibitors and 1
protease inhibitor
Or: Two nucleoside analog RT inhibitors and 1 non
75

nucleoside
 Does HIV Cause AIDS?
Single common factor between:
• Gay San Franciscans
• New York I.V. drug users
• African heterosexuals
• Hemophiliacs
• Spouses of hemophiliacs and drug users
• Children of hemophiliacs and drug users
76
 Does HIV Cause AIDS?

• HIV precedes AIDS in every population

in which AIDS occurs
• Infection by cloned virus
SIV HIV

Simian AIDS Human AIDS 77

 Remember!
• Education led to leveling off of rate of
increase in AIDS
• HAART has greatly slowed death rate
•The fact that fewer people are dying per
year from the infection means that the
number of HIV-infected people in the
population is rising!
• Unless education continues to be
successful and unless we can cure
infected people of virus, the problem of
78