HIV-susceptible target cells in foreskins from medical

male circumcision in South Africa: Markers of HIV

risk?

Abraham J. Olivier
Institute of Infectious Disease and Molecular Medicine
University of Cape Town
 Background
 HIV - 6.4 million people in SA; 4x105 new infections last year

 Medical Male Circumcision (MMC): HIV risk reduction

(~60%); lower STIs

In South Africa:

 ~ 36% of all heterosexual tx of HIV - 15-24 age group

 Biomedical intervention: SA Gov & NGOs aim 4.3 mil MMCs

between 2011 & 2016

 To date: 35% reached (388 000 in KZN alone)

 Hypotheses
1. The underlying mechanism for protection against HIV
acquisition is the removal of potential HIV target cells.

2. That an asymptomatic STI influences the numbers of

HIV targets in the foreskin

Therefore:

 We have started to characterize and enumerate the

frequencies and types of immune cells prevalent in inner
and outer foreskins after MMC
 Differences in keratin thickness between inner and outer
foreskins
 Study Design

OCT tissue blocks: Immunofluorescence

Excision: Tissue
Inner & blocks:
Outer FS primary cell
Maceration: Flow cytometry cultures
 Study sites

South African provinces Gauteng: Chris Hani Baragwanath

Hospital. Khula Ndoda Mass Male
Circumcision Project

12.4% HIV prevalence

KwaZulu Natal:
Edendale Hospital
16.9% HIV
Wizz Kids Soccer Academy
prevalence

Western Cape: University of Cape Town

Divisions of Medical Immunology & Virology labs
 Participants & STIs
Edendale hospital Chris Hani Baragwanath

N 109 41
Age 19 18
[median (IQR)] (19-21) (17-20)
Testosterone [nmol/l; 21.7 _
median (IQR)] (16.8-25.8)
STIs* 18 2
(percentage) (16.5) (7.3)
*At MMC
 Analysis strategy

Subset of 10 young men

Age matched
STI+ & STI-

Immunofluorescence:
Filaggrin (keratin thickness); CD207+ (Langerhans cells);
CD4+(T cells); Ki67(proliferation)
 Results:
Measuring immune cells & keratin
IDL: Interactive Data Language

: Outer
Keratin
layer
K2: Inner
Keratin
layer

: Langerhans cells

Cell density: Nc/A; A = Ni x l1 x l2 x p2

Nc = number of cells l1 = y pixel size

A = area surveyed l2 = x pixel size
Ni = number of images p2 = pixel size in µm squared
 Keratin layers
A subset of 10 participants from the KZN (Edendale) site

Ni = 5/participant

Median difference in keratin thickness = 1.06μm

Testosterone
 Langerhans cells
STI-

p=0.019
p=0.0095

Langerhans cell density /mm2

STI+ 10

0
Inner Outer Inner Outer
STI- STI+
 CD4 & Ki67

STI-

CD4 Ki67
CD4 Ki67

STI+
 CD4 and Ki67 expression are on
different cells
STI+ overlay:

Red: CD4+ cells

Green: Ki67+ cells

Controls
 Results: CD4+ & Ki67+
CD4 Ki67

p=0.038 p=0.0095
80 80
CD4+ T cell density /mm2

p=0.038 ns

Ki67+ cell density /mm2

60 60

40 40

20 20

0 0
Inner Outer Inner Outer Inner Outer Inner Outer
STI- STI+ STI- STI+
 CD4+ CCR5+ expression
CCR5+ cell line Foreskin tissue

 Do CD4+ T cell express CCR5? This is currently ongoing……..

 Expanding numbers from 10
 Future: Macrophages, DC-SIGN expression, CD8 T cells, tight
junction markers
 Results thus far

 Outer foreskin keratin layer thicker than inner (~1 μm median)

 So far, no significant association between keratin thickness and

testosterone or STI status; Older group of young men (20-24 yr) have
higher testosterone levels than younger groups (14-16 yr)

 Immunofluorescence shows no significant differences in Langerhans,

CD4+ or Ki67+ cells counts between inner and outer foreskin

 When analyzing results in the context of STI status, Langerhans cells,

CD4+ and Ki67+ cells are all significantly higher in the foreskins of STI
pos. compared to STI neg. young men.
 Conclusions

 STI-induced inflammation and recruitment of immune cells to the

foreskin may be elevating the risk of HIV acquisition in uncircumcised
men.

 MMC may reduce risk of HIV acquisition and productive infection by

removing potential target cells like CD4+ T cells as well as Langerhans
cells

 LCs are most likely involved in initial exposure to HIV and may be
involved in facilitation of the dispersal of HIV virions that successfully
gain entry into the foreskin.
 Acknowledgements
Prof. Clive Gray (UCT) & Div. of Immunology Funding:
Prof. Jo-Ann Passmore (UCT)
& GEMS (The Genital Mucosal STI Group)

KZN site: Lungile Mayiza (Edendale hospital),

Dr. Doug Wilson (Edendale hospital),
Marcus McGilvray (Wizz Kids),
Rusha Govender (PHRU)

Jburg site: Dr. Hillary Mukudu (Khula Ndoda)

Janan Dietrich, Neil Martinson (PHRU)

UCT: Rushil Harryparsad (Immunology)

Prof. Dirk Lang (Imaging facility)
Susan Cooper (Imaging facility)

Chicago: Prof. Tom Hope (Northwestern University)

Prof. Minh Dinh (Northwestern University)
Dr. Gianguido Cianci (Northwestern University)

Prof. Mathias Mack (University of Regensburg)

All study participants! Thank You!!