Modeling and Understanding the Biology of Transplant-Mediated HIV Cure in a Non-Human Primate Model

Background : The Berlin patient is thus far the only individual considered cured of HIV. Three aspects of the Berlin Patient's treatment are thought to have contributed to his cure following allogeneic hematopoietic stem cell transplantation (HCT): 1) the myeloablative conditioning regimen, 2) transplantation with HIV-resistant cells, and 3) graft-versus-host disease (GVHD). This cure occurred in the context of HCT from an unrelated donor whose cells contained two copies of the CCR5delta32 mutation, which rendered them resistant to CCR5-tropic viruses (the vast majority of the transmitted variants). He also developed GVHD, which is thought to have contributed to his cure by inducing a graft-versus-viral-reservoir (GVVR) effect. While it is still unknown which of these factors was critical to the cure achieved in this patient, the viral rebound observed following allogeneic transplantation with wild-type cells in two Boston patients suggests that HIV-resistance factors may be key to achieving a permanent HIV cure through HCT. Our lab has previously shown that transplantation with autologous unmodified hematopoietic stem cells is not sufficient to eradicate the viral reservoir in a non-human primate (NHP) model of infection. However, the relative contributions of myeloablative conditioning, GVVR, and HIV resistant cells to the clearance of the HIV reservoir have not been rigorously determined. To dissect the impact of each of these factors on the viral reservoir, we have developed the first NHP model of allogeneic bone marrow transplantation (BMT) in Simian/Human Immunodeficiency Virus (SHIV)-infected, combined antiretroviral therapy (cART)-treated rhesus macaques.

Methods : We intravenously infected 6 animals with SHIV-1157ipd3N4 and left them untreated for six months, followed by six months of cART (PMPA, FTC, Raltegravir). 3 animals served as untransplanted controls, and 3 animals received haplo-identical BMT following myeloablative total body irradiation (1020 Gy) without cART discontinuation. Donor chimerism was monitored by molecular analysis and by flow cytometry. Plasma viral RNA was measured by RT-PCR, and cell-associated DNA and RNA were quantified by qPCR in 6 tissues longitudinally, and in >20 tissues at necropsy.

Results : All animals showed peak SHIV plasma viral loads (1.5e7 copies/ml) 10-11 days post-infection, subsequently reaching viral set points. 1 of 6 animal controlled viremia before cART initiation. In all other animals, plasma viral RNA became undetectable 2-3 weeks post cART initiation. We euthanized the transplant recipients at day 47, 29, and 9 post-transplant, due to infection, graft-versus host disease, and renal complications, respectively. Analysis of whole blood and gated CD4⁺ T cells showed acquisition of 100% donor blood chimerism at day 29, with lower T cell chimerism in 1 animal. Despite undetectable SHIV plasma viremia post-transplant, the cell-associated SHIV DNA reservoir persisted in multiple tissues, including lymphoid, hematopoietic and major organs, gut and CNS, and was even increased in certain tissues of transplanted animals compared to untransplanted controls.

Conclusions : Our results indicate that the DNA reservoir persists and may even increase early after transplantion, despite control of peripheral viremia. Thus, allogeneic HCT is likely associated with an initial loss of anti-HIV immunity leading to an increase in the size of the viral reservoir. This may also explain the rebound observed in the Boston patients. Thus, we propose that reservoir eradication will require additional HIV resistance factors and/or anti-HIV strategies post-transplant to enhance 1) donor cell resistance, and 2) the targeted killing of infected cells.