HIV-1 efficient entry in inner foreskin is mediated by elevated CCL5/RANTES that recruits T cells and fuels conjugate formation with Langerhans cells

Modeling mucosal cell-associated HIV type 1 transmission in vitro

Human immunodeficiency virus type 1 (HIV-1) can efficiently spread by direct cell-to-cell contact, a mechanism termed cell-associated HIV transmission. By some estimates, cell-associated HIV transmission is 10-1000-fold more effective than cell-free HIV infection. Mucosal cell-associated HIV transmission may occur when HIV-bearing cells in mucosal secretions from an HIV-infected donor transfer virus directly to recipient target cells in or below the mucosal epithelium, or through HIV transcytosis across the mucosal epithelium of a noninfected host. This mechanism may play an important role in the sexual and vertical transmission of HIV-1, yet most in vitro tests of vaccine and microbicide efficacy assess cell-free virus transmission. This article reviews in vitro assays that have been used to model mucosal cell-associated transmission, including microscopy, immune cell cocultures, use of HIV-infected cells in epithelial cell transcytosis assays, and cell-associated infection of mucosal tissue explants. Assays that authentically simulate mucosal cell-associated HIV transmission could provide valuable insight into mechanisms and molecules that can potentially be targeted for HIV prevention, as well as critical models for testing novel HIV prevention strategies for efficacy against cell-associated HIV transmission.

Calcitonin gene-related peptide inhibits human immunodeficiency type 1 transmission by Langerhans cells via an autocrine/paracrine feedback mechanism

AIM

Peripheral neurones innervating mucosal epithelia are in direct contact with resident immune cells, including Langerhans cells (LCs). Such neurones secrete the neuropeptide calcitonin gene-related peptide (CGRP) that modulates LCs function. We recently found that CGRP strongly inhibits human immunodeficiency virus type 1 (HIV-1) transmission, by interfering with multiple steps of mucosal LC-mediated HIV-1 transfer, including increased expression of the LC-specific lectin langerin. Herein, we investigated the anti-HIV-1 mechanism of CGRP.

METHODS

In the presence of CGRP, HIV-1 transfer from LCs to CD4+ T cells was tested with viral clones using either the HIV-1 co-receptor CCR5 (R5) or CXCR4 (X4). Surface expression of CCR5, CXCR4 and langerin was evaluated by flow cytometry. CGRP secretion by LCs was measured with an enzyme immunoassay. Expression of the multimeric CGRP receptor was examined by quantitative real-time RT-PCR and immuno-fluorescent microscopy.

RESULTS

Calcitonin gene-related peptide decreased transfer of HIV-1 R5, but increased that of X4. These opposing effects correlated with decreased CCR5 vs. increased CXCR4 surface expression in LCs. Inhibition of HIV-1 R5 transfer by CGRP involved signal transducer and activator of transcription 4 (STAT4) activation. Both αCGRP and βCGRP were similarly efficient in decreasing HIV-1 R5 transfer and increasing langerin expression. LCs secreted low basal levels of endogenous CGRP, which increased markedly following CGRP treatment. CGRP also increased expression of its cognate receptor in LCs.

CONCLUSION

CGRP engages a positive feedback mechanism that would further enhance its anti-HIV-1 activity. This information might be relevant for the therapeutic use of CGRP as a prophylactic agent against HIV-1.

The role of human dendritic cells in HIV-1 infection

Dendritic cells (DCs) and their subsets have multifaceted roles in the early stages of HIV-1 transmission and infection. DC studies have led to remarkable discoveries, including identification of restriction factors, cellular structures promoting viral transmission including the infectious synapse or the interplay of the C-type lectins, Langerin on Langerhans cells (LCs), and dendritic cell-specific intercellular adhesion molecule-3-grabbing non-integrin on other DC subsets, limiting or facilitating HIV transmission to CD4(+) T cells, respectively. LCs/DCs are also exposed to encountering HIV-1 and other sexually transmitted infections (herpes simplex virus-2, bacteria, fungi), which reprogram HIV-1 interaction with these cells. This review will summarize advances in the role of DCs during HIV-1 infection and discuss their potential involvement in the development of preventive strategies against HIV-1 and other sexually transmitted infections.

HIV acquisition is associated with increased antimicrobial peptides and reduced HIV neutralizing IgA in the foreskin prepuce of uncircumcised men

BACKGROUND

The foreskin is the site of most HIV acquisition in uncircumcised heterosexual men. Although HIV-exposed, seronegative (HESN) uncircumcised men demonstrate HIV-neutralizing IgA and increased antimicrobial peptides (AMPs) in the foreskin prepuce, no prospective studies have examined the mucosal immune correlates of HIV acquisition.

METHODS

To assess the association of foreskin immune parameters with HIV acquisition, antimicrobial peptides and IgA with the capacity to neutralize a primary clade C HIV strain were quantified by blinded investigators, using sub-preputial swabs collected longitudinally during a randomized trial of male circumcision for HIV prevention in Rakai, Uganda.

RESULTS

Participants were 99 men who acquired HIV (cases) and 109 randomly selected controls who remained HIV seronegative. At enrollment, 44.4% of cases vs. 69.7% of controls demonstrated IgA neutralization (adjusted OR = 0.31; 95% CI, 0.16-0.61). IgA neutralization was detected in 38.7% of cases and 70.7% of controls at the last seronegative case visit prior to HIV acquisition and the comparable control visit (adjusted OR 0.21; 95% CI, 0.11-0.39). Levels of the α-defensins and secretory leukocyte protease inhibitor (SLPI) were over ten-fold higher in the foreskin prepuce of cases who acquired HIV, both at enrollment (mean 4.43 vs. 3.03 and 5.98 vs. 4.61 log(n) pg/mL, P = 0.005 and 0.009, respectively), and at the last seronegative visit (mean 4.81 vs. 3.15 and 6.46 vs. 5.20 log(n) pg/mL, P = 0.0002 and 0.013).

CONCLUSIONS

This prospective, blinded analysis is the first to assess the immune correlates of HIV acquisition in the foreskin. HIV-neutralizing IgA, previously associated with the HESN phenotype, was a biomarker of HIV protection, but other HESN associations correlated with increased HIV acquisition. This emphasizes the importance of prospective epidemiological studies or in vitro tissue studies to define the impact of mucosal parameters on HIV risk.

The inner foreskin of healthy males at risk of HIV infection harbors epithelial CD4+ CCR5+ cells and has features of an inflamed epidermal barrier

Male circumcision provides partial protection against multiple sexually transmitted infections (STIs), including HIV, but the mechanisms are not fully understood. To examine potential vulnerabilities in foreskin epithelial structure, we used Wilcoxon paired tests adjusted using the false discovery rate method to compare inner and outer foreskin samples from 20 healthy, sexually active Peruvian males who have sex with males or transgender females, ages 21–29, at elevated risk of HIV infection. No evidence of epithelial microtrauma was identified, as assessed by keratinocyte activation, fibronectin deposition, or parakeratosis. However, multiple suprabasal tight junction differences were identified: 1) inner foreskin stratum corneum was thinner than outer (p = 0.035); 2) claudin 1 had extended membrane-bound localization throughout inner epidermis stratum spinosum (p = 0.035); 3) membrane-bound claudin 4 was absent from inner foreskin stratum granulosum (p = 0.035); and 4) occludin had increased membrane deposition in inner foreskin stratum granulosum (p = 0.042) versus outer. Together, this suggests subclinical inflammation and paracellular transport modifications to the inner foreskin. A setting of inflammation was further supported by inner foreskin epithelial explant cultures secreting higher levels of GM-CSF (p = 0.029), IP-10 (p = 0.035) and RANTES (p = 0.022) than outer foreskin, and also containing an increased density of CCR5+ and CD4+ CCR5+ cells (p = 0.022). Inner foreskin dermis also secreted more RANTES than outer (p = 0.036), and had increased density of CCR5+ cells (p = 0.022). In conclusion, subclinical changes to the inner foreskin of sexually active males may support an inflammatory state, with availability of target cells for HIV infection and modifications to epidermal barriers, potentially explaining the benefits of circumcision for STI prevention.

Cell-to-cell transfer of HIV infection: implications for HIV viral persistence

A major research priority for HIV eradication is the elucidation of the events involved in HIV reservoir establishment and persistence. Cell-to-cell transmission of HIV represents an important area of study as it allows for the infection of cell types which are not easily infected by HIV, leading to the establishment of long-lived viral reservoirs. This phenomenon enables HIV to escape elimination by the immune system. This process may also enable HIV to escape suppressive effects of anti-retroviral drugs. During cell-to-cell transmission of HIV, a dynamic series of events ensues at the virological synapse that promotes viral dissemination. Cell-to-cell transmission involves various types of cells of the immune system and this mode of transmission has been shown to have an important role in sexual and mother-to-child transmission of HIV and spread of HIV within the central nervous system and gut-associated lymphoid tissues. There is also evidence that cell-to-cell transmission of HIV occurs between thymocytes and renal tubular cells. Herein, following a brief review of the processes involved at the virological synapse, evidence supporting the role for cell-to-cell transmission of HIV in the maintenance of the HIV reservoir will be highlighted. Therapeutic considerations and future directions for this area of research will also be discussed.

Immune correlates of HIV exposure without infection in foreskins of men from Rakai, Uganda

Human immunodeficiency virus (HIV) susceptibility is heterogenous, with some HIV-exposed but seronegative (HESN) individuals remaining uninfected despite repeated exposure. Previous studies in the cervix have shown that reduced HIV susceptibility may be mediated by immune alterations in the genital mucosa. However, immune correlates of HIV exposure without infection have not been investigated in the foreskin. We collected sub-preputial swabs and foreskin tissue from HESN (n=20) and unexposed control (n=57) men undergoing elective circumcision. Blinded investigators assayed swabs for HIV-neutralizing IgA, innate antimicrobial peptides, and cytokine levels. Functional T-cell subsets from foreskin tissue were assessed by flow cytometry. HESN foreskins had elevated α-defensins (3,027 vs. 1,795 pg ml(-1), P=0.011) and HIV-neutralizing IgA (50.0 vs. 13.5% of men, P=0.019). Foreskin tissue from HESN men contained a higher density of CD3 T cells (151.9 vs. 69.9 cells mm(-2), P=0.018), but a lower proportion of these was Th17 cells (6.12 vs. 8.04% of CD4 T cells, P=0.007), and fewer produced tumor necrosis factor α (TNFα) (34.3 vs. 41.8% of CD4 T cells, P=0.037; 36.9 vs. 45.7% of CD8 T cells, P=0.004). A decrease in the relative abundance of susceptible CD4 T cells and local TNFα production, in combination with HIV-neutralizing IgA and α-defensins, may represent a protective immune milieu at a site of HIV exposure.

Differential compartmentalization of HIV-targeting immune cells in inner and outer foreskin tissue

Ex vivo foreskin models have demonstrated that inner foreskin is more susceptible to HIV-1 infection than outer foreskin. In the present study we characterized the compartition of HIV-1 target cells and quantified these cells in the epidermis and dermis of inner and outer foreskins using immunohistochemistry and flow cytometry. Our data showed that the epidermis of the inner foreskin was more enriched with CD4⁺ T cells and Langerhans cells (LCs), with the co-expression of CCR5 and α4β7 receptors, than the outer foreskin. Interestingly, the vast majority of CD4⁺ T cells and LCs expressed CCR5, but not CXCR4, indicating that the inner foreskin might capture and transmit R5-tropic HIV strains more efficiently. In addition, lymphoid aggregates, composed of T cells, macrophages and dendritic cells (DCs) in the dermis, were closer to the epithelial surface in the inner foreskin than in the outer foreskin. As dendritic cells are able to capture and pass HIV particles to susceptible target cells, HIV may be able to more efficiently infect the inner foreskin by hijacking the augmented immune communication pathways in this tissue. After the inoculation of HIV-1 particles in a foreskin explant culture model, the level of p24 antigen in the supernatant from the inner foreskin was slightly higher than that from the outer foreskin, although this difference was not significant. The present study is the first to employ both CCR5 and α4β7 to identify HIV target cells in the foreskin. Our data demonstrated that the inner foreskin was more enriched with HIV target immune cells than the outer foreskin, and this tissue was structured for efficient communication among immune cells that may promote HIV transmission and replication. In addition, our data suggests the R5-tropism of HIV sexual transmission is likely shaped through the inherent receptor composition on HIV target cells in the mucosa.

The development of rectal microbicides for HIV prevention

INTRODUCTION

Individuals practicing unprotected receptive anal intercourse are at particularly high risk of HIV infection. Men who have sex with men in the developed and developing world continue to have disproportionate and increasing levels of HIV infection. The last few years have seen important progress in demonstrating the efficacy of oral antiretroviral pre-exposure prophylaxis, vaginal microbicides, and treatment as prevention, but there has also been significant progress in the development of rectal microbicides for HIV prevention.

AREAS COVERED

The purpose of this review is to summarize the status of rectal microbicide research and to identify opportunities, challenges, and future directions in this important field of HIV prevention research. The design of completed and ongoing Phase I rectal microbicide studies that include the generation of comprehensive pharmacokinetic/pharmacodynamic data may allow for more rational decisions about which rectal microbicides should be advanced to later stage development.

EXPERT OPINION

There is a strong rationale for the development of rectal microbicides for HIV prevention. Preclinical data provide supportive evidence for the feasibility of this approach, and there is significant interest in rectal microbicide development from communities at risk of HIV acquisition through unprotected receptive anal intercourse in both the developed and developing world. Demonstration of sustained safety, acceptability, and product adherence in the MTN-017 Phase II study of tenofovir 1% gel will be an important step in rectal microbicide development and will hopefully lead to Phase III effectiveness testing of this novel HIV prevention strategy.

Calcitonin gene-related peptide inhibits Langerhans cell-mediated HIV-1 transmission

Upon its mucosal entry, human immunodeficiency virus type 1 (HIV-1) is internalized by Langerhans cells (LCs) in stratified epithelia and transferred locally to T cells. In such epithelia, LCs are in direct contact with peripheral neurons secreting calcitonin gene-related peptide (CGRP). Although CGRP has immunomodulatory effects on LC functions, its potential influence on the interactions between LCs and HIV-1 is unknown. We show that CGRP acts via its receptor expressed by LCs and interferes with multiple steps of LC-mediated HIV-1 transmission. CGRP increases langerin expression, decreases selected integrins, and activates NF-κB, resulting in decreased HIV-1 intracellular content, limited formation of LC-T cell conjugates, and elevated secretion of the CCR5-binding chemokine CCL3/MIP-1α. These mechanisms cooperate to efficiently inhibit HIV-1 transfer from LCs to T cells and T cell infection. In vivo, HIV-1 infection decreases CGRP plasma levels in both vaginally SHIV-challenged macaques and HIV-1-infected individuals. CGRP plasma levels return to baseline after highly active antiretroviral therapy. Our results reveal a novel path by which a peripheral neuropeptide acts at the molecular and cellular levels to limit mucosal HIV-1 transmission and suggest that CGRP receptor agonists might be used therapeutically against HIV-1.

Use of human mucosal tissue to study HIV-1 pathogenesis and evaluate HIV-1 prevention modalities

The use of human mucosal tissue models is an important tool advancing our understanding of the specific mechanisms of sexual HIV transmission. Despite 30 years of study, major gaps remain, including how HIV-1 transverses the epithelium and the identity of the early immune targets (gate keepers). Because defining HIV-1 transmission in vivo is difficult, mucosal tissue is being used ex vivo to identify key steps in HIV-1 entry and early dissemination. Elucidating early events of HIV-1 infection will help us develop more potent and specific HIV-1 preventatives such as microbicides and vaccines. Mucosal tissue has been incorporated into testing regimens for antiretroviral drugs and monoclonal antibodies. The use of mucosal tissue recapitulates the epithelium and immune cells that would be exposed in vivo to virus and drug. This review will discuss the use of mucosal tissue to better understand HIV-1 pathogenesis and prevention modalities.

The adult penile urethra is a novel entry site for HIV-1 that preferentially targets resident urethral macrophages

The penile urethra is routinely targeted by sexually transmitted bacterial and viral pathogens, and also represents a probable site for HIV type-1 (HIV-1) entry. Yet, the mechanisms of urethral HIV-1 transmission are unknown. To describe the initial steps of penile HIV-1 entry, we obtained whole penile tissues from individuals undergoing elective gender reassignment and developed ex vivo polarized explants of different penile epithelia, as well as in vitro immunocompetent reconstructed urethra. In penile explants, 1 h exposure to cell-associated HIV-1 results in higher HIV-1 entry into the urethra, whereas the fossa navicularis and glans are relatively resistant to HIV-1. CCR5+/CD4+ urethral macrophages are the initial cells infected by HIV-1, which exit the epithelial compartment following inoculation with cell-associated HIV-1 that induces decreased CCL2/MCP-1 production. Urethral T cells are mostly CD8+ or naive CD4+, and not infected by HIV-1 on its early entry. In urethral reconstructions, efficient translocation of cell-associated HIV-1 depends on viral tropism (R5>X4) and can be decreased by gp41-specific IgAs. Cell-free HIV-1 is inefficient at urethral penetration. Our results identify the male urethra as a novel entry site for HIV-1 that targets resident urethral macrophages. These results might explain the incomplete prophylactic efficacy of male circumcision in reducing HIV-1 transmission.

R5 HIV-1 envelope attracts dendritic cells to cross the human intestinal epithelium and sample luminal virions via engagement of the CCR5

The gastrointestinal tract is a principal route of entry and site of persistence of human immunodeficiency virus type 1 (HIV-1). The intestinal mucosa, being rich of cells that are the main target of the virus, represents a primary site of viral replication and CD4⁺ T-cell depletion. Here, we show both in vitro and ex vivo that HIV-1 of R5 but not X4 phenotype is capable of selectively triggering dendritic cells (DCs) to migrate within 30 min between intestinal epithelial cells to sample virions and transfer infection to target cells. The engagement of the chemokine receptor 5 on DCs and the viral envelope, regardless of the genetic subtype, drive DC migration. Viruses penetrating through transient opening of the tight junctions likely create a paracellular gradient to attract DCs. The formation of junctions with epithelial cells may initiate a haptotactic process of DCs and at the same time favour cell-to-cell viral transmission. Our findings indicate that HIV-1 translocation across the intestinal mucosa occurs through the selective engagement of DCs by R5 viruses, and may guide the design of new prevention strategies.

Antimicrobial peptide LL-37 produced by HSV-2-infected keratinocytes enhances HIV infection of Langerhans cells

Herpes simplex virus (HSV)-2 shedding is associated with increased risk for sexually acquiring HIV. Because Langerhans cells (LCs), the mucosal epithelium resident dendritic cells, are suspected to be one of the initial target cell types infected by HIV following sexual exposure, we examined whether and how HSV-2 affects HIV infection of LCs. Although relatively few HSV-2/HIV-coinfected LCs were detected, HSV-2 dramatically enhanced the HIV susceptibility of LCs within skin explants. HSV-2 stimulated epithelial cell production of antimicrobial peptides (AMPs), including human β defensins and LL-37. LL-37 strongly upregulated the expression of HIV receptors in monocyte-derived LCs (mLCs), thereby enhancing their HIV susceptibility. Culture supernatants of epithelial cells infected with HSV-2 enhanced HIV susceptibility in mLCs, and this effect was abrogated by blocking LL-37 production. These data suggest that HSV-2 enhances sexual transmission of HIV by increasing HIV susceptibility of LCs via epithelial cell production of LL-37.

Biological basis for the protective effect conferred by male circumcision against HIV infection

Here we provide an up-to-date review of research that explains why uncircumcised men are at higher risk of HIV infection. The inner foreskin is a mucosal epithelium deficient in protective keratin, yet rich in HIV target cells. Soon after sexual exposure to infected mucosal secretions of a HIV-positive partner, infected T-cells from the latter form viral synapses with keratinocytes and transfer HIV to Langerhans cells via dendrites that extend to just under the surface of the inner foreskin. The Langerhans cells with internalized HIV migrate to the basal epidermis and then pass HIV on to T-cells, thus leading to the systemic infection that ensues. Infection is exacerbated in inflammatory states associated with balanoposthitis, the presence of smegma and ulceration - including that caused by infection with herpes simplex virus type 2 and some other sexually transmitted infections (STIs). A high foreskin surface area and tearing of the foreskin or associated frenulum during sexual intercourse also facilitate HIV entry. Thus, by various means, the foreskin is the primary biological weak point that permits HIV infection during heterosexual intercourse. The biological findings could explain why male circumcision protects against HIV infection.

Foreskin T-cell subsets differ substantially from blood with respect to HIV co-receptor expression, inflammatory profile, and memory status

The foreskin is the main site of heterosexual human immunodeficiency virus (HIV) acquisition in uncircumcised men, but functional data regarding T-cell subsets present at this site are lacking. Foreskin tissue and blood were obtained from Ugandan men undergoing elective adult circumcision. Tissue was treated by mechanical and enzymatic digestion followed by T-cell subset identification and assessment of cytokine production using flow cytometry. Foreskin CD4(+) T cells were predominantly an effector memory phenotype, and compared with blood they displayed a higher frequency of CCR5 expression (42.0% vs. 9.9%) and interleukin-17 production. There was no difference in T-regulatory cell frequency, but interferon-γ and tumor necrosis factor-α production were increased in foreskin CD8(+) T cells. These novel techniques demonstrate that the foreskin represents a proinflammatory milieu that is enriched for HIV-susceptible T-cell subsets. Further characterization of foreskin T-cell subsets may help to define the correlates of HIV susceptibility in the foreskin.