Depletion of stromal and intraepithelial antigen-presenting cells in cervical neoplasia in human immunodeficiency virus infection

Infiltrating T-cell markers in cervical carcinogenesis: a systematic review and meta-analysis

BACKGROUND

The host adaptive immune response helps determine which cervical HPV infections persist and progress to precancer and cancer, and systematic characterisation of T-cell infiltration would help inform key steps in cervical carcinogenesis.

METHODS

A systematic review and meta-analysis were conducted of infiltrating T-cells in normal cervix, low-grade lesions, high-grade lesions, and invasive cancers including epithelial, stromal, and total tissue and the following markers: CD3, CD4, CD8, FoxP3, CD25, and the CD4:CD8 ratio. An additional qualitative review summarised longitudinal data on associations between infiltrating T-cells and cervical disease persistence, regression, progression, or prognosis.

RESULTS

There were fewer CD3+, CD4+, and CD8+ cells in cervical lesions and more cells in cancers compared to normal epithelium. FoxP3 and CD25+ regulatory T-cell infiltration is high in persistent and precancerous lesions, and longitudinal data show improved outcomes with lower regulatory T-cell levels.

CONCLUSIONS

Successful immune evasion may reduce T-cell infiltration in HPV infected and precancerous epithelium, while invasive cancers are highly immunogenic, and regulatory T-cell infiltration increases with cervical disease progression. Understanding these factors may have prognostic value and could aid in novel treatment development and clinical guidelines, but published data are highly heterogeneous and leave important gaps to be filled by future studies.

Effects of three long-acting reversible contraceptive methods on HIV target cells in the human uterine cervix and peripheral blood

BACKGROUND

Hormonal contraceptives, particularly depot medroxyprogesterone acetate (DMPA), have been reported to be associated with substantially enhanced HIV acquisition; however, the biological mechanisms of this risk remain poorly understood. We aimed to investigate the effects of different hormonal contraceptives on the expression of the HIV co-receptors, CXCR4 and CCR5, on female endocervical and peripheral blood T cells.

METHODS

A total of 59 HIV-negative women were enrolled, including 15 initiating DMPA, 28 initiating a levonorgestrel-releasing intrauterine device (LNG-IUD) and 16 initiating an etonogestrel (ETG)-delivering vaginal ring. Peripheral blood and endocervical cytobrush specimens were collected at enrollment and 3-4 weeks after contraception initiation to analyze the expression of CXCR4 and CCR5, on CD4+ and CD8+ T cells using flow cytometry.

RESULTS

Administration of DMPA increased the percentages of CD4+ and CD8+ T cells expressing CCR5 in the endocervix but not in the peripheral blood. Administration of the LNG-IUD or the ETG vaginal ring did not affect the percentages of T lymphocytes expressing CXCR4 or CCR5 in the female cervix or peripheral blood.

CONCLUSIONS

Increase in the percentage of endocervical T cells expressing CCR5 upon DMPA exposure provides a plausible biological explanation for the association between DMPA use and an elevated risk of HIV infection.

Local Impairment of Immunoreactivity in Hiv-infected Women with Hpv-related Squamous Intraepithelial Lesions of the Cervix

Aims and background

The aim of this study was to compare the local immune response in two groups of patients with high-grade cervical intraepithelial squamous lesions (SIL): one with HIV infection and the other with HPV infection alone.

Materials and methods

16 conization specimens (8 from HIV-infected and 8 from non-HIV-infected patients) of HPV-related, high-grade SIL were selected. The specimens from non-HIV patients were considered as controls. The total number of Langerhans cells, CD4 and CD8 cells present in 10 field areas (3.120 mm2) was recorded in each case. In HIV patients CD4 and CD8 peripheral counts were performed immediately before surgery.

Results

The CD4/CD8 ratio never exceeded 0.71, whereas the lowest ratio in controls was 0.81: this difference was statistically significant (P=0.0009). The mean number of Langerhans cells was markedly reduced in the high-grade SILs in the HIV patients in comparison with controls (P=0.001). The number of CD4 cells and the CD4/CD8 ratio correlated with the peripheral CD4 count (P=0.001 and 0.02).

Conclusions

In our study a marked local impairment of cervical immunoreactivity was observed, which may play a major role in the progression of these lesions in HIV-infected women.

Oropharyngeal Candidiasis in HIV Infection: Analysis of Impaired Mucosal Immune Response to Candida albicans in Mice Expressing the HIV-1 Transgene

IL-17-producing Th17 cells are of critical importance in host defense against oropharyngeal candidiasis (OPC). Speculation about defective Th17 responses to oral C. albicans infection in the context of HIV infection prompted an investigation of innate and adaptive immune responses to Candida albicans in transgenic mice expressing the genome of HIV-1 in immune cells and displaying an AIDS-like disease. Defective IL-17 and IL-22-dependent mucosal responses to C. albicans were found to determine susceptibility to OPC in these transgenic mice. Innate phagocytes were quantitatively and functionally intact, and individually dispensable for control of OPC and to prevent systemic dissemination of Candida to deep organs. CD8+ T-cells recruited to the oral mucosa of the transgenic mice limited the proliferation of C. albicans in these conditions of CD4+ T-cell deficiency. Therefore, the immunopathogenesis of OPC in the context of HIV infection involves defective T-cell-mediated immunity, failure of crosstalk with innate mucosal immune effector mechanisms, and compensatory cell responses, which limit Candida infection to the oral mucosa and prevent systemic dissemination.

Increased vascular endothelial growth factor expression, CD3-positive cell infiltration, and oxidative stress in premalignant lesions of the cervix

BACKGROUND

Vascular endothelial growth factor (VEGF) plays an important role in cervical intraepithelial neoplasia (CIN) progression. The occurrence of leukocytes has been documented in CIN; however, their role in VEGF production remains unknown. Oxidative stress has been involved in the progression of malignant neoplasias, but to the authors' knowledge tissue oxidative stress in CIN has not been documented. The objective of the current study was to investigate the expression of VEGF, leukocyte infiltration, leukocyte VEGF expression, and nitrogen/oxygen metabolism in cervical tissues from patients with CIN.

METHODS

Indirect immunofluorescence was used to study the expression of VEGF and leukocyte infiltration in cervical samples from 55 patients with CIN and 7 normal controls. Superoxide anion (O(2) (-)) expression was determined by a cytochemical method, and tissue and serum nitric oxide by the Griess reaction. Human papillomavirus (HPV) DNA and HPV types were identified by the hybrid capture 2 HPV DNA test.

RESULTS

Increased expression of VEGF was observed related to the progression of CIN. A significant increment of CD3 lymphocytes was found in CIN type 3 (CIN 3) and coexpression of CD3/VEGF and monocyte-macrophage/VEGF in CIN 2 and 3. Increased O(2) (-)-positive cells were found in CIN 2 and 3; however, tissue nitrate-nitrite content remained similar to controls. The incidence of HPV infection was 16% in patients with CIN. No significant differences were observed in the values of HPV-positive or HPV-negative patients.

CONCLUSIONS

Different factors leading to cervical neoplasia progression may be involved in the evolution of CIN, and the presence of these factors is most likely not related to the HPV infection status.

Gynecologic issues in the HIV-infected woman

In this article, gynecologic conditions of increased importance in the HIV-infected woman are discussed. Women living with HIV may have an increase in menstrual disorders, lower genital tract neoplasias, gynecologic surgery, and sexually transmitted infections. The literature relevant to choosing a method of contraception for HIV-positive women is also discussed. With the advent of HAART, seropositive women are now facing issues around longevity, such as menopause and disorders of bone mineral density, as well as those associated with fertility.

Langerhans cell density and high-grade vulvar intraepithelial neoplasia in women with human immunodeficiency virus infection

BACKGROUND

Decreased numbers of Langerhans cells (LCs) in the cervix of human immunodeficiency virus (HIV)-infected women are believed to contribute to the progression of human papilloma virus (HPV)-related squamous intraepithelial lesions. However, this impairment of local immunity has not been well studied in the vulva. The objective of this study was to compare the S100+ LC density in high-grade vulvar intraepithelial neoplasia (VIN) in HIV-positive and HIV-negative women.

METHODS

HIV-positive and HIV-negative patients with high-grade VIN, 48 (55%) and 40 (45%), respectively, were identified by retrospective chart review. Smoking status of patients was noted. The mean LC count per high-power field (HPF) was determined using S100 immunohistochemical staining. In situ hybridization was performed to detect HPV DNA types 16 and 18.

RESULTS

Mean S100+ LC counts for HIV-positive and HIV-negative patients were 5.82 and 9.86 per HPF, respectively (p = 0.0026). LC counts in HIV-positive and HIV-negative patients were compared between smoking and nonsmoking groups (HIV-positive p = 0.4812, HIV-negative p = 0.2821).

CONCLUSIONS

HIV-positive patients with high-grade VIN had significantly lower LC counts compared with HIV-negative patients. This suggests that local vulvar immunity as evaluated by S100+ LCs is impaired in HIV-positive women, possibly contributing to the progression of HPV-related vulvar lesions.

Interactions between human papillomavirus and other sexually transmitted agents in the etiology of cervical cancer

The interplay between human papillomavirus, notably type 16, and HIV in cervical carcinogenesis leads to persistent infection and cervical neoplasia by destruction of the afferent arm (Langerhans cells) of the host immune system. The joint effect takes place at the early stages of squamous intraepithelial lesions and has severe consequences if left untreated. The recent increase of cervical cancer mortality in young women in developed countries may well be a result of the HIV epidemic. Infection with Chlamydia trachomatis is associated with cervical squamous cell carcinoma but not with cervical adenocarcinoma, and the association remains after adjusting for human papillomavirus 16. Joint effects of C. trachomatis and the human papillomaviruses have not been studied at the population level but indirect evidence from epidemiological studies suggests that the interaction might be different (synergistic versus antagonistic) at different stages (cervical intraepithelial neoplasia versus invasive cervical cancer) of cervical carcino-genesis. Concomitant exposure to human papillomaviruses 6 or 11 and human papillomavirus type 16 has not been shown to result in excess risk of cervical squamous cell carcinoma. This antagonistic joint effect was also discovered between human papillomavirus types 18 and 16, as well as 33 and 16. Herpes simplex virus type 2 antibodies are associated with a modest risk of cervical cancer, which is not surprising since the presence of herpes simplex virus antibodies reflects risk-taking sexual behaviour. However, no excess risk remains after adjustment for human papillomavirus type 16, and no interaction between these two viruses has been found in epidemiological studies. Evidence of interaction between human papillomavirus type 16 and the other members of the herpesvirus family is still at an experimental level and difficult to judge. Little progress has been made in the most promising experimental association between the oncogenic human papillomaviruses and adeno-associated viruses. In addition to the well established interaction between human papillomaviruses and HIV, intriguing interactions are emerging between the human papillomaviruses and C. trachomatis, as well as between the different human papillomavirus types.

In situ detection of SOCS and cytokine expression in the uterine cervix from HIV/HPV coinfected women

The purpose of this study was to look for associations between a newly described class of suppressors of cytokine signaling (SSI/SOCS) and cytokine expression in the uterine cervix from HIV/HPV coinfected women. We examined the pro-inflammatory cytokines TNF-alpha and IL-6 since their expressions are linked and responsible for many aspects of both localized and systemic inflammatory responses. Further, expression of SSI/SOCS has been implicated in the negative feedback regulation of cytokine receptor signaling. PCR-amplified HIV-1 cDNA was noted mainly in the stroma, showing a perivascular distribution, and most of the infected cells colabeled with the macrophage marker CD68. The distribution of IL-6 and TNF-alpha was in the same area to HIV-1 and much greater than normal cervices from women with no evidence of viral infection. SOCS/SSI-1 and -3 mRNA positive cells in the uterine cervix were commonly detected in these noninfected cervical tissues; however, very few cells that contained SOCS were evident in areas where HIV-1, TNF-alpha, and IL-6 expressing cells were found. This suggests that viral-related suppression of SOCS/SSI-1-3 expression may be a factor in the marked local enhancement of TNF-alpha and IL-6 production which, in turn, may help facilitate viral spread; however, further studies should be done in order to elucidate the exact mechanisms of SOCS in the cervix.

Relationship between HIV viral load and Langerhans cells of the cervical epithelium

AIM

To determine the relationship between the density of cervical mucosa Langerhans cells, cervical histology, and HIV viral load.

METHODS

Eighty-four HIV-infected and 17 women at high risk for HIV had cervical biopsies assessed for squamous intraepithelial lesions and Langerhans cell density. Langerhans cells were identified using the S-100 immunohistochemical stain and were counted manually. Polymerase chain reaction assays were used to detect cervical human papillomavirus (HPV)-DNA. T-cell subsets were determined using immunofluorescent flow cytometry. Plasma HIV RNA levels were measured using a nucleic acid sequence-based amplification technique. The associations between cervical Langerhans cell density, cervical histology, CD4 counts, HIV viral loads, HPV-DNA detection, and smoking status were assessed using multivariate statistical models.

RESULTS

In multivariate analysis among women infected with HIV, the mean Langerhans cell density per high-powered field was 4.00 among women with no detectable plasma HIV-RNA, and 1.92 among those with detectable HIV-RNA (P = 0.01). The mean cervical Langerhans cell density was increased in women with high-grade squamous intraepithelial lesions compared with those with low-grade squamous intraepithelial lesions and normal/metaplastic histology (3.87 vs 2.11; P = 0.05). Neither HPV-DNA detection, smoking status, nor CD4 count was significantly associated with Langerhans cell density.

CONCLUSIONS

The decrease in cervical Langerhans cell density in women with detectable HIV-RNA suggests an impaired mucosal immune response to local infections, such as HPV. Conversely, HPV infection resulting in high-grade dysplasia might be associated with an enhanced local immune response.

Immune response in cervical dysplasia induced by human papillomavirus: the influence of human immunodeficiency virus-1 co-infection - review

Human immunodeficiency virus (HIV-1) has become an important risk factor for human papillomavirus (HPV) infection and the development of HPV associated lesions in the female genital tract. HIV-1 may also increase the oncogenicity of high risk HPV types and the activation of low risk types. The Center for Disease Control and Prevention declared invasive cervical cancer an acquired immunodeficiency virus (AIDS) defining illness in HIV positive women. Furthermore, cervical cancer happens to be the second most common female cancer worldwide. The host's local immune response plays a critical factor in controlling these conditions, as well as in changes in the number of professional antigen-presenting cells, cytokine, and MHC molecules expression. Also, the production of cytokines may determine which arm of the immune response will be stimulated and may influence the magnitude of immune protection. Although there are many studies describing the inflammatory response in HPV infection, few data are available to demonstrate the influence of the HIV infection and several questions regarding the cervical immune response are still unknown. In this review we present a brief account of the current understanding of HIV/HPV co-infection, emphasizing cervical immune response.

Depressed type 1 cytokine synthesis by superantigen-activated CD4+ T cells of women with human papillomavirus-related high-grade squamous intraepithelial lesions

Carcinoma of the cervix is causally related to infection with the human papillomavirus (HPV), and T cells play a pivotal role in the immune response of the host to rid itself of HPV infection. Therefore, we assessed the T-cell function of women with HPV-related cervical neoplasia against a superantigen, Staphylococcus enterotoxin B (SEB). Each woman provided a cervical brush specimen for HPV DNA testing and Papanicolaou (Pap) smears for the staging of cervical lesions. They also provided a blood specimen for determination of the ability of CD4(+) T and CD8(+) T cells to synthesize Th1 (interleukin-2 [IL-2], gamma interferon [IFN-gamma], and tumor necrosis factor alpha [TNF-alpha]) and Th2 (IL-10) cytokines in response to activation with SEB. Compared with control subjects with self-attested negative Pap smears, women with high-grade squamous intraepithelial lesions (HSIL) had significantly lower percentages of activated CD4(+) T cells that produced IL-2 (P = 0.045), IFN-gamma (P = 0.040), and TNF-alpha (P = 0.015) and a significantly lower percentage of activated CD8(+) T cells that produced IL-2 (P < 0.01). These data indicate that women with HPV-related cervical HSIL show a decrease in Th1 cytokine production by activated CD4(+) T cells and suggested that compromised T-helper functions may negatively impact the function of cytotoxic CD8(+) T cells.

Immunopathogenesis of oropharyngeal candidiasis in human immunodeficiency virus infection

Oropharyngeal and esophageal candidiases remain significant causes of morbidity in human immunodeficiency virus (HIV)-infected patients, despite the dramatic ability of antiretroviral therapy to reconstitute immunity. Notable advances have been achieved in understanding, at the molecular level, the relationships between the progression of HIV infection, the acquisition, maintenance, and clonality of oral candidal populations, and the emergence of antifungal resistance. However, the critical immunological defects which are responsible for the onset and maintenance of mucosal candidiasis in patients with HIV infection have not been elucidated. The devastating impact of HIV infection on mucosal Langerhans' cell and CD4(+) cell populations is most probably central to the pathogenesis of mucosal candidiasis in HIV-infected patients. However, these defects may be partly compensated by preserved host defense mechanisms (calprotectin, keratinocytes, CD8(+) T cells, and phagocytes) which, individually or together, may limit Candida albicans proliferation to the superficial mucosa. The availability of CD4C/HIV transgenic mice expressing HIV-1 in immune cells has provided the opportunity to devise a novel model of mucosal candidiasis that closely mimics the clinical and pathological features of candidal infection in human HIV infection. These transgenic mice allow, for the first time, a precise cause-and-effect analysis of the immunopathogenesis of mucosal candidiasis in HIV infection under controlled conditions in a small laboratory animal.

Langerhans' cell count and HLA class II profile in cervical intraepithelial neoplasia in the presence or absence of HIV infection

OBJECTIVES

The progression of immunosuppression in human immunodeficiency virus (HIV)+ women has been correlated with elevated incidence of squamous intraepithelial lesions (SIL), probably indicating the role of local immune milieu. In this study, we analysed S100, and HLA class II molecule expression in cervical biopsies according to HIV status, to the severity of SIL and to human papillomavirus (HPV) type.

METHODS

Biopsies from 34 HIV+ and 44 HIV- patients with normal cervix or low- or high-grade SIL were studied. Langerhans' cells (LC) (S100), HLA class II and HLA-DQ molecules were evaluated by immunohistochemistry. HPV detection was performed using polymerase chain reaction (PCR). For statistical analysis Mann-Whitney (P< or =0.05) and Spearman test were used.

RESULTS

Epithelial S100 and HLA class II density were significantly increased with the severity of lesion (P=0.032; P=0.005). Epithelial S100+ increased in HPV+ (P=0.038), and HLA class II density decreased in HPV 16+ (P=0.035) or 18+ (P<0.0001) samples. HIV infection was associated with increased stromal S100+ (P=0.0005) and decreased HLA class II densities (P=0.0001). Decreased stromal S100+ was observed in women with CD4<500 cells/microl (P=0.050). Among HIV+ patients with SIL, the lowest S100 and epithelial HLA class II densities were detected in women with CD4<200 cells/microl (P=0.045).

CONCLUSIONS

After the establishment of AIDS, increased numbers of immature LCs and a reduction in HLA class II occurred, possibly turning the cervical milieu more favourable to HPV persistence. HPV 16 and 18 infections may interfere with the antigen presenting activity, possibly as an evasion mechanism.

Gynecologic issues in the HIV-infected woman

Science has made great strides in understanding the management of the many gynecologic conditions that affect HIV-positive women with an increased frequency. As HIV-infected women's life expectancy continues to lengthen, new treatments are necessary for recurring conditions, such as lower genital tract neoplasias. The medical field has much to learn about the interaction between sex steroids, HIV-infection, and the immune system. As knowledge grows, clinicians will be better equipped to counsel women about contraceptive issues, pregnancy, and menopause.

Recruitment of CD4 T lymphocytes and macrophages into the cervical epithelium of women after coitus

OBJECTIVE

T lymphocytes and macrophages are considered essential components of the immune response. Many factors are known to influence the presence and distribution these cells in genital mucosa. This study investigated the effect of sexual intercourse on cervical intraepithelial T lymphocytes and macrophages in healthy uninfected women.

STUDY DESIGN

Cervical intraepithelial samples were obtained with an endocervical brush from 31 women; the cervical T lymphocytes and macrophages were analyzed by flow cytometry. Eleven women with a history of last sexual intercourse at <3 days were compared against 20 women with last sexual intercourse of >3 days. Furthermore, cellular activation markers (CD69, CD25, HLA-DR) on T lymphocytes and costimulatory molecules (CD80, CD86) on macrophages were studied.

RESULTS

Women with last sexual intercourse at <3 days showed predominance of CD4(+) T lymphocytes compared with women with last sexual intercourse of >3 days (P <.02); the numbers of macrophages were higher in the latter (P <.005). No difference was found in the density of T-lymphocyte activation and macrophage costimulatory markers between the two cohorts.

CONCLUSION

Within cervical epithelium, the distribution of mononuclear leucocytes may be altered after coitus. The higher proportion of cervical intraepithelial CD4(+) T cells that were observed in the early postcoital period suggests a mechanism by which the relative risk of the acquisition of human immunodeficiency virus infection is increased in women.

Presence and quantification of macrophages in squamous cell carcinoma of the cervix

Cervical cancer is a major cause of morbidity and mortality in women. The presence of macrophages as well as other inflammatory cells has been noted in many of these tumors. Intratumoral macrophages/monocytes induce anergy to cytokine therapy and cause apoptosis in natural killer(NK) and T cells. The aim of this study was to better evaluate and quantify the presence of macrophages in these tumors. Twenty-four cases of squamous cell carcinoma of the cervix seen at our institution were evaluated. Sections were stained with CD68, a marker for macrophages. Staining was graded microscopically by two reviewers together on a scale of 0-4+, with 4+ representing the greatest number of positive cells. Image analysis was conducted to quantify the percent area stained in a given lesion. For each lesion, 10 fields were evaluated, and a mean percentage area stained was calculated. 4+ staining was observed in five cases, 3+ in zero cases, 2+ in three cases, 1+ in six cases, 1-2+ in one case, and nine cases were negative. Image analysis results correlated well with the light microscopic scoring. Presence of a prominent infiltrate of macrophages did not correlate with tumor grade or with histologic lymph node status, but showed a strong negative correlation with tumor stage. Some squamous cell carcinomas of the cervix show a prominent macrophage component in the tumor-associated inflammatory infiltrate. The presence of this prominent infiltration of macrophages did not correlate with tumor grade or lymph node status, but showed a strong negative correlation with tumor stage. The results suggest that immunotherapy may have a potential role in the treatment of cervical carcinoma. Computerized image analysis appears to be a valid measure to assess macrophage counts in such lesions.

Evaluation of the cervical cytobrush sampling technique for the preparation of CD45+ mononuclear cells from the human cervix

A cytobrush technique developed to prepare mononuclear cells from the intraepithelial layer of the endocervix has been evaluated. Specimens yielded approximately 4-6x10(6) cells, of which 10-15% were CD45+. Between 10% and 15% of these CD45+ cells were mononuclear leukocytes. The non-leukocyte cell fraction exhibited high levels of autofluorescence and for flow cytometry analysis, it was necessary to exclude these cells by gating. Macrophages constituted approximately 60% and T lymphocytes, 40% of the mononuclear cells in cytobrush samples. The CD4/CD8 T-cell ratio was similar to that observed in blood. In 9 of 13 specimens, B lymphocytes constituted less than 1% of the mononuclear cell fraction suggesting that the mononuclear cells were derived from the intraepithelial compartment rather then the deeper lamina propria. Lack of B lymphocytes also indicates minimal blood contamination in these samples, a conclusion supported by labelling for the red blood cell (RBC) glycoprotein glycophorin A. However, the need to monitor all samples for possible blood contamination was indicated by 4 of 13 samples in which B lymphocytes accounted for 2-8% of the mononuclear cells.

Dendritic cells induce the death of human papillomavirus-transformed keratinocytes

Although human papillomavirus (HPV) antigens are expressed in a majority of (pre)neoplastic lesions (squamous intraepithelial lesions; SILs) of the uterine cervix, progression to invasive cancer may occur, which suggests that the presentation of viral antigens to the immune system is deficient in some SILs. To determine whether professional antigen-presenting cells die in SILs, we assayed for the apoptosis of immature dendritic cells (DC) in organotypic cultures of HPV-transformed keratinocytes, which reproduce many features of in vivo observed SILs. Unexpectedly, the infiltration of organotypic cultures by DC specifically induced the apoptosis of HPV+ tumor cells, whereas DC were not affected. In the same conditions and in coculture experiments, apoptosis was not observed in normal keratinocytes. The induction of apoptosis required membrane contacts between DC and HPV-transformed keratinocytes. Although the HPV+cell lines were sensitive to the effects of TRAIL, soluble TRAILR2-Fc did not block the DC-induced apoptosis. Furthermore, although FasL and Fas were detected on DC and HPV+ cell lines, respectively, functional analysis revealed that this pathway is not responsible for the apoptosis induced by the DC. All together these results suggest that DC may be at the interface between innate and adaptive immunity by inducing the apoptosis of (pre)neoplastic cells.

Higher levels of activation markers and chemokine receptors on T lymphocytes in the cervix than peripheral blood of normal healthy women

Heterosexual transmission of human immunodeficiency virus (HIV-1) is the predominant mode of infection world-wide. To better understand sexual transmission of HIV-1 in women we have analysed virus co-receptor and cellular activation marker expression on T lymphocyte subsets from the cervical epithelium and have made comparisons with peripheral blood T cells. Intraepithelial cervical T lymphocytes were obtained with a cytobrush, immunolabelled and analysed by flow cytometry. Activation markers (CD69, CD25 and HLA-DR) were found to be more highly expressed on cervical than on blood T lymphocytes. These higher levels of activation on cervical T lymphocyte subsets could facilitate HIV-1 infection. CXCR4 was expressed at marginally higher levels than CCR5 on T cells from the cervical epithelium and peripheral blood. Thus, the preferential transmission of macrophage tropic strains of HIV-1 following sexual contact cannot be explained solely on the expression of chemokine co-receptors by T lymphocyte subsets.

The organotypic culture of HPV-transformed keratinocytes: an effective in vitro model for the development of new immunotherapeutic approaches for mucosal (pre)neoplastic lesions

The purpose of this study is to develop a reliable in vitro human model to test new immunotherapeutic approaches for squamous cell carcinoma that develop on mucosal surfaces. The organotypic (raft) culture permits cells to proliferate and differentiate at an air-liquid interface on a dermal equivalent support. Normal keratinocytes stratify and fully differentiate in a manner similar to the normal squamous epithelial tissues, while human papillomavirus-immortalized and established squamous carcinoma cell lines exhibit dysplastic morphologies similar to (pre)neoplastic lesions seen in vivo. We have demonstrated the ability of these organotypic cultures to be manipulated by altering the epithelial stratification with cytokines (interferon-gamma and tumor necrosis factor-alpha) and by integrating activated lymphocytes or dendritic cells into the in vitro formed epithelial sheet. This model may provide a useful tool to investigate the factors contributing to the presence and function of immunocompetent cells within a neoplastic epithelium that develops on a mucosal surface.

Clinical care issues for women living with HIV and AIDS in the United States

As the number of women infected with HIV in the United States continues to increase, the medical community is faced with the challenge of providing adequate and appropriate care to them. This paper reviews key questions concerning the state of knowledge on the epidemiology, biology, and clinical care of women living with HIV and AIDS in the United States. Because heterosexual transmission accounts for a growing number of cases among women, biological factors and cofactors that may enhance women's susceptibility to HIV infection are also reviewed. HIV-related gynecological issues are presented separately to evaluate whether gynecological complications are distinct in HIV-uninfected and HIV-infected women. Questions of whether there are sex-specific differences in the efficacy and adverse effects of new antiviral agents are discussed. In addition, significant gaps are highlighted that still exist in our understanding of both the effects of HIV and HIV-related drugs upon pregnancy. Finally, the psychiatric stresses and complications that affect women living with HIV and AIDS are also discussed. In each section of this review, gaps in our knowledge of these issues are identified. To properly address these disparities in knowledge, not only do efforts to gather sex-specific biomedical data need to be more exacting, but there is a distinct need to conduct more sex-specific research concerning HIV.

Dendritic cells in selected head and neck tumors

Specimens from 17 head and neck tumor patients were immunohistochemically stained with monoclonal antibodies against HLA-DR, CD1a, RFD1, LAG, CD3, CD4, CD8, CD45RO, CD68, and cytokeratin to identify the nature and distribution of dendritic cells (DCs), T cells, and macrophages. Small numbers of DCs were present in all but 2 specimens. They were located between the tumor cells and in the stroma, especially in areas of inflammatory cell infiltration. Variable numbers of T lymphocytes (cytotoxic and memory type) occurred in the same locations. Numerous macrophages were found in the epithelium, in the stroma, and in the vicinity of tumor cells. The presence of DCs in head and neck tumors indicates that the organism has activated the immune surveillance system and is trying to present tumor antigens. Considering the sparsity of DCs in the malignant tissues, the T cell response can be only limited.

Synthesis of IFN-gamma by CD8(+) T cells is preserved in HIV-infected women with HPV-related cervical squamous intraepithelial lesions

OBJECTIVE

The aim of this study was to investigate whether coinfection with HIV affects the synthesis of Th1 and Th2 cytokines by peripheral blood T cells of women infected with human papillomavirus (HPV).

METHODS

Cervical swabs and peripheral blood were obtained from women referred for colposcopy. HPV DNA by Digene's hybrid capture assay, HIV RNA by Roche's Amplicor assay, and cytokine synthesis of T-cell subsets by flow cytometry were assessed. HPV-associated cervical and HIV-associated immune deficiency diseases were staged using the Bethesda System and the Centers for Disease Control criteria, respectively.

RESULTS

Patients with HIV and/or HPV infections had lower percentages of IL-2(+) and higher percentages of IL-10(+) T cells than healthy women. Furthermore, women with both virus infections (HIV(+)/HPV(+)) had significantly fewer IL-2(+) CD4(+), IFN-gamma(+) CD4(+), and TNF-alpha(+) CD4(+) T cells than women with HPV infection alone (HPV(+)). Whereas HIV(+) and healthy women had similar numbers of IFN-gamma(+) CD8(+) T cells, HPV(+) women had significantly fewer IFN-gamma(+) CD8(+) T cells than healthy women.

CONCLUSION

HIV infection adversely affects the synthesis of Th1 cytokines by CD4(+), but not IFN-gamma synthesis by CD8(+) T cells of women with active HPV infection. The increase in IFNgamma(+) CD8(+) T cells, a phenotype consistent with cytotoxic T lymphocytes, may account for the stable HIV disease of the women studied. However, the increase in IFN-gamma(+) CD8(+) T cells is less likely to be HPV-specific as there was a higher incidence of HPV-related cervical SIL in HIV(+)/HPV(+) women compared with HPV(+) women.

Colonization of in vitro-formed cervical human papillomavirus- associated (pre)neoplastic lesions with dendritic cells: role of granulocyte/macrophage colony-stimulating factor

The purpose of this study was to investigate the ability of CD1a+ Langerhans/dendritic cells (LCs/DCs) to infiltrate human papillomavirus (HPV)-associated (pre)neoplastic lesions of the uterine cervix. Migration of LCs/DCs in the presence of keratinocytes derived from normal cervix and HPV-transformed cell lines was evaluated in Boyden chambers and in organotypic cultures and correlated with granulocyte/macrophage colony-stimulating factor (GM-CSF) production by the cells, as determined by ELISA. Conditioned media of HPV-transformed keratinocytes contained lower amounts of GM-CSF and induced a decreased motile response of LCs/DCs in the Boyden chamber assay compared with those of normal cervical keratinocytes. The migration of LCs/DCs in the presence of conditioned media from normal keratinocytes could be blocked by an anti-GM-CSF antibody, and the migration of LCs/DCs in the presence of conditioned media from HPV-transformed keratinocytes could be increased by supplementing the media with recombinant GM-CSF. GM-CSF was also a potent factor in enhancing the colonization of LCs/DCs into organotypic cultures of HPV-transformed keratinocytes, as the infiltration of LCs/DCs in the in vitro-formed (pre)neoplastic epithelium was minimal under basal conditions and dramatically increased after the addition of GM-CSF to the cultures. These results suggest that GM-CSF could play an important role in the recruitment of LCs/DCs into the HPV-transformed (pre)neoplastic cervical epithelium and be useful as a new immunotherapeutic approach for cervical (pre)cancers.

Lower genital tract intraepithelial neoplasia in HIV-infected women: guidelines for evaluation and management

Human immunodeficiency virus (HIV) and human papillomavirus (HPV) are both sexually transmitted viruses with many risk factors in common. Studies have found that HIV-seropositive women are at least five times as likely to be infected with HPV as seronegative controls. In immunocompromised HIV-seropositive women, the risk of cervical intraepithelial neoplasia (CIN) is almost as high as in women with squamous intraepithelial lesions on their Pap smear. Some studies have shown the false-negative rate of cervical cytology in HIV-seropositive women to be very high, although others have shown it to be comparable with the rate in seronegative controls. However, given the prevalence of CIN in this population, even a "normal" false-negative rate may result in many missed CIN lesions. Among HIV-seropositive women and especially among those who are immunocompromised, CIN is more likely to progress and recur after treatment. Recurrence rates may reach 87 percent 36 months after treatment in markedly immunosuppressed women. Cryotherapy is especially ineffective in these patients. Vulvar condyloma and vulvar intraepithelial neoplasia (VIN) are much more prevalent in HIV-seropositive women and especially in those who are markedly immunosuppressed or who have been immunosuppressed for a prolonged period of time. It is recommended that all HIV-seropositive women undergo periodic evaluation at intervals no less than every 6 months. Immunocompromised women should be followed with cytology and colposcopy of the cervix and vulva, although those with normal immune systems may be followed with cytology alone. Because the rates of recurrence and progression are so high after treatment of these women, they should be followed with colposcopy and cytology every 6 months. New approaches to treatment need to be explored in this population.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will understand the association between the immune suppression of HIV and HPV-related diseases, be familiar with the treatment options for the HIV-seropositive woman with cervical intraepithelial neoplasia (CIN), understand the natural history of CIN in the patient with HIV-seropositivity, and become aware of the appropriate surveillance of the HIV-seropositive woman treated for CIN.

HLA-DR-positive dendritic cells of the normal human choroid plexus: a potential reservoir of HIV in the central nervous system

In a previous study of choroid plexus (CPx) from patients with the acquired immunodeficiency syndrome (AIDS), we found a population of stromal cells infected with the human immunodeficiency virus (HIV). To determine whether these represented antigen-presenting dendritic cells, we examined the phenotype of normal human choroid plexus by light and electron microscopy (EM) and established the HIV-infected cell type by immunohistochemistry in AIDS cases with HIV-infected CPx. Monoclonal antibodies were used to detect class II major histocompatibility antigens (MHC), S-100 and S-100beta protein, lymphocytes, monocytes/macrophages, and HIV glycoprotein. A variable number of stromal cells had slightly elongated nuclei and long branching processes that were strongly immunoreactive for class II MHCs, rarely reactive for S-100 and S-100beta and immunonegative for monocyte/macrophage markers. Phagocytic activity was absent by EM and immunomarkers. They were numerous in the subepithelial region, and their processes occasionally extended toward the stromal capillaries or between the CPx epithelial cells. The HIV-infected cells were intensely immunoreactive for class II MHC markers and often displayed a dendritic morphology. These results document the presence of dendritic cells in the normal human CPx whose morphology and immunophenotype closely resemble those of DCs elsewhere in the body. They also show that these immunoreactive MHC class II cells are the cell type infected by HIV. We suggest that the functional activity of the CPx DCs is similar to that of antigen-presenting dendritic cells elsewhere in the body. This includes the potential to harbor HIV during the prolonged period of clinical latency, acting as a central nervous system reservoir of infection before the onset of AIDS.