Interactions between HPV and HIV: Interactions between HPV and HIV: STIsSTIs and HIV shedding, and HIV shedding,

regulation of HPV by HIVregulation of HPV by HIVregulation of HPV by HIV, regulation of HPV by HIV, and HPV VLP influence upon HIVand HPV VLP influence upon HIV

Jennifer S. SmithJennifer S. SmithDepartment of EpidemiologyDepartment of Epidemiologyp p d gyp p d gyUniversity of North CarolinaUniversity of North Carolina

Can HPV, cervical neoplasia or genital warts increasegenital warts increase

HIV transmission?

Credible mechanisms (Cohen)

HPV, Cervical Neoplasia or Warts→• ↑HIV genital tract viral burden?↑ g v b• ↑Disruption of tissue barriers and defenses?• ↑Increased number of cells receptive to HIV?

Biological plausibility: HIV/HPV interactions-HIV/HPV interactions

-Induction of specific anti-HIV cytokines

Increased risk of HIV seroconversion?

STIs and HIV SheddingSTIs and HIV Shedding

• HIV shedding associated with genital ulcers or co-infection with other sexually transmitted infections yin several studies.

• Relatively few data have examined associations between HPV infection cervical neoplasia genital warts andHPV infection, cervical neoplasia, genital warts and HIV shedding.

Higher HIV viralHigher HIV viral--shedding among shedding among HIV+ women coHIV+ women co--infected with HPVinfected with HPV

Spinillo et al., Obstet Gynecol, 2001;97(6):999-1004.

•• 124 HIV124 HIV--1 seropositive women1 seropositive women

•• 47 paired samples of cervicovaginal lavage and blood.47 paired samples of cervicovaginal lavage and blood.

•• HIV viral load shedding ascertainedHIV viral load shedding ascertainedP i l DNAP i l DNA•• --Proviral DNAProviral DNA

•• --RNA transcriptsRNA transcripts Lavage

•• --CellCell--free RNAfree RNA Swab

HIV shedding higher among HIV shedding higher among women cowomen co--infected with HPVinfected with HPV

N=124 HIV+ m n HPV DNA (%) Adj t d ORN=124 HIV+ women HPV-DNA (%) Adjusted ORs

HIV-DNA

Negative 62 7 1Negative 62.7 1

<48 copies/105 cells 56.3 0.80 (0.28, 2.31)

≥48 copies/105 cells 72.7 1.7 (0.51, 2.86)

HIV RNA transcripts

Negative 52.6 1

<25 copies/105 cells 60.9 1.4 (0.51, 3.64)

≥25 copies/105 cells 92.0 7.7 (1.58, 37.55)

Cell free HIV RNACell-free HIV-RNA

Negative 54.9 1

<250 copies/mL 68.4 1.9 (0.58, 5.93)p

≥250 copies/mL 91.3 7.5 (1.52, 36.76)

Spinillo et al., Obstet Gynecol, 2001;97(6):999-1004.

Greater HIVGreater HIV--1 RNA Shedding Following 1 RNA Shedding Following Treatment for CIN 2/3Treatment for CIN 2/3

Wright et al., Am J Obstet Gynecol, 2001; 184:279-85

•• 14 HIV14 HIV--seropositive women with CIN 2/3seropositive women with CIN 2/3

•• FollowFollow--up at 2, 4, 8 and 14 weeks postup at 2, 4, 8 and 14 weeks post--treatmenttreatment

•• Quantification of cellQuantification of cell--free HIVfree HIV--RNARNAQQ VV NN--Cervicovaginal lavageCervicovaginal lavageC llC ll f lf l--CellCell--free plasmafree plasma

HIV Shedding Among HIV+ Women HIV Shedding Among HIV+ Women PrePre-- and Postand Post-- Treatment for CIN 2/3Treatment for CIN 2/3

•• Greatest increase in HIV genital tract virus occurred Greatest increase in HIV genital tract virus occurred when the cervical epithelium appeared acutelywhen the cervical epithelium appeared acutelywhen the cervical epithelium appeared acutely when the cervical epithelium appeared acutely inflammed.inflammed.

•• As the cervix healed after treatment (6As the cervix healed after treatment (6--14 weeks), the 14 weeks), the f HIV i l h ddi d df HIV i l h ddi d damount of HIV viral shedding decreased.amount of HIV viral shedding decreased.

•• Relatively constant HIV virus levels in plasma over Relatively constant HIV virus levels in plasma over study followstudy follow--up.up.yy pp

Wright et al., Am J Obstet Gynecol, 2001; 184:279-85.

HIVHIV--1 RNA Higher Following 1 RNA Higher Following Treatment for CIN 2/3Treatment for CIN 2/3

Wright et al., Am J Obstet Gynecol, 2001; 184:279-85.

HIVHIV--1 RNA Higher Following 1 RNA Higher Following Treatment for CIN 2/3Treatment for CIN 2/3

•• Cervical inflammation and ulcerationCervical inflammation and ulcerationincreased elevation of local CD4+ lymphocytes increased elevation of local CD4+ lymphocytes and macrophages and macrophages

increased number of HIVincreased number of HIV--1 infected cells1 infected cellsthat are actively replicatingthat are actively replicating

•• Were HIV infected cells from cervicoWere HIV infected cells from cervico--vaginal mucosae vaginal mucosae or surrounding regional lymphoid tissue?or surrounding regional lymphoid tissue?g g y pg g y p

Wright et al., Am J Obstet Gynecol, 2001; 184:279-85.

HIV Shedding Studies: Limitations to consider

• Most studies are cross-sectional, with no clear direction f litof causality.

Different laborator methodolog for ascertaining HIV• Different laboratory methodology for ascertaining HIV shedding across studies. Potential for blood contamination More data are needed on qualitativecontamination. More data are needed on qualitative measures of HIV shedding, rather than odds ratios.

• Limited sample sizes, particularly for effect measures for cervical neoplasia with no data available on stage offor cervical neoplasia, with no data available on stage of disease (e.g. CIN-1, 2/3).

Disruption of tissue barriers and defenses?

HIV+ women with CIN and genital warts:• Inflammation and increased friability of infected tissue.

Increased number of cells receptive to HIV?Increased number of cells receptive to HIV?

• Increased lymphocyte and macrophage infiltrates m n m n ith CIN r nit l rt mp r damong women with CIN or genital warts as compared

with women with normal diagnoses.

What about HIV/HPV interactions?What about HIV/HPV interactions?

HPV and HIV Protein/Protein HPV and HIV Protein/Protein Interactions Interactions

HIV TAT AND HPV E7HIV TAT AND HPV E7HIV TAT AND HPV E7HIV TAT AND HPV E7

Arany et al., Sex Transm Inf, 1998;74:349-53

•• In HIV+ individuals:In HIV+ individuals:Hi h HIV T l l l d i h hi h HPV E7Hi h HIV T l l l d i h hi h HPV E7Higher HIV Tat levels correlated with higher HPV E7 Higher HIV Tat levels correlated with higher HPV E7 levels in biopsies of condylomas. levels in biopsies of condylomas.

HPV and HIV InteractionsHPV and HIV InteractionsHPV and HIV InteractionsHPV and HIV Interactions

Dolei et al., J Gen Virol, 1990; 80(11): 2937-44

•• HIV Tat appeared to affect HPV gene expression in HIV Tat appeared to affect HPV gene expression in cervical carcinoma cells cocervical carcinoma cells co--cultivated with HIVcultivated with HIV--1 1 infected cells.infected cells.

HIVHIV--1 1 Tat addition to culture Tat addition to culture dose dependent increase in dose dependent increase in HPVHPV 1818 EE11 and Land L11 RNA in HPVRNA in HPV 1818HPV HPV 18 18 EE1 1 and Land L1 1 RNA in HPV RNA in HPV 18 18 infected epithelial cells.infected epithelial cells.

HIVHIV 11 HPVHPV i d i li d i l•• HIVHIV--1 1 may promote HPVmay promote HPV--associated cervical associated cervical carcinogenesis.carcinogenesis.

Does HIV Infect Epithelial Cells?Does HIV Infect Epithelial Cells?Does HIV Infect Epithelial Cells? Does HIV Infect Epithelial Cells?

•• Whether HIV infects cervical epithelial cells is currently Whether HIV infects cervical epithelial cells is currently debated.debated.

•• In vitroIn vitro HPV regulation by HIV may not applyHPV regulation by HIV may not apply•• In vitro In vitro HPV regulation by HIV may not apply HPV regulation by HIV may not apply in vivo if HPVin vivo if HPV--infected epithelial cells may not be infected epithelial cells may not be i f d b HIVi f d b HIVinfected by HIV.infected by HIV.

Primary cervical epithelial Primary cervical epithelial monolayersmonolayers are are resistant to HIVresistant to HIV

Greenhead et al J Virol 2000; 74(12): 5577 86Greenhead et al., J Virol, 2000; 74(12): 5577-86

HIV Type 1 Infection and Replicationin Normal Human Oral Keratinocytes

Liu et al., Journal of Virology, Mar. 2003, p. 3470–3476., J gy, , p

PCR analysis of proviral DNA constructs showed that l h l k ti t b i f t d bnormal human oral keratinocytes can be infected by

CXCR4-tropic and dualtropic (89.6) strains of HIV-1 to t k b t p d ti i f tigenerate a weak but productive infection.

Effects of HPVEffects of HPV--associated Cells on HIV associated Cells on HIV gene expressiongene expression

Gage et al., Obstet Gynecol, 2000; 96(6): 879-85

HPV may enhance HIV expression via production of HPV may enhance HIV expression via production of immune and inflammatory factors.immune and inflammatory factors.

•• Supernatants from cervical biopsy cultures, cervical cancer Supernatants from cervical biopsy cultures, cervical cancer ll li HPV i li d k i d lll li HPV i li d k i d lcell lines, HPV immortalized keratinocytes and normal cell lines, HPV immortalized keratinocytes and normal

keratinocytes incorporated in cultures for cells with latent keratinocytes incorporated in cultures for cells with latent HIV from a U1 monocytic cell lineHIV from a U1 monocytic cell lineHIV from a U1 monocytic cell line.HIV from a U1 monocytic cell line.

•• All supernatants upregulated HIV p24 expression in U1.All supernatants upregulated HIV p24 expression in U1.

Induction of specific anti-HIV cytokinescytokines

I d i f i fl kiIncreased concentration of proinflammatory cytokines influencing HIV replication.

HIV+/HPV+ treatment-naïve women compared to HIV-/HPV+:HIV /HPV :

Dually infected women had higher IL-1α and IL-1β butDually infected women had higher IL 1α and IL 1β but not TNFα.

Data suggest increased immune activation and inflammation of women coinfected with HPV/HIV.

Behbahani et al., J Acquired Defin Syndrome; 45 (1):9-19.

Effect of HPV, cervical neoplasiaor genital warts on HIV

seroconversion?seroconversion?

D l li i dD l li i d•• Data are currently very limited.Data are currently very limited.

•• There are no data, to our knowledge, that report the There are no data, to our knowledge, that report the influence of HPV persistence over time, or of clinically influence of HPV persistence over time, or of clinically p , yp , yascertained cervical neoplasia, on the risk of HIV ascertained cervical neoplasia, on the risk of HIV acquisition.acquisition.qq

Does HPV Increase the Risk of HIV Does HPV Increase the Risk of HIV SeroconversionSeroconversion??

S i h M C l 24 h I i l P ill iSmith-McCune et al., 24th International Papillomavirus Conference & Clinical Workshop, Beijing, Nov 2007

•• 3,040 women enrolled in RCT of female diaphragm use 3,040 women enrolled in RCT of female diaphragm use in Zimbabwein Zimbabwein Zimbabwein Zimbabwe--Median age 28 Median age 28 --Median followMedian follow--up of 21 monthsup of 21 months--Pooled analysis of intervention and control armsPooled analysis of intervention and control armsyy--Baseline positivity of any HPV type increased the risk Baseline positivity of any HPV type increased the risk

of HIV seroconversionof HIV seroconversionof HIV seroconversion of HIV seroconversion Hazard ratio=1.6Hazard ratio=1.6

Does HPV Increase the Risk of HIV Does HPV Increase the Risk of HIV seroconversionseroconversion??

Chin-Hong et al., 24th International PapillomavirusChin Hong et al., 24 International Papillomavirus Conference & Clinical Workshop, Nov 2007

•• 1,409 men having sex with men1,409 men having sex with men•• Higher risk of HIV seroconversion observed amongHigher risk of HIV seroconversion observed among•• Higher risk of HIV seroconversion observed among Higher risk of HIV seroconversion observed among

men HPV DNA positive at baseline, and at the time of men HPV DNA positive at baseline, and at the time of HIV seroconversionHIV seroconversionHIV seroconversion. HIV seroconversion.

•• Hazard ratio (HR)=1.5Hazard ratio (HR)=1.5 for each additional HPV type for each additional HPV type detected at time of HIV seroconversion.detected at time of HIV seroconversion.HR=3.3 for 3 or more HPV types detected.HR=3.3 for 3 or more HPV types detected.

Impact of Genital Warts on the Risk of Impact of Genital Warts on the Risk of HIV Acquisition?HIV Acquisition?

•• Homosexual men in BrazilHomosexual men in BrazilHi h i k f HIV i th ithHi h i k f HIV i th ithHigher risk of HIV seroconversion among those with Higher risk of HIV seroconversion among those with condyloma 6 months before seroconversion condyloma 6 months before seroconversion Risk ratio =4.3Risk ratio =4.3. .

Association not significant after controlling for age, age Association not significant after controlling for age, age at first intercourse, HBV core antibody, and at first intercourse, HBV core antibody, and , y,, y,gonorrhea.gonorrhea.

Ref: Harrison LH et al., JAIDS. 1999; 21(5): 408.Ref: Harrison LH et al., JAIDS. 1999; 21(5): 408.

Effects of HPV VLP on HIV replicationEffects of HPV VLP on HIV replication

HPV Vir Lik P rti lHPV Virus Like Particle

Binds to Toll like receptors (TLR) on dendritic cells-Binds to Toll-like receptors (TLR) on dendritic cells. TLR links innate immune responses against pathogens and prod ces anti HIV 1 cytokinesand produces anti-HIV-1 cytokines.

Induces anti HIV cytokines (IFN α IL 10-Induces anti-HIV cytokines (IFN-α, IL-10, Interferonγ).

Yang et al., J Virology, Yang et al., J Virology, 20042004; ; 1115211152--1116011160..GarainGarain--Pineres et al, Eur J Immunology, Pineres et al, Eur J Immunology, 20062006: : 3636: : 437437--445445..

Effects of HPV VLP on HIV replicationEffects of HPV VLP on HIV replication

HPV-virus like particle

-Strongly inhibit replication of X1 and R5 HIV-1 in peripheral blood mononuclear cells (PBMCs) andperipheral blood mononuclear cells (PBMCs) and monocyte-derived macrophages (MDMs).

-Release HIV suppressive factors (↑ potential antiviral genes including IL-27).g g )

Impact of VLP on X4 or R5 HIV-1 Replication in PBMC

Fakuruddin et al Blood 2007; 109:1841

X4 virus R5 virus

Fakuruddin et al., Blood, 2007; 109:1841

VLP suppresses both X4 and R5 HIV-1 replication in PBMC

Impact of Pretreatment of PBMC with Impact of Pretreatment of PBMC with VLP on XVLP on X4 4 HIVHIV--1 1 ReplicationReplication

24 hr pretreatment is sufficient for inhibition24 hr pretreatment is sufficient for inhibition

Fakuruddin et al., Blood, 2007;109:1841

Impact of Recombinant IL-27 on X4 HIV-1 Replication in PBMCsReplication in PBMCs

Fakuruddin et al., Blood, 2007; 109:1841

Impact of Recombinant IL-27 on X4 HIV Replication in CD4++ T cellsReplication in CD4++ T cells

Fakuruddin et al., Blood, 2007; 109:1841

Impact of Recombinant IL-27 on R5 HIV 1 Replication in MDMsHIV-1 Replication in MDMs

Fakuruddin et al., Blood, 2007; 109:1841

Thus, HPV VLP induced decreases in HIV viral replication would potentially have a therapeutic effect, p p y p ,rather than a prophylactic effect, if confirmed in future clinical trials.

Fakuruddin et al., Blood, 2007; 109:1841

Future Epidemiology Research Needs

HPV, cervical neoplasia and genital warts on the risk of HIV shedding and plasma viral loads, addressing limitations.

HIV seroconversion studies, examining the effect of HPV persistence as well as cervical neoplasia and genital warts with sufficient sample sizes.

HPV vaccine effectiveness studies, examining HIV and associated outcomes.