Effect of a short-term HAART on SIV load in macaque tissues is dependent on time of initiation and antiviral diffusion
© Bourry et al; licensee BioMed Central Ltd. 2010
Received: 5 May 2010
Accepted: 26 September 2010
Published: 26 September 2010
HIV reservoirs are rapidly established after infection, and the effect of HAART initiated very early during acute infection on HIV reservoirs remains poorly documented, particularly in tissue known to actively replicate the virus. In this context, we used the model of experimental infection of macaques with pathogenic SIV to assess in different tissues: (i) the effect of a short term HAART initiated at different stages during acute infection on viral dissemination and replication, and (ii) the local concentration of antiviral drugs.
Here, we show that early treatment with AZT/3TC/IDV initiated either within 4 hours after intravenous infection of macaques with SIVmac251 (as a post exposure prophylaxis) or before viremia peak (7 days post-infection [pi]), had a strong impact on SIV production and dissemination in all tissues but did not prevent infection. When treatment was initiated after the viremia peak (14 days pi) or during early chronic infection (150 days pi), significant viral replication persists in the peripheral lymph nodes and the spleen of treated macaques despite a strong effect of treatment on viremia and gut associated lymphoid tissues. In these animals, the level of virus persistence in tissues was inversely correlated with local concentrations of 3TC: high concentrations of 3TC were measured in the gut whereas low concentrations were observed in the secondary lymphoid tissues. IDV, like 3TC, showed much higher concentration in the colon than in the spleen. AZT concentration was below the quantification threshold in all tissues studied.
Our results suggest that limited antiviral drug diffusion in secondary lymphoid tissues may allow persistent viral replication in these tissues and could represent an obstacle to HIV prevention and eradication.
The acute phase of human or simian immunodeficiency virus (HIV/SIV) infections is decisive as it is characterized by a quick and strong decrease of T CD4+ memory cells, particularly in the gut associated lymphoid tissue (GALT), and a rapid spread of the virus in all lymphoid tissues [1, 2]. In a recent study, we have shown that during acute SIV infection of macaques, the kinetics of viral dissemination and replication differ between the different lymphoid tissues. Following the peak of viremia, viral DNA and RNA persist at high levels in the secondary lymphoid tissues (spleen and lymph nodes), whereas they rapidly decrease in the blood and the gut . Therefore, this study reinforces the need to explore not only the blood, but also the different lymphoid tissues when assessing strategies aimed at reducing SIV/HIV reservoirs.
HAART initiated very early during infection could prevent the loss of CD4+ T cells from the gut and may delay the onset of the disease . While HIV reservoirs are also set up during acute infection, few studies have focused on the effect of early HAART on tissue viral replication and reservoirs.
Because of the difficulty to obtain tissue samples from HIV infected patients, the macaque models are particularly useful for the exploration of viral dissemination and replication in the different body compartments, especially during the early phases of infection . In the present study, we explored the effect of a short term HAART initiated at different stages during SIV acute infection on the viral burden in the main lymphoid tissues, including the gut. Different quantitative approaches were used, including total SIV-DNA to evaluate viral dissemination and SIV-RNA to assess viral replication and production. As 2LTR SIV-DNA circles have been suggested to accumulate in recently infected target cells , we also explored the value of their quantification as an additional method to assess the impact of treatment on viral dissemination.
We show that the Zidovudine (AZT)/Lamivudine (3TC) and Indinavir (IDV) combination could efficiently reduce viral dissemination and replication in all tissues when treatment was initiated before the peak of viremia. Surprisingly, when the same treatment was started after the viremia peak, the effect of treatment was stronger in the gut than in the secondary lymphoid tissues; this is likely due to the very heterogeneous tissue diffusion of several of the antiretroviral drugs.
A short term HAART initiated during early chronic SIV infection reduces plasma viral load but has a weak effect on secondary lymphoid tissues
In a first step, to validate our HAART treatment in the SIV macaque model, we assessed the effect of the AZT/3TC/IDV combination in chronically infected animals. Six macaques infected with SIVmac251 were treated with AZT/3TC/IDV twice a day after viral set point (from day 150 pi). To determine the kinetics of viral load decrease in different tissues, three of these animals were killed at day 14 (chronic HAART 14d) and the other three at day 28 (chronic HAART 28d) after the onset of treatment. Three untreated animals at the same stage of infection were used as controls (chronic untreated). Among the HAART treated animals, one (#20929) had undetectable PVL at the initiation of therapy (day 0), but was nevertheless included in the analysis since cell-associated viral load (CVL) in PBMC evolved within the same range of the other treated macaques.
We then explored viral dissemination and replication in PBMC, spleen, lymph nodes (LN) and the gut to assess whether the decrease in plasma viral load reflects similar dynamics in the other tissues. As previously observed in patients infected with HIV, SIV-DNA in PBMC was only slightly reduced by treatment, with G mean reductions of 0.4 × log10 and 1.1 × log10 after 14 and 28 days of treatment, respectively (Figure 1b). Interestingly, the level of SIV-DNA was not significantly reduced in the lymph nodes and spleen of treated animals (Figure 1c). We surmised that the limited effect of treatment in these tissues could be explained by the limited diffusion of antivirals in these compartments and/or the inefficiency of the drug on long-lived infected cells. In contrast, treatment had a strong effect in the digestive tract with a G mean reduction of 1.8 × log10 in colon (p = 0.049 at day 28). This tissue has predominantly short-lived CD4+ T cells facilitating the effect of HAART . Also, the antivirals may diffuse better in these tissues.
We then measured levels of 2LTR SIV-DNA, as a marker of recently infected cells as previously suggested . In untreated animals, we detected 2LTR SIV-DNA in all the tissues studied. In macaques treated with HAART for 28 days, levels of 2LTR SIV-DNA were significantly reduced (p = 0.04) in the ileum when compared to animals receiving only 14 days of HAART. On the contrary, the antiviral treatment had no effect on the 2LTR SIV-DNA levels in the LN and the spleen. Although the value of 2LTR viral DNA circles is still controversial, our result suggests that treatment probably affects efficiently the tissues with a predominance of new infections (Figure 1d).
Finally, we measured SIV-RNA levels to assess the production of SIV. Under treatment there is a significant (p = 0.03) decrease of SIV-RNA levels if we consider all compartments; but due to the limited number of animals in each group, the effect was not significant for each tissue separately. The strongest effect was observed in the gut, with a G mean decrease of 2.4 × log10 (Figure 1e), confirming the results observed for viral DNA in the GALT. The effect of treatment on SIV-RNA levels was more limited in the LN and spleen (G mean decrease of tissue viral load: 1.8 × log10).
AZT/3TC/IDV treatment initiated before viremia peak results in partial control of viral dissemination and replication in tissues
When started during early chronic infection, a short term HAART showed a limited and not significant effect in LN and spleen. We then evaluated the effect of this treatment initiated at earlier stages hypothesizing that we might expect a better efficacy of HAART since viral reservoirs are probably not yet fully established.
Initiation of AZT/3TC/IDV therapy after the viremia peak results in limited and tissue-dependent effects on viral replication and dissemination
We then addressed the issue whether similar effects could be observed after maximal viral dissemination, at a time where viral reservoirs are expected to be fully established. The same treatment was therefore initiated (day 14 pi) just after viremia peak in a group of five macaques. PVL, CVL, total SIV-DNA, 2LTR SIV-DNA and SIV-RNA levels were determined 14 days later (day 28 pi) in different tissues and compared to levels of three placebo animals also euthanized at day 28 pi.
3TC concentrations vary with tissue and are inversely correlated with viral load
We showed that a short term HAART can reduce viral dissemination and replication in all tissues when initiated very early after intravenous inoculation of SIVmac251, before the viremia peak. In animals treated just after the initial viremia peak or during early chronic infection, we observed significant differences in HAART efficacy depending on the tissue considered. Maximum inhibition occurred in the digestive tract of macaques. These results are in accordance with those described in humans showing a rapid and large decrease of viral replication in GALT after successful HAART [12–15]. Although the GALT is considered today as the major site of HIV replication, there are no data about local diffusion of antiretroviral drugs in these tissues. The dosages of 3TC and IDV we performed demonstrate, for the first time, that two commonly used antiretrovirals can diffuse very efficiently in the digestive tract, thus probably explaining the high treatment efficacy observed in this tissue. As we had recently shown , in the same SIV macaque model, the plasma viral load mainly reflects the viral replication in the digestive tract. We could therefore suppose that the rapid decrease in plasma viral load observed after HAART initiation is mainly due to the control of viral replication in the gut.
Despite a strong effect in the GALT, currently used antiretroviral combinations are not sufficient to eradicate the virus. We therefore assume that residual replication in pharmacological sanctuaries and/or viral reservoirs could provide an explanation to the incomplete success of therapy. In patients treated with suboptimal regimens, like the use of only two NRTI, no significant changes were observed in viral replication in LN or tonsils, even after control of PVL [16–19]. Adding a protease inhibitor (PI) increases the efficiency of treatment without achieving a full control of replication even in infected patients with long term HAART [10, 17, 20, 21].
Our results confirm in the SIV-infected macaque model that HAART has limited impact on viral replication in secondary lymphoid tissues in spite of efficient control of PVL or replication in the gut. Contrary to Solas et al., who did not find any relationship between PI levels and HIV RNA levels in the tissues , the 3TC dosages we performed showed for the first time that low antiretroviral efficacy in spleen and peripheral lymph nodes could be related to poor drug diffusion in these organs, therefore favouring residual replication and viral persistence.
Corroborating the data from Kinman et al. , who showed very low diffusion of IDV in the lymph node of macaque after oral administration, the very low level of IDV measured in the spleen and peripheral lymph nodes of treated macaques confirm that secondary lymphoid tissues could act as real pharmacological sanctuaries.
Although one of the major limitations of our study is that drugs have been administered during a short period (14 to 28 days), several studies in humans indicate that even after several years of HAART, viral mRNA is still produced in peripheral lymph nodes. This confirms that the poor drug diffusion we observed in lymph node and spleen could provide a simple explanation to the absence of virus eradication. As suggested by Stellbrink , this residual replication in lymphoid tissues could also permanently seed the latent reservoir.
In the central nervous system (CNS) and the testis, the low levels of antiretroviral can be explained by poor diffusion across the blood-brain or blood-testicular barriers because of drugs efflux by ABC transporter [22, 25, 26]. In the peripheral lymph node mononuclear cells, we previously demonstrated a higher level of P-gp mRNA expression than in PBMC . However, we did not observe here any differences in the ratios of 3TC and 3TC-TP between the different tissues, indicating that efflux from the cell or kinases activities are not the limiting factors. It is therefore unlikely that P-gp activity is involved in the poor diffusion of antiretroviral we observed in secondary lymphoid tissues.
We also demonstrated that pharmokinetics and pharmacodynamic parameters are important to consider not only in the treatment of infected patients but also in preventive approaches of HIV transmission like post-exposure prophylaxis. After intravenous inoculation of SIVmac251, infection could not be prevented even if AZT/3TC/IDV combination was initiated within a few hours, confirming our previous results [9, 28]. Recently  we have shown that the same regimen prevents vaginal transmission of the same virus, probably because of initial viral compartmentalization and low dissemination  in association with good diffusion of NRTI in the female genital tract . Our results thus demonstrate the need to improve antiretroviral biodistribution for better efficacy and limitation of the pharmacological sanctuaries that allow residual viral replication.
When initiated before the peak of viremia, a short-term antiretroviral treatment can impact viral dissemination and replication in almost all tissues. In this case, the treatment is more effective when initiated earlier. If the identical treatment is started after the peak of viremia, or during chronic infection, the effect of short-term HAART seems to vary according to the tissue considered. In the gut, where antiretroviral drugs diffuse easily, the viral burden decreases rapidly; whereas in secondary lymphoid tissues, poor diffusion of the antiviral drug could explain the weak effect of treatment on the tissue viral load.
Animals, infections, treatment and tissue collection
We studied 33 young adult male cynomolgus macaques (Macaca fascicularis), each weighing between 2.7 and 4.5 kg. Studies were conducted in accordance with European guidelines for animal care and all experiments were approved by the ethics committee for animal experimentation "Ile de France Sud" (Paris, France). All macaques were inoculated intravenously with 50 AID50 of pathogenic SIVmac251 and divided into nine groups.
Six animals were treated with AZT (4.5 mg/kg) and 3TC (2.5 mg/kg) subcutaneously twice daily and indinavir (60 mg/kg), orally, twice daily. The treatment was initiated after viral set point (day 150 pi) and the animals were killed after 14 days (chronic HAART 14 d group) and 28 days (chronic HAART 28 d group) of treatment. In parallel, 3 untreated animals were also killed at 150 days pi (chronic untreated).
Four other animals received the AZT/3TC/IDV combination as early as 4 h post-infection and continued until day 14 when the animals were killed (HAART 4h-d14 group). Four animals receiving a placebo in the same conditions were also killed at 14 days pi (placebo d14).
A group of four animals received the same HAART between days 7 and 21 pi (HAART d7-d21 group), then the animals were killed on day 21 pi. Four animals receiving a placebo in the same conditions were killed at 21 days pi (placebo d21).
In last group, 5 animals received the HAART treatment between day 14 and day 28 pi and were killed on day 28 (HAART d14-d28 group). Three animals receiving a placebo in the same conditions were killed at the same time (placebo d28).
Immediately after killing the animals, tissue samples from the spleen, peripheral lymph nodes (inguinal or axillary) mesenteric lymph nodes, ileum and colon were collected in quadruplicate and stored at -80°C. In order to reduce the heterogeneous presence of lymphoid tissue in the gut, we collected and processed large samples for ileum and colon (250 to 400 mg).
Virological measurements in the blood
Virological measurements in the tissues
RNA and DNA extraction as well as quantification of total SIV DNA, SIV 2 LTR circles and SIV RNA in tissue were performed as previously described .
SIV gag in situ hybridization combined with immunohistochemistry for T cell markers was performed as previously described . The specificity of the hybridization signal was systematically checked by hybridizing sense probes on successive sections. Image acquisition and analysis were performed on a Nikon i90 photomicroscope using NIS-elements software.
Determination of antiretroviral concentration in tissues
Statistical analyses were carried out using Stat View software (SAS institute Inc, Cary, North Carolina, USA). Plasma and cell-associated viral load as well as SIV-RNA, total SIV-DNA and 2LTR SIV-DNA were compared in placebo and HAART-treated macaques using a nonparametric Mann-Whitney test. Differences in 3TC and IDV concentration in lymphoid tissues were assessed by the same test. The correlation between 3TC concentration and residual viral replication/load in tissue, were evaluated using a nonparametric Spearman correlation test.
We greatly thank Patricia Brochard and Benoit Delache for their very efficient technical contribution. We thank Christophe Joubert and the technical staff of the CEA for animal care. We also thank Gaëlle Bourry for critical reading of the manuscript. We thank the Glaxo-Smith-Kline laboratories for helpful discussion and providing antiviral drugs.
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