- Open Access
Development of broadly neutralizing antibodies in HIV-1 infected elite neutralizers
© The Author(s) 2018
- Received: 11 June 2018
- Accepted: 23 August 2018
- Published: 5 September 2018
Broadly neutralizing antibodies (bNAbs), able to prevent viral entry by diverse global viruses, are a major focus of HIV vaccine design, with data from animal studies confirming their ability to prevent HIV infection. However, traditional vaccine approaches have failed to elicit these types of antibodies. During chronic HIV infection, a subset of individuals develops bNAbs, some of which are extremely broad and potent. This review describes the immunological and virological factors leading to the development of bNAbs in such “elite neutralizers”. The features, targets and developmental pathways of bNAbs from their precursors have been defined through extraordinarily detailed within-donor studies. These have enabled the identification of epitope-specific commonalities in bNAb precursors, their intermediates and Env escape patterns, providing a template for vaccine discovery. The unusual features of bNAbs, such as high levels of somatic hypermutation, and precursors with unusually short or long antigen-binding loops, present significant challenges in vaccine design. However, the use of new technologies has led to the isolation of more than 200 bNAbs, including some with genetic profiles more representative of the normal immunoglobulin repertoire, suggesting alternate and shorter pathways to breadth. The insights from these studies have been harnessed for the development of optimized immunogens, novel vaccine regimens and improved delivery schedules, which are providing encouraging data that an HIV vaccine may soon be a realistic possibility.
The design of a preventative HIV vaccine is one of the major current public health challenges. Despite the global successes of antiretroviral therapy, rates of new infections, especially in sub-Saharan Africa, show little sign of abating, and indeed in some areas as many as half of young women are HIV infected . Despite a massive effort, no vaccine has thus far been able to elicit protective neutralizing antibodies. However, extraordinary progress has been made in understanding the immune response to HIV infection and in defining viral targets. We now have a detailed understanding of the obstacles we face in eliciting protective antibodies, and this has enabled the design of new immunogens and vaccine strategies, many of which are based on studies of infection, and will enter clinical trials in the next months and years.
The major focus for HIV vaccine design is the elicitation of broadly neutralizing antibodies (bNAbs), capable of preventing entry by diverse viruses by binding to conserved regions on the HIV envelope glycoprotein trimer, which is the sole entry complex for HIV. This focus on bNAbs is based on the narrow window between HIV infection and the establishment of latency, ideally requiring antibodies to block viral entry. In contrast, although CTL responses have been shown to contribute to HIV control and slow disease progression [2–4], these responses are unlikely to protect from infection. Compelling evidence from animal studies shows that passive administration of bNAbs into non-human primates provides complete protection from mucosal challenge . Non-broadly neutralizing antibodies, though capable of Fc effector functions such as antibody dependent cellular cytotoxicity, do not protect as well [6–8], further supporting a focus on neutralization. These findings, which are currently being further tested in the first human clinical trials of bNAbs as prophylaxis, suggest that such antibodies, if elicited at sufficiently high titers by vaccination, would be protective.
However, eliciting such bNAbs is fraught with difficulties. The Env protein, which consists of three gp120 and three gp41 molecules, has formidable defenses that hinder bNAb development . The trimer is conformationally dynamic, extremely sequence variable, particularly in the antibody accessible regions of the envelope, sparsely arrayed on viral particles  and massively glycosylated, with glycans so tightly packed that they occlude much of the underlying protein surface . Immunological decoys in the form of non-functional envelope proteins such as gp41 stumps, monomeric forms of gp120 and non-native protomers (such as uncleaved trimers) that expose non-neutralizing epitopes normally buried in the trimer, add a further layer of complexity .
Despite these barriers, infected individuals mount a vigorous neutralizing response though these initial responses are almost entirely strain-specific, targeting highly variable regions of Env [13–17]. However, over 2–3 years of infection, many people develop some degree of cross-reactivity , and a small subset of HIV infected individuals mount extremely potent and broad responses. These “elite neutralizers”, which are the focus of this review, have been the subject of intense study, in the hope that they provide a template for HIV vaccine design. Extensive functional (binding and neutralization) and structural (electron microscope, crystallography and glycobiology) characterization of these antibodies, and their precursors, has shed light on the complex molecular mechanisms by which they achieved breadth. Our increased understanding of the unusual features of bNAbs, and the failure of traditional vaccine strategies, have led the field to consider next-generation vaccine regimens which are based on the deep understanding of the host and viral factors leading the development of such antibodies. In this review, we provide a summary of these studies, and define some gaps that need to be addressed to develop an effective HIV vaccine.
For some bNAb epitopes, there is a degree of promiscuity with which an epitope can be recognized [9, 27]. For example, the V3-glycan supersite is relatively accessible to antibodies, perhaps explaining the prevalence of these bNAbs in infection (Fig. 1). BNAbs to this epitope show variable angles of approach centered around a series of conserved glycans at N301 and N332, but incorporating more variable elements in V1, V3 and V4 [28–31]. Similarly, bNAbs targeting the gp120/gp41 interface have diverse footprints delineating different sub-epitopes [22, 32–35]. However, other epitopes can only be accessed through very constrained angles of approach, forcing the immune system to utilize unusual structural features to access these. The stringent requirements for accessing these epitopes are reflected in the features of bNAb precursors, many of which have unusual features that are rare in the human immunoglobulin repertoire. The best examples of this are the VRC01-like CD4bs bNAbs that are characterized by conserved genetic and structural features which enable a common angle of approach [36–38]. This includes short antigen binding loops, required to avoid steric clashes with hypervariable regions and glycans . In contrast, V2-directed bNAbs require a long anionic CDRH3 to penetrate the glycans protecting the apex of the trimer [40–43]. MPER bNAbs also use long variable loops and often develop membrane binding in order to access their epitopes [44, 45]. However, long loops and hydrophobic surfaces are associated with autoreactivity, such that these precursors are frequently deleted through tolerance mechanisms [43, 46–52]. Defining commonalities among bNAb precursors is the basis of “germline targeting” vaccine strategies, that are being pursued by several groups [39–41, 53–56]. Ongoing studies of immunoglobulin repertoires in diverse populations will provide insights into the possibility of reliably eliciting such bNAbs.
One feature that is common to bNAbs to several epitopes is an unusually high level of somatic hypermutation (SHM). Mutations are acquired in the complementarity determining regions of the antibodies which generally form the paratope, but also in the framework regions of antibodies which are normally more conserved . Although the role of these mutations in conferring breadth is evident in studies of their ontogeny from precursors that are strain-specific [47, 58, 59], many of these mutations are “neutral”, conferring no benefit in terms of breadth, and simply a consequence of prolonged maturation in the context of chronic infection [60, 61]. The isolation of less mutated antibodies, described below, may therefore fill an important gap in the field. Much SHM is associated with the need to accommodate the Env glycan shield, either through direct contact and/or by avoiding glycans. Glycan adaptation often involves insertion/deletion events  which are rarely observed in the B-cell repertoire as they are less likely to be productive. Recognition of glycans is itself a limitation, as glycans are typically tolerogenic and are considered “self” epitopes by the immune system. Although some degree of poly- or autoreactivity has been reported for CD4bs (PCIN63, VRC01, 12A21) and to a lesser extent, V3-glycan directed bNAb lineages, this is particularly associated with MPER bNAbs (4E10, 2F5 DH511) . Notably, engineering bNAbs to achieve enhanced breadth and potency sometimes results in enhanced polyreactivity, suggesting that maturation towards breadth is balanced by the need to avoid polyreactivity in the maturation of these lineages [63, 64]. Together, these features suggest complex developmental pathways that pose challenges to traditional vaccine strategies.
Longitudinal studies of the kinetics of plasma breadth have shown that bNAbs develop incrementally, often taking 2–3 years to emerge [19, 21]. This prolonged process suggests that extensive evolution of antibody responses is needed. Indeed, breadth has been associated with high viral loads, duration of infection, viral diversity and low CD4 T cell counts [19, 21, 65–68]. Furthermore, high overall plasma IgG levels and anti-Env IgG binding titers correlate with breadth, suggesting donors with breadth may access a more diverse repertoire of anti-Env Ab responses . These findings emphasize the high levels of antigenic stimulation required to drive the extensive SHM often seen in bNAbs. However, there is also evidence that more specific viral attributes contribute to the development of breadth, with infection with subtype C viruses associated with enhanced breadth, and a bias to V2-glycan directed responses compared to the CD4bs responses more commonly observed in subtype B infected individuals [21, 65]. Another key factor associated with bNAb development is the level of circulating T follicular helper cells and germinal center (GC) function, which likely supports the SHM required for continued maturation [69, 70]. Recent data also showed that HIV-specific Fc effector function early in infection predicts the development of bNAbs, suggesting that intrinsic immune factors within the GC provide a mechanistic link between the Fc and Fab of HIV-specific antibodies . Conversely, low levels of T regulatory cells, possibly enabling survival of B-cell intermediates with potential for autoreactivity, were also associated with development of bNAbs .
Superinfection has also been associated with broader antibody responses in some cohorts [73, 74], but not others . This is an appealing observation for vaccine design, suggesting the possibility that superinfection boosts responses primed by the initial infecting virus, analogous to heterologous prime boost vaccines. However, a detailed comparison of the kinetics and targets of plasma antibodies in four superinfected donors suggested that superinfection was associated with de novo responses to both viral variants, and did not drive neutralization breadth (Sheward, Moore and Williamson, in press). This is further supported by the isolation of monoclonal antibodies (mAbs) from two superinfected donors, CAP256 and QA013. In CAP256, who developed extraordinarily potent bNAbs , these were directed only at the superinfecting virus . Similarly, mAbs isolated from donor QA013 neutralized either primary infecting or superinfecting viruses, with none cross-neutralizing both. Furthermore, bNAbs in QA013 were largely attributable to mAbs targeting the superinfecting virus, with the mAbs that arose to the primary infecting virus only making a minor contribution to plasma breadth . This suggests that HIV superinfection may enhance breadth through additive responses to each individual virus, consistent with the small effect seen in cohort studies , rather than through the boosting of memory responses, a distinction that is important for HIV vaccine design.
A group particularly interesting for HIV vaccine design is pediatric donors who appear to be enriched for “elite neutralizers”. BNAbs in HIV-infected children arise early in the course of infection, often during the first 2 years of life, and become more broad and potent than in adults, with 70% of children developing bNAbs that are equivalent to the top 20% of adults [78–80]. Chronically infected children frequently have an unusual phenotype of consistently high viral loads but normal CD4 counts, which may be highly conducive to the development of breadth . Mapping studies show that bNAbs in children largely target previously defined epitopes, including the V2-glycan, V3-glycan, CD4bs and gp120-gp41 interface . Remarkably, however, three quarters of children had antibodies targeting as many as four distinct bNAb epitopes with breadth mediated by a combination of these specificities. This polyclonality, which is also sometimes seen in adults [20, 21, 82–85], may be more pronounced in chronically infected children due to persistently high viral loads in this group, which is strongly linked to the development of neutralization breadth in adults [21, 65, 86–88]. The extraordinary breadth in these donors may suggest fundamental differences in their development (described in more detail below). This is supported by the isolation of mAb BF520.1 that targets the V3-glycan, like many adult bNAbs, but does so despite low levels of SHM, and in the absence of insertions/deletions that characterise bNAbs to this epitope . The polyclonal nature of pediatric bNAbs may suggest that the immunoglobulin repertoire in children is more diverse than that of adults, or that maternal antibodies may shape the maturation of bNAbs, as has been observed in passive antibody administration in adults [89, 90]. Lastly, studies of GCs in children will shed light into whether these are functionally distinct from those of adults. Several recent studies suggest that children may be fundamentally better at generating antibody responses in vaccination and infection [78, 79, 91–94], which may be valuable for HIV vaccine design. Additional studies will therefore be important in providing insights into whether HIV infection, and therefore vaccination, may induce unique antibody responses in pediatric donors.
Studies of the maturation of broadly neutralizing antibodies
Breadth Median IC50
VH-gene SHM (%nt)
UCA binds/neutralizes T/F
89%; 0.3 µg/mL
H: 14 aa
L: 5 aa
H: 13 aa
L: 5 aa
H: 15 aa
L: 10 aa
Yes Del CDRL1
90%; 0.6 µg/mL
H: 15 aa
L: 8 aa
L: 5 aa
98%; 0.1 µg/mL
L: 5 aa
Yes Del CDRL1
80%; 0.24 µg/mL
H: 15 aa
L: 5 aa
Landais et al. (unpublished)
63%; 0.003 µg/mL
H: 36 aa
L: 13 aa
37%; 0.42 µg/mL
L: 8 aa
Binding of 293S-expressed Env
47%; 0.53 µg/mL
H: 22 aa
45%; 0.03 µg/mL
H: 22 aa
Murrell, Landais et al. (unpublished)
58%; 1.95 µg/mL
H: 20 aa
Cell surface binding
55%; 0.08 µg/mL
L: 9 aa
98%; 0.35 µg/mL
H: 22 aa
L: 11 aa
99%; 1.04 µg/mL
H: 22 aa
L: 11 aa
A key aspect for vaccine design has been the use of longitudinal memory B-cell NGS to accurately infer the sequence of the unmutated common ancestor (UCA) for several bNAb lineages. The accuracy of this inference is highly dependent on the availability of early, less mutated bnAb lineage sequences. In some cases, these UCAs can bind (CH235, CH103, PCT64) and even neutralize early Env variants (CH103, CAP256-VRC26 and PCT64) [47, 58, 96–98]. However, in others, no binding of precursor B-cells was detectable (PCDN, PCIN39, DH270, PCIN63). This observation led to the hypothesis that some of these bNAbs may have matured from responses to other pathogens, however it is also possible that affinity undetectable in existing assays might have been sufficient to induce BCR signaling and initiate clonal expansion in vivo . Moreover, this low affinity, mainly due to the sub-optimal epitope presentation on the Env protein, can be overcome by synthetic minimal epitope molecules such as CD4bs mimics eOD-GT8 and 426c (VRC01) [54, 100, 101], short V3-glycopeptides (DH270) [102, 103] and V2-apex scaffolds [40, 41], providing opportunities for immunogen design.
Activation of the naïve B-cell precursor induces a rapid expansion and diversification of the mAb lineage, which is typically followed by a contraction phase that is likely due to rapid viral escape preventing further maturation . Memory B-cell repertoire analyses have revealed subsequent multi-limb maturation as the early antibody intermediates undergo different fates, depending on whether they can still recognize emerging new viral variants [47, 59]. Some branches display limited maturation (“dead-end” sub-lineages) due to a failure to recognize emerging viral variants . Other branches continue to accumulate SHM in distinct parallel pathways through continual adaptation to new variants in the autologous virus population [47, 59, 96]. However, continued maturation is not always associated with neutralization breadth. Bhiman et al.  described highly mutated “off-track” CAP256-VRC26 mAbs, which have more than 20% SHM but limited neutralization breadth. Similar observations have been made in other bNAb lineages [58, 104, 105], and as mAb isolation methodologies are specifically designed to recover bNAbs, the proportion of bNAb lineages that are off-track is unknown.
Structural studies carried out in parallel to the repertoire analyses have also provided critical insights into the molecular basis of affinity maturation (reviewed in ). The detailed molecular mechanisms allowing neutralization breadth via epitope focusing and by adaptation to the glycan shield (through direct contact or by reducing steric clashes) have been better defined, and exploited for immunogen design (see below). Overall, the low affinity of bNAb precursors for cognate antigens is associated with lower thermodynamic stability, particularly of CDR loops, and SHM leads to epitope focusing , improved shape complementarity and increased buried surface area at the interface with the antigen, by conformational re-organization and stabilization of the paratope [47, 97]. Within bNAb lineages, these changes can occur independently within different sublineages maturing to acquire breadth [46, 47, 58, 96, 104, 105]. These varying pathways to breadth strongly demonstrate the plasticity of the immune system, which, even within one antibody lineage, can find multiple structural and genetic solutions to the same immunological problem.
Although co-evolutionary studies provide fascinating insights into the immune system, their utility as models for vaccine design is based on the notion that there are inter-donor commonalities amenable to vaccine design. As more studies emerge, such common patterns are becoming evident, both in terms of antibody precursors and the viral variants that select them.
The exquisite structural homogeneity with which VRC01-class bNAb precursors bind to the HIV Env CD4bs has been exploited in the design of germline-targeting immunogens (eOD-GT8 and 426c) [54, 100, 101]. These could elicit narrowly neutralizing antibody responses with VRC01-like characteristics, namely VH1-2 gene usage, a 5 amino acid CDRL3 and a short/flexible CDRL1, in mouse models [53, 115–117]. As additional studies of V2 and V3-glycan directed bNAbs define common features in their precursors and in the viral envelopes bound by them, germline targeting is being expanded to other epitopes [40, 41, 55, 114, 118].
Similarly, comparison of the viral diversification that leads to breadth is identifying convergent envelope features, which could be harnessed for vaccine design. For example, in two V2-glycan bNAb donors, there is striking similarity in the viral variants associated with maturation of breadth [96, 97]. In both these donors, localized diversity at the same key V2 epitope residues, specifically residues 166 and 169, selected SHM that drove bNAb maturation toward breadth [96, 97]. Similarly, studies of CD4bs directed antibodies in several donors have highlighted the role of variation in loop D and in the V5 glycans in shaping breadth [58, 108, 119], whereas for V3-glycan bNAbs, shifting glycans at positions 332, 335 and 301, and mutations within the V3 GDIR motif are common escape mechanisms between donors [59, 102]. While these studies support the idea of rational vaccine design and provide the first real hope that common pathways may exist, systematic structural and functional evaluation of longitudinal bNAb/Env autologous complexes and a deeper understanding of Env conformational plasticity, will provide insight into how these interactions drive bNAb lineage maturation towards breadth.
The high level of SHM typically exhibited by bNAbs is seen as a major hurdle for vaccination. This is especially true of bNAbs targeting the CD4bs. Indeed, despite the detection of VRC01-class Ab precursors in the naïve repertoire of a majority of healthy individuals , bNAbs directed to the CD4bs rarely develop in infected individuals and typically only after several (> 5) years of infection. Although about two-thirds of the SHM seen in CD4bs directed bNAb VRC01 conferred no benefit in terms of neutralization breadth , adaptation to the glycan surrounding the CD4bs, such as position N276, appears to be a major hurdle for CD4bs VH1-2 antibody lineages to overcome. This was clearly demonstrated through the study of the DRIVA7 lineage which, despite being encoded by a VH1-2*02 gene, encoding the critical 5 amino acid CDRL3 associated with VRC01-class bNAbs, and acquiring critical mutations in the CDRH1, CDRH3 and FRH3, failed to achieve the light chain maturation necessary to adapt to HIV Env loop D and V5 glycans .
There are however some examples that suggest that there may be shortcuts to the development of breadth, providing a more feasible template for vaccine design. One such example is the CD4bs lineage from donor PC63, which has equivalent breadth and potency to VRC01, but substantially less SHM (13.7% compared to 31.6% of VH1-2 nucleotides) . Notably, the SHM that appears in this lineage is highly focused at positions previously shown to be key CD4bs epitope contacts or glycan adaptation residues, suggesting that the viral variants in this donor might represent an ideal series of immunogens to drive the inclusion of “useful” SHM in CD4bs lineages, and avoiding the selection of redundant mutations that do not contribute to breadth.
In addition to the pediatric V3 glycan mAb BF520.1 described above , lower levels of SHM have also been described for adult bNAbs targeting the V3-glycan supersite. These include the PCDN , DH270  and PCIN39  bNAb lineages, further suggesting that shorter maturation pathways more compatible with vaccination can be achieved for this epitope. Furthermore, three of these V3-glycan lineages also achieved breadth without insertion/deletions (indels) in CDR loops, seen as another major roadblock for vaccination. Interestingly, in the fourth example, CDRH1 insertions of different lengths occurred independently in several branches of the PCIN39 lineage. Together, these studies suggest (i) that indels may not necessarily be required for V3-glycan bNAbs (ii) that indels may be less rare than anticipated, and that given the right selection, Ab lineages with insertions could be elicited by vaccination. Thus, despite substantial genetic and structural heterogeneity, the V3-glycan supersite remains an attractive vaccine target.
For bNAbs to the V2-glycan epitope, the long CDRH3s characteristic of this class of bNAbs arise during naïve rearrangement rather than during maturation , and are extremely rare in the naïve repertoire . Nonetheless, such specificities, once triggered can rapidly mature towards breadth with moderate levels of SHM . Furthermore, V2-glycan bNAbs PCT64, VRC38 and CH01 bear slightly shorter CDRH3 loops of ~ 25 amino acids, which are much more common in the naïve repertoire. Although bNAbs with shorter CDRH3s showed significantly lower breadth than the PG9, PGDM1400 and CAP256-VRC26 bNAbs that have longer CDRH3s, this reduced breadth is potentially off-set in a vaccine scenario by higher precursor frequency [82, 123]. This balance between breadth and more “normal” genetic features of antibodies raises the question of whether the focus on elite neutralizers may have resulted in missed opportunities. With the exception of germline targeting immunogens, most vaccines aim to elicit polyclonal responses to multiple epitopes, a scenario similar to that of most HIV infected individuals, who develop some cross-reactivity , often targeting multiple epitopes [20, 21, 82–85]. It is therefore possible that a renewed focus on more “elicitable” antibodies, with features more representative of the overall repertoire (e.g. few insertions or deletions, lower levels of SHM and average length CDRH3 s) may be valuable in honing vaccine candidates.
In addition to studies of more moderate neutralizers, studies of failed bNAb lineages may also be informative. Although most individuals mount robust neutralizing responses, the low proportion of individuals who develop breadth, and the fact that in some broad neutralizers, bNAbs represent a minority of the overall response [124, 125] suggests that the roadblocks impeding the development of breadth are profound. Analysis of the developmental pathway of Ab lineages failing to develop breadth would also shed light on the molecular events limiting the acquisition of neutralization breadth . Defining both favorable and unfavorable maturation pathways may also allow a better evaluation of the responses elicited by immunization to determine whether they are on the “right” track.
Translating insights from studies of infection into novel immunization strategies
Mechanism in infection
High viral load
Recruitment of larger B and T cell repertoires by increasing chances of activating lower affinity precursors due to higher antigen concentration
Germline-targeting immunogen design based on UCA features → high affinity prime
Adjuvants to boost innate immune responses
High anti-Env IgG Titers and helper lineages of neutralizing antibodies
More diverse repertoire increases chance of productive bNAb UCA encountering antigen
May restrict/slow down viral escape
Adjuvants to ensure high Ab titers and posibly greater diversity
Sustained delivery to ensure prolonged availability of Ags
Adjuvants to boost innate immune responses
High frequency of Tfh
May increase chances of activating lower affinity intermediates with unusual features, thereby sustaining affinity maturation and leading to higher SHM levels
Formulation should include T-cell epitopes
Adjuvants to boost innate immune responses and GC reaction
Burst of viral diversity
Increased chances of activating/maturing low affinity intermediates with unusual features. Sustained affinity maturation and associated high levels of SHM
Immunogen design incorporating incremental diversity. Autologous versus heterologous boosts to avoid “dead-end” pathways
Contemporaneous delivery of “variants” to quickly select relevant intermediates and positive selection
Several solutions are already being explored for the optimization of immunogens, such as the development of high-affinity germline targeting immunogens [39–41, 53–56, 103, 127]. Soluble stabilized Env trimers with key structural features are also a major focus in the field, to select critical antibody intermediates capable of binding the functionally relevant Env native conformation (reviewed in ). While the design of soluble trimers has greatly advanced the field, less is known about envelope signatures that impact the thermodynamics of natural viral trimers, perhaps affecting binding/neutralization by early bnAb intermediates. Understanding the stabilized conformation compared to membrane anchored spikes  and whether some degree of flexibility is necessary for productive interactions within developing bNAb lineages will be informative. Finally, variation in glycosylation also likely impacts trimer properties, and extending recent advances in glycobiology [11, 129, 130] will provide additional insights into controlling the glycan shield for acquisition of breadth [131, 132].
The rationale for further trimer stabilization is, in part, to reduce elicitation of “distracting”, mostly V3 directed, strain-specific responses, which might outcompete the bNAb lineages during affinity maturation . However, during infection bNAbs develop in a highly competitive environment, and immunization studies showed that autologous neutralizing titers were not enhanced by reduction of V3 responses [113, 134]. Additionally, two elegant studies recently showed that most GCs retain substantial clonal diversity during affinity maturation of complex antigens [135, 136]. The effect of interclonal competition as a limiting factor for bNAb elicitation is thus not clear. Much of what we know about the GC reaction comes from studies mimicking an acute infection with non-variable model antigens, and B-cell affinity maturation and differentiation in chronic GCs are incompletely defined (Reviewed in [137–139]). Specifically, the accumulation of higher levels of SHM and its effect on self-reactivity , and the impact of antigenic drift associated with HIV infection on the formation of memory subsets need to be better understood. Ongoing studies aiming to directly sample GC B cells and T follicular helper and regulatory cells during infection, as has recently been done in immunization , will be important.
Translating viral studies from elite neutralizers to vaccine design is another active area of research. Though incorporating some antigen diversity seems crucial, vaccine regimens cannot match the Env diversity seen during infection. How much diversity is required is not known. Several studies suggest that sequential delivery of a mix of Env immunogens may be preferable over a repeated cocktail immunization for the elicitation of bNAb responses [141, 142]. This contrasts by GC modeling studies  and with findings from studies of elite neutralizers, where a burst of viral diversity typically precedes acquisition of breadth [47, 58, 59]. Furthermore, the association of bNAbs with slower viral escape, and the existence of antibody “dead-ends”, suggests that too much variation between prime and boost Envs may terminate a nascent lineage. While animal data suggests that a lineage of autologous Env may specifically drive the maturation of a particular lineage [55, 115, 144], whether this will be a generalizable response in vaccine recipients will require human trials.
A further challenge is how to drive maturing lineages to accommodate glycans, particularly where a given glycan, such as that at residue 276, is incompatible with binding with bNAb precursors, but globally conserved on viruses. One approach has been the creation of “glycan holes” in Env immunogens. These bare Env regions are immunodominant in vaccine studies [145, 146], however the potential of these neutralizing responses to mature to recognize or tolerate glycans is unclear. During infection, breadth is not determined by the overall autologous neutralizing response ([14, 19] Sheward, Moore and Williamson, in press). This highlights the remaining challenges in driving “glycan-hole” directed vaccine responses towards breadth. Finally, the need for sustained exposure to high concentrations of antigens, as in infected donors with high viral loads, has led to strategies incorporating subcutaneous and extended administration with promising improvements in nAb titers [113, 147, 148].
In summary, the identification of elite neutralizers, and the unprecedented detail in which these donors have been studied, has provided crucial immunological and virological insights into the development of bNAbs. The translation of these landmark studies into innovative vaccine strategies that seek to bypass the stringent limitations imposed by rare bNAb precursors, and drive these towards breadth is generating promising data in animal studies. Ongoing and planned experimental medicine trials in humans will take the HIV vaccine field into a hugely exciting era. For the first time in 30 years of an HIV pandemic that has devastated communities, these studies provide hope that an HIV vaccine may be achieved, but also provided immunological lessons that are being harnessed for the design of vaccines against other highly mutable, complex pathogens.
Additional references in Table 1
PLM and EL wrote this manuscript and prepared the figures. Both authors read and approved the final manuscript.
PLM and EL would like to thank members of our laboratories, and many collaborators and students who have contributed to this review through useful discussions.
The authors declare that they have no competing interests.
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Ethics approval and consent to participate
EL is supported by the International AIDS Vaccine Initiative. IAVI’s work is made possible by generous support from many donors including: the Bill & Melinda Gates Foundation; the Ministry of Foreign Affairs of Denmark; Irish Aid; the Ministry of Finance of Japan in partnership with The World Bank; the Ministry of Foreign Affairs of the Netherlands; the Norwegian Agency for Development Cooperation (NORAD); the United Kingdom Department for International Development (DFID), and the United States Agency for International Development (USAID). The full list of IAVI donors is available at www.iavi.org. The contents are the responsibility of the International AIDS Vaccine Initiative and do not necessarily reflect the views of USAID or the United States Government. PLM is supported by the South African Research Chairs Initiative of the Department of Science and Technology and National Research Foundation of South Africa, the National Institutes for Health through a U01 grant (AI116086-01), the SA Medical Research Council SHIP program and Centre for the AIDS Program of Research (CAPRISA). Related research is conducted as part of the DST-NRF Centre of Excellence in HIV Prevention, which is supported by the Department of Science and Technology and the National Research Foundation. This collaboration was supported the generous support of the American people through USAID.
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