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July 24th, 2008 HIV Lifecycle and Mechanisms of Antiretroviral Therapy David Spach, MD.
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July 24th, 2008 HIV Lifecycle and Mechanisms of Antiretroviral Therapy David Spach, MD
HIV/AIDS 2008 Treatment UpdateAn In-Depth Look at the Viral Life Cycle to Understand Old and New Antiretroviral MedicationsDavid H. Spach, MDProfessor of MedicineDivision of Infectious DiseasesUniversity of Washington, Seattle DHS/PP
HIV/AIDS 2008 Treatment Update • Overview of HIV Structure and Life Cycle • 2008 DHHS Antiretroviral Therapy Guidelines • Mechanisms of Action of Antiretroviral Medications DHS/PP
HIV Structure and Life Cycle DHS/PP
HIV: Basic Structure HIV RNA DHS/PP
HIV: Basic Structure Envelope gp120 gp41 Nucleocapsid (p7) Capsid (p24) HIV RNA Matrix (p17) DHS/PP
HIV: Functional Enzymes • What are the three key HIV enzymes involved in HIV replication? DHS/PP
HIV Enzymes Reverse Transcriptase Integrase Protease DHS/PP
Host (Human) Cell: Key HIV Receptors CD4 Receptor CCR5 Co-Receptor CXCR4 Co-Receptor Host Cell DHS/PP
Question • What genetic alteration in human co-receptors is associated with relative resistance to HIV infection? DHS/PP
CCR5-∆32 CCR5 CCR-∆32 Extracellular Space C C C C Host Cell Membrane Intracellular Space DHS/PP
HIV: Life Cycle Nucleus CCR5 CD4 Host DNA HIV Host Cell
HIV: Life Cycle Entry 3 Nucleus 2 CCR5 1 CD4 HIV Host Cell
HIV: Life Cycle Uncoating Entry Nucleus CCR5 CD4 HIV RNA HIV Host Cell
HIV: Life Cycle Uncoating Reverse Transcription Entry Nucleus CCR5 CD4 HIV RNA HIV DNA HIV Reverse Transcriptase Host Cell
HIV: Life Cycle Uncoating Reverse Transcription Entry Integration Integrase Nucleus CCR5 CD4 HIV RNA HIV DNA HIV Proviral DNA HIV Host Cell
HIV: Life Cycle Uncoating Reverse Transcription Transcription Entry Integration Nucleus CCR5 gRNA CD4 HIV RNA HIV DNA mRNA HIV Host Cell
HIV: Life Cycle Uncoating Reverse Transcription Transcription Entry Integration Translation Nucleus CCR5 CD4 gp160 Protease HIV RNA HIV DNA mRNA HIV Myr Gag Host Cell Gag-Pol
HIV: Life Cycle Uncoating Reverse Transcription Transcription Entry Integration Translation Assembly & Budding HIV Nucleus CCR5 CD4 HIV RNA HIV DNA mRNA HIV Myr Gag Host Cell Gag-Pol
HIV: Life Cycle Entry Inhibitors Nucleoside RTI Integrase Inhibitors HIV Nucleus CCR5 CD4 HIV RNA HIV DNA mRNA HIV Protease Inhibitors Non-Nucleoside RTI Gag Host Cell Gag-Pol
Case History • A 32-year-old HIV-infected woman returns to clinic to discuss starting antiretroviral therapy. Her CD4 count is 330 cells/m3 and her HIV RNA is 79,000 copies/ml. • According to the 2008 DHHS Antiretroviral Therapy Guidelines:- When should you start antiretroviral therapy on this patient? DHS/PP
HIV: Natural History Acute HIV Year 1 DHS/PP
Initiating Antiretroviral Therapy 500 350 200 Year 1 DHS/PP
Initiating Antiretroviral TherapyJanuary 2008 DHHS Guidelines 500 Consider Antiretroviral Therapy 350 Initiate Antiretroviral Therapy Year 1 Source: DHHS Guidelines. www.aidsinfo.nih.gov DHS/PP
Question • Why do you think we are more enthusiastic about starting antiretroviral therapy earlier now than 2-3 years ago? DHS/PP
Rationale for Earlier Antiretroviral Therapy • More effective regimens • More convenient regimens • Less toxic regimens • Expanding data suggesting benefit of earlier therapy DHS/PP
Case History • A 32-year-old HIV-infected woman returns to clinic to discuss starting antiretroviral therapy. Her CD4 count is 330 cells/m3 and her HIV RNA is 79,000 copies/ml. • According to the 2008 DHHS Antiretroviral Therapy Guidelines: - What regimen would you use? DHS/PP
DHHS Panel: January 2008 ARV Therapy GuidelinesInitial Therapy: Preferred Regimens Construct Regimen by choosing one component from Column A and one component from Column B Column A Column B NNRTIEfavirenz PIAtazanavir + RitonavirFosamprenavir + Ritonavir BIDLopinavir/ritonavir (Kaletra) BID 2-NRTITenofovir/Emtricitabine(Truvada)Abacavir/Lamivudine(Epzicom): for patients who test negative for HLA-B5701 Picture Source: DHHS Guidelines. www.aidsinfo.nih.gov DHS/PP
DHHS Panel: January 2008 ARV Therapy GuidelinesInitial Therapy: Alternative Regimens Construct Regimen by choosing one component from Column A and one component from Column B Column A Column B NNRTINevirapine PIAtazanavir (unboosted)Fosamprenavir (unboosted)Fosamprenavir + ritonavir qdLopinavir/ritonavir (Kaletra) qdSaquinavir + ritonavir 2-NRTIZidovudine/Lamivudine (Combivir)Didanosine + (Emtricitabine or Lamivudine) Picture Source: www.aidsinfo.nih.gov DHS/PP
Case History • A 32-year-old HIV-infected woman returns to clinic to discuss starting antiretroviral therapy. Her CD4 count is 330 cells/m3 and her HIV RNA is 79,000 copies/ml. • According to the 2008 DHHS Antiretroviral Therapy Guidelines: - How should you ideally monitor after treatment is started? DHS/PP
Antiretroviral Therapy: HIV RNA MonitoringOptimal Response: HIV RNA < 50 copies/ml Antiretroviral Therapy Started √ CD4 50 √ CD4 √ CD4 Goal: HIV RNA < 50 copies/ml 1 2 3 4 5 6 7 8 9 DHS/PP Time (Months)
Entry Inhibitors DHS/PP
HIV: Life Cycle HIV Entry Inhibitors Nucleus CCR5 CD4 HIV RNA HIV DNA mRNA HIV Myr Gag Host Cell Gag-Pol
HIV: Basic Structure Envelope gp120 gp41 DHS/PP
HIV: Envelope HIV gp41 gp120 CD4 Binding Groove V3 Region DHS/PP
HIV: gp41 HIV gp41 DHS/PP
Host Cellular ReceptorsCD4, CCR5, & CXCR4 Extracellular Space CCR5 CXCR4 CD4 Receptor Host Cell Membrane Intracellular Space DHS/PP
HIV Cell Binding and Entry HIV gp120 CD4 Receptor CD4 Receptor Extracellular Space CCR5 Host Cell Membrane Intracellular Space DHS/PP
HIV Cell Binding and Entry HIV CD4 Receptor Extracellular Space CCR5 Host Cell Membrane Intracellular Space DHS/PP
HIV Cell Binding and Entry HIV CD4 Receptor V3 Region Extracellular Space CCR5 Host Cell Membrane Intracellular Space DHS/PP
HIV Cell Binding and Entry HIV CD4 Receptor Extracellular Space CCR5 Host Cell Membrane Intracellular Space DHS/PP
HIV Cell Binding and Entry HIV gp41 CD4 Receptor Extracellular Space CCR5 Host Cell Membrane Intracellular Space DHS/PP
HIV Cell Binding and Entry HIV gp41 Extracellular Space Host Cell Membrane Intracellular Space DHS/PP
HIV Cell Binding and Entry HIV Heptad Repeat 2 [HR2] HR2 gp41 HR1 Heptad Repeat 1 [HR1] Extracellular Space Host Cell Membrane Intracellular Space DHS/PP
HIV Cell Binding and Entry HIV Extracellular Space Host Cell Membrane Intracellular Space DHS/PP
HIV Cell Binding and Entry HIV HIV Membrane Host Cell Membrane DHS/PP
HIV Cell Binding and Entry HIV HIV Membrane Host Cell Membrane DHS/PP
R5-Tropic Virus: Binds to CCR5 R5-Tropic HIV V3 Region CD4 Receptor CD4 Receptor Extracellular Space CXCR4 CCR5 Host Cell Membrane Intracellular Space DHS/PP
X4-Tropic Virus: Binds to CXCR4 X4-Tropic HIV V3 Region CD4 Receptor CD4 Receptor Extracellular Space CXCR4 CCR5 Host Cell Membrane Intracellular Space DHS/PP