National Institute on Deafness and Other Communication Disorders

1. National Institute of Allergy and Infectious Diseases National Heart, Lung and Blood Institute National Institute on Deafness and Other Communication Disorders Metabolic Abnormalities and Mitochondrial Function in Children with Perinatally-Acquired HIV Infection in the Pediatric HIV/AIDS Cohort Study (PHACS) Mariana Gerschenson, Ph.D. Tracie L. Miller MD, Jiajia Wang MS, Denise L. Jacobson PhD, MPH, Jody K. Takemoto PhD, Tanvi Sharma MD, Mitchell Geffner MD, Daniel E. Libutti BS, Susanne Siminski MS, MBA, Gabriel Somarriba DPT, and Patricia Graham MS for the Pediatric HIV/AIDS Cohort Study July 23, 2012 XIX International AIDS Conference

2. National Institute of Allergy and Infectious Diseases National Heart, Lung and Blood Institute National Institute on Deafness and Other Communication Disorders Background • Insulin resistance is common among perinatally HIV-infected children (HIV+) • Mitochondrial dysfunction, induced by antiretroviral therapy (ARV) or chronic viral infection, is a possible mechanism for metabolic dysfunction

3. Mitochondria Inner Structure HIV Inner Membrane Matrix Cristae Outer Membrane Adipocyte TEM Mitochondrial Function • Make ATP • Oxidative phosphorylation  ATP • Citric acid cycle: NADH and FADH  ATP • Fat metabolism: beta oxidation  ATP • Responsible for 90% of the oxygen radicals/oxygen stress • Mitochondrial DNA (mtDNA) • 16 kb, 2-10 copies/mitochondrion in matrix • Replication: mitochondrial genes • The mtDNA polymerase-γ is the principal polymerase required for mtDNA replication • Transcription: mitochondrial proteins • Mitochondrial RNA (mtRNA) polymerase and transcription factors • Apoptosis • Lactic acidosis Adipocyte TEM courtesy of Courtney Kim and Mariana Gerschenson

4. ART Cytokines HIV HIV Hypothesis: Potential Consequences of Mitochondrial Dysfunction • Metabolic Disease • (LD, IR,  TGs) • DNA polymerase-g • Transcription • Uncoupling • Transport • Oxidative Stress • Apoptosis • Phosphorylation • Proteolytic Processing • Glycosylation Cardiovascular Disease Lipodystrophy • Neuropathies • Hepatic Steatosis • Myopathy • Pancreatitis • Lactic Acidosis Day L, et al. Mitochondrion. 2004;4:95–109. AACTG Metabolic Guides: http://aactg.s-3.com/metabolic/lactic.pdf. McComsey GA, Morrow JD. J Acquir Immune Defic Syndr. 2003;34:45-9. Dagan T, Sable C, Bray J, Gerschenson M. Mitochondrion. 2002;1:397-412. Gerschenson, M. and Brinkman, K. Mitochondrion. 2004;4(5-6):763-777.

5. National Institute of Allergy and Infectious Diseases National Heart, Lung and Blood Institute National Institute on Deafness and Other Communication Disorders Hypothetical Model for HIV Pediatric Metabolic Disease  BMI/ Body Measurements  LDL/HDL/TG/HOMA-IR (Glucose) β-oxidation Krebs OXPHOS HIV/ART  Lactate

6. Objectives • To compare mitochondrial function [oxidative phosphorylation (OXPHOS) enzyme activities and lactate levels] of 191 HIV+ and 117 HIV-exposed, uninfected (HEU) children and among HIV+, determine associations with homeostatic model assessment of insulin resistance (IR) (HOMA-IR) and hyperlipidemia • In HIV+ children, to determine if mitochondrial function (oxidative phosphorylation [OXPHOS] enzyme activities and lactate and pyruvate levels) are associated with metabolic abnormalities (IR and hyperlipidemia)

7. Mitochondrial Determinant Component of PHACS • The Adolescent Master Protocol (AMP), a part of the Pediatric HIV/AIDS Cohort Study (PHACS), is a prospective cohort study conducted at 12 US sites designed to define the impact of HIV infection and ARV on pre-adolescents and adolescents with perinatal HIV infection. • The Mitochondrial Determinants Component (MDC) is a separately funded study (R01 NR12885) that has co-enrolled AMP participants since May 2011. • The objective of MDC is to determine the influence of mitochondrial abnormalities on metabolic outcomes in HIV+ children who were previously enrolled in AMP from 7 years of age until their 16th birthday. HIV-exposed, uninfected children (HEU) are also enrolled to serve as controls.

8. National Institute of Allergy and Infectious Diseases National Heart, Lung and Blood Institute National Institute on Deafness and Other Communication Disorders Demographics of Cohort by HIV Status *Wilcoxon Test ** Fisher’s Exact Test

9. National Institute of Allergy and Infectious Diseases National Heart, Lung and Blood Institute National Institute on Deafness and Other Communication Disorders Clinical Characteristics of HIV+ Children at Study Entry

10. National Institute of Allergy and Infectious Diseases National Heart, Lung and Blood Institute National Institute on Deafness and Other Communication Disorders Baseline Metabolic Outcomes in HIV-Infected Children

11. Mitochondrial Function by HIV Status

12. National Institute of Allergy and Infectious Diseases National Heart, Lung and Blood Institute National Institute on Deafness and Other Communication Disorders Insulin Resistance is Associated with Increased Venous Lactate and Pyruvate in HIV+ Children IR - YES IR – NO IR - YES IR – NO Lactate Pyruvate

13. National Institute of Allergy and Infectious Diseases National Heart, Lung and Blood Institute National Institute on Deafness and Other Communication Disorders Hypertriglyceridemia is Associated with Point-of-Care (POC) and Venous Lactate in HIV+ Children P=0.024 P<0.001 High TG Normal TG High TG Normal TG POC Lactate Venous Lactate

14. National Institute of Allergy and Infectious Diseases National Heart, Lung and Blood Institute National Institute on Deafness and Other Communication Disorders Low HDL-Cholesterol is Associated with Lower PBMC OXPHOS CI and CIV Enzyme Activities in HIV+ Children P=0.085 P=0.024 Low HDL Normal HDL Low HDL Normal HDL Complex I Complex IV

15. Venous Lactate is Positively Correlated with Total Cholesterol in HIV+ Children P=0.04; r=0.16

16. Venous Lactate is Positively Correlated with Triglycerides in HIV+ Children P<0.0001; r=0.37

17. National Institute of Allergy and Infectious Diseases National Heart, Lung and Blood Institute National Institute on Deafness and Other Communication Disorders Multivariable Model for HDL-Cholesterol in HIV+Children

18. National Institute of Allergy and Infectious Diseases National Heart, Lung and Blood Institute National Institute on Deafness and Other Communication Disorders Multivariable Model for Triglycerides in HIV+ Children

19. Conclusions in HIV+ Children • Insulin resistance is associated with higher lactate and pyruvate levels • Hypertriglyceridemia is associated with higher lactate levels • Low HDL-cholesterol is associated with lower CI and CIV enzyme activities • Venous lactate is independently associated with higher triglyceride levels

20. Overall Conclusions Mitochondrial dysfunction induced by either HIV or ARV may be responsible for the observed metabolic changes

21. Acknowledgments PHACS is funded by: Under cooperative agreements with Harvard School of Public Health (HD052102, 3 U01 HD052102-05S1, 3 U01 HD052102-06S3) and Tulane School of Medicine (HD052104, 3U01HD052104-06S1) We thank the study participants, PHACS Community Advisory Board, Frontier Science Inc., and Westat.

22. Acknowledgments • The following institutions participated in conducting PHACS in 2011: • Baylor College of Medicine • Bronx Lebanon Hospital Center • Children's Diagnostic & Treatment Center • Children’s Hospital, Boston • Children’s Memorial Hospital • Jacobi Medical Center • New York University School of Medicine • St. Christopher’s Hospital for Children • St. Jude Children's Research Hospital • San Juan Hospital/Department of Pediatrics • SUNY Downstate Medical Center • Tulane University Health Sciences Center • University of Alabama, Birmingham • University of California, San Diego • University of Colorado Health Sciences Center • University of Florida/Jacksonville • University of Illinois, Chicago • University of Medicine and Dentistry of New Jersey • University of Miami • University of Southern California • University of Puerto Rico Medical Center Funding for this study is from DHHS/NIH/NINR grant R0112885 to M. Gerschenson and T.L. Miller. We also acknowledge the support from the John A. Burns School of Medicine, University of Hawaii at Manoa.