In a prospective cross-sectional study we quantified HIV viral load within the alveolar macrophage in a cohort of healthy HIV-infected subjects who did not have medical comorbidities or smoke cigarettes to determine if alveolar macrophage proviral DNA was associated with alveolar macrophage phagocytic immune dysfunction. We enrolled 23 subjects who underwent bronchoscopy and bronchoalveolar lavage. Alveolar macrophages were isolated and HIV-1 RNA was quantified in the cells using the Abbott RealTime HIV-1 Assay. Proviral DNA was qualitatively measured using a modified version of the HIV-1 RNA assay. Phagocytosis measured by incubating alveolar macrophages with FITC-labeled Staphylococcus aureus and determining fluorescence with a Zeiss inverted microscope. Phagocytic index was calculated as (% positive cells × mean channel fluorescence)/100. Sixteen subjects had (+) proviral DNA and seven had (-) proviral DNA in their alveolar macrophages. Of all subjects 100% in both groups were on highly active antiretroviral therapy (HAART). The median plasma viral load was 0 in both groups. HIV-1-infected subjects with (+) proviral DNA in their alveolar macrophages had a significantly lower median alveolar macrophage phagocytic index compared to those with (-) proviral DNA in their alveolar macrophages [11.8 (IQR 4.8-39.0) vs. 64.9 (IQR 14.0-166.0), p = 0.05]. Alveolar macrophages harbor HIV even in otherwise healthy subjects with undetectable plasma viral loads, representing a potential reservoir for the virus. In addition, HIV viral replication within the macrophage may impair phagocytosis and other immune functions in the lung, leading to an increased risk for lung infection.

Background Inflammation is associated with end-organ disease and mortality for people with HIV (PWH). Ruxolitinib, a Jak 1/2 inhibitor, reduces systemic inflammation for individuals without HIV and HIV reservoir markers ex vivo. The goal of this trial was to determine safety and efficacy of ruxolitinib for PWH on antiretroviral therapy (ART). Methods ACTG A5336 was an open-label, multi-site, randomized-controlled trial (RCT). Participants were randomly assigned (2:1) using centralized software to ruxolitinib (10mg twice-daily) plus stable ART for five weeks versus ART alone, stratified by efavirenz-use. Eligible participants were suppressed on ART for ≥2 years, without comorbidities, and had >350 CD4+ T-cells/µL. Primary endpoints were premature discontinuation, safety events, and change in plasma IL-6. Secondary endpoints included other measures of inflammation/immune activation and HIV reservoir. Results Sixty participants enrolled from May 16, 2016 to January 10, 2018. Primary safety events occurred in 2.5% (one participant) for ruxolitinib and 0% for controls, (p=0.67). Three participants (7.5%) prematurely discontinued ruxolitinib. By week five, differences in IL-6 (mean Fold Change (FC) 0.93 vs 1.10, p=0.18) and sCD14 levels (mean FC 0.96 vs 1.08, relative FC=0.96 (90%CI: 0.90,1.02)) for ruxolitinib versus controls was observed. Ruxolitinib reduced CD4+ T-cells expressing HLADR/CD38 (difference in means -0.34%, 90%CI: -0.66,-0.12)) and Bcl-2 (-3.30%, 90%CI: (-4.72,-1.87)). Conclusions In this RCT of healthy, virologically-suppressed PWH on ART, ruxolitinib was well-tolerated. Baseline IL-6 levels were normal, and showed no significant reduction. Ruxolitinib significantly decreased markers of immune activation and cell survival. Future studies of Jak inhibitors should target PWH with residual inflammation despite suppressive ART.

ObjectiveLung infections are a leading cause of death in HIV-infected individuals. Measuring redox in HIV-infected individuals may identify those with chronic oxidative stress who are at increased risk for lung infection. We sought to estimate the association between HIV infection and oxidative stress in the lung, as reflected by decreased levels of glutathione and cysteine in the epithelial lining fluid.MethodsBronchoalveolar lavage (BAL) fluid was collected from healthy HIV-infected subjects and controls. Individuals were excluded if they had evidence of major medical co-morbidities, were malnourished or smoked cigarettes.ResultsWe enrolled 22 otherwise healthy HIV and 21 non-HIV subjects. Among the HIV-infected subjects, 72.7% were on anti-retroviral therapy (ART) with a median CD4 count of 438 (279.8–599) and viral load of 0 (0–1.0) log copies/mL. There were no significant differences in median BAL fluid glutathione and cysteine levels between HIV and HIV-uninfected subjects. However, BAL glutathione was significantly higher in HIV-infected subjects on anti-retroviral therapy (ART) compared to those not on ART [367.4 (102–965.3) nM vs. 30.8 (1.0–112.1) nM, p = 0.008]. Further, HIV infection with ART was associated with an OR of 2.02 for increased BAL glutathione when adjusted for age and body mass index, whereas HIV infection without ART was associated with an OR of 2.17 for decreased BAL glutathione.ConclusionHIV infection without ART was associated with increased oxidative stress, as reflected by decreased alveolar glutathione levels, in otherwise healthy HIV-infected individuals. Further study needs to be done identify predictors of lung health in HIV and to address the role of ART in improving lung immunity.

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Long-term consequences of HIV are likely the result of persistent inflammation and immune dysfunction of which CMV is a known contributor. We leveraged two ACTG clinical trials exploring effects of immune modulators (ruxolitinib and sirolimus) on inflammation in people with HIV on ART to determine if these interventions affected CMV shedding at various mucosal sites. Analyzing 635 mucosal samples collected, we found no significant difference in CMV levels across study arms or time points. Men had more CMV shedding than women. We did confirm an association between higher CMV DNA and immune markers associated with HIV persistence and HIV-associated mortality.