HIV

By Alick Mwambungu

Dublin Institute of Technology

Republic of Ireland
 Contents
 Introduction – History and Overview of HIV

 Pathogenesis – Structure and Lifecycle of HIV

 Effect On The Immune System – Destruction of

Cells and Resulting Immunodeficiencies

 Diagnosis and Treatment

 What is HIV?
 Genus Retroviridae

 Lentivirus, which literally means slow virus - it

takes such a long time to develop adverse
effects in the body.

 This virus attacks the immune system

 There are two strains – HIV 1 & HIV 2

 It belongs to a group of retroviruses.

 These contain RNA, the genetic material of

HIV

 The outer layer of the HIV virus cell is

covered in coat proteins, which can bind to
certain WBCs. This allows the virus to enter
the cell, where it alters the DNA.

 The virus infects and destroys the CD4

lymphocytes which are critical to the body’s
immune response.
 History of HIV

 The HIV virus first came to light during the

early 1980’s.

 A number of healthy gay men in New York

began to develop rare opportunistic infections
& cancers, that were resistant to treatment.

 One such viral opportunistic infection is

cytomegalovirus that causes blindness &
inflammation of the colon
 Transmission
HIV is transmitted from person to person in several
ways:

 Through unprotected sex with an infected person

 Exposure to infected blood

 By the use of contaminated equipment for injections

(by drug users or medical treatment in developing
countries)

 From an infected mother to her baby before or

during birth, or by breast feeding
 HIV Origins
 Research teams in the U.S.A & France made
independent research discoveries of the
virus.

 French researchers discovered a virus linked

to AIDS in 1983, they called it
Lymphadenopathy-Associated Virus (LAV)

 In 1984, American researchers isolated a

virus that caused AIDS, calling it Human T-
lymphotropic Virus type 111 (HTLV-111)

 These two viruses were later found to be the

same virus - HIV
 HIV Origin

 The emergence of HIV & AIDS has resulted

in countless debates as to where it originated
from

 It’s suspected that it originated from S.I.V

(Simian Immunodeficiency Virus)

 SIV affects Monkeys

 HIV Origins
 Certain strains of SIV closely resemble the two types
of HIV

 HIV 1 – was difficult to link with SIV

 In 1999 SIVcpz closely related to HIV 1

 Originated from chimpanzees but it has significant

differences from HIV-1

 HIV 2 closely related to SIVsm

 Originated from the green monkey

 Conspiracy Theories

 Two different SIV infections combined to

form a new third virus, leading to zoonosis

 Several theories regarding zoonosis

 Hunter Colonialism
– Transferred by hunting & killing chimpanzees
- Colonial rule in Africa, forced labour
- Eating SIV infected chimpanzees
 Conspiracy Theories

 Oral Polio Vaccine

- Grown on kidney cells from chimpanzees
- Infected with SIVcm2 leading to HIV 1

 Contaminated needles
- Not sterilising needles between patients
- Sharing of needles

 Manmade

 Linked to the CIA

 Early known cases of HIV
 Plasma sample taken from male adult in the Congo in
1959

 A 1998 analysis of the plasma sample from 1959 has

suggested that HIV-1 was introduced into humans
around the 1940s or the early 1950s

 Tissue sample taken from a teenager, St. Louis in

1969 – died

 Tissue sample from Norwegian sailor- died 1976

 Another sample was dated back to the end of the 19th

Century
 Incidence
 ~ 42 million people have been infected with
HIV to date.

 AIDS has caused millions of deaths

 Only conditions typical of old age, such as

heart disease & stroke cause more fatalities
worldwide

 In Africa, HIV has reached epidemic

proportions, responsible for 1 in 5 deaths in
1998

 In the UK 37,900 HIV + in 1999

Global Incidence
 Global Incidence Trends
 More than 25 million people have died of AIDS since
1981

 Africa has 12 million AIDS orphans

 At the end of 2006, women accounted for 48% of all

adults living with HIV worldwide, and for 59% in sub-
Saharan Africa

 Young people (under 25 years old) account for half of

all new HIV infections worldwide - around 6,000
become infected with HIV every day

 In developing and transitional countries, 6.8 million

people are in immediate need of life-saving AIDS
drugs; of these, only 1.65 million are receiving the
drugs
 Global Incidence Trends
 During 2006 around four million adults and
children became infected with HIV (Human
Immunodeficiency Virus), the virus that
causes AIDS

 By the end of the year, an estimated 39.5

million people worldwide were living with
HIV/AIDS

 The year also saw around three million deaths

from AIDS, despite recent improvements in
access to antiretroviral treatment.
World Statistical Regions of HIV
 Structure of HIV
 Genome and Proteins of HIV
• The genome of HIV is encoded on two identical
strands of RNA when the virus is in the free
form.

• It has nine open reading frames (leading to nine

primary translation products) but 15 proteins
are actually made in all as a result of cleavage of
three of the primary products.

• The GAG gene and the GAG and POL genes

together are translated into polyproteins which
are then cleaved by a protease.
• GAG polyprotein is cleaved to into four proteins: 
 matrix protein (p17) which anchors the gp160
receptor
 capsid protein (p24) which forms a capsule around
the RNA genome
 the nucleocapsid protein which binds to the HIV
packaging signal on viral RNA
 p6 which plays a role in incorporating proteins
into new virons.

• ENV gene is translated to gp160 which is then

cleaved by a host cell protease found in the Golgi
body to:
 Gp41
 Gp120
• Together these form the HIV receptor
• POL polyprotein is cleaved to:
 Protease, an enzyme required for maturation and
functioning of other viral proteins
 Reverse transcriptase which is responsible for
incorporation into the host genome.
 Integrase which cuts the host DNA and attaches
the proviral genome to the cut ends.

• Six other proteins are made by HIV

• Three of these are incorporated into the virus:

 Tat and Rev are regulatory proteins
 Vpu (HIV-1) indirectly assists in assembly

• The others are not found in the mature virus:

 The HIV receptor

• Gp160 is composed of gp41 and gp120 and forms

the receptor for binding to the host cell (CD4
positive cells).

• The gp41 portion is half embedded in the

membrane envelope and interacts with gp120
portion on the exterior side of the membrane.

• Each receptor is composed of 3 subunits of gp41

and 3 subunits of gp120.
The HIV Receptor
 Lifecycle of HIV

 HIV particles enter the body in a fluid as it can not

survive without a support medium.

 The virus targets any cell expressing CD4, including T

helper cells, macrophages, dendritic cells and
monocytes.
 • Receptor Interactions
• The first stage of infection involves the binding of the
gp120 portion of the receptor on the HIV to the CD4
receptor on the host cell.

• This binding also requires the interaction of the virus

with a chemokine co-receptor

• Of the chemokine receptor family the two most

important co-receptors for HIV are CCR5 on
macrophages and CXCR4 on T-cells.

• Attachment of HIV to a co-receptor first allows for a

more stable and intimate association with the CD4
receptor.

• This interaction with the CD4 receptor causes a

conformational change in the gp120 portion, which in
turn causes a change in the gp41 portion, initiating the
membrane fusion step of the infection.
 2. Cell Membrane Fusion and Integration
• Virus particles enter the CD4 positive host cell.

• HIV is transported in as a pre-integration complex and

p17 carries nuclear localisation signals which are a
sequence of proteins recognised by the host cell as
belonging in the nucleus

• Intergrase protein cleaves the host genome and reverse

transcriptase reads the sequence of viral RNA and
transcribes it into a complementary DNA sequence of
the host.

• HIV is now a genetic disease, once the viral genome is

integrated it becomes a permanent component of the
host cell.
 3. Viral Replication
• As with all viruses HIV is an obligate intracellular
parasite – it can only replicate when incorporated with
the host’s genome.

• Once integrated the virus can remain dormant in the

host cells, or can begin the production of new RNA.

• Non-genomic RNA is translated into large polyproteins.

This is then cleaved into structural proteins which are
assembled around genomic RNA.

• Protease completes cleavage of polypeptides into fully

functional proteins resulting in a multiple mature viral
particles being released from the cell.

• This causes cell lysis which is one of the most

destructive mechanisms in the depletion of CD4 T-cell
populations.
Mature Viral Particles Escaping From A T-Helper Cell
Infection of the Lymphocytes

• HIV can exist in two forms, the M-trophic strain

which is associated with infection of macrophages and
the T-trophic which infects T-helper cells.

• Due to the high error frequency of HIV polymerase

one strain can readily mutate with the other strain.

• The M-trophic strain has an important role in the

initial infection as the primary site of infection for
HIV is the macrophage.

• The infected macrophage then acts as a “trojan-

horse” in bringing the virus to the lymphatic system
since it’s job is antigen presentation.
• After infection of the macrophage the M-trophic
genome undergoes mutation and T-trophic strains are
produced.

• The generation of the T-trophic strain results in the

infection of the T-helper cell populations within the
lymph nodes and lymphatic tissue.

• T-cells are attracted to the lymph nodes and lymphatic

system by two chemokines produce by the infected
macrophages - MIP-1alpha and MIP-1beta

• Migration and proliferation of T-helper cells in response

to the infection means more and more cells will be
continuously infected.

• HIV is also thought to have the ability to infect T-

memory cells. This is an important factor in persistence
of the disease in the lymphatic system over decades.
Eventually there is loss of lymph node architecture.
 Effects of HIV on the immune system

3 areas:

1. Destruction of CD4+ T cells population

2. Immune effects due to HIV infection

3. Progression of HIV infection to AIDS

 Destruction of CD4+ T cells
 Direct virological mechanisms
 Host’s immune responses

1.Direct virological mechanisms

 HIV destroys individual infected cells through cell

lysis or the formation of syncytia when large numbers
of uninfected cells fuse with the infected cell.

 This results in the deaths of potentially hundreds of

uninfected cells.

 The half-life of an actively infected CD4+ T cell is

less than 1.5 days.
2.Host’s immune responses

 Both humoral and cell-mediated immune responses

partially control the viral production but in this
process they destroy the infected CD4+T cells,
leading to a gradual decline of CD4+ T cells

 HIV-specific CTLs kill infected CD4+ T cells

 Antibodies that recognize a variety of HIV antigens

are produced - Antibody dependent cell-mediated
cytotoxicity

 Apoptosis of infected cells

 Immune responses fail to eradicate all viruses.
 Viral load is maintained at low level
 Continuous decline of CD4+ T cells
Role of CD4+ T cells
 Role: secrete cytokines that
enable activation of B cells, Tc
cells and macrophages

 CD4+ T cells - TH1 cells and TH2

cells

 TH1 cells – secrete IFN-γ =>

phagocyte-mediated immunity.

 TH2 cells – secrete IL-4 => Ig

synthesis.

 Some studies demonstrate that

the proportion of TH1 T cells
decreases in HIV-infected
patients but TH2 T cells
increases. - disrupt the normal
balance of cytokines.
 Immune defects due to HIV infection
Almost all aspects of immunity are affected as the disease
progresses.

Impaired cell mediated responses

CD4+ T cell
 Rapid loss of memory helper T cells and the inability to replace
these cells leads to increasing immunodeficiency.

 CD4+ T cells that have bound gp120 may not be available to

interact with class II MHC molecules on APC => T cell responses
are inhibited.

 Autoimmune response can occur as the HIV receptor shares

homology with the MHC II molecules.

 HIV becomes a component of the CD4 T-cell genome and as a

result everytime the cell is activated there is further viral
replication.
 Cytokines produced by innate immunity activate infected CD4+ T
cells.
 Immune defects due to HIV infection
CD8+ T cell

 Full differentiation of CD8+CTLs requires cytokines that

are produced by CD4+ T cells

 Progressive decline of CD4+ T cells over time, is

associated with decreased activation and survival of CD8+
cytotoxic T cells resulting in a decreased ability to
destroy virally infected cells.

 HIV Nef protein inhibits expression of Class I MHC

molecules.

 High mutation rates of HIV also allow the virus to escape

adaptive immune responses.
Immune defects due to HIV infection
B cells – impaired humoral response

 B-cell hyperreactivity
 Polyclonal hypergammaglobulinemia due to enhanced
nonspecific IgG and IgA production.
 Impaired Ab-isotype switching and inability to respond to
specific antigen.
 High incidence of B-cell lymphomas

Lymph nodes

 HIV kills cells in the lymph nodes

 Early HIV infection: destruction of dendritic cells
 Late stage: extensive damage, tissue necrosis, a loss of
follicular dendritic cells and germinal centres.
 An inability to trap Ag or support activation of T+B cells
 Immune defects due to HIV infection
Impaired Innate Immunity

Macrophages
 macrophage is infected directly by HIV or phagocytosis of
other infected cells or Fc receptor-mediated endocytosis.

•Act as a reservoir for the virus

• Normal functions are impaired which include

•Phagocytosis + killing of organisms
•Ag presentation
•Chemotaxis
•Cytokine secretion

exhibit defective phagocytic function and

Neutrophils -
impaired chemotaxis due to imbalance of cytokines
production.
 Immunodeficiency
 Immunodeficiency - due to
defects in one or more
components of the immune
system

 Main causes for

immunodeficiency in HIV
infection - destruction of
lymphoid tissue and
depletion of CD4+ T cells.

 The CD4+ T cell count gives

an indication of the level of
damage that has already
occurred to the immune
system as a result of HIV
infection.
 Progression of HIV infection
 After initial infection with
HIV, there is usually an Progression of HIV infection
acute flu-like illness. Exposure to
HIV

This illness may include

normal
 Acute HIV disease
 Fever
 Headache Clinical latency period
Slightly
Tiredness

Immune competence
 reduced -declining CD4+ T cell amount

 Enlarged lymph nodes

Abnormal
 But after this most AIDS

individuals are clinically

asymptomatic for years. Opportunistic
This is called the clinical Severely
infections

latency period. impaired

Time
 Progression to AIDS
 During the latency period, lymph nodes and the spleen are
sites of continuous HIV replication and cell destruction.

 The immune system remains competent at handling most

infections with opportunistic microbes but the number of
CD4+ T cells steadily declines.

Symptoms often experienced months to years before the onset

of AIDS.
 Lack of energy
 Weight loss
 Frequent fevers and sweats
 Persistent or frequent yeast infections
 Persistent skin rashes
 Dysfunction of CNS
 Progression to AIDS
 Final stage of HIV infection - AIDS

 Occurs when the destruction of peripheral lymphoid tissue

is complete and the blood CD4+ T cell count drops below
200 cells/mm3. (Healthy adults usually have CD4+ T-cell
counts of 1,000 or more).

 AIDS – acquired immunodeficiency syndrome – is marked

by development of various opportunistic infections and
malignancies.

 The level of virus in the blood and CD4+ T cell count can
predict the risk of developing AIDS. Viral titres often
accelerate as the patient progresses towards AIDS.

 Without treatment, at least 50% of people infected with

HIV will develop AIDS within ten years.
 Opportunistic Infections
 Opportunistic infections can be caused by
bacteria/viruses/fungi/protozoa that are able to invade the body
only when the immune system is weakened. 

 Common HIV-related opportunistic infections and diseases:

 Bacterial diseases: tuberculosis, bacterial pneumonia, septicaemia

 Protozoal diseases: PCP(pneumocystis carinii pneumonia), -

targets the lungs

 Fungal diseases: candidiasis, cryptococcosis (most often appears

as meningitis)
 Opportunistic Infections
 Loss of cellular immunity - associated with
increased susceptibility to intracellular
pathogens such as viruses.

 Cytomegalovirus, herpes simplex

 HIV-associated malignancies: Kaposi's sarcoma,

lymphoma, squamous cell carcinoma and cervical
cancer.

 In people with AIDS, these infections are often

severe and sometimes fatal.
 Diagnosis of HIV
 Initial test for HIV is an indirect ELISA test
 Economic, rapid, performed easily, high sensitivity and
specificity
 Detects anti-HIV antibodies in patient serum
 Antibodies are generally detectable within 3 months of
infection
 Antibodies are typically directed at the envelope
glycoproteins (gp120 and gp41)
 Absence of antibody, as in ‘window period’ does not exclude
the presence of the virus which can be detected by PCR
amplification approx ten days after infection
 ‘Window period’ – time between infection and detection of
serological viral marker
 Direct ELISA for p24 antigen can also be used although
the false negative rate is higher
 Diagnosis of HIV
 Although very sensitive, ELISA may yield non-
specific reactions resulting in false positive results

 Positive or indeterminate ELISA tests for anti-HIV

antibodies are confirmed by immunoblotting
(Western Blotting) which identifies specific HIV
virus proteins

 PCR can also be used

 Detects pro-viral DNA or viral RNA

 It is highly sensitive and specific but is more costly

than ELISA

 Can be used to test infants born to HIV-infected

mothers
 Principle of ELISA Test
 Recombinant HIV antigens, corresponding to viral proteins
of HIV-1 and HIV-2 are coated on a solid phase
 Patient serum is added and if any antibodies are present,
an antibody-antigen complex is formed
 Unbound material is removed by washing
 The Ab-Ag complex is detected by adding an enzyme-
conjugated secondary antibody that binds to the primary
antibody.
 Washing step
 A substrate for the enzyme is added
 Coloured reaction product formed and absorbance is
measured
 Intensity of the colour of the solution is proportional to
the amount of antibody present
Indirect ELISA test
 Western Blotting
 Confirms HIV infection
 Proteins are separated by electrophoresis and transferred
to a nitrocellulose membrane by the passage of an electric
current
 The proteins are treated with antibodies
 Similar to ELISA technique, addition of secondary
antibodies with an enzyme attached allows the use of
colour to detect a particular protein
 A discrete protein band represents the specific antigen
that the antibody recognizes
 The bands from a positive Western blot are from
antibodies binding to specific proteins and glycoproteins
from the HIV virus
 The CDC recommends that the blot should be positive for
two of the p24, gp41 and gp120/160 markers (gp160 is the
precursor form of gp41 and gp120, the envelope protein)
Western blot
HIV Western blot
 Treatment of HIV
 Eradication of HIV infection not possible with currently
available drugs
 Viral replication can not be completely suppressed
 Latently infected CD4+ T cells established at early stage
 Goals of antiretroviral therapy are to:
- Suppress viral replication
- Restore and/or preserve immune function
- Improve quality of life
- Reduce HIV-associated morbidity and mortality
 Combinations of antiretroviral drugs are used
 Referred to as HAART (highly active antiretroviral
therapy)
 Suppress levels of plasma viraemia for long periods
 Plasma viraemia is a strong prognostic factor in HIV
infection
 Antiretroviral Drugs
 Significant declines in AIDS related morbidity and
mortality are seen as a result of HAART
 Several strategies for development of effective antiviral
drugs
 Potential therapies based on knowledge of the way in which
HIV gains access into the cells and its method of
replication
 Targets for therapeutic anti-retroviral drugs:

- Inhibiting reverse transcription

- Inhibiting proteases
- Inhibiting integrase – interferes with integration of viral
DNA into host genome
- Inhibiting fusion – prevents virus from fusing with host cell
 Inhibition of Viral Replication
 Inhibition of activity of reverse transcriptase (RT), an
enzyme responsible for viral RNA being reverse
transcribed to cDNA
 Example: Zidovudine or AZT (azidothymidine) – first
type of agent to be developed for treatment of HIV
infection
 AZT is an analogue of thymidine that competes with
natural nucleotides at the RT active site for
incorporation into DNA
 Introduction of AZT into a growing cDNA chain of the
retrovirus causes termination of the chain, yielding
inactive proviral DNA
 A different approach - drugs such as nevirapine and
delaviridine (non-nucleoside analogues) which inhibit the
action of the reverse transcriptase enzyme
Action of AZT
 Disadvantages:

 The administered AZT is used not only by the HIV-1 RT

but also by human DNA polymerase
 Incorporation of AZT into the DNA of the host cells kills
them
 Precursors of red blood cells especially sensitive to AZT,
results in anaemia and other side effects
 RT inhibitors have several disadvantages:
 Toxic
 Select for resistant viral variants quickly when used alone
 Lack of effect of cells already effected with HIV, which
no longer require RT to complete the viral replication
cycle
 Protease Inhibitors
 Prevent the assembly of new infectious viruses

 Inhibits activity of viral protease enzyme necessary to

cleave viral precursor proteins (gag proteins) into the p24
and p17 virion components, required for viral activity

 Disadvantages:

 Resistance appears after only a few days, single mutation

required
 In contrast, resistance to AZT takes months to develop as
it requires three or four mutations in the viral reverse
transcriptase
 Therapeutic Options

 Combination of RT inhibitors protease inhibitors

results in potent anti-viral activity

 In most cases, two nucleoside analogues and one

protease inhibitor are taken together

 HAART lowers plasma viral loads in many cases to

levels not detectable by current methods

 Has improved the health of AIDS patients to the

point that they can function at a normal level
Effect of Treatment on Viral Load