Transient HIV Viremia in a Brazilian Woman - A case of exposure but non-infection

Transient HIV Viremia in a Brazilian Woman - A case of exposure but non-infection | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 6 February 2025 V1 Latest version Share on Transient HIV Viremia in a Brazilian Woman - A case of exposure but non-infection Authors : Víctor Â. Folgosi [email protected] , Bosco Da Silva 0000-0002-3883-7178 , Luiz A. M. Fonseca , Claudio Gonsalez , Alberto J.S. Duarte , Shirley Komninakis , and Jorge Casseb Authors Info & Affiliations https://doi.org/10.22541/au.173882885.52029045/v1 347 views 167 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract We report the case of a 32-year-old woman from São Paulo, Brazil, who was exposed to HIV but did not acquire the infection. This case demonstrates unique immune control characterized by transient viremia and the absence of seroconversion over a 10-year follow-up period. Genetic analysis revealed protective HLA alleles, a robust IFN-γ response to p24/Nef peptides, persistently high CD4+ T cell counts, and normal immune responses to other pathogens (e.g., Hepatitis A, CMV). These findings suggest that the inability to establish persistent HIV infection may be linked to the interaction of multiple factors, including a potent and sustained CD4+ T cell and cytotoxic response. Transient HIV Viremia in a Brazilian Woman - A case of exposure but non-infection Víctor Â. Folgosi*; Bosco C. M. da Silva*; Luiz A. M. Fonseca; Claudio R. Gonsalez; Alberto J.S. Duarte; Shirley V. Komninakis** and Jorge Casseb** 1 Laboratório de Investigação Médica LIM-56/HIV out-Clinic - ADEE3002 - Divisão de Dermatologia, Faculdade de Medicina da Universidade de São Paulo. ZIP code: 05403-000; São Paulo, SP, Brasil. *Both contributed equally **Both were senior authors Running title: Woman with HIV Transient Viremia Corresponding Author: Jorge Casseb, Departamento de Dermatologia/Faculdade de Medicina da Universidade de São Paulo; [email protected] Alternative corresponding author: Víctor Ângelo Folgosi, Departamento de Dermatologia/Faculdade de Medicina da Universidade de São Paulo; [email protected] ———————————————————————————————————- Co-authors’ email addresses Bosco C. M. da Silva: [email protected] Luiz A. M. Fonseca: [email protected] Claudio R. Gonsalez: [email protected] Alberto J.S. Duarte: [email protected] Shirley V. Komninakis: [email protected] Abstract We report the case of a 32-year-old woman from São Paulo, Brazil, who was exposed to HIV but did not acquire the infection. This case demonstrates unique immune control characterized by transient viremia and the absence of seroconversion over a 10-year follow-up period. Genetic analysis revealed protective HLA alleles, a robust IFN-γ response to p24/Nef peptides, persistently high CD4+ T cell counts, and normal immune responses to other pathogens (e.g., Hepatitis A, CMV). These findings suggest that the inability to establish persistent HIV infection may be linked to the interaction of multiple factors, including a potent and sustained CD4+ T cell and cytotoxic response. Keywords: HIV-1, Transient HIV, Viremia, Brazil, Subtype B. Case Presentation and Discussion In 2003, a 32-year-old woman from São Paulo, Brazil, was referred for evaluation following potential heterosexual exposure to HIV. She reported no significant risk factors for HIV acquisition, except for a sexual partner who may have died of AIDS. Initial HIV antibody tests (EIA) and the first molecular test were negative. However, during follow-up, a molecular test detected a viral load (VL) of 15,600 copies/mL, suggesting early HIV replication. Despite this, serological tests remained negative until 2017, nearly four years after her last follow-up visit. The patient was monitored longitudinally for approximately 10 years (2003–2013). Due to her consistently high CD4+ cell count (always above 1,500 cells/mm³), controlled VL, and absence of symptoms, she was included in a study and followed without antiretroviral therapy (ART) [1]. The last detectable VL occurred in 2007. Table 1 summarizes the laboratory results during follow-up. Date CD3 % CD3 CD4 % CD4 CD8 % CD8 CD45 CD4/CD8 ratio RNA HIV load (Copies/mL) RNA HIV Load (Log) 12/06/2003 2222 66 1700 50,5 481 14,3 3366 3,53 - - 04/03/2004 2039 77,1 2141 54,3 804 20,4 - 2,66 15600 4,193 14/10/2004 2434 76 1730 54 644 20,1 - 2,69 <400 - 09/05/2005 2364 74,3 1690 53,1 620 19,5 - 2,72 <400 - 04/07/2005 2926 76,2 2147 55,9 749 19,5 - 2,87 2080 3,318 27/04/2006 2572 72,9 1891 53,6 607 17,2 3528 3,12 <400 - 23/11/2006 2525 78,2 1837 56,9 617 19,1 3229 2,98 <400 - 05/09/2007 2959 73,6 2195 54,6 700 17,4 - 3,14 98 1,991 19/03/2009 2875 73 2141 54,4 356 9 3937 6,01 <50 - 07/12/2009 2357 70 1702 50,6 606 18 3365 2,81 <50 - 18/06/2012 2090 68,6 1506 49,4 535 17,6 3047 2,81 <50 - 26/03/2013 2267 – 1613 52 626 21 3117 2,58 <50 - Table 1 . Long term T cell counts and HIV plasma viral load (VL). Legend : HIV RNA was detected using the HIV 3.0 RNA method (2003–2006) and quantified using the b-DNA method (2007–2013), both with Bayer/Siemens kits. Interestingly, longitudinal follow-up revealed a positive correlation between CD4+ T cell counts and VL fluctuations [Figure 1]. This contrasts with the typical course of HIV infection, where VL and CD4+ counts usually show an inverse relationship [2]. While similar dynamics are observed in elite controllers—individuals who maintain undetectable or low VLs without ART—our case suggests a distinct immune mechanism capable of sustaining CD4+ cells despite significant viral replication. Figure 1. Variation in CD4+ T cell counts and plasma viral load from 2003 to 2013. Legend: The orange line represents CD4+ T cell counts, while the grey dashed line represents the viral load on a logarithmic scale. The red line indicates the cut-off values for undetectable viral load (<400 copies/mL from 2003–2006 and On June 12, 2003, the levels of immunoglobulins IgG, IgA, IgM, and IgE were within reference values: IgG at 1303 mg/dL, IgA at 253 mg/dL, IgM at 138 mg/dL, and IgE at 787 IU/mL. Apolipoprotein B levels were 80 mg/dL. On September 23, 2004, slight variations in IgA and IgM were noted. She had antibodies for human cytomegalovirus (IgG 167,800 UA/mL) and toxoplasmosis (IgG 44.50 IU/mL) and her tests for hepatitis B, hepatitis C, and IgM antibodies for hepatitis A were negative, with beta-2-microglobulin at 1.2 µg/mL. These findings indicate prior exposure to cytomegalovirus and toxoplasmosis, with no evidence of significant immune dysregulation, impaired antibody production or any antigen presentation impairment. In addition, conventional PCR was performed on cDNA and DNA from the 2013 sample, targeting the HIV RT (Reverse Transcriptase) and PR (Protease) genes using a three-primer strategy, with pNL4-3 as the positive control. The PCR analysis revealed a weak band for the cDNA, while no amplification was obtained for the DNA. Subsequently, Sanger-based sequencing was performed on the weak band using eight primers; however, the electropherogram displayed a pattern indicating the absence of an amplicon. PCR from DNA was repeated using primers flanking the HIV PR gene, but the result was negative. HIV proviral DNA quantification, as described by Kumar et al. (2007) , was also performed, yielding undetectable levels, with a limit of detection of 1 copy per 1x10 6 CCR5 genomic equivalents [4]. Figure 2 . Agarose gel showing conventional PCR products amplified from cDNA and DNA of the 2013 sample. Legend: The K1/K2 and DP10/F2 primers (Protease) were used (RT). Lanes represent PCR products from a sample of 2013 (5417), positive control (c+; pNL4-3), and negative control (c-; no DNA/cDNA). Genotypic analysis provided deeper understanding into the immunological profile, revealing the alleles HLA-B44, HLA-B45, HLA-A23, HLA-A24, HLA-C04, and HLA-C16, along with wild-type CCR5 (CCR5-WT). Notably, the HLA-B44 allele has been consistently associated with better clinical outcomes in PLHIV, including higher CD4+ T-cell counts and improved VL control [5,6], similar to what was observed in this case. Additionally, HLA-B44 is linked to robust cytotoxic T lymphocyte (CTL) responses [7] and a potential inverse correlation between VL and the amplitude of CTL responses against p24 capacity [5]. To investigate the relationship between CTL response and the immunological profile of this woman, we performed an ELISPOT assay using various viral epitopes (data not shown). The assay showed significant IFN-γ production directed at both the p24 and Nef epitopes only, indicating robust activation of CTL specific to these antigens. These results, supported by the correlation between the HLA-B44 allele and CTL [5,6], particularly in the presentation of the p24 epitope, suggest that the ability to present Nef fragments may also contribute to the amplification of this response, playing a key role in the more effective control of viral replication [ Figure 3 ]. Figure 3. Gamma interferon production quantified by ELISPOT stimulated by HIV epitopes. Legend: The graph shows the number of spots (ELISPOT) for a set of epitopes stimulated: p24 (655 spots), Nef (505 spots), RT-1 (pool 1) (100 spots), and RT2 (pool 2) (100 spots). There was no immune response to the other regions of HIV. It is important to note that although a specific CTL response to p24 has been associated with improved clinical outcomes, IFN-γ production is also associated with the activation of T helper 1 (Th1) and NK cells. The response of these cells to specific regions of p24, combined with the immunogenetic profile described here, appears to mirror findings previously reported in women from the Nairobi cohort in Kenya, who were highly exposed to HIV-1 infection but remained seronegative for HIV [8]. This phenomenon is consistent with our case, in which these women may have had sexual life long exposure to several infectious agents, including HIV antigens [9]. In addition to HLA-B44, the HLA-C04 and HLA-C16 alleles may also contribute to viral control by enhancing interactions with killer-cell immunoglobulin-like receptors (KIR), which serve as an additional defense mechanism against infection. HLA-C molecules, including C04 and C16, are known to positively regulate NK cell activity against HIV and are associated with the maintenance of CD4+ T cell counts and viral load (VL) control [10]. A similar case was reported in the ANRS EPF-CO10 pediatric cohort, where a child achieved sustained viral remission after discontinuing ART. This child carried alleles similar to those found in our case, including HLA-C subtypes and HLA-A2301, a subgroup of HLA-A23 [11]. Although not conclusive, these findings suggest that such alleles may also be associated with efficient viral control and potentially with resistance to HIV infection. Regarding CCR5 receptors, the presence of CCR5-WT (wild-type) indicates the absence of the CCR5-Δ32 mutation, which naturally protects against HIV by preventing the expression of the CCR5 receptor on the cell surface, thereby blocking viral entry [12]. In individuals with CCR5-WT, like in this case, the receptor is fully functional, meaning they lack intrinsic protection against HIV. However, susceptibility to HIV infection in these individuals can vary depending on factors such as CCR5 expression levels, the activation state of CD4+ T cells, and regulatory mechanisms involving KLF2. Higher levels of KLF2 expression can limit CCR5 expression, thereby reducing the likelihood of HIV infection [13]. Another significant observation related to HIV receptor interactions was the identification of a mutation in the central hypervariable region of the V3 loop of gp120, corresponding to the GWGR motif. This substitution is characteristic of HIV-1 subtype B [14]. The presence of basic amino acids at positions 312 and 314 plays a crucial role in determining coreceptor usage, particularly in the shift from CCR5 to CXCR4. Variants carrying the GWGR motif exclusively utilize CCR5, a feature typically associated with slower progression to AIDS [15]. Additionally, this motif is linked to a higher affinity for neutralizing antibodies targeting the V3 region, potentially enhancing the immune system’s ability to recognize and eliminate infected cells [16]. Conclusion This study describes the case of a 32-year-old woman who demonstrated an exceptionally effective immune response, preventing the establishment of persistent HIV infection over a decade despite documented episodes of transient viremia and the absence of seroconversion - a rare and poorly understood phenomenon. Immunogenetic analysis revealed protective HLA alleles, such as HLA-B44, HLA-C04, and HLA-C16, associated with improved clinical outcomes in HIV infection. These alleles may facilitate immune control, potentially playing a role in preventing viral persistence rather than actively combating it. Robust cytotoxic T cell (CTL) responses, particularly against p24 and Nef epitopes, alongside sustained high CD4+ T cell counts, suggest a potent and coordinated immune defense mechanism. The involvement of Th1 and NK cell responses further highlights the complexity of this immune profile, which is also protective. However, while these immunogenetic and immunological factors provide insights into the potential mechanisms of transient viremia and non-infection, the precise mechanisms underlying this phenomenon remain incompletely understood. This case underscores the importance of further research into immune-mediated protection against HIV, which may inform novel strategies for prevention and therapeutic interventions. Acknowledgments We appreciate the technical assistance provided by Mariana A. Monteiro, and Eduardo Martins. Thanks go to Patrícia N. Pereira, Franciane P. Oliveira, Aline S. R. Sobrinho, Rafael A. B. Schmidt, and Ricardo S. Diaz, from the Retrovirology Laboratory at UNIFESP, for their contributions to the development of molecular tests. Funding This study received support from the Department of Surveillance, Prevention, and Control of STIs, HIV/AIDS and Viral Hepatitis of the Ministry of Health of Brazil, grant 749396/2010, and the São Paulo Research Foundation (FAPESP), grants 2013/06584-4, 2014/22827-7 and 2023/14320-9, and CNPq: 301372/2013-6. Ethical considerations: The study protocol was approved by the Ethical Board of the Faculty of Medicine, University of São Paulo, Brazil (CAAE Nº 05749912.6.0000.0068). Conflict of interest: All authors declare no conflict of interest Availability of data and materials : The data and supportive information available under request. Author contributions: Victor Â. Folgosi and Bosco C. M. da Silva contributed equally to this work, designing the study, analyzing data, and drafting the initial manuscript. Luiz A. M. Fonseca, Claudio R. Gonsalez and Alberto J. S. Duarte participated in sample and document collection and critically reviewed the manuscript. Shirley V. Komninakis supervised the experimental phase, assisted in the interpretation of results and performed the final manuscript revision. Jorge Casseb supervised all stages of the study, including project conception, final data analysis, and preparation of the final manuscript, ensuring its scientific accuracy. References 1. Mantovani, N., Defelicibus, A., da Silva, I. T. et al. Latency-associated DNA methylation patterns among HIV-1 infected individuals with distinct disease progression courses or antiretroviral virologic response. Sci. Rep. 11 , 22993 (2021). 2. Vidya Vijayan, K. K., Karthigeyan, K. P., Tripathi, S. P. & Hanna, L. E. Pathophysiology of CD4+ T-cell depletion in HIV-1 and HIV-2 infections. Front. Immunol. 8 , 580 (2017). 3. Walker, B. D. & Yu, X. G. Unravelling the mechanisms of durable control of HIV-1. Nat. Rev. Immunol. 13 , 487–498 (2013). 4. Kumar, A. 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Molecular and structural characterization of HIV-1 subtype B Brazilian isolates with GWGR tetramer at the tip of the V3-loop. Virology 381 , 222–229 (2008). 16. Casseb, J., Montanheiro, P., Komninakis, S., Brito, A. & Duarte, A. J. Human immunodeficiency virus type 1 Brazilian subtype B variant showed an increasing avidity of the anti-V3 antibodies over time compared to the subtype B US/European strain in São Paulo, Brazil. Mem. Inst. Oswaldo Cruz 99 , (2004). Information & Authors Information Version history V1 Version 1 06 February 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords cell-mediated immunity human immunodeficiency virus immune responses immune system pathogenesis virus classification Authors Affiliations Víctor Â. Folgosi [email protected] Universidade de Sao Paulo Laboratorios de Investigacao Medica View all articles by this author Bosco Da Silva 0000-0002-3883-7178 Universidade de Sao Paulo Laboratorios de Investigacao Medica View all articles by this author Luiz A. M. Fonseca Universidade de Sao Paulo Laboratorios de Investigacao Medica View all articles by this author Claudio Gonsalez Universidade de Sao Paulo Laboratorios de Investigacao Medica View all articles by this author Alberto J.S. Duarte Universidade de Sao Paulo Laboratorios de Investigacao Medica View all articles by this author Shirley Komninakis Universidade de Sao Paulo Laboratorios de Investigacao Medica View all articles by this author Jorge Casseb Universidade de Sao Paulo Laboratorios de Investigacao Medica View all articles by this author Metrics & Citations Metrics Article Usage 347 views 167 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Víctor Â. Folgosi, Bosco Da Silva, Luiz A. M. 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