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No description available.

Polymorphism in the Human Leucocyte Antigen (HLA) region of chromosome is the major source of host genetic variability in outcome of HIV-1 infection. However, there is limited understanding of the mechanisms underlying the beneficial effect of protective class I alleles such as HLA-B57, B27 and B51. Taking advantage of a unique cohort (SM cohort) infected with clade B’ HIV-1 through contaminated blood, in which many variables, such as the length of infection, the infecting viral strain and host genetic background are controlled, we performed a comprehensive study in order to understand HLA-B51 associated HIV-1 control. We first focused on the T cell responses against three dominant HLA-B51 restricted epitopes: GagNI9 (NANPDCKTI), Pol TV8 (TAFTIPSV) and Pol LI9 (LPPVVAKEI), and HLA-B51 associated escape mutations in these three epitopes. A sequential selection of epitope mutations (i.e., epitope Pol LI9, Pol TV8 and Gag NI9) was observed. Good control of viral load and higher CD4+ counts were significantly associated with at least one detectable T cell response to un-mutated epitopes. HLA-B51 restricted CD8+ T-cell clones, generated from the patients, could effectively inhibit HIV-1 replication when wild type epitopes are properly processed and presented. We then assessed the evolution of escape mutations under the selecting pressure of HLA-B51 CTLs in vitro by co-culturing HLA-B51 CTL clones with HIV-1 infected target cells (Virus Evolution Assay). Our data showed that three dominant HLA-B51 restricted CTL responses have driven the sequential escape mutations within the epitopes, leading to the loss of viral control, which confirmed our in vivo findings. Furthermore, applying Virus Evolution Assay, we assessed the impact of antigen sensitivity and TCR usage as well as founder virus effect on HIV-1 evolution and control. Our data suggested that antigen sensitivity plays an important role in anti-viral efficacy of CTLs; the TCR usage of CTLs has stronger effect on virus evolution. More importantly, our study highlighted the major impact of the founder virus sequence on viral control. It has been shown that HIV-1 has adapted to the T-cell responses to epitope Pol TI8 in other HLA-B51+ patient cohorts. However, in our cohort, T-cell responses targeting this epitope, with Valine at position 8 (Pol TV8), provide the hosts with a long-term protection against HIV-1 infection, because of a fine balance of efficient viral control, lower level of immune pressure and the slower rate of development of escape mutations. In addition, we assessed the ex vivo phenotypic characteristics of HLA-B51 restricted dominant T cell responses and our preliminary data indicated that the early differentiated and less senescence phenotype of CD8+ T cell responses in HIV-1 chronic infection is likely to be a result of low viral antigen exposure due to T cell driven escape. In conclusion, immune-dominant T-cell responses targeting three HLA-B51 restricted epitopes (Pol LI9, Pol TV8 and Gag NI9) could be advantageous for the host. In particular, the responses against epitope Gag NI9 with slow development of escape mutations or epitope Pol TV8 with a fine balance of moderate immune pressure and delayed escape mutations, are beneficial for long-term control of HIV-1 infection.

Depuis 2013, le traitement « universel » est recommandé en France. Le moment de l’initiation thérapeutique est une question qui reste cependant d’actualité pour les patients se présentant en primo-infection. Cette thèse s’attache à étudier la prise en charge thérapeutique du VIH au stade de la primo-infection (PIV) sous différents angles :1) le suivi par les cliniciens des recommandations d’initiation des traitements antirétroviraux depuis 1996 en fonction de l’évolution de ces recommandations; 2) l’impact d’un traitement ARV transitoire en PIV sur la réponse immuno-virologique lors de la reprise du traitement et 3) l’identification de nouveaux biomarqueurs comme facteurs pronostiques de progression de l’infection VIH. La majorité des travaux présentés dans cette thèse repose sur les données de la cohorte ANRS PRIMO qui comporte environ 1 500 patients infectés par le VIH inclus en PIV entre juin 1996 et décembre 2013, dans 94 hôpitaux français. Tous les patients étaient naïfs de traitement antirétroviral à l'inclusion.La première partie de la thèse analyse la mise en œuvre des recommandations d’initiation du traitement ARV entre 1996 et 2010 par les médecins en France, dans deux situations distinctes : au stade chronique et lors de la primo-infection par le VIH-1. Nous avons montré que les recommandations d’initiation du traitement ARV étaient largement suivies. Néanmoins, il existe un effet d’inertie dans leurs applications lors des changements de recommandation. Il reste à améliorer le délai de mise sous traitement lorsque le taux de CD4 atteint le seuil recommandé. Au stade chronique, le traitement était plus fréquemment initié chez les patients présentant un critère d’initiation dès le diagnostic d’infection par le VIH (96%), que chez les patients qui atteignaient un critère d’initiation au cours du suivi (78%, p<0.001). Nous avons identifié comme facteurs de risque de ne pas être traité en phase chronique malgré une indication de traitement : une charge virale < 5log (versus >5), un plus faible niveau d’éducation et des conditions de vie précaires.L’impact de l’interruption d’un traitement antirétroviral initié en PIV sur la restauration des CD4 après reprise du traitement a été exploré en modélisant l’évolution des CD4 avec des modèles linéaires à effets mixtes avec intercept et pente aléatoires. Les patients qui avaient initié un traitement ARV pendant la phase chronique avaient une meilleure réponse immunologique que les patients reprenant un 2ème traitement après un traitement transitoire en PIV : à 36 mois, les gains en √CD4 cellules/mm3 et en pourcentage de CD4 étaient significativement plus élevés. Cependant, il s’agissait de différences modestes en termes cliniques, qui ne conduisent pas à recommander d’arrêter la recherche clinique sur les arrêts de traitement cherchant à induire des contrôleurs post traitement. Après un état des lieux des mécanismes complexes d’activation/inflammation du système immunitaire pendant la primo-infection nous avons cherché à identifier de nouveaux biomarqueurs prédictifs de l’évolution de l’infection. Le taux de sCD14 (marqueur d’activation monocyte/macrophage et marqueur indirect de translocation microbienne) au moment de la PIV a été identifié comme marqueur potentiel de prédiction du déclin des CD4 et du risque de mortalité d’origine cardio-vasculaire. En conclusion, bien que des progrès considérables aient été réalisés dans la prise en charge du VIH, d'autres études sont nécessaires pour optimiser et adapter le traitement au profil du patient dès les premiers stades de l’infection VIH. / In France, since 2013, HIV treatment has been recommended for all HIV-infected patients independently of their CD4 count. However, when to start anti-retroviral (ARV) treatment is still an issue. This thesis aims to explore the therapeutic management of HIV at the stage of PHI in different aspects: 1) we explored how physicians in France have applied the evolving guidelines for ART initiation since 1996 2) the impact of a transient ARV treatment at PHI on immuno-virological response during 2nd treatment and 3) identification of new biomarkers prognostic of HIV progression.Most of the work presented in this thesis is based on data from the ongoing ANRS PRIMO cohort that enrolled more than 1 500 HIV infected patients enrolled at PHI since June 1996 in 94 French hospitals. All patients were antiretroviral therapy naive at baseline.The first part of the thesis analyzes the implementation of the recommendations of ARV treatment initiation between 1996 and 2010 by physicians in France, in two distinct situations: in the chronic HIV-1 infection and during primary HIV-1 infection. We have shown that the recommendations of ARV treatment initiation were widely followed. Nevertheless, there was inertia in guidelines application when changes in the recommendations took place. The time to treatment when CD4 cell counts reach the threshold to treat can be improved. 96% of the patients initiated ART when they had a CD4 cell count below the threshold to treat at entry, while treatment was less timely initiated when the CD4 threshold was reached during active follow-up (78%, p <0.001).We identified as risk factors for not being timely treated in chronic phase despite an indication for treatment: a viral load <5log (versus> 5), a lower education level and poor living conditions.The impact of ARV interruption after a first treatment initiated at PHI on the CD4 count restoration after resumption was explored by modeling the evolution of CD4 cells with linear mixed effects models with random intercept and slope. Patients who initiated ARV treatment during the chronic phase had a better immune response than patients who initiated a second course treatment after a transient ART at PHI: at 36 months, the gains in √CD4 cells / mm3 and CD4 percentage were significantly higher. However, this difference was clinically modest and further research on treatment interruptions seeking to induce post-treatment controllers is still an issue but only in research settings and under close medical surveillance. After an overview of the complex mechanisms of activation / inflammation of the immune system during primary infection we sought to identify new predictive biomarkers of disease progression. The level of sCD14 (marker of monocyte/macrophage activation and an indirect marker of microbial translocation) at the time of PHI was identified as predictive marker of CD4 decline and of risk of cardio-vascular mortality. In conclusion, although considerable progress has been made in the management of HIV, further studies are needed to optimize and adapt the treatment to the patient profile in the early stages of HIV infection.