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Billions of cells die everyday as a result of normal tissue turnover, infection, trauma or injury. These dead cells are taken up, processed and presented to T cells by antigen presenting cells resulting in tolerance or immunity. Apoptotic cells induce tolerance; however, the precise mechanisms are still unknown. Previous studies have shown that direct infusion of apoptotic cells induce tolerance mediated by TRAIL-expressing CD8+ T cells. We hypothesized that immunologic tolerance induced by apoptotic cells is dependent on the activation status of apoptotic cells and mediated by direct killing of target cells by TRAIL-expressing CD8+ T cells. Three different experimental systems were used to elucidate the mechanisms by which apoptotic cells regulate immune responses. Using a classical system of tolerance induction, we examined the immunological consequence of intravenous (i.v.) delivery of ex vivo-generated naïve or activated apoptotic cells. Naïve apoptotic cells induced tolerance when injected i.v.; however, previously activated apoptotic cells induced immunity. Further analysis revealed a key role for CD154 in the tolerogenic or immunogenic nature of the naïve or activated apoptotic cells, respectively, as tolerance resulted after i.v. injection of either naïve or activated apoptotic CD154-/- cells, while co-injection of an agonistic anti-CD40 mAb with naïve apoptotic T cells induced robust immunity. The infusion of large numbers of apoptotic cells has limited physiological relevance, so the investigation of the influence of apoptotic cells on the immune system turned to another experimental tolerance model where soluble peptide antigen is injected systemically to induce the peripheral deletion of a population of antigen-specific T cells. Using this system, we investigated how apoptotic cells generated in vivo leads to T cell tolerance. Following adoptive transfer of OT-II cells, wild-type mice injected with soluble OVA323-339 became unresponsive to subsequent CFA/OVA immunization. Interestingly, Trail-/- or Dr5-/- mice developed robust immunity; even though all strains displayed peripheral deletion of OVA-specific T cells. Subsequent investigation found the mechanism of action of the CD8+ T cells was TRAIL-mediated deletion of the OVA-responsive T cells in a TCR-specific manner. The experimental systems used above have some clinical relevance but are still not physiologic. To study the impact of apoptotic cells in a physiologic setting, we took advantage of the medical condition sepsis, which is accompanied by massive apoptosis of multiple immune cell populations. Thus, the final set of experiments in this thesis examined the tolerance induced during sepsis using a clinically-relevant cecal-ligation and puncture (CLP) model that included a secondary bacterial infection. CLP-treated WT mice had a reduced ability to control the secondary bacterial infection, which was paralleled by suppressed T cell responses, compared to sham-treated WT mice. In contrast, CLP- and sham-treated Trail-/- and Dr5-/- mice were able to similarly control the bacterial infection and generated bacterial antigen-specific T cell responses. The ability of CLP-treated wild-type mice to control the secondary infection and generate T cell immunity could be restored by the administration of a blocking anti-TRAIL mAb. These results suggest the importance of TRAIL in the induction of sepsis-induced immune suppression, such that TRAIL neutralization may be a potential therapeutic target to restore cellular immunity in septic patients.

T follicular helper cells (T-FH) are a specialized subset of CD4 T cells that reside in B cell follicles and promote B cell maturation into plasma cells and long-lived memory B cells. During chronic infection prior to the development of AIDS, HIV-1 (HIV) replication is largely concentrated in T-FH. Paradoxically, T-FH numbers are increased in early and midstages of disease, thereby promoting HIV replication and disease progression. Despite increased T-FH numbers, numerous defects in humoral immunity are detected in HIV-infected individuals, including dysregulation of B cell maturation, impaired somatic hypermutation, and low quality of antibody production despite hypergammaglobulinemia. Clinically, these defects are manifested by increased vulnerability to bacterial infections and impaired vaccine responses, neither of which is fully reversed by antiretroviral therapy (ART). Deficits in T-FH function, including reduced HIV-specific IL-21 production and low levels of co-stimulatory receptor expression, have been linked to these immune impairments. Impairments in T-FH likely contribute as well to the ability of HIV to persist and evade humoral immunity, particularly the inability to develop broadly neutralizing antibodies. In addition to direct infection of T-FH, other mechanisms that have been linked to T-FH deficits in HIV infection include upregulation of PD-L1 on germinal center B cells and augmented follicular regulatory T cell responses. Challenges to development of strategies to enhance T-FH function in HIV infection include lack of an established phenotype for memory T-FH as well as limited understanding of the relationship between peripheral T-FH and lymphoid tissue T-FH. Interventions to augment T-FH function in HIV-infected individuals could enhance immune reconstitution during ART and potentially augment cure strategies.

Autoimmunity develops over an extended period of time as the result of an amalgamation of genetic, environmental, and immunologic events. Though the precise etiological factors leading to most autoimmune disease are awaiting consensus, a common thread of the autoimmune paradigm is the inappropriate activation of tissue-specific immune cells by one or more autoantigen, which begins the destruction of the tissue. To prohibit immunopathology and fine-tune the immune responses in healthy individuals, the stimulatory activities of effector/memory T (Teffs) cells must be counteracted by the suppressive mechanisms of regulatory T cells (Tregs). Thus, the potential to modulate the ratio between Teff and Tregs in autoimmune patients has been widely investigated with high hopes to permanently cure certain autoimmune diseases such as type 1 diabetes militus (T1D). Autoantigen therapies, which attempt to induce Tregs to suppress pathogenic effector cells in an autoantigen-specific manner, have shown efficacy in preventing T1D in mice, but have largely failed in clinical trials. One approach to improve the effectiveness of islet autoantigen vaccinations is to combine them with an additional modulator of the T cell response which favors a regulatory phenotype. In the work presented here, we asked whether the addition of anti-interleukin-7 receptor-alpha (anti-IL-7Rα) monoclonal antibodies (mAbs) to islet autoantigen immunizations would modulate the T cell response and prevent T1D in non-obese diabetic (NOD) mice. It was found that anti-IL-7Rα mAbs reduced the absolute numbers of islet antigen-specific T cells when immunized with islet peptide in conjunction with the commonly used vaccine adjuvant alum. Such treatments were also observed to increase nonspecific IL-2, IFN-𝛾, and IL-10 cytokine production, resulting in no improvement of T1D onset prevention. In another approach, we generated a conjugate vaccine by conjugating islet autoantigens to the immunogenic carrier protein, Keyhole Limpet Hemocyanin (KLH). We found that islet antigen-KLH (Ag-KLH) vaccination resulted in significant expansion of the desirable antigen-specific Tregs. Further, Ag-KLH immunization successfully delayed, and in some cases entirely prevented, T1D onset in NOD mice. Indicating that KLH-conjugated vaccine may represent a promising approach for future autoantigen therapies against autoimmunity. Interestingly, administration of anti-IL-7Rα mAbs did not improve these outcomes. To the contrary, we again observed excessive nonspecific cytokine production induced by IL-7Rα blockade that inhibited the beneficial effects of Ag-KLH vaccination. Taken together, we concluded that the addition of anti-IL-7Rα mAbs did not improve the efficacy of autoantigen vaccinations to prevent T1D. Significant work still remains to better characterize and isolate the beneficial effects of anti-IL-7Rα mAbs to treat autoimmunity.

As células T regulatórias (Tregs) suprimem a população de células T efetoras e podem capacitar células tumorais a evadir a resposta imune do hospedeiro. Além disso, estas células têm sido correlacionadas com angiogênese em alguns tipos de câncer. O objetivo deste estudo foi avaliar a frequência de células Tregs e sua correlação com angiogênese em carcinomas espinocelulares (CEC) de boca. Amostras de um total de 61 pacientes com CEC de boca, localizados no lábio e na língua e assoalho bucal obtidos dos Departamentos de Patologia dos Hospitais de Base e Estadual da cidade de Bauru, São Paulo, Brasil, no período de 2005 a 2012 foram analisados quanto às características clínicas e demográficas. Avaliou-se também, o índice histopatológico de malignidade e a expressão imunoistoquímica de células Tregs (FOXP-3), densidade microvascular intratumoral (MVD) e VEGF-A. A associação da marcação do anticorpo anti-FOXP-3 e as variáveis clínicas e microscópicas foram avaliadas através do teste qui quadrado. A análise estatística da expressão dos marcadores entre CECs de lábio e CECs de Língua e assoalho bucal foi realizada através do teste t. As correlações entre a frequência de células Treg e MVD, células Tregs e VEGF-A, foram obtidas através do coeficiente de correlação de Pearson, bem como a correlação entre MVD e VEGF-A. Não houve associação da expressão de FOXP-3 com as características clínicas, demográficas e índice de malignidade tumoral. Foram observados valores similares da frequência de células Tregs, índices de MVD e expressão de VEGF-A em CECs de lábio e CECs de língua e assoalho bucal. Uma correlação positiva entre a frequência de células Tregs e a MVD foi observada, embora não estatisticamente significativa (P-valor=0,682). Além disso, uma correlação positiva estatisticamente significativa foi detectada entre a frequência de células Tregs e a expressão de VEGF-A (P-valor=0,029). Não foi observada correlação entre a MVD e a expressão de VEGF-A. Estes resultados sugerem que embora exista uma associação entre a frequência de células Tregs e a angiogênese em CECs de boca, a expressão de FOXP-3 parece não estar associada ao desenvolvimento tumoral. / Regulatory T (Treg) cells suppress effector T-cell populations and can enable tumor cells to evade the host immune response. Moreover, Tregs cells have been correlated with angiogenesis in certain types of cancers. The aim of this study was to evaluate the frequency of Treg cells and its correlation with angiogenesis in oral squamous cell carcinomas (OSCC), as well as its implication on growth and tumor aggressiveness. Samples from a total of 61 patients with OSCC, located on the lip and tongue and floor of the mouth were analyzed for clinical and demographic characteristics. The histopathological malignancy index and immunoexpression of Treg cells (FOXP-3), IMD (CD105) and VEGF-A were also evaluated. The association of FOXP-3 expression and the clinical and microscopic changes were evaluated using the chi square test. Statistical analysis of the expression of markers between SCCs lip and SCCs of the tongue and floor of the mouth was performed using the t test. Pearsons rank correlation was performed to evaluate the correlation between the frequencies of both, Tregs cells and VEGF-A expression and Tregs cells and IMD determinations, as well as between VEGF-A expression and IMD values. There was no association of FOXP-3 expression with clinical and demographic characteristics, and tumor malignancy index. Similar values were observed for the frequency of Treg cells, IMD values and VEGF-A expression in OSCCs of the lip and tongue and floor of mouth. A positive correlation between FOXP-3 expression with IMD values was also detected, however, statistically that was non-significant (P-value=0.682). Furthermore, a significant positive correlation was observed between the frequency of tumor-infiltrating Tregs with VEGF-A expression (P-value=0.029). No correlation was observed between IMD values and with VEGF-A expression. These results suggest that although there is an association between the frequency of Treg cells and angiogenesis in OSCC, FOXP-3 expression was not associated with increased tumor aggressiveness.

As células T regulatórias (Tregs) suprimem a população de células T efetoras e podem capacitar células tumorais a evadir a resposta imune do hospedeiro. Além disso, estas células têm sido correlacionadas com angiogênese em alguns tipos de câncer. O objetivo deste estudo foi avaliar a frequência de células Tregs e sua correlação com angiogênese em carcinomas espinocelulares (CEC) de boca. Amostras de um total de 61 pacientes com CEC de boca, localizados no lábio e na língua e assoalho bucal obtidos dos Departamentos de Patologia dos Hospitais de Base e Estadual da cidade de Bauru, São Paulo, Brasil, no período de 2005 a 2012 foram analisados quanto às características clínicas e demográficas. Avaliou-se também, o índice histopatológico de malignidade e a expressão imunoistoquímica de células Tregs (FOXP-3), densidade microvascular intratumoral (MVD) e VEGF-A. A associação da marcação do anticorpo anti-FOXP-3 e as variáveis clínicas e microscópicas foram avaliadas através do teste qui quadrado. A análise estatística da expressão dos marcadores entre CECs de lábio e CECs de Língua e assoalho bucal foi realizada através do teste t. As correlações entre a frequência de células Treg e MVD, células Tregs e VEGF-A, foram obtidas através do coeficiente de correlação de Pearson, bem como a correlação entre MVD e VEGF-A. Não houve associação da expressão de FOXP-3 com as características clínicas, demográficas e índice de malignidade tumoral. Foram observados valores similares da frequência de células Tregs, índices de MVD e expressão de VEGF-A em CECs de lábio e CECs de língua e assoalho bucal. Uma correlação positiva entre a frequência de células Tregs e a MVD foi observada, embora não estatisticamente significativa (P-valor=0,682). Além disso, uma correlação positiva estatisticamente significativa foi detectada entre a frequência de células Tregs e a expressão de VEGF-A (P-valor=0,029). Não foi observada correlação entre a MVD e a expressão de VEGF-A. Estes resultados sugerem que embora exista uma associação entre a frequência de células Tregs e a angiogênese em CECs de boca, a expressão de FOXP-3 parece não estar associada ao desenvolvimento tumoral. / Regulatory T (Treg) cells suppress effector T-cell populations and can enable tumor cells to evade the host immune response. Moreover, Tregs cells have been correlated with angiogenesis in certain types of cancers. The aim of this study was to evaluate the frequency of Treg cells and its correlation with angiogenesis in oral squamous cell carcinomas (OSCC), as well as its implication on growth and tumor aggressiveness. Samples from a total of 61 patients with OSCC, located on the lip and tongue and floor of the mouth were analyzed for clinical and demographic characteristics. The histopathological malignancy index and immunoexpression of Treg cells (FOXP-3), IMD (CD105) and VEGF-A were also evaluated. The association of FOXP-3 expression and the clinical and microscopic changes were evaluated using the chi square test. Statistical analysis of the expression of markers between SCCs lip and SCCs of the tongue and floor of the mouth was performed using the t test. Pearsons rank correlation was performed to evaluate the correlation between the frequencies of both, Tregs cells and VEGF-A expression and Tregs cells and IMD determinations, as well as between VEGF-A expression and IMD values. There was no association of FOXP-3 expression with clinical and demographic characteristics, and tumor malignancy index. Similar values were observed for the frequency of Treg cells, IMD values and VEGF-A expression in OSCCs of the lip and tongue and floor of mouth. A positive correlation between FOXP-3 expression with IMD values was also detected, however, statistically that was non-significant (P-value=0.682). Furthermore, a significant positive correlation was observed between the frequency of tumor-infiltrating Tregs with VEGF-A expression (P-value=0.029). No correlation was observed between IMD values and with VEGF-A expression. These results suggest that although there is an association between the frequency of Treg cells and angiogenesis in OSCC, FOXP-3 expression was not associated with increased tumor aggressiveness.

Germinal center (GC) reactions are central features of T cell-driven B cell responses, and the site where antibody (Ab) producing cells and memory B cells are generated. Within GCs, a range of complex cellular and molecular events occur which are critical for the generation of high affinity Abs. These processes require exquisite regulation not only to ensure the production of desired Abs, but to minimize unwanted autoreactive or low affinity Abs. To assess whether T regulatory cells (Treg) participate in the control of GC responses, immunized mice were treated with either an anti-glucocorticoid-induced TNFR-related protein (GITR) mAb or an anti-CD25 mAb to disrupt Treg activity. In both groups of treated mice, the GC B cell pool was significantly larger compared with control treated animals, with switched GC B cells composing an abnormally high proportion of the response. With these results indicating Tregs influence on GC dynamics, experiments were conducted to determine if Tregs were located in the GC, which subset of Treg was involved and by which mechanisms were their functions being effected. Within the spleens of immunized mice, CXCR5+ and CCR7- Tregs were documented by flow cytometry and Foxp3+ cells were found within GCs using immunohistology. Studies demonstrated administration of either anti-TGF-β or anti-IL-10R blocking mAb to likewise result in dysregulated GCs, suggesting that generation of inducible Tregs is important in controlling the GC response. Blockade of two Treg methods of suppression, PD-1/PD-L1 pathway and CTLA-4, also resulted in disrupted GCs, indicating the possible use of them for suppression by Treg. Collectively, these findings indicate that Tregs contribute to the overall size and quality of the humoral response by controlling homeostasis within GCs.

Toll-like receptors (TLRs) recognize microbial components as danger signals and induce immune responses. TLR’s are expressed in many tissues of the host that are involved in immune responses including the intestines where they are abundantly expressed. This situation presents a challenge in the gastrointestinal tract which is constantly exposed to a wide variety of commensal organisms. Therefore, innate immune recognition in the intestine must be tightly regulated to prevent unwanted inflammation against harmless commensal micro-organisms and yet allow for the induction of protective immunity to invading pathogens. A dysregulation of this balance can result in intestinal inflammation. Peyer’s patches (PP) are the primary site for the induction of immune responses in the intestine and abundantly express TLRs. It is not known how PP regulate microbial signals from commensal bacteria and yet mount vigorous immune responses against dangerous pathogens. CpG DNA, an agonist for TLR9, can strongly activate immune cells in blood, lymph nodes and spleen. However, CpG very poorly activates immune cells from Peyer’s patches, although these cells express TLR9 [1, 2]. Understanding how TLR responses are regulated in PP cells will unveil important information on how immune responses are regulated in the intestine. Investigations from our laboratory have revealed a B cell population (CD5-CD11c-CD21+) in PP that spontaneously secrete high levels of IL-10 which in turn down regulates TLR9 induced IFN and IL-12 production. These IL-10-secreting PP B cells represent a novel subset of the recently proposed regulatory B cells (Bregs) in the intestine [1, 3]. Bregs may have a role in maintaining tolerance to commensal bacteria thereby achieving intestinal homeostasis. The overall goal of the work described in this thesis was to improve our understanding of the immunobiology of Bregs. We performed several experiments to achieve this goal. First, we studied the development of regulatory B cells in lambs of different ages. Jejunal PP were collected from 3-4 month old, neonatal and fetal lambs and the production of IL-10 (the immunoregulatory cytokine secreted by Bregs) was assayed. We found that IL-10 was secreted by CD21+ B cells from the PP in all the three age groups, confirming that Bregs develop prior to birth. We then wondered whether our CD21+ B cells might be contaminated with other cells or activated when using MACS to enrich B cells. To address this issue, we prepared very highly purified CD21+ B cell population using high speed cell sorting to negatively enrich for B cells. We also sorted DCs and assayed IL-10 production in both cell populations. Only the PP B cells spontaneously secreted IL-10. In contrast, dendritic cells, T cells, macrophages, neutrophils and NK cells did not secrete detectable IL-10. Since B cells exist as regulatory and effector populations in mice, we wondered whether an effector B cell population also existed in ovine PP that secreted the pro-inflammatory cytokines IFN-, IFN- and IL-12. Therefore, ovine PP B cells were fractionated into CD72+CD21+and CD72+CD21- subpopulations to assess their capacity to secrete pro-inflammatory cytokines. Interestingly, the CD72+CD21- B cell population secreted the cytokines IFN-, IFN- and IL-12 suggesting there was an effector population. We then surveyed for Bregs in different mucosal and peripheral tissues in sheep. We observed the Bregs frequency varied among the different lymphoid tissues. Finally, we investigated whether Bregs were present in PP of other ruminant species. We identified Bregs exist in PP of neonatal calves. In conclusion, our investigations reveal that ovine Bregs develop in utero prior to antigen exposure, and are present in a variety of mucosal and peripheral tissues. We also report the novel observation that two distinct B cell sub-populations are present in ovine jejunal PP’s: Regulatory and effector B cells.

Dendritic cells (DC) are potent antigen presenting cells involved in the initiation of the alloimmune response and organ transplant rejection. This thesis, has investigated pharmacological and genetic approaches to manipulate DC in order to generate tolerogenic DC which elicit poor allostimulatory activity as potential cell therapy agents to treat allograft rejection. In the first aspect of this study, human monocyte-derived DC were used to study the influence of Rapamycin (RAPA) on DC phenotype and function. This study showed that RAPA when added to monocytes prior to DC differentiation or after DC maturation generated tolerogenic DC as evidenced by the ability of these cells to induce T cell hyporesponsiveness. However, T cell hyporesponsiveness was associated with downregulation of costimulatory molecules only when added prior to differentiation and surprisingly was not influenced by the induction of CD4 ⁺FoxP3 ⁺ T cells. To assess the effects of RAPA on DC function in the transplant setting an in vivo chimeric model of ovine vascularised skin allograft transplantation was established in immunocompromised NOD/SCID mice as a host. This model was established as a preliminary model to acquire in vivo data prior to testing the effect of pharmacologically modified DC in the preclinical ovine model of renal allograft transplantation, also established in the host laboratory. Firstly, comparison of ovine DC obtained from cannulation of the prefemoral lymphatic vessels in sheep demonstrated that RAPA-modified ovine DC acted as poor stimulators of allogeneic ovine T cells similar to human DC treated with RAPA. Secondly, in NOD/SCID mice engrafted with ovine skin, the infusion of allogeneic ovine T cells together with RAPA-modified ovine DC reduced histological rejection in comparison to control DC. In the second aspect of this study, the effects of genetic manipulation of DC were investigated. In order to investigate the effects of genetic modification of DC, two isoforms of the human HLA-G molecule, HLA-G1 (membrane bound) and HLA-G5 (soluble isoform) were used to generate adenoviral vectors. Unexpectedly, both HLA-G isoforms expressed by human DC transfectants were unable to induce allogeneic T cell hyporesponsiveness in the mixed lymphocyte reaction (MLR). Surprisingly, in the MLR the allogeneic T cells acquired HLA-G1, but not HLA-G5, indicating that direct cell contact and membrane transfer from DC to T cells occurred (Trogocytosis). In addition to HLA-G1, costimulatory molecules (CD40, CD80, CD86 and MHC Class II) were also cotransferred from DC to allogeneic T cells. Accordingly, in secondary proliferation assays T cells immunoselected after co-culture with allogeneic untransfected DC (TUT) demonstrated potent antigen presenting activity when used as stimulators of autologous T cells (analogous to the indirect pathway of antigen presentation). In contrast to TUT, immunoselected T cells that acquired HLA-G1 (THLA-G1) upon co-culture with DCtransfectants showed poor stimulatory capacity. Thus the data reported in this thesis supports the proposed novel concept that HLA-G acquired by T cells through genetically modified DC, functions to autoregulate T cells via T-T cell interaction through the HLA-G receptor ILT2 (negative signalling receptor) expressed on T cells. In conclusion, this thesis has firstly provided supportive evidence that the pharmacological modification of human and ovine DC with RAPA has potential therapeutic effects on allograft rejection. Secondly, the genetic modification of DC to induce expression of HLA-G has specifically allowed the transfer of this molecule to T cells by trogocytosis and the inhibition of alloreactive T cell expansion. / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2009

Vulval intraepithelial neoplasia (VIN) is a distressing, premalignant condition, frequently associated with type HPV16 infection, with increasing incidence in younger women. Traditional surgical treatment is sub optimal. Several different clinical studies influencing local and/or systemic immunity to HPV have been reported. Imiquimod, an immune response modifier, can stimulate local innate immunity and also drive an adaptive immune response. Therapeutic HPV vaccines are designed to generate cell-mediated immunity against HPV infected cells. The rationale of this study was that local imiquimod treatment, in addition to having a direct effect on VIN could also provide an immunological platform for the therapeutic HPV vaccination to achieve an enhanced and durable response. In this phase II trial, we used a combination of imiquimod and vaccination with TA-CIN (HPV16 E6E7L2 fusion protein). Women with biopsy proven high-grade VIN were recruited. Imiquimod treatment for 8 weeks was followed by three i.m. injections of TA-CIN. The objectives were to measure lesion size, histology, lesion HPV status, symptoms, immune responses before and after treatment as well as safety, toxicity, and tolerability. Lymphoproliferation to HPV antigens was used to analyse immunity to HPV before and after treatment. Local immune factors (CD4, CD8 and T regulatory cells) were assessed by immunofluorescence. 74, 85 and 79% of women had a ≥50% reduction in the size of lesion and 32, 58 and 63% had regression of VIN on histology at weeks 10, 20 and 52 respectively. At baseline, 79% had moderate to severe symptoms compared to 21% at week 52(P=0.01). Of the women who showed histological responses at week 52, 5/10 also cleared their HPV 16 infection. Follow-up for an average of 15 months showed 84% of patients with a ≥50% reduction in lesion size. Treatment was well tolerated. A significant post vaccination increase in proliferation to TA-CIN and its components was associated with histological responders (P=0.008) but not the non-responders (P=0.7). In the group as a whole, significant increases in the number of CD4, CD8 and T regulatory cells (Treg) were evident by week 20 compared to baseline (P=0.03, P=0.01, P= 0.04 respectively); At week 20, the increased CD4 and CD8 density was significantly associated only with the histological responders (P=0.03; P= 0.03) while increased Treg density was associated with only non-responders (P=0.05). Intralesional Treg density was significantly higher in non-responders compared to responders pre and post treatment (P=0.01, 0.05 respectively). This study demonstrated that imiquimod followed by vaccination achieved histological clearance of VIN at 52 weeks in almost 60%. Higher pre-existing and post-treatment levels of Treg cells were associated with a lack of treatment response. Lymphoproliferation of PBMC established that the vaccination was immunogenic and HPV 16 antigen specific. Importantly, these systemic immune responses to HPV 16 antigens were significantly associated with treatment responders.