1. Marian Kerbleski, RN UCSF AIDS Division San Francisco General Hospital

2. Disclaimer none

3. Background Despite receiving combination antiretroviral therapy, HIV persists in individuals in ‘hidden’ reservoirs of GUT and lymphatic tissues causing inflammation and damage to the immune system The interaction with the immune system, HIV T-cells in the rectal, colon, ileum, and lymph nodes seem to give a clue to the on/off immune process, the HIV memory cells located in these reservoir tissues Ultimately, these questions need to be answered before we have a ‘cure’ for HIV

4. Objectives Understand and explain to patients the risks and benefits of HIV research to obtain Colon (GUT) and Lymphatic tissue (Lymph node) Identify two additional safety concerns in preparing HIV patients for Colon and Lymph Node procedures Awareness that with HIV inflammation, the patient is at added risk for abnormal GI pathophysiology Knowledge of ‘terms’ related to HIV labs, medications, cell entry and replication

5. HIV related Terms ARV’s (antiretroviral therapy CD4, CD8, nadir CD4 Viral replication (VL) Inflammation Reservoir tissue, memory cell Cell entry WBC GUT tissue, intestinal lining Lymph Node (LN)

6. Theoretical Model of Cumulative HIV-related Disease Risk by CD4 Count

7. Health of Immune System Blood test to calculate the number and ratio of immune cells called CD4 and CD8 lymphocytes Cell count and now ‘ratio’ is most important Initial Biopsies of rectal tissues : clue to the inflammation process and CD4 Colon and Ileum: preserve cells and replication

8. Gut Mucosal Inflammation A large portion of the body’s immune system resides in the lining of the intestines and colon Protects the body from infections Over action can cause Abnormal inflammation and gastrointestinal diseases Increase risk for colon cancer With HIV infection, immune cells living in the ‘gut’ may be reduced leading to abnormal barrier function Current Research limitation: inability to preserve immune cells

9. Colon & Rectal Biopsy risks Bleeding Several tissue biopsies taken (~30) Avoid ASA and NSAIDS Anemia risk, several blood draws with research visits Preparation Adequate housing and bathroom Infection Avoid any rectal insertion x 7 days Discomfort

10. Stool and Blood Samples Additional stool samples brought in the day of procedure, not part of clinical care Blood to be used for measurement of markers of inflammation and immune function (CD4 & CD8) Inform patient that tissue is not stored as a ‘tissue bank’ Blood results available under a ‘coded ID number’

11. Persistent Inflammation and Immune Damage May Contribute to Clinical Risk Inflammation Residual Immune Dysfunction Co-Morbidities of Aging [CVD, Cancer, Bone, Liver, Kidney]

12. Lymph nodes & HIV Infection HIV persists mostly in lymphatic tissues: Lymph Node Does HIV keep replicating in LN’s even when taking HIV medications and the VL cannot be measured in blood? Is the HIV virus that is measured in blood actually coming from lymph Nodes? Are lymph Nodes a site of persistent HIV replication

13. Lymph Node Biopsy LN is size of a pea; under skin in groin Same day procedure under local anesthesia Important to understand if immune problems improve where HIV causes damage Risks: Discomfort Scar Infection, Bleeding Swelling Seroma (collection of fluid under the skin)

14. LN Teaching Preparation Assess CD4 Coags (PT/PTT) Surgeon not to burn LN tissue Pt to understand to limit post activity No work-outs No Swimming Incision=Scar= healing issues Ice to site for 24 hours

15. Nodecell count too low for sort pheno only7/8 node2.95E+0659.62

16. End of AIDS? HIV Cure? HIV as a chronic disease Success of antiretroviral Therapy Motivation to take therapy as a lifelong therapy Although ARV’s often restore CD4 counts, persistent immune dysfunction and inflammation persists Functional cure in special subset populations: acute infection Curative intervention has been slow