1. The Dynamics of HIV RNA, CD4+ Count and Mycobacterium tuberculosis (Mtb) Antigen Specific Cytokines in TB/HIV Patients Following Successful Tuberculosis (TB) Treatment
Desta Kassa (MSc, PhD student)
Ethiopian Health and Nutrition Research Institute (EHNRI)
ICASA
December 4-8, 2011
Addis Ababa

2. Infection with M tuberculosis (Mtb):
Th1/Th2 dichotomy determines clinical outcome (Schkuger NW and Rom WN, 1998)
Th1 (IL-2, IFN-g) : activate macrophage for mycobacterium killing
Th2 (IL-10 ): enhance bacilli survival and replication
Th17 (IL-17): plays protective role (Khader SA, Cooper AM, 2008)
Findings are not always consistent (Lin, Y et al, 1996; Cozemic , et al, 2007)
Immunity against TB is not fully understood
Areas of investigation:
Mtb specific Th1/Th2/Th17 cytokines during TB disease and infection
Effect of HIV co-infection on the modulation of these cytokines
Effect of anti-TB treatment on the modulation of these cytokines

3. Effect of TB during HIV infection (Wallis R S. and ElIner JJ, 1994)
Questions: Does early initiation of TB treatment (deferring HAART) able to:
Suppress viral replication
Restore CD4+ count
Restore immune function specific to TB: Th1 (IFN-γ, IL-2), Th2 (IL-10), Th-17 (IL-17)
Previous studies:
Viremia suppressed (Goletti et al , 1996),
Viremia not suppressed (Lawn SD et al, 1999);
Persistent immune activation (Wolday et al, (2003)
. Increase immune activation/cytokines (TNF….)
. Increase HIV RNA level
. Increase depletion of CD4+
. Increase immune dysfunction specific to TB
. ……. results in TB infectivity, morbidity, mortality

4. Objectives
To assess the pattern of Th1 (IL-2, IFNg) Th2 (IL-10) and inflammatory ( IL-17) cytokines during TB disease and infection
To assess the effect of HIV co-infection and TB treatment on the modulation of these cytokines
To assess the effect TB treatment on the polarization of Th1/Th2/Th17 cytokines
To investigate whether TB treatment (with no HAART) in TB/HIV patients :
Suppress viral replication
Restore CD4+ cell counts
Restores immune responses specific to Mtb (FN, IL-2, IL-10, IL-17)

5. Methods Study design: Prospective cohort study Study sites:
St petrer Specialized TB Hospital
Akaki and kality Health centers
Study groups
Adults (15-60 years) ,of both sexes
Naive for anti-TB and ART
HIV positive TB cases (HIV+TB+)
HIV negative TB cases (HIV-TB+)
Latent TB groups (HIV-TST+)
Controls (HIV-TST-)
Follow-up visit
. TB patients followed at 6th and 18th months
Sample collection: 10 ml whole blood

6. Methods … cont Laboratory tests:
Plasma HIV RNA level (PVL) (copies/ml): NucliSens EasyQ
CD4+ count (cells/l): FACSCalibur (Becton Dickinson)
Immune responses specific to Mtb (FN, IL-2, IL-10, IL-17)
Whole blood (baseline, 6 and 18 months)
Stimulated with Mtb specific antigen (ESAT-6/CFP-10)
Supernatant collected at 7th day (store -80)
Cytokines measured using Luminex assay

7. Results

8. Baseline characteristics
Mean Age (Yrs)
Female (%)
CD4+ (cells/ul)
BMI (kg/m2)
Hgb (g/dl)
PVL (log 10
copies/ml)
HIV+TB+ (n=30)
34.4
43.3
232.3
18.8
12.4
5.2
HIV-TB+ (n=61)
28.5
31.9
472.7
18.9
13.5
HIV-TST+ (22)
26.6
62.5
787.3
21.4
16.3
Controls (n=23)
24.6
64.0
754.8
17.9
. Does the depletion in CD4+ count at periphery associated with immune dysfunction specific to TB ? .

9. The Th1/Th2/Th17 cytokine profile during TB disease and infection
Modulation with HIV co-infection?

11. The effect of TB treatment in: HIV-TB+ HIV+TB+
Immunologic (CD4+ count) recovery
viral suppression (PVL)
Mtb specific immune reconstitution

12. 1) Immunologic (CD4+ count) recovery
2) Plasma viral suppression
HIV+TB+ (n=12) M0 M6
M0-M6
P value
PVL (copies/ml)
0.37
(lo10copies/ml)
5.2
5.6
+0.4

13. 3) Reconstitution of Mtb specific immune response after six month of TB treatment

15. Correlation of CD4+ count recovery and immune reconstitution specific to TB (HIV-TB+)

17. Conclusions At baseline
We found an Increase in IFNg and IL-17 in Latent TB but decrease in TB patients
Decrease in IL-10 during TB disease
HIV coinfection alters the cytokine profile
After six month of TB treatment:
In TB/HIV patients , there was no significant:
Reduction in HIV viral replication,
increase in CD4+ count recovery, and
improve in immune responses (Th1, Th17)
In HIV negative TB patients
CD4+ count were normalized
immune function was restored
Polarizes to Th1 arm
IFNg restoration was correlated with CD4+ count recovery

18. Conclusion/recommendation …cont
Our results showed :
Combination of IFNg and IL-17 might strengthen immunodiagnosis of LTBI relative to TST and IGRAs
Support the notion of early initiation of HAART in TB/HIV patients which might preserve the number and function of immune cells.

19. List of collaborators Yodit Alemayehu Gebremedhin Gebremichael
Amelewerk Alemu
Leonie Ran
Wudneh Gebremeskel
Mekashaw Tebeje
Dr Belete Tegbaru
Dr Dawit Wolday
Dr Tsehaynesh Messele
Dr Debbie van Baarle

20. Acknowledgements
Study participants
EHNR

21. Thank you