Acute HIV Infection Clinical Trial
Official title:
Study SEARCH 026Assessment of the HIV CNS Reservoir, Neurological and Neuro-cognitive Effects, and Source of Rebound HIV in CNS in Subjects Participating in Study SEARCH 019
This study aims to describe in depth the CNS, CNS HIV reservoir and CNS viral rebound in consenting SEARCH 019 subjects prior to, during and after the SEARCH 019 study intervention (VHM + ART or ART only), at 1) baseline, 2) end of study intervention and start of ART interruption, 3) viral rebound (if occurring) or mid-way during observed ART interruption, and 4) at the end of ART interruption. Study SEARCH 026 itself does not employ any therapeutic interventions. However, consenting subjects will participate in lumbar puncture, non-contrast MRI + MRS, and neuropsychological testing at at least three and at most four time points. Any of the 15 subjects to be enrolled in SEARCH 019 may consent to study SEARCH 026 participation and hence a maximum of 15 subjects may enroll. As this is a sub-study, data will be shared from study SEARCH 019 and no interventions (venipunctures) will be repeated unnecessarily.
1. Clinical 1.1 Neurological exam: SEARCH employs the AIDS Clinical Trials Group
(ACTG)-derived HIV macroneurological examination, a physician rated symptoms assessment
of cognitive features typical of HIV-associated neurocognitive disorder (HAND) and
peripheral neuropathy.
1.2 Neuropsychological assessments: SEARCH employs the HIV neurocognitive battery
originally developed by Maj et al. designed to minimize cultural bias and tested in
Bangkok. All subjects will have the full SEARCH battery as previously published,
avoiding evaluations following invasive procedures. All testing is completed by
certified nurse-psychometrists. Data are compared to a normative set of 500
HIV-negative, healthy, community dwelling Thais and stratified by age and educational
attainment to define standardized z-scores. A psychiatric inventory mirrors that used
for RV254 and has broad Thai validity data, and research nurses perform a functional
assessment based on the Clinical Dementia Scale.
1.3 Lumbar puncture: Lumbar punctures are completed per standard clinical procedures
using a Sprotte® (pencil-point) needle to minimize complications. Standard assessments
of CSF and serum, protein and cell count are completed and approximately 20cc are
collected and ultra-centrifuged. Cell pellets of CSF will be cryopreserved for future
potential studies, with subject consent. Supernatants are divided into 0.5cc aliquots,
and frozen to -80oC on the same day. CSF VDRL/RPR will be assessed at baseline for
those with positive serology in SEARCH 019 and in follow-up if a new positive serology
is reported in SEARCH 019 or if subject was CSF positive at baseline. Participant
hospitalization for any research-related adverse events requiring admission will be
arranged, if needed.
1.4 Neuro-imaging: Imaging studies will be performed at the Chulalongkorn University
Hospital which is 100 meters from the TRCARC in Bangkok. These studies will take up to
one hour maximum MRI scanner time for each subject and may include brain MRI, MRS, DTI
and resting state functional MRI (fMRI). MRI and MRS are non-invasive methods to detect
brain pathology (MRI) and to determine the in-vivo concentration of brain metabolites
(MRS). DTI is a sensitive non-invasive magnetic resonance technique to analyze the
three-dimensional diffusion of water within brain tissue. The diffusion of water within
the brain is highly dependent on the underlying micro-architecture of the surrounding
tissue, which is affected by both normal physiological processes (such as aging) as
well as local neuropathological disease processes, such as those seen with HIV
infection. Resting state functional MRI (fMRI) reveals patterns of activation of brain
networks and is a sensitive measure of brain function prior to structural and
anatomical changes detected by other methods. Gadolinium will not be used for research
purposes.
2. Laboratory (all pertaining to CSF)
2.1 Measurement of soluble markers: Commercial ELISA kits (Human Quantikine ELISA kits; R&D
Systems, Inc.) and Millipore Luminex assays will be used following manufacturer's
instructions at the Yale Immune Monitoring Core Laboratory. Soluble biomarkers associated
with immune activation and neurocognitive impairment will be measured, including CSF
neopterin, MCP-1, sCD14, IL-6, sCD163, and IP-10.
2.2 CSF virology Assays: HIV RNA standard quantitation will be completed using the Roche
COBAS/Amplicor HIV-1 Viral Load v2.0 assay, with a lower limit of quantitation of 20cps/mL.
Single Copy Assay (SCA) HIV RNA quantitation in the setting of ART will be performed using
5-10 ml of CSF. In addition, cell associated HIV-DNA (total, integrated and 2LTR circles in
total CD4+ T cells will be assessed at CRC-CHUM.
2.3 TCR repertoire and avidity of HIV-specific CD8+ T cells in CSF: These may be measured in
a subset of samples at VGTI Florida. For the repertoire assay, CSF cell pellets will be
polyclonally expanded, and the TCR repertoire will be determined followed by TCR sequencing
as previously described. For TCR avidity, T cell clones corresponding to the dominant
clonotypes will be generated in vitro to measure their functional sensitivity. The
HIV-specific CD8+ T cells clones generated by expansion in the presence of PHA, IL-2 and
irradiated feeders will be sequenced for their TCR and will be tested for their TCR
functional sensitivity.
2.4 Management of Subjects Resuming ART: If the decision is made to reinitiate ART as per
SEARCH 019 ART resumption criteria, then the study visit before ART resumption will be
considered this study's final visit and all procedures scheduled for end of study will be
conducted at that visit.
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Observational Model: Cohort, Time Perspective: Prospective
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