Lenalidomide potentially reduced the level of cell- associated HIV RNA and improved persistent inflammation in patients with HIV-associated cryptococcal meningitis a pilot study

Abstract

Background: The HIV-1 reservoir is a major barrier to curative strategies. Inflammation is an important factor for HIV-1 reservoir persistence. Lenalidomide regulates inflammatory cytokines efficiently. We examined whether lenalidomide could inhibit HIV-1 transcription and reduce systemic inflammation in people living with HIV.

Methods: Lenalidomide was administered orally for 48 weeks to patients with HIV-associated cryptococcal meningitis (HIV-CM). A HIV-1 latency model was treated with or without lenalidomide ex vivo for 5 days. The primary endpoints were change in HIV reservoir markers and inflammatory cytokines in both the cohort and cell model.

Results: Thirteen participants were enrolled from May 2019 to September 2020. The median change in cell-associated (CA) HIV RNA between baseline and 48 weeks was 0.81 log10 copies/million peripheral blood mononuclear cells (PBMCs). The CA HIV RNA decreased significantly in the cohort (P = 0.021). Serum tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) gradually diminished with lenalidomide treatment until 48 weeks (P = 0.007, P = 0.014, respectively). C-reactive protein/IL-6/TNF-α and CA HIV RNA were significantly correlated (P = 0.0027, 0.0496, and 0.0346, respectively). Lenalidomide also significantly decreased HIV core P24 (P = 0.0038) and CA HIV RNA in CD8-depleted PBMCs (P = 0.0178) ex vivo. TNF-α and IL-6 were significantly reduced in the CD8-depleted PBMC supernatant (P = 0.004, P < 0.0001, respectively) while IL-10 levels increased significantly on lenalidomide compared to no-lenalidomide treatment (P < 0.0001).

Conclusions: Lenalidomide was preliminarily confirmed to reduce the level of cell- associated HIV RNA and improve persistent inflammation in patients with HIV-Associated cryptococcal meningitis, which was a potential intervention for clinical use to inhibit viral transcription of the HIV-1 reservoir and reduced HIV-related inflammation in HIV-1 patients during ART.

Keywords: HIV reservoir; cytokines,; human immunodeficiency virus (HIV); inflammation; lenalidomide.

Figure 1

Longitudinal dynamics of (A) TNF-α, (B) IL-6, (C) CRP, and (D) D-dimer during the 48-week lenalidomide therapy. Participants are color-coded. P-values representing the difference between the time points are shown on the right side of the graphs.

Figure 2

Longitudinal dynamics of (A) HIV-1 RNA, (B) CA HIV-1 RNA, (C) CA HIV-1 RNA/total HIV-1 DNA, and (D) total HIV-1 DNA during the 48-week lenalidomide therapy. Participants are color-coded. P-values representing the difference between the time points are shown on the right side of the graphs.

Figure 3

Spearman correlations between CA HIV-1 RNA and CRP, IL-6, TNF-α, and D-dimer. (A–C), CRP, IL-6, and TNF-α were significantly correlated with CA HIV RNA levels after lenalidomide therapy. (D), The correlation between D-dimer and CA HIV-1 RNA was not significant.

Figure 4

Longitudinal dynamics of (A, B) CD4⁺ and (C, D) CD8⁺ T cell activation at 24W of lenalidomide therapy. Participants are color-coded. P-values representing the values of the change during lenalidomide treatment are shown on the right side of the graphs.

Figure 5

Lenalidomide inhibited HIV-1 reactivation in CD8-depleted PBMCs. CD8-depleted PBMCs were treated with TNF-α and LPS with or without lenalidomide for 5 days, or with the solvent control. (A, B), HIV core antigen was determined by flow cytometry in the PBMCs. (C), CA HIV RNA of CD8-depleted PBMCs was measured by RT-PCR. (D), Cytokine levels in the supernatants were determined by flow cytometry. *P < 0.05, **P < 0.01, *** P< 0.001, ****P < 0.0001.