COMPENSATORY MECHANISM IN CONCURRENT HIV INFECTION AND CUTANEOUS MELANOMA: FROM CLINICAL OBSERVATION TO A STRATEGY FOR COMPLETE PROVIRUS ERADICATION

UDC 616.98:578.828.6:616-006.81

COMPENSATORY MECHANISM IN CONCURRENT HIV INFECTION

AND CUTANEOUS MELANOMA: FROM CLINICAL OBSERVATION

TO A STRATEGY FOR COMPLETE PROVIRUS ERADICATION

 

S.-L.A. Winter, Senior Laboratory Assistant

Russian State Social University

(354053, Russia, Sochi, Krymskaya St., 29B)

E-mail: citokin0701@gmail.com

ORCID: 0009-0000-4447-9656

 

                Abstract. This article presents a clinical case of a 43-year-old patient with comorbid pathologies: HIV infection (stage 4A - notably the Russian HIV Classification System) and stage IIIA melanoma of back skin. The case description covers the medical history, diagnostic workup, surgical treatment, and dynamic of laboratory parameters during antiretroviral therapy. A hypothesis is proposed regarding a compensatory mechanism operating in the lymph nodes through the interaction of dendritic cells, T-lymphocytes, HIV-infected cells, and metastatic melanoma cells. The role of interferon-alpha as a potential modulator of this mechanism is discussed. It is suggested that interferon-induced activation of dendritic cells enhances the presentation of both HIV and melanoma antigens, thereby inducing a cross-reactive immune response. Sustained remission of both diseases accompanied by normal laboratory values is considered indirect evidence supporting this hypothesis. Based on the proposed mechanism, a stepwise strategy for complete eradication of HIV provirus has been developed, comprising reactivation of latent provirus followed by elimination of infected cells, excision of proviral DNA using CRISPR-Cas9 with miR-29b monitoring as a marker of HIV control, and genome modification using the CCR5-delta32 mutation to prevent reinfection. The proposed approach opens prospects for functional cure of patients with comorbid pathology. Further in vitro and ex vivo studies are required to verify the compensatory mechanism and to assess the safety of the proposed methods.

                Keywords: HIV infection, melanoma, compensatory mechanism, dendritic cells, interferon-alpha, CRISPR-Cas9, miR-29b, CCR5-delta32, provirus eradication.

 

                Background. Modern medicine has made substantial progress in the management of HIV infection. Antiretroviral therapy (ART) can suppress viral replication to undetectable levels and restore immune function. However, ART does not eliminate the provirus integrated into the host cell genome and therefore does not achieve a complete cure. Latent HIV reservoirs persist in resting CD4+ memory T cells, macrophages, and astrocytes, necessitating lifelong therapy.

                This report a clinical case of a patient with two concurrent diseases — stage 4A HIV infection and stage IIIA cutaneous melanoma — who achieved durable remission of both conditions while receiving ART and after surgical treatment. The atypical course, marked by normal laboratory values and the absence of disease progression, raises the possibility of a compensatory mechanism operating within the lymph nodes. Therefore propose a stepwise strategy aimed at complete eradication of the HIV provirus, combining immunotherapy, genome editing, and microRNA monitoring.

                The Problem. Of particular interest is the coexistence of HIV infection and cutaneous melanoma — one of the most aggressive malignancies, characterized by early metastasis. Melanoma is highly immunogenic owing to the expression of a range of surface antigens, which in some cases can induce a durable antitumor immune response and even spontaneous tumor regression. Far more often, however, melanoma escapes immunological surveillance, progresses, and gives rise to distant metastases [3].

                To date, the clinical course of melanoma in patients with HIV infection receiving antiretroviral therapy remains insufficiently studied. In particular, it is still an open question whether the simultaneous presence of two immunoactive processes (HIV infection and melanoma) can lead to mutual modulation and to the formation of a compensatory mechanism that limits the progression of both diseases?

                Objective. To present a clinical case of concurrent HIV infection and melanoblastoma of the back skin, to propose a hypothesis regarding a compensatory mechanism involving dendritic cells and interferon, and to outline prospects for further research.

                Main Hypothesis. In concurrent HIV infection and melanoma, the compensatory mechanism operates within the lymph nodes through the interaction of dendritic cells, T lymphocytes, and interferon-α. This interaction leads to simultaneous restriction of HIV replication and melanoma metastasis. The key participants in the mechanism are dendritic cells, as the principal antigen-presenting cells of the lymph nodes; HIV-infected cells; metastatic melanoma cells; and T lymphocytes, including CD8+ cytotoxic and CD4+ helper cells.

                The proposed mechanism of interaction involves several sequential stages. Metastatic melanoma cells enter the lymph node. Dendritic cells capture tumor antigens and present them to T lymphocytes, initiating an antitumor immune response. At the same time, dendritic cells present HIV antigens, activating an antiviral T-cell response. Cross-activation of T cells directed against one antigen may enhance the response against the other through the shared microenvironment. As a result, both pathological processes are mutually restricted: HIV replication is suppressed, and metastatic cells are eliminated.

                Indirect evidence for the existence of this mechanism in the clinical case presented here includes enlargement of the lymph nodes without systemic signs of generalization, normal laboratory values, the absence of systemic inflammation and organ dysfunction, long-term oncological remission, and controlled HIV viral load on ART.

                Clinical Case. Patient and Methods. Patient L., a 43-year-old female. In 2015, during preoperative workup for elective cholecystectomy for chronic calculous cholecystitis and cholelithiasis, she tested positive for HIV infection. The elective surgery had to be postponed indefinitely, and the patient presented to the AIDS Center at his place of residence. She had to undergo repeated blood testing to confirm the HIV infection. The patient also repeatedly sought the help of a clinical psychologist at the local AIDS Center. In late December 2015, she began to note episodes of febrile sensation (by his own account), enlargement of the lymph nodes in the upper third of the neck on the left, and in the axillary and inguinal regions bilaterally. On repeated consultation with an infectious disease specialist, chest radiography, ECG, laboratory tests, psychological consultation, and other evaluations were ordered. All laboratory parameters were within normal limits except for RDW — 36.2 fL and EOS — 6.8%.

                The diagnosis was confirmed on 19 January 2016 using the Genscreen Ultra HIV Ag-Ab and ARCHITECT HIV Ag/Ab Combo Reagent Kit test systems. From 1 February 2016, the patient was registered at the AIDS Center with a diagnosis of B.23.2, stage 4A, progression phase, without ART.

                Diagnosis of melanoma. During the same period, the patient began to note pruritic eruptions on the skin of the back and prolonged itching over the entire body. She was referred to a psychotherapist and a neurologist. On repeated consultation with the psychotherapist, in the setting of a neurological disorder (diagnosed by the psychotherapist), therapy was prescribed — Atarax 25 mg, 1 tablet once daily, with a subsequent dose increase to 50 mg/day because of chronic insomnia.

                On consultation with a neurologist, the patient was found to have an atypical nevus. At the N.N. Petrov National Medical Research Center of Oncology, a biopsy was performed, and cytological examination showed: "abundant material represented by numerous proliferating cells of melanocytic lineage with signs of pronounced atypia." Melanoblastoma was considered the most likely diagnosis.

                Clinical diagnosis as of 1 April 2016: melanoblastoma of the back skin, stage IIIA. Abdominal ultrasound revealed bilateral inguinal lymphadenopathy.

                Surgical treatment. On 14 April 2016, surgical excision of the melanoblastoma was performed. Histological report: superficial spreading pigmented melanoma arising in a compound nevus of the back skin. Clark level 3, Breslow thickness 2.0 mm, pT2aN0M0.

                Subsequent follow-up for cutaneous melanoma of the back showed sustained remission only. Palpable peripheral lymph nodes were not enlarged. The postoperative scar showed no signs of recurrence, was well formed and firm, measuring 10.5 cm × 5 cm (Fig. 1).

 

 

Fig. 1

                                              

                Dynamics and ART. From 1 February 2016 — initiation of ART: Kaletra (lopinavir + ritonavir) 200 + 50 mg, 2 tablets twice daily; Disaverox (zidovudine + lamivudine) 300 + 150 mg, 2 tablets twice daily, stage 4A, progression phase without ART, CD4+ — 459 cells/µL. (After surgery — sustained remission, peripheral lymph nodes not enlarged, scar without signs of recurrence.)

                In 2017 — a change of the ART regimen was made because of worsening well-being, with general malaise, palpitations, and an increase in cholesterol to 6.7 mmol/L. The patient was referred to the S.P. Botkin Clinical Infectious Diseases Hospital with the primary diagnosis of B.23.2, stage 4A, remission on ART, but with complications in the form of persistent oropharyngeal candidiasis. On physical examination and microscopic investigation, the patient was not found to have this persistent diagnosis. Concomitant diseases on admission were: acute gastroenteritis caused by an opportunistic pathogen (Citrobacter) and postcholecystectomy syndrome. During outpatient monitoring, no significant deviations from reference values were found in laboratory tests: ALP — 61 U/L, cholesterol — 5.6 mmol/L, CK — 166 U/L, RW — negative; proteinogram: albumin — 63.2%, α1-globulin — 2.9%, α2-globulin — 10.9%, β-globulin — 9.3%, γ-globulin — 13.8%; cultures: stool culture for dysentery group — not detected, throat culture for flora and diphtheria — not detected, oral culture for Candida — not detected. Therapy was prescribed: Kaletra (lopinavir + ritonavir) 200 + 50 mg, 2 tablets twice daily; Intelence (etravirine) 200 mg, 2 tablets twice daily. Immunological profile after the change of drugs: CD3 — 78% (1943 cells/µL), CD4 — 41% (1020 cells/µL), CD8 — 37% (929 cells/µL), CD4/CD8 ratio — 1.1.

                In December 2018 — cholecystectomy. After surgery, because of worsening well-being, the ART regimen was changed: Tenof 300 mg (tenofovir) — 1 tablet once daily; Heptavir-150 150 mg (lamivudine) — 2 tablets once daily; Intelence (etravirine) 200 mg — 1 tablet twice daily. With the new regimen, the patient's well-being and immunological parameters improved.

                By October 2022, laboratory results were as follows: CD3 — 78% (1390 cells/µL), CD4 — 47% (834 cells/µL), CD8 — 30% (534 cells/µL), CD4/CD8 ratio — 1.56; HIV viral load (VL HIV) — <40 copies/mL. Findings on esophagogastroduodenoscopy and ECG — no change from previous.

                History. The patient denies injecting drug use and promiscuous sexual contacts; denies tuberculosis, sexually transmitted diseases, viral hepatitis, and diabetes mellitus; no history of blood transfusion. The patient was born and raised in the Northwestern Federal District of Russia. She was born into and lived in a two-parent family of four. She had no problems during his school and university years. She started working immediately after university.

                Chronic diseases. Cholelithiasis (cholecystectomy), sinus bradycardia, melanoma (T2), grade 1 dyscirculatory encephalopathy (mixed origin), hypercholesterolemia on ART.

                Allergy history. Penicillin, construction dust, bee stings.

                Family history. Glioblastoma and grade 3 arterial hypertension in the maternal grandmother; diabetes mellitus and alcoholic encephalopathy in the mother. Paternal family history — unremarkable.

                Atypical course. It is noteworthy that, despite the presence of HIV infection and melanoma, most of the patient's laboratory parameters remained within normal limits: ALP — 61 U/L, cholesterol — 5.6 mmol/L, CK — 166 U/L, RW — negative. In classical hematogenous metastasis of melanoma, one would expect: decreased total protein and hemoglobin, increased leukocytes, urea, creatinine, platelets, C-reactive protein, LDH, and ESR by a factor of 3–5. These abnormalities were absent, which suggests that metastasis was restricted to the lymphatic route.

                The role of dendritic cells and interferon-α in the compensatory mechanism. Dendritic cells serve as the link between innate and adaptive immunity. They capture, process, and present antigens, migrate from peripheral tissues to the lymph nodes, and secrete cytokines that determine T-helper differentiation. In HIV infection, several disturbances of the dendritic cell system are observed: a decrease in the number of plasmacytoid dendritic cells, which are the principal producers of interferon-α; impaired maturation and functional activity; and induction of a tolerogenic phenotype. In melanoma, the tumor microenvironment is likewise infiltrated by dendritic cells, often with a tolerogenic phenotype and impaired cross-presentation of tumor antigens.

                The coexistence of the two pathologies may create a unique situation in which dendritic cells are activated simultaneously against two types of antigens, thereby enhancing the overall T-cell response and leading to clinical remission.

                Interferon-α plays a central role in modulating the compensatory mechanism. Its molecular effects include activation of dendritic cell maturation and function, with increased expression of MHC class I and II, CD80, CD86, and CD40. Interferon-α induces the expression of antiviral genes such as MxA, PKR, and OAS, enhances the cytotoxic activity of CD8+ T lymphocytes, inhibits angiogenesis in tumor tissue, and modulates the lymph node microenvironment, thereby promoting cross-presentation of antigens.

                Interferon-α–induced activation of dendritic cells enhances the presentation of both viral and tumor antigens. A proinflammatory milieu favorable for T-cell activation is created. Interferon-α can induce apoptosis of HIV-infected and tumor cells. In clinical practice, interferon-α is already used in melanoma as adjuvant therapy and in certain viral infections; however, its role in concurrent pathology remains unstudied. Albuferon may be considered a promising candidate for further research.

                Discussion. Before proceeding to a strategy of complete eradication, a study must be conducted to confirm the existence of the compensatory mechanism in patients of the experimental group. The study should include several sequential stages. The stages of experimental confirmation of the compensatory mechanism include the following:

                Dendritic cell phenotyping. In the first stage, the dendritic cell phenotype should be assessed in patients with concurrent HIV infection and melanoma in comparison with control groups. The study groups include patients with concurrent pathology, HIV-infected patients without cancer, patients with melanoma without HIV, and healthy donors. The minimum number of samples in each group is five individuals.

                The biomaterial is peripheral blood collected into tubes with EDTA or sodium citrate, in a volume of ten milliliters per patient. Processing time should not exceed four hours after collection. To isolate mononuclear cells, a ficoll-urografin solution with a density of 1.077 g/mL is used. For washing, phosphate-buffered saline with added bovine serum albumin and sodium azide is used.

                For staining, monoclonal antibodies conjugated to fluorochromes are used: anti-CD11c-FITC, anti-CD123-PE, anti-HLA-DR-PerCP, anti-CD80-PE-Cy7, anti-CD86-APC, anti-CD40-BV421, anti-PD-L1-BV510, and anti-CCR7-APC-Cy7. The flow cytometer must be equipped with at least three lasers to excite fluorochromes at 488, 561, and 640 nanometers.

                The procedure includes isolation of mononuclear cells by ficoll-urografin centrifugation, cell counting and preparation for staining, Fc receptor blocking, antibody staining, and flow cytometric analysis. For each sample, at least one hundred thousand events should be recorded in the live cell gate. Data analysis is performed using specialized software. Gating is performed sequentially: the live cell population is selected, doublets are excluded, and dendritic cells are identified as HLA-DR–positive cells that do not express lineage markers CD3, CD14, CD16, CD19, and CD56. Within this population, CD11c and CD123 expression is assessed to separate myeloid and plasmacytoid dendritic cells, as is the expression of the costimulatory molecules CD80, CD86, and CD40, the inhibitory molecule PD-L1, and the chemokine receptor CCR7.

                Patients with concurrent pathology are expected to show increased expression of the costimulatory molecules CD80, CD86, and CD40 on dendritic cells compared with patients with mono-infection or mono-oncology. An increase in the proportion of plasmacytoid dendritic cells, which are the principal producers of interferon-α, is anticipated. PD-L1 expression is expected to be reduced, indicating the absence of a tolerogenic phenotype. Increased CCR7 expression would indicate the capacity of dendritic cells to migrate to the lymph nodes.

                Assessment of dendritic cell functional activity. The second stage should include assessment of the ability of dendritic cells to induce proliferation and polarization of T lymphocytes. The mixed leukocyte reaction method is used, based on the ability of dendritic cells, as professional antigen-presenting cells, to stimulate proliferation of allogeneic or autologous T lymphocytes. The intensity of proliferation reflects the functional activity of dendritic cells.

                Monocytes are isolated from eripheral blood mononuclear cells by negative selection or adhesion to plastic. The isolated monocytes are cultured in RPMI-1640 medium supplemented with granulocyte-macrophage colony-stimulating factor and interleukin-4 for five to seven days. On the fifth to sixth day, interferon-α is added to the culture at a concentration of 1000 units per milliliter to induce maturation. After 24–48 hours, immature dendritic cells are collected and used in the experiment.

                T lymphocytes are usually isolated from autologous or allogeneic peripheral blood mononuclear cells by negative selection. The purity of isolation will be verified by flow cytometry and should be at least 90 percent. The isolated T cells are labeled with CFSE at a final concentration of 5 micromolar. The reaction is stopped by adding cold medium with serum, and the cells are washed three times.

                Dendritic cells at various concentrations are mixed with labeled T lymphocytes at a ratio of 1:5 or 1:10 in 96-well round-bottom plates. Each combination is performed in triplicate. After five to seven days of culture, the cells are analyzed by flow cytometry to assess CFSE dilution. Proliferating cells are identified by the sequential decrease in CFSE fluorescence with each division. The proliferation index is calculated as the ratio of the number of divisions to the number of original cells.

                Dendritic cells from patients with concurrent pathology are expected to demonstrate an increased capacity to stimulate T lymphocyte proliferation compared with control groups. The stimulation index is expected to be above three, indicating functional competence of the dendritic cells.  

                Assessment of the antigen-specific T lymphocyte response. The third stage is aimed at determining the frequency of T lymphocytes specific for HIV and melanoma antigens by quantifying interferon-γ secretion. The ELISpot method is used, which allows individual cytokine-secreting cells to be visualized and counted after stimulation with specific antigens.

                ELISpot plates coated with anti–interferon-γ antibodies are washed with sterile phosphate-buffered saline. RPMI-1640 medium with human AB serum is added to each well to block nonspecific binding. Peripheral blood mononuclear cells are isolated from fresh blood or cryopreserved samples, washed, and resuspended in medium. The concentration is adjusted to two million cells per milliliter.

                One hundred microliters of cell suspension is added to the plate wells, corresponding to 200,000 cells per well. Antigens are added at optimal concentrations: HIV peptides such as gag, pol, and nef, and melanoma peptides such as MART-1, gp100, and NY-ESO-1, at a concentration of two micrograms per milliliter of each. Phytohemagglutinin is used as a positive control, and medium alone is added as a negative control. Each condition is performed in triplicate.

                The plates are incubated in a CO2 incubator at 37 degrees Celsius for 24–48 hours. After incubation, the plates are washed with phosphate-buffered saline supplemented with Tween-20. Biotinylated detection anti–interferon-γ antibody is added and incubated for two hours at room temperature. After washing, streptavidin–alkaline phosphatase is added and incubated for one hour. After a final wash, BCIP/NBT substrate is added and incubated until dark purple spots appear. The reaction is stopped by washing with tap water. After drying, the plates are analyzed on an automated ELISpot reader or under a stereomicroscope.

                Patients with concurrent pathology are expected to have an increased number of T cells specific for both HIV antigens and melanoma antigens. This would indicate cross-activation of the immune response against both pathogens.

                Assessment of the cytotoxic activity of CD8+ T lymphocytes. The fourth stage includes determination of the ability of CD8+ T lymphocytes to lyse autologous HIV-infected cells and melanoma cells. Cytotoxic activity is assessed by the release of lactate dehydrogenase from damaged target cells.

                Target cells, including autologous CD4+ T cells infected with HIV or melanoma cell lines, are cultured to the required quantity and resuspended in phenol red–free medium at a concentration of 100,000 cells per milliliter. CD8+ T lymphocytes are isolated from peripheral blood mononuclear cells by negative selection and activated for three to five days using anti-CD3 and anti-CD28 antibodies with added interleukin-2.

                Target cells are added to 96-well plates at 100 microliters, corresponding to 10,000 cells per well. Effector cells are added at various ratios: 1:1, 5:1, 10:1, 20:1, and 50:1. The final volume is brought to 200 microliters. Each ratio is performed in triplicate. Controls include spontaneous release of lactate dehydrogenase from target cells without effectors and maximum release after cell lysis with detergent.

                The plates are centrifuged at 250 relative centrifugal units for four minutes to ensure cell contact. Incubation is carried out in a CO2 incubator at 37 degrees Celsius for four to six hours. After incubation, the plates are centrifuged, fifty microliters of supernatant is collected from each well and transferred to a flat-bottom plate. The reaction mixture from the lactate dehydrogenase assay kit is added and incubated for thirty minutes in the dark. The reaction is stopped by adding stop solution. Optical density should be measured at a wavelength of 490 nanometers with a reference wavelength of 680 nanometers.

                The percentage of specific lysis is calculated by the formula: percent cytotoxicity equals the difference between experimental and spontaneous release, divided by the difference between maximum and spontaneous release, multiplied by one hundred percent.

                CD8+ T lymphocytes from patients with concurrent pathology are expected to demonstrate increased cytotoxic activity against both HIV-infected cells and melanoma cells. Maximum lysis is expected at an effector-to-target ratio of 20:1 or 50:1 and should exceed fifty percent..

                Assessment of the effect of interferon-α on dendritic cell maturation. The fifth stage is aimed at determining the optimal concentration and duration of interferon-α exposure for inducing dendritic cell maturation.

                Monocytes are cultured in six-well plates in RPMI-1640 medium supplemented with granulocyte-macrophage colony-stimulating factor and interleukin-4. After five days, immature dendritic cells are obtained. The immature dendritic cells are collected and reseeded into new plates at a concentration of 500,000 cells per milliliter. Interferon-α is added at various concentrations: 10, 100, 1000, and 10,000 units per milliliter. Control wells do not receive interferon-α.

                After 24, 48, and 72 hours, the cells are collected and stained with monoclonal antibodies against CD80, CD86, CD40, HLA-DR, and CD83. Analysis is performed by flow cytometry. Supernatants are collected at 24 and 48 hours and analyzed for interleukin-12, interleukin-10, and tumor necrosis factor alpha by flow cytometry using a cytokine assay kit.

                Interferon-α is expected to induce dendritic cell maturation in a dose-dependent manner, manifested by increased expression of CD80, CD86, CD40, and CD83. The optimal concentration is expected to be in the range of 100–1000 units per milliliter. Interleukin-12 secretion also increases, indicating polarization toward a Th1 response.

                MicroRNA expression analysis. The sixth stage should include determination of the expression profile of microRNAs regulating HIV replication and melanoma growth in patients with concurrent pathology. Real-time quantitative polymerase chain reaction allows measurement of the relative expression level of specific microRNAs.

                Blood plasma or cell lysate is used to isolate microRNAs by a column-based method. RNA concentration and purity are assessed spectrophotometrically. Seven microliters of RNA is used in a reverse transcription reaction of thirty-five microliters using universal primers and reverse transcriptase. The reaction is carried out at 42 degrees Celsius for sixty minutes, followed by enzyme inactivation at 95 degrees for five minutes.

                The complementary DNA is diluted fifty-fold. The twenty-microliter reaction mixture contains two microliters of complementary DNA, one microliter of specific primers, eight microliters of master mix, and water. Amplification is carried out according to the following protocol: one cycle at 95 degrees for ten minutes, then forty cycles at 95 degrees for fifteen seconds and at 60 degrees for one minute.

                Threshold cycles are determined automatically. Relative expression is calculated by the ΔΔ Ct method using U6 or miR-16 as an endogenous control. The formula for calculation is: relative expression equals two to the power of minus ΔΔ Ct.

                Patients with concurrent pathology are expected to show increased expression of microRNAs that block HIV replication, such as miR-27b, miR-29b, miR-150, and miR-223. These microRNAs repress cyclin T1, which is required for transcription of the viral genome. Increased expression of miR-155, which participates in immune response activation, and reduced expression of miR-21, which has oncogenic properties, are also expected.

                Integrative assessment of the compensatory mechanism. The final stage includes an integrative assessment of all components of the compensatory mechanism using multiparametric analysis. For each patient, a full spectrum of analyses is performed, including dendritic cell phenotyping, assessment of T lymphocyte functional activity, determination of the cytokine profile, and microRNA expression analysis. The data are integrated using multivariate statistical analysis, such as principal component analysis or cluster analysis.

                Integrative analysis will make it possible to identify correlations between dendritic cell phenotype, their functional activity, the cytokine profile, and microRNA expression. Patients with concurrent pathology are expected to exhibit a unique pattern characterized by an activated dendritic cell phenotype, increased interferon-α production, an enhanced antigen-specific T-cell response, and a specific microRNA profile.

                Strategy for complete eradication of HIV provirus. After confirmation of the compensatory mechanism in patients of the experimental group, a stepwise strategy for complete eradication of HIV provirus may be considered. The strategy includes three sequential stages.

                The first stage is reactivation of latent provirus followed by elimination of infected cells. The first stage is based on the "Shock and Kill" strategy. The goal is to activate latent provirus using latency-reversing agents, followed by elimination of infected cells by the immune system. Interferon-α, which activates provirus transcription without excessive T-cell activation, is considered a mild latency-reversing agent.

                Simultaneously with provirus reactivation, activation of dendritic cells and T lymphocytes is carried out to eliminate the reservoirs. Activated dendritic cells present HIV antigens to T lymphocytes, which triggers a cytotoxic response against infected cells. Interferon-α enhances this process by increasing the expression of MHC class I and II on infected cells, making them more accessible for recognition by CD8+ T lymphocytes.

                The problem with this approach is possible excessive T-cell activation, which may lead to toxicity. However, the use of interferon-α as a mild latency-reversing agent makes it possible to minimize this risk. In addition, combination with ART makes it possible to control viral replication in the event of incomplete elimination of infected cells.

                The second stage is excision of proviral DNA with miR-29b monitoring. The second stage includes physical removal of proviral DNA from the host cell genome using CRISPR-Cas9 technology. The efficacy of this approach has been demonstrated in vivo in mice: a combination of long-acting ART and CRISPR-Cas9 led to complete elimination of HIV in two of seven humanized mice. Lipid nanoparticles targeted to CXCR4 have been developed for delivery of CRISPR-Cas9 into CD4+ T cells. The AAV9-SaCas9 platform showed 37–92 percent efficiency of SIV excision in macaques.

                To monitor the efficiency of excision and to control HIV, the use of miR-29b as a marker is proposed. miR-29b represses cyclin T1, which is required for transcription of the viral genome. An elevated level of miR-29b correlates with suppression of HIV replication. Monitoring of miR-29b in lymph nodes and blood plasma will make it possible to assess the effectiveness of therapy and to detect virus reactivation in a timely manner.

                The third stage is genome modification using CCR5-Δ32. The third stage is aimed at preventing reinfection of cells with HIV by modifying the genome using the CCR5-Δ32 mutation. This mutation, identified in donors or the control group, makes cells resistant to HIV, since the virus cannot use CCR5 as a coreceptor to enter the cell.

                Clinical cases of complete cure of HIV after transplantation of stem cells from donors with the CCR5-Δ32 mutation are known. The "Berlin Patient" and the "London Patient" are examples of successful application of this strategy. However, stem cell transplantation is a risky procedure and is used for life-saving indications in oncohematological diseases.

                An alternative may be editing the patient's own cells using CRISPR-Cas9 to "knock out" the CCR5 gene. This would make it possible to create a population of HIV-resistant cells without the need for transplantation. The combination of CCR5 knockout with provirus excision may yield complete eradication of HIV.

                Conclusion. The clinical case presented demonstrates an atypical course of concurrent pathology — HIV infection and stage III cutaneous melanoma — in a 43-year-old patient. Long-term remission, normal laboratory parameters, and controlled viral load on ART suggest the existence of a compensatory mechanism operating in the lymph nodes with the participation of dendritic cells and interferon-α.

                A stepwise strategy for complete eradication of HIV provirus has been proposed, including reactivation of latent provirus followed by elimination of infected cells, excision of proviral DNA with miR-29b monitoring, and genome modification using CCR5-Δ32. Implementation of this strategy requires experimental studies to confirm the compensatory mechanism and to assess the safety of the proposed methods.

                If verified, the proposed mechanism may become the basis for developing new therapeutic strategies in patients with HIV and malignant neoplasms, as well as for stratifying patients by the risk of progression of both diseases. Complete eradication of HIV, previously considered unattainable, is becoming a realistic prospect, provided there is an interdisciplinary approach combining immunology, oncology, virology, and gene therapy.

 

REFERENCES

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2. Khaitov, R.M. AIDS. – 2nd ed. – 2018. – 496 p.

3. Lushchevich, S.V., Litvinov, V.D. Treatment of oncological and hematological diseases in HIV infection // Oncohematology. – 2023. – Vol. 18, No. 3. – P. 125–133. DOI: 10.17650/1818-8346-2023-18-3-125-133.

4. Mamedov, M.K., Kadyrova, A.A., Dadasheva, A.E. Mechanisms underlying the immunotropic activity of the human immunodeficiency virus // Biomedicine. – 2007. – No. 3. – P. 3–7.

5. Mamedov, M.K. Pathogenesis of immunological disorders caused by HIV infection // Biomedicine. – 2007. – No. 4. – P. 3–10.

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7. Selimova, L.M., Kalnina, L.B., Kaplina, E.N., Nosik, D.N. The effect of ferrovir on to expression of surface markers of activation by cells neoplastic line MT-4. Klinicheskaya Laboratornaya Diagnostika (Russian Clinical Laboratory Diagnostics) 2017; 62 (6): 355-359. (in Russ.). DOI: http://dx.doi.org/10.18821/0869-2084-2017-62-6-355-359.

8. Zolotareva, E.I., Zlatnik, E.Yu., Shulgina, O.G., Novikova, I.A., Bykadorova, O.V. The effect of local administration of cytokine immunomodulators on the growth of transplanted melanoma in mice // Experimental Models. Special Issue, 2017. – Vol. 19. – P. 31–32.

 

REFERENCES

1. Borobova E.A., Zheravin A.A. Immunotherapy for melanoma. Siberian Journal of Oncology. 2017. Vol. 16, No. 4. P. 65–75. DOI: 10.21294/1814-4861-2017-16-4-65-75.

2. Khaitov R.M. AIDS. 2nd ed. 2018. 496 p.

3. Lushchevich S.V., Litvinov V.D. Treatment of oncological and hematological diseases in HIV infection. Oncohematology. 2023. Vol. 18, No. 3. P. 125–133. DOI: 10.17650/1818-8346-2023-18-3-125-133.

4. Mamedov M.K., Kadyrova A.A., Dadasheva A.E. Mechanisms underlying the immunotropic activity of the human immunodeficiency virus. Biomedicine. 2007. No. 3. P. 3–7.

5. Mamedov M.K. Pathogenesis of immunological disorders caused by HIV infection. Biomedicine. 2007. No. 4. P. 3–10.

6. Rockstroh J.K., Hoffmann C. HIV-Infektion 2014/2015. 2014. 923 p.

7. Selimova L.M., Kalnina L.B., Kaplina E.N., Nosik D.N. The effect of ferrovir on to expression of surface markers of activation by cells neoplastic line MT-4. Klinicheskaya Laboratornaya Diagnostika (Russian Clinical Laboratory Diagnostics) 2017; 62 (6): 355-359. (in Russ.). DOI: http://dx.doi.org/10.18821/0869-2084-2017-62-6-355-359.

8. Zolotareva E.I., Zlatnik E.Yu., Shulgina O.G., Novikova I.A., Bykadorova O.V. The effect of local administration of cytokine immunomodulators on the growth of transplanted melanoma in mice. Experimental Models. Special Issue, 2017. Vol. 19. P. 31–32.

 

 

 

E-mail: citokin0701@gmail.com

ORCID: 0009-0000-4447-9656