Immune checkpoint inhibitors (ICIs) can reverse T-cell anergy and boost immune responses against tumours. Nivolumab, an ICI directed against programmed death-1 (PD-1), has become the new standard of care for second-line treatment of advanced nonsmall cell lung cancer (NSCLC) [1–3]. It is thought to be an even clever therapeutic option in HIV-infected patients , as the overexpression of PD-1 on exhausted HIV-specific T cells allows ICIs to reactivate PD-1+ T cells and to improve HIV-specific immune responses [5–7].
So far, two case reports involving HIV-infected patients with melanoma treated with ICIs have shown encouraging safety results but distinct viral effects [8,9]. Upon ipilimumab treatment, CD4+ and CD8+ cell counts, as well as the cell-associated HIV-RNA transiently increased . Upon pembrolizumab, no rebound of HIV viral load was observed . The question of whether anti-PD-1 could be a tool for HIV cure is still pending. Here, we report for the first time the detailed immunovirological evolution upon nivolumab in an HIV-infected patient with lung cancer.
The CD4+ and CD8+ cell counts were analysed on an FC500 flow-cytometer. Phenotypic and functional analysis used a 5-laser-beam LSR-Fortessa cytometer on the CyPS platform. Intracellular-cytokine-staining assay used 15-mer peptides targeting HIV-Gag, reverse transcriptase and Nef and 9-mer Epstein–Barr virus (EBV) peptides [10,11]. The plasma IL-6 levels were quantified using the Simoa-Quanterix SIMOA HD-1 analyzer (Quanterix Corporation, Lexington, Massachusetts, USA). Plasma viral load was quantified using the Amplicor monitors assay . HIV-1 DNA was amplified in LTR gene by real-time PCR .
A 53-year-old man, smoker, HIV-infected since 1993, was diagnosed with advanced NSCLC in May 2014. After a decompressive radiotherapy, six cisplatin/gemcitabine and four taxotere chemotherapy cures, nivolumab was started in September 2015. The patient was virally suppressed with CD4+ and CD8+ T-cell counts of 204 and 1142 cells/μl, respectively, upon abacavir, lamivudine and dolutegravir. Seven nivolumab injections were administered, causing Grade I hepatic toxicity. Tumoral stability was reported after six injections. Nivolumab was discontinued after the seventh injection due to disease progression and the patient finally passed away in June 2016.
During follow-up, no significant changes of ultrasensitive HIV viral load were observed, but a slight two-fold increase in HIV-cell-associated DNA levels (116 at D0, 213 copies/106 peripheral blood mononuclear cells at D30, Fig. 1a). The immunological follow-up showed a marked increase of IL-6 plasma levels peaking at D14 and returning to normal beyond D60. The CD4+ and CD8+ cell counts peaked at D60 to 413 and 1380 cells/μl, respectively, returning to baseline values at D120, together with a slight CD4+/CD8+ ratio increase (0.18–0.30 from D0 to D60). The CD4+ and CD8+ cell activation status showed discordant changes with a modest CD38 increase on CD8+ T cells, whereas human leukocyte antigen – antigen D related on CD4+ and CD8+ T cells remained within normal values (Fig. 1b). The immune check point expression on total CD4+ and CD8+ T cells displayed a marked decrease of both PD-1 and LAG3 at D30 (Fig. 1c, d). In contrast, Tim-3 expression increased on CD4+ and CD8+ T cells during follow-up and returned to baseline values at D120 (Fig. 1c, d). The almost undetectable IFNγ+ Gag-specific CD8+ T cells at baseline (below 0.1%) increased at D30 (0.4%) then returned to baseline values, whereas reverse transcriptase-, Nef-specific CD8+ T cells remained very low (Fig. 1e). Furthermore, PD-1 expression was down-modulated on IFN-γ+ Gag-specific CD8+ T cells at D30 (Fig. 1c). Frequencies of IL-2+ and TNF-α+ HIV and EBV-specific T cells showed no significant modification (data not shown). Finally, the CD4+ T cell differentiation status remained stable (Fig. 1f), whereas transitional-memory CD8+ population increased (+64%) and RA-re-expressing effector-memory decreased (−41%) 4 months after treatment initiation (Fig. 1g).
We describe here the immunovirological effects of nivolumab in an HIV-infected patient. A slight increase in HIV-specific IFNγ+CD8+ cells occurred together with an increase in CD4+ and CD8+ cell counts, in the CD8+ transitional-memory population and in IL-6 plasma levels, contrasting with a decrease of PD-1 expression on T cells. Taken together, these data suggest that nivolumab is successful at enhancing the capacities of HIV-specific CD8+ transitional-memory cells to proliferate and to secrete cytokines [5,6,14], expanding the PD-1 low T-cell subset . Those changes had no or little impact on HIV replication or reservoirs. The transient increase in inflammation has not been reported before and might result either from the PD-1/programmed death-ligand 1 (PD-L1) pathway disruption in immune cells or from a rapid HIV replication in tissues that would have immediately been controlled by the stimulated HIV-specific CD8+ T cells. These first results are encouraging and remain to be confirmed in other HIV-patients treated with anti-PD-1/PD-L1-blocking antibodies.
The authors want to thank the members of the CANCERVIH working group. They thank Karim Dorgham for IL-6 plasma levels measurements. They thank Benedicte Hoareau for help with flow cytometry analysis and Marianne Veyri who is the CANCERVIH national secretary.
Authorship contributions: G.L.G. recruited and took care of the patient. A.L., J.C., A.G. and J.-P.S. validated the therapeutic attitude. S.E., A.S., B.A. and A.G. designed and performed the immunological assays and analysis. S.L. and A.-G.M. performed the virological assays and analysis. A.G., A.S. and B.A. wrote the article. J.-P.S. is the CANCERVIH national coordinator.
Conflicts of interest
There are no conflicts of interest.
1. Borghaei H, Paz-Ares L, Horn L, Spigel DR, Steins M, Ready NE, et al. Nivolumab versus docetaxel in advanced nonsquamous non-small-cell lung cancer
. N Engl J Med
2. Brahmer J, Reckamp KL, Baas P, Crino L, Eberhardt WE, Poddubskaya E, et al. Nivolumab versus docetaxel in advanced squamous-cell non-small-cell lung cancer
. N Engl J Med
3. Herbst RS, Baas P, Kim DW, Felip E, Perez-Gracia JL, Han JY, et al. Pembrolizumab versus docetaxel for previously treated, PD-L1-positive, advanced nonsmall-cell lung cancer (KEYNOTE-010): a randomised controlled trial
4. Guihot A, Cadranel J, Lambotte O, Lavole A, Autran B, Spano JP. Biological follow-up of patients with HIV treated with anti-PD-1 or anti-PD-L1 for nonsmall cell bronchial carcinoma: a task group proposal
. Rev Mal Respir
5. Day CL, Kaufmann DE, Kiepiela P, Brown JA, Moodley ES, Reddy S, et al. PD-1 expression on HIV-specific T cells is associated with T-cell exhaustion and disease progression
6. Trautmann L, Janbazian L, Chomont N, Said EA, Gimmig S, Bessette B, et al. Upregulation of PD-1 expression on HIV-specific CD8+ T cells leads to reversible immune dysfunction
. Nat Med
7. Velu V, Titanji K, Zhu B, Husain S, Pladevega A, Lai L, et al. Enhancing SIV-specific immunity in vivo by PD-1 blockade
8. Davar D, Wilson M, Pruckner C, Kirkwood JM. PD-1 blockade in advanced melanoma in patients with hepatitis C and/or HIV
. Case Rep Oncol Med
9. Wightman F, Solomon A, Kumar SS, Urriola N, Gallagher K, Hiener B, et al. Effect of ipilimumab on the HIV reservoir in an HIV-infected individual with metastatic melanoma
10. Guihot A, Dupin N, Marcelin AG, Gorin I, Bedin AS, Bossi P, et al. Low T cell responses to human herpes virus 8 in patients with AIDS-related and classic Kaposi sarcoma
. J Infect Dis
11. Le Corre N, Thibault F, Pouteil Noble C, Meiffredy V, Daoud S, Cahen R, et al. Effect of two injections of nonadjuvanted influenza A H1N1pdm2009 vaccine in renal transplant recipients: INSERM C09-32 TRANSFLUVAC trial
12. Calin R, Hamimi C, Lambert-Niclot S, Carcelain G, Bellet J, Assoumou L, et al. Treatment interruption in chronically HIV-infected patients with an ultralow HIV reservoir
13. Avettand-Fenoel V, Chaix ML, Blanche S, Burgard M, Floch C, Toure K, et al. LTR real-time PCR for HIV-1 DNA quantitation in blood cells for early diagnosis in infants born to seropositive mothers treated in HAART area (ANRS CO 01)
. J Med Virol
14. Appay V, Dunbar PR, Callan M, Klenerman P, Gillespie GM, Papagno L, et al. Memory CD8+ T cells vary in differentiation phenotype in different persistent virus infections
. Nat Med
15. Blackburn SD, Shin H, Freeman GJ, Wherry EJ. Selective expansion of a subset of exhausted CD8 T cells by alphaPD-L1 blockade
. Proc Natl Acad Sci U S A