Proposal for application of stem cell therapy in the HIV treatment. This was made for a graduate stem cell course I completed at UCI.

1. Hematopoietic Stem Cell Therapy for Human Immunodeficiency Virus Ahmed Ibrahim March 6, 2007

3. 1. Human Immunodeficiency Virus

6. 2. Pathology of AIDS

7. AIDS: Acquired Immunodeficiency Syndrome Collection of symptoms and infections caused by specific damage to the immune system Caused by Human Immunodeficiency Virus Single Stranded RNA Virus (retroviridae) Stage I: asymptomatic Stage II: Minor mucocutaneous manifestations and recurrent upper respiratory tract infections Stage III: includes unexplained chronic diarrhea for longer than a month, severe bacterial infections and pulmonary tuberculosis Stage IV: includes toxoplasmosis of the brain, candidiasis of the esophagus, trachea, bronchi or lungs and Kaposi's sarcoma

8. Route of Transmission (per 10,000 incidences) 0.5 Insertive oral intercourse * 1 Receptive oral intercourse * 5 Insertive penile-vaginal intercourse * 6.5 Insertive anal intercourse * 10 Receptive penile-vaginal intercourse * 30 Percutaneous needle stick 50 Receptive anal intercourse * 67 Needle-sharing injection drug use 2,500 Childbirth 9,000 Blood Transfusion

9. Regional HIV and AIDS statistics and features, 2006 TOTAL North America Eastern Europe & Central Asia Latin America South and South-East Asia Sub-Saharan Africa Oceania Western & Central Europe Caribbean East Asia Middle East & North Africa 18 000 [11 000 – 26 000] 84 000 [58 000 – 120 000] 65 000 [51 000 – 84 000] 590 000 [390 000 – 850 000] 2.1 million [1.8 – 2.4 million] 270 000 [170 000 – 820 000] 2.9 million [2.5 – 3.5 million] 0.8% [0.6% – 1.1%] 0.9% [0.6% – 1.4%] 0.5% [0.4% – 1.2%] 0.6% [0.4% – 1.0%] 5.9% [5.2% – 6.7%] 1.0% [0.9% - 1.2%] 4.3 million [3.6 – 6.6 million] 43 000 [34 000 – 65 000] 140 000 [100 000 – 410 000] 860 000 [550 000 – 2.3 million] 2.8 million [2.4 – 3.2 million] 4000 [2300 – 6600] 12 000 [ <15 000] 19 000 [14 000 – 25 000] 43 000 [26 000 – 64 000] 36 000 [20 000 – 60 000] 0.4% [0.2% – 0.9%] 0.3% [0.2% – 0.4%] 1.2% [0.9% – 1.7%] 0.1% [<0.2%] 0.2% [0.1% – 0.3%] 7100 [ 3400 – 54 000] 22 000 [18 000 – 33 000] 27 000 [20 000 – 41 000] 100 000 [56 000 – 300 000] 68 000 [41 000 – 220 000] Adult & child deaths due to AIDS Adult (15 ‒ 49) prevalence [%] Adults & children newly infected with HIV Adults & children living with HIV 24.7 million [21.8 – 27.7 million] 39.5 million [34.1 – 47.1 million] 1.4 million [880 000 – 2.2 million] 1.7 million [1.2 – 2.6 million] 1.7 million [1.3 – 2.5 million] 7.8 million [5.2 – 12.0 million] 81 000 [50 000 – 170 000] 740 000 [580 000 – 970 000] 250 000 [190 000 – 320 000] 750 000 [460 000 – 1.2 million] 460 000 [270 000 – 760 000]

10. Regional HIV and AIDS statistics and features, 2006

12. Bone Marrow Abnormalities of HIV-1 Infected Patients Suppression of cell growth in the bone marrow (Moses A, Nelson J, Bagby G., 1998) Infection of accessory cells (macrophages, microvascular endothelial cells) result in impairment of the HSC growth network Unable to directly infect hematopoietic stem cells due to: High expression of fas-l and cytokines (ifn-g) inhibits viral invasion of HSC’s (Maciejewski J, Selleri C, Anderson S, Young NS, 1995) A consequence is also a high rate of apoptosis in hematopoietic stem cells (G. Zauli and S. Capitani, 1996) .

13. Clinical Course of HIV-1 Infected Patients

15. 3. Current Treatments and Challenges

19. 5. Challenges to current approaches

21. Rationale of the Therapeutic Approach The main pathology of AIDS is immunodeficiency Poor prognosis not directly related to virus but opportunistic infection Hematopoietic stem cells are the precursors to all immune cells It has been demonstrated that HSC’s can be stably transfected in Cases where mutations/polymorphisms in CXCR4/CCR5 co-receptors have controlled infection exist (Long Term Nonprogressive HIV patients)

23. Research Approach Phase I 1. Developing transgenic versions of CXCR4/CCR5 that are HIV-1 impermissible. -Sequence analysis of known medical cases of HIV resistance -Development of a library of mutants in a yeast expression system 2. Efficient transfection system for modification of implanted HSC’s 3. Appropriate animal for model for studying the effects of HIV-1 Phase II Testing for long term non-progression in mice transplanted with modified HSC's using both X4 and R5 viral HIV viral types. Probe for modification conditions that would provide the best clinical outcome for infected animals

24. 1. Proposes the transplantation of Modified Hematopoietic Stem cells 2. Gammaretroviral vector for M87o, which encodes an artificial transmembrane molecule which inhibits fusion mediated uptake of the virus with CD4 cells. 3. Successfully transfected gene into hematopoietic stem cells into NOD-SCID mice and sustained expression for one generation.

26. 6. Prospective Challenges

30. 6. SIMPLE QUESTIONS ONLY