HIV persists despite antiretroviral therapy (ART) and is associated with chronic inflammation. This inflammation is thought to prevent an effective immune response against the virus and is mediated at least in part by gut epithelial permeability and microbial translocation. HIV accumulates preferentially within Th17 cells with time on ART; these memory CD4+ T cells are highly susceptible to HIV infection and are concentrated within the gut. Vitamin D promotes gut epithelial integrity in animal models and exerts anti-inflammatory effects on the human immune system including down-modulation of Th17 cell frequency. This study will evaluate whether high dose vitamin D is able to reduce immune activation and Th17 cell frequency, to improve gut barrier integrity and the gut microbiome and reduce HIV persistence in participants on long-term suppressive ART.
The major barrier to a cure for HIV infection is the persistence of latently infected CD4+ T cells on antiretroviral therapy (ART). HIV is concentrated in vivo in Th17 cells in blood and the gastrointestinal tract. Th17 cells are critical mediators of mucosal immunity against bacteria and fungi and are rapidly depleted in the gut following HIV acquisition with subsequent gut epithelial permeability, microbial translocation and ensuing chronic inflammation which is not completely reversed on ART. Such inflammation may contribute to HIV persistence by potentiating T cell proliferation and thereby clonal expansion of infected cells, by exacerbating CD8+ T cell exhaustion and potentially by promoting viral replication despite ART. Vitamin D has pleiotropic effects on the immune system including directing naïve CD4+ T cells away from the Th17 phenotype toward an anti-inflammatory regulatory T cell phenotype. It may also have beneficial effects on dendritic cell and CD8+ T cell immunity. Furthermore, vitamin D has been shown in animal models to strengthen gut epithelial integrity and in healthy volunteers to promote a more diverse gut microbiome. The investigators plan to perform a pilot randomized double-blind placebo-controlled trial of high dose vitamin D supplementation in HIV-infected participants on suppressive ART and to determine its effect on immune activation, Th17 cell frequency, gut barrier integrity, the gut microbiome and HIV persistence.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
QUADRUPLE
Enrollment
30
Vitamin D capsule. Over-encapsulated to mimic placebo oral capsule. Eligible study participants will be randomized 1:1 to vitamin D or placebo one capsule daily from week 0 to week 24. All participants will be advised to achieve 1 gram daily dietary calcium intake whilst on study. Blood and urine will be taken at 0, 12, 24 and 36 weeks to evaluate the primary and secondary endpoints. Rectal swabs will be taken at 0, 24 and 36 weeks. All participants will continue antiretroviral therapy throughout the study.
Capsule containing oleic acid. Over-encapsulated to mimic vitamin D3 capsule. Eligible study participants will be randomized 1:1 to vitamin D or placebo one capsule daily from week 0 to week 24. All participants will be advised to achieve 1 gram daily dietary calcium intake whilst on study. Blood and urine will be taken at 0, 12, 24 and 36 weeks to evaluate the primary and secondary endpoints. Rectal swabs will be taken at 0, 24 and 36 weeks. All participants will continue antiretroviral therapy throughout the study.
The Peter Doherty Institute for Infection and Immunity
Melbourne, Victoria, Australia
The Alfred Hospital - Department of Infectious Diseases
Melbourne, Victoria, Australia
Royal Melbourne Hospital
Melbourne, Victoria, Australia
Melbourne Sexual Health Centre
Melbourne, Victoria, Australia
Change in total HIV DNA level
The difference between the vitamin D and placebo arms in the mean change in frequency of total HIV DNA within CD4+ T cells from week 0 to week 24
Time frame: weeks 0 and 24
Change in other DNA markers of HIV persistence
Total HIV DNA, integrated HIV DNA and 2-LTR circles in peripheral blood CD4+ T cells using PCR
Time frame: Weeks 0, 12, 24, 36
Change in cell-associated HIV RNA
Cell-associated unspliced and multiply spliced HIV RNA in peripheral blood CD4+ T cells using RT-PCR and Tat/rev Induced Limiting Dilution Assay (TILDA)
Time frame: Weeks 0, 12, 24, 36
Change in proportion of immune cells
T helper and T cytotoxic subsets, monocytes, dendritic cells and natural killer cells using flow cytometry
Time frame: Weeks 0, 12, 24, 36
Change in T cell subset phenotype
T cell subset activation and exhaustion marker and chemokine receptor expression using flow cytometry
Time frame: Weeks 0, 12, 24, 36
Change in HIV-specific immunity
HIV-specific CD4+ and CD8+ T cell frequency and polyfunctionality using HIV peptides and flow cytometry
Time frame: Weeks 0, 12, 24, 36
Change in CD4+ T cell transcriptional profile
CD4+ T cell transcriptional profile using RNA Seq
Time frame: Weeks 0, 12, 24, 36
Change in high sensitivity C-reactive protein (hsCRP)
hsCRP levels
Time frame: Weeks 0, 12, 24, 36
Change in gut barrier permeability
Gut barrier permeability using plasma lipopolysaccharide (LPS), soluble CD14 and intestinal fatty acid binding protein (I-FABP)
Time frame: Weeks 0, 12, 24, 36
Change in gut microbiome diversity
Gut microbiome diversity using 16S rRNA sequencing and metagenomics
Time frame: Weeks 0, 24, 36
Change in plasma microbiome abundance and diversity
Plasma microbiome abundance and diversity using deep sequencing
Time frame: Weeks 0, 24, 36
25-hydroxyvitamin D levels
Serum 25-hydroxyvitamin D levels and correlation between level achieved and each of the other endpoints (efficacy analysis)
Time frame: Weeks 0, 12, 24, 36
Serum calcium levels
Serum calcium corrected for albumin
Time frame: Weeks 0, 12, 24, 36
Urinary calcium levels
Urinary calcium:creatinine ratios and, where these are abnormal, 24 hour urinary calcium levels
Time frame: Weeks 0, 12, 24, 36
Adverse events
Incidence and severity of adverse events
Time frame: Weeks 0, 12, 24, 36
Study protocol adherence
Adherence to study drug and 1g daily dietary calcium intake as measured by pill count and participant report
Time frame: Weeks 0 to 24
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