In 50% of progressing HIV-1 patients, CXCR4-tropic (X4) virus emerges late in infection, often overtaking CCR5-tropic (R5) virus as the dominant viral strain. This “phenotypic switch” is strongly associated with rapidly declining CD4+ T cell counts and AIDS onset, yet its causes remain unknown. Here, we analyze a mathematical model for the mechanism of X4 emergence in late-stage HIV infection and use this analysis to evaluate the utility of a promising new class of antiretroviral drugs—CCR5 inhibitors—in dual R5, X4 infection. The model shows that the R5-to-X4 switch occurs as CD4+ T cell activation levels increase above a threshold and as CD4+ T cell counts decrease below a threshold during late-stage HIV infection. Importantly, the model also shows that highly active antiretroviral therapy (HAART) can inhibit X4 emergence but that monotherapy with CCR5 blockers can accelerate X4 onset and immunodeficiency if X4 infection of memory CD4+ T cells occurs at a high rate. Fortunately, when CXCR4 blockers or HAART are used in conjunction with CCR5 blockers, this risk of accelerated immunodeficiency is eliminated. The results suggest that CCR5 blockers will be more effective when used in combination with CXCR4 blockers and caution against CCR5 blockers in the absence of an effective HAART regimen or during HAART failure.
HIV has caused over 30 million deaths. The virus is so fatal because it infects and depletes CD4+ T cells, “helper” immune cells critical for orchestrating and stimulating the overall immune response. No one understands why, in about 50% of HIV infections, a more deadly strain emerges late in infection. The new HIV strain, known as X4, differs from its predecessor, known as R5, because X4 only infects CD4+ T cells displaying the receptor CXCR4, while R5 only infects CD4+ T cells displaying the receptor CCR5. Because CXCR4 and CCR5 are found on different CD4+ T cells, X4 depletes a second set of critical immune cells, accelerating immunodeficiency and death. Recently, the FDA began approving drugs that selectively block R5, and some researchers have touted anti-R5 therapy alone as a potentially safer alternative to current anti-HIV drugs. But an open question is whether anti-R5 treatments push HIV toward the more deadly X4 variant earlier. To understand how X4 emerges and how anti-R5 treatments affect X4, we apply a combination of mathematical analysis and simulation. An important medical result of our work is that anti-R5 treatment alone can accelerate X4 emergence and immunodeficiency. Our results suggest that anti-R5 treatment only be used with anti-X4 treatment or anti-HIV drug “cocktails,” which combat R5 and X4 equally.