Abstract
HIV is not cured with currently available combination antiretroviral therapy (ART) alone in large part because the virus establishes virologic latency in long lived CD4 (+) cells. To eliminate this latent reservoir, as required for HIV eradication, latency reversing agents (LRAs) are being developed to force HIV out of latency and induce infected cells to express viral proteins leading to their clearance, in a so-called "Kick-and-Kill" approach. This strategy relies on the immune system to clear the productively-infected cells and is thus limited by HIV immune evasion and the immunological exhaustion that occurs during HIV infection. To counter these limitations and augment an LRA-mediated HIV cure approach, we report herein the utility of HIV-specific truncated CD4-based D1D2 CAR T cells combined with LRA treatment and the mTORC1 inhibitor rapamycin to reduce immune exhaustion and specifically target and kill LRA-stimulated HIV infected cells. We demonstrate that rapamycin does not prevent HIV latency reversal via multiple classes of LRAs in several in vitro models, suggesting that it is compatible with cure approaches utilizing these LRAs. Additionally, rapamycin does not inhibit the early T cell activation (CD69 upregulation) in primary T cells that occurs during protein kinase C (PKC) modulator-mediated HIV latency reversal. Furthermore, in vitro chronically exhausted CAR T cells were found to have a higher frequency of terminally exhausted PD-1 (+) Tim-3 (+) and CD69 (+) PD-1 (+) cells when compared to CAR T cells that were cultured under the same conditions in the presence of rapamycin, validating the use of the mTORC1 inhibitor rapamycin to prevent immune exhaustion of CAR T cells. Finally, we found that latently-infected cells that were stimulated to express HIV proteins using a designed, synthetic PKC modulator LRA (SUW133) were efficiently recognized and killed by CAR T cells. Overall, these data demonstrate the compatibility of immune rejuvenation using rapamycin with HIV reservoir depletion using LRAs and CAR T cells. This combination therapy strategy represents a promising approach to more effectively target the latent reservoir in HIV cure approaches.