Transient plasma viral rebound after SARS-CoV-2 vaccination in an exceptional HIV-1 elite controller woman.

BACKGROUND: Elite controllers are able to control viral replication without antiretroviral therapy. Exceptional elite controllers do not show disease progression for more than 25 years. Different mechanisms have been proposed and several elements of both innate and adaptive immunity are implicated. Vaccines are immune stimulating agents that can promote HIV-RNA transcription; transient plasma HIV-RNA detectability has been described within 7-14 days after different vaccinations. The most reliable mechanism involved in virosuppressed people living with HIV is a generalized inflammatory response that activates bystander cells harboring latent HIV. So far no data about viral load increase in elite controllers after SARS-CoV-2 vaccination are reported in literature. CASE PRESENTATION: We report the case of a 65-year-old woman of European ancestry, diagnosed with HIV-1/HCV co-infection more than 25 years ago. Since then, HIV-RNA remained undetectable and she never received ARV therapy. In 2021 she was vaccinated with mRNA-BNT162b2 vaccine (Pfizer-BioNTech®). She was administered with three doses in June, July and October 2021, respectively. The last available viral load was undetectable in March 2021. We observed an increase of VL at 32 cp/ml and 124 cp/mL, two and seven months after the second vaccine dose, respectively. During monthly follow-up, HIV-RNA gradually and spontaneously dropped becoming undetectable without ARV intervention. COVID-19 serology was positive with IgG 535 BAU/mL, showing response to vaccination. We measured total HIV-DNA at different time-points and we found it detectable both at the time of the higher plasma HIV-RNA (30 cp/10^6 PBMCs) and when it was undetectable (13 cp/10^6 PBMCs), in reduction. CONCLUSIONS: This case is the first report, to our knowledge, describing a rebound of plasma HIV-RNA in an elite controller after three doses of mRNA-BNT162b2 vaccine for SARS-CoV-2. Concomitantly with a spontaneous reduction of plasma HIV-RNA ten months after the third dose of mRNA-BNT162b2 vaccine (Pfizer-BioNTech®) without antiretroviral therapy intervention, we observed a reduction of total HIV-DNA in peripheral mononuclear cells. The potential role of vaccinations in altering HIV reservoir, even in elite controllers when plasma HIV-RNA is undetectable, could be a valuable aspect to take into account for the future HIV eradication interventions.

A UHPLC-MS/MS method for the simultaneous quantification of the anti-COVID-19 drugs remdesivir, molnupiravir and their active metabolites in human plasma

COVID-19 emergency required the development of specific therapeutic choices, especially for patient at higher risk to have a worst prognosis. Among the first and most widely used antivirals are remdesivir (RDV) and molnupiravir (MPV): these are both nucleoside analogs prodrugs, capable to inhibit viral RNA-dependent RNA polymerase by strand termination and a "mutational catastrophe", respectively. While RDV is only available for intravenous use in hospital, MPV is an oral drug, allowing domestic use. The circulating active metabolites of these drugs, GS-441524 and H-hydroxycitidine (NHC), respectively, are considered for the description of their pharmacokinetics (PK) and are related to their antiviral effect. Nevertheless, PK characteristics of RDV, MPV and their metabolites in the real-life use are still poorly explored, particularly due to the lack of validated methods for their quantification in human matrices. Therefore, in this work, we aimed at validating a fast, reliable and rugged ultra-high performance liquid chromatography coupled with tandem mass spectrometry (UHPLC-MS/ MS) method for the simultaneous quantification of these prodrugs and their active metabolites in human plasma, following FDA and EMA guidelines. Sample preparation consisted in a protein precipitation protocol: 50 muL of plasma are added with 50 muL of a solution of isotope-labeled internal standards (IS) in water:methanol (50:50 v:v) and, then, with 400 muL of a mixture of acetonitrile:methanol (50:50 v:v), vortex mixed and centrifuged. After drying at 40 degreeC in vacuum centrifuge (1 h), the extracts are reconstituted with water 0.2% formic acid.Then, 5 muL of the extracts undergo UHPLC separation with a gradient run of water (Phase A) and acetonitrile:methanol 50:50 (v:v, Phase B), both with 0.2% of formic acid at 40degreeC in a core-shell reverse-phase column (Kinetex polar C18, 2.1x100 mm, 2.6 mum). The total runtime is 5 minutes and drug detection is performed by MRM, with 2 specific transitions for each compound and IS. The method fulfilled the requirements from FDA and EMA guidelines in terms of accuracy, precision, recovery, matrix effect, stability and it was applied to samples from a small cohort of patients treated with these drugs, confirming its eligibility for research and clinical use.