Among HIV-infected individuals, co-infection with Mycobacterium tuberculosis is associated with faster progression to AIDS. We investigated the hypothesis that M. bovis BCG and M. tuberculosis (Mtb complex) could enhance susceptibility of CD4+ cells to HIV infection. Peripheral blood mononuclear cells (PBMCs) collected from healthy donors were stimulated with M. bovis BCG, M. tuberculosis CDC1551 and M. smegmatis MC2155, and stimulated CD4+ cells were infected with R5-and X4-tropic single replication-competent pseudovirus. CD4+ cells stimulated with Mtb complex showed enhanced infection with R5- and X4-tropic HIV, compared to unstimulated cells or cells stimulated with M. smegmatis (p<0.01). Treatment with TLR2 siRNA reversed the increased susceptibility of CD4+ cells with R5- and X4-tropic virus induced by Mtb complex. These findings suggest that TB infection and/or BCG vaccination may be a risk factor for HIV acquisition.
Citation: Thayil SM, Ho Y-C, Bollinger RC, Blankson JN, Siliciano RF, Karakousis PC, et al. (2012) Mycobacterium tuberculosis Complex Enhances Susceptibility of CD4 T Cells to HIV through a TLR2-Mediated Pathway. PLoS ONE 7(7): e41093. doi:10.1371/journal.pone.0041093
Editor: Miguel Santin, Barcelona University Hospital, Spain
Received: March 21, 2012; Accepted: June 18, 2012; Published: July 23, 2012
Copyright: © 2012 Thayil et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was supported by National Institutes of Health grants K23HD056957 to KRP and R01AI083125 to PCK. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have read the journal’s policy and have the following conflicts: PCK is a PLoS ONE Editorial Board member. This does not alter the authors’ adherence to all the PLoS ONE policies on sharing data and materials.
Chronic immune activation is central to the pathogenesis of HIV. Activation of CD4+ T cells, macrophages, and dendritic cells enhances and promotes viral replication , , . In the primate model, natural SIV hosts that do not develop pathogenic immunodeficiency have low levels of generalized immune activation compared to pathogenic SIV infections , . In humans, systemic markers of immune activation are associated with higher HIV viral loads and faster progression to AIDS . Variations in immune activation among HIV-infected individuals may result from several factors, such as host genetics, microbial translocation, malnutrition, and co-infection with other pathogens , . For example, HIV co-infection with pathogens that non-specifically activate host immunity, such as P. falciparum, helminths, HSV, and M. tuberculosis, has been associated with enhanced virological replication, which could lead to more efficient HIV transmission and faster progression to AIDS , .
Among HIV-uninfected individuals, immune activation can also enhance HIV susceptibility following exposure to HIV. Non-ulcerative sexually transmitted diseases, such as asymptomatic incident HSV infections, increase the risk of HIV acquisition via local recruitment and activation of CD4+ T cells and macrophages, which increase the number of target cells for HIV entry , . In addition to local inflammation, some sexually transmitted infections, such as chronic asymptomatic HSV, are associated with systemic immune activation . While the effect of systemic immune activation on HIV susceptibility has not been firmly established, there is evidence that factors other than local inflammation influence the immunologic milieu at mucosal sites of HIV exposure. For example, the genital tracts of Kenyan women have more activated CD4+ T cells compared to women from San Francisco, independent of genital co-infections or behavioral factors that may influence local genital inflammation . In addition, systemic immunological profiles correlate with natural resistance to HIV, as low levels of peripheral T cell activation are found in individuals who remain uninfected despite frequent exposure to HIV , . The elevation of systemic immune activation markers found in HIV-uninfected Africans and Asians compared to Europeans has been attributed to chronic exposure to endemic infections, and may be one of the factors driving regional disparities in HIV rates around the world , , .
Among potential exposures in regions with high HIV rates, M. tuberculosis and M. bovis BCG (a live attenuated vaccine) are exceedingly common and elicit potent systemic immune responses that may influence HIV infectiousness. It is estimated that worldwide over 2 billion individuals have latent infection with M. tuberculosis and almost 10 million new cases of active tuberculosis (TB) occur each year. Despite controversy regarding the efficacy of the BCG vaccine, approximately 100 million doses are given to infants each year. The transcriptional signatures of whole blood obtained from patients infected with M. tuberculosis reflect systemic immune activation in both patients with active TB and asymptomatic individuals with latent infection , . BCG vaccination can also activate systemic immune pathways associated with T cell activation which persist even after clearance of the bacteria, enhance immune responses to unrelated pathogens in infants, and modulate mucosal immunity , , , . Among HIV-infected individuals, co-infection with M. tuberculosis is associated with increased viral load and faster progression to AIDS .
Although the effect of TB on HIV pathogenesis has been characterized previously, the impact of systemic immune activation by mycobacterial infections on susceptibility to HIV infection among uninfected exposed individuals is not known. We hypothesized that immune activation by M. tuberculosis or M. bovis BCG, the two most common mycobacterial exposures worldwide, increases susceptibility to HIV infection. Using a single-cycle infection assay, we examined susceptibility to HIV infection in peripheral blood mononuclear cells (PBMC) stimulated with Mtb complex and identified immune pathways associated with enhanced susceptibility to HIV.
M. bovis BCG and M. Tuberculosis (Mtb complex) Enhance Infection of CD4+ T Cells with R5-tropic and X4-tropic HIV
In order to assess whether exposure to mycobacteria affects HIV susceptibility ex vivo, we stimulated PBMC from healthy individuals to Mtb complex for 72 hours and subsequently infected the isolated CD4+ cells with an X4- or R5- tropic HIV pseudovirus. CD4+ cells exposed to Mtb complex had a significantly (p<0.005) higher HIV infectivity rate with X4-tropic (Fig. 1A) as well as R5-tropic virus (Fig. 1B) relative to that of unstimulated cells and to cells exposed to the nonpathogenic mycobacterium M. smegmatis, in which HIV infectivity was similar to that of unstimulated cells. The percentage of HIV-infected cells was comparable following stimulation with M. bovis BCG, a known immunomodulator, and with M. tuberculosis at the same MOI (Fig. 1C; p = 0.3).
The percentage of unstimulated CD4+ cells and CD4+ cells stimulated with PHA (50 µg/ml), M. bovis BCG (Copehnhagen), M. tuberculosis (CDC1551), M. smegmatis (MC2155) from individual subjects infected with X4-tropic pseudovirus (A) or R5-tropic pseudovirus (B). Results from individual donors are color-coded. Statistical analysis was performed using student T test (** p<0.005). Flow cytometry analysis of the representative CD4+ cells after infection with GFP-expressing pseudovirus (C).
Exposure to Mtb Complex does not Alter Expression of CCR5 and CXCR4 Co-receptors in CD4+ T Cells
To evaluate whether the enhanced infectivity observed in CD4+ cells exposed to Mtb complex was due to modulation of the co-receptors CCR5 and CXC4, we measured the expression of CCR5 and CXCR4 in CD4+ cells exposed to mycobacteria. CCR5 receptors were expressed on 0–5% of CD4+ cells in all experimental and control groups (Fig. 2a). Mean fluorescence intensity values for CCR5 receptor were 366.4+78.1, 436.6+112.3, 336.4+54.7, and 403.4+145.3 for unstimulated CD4+ cells, and those stimulated with M. bovis BCG, M. tuberculosis, and M. smegmatis, respectively. CXCR4 was observed to be expressed on 70–85% of CD4+ cells (Fig. 2b), but expression of this co-receptor did not vary among stimulated and unstimulated cells or between different groups of stimulated cells (p = 0.4). Mean fluorescence intensity values for CXCR4 receptor were 1406.6+132.8, 1540.0+407.3, 1492.6+346.7, and 1403.3+168.5 for unstimulated CD4+ cells, and those stimulated with M. bovis BCG, M. tuberculosis, and M. smegmatis, respectively. We concluded that differential expression of the entry co-receptors CXCR4 and CCR5 does not account for the increased susceptibility to HIV of cells exposed to Mtb complex.
Surface expression of co-receptor CXCR4 on unstimulated CD4+ cells, CD4+ cells stimulated with phyohemaglutinin (50 mg/ml), M. bovis BCG (Copenhagen), M. tuberculosis (CDC1551) and M. smegmatis (MC2155), respectively, at the time of infection with pseudovirus (A). Surface expression of co-receptor CCR5 on CD4+ cells from five subjects after stimulation (B).
Increased Immune Activation Markers HLADR and CD38 do not Explain the Increased Susceptibility to HIV Infection Associated with Mtb Complex Stimulation
Next, we compared the expression of two different immune activation markers on the surface of CD4+ cells stimulated with different mycobacteria (Fig. 3a). As expected, CD38 expression was higher in stimulated cells compared to unstimulated cells (p<0.05), but there was no difference in CD38 expression between CD4+ cells exposed to M bovis BCG, M. tuberculosis, or M. smegmatis (Fig. 3b). CD4+ cells exposed to M. bovis BCG and M. tuberculosis had diminished expression of HLA DR (p<0.05) when compared to cells exposed to M. smegmatis (Fig. 3C).
Cells stimulated with different antigens are activated to a similar extent as evidenced by expression of immune activation marker CD38 (A). Dot plots from unstimulated CD4+ cells and CD4+ cells stimulated with PHA (150 g/ml), M. bovis BCG (Copenhagen) and M. tuberculosis (CDC1551) depicting the expression of immune activation marker CD38 (B). Cells stimulated with M. bovis BCG (Copenhagen) and M. tuberculosis (CDC1551) show lower expression of MHC II molecule HLA DR when compared to cells stimulated with M. smegmatis MC2155 (C) *p<0.05.
Enhanced Expression of TLR2, but not of TLR4, in CD4+ T Cells Exposed to M. bovis BCG
Since pathogenic mycobacteria are potent inducers of TLR , and TLR-mediated immune activation is associated with HIV replication , we evaluated the gene expression levels of TLR2, TLR4, and TLR9 in CD4+ cells exposed to M. bovis BCG and M. smegmatis by RT-PCR. Although TLR4 expression was higher and TLR9 expression lower in cells exposed to mycobacteria compared to unstimulated cells, there was no difference in expression of TLR4 or TLR9 between cells stimulated with M. bovis BCG or M. smegmatis. However, gene expression of TLR2 was approximately two-fold higher in cells exposed to M bovis BCG than in unstimulated cells (Fig. 4a).
Expression of TLR2 increases at the transcription level in cells stimulated with M. bovis BCG when compared to cells stimulated with M. smegmatis (A). The expression levels of TLR4 and TLR9 do not show a significant difference in cells stimulated with different strains of mycobacteria as evidenced by RT-PCR. Comparison of HIV infectivity of CD4+ cells transfected with scrambled siRNA and subsequently stimulated with M. bovis BCG to CD4+ cells transfected with TLR2 siRNA and subsequently stimulated with M. bovis BCG (B) **p<0.005. TLR2 expression on CD4+ cells after stimulation with M. bovis BCG, M. tuberculosis, and M. smegmatis compared to TLR2 expression on CD4+ cells transfected with TLR2 siRNA and subsequently stimulated with M. bovis BCG (C). The expression showed similar trends for the four samples tested. Dot plots comparing the percentage of surface expression of TLR2 on unstimulated CD4+ cells and CD4+ cells stimulated with M. bovis BCG, M. tuberculosis (CDC1551), M. smegmatis (MC2155), and CD4+ cells transfected with TLR2 siRNA and subsequently stimulated with M. bovis BCG (D).
Increased Susceptibility of CD4+ T Cells Exposed to Mtb Complex is Mediated through a TLR2-dependent Mechanism
In order to determine whether higher expression of TLR2 results in increased HIV susceptibility of M. bovis BCG-exposed cells, we silenced TLR2 expression in cells prior to stimulation with M. bovis BCG. Relative to M. bovis BCG-stimulated CD4+ cells treated with scrambled siRNA, transfection of CD4+ cells with TLR2 siRNA prior to M. bovis BCG stimulation decreased infection with R5 virus from 6.2±0.7% to 3.6±1.0% (p = 0.005; Fig. 4b), and with X4 virus from 10.7±0.8% to 7.0±1.0% (p = 0.001; data not shown). Flow cytometry confirmed that prior treatment with TLR2 siRNA reduced TLR2 expression in CD4+ cells stimulated with Mtb complex relative to that of similarly stimulated cells pre-treated with scrambled siRNA with M. smegmatis (p<0.005; Figs. 4c and 4d). Therefore, we conclude that the increased susceptibility of CD4+ T cells to HIV infection following Mtb complex exposure is at least partly mediated by TLR2.
In this study, we demonstrate that Mtb complex, but not the nonpathogenic M. smegmatis, enhances HIV infection of CD4+ T cells through a TLR2-dependent mechanism. While increased HIV replication has been previously associated with Mtb, this is the first study demonstrating that mycobacterial infections increase CD4 cell susceptibility to HIV infection. Given the magnitude of the TB epidemic worldwide, these findings could have significant public health implications.
We evaluated various immunological pathways that could be associated with increased HIV susceptibility in T cells exposed to M. tuberculosis and M. bovis BCG, such as increased expression of entry co-receptors (CCR5 and CXCR4), upregulation of immune activation markers HLA DR and CD38, or mediation through TLR pathways known to be modulated by M. tuberculosis and M. bovis BCG (TLR2, TLR4 and TLR9) , , . We found that TLR2 was significantly upregulated in T cells exposed to M. bovis BCG and that blockade of TLR2 expression attenuated the increased susceptibility to HIV. The role of TLR2 in enhanced HIV susceptibility is consistent with previous studies of HIV and TB pathogenesis. Both M. tuberculosis and M. bovis BCG are potent inducers of TLR2 , , , . In HIV transgenic mouse spleens, TLR2 signaling enhances HIV replication through trans-activation of HIV long terminal repeats , . Signaling through TLR2 has been shown to trigger HIV replication in a variety of human cell lines, including latently infected mast cells and dendritic cells , . Co-infection with certain bacteria that stimulate TLR2 can lead to HIV reactivation. For example, periodontal pathogens cause HIV reactivation in a monocyte model of HIV latency via TLR2 activation . HIV transgenic mice infected with M. tuberculosis have enhanced viral production, but this effect is not observed in TLR2-deficient HIV mice . Dendritic cells obtained from HIV-infected individuals co-infected with M. tuberculosis have increased expression of TLR2 and TLR4, which may promote HIV replication and contribute to the faster disease progression observed in patients with opportunistic infections .
In addition to promoting HIV replication in various models of HIV infection, TLR2 has also been implicated in enhancing susceptibility to HIV infection . TLR2 stimulation of Langherhan cells, which are the initial targets of HIV infection following sexual exposure, results in enhanced infection of these cells and subsequent trans-infection of T cells . TLR2 signaling also enhances infection of quiescent naïve and memory CD4+ T cells, which are normally relatively resistant to HIV infection . N. gonorrhea, a sexually transmitted pathogen strongly associated with increased HIV risk, enhanced HIV infection of resting CD4+ cells through TLR2 activation . Similar to the mycobacterial effect we observed, the enhanced susceptibility of CD4+ T cells to HIV following exposure to N. gonorrhea was reduced upon TLR2 blockade. Recently, Ding and Chang have shown that TLR2 activation promotes HIV infection and nuclear import in resting CD4+ T cells through both T cell activation-dependent and -independent mechanisms .
Although previous clinical studies have shown that infection with M. tuberculosis or vaccination with M. bovis BCG systemically activate TLR2-mediated pathways, more work is needed to determine whether these responses lead to enhanced HIV susceptibility in humans as suggested by our ex vivo model , . Potential implications of our findings could be significant, especially for regions with a high prevalence of TB and HIV. Our findings may also have implications for TB vaccine development, since current strategies involve genetically modifying the BCG vaccine, developing adjuvants to strengthen protective responses, or using other attenuated mycobacterial species as potential vaccines , all of which may activate TLR2-mediated pathways.
There are several important limitations of our model, which require further study to assess the clinical and public health implications of our findings. Direct infection of PBMCs with M. tuberculosis complex in our ex vivo model most likely overestimates the level of antigenic stimulation resulting from natural infection in the lungs or intradermal vaccination. Further work is needed to determine whether pulmonary TB infection or intradermal BCG vaccination modulates immune responses at sites of HIV exposure, such as the genital and gastrointestinal mucosa, where local flora may drive mucosal immune responses. Although in the current study we have not elucidated the cell type responsible for CD4+ T cell activation, the potential role of different antigen-presenting cells, including macrophages and dendritic cells, deserves further study. One hypothesis is that TLR2-stimulated dendritic cells encountering M. tuberculosis or M. bovis BCG traffic to lymphoid organs and mucosa-associated lymphoid tissue, where they prime and activate CD4+ T cells. Recent data in a murine model shows dynamic trafficking patterns in dendritic cells exposed to a chronic M. bovis BCG granuloma . Despite very low antigenic availability following BCG vaccination, CD4+ T cell priming still was observed as a result of dendritic cell migration from the site of chronic granuloma formation to systemic sites and lymphoid organs. Furthermore, upregulation of TLR2 has been reported in dendritic cells from patients co-infected with TB and HIV , .
While our findings in an ex vivo model of co-infection likely overestimate the impact of dual infection on actual HIV risk, they provide insights about mechanisms of HIV susceptibility that could guide future studies using clinical samples from patients with TB or BCG vaccination. Given the magnitude of the TB epidemic worldwide, even a modest level of enhanced susceptibility to HIV due to M. tuberculosis infection or BCG vaccination could have a significant impact at a population level. These results provide initial support for the intriguing possibility that pathogenic mycobacterial infections could partially explain variations in HIV susceptibility worldwide.
Materials and Methods
Written informed consent was obtained from all subjects prior to entry into the study, which was approved by the Johns Hopkins University School of Medicine Institutional Review Board.
Ten HIV-seronegative healthy individuals (ages 23–54) without prior history of BCG vaccination or TB infection were recruited at Johns Hopkins University School of Medicine. All subjects were confirmed to have negative tuberculin skin tests prior to entry into the study.
Cell Isolation and Culture
Peripheral blood mononuclear cells (PBMC) were isolated from healthy volunteers and antigenic stimulation of cells was performed by incubating cells with whole bacteria or antigen for 48–72 hours at 37°C with 5% CO2. For infectivity assays, unstimulated cells were used as negative control and PHA (50 µg/ml) stimulated cells were used as positive control to ensure that cells were responsive to in vitro stimulation.
Bacterial Strains and Mycobacterial Infection
M. bovis BCG (Copenhagen), M. tuberculosis CDC1551, and M. smegmatis MC2155 strains procured from ATCC were used for stimulation of PBMC at an MOI of 1∶4. The bacterial strains were grown to mid-logarithmic phase in 7H9 broth (Difco, Sparks MD) supplemented with 10% oleic acid-albumin-dextrose-catalase (OADC, Difco), glycerol, 0.05% Tween 80 at 37°C on a shaker. At the time of stimulation, bacteria were pelleted and resuspended in complete RPMI and co-cultured with isolated PBMC in complete RPMI supplemented with IL-2 at 37°C for 24–48 hours.
Single-cycle HIV-1 Infection Assay
After stimulation, the cells were washed with fresh RPMI and CD4+ cells were isolated from stimulated PBMC by negative selection using a CD4+ T cell isolation kit (Miltenyi biotech; GmbH) according to the manufacturer’s instructions. Isolated CD4+ cells were infected with a single-cycle replication-competent, green fluorescent protein (GFP)-expressing proviral construct pseudotyped with CCR5-tropic or CXCR4-tropic envelope (NL43-deltaEnvGFP), as previously described . Briefly, stimulated CD4+ cells were spinoculated for 2 hrs with the virus. The infected cells were incubated at 37°C for 72 hours. Fluorescence emitted by the cells carrying GFP-expressing virus was quantified using Cellquest Pro software (Beckton Dickinson) to calculate percent infectivity.
Immunoflourescence Staining and Flow Cytometry Analysis
Stimulated CD4+ cells were washed and then stained with directly conjugated antibodies to cell surface markers, including CD4-FITC, CD3-PE, CD38-PE, HLA DR-FITC, CD195–PE, and CD184-FITC (Becton Dickinson, San Jose, CA) and TLR-2 FITC (R&D biosystems). Marker expression analysis was performed using a FACSCalibur flow cytometer (BDIS). A minimum of 10,000 viable lymphocytes was collected for each run.
Quantitative Reverse-transcription PCR
Total RNA was isolated from 106 to 107 CD4+ stimulated cells using RNeasy Mini Kit (Qiagen). Fluorescently-labeled cDNA was generated using oligod(T) primers and Superscript III (Invitrogen), using fluorescent dyes Cy3 and Cy5 (Amersham). cDNA corresponding to each transcript was subjected to 34 cycles of PCR for quantification using the primers listed in Table S1. The cycle threshold value (CT) obtained for each gene of interest (GOI) was normalized with that of GAPDH, a housekeeping gene, in order to obtain the normalized cycle threshold (nCT = (GOI CT) – (HKG CT)). The change in cycle threshold (ΔCT) was calculated using the following formula: (ΔCT = C(nCT) – S(nCT)), where C represents unstimulated cells (negative control) and S represents cells stimulated with mycobacteria or phytohemagglutinin (PHA; positive control). Prior to reverse transcription, control and mutant RNA (10 ng) were treated with RNase-free DNase (Invitrogen) and subjected to 36 cycles of PCR to assure that all DNA had been removed, as assessed by ethidium bromide-stained agarose gel analysis.
Transfection of monocytes was performed using negative control scrambled small interfering RNA (siRNA) or siRNA targeting TLR-2 (Santa Cruz Biotechnology, Inc.) following the manufacturer’s instructions. Briefly, cells were seeded at 2×106 cells per well in a 6 well plate with reduced siRNA transfection reagent (Santa Cruz Biotechnology Inc.) for 5–8 hours at 37°C with 5% CO2. The media were then replaced and the cells were allowed to rest overnight, followed by stimulation with individual strains of mycobacteria. Paired samples were subsequently subject to either immunoflourescence staining with TLR 2 antibody or virus infectivity assays, as described above.
Statistical significance was determined by students T Test. A p-value of <.05 was considered statistically significant.
Primers used for RT-PCR studies.
Conceived and designed the experiments: KRP PCK RFS JNB RCB. Performed the experiments: SMT Y-CH KRP. Analyzed the data: SMT KRP PCK. Contributed reagents/materials/analysis tools: PCK RFS JNB RCB. Wrote the paper: KRP PCK SMT.
- 1. Brenchley JM, Price DA, Douek DC (2006) HIV disease: fallout from a mucosal catastrophe? Nat Immunol 7: 235–239.
- 2. Lama J, Planelles V (2007) Host factors influencing susceptibility to HIV infection and AIDS progression. Retrovirology 4: 52.
- 3. Moir S, Chun TW, Fauci AS (2011) Pathogenic mechanisms of HIV disease. Annu Rev Pathol 6: 223–248.
- 4. Bosinger SE, Sodora DL, Silvestri G (2011) Generalized immune activation and innate immune responses in simian immunodeficiency virus infection. Curr Opin HIV AIDS 6: 411–418.
- 5. Sodora DL, Allan JS, Apetrei C, Brenchley JM, Douek DC, et al. (2009) Toward an AIDS vaccine: lessons from natural simian immunodeficiency virus infections of African nonhuman primate hosts. Nat Med 15: 861–865.
- 6. Giorgi JV, Hultin LE, McKeating JA, Johnson TD, Owens B, et al. (1999) Shorter survival in advanced human immunodeficiency virus type 1 infection is more closely associated with T lymphocyte activation than with plasma virus burden or virus chemokine coreceptor usage. J Infect Dis 179: 859–870.
- 7. Barnabas RV, Webb EL, Weiss HA, Wasserheit JN (2011) The role of coinfections in HIV epidemic trajectory and positive prevention: a systematic review and meta-analysis. AIDS 25: 1559–1573.
- 8. Kaul R, Cohen CR, Chege D, Yi TJ, Tharao W, et al. (2011) Biological factors that may contribute to regional and racial disparities in HIV prevalence. Am J Reprod Immunol 65: 317–324.
- 9. Walson JL, Herrin BR, John-Stewart G (2009) Deworming helminth co-infected individuals for delaying HIV disease progression. Cochrane Database Syst Rev. CD006419 p.
- 10. Heng MC, Heng SY, Allen SG (1994) Co-infection and synergy of human immunodeficiency virus-1 and herpes simplex virus-1. Lancet 343: 255–258.
- 11. Reynolds SJ, Risbud AR, Shepherd ME, Zenilman JM, Brookmeyer RS, et al. (2003) Recent herpes simplex virus type 2 infection and the risk of human immunodeficiency virus type 1 acquisition in India. J Infect Dis 187: 1513–1521.
- 12. Sheth PM, Sunderji S, Shin LY, Rebbapragada A, Huibner S, et al. (2008) Coinfection with herpes simplex virus type 2 is associated with reduced HIV-specific T cell responses and systemic immune activation. J Infect Dis 197: 1394–1401.
- 13. Cohen CR, Moscicki AB, Scott ME, Ma Y, Shiboski S, et al. (2010) Increased levels of immune activation in the genital tract of healthy young women from sub-Saharan Africa. AIDS 24: 2069–2074.
- 14. McLaren PJ, Ball TB, Wachihi C, Jaoko W, Kelvin DJ, et al. (2010) HIV-exposed seronegative commercial sex workers show a quiescent phenotype in the CD4+ T cell compartment and reduced expression of HIV-dependent host factors. J Infect Dis 202: S339–344.
- 15. Pancino G, Saez-Cirion A, Scott-Algara D, Paul P (2010) Natural resistance to HIV infection: lessons learned from HIV-exposed uninfected individuals. J Infect Dis 202: S345–350.
- 16. Kalinkovich A, Borkow G, Weisman Z, Tsimanis A, Stein M, et al. (2001) Increased CCR5 and CXCR4 expression in Ethiopians living in Israel: environmental and constitutive factors. Clin Immunol 100: 107–117.
- 17. Koesters SA, Matu L, Kiama P, Anzala O, Embree J, et al. (2004) Elevation of immune activation in kenyan women is associated with alterations in immune function: implications for vaccine development. J Clin Immunol 24: 702–709.
- 18. WHO (2011) TB Data 2011. Accessed 2012 Jun 25.
- 19. Berry MP, Graham CM, McNab FW, Xu Z, Bloch SA, et al. (2010) An interferon-inducible neutrophil-driven blood transcriptional signature in human tuberculosis. Nature 466: 973–977.
- 20. Jacobsen M, Repsilber D, Gutschmidt A, Neher A, Feldmann K, et al. (2007) Candidate biomarkers for discrimination between infection and disease caused by Mycobacterium tuberculosis. J Mol Med (Berl) 85: 613–621.
- 21. Alexandroff AB, Jackson AM, O’Donnell MA, James K (1999) BCG immunotherapy of bladder cancer: 20 years on. Lancet 353: 1689–1694.
- 22. Croix DA, Capuano S, 3rd, Simpson L, Fallert BA, Fuller CL, et al (2000) Effect of mycobacterial infection on virus loads and disease progression in simian immunodeficiency virus-infected rhesus monkeys. AIDS Res Hum Retroviruses 16: 1895–1908.
- 23. Hanekom WA (2005) The immune response to BCG vaccination of newborns. Ann N Y Acad Sci 1062: 69–78.
- 24. Huang D, Qiu L, Wang R, Lai X, Du G, et al. (2007) Immune gene networks of mycobacterial vaccine-elicited cellular responses and immunity. J Infect Dis 195: 55–69.
- 25. Toossi Z, Mayanja-Kizza H, Hirsch CS, Edmonds KL, Spahlinger T, et al. (2001) Impact of tuberculosis (TB) on HIV-1 activity in dually infected patients. Clin Exp Immunol 123: 233–238.
- 26. Prados-Rosales R, Baena A, Martinez LR, Luque-Garcia J, Kalscheuer R, et al. (2011) Mycobacteria release active membrane vesicles that modulate immune responses in a TLR2-dependent manner in mice. J Clin Invest 121: 1471–1483.
- 27. Equils O, Schito ML, Karahashi H, Madak Z, Yarali A, et al. (2003) Toll-like receptor 2 (TLR2) and TLR9 signaling results in HIV-long terminal repeat trans-activation and HIV replication in HIV-1 transgenic mouse spleen cells: implications of simultaneous activation of TLRs on HIV replication. J Immunol 170: 5159–5164.
- 28. Harding CV, Boom WH (2010) Regulation of antigen presentation by Mycobacterium tuberculosis: a role for Toll-like receptors. Nat Rev Microbiol 8: 296–307.
- 29. Thoma-Uszynski S, Stenger S, Takeuchi O, Ochoa MT, Engele M, et al. (2001) Induction of direct antimicrobial activity through mammalian toll-like receptors. Science 291: 1544–1547.
- 30. van den Biggelaar AH, Prescott SL, Roponen M, Nadal-Sims MA, Devitt CJ, et al. (2009) Neonatal innate cytokine responses to BCG controlling T-cell development vary between populations. J Allergy Clin Immunol 124: 544–550, 550 e541–542.
- 31. Underhill DM, Ozinsky A, Smith KD, Aderem A (1999) Toll-like receptor-2 mediates mycobacteria-induced proinflammatory signaling in macrophages. Proc Natl Acad Sci U S A 96: 14459–14463.
- 32. Page KR, Scott AL, Manabe YC (2006) The expanding realm of heterologous immunity: friend or foe? Cell Microbiol 8: 185–196.
- 33. Sundstrom JB, Little DM, Villinger F, Ellis JE, Ansari AA (2004) Signaling through Toll-like receptors triggers HIV-1 replication in latently infected mast cells. J Immunol 172: 4391–4401.
- 34. Thibault S, Fromentin R, Tardif MR, Tremblay MJ (2009) TLR2 and TLR4 triggering exerts contrasting effects with regard to HIV-1 infection of human dendritic cells and subsequent virus transfer to CD4+ T cells. Retrovirology 6: 42.
- 35. Gonzalez OA, Li M, Ebersole JL, Huang CB (2010) HIV-1 reactivation induced by the periodontal pathogens Fusobacterium nucleatum and Porphyromonas gingivalis involves Toll-like receptor 2 [corrected] and 9 activation in monocytes/macrophages. Clin Vaccine Immunol 17: 1417–1427.
- 36. Bafica A, Scanga CA, Schito ML, Hieny S, Sher A (2003) Cutting edge: in vivo induction of integrated HIV-1 expression by mycobacteria is critically dependent on Toll-like receptor 2. J Immunol 171: 1123–1127.
- 37. Hernandez JC, Arteaga J, Paul S, Kumar A, Latz E, et al. (2011) Up-regulation of TLR2 and TLR4 in dendritic cells in response to HIV type 1 and coinfection with opportunistic pathogens. AIDS Res Hum Retroviruses 27: 1099–1109.
- 38. Bafica A, Scanga CA, Schito M, Chaussabel D, Sher A (2004) Influence of coinfecting pathogens on HIV expression: evidence for a role of Toll-like receptors. J Immunol 172: 7229–7234.
- 39. Ogawa Y, Kawamura T, Kimura T, Ito M, Blauvelt A, et al. (2009) Gram-positive bacteria enhance HIV-1 susceptibility in Langerhans cells, but not in dendritic cells, via Toll-like receptor activation. Blood 113: 5157–5166.
- 40. Thibault S, Tardif MR, Barat C, Tremblay MJ (2007) TLR2 signaling renders quiescent naive and memory CD4+ T cells more susceptible to productive infection with X4 and R5 HIV-type 1. J Immunol 179: 4357–4366.
- 41. Ding J, Rapista A, Teleshova N, Mosoyan G, Jarvis GA, et al. (2010) Neisseria gonorrhoeae enhances HIV-1 infection of primary resting CD4+ T cells through TLR2 activation. J Immunol 184: 2814–2824.
- 42. Ding J, Chang TL (2012) TLR2 activation enhances HIV nuclear import and infection through T cell activation-independent and -dependent pathways. J Immunol 188: 992–1001.
- 43. Chang JS, Huggett JF, Dheda K, Kim LU, Zumla A, et al. (2006) Myobacterium tuberculosis induces selective up-regulation of TLRs in the mononuclear leukocytes of patients with active pulmonary tuberculosis. J Immunol 176: 3010–3018.
- 44. Schreiber HA, Harding JS, Hunt O, Altamirano CJ, Hulseberg PD, et al. (2011) Inflammatory dendritic cells migrate in and out of transplanted chronic mycobacterial granulomas in mice. J Clin Invest 121: 3902–3913.
- 45. Tan DB, Lim A, Yong YK, Ponnampalavanar S, Omar S, et al. (2011) TLR2-induced cytokine responses may characterize HIV-infected patients experiencing mycobacterial immune restoration disease. AIDS 25: 1455–1460.
- 46. Zhang H, Zhou Y, Alcock C, Kiefer T, Monie D, et al. (2004) Novel single-cell-level phenotypic assay for residual drug susceptibility and reduced replication capacity of drug-resistant human immunodeficiency virus type 1. J Virol 78: 1718–1729.