HIV-1 Remission after Allogeneic Hematopoietic-Cell Transplantation

We report the results of the 60-month follow-up of a 63-year-old man who was found to be free of human immunodeficiency virus type 1 (HIV-1) infection after undergoing hematopoietic-cell transplantation (HCT) for the treatment of acute myelogenous leukemia (AML).The transplant was obtained from a donor with a Δ32 mutation, which causes a CCR5 deletion (CCR5-Δ32/Δ32) that has been associated with resistance to HIV-1 infection.At the time of this follow-up, the patient had been free of HIV-1 infection for 35 months after the discontinuation of antiretroviral therapy.The patient had received a diagnosis of HIV-1 infection 31 years before undergoing transplantation, and because of his older age, he had received reduced-intensity conditioning without T-cell depletion, unlike other HCT recipients who have had prolonged HIV-1 control (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org).[1][2][3][4] The patient, who had a history of undetectable HIV-1 RNA levels since 1997 while receiving antiretroviral therapy, had remission from AML after salvage chemotherapy (Table S2).HCT was recommended for AML cure, and a CCR5-Δ32/Δ32 donor was identified.The patient had wild-type homozygous CCR5 receptors and predominantly R5 virus.After approval by the institutional review board at City of Hope National Medical Center, the patient consented to reservoir testing and eventual interruption of his antiretroviral therapy to assess HIV remission.HCT was performed with the use of reduced-intensity conditioning with fludarabine and melphalan as well as sirolimus-tacrolimus prophylaxis against graft-versus-host disease (GVHD) (Fig. 1A).The patient and donor were matched with respect to human leukocyte antigen (Table S3A) with different genotypes of killer-cell immunoglobulin-like receptors (KIRs) (Table S3B).After HCT, bone marrow biopsy was negative for AML with full donor-cell chimerism.Immunity to hepatitis B virus was noted after vaccination.jdickter@coh.org .