The Role of Gender-Affirming Hormone Therapy in Anal Human Papilloma Virus Persistence (HPV) and Systemic and Mucosal Immunity in Transgender Women with and without HIV

Modified Project Summary/Abstract Section People with or at risk for HIV are disproportionately affected by anal high-risk human papillomavirus (HR-HPV). HIV alters HPV immunity and potentiates HPV persistence, thus increasing cancer risk. The peripheral and mucosal immune response against anal HPV is linked to the regression of high-grade anal dysplasia – the precursor to anal cancer. In women, estrogen may alter the immune response against HPV-infected cells, increase HPV persistence, and facilitate the progression to cervical cancer. In men, higher testosterone levels have been linked to a higher prevalence of anal HPV. However, there is a critical gap in understanding the effect of sex-steroids on HPV immunity and persistence, and consequentially the progression to anal dysplasia, particularly in people with or at risk for HIV. This gap hinders the research into urgently needed novel HPV immunotherapies targeting anal dysplasia in these populations. We will conduct a secondary analysis of samples from our HPV natural history cohorts. In one of these cohorts, of 80 people in Washington DC, we found a high prevalence of HR-HPV (73%) and anal dysplasia (48%). In Aim 1, we will assess the effect of estradiol or testosterone blockers (ETB) on systemic HPV16 immunity using flow cytometry. We will compare, crosssectionally in people with natural infection (1a) and longitudinally in response to the HPV 9- valent vaccine (1b), immune markers, the proportion of peripheral HPV-specific CD4 T-cells, and L1-specific antibodies (1a and 1b), and CD8 T-cells (1a), between 60 people with high levels of estradiol and low levels of testosterone and 60 with low levels of estradiol and high levels of testosterone, stratified by HIV status. In Aim 2, we will assess the effect of ETB on the mucosal HPV16 immune response. Using confocal microscopy on anal tissue of participants with anal HPV16 infection, we will compare quantitative and qualitative characteristics of immune cells from 40 people with high levels of estradiol and low levels of testosterone and 40 with low levels of estradiol and high levels of testosterone, stratified by HIV status and lesion type. In Aim 3, we will examine the effect of ETB on anal HR-HPV persistence defined as the detection, on HPV whole-genome sequencing (NGS), of the same HR-HPV sublineage at an initial timepoint and at 6, 12, and 18-months. We will compare HPV persistence between 60 people with high levels of estradiol and low levels of testosterone and 60 with low levels of estradiol and high levels of testosterone, stratified by HIV status. The proposed work will provide training in sex-steroids biology, interpreting results of HPV NGS and immunological techniques, and academic skills needed for a career in translational clinical research under the mentorship of Drs. Gaykalova, Kottilil, Klein, Lisco, and Rosenthal. This data will inform shared decision-making discussions based on hormone levels, provide guidance for optimal anal cancer screening and treatment of anal dysplasia in people with or at risk for HIV, and guide the study of HPV immunotherapies for anal dysplasia by explaining the role of sex-steroids on immunological and virological research endpoints.