PAPILLOMAVIRUS BINDING AND ENTRY

The heparan sulfate receptor and inhibition by lactoferrin

by

Peter Drobni

Department of Clinical Microbiology, Virology Umeå University, Sweden 2005

Front cover: Binding of papillomavirus to glycoseaminoglycans. Aquarelle by Mirva Drobni

© 2005 Peter Drobni Printed in Sweden by Solfjädern Offset AB Umeå 2005 tom tom

Till Elliot & Mirva

TABLE OF CONTENTS

1. Abstract 9 2. List of papers 10 3. Abbreviations 11 4. Sammanfattning 12 5. Summary of papers 14 5.1 Paper I 14 5.2 Paper II 14 5.3 Paper III 15 5.4 Paper IV 15 6. Introduction 17 6.1 Human papillomavirus (HPV) 17 6.1.1 HPV History 17 6.1.2 Phylogeny 18 6.1.3 Genome organization 19 6.1.4 Structure 19 6.1.5 Life cycle 21 6.1.6 VLPs as research tools 22 6.1.7 Receptors for human papillomaviruses 23 6.1.8 Internalization 23 6.1.9 PV proteins 24 6.1.10 Disease 27 6.1.11 Therapy 29 6.1.12 Immune response 31 6.1.13 Vaccines 33

7 6.2 Glycosaminoglycans 35 6.2.1 General 35 6.2.2 As viral receptors 36 6.3 Lactoferrin 36 6.3.1 Structure 37 6.3.2 Antiviral mechanism 38 6.3.3 Lactoferricin 38 7. Aim of the thesis 39 8. Materials and methods 40 8.1 Cell lines 40 8.2 VLP production 40 8.3 CFDA-SE labeling 40 8.4 Binding assays 41 8.5 Internalization assays 41 9. Results and discussion 42 9.1 As a tool to study infection 42 9.2 CFDA-SE as an internalization assay 42 9.3 Heparan sulfate as an HPV receptor 43 9.4 Lactoferrin and lactoferricin as HPV inhibitors 44 9.5 Results from paper I 46 9.6 Results from paper II 46 9.7 Results from paper III 47 9.8 Results from paper IV 48 10. Conclusions 49 11. Concluding remarks 50 12. Acknowledgements 51 13. References 53

8 1. ABSTRACT

Papillomaviruses (PVs) infect epithelial cells and are the main causative agent of cervical carcinoma. There are today more than a hundred different PV types and these can be divided into high risk and low risk types. They infect differentiating epithelial cells which make it cumbersome to propagate and produce human papillomavirus (HPV) virions. A common method to study HPV infection is to use HPV virus like particles (VLPs) produced in recombinant eukaryotic expression systems. Glycosaminoglycans (GAGs) have been described as an initial attachment receptor for several viruses. Our aim was to study the interactions between HPV VLPs and different GAGs to determine how these could affect binding and internalization. We found that soluble heparin was the best GAG inhibitor of HPV-16 VLP binding followed by heparan sulfate of mucosal origin. We could also see that CHO cells deficient in GAG expression had a reduced ability to bind VLPs, as did cells pre- treated with heparinase III. Our results suggested a primary interaction between HPV and heparin sulfate. To be able to study the early steps of internalization we developed a method where we conjugated the CFDA-SE dye to the surface of VLPs. CFDA-SE is activated by cellular esterases inside the cell. This renders the particle fluorescent and thereby visible in flow cytometry analysis. With this new technique we found that entry of the mucosal HPV-6 and HPV-16 was inhibited by heparin. We could also detect differences between mucosal HPV-16 and cutaneous HPV-5 when these where pre-incubated together with GAGs. The cutaneous PV type was not inhibited by heparin to as high degree as the mucosal type. This might be explained by charge differences in the capsid. The mucosal capsid seems to be more positively charged than the epithelial type which should result in a higher affinity for the negatively charged GAGs. Also, we report for the first time that HPV-5 uses a clathrin mediated internalization process. It has been reported for other viruses such as herpes simplex virus (HSV) that lactoferrin, a protein found in high concentrations in breast milk and vaginal fluids could inhibit infection. Interestingly, HSV also use heparan sulfate as a primary attachment molecule. We wanted to investigate if lactoferrin and lactoferricin could have an effect on HPV binding and internalization. We pre-treated HPV-16 VLPs with lactoferrin of bovine or human origin before infection. After incubation we could detect reduced levels of both bound and internalized HPV VLPs to HaCaT cells. In this case, lactoferrin of bovine origin proved to be more efficient in inhibiting both binding and internalization. To further investigate this we used the N-terminal part of lactoferrin, lactoferricin, to study any possible inhibitory effects. Here we found that lactoferricin of bovine origin was a more potent inhibitor of binding, while human lactoferricin was more effective in inhibiting internalization. This could in part be explained by folding differences between these two related proteins. This work further strengthens the proposed interaction between HS and PV for initial interaction and for the first time show charge depending differences between cutaneous and mucosal type binding and internalization and also that lactoferrin and lactoferricin, parts of the innate immune system inhibit PV binding and internalization in vivo.

9 2. LIST OF PAPERS

Paper I Carboxy-flourescein diacetate, succinimidyl ester labeled papillomavirus virus like particles fluoresce after internalization and interact with heparin sulfate for binding and entry. Peter Drobni, Nitesh Mistry, Nigel McMillan and Magnus Evander. (2003) Virology 310 163-172

Paper II Mucosal and cutaneous papillomaviruses interact differently with the attachment receptor heparan sulfate on the cell surface. Nitesh Mistry, Stefan Nord, Peter Drobni, Carl Wibom and Magnus Evander. Manuscript

Paper III Lactoferrin inhibits human papillomavirus binding and uptake in vitro. Peter Drobni, Jonas Näslund and Magnus Evander. (2004) Antiviral Research 64 63-68

Paper IV The anti-HPV activity of human and bovine lactoferricin. Peter Drobni, Jonas Näslund, Håvard Jenssen and Magnus Evander. Manuscript

10 3. ABBREVIATIONS

aa Amino acid BLf Bovine lactoferrin BLfcin Bovine lactoferricin BM Binding medium BPV Bovine papillomavirus CFDA-SE Carboxy-fluorescein diacetate, succinimidyl ester CIN Cervical intraepithelial dysplasia CRPV Cottontail rabbit papillomas virus Dex Dextran sulfate ELISA Enzyme-linked immunosorbent assay GAG Glycosaminoglycan HLf Human lactoferrin HLfcin Human lactoferricin HS Heparan sulfate HPV Human papillomavirus IARC International Agency for Research on Cancer kDa Kilo Dalton Lf Lactoferrin Lfcin Lactoferricin LCR Long control region ORF Open reading frame PV Papilloma virus RT-PCR Reverse-transcriptase polymerase chain reaction VLPs Virus-like particle

11 4. SAMMANFATTNING

Papillomvirus har återfunnits hos många olika däggdjur och finns i en mängd olika typer. De kan bland annat orsaka kondylom och vanliga vårtor, men kan även i vissa fall leda till cancer i livmoderhalsen. Cancer i livmoderhalsen är idag den tredje vanligaste cancertypen i världen hos kvinnor med nästan en halv miljon nya fall varje år, varav ca 500 i sverige. I över 99 procent av alla livmoderhalstumörer som kirurgiskt avlägsnas så går det att påvisa arvsmassa från humant papillomvirus (HPV). Hur viruset tar sig in i sin värdcellen har inte varit känt. Framför allt har det inte varit riktigt klart vilka strukturer på cellens yta som viruset binder till för att kunna ta sig in. I min första artikel har vi utvecklat en ny metod för att studera mängden virus som tar sig in i en cell. En speciell färg som binder till utsidan av viruspartiklarna tillsätts. När de märkta viruspartiklarna tas in i cellen så aktiveras färgen av speciella enzymer inuti cellen och färgen blir synlig. Med denna metod kan man uppskatta hur mycket HPV som en cell tar upp och se om denna mängd förändras när man tillsätter olika substanser till viruset eller cellerna. Genom detta kunde vi visa att en viss typ av sockerstruktur, s.k. glukosaminoglykaner som finns på i princip alla celler, fungerar som en möjlig bindningsplats för HPV. Detta kunde vi ta reda på genom att tillsätta glukosaminoglykan i löst form till virus innan vi lät dem binda till cellerna. Det lösta glukosaminoglykanet band då till HPV vilket ledde till att virus inte längre kunde binda eller ta sig in i cellerna. Vi kunde även visa att celler som saknar dessa specifika sockerstrukturer på sin yta inte kunde binda viruspartiklarna. Dessutom behandlande vi celler med ett ämne som tar bort alla glukosaminoglukaner från cellytan. Efter denna behandling så såg vi att cellerna inte längre kunde binda några virus. I den andra artikeln så studerade vi skillnaderna mellan HPV-5 och HPV-16. HPV-5 är en typ av papillomvirus som oftast återfinns på huden medan HPV-16 är en typ som oftast återfinns i slemhinnor. Vi fann att HPV-5 inte inhiberades lika mycket av löst glykosaminoglykan som HPV-16 när vi undersökte upptag av virus. Detta skulle kunna bero på att ytan på HPV-5 är mindre positivt laddad än på HPV-16. Eftersom glykosaminoglykanerna på cellen är negativt laddade kommer HPV-16 att dras till cellens yta med högre affinitet än HPV-5. HPV-5 kan möjligen också använda annan receptor och inte påverkas i samma grad. Med den metoden som vi använde såg vi även att både HPV-5 och HPV-16 använder sig av samma mekanism för att ta sig in i cellen när viruset väl bundit till cellytan.

12 I min tredje artikel så undersökte vi om proteinet lactoferrin, som är en del av vårt medfödda immunförsvar, kunde hindra papillomvirus från att binda till sina värdceller. När vi tillsatte lactoferrin till virus så visade det sig att det var mycket effektivt från att hindra virus från att både binda till cellytan och att ta sig in i cellen. Detta är intressant eftersom lactoferrin är ett protein som finns i t.ex. saliv, tårar och i bröstmjölk men även i vaginala sekretioner. Vi upptäckte även att lactoferrin från komjölk var mycket mer effektiv i att hindra infektion än den mänskliga varianten. Lactoferrin är även effektivt mot andra mikroorganismer som bakterier och svamp och har visat sig vara effektiv till att bl.a. minska candida hos ammande barn. I den fjärde artikeln så har vi försökt att se om en mindre del av lactoferrin, sk lactoferricin är lika effektiv i att hindra infektion av papillomvirus, då lactoferricin i andra organismer har visat sig vara en mycket effektiv inhibitor. Lactoferricin bildas i bl.a. magen genom att vissa enzymer klyver lactoferrinet till mindre delar. När vi studerade effekten av lactoferricin på papillomvirusinfektion kunde vi se att lactoferricin från ko var mycket mer effektiv än lactoferricin liknande de hos människa i att reducera antalet bundna virus till cellytan. Det rakt motsatta visade sig vara fallet när vi studerade hur mängden HPV som togs upp av cellen förändrades efter tillsatts av dessa lactoferricinpeptider. De humana peptiderna var mer effektiva i att hindra upptag än de med ursprung från ko. Detta kan delvis förklaras av att skillnader i den tredimensionella strukturen hos de olika lactoferricinpeptiderna. Eftersom så lite är känt om hur HPV binder till och infekterar sin värdcell, samt att det idag inte finns så bra behandlingsmetoder mot t.ex. kondylom, är det viktigt att undersöka hur de tidiga stegen i virusets upptagsmekanism fungerar, samt att hitta möjliga ämnen som skulle kunna fungera som potentiella läkemedel.

13 5. SUMMARY OF PAPERS

5.1 Paper I

Carboxy-flourescein diacetate, succinimidyl ester labeled papillomavirus virus like particles fluoresce after internalization and interact with heparan sulfate for binding and entry. (2003) Virology 310 163-172

Our aim was to investigate the initial attachment and entry of HPV using CFDA-SE labeled virus like particles and western blot. When cells were pretreated with different concentrations of several types of soluble glycosaminoglycans (GAGs) a dose dependent inhibition of binding was found, with heparin being the most effective agent, but heparan sulfate from a mucosal source also reduced HPV-16 VLP binding at very low concentrations. To further show the interactions between GAGs and HPV-16 VLPs we used one cell line unable to express GAGs on the cell surface and another unable to express heparan sulfate but did express the other GAGs. These cells were virtually unable to bind any HPV-16 VLPs. Furthermore, we treated the cells with heparinase III that removes heparan sulfate from the cell surface. This removal of heparan sulfate from the surface strongly reduced the amount of bound HPV-16 particles to the cell surface. CFDA-SE is a dye that only becomes fluorescent after being internalized inside the cell and activated by intracellular esterases. This was a good tool for studying the early steps of uptake of the VLPs into the cells. Using this assay we found dose dependent inhibition of uptake for both HPV-6 and HPV-16 VLPs.

5.2 Paper II

Mucosal and cutaneous papillomaviruses interact differently with the attachment receptor heparan sulfate on the cell surface. Manuscript

The HPV types that are able to infect the skin are usually unable to infect the mucosa and vice versa. We therefore wanted to investigate how the different types of HPVs use heparan sulfate as a receptor for both binding and entry. We investigated whether the cutaneous HPV-5 use a different internalization mechanism than the mucosal HPV-16, by treating cells with

14 chlorpromazine, an inhibitor of the endocytic pathway. We found that both HPV-16 and HPV-5 were unable to internalize particles after this treatment, suggesting that they use the same uptake mechanism. However we also found that the cutaneous HPV type was not inhibited by heparin to such a high degree as the mucosal type. The HPV-16 L1 capsid protein is more positively charged than HPV-5 L1 and this could in part explain the inhibitory differences. When we predicted the isoelectric point (pI) of 70 HPV-types, basically all mucosal types had positive charge, while the cutaneous types had a negative charge at physiological pH. Whether this is of importance for HPV tropism remains to be examined.

5.3 Paper III

Lactoferrin inhibits human papillomavirus binding and uptake in vitro. Antiviral Research 64 (2004) 63-68

Lactoferrin, a protein found in milk and vaginal secretions, and known to have antimicrobial activity against many different organisms was analyzed for its effect in reducing binding and uptake of CFDA-SE labeled HPV-16 VLPs. We used lactoferrin of both bovine and human origin. We found that both lactoferrins strongly reduced binding of HPV-16 VLPs in vitro although BLf was more effective than HLf. For inhibition of uptake, only BLf was able to inhibit viral entry. We could also show that BLf acts early in the internalization process, probably by interacting with the heparan sulfate receptor. This was performed by adding lactoferrin after allowing VLPs to bind to the cell surface.

5.4 Paper IV

The anti-HPV activity of human and bovine lactoferricin. Manuscript

In this report we investigated how effective lactoferricin, the pepsin cleaved N-terminal part of Lactoferrin (Lf), was in inhibiting binding of HPV-16 VLPs to HaCaT cells. Lactoferricin (Lfcin) is known to be active against many different microorganisms including herpes simplex virus (HSV). For HSV others have shown that bovine lactoferricin (BLfcin) is more effective in reducing the infection of the virus in comparison to human lactoferricin (HLfcin). We found that the different Lfcin peptides analyzed did function as inhibitors for

15 papillomavirus binding and uptake. In our assays BLfcin was a better inhibitor of HPV-16 binding than HLfcin. Interestingly, HLfcin was a better inhibitor of internalization of HPV-16 than BLfcin. This could be due to differences in charge or the three dimensional protein structure. Lf was a more effective inhibitor oh HPV-16 binding than Lfcin. This could be explained by a low but significant interaction between Lf and HPV-16 VLPs. By ELISA we found that Lfcin only had a weak interaction with HPV-16 VLPs, while Lf showed stronger interaction.

16 6. INTRODUCTION

6.1 Human papillomavirus (HPV)

HPV is the main causative agent for cervical cancer and is found in nearly all cervical tumors (Walboomers et al., 1999). Except from causing cancer in the cervix, HPV is responsible also for causing condyloma accuminata and warts. There are today more than a hundred different types of PVs known and these can be divided into high risk and low risk papilloma viruses. Amongst these only the high risk types are associated with cervical cancer. Because of the difficulties in propagating HPV in vitro, investigations of HPV have been hampered. Instead of virus prepared from warts so called virus-like particles (VLPs) are used. These are particles expressed in various systems and can be used as a powerful tool to study the early events of the viral life cycle.

6.1.1 HPV History

Papillomavirus (PV) was first scientifically described 1907 when Giuseppe Ciuffo, Universita di Cagliari in Italy demonstrated that cell free filtrates prepared from warts were able to transmit the disease (Ciuffo, 1907). Shope and coworkers later demonstrated that papillomas from the cotton tail rabbit were transmissible and thereby identified the first non-human papillomavirus, CRPV (Shope and Hurst, 1933). The cottontail rabbit was for a long period an important model system. The first correlation between papillomavirus and cervical intraepithelial dysplasia (CIN) was first suggested in the mid 70s when Meisels and co- workers observed the papillomavirus infection of the cervix often had similar characteristics of low grade CIN (Meisels and Fortin, 1976; Meisels et al., 1977). At the same time it was shown that the sexually transmitted HPV had a close correlation to cervical cancer (zur Hausen, 1976).

17 6.1.2 Phylogeny

Traditionally papillomaviruses belonged to the family papovaviridae because of similar capsid structure and the double stranded circular DNA. Later it was shown that they differed in genome size and genome organization, and shared a very small nucleotide sequence similarity. Today papillomaviruses and polyomaviruses are divided into the two distinct families “polyomaviridae” and “papillomaviridae” and there are more than 100 human types characterized. PVs have been identified in different mammals and are believed to have evolved together with the vertebrates (Jenson et al., 2001). Papillomaviruses are divided into the taxonomical levels, genus, species, types, subtypes and variants (Fig. 6.1). The L1 open reading frame has in recent years, due to its conserved sequence, been used for the identification of new papillomavirus types. Variants are recognized when the cloned sequence of L1 differs less then 2%. Subtypes are defined as having differences between 2 and 10%. Different genera have less than 60 % homology and species with homology between 60-70% (de Villiers et al., 2004).

Figure 6.1 Phylogenetic tree containing 118 PVs. From De Villiers et.al 2004, with permission

18 6.1.3 Genome organistation

The HPV genome is approximately 8000 bp and encodes for eight open reading frames (ORFs) and these are all located on one strand. These open reading frames are divided into the early genes and the late genes (Fig. 6.2). There is a non coding region called the long control region (LCR) containing the origin of replication. This region controls transcription of the E6 and E7 genes. Several cellular proteins can bind and enhance this activity (Struyk et al., 2000).

Figure 6.2 HPV-16 genome. Modified from Fields et.al 2001

6.1.4 Structure

The papillomavirus particle has an approximate size of 55nm in diameter with a density of 1.34 g/mL in cesium chloride. The capsid is made up of 72 L1 capsomeres arranged in a t = 7 icosahedral symmetry. All of the capsomeres are mushroom like protrusions with pentameric star shaped heads (Fig. 6.3). Some of the papillomavirus capsids such as CRPV contain several large holes, while others such as HPV-1 only contain two small holes (Hagensee et al., 1994). The papillomavirus genome encodes two structural proteins: the 510 amino acid residue long major capsid protein L1 (58 kDa) and the 470 amino acid long minor capsid protein L2. The L1 protein forms pentameres and these are arranged into capsomeres. Twelve of the capsomeres are pentavalent (surrounded by five other capsomeres) and 60 of them are

19 hexavalent (surrounded by six other capsomeres). There are twelve 74 kDa L2 molecules in one papillomavirus virion and these are believed to be located in the center of the twelve pentavalent capsomeres. The interaction between the L1 and the L2 molecules does not seem to be of covalent nature (Sapp et al., 1995). It has been shown that parts of L2 are accessible from the outside and that there are epitopes on VLPs composed of HPV-16 L1 and L2 particles that are recognizable by anti-L2 antibodies (Kawana et al., 1998a).

L2 has been suggested to be important in the DNA encapcidation and infectivity process, because of the DNA binding properties of L2. Also, some positively charged residues in L2 are important for the infection of HPV6 (Roden et al., 2001). Pseudovirions composed of only L1 does not transduce reporter plasmids as well as pseudovirions composed of both L1 and L2 (Rossi et al., 2000; Unckell et al., 1997). This has also shown to be the case in L2 deficient true virus particles in where it was a 100 fold reduction of infectivity (Holmgren et al., 2005). Also, L2 seems to play an important role in relocalizing the E2 trans activator protein to nuclear subdomains known as PODs (Day et al., 1998; Florin et al., 2002; Heino et al., 2000). The exact role of PODs are not known. When L2 is co expressed with L1 in cells harboring episomal DNA, the encapcidation of this DNA is increased more than 50-fold. (Stauffer et al., 1998; Zhao et al., 1998; Zhou et al., 1993)

Figure 6.3 PV capsid structure

20 6.1.5 Life cycle

The life cycle of papillomavirus is strongly connected to the differentiation pattern of the host cells, the keratinocytes (Fig. 6.4). Replication of the virus first begins with the expression of the early proteins at the more basal layers of the skin or mucosa. These layers contain cells that are capable of dividing and therefore are essential for the virus to maintain a persistent infection. It is possible that the virus gains access to the basal cells through micro lesions. The basal cells of the epithelium are constantly dividing and serve as a reservoir for the virus (Hummel et al., 1992). These stem cells are also available in hair follicles that could also serve as a point of entry (Schmitt et al., 1996). The viral genome is kept extra chromosomally at low maintenance replication at 50-100 copies per cell (Stubenrauch and Laimins, 1999). These are shared between the two daughter cells when dividing. The virion production only takes place in the suprabasal regions and therefore protects the basal cell from lysis. The virus reprograms the post-mitotic cells to support DNA synthesis. This makes it possible for HPV to keep infected cells proliferating for a long time. In the more differentiated cell layers there is an induction of the late viral late promoters and viral DNA amplification. At the more superficial layers the L1 and L2 proteins and the HPV DNA are assembled into virions.

Figure 6.4 Different steps of the viral replication (modified from (Stubenrauch and Laimins, 1999)).

21 6.1.6 VLPs as research tools

The difficulties of propagating papillomavirus in vitro had led to the development of virus like particles (VLPs) (Fig. 6.5). The VLPs are composed of either the L1 protein alone or both the L1 and L2 protein. These are produced in different expression systems. The first HPV VLPs were produced in vaccinia systems recombinant for producing HPV-16 L1 and L2 (Zhou et al., 1992). VLPs have also been produced in other systems such as insect cells, E- coli and yeast (Kirnbauer et al., 1993; Li et al., 1997; Rose et al., 1993). These particles have similar structure as virions prepared from warts. Reporter genes can be inserted to the inside or conjugated to the outside. The internalized reporter genes can be introduced in a cell free system or introduced into the VLP inside a cell. These VLPs have many structural similarities and can be used to study the internalization process although some reports have pointed towards some differences. The internalization time have been shown to vary significantly between VLPs and pseudovirions. Using electron microscope it was shown that with BPV-1 VLPs were endocytosed within 30 minutes (Zhou et al., 1995) and accumulated in the perinuclear zone after 60 minutes (Liu et al., 2001). Entry times of up to 4 hours have have also been reported for HPV-33 pseudovirions (Selinka et al., 2002). An entry time of 4 hours was shown both for BPV-1 and HPV-31 virions (Day et al., 2003; Ozbun, 2002).These reports show that depending on PV-type, cell line and assay system, the internalization time differs. Recently it was shown by quantitative RT-PCR that complete HPV-11 and -40 virions infected cultured cells with slow kinetics (Culp and Christensen, 2004).

Figure 6.5 EM image showing HPV-16 L1 VLPs prepared in our lab. Photograph by Rolf Sjöberg

22 6.1.7 Receptors for papillomaviruses

The α6-integrin was the first identified viral attachment protein for human papillomavirus type

6b using virus like particles. α6-integrin is a cell surface protein that is coupled to either the β4 or the β1 integrin. By using antibodies against the α6 protein, binding of VLPs was blocked in a keratinocyte cell line (Evander et al., 1997). It was later shown that cells expressing either

β4 or β1 were equally able to bind VLPs with the conclusion that the beta part of the integrin does not play any major part. The α6β4-integrin is a part of the hemidesmosome and functions as a receptor for laminin (Niessen et al., 1994; Sonnenberg et al., 1991). When DG75 (a cell line negative for expression of α6-integrin), not able to bind VLPs was used and expression of

α6 was transduced into these cells, they became able to bind VLPs (McMillan et al., 1999). Similar results were later shown by other researchers (Yoon et al., 2001). Others did however detect some infection in the wild type DG-75 cell line using RT-PCR. Also, it was demonstrated that HPV-11 needs the expression of heparan sulfate on the surface of COS-7 cells for infection (Joyce et al., 1999). This was later also demonstrated to be true using HPV- 16 and HPV-33 (Giroglou et al., 2001). The requirement for heparan sulfate as a receptor has also been shown for HPV types 18, 31, 33, 39, 45, 58, 59 and 68 (Combita et al., 2001).

Syndecans have been proposed to be the proteins that carries heparan sulfate (Selinka et al., 2002). Furthermore, the syndican-1 was suggested after transfecting K562 cells with cDNA from different syndecans (Shafti-Keramat et al., 2003). Syndican-1 expressing cells were able to bind VLPs to a higher degree than cells expressing syndican-4 or glypican-1. The cells expressing syndican-1 were also the ones expressing the highest levels of heparan sulfate on the cell surface (Shafti-Keramat et al., 2003).

6.1.8 Internalization

Small and smooth pinocytotic vesicles were first suggested by researchers to be used as an internalization mechanism for papillomavirus. By using immunoelectron microscopy (Volpers et al., 1995) it was observed with HPV-33 particles that they bound to HeLa cells and seemed to internalize in compartments lacking the distinctive features of clathrin coated pits. It was later shown by others that bovine papillomavirus was internalized through the clathrin dependent system (Day et al., 2003). This was to some extent surprising since internalization using the clathrin dependent pathway usually is faster (5-15min) than the internalization times

23 reported for papillomaviruses (Bousarghin et al., 2003; Christensen et al., 1995; Day et al., 2003; Selinka et al., 2002). A two-fold reduction of infection has been shown as long as 24 hours after the addition of antibodies targeting the viral capsid. After this, several reports using different toxins to inhibit the different internalization processes have been published (Bousarghin et al., 2003; Day et al., 2003). Cytochalasine D and nocadozole were used to inhibit internalization of HPV-33 pseudovirions suggesting the need for intact actin and microtubule formation. For HPV-33 virions, nystatin, an inhibitor of caveolae mediated endocytosis, did not significantly affect internalization (Selinka et al., 2002). Interestingly the same substance effectively inhibited gene transfer of HPV-31 pseudovirions, but not HPV-16 or HPV-58. This is so far the only report of an HPV that uses caveolae mediated endocytosis and not clathrinmediated endocytosis (Bousarghin et al., 2003).

6.1.9 PV proteins

E1 and E2 E1 is one of the highly conserved viral proteins and is also the largest. It is a 593 aa, 68 kDa protein and is not expressed in high levels in HPV infected cells. This early protein functions in origin recognition when it forms a complex together with E2 and binds to A/T sequences to recruit cellular polymerases and other accessory proteins (Mohr et al., 1990). E1 has a very important helicase function. It is a 3´→5´ helicase that can function on a variety of substrates, both linear and circular double stranded DNA. (Longworth and Laimins, 2004; Wilson et al., 2002). This function of the E1 protein is important to maintain the viral DNA as an episome. Furthermore, E1 has been shown to interact with many other proteins such as the DNA polymerase α-primase and recruiting the cellular DNA replication machinery to the viral origin of replication (Bonne-Andrea et al., 1995; Park et al., 1994).

The E2 protein is transactivating and have key functions in the PV life cycle. E2 proteins are 360 amino acids and 50kDa in size and forms dimers. E2 helps to recruit E1 by site specific interactions. In comparison with E1, E2 binds with high affinity to the DNA. After guiding E1 to the correct site and forming the complex E2 is released from the origin (Baxter and McBride, 2005). E2 has also been described to be able to induce a p53 independent apoptosis upon overexpression (Dowhanick et al., 1995). Furthermore, an interaction between the cellular protein A and HPV E2 has also been described (Li and Botchan, 1993). The capsid protein L2 can bind to E2 (Heino et al., 2000) and then E2 is relocalized to subnuclear

24 domains together with L1 (Day et al., 1998). Since the viral genome have a specific binding site for E2 (McBride et al., 1991), the HPV genome is also relocalized by L2 to the same sub nuclear domains (Day et al., 1998) as L1. Possibly, L2 can use E2 to recruit the HPV genome to the site of virion assembly.

E4 The E4 protein is translated as a fusion protein together with E1 to form the E1^E4 protein. The function of E4 is not very well understood. E4 from high risk papillomavirus types has been shown to be able to interact with the keratin networks in the host cell and thereby induce their collapse, although in the natural infections only a limited level of keratin collapse have been observed (Doorbar et al., 1991). Also, E4 may be involved in gene expression since it has been shown to interact with the RNA helicase, E4-DBD, involved in mRNA splicing

(Yoshioka et al., 2000). Over expression of E4 can also induce a G2 cell arrest in several cell types (Davy et al., 2002).

E5 The E5 protein plays a important role in the transforming activities in BPV by acting on the platelet derived cellular growth factor receptors (Petti et al., 1991). The human E5 is a hydrophobic 90 amino acid transmembrane protein found mainly in intracellular membranes such as the golgi and the endoplasmatic reticulum, but is also found in the nuclear membrane (Conrad et al., 1993). One of the first experiments showing the oncogenic capacities of HPV E5 showed that this viral protein was able to induce anchorage independent growth in established murine fibroblasts (Chen and Mounts, 1990). The E5 protein does not seem to have any enzymatic activity but is able to modulate cell growth by interfering with the activity of different cellular proteins that regulate cell growth. One of the suggested mechanisms behind this is an interaction with the tyrosine kinase signaling pathway and in this way modulate the epidermal growth factor receptor and the platelet derived growth factor receptor- β (Hwang et al., 1995). Furthermore, HPV-16 E5 have been shown to interact and downregulate surface HLA Class I molecules (Ashrafi et al., 2005). The E5 gene does not seem to score as a major transforming gene in human papillomaviruses and is not necessary for the transforming activities of HPVs (Munger and Howley, 2002).

25 E6 The HPV 16 E6 is a 151 amino acid protein and contains two zinc binding motifs (Li et al., 2005). Expression of E6 is consistent in malignant tissue and expression of E6 alone leads to immortalization of many cell lines, such as NIH3T3 cells and some human epithelial cells (Liu et al., 1999). Human keratinocytes needs both E6 and E7 to be immortalized (Hawley- Nelson et al., 1989). The E6 protein from the high risk types, but not the low risk types, acts as viral oncoproteins. To overcome apoptosis in the cells, the E6 protein from the high risk types is able to bind to the p53 tumor suppressor protein in a trimeric complex together with the E6AP protein and the ubiquitin ligase (Fig. 6.6)(Huibregtse et al., 1991). This leads to a rapid breakdown of p53 through the 26s proteaosome with a turnover shortened from 3 hours to 30 minutes. Also E6 can directly downregulate p53 by interacting with one of the co- activators, p300/CBP (Lechner and Laimins, 1994).

E6 has also been shown to be able to transcriptionaly activate the telomerase hTERT gene (Fig. 6.6)(Veldman et al., 2001) and interact with a variety of other proteins such as paxillin (Tong and Howley, 1997) and MUPP1 (Lee et al., 2000).

Figure 6.6 Different functions of the E6 protein

26 E7 The E7 proteins of HPVs are zinc binding proteins of approximately 100 amino acids in size (Munger and Howley, 2002). E7 is able to interact with Rb family tumor suppressor genes through a binding site at the N-terminal part (Barbosa et al., 1990; Dyson et al., 1992). The proteins in this family are pRb, p107 and p130. This interaction then leads to the inactivation of pRb and this in turn permits the cells to enter S-phase. The Rb proteins regulate the cell cycle by suppressing the E2F/DP1 transcription factors binding to promoters regulating S- phase progression and apoptosis. E7 is able to reduce the amount of pRB by promoting proteolysis through the proteaosome (Boyer et al., 1996). The E7 proteins from high risk and low risk types differ in their ability to bind to the pRB protein although they have similar, but not identical, amino acids in the Rb binding domains. The low risk HPV-1 E7 proteins are able to bind to Rb with high affinity but are still not able to transform rodent cells or degrade the Rb protein. E7 is also capable of associating with other proteins important in the regulation of the cell cycle. This includes includes proteins such as histone deacetylase (Antinore et al., 1996) and the two cycline dependent kinase inhibitors p21 and p27 (Funk et al., 1997).

6.1.10 Disease

HPV can give rise to several different diseases but most of the infections seem to be subclinical. Among the diseases are condyloma accuminata, epidermodysplasia veruciformis, warts and anogenital cancer (Table 6.1). Papillomavirus lesions are usually referred to as warts when found on the skin and condylomas when found on the genitalia.

Epidermodysplasia verruciformis Patients that develop epidermodysplasia have in about half of the cases an autosomal recessively inherited defective cell-mediated immune response towards papillomavirus infections. Patients with epidermodysplasia develop polymorphic warty and scaly reddish brown plaques on the skin. The warty areas are mainly distributed on the hands, feet and the face. The reddish brown plaques are most often distributed on the trunk, neck and the proximal extremities. These areas are more common on sun exposed sites on the body. The warts usually develop in childhood and usually regress. However, about one third of these patients later develop squamous cell carcinomas, and in some cases these are very aggressive and are likely to metastasize (reviewed in Fields et.al 2001). The most common HPV types

27 found in these lesions are HPV-5, -8 and -47 (more than 90 % of the cases) although types 14, 17, 20 and 25 are sometimes found. In total, more than 30 different HPV types have been identified in EV tumors. Many of these PV types are harmless in the general population. The mechanism of EV carcinogenesis in not fully understood. One of the characteristic features of EV HPV is that the viral DNA is not integrated into the host cell. The E6 oncoporotein does not bind and degrade the p53 tumor suppressor protein and there is only a very low transforming activity (Majewski and Jablonska, 2004). There has been a proposed involvement of epidermodysplasia verruciformis in the development of psoriasis (Majewski and Jablonska, 2003).

Common warts Common warts (verruca vulgaris) are benign lesions appearing as hard papules with a rough irregular scaly surface and often regress spontaneously within a few years. The warts range in size from 1mm-1cm and can occure on any part of the body but most often appear on hands and knees. These warts have the highest prevalence in ages between 10 and 16 years of age. There are also different types of warts including filiform warts seen around the lips and eyelids, plantar warts (myrmecia warts) most often seen on weight bearing areas such as the heel, flat warts appearing at any site and often seen in a linear distribution called the Koebner phenomenon, butcher’s warts with a similar morphology seen in people often handling raw meat, mosaic warts found on palms and soles and Heck disease with lesions found in the oral cavity (Table 6.1)(Syrjanen, 2003). The common warts are most often caused by HPV types 2 and 4, but in some cases by 1, 3, 27, 29 or 57. The plantar warts are caused by the same types but in some cases also by HPV-2. Flat warts are caused by HPV-3, -10 and -28 while butcher’s warts are only caused by HPV-7. The transmission routes are often from person to person, auto-inoculation and in many cases also from contaminated objects.

Table 6.1 Diseases caused by papillomavirus and common sites of infection Name Site HPV types Common warts Any part. Often hand and knees 2 and 4 (1, 3, 27, 29 and 58) Palmoplantar warts Hands and feet 1 (2, 3, 4, 27, 29 and 57) Flat warts Anywhere. Often face, hands and chin 3, 10 and 28 Butcher’s warts Hands 7 Condyloma Genitalia 6 and 11

28 Condyloma Condyloma accuminata, also called veneral warts is a sexually transmitted disease affecting the skin and the mucus membranes of the genital tract. These warts are also most prevalent among sexually active adults. The incubation time for warts range from a few weeks to several months. The warts may appear anywhere on the genitalia and can in many cases be found simultaneously in many sites. The condylomas are in most cases self limiting and usually regress, however some lesions may persist for years. The most common types of PVs found in these lesions are HPV-6 and HPV-11 and in some rare cases also HPV-16.

Cervical Cancer In developing countries cervical cancer is the most common cancer and more than 400.000 new cases are reported every year with approximately 500 in Sweden. The lesions most often occur in the transformation zone in the cervix. Here the columnar cells in the epithelia forms a transformation zone with the squamous epithelia in the exocervix. The progression from a persistent PV infection to an carcinoma in situ usually takes several years and requires integration of the HPV genome into the host DNA. The steps from mild dysplasia to carcinoma in situ are usually classified from cervical intraepithelial dysplasia grade I to grade III. Most of the dysplasias usually resolve spontaneously. The most common PV types found in cervical cancer are 16, 18, 31,33, 35, 39, 45, 52, 58, 59, 67, 68 and 70.

6.1.11 Therapy

The different agents and methods used to treat papillomavirus warts can be divided into three different groups. The anti-proliferative agents, methods to induce epidermal and dermal necrosis, such as cryotherapy and the usage of cellular toxins. Some different surgical methods to remove warts and also immunomodulatory chemicals are used.

Three different agents are mainly used as anti-proliferative agents against papillomavirus infections; Podophyllin/Podophyllotoxin, 5-fluorouracil and Cidofovir. Podophyllin is extracted from the Berberiacae plant and actually contains many active constituents with podophyllotoxin being the most active in mouse and rabbit models. Podophyllotoxin acts by binding to the microtubule subunits and thereby hindering the formation of the mitotic spindle and thereby arresting the cell in mitosis. Podophyllin can cause severe side effects ranging from inflammation to a variety of neurological complications (Lacey, 2005). This fact has

29 lead to the preferred usage of podophyllotoxin as primary therapy. Comparative trials between podophyllin and podophyllotoxin have shown that podophyllotoxin is both more effective and cheaper than podophyllin (Lacey et al., 2003). 5-fluorouracil is a pyrimydine antagonist that inhibits nucleic acid synthesis. This substance is available as a 5% cream but has due to the high degree of inflammation limited usage. Cidofovir, a nucleoside analogue (Christensen et al., 2000; Snoeck and De Clercq, 2002) agent used to intravenously treat patients with cytomegalovirus retinitis has been shown to have good results when applying a 1% gel to immunocompetent patients (Snoeck et al., 1995). This substance is substantially limited because difficulties in production and a very high cost. Recently it was reported that α- lactalbumin-oleic acid reduced the volume of cutaneous papillomas resistant to conventional treatment with 75% (Gustafsson et al., 2004).

The methods used to remove warts are in most cases aimed at directly killing the infected tissue or inducing epidermal and dermal necrosis and thereby apoptosis. By freezing the warts with liquid nitrogen using a spray gun, the wart and the immediate surrounding tissue is frozen. This method showed good efficacy with a regression of 79-80% and with a recurrence of 25-39% of the cases. (Godley et al., 1987). Trichloracetic acid has been used as a topical therapy by applying a 90% solution to genital warts. The acid locally destroys tissue in a controlled manner and the side affects are tolerated. Clearance rates up to 81 % after treatment have been reported with a recurrence rate of 36% (Abdullah et al., 1993). Surgical removal of warts with scalpel or scissor excision have an initial complete clearance rate of up to 93 % with a recurrence rate after 6 months of 22%. This method is most often used on bulky lesions (Jensen, 1985). Interferons are immunomodulatory cytokines that have been used to some success but is in many cases accompanied by severe side effects as fever and headache. Due to high costs and modest efficacy, interferon treatments are not widely used and today not recommended for clinical use (Lacey, 2005). Imiquimod acts by stimulating the production of chemokines and have been shown to be an effective immunomodulatory substance with antiviral activities. A 5% cream showed 77% complete clearance in women and 62% clearance in uncircumcised men (Edwards et al., 1998; Gollnick et al., 2001). Recurrence after three month has been as low as 9%.

30 6.1.12 Immune response

When acquiring HPV the infection may or may not manifest itself in a clinically apparent way. Infections with skin types most often are self limiting and the infection is usually cleared over a period of months to years. Anogenital infections of papillomavirus will more often not be clinically apparent but will in most cases be self-limiting. The role of the immune response and its importance in the host has been widely studied in immunosuppressed populations such as HIV infected persons and renal transplant recipients. Some studies have been performed in cell culture systems and in many cases display contradictory affects for one single immune protein, this could be due to different cell lines, HPV types and experimental variations (Scott et al., 2001)

Innate Immunity Several important cytokines, growth factors and chemokines has antiviral and antiproliferative effects against papillomaviruses. These include transforming growth factor β (TGF-β), tumor necrosis factor (TNF) and many of the interferons such as the α- and β-interferons. These most often exert their function by either inhibiting expression of the E6 and E7 early genes or by acting as antiproliferative agents. TGF-β has been shown both to be a proliferative inhibitor of HPV-16 or -18-transformed cells by acting as an inhibitor of E6 and E7 (Braun et al., 1992; Woodworth and Simpson, 1993). Overexpression of TGF-β1 in HPV-11 transformed xenografts showed down regulation of proliferative genes such as bcl-1, c-myc, c-jun and Ha-ras (Shier et al., 1999). Tumor necrosis factor (TNF) seems to function in a similar way by repressing E6 and E7 at the transcriptional level in a human keratinocyte cell line (Kyo et al., 1994). Interferon-α has also been shown to be a proliferation inhibitor if human keratinocytes immortalized with HPV-16 at very low concentrations (Khan et al., 1993). In addition, IFN- α inhibits transcription of both HPV-18 E6 and E7 in HeLa cells (Nawa et al., 1990). Furthermore, NK cells seem to play an important role in the prevention of HPV induced lesions. NK cells isolated from patients with epidermodysplasia verruciformis show reduced cytotoxicity against keratinocytes isolated from lesions (Majewski et al., 1990). This low cytotoxicity of NK cells against HPV-16 infected keratinocytes has also been shown in the development of squamous intraepithelial lesions (SIL) (Malejczyk et al., 1989).

31 Adaptive cell-mediated immunity The most important players of the adaptive immune response when facing a papillomavirus infection are the Langerhans cells, the naive and the clonally expanded T-cells. The Langerhans cells capture the antigen and transports them to local lymph nodes. In the lymph nodes the antigen is presented to naive T-cells which then home back to the infection site. In HPV infections it has been shown that the number of CD1+ Langerhans cells are reduced in infected tissue such as plantar and hand warts (Viac et al., 1993). A reduced number of these cells have also been shown in condylomas and SIL (Tay et al., 1987). In these reports the authors discuss the possibility that the reduced number of Langerhans cells could lead to an impaired immune response at the infection site. However, they also suggest that it could simply be to normal regress of the cells due to a high migration and antigen presentation at the lymph nodes. This migration of the Langerhans cells out to the lymph nodes then leads to presentation of antigens to T-helper lymphocytes. Because E6 and E7 play such an important role in the transformation of cells the presentation of these antigens has been widely studied. It has been shown that there is a higher degree of response to E6 and E7 antigens in healthy patients than in patients with SIL (Luxton et al., 2003). Also the response to HPV-16 L1 seems to be higher in patients with SIL than in healthy controls (Luxton et al., 1996). It seems as the most prevalent antibodies in reaction to an HPV infection are of the IgA and the IgG classes (Wang et al., 2000). There has also been reports of antibodies directed against E2, E7, L1 and L2 of HPV-16 in both cervicovaginal washings and cervical secretions in patients with cervical neoplasia and condylomata although in many cases it is possible to detect high levels of IgA against E2, E7, L1 and L2 from HPV-16 even in healthy patients (Dillner et al., 1989).

Evasion of cell-mediated immunity. There are several suggested ways for the papillomavirus to escape the cell mediated immunity although these are very speculative. HPV has a very late expression of the structural proteins which leads to a very low possibility for the immune system to recognize viral proteins. These structural proteins are only expressed at the very superficial location at the squamous epithelium where immunological cells such as Langerhans cells have very low access and therefore do not get access to viral antigens. Also, since there is no blood-borne phase of the HPV infection, the immune system outside the epithelium has very little opportunity to detect the virus. The early proteins such as E6 and E7 are expressed at the basal layers in the epithelium but are not very abundant and they are restricted to a nuclear localization and are therefore not presented on the cell surface. As mentioned in the previous section it seems as if

32 HPV can downregulate the amount of Langerhans cells in the epithelium as a way to evade detection. It is also reported that keratinocytes are not very susceptible to CTL lysis. A down regulation of HLA class one molecules has also been described (Connor and Stern, 1990) as well as a downregulation of CD8+ T-cell response in transgenic mice expressing HPV 16 E7 (Tindle et al., 2001).

6.1.13 Vaccines

More than 50% of the cervical cancers are caused by HPV-16 and 30% by 18, 31 and 45 (Bosch et al., 1995; Munoz et al., 2003). This had lead to the focus on these few HPV types in the recent HPV vaccine developments. The difficulty in propagating HPV virions and the problem with few animal models has made this field difficult. A putative HPV vaccine should fulfill some very important criteria. First, it would have to be very safe since it has to be administered to young and healthy individuals. Most of these individuals receiving the vaccine would never develop cancer even without the vaccine. Second, it would have to be produced in large quantities without requireing a cold chain. Third, it would have to be easy to administer and to be effective only after a single dose. Fourth, the vaccine would have to be protective for many years since multiple vaccinations would be impossible in many cases. Fifth, the vaccine would have to be effective to many different HPV types to effectively reduce the incidence of cervical cancer (Lowy and Frazer, 2003) It has been shown that neutralizing antibodies gives protection in animal models when challenged with papillomavirus (Breitburd et al., 1995). Protective effects have also been achieved when vaccinating rabbits with the L2 peptides. These rabbits were protected when challenged with virus but not from viral DNA challenge (Embers et al., 2002). Today most of the candidate vaccines are based on highly immunogenic VLPs produced in yeast, insect cells or bacterial cells.

Prophylactic vaccines To this date DNA vaccine trials have not been conducted in humans although some researchers have managed to get protection in animal models. Rabbits were protected when challenged after four weeks with CRPV after immunization with 1mg of L1 DNA that was administered first at zero weeks and then again after three weeks (Donnelly et al., 1996). Also, 9 µg of L1 DNA gave high titers of antibodies and protection in dogs after 0,6 and 12 weeks immunizations when challenged with COPV (Stanley et al., 2001). In human trials

33 vaccination with VLPs has perhaps been the most promising. Several studies have shown a protective effect after vaccination with VLPs. In one double blind study 2393 randomly assigned women were inoculated with three doses of HPV-16 VLPs. After a median of 17.4 months the incidence of a persistent HPV infection in the control group was 3.8 per 100 women while the vaccinated group showed 0 per 100 women (Koutsky et al., 2002). Gardasil, a quadrivalent vaccine composed of HPV-6,-11,-16 and -18 is being tested in phase II trials by the MERCK company and show that vaccination with several different HPV types can be well tolerated and generate high levels of neutralizing antibodies. Gardasil reduced persistant infections of HPV 6, 11, 16 and 18 by 90% compared to controls (Villa et al., 2005) .This vaccine is also very promising since it shows that a vaccine could not only protect against cervical cancer but also another malignancies such as head and neck carcinomas, vulvar cancers and other anogenital cancers. Also, another VLP-based vaccine from GlaxoSmithKline Biologicals has shown 100% of protection against persistent infections with HPV types 16 and 18 (Harper et al., 2004).

Therapeutic vaccines A therapeutic vaccine has to induce a very specific cell-mediated immunity that prevents the growth of tumors or the progression of HPV induced lesions. Several of the viral antigens have not been widely used as putative vaccines due to different reasons. E1 and E2 are not expressed consistently in tumors, E5 has been shown not to be very immunogenic and the two late proteins L1 and L2 are not good candidates as a therapeutic vaccine since that they are not expressed at high levels at the basal epithelial cells of the lesions. The most extensively used candidates fore therapeutic vaccines are E6 and E7 for several reasons. First, since the E6 and the E7 genes are required to maintain malignancy they are not very likely to evade the immune response due to antigen loss. Second, in comparison to many of the cellular tumor- specific antigens E6 and E7 probably harbors more antigenic epitopes. Third, E7 is a highly conserved protein and is therefore a very good target.

Studies have been performed using viral vectors to deliver the DNA encoding the gene of choice. Vaccinia virus vectors have been used to deliver E6 and E7 and have been shown to induce a good CTL response (Boursnell et al., 1996; Gao et al., 1994). It was also demonstrated in a phase I/II clinical trial that patients with CIN 3 had developed CTL response after vaccination of vaccinia virus expressing either HPV-16 E6/E7 or HPV 18 E6/E7 (Adams et al., 2001). Tumors were eradicated when mice were vaccinated with

34 Venezuelan equine encephalitis virus replicon particle vector containing HPV-16 E7 RNA by enhancing the E7 specific CD8+ T-cell immune response (Velders et al., 2001). Pseudovirions are formed when naked DNA is incorporated into the capsid when expressing HPV L1 in various expression systems, such as vaccinia virus, bacculovirus or yeast. These pseudovirions are non-replicative and effectively protects the naked DNA and also functions as a adjuvant. Studies using these pseudovirions have proved them to effectively transfer DNA into the nucleus and induce a mucosal and systemic E7 CTL response (Shi et al., 2001) The TA-GW fusion protein which consists of HPV-6 L2 that has been fused to the E7 protein used in clinical trials for treatment of genital warts with promising results (Lacey et al., 1999).

6.2 Glycosaminoglycans

6.2.1 General

Glycosaminoglycans (GAGs) are the most abundant of all the heteropolysaccarides in the body and virtually all mammalian cells produce GAGs and either secretes them to the extracellular matrix or inserts them into the plasma membrane. These long molecules consist of unbranched polysaccharides containing repeating disaccharide units. All glycosaminoglycans contain either of the two sugars N-acetylgalactosamine (GalNAc) or N- acetylglucosamine (GlcNAc) and a uronic acid such as glucorunate (GlcA) or iduronate (IdoA). All GAGs are highly negatively charged molecules. There are seven different types of glycosaminoglycans; heparan sulfate, chondroitinsulfate A, chondroitinsulfate B, chondroitinsulfate C, hyaluronic acid, keratan sulfate and heparin. Many of the GAGs in the body are linked to a core protein, forming the heavily O-glycosylated proteoglycans. The GAGs extend perpendicularly from these core proteins to form large brush like structures. The linkage to the core protein for heparan sulfate is through an O-xylose on a serine (Taylor, 2003). Heparan sulfate and heparin are composed of D-glucuronate-2-sulfate (or iduronate-2- sulfate) and N-sulfo-D-glucoseamine-6-sulfate (Fig. 6.7). The linkage between the sugar residues is α(1,4). Heparan sulfate is primary localized at the basement membranes and at the cell surfaces and in comparison with heparin highly acetylated and carries 1 or 2 sulfates per disaccharide. One of the functions of heparan sulfate is to act as an co receptor for the fibroblast growth factor (Klagsbrun, 1990). Heparin in turn is a component of the intracellular

35 granules of mast cells lining the arteries of the skin, lungs and liver. Heparin carries 4-6 sulfates per disaccharide.

Figure 6.7 Structure of heparan sulfate

6.2.2 As viral receptors

Several different viruses use GAGs as viral receptors. Heparan sulfate is used by viruses such as herpes virus (Shieh et al., 1992; Shukla et al., 1999; Shukla and Spear, 2001), adeno associated virus (Summerford and Samulski, 1998), dengue virus (Chen et al., 1997), and sindbis virus (Byrnes and Griffin, 1998). Some viruses use the GAGs as primary attachment molecules and some as secondary attachment molecules. Herpesvirus first bind to heparan sulfate on the cell surface followed by an interaction with members of both the TNF receptor family and the immunoglobulin superfamily (Spear, 2004; WuDunn and Spear, 1989). Glycosaminoglycans are highly negatively charged molecules and studies have shown that the level of sulfatation is important for virus binding (Trybala et al., 2000). Studies with pseudorabies virus have shown that preparations with a higher level of sulfatation is up to 200 fold more effective in reducing infection (Trybala et al., 2000).

6.3 Lactoferrin

Lactoferrin, a member of the transferrin family, is present in milk, saliva, tears, semen and vaginal secretions with the highest concentration found in colostrum with concentrations as high as 7g/ml (Cohen et al., 1987). It is an 80kDa protein with high degree of homology between different species. Lactoferrin plays an important role in the defense against pathogenic microorganisms and have been reported to be effective against both gram positive and gram negative bacteria. In addition to this, lactoferrin has both anti fungicidal properties

36 as well as antiviral effect against viruses such as rotavirus (Superti et al., 1997), herpes virus (Hasegawa et al., 1994; Marchetti et al., 1996), poliovirus (McCann et al., 2003), respiratory syncytial virus (Grover et al., 1997), HIV (van der Strate et al., 2001) and adenovirus (Di Biase et al., 2003). Lactoferrin has been shown to have high affinity towards heparan sulfate by binding with its N-terminal part (Di Biase et al., 2003) but can also bind to a 105kDa receptor (Spik et al., 1994). Caco-2 cells incubated with heparin prior to the addition of lactoferrin were not able to internalize any lactoferrin (Ashida et al., 2004). Lactoferrin is present in the vaginal mucosa in varied concentrations depending of the phase of the menses cycle with the highest concentrations just after menses (Cohen et al., 1987). Women taking oral contraceptives show constantly low levels of lactoferrin (Cohen et al., 1987).

6.3.1 Structure

Lactoferrin is a bi-globular protein connected with an 11 amino acid long α-helix hinge region (Fig. 6.8)(Moore et al., 1997) Both the N- and the C-lobe can bind one Fe2+ or Fe3+ in a reversible manner but can also bind Cu2+ . This binding takes place in a deep cleft and each 3- Fe3+ ion is ligated by two tyrosine side chains, one histidine, one aspargine and one CO2 anion (Haridas et al., 1995). The iron saturated lactoferrin is called holo-lactoferrin and the non iron binding lactoferrin is called apo-lactoferrin The structure is well conserved among different species and the most conserved parts of lactoferrin is found at the surface of the protein with a sequence homology of 69% (Pierce et al., 1991)

Figure 6.8 3-dimensional structure of bovine lactoferrin

37 6.3.2 Antiviral mechanism

In the body transferrin and lactoferrin works as antimicrobial elements by purging the different body fluids from free iron. Transferrin keeps serum, lymph nodes and cerebrospinal fluids free from non-protein bound iron, whilst lactoferrin is secreted into regions exposed to the normal flora. In most of the cases lactoferrin exerts its antiviral effect on the early stages of the infection by interfering with the binding of the virus particles to their receptors. This either by directly binding to the virus particle as in the case of rotavirus (Superti et al., 1997) or by reducing the infectivity of the virus by binding to its receptor as in the case of herpes simplex virus (Andersen et al., 2003; Andersen et al., 2004; Jenssen et al., 2004).

6.3.3 Lactoferricin

Lactoferricin have been reported to have antimicrobial activity against herpes simplex virus (Andersen et al., 2003), cytomegalovirus (Andersen et al., 2001) and poliovirus (McCann et al., 2003). Lactoferricin is the N-terminal part of lactoferrin and is generated by proteolytic cleavage by pepsin. The human lactoferricin composes amino acids 1-47 of human lactoferrin and the bovine lactoferricin compose aminoacids 17-41 from bovine lactoferrin. The human lactoferricin is composed of two peptides joined together by disulphide bond between cystein 10 and cystein 46. One shorter peptide (aa 1-11) and one longer peptide (aa 12-47). Both human and bovine lactoferricin has an additional disulphide bond which creates a loop structure (Hwang et al., 1998). Four Lfcin peptides were used in our experiments (Fig.6.9)

Figure 6.9 Lactoferricin peptides used in our experiments

38 7. AIM OF THE THESIS

The aim of the thesis can be summarized to the following points.

We wanted to… •…investigate if heparan sulfate and/or other glycosaminoglycans were a human papillomavirus attachment receptor.

•…develop a good method for studying viral entry.

•…investigate if cutaneous and mucosal tropism could be explained by different affinity for the heparan sulfate receptor.

•…study if lactoferrin and lactoferrin derivatives could inhibit viral attachment and internalization.

39 8. MATERIALS AND METHODS

8.1 Cell lines

The human keratinocyte cell line HaCaT was grown in DMEM plus 10% FCS (Life Technologies, Inc. MD). The human cervical epithelial cell line C33A was grown in DMEM plus 10% FCS (Life Technologies, Inc. MD). CHO cells were grown in Ham’s F12 medium (Life Technologies, Inc. MD) supplemented with 10% FCS, 2mM L-glutamine, (wt CHO and pgsB-618) and Ham’s F12K (Life Technologies, Inc. MD) supplemented with 10 % FCS (pgsD-677). The burkitts lymphoma cell line DG 75 was grown in RPMI plus 10% FCS (Life Technologies, Inc. MD).

8.2 VLP production

Human papillomavirus virus like particles from types 16 and 6 and 5 consisting of L1 were produced in Sf-21 insect cells by using a recombinant baculovirus as previously described (Drobni et al., 2003). In short, cells were grown in a flask until infection with recombinant baculovirus with multiplicity of infection (MOI) of 10. The insect cells were then grown in flask until approximately 90% cell death. The nuclei from these cells were prepared by different steps of mechanical disruption and sonication. VLPs were then extracted through a sucrose gradient and a CsCl gradient. The final step involves dialyzing VLPs extensively against PBS buffer to remove any residual CsCl and small particles. To visualize VLPs in western blots a L1 antibody (MAB885) was used. This antibody was purchased from Chemicon International (Inc. CA). Horseradish peroxidase (HRP)-conjugated and fluorescein isothiocyanate (FITC)-conjugated anti-mouse immunoglobulin antisera were purchased from Dakopatts AB (Älvsjö, Sweden). The integrity of the particles was verified using electron microscopy.

8.3 CFDA-SE labeling

The carboxy-fluorescein diacetate, succinimidyl ester (CFDA SE) was purchased from Molecular Probes, Inc, Eugene, OR. First, a stock solution was prepared by dissolving CFDA

40 SE in DMSO supplied by the manufacturer. To label the VLPs CFDA SE dye was mixed with VLPs in a final volume of 1 ml in PBS (pH 7.4). The mixture was incubated for 24 h in room temperature while kept in dark and then dialyzed against PBS. The integrity of the particles was analyzed by electron microscopy after preparation.

8.4 Binding assays

The human keratinocyte cell line HaCaT was grown to approximately 90% confluence in DMEM supplemented with BSA before being trypsinated and dislodged. To allow the cells to re-express surface molecules removed during trypsination the cells were grown for two hours in a suspension while shaking. During this time, VLPs were treated with the appropriate glycosaminoglycan, lactoferrin or lactoferricin in binding medium (BM) containing 2% BSA. After incubation this mixture was added to the cells in an eppendorf tube and the sample was incubated on ice for 30 minutes. After incubation on ice the cells were washed twice with ice cold PBS + 2% BSA before adding SDS-PAGE sample buffer. The amount of L1 was detected using an antibody against HPV L1. The bands were quantified using the GelPro analyzer software (Media Cybernetics, Silver Spring, MD).

8.5 Internalization assays

The cells were trypsinated, dislodged, diluted to 10 ml and grown in suspension as above, except for DG75 cells, which were already in suspension. Cells were washed once with binding medium and then 2x105 cells were transferred to a tube and diluted to 200 µl with binding medium. Before addition to the cells, VLPs were incubated with the appropriate GAG, lactoferrin or lactoferricin for 60 minutes on ice in binding medium. The CFDA-SE VLPs were added to the cells and then transferred to 37oC for the times indicated. Control cells were incubated with CFDA-SE VLPs without GAGs on ice. After incubation the cells were washed twice with PBS/2% BSA before flow cytometry analysis. The approximate excitation and emission peaks of CFDA SE after hydrolysis are 492 nm and 517 nm respectively according to the manufacturer (Molecular Probes, Inc, Eugene, OR) we measured the fluorescence by flow cytometry on the FITC channel.

41 9. RESULTS AND DISCUSSION

9.1 VLPs as a tool to study infection

Since papillomavirus production takes place late in the differentiated epithelium it has been very difficult to produce large quantities of papillomavirus virions.We express the L1 capsid protein of papillomavirus in an insect cell line using recombinant baculovirus expressing L1 from a polyhedrin promotor. These self-assembles to form VLPs and have similar appearance as virions prepared from warts when analyzed in electron microscope (Rose et al., 1993). It is possible to produce PV virions by using organotypic raft cultures (Meyers et al., 1992). However the virus yield not large and have not been used in binding or uptake studies until very recently (Holmgren et al., 2005) when the quantitative RT-PCR technique have made it possible to analyse very small amounts of virus products. Instead VLPs have been produced by expressing either the late protein L1 alone or together with the L2 protein. Recently, reports have shown that VLPs with DNA and L1 protein does transfect cells to a lesser degree than VLPs with DNA and both L1 and L2 (Holmgren et al., 2005; Rossi et al., 2000; Unckell et al., 1997). This is possibly due to L2s role in transporting the DNA to the nucleus in the infected cell. The VLPs have similar characteristics as virions prepared from warts although there are some reports suggesting differences in structure and internalization times (Giroglou et al., 2001; Selinka et al., 2002). It has also been reported that pseudovirions undergo conformational changes after attachment to the cell surface (Selinka et al., 2003).

9.2 CFDA-SE as an internalization assay

In order to visualize the early events of the papillomavirus uptake process we have used a method in where we conjugate the CFDA-SE dye to the surface of the particle. This dye gets activated inside the cells by cellular esterases and can then be visualized by using either a microscope or using flow cytometry. By using flow cytometry the amount of internalized particles can easily be quantified and CFDA-SE labeled VLPs are also visible using confocal microscope (Fig. 9.1). The labeled particles have the same appearance in the electron microscope and have in our experiments similar properties as non labeled VLPs when used in binding experiments. Also, the CFDA-SE labeled particles can be competed out by non

42 labeled VLPs. Other groups have successfully used pseudovirions by encapsidating reporter plasmids into the viral particles (Kawana et al., 1998b; Touze and Coursaget, 1998). Pseudovirions have also been constructed by directly conjugating reporter DNA on the VLP surface (Bousarghin et al., 2002). Our CFDA-SE labeled particles do not carry any reporter DNA and makes the method limited to study the early steps of internalization. Pseudovirions have also been produced by infecting cells harboring autonomously replicating bovine papillomavirus type 1 (BPV-1) genomes with L1 or L2 expressing baculovirus (Roden et al., 1996). These pseudovirions are good tools for analyzing infection but do not however give a good insight in the kinetics of the very early steps of the internalization. Pseudovirions or real virions in comparison to CFDA-SE labeled VLPs give the possibility to use RT-PCR as a way to detect internalized particles transported to the nucleus. Whole virus particles have been produced by using raft-cultures (Meyers et al., 1997). These are however only produced in very small amounts and is today limited to a few PV types.

Figure 9.1 Confocal microscope image showing internalized CFDA-SE labeled VLPs. Photograph by Nitesh Mistry

9.3 Heparan sulfate as an HPV receptor

Interactions between heparan sulfate and human papillomavirus were first described by Joyce et al 1999. They were able to show that HPV VLPs from type 11 were able to interact with soluble heparin and with cell-surface glycosaminoglycans on Chinese hamster ovary cells and HaCaT cells. Also, they could show that the C-terminus of nine different HPV types

43 contained conserved regions that bears resemblance to proposed heparin-binding motifs. Enzymatic cleavage and removal of this region eliminated binding to heparin and HaCaT cells. In the same report they also enzymatically removed glycosaminoglycans with heparinase and heparitinase (heparinase III) from the cell surface of keratinocytes and thereby highly reduced binding of HPV-11 VLPs to these cells. Giroglou and co-workers (2001) studied HPV-33 pseudovirus infection of COS-7 cells. They showed interaction between heparin and HPV-16, -33 and -39 VLPs using ELISA and also showed that heparan sulfate was essential for pseudovirus infection. Interestingly, they did not detect any reduced activity after removal of the C-terminal part of the L1 protein in HPV-33 VLPs (Giroglou et al., 2001). The importance for heparan sulfate as an receptor has also been shown for other mucosal HPVs, namely 16, 18, 31, 33, 39, 45, 58, 59, and 68 (Combita et al., 2001). We could show that the cutaneous HPV-5 also was inhibited by heparin, although to a lesser degree than the mucosal HPV-16. When predicting the isoelectric point of L1 capsid protein HPV-5 was not negatively charged at physiological pH in comparison to the tested mucosal HPV types which are all positively charged at physiological pH. This charge difference could play a role in the interaction between VLP and its receptor. It has recently been described that for HPV certain conformational requirements are needed for an interaction with heparan sulfate. These requirements are met with VLPs and capsomeres, but not with monomers of L1 (Rommel et al., 2005). Also, Selinka and co-workers could show that O sulfation of heparan sulfate is essential for HPV binding and infection, whereas de-N-sulfated heparin interfered with VLP binding but not with HPV pseudovirions (Selinka et al., 2003).

9.4 Lactoferrin and lactoferricin as an HPV inhibitor.

By pre-treating VLPs with lactoferrin (Lf) we could for the first time show that Lf of both bovine (BLf) and human origin (HLf) could inhibit HPV-16 and HPV-6 VLP binding to HaCaT cells, although BLf was somewhat more effective. We were however not in any of the cases able to reduce binding to 100%. This can perhaps be explained by a possible secondary receptor, such as the α6-integrin. When internalization was studied after pre-treating HaCaT cells with BLf and HLf virtually no inhibition could be detected for HLf in comparison to BLf. This difference can in part be explained by structural and charge differences between BLf and HLf (Metz-Boutigue et al., 1984). Furthermore, it has been described that commercial preparations of lactoferrin sometimes lose N-terminal arginine residues which

44 could change the properties (van der Strate et al., 2001). The antiviral effect of lactoferrin can probably be explained by its ability to bind to surface HS. This mode of action has been described for viruses such as herpesvirus (Andersen et al., 2003) and cytomegalovirus (Andersen et al., 2001) and would be possible for PVs that use the same receptor (Combita et al., 2001; Drobni et al., 2003; Giroglou et al., 2001; Joyce et al., 1999; Shafti-Keramat et al., 2003). For rotavirus a direct interaction was described in where Superti and collegues (1997) could show that Lf both inhibited heamaggluttination and binding of the virus to cells. To study such an interaction between Lf and HPV we performed an ELISA where both BLf and BLfcin were coated in wells prior to the addition of VLPs. We could only detect low levels of interactions between VLPs and BLf and even lower levels with BLfcin, which correlates well with a possible interaction of Lf with HS. To investigate how early in the internalization process Lf acted we incubated VLPs with cells for increasing time periods before adding Lf. We could detect a 50% reduction of internalized CFDA-SE VLPs already after 20 minutes which again would suggest that Lf exerts its antiviral effect early in the entry process of PV. The N-terminal part of Lf, Lactoferricin (Lfcin), was shown by others to have an antiviral effect on herpesvirus (Andersen et al., 2003), cytomegalovirus (Andersen et al., 2001), feline calicivirus and poliovirus (McCann et al., 2003). To study a possible inhibitory action on HPV we pre-treated both unlabeled and CFDA-SE labeled VLPs with either BLfcin or HLfcin before addition to cells. Interestingly, we could detect major differences between binding and internalization. BLfcin was much more effective in reducing the amount of bound HPV-16 L1 VLPs to HaCaT cells in comparison to HLfcin. The opposite pattern was detected when internalization was studied where HLfcin showed to be a more effective inhibitor than BLfcin. This difference between binding and internalization could in part be explained by the structural differences between BLfcin. In HLf the N-terminal part consist of a β-sheet and an α-helical domain. This α-helical domain is intact in HLfcin after pepsin digestion, while the β- sheet is lost. However, BLf does not keep its α-helical structure in the N-terminal domain after digestion with pepsin. Instead the N-terminal part folds into a distorted β-sheet (Hwang et al., 1998).

45 9.5 Results from paper I

We used different soluble glycosaminoglycans (GAGs) to investigate putative inhibitory effects of binding and internalization of CFDA-SE labeled HPV-6 and HPV-16 VLPs. After incubating the cells with different concentrations of GAGs we could detect a dose dependent inhibition. The heparan sulfates used were prepared from either bovine intestinal mucosa, bovine kidney or from porcine intestinal mucosa. We also used dextran sulfate and heparin in our assays. The highly sulfated heparin was the most efficient inhibitor of binding, followed by heparan sulfate from bovine intestinal mucosa, dextran sulfate, porcine intestinal mucosa and bovine kidney. Heparin reduced binding to 50% already at 0,5 µg/ml. It has been shown by using pseudorabies virus that preparations from the more sulfated pig intestinal mucosa were more efficient in inhibiting binding to cells than the less sulfated heparan sulfate prepared from porcine kidney. The heparan sulfates we have used are commercially available and we do not have any information about the level of sulfatation. In addition to confirming results showing the interaction between HPV-16 VLPs and heparan sulfate, we showed that heparan sulfate from mucosal origin were more efficient in inhibiting binding and internalization than heparan sulfate from kidney. This could be due to a higher level of sulfatation in the heparan sulfate from mucosal origin. We were not able to detect major differences between the mucosal HPV-16 and HPV-6 virus particles. These results points at an electrostatic interaction between HPV and the initial receptor on the cell surface. For herpes virus a secondary receptor is used as an entry receptor after interacting with heparan sulfate on the cell surface. A similar interaction is possible for PV and the involvement of the

α6-integrin in the early steps in entry still have to be more carefully studied. Syndecans have been suggested as a possible protein part of the proteoglycan complex (Selinka et al., 2002; Shafti-Keramat et al., 2003) and may have a function in viral entry.

9.6 Results from paper II

We were able to show that there are differences between HPV-5 and HPV-16 in the level of inhibition when incubated with different concentrations of GAGs. Two different cell lines were used in these studies. The skin derived HaCaT cell line and the cervical carcinoma cell line C33A, both without any HPV DNA. HPV-16 was inhibited to 70% compared to 43% for HPV-5 after pre-treatment with heparin in HaCaT cells. In C33A cells the difference was

46 similar although both types were more inhibited with a maximum inhibition for HPV-16 of 100%. This could possibly be explained by charge differences on the L1 VLPs with HPV-16 predicted as being more positively charged at a physiological pH and therefore being more susceptible to a interaction with negatively charged heparin. C33A cells could also perhaps express lower amounts of a possible secondary receptor for PVs. In our assay, we found that although differences in GAG inhibition, both HPV-5 as well as HPV-16 were inhibited when cells were treated with chlorpromazine, indicating a clathrin dependent internalization for both types. It has previously been published that most PV types, except from HPV-31 (Bousarghin et al., 2003) use clathrin mediated endocytosis for uptake (Day et al., 2003) What determines the tissue specificity for human papillomaviruses is today not fully understood. The phylogenetic tree, based on L1 gene sequence, divides mucosal and cutaneous types into roughly two groups (fig. 6.1). When comparing this tree to the predicted charge of L1, it is striking that almost all cutaneous types have a negative charge at physiological pH, while almost all mucosal types are positive at pH 7,4. These structural differences could in part explain the differences in tropism for PVs. However, it has been shown that HPV of mucosal origin could infect cutaneous hand skin grafts in athymic mice (Jenkins et al., 2003). The tropism could also be determined at other stages. Transcriptional regulation and HPV DNA replication are two possible determining factors.

9.7 Results from Paper III

When HPV-16 and HPV-6 VLPs were incubated with different concentrations of either bovine or human lactoferrin a dose dependent inhibition of both binding and uptake was observed. BLf was a more potent inhibitor of both binding and internalization than HLf. These results are similar to those observed with herpes simplex virus that also use heparan sulfate as a primary receptor. BLf is slightly more charged than HLf and this could in part explain the higher inhibition. Furthermore, it has been reported that commercial preparations of HLf can sometimes lose the N-terminal arginines which could affect the antiviral properties (van der Strate et al., 2001). When Lf was added at different time points to HaCaT cells after previously being incubated with VLPs we found that the inhibitory effect of lactoferrin took place early in the internalization process and was directed towards the receptor binding step. We could detect a 50% inhibition already after 20 minutes of incubation prior to the addition of Lf.

47 Lf is predominantly found in milk but also is abundant in vaginal secretions. The in vivo actions of Lf against papillomavirus and the importance of the interactions have not yet been studied. The vaginal concentrations vary with the menses cycle except for in women taking oral contraceptives in where levels of lactoferrin are constantly low (Cohen et al., 1987). There is today a strong correlation between long term use of oral contraceptives and cervix cancer and in a recent study conducted by IARC it was shown that the prolonged use of combined oral contraceptives increased the risk of cervical cancer up to fourfold in women who have persistent HPV infections (Moreno et al., 2002). Any correlation between lactoferrin levels in vaginal fluids, persistent HPV infections and cervical cancer has however not yet been studied. Lactoferrin is also found in high concentrations in saliva and there are several different HPV types that can cause infection in the oral mucosa. The importance of lactoferrin in the oral cavity in the case of HPV infections has not been studied.

9.8 Results from paper IV

When using both HLfcin and BLfcin for inhibition of HPV-16 VLP binding to HaCaT cells we found that BLfcin was the more effective peptide. We analyzed the effect of two different cyclic BLfcins, BLfcin 17-4 and 17-42. Both bovine peptides could inhibit 50 % of HPV-16 VLP binding at 5-8 µM concentrations. The two human cyclic lactoferricins HLfcin 17-41 and HLfcin 18-42 showed very little inhibition and did not reach more than a few percent of inhibition. The higher positive charge in the bovine lactoferricin in comparison to human lactoferricin is a likely explanation for this, but another reason might be that the mirror sequence of the heparin binding motif XBBXBX where B is either an Arg or a Lys, is found in the loop structure of BLfcin but not HLfcin and could be a reason for a higher affinity towards surface heparan sulfate. Interestingly the internalization assays showed an opposite interaction, where the human lactoferricin was a more potent inhibitor than the bovine lactoferricin. The reason for this is at this point still uncertain. When human lactoferrin is cleaved by pepsin, the N-terminal part that forms lactoferricin keeps its α-helical domain but looses the β-sheet. In a different manner, the bovine lactoferrin N-terminal part is composed of only an α-helical domain that after pepsin cleavage folds into a distorted β-sheet (Hwang et al., 1998; Jenssen et al., 2004). It seems like the amhpipatic α-helical domain without the β- sheet is more effective at inhibiting papillomavirus uptake.

48 10. CONCLUSIONS

• Heparan sulfate is important for HPV-6 and -16 binding and internalization

• The highly sulfated heparin is the most potent inhibitor.

• Heparan sulfate from a mucosal source is a much better inhibitor of HPV-16 than heparan sulfate from kidney.

• CFDA-SE labeled HPV VLPs are a good tool to study viral entry into the host cell.

• The cutaneous HPV-5 is to a lesser degree inhibited by heparin than the mucosal HPV-16.

• HPV-5 use the same internalization mechanism as HPV-16

• Bovine lactoferrin is a potent inhibitor of HPV binding and internalization.

• Human lactoferrin inhibits only HPV binding

• Lactoferrin exerts its viral effect early in the internalization process, probably by binding to the heparan sulfate receptor.

• The more positively charged bovine lactoferrin is a better inhibitor than the human lactoferrin.

• Lactoferrin can to some extent interact with the HPV particle.

• Bovine lactoferricin is a better inhibitor of viral attachment than lactoferricin of human origin.

• Human lactoferrin reduced internalization of VLPs better than bovine lactoferricin.

49 11. CONCLUDING REMARKS

For HPV to make a productive infection the virus first has to gain access to the host cell and bind to at least one type of cell surface receptor. Even though many extremely promising prophylactic vaccine trials are being performed today, there still is a need for therapeutic substances for the treatment of PV induced lesions. Our innate defence system is able to express a variety of antimicrobial substances. Many of these proteins are found in both saliva and vaginal secretions. Lactoferrin is one of these proteins and have been shown to have activity against a variety of microorgansims such as bacteria, fungi and viruses. We have for the first time shown that lactoferrin of both bovine and human origin was able to reduce binding of HPV VLPs to HaCaT cells in vitro. We could also show that lactoferricin was effective as an inhibitor of binding and uptake. The potential use for lactoferrin or lactoferricin as a therapeutic substance would still have to be carefully evaluated and studied. The vaginal mucosa harbours a complex flora of microrgansims of which some types could use increased levels of lactoferrin to its advantage. We have shown that heparan sulfate is important for this initial interaction between the virus and the host cell and also for the first time been able to show that the mucosal HPV-16 interacts differently with HS than the cutaneous HPV-5.

50 12. ACKNOWLEDGEMENTS

Detta arbete skulle ha varit omöjligt att genomföra utan hjälp från familj, vänner och kollegor, varav jag här bara har plats att tacka några.

Först så vill tacka Magnus Evander som har varit en fantastisk handledare under min doktorandtid. För att ha gett mig möjligheten att jobbat med detta projekt, inspirerat mig och väckt mitt intresse för fältet.

Professor Göran Wadell för en trevlig miljö på avdelningen för virologi och för att ha delat med sig av sitt oändliga kunnande i virologi.

Katrine Isaksson-Nyström, som under alla dessa år hjälp till med så mycket av det praktiska. Framför allt under den sista tiden med allt som måste ordnas kring att skriva en avhandling.

Kristina Lindman och Karin Edlund för ert kunnande på labb och för att alltid varit så hjälpsamma. Ett speciellt tack till Karin och hennes man Anders för att ha tagit hand om vår katt Yoda när vi varit på resor och inte nämnt något om de prylar som jag antar att han hade sönder.

Rolf Sjöberg för de fina EM bilderna, samt för att alltid varit hjälpsam och ställt upp med hjälp med allehanda tekniska problem som dykt upp under åren.

Mei Ya-Fang för all hjälp på labb och för alla buffertar som jag ”lånat” och säkert inte lämnat tillbaka.

Jag vill även tacka Johan Skog and Åsa Bengtsson, som varit goda vänner, trevligt sällskap på vandringen längst kungsleden och för alla trevliga middagar.

Den alltid hårt rockande Nitesh Mistry, en god vän, en utmärkt labbkompis och klätterkompis. Nitte är den enda person som jag sett sova med huvudet utanför ett tält och är den mest oförutsägbara pokerspelare man kan tänka sig.

Mikael Sandström, en god vän och en stor fiskare!

Marko Marttila, som sett till att jag fått röra på mig lite då och då genom att utmana mig på badminton. Den enda personen jag kan tänka mig som även då han med 13 matchbollar emot sig kan offra sig med livet som insatts för att rädda en boll !

Niklas Arnberg som utöver att dela mitt veteskapliga intresse för virologi även i allra högsta grad verkar dela mitt intresse för kortspel.

Anna Segerman, för att ha varit en trevlig ”skrivrums-kompis” och för att ha lyckats få mitt skrivbord att verka förhållandevis städat.

51 Alla andra på avdelningen för virologi som jag haft förmånen att träffa dagligen varav jag här bara nämner några; Anci, Annika, Bert, Cissi, Dan, David, Emma, Emma, Iréne, Jim, Linda, Maria, Olle, Per, Rolf, Torgny, Ulrika (som även tagit hand om Yoda), Urban och Yvonne. Åren på virologen har varit en fantastisk tid i mitt liv som jag kommer att se tillbaka på med glädje!

Alla övriga på ”landstinget” för den otroligt trevliga stämningen under lunch och fika.

”Pokergänget” för alla trevliga spelkvällar som sett till att dryga ut min doktorandlön med ibland flera tiotals kronor! Jag har aldrig sett en samling kortspelare som så missbrukat möjligheten att gå ”all-in” i texas hold-em.

Ett speciellt tack till alla studenter som gjort examensarbeten och projekt hos oss och som så många gånger fått höra mig säga ”Ok, kanonbra!– Gör om det! “-. Linn, Taru, Jonas, Maria, Carin, Daniela, Maria, Linda och alla andra som jag glömt att räkna upp!

Sari och Stefan, vars besök i Umeå alltid varit ett trevligt avbrott i vardagen. Stefan även för att vara trevligt fiskesällskap och Sari för att vara en sann expert på att tillaga enchiladas.

Mina svärföräldrar Kalle och Arja Lohilahti, som varit så hjälpsamma under alla dessa år med allt från att laga vår bil till att otaliga gånger ha fyllt vår frys med bullar och dessa fantastiska karelska piroger.

Till mina föräldrar Imre och Sara. Utan er hade detta inte varit möjligt !

Till min son Elliot, för den helt underbara personen du är och för att du alltid mött mig med ditt fantastiska leende när jag kommit hem trött efter att ha jobbat med denna avhandling. Samt för att du under tiden precis före inlämnandet av detta arbete till tryckning lyckats att stressa av mig med ditt minst sagt lugna tempo.

Till min älskade fru, Mirva. Utan dig hade denna avhandling med största sannolikhet aldrig blivit av. Tack för att du även är min bästa vän och för att du stått ut med mig under skrivandet av detta arbete.

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