Microbial Interactions Impacting Inflammation and Pharmacomicrobiomics in HIV Nichole Klatt, PhD June 16th, 2017 UCSD HIV & Global Health Rounds

2. Microbial)Interac.ons)
Impac.ng)Inflamma.on)and)
)Pharmacomicrobiomics)in)
HIV
Nichole(Kla+(
UCSD(
June(16th,(2017(

3. Overlapping mechanisms underlying increased HIV transmission risk AND
increased HIV pathogenesis
TRANSMISSION
1. Barrier Damage
2. Inflammation
3. Altered Microbiome
PATHOGENESIS
1. Barrier Damage
2. Inflammation
3. Altered Microbiome

4. UNAIDS_The+Gap+Report,+updated+Sept.+2014+

5. Inflamma=on((par=cularly(associated(with(mucosal(
dysfunc=on)(is(a(key(predictor(of(morbidi=es(and(
mortality(

6. Epithelial+Barrier+Breaches+and+Microbial+TranslocaDon+
Estes et al., Plos Pathogens 2010
What(are(the(mechanisms(of(mucosal(dysfunc=on(in(HIV(Infec=on?((
5+

7. HIV$Dysbiosis:$
• Bad/Increased+in+HIV:+
• ↑+Prevotella++
• ↑+Proteobacteria+
• Good/Decreased+in+HIV:+
• ↓+Firmicutes+
• ↓+Bacteroides+

8. Dysbiosis+in+HIV+infecDon+
Zevin,'McKinnon,'Burgener,'Kla2;'Curr'Opinion'HIV/AIDS'2016'

9. An/microbial$func/ons$of$neutrophils$
8+
(Kolaczkowska,+et+al.+Nat.+Rev.+Immun.,+2013)+
Tissue(Damage(
(
An=Pmicrobial(
func=ons(
• ProtecDve+role+in+HIV+
• ProtecDon+from+
secondary+infecDons+
• GI+mucosal+dysfuncDon+
• Vaginal+transmission+
An=microbial(pep=des(
Proteases(
Reac=ve(oxygen(species((ROS)(
(

11. Study$Design
10+
Colorectal(Biopsies(
10[30+biopsies+(~3mm+each)+
+
Transferred+to+lab+in+RPMI+on+ice+
(some+flown+same[day+from+UCSF)+
+
14(HIV+,(ARTPtreated(
(
11(HIVPnega=ve(

12. Assessing$neutrophils$by$flow$cytometry
Blood(Colorectal(Biopsy(
Neutrophils( Apoptosis((
Exclude:((
(T(cells(
(B(cells(
(Monocytes(
(Eosinophils(
(
Posi=ve(iden=fica=on:(
(Integrins(
(Adhesion(
((((((molecules(

13. Increased$colorectal$neutrophil$frequencies$in$
HIV+$individuals

14. Reduced$neutrophil$apoptosis$in$
treated$HIV$infec/on

15. What+drives+reduced+apoptosis+and+how+can+we+
therapeuDcally+target+it?+
14+
HomeostaDc+
neutrophil+
apoptosis+
Neutrophil+
accumulaDon+

16. Ques/on:$Does$altered$microbiome$in$HIV$infec/on$
affect$neutrophil$popula/ons?$
HIVP(or(
HIV+(ARTPtreated(

17. Dysbio/c$
bacteria$reduce$
ac/ve$CaspaseH3$
expression$in$
neutrophils;$
poten/al$
mechanism$for$
neutrophil$
accumula/on$in$
HIV

18. Lactobacillus$can$override$survival$signals$
mediated$by$inflammatory$s/mulants
*=p<0.05&
**=p<0.01&
***=p<0.001&
By&one&way&ANOVA&and&Tukey&&
post;hoc&analysis(
17+

19. Conclusions$I:$Neutrophils$and$Dysbio/c$
Bacteria$in$HIV$Pathogenesis
• Neutrophils+are+increased+in+the+GI+of+treated+HIV+infecDon++
• Associated+with+decreased+neutrophil+apoptosis+
• HIV[altered+mucosal+bacteria+differenDally+affect+neutrophil+apoptosis+
• Decreased+Lactobacillus'spp.'and+increased+Prevotella'spp+may+prolong+
neutrophil+lifespan+in+the+GI+in+treated+HIV+infecDon.++
• Future+direcDons:+Further+understanding+how+neutrophils+contribute+to+HIV+
pathogenesis+and+barrier+damage+may+elucidate+potenDal+targets+for+
therapeuDc+intervenDons+

20. Overlapping mechanisms underlying increased HIV transmission risk
AND increased HIV pathogenesis
TRANSMISSION
1. Barrier Damage
2. Inflammation
3. Altered Microbiome
PATHOGENESIS
1. Barrier Damage
2. Inflammation
3. Altered Microbiome

21. Every$minute,$two$women$are$infected$with$HIV
• Women+tend+to+get+infected+at+a+
younger+age+
• Sub[Saharan+Africa+has+2x+
women+ages+15[24+than+men+
with+HIV+infecDon+
• Pregnancy+/+mother[to[child+
transmission+
• Sexual+violence,+lack+of+condom/
sexual+protecDon+negoDaDon+rights+
+

22. (Burgener,'McGowan,'Kla2;'Curr'Opinion'Immunol'2015)'
21+

23. Vaginal$Dysbiosis:$Bacterial$Vaginosis$(BV)
• Most+common+cause+of+vaginiDs+
• Loss+of+Lactobacillus'spp.'And+increased+diversity+of+vaginal+
microbiome+
• Gardnerella'vaginalis,'Atopobium'vaginae,'Prevotella+spp.,+BV[associated+
bacteria+(BVAB),+etc.++
• Vaginal+inflammaDon,+discharge,+discomfort+
• Associated+with+increased+HIV+risk+
• Male+to+female+
• Female+to+male+
• Mother+to+child+

24. Metaproteomic$and$genomic$analysis$iden/fy$2$major$vaginal$
microbial$groups$in$African$women
Microbial+16S+rRNA+ Microbial+proteome+(MS)+
Lactobacillus
dominant
G. vaginalis
dominant
BV +
BV - longitudinal sampling
(cervical swab)
10 Kenyan
women
637+bacterial+
proteins+
Zevin'et'al.,'PLoS'Pathogens'2016'
Lactobacillus
dominant
G. vaginalis
dominant

25. Vaginal$microbial$communi/es$are$func/onally$different$$
$
Uncategorized
Excretory system
Cell growth and death
Signaling molecules and interaction
Environmental adaptation
Lipid metabolism
Biosynthesis of other secondary metabolites
Cell motility
Enzyme families
Transcription
Metabolism of terpenoids and polyketides
Metabolism of other amino acids
Metabolism of cofactors and vitamins
Replication and repair
Amino acid metabolism
Infectious diseases
Drug resistance
Nucleotide metabolism
Folding sorting & degradation (G1>G2, P=0.0002)
Signal transduction
Energy metabolism (G1>G2, P=0.0001)
Translation
Membrane transport (G1<G2, P=0.0000002)
Carbohydrate metabolism
Transport and catabolism (G1>G2, P=0.00001)
AbundanceofKOFunctions
0.0
0.2
0.4
0.6
0.8
1.0
G1G1 G2 G2
Cohort 1 Cohort 2
‘Core’+metabolic+
pathways+
Pathways+likely+important+
for+pathogenesis+
G1=Lactobacillus'dominant'
G2=Gardnerella'dominant+
Zevin'et'al.,'PLoS'Pathogens'2016'

26. Cervical$epithelial$wound$healing$is$facilitated$by$Lactobacillus$
species$products$and$impaired$by$Gardnerella$products
A+
B+
L. iners
supernatant
G. vaginalis
supernatant
0 Hours 24 Hours
NYCIII
medium
(control)
-100
-50
0
50
100
N
YC
IIIM
edium
L.iners
supernatant
G
.vaginalis
supernatant
***
***
%WoundHealed
Zevin'et'al.,'PLoS'Pathogens'2016'

27. High G. vaginalis prevalence in areas
of high HIV infections in women
Africa
North
America
How does vaginal
microbiome dysbiosis
affect PrEP efficacy?

28. TDF2 – daily Tenovofir-Emtricitabine
(Women & Men - Botswana)#
75%* (24; 94)
Partners PrEP – daily Tenovofir-Emtricitabine
(Discordant couples – Kenya, Uganda)
66%* (28; 84)
Partners PrEP – daily oral Tenofovir
(Discordant couples – Kenya, Uganda)
71%* (37; 87)
#(Study population and countries where the study was conducted)
*Effect size calculated from the incidence rate ratio for women only
Effectiveness (%)
Study
!130% !60% !40% !20% 0% 20% 40% 60% 80% 100%
Effect size (CI)
MTN003/VOICE – daily Tenofovir gel
(Women – South Africa, Uganda, Zimbabwe)
15% (-21; 40)
CAPRISA 004 – coital Tenofovir gel
(Women – South Africa) 39% (6; 60)
FEMPrEP – daily Tenovofir-Emtricitabine
(Women – Kenya, South Africa, Tanzania)
6% (-52; 41)
MTN003/VOICE – daily Tenovofir-Emtricitabine
(Women – South Africa, Uganda, Zimbabwe)
-4% (-49; 27)
MTN003/VOICE – daily Tenofovir
(Women - South Africa, Uganda, Zimbabwe)
-49% (-129; 3)
OralPrEPTopicalPrEP
FACTS 001– coital Tenofovir gel
(Women – South Africa)
0% (-40, 30)
Effec/veness$of$Tenofovir$/$Truvada$
an/retroviral$pills$&$gels$in$women
Varying outcomes from PrEP trials - attributed to adherence
What biological factors affect PrEP?

29. Par/cipants$and$study$design:$CAPRISAH004
Kla2'et'al.,'Science'2017'

30. Vaginal$microbial$groups$in$CAPRISA$004
>50%
Lactobacillus
<50%
Lactobacillus
n=423
n=265
<50%
>50%
3
4
5
6
7
8
VaginalpH
% Lactobacillus
5.4 4.0
P=0.001
G. vaginalis
dominant
Lactobacillus
dominant
Kla2'et'al.,'Science'2017'

31. 0.0 0.5 1.0 1.5 2.0 2.5
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
Years in Study
ProbabilityofHIVinfection
Tenofovir Placebo
0.0 0.5 1.0 1.5 2.0 2.5
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
Years in Study
ProbabilityofHIVinfection
Tenofovir Placebo
Lactobacillus !dominant!women!at!risk!(Cumulative!number!of!infections)
Tenofovir 205,(0) 204,(1) 183,(3) 129,(7) 46,(9) 0,(9)
Placebo 202,(0) 196,(4) 173,(12) 123,(19) 51,(22) 0,(22)
Non$Lactobacillus %dominant%women%at%risk%(Cumulative%number%of%infections)
Tenofovir 140,(0) 137,(2) 123,(6) 87,(10) 32,(13) 0,(14)
Placebo 141,(0) 137,(4) 116,(12) 84,(17) 28,(17) 0,(17)
Efficacy, 61%
95% CI, 11 to 84%
Efficacy, 18%
95% CI, -77 to 63%
P=0.013
P=0.644
A. Lactobacillus dominant B. Non-Lactobacillus dominant
HR = 0.39 (95% CI: 0.20; 0.83) HR = 0.82 (95% CI: 0.40; 1.65)
0.0 0.5 1.0 1.5 2.0 2.5
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
Years in Study
ProbabilityofHIVinfection
Tenofovir Placebo
0.0 0.5 1.0 1.5 2.0 2.5
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
Years in Study
ProbabilityofHIVinfection
Tenofovir Placebo
Lactobacillus !dominant!women!at!risk!(Cumulative!number!of!infections)
Tenofovir 205,(0) 204,(1) 183,(3) 129,(7) 46,(9) 0,(9)
Placebo 202,(0) 196,(4) 173,(12) 123,(19) 51,(22) 0,(22)
Non$Lactobacillus %dominant%women%at%risk%(Cumulative%number%of%infections)
Tenofovir 140,(0) 137,(2) 123,(6) 87,(10) 32,(13) 0,(14)
Placebo 141,(0) 137,(4) 116,(12) 84,(17) 28,(17) 0,(17)
Efficacy, 61%
95% CI, 11 to 84%
Efficacy, 18%
95% CI, -77 to 63%
P=0.013
P=0.644
A. Lactobacillus dominant B. Non-Lactobacillus dominant
HR = 0.39 (95% CI: 0.20; 0.83) HR = 0.82 (95% CI: 0.40; 1.65)
Tenofovir gel effective against HIV with
Lactobacillus dominance
Lactobacillus dominant non- Lactobacillus dominant
Tenofovir Placebo Tenofovir Placebo
# HIV-1 infections 9 22 14 17
HIV-1 incidence
per 100 person-years
2.7 6.9 6.4 7.8
HIV-1 protection effectiveness
95% CI, P-value
61%
(11, 84), p=0.013
18%
(-77, 63), p=0.644
Kla2'et'al.,'Science'2017'

32. Discordance$between$adherence$and$genital$tenofovir$
concentra/ons
• Tenofovir+concentraDons+were+assessed+in+a+random+sample+of+CVLs+from+HIV[
negaDve+women+and+from+the+last+HIV+negaDve+CVL+from+HIV+seroconvertors+
(n=270)+
Genital tract tenofovir levels
Tenofovir level
Lactobacillus
dominant (n)
non-Lactobacillus
dominant (n)
Detectable 46% (72/156) 30% (34/114)
Undetectable 54% (84/156) 70% (80/114)
P value
(Fisher’s exact test)
0.008
non-Lactobacillus
dominant
Lactobacillus
dominant
0
20
40
60
80
Percent(%)
Detectible
Undetectible
70%
30%
46%
54%
Kla2'et'al.,'Science'2017'

33. 1) Inoculate NYCIII medium with or without
TFV, and abiotic controls
+TFV -TFV
Lactobacillus
+TFV -TFV
G. vaginalis (or
BV bacteria) Abiotic
+TFV
2) Sample. Separate cells from culture
supernatant by centrifugation. Extract TFV
into acetonitrile and analyze on MS
(Supe) MS
3) Track supernatant and intracellular
TFV levels, and metabolic products
= Tenofovir
AcetonitrileCulture
sample
Assessing$biodegrada/on$of$
tenofovir$by$bacteria$
m/z
Intensity
TFV
hips://pubchem.ncbi.nlm.nih.gov/compound/Tenofovir#secDon=Top+

34. Tenofovir$is$rapidly$depleted$by$
Gardnerella$but$not$Lactobacillus
0 10 20 30
0.0
0.2
0.4
0.6
0.8
1.0
1.2
Time (hours)
TenofovirFoldChange
G. vaginalis
L. iners
Abiotic
4 hours:
G. vag vs Abiotic: P<0.0001
G. vag vs. L. iners: P=0.0037
G. vag vs. L. crisp: P=0.0019
L. iners vs L. crisp: P=ns
24 hours:
G. vag vs Abiotic: P<0.0001
G. vag vs. L. iners: P<0.0001
G. vag vs. L. crisp: P<0.0001
L. iners vs. L. crisp: P=ns
Tenofovir (supernatant)
L. crispatus
0 10 20 30
0.000
0.001
0.002
0.003
Time (hours)
Tenofovir(mg/mL)
G. vaginalis
L. iners
Tenofovir (cell)
4 hours:
G. vag vs. L. iners: P<0.0001
G. vag vs. L. crispatus: P<0.0001
L. iners vs. L. crispaturs: P=ns
24 hours:
G. vag vs. L. iners: P<0.0001
G. vag vs. L. crispatus: P<0.0001
L. iners vs. L. crispaturs: P=ns
L. crispatus
Kla2'et'al.,'Science'2017'

35. Is$tenofovir$truly$metabolized?
Tenofovir+ Adenine+ Oxy[methylphosphonic+
+acid++
Measured'putaQve'metabolites'at'135.1021'(adenine),'206.1037,'159.0663,'and'59.0491'm/z''

36. Tenofovir$is$metabolized$to$adenine$by$
Gardnerella
0 10 20 30
0.00
0.02
0.04
0.06
0.08
Time (hours)
Adenine(mg/mL)
G vaginalis
L. iners
Abiotic
4 hours:
G. vag vs Abiotic: P<0.0001
G. vag vs. L. iners: P<0.0001
G. vag vs. L. crispatus: P<0.0001
L. iners vs. L. crispatus: P=0.02
24 hours:
G. vag vs Abiotic: P<0.0001
G. vag vs. L. iners: P<0.0001
G. vag vs. L. crispatus: P<0.0001
L. iners vs. L. crispatus: P=ns
TFV Metabolite formation
L. crispatus
0 10 20 30
0
50
100
150
Time (hours)
TFV+Adenine
G vaginalis
L. iners
Abiotic
Total Drug Recovery
4 hours:
G. vag vs Abiotic: P=ns
G. vag vs. L. iners: P=ns
G. vag vs. L. crispatus: P=ns
L. iners vs. L. crispatus: P=ns
24 hours:
G. vag vs Abiotic: P=ns
G. vag vs. L. iners: P=ns
G. vag vs. L. crispatus: P=ns
L. iners vs. L. crispatus: P=ns
L. crispatus
Kla2'et'al.,'Science'2017'

37. Mul/ple$BVHassociated$bacteria$(but$not$
Lactobacillus)$can$metabolize$tenofovir
0 10 20 30
0.4
0.6
0.8
1.0
1.2
Time (hours)
TenofovirFoldChange
Abiotic NYC-III
Abiotic Tryptic Soy
P. amnii
24 hours:
P. amnii vs Abiotic (NYCIII): P=0.0007
P. bivia vs Abiotic (NYCIII): P=0.0007
M. mulierus vs Abiotic (NYCIII): P=0.0007
E. coli vs Abiotic (TS): P=0.1000
Tenofovir (supernatant)
P. bivia
E. coli
M. mulierius
Kla2'et'al.,'Science'2017'

38. • Loss+of+TFV+in+supernatant+
• Bacteria[mediated+metabolism+vs.+target+cell+uptake+
• Presence+of+intracellular+TFV[DP+
• TFV+is+completely+and+rapidly+converted+to+TFV[DP+
• Target+cell+uptake+
• Presence+of+intracellular+Adenine+
• BiodegradaDon+of+TFV+by+G.'vaginalis+yields+single+
major+metabolite+
• Metabolism+by+bacteria+
• Presence+of+intracellular+TFV+
• Mass+balance+drug+recovery+
Jurkat+cells+
Bacteria++
(Gardnerella)+or+(Lactobacillus)+
Tenofovir++
• Supernatant+TFV+
• Intracellular+TFV[DP+
• Intracellular+Adenine+
• Total+Drug+Recovery+

39. TFV$loss$in$supernatant$is$more$rapid$in$
Gardnerella$than$Lactobacillus,)associated$with$
adenine$forma/on
0 15 30 45 60
0.00
0.05
0.10
TIme (minutes)
TFV(mg/mL)
TFV alone
TFV + cells
TFV + cells + G. vaginalis
TFV + cells+ L. iners
TFV + cells + L. crispatus
60 minutes:
G. vag vs TFV + cells: P=0.0001
G. vag vs. L. iners: P=0;0022
G. vag vs. L. crispatus: P=0;0238
Lactobacillus vs TFV/cells: P=ns
0 20 40 60
0.000
0.025
0.050
0.075
Adenine Formation
Time (minutes)
Adenine(mg/mL)
TFV alone
TFV + cells
TFV + cells + G. vaginalis
TFV + cells+ L. iners
TFV + cells + L. crispatus
60 minutes:
G. vag vs TFV + cells: P=0.0022
Lactobacillus vs TFV/cells: P=ns
Kla2'et'al.,'Science'2017'

40. TFV$is$phosphorylated$a]er$Jurkat$cellular$uptake$
in$presence$of$Lactobacillus$but$not$Gardnerella
0 20 40 60
0.00
0.01
0.02
0.03
0.04
0.05
0.06
0.07
TFV-DP Formation
Time (minutes)
TFV-DP(mg/mL)
TFV alone
TFV + cells
TFV + cells + G. vaginalis
TFV + cells+ L. iners
TFV + cells + L. crispatus
60 minutes:
G. vag vs TFV + cells: P=0.0002
Lactobacillus vs TFV/cells: P=ns
0 15 30 45 60
0
50
100
TIme (minutes)
IntracellularTFV+Adenine+TFV-DP
TFV + cells
TFV + cells + G. vaginalis
TFV + cells+ L. iners
Total Drug Recovery
TFV + cells + L. crispatus
Kla2'et'al.,'Science'2017'

41. Efficiency$of$pharmacodynamicallyHac/ve$
metabolite$forma/on$significantly$lower$in$the$
presence$of$G.)vaginalis
TFV
+
cells
TFV
+
cells
+
G
.vaginalis
TFV
+
cells+
L.iners
TFV
+
cells
+
L.crispatus
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
TFV-DP/TFVratio
15 min
****
TFV
+
cells
TFV
+
cells
+
G
.vaginalis
TFV
+
cells+
L.iners
TFV
+
cells
+
L.crispatus
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
TFV-DP/TFVratio
30 min
****
TFV
+
cells
TFV
+
cells
+
G
.vaginalis
TFV
+
cells+
L.iners
TFV
+
cells
+
L.crispatus
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
TFV-DP/TFVratio
1 hour
****

42. Conclusions$IV:$Vaginal$microbiota$contribute$
to$HIV$transmission$risk$despite$PrEP
• Iden=fied(a(microbial(signature(associated(with(high(effec=veness(of(
vaginal(PrEP(+
• Tenofovir+gel+efficacy+was+3Pfold(higher(in+women+with+vaginal+
Lactobacillus'dominance+
• Tenofovir+gel+was+not(effec=ve(in+women+with+non[Lactobacillus'
communiDes+containing+high+amounts+of+G.'vaginalis'
• Tenofovir+is+rapidly+depleted+by+G.'vaginalis+(and+other+BV[associated+
bacteria)+but+not+Lactobacillus'
• AcDve+TFV+is+decreased+in+the+presence+of+G.'vaginalis,'more+rapidly+than+
uptake+by+target+cells+occurs'
• Importance+of+adherence+and+vaginal(health(for+PrEP+efficacy+against+HIV+in+
women+
• Vaginal+pH+screening+and+microbiota+monitoring/treatment+are+potenDal+adjunct+
intervenDons+to+enhance+PrEP+impact+in+women++
'

43. • UW/WaNPRC/Pharmaceu=cs(
• Kla+(Lab(
• Tiffany(HensleyPMcBain(
• Alex(Zevin,(PhD(
• Ryan(Cheu((
• Jennifer(Manuzak,(PhD(
• Charlene(Miller(
• Andrew(Gus=n(
• Debbie(Bra+(
• Ernesto(Coronado(
• De’Neka(Gary(
• Toni(Go+(
• Jake(Modesi+(
• Alex(Roederer(
• UW(Harborview(Hospital(
• Ann(Collier(
• Michalina(Montano(
• Lindsay(Legg(
Acknowledgements(
• UCSF(SCOPE(
• Peter(Hunt(
• Ma(Somsouk(
• Montha(Pao(
• Monika(Deswal(
• Rebecca(Hoh(
(
• Northwestern(University(
• Tom(Hope(
• Mike(McRaven(
(
(
(
• NIH/NIAID(1K22AI098440(
• NIH/NIAID(1R01AI117828(
• NIH/NIDDK(RO1DK112254+(
• NIH/NIDA(1DP13A037979(
• NSF(Fellowship((HensleyPMcBain)(
• UW(CFAR(
• CIHR(Mucosal(Team(Grant((Burgener)(
• University(of(Manitoba/
Na=onal(Microbiology(
Laboratory(
• Adam(Burgener(
• Kenzie(Birse(
• Laura(Romas(
• Michelle(Perner(
(
• CAPRISA(
• Salim(Abdool(Karim(
• Quarraisha(Abdool(Karim(
• Lyle(McKinnon(
• Anneke(Grobler(
(

44. Dis/nguishing$neutrophils$by$flow$
cytometry
Colorectal(Biopsy(
Blood(
43+
Live(
CD45+(
CD3P/CD20P(
CD14P/High(SSC((
((granularity)(

45. PCHOL,PK,PD…
Lee+Wam+et+al.+AnDmicrob+Agents+Chemother+2005;+49:1898[906+
44+

46. Microbiome$pathways$correlate$with$epithelial$
wounding$markers
INVO'is'key'in'epithelial'keraQnizaQon,'epidermis'development,'and'cornified'envelope''
Zevin'et'al.,'PLoS'Pathogens'2016'

47. Conclusions$II:$Vaginal$dysbiosis$affects$metabolic$
processes$and$can$lead$to$decreased$epithelial$integrity
• G.'vaginalis'may+outcompete+Lactobacillus'spp.+via+metabolism+
• carbohydrate+substrates+in+the+FGT+through+increased+expression+of+membrane+transporters,+
secreted+sugar+binding+proteins,+and+starch+phosphorylases+
• G.'vaginalis[dominated+communiDes+associate+with+decreased+expression+of+
epithelial+barrier+factors+compared+to+Lactobacillus[dominated+communiDes,+
regardless+of+BV+diagnosis+
• G.'vaginalisZderived+products+inhibit+in'vitro'wound+closure+while+L.'iners[derived+
products+do+not+affect+wound+closure+
+
+