Patent Publication Number: US-11376268-B2

Title: Methods and materials for treating human immunodeficiency virus infections

Description:
CROSS REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation of U.S. application Ser. No. 15/552,636, filed Aug. 22, 2017 know U.S. Pat. No. 10,786,519), which is a National Stage application under 35 U.S.C. § 371 of International Application No. PCT/US2016/018776, having an International Filing Date of Feb. 19, 2016, which claims the benefit of U.S. Provisional Ser. No. 62/119,318, filed Feb. 23, 2015. This disclosure of the prior applications are considered part of (and are incorporated by reference in) the disclosure of this application. 
    
    
     STATEMENT AS TO FEDERALLY SPONSORED RESEARCH 
     This inventor was made with government supposed under AI110173 awarded by the National Institutes of Health. The government has certain rights in the invention. 
    
    
     BACKGROUND 
     1. Technical Field 
     This document relates to methods and materials involved in treating human immunodeficiency virus (HIV) infections. For example, this document provides methods and materials for using one or more proteosome inhibitors in combination with one or more other agents to treat HIV infections. 
     2. Background Information 
     HIV is a retrovirus that causes the acquired immunodeficiency syndrome (AIDS), which is a medical condition where progressive failure of the immune system leads to life-threatening opportunistic infections. The HIV infection, while treatable for long periods of time, remains a largely incurable infection. On the other hand, an HIV infection was “cured” in one patient, which involved using myeloablative chemotherapy and maximally suppressive antiretroviral therapy (ART), followed by bone marrow transplantation (BMT; Hater et al.,  N. Engl. J. Med.,  360:692-698 (2009)). 
     SUMMARY 
     This document provides methods and materials for treating HIV infections. For example, this document provides methods and materials for using one or more proteosome inhibitors in combination with one or more other agents to treat HIV infections. An obstacle to curing an HIV infection is the existence of transcriptionally silent integrated HIV proviruses that reside in resting memory CD4 T cells, which are difficult to eliminate because they are resistant to the cytotoxic and pro-apoptotic effects of viral reactivation. The reasons that latently infected CD4 T cells resist the pro-death effects of intracellular HIV proteins are (i) memory CD4 T cells are apoptosis resistant, and (ii) chronic or latent HIV infection causes an apoptosis resistant phenotype. It is this apoptosis resistance that appears to be the reason that latently HIV infected cells do not die following viral reactivation, even though viral reactivation results in expression of pro-apoptotic factors (e.g., Env, Tat, Nef, protease and Vpr, and likely others factors such as FasL and TRAIL). 
     As described herein, altering the susceptibility of latently HIV infected cells (e.g., latently HIV infected CD4 T cells or resting memory CD4 T cells) that have become resistant to the pro-apoptotic effects of intracellular HIV replication, so that these cells become susceptible again to the pro-apoptotic effects of productive HIV replication can be used to treat HIV infections. ART drugs do not treat latently HIV infected cells. The only drugs that act on these latently HIV infected cells are latency reversing agents (LRAs), but LRAs do not cause latently HIV infected cells to die. Thus, the number of latently HIV infected cells can remain stable over time. As described herein, proteosome inhibitors alone such as bortezomib or ixazomib can induce HIV reactivation. Moreover, when HIV is reactivated in latently HIV infected cells (whether the HIV reactivation is induced by a proteosome inhibitor, another agent such as an LRA, or a condition such as an inflammatory reaction) in the presence of a proteosome inhibitor, those HIV reactivating cells die. Thus, in some cases, HIV infections can be treated by administering maximally suppressive ART to prevent or reduce the level of repopulation of the HIV reservoir and by administering one or more proteosome inhibitors such as bortezomib or ixazomib to render latently HIV infected cells susceptible to the cytotoxic effects of pro-apoptotic HIV proteins, to promote HIV reactivation (e.g., with a proteosome inhibitor or with an LRA), and to cause accumulation of HIV proteins within the infected cell (since proteasome inhibitors can prevent HIV budding and prevent proteasome mediated degradation of those proteins), altogether resulting in the intracellular expression of the pro-apoptotic HIV proteins such as Tat, Nef, Env, Vpr, and protease, which then can cause the death of those HIV reactivating cells that were latently infected with HIV. 
     In general, one aspect of this document features a method for reducing the number of latently HIV infected cells within a human infected with HIV. The method comprises, or consists essentially of, (a) administering a proteosome inhibitor to the human, and (b) administering a combination of anti-retroviral agents to the human. The cells can be CD4 +  T cells. The proteosome inhibitor can be ixazomib or bortezomib. The proteosome inhibitor can be ixazomib. The combination can comprise an integrase inhibitor, a protease inhibitor, and a reverse transcriptase inhibitor. The integrase inhibitor can be raltegravir. The protease inhibitor can be darunavir or atazanavir. The reverse transcriptase inhibitor can be selected from the group consisting of emtricitabine, rilpivirine, and tenofovir. The method can comprise administering a latency reversing agent to the human. The latency reversing agent can be selected from the group consisting of an HDAC inhibitor, a phorbol ester (e.g., prostratin), IL-2, and a bromodomain inhibitor. The method can comprise administering an immunotherapeutic agent, a vaccine, or a nucleic acid to the human. The method can comprise administering an immunotherapeutic agent to the human, wherein the immunotherapeutic agent is IL-15. The method can comprise administering a vaccine to the human. The method can comprise administering a nucleic acid to the human, wherein the nucleic acid is designed to reduce CCR5 polypeptide expression. 
     Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention pertains. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, suitable methods and materials are described below. All publications, patent applications, patents, and other references mentioned herein are incorporated by reference in their entirety. In case of conflict, the present specification, including definitions, will control. In addition, the materials, methods, and examples are illustrative only and not intended to be limiting. 
     Other features and advantages of the invention will be apparent from the following detailed description, and from the claims. 
    
    
     
       DESCRIPTION OF DRAWINGS 
         FIG. 1  is a graph plotting the percent of viable HIVIIIb infected Jurkat T cells that were untreated or treated (10 or 25 nM of bortezomib) for up to five days. 
         FIG. 2  is a graph plotting the level of p24 (ng/mL) in the supernatant of a culture of HIV IIIb infected Jurkat T cells that were untreated or treated (10 or 25 nM of bortezomib) as described in  FIG. 1 . 
         FIGS. 3 and 4 . CD4 T cells infected with HIV-pNL4.3-Luc were activated and cultured for three days. Cells were treated with TDF/T20 and then with bortezomib (10 nM) or MLN-2238 (100 nM) or control. Cells were harvested 48 hours after treatment and analyzed for intracellular luciferase ( FIG. 3 ) or proviral DNA ( FIG. 4 ). 
         FIG. 5  is a graph plotting resting CD4 T cells treated with CCL19/IL2, infected with HIV-pNL4.3-Luc, and cultured in the presence of TDF/T20. The cells were treated with bortezomib (10 nM) or MLN-2238 (100 nM) or control for 24 hours prior to reactivation with panobinostat. Cells were harvested 48 hours after reactivation and analyzed for intracellular luciferase activity. 
         FIG. 6  contains flow cytometry results of J-Lat cells (a model of HIV latency, using GFP tagged HIV) treated with nothing, bortezomib (1, 10, or 20 nM), or MLN-2238 (ixazomib; 10 or 50 nM) and analyzed 24 hours later for activated caspase 3 expression and for HIV expression. Both bortezomib, and ixazomib independently caused HIV reactivation as indicated by increased HIV GFP expression, and caused HIV GFP positive cells to die, as indicated by activated caspase 3 expression in the GFP positive cells. 
         FIG. 7  contains flow cytometry results of CD4 T cells from an HIV positive patient with ART suppressed HIV replication. Cells were treated with bortezomib or MLN-2238 (ixazomib) at the indicated doses and analyzed 48 hours later for intracellular p24 expression (as a measure of HIV reactivation), and for activated caspase 3 expression (as a measure of cell death). Both bortezomib, and ixazomib independently caused HIV reactivation as indicated by increased HIV p24 expression, and caused HIV positive cells to die as indicated by activated caspase 3 expression in the p24 positive cells. 
         FIG. 8  contains flow cytometry results demonstrating that inhibited budding leads to accumulation of HIV proteins. J-Lat cells (a model of HIV latency using GFP HIV) were treated with bortezomib or ixazomib at the indicated doses and analyzed at 24, 48, and 72 hours. Both drugs caused HIV reactivation from latency. 
         FIG. 9  provides data demonstrating that proteosome inhibitors stimulate HIV. Primary CD4 T cells infected with HIV luc (top panel) or primary CD4 T cells transfected with HIV-LTR Luc and co-transfected TK renilla (bottom panel) were treated with the indicated doses of bortezomib or ixazomib, and analyzed for Luc expression as a measure of HIV reactivation. Both drugs independently reactivated HIV in primary CD4 T cell model systems. 
         FIG. 10  provides data demonstrating that proteosome inhibitors stimulate ATF4, leading to HIV-LTR activation. Proteosome inhibitors activated the unfolded protein response (UPR) pathway, which includes ATF-4, and ATF4 can independently activate the HIV LTR. To determine if AFT4 is a plausible mechanism of HIV reactivation in primary CD4 T cells, cells were treated with bortezomib or ixazomib, and ATF-4 was analyzed over time. 
         FIG. 11 . HIV latency is maintained in part by the action of HDAC, and HDAC inhibitors caused HIV reactivation. Proteosome inhibitors were analyzed for the ability to alter the expression of HDAC. Bortezomib and ixazomib decreased HDAC-1, HDAC-3, and HDAC-4 expression in primary CD4 T cells. 
         FIG. 12 . J-LAT-10.6 or Jurkat cells were treated with bortezomib (10 nM) or ixazomib (50 nM) for the indicated times. Bortezomib and ixazomib induced phospho PERK, phospho IRE1, and JNK activation in J Lat cells, indicating the activation of the UPR pathway. 
         FIG. 13 . J-LAT-10.6 or Jurkat cells were treated with bortezomib (10 nM) or ixazomib (50 nM) for the indicated times. Bortezomib and ixazomib induced ATF4 and CHOP translocation into the nucleus, and ATF6 cleavage in J Lat cells, indicating the activation of the UPR pathway. 
     
    
    
     DETAILED DESCRIPTION 
     This document provides methods and materials for treating HIV infections. For example, this document provides methods and materials for using one or more proteosome inhibitors in combination with one or more other agents to treat HIV infections. In some cases, one or more proteosome inhibitors can be used to cause latently HIV infected cells to die following HIV reactivation in those latently HIV infected cells. 
     Any appropriate method can be used to identify a human having an HIV infection. For example, HIV blood tests can be used to identify a human having an HIV infection. 
     Once identified as having an HIV infection, the human can be administered ART (e.g., maximally suppressive ART) to prevent or reduce the level of repopulation of the HIV reservoir and one or more proteosome inhibitors to increase the susceptibility of latently HIV infected cells to cell death upon HIV reactivation, to induce HIV reactivation of latently HIV infected cells, and/or to cause accumulation of HIV proteins within the reactivating cells, all of which can synergize to cause the death of HIV infected cells. 
     An ART can include any appropriate anti-retroviral agent or combination of anti-retroviral agents. Examples of anti-retroviral agents that can be used for ART include, without limitation, HIV integrase inhibitors, HIV protease inhibitors, and reverse transcriptase inhibitors. Examples of ITV integrase inhibitors include, without limitation, raltegravir (also known as Isentress or MK-0518), dolutegravir, and elvitegravir. Examples of HIV protease inhibitors include, without limitation, lopinavir and atazanavir. Examples of reverse transcriptase inhibitors include, without limitation, emtricitabine, rilpivirine, and tenofovir. In some cases, combinations of anti-retroviral agents can be formulated into a single dosage form (e.g., a single pill or capsule) such as Complera® (emtricitabine, rilpivirine, and tenofovir), Atripla® (efavirenz, emtricitabine, and tenofovir DF), Stribild® (cobicistat, elvitegravir, emtricitabine, and tenofovir), and Triumeq® (abacavir, dolutegravir, and lamivudine). 
     Any appropriate proteosome inhibitor or combination of proteosome inhibitors (e.g., a combination of two, three, four, five, or more different proteosome inhibitors) can be used as described herein. Examples of proteosome inhibitors that can be used as described herein include, without limitation, bortezomib (N-pyrazinecarbonyl-L-phenylalanine-L-leucine boronic acid; Velcade®; Millennium Pharmaceuticals), ixazomib (4-(carboxymethyl)-2-((R)-1-(2-(2,5-dichlorobenzamido)acetamido)-3-methylbutyl)-6-oxo-1,3,2-dioxaborinane-4-carboxylic acid, Millennium Pharmaceuticals), and carfilzomib ((S)-4-Methyl-N-((S)-1-4(S)-4-methyl-1-((R)-2-methyloxiran-2-yl)-1-oxopentan-2-yl)amino)-1-oxo-3-phenylpropan-2-yl)-2-((S)-2-(2-morpholinoacetamido)-4-phenylbutanamido)pentanamide; Kyprolis®, Onyx Pharmaceuticals, Inc.). 
     In some cases, one or more proteosome inhibitors can be formulated into a pharmaceutically acceptable composition for administration to a human having an HIV infection. For example, a therapeutically effective amount of bortezomib or ixazomib can be formulated together with one or more pharmaceutically acceptable carriers (additives) and/or diluents. A pharmaceutical composition can be formulated for administration in solid or liquid form including, without limitation, sterile solutions, suspensions, sustained-release formulations, tablets, capsules, pills, powders, and granules. A pharmaceutical composition containing one or more proteosome inhibitors can be designed for oral or parenteral (including subcutaneous, intramuscular, intravenous, and intradermal) administration. When being administered orally, a pharmaceutical composition containing one or more proteosome inhibitors can be in the form of a pill, tablet, or capsule. Compositions suitable for parenteral administration include aqueous and non-aqueous sterile injection solutions that can contain anti-oxidants, buffers, bacteriostats, and solutes which render the formulation isotonic with the blood of the intended recipient; and aqueous and non-aqueous sterile suspensions which may include suspending agents and thickening agents. The formulations can be presented in unit-dose or multi-dose containers, for example, sealed ampules and vials, and may be stored in a freeze dried (lyophilized) condition requiring only the addition of the sterile liquid carrier, for example water for injections, immediately prior to use. Extemporaneous injection solutions and suspensions may be prepared from sterile powders, granules, and tablets. 
     In some cases, a pharmaceutically acceptable composition including one or more proteosome inhibitors can be administered systemically. For example, a composition containing a proteosome inhibitor can be administered systemically orally or by injection to a human. 
     Effective doses can vary depending the route of administration, the age and general health condition of the human, excipient usage, the possibility of co-usage with other therapeutic treatments such as use of anti-retroviral agents and/or latency reversing agents, and the judgment of the treating physician. 
     An effective amount of a composition containing one or more proteosome inhibitors can be any amount that increases the susceptibility of latently HIV infected cells to cell death upon HIV reactivation, incudes HIV reactivation of latently HIV infected cells, or both increases the susceptibility of latently HIV infected cells to cell death upon HIV reactivation and induces HIV reactivation of latently HIV infected cells, thereby causing the latently HIV infected cells to die, without producing significant toxicity to the human. If a particular human fails to respond to a particular amount, then the amount of proteosome inhibitor can be increased by, for example, two fold. After receiving this higher amount, the human can be monitored for both responsiveness to the treatment and toxicity symptoms, and adjustments made accordingly. The effective amount can remain constant or can be adjusted as a sliding scale or variable dose depending on the human&#39;s response to treatment. Various factors can influence the actual effective amount used for a particular application. For example, the frequency of administration, duration of treatment, use of multiple treatment agents, route of administration, and severity of the HIV infection may require an increase or decrease in the actual effective amount administered. 
     The frequency of administration of a composition containing one or more proteosome inhibitors can be any frequency that increases the susceptibility of latently HIV infected cells to cell death upon HIV reactivation, incudes HIV reactivation of latently HIV infected cells, or both increases the susceptibility of latently HIV infected cells to cell death upon HIV reactivation and induces HIV reactivation of latently HIV infected cells, thereby causing the latently HIV infected cells to die, without producing significant toxicity to the human. For example, the frequency of administration can be from about daily to about once a week. The frequency of administration can remain constant or can be variable during the duration of treatment. As with the effective amount, various factors can influence the actual frequency of administration used for a particular application. For example, the effective amount, duration of treatment, use of multiple treatment agents, route of administration, and severity of the HIV infection may require an increase or decrease in administration frequency. 
     An effective duration for administering a composition containing one or more proteosome inhibitors can be any duration that increases the susceptibility of latently HIV infected cells to cell death upon HIV reactivation, incudes HIV reactivation of latently HIV infected cells, or both increases the susceptibility of latently HIV infected cells to cell death upon HIV reactivation and induces HIV reactivation of latently HIV infected cells, thereby causing the latently HIV infected cells to die, without producing significant toxicity to the human. Thus, the effective duration can vary from several months to several years. In general, the effective duration for the treatment of an HIV infection as described herein can range in duration from about two months to about five years. Multiple factors can influence the actual effective duration used for a particular treatment. For example, an effective duration can vary with the frequency of administration, effective amount, use of multiple treatment agents, route of administration, and severity of the HIV infection being treated. 
     In some cases, a human having an HIV infection can be treated with one or more proteosome inhibitors as described herein in combination with (a) one or more anti-retroviral agents, (b) one or more latency reversing agents, (c) one or more immunotherapeutic agents, (d) one or more vaccines (e.g., a vaccine formulated for assisting in the treatment of an HIV infection), (e) one or more nucleic acid-based therapies, (f) one or more chimeric TRIMS a polypeptides designed to restrict HIV expression, and (g) one or more advanced (e.g., third or later generation) chimeric antigen receptors expressed on CD8 T cells or NK cells designed to generate anti-HIV immunity. Examples of latency reversing agents that can be used in combination with one or more proteosome inhibitors as described herein include, without limitation, HDAC inhibitors, phorbol esters, IL-2, bromodomain inhibitors, and those described elsewhere (Bullen et al.,  Nature Medicine,  20:425-429 (2014)). Examples of HDAC inhibitors that can be used as latency reversing agents include, without limitation, vorinostat, panabinostat, and valproic acid. Examples of phorbol esters that can be used as latency reversing agents include, without limitation, prostratin and PMA. An example of a bromodomain inhibitor that can be used as a latency reversing agent includes, without limitation, JQ1 ((S)-tert-butyl 2-(4-(4-chlorophenyl)-2,3,9-trimethyl-6H-thieno[3,2-f][1,2,4]triazolo[4,3-a][1,4]diazepin-6-yl)acetate). 
     Examples of immunotherapeutic agents that can be used in combination with one or more proteosome inhibitors as described herein include, without limitation, IL-15, CD4 immunotoxin, and neutralizing anti-HIV antibodies. For example, a human having an HIV infection can be administered one or more proteosome inhibitors as described herein and IL-15. 
     Examples of vaccines that can be used in combination with one or more proteosome inhibitors as described herein include, without limitation, HIV tat or env antigens delivered by any number of platforms including genetic immunization, viral or virus like particle delivery, or delivery as recombinant proteins. The HIV antigens can be delivered with adjuvants such as CPG or GM-CSF. In some cases, a human having an HIV infection can be administered one or more proteosome inhibitors as described herein and a HIV tat or env vaccine. 
     Examples of nucleic acid-based therapies that can be used in combination with one or more proteosome inhibitors as described herein include, without limitation, nucleic acid molecules having the ability to reduce CCR5 polypeptide expression (e.g., siRNA molecules designed to reduce CCR5 polypeptide expression) and TALEN or CRISPR/Cas constructs designed to excise HIV DNA. For example, a human having an HIV infection can be administered one or more proteosome inhibitors as described herein and an siRNA molecule designed to reduce CCr5 polypeptide expression. 
     In some cases, a human having an HIV infection can be treated with one or more proteosome inhibitors as described herein in combination with one or more anti-retroviral agents plus any one or more of (a) one or more latency reversing agents, (b) one or more immunotherapeutic agents, (c) one or more vaccines (e.g., a vaccine formulated for assisting in the treatment of an HIV infection), and (d) one or more nucleic acid-based therapies. 
     In some cases, the level of HIV infected cells within a human being treated can be monitored during the course of treatment. Any appropriate method can be used to determine the level of HIV infected cells within a human. For example, the level of HIV infected cells within a human can be assessed using PCR based detection methods (nested or un-nested) for detecting HIV DNA, quantitative viral outgrowth assays (QVOA) for measuring replication competent HIV levels, or TILDA (Tat/rev; Induced Limiting Dilution Assay) that can measure the frequency of cells with multiply spliced HIV RNA as a surrogate for replication competent HIV. 
     The invention will be further described in the following examples, which do not limit the scope of the invention described in the claims. 
     EXAMPLES 
     Example 1 
     Using Proteosome Inhibitors to Cause Latently HIV Infected Cells to Die Following HIV Reactivation 
     HIV infection is effectively treated by a number of antiretroviral medication, which when used in well proven combinations effectively suppress HIV replication, and persons on these treatments no longer experience life threatening immunosuppression associated with HIV infection. Even though combination antiretroviral therapy reverses the immunodeficiency of HIV, it does not normalize health of infected individuals. For example, treated HIV patients experience accelerated rates of diseases associated with ageing, likely as a consequence of on-going inflammation, including stroke, heart disease, diabetes, and osteoporosis (Warriner et al.,  Infect. Dis. Clin. North Am.,  28(3):457-76 (2014)). 
     A principal obstacle to curing an HIV infection is the existence of a long lived population of resting memory CD4 T cells, in which HIV has integrated into the host genome, where it lays dormant, and thus does not express any HIV proteins. Thus, current antiretroviral agents, which target HIV encoded proteins do not target these cells, nor do anti-HIV specific immune response as no target antigen is expressed. Current ART does, however, efficiently control and reduce HIV replication (reflected by HIV plasma RNA levels) to undetectable levels, such that in a well-treated patient, the majority of HIV persists in the latent (integrated DNA) state. The quiescent nature of this reservoir is associated with a long half-life of latently HIV infected CD4 T cells (estimated at about 44 months), such that a predicted 70 years of therapy would be required to cure HIV assuming that no HIV reactivation would occur during that time frame. Of course, however HIV reactivates with concomitant inflammation for example during “colds” or with vaccinations, and these viral “blips” serve to repopulate the HIV reservoir. Thus, the size of the HIV reservoir can be remarkable stable over years, and to date there have been no interventions identified which reliably reduce the size of the HIV reservoir. Importantly, when HIV reactivates from latency, those reactivating cells do not die. As described herein, when latently HIV infected cells are treated with proteasome inhibitors, those cells which reactivate HIV die, whereas cells which do not contain HIV are spared. 
     Latently infected CD4 T cells are rare in HIV infected and treated individuals, being present at a frequency of about 1 per million CD4 T cells. Moreover, as HIV is latent, there are no cell surface markers that can be used to identify latently infected cells. Thus, isolation, purification, and study of these cells using ex vivo samples is practically impossible. Accordingly, the HIV field developed a number of in vitro models to recapitulate many of the properties of latency. One model of HIV latency uses CCL19, which is the ligand of CCR7, to polarize cells towards a resting memory and thus a latency resembling phenotype. Pretreatment of resting CD4 +  T cells from blood with CCL19 allows for efficient HIV-1 entry and viral integration with restricted spontaneous viral expression yet robust HIV expression post stimulation consistent with postintegration HIV-1 latency (Saleh et al., Blood, 110:4161-4164 (2007)). 
     ART drugs do not treat latently HIV infected cells. The only drugs that act on these latently HIV infected cells are latency reversing agents (LRAs), but LRAs do not cause latently HIV infected cells to die. Thus, the number of latently HIV infected cells can remain stable over time. 
     The results provided herein (see, e.g.,  FIGS. 1-13 ) demonstrate that proteosome inhibitors alone such as bortezomib or ixazomib can induce HIV reactivation and that, following HIV reactivation, HIV proteins accumulate in the HIV infected cell. Moreover, the results provided herein demonstrate that when HIV is reactivated in latently HIV infected cells (whether the HIV reactivation is induced by a proteosome inhibitor, another agent such as an LRA, or a condition such as an inflammatory reaction) in the presence of a proteosome inhibitor, those HIV reactivating cells die, resulting in fewer cells containing HIV. 
     Example 2 
     Reducing the Number of Latently HIV Infected Cells within an HIV Infected Human 
     A human having an HIV infection is treated with an ART regimen that includes 400 mg po bid of Raltegravir or 50 mg per day of Dolutegravir plus either two nucleoside analogues such as tenofovir (300 mg per day) and emtracitibine (200 mg per day or Complera® (emtricitabine, rilpivirine, and tenofovir; fixed dose pill once daily). In addition, the human is treated with 2 mg/m 2  of ixazomib twice a week. 
     OTHER EMBODIMENTS 
     It is to be understood that while the invention has been described in conjunction with the detailed description thereof, the foregoing description is intended to illustrate and not limit the scope of the invention, which is defined by the scope of the appended claims. Other aspects, advantages, and modifications are within the scope of the following claims.