Female-predominant anti-CD4 IgG autoantibody production and its correlations with plasma levels of progesterone, microbial translocation, and blunted immune reconstitution in HIV-infected patients on suppressive ART

Autoimmunity contributes to HIV immunopathogenesis even in the absence of overt autoimmune disease. We previously showed that anti-CD4 autoantibodies from people with HIV (PWH) on suppressive antiretroviral therapy (ART) can mediate cytotoxicity against CD4+ T cells, implicating a role in impaired immune reconstitution. Despite viral suppression, many PWH with poor CD4 recovery exhibit chronic immune activation, microbial translocation, and dysregulated humoral immunity. Here, we identify a female-predominant elevation of plasma anti-CD4 IgG autoantibodies in aviremic PWH receiving ART. Across two independent cohorts, HIV-positive females, but not males, displayed significantly higher anti-CD4 IgG, predominantly IgG1, compared with HIV-negative controls, without parallel increases in anti-CD4 IgA or IgM. This sex-specific pattern was unique to anti-CD4 IgG and was not observed for anti-CD8 IgG, anti-double-stranded DNA IgG, or anti-nuclear antigen IgG; these control autoantibodies correlated with one another but not with anti-CD4 IgG. Elevated anti-CD4 IgG levels were associated with lower plasma progesterone levels and reduced absolute CD4+ T-cell counts. Markers of microbial translocation, soluble CD14 (sCD14), lipopolysaccharide-binding protein (LBP), and lipopolysaccharide (LPS), were also selectively increased in HIV-positive females, with sCD14 and LBP showing significant or borderline associations with anti-CD4 IgG. Together, these findings identify anti-CD4 IgG as a sex-dimorphic autoimmune signature in treated HIV infection, linked to progesterone levels, persistent microbial translocation, and incomplete immune recovery. This work highlights an under-recognized intersection of sex, mucosal barrier dysfunction, and autoimmunity in HIV pathogenesis and suggests potential therapeutic targets to improve immune reconstitution in women.