Clinical HIV-1 eradication studies

Mathias Lichterfeld, M. D., Ph. D. Massachusetts General Hospital

Harvard Medical School

No disclosures

HIV

RN

A (c

ps/m

L)

50

Years on cART 0 1

1

Slide courtesy of Javier Martinez-Picado/Sharon Lewin

Plasma single copy assay

Cell associated HIV DNA

Infectious virus (IUPM)

Blood Tissue Cell associated HIV DNA

Cell associated HIV RNA

HIV-1 persistence despite HAART

>10 years

Eckstein, Immunity 2001; Swiggard, J Virol 2005; Saleh, Blood 2007; Marini, J Immunol 2008; Bosque, Blood 2009; Cameron, PNAS 2010; Lassen, PLoS One 2012

Activated CD4+ T cell

Resting CD4+ T cell

cART

Survival (long-half life)

Homeostatic proliferation

Latent and replicative HIV-1 infection in CD4 T cells

Slide courtesy of Javier Martinez-Picado/Sharon Lewin

Clinical HIV-1 eradication strategies

•Ex-vivo gene editing/gene therapy to reduce viral co-receptor

expression, followed by adoptive immunotherapy of HIV-1 resistant cells

• Bone marrow/HSC transplantation with CCR5-negative grafts

• Combination of latency reversing agents with immune mediated

interventions (“kick and kill”)

HMTi EZH2 inhibitors

PKC activators Prostratin

DNA methylation Inhibitors

Didier Trono et, al. Science 2010

Pharmacological latency-reversing agents “Shock” component

HDACi Panobinostat Romidepsin Vorinostat

• Vaccines designed to induce effector T cell responses • Broadly-neutralizing antibodies, possibly labeled with

Immunotoxins etc.

• Activators of innate immunity • Immunoregulatory interventions (i. e. PD-1 inhibitors etc)

Immune-mediated interventions “kill” component

TF

OFF

Bolden, Nat Rev Drug Disc 2006; Prince. Clin Canc Res 2009; Contreras, J Biol Chem 2009; Archin AIDS Res Hum Retrovir 2009; Reuse, PLoS One 2009; Burnett , J Virol 2010

HDACi

DNA nucleosomes

HDACi turn HIV-1 transcription “on”

Slide courtesy of Javier Martinez-Picado/Sharon Lewin

Clinical studies with HDACi

Vorinostat (Merck) Romidepsin (Celgene/Gilead)

Panobinostat (Novartis)

Ex-vivo HIV-1 reactivation

weaker strong strong

Dose, dosing schedule and formulation

400mg p. o. •Single-dose (Archin et al, Nature 2012)

•three consecutive doses per week for eight weeks (Archin et al, JID 2014)

•daily for 14 days (Elliott et al, CROI 2013)

• 5mg/m2 i. v. single-dose infusion (Aarhus)

• 0.5/2/5mg/m2 (ACTG)

20mg p. o. TIW (M, W, F) QOW •Rasmussen et al, Lancet HIV 2014

Pilot clinical trials in HAART-treated

HIV patients

completed (UNC, Melbourne)

in process (ACTG, Aarhus)

completed (Aarhus)

Archin et al, Nature 2012 and JID 2014

Elliott/Lewin, CROI 2013

• Single dose vorinostat led to a 4.8-fold increase in cell-associated HIV RNA.

• No significant increases in HIV-1 RNA during repetitive dosing

• No change in HIV-1 DNA

• Multiple dose vorinostat led to a mean 2.5-fold increase in cell-associated HIV RNA in total CD4+ T cells.

• No effect on CD4 T cell-associated HIV-1 DNA or plasma HIV-1 RNA

Clinical studies with Vorinostat (Saha)

• Licensed in US for treatment of PTCL and CTCL

• Can reactive HIV-1 in ex-vivo assays (Wei et al, Plos Path 2014)

• Currently being tested in RCT (ACTG5315) (single dose at 0.5mg/m2, 2mg/m2, 5mg/m2)

• In vivo evaluation in a non-randomized trial in six patients (Sogaard et al, IAS 2014)

– Romidepsin (5 mg/m2) iv on day 0, 7, and 14 – Endpoints: Safety, cell-associated HIV RNA, plasma HIV RNA

– Self-reported AEs: Total of 40, 36 related to RMD. Most common:

• Nausea, vomiting, diarrhea, abdominal pain • Fatigue • All self-resolving, none with > grade 2

Romidepsin

http://en.wikipedia.org/wiki/File:Romidepsin_structure_(2).svg

Cell-associated HIV-1 RNA during treatment with Romidepsin

Sogaard et al, IAS 2014

Viral load: COBAS® TaqMan® HIV-1 Test, v2.0 TMA: Qualitative NAT screening system (PROCLEIX ULTRIO Plus, Genprobe)

Plasma HIV-1 RNA during treatment with Romidepsin

Sogaard et al, IAS 2014

Cell-associated HIV-1 DNA during treatment with Romidepsin

Sogaard et al, IAS 2014

Panobinostat (LBH589)

• A hydroxamic acid pan-HDAC inhibitor • Developed by Novartis for the treatment

of multiple myeloma (approval expected in 2014)

• Dosed 30-60 mg TIW or TIW QOW • Inhibitory activity in the lower nM range

against HDACs 1, 2 and 3 which appear important to maintaining HIV latency

Huber et al 2011. J Biol Chem Keedy et al 2009. Journal of Virology Archin et al 2009. AIDS

• Panobinostat induced HIV production in latently infected cell lines and primary T cells with high potency

Rasmussen et al 2013, HVI

Overall study design

• Blood draws – Twice at baseline – Twice every treatment cycle and once every pause week (13 times during panobinostat

treatment) – 12 and 32 weeks after panobinostat initiation

• Lumbar puncture and sigmoid biopsies before and during the last treatment cycle

Safety – adverse events

• A total of 16 AEs presumed related to panobinostat (all CTCAE grade 1) • 10/15 patients experienced AEs presumed related to panobinostat • Fatigue the most frequent AE (experienced by 7/15 patients) • All completed full panobinostat dosing and follow-up

Rasmussen et al, Lancet HIV 2014

• A highly statistically significant increase over time (repeated measurement ANOVA; P

HIV-1 plasma viremia during treatment with panobinostat

Transcription mediated amplification (TMA)-based detection of HIV RNA:

50% analytic sensitivity to detect 3.8 copies/ml

95% analytic sensitivity to detect 12 copies/ml

• Only 1/15 remained undetectable at all time points during panobinostat treatment • 4/15 patients positive at all time points (make up 8/9 positive baseline values) • 9/15 negative at both baseline samples and became positive during panobinostat treatment

Rasmussen et al, Lancet HIV 2014

Total cell-associated HIV-1 DNA during treatment with panobinostat

• Decrease from baseline to day 14 (end of first treatment cycle) • Overall no decline in total HIV DNA from baseline to week 12 (4 weeks post treatment)

Measured per 106 CD4+ T cells using ddPCR

Rasmussen et al, Lancet HIV 2014

• 4/15 patients displayed sustained reductions in total HIV DNA • No difference in nadir CD4, baseline CD4 or baseline HIV DNA

Total cell-associated HIV-1 DNA during treatment with panobinostat

Total HIV DNA during panobinostat treatment – post-hoc analysis

Change in HIV-1 DNA during treatment with panobinostat correlates with kinetics

of viral rebound during ATI

• 9/15 patients agreed to participate in ATI, including three “responder patients”

• No association between baseline characteristics and viral rebound during ATI

Rasmussen et al, Lancet HIV 2014

0 20 40 60 80101

102

103

104

105

106

107

time after treatment interruption (days)

plas

ma

viral

load

(cop

ies/

ml)

0 20 40 60 80101

102

103

104

105

106

107

time after treatment interruption (days)

plas

ma

viral

load

(cop

ies/

ml)

Expansion of HIV-1-specific CTL during Panobinostat treatment

0

500

1000

1500

2000

tota

l mag

nitu

de o

fH

IV-1

-spe

cific

CTL

(SFC

/mill

ion

PBM

C)

p=0.007

Magnitude Breadth

0

2

4

6

8

tota

l bre

adth

of

HIV

-1-s

peci

fic C

TL(n

o of

res

pons

es)

p=0.01

before treatment

before treatment

after treatment

after treatment

• Screening for CTL with library of optimal CTL epitopic peptides (IFN-γ Elispot)

HIV-1-specific CTL are not associated with HIV-1 DNA changes during

panobinostat treatment

Interferon-γ TNF-α

FC HIV-1 DNA (log10) FC HIV-1 DNA (log10) FC H

IV-1

-spe

cific

effe

ctor

CTL

FC H

IV-1

-spe

cific

effe

ctor

CTL

• no associations between CTL magnitude or breadth and HIV-1 DNA levels • also no associations between protective HLA class I alleles and HIV-1 DNA levels

Expression patterns of Interferon-stimulated genes correlate with HIV-1 DNA decrease during treatment

with panobinostat

HIV-1 DNA decrease during panobinostat treatment occurs preferentially in carriers of IL28B “CC”

carriers

CC CT0.1

1

10Fo

ldc h

ange

into

talH

I V-1

DN

A p=0.04

CC CT0.1

1

10Fo

ldc h

ange

into

talH

IV- 1

DN

A p=0.04

IL-28B

Changes in HIV-1 DNA during panobinostat treatment are correlated to changes in NK cells

0.1 1 100

1

2

3

FC in HIV-1 DNA (log10)

FC in

CD

69+

NK

cel

ls

0.1 1 100.0

0.5

1.0

1.5

2.0

2.5

FC in HIV-1 DNA (log10)

FC in

CD

69+

NK

cel

ls

0.25 1 4 160

1

2

3

FC in HIV-1 DNA (log10)

FC in

CD

69+

NK

cel

ls

rho:-0.64, p=0.02rho:-0.66; p=0.02 rho:-0.56; p=0.05

Week 2 Week 6 Week 8(end of study)

0.1 1 100

1

2

3

FC in HIV-1 DNA (log10)

FC in

CD

69+

NK

cel

ls

0.1 1 100.0

0.5

1.0

1.5

2.0

2.5

FC in HIV-1 DNA (log10)

FC in

CD

69+

NK

cel

ls

0.25 1 4 160

1

2

3

FC in HIV-1 DNA (log10)

FC in

CD

69+

NK

cel

ls

rho:-0.64, p=0.02rho:-0.66; p=0.02 rho:-0.56; p=0.05

Week 2 Week 6 Week 8(end of study)

Changes in HIV-1 DNA during panobinostat treatment are correlated with changes in NK cells

pre-IFN post-IFN100

101

102

103

104

105HI

V-1

DNA

copi

es/1

06 C

D4+

T c

ells

p=0.0003

Changes in HIV-1 DNA during treatment with IFN-a/RBV in HIV/HCV co-infected patients

Conclusions

• HDACi can increase HIV-1 transcription in CD4 T cells from ART-treated

patients

• Viral reactivation with RMD and PBT leads to transient increases of plasma RNA

• All HDACi have an acceptable safety profile in ART-treated patients

• No significant changes in HIV-1 DNA during HDACi treatment on population

level

• Some patients during treatment with PBT and RMA have substantial decline of

HIV-1 DNA

• Patients with reduction of HIV-1 DNA during PBT treatment differ in • IL-28B “CC” GT

• ISG expression patterns

• Innate effector cell activity

• Kinetics of viral rebound during ATI

Department of Infectious Diseases, Aarhus University Hospital •Thomas Rasmussen, MD •Ole Schmeltz Søgaard, MD, PhD •Martin Tolstrup, MSc, PhD •Lars Østergaard, Professor/Head, MD, DMSc, PhD •Christel Rothe Brinkmann, MSc, PhD •Rikke Olesen, MD, PhD •Anni Winckelmann and Ann-Sofie Kjer •Lene Svinth Jøhnke and Erik Hagen Nielsen

Department of Infectious Diseases, Alfred Hospital, Melbourne •Sharon Lewin, Professor/Head, PhD •Ajantha Solomon, BSc

Massachusetts General Hospital, Ragon Institute, Boston •Maria Buzon, MSc, PhD •Selena Vigano, PhD

Westmead Millennium Institute for Medical Research, Sydney •Sarah Palmer, PhD

University of Colorado, School of Medicine •Charles A. Dinarello, Professor of Medicine and Immunology

Acknowledgments

Clinical HIV-1 eradication �studies��Mathias Lichterfeld, M. D., Ph. D.�Massachusetts General Hospital�Harvard Medical School�� �Dianummer 2Dianummer 3Clinical HIV-1 eradication strategiesPharmacological latency-reversing agents�“Shock” componentImmune-mediated interventions�“kill” componentDianummer 7Clinical studies with HDACiClinical studies with Vorinostat (Saha)Dianummer 10Dianummer 11Dianummer 12Dianummer 13Panobinostat (LBH589)Overall study designSafety – adverse eventsCell-associated unspliced HIV RNA (CA US HIV-RNA)HIV-1 plasma viremia during treatment with panobinostatTotal cell-associated HIV-1 DNA during �treatment with panobinostatTotal cell-associated HIV-1 DNA during �treatment with panobinostatTotal HIV DNA during panobinostat treatment – post-hoc analysisChange in HIV-1 DNA during treatment with panobinostat correlates with kinetics �of viral rebound during ATIExpansion of HIV-1-specific CTL �during Panobinostat treatmentHIV-1-specific CTL �are not associated with HIV-1 DNA changes during �panobinostat treatmentExpression patterns of Interferon-stimulated genes�correlate with HIV-1 DNA decrease during treatment with panobinostatHIV-1 DNA decrease during panobinostat treatment occurs preferentially in carriers of IL28B “CC” carriersDianummer 27Dianummer 28Dianummer 29ConclusionsDianummer 31