Clinical HIV-1 eradication studies

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1 Clinical HIV-1 eradication studies Mathias Lichterfeld, M. D., Ph. D. Massachusetts General Hospital Harvard Medical School No disclosures

2 HIV-1 persistence despite HAART Blood Tissue HIV RNA (cps/ml) 50 >10 years Cell associated HIV DNA Cell associated HIV RNA Cell associated HIV DNA Infectious virus (IUPM) Plasma single copy assay Years on cart Slide courtesy of Javier Martinez-Picado/Sharon Lewin

3 Latent and replicative HIV-1 infection in CD4 T cells Activated CD4+ T cell cart Resting CD4+ T cell Survival (long-half life) Homeostatic proliferation Slide courtesy of Javier Martinez-Picado/Sharon Lewin Eckstein, Immunity 2001; Swiggard, J Virol 2005; Saleh, Blood 2007; Marini, J Immunol 2008; Bosque, Blood 2009; Cameron, PNAS 2010; Lassen, PLoS One 2012

4 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 )

5 Pharmacological latency-reversing agents Shock component HDACi Panobinostat Romidepsin Vorinostat HMTi EZH2 inhibitors PKC activators Prostratin Didier Trono et, al. Science 2010 DNA methylation Inhibitors

6 Immune-mediated interventions kill component 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)

7 HDACi turn HIV-1 transcription on HDACi DNA nucleosomes OFF TF 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 Slide courtesy of Javier Martinez-Picado/Sharon Lewin

8 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/m 2 i. v. singledose infusion (Aarhus) 0.5/2/5mg/m 2 (ACTG) 20mg p. o. TIW (M, W, F) QOW Rasmussen et al, Lancet HIV 2014 Pilot clinical trials completed in process completed (Aarhus) in HAART-treated HIV patients (UNC, Melbourne) (ACTG, Aarhus)

9 Clinical studies with Vorinostat (Saha) 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 Elliott/Lewin, CROI 2013 Archin et al, Nature 2012 and JID 2014

10 Romidepsin 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/m 2, 2mg/m 2, 5mg/m 2 ) In vivo evaluation in a non-randomized trial in six patients (Sogaard et al, IAS 2014) Romidepsin (5 mg/m 2 ) 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

11 Cell-associated HIV-1 RNA during treatment with Romidepsin Sogaard et al, IAS 2014

12 Plasma HIV-1 RNA during treatment with Romidepsin Viral load: COBAS TaqMan HIV-1 Test, v2.0 TMA: Qualitative NAT screening system (PROCLEIX ULTRIO Plus, Genprobe) Sogaard et al, IAS 2014

13 Cell-associated HIV-1 DNA during treatment with Romidepsin Sogaard et al, IAS 2014

14 Panobinostat (LBH589) A hydroxamic acid pan-hdac inhibitor Developed by Novartis for the treatment of multiple myeloma (approval expected in 2014) Dosed 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 Panobinostat induced HIV production in latently infected cell lines and primary T cells with high potency Huber et al J Biol Chem Keedy et al Journal of Virology Archin et al AIDS Rasmussen et al 2013, HVI

15 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

16 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

17 Cell-associated unspliced HIV RNA (CA US HIV-RNA) Measured in total CD4+ T cells using semi-nested qpcr (quadruplicates) A highly statistically significant increase over time (repeated measurement ANOVA; P<0.0001) Rapid increase only 2 hours after first dose Significant increases on all time points Median maximal increase of 3.5 (range ) Rasmussen et al, Lancet HIV 2014

18 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

19 Total cell-associated HIV-1 DNA during treatment with panobinostat Measured per 10 6 CD4+ T cells using ddpcr 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) Rasmussen et al, Lancet HIV 2014

20 Total cell-associated HIV-1 DNA during treatment with panobinostat 4/15 patients displayed sustained reductions in total HIV DNA No difference in nadir CD4, baseline CD4 or baseline HIV DNA

21 Total HIV DNA during panobinostat treatment post-hoc analysis

22 Change in HIV-1 DNA during treatment with panobinostat correlates with kinetics of viral rebound during ATI plasma viral load (copies/ml) time after treatment interruption (days) 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

23 Expansion of HIV-1-specific CTL during Panobinostat treatment Magnitude Breadth 2000 p= p=0.01 total magnitude of HIV-1-specific CTL (SFC/million PBMC) total breadth of HIV-1-specific CTL (no of responses) before treatment after treatment 0 before treatment after treatment Screening for CTL with library of optimal CTL epitopic peptides (IFN-γ Elispot)

24 HIV-1-specific CTL are not associated with HIV-1 DNA changes during panobinostat treatment Interferon-γ TNF-α FC HIV-1-specific effector CTL FC HIV-1 DNA (log10) FC HIV-1-specific effector CTL FC HIV-1 DNA (log10) 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

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

26 HIV-1 DNA decrease during panobinostat treatment occurs preferentially in carriers of IL28B CC carriers Fold change in total HIV-1 DNA p= CC CT IL-28B

27 Changes in HIV-1 DNA during panobinostat treatment are correlated to changes in NK cells FC in CD69+ NK cells Week 2 Week 6 Week 8 (end of study) rho:-0.66; p= FC in HIV-1 DNA (log10) FC in CD69+ NK cells rho:-0.56; p= FC in HIV-1 DNA (log10) FC in CD69+ NK cells rho:-0.64, p= FC in HIV-1 DNA (log10)

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

29 Changes in HIV-1 DNA during treatment with IFN-a/RBV in HIV/HCV co-infected patients 10 5 p= HIV-1 DNA copies/10 6 CD4+ T cells pre-ifn post-ifn

30 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

31 Acknowledgments 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