Understanding and intervening in HIV-associated tuberculosis

Transcription

1 Understanding and intervening in HIV-associated tuberculosis Robert J Wilkinson The Francis Crick Institute Imperial College London University of Cape Town University College London (elect) Francis Crick Institute tuberculosis symposium Thursday 24th March 2016 Wellcome Conference Centre, London, UK

2 COMBAT IMPERIALISM!

3 Acknowledgements g roles honi geng Rangaka n Lawn e Meintjes n Marais smail l Lai Wilkinson s Crick Institute Garra Bloom ne Graham w Berry s Young Univ. of Cape Town Rene Goliath Lebo Tsekela Virginia de Azevedo Bekekile Kwaza Sindiswa Kamteni Kathryn Wood Vanessa January Maia Lesosky Brian Basini Gary Maartens Yolande Harley Andrew Boulle Anna Coussens Amanda Jackson Collaborators Gilles van Cutsem (MSF) Eric Goemaere (MSF) Gerhard Walzl (Stellenbosch) James Warwick (Stellenbosch) Damien Chaussabel (Sidra) Jacques Banchereau (Jackson) Clifton Earl Barry III (NIAID) JoAnne Flynn (Univ. Pittsburgh)

4 Particular acknowledgements n D Lawn Molebogeng X Rangaka Tollulah Oni EU and EDCTP Rachel Lai MRC CDF

5 erculosis (TB) incidence rates by WHO region

6 stimated HIV-1 prevalence in new TB cases

7 00 Estimated TB incidence rates

8 HIV-associated TB mortality rates HIV TB deaths / 100, HIV-Associated TB Deaths 0.36 M in 2013

9 TB in Khayelitsha, South Africa Population: 391,749 Antenatal HIV prevalence: ~ 30% TB incidence ~1267/100,000 (i.e. > 1 % per annum) ~67% TB is HIV associated ~ 6000 cases per year ~ 20% deaths due to TB

10 Needs in tuberculosis New diagnostics New vaccines New treatments and new ways to evaluate them To know better what is going on

11 Diagnosis of latent tuberculosis 0 1 A 21st Century Solution for Latent TB Detection 2 3

12 atent TB is near universal in Khayelitsha but its ascertainment is impaired by HIV-1 infection ninfected persons -Spot.TB +ve 20% double positive 41% T +ve (> 15 mm) 16% % positive HIVuninfected HIVinfected >26 Induration (mm) 166 HIV infected persons

13 ymptomatic prevalent active TB is common amongst HIV-1 infected persons T plus cart versus cart alone for the prevention of tuberculosis Amongst persons starting or established on ART the prevalence of TB by culture was 6.4% (95% CI %)

14 r TB 41% N=657 44% N=652 oniazid plus antiretroviral therapy to prevent tuberculosis: a randomized double-blind placebo-controlled trial racteristic 667 Placebo 662 INH ian age (IQR) 34 (29-40) 34 (30-40) ale 75% 76% blished on ART 74% 70% ian days on ART (IQR) 189 (28-557) 169 (28-631) ian CD4+ count (IQR) 214 ( ) N= ( ) N=587

15 Placebo INH TB rate by treatment allocation Cumulative TB incidence rate Placebo (n=58): 3.6 per 100 PY (95%CI ) INH (n=37): 2.3 per 100 PY (95% CI ) HRunadjusted=0.63 (95% CI ) Log rank P=0.02

16 Isoniazid benefit greatest in TST negative placebo isoniazid HRa (95% CI) n Rate/ n Rate/ 100 PY 100 PY IGRA Negative * ( ) Positive ( ) TST Negative * ( )

17 spectrum of responses to tuberculosis infection clinical disease bacterial replication maintained at a subclinical level by immune response disease active infection effect of antiretrovirals bacterial load infection controlled ith some bacteria persisting in non-replicating form infection eliminated in association with T cell priming quiescent infection acquired immune TB reinfection infection eliminated without priming antigen-specific T cells innate immune effect of HIV infection effect of antibiotics

18 How latent is latent tuberculosis?

19 Hypotheses spectrum of subclinical pathologies will be observed healthy HIV-1 infected persons with immune evidence sensitization by M. tuberculosis ( latent TB) blood transcriptional signature will characterize bclinical tuberculosis

20 18 F-fluoro-2-deoxy-D-glucose positron emission omography/computer tomography (FDG-PET/CT) scanner + CT scanner (hybrid with functional imaging) istration of metabolic activity Uptake into cells through glucose transport proteins Phosphorylation within cell radioisotope undergoes positron emission itron-electron annihilation, recorded on camera images superimposed with CT scan

21 Study schema 35 HIV+ve, ART naïve, CD4>350/mm 3 LTBI, No Previous TB Asymptomatic QFGIT POSITIVE CXR No active TB RVATION IMAGING TREATMENT IMAGING tum Culture eat CXR PET/CT Sputum Cult 6 months INH PET/CT Sputum Cult -6 eeks 0 Weeks 1 Week 4 Week 12 Week 24 Week AMPLING PBMC RNA QFGIT SERUM URINE

22 infection eliminated in association A spectrum of lung parenchymal lesions Infiltrates/Fibrotic scars Nodules subclinical disease SUVmax=6.31 VS3 SUVmax=5.07 bacterial replication maintained at a subclinical level by immune response SUVmax=2.24 VS1 SUVmax=0.93 infection controlled with some bacteria persisting in non-replicating form

23 mmary and classification of PET/CT findings sed e d on nt 9 Upper Lobe Reactivation Miliary Pattern INFILTRATES/SCARS ACTIVE NODULES? High Risk Latent (Subclinical) ? Ghon focus Normal lungs 20? Lower Risk Latent

24 Transcriptomic profiling in human tuberculosis ive tuberculosis has a transcriptomic signature dominated by a trophil-driven type 1 and type 2 interferon-inducible gene profile 1 transcriptomic signature relates to disease extent and resolves ing successful treatment 1,2 differentiation of active from latent tuberculosis and other conditions y be aided by transcriptomic profiling 3,4 diagnosis of tuberculosis in children may be aided by transcriptomic filing 5 erry MP et al. Nature (2010) 466: loom, CI, et al. PLOS One (2012) 7:e46191

25 transcripts differentially abundant in active HIV-TB vs low risk latent (corr) 0.05 (Benjamini Hochberg FDR) + >1.5 Fold Change 2/10 subclinical cluster with active Clustering may be affected by 1. Biological Processes specific to late stages of disease 2. Expression of relevant genes in blood may be weaker in subclinical disease

26 upervised increased statistical stringency reveals a signature and underlying biology of subclinical TB Interferon signalling Neutrophil related nscripts at FC>1.5 ng with Active TB Complement Acute Phase response Fcγ Recept 639 transcripts Act vs Lat FC>1.5 + Sub vs Lat FC>1 203 transcripts 82 transcripts Act vs Lat FC>1.5 + Sub vs Lat FC>1.25 Act vs Lat FC>1.5 + Sub vs Lat FC>1.5

27 Pathways analysis of signatures

28 etwork analysis of 82-transcript signature

29 act of disease activity on serum concentration of analytes IP10 IFNγ IL1 TNF CCL23 IL5 Serum concentration in pg/ml

30 Conclusions: latent tuberculosis ology consistent with different aspects of early TB infection can be identified by PET/CT scriptional profile associates with subclinical HIV-TB: a subset of the active signature ork analysis predicts elevation of cytokine mediators proportional to disease extent ional consequences criptomic or protein signature might form basis of a predictive test of latency

31 edical aspects of large scale antiretroviral roll out ccess, and adherence, to care rug interactions hared side effects ntiretroviral and antibiotic resistance etabolic effects of antiretrovirals nteraction with non-communicable disease mmune reconstitution inflammatory syndrome n V, et al. AIDS (2010) 24:2871. Pepper DJ, et al. PLoS ONE (2011) 6:e19484.

32 Paradoxical TB-IRIS Patient diagnosed with TB and started on TB treatment Improving on TB treatment then starts ART Up to 40% of patients starting ART in sub-saharan Africa are on TB treatment Major risk factors: Low CD4 count Disseminated TB Short interval between TB treatment and ART currence of TB symptoms and new or recurrent clinical manifestations of TB (Usually 1-4 weeks after starting ART)

33 -IRIS is highly inflammatory and can present with suppurative lesions

34 Management of TB-IRIS Corticosteroids most frequently used with reported benefit, but potential risks Kaposi s sarcoma Herpes virus reactivations Candidiasis Strongyloides hyperinfection If undiagnosed MDR-TB, may worsen condition Other treatments NSAIDs and other immunomodulatory agents Aspiration and surgical procedures

35 andomized controlled trial of prednisone vs placebo 110 participants Life-threatening TB-IRIS was an exclusion Prednisone (or placebo) dose 1.5 mg/kg/d for 2 weeks then 0.75 mg/kg/d for 2 weeks Open-label prednisone at physician discretion if clinical deterioration/relapse

36 tive primary endpoint (median, IQR) 3 (0-9) 0 (0-3) 0.04 Primary endpoint Cumulative number of days hospitalized and outpatient herapeutic procedures (counted as 1 additional day), ITT analysis Placebo arm N = 55 Prednisone arm N = 55 p-value ys hospitalized mber outpatient procedures

37 C-reactive protein

38 isone (but not placebo) therapy associates with a fall in inflammatory cytokines of both innate and acquired origin IL-6 IL-10 IL-12p40 TNF IFN-gamma CXCL-10 No significant change In placebo group

39 The worst form of TB-IRIS is neurological IRIS F C A

40 macroscopic pathology of tuberculous meningitis

41 Implication of neutrophils in TBM-IRIS Non-IRIS TBM CSF Polymorph count x 10 6 /l TB meningitis IRIS therapy ART Non-IRIS TB therapy ART IRIS

42 SF M. tuberculosis culture positivity strongly associates with TBM-IRIS TBM iagnosis ART start 2 weeks post ART start IRI S IRIS 15/16 16 (15-20 days) No IRIS 6/18 (14-32 days) Relative risk of IRIS if culture positive= % CI P= No IRIS

43 Sample schedule

44 Study design

45 Analysis plan

46 Differentially abundant transcripts in TB-IRIS are associated with innate signalling pathways 0.5 Top 5 Canonical Pathways Role of JAK family kinases in IL-6-type cytokine signaling Acute phase response signaling Role of macrophages, fibroblasts & endothelial cells in Rheumatoid Arthritis Role of JAK2 in hormone-like cytokine signaling Role of JAK1 & JAK3 in cytokine signaling p-value 1.14E E E E E-03 2 Top 5 Canonical Pathways Toll-like-receptor signaling TREM1 signaling Role of pattern recognition receptors in recognition of bacteria & viruses Role of macrophages, fibroblasts & endothelial cells in Rheumatoid Arthritis p-value 1.29E E E E-04

47 acking the transcriptomic dysregulation that leads to TB-IRIS Weighted Temporal Molecular Distance Non-IRIS TB-IRIS ** ** Week ** Top 5 Canonical Pathways (43 genes) TREM1 signaling Toll-like receptor signaling Endothelin-1 signaling Role of pattern recognition receptors in recognition of bacteria & viruses IL-1 signaling p-value 2.01E E E E E-04 Week 2 (43 consistently overabundant transcripts) ACSL1 C19orf35 HECW2 RHOBTB1 ADCY3 CARD17 IFIT3 SERPING1 AGPAT9 CASP5 IFITM3 SIGLEC9 AIG1 CDK5RAP2 KCNJ15 SIPA1L2 ANXA3 DHRS13 KLHL2 SMARCD3 APOB48R DKFZp761E198 LOC TLR2 ASPRV1 DOK3 MANSC1 TLR5 B3GNT8 ECE1 MAPK14 TPST1

48 ranscriptomic signature of TB-IRIS at week 2 predicts activation of innate lling pathways and production of proinflammatory cytokines and chemokines

49 tokine production at week 2 of TB-IRIS reflects the transcriptomic prediction IL-12p40 IFN- TNF IL-6 IL-8 IFN- 2

50 nhibition of the MyD88 adaptor results in reduced cytokine production IL12p40 IFN- TNF- IL-1

51 th canonical and non-canonical inflammasomes are activated in TB-IRIS Caspase 1 Caspase 5 Caspase 3 IL-1 IL-1

52 nship to prior findings: multiply elevated cytokines, a distinct pattern of metalloproteinase, and innate immune activation characterizes TB-IRIS IL-1 IL-5 IL-6 IL-10 IL-13 IL-17A IFN- GM-CSF TNF, MMP1,3,7,8,10,12 TIMP1 IL-6 IL-10 IL-12p40 IL- 13 IL-17A IFN- MMP1,3,7,10.12 IL-1 IL-2 IL-6 IL-8 IL-10 IL-12p40 IFN- GM-CSF TNF IL-6 IFN- TNF, MMP7 MMP7 IL-6 TNF MTB stimulated transcript abundance in vitro at either 6 or 24 hrs MTB stimulated gene induction in vitro at either 6 or 24 hours MTB stimulated cytokine secretion in vitro Cytokine detection in vivo Corticosteroid modulated in vivo Andrade B, et al. PLOS Pathog (2014) 10(10):e Tadokera R, et al. Eur Respir J. (2011) 37:1248

53 Conclusions ined life-saving therapy for HIV-TB is frequently complicated by nic worsened immunopathology that can be fatal: TB-IRIS use of TB-IRIS appears to be a change in innate immune recognition of a isting pathogen load with downstream inflammatory consequences ational consequences ational, effective and safe host-directed therapies of inflammation in ulosis should be feasible including both biologics and small molecules doxycycline anti-tnf anti-il-6

54 Thank you! Zeke du Plessis

55 D4 Cell Counts and TB risk Pre-ART and on ART Falling CD4 Counts Pre-ART Rising CD4 Counts With ART

56 This image cannot currently be displayed. This image cannot currently be displayed. This image cannot currently be displayed. immunogenicity and efficacy of the candidate tuberculosis vaccine MVA85A in althy HIV-1-infected adults: a randomized, placebo-controlled phase 2 trial l Ndiaye r Camara ye ha Ndiaye Dieye a Ndiaye Thiam ane Mboup CIDRI Fred Thienemann Hanif Esmail Rene Goliath Vanessa January Tolu Oni Katalin A Wilkinson Yolande X R Harley ISP-WIV Kris Huygen Marta Romano Aeras Bernard S Landry Sharon Sutton Univ. Oxford Iman Satti Helen McShane MRC Gambia Martin Ota

57 Need additional interventions: MVA85A? Well tolerated and immunogenic in HIV-1-infected and -uninfected adults and in HIV-1-unexposed infants Confers modest protection against mycobacterial challenge in some preclinical animal models Boosting BCG with MVA85A in South African HIV-1-uninfected infants did not confer additional protection against tuberculosis disease or M. tuberculosis infection M. vaccae decreased risk of protocol-defined pulmonary tuberculosis by 39% in HIV-1-infected adults D, et al. Lancet 2013;381: Williams A, et al. Infect Immun 2005;73:3814-6

58 Endpoints mber and % AE (including solicited, unsolicited, and serious) dian CD4 counts by antiretroviral status by randomization, site, allocation, time -1 viral load by ART status at randomization, site, allocation, and time nological ccine-induced immune responses munological correlates of protection in vaccinated participants cy robiologically confirmed TB dpoint 1 plus clinical criteria (exploratory endpoint)

59 Screening and enrollment 1,233 Patients consented and screened for eligibility 696 in Cape Town; 537 in Dakar Screening failures in Cape Town (Total 404, 58%) 129 (32%) Were lost to follow-up / relocated 97 (24%) Incomplete screening before study closure 53 (13%) Had active tuberculosis 37 (9%) Met other medical exclusion criteria 24 (6%) Withdrew consent prior to randomization 20 (5%) HIV viral load did not meet eligibility 16 (4%) CD4 count did not meet eligibility 16 (4%) Were pregnant 12 (3%) Had an age outside eligibility Screening failures in Dakar (Total 179, 33%) 30 (17%) Were lost to follow-up / relocated 12 (7%) Incomplete screening before study closure 2 (1%) Had active tuberculosis 5 (3%) Met other medical exclusion criteria 10 (6%) Withdrew consent prior to randomization 47 (26%) HIV viral load did not meet eligibility 63 (35%) CD4 count did not meet eligibility 3 (2%) Were pregnant 4 (2%) Had an age outside eligibility 3 (2%) Other 650 Patients randomized 292 in Cape Town; 358 in Dakar 326 Randomized to placebo 324 Randomized to MVA85A 1 Randomized to MVA85A, but was not vaccinated 1 Randomized to placebo but received MVA85A 325 Received placebo 324 Received MVA85A 0 Excluded from analysis 4 Excluded from analysis 1 Protocol deviation 2 Withdrew within 28 days of randomization 1 Diagnosed with tuberculosis within 28

60 Safety

61 Adverse events during the trial ipants died (four placebo, two MVA85A) rence in Viral load or CD4 by allocation irrespective of ART status at any time Overall ART- ART+ ts Placebo MVA85A Placebo MVA85A Placebo MVA85A E (N=325) (N=324) (N=69) (N=67) (N=256) (N=257) % % % % % % E

62 Immunogenicity

63 Ag85A IFN- ELISPOT responses

64 Efficacy

65 umulative incidence of tuberculosis endpoint 1 by treatment group Placebo (N=325) MVA85A (N=320) Cumulative incidence Number at risk Number at Risk Months since Study Day 28

66 Primary and secondary efficacy endpoints Overall Placebo n (%) MVA85A n (%) VE % (CI) Endpoint 1 9 (2.8) 6 (1.9) 32.8 (-111.5; 80.3) y efficacy endpoint) sitive conversion 40 (23.1) 38 (20.4) 11.7 (-41.3; 44.9)

67

68 in D deficiency associates with TB and HIV-TB in Cape Town deficiency severe deficiency

69 A major determinant of vitamin D deficiency in Cape Town is a lack of winter sun

70 onal variation: peak vitamin D levels precede lowest quarterly case notifications

71 anscripts differentially abundant between ive HIV-TB vs subclinical vs low risk latent res t ts with C AND -log 10 (p value) active Active vs Latent latent active Active vs Subclinical subclinical subclinical Subclinical vs vs Latent latent p value not corrected -log 10 (B-H ected p value)

72 Gradient of differential abundance between groups Latent Subclinical Active

73 Conclusions -90% young adults in Khayelitsha are infected by TB. ere is therefore a role for TB preventive therapy which reduces the risk ction conferred by antiretrovirals by 37%. new TB vaccine was safe in HIV infected people and led to an immune onse but could not prevent HIV-TB. and HIV-TB are strongly associated with vitamin D deficiency. -IRIS can be ameliorated with steroid therapy and is not usually a reason to r or stop antiretrovirals. It is severe in the central nervous system.