HIV-1 DNA levels after antiretroviral therapy in primary infection predict disease progression: the SPARTAC Trial James Williams 1,2,3, Jacob Hurst 1,2,3, Nicola Robinson 1,2,3, Sarah Fidler 4, Jonathan Weber 4, Abdel Babiker 5, Rodney Phillips 1,2,3, Kersten Koelsch 6 *, Tony Kelleher 6 *, John Frater 1,2,3 * On behalf of the SPARTAC Trial Investigators *contributed equally 1 Peter Medawar Building for Pathogen Research, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford; 2 Institute for Emerging Infections, The Oxford Martin School, Oxford, UK; 3 Oxford National Institute of Health Research Biomedical Research Centre, Oxford, UK; 4 Division of Medicine, Wright Fleming Institute, Imperial College, London, UK; 5 Medical Research Council Clinical Trials Unit, London, UK; 6 The Kirby Institute, UNSW, Sydney, Australia. IAS 2013 Towards an HIV Cure Symposium
SPARTAC Trial: Design Design: Largest randomised clinical trial investigating the effect of short-course ART compared with no ART in Primary HIV infection. Definition of PHI Lab evidence of infection within 6 months of a previous negative test, <3 bands WB, RITA incident, antibody negative PCR+ Randomisation to 3 arms: 48-week short course ART (ART-48) 12-week short course ART (ART-12) No therapy (Standard of Care SOC) Composite primary end point time to CD4 <350 cells/mm 3 or long-term ART initiation Fidler et al, NEJM, 2013
The SPARTAC Trial; Findings 1.00 ART48 HR 0.63 (0.45,0.90), p=0.01 Probability of not reaching primary endpoint 0.75 0.50 0.25 SOC ART12 HR 0.93 (0.67,1.29), p=0.67 0.00 0.5 1 1.5 2 2.5 3 3.5 4 4.5 Time (years) Fidler et al, NEJM, 2013
The SPARTAC Trial; HIV RNA rebound following ART Interruption Change in log10 HIV RNA from baseline 0.2.4.6.8 SOC ART-12 ART-48 Fidler et al, NEJM, 2013 12 24 36 48 60 Weeks from ART interruption or randomisation (SOC) - High total HIV-DNA predicts a shorter rebound time (Piketty et al J.Med.Virol, 2010). - Proviral and total HIV DNA predicts viral rebound and viral setpoint after STI (Swiss Cohort Study) in acutes (Yerly et al, AIDS, 2004)
Methods to measure the HIV-1 reservoir Two assays: Total HIV-1 qpcr : measures all HIV-1 DNA (integrated and unintegrated) Integrated HIV-1 qpcr: measures integrated HIV-1 DNA Total Assay Single Round LTR qpcr FAM-labelled probe binds to the HIV-1 LTR Integrated Assay 1 st round PCR 40 cycle 40 repeats Prime across ALU element to Gag Second round nested Total Q- PCR assay
Patient selection Two assays: Total HIV-1 qpcr : measures all HIV-1 DNA (integrated and unintegrated) Integrated HIV-1 qpcr: measures integrated HIV-1 DNA UK Predominantly subtype B Cross-clade compatible primers and probes TRIAL ARM PARTICIPANTS SOC 29 ART-12 34 ART-48 33
Results of Proviral Analysis Associations of HIV cell associated DNA levels with: Baseline plasma VL Estimated time since seroconversion Time to plasma VL rebound on stopping ART Clinical progression (Trial primary endpoint)
Quantification of the proviral load in the SPARTAC Trial ART48 Total ART48 Integrated
Correlation of HIV-1 DNA with plasma viral load Baseline VL vs Baseline cell-associated HIV-1 DNA (Total Assay) r 2 = 0.18 r 2 = 0.34 ART12 (wk12) r 2 = 0.34 r 2 = 0.30 r 2 = 0.23 ART48 (wk48)
Association of HIV-1 DNA levels with the estimated time since seroconversion Baseline HIV-DNA vs ETS r 2 = 0.04 No evidence for a statistical association between HIV DNA levels and ETS at time of enrolment No association between plasma HIV-1 viral load and ETS (p=0.55) (not shown)
No evidence to associate HIV-1 DNA levels with time to viral rebound at wk48. Time on ART is associated with time to VL rebound on stopping But, no evidence for an association between proviral load and time to rebound Total P = 0.31, r 2 = 0.03 Integrated P = 0.74, r 2 = 0.003 Stohr et al; unpublished
Association of proviral load with primary endpoint after STI. TOTAL (Wk48) INTEGRATED (Wk48) Univariate Cox Regression Analyses (log total) vs survival: P = 0.017; Hazard Ratio: 7.22 (1.42-36.84) (log integrated) vs survival: P = 0.041; Hazard Ratio: 2.68 (1.04-6.90) (log baseline VL) vs survival: P = 0.022; Hazard Ratio: 1.81 (1.09-3.00) (wk48 CD4 count) vs survival: P = 0.684; Hazard Ratio: 0.97 (0.83-1.13)
Conclusions 12 or 48 weeks of ART significantly decreases the cell associated HIV-DNA. Viral Load at baseline associates with HIV DNA levels at baseline and after therapy. Viral load and HIV DNA levels are not determined by estimated time since seroconversion. No evidence to suggest proviral load is associated with time to viral rebound. Total and Integrated proviral levels both predict primary endpoint of the clinical trial.
Acknowledgements PETER MEDAWAR BUILDING FOR PATHOGEN RESEARCH, OXFORD, UK John Frater Rodney Phillips Jacob Hurst Nicola Robinson MRC CTU, LONDON, UK Wolfgang Stöhr Abdel Babiker UNSW, SYDNEY, AUSTRALIA Tony Kelleher Kersten Koelsch IMPERIAL COLLEGE, LONDON, UK Jonathan Weber Sarah Fidler UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA, USA Una O Doherty The SPARTAC trial Investigators Participants of SPARTAC