Professor Brigitte Autran

16 th Annual Resistance and Antiviral Professor Brigitte Autran Centre Hospitalier Universitaire Pitié-Salpétrière, Paris, France Thursday 20 September 2012, Wellcome Collection Conference Centre, London How controlling HIV-1 reservoirs and strategies for an HIV Cure What is going to work? Pr Brigitte Autran Inst. of Researches Immunity, Cancer and Infection, Université Pierre et Marie Curie - Hôpital Pitié-Salpêtrière, France Professor Brigitte Autran 1

«Towards an HIV CURE» F Barré-Sinoussi Workshop on towards a cure Connecting researchers together WHAT ELSE? INTERNATIONAL SCIENTIFIC WORKING GROUP INTERNATIONAL ADORY BOARD Development Implementation INTERNATIONAL CONSULTATIONS Clinical Trials A global scientific strategy defining research priorities Basic Science Launch What is the HIV reservoir? resting cells hosting inducible integrated HIV-DNA (Blankson 2002) Estimated life span: 69 years (Chomont 2009) Free Virions Non T cells Monocytes 1,5 weeks Macrophages 3 months Naive years TCM < 3-6 months TTM? TEM 1-3 months Effector cells 8-15 days Infected activated producing HIV RestingCD4+ T cells harboringhiv DNA (integrated or not) Free Virions on Follicular dendritic cells (lymphoid tissues) Infected Macrophages (all tissues and sanctuaries) 0 30 60 90 120? Half-life (days) Resting CD4+ T cell harboring integrated HIV- DNA (Siliciano 1999) Professor Brigitte Autran 2

HIV RESERVOIRS at various stages of HIV infection UNTREATED HIV RESERVOIRS at various stages of the HIV infection Effect of early and long term ART Data from the french ANRS Cohorts Decamune Guihot, AIDS 2010 UN-TREATED 10y HAART Chronic UN-TREATED 5-y HAART PHI / PTC Professor Brigitte Autran 3

Proposed mechanisms of HIV persistence during HIV infection and targeting for an HIV cure Targeted by HIV-specific s anti-latency agents HAART => Immune recovery + persisting anti-hiv CD8 TCM but decay in anti-hiv TEM Limited lifespan of the HIV Immune Reservoirs : Clues for a Long Term Immune or a Therapeutic HIV control Naive CD4+cell effector Effector effector CD4 T cells Effector Memory Apoptosis Monocytes Macrophages Central Memory CD27 Transitionnal Turnover CD4 T cell Life span Naive CD4 Effector TCM Transitional TEM 10 Years (?) (8-15 days) (> 3-6 mths)? (1-3 mths) Non T cells Monocytes Macrophages 1,5 week 3 months Professor Brigitte Autran 4

Rapid dissemination of HIV infection HIV Reservoirs Naive CD4+cell Effector Memory Effector effector CD4 effector T cells Apoptosis Central Memory CD27 Transitionnal Turnover = Irreversible integration of HIV-DNA in the cellular genome Massive depletion of CD4 cells Peindre Peindre (Haase 2010) Description of the HIV reservoir Primary HIV infection (PHI): Simian - Mucosal TTM and TEM CD4 subsets from the gut lamina propria (Rhesus Macaques) - Integrated SIV-DNA in CD4+ T cells (1 copie/10 cells) (Mattapallil 2005) (Nishimura 2007) Human - Latently-infected CD4 cells 30 days from transmission - Total TN, TCM, TTM and TEM infected 225 days from contamination (Chun 1998) (Ganesan 2010) Chronic phase: - Resting (HLA DR-) - Weakly differentiated CD4 (CD45RO+ / CD57-) - TCM et TTM subsets (- +/- CD27+) (Chun 1997) (Brenchley 2003) (Chomont 2009) Professor Brigitte Autran 5

Multiple factors ensuring HIV persistence What is going to work????? Immune Activation Residual Replication HIV Reservoirs Latency When? at PHI or during Chronic infection? How? combined strategies will be required to reduce HIV reservoirs C Katlama, IAS-2011 Satellite meeting: New Concepts in HIV Immunepathogenesis, Treatment and Vaccines Targeting PHI for strategies of an HIV Cure? The sequence of events happening during PHI is a strong predictor of the subsequent progression of the infection HIV-DNA decay for 1 year after cessation of therapy < 6 months after seroconversion Control of viral rebound after therapy interruption < 3 weeks from infection (Goujard 2006) (Strain 2005) (Paci 2011) Preventing the early viral cytopathogenic effets on the CD4 compartment Reducing the size of viral reservoirs Reaching a host-virus equilibrium as a «functional cure»?? Professor Brigitte Autran 6

Patients Comparison of early-treated groups: Post Treatment Controllers: (PTC) n=11, HAART within 10 weeks of PHI, median 3 years on HAART, median 6 years after HAART interruption Early HAART: n=10, HAART within 10 weeks of PHI, median of 6 years under HAART To untreated groups: Elite Controlers: (EC) n=8, untreated patients with CD4 count > 600 cells/mm 3 and viral load < 200 HIV-RNA copies/ml for at least 8 years Viremic patients: (V) n=10, untreated patients with CD4 count > 600 cells/mm 3 and viral load > 200 HIV-RNA copies/ml for at least 8 years Very early dissemination of the HIV reservoirs Log copies ADN HIV / Mo de cellules 6 5 4 3 2 1 0 Day 30 post-infection N *** *** *** *** *** *** C Bacchus and A Cheret et al. the ANRS Optiprim study CM TM EM 4NA 4A CD8 Mono Professor Brigitte Autran 7

Very early dissemination of the HIV reservoirs Effect of early treatment: the Post-Treatment Controllers (CONTI study) Day 30 post-infection Log copies ADN HIV / Mo de cellules 6 5 4 3 2 1 0 N *** *** *** *** *** *** C Bacchus and A Cheret et al. the ANRS Optiprim study Log copies ADN HIV / Mo de cellules CM TM EM 4NA 4A CD8 Mono N 6 5 4 3 2 1 0 *** *** *** *** *** *** Post-Treatment Controllers: (PTC) pvl<500cp/ml for a median 3.5 y after 3-5 y ARV initiated very early at PHI (Hoqueloux et al. AIDS 2010) CM TM EM 4NA 4A CD8 Mono Similar Distribution of the HIV reservoir in Elite Controlers (EC) and Post-Treatment Controlers (PTC): Low infection levels in long-lived Naive and central Memory Empty Symbols : 50% detection threshold value C Bacchus and A Cheret et al. the ANRS Optiprim study; B Descours & V Avettand et al. Clin. Inf. Dis 2012 Professor Brigitte Autran 8

Conclusion 1 A low HIV reservoir in PTC and Early HAART vs V patients PTC have the same HIV reservoir size and distribution as Elite Controllers PTC Long-lived Naive are poorly infected Viral replication recovered upon in vitro stimulation in all patients and from all subsets Multiple factors ensuring HIV persistence What is going to work????? Immune Activation Residual Replication HIV Reservoirs Latency When? at PHI or during Chronic infection? How? combined strategies will be required to reduce HIV reservoirs C Katlama, IAS-2011 Satellite meeting: New Concepts in HIV Immunepathogenesis, Treatment and Vaccines Professor Brigitte Autran 9

G Hutter et al. How? Towards the Dream of HIV eradication Contrary cases but from CCR5+ donors: C Rouzioux AIDS, 2007, Y. Levy, unpublished. Is exhaustion of HIV Reservoirs feasible in Chronic infection? The Eramune Projects Rationale: TOC studies combining in CHI ARV super-intensification + immune interventions targeting: -Eramune-01=>«latently» infectedcells: - IL-7 (results: November 2012) - Eramune-02 => residual HIV replication: - VRC vaccine (HIV DNA+ recad5) (results: 2013) Science May 2011 HIV DNA HIV RNA Hyper-ART + Immune interventions cart Intensification + Immune Intervention Optimized cart (control) Anti_HIV VRC Vaccines IL-7 Autran et al Science 2000, 200404, Nat Rev Immunol 2003, Murphy Science 2009, IAS Working group Nat.Rev.Immunol. 2012 Professor Brigitte Autran 10

Eradication: Role of IL-7 in inducing viral replication? TCR IL-7 Pi3K JAK-1 p27 AKT JAK-3 CDC25A HIV induction CD4 T Cell STAT-5 Survival, Proliferation IL-7 signaling evaluation IL-7R expression : N CM TM EM CD127 Expression Representative patient Median % 91 Median MFI 3507 79,5 3710 76,1 3676 75,9 3450 Signal transduction via pstat5: IL-7 receptor : expressed on all CD4 T cell subsets though mainly in Naive Transduce the IL-7 signal in all resting CD4 cell subsets C Bacchus and A Cheret et al. the ANRS Optiprim study Professor Brigitte Autran 11

IL-7 : Viral inductibility & Proliferation copies AR N VIH / ADN VIH J0 Viral Inducibility Cell Proliferation Cell Survival 9 8 7 6 5 4 3 2 1 0 J3 J6J8 IL-7 1 ng/ml J10 J13 J3 J6 J8 J10 J13 J3 J6 J8 J10 J13 J3 J6 J8 J10 J13 N CM TM EM IL-7 capable to induce virus production: mainly in long-lived Naive as in all Memory, independently of cell proliferation C Bacchus and A Cheret et al. the ANRS Optiprim study Anti-latency agents Purging the HIV reservoirs Require synergistic effects of: Therapeutic vaccines? Inducing s or Abs Professor Brigitte Autran 12

16th Annual Resistance and Antiviral Dynamics of and HIV-infected CD4 cells HAART: Quiescent Latently infected CD4 + rare residual replicating cells HAART interruption or Antigenic burst or anti-latency agents CD4 Acutely replicate HIV Provirus cannot detect latently infected cells and proceed toward clonal TEM/E contraction TCM are activated by replicating HIV Can a Therapeutic vaccine synergize with an anti-latency agent? Anti-latency agent (SAHA) Reactivates HIV production But not HIV-specific s HIV antigen stimulation: Reactivates HIV-specific killing Rationalefor a Therapeutic vaccine Professor Brigitte Autran 13

Impact of HIV-specific CD8 T cells on the HIV Reservoirs: Distinct impacts of HLA-B27- or B-57 on Gag-specific CD8 T cells on the magnitude of the cell-associated HIV-DNA in the ALT ANRS CO-15 cohort: HIV Reservoirs and HLA B27/57 Gag-specific CD8+ T cells HLA-B27/57 restricted CD8 cell anti-hiv-gag Magnitude B27 donors Gag-specific CD27+TCM CD8+ T cells Differentiation B57+ donors Functional avidity Descours &Avettand-Fenoel et al. CID 2012 /Gag epitopes Martinez V et al. J.I.D. 2005; Almeida et al. J Exp Med 2007, Blood 2009 X Jie et al. AIDS 2010 Distinct Hierarchy of HIV reservoirs in In LTNPs : B Descours, V Avettand et al. CID 2011 LTNP HIV Reservoirs in quiescent CD4 subsets: (T TM > T CM ) (T EM >T N ) HLA-B27/57+ HLA-B27/B57 Non non HLA-B27/57 HLA-B27/B57 Strong Gag-specific CD8 T cells negatively correlated with HIV reservoirs in CD4 TCM cells 10 4 cell HIV-DNA (copies /millions cells) 10 3 10 2 10 1 p=0.0081 T N T CM T TM T EM 0.0313 T N T CM T TM T EM 0.0078 0.0078 0.0078 0.0469 T CM limited infection in HLA-B27+/57+ but not in aviremic HLA-B27/57-LTNPs Reminiscent from the preservation of TCM numbers in vaccinated macaques (Letvin et al. 2005) Professor Brigitte Autran 14

CD27 16th Annual Resistance and Antiviral Anti-HIV CD8 T Lymphocytes : Key for the control of HIV Reservoirs intcm HLA-B27/57 neg TN TCM TTM TEM Antigens Antigens Antigens HLA-B27/57pos TN TCM TTM TEM Critical protection of long-lived Central- Memory CD4 T Lymphocytes (TCM): required for maintaining Naive CD4+cell Effector Memory effector effector Effector CD4 T cells Apoptosis T cell Numbers and Function in the long term Central Memory Transitionnal Turnover preserved in LTNP / Controllers HIV Transcriptionally active HIV Transcriptionally inactive Anti gag CD8 T cells B Descours et al CID 2012. 2008 - : Emergence of a new therapeutic concept : Can therapeutic vaccines help at purging the HIV Reservoirs? Anti-latency Purging the HIV reservoirs? s/abs ATherapeutic Vaccine should induce anti-hiv CD8 T cells or Abs D Richmann et al. Science 2009 to kill the residual replicating cells or block cell to cell HIV spreading Lessons from past Therapeutic vaccines against HIV? - Limited capacity to control plasma virus bursts - Manon-02 trial: Facilitation of virus production reflecting CD4 T cellactivation withoutcd8 T cellsor Abs BUT: No modification of the cell-associatedhiv-dna suggesting a lower plasticity of the HIV reservoirs (B Autran et al. AIDS 2008) Autran et al NRI 2003, Science 2004, Murphy et al. Science 2009; D Richman Nat.Med. 2009; the IAS Working Scientific group on HIV Cure, NRI 2012 Professor Brigitte Autran 15

Can a Therapeutic vaccine against HIV decrease the HIV reservoirs? 19 young adults (23 y.o) on ART, HIV RNA < 50 cp/ml vaccine: HIV env, gag, tat, rev, nef, RT recombinant MVA +FowlPoxV - 2 MVA: D0, W4-1 FPV: W8 Transient decrease in decay of latently infected CD4+ T cells Raises the question of the HIV reservoir read-out: - Total cell-associated HIV-DNA: easy and standardizable - Replication competent cells? Heavy, difficult to standardize.. The EraMune-01 and -02 Trials : Parallel Study Design International, multicenter, randomized, non-comparative controlled study of therapeutic intensification plus immunomodulation in HIV-infected patients with long-term viral suppression ERAMUNE-01 (Europe, PI: C Katlama) ERAMUNE-02 (USA, PI: R Murphy) ARM A (n=14) 3 ARV + Intensification (raltegravir + maraviroc) SCREENING W -4 D0 Randomization W8 ARM B (n=14) 3 ARV + Intensification (raltegravir + maraviroc) + IL-7 (3: W8, 9,10) ARM A (n=14) 3 ARV + Intensification (raltegravir + maraviroc) SCREENING W -4 D0 Randomization W8 ARM B (n=14) 3 ARV + Intensification (raltegravir + maraviroc) + VRC Vaccine: 3x HIVDNA016-00-VP (W8,12, 16) 1x rad5 (W32) VRC-HIVADV014-00-VP Primary Evaluation W56 r-hil-7 (CYT107) injections at 20 μg/kg/week (1 per week) W56 Similar Primary objective: Decrease in the HIV-1 viral reservoir Results expected: Eramune-01: December 2012; Eramune-02: March 2013 Primary Evaluation VRC: HIVDNA016-00-VP : 3 DNA clade B HIV-1 Gag, Pol, or Nef 3 DNA HIV-1 Env clade A, B and C, HIV-Ad5 VRC-HIVADV014-00-VP (clade B HIV-1 Gag Pol fusion protein, + clade A, B, and C Env proteins. Professor Brigitte Autran 16

Potential strategies to reduce HIV reservoirs Maraviroc Anti-inflammatory drugs -Statins - OH-Chlorochin Systemic Inflammation Massive CD4 T-cell depletion Bacterial translocation Pre-Probiotics ARV Intervention - Intensification - Nevirapine CD8 CD4 Cellular Immunity Immune Intervention - Anti-HIV vaccine -IL7 Viral Co- Infections Antiviral drugs Immune Activation Residual Replication Gene therapy DC CD4 Anti-co-stimulatory molecules -anti PD1 / anti PDL1 - anti-a4 - anti-cd137 HIV Reservoirs Latency Quiescent T cells activation -IL7 Pre/post-transcriptional factors disruption -HDACi -HMBA «Towards an HIV CURE» F Barré-Sinoussi Workshop on towards a cure Connecting researchers together WHAT ELSE? INTERNATIONAL SCIENTIFIC WORKING GROUP INTERNATIONAL ADORY BOARD Development Implementation INTERNATIONAL CONSULTATIONS Clinical Trials A global scientific strategy defining research priorities Basic Science Launch Professor Brigitte Autran 17

Univ Pierre et Marie Curie, Pitié-Salpétrière, IFR Immunité-Cancer-Infection CRIV (Centre de Recherches Intégrées sur le VIH) Immunology, INSERM U945 Immunity to viruses immunogenetics HIV immunosenescence A Samri B Descours I Theodorou V Appay A Guihot V Martinez J Guergnon J Almeida G Carcelain C Bacchus ALT ANRS CO15 Cohort, CONTI, IPRIM and Reservoir study groups: Virology and serology : C Rouzioux, V Avettand, Univ. Paris-5 Viro-Immunology: A Saez-Cirion, Inst. Pasteur Clinics: JP Clauvel, Saint-Louis Hosp. Univ Paris-7 ; D Sicard, Cochin Hosp. Univ. Paris-5 L Hoqueloux, CH Orléans; A Cheret CHU Lille-Tourcoing, France GISHEAL ORVACS (Objectif recherche Vaccins SIDA) An International Research Platform The Eramune trials NIH VRC: G Nabel R Koup J Cassazza RFH Group M Youle, S Kinloch et al. AM Geretti Cytheris : IL-7 Merck: Raltegravir Pfizer: Maraviroc Professor Brigitte Autran 18