The State of the Art in HIV Cure Research – Hope or Hype: What Does It Mean for Patients

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Joseph Eron, M.D., of University of North Carolina at Chapel Hill, presents "The State of the Art in HIV Cure Research – Hope or Hype: What Does It Mean for Patients" at AIDS Clinical Rounds

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The State of the Art in HIV Cure Research – Hope or Hype: What Does It Mean for Patients

  1. 1. The UC San Diego AntiViral Research Center sponsors weekly presentations by infectious disease clinicians, physicians and researchers. The goal of these presentations is to provide the most current research, clinical practices and trends in HIV, HBV, HCV, TB and other infectious diseases of global significance. The slides from the AIDS Clinical Rounds presentation that you are about to view are intended for the educational purposes of our audience. They may not be used for other purposes without the presenter’s express permission. AIDS CLINICAL ROUNDS
  2. 2. The State of the Art in HIV Cure Research— Hope or Hype Joseph J. Eron, Jr., MD Professor of Medicine The University of North Carolina
  3. 3. Disclosures • Joseph J. Eron, Jr., MD, has disclosed that he has received consulting fees from Argos, Bristol-Myers Squibb, GlaxoSmithKline/ViiV, Gilead Sciences, Janssen, Kainos, Koronis, Merck, and Tobira; has served on the data and safety monitoring board for Vertex; and has served as a principal investigator for research with funds paid to the University of North Carolina from Bristol-Myers Squibb, GlaxoSmithKline/ViiV, and Tobira.
  4. 4. What percentage of your patients have asked whether HIV can be cured? 1. < 5% 2. 5%-25% 3. 25%-75% 4. Almost everyone has asked at one time or another
  5. 5. Why Cure HIV? • Shortened life expectancy of HIV-infected persons, even with treated HIV infection[1] • Cost, consequences (known and unknown) and the impact on QOL of antiretroviral therapy[2] – ART needed for decades of life with high level of adherence[2] • Stigma, discrimination, fear of transmission, isolation[3] • Global burden of HIV-1 disease[4] 1. Lohse N, et al. Ann Intern Med. 2007;146:87-95. 2. Volberding PA, et al. Lancet. 2010;376:49-62. 3. Parker R, et al. Soc Sci Med. 2003;57:13-24. 4. Mathers CD, et al. PLoS Med. 2006;3:e442.
  6. 6. HIV-1 CAN BE CURED The State of the Art in HIV Cure Research— Hope or Hype
  7. 7. CAN HIV-1 BE CURED? Berlin Patient Hütter G, et al. N Engl J Med. 2009;360:692-698.
  8. 8. Substantial graft vs host disease 1. Hütter G, et al. N Engl J Med. 2009;360:692-698. 2. Allers K, et al. Blood. 2011;117:2791-2799.
  9. 9. Yukl et al PLoS Pathogens May 2013 Challenges in Detecting HIV Persistence during Potentially Curative Interventions: A Study of The Berlin Patient
  10. 10. Original Article: Brief Report Absence of Detectable HIV-1 Viremia after Treatment Cessation in an Infant Deborah Persaud, M.D., Hannah Gay, M.D., Carrie Ziemniak, M.S., Ya Hui Chen, B.A., Michael Piatak, Jr., Ph.D., Tae-Wook Chun, Ph.D., Matthew Strain, M.D., Ph.D., Douglas Richman, M.D., and Katherine Luzuriaga, M.D. N Engl J Med Volume 369(19):1828-1835 November 7, 2013
  11. 11. Very Early Triple-Drug ART Elicits “Potential Cure” in HIV-Infected Child  Infant born to untreated HIV-infected mother at 35 wks’ gestation via spontaneous vaginal delivery[1] – Maternal HIV infection identified during labor via ELISA and Western blot – Infant HIV infection confirmed via HIV-1 DNA PCR, HIV-1 RNA analysis of 2 separate samples at 30 and 31 hrs of age[2] – ZDV/3TC + NVP (at therapeutic dose) initiated at 31 hrs of age, continued for 7 days – ZDV/3TC + LPV/RTV continued from 7 days to 18 mos of age – HIV-1 RNA undetectable by Day 30 – Mother removed patient from care at 18 mos of age 1. Persaud D, et al. CROI 2013. Abstract 48LB. 2. DHHS Pediatric Guidelines. 2012.
  12. 12. “Potential Cure” Child: Standard HIV-1 Assays Undetectable to Age 26 Mos  Assessments at Mos 24, 26 – Western blot negative – No HIV-specific CD8+ or CD4+ T-cell responses  Standard HIV-1 RNA and HIV- 1 DNA undetectable  Ultrasensitive assays – Mo 24: HIV-1 RNA 1 c/mL; HIV-1 DNA 37 c/million PBMCs – Mo 26: HIV-1 DNA < 2.7 c/million PBMCs Persaud D, et al. CROI 2013. Abstract 48LB HIV-1RNA(copies/mL) 105 104 103 102 101 0 20 40 60 80 100 Age (days) 19,812 c/mL (4.3 log) Closed symbols = Detectable HIV-1 RNA Open symbols = Undetectable HIV-1 RNA 2617 c/mL (3.4 log) 516 c/mL (2.7 log) 265 c/mL (2.4 log) < 48 c/mL (<1.68 log) ZDV/3TC + NVP 31 hours – 7 days ZDV/3TC + LPV/RTV 7 days – 18 months Biphasic Decay in Plasma Viral Load on ART
  13. 13. Specialized Studies to Assess Persistence of HIV-1 Infection in the Child. Persaud D et al. N Engl J Med 2013;369:1828-1835
  14. 14. CURING HIV WILL BE DIFFICULT The State of the Art in HIV Cure Research— Hope or Hype
  15. 15. “Boston Patients” Two HIV+ patients who underwent allogeneic hematopoietic stem cell transplant Both failed conventional therapy for lymphoma Reduced-intensity conditioning; no total body irradiation, no ATG Both had graph vs. host disease Donors CCR5 wild-type; recipients achieved full donor chimerism No detectable HIV reservoirs in blood or rectal tissue (2-4 yrs after HSCT) Henrich T, et al. 7th IAS Conference. Kuala Lumpur, 2013. Abstract WeLBA05. Henrich TJ, et al. J Infect Dis. 2013;207:1694-1702. Henrich T et al CROI 2014 #144LB
  16. 16. Long-Term PBMC DNA and CD4 Count Following RIC-alloHSCT Henrich T, et al. 7th IAS Conference. Kuala Lumpur, 2013. Abstract WeLBA05. HSCT: hematopoietic stem cell transplantation. Patient A: PBMC DNA CD4 Count Post HSCT (days) 0 200 400 600 800 1000 1200 1400 1600 HIVDNA (copies/106PBMC) Post HSCT (days) 0 200 400 600 800 1000 1200 1400 1600 CD4(cells/mm3) 4.3 Years Post-HSCT (<0.07 copies/106) HCST 100% Donor Lymphocyte Chimerism Patient B: PBMC DNA CD4 Count Post HSCT (days) 0 200 400 600 800 1000 1200 1400 1600 HIVDNA (copies/106PBMC) Post HSCT (days) 0 200 400 600 800 1000 1200 1400 1600 CD4(cells/mm3) 2.6 Years Post-HSCT (<0.04 copies/106) HCST 100% Donor Lymphocyte Chimerism
  17. 17. Long-Term Reduction in Peripheral Blood HIV-1 Reservoirs Following RIC-alloHSCT ● ART in the context of RIC-alloHSCT is well tolerated ● More extensive testing in the setting of full donor chimerism failed to identify evidence of HIV-1 infection of donor cells - Viral outgrowth assays and qPCR incorporating large PBMC or CD4 cell quantities - HIV-1 DNA from rectal tissue ● No evidence for HIV-specific cellular immune responses ● Implications - Donor cells in various tissues are protected from infection by ongoing ART Henrich T, et al. 7th IAS Conference. Kuala Lumpur, 2013. Abstract WeLBA05. *6 weeks (results from patient A pending). ATI: analytical treatment interruption. SCA: single-copy RNA assay. RIC-alloHSCT: reduced intensity allogeneic hematopoietic stem cell transplantation. Additional/Ongoing Results Patient A Patient B Post-HSCT Highly sensitive PCR-based chimerism Host cells: 0.00041% to 0.00081% of PBMCs Host cells: 0.00035% to 0.00096%of PBMCs Immune response HIV-specific (INF-γ ELISpot) Other None None None CMV/EBV/ Influenza ATI HIV plasma RNA PBMC DNA SCA* Proviral DNA* 7 weeks Not detectable Not detectable -- -- 15 weeks Not detectable Not detectable Not detectable Not detectable
  18. 18. Analytical Treatment Interruption Patient Tacrolimus GVHD txt during ATI
  19. 19. Analytical Treatment Interruption Patient
  20. 20. What Should “Cure” Look Like? • BMT too toxic, too dangerous, and too expensive for most infected individuals – For patients who need BMT, though, cure can and should be a goal • Treatment for cure must be time limited, tolerable and have limited risk • May be expensive – Modest success rate may be cost-saving • Many hurdles but we have to start somewhere
  21. 21. Barriers to Cure • Low level viremia detectable in most ARV treated patients[1] • Residual viral replication?[2] • Potential pharmacologic reservoirs[2] • Latently infected cells[2,3] • Resting CD4+ T cells which replenish [2,3] • Other (potential) cell types [2,3] • Long-lived cells (macrophage, microglia) [3] • Failure of HIV-specific immunity and generalized immune dysfunction[4] 1. Palmer S, et al Proc Natl Acad Sci 2008 105:3879-84. 2. Johnston R, et al. J Int AIDS Soc. 2012;15:16. 3. Richman DD, et al. Science. 2009;323:1304-1307. 4. Kaufmann DE, et al. J HIV Ther. 2003;8:19-25.
  22. 22. Patients Treated During Acute HIV Infection Enhance the opportunity for Cure? • Most individuals are infected with a single viral variant or a few highly related variants[1] • CTL responses occur very early and can be robust • HIV-specific CD4-cell responses may be preserved by early therapy[2] • Persistent activation may be diminished • HIV reservoirs may be smaller and appears be inversely related to replication AUC[3,4] • Effective therapy stops viral evolution and appears to fix early variants in latent reservoir[5] 1. Abrahams M-R, et al. J Virol. 2009;83:3556-3567. 2. Oxenius A, et al. Proc Natl Acad Sci USA. 2000;97:3382- 3387. 3. Ananworanich J, et al. 5th International Workshop on HIV Persistence During Therapy. 2011. Abstract 32. 4. Archin et al PNAS 2012 5. Anderson et al J Virol 2011
  23. 23. Reservoir Size in Treated AHI Model including VL, CD4 and latent cell decay Archin … Margolis, Perelson PNAS 2012
  24. 24. clinicaloptions.com/hiv Clinical Impact of New Data From Atlanta 2013 Early Treatment of Pts With Acute HIV Infection Restricts Seeding of Reservoirs  RV254/SEARCH 010: ongoing, prospective, open-label study of subjects seeking voluntary HIV testing (n = 75 with Fiebig stage I-III acute infection)  Before ART, HIV reservoir seeding limited – Integrated HIV DNA undetectable in PBMCs (92%) and sigmoid colon (88%) of most Fiebig I pts – Lower infection frequencies of central memory CD4+ T cells vs other memory cells  After ART, decline in HIV reservoir size – Integrated HIV DNA undetectable in PBMCs in 90% of pts at 1 yr – Reservoir primarily in transitional and effector memory CD4+ T cells  Suggests very early ART may prevent seeding of reservoirs Fiebig Stages Fiebig I: RNA+, p24̶ neg, 3rd gen ELISA-neg – Would not be detected by 4th gen ELISA Fiebig II: RNA+, p24+; 3rd gen ELISA-neg Fiebig III: 3rd gen ELISA+, WB-neg Ananworanich J, et al. CROI 2013. Abstract 47.
  25. 25. Fiebig I Integrated HIV DNA at 24 weeks after ART Not detected Chronic HIV Not detected Fiebig III
  26. 26. Limited viral diversification in virus from plasma and resting CD4 cells 5 years after treated acute HIV infection. Anderson et al J Virol 2011
  27. 27. Barriers to Cure • Low level viremia detectable in most ARV treated patients[1] • Residual viral replication?[2] • Potential pharmacologic reservoirs[2] • Latently infected cells[2,3] • Resting CD4+ T cells which replenish [2,3] • Other (potential) cell types [2,3] • Long-lived cells (macrophage, microglia) [3] • Failure of HIV-specific immunity and generalized immune dysfunction[4] 1. Palmer S, et al Proc Natl Acad Sci 2008 105:3879-84. 2. Johnston R, et al. J Int AIDS Soc. 2012;15:16. 3. Richman DD, et al. Science. 2009;323:1304-1307. 4. Kaufmann DE, et al. J HIV Ther. 2003;8:19-25.
  28. 28. HIV-1 in the “Suppressed” Patient • Latent virus reservoir • Virus expressing reservoir – > 70% of “suppressed” patients have detectable viremia • Latent cells intermittently activate? • Persistent shedding from macrophage or other long lived cells? • Ongoing replication? Palmer et al, Maldarelli F, et al. PLoS Pathog. 2007;3:e46. Riddler et al CROI 2014
  29. 29. HIV-1 RNA Diversity No Sequence Evolution after 7 years on cART Emergence of a Predominant Plasma Clone (PPC) After Years on ART 0.005 Days on ART -20 0 20 40 60 101 102 103 104 105 106 0.0 0.5 1.0 1.5 2.0 2.5 3.0 1500 1750 2000 HIV-1RNA(copies/mL) Diversity(%) Start ART 2250 3.5107 Kearney M, et al. Unpublished data used with permission.
  30. 30. 0.0001 0.001 0.01 0.1 1 10 100 1000 10000 0 1 2 3 4 5 6 7 Time on HAART (years) Frequency (per106cells)Resting CD4+ Cell Infection Extremely Stable Despite ART - Time to eradication > 73.4 years 0.00001 1. Finzi D, et al. Science. 1997;278:1295-1300. 5. Siliciano JD, et al. Nature Med. 2003;9:727-728. 2. Wong JK, et al. Science. 1997;278:1291-1295. 6. Chun TW, et al. Nature Med. 1995;1:1284-1290. 3. Chun TW, et al. PNAS. 1997;94:13193-13197. 7. Chun TW, et al. Nature. 1997;387:183:188. 4. Finzi D, et al. Nature Med. 1999;5:512-517.
  31. 31. New Explanations for HIV Persistence • Infection and persistence in long-lived CD4+ T memory stem cells1 • Homeostatic proliferation of infected cells may sustain the HIV reservoir2 • Integration of HIV into cancer genes which may give infected clones a survival advantage3 1Lichterfeld M et al, CROI 2014, #54; 2Wagner T et al, CROI #138; 3Maldarelli F et al, CROI 2014, # 407LB
  32. 32. Other Challenges: •Clearance of infected cells •Clearance of virions •Complete block of new infection Step 1: Eliminate Latent HIV Infection From Resting CD4+ Cells Anti-latency therapy 1. Rong L, et al. PLoS Comput Biol. 2009;5:e1000533. 2. Lewin SR, et al. AIDS. 2011;25:885-897.
  33. 33. Potential Interventions to Disrupt Latency Richman DD, et al. Science. 2009;323:1304-1307.
  34. 34. “Open” Histones Acetylated Histone tails Reduced Higher Order Structure Access to Transcription Factors Transcription Active “Closed” Nucleosome Hypo-Acetylated Histone tails Stable, Compact Chromatin Less accessible to Transcription Factors Transcription Repressed deacetylated acetylated HIV lives within chromatin: tipping the balance towards acetylation removes a restriction at the initiation of proviral expression Schiralli Lester GM, et al. Mol Biol Int. 2012;2012:614120.
  35. 35. Single 400 mg VOR dose: Remeasure resting CD4+ T cell HIV RNA expression. Define potential for VOR to disrupt latency  Mean 4.8-fold induction (range 1.5- to 10-fold)  All increases significant (P < .01)  No AE > Grade I  No AE due to VOR Pt. 1 Pt. 2 Pt. 3 Pt. 4 Pt. 5 Pt. 6 Pt. 7 Pt. 8 HIV-1gagRNAcopiesperwell Archin NM, et al. Nature. 2012;487:482-485.
  36. 36. HDAC Inhibitors Selected for Clinical Trials in HIV+ Subjects on ART Vorinostat SAHA Romidepsin Panobinostat Structure Regulatory Status FDA Approved FDA Approved Phase 3 Indication CTCL CTCL MM/AML Dose 400 mg QD PO 14 mg/m2 IV Days 1, 8, 15 (28 day cycle) 20 mg TIW PO Clinical studies in HIV+ Subjects Underway (US & Australia) Clinical protocol development (US-ACTG) Enrolling (Denmark) Dose / Duration 400 mg (single & 14 days) < 14 mg/m2 SAD 20 mg TIW every other week / 8 weeks N H H N NH O OH Wei G, et al. CROI 2013. Abstract 376.
  37. 37. Slide 42 In Vitro Activation of HIV by HDAC Inhibitors -11 -10 -9 -8 -7 -6 -5 -4 0 1×1005 2×1005 3×1005 Concentrations [Log10, M] Luciferasesignal(RLU) EC50 (nM) CC50 (nM) %max Romidepsin 4.49 107 98% Panobinostat 10.1 > 2,500 108% Givinostat 95.8 24,000 79% SB939 212 > 50,000 104% Vorinostat 3,950 > 25,000 100% Mocetinostat 13,600 10,100 75% RMD and Panobinostat approximately 400-900X more potent than Vorinostat
  38. 38. Will HDACi be Enough? • Not all studies show induction of viral expression by HDACi ex vivo • Combinations of anti-latency compounds with different mechanism of action may be more effective[1] • Latently infected cells that express HIV-1 RNA may not die![2] 1. Moreno S. Retrovirology. 2012;9:I16. 2. Persaud D, et al. J Virol. 2003;77:1659-1665.
  39. 39. Vorinostat and Cell Death • Resting cells stimulated with vorinostat ex vivo did not die • In a model system of latency CD8+ cells from most patients did not kill CD4 cells that expressed virus Shan et al Immunity 2012
  40. 40. Presence of Non-induced Proviruses in Resting CD4+ Cells • 12% of non-induced proviruses appear replication competent • Is reactivation a stochastic event? Can these pro-virus be reactivated or are they buried? Ho Y-C, et al. Cell 155, 540–551, October 24, 2013.
  41. 41. Clones of Intact Non-induced Proviruses Have Similar p24 Kinetics Ho Y-C, et al. Cell 155, 540–551, October 24, 2013.
  42. 42. “Kick and Kill” • When latency is disrupted, mechanisms to kill virus-expressing cells may be needed – Augment HIV-1 specific immune response with HIV-1 vaccine prior to “kick”[1] – Improve HIV-1 specific CD8 response through ex vivo manipulation[2] • TCR enhancement[2] – Infuse broadly neutralizing antibody or antibody primed for ADCC[3] – Wake up “exhausted” HIV-1 specific cells[4] • Anti PD1 or Anti PD-L1[4] 1. Pantaleo G, et al.. Nat Med. 2004;10:806-810. 2. Oxenius A, et al. Eur J Immunol. 2001;31:1115-1121. 3. Kwong PD, et al. Cold Spring Harb Perspect Med. 2011;1:a007278. 4. Freeman GJ, et al. J Exp Med. 2006;203:2223-2227.
  43. 43. Spontaneous or Induced Reversal of Latency Stimulation and recruitment of immune effector cells Targeted antibody or antibody-drug conjugate delivery YY Elimination of expressing cells No Infection of CD4+T- cells Modified from Romas Geleziunas et al. Strategies to reduce and/or control HIV reservoirs
  44. 44. 0% 20% 40% 60% 80% 100% 120% 0 2 4 6 8 Healthy Donor 01 Healthy Donor 02 Healthy Donor 03 Elite Suppressor 01 Elite Suppressor 02 Elite Suppressor 04 HAART Patient 03 HAART Patient 05 HAART Patient 06 HAART Patient 12 HAART Patient 16 HAART Patient 17 HAART Patient 18 HAART Patient 19 ResidualinfectedCD4+Tcells(%) Days in co-culture CD8+ T cells from patients on ART do not reliably kill latently infected CD4+ T cells after virus reactivation Shan Immunity 2012
  45. 45. 0% 20% 40% 60% 80% 100% 120% 1 2 3 4 5 HAART Patient 03 HAART Patient 05 HAART Patient 06 HAART Patient 16 HAART Patient 18 HAART Patient 19 ResidualinfectedCD4+Tcells(%) Days in co-culture CD8+ T cells from patients on ART do not reliably kill latently infected CD4+ T cells after virus reactivation Shan Immunity 2012 HAART Patient 19 HAART Patient 18 HAART Patient 16 HAART Patient 5 HAART Patient 3 HAART Patient 6
  46. 46. Pre-stimulation of CD8+ T Cells Enhanced CTL Responses Shan et al Immunity 2012
  47. 47. Adapted from Freeman G. et.al., J Exp Med 2006. Evidence supports blockade of the PD-1/PD-L1 pathway as a viable therapeutic strategy in chronic HIV infection PD-L1 PD-1 PD-1 /-L1 Blockade • Persistent antigenemia leads to T cell exhaustion • PD-1 is a key inhibitory receptor affecting T-cell response – Elevated on virus-specific T- cells in chronic HIV; – seen on both CD4+ and CD8+ subsets; – cells display exhausted phenotype ex vivo • Blockade of PD-1/PD-L1 – Restores HIV-specific immune functions in vitro and ex vivo – Reduces viremia and prolongs survival in animal models in vivo Barrier to HIV eradication: T cell exhaustion and the PD-1 pathway 52
  48. 48. PD-L1 blockade in ARV suppressed SIVmac251-infected Rhesus Macaques Hypothesis: – Treatment of ARV-suppressed SIV infected macaques with αPD-L1 should: – restore SIV-specific T cell function. Subsequently, this may: – reduce the latent SIV reservoir – lead to host control of virus following interruption of ARV 1. Virus-specific T cell functionality, 2. Cell-associated viral DNA (latent reservoir) in tissues and periphery, 3. Virus recrudescence after cessation of ARV treatment. Objectives: – Determine whether multiple doses of BMS-936559 affect: PD-L1 blockade Start ARV BMS-936559 (8) Isotype control (5) 5 X 10mg/kg 6 weeks ARV TI Viral load rebound off ARV Study design: SIV Infection 2 weeks
  49. 49. Kinetics of viral load rebound post-treatment interruption • Half of BMS-936559-treated animals had rebound similar to isotype-treated animals • BMS-936559-responder group remained below 1000 cp/mL for >8 weeks • Two had undetectable VL for 3-4 weeks LOQ at 50 SIV RNA copies/mL * J. Whitney S. Sanisetty BMS-936559 Isotype
  50. 50. ACTG 5326 Safety and immunotherapeutic activity of an anti-PD-L1 antibody (BMS-936559) in HIV-1 infected subjects on suppressive ART: pilot phase II, 24 week, double-blind, placebo-controlled, ascending single dose study
  51. 51. 1. Barber D.L. et al. Nature. 2006; 2. Day CL. et.al. Nature. 2006; 3. Streeck H. PLOS Med. 2008; 4.Petrovas C. et.al. J Exp. Med. 2006; 5. Boni C. et.al. J Virol. 2007; 6. Golden-Mason L. et.al. J Virol. 2007; 7. Evans A. et.al. Hepatol. 2008; 8. Velu V. et al. Nature. 2009 Rationale for A5326  The PD-1 inhibitory receptor dampens T-cell responses and is a marker of immune exhaustion in chronic HIV and other viral infections  PD-1 and its natural ligand PD-L1 remain elevated in HIV-infected patients on suppressive ART  T cell exhaustion mediated by PD-1/PD-L1 may be a barrier to HIV eradication
  52. 52. Multifunctional, anti-viral CD28+ memory T cell responses after four doses of AGS-004 after treatment in acute infection
  53. 53. 59 Impact of Env-Specific Immunotoxin on Residual Active HIV-1 Reservoirs ● Prospective trial of HIV-infected, humanized BLT mice - ART for 42 days, env-specific immunotoxin (3B3-PE38) for 14 days (day 28-42) - Tissue viral load (bone marrow, thymic organoid, spleen, lymph nodes, liver, lung, peripheral blood cells) ● Results - ART reduced HIV RNA in peripheral blood and systemically - Env-specific immunotoxin further reduced HIV RNA by • Up to 1000-fold in individual tissues • 0.8 log10 copies/mL systemically - Mechanism of reduced HIV RNA • Loss of productively infected cells Denton PW, et al. 7th IAS Conference. Kuala Lumpur, 2013. Abstract TuAA0101. No ART (n=68 samples) 10 mice Log10HIVRNAcopiesper 105CD4orTotalThymocytes HIV RNA Levels: All Tissues ART (n=99 samples) 15 mice ART + 3B3-PE38 (n=40 samples) 6 mice -2.9 log10* *P<0.001. -2.1 log10* -0.8 log10*
  54. 54. Additional Cure Strategies • Genetic modification of CD4+ cells to limit or stop HIV replication[1] – eg, Zinc finger nuclease “excision” of CCR5 gene[1] • Specific activation of HIV-infected resting memory cells using targeted nano-particles[2] • IL-7 or IL-16 with ARV intensification[3] • Reduce residual activation/inflammation and limit replication in tissue?? 1. Berger EA. Curr Opin HIV AIDS. 2011;6:80-85. 2. Wayengera M. HIV AIDS Rev. 2011;10:1-8. 3. Beq S, et al. Eur Cytokine Netw. 2004;15:279-289.
  55. 55. Cure Studies In ACTG HIV-1 infected patients suppressed on ART • A5315 – Single dose romidepsin • A5326 – Anti-PD-L1 antibody – Single infusion • A5337 – Sirolimus (rapamycin)
  56. 56. Will HIV Infection be Curable? • HIV-1 can be cured in rare situations – Bone marrow transplant (with resistant cells?) – Very early infection in infants (and maybe adults?) • Substantial barriers to scalable curative treatments exist – Latently infected cells that sustain themselves – The possibility of ongoing replication – Inflammation may contribute to both of the above – Tissue or cellular sanctuaries (especially brain?) • However – initial steps have been taken • Improvement in assays, medications and medical technology • Modestly effective therapy (30% cure) can be very cost effective
  57. 57. Acknowledgements • David Margolis • JoAnn Kuruc • Victor Garcia • John Mellors • Mike Cohen • Mary Kearney • Joe Wong • Bob Siliciano • Steve Mason • Steve Deeks Volunteers across all cure studies for their altruism and bravery
  58. 58. Thanks to all the patients participating in cure research!
  59. 59. “Post-Treatment Controllers” in ANRS Visconti Cohort  14 HIV patients whose viremia remained controlled for several yrs after the interruption of prolonged cART initiated during primary infection  Pts standard cART available at time of tx (for some, all-NRTI tx)  HIV-1 RNA became undetectable in median of 3 months (0.5 to < 8 months)  Median cART duration: 36.5 months  PTCs lacked protective HLA-B alleles overrepresented in spontaneous HIV controllers (HICs) Sáez-Cirio´A, et al. . Plos Pathogen. 2013;9: e1003211.
  60. 60. clinicaloptions.com/hiv Clinical Impact of New Data From Atlanta 2013 Long-Term Control of Viral Replication After Treatment During Primary Infection Sáez-Cirio´A, et al. . Plos Pathogen. 2013;9: e1003211.

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