2014 “Towards an HIV Cure” symposium Melbourne

2014 “Towards an HIV Cure” symposiumMelbourne

Pr Christine ROUZIOUX

Virologie – Université Paris Descartes

Impact of HAART on HIV Reservoirs

The objective of this presentation is to understand the extent of which ART can reduce and limit the establishment and the persistence of the HIV reservoirs, as an important step towards HIV cure.

There is no consensus on the definition of HIV reservoirs There is no consensus on HIV reservoir markers However, there are many recent results which bring

information that could help to design studies, to select patients as good candidates to receive the best combinations aiming at reducing HIV reservoirs and to achieve HIV drug free remission.

Definition of HIV reservoirs

Lewin & Rouzioux, AIDS 2011Rouzioux & Richman, 2012

Culture assay : IUPMCulture assay : IUPM

METHODS OBJECTIVE ADVANTAGES DRAWBACKS

Cell viremia(IUPM)

Measures cell capacity to produce infectious virus IUPM

Gold Standard to identify productive and/or resting cells

Long and heavy techniqueHigh amount of Fresh blood needed 180 mlReproducibility unknown

Integrated HIV-DNA To quantify integrated provirus in resting and productive infected cells

Good Marker of Latency in sorted resting CD4+TcellsFrozen samples

Labour intensive techniqueNo standard methodReproducibility across multiple labs unknown

2 LTR circles un-integrated HIV-DNA

Measures by product of HIV integration, marker of ongoing replication

Marker of recent cycles of replicationFrozen samples

Reproducibility across multiple labs unknown

Total HIV-DNA Measures unintegrated,, integrated, linear DNA and 2LTR circles, in blood and tissues

Small amount of frozen whole blood, PBMCStandardized, simple reproducible,International Quality Controls

Includes quantification of competent and incompetent virusReproducibility across multiple labs unknown

Cell-Associated US-RNA and MS-RNA

Marker of ongoing replication in productive cellsMarker of HIV transcription

marker for residual productive cells in patients on cART

Few published studiesReproducibility across multiple labs unknown

Plasma HIV-RNA

HIV-RNA (SCA)

Marker of viral production by infected cellsUltrasensitive method (Single Copy Assay) to quantify residual replication

Universal well standardized methodFeasible with all HIV subtypes with someassays

Large volume of plasma neededIndirect marker of productive cells

Lewin & Rouzioux, AIDS 2011

r=0.65 p=0.016

r=0.58 p=0.015r= 0.63 p=0.0042

r=0.70 p=0,008

Comparative analysis of measures of viral reservoirs inHIV eradication studies: Erickson et al , Plos Path, 2013Comparative analysis of measures of viral reservoirs inHIV eradication studies: Erickson et al , Plos Path, 2013

Palmer S et al. J Internal Medicine 2011

- Naïves

Treatment InterruptionViral Rebound

Kinetics of HIV reservoir decrease

Impact of Early HAART on HIV ReservoirsImpact of Early HAART on HIV Reservoirs

Hocqueloux et al , JAC 2013

ADN

-VIH

(Log

/ M

PBM

C)

35 Primary- infections

272 Chronic Infections

Time with HIV-RNA <50 copies/ml (Years)

Better HIV-DNA decrease Better

immune restoration

Better HIV-DNA decrease Better

immune restoration

Impact of ART on Gut reservoirs

Yukl S et al, AIDS 2010The Distribution of HIV DNA and HIV RNA in Cell Subsets differs in Gut and Blood in patients on HAART. Intensification with raltegravir produced no consistent decrease in HIV-RNA and HIV-DNA in blood, duodenum, colon or rectum. Moreover, ileum support ongoing productive infection, even in patients with plasma HIV-RNA undetectable.

Chege D et al AIDS 2012In long term virologically suppressed patients on HAART, intensification with raltegravir did not result in further decay of HIV-DNA in either the blood or GUT after 48 and 96 weeks of therapy.

Ananvoranitch J et al, Plos one 2012:Gut T cell depletion and HIV reservoir seeding increases with progression . HAART induced immune restoration and reduced reservoir size

Kök A et al, Mucosal Immunology, 2014:Early initiation of HAART helps to preserve and /or restore mucosal gut homeostasis, and reduce the gut reservoirs HIV-DNA level.

ANRS 147 OPTIPRIM : Study design

Treatment interruption

0 M24 M30

Darunavir/R: 800/100 mg QD

+ Tenofovir/emtricitabine: 245/200 mg QD+ Raltegravir: 400 mg BID+ Maraviroc: 150 mg BID

Primary end-point : HIV-DNA level at M24

VISCONTI ?

Inclusion criteria : Patients with Acute HIV-1 infection < 10weeks

Darunavir/R: 800/100 mg QD

+ Tenofovir/emtricitabine: 245/200 mg QD

Arm 1 (N=45):

Arm 2 (N=45):Co-enrollment:-Cohort CO6 PRIMO

-

Chéret et al , CROI 2014

A. HIV-DNA log copies/ per 106 PBMC strong decrease and continious slope

A B

B. HIV-DNA log copies per ml of blood

ANRS 147 : OPTIPRIM trial : impact on reservoirsANRS 147 : OPTIPRIM trial : impact on reservoirs

HIV-DNA kinetic from baseline to month 24

Chéret et al , CROI 2014

Could we do better?

Persistent HIV-1 replication is associated with lower antiretroviral drug concentrations in lymphatic tissues

Persistent HIV-1 replication is associated with lower antiretroviral drug concentrations in lymphatic tissues

Fletcher et al PNAS 2014

(PTC 1 and 2).

A

C D

Probability to maintain HIV RNA <400 copies/ml after treatment interruption.

: Immunovirological parameter evolution of the two post treatment

controller patients

1

2

3

4

5

6

D0 M24

PBMCs CD4 TLy ActivatedCD4 TLy

RestingCD4 TLy

TN TCM TTM TEM

p=0.001 p=0.001 p<0.004 p=0.001 p=0.001p=0.001 p=0.002p=0.001

p<0.009

D0 M24 D0 M24 D0 M24 D0 M24 D0 M24 D0 M24 D0 M24

Ce

ll-a

ss

oc

iate

d H

IV-1

DN

A(L

og

co

pie

s/m

illi

on

ce

lls

)

Chéret et al CROI 2014

Impact of 2 years of HAART in acute patients:OPTIPRIM ANRS147

13

HIV blood reservoirs in T CD4+ subsetsHIV blood reservoirs in T CD4+ subsets

Chomont et al, Nat. Med 2009

HAART at the Chronic Phase HAART in Primary infection

Elite controllers - VISCONTI Patients

Chéret et al, 2014 : OPTIPRIM ANRS 147

Interactions between Activation/ Inflammation and HIV reservoir levels

Interactions between Activation/ Inflammation and HIV reservoir levels

Jain et al JID, 2013

Interactions between Activation/ Inflammation and HIV reservoir levels

Interactions between Activation/ Inflammation and HIV reservoir levels

Murray et al J Virol, 2014

Impact of early HAART

Murray et al J Virol, 2014

2013

Year01 02 03 04 05 06 07 08 09 10 11

CD

4+ T

cel

ls/m

m3

0

500

1000

1500

2000

Year98 99 00 01 02 03 04 05 06 07 08 09 10 11

CD

4+ T

cel

ls/m

m3

0

500

1000

1500

2000

Year98 99 00 01 02 03 04 05 06 07 08 09 10

CD

4+ T

cel

ls/m

m3

0

500

1000

1500

2000

Year99 00 01 02 03 04 05 06 07 08 09

CD

4+ T

cel

ls/m

m3

0

500

1000

1500

2000

Year99 00 01 02 03 04 05 06 07 08 09 10

CD

4+ T

cel

ls/m

m3

0

500

1000

1500

2000

Year02 03 04 05 06 07 08 09 10

CD

4+ T

cel

ls/m

m3

0

500

1000

1500

2000

Year02 03 04 05 06 07 08 09 10

CD

4+ T

cel

ls/m

m3

0

500

1000

1500

2000

Year01 02 03 04 05 06 07 08 09 10

CD

4+ T

cel

ls/m

m3

0

500

1000

1500

2000

Year00 01 02 03 04 05 06 07 08 09 10 11

CD

4+ T

cel

ls/m

m3

0

500

1000

1500

2000R

NA

co

pie

s/m

l

100101102103104105106107108109

RN

A c

op

ies/

ml

100101102103104105106107108109

RN

A c

op

ies/

ml

100101102103104105106107108109

RN

A c

op

ies/

ml

100101102103104105106107108109

RN

A c

op

ies/

ml

100101102103104105106107108109

RN

A c

op

ies/

ml

100101102103104105106107108109

RN

A c

op

ies/

ml

100101102103104105106107108109

RN

A c

op

ies/

ml

100101102103104105106107108109

RN

A c

op

ies/

ml

100101102103104105106107108109

OR1

OR2

OR3

KPV

OR8

GXR

CXK

MWP

JOGA

OCP

LY1

LY2

Year96 98 00 02 04 06 08 10

0

500

1000

1500

2000

100101102103104105106107108109

CD

4+ T

cel

ls/m

m3

RN

A c

op

ies/

ml

Year01 02 03 04 05 06 07 08 09 10 11

0

500

1000

1500

2000

101

102

103

104

105

106

107

108

109

CD

4+ T

cel

ls/m

m3

RN

A c

op

ies/

ml

Year99 00 01 02 03 04 05 06 07 08 09 10 11 12

Year99 00 01 02 03 04 05 06 07 08 09 10 11 12

CD

4+ T

cel

ls/m

m3

RN

A c

op

ies/

ml

CD

4+ T

cel

ls/m

m3

RN

A c

op

ies/

ml

0

500

1000

1500

2000

100101102103104105106107108109

0

500

1000

1500

2000

100101102103104105106107108109

MO1 SL2

Year96 98 00 02 04 06 08 10 12

CD

4+ T

cel

ls/m

m3

RN

A c

op

ies/

ml

0

500

1000

1500

2000

1102103104105106107108109

10

14 patients with Remission

Saez-Cirion et al Plos Pathogens 2013

The VISCONTI study

PHI Chronic cART ALT HIC PTC

HIV

-DN

A (lo

g10

copi

es/1

06 PBM

C)

1

2

3

4

5

6

Lewin and Rouzioux AIDS, 2011

Post-treatment controllers have low levels of HIV-1 DNA in PBMC, which further decreased after treatment interruption

in some cases

Post-treatment controllers have low levels of HIV-1 DNA in PBMC, which further decreased after treatment interruption

in some cases

Saez-Cirion et al Plos Pathogens 2013

Time after treatment

interruption (months)

0 30 60 90 120

Cel

l ass

oci

ated

HIV

-1 D

NA

(Lo

g c

op

ies/

106

PB

MC

)

0

1

2

3

4

Médian(IQR)

At PHI Before interruption

After interruption

CD4/mm3 544 915 855

Ratio CD4/CD8 0.70 1.51 1.48

Viral loads, Log cp/mL 5.2 <1.7 <1.7

The VISCONTI patients, now ! (n=20)

Post-treatment interruptionMedian Follow-up = 9.3 years(IQR: 8.4-10 – range: 4.5-12.5)Median age = 48 (IQR: 43-53)No AIDS eventTreatment resumption in 1/20 patient

Cancer ORL VL <40 cp/mL before cART resumption In remission after 2 years

• No treatment resumption linked to viral replication

• 338 Viral loads measured after treatment interruption– 287/338 (85%) were <50 cp/mL– 45/338 (13%) were >50 et <400

cp/mL– 6/338 (2%) were >400 cp/mL

CONCLUSIONS

The study of HIV reservoirs in treated patients bring many new arguments in favor of early treatment initiation:

Protecting long-life memory T cells Reducing the damage of activation/inflammation Inducing VISCONTI cases with long-term control after treatment

interruption

Pharmacological studies indicate that better combinations with better concentrations in lymphoïd tissues, including lymph nodes, might have a better impact on HIV reservoirs.

Lastly, the impact of new drugs, new combinations should be systematically evaluated on HIV reservoirs, to prepare patients to the next objective to achieve long-term HIV drug free remission.

Institut PasteurRégulation des Infections Rétrovirales

Asier Saez-CirionGianfranco PancinoDaniel Scott-Algara

Françoise Barré-SinoussiPierre Versmisse Faculté de Médecine Paris Sud

INSERM U1012Alain Venet

Olivier LambotteCécile GoujardIsabelle Girault

Camille Lecuroux

INSERM U1018Laurence Meyer

Faroudy Boufassa

CHU Necker Enfants MaladesLaboratoire de Virologie

Christine RouziouxVéronique Avettand-Fenoel

Adeline Mélard

CHR Orléans La SourceService Maladies Infectieuses

Thierry PrazuckLaurent Hocqueloux

CHU Hôtel-DieuUnité Immuno-Infectiologie

Jean-Paul Viard

ANRS CO18 “HIV controllers”

ANRS CO15 “ALT”

AcknowledgementsAcknowledgementsPatients and clinicians who participate in the study

CHU Pitié-SalpetriereINSERM UMR-S 945

Brigitte AutranCharline Bacchus

Benjamin DescoursAssia Samri

Ioannis TheodorouJulien Guergnon

ANRS CO6 “PRIMO”

INSERM UPMC U943Dominique Costagliola

Valérie Portard

FHDH“French Hospital Database on HIV”

Merci