Effect of 24 Week Intensification with a CCR5-Antagonist on the Decay of

the HIV-1 Latent Reservoir

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Laura Díaz1, Carolina Gutiérrez2, Carmen Page2, Raquel Lorente1, Beatriz Hernández-Novoa2, Alejandro Vallejo2, Ester Domínguez2, María Abad2,

Nadia Madrid2, Ana Moreno2, María Jesús Pérez-Elías2, Rafael Rubio3, María Ángeles Muñoz-Fernández1 and Santiago Moreno2.

1Immunobiology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain, 2Infectious Diseases Service, Hospital Universitario Ramón y Cajal, Madrid, 3Infectious Diseases Service Hospital Universitario Doce de Octubre, Madrid, Spain

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ABackgroundBackground

1Chun TW, et al. J Infect Dis 2007; 2 2Dinoso JB et al. PNAs 2009, Dinoso JB et al. PNAs 2009, 33Buzón MJ et al. Nature Med 2010Buzón MJ et al. Nature Med 2010

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To evaluate the influence of treatment intensification To evaluate the influence of treatment intensification

with a CCR5 coreceptor antagonist (maraviroc) on:with a CCR5 coreceptor antagonist (maraviroc) on:

ObjectivesObjectives

Primary endpoint - Latent HIV-1 reservoir

Secondary endpoints - Residual viremia measured by ultrasensitive PCR

(SCA, <1 copy HIV RNA/mL) - Episomal DNA with 2 LTRs - Immune activation markers

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ART + MaravirocART + Maraviroc

Week 0Week 0 Week 24Week 24Baseline StudyBaseline Study(3 months)(3 months) Week 48Week 48

ARTART

Laboratory DeterminationsLaboratory Determinations

Week 12Week 12 Week 36Week 36

Study DesignStudy Design

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Inclusion criteriaInclusion criteria

Over 18 years of ageOver 18 years of age

Chronic HIV infectionChronic HIV infection

Successful antiretroviral therapy with at least 3 drugs Successful antiretroviral therapy with at least 3 drugs with viral load with viral load below 50 copies below 50 copies HIV RNA/mL for at least HIV RNA/mL for at least 2 years2 years

CD4CD4++ T lymphocyte count T lymphocyte count above 350 cells/mmabove 350 cells/mm33

Demonstration of Demonstration of R5 viral tropismR5 viral tropism by phenotyping by phenotyping plasma samples stored before antiretroviral therapyplasma samples stored before antiretroviral therapy

MethodsMethods

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Laboratory DeterminationsLaboratory Determinations

2-Residual viremia2-Residual viremia 3-Episomal DNA with 2 LTRs3-Episomal DNA with 2 LTRs

1-Latent reservoir 1-Latent reservoir 4-Immune activation 4-Immune activation markersmarkers

450ml

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Methods: Latent reservoir Methods: Latent reservoir

Every week

CD8 T cells

Day 15 and 21Results: IUPM

1 2 3

456

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MethodsMethods

Immune activation markers: CD38Immune activation markers: CD38++ and HLA-DR and HLA-DR++ on CD4 and CD8 cells on CD4 and CD8 cells

Single Copy Assay (Dr. Sarah Palmer)Single Copy Assay (Dr. Sarah Palmer)

Episomal DNA with 2 LTRsEpisomal DNA with 2 LTRs

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PatientPatient GenderGender AgeAgeCD4 countCD4 count(cells/mm(cells/mm33))

CD8 countCD8 count(cells/mm(cells/mm33))

HIV Viral loadHIV Viral load(copies/mL)(copies/mL)

ARTARTDuration of ART Duration of ART

(months)(months)

1 M 49 1169 683 <50 ddI+3TC+NVP 124

2 M 47 486 673 <50 FTC+TDF+ATV/r 75

3 M 46 796 650 <50 3TC+ABC+ATV 78

4 F 46 787 1109 <50 FTC+TDF+LPV/r 57

5 M 45 534 784 <50 AZT+3TC+ABC 142

6 M 58 728 639 <50 AZT+3TC+ABC 144

7 M 32 694 1608 <50 FTC+TDF+ATV/r 50

8 M 30 1241 1414 <50 FTC+TDF+LPV/r 42

9 M 30 589 1064 <50 FTC+TDF+EFV 38

Median Median [IQR][IQR] 46 [31-48]46 [31-48] 711711

[547-793][547-793]784 784

[673-1109][673-1109] <50<50 -- 75 [38-144]75 [38-144]

Baseline characteristics of the patientsBaseline characteristics of the patients

HIV-1 Latent ReservoirHIV-1 Latent Reservoir

Open symbols represent measurements below the limit of detection

IUP

M

Open symbols represent measurements below the limit of detection

UIP

M

UIP

MU

IPM

UIP

MU

IPM

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HIV-1 Residual ViremiaHIV-1 Residual Viremia (Single Copy Assay)(Single Copy Assay)

HIV

-1 R

NA

co

pie

s/m

L

Basal Week 12 *

* Failure of internal standardin 2 samplesDetection limit < 0,3 cop/mL

Detection limit < 2 cop/mL

Detection limit <0,6 and < 0,4 cop/mL

Week 24

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Episomal DNA with 2 LTRsEpisomal DNA with 2 LTRs

Follow up (weeks)

Num

ber

of p

atie

nts

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Baselinew4w12w24w36

5.4 [4.7-7.6]5.4 [3.5-6.5] 2.3 [0.4-2.9] 3.3 [2.3-4.7] 3.5 [0.9-4.6]

Baselinew4w12w24w36

3.2 [2.6-3.5]2.5 [0.9-3.3] 0.8 [0.2-2.4]

1.6 [1.1-2.3] 1.8 [1.4-2.0]

CD4 cell activation

p<0.001

p=0.115

p=0.03

p=0.05

p=0.755

CD

38

+H

LA

-DR

+ (

%)

Follow up (weeks)

0

10

8

6

4

2

Basal w12w4 w24HIV-1Negative

w36

p=0.031

CD8 cell activation

p<0.001

p=0.009

p=0.04p=0.19

p=0.731

CD

38

+H

LA

-DR

+ (

%)

0

10

8

6

4

2

Basal w12w4 w24HIV-1Negative

w36

Follow up (weeks)

p=0.28

Immune Activation Markers

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w12Baseline w12 w4

CD4 cell countCe

ll/m

m3

w24

Naive CD4 cells

CD45

RA+ C

D62

L+ (%

)

w24

BaselineW12W24

711 [547-793]686 [589-1005]680 [601-910]

BaselineW4W12W24

42 [22-53]46 [35-51] p= 0.83338 [30-58] p= 0.71551 [18-55] p= 0.917

Baseline

Immunological Status

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After 48 weeks of intensification with MVC, a decrease in the After 48 weeks of intensification with MVC, a decrease in the size of the latent reservoir is observed in most patients size of the latent reservoir is observed in most patients evaluated. The quantification of the reduction is limited by the evaluated. The quantification of the reduction is limited by the sensitivity of the method.sensitivity of the method.

In an apparent paradox, an increase in the residual viremia In an apparent paradox, an increase in the residual viremia (SCA) and the episomal DNA with 2 LTRs is found in some of (SCA) and the episomal DNA with 2 LTRs is found in some of the patients evaluated.the patients evaluated.

A reduction in the proportion of activated CD4 and CD8 cells A reduction in the proportion of activated CD4 and CD8 cells was observed.was observed.

Overall, we feel that intensification with a CCR5 antagonist Overall, we feel that intensification with a CCR5 antagonist may have an impact on the reservoirs and deserves further may have an impact on the reservoirs and deserves further evaluation.evaluation.

ConclusionsConclusions

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DiscussionDiscussion

The impact on residual replication and viremia is similar to previous reports: The impact on residual replication and viremia is similar to previous reports: no impact/increase (Dinoso et al. PNAs 2009; Buzón et al. Nature Medicine, no impact/increase (Dinoso et al. PNAs 2009; Buzón et al. Nature Medicine, 2010)2010)

Only one previous study has measured episomal DNA with 2 LTRs: a Only one previous study has measured episomal DNA with 2 LTRs: a transient increase was found during intensification with raltegravir (Buzón et transient increase was found during intensification with raltegravir (Buzón et al. Nature Medicine, 2010)al. Nature Medicine, 2010)

No previous studies have evaluated the consequences of intensification on No previous studies have evaluated the consequences of intensification on the latent reservoir in resting CD4 T cells in chronically infected patientsthe latent reservoir in resting CD4 T cells in chronically infected patients

-Only one study has measured the effect of initial therapy with a 4 drug -Only one study has measured the effect of initial therapy with a 4 drug regimen, including enfuvirtide (Gandhi et al.JID 2009)regimen, including enfuvirtide (Gandhi et al.JID 2009)

-One study evaluated the impact in patients treated during acute infection -One study evaluated the impact in patients treated during acute infection (Chun TW et al.JID 2007) (Chun TW et al.JID 2007)

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DiscussionDiscussion

- Inhibition of viral replication in extra plasma sites (e.g. Gut)

- Activation of transcription by the mechanism of action of MVC

- Evaluation of these mechanisms are currently in progress

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A Hospital University Ramón y CajalHospital University Ramón y CajalService of Infectious DiseasesService of Infectious Diseases

Madrid, SpainMadrid, SpainSantiago Moreno Guillén

Carolina GutiérrezBeatriz HernándezAlejandro Vallejo

Carmen PageNadia MadridMaría Abad

Ester Dominguez

José Luis CasadoFernando Dronda

Ana MorenoEnrique Navas

María Jesús Pérez-Elías

Paloma Martí-BeldaMaria Pumares

Javier Zamora. StatisticianBelén Capuz. Radiophysic

Hospital University Gregorio MarañónHospital University Gregorio MarañónLaboratory of Immunovirology Laboratory of Immunovirology

Madrid, SpainMadrid, SpainMaría Angeles Muñoz-Fernández

Laura DíazRaquel Lorente

D. Pedrero. Radiophysic

University of Córdoba. SpainUniversity of Córdoba. Spain

Eduardo Muñoz

Karolinska Institute. Stockholm, SwedenKarolinska Institute. Stockholm, Sweden

Viktor DahlSarah Palmer

Hospital 12 de Octubre. Madrid, SpainHospital 12 de Octubre. Madrid, SpainRafael Rubio

Thanks to all participating patients and their families

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Spanish Medical Research Fund (FIS) PI08/0958&The Spanish AIDS Research Network (RIS) RD06/006