HIV Cure Research Training Curriculum Latency Reversing Agents Module by Scientific Leads David M Margolis CARE and Sharon Lewin DARE Community Leads Cipri Martinez DARE and David Palm CARE ID: 317045
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Latency reversing agents
HIV Cure Research Training Curriculum
Latency Reversing Agents
Module by:
Scientific
Leads
: David M. Margolis (CARE) and Sharon Lewin (DARE
)
Community Leads
: Cipri Martinez (DARE) and David Palm (CARE)
The HIV CURE training curriculum is a collaborative project aimed at making HIV cure research science accessible to the community and the HIV research field. Slide2
US military cohort (n = 2327, mean age 35) who started ART after 2000, 5-year mortality 0.3
%
Marconi 2010
Predicted survival if HIV+ at 25
yrsSlide3
Combination
HIV
Prevention
Reduce the number of new HIV infections
Treatments
that clear Infection
Reduce the number of
HIV-infected peopleSlide4
Last public appearance of the entire AIDS Quilt, 1996Slide5
Transient “remission” is possible
Two Boston Patients
1,2
The Mississippi Child
3
Treatment
CCR5+/+
bone marrow transplant
Early ART
Remission off ART
3 months and
7 months
2.5 years
Lesson
Delayed viral rebound is achievable
But unknown biomarkers for HIV remission
Henrich
et al.,
J
Infect
Dis
2013,
207(11):1694-702
Henrich
et al.,
Ann Intern Med
. 2014 Jul 22;
Persaud
et al.,
N
Engl
J Med
2013 Nov 7;369(19):1828-35Slide6
Cohen J.
Science
2014 July
Aiming for sustained “remission” off ARTSlide7
Latently
infected T-cells
cART
Homeostatic
proliferationSlide8
Science 2014
The persistent pool of HIV-
1 antiretroviral
therapy can prevent the creation of new latently infected cells, but it does not affect cells in which latency was initially established. Slide9
Residual viral expression
cART
cART
Evidence for residual viral expression in about one third
of
patients on
cART
Buzon
et al.,
Nature Med
2010; 16: 460;
Hatano
et al,
J Infect Dis
2013
Slide10
Anatomical reservoirsSlide11
Archin
et al. 2012
A model using the exposure to
viremia
over time in early infection predicts the frequency of latent infection (“…size of the reservoir…”)Slide12
Ananworanich
et al, 20
th
International AIDS Conference AIDS2014, Melbourne, Australia, 2014
N 20 27 28
100%
74%
14%
Duration of HIV before ART
Very early ART significantly reduces reservoir sizeSlide13
Very early ART reduces reservoirs but…rebound still occurs in SIV
Day of ART initiation post infection
Log HIV DNA in PBMC
Time to viral rebound, days
N=20, SIVmac251 infected macaques treated with
tenofovir
/FTC/
dolutegravir
for 24W
Whitney et al.,
Nature
2014, July 20Slide14
Balance between reservoir and immunity
immunity
latent
virus
Lewin
SR.
Ann
Int
Med
2014 July 22
Boston patients
Mississippi child
VISCONTI patients
(EM>CM)
?Slide15
Activating latent HIV
The Economist, July 17, 2011Slide16
Other Challenges:
Clearance of infected cells
Clearance of
virions
Complete block of new infection
A first step to eliminate latent HIV infection
Anti-latency
therapy
A second step to eliminate latent HIV infection
ImmunotherapySlide17
HIV DNA
HIV US RNA
HIV DNA
HIV proteins
HIV virions
Latent infection
“activate”
Cell death
HDACi
Methylation inh
Cytokines eg., IL7
disulfiram
quinolines
Histone methyl transf inh
BET inh
Activating latent infection: in vitroSlide18
Latently infected cell lines
e.g., J-Lat, ACH2, U1
Constantly dividing
Clonal
Integrate in heterochromatin
Latently infected
primary T-cells
Resting cells
High frequency of latency
Pre and post activation models
Resting CD4+ T-cells
from HIV-infected patients
on ART
Often needs leukapharesis
Frequency of latency low
Mechanistic studies difficult
Highly variable responses
Identifying latency reversing agents (LRA) in vitroSlide19
T-cell activation
PKC
Cytokines
HDACi
other
Spina
et al.,
Plos
Pathogens
2013 Dec;9(12):e1003834
No model ideally represents latently infected ells from patientsSlide20
TF
OFF
HDACi
Histone
deacetylase
inhibitors turn HIV genes “on”Slide21
HIV DNA
HIV US RNA
HIV DNA
HIV proteins
HIV virions
Latent infection
“activate”
Cell death
cART
Latency “activating” agent
cART>3 years
HIV RNA<50 c/ml
CD4>350 cells/ml
Activating latent infection: clinical trialsSlide22
HDACi
Activity
Clinical development
HIV latency
Vorinostat
Pan HDACi
Licensed - CTCL
Single dose
1
Intermittent
2
Continuous
3
Panobinostat
Pan HDACi
Phase III – multiple myeloma
Intermittent dose
4
Romedepsin
Class I HDACi
Licensed - CTCL
Weekly dose
5
EntinostatClass I HDACiPhase III – breast cancerTBD6CTCL – cutaneous T-cell lymphoma1 Archin et al., Nature 2012; 487: 482–85; 2 Archin et al., J Infect Dis 2014; 210: 728–35; 3Elliott J et al., PlosPathogens 2014 (in press); 4Rasmussen et al., Lancet HIV 2014; epub Sept 16; 5Sogaard et al., 20th International AIDS Conference (AIDS2014), Melbourne, 2014; 6Wightman et al., AIDS. 2013 Nov 28;27(18):2853-62 HDACi: activity in cancer and HIVSlide23
Baseline cART
Vorinostat 400 mg
Archin et al.,
Nature
2012; 487: 482
800
600
400
200
60
40
20
0
Pt 1
Pt 2
Pt 3
Pt 4
Pt 5
Pt 6
Relative HIV-1
gag
RNA copies
100
Pt 7
Pt 8
A single dose of
HDACi
vorinostat
activates HIV transcription in vivoSlide24
*
*
cART
Vorinostat 400 mg/day
0
14
84
n=20
Rectal biopsy
*
day
cART
>3 years
HIV RNA<50 c/ml
CD4>500 cells/ml
7
1
3
21
28
Single site, single arm, non-randomised observational study
Elliott et al., Plos Pathogens 2014
Can continuous doses of
vorinostat
“activate” latent infection?Slide25
Fold increase CA-US HIV RNA above baseline
Median fold change max =
7.4 (IQR 3.4, 9.1)
Elliott et al.,
Plos
Pathogens 2014
Vorinostat
induces a significant increase in
unspliced
HIV RNASlide26
But…no change in plasma HIV RNA or HIV DNASlide27
Panobinostat
: a more potent
HDACi
cART
M/W/F
0
28
49
n=16
day
cART
>3 years
HIV RNA<50 c/ml
CD4>350 cells/ml
21
7
14
35
42
M/W/F
M/W/F
M/W/F
Panobinostat
20mg/day, 3 times a week
(Monday, Wednesday, Friday)Slide28
The
HDACi
panobinostat activates latent HIV and produces some virus
days
Fold increase in CA-US RNA
ANOVA p<0.0001
Some increase in virus in plasma in some patients
No change in the reservoir ie no change in HIV DNA
Rasmussen et al., Lancet HIV 2014Slide29
The
HDACi
romidepsin is more potent and activates virus release
Sogaard
et al., 20
th
International AIDS Conference, Melbourne, 2014
No change in HIV DNA following romidepsin x 3
romidepsin
romidepsin
romidepsin
HIV RNA in plasma, copies/ml
Days post first infusionSlide30
What we have found so far:
A
single dose of VOR induces expression of full-length HIV RNA within latently infected resting CD4+ T cells.
The optimal dosing schedule of VOR, and its ability to repeatedly and completely perturb latency in all relevant infected cells, must be establishedSeparately, the potential for VOR to induce antigen expression in (some or all) latently infected cells must be establishedSlide31
Will
HDACi
be enough?
Not all studies show induction of viral expression by HDACi
ex vivoCombinations of anti-latency compounds with different mechanism of action may be more effective
Latently infected cells that express HIV-1 RNA may not all dieSlide32
Latently infected cells are rareSlide33
HIV DNA, RNA, antigen & viruses
HIV Antigen
(protein)
detector
The “Real”
Reservoir
HIV DNA
QVOA
growing virusSlide34
Where can HIV eradication approaches be tested?
“
HUMANIZED
”
MICESlide35
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”
IMPROVE
HIV-1 SPECIFIC CD8 RESPONSE THROUGH
EX VIVO MANIPULATION
EXPANSION orTCR ENHANCEMENTWake up “exhausted” HIV-1 specific cellseg
. Checkpoint inhibitors
Dual function Ab to recruit immune effectors without the need for
HIV-specific cells
INFUSE BROADLY NEUTRALIZING ANTIBODY OR ANTIBODY PRIMED FOR ADCCSlide36
Blocking PD1-PDL1 to boost immune function
Mason et al.,
CROI
2014Slide37
Anti-PDL1 led to successful virus control following ART in half the monkeys
isotype n=5; anti-PDL1 n=9
responders n=4, non-responders n=5
ACTG: single infusion of anti PDL-1 (BMS) to start in 2014Slide38
Current clinical trials to eliminate latently infected cells
Agent
Design
PI (location)
Status
HDACi
Vorinostat
+ vaccine
10 days (acute treated HIV)
Frater (UK)
Approved
Rhomedepsin
Single dose
ACTG (US)
Approved
Rhomedepsin
+ vaccine
Single dose
Ostergaard
(Denmark)
Rhomedepsin
alone (complete)
Other
Disulfiram14 days 500mg/dayDeeks (US)Transient increase in plasma RNA (Spivak CID 2014)Disulfiram3 days500mg-2g/dayDeeks (US)Elliot/Lewin (Australia)Enrolment completeAnti-PDL1 (BMS)Single doseEron (US/ACTG)EnrollingSlide39
Managing the hope and hype
Danish breakthrough for HIV cure expected 'within months'
April
29
th
,
2013Slide40
Expectations of study participants
20 participants with \ HIV infection in
vorinostat
(
HDACi
) trial
Top priority in cure research (%)
McMahon et al., AIDS 2014 (in press)Slide41
Conclusions
We are assembling the tools to design, discover, and test anti-latency therapy
Rational design based on biological understanding of latency
Screen-based discovery
Harnessing the immune response, or other cellular pathways, or new technology to assist in the clearance of persistently infected cells is the next step
Developing platforms and novel assays to allow these developments to be efficiently validated, and safely tested in the
clinicSlide42
AcknowledgementsSlide43
Module Collaborators