Timothy J. Henrich, MD Assistant Professor of Medicine Division of Experimental Medicine University of California San Francisco San Francisco, California The Beginning of the End? Update on Curative Strategies for HIV New York: New York: March 23, 2016From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA.

Slide 2 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Learning Objectives After attending this presentation, participants will be able to: Describe various approaches to HIV eradication List several HIV curative strategies currently in human studies Describe the challenges facing an HIV cure

Slide 3 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Antiretroviral Therapy and HIV Persistence Davey et al. PNAS 1999 HIV rebounds rapidly after stopping ART

Slide 4 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. HIV-1 Latency During ART < 1 in 1,000,000 latently infected resting CD4+ T cells can harbor replication competent HIV on ART Ruelas & Greene, Cell 2013

Slide 5 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Definition of HIV Cure Sterilizing Cure: - eradication of all infected cells from the body - no replication competent HIV in cells, plasma, tissues - immune system recovery Functional Cure: - detectable HIV in body - no progression of disease or CD4+ T cell decline off ART - not transmissible to others (e.g. viral load < 2,000 c/ml) ART-Free Remission: terminology adapted from oncology

Slide 6 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Viral Reservoir Ablation/Elimination: stem cell transplantation, cytoreductive therapy Early ART Initiation - aborting reservoir establishment Gene Therapies - CCR5 modification or modifying antiviral genes Shock and Kill – stimulating cells to produce virus, TLR agonism Immune Modifying Therapies – vaccines, monoclonal Ab, TLR agonism, immune checkpoint blockade Lockdown - keeping latent virus latent HIV “Cure” Strategies

Slide 7 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. HIV “Cure” Hutter et al. NEJM 2009

Slide 8 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. CCR5 ∆32/∆32 Donor Allogeneic Stem Cell Transplant Donor Stem Cell Infusion Images adapted from and Recipient (Host) Cells CCR5 Conditioning Chemo ± Irradiation

Slide 9 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Viral Reservoir Ablation/Elimination: stem cell transplantation, cytoreductive therapy Early ART Initiation - aborting reservoir establishment Gene Therapies - CCR5 modification or modifying antiviral genes Shock and Kill – stimulating cells to produce virus Immune Modifying Therapies – vaccines, monoclonal Ab… Lockdown - keeping latent virus latent Elimination of Infected Cells

Slide 10 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Other CCR5 ∆32/∆32 Stem Cell Transplants Hutter NEJM 2014

Slide 11 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. CCR5 Wild-Type Allogeneic Stem Cell Transplantation Henrich et al. Ann Int Med 2014

Slide 12 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. The Participant Perspective “It was emotionally beyond comprehension. To envision myself after 30 years of being HIV positive suddenly being HIV negative was both exhilarating and also so scary. HIV had become a part of me. It was who I was. My identity, my personality, my drive and the decisions I made in my life.“ “The emotional layering that happened during the early stages of the HIV struggle—the challenge of shame, ostracization and separation— all of that was coming back up.” How did it feel to believe that you were HIV negative? Gary Steinkohl

Slide 13 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. CCR5 Wild-Type Allogeneic Stem Cell Transplantation Henrich et al, Ann Int Med 2014

Slide 14 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. CCR5 Wild-Type Allogeneic Stem Cell Transplantation Henrich et al, Ann Int Med 2014

Slide 15 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. The Participant Perspective “It was emotionally devastating. I went back on HIV meds immediately… I was sad for the community, and myself, but the follow-ups with the study team were wonderful. They told me that I had helped change medical knowledge and that they had discovered so much new information with my case. I felt warm about that, but it didn’t take away from my personal sadness.” What was the aftermath of the study like for you? Gary Steinkohl

Slide 16 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. CCR5 Wild-Type Allogeneic Stem Cell Transplantation Hill et al VariablePatient APatient B Reservoir size (# infected cells) cells cells Time to rebound (weeks) Probability of “Cure” 0-3%0-65%

Slide 17 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Viral Reservoir Ablation/Elimination: stem cell transplantation, cytoreductive therapy Early ART Initiation - aborting reservoir establishment Gene Therapies - CCR5 modification or modifying antiviral genes Shock and Kill – stimulating cells to produce virus Immune Modifying Therapies – vaccines, monoclonal Ab… Lockdown - keeping latent virus latent Early ART Initiation

Slide 18 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Viral Reservoirs Are Established Early Early ART Initiation Whitney et al. Nature 2014 Non-human primate SIV model

Slide 19 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Viral Reservoirs Are Established Early Whitney et al. Nature 2014

Slide 20 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Post Early Treatment Control Sáez-Cirión et al. Plos Path 2013 ART

Slide 21 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Post Early Treatment Control Sáez-Cirión et al. Plos Path 2013 Immune phenotype different than viremic/elite controllers HLA alleles associated with rapid HIV progression Relatively weak T cell activation and HIV-specific responses

Slide 22 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Early Infant ART Initiation Persaud et al, NEJM 2013 Rapid viral decay after ART Initiation Sustained viral remission following ART cessation

Slide 23 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Early Infant ART Initiation "Mississippi Baby" Now Has Detectable HIV, Researchers Find The child known as the “Mississippi baby”—an infant seemingly cured of HIV that was reported as a case study of a prolonged remission of HIV infection in The New England Journal of Medicine last fall—now has detectable levels of HIV after more than two years of not taking antiretroviral therapy without evidence of virus, according to the pediatric HIV specialist and researchers involved in the case. FOR IMMEDIATE RELEASE Thursday, July 10, 2014

Slide 24 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Early Infant ART Initiation Viral load 152,560 RNA copies/mL at birth Started AZT/NVP 12 hours after birth At 3 years of age, all HIV testing negative Virus rebounded to >30,000 c/mL 2 weeks after ART stopped

Slide 25 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Early Infant ART Initiation and Post Treatment Control Frange et al. Lancet HIV 2016 HIV subtype H

Slide 26 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Viral Reservoir Ablation/Elimination: stem cell transplantation, cytoreductive therapy Early ART Initiation - aborting reservoir establishment Gene Therapies - CCR5 modification or modifying antiviral genes Shock and Kill – stimulating cells to produce virus Immune Modifying Therapies – vaccines, monoclonal Ab… Lockdown - keeping latent virus latent Gene Editing Strategies

Slide 27 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. CCR5 Gene Editing Zinc-Finger CCR5 modified CD4+ T cells persist after infusion, but are the minority population HIV recrudesces following ART interruption Tebas et al. NEJM 2014

Slide 28 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Further 18 ART treated subjects with CD4 counts above 500 were conditioned with cyclophosphamide prior to CCR5 zing-finger modified cell infusion 6 participants experienced viral control following ART cessation Control associated with greater engraftment, better CD8 T cell function and smaller HIV reservoir CCR5 Gene Editing Strategies with Pre-Conditioning Zeidan et al. CROI 2016

Slide 29 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Upcoming Gene Editing Strategies CRISP-Cas9 - specific gene editing - can be used to modify human genes or integrated HIV genomes directly Hua et al. PNAS 2015; Liao et al. Cell Cycle 2015

Slide 30 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Viral Reservoir Ablation/Elimination: stem cell transplantation, cytoreductive therapy Early ART Initiation - aborting reservoir establishment Gene Therapies - CCR5 modification or modifying antiviral genes Shock and Kill – stimulating cells to produce virus Immune Modifying Therapies – vaccines, monoclonal Ab… Lockdown - keeping latent virus latent Latency Reversing Agents

Slide 31 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. “Shock and Kill” – Latency Reversing Agents Histone Deacetylase (HDAC) Inhibitors Ken Kragsfeldt, Aarhus University Hospital

Slide 32 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. HDAC Inhibitors Romidepsin: 6 adults on ART received drug 1 x week for 3 weeks (Søgaard et al. Plos Path 2015) Dose-related reactivation of HIV RNA in plasma and no decrease in HIV-specific T cell numbers

Slide 33 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Romidepsin plus Therapeutic Vaccine 20 individuals on ART received 6 Vacc-4x immunizations prior to receiving romidepsin once weekly for 3 weeks ATI performed following vaccine and RMD administration Increased HIV-1 RNA in plasma in 8 participants 40% (0.22 Log 10 ) decrease in HIV-1 DNA prior to ATI 40% reduction in IUPMs by quantitative outgrowth assay Median time to viral relapse after ART cessation: 14 days (Leth et al. CROI 2016) Minimal HIV-specific response to vaccine

Slide 34 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. HDAC Inhibitors Vorinostat: 8 participants received single dose - observed increased CD4+ T cell HIV RNA levels (Archin et al. Nature 2012) Disulfiram: 30 participants received daily x 3 days - increased ca-usRNA, increased plasma RNA (Elliott et al. Lancet HIV 2015) Panobinostat: 15 participant study received drug for 8 weeks - increased levels of cell-associated HIV-1 RNA - increased levels of plasma viremia - no overall change in HIV-1 DNA - no overall change in replication competent virus (IUPMs) (Rasmussen et al. Lancet HIV 2014)

Slide 35 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Other Latency Reversing Agents and Synergy Laird et al. JCI 2015 Protein Kinase C (PKC) activators (HIV LTR activation through NF-κB and AP-1 signaling) - prostatin - bryostatin - ingenol-B Bryostatin used in phase I study, but serum concentration inadequate and no observed increase in PKC activity or changes in HIV reactivation Gutiérrez et al. AIDS 2016; Darcis et al. Plos Path 2015; Abreu et al. Plos One 2014

Slide 36 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Viral Reservoir Ablation/Elimination: stem cell transplantation, cytoreductive therapy Early ART Initiation - aborting reservoir establishment Gene Therapies - CCR5 modification or modifying antiviral genes Shock and Kill – stimulating cells to produce virus Immune Modifying Therapies – vaccines, monoclonal Ab, TLR agonists, immune checkpoint blockage and more Lockdown - keeping latent virus latent Immune Modifying Therapies

Slide 37 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Toll-Like Receptor (TLR) Agonists Chao AJP/HCP 2009 TLR7 recognizes viral ssRNA in endosomes (pDCs, B cells)

Slide 38 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Immune Checkpoint Blockade Eron et al. CROI 2016 PD-1 Antagonists (e.g. nivolumab, pembrolizumab) - PD-1 expression is a marker for CD8 + T cell exhaustion - T cell exhaustion reversible with PD-1 blockade (Velu et al. Nature 2009) Anti-PD-L1 - ACTG 5326 study of 8 individuals on ART received single low-dose anti PD- L1 mAb (BMS ) - HIV-1 gag-specific CD8+ T cell numbers and function increased after treatment - No overall changes in low-level residual viremia or cell-associated HIV RNA - Pituitary insufficiency noted in 1 patient

Slide 39 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Broadly Neutralizing Antibodies A5340: 14 individuals on ART received VRC01 3 doses given 1 week prior to ATI (last dose) Some delay in rebound compared with historical ACTG controls Bar et al. CROI 2016

Slide 40 of 40 From TJ Henrich, MD, at New York, NY: March 23, 2016, IAS-USA. Other Immune Approaches to HIV Eradication mTOR inhibition (e.g. sirolimus/rapamycin) – multipronged approach to boost HIV-specific immunity, reducing detrimental inflammation, decreasing CCR5 and PD1 expression JAK/STAT inhibitors –reduce detrimental inflammation