Session Code: MOAA01, Abstract #MOAA0103 Session Title: Hide and Seek: Biology of Reservoirs Session Date: Monday, 24 July 2017 A subset of extreme HIV controllers is characterized by a small HIV blood reservoir and a weak T cell activation level Etienne Canoui, Camille Lécuroux, Véronique Avettand-Fenoël, Marine Gousset, Christine Rouzioux, Asier Saez-Cirion, Laurence Meyer, Faroudy Boufassa, Olivier Lambotte, Nicolas Noël* APHP - Service de Médecine Interne et Immunologie Clinique; Le Kremlin Bicêtre - FRANCE INSERM U1184 – Immunologie des maladies virales et autoimmunes; Le Kremlin Bicêtre - FRANCE APHP - Service de Virologie – Necker; Paris - FRANCE Institut Pasteur – Unité HIV, Inflammation et Persistance; Paris - FRANCE INSERM U1018 – CESP; Le Kremlin-Bicêtre - FRANCE Université Paris Sud; Le Kremlin-Bicêtre - FRANCE

No conflicts if interest to declare

« HIV controller » patients General background: « HIV controller » patients Rare patients with spontaneous control of the viral replication In France: ANRS CO21 « CODEX » cohort Current definition: Diagnosis/Follow up > 5 years, 5 last consecutive HIV VL < 400 copies/mL Global characteristics showed by previous studies Replication-competent viruses Involvement of the genetic background? (HLA B57/58, HLA B27) Preserved and effective immune response (CD8, CD4, ADCC) Low level of HIV reservoir/cellular HIV DNA …but… Low grade systemic inflammation (IFN pathway, IP10 levels) in some HICs Risk of progression (CD4 T cell decline/loss of viral control) Lambotte O et al, Clin Infect Dis 2005;41(7):1053–6 Lamine A et al, AIDS 2007;21(8):1043–5 Saez-Cirion A et al, PNAS 2007;104(16):6776–81 Lécuroux C et al, J Virol 2014;88(1):176–87 Noel N et al, AIDS 2014;28(4):467–76 Noel N et al, J Virol 2016;90(13):6148-58 Avettand-Fenoël V et al, Clin Microbiol Rev 2016;29(4):859–80.

Problems: heterogeneity of definitions Place for cART therapy? « HIV controllers »/ « Elite controllers »: > 10 definitions in the literature… Heterogeneity of the evolution profile according to the VL threshold considered History of viral blips/elevated HIV DNA: risk to lose the definition, immune activation Should HICs receive anti-viral therapy? Variability in the response to cART… Olson AD et al, PLoS One 2014;9(1):e86719. Noel N, Lerolle N et al, PLoS One 2015; 10(7): e0131922. Boufassa F et al, PLoS One 2014;9(1): e85516.

First consecutive 230 patients Patients & Methods ANRS CO21 CODEX cohort First consecutive 230 patients (enrolled from 2009-2013) All routinely determined HIV RNA VL undetectable (below threshold) N=52 uHICs At least ONE detectable HIV RNA VL (except for PHI) N=178 bHICs Analyses -Demographic characteristics, HLA typing, CD4 T cell count/nadir -Ultrasensitive HIV RNA VL (threshold: 1-13 cp/mL) -Total cell-associated HIV DNA VL (threshold 10 cp/millions PBMC) -Immune activation (cyto/chemokines, HLA DR/CD38 cellular expression) -CD8 Tc in vitro suppression of HIV infection (weak/strong responders) -Anti-HIV IgG levels (Western Blot)

Table 1. Characteristics of the study population at enrollment in the CODEX cohort.   uHICs (n=52) bHICs (n=178) p Male, n (%)  18 (35) 88 (49) 0.06 Age at HIV diagnosis (years) 29 [25-35] 31 [26-37] 0.29 Year of HIV diagnosis 1996 [1989-2002] 1998 [1990-2004] 0.21 Age at enrolment in the CODEX cohort (years) 45 [40-52] 46 [39-51] 0.83 Year of enrolment 2010 [2009-2011] 2010 [2009-2012] 0.37 Duration of follow-up (years) since HIV diagnosis 18 [12-24] 16 [10-24] 0.15 Protective HLA alleles HLA-B57, n (%) HLA-B27/57/58, n (%) 25/50 (50) 35/50 (70) 58/175 (33) 90/165 (55) 0.03 0.05 HCV co-infection, n (%) 19 (31.7) 34 (21.0) 0.10 HBV co-infection, n (%) 1 (0.6) 1 CD4+ T cell count (cells /µL) at enrolment 790 [638-1038] 711 [520-920] 0.04 Ultrasensitive HIV-RNA (copies/mL), n=168 <4 [<2-<4] 21 [7-84] <0.0001 % undetectable ultrasensitive HIV-RNA VL, n=168 33/41 (80) 30/127 (24) HIV-DNA (copies per 106 PBMCs), n=136 <10 [<10-11] 21 [<10-52] 0.0004 % undetectable HIV-DNA 18/30 (60) 28/106 (26) 0.0006 Weak responders (%) 31/44 (70) 105/156 (67) 0.69 WR + protective HLA alleles (%) 23/44 (52) 51/156 (33) 0.02 Data are presented as median [IQR] or n (%), respectively. uHICs= “VL undetectable” HICs; bHICs= “with blips” HICs; HCV= Hepatitis C virus; Hepatitis B virus; HBV and HCV status were determined by hepatitis B surface antigen and anti-hepatitis C antibody; WR= Weak responder; VL= viral load

Immunologic characteristics of uHICs Linear mixed-model effect (back-model: inclusion in the cohort – first available measurement) The slope in the uHICs group did not differ significantly from zero The percentage of CD4 T cells remained above 40% all throughout the history of uHICs (and < 40% in bHICs)

Dynamics of total HIV DNA over > 6 years in HICs (CODEX cohort) Mixed-effect linear model of 840 total HIV-DNA loads from 202 patients HIV controllers with HIV-RNA always ≥ 1 log cp/mL Other HIV controllers HIV-DNA of patients who always had HIV-RNA ≥1 log cp/mL during follow-up significantly increased over time (slope: +0.06 log/year, p<0.0001) and differs significantly of HIV-DNA slope of other patients that trends to decrease over time (slope: -0.024 log/year, p=0.07) (p<0.0001) Avettand-Fenoel et al. Poster TUPEA0148

Immune activation in uHICs vs. bHICs D. HLADR+CD38+CD8 HLADR+CD38+CD4 At enrollment & during FU: lower CD8 T cell activation in uHICs Correlation between CD4 and CD8 activation and ultrasensitive HIV RNA (not HIV DNA)

Immune activation: comparison with HD and ART-controlled patients Higher immune activation in uHICs and bHICs than in HD Higher IP10 levels in u/bHICs and cART than HD Similar levels of sCD14 and IL6 in uHICs than HD Higher IL6 levels in cART than in uHICs or bHICs

Anti-HIV IgG (semi-quantitative WB for 47 uHICs)   Intact positivity Weak positivity Smear Absent band Anti-HIV IgG (semi-quantitative WB for 47 uHICs) 10/47 uHICs (21%) lacked ≥ 1 IgG These uHICs had very low HIV-DNA levels (median: <10 cp/106 PBMCs [IQR, <9–10]) 83% of these uHICs had both undetectable HIV-DNA and us HIV-RNA, vs. 40% among uHICs with “complete” WB A

Discussion Extensive analysis of HICs with the most stringent viral control phenotype over > 16 years uHICs: 80% had undetectable usRNA and 60% undetectable HIV DNA Stable CD4 T cell slope, low levels of immune activation Low anti-HIV1 specific IgG levels: reflecting reservoir levels/antigenic stimulation? Low level of blood HIV reservoirs are associated with a persistent control of the infection Mechanisms? Innate mechanisms (reduced susceptibility to infection) Role of protective HLA alleles: optimal peptide presentation via « protective » HLA to CD8 T cells Little antigenic stimulation: preservation of the HIV-specific CD8 ability to activate rapidly Questions raised Are uHICs exposed to the same consequences of chronic inflammation than patients on cART? Do we need to introduce cART in such patients? Burbelo PD et al, J Infect Dis 2014;209(10):1613–7 Saez-Cirion A et al, Blood 2011;118(4):955–64 Canoui et al, JAIDS 2016. [Epub ahead of print] Noel N et al, J Virol 2016;90(13):6148-58 Avettand-Fenoël V et al, Clin Microbiol Rev 2016;29(4):859–80 Bansal A et al, AIDS 2015;29(17):2245–54

Conclusion Interesting phenotype of durable control in HICs (≈ 15% in the CODEX cohort) combining: protective HLA alleles sustained undetectable plasma ultrasensitive HIV-RNA loads low HIV-DNA levels reduced immune activation and preserved CD4 T cells HICs with persistently undetectable ultrasensitive HIV-RNA tend to decrease their HIV-DNA slope over time Benefit of cART in HICs? : take into account the identification of uHICs and bHICs Peut etre indiquer ici les % de uHIC répondant à ton premier bullet

Acknowledgements The patients ! Institut Pasteur A.Saez-Cirion G.Pancino M.Müller-Trutwin CHU Bicêtre C.Goujard N.Lerolle K.Bourdic INSERM U1184 O.Lambotte E.Canoui C.Lécuroux C.Bourgeois R.Legrand S.Gérard M.Bitu S.Hua A.Damouche The patients ! INSERM U1018 L.Meyer F.Boufassa A.Tadesse S.Hendou L.Tran ANRS CO21 B.Autran J-F Delfraissy ANRS CO21 Study Group CHU Necker V.Avettand-Fenoël C.Rouzioux M.Gousset

A B Slide pas simple à expliquer, peut etre ne garder que la partie A   Intact positivity Weak positivity Smear Absent band uHICs with weak IgG responses Slide pas simple à expliquer, peut etre ne garder que la partie A A B uHICs with full IgG responses