UK CAB HIV Cure meeting 3rd August 2018

Introductions & Welcome Presentation of results Discussion Agenda Introductions & Welcome Presentation of results Discussion Mention confidentiality

Barriers to HIV cure: viral reservoirs HIV infects CD4+ cells Dormant memory T cells in lymph nodes and blood CD4 T cells & macrophages and in various tissues (especially in lymph nodes, gut and central nervous system)2 Major reservoirs Some become resting memory cells; ‘reservoir’ Latently infected cell Productively infected cell Larger reservoir size accelerates clinical progression1 & predicts time to viral rebound2 Most CD4+ T cells infected with HIV die due to the effects of the virus; however, a small sub-set of so-called ‘resting’ memory T cells that harbour the virus persist indefinitely – this is known as latent infection1 Latent HIV infection may also occur in cell populations other than memory CD4+ T cells, including naive CD4+ T cells, tissue macrophages, astrocytes, thymocytes and perhaps haematopoietic progenitor cells2-6 In essence, latency can be defined as ‘the maintenance in the host genome of integrated viral DNA that is replication-competent but transcriptionally silent’1  Circulating CD4+ T cells comprise less than 2% of total-body CD4+ T-cell numbers with the majority present in tissues The inability of the immune system to recognise cells harbouring latent virus and to eliminate cells actively producing virus is the biggest challenge to cure treatments The HIV reservoir is established during primary infection. Early treatment can reduce the total size of the reservoir; however, a stable population of latently infected CD4 cells transits into the long-lived latent reservoir, and is unaffected by early combination ART (cART)1. Cellular reservoirs7: In addition to the CD4+ T cells reservoir in the lymph nodes, there are different cellular reservoirs for different anatomical reservoirs eg. microglia in the CNS. Anatomical reservoirs7,8 GALT is one of the major anatomical reservoirs The lymph nodes, CNS and the blood are also important anatomical reservoirs of latent virus References Deeks SG, et al. Nat Rev Immunol 2012;12(8):607–14. Stebbing J, et al. N Engl J Med 2004;350(18):1872–80. Wightman F, et al. J Infect Dis 2010;202:1738–48. Kitchen SG, Zack JA. J Virol 1997;71:6928–34. Carter CC, et al. Nature Med 2010;16:446–51. Churchill MJ, et al. Ann Neurol 2009;66(2):253–58. Alexaki A, et al. Curr HIV Res 2008;6(5):388–400. Yukl SA, et al. J Infect Dis 2010;202(10):1553–61

How do we measure the HIV reservoir Productive infection Latent infection HIV DNA 2-LTR circles Integrated DNA Infectious Units (IUPM) Cell associated RNA US RNA and MS RNA Viral outgrowth assays HIV RNA (SCA)

Total HIV DNA predicts time to viral rebound after Treatment interruption; The SPARTAC study Williams et al eLife

HIV Cure approach “Kick and Kill” Latency reversal Immune system ART ‘Shock’ ‘Kill’ HIV genome HIV proteins Dying infected cell 1. Deeks SG. Nature 2012;487:439–40. 2. Walker-Sperling VE, et al. J Virol 2015;89:9631–8.

The research question: Did immediate ART started in acute HIV infection with a vaccine and Vorinostat reduce HIV reservoir more than ART alone? The answer….

RIVER study design Treated Primary HIV infection: lowest reservoirs, preserved immune responses The Kick: HDAC inhibitor Vorinostat The Kill: ChAdV63.HIVconsv and MVA.HIVconsv* Design: Randomised control comparison with ART alone Primary endpoint: Total HIV DNA in peripheral blood CD4+ T-cells at weeks 16 & 18 post randomisation *Letourneau S Plos One 2007

Immediate standard ART (irrespective of CD4) + integrase inhibitor Study design Individual with defined PHI Primary outcome: total proviral DNA in CD4+ T cells Secondary outcomes Undetectable viral load Randomisation ART only ART + V + V Vaccines HDACi Immediate standard ART (irrespective of CD4) + integrase inhibitor Approx. 24 weeks 18 weeks

Outcome measures Primary outcome Total HIV DNA in CD4+ T-cells averaged across post-randomisation weeks 16 and 18. Comparison of two groups on a log10-scale by analysis of covariance with adjustment for values at randomisation. Secondary outcomes Clinical and laboratory adverse events all grades including SAE; HIV integrated DNA; HIV cell associated RNA; HIV viral load <1 copy/mL; Viral outgrowth HDAC inhibition P24 ultra-sensitive assay T-cell responses ICS Ex vivo viral inhibition assays Substudy HIV reservoir in GALT

Method of PHI diagnosis Can you change the title of study arms throughout to ART only and ART + V + V Note: PHE RITA test algorithm reported as “Incident” confirming the HIV-1 antibody avidity is consistent with recent infection (within the preceding 16 wks)

Description of participants at randomisation ART only N = 30 ART + V + V Total n = 60 Age (years) 31 (30,38) 35 (28,44) 32 (29,40) Gender 30 (100%) male 60 (100%) male Route of transmission MSM MSW Other 26 (87%) 1 (3%) 3 (10%) 29 (97%) 1 (3%) 55 (92%) 2 (3%) 3 (5%) CD4 count (cells/mm3) 694 (561, 844) 710 (579, 759) 708 (568, 788) HIV Viral Load (copies/mL) <50 50 - <200 29(97%) 30 (100%) 59 (98%) 1 (2%) Weeks since PHI diagnosis to randomisation 28 (27,41) 28 (27,34) 28 (27,36) Note: Numbers are N (%) or median (IQR)

Exceptional commitment to the trial design Did people stay in the study and did we get all the blood tests we needed to find the answer? Exceptional commitment to the trial design

Attendance of scheduled trial visits

Clinical adverse events ART only ART + V + V N=30 Any AE post-randomisation no 8 (27%) 1 (3%) p = 0.026 yes 22 (73%) 29 (97%) Maximum grade mild 10 (33%) 21 (70%) p = 0.023 moderate 6 (20%) 7 (23%) severe Median N of AEs post-randomisation 1 (0,2) 3 (2,5) p < 0.001 Grade 3 events: - Infections And Infestations: Acute Hepatitis A (n=1), Influenza (n=1), Proctitis Herpes (n=1), Shingles (n=1) - Injury, Poisoning And Procedural Complications: Wrist Injury (n=1) - Musculoskeletal And Connective Tissue Disorders: Back Pain (n=2; 1 Arm A, 1 Arm B)

Primary outcome Difference by arm in total HIV DNA/ million CD4+ T-cells at weeks 16 & 18 post-randomisation

We saw a large drop in HIV reservoir (Total HIV DNA) over time 3.84 3.14 3.03 3.06 3.04 log10, mean Individual results plus median (for both arms combined)

BUT; the change seen in HIV reservoir (Total HIV DNA) over time, was the same by study group Primary endpoint: Difference (ART+V+V minus ART only) in mean log10 HIV DNA copies/million CD4+T cells averaged across PR weeks 16 and 18: 0.04 (95% CI: -0.03 to 0.11); p=0.26 ART only ART +V+V

Other measures of the HIV reservoir Viral outgrowth assay

Viral outgrowth assay ART only ART +V+V

Association of replication competence with Total HIV DNA

What do the main results mean? We saw no significant difference in measures of the HIV reservoir (total HIV DNA or viral outgrowth) between the 2 study groups. The answer to the trial design was Vaccine and Vorinostat in addition to early ART did NOT affect measures of the HIV reservoir any differently than ART alone. In both study groups we saw a rapid and significant drop in measures of HIV reservoir over time.

Did the vaccine work?

Did everyone randomised to the vaccination group attend for the vaccinations? YES!

ART + V + V boosts functional HIV-specific CD4+ T cells CD154+ IFN-g+ cells (% CD4+ T cells) Change the name of the study arms p-values: rank tests for difference between groups per time-point ART only ART +V+V

ART + V + V boosts functional HIV-specific CD8+ T cells CD107+ IFN-g+ cells (% CD8+ T cells) Change the name of the study arms p-values: rank tests for difference between groups per time-point ART only ART +V+V

ART + V + V preserves CD8+ T cell killing capacity Overall difference in mean change between the arms: p = 0.038 Change the name of the study arms

The Vaccine was safe and worked to stimulate T-cell responses to HIV proteins Study participants who received the vaccine had stronger CD4 and CD8 T-cell responses to HIV compared to non-vaccinated people. CD8 T-cells from vaccinated participants remained able to kill HIV infected cells in a test-tube, whilst the T-cells from people who did have have the vaccine lost this ability over time. The vaccine seems to preserve immune responses to HIV that are usually lost with ART alone.

Did it cause the virus to “wake up”? Did vorinostat work? Did it cause the virus to “wake up”?

Vorinostat forced expression of genes HDAC inhibition: N = 22 participants from ART + V + V arm Acetylation 2 hours post vorinostat had increased by a factor of 3.2 (95%CI 2.4-4.2; p<0.001) compared to pre vorinostat, with no difference between visits.

Was Vorinostat safe and did people take it? YES #1 Ineligibility to start vorinostat: ALT >5xULN due to hepatitis #2 Early stop of vorinostat: after 5 doses due to nausea & vomiting #3 Missed three vorinostat doses (doses 4,5,6) out of confusion over schedule; no evidence of an AE

Vorinostat-related events (Arm B) Notes: Events reported as possibly, probably or definitely related. Only patients included who started vorinostat

HIV-RNA One patient in Arm A with one single detectable HIV-RNA (304 cop/mL), followed by <20 cop/mL one week later.

Summary The commitment of the RIVER trial participants is exceptional, nobody dropped out of the study and almost every study drug dose was taken and blood sample and test was available; this is unheard of! The Vaccine and Vorinostat with early ART did not reduce measures of HIV reservoir any more than ART alone. This is a clear or definitive answer, not previously shown. The Vaccine and Vorinostat did work as we expected and were both safe and well tolerated.

Why didn't it work? We tested the wrong measures of HIV reservoir. We tested the impact too soon. The approach using the drugs and vaccine we chose for this study were not powerful enough to make a big enough impact on the reservoir. Including an ART alone group has dramatically helped the field of research. Without this comparison we would not know how good ART on its own can be and would not have been able to tell if the big changes we see in reducing the size of the reservoir were due to ART alone or the kick and kill approach.

What does it mean? We have no evidence at the moment that we would recommend anyone interrupting ART We do not have any strong evidence to recommend participants in the ART only group should now have vaccine and vorinostat. We recommend you continue with ART for the time-being: it has made a dramatic difference to the measures of the viral reservoir. We would love to keep seeing you for the next 5 years if you are interested and can spare the time (and blood) to see if we have measured things too soon and also to check for safety of the interventions. And also to try other lab tests that might better measure the virus levels over time.

Does this mean the kick and kill approach doesn't work? No it just shows that for the particular vaccine and Vorinostat combination we chose in this study to measure the viral reservoir using the lab test we chose in this study they didn't make a big difference over ART alone. Other trials testing other vaccines and other virus activating drugs are ongoing. There is no doubt the vaccination has stimulated the immune responses to HIV, but maybe the Vorinostat didn't lead to enough virus proteins being “woken up” to be killed by the T-cells.

How does what we found fit with other similar research studies? BCN02: interrupted ART, they had ONLY a vaccine Romidepsin arm (no ART alone) and showed 5/13 people controlled virus off ART for up to 6 months (unusual most people virus returns after 30 days). Two other studies are now recruiting; eCLEAR (Vaccination and Romidepsin) and VORVAX (Vorinostat with a different vaccine). They have not yet finished.

What next? We will share the research findings you have just seen next week at the world AIDS conference in Amsterdam. We hope you will stay on ART at the moment, and if you would like, that you will kindly agree to help us understand what we have found by keeping in the follow-up study until 2021. In the future: We may wish to explore additional new interventions or look at interrupting ART in certain people who seem to have very low measures of viral reservoir.

IS PHI the best time to move towards an HIV cure? All the RIVER study participants RIVER Chief Investigator: Sarah Fidler RIVER co-investigator and laboratory lead: John Frater RIVER statisticians: Abdel Babiker, Wolfgang Stöhr RIVER laboratory investigators: Lucy Dorrell, Tom Hanke, Andrew Lever, Myra McClure, Steve Kaye, Matt Pace, Axel Fun, Mikaila Bandara, Maryam Khan, Andrew Lovell, HongBing Yang, Jakub Kopycinski, Natalia Olejniczak, Helen Brown, Nicola Robinson, Otto Erlwein, Alison Crook RIVER trial management team: Sarah Pett, Rachel Bennett, Michelle Gabriel, Fleur Hudson, Aminata Sy, Adam Gregory, Hanna Box, Cherry Kingsley, Katie Topping RIVER clinical investigators: Sarah Fidler, Sabine Kinloch, Sarah Pett, Julie Fox, Amanda Clarke, Mark Nelson, Margaret Johnson RIVER Trial Steering Committee (TSC): Independent Members: Eric Sandström , Janet Darbyshire, Frank Post, Chris Conlon, Jane Anderson, Mala Maini RIVER Independent Data and Monitoring Committee (IDMC): Tim Peto, Peter Sasieni, Veronica Miller, Ian Weller Community of people living with HIV: Simon Collins, Damian Kelly CHERUB collaboration Funders: MRC (MRL00528X1), NIHR Imperial BRC, NIHR Oxford BRC, NIHR Cambridge BRC Industry partners: MSD, GSK IS PHI the best time to move towards an HIV cure?

ART + V + V boosts functional HIV-specific CD8+ T cells CD107+ IFN-g+ cells (% CD8+ T cells) Change the name of the study arms p-values: rank tests for difference between groups per time-point ART only ART +V+V

ART + V + V boosts functional HIV-specific CD4+ T cells CD154+ IFN-g+ cells (% CD4+ T cells) Change the name of the study arms p-values: rank tests for difference between groups per time-point ART only ART +V+V