2011 Bio-K+ ® to improve health of HIV patients on HAART A safe and effective solution 6 TH IAS CONFERENCE ON HIV PATHOGENESIS, TREATMENT AND PREVENTION NAPWA Treatment Horizons Satellite Symposium J ULY, ; R OME, I TALY M ATHIEU M ILLETTE, P H.D. D IRECTOR OF FUNDAMENTAL RESEARCH, B IO -K P LUS I NTERNATIONAL INC I NVITED PROFESSOR, INRS-I NSTITUT A RMAND -F RAPPIER 1

Bacterial diarrhea in HIV-infected patients 2 Sanchez et al Bacterial diarrhea in persons with HIV infection, United States, Clin. Infect. Dis. 41: Number of patients in cohort44,778 Duration of follow up (mean)2.6 years Diarrheal disease11,320 Bacterial pathogen1320 (10%) Etiologic agent Clostridium difficile598 (54%) Shigella156 (14%) Campylobacter jejuni154 (14%) Salmonella82 (7%) Staphylococcus aureus43 (4%) Mycobacterium avium complex22 (2%)

HIV enteropathy 3  50% HIV-infected patients develop GI symptoms and almost 100% present GI complications  Diarrhea   Intestinal permeability  Malabsorption  Villous atrophy  Abdominal pain  Weight loss  Dysphagia  Odynophagia Opportunistic GI infections by:  Protozoans (Cryptosporidium, Giardia, Isospora...)  Fungi (Cryptococcus, Candida, Histoplasma,...)  Bacteria (Mycobacterium avium-intracellulare, Salmonella, Shigella, Clostridium difficile,...)  Virus (Cytomegalovirus, Herpesvirus) Bhaijee et al Human immunodeficiency virus-associated gastrointestinal disease: common endoscopic biopsy diagnoses. Patholog. Res. Int. 2011: Montessori et al CMAJ. 170(2):

4 HIV-associated insult to GI tract integrity Brenchley and Douek HIV infection and the gastrointestinal immune response. Muc. Immunol. 1:23-30

Bio-K+ ® treating GI SAEs in HIV-infected patients 5 1- Hummelen et al Altered host-microbe interaction in HIV: a target for intervention with pro- and prebiotics. Int. Rev. Immunol. 29:

Bio-K+ ® probiotic formula 6 Capsules Minimum of 50×10 9 CFU guaranteed for 2 years (refrigerated) Enteric coating Fermented liquid product Minimum of 50×10 9 CFU guaranteed for 140 days (refrigerated) Lactobacillus acidophilus CL1285 ® + L. casei LBC80R ® Probiotics are strains of bacteria that have beneficial effects on the gut flora, facilitating the growth of friendly bacteria and diminishing harmful bacteria

7 Summary of Bio-K+ ® clinical trials in GI pathologies Clinical trial # Patients Dosage Study population Principal results Beausoleil et al, 2007 (HMR) 89 1 x 50B liquid product / die ( Rx antibio)  18 y/o, Rx antibio AAD : ↓55% in incidence (p= 0.05) CDAD : 1 case vs 7 in placebo (p= 0.06) Psaradellis and Sampalis, 2010 (8 hospitals in QC and ON) x 50B liquid product / die (Rx antibio + 5 d)  18 y/o, Rx antibio AAD : ↓ 51.5% duration (p= 0.045) AAD : ↓ 37% in incidence (p= 0.037) Gao et al, 2010 (AAD/CDAD prevention) 255 1X 1 or 2 capsules 50B / die (Rx antibio + 5 d) y/o, Rx antibio (penicillins, cephalosporin, clindamycin) AAD incidence : ↓ 36% (50B/d) (p= 0.02) ↓ 65% (100B/d) (p < 0.001) CDAD incidence: ↓61% (50B/d) (p= 0.03) ↓95% (100B/d) (p= 0.002) Maziade et al, 2011 (HPLG), Submitted  35,000 50B liquid product; 2X 30B capsules / die for 30 d  18 y/o, Rx antibio CDAD : ↓73% incidence (p= 0.003) ↓94% severe cases(p= 0.003) ↓39% recurrent CDAD ↓ 91% mortality rate

8 1- Gao et al Am J Gastroenterol. 105 (7): Wolvers et al Guidance for substantiating the evidence for beneficial effects of probiotics: Prevention and management of infections by probiotics. J. Nutr. 140: Results of clinical studies with Bio-K+ ® Dose-response efficacy of Bio-K+ ® on AAD and CDAD incidence 1 AAD incidence (%) Placebo 1 capsule 50B 2 capsules 50B 65% Placebo 1 capsule 50B 2 capsules 50B Incidence DACD (%) CDAD incidence (%) 95%

9 1- Gao et al Am. J. Gastroenterol. 105 (7): % reduction in AAD duration (with 2 capsules) Reduction of GI symptoms (commonly associated to IBS) (%) Placebo (n=84) 1 capsule (n=85) 2 capsules (n=86) Abdominal pain Bloating Liquid stools I leus P < 0.05 : All Clinical studies with Bio-K+ ® AAD duration (days) Dose response efficacy of Bio-K+ ® on AAD duration and GI symptoms Placebo 1 capsule 50B 2 capsules 50B

Pierre-Le Gardeur Hospital experience 10 Maziade et al Submitted to Infect. Control Hosp. Epidemiol. 7 years of Clostridium difficile infection prevention in a community hospital – Role of a proprietary probiotic formula of Lactobacillus acidophilus CL1285 and Lactobacillus casei LBC80R Maziade PJ, Andriessen A, Gagné D, Murray G, Jacob C, Pereira P and Méthot L. Protocol: Hospitalization + Antibiotics Bio-K+ ®  CDI cases =  73%  Severe CDI cases =  94%  Mortality rate =  91%  Recurrent CDI =  39%

Evolution of CDI incidence 11 Maziade et al Submitted to Infect. Control Hosp. Epidemiol. CDI/10,000 patient-days Pierre-Le Gardeur Hospital

Enhancing pharmacology of ARVs using evidence- based probiotics HIV mediated loss of Th17 cells from GALT during acute infection 4  Impairs mucosal integrity and innate defense mechanisms  Microbial translocation correlates with chronic immune hyperactivation  Maintaining a healthy GALT may be key to reducing pathogenic potential of HIV due to compromised flora and subsequent barrier disruption resulting in elevation in inflammation 12

13 Conclusion Intervention with therapeutic probiotics HIV\AIDS  of drug absorption and  drug resistance  compliance to HAART  diarrhea and GI side-effects and other SAEs

Protocol synopsis 14 X HIV-infected patients X on ART + Imodium + Placebo X on ART + Imodium + Bio-K+ ® Outcomes  diarrhea and SAEs  OIs Stabilization of CD4 Suppression of viral load Improvements of micronutrients level  adherence and persistence to HAART DEXA + BIA Inclusion Confirmed HIV infection HIV-related anemia PCP, thrush, vaginosis, vaginitis Anal dysplasia Hairy leucopenia

References 1. Anukam, KC., Osazuwa, E., Osadolar, H., Bruce, A., Reid, G. Yogurt Containing Probiotic Lactobacillus rhamnosus GR-1and L. reuteri RC-14 Helps Resolve Moderate Diarrhea and Increases CD4 Counts in HIV Patients. Journal of Clinical Gastroenterology. March 2008; 42(3). 2. Trois, L., Cardoso, E., Mirua, E. Use of Probiotics in HIV-infected Children: A Randomized Double-blind Controlled Study. Journal of Tropical Pediatrics. 2008; 54(1). 3. Saavedra, JM., Tschernia, A. Human studies with probiotics and prebiotics: clinical implications. British Journal of Nutrition. 2002; Hofer, U., Speck, R. Disturbance of the gut-associated lymphoid tissue is associated with disease progression in chronic HIV infection. Semimars in Immunopathology. 2007; 31(2). 15