HIV rebound and meningoencephalitis following ART interruption after allogeneic hematopoietic stem cell transplant: an investigation of the source of HIV rebound 8 th IAS Conference on HIV Pathogenesis, Treatment and Prevention Vancouver, British Columbia, Canada July 20 th, No Disclosers- Adam Capoferri Johns Hopkins University School of Medicine, Baltimore, MD, United States Howard Hughes Medical Institute

Allogeneic hematopoeitic stem cell transplant (alloHSCT) ‘Berlin Patient’, received alloHSCT for AML treatment 1 –Donor was homozygous CCR5Δ32 ‘Boston Patients’, identified 5 and 3 years after alloHSCT 2,3 –Donors were wild-type for CCR5 –HIV-1 not found in multiple compartments; donor chimerism >99.99% –Analytical treatment interruption; delayed rebound, 12 and 32 weeks –Both patients with symptoms of acute retroviral syndrome One patient also had HIV-associated meningitis –Source of rebound unclear 1 Hütter, G., et al. (2009) NEJM; 2 Henrich, T., et al. (2013) JID; 3 Henrich, T., et al. (2014) Annals of Internal Medicine Study Background At Johns Hopkins, we are conducting a clinical trial of optimized ART in HIV+ patients undergoing alloHSCT –Optimized ART includes: avoiding ritonavir-boosted PIs, ART changes as needed, and administration of Enfuvirtide (ENF) Within this study, we present the case of a patient who had HIV viral breakthrough and experienced acute retroviral syndrome and meningoencephalitis after self-discontinuing ART post-alloHSCT

2004: Diagnosed with chronic HIV-1 infection and AML –Unstable VL and CD4 counts; multiply-relapsed AML –Lack of ART adherence and lost to follow-up –Drug resistance history with K103N and M184V –Virus Tropism determined R5 2013: Re-engaged in care for multiply-relapsed AML –Optimized ART regimen: RAL, ABC/3TC, MVC –Became virally suppressed on his optimized ART regimen –Reduced intensity conditioning match related alloHSCT Background Patient History BMT Clinical Course: –Engrafted by day 20 –>95% donor chimerism measured in peripheral blood –Day 84, HIV RNA was <20 c/mL –Patient began missing clinic appointments –Day 100, developed fevers; recommended HIV-1 VL--not done –Day 146, admitted to hospital, lumbar puncture with CSF analysis: Protein 150 [range mg/dL], WBC 28 [range 0-3 cells/uL] CSF microbiology studies negative for VZV, EBV, CMV, HSV, JCV, cryptococal, VDRL, West Nile, parvovirus; blood tests negative for histoplasma, syphilis, Hepatitis B and C, adenovirus; and bacterial, fungal, and AFB stains HIV plasma VL= 25,518 c/ml HIV CSF VL= 17,000 c/ml What is the source of viral rebound? Other reservoirs (e.g. CNS)? Persistent circulating resting memory CD4+ T cells? Henrich, T., et al. (2014) Annals of Internal Medicine

31 distinct sequences VOA 55 sequences rebound CSF 92 sequences rebound plasma Methods Limiting-dilution viral outgrowth assay (VOA) –Resting memory CD4+ T cells obtained 100 and 25 days pre- alloHSCT Sequencing of RT region of pol –Sanger sequencing of supernatant from p24+ viral outgrowth wells from VOA –Deep sequencing (Roche 454) of rebound virus from peripheral blood (PB) and cerebrospinal fluid (CSF) Sequence reads: CSF= 14,645; PB= 5,003 Consensus sequences using cut-off of >0.2% of total sequence reads Phylogenetic analysis of final sequence alignment using maximum likelihood (ML) in PAUP*v.4b –Model of evolution selected using jModelTest –Bootstrapping of 1,000 replicates –Finzi D et al, 1997; Siliciano JD et al, 2005 Conclusions In this case: –Rebound virus is consistent with virus found in resting memory CD4+ T cells isolated from multiple pre-transplant time-points –Rebound virus appears to be consistent with virus from the circulating peripheral blood –Interruption of ART post-alloHSCT can lead to severe symptoms consistent with those of HIV-1 acute infection

Thank you Questions? Special Thanks Dr. Christine Durand Dr. Richard F. Ambinder Dr. Mark Levis Dr. Robert F. Siliciano Dr. Thomas Quinn Dr. Andrew Redd Dr. Steven F. Porcella Matthew Sievers Ayla Cash Daniel Xu