1. HIV: Science, Sex and Society. Lecture 2. Strategies for the cure of HIV-1. Mario Stevenson, Ph.D Department of Medicine.

2. Main topics: Review of the obstacles to viral eradication Treatment as prevention Berlin Patient; Visconti Patients; Mississippi Baby; Boston Patients Gene therapy approaches Shock and kill Immune-based strategies

3. Question: What was likely the most important component of Timothy Brown’s treatment that led to him being cured of HIV infection? A: He also had leukemia B: He received an experimental vaccine C: His treatment was started early after he first became infected D: He received a bone marrow transplant from an individual with a CCR5 mutation E: All of the above

4. Mechanisms of HIV persistence T cell survival Homeostatic proliferation Ongoing viral replication Finzi et al. Science 1997 ; Wong et al. Science 1997 ; Chun et al. PNAS 1997 ; Palmer et al. PNAS 2008 ; Chomont et al. Nat Med 2009 Active reservoir Latent reservoir Courtesy N. Chomont

5. Treatment as prevention: The power of PreP! Treatment as prevention: The power of PreP!

6. Time on antiviral cocktails (ART) virus particles in plasma (log10) Antiviral treatment: impact on transmission Years 0 0 10 7 10 6 10 5 10 4 10 3 10 2 10 1

7. months on antiviral cocktails (ART) virus particles in plasma (log10) Antiviral treatment: impact on transmission 3210 0 10 7 10 6 10 5 10 4 10 3 10 2 10 1 When an infected individual has low viral load on therapy, that individual does not transmit the virus!

8. PARTNER Cohort – Follow-up of Serodiscordant Couples when HIV+ Partner Has Suppressed Viral Load Behavior - HIV Neg Partner # Condomless Sex Acts Observed Linked Transmissions 95% CI (transmissions/100 CYFU) HT - Receptive Vaginal Intercourse13,728 0 1.25 HT - Insertive Vaginal Intercourse14,295 0 1.32 MSM - Receptive Anal Intercourse7,738 0 1.97 MSM - Insertive Anal Intercourse11,749 0 1.37 Rodger A, et al. 21st CROI Meeting, Boston, MA; March 3-6, 2014. Abst. 153LB.

9. Prior to exposure Time of transmission After infection PrEPPEPART Using Antiretroviral Medications for HIV-1 Prevention PreP trial HPTN 052: 1763 discordant couples (1 partner infected, the other uninfected) in nine countries. Infection and clinical status was monitored. Both partners started on ARVs immediately or after delayed interval.

10. HPTN 052: HIV-1 Transmissions 96% Decrease Cohen MS, Chen YQ, McCauley M, et al. N Engl J Med 2011; 365(6):493.

11. The Global iPrEx Study Use antivirals in high-risk individuals to prevent infection- a drug-based vaccine Limitations Success depends on how well enrollees took the drugs and stayed on the drugs. New formulations of drugs last for months after single dose.

12. 34 MILLION PEOPLE LIVE WITH HIV/AIDS WORLDWIDE A cure is needed!

13. Current therapies are extremely effective - reduced pill burden, fewer side effects. Virus in blood can be reduced to undetectable levels for years. Why not maintain the status quo and go with life-long ART? Immune inflammation reduces lifespan!

14. Hunt et al JID 2003, PLoS ONE 2011 and unpublished HIV- (n = 132) HIV+ ART (n = 65) HIV+ Untreated (n = 82) Immune inflammation, as measured by T- cell activation, is lower in treated than untreated adults, but consistently higher than “normal”

15. Hunt et al JID 2003, PLoS ONE 2011 and unpublished HIV- (n = 132) HIV+ ART (n = 65) HIV+ Untreated (n = 82) Immune inflammation, as measured by T-cell activation, is lower in treated than untreated adults, but consistently higher than “normal” Individuals on ART develop “aging” diseases earlier in life. Immune inflammation leads to co- morbidities including cardiovascular issues and diabetes that can reduce an HIV- infected individuals lifespan by 5-6 years- even though the individual is on ARVs and virus is undetectable in blood! Individuals on ART develop “aging” diseases earlier in life. Immune inflammation leads to co- morbidities including cardiovascular issues and diabetes that can reduce an HIV- infected individuals lifespan by 5-6 years- even though the individual is on ARVs and virus is undetectable in blood!

16. The changing face of ART 15 years ago! Today! Tomorrow?

17. Is HIV curable? Lessons from early ART initiation!

18. Sterilizing cure- all virus has been eliminated from the body Functional cure- virus remains but doesn’t rebound after antiviral cocktails are removed

19. Early phases of HIV-1 infection

20. 20 adults (and one child) who started therapy early (but not in “hyperacute” stage), remained on therapy for years, and had no rebound after stopping therapy Virus still remains detectable in blood but under control-even in absence of ART- functional cure?

21. “Mississippi baby” born to an HIV-positive mother who had not received antiretroviral treatment during pregnancy. Infant was treated from 30 hours after birth but parents stopped therapy after 18 months. Infant remained off drugs for next 27 months yet virus remained undetectable in blood until virus rebounded two months shy of infant’s 4 th birthday.

22. 44 million HIV infections; 1 validated cure, Timothy Brown (Berlin Patient) What was different about this case?

23. 44 million HIV infections; 1 validated cure, Timothy Brown (Berlin Patient) What was different about this case? Infected 1995. On ARVs until 2006 where he develops acute myeloid leukemia. Fails chemotherapy then receives two bone marrow transplants from a donor who had a mutation in CCR5- a co-receptor for the virus. 8 years later, virus is undetectable in all tissues even though Timothy Brown is not on therapy.

24. CCR5 alleles

27. ATI: Patient B 27

28. ATI: Patient B 28 Suggests presence of CCR5 null stem cells is necessary for the cure in the setting of BMT Suggests presence of CCR5 null stem cells is necessary for the cure in the setting of BMT

29. Genetic approaches to eliminating HIV infection!

30. Why can’t we use CCR5 null BMT to cure HIV infection? Identification of immunologically matched donors with CCR5 mutation is challenging BMT carries a 25% mortality rate. Costs are significant ~300K BMT to cure HIV is unethical when ARVs sustain survival. Physician can not increase risk for patient. Scientists are developing approaches to create the CCR5 mutation in an infected individuals stem cells

31. Gene therapy for cure of HIV-1

33. Challenges behind genetic therapies to cure HIV-1 infection! Cost- $100K! Most of the 40 million infections worldwide are in resource-limited regions where average per capita healthcare expenditure is several hundred dollars Long-term concerns with modifying an individuals DNA.

34. Eliminating the latent reservoir using kick and kill approaches!

35. Comparison of latent and active HIV infection

36. Time on HAART (years) Latent Cell Frequency Slow decay of latently infected CD4 + T cells Time to eradication > 73.4 years Courtesy Bob Siliciano 45 30 15 0

37. Shock and kill approach for cure of HIV!

38. “Kick and Kill” Pilot study of vorinostat (SAHA) in long-term treated adults

39. Changes in viral RNA levels were very modest Unclear whether viral protein- the essential target of “shock and kill” strategy, was produced Unclear whether latency is the same in all cells Changes in viral RNA levels were very modest Unclear whether viral protein- the essential target of “shock and kill” strategy, was produced Unclear whether latency is the same in all cells

40. If there are different faucets or reservoirs, water in each sink empties at different rates

41. Immune-based approaches to eliminate the viral reservoirs!

42. CMV engineered as a live HIV/SIV vaccine causes high levels of tissue-based “killer” CD8+ T cells that target novel parts of the virus Vector stimulates “unconventional” MHC II/HLA E restricted CD8+ T cell responses that are potent, effector memory differentiated, widely distributed and indefinitely persistent These cells clear latency during early infection, resulting in first clear documentation of a “cure” in this model

43. Getting CD8 T-cells to the right place!

44. Baseline reservoir size and timing of viral rebound Jonathan Li

45. Baseline reservoir size and timing of viral rebound Jonathan Li Implications of active reservoir: Infected cells may be recognizeable to immune system- “shock and kill” may not be required. Therefore, boosting antiviral immunity may help clear the viral reservoirs Implications of active reservoir: Infected cells may be recognizeable to immune system- “shock and kill” may not be required. Therefore, boosting antiviral immunity may help clear the viral reservoirs