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2014 “Towards an HIV Cure” symposium
Melbourne
Impact of HAART on HIV Reservoirs
Pr Christine ROUZIOUX
Virologie – Université Paris Descartes
 The objective of this presentation is to understand the
extent of which ART can reduce and limit the establishment
and the persistence of the HIV reservoirs, as an important
step towards HIV cure.
 There is no consensus on the definition of HIV reservoirs
 There is no consensus on HIV reservoir markers
 However, there are many recent results which bring
information that could help to design studies, to select
patients as good candidates to receive the best
combinations aiming at reducing HIV reservoirs and to
achieve HIV drug free remission.
Definition of HIV reservoirs
Culture assay : IUPM
Lewin & Rouzioux, AIDS 2011
Rouzioux & Richman, 2012
METHODS
OBJECTIVE
ADVANTAGES
DRAWBACKS
Cell viremia
(IUPM)
Measures cell capacity to
produce infectious virus IUPM
Gold Standard to identify
productive
and/or resting cells
Long and heavy technique
High amount of Fresh
blood needed 180 ml
Reproducibility unknown
Integrated HIV-DNA
To quantify integrated provirus
in resting and productive
infected cells
Good Marker of Latency in
sorted resting CD4+Tcells
Frozen samples
Labour intensive
technique
No standard method
Reproducibility across
multiple labs unknown
2 LTR circles unintegrated HIV-DNA
Measures by product of HIV
integration, marker of ongoing
replication
Marker of recent cycles of
replication
Frozen samples
Reproducibility across
multiple labs unknown
Total HIV-DNA
Measures unintegrated,,
integrated, linear DNA and
2LTR circles,
in blood and tissues
Small amount of frozen
whole blood, PBMC
Standardized, simple
reproducible,
International Quality
Controls
Includes quantification of
competent and
incompetent virus
Reproducibility across
multiple labs unknown
Cell-Associated
US-RNA and MSRNA
Marker of ongoing replication
in productive cells
Marker of HIV transcription
marker for residual
productive cells in patients
on cART
Few published studies
Reproducibility across
multiple labs unknown
Plasma HIV-RNA
Marker of viral production by
infected cells
Ultrasensitive method (Single
Copy Assay) to quantify
residual replication
Universal well
standardized method
Feasible with all HIV
subtypes with some
Lewin
assays
Large volume of plasma
needed
Indirect marker of
productive cells
HIV-RNA (SCA)
& Rouzioux, AIDS 2011
Comparative analysis of measures of viral reservoirs in
HIV eradication studies: Erickson et al , Plos Path, 2013
r=0.70 p=0,008
r=0.65 p=0.016
r=0.58 p=0.015
r= 0.63 p=0.0042
Kinetics of HIV reservoir decrease
Treatment
Interruption
Viral Rebound
- Naïves
Palmer S et al. J Internal Medicine 2011
Impact of Early HAART on HIV Reservoirs
ADN-VIH (Log / M PBMC)
272 Chronic Infections
35 Primary- infections
Better HIV-DNA
decrease Better
immune restoration
Time with HIV-RNA <50 copies/ml (Years)
Hocqueloux et al , JAC 2013
Impact of ART on Gut reservoirs
 Yukl S et al, AIDS 2010
The Distribution of HIV DNA and HIV RNA in Cell Subsets differs in Gut and
Blood in patients on HAART. Intensification with raltegravir produced no
consistent decrease in HIV-RNA and HIV-DNA in blood, duodenum, colon or
rectum. Moreover, ileum support ongoing productive infection, even in patients
with plasma HIV-RNA undetectable.
 Chege D et al AIDS 2012
In long term virologically suppressed patients on HAART, intensification with
raltegravir did not result in further decay of HIV-DNA in either the blood or GUT
after 48 and 96 weeks of therapy.
 Ananvoranitch J et al, Plos one 2012:
Gut T cell depletion and HIV reservoir seeding increases with progression .
HAART induced immune restoration and reduced reservoir size
 Kök A et al, Mucosal Immunology, 2014:
Early initiation of HAART helps to preserve and /or restore mucosal gut
homeostasis, and reduce the gut reservoirs HIV-DNA level.
ANRS 147 OPTIPRIM : Study design
Arm 1 (N=45):
Primary end-point :
HIV-DNA level at M24
Darunavir/R: 800/100 mg QD
+ Tenofovir/emtricitabine:
245/200 mg QD
+ Raltegravir: 400 mg BID
+ Maraviroc: 150 mg BID
Treatment
interruption
0
Arm 2 (N=45):
Darunavir/R: 800/100 mg QD
+ Tenofovir/emtricitabine:
245/200 mg QD
Co-enrollment:
-Cohort CO6 PRIMO
M24
M30
VISCONTI ?
-
Inclusion criteria :
Patients with Acute HIV-1 infection < 10weeks
Chéret et al , CROI 2014
ANRS 147 : OPTIPRIM trial : impact on reservoirs
HIV-DNA kinetic from baseline to month 24
A
B
A. HIV-DNA log copies/ per 106 PBMC
strong decrease and continious slope
B. HIV-DNA log copies per ml
of blood
Could we do better?
Chéret et al , CROI 2014
Persistent HIV-1 replication is associated with lower
antiretroviral drug concentrations in lymphatic tissues
Fletcher et al PNAS 2014
Probability to maintain HIV RNA <400
copies/ml after treatment interruption.
: Immunovirological parameter
evolution of the two post treatment
controller patients
A
C
(PTC 1 and 2).
D
Impact of 2 years of HAART in acute patients:
OPTIPRIM ANRS147
p<0.009
p=0.001
p=0.001
p<0.004
p=0.001
D0
D0
p=0.001
p=0.001
p=0.001
p=0.002
Cell-associated HIV-1 DNA
(Log copies/million cells)
6
5
4
3
2
1
D0
M24
PBMCs
D0
M24
CD4 TLy
M24
M24
Activated Resting
CD4 TLy CD4 TLy
D0
M24
TN
D0
M24
TCM
D0
M24
TTM
D0
M24
TEM
13
Chéret et al CROI 2014
HIV blood reservoirs in T CD4+ subsets
HAART at the Chronic Phase
Chomont et al, Nat. Med 2009
HAART in Primary infection
Chéret et al, 2014 : OPTIPRIM ANRS 147
Elite controllers - VISCONTI Patients
Interactions between Activation/ Inflammation
and HIV reservoir levels
Jain et al JID, 2013
Interactions between Activation/ Inflammation
and HIV reservoir levels
Murray et al J Virol, 2014
Impact of early HAART
Murray et al J Virol, 2014
2013
The VISCONTI study
06
08
107
106
105
1000
104
103
500
102
RNA copies/ml
108
1500
CD4+ T cells/mm3
109
2000
CD4+ T cells/mm3
0
99 00 01 02 03 04 05 06 07 08 09
Year
101
01 02 03 04 05 06 07 08 09 10 11
10 9
10 8
10 7
1500
10 6
10 5
1000
10 4
10 3
500
10 2
10 1
0
10 0
98 99 00 01 02 03 04 05 06 07 08 09 10 11
Year
MWP
2000
2000
1500
1000
500
0
99 00 01 02 03 04 05 06 07 08 09 10
Year
10 9
10 8
10 7
10 6
10 5
10 4
10 3
10 2
10 1
10 0
CD4+ T cells/mm3
RNA copies/ml
500
OR8
OR2
0
1000
OCP
2000
1500
1000
500
0
02 03 04 05 06 07 08 09 10
Year
LY1
2000
1500
1000
500
0
01 02 03 04 05 06 07 08 09 10
Year
10 9
10 8
10 7
10 6
10 5
10 4
10 3
10 2
10 1
10 0
10 9
10 8
10 7
10 6
10 5
10 4
10 3
10 2
10 1
10 0
RNA copies/ml
02 04
Year
1500
10 9
10 8
10 7
10 6
10 5
10 4
10 3
10 2
10 1
10 0
CD4+ T cells/mm3
00
CD4+ T cells/mm3
98
RNA copies/ml
96
CXK
2000
CD4+ T cells/mm3
0
10 9
10 8
10 7
1500
10 6
10 5
1000
10 4
10 3
500
10 2
10 1
0
10 0
01 02 03 04 05 06 07 08 09 10 11
Year
2000
RNA copies/ml
500
CD4+ T cells/mm3
1000
KPV
RNA copies/ml
CD4+ T cells/mm3
1500
109
108
107
106
105
104
103
102
101
100
10
RNA copies/ml
OR1
2000
RNA copies/ml
14 patients with Remission
0
96
98
00
02
04 06
Year
08
10
500
0
CD4+ T cells/mm3
1000
RNA copies/ml
CD4+ T cells/mm3
1500
10 9
10 8
10 7
10 6
10 5
10 4
10 3
10 2
10 1
10 0
99 00 01 02 03 04 05 06 07 08 09 10 11 12
Year
1000
500
0
02 03 04 05 06 07 08 09 10
Year
LY2
CD4+ T cells/mm3
CD4+ T cells/mm3
RNA copies/ml
1500
10 9
10 8
10 7
10 6
10 5
10 4
10 3
10 2
10 1
10 0
2000
1500
1000
500
0
00 01 02 03 04 05 06 07 08 09 10 11
Year
10 9
10 8
10 7
10 6
10 5
10 4
10 3
10 2
10 1
10 0
SL2
MO1
2000
JOGA
2000
10 9
10 8
10 7
1500
10 6
10 5
1000
10 4
10 3
500
10 2
10 1
0
10 0
99 00 01 02 03 04 05 06 07 08 09 10 11 12
Year
2000
RNA copies/ml
500
CD4+ T cells/mm3
1000
10 9
10 8
10 7
1500
10 6
10 5
1000
10 4
10 3
500
10 2
10 1
0
10 0
98 99 00 01 02 03 04 05 06 07 08 09 10
Year
2000
RNA copies/ml
CD4+ T cells/mm3
1500
109
108
107
106
105
104
103
102
101
12
RNA copies/ml
GXR
OR3
2000
RNA copies/ml
Year
Saez-Cirion et al Plos Pathogens 2013
6
HIV-DNA (log10 copies/106 PBMC)
5
4
3
2
1
PHI
Chronic
cART
ALT
HIC
PTC
Lewin and Rouzioux AIDS, 2011
Post-treatment controllers have low levels of HIV-1 DNA in
PBMC, which further decreased after treatment interruption in
some cases
Cell associated HIV-1 DNA
(Log copies/106 PBMC)
4
3
2
1
0
0
30
60
90
120
Time after treatment
interruption (months)
Saez-Cirion et al Plos Pathogens 2013
The VISCONTI patients, now ! (n=20)
Médian
(IQR)
At PHI
Before
interruption
After
interruption
CD4/mm3
544
915
855
Ratio CD4/CD8
0.70
1.51
1.48
Viral loads, Log cp/mL
5.2
<1.7
<1.7
Post-treatment interruption
•
Median Follow-up = 9.3 years
(IQR: 8.4-10 – range: 4.5-12.5)
•
Median age = 48 (IQR: 43-53)
No AIDS event
Treatment resumption in 1/20 patient
 Cancer ORL
 VL <40 cp/mL before cART resumption
 In remission after 2 years
No treatment resumption linked to viral
replication
338 Viral loads measured after
treatment interruption
– 287/338 (85%) were <50 cp/mL
– 45/338 (13%) were >50 et <400
cp/mL
– 6/338 (2%) were >400 cp/mL
CONCLUSIONS
 The study of HIV reservoirs in treated patients bring many new
arguments in favor of early treatment initiation:
 Protecting long-life memory T cells
 Reducing the damage of activation/inflammation
 Inducing VISCONTI cases with long-term control after treatment
interruption
 Pharmacological studies indicate that better combinations with better
concentrations in lymphoïd tissues, including lymph nodes, might have
a better impact on HIV reservoirs.
 Lastly, the impact of new drugs, new combinations should be
systematically evaluated on HIV reservoirs, to prepare patients to the
next objective to achieve long-term HIV drug free remission.
Acknowledgements
Patients and clinicians who participate in the study
Institut Pasteur
CHU Necker Enfants Malades
Régulation des Infections Rétrovirales
Laboratoire de Virologie
Asier Saez-Cirion
Christine Rouzioux
Gianfranco Pancino
Véronique Avettand-Fenoel
Daniel Scott-Algara
Adeline Mélard
Françoise Barré-Sinoussi
Pierre Versmisse
Faculté de Médecine Paris Sud
CHR Orléans La Source
Service Maladies Infectieuses
Thierry Prazuck
Laurent Hocqueloux
INSERM U1012
Alain Venet
Olivier Lambotte
Cécile Goujard
Isabelle Girault
Camille Lecuroux
CHU Hôtel-Dieu
Unité Immuno-Infectiologie
Jean-Paul Viard
INSERM U1018
Laurence Meyer
Faroudy Boufassa
ANRS CO6
“PRIMO”
ANRS CO18
ANRS CO15
“HIV controllers”
“ALT”
CHU Pitié-Salpetriere
INSERM UMR-S 945
Brigitte Autran
Charline Bacchus
Benjamin Descours
Assia Samri
Ioannis Theodorou
Julien Guergnon
INSERM UPMC U943
Dominique Costagliola
Valérie Portard
FHDH
“French Hospital
Database on HIV”
Merci