Long-term ART initiated during primaryHIV-1 infection limits the HIV-1 reservoir size

but not to levels found in LTNPs

Eva Malatinkova, Ward De Spiegelaere, Pawel Bonczkowski, Maja Kiselinova, Karen Vervisch, Wim Trypsteen, Margaret Johnson, Chris Verhofstede, Danny de Looze,

Charles Murray, Sabine Kinloch-de Loes, Linos Vandekerckhove

HIV Translational Research Unit (HTRU)Ghent University, Ghent, Belgium

8th IAS Conference on HIV Pathogenesis, Treatment and Prevention, Vancouver, Canada, 19-22 July 2015

Background: HIV-1 reservoir• Persistent long-lived reservoir: one of the major obstacles to

achieve an HIV-1 cure• Reservoir: integrated HIV-1 DNA that is replication competent

100 000

1000

10 000

100

50 copies

ARTART

HIV-1 reservoir

Time

Vira

l loa

d

ART stop = Viral rebound

• Early initiation of ART:• is associated with reduced HIV-1 reservoir• may lead to post-treatment viral control (VISCONTI controllers1)

• START study: early ART: lower risk of developing AIDS or other serious ilnesses

• In a treatment interruption study (SPARTAC2), total HIV-1 DNA correlates with time to viral rebound

Better understanding of HIV-1 reservoir can guide therapeutic strategies towards a functional cure

1 Saez-Cirion et al., Plos Pathog. 20132 Williams et al., eLife. 2014

Background: Early ART

• To assess the long-term impact of early ART on HIV-1 reservoir in blood and gut mucosa

• To compare the reservoirs between:• early or late treated patients• LTNPs, representing virological control without ART• acute seroconverters as early stage viremic patients

Can a decade of ART initiated during primary HIV-1 infection reduce the HIV-1 reservoir to the levels found in LTNPs?

Aim of the study

PHI: Primary HIV-1 infection

• A cross-sectional, observational study• Patients consisted of 4 defined cohorts in 2 clinical centers:

PHI

PHI ART *

Early ARTPHI

Late ART

ART

PHI

LTNP

no ART

PHI

no ART

(n=25)

(n=17)

(n=32)

(n=10)

ARTno ART

Patient cohorts

years (total=84)10 years

* Fiebig: II-IV (n=10), V (n=15)

Value for cohort*    

PHI Late ART Early ART LTNP

  n=10 N=32 n=25 n=17Clinical characteristics      

Age (years) 39 (30-46) 48 (31-53) 44 (34-53) 49 (31-51)

Number of females (%) 1 (10) 5 (15.6) 0 (0) 7 (41.2)

Total ART duration (years) 0 9.8 (4.9-14.7) 10.8 (4.2-11.9) 0

Viremia zenith (log10 HIV-1 c/ml) 6.2 (5.2-6.4) 4.9 (1.9-5.5) 5.5 (2.4-5.9) 2.5 (1.6-2.8)

CD4 count, nadir (cells/mm3) 440 (284-495) 155 (0-266) 390 (107-466) 624 (507-693)

CD4 count at sampling (cells/ mm3) 440 (284-604) 624.5 (172-889) 714 (476-977) 793 (414-1010)

CD4/CD8 ratio 0.62 (0.36-0.94) 0.74 (0.23-0.93) 1.10 (0.52-1.35) 0.91 (0.36-1.47)

* Values are reported as median (IQR)      

Study participant characteristics

• HIV-1 reservoir size• integrated HIV-1 DNA• total HIV-1 DNA

• Ongoing replication (2-LTR circles)• Transcriptional activity (HIV-1 usRNA)

HIV-1 reservoir size and dynamics

Materials and methods

• HIV-1 reservoir size and dynamics: newly-developed PCR-based quantification methods:• Total HIV-1 DNA, 2-LTR1 and usRNA2 measured by ddPCR• Integrated HIV-1 DNA by repetitive sampling Alu-HIV PCR3

• Differences between cohorts:• Wilcoxon signed-rank test

• Correlations:• Linear regression

1 Malatinkova et al., J Clin Microbiol. 20152 Kiselinova et al., PLoS One. 20143 De Spiegelaere et al., Clin Chem. 2014

Results: HIV-1 DNA reservoir sizein blood

Reduced total HIV-1 DNA in early vs late, however not reaching LTNP levels

Early ART(n=25)

PHI(n=10)

LTNP(n=17)

Late ART(n=32)

p=0.015*

p<0.001*

p=0.041*

p<0.001* p<0.001*p<0.001*

Results: HIV-1 DNA reservoir sizein blood

Reduced integrated HIV-1 DNA in early vs late, however not reaching LTNP levels

Early ART(n=25)

PHI(n=10)

LTNP(n=17)

Late ART(n=32)

p=0.021*

p<0.001*

p=0.003*

p=0.006* p=0.002*p=0.104

Results: HIV-1 reservoir dynamicsin blood

Early ART(n=25)

PHI(n=10)

LTNP(n=17)

Late ART(n=32)

Episomal 2-LTR circles high in recent ART-naïve seroconverters

p=0.595

p=0.743

p=0.259

p=0.002* p=0.002*p<0.001*

Results: HIV-1 reservoir dynamicsin blood

Cell-associated HIV-1 usRNA lower in early vs late treated patients and not different from LTNP levels

Early ART(n=24)

PHI(n=10)

LTNP(n=17)

Late ART(n=30)

p=0.615

p=0.027*

p=0.007*

p=0.117 p=0.092p=0.426

Results: CD4/CD8 ratio

Higher CD4/CD8 ratio in LTNPs and early vs late treated patients

Early ART(n=25)

LTNP(n=17)

PHI(n=10)

Late ART(n=32)

p=0.978

p=0.036*

p=0.009*

p=0.007* p=0.048*p=0.448

Negative correlation: CD4/CD8 ratio and integrated HIV-1 DNAin blood

R2=0.14, p<0.01

Results: HIV-1 DNA reservoir sizein rectal biopsies

Total HIV-1 DNA in rectal biopsies not different in earlyor late treated patients and LTNP

• No correlation of total HIV-1 DNA measured in blood and rectal biopsies

Early ART(n=14)

LTNP(n=8)

Late ART(n=29)

p=0.375

p=0.337

p=0.259

• Cross-sectional study design

• PCR-based assays for HIV-1 reservoir quantification, not measured replication-competent reservoir (e.g. QVOA)

• Inadequate power to examine influence of Fiebig stage

• Qualitative differences in HIV-1 sequence not examined

Limitations of the study

Conclusions

↓total and integrated HIV-1 DNA Late treated

Reduced reservoir size in blood LTNP

↓usRNA ↑ CD4/CD8 ratio

LTNP

Fast seeding of reservoir andother immunological aspects

Late treated

Lower transcriptional activity and enhanced immune restoration

Late treated

Early treated

We thank the study participants for their essential contribution

UCL LondonSabine Kinloch-de LoesMargaret JonhsonCharles Murray

AIDS Reference LaboratoryChris Verhofstede

HTRULinos VandekerckhoveWard De SpiegelaerePawel BonczkowskiMaja KiselinovaWim TrypsteenSofie RutsaertMarie-Angélique De ScheerderClarissa Van HeckeKaren Vervisch

UZ GhentDirk VogelaersSteven CallensErica SermijnJolanda PelgromBeatrijs Van Der GuchtFilip Van WanzeeleEls CaluwéDanny De Looze

Acknowledgements

Thank you!