The views expressed are those of the authors and should not be construed to represent the positions of the U.S. Army or the DoD.

HIV cure research: Focus on women

Jintanat Ananworanich, MD, PhDAssociate Director for Therapeutics Research, U.S. Military HIV Research Program

Co-director, SEARCH, The Thai Red Cross AIDS Research CenterProfessor of Internal Medicine, University of Amsterdam

Professor of Pediatrics, University of Maryland School of Medicinejananworanich@hivresearch.org

Disclosures

• The speaker is a consultant and/or has received honoraria and/or grant support from the following companies

➢ ViiV Healthcare

➢ Gilead

➢ Merck

➢ AbbVie

➢ Roche

➢ Janssen

Equal HIV burden but low trial participation of women:A missed opportunity for HIV cure research

Burden of infection Enrollment in Cure Trials

Enrollment in LRA Trials

Johnston and Heitzeg, AIDS Res and Human Retroviruses, 2015Also see Curno MJ, JAIDS 2016; Grewe ME, JVE 2016

Slides courtesy of Eileen Scully (Johns Hopkins)

• Almost no data in transgender women

Wansom T, Vasan S, JVE 2016; Vasan S, CROI 2018

WomenMen

Higher prevalence of spontaneous elite controllers in women

Yang, AIDS 2017; Viera, AIDS 2019

• US cohort: women were more likely to have spontaneous viral control

• Pediatric international cohort: 10 of 11 EC were girls

53 EC of 29811 (0.18%)• 26 women• 24 men• 3 transgender women

Sex differences relevant to HIV cure research

Anatomic differences

Microbiome differences

Latency maintenance differences

Immune cell phenotype differences

Genetic differences

Scully EP, Current HIV/AIDS Reports 2018

Hormonal influence

Sex differences in HIV pathogenesis

Active innate immunity

Better anti-viral immunity

Lower initial HIV viral load

Higher CD4

Better response to vaccines

Chronic immune activation

Higher autoimmunity

Faster HIV disease progression at the same viral load as men

Reservoir and response to interventions for remission?

Grabar S, AIDS 2009; Saez-Cirion A, Blood 2011; Ruel TD, CID 2011; Cuzin L, AIDS 2015 Giefing-Kroll C, Aging Cell 2015; Griesbech M, CliniSci 2016; Gianella S, JIAS 2016; Ziegler S, Curr Opin 2016; Hagen S, JVE 2016

Rechtien and Altfeld, Sem Imm 2018; Scully EP, JID 2018; Das B, PNAS 2018; Scully EP, Current HIV/AIDS Reports 2018

Considerations for research towards a cure in women

• Viral burden and reservoir

• Strategies towards a cure

➢ Latency modifying agents

➢ Immune modulating agents

• Gaps and future research

MHRP Acute Infection Studies

Fiebig I/II: RNA+, HIV IgM-

Twice weekly testing in E. Africa and Thailand of 2276 uninfected persons

Acute HIV infection (n=112)

50+ Fiebig I/II

53% female

RV217 Prospective acute infection study

in high risk individuals

Robb ML, NEJM 2016

The US Military HIV Research Program (MHRP) leads two unique acute infection cohort studies in Africa and Thailand

Real-time screening of 315,354 samples in Thailand

Acute HIV infection (n=579)

150+ Fiebig I/II

3% female

RV254 Acute infection cohort with early ART

Updated from de Souza M, Ananworanich J, AIDS 2015

Lower viral load set point in predominantly female African vs. male Thai cohorts (RV217)

95% female85% clades A/AC/AD/ACD

5% female82% clade CRF01_AE

Robb ML, NEJM 2016

• Viral load set point was 0.8 log copies/ml lower in East Africans vs. Thais

E. Africa (N=24)

-10 -5 0 5 10 15 20 25 30 35 40 45 50 55 60100

101

102

103

104

105

106

107

108

109

Days from 1st RNA Positive

Lo

g V

ira

l lo

ad

(co

pie

s/m

l)

Peak VL: 13 days

Median: log10 6.75 (IQR: 6.12-7.51)

Set point VL

Median: log10 3.99 (IQR: 3.39-4.50)

Day

Thailand (N=17)

-10 -5 0 5 10 15 20 25 30 35 40 45 50 55 60100

101

102

103

104

105

106

107

108

109

Days from 1st RNA Positive

Lo

g V

ira

l lo

ad

(co

pie

s/m

l)

Peak VL: 14 daysMedian: log10 6.66 (6.26-6.91)

Set point VL

Median: log10 4.77 (4.41-5.22)

ThailandEast Africa

Response to ART in acutely infected Thai females vs. males in RV254

14 females and 42 males matched for age, Fiebig stage, ART regimen

• No differences in viral load

• Higher CD4/CD8 ratio in females

Viral load CD4/CD8 ratio

ARTART

Time to viral rebound in early treated participants from the RV254 study

• In three trials with analytical treatment interruption• 40 participants: 18 placebo/control, 13 VRC01 bNAb, 9 vorinostat (LRA)• Two women, both in control arms

• Rebound at 40 days and 77 days

Women (n=2)Men (n= 38)

Median time to viral rebound was 26 days

Kroon E, IAS 2016; Colby D, Nat Med 2018; Crowell T, Lancet HIV 2019

Effects of estrogen on latency

Altfeld M, Curr Opin 2015, Clin Sci 2016; Laffont S, J Immunol 2014Meier A, Nat Med 2009; Scully EP, JID 2018; Das B, PNAS 2018

Estrogen

Inhibit reactivation

estrogenreceptor 1

Latently infected cell

Productivelyinfected cell

Modified from slides courtesy of Eillen Scully (Johns Hopkins). Scully EP, JID, 2018

Equivalent levels of HIV DNA

Lower HIV RNA expression in women

Lower HIV plasma virus levels in women

Tendency for HIV latency in women26 women26 Men

Estrogen blocks HIV induction in cells from women

No stimulation(Neg control)

T cell Activation

(Pos control)

T cell Activation+ Estrogen

HIV

RN

A+

cells

per

mill

ion

CD

4 c

ells

Courtesy of Eileen Scully (Johns Hopkins); Scully EP, JID 2018; Das B, PNAS 2018

Replicate data froma single representative

female participant

Effects of estrogen on latency inform interventions

Altfeld M, Curr Opin 2015, Altfeld M, Clin Sci 2016; Meier A, Nature Medicine 2009; Laffont S, J Immunol 2014 Rechtien and Altfeld, Sem Immun 2018; Scully EP, JID 2018; Das B, PNAS 2018; Scully EP, Current HIV/AIDS Reports 2018

Estrogen

Promotereactivation

Estrogenreceptor 1

Latently infected cell

Productivelyinfected cell

Estrogenreceptor

antagonists

Other latency reversing agents

No stimulation(Neg control)

T cell Activation

(Pos control)

T cell Activation+ Estrogen

Vorinostat(LRA)

ER blockade

Vorinostat +ER blockade

Courtesy of Eileen Scully (Johns Hopkins); Scully EP, JID 2018; Das B, PNAS 2018

• More HIV transcription with estrogen receptor blockade + latency reversing agent (vorinostat)

Latency reversal with estrogen receptor blockade + latency reversing agent

HIV

RN

A+

cells

per

mill

ion

CD

4 c

ells

The MOXIE trial (A5366): Tamoxifen + Vorinostat

Clinicaltrials.gov NCT03382834 (PI: Scully EP, Gandhi R)

Day 0 Day 38Day 35

Varinostat 400mg orally

• Hypothesis: Tamoxifen will enhance vorinostat (SAHA) to reverse latency• Higher levels of HIV cell-associated RNA than vorinostat alone

TLR7 or TLR9 agonist and interferon therapy

X chromosome Estrogen

TLR7/9receptors

ISGIFN alphacytokines

CD4 and CD8 expansion/activation

CCR5 upregulation on CD4

Dendritic cellT cell

• Cells from females produce more IFN alpha from pDC after TLR7 stimulation• Potential for an enhanced response to TLR7 or 9 agonists in women

Promotereactivation

Latently infected cell

Productivelyinfected cell

TLR7 or 9 agonist

Studies of TLR7 and TLR9 agonists

Ongoing studies: TLR7 agonist (Vesatolimod) in virally suppressed adults- Dose finding study (n=56) (NCT 02858401)

- 10 doses TLR7 agonist vs. placebo followed by ATI (n=28) (NCT 03060447)

TLR9 agonist induced pDC and NK activation and IFN-response, and in some, plasma viremia

TLR9 agonist IFN-response

Vibholm et al CID 2017

Krarup et al Mucosal Immunol 2018

N=15(2 women)

8 doses from wk 0 to 24

Vibholm L, CID 2017; NCT02443935

Wk 4 Wk24

>28 wkNCT03837756

Interferon therapy and its role in women

• Higher interferon levels in women may be relevant for research towards a cure• Differences in quantity and quality of innate immune cells

• Hepatitis C example• Women clear hepatitis C at a higher rate than men• Pegylated interferon α2a (pegIFN-α2a) and α2b (pegIFN-α2b) Hep C treatment

• pegIFN-α2a resulted in higher proportion (45%) with viremic control post ATI• Lower integrated HIV DNA

Azzoni L, Montaner LJ, JID 2013

(n=20, 4 were women)

Historic controls

pegIFN-α2a

Studies of interferon therapyin virally suppressed individuals

BEAT-HIV

BEAT-2

• Fully enrolled: 54 enrolled (6 women) • pegIFN-α2b with ATI vs. pegIFN-α2b with continuous ART vs. continuous ART

Clinicaltrials.gov NCT03588715 (PI: L. Montaner and P. Tebas)

Clinicaltrials.gov NCT02227277 (PI: L. Montaner)Azzoni L, CROI 2019 (Abs 136); Giron LB, CROI 2019 (Abs 304)

• Not yet enrolled: 21 participants• pegIFN-α2b + two bNAbs (3BNC117+10-1074) vs. two bNAbs

Hypothesis: pegIFN-α2b will be more effective in• BEAT-HIV: Reducing integrated HIV DNA/inducible p24 in blood and tissues• BEAT-2: Controlling viremia post-analytical treatment interruption (ATI)

Female relevant strategies for HIV remission

Marcus Altfeld (Current Opinion 2015, Clinical Science 2016); Laffont S, J Immunol 2014Conforti F, Lancet Oncology 2018; Scully EP, JID 2018; Das B, PNAS 2018

Estrogenreceptor

antagonists + LRA

Estrogen

TLR7/9receptors

ISGIFNa

cytokines

CD4 and CD8 expansion/activation

CCR5 upregulationon CD4

Dendritic cell T cell

TLR7/9 agonists

Anti-inflammatory agents

Therapeutic vaccines/

immunotherapiesGene-editing

therapy

Estrogen

Induce transcription

estrogenreceptor

Latently infected cell

Productivelyinfected cell

dCA (Block and Lock)

Checkpoint blockers

Knowledge gaps regarding sex-based differences in the HIV reservoirs

Gianella, Tsibris, Barr and Godfrey, JIAS 2016

Future research• Animal models

➢ Mice/rats and NHP

➢ Test combination therapies relevant to women

• Cohorts

➢ Collect relevant information on menstrual cycle and hormonal use

➢ Characterize reservoirs, immune responses and microbiomes in female/TGW vs. male

• Acute and chronic HIV cohorts

• Diverse populations: adolescence, menopause, pregnancy, lactation, transgender women

• Cohorts studying exogenous hormonal therapy, estrogen receptor antagonists

• HIV remission related trials

➢ Increase TGW and women’s participation• Analyze and report data on women separately from the whole cohort

➢ Design trials with female relevant strategies

Das B, PNAS 2018; Torcia MG, Int J Mol Sci 2019

Conclusion

• There are sex differences relevant to HIV cure research➢ Tendency for HIV latency in women

➢ Usage of estrogen receptor blockade to reverse latency

• Response to interventions may differ in women➢ TLR7 and 9 agonists and IFN therapy

➢ Block and lock strategy

• Efforts towards a cure need more participation of women and transgender women in cure research

The views expressed are those of the authors and should not be construed to represent the positions of the U.S. Army or the DoD.

Johns HopkinsEileen Scully

Wistar InstituteLuis Montaner

University of AarhusMartin Tolstrup

Harvard UDaniel Kuritzkes

Study Participantsand Investigators

AcknowledgementsThai Red CrossPraphan PhanuphakNittaya PhanuphakEugene KroonDonn Colby

MHRPMerlin RobbSuteeraporn PinyakornShelly KrebsBonnie SlikeLisa ReillyJamie Livengood

ARV support for RV254: ViiV Healthcare, Merck, Gilead, Thai GPO