HIV-1 Low Level Viremia: Clinical, Virological, and Immunological - - PowerPoint PPT Presentation

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

AREVIR-Meeting 2018 - Immune control in immunocompromised patients Marek Widera

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Definitions of HIV-1 Persistent Viremia, Low-Level Viremia, blips

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients Viremia between 50 and 1000 cp/ml might predict the risk of subsequent virologic failure (Swenson et al. 2014) LLV between >50 and <1000 cp/ml associated with increased risk of VF (Laprise et al. 2013) HIV-1 LLV >200 cp/ml predictor for VF (Navarro et al. 2016)

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HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

Clinical Society (year of the guideline release) Therapy success Low Level Viremia Virological Failure DAIG, Deutsche AIDS-Gesellschaft (2017) < 50 cp/ml (within 6 months) 50 – 200 cp/ml < log ↓ after 4 weeks or >50 cp/ml after 6 months >2x >50 cp/ml after suppression DHHS, Department of Health and Human Service (2018) VL < LLOD (<20-75 cp/ml) (within 12-24 weeks) LLOD – 200 cp/ml 2x > 200 cp/ml IAS-USA, International AIDS Society (2016) < 50 cp/ml (within 24 weeks) 50 – 200 cp/ml 2x > 200 cp/ml (after suppression) EACS, European AIDS Clinical Society (2017/2015) < 50 cp/ml (within 6 months) 50 – 500 cp/ml (from 10/2017) 50 – 1000 cp/ml (before 10/2017) 2x > 50 cp/ml (6 month after ART start)

The definition of HIV-1 Low Level Viremia and failure is not consistent

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HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

Issues associated with HIV-1 LLV and blips

Therapy associated drug resistance mutations (DRMs) Adherence or compliance issues, drug-drug interactions, pharmacogenomics and metabolism High baseline viral load, older generation drugs (former PI) Co-infections, vaccination Different test systems, inaccuracy of sampling and measurements Very low CD4 levels (AIDS-patients) Cellular reservoir release of defective viruses

Possible causes of HIV-1 Low Level Viremia

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Is there a marker to predict clinical and immunological outcomes? Are there further markers/features that can predict episodes of LLV? Where does LLV originate from? Periphery blood cells or viral reservoirs?

Rationale of the study and study design

What are the implications of long term LLV?

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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Part I) A retrospective data analysis was performed on a treatment history dataset containing parameters from routine diagnostics (pVL, ART-regimen, immunologic parameters ) 1388 HIV-positive patients (HIV+) all cART treated at the University Hospital

• f Essen from January 2006 to March 2015.

Part II) Detailed molecular analysis of PBMCs (n=29) derived from LLV patients. Drug levels, viral evolution of DRMs using next-generation sequencing (NGS), proviral DNA, cell. RNA, immunological surrogate markers.

Rationale of the study and study design

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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Part I) A retrospective data analysis was performed on a treatment history dataset containing parameters from routine diagnostics (pVL, ART-regimen, immunologic parameters ) 1388 HIV-positive patients (HIV+) all cART treated at the University Hospital

• f Essen from January 2006 to March 2015.

Part II) Detailed molecular analysis of PBMCs (n=29) derived from LLV patients. Drug levels, viral evolution of DRMs using next-generation sequencing (NGS), Proviral DNA, cell. RNA, surrogate markers.

Rationale of the study and study design

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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Blips had no significant impact on the frequency of subsequent events An initial LLV increases the frequency of further LLV episodes Viremia >1000 cp/ml (VF) was associated with frequent subsequent LLV and viremia events. ART begin first event subsequent event <40 <40 …

After initial viremic phases, subsequent episodes of LLV are observed more frequently

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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HIV-1 Low Level occurs more frequent in patients with prolonged decline periods after ART

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients (Widera, Dirks et al. 2017)

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posterior distribution (𝜄𝑞𝑤, 𝜄𝑜𝑝 𝑞𝑤)

5% - 15% 15% - 35% 5% - 10% 13% - 30%

Persistent Viremia is frequently followed by episodes of LLV

The probability of HIV-1 LLV in patients with prolonged decline

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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The longer the decline period, the higher the frequency of LLV

The probability of HIV-1 LLV in patients with prolonged decline

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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Comparison of immunological markers of patients witch HIV-1 blips, LLV, and Viremia

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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Routine immunograms of HIV-1 LLV patients do not differ from those with blips but from those with virologic failure (>1000 cp/ml).

Comparison of immunological markers of patients witch HIV-1 blips, LLV, and Viremia

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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Part I) A retrospective data analysis was performed on a treatment history dataset containing parameters from routine diagnostics (pVL, ART-regimen, immunologic parameters ) 1388 HIV-positive patients (HIV+) all cART treated at the University Hospital

• f Essen from January 2006 to March 2015.

Part II) Detailed molecular analysis of PBMCs (n=29) derived from LLV patients. Drug levels, viral evolution of DRMs using next-generation sequencing (NGS), Proviral DNA, cell. RNA, surrogate markers.

Rationale of the study and study design:

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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Detailed analysis of LLV (n=29) patients from routine diagnostics (2013-2015): VL: 234 (+/-231) cp/ml Duration of LLV: 270 (+/-151) days Analysis of plasma and PBMC samples pVL, drug level, DRMs (NGS). Isolation of fresh PBMC samples, same day as blood sampling (DNA/RNA analysis)

HIV-1 Persistent Viremia, Low-Level Viremia, blips

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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In approx. 30% of LLV patients new therapy associated DRM were identified (NGS) In approx. 27% of the LLV patients drug levels were to low In approx. 55% of the LLV were treated with PI 72% of the LLV patients were infected with HIV-1 subtype B

Characteristics of Patients with HIV-1 Low Level Viremia > The group of LLV patients is heterogeneous

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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L L V T N < 4 0 1 0 1 1 0 2 1 0 3 1 0 4 1 0 5 1 0 6

to ta l H IV D N A [c p /1 0 6 c e lls ] n s

*** ***

L L V T N < 4 0 1 0 -1 1 0 0 1 0 1 1 0 2 1 0 3 1 0 4 1 0 5 1 0 6 1 0 7

in te g ra te d H IV D N A [c p /1 0 6 c e lls ]]

* *** *

L L V T N < 4 0 1 0 0 1 0 1 1 0 2 1 0 3 1 0 4 1 0 5 1 0 6 1 0 7 1 0 8

2 -L T R c irc le s [c p /1 0 6 c e lls ]] n s n s n s

Transcriptional HIV-1 activity in PBMCs:

L L V T N < 4 0 1 0 0 1 0 1 1 0 2 1 0 3 1 0 4

c o p ie s H IV c e ll R N A [c p /1 0 5 c e lls ]

** ****

n s

Proviral HIV-1 DNA in PBMCs:

HIV-1 proviral DNA loads during LLV are higher than in patients under the LOD

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

LLV might derive from infected transcriptionally active periphery blood cells; active replication

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< 4 0 L L V T N 1 0 -2 1 0 -1 1 0 0 1 0 1 1 0 2

x -fo ld ch a n g e P K R e x p re s sio n

** **

< 4 0 L L V T N 1 0 -2 1 0 -1 1 0 0 1 0 1 1 0 2

x -fo ld c h a n g e IF N b e xp re s sio n

< 4 0 L L V T N 1 0 -2 1 0 -1 1 0 0 1 0 1 1 0 2

x -fo ld ch a n g e O A S 1 e x p re s sio n

Expression levels of IFN stimulated genes (ISGs):

Patients with LLV might have higher ISG expression indicating chronic inflammation

Expression of IFN stimulated genes during LLV is higher than in patients under the LOD

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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Torque teno virus (TTV)

• Non-enveloped ssDNA virus Family: Anelloviridae

Prevalence in the general adult population is approximately 90-100%

• Tropism: predominantly hepatocytes, but also periphery blood cells

Establishes a chronic infection without inducing a previously known pathology in healthy individuals TTV viremia appears to be correlated with immune status

L L V < 4 0 1 0 2 1 0 3 1 0 4 1 0 5 1 0 6 1 0 7

T T V D N A [c o p ie s /m l p la s m a ]

**

M a n n -W h itn e y te s t; ** p < 0 .0 0 6 8 M e a n w ith in te rq u a rtile ra n g e

L L V < 4 0 1 0 2 1 0 3 1 0 4 1 0 5 1 0 6 1 0 7 1 0 8

T T V D N A [c o p ie s /1 0 *6 c e lls ] n .s .

TTV as a suitable surrogate marker for HIV LLV and disease progression?

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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Part I: Prolonged decline periods as well as previous viremia and LLV episodes appear to be a risk factor for imminent episodes of LLV. In general, the longer the decline period, the higher the LLV frequency. Routine immunograms of LLV patients do not differ from those with blips, but VL. Part II: The group of LLV patients is heterogeneous (DRMs, adherence, ART-regimen…) Viral reservoir and HIV-1 transcriptional activity in PBMCs from LLV patients were as high a in TN naive patients, and significantly higher than in patients <40 indicating ongoing viral replication during LLV. Patients with LLV have higher ISG expression indicating chronic inflammation TTV-DNA levels were higher in LLV-patients when compared to those with undetectable viral load. Indicating limited immunocompetence in LLV

• patients. Marker for disease progression?

Impact of Low Level Viremia on Clinical and Virological Outcomes in ART Treated HIV-1-Infected Patients - Summary

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

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Acknowledgements

HIV/HPSTD-Studienambulanz Stefan Esser Robert Jablonka Institute for Virology Ulf Dittmer Barbara Bleekmann Miriam Dirks Helene Sertznig Jonas Schuhenn Jana Reich NCT02411071 Institut für Immunologie und Genetik, Kaiserslautern Jens Verheyen Martin Däumer Alexander Thielen

Ethics Committee of the medical faculty of the University Duisburg-Essen (14-6155-BO)

University of Cologne, Virology Rolf Kaiser Veronica di Cristanziano Bioinformatics and Computational Biophysics, University of Duisburg-Essen Daniel Hoffmann Daniel Habermann University Düsseldorf, Virology Nadine Lübke

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• Inclusion of recent data from 2016-2018 and reanalysis.
• In cooperation with Rolf Kaiser (Cologne), additional 300 LLV samples

will be incorporated into the study (RESINA-cohort).

• Analysis of PBMC derived mRNAs (LLV vs. <40 vs. TN)
• Expression levels of ISGs
• Comparison of A3G/F signatures in proviral DNA
• HIV-AND HEART cohort (Stefan Esser):

impact of HIV-1 LLV on chronic inflammation and cardiovascular diseases.

• Long term observation: Is TTV a marker for treatment failure?

Outlook and future perspectives

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients