Presentation on theme: "Effect of intensification of long-term highly active antiretroviral therapy (HAART) with raltegravir on proviral HIV-1 DNA in blood and gut associated."— Presentation transcript:
Effect of intensification of long-term highly active antiretroviral therapy (HAART) with raltegravir on proviral HIV-1 DNA in blood and gut associated lymphoid tissue (GALT): a randomized, placebo controlled trial Jason Brunetta 1, Colin Kovacs 1,2,Tae Wook-Chun 3, Janet Raboud 2,4, Desheng Su 4, Mario Ostrowski 2,5,Gabor Kandel 2,5, Graham Smith 1, Rupert Kaul 2,4, Roberta Halpenny 1, Duncan Chege 2, Mona Loutfy 1,2,5 1 Maple Leaf Medical Clinic, Toronto, Ontario, Canada; 2 University of Toronto, Toronto, Ontario, Canada; 3 Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA; 4 Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada; 5 St. Michael’s Hospital, Toronto, Ontario, Canada
Conflict of Interest Disclosure Funding for this project was provided by a Research Grant from Merck Frosst Canada Ltd.
Background Eradication of HIV remains elusive due to the persistence of viral reservoirs. -The gut-mucosal compartment is an important viral reservoir -Viral reservoirs mainly consist of long-lived and latently infected CD4+ T cells New HAART drug classes may help target these latently infected reservoirs. E.g; -Integrase inhibitors (e.g. raltegravir) -Entry/fusion inhibitors
Background Recent studies examining raltegravir intensification therapy failed to show a reduction in plasma HIV RNA [Reviewed in Schulze, et al JID 2011] -However, changes in plasma viremia may not reflect changes in the mucosal reservoir. 1 recent study suggested no reduction in proviral DNA in the gut [Yukl et al, AIDS 2010]. However, this pilot study: -was an open-label study without controls -had a relatively small sample size (n=7) -intensified participants with raltegravir for a brief period (12 weeks).
HYPOTHESIS Raltegravir intensification in long-term suppressed individuals will decrease blood and sigmoid CD4+ T cell HIV proviral levels.
Methods Study design – A prospective, double-blind, placebo-controlled randomized controlled trial (ClinicalTrials.gov # NCT00520897) Enrolled participants – HIV-infected individuals recruited from the Maple Leaf Medical Clinic Inclusion criteria – Sustained virologic suppression (<50 viral copies/ml) for over 4years – Participant must be on first standard HAART with 2-3 NRTIs and 1-2 PIs or an NNRTI for at least four years Exclusion criteria – Active AIDS-defining illness in past six months – Abnormal clinical laboratory test results at screening
Methods – Study schematic Raltegravir- intensification (400mg twice/day) Placebo Randomize n=12 24 HIV+ patients fully suppressed on HAART 4w 8w 12w 16w 28w 40w 48w Primary analysis at week 48 n=12 Measured Outcomes: - Blood & sigmoid HIV-1 proviral DNA in CD4+ T cells - Blood CD4+ T cell counts 48w 0w Sigmoid biopsy Blood phlebotomy 4w 8w 12w 16w 28w 40w 48w 48w 0w Sigmoid biopsy Blood phlebotomy
Study Endpoints Primary endpoint Determine if 48 weeks of raltegravir intensification in long-term virologically suppressed participants on HAART is associated with a change in HIV-1 proviral DNA in blood and sigmoid CD4+ T cells Secondary endpoint Determine effect of raltegravir intensification on blood CD4+ T cell populations
Laboratory methods Blood Phlebotomy Ficoll density separation PBMC/Sigmoid CD8 Depletion Real time PCR: HIV-1 Proviral DNA amplification & quantitation Sigmoidoscopy 0.5 & 1.0 ug/ml Collagenase-II tissue digestion (30 min each) CD4+ T cell counts done on whole blood (counts/mm 3 ) using FACS HIV-1 DNA copy number per 1x10 6 CD4+ T cells reported (LOD: 2.6 copies) PBMC GALT
Results – Table 1 Baseline clinical and demographic characteristics were similar between the groups.
Results Treatment Median Baseline proviral load (log 10 ) Median w48 proviral load (log 10 ) Raltegravir group3.053.11 Placebo group2.862.91 No difference in blood HIV DNA proviral load between groups at week 48 (p=0.62) p from ANCOVA
Results Treatment Median Baseline CD4 count (cells/mm 3 ) Median w48 CD4 count (cells/mm 3 ) Raltegravir group665690 Placebo group610700 No difference in blood CD4+ T cell counts between groups at week 48 (p=0.25) p from ANCOVA
Results Treatment Median Baseline proviral load (log 10 ) Median w48 proviral load (log 10 ) Raltegravir group3.102.84 Placebo group3.203.08 No difference in sigmoid HIV DNA proviral load between groups at week 48 (p=0.74) p from ANCOVA
Summary In virologically suppressed patients on HAART, 48 weeks of raltegravir-intensified therapy, as compared to placebo, -did NOT result in decay of blood or sigmoid HIV DNA in CD4+ T-lymphocytes -had NO impact on blood CD4+ T cell populations Extending raltegravir intensification out to 96 weeks also did NOT result in any significant decrease in HIV DNA in blood or sigmoid CD4+ T lymphocytes (data not shown) Additional novel approaches are required to help reduce the latent viral reservoir.
Acknowledgments All the patients Research staff at Maple Leaf Medical Clinic - For working on this project Dr. Kandel for sigmoid biopsies HIV Statistical Analytical Group at UHN - Dr. Janet Raboud’s team Duncan Chege for analytical work, work on presentation & slides Funders