1. CCR5 Antagonists and Tropism Testing in Clinical Practice This activity is supported by educational grants from Faculty: W. David Hardy, M.D. Director, Division of Infectious Diseases Cedars-Sinai Medical Center; Los Angeles, California W. David Hardy, M.D. Copyright © 2008 Body Health Resources Corporation. All rights reserved. The Body PRO Presents: This activity is jointly sponsored by Postgraduate Institute for Medicine and The Body PRO.

2. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 2 Faculty for This Activity W. David Hardy, M.D. W. David Hardy, M.D., is an associate professor of medicine-in-residence at the David Geffen School of Medicine, University of California, Los Angeles (UCLA). He gained his medical degree from the Baylor College of Medicine in Houston, Texas, in 1981, completed a residency in internal medicine at Harbor-UCLA Medical Center in Torrance, California in 1984 and a clinical fellowship in infectious diseases and immunology in 1986 at UCLA School of Medicine. Later in his career he also completed a postdoctoral fellowship in basic retrovirology in 2002, also at the UCLA School of Medicine. Dr. Hardy has conducted clinical trials with several antiretroviral agents beginning in 1986. He is a member of numerous professional societies including the American Academy of HIV Medicine, for whom he serves as a member of the National Board of Directors and Chairman of the California/Hawaii Chapter. Disclosures Dr. Hardy has received grants or research support from Boehringer Ingelheim, Gilead Sciences, GlaxoSmithKline, Pfizer and Tibotec. He has served as a consultant for Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Merck, Monogram, Pfizer and Tibotec. He has received fees for non-CME services from Gilead Sciences, Pfizer and Tibotec. He owns stock in Merck.

3. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 3 Case Studies

4. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 4 Case 1

5. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 5 37-year-old male with extensive ART history dating back to 1995 Past ARVs included all NRTIs except ddC, all NNRTIs except DLV, and all PIs except FPV and full-dose RTV History of “buffalo hump” while taking IDV; removed with liposuction Former participant in the RESIST 1 trial (2003-2005); ART regimen—TPV/r, TDF-FTC, EFV, ddI and ENV –HIV-1 RNA decreased from 510,000 to 5,200 copies/mL –CD4+ increased from 75 to 120 cells/mm 3 –Failed to achieve HIV-1 RNA < 50 copies/mL Discontinued ENF after 2.5 years due to lack of any available injection sites Experienced low-level viremia prior to discontinuing ENF Case 1: Patient History

6. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 6 Patient also a participant in the MOTIVATE 1 trial Randomized to placebo with OBR* of: SQV/RTV, TDF/FTC, ddI, EFV –IDV/RTV predicted to have full activity by resistance testing, but refused by patient due to prior history of lipodystrophy (buffalo hump) After eight weeks, VL 734,000 copies/mL (from 1,162,500 copies/mL), CD4+ 75 cells/mm 3 (7.8%) –< 0.5 log 10 decrease, thus considered a virologic failure Switched to open-label MVC 150 mg BID, IDV/RTV, TDF/FTC, ddI –Patient achieved HIV-1 RNA < 50 c/mL by week 24 and CD4+ cells increase to 155/mm 3 (22%); maintained for the next six months –At this time, patient develops bilateral hip pain, is diagnosed with advanced aseptic necrosis of the right hip joint and undergoes right total hip replacement surgery * Optimized Background Regimen Case 1: Patient History Continued

7. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 7 A. No B. Not Sure C. Yes Case 1: Would You Consider Changing the Patient’s Regimen at This Time?

8. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 8 Case 1: Case Progression You convince the patient to remain on his current regimen to maintain his HIV RNA < 50 copies/mL HIV-1 RNA increases to 580 copies/mL (repeat 1,280 copies/mL) (You suspect that patient’s confidence in his ART regimen has waned due to his hip surgery.) You determine that a change in regimen is indicated and order a phenotype and tropism assay

9. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 9 Case 1: Results of a Tropism Assay Tropism Result Copyright © Monogram Biosciences. Reprinted with permission.

10. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 10 Case 1: Results of Patient’s Resistance Test

11. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 11 Case 1: Should a Boosted PI Be Included in the Patient’s New Regimen? A.Yes B.No C.Not sure

12. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 12 Case 1: If You Included a PI, Which Would You Use? A.Atazanavir + ritonavir B.Darunavir + ritonavir C.Fosamprenavir + ritonavir D.Lopinavir/ritonavir E.Saquinavir + ritonavir F.Tipranavir + ritonavir G.No PIs

13. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 13 Case 1: Would You Switch the NRTI Component of the Patient’s Regimen? A. No B. Yes, I would drop ddI C. Yes, I would drop tenofovir/FTC D. Yes, I would not use NRTIs in his new regimen

14. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 14 Case 1: Would You Include Raltegravir in the Patient’s New Regimen? A. Yes B. No C. Not sure

15. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 15 Case 1: Would You Include Etravirine in the Patient’s New Regimen? A.Yes B.No C.Not sure

16. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 16 Case 1: Etravirine Resistance Information 2008 Update Clinical cut offs (CCOs) determined for phenotypic sensitivity Four additional etravirine RAMS identified (17 total) Weighted scoring system developed

17. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 17 Case 1: Response According to Phenotypic Etravirine CCOs Etravirine CCO Proportion of Patients With Viral Load < 50 Copies/mL (DUET Week 24), % (n) Decrease in log 10 Viral Load From Baseline (DUET Week 24), Mean (SE) < 371 (190/269)–2.67 (1.03) 3–1350 (37/74)–2.39 (1.21) > 1337 (22/60)–1.79 (1.42) Overall Placebo 36 (149/414)–1.51 (1.42) The highest responses occurred in patients with a fold change < 3 Virological responses were greater than placebo in patients with a fold change < 13 The highest responses occurred in patients with a fold change < 3 Virological responses were greater than placebo in patients with a fold change < 13

18. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 18 0 0 10 20 30 40 50 60 70 80 no mutation* L100I G190A V90I E138A Y181I M230L A98G Y181C K101E K101P K101H V179D V106I V179T Y181V G190S V179F 34115459110265248614 7 Patients with confirmed VL <50 HIV-1 RNA copies/mL (%) *no detectable baseline NNRTI RAM from the list of 44; Dashed line indicates 75% of response in patients without NNRTI RAMs 22128539 n= New 52 Effect of the Etravirine RAMs 2008 (17) on Virological Response

19. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 19

20. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 20 § § Y181I Y181V K101P L100I Y181C M230L E138A V106I G190S V179F V90I V179D K101E K101H A98G V179T G190A § V179F was never present as single Etravirine RAM (always with Y181C) Weight for Individual Mutations Weight for Individual Mutations Add Together Total Weighted Score Total Weighted Score 3 3 2.5 1.5 1 1 1 1 1 1 1 Case 1: Weighting of 2008 Etravirine RAMs

21. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 21 Case 1: Relation Between the 2008 Etravirine Genotypic Score and the Virological Response (< 50 Copies/mL At Week 24)

22. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 22 Case 1: Would You Continue Maraviroc in the Patient’s New Regimen? A. Yes B. No C. Not sure

23. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 23 Case 1: Case Progression On his new regimen of MVC, DRV/r, ETV, RAL and TDF/FTC his HIV-1 RNA remains < 50 copies/mL and CD4+ cells slowly rise to 280 cells/mm 3 (28%) over the next eight months His left hip pain and MRI of it stabilize showing no further progression He continues to tolerate his ART regimen well

24. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 24 Case 2

25. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 25 Case 2: Patient History 45-year-old man Diagnosed with HIV-1 in 1994 when he presented with cutaneous Kaposi’s Sarcoma –CD4+ cell count: 360 cells/mm³ –HIV-1 RNA test not available in 1994 PMH: mild hypertension, controlled with diuretics FMH: diabetes, CVD

26. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 26 Case 2: Patient ARV History 1994: ZDV monotherapy –Discontinued six months later due to anemia and nausea ddI monotherapy –Tolerated for nine months, then developed pancreatitis Discontinued ARVs: KS quiescent, CD4+ cell count stable at 360 cells/mm³

27. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 27 Case 2: Patient History on HAART Regimens Starting in 1996, various regimens including –d4T + 3TC + SQV –d4T + 3TC + NFV –ABC + 3TC + EFV –d4T + 3TC + LPV/RTV –TDF + 3TC + LPV/RTV + FPV Intolerant to ZDV (anemia), ddI (pancreatitis), d4T (peripheral neuropathy), NFV (diarrhea), dual-boosted PIs (GI symptoms)

28. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 28 Case 2: Patient History on HAART Regimens (Continued) Reached HIV-1 RNA < 400 copies/mL but never < 50 copies/mL First genotypic assay (after d4T + 3TC + SQV) –RT gene: M41L, L74V, M184V, T215Y PR gene: L10I, L63P, L90M Second genotypic assay (after ABC + 3TC + EFV) –RT gene: M41L, L74V, K101P, K103N, Y181C, M184V, T215Y, K219R –PR gene: L10I, D30D/N, L63P, G73T, V77I, L90M CD4+ cell counts rose and fell, nadir: 240 cells/mm³

29. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 29 Case 2: Current History: 2008 Regimen: TDF + 3TC + LPV/RTV –HIV-1 RNA: 1,500-2,500 copies/mL –CD4+ cell count: 300-350 cells/mm³ Hypertension poorly controlled with ACE inhibitor/diuretic + β-blocker Fasting glucose > 180 mg/dL Serum creatinine 1.9 mg/dL (baseline 1.0-1.4 mg/dL) Patient wants to consider a new regimen

30. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 30 Case 2: Drug Resistance Test Results

31. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 31 Case 2: Viral Tropism Assay Tropism Result Copyright © Monogram Biosciences. Reprinted with permission.

32. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 32 Darunavir Resistance Mutations 11I, 32I, 33F, 47V, 50V, 54L/M, 74P, 76V, 84V, 89V Tipranavir Resistance Mutations 10V, 13V, 20M/R/V, 33F, 35G, 36I, 43T, 46L, 47V, 54A/M/V, 58E, 69K, 74P, 82L/T, 83D, 84V Case 2: Would You Use Darunavir or Tipranavir in the New Regimen? A.Yes, I would use darunavir + ritonavir B.Yes, I would use tipranavir + ritonavir C.Yes, I would use both D.No, I would not use either

33. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 33 Case 2: Would You Use NRTIs in This Regimen? Phenotype NRTIs: susceptible to TDF, ZDV, d4T NNRTIs: resistant to DLV, EFV, NVP PIs: partially susceptible to DRV A.Yes B.No

34. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 34 Case 2: How Many Additional Active Agents Does This Patient Need to Achieve HIV-1 RNA < 50 Copies/mL? A.1 B.2 C.3 D.Individualized for patient’s viral resistance

35. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 35 BENCHMRK-1 and -2 with virologic failures carried forward 5 PSSGSS 63 34 61 41 87 79 57 71 56 37 71 6 44 01≥ 201 Overall Efficacy Data Patients With VL < 50 c/mL At Week 24 by PSS/GSS of OBT* (%) 0 20 40 60 80 100 Raltegravir Placebo BENCHMRK 1&2: Response by Number of Active Agents in OBT (24 Weeks) Adapted from PN Kumar et al. EACS 2007; abstract P7.2/06.

36. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 36 DUET 1&2: Response by Number of Active Agents in OBT (24 Weeks) Anthony Mills and Christine Katlama et al. IAS 2007, abstract WESS204. Reprinted with permission.

37. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 37 MOTIVATE 1&2: Response by Number of Active Agents in OBT (24 Weeks) 3 58 61 53 55 19 52 43 9 29 18 N= 121 132 64 104 88 59 134 130 44 56 51 35 Number of Active Drugs in OBT Adapted from Mark Nelson et al. CROI 2007; abstract 104aLB. Adapted from Jacob Lalezari et al. CROI 2007; abstract 104bLB.

38. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 38 Case 2: Which Regimen Would You Choose? A.tenofovir/emtricitabine, darunavir + ritonavir, etravirine, maraviroc B.tenofovir/emtricitabine, darunavir + ritonavir, maraviroc, raltegravir C.tenofovir/emtricitabine, darunavir + ritonavir, etravirine, raltegravir D.tenofovir/emtricitabine, darunavir + ritonavir, etravirine, maraviroc, raltegravir E.Something else

39. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 39 Case 2: Evolution New regimen: TDF/FTC + DRV/RTV + ETR + MVC + RAL HIV-1 RNA at 6 weeks: < 50 copies/mL CD4+ cell count at 10 weeks: 420 cells/mm³ Serum creatinine ↑ to 2.7 mg/dL (from 1.9 mg/dL); 24-hour Cl Cr: 48 mL/min

40. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 40 Case 2: What Would You Do Now With the NRTI Portion of the Regimen? A.Continue TDF/FTC QD B.Continue TDF/FTC but decrease the dose to QOD C.Change TDF/FTC to ABC/3TC D.Discontinue TDF/FTC

41. The Body PRO CCR5 Antagonists and Tropism Testing in Clinical Practice 41 Case 2: Evolution Tenofovir discontinued due to concerns about decreased renal function New regimen: DRV/RTV + ETR + MVC + RAL HIV-1 RNA < 50 copies/mL CD4+ count ↑ to 550 cells/mm³ (from 420 cells/mm³) Serum creatinine  to 1.8 mg/dL (from 2.7 mg/dL); 24-hour Cl Cr: ↑ to 80 mL/min (from 24 mL/min)