1. 23 July 2012 1  RV144: Clinical Development Plans IAS 2012, Washington, DC USA The views expressed are those of the presenter and should not be construed to represent the positions of the U.S. Army or DoD Nelson L. Michael, M.D., Ph.D Colonel, Medical Corps, U.S. Army Director US Military HIV Research Program (MHRP) Walter Reed Army Institute of Research

2. 23 July 2012 2 Past HIV Vaccine Concepts 2 2003: AIDSVAX VaxGen Env gp120 Humoral Immunity Phase III studies in high- risk subjects in the US/Thailand Elicited type-specific Abs but not broadly reactive NAbs No efficacy 2007: STEP-PHAMBILI STUDIES Merck Ad5-Gag/Pol/Nef Cellular Immunity Phase IIb study in high-risk subjects in North/South America Elicited cellular immunity by IFN- γ ELISPOT assays No efficacy, possible increased HIV-1 acquisition 2009: RV144 Sanofi ALVAC prime, AIDSVAX gp120 boost Humoral and Cellular Immunity Phase III study in low-risk subjects in Thailand 31% reduction in HIV-1 acquisition with no viral load effect 2003200720052009 Advancing HIV vaccine candidates to efficacy trials will accelerate progress in the field, bringing us closer to an effective global vaccine. Although only three concepts have undergone clinical efficacy testing to date, each HIV vaccine efficacy trial has yielded unexpected outcomes that have transformed the HIV landscape.

3. 23 July 2012 3 NEJM 361:2209 (03 Dec 09)

4. 23 July 2012 4  RV 144 demonstrated efficacy for HIV acquisition N=16,395 51 vaccine, 74 placebo HIV infected Est. VE = 31% 95% CI 1-51% (p=0.04) Rerks-Ngarm et al. (2009, NEJM) 0.00.51.01.52.02.53.03.5 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Years Probability of HIV Infection (%) Placebo Vaccine C. Modified Intention-to-Treat Analysis*

5. 23 July 2012 5 What we have learned—RV 144  Protection among low incidence heterosexual Thais, VE 31.2% at 42 months  No effect on post-infection viremia or CD4 count  Relatively monophyletic circulating variants CRF01_AE  Efficacy appears to be early and non-durable  Evoked binding Ab but not measurable, primary isolate Nab— BAb appeared early and decreased by > 10 fold over 6 months  CD4+ Env responses, but not CD8 responses  Correlate/surrogate studies limited by samples and endpoints

6. 23 July 2012 6 What we would want next  Extend the observation of early 60% efficacy by increasing the durability of immune responses  Additional vaccine boosts  Improved adjuvants  Improved vaccines  Elucidate correlates of risk of infection.  Adequately powered studies  Adequate sample collections  Public health implementation--establish protection in higher incidence populations (additional boosts/improved adjuvants)  Heterosexuals in sub-Saharan Africa  MSM in Africa and Asia

7. 23 July 2012 7  RV 144 correlates of risk—a teaser

8. 23 July 2012 8 RV 144 Correlates Discovery Effort RV144 Steering Committee Scientific Steering Committee Product Development Advisory Group Humoral & Innate Immunity Cellular Immunity Host Genetics Animal Models Scientific Advisory Groups MHRP - DAIDS Steering Committee PA H Steering Committee ADVISORY GROUPS Clinical Development Correlates

9. 23 July 2012 9 NEJM 366:1275 (05 Apr 2012)

10. 23 July 2012 10 Multivariate Logistic Regression: Quantitative Variables VariableRelative riskP-valueQ-value IgA Binding to Envelope Panel1.540.0270.08 IgG Avidity A244 gp1200.810.370.56 ADCC AE.HIV-1 Infected CD4 Cells0.920.68 Tier 1 Neutralizing Antibodies1.370.220.45 IgG Binding to gp70-V1V20.570.0150.08 CD4+ T Cell Intracellular Cytokines1.090.610.68 All 6 variables together in multivariate analysis, P=0.08 Only  -Env IgA and IgG gp70:V1V2 binding, p = 0.009 (log reg), 0.012 (Cox) 2 individual variables were significant: gp70 V1V2 inversely correlates with infection [q = 0.08] Estimated 43% reduction in infection rate (per SD) Plasma IgA directly correlates with infection [q = 0.08] Estimated 54% increase in infection rate (per SD)

11. 23 July 2012 11  Is it V1V2 or both?

12. 23 July 2012 12  Case control analysis of microarray shows trend to inverse correlation at tip of V2 and in CD4 binding site

13. 23 July 2012 13  Sieve Analysis of RV144 Breakthrough Viruses supports importance of V2 loop

14. 23 July 2012 14 Sieve Analysis of V2  Comparison of viruses from HIV-1 infected vaccine versus HIV-1 infected placebo recipients  These are not transmitted/founder viruses—the mean time to last negative visit was ~ 3 months.  V2 was a major focus of analysis.  Analysis—collaboration between Dr. Morgane Rolland (MHRP), Dr. Jim Mullins (UW), SCHARP

15. 23 July 2012 15  Sequence variation in position 169 Edlefsen, SCHARP

16. 23 July 2012 16  Sequence variation in position 181 Edlefsen, SCHARP

17. 23 July 2012 17 Results: Sites 169 and 181 Separately  For each site, VE significantly differs against match vs. mismatched infection  vaccine reduced infection rate 3.77 times more for 181-mm than 181-m  Positive VE for 169-matched infection and181-mismatched infection  The sieve analysis suggests that the vaccine selectively blocked acquisition with 169-matched and with 181-mismatched virus; but conferred no protection against 169-mismatched or 181-matched virus GenotypeNo. InfectionsEst. VE95% CIP-value 169m8748%18% to 66%0.0036 169mm23-45%-258% to 33%0.30 181m88-20%-26% to 45%0.38 181mm2278%35% to 93%0.0028 GenotypesNo. InfectionsEst. HR / HR95% CIP-value 169mm/169 m 87/232.731.08 to 6.920.034 181m/181m m 22/883.771.19 to 11.920.024

18. 23 July 2012 18 Correlates of Risk of Infection  WARNING—it is textbook (Stan Plotkin’s) knowledge that different vaccines for the same pathogen can have different correlates of risk/protection.  Will correlate of risk for ALVAC-AIDSVAX B/E in RV 144 generalize to….  These products in Thai MSM?  ALVAC-gp120 engineered for heterosexuals in Africa?  Other HIV vaccines such as DNA/Ad5 (HVTN 505 phase IIb), Ad26- MVA, etc?  We want all subsequent efficacy trials to seek correlates—now more than ever. This impacts clinical design.

19. 23 July 2012 19 Collaborators Duke Bart Haynes Larry Liao Georgia Tomaras Nathan Vandergrift Garnett Kelsoe David Montefiori Thomas Kepler Marcella Sarzotti-Kelsoe Munir Alam Bill and Melinda Gates Foundation Nina Russell Francine McCutchan HVTN Peter Gilbert Nicole Frahm Julie McElrath UMDNJ Abe Pinter NYU/VA Susan Zolla-Pazner Harvard Joseph Sodroski Steve Harrison Norm Letvin IHV George Lewis Tony DeVico NIH VRC Gary Nabel Peter Kwong John Mascola Marie Pancera Jason McLellan Thai Ministry of Public Health

20. 23 July 2012 20 Towards a Globally Effective HIV Vaccine

21. 23 July 2012 21 MHRP’s Product Development Plan 21 REGIONAL VACCINE STRATEGY Building on the RV144 outcome and lessons learned, conduct efficacy trials of the prime-boost concept in: a)Thai MSM populations b)High-risk populations in Southern Africa BUILDING ON RV144 1 GLOBAL VACCINE STRATEGY Pursuing diverse platforms (e.g. vectors, multi- valent constructs or mosaic inserts) that build on the prime-boost concept and readily translate to multi-clade testing and a globally effective vaccine. DIVERSIFYING AND REFINING THE PORTFOLIO 2 MHRP’s vaccine development strategy emphasizes regional and global approaches.

22. 23 July 2012 22 Pox-Protein Public Private Partnership (NIAID-Gates led)

23. 23 July 2012 23 Planned studies are mutually reinforcing and will amplify public health impact and regional relevance. 23 May 2011 Precedent for vaccine efficacy Focus on regional public health impact Strategy for achieving potential licensure in target markets and having the broadest public health impact. Future amplification of global reach Mutually reinforcing studies strengthen and support public health benefit in target populations and the translation of the platform globally. THAILAND High Risk MSM THAILAND High Risk MSM US/EUROPE SOUTHEAST ASIA Republic of South Africa (RSA) High Risk Heterosexual Republic of South Africa (RSA) High Risk Heterosexual RV144 SOUTHERN AFRICA

24. 23 July 2012 24 Timeline 12131415161718 RV305 RV328 RV306 217-Vax (?) RV348 Bridge Study RV349 Go/No-Go

25. 23 July 2012 25 Short-term Development Objectives  Characterize vaccine immune responses using samples collected  In sufficient amounts  At the right times  From systemic as well as mucosal sites  Improve magnitude and durability of vaccine- induced responses

26. 23 July 2012 26 Research Strategy Three Exploratory Phase II immunogenicity trials in Thailand  Collections: serum, plasma, cells, genital fluids  Special collections: leukapheresis, gut biopsy, cervical biopsy, bone marrow aspiration (except RV305)  Broad array of humoral and cellular assays

27. 23 July 2012 27 RV305 (RV144 extended boost study) 135+27=162

28. 23 July 2012 28 RV306 (Intensive Immunogenicity) 404+56=460

29. 23 July 2012 29 Bridging Study—from AIDSVAX/alum to delta 11/MF59  ALVAC-HIV prime as before  gp120 boost comparison:  One B and one E, both gD negative, C1 delta 11  Novartis process and MF59 adjuvant  Part A Open Label safety assessment in the U.S. for Novartis product: Wk024812243248 GpN A110AAA/N A=ALVAC-HIV, N=Novartis rgp120B/E

30. 23 July 2012 30 Bridging Study Part B Thailand— compare AIDSVAX/alum vs Novartis gp120/MF59 BWk024812243248 GpN B1*90AAA/AVX 10PPP/P B290AAA/N 10PPP/P B390AAA/N 10PPP/P A=ALVAC-HIV, AVX=AIDSVAX B/E, N=Novartis rgp120B/E *Possibly use RV306 samples

31. 23 July 2012 31 Studies: RV144i immune correlates studies RV305 protein boosting study RV306 expanded immunogenicity study Objective: Determine correlate of protection for use in future trials; optimize the regimen Partners/Funders: US Army, Thai Gov’t, NIH, sanofi pasteur, BMGF 20102011201220132014201520162017 Ongoing RV144 Follow- up in Thailand Population: MSM, high-risk Products: ALVAC (sanofi) + gp120/MF59 (NVD) Objective: Confirm result & demonstrate efficacy in target population with potential for licensure Partners/Funders: US Army, Thai Gov’t, NIH, sanofi, BMGF? Thailand ph2b Population: Heterosexual, high-risk Products: ALVAC (sanofi) + gp120/MF59 (NVD) Objective: Extend result & translate vaccine to Africa, other high-risk groups Partners/Funders: NIH, HVTN, sanofi, Novartis, BMGF, RSA? Africa ph2b Population: Heterosexual, high-risk Products: DNA + NYVAC (sanofi) + gp140 (Polymun)/MF59 (NVD) vs. NYVAC (sanofi) + gp140 (Polymun)/MF59 (NVD) Objective: Extend results & accelerate evaluation of other products using adaptive trial design and first available protein Partners/Funders: NIH, HVTN, sanofi pasteur, Novartis, BMGF S. Africa ph2b Licensure Research Candidate selection ALVAC is default vector prime Proteins boosts TBD RV144 immune correlates Immune grid Cost, product availability Pox-Protein Development Plan

32. 23 July 2012 32 Ad26-MVA +/- protein Barouch et al Nature 482:89-93 02 Feb 2012

33. 23 July 2012 33 Nature 482, 89–93 (02 February 2012) 0 20 40 60 80 100 02468 % Uninfected Number of IR Challenges DNA/MVA MVA/MVA Ad26/MVA MVA/Ad26 Sham

34. 23 July 2012 34 MVA/Ad26 and Ad26/MVA Regimens Lower Early Setpoint Viral Loads Following SIVmac251 Infection Log SIV RNA Days Following Infection Log SIV RNA Sham MVA/MVADNA/MVA MVA/Ad26 5.75 6.09 5.47 4.55 Days Following Infection Ad26/MVA 3.83 3x resistance to infection 4/8 : viremia blunted 1 log 3/8 : rapid virologic control 1/8 : persistently uninfected

35. 23 July 2012 35 Protection Against Acquisition of IR SIVmac251 by Ad35/Ad26-SIVsmE543GagPolEnv Vaccine

36. 23 July 2012 36 Ad26-MVA correlates analysis Acquisition endpoint. envelope binding antibody r=.79 p<.0001. neutralization antibody r=.50 p=.0034 ADCC r=.38 p=.034 (trend) set point viral load endpoint, Many correlates (N=27); prechallenge gag elispot count and gag elispot breadth were both correlated (r=-.50 p=.006 and r=-.64 p=.0002, respectively) with the endpoint. peak envelope binding antibody r=-.70 followed by prechallenge neutralizing antibody r=.67.

37. 23 July 2012 37 Summary  RV 144 demonstrated that vaccines can provide HIV acquisition protection.  Correlates of risk of infection were discovered in RV 144.  Correlates of risk of infection in Ad26-MVA (and other) vaccines have been discovered in NHP models.  We must educate (and remind) ourselves that correlates of risk may or may not generalize.  There is great value (but at a cost) to seek correlates of infection risk in future HIV vaccine trials.  Product development and scientific rationale must communicate with each other.

38. 23 July 2012 38 Acknowledgements Supported by: Collaboration for AIDS Vaccine Discovery Grant From the Bill and Melinda Gates Foundation HVTN, DAIDS, NIAID With Collaborations with the MHRP and Thai Ministry of Public Health  National Institute of Allergy and Infectious Diseases (NIAID)  National Institutes of Health (NIH)  Division of AIDS (DAIDS)  U.S. Department of Health and Human Services (HHS) Center for HIV/AIDS Vaccine Immunology (CHAVI) # U19 AI067854-06 HVTN