1. Future of HIV vaccines Charlotta Nilsson Folkhälsomyndigheten
Public Health Agency of Sweden
Charlotta Nilsson

2. A vaccine with 50% protective efficacy would have an effect % change in the HIV-positive population over 20 years
Gray et al AIDS 2003, 17: Rakai, Uganda as an example
Charlotta Nilsson

3. HIV vaccine Preventive (prophylactic) Therapeutic
Charlotta Nilsson

4. Presentation outline
Charlotta Nilsson

5. Immune response Blood Cell mediated immune response
Antibody mediated immune response
Charlotta Nilsson

6. Immune response- cytotoxic T cells
Charlotta Nilsson

7. Immune response-Antibodies
Isotype
Structure
Passes the
placenta
Bind mast cells
Bind
phagocytes
Activates complement
Other
IgM - +
First antibody to develope
IgD
B-cell receptor.
IgG
Opsonization and ADCC. Four subclasses; IgG1, IgG2, IgG3, IgG4.
IgE
Allergic reactions
IgA
Two subclasses; IgA1, IgA2. Available as secretory IgA (sIgA)
Charlotta Nilsson

8. Immune mechanisms Helper T cells (CD4+) Cytotoxic T celler (CD8+)
Antibodies produced by B-cells
Soluble proteines (cytokines, chemokines)
CD8+
Charlotta Nilsson

9. HIV-1
Vi har valt att inkludera gener som kodar för flera delar av HIV – detta föra tt bredda svaret och inte förlika sig på svar mot endsast en komponent. Vi har valt att inkludera både interna struktirella delar av HIV .nukleokapsiden, ytproteinerna samt några av de enzymer HIV kodar för.
Vi har designat vaccinet med målet att vaccinera I östra afrika och mer specifikt I Tanzania, vi har därför valt att inkludera gener från HIV av olika subtyper.
Så här ser vårt vaccin ut, sju olika plasmider som kodar för de proteiner jag talade om. Vår rekombinanta virusvektor är som sagt modified vaccinia ankara och det kodar också för tre olika delar av HIV.
Charlotta Nilsson

10. Transmitted as viral particles or as cell associated virus
Charlotta Nilsson

11. HIV infects and destroys immune cells
Charlotta Nilsson

12. HIV infects and destroys immune cells
Natural infection
Charlotta Nilsson

13. HIV integrates in the host cell genome and evades the immune system
Charlotta Nilsson

14. HIV Env variability
Charlotta Nilsson

15. HIV Env variability
Charlotta Nilsson

16. Vaccine strategies Live attenuated Killed/ inactivated
Protein/ subcomponents
Recombinant protein
Yellow fever
Polio
Diftheria
Human papiloma virus (HPV)
Tuberculosis (BCG)
Cholera
Pertussis
Hepatitis B
Measles
Hepatitis A
Tetanus
Mumps
Influenza
Haemophilus influenzae type B (Hib)
Rubella
Pneumococci
Charlotta Nilsson

17. Model for the effectiveness of a live attenuated vaccine
Virus-
load
Limit for
disease
progression
vaccine-
effect
virus-
detection
Vaccine-
induced
disease
protection
no vaccine
effect
Time
Charlotta Nilsson

18. What type of HIV-vaccine?
A live attenuated vaccine
is too dangerous
Inactivated virus is also
too dangerous
Purified virus proteins
have been shown to be
ineffective
New vaccine concepts
are needed
RNA
Charlotta Nilsson

19. HIV vaccine candidates new concepts Live recombinant virus
HIV “harmless” virus “harmless”
hybrid virus
expressing
HIV gene
products
Charlotta Nilsson

20. Examples of live recombinant vaccines used as HIV vaccine candidates
Poxvirus
Vaccinia
Modified vaccinia Ankara
Attenuated vaccinia (NYVAC)
Avipox (canarypox, ALVAC)
Adenovirus
Semliki Forest virus
Venuzuelan Equine Encephalitis virus
Charlotta Nilsson

21. An single immune correlate of protection has not been identified
T-helper cells (CD4+ T celler)
Ranki et al. AIDS 1989; 3:63-69 (exposed uninfected individuals)
Clerici et al. J Infect Dis 1992;165: (exposed uninfected individuals)
Cytotoxic T cells (CD8+ T celler)
Betts et al. Blood 2006, 107: (long-term non-progressors)
Langlade-Demoyen etal. J Clin Invest 1994; 93: (exposed uninfected individuals)
Schmitz et al. Science 1999, 283: (non-human primates)
Jin et al. J Exp Med 1999, 189: (non-human primates)
Antibodies
Rasmussen et al. AIDS 2002, 16: (non-human primates)
Baba et al. Nat Med 2000, 6: (non-human primates)
Mucosal IgA and serum IgA
Devito et al. AIDS 2000;14: (exposed uninfected individuals)
Natural killer cells (NK cells)
Jennes et al. J Immunol 2006; 177: (exposed uninfected individuals)
Charlotta Nilsson

22. A single immune correlate of protection has not been identified
Exposed uninfected individuals
Long-term non progressors or elite controllers
Animal models (mouse, non-human primates)
Clinical efficacy trials are needed!
Charlotta Nilsson

23. Obstacles in finding a safe and effective prophylactic HIV vaccine
HIV targets immune cells
The HIV genome integrates in the host cells, thereby avoiding the immune response
Transmitted as virus particles and/or as cell-associated virus
HIV is variable, especially with regards to the envelope
Traditional vaccine strategies are not applicable
A singel immune correlate of protection has not been identified
Charlotta Nilsson

24. The ideal prophylactic vaccine
Induce a broad immune response
Induce a durable immune response
Systemic and local (mucosal) immunity
Protect against both free virus particles and virus infected cells
Excellent safety profile
Simple and cheap to produce
Have a simple vaccination regimen
Charlotta Nilsson

25. HIV vaccine Prevent infection (sterilizing immunity)
Chronic controlled infection
Lower/low viral load
Prevent/delay disease progression
Prevent/reduce transmission
Charlotta Nilsson

26. HIV-vaccine candidate look like?
What would your
HIV-vaccine candidate
look like?
How would you go about testing it?
Charlotta Nilsson

27. Clinical vaccine trials
Phase I
10s with low risk
Safety and immunogenicity
1-2 years
Phase II
100s with low risk
Phase III
High risk groups
Efficacy trial, needed for product registration
3-5 years
Test-of-
concept
3000 high risk groups
Efficacy trial, in preparation for possible phase III trial
2-3 years

28. HIV vaccine studies (www.iavi.org)
Charlotta Nilsson

29. Completed phase III clinical HIV vaccine trials
Recombinant protein/peptide 2
Live recombinant pox virus + protein 1
DNA prime + recombinant Adeno virus 1
Charlotta Nilsson

30. RV144, ”the Thai trial”, a phase III HIV vaccine trial AIDS Vaccine 09 conference
Supachai Rerks-Ngarm,
Ministry of Public Health, Nonthaburi, Thailand
Nelson Michael,
US Military HIV Research program, Rockville, USA
Mark de Souza,
US Military HIV Research program/AFRIMS, Bankok, Thailand
Charlotta Nilsson

31. Background Phase I/II trial testing AIDSVAX B/E (n=92)
J Aquir Immune Defic Syndr 2004;37:
Phase I/II trial testing ALVAC-HIV (vCP1521) and AIDSVAX B/E (n=133)
J Infect Dis 2004;190:702-6
Phase I/II trial testing ALVAC-HIV (vCP1521) prime with oligomeric gp160 (92TH023/LAI/DID) or bivalent gp120 (AIDSVAX B/E) boost (n=130)
J Aquir Immune Defic Syndr 2007;46:48-55
Charlotta Nilsson

32. Background
1. Phase III trial testing recombinant gp120 AIDSVAX B/B (n=5403)
J Infect Dis 2005;191:654-65
2. Phase III trial testing AIDSVAX B/E (n=2546)
J Infect Dis 2006;194:
3. Phase III trial testing ALVAC-HIV (vCP1521) and AIDSVAX B/E ( n=16402)
N Engl J Med 2009;361
Charlotta Nilsson

33. RV144- Volunteers 18-30 y old Raygong and Chon Buri Provinses in
26676 assessed for eligibility
128 were excluded
26548 were tested for HIV
17350 underwent clinical screeening
947 were excluded
16402 underwent randomization
7 were HIV –positive on PCR
5 received vaccine
2 received placebo
16395 did not have HIV infection
8179 received vaccine
8198 received placebo
6176 were included in per-protocol analysis
6366 were included in per-protocol analysis
Intention-to-treat
18-30 y old
Raygong and
Chon Buri
Provinses in
Thailand
8780 withdrew
418 had HIV infection
Modified intention-to-treat
Rerks-Ngarm S et al. N Engl J Med 2009; /NEJMoa

34. RV144-Vaccines ALVAC-HIV (vCP1521) AIDSVAX B/E
Canarypox vaccine developed by Virogenetics Corporation and producerd by Sanofi Pasteur.
Gag and Pro of subtype B (LAI)
gp120 of subtype E (CRF01_AE )
gp41 of subtype B (LAI)
AIDSVAX B/E
Bivalent gp120 vaccine produced originally by Genentech, Inc., further developed by VaxGen, Inc.
Subtyp E from HIV-1CM mg
Subtyp B from HIV-1MN 300mg
Alum adjuvant 600mg
Charlotta Nilsson

35. RV144- Vaccination scheme4 12 24
ALVAC
AIDSVAX B/E
weeks
Follow-up: every 6 months for 3 years
Charlotta Nilsson

36. RV144-endpoint HIV-1 infection Early primary viremia
Serology
Enzyme immunoassay
Western blotting
Molecular biology techniques
Amplicor HIV Monitor assay (Roche)
Procleix HIV discriminatory assay (Novartis)
CD4+ T cell determination
Three determinations of HIV-1 RNA within 6 weeks of seroconversion -> mean viral load
Charlotta Nilsson

37. Protective efficacy: 26.4% (95% CI, -4 to 47.9;P=0.08) RV144- resutat
Kaplan-Meier Cumulative Rates of Infection, According to Type of Analysis
Rerks-Ngarm S et al. N Engl J Med 2009; /NEJMoa
Protective efficacy:
26.4% (95% CI, -4 to 47.9;P=0.08)
RV144- resutat
26.2% (95%CI, to 51.9;P=0.16)
Figure 2. Kaplan-Meier Cumulative Rates of Infection, According to Type of Analysis. The vaccination regimen was completed approximately 6 months after the first dose was administered. In the intention-to-treat analysis involving 16,402 subjects, the vaccine efficacy was 26.4% (95% confidence interval [CI], -4.0 to 47.9; P=0.08) (Panel A). In the per-protocol analysis involving 12,542 subjects, the vaccine efficacy was 26.2% (95% CI, to 51.9; P=0.16) (Panel B). In the modified intention-to-treat analysis involving 16,395 subjects (excluding 7 subjects who were found to have had HIV infection at baseline), the vaccine efficacy was 31.2% (95% CI, 1.1 to 51.2; P=0.04) (Panel C).
31.2% (95%CI, 1.1 to 51.2;P=0.04)
Charlotta Nilsson

38. RV144- immune response
Substudy of volunteers (vaccinated vs. placebo, 4:1)
Cell mediated immune response
Interferon-g ELISpot (subtype E-Env, B-Gag)
Intracellular cytokine staining (IFN-g/IL2)
Lymfocytproliferation assay (3H-thymidine uptake)
Antibody mediated immune response
ELISA-gp120 HIV-1MN, gp120 HIV-1CM244,
p24 Gag (subtype B)
Charlotta Nilsson

39. Immune response at the time of trial initiation
and 12 months after vaccinations
Rerks-Ngarm S et al. N Engl J Med 2009; /NEJMoa
RV144-results
Geometric mean Ab titer:
gp120MN
gp120A p
Median SI:
Gp120MN 24
gp120A
p24 4
Table 3. Immunogenicity Analyses at Baseline and 12 Months.
Charlotta Nilsson

40. RV144-conclusion
”This ALVAC-HIV and AIDSVAXB/E vaccine regimen may reduce the risk of HIV infection in a community-based population with largely heterosexual risk”
”Vaccination did not affect the viral load or CD4+ count in subjects with HIV infection”
”Although the results show only modest benefit, they offer insight for future research”
Charlotta Nilsson

41. Continued work with RV144 Identify correlates of protection
Improve the vaccine to give better protection than the 60 % protective efficacy that was seen after 1 year of follow-up.
Nelson Michael AIDS Vaccine 2010
Charlotta Nilsson

42. RV144- correlates of infection risk
In pilot studies, 17 antibody and cellular assays met pre-specified criteria, of which 6 were chosen for primary analysis
Binding of plasma IgA to Env
Avidity of IgG antibodies to Env
Antibody-dependent cellular cytotoxicity
HIV-1 neutralizing antibodies
The binding of IgG antibodies to variable regions 1 and 2 (V1V2) of gp120 Env
The level of Env-specific CD4+ T cells
Charlotta Nilsson

43. RV144- correlates of infection risk
Assays were performed in samples from 41 vaccinees who became infected and 205 uninfected vaccinees, obtained 2 weeks after the final vaccination.
1. Binding of IgG antibodies to variable region 1 and 2 (V1V2) correlated inversely with the rate of HIV infection.
2. The binding of plasma IgA antibodies to Env correlated directly with the rate of infection.
Secondary analyses suggested that Env-specific IgA antibodies may mitigate the effects of potential protective antibodies.
Haynes BF, Gilbert PB, McElrath MJ, et al. Immune-correlates analysis of an HIV-1 vaccine efficacy trial. N Engl J Med 2012; 366:
Charlotta Nilsson

44. HIVIS03 En phase I/II HIV vaccine study at Muhimbili University of
Health and Allied Sciences och Muhimbili National Hospital,
Dar es salaam, Tanzania

45. HIV multi-gene/multi-subtype vaccine9% D 6% C
30% AC
34% CD
ACD AD
Tanzania
p37 gag A
gp160 env B
p37 gag B
gp160 env A
RTmut B
gp160 env C
Vi har valt att inkludera gener som kodar för flera delar av HIV – detta föra tt bredda svaret och inte förlika sig på svar mot endsast en komponent. Vi har valt att inkludera både interna struktirella delar av HIV .nukleokapsiden, ytproteinerna samt några av de enzymer HIV kodar för.
Vi har designat vaccinet med målet att vaccinera I östra afrika och mer specifikt I Tanzania, vi har därför valt att inkludera gener från HIV av olika subtyper.
Så här ser vårt vaccin ut, sju olika plasmider som kodar för de proteiner jag talade om. Vår rekombinanta virusvektor är som sagt modified vaccinia ankara och det kodar också för tre olika delar av HIV.
rev B
Charlotta Nilsson

46. MVA* / CMDR boost Subtype A Subtype E *Modified Vaccinia Ankara
Developed by P Earl and B Moss, Laboratory of Viral Diseases, NIAID, NIH
Produced by Walter Reed Army Institute of Research
Deletion III
Deletion II
MVA
gag
protease / RT
gp150 env
Subtype E
CM235
Subtype A
CM240
mH5
Charlotta Nilsson
*Modified Vaccinia Ankara 46

47. HIVIS Bioject immunization
Injections are performed in the area of the deltoid muscle in both right and left arm. Even thou we have to give up to five shots at each immunization with the Bioject, the injections have been well tolerated and usually commented by the voluntaries as less painful than regular needle injections.
Charlotta Nilsson

48. HIVIS03 Study Objectives
To assess safety and immunogenicity of a HIV-1 plasmid DNA-MVA prime boost vaccine candidate*
To build expertise and capacity in evaluating HIV vaccine candidates in Tanzania
*Previously underwent phase I trial in Sweden with excellent safety and immunogenicity results. JID 2008, Nov 15.
Charlotta Nilsson

49. Between >18 and <40 years of age HIV negative
HIVIS03 Volunteers were recruited among police officers in Dar es Salaam
Inclusion criteria
Informed consent
Between >18 and <40 years of age
HIV negative
Clinically healthy with normal laboratory values
At low risk of acquiring HIV
Charlotta Nilsson 49

50. Baraza at Police station
Charlotta Nilsson 50

51. HIVIS03 Study Design RCT, conducted 2007 to 2012
Arm
No.
DNA immunization
MVA boost I 20
DNA IM by Biojector (3.8 mg)
MVA 108 pfu IM II
DNA ID by Biojector (1.0 mg)
IIIa 10
Saline IM by Biojector
Saline IM
IIIb
Saline ID by Biojector
Months 1 3 9 21
Recombinant MVA/Placebo
Plasmid DNA/
Placebo
Charlotta Nilsson

52. HIVIS03 Summary Well tolerated.
Induces Broad and Potent Immune Responses (Bakari et al., Vaccine; 2011)
Id DNA immunization more efficient prime than Im.
Balanced CD4 vs CD8 and Gag vs Env responses.
Broadly cross-reactive and persistent lymphocyte proliferation assay responses.
All vaccinees serologically reactive after 2nd MVA.
Functional antibodies in up to 83% of the vaccinees
In summary, the results with the WP 1 of TMV-I project show that the DNA-MVA vaccine was………………………………………
Charlotta Nilsson

53. HIV vaccines New developments Delivery of DNA plasmids
Bioject®ZetaJet™
Ability to deliver to all three injection depths: Intramuscular, subcutaneous or intradermal 
Injection volumes range from 0.05mL to 0.5mL

54. HIV vaccines New developments
The DNA and MVA vaccines are given in combination with HIV envelope protein (Env)
DNA vaccines are given in combination with electroporation.
Total puls length: 0,27 seconds
Tid
Volt
2x450V
8x110V
Charlotta Nilsson

55. - + The current opens pores in the cell Before electroporation
Picture
courtesy of Inovio
Before
electroporation
Directly after
electroporation.
After electroporation
Cell - +
Electrode
Plasmid
Charlotta Nilsson
Roos et al, CytoPulse

56. Addition of gp140/GLA to MVA boost
Studies and Timelines
Study sites
Designation  N 
Vac. (placebo)
2004
2006
2007
2009
2010
2011
2012
2013
Stockholm HIVIS 01/02/05 40
Phase I
DNAx3
1st MVA
Published
2ndMVA
Dar es Salaam
HIVIS 03/06
40 (+20)
Phase I/II
3DNA
1st MVA
2nd MVA
Vaccine
29 (2011);
3rd MVA
Analysis ongoing
Dar + Mbeya
TaMoVac I (Tz)
108 (+12)
Phase II
MVAx2 
 gp140/GLA
Maputo
TaMoVac I (Moz)
20 (+4)
MVAx2
Stockholm
HIVIS 07 27
Phase 1
+/-elpor.*
+/-gp140
Dar+Mbeya+
TaMoVac II
180 (+18)
 DNAx3
+/- elpor*
Addition of gp140/GLA to MVA boost
Subsequently, a number of studies have been or are being conducted in Tanzania, Sweden and Mozambique as summarised in this slide
For the sake of this presentation I will focus on studies in Tanzania and Mozambique; and furthermore I will dwell on Immunogenicity data only.
Suffice to say here that so far we have not observed a safety issue of concern in all these trials
*elpor = i.d. electroporation
Finished; Ongoing; Planned

57. All-Collaborators Meeting, February 2011, Bagamoyo, Tanzania
This picture is from a 2011 collaborators meeting where the Guest of Honour was HE the Ambassador of Sweden in Tanzania.
This is part of networking, and these meetings are held annually
All-Collaborators Meeting, February 2011, Bagamoyo, Tanzania 57 57

58. Summary
Developing a prophylactic HIV vaccine has proven to be difficult.
No singel correlate of protection is known but we have evidence supporting development of vaccine candidates that induce both cell-mediated immunity and functional antibodies.
Several HIV vaccine candidates are being tested in large efficacy trials
It is a collaborative effort!
Charlotta Nilsson

59. When do we have an HIV vaccine?
Discovery
Vaccine for use
Time until a vaccine was available (years)
Smallpox -
1796
Measles
1953
1963 10
Polio
1908
1955, 1961 47
Mumps
1934
1948, 1967 12
Rubella
1938
1969 31
Varicella
1954
1988 34
Hepatitis B
1965
1981 16
Hepatitis A
1973
1995 22
HIV
1983
??? ??
When can we expect to have a functionally working vaccine in the market? Can we learn from history or is HIV so fundamentally different that it will take another generation before we have the first vaccine?
I will leave you with this question. Hopefully we will live long enough to answer this question.
Charlotta Nilsson

60. Tack! Thank you! Asante sana! Obrigada!
Charlotta Nilsson