Safety and immunogenicity of H1/IC31 ®, an adjuvanted TB subunit vaccine, in HIV-infected adults with CD4+ lymphocyte counts greater than 350 cells/mm 3 : a phase II, multi-centre, double-blind, randomized, placebo-controlled trial Dr. Klaus Reither Swiss Tropical and Public Health Institute AIDS Melbourne On behalf of the Aurum102/THYB05 team

Background Tuberculosis: 8.6 million new active TB cases and 1.3 million TB deaths in 2012 (WHO). Urgent need to develop safe and effective TB vaccines to accelerate progress towards TB elimination. Essential to evaluate the safety and immuno- genicity of TB vaccines in HIV-infected persons. Abu Raddad et al, PNAS 2009

Background The H1/IC31 vaccine: recombinant fusion protein Ag85B-ESAT-6 TB vaccine [Hybrid (H1)], adjuvanted with IC31 ® H1/IC31 trials Phase Ia n=36 Phase Ib n=20 Phase Ic n=39 Phase IIa n=240 First trial in HIV-infected individuals Phase IIa n=48

Background Primary objective To evaluate the H1/IC31 TB vaccine in HIV- infected adults for:  Safety  Induction of cellular and humoral immunity Secondary objective To describe the effect of the H1/IC31 TB vaccine in HIV-infected adults on:  CD4+ lymphocyte counts  HIV viral loads

Trial sites Ifakara Health Institute: Bagamoyo, TZ Aurum Institute: Tembisa, SA

Trial design Inclusion criteria (summary)  Healthy (no evidence of active TB)  years of age  HIV infection CD4 > 350/mm 3  Naïve to antiretroviral therapy  Women of child bearing potential must not be pregnant and agree to avoid pregnancy  No medical history on conditions that compromise the safety evaluation Randomisation H1/IC31 vaccine or placebo was randomly allocated in a 5:1 ratio. Blinding The investigators, study monitors and participants were blinded. The study pharmacists prepared the investigational product. Syringes were masked in order to conceal a slight difference in the appearance of the H1/IC31 and placebo.

Primary immunogenicity endpoint Trial design Study day SCREEN Visit number Vaccination Safety Solicited local/systemic AEs XXX XXX Unsolicited AEsXXXXXXXXX QuantiFERONX X Haematology, Serum chemistryX XX XX UrinalysisXXXXXXXXX CD4+ count, HIV-1 viral loadXX X XXXX Immunogenicity WBA ICS X X X XX Schedule of events (summary)

Excluded (n=119) - Screening failure (n=109) - Withdrawn consent (n=1) - Sleep apnoea, persistent shortness of breath (n=1) - Enrolment closed (n=8) Randomised (n=48) H1/IC31 arm (n=40) Received 1 st vaccination (n=40) Placebo arm (n=8) Received 1 st vaccination (n=8) Received 2nd vaccination (n=39) Did not receive 2nd vaccination (n=1), because of pregnancy Received 2nd vaccination (n=8) Lost to follow-up (2nd vaccination and end of study) (n=1) Lost to follow-up (2nd vaccination and end of study) (n=0) Safety analysis (n=8) Screened (n=167) Immunogenicity analysis (n=4) Immunogenicity analysis (n=20) Consort diagram Safety analysis (n=40) Samples from Tembisa Site did not meet internal quality control standards

Variable Placebo (n=8)H1/IC31 (n=40) AgeMean (SD)34 (11.0)35.6 (8.0) GenderFemale n (%)6 (75.0)21 (52.5) Ethnic groupBlack n (%)8 (100)40 (100) Body Mass IndexMean (SD)23.5 (4.2)26.4 (7.4) BCG vaccination (self-report) Yes n (%)6 (75.0)33 (82.5) CD4 (cells/uL)Mean (SD)590.1 (155.5)652.9 (258.4) Viral load (cp/mL)Median (IQR)17887 (544, 43297)16968 (2228, 52547) Demographic and baseline characteristics

Safety Adverse events Placebo (n=8) H1/IC31 (n=40) All gradesGrade ≥3All gradesGrade ≥3 Solicited local AEs pain, tenderness, erythema, induration, nodules Solicited systemic AEs malaise, myalgia, headache, nausea, vomiting, athralgia, fatigue, chills, fever Unsolicited AEs Total Local injection site reactions were more common in H1/IC31 versus placebo recipients (65.0% vs. 12.5%, p=0.015) 3 serious adverse events (malaria, perianal abscess and pregnancy with death of premature child): not related to the investigational product No effect on CD4+ T cell count and HIV viral load

H1/IC31 vaccination group (n=20): IFN-γ, TNF-α, IL-2 and IL-17 expressing CD4+ T cells after stimulation with H1 Durable immune response: CD4+ T cell expressing IFN-γ, IL-2 or TNF-α Response independent of CD4 count or QFT status. Data not shown Immunogenicity - whole blood intracellular cytokine assay

H1/IC31 vaccination group (n=20): H1 specific CD4+ T cells expressing any combination of IFN- , TNF-  and IL-2 Predominately IFN-γ/TNF-α/IL-2 or TNF-α and IL-2 Poor CD8+ T cells responses. No humoral responses. Data not shown Immunogenicity - whole blood intracellular cytokine assay

Conclusions  Safety H1/IC31 was well tolerated and safe in HIV-infected adults, with CD4+ lymphocyte counts greater than 350 cells/mm 3, from TB endemic areas. Similar to safety profiles of previous trials in HIV-uninfected TB-uninfected, BCG vaccinated or latently TB-infected participants.  Immunogenicity H1/IC31 induced a persistent Th1-immune response with predominately TNF-α and IL-2 co-expressing CD4+ T cells and polyfunctional IFN-γ, TNF-α and IL-2 expressing CD4+ T cells.  Future clinical TB vaccine development Multistage vaccine H56/IC31 will continue in clinical development, might prevent acute TB disease as well as re-activation of LTBI. H1/IC31 data has been and will be used as supportive data. Aagaard C et al., Nat Med. 2011

PI: Gavin J Churchyard Lynn Katsoulis Trevor Beattie Nicolene Gardiner Sponsor: SSI Peter Andersen Søren T Hoff Peter Bang Ingrid Kromann Khadija Said Elirehema Mfinanga Claudia Dauben- berger Nicole Lenz Christian Pohl Benjamin M Kagina Elisabeth J Hughes Willem A Hanekom Thomas J Scriba Katherine L Fielding Hannah Jeffery Funded by the European Developing Countries Clinical Trials Partnership (EDCTP) Acknowledgment