HIV-1 Low Level Viremia: Clinical, Virological, and Immunological - PowerPoint PPT Presentation

HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients AREVIR-Meeting 2018 - Immune control in immunocompromised patients Marek Widera

Definitions of HIV-1 Persistent Viremia, Low-Level Viremia, blips LLV between >50 and <1000 cp/ml associated with increased risk of VF (Laprise et al. 2013) Viremia between 50 and 1000 cp/ml might predict the risk of subsequent virologic failure (Swenson et al. 2014) HIV-1 LLV >200 cp/ml predictor for VF (Navarro et al. 2016) Folie 2 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

The definition of HIV-1 Low Level Viremia and failure is not consistent Clinical Society Therapy success Low Level Viremia Virological Failure (year of the guideline release) < log ↓ after 4 weeks or DAIG , Deutsche AIDS-Gesellschaft < 50 cp/ml >50 cp/ml after 6 months 50 – 200 cp/ml (2017) (within 6 months) >2x >50 cp/ml after suppression DHHS , Department of Health and VL < LLOD (<20-75 cp/ml) LLOD – 200 cp/ml 2x > 200 cp/ml Human Service (2018) (within 12-24 weeks) IAS-USA , International AIDS Society < 50 cp/ml 2x > 200 cp/ml (2016) 50 – 200 cp/ml (within 24 weeks) (after suppression) 50 – 500 cp/ml (from 10/2017) EACS , European AIDS Clinical Society < 50 cp/ml 2x > 50 cp/ml (2017/2015) (within 6 months) (6 month after ART start) 50 – 1000 cp/ml (before 10/2017) Folie 3 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

Possible causes of HIV-1 Low Level Viremia Issues associated with HIV-1 LLV and blips Therapy associated drug resistance mutations (DRMs) Adherence or compliance issues, drug-drug interactions, pharmacogenomics and metabolism High baseline viral load, older generation drugs (former PI) Co-infections, vaccination Different test systems, inaccuracy of sampling and measurements Very low CD4 levels (AIDS-patients) Cellular reservoir release of defective viruses Folie 4 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

Rationale of the study and study design Are there further markers/features that can predict episodes of LLV? Where does LLV originate from? Periphery blood cells or viral reservoirs? What are the implications of long term LLV? Is there a marker to predict clinical and immunological outcomes? Folie 5 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

Rationale of the study and study design Part I) A retrospective data analysis was performed on a treatment history dataset containing parameters from routine diagnostics (pVL, ART-regimen, immunologic parameters ) 1388 HIV-positive patients (HIV+) all cART treated at the University Hospital of Essen from January 2006 to March 2015. Part II) Detailed molecular analysis of PBMCs (n=29) derived from LLV patients. Drug levels, viral evolution of DRMs using next-generation sequencing (NGS), proviral DNA, cell. RNA, immunological surrogate markers. Folie 6 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

Rationale of the study and study design Part I) A retrospective data analysis was performed on a treatment history dataset containing parameters from routine diagnostics (pVL, ART-regimen, immunologic parameters ) 1388 HIV-positive patients (HIV+) all cART treated at the University Hospital of Essen from January 2006 to March 2015. Part II) Detailed molecular analysis of PBMCs (n=29) derived from LLV patients. Drug levels, viral evolution of DRMs using next-generation sequencing (NGS), Proviral DNA, cell. RNA, surrogate markers. Folie 7 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

After initial viremic phases, subsequent episodes of LLV are observed more frequently ART begin first event subsequent event <40 <40 … Blips had no significant impact on the frequency of subsequent events An initial LLV increases the frequency of further LLV episodes Viremia >1000 cp/ml (VF) was associated with frequent subsequent LLV and viremia events. Folie 8 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

HIV-1 Low Level occurs more frequent in patients with prolonged decline periods after ART (Widera, Dirks et al. 2017) Folie 9 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

The probability of HIV-1 LLV in patients with prolonged decline posterior distribution ( 𝜄𝑞𝑤 , 𝜄𝑜𝑝 𝑞𝑤 ) 5% - 15% 15% - 35% 5% - 10% 13% - 30% Persistent Viremia is frequently followed by episodes of LLV Folie 10 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

The probability of HIV-1 LLV in patients with prolonged decline The longer the decline period, the higher the frequency of LLV Folie 11 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

Comparison of immunological markers of patients witch HIV-1 blips, LLV, and Viremia Folie 12 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

Comparison of immunological markers of patients witch HIV-1 blips, LLV, and Viremia Routine immunograms of HIV-1 LLV patients do not differ from those with blips but from those with virologic failure (>1000 cp/ml). Folie 13 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

Rationale of the study and study design: Part I) A retrospective data analysis was performed on a treatment history dataset containing parameters from routine diagnostics (pVL, ART-regimen, immunologic parameters ) 1388 HIV-positive patients (HIV+) all cART treated at the University Hospital of Essen from January 2006 to March 2015. Part II) Detailed molecular analysis of PBMCs (n=29) derived from LLV patients. Drug levels, viral evolution of DRMs using next-generation sequencing (NGS), Proviral DNA, cell. RNA, surrogate markers. Folie 14 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

HIV-1 Persistent Viremia, Low-Level Viremia, blips Detailed analysis of LLV (n=29) patients from routine diagnostics (2013-2015): VL: 234 (+/-231) cp/ml Duration of LLV: 270 (+/-151) days Analysis of plasma and PBMC samples pVL, drug level, DRMs (NGS). Isolation of fresh PBMC samples, same day as blood sampling (DNA/RNA analysis) Folie 15 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

Characteristics of Patients with HIV-1 Low Level Viremia In approx. 55% of the LLV were treated with PI In approx. 27% of the LLV patients drug levels were to low In approx. 30% of LLV patients new therapy associated DRM were identified (NGS) 72% of the LLV patients were infected with HIV-1 subtype B > The group of LLV patients is heterogeneous Folie 16 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

HIV-1 proviral DNA loads during LLV are higher than in patients under the LOD Proviral HIV-1 DNA in PBMCs: n s *** * in te g ra te d H IV D N A [c p /1 0 6 c e lls ]] n s * n s n s *** *** 1 0 6 1 0 7 1 0 8 to ta l H IV D N A [c p /1 0 6 c e lls ] 2 -L T R c irc le s [c p /1 0 6 c e lls ]] 1 0 6 1 0 7 1 0 5 1 0 5 1 0 6 1 0 4 1 0 5 1 0 4 1 0 3 1 0 4 1 0 3 1 0 2 1 0 3 1 0 1 1 0 2 1 0 2 1 0 0 1 0 1 1 0 1 1 0 -1 1 0 0 L L V T N < 4 0 L L V T N < 4 0 L L V T N < 4 0 Transcriptional HIV-1 activity in PBMCs: ** n s **** c o p ie s H IV c e ll R N A [c p /1 0 5 c e lls ] 1 0 4 LLV might derive from infected transcriptionally active 1 0 3 periphery blood cells; active replication 1 0 2 1 0 1 1 0 0 L L V T N < 4 0 Folie 17 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients

Expression of IFN stimulated genes during LLV is higher than in patients under the LOD Expression levels of IFN stimulated genes (ISGs): ** ** x -fo ld ch a n g e O A S 1 e x p re s sio n x -fo ld ch a n g e P K R e x p re s sio n x -fo ld c h a n g e IF N b e xp re s sio n 1 0 2 1 0 2 1 0 2 1 0 1 1 0 1 1 0 1 1 0 0 1 0 0 1 0 0 1 0 -1 1 0 -1 1 0 -1 1 0 -2 1 0 -2 1 0 -2 < 4 0 L L V T N < 4 0 L L V T N < 4 0 L L V T N Patients with LLV might have higher ISG expression indicating chronic inflammation Folie 18 Titel HIV-1 Low Level Viremia: Clinical, Virological, and Immunological Features in ART Treated Patients