Kristen Chalmet, Kenny Dauwe, Lander Foquet, Bea Van Der Gucht, Dirk - PowerPoint PPT Presentation

Kristen Chalmet, Kenny Dauwe, Lander Foquet, Bea Van Der Gucht, Dirk Vogelaers, Jean Plum, Linos Vandekerckhove and Chris Verhofstede AIDS Reference Laboratory and AIDS Reference Centre, Ghent University, Belgium Arevir Meeting, Bonn, Germany, May 2011

University Hospital Ghent, Belgium ž Patients newly diagnosed between 2001 and March 2009 ž No follow-up elsewhere, treatment naïve ž Willing to participate ž Part 1 à 519 patients selected

ž Demographics: age, gender, race ž Infection: route, timing, source ž Laboratory data: viral load, CD4 count, baseline drug resistance, history of STI infection (Syphilis, HBV, HCV, Chlamydia) ¤ PR-RT sequences contain sufficient information for phylogenetic analysis and localization of transmission events ( Hue et al. AIDS 2004; 18: 719-728 ) à 506 successfully sequenced pol sequences (97.5%) Transmission Cluster ⇔ at least 2 out of 3 criteria are fulfilled: 1. Bootstrap value ≥ 90 NJ analysis 2. Mean genetic distance ≤ 0.015 Bayesian analysis 3. Posterior probability = 1

ž Subtype: B: 60% non-B: 40% B Non B Chalmet et al. 2010, BMC Infectious Diseases, 10, 262.

26 transmission clusters (n ≥ 3) containing 169 individuals • Subtype B: 18 clusters (av. Number of patients 4.7 [3-10]) + 1 cluster of 57 patients • Non B subtypes: 7 clusters (av. Number of patients 3.7 [3-6]) B Non B Chalmet et al. 2010, BMC Infectious Diseases, 10, 262.

cluster cluster cluster cluster cluster cluster Multivariate Bin. Log. Regression Multivariate Bin. Log. Regression Multivariate Bin. Log. Regression Count Count Count Count Count Count p-value ODDS ratio p-value ODDS ratio p-value ODDS ratio 95% CI 95% CI 95% CI p-value p-value p-value 169 (33.4%) 337 (66.6%) 169 (33.4%) 169 (33.4%) 337 (66.6%) 337 (66.6%) Subtype B Subtype B Subtype B 84.6% 84.6% 84.6% 47.2% 47.2% 47.2% <0.001 <0.001 <0.001 - - - Homosexual transmission 83.3% 45.3% <0.001 3.1 1.8 - 5.4 <0.001 Homosexual transmission Homosexual transmission 83.3% 83.3% 45.3% 45.3% <0.001 <0.001 3.1 3.1 1.8 - 5.4 1.8 - 5.4 <0.001 <0.001 HBV + HBV + HBV + 33.5% 33.5% 33.5% 40.7% 40.7% 40.7% 0.12 0.12 0.12 - - - HCV + HCV + HCV + 8.4% 8.4% 8.4% 6.2% 6.2% 6.2% 0.356 0.356 0.356 Syphilis + Syphilis + Syphilis + 40.2% 40.2% 40.2% 21.8% 21.8% 21.8% <0.001 <0.001 <0.001 - - - Chlamydia + Chlamydia + Chlamydia + 40.4% 40.4% 40.4% 28.2% 28.2% 28.2% 0.013 0.013 0.013 - - - Gender (male) Gender (male) Gender (male) 91.1% 91.1% 91.1% 64.4% 64.4% 64.4% <0.001 <0.001 <0.001 - - - Caucasian origin 95.2% 58.2% <0.001 14.5 4.2 - 49.9 <0.001 Caucasian origin Caucasian origin 95.2% 95.2% 58.2% 58.2% <0.001 <0.001 14.5 14.5 4.2 - 49.9 4.2 - 49.9 <0.001 <0.001 DRM 7,10% 6,20% 0,709 DRM DRM 7,10% 7,10% 6,20% 6,20% 0,709 0,709 PHI PHI PHI 21.0% 21.0% 21.0% 12.6% 12.6% 12.6% 0.017 0.017 0.017 - - - Median (IQR) Median (IQR) Median (IQR) Median(IQR) Median(IQR) Median(IQR) p-value p-value p-value CD4 + T cells (cells/ µ l) CD4 + T cells (cells/ µ l) CD4 + T cells (cells/ µ l) 419.5 (311-580) 419.5 (311-580) 419.5 (311-580) 351 (192-550) 351 (192-550) 351 (192-550) 0.002 0.002 0.002 - - - Age (years) Age (years) Age (years) 36 (31-42) 36 (31-42) 36 (31-42) 38 (32-45) 38 (32-45) 38 (32-45) 0.067 0.067 0.067 0.9 0.9 0.9 0.92 - 0.97 0.92 - 0.97 0.92 - 0.97 <0.001 <0.001 <0.001 Predictors for being a member of a cluster ž Subtype B infection - Homosexual transmission – Male – Caucasian origin ž Homosexual transmission ž More STI à Risk behavior? ž Caucasian origin ž Higher CD4 + T cell counts and more PHI à Earlier presentation? ž Slightly younger of age

Combination of genetic variability with patients demographics and laboratory data provides a more in depth understanding of the local epidemic More and larger transmission clusters are seen in Subtype B infected ž patients compared to non B infected Association between phylogenetic clustering, homosexual transmission ž and presence of other STI à high risk-taking MSM are the most important source for local onward HIV transmission. Tendency for earlier presentation of MSM ž à Higher awareness of risk-taking?  Continuous efforts to sustain prevention programs targeting MSM are needed!

University Hospital Ghent, Belgium ž Patients newly diagnosed between 2001 and 2009 ž No follow-up elsewhere, treatment naïve ž Willing to participate ž à 594 patients selected PR-RT sequences contain sufficient information for ¤ phylogenetic analysis and localization of transmission events ( Hue et al. AIDS 2004; 18: 719-728 ) à Succesful pol sequencing for 576 patients (97%) Transmission Cluster ⇔ at least 2 out of 3 criteria are fulfilled: 1. Bootstrap value ≥ 90 NJ analysis 2. Mean genetic distance ≤ 0.015 3. Posterior probability = 1 Bayesian analysis

University Hospital Ghent, Belgium ž Patients newly diagnosed ž between 2001 and December 2009 No follow-up elsewhere, treatment naïve ž Baseline plasma sample available and qualified for ž sequencing of pol region Willing to participate ž Part 2 à 576 patients selected (=part 1 + 70 patients)

ž Demographics: age, gender, race ž Infection: route, timing, source ž Laboratory data: viral load, CD4 count, baseline drug resistance ž Subtype: B: 60% non-B: 40% ž CCR5 genotype: wt/wt: 414 (87.5%) wt/ Δ 32: 59 (12.5%) Δ 32/ Δ 32: 0 ž Co-receptor tropism: population V3 sequencing, Geno2pheno (5.75% and 10% FPR cut off) Successful for 539 individuals: 11.9% X4/DM (5.75%) 19.1% X4/DM (10%)

Correlates for tropism X4/DM R5 Patients (total n=539) 103 436 19,1% 80,9% p-value Age 38 (31-43) 37 (31-44) 0,67 Gender Male 76% 73% 0,63 Female 24% 27% Origin Caucasian 73% 71% 0,70 African 19% 25% 0,26 Other 8% 4% 0,16 CCR5 genotype wt-wt 89% 87% 0,63* wt-D32 11% 13% Infection status Acute 56% 63% 0,51 (n=144; X4/DM: n=25; R5: n=119) Chronic 44% 37% Transmission route Homosexual 62% 59% 0,65 Heterosexual 33% 38% 0,42 IVDU 5% 1% 0,05 Other 0% 1% 0,59 Transmitted drug resistance Yes (n=38) 13% 6% 0,01 No 87% 94%

X4/DM R5 Patient n 539 103 436 19,1% 80,9% p-value Baseline CD4 count Median (IQR) 360 (160-521) 385 (256-581) 0,012 CD4 <200 (n=108) 33% 17% <0,001 Viral load X4/DM R5 Patient n 539 103 436 19,1% 80,9% p-value Baseline viral load Median (IQR) 4,6 (4,0-5,0) 4,5 (3,9-5,0) 0,27 VL > 100 000 c/ml 29% 27% 0,59

X4/DM X4/DM R5 R5 Patient n=539 Patient n=539 103 103 436 436 19,1% 19,1% 80,9% 80,9% p-value p-value Subtype Subtype B B 323 323 55% 55% 61% 61% 0,29 non-B 216 45% 39% C 31 5% 6% 0,66 A 34 7% 6% 0,83 01_AE 43 17% 6% <0,001 02_AG 58 8% 11% 0,30 Other 50 9% 9% 0,83

ž 103/539 (19.1%) of newly diagnosed patients were infected with X4/ DM viruses (G2P 10%FPR). ž Presence of X4/DM virus was associated with lower CD4 counts but not with higher viral load. ž Presence of X4/DM virus was not associated with the wt/ ∆ 32 CCR5 genotype ž Significant higher prevalence of X4/DM viruses in patients infected with the 01_AE subtype, through IVDU or with a resistant strain.

B B Non B Non B Blue branches: transmission cluster (n ≥ 2) Red stars: X4/DM virus Chalmet et al. 2010, BMC Infectious Diseases, 10, 262.

X4/DM R5 X4/DM + R5 n (pts) n (pts) n (pts) n (pts) Transmission clusters 63 (261) 7 (20) 38 (167) 18 (74) Clusters (=2) 36 (72) 5 (10) 25 (50) 6 (12) Clusters (>=3) 27 (189) 2 (10) 13 (117) 12 (62) X4/DM viruses only 7/63 (11.1%) of all clusters

¤ MSM ¤ Almost identical PR-RT and V3 sequences ¤ Epidemiological link (n=3) ¤ Acute infection (n=3) ¤ Phenotype: DM (n=1); MT2 positive virus (n=2)

Selection of transmission pairs ¤ Epidemiologically linked as source and receptor ¤ Phylogenetically confirmed à 38 transmission pairs ¤ Genetic distance in pol ≤ 0.001 à 13 transmission pairs X4/DM R5 X4/DM + R5 Source-receptor pairs 13 4 (31%) 9 (69%) 0 Transmission route 2 HoS 2 HeS 7 HoS 2 HeS Subtype 2 B 2 non B 7 B 2 non B

ž Viruses reported as X4/DM (FPR <10%) can be readily transmitted: Overall X4/DM incidence in newly diagnosed individuals: 19.1% Ø X4/DM in transmission clusters: 11.1% Ø X4/DM in transmission pairs: 31% Ø ž This observation DOES NOT exclude the use of the CCR5 receptor at transmission but warrants a rethinking of the dogma that mainly R5 strains are transmitted. ž Patients infected with X4/DM strains are at risk for Faster immune deterioration Ø Intrinsic resistance to CCR5 inhibitors. Ø  Baseline tropism determination and early treatment of those infected with X4/DM ?

ARL ARC Chris Verhofstede Dirk Vogelaers Linos Vandekerckhove Kenny Dauwe Bea Vandergucht Jacqueline Reynaerts Jolanda Pelgrom Els Demecheleer Filip Van Wanzeele Delfien Staelens Steven Callens Marlies Schauvliege Erica Sermyn Jean Plum Ghent University