The HVTN: Strategic Accomplishments of the First Decade and Beyond Tracey Day, Cecilia Morgan, Adi Ferrara, and Jim Kublin

a Publication of the HIV Vaccine Trials Network

Volume 3, issue 2 | march, 2012

Welcome to a new edition of the Our featured article in this issue is a HVTNews, the newsletter of the HIV look back at the Network’s achieve- Vaccine Trials Network. Our newslet- ments in 12 years of operation, and ter’s mission is to provide timely up- the impact it had on the HIV vaccine dates on the science of HIV vaccines, field. and the science of the HVTN. To that end, this issue features discussions that The search for an HIV vaccine is as include innate immunity studies at relevant and urgent today as it was at the HVTN, the possible impact of the the outset of the epidemic. We hope RV144 Correlates Analyses on future this issue gives you a glimpse of the vaccine trials, and the Network’s myriad ways in which the HVTN ongoing commitment to its study par- pursues our ultimate goal -- eradica- ticipants via our VISP testing service. tion with vaccination. Post RV144 Selection of gp120 [p. 8]. Figure of HIV-1 gp120 Env protein (red), bound to CD4 (yellow) and 17b antibody (blue) provided by Jonathan Stuckey, Vaccine Research Center, NIAID, NIH. The HVTN: Strategic Accomplishments of the First Decade and Beyond Tracey Day, Cecilia Morgan, Adi Ferrara, and Jim Kublin

The development of an effective HIV Streamlined Protocol has been streamlining the protocol vaccine is one of humanity’s greatest Development Process development and implementation scientific challenges. In acknowledg- process. This has been achieved largely ing that the path to an effective HIV Before a clinical trial can begin, a through efforts to bring stakeholders vaccine will likely require numerous trial protocol outlining the protocol’s to the table at the appropriate time iterative steps, the HVTN has aimed objectives, target population, and con- and ensure that all support opera- to improve the process of designing, duct must be approved. Defining and tions are in place at the projected trial implementing, and analyzing HIV compiling the required information opening date. vaccine clinical trials. Over the last is performed by the protocol team, decade, while conducting numerous which comprises a diverse group of A standard protocol template has also clinical trials, the Network has made stakeholders. They include community improved efficiency. A standardized significant scientific contributions to members, product experts, clinicians, template saves considerable time and the field and set precedents in com- laboratorians, statisticians, researchers, effort by allowing the focus to stay on munity engagement. These and other regulatory experts, and representa- the unique aspects of the particular major achievements are discussed tives from the Division of AIDS trial. The current template represents below (see Figure 1). (DAIDS), which usually sponsors the over a decade of historical learning by trial. A major Network achievement the HVTN. IN THIS ISSUE

ARTICLES 1 The HVTN: Strategic Accomplishments of the First Decade and Beyond 13 Auxiliary Research Projects 2011 6 Highlights from the Plenary Sessions of the HVTN Fall Conference 18 VISP and the HVTN’s Commitment to Poststudy HIV Testing 9 The RV144 Immune Correlates Analysis: Implications for Vaccine Evaluation CALENDAR [back cover] 10 The Role of Innate Immunity in Vaccinology The HVTN: Strategic Accomplishments of the First Decade and Beyond

The protocol drafting process culminates in a “face to face can and Hispanic populations are among those at highest risk meeting” in which every team member signs off on a final for HIV infection, but are under-represented in clinical trials, protocol document that is then submitted to DAIDS for in part because of mistrust in medical research due to histori- review, and ultimately for regulatory submission. Together, cal abuses. To improve representation of these cohorts, the the measures outlined above significantly improve the proto- HVTN pioneered the Legacy Project. This project’s mission is col development process and thus minimize the time to trial to build trust between researchers and minority populations, opening. and its success led to expansion into all DAIDS-supported HIV research networks (http://www.hanc.info/legacy/Pages). Commitment to Community Engagement Generation of Robust Immunogenicity Data To successfully conduct vaccine clinical trials, it is necessary for trial sites to communicate with and educate the community From the beginning, the importance of a centralized labora- about HIV prevention and clinical trials. Community advisory tory program that provides standardized, high quality im- boards (CABs) provide a means for community members and munogenicity data was recognized. A major HVTN accom- vaccine researchers to interact and thereby give a voice to the plishment has been the establishment of a laboratory program communities where trials are conducted. The HVTN in- endowed with standardized processes, comprehensive quality volves CAB representatives throughout the life of a trial from assurance measures, and robust data management systems that protocol development through trial implementation, and CAB ensure data integrity for complex immunogenicity assays. members also sit on HVTN committees. Community education programs are also conducted at trial sites to enhance the The Laboratory Program invests significant effort in assay enrollment and retention of trial participants. development and optimization, as well as training in specimen handling at all trial sites. A large number of assays are per- Another example of the HVTN’s strong commitment to com- formed in HVTN trials, including multiple “validated” assays munity is the provision of treatment for trial participants who for which stringent pass/fail criteria are defined, “qualified” as- become infected with HIV.1 The Network ensures these indi- says, for which optimization studies have been completed, and viduals have access to antiretroviral treatment, and maintains several exploratory assays are conducted as well. funds to provide this treatment in the event that it is not available. Following through on this commitment required strong Management of such vast and complex laboratory data poses community partnerships, especially in developing countries a number of challenges. For example, early phase trials place where treatment may not be easily accessible. high priority on rapid access to safety data. The data management system must also function among trial sites which Preventive HIV vaccine candidates should be tested in a wide vary in their ability to support such systems. To meet these range of individuals to ensure that a developed vaccine is varied challenges, programmers at the Statistical Center for protective in diverse populations. In the U.S., African Ameri- HIV/AIDS Research and Prevention (SCHARP) created an 2006 2002 Legacy Project consul- tation with Hispanic/ Latino and African- First “Face to Face” American leaders 2001 protocol meeting 2003 2005

Web portal for assay Sieve analysis Protocol development Commitment to ensure Neutralizing antibody data management developed process improvement ARV treatment assay validated 2004 initiated

STRATEGIC ACCOMPLISHMENTS ACHIEVED BY THE HVTN

2 MARCH 2012 VOLUME 3:2 | HVTNEWS The HVTN: Strategic Accomplishments of the First Decade and Beyond

integrated web portal system that allows incoming data to be “sieve analysis” methods. This novel approach determines monitored daily from any computer. This allows laboratory whether and how vaccine efficacy selectively blocks HIV staff to respond immediately to any deviations in specimen acquisition with certain HIV genotypes, and/or drives the or assay data at specific sites, and allows clinical development evolution of infecting viruses.8 In a collaborative effort that staff to assess safety data in a continuous manner. included SCHARP statisticians, sieve analysis methods were carried out for the Step study, and provided the first evidence Thus far, immunogenicity data typically serves as the driv- that a T-cell-based vaccine can have an effect on HIV-1.9 ing force for critical decisions on advancing products through clinical phases, since the majority of products tested by the Identification of immune responses that reliably predict vac- 2,3 HVTN to date have not generated adverse safety concerns. cine efficacy is a primary goal of vaccine research. The RV144 The Network’s efforts to generate robust immunogenicity HIV vaccine regimen, in a trial conducted by the U.S. Military data, therefore, provide the HVTN with the best possible HIV Research Program (USMHRP) and the Thai Ministry means with which to drive vaccine development. In addition, of Health, offered a modest vaccine efficacy of 31.2%, but pro- these measures yield a wealth of valuable resources to the field vided, for the first time, an opportunity to examine potential through assay methodology, reagent sharing, and the provision immune responses correlating with infection risk.10 SCHARP of high quality specimens to collaborators conducting ancillary statisticians and the HVTN Laboratory Program participated studies. in a large collaborative effort to investigate potential vaccine induced immune responses that correlated with HIV infection Statistical Leadership risk in the RV144 study. The group’s successful identification of two such correlates of risk was a major highlight of the The HVTN has been extremely fortunate to work with statis- recent AIDS Vaccine conference held in Bangkok, Thailand.11 ticians that are leaders in the field. SCHARP statisticians and These findings represent a milestone in HIV vaccine develop- programmers contribute to many aspects of HVTN vaccine ment, and have the potential to significantly affect future HIV testing, providing key input into trial design and assisting vaccine trials. in data analysis and management. Additionally, SCHARP statisticians are well known for their achievements in develop- Significant Scientific Contributions ing novel trial designs. For example, statistical parameters have been developed to provide earlier efficacy evaluations through The Network’s successful completion of many HIV vaccine phase 2b trials and for adaptive trial designs in which vaccine clinical trials has provided a wealth of information on the candidates failing to meet predetermined criteria are aban- safety and immunogenicity of a large number of diverse prod- doned, thus conserving resources and allowing only the most ucts and regimens (Table 1). Vaccine candidates that progress 4-7 promising candidates to proceed. into efficacy trials have the greatest potential to advance the field and generate immune correlates of protection. The largest SCHARP statisticians are also well known for developing ongoing HIV vaccine clinical trial, known as HVTN 505, is 2007 2010

Scientific outreach for post Step study ancillary P5 collaboration research 2009 initiated 2011 RV144 immune Intracellular cytokine Social science initiative HVTN 505 trial opened correlates collaboration staining assay validated 2008 initiated launched

Figure 1: Timeline of some of the strategic accomplishments achieved by the HVTN in the design, conduct, and evaluation of clinical vaccine trials globally. Color coding depicts accomplishments in the areas of protocol development (grey), laboratory (blue), statistics (orange), science (lavender), community engagement (green), and new directions (brown).

www.hvtn.org HVTNEWS | VOLUME 3:2 MARCH 2012 3 The HVTN: Strategic Accomplishments of the First Decade and Beyond

LOCATION OF CLINICAL TRIAL SITES THAT HAVE WORKED WITH THE HVTN

NORTH AMERICA Decatur, Georgia Rochester, New York San Juan, P.R. AFRICA ASIA Annandale, Virginia Denver, Colorado San Francisco, California Santo Domingo, D.R. Blantyre, Malawi Chiang Mai, Thailand Baltimore, Maryland (2) Houston, Texas Seattle, Washington SOUTH AMERICA Cape Town, South Africa Bethesda, Maryland Los Angeles, California St. Louis, Missouri Iquitos, Peru Durban, South Africa (2) EUROPE Birmingham, Alabama Nashville, Tennessee CARIBBEAN Lima, Peru Gaborone, Botswana Lausanne, Switzerland Boston, Massachusetts (2) New York City, NY (3) Kingston, Jamaica Rio de Janerio, Brazil Klerksdorp, South Africa Chicago, Illinois Orlando, Florida Port of Spain, Trinidad Sao Paulo, Brazil Medunsa, South Africa Cleveland, Ohio Philadelphia, Pennsylvania and Tobago Rustenburg, South Africa Dallas, Texas Providence, Rhode Island Port-au-Prince, Haiti Soweto, South Africa Raleigh, North Carolina

a phase 2b trial testing a vaccine regimen developed by the Future Directions Vaccine Research Center at the National Institute of Allergy A primary focus of HVTN activities is improving on the ef- and Infectious Diseases (NIAID). The regimen, a DNA prime ficacy and durability of the RV144 vaccine regimen. Toward followed by a recombinant adenovirus type 5 (Ad5) boost, was this effort, the HVTN is participating in a novel collaboration found to be the most immunogenic in any HVTN study to between pharmaceutical companies and non-profit organiza- date.12 The results of this trial together with the large amount tions, known as the Pox Protein Public Private Partnership of immunogenicity data being collected are expected to pro- (P5). P5 is a partnership between NIAID, the Bill & Melinda vide valuable information for future vaccine development. Gates Foundation, HVTN, the U.S. Military HIV Research Program, Sanofi Pasteur, and Novartis Vaccines. A primary Significant scientific advances are also made by collaborative aim is to extend and confirm the RV144 findings in other research. The HVTN has made a concerted effort to reach out geographical locations, such as South Africa, and to prepare a to the entire HIV vaccine research community for ancillary path to eventual vaccine licensure. studies. These studies provide a novel means for research to be conducted in conjunction with vaccine trials, which differs Completion and follow up analyses of the numerous ongoing from typical industry-run trials. Examples include the HVTN HVTN clinical trials, in particular HVTN 505, are expected laboratory oversight of over 25 studies by investigators around 13-15 to provide insight into future vaccine development strategies. the world on samples from the Step study. These and future trials also provide a valuable opportunity to perform behavioral research on aspects of clinical trial partici- Collaborative research conducted by the HVTN Laboratory pation. The HVTN recently launched its social science initia- Program also serves as a valuable resource to the HIV vaccine tive, to identify facilitators and barriers to trial participation, field in developing and evaluating vaccine concepts and ef- and improve recruitment and retention of participants in HIV ficacy signals. The program’s standardized approaches and years prevention clinical trials. of experience serve the vaccine community well in the ability to rapidly assemble collaborative teams that carry out state of After over a decade in existence, the HVTN has become the art immunological and virological analyses, which clarify known as an efficient, high quality network with processes and findings in efficacy studies worldwide. infrastructure that optimize HIV vaccine development. While still maintaining its intense focus on HIV vaccine development, the HVTN is exploring ways to leverage its strengths through collaborations with other HIV research networks

4 MARCH 2012 VOLUME 3:2 | HVTNEWS The HVTN: Strategic Accomplishments of the First Decade and Beyond

YEAR 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011* Total

Trials opened 1 2 2 6 7 5 4 5 1 11 3 10 57 Participants enrolled 14 389 282 338 1336 1180 2247 1216 124 3614 1616 1251 13607 Publications 12 10 5 13 15 16 14 14 18 20 27 28 192 Trials by product: Protein 1 2 3 DNA 2 2 1 1 1 7 Viral Vector 1 2 3 2 3 2 1 4 18 DNA + Protein 1 1 1 1 4 DNA + Viral Vector 1 1 3 1 3 1 2 12 Viral Vector + Protein 1 1 2 Trials by phase: ph 1 2 1 5 6 3 2 2 2 5 28 ph 1b 1 2 2 2 2 3 12 ph 2a 1 1 1 3 ph 2b 1 1 1 3 OTHER 1 1 1 5 1 2 11

Table 1: Table of HVTN Trials by Year. *Reflects numbers available at time of submission.

and through work in other disease areas. By incorporating the 3. DeBruyn G, Rossini AJ, Chiu YL et al. Safety profile of recom- expertise of leaders in the scientific, clinical, laboratory, and binant canarypox HIV vaccines. Vaccine. 2004;22(5-6):704-713. statistical arenas, and actively engaging local communities, the 4. Moodie Z, Rossini AJ, Hudgens MG, Gilbert PB, Self SG, Rus- HVTN generates a forceful synergy, propelling the field ever sell ND. Statistical evaluation of HIV vaccines in early clinical trials. closer to its goal of developing an effective HIV vaccine. Contemp Clin Trials. 2006;27(2):147-160.

Acknowledgements 5. Follmann D, Duerr A, Tabet S et al. Endpoints and Regula- tory Issues in HIV vaccine clinical trials: Lessons from a workshop. J For helpful discussions and input: Peter B. Gilbert, Steve G. Acquir Immune Defic Syndr. 2006. Self, M. Juliana McElrath, Lawrence Corey, Steve Wakefield, John Hural, Niles Eaton, Carter Bentley, Yunda Huang, Cris- 6. Gilbert PB. Some design issues in phase 2B vs phase 3 prevention trials for testing efficacy of products or concepts. Stat Med. tine Cooper-Trenbeath, Fatima Laher, Michael Keefer, Gail 2010;29(10):1061-1071. Broder, Elizabeth Adams, Mary Allen, Alan Fix, and Philip Renzullo. 7. Corey L, Nabel GJ, Dieffenbach C et al. HIV-1 vaccines and adaptive trial designs. Sci Transl Med. 2011;3(79):79ps13. Tracey Day is Senior Science Writer, Cecilia Morgan is Associate Director, Scientific Development, Adi Ferrara is Technical Editor, 8. Gilbert P, Self S, Rao M, Naficy A, Clemens J. Sieve analysis: methods for assessing from vaccine trial data how vaccine efficacy and Jim Kublin is Executive Director, HVTN. varies with genotypic and phenotypic pathogen variation. J Clin Epi- demiol. 2001;54(1):68-85.

9. Rolland M, Tovanabutra S, Decamp AC et al. Genetic impact of vaccination on breakthrough HIV-1 sequences from the STEP trial. References Nat Med. 2011;17(3):366-371.

1. Fitzgerald DW, Pape JW, Wasserheit JN, Counts GW, Corey L. 10. Rerks-Ngarm S, Pitisuttithum P, Nitayaphan S et al. Vaccination Provision of treatment in HIV-1 vaccine trials in developing coun- with ALVAC and AIDSVAX to prevent HIV-1 infection in Thailand. tries. Lancet. 2003;362(9388):993-994. N Engl J Med. 2009.

2. Gilbert PB, Chiu YL, Allen M et al. Long-term safety analysis 11. Haynes BF, Gilbert PB, McElrath JM, et al. Immune correlates of preventive HIV-1 vaccines evaluated in AIDS vaccine evalua- analysis of the ALVAC-AIDSVAX HIV-1 vaccine efficacy trial. N tion group NIAID-sponsored Phase I and II clinical trials. Vaccine. Engl J Med. Submitted. Continued on page 19... 2003;21(21-22):2933-2947.

www.hvtn.org HVTNEWS | VOLUME 3:2 MARCH 2012 5 Highlights from the Plenary Sessions of the HVTN Fall Conference Tracey Day and Cecilia Morgan

The HVTN Fall Conference took place in Seattle last No- The first correlate was the presence of IgG antibodies targeting vember. The meeting focused on several pertinent issues in the a highly variable region, called V1/V2, on the HIV Envelope HIV vaccine field, including updates from the RV144 cor- protein (Env). Vaccine recipients who generated the high- relates analyses, a session on lessons learned from viral sieve est levels of these antibodies had the greatest reduction in analyses, and a discussion on how pre-exposure prophylaxis HIV infection rate. These results were presented by Dr. Susan (PrEP) may impact HIV vaccine efficacy trials. As promised Zolla-Pazner (NYU School of Medicine). Dr. Corey asked by HVTN PI Dr. Larry Corey during his welcoming com- Dr. Zolla-Pazner how her group knew to look at the V1/V2 ments, the conference was a data-rich meeting representing region. The response was that they didn’t know but they should current and forward thinking. have, based on historical evidence indicating that antibodies targeting conserved variable regions can be broadly cross- RV144 Correlates Updates reactive. Pilot studies suggested that V1/V2 was a region of interest, which led to its selection for the correlates analysis. It The first of several RV144-related plenary sessions began was also noted that one advantage of binding antibodies (such with Dr. Jerome Kim (U.S. Military HIV Research Program as these IgG antibodies) is that they are more easily induced [USMHRP]), providing a quick summary of salient lessons via vaccination than the broadly neutralizing antibodies. learned from this study conducted by the USMHRP and the Thai Ministry of Health. This large efficacy trial, which was The second correlate was the presence of plasma IgA anti- held in Thailand, is the only preventative HIV vaccine trial bodies that bind to Env. In contrast to the Env-specific IgG to date where a reduced HIV infection risk was observed. antibodies, presence of these antibodies correlated with an Although the vaccine offered only a modest benefit, with a increased HIV infection rate. Importantly, the IgA antibodies vaccine efficacy of 31.2%, the results have significantly affected did not increase a person’s risk for HIV infection, but rather the field. During the last two years since publication of the interfered with the ability of the vaccine to decrease HIV in- primary study results, an enormous collaborative effort has fection. Exactly how an IgA antibody might interfere with an taken place to identify correlates of risk (ie, immune responses otherwise protective immune response is not known, but one that correlated with HIV infection). The initial results of this hypothesis is that the IgA antibody could block antibody-de- analysis were recently presented at the AIDS Vaccine 2011 pendent cellular cytotoxicity (ADCC), a mechanism by which Conference in Bangkok, Thailand. The HVTN Fall Confer- other antibodies promote destruction of HIV in infected ence provided an opportunity for researchers to share these cells. One way that IgA antibodies could do this would be by results with HVTN members in more depth. binding to the same site that IgG antibodies bind to when triggering ADCC. Dr. Georgia Tomaras (Duke University) Based on a series of pilot studies, the collaborative team presented unpublished data that support this hypothesis. She selected six assays measuring specific immune responses for also suggested that IgA antibodies could block other kinds of the correlates analysis. Responses from vaccine recipients who protective IgG functions, a topic that is the focus of ongoing became infected were compared with those from recipients research. Dr. Tomaras emphasized the need for future trials who remained uninfected. A statistical analysis plan, devel- to examine IgA responses not only in plasma, as was done in oped by Dr. Peter Gilbert (Statistical Center for HIV/AIDS RV144, but also in mucosal specimens where HIV infection Research & Prevention [SCHARP]) and colleagues, identified takes place, and where antibodies could have different effects. two correlates of risk.

6 MARCH 2012 VOLUME 3:2 | HVTNEWS HighLights from the Plenary Sessions of the HVTN Fall Conference

Thus far, the correlates analysis identified only antibody viral sequences from both the vaccine and placebo recipients responses as being potentially associated with protection; are then compared to the sequences in the vaccine. If, for ex- however T cell responses were also assessed. Dr. Julie McEl- ample, the virus sequences of vaccine recipients are less similar rath (Fred Hutchinson Cancer Research Center [FHCRC]) to the vaccine than those of placebo recipients, it suggests summarized these results. The vaccine reliably induced CD4+ that the vaccine had a sieve effect -- the immune responses T cell responses, which was encouraging, and analyses of sev- produced by the vaccine were able to “sift out” a specific kind eral exploratory assays, such as gene expression from individual of infecting virus (an acquisition effect), and / or affected viral T cell subsets, are still pending. Results from these analyses evolution during the course of infection (a postinfection ef- may point to T cell responses that also correlate with infection fect). risk; for example, those that promote antibody production by B cells. One of the first applications of sieve analysis involved the Step (HVTN 502/Merck 023) study. It found that although no ef- While the first correlates analyses were performed using each ficacy was observed, the vaccine did exert immune pressure on of the primary assays independently, subsequent research has the virus. More recently, sieve analysis was conducted for the examined the potential for pair-wise interactions between Phambili (HVTN 503) trial, which utilized the same vaccine assays to correlate with risk of HIV infection. Dr. Holly Janes regimen as Step. Unlike the Step study, only very weak effects (SCHARP) presented these studies, which found numerous were found on viral sequences of infected vaccine recipients interactions between assays. All of these interactions correlated in this trial. Dr. Tomer Hertz (SCHARP) explained that this inversely with IgA levels, suggesting that IgA antibodies can discrepancy could be due to the small number of infections interfere with multiple protective mechanisms provided by occurring in the trial (only 43 vs. 66 in Step). Another possible IgG antibodies. These findings suggest that considering mul- explanation for the difference is that the vaccine in the Pham- tiple assays may better predict infection risk. The ideal, how- bili trial utilized immunogens from HIV clade B in a region ever, is to identify immune responses that do not just correlate where clade C is predominant, whereas the Step study vaccine with infection risk but rather can predict vaccine efficacies. matched the predominant clade. These so-called surrogates of protection are ultimately needed to drive vaccine development; methods to identify them face a Dr. Morgane Rolland (USMHRP) presented results from a major hurdle, however, as identification requires comparison of global sieve analysis of the RV144 trial in which no acquisition vaccine induced immune responses between vaccine recipients effects were observed, but post-infection effects were noted. A and placebo recipients. Placebo recipients, however, have no follow-up study, presented by Dr. Paul Edlefsen (SCHARP), “vaccine induced” immune responses. Janes described how sought to focus the sieve analysis on the V1/V2 region of Env future trials could facilitate surrogate discovery by evaluating identified in the correlates analysis. Two viral amino acid sites baseline immune responses, and incorporating trial designs in within the V2 region of Env were found to be affected, lending which placebo recipients are vaccinated after trial completion credence to the notion that the immune responses identified in to obtain the missing data. the correlates analysis are indeed associated with the observed vaccine efficacy. Viral Sieve Analyses in Vaccine Trials: What Are They Teaching Us? In the roundtable discussion, Dr. McElrath noted that there is a pressing need to identify how best to collect samples for Viral sieve analysis is an approach developed by Dr. Peter viral sequencing analysis because the next efficacy trials are Gilbert and colleagues to determine whether a vaccine is hav- currently being planned. It was generally agreed that early and ing an impact on the virus. In the case where vaccine efficacy frequent samplings are essential for determining acquisition is observed, such as the RV144 trial, this information may also effects. However, there were differing opinions regarding how support hypotheses on the mechanisms of protection. comprehensive the sequencing should be. McElrath then con- cluded the session applauding the synergy achieved between In order to perform sieve analysis, the nucleic acid sequences the various sieve analysis experts representing the divergent of virus isolates from infected participants are determined. The fields of statistics, molecular biology, and virology.

www.hvtn.org HVTNEWS | VOLUME 3:2 MARCH 2012 7 HighLights from the Plenary Sessions of the HVTN Fall Conference

Post RV144 Selection of gp120 of high through-put sequencing (deep sequencing) to track PG9 development in B cells during the immune response. The In general protein immunogens are the most effective method ultimate goal of all of these studies is to identify vaccination of eliciting antibody responses. Based on the encouraging strategies to induce these potent antibodies. RV144 correlates results, suggesting the importance of antibodies binding to the gp120 portion of Env, there is intense Pox Vector Programs interest in including similar or improved gp120-derived immunogens in future efficacy trials. Dr. Antu Dey (Novar- In this plenary session, two major programs developing pox tis) described the selection process for HIV-1 clade C gp120 viral vectors for HIV vaccines were highlighted. proteins for use in South Africa, a predominantly clade C region. Based on immunogenicity, RV144 correlates results, and Dr. Giuseppe Pantaleo (Centre Hospitalier Universitaire Vau- production considerations, two proteins, TV1.C (Novartis) dois) described the development of NYVAC-C, a EuroVacc and 1086.C (CHAVI/Duke) were selected and will be used consortium pox virus vector. NYVAC-C is based on a vaccinia with the MF59 adjuvant in future trials conducted via the Pox virus strain that was attenuated by the deletion of 18 genes. Protein Public Private Partnership (P5; a partnership between By adding back a few of these genes, a replication competent the National Institute of Allergies and Infectious Diseases yet still attenuated version of the vector, called NYVAC-KC, [NIAID], Bill & Melinda Gates Foundation, HVTN, was also generated. Pantaleo presented data from nonhuman USMHRP, Sanofi Pasteur, and Novartis Vaccines). This novel primate studies comparing the immune responses induced collaboration aims to extend and confirm the RV144 findings by each of these vectors plus a gp120 boost, with or without and to prepare a path to eventual licensure. a DNA prime containing the env, gag, pol, and nef genes. The vaccines induced T cell responses and antibody responses, HIV virus isolates that succeed in infecting a new host differ including ADCC activity and IgG responses to V1/V2. In ad- from the viruses that persist in chronically infected individuals. dition, Pantaleo’s data showed that waning antibody responses A vaccine that prevents HIV infection will need to generate could be strengthened by including an additional protein boost immune responses against the types of viruses that are able to at 12 months. infect, also known as transmitted/founder viruses. Dr. Tomaras spoke on behalf of Dr. Bart Haynes, also of Duke University, Yiming Shao of the Chinese Center for Disease Control and regarding comparative studies of Env proteins from transmit- Prevention presented an overview of a large HIV vaccine pro- ter/founder viruses versus chronic phase viruses. This research gram ongoing in China. Multiple pox virus vectors are under aimed to identify gp120 proteins that may be able to improve development, including several derivatives of a smallpox vac- upon the efficacy observed for RV144. Tomaras reported that cine widely used in China (vaccinia Tiantan). Shao presented the TV1.C and 1086.C candidate proteins show the desired data from a phase 1a trial utilizing a replicating but highly profile, based on the RV144 correlates findings, of inducing attenuated version of this vector, called rTV. rTV contains the high IgG and low IgA Env-specific antibody titers in non- env, gag, and pol genes. He also showed results from a phase 1b human primates. trial utilizing rTV with a DNA prime. These studies indicated that the vaccine is safe and well tolerated. When the DNA The following presentations focused on the generation of prime was included, binding antibody responses were induced broadly neutralizing antibodies that bind to Env. Dr. Leonidas in all recipients and T cell responses in most. The HIV-specific Stamatatos (Seattle BioMed) presented ongoing studies aimed immune responses were somewhat reduced in those who to identify Env variants that elicit the broadest cross-neutral- had been previously exposed to vaccinia virus. A phase 2 trial izing antibody responses. His group sequenced numerous Env evaluating this regimen is underway, with additional phase 1 sequences from transmitter/founder viruses from the Pham- trials and a phase 2b trial planned for 2013. Likening the quest bili trial, and has identified some promising candidates. Dr. for an HIV vaccine to another seemingly insurmountable bar- Jason McLellan (Vaccine Research Center [VRC], NIAID) rier, the Mount Everest North Face, Shao ended his presenta- described the 3-dimensional structure of a broadly neutralizing tion with an image of a ladder installed by Chinese climbers, antibody, PG9, showing how it is able to bind a highly variable which enabled thousands of people to reach the summit via region among so many viral isolates. Dr. Marie Pancera (VRC, this route. NIAID) described an ongoing study utilizing a new method Continued on page 16...

8 MARCH 2012 VOLUME 3:2 | HVTNEWS The RV144 Immune Correlates Analysis: Implications for Vaccine Evaluation Holly Janes

The RV144 immune correlates analysis, of the search for surrogates of protection. by different types of vaccines. Related which identified IgG V1V2 and IgA An immune correlates study can only to the 2 considerations above is the binding antibody responses as significant evaluate the extent to which immune question of what role the V1V2 and IgA correlates of risk, was the first study of its markers are correlated with risk of infec- antibody responses should play in go/no- kind. This analysis was a follow-up study tion in vaccine recipients, since immune go rules for determining whether future within RV144, the first HIV vaccine responses are not observable in placebo vaccine candidates should be advanced efficacy trial with evidence of partial effi- recipients. Therefore it cannot distin- for further study based on phase 1 data. cacy. The statistical analysis was prespeci- guish between markers that are corre- fied and focused on six primary immu- lated with risk, regardless of vaccination, The design of future efficacy trials will nological variables. These variables were and markers that measure the degree of also be influenced by the correlates selected by an international consortium vaccine-induced protection (ie, surro- analysis. Increased attention is being of investigators based on pilot studies gates). Additional studies are needed to paid to ensuring that designs have ad- of 17 assay subtypes. The study demon- discriminate between these two hy- equate power for correlates assessment, strated the feasibility and importance of potheses. In RV144, the hypothesis that by having at least as many breakthrough a prespecified analysis plan to preserve the V1V2 antibody response measures infections in the vaccine arm as were ob- data integrity. Its primary focus on a very vaccine-induced protection is currently served in RV144. There is also discussion limited number of immunogenicity vari- being evaluated in the sieve analysis and of novel trial designs that would facili- ables enabled the analysis team to avoid in analyses of vaccine efficacy by HIV tate more complete vetting of putative spending power over a larger set; had all genotype. It will be further assessed in correlates, such as vaccinating all trial 165 variables been analyzed together, follow-up non-human primate studies. participants at baseline with a non-HIV the multiplicity adjustment would have Questions remain about what additional vaccine. Such a design modification lowered the required significance level studies are needed to confirm or refute would allow the missing HIV vaccine substantially, and the V1V2 and IgA the IgA abrogation hypothesis. immune responses in placebo recipients antibody correlates would not have been to be filled in, or “imputed”, under the detected. The results of the correlates study will assumption that the responses to the two impact the design of future phase 1 vaccines are correlated. Importantly, this The correlates analysis also demonstrated vaccine trials, particularly in the choice design would allow markers that are sim- the importance of examining potential of immune assays. IgG and IgA bind- ple correlates to be distinguished from correlates jointly as well as individually. ing antibody responses are now being markers that are true surrogates. Analyses of interactions among the six considered as primary immunogenicity primary variables raised the hypothesis endpoints. Yet there is some consensus The RV144 correlates analysis set a prec- that the V1V2 antibody response is an that these should not be the exclusive fo- edent for future correlates studies. The independent predictor of vaccine-in- cus given that much additional research results will impact the design of future duced protection, while the IgA antibody is needed to determine if the V1V2 and trials, although exactly how remains un- response acts by abrogating the protec- IgA antibody responses actually measure clear. As is typical of exploratory studies, tive effects of the ADCC, neutralizing the degree of vaccine-induced protection. the study raises more questions than it antibodies, IgG avidity, and CD4+ T cell It is possible that these correlates of risk answers. responses. are, in reality, measures of susceptibility to infection, regardless of vaccination. Holly Janes is a Statistician at the HVTN This study illustrated the role of a corre- Moreover, these responses may not have Statistics and Data Management Center lates analysis within the broader context any ability to predict protection afforded

www.hvtn.org HVTNEWS | VOLUME 3:2 MARCH 2012 9 The Role of Innate Immunity in Vaccinology Antje Heit and Erica Andersen-Nissen

C-Type erial Cell Wall Two distinct parts of the immune system Bact Funga p o n e n ts L e c t in R e c e p t o r s l Cell W protect the body from pathogens. The C o m Comp all TLR4 onents first line of defense is the immediate, ol short-lived and non-specific innate Cytos immune response. It is followed by the long-lasting adaptive immune response, consisting of B and T cells that produce Double-stranded RNA TLR3 RNA ALUM, MF59 antibodies and kill infected cells in a pathogen-specific manner. Thus far, vac- RLR NLR ENDO-LYSOSOMAL Single-stranded RNA Receptors Receptors cine development efforts have primar- COMPARTMENT TLR 7/8 ily focused on analyzing the vaccine- DNA DNA induced adaptive immune response. TLR9 However, we now know that the type Cytoplasmic DNA and strength of the early innate response Recognition Receptors dramatically affects the nature of the ensuing adaptive response. Thus, there is Figure 1: Schematic overview of the localization of the five different PRR families and their corre- currently an intense interest in learning sponding ligands in different compartments (cell membrane, endosome, or cytosol) of innate immune how best to manipulate innate responses, cells. TLR = Toll-like-receptors; NLR = Nucleotide-binding oligomerization domain-containing protein in order to induce optimally protective (NOD)-like receptor; RLR = retinoic acid-inducible gene I (RIG-I)-like receptors. adaptive responses for vaccine develop- 1 ment. of the innate immune system, such as tion and influences the type of adaptive dendritic cells (DCs) and macrophages, response that develops.3 The exact nature Certain types of immune responses are positioned at ports of pathogen entry of this influence is not yet known. are better for ridding the body of some and detect invading microbes by recog- pathogens than others. For example, nizing their PAMPs. Innate immune Upon binding a PAMP, PRRs sig- antibodies are more effective in clearing cells contain numerous receptors known nal to other molecules in a cascading parasites that reside outside the cells, as pattern recognition receptors (PRRs), response that leads to the activation of while T cells can be better for killing which allow them to bind to and recog- the immune cell. As a result, the cell will bacterial pathogens that reside inside nize PAMPs. These receptors in concert upregulate its expression of stimulatory the cells. One important role of the read the different types and combina- surface molecules and release signal- innate response, in addition to alerting tions of PAMPs like a barcode, and allow ing molecules, such as cytokines and the body that an infection is in progress, the cell to classify a pathogen. chemokines. In this way, information is to identify the nature of the infecting about the infection is passed on to other pathogen and orchestrate the most ap- To date, five major families of PRRs surrounding immune cells, which then 2 propriate kind of immune response. are known: toll-like receptors (TLRs), impact the developing adaptive response. nucleotide-binding oligomerization For example, DCs are a type of in- To detect and identify invading mi- domain-containing protein (NOD)- nate immune cell that engulfs microbes crobes, the innate immune system takes like receptors (NLRs), retinoic acid- and then processes pieces of them into advantage of the fact that pathogens inducible gene I (RIG-I)-like receptors smaller protein fragments, known as an- contain several types of common com- (RLRs), C-type lectin receptors, and tigens (Ag). When DCs receive signals ponents, such as cell wall fragments and cytosolic DNA detectors (see Figure 1). from their PRR detecting PAMPS, and nucleic acids that distinguish bacterial, Each family recognizes specific types from chemokines and cytokines released parasitic, fungal, and viral pathogens of PAMPs, and is located in the cel- by other innate cells, they migrate from from host cells and from each other. lular compartment where the PAMP is the site of infection to the secondary These common microbial components typically encountered. Their combined lymphatic tissues (eg, lymph nodes). are known as pathogen-associated mo- response upon exposure to a pathogen While in the lymph nodes, DCs display lecular patterns (PAMPs). Different cells triggers the initiation of immune ac- the pathogen-derived antigens to cells

10 MARCH 2012 VOLUME 3:2 | HVTNEWS the role of innate immunity in vaccinology

of the adaptive immune system HVTN trials investigating innate Viral vector recognizing innate (Ag-specific T and B cells). If cells immune responses or adjuvant receptor (PRR) of the adaptive immune system HVTN 071 Merck rAd5 TLR2, TLR9, RLR recognize the presented antigen, an antigen-driven and pathogen- HVTN 205/908 GeoVax rMVA TLR2, TLR9, RLR, NLR specific adaptive immune response HVTN 076, 082 VRC rAd5 TLR2, TLR9, RLR begins. The DCs therefore connect the innate and adaptive immunity HVTN 088 Novartis MF59 NLR by delivering the microbial information from the site of infection HVTN trials in preparation to the secondary lymphoid organs, the home of the adaptive immune HVTN 087 Profectus rVSV TLR7, RLR 1, 2, 4, 5 cells. HVTN 094 GeoVax rMVA TLR2, TLR9, RLR, NLR

Recent advances have begun to Table 1: Summary of different HVTN HIV vaccine trials conducted or planned that includes innate immu- unravel how the initial stimulation nity assessments. rVSV = recombinant vesicular atomatitis virus; rMVA = recombinant modified vaccinia Ankara of the innate immune system via virus; rAd5 = recombinant adenovirus serotype 5. PAMPs, as well as the resulting activation of the dendritic cells, 12 can direct the adaptive immune vaccines that effectively protect against immune response. response.3 This is of particular inter- HIV, it is also important that we est for vaccine development, in which a understand how we can vary adjuvants Key data that we record (see Figure 2) pathogen-specific antigen is introduced and vaccination schedules to improve include changes in the frequency and along with an innate immune system upon vaccines that show partial efficacy, phenotypes of various immune-cell pop- stimulate, such as an adjuvant. One such such as the regimen used in the Thai ulations categorized by the use of multi- adjuvant is potassium aluminum sulfate trial (RV144), which had a 31% vaccine color flow cytometry and fluorescence- 8, 9 (Alum), a synthetic compound used in efficacy. To achieve this aim, we must activated cell sorting (FACS), changes several commercial vaccines, and another first determine how the individual facets in gene expression (microarray analysis), is an oil-in-water emulsion adjuvant of various vaccine induced immune re- functional analyses, and the release of 9-14 developed by Novartis, called MF59. sponses correlate to vaccine efficacy. soluble factors (multiplex analysis). Precisely how these synthetic adjuvants work is unknown, but they are thought To address these requirements, we estab- The peripheral blood contains lym- to mimic PAMPs by engaging with lished a suite of procedures that measure phocytes and several soluble factors. PRRs and thereby succeed in inducing early activation of the innate immune Changes in their phenotype as well as an innate immune response.6, 7 In the response upon vaccination in peripheral in quantities reflect the impact of an case of protein antigens in vaccines, in- blood and mucosal surfaces in humans. infection or vaccination on the host. clusion of an adjuvant is considered criti- To investigate the innate immune For example, we observed transient but cal for generating an immune response. response to vaccination, we have strategi- dramatic changes in the peripheral blood In contrast, antigens that are introduced cally chosen key sampling timepoints, lymphocyte populations 24 hours after via a viral vector do not typically require such as 1 and 3 days post vaccination, vaccination with the Merck recombinant adjuvants, because they contain virus- reflecting the different stages of innate adenovirus serotype 5 (rAd5) HIV vac- derived PAMPs. immune activation as well as feasibility cine (HVTN 071) and with the GeoVax for the participants and the clinic and recombinant modified vaccinia An- Vaccine development for pathogens laboratory personnel. In several recently kara (rMVA)/HIV62 vaccine (HVTN with an as-yet-unknown mechanism of initiated studies, we compare these data 205/908). We also observed that the protective immunity (eg, HIV) is ham- across trials to identify factors associated abundance of inflammatory monocytes pered by the lack of knowledge of which with successful vaccination (see Table in the peripheral blood peaks three days type of immune response, and therefore 1). The long term goal of these studies after vaccination. Our data demonstrate which adjuvant/antigen combination, is to improve our understanding of the that these vaccines have an instant influ- would result in effective protection. innate immune response to vaccination, ence on the behavior of innate immune 12 While HVTN trials ultimately seek and its influence on the ensuing adaptive cells within the peripheral blood.

www.hvtn.org HVTNEWS | VOLUME 3:2 MARCH 2012 11 the role of innate immunity in vaccinology

peripheral blood: mucosa:

Whole blood Cells from Cytobrush

Serum/Plasma Soluble factors from wick/sponge

PBMCs Tissue from biopsy

FACS (cell counts, phenotype, isolation of cell subsets)

RNA (microarray analysis/qPCR)

In vitro functional assays (ICS, B & T cell ELISpot, proliferation assay, viral inhibition assay, epitope mapping)

Multiplex assay (cytokine/antibody concentrations)

ELISpot = enzyme-linked immunosorbent spot; FACS = fluorescence-activated cell sorting; ICS = intracellular cytokine staining; PBMC = peripheral blood mononuclear cells ; qPCR = quantitative real time polymerase chain reaction.

Fig 2: Overview of key specimens and assays used by the HVTN to measure innate and adaptive immune responses

References 9. McElrath MJ. Immune responses to Since mucosal surfaces reflect the pri- HIV vaccines and potential impact on con- mary site of HIV transmission, they are 1. Sallusto F, Lanzavecchia A, Araki K, trol of acute HIV-1 infection. J Infect Dis. of great interest for assessing vaccine- Ahmed R. From vaccines to memory and 2010;202 Suppl 2:S323-S326. back. Immunity. 2010;33(4):451-463. induced immune responses. Synchro- 10. Rolland M, Gilbert P. Evaluating im- nized collection of mucosal specimens 2. Zielinski CE, Corti D, Mele F, Pinto mune correlates in HIV Type 1 vaccine ef- and peripheral blood samples at peak D, Lanzavecchia A, Sallusto F. Dissecting ficacy trials: what RV144 may provide. AIDS time points of the innate as well as the the human immunologic memory for patho- Res Hum Retroviruses. 2011. adaptive immune responses have been gens. Immunol Rev. 2011;240(1):40-51. included in our study protocols, and will 11. Ackerman M, Dugast AS, Alter G. 3. Kumar H, Kawai T, Akira S. Pathogen Emerging concepts on the role of innate provide comprehensive information of recognition by the innate immune system. immunity in the prevention and control of vaccine-induced immune responses at Int Rev Immunol. 2.011;30(1):16-34. HIV infection. Annu Rev Med. 2011. key sites of immune reaction.12, 15 4. Iwasaki A, Medzhitov R. Regulation 12. Andersen-Nissen E, Heit A, McElrath Our studies comprehensively evaluate of adaptive immunity by the innate immune MJ. Profiling immunity to HIV vaccines innate and adaptive immune responses system. Science. 2010;327(5963):291-295. with systems biology. Curr Opin HIV AIDS. on the cellular and molecular level. In the 2012;7(1):32-37. 5. Steinman RM, Hemmi H. Den- long term, we aim to correlate the types dritic cells: translating innate to adaptive 13. McElrath MJ, Haynes BF. Induction of adjuvants used with the observed immunity. Curr Top Microbiol Immunol. of immunity to human immunodeficiency initial innate immune response. We 2006;311:17-58. virus type-1 by vaccination. Immunity. would also like to correlate them with 2010;33(4):542-554. the adaptive immune response to a vac- 6. Coffman RL, Sher A, Seder RA. Vac- cine, and with its efficacy. This will enable cine adjuvants: putting innate immunity to 14. Pulendran B, Ahmed R. Immunologi- cal mechanisms of vaccination. Nat Immunol. better prediction of vaccine success and work. Immunity. 2010;33(4):492-503. 2011;12(6):509-517. ultimately facilitate development of a 7. Reed SG, Bertholet S, Coler RN, truly protective HIV vaccine. Friede M. New horizons in adjuvants for 15. Hladik F, McElrath MJ. Setting the vaccine development. Trends Immunol. stage: host invasion by HIV. Nat Rev Im- Erica Andersen-Nissen is a Staff Scientist 2009;30(1):23-32. munol. 2008;8(6):447-457. within the HVTN Laboratory Program; Antje Heit is a Research Associate working 8. Vaccari M, Poonam P, Franchini G. Phase III HIV vaccine trial in Thailand: a with the HVTN step toward a protective vaccine for HIV. Expert Rev Vaccines. 2010;9(9):997-1005.

12 MARCH 2012 VOLUME 3:2 | HVTNEWS Auxiliary Research Projects 2011

The HVTN, having data and specimens available from multiple trials, is well-suited to collaborate on studies going beyond the primary analyses in our clinical trials. The HVTN encourages these auxiliary studies to address novel scientific questions. The following table includes an overview of over 35 auxiliary studies with activity in 2011, involving over 35 institutions in 9 countries.

PI Name Project Title Institution

Perinatal HIV Research Unit Soweto/ DeBruyn G, Gray G, Bekker LG, Churchyard G, A prospective study of partners of individuals enrolled in HVTN 503 Desmond Tutu HIV Center/Aurum Institute/ Kublin J, McElrath MJ, Allen M, Moodie Z. FHCRC/DAIDS

Jin X, Morgan C, Kublin J, DeRosa S, Keefer M, Meta-analysis of immunogenicity in multiple clinical trials of healthy University of Rochester/FHCRC/University Hural J, Stofel J, Yu X. volunteers primed with HIV DNA vaccines of Washington

FHCRC/Centre Hospitalier Universitaire Kublin J, Pantaleo G, Karuna S, Elizaga M, Cross protocol pox/protein analyses Vaudois Hospices/Duke University School Defawe O, Frahm N, Weinhold K, Yu X. of Medicine

FHCRC/WRAIR/University of Rochester/ Elizaga M, Chaitman B, Frey S, Keefer M, Cross protocol MVA safety Saint Louis University School of Medicine/ Marovich M, Vasan S, Sata A, Qin L, Adams E. DAIDS

Frahm N, Kublin J, Casimiro D, Robertson M, Epitope mapping of adenovirus-specific T cells after natural infection Duerr A, Carter D, DeRosa S, Defawe O, Friedrich FHCRC/Merck/University of Washington and immunization with the MRKAd5/HIV-1 vaccine D, Spies G., DeCamp A, Huang Y, McElrath MJ.

ELISA assay of serum samples from volunteers who were immunized with liposome-encapsulated MPL with alum from the AIDS Vaccine Matyas G. WRAIR Evaluation Group (AVEG) Protocol 015, for antibodies to lipids used in the immunizations

Antigen microarray pilot study to assess utility for identifying novel Cooper-Trenbeath C, Hertz, T. FHCRC antigens for HIV diagnostics

Antigen microarray pilot study to assess utility for identifying novel Jin X. University of Rochester antigens for HIV diagnostics

Comparison of avidity index to HIV-1 Env gp41 immunodominant Tomaras G, Seaton K, Robinson H, Goepfert P, Duke University School of Medicine/ region using MVA prime/boost strategy vs DNA prime MVA/boost Lan A, Munir Alam S, Parekh B. GeoVax Inc/University of Alabama/CDC (HVTN 065)

Identification of multi-clade HIV reactive B cells at the single cell level Kobie J, Keefer M, Jin X, Sanz I, University of Rochester following vaccination

Assessment of HIV-specific IgG-producing B cells induced by FHCRC/Duke University School of Frahm N, Montefiori, D, Tomaras, G. vaccination with DNA, Ad5 and MVA Medicine

www.hvtn.org HVTNEWS | VOLUME 3:2 MARCH 2012 13 Auxiliary Research Projects 2011

PI Name Project Title Institution

Goepfert P. Induction of cryptic epitopes by HIV-1 vaccines University of Alabama

Baden L., Metch B.. Defining antivector immunity to MVA Brigham and Women’s Hospital

Janes H, Kallas E, Friedrich D, McElrath MJ, Frahm N, HLA and factors influencing viral load; epitope FHCRC/University of Sao Paulo Krambrink A. mapping

Frahm N, Friedrich D, Robertson M, Hertz T, T cell epitope mapping with MRKAd5 HIV-1 vaccine FHCRC/Merck McElrath MJ.

T-cell responses among HIV-infected persons after Janes H, Kallas E, Goepfert P, Frahm N, Rolland M, receipt of the MRKAd5/HIV gag/pol/nef vaccine: FHCRC/University of Washington/University of Sao Gabriel E, Wolfson J, DeCamp A, Hertz T, Friedrich D, Their association with viral sequences and viral load Paulo/University of Alabama/Merck Corey L, Mullins J, McElrath MJ, Gilbert P. measurements

Sexual risk behaviors, circumcision status and pre- Koblin B, Mayer K, Noonan E, Wang CY, Marmor M, New York Blood Center/ Brown University/New York existing immunity to adenovirus type 5 among men Sanchez J, Renzullo P, Robertson M, Lawrence D, Medical Center/Impacta Peru/ DAIDS/Merck/San who have sex with men participating in a randomized Buchbinder S. Francisco Dept. Public Health/FHCRC HIV-1 vaccine efficacy trial: Step Study

University of Illinois/University of Puerto Rico/Unidad Novak R, Zorrilla C, Cabello R, Donastorg Y, Koblin B, de Vacunas IDCP-COIN-DIGECITSS/New York Blood Joseph P, Lawrence D, Metzger D, Figueroa P, Metch Step risk behavior (women) Center/GHESKIO/DAIDS/University of Pennsylvania/ B, Adams E, Allen M. Ministry of Health, Jamaica/FHCRC

Sobieszczyk M, Carrington M, McElrath MJ, Frahm N, KIR - The effect of KIR genotype on the course of Columbia University/FHCRC Geraghty D, Janes H, Li S. HIV-1 infection among Step participants

Spies G, Curlin M, Duerr A, Noonan E, Frahm N. Step effect of Ad5 serology FHCRC

Phambili risk behavior modification: Did unblinding Desmond Tutu HIV Center/Perinatal HIV Research Bekker LG, Gray G, Metch B, Moodie Z. affect HIV risk behaviour and the perception of risk in Unit, Soweto/FHCRC the HVTN503/Phambili study?

Phambili circumcision uptake: offering new prevention Perinatal HIV Research Unit, Soweto/Centre for the DeBruyn G, Gray G, Metch B, Moodie Z, Mlisana K. modalities in HIV vaccine trials - experience with male AIDS Programme for Research in South Africa/FHCRC circumcision in the Phambili trial

Phambili pregnancy predictors: Factors associated Aurum Institute for Health Research/Desmond Tutu Latka M, Bekker LG, Churchyard G, DeBruyn G, Gray with pregnancy during the HVTN 503/Phambili Trial, a HIV Center/Perinatal HIV Research Unit, Soweto/ G, Allen M, Kublin J, Mathebula M, Mlisana K, phase 2B HIV trial of the MerckAd-5 multi-clade HIV Medunsa HIV Research Unit/Centre for the AIDS Mkhize B. vaccine Programme for Research in South Africa, FHCRC

14 MARCH 2012 VOLUME 3:2 | HVTNEWS Auxiliary Research Projects 2011

PI Name Project Title Institution

Vanderbilt University/Brigham & Women’s Hospital/ Kalams S, Baden L, Edupuganti S, Eldridge J, Frank Emory University/University of Pennsylvania/San I, Fuchs J, Weiner D, Elizaga M, DeRosa S, Hural J, Durability of responses in HVTN 070/080 Francisco Dept of Public Health/Profectus Biosciences Allen M, Butler C, Pensiero M, et al. Inc/DAIDS/FHCRC/University of Washington

Andersen-Nissen, E, Aderem A, Zak D, Duerr A, Systems analysis of the human innate immune FHCRC/Institute for Systems Biology/University of Peterson E, Borgerding J, Hamilton MK, Krishnamurty response to the candidate Merck Ad5/HIV-1 Vaccine Washington A, Chang J, DeRosa S, Aderem A, McElrath MJ.

Adamson B. Predictors of immunogenicity FHCRC

Genital tract infections, bacterial vaginosis, HIV Perla M, Lama J, Sanchez J. and reproductive health issues among Lima-based University of Washington/Impacta Peru clandestine female sex workers

The MRKAd5/HIV-1 vaccine induced durable CD4+ Peut V, Thomas E, Adams D, De Rosa S, Frahm N, Th1 responses that were not maintained upon HIV-1 FHCRC McElrath MJ. infection

Characteristics of response after 1 v 2 v 3 doses of Rajagopal S, Duerr A. University of Washington/FHCRC MRKAd5

Carter D, Frahm N, Friedrich D, McElrath MJ. Cross protocol PTE peptides methods FHCRC

Duerr A, Buchbinder S, Casapia M, Del Rio C, FHCRC/University of Washington/San Francisco Dept Robertson M, Sanchez J, Coombs R, Gilbert P, Extended follow-up Step study participants of Public Health/Asociacion Civil Selva Amazonica/ Huang Y. Emory University/IMPACTA Peru/Merck

Design of optimal multi-epitope vaccines to elicit CD4 Jin X. University of Rochester T cell immunity to HIV

Rolland M, Herbeck J, Janes H, Mullins J. Multiplicity of HIV-1 founder variants and viral load WRAIR/University of Washington/FHCRC setpoint

A pilot study to evaluate baseline immune activation Young K, Bekker LG, Gray C, Frahm N, Moodie Z, in HIV vaccine trial participants and the impact this Desmond Tutu HIV Center/University of Cape Town/ Andersen-Nissen E, Riou C. has on immune responses to vaccination (HVTN 204, FHCRC HVTN 073)

Metch B, Escamilla G, Graham P, Madenwald T, Recruitment of urban US women at risk for HIV FHRC/University of Illinois, Chicago/New York Blood Morgan C, Swann E, Koblin B, Frank I, Novak R, infection and willingness to participate in future HIV Center/University of Pennsylvania/DAIDS/FHCRC Metzger D, Dunbar D. vaccine trials (HVTN 906)

Deschamps M, Morgan C, Metch B, Swann E, Zorrilla Recruitment of Caribbean female commercial sex GHESKIO/University of Puerto Rico/ Unidad de C, Donastorg Y, Madenwald T, Joseph P, Severe K, workers at high risk of HIV infection and willingness to Vacunas IDCP-COIN-DIGECITSS/ DAIDS/FHCRC Garced S, Perez M, Escamilla G, Pape JW. participate in future HIV vaccine trials

www.hvtn.org HVTNEWS | VOLUME 3:2 MARCH 2012 15 HighLights from the Plenary Sessions of the HVTN Fall Conference

Continued from page 8

PrEP: Implications for HIV Vaccine Efficacy Trials One major concern for PrEP is the po- Pre-exposure prophylaxis (PrEP) is an HIV prevention strat- tential for viral drug egy in which HIV-negative people take antiretroviral drugs. resistance to develop Several recent studies have shown that PrEP decreases HIV if an individual be- infection rate in specific populations. These results represent comes infected and an exciting advance for reduction of HIV infections. Al- continues to use the though many questions remain, this approach may eventually drug. Hendrix re- be adopted by individuals at high risk for HIV infection, in ported that resistance combination with other prevention methods such as condoms has not yet been a and the use of sterile needles. This session addressed several problem and proposed key questions regarding PrEP and its impact on HIV vaccine that variable adherence trials. was one reason for this. His data suggested that individuals While the majority of studies thus far have found PrEP to with high adherence maintained reduce HIV infection risk, a wide range of efficacies (40-80%) high drug levels, which prevented has been observed, and some PrEP methods have not shown HIV infection and thus also prevented any effect. One important question then is what led to the development of viral resistance; in indi- different results across studies? A possible explanation is the viduals with poor adherence no drug large number of differences among the studies. These include was detected and thus, although different drug formulations (eg, oral pill versus topical gel) some became infected, there and different participant populations (eg, men who have sex was no drug pressure to drive with men versus heterosexual women at high risk). However, viral resistance. PrEP trial speakers focused on evidence suggesting that adherence is participants undergo the key factor affecting efficacy. Several possible reasons were frequent HIV testing suggested for adherence differences between individuals. These and are told to stop included differences in the participant’s perception of their the regimen if they own risk and their willingness to take a pill as opposed to use a become infected. gel on a daily basis. This level of support likely contributes Another possible explanation cited for the discordant study to the lack of viral results was that the amount of drug reaching rectal versus resistance develop- vaginal tissues could be different, and these could also vary ing in the trials. for a pill versus topical gel. Thus far only a few of the PrEP studies have examined drug levels in these tissues; however in Until a preventative one study, 10 times more drug from an oral pill was found to HIV vaccine is available, PrEP usage will likely increase. The accumulate in rectal tissue compared to vaginal. These results impact of such increase on HIV vaccine efficacy trials was dis- were presented by Dr. Craig Hendrix ( Johns Hopkins Univer- cussed by a panel of experts. Although it is not yet known how sity). Dr. Hendrix acknowledged that the minimum drug levels widespread PrEP usage will be, it is expected that its utiliza- required for efficacy in tissues and more importantly, within tion by trial participants will reduce the number of HIV infec- the cellular targets of HIV, are currently unknown and thus tions occurring during an HIV vaccine study. This is a positive confound dose selection. In general, investigators agree that outcome on one hand; however, it will result in the need for the products would most likely be used intermittently rather a larger number of participants to prove vaccine efficacy. Dr. than daily, and therefore the ideal PrEP regimen would involve Corey suggested there is a potential for a beneficial synergistic a drug that is immediately active in the appropriate anatomi- effect between PrEP and a vaccine. This synergy could benefit cal location, rather than one requiring a loading phase to reach the partial efficacy thus far achieved by each strategy alone. sufficient levels in tissues.

16 MARCH 2012 VOLUME 3:2 | HVTNEWS HighLights from the Plenary Sessions of the HVTN Fall Conference

NHVREI, Social Sciences, and RAMP Scholars Cesar Angel (Stanford Medi- cal School) discussed his work This session highlighted the accomplishments of the NIAID identifying methods to enhance HIV Vaccine Research Education Initiative (NHVREI) in Latino MSM participation in assessing and increasing awareness of HIV vaccine research. HIV vaccine trials. His study, Cornelius Baker of FHI 360 (a global development organi- involving several focus groups zation), summarized the initiative’s formative research and around the San Francisco Bay reported that in general, there was very little public awareness Area, observed that the poor of HIV vaccine research, and a significant amount of stigma understanding and specific con- related to HIV/AIDS still exists. Among those expressing an notation of the term vaccine are interest in trial participation, the desire to help their commu- key barriers to participation. The nity was a key motivator; however, concerns over safety and focus group feedback indicated RAMP Scholar John Chiosi general public distrust of medical research was a significant that campaigns should engage barrier to participation. In addition, Baker emphasized the in grass roots efforts, particu- importance of engaging the community over time, rather than larly those evoking feelings of just once. These findings have been incorporated into the next empowerment and community phase of NHVREI followup effort, known as the “Be the support. generation bridge project.” “Be the Generation” is a NIAID supported interim project run by the Legacy Project and FHI In the final presentation, Daniel 360. (The Legacy Project is a national effort run by the HIV/ Gonzalez (Commonwealth AIDS Network Coordination [HANC].) Medical College) discussed his work on the parameters affecting HVTN social scientist, Dr. Michele Andrasik, described her U.S. MSM participation in HIV work researching HIV vaccine trial recruitment strategies for vaccine trials. This study sought U.S. men who have sex with men (MSM). She cited concerns to identify specific versus com- about vaccine induced seropositivity (VISP) and its impact on mon themes across several major RAMP Scholar Cesar Angel participants as a key impediment to recruitment. VISP refers cities. Common facilitators to cases of reactivity in standard HIV tests in HIV vaccine included altruism and compen- trial participants as a result of vaccination. This reactivity result sation. Safety fears and mistrust may be interpreted as an HIV infection, even when a partici- appeared as common barriers. pant is uninfected. The HVTN provides access to accurate HIV tests for trial participants, to reduce the risk and resulting Larry Corey asked the scholars impact of VISP. to report on what they got out of their research experience, what The following plenary session featured presentations from Re- they planned to do next in their search and Mentorship Program (RAMP) scholars. This effort careers, and whether the experi- aims to increase the numbers of black and Latino researchers ence had been fun. The scholars in the HIV prevention field. The program supports short term unanimously agreed that it had research projects by U.S. medical students under the mentor- been an enriching experience ship of HVTN-affiliated investigators. that had influenced their future RAMP Scholar Daniel Gonzalez plans. They also agreed it was John Chiosi (Mount Sinai School of Medicine) presented a fun. study assessing the feasibility of HIV education programs conducted in neighborhood taverns in Cape Town, South Africa. Tracey Day is Senior Science Writer He reported that both tavern owners and patrons expressed and Cecilia Morgan is Associate a willingness to utilize HIV education materials, indicating Director, Scientific Development, that these may be good locations for targeted HIV educational HVTN campaigns and clinical trial recruitment.

www.hvtn.org HVTNEWS | VOLUME 3:2 MARCH 2012 17 VISP and the HVTN’s Commitment to Poststudy HIV Testing Carissa Karg, Margaret Wecker

The goal of an HIV vaccine is to induce an anti-HIV immune for immigration, obtaining student or travel visas, enlisting in response; while an effective vaccine has not yet been found, the military, or disruption of personal relationships with family many of the experimental HIV vaccines have induced immune or friends. For participants in later phase efficacy trials, who responses that include anti-HIV antibodies. These antibodies are often at higher risk for HIV infection, this becomes an may react on common HIV serologic tests, causing the test to even more complex problem. In addition to emotional stress, appear positive even in the absence of actual HIV infection. participants could be subjected to inappropriate treatment This phenomenon is known as vaccine-induced seropositivity with antiviral drugs. or VISP (this is also referred to as vaccine-induced serore- activity or VISR). As part of every HIV vaccine clinical trial Test results with a false diagnosis could also have serious conducted by the HVTN, study participants undergo HIV implications related to HIV surveillance and future program diagnostic testing throughout the trial, and participants are planning. In areas where HIV infections must be reported encouraged to only have their HIV testing done through their to the public health authorities, a false diagnosis could have study site. This testing follows an algorithm that can distin- implications on HIV epidemic estimates data.3 guish true infection from VISP through RNA polymerase chain reaction (PCR), Western blots, enzyme immunoassay The HVTN, with the support of the Division of AIDS (EIA), chemiluminescence assay (CIA), or Rapid serology (DAIDS), has worked to develop policies, procedures, and ma- tests along with knowledge of the different vaccine delivery terials to support study participants prior to joining a trial, as systems and HIV inserts. At the conclusion of a participant’s well as during and after completing a trial. Study sites educate scheduled study visits, end of study testing is performed their participants about VISP and the implications of request- to determine whether or not the HIV vaccine has induced ing HIV testing outside the study site via discussion and antibodies that would result in a positive test on standard HIV supplementary resources. These resources include participant antibody tests. brochures, information sheets, and a publicly accessible website with VISP-related information. The HVTN provides accurate After more than 12 years of research, the HVTN has data on HIV testing free of charge for as long as the HIV vaccine- a number of HIV vaccine candidates. Among the individuals induced antibodies persist. Individual study sites have taken who received an HIV vaccine product in 27 phase 1 or 2a tri- the lead in developing mechanisms to provide testing and als, VISP occurred in approximately 42% (908 VISP partici- counseling to fulfill this commitment. In addition, the HVTN pants at the end of the studies out of 2176 non-HIV-infected developed the VISP Testing Service to support participants vaccine recipients). These trials were conducted in a total of 9 who may have moved away from their study site or for those countries between December 14, 2000 and January 15, 2010. whose study site is no longer open. The Testing Service in- VISP was determined by HIV EIA.1 cludes a toll-free phone service that study participants can call to request HIV testing. Currently, this service is only accessible Recent data suggest that VISP is a “common but highly vari- for participants living in the United States but there are future able” outcome of preventive HIV vaccine trials. Once a par- plans to expand it internationally. ticipant tests VISP, the duration of the response may be highly unpredictable. Some participants have a transient response, In addition to the VISP Testing Service, a voluntary VISP while other participants’ responses last longer than 15 years.2 Registry was developed to support former study participants. The HVTN is currently conducting a long term follow-up The Registry’s intent is to enable the Testing Service to iden- observational clinical trial (HVTN 910) to collect data that tify participants in DAIDS-funded HIV preventive vaccine better characterizes the persistence of VISP, by routinely test- trials, and provide support to such participants for possible so- ing former trial participants. cial harms resulting from testing VISP. The Registry allows the centralized VISP Testing Service to access information about The effects of a false diagnosis because of VISP may include a participant’s involvement in a trial, and identify whether or difficulties in obtaining medical or disability/life insurance, do- not they received an HIV vaccine which might put them at nating blood or organs, finding or keeping employment, filing risk for VISP. Sites will offer the opportunity to be part of the

18 MARCH 2012 VOLUME 3:2 | HVTNEWS VISP and the HVTN’s commitment to poststudy HIV testing

VISP Registry to all participants following enrollment in an following the RV144 trial results, may increase the potential HIV vaccine clinical trial. This Registry is solely intended to for VISP outcomes. Unfortunately, with this, the likelihood facilitate a participant’s request to get post-study HIV testing, of participants with VISP testing outside the study site or the and cannot be used for any other purpose, including research. HVTN Testing Service may be elevated, as more participants If a participant is unwilling to join the VISP Registry, HIV enroll in trials, and “opt out” testing procedures are becoming testing will still be provided; however, the ability to mitigate increasingly common. social harms may be limited since the HVTN may not be able to attest to their participation in a trial, nor verify whether they In the past, the differentiation between HIV infection and received an experimental HIV vaccine or placebo/control. VISP has been manageable at the study site level; however, as the number of participants in HIV vaccine clinical trials Participants are sometimes tested in the community with- increases, and the opportunities for HIV testing increase, it out their knowledge, particularly with the recent adoption becomes more important than ever to ensure that health care of “opt-out” HIV testing recommended by the Centers for providers and testing centers are educated about VISP. Disease Control and Prevention. For this reason, beyond the education of the participants, it is also imperative that the The HVTN values the critical role clinical trial volunteers play surrounding communities and healthcare service providers, in the effort to develop an effective preventive HIV vaccine especially in places where HIV community testing is promi- and remains committed to support those volunteers in many nent, understand the issues of testing current and former HIV ways, including the provision of accurate HIV testing for as vaccine trial participants. For example, as part of the VISP long as necessary. For more information about VISP, please education outreach program, the Fred Hutchinson Cancer visit our web site: http://www.hvtn.org/visp. Research Center/University of Washington Vaccine Clinical Research Site located in Seattle, WA worked with the public Carissa Karg is a Clinical Trials Manager and Margaret Wecker health authorities in Washington State to incorporate VISP is Director, Scientific Operations, HVTN education into state-mandated health care provider training. This included adding information about VISP into the health department’s training sessions on HIV testing and counseling, and the addition of VISP information into HIV educational training required for Washington State licensure of all References health care providers. These efforts are designed to improve 1. Cooper CJ, Metch B, Dragavon J, Coombs RW, Baden LR. provider awareness of VISP and, and thereby allow them to Vaccine-induced HIV seropositivity/reactivity in noninfected HIV better identify HIV vaccine recipients when these individuals vaccine recipients. JAMA. 2010;304(3):275-283. seek community HIV testing. An awareness of VISP and its implications is extremely important in HIV vaccine research, 2. Reported by clinic staff at HVTN Nashville Clinical Research Site, 2011. especially given the stigma associated with HIV/AIDS. 3. Ackers ML, Parekh B, Evans TG et al. Human immunodefi- The development of more immunogenic HIV vaccine regi- ciency virus (HIV) seropositivity among uninfected HIV vaccine mens, with particular interest in increasing antibody responses recipients. J Infect Dis. 2003;187(6):879-886.

References (continued from page 5)

12. Churchyard GJ, Morgan C, Adams E et al. A phase IIA random- 14. McElrath MJ, De Rosa S, Moodie Z et al. HIV-1 vaccine-induced ized clinical trial of a multiclade HIV-1 DNA prime followed by a immunity in the test-of-concept Step Study: a case-cohort analysis. multiclade rAd5 HIV-1 vaccine boost in healthy adults (HVTN204). Lancet. 2008. PLoS ONE. 2011;6(8):e21225. 15. Gray G, Buchbinder S, Duerr A. Overview of STEP and Pham- 13. Buchbinder S, Mehrotra D, Duerr A et al. Efficacy assessment of a bili trial results: two phase IIb test-of-concept studies investigating the cell-mediated immunity HIV-1 vaccine (the Step Study): a double-blind, efficacy of MRK adenovirus type 5 gag/pol/nef subtype B HIV vaccine. randomised, placebo-controlled, test-of-concept trial. Lancet. 2008. Curr Opin HIV AIDS. 2010;5(5):357-361.

www.hvtn.org HVTNEWS | VOLUME 3:2 MARCH 2012 19 Managing Editor: cecilia morgan EDITOR: adi ferrara Calendar senior SCIENCE WRITER: tracey day PRODUCTION MANAGER: courtney liebi design & layout: lisa donohue conference on retroviruses and FOR MORE INFORMATION, VISIT: hvtn.org opportunistic infections march 5-8, 2012 COMMENTS/QUESTIONS? Washington State Convention Center [email protected] Seattle, Washington Tel: 206 667-5300 Fax: 206 667-6366 HVTN EXTERNAL ADVISORY COMMITTEE HVTN/FHCRC, 1100 Fairview Ave North, LE-500 MEETING PO Box 19024 Seattle, Washington 98109-1024 march 9, 2012 Seattle, Washington Thank you to: Larry Corey, Jim Kublin, Blythe Adamson, Peter Kwong, Jonathan Stuckey keystone symposia, hiv vaccines march 21-26, 2012 For current and archived editions of HVTNews, Keystone Resort please visit us here - Keystone, Colorado hvtn.org/science/hvtnews.html hvtn conference may 30-june 2, 2012 The HIV Vaccine Trials Network is an international collaboration of Renaissance Mayflower Hotel scientists and educators searching for an effective and safe HIV Washington, D.C. vaccine. Support for the HVTN comes from the National Institute of Allergy and Infectious Diseases (NIAID) of the U.S. National Institutes of Health, an agency of the U.S. Department of Health and Human International AIDS Conference Services. The Network and NIAID have a close, cooperative working 2012 relationship, with shared attention to intellectual and scientific issues. july 22-27, 2012 Walter E. Washington Convention Center Washington, D.C. Mission of the HVTN aids vaccine 2012 To enhance the discovery and drive the development of a september 9-13, 2012 safe and globally effective vaccine to prevent HIV. Boston Convention and Exhibition Center Boston, Massachusetts We do this through well-designed clinical research trials that objectively and ethically address the critical questions of the field.

Our objective clinical trial platform lets us evaluate safety, immunogenicity and efficacy of candidate vaccines, as well as design clinical trials that will provide clues on ways to enhance the effectiveness of new vaccines. We promote the use of new innovations, which may help us get closer to a safe and effective vaccine more quickly.