The Hvtnews Jim Kublin, Executive Director, HVTN

a Publication of the HIV Vaccine Trials Network VOLUME 3, ISSUE 1 | SEPTEMBER, 2011 Welcome to the HVTNews Jim Kublin, Executive Director, HVTN

Welcome to the HVTNews. With this immune system’s response to it grows, the edition, we would like to welcome new au- Network and its partners are developing diences and reintroduce our newsletter. In vaccine candidates that elicit promising im- this and future editions we will clarify why mune responses, with new vectors, proteins, HIV vaccine research in humans provides inserts, and new vaccine delivery mecha- critical momentum for the discovery and nisms; an important scientific milestone in development of effective vaccines. Upcom- our trials this past year was the use of elec- ing newsletter topics include monoclonal troporation of DNA plasmids, which nearly antibodies for prevention, electroporation, doubled the detectable immune response to efficacy trial capacity building, immu- the study’s vaccine candidate. notherapy, and community engagement. We will highlight the management of the Though the promising results of the latest Network’s many multilateral collaborations biomedical prevention trials are great news, Photo by Sarah Stefana Smith and our outstanding clinical sites that work the search for a vaccine is as relevant and Exploring Barriers: Participation of Male-to-Female Transgender Persons in HIV Vaccine Trials [p.16] in service to our mission. We are focused on urgent today as it was at the outset of the the dynamic field of combination preven- epidemic. Several factors must be consid- tion and the role of vaccine development ered in the context of an effective bio- activism and innovation the field deserves, plays and deployment in control of the HIV medical prevention regimen -- compliance, a major role in the ultimate control of this pan- pandemic. cost, and resistance are among the most demic. As you read this issue, we hope you will important. gain a perspective about where we are going as We are currently developing novel trial a field and as an organization, in our quest for designs that, combined with new analy- The best biomedical prevention regimen is this ultimate goal. ses tools, will speed up clinical trials and still only as good as its users’ compliance. allow us to zoom in quicker on the most When compliance is spotty or inconsistent, promising candidates, and identify the new infections will still occur. Additionally, MISSION OF THE HVTN much needed correlates and surrogates of the regular use of antiviral drugs as prophy- TO ENHANCE THE DISCOVERY AND DRIVE THE protection. Epitope mapping allows us to laxis may result in resistant strains of the DEVELOPMENT OF A SAFE AND GLOBALLY characterize the breadth and depth of T cell virus, complicating the already challenging EFFECTIVE VACCINE TO PREVENT HIV. responses to specific epitopes in our vaccine picture of HIV treatment and preven- candidates, and sieve analyses enables us to tion. On top of that, when considering the We will do this through well-designed clinical more accurately recognize vaccine candi- global distribution of HIV infections, it is research trials that objectively and ethically dates that exert pressure on the virus. These clear that the cost of preventive medica- address the critical questions of the field. topics are discussed more in depth in the tions will figure prominently in many of the Our objective clinical trial platform lets us following pages. hardest hit communities. evaluate safety, immunogenicity and efficacy of candidate vaccines, as well as design clinical The search for an HIV vaccine, as with Considering the enormous toll exerted trials that will provide clues on ways to enhance other vaccines, has been long and, for many globally by the HIV pandemic, in terms of the effectiveness of new vaccines. years, frustrating. At the moment, however, human suffering and social and economic we find ourselves in the midst of a very ex- devastation, it is clear that definitive, reli- We promote the use of new innovations such as adaptive trial designs, which may help us citing time in the HIV prevention field in able methods to halt the spread of HIV get closer to a safe and effective vaccine more general, and the vaccine field in particular. are needed. A preventive vaccine, building quickly. As our understanding of the virus and the on recent advances, with the continued IN THIS ISSUE ARTICLES

2 A Sequential Two-stage Trial Design for Evaluating Efficacy and Immune 15 HVTN 505: Expansion in Response to an Evolving Field Correlates for Multiple Vaccine Regimens 16 Exploring Barriers and Facilitators to Participation of Male-To-Female 5 Sieve Analysis of HIV Sequences in Vaccine Efficacy Trials Transgender Persons in HIV Vaccine Clinical Trials 7 Training and Mentorship Programs at the HVTN 12 PROTOCOLS 10 Defining the Targets of HIV-specific T-cell Responses (Epitope Mapping) 19 PUBLICATIONS 20 14 HVTN Annual Network Award Winners CALENDAR [Back Cover] A Sequential Two-stage Trial Design for Evaluating Efficacy and Immune Correlates for Multiple Vaccine Regimens Peter Gilbert, Doug Grove

Of the 5 preventive HIV vaccine efficacy trials that have been Multiple Concurrent Two-stage Designs with a conducted to date, 3 (Vax004, Vax003, and Step/HVTN Shared Placebo Group 502) showed a vaccine efficacy (VE) near zero.1,2,3 The fourth trial, RV144, provided an estimated VE = 31%.4 The 5th trial The new trial design may be viewed as multiple concurrent (Phambili/HVTN 503) was halted early and did not yield two-stage vaccine-versus-placebo trials, with resource savings reliable efficacy data. HIV infection was a primary endpoint in accrued via a shared placebo group. For each vaccine regimen, all 5 trials. stage 1 evaluates VE over 18 months. Only if positive efficacy is demonstrated, stage 2 occurs and evaluates VE through 36 This article summarizes a novel efficacy trial design proposed months. Such adaptive assessment of VE durability is by the HVTN that seeks improvements in 4 specific aspects of motivated by the supposition that only vaccines conferring the previous trials, namely: (1) The primary analysis evaluated protection over 18 months merit longer-term assessment. VE against infections occurring at any time during follow- This is because durability largely influences a vaccine’s public health utility,6, 7, 8 and HIV vaccine-induced immune responses up, including well after the immunization series; (2) A single 4 vaccine regimen was evaluated; (3) Some of the trials did not can wane over time (eg, RV144) . The 2 stages are also used monitor for vaccine efficacy futility, resulting in inefficiency; for adaptively assessing immune correlates, as this assessment (4) Prospective planning for timely assessment of immune becomes a priority once a vaccine shows positive VE(0-18). correlates was limited, and correlates, but not surrogates, were assessed. Prospectively Planned and More Rigorous Evaluation of Immune Correlates While the proposed novel design was developed with primary 5 An ultimate goal for HIV vaccine research is development application for future efficacy trials in South Africa , many of of an immune response biomarker that reliably predicts VE, its features are being implemented in the only ongoing efficacy 9 a so-called “surrogate of protection (SoP).” An identified trial, HVTN 505. SoP would guide vaccine development as an evidence-based Objectives of the Proposed Design primary endpoint in subsequent phase I/II trials.

For each of 1 to 3 vaccine regimens versus a shared placebo Identification of SoPs proceeds in two steps. First, immune group, the new design’s primary objective is the timely evalu- biomarkers are assessed as correlates of infection rate among 10 ation of VE against HIV infections diagnosed within 18 vaccinated subjects, named correlates of risk (CoRs). Howev- months of entry [a parameter we refer to as VE(0-18)]. This er, a discovered CoR may have no value to predict VE, because design uses sequential monitoring to maximize efficiency and it may merely correlate with an intrinsic factor that actually 11 ethics. Trial efficiency is maximized by restricting the assess- determines relative resistance to infection. Because of this ment to HIV exposures near the immunization series before limitation, statistical methods have been developed to assess immune responses wane. The trial is event-driven, with sample whether an identified CoR reliably predicts VE, and, if it does, 12-16 sizes chosen to ensure high probability that the trial will it is called a SoP. identify vaccines with VE(0-18) of at least 40%. The secondary objectives include: (1) to evaluate durability of VE for each Assessing a SoP requires predicting the vaccine-induced im- regimen showing reliable evidence for positive VE(0-18); (2) mune biomarker for placebo recipients; these predictions may to expeditiously and rigorously evaluate immune correlates of be derived either by (1) Modeling the relationship between protection if any of the vaccine regimens show positive VE(0- baseline subject characteristics and the immune biomarker 18); (3) to compare VE among the vaccine regimens, aiding (baseline immunogenicity predictor approach, BIP), and/or by decisions about whether and which regimen to advance to a (2) Vaccinating uninfected placebo recipients at study close- licensure trial; and (4) to evaluate vaccine effects on HIV-1 out and directly measuring their vaccine-induced biomarkers 12 infection progression. (closeout placebo vaccination approach, CPV). Accordingly,

2 SEPTEMBER 2011 VOLUME 3:1 | HVTNEWS A SEQUENTIAL TWO-STAGE TRIAL DESIGN FOR EVALUATING EFFICACY AND IMMUNE CORRELATES FOR MULTIPLE VACCINE REGIMENS

KEY ASSUMPTIONS FOR THE TRIAL DESIGN IN THE FIGURE:

N=2,150 randomized per arm

12-month accrual period

Uniform accrual with average of (a) 95 per week (b) 142 per week (c) 189 per week halved in the first 6 months

4% annualized HIV incidence in placebo group

5% annualized drop-out incidence

For each vaccine regimen versus placebo, a maximum of 9 analyses for VE(0-18) futility, starting at the 65th and ending at the 176th HIV infection

For each vaccine regimen VE(0-18) is constant over time

a research agenda for the HVTN is to discover BIPs and to implement CPV in stage 2 for vaccines showing positive VE(0-18). Sequential Monitoring of VE(0-18)

Each vaccine regimen is sequentially monitored for vaccine efficacy futility. The monitoring plan is designed to meet three operating characteristics: (1) vaccines with VE(0-18) = 0% are weeded out with high probability (at least 80-90% chance); (2) the risk of weeding out vaccines with VE(0-18) = 40% but halved efficacy during the period of ramping immunity is bound- ed at 20%; and (3) for weeded-out vaccines, the reported 95% confidence interval about VE(0- 18) lies below 50%. Thus the design tends to be shorter and cheaper for worthless vaccines and longer and pricier for protective vaccines (Figure). Stage 2 occurs only if efficacy futility Distributions of the total trial duration for trials with varying numbers of study groups. is not declared, and thus a central feature of the (a) 1 vaccine regimen versus placebo. (b) 2 vaccine regimens versus placebo. (c) 3 vaccine design is adaptive evidence-based expansion regimens versus placebo. For trials with multiple vaccine groups, a trial completes once all of the vaccine groups reach the end of evaluation. Each line shows the cumulative probability of the of resources to evaluate VE durability and im- trial completing over time since the trial began, for a given scenario of true values for VE(0-18). mune correlates.

www.hvtn.org HVTNEWS | VOLUME 3:1 SEPTEMBER 2011 3 A SEQUENTIAL TWO-STAGE TRIAL DESIGN FOR EVALUATING EFFICACY AND IMMUNE CORRELATES FOR MULTIPLE VACCINE REGIMENS

Gilbert et al.5 showed that application of the proposed moni- 5. Gilbert PB, Grove D, Gabriel E, et al. A Sequential Phase 2b toring approach to Vax004, Vax003, and Step would have led Trial Design for Evaluating Vaccine Efficacy and Immune Correlates to a conclusion of efficacy futility (and hence trial completion) for Multiple HIV Vaccine Regimens. Statistical Communications in about 24, 33, and 9 months sooner than the actual designs Infectious Diseases. 2011;3(1):Article 1. that were used. Moreover, for RV144 the proposed monitoring 6. Anderson RM, Swinton J, Garnett GP. Potential impact of low would have concluded some positive efficacy (VE(0-18) > 0%), efficacy HIV-1 vaccines in populations with high rates of infection. triggering assessment of VE durability and immune correlates. Proc Biol Sci. 1995;261:147–151.

In conclusion, the essential elements of the HVTN’s proposed 7. Anderson RM, Garnett GP. Low-efficacy HIV vaccines: efficacy trial design are: (1) adaptive two-stage evaluation of potential for community-based intervention programmes. Lancet. 1996;348:1010–1013. vaccine efficacy, which is efficient because evaluating durability of VE and immune correlates become a priority if, and only if, 8. Abu-Raddad L, Boily M-C, Self SG, Longini IM Jr. Analytic a vaccine regimen protects earlier; (2) multiple vaccine regi- insights into the population level impact of imperfect prophylactic mens versus a shared placebo group, which is efficient, provides HIV vaccines. J Acq Imm Def Synd Hum Retrov. 2007;45:454–467. head-to-head comparisons, and enriches immune correlates assessment; (3) optimized sequential monitoring to meet ethi- 9. Plotkin SA. Vaccines: Correlates of vaccine-induced immunity. C Infect Dis. 2008;47:401–409. cal and efficiency requirements; and (4) emphasis on planning for immune correlates assessment and evaluating surrogates as 10. Qin L, Gilbert P, Corey L, McElrath J, Self S. A framework for well as correlates. assessing immunological correlates of protection in vaccine trials. J Infect Dis. 2007;96:1304–1312. Peter Gilbert is the Principal Investigator of the HVTN Statistics and Data Management Center. Doug Grove is a Statistical Research Associate working with 11. Gilbert PB, Peterson M, Follmann D, et al. Immunologic the HVTN. responses to rgp120 vaccine correlate with the incidence of HIV-1 infection in a Phase 3 preventive HIV-1 vaccine trial. J Infect Dis. 2005; 191:666–677.

12. Follmann D. Augmented designs to assess immune response in References vaccine trials. Biometrics. 2006;62:1161–1169. 1. Flynn NM, Forthal DN, Harro CD, et al. Placebo-controlled 13. Gilbert PB, Hudgens MG. Evaluating candidate principal sur- trial of a recombinant glycoprotein 120 vaccine to prevent HIV infec- rogate endpoints. Biometrics. 2008;64:1146–1154. tion. J Infect Dis. 2005;191:654–665. 14. Gilbert PB, Qin L, Self SG. Evaluating a surrogate endpoint 2. Pitisuttithum P, Gilbert P, Gurwith M, et al. Randomized, at three levels, with application to vaccine development. Stat Med. double-blind, placebo-controlled efficacy trial of a bivalent recombi- 2008;27:4758–4778. nant glycoprotein 120 HIV-1 vaccine among injection drug users in Bangkok, Thailand. J Infect Dis. 2006;194:1661–1671. 15. Qin L, Gilbert P, Follmann D, Li D. Assessing surrogate endpoints in vaccine trials with case-cohort sampling and the Cox model. 3. Buchbinder SP, Mehrotra DV, Duerr A, et al. Efficacy assess- Annals of Applied Statistics. 2008;2:386–407. ment of a cell-mediated immunity HIV-1 vaccine (the Step Study): A double-blind, randomised, placebo-controlled, test-of-concept trial. 16. Wolfson J, Gilbert P. Statistical identifiability and the surrogate Lancet. 2008;372:1881–1893. endpoint problem, with application to vaccine trials. Biometrics. In press. 4. Rerks-Ngarm S, Pitisuttithum P, Nitayaphan S, et al. Vaccina- tion with ALVAC and AIDSVAX to prevent HIV-1 infection in Thailand. N Engl J Med. 2009; 361:2209–2220.

4 SEPTEMBER 2011 VOLUME 3:1 | HVTNEWS Sieve Analysis of HIV Sequences in Vaccine Efficacy Trials Peter Gilbert, Allan deCamp, Paul Edlefsen, Craig Magaret, Tomer Hertz

Sieve analysis is integral to the evalua- notypic differences between the incoming Gag) or on short peptide regions such as tion of immune correlates of protection, as exposing/founder sequences and the HIV 9-mers and individual sites. vaccine-induced immune responses (whether insert sequence(s) represented in the vac- measurable or not) are the cause of vaccine construct. cine sieve effects. (Vaccine sieve effects are Sieve Analysis of the HVTN vaccine-induced adaptive immune responses Postinfection sieve analysis evaluates the 502 Step Trial that may partially block HIV acquisition, vaccine effect on the founder virus after and/or alter HIV’s evolution postacquisi- infection. Acquisition sieve analysis is of limited inter- tion.) Sieve analysis can shed light on est for Step, given the absence of evidence Both assessments are useful for guiding the 4 potential mechanisms of immune protection, for protective efficacy. However, the post- design of insert sequences to include in can- as well as generate hypotheses on which im- infection sieve analysis for Step supported didate vaccines, to maximize their protective 5 munological measurements may be immune vaccine pressure on founder sequences. The coverage of circulating HIVs. correlates. McCutchan / Tovanabutra and Mullins labs measured 5–14 full-length genomes per sub- HVTN statisticians have developed The enormous variability of the HIV ge- ject (n=68) via single genome amplification. methods for both types of analyses. The nome and the spread of multiple HIV geno- Known and likely class I major histocompat- acquisition methods focus on estimating the types and recombinants has posed a difficult ability complex (MHC)-restricted CTL epi- vaccine efficacy curve [VE(v)], which is the challenge to developing a vaccine.1,2,3 In topes were identified in founder sequences percent reduction (vaccine versus placebo) preventive HIV vaccine efficacy trials, HIV and in the vaccine-insert sequence, based on in the instantaneous rate of HIV infection sequences are measured and characterized each volunteer’s HLA type. Known epitopes with an HIV with genetic distance v from a from trial participants who become infected. were defined by the Los Alamos National vaccine-insert sequence. The post-infection 6 Sieve analysis of these HIV sequences inves- Laboratory (LANL) database and likely methods focus on estimating the vac- 7 tigates potential vaccine sieve effects. Two epitopes were predicted using Epipred and cine effect on genetic distances of founder 8 types of sieve analysis are of interest: NetMHC. A genetic distance between a sequences to the insert sequence(s) within subject’s founder sequences and the vaccine- infected subjects, where the distances are Acquisition sieve analysis evaluates the insert was defined as the percentage of based on predicted cytotoxic T lymphocyte relationship between the vaccine effect on known or predicted epitopes in the insert HIV acquisition, and the genotypic/phe- (CTL) epitopes within whole proteins (eg,

a b c d P = 0.01 P < 0.0001 P = 0.75 P = 0.50 100 100 100 100

80 80 80 80

60 60 60 60

40 40 41.3 40 40 39.6 37.7 35.5 34.8 34.6 29.8 24.4 20 20 20 20 Percent epitope mismatch Percent 0 0 0 0 PlaceboV accine PlaceboV accine PlaceboV accine PlaceboV accine n = 26 n = 39 n = 25 n = 39 n = 25 n = 39 n = 23 n = 38

Figure 1. Percent epitope mismatch distances (NetMHC) to the vaccine-insert proteins. (a) Gag-Pol-Nef, (b) Gag, (c) Pol, (d) Nef; (2-sided P-values computed via the Mann-Whitney test).

www.hvtn.org HVTNEWS | VOLUME 3:1 SEPTEMBER 2011 5 SIEVE ANALYSIS OF HIV SEQUENCES IN VACCINE EFFICACY TRIALS

2. To achieve reasonable statistical power to detect vaccine sieve effects, the measure of genetic distance between a subject’s founder sequences and the vaccine insert sequence(s) must be highly immunologically relevant, based on knowledge of antibody epitopes and T cell epitopes.

3. Env sequences, of primary importance for acquisition sieve analysis, are difficult to align.

Challenge 1 is fundamental, in that acquisition sieve analysis assesses selective blockage of infection with different exposing viruses, and hence requires sequence data that approximate the exposing virus. Moreover, sequence data from a single sampling timepoint are insuf- ficient for discriminating an acquisition from a post-infection sieve effect; for this longitudinal sequence data are needed, starting in the Figure 2. Distribution of Gag-84 residues (T or V) by vaccine/placebo group and whether the subject has an A-list allele10 restricting an epitope acute phase. Therefore, sieve analysis is aided by diagnosing at least containing Gag-84. Each vertical bar is for one infected subject, with height 40−50% of infections in the acute-phase, and by using two-phase representing the number of founder sequences measured. statistical methods that recover information by predicting missing acute-phase sequences. This requirement motivates relatively frequent that mismatched at least one founder sequence. These distances were HIV diagnostic testing (eg, bimonthly). greater in the vaccine than placebo group (Figure 1). Challenge 2 is being addressed for acquisition sieve analysis by col- Based on our method9 and extensions, we also found evidence for laborating with structural biologists (including Drs. Peter Kwong several amino acid “signature sites,” defined as sites where the rate and Bill Schief ) to account for knowledge of monoclonal antibody of mismatch of founder sequence residues to the insert residue was Env contact sites, and for knowledge of sets of Env sites that may significantly greater in vaccine than placebo recipients. The strongest constitute antibody epitopes. It is being addressed for postinfection sieve analysis by research to improve machine learning T cell epitope signature site was Gag-84 (Figure 2). Gag-84 is in the extensively 14, 15, 16 studied and immunodominant SLYNTVATL epitope, and the fact prediction methods (led by Dr. Tomer Hertz) and by direct that this signature is more pronounced in subjects with an HLA allele validation with HVTN trial datasets (led by Dr. Nicole Frahm). 10 Challenge 3 is being addressed by Dr. Edlefsen, using profile hidden known to restrict an A-list CTL epitope covering Gag-84 enhances 17 support for vaccine-pressure at this site. Markov models to directly assess and aggregate models over align- ment uncertainty. HVTN statisticians are completing follow-up analyses of the functional consequences of the observed sieve effect, accounting for viral The sieve analysis of the Step trial demonstrated the value of sieve load and T cell response data. While the sieve effect did not trans- analysis in detecting vaccine-pressure on HIV. In collaboration with late into ameliorated HIV infection progression,11 some evidence is the labs of Carolyn Williamson, Jim Mullins, and Jerome Kim/ emerging for weak and transient vaccine-mediated suppression of Morgane Rolland, HVTN scientists are now focusing on the sieve acute-phase viral load. By establishing that a T-cell based vaccine analysis of Phambili/HVTN 503 and RV144. The vaccine tested can impose constraints (albeit weak ones) on the viruses establishing in HVTN 502 was the same as the one tested in HVTN 503, with infection, the detected sieve effect may be a milestone in T-cell based insert genes that subtype-matched the circulating HIVs for 502 (B HIV vaccine research, suggesting that improved T-cell based vaccines vs B) but subtype-mismatched for 503 (B vs C). Thus, a goal of the could potentially constrain the founder virus in a more useful way, HVTN 503 sieve analysis is to learn whether the finding of vaccine- incurring a greater fitness cost and hence suppressing viremia.12, 13 pressure in the subtype-matched context generalizes to the subtype- mismatched setting; the answer to this question informs about the priority of subtype-matching of gag, pol, and nef inserts. Two goals Statistical Methods Research for Sieve Analysis of the RV144 sieve analysis are to provide additional evidence about whether the observed protective efficacy was real or a false posi- The HVTN’s ongoing sieve analysis statistical methods research tive result (detection of a biologically interpretable acquisition sieve focuses on 3 challenges: effect would support real efficacy), and to identify Env specificities 1. Ideally the acquisition sieve analysis would focus on viruses mea- responsible for an acquisition sieve effect, which would directly guide sured in the acute phase, before immune responses significantly optimal insert-sequence selection for future vaccine candidates. 13 impact the virus quasispecies however, acute-phase viruses are Peter Gilbert is the Principal Investigator of the HVTN Statistics and Data only observed in a fraction of infected subjects. Management Center. Allan deCamp, Paul Edlefsen, Craig Magaret, and Tomer Hertz conduct statistical analyses with the HVTN.

6 SEPTEMBER 2011 VOLUME 3:1 | HVTNEWS SIEVE ANALYSIS OF HIV SEQUENCES IN VACCINE EFFICACY TRIALS

References: 10. Frahm N, Yusim K, Suscovich TJ, et al. Extensive HLA class I allele promiscuity among viral CTL epitopes. Eur J Immunol. 1. Future access to HIV vaccines. Report from a WHO-UNAIDS 2007;37(9):2419–33. Consultation, Geneva, 2-3 October 2000. AIDS. 2001;15:W27–W24. 11. Fitzgerald D, Janes H, Robertson M, et al. An Ad5-vectored 2. Burton DR, Desrosiers RC, Doms RW, et al. HIV vaccine HIV-1 vaccine elicits cell-mediated immunity but does not affect design and the neutralizing antibody problem. Nature Immunology. disease progression in HIV-1 infected male subjects: results from 2004;5:233–236. a randomized placebo-controlled trial (the Step study). J Infec Dis. 2011;203:765–772. 3. Fauci AS, Johnston MI, Dieffenbach CW, et al. HIV vaccine research: the way forward. Science. 2008;321:530–532. 12. Troyer RM, McNevin J, Liu Y, et al. Variable fitness impact of HIV-1 escape mutations to cytotoxic T lymphocyte (CTL) response. 4. Buchbinder SP, Mehrotra DV, Duerr A, et al. Efficacy assess- PLoS Pathog. 2009;5(4):e1000365. ment of a cell-mediated immunity HIV-1 vaccine (the Step Study). Lancet. 2008;372:1881–1893. 13. Goonetilleke N, Liu MK, Salazar-Gonzalez JF, et al. The first T cell response to transmitted/founder virus contributes to the control 5. Rolland M, Tovanabutra S, deCamp AC, et al. Genetic impact of acute viremia in HIV-1 infection. J Exp Med. 2009;206(6):1253–72. of vaccination on breakthrough HIV-1 sequences from the Step trial. Nature Medicine. 2011;17:366–371. 14. Yanover C, Hertz Tomer. Predicting Protein-Peptide Binding Affinity by Learning Peptide-Peptide Distance Functions. Research in 6. Korber BTM, Brander C, Haynes BF, et al. HIV Molecular Computational Molecular Biology. 2005;3500:456–471. Immunology 2006/2007. In: Korber BTM, Brander C, Haynes BF, Koup RA, Moore JP.(eds.) Los Alamos, NM: Los Alamos National 15. Hertz T, Yanover C. PepDist: a new framework for protein-pep- Laboratory, Theoretical Biology and Biophysics. 2007. tide binding prediction based on learning peptide distance functions. BMC Bioinformatics. 2006;7(Suppl 1):S3. 7. Heckerman D, Kadie C, Listgarten J. Leveraging information HLA alleles/supertypes improves epitope prediction. Journal of Com- 16. Hertz T, Yanover C. Identifying HLA supertypes by learning putational Biology. 2007;14:736–746. distance functions. Bioinformatics. 2007;23:e148–e155.

8. Buus S, Lauemøller SL, Worning P, et al. Sensitive quantitative 17. Edlefsen, PT, Liu, JS. Transposon identification using profile predictions of peptide-MHC binding by a ‘Query by Committee’ ar- HMMs. MC Genomics. 2010;11(Suppl 1):S10. tificial neural network approach. Tissue Antigens. 2003;62(5):378–384.

9. Gilbert PB, Wu C, Jobes DV. Genome scanning tests for comparing amino acid sequences between groups. Biometrics. 2008;64:198–207.

Training and Mentorship Programs at the HVTN Blythe Adamson

The HVTN believes that the continued investment in research and pating organizations include the Center for HIV/AIDS Vaccine in the next generation of researchers is crucial to the success of our Immunology (CHAVI), the Global HIV Vaccine Enterprise, and the ultimate goal -- finding an effective preventive HIV vaccine. To that National Institute of Allergy and Infectious Diseases. end, the Network established 3 programs that address the unique requirements of the HIV vaccine field. The primary objectives of the HVTN/CHAVI NHP ESI Scholar Award are to: The Non-human Primate (NHP) Early Stage Attract and retain promising ESIs interested in improving Investigator (ESI) Award non-human primate models that support preventive HIV vaccine The NHP ESI Scholar Program was developed to address high prior- development, and ity scientific questions relevant to NHP models and vaccine discovery, Provide a framework for ongoing ESI mentorship to increase and to provide novel opportunities for young investigators willing to collaboration between clinical and NHP scientists addressing com- dedicate their efforts to this fundamental area of research. Partici- mon questions in vaccine discovery.

www.hvtn.org HVTNEWS | VOLUME 3:1 SEPTEMBER 2011 7 TRAINING AND MENTORSHIP PROGRAMS AT THE HVTN

TABLE 1. ESI COHORT 3 RESEARCH PROJECTS

SCHOLAR’S NAME INSTITUTION PROJECT TITLE

St. George’s University Use of Tissue Explants to Evaluate Mucosal Immune Response in NHPs and Carolina Herrera, PhD of London Humans

Oregon Health and Afam Okoye, PhD Role of NK cells in Antibody Mediated Protection Following SHIV Challenge Science University

New England Primate An in vivo Cytolytic CD8+ T Lymphocyte Assay for Evaluating AIDS Vaccine Lu-Ann Pozzi, PhD Research Center Efficacy

New England Primate Keith Reeves, PhD Role of Natural Killer Cells in Control of HIV/SIV Infections Research Center

Duke University Medical B Cell and Antibody Measurements Indicative of Protective Antibodies for Shaunna (Xiaoying) Shen, DVM, PhD Center HIV-1

Beth Israel Deaconess Wendy Yeh, MD HIV/SIV Mucosal Pathogenesis in the Male Genital Tract Medical Center

Since 2009, 14 investigators have received 1-2 year ESI awards, and the availability of the investigator expertise required to conduct the program has resulted in 16 published manuscripts, 9 manuscripts HVTN studies in South Africa. in development, 26 oral abstracts, 9 posters, and 1 patent pending. Table 1 lists the latest award recipients, and the titles of their projects. Scholars have full-time positions at established HVTN research sites where they are engaged in study implementation and conduct The HVTN hopes to release the 4th Request for Applications for research projects addressing priorities of the HVTN scientific agenda. 2-year scholars in Fall 2011. Scholars will also complete a PhD during the course of this program. SHAPe is led by Dr. Linda-Gail Bekker and Dr. Gavin Churchyard, The South African/HVTN AIDS Vaccine Early and is jointly supported by the HVTN and the NIH Fogarty Inter- Stage Investigator Scholar Program (SHAPe) national Center. The program is further enhanced through organized mentorship, training, and targeted career development activities. South Africa remains an important country in which to conduct HIV vaccine studies. In the coming years, the HVTN will launch key It’s anticipated that the success of SHAPe will significantly contrib- protocols that will utilize the strengths of the South African sites. ute to the HVTN’s scientific agenda, while helping to ensure long- lasting leadership for HIV vaccine research in South Africa. SHAPe is a research and mentorship program designed to establish, support, and retain a cohort of talented young South African physi- Table 2 lists the names and research interests of our first SHAPe cians as they develop research careers in the HIV vaccine sciences. Scholars. Contributing to the development of these researchers will help ensure

TABLE 2. SHAPe RESEARCH INTERESTS

SCHOLAR’S NAME INSTITUTION RESEARCH INTERESTS

Impact of genital tract inflammation and cellular activation on mucosal vaccine- Shaun Barnabas, MBBCh University of Cape Town induced antibody responses following HIV vaccination

Factors within the South African population contributing to differences in im- Katherine Young, MBBCh University of Cape Town mune activation (particularly co-morbid infectious diseases and risk behav- iours)

8 SEPTEMBER 2011 VOLUME 3:1 | HVTNEWS TRAINING AND MENTORSHIP PROGRAMS AT THE HVTN

The Research and Mentorship Program (RAMP) 3. Evaluate the impact of these activities on the attitudes and future career decisions of RAMP Scholars Black and Latino HIV prevention researchers (clinical and trans- lational) are underrepresented in our community of scientists. The Established HVTN investigators across the globe worked closely HVTN’s RAMP, established by The Legacy Project in collaboration with medical student applicants to develop research project proposals. with the HVTN’s Training Unit, aims to attract and retain an in- HVTN selected 6 RAMP scholars in 2011; 4 students will be con- creasing number of researchers from these communities to the field of ducting 3 month projects (during summer or a clinical elective block) HIV vaccine science. This program is intended to support U.S. medi- and 2 students will have a year-long experience between their 3rd cal students under the mentorship of HVTN-affiliated investigators. and 4th year of medical school. In addition to their projects, RAMP The students conduct short term research projects on aspects of basic, Scholars will participate in 2 HVTN conferences, training activities, clinical, behavioral, and social sciences aligned with the HVTN scien- and a professional development workshop. tific agenda. RAMP has 3 major aims: HVTN plans to release a new Request for Applications for a 2nd cohort of scholars in the Fall of 2011. 1. Increase the awareness of career opportunities in HIV vaccine research among Black and Latino medical students The table below lists our first scholars’ chosen research projects and home institution. 2. Create a structured learning opportunity that combines research, senior and peer mentorships, and training in research methods Blythe Adamson is Project Manager for Training Initiatives at the HVTN. to attract Black and Latino medical students to future careers in HIV vaccine research

TABLE 3. RAMP SCHOLARS AND PROJECT TITLES

SCHOLAR’S NAME INSTITUTION PROJECT TITLE

Kathy Jo Carstarphen, MA University of Alabama Public Perceptions of HIV Prevention Strategies

Mount Sinai School of Assessing the Impact of an HIV Education Campaign in a Peri-urban Community of John Chiosi Medicine Cape Town, South Africa.

University of Kentucky HIV Vaccine Acceptability Among Groups at High Risk for HIV Infection in Lima, Chris Garnett, MPH School of Medicine Peru

The Commonwealth Evaluating the Effectiveness of HIV Clinical Trials Recruitment Strategies in Sub- Daniel Gonzalez Medical College populations of MSM and MTF Transgender Individuals

Characterization of the Memory B Cell and Plasma Cell Repertoires with Functional Kathryn Lorraine Jones, PhD Duke Medical School Analysis of the Antibodies Generated in Response to a HIV Envelope DNA Prime and rAd5 Vector Boost Vaccination Regimen.

Stanford School of Cesar Lopez Angel Facilitators and Barriers to Participating in HIV Vaccine Trials Medicine

For more details on the RAMP, NHP ESI, and SHAPe programs, and to find out when the next Request for Applications will be posted, visit www.hvtn.org/awards.

www.hvtn.org HVTNEWS | VOLUME 3:1 SEPTEMBER 2011 9 Defining the Targets of HIV-specific T-cell Responses (Epitope Mapping) Nicole Frahm

Epitope mapping determines which regions of a given patho- induced response was inadequate to contain virus replication gen (eg, HIV) are recognized by T cells in response to infec- upon infection. tion or vaccination. The size and makeup of these mapped regions are characterized by the tools used in the process, ie, the Indeed, as shown in the figure on page 11, a total of up to 15 peptides tested in the immune assay of choice. In most cases, single 15-mer peptides were targeted by Step vaccine recipi- the peptides will be relatively short and will cover the protein ents, but the median number of responses in this cohort was 1. in question in an overlapping design (eg, 15-mers overlapping by 11); this approach has been developed to ensure relative This limited breadth is in stark contrast to the very broad sensitivity (longer peptides are less well recognized) as well responses detected after vaccination of rhesus macaques with as good coverage of potential CD8 T-cell epitopes, which are Ad5 expressing all SIV proteins minus Env:9 a median of usually 8-12 amino acids (aa) in length (shorter overlaps would 13 responses were detected to Gag, Nef and Pol at 2 weeks lead to truncated epitopes that cannot be recognized). Epitope post Ad5 boost in this study, and vaccinated macaques had mapping is mostly carried out in a step-wise manner, with significantly lower viral loads both at peak and setpoint. It is larger pools (encompassing up to 160 15-mers) being tested therefore plausible that the limited breadth of vaccine-induced first and positive pools being deconvoluted, subsequently using immune responses in Step vaccinees may represent a factor smaller pools followed by single peptides. Results are usually in the lack of protection afforded by the MRKAd5 HIV-1 presented as the breadth of the T-cell response (ie, the number vaccine, due to the limited match of sequences targeted by of targeted peptides/epitopes), and sometimes as the specific vaccine-induced T-cell responses and those present in circulat- sequences representing the dominant targets of HIV-specific T ing virus strains. cells. The assay of choice is predominantly an IFN-γ ELISpot since it allows for testing of large numbers of conditions using To make up for this potential stumbling block, new strategies relatively few cells; it comes at the cost of not being able to for increasing the breadth of vaccine-induced responses have distinguish whether the targeted regions are recognized by been developed in the recent years. One of the most promis- CD4 or CD8 T cells unless followed up by intracellular cyto- ing strategies is the use of mosaic antigens: these maximize kine staining or depletion studies. HIV sequence coverage in a parsimonious set of antigen constructs.10 Mosaic vaccines have been shown to significantly The influence of the breadth of HIV-specific T-cell responses increase the breadth and depth of T-cell responses (the latter on HIV disease progression in unvaccinated HIV-infected being defined as the ability to recognize several epitope vari- subjects has been the subject of controversy since the establish- ants rather than a single epitope sequence) in non-human pri- ment of high throughput assays allowing for its determina- mate models;11,12 unfortunately, since mosaic designs are based tion, around 10 years ago. Early on, studies were published on HIV rather than SIV sequences, the vaccinated animals claiming a positive,1 a negative2 or no correlation3 between have not been used in a challenge study, therefore the clinical epitope breadth and viral load or CD4 counts; more recently, benefit of the increased breadth has not yet been assessed. Mo- a consensus is emerging that increased targeting of Gag saic antigens are currently being manufactured in the context epitopes is associated with reduced viral loads and/or higher of several different vaccine vectors, including rare serotype CD4 counts.4-6 Similarly, the number of vaccine-induced Gag adenoviruses and poxvectors, and will be available for testing epitopes inversely correlates with post-challenge viral load in HVTN trials within the next couple of years. Epitope map- setpoint in a nonhuman primate (NHP) model using various ping will provide one of the main readouts in these early phase adenovirus (Ad) serotype vectors in heterologous prime-boost studies, and recapitulating the increased breadth and depth of vaccine regimens.7 Since the viral load in Step Study vaccinees T-cell responses observed in animal studies will be an impor- who acquired HIV infection was not lower than that observed tant factor in moving these products into efficacy trials. in infected placebo recipients, even though T-cell responses of substantial magnitude were induced with the MRKAd5 HIV- In addition to studying mosaics, the HVTN is currently 1 vaccine,8 it was postulated that the breadth of the vaccine- enrolling for 2 studies (and planning to open a 3rd one within

10 SEPTEMBER 2011 VOLUME 3:1 | HVTNEWS DEFINING THE TARGETS OF HIV-SPECIFIC T-CELL RESPONSES (EPITOPE MAPPING)

Breadth of the vaccine-induced T-cell response. Responses were mapped down to the 15-mer in 73 Step Study vaccine recipients using insert-matched peptides. Responses to 2 consecutive overlapping 15-mers were counted as a single response. Horizontal lines show the median number of responses to each protein.

the next 6 months) designed to understand factors that influ- expressed HIV-1 genome demonstrate broadly directed responses, but ence breadth in response to vaccination. HVTN 083 will no correlation to viral load. J. Virol. 2003;77:2081–2092. assess whether repeated exposure to the same vaccine leads to 4. Kiepiela P, Ngumbela K, Thobakgale C, et al. CD8+ T-cell relative narrowing of the immune response compared to vacci- responses to different HIV proteins have discordant associations with nation with heterologous vectors and inserts. HVTN 084 will viral load. Nat Med. 2007;13:46–53. measure the breadth of Gag– and Pol-specific T-cell responses after vaccination with immunogens consisting of Gag/Pol 5. Masemola A, Mashishi T, Khoury G, et al. Hierarchical target- alone, or Gag/Pol in combination with three Env constructs, ing of subtype C human immunodeficiency virus type 1 proteins by to assess whether the presence of additional proteins leads to CD8+ T cells: correlation with viral load. J Virol. 2004:78:3233–3243. antigenic competition. Finally, HVTN 085 was designed to 6. Zuniga R, Lucchetti A, Galvan P, et al. Relative Dominance of determine whether the separation of epitopes across multiple Gag p24-Specific Cytotoxic T Lymphocytes Is Associated with Hu- sites of vaccination (ie, left and right arms as well as left and man Immunodeficiency Virus Control. J Virol. 2006;80:3122–3125. right thighs) leads to an increased breadth of T-cell responses. Together, these studies will provide insight into the basic 7. Liu J, O'Brien KL, Lynch DM, et al. Immune control of an principles of the induction of T-cell responses in response SIV challenge by a T-cell-based vaccine in rhesus monkeys. Nature. to vaccination, and incorporating all of the factors shown to 2009;457:87–91. increase response breadth by epitope mapping may lead to the 8. McElrath MJ, De Rosa SC, Moodie Z, et al. HIV-1 vaccine- design of a more efficacious HIV vaccine. induced immunity in the test-of-concept Step Study: a case-cohort analysis. Lancet. 2008;372(9653):1894–1905. Nicole Frahm is Associate Director, Laboratory Science, HVTN. 9. Wilson NA, Keele BF, Reed JS, et al. Vaccine-induced cellular responses control simian immunodeficiency virus replication after heterologous challenge. J Virol. 2009;83:6508–6521.

References 10. Fischer W, Perkins S, Theiler J, et al. Polyvalent vaccines for optimal coverage of potential T-cell epitopes in global HIV-1 variants. 1. Betts MR, Ambrozak DR, Douek DC, et al. Analysis of total Nat. Med. 2007;13:100–106. human immunodeficiency virus (HIV)-specific CD4(+) and CD8(+) T-cell responses: relationship to viral load in untreated HIV infection. 11. Barouch DH, O'Brien KL, Simmons NL, et al. Mosaic HIV-1 J. Virol. 2001;75:11983–11991. vaccines expand the breadth and depth of cellular immune responses in rhesus monkeys. Nat Med. 2010;16:319–323. 2. Chouquet C, Autran B, Gomard E, et al. Correlation between breadth of memory HIV-specific cytotoxic T cells, viral load and 12. Santra S, Liao HX, Zhang R, et al. Mosaic vaccines elicit CD8+ disease progression in HIV infection. AIDS. 2002;16:2399–2407. T lymphocyte responses that confer enhanced immune coverage of diverse HIV strains in monkeys. Nat Med. 2010;16:324–328. 3. Addo MM, Yu XG, Rathod A, et al. Comprehensive epitope analysis of HIV-1-specific T cell responses directed against the entire

www.hvtn.org HVTNEWS | VOLUME 3:1 SEPTEMBER 2011 11 HVTN Protocols -- Enrolling or in Active Follow Up

Start Date HVTN# N Sites Description

This is a phase 2a clinical trial to evaluate the safety and tolerability of a prime-boost regimen of the GeoVax DNA vaccine and modified vaccinia Ankara (MVA) vaccine, Atlanta; Birmingham; Boston; New York; Iquitos; Lima; Nashville; Rochester; Jan-09 205 Geovax Phase 2 120 or of MVA vaccine alone, in healthy, HIV-1–uninfected, vaccinia-naive individuals. The vaccines express HIV-1 Clade B Gag, Pol and Env. Immune responses will be San Francisco; Seattle tested in rectal and genital secretions as well as in blood.

This is a longitudinal study of women at high risk for HIV-1 infection to inform HIV vaccine trial participation. The primary objectives are 1) To determine the feasibility Jan-09 906 US High-Risk Women 800 Chicago; Phaladelphia; New York of recruiting and retaining women at high risk of HIV infection with a focus on women who reside or engage in risk behavior in local risk pockets and/or are partners of men who are from subgroups with a high prevalence of HIV; and 2) To determine whether the HIV incidence rate in the longitudinal cohort is at least 1% per year.

This is a longitudinal study of women at high risk for HIV-1 infection to inform HIV vaccine trial participation. The primary objectives are 1) To determine the feasibility May-09 907 Caribbean High-Risk Women 800 San Juan; Port-au-Prince; Santo Domingo of recruiting and retaining women at high risk of HIV infection with a focus on female sex workers with demographic, behavioral, or other social factors associated with high prevalence of HIV; and 2) To determine whether the HIV incidence rate in the longitudinal cohort is at least 1% per year.

A phase 2b, randomized, placebo-controlled test-of-concept trial to evaluate the effect of the VRC DNA/rAd5 vaccine regimen on the rate of HIV-1 acquisition and HIV-1 Jun-09 505 VRC Phase 2b 2200 All US Sites VL setpoint compared to placebo participants who are diagnosed with HIV-1 infection at or after Day 196 post-enrollment through the Month 24 visit.

An ancillary study to HVTN 205, the aim of this protocol is to do a characterization of the innate immune response to candidate HIV vaccines. The objectives of the study Jul-09 908 Geovax Phase 2 Ancillary --- Birmingham; San Francisco; Seattle are to 1) To define the early systemic innate immune response to candidate HIV vaccines; 2) To determine which innate immune responses correlate with the ensuing adaptive immune responses.

A phase 1b clinical trial to evaluate the safety and immunogenicity of heterologous prime/boost vaccine regimens (NYVAC-B/rAd5 vs. rAd5/NYVAC-B) in healthy, HIV-1 Oct-09 078 NYVAC-rAd5 80 Lausanne uninfected, Ad5 nAb seronegative adult participants.

The goal of this phase 1b clinical trial is to examine the role of genetic background in governing the immune responses following vaccination with HIV antigens delivered Jan-10 082 Twins ~8 Boston; Rochester; San Francisco; Seattle via a DNA-prime Ad5-vectored boost regimen.

A phase 1 clinical trial to assess the safety, tolerability, and ability to increase breadth and magnitude of immune responses by using heterologous-inserts (env from Sep-10 083 Heterologous Insert 180 Atlanta; Birmingham; Boston; New York; Nashville; Rochester; San Francisco different HIV-1 clades) and heterologous vectors (recombinant adenovirus vectors of different serotypes) in prime-boost vaccine regimens in healthy, HIV-1–uninfected adults.

This randomized, double blind phase 1b trial is designed to examine the influence of antigenic competition on the immunogenicity of HIV-1 Gag/Pol. With this study, we Jan-11 084 Antigenic Competition 100 Iquitos; Lima; Lausanne; Sao Paulo want to determine whether the breadth and magnitude of T-cell responses to Gag and/or Pol is altered by co-immunization with env.

HVTN 914 is a cohort study designed to evaluate the feasibility of measuring immune responses and activation levels in the foreskin and rectosigmoid mucosa in HIV- May-11 914 Peru Circumcision 40 Lima negative, uncircumcised men who have sex with men and who are at high risk for HIV acquisition.

In a collaborative effort with IAVI, our South African sites are conducting a phase 1 placebo-controlled, double-blind, randomized trial to evaluate the safety and toler- May-11 091 Ad26/Ad35 IAVI Collaboration 80 Klerksdorp; Soweto; Cape Town ability of the Ad26.ENVA.01 and Ad35-ENV vaccines administered in heterologous and homologous prime-boost regimens.

A follow-on study to SASHA, an adolescent HIV vaccine preparedness study in South Africa, this is designed to document the incidence of HIV, other sexually trans- Jun-11 913 RSA Adolescent 269 Cape Town mitted infections, pregnancy, and circumcision in adolescents at clinical research sites (CRSs) in South Africa, extending the study period of observation from 9 to 18 months.

HVTN 076 is a phase 1b clinical trial to evaluate mucosal immune responses following intramuscular injections of a HIV-1 DNA plasmid vaccine prime followed by an Jul-11 076 Mucosal 45 Seattle HIV-1 adenoviral vector boost in healthy adenovirus type 5 seronegative HIV-1–uninfected adults.

The primary objectives of this phase 1 open-label trial are two-fold: 1) To evaluate the safety and tolerability of and 2) To evaluate neutralizing antibody responses to Jul-11 088 Novartis Clade C Boost 40 Birmingham; Nashville; Rochester; Seattle HIV-1 Sub C gp140 vaccine with MF59 in healthy HIV-1–uninfected adults, primed or unprimed with HIV-1 subtype B envelope subunit vaccines with MF59.

A phase 1 placebo-controlled study extension to HVTN 073 / SAAVI 102, the primary objective of this trial is to evaluate the safety and tolerability of IM administration of Aug-11 073E Novartis Boost 48 Boston; Cape Town; Soweto Novartis Sub C gp140 vaccine with MF59 adjuvant given to HIV uninfected healthy adult participants in South Africa and the United States who have previously received SAAVI DNA-C2 vaccine followed by SAAVI MVA-C vaccine.

This is a phase 1 placebo-controlled clinical trial to evaluate the safety and immunogenicity of vesicular stomatitis virus serotype Indiana (VSVIN) HIV gag vaccine given Sep-11 090 Profectus VSV 60 Atlanta; Nashville; Philadelphia; San Francisco to healthy, HIV-1–uninfected adult participants. The primary objective of this dose-escalation trial is to establish the maximum safe and tolerated dose of a recombinant VSV HIV gag vaccine being given for the first time in humans.

12 SEPTEMBER 2011 VOLUME 3:1 | HVTNEWS Start Date HVTN# N Sites Description

www.hvtn.org HVTNEWS | VOLUME 3:1 SEPTEMBER 2011 13 HVTN Annual Network Award Winners On June 3rd 2011 in Washington DC, the HVTN honored individuals who perform outstanding work at our sites

Octavio Valente, Jr. HVTN Service Award HVTN Mentoring Award HVTN Citizenship Award Volunteer Service Award

Award Recipient: Award Recipient: Award Recipient: Award Recipient: Reverend Edwin C. Sanders II Michael Keefer, MD Theresa Wagner Miko Robertson Co-Chair of the Legacy Principal Investigator, Study Coordinator, San Francisco Community Advisory Board (CAB) Working Group Rochester Member, Seattle

The HVTN Service Award The HVTN Mentoring Award The HVTN Citizenship Award Octavio Valente, Jr. was a recognizes individuals who recognizes an individual who is given to individuals deserving dedicated CAB member from have creatively responded to has demonstrated extraordinary special recognition for good Rio de Janeiro, Brazil who a particular challenge arising commitment as a mentor by citizenship with regard to passed away on March 21, 2006. in their HVTU work, and by promoting research, training/ consistent, reliable, and quality Octavio served many roles in which value has been added to education, and professional performance of HVTN research the HVTN and in the HIV/ the HVTU / HVTN enterprise. development of those they have sites’ duties and activities. AIDS community through mentored. his advocacy, dedication and Accolades for Reverend Accolades for Theresa spirited energy. Sanders Accolades for Dr. Keefer “Theresa has been a tireless In his honor, this service award “Rev. Ed has taken on the greatest “He enthusiastically promotes advocate for HVTN and for our is given to a CAB member who challenge - changing the church’s HIV research at multiple levels, participants and staff, working has demonstrated exemplary view around HIV/AIDS involv- with critical attention and to ensure smooth site clinical and leadership and dedication in the ing issues of sexuality and drug genuine support at the personal counseling operations, regulatory HVTN. use. His spiritual perspective level. His sincere nature in which oversight, and coordinating visits resonates with African-American he works with others to promote with our frequent monitoring Accolades for Miko leaders and provides the oppor- their individual growth makes “visitors”!” tunity for vaccine research to be him an outstanding mentor. This “Miko has been an active member brought to the table.” has been evident in the relation- of her local CAB for many years, ships he has developed with indi- including her service as co-chair viduals involved with community and Global CAB representative. outreach, clinical fellows, gradu- She has served as a community ate students, and faculty members member on protocol teams, and and their personal growth.” currently serves as the Global CAB’s representative to the SSC [Scientific Steering Committee] of the HVTN.”

14 SEPTEMBER 2011 VOLUME 3:1 | HVTNEWS HVTN 505: Expansion in Response to an Evolving Field Shelly Karuna, Carter Bentley

HVTN 505 is a study of an HIV vaccine regimen developed efficacy of daily oral PrEP among an international population of by the Vaccine Research Center (VRC) at the National In- men and transgender women who have sex with men.5 In July stitute of Allergy and Infectious Diseases (NIAID), National 2011, preliminary results of the Partners PrEP and CDC TDF2 Institutes of Health (NIH). In June 2009, the study began studies were presented in Rome, demonstrating efficacy of daily enrolling 1350 men and transgender women who have sex anti-retroviral therapy for prevention in serodiscordant couples with men. and in heterosexually active young adults, respectively.6, 7, 8

The vaccine regimen in HVTN 505 consists of a DNA prime The team of investigators, clinicians, educators, recruiters, and containing HIV-1 subtype B gag, pol, and nef genes and HIV- other staff conducting HVTN 505 had one overarching ques- 1 subtypes A, B, and C env given three times followed by a tion: how should HVTN 505 respond to these results? Should single recombinant adenovirus type 5 (rAd5) boost containing PrEP be offered to some or all HVTN 505 participants as gag-pol from subtype B and envelope genes from subtypes A, part of a revised trial design? Should the team monitor PrEP B and C. On the basis of non-human primate (NHP) and hu- uptake among study participants and adjust its analyses of man data for this and other vaccine regimens, the primary ob- study results accordingly? To answer these questions, the jectives of the protocol when it opened were: (1) the continued HVTN 505 Protocol Team sought input from the nearly 800 assessment of the safety and tolerability of the regimen; and participants enrolled in HVTN 505 at that time, and also from (2) assessment of the vaccine’s impact on viral load setpoint a wide range of scientists, community leaders, and other stake- among participants who became HIV-infected. holders in the HIV prevention field. With striking consistency, these groups expressed interest in learning more about PrEP’s In late 2009, results of the HIV vaccine study RV144 were potential to prevent HIV acquisition, but also urged HVTN published, showing a modest reduction in HIV infections 505 to maintain its focus on testing the HIV vaccine regimen among people who received the protocol’s study vaccines.1 while separate clinical trials continued to address the many RV144 enrolled approximately 16,000 individuals in Thailand. questions surrounding PrEP. In response to this feedback, This protocol tested a different vaccine regimen than that HVTN 505 expanded its exploratory objectives to monitor being evaluated in HVTN 505, but some of the immune re- and study the use of PrEP by HVTN 505 participants, includ- sponses to the vaccines in the Thai study are similar to immune ing learning more about how PrEP may work in combination responses seen in prior human studies of the HVTN 505 with this vaccine regimen in those participants who voluntarily vaccines.2 New results of non-human primate challenge stud- choose to take PrEP. ies also demonstrated a reduction in HIV acquisition among monkeys that received SIV (simian immunodeficiency virus) HVTN 505 has already had many opportunities to adjust to versions of the HVTN 505 vaccines.3 advances in the rapidly evolving field of HIV prevention. The people behind HVTN 505 have worked, and continue work- Based upon results from these human and NHP HIV vaccine ing to respond to these opportunities. We owe this effort to studies, HVTN 505 raised the previous secondary study objec- our many colleagues in HIV prevention working throughout tive on HIV acquisition to be another primary objective of the the world, and to support from our generous participants, study: to assess whether or not the 505 vaccines might protect dedicated staff at our clinical trial sites, and the NIAID/NIH. against HIV infection. In order to have sufficient statistical We hope that the responsiveness to HIV prevention advances power to assess this new primary objective, the size of the in the field demonstrated in HVTN 505 is but one example study was increased from 1350 to 2200 participants. of what is possible as we all work together to end the HIV pandemic. In addition, since HVTN 505 opened, the broader HIV prevention field has been making headlines with new results. In Shelly Karuna is Director, Clinical Development, HVTN. Carter Bentley is Senior Protocol Development Coordinator, HVTN. late 2010, CAPRISA 004 demonstrated moderate efficacy of coitally-dependent topical PrEP among women in South Af- 4 rica. Also in late 2010, the iPrEx study demonstrated moderate References on page 18...

www.hvtn.org HVTNEWS | VOLUME 3:1 SEPTEMBER 2011 15 Exploring Barriers and Facilitators to Participation of Male- To-Female Transgender Persons in HIV Vaccine Clinical Trials Michele Peake Andrasik

Transgender is a term used to describe a range of individuals had the greatest impact on decisions to participate. The major- with atypical gender characteristics, or with gender identities ity of participants perceived themselves as being excluded from discordant from their biological sex. Male-to-female (MTF) research. Their perception was that research was either focused transgender communities experience high HIV prevalence and on men who have sex with men, and as MTF transgender African American race has been found to be the strongest risk they were lumped with this group, or it focused on biological factor for HIV infection among MTF transgender persons. women, and they were excluded. As one woman in Atlanta ex- Additional HIV risk factors in this population include (but plained, “... It’s all MSM’s and most [transgender] people don’t are not limited to) depression, homelessness, and having less consider themselves men having sex with men. And I heard than a high school degree. MTF transgender persons are often of one that was for women, but is it for the trans [women]?” marginalized and have many unmet needs. Behavioral and Several women questioned the need for an HIV vaccine and biomedical HIV prevention strategies are urgently needed for perceived the use of antiretroviral therapy (ART), once HIV this population. infected, as a better option.

Enrollment of MTF transgender participants in HIV vaccine “I’ll protect myself, but if I get infected, then I’ll trials has been modest. To explore barriers and facilitators to just go get medication, and that will be that. … participation, focus groups of MTF transgender women were I’d rather wait until that happens and just take the conducted in four urban areas (Atlanta, Boston, Philadelphia medicine than… put something I don’t know in my and San Francisco). Forty-two individuals participated in these body.” groups. The figure on page 17 depicts the participants’ major (San Francisco woman) demographic characteristics. In addition, the mean number of unprotected anal sex partners in the 6 months prior to the Additional barriers to participation included: mistrust of the focus group was 6.5 (range = 0-100). Over half (57%) had scientific community, perceived possible vaccine side effects, never participated in behavioral or biomedical research. Seven vaccine interactions with hormones, and a fear of being mis- (16.7) were unsure of past participation and 2 (5%) chose not treated. Although a few participants indicated that they would to answer. Among those with a confirmed history of biomedi- never participate in a vaccine trial, the large majority identified cal research participation (n=11), 2 reported participating in a factors that would facilitate participation. The most commonly PrEP clinical trial and one in a vaccine clinical trial. reported facilitator was receiving education and information that was focused on the transgender community. Women Focus groups were digitally recorded, transcribed verbatim and stated that the information provided would need to be very uploaded into Atlas.ti software. Thematic analysis was utilized user friendly, and include a step by step guide to what could to review and code transcripts, including in vivo, line-by-line be expected as a participant as well as a brief history of vaccine and focused coding, and a constant comparative method. First, trials, and how trials would benefit the MTF community. 3 investigators independently coded the focus group transcripts and then met to review codes and create a codebook. Many women identified “trans-friendly” doctors or health Next, we utilized the codebook to reanalyze the transcripts and care providers as important referral sources. For many of the generated new codes as they arose in an iterative process. Dif- women, the search for a good provider was challenging and ferences in coding were resolved by consensus among 3 inves- most women could readily identify the “trans-friendly’ doctors tigators. To enhance the validity of the findings, we employed in their city. These individuals were seen as reliable sources of data source triangulation (feedback from participants on final information and people whom they could trust. themes), investigator triangulation (3 investigators independently coded the transcripts), and peer debriefing (investiga- “If the doctor was talking to me about it, I think tors discussed emerging themes and interpretations with other it would stand out more. I’d probably be more researchers). inclined because then there would be someone actually talking to you about it and providing you Participants were largely unaware of vaccine research and with information.” information they reported receiving was often incorrect. Lack (Atlanta woman) of awareness and information regarding vaccine clinical trials

16 SEPTEMBER 2011 VOLUME 3:1 | HVTNEWS EXPLORING BARRIERS AND FACILITATORS TO PARTICIPATION OF MALE-TO-FEMALE TRANSGENDER PERSONS IN HIV VACCINE CLINICAL TRIALS

Many women expressed altruism as a strong facilitator for investment in the community. participation. As one woman explained, “I think I have a responsibility as a negative transgender woman to try to help “It all boils down to because we’re always so eradicate this for future… if I could just make some impact at quick to think of the negative because we have all.” However, altruistic intentions were often overshadowed always been put in the negative. Every time they by the realities of everyday life. Many women reported having [society] talk about anything that’s transgender, their needs unmet and that day to day survival often precluded it’s the negative. So of course, when we hear participation in anything that might benefit the larger com- these things, and you’re coming to us now, oh, you munity. must want something for nothing or something for something.” “If they’re really worried about us then make us (Atlanta woman) the transitional home, make us the pharmacy for our hormones because that’s why we’re Currently, the HVTN is utilizing this data to develop strate- prostituting and doing all this sex stuff… Give us a gies and recommendations to improve vaccine education and home. Give us a foundation, and we’ll do the rest” clinical trial recruitment and retention among MTF transgen- (San Francisco woman) der individuals in the Network. In addition, a manuscript of this work is in preparation for publication. Finally, ensuring that researchers and staff understand and work to address the struggles of the MTF transgender com- Michele Peake Andrasik is an HVTN Social Scientist. munity was identified as an important way to demonstrate FOCUS GROUP PARTICIPANTS’ DEMOGRAPHICS

RACE/ETHNICITY AGE (YEARS)

AFRICAN AMERICAN (24) 18-24 (7) WHITE (6) 25-29 (8) MULTIRACIAL (6) 30-39 (12) LATINA (4) 2.4% 40-49 (9) 28.6% 16.7% ASIAN (1) ≥50 (6) NATIVE HAWAIIAN (1) 57.1%

9.5% 14.3% 21.4% 19% 2.4% 14.3% 14.3%

SELF-IDENTIFIED ANNUAL INCOME SEXUAL ORIENTATION

HETEROSEXUAL (32) BELOW POVERTY BISEXUAL (5) LINE ($10,890) (19) HOMOSEXUAL OR GAY (2) $11,000-$19,999 (12) CHOSE NOT TO $20,000-$49,999 (4) 45.2% IDENTIFY (2) CHOSE NOT TO GENDER QUEER (1) 76.2% ANSWER (7) 16.7%

2.4% 9.5% 4.8% 28.6% 4.8% 11.9%

www.hvtn.org HVTNEWS | VOLUME 3:1 SEPTEMBER 2011 17 Photos by Geneveive Meyer

Members of our Nashville site team at a Karaoke event for trial participants. Members of our Atlanta site team were photographed at a recruitment event.

HVTN 505: EXPANSION IN RESPONSE TO AN EVOLVING FIELD Continued from page 15

References: 6. Centers for Disease Control and Prevention. CDC trial and another major study find PrEP can reduce risk of HIV infection among 1. Rerks-Ngarm S, Pitisuttithum P, Nitayaphan S, et al. Vaccina- heterosexuals, July 13. 2011. Available online: http://www.cdc.gov/ tion with ALVAC and AIDSVAX to prevent HIV-1 infection in nchhstp/newsroom/PrEPHeterosexuals.html. Last accessed August Thailand. N Engl J Med. 2009;361:2209–2220. 8, 2011.

2. Koup RA. Antibody responses to the VRC vaccine: Implications 7. University of Washington ICRCPPS. Pivotal study finds that for HVTN 505. HVTN Full Group Meeting, Washington, DC, May HIV medications are highly effective as prophylaxis against HIV in- 5, 2010. fection in men and women in Africa. 2011. Available online: http:// depts.washington.edu/uwicrc/research/studies/files/PrEP_PressRe- 3. Letvin NL, Rao SS, Montefiori DC, et al. Immune and Genetic lease-UW_13Jul2011.pdf. Last accessed August 8, 2011. Correlates of Vaccine Protection Against Mucosal Infection by SIV in Monkeys. Sci Transl Med. 2011;3:81ra36. 8. Thigpen M, Kebaabetswe P, Smith D, et al. Daily oral antiretroviral use for the prevention of HIV infection in heterosexually active 4. Abdool KQ, Abdool Karim SS, Frohlich JA, et al. Effectiveness young adults in Botswana: Results from the TDF2 study. 6th IAS and safety of tenofovir gel, an antiretroviral microbicide, for the pre- Conference on HIV Pathogenesis, Treatment and Prevention, Rome, vention of HIV infection in women. Science. 2010;329:1168–1174. Italy, 17–20 July, 2011.

5. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemo- prophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363:2587–2599.

18 SEPTEMBER 2011 VOLUME 3:1 | HVTNEWS Recent HVTN Publications

A complete list of recent HVTN publications can be found within our HVTNews website, hvtn.org/science/hvtnews.html - A sample of our publications are included below. MANUSCRIPTS

Corey L, Nabel GJ, Dieffenbach C, Gilbert P, Haynes BF, Johnston M, Kublin J, Lane HC, Pantaleo G, Picker LJ, Fauci AS.HIV-1 vaccines and adaptive trial designs. Sci Transl Med. 2011 Apr 20; 3(79):79ps13. PMID: 21508308.

Gray GE, Allen M, Moodie Z, Churchyard G, Bekker LG, Nchabeleng M, Mlisana K, Metch B, de Bruyn G, Latka MH, Roux S, Mathebula M, Naicker N, Ducar C, Carter DK, Puren A, Eaton N, McElrath MJ, Robertson M, Corey L, Kublin JG; on behalf of the HVTN 503/Pham- bili study team. Safety and efficacy of the HVTN 503/Phambili Study of a clade-B-based HIV-1 vaccine in South Africa: a double-blind, randomised, placebo-controlled test-of-concept phase 2b study. Lancet Infect Dis. 2011 Jul; 11(7):507-515. Epub 2011 May 11. PMID: 21570355.

Pine SO, Kublin JG, Hammer SM, Borgerding J, Huang Y, Casimiro DR, McElrath MJ Pre-existing adenovirus immunity modifies a complex mixed Th1 and Th2 cytokine response to an Ad5/HIV-1 vaccine candidate in humans.PLoS One. 2011 Apr 13; 6(4):e18526. PMID: 21533229.

Rolland M*, Tovanabutra S*, deCamp A*, Gilbert P, Sanders-Buell E, Heath L, Magaret C, Bose M, Bradfield M, O’Sullivan A, Crossler J, Jones T, Nau M, Wong K, Zhao H, Raugi D, Sorensen S, Stoddard J, Maust B, Deng W, Hural J, Dubey S, Frahm N, Michael N, Shiver J, Corey L, Li F, Self S, Kim J, Buchbinder S, Casimiro D, Robertson M, Duerr A, McElrath MJ, McCutchan F, Mullins J.*contributed equally. Genetic impact of vaccination on breakthrough HIV-1 sequences from the STEP trial. Nature Medicine (2011) doi:10.1038/nm.2316. Published online 27 February 2011. NIHMS269267. AIDS VACCINE 2011 ABSTRACTS

Andersen-Nissen E, et al. Innate immune response signatures to Janes H, et al. Integrated analysis of immunogenicity, viral sequence, Ad5 and MVA-vectored candidate HIV vaccines predict induc- and viral load data in the Step Study. AIDS Vaccine 2011. Poster tion of adaptive responses. AIDS Vaccine 2011. Oral Presentation. Presentation. [P01.08] [OA02.01] Kalams SA, et al. Robust Immunogenicity after HIV DNA Vaccina- Bunce C, et al. Project VOGUE: HIV Vaccine Education in an tion with IL-12 Plasmid Cytokine Adjuvant Delivered via Electro- Underserved Racial/Ethnic MSM Population. AIDS Vaccine 2011. poration in HIV Uninfected Adults. AIDS Vaccine 2011 Latebreaker. Poster Presentation. [P15.08] Poster Presentation. [P18.25 LB]

Chen H, et al. Immune selection of T helper epitopes in healthy Keefer MC, et al. Education and research initiatives for the Mobi- volunteers received a multiepitope candidate HIV vaccine. AIDS lization of African-American Faith Communities for HIV/AIDS Vaccine 2011. Poster Presentation. [P18.02] prevention and HIV vaccine awareness. AIDS Vaccine 2011. Poster Presentation. [P06.08] Flood D, et al. Evaluation of a mentorship program to enhance capacity to deliver HIV risk reduction counseling to study participants Logan M*, Hertz T*, et al. HVTN503/Phambili Phase 2b vaccine in global HIV vaccine trials. AIDS Vaccine 2011. Poster Presentation. trial: The effect of the HIV-1 Clade B-based MRKAd5 vaccine on [P06.11] breakthrough founder viruses from a Clade C infected population. AIDS Vaccine 2011 Latebreaker. Poster Presentation. [P18.28 LB] Frahm N, et al. B Cell Immunology and Neutralizing Antibodies. AIDS Vaccine 2011. Oral Presentation. [OA10.06] Madenwald T, et al. Attitudes and intent to use PrEP among current phase II preventive HIV-1 vaccine trial participants. AIDS Vaccine Hertz T, et al. HIV T-cell vaccines induce specific epitope hotspots 2011. Poster Presentation. [P15.11] that differ from those observed in natural infection and target variable regions of the HIV genome. AIDS Vaccine 2011 Latebreaker. Poster Presentation. [P18.27 LB]

www.hvtn.org HVTNEWS | VOLUME 3:1 SEPTEMBER 2011 19 MANAGING EDITOR: CECILIA MORGAN EDITOR: ADI FERRARA PRODUCTION MANAGER: COURTNEY LIEBI DESIGN & LAYOUT: LISA DONOHUE CALENDAR FOR MORE INFORMATION, VISIT: hvtn.org AIDS VACCINE RESEARCH SUBCOMMITTEE (AVRS) SEPTEMBER 20-21, 2011 COMMENTS/QUESTIONS? Bethesda, MD [email protected] Tel: 206 667-6300 / Fax: 206 667-6366 HVTN CONFERENCE HVTN/FHCRC, 1100 Fairview Ave North, LE-500 PO Box 19024 Seattle, Washington 98109-1024 NOVEMBER 7-9, 2011 Seattle Grand Hyatt

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The HIV Vaccine Trials Network is an international collaboration of scientists and educators searching for an effective and safe HIV 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 Services. The Network and NIAID have a close, cooperative working relationship, with shared attention to intellectual and scientific issues.