Impact of Early vs Late ART on HIV-1 DNA Levels in Children

1. Abstract # WEAB0208LB Impact of late versus early antiretroviral therapy on PBMC-associated HIV-1-DNA levels and the percentage of naive T lymphocytes in HIV-1 infected children and adolescents -- The ANRS-EP59-CLEAC study P. Frange, V. Avettand-Fenoel, J. Le Chenadec, C. Dollfus, L. Nailler, O. Dialla, T. Montange, D. Batalie, M. Fillion, I. Leymarie, L. Ait Si Selmi, T. Wack, J.Warszawski, and F. Buseyne #AIDS2018 | @AIDS_conference| www.aids2018.org

2. CLEAC Background • Early initiation of combined antiretroviral treatment (cART) decreases mortality as compared to deferred treatment (Faye et al. Clin.Infect.Dis. 2004, Violari et al. N.Engl.J.Med. 2008) • Early cART results in lower blood viral reservoir • In infancy and in early childhood Persaud et al. AIDS 2012; Bitnunet al. Clin. Infect. Dis. 2014; Martínez-Bonet et al. Clin. Infect. Dis. 2015; Uprety et al. Clin. Infect. Dis. 2015 • In children and adolescents with sustained virological success Luzuriaga et al. J. Infect. Dis. 2014; Uprety et al. Clin. Infect. Dis. 2017; Kuhn et al. PLoS One 2018 • Early cART results higher CD4 T-cell levels • However, persistence of early cART benefit has been questioned (Goetghebuer et al. Clin. Infect. Dis. 2012) • Lifelong cART is a challenge • Does early cART benefit persist until late childhood and adolescence? • Does early cART benefit persist if viral replication resumes? • Early cART establishes a beneficial virus/host equilibrium: lessons for therapeutic strategies in pediatric patients?

3. CLEAC New information on earlycART • The CLEAC project innovates in the field • The medium/long-term benefits of cART • Children 5 – 12 years of age • Adolescents13 – 17 years of age • Patients with initial virologicalcontrol ( < 400 HIV RNA copies/ml) • Sustained or not until the time of the study • Physiopathological study • Immunological and virologicalmarkers, analyzed jointly • The CLEAC study is a cross-sectional study partly nested in the prospective French ANRS-EPF-CO10 cohort • The objective is to compare immunological and virological characteristics between HIV-1-infected children with early (before the age of six months) versus late (over the age of 24 months) initiation of cART

4. CLEAC Inclusion criteria • HIV-1 infection in the perinatalperiod • Age: 5-17 years • No HIV-2 coinfection • HIV-1 diagnosis < 13 years • Followed-up at clinical sites within the Paris area participating to the prospective ANRS-EPF-CO10 cohort of HIV-1-infected children • On cART at least once • ART initiation < 6 months or > 24 months of age • HIV-1 RNA < 400 copies/ml reached < 24 months of initiation • Affiliated person or beneficiary of a social security system • Informed consent formsigned by at least one parent/legalguardian • Participant agreement if in age to give an opinion

5. CLEAC Study design • Patients followed-up at clinical sites within the Paris area ← 0 - 12 mo → ← 6 ± 3 mo → ← 6 ± 3 mo → Inclusion Visit 1 Visit 2 Visit 3 Optional Clear ____ Clear ____ Cleac ____ Cleac ____ Check inclusion criteria + Consent Blood sample 1 15 mL EDTA Blood sample2 15 mL EDTA Blood sample3 50 mL Citrate Demographics, currentstatus, historysince HIV diagnosis HIV-1 DNA T-cellphenotype NK HIV inhibition Biobank T and B-cellfunction Activation Reservoir n=10, > 45kg Sustained control

6. CLEAC Study timing and objectives of the presentation • March 2018: End of inclusions • July 2018: Visits 1 completed • Today: Presentation of data from72 patients on twooutcomes • Total blood HIV-1 DNA (n=72) • Naive CD4 and CD8 T-celllevels(n=58)

7. CLEAC Outcomes • Total blood HIV-1 DNA loadis a clinically relevant marker of the viral reservoir • Blood HIV-1 DNA wasquantified by ultrasensitiveqPCR, Avettand-Fenoëlet al., J.Med. Virol., 2009 • Naive T lymphocytes are critical for immunity against pathogens, vaccines and tumor cells • Flow-cellcytometry on freshwholebloodsamples, Blanche et al., Clin Infect Dis, 2014 • Naive T cells were defined by the co-expression of CD45RA, CCR7, CD27 and CD28 molecules • Results were expressed as percentages among CD4 or CD8 T lymphocytes

8. CLEAC Statistical analyses • Comparison of outcomes’ levelswith the Kruskall-Wallis test • Four groups defined by cART initiation and age at the time of the study • Early / LatecART • Children / Adolescents • Multivariateanalysis: Medianregression • Study of potential interactions • Independent variables • Age at cART initiation (early versus late) • Age at the time of the study (children versus adolescents) • HIV-1 RNA level at the time of the study(< or ≥ 50 copies/ml) • Geographicalorigin (Sub-SaharanAfrica vs. Other)

9. CLEAC Patients’ demographics

10. CLEAC Patients’ characteristics at evaluation * n = 5, < 500 CD4 T-cells/µl

11. CLEAC Lower HIV-1 DNA in earlytreated patients • Earlytreatmentwasassociatedwithlower HIV-1 DNA levels in children and adolescents • Wide range of HIV-1 DNA levels in earlytreatedchildren and adolescents • Total HIV-DNA quantified in bloodby ultrasensitiveqPCR • Kruskal-Wallis test

12. CLEAC HIV-1 DNA: Multivariatemedianregression • Total HIV-1 DNA levelswereindependentlyassociatedwithage at cART initiation and HIV-1 RNA levels at the time of the study

13. CLEAC Highernaive T lymphocytes in earlytreatedchildren • Higher naive CD4 and CD8 T-cell percentages in early treated children • Data from the adolescent groups require cautious interpretation • Probable impact of past and current HIV replication • Only preliminary data on 58 subjects • Flow cell cytometry on fresh whole blood samples • Kruskal-Wallis test

14. Discussion: The spectrum of HIV-1 DNA levels • Total HIV-1-DNA levelsquantifiedwith the sameassay in the samelaboratory for pediatric and adult patients followed in France Avettand-Fenoelet al., Clin. Microbiol. Rev., 2016 • Some early treated children and adolescents from the CLEAC study reached HIV-1 DNA levels as low as those observed in adults with controlled HIV-1 replication ANRS cohorts PRIMO, SEROCO, HIC and VISCONTI; Single-center observational studies site (Children, Necker Hospital; Adults on cART, Orléans Hospital) N=552, PRIMO cohortGoujard et al., Clin. Infect. Dis., 2006 N=271, SEROCO, Rouzioux et al., J. Infect. Dis., 2005 N=44, Necker Cytotox, (Scott-Algara et al. JAIDS 2010) N=35 – n=272, Orléans HospitalHocqueloux et al. J. Antimicrob. Chemother. 2013 N=15 HIC (SEROCO) Lambotte et al. Clin. Infect. Dis. 2005 N=14 VISCONTI (PRIMO) Saez-Cirion et al. PLoSPathog. 2013

15. CLEAC Conclusions • Early cART initiation during infancy was associated with lower PBMC-associated HIV-1 DNA levels in children older than 5 and adolescents • An immunological benefit of early cART initiation was suggested in children • Investigations are planned to define the factorsimpacting • The viral reservoir • The T-cellrestoration

16. CLEAC Members Institut Pasteur Immunology F. Buseyne T. Montange D. Batalie Necker Hospital Virology V. Avettand-Fenoël M. Fillion Necker Hospital Principal Investigator P. Frange INSERM Methodology J. Warszawski J. Lechenadec O. Dialla L. Nailler L. Ait Si Selmi I. Leymarie T. Wack ANRS L. Marchand V. Petrov-Sanchez Members of the ANRS-EP59-CLEAC study B. Autran, A. Samri D. Scott-Algara A. Saez-Cirion S. Caillat-Zucman C. Dollfus, Albert Faye Institut Pasteur Logisticteam Cytometryplatform

17. CLEAC Clinical sites and investigators • Hôpital Armand Trousseau, Paris: Mary-FranceCourcoux, Catherine Dollfus, Marie-Dominique Tabone, • Hôpital Bicêtre, Le Kremlin-Bicêtre: Corinne Fourcade • Centre hospitalier intercommunal de Créteil: Isabelle Hau • Hôpital Delafontaine, Saint-Denis: Cécile Gakobwa • Hôpital Necker-Enfants Malade, Paris: Stéphane Blanche, Pierre Frange, NizarMahlaoui, Florence Veber • Maternité Port-Royal, Paris: Valérie Marcou • Hôpital Robert Debré, Paris: Albert Faye, Martine Lévine • Centre hospitalier intercommunal de Villeneuve-Saint-Georges: Anne Chacé Helped by Sandrine Leveillé, Marie-Christine Mourey, Geneviève Vaudre • Sponsor: Agence Nationale de recherches sur le VIH et les hépatites (ANRS) Wethank the patients and theirfamilies

18. Thank for your attention ComparisonLateEarlyAntiretroviraltherapyChildren…………CLEAC! #AIDS2018 | @AIDS_conference| www.aids2018.org