HIV | EPIICAL

Authors: Cotugno N, Morrocchi E, Rinaldi S, et al; EPIICAL Consortium.

Published in: AIDS. 2020 Feb 3.

Objective To investigate long-term persistence of HIV-specific lymphocyte immunity in perinatally HIV-infected children treated within the first year of life.

Design Twenty perinatally HIV-infected children who received ART therapy within the first year of life (early treated) and with stable viral control (>5 years) were grouped according to their serological response to HIV.

Methods Western blot analysis and ELISA defined 14 HIV-seropositive and 6 seronegative patients. Frequencies of gp140-specific T-cell and B-cell, and T-cell cytokine production were quantified by flow cytometry in both seronegatives and seropositives. Transcriptional signatures in purified gp140-specific B-cell subsets, in response to in-vitro stimulation with HIV peptides was evaluated by multiplex RT-PCR.

Authors: S. Rinaldi, V. Dinh, S. Pallikkuth, L. De Armas, R. Pahwa, N. Cotugno, E. Nastouli, C. Foster, P. Palma, S. Pahwa

Published in: Poster presented at 9^th International Workshop on HIV Persistence during Therapy; December, 2019; Miami, FL

Authors: Domínguez-Rodríguez S, Tagarro A. Palma P, et al.

Published in: JAIDS 2019;82(5):483-490

Authors: Schröter J.

Published in: Poster presented at 4th Workshop on Virus Dynamics, October 21st-23rd, 2019 -Paris, FR

Authors: Gärtner K, Gkouleli T, Heaney J, et al; on behalf of the EPIICAL consortium

Published: Poster presented at HIV Cure and Reservoir Symposium, September, 16th-20th, 2019 -Ghent, BE

Authors: Foster C, Dominguez S, Tagarro A, Nastouli E, Gkouleli R, Heaney J, PalmaP, Rossi P, Giaquinto C, Rojo P

Published: 10th IAS Conference on HIV Science, July 21rd-24th 2019, Mexico City

Background Future strategies aimed at achieving antiretroviral therapy (ART)-free HIV remission are likely to target individuals with a limited size of viral reservoir. We investigated factors associated with a low reservoir measured as total HIV-1 DNA in PBMCs in perinatally infected children (PaHIV) from 5 European centers in the EPIICAL consortium.

Authors: Heaney J, Busby E, Gärtner K, Grant P, Spyer MJ, O’Sullivan DM, Gkouleli T, Marcelin AG, Pillay D, Foster C, Rojo P, Palma P, Muñoz Fernández MA, deRossi A, Huggett JF, Nastouli E

Published: International Workshop on HIV Pediatrics, July 19th-20th, 2019. P_102

Background Despite effective antiretroviral therapy(ART), HIV persists as integrated provirus generating latent viral reservoirs even in the absence of detectable plasma viremia.

Latently infected cells, primarily CD4+ T cells, have the potential to release progeny virus and contribute to viral rebound after treatment interruption or HIV-1 remission.

Robust assays are needed to monitor the viral reservoir, and remission, as emerging therapeutic approaches aimed at achieving ART-free HIV remission, or cure, are likely to target individuals with low levels of total HIV-1 DNA. The current gold standard for measuring specific DNA amounts in clinical diagnostics and research is quantitative PCR (qPCR), whereas digital PCR (dPCR) is a more recent technology that has become commercially available since 2011.

Authors: Tagarro A, Dominguez Rodriguez S, Puthanakit T, et al.

Published: Oral presentation at 27th Conference on Retroviruses and Opportunistic Infections, March 4th-7th, 2019 – Seattle, WA

Abstract: Early antiretroviral therapy (ART) in children is associated with better clinical and virological outcome. Few data are available about long-term outcome of children starting ART in the neonatal period. Our hypothesis is that HIV-perinatally infected neonates initiating ART within <7 days of life have a better long-term clinical and virological response than neonates treated ≥7 days and ≤28 days of life.

44 children with perinatal HIV aged ≤28 days at start of ART were included from 4 cohorts (11%UK, 52% Spain, 7% Italy, and 29% Thailand). Primary endpoints were clinical – mortality, and progression to AIDS – and virological: time to suppression, time to virological failure, and proportion of time suppressed. Data were collected up to 15-years of follow-up. Those subjects who received triple postpartum prophylaxis and subsequently transitioned to ART within <15 days were considered as starting ART from date of prophylaxis initiation. A flexible spline interval censored survival model was applied adjusting for CD4 and viral load (VL) at the start of ART.

57% were female and 35% preterm. Median follow-up was 11.5[IQR 8.2-15.6] years. No patient died. 84% received postpartum prophylaxis. At ART initiation, children were aged 15.5 [0.00;24.2] days, with CD4 total 2766[2126;3368], CD4:CD8 2.5[1.6;3.1], and log10VL 4.2[2.9;5.2] copies/ml. 36/44 (83%) ever suppressed (VL≤50). Time to viral suppression was 0.57[0.25;1.04] years. 12/44 (34%) had subsequent virological failure after suppression (median time to failure, 2.40 [1.01;9.61] years). Participants had 2.9 ±1.8 ART regimen switches, 26% progressed to AIDS. 19/44 (43%) patients started ART <7 days of age. Viral load was higher in children treated <7 days (log10VL 4.4 [4.2;5.4] vs 3.3 [2.9;4.4], p=0.018). Time to suppression was shorter in those treated in the first 7 days of life (18.9[7;41.7] y 44.1[24.6;61.0] weeks, p = 0.038). The probability of suppression decreased by 24% for each week the ART initiation was delayed (aHR=0.76 [0.6;0.97], p=0.035, Figure 1). No differences were observed in progression to AIDS, ART switches, time to immunological recovery (CD4:CD8>1), time to virological failure or proportion of time suppressed.

Even among children initiating ART<28 days of age, children starting ART in the first week of life suppress earlier. There was similar long-term clinical, virological and immunological outcomes in children treated <7 days vs. 7 to 28 days.

Authors: Schröter J.

Published: Oral presentation at 26th International HIV Dynamics & Evolution, March 24th-27th, 2019, Cascais, PT

Authors: Chan MK, Goodall R, Judd A, et al.

Published in: Aids. 2019; 33(7):1155-1165

Objective To identify predictors of faster time to virological suppression among infants starting combination antiretroviral therapy (cART) early in infancy.

Design Cohort study of infants from Europe and Thailand included in studies participating in the European Pregnancy and Paediatric HIV Cohort Collaboration (EPPICC).

Methods Infants with perinatal HIV starting cART aged <6 months with ≥1 viral load (VL) measurement within 15 months of cART initiation were included. Multivariable interval-censored flexible parametric proportional hazards models were used to assess predictors of faster virological suppression, with timing of suppression assumed to lie in the interval between last VL≥400 and first VL<400copies/ml.

Results Of 420 infants, 59% were female and 56% from Central/Western Europe, 26% UK/Ireland, 15% Eastern Europe and 3% Thailand; 46% and 54% started a boosted protease inhibitor- or non-nucleoside reverse transcriptase inhibitor- based regimen, respectively. At cART initiation, the median age, CD4% and VL were 2.9 (IQR:1.4-4.1) months, 34 (IQR:24-45)% and 5.5 (IQR:4.5-6.0) log10copies/ml, respectively. Overall, an estimated 89% (95%CI:86-92%) achieved virological suppression within 12 months of cART start. In multivariable analysis, younger age (aHR:0.84 per month older; P < 0.001), higher CD4% (aHR:1.11 per 10% higher; P = 0.010) and lower log10 VL (aHR:0.85 per log10 higher; P < 0.001) at cART initiation independently predicted faster virological suppression.

Conclusion We observed a significant independent effect of age at cART initiation, even within a narrow 6 months window from birth. These findings support the earliest feasible cART initiation in infants and suggest that early therapy influences key virological and immunological parameters that could have important consequences for long term health.

Authors: Cotugno N, Morrocchi E, Pepponi I, et al.

Published in: J Immunol. 2018; 200 (1 ) 182.34;

Abstract Early initiation of ART in HIV vertically infected infants influences specific immunity by limiting Ag exposure and reducing the viral reservoir size. Currently these patients represent ideal candidates for testing immune therapeutic strategies towards HIV-remission. However a proportion of these early ART treated children (ET) show an undetectable HIV Ab response. It is still unknown whether such profile is associated with a lower ability of these children to mount HIV specific responses once the Ag is re-encountered.

In the present study, we investigated whether HIV specific B-cells persist in seronegative (SN) patients, and the associated gene signatures after re-encountering the virus in vitro. We enrolled 20 ET (6 SN and 14 seropositive, SP), who initiated ART at a mean age of 4.4±3.6 mo. and under durable viral control (> 2 years). We found that gp140+ B-cells, analyzed by FACS, persist in SN patients with a similar frequency of SP. Further analysis revealed a higher percentage of HIV-specific IgM cells in SN CD27+ IgD+ memory subset compared to SP (P=0.002). In addition we investigated by multiplexed RT-PCR, gene expression dynamics after in vitro stimulation with HIV peptides mix. Our results on sorted HIV specific IgM+ cells showed up-regulation of Blimp1 expression only in SP (fold change=1.9; p=0.03), suggesting an impairment of plasma cell differentiation in IgM+gp140+ B-cells in SN patients. Our results firstly reveal that HIV specific B-cell response persists in SN ET, and predominantly resides in the IgM memory compartment. We hypothesize that such responses could be targeted by novel strategies aiming at HIV remission in HIV early treated children.

Authors: Rinaldi S, Cotugno N, Pallikkuth S, Pahwa R, Palma P, Pahwa S

Published in: J Immunol. 2018; 200(1):166

Abstract Early initiation of antiretroviral therapy (ART) in vertically HIV-infected children provides an opportunity to limit the size of HIV reservoir. However, how the time of ART initiation impacts host HIV-specific immune responses is still poorly understood. In this study, we analyzed HIV-specific CD4 and CD8 T cell functionality in vertically HIV-infected children (age range 2.3–17.5yrs) enrolled at Bambino Gesù Children Hospital under suppressive ART and durable viral control (plasma HIV-RNA<50cp/mL). Children were designated as early treated (ET, n=8, ART initiated at age <6mo) or late treated (LT, n=7, ART initiated at age >1 year) with longer duration of ART in ET (p<0.05). Antigen-specific (CD40L+CD4+/CD107a+CD8+) T cells were evaluated in cryopreserved PBMC by flow cytometry for intracellular cytokines (IL2, IFN g, TNFα, IL21, Perforin, Granzyme B) following 12hr stimulation with GAG PTE peptides. Differences between groups were determined by Mann-Whitney t tests (P≤0.05).

Frequencies of GAG-specific CD8 and CD4 T cells were not different between ET and LT. Boolean analyses revealed that CD8 T cells of LT had a higher frequency of Granzyme B+ cells compared to ET whereas CD4 T cells were qualitatively superior in ET compared to LT and exhibited higher proportions of IL2, IFNg and TNFα producing T cells and enrichment of polyfunctional T cells.

Our results suggest that time of ART initiation in HIV-infected children has a long-term impact on the quality but not the quantity of the host HIV-specific T-cell immune responses. Larger studies are needed to confirm these results and to further evaluate their role in future strategies aiming at functional cure.

Authors: Violari A, Chan M, Otwombe KN, Panchia R, Jean-Philippe P, Gibb D, Cotton M, Babiker A

Published: Oral presentation at 25th Conference on Retroviruses and Opportunistic Infections, March 4th – 7th, 2018 – Boston. 

Authors: Cameron M, Rinaldi S, Richardson B, Cotugno N, Williams S, Pallikkuth S, de Armas LR, Cameron C, Pahwa R, Palma P, Pahwa S

Published: 25th Conference on Retroviruses and Opportunistic Infections, March 4th – 7th, 2018 – Boston. P_868

Abstract The study explores the impact of early ART on host immune response looking at HIV-specific CD4 T cell functionality and host transcriptome analysis.

Authors: Chan M, Tagarro A, Zangari P, Ferns B, Foster C, De Rossi A, Nastouli E, Ángeles Muñoz-Fernández M, Gibb D, Rossi P, Giaquinto C, Babiker A , Palma P, Rojo Conejo P

Published: 25th Conference on Retroviruses and Opportunistic Infections, March 4th – 7th, 2018 – Boston. P_ 866

Abstract The study focused on the determinants of low viral reservoir in a large cohort of European early treated HIV-1 infected children. Timing of cArt initiation and timing spent on effective ART are main factors associated with low HIV-DNA

Authors: Rocca S, Zangari P, Cotugno N, et al.

Published in: J Pediatric Infect Dis Soc.2018; 28. doi:10

Background Assays to estimate human immunodeficiency virus (HIV) reservoir size require large amounts of blood, which represents a drawback especially in pediatric settings. We investigated whether HIV-antibody repertoire could estimate the viral reservoir size. Moreover, we assessed the magnitude of HIV-antibody response as a predictor of time of antiretroviral therapy (ART) initiation.

Methods Human immunodeficiency virus-antibody responses to 10 different viral proteins were evaluated by HIV Western blot (WB) kit and a WB score was assigned to each patient. Patients were classified in 2 subgroups based on the timing of ART initiation (early treated [ET], 0–24 weeks and late treated [LT], >24 weeks). Human immunodeficiency virus-deoxyribonucleic acid (DNA) was quantified using real-time quantitative polymerase chain reaction on total peripheral blood mononuclear cells. Logistic regression and principal component analysis were built on these data to test the ability of WB score to predict the expected value of HIV-DNA and the timing of ART initiation.

Results Sixty-nine perinatally HIV-infected children were evaluated. Reduced HIV-specific antibody responses and lower size of HIV-DNA were observed in ET compared with LT patients (P < .001 and P = .02, respectively). We found that WB score correlates with HIV-DNA (P = .032) and timing of ART initiation (P < .001). Based on the logistic regression analysis, we found that WB score can predict the HIV-DNA size and the timing of ART initiation with an Akaike information criterion of −118.13 and −151.51, respectively.

Conclusions Western blot score can estimate HIV-DNA size and timing of ART initiation in long-term virally suppressed children. This rapid, inexpensive, and easily reproducible tool can provide useful information to identify potential candidates for HIV remission studies.

Authors: Cotugno N, Morrocchi E, Pepponi I, Rocca S, Cameron M, Rinaldi S, Di Cesare S, Pallikkuth S, Bernardi S, Klein N, Ananworanich J, Rossi P, Pahwa S, Palma P

Published:  25th Conference on Retroviruses and Opportunistic Infections, March 4th – 7th, 2018 – Boston. P_ 866

Abstract This fascinating study investigates whether HIV specific B cells persist in seronegative HIV infected seronegative patients and what are the associated gene signatures after re-encountering the virus.

Authors: Tagarro A, Chan M, Zangari P, et al; on behalf of the EPIICAL Consortium

Published in: J Acquir Immune Defic Syndr. 2018;79(2):269-276

Background Future strategies aiming to achieve HIV-1 remission are likely to target individuals with small reservoir size.

Setting We retrospectively investigated factors associated with HIV-1 DNA levels in European, perinatally HIV-infected children starting ART <6 months of age.

Methods Total HIV-1 DNA was measured from 51 long-term suppressed children 6.3 years (median) after initial viral suppression. Factors associated with log10 total HIV-1 DNA were analyzed using linear regression.

Results At ART initiation, children were aged median [IQR] 2.3 [1.2,4.1] months, CD4% 37 [24,45] %, CD8% 28 [18,36] %, log10 plasma viral load (VL) 5.4 [4.4,5.9] copies/ml. Time to viral suppression was 7.98 [4.6,19.3] months. Following suppression, 13 (25%) children had suboptimal response [≥2 consecutive VL50-400 followed by VL<50] and/or experienced periods of virological failure [≥2 consecutive VL≥400 followed by VL<50]. Median total HIV-1 DNA was 43 [6,195] copies/106 PBMC. Younger age at therapy initiation was associated with lower total HIV-1 DNA (adjusted coefficient [AC] 0.12 per month older, p=0.0091), with a month increase in age at ART start being associated with a 13% increase in HIV DNA. Similarly, a higher proportion of time spent virally suppressed (AC 0.10 per 10% higher, p=0.0022) and absence of viral failure/suboptimal response (AC 0.34 for those with fail/ suboptimal response, p=0.0483) were associated with lower total HIV-1 DNA.

Conclusion Early ART initiation and a higher proportion of time suppressed are linked with lower total HIV-1 DNA. Early ART start and improving adherence in perinatally HIV-1 infected children minimize the size of viral reservoir.

Authors: Zangari P, Palma P, Cotugno N, et al.

Published in: J Virus Erad.2018;4: 51–54

Abstract: The first EPIICAL General Assembly meeting was held in an atmosphere of growing optimism. Many novel and exciting proposals for HIV research studies were discussed and are described above. The consortium aims to maintain this integrated developmental research on NDMTs, from predictive platforms to proof-of-concept studies, through the excellent collaborative effort made during the first 18 months of EPIICAL, some of which is described in this report. The emphasis on an innovative research platform is unique and may lead to optimisation of the management of perinatally HIV-infected children. Collectively, the updates and the discussions from the General Assembly attest to the benefit of nurturing an international collaborative effort on paediatric HIV research and confirm that EPIICAL is successfully on track.

Authors: Rinaldi S, Cotugno N, Pallikkuth S, Palma P, Pahwa S; on behalf of the EPIICAL Consortium

Published: 8th Conference on HIV Persistence

Background Early initiation of antiretroviral therapy (ART) in vertically HIV-infected children provides an opportunity to limit the size of reservoir, but whether and how the time of ART treatment initiation can durably impact host immune responses associated with HIV infection is still unknown. In this study, we analyzed HIV-specific CD4 T cell functionality in vertically HIV-infected children in whom ART was initiated early or late after birth.

Authors: Palma P, Chan M, Goodall R, Judd A, Gibb D, Babiker A, Rojo P.

Published: 35th Annual Meeting of the European Society for Paediatric Infectious Diseases (ESPID), May 23rd-27th May, 2017, Madrid

Background A major obstacle to curing HIV infection is persistence of virus as integrated proviral DNA in long-lived cells even after many years on ART. ART-free HIV remission is more likely to occur if viral suppression is achieved very early in infection. We investigated factors associated with time to virological suppression in early ART treated children from the European Pregnancy and Paediatric HIV Cohort Collaboration (EPPICC).

Authors: Palma P, Zangari P, Cotugno N, Rocca S, Nastouli E, McCoy LE, Ferns RB, Pahwa S, Rossi P

Published: 24th Conference on Retroviruses and Opportunistic Infections, February 13th – 16th, 2017, Seattle. P_1975.

Background It is still unknown whether the paucity of HIV-specific immune responses in early-treated (treated within 6 months of age; ET) HIV-infected children may represent a limitation or an advantage in the perspective of immune therapeutic studies. In ET patients, the failure to develop an immune response is attributed to the lack of antigen (Ag) stimulation, possibly indicating shrinking HIV reservoirs (Luzuriaga, JID 2014). Analysis of HIV antibodies (Ab) can reveal important insights to characterizing host immune profiles associated with HIV remission which appears to be linked with different serological profiles (Burbelo, JID 2014). Recent findings showed a functional plasticity of memory B-cell compartment, suggesting that IgM memory B-cells during a primary stage of infection share specific memory characteristics with IgG memory B-cells. The role of IgM memory responses in humans is debated (Seifert, PNAS 2015). Their generation, in the context of short-term Ag persistence such as in ET HIV-infected children, has been poorly investigated. Our aim was to further dissect Bcell responses in ET patients with different HIV Ab profiles and relate those to the predicted size of HIV reservoir (Total HIV-DNA) and to immune memory B-cell response.

Authors: Hinkula J, Petkov S, Ljungberg K, Hallengärd D, Bråve A, Isaguliants M, Falkeborn T, Sharma S, Liakina V, Robb M, Eller M, Moss B, Biberfeld G, Sandström E, Nilsson C, Markland K, Blomberg P, Wahren B.

Published in: Heliyon

Authors: Klein N, Palma P, Luzuriaga K, et al.

Published in: Lancet Infect Dis. 2015;15(9):1108-1114

Abstract From the use of antiretroviral therapy to prevent mother-to-child transmission to the possibility of HIV cure hinted at by the Mississippi baby experience, paediatric HIV infection has been pivotal to our understanding of HIV pathogenesis and management. Daily medication and indefinite antiretroviral therapy is recommended for children infected with HIV. Maintenance of life-long adherence is difficult and the incidence of triple-class virological failure after initiation of antiretroviral therapy increases with time. This challenge shows the urgent need to define novel strategies to provide long-term viral suppression that will allow safe interruption of antiretroviral therapy without viral rebound and any associated complications. HIV-infected babies treated within a few days of birth have a unique combination of a very small pool of integrated viruses, a very high proportion of relatively HIV resistant naive T cells, and an unparalleled capacity to regenerate an immune repertoire. These features make this group the optimum model population to investigate the potential efficacy of immune-based therapies. If successful, these investigations could change the way we manage HIV infection.

Authors: Palma P, Foster C, Rojo P, et al.

Published in: J Virus Erad. 2015;1(3):134-139.

Abstract The EPIICAL (Early-treated Perinatally HIV-infected Individuals: Improving Children’s Actual Life with Novel Immunotherapeutic Strategies) project arises from the firm belief that perinatally infected children treated with suppressive antiretroviral therapy (ART) from early infancy represent the optimal population model in which to study novel immunotherapeutic strategies aimed at achieving ART-free remission. This is because HIV-infected infants treated within 2–3 months of life have a much reduced viral reservoir size, and rarely show HIV-specific immunity but preserve normal immune development. The goal of EPIICAL is the establishment of an international collaboration to develop a predictive platform using this model to select promising HIV therapeutic vaccine candidates, leading to prioritisation or deprioritisation of novel immunotherapeutic strategies. To establish this platform, the EPIICAL Consortium aims to: develop predictive models of virological and immunological dynamics associated with response to early ART and to treatment interruption using available data from existing cohorts/studies of early-treated perinatally HIV-infected children; optimise methodologies to better characterise immunological, virological and genomic correlates/profiles associated with viral control; test novel immunotherapeutic strategies using in vivoproof-of-concept (PoC) studies with the aim of inducing virological, immunological and transcriptomic correlates/profiles equivalent to those defined by the predictive model. This approach will strengthen the capacity for discovery, development and initial testing of new therapeutic vaccine strategies through the integrated efforts of leading international scientific groups, with the aim of improving the health of HIV-infected individuals.