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Moore CL, Stöhr W, Crook AM, Richert L, Leliévre JD, Pantaleo G, García F, Vella S, Lévy Y, Thiébaut R, McCormack S. Multi-arm, multi-stage randomised controlled trials for evaluating therapeutic HIV cure interventions. Lancet HIV 2020; 6:e334-e340. [PMID: 31047670 DOI: 10.1016/s2352-3018(19)30082-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 03/12/2019] [Accepted: 03/15/2019] [Indexed: 12/22/2022]
Abstract
The evaluation of immune-based approaches to achieve an antiretroviral therapy free remission of HIV infection requires proven efficacy through antiretroviral therapy interruption placebo-controlled trials. This approach is not without risk to participants and innovative trial designs need to be developed that minimise the number of participants treated with placebo and ineffective candidates. Multi-arm, multi-stage (MAMS) trial designs can be used in this context to accelerate the development of an immune-based therapeutic agent for HIV cure. Issues related to implementing a MAMS design within the planned EHVA T01 trial are considered here. EHVA T01 is a multicentre, MAMS, double-blind, phase 1 and 2 trial that aims to evaluate the effect of immune interventions on viral control in HIV-1 infected participants following analytic treatment interruption. The application of a MAMS design increases the likelihood that the EHVA T01 trial will identify a successful treatment and minimises the number of participants undergoing analytical treatment interruptions who have been treated with futile agents. The use of a MAMS design is a promising strategy to evaluate complex immune-based approaches aimed at curing HIV-infection, particularly relevant to the pipeline with multiple agents requiring examination.
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Affiliation(s)
- Cecilia L Moore
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK.
| | - Wolfgang Stöhr
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Angela M Crook
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Laura Richert
- Vaccine Research Institute, Créteil, France; University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team SISTM, UMR 1219, and Inria, Bordeaux, France; European Clinical Trials Platform and Development, and French Clinical Research Infrastructure Network, CIC 1401, University of Bordeaux, Inserm, CHU Bordeaux, Bordeaux, France
| | - Jean-Daniel Leliévre
- Vaccine Research Institute, Créteil, France; INSERM U955, Paris Est Créteil University, Créteil, France
| | - Giuseppe Pantaleo
- Service of Immunology and Allergy, and Swiss Vaccine Research Institute, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Felipe García
- Infectious Diseases Department, Hospital Clinic of Barcelona-HIVACAT, University of Barcelona, Barcelona, Spain; Retrovirology and Viral Immunopathology Laboratory, AIDS Research Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS)-HIVACAT, Barcelona, Spain
| | - Stefano Vella
- Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Yves Lévy
- Vaccine Research Institute, Créteil, France; INSERM U955, Paris Est Créteil University, Créteil, France; AP-HP, Hôpital Henri-Mondor Albert-Chenevier, Service d'Immunologie Clinique et Maladies Infectieuses, Créteil, France
| | - Rodolphe Thiébaut
- Vaccine Research Institute, Créteil, France; University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team SISTM, UMR 1219, and Inria, Bordeaux, France; European Clinical Trials Platform and Development, and French Clinical Research Infrastructure Network, CIC 1401, University of Bordeaux, Inserm, CHU Bordeaux, Bordeaux, France
| | - Sheena McCormack
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
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T-Regulatory Cells and Vaccination "Pay Attention and Do Not Neglect Them": Lessons from HIV and Cancer Vaccine Trials. Vaccines (Basel) 2016; 4:vaccines4030030. [PMID: 27608046 PMCID: PMC5041024 DOI: 10.3390/vaccines4030030] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/18/2016] [Accepted: 08/26/2016] [Indexed: 01/24/2023] Open
Abstract
Efficient vaccines are characterized by the establishment of long-lived memory T cells, including T-helper (effectors and follicular) and T-regulatory cells (Tregs). While the former induces cytotoxic or antibody responses, the latter regulates immune responses by maintaining homeostasis. The role of Tregs in inflammatory conditions is ambiguous and their systematic monitoring in vaccination along with effector T-cells is not instinctive. Recent studies from the cancer field clearly showed that Tregs suppress vaccine-induced immune responses and correlate with poor clinical benefit. In HIV infection, Tregs are needed during acute infection to preserve tissue integrity from an overwhelmed activation, but are not beneficial in chronic infection as they suppress anti-HIV responses. Current assays used to evaluate vaccine-induced specific responses are limited as they do not take into account antigen-specific Tregs. However, new assays, such as the OX40 assay, which allow for the simultaneous detection of a full range of Th-responses including antigen-specific Tregs responses, can overcome these issues. In this review article we will revise the role of Tregs in vaccination and review the recent work performed in the field, including the available tools to monitor them, from novel assays to humanized mouse models.
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Graziani GM, Angel JB. Evaluating the efficacy of therapeutic HIV vaccines through analytical treatment interruptions. J Int AIDS Soc 2015; 18:20497. [PMID: 26561337 PMCID: PMC4641978 DOI: 10.7448/ias.18.1.20497] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/16/2015] [Accepted: 10/08/2015] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION The development of an effective therapeutic HIV vaccine that induces immunologic control of viral replication, thereby eliminating or reducing the need for antiretroviral therapy (ART), would be of great value. Besides the obvious challenges of developing a therapeutic vaccine that would generate effective, sustained anti-HIV immunity in infected individuals is the issue of how to best assess the efficacy of vaccine candidates. DISCUSSION This review discusses the various outcome measures assessed in therapeutic HIV vaccine clinical trials involving individuals receiving suppressive ART, with a particular focus on the role of analytical treatment interruption (ATI) as a way to assess the virologic control induced by an immunotherapy. This strategy is critical given that there are otherwise no readily available measures to determine the ability of a vaccine-induced immune response to effectively control HIV replication. The various outcome measures that have been used to assess vaccine efficacy in published therapeutic HIV vaccine clinical trials will also be discussed. Outcome measures have included the kinetics of viral rebound, the new viral set point and changes in the size of the viral reservoir. Clinically relevant outcomes such as the CD4 decline, the time to resume therapy or the time to meet the criterion to resume therapy, the proportion of participants who resume therapy and/or the development of clinical symptoms such as acute retroviral syndrome are also measures of vaccine efficacy. CONCLUSIONS Given the lack of consistency between therapeutic HIV vaccine trials in how efficacy is assessed, comparing vaccines has been difficult. It would, therefore, be beneficial to determine the most clinically relevant measure for use in future studies. Other recommendations for future clinical trials also include studying compartments in addition to blood and replacing ATIs with single-copy assays in situations in which the use of an ATI is not ideal.
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Affiliation(s)
| | - Jonathan B Angel
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Infectious Disease, The Ottawa Hospital, Ottawa, ON, Canada;
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Lévy Y, Thiébaut R, Montes M, Lacabaratz C, Sloan L, King B, Pérusat S, Harrod C, Cobb A, Roberts LK, Surenaud M, Boucherie C, Zurawski S, Delaugerre C, Richert L, Chêne G, Banchereau J, Palucka K. Dendritic cell-based therapeutic vaccine elicits polyfunctional HIV-specific T-cell immunity associated with control of viral load. Eur J Immunol 2014; 44:2802-10. [PMID: 25042008 DOI: 10.1002/eji.201344433] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 05/22/2014] [Accepted: 07/10/2014] [Indexed: 02/02/2023]
Abstract
Efforts aimed at restoring robust immune responses limiting human immunodeficiency virus (HIV)-1 replication therapeutically are warranted. We report that vaccination with dendritic cells generated ex vivo and loaded with HIV lipopeptides in patients (n = 19) on antiretroviral therapy was well tolerated and immunogenic. Vaccination increased: (i) the breadth of the immune response from 1 (1-3) to 4 (2-5) peptide-pool responses/patient (p = 0.009); (ii) the frequency of functional T cells (producing at least two cytokines among IFN-γ, TNF-α, and IL-2) from 0.026 to 0.32% (p = 0.002) and from 0.26 to 0.35% (p = 0.005) for CD4(+) and CD8(+) T cells, respectively; and (iii) the breadth of cytokines secreted by PBMCs upon antigen exposure, including IL-2, IFN-γ, IL-21, IL-17, and IL-13. Fifty percent of patients experienced a maximum of viral load (VL) 1 log10 lower than the other half following antiretroviral treatment interruption. An inverse correlation was found between the maximum of VL and the frequency of polyfunctional CD4(+) T cells (p = 0.007), production of IL-2 (p = 0.006), IFN-γ (p = 0.01), IL-21 (p = 0.006), and IL-13 (p = 0.001). These results suggest an association between vaccine responses and a better control of viral replication. These findings will help in the development of strategies for a functional cure for HIV infection.
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Affiliation(s)
- Yves Lévy
- INSERM, Unite, Creteil, France; Universite Paris-Est, Creteil, France; Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Henri-Mondor Albert-Chenevier, service d'immunologie clinique, Creteil, France; Vaccine Research Institute (VRI), Creteil, France
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Abstract
PURPOSE OF REVIEW As we enter the fourth decade in HIV epidemic, advances in understanding HIV pathogenesis and development of potent and safer antiretroviral drugs have been spectacular. More than 30 antiviral drugs have been registered and the impact of combination antiviral therapy on morbidity and mortality has been dramatic. However, despite long-term virus suppression, HIV invariably rebounds after interruption of therapy. Long-term antiviral therapy does not cure HIV infection nor does it induce restoration/development of virus-specific immune responses capable of controlling HIV replication. Therefore, development of immune-based interventions is needed to restore effective defenses that can lead to HIV functional cure and ultimately eradication. RECENT FINDINGS Therapeutic vaccination and immune interventions that generate de-novo or that boost preexisting HIV-specific T-cell responses are being investigated as a potential means to achieve a 'functional HIV cure'. One major hurdle in the quest of an HIV cure is control and elimination of the HIV latent reservoir. Several immune interventions that target the latent reservoir have been tried in recent years. In parallel, several therapeutic vaccination strategies have been developed and tested in early clinical studies. Recent encouraging studies show for the first time that vaccination can have an impact on HIV load. SUMMARY This review summarizes the main immune interventions evaluated over the last years. Ways to improve them, as well as challenges in monitoring/evaluating effects of such strategies, are being discussed. In addition, clinical efficacy and potential clinical benefits of immunotherapeutic interventions are particularly difficult to measure. This review highlights current assays used and their shortcoming.
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Palucka K, Banchereau J. Human dendritic cell subsets in vaccination. Curr Opin Immunol 2013; 25:396-402. [PMID: 23725656 DOI: 10.1016/j.coi.2013.05.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 04/18/2013] [Accepted: 05/03/2013] [Indexed: 12/22/2022]
Abstract
Owing to their properties, dendritic cells (DCs) are often called 'nature's adjuvants' and thus have become the natural targets for antigen delivery. DCs provide an essential link between the innate and the adaptive immune responses. DCs are at the center of the immune system owing to their ability to control both tolerance and immunity. DCs are thus key targets for both preventive and therapeutic vaccination. Herein, we will discuss recent progresses in our understanding of DC subsets physiology as it applies to vaccination.
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Affiliation(s)
- Karolina Palucka
- Ralph M. Steinmann Center for Cancer Vaccines, Baylor Institute for Immunology Research, Baylor Research Institute, Dallas, TX, USA.
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