Safety and efficacy of the peptide-based therapeutic vaccine for HIV-1, Vacc-4x: a phase 2 randomised, double-blind, placebo-controlled trial

BACKGROUND

Present combination antiretroviral therapy (cART) alone does not cure HIV infection and requires lifelong drug treatment. The potential role of HIV therapeutic vaccines as part of an HIV cure is under consideration. Our aim was to assess the efficacy, safety, and immunogenicity of Vacc-4x, a peptide-based HIV-1 therapeutic vaccine targeting conserved domains on p24(Gag), in adults infected with HIV-1.

METHODS

Between July, 2008, and June, 2010, we did a multinational double-blind, randomised, phase 2 study comparing Vacc-4x with placebo. Participants were adults infected with HIV-1 who were aged 18-55 years and virologically suppressed on cART (viral load <50 copies per mL) with CD4 cell counts of 400 × 10(6) cells per L or greater. The trial was done at 18 sites in Germany, Italy, Spain, the UK, and the USA. Participants were randomly assigned (2:1) to Vacc-4x or placebo. Group allocation was masked from participants and investigators. Four primary immunisations, weekly for 4 weeks, containing Vacc-4x (or placebo) were given intradermally after administration of adjuvant. Booster immunisations were given at weeks 16 and 18. At week 28, cART was interrupted for up to 24 weeks. The coprimary endpoints were cART resumption and changes in CD4 counts during treatment interruption. Analyses were by modified intention to treat: all participants who received one intervention. Furthermore, safety, viral load, and immunogenicity (as measured by ELISPOT and proliferation assays) were assessed. The 52 week follow-up period was completed in June, 2011. For the coprimary endpoints the proportion of participants who met the criteria for cART resumption was analysed with a logistic regression model with the treatment effect being assessed in a model including country as a covariate. This study is registered with ClinicalTrials.gov, number NCT00659789.

FINDINGS

174 individuals were screened; because of slow recruitment, enrolment stopped with 136 of a planned 345 participants and 93 were randomly assigned to receive Vacc-4x and 43 to receive placebo. There were no differences between the two groups for the primary efficacy endpoints in those participants who stopped cART at week 28. Of the participants who resumed cART, 30 (34%) were in the Vacc-4x group and 11 (29%) in the placebo group, and percentage changes in CD4 counts were not significant (mean treatment difference -5·71, 95% CI -13·01 to 1·59). However, a significant difference in viral load was noted for the Vacc-4x group both at week 48 (median 23,100 copies per mL Vacc-4x vs 71,800 copies per mL placebo; p=0·025) and week 52 (median 19,550 copies per mL vs 51,000 copies per mL; p=0·041). One serious adverse event, exacerbation of multiple sclerosis, was reported as possibly related to study treatment. Vacc-4x was immunogenic, inducing proliferative responses in both CD4 and CD8 T-cell populations.

INTERPRETATION

The proportion of participants resuming cART before end of study and change in CD4 counts during the treatment interruption showed no benefit of vaccination. Vacc-4x was safe, well tolerated, immunogenic, seemed to contribute to a viral-load setpoint reduction after cART interruption, and might be worth consideration in future HIV-cure investigative strategies.

FUNDING

Norwegian Research Council GLOBVAC Program and Bionor Pharma ASA.

Cytogenetic studies of stainless steel welders using the tungsten inert gas and metal inert gas methods for welding

Cytogenetic damage was studied in lymphocytes from 23 welders using the Tungsten Inert Gas (TIG), and 21 welders using the Metal Inert Gas (MIG) and/or Metal Active Gas (MAG) methods on stainless steel (SS). A matched reference group I, and a larger reference group II of 94 subjects studied during the same time period, was established for comparison. Whole blood conventional cultures (CC), cultures in which DNA synthesis and repair were inhibited (IC), and the sister chromatid exchange (SCE) assay were applied in the study. For the CC a statistically significant decrease in chromosome breaks and cells with aberrations was found for both TIG/SS and MIG/MAG/SS welders when compared with reference group II. A non-significant decrease was found for the corresponding parameters for the two groups of welders when compared with their matched referents. A statistically significant negative association was found between measurements of total chromium (Cr) in inhaled air and SCE, and a weaker negative correlation with hexavalent Cr (Cr(VI)) in air. In conclusion, no cytogenetic damage was found in welders exposed to the TIG/SS and MIG/MAG/SS welding fumes with low content of Cr and Ni. On the contrary, a decline in the prevalence of chromosomal aberrations was indicated in the TIG/SS and MIG/MAG/SS welders, possibly related to the suggested enhancement of DNA repair capacity at slightly elevated exposures.

Chromosome damage in lymphocytes of stainless steel welders related to past and current exposure to manual metal arc welding fumes

Cytogenetic damage was studied in lymphocytes from 42 welders using the manual metal arc (MMA) method on stainless steel (SS). A detailed characterization of previous exposure by job interviews, and for current exposure with personal air sampling and biological monitoring of chromium (Cr) and nickel (Ni) in blood and urine, was done for 32 of these welders. A subgroup of 20 welders was studied before and after 1-4 months of MMA/SS welding. A matched reference group I, and a larger reference group II were established for comparison. A significant increase in chromatid breaks (1.4 vs. 0.9 and 0.8 for group I and II) and for cells with aberrations (2.2 vs. 1.6 in group II) was found in the welders. An even larger difference was found when comparing non-smoking welders with their non-smoking referents. No synergistic effect between smoking and MMA/SS welding fumes was observed for any type of aberrations. Current welding fume exposure during the week before sampling was not associated with increases in any type of cytogenetic damage. The results indicated that the increase in chromatid breaks was associated with cumulated welding fume exposure for more than a year, and with not using respirators. Exposure to MMA/SS welding fumes for up to 4 months gave a slight, but significant increase in chromatid breaks when using the welders as their own referents. However, when using matched referents in the study after exposure, no difference was found between these welders and their matched referents. No differences between the groups were observed in the DNA synthesis and repair-inhibited cultures or for SCE.

Enhanced cytogenetic detection of previous in vivo exposure to mutagens in human lymphocytes after treatment with inhibitors of DNA synthesis and DNA repair in vitro

To increase the sensitivity of cytogenetic surveillance of exposure to mutagens in the peripheral lymphocyte assay, structural chromosome aberrations (CA) were studied after inhibition of DNA synthesis and DNA repair with hydroxyurea and caffeine in culture 3 h prior to harvesting. CA and sister-chromatid exchanges (SCE) from conventional cultures from the same subjects were used for comparison. Smoking was used as exposure parameter. Thirty-two smokers and 35 nonsmokers were studied. In the inhibited cultures a significantly higher number of aberrations was found in lymphocytes from smokers than nonsmokers: chromatid breaks (20.4 vs. 11.8, p = 0.0002), chromosome breaks (4.5 vs. 1.7, p = 0.0003), and the number of cells with aberrations (18.9 vs. 12.4, p = 0.0001), when 50 cells per subject were analyzed. In conventional cultures no increase in gaps, chromatid and chromosome breaks or number of cells with aberrations was found in smokers when 100 cells from each subject were studied. Smokers showed an increased number of SCE (6.8 vs. nonsmokers 5.9, p = 0.02). A significant positive linear correlation (r = 0.39, p = 0.01) was seen between SCE and the number of cells with chromatid breaks from inhibited cultures. The present results indicate that adding hydroxyurea and caffeine to lymphocyte cultures for the last 3 h prior to harvesting may enhance the detection of cytogenetic damage from previous in vivo exposure to mutagens.

A cytogenetic and haematological investigation of oil exposed workers in a Norwegian cable manufacturing company

Cytogenetic and haematological parameters were studied in 31 oil exposed workers and 31 office workers matched for age and smoking, all men employed by a Norwegian cable manufacturing company. Information was obtained about tobacco and alcohol consumption, infections, allergies, chronic diseases, use of medicines, and exposure to radiography. A decrease in the absolute lymphocyte counts was observed in the most heavily exposed subgroup (p less than 0.05) but no other significant differences were found between exposed workers and referents. The influence of non-occupational variables on the cytogenetic parameters was studied by stepwise multiple linear regression analysis. The frequency of sister chromatid exchanges appeared to be influenced by smoking history (p less than 0.05) and season of sampling (p less than 0.01) and, if season was excluded, by age (p less than 0.05) and current smoking (p less than 0.05). The number of cells with chromosomal aberrations increased with age (p less than 0.05) and lymphocyte count (p less than 0.05), whereas the frequency of stable rearrangements was negatively correlated with current smoking (p less than 0.01).