CROI 2020 Abstract eBook

Abstract eBook

General Information

CONTENTS

General Information

ABSTRACT PROCESS 2

ORAL ABSTRACTS 4

POSTER ABSTRACTS 56

DISCLOSURE OF FINANCIAL RELATIONSHIPS WITH COMMERCIAL CONCERNS 434

AUTHOR INDEX 441

KEYWORD INDEX 462

The contents of this Abstract eBook are current as of February 24, 2020. Please note that the contents may be periodically updated.

©Copyright 2020 CROI Foundation/IAS–USA. All rights reserved. ISBN # 978-1-7320053-3-4

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ABSTRACT PROCESS

Special Notes on Abstract Content Presentations from randomized trials and cohorts should follow the International Committee of Medical Journal Editors (ICMJE) guidelines, including reporting of study designs, (eg, prospective, observational, randomized, double-blind, STROBE, CONSORT, or others), statistical methods, and outcomes by demographic variables. Appropriate information and correct terminology should be used with regard to sex and gender . For human clinical or epidemiologic studies, sex-stratified results should be provided or who was included if the study includes only a single population. Appropriate terminology such as cisgender (people whose gender match the sex assigned at birth) or transgender (people whose gender does not match the sex assigned at birth) should be used. Both sex and gender data should be provided in the presentation. Presentations of preclinical data including use of cell lines and animal studies should include the sex of the animals or the sex of the source of the cell lines. If data are not available on sex and gender, this should be identified as a limitation in your presentation. Out of respect for their contributions to our scientific advances, avoid calling study volunteers“subjects.” The preferred terms are study “participants”or“volunteers.” Presenting Author Responsibilities The presenting author is responsible for presenting the abstract at the conference and must be present at the poster during the entire session. Submitting authors are responsible for ensuring that all coauthors have reviewed and approved the abstract contents before submission. Embargo Policies and Social Media All research presented at CROI 2020 is embargoed until the conclusion of the study’s presentation at the conference. For example, if a study is presented from 2:15 PM to 2:30 PM, as part of a session that begins at 2:00 PM and ends at 3:00 PM, the embargo on that study lifts at 2:30 PM. Embargoes on poster presentations lift at the beginning of the session in which the poster is presented. If a study to be presented at CROI 2020 is included in an official CROI press conference that takes place before the scheduled presentation of the study, the embargo on that study lifts at the conclusion of the press conference panel in which the study is featured.

Scientific Categories A. Virology B. Pathogenesis: Human Studies and Animal Models C. HIV-Associated Tumor Viruses D. Host Immune Responses to Infection, Vaccines, and Immunotherapy E. HIV Reservoirs, Latency, and All Curative Strategies Including Therapeutic Vaccines and Gene Therapy F. Neuropathogenesis and Neurologic Complications G. Clinical Pharmacology H. Antiretroviral Therapy: Pre-Clinical Data, Randomized Trials, Efficacy and Effectiveness Studies I. HIV Drug Resistance J. Hepatitis Viruses and Liver Complications K. AIDS-Related Malignancies L. Cardiovascular Complications of HIV Infection and Antiretroviral Therapy M. Other Complications of HIV Infection and Antiretroviral Therapy N. Tuberculosis and Other Opportunistic Infections O. Maternal and Fetal HIV P. Pediatrics and Adolescents Q. Epidemiology R. Testing S. Prevention Interventions T. Contraception, Sexually Transmitted Infections, and Reproductive Health U. Implementation and Scale-Up of Treatment and Care Abstract Content Author names, institutions, titles, and abstracts in the CROI Program and Information Guide, Abstract eBook, Mobile App, and other materials are presented largely as submitted by the submitting author. The submitting author is responsible for ensuring that all coauthors have reviewed and approved the abstract before submission and for providing the complete and accurate contact information for all authors, including email address. THE SUBMITTING AUTHOR MUST ENSURE THAT THE EMAIL ADDRESSES OF ALL LISTED AUTHORS IN THEIR SUBMISSION ARE CORRECT in order for authors to receive important information regarding dispositions, presentation details, registration and housing information, and other CROI-related announcements.

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Statistics for Abstracts General abstract submitted ����������������������������������������������������������� 1852 General abstracts accepted ������������������������������������������������������������� 1035 General oral abstracts����������������������������������������������������������������������� 85 General poster abstracts ��������������������������������������������������������������� 878 Late-breaking abstracts submitted ������������������������������������������������� 188 Late-breaking abstracts accepted ������������������������������������������������������46 Late-breaking oral abstracts ������������������������������������������������������������17 Late-breaking poster abstracts ������������������������������������������������������� 29 Total abstracts submitted ��������������������������������������������������� 2040 Total abstract accepted ������������������������������������������������������ 1081 All Presenting Authors on Accepted Abstracts Region N Percent Africa.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 � � � � � � � � � � � � � � � � � � � 9% Asia .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 � � � � � � � � � � � � � � � � � � � 2% Australia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 � � � � � � � � � � � � � � � � � � . 2% Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 � � � � � � � � � � � � � � � � � � . 1% Central and South America . . . . . . . . . . . . 206 � � � � � � � � � � � � � � � � � 23% North America .. . . . . . . . . . . . . . . . . . . . . . . 570 � � � � � � � � � � � � � � � � � 63% Abstracts Related to Study Populations 1. Adolescents ����������������������������������������������������������������������������������������52 2.Men who have sex with men (MSM) ��������������������������������������������118 3. People who inject drugs (PWID) ����������������������������������������������������38 4. Transgender men or women ������������������������������������������������������������19 5.Women ��������������������������������������������������������������������������������������������114 Authors have noted specific populations as the focus of their study, if applicable. Indexes that list abstracts that relate to specific populations are on the CROI Mobile App and Abstract eBook on the CROI website. These indexes are developed for attendees with an interest in these areas.

No public dissemination of research information from the conference is permitted prior to the lifting of the conference embargo. CROI embargo policies apply to any public dissemination of research information presented at the conference, including electronic publications (eg, blogs) or social media (eg, Twitter, Instagram, Facebook). Individuals or organizations that violate the conference embargo policy may have their conference credentials revoked and may forfeit the opportunity to participate in future conferences. Abstract Review Process The PC and a panel of volunteer external reviewers reviewed more than 2000 submitted abstracts. Each abstract was reviewed by 5 to 10 reviewers selected for each abstract category based upon their individual expertise. Abstracts were reviewed for the quality and originality of the work and were scored numerically. All reviewers were instructed to abstain from scoring any abstract on which they are an author or coauthor, have a financial or personal conflict of interest, or do not have the appropriate expertise to evaluate. Scores for each abstract were averaged and the standard deviation was calculated to assess variability. If variability was high, outlier scores were discussed. Abstracts were accepted for oral presentations, for poster presentations, or rejected. Late-breaking abstract reviews included an assessment of the late-breaking nature of the work (distinct from a late submission, as they must meet a high threshold of scientific merit). Common Reasons for Abstract Rejection • Subject matter is not appropriate for CROI • All coauthors did not approve the abstract prior to submission • Information is not novel (new enough) • Abstract is duplicative of other submissions • Format does not follow guidelines (eg, data missing, more than 1 table or figure submitted) • Submission is poorly written and difficult to understand • Background does not summarize the hypothesis • Methodology is inadequate or insufficient to support conclusions • Controls are absent or inadequate • Statistical evaluation is inadequate or absent • Summary of essential results is inadequate or absent • Data are not included or offer inadequate or insufficient support for conclusions • Submission reports clinical trial data from unplanned analyses or incomplete or ongoing studies

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ORAL ABSTRACTS

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SESSION OVERVIEW: PROGRAM COMMITTEE WORKSHOP FOR NEW INVESTIGATORS AND TRAINEES John W. Mellors 1 , Serena S. Spudich 2 1 University of Pittsburgh, Pittsburgh, PA, USA, 2 Yale University, New Haven, CT, USA Over the past four decades, remarkable progress has been made in understanding HIV epidemiology, pathogenesis, treatment, and prevention from the combined efforts of community members, clinicians, investigators, and funding agencies worldwide. Yet more work and new approaches are needed to achieve the ambitious goal of ending the epidemic and ensuring optimal quality of life for those living with HIV. To encourage and stimulate the next generation of investigators, the CROI Program Committee organizes an annual Workshop for New Investigators and Trainees comprised of expert and comprehensible talks to cover current knowledge and controversies in basic, clinical and public health investigation into HIV and related infections, and to highlight relevant work to be presented over the ensuing days at CROI. This year’s Workshop will begin with Dr. Wes Sundquist who will review aspects of HIV-1 replication and innate immunity, in particular recent developments in our understanding of mechanisms of virus sensing, early steps in the viral replication cycle, and virus-host arms races. Dr. Richard Koup will cover recent preclinical HIV vaccine advances, concentrating on efforts to induce either broad neutralizing antibody responses or protective CD8 T cells, and discuss the latest data on the development and use of broadly neutralizing antibodies in prevention and treatment of HIV. Dr. Hermione Lyall will review ongoing challenges in prevention of vertical HIV transmission during pregnancy and breastfeeding, short and long term challenges of getting infants on to treatment, and approaches to sustaining health and supporting ‘undetectable=untransmittable’ in youth with HIV. Dr. Susan Buchbinder will describe the current status of new infections globally, and discuss recent advances in biomedical HIV-1 prevention including treatment as prevention, pre-exposure prophylaxis, topical preventive agents, HIV vaccines, and combination approaches to HIV prevention. Finally, Dr. Nicolas Chomont will review the mechanisms that contribute to HIV persistence during ART, highlight the role of cell proliferation in that process and present recent therapeutic approaches aimed at curing HIV infection. The Workshop serves as the initial opportunity for Trainees and New Investigators to interact with Program Committee members. Such interactions will continue during newmorning sessions organized to provide support and guidance for emerging investigators at this year’s CROI. SHIFTING FROM ACUTE TO CHRONIC, AGING, LONGEVITY, AND LIVED EXPERIENCE Jim Pickett 1 , Martha Tholanah 2 , Gabriel Maldonado 3 , Celeste Watkins-Hayes 4 1 AIDS Foundation of Chicago, Chicago, IL, USA, 2 Advocate, Harare, Zimbabwe, 3 TruEvolution, Riverside, CA, USA, 4 Northwestern University, Chicago, IL, USA Globally, there were 5.7 million [4.7 million– 6.6 million] people living with HIV (PLHIV) 50 years of age and older (50+) in 2016. Although the proportion of PLHIV50+ was greater in high-income countries, low-and-middle-income countries have higher numbers of PLHIV50+ that are expected to continue to increase by 2020. The proportion of PLHIV50+ across the world increased substantially from 8% in 2000 to 16% in 2016 and is expected to increase to 21% by 2020*. In the United States, it is estimated that more than 70% of PLHIV will be 50 or older in 2020. Thirty-nine years into the epidemic, we’ve seen a remarkable shift in the trajectory of HIV. No longer is an HIV diagnosis simply a death sentence, individuals with HIV are living longer than ever before. Issues related to aging, long ignored due largely to irrelevance, are coming to the fore. What does it mean to age with HIV across the lifespan? How do co-morbidities, polypharmacy, long-term adherence to medications, mental health, neurocognitive impairment, stigma, discrimination, and fatigue factor into long-term survival? How do resilience and other mechanisms shift the narrative from surviving to thriving? What factors must be considered beyond viral

suppression when assessing the quality of life? Each panelist will share their distinctive perspectives and experiences and will then open up the discussion to include audience members. * Global and regional trends of people living with HIV aged 50 and over: Estimates and projections for 2000–2020, PLoS One. 2018; 13(11): e0207005.

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SHAPING VACCINES WITH DNA ORIGAMI Mark Bathe , MIT, Cambridge, MA, USA

Viral-like structured DNA and RNA assemblies, also known as DNA and RNA origami, offer the ability to co-formulate gene-length single-stranded DNA or mRNA with CRISPR-RNPs, siRNAs, or ASOs, with the integration of active cellular targeting, stimulation, and uptake moieties including peptides, sugars, and small molecules. Biological stability and immunostimulation can additionally be programmed selectively through the use of chemical modifications. Scaleable bacterial production of custom length and sequence single-stranded DNA offers a low-cost path towards clinical-scale production. Here, I will present our lab’s formulation and preclinical work in the context of the field, to produce pre- clinical scale, endotoxin-free structured DNA and RNA assemblies for targeted delivery of nucleic acid gene therapeutics and vaccines, including a case study of viral-like DNA assemblies applied to an HIV vaccine candidate. CONCEPTS IN RESERVOIR MEASUREMENTS Janet M. Siliciano , Johns Hopkins University School of Medicine, Baltimore, MD, USA A stable latent reservoir for HIV-1 in resting CD4+ T cells precludes cure. Curative strategies targeting the reservoir are being tested and require accurate, scalable reservoir assays. The reservoir was originally defined with a quantitative viral outgrowth assays (QVOA) for cells releasing infectious virus following one round of T cell activation. This assay requires growing virus from individual latently infected cells and is costly and time consuming. Therefore, many studies have used DNA PCR to detect HIV-1 proviruses in infected cells or RT-PCR to detect the induction of viral RNA production from latently infected cells. However, two fundamental findings have altered how we view reservoir measurements. The first is that the vast majority of HIV-1 proviruses are defective due to the presence of large deletions and/or APOBEC-mediated hypermutation, as revealed by near-full genome proviral sequencing. These defective proviruses cannot contribute to viral rebound and should not be considered part of the latent reservoir. Most PCR assays fail to distinguish intact and defective proviruses. Therefore, they dramatically overestimate reservoir size and should not be used. The second important finding is that not all intact proviruses are induced by a single round of in vitro T cells activation. Therefore, induction assays that measure viral outgrowth or viral RNA production after a single round of T cell activation will underestimate reservoir size. A conceptually novel approach to measuring the latent reservoir is to count all of the intact proviruses regardless of their transcriptional status at any particular time. This can be done with the intact proviral DNA assay (IPDA). More recently identified conceptual issues in reservoir measurement include the problem of clonal expansion. The reservoir is dominated by large clones of infected cells that wax and wane over time, and current measurements do not capture dynamic changes in reservoir composition. In addition, the relationship between the viruses that cause rebound following interruption of antiretroviral therapy and the viruses detected in various reservoir assays needs to be clarified. This talk will discuss these issues and summarize the current state of reservoir measurements. The HIV replication cycle includes integration of the reverse-transcribed viral genome into the host cell DNA where the provirus is retained for the life of the cell. Cellular machinery is used for proviral genetic expression, however, by means that are not fully understood, some HIV proviruses can maintain a latent, or transcriptionally-silent, state. It is thought that cells expressing HIV are susceptible to cell killing by cytopathic effects or immune responses. It stands CHARTING GENOME-WIDE INTEGRATION Mary F. Kearney , National Cancer Institute, Frederick, MD, USA

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to reason, therefore, that long-lived latently-infected cells may accumulate over the course of HIV infection and persist after ART is initiated. Indeed, many studies have demonstrated the persistence of latently-infected cells during ART and, it is believed that such cells carrying replication-competent proviruses, when activated, are the source of viral rebound when ART is interrupted. It was recently discovered that HIV infected T-cells can persist in vivo through cellular proliferation, which occurs both prior to and during ART. Several cases, thus far, have described highly expanded infected CD4+ T cell clones that were shown to be the source of persistent infectious viremia during ART. This talk will summarize emerging data from studies investigating HIV infected CD4+ T cell clones including their sites of HIV integration in blood and tissues both prior to and during ART, the fraction of HIV expressing cells within cell clones, including those carrying replication-competent proviruses, and explore new technologies for investigating HIV integration landscape and full-length proviral structures. Understanding the integration site landscape in cell clones that persist during ART will lead to a better understanding of the HIV reservoir, the nature of latency, and the sources of rebound viremia when ART is interrupted. SINGLE-CELL EPIGENETICS: COLORING IMMUNE CELLS WITH A RICH PALETTE OF HISTONE MARKS Alex J. Kuo , Stanford University, Stanford, CA, USA Chromatin-based epigenetic mechanisms govern diverse cellular and organismal phenotypes without DNA base alterations. Post-translational modifications of histone proteins, often referred to as histone marks, directly modulate chromatin dynamics and genome organization, adding additional complexity and plasticity to the relatively static genetic code. The harmonious orchestration of chromatin regulators is essential for hematopoiesis and immune system development, effective immune responses against foreign substances and pathogens, and immune tolerance to prevent damage to host tissues. Previously, we have leveraged highly multiplexed single-cell mass cytometry to characterize global histone modification profiles of various immune cells in the human immune system. This powerful analytic platform, which we term “Epigenetic landscape profiling using cytometry by Time- Of-Flight (EpiTOF)”, facilitates the discovery of histone marks preferentially enriched in selected immune cells. We identify immune cell subtype- and hematopoietic lineage-specific epigenetic patterns, which predict immune cell identity. Differential analysis between younger and older adults reveals increased epigenetic variation between individuals, and elevated cell-to-cell epigenetic variability between single cells with age. Analysis of a twin cohort further shows that these aging-related epigenetic alterations are driven predominantly by non-heritable influences. Recently, we have demonstrated how EpiTOF can be integrated with genomic methods to investigate chromatin dynamics (i.e. ChIP-seq, ATAC-seq), and combined with transcriptomic and functional analyses to gain a comprehensive understanding of how the immune system is regulated by chromatin-based mechanisms. Using this “systems epigenetics” approach, we have extensively characterized the biological significance of a histone mark involving histone H3 proteolytic cleavage in monocyte-to-macrophage differentiation. Our findings have marked implications for cellular fate determination, trained immunity, and human diseases with prominent monocyte and/or macrophage involvements. Together, EpiTOF provides a unique opportunity to interrogate epigenetic regulation of the immune system. We propose that a systems epigenetics approach will i) reveal how acute and chronic viral infection alters the host chromatin landscape; ii) uncover chromatin-based mechanisms by which host immune cells develop an effective defense against viruses, and iii) provide insights into the variability of anti-viral response between single cells and between individuals. PUTTING ANALYSIS INTO ANALYTICAL TREATMENT INTERRUPTIONS Lu (Summer) Zheng , Harvard T.H. Chan School of Public Health, Boston, MA, USA Analytic treatment interruption (ATI) is an essential component for HIV clinical trials assessing efficacy of interventions aimed at achieving HIV remission or virological control in the absence of antiretroviral or other treatments. With recent experiences of evaluating a variety of novel therapeutic interventions, including latency-reversing agents, therapeutic vaccines, and broadly neutralizing antibodies utilizing ATI, the design of treatment interruption studies has evolved towards shorter durations with more frequent monitoring and time to viral rebound as primary outcome measure. This talk will review and discuss the current practices of ATI studies on analytical approaches, design features related to the mechanism of action of the agents being

evaluated, including the selection of study outcomes, ART re-initiation criteria, using historical controls vs. placebo-controlled design, as well as ethical considerations. ADVANCING FROM PHASE II TO PHASE III: NAVIGATING THE LAND OF EXPECTATIONS Patrick Phillips , University of California San Francisco, San Francisco, CA, USA Mycobacteria tuberculosis kills more people every year than any other single pathogen, yet the first-line treatment regimen used globally has remained largely unchanged for 40 years. Shorter, safer, and more effective regimens are urgently needed to halt the epidemic. Clinical trials for new drugs to treat HIV depend on changes in HIV viral load as an established marker of infection and treatment response. In contrast, while several new TB drugs are in clinical development, the absence of a reliable surrogate endpoint hampers decisions about whether and when a new TB regimen is ready for confirmatory phase III evaluation. Further challenges include the necessity of determining the optimal combination and duration of therapy during phase II development alongside the limited funding for TB drug development and the allure of accelerated approval. In this workshop, I will talk about the burden of expectations and the latest developments in designing phase II trials to identify the best regimens to advance to phase III. I will talk about platform and other adaptive treatment- selection trial designs, the novel phase IIC design, designs to identify the optimal duration of therapy and the role of an internal control. I will also touch on challenges in TB prevention trials in the absence of a true marker of infection. In general, active-controlled noninferiority (NI) trials are considered when superiority trials, to an active control or placebo, are not possible due to ethical or other considerations. NI trials share some of the same biases as historically controlled trials because they rely on information external to the clinical trial. Food and Drug Administration (FDA) guidance states that NI designs are credible and appropriate only in situations in which the active control has shown a consistent effect (generally compared to placebo) in prior superiority trials conducted in a patient population similar to the population in the clinical investigation being planned. This is called the constancy assumption and allows for assay sensitivity in an NI trial. NI is met if the new intervention is 'not unacceptably worse' than the active control by a specified amount, the NI margin. The NI margin should be no larger than the effect the active control had in previous trials. Unless a placebo group is also included, NI trials depend on the assumption that the active control had its expected effect in the trial. From a regulatory perspective knowing the active control had its expected effect is necessary to ensure that a trial that concludes NI has identified a treatment that is superior to placebo. HIV treatment trials have successfully used NI trials for antiretroviral (ARV) drug development for many years; however, quantifying the treatment effect of each component of an ARV regimen has been challenging as drug regimens evolve, which can have consequences when designing an NI trial. HIV prevention research also illustrates the limitations of NI trial designs. Although collective data show that emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) can be highly efficacious at preventing HIV infection when taken as prescribed in uninfected individuals, the prophylactic effect has been highly variable over time and by population. Two trials that included FTC/TDF arms in cisgender women in Africa showed a lack of pre-exposure prophylaxis (PrEP) efficacy due to poor adherence. The lack of a consistent PrEP effect across trials in all populations invalidates a constancy assumption of FTC/TDF as an active control in an NI trial for some populations. Other types of trial designs using external controls might be more credible and appropriate than NI trials and are currently being explored. NONINFERIORITY COMPLEX Jeffrey Murray , FDA, Silver Spring, MD, USA The unprecedented nature of AIDS as a syndrome and a pandemic created unprecedented demands on clinical trials investigators and networks to creatively and meaningfully address the syndromic nature of AIDS, the complex etiology and pathogenesis of HIV infection, its associated opportunistic infections, coinfections, and malignant, end-organ, and neurologic sequelae, in diverse affected populations including men who have sex with men, drug users, sex workers, young people, infants, children, adolescents, pregnant women, and people grappling with multiple syndemics (opioids, viral hepatitis, sexually INCLUSION OF DIVERSE POPULATIONS IN TRIALS Mark Harrington , Treatment Action Group, New York, NY, USA

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transmitted infections), social and structural barriers to research, prevention, treatment, access, care, and support. Traditional models of infectious disease clinical research needed to be adapted to the complex disease settings and diverse populations which made studying HIV and its complications more challenging than studies of a single drug for a single infectious agent. In this talk I will review 1) contributions made by activists, people living with HIV, and their communities to restructure and reform clinical trial designs to make themmore relevant, ethical and efficient in the early days of clinical HIV research, including by expanding eligible trial populations and changing trial designs to make them more flexible, inclusive, and adapted to the real needs of people living with HIV; 2) the impact of broadened inclusion criteria and community priorities on HIV clinical research in the discovery of highly effective combination therapy (cART), pre-exposure prophylaxis (PrEP), and defining the optimal time to begin cART in all people living with HIV; and 3) current challenges and opportunities facing trial designers and networks in selected key high priority populations including those co-infected with HIV and Mycobacterium tuberculosis and those at risk for those infections in current and upcoming multi-modality prevention and treatment trials in selected diverse populations. I will close with some observations about the impact of diverse community engagement and participation in all aspects of the clinical trial process. WHEN AT THIRD YOU DON'T SUCCEED David L. Wyles , Denver Health and Hospital Authority, Denver, CO, USA Current HCV direct acting antiviral (DAA) regimens are highly efficacious; including in populations previously recognized to have poor responses to interferon-based therapies (e.g. HIV co-infection, cirrhosis etc.). However, as DAAs are used in a greater number of patients in clinical practice, scenarios which have not been adequately addressed in clinical trials, or are impractical to study, will invariably arise. The approach to management of HCV treatment interruptions of varying durations at different times during therapy and re- treatment for multiple DAA regimens failures are examples of such scenarios. In this interactive session, cases will be used to highlight clinical conundrums focusing on: • Determination or HCV relapse versus reinfection • Multiple DAA regimens failure retreatment • Approach to treatment interruptions during DAA therapy While FDA approved options for retreatment exist for initial DAA regimen failure, robust data are lacking for patients failing multiple DAA regimens and retreatment approaches are not standardized. Inferences from studies in other HCV scenarios can provide insight into reasonable re-treatment approaches which generally rely on extension of therapy with addition of other drug classes and ribavirin when possible. In situations where no data exists- such as evidence based approaches for dealing with treatment interruptions, expert opinion and audience input will be used to offer management options. “A” CASE TO REMEMBER: HEPATITIS A - MANAGING AN OLD VIRUS IN NEW POPULATIONS AT RISK Darcy Wooten , University of California San Diego, San Diego, CA, USA This session will use a case-based approach with audience response questions to review important updates in epidemiological risk factors for hepatitis A virus (HAV) infection, unusual presentations and complications that occur with HAV, and strategies for prevention. Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death globally. Viral hepatitis, specifically hepatitis B and hepatitis C infections are a major cause of HCC. Antiviral therapies for both HBV and HCV infection can decrease the risk of HCC. This presentation will focus on the contribution of HCC to global liver-related mortality and the impact of antiviral therapies on the incidence of HCC. This presentation will discuss the emerging data on the impact of direct-acting antivirals (DAA) on HCC incidence and recurrence and on the role of DAA therapies in patients diagnosed with HCC. In particular, the presentation will discuss in detail (1) the evidence supporting the safety of DAA therapies in patients with cirrhosis as it relates to risk of HCC development, (2) the optimal timing for initiating DAA therapy in patients who have been diagnosed with HCC and will discuss the impact, if any, of HCC diagnosis on response to DAA therapy, and (3) the impact of SVR on HCC incidence. Lastly, the presentation will discuss monitoring for HCC after SVR in patients with HCC and will highlight emerging Hepatocellular Carcinoma Susanna Naggie , Duke University, Durham, NC, USA

non-invasive biomarkers that may be utilized after DAA HCV cure to improve risk stratification. When possible the presentation will discuss differences in HCC presentation and outcome in people with HIV and viral hepatitis. NONALCOHOLIC STEATOHEPATITIS Kathleen E. Corey , Massachusetts General Hospital, Boston, MA, USA Non-alcoholic fatty liver disease (NAFLD) impacts affecting 25% of adults worldwide. NAFLD is a spectrum of pathology including steatosis and non-alcoholic steatohepatitis (NASH), the progressive form of NASH which can lead to fibrosis development, cirrhosis, end-stage liver disease, and hepatocellular carcinoma. NASH cirrhosis is the second leading indication for liver transplantation in the United States. In addition, NAFLD is strongly associated with the metabolic syndrome and obesity and is an independent risk factor for cardiovascular disease (CVD) and CVD-related death. In persons with HIV (PWH) liver disease is a significant cause of mortality. With the high prevalence of diabetes and metabolic disease in PLWH, NAFLD and NASH are being increasingly diagnosed. This talk will present strategies for the risk factors for and diagnosis and management of NAFLD in PWH. THE ANCIENT AND MODERN ORIGINS OF HIV Michael Emerman, Fred Hutchinson Cancer Research Center, Seattle, WA, USA How did HIV-1 become a human pathogen? In this talk, I will trace the origins of HIV-1 through the cross-species transmissions and viral adaptations that preceded its emergence in humans. The immediate precursor of HIV-1 is a virus that infects chimpanzees, Simian Immunodeficiency Virus of Chimpanzees (SIVcpz). SIVcpz is itself derived from other SIV lineages that infect old world monkeys. Cross-species transmission events require mutations to the viral genome that allow adaption to replicate in a new host. Much of this adaptation involves gaining the ability to counteract or evade a repertoire of antiviral genes, called restriction factors. The selective pressure between host restriction factors and the viral proteins that antagonize these factors sets up an “arms- race” that can be read out in the rapid evolution of the two proteins. The example of such restriction factors and viral antagonists that I will describe in the most detail is that of the primate APOBEC3 proteins that hypermutate viral genomes and the lentiviral Vif proteins that antagonize APOBEC3 activity. Study of the functional and evolutionary relationships between APOBEC3 proteins in primates and Vif proteins in primate lentiviruses allow us to make inferences about how long lentiviruses have been present in primates and about the steps that occurred for a lentivirus in monkeys to adapt to replicate first in chimpanzees, and then in humans. This talk will also highlight the role that basic science can play in ending the current HIV-1 pandemic. 16 TRANSLATING HIV SCIENCE INTO POPULATION IMPACT: A REALITY CHECK FROM THE FRONTLINE Alex G. Coutinho , Partners in Health, Kigali, Rwanda Over the past 20 years, tremendous strides have been achieved in the response to HIV/AIDS, especially in the incredible scale-up of life-saving ART to over 25 million people globally, most of them in Africa. This heroic achievement has resulted in an estimated 56% reduction in mortality since 2004 and as a consequence led to an increasing life expectancy and a marked drop in HIV/ AIDS orphans – all of which are significant population impacts. However, the expected reductions in new infections have only been achieved modestly with an estimated reduction of HIV incidence of 16% in the 10 years since 2010. This is in part due to the challenge of translating scientifically proven HIV prevention interventions like ART, PMTCT, and VMMC and PreP into an environment that has many obstacles and challenges that include funding constraints, struggling health systems, disempowered communities and structural barriers. In particular, HIV prevention faces the challenge of promoting approaches like condoms that often face opposition from some politicians, cultural leaders, and religious leaders. Other approaches like VMMC and PreP face both opposition and skepticism, on the grounds that there are fears that individuals using these partially effective approaches will exhibit a rebound increase in risky sexual behaviors that will lead to new HIV infections. In addition, many of the target populations that are at greatest risk for HIV infection are also the groups that are the hardest to reach because they are considered illegal, are harassed and discriminated and often live and operate underground to avoid scrutiny. However, there are several excellent examples of effective scale-up of scientifically proven interventions and population impact, as well as a few examples of large scale combination HIV treatment/prevention interventions 14 15

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that have reduced HIV incidence at a population level. These examples provide hope and a template to use when planning to scale up new technologies like PreP, as well as scaling up the use of older technologies like condoms. However for this to be successful at the frontline it will require scientists and politicians and communities and frontline implementers to sit down together, listen to each other, understand the science AND the realities of people’s lives and the systems that support them, and come up with scientifically sound and pragmatic approaches to scale up services, impact populations and measure progress. The history of HIV has many lessons for us as we look into the future. Science, even brilliant science, will not end the HIV epidemic without collaboration and synergy with a wide range of other actors, strategies and full involvement of infected and affected communities. Sharon R. Lewin , University of Melbourne, Melbourne, Australia Despite the great success of antiviral therapy (ART), treatment is life long for the majority of people living with HIV (PLWH). Antiviral treatment is simple and relatively cheap and close to 60% of PLWH have access to treatment. However, ART is still not available or secure for many, drug resistance is common globally and there are emerging toxicities from some of the most potent antivirals. Modelling studies of the cost and impact of a cure have identified that the need for frequent follow up and viral load testing after cessation of ART, unpredictable viral rebound and lack of protection from re-infection will all reduce the impact of a cure at a population level. Therefore there is now an increasing focus in the field to achieve a true cure and not HIV remission. Understanding where and how virus persists is key to the development of novel interventions to achieve a cure. Recent work has identified the significant contribution of proliferation of infected cells to HIV persistence on ART. Understanding the drivers of proliferation and clonal expansion remains a key unanswered question. In addition, multiple factors including the site of integration can influence the transcriptional activity of a virus and a deeper state of latency may reduce the chance of viral rebound off ART. Finally, the majority of viruses that persist on ART are defective and unable to replicate. A cure may therefore occur with loss of intact virus but persistence of only defective forms. New high throughput assays can now quantify intact and defective viruses more accurately and positive emission tomography and imaging can potentially identify tissue reservoirs of virus persistence. Multiple strategies to achieve a cure are being evaluated in both animal models and human clinical trials including combination immunotherapy to reduce the viral burden and enhance immune clearance. Results from recent clinical trials of newer latency reversing agents, immune checkpoint blockade and other immune adjuvants, broadly neutralising antibodies and gene therapy will be discussed. It is likely that in the next few years long acting and implantable antiretrovirals will be available and these newer modalities may address many of the current challenges of ART. Therefore, ongoing consultation is needed with PLWH and all other stakeholders to develop an acceptable target product profile for a cure that will have the greatest personal and population impact and can be implemented at scale. 18 UNIVERSAL TEST AND TREAT (UTT): LESSONS FROM THE PAST AND FOR THE FUTURE Kevin M. De Cock , US CDC Nairobi, Nairobi, Kenya This presentation discusses the four recently completed community randomized trials of “Universal Test and Treat” (UTT) in East and southern Africa and their implications. Three themes developed in parallel and led to these ambitious implementation studies: recognition of the centrality of viral load for HIV pathogenesis and HIV transmission; studies showing >90% effectiveness of “treatment for prevention”; and evolution of antiretroviral treatment guidelines that since 2015 recommend immediate treatment of all persons living with HIV. Mathematical modeling in 2008 suggested UTT, with repeated and regular HIV testing, could eliminate HIV in an epidemic of South African severity (Granich et al, Lancet, 2009). Political advocacy highlighted the concept of “Ending AIDS” while scientific debate culminated in four community randomized trials aiming to assess UTT with HIV incidence as the primary outcome in Botswana (BCPP); Kenya and Uganda (SEARCH); South Africa (TASP); and South Africa and Zambia (PopART), from 2012-2018. Primary results of the four trials were published in Lancet HIV (TASP, 2018) and NEJM (2019) and additional analyses, including on cost-effectiveness, are underway. All four trials achieved >90% knowledge of HIV serostatus but TASP yielded low linkage to treatment. The other three 17 HIV CURE FROM BENCH TO BEDSIDE

trials met the UNAIDS 90:90:90 targets, achieving 74-88% population-level viral suppression. Treatment guidelines changed over the studies’ course, resulting in some erosion of differences between intervention and control communities. BCCP and one of PopART’s two intervention arms showed 30% reduction in HIV incidence compared to control communities, while no significant differences were found in the other studies. Despite the successful achievement of 90:90:90 targets, HIV incidence in intervention communities (6-22.3/1000/year) remained well above an arbitrary definition of HIV elimination of <1/1000/year. Knowledge of HIV serostatus and early treatment are essential for individual and the public health, but UTT alone will not lead to HIV elimination. Priorities include expansion in scale and scope of HIV testing to reduce the diagnostic and treatment gap in generalized epidemic settings, addressing needs of key and underserved populations (including youth and men), and scale-up of highly effective interventions such as voluntary medical male circumcision and PrEP. Greater focus on measuring HIV incidence and mortality is required to better understand epidemic trends in the face of combinations of preventive interventions. 19 MECHANISMS OF PSGL-1 AND CD43 RESTRICTION OF HIV INFECTION OF CD4 T CELLS Yajing Fu 1 , Yuntao Wu 1 , Sijia He 1 , Abdul A. Waheed 2 , Deemah Dabbagh 1 , Hong Shang 3 , David N Levy 4 , Eric O. Freed 5 1 George Mason University, Fairfax, VA, USA, 2 NIH, Frederick, MD, USA, 3 China Medical University, Shenyang, China, 4 New York University College of Dentistry, New York, NY, USA, 5 National Cancer Institute, Frederick, MD, USA Background: PSGL-1 (P-selectin glycoprotein ligand-1) and CD43 are surface glycoproteins that are expressed on blood CD4 T cells to bind to selectins for T cell tethering, rolling, and migration into inflamed tissues. PSGL-1 is primarily expressed on the surface of lymphoid and myeloid cells and is up-regulated during inflammation to mediate leukocyte tethering and rolling on the surface of the endothelium for migration into inflamed tissues. Recently, PSGL-1 has also been identified as an INF-γ-regulated anti-HIV-1 restriction factor that inactivates virion infectivity. However, the mechanisms of PSGL-1-mediated anti-HIV activity remain to be elucidated. Methods: We studied PSGL-1 and CD43 restriction of HIV-1 virion infectivity by co-expression of PSGL-1 or CD43 DNA with HIV-1 DNA in virion producer cells, and then quantified virion infectivity in an HIV Rev-dependent GFP indicator cell. We also studied virion incorporation of PSGL-1 by gradient ultracentrifugation and western blot detection of PSGL-1 in virion particels. In addition, we examined virion proteins of PSGL-1 imprinted particles. We also performed mapping studies to identify functional domains of PSGL-1 necessary for blocking virion infectivity. Furthermore, we performed HIV-1 entry and attachment assays to study the interaction of PSGL-1 imprinted virion particles with target cells. Results: We found that the expression of PSGL-1 in virus-producing cells inhibits virion infectivity by inhibiting virion attachment to target cells. Mapping studies show that the extracellular, N-terminal domain of PSGL-1 is necessary for its anti-HIV-1 activity, and the PSGL-1 cytoplasmic tail contributes to inhibition. In addition, we demonstrate that the PSGL-1 related monomeric E-selectin binding glycoprotein CD43 also effectively blocks HIV-1 infectivity. HIV-1 infection, or expression of either Vpu or Nef, downregulates PSGL-1 from the cell surface; expression of Vpu appears to be primarily responsible for enabling the virus to partially escape PSGL-1-mediated restriction. Finally, we found that PSGL-1 inhibits the infectivity of other viruses such as murine leukemia virus and influenza A virus. Conclusion: These findings demonstrate that PSGL-1 is a broad-spectrum antiviral host factor with a novel mechanism of action. Further elucidation of PSGL-1 and CD43 interaction with HIV-1 and other viruses may offer new therapeutic strategies for targeting viral infections. 20 STRUCTURAL ANALYSES OF A BOUND ANTI-CD4 ADNECTIN INHIBITOR OF HIV-1 David Wensel 1 , Shawn William 2 , David P. Dixon 3 , Paris Ward 2 , Patti McCormick 2 , Nestor Concha 2 , Eugene Stewart 2 , Xuan Hong 2 , Shreya Pal 1 , Charles Maxxucco 1 , Bo Ding 1 , Mark Krystal 1 1 ViiV Healthcare, Branford, CT, USA, 2 GlaxoSmithKline, Collegeville, PA, USA, 3 GlaxoSmithKline, Uxbridge, UK Background: GSK3732394 is a multi-specific biologic inhibitor of HIV entry currently under clinical evaluation. A key component of this molecule is an

Oral Abstracts

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Abstract eBook

Oral Abstracts

Adnectin that binds to CD4 and inhibits downstream actions of gp160. Studies were performed to help elucidate the binding site of the Adnectin on CD4 and understand the mechanism of inhibition. Methods: Hydrogen-deuterium exchange mass spectrometry (HDX) was used to examine comparative deuteration rates of amide backbone protons of CD4, either in the absence or presence of saturating amounts of Adnectin. In addition, crystal structures of CD4 bound to both the Adnectin and a Fab subunit of ibalizumab were solved at a 3.7Å resolution. Cryo-EM studies of Adnectin bound to soluble CD4 were also generated. Finally, mutagenic analyses on CD4 were performed to confirm and extend these findings. Results: Using HDX, CD4 peptides at the N-terminus of D2 and in D3 showed differential rates of deuteration (both enhanced and slowed) in the presence of the Adnectin that mapped predominantly to the D2-D3 interface. The structure of the ibalizumab Fab/CD4 D1-D4/Adnectin complex revealed an extensive interface between the Adnectin and residues on CD4 domains D2-D4 that stabilize a novel T-shaped CD4 conformation. A cryo-EMmap of the gp140/CD4/ combinectin complex clearly shows the bent conformation for CD4 while bound to gp140. Mutagenic analyses on CD4 confirmed that amino acid F202 forms a key interaction with the Adnectin. In addition, amino acid L151 was shown to be a critical determinant of the specificity for binding to human CD4 protein over related primate CD4 molecules. Mutation of L151 to R (the residue present in cynomolgus monkey CD4) abrogated Adnectin binding to human CD4, while the reverse mutation (R151L) restored binding to cynomolgus monkey CD4. Conclusion: The significant conformational change of CD4 upon Adnectin binding brings the D1 domain of CD4 in proximity to the host cell membrane surface and provides a potential explanation for the ability of the CD4-bound Adnectin to inhibit HIV-1 infection. In addition, mutations of D2-D3-interface residues, specifically F202 and L151, dramatically impacted Adnectin binding to human and primate CD4, providing a rationale for the observed species specificity of the Adnectin. 21LB SERINC3/5 PERTURB HIV MEMBRANE FUSION POST-HEMIFUSION AT FUSION-PORE DILATION STEPS Amanda E. Ward 1 , Volker Kiessling 1 , Judith M. White 1 , Owen Pornillos 1 , Barbie K. Ganser-Pornillos 1 , Lukas K. Tamm 1 1 University of Virginia, Charlottesville, VA, USA Background: Serinc3 and Serinc5 are recently described host restriction factors that in the absence of Nef, can block HIV infection by incorporating into budding viral particles and decreasing their ability to infect subsequent cells. Serincs are thought to block the very earliest stages of infection, membrane fusion and cell entry, by an incompletely understood mechanism. Methods: We used giant plasma membrane vesicles (blebs) as model target membranes to study “wildtype” and Serinc-disrupted HIV membrane fusion at a single-particle level with cryoElectron Tomography and Total Internal Reflection Fluorescence (TIRF) microscopy. Results: Using fluorescent reporters of membrane and content mixing, we observed that Serinc3 and Serinc5 do not cause a defect in mixing of the outer lipid leaflets (hemifusion), but a pronounced defect in fusion pore opening. Additionally, cryo-electron tomography of HIV pseudoviruses mixed with blebs showed rearrangements of viral and target membranes and proteins at multiple intermediates steps of HIV membrane fusion. We found that Serinc3 and Serinc5 increased the number of hemifusion and early fusion product events and that many of the fusion products are cinched between former virus and bleb. Conclusion: These results suggest that Serinc3 and Serinc5 create bottlenecks in the process of membrane fusion; a first bottleneck after hemifusion and an additional bottleneck that prevents full fusion pore dilation such that the viral capsid cannot pass into the cytosol. Understanding how Serincs disrupt HIV membrane fusion will clarify the requirements for normal HIV membrane fusion and potentially identify new viral weaknesses that could become drug targets. 22 CRISPR-INDUCED MUTAGENESIS POINTS TOWARD A ROLE OF TRN-SR2 IN HIV NUCLEAR IMPORT Frauke Christ 1 , Julie Janssens 1 , Flore De Wit 1 , Jolien Blokken 1 , Youlia Lampi 1 ,

the importance of TRN-SR2 for HIV nuclear import is generally accepted, the detailed mechanism and role of TRN-SR2 remains under debate. According to one model the direct interaction of TRN-SR2 with HIV integrase drives nuclear import of the pre-integration complex (PIC), alternatively TRN-SR2 may play an indirect role linked to uncoating of the PIC and the protein CPSF6. Methods: We have designed CRISPR-Cas9 guide RNAs targeting exon 2 and 8 of TNPO3 in HeLaP4 cells. After selection of clones with reduced TRN-SR2 expression on both mRNA (QPCR) and protein expression levels (western blotting), a detailed analysis of HIV replication and PIC nuclear import was performed. Results: CRISPR-Cas9 induced DNA breaks in TNPO3 using guide 2 and 8 failed to generate complete knockout clones but instead allowed for selection of 2 HeLaP4 clones with a single allelic KO, resulting in 2-fold reduced TRN-SR2 levels (clone #20 and #25). Nevertheless, HIV single round and multiple round replication was severely hampered in clone #20 and #25. Interestingly genome sequencing of TNPO3 revealed that the remaining allele showed small in-frame deletions resulting in deletion of Aa (V103 and 373LHAL376). We then analyzed the PIC nuclear import in the respective cell lines by QPCR and fluorescent imaging of eGFP-IN labeled PICs. Both techniques evidenced a strong defect in nuclear import. Recombinant TRN-SR2 deletion mutants demonstrated an impairment of the molecular interaction with HIV-integrase. Conclusion: CRISPR-Cas9 targeting two different exons of TNPO3 failed to generate KO cell lines indicating that a full KO of TRN-SR2 might be toxic for HeLaP4. Yet, CRISPR-Cas9 unexpectedly led to mutagenesis. The resulting clones were fully viable but failed to support HIV replication. The block of replication was pinpointed to nuclear import and the corresponding recombinant mutant TRN-SR2 was impaired for interaction with HIV-IN. The presented data support the notion that TRN-SR2 is a genuine co-factor of HIV replication and interacts differently with HIV-IN than with its cellular cargoes. 23 NUCLEAR UNCOATING OF HIV-1 OCCURS NEAR SITES OF INTEGRATION Ryan C. Burdick 1 , Chenglei Li 1 , Mohamed Husen Munshi 1 , Jonathan Rawson 1 , Kunio Nagashima 2 , Wei-Shau Hu 1 , Vinay K. Pathak 1 1 National Cancer Institute, Frederick, MD, USA, 2 Leidos Biomedical Research, Inc, Frederick, MD, USA Background: A critical step in HIV-1 replication is the disassembly (uncoating) of the viral core. Remarkably, the timing and intracellular location of HIV-1 uncoating remain unknown. Studies of HIV-1 uncoating have been hampered by an inability to accurately quantify capsid protein (CA) loss from the viral complexes and by an inability to identify rare infectious viral complexes (~1/50) in infected cells. Methods: We developed methods to label CA with GFP (GFP-CA) in infectious viral complexes and to identify transcriptionally-active proviruses in live-cell imaging assays. We analyzed the dynamics of viral complex association with nuclear envelope and nuclear uncoating, and identified rare viral complexes that integrate to form transcriptionally active proviruses. Results: Using live-cell imaging, we observed >110 GFP-CA-labeled infectious viral complexes that integrated and expressed HIV-1 RNA and the gfp reporter gene. The infectious viral complexes maintained steady GFP-CA fluorescence signals for several hours after nuclear import followed by abrupt (<20 min) GFP-CA loss ~10.5 hours after infection, signifying nuclear uncoating. HIV-1 transcription sites appeared near the sites of nuclear uncoating, indicating that uncoating occurs at or very close to the site of integration. Similar GFP-CA fluorescence intensities of nuclear viral complexes and viral cores in vitro suggest that viral cores in the nucleus retain >90% of the CA and that nuclear uncoating is the major uncoating event. The nuclear GFP-CA-labeled viral complexes rapidly disassembled after treatment of the infected cells with capsid inhibitor PF74 indicating that the nuclear viral complexes retained CA hexamers. Time-of-addition assays with PF74, nevirapine, and raltegravir indicate that nuclear uncoating occurs ~3 hrs after the completion of reverse transcription and ~1 hr before integration. We probed the potential mechanism by which viral cores enter the nucleus and found that cleavage and polyadenylation specificity factor 6 (CPSF6), a host nuclear protein that binds to CA, influences the intracellular location of uncoating and facilitates the nuclear import of intact or nearly intact viral cores. Conclusion: Intact or nearly intact viral cores of infectious viral complexes that retain >90% of their CA enter the nucleus and uncoat near their genomic integration sites just before integration.

Oral Abstracts

Irena Zurnic 1 , Rik Gijsbers 1 , Zeger Debyser 1 1 Katholieke University Leuven, Leuven, Belgium

Background: In order to infect non-dividing cells, HIV needs to cross the nuclear envelop. In 2010 we reported the identification of the importin TRN-SR2 (TNPO3) as the determining host factor for nuclear import. While

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