With Demand for Treatment Breaks at Record Level, Market for Tiny, Uninterpretable Studies Flourishes
Diverse DefinitionsAt least eighteen studies and speeches presented at the Seventh Retrovirus Conference included discussions related to treatment interruptions (TIs) and structured treatment interruptions (STIs) in various HIV infected populations -- including primary HIV infection (three papers), chronic and virally suppressed (13 papers), and chronic and unsuppressed (two papers). On the final day, three late-breaker presentations also focused on recent developments in STI research.
In his opening overview of recent data on metabolic toxicities associated with long-term antiretroviral therapy, Bill Powderly of Washington University suggested that the heightened interest in when to start -- or stop -- antiretroviral therapy had re-emerged in the spotlight due to an ever-shifting HIV treatment paradigm. In the four years since Vancouver, the discovery of latently infected cell compartments, the diminution (or disappearance) of the eradication imperative, and the emergence of significant drug-related toxicities have combined to emasculate much of the macho HIE, HIH bravado. Indeed, Powderly suggested that the only people for whom therapy is absolutely indicated are those with constitutional symptoms, opportunistic infections, or a CD4 count below 200.
In HIV-infected persons with earlier or asymptomatic disease, intermittent therapy (pulsed HAART interspersed with STIs) may help prolong therapeutic efficacy. Viral load-based therapeutic goals should perhaps be supplemented or even replaced by CD4-based ones (keeping the CD4 count above a certain risk threshold; Powderly 2000). Donald Kotler commented that Powderly's discussion of "these heretofore heretical propositions" was "a measure of our maturation in treating this disease" (Kotler 2000). Such discussions have certainly not been heretical among treatment activists in the past three years.
Several conclusions can be drawn from the STI research presented at the Retrovirus Conference: most STI research is still uncontrolled, carried out for short periods of time in small patient groups; STIs appear safe in the short-term if patients receive frequent RNA and CD4 measurements and are retreated as necessary; resumption of therapy appears to be successful if the patients were fully-suppressed before the STI; and the emergence of drug resistance has not been observed in this population. The immunologic benefit of intermittent therapy, however, remains undefined, and the clinical usefulness of HIV-specific CD4 and CD8 responses has yet to be demonstrated in this setting.
The usefulness of adjunctive approaches such as interleukin-2 (IL-2) or putative "therapeutic" vaccines such as ALVAC/gp120 (a prime-boost vaccination schedule which uses the canarypox-based "ALVAC" vaccine as the initial immunization and then the recombinant envelope based vaccine (in this case, gp120) for a series of subsequent booster immunizations; the canarypox products are best at producing cellular immune responses while the recombinant envelope products (e.g., gp120, gp160) have been shown to elicit some sort of an antibody response) remain unconvincing.
Different teams reported divergent results with IL-2 during or after HAART suppression. Reports about HAART plus ALVAC/gp120 followed by an STI are too preliminary to yield any conclusions and, in any case, were no better than results shown for HAART followed by an STI with no vaccine.
In unsuppressed patients, the incidence of "reversion to wild-type" virus in plasma is at least as high as previously reported (see TAGLine's report from the summer 1999 Salvage Therapy Workshop), but drug-resistant virus remains archived in mononuclear cells in half or more of the cases observed. The clinical implications of reversion to wild-type in plasma -- or persistence of resistance in cells -- require prospective investigation. The most important -- if not immediately useful -- conclusion is that further well-designed, prospective, and well-controlled studies of intermittent therapy and STIs need to be conducted across the spectrum of HIV disease.
The treatment interruption (TI) and structured treatment interruption (STI) papers included preliminary (mostly uncontrolled) reports on experience with various treatment interruption designs -- some structured, some more haphazard. This research can be divided into three patient populations or scenarios: acute primary infection, chronic infection with ongoing therapeutic success and chronic infection with a waning therapeutic effect.
Scenario A: Primary HIV Infection, Viral Load Successfully ContainedWhat the studies showed:
STI following HAART given during acute infection boosts and broadens anti-HIV CTL responses.
HIV RNA, CD4, and cytotoxic T lymphocytes (CTLs) against env, gag, nef and RT, were measured weekly. Mean baseline viral load at diagnosis was 13.8 million; RNA became undetectable in all patients after a median ten weeks (range 4-19) of HAART and remained undetectable during HAART treatment. Low magnitude CTL responses against one to four epitopes were seen in 10/15 subjects (66.7%) at diagnosis and persisted at lower frequencies during HAART.
In the seven STI patients, virus rebounded within one to eight weeks [levels not given] and HAART was reintroduced. CTL responses were boosted in all STI patients, who gained a median of two new recognized epitopes and increased responses to previously recognized epitopes. Two people with no previous CTL responses gained them post-STI.
In two people who had a second STI, additional CTL increases were seen. The authors concluded that, "CTL responses are detectable during acute HIV-1 infection prior to seroconversion, but are narrowly defined at a few epitopes. These responses persist at lower levels during HAART. STIs result in a persistent augmentation of the frequency and breadth of CTL responses in these subjects, which can be further boosted by additional controlled interruptions."
Of concern was an episode reported in the poster (but not the abstract) in which an individual simultaneously stopped HAART (for financial reasons and without telling the investigators) and received a flu shot; his viral load rebounded sky-high and he experienced the equivalent of a seroconversion syndrome (Altfeld et al., abstract and poster 357).
Comment: This paper suggests the possibility of broadening anti-HIV cellular responses by using STIs after suppressive HAART during acute infection and emphasizes the need for randomized studies of "when to start/when to stop" in the acute infection population.
STI following 48 weeks of HAART + hydroxyurea during acute infection: rebound observed regardless of hydroxyurea; rebound is blunted after three weeks; rechallenge is effective.
After 48 weeks of HAART, 83% had viral load <500 and 67% had <50. Eight patients (five on hydroxyurea) interrupted therapy after a median 57 weeks (range 53-75). All eight rebounded to >5,000 copies after 21 days. The authors noted that, "Plasma viral load peaked within three weeks and decreased thereafter by a median of 0.69 log." HU did not significantly affect the kinetics of rebound. All patients responded to rechallenge (viral load <500) within a median of four weeks. One patient on ddI/d4T/NVP discontinued treatment due to grade-three peripheral neuropathy at week 20 and his viral load remained <50 after 46 weeks off therapy (Zala et al., abstract 558).
Two of four acutely infected patients treated with HAART and immunized with ALVAC/gp160. STI blunted viral rebound and may have broadened anti-HIV CTL responses.
In two individuals (50%) delayed viral rebound was observed; RNA became detectable at 68 and 85 days post vaccination; initial virus doubling times were 4.5 and 3.2 days respectively. The other two patients (50%) experienced rapid viral rebound with detectable virus within 13 and 23 days; both had viral doubling times of 1.4 days -- similar to previously reported rates.
The two delayed rebounders had significant increases in CTLs to more than one viral antigen following vaccination. One rapid rebounder had a monospecific response to gag, while the other had CTL response to the vaccination. After four to eight months off therapy, the delayed rebounders had RNA levels of 3.75 and 2.52 log, while the rapid rebounders had 3.55 and >4.70 logs after four months off therapy. The authors speculated that "Therapeutic vaccination can enhance cellular immune responses that are temporally associated with suppressed HIV-1 rebound kinetics after discontinuation of HAART" (Jin et al., abstract LB12).
Comment: This small, uncontrolled study did not display results significantly different from those of Garcia et al. [see below], whose study involved three STI cycles post-viral suppression, but no "therapeutic" vaccination. The Garcia study showed 4/9 "lower rebounders" developed anti-HIV CTLs during their STIs, similar to the 2/4 "slower rebounders" reported on here. In the final question of the conference, Luís Montaner of the Wistar Institute pointed out that, as the study lacked controls, it was difficult to interpret. Of the three late-breaking STI papers, only the Deeks study was well-controlled.
Scenario B: Chronic HIV Infection, Viral Load (Moderately to Fully) SuppressedWhat the studies showed:
Virus rebounding during STI differs from that detected in latent reservoirs.
Rebound and reservoir RNA were identical in just two of nine patients, and diverged in seven of nine. This disparity could result from sampling error (the RNA may have rebounded from latent cells in another, unmeasured compartment), but the paper also suggested that the RNA may rebound from another, as-yet unidentified reservoir, where active replication may be ongoing despite HAART. Possibilities include tissue macrophages and microglia in the central nervous system (Chun et al., abstract 239).
Viral setpoint not altered after two years of HAART followed by treatment interruption.
The median difference between pre- and post-HAART viral load was 0.45 logs (mean 0.65). Eight patients had post-HAART viral load values higher than pre-HAART; four had lower values. The median duration between pre- and post-HAART values was 2,168 days (5.9 years). The authors concluded that, "After discontinuing HAART most individuals had rebounds in their viral burden approximating pre-HAART levels, even after a significant lapse of time approaching six years. Our data suggest that HAART with good viral suppression for almost two years may not alter intrinsic viral setpoints" (Hatano et al., abstract 349).
Low viral load during treatment interruption may not reflect a therapeutic effect.
Comment: What was the denominator here (e.g., how many other patients went off therapy and didn't achieve a viral load below 500 copies)?
ddI/hydroxyurea followed by STI may provide better immune control than HAART followed by STI.
Lori concluded that, "Reconstitution of HIV-specific cellular immune responses obtained during the treatment of chronically infected patients was associated with the control of viral rebound during treatment interruption" (Lori et al., abstract 352).
Comment: This case-matched control study would be more compelling if it were randomized.
STIs augment HIV-specific CD4 and CTL responses in some individuals with chronic HIV infection who previously controlled HIV with HAART.
The STI group experienced significant increases in anti-HIV T-helper responses against p24 and gp160 "preceding significant increases in interferon-gamma secreting CD8 T-cell responses against viral envelope antigens."
After a median 46-day STI, three subjects restarted HAART and achieved 98.86% reductions in plasma viremia by 21 days and maintained or further increased the cell-mediated anti-HIV responses. The remaining two subjects stayed off therapy, maintained high cell-mediated responses, and maintained RNA below 1,000 copies. "These observations," the authors noted, "provide the first demonstration that CD4 and CD8-mediated cellular immune responses against autologous HIV-1 are augmented as a result of temporary treatment interruption in a subset of chronically infected individuals." (Papasavvas et al., abstract 353).
Comment: This small, uncontrolled study suggests that CD4-mediated help may be required to stimulate anti-HIV CD8 activity.
Randomized STI trial in virally suppressed chronic infection shows only transient HIV-specific immune responses in a minority of participants, but is safe.
2/12 patients did not rebound after 30 days during the first STI. Only one maintained viral load <20 during the second STI. Among the rest, viral load became detectable (>20) for a median of 14 and 15 days during the first and second STIs, respectively. Viral load rose exponentially with a mean half-life of 1.6 and 2.2 days during the first and second STIs, respectively. CD4 and CD8 percentages did not change during STIs, but CD38+ (activation) expression rose significantly in response to viral rebound.
Four patients (33%) gained T-helper responses to recall antigens, and two of these (16.5%) developed HIV-specific p24 responses during the first STI. Only recall antigen T-helper responses were maintained by the start of the second STI. Drug resistance was not observed.
The investigators concluded that STIs were not associated with CD4 reductions or clinical complications after two years of effective viral suppression, that virus rebounded in most but not all patients, that virus was effectively controlled upon rechallenge, and that "HIV-specific helper T-cell responses may require subsequent cycles of STI to keep viral replication under control" (Ruiz et al., abstract 354).
HAART + IL-2 followed by an STI while continuing IL-2 elicits viral rebound followed by partial immune control, resulting in detectable viremia below pre-treatment setpoint.
CD4 counts dropped by 24% compared to baseline (p<0.01) just after the peak of viremia. CD8 cells rose to 200% of baseline (p<0.01) and remained high while viremia declined. The authors concluded that, "Contrary to previous assumptions, chronic HIV infection does not preclude the development of effective immune reactivity to HIV." Additional trials of HAART cessation while continuing IL-2 "to permit endogenous HIV antigenic stimulation . . . [and] promote the expansion of antigen-activated CD8+ T cells, now appear warranted" (Smith et al., abstract 355).
Randomized HAART vs. IL-2/HAART study suggests IL-2 may not affect virus production, latent infection, or immunologic control.
Viral load and CD4 counts were measured at days 0, 14, 28 and monthly; and after treatment discontinuation at weeks one, two, four and eight. Lymph nodes were biopsied before treatment and after six months of maintaining viral load below 50 copies. 120 HIV negative controls were used for normalizing age-matched T cell subsets. Median age was 41, median CD4 count 410, median CD8 count 878, and HIV RNA 4.83 log.
IL-2 did not affect the magnitude or kinetics of plasma viral load drop, but did increase the rate of normalization of CD4 counts. Viral replication was detected in the follow-up lymph node biopsies of 11/15 non-IL-2 and 10/16 IL-2 patients (non-significant). Proviral DNA levels and decay kinetics did not differ between the two groups. After treatment discontinuation, RNA rebounded rapidly and was transiently higher than baseline. One IL-2 patient subsequently cleared viremia in the absence of therapy.
Conclusions: Despite a strong and durable immunomodulatory effect, IL-2 has no persistent effect on virus production or latent infection in vivo [or] immunological control over HIV infection" (Stellbrink et al., abstract 240).
Comment: Whereas the Smith patients were selected, the Stellbrink patients were randomized.
Lymph node RNA rebounds in parallel to plasma RNA during STI.
Lymph nodes were excised after at least one year of HAART with CD4>600 and viral load <50, and then after viral rebound. Lymph nodes at baseline on HAART were quiescent to mildly hyperplastic. They had no detectable follicular dendritic cell (FDC) associated HIV RNA or p24 protein and only rare mononuclear cells (MNC) expressing RNA (one lymph node) or p24 (two lymph nodes).
Plasma viral load after a one to two month STI ranged from 329 to 3.2 million. CD4 counts declined by 5-48% and did so most in those with the highest viral rebound. Four of five second lymph node biopsies (80%) were more hyperplastic than the initial lymph node. The fifth lymph node showed paracortical hyperplasia but no germinal centers.
Cellular HIV RNA in the second lymph node paralleled plasma viremia. Cell activation increased. "Quiescent lymph node from individuals on extended treatment with HAART rapidly became hyperplastic and activated following one to two months of treatment interruption. Virus expression in lymph node MNC parallels the rebound in plasma viremia and fall in CD4 cells." The lymph node photographs in Orenstein's poster were a chilling reminder of the fact that the viral rebound seen after STIs visually resembles that seen during chronic, progressive HIV infection (Orenstein et al., abstract 358).
Comment: What would happen to viral expression in lymphoid tissue if anti-HIV cellular immune responses returned in association with blunting of plasma viremia?
Viral load does not rebound during an eight-day STI after HAART suppression.
Eight day rebound kinetics were similar in the four with RNA<20 and the one whose RNA was 100 on HAART; the latter actually did not experience a rebound. The two subjects whose virus rebounded re-suppressed after rechallenge. Three subjects had a lymph node (LN) biopsy at day eight. There was no increase in RNA+ cells above the low pre-STI level. CD4 cells dropped slightly but significantly during the STI and returned to baseline after 30 days of HAART. Activated CD4 and CD8 cells also increased, even in those whose viral RNA did not rise during the STI (Kilby et al., abstract 359).
Comment: The eight-day STI here may be too short to show much.
French group reports no immunologic benefit to brief treatment interruption.
The investigators measured RNA levels, HIV p24-specific T helper proliferation and interferon-gamma production, CD8 responses and T cell activation. Before treatment interruption, there were no significant CD4 and weak CD8 responses to HIV.
In patient one, three seven-day interruptions did not induce viral rebound or T helper stimulation. In patient two, HIV-specific CD4 responses increased only at the first rebound. In patient three, these responses occurred at each interruption but were transient. HIV-specific CD8 cell frequencies did not increase. Interferon gamma producing CD4 cells were observed after the treatment interruption, but the cells were rapidly deleted after virus replication resumed (Carcelain et al., abstract 356).
Comment: These were brief STIs. Virus may need to rebound to higher levels for longer durations to induce more durable HIV-specific responses. [See the similar low rebound observed in the Kilby study described above.] (abstract 359).
Preliminary results from Swiss study indicate viral rebound may be blunted after three STIs.
57 of a projected 120 patients enrolled between April and September 1999. Pre-HAART median CD4 count was 398, viral load 4.56 logs. Median pre-SITT HAART duration was 22 months; median CD4 count on starting SITT was 700. By the reporting deadline, 16 patients had two STIs and four had three STIs. Viral rebound in the first STI occurred in 28/43 (65%) and during the second STI in 12/16 (75%, p = NS). The two rebounds were similar in amplitude (p = 0.2).
After seven weeks' retreatment, 3/20 evaluable and compliant patients did not achieve viral load <50 (RNA = 62, 105 and 147). One had a fever and sore throat at the end of the first STI; viral load here was 925,000. "Very early results in the few patients with three treatment stops are modestly encouraging" (Fagard et al., abstract 458).
In four of nine (44%) previously suppressed, chronically infected individuals, anti-HIV CD4 and CD8 responses increased in parallel with control of viral rebound after three STIs.
They were given three four-week STIs; after the first two, HAART was resumed for 12 weeks and stopped again if viral load went back below 20 copies; after the third cycle, they were kept off HAART until the viral load reached a new setpoint.
Baseline plasma viral load was <20 copies in all cases and <5 copies in 7/10 cases (first STI) and in 7/9 cases (second and third STI). Viral rebound occurred in all cases with a mean doubling time of 2.23, 3.38 and 3.25 days over the three STIs.
At the second STI, in 4/9 patients (44.4%) viral rebounded to levels similar to baseline and then dropped spontaneously by 0.8, 0.8, 1.3 and 2.09 logs respectively. The authors explained that, "These four patients developed strong and broad CTL responses and a strong CD4+ lymphocyte proliferative response to HIV-1 antigens."
After the third STI, the viral load setpoint appeared significantly lower than baseline in four of seven patients. Drug resistance mutations were not detected after any of the STIs. Recovery of HIV-specific immune responses (CD4 proliferative and CD8 cytotoxic) correlated with spontaneous control of viremia.
The authors concluded that STIs "may induce effective specific cytotoxic and CD4+ lymphocyte proliferative immune responses against HIV-1 antigens associated with a spontaneous drop in plasma viral load in chronic HIV infection." Drug resistance did not emerge during the STIs, but CD4 counts dropped, and took at least six months from rechallenge to recover (Garcia et al., abstract LB11).
Scenario C: Chronic HIV Infection, Viral Load Unsuccessfully Contained ("Salvage")What the studies showed:
Two of four salvage STI patients experienced increases in CSF HIV RNA and white count.
In two subjects plasma RNA rose by less than one log during the STI and the CSF RNA was maintained in a nearly fixed proportion. In the other two patients, however, whose plasma RNA rose by one log, their CSF RNA rose by two to three logs, as did the WBC. The two "showed a disproportionate increase in local [CSF] infection and related host cell response"; however, there were no overt neurological symptoms (Price et al., abstract 306).
STIs in virologic failures after partial suppression on PIs result in reversion of protease inhibitor-resistance to protease inhibitor-sensitivity, CD4 drops and RNA rebounds, and return of a fitter viral phenotype.
Deeks and colleagues randomized patients to undergo an STI or stay on partially suppressive protease inhibitor-containing HAART. Eligible patients had virologic failure for at least 12 months, a viral load >2,500, had been on a stable regimen for at least ten weeks, and were willing to discontinue therapy.
Eighteen patients were randomized to a twelve-week STI. Phenotypic resistance (Virologic assay), HIV RNA, and CD4 counts were measured weekly for 12 weeks, then every four weeks. Replicative fitness was measured (see abstract 233). Among the 18 STI patients, the baseline CD4 count was 254; the baseline RNA 4.6 log; the median prior protease inhibitor therapy duration 36 months (of which virologic failure had been evident for 31 months), the median decrease in protease inhibitor susceptibility 56-fold. After the three-month STI, the median CD4 decrease was 94 cells (range -28 to -128) and the median viral load increase was 0.82 log (range 0.34-0.92). (Patients were encouraged to resume therapy if the CD4 count dropped by half or the viral load rose over one log.)
Virus reverted to protease inhibitor-susceptible in 16/17 patients [higher than the 67% rate in the Frankfurt cohort]. The mean time to reversion was 8.5 weeks; however, it ranged widely from 2-15 weeks. Importantly, in most patients, phenotypic resistance to most or all drugs dropped precipitously and simultaneously. In other words, a true wild-type virus re-emerged all at once, rather than sequentially. Moreover, this wild-type reversion was highly correlated with a steep viral RNA rebound and CD4 drop which contrasted with milder changes observed in the first weeks of the STI. Greater protease inhibitor resistance and higher viral load over baseline values were associated with delayed reversion (p = 0.04, 0.003). Nucleoside resistance persisted, though at lower levels, after reversion to a protease inhibitor-susceptible virus in 7/17 patients.
"Replicative fitness (relative to wild-type virus) increased from a median 22.3% to 67.1% (p=0.004). Resistant virus identical to baseline was cultured from PBMCs 12 to 36 weeks after therapy discontinuation in four of eight patients showing phenotypic reversion in plasma virus." Thus, drug-resistant virus remained archived in proviral DNA in half the cases measured.
It's possible that resistant virus could occur in non-sampled cells; more importantly, virologic results of rechallenge remain to be determined. "Discontinuing therapy was associated with either decreased T cell half-life or decreased CD4 production." These T cell turnover data were not shown in the late-breaker due to time constraints. The abstract concluded that "These data suggest that antiretroviral therapy [at least with a protease inhibitor] is associated with continued immunologic and virologic benefit, despite high level resistance. This benefit may reflect, in part, the maintenance of a less fit virus" [abstract]. "Interrupting therapy is often associated with biphasic increases in viral load and decreases in CD4 cells, reversion to wild-type virus (often abrupt but with variable time course), [and] increased replication capacity" [presentation] (Deeks et al., abstract and presentation LB10).
Comment: If more STI studies were as well-controlled, prospective, and data-intensive as this one, progress in STI research would accelerate.
Treatment Interruption: Experts Sound Cautious Note at San Francisco Forum; Meeting Proceeds Despite Disruption
Not Without My Data: Trend In Treatment Interruptions Gains Popularity;
Activists Call for Systematic Observation
This article was provided by Treatment Action Group. It is a part of the publication TAGline.