Medecins Sans Frontieres warned this week, again, that declining international donor funds could reverse the dramatic gains made in AIDS treatment, particularly across Africa.
Launching the report ‘Punishing success? Early signs of a retreat from commitment to HIV/AIDS care and treatment’, Dr Tido von Schoen-Angerer said: “We think we are at a very dangerous turning point.”
The director of MSF’s campaign to provide essential medicines, he said: “The donors are getting cold feet about commitment to longterm, chronic disease.”
If the funding of antiretroviral treatment is reversed, lives will be lost.
AIDSVACC 2009 Paris is officially over but in the lobby, where people are drinking coffee and eating croissants, they are still talking about neutralising antibodies, T-cells and the results of the Thailand RV144 trial. Honestly, even after three days.
Dr Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, opened his final presentation with a quote from Thomas A. Edison: “Results! Why man, I have gotten thousands of results. I know several thousand things that won’t work.”
Presentations and posters at this conference have shed light on elements of the immune system that do work, don’t work and, importantly, on the need to expand the tests that measure what works or not.
The research results have been exciting and are sure to inform the 2010 Scientific Strategic Plan of the HIV Global Vaccine Enterprise, one of the hosts of this conference, with the ANRS, the French National Agency for Research on AIDS and Viral Hepatits.
In the closing session Nobel prize winner, Dr Francoise Barre-Sinoussi from the ANRS, challenged the 1100 delegates to move forward with “no dogma”, exploring new technologies and innovations – and taking risks.
The progress from last year’s HIV vaccine conference in Cape Town is evident and hopefully scientists attending the 2010 HIV vaccine conference next year in Atlanta, in the US, will say the same when they leave that meeting.
*Reports on the closing session and conference highlights will be published in The Times tomorrow and in the Sunday Times, with views from prominent South African and African scientists.
Today is the final day of AIDS Vaccine 2009 in Paris, an annual conference on HIV vaccine research, which started in the city of light in 2000.
Eminent HIV scientist Dr Anthony Fauci and Nobel prize winner, Francoise Barre-Sinoussi, will highlight the way forward at the closing ceremony before handing over to the 2010 chair, Dr Eric Hunter from the Emory Vaccine Center in the US.
Hunter is doing groundbreaking research on serodiscordant couples (one partner HIV positive, one partner HIV negative) in Zambia and Rwanda, focusing on how HIV is transmitted from one partner to the other. He presented findings from these studies yesterday and explained them to journalists.
His team found that about 20% of the couples they tested in Zambia were serodiscordant and about 12% of the couples tested in Rwanda.
He showed that 90% of the time the virus is transmitted from the infected parter to the other person only a single virus variation is passed on – even though person with the original infection (host) has a huge numbers of variants of the virus.
In other words, the host genetic diversity usually narrows down to a single HIV variation in the recipient, in what Hunter called a “genetic bottleneck during transmission”.
“For 20 days after infection the virus population is remarkably homogenous (67%) in the acutely infected person,” he said.
Dr Wayne Koff from the International AIDS Vaccine Initiative said: “This is an opportunity for vaccine development. If we attack the virus early it is not as variable as later.”
A single person who has been infected with HIV for six years has a greater variation of the virus than all the variations identified in the global flu epidemic in 1996, said Hunter.
Also explaining what happens in the genital mucosa during early infection, he said: “This is a narrow window at which the virus is most vulnerable. Once it is out (of the cervical mucosa), we can’t block infection.”
Adenovirus 26 looks like it could be a safe, new HIV vaccine vector said Dr Dan Barouch from Boston, US, this afternoon at AIDS Vaccine 2009.
The Ad5 virus, which has been tested as a vector (an altered virus to transport the vaccine into the body) in large human clinical trials, initially appeared to have some complications that will not apply to Ad26.
The adenovirus is a common virus that causes colds.
Dr Dan Barouch from Boston said: “One of the main problems with Ad5 is that there is a high pre-existing immunity in the population (many people have been exposed and their immune responses altered). Ad26 is rarely found naturally and so we hope it will be useful.”
Speaking to journalists Barouch, from Beth Israel Deaconess Medical Center, said: “It has a very different interaction on the immune system to Ad5 in triggering an immune response.”
He said: “We showed it gave substantial protection against HIV last year. Now, in a Phase I human study among 36 volunteer and placebo participants, who were given three different doses, it was safe and immunogenic.”
Barouch said the Ad26 vector induced cellular and humoral (antibody) immune responses.
When the results of the STEP Merck Ad5 HIV-1 trial were first released in 2007, there was an initial concern that uncircumcised men who had Ad5 immunity, could be at slightly raised risk of infection.
But further analyses of these results, and its companion Phambili study in South Africa, released at the conference this week found there was no raised risk.
Young scientists around their world are finding clues to crack the puzzle of what it will take to make an effective HIV vaccine.
Speaking at the AIDS Vaccine 2009 conference in Paris this afternoon they reported on pioneering work, most of which revolved around a type of cells known as denditric cells.
*Mathias Lichterfeld from Massachusetts General Hospital in Boston, US, explained: “Denditric cells are like the conductors of a concert. They are what get effector cells working: they prime T-cell (cellular) response and B-cell (antibody) responses.”
Elite controllers – a rare group of people who have HIV but keep it under control – have extremely effective denditric cells compared to other people with HIV or those who are HIV negative, his work has shown. “Manipulating denditric cells is an important element to any (HIV) vaccine,” he said.
*Jacques Bancherau from INSERM/Center for Human Vaccines in Texas, US, said his team was working on targeting and manipulating denditric cells, which he has been researching among cancer patients for 10 years.
“ One year ago we started injecting them into HIV patients and we have found this is safe. We need a proof of concept study on whether there is a future in manipulating these cells.”
He said if this proved to effective, it would be a “new methodology for HIV vaccine” that could be done anywhere off the shelf.
*Michael Liu from Oxford University said he was researching what happens to the T-cell response among patients very early on when they are infected. “We have found that T-cells have an effect on the virus in the early stages but that the virus can escape easily.”
*Sylvie le Gall from Harvard Medical School said her team was working on how the immune cells could improve their recognition of infected cells – research that could benefit the immune design of a vaccine candidate.
“We want to improve immune design. We want to improve the presentation of epitopes (a part of the virus surface that the body’s immune system targets for destruction) to evoke strong immune protection and to avoid epitopes that are useless.”
Six years ago there were no TB vaccines in trials and now there are 13 being tested in sites or clinics, Dr Jerald Sadoff, MD of the Aeras Global TB Vaccine Foundation, said this morning at AIDS Vaccine 2009 in Paris.
Now four AERAS-sponsored trials are currently taking place in Africa with two more in the pipeline for 2010.
UCT’s TB Vaccine Initiative (SATVI) with a human clinical trial site in Worcester and the Aurum Health Institute in Johannesburg are among its international partners currently engaged in trials.
Sadoff, who has been involved in the successful development of many vaccines, said that in Worcester: “On 15 July 2009 the first baby was vaccinated (with a new TB vaccine) in more than 80 years.”
He told the HIV vaccine researchers: “TB and HIV live together and they are an unholy marriage that is killing people. We do not like this and would like them to get a divorce.”
TB kills 1.77 million people per year and infects 9.27 million people around the world: nearly half a million those deaths and 1.5 million of these infections are among people with HIV, mostly in Southern Africa.
The death rate is much higher among people with drug-resistant forms of TB.
The existing TB vaccine, BCG, is among the most widely used vaccines in the world yet it is probably one of the most ineffective, Sadoff observed.
BCG, a routine vaccination for babies, is not safe for infants who are HIV positive.
Despite its limitations, Sadoff said, BCG still prevents about 70 000 deaths a year by playing a role in stopping the spread of TB among children.
US scientist Louis Picker announced encouraging results from a big monkey trial at AIDS Vaccine 2009 in Paris this morning.
The study found that 54% – 13 of the 24 rhesus macaques monkeys infected with SIV – showed complete control of infection after an initial viral “blip”.
And significantly for vaccine researchers, this research identified the type of immune cells with the capacity to completely suppress the monkey version of HIV (known as SIV).
The effector memory T-cells (CD8+ T-cells) seem to be powerful at blocking SIV at the early stage of infection as the virus enters the body.
This is a critical time for the body’s immune defence against HIV, as Dr Alan Bernstein, executive director of the HIV Global Vaccine Enterprise, explains: “It looks like the body has a narrow window of opportunity to stop HIV of hours up to a day or two.”
Picker said the cytomegalovirus (CMV) was known to be the best at triggering effector site-based T-cells. His team made three versions of a SIV vaccine using a modified form of CMV as the vector (vehicle to take virus particles into the body).
The form of CMV he used was replication competent vector (which means it can copy itself) and so far only non-replicating vectors have been used in human trials since they are safer.
Dr Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said scientists did not know if a non-replicating vector could produce these results and this was the “big punch” in Louis’s results.
A smaller study of this last year found that his type of vaccine protected a third of the 12 monkeys on which it was tested.
The results announced today are more significant since it is a bigger trial and all three groups showed “robust” responses, confirming that effector memory T-cells are providing protection (are the correlates of protection).
Picker said: “The effector memory control was abrupt (immediate), seemingly stable and correlates to CD8+ T-cells.”
The way in which the immune responses protect the body is a major, and complex, question for HIV researchers.
Bernstein said: “This reseach is very important for two reasons: understanding the correlates of protection is critical and we should be looking to see if effector memory T-cells were activated in the Thailand and STEP trials.”
Scientists do not yet know how the RV144 vaccine tested in Thailand provided partial protection (31%). The standard assays (lab tests) they do to test immune strength were discouraging yet the vaccine had some positive results – so they must now discover why.
Picker said an effective vaccine could combine neutralising antibodies, plus a CMV vector, and prime-boost vaccine (to boost the effect).
He is director of the vaccine programme at the Oregon Health and Science University’s Vaccine and Gene Therapy Institute in the US.
The Phambili study recruited 801 volunteers before it was halted and most of them were under 25 years old. Men and women were roughly equal in number.
Most of the men and women reported having one sexual partner and about half reported having unprotected penetrative sex.
About half of the men and women did not live with their main partner (were apart regularly).
Nearly half of the men also reported having casual, anonymous partners (with women this was about 11%) and about 40% said they drank or had drugs with sex (with women this was about 11%).
The only significant predictor of time to HIV infection was among men who had reported sexually transmitted infections at screening for the trial.
Dr Glenda Gray, director of the Wits Perinatal HIV Research Unit, today presented an “interim efficacy” analysis of data collected in the South African Phambili HIV Vaccine study.
This human clinical trial was halted in September 2007 due to futility (not showing efficacy) found in its companion study known as the STEP study. Both these trials were set up to test the same vaccine, the Merck Adenovirus 5, in uninfected adults.
Concern was raised at the time that uncircumcised men, who had pre-existing immunity to the Adenovirus 5, could be at slightly raised risk. But subsequent analysis of the STEP and Phambili data and follow up presented today showed that this was not in fact associated with increased risk of being infected. In the Phambili trial less than 20% of the participants had no pre-existing immunity to Ad5.
The trial was run in five provinces in South Africa with sites in Gauteng, North West, KwaZulu-Natal and the Western Cape and patients were followed up after September 2007 (data was frozen in August 2009).
Among the major findings that Gray presented were:
*This vaccine did not protect against HIV and there were no difference in new infections between the vaccine and placebo groups by the time of the first vaccination;
*But good cross clade immune reactivity was demonstrated: the vaccine being tested was a sub-type B candidate in an area where sub-type C is most common, but this finding shows at four weeks after two injections most volunteers had developed an immune response to both clades B and C (for clade C the response rate was 77%);
*A reduction in HIV viral load among the women who received the vaccine: 0.57 log reduction in viral load at the set-point (measured at the start of the study);
*early differences in CD4 decline between the vaccine and placebo participants: CD4 counts indicate immune strength so a slower decline is advantageous and over 12 months the vaccine group experienced this benefit but it was not sustained over time;
*Risk reduction behaviour was sustained over time; and
*Good uptake of male circumcision post-enrolment of about 32%: medical male circumcision reduces the risk of a man acquiring HIV by about 60% many studies have proved.
The new HIV infection rate that Gray reported was roughly 4% – about 10 to 20 times higher than the infection rate in the Thailand trial which was conducted among a low-risk population.
The number of vaccinations received did not impact on the probability of acquiring HIV (no statistical difference was found). During the trial 60 volunteers were infected – 40 of them were women.
Two-thirds of the volunteers got two vaccinations and a quarter got only one shot before the trial was suspended.
An update on clinical trials in the first plenary session at AIDS Vaccine 2009 today showed that more effective HIV vaccines are in the pipeline than any that have been tested before.
Gary Nabel, director of the Vaccine Research Centre at the US National Institute of Allergy and Infectious Diseases, said: “We have exciting new candidates that are eliciting response that have not been seen before.”
He told the packed hall that the HIV Vaccine Trials Network is currently testing a product that has shown great promise immunologically – in the lab delivering a “robust” response in stimulating CD4 cells and antibodies.
The HVTN 505 trial is testing a multiclade (includes different sub-types of HIV) DNA vaccine with an Adno booster (intended to stimulate the immune system). This Phase II trial started this year and will wrap up in 2012.
He also described new concepts around T-cell vectors (vaccines that stimulate cell-mediated immune response) and said this field was making advances. In particular he reported on the efficacy of the LCMV (a type of virus) at stimulating a powerful immune response in lab tests and he talked about a new generation of vaccines using the “mosaic” concept.
“On the T-cell side we can look forward to a lot of improvements,” he indicated.
Nabel said progress has been made on stimulating antibody immunity, guided by the analyses of blood from people who successfully generate broad neutralising antibodies.
“These individuals can serve as a guide to vaccine development,” he said.
Nabel emphasised the need to find new ways to measure immunity that will correlate (show a link to) protection against HIV and the important the window of opportunity to stop HIV as soon as it infects the cervix.