A Phase 1 Randomized, Double-Blind, Placebo-Controlled Rectal Safety and

Acceptability Study of Tenofovir 1% Gel

Ian McGowan, Craig Hoesley, Ross Cranston, Philip Andrew, Laura Janocko, James Dai, Alex Carballo-Dieguez, Ratiya Kunjara Na Ayudhya,

Jeanna Piper, Florian Hladik, Ken Mayer, and the MTN-007 Protocol Team.

19th Conference on Retroviruses and Opportunistic Infections Seattle

6th March, 2012

MTN-007

Background

Receptive anal intercourse is a high risk but common sexual behavior among men and women in the developed and developing world.

Non human primate studies have demonstrated that an antiretroviral rectal microbicide (RM) can reduce the acquisition of SIV#.

RMP-02/MTN-006 demonstrated a favorable PK/PD profile for rectal tenofovir (TFV) 1% gel but suboptimal safety profile* Gastrointestinal symptoms

#Cranage M et al. PLoS Med, 2008; *Anton PA et al. CROI 2011

Rationale for MTN-007

To characterize the safety and acceptability of a reduced glycerin (RG) formulation of TFV 1% gel Original TFV 1% gel: 3111 mOsmol/kg RG TFV 1% gel: 836 mOsmol/kg Iso-osmolar: 290 mOsmol/kg

To evaluate the utility of a broad range of biomarkers of mucosal safety

Study Population

Healthy, receptive anal intercourse abstinent, HIV-1 uninfected men and women

Key exclusion criteria Rectal or reproductive tract STI Hepatitis B surface antigen positive Bleeding tendency Pregnancy or breastfeeding

Study Design

N=65

HEC(N=16)

1% TFV(N=16)

2% N-9(N=17)

Single dose

7 day daily doses

7-14 dayinterval

EndoscopySafety/behavioral

assessment

ScreeningNo

Treatment(N=16)

BaselineEvaluation

7-14 dayinterval

Study Endpoints

Primary Grade 2 or higher adverse events

Secondary The proportion of participants who at their

final clinic visit report via the acceptability questionnaire that they would be very likely to use the candidate microbicide during receptive anal intercourse

Changes in mucosal parameters

Mucosal Safety Endpoints Histopathology Epithelial sloughing Fecal calprotectin Rectal microflora Mucosal mononuclear cell phenotype by

flow cytometry Cytokines and chemokines

qRT-PCR Luminex

Gene expression by microarray

Baseline Demographics by ArmAll Arms TFV Gel N9 Gel HEC No Rx

N 65 16 17 16 16

Mean Age 35.7 35.3 37.0 36.8 33.5

Gender

• Male (%) 45 (69%) 10 (63%) 13 (76%) 12 (75%) 10 (63%)

• Female (%) 20 (31%) 6 (38%) 4 (24%) 4 (25%) 6 (38%)

Hispanic 6 (9%) 1 (6%) 2 (12%) 2 (13%) 1 (6%)

Race

• Black (%) 11 (17%) 3 (19%) 2 (12%) 5 (31%) 1 (6%)

• White (%) 44 (68%) 10 (63%) 13 (76%) 9 (56%) 12 (75%)

• Other (%) 10 (15%) 3 (19%) 2 (12%) 2 (13%) 3 (19%)

Incident Adverse Events by ArmAll Arms TFV Gel N9 Gel HEC No Rx

N 65 16 17 16 16

Grade 1 30 (46.2%) 7 (43.8%) 10 (58.8%) 7 (43.8%) 6 (37.5%)

Grade 2 18 (27.7%) 3 (18.8%) 7 (41.2%) 4 (25.0%) 4 (25.0%)

Grade 3 2 (3.1%) 0 0 0 2 (12.5%)

Grade 4 1 (1.5%) 0 0 1 (6.3%) 0

Grade 5 0 0 0 0 0

Total 51 (78.5%) 10 (62.5%) 17 (100.0%) 12 (75.0%) 12 (75.0%)

Incident GI Adverse EventsGI Adverse Eventsin the Tenofovir Arm

MTN-007(N = 16)

RG Formulation

N %

Abdominal pain 3 19%

Rectal urgency 0 0%

Bloating 0 0%

Nausea 0 0%

Diarrhea 1 6%

Flatulence 6 38%

Proctalgia 1 6%

Other 3 19%

Total 9 56%

Gastrointestinal Adverse EventsGI Adverse Eventsin the Tenofovir Arm

MTN-007(N = 16)

RG Formulation

RMP-02/MTN-006(N = 12)

Original Formulation

N % N %

Abdominal pain 3 16% 6 50%

Rectal urgency 0 0% 5 42%

Bloating 0 0% 5 42%

Nausea 0 0% 4 33%

Diarrhea 1 6% 7 58%

Flatulence 6 38% 3 25%

Proctalgia 1 6% 0 0%

Other 4 25% 5 42%

Total 9 56% 12 100%

Acceptability

Product (N) Intention to Use (%)

RG Tenofovir (15) 87%

HEC Placebo (15) 93%

N-9 (16) 63%

Mucosal Safety Assays No significant changes were seen in

histology, fecal calprotectin, and epithelial sloughing after single dose (SD) or 7 daily doses (7D)

Suggestive evidence of change (▲ and ▼) were seen with flow cytometry, qRT-PCR, and Luminex assays at SD and 7D

The majority of changes were seen when comparing N-9 to the other arms of the study

Mucosal qRT-PCR

9 cm 15 cm

BL SD 7D BL SD 7D

Mucosal Safety Parameters (1)qRT-PCR SD 7D SD + 7D Comparison P Value (s)

IL-1 b (9 cm) ▲ N9 vs. No Rx 1.3e-3

▲ N9 vs. HEC 6.8e-4

▼ TNF vs. N-9 6.1e-4

IL-6 (9 cm) ▲ ▲ N9 vs. HEC 3.0e-4; 8.4e-5

▼ ▼ TNF vs. N-9 1.3e-5; 1.8e-4

IL-6 (15 cm) ▼ N9 vs. HEC 1.8e-3

IL-8 (9 cm) ▲ N9 vs. HEC 2.8e-4

▼ ▼ TNF vs. N-9 4.2e-5; 1.4e-3

MIP-1 a (9 cm) ▼ TNF vs. N-9 2.7e-4

Mucosal Safety Parameters (2)

Flow Cytometry SD 7D SD + 7D Comparison P Value (s)

CD3+/CD8+ ▼ ▼ N9 vs. No Rx 1.6e-3; 4.0e-4

Luminex

RANTES ▲ ▲ N9 vs. HEC 1.3e-3; 2.7e-4

Microarray Data Gene array studies were performed on a subset

of 8 participants per study arm (9 cm and 15 cm samples)

Labeled cRNA were hybridized to Illumina Human-HT12 v4 gene expression BeadChips.

The Benjamini Hochberg method was used to control for multiple testing (false discovery rate).

Fold change was calculated as the fold difference between treatment over baseline.

N-9 gel

HEC gel

No Treatment

Tenofovir gel

9 cm Gene Expression at Day 7

Summary of Microarray Data

N9 TNF HEC No Rx

Gene expression 9 cm rectum following 7 days of product application

Summary

The reduced glycerin formulation of TFV 1% gel was safe and acceptable and should move forward to Phase 2 development

The majority of mucosal safety signals were associated with the use of N-9

TFV 1% gel associated changes in gene expression require further evaluation

Key Issues Moving Forward

Determine whether gene array signals are important

Validation initial observations MTN-007 & Project Gel

Linked to hyperosmolar formulations: CHARM-01

Linked to tenofovir: MTN-017

Implications for vaginal microbicides

Acknowledgements

The MTN-007 study participants CONRAD MTN is funded by NIAID (5UM1AI068633),

NICHD and NIMH, all of the United States National Institutes of Health