Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy 03/2010 M. Obermeier

Tropism testing from proviral DNA

Analysis of a subgroup from the Berlin Maraviroc cohort

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

HIV-1 Tropism

Macrophage CD4+ CCR5+

Primary T cell CD4+ CCR5+/CXCR4+

T-cell line CD4+ CXCR4+

R5 Virus StrainsM-tropic virusTransmission

R5/X4 Virus StrainsDual-tropic virus

X4 Virus StrainsT-tropic virusEmerge late

non-syncitia-inducing strains (NSI)

syncitia-inducing strains (SI)

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

geno2pheno[coreceptor]

Specificity = 1 - FPR

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Comparison of performance of genotypic tropism testing form viral RNA and proviral DNA

127 viremic patients

VL range 0.5*101 -1.6*106 cop./ml

47 samples were detected CXCR4- tropic using viral RNA

56 samples were detected CXCR4- tropic virus using proviral DNA

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Distribution of FPR in viral and proviral samples

Viral Proviral

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Distribution of CCR5-tropic and CXCR4-tropic detection in viral and proviral samples

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Bland-Altmann analysis of viral and proviral FPR

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Differences in FPR compared to viral load

1 2 3 4 5 6 7

-150

-100

-50

0

50

100

Viral

load

in log cop./ml

ΔFPR

gen

o2ph

eno[

core

cept

or]

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Comparison of Trofile® with geno2pheno[coreceptor] analysis of viral and proviral DNA of 101 samples

0%

10%

20%

30%

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90%

100%

trofile viral proviral

Trofile R5 g2p X4/X4Trofile R5 g2p X4/R5Trofile R5 g2p R5/X4Trofile R5 vir or pro g2p X4all R5Trofile X4 g2p R5/R5Trofile X4 g2p R5/X4Trofile X4 g2p X4/R5Trofile R5 vir or pro g2p R5all X4

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

The Berlin Maraviroc cohort

157 patients

Reasons for treatment change:

Virological failure

Adverse effects

Tropism Testing

141 (89%) had a genotypic tropism test

95 (60%) had only a genotypic tropism test

53 (32%) had only a genotypic tropism test from poviral DNA

70 (45%) had a Trofile® test (59 Standard Trofile® and 11 Trofile®-ES)

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Results (proviral)

FPR cut-off: 20%

49 patients CCR5

4 patients CXCR4

Baseline:

70% viral load <50 cop./ml

30% low level Virämie (<500 cop./ml)

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Maraviroc cohort FPR

02

46

810

1214

1618

2022

2426

2830

3234

3638

4042

4446

4850

5254

5658

6062

6466

6870

7274

7678

8082

8486

8890

9294

9698100

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FPR -g2p[coreceptor] false positive rate

Perc

ent C

XCR

4-tro

pic

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Results (proviral)

Week 12 (N= 49)

86% viral load <50 cop./ml

5 patients with virologic failure

1 patient with treatment change due to adverse effects

Week 24 (N=40)

80% viral load <50

4 patients with virologic failure (VL <1000 cop/ml)

1 patient with 60 cop/ml, without treatment change at week 48 below detection limit)

2 patients with treatment change due to adverse effects

Week 48 (N=19)

89% viral load <50 cop./ml

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Results (proviral)

0 12 24 480

10

20

30

40

50

60 >50 cop/ml<50 cop/ml change due to adverse-ef-fects<50 cop/mlNumber of patients

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Patient 153

38 years old, male

HIV diagnosis 1986, Risk MSM

Begin of first ART: 1998

ART-experience: 3TC, ABC, d4T, TDF, FTC, NVP, EFV, SQV, Lopinavir, Ritonavir (fulldose and booster), Darunavir

Last cART: TDF/FTC + NVP

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Patient 153

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HIV-load [cop/ml]CD4 cell count [/µl]

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Patient 153

No tropism testing from viral RNA possible

Tropism testing from proviral DNA: CCR5-tropic (FPR 31%)

Genotypic Resistance: No drug resistance associated mutations

Switch to MVC + RAL

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Patient 153

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HIV-load [cop/ml]CD4 cell count [/µl]

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Patient 153

Integrase-gene: N155H

CXCR4-Tropism detected from viral RNA (FPR: 0.1%)

But:

Patient 74: MVC +RAL

Proviral: CCR5 (25% FPR)

At Week 48 <50 cop/ml

MVC + RAL

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Treatment change in the cohort (proviral subgroup)

Number of drugs in cART

18 patients (34%) received less drugs than before

50 patients (51%) received the same amount of drugs

8 patients (15%) received more drugs

Maximal 8, Minimal 2, Median 3

45 % of the patients received Raltegravir (28% as new drug)

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

What about the CXCR4-tropic proviral results

1 patient with ABC,3TC, DRV/r, RAL + add-on MVC (FPR: 9%) had a viral load of 160 cop./ml at the time of MVC start and 250 cop./ml at week 12

3 other patients (FPR 1%, 16% and 20%) received additional DRV/r or Raltegravir and had a viral load <50 cop/ml at week 12

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Conclusions

Genotypic tropism testing using proviral DNA shows a higher rate of CXCR4 detection as compared to genotypic tropism testing using viral RNA. In combination with a high FPR-cutoff of 20% reasonable safety for the patients can be realized.

Patients from the Berlin Maraviroc cohort that were switched to Maraviroc based on proviral tropism testing showed a high rate of treatment success at weeks 12 and 24.

Due to low patient number harboring a virus with a FPR below 20%, it remains unclear at the moment if lower FPR-cutoff settings than 20% are also feasible.

Presented at the 8th European HIV Drug Resistance Workshop, March 17-19 2010, Sorrento, Italy

Acknowledgement

Physicians in Berlin: Andreas Carganico, Bernhard Bieniek, Christiane Cordes, Stephan Dupke, Klaus Fischer, M Freiwald, Jörg Gölz, Heribert Hillenbrand, Bettina Hintsche, Gerd Klausen, Siegfried Köppe, Peter Kreckel, Elke Lauenroth-Mai, Christoph Mayr, Arend Moll, Stefan Neifer, Daniel Prziwara9, M Rausch, Frank Schlote, Christoph Schuler, Wolfgang Schmidt, Dorothea Schleehauf, Dietmar Schranz, Thomas Wünsche, Axel Baumgarten

Laboratory: Thomas Berg, Stefan Neifer, Andreas Wienbreyer

Pfizer Germany for supporting the physicians in data collection