Increases in CD4 Counts and Effects on HIV in Aviremic HIV-infected Subjects Infused with Zinc Finger Nuclease (ZFN) CCR5 Modified Autologous
CD4 T-cells (SB-728-T) and the use of Cytoxan prior to the infusion
Raul H. Morales-Borges, MDMedical Director
Puerto Rico Region, Biomedical ServicesAmerican Red Cross
For the ARC Medical Directors Meeting Sept. 12, 2012
Increases in CD4 Counts and Effects on HIV in Aviremic HIV-infected Subjects Infused with Zinc Finger Nuclease (ZFN) CCR5 Modified
Autologous CD4 T-cells (SB-728-T)
W Tang1, J Lalezari2, C June3, P Tebas3, D Stein4, R Mitsuyasu5, G Lee1, M Giedlin1, S Wang1 and D Ando1.
1Sangamo BioSciences Inc, Richmond, CA; 2Quest Clinical Research, San Francisco, CA; 3PENN, Philadelphia, PA; 4Albert Einstein College of Medicine, Bronx, NY; and 5UCLA, Los Angeles, CA
Disclosure• No conflicts of interest to disclose
Jay Lalezari, MD – Quest Clinical Research, San Francisco, CA Carl June, MD – University of Pennsylvania, Philadelphia, PN Pablo Tebas, MD - University of Pennsylvania, Philadelphia, PN David Stein, MD – Albert Einstein College of Medicine, Bronx, NY Ronald Mitsuyasu, MD – UCLA David Geffen School of Medicine, LA, CA
• The following individuals are employees of Sangamo BioSciences Shelley Wang, MD Gary Lee, PhD Martin Giedlin, PhD Winson Tang, MD Dale Ando, MD
Why Target CCR5 ?
• HIV (R5 virus) targets CD4 T-cell by binding to CCR5, one of the major co-receptor for HIV entry
• CCR5 delta-32 mutation produces a nonfunctional protein― Homozygotes are resistant to HIV infection ― Heterozygotes have slower disease progression
• The “Berlin Patient” is HIV-free w/o HAART for 3.5 years following hematopoietic stem cell transplant (HSC) from an allogeneic, HLA matched, CCR5 delta-32 homozygous donor
• Zinc Finger Nuclease technology enables the precise disruption of the CCR5 gene
• The therapeutic potential of CCR5 modification as seen with natural mutations and the Berlin Patient can be extended with ZFN disruption of autologous CD4+ T cells (SB-728-T) in any HIV subject
CCR5 ZFN modification
Site 165
D32 mutation
Targeting CCR5 with a ZFN
04/12/2023 5
Phase 1 SB-728-T Study Design
• Study Design: Open label, single dose studies- University of Pennsylvania/Albert Einstein College of Medicine- Quest Clinical Research/University California at Los Angeles
• Study population: Aviremic HIV subjects on HAART- Immune Responders (CD4 >450 cells/uL): n=6- Immune Nonresponders (CD4 <500 cells/uL): n=15
• Single infusion of 0.5 - 3.0 x 1010 SB-728-T • Study duration: 9-12 months• Study Endpoints
- Safety and Tolerability- Change in CD4 count and CD4/CD8 ratio- Persistence and trafficking of SB-728-T to lymphoid tissue- Change in HIV-RNA during HAART (Highly Active Antiretroviral Therapy)
treatment interruption in Immune Responders (n=6)
04/12/2023 6
Subject CharacteristicsImmune
Responders(n=6)
Immune Nonresponders
(n=15)
Age (mean + SD) 46.5 + 9.8 48.0 + 6.9
Gender 6 male 13 Male/2 Female
Ethnicity 4 Cauc/1 Asian/1 Black 8 Cauc/3 Hisp/3 Black/1 American Indian
Years HIV Infection mean median
11.8 + 10.111.8 + 9.2
17.5 + 7.218.0 + 5.1
CD4 mean median
921 + 222974 + 159
335 + 89357 + 73
CD4/CD8 mean median
1.4 + 0.61.4 + 0.5
0.7 + 0.30.7 + 0.2
04/12/2023 7
G T C A T C C T C A T C C T G A T A A A C T G C A A A A GC A G T A G G A G T A G G A C T A T T T G A C G T T T T C
SBS8267
SBS8196z
G T C A T C C T C A T C C T G A T A A A C T G C A A A A GC A G T A G G A G T A G G A C T A T T T G A C G T T T T C
SBS8267
SBS8196z
G T C A T C C T C A T C C T G A T A A A C T G C A A A A GC A G T A G G A G T A G G A C T A T T T G A C G T T T T C
SBS8267
SBS8196z
SB-728 Plasmid transfected intoAd5/35 chimeric vector
pVAX-SB-7285016 bp
KanR
BGH polyA
CMV promoterpUC ori
8267-FokEL (ZFN1)
8196z-FokKK (ZFN2)
2A peptide
Avr II (1805)
Bgl II (1739)
Eco RI (740)
Xho I (2804)
Bam HI (1145)
Bam HI (2204)
Kpn I (791)
Kpn I (1853)
ApheresisEnrich CD4+
SB-728
ExpandCryopreserve
Test cell product(SB-728-T)
Infuse
13-36% R5 disruption
SB-728-T Treatment Concept Autologous CCR5 Modified CD4+ T-cells
04/12/2023 8
SB-728-T Infusion is Safe and Well Tolerated
• Serious Adverse Events: One SAE (transfusion reaction) reported to date with a mean follow up duration of 325 days (range: 90-738 days)
• Adverse Events: 176 AEs – 120 mild severity, 55 moderate severity, 1 severe – 96 were related to study drug– 80 occurred within 24 hrs of study drug infusion and
included chills, fever, headache, hyperhidrosis, dizziness, fatigue, and abnormal garlic body odor
– No apparent relationship to dose of SB-728-T– All AEs were reversible and resolved without sequelae
04/12/2023 9
0 30 60 90 120 150 180 210 240 270 300 330 360-500
0
500
1000
1500
2000
Immune Non-Responders (N=15)
Immune Responders (N=6)
Days
Chan
ge in
CD
4 Co
unt f
rom
Bas
elin
e
Median ± SE
SB-728-T Increases CD4+ T-cell Counts
04/12/2023 10
0 30 60 90 120 150 180 210 240 270 300 330 3600.5
1.0
1.5
2.0
2.5
3.0
3.5
Immune Non-Responders (N=15)
Immune Responders (N=6)
Days
CD4:
CD8
Median ± SE
SB-728-T Normalizes CD4:CD8 T-cell Ratio in Majority of Study Subjects
04/12/2023 11
0 30 60 90 120 150 180 210 240 270 300 330 3600
10000
20000
30000
40000
50000
Immune Non-Responders (N=15)
Immune Responders (N=6)
Days
Pent
amer
Dup
licati
on p
er m
ill. C
D4
Cells
Median ± SE
SB-728-T is Detected in the Peripheral Blood for One Year and Beyond
04/12/2023 12
SB-728-T Traffics to the Rectal Mucosa
Time
Pe
rce
nt
CC
R5
Dis
rup
tio
n i
n M
uc
os
al
CD
4
0
10
20
30
40
50
60
70
N=19 N=11 N=12 N=9 N=3
Outliers
Median
Mean
75 %
25 %
Std. Error
04/12/2023 13
Asymptomatic Rectal Inflammation
0
50
100
150
200
250
Base
line
Day
14
Mon
th 3
Mon
th 6
Mon
th 1
2
Cell
Cou
nt p
er 1
0 Cr
ypts
Lymphocytes Plasma cells IEL
Time Grade* (Inflammation)
Baseline 0Day 14 0
Month 3 1.27Month 6 0.7
Month 12 0.67
6 MonthsBaseline
12 Months
SB-728-T Traffics to Rectal MucosaDuring Inflammation
04/12/2023 15
Baseline Day 14 Month 3 Month 6 Month 120
10
20
30
40
50
60
CD38/HLA-DR + CD4
CD38/HLA-DR + CD8
CCR5 Disruption in Mucosal CD4
% o
f Cel
ls
HIV-RNA Decreases during HAART Interruption in Immune Responders
04/12/2023 16
Days
0 28 56 84 112 140 168 196 224 252
Vir
al
loa
d (
Co
pie
s/m
L)
101
102
103
104
105
106
LOD
His
tori
cal
Vir
al
Se
tpo
int
(Co
pie
s/m
L)
102
103
104
105
106
PENN
201203204205 *251253
Treatment Interruption
*CCR5 - 32 Heterozygote
Dotted line denotes reinstitution of HAART
Subject 251 was excluded from the analysis due to a dual tropic HIV Infection
Estimated Biallelic CCR5 Modified T-Cells at the end of Treatment Interruption
0 5 10 15 20
Log
Vira
l Loa
d at
End
of
Tre
atm
ent I
nter
rupt
ion
(Cop
ies/
mL)
1
2
3
4
5
6
7
32 Heterozygote
rs = -0.71, P Value = <0.0001
Estimated Biallelic CCR5 Modified T-CellsDuring Treatment Interruption (% of CD4 Cells)
0 5 10 15 20
Log
Vira
l Loa
d-Ar
ea U
nder
Cur
ve
Dur
ing
Trea
tmen
t Int
erru
ptio
n (C
opie
s/m
L/Ti
me)
1
2
3
4
5
6
7
201203204205 *253
PENN
rs = -0.39, P Value = 0.036
32 Heterozygote
Control of HIV-RNA Correlates Significantly with Estimated Biallelic CCR5 Modification
04/12/2023 17
SB-728-T Summary
• Infusion of SB-728-T:– Safe and well-tolerated– Durable increases in total CD4 T-cells; normalization of CD4:CD8 ratio– Engrafts, expands, persists (>1 yr) in blood and lymphoid tissues– Traffic to lymphoid tissues during inflammation– May reduce HIV-RNA during HAART interruption in subjects with CD4 >450
cells/mm3
HIV-RNA in a Δ32 heterozygous subject became undetectable Biallelic CCR5 modification correlates with HIV-RNA suppression
04/12/2023 18
SB-728-TConclusion and Next Steps• Data from these two Phase 1 studies are promising and warrants
further evaluation
• Further clinical development of SB-728-T will aim to maximize patient exposure to CCR5 modified CD4 T-cells in two ongoing clinical trials:
– Treatment of CCR5 Δ32 heterozygous patients – Use of lymphopenic conditioning regimens to increase in vivo expansion of CCR5
modified CD4 T-cells
04/12/2023 19
SB-728-1101 Study Design• Phase 1, open-label, dose-escalation, multi-center study
• Nine subjects will be enrolled into 3 cyclophosphamide dose escalating cohorts (3 subjects/cohort) Cohort 1: Intravenous cyclophosphamide 200 mg Cohort 2: Intravenous cyclophosphamide .5 g/m2
Cohort 3: Intravenous cyclophosphamide 1.0 g/m2
A Safety Monitoring Committee will evaluate safety data and determine if it is safe to dose escalate.
• SB-728-T (0.5 to 3.0 x 1010 SB-728-T cells) will be infused one day after cyclophosphamide
• 16 week Treatment Interruption (TI) will begin 6 weeks after infusion of SB-728-T – Subjects who are aviremic and have CD4 ≥500 cells/µL
• Subjects will be followed for 12 months after the infusion
Cytoxan prior to SB-728 infusion study now open SB-728-1101 (7 sites)
• Within each cohort, treatment will be staggered so that each subsequent subject cannot be infused with Cytoxan until at least 2 weeks after the preceding subject. One day after receiving Cytoxan, subjects will be infused with SB-728-T (5 to 30 billion cells). Six weeks after SB-728-T infusion, subjects with CD4 cell counts >500 cells/mm3 will undergo a 16 week TI during which time their anti-retroviral therapy will be discontinued.
• Now we can see from cinicaltrials. gov that 18 subjects will be treated:• Estimated Enrollment: 18• Study Start Date: December 2011• Estimated Study Completion Date: December 2013• Estimated Primary Completion Date: January 2013 (Final data collection
date for primary outcome measure)• 18 people are scheduled to be treated. That should at least mean that they are
not having any safety concerns so far, one would assume. For me this is more confirming that everything is going well and they have "expanded" the trial.
Experience in Puerto Rico
• We got involved in planning to bring this study to ARC since last year in communication with Dr. Javier Morales-Ramirez (Infectious disease and AIDS Specialist from PR) and Clinical Research Puerto Rico, Inc. (CRPR).
• One patient enrolled successfully. He is a 34-years-old-male with Ht of 5’10” and Wt of 160 #. Normal labs including CBC. His prior anti-retroviral therapy includes:– Reyataz 05/27/09 – 12/20/10– Norvir 05/27/09 – 12/20/10– Truvada 05/27/09 – 12/20/10– Complera12/21/10 – to the present
• Leukapheresis done successfully by ARC Staff from Clinical Services using the Cobe Spectra machine; Collected on 07/09/12; and the procedure last 2 ½ hours. They used peripheral veins: right arm for collection and left arm for return. They processed 10,006 ml, with ACDA 16 ml, and the total volume collected and sent to Sangamo was 113 ml. Patient was hemodynamically stable all time. CRPR are waiting for the product to be infused to the patient. They have 2 possible candidates for the study under screening evaluation.
Acknowledgement by Puerto Rico Site
• Sangamo BioSciences, Inc – Donna Bednarski, Sr., CRA
• American Red Cross, Puerto Rico Region– Gladys Colon, Manager of Apheresis & Clinical Services– Maria Rodriguez, Clinical Service Supervisor and Compliance Coordinator – Rosa Vargas, Clinical Service Nurse Supervisor
• Clinical Research Puerto Rico, Inc. – Dr. Javier Morales Ramirez, Infectious Disease (PI of the Study in PR)– Helvetia Negron Gelabert, CEO– Monica Rodriguez-Melendez, Regulatory Officer
University of Pennsylvania
Albert Einstein College of MedDavid Stein, MDAngelo Seda
Carl June, MDPablo Tebas, MDGabriela Plesa, PhD
Sangamo BioSciences Dale Ando, MDWinson Tang, MDShelley Wang, MDMarty Giedlin, PhDGary Lee, PhDShirley CliftTravis WoodBaolu Chen, PhDKaye Spratt, PhDRichard Surosky, PhDMichael Holmes, PhDPhilip Gregory, PhD
Quest Clinical ResearchJay Lalezari, MDPriscila-Grace Gonzaga
University California, Los AngelesRonald Mitsuyasu, MD
University California, San FranciscoSteven Deeks, MD
National Institute of Health Sarah Read, MD, MHS Sandra Bridges, PhD Frosso Voulgaropoulou, PhD
Acknowledgements by Sangamo
04/12/2023 24