Adeno-associated viral vector-mediated transfer of DNA coding for broadly neutralizing anti-HIV antibodies (bnAbs) offers an alternative to attempting to induce protection by vaccination or by repeated infusions of bnAbs. In this study, we administered a recombinant bicistronic adeno-associated virus (AAV8) vector coding for both the light and heavy chains of the potent broadly neutralizing HIV-1 antibody VRC07 (AAV8-VRC07) to eight adults living with HIV. All participants remained on effective anti-retroviral therapy (viral load (VL) <50 copies per milliliter) throughout this phase 1, dose-escalation clinical trial (NCT03374202). AAV8-VRC07 was given at doses of 5 × 1010, 5 × 1011 and 2.5 × 1012 vector genomes per kilogram by intramuscular (IM) injection. Primary endpoints of this study were to assess the safety and tolerability of AAV8-VRC07; to determine the pharmacokinetics and immunogenicity of in vivo VRC07 production; and to describe the immune response directed against AAV8-VRC07 vector and its products. Secondary endpoints were to assess the clinical effects of AAV8-VRC07 on CD4 T cell count and VL and to assess the persistence of VRC07 produced in participants. In this cohort, IM injection of AAV8-VRC07 was safe and well tolerated. No clinically significant change in CD4 T cell count or VL occurred during the 1–3 years of follow-up reported here. In participants who received AAV8-VRC07, concentrations of VRC07 were increased 6 weeks (P = 0.008) and 52 weeks (P = 0.016) after IM injection of the product. All eight individuals produced measurable amounts of serum VRC07, with maximal VRC07 concentrations >1 µg ml−1 in three individuals. In four individuals, VRC07 serum concentrations remained stable near maximal concentration for up to 3 years of follow-up. In exploratory analyses, neutralizing activity of in vivo produced VRC07 was similar to that of in vitro produced VRC07. Three of eight participants showed a non-idiotypic anti-drug antibody (ADA) response directed against the Fab portion of VRC07. This ADA response appeared to decrease the production of serum VRC07 in two of these three participants. These data represent a proof of concept that adeno-associated viral vectors can durably produce biologically active, difficult-to-induce bnAbs in vivo, which could add valuable new tools to the fight against infectious diseases.
This is a preview of subscription content, access via your institution
Open Access articles citing this article.
Immunogenicity of Recombinant Adeno-Associated Virus (AAV) Vectors for Gene Transfer
BioDrugs Open Access 02 March 2023
Access Nature and 54 other Nature Portfolio journals
Get Nature+, our best-value online-access subscription
$29.99 per month
cancel any time
Subscribe to this journal
Receive 12 print issues and online access
$189.00 per year
only $15.75 per issue
Rent or buy this article
Get just this article for as long as you need it
Prices may be subject to local taxes which are calculated during checkout
Data generated in this study, including the study protocol, statistical analysis plan and informed consent form, will be available as de-identified data on ClinicalTrials.gov (NCT03186781) within 1 year from the primary completion date of the study. Individual de-identified participant data that underlie the results reported in this article are available, after de-identification, in the Supplementary Information section immediately after publication with no end date. Requests for additional data or materials will be promptly reviewed by the corresponding author (J.C.) to determine if these are subject to intellectual property, confidentiality or ethical obligations. Any data and materials that can be shared will be released via a material transfer agreement. Personal data underlying this article cannot be shared publicly as they are sensitive. Inquiries regarding data or material availability should be directed to email@example.com.
Fuchs, S. P. & Desrosiers, R. C. Promise and problems associated with the use of recombinant AAV for the delivery of anti-HIV antibodies. Mol. Ther. Methods Clin. Dev. 3, 16068 (2016).
Rerks-Ngarm, S. et al. Vaccination with ALVAC and AIDSVAX to prevent HIV-1 infection in Thailand. N. Engl. J. Med. 361, 2209–2220 (2009).
Gift, S. K., Leaman, D. P., Zhang, L., Kim, A. S. & Zwick, M. B. Functional stability of HIV-1 envelope trimer affects accessibility to broadly neutralizing antibodies at its apex. J. Virol. 91, e01216–17 (2017).
Torrents de la Pena, A. et al. Improving the immunogenicity of native-like HIV-1 envelope trimers by hyperstabilization. Cell Rep. 20, 1805–1817 (2017).
Klein, J. S. & Bjorkman, P. J. Few and far between: how HIV may be evading antibody avidity. PLoS Pathog. 6, e1000908 (2010).
Schiller, J. & Chackerian, B. Why HIV virions have low numbers of envelope spikes: implications for vaccine development. PLoS Pathog. 10, e1004254 (2014).
Burton, D. R. & Mascola, J. R. Antibody responses to envelope glycoproteins in HIV-1 infection. Nat. Immunol. 16, 571–576 (2015).
Pancera, M. et al. Structural basis for diverse N-glycan recognition by HIV-1-neutralizing V1–V2-directed antibody PG16. Nat. Struct. Mol. Biol. 20, 804–813 (2013).
Wei, X. et al. Antibody neutralization and escape by HIV-1. Nature 422, 307–312 (2003).
Hartley, O., Klasse, P. J., Sattentau, Q. J. & Moore, J. P. V3: HIV’s switch-hitter. AIDS Res Hum. Retroviruses 21, 171–189 (2005).
Bonsignori, M. et al. Antibody-virus co-evolution in HIV infection: paths for HIV vaccine development. Immunol. Rev. 275, 145–160 (2017).
Korber, B. et al. Evolutionary and immunological implications of contemporary HIV-1 variation. Br. Med. Bull. 58, 19–42 (2001).
Huang, J. et al. Identification of a CD4-binding-site antibody to HIV that evolved near-pan neutralization breadth. Immunity 45, 1108–1121 (2016).
Huang, J. et al. Broad and potent neutralization of HIV-1 by a gp41-specific human antibody. Nature 491, 406–412 (2012).
Mouquet, H. et al. Complex-type N-glycan recognition by potent broadly neutralizing HIV antibodies. Proc. Natl Acad. Sci. USA 109, E3268–3277 (2012).
Sok, D. et al. Recombinant HIV envelope trimer selects for quaternary-dependent antibodies targeting the trimer apex. Proc. Natl Acad. Sci. USA 111, 17624–17629 (2014).
Wu, X. HIV broadly neutralizing antibodies: VRC01 and beyond. Adv. Exp. Med. Biol. 1075, 53–72 (2018).
Liu, J. et al. Antibody-mediated protection against SHIV challenge includes systemic clearance of distal virus. Science 353, 1045–1049 (2016).
Mascola, J. R. et al. Protection of macaques against pathogenic simian/human immunodeficiency virus 89.6PD by passive transfer of neutralizing antibodies. J. Virol. 73, 4009–4018 (1999).
Rudicell, R. S. et al. Enhanced potency of a broadly neutralizing HIV-1 antibody in vitro improves protection against lentiviral infection in vivo. J. Virol. 88, 12669–12682 (2014).
Saunders, K. O. et al. Sustained delivery of a broadly neutralizing antibody in nonhuman primates confers long-term protection against simian/human immunodeficiency virus infection. J. Virol. 89, 5895–5903 (2015).
Caskey, M. et al. Viraemia suppressed in HIV-1-infected humans by broadly neutralizing antibody 3BNC117. Nature 522, 487–491 (2015).
Lynch, R. M. et al. Virologic effects of broadly neutralizing antibody VRC01 administration during chronic HIV-1 infection. Sci. Transl. Med. 7, 319ra206 (2015).
Mendoza, P. et al. Combination therapy with anti-HIV-1 antibodies maintains viral suppression. Nature 561, 479–484 (2018).
Burton, D. R. & Hangartner, L. Broadly neutralizing antibodies to HIV and their role in vaccine design. Annu Rev. Immunol. 34, 635–659 (2016).
Kwong, P. D., Mascola, J. R. & Nabel, G. J. Rational design of vaccines to elicit broadly neutralizing antibodies to HIV-1. Cold Spring Harb. Perspect. Med. 1, a007278 (2011).
Balazs, A. B. et al. Antibody-based protection against HIV infection by vectored immunoprophylaxis. Nature 481, 81–84 (2011).
Johnson, P. R. et al. Vector-mediated gene transfer engenders long-lived neutralizing activity and protection against SIV infection in monkeys. Nat. Med. 15, 901–906 (2009).
Sharon, D. & Kamen, A. Advancements in the design and scalable production of viral gene transfer vectors. Biotechnol. Bioeng. 115, 25–40 (2018).
Daya, S. & Berns, K. I. Gene therapy using adeno-associated virus vectors. Clin. Microbiol. Rev. 21, 583–593 (2008).
Duan, D. et al. Circular intermediates of recombinant adeno-associated virus have defined structural characteristics responsible for long-term episomal persistence in muscle tissue. J. Virol. 72, 8568–8577 (1998).
Nowrouzi, A. et al. Integration frequency and intermolecular recombination of rAAV vectors in non-human primate skeletal muscle and liver. Mol. Ther. 20, 1177–1186 (2012).
Penaud-Budloo, M. et al. Adeno-associated virus vector genomes persist as episomal chromatin in primate muscle. J. Virol. 82, 7875–7885 (2008).
Brady, J. M., Baltimore, D. & Balazs, A. B. Antibody gene transfer with adeno-associated viral vectors as a method for HIV prevention. Immunol. Rev. 275, 324–333 (2017).
Schnepp, B. C. & Johnson, P. R. Adeno-associated virus delivery of broadly neutralizing antibodies. Curr. Opin. HIV AIDS 9, 250–256 (2014).
Calcedo, R., Vandenberghe, L. H., Gao, G., Lin, J. & Wilson, J. M. Worldwide epidemiology of neutralizing antibodies to adeno-associated viruses. J. Infect. Dis. 199, 381–390 (2009).
Srivastava, A. In vivo tissue-tropism of adeno-associated viral vectors. Curr. Opin. Virol. 21, 75–80 (2016).
Balazs, A. B. et al. Vectored immunoprophylaxis protects humanized mice from mucosal HIV transmission. Nat. Med. 20, 296–300 (2014).
Saunders, K. O. et al. Broadly neutralizing human immunodeficiency virus type 1 antibody gene transfer protects nonhuman primates from mucosal simian-human immunodeficiency virus infection. J. Virol. 89, 8334–8345 (2015).
Welles, H. C. et al. Vectored delivery of anti-SIV envelope targeting mAb via AAV8 protects rhesus macaques from repeated limiting dose intrarectal swarm SIVsmE660 challenge. PLoS Pathog. 14, e1007395 (2018).
Martinez-Navio, J. M. et al. Adeno-associated virus delivery of anti-HIV monoclonal antibodies can drive long-term virologic suppression. Immunity 50, 567–575 e565 (2019).
Priddy, F. H. et al. Adeno-associated virus vectored immunoprophylaxis to prevent HIV in healthy adults: a phase 1 randomised controlled trial. Lancet HIV 6, e230–e239 (2019).
Szymczak, A. L. et al. Correction of multi-gene deficiency in vivo using a single ‘self-cleaving’ 2A peptide-based retroviral vector. Nat. Biotechnol. 22, 589–594 (2004).
Manno, C. S. et al. Successful transduction of liver in hemophilia by AAV-Factor IX and limitations imposed by the host immune response. Nat. Med. 12, 342–347 (2006).
Rangarajan, S. et al. AAV5-Factor VIII gene transfer in severe hemophilia A. N. Engl. J. Med. 377, 2519–2530 (2017).
Jefferis, R. & Lefranc, M. P. Human immunoglobulin allotypes: possible implications for immunogenicity. MAbs 1, 332–338 (2009).
Ledgerwood, J. E. et al. Safety, pharmacokinetics and neutralization of the broadly neutralizing HIV-1 human monoclonal antibody VRC01 in healthy adults. Clin. Exp. Immunol. 182, 289–301 (2015).
Sarzotti-Kelsoe, M. et al. Optimization and validation of the TZM-bl assay for standardized assessments of neutralizing antibodies against HIV-1. J. Immunol. Methods 409, 131–146 (2014).
Nathwani, A. C. et al. Long-term safety and efficacy of Factor IX gene therapy in hemophilia B. N. Engl. J. Med. 371, 1994–2004 (2014).
Lisowski, L., Tay, S. S. & Alexander, I. E. Adeno-associated virus serotypes for gene therapeutics. Curr. Opin. Pharm. 24, 59–67 (2015).
Fuchs, S. P. et al. AAV-delivered antibody mediates significant protective effects against SIVmac239 challenge in the absence of neutralizing activity. PLoS Pathog. 11, e1005090 (2015).
Fuchs, S. P., Martinez-Navio, J. M., Rakasz, E. G., Gao, G. & Desrosiers, R. C. Liver-directed but not muscle-directed AAV-antibody gene transfer limits humoral immune responses in rhesus monkeys. Mol. Ther. Methods Clin. Dev. 16, 94–102 (2020).
Bar, K. J. et al. Effect of HIV antibody VRC01 on viral rebound after treatment interruption. N. Engl. J. Med. 375, 2037–2050 (2016).
Cale, E. M. et al. Neutralizing antibody VRC01 failed to select for HIV-1 mutations upon viral rebound. J. Clin. Invest. 130, 3299–3304 (2020).
Crowell, T. A. et al. Safety and efficacy of VRC01 broadly neutralising antibodies in adults with acutely treated HIV (RV397): a phase 2, randomised, double-blind, placebo-controlled trial. Lancet HIV 6, e297–e306 (2019).
Cunningham, C. K. et al. Safety, tolerability, and pharmacokinetics of the broadly neutralizing human immunodeficiency virus (HIV)-1 monoclonal antibody VRC01 in HIV-exposed newborn infants. J. Infect. Dis. 222, 628–636 (2020).
Riddler, S. A. et al. Randomized clinical trial to assess the impact of the broadly neutralizing HIV-1 monoclonal antibody VRC01 on HIV-1 persistence in individuals on effective ART. Open Forum Infect. Dis. 5, ofy242 (2018).
Gaudinski, M. R. et al. Safety and pharmacokinetics of the Fc-modified HIV-1 human monoclonal antibody VRC01LS: a phase 1 open-label clinical trial in healthy adults. PLoS Med. 15, e1002493 (2018).
Gaudinski, M. R. et al. Safety and pharmacokinetics of broadly neutralising human monoclonal antibody VRC07-523LS in healthy adults: a phase 1 dose-escalation clinical trial. Lancet HIV 6, e667–e679 (2019).
Caskey, M. et al. Antibody 10-1074 suppresses viremia in HIV-1-infected individuals. Nat. Med. 23, 185–191 (2017).
Fang, J. et al. Stable antibody expression at therapeutic levels using the 2A peptide. Nat. Biotechnol. 23, 584–590 (2005).
Zhou, T. et al. Multidonor analysis reveals structural elements, genetic determinants, and maturation pathway for HIV-1 neutralization by VRC01-class antibodies. Immunity 39, 245–258 (2013).
Fang, J. et al. An antibody delivery system for regulated expression of therapeutic levels of monoclonal antibodies in vivo. Mol. Ther. 15, 1153–1159 (2007).
Schambach, A. et al. Woodchuck hepatitis virus post-transcriptional regulatory element deleted from X protein and promoter sequences enhances retroviral vector titer and expression. Gene Ther. 13, 641–645 (2006).
Casazza, J. P. et al. Therapeutic vaccination expands and improves the function of the HIV-specific memory T-cell repertoire. J. Infect. Dis. 207, 1829–1840 (2013).
Prabhakaran, M. et al. A sensitive method to quantify HIV-1 antibodies in mucosal samples. J. Immunol. Methods 491, 112995 (2021).
Seaman, M. S. et al. Optimization and qualification of a functional anti-drug antibody assay for HIV-1 bnAbs. J. Immunol. Methods 479, 112736 (2020).
Pandey, J. P. et al. Immunoglobulin genes and immunity to HSV1 in Alzheimer’s disease. J. Alzheimers Dis. 70, 917–924 (2019).
Schanfield, M. & van Logem, E. in Handbook of Experimental Immunology Vol. 94 (ed. Weir, D.) 1–18 (Blackwell, 1986).
We would like to acknowledge J. Gilly and C. Case of Science Applications International Corporation for their contributions to study product manufacturing as well as P. Johnson and F. Wright of Children’s Hospital of Philadelphia for providing critical AAV expertise. We thank R. Kothera for technical assistance in GM allotyping. We would like to thank our trial volunteers for their contribution and commitment to developing an effective clinical intervention for the prevention and control of HIV. This work was supported by intramural funding from the National Institute of Allergy and Infectious Diseases through the National Institutes of Health Intramural Research Program. A.B.B. is supported by National Institutes for Drug Abuse Avenir New Innovator Award DP2DA040254, the MGH Transformative Scholars Program as well as funding from the Charles H. Hood Foundation. J.P.P. received funding from Leidos Biomedical Research, Inc. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
A.B. and D.B. are named inventors on patent US9527904B2 held by the California Institute of Technology describing the vector used in this study. J.M. and G.N. are named inventors on patents US 61/568,520, 14/363,740 and 15/612,846 held by the National Institutes of Health describing the ex vivo production of VRC07. The remaining authors declare no competing interests.
Peer review information
Nature Medicine thanks Keith Jerome, Jialu Li, Jean-Pierre Routy and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. Alison Farrell was the primary editor on this article and managed its editorial process and peer review in collaboration with the rest of the editorial team.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplemental Tables 1–5 and Figs. 1–10.
Rights and permissions
About this article
Cite this article
Casazza, J.P., Cale, E.M., Narpala, S. et al. Safety and tolerability of AAV8 delivery of a broadly neutralizing antibody in adults living with HIV: a phase 1, dose-escalation trial. Nat Med 28, 1022–1030 (2022). https://doi.org/10.1038/s41591-022-01762-x