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Aging from Infection: Is there a Fountain of Youth?

Vincent Marconi, MD

Professor of Medicine and Global Health

Emory University School of Medicine

Rollins School of Public Health

Emory Vaccine Center

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Disclosure

At the time this presentation was given I had no real or perceived vested interests that related to this presentation nor did I have any relationships with pharmaceutical companies, biomedical device manufacturers, and/or other corporations whose products or services are related to pertinent therapeutic areas. I have received funding from ViiV, Merck, Gilead, Lilly, Optinosis, Pfizer, and Bayer.

Vincent Marconi

2

“If I could live my life over again, I would devote it to proving that germs seek their natural habitat – diseased tissue – rather than being the cause of diseased tissue. For example, mosquitoes seek stagnant water, but do not cause the pool to become stagnant” --- Rudolf Virchow 19^th Century

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Aging Conceptual Framework
Explore Holistic Interventions

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Outline

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Special thanks to the participants and staff from the Emory Clinical Sites

4

Grady Hospital

6,500 patients

Emory Midtown

2,100 patients

Atlanta VAMC

2,000 patients

HIV Clinics

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Do we live longer today than in the past?

Paleontological evidence shows same percentage of Neanderthals lived to various ages as modern humans
Mortality in the past due to infections and trauma
Life expectancy skewed by infant/childhood mortality (decreased due to vaccinations and clean water)
NCDs emerged but treatment extended survival

5

There is evidence that ancient peoples had similar proportions octogenarians, nonagenarians, and centenarians as modern people. Since the vast majority of deaths were attributed to infections and trauma, it is unclear to what extent non-communicable diseases played a role in the ancient world. As public health and hygiene improved living conditions especially eliminating infant and childhood mortality, life expectancy greatly improved. Subsequently, non-communicable diseases rose to replace infectious diseases as the major causes of death.

Proportions of each decade mostly unchanged as well as maximum lifespan
Infections/Trauma
1^st 100 years reduced mortality through Public health/hygiene especially infant/children
These public health advances (and lifestyle changes) uncovered NCDs which then were also improved with medicine further reducing mortality subsequent 100 years

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Lifespan versus Healthspan and Age-Related Diseases

6

Borras Mech Ageing Dev 2019

Atul Gawande “Being Mortal”

Atul introduced three models of aging and concepts of lifespan/healthspan from Claudio Franceschi to the general public
Fries thought in 1980 that modern medicine would rectangularize the curve to the right (increase lifespan while maintaining full healthspan)
Instead, medical advances led to a stepped model of chronic disease and the frailty phenotype
The same shift from infections to NCDs that happened over time, is also observed as countries transition from lower to higher GDP
Evidence that these advances did not necessarily improve lifespan/healthspan is shown by the US ranking for centernarians

In the award winning book “Being Mortal”, Atul Gawande tried to demonstrate two important concepts “lifespan vs healthspan”. The length of these curves on the x axis represents lifespan but the height on the y axis represents quality of life (healthspan). These three examples were adapted from the model of aging developed by Claudio Franceschi at the University of Bologna. He proposed varying aging trajectories depending on the individual: Rectangularization (Fries 1980), Stepped Model of Age-related diseases/NCD/comorbidities and finally Frailty phenotype. It has been well-documented that as countries shift to higher average incomes, the rate of communicable diseases decrease while NCD coincidentally increase. Increased wealth does not necessarily guarantee increased lifespan or healthspan as you can see the US (red arrow) is below average in its percent centenarians.

___________________________________________________________________________________________________________________________________________________

There may be a few models of delayed aging:

1. Right phase shift of morbidity onset (short delay) and lifespan maintaining proportional aging process (same rate) after shift

2. Right phase shift of morbidity onset (long delay) and lifespan but with compressed aging process (faster rate) after shift

3. Decelerated aging process (same morbidity onset)

Centenarian men, although generally scarce in number, tend to have better cognitive and physical functional status than centenarian women. In fact, it has been reported that centenarian men have lower morbidity and fewer geriatric syndromes than women (Hazra et al., 2015). In this regard, whereas compression of both morbidity and disability seems to be an essential feature of survival to an old age for most centenarians, for others, particularly men, compression of disability and not necessarily morbidity, may be the key prerequisite (Terry et al., 2008).

Aging and specifically the frailty phenotype is counterbalanced by the (a) intrinsic capacity and (b) resilience which both tend to decline before the frailty process begins.

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Improved Life Expectancy*, but Gap Persists: HIV vs. HIV-

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Marcus JAIDS, 2016 (see also: Legarth/Obel, JAIDS, 2016; Samji for NA-ACCORD, PLoS One, 2013)

Deaths per 100,000 person-yrs

Est. Years of Life Remaining

Gap only 6y if CD4 nadir >500 and no smoking, EtOH or hepatitis

12y gap

Gap ~20y if CD4 nadir <350

(Samji, PLoS One, 2013)

*For 20yr old

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Many age-associated comorbidities are

increased in treated HIV

Cardiovascular disease ^[1-3]
Cancer (non-AIDS)^[4]
Bone fractures/osteoporosis ^[5,6]
COPD ^[12]
Liver disease ^[7]
Kidney disease ^[8]
Cognitive decline ^[9]
Non-AIDS infections ^[10]
Frailty ^[11]

1. Freiberg, M., et al. JAMA Int Med. 2013;173(8):614-22. 2; Tseng, Z, et al. JACC. 2012;59(21):1891-6. 3. Grinspoon SK, et al. Circulation. 2008;118:198-210. 4. Silverberg, M., et al. AIDS, 2009;23(17):2337-45. 5. Triant V, et al. J Clin Endocrinol Metab. 2008;93:3499-3504. 6. Arnsten JH, et al. AIDS. 2007 ;21:617-623. 7. Odden MC, et al. Arch Intern Med. 2007;167:2213-2219. 8. Choi A, et al. AIDS, 2009;23(16):2143-49. 9. McCutchan JA, et a. AIDS. 2007 ;21:1109-1117. 10. Sogaard, CID, 2008; 47(10): 1345-53. 11. Desquilbet L, et al. J Gerontol A Biol Sci Med Sci. 2007;62:1279-1286; 12. Attia, Chest, 2014

Viruses (review). Zicari et al. 2019 Mar; 11(3):200.

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The Good and the Bad of Inflammation

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Medzhitov Nature 2008

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Inflammation Predicts Disease and Mortality in Treated HIV Infection

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Cardiovascular Disease (Duprez Atherosclerosis 2009)
Cancer (Breen Cancer Epi Bio Prev 2010; Borges AIDS 2013)
Venous Thromboembolism (Musselwhite AIDS 2011)
Type II Diabetes (Brown Diabetes Care 2010)
COPD (Attia Chest 2014)
Renal Disease (Gupta HIV Med 2015)
Bacterial Pneumonia (Bjerk PLoS One 2014)
Cognitive Dysfunction (Burdo AIDS 2013; Letendre CROI 2012)
Depression (Martinez JAIDS 2014)
Frailty (Erlandson JID 2013)
Mortality (Kuller PLoS Med 2008; Tien JAIDS 2010; Tenorio JID 2014; Hunt JID 2014)

Inflammation 🡪 Diseases 🡪 Mortality

Hunt JID 2014, Tenorio JID 2014, French AIDS 2015

Comorbidities: IL-6, D-Dimer, TNF-R1

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Inflammation is only part of the story

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Montano Lancet HL 2022

Medzhitov Nature 2008

Inflammation

Cellular Senescence

Macromolecular Damage

Stem Cell Exhaustion

Although inflammation is a cornerstone of aging, damage to macromolecules, cellular senescence and loss of stem cells are among the key pillars that contribute to tissue damage and dysfunction.

----------------In particular, the neuroendocrine

----------------and immune systems mediate and accelerate this process throughout the entire body.

______________________________________________________________________________________________________________________________________________________________________________

There is growing evidence that the CD8⁺CD28⁻ (CD8⁺CD57⁺) T-cell population plays a significant role in various diseases or conditions, associated with chronic immune activation such as cancer, chronic intracellular infections, chronic alcoholism, some chronic pulmonary diseases, autoimmune diseases, allogeneic transplantation, as well as has a great influence on age-related changes in the immune system status. CD8⁺CD28⁻ (CD8⁺CD57⁺) T-cell population is heterogeneous and composed of various functionally competing (cytotoxic and immunosuppressive) subsets thus the overall effect of CD8⁺CD28⁻ (CD8⁺CD57⁺) T-cell-mediated immunity depends on the predominance of a particular subset. Many articles claim that CD8⁺CD28⁻ (CD8⁺CD57⁺) T cells have lost their proliferative capacity during process of replicative senescence triggered by repeated antigenic stimulation. However recent data indicate that CD8⁺CD28⁻ (CD8⁺CD57⁺) T cells can transiently up-regulate telomerase activity and proliferate under certain stimulation conditions.

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Normal Stress Response

Visual

Auditory

Olfactory

Somatic

Gustatory

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The Stress Response Influences Immunity and Inflammation

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Cole Genome Biology 2007

Type I interferon antiviral response

Immunoglobulin G1 production

Inflammation

Conserved Transcriptional Response to Adversity (CTRA)

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Extreme Acute Stress

Chronic Stress

Social or Environmental Experience

CNS Interpretation

Neuroendocrine Function

Cell Signal Transduction

Transcription Factors

Protein Expression

Low SES

Social loss/bereavement

PTSD

Cancer Diagnosis

Social Threat

Loneliness

Social Instability

Chronic Stress

Low Social Rank

Caregiving for seriously Ill

Anxiety

Early life adversity

Through multiple similar studies, Cole et al demonstrated how

---------------------a social or environmental experience could have a dramatic impact on protein expression through neuroendocrine pathways. When stress was chronic, the antiviral genes were turned off and inflammatory genes turned on. When it was severe/acute, both pathways shut down.

-------------------It turns out that individuals with low SES, social loss, etc. maintain a chronic state of decreased CMI and persistent inflammation.

___________________________________________________________________________________________________________________________________________________________________________

Longstanding exercise results in decreased inflammation without the decrease in antiviral response. Acute exercise can cause increased inflammation and decreased antiviral response much like the chronic stress paradigm. However, this may depend on diet, glycogen stores, etc.

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Epigenetic Modification Can Be Durable

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Kanherkar Front Cell Dev Biol 2014

Change in birth outcomes among infants born to Latina mothers after a major immigration raid (Novak IJE 2017)

s

x

and Inflammation

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Nelson AIDS 2017

DNAm age “biological aging” for HIV+ 11.2 years greater than matched HIV- (pre-ART)
Most HIV+ approached HIV- levels after 9 years of ART; 2 increased in DNAm age
Methylated sites were associated with inflammatory genes
VPS37B significant: vesicular trafficking protein involved in HIV budding and transport

Yan Sun, PhD

HIV+ DNA Methylation Clock older and associated with Inflammatory Genes

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Results : Meta-analysis 450K and EPIC

We identified 118 DNAm sites significantly associated with sCD14 in the meta-analysis of 1,075 PWH.
The principal associated DNAm sites mapped to genes related to inflammation and antiviral response.
Adjusting for multiple testing, 10 of 118 sCD14-associated DNAm sites significantly predicted survival time conditional on sCD14 levels.

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QQ-Plot

Manhattan Plot

TOP 5 ASSOCIATED GENES

PARP9

STAT1

IFITM1

IFIT1

MX1

IFN-stimulated = Key roles

in antiviral an inflammatory

pathways

BK. Titanji, CROI 2021, Science Spotlight

Boghuma Titanji,

MD/PhD

Mathur JID 2019

Chen CID 2020

BX006008

Boghuma Titanji from our group has identified epigenetic associations with sCD14 (a marker of monocyte activation which is highly correlated with the gut pathology seen in HIV infection). The top 5 genes are IFN-stimulated genes (ISGs) related to inflammation, the antiviral response, and ultimately aging such as PARP9 (previously shown) and STAT1 which will be further discussed when we look at Jak inhibitors.

-----------We additionally found inflammatory genes upregulated via epigenetic mechanisms in type 2 DM

------------and renal disease.

-----------In the Million Veteran Program, we have been exploring the genetic and epigenetic relationships between viral infections and age-related diseases.

______________________________________________________________________________________________________________________________________________

It is remarkable that all top five genes identified in our sCD14 EWAS are IFN-stimulated genes. IFN-I blockade in conjunction with antiretroviral therapy has been suggested as a plausible approach for targeting the chronic immune activation associated with HIV infection. In an in-vivo mouse study, blockade of IFN-I signaling during chronic HIV-infection reduced immune activation, decreased expression of markers of T-cell exhaustion, restored HIV-specific CD8⁺ T- cell function and reduced viral replication²⁹. Our study strengthens the key role of the IFN-signaling pathway in sustaining chronic inflammation and immune activation during HIV infection.

Among the 118 significant DNAm sites from the meta-analysis, we conducted survival analysis using a Cox proportional-hazards model to analyze the association between survival time and DNA methylation level, adjusted for, age, BMI, smoking, VL, alcohol abuse, race/ethnicity, HBV, HCV, sCD14, and cell type proportions.

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Marconi JACI 2022

Immunologic Resilience

Sunil Ahuja MD

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IR and INR at the following time points:

One Pre-ART
2-3 Post-ART

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VL

INR

IR

CD4

ART

12 mos

Blood

Blood & LN

NIH/NIAID 1R01AI110334-01

Mirko Paiardini, PhD

24 mos

Central Memory T Cell Study:

Poor CD4 T cell recovery or “immune non responders (INR)”

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Predictive and Greater Pre-ART

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CD8

CD4

Pino/Marconi PLoS Path 2021

After ART

Before ART

INR is Associated with Immune Activation

Maria Pino, PhD

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CD4 Recovery Predicts End-Organ Disease

Sol Aldrete, MD

Aldrete PLoS ONE 2020

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INR/Inflammation is also Associated with HIV Persistence

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IL-7 IL-15

Pino/Marconi PLoS Path 2021

Christina Mallarino, MD

UM1 AI164561 UM1AI164562

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Montano Lancet HL 2022

Monty Montano PhD

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Deeks Immunity 2013

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Infections

Psychosocial

Neurocognitive Impairment

Cardiovascular Disease

Frailty/Arthritis

SARS-CoV-2

Influenza

HIV

Stigma/Discrimination

Poverty

Isolation

Toxins Food Drugs Radiation

Neuro-Endocrine-Immune-Microbiome

Oxidative Stress

Coagulopathy

Inflammation

Autoreactivity

Digestive Disease

Environmental

Autoimmune Disorders

Neuropathy

Interventions

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Ancient Humans

Modern Humans

Time

Threat Exposures?

Yes

No

Cole PLoS Genetics 2014

Inflammation

Immune

Competence

End-organ disease

Susceptible to infections

Autoimmune disorders

Less end-organ disease

Resistant to infections

Increased longevity

Goal

Ideally

Practically

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Interventions

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Fulop Clinical Interventions in Aging 2007

• Decreased sugar/salt

Aging Interventions

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Deeks Immunity 2013

Funderburg JAIDS 2015

Paiardini PLoS Path 2013

Micci JCI 2015

Marconi ACTG 5336

Henrich ACTG 5337

Current Anti-Inflammation Strategies

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Increased TNF-α, IL-1α/β, IL-6, IL-7, IL-15 which promote:

Activation of latently infected and bystander uninfected cells
Homeostatic proliferation and cell survival
Recruitment of uninfected cells to sites with infected cells
Trafficking activated infected monocytes via BBB
Immune exhaustion (CD4/8) and reduced control of the HIV-1 reservoir
Associated with increased end-organ disease

STAT binding sites HIV-1 LTR 🡪 HIV-1 transcription

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JAK-STAT signaling key mechanism for HIV disease

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Ruxolitinib-Janus Kinase (JAK) 1 and 2 inhibitor

FDA approved for myelofibrosis and PCV (5-25 mg BID)
43 clinical trials for MF, psoriasis, PCV, and rheumatoid arthritis*
Marked decrease in cytokines, especially IL-6**
Ruxolitinib is a potent inhibitor of HIV-1 replication AND reactivation of latent HIV-1 in primary human lymphocytes and macrophages (in vitro)***

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*Tam Expert Opin Invest Drugs 2013 **Verstovsek NEJM 2010 and 2012 ***Gavegnano PLoS Pathog 2017

for Myelofibrosis

Ray Schinazi, PhD

Christina Gavegnano, PhD

ACTG A5336 - Background and Rationale

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0.93

1.10

0.97

1.10

Rafick Sekaly, PhD

Marconi CID 2021

P= 0.18

P= 0.034

P= 0.11

Michael Lederman, MD

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-11

P = 0.007 at wk 2

P = 0.038

P = 0.001

P < 0.001

P = 0.26

P < 0.001

Ruxolitinib reduced key immune dysregulatory markers in CD4⁺ T-cells , including HLADR/CD38 and Bcl2, a key marker of cell survival

Very healthy patients with HIV were randomized to 5 weeks of a low dose of ruxolitinib while continuing their ART compared to ART alone. Rafick Sekaly and his team measured our plasma biomarkers using mesoscale (except for IL-6 which was done by high sensitivity ELISA). Interestingly, IL-6, sCD14 and TNFa decreased for the rux arm compared to the control arm but was significant for sCD14 only.

Michael Lederman and his group measured cell surface markers using flow cytometry. We saw significant increases in CD4 counts for the rux arm compared to the control arm. Additionally, we saw a significant decrease in HLADR/CD38+ CD4 cells (marker of immune activation not previously shown with any treatment aside from ART) and Bcl2 expression (cell survival) for ruxolitinib treated patients.

So in summary, this was the first time an anti-inflammatory agent was able to demonstrate a significant reduction in T cell activation, inflammation and cell survival of potentially infected cells. This was going to be followed up by additional studies with baricitinib because of its several advantages over ruxolitinib (dosing, PK, cost, etc.).

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n =40

n =20

Ruxolitinib markedly reduces the HIV reservoir (peripheral blood) across the top tertile of starting reservoir size at baseline (IPDA).

Duration of treatment is week 0-5, yet reservoir declines after treatment is withdrawn, through week 12.

Monica Reece

Deanna Kulpa PhD

Zhan Zhang

Reece IAS 2023

Christina Gavegnano’s team shown here measured the reservoir using the intact proviral DNA assay (or IPDA) which assesses the most relevant part of the HIV reservoir. This measure internally correlated well with independently measured intact DNA (R2 = 0.86). The data presented here are from the TOP TERTILE of baseline reservoir for each group because the remaining patients had low reservoir at baseline. Interestingly, we observed a significant decline in the reservoir AFTER the treatment was withdrawn at week 5. We are currently working through the biomarker panels that we have collected (>100 markers) to understand what may be driving the decline, how the immune system may have been reset to control the reservoir, and also to determine the key predictive biomarkers of “responders” to this treatment.

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RCT: n=64 PWH on suppressive ART

Baricitinib 2 mg daily versus placebo x 10 weeks
Primary outcome= CNS HIV persistence (HIV RNA and DNA in CSF)
Secondary outcomes= CSF IPDA, peripheral HIV persistence, CNS inflammation/imaging

Howard Pope

Ph: 404-616-9786

hpope@emory.edu

OR

Dr. William Tyor

Ph: 404-728-7609

wtyor@emory.edu

OR

Dr. Vincent Marconi

Ph: 404-616-0673

vcmarco@emory.edu

Bari CNS, Bari Depression and Bari CURE

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Baricitinib normalized cytokines implicated in COVID-19 including IL-6, IFN-γ, MCP-3, CXCL10, IL-10, MCP-2, CCL19, PTX3, and IL-27

These are involved in

myeloid dysregulation
endothelial and cardiovascular inflammation
reduced antigen presenting plasmacytoid dendritic cells

Sims et al. 2021

Confidential

�Mechanism of action: baricitinib normalizes dysregulated plasma markers in hospitalized patients with COVID-19 infection �

Similar mechanistic paradigm to HIV-1:

Just as we were finalizing the paper for that study, the initial reports about COVID-19 were emerging. It became clear to our team that the uncontrolled cytokine release syndrome driving morbidity and mortality in COVID could be reduced by anti-inflammatory/immune modulator therapies. Ray and I began discussing a study that could involve baricitinib when someone in his lab passed along this Lancet article by Stebbing et al showing an in silica study of thousands of anti-inflammatory therapies searching for the best candidates which might also affect SARS-CoV-2 replication. Baricitinib among all anti-inflammatory therapies studied was found to be the most potent having the potential ability to block several steps in the viral life cycle. Whether these specific mechanisms were going to be impactful or not was irrelevant to us as we believed its true value to be its ability to stop the inflammatory cascade in a mechanism similar to what was occurring on a less intense level in HIV infection.

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Treatment

Boghuma Titanji,

MD/PhD

Titanji CID 2020

After coming back from Boston in March, we began to have daily meetings at the VA to discuss our patients and what little we could do. I had additional discussions with Boghuma and Dr. Farley who were on service at that time. When one of these patients, a 42 relatively healthy male became desperately ill after a trip to New Orleans, the three of us decided to administer baricitinib off-label to him with his permission. As you can see here, we were pleased that he improved and ultimately weaned from ventilation and pressors transitioning to supplemental low-flow oxygen not knowing definitively whether the drug was having an impact. Encouraged by his recovery, baricitinib was given to an additional 14 patients hospitalized with COVID. We saw reductions in inflammatory biomarkers and clinical signs of severe/critical COVID. Nearly all patients recovered with the exception of those who requested DNR/DNI at the time of therapy.

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ACTT-2 and ACTT-4

2

Kalil NEJM 2021 Wolfe Lancet RM 2022

Ordinal 6

Andre Kalil, MD

4

John Beigel, MD

Cam Wolfe, MD

Thanks to Nadine, Aneesh and David Stephens, we were able to gain an audience with the ACTT team including a critical discussion with an old Air Force friend of mine Greg Deye. Because of the off-label data and Stebbing’s paper, baricitinib was selected among 60 other candidates to be the drug studied in ACTT2. In this trial comparing bari plus remdesivir vs placebo plus remdesivir, bari was found to significantly reduce the time to recovery with a rate ratio of 1.15 (8 to 7 days). Also, in pre-ventilated pts bari +rem vs rem significantly reduced mortality by 53%. In contrast, the subgroup of 110 ventilated patients bari did not show a mortality benefit.

There were only 61 deaths overall in ACTT2 where 4x as many would have been needed for sufficient power. Despite this, the trial almost reached significance overall (p=0.09) for mortality (35% reduction) compared to the 17% significant reduction for dex in RECOVERY. The KM curve shown here is for OS6 (high flow oxygen) which had the greatest impact for bari in ACTT2. Then in ACTT4, bari + rem was compared to dex 6 mg + rem with matching placebos. Bari was not superior (essentially equivalent but not an equivalency trial); however, there were more AE’s/SAE’s in the dex arm.

______________________________________________________________________________________________________________________________________________________________________________

In pre-ventilated pts bari+rem vs rem significantly reduced progression to vent or death: from 29.3% to 22.6%; p= 0.024, 22% relative risk reduction; dex had a numerical reduction but not significant trend to lower progression to vent or death– risk ratio 0.92 (not significant)

Compared to the open-label pragmatic RECOVERY trial with over 6,000 patients, dex reduced numerically (not significant) from 13 to 12 the time to recovery rate ratio 1.10. Also, in pre-ventilated pts bari +rem vs rem significantly reduced mortality by 53% compared to 18% for dex in RECOVERY (not significant). In contrast, the subgroup of ventilated patients where dex had its more pronounced effect, dex significantly reduced mortality by 36% whereas bari did not for the 110 patients in that arm. Only 61 deaths occurred overall in ACTT2 where 4x as many would have been needed for sufficient power. Despite this, the trial almost reached significance overall (p=0.09) for mortality (35% reduction) compared to the 17% significant reduction for dex in RECOVERY.

Again, not significant but the risk reduction in mortality (not vent+mortality) was 45% in OS 6 and 60% in OS5 compared to 18% in OS5/6 combined in RECOVERY.

In contrast, in the subgroup of ventilated pts where dex had its more pronounced effect, dex reduced mortality and bari did not while both seemed to improve % pts who could leave ventilator earlier.

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Treatment with bari when added to SoC significantly reduced 28-day all-cause mortality by 38%, compared to SoC

One additional death was prevented per 20 patients treated with baricitinib

Overall Population (ITT) (multiplicity-controlled)	Placebo+ SoC (N= 761 )	Baricitinib+SoC (N= 764 )	Effect Size (Bari% -Pbo%)
Proportion of patients died �(Day 1 to Day 28), n (%)	100 (13.1%)	62 (8.1%)	-5.0 %
HR (95% CI)^a Nominal p-value^b	0.57 (0.41, 0.78) p=0.0018

% are based on observed n’s.

^*aHR - the hazard ratio and 95% CIs were calculated using cox proportional hazard regression model adjusted for baseline disease severity (OS 4,

OS 5, OS 6), age (<65 years, >=65 years), region (United States, Europe, rest of world), and systemic corticosteroids used at baseline for primary

study condition (Yes/No).

^*bp-value was calculated from log-rank test.

Day 28 All-Cause Mortality

Marconi Lancet RM 2021

Ely Lancet RM 2022

Wes Ely, MD

Ordinal Scale 6

Ordinal Scale 7

Then in the largest placebo controlled COVID trial to date, COV-BARRIER, my co-chair Wes Ely from Vanderbilt and I examined the use of baricitinib with SOC (more than 85% receiving dex). Treatment with bari significantly reduced all-cause mortality at 28 and 60 days with a HR of 0.57 (NNT 20) but unfortunately the reduction of disease progression (the primary endpoint) did not quite reach stat signif.

------------------------The mortality reduction was even greater among patients in OS6 (stat sign HR 0.52)

------------------------and in a separate pilot study of OS7 the stat significant HR 0.56 with a NNT of 6.

____________________________________________________________________________________________________________________________________________________________________________________________

QCed:/lillyce/prd/ly3009104/i4v_mc_khaa/intrm1/output/restricted/tfl/t_evervent_itt_mi.rtf

CI = confidence interval; HR=hazard ratio; ITT= intention-to-treat; N = number of patients in the analysis population;

Data source: t_ttdie_itt.pdf; t_ttdie_km_itt.rtf

Note: All-cause mortality = death for any cause (including potentially related with COVID-19 and attributed to AEs)

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Baricitinib COVID-19 Indications

January 13, 2022

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Randomized Double-Blind Placebo-Controlled Trial EValuating Baricitinib on PERSistent NEurologic and Cardiopulmonary symptoms of Long COVID (REVERSE-LC)

To determine the impact of baricitinib versus placebo for 6 months in patients with LC on:

Neurocognitive performance and at 6 and 12 months
Exercise capacity (peak VO2) using cardiopulmonary exercise testing (CPET), functional status, and QoL at 6 and 12 months
Plasma biomarkers of inflammation and viral reservoirs at 6 and 12 months

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Gleeson M, 2011

S. Balducci Nut, Metab & CVD 2010

Sedentary controls

Low-intensity AEX

High-AEX

High-AEX + RT

Oursler MD

Effects of exercise on systemic inflammation

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Mod-AEX + RT in 89 HIV+ adults, mean age 48 yr¹

No change hsCRP (even stratified by compliance)
Modest change VO₂peak (2.2 mL/kg/min, p=0.07)

Mod-AEX +/- RT in 35 HIV+ adults, median age 48 yr²

Significant change hsCRP and biomarkers inflammation
30% receiving statins (at entry and during intervention)

Is high-intensity AEX/RT needed to improve VO₂peak, systemic inflammation and aging?

43

¹ SE Cutrono AIDS Behav 2016

² M Bonato BMC ID 2017

HAL MAYFORTH

Kris Ann Oursler, MD

Effects of exercise on �inflammation in younger HIV+

5I01RX000667

Alice Ryan, PhD

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Pace Psychoneuroendo 2009

Cognitively-Based Compassion Training (CBCT)

Eugene Farber, PhD

Thaddeus Pace, PhD

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CBCT increased psychological well-being and overall acceptance of their HIV illness in comparison to controls
Less VF in CBCT than control (9.7% vs 18.8%, NS)

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Self-reported Scale	Measurement	Control	Intervention	P-value
GWB score	Median (Q1, Q3) baseline score	76.5 (66, 85)	70 (53, 89)
	Median (Q1, Q3) change in score	0 (-6, 8)	+10 (1, 18)	0.023
ICQ Acceptance	Median (Q1, Q3) baseline score	19 (14, 22)	19 (15,21)
	Median (Q1, Q3) change in score	+1.5 (-1.5, 4)	+3 (1, 9)	0.041

Mehul Tejani MD

Results

Titanji JAIDS 2021

Boghuma Titanji,

MD/PhD

p=0.01 p=0.83

p=0.04 p=0.64

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Summary: CBCT Reverses Pro-Inflammatory Gene Expression in HIV Immune Non-Responders

TRANSCRIPTOMIC EVIDENCE | GSEA of PBMCs (n=28 INRs)

Fold change heatmaps: IL-1β (left) and TNFα (right). Blue = downregulated post-CBCT.

Study Population: Virologically suppressed HIV INRs (CD4 <350). Banked PBMCs from RCT (CBCT n=13, control n=15). RNA-seq + GSEA, 12 curated gene sets.

Convergent Signal: NLRP3, NLRC4, CASP1 downregulated across 3 independent pathway analyses. Controls show no consistent directional change. First GSEA-level evidence of CTRA reversal in PLWH.

MECHANISTIC PATHWAY | Stress → Immune Reprogramming

1 ↓ Adrenergic Signaling (upstream CTRA driver)

ADRA2A↑, PDE4D↑ — inhibitory feedback on SNS-immune axis; mechanistic link between stress reduction and NF-κB suppression

2 ↓ TLR/MYD88 Innate Sensing

TLR2/4/5/8↓, MYD88↓ — reduces chronic innate immune danger signal; upstream of inflammasome priming

3 ↓ NLRP3 Inflammasome (convergent across 3 gene sets) NLRP3↓, NLRC4↓, CASP1↓ — dampens IL-1β cleavage and pyroptosis; chronically activated in HIV INRs

KEY MESSAGE: CBCT produces broad, coherent suppression of the pro-inflammatory gene signature driving immune non-response in HIV — first GSEA-level transcriptomic evidence of CTRA reversal in virologically suppressed PLWH.

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47

Spirit

Mind

Body

Community/Family

Nature

Sleep

Meditate

Participate

Nourish

Breathe

Move

Boccaccio’s prescription for an epidemic was a good dose of “narrative prophylaxis”. That meant protecting yourself with stories. Boccaccio suggested you could save yourself by fleeing towns, surrounding yourself with pleasant company and telling amusing stories to keep spirits up...a mixture of…pleasant activities, it was possible to survive the worst days of an epidemic.

---The Decameron by Boccaccio, Florence in 1348

There is now a substantial and growing body of evidence for behavioral interventions that serve as geroprotectors including diet, exercise, meditation and community engagement.

----------------Perhaps it is no wonder that Giovanni Boccaccio recommended many of these interventions during the plague in 1348 Florence.

______________________________________________________________________________________________________________________________________________________________________________

Diet – what goes in your body, becomes your body; follow trophology

Avoid harmful substances – alcohol, tobacco, caffeine, drugs

Avoid processed foods – additives, preservatives, flavors, canned/frozen, restaurants

Avoid sugar and salt

Fast weekly

Eat whole/multi-grains and toast bread

Avoid animal products (meat, eggs, dairy) and only once per day (fish/cheese/eggs)

Reverse the omega 6:omega 3 ratio to help reduce inflammation

Drink plenty of water

Eat superfoods, raw entire fruits and vegetables (avoid mixing sugar or citrus and melon fruits with other food)

Eat as a king for breakfast, prince for lunch and pauper for dinner

Restraint in portion sizes

Avoid eating beyond 6 pm

Avoid microwave cooking especially with plastics

Sleep – proper rest and sleep are key to revitalize the body

Nothing but sex or sleep in the bed, read or watch TV in bedside chair or elsewhere

More sleep before midnight the better, before 10 pm is best (early to bed, early to rise)

Sleep on 90 minute cycles for REM activity

Sleep on a firm mattress; elevate head if on side but not if on back; sleep on side or stomach; pillow between knees on side or under knees if on back

Turn off any electrical devices in the bedroom

Regular sexual intercourse but reduce ejaculation to twice monthly with deep breathing

Exercise – outside of work or other activities, this is as necessary every day as sleep and eating

Cardiovascular fitness/stamina – CDC recommends at least 150 minutes per week in addition to resistance training

Resistance Training – improve motor strength, endurance, and tone (lean or bulk)

Flexibility

Coordination

Balance

Agility

Qigong with deep breathing

Mind Practice – outside of work to refresh and awaken the mind

Leisure Vacations in addition to high adventure or tourist excursions (long weekends and 7-10 days stretches at least once per year)

Hobbies weekly (card games, music, chess, gardening, reading, arts/crafts, museums)

Sports and Recreation weekly (walks, bicycling, hiking, camping, rock climbing, soccer, tennis, martial arts)

Adventure or Tourist Travel annually if possible (domestic and abroad)

Meditate to improve mental attention (concentrated focus) with deep breathing

Spiritual Practice – this does not imply religious experiences but can include them to refresh and awaken the spirit/psyche/emotions

Contemplate your existence in the universe within nature

Contemplate the supreme existence within nature

Be kind to family, friends and strangers

Avoid listening to harmful music, watching harmful movies, reading harmful books, speaking harmful words, thinking harmful thoughts and performing harmful actions

Volunteer in your community and/or abroad

Mindfulness meditation/prayer alone and with family/friends with deep breathing

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Regular Yoga
Taiji and Qigong
Dance Yoga
Fashion Show
Soul Yoga
Meditation
Movies at Ponce
Men’s Group
Belly Dancing
Women’s Support/Wellness
Nutrition
Mandala
Healthy Relationships
Skills Wellness
Library use, Money Wellness
Oncology
Performance Art/Interpretive Dance
Music Therapy
Aroma Therapy
Art Therapy
Relationships
Meditation
Belly Dancing
Laughter Yoga
APD Safety
Students Summer Health Fair
Money Wellness
Gardening
Pet Wellness
Wellness Improv
Legal Assistance
Literacy Action and The Atlanta Urban League
Managing Holiday Stress/Eating
Zumba
Diabetes
Wellness Workshops
Disability/Social Security Workshop
Affordable Care Act
GED
Tea Therapy
African Dance
Botanical Garden trip
Addiction movie
Sign Language and Pilates
Numerology
Mindfulness

48

Mind Body Spirit Health & Wellness Program

Magdalene Yonker

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49

Ancient Humans

Modern Humans

Time

Yes

No

Cole PLoS Genetics 2014

Inflammation

End-organ disease

Susceptible to infections

Autoimmune disorders

Less end-organ disease

Resistant to infections

Increased longevity

Goal

CBCT

JAK-Stat

Zn/SAMe

Exercise

Immune

Competence

Threat Exposures?

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Non-communicable diseases are the leading cause of death in high income countries
Inflammation is a primary driver of NCDs and aging
Stress and social isolation increase inflammation and decrease cell-mediated immunity
Viral infections (HIV) exacerbate age-related NCDs via inflammation
JAK-STAT inhibition reduces inflammation and senescent cells with potential clinical benefits in HIV and proven clinical benefits in COVID-19
Compassion-based meditation improves wellness and inflammation
Currently exploring exercise to slow aging and improve healthspan

50

Conclusions

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FIT VET (VA 5I01RX000667)

Kimberly Birkett
Theron Clark-Stuart
Julia Gallini
Chani Jain
Ngoc-Anh Le
Kathryn Meagley
Joe Nocera
Kris Ann Oursler
Alice Ryan
Yan Sun
Ernest Tate

VACS (NIAAA/NIH U01-AA020790)

Matt Freiberg
Qin Hui
Amy Justice
Kristin Nelson
Dave Rimland
Yan Sun
Boghuma Titanji
Ke Xu

TCM INR (R01 AI110334 NIAID)

Sol Aldrete
Nicolas Chomont
Keith Delman
Kirk Easley
Jake Estes
Justin Harper
Anum Khan
Michael Lowe
Christina Mallarino
Darius McDaniel
Luca Micci
Elena Morales
Mirko Paiardini
Amelie Pagliuzza
Ericka Patrick
Maria Pino
Jonathan Pollock
Emily Ryan
Rafick Sekaly
Theron Stuart
Tanisha Sullivan
Cameron Tran

ACTG 5336 (NIAID/NIH)

Carlos del Rio
Steve Deeks
Charlie Flexner
Christina Gavegnano
Selwyn Hurwitz
Amy Kantor
Jeff Lennox
Carlee Moser
Ray Schinazi
Guido Silvestri
Athe Tsibris

Zn/SAMe (R01 HL125042 NHLBI)

Sushma Cribbs
David Guidot
Igho Ofotokun

CBCT (EMCF)

Gene Farber
Kathryn Meagley
Christina Mehta
Mehul Tejani
Boghuma Titanji
Thaddeus Pace

51

Acknowledgments

Martin Delaney

Collaboratory

for HIV Cure Research

NIAID/NHLBI/NIDDK

NINDS/NIDA

UM1AI164561

UM1AI164562

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52

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ACTT-2 Study Team

53

Networks / Partners

IDCRC

NETEC

DOD / IDCRP

INSIGHT

BARDA

CDC

Gilead

Eli Lilly

US Sites:

Baylor College of Medicine

Baylor Scott & White Health

Brooke Army Medical Center

Cedars-Sinai

Denver Health

Duke University

Eastern Colorado Health

Emory University

Evergreen Healthcare

Georgetown University

Indiana University

Johns Hopkins Hospital

Kaiser Permanente Northwest Portland

Madigan Army Medical Center

Massachusetts General Hospital

Montefiore/Albert Einstein

Navy Medical Center Portsmouth

Navy Medical Center San Diego

NIH Clinical Center

Northwestern University

NYU Langone

Ochsner Medical Center Kenner

Penn State Medical Center

Providence Sacred Heart

Saint Louis University

Southeast Louisiana Veterans

Stanford University

University of California Davis

University of California Irvine

University of California Los Angeles

University of California San Diego

University of California San Francisco

University of Alabama

University of Florida Health

University of Illinois at Chicago

University of Maryland

University of Massachusetts

University of Miami

University of Minnesota

University of Nebraska

University of New Mexico

University of Pennsylvania

University of Rochester

University of Texas San Antonio

University of Texas Medical Branch

University of Texas Southwestern

University of Utah

University of Virginia

VAMC Atlanta

VAMC Palo Alto

Vanderbilt University

Walter Reed National Medical Center

Womack Army Medical Center

International

Denmark

Rigshospitalet Dept of Infectious Diseases (CHIP)

Aalborg University Hospital

Aarhus University Hospital

Hvidovre Hospital

Nordsjællands Hospital

Odense University Hospital

Rigshospitalet Infectious Medicine Clinic

Sjaellands University Hospital

Kolding Sygehus

Japan

National Center for Global Health and Medicine

Korea

Seoul National University Hospital

Seoul National University Bundang Hospital

Mexico

INER

Nutricion

International

Singapore

National Centre for Infectious Diseases

Changi General Hospital

Ng Teng Fong General Hospital

National University Hospital

Spain

Hospital Germans Trias i Pujol

Hospital Clinic Barcelona

Hospital Clinic San Carlos

United Kingdom

John Radcliffe/Churchill Hospital

Guy's & St. Thomas' NHS Foundation Trust

Royal Sussex County Hospital

Royal Victoria Infirmary

St James's University Hospital

2

It is a very complicated issue in part because of the earlier approach with clinical trial design (the aspirin analogy - study the impact of aspirin on mortality in one study that included 4 groups: (1) People over age 50, (2) people over age 50 with HTN/DM, (3) people over age 50 with HTN/DM and history of MI, and (4) people admitted for an acute MI all while we throw in statins, Ace inhibitors, better glucose control, etc.) for these reasons:

1. Power – unless each category has sufficient sample size, some individual categories may not (see below) show a statistical difference and can impact the overall trial result (via diluting the other categories’ effects)

2. Pathogenesis – it is conceivable that antivirals have their greatest effect prior to the accelerated inflammatory stage; once the horse is out of the barn, eliminating virus would be like spreading out the coals in your fire ring after the forest is already ablaze. This is an exaggeration of course as antivirals likely still have an impact of varying degree at this stage depending on how much replication is still occurring and how potent the drug. Similarly, it is not clear that pure anti-inflammatories have any impact early in disease (i.e. dex even caused harm in ordinal 4 – no oxygen). I think the putative baricitinib antiviral effect is minimal if any in vivo (will be available in ACTT2 in about 2 months). Similarly, 4 mg of baricitinib (higher doses may be required) may not have much of an effect for someone already ventilated if pulmonary fibrosis has already begun. Although baricitinib in ACTT2 did show some differentiation between arms within 29 days, there were only about 50 people in each arm and may require a longer follow up time to observe the true difference.

3. Population – as in the aspirin analysis, if absolutely every patient was destined to progress to subsequent stages yet at different rates say due to underlying risk factors, the number needed to treat in each category would be much less than it is. However, the vast majority in each category (although progressively fewer in absolute numbers) do not progress regardless of treatment. This again creates an added challenge pooling these groups together

RDV is not a potent antiviral but because it showed a clear statistical benefit in a highly rigorous RCT for patients in ordinal 5, it would be ethical to provide RDV to ordinal 5 participants in subsequent ACTT trials. Additionally, ordinal 6 shows an early difference but later overlaps/not significant (only 90+ in each arm compared to 200+ in each arm for ordinal 5). ACTT4 has only ordinal 5 and 6. Since these two groups can overlap closely in the hospital, separately giving RDV to ordinal 5 only in the trial because of the significance shown for one over the other could be scientifically and operationally challenging. Here are the ACTT1 summary results:

5 days shorter recovery for all, and 7 days shorter time to recovery in the sickest patients

50% faster clinical status improvement

8 days less receiving oxygen

lower progression to non-invasive ventilation

lower progression to invasive mechanical ventilation

lower overall mortality at day 28 (0.73[0.52-1.03])

Significant overall mortality reduction at day 14 (0.55[0.36-0.83])

significant mortality reduction in patients who were requiring oxygen at day 14 (0.28[0.12-0.66]) and at day 28 (0.30[0.14-0.64])

all of the above mortality reduction estimates were detected even though the trial was not powered for mortality.

SOLIDARITY has a few challenges with its design but is not an altogether problematic study:

1. The greatest challenge interpreting this trial is all non-ventilated patients (ordinal scales 4/5/6) would be combined. For the reasons stated above, this could lead to a null effect.

2. Although not affecting mortality, participants were required to have 10 days of RDV regardless of their recovery time. This fixed recovery time at > 10 days for the secondary endpoint of hospital duration.

3. Supportive care provided was unknown and/or supportive care was very limited and highly heterogeneous in many sites included in the trial; similar with regards to healthcare personnel capacity

4. There was also a significant amount of missing data

5. Study drug distribution was plagued by delivery failures and disorganization, which compromised the proper conduct of the trial.

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54

COV-BARRIER KHAA Clinical Sites

1

3

2

1

2

1

2

8

1

2

1

2

1

13

4

1

3

1

3

1

3

1

2

1

2

1

2

1

2

1

3

4

1

Country	Sites	Subjects
USA	27	320
UK	3	11
Argentina	11	208
Brazil	18	337
Germany	4	20
Italy	1	25
India	4	50
Japan	3	38
S Korea	4	36
Russia	3	112
Mexico	7	281
Spain	5	87

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United States (includes Puerto Rico)	Argentina	Germany	Mexico
Valleywise Health	Sanatorio Sagrado Corazón	Universitätsklinikum Erlangen	Instituto Nacional de Cardiologia Ignacio Chavez
St Joseph's Hospital and Medical Center	ClÃ-nica Zabala	Klinikum Rechts der Isar der TU München	Instituto Nacional de Enfermedades Respiratorias
Hoag Memorial Hospital Presbyterian	Hospital Z.G.A.D "Evita Pueblo"	Universitätsklinikum Schleswig-Holstein	Instituto Nacional de Cancerologia
San Francisco VA Medical Center	Sanatorio de la Trinidad Mitre	Klinikum Chemnitz gGmbH	Hospital General Agustín O'Horán
Torrance Memorial Medical Center	Fundacion Sanatorio Guemes	India	ITESM Campus Monterrey
Holy Cross Hospital Inc.	Casa Hospital San Juan de Dios	Sir Ganga Ram Hospital	Hospital Universitario
Westchester General Hospital	Hospital Interzonal General de Agudos "Eva Peron"	Unity Hospital	Instituto Nacional de Ciencias Medicas y Nutrici Salva Zubir
Grady Health System	Clinica Adventista Belgrano	Medanta-The Medicity	Russian Federation
Atlanta VA Medical Center	Clinica Central S.A.	Government Medical College (GMC) Aurangabad	City Clinical Hospital #15 named after O.M. Filatov
Great Lakes Clinical Trials	Clinica Viedma	Government Medical College	First Moscow State Medical University n.a. Sechenov
Parkview Regional Medical Center	Hospital San Roque	Ruby Hall Clinic and Grant Medical Foundation	Saint-Petersburg City Pokrovskaya Hospital
Community Hospital South	Brazil	Medica Superspecialty Hospital	Spain
Franciscan St. Francis Health	Hospital Felício Rocho	Aakash Healthcare Super Speciality Hospital	Hospital Txagorritxu
South Shore Hospital	Centro Hospitalar de Reabilitacao Ana Carolina Moura Xavier	Italy	Hospital Universitario Quironsalud Madrid
Henry Ford Hospital	CEPETI Centro de Ensino e Pesquisa em Terapia Intensiva	INMI Lazzaro Spallanzani	Hospital Universitario Infanta Leonor-INTERNAL MED
Renown Regional Med. Center	CPCLIN	Ospedale Niguarda Ca Granda	Hospital Clinico San Carlos
SUNY Downstate	Hospital de Clinicas de Porto Alegre	Nuovo Ospedale di Prato S. Stefano	Hospital Clínico Universitario de Valencia
East Carolina University	Hospital Carlos Fernando Malzoni Matao	Japan	United Kingdom
OSU Med Intl Med Houston Ctr	Pesquisare	Yokohama Municipal Citizen's Hospital	The Royal Cornwall Hospital
Oregon Health and Science University	Praxis Pesquisa Medica	Edogawa Medicare Hospital	Barnet Hospital
Temple Univ School of Med	Faculdade de Medicina do ABC	Tokyo Medical University Hachioji Medical Center	St. George's University Hospitals NHS Foundation Trust
Swedish Medical Center	Upeclin - Unidade de Pesquisa Clínica da Faculdade de Medicina de Botucatu - UNESP	Korea, Republic of
MultiCare Good Samaritan Hospital	IPECC - Instituto de Pesquisa Clinica de Campinas	Korea University Ansan Hospital
Advanced Clinical Research, LLC	Hospital PUC-CAMPINAS	Ajou University Hospital
	CECIP - Centro de Estudos do Interior Paulista	Seoul National University Boramae Medical Center
	CEMEC - Centro Multidisciplinar de Estudos Clinicos EPP Ltda	Seoul Medical Center
	Real e Benemerita Associação Portuguesa de Beneficiencia
	Hospital Alemão Oswaldo Cruz
	Universidade Federal de São Paulo - Escola Paulista de Medicina
	Hospital Santa Paula
	Casa de Saude Santa Marcelina - Centro de Pesquisa Clinica

David Henry Adams

Jorge Alatorre-Alexander

Nicole Byers

Anabela Cardoso

Sujatro Chakladar

Brenda Crowe

Stephanie de Bono

Wes Ely

Vicente Estrada

Jason Goldman

Cynthia Elise Kartman

Venkatesh Krishnan

Ran Liao

Rita de Cassia Pellegrini

Maria Lucia Buziqui Piruzeli

A.V. Ramanan

Paulo Jorge Simoes Reis

Mousumi Som

Jorge Alfonso Ross Terres

Xin Zhang