Invasive pneumococcal disease is a major cause of morbidity and mortality among HIV-infected patients [1–7]. This population has a higher risk of invasive pneumococcal disease than that observed in the general population [5,8,9]. Although pneumococcal infections often occur earlier in the course of HIV disease than do opportunistic infections , low CD4 cell counts and high plasma HIV RNA remain the main determinants of invasive pneumococcal disease occurrence . Since the introduction of HAART, the incidence of AIDS-related opportunistic infections markedly decreased. However, in HAART-treated patients, the impact of immune reconstitution on invasive pneumococcal disease incidence remains debated [10–13]. Even in studies showing that HAART is protective against pneumococcal disease, its incidence in HIV-infected patients remains higher than that observed in non-HIV infected adults of the same age [13,14].
Invasive pneumococcal disease is a preventable disease and the efficacy of the 23-valent pneumococcal polysaccharide vaccine (PPV) is well documented in immunocompetent populations. Immunization with a single dose of PPV is recommended for HIV-infected adults who have a CD4 cell count ≥ 200 cells/μl in order to prevent severe pneumococcal infections [15,16]. However, the effectiveness of this vaccine is controversial and remains highly dependent on the level of competence of the immune system [17–26]. Several studies have shown that HIV-infected patients with CD4 cell counts < 500/μl have impaired IgG response against several Streptococcus pneumoniae polysaccharides (SPP) compared to HIV-infected patients less immunocompromised or healthy controls [23,26–29]. PPV is also limited since it does not elicit a long-lasting immunity in HIV-infected adults as compared to the non-HIV-infected population [26,30–32]. Antibody production against SPP, i.e., type 2 T-cell-independent antigens, is supposed to be a T-independent process which does not induce a booster effect following revaccination .
The recent 7-valent conjugate vaccine (PCV) contains seven SPP combined with a carrier protein. This vaccine improves the antibody responses and the clinical efficacy in children who have poor responses to PPV [34,35]. SPP conjugated with the carrier protein induces a T-cell-dependent immune response and memory T and B cells [33,36]. This latter phenomenon is called priming and it is hypothesized that it enhances a secondary antibody response after contact with the pathogen or revaccination and prolongs the period of protection among the vaccine recipients. A previous study performed in adults with Hodgkin's disease, patients considered to be low responders to PPV, showed that PCV primed for antibody responses to PPV and that this strategy might be helpful to protect high-risk adults .
This randomized, open-labelled phase II trial was designed to assess the immunological efficacy and safety of a combined vaccination strategy with PCV followed by PPV boost as compared to PPV alone in HIV-infected adults with a moderate immunodepression.
Patients and methods
HIV-1 infected adult patients were eligible if they had CD4 cell counts of 200–500 cells/μl, with plasma HIV RNA < 50 000 copies/ml, were antiretroviral naive or on stable antiretroviral therapy in the last 3 months, free of current bacterial infection and had no history of pneumococcal vaccination in the last 5 years. The institutional ethics review boards approved the trial and all patients gave written informed consent.
Patients were screened in 17 clinics in France, then randomized to receive either one dose of PCV (7-valent Prevenar, Wyeth-Lederlé) vaccination at week 0 followed by a boost of PPV (23-valent Pneumo 23, Aventis Pasteur MSD) at week 4 (prime-boost group) or PPV alone at week 4 (PPV-alone group).
Randomization was centralized and stratified by prior antiretroviral status history and baseline CD4 cell counts (200–349 and 350–500 cells/μl). The randomization allocation sequence was obtained using the PROC PLAN procedure of SAS software. Patients had an equal probability of assignment to the two interventions and the block size was four. A form summarizing all eligibility criteria was completed by investigators of the clinical centres and sent by fax to the central Clinical Trials Unit (INSERM U593). Eligibility criteria were checked and if met, the Clinical Trials Unit allocated the next available number on entry into the trial, and each patient collected his or her vaccines from the pharmacy department. During the trial, only the study statisticians and the data and safety monitoring committee saw unblinded data, but none had any contact with study participants.
Immediate (within 30 min) and short-term (5 days) side effects of the vaccination were recorded for safety evaluation. Laboratory, routine immunological measures and plasma HIV RNA measured by bDNA assay (detection limit 50 copies/ml) were performed locally at each protocol visit.
Evaluation of IgG-specific antibody levels to each of the seven serotypes shared by PCV and PPV (serotypes 4, 6B, 9V, 14, 18C, 19F and 23F) and serotypes 1 and 5 (contained only in the PPV) was centralized (Wyeth-Lederlé Rochester, USA) and performed at weeks 0, 4, 8 and 24. Specific IgG levels were measured using a standardized ELISA method as previously reported . Serum samples were preadsorbed with optimal concentrations of pneumococcal cell wall and 22F capsular polysaccharides. The lower limit of quantification of this assay was 0.01 mg/ml. Immunological personnel assessing these outcomes at Wyeth were blinded to the interventions.
The primary efficacy endpoint was the proportion of patients responders to the seven SPP shared by the PCV and PPV at week 8, i.e., 4 weeks after the administration of PPV, in both groups of the study. Response was defined using a primary outcome: patients who had at time point evaluation a twofold increase from baseline of serotype-specific IgG antibody levels (μg/ml). A secondary, more stringent, outcome was patients who met both this first criterion and serotype_specific IgG levels at least ≥ 1 μg/ml at week 8. For analysis, each variable was categorized into four ordered levels in order to use all available information and detect both improvement and deterioration: 0 response, response to 1 or 2 serotypes, response to 3 or 4 serotypes or response to 5–7 serotypes. Patients with missing serotype-specific IgG levels were considered non-responders. Other secondary outcomes were: (i) clinical, virological and immunological safeties; (ii) SPP-specific IgG levels (geometrical mean titres, at week 8; (iii) durability of SPP-specific antibody responses at week 24.
The sample size of 106 per group was calculated to provide 90% power of detecting a 10% and 15% absolute difference in the proportions of patients responders to 3–4 and 5–7 SPP, respectively, in favour of the prime-boost strategy at week 8 of the trial using the primary outcome (global type I error, 5%). Sample size calculation was based on the solution proposed by Whitehead . The ranked primary outcome was analyzed using a proportional odds model . This model yields a proportional odds ratio (OR) and data was coded in order to interpret the results as follows: proportional OR > 1 when response of prime-boost strategy is better than PPV-alone, proportional OR = 1 when response of both groups do not differ, proportional OR < 1 when response of prime-boost is not as good as PPV-alone. The proportional OR for the vaccine group was adjusted for stratification variables, i.e., CD4 cell count and prior antiretroviral therapy, and for plasma HIV RNA. All analyses were performed using a modified intent-to-treat approach in which all randomized patients that received at least one immunization were included. A strict intent-to-treat approach including all patients randomized has been applied for the primary outcome in a robustness analysis. Quantitative outcomes were tested with a Student t test or a Wilcoxon test. The multivariate analysis of vaccine response profile using the ranked primary outcome used a proportional odds model and included the following potential determinants: vaccination randomization group, HIV transmission category, age, sex, smoking status, body mass index, nadir and baseline CD4 cell count, baseline HIV RNA, CDC HIV clinical stage, prior antiretroviral therapy, hepatitis C virus (HCV) status.
Of 277 patients screened between December 2002 and December 2003, 212 eligible patients were randomized to receive either a prime with PCV at week 0 followed by a boost with PPV at week 4 (n = 106, prime-boost) or PPV-alone at week 4 (n = 106, PPV-alone). The 24-week visit of the last patient included occurred in September 2004. Four patients (one from the prime-boost group and three from the PPV-alone group) were excluded from the analysis since they did not receive any vaccination and remained blinded to the randomization group (Fig. 1). The two randomized groups were similar for all baseline characteristics considered (Table 1). On average, baseline CD4 cell counts and plasma HIV RNA reflected a medium immunodepression and a fair control of HIV disease (Table 1). The mean nadir of CD4 cell count was < 200/μl. Prior to the randomization, 87% of patients were treated with a combination antiretroviral therapy. One-third of the patients had a history of an AIDS defining-event. All patients, with the exception of one from the prime-boost group who did not receive the PPV boost, received the vaccination according to protocol schedule. Four patients from the prime-boost group and three from the PPV-alone group did not return to complete the follow-up visit at week 24.
Both strategies were well tolerated, in terms of clinical, immunological and virological safety. No serious adverse events (> grade 2) were reported after PPV or PCV administrations. The most frequent adverse event was pain at the injection site, which was observed in the prime-boost group after the PCV injection at week 0 among 52 patients, followed by injection site induration (13 patients) and injection site inflammation (nine patients). In the PPV-alone group, pain at injection site was observed among 43 patients after PPV injection at week 4 and injection site induration and injection site inflammation among 12 and 11 patients respectively. One episode of pneumococcal pneumonia in the PPV-alone group was notified during the follow up. This event occurred 10 weeks after vaccination in a patient who received zidovudine, lamivudine and indinavir boosted by ritonavir. He was not bacteraemic and the episode fully resolved with antibiotic therapy. No significant changes in CD4 cell counts or plasma HIV RNA were reported during the 24-week follow-up.
Baseline anticapsular IgG concentrations were similar in the two groups (Table 2). Using the less stringent primary outcome criteria of vaccine responses (i.e., twofold increase of SPP levels at week 8), the frequency of responses was high in each group. Responders to 0, 1–2, 3–4 and 5–7 SPP were 2, 5, 15 and 78% in the prime-boost group versus 7, 5, 20 and 68% in the PPV-alone group. However, the difference between groups in the distribution of responders to each category of SPP did not reach statistical significance: proportional OR, 1.74 [95% confidence interval (CI), 0.94–3.23; P = 0.08]. According to the more specific secondary outcome, patients who experienced both a twofold increase in SPP-specific antibody levels and IgG concentrations > 1 μg/ml at week 8 were considered as vaccine responders. The prime-boost strategy generated a higher immunogenicity as compared to the administration of the PPV-alone strategy (Fig. 2). Responders to 0, 1–2, 3–4 and 5–7 SPP were 5, 16, 20 and 59% in the prime-boost group as compared to 10, 23, 27 and 40% in the PPV-alone group, yielding a proportional OR of 2.09 (95% CI, 1.25–3.51; P = 0.005).
The study design allowed the impact of the PPV boost in patients from the prime-boost group to be evaluated. For this, we compared frequency and distribution of responders (i.e., patients who experienced both a twofold increase in SPP-specific antibody levels and IgG concentrations > 1 μg/ml), 4 weeks following the administration of either the PCV in the prime-boost group or PPV in the PPV group. The distribution of frequency of responders in the categories 0, 1–2, 3–4 and 5–7 SPP were 9, 20, 22 and 49% in the prime-boost group at week 4 and did not differ significantly from frequency of responders of the PPV-alone strategy at week 8: proportional OR 1.36 (95% CI, 0.82–2.25; P = 0.23). Altogether, these results showed that the PPV boost in patients from the prime-boost group contributed to increase the rate of responders at week 8, as compared to a single PPV administration in patients from the PPV group.
At week 8, compared with the PPV group, SPP-specific IgG concentrations (geometric mean of antibody concentrations) were significantly higher in patients who received the PCV prime followed by the PPV boost for six of seven serotypes shared by the PCV and PPV vaccines: serotypes 4, 9V, 14, 18C, 19F, and 23F. As expected, there were no differences between groups in the IgG antibody concentrations for serotypes 5 and 1 which are not contained in the PCV, indicating that PCV prime did not inhibit any of the PPV unshared subtype responses (Table 2).
The sustainability of SPP-specific IgG responses was evaluated at week 24. Patients from the prime-boost group had significantly higher levels as compared to the PPV-alone group for four of seven SPP shared by the two vaccines (Table 2). The frequency and the distribution of patients who experienced both a twofold increase in SPP levels and IgG concentrations > 1 μg/ml was significantly higher in the prime-boost group as compared with the PPV-alone group. Responders to 0, 1–2, 3–4 and 5–7 SPP were 17, 30, 24 and 30% in the prime-boost group as compared to 23, 40, 27 and 10% in the PPV group: proportional OR, 2.14 (95% CI, 1.30–3.53; P = 0.003) (Fig. 3).
Finally, we analyzed predictive factors of IgG-specific immunological responses to vaccination. In the multivariate model (Table 3), the prime-boost strategy remained significantly associated with a better immunological response. Moreover, smokers and patients co-infected with HCV had a significantly lower chance of being responders to vaccination than others. However, in these categories of patients, the rate of responders remained higher in those who received the prime-boost regimen as compared to recipients of the PPV-alone.
In this randomized, controlled trial, we show that a vaccination combining PCV as a prime followed by a PPV boost led to a higher rate of immunological responders as compared to the administration of a single injection of the currently recommended PPV. Moreover, the prime-boost strategy led to a higher level of SPP-specific IgG against all but one, of the seven polysaccharides shared by the two vaccines. Both vaccine strategies were well tolerated.
Studies evaluating antibody responses to PPV consistently concluded low immunogenicity and lack of efficacy in HIV-infected patients with CD4 cell counts < 500/μl [17,23,24,27–29,41]. Several trials performed in children, who have poor responses to PPV, have shown that the PCV is highly efficacious against invasive disease [34,35,42,43]. Therefore, conjugated vaccines might be a very promising strategy to protect high-risk adults. For example, vaccination of adult HIV-infected patients with conjugated-Hemophilus influenzae b (Hib) vaccine led to a greater antibody response than the Hib polysaccharide vaccine . However, regarding pneumococcal vaccination, results are less clear-cut since no differences in immunological responses elicited by a single dose of PCV compared to PPV were shown in adult patients with CD4 cell counts > 200/μl . This defect in humoral immunity was not overcome by revaccination either by a double dose of PPV [31,32] or by vaccination with one or two doses of PCV [29,41].
As seven SPP are shared by the PPV and PCV, we evaluated whether a prime with PCV would be more effective in obtaining a longer-term response to a boost with PPV. We chose this combination following the demonstration of a booster effect of the PPV after priming with PCV both in HIV and non-HIV infected infants and children [45–47]. Moreover, we hypothesized that this strategy might help to extend the breadth of the antibody response against SPP serotypes. Our design allowed evaluation of the rate of responders to the seven SPP shared by the two vaccines and to SPP 1 and 5 contained only in the PPV. Following administration of the PPV boost in patients primed with PCV, the proportion of responders to 5–7 SPP became 20% higher as compared to the PPV group. Our results contrast with those of another study showing no additional increases in antibody concentrations elicited by a dose of PPV following a first dose of PCV in HIV-infected patients with CD4 cell counts > 200 cells/μl . Several differences between this study and our results may explain these different findings including the timing of the PPV boost 8 weeks following the PCV, the small sample size (18 patients received the combination strategy) and the high rate of lost of follow-up (20%) which jeopardized the power of this study.
Continued uncertainty regarding the nature of SPP vaccine responses that translate into vaccine efficacy in the setting of HIV infection underscores the need to define useful surrogates for vaccine efficacy. The levels of IgG required for protection remain unknown. However, previous studies have shown that vaccine failures are often associated with lack of antibody response [49–51]. We used two different criteria of antibody responses. The first one (twofold increase in IgG levels) has been routinely used in studies of pneumococcal immunization in adults [23,26,48]. However, it does not assess the absolute post-vaccination value which could be a surrogate marker of protection against invasive pneumococcal disease. To overcome this, we used a second and stricter criterion of response which includes both a twofold response and a level of antibody ≥ 1 μg/ml. Our results show that the prime-boost strategy led to higher values of the geometric mean of IgG-specific for six of the seven serotypes shared by the two vaccines, except for SPP 6b, which is known to be an antigen with poor immunogenicity [52,53]. It seems unlikely that the low antibody responses against serotype 6b could have any clinical relevance, because this serotype is rarely found in adults with pneumococcal invasive disease .
Several studies reported that immunological responses to vaccination with either T-cell-dependent antigens or SPP are impaired in HIV-infected adults with low CD4+ cell count [55,56]. In the context of the multiple immune dysregulations that complicate HIV infection, SPP specific suboptimal antibody responses may be less protective. Our results show that a combination strategy including a prime with a T-cell dependent antigen may help to overcome limitations to an effective antibody response in HIV infection. These provide arguments for testing such strategy in patients who less likely may have chance to mount a significant antibody response to SPP such as non-white patients or individuals with low CD4+ cell counts .
Interestingly, we observed that a higher rate of responders was maintained 6 months following vaccination with PCV combined with PPV. This observation might have clinical relevance since a rapid loss of vaccine antibodies is observed in HIV individuals receiving either PCV or PPV-alone . The limited responses after re-immunization of patients with the current PPV do not overcome this loss of antibody titres and reinforce the need for a more immunogenic strategy. As with previous studies, we found that the percentages of responders to SPP dropped in each group of the study six months following the end of the vaccination. Previous studies have shown that the rate of decline of vaccine antibodies against SPP is similar in HIV-infected individuals and healthy controls suggesting that the period of protection following vaccination is dependent on the levels achieved after vaccination [32,41,57]. We found that the levels of IgG specific to four of seven of the SPP shared by the two vaccines remained significantly higher in recipients of the PCV-PPV combination as compared to patients vaccinated with PPV alone. This observation suggests that the period of protection might be significantly prolonged in patients who received a sequential vaccination with PCV and PPV.
We evaluated the impact of the prime-boost strategy in a multicentric trial as close as possible to the practical care of a population of HIV-infected individuals. Although a vast majority of patients were treated with HAART, all patients treated or not with antiviral drugs were eligible to participate to this study. Similarly, there was no restriction based upon the nadir CD4 T cell count, a clear predictive factor of the response to vaccination in HIV-infected patients [18,19,41,55]. We found that the efficacy of the prime-boost strategy remained significantly higher than that of PPV alone when adjusted for CD4 cell counts, viral load and antiviral therapy. In the multivariate analysis, the prime-boost strategy remained associated with better immunological responses in smokers and patients with HCV infection. Several studies have shown that cirrhosis is a risk factor for both pneumococcal infection and low response to vaccination against SPP [58–60]. In addition, HCV infection was found to inhibit humoral response to hepatitis B virus vaccine in patients . More recently, HCV infection was identified as a risk factor for invasive pneumococcal disease in HIV-infected patients . However, to our knowledge, an association between HCV infection status and response to pneumococcal vaccination in HIV-infected patients has not been documented previously. This result would help to identify, among HIV-infected individuals, subjects who likely may have a better benefit of the prime-boost strategy.
Our study provides evidence to support the use of a PCV primed-PPV boosted strategy to overcome limitations of the immunogenicity of the currently recommended immunization with PPV alone. We found that this strategy led to a higher efficacy of the vaccination in frequency, breadth, magnitude and sustainability of antibody responses among HIV-infected adults with CD4 cell counts between 200 and 500 cells/μl.
We would like to thank Dr Bernard Fritzell (Wyeth Pharmaceuticals Vaccines) for his contribution to this paper, Dr Madore DV (Wyeth-Lederlé Rochester, USA) for the evaluation of IgG responses to pneumococcal serotypes, Pr David Goldblatt (Immunobiology Unit, Institute of Child Health, UK) for expertise in the quality control evaluation of IgG responses, and Mrs Inga Tschöpe for checking the results of statistical analysis. We also gratefully acknowledge the contribution of the Data and Safety Monitoring Committee: France Mentré, Philippe Morlat. This study was performed with the financial support of the Agence Nationale de Recherches sur le Sida et les Hépatites Virales (ANRS).
Conflict of interest statement: Jean-Michel Molina has received consulting and lectures fees from Bristol-Myers Squibb (BMS). B. Fritzell is Vice President International Scientific & Clinical Affairs Vaccines, Wyeth. G. Chêne has received grant support and lecture fees from Boeringer-Ingelheim, Gilead, Roche and Sanofi-Aventis. All other authors: no conflicts.
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Appendix: Members of the ANRS 114-Pneumovac Study Group
P. Lesprit,Y. Levy (principal investigators); G. Chêne (trial coordinator); N. Sarrazin (trial monitor); G. Pedrono (trial statistician); C. Rabian (trial immunologist); P. Bursachi, M.-J. Commoy, J.-F. Delfraissy, F. Denis, B. Fritzell, C. Goujard, R. Salamon, R. Tubiana, J. P. Viard.
Participating clinical departments and investigators
Hôpital Avicenne, Bobigny: A. Krivitzky, M. Bentata, S. Makki, R. Mansouri, L. Guillevin, B. Jarousse, A.-K. Klutse, G. Obenga, P. Honoré-Berlureau, Y. Baazia and S. Soreda; Hôpital Saint-Louis, Paris: J.-P. Clauvel, E. Oksenhendler, L. Gerard, J. Delgado, J.-M. Molina, N. Colin de Verdière, P. Palmer, I. Madelaine; Hôpital Pellegrin, Bordeaux: M. Dupon, J.-M. Ragnaud, D. Neau, I. Raymond, I. Garrigue, J.-P. Dupin; Hôpital Necker, Paris: Ch. Boitard, J.-P. Viard, S. El Marsafy, R. Lahoulou, A. Mogenet, C. Broissand; Hôpital de Bicêtre, Le Kremlin-Bicêtre: J.-F.Delfraissy, C. Goujard, D. Pereti, Y. Quertainmont, P. Robquin, O. Segeral, S. Poirier, M.-T Rannou, N. Idri, C. Le Tiec; Hôpital Cochin, Paris: D. Sicard, D. Salmon, O. Launay, B. Silbermann, C. Desaint, A. Krivine, C. Guérin; Hôpital Henri-Mondor, Créteil: A. Sobel, Y. Lévy, P. Lesprit, A.-S. Lascaux, Ch. Chesnel, C. Jung, A. Miladi, C. Antoine; Hôpital Pitié-Salpêtrière, Paris: F. Bricaire, Ch. Katlama, I. Boubezari, S. Pierre-François, L. Schneider, C. Seulié, M.-H. Fievet; Hôpital Saint-Antoine, Paris: P.-M. Girard, A.-M. Béglé, F. Besse, R. Mouchotte, A. Charrois, A. Duaguenel-Nguyen; Hôpital Bichat, Paris: P. Yeni, I. Fournier, S. Lariven, B. Phung, P. Ralaïmazava, Ch. Gaudebout, J. Gerbe, D. Descamps, S. LePoole; Hôpital Gui de Chauliac, Montpellier: J. Reynes, P. André, V. Baillat, V. Le Moing, C. Merle, M. Vidal, J.-M. Fondère, I. Roch-Torreilles; Hôpital Hôtel-Dieu, Nantes: F. Raffi, P. Morineau, C. Allavena, B. Bonnet, H. Hue, E. Guarnier, A. Lepelletier; Hôpital Les Oudairies, La Roche sur Yon: P. Perré, O. Aubry, S. Leautez, C. Leroy, I. Suaud, A.-S. Poirier, A. Lepelletier; Hôpital de L'Archet, Nice: P. Dellamonica, V. Rahelinirina, M.-A. Sereni, S. Benhamou, M.-Ch. Rigault; Hôpital Purpan, Toulouse: P. Massip, B. Marchou, M. Alvarez, E. Bonnet, L. Cuzin, M. Obadia, F. Balsarin, M. Barone, M. Heraud, I. Peyranne.
Data and safety monitoring board
F. Mentré, P. Morlat.
Coordinating trial centre
INSERM U593, Bordeaux, France (G. Chêne, N. Sarrazin, G. Pedrono, I. Tschöpe, G. Palmer)