Immuron Ltd — Investor Presentation 2008

Nov 19, 2008

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Inaugural “Research Day” Presentations

Thursday 20 November 2008

Anadis Limited (ANX.AX ; ANDIY.PK; CUSIP: 032517104), a biopharmaceutical company specializing in oral immunotherapy development and antibody manufacturing, today had its inaugural “Research Day” event showcasing the scientific basis for the Company’s R&D programs.

CEO Dr. Zeil Rosenberg introduced the presentation by summarizing the strategy of the company and its aims in bringing to market therapies in the areas of E.Coli related diseases, Influenza and HIV/AIDS. The attendance of the event by investment professionals, biotechnology analysts and biotechnology industry professionals gave the opportunity to hear firsthand about the research programs which form the main value drivers for the company.

Presenters of the respective programs, with copies of the presentations attached:

Prof. Roy Robins-Browne

Deputy Head of Microbiology and Immunology University of Melbourne

Topic: Enteric Infectious Disease Immunology (Travelan for Traveller’s Diarrhoea, Cancer Therapy related Mucositis and Inflammatory Bowel Disease (IBD))

Prof. Lorena Brown

University of Melbourne Microbiology and Immunology Topic: Influenza Virus (pandemic and seasonal)

Dr. Damien Purcell

Head, Molecular Virology Laboratory University of Melbourne

Topic: HIV/AIDS: Immune Activation

Contact:

Arie Nudel- Investor Relations Email: arie@anadis.com Tel: +61 3 9014 4880

AUSTRALIA L1 39 Levenson St, North Melbourne, VICTORIA, 3051

USA The Empire State Building 350 Fifth Avenue 59th Floor New York, N.Y. 10118

www.anadis.com

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The Use of Bovine Antibodies to Prevent and Treat Intestinal Infections and Inflammation

Roy Robins-Browne Dept of Microbiology and Immunology, University of Melbourne; Royal Children’s Hospital and Murdoch Childrens Research Institute

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Presentation Outline

• The intestinal microbiota

• Enterotoxigenic E. coli (ETEC)

• The development and use of Travelan

• The use of bovine immune colostrum to treat inflammatory bowel disease and mucositis

1

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The Human Body is a Complex Ecosytem

• We are home to trillions of bacteria

• Most of these live in the intestine

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Distribution of Bacteria in the Gut
Region No. per g
Stomach 0 - 10 [8]
Proximal small 0 - 10 [5]
intestine
Distal small 10 [3] - 10 [9]
intestine
Large intestine 10 [10] - 10 [12]
More than 500 different species occur in any one person
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Role of Intestinal Bacteria in Health & Disease

• Promote development of the immune system

• Pla y various roles in metabolism

• Protect against infection (colonisation resistance):

• e.g., diarrhoeal pathogens; Clostridium difficile

• Are a source of infectious agents:

• for urinar y, res p irator y, abdominal , s y stemic infections

• Provide an enormous pool of genes

• for virulence, antibiotic resistance

• A source of immunostimulatory molecules

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The Best Known is:
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Some Types of E. coli that Cause Diarrhoea

• Enterotoxigenic E. coli (ETEC)

• Enteropathogenic E. coli (EPEC)

• Enterohaemorrhagic E. coli (EHEC)

• Enteroinvasive E. coli (EIEC)

• Enteroaggregative E. coli (EAggEC)

Burden of Disease Attributed to ETEC

• In children <5 yrs in high risk countries

• 200 million cases of diarrhoea p.a.

• approx 400,000 deaths p.a.

• In travellers

WHO. Wkly Epidemiol Rec 1999; 44:98

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Areas at Risk for ETEC
Travellers’ Diarrhoea
•
~20 million cases per year
•
~50% due to ETEC
Risk level
low
intermediate
high http://www.ncid.cdc.gov/travel/
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How Does ETEC Cause Diarrhoea?
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• Enterotoxins:

• heat-labile [LT]

• heat-stable [ST]

• Adhesins colonisation factor anti ens : ( g )

• CFA/I, CFA/II, CFA/IV, etc. (human strains)

• K88, etc. (animal strains)

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Demonstration of the Importance of Enterotoxins and CFA's in ETEC from Piglets Form of No. of No. with Strain piglets diarrhoea K88[+] Tox[+] 16 12 K88[+] Tox[−] 11 3 K88[−] Tox[+] 6 0

HW Smith et al J Med Microbiol 1971; 4:467

Immunisation of Piglets Against ETEC

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(Morgan et al Infect Immun 1978; 22:771)
K88
K88+ ETEC
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Use of Milk Immunoglobulin Concentrate Against ETEC

(Tacket et al. N Engl J Med 1988; 318:1240)

• Cows immunised 7-8 times with Freunds + LT, CTx, 14 ETEC

• Milk collected up to 10 days after calving

• Fat and casein removed; whey protein concentrated

• Mixed with antacid

• One dose contained 3 g protein, 0.55 g antacid in 250 ml water

• Volunteers given 3 doses per day 15 min after meals and after

• Challenged with 10[9 ] ETEC strain H10407 (ST, LT, CFA/I)

Results of Volunteer Study

(Tacket et al. N Engl J Med 1988; 318:1240)

	Results of Volunteer Study (Tacket et al._N Engl J Med_1988; 318:1240)	Results of Volunteer Study (Tacket et al._N Engl J Med_1988; 318:1240)
	Placebo Active
	( 10) P ( 10) Diarrhoea 9 0 Anorexia 9 0 n = arameter n =
	Malaise 9 0
	C ramps 8 0 Vomiting 6 0 Fever 2 0

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How Does Travelan Work?

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Which Antigens are Protective?

• Generally thought to be LT and CFA

• However , experimental and epidemiological evidence suggest that other antigens may be as important

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O-antigen (LPS)
H-antigen (flagella)
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Anadis’s Approach

• Vaccine from 14 ETEC strains

• Enriched for LPS and other surface antigens

• Cows immunised 3 times with vaccine + Montanide

• First milk collected after calving

• Fat and casein removed

• Remaining protein freeze-dried , pasteurised tablet

• Final product ( Travelan® ) is >85% protein, incl. ~50% Ig

• Approx 80% IgG1 , 4% IgG2, 8% IgA, 8% IgM

• 1 tablet contains 200 mg powder + proprietary protectant

		Clinical Trials in USA and Poland Placebo Study design Active Efficacy	Clinical Trials in USA and Poland Placebo Study design Active Efficacy
		Clinical Trials in USA and Poland Placebo Study design Active Efficacy
	1) 2 tabs tds with NaHCO3 no./total no./total %
	diarrhoea 11/15 1/15 91 other symptoms 8/15 1/15 88 2a) 1 tabs tds with NaHCO3
	diarrhoea 12/14 2/14 83
	other symptoms 5/14 1/14 80 2b) 1 tab tds with protectant diarrhoea 12/14 3/15 77 other symptoms 5/14 1/15 81

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Some Other Prophylactic and Therapeutic Applications of Orally Administered Bovine Ig

• Shigella dysentery

• Rotavirus diarrhoea

• Cryptosporidiosis

• Clostridium difficile colitis

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www.travelan.com
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Unsolicited Endorsements From:

• Individual travellers

• Travel groups

• Sports teams

• Doctors

• Patients with chronic diarrhoea due to inflammatory bowel disease

What is Inflammatory Bowel Disease?

• Ulcerative colitis and Crohn's disease

• Persistent and debilitating

• Unknown cause

• No cure

• Predisposes to cancer

• May require radical surgery

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Pathogenesis of Inflammatory Bowel Disease
genetic predisposition
+
environmental factors
(e.g., infection)
damage to intestinal lining
inflammation,
increased permeability
gut bacteria &
their products
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Pathogenesis of Cancer-Related Mucositis
cancer
+
chemotherapy/radiation therapy
damage to intestinal lining
inflammation,
increased permeability
gut bacteria &
their products
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Features of Innate Immunity

Innate Immunity:

• Is rapid

• Relatively non-specific

• Protects us when infectious agents first invade

• Interacts with and coordinates the acquired immune response

• Primitive: developed early in evolution

• Is activated by the recognition of PAMPs

Examples of PAMPS (pathogen-associated molecular patterns)

• Bacterial and viral nucleic acids

• Bacterial lipopolysaccharide (LPS)

• Bacterial flagellar protein

• Bacterial lipoproteins and other cell wall components

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How Bacteria
Activate the Innate
Immune System
www.SABiosciences.com
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A Simplified Model of How Bacteria Activate
the Innate Immune System
Bacterial
lysis/growth
PAMP
pattern
recognition
receptor inflammatory
mediators
co-receptor
intracellular
processing
signalling
receptor
nucleus mRNA
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Hyperimmune Colostrum Contains Antibodies to LPS

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Before Receiving ETEC Vaccine After Receiving ETEC Vaccine
1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9
1 – Enterobacter species 2 – Enteropathogenic E. coli
3 – Klebsiella pneumoniae 4 – Pseudomonas aeruginosa
5 – Salmonella enterica 6 – Vibrio cholerae
7 – Yersinia enterocolitica 8 – Citrobacter rodentium
9 – ETEC
Clare Oates (Anadis)
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Hyperimmune Colostrum Also Contains:

Antibodies to

• Bacterial flagella

• Various cell wall components

Antimicrobial compounds , e.g.

• Lactoferrin

Growth factors , including

• Transforming growth factor beta (TGF-β)

• Epidermal growth factor (EGF)

• Insulin-like growth factors (IGF)

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Summary

• Bovine immune colostrum provides a rich source o po yc ona an f l l l tib o di es or a var e y f i t of therapeutic applications

• Bovine Ig is well tolerated by mouth and survives p assa g e throu g h the intestine

• Licensing of new colostrum-based products for oral administration can be fast tracked

Summary

• H yper mmune ov ne co os rum s e i b i l t i ff ec ti ve against ETEC and other causes of acute diarrhoea and colitis

• Colostrum is also likel y to be effective in inflammatory bowel disease and mucositis

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A colostrum-derived product
for the treatment or
prevention of influenza
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Lorena Brown 2008
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Potential Uses

Seasonal influenza context

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1. Preventative in a high risk situation eg. air flight, crowds, family groups, nursing homes

2. Treatment when symptoms first show

Market depends on:

• Young adults and children typically not vaccinated

• Current vaccines only show 70% overall efficacy

• Less in target groups

• Vaccines have to be continuously updated due to antigenic drift of the virus and vaccine miss-match does occur

• Antiviral drugs need continuous administration (2x daily)

• Antiviral resistance is increasing

Potential Uses

Pandemic influenza context

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1. Treatment of infected individuals not responding to antiviral therapy

2. Treatment of contacts to prevent potential spread in early phase of the outbreak

Market depends on:

• No vaccine currently used for H5N1 avian influenza in high risk countries

• Sufficient pandemic vaccine will not be prepared and stockpiled in advance due to lack of information on emerging strain

• May take 2 doses of adjuvanted vaccine to achieve protection

• Eggs and adjuvant limit amounts produced

• Time to produce sufficient amounts leaves population reliant on antiviral drugs

Theoretical advantages of colostrumderived polyclonal Abs in these settings

• Many different Abs so selection of resistant virus not envisaged

• May need less frequent administration than antivirals

• Longevity of Ab means preventative use appropriate

• Potentially capable of halting disease at any stage of infection when used for treatment

• Should work in elderly and immunocompromised as independent of immune function

• Will not interfere with vaccines or antivirals

• Safety should be high

• Could be available over the counter

• 1000 to 10000 times cheaper than MAbs

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Data so far

• Cows were vaccinated against a virulent strain of mouse-adapted influenza virus A/Puerto/Rico/34 (PR8)

• At calving, first colostrum was harvested

• IgG Ab and F(ab’)2 fragments from these were prepared

• Abs were assessed for ability to inhibit the binding of virus to its receptors on red blood cells (HI), bind directly to virus (ELISA) and neutralise viral infectivity (VN) in vitro.

		Table 1. HI,ELISA Ab-binding titres and VN activity ofanti-PR8IgG andF(ab’)2 preparations	Table 1. HI,ELISA Ab-binding titres and VN activity ofanti-PR8IgG andF(ab’)2 preparations	Table 1. HI,ELISA Ab-binding titres and VN activity ofanti-PR8IgG andF(ab’)2 preparations	Table 1. HI,ELISA Ab-binding titres and VN activity ofanti-PR8IgG andF(ab’)2 preparations
		Purified Ab Sample	HI titre	**ELISA titre (log10) **	VN titre
		Anti-PR8IgG	1280	4.8	79,000
		Anti-PR8 F(ab’)2	2560	4.0	400,000
		Non-immuneIgG	<10	1.2	<10
		Non-immuneF(ab’)2	<10	1.2	<10

Models to assess Ab-induced protection and viral clearance 1. Clearance from the upper respiratory tract

10 µ l 500 pfu PR8 virus i.n.

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Kill mice and
assay viral load in
5 days post nose by plaque
Colostrum-derived infection formation
anti-PR8 Ab (IgG)
delivered i.n. 24 hr
after infection
Compare to mice
treated with
irrelevant Ab
Awake mouse
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1. Clearance from the upper respiratory tract

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•Ab treatment 24 hrs after infection is established specifically reduces virus loads in the nose •The effect was observed, even at 4 days after treatment •Less nasal shedding is expected to correlate with reduction in symptom severity in individuals and decreased transmission within populations

Models to assess Ab-induced protection and viral clearance 2. Clearance from the lungs

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50 µ l 50 pfu PR8 virus i.n.
(sub-lethal dose)
Kill mice and
assay viral load in
5 days post lungs by plaque
Colostrum-derived infection formation
anti-PR8 Ab (IgG)
delivered i.n. 24 hr
after infection
Compare to mice
treated with
irrelevant Ab
Penthrane-anaesthetised
mouse
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2. Clearance from the lungs

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Lung
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• Ab treatment 24 hrs after infection is established specifically reduces pulmonary virus loads • The effect was observed, even at 4 days after treatment • At high concentrations of immune IgG, virus was undetectable in the lungs of individual animals

• This may correlate with prevention of pneumonia

Models to assess Ab-induced protection and viral clearance 3. Protection from death

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50 µ l 500 pfu PR8 virus i.n.
(lethal dose)
Weigh mice daily
and record clinical
sighs and symptoms
1 mg Ab - IgG and F(ab’)2
- delivered 24 hrs after
Note survival time
infection by i.n. route
(Kill mice at humane
end-point)
Compare to mice
treated with
irrelevant Ab
Penthrane-anaesthetised
mouse
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3. Protection from death
culled PR8 IgG
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• Both immune IgG and F(ab’)2 preparations not only protected mice from death but also prevented clinical signs of infection including weight loss

Conclusions

• A method for generating very highly active Ab preparations has been determined

• Our mouse models have shown that a single treatment of colostrum-derived Ab given 24 hrs after establishment of influenza infection can

• (1) reduce the capacity of the virus to replicate in the nose.

• (2) completely clear virus from the lungs

• (3) protect against severe disease and death

Future questions

• How late after infection are Abs protective?

• Can Abs be given prior to infection and prevent disease?

• How long does the effect last?

• Is a second treatment beneficial?

• Can Abs protect against recent influenza isolates in a ferret model?

• Can Abs protect against highly pathogenic avian H5N1 virus?

• Where is the best spot in the respiratory tract to deliver these Abs?

• How might this best be achieved in humans?

• In Australia, influenza is responsible for a million medical consultations, 20,000-40,000 hospitalisations, 1,500 deaths and 1.5 million days off work each year

• The total economic cost of of this is about $600 million annually

• Globally, the death rate is estimated as 250-500 million each year.

• Pandemic influenza can kill 50 million people in the period of 18 months

• The rare individuals currently infected with avian H5N1 influenza have only about 40% chance of survival

Can the Anadis technology help reduce this disease burden?

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The CORAL Study
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Outline Background HIV/AIDS and combination antiretroviral therapies Suboptimal CD4 rises on cART Causes of persistent immune activation Microbial translocation in HIV patients Hyperimmune bovine colostrum Antiviral intensification Study Design Projected Study Timeline

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1

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The HIV-1 Pandemic

• Since 1981 approximately 25 million people have died from HIV/AIDS

• In 2007 33.2 million people were estimated to be living with HIV/AIDS

• Combination antiretroviral therapy (cART)

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• makes HIV/AIDS chronically managable ( > $50 billion for 3rd world)
1.6 million
760 000
1.3 million
800 000
380 000 4.0 million
1.6 million 22.5 million
75 000
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HIV-1 replication cycle
Entry
Maturation
CD4
Uncoating
CCR5/CXCR4 genomic RNA
Reverse Transcription
Budding
Integration LTR LTR
LTR LTR cDNA
Transcription genomic RNA
9kb m7G An
LATE EARLY
(High Rev) (Low Rev)
Rev/RRE
m7G Splicing An 9kb Degradem7G An
Splicing m7G Less SplicingAn 4kb m7G An Tat, Rev, Nef, Vpr Gag, Gag-Pol
m7G An 1.8kb m7G An
Export Translation Env, Vpu,
Vpr, Vif
NUCLEUS CYTOPLASM
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2

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Current Antiretroviral Targets
Protease Inhibitors
Fusion Inhibitors
Entry
Maturation
CD4
Uncoating N ucleoside analogues
CCR5/CXCR4 genomic RNA
Non-nucleoside analogues
Integrase Inhibitor: Reverse Transcription
RALTEGRAVIR Integration LTR LTR
LTR LTR cDNA
Transcription genomic RNA
9kb m7G An
LATE EARLY
(High Rev) (Low Rev)
Rev/RRE
m7G Splicing An 9kb Degradem7G An
Splicing m7G Less SplicingAn 4kb m7G An Tat, Rev, Nef, Vpr Gag, Gag-Pol
m7G An 1.8kb m7G An
Export Translation Env, Vpu,
Multiple drug resistance is a problem Vpr, Vif
NUCLEUS CYTOPLASM
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Suboptimal CD4 count despite cART

Immunological non-responder (INR) Definition:

Failure of CD4 counts to rise above 350 despite successful viral suppression on ART for 12 months

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Prevalence:

5-15% reported 14% of patients (AHOD)

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Immunological non-responders have poorer prognosis Patients with CD4 < 200 on cART: Increased risk of AIDS[1] Patients with CD4 < 350 on cART: Increased risk of serious non-AIDS events[1] : • Cardiac, non-AIDS malignancy • Hepatic and renal events Life expectancy of patients with CD4 < 500 on cART: Less than that of patients with CD4 > 500 1 Baker AIDS, 2008

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Predictors of poor CD4 increases on cART Particular antiretroviral therapy; Older age; Nadir CD4 count; Lower baseline plasma viral load; Failure to replete the pool of naïve T cells: Failure to regenerate thymus Persistent immune activation.

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.
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Rhesus Macaque Sooty Mangabey
High viral load High viral load
Disease No Disease
High Immune Activation Low Immune Activation
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HIV-1 associated destruction of GALT

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•HIV infects and kills >
60% of mucosal T-cells
within days
– both activated and
rest ng i CD4 + CCR5 +
memory T-cells
Brenchley and Douek
J Exp Med 2004
Normal small
intestine
Haynes. (2006) Nature
Med. 12:1351
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HIV-1 associated destruction of GALT
• Loss of gut CD4+ cells,
includes the TH17 cells that
make IL-17
• IL - 17 maintains tight junctions
between intestinal epithelial
cells.
HIV+ small
intestine
Haynes. (2006) Nature
Med. 12:1351
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HIV-1 associated destruction of GALT
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• Loss of gut CD4+ cells, includes the TH17 cells that make IL-17

• • IL - 17 maintains tight junctions between intestinal epithelial cells.

• • Gram negative cell wall contains LPS, flagellin and peptidoglycan

• • Potent immune activators that engage proinflammatory TLR

• • Normally restricted to the gut lumen • A damaged gut mucosa allows translocation of microbial products into the systemic circulation (“microbial translocation”)

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Long term immune recovery with HAART
Normalized CD4 count
PB
GALT
GALT
PB
Normalized immune activation
50
1 4 8
Years post HAART
Mahendru et al, 2006; Guadalupe et al, 2006; Mahendru et al, 2004;
Hunt et al, 2003; Guadalupe et al, 2003
CD4 count
HIV viral load Level of immune ac
tivation
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Bacterial translocation
HIV replication
2 [o] to a leaky gut? ?
Causes of persistent
immune activation on
antiretroviral therapy
Persistent abnormal immune function
T reg cells
Lymphocyte recirculation
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What is the relationship between immune activation and microbial translocation in persons with HIV?

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Microbial translocation in HIV:
Bacterial DNA and lipopolysaccharide (LPS)
PCR for serum 16S rRNA gene Plasma LPS
Brenchley, Nature Med 2006
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HAART significantly reduced LPS and sCD14 levels
p<0 . 001
p<0.001
p<0.001
p=0.086
n 72 72 7 n 72 72 7
Median (IQR) time on HAART = 5 years (3-8)
Baseline CD4 T-cell count 153 cells/µl (IQR 51-285)
All aviremic for duration of follow up Rajasuriar, Lewin et al
*Wilcoxon Signed rank; Mann-Whitney U
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LPS and sCD14 are correlated on and off HAART
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R=0.425, p<0.001
n = 151
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Microbial translocation in HIV:
LPS levels during cART
Untreated:
LPS ↑
cART:
LPS ‘normalizes’
INR:
LPS > FR
Marchetti AIDS 2008;22:2035
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Serum IgA levels inversely correlate with CD4 T cell counts
after 6 years of effective ART (Abbott 720 study)
2500
2000
R = -0.34
p=0.01
1500
1000
500
0
0 200 400 600 800
Year 6 IgA (mg/mL)
French MA et al, in preparation
3(cells/mm)
ar 6 CD4+ T-cell count
Ye
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Hypothesis of causes of persistent immune
activation in immunological non-responders
HIV driven
mechanisms
Mucosal
Immune ????
dysfunction
Mucosal
Integrity
Bacterial
translocation
Immune
activation
Ongoing HIV Replication and Immune Activation
Shen and Siliciano, J Allergy Clin Immunol, 2008
Using ultra-sensitive viral load assay to 1 copy/ml
• >80% of patients had detectable HIV RNA on long term HAART
• Steady state viremia at 1-5 copies/ml
• Correlation with pre-HAART HIV RNA
Maldarelli, Plos Pathogens 2007; Palmer, Proc Natl Acad Sci USA 2008
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Testable interventions
Reduction in viral replication:
Raltegravir:
• First in class integrase inhibitor
• May lead to reduced immune activation
• May have specific effect on ‘reservoir sites’
Reduction in gut microbial translocation:
Hyper-immune bovine colostrum;
Pass ve mucosai l delivery of immunog ol bulins;
� suppression of gut-associated inflammation with
promotion of mucosal repair and regeneration
Reduction in immune activation
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Colostrum and gut immunobiology
Placental mammals are born with highly immature mucosal immune
system and ‘leaky gut’ which if not immediately corrected will lead to
death due to infection;
Colostrum contains:
Neutralizing polyclonal antibodies;
Antimicrobial peptides;
• Lactoferrin and lactoperoxidase;
Cytokine tissue repair and growth factors;
• TGFa, TGFb, IGF Playford, Am J Clin Nutr 2000
Paradoxical CD4 rise in pts receiving colostrum for HIV-associated
diarrhoea
350 N = 30
300
250
200
150
100
50
0 Floren, Scand J Gastro 2006
Baseline Week 7
CD4 count / mm3
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BioGARD : Hyper-Immune Bovine Colostrum

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A. Western blot of LPS from different E.coli strains using BioGARD anti-LPS HIBC
1 2 3 4 5 6 7 8 9 10 Pregnant cows vaccinated with
bacterial cell wall antigens
produce highly concentrated IgG
t o LPS i n th e rs co os rum m fi t l t ilk .
Each BioGARD tablet contains
400mg of these antibodies.
B. Western blot of LPS from different E.coli strains using regular non-immune colostrum Ig
1 2 3 4 5 6 7 8 9 10
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BioGARD : Hyper-Immune Bovine Colostrum

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A. Western blot of LPS from different Gram negatives using BioGARD anti-LPS HIBC
1 2 3 4 5 6 7 8 9 10 Pregnant cows vaccinated with
bacterial cell wall antigens
produce highly concentrated IgG
t o LPS i n th e rs co os rum m fi t l t ilk .
Each BioGARD tablet contains
400mg of these antibodies.
B. Western blot of LPS from different Gram negatives using regular non-immune colostrum Ig
1 2 3 4 5 6 7 8 9 10
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The CORAL Study Randomised double-blind placebo controlled study to measure the effect of ART intensification with raltegravir and/or hyperimmune bovine colostrum on CD4+ T cell count in ART treated, HIV-1 infected individuals with suboptimal CD4+ T cell responses despite prolonged virologic suppression

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Primary Objective

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To measure the effect on CD4+ T cell outcome as measured by the mean time weighted CD4+ T cell count change over 24 weeks of two interventions in HIV-1 infected individuals who have failed to achieve a CD4+ T cell count greater than 350 cells/µL despite persistent HIV plasma viral load below 50 copies/mL on cART: (I) cART intensification with raltegrav ri (II) cART plus hyper-immune bovine colostrum

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Secondary Objectives
CD4 changes:
Proportion of patients with CD4 > 350/ μ L
CD4 (and CD8) absolute count
CD4 (and CD8) percentage
Immune activation:
CD4 and CD8 surface markers
• CD38
• HLADR
Plasma markers
• Interferon α ,
•
IgA/G/M
Viral load:
ultra sensitive assay LLD 0.4 copies/mL
Bacterial translocation markers:
LPS, sCD14, 16S rDNA fragments,
nge from baseline
Cha
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Inclusion Criteria (unique)

cART for 12 months with VL below level of detection either 50 cpm or 400 cpm for 9 months transient viral ‘blips’ not excluded Stable cART for 6 months; CD4 count: < 350/ μ L during past 6 months Rise in past 12 months < 50/ μ L

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Study Design
Arm Raltegravir HIBC Number
1x400mg tablet BD 3x600mg tablet BD
1 Active Placebo 18
2 Placebo Active 18
3 Active Active 18
4 Placebo Placebo 18
Randomised double-blind placebo controlled trial:
stratification by: site and screening CD4 count (≤200 or > 200)
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Sample size
Assumptions:
24 week change in CD4 count
• ↑ 75 (+/- 100 / μ L)
•
0 (+/- 80 / μ L)
No interaction between Raltegravir and HIBC
Loss to follow-up
10%
Power
90%
Total N = 72 = 4 x 18
N on raltegravir = 36
N on HIBC = 36
N on placebo = 18
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Study time-line
Screen Blinded Phase Unblinded
3 weeks 48 weeks X weeks
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Unblinding

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The blinded phase will end when the analysis of the week 24 data is complete for entire cohort Patients who reach week 48 before the study is unblinded will receive open-labelled RAL and HIBC without unblinding their original Rx Raltegravir and HIBC will be provided for up to one year after unblinding Supply of unblinded Raltegravir and/or HIBC may be modified depending on the outcome of the 24 week data

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Projected time-line Site selection Complete Ethics committee Approval Complete - October 16, 2008 Recruitment commences January - February 2009 Recruitment complete April-May 2009 24 week data analysis November 2009

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Gladstone Road Medical Centre
AIDS Medical Unit
Nambour • Nambour
Hospital
• Gold Coast
Lismore Sexual • Lismore Gold Coast
Health Service Sexual
Royal Perth Health
Hospital
Fremantle
�
Fremantle
Hospital RPAH
Liverpool HopsitalDr Doong’s Surgery
POWH
Melbourne Sexual Health ClinicPrahran MarketCentre ClinicCarlton ClinicThe Alfred Hospital Albion Street CentreSt VincentHHMPRoyal North ShoreEast Sydney Doctors’s Hospital
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Investigators Study Director: Prof. David Cooper Protocol Steering Committee: A/Prof Damian Purcell Dr Mark Kelly Prof Martyn French A/Prof Sean Emery A/Prof Anthony Kelleher Prof Sharon Lewin Dr Roger Garsia Dr Janaki Amin Dr Mark Boyd Dr Janaki Amin Dr Helen Byakwaga

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