Effect of PCSK9 Inhibition on Cardiovascular Risk in Treated HIV Infection (EPIC-HIV Study)

Cardiovascular disease (CVD) due to atherosclerosis continues to be the leading single cause
of death in industrialized countries. High serum lipid levels, and especially high
low-density lipoprotein cholesterol (LDL-C) levels, have been demonstrated to strongly and
directly correlate with CVD risks by numerous epidemiological studies. Moreover, large
prospective clinical outcome trials have demonstrated that lowering LDL-C decreases
cardiovascular morbidity and mortality. A meta-analysis of 26 randomized clinical trials
comprising 170,000 participants showed that more intensive statin therapy compared to less
intensive regimens will reduce coronary deaths or myocardial infarction by an additional 13%.

HIV-infected individuals represent a unique and increasing subset of atherosclerosis. With
the advent of antiretroviral therapy, HIV-infected individuals now have much improved
survival and are faced with health issues related to aging, including cardiovascular disease.
Individuals with HIV have higher rates of coronary events compared to controls even in the
setting of treated and suppressed disease and a growing body of literature suggests that they
are at increased risk for myocardial infarction, atherosclerosis, and sudden cardiac death.
Many facets of atherosclerosis differ in HIV-infected individuals compared to uninfected
individuals with atherosclerosis. HIV-infected patients with acute coronary syndromes are
younger and more likely to be males and smokers, with low high density
lipoprotein-cholesterol (HDL-C), compared to other acute coronary syndrome patients. With
respect to pathophysiology, viral replication, antiretroviral drugs all contribute to
atherosclerosis.

HIV-associated inflammation induces pro-atherogenic lipid abnormalities and anti-retroviral
therapy leads to the development of metabolic abnormalities such as dyslipidemia,
lipodystrophy and insulin resistance. In a large cross-sectional study, 27% of subjects
receiving combination therapy including a protease inhibitor had a total cholesterol level
exceeding 240 mg/dl, compared to 8% of untreated HIV subjects, and 40% had triglyceride
levels above 200 mg/dl, compared to 15% in untreated subjects. The prevalence and severity of
dyslipidemia varies among different antiretroviral drugs; however, hypertriglyceridemia and
low HDL-cholesterol were associated with HIV infection even before the advent of
antiretroviral therapy. Total, HDL-C, and LDL-C decrease at the time of HIV infection, and
with antiretroviral treatment total and LDL-C levels increase to pre-infection levels while
HDL-C remains low.

Abnormalities in body composition have been reported in 40-50% of HIV-infected patients, with
higher rates in those receiving combination antiretroviral therapies. Subcutaneous
lipoatrophy commonly affects the face, limbs, and buttocks, and is accompanied by central fat
accumulation. Hyperinsulinemia is often also present. In a representative study, diabetes was
present in 7% of HIV-infected adults with fat accumulation or lipoatrophy, as compared to
0.5% of control subjects matched for age and BMI. The corresponding rates of glucose
intolerance were 35% and 5% respectively. Compared to healthy control subjects, HIV-infected
men treated with combination antiretroviral therapy were 4 times as likely to develop
diabetes over a 3-year observation period.

The increased cardiovascular risk and dyslipidemia in HIV-infected individuals is difficult
to treat for several reasons. Statins reduce LDL-C levels less in HIV-infected individuals
compared to uninfected controls. Fibrates reduce triglyceride levels less in HIV-infected
individuals compared to uninfected controls as well. Drug-drug interactions between statins
and protease inhibitors increase the risk of adverse events. Due to these interactions,
simvastatin and lovastatin are contraindicated among individuals receiving protease
inhibitors and the dose of atorvastatin should not exceed 40 mg. Even interactions with
rosuvastatin, which is not metabolized by the cytochrome P450 system, have been described.

As a consequence, physicians may avoid treating HIV-infected individuals who would benefit
from statins, or use lower doses or less potent statins, reducing the potential for
cardiovascular event reduction. High triglyceride levels in HIV-infected subjects are common,
and the combination of a fibrate plus antiretroviral therapy increases the risk of drug-drug
adverse events, even before consideration of a statin.

Statin treatment reduces lipid levels modestly in HIV subjects. Among 72 HIV-infected
subjects in the SATURN-HIV trial randomized to rosuvastatin 10 mg/day, LDL-C was reduced by
25.3% by week 24. In another study, of 83 HIV-infected subjects, rosuvastatin 10 mg and
pravastatin 40 mg/day reduced LDL-C by 37% and 19% respectively at 45 days. Among 151
HIV-infected subjects randomized to rosuvastatin 10 mg, atorvastatin 10 mg, or pravastatin 40
mg/day, LDL-C reductions were greater with rosuvastatin at this dose, but all 3 statins
significantly and similarly reduced serum levels of hs-CRP and TNF-a.

Approximately 1/3 of individuals with HIV-infection are co-infected with hepatitis C.
Elevated hepatic enzymes due to hepatitis C represent a relative contraindication to statin
therapy, and some evidence suggests that a statin might increase hepatitis C activity.
Finally, HIV-infected patients often need many medications and have a large daily pill
burden. Compliance suffers, but has been shown to improve when single tablet regimens reduce
daily pill load. Long-acting injectable antiretroviral drugs are under development as a
strategy to reduce pill burden and improve compliance. PCSK9 inhibitor injections would
dovetail well with this approach. For these reasons, PCSK9 inhibitor therapy offers
advantages over statin therapy in this unique population.

That statins might favorably influence the evolution of atherosclerosis in HIV-infected
subjects is suggested by a recent trial where 40 HIV subjects with mild coronary
atherosclerosis by CT angiography and aortic inflammation by FDG-PET imaging were randomized
to atorvastatin 20-40 mg/day or placebo and were followed for 12 months. Atorvastatin
significantly reduced non-calcified coronary plaque volume relative to placebo, as well as
the number of high-risk plaques.

In the HIV-uninfected population, statin therapy produced significant and rapid
dose-dependent reductions in FDG update that were reflective of changes in atherosclerotic
plaque inflammation. In addition, lipoprotein apheresis resulted in significant reduction of
arterial inflammation. Recently, addition of evolocumab was found to result in a greater
decrease in percent atheroma volume using intravascular ultrasound. All of these studies
which were performed in the non-HIV population provide a strong scientific rationale for
studying the role of PCSK9 inhibition in HIV. Namely, given the strong association between
HIV, noncalcified plaque, and arterial inflammation, PCSK9 therapy may play a unique role in
reducing HIV-associated atherosclerosis, Alirocumab (Sar236553/REG 727) is a fully humanized
monoclonal antibody against the proprotein convertase subtilisin kexin type 9 (PCSK9) enzyme
responsible for the degradation of the low-density lipoprotein receptor (LDLR), and is
developed by Regeneron Pharmaceuticals/Sanofi. In a randomized trial of 2341 patients with
heterozygous familiar hypercholesterolemia or with established coronary heart disease or a
CHD risk equivalent with LDL levels≥70mg/dL and were receiving treatment with statins at the
maximum tolerated dose with or without other lipid-lowering therapy. Patients were randomly
assigned to a 2:1 ratio to receive alirocumab 150mg or placebo every 2 weeks for 78 weeks. At
week 24 the difference between the alirocumab and placebo groups from baseline to calculated
LDL was -62 percentage points. The alirocumab group had higher rates of injection site
reactions, myalgia, neurocognitive events and ophthalmologic events. The rate of major
adverse cardiovascular events was lower in the alirocumab group as compared to placebo in a
post hoc analysis (p=0.02).

Preliminary data on 6 HIV-infected individuals inadvertently enrolled in a PCSK9 inhibitor
study using evolocumab demonstrated that LDL was lowered 60%, along with significant
reductions in triglycerides and Lp(a) and was well tolerated (unpublished data)

Based on these findings a dose of 75 mg every 2 weeks for 6 weeks followed by an upward
titration to 150 mg every 2 weeks for those with LDL-C >50 mg/dl for the remainder of the
study for this trial will be used. Based on population PK/PD modeling, a dose of 150 mg every
2 weeks in patients on a background of statins is estimated to be equivalent to approximately
80% of the maximal response for LDL-C lowering (-67%). Assuming an average LDL C at baseline
of 100 mg/dL for HIV-infected individuals, the mean absolute LDL-C reduction is predicted to
be approximately -60 mg/dL.

Inclusion Criteria:

1. Evidence of a personally signed and dated informed consent document indicating that
the subject has been informed of all pertinent aspects of the study.

2. Subjects who are willing and able to comply with scheduled visits, treatment plan,
laboratory tests, and other study procedures.

3. Males and females equal or greater than 40 years of age.

4. Documented HIV infection.

5. HIV-1 RNA level below 200 copies/mL for at least 12 weeks prior to study entry

6. CD4 T Cells ≥200 cells/mm3 at screening

7. Continuous ART for at least 12 weeks with no change in regimen prior to study entry.

8. Moderate or high CVD risk defined as: documented CVD as assessed by meeting at least 1
of 3 criteria below:

1. Coronary artery disease (CAD)

2. Cerebrovascular disease

3. Peripheral arterial disease

OR any one of the following CVD risk factors:

1. Controlled type II diabetes mellitus (HbA1C ≤ 8.0%)

2. Family history: a first degree relative who had a heart attack, stroke, or
documented CVD as defined in the previous section that occurred: a. When they
were age 55 years or younger for males (father, uncle, or brother) b. When they
were age 60 years or younger for females (mother, aunt, or sister)

3. Current smoking

4. Hypertension

5. Dyslipidemia

6. A hsCRP ≥ 2mg/L at screening.

9. Lipids at screening visit:

- Fasting LDL-C ≥ 70 mg/dL (1.81 mmol/L);

- Fasting TG ≤ 600 mg/dL (6.78 mmol/L).

10. If subjects meet ACC/AHA criteria for statin therapy and are not currently on a
statin, subjects must be taking a stable dose of statin for at least 4 weeks, unless
they are statin intolerant, refuse to take a statin, or have a medical condition (e.g.
chronic hepatitis) where a statin is contraindicated.

Exclusion Criteria:

1. Subjects who are investigational site staff members directly involved in the conduct
of the trial and their family members, site staff members otherwise supervised by the
Investigator, or subjects who are Regeneron employees.

2. Participation in other studies involving small molecule investigational drug(s).

3. Subjects who are unable to receive injections, as either a self-injection, or
administered by another person.

4. Subjects requiring daily insulin therapy

5. Intended modification of ART in the next 52 weeks

6. History of a cardiovascular or cerebrovascular event or procedure (e.g., myocardial
infarction, stroke, transient ischemic attack, angioplasty) during the past 90 days.

7. Congestive heart failure, New York Heart Association functional class IV, or left
ventricular ejection fraction measured by imaging known to be <25%. (Imaging not
required for study inclusion).

8. Poorly controlled hypertension

9. Any history of hemorrhagic stroke or lacunar infarct.

10. Current untreated hypothyroidism or thyroid stimulating hormone (TSH)

11. Current history of alcoholism or drug addiction according to the Diagnostic and
Statistical Manual of Mental Disorders (DSM) IV criteria within 12 months prior to
screening. Use of any illicit drug confirmed by urine toxicology test at screening
that would in the opinion of the investigator interfere with study procedures or
results.

12. History of cancer within the last 5 years (except for cutaneous basal cell or squamous
cell cancer resolved by excision, or cervical carcinoma in situ).

13. Any disease or condition that might compromise the hematological, renal, hepatic,
pulmonary, endocrine, central nervous, immune, or gastrointestinal systems.

14. Undergoing apheresis or have a planned start of apheresis.

15. Initiation of or change in non-lipid lowering prescription drugs, herbal medicine or
supplements (including foods with added plant sterols and stanols) within 6 weeks of
screening with the exception of initiation or change in multivitamins used for general
health purposes. Short-term use of medications to treat acute conditions, and vaccines
are allowed (e.g., antibiotics or allergy medication).

16. History of allergic or anaphylactic reaction to any therapeutic or diagnostic
monoclonal antibody (IgG protein) or molecules made of components of monoclonal
antibodies (e.g., Enbrel® which contains the Fc portion of an antibody or Lucentis®
which is a Fab).

17. Any abnormal hematology values, clinical chemistries, or ECGs at screening judged by
the Investigator as clinically significant, which could impact on subject safety, were
the potential subject to be included in the study, or interfere with the
interpretation of study results.

18. Active phase hepatitis. Stable patients with hepatitis B or C infection >2 years
before randomization are eligible.

19. Aspartate transaminase (AST) or alanine transaminase (ALT) > 5 X ULN at screening.

20. Direct bilirubin > 4 X ULN at screening.

22. GFR < 60 mL/min/1.73m2 at screening or undergoing dialysis.

23. Changes in lipid-lowering or antihypertensive medication within 90 days prior to study
entry or expected need to modify these medications during study

24. Female subject who has either (1) not used at least 1 highly effective method of birth
control for at least 1 month prior to screening or (2) is not willing to use such a method
during treatment and for an additional 105 days after the end of treatment, unless the
subject is sterilized or postmenopausal.

- Highly effective methods of birth control include not having intercourse or using
birth control methods that work at least 99% of the time when used correctly and
include: birth control pills, shots, implants or patches, intrauterine devices (IUDs),
tubal ligation/occlusion, sexual activity with a male partner who has had a vasectomy,
condom or occlusive cap (diaphragm or cervical/vault caps) used with spermicide

- Achieved post-menopausal status is defined as 12 months of spontaneous and continuous
amenorrhea in a female

- 55 years old or 12 months of spontaneous and continuous amenorrhea with a
follicle-stimulating hormone (FSH) level > 40 IU/L (or according to the
definition of "postmenopausal range" for the laboratory involved in a female <50
years old unless the subject has undergone bilateral oophorectomy.

25. Pregnant females; breastfeeding females.

26. Additional exclusion criteria for the FDG-PET/CT imaging (patients with these
exclusions may participate in the rest of the trial):

a. Significant radiation exposure during the year prior to randomization.
Significant exposure is defined as i) more than 2 PCI procedures, ii) more than 2
myocardial perfusion studies, or iii) more than 2 CT angiograms.

b. Any history of radiation therapy.

c. Current insulin use

26. Additional exclusion criteria for CTA imaging:

1. Significant radiation exposure during the year prior to randomization.
Significant exposure is defined as i) more than 2 PCI procedures, ii) more
than 2 myocardial perfusion studies, or iii) more than 2 CT angiograms (as
with FDG-PET/CT).

2. Any history of radiation therapy (as with FDG-PET/CT).

3. Any contraindication to beta-blocker (atenolol and metoprolol) or
nitroglycerin use, because these drugs are given as part of the standard
cardiac CT protocol.

4. Significant renal dysfunction (defined as an eGFR < 60 mL/min/1.73m2).

5. Body weight > 300 pounds (136 Kg), because of the CT scanner table
limitations.

6. Allergy to iodine-containing contrast media.

7. Any history of CABG.