Treatment of HIV- and HIV+ Patients with HPV16+ CIN2/3 Using pNGLV4a-hCRTE6E7L2 DNA vaccine administered intramuscularly via electroporation

致癌性人乳头瘤病毒（HPV）是99%的宫颈癌的病原体，但HPV 16是最重要的类型，因为它导致所有宫颈癌病例的一半和其他部位HPV相关癌症的>90%。许可的疫苗无法消除现有的HPV感染是一个主要的未满足的医疗需求，因为世界范围内HPV相关疾病的负担相当大，并且HPV疫苗接种在美国的实施受到限制。HPV相关癌症的发病率在宫颈和HIV+患者的其他部位也显著升高。HIV+患者获得更频繁的多类型感染，包括许多在健康个体中不常见的基因型，并且不是当前HPV疫苗的靶向。在本SPORE中，我们开发了一种候选的治疗性和预防性HPV疫苗，pNGVL 4ahCRTE 6 E7 L2，其包含编码钙网蛋白（CRT）的DNA载体，所述钙网蛋白与HPV 16 E6、E7（其在所有HPV感染的细胞中表达）和L2衣壳蛋白（广泛保护性抗原）基因融合。与热休克蛋白CRT的融合已经显示出增强DNA疫苗的效力，甚至在CD 4耗尽的动物中，使得pNGVL 4a-hCRTE 6 E7 L2 DNA疫苗特别有希望用于HIV+患者，这是一个特别具有挑战性的治疗组。尽管DNA疫苗相对安全，但是当通过常规肌内针注射施用时，它们通常表现出次优的免疫原性，这可能反映了宿主细胞转导的效率低下。我们以前已经表明，电穿孔是最有效的DNA疫苗管理方法，以产生HPV特异性的CD 8 + T细胞免疫应答，相比传统的肌肉注射和表皮通过基因枪交付。在这里，我们建议使用Ichor TriGrid电穿孔装置，该装置已用于多项临床试验，在患有HPV 16相关的高度宫颈上皮内瘤变（CIN 2/3）的HIV-和HIV+患者中以递增剂量肌内注射pNGVL 4a-hCRTE 6 E7 L2 DNA疫苗，并检查安全性、病毒学和疾病结局。全身和局部免疫应答将与这些结果以及PD-L1的病灶表达相关，PD-L1是与免疫逃逸相关的途径。

Oncogenic human papillomaviruses (HPVs) are the etiologic agents of 99% of cervical cancer, but HPV16 is the most important type as it causes half of all cervical cancer cases and >90% of HPV-associated cancers at other sites. The inability of licensed vaccines to eliminate existing HPV infections is a major unmet medical need since there is a considerable burden of HPV-associated disease worldwide, and implementation of HPV vaccination in the US has been limited. HPV-associated cancer incidence is also significantly elevated in cervical and at other sites in HIV+ patients. HIV+ patients acquire more frequent multi-type infections, including many genotypes infrequently seen in healthy individuals, and not targeted by the current HPV vaccines. In this SPORE we developed a candidate therapeutic and preventive HPV vaccine, pNGVL4ahCRTE6E7L2, which comprises a DNA vector encoding calreticulin (CRT) fused genetically with HPV16 E6, E7 (that are expressed in all HPV infected cells) and L2 capsid protein (a broadly protective antigen). Fusion with the heat shock protein CRT has been shown to enhance the potency of DNA vaccines, even in CD4 depleted animals, making the pNGVL4a-hCRTE6E7L2 DNA vaccine particularly promising for use in HIV+ patients, a particularly challenging group to treat. Although DNA vaccines are relatively safe, they generally exhibit suboptimal immunogenicity when administered by conventional intramuscular needle injection, likely reflecting inefficient host cell transduction. We have previously shown that electroporation was the most effective DNA vaccine administration method to generate HPV-specific CD8+ T cell immune responses, compared to conventional intramuscular injection and epidermal delivery via gene gun. Here we propose to use the Ichor TriGrid Electroporation Device, which has been used in multiple clinical trials, for intramuscular administration of pNGVL4a-hCRTE6E7L2 DNA vaccine at escalating doses in HIV- and HIV+ patients with HPV16-associated high-grade cervical intraepithelial neoplasia (CIN 2/3) and to examine the safety, virologic and disease outcomes. The systemic and local immune responses will be correlated with these outcomes as well as lesional expression of PD-L1, a pathway associated with immune escape.