INVITED ARTICLE

HIV/AIDS

Kenneth H. Mayer, Section Editor

HIV Vaccines: New Frontiers in Vaccine Development

Ann Duerr,1 Judith N. Wasserheit,1,2 and Lawrence Corey1,2
1

Clinical Research Division, Fred Hutchinson Cancer Research Center, and 2Department of Medicine, University of Washington, Seattle, Washington

The human immunodeficiency virus (HIV) pandemic is now

in its third decade. To date, 20 million people have died of
AIDS, and 14,000 are newly infected with HIV every day.
Prevention strategiesincluding behavioral interventions, antibiotic treatment for sexually transmitted diseases other than
HIV (such as syphilis), and prescreening of blood products
have failed to control the spread of HIV infection in many
populations. Antiretroviral therapies remain woefully inadequate to meet the needs of all who require treatment for HIV
infection. Even if one were able to use antiretroviral therapy
to treat everyone with HIV infection, it could not be initiated
quickly enough to prevent critical early events, such as enhanced transmission to sexual partners during the spike in the
HIV viremia that is associated with acute infection [1] and the
massive destruction of gut CD4+ T cells that occurs within the
initial weeks of HIV infection [2].
An HIV vaccine is the most promising and feasible strategy
to prevent these events that influence both HIV disease course
and transmission. Yet, despite initial optimism and evaluation
of 130 products in 185 trials, the search for an HIV vaccine
has yet to reach its goal after 120 years. Although there are no
established correlates of protection and no candidates capable
of eliciting a sterilizing immunity, the field has seen a rapid
expansion in recent years in the number and types of candidate
vaccines. Although spontaneous clearing of HIV infection that
Received 3 February 2006; accepted 22 April 2006; electronically published 6 July 2006.
Reprints or correspondence: Dr. Ann Duerr, Fred Hutchinson Cancer Research Center, 1100
Fairview Ave. N, LE-500, Seattle, WA 98109-1024 (aduerr@hvtn.org).
Clinical Infectious Diseases 2006; 43:50011
 2006 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2006/4304-0018$15.00

500 CID 2006:43 (15 August) INVITED ARTICLE

is attributable to natural immunity has not been observed,

testing in animal models suggest that vaccine-induced cellular
immunity reduces the HIV viremia and prevents CD4+ T cell
loss. Ongoing trials will test whether vaccine-induced immunity
leads to amelioration of disease course. Although developing a
safe, globally effective HIV vaccine is a daunting challenge, it
is perhaps the worlds highest public health priority.
KEY BIOLOGICAL DIMENSIONS
OF THE CHALLENGE
Although correlates of protection and animal models would
facilitate the search for an HIV vaccine, 3 fundamental, biological properties of the virus make HIV a cunning foe. First,
like all retroviruses, HIV is rapidly reverse-transcribed and integrated into host DNA, thereby establishing a beachhead for
lifelong infection. The resulting reservoir of latently infected
CD4+ T cells means that, without induction of durable, sterilizing immunity, HIV vaccines are unlikely to prevent persistent infection. Second, HIV infection progressively disables the
very host immune responses required for vaccine efficacy and
for control of viral replication. Although direct destruction of
infected CD4+ T helper cells is a primary mechanism for this
immune dysfunction, uninfected immune system cells may also
be depleted or functionally compromised as a result.
Continuously evolving antigenic variation in HIV poses the
third formidable challenge to vaccine development. On the
basis of full-length genome sequences, HIV is classified into 3
main groups: M (main), O (outlier), and N (non-M, non-O).
The vast majority of HIV subtypes belong to the M group,
which contains 22 circulating genetic forms. Nine of these

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A human immunodeficiency virus (HIV) vaccine is the most promising and feasible strategy to prevent the events during
acute infection that simultaneously set the course of the epidemic in the community and the course of the disease for the
individual. Because safety concerns limit the use of live, attenuated HIV and inactivated HIV, a variety of alternate approaches
is being investigated. Traditional antibody-mediated approaches using recombinant HIV envelope proteins have shown no
efficacy in 2 phase III trials. Current HIV vaccine trials are focusing primarily on cytotoxic T lymphocytemediated products
that use viral vectors, either alone or as boosts to DNA plasmids that contain viral genes. The most immunogenic of these
products appear to be the recombinant adenovirus vector vaccines, 2 of which are now in advanced clinical development.

APPROACHES TO DEVELOPMENT OF
PREVENTIVE HIV VACCINES
The traditional strategy: stimulating neutralizing antibodies.
Ideally, all preventive HIV vaccines would abort HIV infection
by providing sterilizing immunity, through stimulation of high
titers of broadly neutralizing antibodies. Indeed, most licensed

vaccines depend primarily on such responses [14]; in the 1990s,

experiments in nonhuman primates indicated that passive
transfer of neutralizing antibodies could protect against experimental challenge from primate lentiviruses [1517]. Therefore,
the initial strategy for HIV vaccine development used recombinant HIV envelope proteins (gp160 or gp120) in an attempt
to elicit neutralizing antibodies. A large variety of these proteins
were administered in various adjuvants. Although the products
proved to be very safe [1820], the antibody responses they
elicited were generally low in titer, narrow in breadth, and
limited in their ability to neutralize primary isolates (i.e., viruses
isolated from recently infected individuals) [21]. Two recent
phase III trials of rgp120 products evaluated a clade B candidate
in the United States, Canada, and Europe and a clade B/E
mixture in Thailand. Neither vaccine prevented infection or
ameliorated postinfection course [2225].
Several features of HIV envelope contribute to its ability to
evade effective surveillance by the humoral immune system.
The HIV envelope is a trimer of heterodimers. Each heterodimer consists of a surface subunit (gp120) and a transmembrane subunit (gp41) that are noncovalently bound to each
other. Maintenance of this native trimeric structure appears
necessary to elicit the production of neutralizing antibodies.
Conversely, the native structure of the HIV envelope shields it
from many potentially neutralizing epitopes, such as the coreceptor binding site, which is made accessible only after CD4+
T cell binding [26]. Similarly, mutational substitution studies
of glycosylation sites demonstrated that changes at these sites
affected neutralization of distant epitopes [27].

Figure 1. Global distribution of HIV-1 subtypes and recombinants. Reproduced with permission from the International AIDS Vaccine Initiative Report,
published by the International AIDS Vaccine Initiative. (Source: F. E. McCutchan and international colleagues, Henry M. Jackson Foundation, personal
communication).
INVITED ARTICLE CID 2006:43 (15 August) 501

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forms are designated HIV subtypes or clades (subtypes A

D, FH, JK), which differ by 25%35% in env sequences
and 15% in gag sequences [3]. A growing number of new
circulating recombinant forms are being identified. The tremendous global variation in HIV strains (figure 1), which
dwarfs that of other vaccine-preventable pathogens such as
influenza virus [4], raises concern about whether vaccine candidates can effectively protect against the wide diversity of globally circulating vaccines. Novel approaches to the formulation
of multivarient vaccines are likely to be required.
Because cellular responses to natural infection or immunization are generally broader than humoral responses, crossclade cytotoxic T lymphocytes (CTLs) are detected in individuals infected with a single HIV subtype [5]. Vaccination with
products directed at subtype B viruses results in CTL responses
that recognize multiple subtypes, although intraclade responses
are generally strongest [513]. This cross-clade response is due
not only to generation of CTLs that recognize conserved epitopes common to several clades, but also to the promiscuity
of the T cell receptor, which can accommodate variability in
the epitopes it recognizes. However, escape from CTLmediated
containment is well described.

Several human monoclonal antibodies that have broadly

neutralizing activities have been described, and their study may
provide insights into vaccine design. These antibodies include
F105 and b12, which are specific to the CD4+ T cell binding
site on gp120; 2G12, which recognizes a complex epitope on
gp120; and 2F5 and 4E10, which recognize linear epitopes on
gp41 (figure 2) [28]. Combinations of these monoclonal antibodies reveal strong cross-clade neutralization against clades
A, B, C, and D in vitro, as well as strong antiviral protection
in neonatal macaques [29, 30]. The use of these epitopes in
vaccine development is the object of intense study. For example,
the b12 monoclonal antibody has an unusual, extended, antigen-binding finger that accesses a normally recessed epitope
on gp120, thereby blocking CD4+ T cell binding [26]. Moreover,
antibodies that target gp41 domains involved in virus fusion
with the target cell, as 2F5 and 4E10 do, may be limited by
steric hindrance and by the rapidity of the fusion process [26,
31]. Understanding how to develop immunogens that can
mimic the effects of these monoclonal antibodies and that can
elicit the production of effective neutralizing antibodies to a
wide variety of circulating strains of HIV remains a challenge.
The current strategy: stimulating cellular immunity.
Faced with the lack of efficacy of products designed to elicit
the production of neutralizing antibodies, HIV vaccine development has shifted its primary focus to cellular immunity. Most
ongoing trials are testing vaccine candidates that are meant to
induce HIV-specific CTL production. These immune effector
cells recognize HIV epitopes that are displayed on cell surfaces
in conjunction with human leukocyte antigen but do not recognize free viruses. They limit the spread of HIV infection by
502 CID 2006:43 (15 August) INVITED ARTICLE

destroying infected cells via apoptosis or by secreting chemokines and cytokines that interfere with subsequent rounds of
infection.
Work in nonhuman primates indicates that vaccines that
elicit the production of HIV-specific CTLs probably act by limiting HIV replication, thereby reducing the HIV load in infected
individuals, rather than by preventing HIV acquisition. In some
animals, viral replication appears to be completely suppressed
with the use of these vaccines, whereas limited residual viral
replication continues in other animals [3234]. In humans, the
set-point viral load predicts the subsequent disease course [35],
whereas transmission to sexual partners correlates with the
plasma viral load and may be completely prevented when the
viral load decreases to !1500 copies/mL [36]. Thus, HIV-specific CTLs may mitigate the individual- and population-level
effects of HIV infection, even if they do not prevent acquisition
of infection itself.
Considerations in vaccine design. Since 1798, when Edward Jenner established the vaccine era with his treatise on
ariolae vaccinae [37], 5 basic approaches to viral vaccine design
have been used (table 1). Two of the most effective approaches
have harnessed live, attenuated organisms and inactivated organisms. Unfortunately, neither has proven optimal for HIV
vaccine development. Live, attenuated virus vaccines initially
appeared to be successful in preventing experimental challenge
in nonhuman primates [38, 39]; however, attenuated HIV mutants appear to be pathogenic in humans: late-onset immunosuppression occurred in 3 of 6 individuals who were exposed
through blood transfusion to HIV carrying deletions in both
nef and the long terminal repeat [38, 39]. The delayed path-

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Figure 2. Schematic revealing the location of neutralizing antibody epitopes on gp120 and gp 41 (shown in the native form and the transient,
prehairpin form). Reproduced with permission from [28].

Table 1. Potential advantages and disadvantages of major HIV vaccine design strategies.
Immunogen

Advantages

Disadvantages

Successfully used for other pathogens; protective in

some nonhuman primate systems

Inactivated SIV/HIV

Successfully used for other pathogens

Envelope proteins

Successfully used for other pathogens; safe; targets humoral immunity

Narrow neutralizing specificity; no CTLs; provided

no protection in 2 efficacy trials

Peptides

Safe; inexpensive; potentially useful for wide antigenic

diversity

Poorly immunogenic in human trials; formulation/

adjuvant development required

DNA

Presents immunogen in conjunction with HLA; immunogenic in mice, NHP; safe; able to give multiple doses

Poor immunogenicity in humans; concerns about

DNA integration

Viral vectors
Poxviruses

Widely used in vaccines (vaccinia/smallpox vaccine)

Can be highly immunogenic; induces cellular immunity

Safety concerns (vaccinia)

Response to vaccinia is limited by preexisting immunity (smallpox vaccination); limited immunogenicity (canarypox); limited/narrow neutralizing
antibody response

Highly immunogenic; robust CTL response; safe

Response limited by preexisting immunity (especially adenovirus serotype 5)

Adenoviruses

Safety concerns; attenuated variants cause disease in juvenile, and some adult, macaques; attenuated viruses cause disease in humans
Safety concerns about consistent inactivation; no/
few neutralizing antibodies; no CTLs

NOTE. CTL, cytotoxic T cell; HLA, human leukocyte antigen; NHP, nonhuman primate; SIV, simian immunodeficiency virus.

ogenicity of such a double-deletion virus has cast doubt on the

safety of using live, attenuated approaches.
A variety of killed vaccines has been tested, with little efficacy
in nonhuman primate models [38, 39]. Interest in pursuing
this approach has been limited by a lack of inducible T cell
immunity and by safety concerns about potential residual infectivity in the product due to incomplete inactivation (such
as that which occurred during the Cutter incident with the Salk
polio vaccine [40]).
Other approaches to vaccine development have employed
viral proteins, peptides, or subunits, DNA plasmids carrying
viral genes, and other viruses or bacteria as Trojan horse
vectors to deliver viral genes. As discussed above, HIV envelope
proteins have not proven efficacious in 2 phase III vaccine trials
[2224] (table 2). Therefore, the primary emphasis of current
HIV vaccine trials has shifted to viral vectors, either alone or
in combination with DNA plasmid vaccines (table 2).
DNA plasmids that deliver viral genes that code for HIV
epitopes do not integrate into the host cells of vaccinated individuals. They remain episomal and act as expression vectors,
producing peptides that can induce cellular immunity. In contrast to viral or bacterial vectors, protein production in response
to DNA vaccines can focus the immune response more narrowly on HIV insert sequences. Although immunization with
DNA plasmids that contain HIV inserts has elicited substantial
cellular responses in mice and nonhuman primates, these products have been poorly immunogenic in humans. One strategy
to increase immune response has incorporated genetic adjuvantsspecifically, the coadministration of DNA plasmids coding for cytokines (most notably IL-12 and IL-15).
The second approach to increase immune response uses

DNA as a prime, followed by a protein or a viral vector boost.

Experiments in nonhuman primates have had promising results. For example, animals primed with DNA and then boosted
with poxvirus vaccines (modified vaccinia Ankara or fowlpox)
displayed strong CD8+ T cell responses [41, 42] and controlled
viremia after parenteral or mucosal challenge [43, 44]. Currently, the most promising DNA candidate appears to be a
multiclade construct developed by the National Institutes of
Healths Vaccine Research Center (VRC) that expresses clades
A, B, and C of the env gene and clade B of the gag, pol, and
nef genes [45]. Early data suggest that this vaccine elicits antibody production and CD4+ T cell responses in the majority
of vaccinees, and CD8+ T cell responses in up to 35% of vaccinees [46].
Although several viral vectors are being explored in the design of HIV vaccines, poxviruses and adenoviruses have received the most attention. The most extensive trial experience
has been with poxvirus vectors; more than a dozen are currently
in clinical trials. Early trials evaluated vaccinia-vectored products; the 2 most commonly studied of these products elicited
cellular immune responses to simian immunodeficiency virus
antigens in nonhuman primate models and HIV antigens in
human test subjects [47, 48]. However, concerns about preexisting immunity to poxvirus vectors and about potential dissemination of vaccinia in areas with a high prevalence of immunodeficient individuals has resulted in the construction of
more attenuated poxvirus vectors [49].
Among the poxviruses, the canarypox vector and 2 attenuated vaccinia strains, modified vaccinia Ankara and the New
York strain, have been most studied. Modified vaccinia Ankara
was initially used in Turkey in smallpox vaccine production.
INVITED ARTICLE CID 2006:43 (15 August) 503

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Live, attenuated SIV/HIV

A clinical trial to evaluate the safety and immunogenicity of an HIV-1 gag DNA vaccine, with or
without IL-12 DNA adjuvant, boosted with homologous plasmids or with HIV CTL multiepitope peptide vaccine, RC529-SE plus GM-CSF
A clinical trial to evaluate the safety and immunogenicity of a CTL multiepitope peptide vaccine
formulated with RC529-SE, with or without
GM-CSF

A clinical trial to evaluate the safety and immunogenicity of a gag DNA/PLG and env DNA/PLG
microparticle vaccine and a gp140/MF59 adjuvant vaccine
A phase I/II clinical trial to evaluate the safety and
immunogenicity of LIPO-5 alone, ALVAC-HIV
(vCP1452) alone, and ALVAC prime/LIPO-5
boost in healthy, HIV-1uninfected adults

A clinical trial to assess the safety and immunogenicity of an HIV vaccine based on AVANT Immunotherapeutics Therapore (R) technology

HVTN 060

HVTN 049

N/A

HVTN 042

HVTN 056

A clinical trial to evaluate the safety and immunogenicity of recombinant protein vaccine EP1043 and the DNA vaccine EP HIV-1090, given
alone or in combination
A clinical trial to evaluate the safety and immunogenicity of HIV-1 gag DNA vaccine, alone or
with IL-15 DNA, boosted with HIV-1 gag DNA
+ IL-15 DNA, HIV CTL multiepitope peptide
vaccine, or HIV-1 gag DNA + IL-12 DNA

HVTN 064

HVTN 063

II

ANRS VAC A randomized, double-blind vaccine trial to com018

pare the safety and immunogenicity of 3 doses
of LIPO-5 versus placebo

Trial phase

III

Title

A trial of Aventis Pasteur live recombinant ALVACHIV (vCP1521) priming with VaxGen gp120 B/E
(AIDSVAX B/E) boosting

RV 144

Peptide/
protein

Trial number

Table 2. HIV vaccine candidates in ongoing clinical trials.

WRAIR, NIAID, AVANT Immunotherapeutics

HVTN, NIAID, Aventis Pasteur

HVTN, NIAID, Chiron

HVTN, NIAID, Wyeth

HVTN, NIAID, Wyeth

HVTN, NIAID, Wyeth

HVTN, NIAID, Pharmexa-Epimmune

WRAIR/Department of Community Disease Control, Ministry of Public Health, and the Thai
AIDS Vaccine Evaluation Group, Armed Forces
Research Institute of Medical Sciences
ANRS, Aventis Pasteur

Organizer, sponsor, or developer

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504

Peptides: gag (B); gag

(B) or env, gag, nef
(B)

CTL epitopes from env

or gag (B)

Oligomeric gp140 (B)

5 lipopeptides containing CTL epitopes

from gag, pol, nef
(B)
Anthrax-derived polypeptide LFn gag p24
protein (B)

United States (7)

United States (11)

United States (10)

United States

gag, pol, vpr, nef (B);

protein containing T
helper epitopes from
evn, gag, pol vpu (B)
Peptides: gag (B); env,
gag, nef (B) or gag
(B)

5 lipopeptides containing CTL epitopes

from gag, pol, nef
(B)

gp120: env (B, E)

Antigen (clade)

United States (3), Thailand

(1)

United States (7), Brazil (2)

United States (3), Peru (2)

France (6)

Thailand (several)

Project location (no. of sites)

A phase I/II clinical trial to evaluate the safety and

immunogenicity of a multiclade HIV-1 DNA
plasmid vaccine, VRC-HIVDNA016-00-VP,
boosted by a multiclade HIV-1 recombinant adenovirus-5 vector vaccine, VRC-HIVADV014-00VP, in HIV uninfected adult volunteers in East
Africa

A phase I clinical trial to evaluate immune response kinetics and safety of 2 different
primes, adenoviral vector vaccine (VRC-HIVADV014-00-VP) and DNA vaccine (VRC-HIVDNA009-00-VP), each followed by adenoviral
vector boost in healthy, HIV-1uninfected adults
See peptide/protein, above

See peptide/protein, above

See peptide/protein, above

See peptide/protein, above

A clinical trial to evaluate the safety and immunogenicity of the DNA vaccine VRC-HIVDNA00900-VP with plasmid cytokine adjuvant VRCADJDNA004-IL2-VP

A clinical trial of a prime-boost HIV-1 vaccination

schedule: VRC-HIVDNA016-00-VP, followed by
the multiclade adenoviral vector vaccine VRCHIVADV014-00-VP

A randomized, placebo-controlled, double-blind

trial to evaluate the safety and immunogenicity
of a multiclade HIV-1 DNA plasmid vaccine

RV 172

HVTN 068

HVTN 063

HVTN 060

HVTN 049

HVTN 044

VRC 008

N/A

HVTN 064

A randomized, placebo-controlled, double-blind

trial to evaluate the safety and immunogenicity
of a multiclade HIV-1 DNA plasmid vaccine followed by a recombinant, multiclade HIV-1 adenoviral vector vaccine, or the multiclade HIV-1
adenoviral vector vaccine alone

A clinical trial to evaluate the safety and immunogenicity of a multiclade HIV-1 DNA plasmid vaccine, VRC-HIVDNA016-00-VP, followed by a
multiclade recombinant adenoviral vector HIV-1
vaccine boost, VRC-HIVADV014-00-VP

IAVI V001

DNA
HVTN 204

I/II

II

Guangxi Centre for Disease Control and

Prevention

NIAID, VRC

HVTN, NIAID, VRC

HVTN, NIAID, VRC

USMHRP, NIAID, VRC

IAVI, NIAID, VRC

HVTN, NIAID, VRC

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505

DNA: gag (B); env,

gag, nef (B) or gag
(B)
DNA: gag (B); gag (B)
or env, gag, nef (B)
DNA: gag, env DNA/
PLG (B)
gag/pol/nef (B), env (A,
B, C)

gag, pol, nef (B), env

(A, B, C)

DNA plasmid (B, C)

United States

China

United States (7)

Plasmids coding for

conserved HIV peptides (A, B, C, D, F,
G)

DNA: gag/pol/nef (B),

env (A, B, C)

DNA: gag, pol, nef (B),

env (A, B, C)

DNA: gag, pol, nef (B),

env (A, B, C)

DNA: gag, pol, nef (B),

env (A, B, C)

United States (6)

Kenya, Uganda, Tanzania

Kenya, Rwanda

United States (7), Brazil (2),

South Africa (3), Haiti,
Jamaica

A double-blind, randomized, dose-escalating, placebo-controlled study of safety and immunogenicity of WRAIR/NIH live recombinant MVACMDR (HIV-CM235 env/CM240 gag/pol)
administered intramuscularly or intradermally
A randomized, placebo-controlled, dose-escalating, double-blinded study to evaluate the safety
and immunogenicity of an MVA HIV-1 multigenic subtype C vaccine (TBC-M4)

RV 158

See peptide/protein, above

HVTN
042

See DNA, above

See DNA, above

IAVI
V001

RV 172

HVTN
A double-blind, randomized, placebo-controlled
502/
proof-of-concept study to evaluate the safety
Merck
and efficacy of a 3-dose regimen of the Merck
023
adenovirus serotype 5 vaccine (MRKAd5 HIV-1
gag/pol/nef)
HVTN
See DNA, above
204

Adenovirus

B011/RV A study of Aventis Pasteur live recombinant AL138

VAC-HIV (vCP205, HIV-1 env/gag/pol) administered subcutaneously via ex vivo transfected
autologous dendritic cells

HVTN
055

A randomized, placebo-controlled, dose-escalating, double-blinded study to evaluate the safety

and immunogenicity of an MVA expressing HIV1 clade C env/gag-pol and nef-tat fusion genes
(ADMVA) vaccine
A trial to evaluate the safety and immunogenicity
of rMVAHIV and rFPV-HIV vaccines, alone or in
combination

IAVI
C002

IAVI
D001

See peptide/protein, above

Evaluation of the tolerability and safety of a recombinant HIV-1 multienvelope DNA plasmid
vaccine (EnvDNA)

Title

RV 144

Vectors
Poxvirus

N/A

Trial number

II

Trial phase

HVTN, NIAID, Merck

WRAIR

HVTN, NIAID, Therion

Aaron Diamond AIDS Research Center, IAVI

IAVI, Therion

WRAIR, NIH

St. Jude Childrens Hospital, NIH

Organizer, sponsor, or developer

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506

ALVAC: env, pol, gag;

epitopes from nef,
pol (B)
env, gag, pol (B)

Adenovirus: gag/pol
(B), env (A, B, C)
Adenovirus: gag/pol
(B), env (A, B, C)

United States (12), Canada

gag, pol, nef (B)
(1), Brazil (2), Peru (2), Dominican Republic (1), Jamaica (1), Haiti (1), Puerto
Rico (1), Australia (1)

Adenovirus: gag/pol
(B), env (A, B, C)

United States

env, gag (B); tat, rev,

nef, RT (B); env gag
(B); tat, rev, nef, RT
(B)

United States (4), Brazil (2)

United States (2)

env/gag-pol, nef-tat (C)

gp160, gag, and pol

(integrase-deleted
and reverse transcriptase nonfunctional) (A, E)
env, gag, tat-rev, nefRT (C)

United Statesa

India

ALVAC: env (E), gag/

pol (B)

env (A, B, C, D, E)

Antigen (clade)

United States

Project site (no. of locations)

A study to evaluate the safety of and immune response to an alphavirus replicon, HIV-1 subtype
C gag vaccine, AVX101

HVTN
059

II

HVTN, NIAID, AlphaVax

IAVI, Targeted Genetics

IAVI, Targeted Genetics

NIAID, VRC

HVTN, NIAID, Merck

HVTN, NIAID, VRC

HVTN, NIAID, VRC

gag, protease, RT (C)

gag c

USA (6), South Africa (1),

Botswana (1)

gag, PR, RT (C)

Adenovirus: gag/pol
(B), env (A, B, C)

gag/pol (B), env (A, B,

C)

MRKAd5 HIV-1 gag (B)

gag/pol (B), env (A, B,

C)

gag/pol (B), env (A, B,

C)

Adenovirus: gag/pol
(B), env (A, B, C)

Belgium (2), Germany (2),

India

South Africa (3)

United States

United States (11), Malawi,

South Africa, Thailand,
Brazil, Haiti, Puerto Rico,
Dominican Republic, Peru

United States (4)

United States (14)

Future project site: Thailand.

Future project sites: Uganda, Zambia.

NOTE. From [67, 68]. AAV, adeno-associated virus; Ad5, adenovirus type 5; CTL, cytotoxic T cell; HVTN, HIV Vaccine Trials Network; IAVI, International AIDS Vaccine Initiative; MVA, modified vaccinia Ankara;
NIAID, National Institute of Allergy and Infectious Diseases; NIH, National Institutes of Health; PLG, plasminogen; USMHRP, US Military HIV Research Program; VRC, Vaccine Research Center; WRAIR, Walter
Reed Army Institute of Research.

IAVI
A001

A placebo-controlled, double-blind trial to evaluate

the safety and immunogenicity of tgAAC09, an
HIV vaccine containing clade C gag-PR-dRT
DNA in an AAV capsid, administered twice, at
3 dosage levels and 2 dosing intervals
A randomized, placebo-controlled, double-blind
dose-escalation trial to evaluate the safety and
immunogenicity of tgAAC09, a gag-PR-dRT AAV
HIV vaccine

IAVI
A002

Other

VRC 009 A clinical trial to evaluate the safety and immunogenicity of a booster dose of a recombinant
multiclade HIV-1 adenoviral vector vaccine,
VRC-HIVADV014-00-VP, in volunteers who were
previously immunized with VRC-HIVDNA00900-VP in VRC 004 (03-I-0022)
VRC 008 See DNA, above

A dose-escalation clinical trial to evaluate the

safety and immunogenicity of a multiclade,
multivalent recombinant adenoviral vector HIV
vaccine, VRC-HIVADV014-00-VP, in participants
who have low titers of preexisiting Ad5 neutralizing antibodies
HVTN
A dose-escalating study of the safety, tolerability,
050/
and immunogenicity of a 3-dose regimen of the
Merck
MRKAd5 HIV-1 gag vaccine
018

A clinical trial to evaluate the safety of a multiclade recombinant adenoviral vector vaccine administered to participants in HVTN 052

HVTN
057

HVTN
054

See DNA, above

HVTN
068

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507

Table 3. Comparison of ELISPOT responses, elicited by MRK gag only and by multigene adenovirus
type 5 vaccines.
Week 30 ELISPOT response
Monogene

Multigene

gag

gag

pol

nef

No. (%)
of subjects

GM

No. (%)
of subjects

GM

No. (%)
of subjects

GM

No. (%)
of subjects

GM

200

2 (72)

207

20 (75)

281

20 (45)

490

20 (60)

196

1200

14 (21)

105

17 (35)

219

17 (18)

233

17 (24)

223

32 (53)

221

22 (73)

205

22 (59)

342

22 (68)

177

24 (29)

287

14 (71)

405

14 (43)

641

14 (57)

401

Dose level, Ad5 titer

1 109 vp/d

1 1010 vp/d
200
1200

NOTE. Data from R. Isaacs and M. Robertson, personal communication. ELISPOT GM response for responders only.
ELISPOT responder was defined as 55 SFC/106 PBMCs and 4-fold increase over media control. Dose level for the
trivalent represents the gag-only component. GM, geometric mean; vp/d, viral particles per dose.

508 CID 2006:43 (15 August) INVITED ARTICLE

responses [20, 55, 56]. However, in more quantitative ex vivo

assays, the level of immunogenicity is much lower (!20% of
vaccinees) [57]. A phase III trial in Thailand of a canarypox
vector (vCP 1521) containing the HIV-1 clade B env, gag, and
protease genes, in combination with gp120 (clade B and E)
completed enrollment in January 2006; follow-up is ongoing.
Recombinant adenovirus type 5 (Ad5) vectors are the most
immunogenic viral vectors in HIV vaccine development today.
These viral vectors are rendered replication-defective by mutations and by deletion of an adenovirus gene; HIV genes are
inserted in place of the deleted adenovirus gene under the
control of exogenous promoters and regulatory elements that
drive high-level gene expression. The replication-incompetent
adenoviruses retain the ability to infect cells and to deliver their
genomes to these cells nuclei. Two different products, both
using replication-incompetent Ad5 backbones, are currently in
advanced clinical development. The first, produced by Merck,
is an admixture of 3 adenoviruses, each containing codonoptimized subtype B gag, pol, or nef genes. These 3 HIV genes
are highly conserved (80% to 190%) across subtypes. The
Merck adenovirus vectors that contain the gag gene alone or
that are a trivalent preparation containing the gag, pol, and nef
genes, produce robust CD8+ CTL responses in macaques (500
1000 IFN-gproducing cells/106 PBMCs after vaccination with
1011 viral particles) [58, 59].
The second Ad5 candidate, developed by the National Institutes of Healths VRC, is an admixture of 4 adenoviruses, 1
of which contains a subtype B gag-pol gene fusion. The other
3 adenoviruses contain subtype A, B, or C envelope genes. This
VRC construct has also elicited strong humoral and cellular
responses in macaques; the magnitude and breadth of the response was improved by prior priming of the product with the
DNA plasmids discussed above [45, 60].
Both approaches (the Merck trigenic adenovirus vaccine and

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In the 1950s, this strain was brought to Germany, and it was

further attenuated by repeated passage through chick embryo
fibroblastsa process that resulted in an accumulation of multiple mutations and the deletion of 15% of the genome [50].
A very favorable safety profile was seen in the 120,000 vaccinees
who received this product in Turkey and Germany as part of
the smallpox campaign. Modified vaccinia Ankara has subsequently been used in experimental HIV, malaria, and cancer
vaccines [50]. The New York strain of vaccinia was developed
through a deletion of 18 open reading frames and is blocked
at an early stage of replication [51]. These attenuated viruses
retain little or no ability to replicate in human cells, but they
can elicit humoral and cellular responses to vaccine inserts and
viral sequences.
Unfortunately, although most recombinant HIV vaccines using poxvirus vectors are effective in nonhuman primate models
[41, 44, 52, 53], they have much more limited immunogenicity
in humans. For example, initial trials of modified vaccinia Ankara vectors in humans were disappointingonly 10%25%
of participants in trials of a DNA/modified vaccinia Ankara
regimen were shown to have anti-HIV cellular responses by
ELISPOT [54]. Other prototype vaccines using different inserts
and promoters have recently entered clinical trials. Data indicating whether these constructs display increased immunogenicity are forthcoming.
Canarypox vectors have also been studied extensively in humans. Five different canarypox constructs containing HIV-1
clade B and E genes have been tested in 11500 subjects. These
vectors have been very well tolerated by test subjects, with
reactogenicity levels comparable to those of currently licensed
vaccines [19]. However, like most poxvirus vectors, canarypox
vaccines have not induced durable CTL responses. In chromium release assays in which postvaccination PBMCs are stimulated with HIV-1, 40%50% of vaccinees demonstrate T cell

CONCLUSIONS
Last year, HIV vaccine development entered the era of CTLmediated vaccine efficacy trials with the initiation of the HIV
Vaccine Trials Network/Merck STEP study. Together with other

ongoing and upcoming trials, this landmark study will determine whether the current viral vector vaccines are capable of
eliciting the quantity and quality of T cell responses that might
alter the course of individual and global HIV-1 infection.
Acknowledgments
We thank Francine McCutchen, Robin Isaacs, and the International AIDS
Vaccine Initiative for generously sharing data for manuscript figures and
tables; and Cecilia Morgan, Margaret Wecker, Richard Newman, Erik
Schwab, Benjamin Sheppard, and Aleta Howard for their outstanding assistance in preparation of this manuscript.
Financial support. National Institutes of Health/National Institute of
Allergy and Infectious Diseases UO1 AI-46747 (HIV Vaccine Trials
Network).
Potential conflicts of interest. All authors: no conflicts.

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