Thresholds for post-rebound SHIV control after CCR5 gene-edited autologous hematopoietic cell transplantation

Autologous, CCR5 gene-edited hematopoietic stem and progenitor cell (HSPC) transplantation is a promising strategy for achieving HIV remission. However, only a fraction of HSPCs can be edited ex vivo to provide protection against infection prior to autologous transplantation. The optimal transplantation conditions for achieving viral control in the absence of suppressive antiretroviral therapy (ART) are still unknown. We analyzed data from SHIV-1157ipd3N4-infected juvenile pig-tailed macaques that underwent autologous HSPC transplantation with and without CCR5 gene editing. We developed a mathematical model that recapitulates reconstitution of T cell subset counts and SHIV plasma viral loads in control and transplanted macaques. The model predicts that viral control can be obtained following ART treatment interruption (ATI) when: 1) levels of transplanted HSPCs are at least 10-fold higher than residual endogenous HSPCs after total body irradiation and 2) the fraction of protected HSPCs in the transplant achieves a threshold (73%-90%) sufficient to overcome transplantation-dependent loss of SHIV immunity. Under these conditions, if ATI is withheld until transplanted gene-modified cells engraft and reconstitute to a steady state, then spontaneous viral control is projected to occur immediately. Our results support strategies that 1) increase stem cell dose, 2) enhance potency of conditioning regimen, 3) elevate fraction of gene modified SHIV-resistant cells, 4) extend periods between HSPC transplantation and ATI with tracking of CD4 + CCR5 - cell recovery and / or 5) augment anti-SHIV immunity to achieve sustained SHIV remission. One Sentence Summary Autologous transplantation of ΔCCR5 HSPCs may induce post-ATI SHIV control when the gene-edited cell dose is sufficient to overcome SHIV immunity loss.