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Ekollo Mbange A, Malick Diouara AA, Diop-Ndiaye H, Diaw Diouf NA, Ngom-Ngueye NF, Ndiaye Touré K, Dieng A, Lô S, Fall M, Fon Mbacham W, Mboup S, Touré-Kane C. High HIV-1 Virological Failure and Drug Resistance among Adult Patients Receiving First-Line ART for At least 12 Months at a Decentralized Urban HIV Clinic Setting in Senegal before the Test-and-Treat. Infect Dis (Lond) 2021; 14:11786337211014503. [PMID: 34025122 PMCID: PMC8120520 DOI: 10.1177/11786337211014503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 04/05/2021] [Indexed: 11/21/2022] Open
Abstract
Background: The feasibility of antiretroviral therapy (ART) monitoring remains problematic in decentralized HIV clinic settings of sub-Saharan Africa. We assessed the rates and correlates of HIV-1 virological failure (VF) and drug resistance (DR) in 2 pre-test-and-treat urban clinic settings of Senegal. Methods: Consenting HIV-1-infected adults (⩾18 years) receiving first-line ART for ⩾12 months were cross-sectionally enrolled between January and March 2015, at the referral outpatient treatment center of Dakar (n = 151) and decentralized regional hospital of Saint-Louis (n = 127). In the 12 months preceding plasma specimens’ collection patients at Saint-Louis had no viral load (VL) testing. Significant predictors of VF (VL ⩾ 1000 copies/ml) and DR (clinically relevant mutations) were determined using binomial logistic regression in R software. Results: Of the 278 adults on EFV-/NVP-based regimens, 32 (11.5% [95%CI: 8.0-15.9]) experienced VF. Failing and non-failing patients had comparable median time [interquartile] on ART (69.5 [23.0-89.5] vs 64.0 [34.0-99.0] months; P = .46, Mann–Whitney U-test). Of the 27 viraemic isolates successfully genotyped, 20 (74.1%) carried DR mutations; most frequent were M184VI (55.6%), K103N (37.1%), thymidine analog mutations (29.6%), Y181CY (22.2%). The pattern of mutations did not always correspond to the ongoing treatment. The adjusted odds of VF was significantly associated with the decentralized clinic site (P < .001) and CD4 < 350 cells/mm3 (P < .006). Strong correlates of DR also included Saint-Louis (P < .009), CD4 < 350 cells/mm3 (P <. 001), and nevirapine-based therapies (comparator: efavirenz-based therapies; P < .027). In stratification analyses by site, higher rate of VF at Saint-Louis (20.5% [95%CI: 13.8-28.5] vs 4.0% [95%CI: 1.5-8.5] in Dakar) was associated with nevirapine-based therapies (OR = 3.34 [1.07-11.75], P = .038), self-reported missing doses (OR = 3.30 [1.13-10.24], P = .029), and medical appointments (OR = 2.91 [1.05-8.47], P = .039) in the last 1 and 12 months(s), respectively. The higher rate of DR at Saint-Louis (12.9% [95%CI: 7.6-20.1] vs 2.7% [95%CI: 0.7-6.7] in Dakar) was associated with nevirapine-based therapies (OR = 5.13 [1.12-37.35], P = .035). Conclusion: At decentralized urban settings, there is need for enhanced virological monitoring and adherence support. HIV programs in Senegal should intensify early HIV diagnosis for effective test-and-treat. These interventions, in addition to the superiority of efavirenz-based therapies provide a favorable framework for transitioning to the recommended potent drug dolutegravir, thereby ensuring its long-term use.
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Affiliation(s)
- Aristid Ekollo Mbange
- The Institute for Health Research, Epidemiological Surveillance and Training (IRESSEF), Diamniadio, Senegal.,The Biotechnology Center and Department of Biochemistry, University of Yaoundé I, Yaoundé, Cameroon.,Laboratoire de Bactériologie-Virologie, Centre Hospitalier Universitaire, Aristide Le Dantec/Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Abou Abdallah Malick Diouara
- The Institute for Health Research, Epidemiological Surveillance and Training (IRESSEF), Diamniadio, Senegal.,Département de Génie Chimique et de Biologie Appliquée, Ecole Supérieure Polytechnique/Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Halimatou Diop-Ndiaye
- The Institute for Health Research, Epidemiological Surveillance and Training (IRESSEF), Diamniadio, Senegal.,Laboratoire de Bactériologie-Virologie, Centre Hospitalier Universitaire, Aristide Le Dantec/Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Ndèye Aminata Diaw Diouf
- The Institute for Health Research, Epidemiological Surveillance and Training (IRESSEF), Diamniadio, Senegal.,Laboratoire de Bactériologie-Virologie, Centre Hospitalier Universitaire, Aristide Le Dantec/Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | | | | | - Ahmed Dieng
- Centre de Traitement Ambulatoire, Centre Hospitalier Universitaire de Fann, Dakar, Sénégal
| | - Seynabou Lô
- Hôpital Régional de Saint-Louis, Saint-Louis, Sénégal
| | - Mamadou Fall
- Laboratoire de Bactériologie-Virologie, Centre Hospitalier Universitaire, Aristide Le Dantec/Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Wilfred Fon Mbacham
- The Biotechnology Center and Department of Biochemistry, University of Yaoundé I, Yaoundé, Cameroon
| | - Souleymane Mboup
- The Institute for Health Research, Epidemiological Surveillance and Training (IRESSEF), Diamniadio, Senegal
| | - Coumba Touré-Kane
- The Institute for Health Research, Epidemiological Surveillance and Training (IRESSEF), Diamniadio, Senegal.,Laboratoire de Bactériologie-Virologie, Centre Hospitalier Universitaire, Aristide Le Dantec/Université Cheikh Anta Diop de Dakar, Dakar, Sénégal.,Laboratoire de Bactériologie-Virologie CHNU Dalal Jam, Dakar, Sénégal
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Song J, Pandian V, Mauk MG, Bau HH, Cherry S, Tisi LC, Liu C. Smartphone-Based Mobile Detection Platform for Molecular Diagnostics and Spatiotemporal Disease Mapping. Anal Chem 2018; 90:4823-4831. [PMID: 29542319 PMCID: PMC5928517 DOI: 10.1021/acs.analchem.8b00283] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Rapid and quantitative molecular diagnostics in the field, at home, and at remote clinics is essential for evidence-based disease management, control, and prevention. Conventional molecular diagnostics requires extensive sample preparation, relatively sophisticated instruments, and trained personnel, restricting its use to centralized laboratories. To overcome these limitations, we designed a simple, inexpensive, hand-held, smartphone-based mobile detection platform, dubbed "smart-connected cup" (SCC), for rapid, connected, and quantitative molecular diagnostics. Our platform combines bioluminescent assay in real-time and loop-mediated isothermal amplification (BART-LAMP) technology with smartphone-based detection, eliminating the need for an excitation source and optical filters that are essential in fluorescent-based detection. The incubation heating for the isothermal amplification is provided, electricity-free, with an exothermic chemical reaction, and incubation temperature is regulated with a phase change material. A custom Android App was developed for bioluminescent signal monitoring and analysis, target quantification, data sharing, and spatiotemporal mapping of disease. SCC's utility is demonstrated by quantitative detection of Zika virus (ZIKV) in urine and saliva and HIV in blood within 45 min. We demonstrate SCC's connectivity for disease spatiotemporal mapping with a custom-designed website. Such a smart- and connected-diagnostic system does not require any lab facilities and is suitable for use at home, in the field, in the clinic, and particularly in resource-limited settings in the context of Internet of Medical Things (IoMT).
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Affiliation(s)
- Jinzhao Song
- Department of Mechanical Engineering and Applied Mechanics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Vikram Pandian
- Department of Mechanical Engineering and Applied Mechanics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Michael G. Mauk
- Department of Mechanical Engineering and Applied Mechanics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Haim H. Bau
- Department of Mechanical Engineering and Applied Mechanics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Sara Cherry
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | | | - Changchun Liu
- Department of Mechanical Engineering and Applied Mechanics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
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Trible RP, Narute P, Emert-Sedlak LA, Alvarado JJ, Atkins K, Thomas L, Kodama T, Yanamala N, Korotchenko V, Day BW, Thomas G, Smithgall TE. Discovery of a diaminoquinoxaline benzenesulfonamide antagonist of HIV-1 Nef function using a yeast-based phenotypic screen. Retrovirology 2013; 10:135. [PMID: 24229420 PMCID: PMC3874621 DOI: 10.1186/1742-4690-10-135] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 10/31/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV-1 Nef is a viral accessory protein critical for AIDS progression. Nef lacks intrinsic catalytic activity and binds multiple host cell signaling proteins, including Hck and other Src-family tyrosine kinases. Nef binding induces constitutive Hck activation that may contribute to HIV pathogenesis by promoting viral infectivity, replication and downregulation of cell-surface MHC-I molecules. In this study, we developed a yeast-based phenotypic screen to identify small molecules that inhibit the Nef-Hck complex. RESULTS Nef-Hck interaction was faithfully reconstituted in yeast cells, resulting in kinase activation and growth arrest. Yeast cells expressing the Nef-Hck complex were used to screen a library of small heterocyclic compounds for their ability to rescue growth inhibition. The screen identified a dihydrobenzo-1,4-dioxin-substituted analog of 2-quinoxalinyl-3-aminobenzene-sulfonamide (DQBS) as a potent inhibitor of Nef-dependent HIV-1 replication and MHC-I downregulation in T-cells. Docking studies predicted direct binding of DQBS to Nef which was confirmed in differential scanning fluorimetry assays with recombinant purified Nef protein. DQBS also potently inhibited the replication of HIV-1 NL4-3 chimeras expressing Nef alleles representative of all M-group HIV-1 clades. CONCLUSIONS Our findings demonstrate the utility of a yeast-based growth reversion assay for the identification of small molecule Nef antagonists. Inhibitors of Nef function discovered with this assay, such as DQBS, may complement the activity of current antiretroviral therapies by enabling immune recognition of HIV-infected cells through the rescue of cell surface MHC-I.
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Affiliation(s)
- Ronald P Trible
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Bridgeside Point II, Suite 523, 15219, Pittsburgh, PA USA
| | - Purushottam Narute
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Bridgeside Point II, Suite 523, 15219, Pittsburgh, PA USA
| | - Lori A Emert-Sedlak
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Bridgeside Point II, Suite 523, 15219, Pittsburgh, PA USA
| | - John Jeff Alvarado
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Bridgeside Point II, Suite 523, 15219, Pittsburgh, PA USA
| | - Katelyn Atkins
- School of Medicine, Oregon Health and Science University, 97239, Portland, OR, USA
| | - Laurel Thomas
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Bridgeside Point II, Suite 523, 15219, Pittsburgh, PA USA
| | - Toshiaki Kodama
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Bridgeside Point II, Suite 523, 15219, Pittsburgh, PA USA
| | - Naveena Yanamala
- Department of Structural Biology, University of Pittsburgh School of Medicine, 15261, Pittsburgh, PA USA
| | - Vasiliy Korotchenko
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, 15261, Pittsburgh, PA USA
| | - Billy W Day
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, 15261, Pittsburgh, PA USA
| | - Gary Thomas
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Bridgeside Point II, Suite 523, 15219, Pittsburgh, PA USA
| | - Thomas E Smithgall
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Bridgeside Point II, Suite 523, 15219, Pittsburgh, PA USA
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Ngo-Giang-Huong N, Jourdain G, Amzal B, Sang-a-gad P, Lertkoonalak R, Eiamsirikit N, Tansuphasawasdikul S, Buranawanitchakorn Y, Yutthakasemsunt N, Mekviwattanawong S, McIntosh K, Lallemant M. Resistance patterns selected by nevirapine vs. efavirenz in HIV-infected patients failing first-line antiretroviral treatment: a bayesian analysis. PLoS One 2011; 6:e27427. [PMID: 22132100 PMCID: PMC3223170 DOI: 10.1371/journal.pone.0027427] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 10/16/2011] [Indexed: 11/18/2022] Open
Abstract
Background WHO recommends starting therapy with a non-nucleoside reverse transcriptase inhibitor (NNRTI) and two nucleoside reverse transcriptase inhibitors (NRTIs), i.e. nevirapine or efavirenz, with lamivudine or emtricitabine, plus zidovudine or tenofovir. Few studies have compared resistance patterns induced by efavirenz and nevirapine in patients infected with the CRF01_AE Southeast Asian HIV-subtype. We compared patterns of NNRTI- and NRTI-associated mutations in Thai adults failing first-line nevirapine- and efavirenz -based combinations, using Bayesian statistics to optimize use of data. Methods and Findings In a treatment cohort of HIV-infected adults on NNRTI-based regimens, 119 experienced virologic failure (>500 copies/mL), with resistance mutations detected by consensus sequencing. Mutations were analyzed in relation to demographic, clinical, and laboratory variables at time of genotyping. The Geno2Pheno system was used to evaluate second-line drug options. Eighty-nine subjects were on nevirapine and 30 on efavirenz. The NRTI backbone consisted of lamivudine or emtricitabine plus either zidovudine (37), stavudine (65), or tenofovir (19). The K103N mutation was detected in 83% of patients on efavirenz vs. 28% on nevirapine, whereas Y181C was detected in 56% on nevirapine vs. 20% efavirenz. M184V was more common with nevirapine (87%) than efavirenz (63%). Nevirapine favored TAM-2 resistance pathways whereas efavirenz selected both TAM-2 and TAM-1 pathways. Emergence of TAM-2 mutations increased with the duration of virologic replication (OR 1.25–1.87 per month increment). In zidovudine-containing regimens, the overall risk of resistance across all drugs was lower with nevirapine than with efavirenz, whereas in tenofovir-containing regimen the opposite was true. Conclusions TAM-2 was the major NRTI resistance pathway for CRF01_AE, particularly with nevirapine; it appeared late after virological failure. In patients who failed, there appeared to be more second-line drug options when zidovudine was combined with nevirapine or tenofovir with efavirenz than with alternative combinations.
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Takahashi M, Hirano A, Okubo N, Kinoshita E, Nomura T, Kaneda T. Development and application of a simple LC-MS method for the determination of plasma maraviroc concentrations. THE JOURNAL OF MEDICAL INVESTIGATION 2011; 57:245-50. [PMID: 20847524 DOI: 10.2152/jmi.57.245] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Maraviroc is an orally available antagonist of the CCR5 chemokine receptor, which acts as a human immunodeficiency virus type 1 (HIV-1) coreceptor. Binding of maraviroc to this receptor blocks HIV-1 attachment to the coreceptor and prevents HIV-1 from entering host cells. Maraviroc does not require intracellular processing to exert this activity. Drug interaction studies have shown changes in maraviroc exposure when given with other anti-HIV medications, and thus quantification of maraviroc in human plasma is important to manage drug interactions and to evaluate the relationship between plasma concentrations and treatment response. We developed a conventional LC-MS method for determining plasma maraviroc concentrations, validated by estimating precision and accuracy for inter- and intraday analysis in the concentration range of 0.011-2.188 µg/ml. The calibration curve was linear within this range. The average accuracy ranged from 92.7% to 99.7%, while the relative standard deviations of both inter- and intraday assays were less than 7.1%. Recovery of maraviroc exceeded 86.7%. Our LC-MS method provides a conventional, accurate and precise way to determine the maraviroc concentration in human plasma. This method enables dose adjustment based on monitoring plasma maraviroc concentrations and permits management of drug interactions and toxicity.
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Affiliation(s)
- Masaaki Takahashi
- Department of Pharmacy, National Hospital Organization Nagoya Medical Center, Aichi, Japan
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Palmer AK, Klein MB, Raboud J, Cooper C, Hosein S, Loutfy M, Machouf N, Montaner J, Rourke SB, Smieja M, Tsoukas C, Yip B, Milan D, Hogg RS. Cohort profile: the Canadian Observational Cohort collaboration. Int J Epidemiol 2010; 40:25-32. [PMID: 20157000 DOI: 10.1093/ije/dyp393] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Alexis K Palmer
- The British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
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Drug resistance mutations and the cellular immune response: a valuable synergy for the development of novel immune therapies. Curr Opin HIV AIDS 2009; 2:116-22. [PMID: 19372876 DOI: 10.1097/coh.0b013e3280287a4d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The escape of HIV-1 is a cardinal feature of the virus and a major hindrance to the development of effective therapeutic strategies. In highly active antiretroviral therapy-treated patients, the virus is subjected to selective pressures from cellular immune response directed against the viral proteome and antiretroviral treatment targetting a few genes of the HIV-1 genome. This review will focus on the relationship between these two pressures and its potential advantage in the development of novel immune therapies. RECENT FINDINGS Recent studies have investigated the conflicting selective forces between viral fitness and escape to immunological and therapeutic pressures in natural HIV infection and the SIV model. Simultaneous pressures driven by cytotoxic T lymphocytes and highly active antiretroviral therapy could potentially reduce viral fitness, leading to better control of the viral load. Two studies have described a potential therapeutic vaccine strategy against viral escape mutant epitopes from reverse transcriptase inhibitors. SUMMARY The emergence of multidrug-resistant viruses is associated with enhanced T-cell-mediated immune response as a possible consequence of reduced viral fitness. Amino acid substitutions generate potential cytotoxic T-lymphocyte epitopes that may elicit new reactivities against mutated viruses. Both could significantly enhance the immune response through direct and indirect mechanisms.
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Shimura K, Kodama EN. Elvitegravir: a new HIV integrase inhibitor. Antivir Chem Chemother 2009; 20:79-85. [PMID: 19843978 DOI: 10.3851/imp1397] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Integration is a distinctive and essential process in the HIV infection cycle and thus represents an attractive antiviral drug target. Integrase inhibitors combined with other classes of drug might contribute to long-lasting suppression of HIV type-1 (HIV-1) replication for many patients. Of the numerous potential integrase inhibitor leads that have been reported, few have reached clinical trials and only one, raltegravir, has been approved (in late 2007) for the treatment of HIV-1-infected patients. Another integrase inhibitor, elvitegravir, is currently showing promise in Phase III clinical studies. Once-daily administration of elvitegravir has a comparable antiviral activity to twice-daily of raltegravir in HIV-1-infected patients. Here, we highlight the salient features of elvitegravir: its chemical structure compared with representative integrase inhibitors, mechanism of action, in vitro and in vivo activity against HIV and other retroviruses, and the effect of integrase polymorphisms and resistance mutations on its anti-HIV activity.
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Affiliation(s)
- Kazuya Shimura
- Laboratory of Virus Control, Institute for Virus Research, Kyoto University, Kyoto, Japan
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Ward ZD, White KAJ, van Voorn GAK. Exploring the impact of target cell heterogeneity on HIV loads in a within-host model. Epidemics 2009; 1:168-74. [PMID: 21352764 DOI: 10.1016/j.epidem.2009.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Revised: 05/22/2009] [Accepted: 06/11/2009] [Indexed: 11/26/2022] Open
Abstract
HIV can be transmitted from blood plasma or semen of an infected male. Viral loads in blood plasma are routinely measured, but the same is not true of semen. Even before drug treatment, viral loads have been shown to be different in the two body compartments (blood and genital tract), and this heterogeneity may be exacerbated by treatments using those antiretroviral drugs which have different efficacies in the two compartments. In addition to this heterogeneity, and despite highly effective drugs (in the blood) low-level viral replication is commonly reported for HIV patients as are differences in drug resistant mutation patterns in the two compartments. In this paper we investigate the effect of target cell heterogeneity between compartments on HIV viral loads using a within-host model that includes wildtype and drug resistant strains of HIV. We find that modelling target cell heterogeneity in the blood and male genital tract gives different viral loads in the two compartments prior to treatment and allows low-level viral loads to persist during therapy even if drug penetration is good. The model also allows coexistence of the two viral strains (in the absence of a mutation mechanism) with different dominance patterns in each body compartment. Our results suggest that monitoring of blood plasma viral strains may not give an accurate picture of the strains of HIV being transmitted between individuals and that continued research into the nature of HIV target cells in the male genital tract would be beneficial.
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Affiliation(s)
- Zoë D Ward
- Centre for Mathematical Biology, University of Bath, Claverton Down, Bath, UK.
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Raza A, Sham YY, Vince R. Design and synthesis of sulfoximine based inhibitors for HIV-1 protease. Bioorg Med Chem Lett 2008; 18:5406-10. [DOI: 10.1016/j.bmcl.2008.09.044] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Revised: 09/09/2008] [Accepted: 09/10/2008] [Indexed: 10/21/2022]
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Steigbigel RT, Cooper DA, Kumar PN, Eron JE, Schechter M, Markowitz M, Loutfy MR, Lennox JL, Gatell JM, Rockstroh JK, Katlama C, Yeni P, Lazzarin A, Clotet B, Zhao J, Chen J, Ryan DM, Rhodes RR, Killar JA, Gilde LR, Strohmaier KM, Meibohm AR, Miller MD, Hazuda DJ, Nessly ML, DiNubile MJ, Isaacs RD, Nguyen BY, Teppler H. Raltegravir with optimized background therapy for resistant HIV-1 infection. N Engl J Med 2008; 359:339-54. [PMID: 18650512 DOI: 10.1056/nejmoa0708975] [Citation(s) in RCA: 537] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Raltegravir (MK-0518) is an inhibitor of human immunodeficiency virus type 1 (HIV-1) integrase active against HIV-1 susceptible or resistant to older antiretroviral drugs. METHODS We conducted two identical trials in different geographic regions to evaluate the safety and efficacy of raltegravir, as compared with placebo, in combination with optimized background therapy, in patients infected with HIV-1 that has triple-class drug resistance in whom antiretroviral therapy had failed. Patients were randomly assigned to raltegravir or placebo in a 2:1 ratio. RESULTS In the combined studies, 699 of 703 randomized patients (462 and 237 in the raltegravir and placebo groups, respectively) received the study drug. Seventeen of the 699 patients (2.4%) discontinued the study before week 16. Discontinuation was related to the study treatment in 13 of these 17 patients: 7 of the 462 raltegravir recipients (1.5%) and 6 of the 237 placebo recipients (2.5%). The results of the two studies were consistent. At week 16, counting noncompletion as treatment failure, 355 of 458 raltegravir recipients (77.5%) had HIV-1 RNA levels below 400 copies per milliliter, as compared with 99 of 236 placebo recipients (41.9%, P<0.001). Suppression of HIV-1 RNA to a level below 50 copies per milliliter was achieved at week 16 in 61.8% of the raltegravir recipients, as compared with 34.7% of placebo recipients, and at week 48 in 62.1% as compared with 32.9% (P<0.001 for both comparisons). Without adjustment for the length of follow-up, cancers were detected in 3.5% of raltegravir recipients and in 1.7% of placebo recipients. The overall frequencies of drug-related adverse events were similar in the raltegravir and placebo groups. CONCLUSIONS In HIV-infected patients with limited treatment options, raltegravir plus optimized background therapy provided better viral suppression than optimized background therapy alone for at least 48 weeks. (ClinicalTrials.gov numbers, NCT00293267 and NCT00293254.)
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Xu L, Anderson J, Ferns B, Cook P, Wildfire A, Workman J, Graham S, Smit E. Genetic diversity of integrase (IN) sequences in antiretroviral treatment-naive and treatment-experienced HIV type 2 patients. AIDS Res Hum Retroviruses 2008; 24:1003-7. [PMID: 18593344 DOI: 10.1089/aid.2007.0303] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Two potent integrase inhibitors (IN-Is), raltegravir (RAL, MK-0518) and elvitegravir (EGV, GS-9137), have been shown to be potent inhibitors for HIV-1 and resistance mutations have been identified in HIV-1 clinical trials. In this study, sequences from 11 HIV-2 patients were examined for IN polymorphisms. The primary mutations associated with RAL and EGV resistance were not detected despite the genetic variability among clinical isolates. Our study provides basic information on genotypic susceptibility of HIV-2 to RAL and EGV and supports the suggestion that RAL and EGV could be considered as a new therapeutic option for treating HIV-2-infected patients.
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Affiliation(s)
- L. Xu
- Health Protection Agency, West Midlands Public Health Laboratory, Birmingham Heartlands & Solihull NHS Trust, Birmingham, UK
| | - J. Anderson
- Homerton University Hospital NHS Foundation Trust, London, UK
| | - B. Ferns
- University College London, London, UK
| | - P. Cook
- Health Protection Agency, West Midlands Public Health Laboratory, Birmingham Heartlands & Solihull NHS Trust, Birmingham, UK
| | | | - J. Workman
- Health Protection Agency, West Midlands Public Health Laboratory, Birmingham Heartlands & Solihull NHS Trust, Birmingham, UK
| | - S. Graham
- Health Protection Agency, West Midlands Public Health Laboratory, Birmingham Heartlands & Solihull NHS Trust, Birmingham, UK
| | - E. Smit
- Health Protection Agency, West Midlands Public Health Laboratory, Birmingham Heartlands & Solihull NHS Trust, Birmingham, UK
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Dayam R, Al-Mawsawi LQ, Zawahir Z, Witvrouw M, Debyser Z, Neamati N. Quinolone 3-Carboxylic Acid Pharmacophore: Design of Second Generation HIV-1 Integrase Inhibitors. J Med Chem 2008; 51:1136-44. [DOI: 10.1021/jm070609b] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Raveendra Dayam
- Department of Pharmacology and Pharmaceutical Sciences, University of Southern California, School of Pharmacy, 1985 Zonal Avenue, Los Angeles, California 90089, and Molecular Medicine, Katholieke Universiteit Leuven and IRC KULAK, Kapucijnenvoer 33, B-3000 Leuven, Flanders, Belgium
| | - Laith Q. Al-Mawsawi
- Department of Pharmacology and Pharmaceutical Sciences, University of Southern California, School of Pharmacy, 1985 Zonal Avenue, Los Angeles, California 90089, and Molecular Medicine, Katholieke Universiteit Leuven and IRC KULAK, Kapucijnenvoer 33, B-3000 Leuven, Flanders, Belgium
| | - Zahrah Zawahir
- Department of Pharmacology and Pharmaceutical Sciences, University of Southern California, School of Pharmacy, 1985 Zonal Avenue, Los Angeles, California 90089, and Molecular Medicine, Katholieke Universiteit Leuven and IRC KULAK, Kapucijnenvoer 33, B-3000 Leuven, Flanders, Belgium
| | - Myriam Witvrouw
- Department of Pharmacology and Pharmaceutical Sciences, University of Southern California, School of Pharmacy, 1985 Zonal Avenue, Los Angeles, California 90089, and Molecular Medicine, Katholieke Universiteit Leuven and IRC KULAK, Kapucijnenvoer 33, B-3000 Leuven, Flanders, Belgium
| | - Zeger Debyser
- Department of Pharmacology and Pharmaceutical Sciences, University of Southern California, School of Pharmacy, 1985 Zonal Avenue, Los Angeles, California 90089, and Molecular Medicine, Katholieke Universiteit Leuven and IRC KULAK, Kapucijnenvoer 33, B-3000 Leuven, Flanders, Belgium
| | - Nouri Neamati
- Department of Pharmacology and Pharmaceutical Sciences, University of Southern California, School of Pharmacy, 1985 Zonal Avenue, Los Angeles, California 90089, and Molecular Medicine, Katholieke Universiteit Leuven and IRC KULAK, Kapucijnenvoer 33, B-3000 Leuven, Flanders, Belgium
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14
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Takahashi M, Konishi M, Kudaka Y, Okumura N, Hirano A, Terahata N, Banno K, Kaneda T. A Conventional LC-MS Method Developed for the Determination of Plasma Raltegravir Concentrations. Biol Pharm Bull 2008; 31:1601-4. [DOI: 10.1248/bpb.31.1601] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Masaaki Takahashi
- Department of Pharmacy, National Hospital Organization Nagoya Medical Center (Tokai Area Central Hospital for AIDS Treatment and Research)
- Clinical Research Center, National Hospital Organization Nagoya Medical Center (Tokai Area Central Hospital for AIDS Treatment and Research)
| | | | - Yuichi Kudaka
- Department of Pharmacy, National Hospital Organization Nagoya Medical Center (Tokai Area Central Hospital for AIDS Treatment and Research)
- Clinical Research Center, National Hospital Organization Nagoya Medical Center (Tokai Area Central Hospital for AIDS Treatment and Research)
| | - Naoya Okumura
- Department of Pharmacy, National Hospital Organization Nagoya Medical Center (Tokai Area Central Hospital for AIDS Treatment and Research)
- Clinical Research Center, National Hospital Organization Nagoya Medical Center (Tokai Area Central Hospital for AIDS Treatment and Research)
| | - Atsushi Hirano
- Department of Pharmacy, National Hospital Organization Nagoya Medical Center (Tokai Area Central Hospital for AIDS Treatment and Research)
- Clinical Research Center, National Hospital Organization Nagoya Medical Center (Tokai Area Central Hospital for AIDS Treatment and Research)
| | - Nami Terahata
- Department of Pharmacy, National Hospital Organization Nagoya Medical Center (Tokai Area Central Hospital for AIDS Treatment and Research)
| | - Kazuhide Banno
- Department of Pharmacy, National Hospital Organization Nagoya Medical Center (Tokai Area Central Hospital for AIDS Treatment and Research)
| | - Tsuguhiro Kaneda
- Clinical Research Center, National Hospital Organization Nagoya Medical Center (Tokai Area Central Hospital for AIDS Treatment and Research)
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15
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Clinical comparison of branched DNA and reverse transcriptase-PCR and nucleic acid sequence-based amplification assay for the quantitation of circulating recombinant form_BC HIV-1 RNA in plasma. AIDS 2007; 21 Suppl 8:S27-32. [PMID: 18172387 DOI: 10.1097/01.aids.0000304693.16767.66] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the correlation between three viral load assays for circulating recombinant form (CRF)_BC. DESIGN Recent studies in HIV-1 molecular epidemiology, reveals that CRF_BC is the dominant subtype of HIV-1 virus in mainland China, representing over 45% of the HIV-1 infected population. The performances of nucleic acid sequence-based amplification (NASBA), branched DNA (bDNA) and reverse transcriptase polymerase chain reaction (RT-PCR) were compared for the HIV-1 viral load detection and quantitation of CRF_BC in China. METHODS Sixteen HIV-1 positive and three HIV-1 negative samples were collected. Sequencing of the positive samples in the gp41 region was conducted. The HIV-1 viral load values were determined using bDNA, RT-PCR and NASBA assays. Deming regression analysis with SPSS 12.0 (SPS Inc., Chicago, Illinois, USA) was performed for data analysis. RESULTS Sequencing and phylogenetic analysis of env gene (gp41) region of the 16 HIV-1 positive clinical specimens from Guizhou Province in southwest China revealed the dominance of the subtype CRF_BC in that region. A good correlation of their viral load values was observed among three assays. Pearson's correlation between RT-PCR and bDNA is 0.969, Lg(VL)RT-PCR = 0.969 * Lg(VL)bDNA + 0.55; Pearson's correlation between RT-PCR and NASBA is 0.968, Lg(VL)RT-PCR = 0.968 * Lg(VL)NASBA + 0.937; Pearson's correlation between NASBA and bDNA is 0.980, Lg(VL)NASBA = 0.980 * Lg(VL)bDNA - 0.318. CONCLUSION When testing with 3 different assays, RT-PCR, bDNA and NASBA, the group of 16 HIV-1 positive samples showed the viral load value was highest for RT-PCR, followed by bDNA then NASBA, which is consistent with the former results in subtype B. The three viral load assays are highly correlative for CRF_BC in China.
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16
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Gazzard B, Bernard AJ, Boffito M, Churchill D, Edwards S, Fisher N, Geretti AM, Johnson M, Leen C, Peters B, Pozniak A, Ross J, Walsh J, Wilkins E, Youle M. British HIV Association (BHIVA) guidelines for the treatment of HIV-infected adults with antiretroviral therapy (2006). HIV Med 2007; 7:487-503. [PMID: 17105508 DOI: 10.1111/j.1468-1293.2006.00424.x] [Citation(s) in RCA: 164] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- B Gazzard
- Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK.
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17
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Lohse N, Jørgensen LB, Kronborg G, Møller A, Kvinesdal B, Sørensen HT, Obel N, Gerstoft J, Gerstat J, Obel N, Kronborg G, Pedersen C, Larsen CS, Pedersen G, Laursen AL, Kvinesdal B, Møller A. Genotypic Drug Resistance and Long-Term Mortality in Patients with Triple-Class Antiretroviral Drug Failure. Antivir Ther 2007. [DOI: 10.1177/135965350701200606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To examine the prevalence of drug-resistance-associated mutations in HIV patients with triple-drug class virological failure (TCF) and their association with long-term mortality. Design Population-based study from the Danish HIV Cohort Study (DHCS). Methods We included all patients in the DHCS who experienced TCF between January 1995 and November 2004, and we performed genotypic resistance tests for International AIDS Society (IAS)-USA primary mutations on virus from plasma samples taken around the date of TCF. We computed time to all-cause death from date of TCF. The relative risk of death according to the number of mutations and individual mutations was estimated by Cox regression analysis and adjusted for potential confounders. Results Resistance tests were done for 133 of the 179 patients who experienced TCF. The median number of resistance mutations was eight (interquartile range 2–10), and 81 (61%) patients had mutations conferring resistance towards all three major drug classes. In a regression model adjusted for CD4+ T-cell count, HIV RNA, year of TCF, age, gender and previous inferior antiretroviral therapy, harbouring ≥9 versus ≤8 mutations was associated with increased mortality (mortality rate ratio [MRR] 2.3 [95% confidence interval (CI) 1.1–4.8]), as were the individual mutations T215Y (MRR 3.4 [95% CI 1.6–7.0]), G190A/S (MRR 3.2 [95% CI 1.6–6.6]) and V82F/A/T/S (MRR 2.5 [95% CI 1.2–5.3]). Conclusions In HIV patients with TCF, the total number of genotypic resistance mutations and specific single mutations predicted mortality.
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Affiliation(s)
- Nicolai Lohse
- Department of Clinical Epidemiology, Århus University Hospital, Århus, Denmark
- The Danish HIV Cohort Study, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Gitte Kronborg
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
| | - Axel Møller
- Department of Infectious Diseases, Kolding Hospital, Kolding, Denmark
| | - Birgit Kvinesdal
- Department of Infectious Diseases, Helsingør Hospital, Helsingør, Denmark
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Århus University Hospital, Århus, Denmark
- School of Public Health, Boston University, Boston, MA, USA
| | - Niels Obel
- The Danish HIV Cohort Study, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Jan Gerstoft
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - J Gerstat
- Departments of Infectious Diseases at Copenhagen University Hospitals, Rigshospitalet
| | - N Obel
- Departments of Infectious Diseases at Copenhagen University Hospitals, Rigshospitalet
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18
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Seyler C, Adjé-Touré C, Messou E, Dakoury-Dogbo N, Rouet F, Gabillard D, Nolan M, Toure S, Anglaret X. Impact of genotypic drug resistance mutations on clinical and immunological outcomes in HIV-infected adults on HAART in West Africa. AIDS 2007; 21:1157-64. [PMID: 17502726 PMCID: PMC2486349 DOI: 10.1097/qad.0b013e3281c615da] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To analyse the association between the presence of resistance mutations and treatment outcomes. The impact of HIV-1 drug resistance mutations in African adults on HAART has so far never been reported. METHODS In 2004 in Abidjan, Côte d'Ivoire, 106 adults on HAART had plasma viral load measurements. Patients with detectable viral loads had resistance genotypic tests. Patients were followed until 2006. Main outcomes were serious morbidity and immunological failure (CD4 cell count < 200 cells/microl). RESULTS At study entry, the median previous time on HAART was 37 months and the median CD4 cell count was 266 cells/microl; 58% of patients had undetectable viral loads, 20% had detectable viral loads with no major resistance mutations, and 22% had detectable viral loads with one or more major mutations. The median change in CD4 cell count between study entry and study termination was +129 cells/microl in patients with undetectable viral loads, +51 cells/microl in those with detectable viral loads with no mutations and +3 cells/microl in those with detectable viral loads with resistance mutations. Compared with patients with undetectable viral loads, those with detectable viral loads with resistance mutations had adjusted hazard ratios of immunological failure of 4.32 (95%CI 1.38-13.57, P = 0.01). One patient died. The 18-month probability of remaining free of morbidity was 0.79 in patients with undetectable viral loads and 0.69 in those with resistance mutations (P = 0.19). CONCLUSION In this setting with restricted access to second-line HAART, patients with major resistance mutations had higher rates of immunological failure, but most maintained stable CD4 cell counts and stayed alive for at least 20 months.
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Affiliation(s)
- Catherine Seyler
- INSERM U593, Université Victor Segalen Bordeaux 2, 146 rue Léo Saignat, 33076 Bordeaux, France.
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19
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Bartlett JA, Muro EP. Generic and branded drugs for the treatment of people living with HIV/AIDS. ACTA ACUST UNITED AC 2007; 6:15-23. [PMID: 17329500 DOI: 10.1177/1545109707299856] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
HIV/AIDS care has benefited tremendously from the availability of antiretroviral (ARV) drugs, both branded and generic. Drug discovery and innovation is the result of direct investment in the development of branded medications, a crucial process for future improvements in care. However, the cost of branded medications is too high for resource-limited countries, where most persons with HIV/AIDS live. Generic drugs dramatically lower the cost of care; however, their safety and efficacy must be ensured and maintained. Proven bioavailability and bioequivalence, in addition to satisfactory manufacturing, distribution, and administration, are keys to successfully implementing the use of qualified generic ARVs. Agencies such as the US Food and Drug Administration (FDA), European Medicines Agency (EMEA), and the World Health Organization (WHO), continue to strengthen the surveillance process through which qualified generic and branded drugs are provided worldwide. Generic drugs have the potential to cause harm if rigorous standards for their use are not followed, but those that are qualified offer great promise in the treatment of HIV/AIDS.
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Affiliation(s)
- John A Bartlett
- Division of Infectious Disease and International Health, Duke University Medical Center, Durham, North Carolina 27710, USA.
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20
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Grinsztejn B, Nguyen BY, Katlama C, Gatell JM, Lazzarin A, Vittecoq D, Gonzalez CJ, Chen J, Harvey CM, Isaacs RD. Safety and efficacy of the HIV-1 integrase inhibitor raltegravir (MK-0518) in treatment-experienced patients with multidrug-resistant virus: a phase II randomised controlled trial. Lancet 2007; 369:1261-1269. [PMID: 17434401 DOI: 10.1016/s0140-6736(07)60597-2] [Citation(s) in RCA: 441] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Raltegravir (MK-0518) is an HIV-1 integrase inhibitor with potent in-vitro activity against HIV-1 strains including those resistant to currently available antiretroviral drugs. The aim of this study was to assess the safety and efficacy of raltegravir when added to optimised background regimens in HIV-infected patients. METHODS HIV-infected patients with HIV-1 RNA viral load over 5000 copies per mL, CD4 cell counts over 50 cells per muL, and documented genotypic and phenotypic resistance to at least one nucleoside reverse transcriptase inhibitor, one non-nucleoside reverse transcriptase inhibitor, and one protease inhibitor were randomly assigned to receive raltegravir (200 mg, 400 mg, or 600 mg) or placebo orally twice daily in this multicentre, triple-blind, dose-ranging, randomised study. The primary endpoints were change in viral load from baseline at week 24 and safety. Analyses were done on a modified intention-to-treat basis. This trial is registered with ClinicalTrials.gov, with the number NCT00105157. FINDINGS 179 patients were eligible for randomisation. 44 patients were randomly assigned to receive 200 mg raltegravir, 45 to receive 400 mg raltegravir, and 45 to receive 600 mg raltegravir; 45 patients were randomly assigned to receive placebo. One patient in the 200 mg group did not receive treatment and was therefore excluded from the analyses. For all groups, the median duration of previous antiretroviral therapy was 9.9 years (range 0.4-17.3 years) and the mean baseline viral load was 4.7 (SD 0.5) log10 copies per mL. Four patients discontinued due to adverse experiences, three (2%) of the 133 patients across all raltegravir groups and one (2%) of the 45 patients on placebo. 41 patients discontinued due to lack of efficacy: 14 (11%) of the 133 patients across all raltegravir groups and 27 (60%) of the 45 patients on placebo. At week 24, mean change in viral load from baseline was -1.80 (95% CI -2.10 to -1.50) log10 copies per mL in the 200 mg group, -1.87 (-2.16 to -1.58) log10 copies per mL in the 400 mg group, -1.84 (-2.10 to -1.58) log10 copies per mL in the 600 mg group, and -0.35 (-0.61 to -0.09) log(10) copies per mL for the placebo group. Raltegravir at all doses showed a safety profile much the same as placebo; there were no dose-related toxicities. INTERPRETATION In patients with few remaining treatment options, raltegravir at all doses studied provided better viral suppression than placebo when added to an optimised background regimen. The safety profile of raltegravir is comparable with that of placebo at all doses studied.
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Affiliation(s)
- Beatriz Grinsztejn
- Evandro Chagas Clinical Research Institute/Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | | | | | | | | | | | | | - Joshua Chen
- Merck Research Laboratories, West Point, PA, USA
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21
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Martinez J, Coplan P, Wainberg MA. Is HIV drug resistance a limiting factor in the development of anti-HIV NNRTI and NRTI-based vaginal microbicide strategies? Antiviral Res 2006; 71:343-50. [PMID: 16787667 DOI: 10.1016/j.antiviral.2006.05.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Revised: 04/21/2006] [Accepted: 05/22/2006] [Indexed: 11/16/2022]
Abstract
Antiviral drugs that act at specific sites within the HIV life cycle have important rationale for development as anti-HIV microbicides. However, to be effective, such drugs must act by directly interfering with viral enzymatic function and eliminate the ability of HIV to mediate infection. Compounds that are developed as microbicides must have high potency, and should ideally not be well absorbed from the vaginal cavity in order to minimize any potential problems of drug resistance. Such compounds should also be active over long periods of time and should be able to be combined with other active agents, in order to promote the concept of synergy, such as that which has been demonstrated in HIV therapeutic studies.
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Affiliation(s)
- Jorge Martinez
- McGill University AIDS Center, Lady Davis Institute-Jewish General Hospital, 3755 Chemin Côte Ste-Catherine, Montreal, Quebec H3T 1E1, Canada
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