Safety and efficacy of coformulated efavirenz/emtricitabine/tenofovir single-tablet regimen in treatment-naive patients infected with HIV-1

The association between the use of efavirenz and the occurrence of depressive disorders among HIV-treated patients: An application of Bayesian cox regression

OBJECTIVES: Efavirenz therapy plays an important role in controlling the progression of HIV/AIDS. However, efavirenz often causes short-term side effects for the central nervous system, and it remained controversial as to whether efavirenz leads to depression or even suicidal attempt when applied for a longer period of time. The purpose of this study is to determine the association between the use of efavirenz and depressive disorders. METHODS: This study explored the use of efavirenz on HIV-infected patients using National Health Insurance Research Database (NHIRD) in Taiwan by Bayesian survival analysis and investigated whether the use of efavirenz has the risk of depressive disorders. To reduce the dependence of statistical modeling assumptions, this study applied propensity score matching to research data. RESULTS: Based on the result of this study, it can be found that the use of efavirenz (HR = 1.009, 95% CI=–0.505 0.554), gender (HR = 0.324, 95% CI = –2.544 0.381) were not significantly associated with the occurrence of depressive disorders, whereas age of HIV diagnosis (HR = 1.021, 95% CI = 0.011 0.055) was significantly associated with the occurrence of depressive disorders. This study concludes that the use of efavirenz does not in-crease the risk of depressive disorders among HIV-treated patients. CONCLUSIONS: For the care of HIV-infected patients (especially the older ones), the psychological harm from society, such as lack of social support, social stigma or unemployment is higher than the harm of medicine.

Leveraging early HIV diagnosis and treatment in Thailand to conduct HIV cure research

Thailand has the highest prevalence of HIV among countries in Asia but has also been a pioneer in HIV prevention and treatment efforts in the region, reducing the incidence of new infections significantly over the last two decades. Building upon this remarkable history, Thailand has set an ambitious goal to stop the AIDS epidemic in the country by 2030. A key component of the strategy to achieve this goal includes scale-up of HIV screening programs to facilitate early HIV diagnosis and investment in mechanisms to support immediate initiation of antiretroviral therapy (ART). Initiation of ART during early or acute HIV infection not only reduces viremia, thereby halting onward transmission of HIV, but also may facilitate HIV remission by reducing the size of the latent HIV reservoir and preserving immune function. In Thailand, many efforts have been made to reduce the time from HIV infection to diagnosis and from diagnosis to treatment, especially among men who have sex with men and transgender women. Successfully identifying and initiating ART in individuals with acute HIV infection has been leveraged to conduct groundbreaking studies of novel strategies to achieve HIV remission, including studies of broadly-neutralizing HIV-specific monoclonal antibodies and candidate therapeutic vaccines. These efforts have mostly been deployed in Bangkok and future efforts should include other urban and more rural areas. Continued progress in HIV prevention, screening, and treatment will position Thailand to substantially limit new infections and may pave the way for an HIV cure.

HIV-1 genotypic drug resistance in patients with virological failure to single-tablet antiretroviral regimens in southern Taiwan

Purpose

Sparse data are available on the prevalence of resistance among HIV-1-infected patients with virological failure to a single-tablet regimen (STR). This study aimed to evaluate the prevalence of HIV genotypic drug resistance in HIV-1-infected patients with virological failure to STRs in southern Taiwan.

Patients and methods

This retrospective study investigated drug resistance in patients with virological failure to STR from January 2016 to September 2017. Antiretroviral resistance mutations were defined using the 2017 International AIDS Society-USA HIV drug resistance algorithm, and drug resistance was compared using the HIVdb program of the Stanford University HIV Drug Resistance Database. Variables between resistance and non-resistance groups were compared.

Results

Thirty-nine HIV-1-infected patients with treatment failure were tested for resistance, of whom 89% were infected by men who have sex with men. Subtype B HIV-1 strains were found in 90% of the patients. Eight patients were treatment naïve and initiated STRs, while 31 patients experienced treatment failure after switching to STRs. Eighty-seven percent of the patients harbored any of four classes of resistance (nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, protease inhibitors (PIs), and integrase strand transfer inhibitors). The prevalence rates of nucleoside reverse transcriptase inhibitor, non-nucleoside reverse transcriptase inhibitor, PI, and integrase strand transfer inhibitor resistance were 72%, 82%, 10%, and 3%, respectively. Patients with PI resistance were more likely to respond to treatment with a non-tenofovir disoproxil fumarate/emtricitabine/efavirenz-based STR (.=0.004) and a longer duration of antiretroviral therapy (101 months [72.0-123.3] vs 11 months [7-44], P=0.007). There were no associations between different STRs and transmission risk factors, HIV subtype, duration of antiretroviral therapy, and resistance to tenofovir disoproxil fumarate.

Conclusion

A high rate of antiretroviral drug resistance was found in the patients who failed STR treatment. The presence of PI resistance in these patients represented an inappropriate switch from a multiple tablet regimen to an STR. These findings should remind clinicians that detailed drug resistance history and close monitoring are mandatory after switching to an STR.

Structural equation modelling of viral tropism reveals its impact on achieving viral suppression within 6 months in treatment-naive HIV-1-infected patients after combination antiretroviral therapy

OBJECTIVES

To evaluate the role of pre-treatment co-receptor tropism of plasma HIV on the achievement of viral suppression (plasma HIV RNA 1.69 log₁₀ copies/mL) at the sixth month of combination antiretroviral therapy (cART) in a cohort of naive patients using, for the first time in this context, a path analysis (PA) approach.

PATIENTS AND METHODS

Adult patients with chronic infection by subtype B HIV-1 were consecutively enrolled from the start of first-line cART (T0). Genotypic analysis of viral tropism was performed on plasma and interpreted using the bioinformatic tool Geno2pheno, with a false positive rate of 10%. A Bayesian network starting from the viro-immunological data at T0 and at the sixth month of treatment (T1) was set up and this model was evaluated using a PA approach.

RESULTS

A total of 262 patients (22.1% bearing an X4 virus) were included; 178 subjects (67.9%) achieved viral suppression. A significant positive indirect effect of bearing X4 virus in plasma at T0 on log₁₀ HIV RNA at T1 was detected (P = 0.009), the magnitude of this effect was, however, over 10-fold lower than the direct effect of log₁₀ HIV RNA at T0 on log₁₀ HIV RNA at T1 (P = 0.000). Moreover, a significant positive indirect effect of bearing an X4 virus on log₁₀ HIV RNA at T0 (P = 0.003) was apparent.

CONCLUSIONS

PA overcame the limitations implicit in common multiple regression analysis and showed the possible role of pre-treatment viral tropism at the recommended threshold on the outcome of plasma viraemia in naive patients after 6 months of therapy.

Virologic failure is uncommon after treatment initiation during acute HIV infection

OBJECTIVE

In chronic HIV infection, initiation of antiretroviral therapy (ART) typically induces swift HIV RNA declines and virologic suppression within 24 weeks. The objective of this study was to investigate viral dynamics and common criteria for treatment success after ART initiation during acute HIV infection (AHI).

METHODS

Participants were prospectively enrolled and offered ART during AHI from May 2009-June 2015 in Bangkok, Thailand. Regimens included tenofovir, lamivudine or emtricitabine, and efavirenz with or without raltegravir and maraviroc. Participants were monitored for several HIV RNA end points: one-log reduction at week 2; two-log reduction at week 4; less than 1000 copies/ml at week 24; and less than 200 copies/ml at week 24. Factors associated with each end point, time to suppression, and virologic blips were explored.

RESULTS

Two hundred and sixty-four Thai participants initiated ART during AHI. Their median age was 27 years and 96% were men. At 2 weeks, 6.5% had not achieved a one-log reduction in HIV RNA. At 4 weeks, 11.0% had not achieved a two-log reduction. At 24 weeks, 1.1% had not achieved HIV RNA less than 1000 copies/ml and 1.5% had not achieved HIV RNA less than 200 copies/ml. Participants who initiated ART during Fiebig I demonstrated a shorter median time to virologic suppression than did all other stages combined, [4 (interquartile range 2-8) vs. 8 (interquartile range 4-12) weeks, P < 0.001] and 7.3% had subsequent blips (16.1% in other stages, P = 0.23).

CONCLUSION

Virologic failure is uncommon in individuals who initiate ART during AHI. ART initiation during AHI is efficacious and clinicians can monitor for virologic failure after 24 weeks of therapy.

Reduced risk of Efavirenz Discontinuation in Naïve Patients Starting First-Line Antiretroviral Therapy with Single Tablet versus dual Tablet Regimen

OBJECTIVES

Despite not being approved in Europe as first-line therapy, the efavirenz (EFV)-containing single tablet regimen (STR) is frequently used in clinical practice in naïve patients but few data are available on this strategy. In our study, we aimed to assess the risk of EFV discontinuation in patients starting antiretroviral therapy with STR vs. nonSTR.

METHODS

This was a multicentre study retrospectively enrolling naïve patients starting EFV+TDF+FTC. Patients were followed from the time of treatment initiation to the discontinuation of the EFV-containing regimen, comparing STR vs. nonSTR. Two different analyses were performed: (A) nonSTR patients censored at the last observation (switch to STR not considered as the end of observation); (B) nonSTR patients censored at the time of switch to STR.

RESULTS

The study included 235 patients, of whom 74 (31.5%) directly started STR. Among patients starting nonSTR, 108 (67.1%) switched to STR after a median period of 6 months. Forty-four EFV discontinuations were observed (13 among STR vs. 31 among nonSTR patients). The overall estimated probability of discontinuation was 30% at 5 years, about half (14.8%) of these occurring during the first year. Analysis A did not show significant differences between STR and nonSTR regarding the probability of efavirenz discontinuation (19.9% vs. 24.7% at 5 years, P = 0.630). In contrast, Analysis B showed that the probability of EFV discontinuation was similar (8.3%) between STR and nonSTR patients up to 8 months. Thereafter, a significantly higher rate of discontinuation was observed in nonSTR patients (47.5% vs. 19.9% at 5 years, P = 0.034).

CONCLUSIONS

Our data suggest that an early switch to STR during the first months of treatment could reduce the risk of EFV discontinuation.

Persistence and adherence to single-tablet regimens in HIV treatment: a cohort study from the French National Healthcare Insurance Database

OBJECTIVES

To compare adherence and persistence (continuous treatment with a prescribed medication) in HIV adult patients who received combination ART (cART) as a once-daily single-tablet regimen (STR) versus other administration schedules.

METHODS

A representative random sample of the French National Healthcare Insurance Database was used. Adherence and persistence were compared according to their administration schedules using χ(2) and survival analyses. STRs were marketed in France in 2009 and the study period was selected to allow a sufficient number of patients with an STR and a relevant duration of follow-up.

RESULTS

During the period covered (2006-11), 362 HIV-positive adult antiretroviral-naive patients (566 lines of treatments) were selected. The mean rates of adherence were 89.6% for the STR (tenofovir/emtricitabine/efavirenz; n = 76), 86.4% for cART with >1 pill once daily (n = 242) and 77.0% for cART with >1 daily intake (n = 248; P < 0.0001 versus STR). Kaplan-Meier estimations of persistence after 2 years of treatment were 79.1% for the STR, 53.3% for cART with >1 pill once daily and 51.8% for cART with >1 daily intake (P = 0.001; log-rank test). Sensitivity analyses confirmed these results. After excluding treatment sequences showing a switch from tenofovir/emtricitabine plus efavirenz to the similar STR, the rates of persistence were 80.3% for the STR (n = 60), 77.3% for atazanavir-containing cART (n = 96) and 68.3% for darunavir-containing cART (n = 56) at 18 months (global P = 0.006).

CONCLUSIONS

These results suggest that persistence is higher in HIV patients treated with an STR compared with other administration schedules. Significant benefit in terms of adherence was observed with the STR in comparison with regimens with >1 daily intake but no difference was observed when comparing with regimens involving >1 pill once daily.