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Matthews G, Jacoby S, Borok M, Eriobu N, Kaplan R, Kumarasamy N, Bennet JA, Avihingsanon A, Chetchotisakd P, Wagner Cardoso S, Azwa I, Losso M, Brown D, Arlinda D, Hutchinson J, Kelleher A, Cisse M, Dao S, Polizzotto M, Emery S, Law M, Papot E, Karyana M, Lupo S, Solari AM, Grinsztejn B, Wolff M, Andrade-Villanueva J, Mosqueda Gómez JL, Chow TS, Mohapi L, Yunihastuti E, Hadi U, Katu S, Subronto YW, Lane HC, Perelis L. Dolutegravir plus boosted darunavir versus recommended standard-of-care antiretroviral regimens in people with HIV-1 for whom recommended first-line non-nucleoside reverse transcriptase inhibitor therapy has failed (D 2EFT): an open-label, randomised, phase 3b/4 trial. Lancet HIV 2024; 11:e436-e448. [PMID: 38788744 DOI: 10.1016/s2352-3018(24)00089-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/18/2024] [Accepted: 03/25/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Randomised comparative data on efficacy and safety of second-line antiretroviral therapy (ART) after failure of non-nucleoside reverse transcriptase inhibitors (NNRTIs) across diverse geographical settings are scarce. The aim of this study was to evaluate optimal second-line ART for people with HIV. METHODS D2EFT is a completed international, randomised, open-label, phase 3b/4 trial evaluating three second-line ART strategies in adults (aged ≥18 years) with HIV-1 for whom first-line NNRTI therapy has failed. The study was done at 28 sites across 14 countries in Asia, Africa, and Latin America. It was originally designed to compare recommended standard of care (ritonavir-boosted darunavir [800 mg darunavir plus 100 mg ritonavir once daily] plus two nucleoside reverse transcriptase inhibitors [NRTIs; dosed once or twice daily]) with a novel nucleoside sparing regimen of dolutegravir (50 mg once daily) with ritonavir-boosted darunavir. The study was adapted during the first year to add a third arm of dolutegravir (50 mg once daily) with fixed tenofovir disoproxil fumarate (300 mg once daily) plus either lamivudine (300 mg once daily) or emtricitabine (200 mg once daily). Participants were randomly assigned with a computer-generated, blocked randomisation scheme (block size of two) stratified by site, previous tenofovir disoproxil fumarate use, and HIV viral load. The trial was designed to evaluate non-inferiority of either interventional arm against standard of care for the primary outcome of virological suppression, as determined by HIV RNA load of less than 50 copies per mL at 48 weeks. The prespecified non-inferiority margin was 12%. Comparisons were made with a modified intention-to-treat population, including all participants randomly assigned but excluding administrative withdrawals. This study is registered with ClinicalTrials.gov, NCT03017872. FINDINGS 1190 individuals were screened; 828 participants were enrolled between Nov 1, 2017, and Dec 31, 2021. Two participants were unable to receive their assigned regimen for administrative reasons; and 826 participants were included in analyses. Median age was 39 years (IQR 33-46), and 450 (54%) participants were female. Baseline median CD4 count was 206 cells per μL (23-354) and median HIV RNA was 15 400 copies per mL (3600-65 986). The proportion of participants with HIV RNA of less than 50 copies per mL at 48 weeks was 194 (75%) of 257 in the ritonavir-boosted darunavir plus two NRTIs group, 222 (84%) of 264 in the ritonavir-boosted darunavir plus dolutegravir group, and 227 (78%) of 291 in the dolutegravir with tenofovir disoproxil fumarate plus either lamivudine or emtricitabine group. Compared with ritonavir-boosted darunavir plus two NRTIs, the difference in virological suppression was 8·6% (95% CI 1·7 to 15·5; p=0·016) for dolutegravir plus ritonavir-boosted darunavir and 6·7% (-1·2 to 14·4; p=0·093) for dolutegravir with tenofovir disoproxil fumarate plus either lamivudine or emtricitabine. Six deaths occurred, none of which were related to treatment. 19 pregnancies (11 livebirths) occurred with no congenital defects. INTERPRETATION In individuals experiencing failure of an NNRTI-based first-line ART, a switch to either dolutegravir plus ritonavir-boosted darunavir or dolutegravir with tenofovir disoproxil fumarate plus either lamivudine or emtricitabine, without universal access to genotyping, was non-inferior in achieving viral suppression compared with ritonavir-boosted darunavir plus two NRTIs. These global data support the most recent WHO treatment guidelines. FUNDING UNITAID; National Institute of Allergy and Infectious Diseases, USA; National Health and Medical Research Council, Australia; ViiV Healthcare; and Janssen.
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Bacic Lima D, Solomon DA. Switching Human Immunodeficiency Virus Therapy: Basic Principles and Options. Infect Dis Clin North Am 2024:S0891-5520(24)00026-6. [PMID: 38871570 DOI: 10.1016/j.idc.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
The number of options for effective antiretroviral therapy (ART) is steadily increasing. Although older regimens may achieve the goal of virologic suppression, newer options can offer advantages in safety, tolerability, and convenience. In this article, we offer guiding principles for switching ART, highlighting reasons to pursue a switch and key factors to consider when selecting a new regimen.
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Affiliation(s)
- Danilo Bacic Lima
- Massachusetts General Hospital and Brigham & Women's Hospital; Infectious Diseases Division, Brigham and Women's Hospital, 75 Francis Street, PBB-A4, Boston, MA 02115, USA. https://twitter.com/danbacic
| | - Daniel Aran Solomon
- Infectious Diseases Division, Brigham and Women's Hospital, 75 Francis Street, PBB-A4, Boston, MA 02115, USA; Harvard Medical School.
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Moyle G, Assoumou L, de Castro N, Post FA, Curran A, Rusconi S, De Wit S, Stephan C, Raffi F, Johnson M, Masia M, Vera J, Jones B, Grove R, Fletcher C, Duffy A, Morris K, Pozniak A. Switching to dolutegravir plus rilpivirine versus maintaining current antiretroviral therapy regimen in virologically suppressed people with HIV-1 and the Lys103Asn (K103N) mutation: 48-week results from a randomised, open-label pilot clinical trial. Lancet HIV 2024; 11:e156-e166. [PMID: 38417976 DOI: 10.1016/s2352-3018(23)00292-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND The combination of dolutegravir plus rilpivirine has been studied in people with virologically suppressed HIV with no previous history of treatment failure or resistance. We investigated the potential to maintain viral suppression with dolutegravir plus rilpivirine in people with Lys103Asn mutations whose HIV was previously managed with other treatment regimens. METHODS In this open-label pilot trial at 32 clinical sites in seven European countries, virologically suppressed, HBsAg-negative adults aged 18 years or older with HIV-1 and Lys103Asn mutations were randomly assigned (2:1) to switch to 50 mg dolutegravir plus 25 mg rilpivirine (given as a single tablet) once daily or to continue their current antiretroviral therapy regimen (control group). After 48 weeks, participants in the control group also switched to dolutegravir plus rilpivirine. Randomisation was stratified by country, and a computer-generated randomisation list with permuted blocks within strata was used to assign participants to treatment groups. The primary endpoints were virological failure (ie, two consecutive measurements of 50 copies or more of HIV RNA per mL at least 2 weeks apart) and virological suppression (the proportion of participants with fewer than 50 copies of HIV RNA per mL) at week 48 (week 96 data will be reported separately). Analyses were done in the modified intention-to-treat population, which included all participants who received at least one dose of the study medication. This trial is registered with ClinicalTrials.gov, NCT05349838, and EudraCT, 2017-004040-38. FINDINGS Between Nov 5, 2018, and Dec 9, 2020, 140 participants were enrolled and randomly assigned, 95 to the dolutegravir plus rilpivirine group and 45 to the control group. Virological failure was recorded in three participants (3·2%, 95% CI 0·7 to 9·0) in the the dolutegravir plus rilpivirine group and one (2·2%, 0·1 to 11·8) in the control group. The proportion of participants in whom virological suppression was maintained at week 48 was 88·4% (80·2 to 94·1) in the dolutegravir plus rilpivirine group versus 88·9% (75·9 to 96·3) in the control group (difference -0·5, -11·7 to 10·7). Significantly more adverse events were recorded in the dolutegravir plus rilpivirine group than in the control group (234 vs 72; p=0·0034), but the proportion of participants who reported at least one adverse event was similar between groups (76 [80%] of 95 vs 33 [73%] of 45; p=0·39). The frequency of serious adverse events was low and similar between groups. INTERPRETATION Virological suppression was maintained at week 48 in most participants with Lys103Asn mutations when they switched from standard regimens to dolutegravir plus rilpivirine. The results of this pilot study, if maintained when the week 96 data are reported, support conduct of a large, well-powered trial of dolutegravir plus rilpivirine. FUNDING ViiV Healthcare.
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Affiliation(s)
| | - Lambert Assoumou
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Université, Paris, France
| | | | - Frank A Post
- King's College Hospital NHS Foundation Trust, London, UK
| | - Adrian Curran
- Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Stefano Rusconi
- Dipartimento di Scienze Biomediche e Cliniche Luigi Sacco, University of Milan, Milan, Italy; Infectious Disease Unit, Aziende Socio Sanitarie Territoriali Ovest Milanese, Legnano, Italy
| | | | - Christoph Stephan
- University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - François Raffi
- Centre Hospitalier Universitaire de Nantes, Nantes, France; Centre d'Investigation Clinique 1413, INSERM, Nantes, France
| | | | - Mar Masia
- General University Hospital of Elche, Elche, Spain; Centro de investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Jaime Vera
- Brighton and Sussex University Hospitals, Brighton, UK; Brighton and Sussex Medical School Centre for Global Health Research, Brighton, UK
| | | | | | | | | | | | - Anton Pozniak
- Chelsea and Westminster Hospital, London, UK; London School of Hygiene & Tropical Medicine, London, UK
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Santos JR, Domingo P, Portilla J, Gutiérrez F, Imaz A, Vilchez H, Curran A, Valcarce-Pardeiro N, Payeras A, Bernal E, Montero-Alonso M, Yzusqui M, Clotet B, Videla S, Moltó J, Paredes R. A Randomized Trial of Dolutegravir Plus Darunavir/Cobicistat as a Switch Strategy in HIV-1-Infected Patients With Resistance to at Least 2 Antiretroviral Classes. Open Forum Infect Dis 2023; 10:ofad542. [PMID: 38023553 PMCID: PMC10661076 DOI: 10.1093/ofid/ofad542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/28/2023] [Indexed: 12/01/2023] Open
Abstract
Background Suppressed patients with drug-resistant HIV-1 require effective and simple antiretroviral therapy to maintain treatment adherence and viral suppression. Methods This randomized, open-label, noninferiority, multicenter pilot study involved HIV-infected adults who met the following criteria: confirmed HIV-1 RNA <50 copies/mL for ≥6 months preceding the study randomization, treatment with at least 3 antiretroviral drugs, and a history of drug resistance mutations against at least 2 antiretroviral classes but remaining fully susceptible to darunavir (DRV) and integrase inhibitors. Participants were randomized 1:1 to switch to dolutegravir (DTG; 50 mg once per day) plus DRV boosted with cobicistat (DRV/c; 800/150 mg once per day; 2D group) or continue with their baseline regimen (standard-of-care [SOC] group). The primary endpoint was the proportion of patients with HIV-1 RNA <50 copies/mL at week 48 relative to time to loss of virologic response, with a noninferiority margin set at -12.5%. Virologic failure was defined as confirmed HIV-1 RNA ≥50 copies/mL or a single determination of HIV-1 RNA >50 copies/mL followed by antiretroviral therapy discontinuation. Results Forty-five participants were assigned to the 2D group and 44 to the SOC group. Time to loss of virologic response showed no difference in the proportion maintaining HIV-1 RNA <50 copies/mL at week 48: 39 of 45 (86.7%; 95% CI, 73.21%-94.95%) in the 2D group vs 42 of 44 (95.4%; 95% CI, 84.53%-99.44%) in the SOC group (log-rank P = .159) with an estimated difference of -8.7 (95% CI, -22.72 to 5.14). Only 2 (4.5%) in the SOC group experienced virologic failure, and 3 participants from the 2D group experienced adverse events leading to treatment discontinuation. Conclusions In suppressed patients with at least 2 resistant antiretroviral classes, noninferiority could not be demonstrated by fully active DRV/c plus DTG. Nevertheless, there were no unexpected adverse events or virologic failure. DRV/c plus DTG may be considered a once-daily therapy option only for well-selected patients. Clinical Trials Registration. ClinicalTrials.gov (NCT03683524).
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Affiliation(s)
- José R Santos
- Infectious Diseases Department and Fundació Lluita contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
| | - Pere Domingo
- HIV Unit, Service of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Félix Gutiérrez
- Infectious Diseases Unit, Department of Internal Medicine, Hospital General Universitario de Elche, Elche, Spain
- University Miguel Hernández, Alicante, Spain
- CIBERINFEC, ISCIII, Madrid, Spain
| | - Arkaitz Imaz
- HIV Unit, Infectious Diseases Service, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Helem Vilchez
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitari Son Espases, Fundació Institut d’Investigació Sanitària Illes Balears, Palma de Mallorca, Spain
| | - Adrià Curran
- HIV Unit, Service of Infectious Diseases, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | | | - Antoni Payeras
- Service of Internal Medicine, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | - Enrique Bernal
- Infectious Diseases Unit, Hospital General Universitario Reina Sofía de Murcia, Murcia, Spain
- Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - Marta Montero-Alonso
- Infectious Diseases Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Miguel Yzusqui
- Department of Internal Medicine, Hospital General Nuestra Señora del Prado, Talavera de la Reina, Spain
| | - Bonaventura Clotet
- Infectious Diseases Department and Fundació Lluita contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- IrsiCaixa AIDS Research Institute, Badalona, Spain
| | - Sebastià Videla
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, IDIBELL, University of Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain
- Lluita contra les Infeccions Foundation, Badalona, Spain
| | - José Moltó
- Infectious Diseases Department and Fundació Lluita contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- CIBERINFEC, ISCIII, Madrid, Spain
| | - Roger Paredes
- Infectious Diseases Department and Fundació Lluita contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain
- IrsiCaixa AIDS Research Institute, Badalona, Spain
- Center for Global Health and Diseases, Department of Pathology, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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5
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Vasishta S, Dieterich D, Mullen M, Aberg J. Brief Report: Hepatitis B Infection or Reactivation After Switch to 2-Drug Antiretroviral Therapy: A Case Series, Literature Review, and Management Discussion. J Acquir Immune Defic Syndr 2023; 94:160-164. [PMID: 37345994 DOI: 10.1097/qai.0000000000003239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Two-drug antiretroviral therapy (ART) without hepatitis B virus (HBV) activity is prescribed for persons with HIV as simplified or salvage therapy. Although two-drug regimens are not recommended for persons with chronic HBV infection, guidelines do not address their use in those with HBV susceptibility and/or core antibody reactivity. We present a case series of individuals with HBV infection or reactivation following switch to two-drug, non-HBV-active ART. SETTING HIV primary care clinics of an academic medical center in New York, NY. METHODS Case surveillance was conducted to identify persons with HBV surface antigenemia and viremia following two-drug ART switch. Clinical characteristics and outcomes were ascertained through chart review. RESULTS Four individuals with HBV infection or reactivation after ART switch were identified. Two had HBV susceptibility, 1 had core antibody reactivity, and 1 had surface antigen reactivity preswitch. All eligible persons had received HBV vaccination: 2 with low-level antibody response and 1 with persistent nonresponse. Two presented with fulminant hepatitis, with 1 required liver transplantation. CONCLUSION Two-drug ART switch may pose risk of HBV infection or reactivation. We propose careful patient selection and monitoring through the following: (1) assessment of HBV serologies before switch and periodically thereafter, (2) vaccination and confirmation of immunity before switch, (3) risk stratification and counseling about HBV reactivation for those with core antibody, (4) preemptive HBV DNA monitoring for those at the risk of reactivation, (5) continuation of HBV-active prophylaxis when above measures are not feasible, and (6) continuation of HBV-active therapy and surveillance for chronic HBV infection.
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Affiliation(s)
- Shilpa Vasishta
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; and
| | - Douglas Dieterich
- Division of Gastroenterology and Liver Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael Mullen
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; and
| | - Judith Aberg
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; and
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Steegen K, van Zyl GU, Claassen M, Khan A, Pillay M, Govender S, Bester PA, van Straaten JM, Kana V, Cutler E, Kalimashe MN, Lebelo RL, Moloi MBH, Hans L. Advancing HIV Drug Resistance Technologies and Strategies: Insights from South Africa's Experience and Future Directions for Resource-Limited Settings. Diagnostics (Basel) 2023; 13:2209. [PMID: 37443603 DOI: 10.3390/diagnostics13132209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Monitoring of HIV drug resistance (HIVDR) remains critical for ensuring countries attain and sustain the global goals for ending HIV as a public health threat by 2030. On an individual patient level, drug resistance results assist in ensuring unnecessary treatment switches are avoided and subsequent regimens are tailored on a case-by-case basis, should resistance be detected. Although there is a disparity in access to HIVDR testing in high-income countries compared to low- and middle-income countries (LMICS), more LMICs have now included HIVDR testing for individual patient management in some groups of patients. In this review, we describe different strategies for surveillance as well as where HIVDR testing can be implemented for individual patient management. In addition, we briefly review available technologies for HIVDR testing in LMICs, including Sanger sequencing, next-generation sequencing, and some point-of-care options. Finally, we describe how South Africa has implemented HIVDR testing in the public sector.
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Affiliation(s)
- Kim Steegen
- Department of Molecular Medicine and Haematology, National Health Laboratory Service, Charlotte Maxeke Johannesburg Hospital, Johannesburg 2193, South Africa
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
- Wits Diagnostic Innovation Hub, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Gert U van Zyl
- Division of Medical Virology, Stellenbosh University, Stellenbosh 7602, South Africa
- Division of Medical Virology, Stellenbosh National Health Laboratory Service, Tygerberg Hospital, Tygerberg 7505, South Africa
| | - Mathilda Claassen
- Division of Medical Virology, Stellenbosh University, Stellenbosh 7602, South Africa
- Division of Medical Virology, Stellenbosh National Health Laboratory Service, Tygerberg Hospital, Tygerberg 7505, South Africa
| | - Aabida Khan
- Department of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban 4041, South Africa
- Department of Virology, National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban 4058, South Africa
| | - Melendhran Pillay
- Department of Virology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban 4041, South Africa
- Department of Virology, National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban 4058, South Africa
| | - Subitha Govender
- Department of Virology, National Health Laboratory Service, Inkosi Albert Luthuli Central Hospital, Durban 4058, South Africa
| | - Phillip A Bester
- Department of Medical Microbiology and Virology, University of the Free State, Bloemfontein 9300, South Africa
- Department of Medical Microbiology and Virology, National Health Laboratory Service, Universitas Academic Hospital, Bloemfontein 9301, South Africa
| | - Johanna M van Straaten
- Department of Medical Microbiology and Virology, National Health Laboratory Service, Universitas Academic Hospital, Bloemfontein 9301, South Africa
| | - Vibha Kana
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg 2192, South Africa
| | - Ewaldé Cutler
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg 2192, South Africa
| | - Monalisa N Kalimashe
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg 2192, South Africa
| | - Ramokone L Lebelo
- Department of Virological Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
- Department of Virological Pathology, National Health Laboratory Service, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
| | - Mokopi B H Moloi
- Department of Virological Pathology, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
- Department of Virological Pathology, National Health Laboratory Service, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
| | - Lucia Hans
- Department of Molecular Medicine and Haematology, National Health Laboratory Service, Charlotte Maxeke Johannesburg Hospital, Johannesburg 2193, South Africa
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
- Wits Diagnostic Innovation Hub, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
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Kantor R, Gupta RK. We should not stop considering HIV drug resistance testing at failure of first-line antiretroviral therapy. Lancet HIV 2023; 10:e202-e208. [PMID: 36610438 PMCID: PMC10067973 DOI: 10.1016/s2352-3018(22)00327-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 01/06/2023]
Abstract
HIV drug resistance is a major global hurdle to successful and sustained antiretroviral therapy. Global guidelines recommend testing for antiretroviral drug resistance and results are used to inform treatment regimen design for patients at different stages of therapy. Several clinical trials investigated optimal regimens after failure of first-line antiretroviral therapy, yielding data that advanced knowledge and informed care. However, further interpretation of data from these studies questioned the benefit of antiretroviral drug resistance testing for cases in which first-line treatment is not effective and, furthermore, that relying on the results of antiretroviral drug resistance testing could be misleading and unnecessary. In this Viewpoint, which is largely focused on high-income settings, we review these data, reflect on the potential problems with their interpretation, and call for caution in their extrapolation. Without negating the importance of the data, and recognising the varied circumstances related to HIV drug resistance testing in different global settings, we advise caution before changing current practice and recommendations. We believe that we should not universally stop considering HIV drug resistance testing at failure of first-line antiretroviral therapy.
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Affiliation(s)
- Rami Kantor
- Division of Infectious Diseases, Department of Medicine, Brown University, The Miriam Hospital, Providence, RI, USA.
| | - Ravindra K Gupta
- Cambridge Institute of Therapeutic Immunology and Infectious Diseases, University of Cambridge, Cambridge, UK; Africa Health Research Institute, Kwazulu-Natal, South Africa
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Minimal Cross-resistance to Tenofovir in Children and Adolescents Failing ART Makes Them Eligible for Tenofovir-Lamivudine-Dolutegravir Treatment. Pediatr Infect Dis J 2022; 41:827-834. [PMID: 35895893 PMCID: PMC9508940 DOI: 10.1097/inf.0000000000003647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Fixed-dose combination of dolutegravir (DTG) with tenofovir disoproxil fumarate (TDF) and lamivudine (3TC) likely improves adherence and has a favorable resistance profile. We evaluated predicted efficacy of TLD (TDF-3TC-DTG) in children and adolescents failing abacavir (ABC), zidovudine (AZT), or TDF containing regimens. METHODS Drug resistance mutations were analyzed in a retrospective dataset of individuals <19 years of age, failing ABC (n = 293) AZT (n = 288) or TDF (n = 69) based treatment. Pol sequences were submitted to Stanford HIVdb v8.9. Genotypic susceptibility scores were calculated for various DTG-containing regimens. RESULTS Genotypes were assessed for 650 individuals with a median age of 14 years (IQR 10-17 years). More individuals failed a protease inhibitor (PI)-based (78.3%) than a non-nucleoside reverse transcriptase inhibitors (NNRTI)-based (21.7%) regimen. Most individuals in the AZT group (n = 288; 94.4%) failed a PI-based regimen, compared with 71.0% and 64.2% in the TDF (n = 69) and ABC group (n = 293). Genotypic sensitivity scores <2 to TLD were observed in 8.5% and 9.4% of ABC- and AZT-exposed individuals, compared with 23.2% in the TDF group. The M184V mutation was most often detected in the ABC group (70.6%) versus 60.0% and 52.4% in TDF and AZT groups. The presence of K65R was rare (n = 13, 2.0%) and reduced TLD susceptibility was commonly caused by accumulation of nucleoside reverse transcriptase inhibitor (NRTI) mutations. CONCLUSIONS Cross-resistance to TDF was limited, further reducing concerns about use of transition to TLD in children and adolescents. The NADIA trial has subsequently shown that patients failing a TDF/3TC/EFV regimen can safely be transitioned to a TLD regimen but we do not have data for patients failing an ABC/3TC/NNRTI or PI regimens. Frequent virological monitoring is recommended after switch to DTG, especially in children continuing ABC in the backbone. Clinical studies correlating predicted resistance with clinical outcomes, especially in settings without access to genotyping, are required.
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9
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Reply to Epling and Powers, "Cefiderocol and the Need for Higher-Quality Evidence: Methods Matter for Patients". Antimicrob Agents Chemother 2022; 66:e0079522. [PMID: 35867525 PMCID: PMC9380543 DOI: 10.1128/aac.00795-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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10
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Clements MN, White IR, Copas AJ, Cornelius V, Cro S, Dunn DT, Quartagno M, Turner RM, Tweed CD, Walker AS. Improving clinical trial interpretation with ACCEPT analyses. NEJM EVIDENCE 2022; 1:evidctw2200018. [PMID: 35965674 PMCID: PMC7613267 DOI: 10.1056/evidctw2200018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | | | | | | | - Suzie Cro
- Imperial Clinical Trials Unit, Imperial College London, London
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11
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Paton NI, Musaazi J, Kityo C, Walimbwa S, Hoppe A, Balyegisawa A, Asienzo J, Kaimal A, Mirembe G, Lugemwa A, Ategeka G, Borok M, Mugerwa H, Siika A, Odongpiny ELA, Castelnuovo B, Kiragga A, Kambugu A, Kambugu A, Kaimal A, Castelnuovo B, Kiiza D, Asienzo J, Kisembo J, Nsubuga J, Okwero M, Muyise R, Kityo C, Nasaazi C, Nakiboneka DL, Mugerwa H, Namusanje J, Najjuuko T, Masaba T, Serumaga T, Alinaitwe A, Arinda A, Rweyora A, Ategeka G, Kangah MG, Lugemwa A, Kasozi M, Tukumushabe P, Akunda R, Makumbi S, Musumba S, Myalo S, Ahuura J, Namusisi AM, Kibirige D, Kiweewa F, Mirembe G, Mabonga H, Wandege J, Nakakeeto J, Namubiru S, Nansalire W, Siika AM, Kwobah CM, Mboya CS, Mokaya MMB, Karoney MJ, Cheruiyot PC, Cherutich S, Njuguna SW, Kirui VC, Borok M, Chidziva E, Musoro G, Hakim J, Bhiri J, Phiri M, Mudzingwa S, Manyanga T, Kiragga A, Banegura AM, Hoppe A, Balyegisawa A, Agwang B, Isaaya B, Tumwine C, Odongpiny ELA, Asienzo J, Musaazi J, Paton N, Senkungu P, Walimbwa S, Kamara Y, Amperiize M, Allen E, Opondo C, Mohammed P, van Rein-van der Horst W, Van Delft Y, Boateng FA, Namara D, Kaleebu P, Ojoo S, Bwakura T, Katana M, Venter F, Phiri S, Walker S. Efficacy and safety of dolutegravir or darunavir in combination with lamivudine plus either zidovudine or tenofovir for second-line treatment of HIV infection (NADIA): week 96 results from a prospective, multicentre, open-label, factorial, randomised, non-inferiority trial. THE LANCET HIV 2022; 9:e381-e393. [DOI: 10.1016/s2352-3018(22)00092-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 12/28/2022]
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Pérez-González A, Suárez-García I, Ocampo A, Poveda E. Two-Drug Regimens for HIV-Current Evidence, Research Gaps and Future Challenges. Microorganisms 2022; 10:433. [PMID: 35208887 PMCID: PMC8880461 DOI: 10.3390/microorganisms10020433] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 02/04/2023] Open
Abstract
During the last 30 years, antiretroviral treatment (ART) for human immunodeficiency virus (HIV) infection has been continuously evolving. Since 1996, three-drug regimens (3DR) have been standard-of-care for HIV treatment and are based on a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI) plus two nucleoside reverse transcriptase inhibitors (NRTIs). The effectiveness of first-generation 3DRs allowed a dramatic increase in the life expectancy of HIV-infected patients, although it was associated with several side effects and ART-related toxicities. The development of novel two-drug regimens (2DRs) started in the mid-2000s in order to minimize side effects, reduce drug-drug interactions and improve treatment compliance. Several clinical trials compared 2DRs and 3DRs in treatment-naïve and treatment-experienced patients and showed the non-inferiority of 2DRs in terms of efficacy, which led to 2DRs being used as first-line treatment in several clinical scenarios, according to HIV clinical guidelines. In this review, we summarize the current evidence, research gaps and future prospects of 2DRs.
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Affiliation(s)
- Alexandre Pérez-González
- Group of Virology and Pathogenesis, Galicia Sur Health Research Institute (IIS Galicia Sur), Complexo Hospitalario Universitario de Vigo, SERGAS-UVigo, 36213 Vigo, Spain;
- Infectious Diseases Unit, Department of Internal Medicine, Galicia Sur Health Research Institute (IIS Galicia Sur), Complexo Hospitalario Universitario de Vigo, SERGAS-UVigo, 36213 Vigo, Spain;
| | - Inés Suárez-García
- Infectious Diseases Group, Internal Medicine Department, Hospital Universitario Infanta Sofía, FIIB HUIS HHEN, 28703 San Sebastián de los Reyes, Spain;
- Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea, 28670 Madrid, Spain
- CIBER de Enfermedades Infecciosas, 28029 Madrid, Spain
| | - Antonio Ocampo
- Infectious Diseases Unit, Department of Internal Medicine, Galicia Sur Health Research Institute (IIS Galicia Sur), Complexo Hospitalario Universitario de Vigo, SERGAS-UVigo, 36213 Vigo, Spain;
| | - Eva Poveda
- Group of Virology and Pathogenesis, Galicia Sur Health Research Institute (IIS Galicia Sur), Complexo Hospitalario Universitario de Vigo, SERGAS-UVigo, 36213 Vigo, Spain;
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Ketema W, Taye K, Shibeshi MS, Tagesse N, Hirigo AT, Woubishet K, Gutema S, Eifa A, Toma A. The First Experience of Effective 3rd Line Antiretroviral Therapy - A Case of 40-Year-Old Female Retroviral-Infected Patient at Hawassa University Comprehensive Specialized Hospital, Hawassa, Sidama, Ethiopia. Res Rep Trop Med 2021; 12:263-266. [PMID: 34858075 PMCID: PMC8631462 DOI: 10.2147/rrtm.s341711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/17/2021] [Indexed: 11/23/2022] Open
Abstract
Background Treatment failure continues to be an impediment to the efficacy of highly active antiretroviral therapy (HART) in the treatment of human immunodeficiency virus type 1 infection (HIV-1). The World Health Organization (WHO) recommends third-line antiretroviral therapy (ART) for patients who have failed second-line ART. Darunavir (DRV) boosted with ritonavir (DRV/r) has a higher genetic barrier to resistance, is active against multidrug-resistant HIV isolates, retaining virological activity even when multiple protease mutations are present, and has been shown to be cost-effective when compared to other boosted protease inhibitors (PIs). Case Summary This is a case of a 40-year-old female known HIV/AIDS patient who has been on ART for the last 14 years with good adherence and regular follow-up, and who is now on 3rd line ART medication with TLD (tenofovir/lamivudine/dolutegravir)+DRV/r (in her 11th month) after being diagnosed with second-line treatment failure. After 6 months and 1 week of therapy, the viral load (VL) was sent, and the result was undetectable. The patient's clinical conditions had greatly improved. Conclusion Third-line ART therapy, which was once thought to be a salvageable treatment, is now the primary option for second-line ART failure. TLD in combination with ritonavir-boosted darunavir is found to be effective at lowering viral loads in the blood below detectable limits. Despite a lack of data on the use of third-line ART in Ethiopia, access to third-line ART containing ritonavir-boosted darunavir is recommended because it has been shown to be an effective alternative for patients who have failed second-line ART. We recommend that more research be done with a larger sample size, and that the findings in this paper be used with caution.
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Affiliation(s)
- Worku Ketema
- Department of Pediatrics and Child Health, College of Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Kefyalew Taye
- Department of Pediatrics and Child Health, College of Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Mulugeta Sitot Shibeshi
- Department of Pediatrics and Child Health, College of Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Negash Tagesse
- Department of Pediatrics and Child Health, College of Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Agete Tadewos Hirigo
- Department of Medical Laboratory Technology, College of Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Kindie Woubishet
- Department of Internal Medicine, College of Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Selamawit Gutema
- Department of Internal Medicine, College of Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Aberash Eifa
- Department of Midwifery, College of Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Alemayehu Toma
- Department of Pharmacology, College of Health Sciences, Hawassa University, Hawassa, Ethiopia
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Siedner MJ, Moosa MYS, McCluskey S, Gilbert RF, Pillay S, Aturinda I, Ard K, Muyindike W, Musinguzi N, Masette G, Pillay M, Moodley P, Brijkumar J, Rautenberg T, George G, Gandhi RT, Johnson BA, Sunpath H, Bwana MB, Marconi VC. Resistance Testing for Management of HIV Virologic Failure in Sub-Saharan Africa : An Unblinded Randomized Controlled Trial. Ann Intern Med 2021; 174:1683-1692. [PMID: 34698502 PMCID: PMC8688215 DOI: 10.7326/m21-2229] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Virologic failure in HIV predicts the development of drug resistance and mortality. Genotypic resistance testing (GRT), which is the standard of care after virologic failure in high-income settings, is rarely implemented in sub-Saharan Africa. OBJECTIVE To estimate the effectiveness of GRT for improving virologic suppression rates among people with HIV in sub-Saharan Africa for whom first-line therapy fails. DESIGN Pragmatic, unblinded, randomized controlled trial. (ClinicalTrials.gov: NCT02787499). SETTING Ambulatory HIV clinics in the public sector in Uganda and South Africa. PATIENTS Adults receiving first-line antiretroviral therapy with a recent HIV RNA viral load of 1000 copies/mL or higher. INTERVENTION Participants were randomly assigned to receive standard of care (SOC), including adherence counseling sessions and repeated viral load testing, or immediate GRT. MEASUREMENTS The primary outcome of interest was achievement of an HIV RNA viral load below 200 copies/mL 9 months after enrollment. RESULTS The trial enrolled 840 persons, divided equally between countries. Approximately half (51%) were women. Most (72%) were receiving a regimen of tenofovir, emtricitabine, and efavirenz at enrollment. The rate of virologic suppression did not differ 9 months after enrollment between the GRT group (63% [263 of 417]) and SOC group (61% [256 of 423]; odds ratio [OR], 1.11 [95% CI, 0.83 to 1.49]; P = 0.46). Among participants with persistent failure (HIV RNA viral load ≥1000 copies/mL) at 9 months, the prevalence of drug resistance was higher in the SOC group (76% [78 of 103] vs. 59% [48 of 82]; OR, 2.30 [CI, 1.22 to 4.35]; P = 0.014). Other secondary outcomes, including 9-month survival and retention in care, were similar between groups. LIMITATION Participants were receiving nonnucleoside reverse transcriptase inhibitor-based therapy at enrollment, limiting the generalizability of the findings. CONCLUSION The addition of GRT to routine care after first-line virologic failure in Uganda and South Africa did not improve rates of resuppression. PRIMARY FUNDING SOURCE The President's Emergency Plan for AIDS Relief and the National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Mark J Siedner
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, Mbarara University of Science and Technology, Mbarara, Uganda, Africa Health Research Institute, KwaZulu-Natal, South Africa, and University of KwaZulu-Natal, Durban, South Africa (M.J.S.)
| | | | - Suzanne McCluskey
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (S.M., K.A., R.T.G.)
| | | | - Selvan Pillay
- University of KwaZulu-Natal, Durban, South Africa (M.S.M., S.P., J.B., G.G., H.S.)
| | - Isaac Aturinda
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Kevin Ard
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (S.M., K.A., R.T.G.)
| | - Winnie Muyindike
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Nicholas Musinguzi
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Godfrey Masette
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Melendhran Pillay
- National Health Laboratory Service, Durban, South Africa (M.P., P.M.)
| | | | - Jaysingh Brijkumar
- University of KwaZulu-Natal, Durban, South Africa (M.S.M., S.P., J.B., G.G., H.S.)
| | | | - Gavin George
- University of KwaZulu-Natal, Durban, South Africa (M.S.M., S.P., J.B., G.G., H.S.)
| | - Rajesh T Gandhi
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (S.M., K.A., R.T.G.)
| | | | - Henry Sunpath
- University of KwaZulu-Natal, Durban, South Africa (M.S.M., S.P., J.B., G.G., H.S.)
| | - Mwebesa B Bwana
- Mbarara University of Science and Technology, Mbarara, Uganda (I.A., W.M., N.M., G.M., M.B.B.)
| | - Vincent C Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia (V.C.M.)
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Mwasakifwa GE, Amin J, Kelleher A, Boyd MA. Inflammatory biomarkers and soft tissue changes among patients commencing second-line antiretroviral therapy after first-line virological failure. AIDS 2021; 35:2289-2298. [PMID: 34224441 DOI: 10.1097/qad.0000000000003014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION We explored associations of inflammatory and immune activation biomarkers at baseline and percentage gain in peripheral and trunk fat and lean mass over 96 weeks in patients with confirmed virological failure initiating lopinavir-anchored second-line antiretroviral therapy (ART) regimens. METHOD We measured baseline plasma concentration of interleukin (IL)-6, tumour necrosis factor (TNF), neopterin, IL-6, high-sensitivity C-reactive protein (hs-CRP), D-dimer, soluble cluster of differentiation 14 (sCD14), and soluble CD163 in 123 participants of the SECOND-LINE body composition substudy. Linear regression assessed the association between biomarkers and percentage gain in limb/trunk fat and lean mass, adjusting for age, nucleoside or nucleotide reverse transcriptase inhibitor (N(t)RTI) use, body mass index, ethnicity, smoking, viral load, CD4+ T-cell counts, smoking, duration of ART use, and cholesterol. RESULTS Mean (standard deviation) age was 38 (7.3) years, CD4+ T-cell count was 252 (185.9) cells/μl, human immunodeficiency virus viral load was 4.2 (0.9) log10 copies/ml, 47% (58/123) were in the N(t)RTI arm (vs. raltegravir [RAL] arm in 53%); 56.1% (69/123) were females. In adjusted analyses, for every log10 increase in baseline levels of IL-6, neopterin, and D-dimer, the percentage gain in peripheral fat over 96 weeks was 11.8% (95% confidence interval [CI]: 0.9-22.6, P = 0.033); neopterin, 11.2% (95% CI: 3.2-19.2, P = 0.007); D-dimer 9.6% (95% CI: 3.1-15.9, P = 0.004), respectively. The associations remained significant when analysis was stratified by N(t)RTI vs. RAL and included only patients with viral suppression at week 48. A significant gradient in lean mass gain was seen across quartiles of IL-6, TNF, neopterin, hsCRP, D-dimer, and sCD14. CONCLUSION Inflammatory biomarkers provide important mechanistic insights into the pathogenesis of limb fat and lean mass changes independently of ART.
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Affiliation(s)
| | - Janaki Amin
- The Kirby Institute, University of New South Wales
- Department of Health Systems and Populations, Macquarie University, Sydney, NSW
| | | | - Mark A Boyd
- The Kirby Institute, University of New South Wales
- Faculty of Health and Medical Sciences, University of Adelaide, South Australia, Australia
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Saeed AM, Schmidt JM, Munasinghe WP, Vallabh BK, Jarvis MF, Morris JB, Mostafa NM. Comparative Bioavailability of Two Formulations of Biopharmaceutical Classification System (BCS) Class IV Drugs: A Case Study of Lopinavir/Ritonavir. J Pharm Sci 2021; 110:3963-3968. [PMID: 34530003 DOI: 10.1016/j.xphs.2021.08.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Lopinavir/ritonavir (LPV/r-A, Kaletra®), a fixed dose, co-formulated antiviral therapy for the treatment of HIV infection has been used worldwide for over two decades. Both active substances have low solubility in water and low membrane permeability. LPV/r-A tablets contain key excipients critical to ensuring acceptable bioavailability of lopinavir and ritonavir in humans. An established dog pharmacokinetic model demonstrated several generic LPV/r tablet formulations have significant oral bioavailability variability compared to LPV/r-A. METHODS Analytical characterizations of LPV/r-B tablets were performed and a clinical study was conducted to assess the relative bioavailability of Kalidavir® (LPV/r-B) 400/100 mg tablets relative to Kaletra® (LPV/r-A) 400/100 mg tablets under fasting conditions. RESULTS The presence of active substances were confirmed in LPV/r-B tablets in an apparent amorphous state at essentially the labeled amounts, and dissolution profiles were generally similar to LPV/r-A tablets. Excipients in the tablet formulation were found to be variable and deviate from the labeled composition. Lopinavir and ritonavir exposures (AUC) following LPV/r-B administration were approximately 90% and 20% lower compared to that of LPV/r-A. CONCLUSIONS LPV/r-B was not shown to be bioequivalent to LPV/r-A.
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Affiliation(s)
- Ahmed M Saeed
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, IL, USA
| | | | | | | | | | - John B Morris
- Development Sciences, AbbVie, Inc., North Chicago, IL, USA
| | - Nael M Mostafa
- Clinical Pharmacology and Pharmacometrics, AbbVie, Inc., North Chicago, IL, USA.
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17
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Paton NI, Musaazi J, Kityo C, Walimbwa S, Hoppe A, Balyegisawa A, Kaimal A, Mirembe G, Tukamushabe P, Ategeka G, Hakim J, Mugerwa H, Siika A, Asienzo J, Castelnuovo B, Kiragga A, Kambugu A. Dolutegravir or Darunavir in Combination with Zidovudine or Tenofovir to Treat HIV. N Engl J Med 2021; 385:330-341. [PMID: 34289276 DOI: 10.1056/nejmoa2101609] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The World Health Organization recommends dolutegravir with two nucleoside reverse-transcriptase inhibitors (NRTIs) for second-line treatment of human immunodeficiency virus type 1 (HIV-1) infection. Evidence is limited for the efficacy of this regimen when NRTIs are predicted to lack activity because of drug resistance, as well as for the recommended switch of an NRTI from tenofovir to zidovudine. METHODS In a two-by-two factorial, open-label, noninferiority trial, we randomly assigned patients for whom first-line therapy was failing (HIV-1 viral load, ≥1000 copies per milliliter) to receive dolutegravir or ritonavir-boosted darunavir and to receive tenofovir or zidovudine; all patients received lamivudine. The primary outcome was a week 48 viral load of less than 400 copies per milliliter, assessed with the Food and Drug Administration snapshot algorithm (noninferiority margin for the between-group difference in the percentage of patients with the primary outcome, 12 percentage points). RESULTS We enrolled 464 patients at seven sub-Saharan African sites. A week 48 viral load of less than 400 copies per milliliter was observed in 90.2% of the patients in the dolutegravir group (212 of 235) and in 91.7% of those in the darunavir group (210 of 229) (difference, -1.5 percentage points; 95% confidence interval [CI], -6.7 to 3.7; P = 0.58; indicating noninferiority of dolutegravir, without superiority) and in 92.3% of the patients in the tenofovir group (215 of 233) and in 89.6% of those in the zidovudine group (207 of 231) (difference, 2.7 percentage points; 95% CI, -2.6 to 7.9; P = 0.32; indicating noninferiority of tenofovir, without superiority). In the subgroup of patients with no NRTIs that were predicted to have activity, a viral load of less than 400 copies per milliliter was observed in more than 90% of the patients in the dolutegravir group and the darunavir group. The incidence of adverse events did not differ substantially between the groups in either factorial comparison. CONCLUSIONS Dolutegravir in combination with NRTIs was effective in treating patients with HIV-1 infection, including those with extensive NRTI resistance in whom no NRTIs were predicted to have activity. Tenofovir was noninferior to zidovudine as second-line therapy. (Funded by Janssen; NADIA ClinicalTrials.gov number, NCT03988452.).
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Affiliation(s)
- Nicholas I Paton
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Joseph Musaazi
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Cissy Kityo
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Stephen Walimbwa
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Anne Hoppe
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Apolo Balyegisawa
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Arvind Kaimal
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Grace Mirembe
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Phionah Tukamushabe
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Gilbert Ategeka
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - James Hakim
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Henry Mugerwa
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Abraham Siika
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Jesca Asienzo
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Barbara Castelnuovo
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Agnes Kiragga
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
| | - Andrew Kambugu
- From the Infectious Diseases Translational Research Programme and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (N.I.P.); the London School of Hygiene and Tropical Medicine, London (N.I.P.); the Infectious Diseases Institute, Makerere University (J.M., S.W., A.H., A.B., A. Kaimal, J.A., B.C., A. Kiragga, A. Kambugu), the Joint Clinical Research Centre (JCRC) (C.K., H.M.), and the Makerere University Walter Reed Project (G.M.), Kampala, JCRC, Mbarara (P.T.), and JCRC, Fort Portal (G.A.) - all in Uganda; the University of Zimbabwe Clinical Research Centre, Harare (J.H.); and the Moi University School of Medicine, Eldoret, Kenya (A.S.)
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Dual therapy with dolutegravir plus boosted protease inhibitor as maintenance or salvage therapy in highly experienced people living with HIV. Int J Antimicrob Agents 2021; 58:106403. [PMID: 34289404 DOI: 10.1016/j.ijantimicag.2021.106403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 06/12/2021] [Accepted: 07/03/2021] [Indexed: 01/11/2023]
Abstract
Real-world experience with dolutegravir (DTG) plus boosted protease inhibitor (bPI) as a two-drug regimen is limited for highly experienced HIV-positive patients with virological failure or intolerance to antiretroviral therapy. Patients receiving DTG plus bPI between September 2016 and June 2019 at 15 designated hospitals for HIV care in Taiwan were retrospectively included in this study. A standardised case record form was used to collect clinical data. The primary endpoint was virological response, defined as achieving or maintaining plasma HIV-RNA <50 copies/mL at Week 48. A total of 77 patients were included; 58 (75.3%) had documented genotypic resistance to 1-4 antiretroviral classes. The most commonly used PI was darunavir (87.0%; 67/77). Seven patients (9.1%) had no virological data at Week 48, including three with loss to follow-up, one severe hyperlipidaemia, one renal failure and cardiovascular disease, one superimposed HBV infection and one death from anal cancer. The virological response rate increased from 59.7% at baseline to 90.9% at Week 24 and 85.7% at Week 48. The only patient (1.3%) with virological failure at Week 48 had poor adherence and baseline low-level resistance to darunavir with resistance-associated mutations at M46L, I50V and V82A. Compared with baseline, mean total cholesterol increased by 20.1 mg/dL and weight by 2.8 kg at Week 48, while the estimated glomerular filtration rate decreased by 14.4 mL/min/1.73m2 (both P < 0.05). We conclude that a two-drug regimen containing DTG plus bPI was effective in highly-experienced HIV-positive patients, but metabolic impact and weight gain should be closely monitored.
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Marukutira T, Wood BR. Growing data for recycling tenofovir and lamivudine with dolutegravir as empiric second-line antiretroviral therapy in resource-limited settings. AIDS 2021; 35:1505-1507. [PMID: 34185718 DOI: 10.1097/qad.0000000000002958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Tafireyi Marukutira
- Public Health, Burnet Institute
- School of Public Health and Preventive Medicine, Monash University
| | - Brian R Wood
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
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20
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Keene CM, Griesel R, Zhao Y, Gcwabe Z, Sayed K, Hill A, Cassidy T, Ngwenya O, Jackson A, Van Zyl G, Schutz C, Goliath R, Flowers T, Goemaere E, Wiesner L, Simmons B, Maartens G, Meintjes G. Virologic efficacy of tenofovir, lamivudine and dolutegravir as second-line antiretroviral therapy in adults failing a tenofovir-based first-line regimen. AIDS 2021; 35:1423-1432. [PMID: 33973876 PMCID: PMC7612028 DOI: 10.1097/qad.0000000000002936] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Recycling tenofovir and lamivudine/emtricitabine (XTC) with dolutegravir would provide a more tolerable, affordable, and scalable second-line regimen than dolutegravir with an optimized nucleoside reverse transcriptase inhibitor (NRTI) backbone. We evaluated efficacy of tenofovir/lamivudine/dolutegravir (TLD) in patients failing first-line tenofovir/XTC/efavirenz or nevirapine. DESIGN Single arm, prospective, interventional study. SETTING Two primary care clinics in Khayelitsha, South Africa. PARTICIPANTS Sixty adult patients with two viral loads greater than 1000 copies/ml. INTERVENTION Participants were switched to TLD with additional dolutegravir (50 mg) for 2 weeks to overcome efavirenz induction. PRIMARY OUTCOME Proportion achieving viral load less than 50 copies/ml at week 24 using the FDA snapshot algorithm. RESULTS Baseline median CD4+ cell count was 248 cells/μl, viral load 10 580 copies/ml and 48 of 54 (89%) had resistance (Stanford score ≥15) to one or both of tenofovir and XTC. No participants were lost to follow-up. At week 24, 51 of 60 [85%, 95% confidence interval (CI) 73-93%] were virologically suppressed, six had viral load 50-100 copies/ml, one had viral load 100-1000 copies/ml, one no viral load in window, and one switched because of tenofovir-related adverse event. No integrase mutations were detected in the one participant meeting criteria for resistance testing. Virological suppression was achieved by 29 of 35 (83%, 95% CI 66-93%) with resistance to tenofovir and XTC, 11 of 13 (85%, 95% CI 55-98%) with resistance to XTC, and six of six (100%, 95% CI 54-100%) with resistance to neither. CONCLUSION A high proportion of adults switching to second-line TLD achieved virologic suppression despite substantial baseline NRTI resistance and most not suppressed had low-level viraemia (≤100 copies/ml). This suggests recycling tenofovir and XTC with dolutegravir could provide an effective second-line option.
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Affiliation(s)
| | - Rulan Griesel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Ying Zhao
- University of Cape Town, Cape Town, South Africa
| | | | - Kaneez Sayed
- University of Cape Town, Cape Town, South Africa
| | - Andrew Hill
- University of Liverpool, Department of Pharmacology, Liverpool, United Kingdom
| | - Tali Cassidy
- Médecins Sans Frontières South Africa
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Gert Van Zyl
- University of Stellenbosch, Division of Medical Virology, Cape Town, South Africa
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rene Goliath
- University of Cape Town, Cape Town, South Africa
| | | | - Eric Goemaere
- Médecins Sans Frontières South Africa
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Bryony Simmons
- Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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21
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Jiménez de Ory S, Beltrán-Pavez C, Gutiérrez-López M, Santos MDM, Prieto L, Sainz T, Guillen S, Aguilera-Alonso D, Díez C, Bernardino JI, Mellado MJ, Ramos JT, Holguín Á, Navarro M. Prevalence of M184V and K65R in proviral DNA from PBMCs in HIV-infected youths with lamivudine/emtricitabine exposure. J Antimicrob Chemother 2021; 76:1886-1892. [PMID: 33734374 PMCID: PMC8212770 DOI: 10.1093/jac/dkab080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/23/2021] [Indexed: 12/13/2022] Open
Abstract
Objectives We analysed the prevalence of M184V/I and/or K65R/E/N mutations archived in proviral DNA (pDNA) in youths with perinatal HIV, virological control and who previously carried these resistance mutations in historic plasma samples. Methods We included vertically HIV-infected youths/young adults aged ≥10 years in the Madrid Cohort of HIV-1 Infected Children and Adolescents, exposed to lamivudine and/or emtricitabine, with M184V/I and/or K65R/E/N in historic plasma samples, on antiretroviral therapy (ART), virologically suppressed (HIV-1 RNA <50 copies/mL), and with available PBMCs in the Spanish HIV BioBank. Genomic DNA was extracted from PBMCs and HIV-1 RT gene was amplified and sequenced for resistance testing by Stanford HIV Resistance tool. Results Among the 225 patients under follow-up in the study cohort, 13 (5.8%) met selection criteria, and RT sequences were recovered in 12 (92.3%) of them. All but one were Spaniards, carrying subtype B, with a median age at PBMCs sampling of 21.3 years (IQR: 15.6–23.1) with 4 years (IQR 2.1–6.5) of suppressed viral load (VL). Nine (75%) youths did not present M184V/I in pDNA after at least 1 year of viral suppression. In December 2019, the remaining three subjects carrying M184V/I in pDNA maintained suppressed viraemia, and two still used emtricitabine in ART. Conclusions The prevalence of resistance mutations to lamivudine and emtricitabine in pDNA in a cohort of youths perinatally infected with HIV who remain with undetectable VL, previously lamivudine and/or emtricitabine experienced, was infrequent. Our results indicate that ART including lamivudine or emtricitabine may also be safe and successful in youths with perinatal HIV with previous experience of and resistances to these drugs detected in plasma.
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Affiliation(s)
- Santiago Jiménez de Ory
- Hospital General Universitario Gregorio Marañón, Fundación para la Investigación Biomédica, Instituto de Investigación Gregorio Marañón (IiSGM), Madrid, Spain
| | - Carolina Beltrán-Pavez
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, Hospital Ramón y Cajal-IRYCIS and CIBEREsp-RITIP, Madrid, Spain
| | - Miguel Gutiérrez-López
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, Hospital Ramón y Cajal-IRYCIS and CIBEREsp-RITIP, Madrid, Spain
| | - María Del Mar Santos
- Pediatric Infectious Diseases Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiGM), Madrid, Spain
| | - Luis Prieto
- Department of Infectious Diseases, Hospital 12 de Octubre, Madrid, Spain
| | - Talía Sainz
- Department of Infectious Diseases and Tropical Pediatrics, Hospital La Paz, Madrid, Spain
| | - Sara Guillen
- Department of Pediatrics, Hospital de Getafe, Getafe, Spain
| | - David Aguilera-Alonso
- Pediatric Infectious Diseases Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiGM), Madrid, Spain
| | - Cristina Díez
- Infectious Diseases/HIV Unit, Hospital General Universitario Gregorio Marañón, Fundación para la Investigación Biomédica, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | | | - María José Mellado
- Department of Infectious Diseases and Tropical Pediatrics, Hospital La Paz, Madrid, Spain
| | - José Tomás Ramos
- Department of Infectious Diseases, Hospital Clínico Universitario and Universidad Complutense, Madrid, Spain
| | - África Holguín
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, Hospital Ramón y Cajal-IRYCIS and CIBEREsp-RITIP, Madrid, Spain
| | - Marisa Navarro
- Pediatric Infectious Diseases Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Gregorio Marañón (IiSGM) and RITIP, Madrid, Spain
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Henry RT, Jiamsakul A, Law M, Losso M, Kamarulzaman A, Phanuphak P, Kumarasamy N, Foulkes S, Mohapi L, Nwizu C, Wood R, Kelleher A, Polizzotto M. Factors Associated With and Characteristic of HIV/Tuberculosis Co-Infection: A Retrospective Analysis of SECOND-LINE Clinical Trial Participants. J Acquir Immune Defic Syndr 2021; 87:720-729. [PMID: 33399309 DOI: 10.1097/qai.0000000000002619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 12/01/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tuberculosis (TB) is a common infection in people living with HIV. However, the risk factors for HIV/TB co-infection in second-line HIV therapy are poorly understood. We aimed to determine the incidence and risk factors for TB co-infection in SECOND-LINE, an international randomized clinical trial of second-line HIV therapy. METHODS We did a cohort analysis of TB cases in SECOND-LINE. TB cases included any clinical or laboratory-confirmed diagnoses and/or commencement of treatment for TB after randomization. Baseline factors associated with TB were analyzed using Cox regression stratified by site. RESULTS TB cases occurred at sites in Argentina, India, Malaysia, Nigeria, South Africa, and Thailand, in a cohort of 355 of the 541 SECOND-LINE participants. Overall, 20 cases of TB occurred, an incidence rate of 3.4 per 100 person-years (95% CI: 2.1 to 5.1). Increased TB risk was associated with a low CD4+-cell count (≤200 cells/μL), high viral load (>200 copies/mL), low platelet count (<150 ×109/L), and low total serum cholesterol (≤4.5 mmol/L) at baseline. An increased risk of death was associated with TB, adjusted for CD4, platelets, and cholesterol. A low CD4+-cell count was significantly associated with incident TB, mortality, other AIDS diagnoses, and virologic failure. DISCUSSION The risk of TB remains elevated in PLHIV in the setting of second-line HIV therapy in TB endemic regions. TB was associated with a greater risk of death. Finding that low CD4+ T-cell count was significantly associated with poor outcomes in this population supports the value of CD4+ monitoring in HIV clinical management.
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Affiliation(s)
- Rebecca T Henry
- Kirby Institute, University of New South Wales, Sydney, Australia
| | | | - Matthew Law
- Kirby Institute, University of New South Wales, Sydney, Australia
| | | | | | | | - Nagalingeswaran Kumarasamy
- CART Clinical Research Site, Infectious Diseases Medical Centre, Voluntary Health Services (VHS), Chennai, India
| | | | - Lerato Mohapi
- Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Chidi Nwizu
- Plateau State Specialist Hospital, Bingham University Teaching Hospital, Jos, Nigeria; and
| | - Robin Wood
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Anthony Kelleher
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Mark Polizzotto
- Kirby Institute, University of New South Wales, Sydney, Australia
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23
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Wallis CL, Hughes MD, Ritz J, Viana R, de Jesus CS, Saravanan S, van Schalkwyk M, Mngqibisa R, Salata R, Mugyenyi P, Hogg E, Hovind L, Wieclaw L, Gross R, Godfrey C, Collier AC, Grinsztejn B, Mellors JW. Diverse Human Immunodeficiency Virus-1 Drug Resistance Profiles at Screening for ACTG A5288: A Study of People Experiencing Virologic Failure on Second-line Antiretroviral Therapy in Resource-limited Settings. Clin Infect Dis 2021; 71:e170-e177. [PMID: 31724034 DOI: 10.1093/cid/ciz1116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/12/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV) drug resistance profiles are needed to optimize individual patient management and to develop treatment guidelines. Resistance profiles are not well defined among individuals on failing second-line antiretroviral therapy (ART) in low- and middle-income countries (LMIC). METHODS Resistance genotypes were performed during screening for enrollment into a trial of third-line ART (AIDS Clinical Trials Group protocol 5288). Prior exposure to both nucleoside reverse transcriptase inhibitors (NRTIs) and non-NRTIs and confirmed virologic failure on a protease inhibitor-containing regimen were required. Associations of drug resistance with sex, age, treatment history, plasma HIV RNA, nadir CD4+T-cell count, HIV subtype, and country were investigated. RESULTS Plasma HIV genotypes were analyzed for 653 screened candidates; most had resistance (508 of 653; 78%) to 1 or more drugs. Genotypes from 133 (20%) showed resistance to at least 1 drug in a drug class, from 206 (32%) showed resistance to at least 1 drug in 2 drug classes, and from 169 (26%) showed resistance to at least 1 drug in all 3 commonly available drug classes. Susceptibility to at least 1 second-line regimen was preserved in 59%, as were susceptibility to etravirine (78%) and darunavir/ritonavir (97%). Susceptibility to a second-line regimen was significantly higher among women, younger individuals, those with higher nadir CD4+ T-cell counts, and those who had received lopinavir/ritonavir, but was lower among prior nevirapine recipients. CONCLUSIONS Highly divergent HIV drug resistance profiles were observed among candidates screened for third-line ART in LMIC, ranging from no resistance to resistance to 3 drug classes. These findings underscore the need for access to resistance testing and newer antiretrovirals for the optimal management of third-line ART in LMIC.
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Affiliation(s)
- Carole L Wallis
- Bio Analytical Research Corporation South Africa and Lancet Laboratories, Johannesburg, South Africa
| | - Michael D Hughes
- Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Justin Ritz
- Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Raquel Viana
- Bio Analytical Research Corporation South Africa and Lancet Laboratories, Johannesburg, South Africa
| | - Carlos Silva de Jesus
- Instituto Nacional de Infectologia Evandro Chagas, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - Marije van Schalkwyk
- Family Clinical Research Unit Clinical Research Site, Stellenbosch University, Cape Town, South Africa
| | - Rosie Mngqibisa
- Durban Adult Human Immunodeficiency Virus Clinical Research Site, Enhancing Care Foundation, Durban, South Africa
| | - Robert Salata
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Evelyn Hogg
- Social and Scientific Systems, Inc, Silver Spring, Maryland, USA
| | - Laura Hovind
- Frontier Science & Technology Research Foundation, Amherst, New York, USA
| | - Linda Wieclaw
- Frontier Science & Technology Research Foundation, Amherst, New York, USA
| | - Robert Gross
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Catherine Godfrey
- Division of Acquired Immunodeficiency Syndrome, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Ann C Collier
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil
| | - John W Mellors
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Costa C, Scabini S, Kaimal A, Kasozi W, Cusato J, Kafufu B, Borderi M, Mwaka E, Di Perri G, Lamorde M, Calcagno A, Castelnuovo B. Calcaneal Quantitative Ultrasonography and Urinary Retinol-Binding Protein in Antiretroviral-Treated Patients With Human Immunodeficiency Virus in Uganda: A Pilot Study. J Infect Dis 2021; 222:263-272. [PMID: 32112093 DOI: 10.1093/infdis/jiaa088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Data on bone health and renal impairment in people with human immunodeficiency virus (HIV) in resource-limited settings are limited. The primary aim of this study was to investigate the potential role of calcaneal quantitative ultrasonography (QUS) in predicting bone mineral density (BMD) reduction in a population of Ugandan HIV-infected individuals receiving long-term antiretroviral therapy; the secondary end point was to assess the prevalence of proximal tubular dysfunction and the correlation between elevated urinary retinol-binding protein-urinary creatinine ratio (uRBP/uCr) and reduced BMD. METHODS We conducted a cross-sectional study at the Infectious Diseases Institute, Kampala, Uganda. We included 101 HIV-infected adults who had been receiving continuous antiretroviral therapy for ≥10 years and had undergone dual-energy x-ray absorptiometry (DXA) during the previous 12 months. All patients underwent calcaneal QUS evaluation and urine sample collection. RESULTS DXA BMD measurements were significantly associated (P < .01) with calcaneal speed of sound, broadband ultrasound attenuation, and QUS index. Forty-seven individuals (47%) had abnormal uRBP/uCr values. A significant inverse correlation was observed between uRBP/uCr and DXA T scores (lumbar [P = .03], femoral neck [P < .001], and total hip [P = .002]). CONCLUSIONS Calcaneal QUS results showed a moderate correlation with DXA outputs. The identified high prevalence of subclinical tubular impairment also highlights the importance of expanding access to tenofovir disoproxil fumarate-sparing regimens in resource-limited settings.
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Affiliation(s)
- Cecilia Costa
- Unit of Infectious Diseases, Amedeo di Savoia Hospital, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Silvia Scabini
- Unit of Infectious Diseases, Amedeo di Savoia Hospital, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Arvind Kaimal
- Infectious Diseases Institute-Mulago Hospital, Research Department, Kampala, Uganda
| | - William Kasozi
- Infectious Diseases Institute-Mulago Hospital, Research Department, Kampala, Uganda
| | - Jessica Cusato
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Turin-ASL "Città di Torino," Turin, Italy
| | - Bosco Kafufu
- Infectious Diseases Institute-Mulago Hospital, Research Department, Kampala, Uganda
| | - Marco Borderi
- Unit of Infectious Diseases, Department of Medical and Surgical Sciences, S. Orsola Hospital, "Alma Mater Studiorum" University of Bologna, Bologna, Italy
| | - Erisa Mwaka
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Amedeo di Savoia Hospital, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Mohammed Lamorde
- Infectious Diseases Institute-Mulago Hospital, Research Department, Kampala, Uganda
| | - Andrea Calcagno
- Unit of Infectious Diseases, Amedeo di Savoia Hospital, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Barbara Castelnuovo
- Infectious Diseases Institute-Mulago Hospital, Research Department, Kampala, Uganda
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Hawkins KL, Montague BT, Rowan SE, Beum R, McLees MP, Johnson S, Gardner EM. Boosted darunavir and dolutegravir dual therapy among a cohort of highly treatment-experienced individuals. Antivir Ther 2020; 24:513-519. [PMID: 31538963 DOI: 10.3851/imp3330] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The use of dual antiretroviral therapy (ART) regimens for treatment of HIV is increasing. The contemporary combination of boosted darunavir with dolutegravir has not been widely studied. METHODS This was a retrospective cohort study that evaluated treatment-experienced individuals within three large urban clinics prescribed boosted darunavir with dolutegravir (study regimen) dual therapy. Follow-up was defined as the number of days from regimen initiation until the last HIV RNA determination on the study regimen. Virological outcomes, HIV RNA ≤50 copies/ml (undetectable), were assessed overall and by baseline HIV RNA status. RESULTS Of 65 individuals included, 83% were at least 3-class antiretroviral-experienced and median time since starting ART was 19 years (IQR 13-22). Median follow-up was 419 days (IQR 286-744). An undetectable HIV RNA was achieved by 62/65 (95%) individuals at any time point on the study regimen. At the end of follow-up 61/65 (94%) individuals remained undetectable, including 48/49 (98%) with an undetectable HIV RNA at baseline (those changing for optimization) and 13/16 (81%) with viraemia at baseline (those changing therapy during virological failure). At the end of follow-up, 55 (85%) individuals were still taking the study regimen. No individuals stopped therapy due to virological failure or intolerance. CONCLUSIONS In a highly treatment-experienced cohort, boosted darunavir with dolutegravir dual therapy demonstrated high rates of virological success, even in those with detectable HIV RNA prior to initiating the study regimen. Further study of this potent, simple, high-barrier dual-class regimen is warranted.
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Affiliation(s)
- Kellie L Hawkins
- Denver Public Health, Denver, CO, USA.,Department of Infectious Disease, University of Colorado, Aurora, CO, USA
| | - Brian T Montague
- Department of Infectious Disease, University of Colorado, Aurora, CO, USA
| | - Sarah E Rowan
- Denver Public Health, Denver, CO, USA.,Department of Infectious Disease, University of Colorado, Aurora, CO, USA
| | | | - Margaret P McLees
- Denver Public Health, Denver, CO, USA.,Department of Infectious Disease, University of Colorado, Aurora, CO, USA
| | - Steven Johnson
- Department of Infectious Disease, University of Colorado, Aurora, CO, USA
| | - Edward M Gardner
- Denver Public Health, Denver, CO, USA.,Department of Infectious Disease, University of Colorado, Aurora, CO, USA
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26
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Kuritzkes DR. New Perspectives on the Virologic Consequences of M184V or I in Human Immunodeficiency Virus-1 Reverse Transcriptase. J Infect Dis 2020; 222:1067-1069. [PMID: 31774915 DOI: 10.1093/infdis/jiz632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 11/26/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniel R Kuritzkes
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School
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27
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Crowell TA, Danboise B, Parikh A, Esber A, Dear N, Coakley P, Kasembeli A, Maswai J, Khamadi S, Bahemana E, Iroezindu M, Kiweewa F, Owuoth J, Freeman J, Jagodzinski LL, Malia JA, Eller LA, Tovanabutra S, Peel SA, Ake JA, Polyak CS. Pretreatment and Acquired Antiretroviral Drug Resistance Among Persons Living With HIV in Four African Countries. Clin Infect Dis 2020; 73:e2311-e2322. [PMID: 32785695 PMCID: PMC8492117 DOI: 10.1093/cid/ciaa1161] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Emerging HIV drug resistance (HIVDR) could jeopardize the success of standardized HIV management protocols in resource-limited settings. We characterized HIVDR among antiretroviral therapy (ART)-naive and experienced participants in the African Cohort Study (AFRICOS). METHODS From January 2013 to April 2019, adults with HIV-1 RNA >1000 copies/mL underwent ART history review and HIVDR testing upon enrollment at 12 clinics in Uganda, Kenya, Tanzania, and Nigeria. We calculated resistance scores for specific drugs and tallied major mutations to non-nucleoside reverse transcriptase inhibitors (NNRTIs), nucleoside reverse transcriptase inhibitors (NRTIs), and protease inhibitors (PIs) using Stanford HIVDB 8.8 and SmartGene IDNS software. For ART-naive participants, World Health Organization surveillance drug resistance mutations (SDRMs) were noted. RESULTS HIVDR testing was performed on 972 participants with median age 35.7 (interquartile range [IQR] 29.7-42.7) years and median CD4 295 (IQR 148-478) cells/mm3. Among 801 ART-naive participants, the prevalence of SDRMs was 11.0%, NNRTI mutations 8.2%, NRTI mutations 4.7%, and PI mutations 0.4%. Among 171 viremic ART-experienced participants, NNRTI mutation prevalence was 83.6%, NRTI 67.8%, and PI 1.8%. There were 90 ART-experienced participants with resistance to both efavirenz and lamivudine, 33 (36.7%) of whom were still prescribed these drugs. There were 10 with resistance to both tenofovir and lamivudine, 8 (80.0%) of whom were prescribed these drugs. CONCLUSIONS Participants on failing ART regimens had a high burden of HIVDR that potentially limited the efficacy of standardized first- and second-line regimens. Management strategies that emphasize adherence counseling while delaying ART switch may promote drug resistance and should be reconsidered.
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Affiliation(s)
- Trevor A Crowell
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Brook Danboise
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Ajay Parikh
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Allahna Esber
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Nicole Dear
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Peter Coakley
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Alex Kasembeli
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,HJF Medical Research International, Kericho, Kenya
| | - Jonah Maswai
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,HJF Medical Research International, Kericho, Kenya
| | - Samoel Khamadi
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,HJF Medical Research International, Mbeya, Tanzania
| | - Emmanuel Bahemana
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,HJF Medical Research International, Mbeya, Tanzania
| | - Michael Iroezindu
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,HJF Medical Research International, Abuja, Nigeria
| | | | - John Owuoth
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,HJF Medical Research International, Kisumu, Kenya
| | - Joanna Freeman
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Linda L Jagodzinski
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Jennifer A Malia
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Leigh Ann Eller
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Sodsai Tovanabutra
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Sheila A Peel
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Julie A Ake
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Christina S Polyak
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
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Hudson FP, Mulenga L, Westfall AO, Warrier R, Mweemba A, Saag MS, Stringer JS, Eron JJ, Chi BH. Evolution of HIV-1 drug resistance after virological failure of first-line antiretroviral therapy in Lusaka, Zambia. Antivir Ther 2020; 24:291-300. [PMID: 30977467 DOI: 10.3851/imp3299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND HIV viral load (VL) and resistance testing are limited in sub-Saharan Africa, so individuals may have prolonged time on failing first-line antiretroviral therapy (ART). Our objective was to describe the evolution of drug resistance mutations among adults failing first-line ART in Zambia. METHODS We analysed data from a trial of VL monitoring in Lusaka, Zambia. From 2006 to 2011, 12 randomized sites provided either routine VL monitoring (intervention) or discretionary (control) after ART initiation. Samples were collected prospectively following the same schedule in each arm but analysed retrospectively in the control group. For those with virological failure (VF; >400 copies/ml), HIV genotyping was performed retrospectively on baseline (BL) and on all subsequent specimens until censored due to study completion, withdrawal or death. RESULTS Of 1,973 enrollees, 165 (8.4%) developed VF. 464 genotype results were available including 132 (80%) at BL, 116 (70%) at VF and 125 (76%) had at least one result between VF and censoring. Major nucleoside reverse transcriptase inhibitor (NRTI) or non-nucleoside reverse transcriptase inhibitor (NNRTI) mutations increased from 26% (BL) to 82% (VF) to 89% at last genotype (LG). M184 mutations increased from 2% to 59% to 71%; K65R from 2% to 11% to 13%; 2 or more thymidine analogue mutations from 1% to 3% to 12%. Among those on a failing tenofovir disoproxil fumarate (TDF)-based regimen, TDF resistance increased from 42% to 58%. CONCLUSIONS We found substantial resistance to NRTIs and NNRTIs at VF with incremental increases after VF while still on a failing first-line ART; this resistance may compromise attainment of the UNAIDS 90-90-90 goals.
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Affiliation(s)
- F Parker Hudson
- Department of Internal Medicine, University of Texas at Austin, Austin, TX, USA
| | - Lloyd Mulenga
- School of Medicine, University of Zambia, Lusaka, Zambia
| | - Andrew O Westfall
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ranjit Warrier
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Aggrey Mweemba
- School of Medicine, University of Zambia, Lusaka, Zambia
| | - Michael S Saag
- Department of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffrey Sa Stringer
- UNC Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joseph J Eron
- Department of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Benjamin H Chi
- UNC Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Mwasakifwa GE, Amin J, White CP, Center JR, Kelleher A, Boyd MA. Early changes in bone turnover and inflammatory biomarkers and clinically significant bone mineral density loss over 48 weeks among HIV-infected patients with virological failure of a standard first-line antiretroviral therapy regimen in the SECOND-LINE study. HIV Med 2020; 21:492-504. [PMID: 32573910 DOI: 10.1111/hiv.12882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 01/31/2020] [Accepted: 04/28/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We assessed whether changes at week 12 in markers of bone turnover, inflammation, and immune activation were associated with clinically important (≥ 5%) bone mineral density (BMD) loss from baseline to week 48 at the proximal femur (hip) and lumbar spine in the SECOND-LINE study. METHODS We measured concentrations of procollagen type 1 pro-peptide (P1NP), carboxyl-terminal collagen crosslinks (CTX), high-sensitivity C-reactive protein (hs-CRP), D-dimer, interleukin (IL)-6, tumor necrosis factor (TNF), neopterin, and soluble CD14 and 163 at weeks 0, 12, and 48 in 123 SECOND-LINE dual-energy X-ray absorptiometry (DXA) substudy participants. Linear regression was used to compare changes in biomarkers. Predictors of ≥ 5% BMD loss were examined using multivariable regression. RESULTS The mean age was 38 years, the mean CD4 T-cell count was 252 cells/µL and the mean viral load was 4.2 log HIV-1 RNA copies/mL; 56% of participants were female and 47% were randomized to receive a nucleos(t)ide reverse transcriptase inhibitor [N(t)RTI]-based regimen [91% (53/58) were randomized to receive a tenofovir disoproxil fumarate (TDF)-containing regimen]. Over 48 weeks, 71% in the N(t)RTI arm experienced ≥ 5% hip BMD loss vs. 29% in the raltegravir arm (P = 0.001). Week 12 changes in P1NP and CTX were significantly greater among patients experiencing ≥ 5% hip BMD loss, patients randomized to N(t)RTI, and male patients. Predictors of ≥ 5% hip BMD loss at week 48 were P1NP increase [odds ratio (OR) 5.0; 95% confidence interval (CI) 1.1-27; P < 0.043]; N(t)RTI randomization (OR 6.7; 95% CI 2.0-27.1; P < 0.003), being African, higher baseline CD4 T cell count , and smoking. CONCLUSIONS In a diverse cohort of viraemic HIV-infected patients, switching to second-line antiretroviral therapy (ART) was associated with clinically significant BMD loss, which was correlated with an early increase in P1NP. Measurement of P1NP may facilitate timely interventions to reduce rapid BMD loss among at-risk patients.
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Affiliation(s)
- G E Mwasakifwa
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - J Amin
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.,Department of Health Systems and Populations, Macquarie University, Sydney, NSW, Australia
| | - C P White
- Department of Endocrinology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - J R Center
- The Garvan Institute of Medical Research, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - A Kelleher
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - M A Boyd
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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30
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Dolutegravir plus lamivudine for maintenance of HIV viral suppression in adults with and without historical resistance to lamivudine: 48-week results of a non-randomized, pilot clinical trial (ART-PRO). EBioMedicine 2020; 55:102779. [PMID: 32408111 PMCID: PMC7225620 DOI: 10.1016/j.ebiom.2020.102779] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/11/2020] [Accepted: 04/20/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND We investigated the efficacy of a switch to dolutegravir plus lamivudine in aviremic individuals without evidence of persistent lamivudine resistance-associated mutations in baseline proviral DNA population sequencing. METHODS Open-label, single-arm, 48-week pilot trial. HIV-1 infected adults, naïve to integrase inhibitors, with CD4+ above 350 cell/μL and fewer than 50 HIV-1 RNA copies per mL the year prior to study entry switched to dolutegravir plus lamivudine. Participants were excluded if baseline proviral DNA population genotyping detected lamivudine resistance-associated mutations. To detect resistance minority variants, proviral DNA next-generation sequencing was retrospectively performed from baseline samples. Primary efficacy endpoint was proportion of participants with fewer than 50 HIV-1 RNA copies per mL at week 48. Safety and tolerability outcomes were incidence of adverse events and treatment discontinuations. ART-PRO is registered with ClinicalTrials.gov, NCT03539224. FINDINGS 41 participants switched to dolutegravir plus lamivudine, 21 with lamivudine resistance mutations in historical plasma genotypes. Baseline next-generation sequencing detected lamivudine resistance mutations (M184V/I and/or K65R/E/N) over a 5% threshold in 15/21 (71·4%) and 3/20 (15%) of participants with and without history of lamivudine resistance, respectively. At week 48, 92·7% of participants (38/41) had fewer than 50 HIV-1 RNA copies per mL. There were no cases of virologic failure. Three participants with historical lamivudine resistance were prematurely discontinued from the study (2 protocol violations, one adverse event). Ten participants (4 in the group with historical lamivudine resistance) had a transient viral rebound, all resuppressed on dolutegravir plus lamivudine. There were 28 drug-related adverse events, only one leading to discontinuation. INTERPRETATION In this pilot trial, dolutegravir plus lamivudine was effective in maintaining virologic control despite past historical lamivudine resistance and presence of archived lamivudine resistance-associated mutations detected by next generation sequencing. Further studies are needed to confirm our results. FUNDING Fondo de Investigaciones Sanitarias, Instituto de Salud Carlos III PI16/00837-PI16/00678.
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Claassen CW, Keckich D, Nwizu C, Abimiku A, Salami D, Obiefune M, Gilliam BL, Amoroso A. HIV Viral Dynamics of Lopinavir/Ritonavir Monotherapy as Second-Line Treatment: A Prospective, Single-Arm Trial. J Int Assoc Provid AIDS Care 2020; 18:2325958218823209. [PMID: 30798695 PMCID: PMC6748552 DOI: 10.1177/2325958218823209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Characterizing viral response to lopinavir/ritonavir (LPV/r) monotherapy as second-line treatment may guide recommendations for resource-limited settings (RLS). Methods: We conducted a 48-week prospective, single-arm study of LPV/r monotherapy in patients failing first-line therapy in Nigeria. The primary outcome was sustained HIV-1 viral load (VL) <400 copies/mL at 48 weeks. Results: Of 30 enrolled patients, 28 (93%) achieved viral suppression on LPV/r, while 29 (96%) experienced low-level viremia. At 48 weeks, 9 (30%) met the primary outcome of sustained viral suppression; 14 (47%) patients were suppressed on LPV/r in a snapshot analysis. Detectable VLs at 12 and 24 weeks were strongly associated with treatment failure at 48 weeks. New resistance mutations were not detected. The trial was stopped early due to treatment failure. Conclusion: In this study, the rate of virologic failure among patients on a second-line lopinavir monotherapy regimen was relatively high and predicted by early detectable viremia. However, no LPV/r-associated resistance mutations were detected despite fluctuating low-level viremia, demonstrating the high genetic barrier to resistance of the protease inhibitor class which could be useful in RLS.
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Affiliation(s)
- Cassidy W Claassen
- 1 Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Chidi Nwizu
- 1 Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.,3 Center for Clinical Care and Clinical Research, Abuja, Nigeria
| | - Alash'le Abimiku
- 1 Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Donald Salami
- 4 University of Maryland, Maryland Global Initiatives Corporation, Abuja, Nigeria
| | - Michael Obiefune
- 3 Center for Clinical Care and Clinical Research, Abuja, Nigeria.,4 University of Maryland, Maryland Global Initiatives Corporation, Abuja, Nigeria
| | - Bruce L Gilliam
- 1 Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anthony Amoroso
- 1 Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
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32
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Cutrell J, Jodlowski T, Bedimo R. The management of treatment-experienced HIV patients (including virologic failure and switches). Ther Adv Infect Dis 2020; 7:2049936120901395. [PMID: 32010443 PMCID: PMC6974747 DOI: 10.1177/2049936120901395] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 11/22/2019] [Indexed: 02/06/2023] Open
Abstract
Significant advances in the potency and tolerability of antiretroviral therapy (ART) have led to very high rates of virologic success for most who remain adherent to therapy. As a result, the life expectancy of people living with HIV (PLWH) has increased significantly. PLWH do, however, continue to experience a significantly higher risk of noninfectious comorbidities and chronic age-related complications, including cardiovascular disease and malignancies, which are now the biggest drivers of this excess morbidity and mortality. Therefore, in addition to virologic failure, the management of the treatment-experienced patient increasingly requires optimization of ART to enhance tolerability, avoid drug-drug interactions, and mitigate non-AIDS complications and comorbid conditions. This article will present principles of the management of virologic failure, poor immunologic recovery, and strategies for optimizing ART in the setting of virologic suppression.
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Affiliation(s)
- James Cutrell
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, USA
| | - Tomasz Jodlowski
- Department of Pharmacy, VA North Texas Health Care System, Dallas, USA
| | - Roger Bedimo
- Department of Medicine, VA North Texas Health Care System and the University of Texas Southwestern Medical Center, 4500 South Lancaster Road, 111-D, Dallas, TX 75216, USA
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Bircher RE, Ntamatungiro AJ, Glass TR, Mnzava D, Nyuri A, Mapesi H, Paris DH, Battegay M, Klimkait T, Weisser M. High failure rates of protease inhibitor-based antiretroviral treatment in rural Tanzania - A prospective cohort study. PLoS One 2020; 15:e0227600. [PMID: 31929566 PMCID: PMC6957142 DOI: 10.1371/journal.pone.0227600] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 12/24/2019] [Indexed: 01/12/2023] Open
Abstract
Background Poor adherence to antiretroviral drugs and viral resistance are the main drivers of treatment failure in HIV-infected patients. In sub-Saharan Africa, avoidance of treatment failure on second-line protease inhibitor therapy is critical as treatment options are limited. Methods In the prospective observational study of the Kilombero & Ulanga Antiretroviral Cohort in rural Tanzania, we assessed virologic failure (viral load ≥1,000 copies/mL) and drug resistance mutations in bio-banked plasma samples 6–12 months after initiation of a protease inhibitor-based treatment regimen. Additionally, viral load was measured before start of protease inhibitor, a second time between 1–5 years after start, and at suspected treatment failure in patients with available bio-banked samples. We performed resistance testing if viral load was ≥1000 copies/ml. Risk factors for virologic failure were analyzed using logistic regression. Results In total, 252 patients were included; of those 56% were female and 21% children. Virologic failure occurred 6–12 months after the start of a protease inhibitor in 26/199 (13.1%) of adults and 7/53 of children (13.2%). The prevalence of virologic failure did not change over time. Nucleoside reverse transcriptase inhibitors drug resistance mutation testing performed at 6–12 months showed a positive signal in only 9/16 adults. No cases of resistance mutations for protease inhibitors were seen at this time. In samples taken between 1–5 years protease inhibitor resistance was demonstrated in 2/7 adults. In adult samples before protease inhibitor start, resistance to nucleoside reverse transcriptase inhibitors was detected in 30/41, and to non-nucleoside reverse-transcriptase inhibitors in 35/41 patients. In 15/16 pediatric samples, resistance to both drug classes but not for protease inhibitors was present. Conclusion Our study confirms high early failure rates in adults and children treated with protease inhibitors, even in the absence of protease inhibitors resistance mutations, suggesting an urgent need for adherence support in this setting.
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Affiliation(s)
- Rahel E. Bircher
- Ifakara Health Institute, Ifakara, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Molecular Virology, Department Biomedicine Petersplatz, University of Basel, Basel, Switzerland
| | | | - Tracy R. Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | | | - Herry Mapesi
- Ifakara Health Institute, Ifakara, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- St. Francis Referral Hospital, Ifakara, Tanzania
| | - Daniel H. Paris
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Manuel Battegay
- University of Basel, Basel, Switzerland
- Departments of Medicine and Clinical Research, Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Thomas Klimkait
- Molecular Virology, Department Biomedicine Petersplatz, University of Basel, Basel, Switzerland
| | - Maja Weisser
- Ifakara Health Institute, Ifakara, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Departments of Medicine and Clinical Research, Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
- * E-mail:
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Boffito M, Waters L, Cahn P, Paredes R, Koteff J, Van Wyk J, Vincent T, Demarest J, Adkison K, Quercia R. Perspectives on the Barrier to Resistance for Dolutegravir + Lamivudine, a Two-Drug Antiretroviral Therapy for HIV-1 Infection. AIDS Res Hum Retroviruses 2020; 36:13-18. [PMID: 31507204 PMCID: PMC6944139 DOI: 10.1089/aid.2019.0171] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
In HIV-1-infected patients, virological failure can occur as a consequence of the mutations that accumulate in the viral genome that allow replication to continue in the presence of antiretrovirals (ARVs). The development of treatment-emergent resistance to an ARV can limit a patient's options for future therapy, prompting the need for ARV regimens that are resilient to the emergence of resistance. The genetic barrier to resistance refers to the number of mutations in an ARV's therapeutic target that are required to confer a clinically meaningful loss of susceptibility to the drug. The emergence of resistance can be affected by pharmacological aspects of the ARV, including its structure, inhibitory quotient, therapeutic index, and pharmacokinetic characteristics. Dolutegravir (DTG) has demonstrated a high barrier to resistance, including when used in a two-drug regimen (2DR) with lamivudine (3TC). In the GEMINI-1 and GEMINI-2 studies, DTG +3TC was noninferior to DTG + emtricitabine/tenofovir disoproxil fumarate in treatment-naive participants, with similar proportions achieving HIV-1 RNA <50 copies/mL through 96 weeks. Furthermore, in the TANGO study, virological suppression was maintained at 48 weeks after switching to DTG +3TC from a tenofovir alafenamide (TAF)-based regimen compared with continuing a TAF-based regimen. Most other 2DRs with successful outcomes compared with three-drug regimens have been based on protease inhibitors (PIs); however, this class is associated with adverse metabolic effects and drug–drug interactions. In this review, we discuss the barrier to resistance in the context of a 2DR in which a boosted PI is replaced with DTG +3TC.
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Affiliation(s)
- Marta Boffito
- Chelsea and Westminister Hospital, London, United Kingdom
| | | | - Pedro Cahn
- Fundación Huésped, Buenos Aires, Argentina
| | | | - Justin Koteff
- ViiV Healthcare, Research Triangle Park, North Carolina
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Third-Line Antiretroviral Therapy Program in the South African Public Sector: Cohort Description and Virological Outcomes. J Acquir Immune Defic Syndr 2019; 80:73-78. [PMID: 30334876 PMCID: PMC6319697 DOI: 10.1097/qai.0000000000001883] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background: The World Health Organization recommends that antiretroviral therapy (ART) programs in resource-limited settings develop third-line ART policies. South Africa developed a national third-line ART program for patients who have failed both first-line non-nucleoside reverse transcriptase inhibitor–based ART and second-line protease inhibitor (PI)-based ART. We report on this program. Methods: Third-line ART in South Africa is accessed through a national committee that assesses eligibility and makes individual regimen recommendations. Criteria for third-line include the following: ≥1 year on PI-based ART with virologic failure, despite adherence optimization, and genotypic antiretroviral resistance test showing PI resistance. We describe baseline characteristics and resistance patterns of this cohort and present longitudinal data on virological suppression rates. Results: Between August 2013 and July 2014, 144 patients were approved for third-line ART. Median age was 41 years [interquartile range (IQR): 19–47]; 60% were women (N = 85). Median CD4+ count and viral load were 172 (IQR: 128–351) and 14,759 (IQR: 314–90,378), respectively. About 2.8% started PI-based ART before 2004; 11.1% from 2004 to 2007; 31.3% from 2008 to 2011; and 6.3% from 2012 to 2014 (48.6% unknown start date). Of the 144 patients, 97% and 98% had resistance to lopinavir and atazanavir, respectively; 57% had resistance to darunavir. All were initiated on a regimen containing darunavir, with raltegravir in 101, and etravirine in 33. Among those with at least 1 viral load at least 6 months after third-line approval (n = 118), a large proportion (83%, n = 98) suppressed to <1000 copies per milliliter, and 79% (n = 93) to <400 copies per milliliter. Conclusion: A high proportion of third-line patients with follow-up viral loads are virologically suppressed.
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36
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Yang LL, Li Q, Zhou LB, Chen SQ. Meta-analysis and systematic review of the efficacy and resistance for human immunodeficiency virus type 1 integrase strand transfer inhibitors. Int J Antimicrob Agents 2019; 54:547-555. [PMID: 31398480 DOI: 10.1016/j.ijantimicag.2019.08.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/16/2019] [Accepted: 08/01/2019] [Indexed: 11/22/2022]
Abstract
Integrase strand transfer inhibitors (INSTIs) are the most recent class of antiretroviral drugs with potent and durable antiviral activity used to treat human immunodeficiency virus type 1 (HIV-1) infection. However, development of drug resistance increases the risk of treatment failure, disease progression and mortality. A better understanding of drug efficacy and resistance against INSTIs is crucial for their efficient use and the development of new antiretrovirals. A meta-analysis of studies reporting efficacy and resistance data on INSTI use in HIV-infected patients was performed. Odds ratios (ORs) of efficacy outcome data favouring INSTI use in different clinical settings demonstrated that INSTIs have higher efficacy compared with drugs of other classes. For combination antiretroviral therapy-naïve patients and virologically-suppressed patients who switched to INSTI-based therapy, the OR was 1.484 (95% CI 1.229-1.790) and 1.341 (95% CI 0.913-1.971), respectively. ORs of resistance data indicated decreased treatment-emergent resistance development to dolutegravir (DTG) upon virological failure than to non-INSTIs (OR = 0.081, 95% CI 0.004-1.849), whereas the opposite was observed for raltegravir (RAL) (OR = 3.137, 95% CI 1.827-5.385) and elvitegravir (EVG) (OR = 1.886, 95% CI 0.569-6.252). Pooled analysis of resistance data indicated that development of resistance to DTG and bictegravir was rare, whereas EVG and RAL had low genetic barriers to resistance and the intensive cross-resistance between them limits INSTI efficiency. Efficient means of monitoring the emergence of resistance to INSTIs and the development of drugs with high genetic barriers are clear paths for future research.
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Affiliation(s)
- Li-Li Yang
- Institute of Drug Metabolism and Pharmaceutical Analysis, College of Pharmaceutical Sciences, Zhejiang University, No. 866 Yuhangtang Road, Hangzhou 310058, China
| | - Qi Li
- Department of Nephrology, Central Hospital of Zibo, Zibo 255020, China
| | - Li-Bo Zhou
- Department of Molecular and Medical Pharmacology, Molecular Biology Institute and AIDS Institute, School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - Shu-Qing Chen
- Institute of Drug Metabolism and Pharmaceutical Analysis, College of Pharmaceutical Sciences, Zhejiang University, No. 866 Yuhangtang Road, Hangzhou 310058, China.
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Huang Y, Huang X, Chen H, Wu H, Chen Y. Efficacy and Safety of Raltegravir-Based Dual Therapy in AIDS Patients: A Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2019; 10:1225. [PMID: 31749699 PMCID: PMC6842978 DOI: 10.3389/fphar.2019.01225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/23/2019] [Indexed: 11/13/2022] Open
Abstract
Background: The life expectancy for HIV-infected individuals has improved dramatically because of improvements in antiretroviral therapy (ART). Today, a simplified two-drug regimen enhances adherence and treatment satisfaction by reducing adverse effects. Therefore, we need more evidence to show the benefits and risks of simplified ART regimens from randomized controlled trials (RCTs). We compared the efficacy and safety of raltegravir-based simplified dual therapy (DT) and of traditional triple therapy (TT) for people living with HIV/AIDS (PLWHA). Methods: We carried out a systematic review of RCTs. After using a combination of the key words "HIV," "raltegravir," and "protease inhibitor" to search the English-language electronic databases from January 1, 2004, to September 11, 2019, we pooled data across eligible studies and estimated the summary effect sizes with Review Manager (version 5.3). Results: We included eight RCTs involving 4420 PLWHA: 2187 (49.5%) received raltegravir-based simplified DT, and 2144 (48.5%) received traditional TT. The proportion of viral suppression was 79% at 48 weeks and 74% at 96 weeks in the simplified regimen, and the proportion of viral suppression was 78% at 48 weeks and 71% at 96 weeks in the traditional TT group. Furthermore, the proportion of viral suppression in the simplified DT group was greater than that in the TT group at 24 weeks (risk ratio 1.11, 95% confidence interval 1.02-1.21; p = 0.01). The CD4 cell counts in the simplified DT group were significantly higher at 48 weeks and 96 weeks than those in the group that received the traditional TT. Regarding adverse events and mortality rates, the DT and TT groups were similar. However, there was better adherence in the DT group than in the TT group. Conclusion: We found that the simplified regimen was noninferior to TT regimen in regard to viral suppression. Furthermore, the simplified DT regimen had a better CD4 cell count and lower adverse events than the TT regimen.
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Affiliation(s)
- Yinqiu Huang
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China.,Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Xiaojie Huang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Yaokai Chen
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China.,Department of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
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Yao AH, Moore CL, Lim PL, Molina JM, Madero JS, Kerr S, Mallon PW, Emery S, Cooper DA, Boyd MA. Metabolic profiles of individuals switched to second-line antiretroviral therapy after failing standard first-line therapy for treatment of HIV-1 infection in a randomized, controlled trial. Antivir Ther 2019; 23:21-32. [PMID: 28447585 DOI: 10.3851/imp3171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND To investigate metabolic changes associated with second-line antiretroviral therapy (ART) following virological failure of first-line ART. METHODS SECOND-LINE was an open-label randomized controlled trial. Participants were randomized 1:1 to receive ritonavir-boosted lopinavir (LPV/r) with 2-3 nucleoside/nucleotide reverse transcriptase inhibitors (N[t]RTI group) or raltegravir (RAL group). 210 participants had a dual energy X-ray absorptiometry (DXA)-scan at baseline, week 48 and 96. We categorized participants according to second-line ART backbone: thymidine analogue (ta-NRTI) + lamivudine/emtricitabine (3[F]TC; ta-NRTI group); tenofovir (TDF)+3(F)TC (TDF group); TDF+ta-NRTI ±3(F)TC (TDF+ta-NRTI group); RAL. Changes in fasted total cholesterol (TC), low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol, TC/HDL-cholesterol ratio, triglycerides and glucose from baseline to week 96 were examined. We explored the association between metabolic and DXA-assessed soft-tissue changes. Linear regression methods were used. RESULTS We analysed 454 participants. Participants in RAL group had greater TC increases, TC (adjusted mean difference [aMD]=0.65, 95% CI 0.33, 0.96), LDL-c (aMD=0.38, 95% CI 0.15, 0.61) and glucose (aMD=0.47, 95% CI -0.01, 0.92) compared to TDF group, and had greater increases in TC (aMD=0.65, 95% CI 0.28, 1.03), HDL-c (aMD=0.12, 95% CI 0.02, 0.23) and LDL-c (aMD=0.41, 95% CI 0.13, 0.69) compared to TDF+ta-NRTI group. TC/HDL ratio and triglycerides increased in all groups without significant differences between groups. A 1 kg increase in trunk fat mass was associated with an increase in TC. CONCLUSIONS We observed metabolic changes of limited clinical significance in the relatively young population enrolled in this study. However, the metabolic changes observed may have greater clinical significance in older people living with HIV or those with other concomitant cardiovascular risks.
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Affiliation(s)
| | - Cecilia L Moore
- The Kirby Institute, UNSW, Sydney, Australia.,MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, London, United Kingdom
| | - Poh Lian Lim
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Jean-Michel Molina
- Department of Infectious Diseases, Hôpital Saint-Louis, Paris, France.,University of Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Juan Sierra Madero
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Stephen Kerr
- The Kirby Institute, UNSW, Sydney, Australia.,HIV-NAT, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Paddy Wg Mallon
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Sean Emery
- The Kirby Institute, UNSW, Sydney, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | | | - Mark A Boyd
- The Kirby Institute, UNSW, Sydney, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Hoppe A, Giuliano M, Lugemwa A, Thompson JA, Floridia M, Walker AS, Senoga I, Abwola MC, Pirillo MF, Kityo CM, Arenas-Pinto A, Paton NI. HIV-1 viral load and resistance in genital secretions in patients taking protease-inhibitor-based second-line therapy in Africa. Antivir Ther 2019; 23:191-195. [PMID: 29021409 DOI: 10.3851/imp3200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND HIV is transmitted primarily through sexual intercourse, and the objective of this study was therefore to assess whether there is occult viral replication and resistance in genital secretions in patients on protease inhibitor (PI)-based second-line therapy. METHODS HIV-infected adults taking ritonavir-boosted lopinavir with either two nucleoside reverse transcriptase inhibitors (NRTIs), raltegravir or as monotherapy for 96 weeks, were enrolled at seven clinical sites in Uganda. Viral load (VL) was measured in cervico-vaginal secretions or semen and in a corresponding plasma sample. Genotypic resistance was assessed in genital secretion samples and plasma samples. Results were compared between compartments and with the plasma resistance profile at first-line failure. RESULTS Of the 111 participants enrolled (91 female, 20 male), 16 (14%) and 30 (27%) had VL >1,000 and >40 copies/ml, respectively, in plasma; 3 (3%) and 23 (21%) had VL >1,000 copies/ml and >40 copies/ml, respectively, in genital secretions. There was 74% agreement between plasma and genital secretion VL classification above/below 40 copies/ml threshold (kappa-statistic =0.29; P=0.001). RT mutations (both NRTI and non-nucleoside reverse transcriptase inhibitor) were detected in genital secretions in four patients (similar profile to corresponding plasma sample at first-line failure) and PI mutations were detected in two (one polymorphism with no impact on resistance; one with high-level PI resistance). CONCLUSIONS High level (>1,000 copies/ml) viral replication and development of new RT or PI resistance in the genital compartment were rare. The risks of transmission arising from resistance evolution in the genital compartment are likely to be low on PI-based second-line therapy.
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Affiliation(s)
- Anne Hoppe
- Infection and Immunity, University College London, London, United Kingdom.,MRC Clinical Trials Unit at University College London, London, United Kingdom
| | | | - Abbas Lugemwa
- Joint Clinical Research Centre (JCRC), Mbarara, Uganda
| | - Jennifer A Thompson
- MRC Clinical Trials Unit at University College London, London, United Kingdom
| | | | - Ann S Walker
- MRC Clinical Trials Unit at University College London, London, United Kingdom
| | | | | | | | | | | | - Nicholas I Paton
- MRC Clinical Trials Unit at University College London, London, United Kingdom.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Abstract
Approximately 20% of people with HIV in the United States prescribed antiretroviral therapy are not virally suppressed. Thus, optimal management of virologic failure has a critical role in the ability to improve viral suppression rates to improve long-term health outcomes for those infected and to achieve epidemic control. This article discusses the causes of virologic failure, the use of resistance testing to guide management after failure, interpretation and relevance of HIV drug resistance patterns, considerations for selection of second-line and salvage therapies, and management of virologic failure in special populations.
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Affiliation(s)
- Suzanne M McCluskey
- Division of Infectious Diseases, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, GRJ5, Boston, MA 02114, USA.
| | - Mark J Siedner
- Division of Infectious Diseases, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, GRJ5, Boston, MA 02114, USA
| | - Vincent C Marconi
- Division of Infectious Diseases, Department of Global Health, Emory University School of Medicine, Rollins School of Public Health, Health Sciences Research Building, 1760 Haygood Dr NE, Room W325, Atlanta, GA 30322, USA
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41
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Fily F, Ayikobua E, Ssemwanga D, Nicholas S, Kaleebu P, Delaugerre C, Pasquier E, Amoros Quiles I, Balkan S, Schramm B. HIV-1 drug resistance testing at second-line regimen failure in Arua, Uganda: avoiding unnecessary switch to an empiric third-line. Trop Med Int Health 2019; 23:1075-1083. [PMID: 30058269 DOI: 10.1111/tmi.13131] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES The number of patients on second-line antiretroviral therapy is growing, but data on HIV drug resistance patterns at failure in resource-constrained settings are scarce. We aimed to describe drug resistance and investigate the factors associated with extensive resistance to nucleoside/nucleotide reverse transcriptase inhibitors (NRTI), in patients failing second-line therapy in the HIV outpatient clinic at Arua Regional Referral Hospital, Uganda. METHODS We included patients who failed on second-line therapy (two consecutive viral loads ≥1000 copies/mm3 by SAMBA-1 point-of-care test) and who had a drug resistance test performed between September 2014 and March 2017. Logistic regression was used to investigate factors associated with NRTI genotypic sensitivity score (GSS) ≤1. RESULTS Seventy-eight patients were included: 42% female, median age 31 years and median time of 29 months on second-line therapy. Among 70 cases with drug resistance test results, predominant subtypes were A (47%) and D (40%); 18.5% had ≥1 major protease inhibitor mutation; 82.8% had ≥1 NRTI mutation and 38.5% had extensive NRTI resistance (NRTI GSS ≤1). A nadir CD4 count ≤100/ml was associated with NRTI GSS ≤1 (OR 4.2, 95% CI [1.3-15.1]). Thirty (42.8%) patients were switched to third-line therapy, composed of integrase inhibitor and protease inhibitor (60% darunavir/r) +/- NRTI. A follow-up viral load was available for 19 third-line patients at 12 months: 84.2% were undetectable. CONCLUSIONS Our study highlights the need for access to drug resistance tests to avoid unnecessary switches to third-line therapy, but also for access to third-line drugs, in particular integrase inhibitors. Low nadir CD4 count might be an indicator of third-line drug requirement for patients failing second-line therapy.
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Affiliation(s)
- F Fily
- Epicentre, Paris, France.,Service des Maladies Respiratoires et Infectieuses, Hôpital Broussais, Saint-Malo, France
| | - E Ayikobua
- Médecins Sans Frontières-France, Paris, France
| | - D Ssemwanga
- MRC/UVRI Uganda Virus Research Unit, Entebbe, Uganda
| | | | - P Kaleebu
- MRC/UVRI Uganda Virus Research Unit, Entebbe, Uganda
| | - C Delaugerre
- Laboratoire de Virologie, Hôpital Saint Louis, AP-HP, Paris, France.,Université Paris-Diderot, Paris, France
| | - E Pasquier
- Epicentre, Paris, France.,Médecins Sans Frontières-France, Paris, France
| | | | - S Balkan
- Médecins Sans Frontières-France, Paris, France
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Effectiveness of switching from protease inhibitors to dolutegravir in combination with nucleoside reverse transcriptase inhibitors as maintenance antiretroviral therapy among HIV-positive patients. Int J Antimicrob Agents 2019; 54:35-42. [PMID: 30905695 DOI: 10.1016/j.ijantimicag.2019.03.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 02/20/2019] [Accepted: 03/16/2019] [Indexed: 12/18/2022]
Abstract
Prolonged exposure to regimens containing protease inhibitors (PIs) as second-line therapy for human immunodeficiency virus (HIV) infection may have a negative impact on metabolic profiles and increase the risk of cardiovascular diseases. Real-world experience with dolutegravir (DTG)-based regimens as alternatives to PI-based regimens is limited in antiretroviral-experienced patients with previous failure or intolerance to first-line therapy. The current study included HIV-positive patients receiving PI-containing regimens with viral suppression for ≥6 months. Virological response and lipid profiles were compared between patients who were subsequently switched to DTG-based therapy plus nucleoside reverse transcriptase inhibitors (NRTIs) and those remaining on their PI-containing regimen at Week 48. In total, 189 patients were switched to DTG-based regimens and 313 remained on PI-containing regimens during the observation period. Patients in the DTG group were younger (mean age 40.0 years vs. 44.6 years) and were more likely to have a previous history of virological failure (44.4% vs. 19.5%) than those in the PI group. At Week 48, 1.1% of the DTG group and 3.8% of the PI group had virological non-response (HIV-RNA load >50 copies/mL) (difference, -2.7%, 95% CI -5.5% to 0.5%). The presence of M184V/I mutation and other NRTI resistance-associated mutations (RAMs) did not increase the risk of virological failure in either group. Patients switched to DTG-based therapy had statistically significant improvement of lipid profiles. Among virally suppressed HIV-positive patients, a switch to DTG-based therapy was non-inferior to continuation of PI-based therapy in virological effectiveness at Week 48, even in the presence of NRTI RAMs.
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43
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Dolutegravir versus ritonavir-boosted lopinavir both with dual nucleoside reverse transcriptase inhibitor therapy in adults with HIV-1 infection in whom first-line therapy has failed (DAWNING): an open-label, non-inferiority, phase 3b trial. THE LANCET INFECTIOUS DISEASES 2019; 19:253-264. [DOI: 10.1016/s1473-3099(19)30036-2] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/08/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022]
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Huang Y, Huang X, Chen H, Wu H, Chen Y. Efficacy and Safety of Raltegravir-Based Dual Therapy in AIDS Patients: A Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2019. [PMID: 31749699 DOI: 10.3389/fphar.2019.01225/bibtex] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023] Open
Abstract
Background: The life expectancy for HIV-infected individuals has improved dramatically because of improvements in antiretroviral therapy (ART). Today, a simplified two-drug regimen enhances adherence and treatment satisfaction by reducing adverse effects. Therefore, we need more evidence to show the benefits and risks of simplified ART regimens from randomized controlled trials (RCTs). We compared the efficacy and safety of raltegravir-based simplified dual therapy (DT) and of traditional triple therapy (TT) for people living with HIV/AIDS (PLWHA). Methods: We carried out a systematic review of RCTs. After using a combination of the key words "HIV," "raltegravir," and "protease inhibitor" to search the English-language electronic databases from January 1, 2004, to September 11, 2019, we pooled data across eligible studies and estimated the summary effect sizes with Review Manager (version 5.3). Results: We included eight RCTs involving 4420 PLWHA: 2187 (49.5%) received raltegravir-based simplified DT, and 2144 (48.5%) received traditional TT. The proportion of viral suppression was 79% at 48 weeks and 74% at 96 weeks in the simplified regimen, and the proportion of viral suppression was 78% at 48 weeks and 71% at 96 weeks in the traditional TT group. Furthermore, the proportion of viral suppression in the simplified DT group was greater than that in the TT group at 24 weeks (risk ratio 1.11, 95% confidence interval 1.02-1.21; p = 0.01). The CD4 cell counts in the simplified DT group were significantly higher at 48 weeks and 96 weeks than those in the group that received the traditional TT. Regarding adverse events and mortality rates, the DT and TT groups were similar. However, there was better adherence in the DT group than in the TT group. Conclusion: We found that the simplified regimen was noninferior to TT regimen in regard to viral suppression. Furthermore, the simplified DT regimen had a better CD4 cell count and lower adverse events than the TT regimen.
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Affiliation(s)
- Yinqiu Huang
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Xiaojie Huang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Yaokai Chen
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China
- Department of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
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HIV-1 second-line failure and drug resistance at high-level and low-level viremia in Western Kenya. AIDS 2018; 32:2485-2496. [PMID: 30134290 DOI: 10.1097/qad.0000000000001964] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Characterize failure and resistance above and below guidelines-recommended 1000 copies/ml virologic threshold, upon second-line failure. DESIGN Cross-sectional study. METHODS Kenyan adults on lopinavir/ritonavir-based second-line were enrolled at AMPATH (Academic Model Providing Access to Healthcare). Charts were reviewed for demographic/clinical characteristics and CD4/viral load were obtained. Participants with detectable viral load had a second visit and pol genotyping was attempted in both visits. Accumulated resistance was defined as mutations in the second, not the first visit. Low-level viremia (LLV) was detectable viral load less than 1000 copies/ml. Failure and resistance associations were evaluated using logistic and Poisson regression, Fisher Exact and t-tests. RESULTS Of 394 participants (median age 42, 60% women, median 1.9 years on second-line) 48% had detectable viral load; 21% had viral load more than 1000 copies/ml, associated with younger age, tuberculosis treatment, shorter time on second-line, lower CD4count/percentage, longer first-line treatment interruption and pregnancy. In 105 sequences from the first visit (35 with LLV), 79% had resistance (57% dual-class, 7% triple-class; 46% with intermediate-to-high-level resistance to ≥1 future drug option). LLV was associated with more overall and NRTI-associated mutations and with predicted resistance to more next-regimen drugs. In 48 second-visit sequences (after median 55 days; IQR 28-33), 40% accumulated resistance and LLV was associated with more mutation accumulation. CONCLUSION High resistance upon second-line failure exists at levels above and below guideline-recommended virologic-failure threshold, impacting future treatment options. Optimization of care should include increased viral load monitoring, resistance testing and third-line ART access, and consideration of lowering the virologic failure threshold, though this demands further investigation.
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Oliveira MI, Romão de Souza Junior V, Fernanda de Lacerda Vidal C, Sérgio Ramos de Araújo P. Virologic suppression in response to antiretroviral therapy despite extensive resistance within HIV-1 reverse transcriptase after the first virologic failure. BMC Infect Dis 2018; 18:514. [PMID: 30314470 PMCID: PMC6186096 DOI: 10.1186/s12879-018-3400-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 09/20/2018] [Indexed: 11/20/2022] Open
Abstract
Background Incomplete virologic suppression results in mutations associated with resistance and is a major obstacle to disease control. We analyzed the genotypic profiles of HIV-1 patients at the time of the first virologic failure and the response to a salvage regimen after 48 weeks. Methods This work was a cross-sectional, retrospective, analytical study based on data collected from medical records and genotyping tests between 2006 and 2016. The sample consisted of data on individuals living with HIV (PLWH) from three major reference centers. Results A total of 184 patients were included in the data analysis. Viral subtype B was the most common (81.3%) as well as M184 V/I (85.3%) and K103 codon mutations (65.8%). Forty-eight weeks after switching to a salvage regimen, 67.3% of patients achieved an undetectable viral load. Discussion The number of mutations associated with nucleos(t)ide reverse transcriptase inhibitors (NRTI(t)s) did not affect virologic suppression (9.3% for zero NRTI(t)-associated mutations vs 48.6% for 1–2 NRTI(t)-associated mutations vs 42.1% for ≥3 NRTI(t)-associated mutations, p = 0.179). An ARV time (the beginning of the first ARV regimen up to genotyping) of > 36 months was a protective factor for detectable viral load (PR = 0.60, 95% CI = 0.39–0.92, p = 0.020) and a risk factor for developing ≥3 NRTI(t)-associated mutations (PR = 2.43, 95% CI 1.38–4.28, p = 0.002). Conclusions We found that extensive resistance to NRTI(t)s at the time of the first virologic failure did not impact virologic suppression at 48 weeks after switching to a second-line therapy based on NRTI(t)s plus protease inhibitors.
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Affiliation(s)
- Marta Iglis Oliveira
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal de Pernambuco, Av. Prof. Moraes Rego 1235, Recife, 50670-901, Brazil
| | - Valter Romão de Souza Junior
- Faculdade de Medicina do Recife, Universidade Federal de Pernambuco, Av. Prof. Moraes Rego, 1235, Recife, Pernambuco, Brazil.
| | | | - Paulo Sérgio Ramos de Araújo
- Programa de Pós-graduação em Ciências da Saúde, Universidade Federal de Pernambuco, Av. Prof. Moraes Rego 1235, Recife, 50670-901, Brazil.,Instituto Aggeu Magalhaes, FIOCRUZ, Av. Prof. Moraes Rego 1235, Recife, 50670-901, Brazil
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47
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Churchill D, Waters L, Ahmed N, Angus B, Boffito M, Bower M, Dunn D, Edwards S, Emerson C, Fidler S, Fisher M, Horne R, Khoo S, Leen C, Mackie N, Marshall N, Monteiro F, Nelson M, Orkin C, Palfreeman A, Pett S, Phillips A, Post F, Pozniak A, Reeves I, Sabin C, Trevelion R, Walsh J, Wilkins E, Williams I, Winston A. British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2015. HIV Med 2018; 17 Suppl 4:s2-s104. [PMID: 27568911 DOI: 10.1111/hiv.12426] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | | | | | - Mark Bower
- Chelsea and Westminster Hospital, London, UK
| | | | - Simon Edwards
- Central and North West London NHS Foundation Trust, UK
| | | | - Sarah Fidler
- Imperial College School of Medicine at St Mary's, London, UK
| | | | | | | | | | | | | | | | - Mark Nelson
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | | | | | | | | | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Caroline Sabin
- Royal Free and University College Medical School, London, UK
| | | | - John Walsh
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Ian Williams
- Royal Free and University College Medical School, London, UK
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48
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Abstract
Background The classification of phase 3 trials as superiority or non-inferiority has become routine, and it is widely accepted that there are important differences between the two types of trial in their design, analysis and interpretation. Main text There is a clear rationale for the superiority/non-inferiority framework in the context of regulatory trials. The focus of our article is non-regulatory trials with a public health objective. First, using two examples from infectious disease research, we show that the classification of superiority or non-inferiority trials is not always straightforward. Second, we show that several arguments for different approaches to the design, analysis and interpretation of superiority and non-inferiority trials are unconvincing when examined in detail. We consider, in particular, the calculation of sample size (and the choice of delta or the non-inferiority margin), intention-to-treat versus per-protocol analyses, and one-sided versus two-sided confidence intervals. We argue that the superiority/non-inferiority framework is not just unnecessary but can have a detrimental effect, being a barrier to clear scientific thought and communication. In particular, it places undue emphasis on tests for significance or non-inferiority at the expense of estimation. We emphasise that these concerns apply to phase 3 non-regulatory trials in general, not just to those where the classification of the trial as superiority or non-inferiority is ambiguous. Conclusions Guidelines and statistical practice should abandon the sharp division between superiority and non-inferiority phase 3 non-regulatory trials and be more closely aligned to the clinical and public health questions that motivate the trial.
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49
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Huang Y, Huang X, Luo Y, Zhou Y, Tao X, Chen H, Song A, Chen Y, Wu H. Assessing the Efficacy of Lopinavir/Ritonavir-Based Preferred and Alternative Second-Line Regimens in HIV-Infected Patients: A Meta-Analysis of Key Evidence to Support WHO Recommendations. Front Pharmacol 2018; 9:890. [PMID: 30174599 PMCID: PMC6107847 DOI: 10.3389/fphar.2018.00890] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/23/2018] [Indexed: 12/12/2022] Open
Abstract
Background: Nucleoside reverse transcriptase inhibitors (NRTIs) and non-NRTIs (NNRTIs) with boosted protease inhibitors are included in standardized first-line and second-line regimens. Recent World Health Organization (WHO) guidelines recommend a boosted protease inhibitor (PI) combined with 2 NRTIs or raltegravir as a second-line regimen. Objective: Ritonavir-boosted lopinavir (LPV/r) is known as a key second-line antiretroviral therapy (ART) in resource-limited settings. We carried out a meta-analysis to analyze virologic suppression and effectiveness of LPV/r-based second-line therapy in HIV-infected patients. Methods: In this meta-analysis, we searched randomized controlled trials and observational cohort studies to evaluate outcomes of second-line ART for patients with HIV who failed first-line therapy. A systematic search was conducted in Pubmed, Cochrane Library, and Embase from inception to January 2018. Outcomes included viral suppression, CD4 cell counts, drug resistance, adverse events, and self-reported adherence. We assessed comparative efficacy and safety in a meta-analysis. Data analysis was performed using RevMan 5.3 and Stata12.0. Results: Nine studies comprising 3,923 patients were included in the meta-analysis. The overall successful virologic suppression rate of the second-line regimen was 77% (ITT) and 87% (PP) at 48 weeks with a plasma HIV RNA load of <400 copies/mL. No statistical significance was found in CD4 cell count recoveries between LPV/r plus 2-3 NRTIs and simplified regimens (LPV/r plus raltegravir) at 48 weeks (P = 0.09), 96 weeks (P = 0.05), and 144 weeks (P = 0.73). Four studies indicated that the virus had low-level resistance to LPV/r, and the most common clinically significant PI-resistance mutations were 46I, 54V, 82A/82F, and 76V; however, no virologic failure due to LPV/r resistance was detected. In addition, no statistical significance was found between the two groups in self-reported adherence [relative risks (RR) = 1.03,95% confidence interval (CI) 1.00, 1.07, P = 0.06], grade 3 or 4 adverse events (RR = 0.84, 95% CI 0.64, 1.10, P = 0.20) or serious events (RR = 0.85, 95% CI 0.77, 1.17, P = 0.62). Conclusions: These results suggest that the LPV/r-based regimen demonstrates efficacious and low resistance as second-line antiretroviral therapy.Both LPV/r plus 2-3 NRTIs and LPV/r plus RAL regimens improved CD4 cell counts. There was no evidence of superiority of simplified regimens over LPV/r plus 2-3 NRTIs.
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Affiliation(s)
- Yinqiu Huang
- National Key Laboratory for Infectious Diseases Prevention and Treatment With Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China
| | - Xiaojie Huang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Yadong Luo
- Center for Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yihong Zhou
- Center for Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Xingbao Tao
- National Key Laboratory for Infectious Diseases Prevention and Treatment With Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Aixin Song
- Center for Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yaokai Chen
- National Key Laboratory for Infectious Diseases Prevention and Treatment With Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China.,Center for Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
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50
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Stockdale AJ, Saunders MJ, Boyd MA, Bonnett LJ, Johnston V, Wandeler G, Schoffelen AF, Ciaffi L, Stafford K, Collier AC, Paton NI, Geretti AM. Effectiveness of Protease Inhibitor/Nucleos(t)ide Reverse Transcriptase Inhibitor-Based Second-line Antiretroviral Therapy for the Treatment of Human Immunodeficiency Virus Type 1 Infection in Sub-Saharan Africa: A Systematic Review and Meta-analysis. Clin Infect Dis 2018; 66:1846-1857. [PMID: 29272346 PMCID: PMC5982734 DOI: 10.1093/cid/cix1108] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/18/2017] [Indexed: 02/02/2023] Open
Abstract
Background In sub-Saharan Africa, 25.5 million people are living with human immunodeficiency virus (HIV), representing 70% of the global total. The need for second-line antiretroviral therapy (ART) is projected to increase in the next decade in keeping with the expansion of treatment provision. Outcome data are required to inform policy. Methods We performed a systematic review and meta-analysis of studies reporting the virological outcomes of protease inhibitor (PI)-based second-line ART in sub-Saharan Africa. The primary outcome was virological suppression (HIV-1 RNA <400 copies/mL) after 48 and 96 weeks of treatment. The secondary outcome was the proportion of patients with PI resistance. Pooled aggregate data were analyzed using a DerSimonian-Laird random effects model. Results By intention-to-treat analysis, virological suppression occurred in 69.3% (95% confidence interval [CI], 58.2%-79.3%) of patients at week 48 (4558 participants, 14 studies), and in 61.5% (95% CI, 47.2%-74.9%) at week 96 (2145 participants, 8 studies). Preexisting resistance to nucleos(t)ide reverse transcriptase inhibitors (NRTIs) increased the likelihood of virological suppression. Major protease resistance mutations occurred in a median of 17% (interquartile range, 0-25%) of the virological failure population and increased with duration of second-line ART. Conclusions One-third of patients receiving PI-based second-line ART with continued NRTI use in sub-Saharan Africa did not achieve virological suppression, although among viremic patients, protease resistance was infrequent. Significant challenges remain in implementation of viral load monitoring. Optimizing definitions and strategies for management of second-line ART failure is a research priority. Prospero Registration CRD42016048985.
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Affiliation(s)
- Alexander J Stockdale
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre
- Institute of Infection and Global Health, University of Liverpool
| | - Matthew J Saunders
- Section of Infectious Diseases and Immunity and Wellcome Trust–Imperial College Centre for Global Health Research, Imperial College London, United Kingdom
| | - Mark A Boyd
- Kirby Institute for Infection and Immunity, University of New South Wales, Sydney
- Lyell McEwin Hospital, University of Adelaide, South Australia, Australia
| | | | | | - Gilles Wandeler
- Institute of Social and Preventative Medicine, University of Bern
- Department of Infectious Diseases, Bern University Hospital, Switzerland
| | - Annelot F Schoffelen
- Department of Infectious Diseases, University Medical Centre Utrecht, The Netherlands
| | - Laura Ciaffi
- Unité Mixte de Recherche de l’Institut de Rech (UMI), Institute de Recherche pour le Développement, Institute National de la Santé et de la Recherche Medicale, University of Montpellier, France
| | - Kristen Stafford
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore
| | - Ann C Collier
- University of Washington School of Medicine, Seattle
| | - Nicholas I Paton
- Yong Loo Lin School of Medicine, National University of Singapore
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