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Chimbola OM, Lungu EM, Szomolay B. Effect of innate and adaptive immune mechanisms on treatment regimens in an AIDS-related Kaposi's Sarcoma model. JOURNAL OF BIOLOGICAL DYNAMICS 2021; 15:213-249. [PMID: 33843468 DOI: 10.1080/17513758.2021.1912420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/16/2021] [Indexed: 06/12/2023]
Abstract
Kaposi Sarcoma (KS) is the most common AIDS-defining cancer, even as HIV-positive people live longer. Like other herpesviruses, human herpesvirus-8 (HHV-8) establishes a lifelong infection of the host that in association with HIV infection may develop at any time during the illness. With the increasing global incidence of KS, there is an urgent need of designing optimal therapeutic strategies for HHV-8-related infections. Here we formulate two models with innate and adaptive immune mechanisms, relevant for non-AIDS KS (NAKS) and AIDS-KS, where the initial condition of the second model is given by the equilibrium state of the first one. For the model with innate mechanism (MIM), we define an infectivity resistance threshold that will determine whether the primary HHV-8 infection of B-cells will progress to secondary infection of progenitor cells, a concept relevant for viral carriers in the asymptomatic phase. The optimal control strategy has been employed to obtain treatment efficacy in case of a combined antiretroviral therapy (cART). For the MIM we have shown that KS therapy alone is capable of reducing the HHV-8 load. In the model with adaptive mechanism (MAM), we show that if cART is administered at optimal levels, that is, 0.48 for protease inhibitors, 0.79 for reverse transcriptase inhibitors and 0.25 for KS therapy, both HIV-1 and HHV-8 can be reduced. The predictions of these mathematical models have the potential to offer more effective therapeutic interventions in the treatment of NAKS and AIDS-KS.
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Affiliation(s)
- Obias Mulenga Chimbola
- Department of Mathematics and Statistical Sciences, Faculty of Science, Botswana International University of Science and Technology, Palapye, Botswana
- Department of Mathematics and Statistics, School of Science, Engineering and Technology (SSET), Mulungushi University, Kabwe, Zambia
| | - Edward M Lungu
- Department of Mathematics and Statistical Sciences, Faculty of Science, Botswana International University of Science and Technology, Palapye, Botswana
| | - Barbara Szomolay
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
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2
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High rate of long-term clinical events after antiretroviral therapy resumption in HIV-positive patients exposed to antiretroviral therapy interruption. AIDS 2021; 35:2463-2468. [PMID: 34870929 DOI: 10.1097/qad.0000000000003058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE We analyzed the incidence rate of long-term events in patients on antiretroviral therapy (ART) previously exposed to therapy interruption. DESIGN A single-center cohort study involving participants in ART interruptions (ARTI) clinical trials (n = 10) was conducted. METHODS Non-AIDS events after ART resumption were analyzed. A control group not exposed to ARTI was randomly selected from the same cohort and a propensity score of belonging to ARTI group was estimated based on age, sex, CD4+ nadir value, time from HIV diagnosis to ARTI, time from HIV diagnosis to starting ART and time of suppressed viral load, and used to adjust effect estimates. RESULTS One hundred and eighty-one patients were included, 136 in ARTI and 45 in the control arm. Median time of known HIV-1 infection was 21 years and median time from ART resumption to first non-AIDS event was 5.2 years. A significantly higher proportion of patients with ARTI had an event as compared with control group [raw percentages: 43% (n = 53) vs. 23% (n = 10), P = 0.015]. These differences were confirmed when only the non-AIDS events occurring after ART resumption were analyzed [adjusted hazard ratio (aHR) = 2.43, 95% confidence interval (CI) 1.15-5.12]. The logistic model adjusted for the propensity score indicated that patients with an ARTI had a four-fold higher risk of having at least one non-AIDS event (P = 0.002). CONCLUSION We found a higher risk of having at least one non-AIDS event years after ART resumption in HIV-infected patients exposed to ARTI as compared with controls. These data should be taken into consideration for future functional cure clinical trials.
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Ugarte A, Romero Y, Tricas A, Casado C, Lopez-Galindez C, Garcia F, Leal L. Unintended HIV-1 Infection During Analytical Therapy Interruption. J Infect Dis 2021; 221:1740-1742. [PMID: 31742347 DOI: 10.1093/infdis/jiz611] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 11/17/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ainoa Ugarte
- Infectious Diseases-HIV Unit, Hospital Clínic Barcelona, University of Barcelona, Spain
| | - Yolanda Romero
- Infectious Diseases-HIV Unit, Hospital Clínic Barcelona, University of Barcelona, Spain
| | - Amparo Tricas
- Infectious Diseases-HIV Unit, Hospital Clínic Barcelona, University of Barcelona, Spain
| | - Concepcion Casado
- Molecular Virology Unit, Reference Laboratory and Retroviruses Research, Microbiology National Center, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Cecilio Lopez-Galindez
- Molecular Virology Unit, Reference Laboratory and Retroviruses Research, Microbiology National Center, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Felipe Garcia
- Infectious Diseases-HIV Unit, Hospital Clínic Barcelona, University of Barcelona, Spain.,AIDS Research Group-HIVACAT (HIV Vaccine development program in Catalonia), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Lorna Leal
- Infectious Diseases-HIV Unit, Hospital Clínic Barcelona, University of Barcelona, Spain.,AIDS Research Group-HIVACAT (HIV Vaccine development program in Catalonia), Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
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4
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Leal L, Fehér C, Richart V, Torres B, García F. Antiretroviral Therapy Interruption (ATI) in HIV-1 Infected Patients Participating in Therapeutic Vaccine Trials: Surrogate Markers of Virological Response. Vaccines (Basel) 2020; 8:vaccines8030442. [PMID: 32764508 PMCID: PMC7564579 DOI: 10.3390/vaccines8030442] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 12/18/2022] Open
Abstract
A functional Human immunodeficiency Virus (HIV) cure has been proposed as an alternative to antiretroviral treatment for life, and therapeutic vaccines represent one of the most promising approaches. The goal of therapeutic vaccination is to augment virus-specific immune responses that have an impact on HIV viral load dynamics. To date, the agreed feature to evaluate the effects of these therapeutic interventions is analytical antiretroviral treatment interruption (ATI), at least until we find a reliable biomarker that can predict viral control. Different host, immunologic, and virologic markers have been proposed as predictors of viral control during ATI after therapeutic interventions. This review describes the relevance of ATI and the different surrogate markers of virological control assessed in HIV therapeutic vaccine clinical trials.
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Affiliation(s)
- Lorna Leal
- Infectious Diseases Department—HIV Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (C.F.); (V.R.); (B.T.); (F.G.)
- AIDS Research Group, IDIBAPS, Hospital Clinic, University of Barcelona, 08036 Barcelona, Spain
- Correspondence: ; Tel.: +34-93-2275586; Fax: +34-93-4514-438
| | - Csaba Fehér
- Infectious Diseases Department—HIV Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (C.F.); (V.R.); (B.T.); (F.G.)
| | - Valèria Richart
- Infectious Diseases Department—HIV Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (C.F.); (V.R.); (B.T.); (F.G.)
| | - Berta Torres
- Infectious Diseases Department—HIV Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (C.F.); (V.R.); (B.T.); (F.G.)
| | - Felipe García
- Infectious Diseases Department—HIV Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (C.F.); (V.R.); (B.T.); (F.G.)
- AIDS Research Group, IDIBAPS, Hospital Clinic, University of Barcelona, 08036 Barcelona, Spain
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5
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Lee JS, Paintsil E, Gopalakrishnan V, Ghebremichael M. A comparison of machine learning techniques for classification of HIV patients with antiretroviral therapy-induced mitochondrial toxicity from those without mitochondrial toxicity. BMC Med Res Methodol 2019; 19:216. [PMID: 31775643 PMCID: PMC6882363 DOI: 10.1186/s12874-019-0848-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 10/10/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) has significantly reduced HIV-related morbidity and mortality. However, therapeutic benefit of ART is often limited by delayed drug-associated toxicity. Nucleoside reverse transcriptase inhibitors (NRTIs) are the backbone of ART regimens. NRTIs compete with endogenous deoxyribonucleotide triphosphates (dNTPs) in incorporation into elongating DNA chain resulting in their cytotoxic or antiviral effect. Thus, the efficacy of NRTIs could be affected by direct competition with endogenous dNTPs and/or feedback inhibition of their metabolic enzymes. In this paper, we assessed whether the levels of ribonucleotides (RN) and dNTP pool sizes can be used as biomarkers in distinguishing between HIV-infected patients with ART-induced mitochondrial toxicity and HIV-infected patients without toxicity. METHODS We used data collected through a case-control study from 50 subjects. Cases were defined as HIV-infected individuals with clinical and/or laboratory evidence of mitochondrial toxicity. Each case was age, gender, and race matched with an HIV-positive without evidence of toxicity. We used a range of machine learning procedures to distinguish between patients with and without toxicity. Using resampling methods like Monte Carlo k-fold cross validation, we compared the accuracy of several machine learning algorithms applied to our data. We used the algorithm with highest classification accuracy rate in evaluating the diagnostic performance of 12 RN and 14 dNTP pool sizes as biomarkers of mitochondrial toxicity. RESULTS We used eight classification algorithms to assess the diagnostic performance of RN and dNTP pool sizes distinguishing HIV patients with and without NRTI-associated mitochondrial toxicity. The algorithms resulted in cross-validated classification rates of 0.65-0.76 for dNTP and 0.72-0.83 for RN, following reduction of the dimensionality of the input data. The reduction of input variables improved the classification performance of the algorithms, with the most pronounced improvement for RN. Complex tree-based methods worked the best for both the deoxyribose dataset (Random Forest) and the ribose dataset (Classification Tree and AdaBoost), but it is worth noting that simple methods such as Linear Discriminant Analysis and Logistic Regression were very competitive in terms of classification performance. CONCLUSIONS Our finding of changes in RN and dNTP pools in participants with mitochondrial toxicity validates the importance of dNTP pools in mitochondrial function. Hence, levels of RN and dNTP pools can be used as biomarkers of ART-induced mitochondrial toxicity.
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Affiliation(s)
- Jong Soo Lee
- Department of Mathematical Sciences, University of Massachusetts, Lowell, MA USA
| | - Elijah Paintsil
- Department of Pediatrics, Yale University, New Haven, CT USA
| | - Vivek Gopalakrishnan
- Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, MD USA
| | - Musie Ghebremichael
- Ragon Institute of Harvard, MGH and MIT, 400 Technology Square, Cambridge, MA 02129 USA
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6
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Fehér C, Leal L, Plana M, Climent N, Crespo Guardo A, Martínez E, Castro P, Díaz-Brito V, Mothe B, López Bernaldo De Quirós JC, Gatell JM, Aloy P, García F. Virological Outcome Measures During Analytical Treatment Interruptions in Chronic HIV-1-Infected Patients. Open Forum Infect Dis 2019; 6:ofz485. [PMID: 32128329 PMCID: PMC7047957 DOI: 10.1093/ofid/ofz485] [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: 05/27/2019] [Accepted: 11/11/2019] [Indexed: 12/02/2022] Open
Abstract
Background Analytical treatment interruptions (ATIs) are essential in research on HIV cure. However, the heterogeneity of virological outcome measures used in different trials hinders the interpretation of the efficacy of different strategies. Methods We conducted a retrospective analysis of viral load (VL) evolution in 334 ATI episodes in chronic HIV-1-infected patients collected from 11 prospective studies. Quantitative (baseline VL, set point, delta set point, VL, and delta VL at given weeks after ATI, peak VL, delta peak VL, and area under the rebound curve) and temporal parameters (time to rebound [TtR], set point, peak, and certain absolute and relative VL thresholds) were described. Pairwise correlations between parameters were analyzed, and potential confounding factors (sex, age, time of known HIV infection, time on ART, and immunological interventions) were evaluated. Results The set point was lower than baseline VL (median delta set point, –0.26; P < .001). This difference was >1 log10 copies/mL in 13.9% of the cases. The median TtR was 2 weeks; no patients had an undetectable VL at week 12. The median time to set point was 8 weeks: by week 12, 97.4% of the patients had reached the set point. TtR and baseline VL were correlated with most temporal and quantitative parameters. The variables independently associated with TtR were baseline VL and the use of immunological interventions. Conclusions TtR could be an optimal surrogate marker of response in HIV cure strategies. Our results underline the importance of taking into account baseline VL and other confounding factors in the design and interpretation of these studies.
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Affiliation(s)
- Csaba Fehér
- Institute for Research in Biomedicine (IRB Barcelona), the Barcelona Institute for Science and Technology, Barcelona, Spain.,Infectious Diseases Department, Hospital Clinic of Barcelona - HIVACAT, University of Barcelona, Barcelona, Spain.,Retrovirology and Viral Immunopathology Laboratory, AIDS Research Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) - HIVACAT, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Lorna Leal
- Infectious Diseases Department, Hospital Clinic of Barcelona - HIVACAT, University of Barcelona, Barcelona, Spain.,Retrovirology and Viral Immunopathology Laboratory, AIDS Research Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) - HIVACAT, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Montserrat Plana
- Retrovirology and Viral Immunopathology Laboratory, AIDS Research Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) - HIVACAT, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Nuria Climent
- Retrovirology and Viral Immunopathology Laboratory, AIDS Research Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) - HIVACAT, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Alberto Crespo Guardo
- Retrovirology and Viral Immunopathology Laboratory, AIDS Research Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) - HIVACAT, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Esteban Martínez
- Infectious Diseases Department, Hospital Clinic of Barcelona - HIVACAT, University of Barcelona, Barcelona, Spain.,Retrovirology and Viral Immunopathology Laboratory, AIDS Research Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) - HIVACAT, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Pedro Castro
- Infectious Diseases Department, Hospital Clinic of Barcelona - HIVACAT, University of Barcelona, Barcelona, Spain.,Retrovirology and Viral Immunopathology Laboratory, AIDS Research Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) - HIVACAT, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.,Medical Intensive Care Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Vicens Díaz-Brito
- Infectious Diseases Department, Hospital Clinic of Barcelona - HIVACAT, University of Barcelona, Barcelona, Spain
| | - Beatriz Mothe
- IrsiCaixa AIDS Research Institute, Badalona, Spain.,Infectious Diseases Department, Hospital Germans Trias i Pujol, Badalona, Spain.,University of Vic - Central University of Catalonia, Vic, Spain
| | - Juan Carlos López Bernaldo De Quirós
- HIV/Infectious Diseases Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Josep María Gatell
- Infectious Diseases Department, Hospital Clinic of Barcelona - HIVACAT, University of Barcelona, Barcelona, Spain.,Retrovirology and Viral Immunopathology Laboratory, AIDS Research Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) - HIVACAT, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.,ViiV Healthcare, Tres Cantos, Spain
| | - Patrick Aloy
- Institute for Research in Biomedicine (IRB Barcelona), the Barcelona Institute for Science and Technology, Barcelona, Spain.,Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Felipe García
- Infectious Diseases Department, Hospital Clinic of Barcelona - HIVACAT, University of Barcelona, Barcelona, Spain.,Retrovirology and Viral Immunopathology Laboratory, AIDS Research Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) - HIVACAT, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
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7
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Lau JS, Smith MZ, Lewin SR, McMahon JH. Clinical trials of antiretroviral treatment interruption in HIV-infected individuals. AIDS 2019; 33:773-791. [PMID: 30883388 DOI: 10.1097/qad.0000000000002113] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
: Despite the benefits of antiretroviral therapy (ART) for people living with HIV, there has been a long-standing research interest in interrupting ART as a strategy to minimize adverse effects of ART as well as to test interventions aiming to achieve a degree of virological control without ART. We performed a systematic review of HIV clinical studies involving treatment interruption from 2000 to 2017 to describe the differences between treatment interruption in studies that contained and didn't contain an intervention. We assessed differences in monitoring strategies, threshold to restart ART, duration and adverse outcomes of treatment interruption, and factors aimed at minimizing transmission. We found that treatment interruption has been incorporated into 159 clinical studies since 2000 and is increasingly being included in trials to assess the efficacy of interventions to achieve sustained virological remission off ART. Great heterogeneity was noted in immunological, virological and clinical monitoring strategies, as well as in thresholds to recommence ART. Treatment interruption in recent intervention studies were more closely monitored, had more conservative thresholds to restart ART and had a shorter treatment interruption duration, compared with older treatment interruption studies that didn't include an intervention.
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8
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Leal L, Lucero C, Gatell JM, Gallart T, Plana M, García F. New challenges in therapeutic vaccines against HIV infection. Expert Rev Vaccines 2017; 16:587-600. [PMID: 28431490 DOI: 10.1080/14760584.2017.1322513] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION There is a growing interest in developing curative strategies for HIV infection. Therapeutic vaccines are one of the most promising approaches. We will review the current knowledge and the new challenges in this research field. Areas covered: PubMed and ClinicalTrial.gov databases were searched to review the progress and prospects for clinical development of immunotherapies aimed to cure HIV infection. Dendritic cells (DC)-based vaccines have yielded the best results in the field. However, major immune-virologic barriers may hamper current vaccine strategies. We will focus on some new challenges as the antigen presentation by DCs, CTL escape mutations, B cell follicle sanctuary, host immune environment (inflammation, immune activation, tolerance), latent reservoir and the lack of surrogate markers of response. Finally, we will review the rationale for designing new therapeutic vaccine candidates to be used alone or in combination with other strategies to improve their effectiveness. Expert commentary: In the next future, the combination of DCs targeting candidates, inserts to redirect responses to unmutated parts of the virus, adjuvants to redirect responses to sanctuaries or improve the balance between activation/tolerance (IL-15, anti-PD1 antibodies) and latency reversing agents could be necessary to finally achieve the remission of HIV-1 infection.
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Affiliation(s)
- Lorna Leal
- a Infectious Diseases Unit, HIVACAT, Hospital Clínic, IDIBAPS , University of Barcelona , Barcelona , Spain
| | - Constanza Lucero
- a Infectious Diseases Unit, HIVACAT, Hospital Clínic, IDIBAPS , University of Barcelona , Barcelona , Spain
| | - Josep M Gatell
- a Infectious Diseases Unit, HIVACAT, Hospital Clínic, IDIBAPS , University of Barcelona , Barcelona , Spain
| | - Teresa Gallart
- b Retrovirology and Viral Immunopathology Laboratories, HIVACAT, Hospital Clínic, IDIBAPS , University of Barcelona , Barcelona , Spain
| | - Montserrat Plana
- b Retrovirology and Viral Immunopathology Laboratories, HIVACAT, Hospital Clínic, IDIBAPS , University of Barcelona , Barcelona , Spain
| | - Felipe García
- a Infectious Diseases Unit, HIVACAT, Hospital Clínic, IDIBAPS , University of Barcelona , Barcelona , Spain
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9
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Jose S, Quinn K, Dunn D, Cox A, Sabin C, Fidler S. Virological failure and development of new resistance mutations according to CD4 count at combination antiretroviral therapy initiation. HIV Med 2015; 17:368-72. [PMID: 26306942 PMCID: PMC4949527 DOI: 10.1111/hiv.12302] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2015] [Indexed: 11/28/2022]
Abstract
Objectives No randomized controlled trials have yet reported an individual patient benefit of initiating combination antiretroviral therapy (cART) at CD4 counts > 350 cells/μL. It is hypothesized that earlier initiation of cART in asymptomatic and otherwise healthy individuals may lead to poorer adherence and subsequently higher rates of resistance development. Methods In a large cohort of HIV‐positive individuals, we investigated the emergence of new resistance mutations upon virological treatment failure according to the CD4 count at the initiation of cART. Results Of 7918 included individuals, 6514 (82.3%), 996 (12.6%) and 408 (5.2%) started cART with a CD4 count ≤ 350, 351–499 and ≥ 500 cells/μL, respectively. Virological rebound occurred while on cART in 488 (7.5%), 46 (4.6%) and 30 (7.4%) with a baseline CD4 count ≤ 350, 351–499 and ≥ 500 cells/μL, respectively. Only four (13.0%) individuals with a baseline CD4 count > 350 cells/μL in receipt of a resistance test at viral load rebound were found to have developed new resistance mutations. This compared to 107 (41.2%) of those with virological failure who had initiated cART with a CD4 count < 350 cells/μL. Conclusions We found no evidence of increased rates of resistance development when cART was initiated at CD4 counts above 350 cells/μL.
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Affiliation(s)
- S Jose
- Research Department of Infection and Population Health, UCL, London, UK
| | - K Quinn
- Department of Medicine, Imperial College London, London, UK
| | - D Dunn
- Medical Research Council Clinical Trials Unit at UCL, London, UK
| | - A Cox
- Infection and Immunity, Imperial College Healthcare NHS Trust, London, UK
| | - C Sabin
- Research Department of Infection and Population Health, UCL, London, UK
| | - S Fidler
- Department of Medicine, Imperial College London, London, UK
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10
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Bruner KM, Hosmane NN, Siliciano RF. Towards an HIV-1 cure: measuring the latent reservoir. Trends Microbiol 2015; 23:192-203. [PMID: 25747663 PMCID: PMC4386620 DOI: 10.1016/j.tim.2015.01.013] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/23/2015] [Accepted: 01/28/2015] [Indexed: 02/07/2023]
Abstract
The latent reservoir (LR) of HIV-1 in resting memory CD4(+) T cells serves as a major barrier to curing HIV-1 infection. While many PCR- and culture-based assays have been used to measure the size of the LR, correlation between results of different assays is poor and recent studies indicate that no available assay provides an accurate measurement of reservoir size. The discrepancies between assays are a hurdle to clinical trials that aim to measure the efficacy of HIV-1 eradication strategies. Here we describe the advantages and disadvantages of various approaches to measuring the LR.
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Affiliation(s)
- Katherine M Bruner
- Department of Medicine, Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD 21205, USA
| | - Nina N Hosmane
- Department of Medicine, Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD 21205, USA
| | - Robert F Siliciano
- Department of Medicine, Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD 21205, USA; Howard Hughes Medical Institute, 733 North Broadway, Baltimore, MD 21205, USA.
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Sigaloff KCE, Lange JMA, Montaner J. Global response to HIV: treatment as prevention, or treatment for treatment? Clin Infect Dis 2015; 59 Suppl 1:S7-S11. [PMID: 24926037 DOI: 10.1093/cid/ciu267] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The concept of "treatment as prevention" has emerged as a means to curb the global HIV epidemic. There is, however, still ongoing debate about the evidence on when to start antiretroviral therapy in resource-poor settings. Critics have brought forward multiple arguments against a "test and treat" approach, including the potential burden of such a strategy on weak health systems and a presumed lack of scientific support for individual patient benefit of early treatment initiation. In this article, we highlight the societal and individual advantages of treatment as prevention in resource-poor settings. We argue that the available evidence renders the discussion on when to start antiretroviral therapy unnecessary and that, instead, efforts should be aimed at offering treatment as soon as possible.
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Affiliation(s)
- Kim C E Sigaloff
- Department of Global Health Department of Internal Medicine, Academic Medical Center, University of Amsterdam Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | | | - Julio Montaner
- British Columbia Center for Excellence in HIV/AIDS, Vancouver, Canada
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12
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Langs-Barlow A, Selvaraj S, Ogbuagu O, Shabanova V, Shapiro ED, Paintsil E. Association of circulating cytochrome c with clinical manifestations of antiretroviral-induced toxicity. Mitochondrion 2014; 20:71-4. [PMID: 25435346 DOI: 10.1016/j.mito.2014.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 11/19/2014] [Accepted: 11/21/2014] [Indexed: 01/03/2023]
Abstract
Diagnosis of antiretroviral therapy (ART) toxicity is complicated. Apoptosis has been implicated in ART toxicity. Cytochrome c (Cyt-C) is a mitochondrial protein found in plasma during pro-apoptotic states. We conducted a study of HIV-infected individuals on ART with (cases, n=21) and without (controls, n=21) clinical evidence of toxicity to determine if elevated plasma Cyt-C is associated with ART toxicity. When corrected for CD4 count, viral load, and duration of HIV infection, cases are 7.86 times more likely than controls to have plasma Cyt-C>0.216 ng/mL. Cyt-C could be a useful clinical tool to guide treatment decisions in this population.
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Affiliation(s)
- Allison Langs-Barlow
- Department of Pediatrics, Yale School of Medicine, PO Box 208064, New Haven, CT 06520-8064, USA.
| | - Shanmugapriya Selvaraj
- Department of Medicine, Yale School of Medicine, 330 Cedar St., Boardman 110, PO Box 208056, New Haven, CT 06520-8056, USA.
| | - Onyema Ogbuagu
- Department of Medicine, Yale School of Medicine, 330 Cedar St., Boardman 110, PO Box 208056, New Haven, CT 06520-8056, USA.
| | - Veronika Shabanova
- Center for Analytical Sciences, Yale School of Public Health, 300 George Street, Suite 555, New Haven, CT 06520, USA.
| | - Eugene D Shapiro
- Department of Pediatrics, Yale School of Medicine, PO Box 208064, New Haven, CT 06520-8064, USA; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 60 College Street, PO Box 208034, New Haven, CT 06520-8034, USA.
| | - Elijah Paintsil
- Department of Pediatrics, Yale School of Medicine, PO Box 208064, New Haven, CT 06520-8064, USA; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 60 College Street, PO Box 208034, New Haven, CT 06520-8034, USA; Department of Pharmacology, Yale School of Medicine, Sterling Hall of Medicine, 333 Cedar Street, SHM B-208, New Haven, CT 06520-8066, USA.
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Robbins GK, Lester W, Johnson KL, Chang Y, Estey G, Surrao D, Zachary K, Lammert SM, Chueh HC, Meigs JB, Freedberg KA. Efficacy of a clinical decision-support system in an HIV practice: a randomized trial. Ann Intern Med 2012; 157:757-66. [PMID: 23208165 PMCID: PMC3829692 DOI: 10.7326/0003-4819-157-11-201212040-00003] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Data to support improved patient outcomes from clinical decision-support systems (CDSSs) are lacking in HIV care. OBJECTIVE To test the efficacy of a CDSS in improving HIV outcomes in an outpatient clinic. DESIGN Randomized, controlled trial. (ClinicalTrials.gov registration number: NCT00678600) SETTING Massachusetts General Hospital HIV Clinic. PARTICIPANTS HIV care providers and their patients. INTERVENTION Computer alerts were generated for virologic failure (HIV RNA level >400 copies/mL after a previous HIV RNA level ≤400 copies/mL), evidence of suboptimal follow-up, and 11 abnormal laboratory test results. Providers received interactive computer alerts, facilitating appointment rescheduling and repeated laboratory testing, for half of their patients and static alerts for the other half. MEASUREMENTS The primary end point was change in CD4 cell count. Other end points included time to clinical event, 6-month suboptimal follow-up, and severe laboratory toxicity. RESULTS Thirty-three HIV care providers followed 1011 patients with HIV. In the intervention group, the mean increase in CD4 cell count was greater (0.0053 vs. 0.0032 × 109 cells/L per month; difference, 0.0021 × 109 cells/L per month [95% CI, 0.0001 to 0.004]; P = 0.040) and the rate of 6-month suboptimal follow-up was lower (20.6 vs. 30.1 events per 100 patient-years; P = 0.022) than those in the control group. Median time to next scheduled appointment was shorter in the intervention group than in the control group after a suboptimal follow-up alert (1.71 vs. 3.48 months; P < 0.001) and after a toxicity alert (2.79 vs. >6 months; P = 0.072). More than 90% of providers supported adopting the CDSS as part of standard care. LIMITATION This was a 1-year informatics study conducted at a single hospital subspecialty clinic. CONCLUSION A CDSS using interactive provider alerts improved CD4 cell counts and clinic follow-up for patients with HIV. Wider implementation of such systems can provide important clinical benefits. PRIMARY FUNDING SOURCE National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Gregory K Robbins
- Massachusetts General Hospital, Division of Infectious Diseases, 55 Fruit Street, Cox 5, Boston, MA 02114, USA.
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Machado C, Ríos-Villegas MJ, Gálvez-Acebal J, Domínguez-Castellano A, Fernández-Cuenca F, Palomo V, Muniain MA, Rodríguez-Baño J. Long-term outcome of patients after a single interruption of antiretroviral therapy: a cohort study. BMC Res Notes 2012; 5:578. [PMID: 23095460 PMCID: PMC3532099 DOI: 10.1186/1756-0500-5-578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 10/17/2012] [Indexed: 11/10/2022] Open
Abstract
Background To describe the long term outcome of patients who interrupted highly active antiretroviral therapy (HAART) once, identify the variables associated with earlier need to re-start HAART, and the response when therapy was resumed. A retrospective observational cohort of 66 adult patients with HIV-1 infection who interrupted HAART with a CD4+cell count ≥350 cells/μL and undetectable viral load (VL) was performed. The pre-established CD4+ cell count for restarting therapy was 300cells/μL. Cox regression was used to analyse the variables associated with earlier HAART reinitiation. Results The median follow-up was 209 weeks (range, 64–395). Rates of HIV-related or possible HIV-related events were 0.37 (one case of acute retroviral syndrome) and 1.49 per 100 patient-years, respectively. Two patients died after re-starting therapy and having reached undetectable VL. Three patients suffered a sexually transmitted disease while off therapy. Fifty patients (76%) resumed therapy after a median of 97 weeks (range, 17–267). Age, a nadir of CD4+ <250 cells/μL, and a mean VL during interruption of >10,000 copies/ml were independent predictors for earlier re-start. The intention-to-treat success rate of the first HAART resumed regimen was 85.4%. There were no differences by regimen used, nor between regimens that were the same as or different from the one that had been interrupted. Conclusions Our data suggest highly active antiretroviral therapy may be interrupted in selected patients because in these patients, when the HAART is restarted, the viral and clinical response may be achieved.
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Affiliation(s)
- Carmen Machado
- Infectious Diseases Unit, Hospital Universitario Virgen Macarena, Seville, Avda Dr Fedriani 3, Seville, 41009, Spain.
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Standing genetic variation and the evolution of drug resistance in HIV. PLoS Comput Biol 2012; 8:e1002527. [PMID: 22685388 PMCID: PMC3369920 DOI: 10.1371/journal.pcbi.1002527] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 04/04/2012] [Indexed: 11/25/2022] Open
Abstract
Drug resistance remains a major problem for the treatment of HIV. Resistance can occur due to mutations that were present before treatment starts or due to mutations that occur during treatment. The relative importance of these two sources is unknown. Resistance can also be transmitted between patients, but this process is not considered in the current study. We study three different situations in which HIV drug resistance may evolve: starting triple-drug therapy, treatment with a single dose of nevirapine and interruption of treatment. For each of these three cases good data are available from literature, which allows us to estimate the probability that resistance evolves from standing genetic variation. Depending on the treatment we find probabilities of the evolution of drug resistance due to standing genetic variation between and . For patients who start triple-drug combination therapy, we find that drug resistance evolves from standing genetic variation in approximately 6% of the patients. We use a population-dynamic and population-genetic model to understand the observations and to estimate important evolutionary parameters under the assumption that treatment failure is caused by the fixation of a single drug resistance mutation. We find that both the effective population size of the virus before treatment, and the fitness of the resistant mutant during treatment, are key-parameters which determine the probability that resistance evolves from standing genetic variation. Importantly, clinical data indicate that both of these parameters can be manipulated by the kind of treatment that is used. For HIV patients who are treated with antiretroviral drugs, treatment usually works well. However, the virus can, and sometimes does, become resistant against one or more drugs. HIV drug resistance results from the acquisition of specific and well known mutations. It is currently unknown whether drug resistance mutations usually stem from standing genetic variation, i.e., they were already present at low frequency before treatment started, or whether they tend to occur during treatment. In the current manuscript, I make use of several large datasets and evolutionary modeling to estimate the probability that drug resistance mutations are present before treatment starts and lead to viral failure. I find that for the most common type of treatment with a combination of three drugs, drug resistance evolves from pre-existing mutations in 6% of the patients. With other types of treatment, this probability varies from 0 to 39%. I conclude that there is room for improvement in preventing the evolution of drug resistance from pre-existing mutations.
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Imaz A, Olmo M, Peñaranda M, Gutiérrez F, Romeu J, Larrousse M, Domingo P, Oteo JA, Niubó J, Curto J, Vilallonga C, Masiá M, López-Aldeguer J, Iribarren JA, Podzamczer D. Evolution of HIV-1 genotype in plasma RNA and peripheral blood mononuclear cells proviral DNA after interruption and resumption of antiretroviral therapy. Antivir Ther 2011; 17:577-83. [PMID: 22301439 DOI: 10.3851/imp2025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Structured antiretroviral therapy interruption (TI) is discouraged because of poorer AIDS and non-AIDS-related outcomes, but is often inevitable in clinical practice. Certain strategies could reduce the emergence of resistance mutations related to TI. METHODS A total of 106 HIV-1-infected patients on stable HAART with undetectable plasma viral load were randomized to therapy continuation (n=50) or CD4(+) T-cell-guided TI (n=56). Staggered interruption involved stopping non-nucleoside reverse transcriptase inhibitors (NNRTIs) 7 days before the nucleoside backbone. Genotypic resistance testing (GRT) was performed on proviral DNA from peripheral blood mononuclear cells (PBMCs) at baseline and before each TI, and on plasma RNA after each TI. RESULTS At baseline, GRT on PBMCs detected mutations in nine patients and only two major mutations were identified. GRT on plasma samples performed after TIs showed nucleoside reverse transcriptase inhibitors (NRTI), NNRTI and protease inhibitor major resistance associated mutations in 10/56, 3/46 and 1/8 patients receiving these drugs, respectively. Only in two patients had the same mutations been observed in GRT on PBMCs at baseline. Three patients presented virological failure after resumption of therapy, all receiving NNRTIs. In one of them, resistance mutations detected at failure had been also observed previously in GRT on plasma after TI. CONCLUSIONS Staggered interruption of NNRTIs 7 days before the nucleoside backbone does not avoid resistance emergence completely, but does not necessarily lead to virological failure after treatment resumption. Plasma HIV-1 RNA genotype after the interruption and the patient's treatment history seem to be more useful than baseline proviral DNA genotype to assess the risk of virological failure after restarting therapy.
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Affiliation(s)
- Arkaitz Imaz
- HIV Unit, Infectious Diseases Department, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain.
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Lanoix JP, Andrejak C, Schmit JL. Antiretroviral therapy in intensive care. Med Mal Infect 2011; 41:353-8. [PMID: 21680122 DOI: 10.1016/j.medmal.2011.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Revised: 01/24/2011] [Accepted: 05/11/2011] [Indexed: 10/18/2022]
Abstract
Using antiretroviral therapy (ART) raises numerous issues in intensive care units (ICU): drug administration and kinetics issues in ventilated patients and/or with gastric tube, drug interactions, and risk of immune reconstitution inflammatory syndrome. This is why a lot of ICU physicians stop ART on admission and few initiate it during the ICU stay. However, the literature review suggests that the earlier the ART is started the more effective it is. Furthermore, stopping ART could be hazardous for some patients. The authors present the most frequent issues raised by ART use in an ICU and how to deal with them.
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Affiliation(s)
- J-P Lanoix
- Infectious and tropical diseases unit, CHU d'Amiens, place Victor-Pauchet, Amiens, France.
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Yazdanpanah Y, Wolf LL, Anglaret X, Gabillard D, Walensky RP, Moh R, Danel C, Sloan CE, Losina E, Freedberg KA. CD4+ T-cell-guided structured treatment interruptions of antiretroviral therapy in HIV disease: projecting beyond clinical trials. Antivir Ther 2010; 15:351-61. [PMID: 20516555 DOI: 10.3851/imp1542] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND International trials have shown that CD4+ T-cell-guided structured treatment interruptions (STI) of antiretroviral therapy (ART) lead to worse outcomes than continuous treatment. We simulated continuous ART and STI strategies with higher CD4+ T-cell interruption/reintroduction thresholds than those assessed in actual trials. METHODS Using a model of HIV, we simulated cohorts of African adults with different baseline CD4+ T-cell counts (< or = 200; 201-350; and 351-500 cells/microl). We varied ART initiation criteria (immediate; CD4+ T-cell count < 350 cells/microl or > or = 350 cells/microl with severe HIV-related disease; and CD4+ T-cell count <200 cells/microl or > or = 200 cells/microl with severe HIV-related disease), and ART interruption/reintroduction thresholds (350/250; 500/350; and 700/500 cells/microl). First-line therapy was non-nucleoside reverse transcriptase inhibitor (NNRTI)-based and second-line therapy was protease inhibitor (PI)-based. RESULTS STI generally reduced life expectancy compared with continuous ART. Life expectancy increased with earlier ART initiation and higher interruption/reintroduction thresholds. STI reduced life expectancy by 48-69 and 11-30 months compared with continuous ART when interruption/reintroduction thresholds were 350/250 and 500/350 cells/microl, depending on ART initiation criteria. When patients interrupted/reintroduced ART at 700/500 cells/microl, life expectancies ranged from 2 months lower to 1 month higher than continuous ART. STI-related life expectancy increased with decreased risk of virological resistance after ART interruptions. CONCLUSIONS STI with NNRTI-based regimens was almost always less effective than continuous treatment, regardless of interruption/reintroduction thresholds. The risks associated with STI decrease only if patients start ART earlier, interrupt/reintroduce treatment at very high CD4+ T-cell thresholds (700/500 cells/microl) and use first-line medications with higher resistance barriers, such as PIs.
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Affiliation(s)
- Yazdan Yazdanpanah
- Service Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, Tourcoing, France.
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Lack of minority K65R-resistant viral populations detected after repeated treatment interruptions of tenofovir/zidovudine and lamivudine in a resource-limited setting. J Acquir Immune Defic Syndr 2010; 54:215-6. [PMID: 20505473 DOI: 10.1097/qai.0b013e3181cc1058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Palacios GC, Sanchez LM, Briones E, Ramirez TJ, Castillo H, Rivera LG, Vazquez CA, Rodriguez-Padilla C, Holodniy M. Structured interruptions of highly active antiretroviral therapy in cycles of 4 weeks off/12 weeks on therapy in children having a chronically undetectable viral load cause progressively smaller viral rebounds. Int J Infect Dis 2010; 14:e34-40. [DOI: 10.1016/j.ijid.2009.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 02/19/2009] [Accepted: 03/01/2009] [Indexed: 11/27/2022] Open
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Palmisano L, Giuliano M, Galluzzo CM, Amici R, Andreotti M, Weimer LE, Pirillo MF, Fragola V, Bucciardini R, Vella S. The mutational archive in proviral DNA does not change during 24 months of continuous or intermittent highly active antiretroviral therapy. HIV Med 2009; 10:477-81. [DOI: 10.1111/j.1468-1293.2009.00715.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rudy BJ, Sleasman J, Kapogiannis B, Wilson CM, Bethel J, Serchuck L, Ahmad S, Cunningham CK. Short-cycle therapy in adolescents after continuous therapy with established viral suppression: the impact on viral load suppression. AIDS Res Hum Retroviruses 2009; 25:555-61. [PMID: 19534628 PMCID: PMC2853866 DOI: 10.1089/aid.2008.0203] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This was a proof-of-principle study to evaluate the impact of short cycle therapy (SCT; 4 days on/3 days off) in adolescents and young adults with good viral suppression on a protease inhibitor-based antiretroviral regimen. Subjects were recruited by the Adolescent Trials Network for HIV/AIDS Interventions and the Pediatric AIDS Clinical Trials Group. Subjects were infected either through perinatal/early childhood transmission or later via risk behaviors. All subjects were required to have at least 6 months of documented viral suppression below 400 copies/ml plus a preentry value below 200 copies/ml and an entry CD4+ T cell count above 350 cells/mm3. Of the 32 subjects enrolled, 12 (37.5%) had confirmed viral load rebound >400 copies, with 18 subjects (56%) coming off for any reason. The majority of subjects resuppressed when placed back onto continuous therapy using the same agents. Although no difference was found in virologic rebound rates between the early and later transmission groups, those infected early in life had higher rates of coming off SCT for any reason. There was no impact of SCT on the CD4+ T cell counts in those who remained on study or those who came off SCT for any reason. Subjects demonstrated good adherence to the SCT regimen. This study suggests that further evaluation of SCT may be warranted in some groups of adolescents and young adults infected with HIV.
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Affiliation(s)
- Bret J Rudy
- Craig Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, 3535 Market Street, Suite 1517, Philadelphia, PA 19104, USA.
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Danel C, Moh R, Chaix ML, Gabillard D, Gnokoro J, Diby CJ, Toni T, Dohoun L, Rouzioux C, Bissagnene E, Salamon R, Anglaret X. Two-months-off, four-months-on antiretroviral regimen increases the risk of resistance, compared with continuous therapy: a randomized trial involving West African adults. J Infect Dis 2009; 199:66-76. [PMID: 18986246 DOI: 10.1086/595298] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND A randomized trial was launched in Côte d'Ivoire in 2002 to compare continuous antiretroviral treatment (hereafter, "C-ART") to an ART regimen of 2 months off and 4 months on therapy (hereafter, "2/4-ART"). We report the final analysis. METHODS A total of 435 adults who were receiving successful ART ((median CD4 cell count prior to ART, 272 cells/mm(3); 88% were receiving a zidovudine-lamivudine-efavirenz regimen) were randomized to receive C-ART or 2/4-ART. The main primary end point was the percentage of patients with <350 CD4 cells/mm(3) at 24 months. The sample size ensured 80% power to demonstrate noninferiority (noninferiority bound, -15%), assuming that 30% of the patients in the C-ART arm would have <350 CD4 cells/mm(3). Other end points were mortality, morbidity, cost of care, genotypic resistance, adherence, and toxicity. RESULTS The percentage of patients with <350 CD4 cells/mm(3) at 24 months was 5.6% (6 of 107) in the C-ART arm and 14.6% (46 of 315) in the 2/4-ART arm (lower bound of the 95% CI for the difference, -14%). Cost was 18% higher in the C-ART arm, and resistance to nonnucleoside reverse-transcriptase inhibitors (NNRTIs) was 20% higher in the 2/4-ART arm. Other end points were nonconclusive. CONCLUSIONS Although 2/4-ART met the predetermined criteria for noninferiority, the percentage of patients with <350 CD4 cells/mm(3) in the C-ART arm was lower than anticipated, which makes the clinical significance of this noninferiority uncertain. In addition, 2/4-ART led to an unacceptable additional risk of selecting for drug-resistant virus. This new argument against episodic ART strategies is also a caveat against any unplanned ART interruptions in Africa, where most patients receive NNRTIs.
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Affiliation(s)
- Christine Danel
- INSERM, Unité 897, Centre de Recherche Epidémiologie et Biostatistique, Bordeaux, France
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Viral resuppression and detection of drug resistance following interruption of a suppressive non-nucleoside reverse transcriptase inhibitor-based regimen. AIDS 2008; 22:2279-89. [PMID: 18981767 DOI: 10.1097/qad.0b013e328311d16f] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Interruption of a non-nucleoside reverse transcriptase inhibitor (NNRTI)-regimen is often necessary, but must be performed with caution because NNRTIs have a low genetic barrier to resistance. Limited data exist to guide clinical practice on the best interruption strategy to use. METHODS Patients in the drug-conservation arm of the Strategies for Management of Antiretroviral Therapy (SMART) trial who interrupted a fully suppressive NNRTI-regimen were evaluated. From 2003, SMART recommended interruption of an NNRTI by a staggered interruption, in which the NNRTI was stopped before the NRTIs, or by replacing the NNRTI with another drug before interruption. Simultaneous interruption of all antiretrovirals was discouraged. Resuppression rates 4-8 months after reinitiating NNRTI-therapy were assessed, as was the detection of drug-resistance mutations within 2 months of the treatment interruption in a subset (N = 141). RESULTS Overall, 601/688 (87.4%) patients who restarted an NNRTI achieved viral resuppression. The adjusted odds ratio (95% confidence interval) for achieving resuppression was 1.94 (1.02-3.69) for patients with a staggered interruption and 3.64 (1.37-9.64) for those with a switched interruption compared with patients with a simultaneous interruption. At least one NNRTI-mutation was detected in the virus of 16.4% patients with simultaneous interruption, 12.5% patients with staggered interruption and 4.2% patients with switched interruption. Fewer patients with detectable mutations (i.e. 69.2%) achieved HIV-RNA of 400 copies/ml or less compared with those in whom no mutations were detected (i.e. 86.7%; P = 0.05). CONCLUSION In patients who interrupt a suppressive NNRTI-regimen, the choice of interruption strategy may influence resuppression rates when restarting a similar regimen. NNRTI drug-resistance mutations were observed in a relatively high proportion of patients. These data provide additional support for a staggered or switched interruption strategy for NNRTI drugs.
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Leon A, Martinez E, Milinkovic A, Mora B, Mallolas J, Blanco JL, Larrousse M, Laguno M, Gallart T, Plana M, Gatell JM, Garcia F. Influence of repeated cycles of structured therapy interruption on the rate of recovery of CD4+ T cells after highly active antiretroviral therapy resumption. J Antimicrob Chemother 2008; 63:184-8. [DOI: 10.1093/jac/dkn461] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Variability in the Plasma Concentration of Efavirenz and Nevirapine is Associated with Genotypic Resistance after Treatment Interruption. Antivir Ther 2008. [DOI: 10.1177/135965350801300705] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Selection and persistence of non-nucleoside reverse transcriptase inhibitor (NNRTI)-associated mutations during treatment interruptions (TIs) has been attributed to the long plasma half-life of these drugs. However, little is known about the contribution of variable NNRTI plasma levels before a TI. We evaluated the selection of NNRTI-related mutations and the coefficient of variation of NNRTI plasma concentrations during different TI periods. Methods The selection of NNRTI-related mutations was examined in 50 HIV type-1 (HIV-1)-infected patients on a virologically suppressive regimen who underwent TI guided by CD4+ T-cell counts and plasma viraemia. Population and clone-based sequencing of the reverse transcriptase coding region was performed using plasma HIV-1 RNA samples during TI and proviral DNA from peripheral blood mononuclear cells before TI. NNRTI plasma concentrations were determined by HPLC. Results In 7/50 treated patients, de novo and transient NNRTI-related mutations appeared when treatment was interrupted. Emergence of resistant variants (including K103N, Y181C or G190S) after interruption was associated with a higher coefficient of variation in NNRTI plasma concentrations during the treatment period. Moreover, minority HIV-1 variants containing different resistance patterns (V106I/A, K103R/E or Y188C/D/H) were detected regardless of NNRTI concentrations. Conclusions The emergence of NNRTI-associated mutations during TI appears to be associated with the variation of NNRTI plasma concentrations during the preceding treatment period. The selection of minority HIV-1 variants with different patterns of NNRTI resistance in the absence of drug pressure should be considered for the efficacy of future NNRTI-containing antiretroviral regimens.
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Makinson A, Moing VL, Kouanfack C, Laurent C, Delaporte E. Safety of stavudine in the treatment of HIV infection with a special focus on resource-limited settings. Expert Opin Drug Saf 2008; 7:283-93. [PMID: 18462186 DOI: 10.1517/14740338.7.3.283] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Western randomized trials and prospective cohorts in resource-limited settings have proven virological success with stavudine-based highly active antiretroviral therapy. However, stavudine is no longer recommended in first-line treatments in these two settings due to its intrinsic toxicities and side effects. Yet it remains a cornerstone of treatment in resource-limited settings, due to lack of alternatives and its availability in generic fixed-dose combinations. OBJECTIVE To review the toxic effects of stavudine and their prevention and management strategies, especially in resource-limited settings. METHODS Data from clinical and pharmacological trials in Western countries, as well as prospective cohorts in resource-limited settings, were reviewed. CONCLUSION Initiating or switching to less toxic nucleoside analogues whenever possible, or lowering stavudine doses to 30 mg b.i.d., is strongly recommended.
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Affiliation(s)
- Alain Makinson
- University Hospital, Department of Infectious and Tropical Diseases, Montpellier, France
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Cressey TR, Green H, Khoo S, Treluyer JM, Compagnucci A, Saidi Y, Lallemant M, Gibb DM, Burger DM. Plasma drug concentrations and virologic evaluations after stopping treatment with nonnucleoside reverse-transcriptase inhibitors in HIV type 1-infected children. Clin Infect Dis 2008; 46:1601-8. [PMID: 18419497 PMCID: PMC3597130 DOI: 10.1086/587657] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The optimum strategy for stopping treatment with drugs that have different half-lives in a combination regimen to minimize the risk of selecting drug-resistant viruses remains unknown. We evaluated drug concentrations in plasma, human immunodeficiency virus (HIV) load, and development of drug resistance after a planned treatment interruption of a nonnucleoside reverse-transcriptase inhibitor (NNRTI)-containing regimen in HIV type 1-infected children. METHODS Children with viral loads <50 copies/mL and CD4 cell percentages > or =30% (for children aged 2-6 years) or CD4 cell percentages > or =25% and CD4 cell counts > or =500 cells/microL (for children aged 7-15 years) were randomized to either a planned treatment interruption or to continuous therapy. In the planned treatment interruption arm, either (1) treatment with nevirapine or efavirenz was stopped, and treatment with the remaining drugs was continued for 7-14 days, or (2) nevirapine or efavirenz were replaced by a protease inhibitor, and all drugs were stopped after 7-14 days. Sampling for determination of plasma drug concentrations, measurement of viral load, and drug resistance testing was scheduled at day 0, day 7 (drug concentrations only), day 14, and day 28 after interruption of treatment with an NNRTI. RESULTS Treatment with an NNRTI was interrupted for 35 children (20 were receiving nevirapine, and 15 were receiving efavirenz). Median time from NNRTI cessation to stopping all drugs was 9 days (range, 6-15 days) for nevirapine and 14 days (range, 6-18 days) for efavirenz. At 7 days, 1 (5%) of 19 and 4 (50%) of 8 children had detectable nevirapine and efavirenz concentrations, respectively; efavirenz remained detectable in 3 (25%) of 12 children at 14 days. At 14 days, viral load was > or =50 copies/mL in 6 of 16 children interrupting treatment with nevirapine (range, 52-7000 copies/mL) and in 2 of 12 children interrupting treatment with efavirenz (range, 120-1600 copies/mL). No new NNRTI mutations were observed. CONCLUSIONS In children with virological suppression who experienced interruption of treatment with an NNRTI, staggered or replacement stopping strategies for a median of 9 days for nevirapine and 14 days for efavirenz were not associated with the selection of NNRTI resistance mutations.
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Affiliation(s)
- Tim R. Cressey
- Institut de Recherché pour le Développement, Program for HIV Prevention and Treatment, UR 174, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Harvard School of Public Health, Harvard University, Boston, Massachusetts
| | | | - Saye Khoo
- University of Liverpool, Liverpool, United Kingdom
| | | | | | | | - Marc Lallemant
- Institut de Recherché pour le Développement, Program for HIV Prevention and Treatment, UR 174, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
- Harvard School of Public Health, Harvard University, Boston, Massachusetts
| | | | - David M. Burger
- Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
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Izopet J, Marchou B, Charreau I, Sauné K, Tangre P, Molina JM, Jean-Pierre A. HIV-1-Resistant Strains during 8-Week on 8-Week off Intermittent Therapy and their Effect on CD4 + T-cell Counts and Antiviral Response. Antivir Ther 2008. [DOI: 10.1177/135965350801300410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background We aimed here to study drug-associated HIV resistance mutations in peripheral blood mononuclear cells (PBMC) and plasma during intermittent therapy. Methods A substudy of 86 patients randomized to the intermittent treatment arm (8-week on/8-week off) of the ANRS 106 Window trial. HIV reverse transcriptase and protease genes were sequenced and resistance mutations identified according to the International AIDS Society list. Results Resistance mutations were detected in PBMC of 27/86 (31%) patients at baseline and 25/72 (35%) patients at week 96. Resistance mutations were detected in plasma of 28/86 (33%), 24/83 (29%) and 33/80 (41%) patients at weeks 8, 40 and 88, respectively. The detection of nucleoside reverse transcriptase inhibitor and protease inhibitor associated resistance mutations in plasma remained stable over time, but there was an increase in non-nucleoside reverse transcriptase inhibitor (NNRTI)-associated resistance mutations in patients on an NNRTI-based regimen: 1/33 (3%) versus 7/26 patients (27%) at weeks 8 and 88, respectively ( P=0.02). The proportions of patients with plasma HIV RNA levels ≤400 copies/ml after 8 weeks of treatment at weeks 16, 48 and 96 in patients with drug-resistant and wild-type viruses were 93% versus 74% ( P=0.04), 96% versus 88% ( P=0.43) and 70% versus 84% ( P=0.13), respectively. Patients with drug-resistant virus had a lower CD4+ T-cell decrease from baseline at weeks 40 and 88 as compared to patients with wild-type virus ( P=0.05 and 0.002, respectively). Conclusions NNRTI-associated resistance mutations increased over time in plasma of patients who were given NNRTIs. Drug-associated HIV resistance mutations did not seem to impair short-term antiviral response and might be associated with reduced CD4+ T-cell loss during interruptions.
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Affiliation(s)
- Jacques Izopet
- INSERM U563 - IFR30, Université de Toulouse et Laboratoire de, Virologie, Institut Fédératif de Biologie de Purpan, CHU de Toulouse, France
| | - Bruno Marchou
- Service des Maladies infectieuses et tropicales, CHU deToulouse, France
| | | | - Karine Sauné
- INSERM U563 - IFR30, Université de Toulouse et Laboratoire de, Virologie, Institut Fédératif de Biologie de Purpan, CHU de Toulouse, France
| | | | - Jean-Michel Molina
- Service des Maladies infectieuses et tropicales, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris, et Université de Paris 7, France
| | - Aboulker Jean-Pierre
- Service des Maladies infectieuses et tropicales, Hôpital Saint-Louis, Assistance Publique des Hôpitaux de Paris, et Université de Paris 7, France
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Darwich L, Esteve A, Ruiz L, Paredes R, Bellido R, Cabrera C, Romeu J, Bofill M, Clotet B, Martinez-Picado J. Drug-resistance mutations number and K70R or T215Y/F substitutions predict treatment resumption during guided treatment interruptions. AIDS Res Hum Retroviruses 2008; 24:725-32. [PMID: 18462084 DOI: 10.1089/aid.2007.0255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The role of antiretroviral history and genotypic resistance information as predictors of the first treatment interruption (TI) length in a CD4(+) cell count and plasma viremia-guided TI study (GTI) was assessed. Drug-resistance mutations (DRMs) were monitored in chronically HIV-1-infected subjects who underwent GTI. Patients were retrospectively classified into those who received monotherapy or dual therapy prior to HAART (pre-HAART group, n = 44) or directly initiated HAART (HAART group, n = 43). DRMs were assessed by population-based sequencing of proviral DNA at baseline and plasma RNA monthly during TI up to 180 weeks. Univariate and multivariate Cox's proportional hazard models were used to determine time off therapy predictors. The emergence of viruses with DRMs during TI was 5.1-fold more likely in pre-HAART than in HAART patients. The presence of DRMs in proviral DNA or plasma RNA was associated with shorter time off therapy. An accumulation of three or more DRMs duplicated the risk of restarting therapy with respect to having one or two mutations. Regardless of the number of DRMs, the presence of K70R or T215F/Y predicted the shortest TI time. Multivariate analyses adjusted by nadir CD4(+) counts supported the presence of DRMs in plasma HIV-1 RNA, and specifically the K70R or T215F/Y, as potent predictors of time off therapy. A history of monotherapy or dual therapy, accumulation of three or more key DRMs in the HIV-1 polymerase, and/or the presence of substitutions K70R or T215F/Y were associated with shorter time off therapy during GTI. A genotypic profile could provide clinicians with a predictive tool for time off therapy when TI is required in patients with suppressed viremia in whom nadir CD4(+) count is not available.
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Affiliation(s)
- Laila Darwich
- irsiCaixa Foundation, Center for Epidemiological Studies on Sexually Transmitted Infections and AIDS in Catalonia
| | - Anna Esteve
- CEEISCAT, Center for Epidemiological Studies on Sexually Transmitted Infections and AIDS in Catalonia
| | - Lidia Ruiz
- irsiCaixa Foundation, Center for Epidemiological Studies on Sexually Transmitted Infections and AIDS in Catalonia
| | - Roger Paredes
- irsiCaixa Foundation, Center for Epidemiological Studies on Sexually Transmitted Infections and AIDS in Catalonia
- HIV Clinical Unit, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Barcelona, Spain
| | - Rocio Bellido
- irsiCaixa Foundation, Center for Epidemiological Studies on Sexually Transmitted Infections and AIDS in Catalonia
| | - Cecilia Cabrera
- irsiCaixa Foundation, Center for Epidemiological Studies on Sexually Transmitted Infections and AIDS in Catalonia
| | - Joan Romeu
- HIV Clinical Unit, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Barcelona, Spain
| | - Margarita Bofill
- irsiCaixa Foundation, Center for Epidemiological Studies on Sexually Transmitted Infections and AIDS in Catalonia
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Badalona, Barcelona, Spain
| | - Bonaventura Clotet
- irsiCaixa Foundation, Center for Epidemiological Studies on Sexually Transmitted Infections and AIDS in Catalonia
- HIV Clinical Unit, Hospital Universitari Germans Trias i Pujol, 08916 Badalona, Barcelona, Spain
| | - Javier Martinez-Picado
- irsiCaixa Foundation, Center for Epidemiological Studies on Sexually Transmitted Infections and AIDS in Catalonia
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Badalona, Barcelona, Spain
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Effect of twice-daily nevirapine on adherence in HIV-1-infected patients: a randomized controlled study. AIDS 2007; 21:2217-22. [PMID: 18090049 DOI: 10.1097/qad.0b013e3282eff388] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE For optimal adherence, once-daily dosing is best. Whether this applies to antiretroviral therapy is unknown. We thus aimed to determine the effect of once-daily dosing on adherence to nevirapine. DESIGN A three-phase (3-month observational, 4-month randomized, 5-month interventional) open-label, clinical trial at four French academic medical centres during 2005-2006 among 62 chronically HIV-1-infected subjects with long-lasting viral suppression under a twice-a-day nevirapine-based antiretroviral combination. METHODS Adherence was measured using electronic monitoring devices and validated by sequential plasma drug levels. Participants were randomly assigned to switch to nevirapine 400 mg once-daily (n = 31) or continue nevirapine 200 mg twice-a-day (n = 31). After the randomized phase, participants had an opportunity to choose their antiretroviral dosage. Primary outcome was the mean percentage of adherence. RESULTS Fifty-two patients qualified for electronic data analysis. During the randomized phase, the mean adherence rate was non-significantly superior by 0.5% in once-daily versus twice-a-day dosing (P = 0.68), adjusting for previous twice-a-day adherence rate (P < 0.0001). Once-daily group increased days without dose [odds ratio (OR) 1.7; 95% confidence interval (CI) 1.0, 2.8; P = 0.04], adjusting for previous drug interruptions (P < 0.0001). In the longitudinal analysis, once-daily dosing was significantly associated with at least two consecutive days without dose (OR 4.4; 95% CI 1.9, 10.3; P < 0.001). CONCLUSION Changing from twice to once-daily nevirapine does not improve adherence. Supporting continuous adherence to antiretroviral therapy in the 'once-a-day era' remains a challenge, even if more potent regimens can achieve viral suppression at lower adherence levels.
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Ambrose Z, Palmer S, Boltz VF, Kearney M, Larsen K, Polacino P, Flanary L, Oswald K, Piatak M, Smedley J, Shao W, Bischofberger N, Maldarelli F, Kimata JT, Mellors JW, Hu SL, Coffin JM, Lifson JD, KewalRamani VN. Suppression of viremia and evolution of human immunodeficiency virus type 1 drug resistance in a macaque model for antiretroviral therapy. J Virol 2007; 81:12145-55. [PMID: 17855539 PMCID: PMC2169021 DOI: 10.1128/jvi.01301-07] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Antiretroviral therapy (ART) in human immunodeficiency virus type 1 (HIV-1)-infected patients does not clear the infection and can select for drug resistance over time. Not only is drug-resistant HIV-1 a concern for infected individuals on continual therapy, but it is an emerging problem in resource-limited settings where, in efforts to stem mother-to-child-transmission of HIV-1, transient nonnucleoside reverse transcriptase inhibitor (NNRTI) therapy given during labor can select for NNRTI resistance in both mother and child. Questions of HIV-1 persistence and drug resistance are highly amenable to exploration within animals models, where therapy manipulation is less constrained. We examined a pigtail macaque infection model responsive to anti-HIV-1 therapy to study the development of resistance. Pigtail macaques were infected with a pathogenic simian immunodeficiency virus encoding HIV-1 reverse transcriptase (RT-SHIV) to examine the impact of prior exposure to a NNRTI on subsequent ART comprised of a NNRTI and two nucleoside RT inhibitors. K103N resistance-conferring mutations in RT rapidly accumulated in 2/3 infected animals after NNRTI monotherapy and contributed to virologic failure during ART in 1/3 animals. By contrast, ART effectively suppressed RT-SHIV in 5/6 animals. These data indicate that suboptimal therapy facilitates HIV-1 drug resistance and suggest that this model can be used to investigate persisting viral reservoirs.
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Affiliation(s)
- Zandrea Ambrose
- HIV Drug Resistance Program, National Cancer Institute, Building 535, Room 123, Frederick, MD 21702, USA
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Determinants of Virologic and Immunologic Outcomes in Chronically HIV-Infected Subjects Undergoing Repeated Treatment Interruptions. J Acquir Immune Defic Syndr 2007. [DOI: 10.1097/qai.0b013e31813e62e1] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Danel C, Moh R, Minga A, Anzian A, Ba-Gomis O, Kanga C, Nzunetu G, Gabillard D, Rouet F, Sorho S, Chaix ML, Eholié S, Menan H, Sauvageot D, Bissagnene E, Salamon R, Anglaret X. CD4-guided structured antiretroviral treatment interruption strategy in HIV-infected adults in west Africa (Trivacan ANRS 1269 trial): a randomised trial. Lancet 2006; 367:1981-9. [PMID: 16782488 DOI: 10.1016/s0140-6736(06)68887-9] [Citation(s) in RCA: 157] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Structured treatment interruptions of highly-active antiretroviral therapy (HAART) might be particularly relevant for sub-Saharan Africa, where cost-saving strategies could help to increase the number of patients on HAART. We did a randomised trial of structured treatment interruption in Abidjan, Côte d'Ivoire. METHODS HIV-infected adults were randomised to receive continuous HAART (CT), CD4-guided HAART (CD4GT) with interruption and reintroduction thresholds at 350 and 250 cells per mm3, respectively, or 2-months-off, 4-months-on HAART. Primary endpoints were death and severe morbidity (any WHO stage 3 or 4 events and any events leading to death) at month 24. We report data from the CT and CD4GT groups until Oct 31, 2005, when the data safety monitoring board recommended to prematurely stop the CD4GT arm. Analyses were intention-to-treat. This study is registered at ClinicalTrials.gov, number NCT00158405. RESULTS 326 adults (median CD4 count nadir 272 per mm3) were randomised to the CT or CD4GT groups and followed up for median of 20 months. Incidence of mortality (per 100 person-years) was not different between groups (CT 0.6, CD4GT 1.2; p=0.57). Incidence of severe morbidity (per 100 person-years) was higher in the CDG4T group (17.6) than in the CT group (6.7; p=0.001). The most frequent severe events were invasive bacterial diseases. 79% of severe morbidity episodes occurred in patients with CD4 count 200-500 per mm3. CONCLUSION Patients on CD4GT had severe morbidity rates 2.5-fold higher than those on CT. This difference was mainly due to high rates of common diseases in patients with CD4 count 200-500 per mm3. This CD4-guided structured treatment interruption strategy should not be recommended in Abidjan.
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