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Thurman AR, Ouattara LA, Yousefieh N, Anderson PL, Bushman LR, Fang X, Hanif H, Clark M, Singh O, Doncel GF. A phase I study to assess safety, pharmacokinetics, and pharmacodynamics of a vaginal insert containing tenofovir alafenamide and elvitegravir. Front Cell Infect Microbiol 2023; 13:1130101. [PMID: 37153145 PMCID: PMC10154607 DOI: 10.3389/fcimb.2023.1130101] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/31/2023] [Indexed: 05/09/2023] Open
Abstract
Background New multi-purpose prevention technology (MPT) products are needed to prevent human immunodeficiency virus (HIV) and herpes simplex virus type 2 (HSV2). In this study, we evaluated a fast-dissolve insert that may be used vaginally or rectally for prevention of infection. Objective To describe the safety, acceptability, multi-compartment pharmacokinetics (PK), and in vitro modeled pharmacodynamics (PD) after a single vaginal dose of an insert containing tenofovir alafenamide (TAF) and elvitegravir (EVG) in healthy women. Methods This was a Phase I, open-label, study. Women (n=16) applied one TAF (20mg)/EVG (16mg) vaginal insert and were randomized (1:1) to sample collection time groups for up to 7 days post dosing. Safety was assessed by treatment-emergent adverse events (TEAEs). EVG, TAF and tenofovir (TFV) concentrations were measured in plasma, vaginal fluid and tissue, and TFV-diphosphate (TFV-DP) concentration in vaginal tissue. PD was modeled in vitro by quantifying the change in inhibitory activity of vaginal fluid and vaginal tissue against HIV and HSV2 from baseline to after treatment. Acceptability data was collected by a quantitative survey at baseline and post treatment. Results The TAF/EVG insert was safe, with all TEAEs graded as mild, and acceptable to participants. Systemic plasma exposure was low, consistent with topical delivery, while high mucosal levels were detected, with median TFV vaginal fluid concentrations exceeding 200,000 ng/mL and 1,000 ng/mL for up to 24 hours and 7 days post dosing, respectively. All participants had vaginal tissue EVG concentrations of > 1 ng/mg at 4 and 24 hours post dosing. The majority had tissue TFV-DP concentrations exceeding 1000 fmol/mg by 24 - 72 hours post dosing. Vaginal fluid inhibition of HIV-1 and HSV-2 in vitro significantly increased from baseline and was similarly high at 4 and 24 hours post dosing. Consistent with high tissue TFV-DP concentrations, p24 HIV antigen production from ectocervical tissues infected ex vivo with HIV-1 significantly decreased from baseline at 4 hours post dosing. HSV-2 production from tissue also decreased post treatment. Conclusions A single dose of TAF/EVG inserts met PK benchmarks, with PK data supporting an extended window of high mucosal protection. PD modeling supports mucosal protection against both HIV-1 and HSV-2. The inserts were safe and highly acceptable. Clinical trial registration ClinicalTrials.gov, identifier NCT03762772.
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Affiliation(s)
- Andrea R. Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
- *Correspondence: Andrea R. Thurman,
| | - Louise A. Ouattara
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Nazita Yousefieh
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Peter L. Anderson
- University of Colorado, Colorado Antiviral Pharmacology Lab, School of Pharmacy, Anschutz Medical Campus, Aurora, CO, United States
| | - Lane R. Bushman
- University of Colorado, Colorado Antiviral Pharmacology Lab, School of Pharmacy, Anschutz Medical Campus, Aurora, CO, United States
| | - Xi Fang
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Homaira Hanif
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Meredith Clark
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Onkar Singh
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States
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Karim QA, Archary D, Barré-Sinoussi F, Broliden K, Cabrera C, Chiodi F, Fidler SJ, Gengiah TN, Herrera C, Kharsany ABM, Liebenberg LJP, Mahomed S, Menu E, Moog C, Scarlatti G, Seddiki N, Sivro A, Cavarelli M. Women for science and science for women: Gaps, challenges and opportunities towards optimizing pre-exposure prophylaxis for HIV-1 prevention. Front Immunol 2022; 13:1055042. [PMID: 36561760 PMCID: PMC9763292 DOI: 10.3389/fimmu.2022.1055042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022] Open
Abstract
Preventing new HIV infections remains a global challenge. Young women continue to bear a disproportionate burden of infection. Oral pre-exposure prophylaxis (PrEP), offers a novel women-initiated prevention technology and PrEP trials completed to date underscore the importance of their inclusion early in trials evaluating new HIV PrEP technologies. Data from completed topical and systemic PrEP trials highlight the role of gender specific physiological and social factors that impact PrEP uptake, adherence and efficacy. Here we review the past and current developments of HIV-1 prevention options for women with special focus on PrEP considering the diverse factors that can impact PrEP efficacy. Furthermore, we highlight the importance of inclusion of female scientists, clinicians, and community advocates in scientific efforts to further improve HIV prevention strategies.
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Affiliation(s)
- Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Derseree Archary
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | | | - Kristina Broliden
- Department of Medicine Solna, Division of Infectious Diseases, Karolinska Institutet, Department of Infectious Diseases, Karolinska University Hospital, Center for Molecular Medicine, Stockholm, Sweden
| | - Cecilia Cabrera
- AIDS Research Institute IrsiCaixa, Institut de Recerca en Ciències de la Salut Germans Trias i Pujol (IGTP), Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesca Chiodi
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Sarah J. Fidler
- Department of Infectious Disease, Faculty of Medicine, Imperial College London UK and Imperial College NIHR BRC, London, United Kingdom
| | - Tanuja N. Gengiah
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Carolina Herrera
- Department of Infectious Disease, Section of Virology, Faculty of Medicine, Imperial College London, London, United Kingdom,*Correspondence: Carolina Herrera,
| | - Ayesha B. M. Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Lenine J. P. Liebenberg
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Sharana Mahomed
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Elisabeth Menu
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial diseases (IMVA-HB/IDMIT), Fontenay-aux-Roses & Le Kremlin-Bicêtre, France,MISTIC Group, Department of Virology, Institut Pasteur, Paris, France
| | - Christiane Moog
- Laboratoire d’ImmunoRhumatologie Moléculaire, Institut national de la santé et de la recherche médicale (INSERM) UMR_S 1109, Institut thématique interdisciplinaire (ITI) de Médecine de Précision de Strasbourg, Transplantex NG, Faculté de Médecine, Fédération Hospitalo-Universitaire OMICARE, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Gabriella Scarlatti
- Viral Evolution and Transmission Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Nabila Seddiki
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial diseases (IMVA-HB/IDMIT), Fontenay-aux-Roses & Le Kremlin-Bicêtre, France
| | - Aida Sivro
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute (2Floor), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa,JC Wilt Infectious Disease Research Centre, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB, Canada
| | - Mariangela Cavarelli
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-immune, Hematological and Bacterial diseases (IMVA-HB/IDMIT), Fontenay-aux-Roses & Le Kremlin-Bicêtre, France
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Thurman AR, Brache V, Cochon L, Ouattara LA, Chandra N, Jacot T, Yousefieh N, Clark MR, Peet M, Hanif H, Schwartz JL, Ju S, Marzinke MA, Erikson DW, Parikh U, Herold BC, Fichorova RN, Tolley E, Doncel GF. Randomized, placebo controlled phase I trial of the safety, pharmacokinetics, pharmacodynamics and acceptability of a 90 day tenofovir plus levonorgestrel vaginal ring used continuously or cyclically in women: The CONRAD 138 study. PLoS One 2022; 17:e0275794. [PMID: 36215267 PMCID: PMC9550080 DOI: 10.1371/journal.pone.0275794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 08/29/2022] [Indexed: 11/04/2022] Open
Abstract
Multipurpose prevention technologies (MPTs), which prevent sexually transmitted infection(s) and unintended pregnancy, are highly desirable to women. In this randomized, placebo-controlled, phase I study, women used a placebo or tenofovir (TFV) and levonorgestrel (LNG) intravaginal ring (IVR), either continuously or cyclically (three, 28-day cycles with a 3 day interruption in between each cycle), for 90 days. Sixty-eight women were screened; 47 were randomized to 4 arms: TFV/LNG or placebo IVRs used continuously or cyclically (4:4:1:1). Safety was assessed by adverse events and changes from baseline in mucosal histology and immune mediators. TFV concentrations were evaluated in multiple compartments. LNG concentration was determined in serum. Modeled TFV pharmacodynamic antiviral activity was evaluated in vaginal and rectal fluids and cervicovaginal tissue ex vivo. LNG pharmacodynamics was assessed with cervical mucus quality and anovulation. All IVRs were safe with no serious adverse events nor significant changes in genital tract histology, immune cell density or secreted soluble proteins from baseline. Median vaginal fluid TFV concentrations were >500 ng/mg throughout 90d. TFV-diphosphate tissue concentrations exceeded 1,000 fmol/mg within 72hrs of IVR insertion. Mean serum LNG concentrations exceeded 200 pg/mL within 2h of TFV/LNG use, decreasing quickly after IVR removal. Vaginal fluid of women using TFV-containing IVRs had significantly greater inhibitory activity (87-98% versus 10% at baseline; p<0.01) against HIV replication in vitro. There was a >10-fold reduction in HIV p24 antigen production from ectocervical tissues after TFV/LNG exposure. TFV/LNG IVR users had significantly higher rates of anovulation, lower Insler scores and poorer/abnormal cervical mucus sperm penetration. Most TFV/LNG IVR users reported no change in menstrual cycles or fewer days of and/or lighter bleeding. All IVRs were safe. Active rings delivered high TFV concentrations locally. LNG caused changes in cervical mucus, sperm penetration, and ovulation compatible with contraceptive efficacy. Trial registration: ClinicalTrials.gov #NCT03279120.
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Affiliation(s)
- Andrea R. Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
- * E-mail:
| | | | | | - Louise A. Ouattara
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Neelima Chandra
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Terry Jacot
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Nazita Yousefieh
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Meredith R. Clark
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Melissa Peet
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Homaira Hanif
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Jill L. Schwartz
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Susan Ju
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Mark A. Marzinke
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - David W. Erikson
- Endocrine Technologies Core (ETC), Oregon National Primate Research Center (ONPRC), Beaverton, OR, United States of America
| | - Urvi Parikh
- Department of Medicine, Division of Infectious Diseases and Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Betsy C. Herold
- Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Raina N. Fichorova
- Laboratory of Genital Tract Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Elizabeth Tolley
- Family Health International 360, Research Triangle, NC, United States of America
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
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4
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Ouattara LA, Thurman AR, Jacot TA, Cottrell M, Sykes C, Blake K, Fang X, Ju S, Vann NC, Schwartz J, Doncel GF. Genital Mucosal Drug Concentrations and anti-HIV Activity in Tenofovir-Based PrEP Products: Intravaginal Ring vs. Oral Administration. J Acquir Immune Defic Syndr 2022; 89:87-97. [PMID: 34878438 PMCID: PMC8647693 DOI: 10.1097/qai.0000000000002820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 09/20/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To describe and compare systemic and local pharmacokinetics (PK) and cervicovaginal (CV) pharmacodynamics (PD) of oral tenofovir disoproxil fumarate (TDF) in combination with emtricitabine (FTC) with tenofovir (TFV) intravaginal ring (IVR). DESIGN Phase I, randomized, parallel-group study. Women (n = 22) used TDF/FTC oral tablets daily or TFV IVR continuously and were assessed at baseline and 14 days. METHODS TFV and FTC concentrations were measured in plasma, CV fluid (CVF), and CV tissue. TFV-diphosphate and FTC-triphosphate were assessed in CV tissue. In vitro PD antiviral activities of TFV and FTC (using in vivo concentration ranges) were modeled in the CVF and by infecting CV tissue explants ex vivo with HIV-1BaL. RESULTS Adverse events (AEs) were more common with oral TDF/FTC use (P < 0.01). The median CVF TFV concentrations were 106 ng/mL after use of TFV IVR vs. 102 ng/mL for TDF/FTC. The median TFV and TFV-diphosphate concentrations in CV tissue were >100-fold higher among IVR users. The median CVF FTC concentrations were 103 ng/mL. FTC and FTC-triphosphate were detected in all CV tissues from TDF/FTC users. HIV inhibitory activity of CVF increased significantly with treatment in both cohorts (P < 0.01) but was higher in TFV IVR users (P < 0.01). In vitro inhibition of tissue infection with ex vivo administration of TFV and FTC was dose dependent, with maximal efficacy achieved with 10 µg/mL TFV, 1 µg/mL FTC, and 0.1 µg/mL of TFV and FTC combined. CONCLUSIONS Both products were safe and increased mucosal HIV inhibitory activity. In addition to systemic protection, oral TDF/FTC displays a PK/PD profile compatible with CV mucosal antiviral activity. TFV IVR resulted in fewer AEs, lower TFV plasma concentrations, higher CVF and tissue TFV and TFV-DP concentrations, and greater anti-HIV activity in CVF.
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Affiliation(s)
| | - Andrea R. Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Terry A. Jacot
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | | | - Craig Sykes
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kimberly Blake
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Xi Fang
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Susan Ju
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Nikolas C. Vann
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Jill Schwartz
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
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5
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Jewanraj J, Ngcapu S, Liebenberg LJP. Semen: A modulator of female genital tract inflammation and a vector for HIV-1 transmission. Am J Reprod Immunol 2021; 86:e13478. [PMID: 34077596 PMCID: PMC9286343 DOI: 10.1111/aji.13478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/07/2021] [Accepted: 05/27/2021] [Indexed: 12/12/2022] Open
Abstract
In order to establish productive infection in women, HIV must transverse the vaginal epithelium and gain access to local target cells. Genital inflammation contributes to the availability of HIV susceptible cells at the female genital mucosa and is associated with higher HIV transmission rates in women. Factors that contribute to genital inflammation may subsequently increase the risk of HIV infection in women. Semen is a highly immunomodulatory fluid containing several bioactive molecules with the potential to influence inflammation and immune activation at the female genital tract. In addition to its role as a vector for HIV transmission, semen induces profound mucosal changes to prime the female reproductive tract for conception. Still, most studies of mucosal immunity are conducted in the absence of semen or without considering its immune impact on the female genital tract. This review discusses the various mechanisms by which semen exposure may influence female genital inflammation and highlights the importance of routine screening for semen biomarkers in vaginal specimens to account for its impact on genital inflammation.
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Affiliation(s)
- Janine Jewanraj
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)DurbanSouth Africa
- Department of Medical MicrobiologyUniversity of KwaZulu‐NatalDurbanSouth Africa
| | - Sinaye Ngcapu
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)DurbanSouth Africa
- Department of Medical MicrobiologyUniversity of KwaZulu‐NatalDurbanSouth Africa
| | - Lenine J. P. Liebenberg
- Centre for the AIDS Programme of Research in South Africa (CAPRISA)DurbanSouth Africa
- Department of Medical MicrobiologyUniversity of KwaZulu‐NatalDurbanSouth Africa
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Mngomezulu K, Mzobe G, Mtshali A, Baxter C, Ngcapu S. The use of PSA as a biomarker of recent semen exposure in female reproductive health studies. J Reprod Immunol 2021; 148:103381. [PMID: 34563757 DOI: 10.1016/j.jri.2021.103381] [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: 02/27/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/16/2022]
Abstract
Semen contains potent soluble proteins, bacteria, viruses, activated immune cells as well as anti- and pro-inflammatory cytokines that may influence the inflammatory response and alter microbial composition of the female genital tract. The presence of semen in the female genital mucosa may be a significant confounder that most studies have failed to control for in their analysis. Prostate-specific antigen (PSA), a protein secreted by the prostate into the urethra during ejaculation, is a well-established biomarker of semen exposure. Several studies have demonstrated discordance between self-reports of sexual behavior and the presence of PSA. Recent semen exposure has been shown to promote pro-inflammatory responses, stimulate the recruitment of activated immune cells and decrease Lactobacilli abundance in the female genital mucosa. As a result, it is important to understand the concordance between self-reported consistent condom use and the presence of semen biomarkers. Furthermore, to ensure that the interpretation of data in clinical studies of the immunological and microbial environment in the female genital mucosa are accurate, it is essential to establish whether semen is present in the vaginal fluid. This review explores the impact of semen exposure on the mucosal microenvironment and assesses the use of the PSA as an objective biomarker of semen exposure to reduce reliance on self-reported sexual intercourse.
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Affiliation(s)
- Khanyisile Mngomezulu
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Gugulethu Mzobe
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Andile Mtshali
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Cheryl Baxter
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Department of Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Sinaye Ngcapu
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Department of Medical Microbiology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
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Chen BA, Zhang J, Gundacker HM, Hendrix CW, Hoesley CJ, Salata RA, Dezzutti CS, van der Straten A, Hall WB, Jacobson CE, Johnson S, McGowan I, Nel AM, Soto-Torres L, Marzinke MA. Phase 2a Safety, Pharmacokinetics, and Acceptability of Dapivirine Vaginal Rings in US Postmenopausal Women. Clin Infect Dis 2020; 68:1144-1151. [PMID: 30289485 DOI: 10.1093/cid/ciy654] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 08/02/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Postmenopausal women have unique sociobiological human immunodeficiency virus (HIV) risks. We evaluated the safety, pharmacokinetics, and acceptability of a microbicide dapivirine (DPV) vaginal ring (VR) versus placebo in postmenopausal women. METHODS We enrolled 96 HIV-negative postmenopausal US women in a phase 2a double-blind, randomized (3:1) trial of monthly VRs containing 25 mg DPV or placebo used continuously for 12 weeks. We assessed safety by adverse events (AEs). DPV concentrations were quantified in plasma and vaginal fluid. Steady-state concentrations were analyzed at 4, 8, and 12 weeks using repeated measures ANOVA. We assessed acceptability by self-report. RESULTS We found no differences in the proportion of women with related grade 2 or higher reproductive system AEs (DPV: 6/72 (8%), placebo: 3/24 (13%), P = .68) or grade 3 or higher AEs (DPV: 4/72 (6%), placebo: 0/24 (0%), P = .57). In the DPV arm, 2/72 (3%) declined to resume product use due to AEs. Median DPV concentrations in plasma (262.0 pg/mL at week 12) and vaginal fluid (40.6 ng/mg at week 12) were constant over 12 weeks and exceeded the in vitro 50% effective concentration by 5000-fold in vaginal fluid by week 4. VR acceptability was high; 84/93 (90%) "very much liked or liked" the VR. CONCLUSIONS DPV VRs were safe, well tolerated, and acceptable in postmenopausal women. Plasma concentrations were comparable to published data on DPV use in reproductive-age women (median plasma concentration: 264 pg/mL). Given the reassuring safety and pharmacokinetic data, the DPV VR is promising for preexposure prophylaxis in postmenopausal women. CLINICAL TRIALS REGISTRATION NCT02010593.
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Affiliation(s)
- Beatrice A Chen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh.,Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - Jingyang Zhang
- Statistical Center for HIV/AIDS Research and Prevention/Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Holly M Gundacker
- Statistical Center for HIV/AIDS Research and Prevention/Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Craig W Hendrix
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Robert A Salata
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Charlene S Dezzutti
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh.,Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | | | - Wayne B Hall
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | | | | | - Ian McGowan
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania.,Department of Medicine, University of Pittsburgh, Pennsylvania
| | - Annalene M Nel
- International Partnership for Microbicides, Silver Spring
| | - Lydia Soto-Torres
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Mark A Marzinke
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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8
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Effect of Hormonal Contraception on Pharmacokinetics of Vaginal Tenofovir in Healthy Women: Increased Tenofovir Diphosphate in Injectable Depot Medroxyprogesterone Acetate Users. J Acquir Immune Defic Syndr 2019; 80:79-88. [PMID: 30212395 DOI: 10.1097/qai.0000000000001864] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Endogenous and exogenous contraceptive hormones may affect mucosal pharmacokinetics (PKs) of topical antiretrovirals such as tenofovir. We present PK data from healthy women using tenofovir vaginal gel, at baseline (follicular and luteal phases) and after oral contraceptive pill (OCP) or depot medroxyprogesterone acetate (DMPA) use. METHODS CONRAD A10-114 was a prospective, interventional, open-label, parallel study. We enrolled 74 women and 60 completed the study (32 and 28 who selected OCPs or DMPA, respectively). Participants used 2 doses of tenofovir gel separated by 2 hours, without intercourse, and were examined 3 or 11 hours after the last dose. We assessed pharmacokinetics in plasma, cervicovaginal (CV) aspirate, and vaginal tissue. RESULTS In general, there were no significant differences in mucosal tenofovir and tenofovir diphosphate concentrations (P > 0.23) in the follicular and luteal phases, except for lower mean tenofovir tissue concentrations (P < 0.01) in the follicular phase. Tenofovir concentrations significantly decreased in CV aspirate (P < 0.01) after contraceptive use, but overall remained very high (>10 ng/mL). Mean tissue tenofovir diphosphate increased to 6229 fmol/mg after DMPA use compared with 3693 and 1460 fmol/mg in the follicular and luteal phases, respectively (P < 0.01). The molecular conversion of tenofovir into tenofovir diphosphate was more effective in DMPA users (molecular ratio of 2.02 versus 0.65 luteal phase, P < 0.01). CONCLUSIONS Both menstrual cycle phase and exogenous hormones affect topical tenofovir mucosal and systemic PKs. However, high levels of tenofovir and tenofovir diphosphate were observed in the CV mucosa in the presence or absence of OCPs and DMPA, with tissue levels exceeding benchmarks of predicted mucosal anti-HIV efficacy (tenofovir >1.00 ng/mL in CV aspirate and tenofovir diphosphate >1000 fmol/mg).
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9
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Herrera C. The Pre-clinical Toolbox of Pharmacokinetics and Pharmacodynamics: in vitro and ex vivo Models. Front Pharmacol 2019; 10:578. [PMID: 31178736 PMCID: PMC6543330 DOI: 10.3389/fphar.2019.00578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 05/06/2019] [Indexed: 01/05/2023] Open
Abstract
Prevention strategies against sexual transmission of human immunodeficiency virus (HIV) are essential to curb the rate of new infections. In the absence of a correlate of protection against HIV infection, pre-clinical evaluation is fundamental to facilitate and accelerate prioritization of prevention candidates and their formulations in a rapidly evolving clinical landscape. Characterization of pharmacokinetic (PK) and pharmacodynamic (PD) properties for candidate inhibitors is the main objective of pre-clinical evaluation. in vitro and ex vivo systems for pharmacological assessment allow experimental flexibility and adaptability at a relatively low cost without raising as significant ethical concerns as in vivo models. Applications and limitations of pre-clinical PK/PD models and future alternatives are reviewed in the context of HIV prevention.
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Affiliation(s)
- Carolina Herrera
- Section of Virology, Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Imperial College London, London, United Kingdom
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10
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Thurman AR, Schwartz JL, Ravel J, Gajer P, Marzinke MA, Yousefieh N, Anderson SM, Doncel GF. Vaginal microbiota and mucosal pharmacokinetics of tenofovir in healthy women using tenofovir and tenofovir/levonorgestrel vaginal rings. PLoS One 2019; 14:e0217229. [PMID: 31107913 PMCID: PMC6527208 DOI: 10.1371/journal.pone.0217229] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 05/05/2019] [Indexed: 12/25/2022] Open
Abstract
Recent data support that the vaginal microbiota may alter mucosal pharmacokinetics (PK) of topically delivered microbicides. Our team developed an intravaginal ring (IVR) that delivers tenofovir (TFV) (8–10 mg/day) alone or with levonorgestrel (LNG) (20 ug/day). We evaluated the effect of IVRs on the vaginal microbiota, and describe how the vaginal microbiota impacts mucosal PK of TFV. CONRAD A13-128 was a randomized, placebo controlled phase I study. We randomized 51 women to TFV, TFV/LNG or placebo IVR. We assessed the vaginal microbiota by sequencing the V3-V4 regions of 16S rRNA genes prior to IVR insertion and after approximately 15 days of use. We measured the concentration of TFV in the cervicovaginal (CV) aspirate, and TFV and TFV-diphosphate (TFV-DP) in vaginal tissue at the end of IVR use. The change in relative or absolute abundance of vaginal bacterial phylotypes was similar among active and placebo IVR users (all q values >0.13). TFV concentrations in CV aspirate and vaginal tissue, and TFV-DP concentrations in vaginal tissue were not significantly different among users with community state type (CST) 4 versus those with Lactobacillus dominated microbiota (all p values >0.07). The proportions of participants with CV aspirate concentrations of TFV >200,000 ng/mL and those with tissue TFV-DP concentrations >1,000 fmol/mg were similar among women with anaerobe versus Lactobacillus dominated microbiota (p = 0.43, 0.95 respectively). There were no significant correlations between the CV aspirate concentration of TFV and the relative abundances of Gardnerella vaginalis or Prevotella species. Tissue concentrations of TFV-DP did not correlate with any the relative abundances of any species, including Gardnerella vaginalis. In conclusion, active IVRs did not differ from the placebo IVR on the effect on the vaginal microbiota. Local TFV and TFV-DP concentrations were high and similar among IVR users with Lactobacillus dominated microbiota versus CST IV vaginal microbiota. Trial registration: ClinicalTrials.gov NCT02235662.
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Affiliation(s)
- Andrea Ries Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States of America
- * E-mail:
| | - Jill L. Schwartz
- CONRAD, Eastern Virginia Medical School, Arlington, VA, United States of America
| | - Jacques Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Pawel Gajer
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Mark A. Marzinke
- Johns Hopkins University School of Medicine, Clinical Pharmacology Analytical Laboratory, Baltimore, MD, United States of America
| | - Nazita Yousefieh
- CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States of America
| | - Sharon M. Anderson
- CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States of America
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Arlington, VA, United States of America
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11
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Epithelial Cells and Fibroblasts from the Human Female Reproductive Tract Accumulate and Release TFV and TAF to Sustain Inhibition of HIV Infection of CD4+ T cells. Sci Rep 2019; 9:1864. [PMID: 30755713 PMCID: PMC6372694 DOI: 10.1038/s41598-018-38205-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 12/20/2018] [Indexed: 12/30/2022] Open
Abstract
Tenofovir (TFV) treatment of female reproductive tract (FRT) cells results in differential accumulation of intracellular Tenofovir diphosphate (TFV-DP) in different cell types, with greater concentrations in epithelial cells (100-fold) and fibroblasts (10-fold) than in CD4+ T cells. The possibility that TFV-DP accumulation and retention in epithelial cells and fibroblasts may alter TFV availability and protection of CD4+ T cells against HIV infection, prompted us to evaluate TFV and/or Tenofovir alafenamide (TAF) release from FRT cells. Endometrial, endocervical and ectocervical polarized epithelial cells and fibroblasts were pre-loaded with TFV or TAF, and secretions tested for their ability to inhibit HIV infection of activated blood CD4+ T cells. Epithelial cell basolateral secretions (1, 2 and 3 days post-loading), but not apical secretions, suppressed HIV infection of CD4+ T cells, as did secretions from pre-loaded fibroblasts from each site. Intracellular TFV-DP levels in epithelial cells following preloading with TFV or TAF correlated directly with ARV protection of CD4+ T cells from HIV infection. When added apically to epithelial cells, TFV/TAF was released basolaterally, in part through Multidrug Resistant Protein transporters, taken up by fibroblasts and released into secretions to partially protect CD4+ T cells. These findings demonstrate that epithelial cells and fibroblasts release TFV/TAF for use by CD4+ T cells and suggest that the tissue environment plays a major role in the sustained protection against HIV infection.
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12
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Delany-Moretlwe S, Lombard C, Baron D, Bekker LG, Nkala B, Ahmed K, Sebe M, Brumskine W, Nchabeleng M, Palanee-Philips T, Ntshangase J, Sibiya S, Smith E, Panchia R, Myer L, Schwartz JL, Marzinke M, Morris L, Brown ER, Doncel GF, Gray G, Rees H. Tenofovir 1% vaginal gel for prevention of HIV-1 infection in women in South Africa (FACTS-001): a phase 3, randomised, double-blind, placebo-controlled trial. THE LANCET. INFECTIOUS DISEASES 2018; 18:1241-1250. [PMID: 30507409 DOI: 10.1016/s1473-3099(18)30428-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 06/22/2018] [Accepted: 07/03/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Young women in southern Africa have substantial risk of HIV acquisition. Female-controlled biomedical interventions are needed to mitigate this risk. We aimed to assess the safety and efficacy of a pericoitally applied tenofovir 1% gel. METHODS We did a phase 3, double-blind, randomised, placebo-controlled trial at nine community-based clinical trial sites in South Africa to evaluate the safety and efficacy of tenofovir 1% gel. Sexually active women who were HIV negative and aged 18-30 years were enrolled. Participants were randomly assigned (1:1) using sequential participant numbers to either tenofovir 1% gel or a placebo gel (one dose within 12 h before sex and one dose within 12 h after sex [BAT-24 regimen]), using dynamic permuted block sizes of 8 and 16 within each site. Women received monthly HIV-1 testing, risk reduction support, physical examinations, and product dispensing for up to 27 months. The primary efficacy outcome was incident HIV infection and the primary safety outcome was occurrence of grade 2-4 adverse events, both analysed in the modified intention-to-treat population. To assess the efficacy of tenofovir gel, the cumulative probability of HIV infection was calculated for each treatment using the Kaplan-Meier method. This trial is registered with ClinicalTrials.gov, number NCT01386294. FINDINGS From Oct 11, 2011, to Aug 29, 2014, 3844 women were screened, 2059 enrolled, and 2029 included in the primary analysis (1032 in the tenofovir group and 1027 in the placebo group); 39 (4%) in the tenofovir group and 36 (4%) in the placebo group were lost to follow-up. 123 HIV-1 infections occurred over 3036 woman-years of observation; 61 in the tenofovir group (HIV incidence 4·0 per 100 woman-years, 95% CI 3·1-5·2) and 62 in the placebo group (4·0 per 100 woman-years, 3·1-5·2; incidence rate ratio [IRR] 0·98, 95% CI 0·7-1·4). A higher incidence of grade 2 adverse events was observed in the tenofovir group than in the placebo group (IRR 1·09, 95% CI 1·0-1·2; p=0·02). The most common grade 2 or higher product-related adverse events were hypophosphataemia (n=22 for tenofovir vs n=22 for placebo), genital symptoms (n=6 for tenofovir vs n=2 for placebo), or elevated transaminases (n=2 for tenofovir vs n=2 for placebo). No product-related serious adverse events were reported, and no differences in product-related adverse events (p=0·78), grade 3 events (p=0·64), or grade 4 events (p=0·74) were observed between treatment groups. INTERPRETATION Overall, pericoital tenofovir gel did not prevent HIV-1 acquisition in this population of young women at risk of HIV infection in South Africa. Alternate safe and effective products that are less user dependent than this product or do not require high adherence are needed. FUNDING The US Agency for International Development (USAID), the Bill & Melinda Gates Foundation, and the South African Department of Science and Technology and Department of Health.
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Affiliation(s)
| | - Carl Lombard
- Biostatistics Unit, Cape Town, South Africa; Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Deborah Baron
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Busi Nkala
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | - Maposhane Nchabeleng
- Mecru Clinical Research Unit, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | | | | | - Sidney Sibiya
- Qhakaza Mbokodo Research Centre, Ladysmith, South Africa
| | - Emilee Smith
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Ravindre Panchia
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Mark Marzinke
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lynn Morris
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Elizabeth R Brown
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Glenda Gray
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa; South African Medical Research Council, Cape Town, South Africa
| | - Helen Rees
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
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13
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Hendrix CW. HIV Antiretroviral Pre-Exposure Prophylaxis: Development Challenges and Pipeline Promise. Clin Pharmacol Ther 2018; 104:1082-1097. [PMID: 30199098 DOI: 10.1002/cpt.1227] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/20/2018] [Indexed: 12/17/2022]
Abstract
The US Food and Drug Administration (FDA) approved oral daily tenofovir/emtricitabine (Truvada) for pre-exposure prophylaxis of human immunodeficiency virus (HIV) infection in 2012 on the basis of two randomized controlled trials (RCTs), one in men who have sex with men (MSM) and another in HIV serodiscordant heterosexual couples. Subsequently, even greater efficacy has been demonstrated in MSM with rapid population-level incidence reductions in some locations. In contrast, studies of antiretroviral pre-exposure prophylaxis (PrEP) in heterosexual women showed only modest or no efficacy, largely attributed to low adherence. The mixed results of antiretroviral-based PrEP bear witness to unique drug development challenges at this complicated intersection of sexual behavior, public health, and drug development. Multiple innovative methods and formulation strategies followed to address unmet medical needs of persons struggling with daily oral PrEP adherence or preference for nonsystemic PrEP options. Clinical pharmacology plays essential roles throughout this PrEP development process, especially in early product development and through pharmacologically informed enhancement and interpretation of clinical trials.
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Affiliation(s)
- Craig W Hendrix
- 1Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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14
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Taneva E, Sinclair S, Mesquita PM, Weinrick B, Cameron SA, Cheshenko N, Reagle K, Frank B, Srinivasan S, Fredricks D, Keller MJ, Herold BC. Vaginal microbiome modulates topical antiretroviral drug pharmacokinetics. JCI Insight 2018; 3:99545. [PMID: 29997295 PMCID: PMC6124523 DOI: 10.1172/jci.insight.99545] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 05/31/2018] [Indexed: 01/04/2023] Open
Abstract
Tenofovir gel and dapivirine ring provided variable HIV protection in clinical trials, reflecting poor adherence and possibly biological factors. We hypothesized that vaginal microbiota modulates pharmacokinetics and tested the effects of pH, individual bacteria, and vaginal swabs from women on pharmacokinetics and antiviral activity. Tenofovir, but not dapivirine, uptake by human cells was reduced as pH increased. Lactobacillus crispatus actively transported tenofovir leading to a loss in drug bioavailability and culture supernatants from Gardnerella vaginalis, but not Atopobium vaginae, blocked tenofovir endocytosis. The inhibition of endocytosis mapped to adenine. Adenine increased from 65.5 μM in broth to 246 μM in Gardnerella, but decreased to 9.5 μM in Atopobium supernatants. This translated into a decrease in anti-HIV activity when Gardnerella supernatants or adenine were added to cultures. Dapivirine was also impacted by microbiota, as drug bound irreversibly to bacteria, resulting in decreased antiviral activity. When drugs were incubated with vaginal swabs, 30.7% ± 5.7% of dapivirine and 63.9% ± 8.8% of tenofovir were recovered in supernatants after centrifugation of the bacterial cell pellet. In contrast, no impact of microbiota on the pharmacokinetics of the prodrugs, tenofovir disoproxil fumarate or tenofovir alafenamide, was observed. Together, these results demonstrate that microbiota may impact pharmacokinetics and contribute to inconsistent efficacy.
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Affiliation(s)
| | | | | | | | - Scott A. Cameron
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Kerry Reagle
- Particle Sciences, Inc., Bethlehem, Pennsylvania, USA
| | - Bruce Frank
- Particle Sciences, Inc., Bethlehem, Pennsylvania, USA
| | - Sujatha Srinivasan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
| | - David Fredricks
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
| | - Marla J. Keller
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Betsy C. Herold
- Department of Microbiology & Immunology
- Department of Pediatrics, and
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15
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Thurman AR, Schwartz JL, Brache V, Clark MR, McCormick T, Chandra N, Marzinke MA, Stanczyk FZ, Dezzutti CS, Hillier SL, Herold BC, Fichorova R, Asin SN, Rollenhagen C, Weiner D, Kiser P, Doncel GF. Randomized, placebo controlled phase I trial of safety, pharmacokinetics, pharmacodynamics and acceptability of tenofovir and tenofovir plus levonorgestrel vaginal rings in women. PLoS One 2018; 13:e0199778. [PMID: 29953547 PMCID: PMC6023238 DOI: 10.1371/journal.pone.0199778] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 06/07/2018] [Indexed: 01/28/2023] Open
Abstract
To prevent the global health burdens of human immunodeficiency virus [HIV] and unintended/mistimed pregnancies, we developed an intravaginal ring [IVR] that delivers tenofovir [TFV] at ~10mg/day alone or with levonorgestrel [LNG] at ~20μg/day for 90 days. We present safety, pharmacokinetics, pharmacodynamics, acceptability and drug release data in healthy women. CONRAD A13-128 was a randomized, placebo controlled phase I study. We screened 86 women; 51 were randomized to TFV, TFV/LNG or placebo IVR [2:2:1] and 50 completed all visits, using the IVR for approximately 15 days. We assessed safety by adverse events, colposcopy, vaginal microbiota, epithelial integrity, mucosal histology and immune cell numbers and phenotype, cervicovaginal [CV] cytokines and antimicrobial proteins and changes in systemic laboratory measurements, and LNG and TFV pharmacokinetics in multiple compartments. TFV pharmacodynamic activity was measured by evaluating CV fluid [CVF] and tissue for antiviral activity using in vitro models. LNG pharmacodynamic assessments were timed based on peak urinary luteinizing hormone levels. All IVRs were safe with no significant colposcopic, mucosal, immune and microbiota changes and were acceptable. Among TFV containing IVR users, median and mean CV aspirate TFV concentrations remained above 100,000 ng/mL 4 hours post IVR insertion and mean TFV-diphosphate [DP] concentrations in vaginal tissue remained above 1,000 fmol/mg even 3 days post IVR removal. CVF of women using TFV-containing IVRs completely inhibited [94-100%] HIV infection in vitro. TFV/LNG IVR users had mean serum LNG concentrations exceeding 300 pg/mL within 1 hour, remaining high throughout IVR use. All LNG IVR users had a cervical mucus Insler score <10 and the majority [95%] were anovulatory or had abnormal cervical mucus sperm penetration. Estimated in vivo TFV and LNG release rates were within expected ranges. All IVRs were safe with the active ones delivering sustained high concentrations of TFV locally. LNG caused changes in cervical mucus, sperm penetration, and ovulation compatible with contraceptive efficacy. The TFV and TFV/LNG rings are ready for expanded 90 day clinical testing. Trial registration ClinicalTrials.gov #NCT02235662.
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Affiliation(s)
- Andrea Ries Thurman
- CONRAD, Eastern Virginia Medical School, Arlington, Virginia, United States of America
| | - Jill L. Schwartz
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | | | - Meredith R. Clark
- CONRAD, Eastern Virginia Medical School, Arlington, Virginia, United States of America
| | - Timothy McCormick
- CONRAD, Eastern Virginia Medical School, Arlington, Virginia, United States of America
| | - Neelima Chandra
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | - Mark A. Marzinke
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Frank Z. Stanczyk
- University of Southern California Keck School of Medicine, Los Angeles, California, United States of America
| | - Charlene S. Dezzutti
- University of Pittsburgh, Department of Obstetrics, Gynecology & Reproductive Sciences, Department of Infectious Diseases & Microbiology, Graduate School of Public Health, Pittsburgh, Pennsylvania, United States of America
| | - Sharon L. Hillier
- University of Pittsburgh School of Medicine, Departments of Obstetrics, Gynecology and Reproductive Sciences and Microbiology and Molecular Genetics, Pittsburgh, Pennsylvania, United States of America
| | - Betsy C. Herold
- Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Raina Fichorova
- Laboratory of Genital Tract Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Susana N. Asin
- V.A. Medical Center, White River Junction, VT and Geisel School of Medicine at Dartmouth, New Hampshire
| | - Christiane Rollenhagen
- V.A. Medical Center, White River Junction, VT and Geisel School of Medicine at Dartmouth, New Hampshire
| | - Debra Weiner
- FHI360, Durham, North Carolina, United States of America
| | - Patrick Kiser
- Northwestern University, Evanston, Illinois, United States of America
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Arlington, Virginia, United States of America
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16
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Dezzutti CS, Park SY, Marks KM, Lawlor SE, Russo JR, Macio I, Chappell CA, Bunge KE. Heterogeneity of HIV-1 Replication in Ectocervical and Vaginal Tissue Ex Vivo. AIDS Res Hum Retroviruses 2018; 34:185-192. [PMID: 28982249 DOI: 10.1089/aid.2017.0107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
In clinical trials evaluating HIV-1 prevention products, ex vivo exposure of mucosal tissue to HIV-1 is performed to inform drug levels needed to suppress viral infection. Understanding assay and participant variables that influence HIV-1 replication will help with assay implementation. Demographic and behavioral data were obtained from 61 healthy women aged 21-45. Paired cervical tissue (CT) and vaginal tissue (VT) biopsies were collected and treated with HIV-1BaL or HIV-1JR-CSF, washed, and cultured. On days 3, 7, and/or 11, culture supernatant was collected, and viral replication was monitored by p24 ELISA. Tissue was extracted at study end, and HIV-1 relative RNA copies were determined by polymerase chain reaction. Cumulative p24 and RNA were log-transformed and analyzed using a linear mixed model, t-test, and an intraclass correlation coefficient (ICC). HIV replication was similar between CT and VT for each virus, but HIV-1BaL had 1.5 log10 and 0.9 log10 higher levels of p24 than HIV-1JR-CSF in CT and VT, respectively (p < .001), which correlated with HIV-1 relative RNA copies. Cumulative p24 and RNA copies in both tissues demonstrated low intraperson correlation for both viruses (ICC ≤0.513 HIV-1BaL; ICC ≤0.419 HIV-1JR-CSF). Enrollment into previous clinical studies in which genital biopsies were collected modestly decreased the HIV-1BaL cumulative p24 for CT, but not for VT. To improve the ex vivo challenge assay, viruses should be evaluated for replication in mucosal tissue before study implementation, baseline mucosal tissue is not needed if a placebo/no treatment group is included within the clinical trial, and previous biopsy sites should be avoided.
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Affiliation(s)
- Charlene S. Dezzutti
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - Seo Young Park
- Department of Medicine Bio Statisics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Julie R. Russo
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - Ingrid Macio
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Catherine A. Chappell
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - Katherine E. Bunge
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
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17
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van de Wijgert J, McCormack S. Vaginal dysbiosis and pre-exposure prophylaxis efficacy. Lancet HIV 2017; 4:e427-e429. [PMID: 28732774 DOI: 10.1016/s2352-3018(17)30130-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 06/22/2017] [Indexed: 01/15/2023]
Affiliation(s)
- Janneke van de Wijgert
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Huispost nr STR 6.131, PO Box 85 500, 3508 GA, Utrecht, Netherlands; Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.
| | - Sheena McCormack
- Medical Research Council Clinical Trials Unit, University College London, London, UK
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18
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Notario-Pérez F, Ruiz-Caro R, Veiga-Ochoa MD. Historical development of vaginal microbicides to prevent sexual transmission of HIV in women: from past failures to future hopes. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:1767-1787. [PMID: 28670111 PMCID: PMC5479294 DOI: 10.2147/dddt.s133170] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Infection with human immunodeficiency virus (HIV) remains a global public health concern and is particularly serious in low- and middle-income countries. Widespread sexual violence and poverty, among other factors, increase the risk of infection in women, while currently available prevention methods are outside the control of most. This has driven the study of vaginal microbicides to prevent sexual transmission of HIV from men to women in recent decades. The first microbicides evaluated were formulated as gels for daily use and contained different substances such as surfactants, acidifiers and monoclonal antibodies, which failed to demonstrate efficacy in clinical trials. A gel containing the reverse transcriptase inhibitor tenofovir showed protective efficacy in women. However, the lack of adherence by patients led to the search for dosage forms capable of releasing the active principle for longer periods, and hence to the emergence of the vaginal ring loaded with dapivirine, which requires a monthly application and is able to reduce the sexual transmission of HIV. The future of vaginal microbicides will feature the use of alternative dosage forms, nanosystems for drug release and probiotics, which have emerged as potential microbicides but are still in the early stages of development. Protecting women with vaginal microbicide formulations would, therefore, be a valuable tool for avoiding sexual transmission of HIV.
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Affiliation(s)
- Fernando Notario-Pérez
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, Universidad Complutense de Madrid, Madrid, Spain
| | - Roberto Ruiz-Caro
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, Universidad Complutense de Madrid, Madrid, Spain
| | - María-Dolores Veiga-Ochoa
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, Universidad Complutense de Madrid, Madrid, Spain
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19
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Rambharose S, Kalhapure RS, Govender T. Nanoemulgel using a bicephalous heterolipid as a novel approach to enhance transdermal permeation of tenofovir. Colloids Surf B Biointerfaces 2017; 154:221-227. [PMID: 28343120 DOI: 10.1016/j.colsurfb.2017.03.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 02/21/2017] [Accepted: 03/17/2017] [Indexed: 11/30/2022]
Abstract
Improvements in permeation enhancement strategies, such as nanoemulsions (NEs) and nanoemulgels (NEGs), have led to a renewed interest in transdermal drug delivery (TDD). This study aimed to investigate the potential of LLA1E, a novel dendritic permeation enhancer, as an oily phase in the development of a NEG for the TDD of tenofovir (TNF). TNF loaded NEs (TNEs) were prepared and analysed for mean globule diameter (MGD), polydispersity index (PDI), zeta potential (ZP) and morphology. NEGs of the TNEs (TNEGs) were prepared and evaluated for ex vivo transdermal permeation efficacy. The skin integrity before and after the experiments was assessed using histology and transepithelial electrical resistance (TEER). TNEs had a MGD of 129.06±3.35nm, a PDI of 0.192±0.038 and a ZP of 20.9±2.02mV, with an incorporation efficiency of 91.94±0.84%. There was no significant change is these properties after incorporating the TNEs into the hydrogel, as MGD, PDI and ZP of TNEGs were found to be 136.13±5.21nm, 0.182±0.020 and -20.9±2.08mV respectively. Ex vivo permeation studies showed that the TNEG significantly enhanced the TNF permeation by 39.65-fold, with a cumulative amount of 1866.54±108.62μgcm-2. Histological and TEER assessments showed no permanent effects on the skin by TNEG, indicating that this novel TNEG nanosystem has the potential to translate into clinical trials as treatment alternatives for HIV/AIDs patients.
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Affiliation(s)
- Sanjeev Rambharose
- Department of Pharmaceutical Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban 4000, South Africa
| | - Rahul S Kalhapure
- Department of Pharmaceutical Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban 4000, South Africa.
| | - Thirumala Govender
- Department of Pharmaceutical Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban 4000, South Africa.
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Nanoparticles-in-film for the combined vaginal delivery of anti-HIV microbicide drugs. J Control Release 2016; 243:43-53. [PMID: 27664327 DOI: 10.1016/j.jconrel.2016.09.020] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 09/15/2016] [Accepted: 09/20/2016] [Indexed: 11/22/2022]
Abstract
Combining two or more antiretroviral drugs in one medical product is an interesting but challenging strategy for developing topical anti-HIV microbicides. We developed a new vaginal delivery system comprising the incorporation of nanoparticles (NPs) into a polymeric film base - NPs-in-film - and tested its ability to deliver tenofovir (TFV) and efavirenz (EFV). EFV-loaded poly(lactic-co-glycolic acid) NPs were incorporated alongside free TFV into fast dissolving films during film manufacturing. The delivery system was characterized for physicochemical properties, as well as genital distribution, local and systemic 24h pharmacokinetics (PK), and safety upon intravaginal administration to mice. NPs-in-film presented suitable technological, mechanical and cytotoxicity features for vaginal use. Retention of NPs in vivo was enhanced both in vaginal lavages and tissue when associated to film. PK data evidenced that vaginal drug levels rapidly decreased after administration but NPs-in-film were still able to enhance drug concentrations of EFV. Obtained values for area-under-the-curve for EFV were around one log10 higher than those for the free drugs in aqueous vehicle (phosphate buffered saline). Film alone also contributed to higher and more prolonged local drug levels as compared to the administration of TFV and EFV in aqueous vehicle. Systemic exposure to both drugs was low. NPs-in-film was found to be safe upon once daily vaginal administration to mice, with no significant genital histological changes or major alterations in cytokine/chemokine profiles being observed. Overall, the proposed NPs-in-film system seems to be an interesting delivery platform for developing combination vaginal anti-HIV microbicides.
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