Exploratory study comparing the metabolic toxicities of a lopinavir/ritonavir plus saquinavir dual protease inhibitor regimen versus a lopinavir/ritonavir plus zidovudine/lamivudine nucleoside regimen

Effectiveness and Safety Analysis of PIs/r Based Dual Therapy in Treatment-Naïve, HIV/AIDS Patients: A Network Meta Analysis of Randomized Controlled Trials

Background: Dual anti-retroviral therapy is the main proven valuable intervention type for treating naïve HIV/AIDS. Currently, no high-quality evidence is available regarding the best dual schemes.

Objectives: The aim of this study is to evaluate the effectiveness and safety of PIs/r-based dual therapy in treatment-naïve HIV/AIDS patients by using network meta-analysis.

Methods: Randomized controlled trials of PIs/r-based dual therapy in treatment-naïve HIV/AIDS were searched based on Embase, PubMed and Cochrane library database from January 2006 to June 2021. Taking viral suppression rate, CD4+T cell count changes from baseline as the primary indicator and adverse events rate as secondary indicator, the network meta-analysis was performed on Review Manager and STATA software. Heterogeneity was assessed by the Q statistic and I2. We registered our protocol in Prospero with ID CRD42021275466.

Results: Among 15 randomized controlled trials (3,497 patients and 7 PIs/r-based dual therapy) were reviewed in this study. According to the forest map, DRV/r + INSTIs was more effective compared to triple therapy (TT) in viral suppression [OR 0.82, 95% CI (0.61–1.11)], in CD4+T cell count changes from baseline [MD 1.9, 95% CI (0.7, 3.1), I2 86%], in adverse events [OR 0.98, 95% CI (0.68–1.39)]. Furthermore, SUCRA ranking analysis indicated that DRV/r + INSTIs was superior to TT in viral suppression (DRV/r + INSTIs 75.5% > TT 41.2%) and in immune construction (DRV/r + INSTIs 67% > TT 42%). In addition, DRV/r + INSTIs was similar to TT in adverse events (DRV/r + INSTIs 54.9% ≈ TT 54.7%).

Conclusion: DRV/r + INSTIs was obviously superior to TT in viral suppression and immune reconstruction, and was not higher than TT in adverse events.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier CRD42021275466

Anthropometric definitions for antiretroviral-associated lipodystrophy derived from a longitudinal South African cohort with serial dual-energy X-ray absorptiometry measurements

The development of lipodystrophy is associated with the long-term use of antiretroviral therapy (ART). We assessed agreement between patient-reported lipodystrophy and body composition measures using dual-energy X-ray absorptiometry (DXA) and developed objective measures to define lipoatrophy and lipohypertrophy in black South Africans. One hundred and eighty-seven ART-naïve HIV-infected adults were enrolled in a 24-month longitudinal study. Self-reported information on regional fat loss and fat gain, anthropometry, and DXA measures were collected at baseline, three, six, 12, 18, and 24 months after starting ART. Receiver operating characteristic curves were used to describe the performance of anthropometric variables using change in limb and trunk fat measured by DXA, as the reference standard. The proportion of men and women who developed lipoatrophy and lipohypertrophy increased over the 24-month period, with lipoatrophy occurring more frequently in men (21% versus 10%). In women, lipoatrophy was best determined by thigh skinfold thickness (80.3% correctly classified) and mid-arm circumference (77.6% correctly classified). None of the anthropometric measures performed well for defining lipoatrophy in men. Anthropometric measures performed well for defining lipoatrophy in women, but not lipohypertrophy.

Zidovudine/lamivudine but not nevirapine in combination with lopinavir/ritonavir decreases subcutaneous adipose tissue mitochondrial DNA

OBJECTIVE

No randomized study has prospectively followed subcutaneous adipose tissue mitochondrial DNA (mtDNA) changes when starting thymidine nucleoside reverse transcriptase inhibitors (tNRTIs).

DESIGN

The Metabolic Effects of DIfferent CLasses of AntiretroviralS study randomized HIV-positive, treatment-naive male participants to start lopinavir/ritonavir (LPVr) with either zidovudine/lamivudine (ZDV/3TC) or nevirapine (NVP).

METHODS

Regional body fat was assessed by dual energy x-ray absorptiometry and abdominal computed tomography at months 0, 3, 12, 24 and 36. In a molecular substudy, subcutaneous adipose tissue (SAT) biopsies were taken, with mtDNA quantified by quantitative PCR. Data were analyzed using repeated measures linear regression analyses.

RESULTS

Of 50 participants recruited (23 to LPVr/ZDV/3TC), 48 started therapy, and 37 participants (19 on LPVr/ZDV/3TC) enrolled in the substudy. At 36 months, the LPVr/ZDV/3TC group had significantly lower limb fat [6.4 kg (0.26) versus 7.3 kg (0.31), P = 0.017] and a trend toward lower abdominal SAT compared to the LPVr/NVP group [131 cm (6.86) versus 146 cm (6.33), P = 0.097]. Over 36 months, mtDNA declined in the LPVr/ZDV/3TC group [mtDNA region 1: -190 (95) copies/cell, P = 0.053, region 2: -269 (106) copies/cell, P = 0.016] but not within the LPVr/NVP group [region 1: +28 (99) copies/cell, P = 0.78, region 2: +51 (111) copies/cell, P = 0.65, between-group difference P < 0.01 for both measurements]. mtDNA was significantly lower in the LPVr/ZDV/3TC group at 36 months.

CONCLUSION

This is the first randomized study to prospectively demonstrate reductions in SAT mtDNA in patients initiating ZDV/3TC-containing antiretroviral therapy (ART) but not in those initiating nucleoside reverse transcriptase inhibitor-sparing ART containing NVP and protease inhibitor. That reductions in SAT mtDNA were also accompanied by lower limb fat suggests that use of ART not containing ZDV/3TC may help prevent development of peripheral lipoatrophy.

Longitudinal study of body composition of 101 HIV men with lipodystrophy: dual-energy X-ray criteria for lipodystrophy evolution

The aim of this study was to define evolution profiles of body composition among human immunodeficiency virus (HIV)-infected men with lipodystrophy. The design is a retrospective analysis using observational data collected longitudinally. We included 101 HIV-infected men with lipodystrophy managed in routine practice and who had 2 dual energy X-ray absorptiometry scans within a minimum interval of 18 mo. Lipodystrophy was defined as a fat mass ratio (FMR, defined as the ratio of the percentage of the trunk fat mass over the percentage of the lower limbs fat mass) equal or superior to 1.5. Patients were classified in "improved" group (IG: increase of lower limbs fat mass >/= 10%) or "nonimproved" group (NIG). Body composition, immunovirological and epidemiological data were collected and compared between the 2 groups. In the whole population, over a 4-yr period, a significant increase was observed for total fat mass, trunk fat mass, and lower limbs fat mass, whereas total lean mass was stable. Total body mineral density decreased. Fifty-nine patients (IG), less exposed to zidovudine than the NIG, had an increase of lower limbs fat mass higher than 10%. But only 13 (22%) regained a normal distribution of fat mass (FMR < 1.5), showing that lipodystrophy was slowly reversible. Among the NIG, 5 patients (11.9%), less exposed to zidovudine and with a higher mean of viral load, reached an FMR below 1.5. It was mainly because of a loss of trunk fat mass, which could be the sign of a lipodystrophy worsening. Lipodystrophy improved for 58.4% of men. The improvement was very slow. Recovery was observed only in patients with an earlier intervention. No correlation was observed between lipodystrophy and total body bone mineral density. The loss of trunk fat mass without gain of lower limbs fat mass may indicate a worsening of HIV disease.

Protease inhibitor therapy in resource-limited settings

PURPOSE OF REVIEW

The use of protease inhibitors in resource-limited settings will increase in coming years as HIV treatment cohorts mature. We review data available to guide the expanded use of protease inhibitors in these settings.

RECENT FINDINGS

The safety and effectiveness of protease inhibitors may be affected by the context of their use, yet limited data exist regarding the use of these agents in resource-limited settings in either first or subsequent regimens. Critically, data are needed regarding optimal regimens at time of first-line nonnucleoside reverse transcriptase inhibitor-based regimen failure. A number of alternative strategies are being investigated, including dual-boosting, monotherapy and dose reduction. Despite recent progress cost, storage requirements, drug interactions and formulation continue to hinder the use of protease inhibitors, particularly for children.

SUMMARY

Protease inhibitors are the core component of second-line therapy in resource-limited settings and are used in specific situations in first-line therapy. Use of second-line regimens has been more diverse than first line, but WHO has recently prioritized regimens containing lopinavir/ritonavir or ritonavir-boosted atazanavir. As use of protease inhibitors in resource-limited settings increases evidence needs to be accrued to guide further expanded use.

Zidovudine/lamivudine for HIV-1 infection contributes to limb fat loss

Background

Lipoatrophy is known to be associated with stavudine as part of the treatment for HIV infection, but it is less clear if this serious side effect is also related to other nucleoside reverse transcriptase inhibitors like zidovudine. We aimed to determine whether zidovudine-sparing first-line antiretroviral therapy would lead to less lipoatrophy and other metabolic changes than zidovudine-containing therapy.

Methodology/Principal Findings

Fifty antiretroviral therapy-naïve HIV-1 infected men with an indication to start antiretroviral therapy were included in a randomized single blinded clinical trial. Randomisation was between zidovudine-containing therapy (zidovudine/lamivudine+lopinavir/ritonavir) and zidovudine-sparing therapy (nevirapine+lopinavir/ritonavir). Main outcome measures were body composition assessed by computed tomography and dual-energy X-ray absorptiometry scan and lipid profile before and after 3, 12, 24 months of antiretroviral therapy. In the zidovudine/lamivudine+lopinavir/ritonavir group, from 3 months onward limb fat decreased progressively by 684±293 grams (estimated mean±standard error of the mean)(p = 0.02) up to 24 months whereas abdominal fat increased, but exclusively in the visceral compartment (+21.9±8.1 cm², p = 0.008)). In contrast, in the nevirapine+lopinavir/ritonavir group, a generalized increase in fat mass was observed. After 24 months no significant differences in high density lipoprotein and total/high density lipoprotein cholesterol ratio were found between both treatment groups, but total and low density lipoprotein cholesterol levels were higher in the nevirapine+lopinavir/ritonavir group (6.1±0.2 versus 5.3±0.2 and 3.6±0.1 versus 2.8±0.1 mmol/l respectively, p<0.05). Virologic response and safety were comparable in both groups.

Conclusions/Significance

Zidovudine/lamivudine+lopinavir/ritonavir, but not nevirapine+lopinavir/ritonavir in antiretroviral therapy-naïve patients, is associated with lipoatrophy and greater relative intraabdominal lipohypertrophy, suggesting that zidovudine/lamivudine contributes to both these features of lipodystrophy. These findings support to no longer consider zidovudine/lamivudine as one of the preferred possible components of first-line antiretroviral therapy where alternative treatments are available.

Trial Registration

ClinicalTrials.gov NCT 00122226

Efficacy and safety of ritonavir-boosted dual protease inhibitor therapy in antiretroviral-naive HIV-1-infected patients: the 2IP ANRS 127 study

OBJECTIVES

We evaluate the efficacy and tolerability of ritonavir-boosted dual protease inhibitor as a nucleoside reverse transcriptase inhibitor-sparing regimen in a prospective open-label randomized pilot trial in antiretroviral-naive patients.

METHODS

Thirty patients received fosamprenavir/atazanavir/ritonavir (Group 1) and 31 patients received saquinavir/atazanavir/ritonavir (Group 2). The primary endpoint for efficacy was the rate of early virological success, defined as plasma viral load <50 copies/mL at week 16. The study is registered with ClinicalTrials.gov (NCT00122603).

RESULTS

At baseline, median (range) viral load was 4.8 log(10) copies/mL (4.0-5.7) and the median CD4 cell count was 271/mm(3) (197-740). Viral load was <50 copies/mL in 12/30 patients [40%, 95% confidence interval (CI) 23%-58%] and 13/31 patients (42%, 95% CI 25%-59%) at week 16 in Groups 1 and 2, respectively. Patients with failing regimens (viral load >or=400 copies/mL at week 16 or >or=50 copies/mL at week 24) were switched to a standard antiretroviral regimen. At week 48, by an intention-to-treat analysis, 23/30 patients (77%) and 26/31 patients (84%) had plasma HIV-1 RNA <50 copies/mL in Groups 1 and 2, respectively. Four patients discontinued treatment for adverse events, all before week 4. No major changes in the protease gene were detected at treatment failure relative to baseline. Baseline viral load <50 000 copies/mL was the only predictor of virological success at week 16.

CONCLUSIONS

Ritonavir-boosted dual protease inhibitor regimens targeting only one step of viral replication were insufficient to rapidly suppress plasma HIV RNA to <50 copies/mL in antiretroviral-naive patients with high viral load at baseline.

Body mass index and nutritional intake in patients with HIV and chronic diarrhea: a secondary analysis

PURPOSE

The purpose of this study was to examine the differences in nutritional intake and body mass index (BMI) in HIV patients with chronic diarrhea via secondary analysis of patients' nutritional diaries. A secondary purpose was to evaluate the quality of diets against national dietary guidelines.

DATA SOURCES

Seventy-five ambulatory patients with HIV were included in this study. Patients were categorized using baseline BMI as normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2), and obese (BMI >or=30.0 kg/m2). Seven-day nutritional diaries were used to estimate diet in terms of dietary fats, cholesterol, fiber, protein, and sugar. A one-way analysis of variance was conducted to evaluate the relationship between BMI and mean nutritional intake from fat, saturated fat, polyunsaturated fat, monounsaturated fat, cholesterol, fiber, and sugar.

CONCLUSIONS

39.7% and 13.3% of participants were overweight and obese, respectively. The mean intake of fat, saturated fat, and cholesterol was higher than the recommended levels by the National Cholesterol Education Program (NCEP), while the mean intake of monounsaturated fat, polyunsaturated fat, and fiber was below the NCEP guideline. Although the results were not statistically different between groups, grams of fiber intake were lowest for individuals with BMI >or=30.0 kg/m2.

IMPLICATIONS FOR PRACTICE

Advanced practice nurses should encourage increased physical activity and healthy diets at each visit for individuals living with HIV. The continued use of nutritional supplements to boost weight should also be reviewed at each visit to prevent the consumption of unnecessary calories.