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Lantz AM, Nicol MR. Translational Models to Predict Target Concentrations for Pre-Exposure Prophylaxis in Women. AIDS Res Hum Retroviruses 2022; 38:909-923. [PMID: 36097755 PMCID: PMC9805887 DOI: 10.1089/aid.2022.0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The HIV epidemic remains a significant public health burden. Women represent half of the global HIV epidemic, yet there is an urgent need for a variety of prevention options to meet the needs of more women. Pre-exposure prophylaxis (PrEP) is a valuable prevention tool that uses antiretrovirals before a potential HIV exposure to prevent virus transmission. Development of effective preventive drug regimens for women is dependent on convenient dosing schedules and routes of administration, and on identifying defined target concentrations in mucosal tissues that provide complete protection against HIV transmission. There is a critical need for a translational model that can accurately predict in vivo target concentrations that are completely protective against HIV infection. There is no gold-standard preclinical model to predict PrEP efficacy. In this study, we review the strengths and limitations of three different preclinical models and their utility in predicting target concentrations in the female genital tract: humanized mice, non-human primates, and the ex vivo tissue model.
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Affiliation(s)
- Alyssa M. Lantz
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Melanie R. Nicol
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
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McGowan IM, Chawki S, Hendrix CW, Anton PA, Marzinke MA, Brand RM, Engstrom JC, Rohan LC, Abebe KZ, Richardson-Harman N, Siegel A, Reinhart A, Steytler J, Stall R, Spiegel H, Chen B, Achilles SL, Jacobson CE, Khanukova E, Cranston RD. A Randomized, Open-Label, Crossover Phase 1 Safety and Pharmacokinetic Study of Oral Maraviroc and Maraviroc 1% Gel (the CHARM-03 Study). AIDS Res Hum Retroviruses 2022; 38:269-278. [PMID: 34384282 PMCID: PMC9048171 DOI: 10.1089/aid.2021.0096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The Combination HIV Antiretroviral Rectal Microbicide-3 (CHARM-03) study was a randomized, open-label, crossover Phase 1 safety and pharmacokinetic (PK) study of oral maraviroc (MVC) and MVC 1% gel. At a single site, healthy HIV-uninfected men and women were enrolled and randomized to an open label crossover sequence of eight consecutive daily exposures to MVC 300 mg dosed orally, MCV 1% gel dosed rectally, and MVC 1% gel dosed vaginally. Male participants received oral and rectal dosing and female participants received oral, rectal, and vaginal dosing. Assessments were undertaken at baseline and following each 8-day period and included collection of plasma, rectal/cervical tissue (CT), and rectal/endocervical/vaginal fluids. Eleven men and nine women were enrolled. Two participants withdrew from the study before receiving study product. There were 25 adverse events, of which 24 were Grade 1 (G1) and one was G2 (unrelated). After eight doses, MVC was quantifiable in all samples following oral, rectal, or vaginal product administration. The highest drug concentrations in plasma, rectal tissue (RT), and CT were associated with oral, rectal, and vaginal drug delivery, respectively. There were significant reductions in tissue drug concentrations when rectal and cervical biopsies were incubated in media before tissue processing for PK (p < .0001). Only oral MVC was associated with limited protection in the rectal explant HIV challenge model (p < .05). There were no immunological changes in RT, and all products were acceptable to participants. In conclusion, all products were found to be safe and acceptable and did not induce local inflammation. The lack of ex vivo efficacy demonstrated in study samples may be due to rapid disassociation of MVC from the explant tissue. ClinicalTrials.gov Identifier: NCT02346084.
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Affiliation(s)
- Ian M. McGowan
- Orion Biotechnology, Ottawa, Canada
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - Sylvain Chawki
- INSERM, Paris, France
- Department of Virology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, France
| | - Craig W. Hendrix
- Division of Clinical Pharmacology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Peter A. Anton
- Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Mark A. Marzinke
- Division of Clinical Pharmacology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Rhonda M. Brand
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | | | - Lisa C. Rohan
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - Kaleab Z. Abebe
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Aaron Siegel
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | | | - John Steytler
- International Partnership for Microbicides, Silver Spring, Maryland, USA
| | - Ronald Stall
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hans Spiegel
- Kelly Government Solutions, Department of Health and Human Services, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, USA
| | - Beatrice Chen
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - Sharon L. Achilles
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | | | - Elena Khanukova
- Division of Clinical Pharmacology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ross D. Cranston
- Department of Medicine, University of Barcelona, Barcelona, Spain
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3
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Sang Y, Ding L, Zhuang C, Chen F. Design strategies for long-acting anti-HIV pharmaceuticals. Curr Opin Pharmacol 2020; 54:158-165. [PMID: 33176247 DOI: 10.1016/j.coph.2020.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 12/27/2022]
Abstract
Current combination antiretroviral therapy (cART) for human immunodeficiency virus (HIV) is limited by the frequent dosing and unfavorable adherence, and the rapid appearance of resistant mutants. Thus, there is a continuous need to improve and optimize the present therapies. The clinical phase III trials of FLAIR and ATLAS, showed two-drug injectable cabotegravir (CAB) and rilpivirine (RPV) formulation is potent, safe, and tolerable in HIV-infected patients. The recent approval of cabenuva (CAB+RPV) by Health Canada is a milestone in the development of long-term therapies for HIV infection. Broadly neutralizing antibodies (bNAbs) with excellent breath and efficiency against HIV have been investigated as LA antiviral weapons. Several modern modalities capable of sustained drug release for long-term treatment and prevention of HIV infection are also in development, such as implants, vaginal rings, and nanotherapies.
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Affiliation(s)
- Yali Sang
- School of Science, Harbin Institute of Technology (Shenzhen), Shenzhen 518055, China; Green Pharmaceutical Engineering Research Center, Harbin Institute of Technology (Shenzhen), Shenzhen 518055, China
| | - Li Ding
- Engineering Center of Catalysis and Synthesis for Chiral Molecules, Department of Chemistry, Fudan University, Shanghai 200433, China
| | - Chunlin Zhuang
- Engineering Center of Catalysis and Synthesis for Chiral Molecules, Department of Chemistry, Fudan University, Shanghai 200433, China.
| | - Fener Chen
- School of Science, Harbin Institute of Technology (Shenzhen), Shenzhen 518055, China; Green Pharmaceutical Engineering Research Center, Harbin Institute of Technology (Shenzhen), Shenzhen 518055, China; Engineering Center of Catalysis and Synthesis for Chiral Molecules, Department of Chemistry, Fudan University, Shanghai 200433, China.
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Hoesley CJ, Chen BA, Anderson PL, Dezzutti CS, Strizki J, Sprinkle C, Heard F, Bauermeister J, Hall W, Jacobson C, Berthiaume J, Mayo A, Gundacker H, Richardson-Harman N, Piper J. Phase 1 Safety and Pharmacokinetics Study of MK-2048/Vicriviroc (MK-4176)/MK-2048A Intravaginal Rings. Clin Infect Dis 2020; 68:1136-1143. [PMID: 30289435 DOI: 10.1093/cid/ciy653] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/07/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Vaginal rings (VR) containing antiretroviral (ARV) drugs can be utilized for prevention of human immunodeficiency virus (HIV) with potential for improved adherence compared to daily pills. Combination ARV VRs could improve efficacy. METHODS MTN-027, a single-blind, randomized, placebo-controlled trial in 48 women, evaluated VRs containing MK-2048 (30 mg) and vicriviroc (VCV, 182 mg), alone or in combination, and placebo used continuously for 28 days. Safety was assessed by recording adverse events. Drug concentrations were quantified in plasma, vaginal fluid, cervical tissue, and rectal fluid. Cervical tissue was utilized for ex vivo HIV inhibition analysis. RESULTS There was no difference in related genitourinary adverse events between treatment arms compared to placebo. VCV and MK-2048 released from single or combination VRs both achieved peak concentrations in vaginal fluids, which were substantially higher compared to plasma (200× for VCV, 30× for MK-2048) and rectal fluid. In an ex vivo challenge assay, the antiviral activity of VCV and/or MK-2048 was not correlated with tissue-associated drug concentrations. Most women (77%) were fully adherent to 28 days of continuous VR use and found the VR acceptable. CONCLUSIONS VCV and/or MK-2048 containing VRs were safe and acceptable. Both VCV and MK-2048 were quantifiable in all matrixes tested with peak compartmental drug concentrations similar for single and combination drug VRs. Tissue-associated VCV and/or MK-2048 did not correlate with inhibition of HIV infection. These data highlight the need to assess adequacy of drug dosing in the VR and measuring genital tissue drug concentrations to develop more precise concentration-response relationships.
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Affiliation(s)
| | - Beatrice A Chen
- School of Medicine, University of Pittsburgh, Pennsylvania.,Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - Peter L Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | - Charlene S Dezzutti
- School of Medicine, University of Pittsburgh, Pennsylvania.,Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | | | - Carol Sprinkle
- School of Medicine, University of Pittsburgh, Pennsylvania
| | | | | | - Wayne Hall
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - Cindy Jacobson
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania
| | - Jennifer Berthiaume
- Fred Hutchinson Cancer Research Center, Statistical Center for HIV/AIDS Research and Prevention, Seattle, Washington
| | | | - Holly Gundacker
- Fred Hutchinson Cancer Research Center, Statistical Center for HIV/AIDS Research and Prevention, Seattle, Washington
| | | | - Jeanna Piper
- National Institutes of Health, Division of AIDS, Bethesda, Maryland
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Calenda G, Villegas G, Reis A, Millen L, Barnable P, Mamkina L, Kumar N, Roberts K, Kalir T, Martinelli E, Sperling R, Teleshova N. Mucosal Susceptibility to Human Immunodeficiency Virus Infection in the Proliferative and Secretory Phases of the Menstrual Cycle. AIDS Res Hum Retroviruses 2019; 35:335-347. [PMID: 30600686 DOI: 10.1089/aid.2018.0154] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Factors underlying HIV acquisition in women remain incompletely understood. This study evaluated ex vivo mucosal HIV-1BaL infection (ectocervix, endocervix), T cell frequencies and phenotype (ectocervix, endocervix, peripheral blood), and HIV-1BaL-induced tissue immune responses (ectocervix) in the proliferative and secretory phases of the menstrual cycle using samples obtained from women undergoing hysterectomies. Tissue infectivity (number of productively infected explants) and infection level following 500 and/or fifty 50% tissue culture infectious dose (TCID50) HIV-1BaL challenge were similar in the proliferative and secretory phases. Although not associated with infection outcomes, higher frequencies of HIV target CD4+α4β7+ T cells, and stronger HIV-1BaL-induced proinflammatory responses were detected in ectocervix in the secretory versus proliferative phase. Independently of the cycle phase, serum E2 concentrations were inversely associated with ectocervical and endocervical tissue infection levels following high-dose 500 TCID50 HIV-1BaL challenge, with frequencies of CD4+α4β7+ T cells in endocervix, and with HIV-induced interleukin (IL)2R and IL4 in ectocervix. Although serum P4 concentrations and P4/E2 ratios were neither associated with tissue infection level nor infectivity, high P4 concentrations and/or P4/E2 ratios correlated with high frequencies of CD4+α4β7+ T cells in ectocervix, low frequencies of CD4+CD103+ blood T cells, low CD4+LFA-1+ T cells in endocervix, and high proinflammatory (IL1β, IL17, tumor necrosis factor α) ectocervical tissue responses to HIV-1BaL. The data suggest an inhibitory effect of E2 on mucosal HIV infection, provide insights into potential mechanisms of E2-mediated anti-HIV activity, and highlight P4-associated immune changes in the mucosa.
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Affiliation(s)
- Giulia Calenda
- Center for Biomedical Research, Population Council, New York, New York
| | | | - Alexandra Reis
- Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Lily Millen
- Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Patrick Barnable
- Center for Biomedical Research, Population Council, New York, New York
| | - Lisa Mamkina
- Center for Biomedical Research, Population Council, New York, New York
| | - Narender Kumar
- Center for Biomedical Research, Population Council, New York, New York
| | - Kevin Roberts
- Center for Biomedical Research, Population Council, New York, New York
| | - Tamara Kalir
- Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Elena Martinelli
- Center for Biomedical Research, Population Council, New York, New York
| | - Rhoda Sperling
- Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Natalia Teleshova
- Center for Biomedical Research, Population Council, New York, New York
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McGowan I, Wilkin T, Landovitz RJ, Wu C, Chen Y, Marzinke MA, Hendrix CW, Richardson P, Eshleman SH, Andrade A, Chege W, Anderson PL, McCauley M, Farley J, Mayer KH, Anton P, Brand RM, Cranston RD, Gulick R. The pharmacokinetics, pharmacodynamics, and mucosal responses to maraviroc-containing pre-exposure prophylaxis regimens in MSM. AIDS 2019; 33:237-246. [PMID: 30557160 DOI: 10.1097/qad.0000000000002038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE HIV Prevention Trials Network 069/AIDS Clinical Trials Group A5305 was a study of 48-week oral pre-exposure prophylaxis (PrEP) regimens in MSM and transgender women. A rectal substudy was included to evaluate drug concentrations in rectal compartment vs. blood, gut-associated lymphoid tissue (GALT) responses to four antiretroviral PrEP regimens [maraviroc (MVC), MVC + emtricitabine (FTC), MVC + tenofovir (TFV) disoproxil fumarate, and TFV disoproxil fumarate + FTC], and to determine whether ARV exposure was associated with ex-vivo suppression of HIV infection in colorectal explants. METHODS C-C chemokine receptor type 5 (CCR5) genotype was characterized using PCR. At baseline and at Weeks 24, 48, and 49, GALT phenotype was characterized by flow cytometry, rectal biopsies were challenged with HIV-1BaL, and tissue and plasma pharmacokinetics were measured via mass spectrometry. RESULTS Exposure to MVC was not associated with increased expression of CD4+/CCR5+ HIV target T cells. Significant ex-vivo viral suppression compared with baseline was seen at Weeks 24 and 48, ranging from 1.4 to 1.8 log10 for all study regimens except the MVC-alone arm which did not show statistically significant viral suppression at Week 48. Tissue concentrations of TFV, TFV-diphosphate, and FTC were correlated with viral suppression. CONCLUSION MVC-containing HIV PrEP regimens did not increase GALT CD4+ T-cell activation or the CD4+/CCR5+ phenotype. No virologic suppression was seen with MVC-alone at Week 48 compared with combination regimens, suggesting MVC monotherapy might be less effective than combination antiretroviral PrEP regimens.
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Nicol MR, Corbino JA, Cottrell ML. Pharmacology of Antiretrovirals in the Female Genital Tract for HIV Prevention. J Clin Pharmacol 2018; 58:1381-1395. [PMID: 29901863 PMCID: PMC6333200 DOI: 10.1002/jcph.1270] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 05/15/2018] [Indexed: 02/06/2023]
Abstract
Preexposure prophylaxis (PrEP) is a powerful tool that, as part of a comprehensive prevention package, has potential to significantly impact the HIV epidemic. PrEP effectiveness is believed to be dependent on the exposure and efficacy of antiretrovirals at the site of HIV transmission. Clinical trial results as well as modeling and simulation indicate the threshold of adherence required for PrEP efficacy of emtricitabine/tenofovir disoproxil fumarate may differ between sites of HIV transmission with less forgiveness for missed doses in women exposed through genital tissue compared to people exposed through colorectal tissue. This suggests a role for local and host factors to influence mucosal pharmacology. Here we review the mucosal pharmacology of antiretrovirals in the female genital tract and explore potential determinants of PrEP efficacy. Host factors such as inflammation, coinfections, hormonal status, and the vaginal microbiome will be explored as well as the role of drug-metabolizing enzymes and transporters in regulating local drug exposure. The use of preclinical and early clinical models to predict clinical effectiveness is also discussed.
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Affiliation(s)
- Melanie R Nicol
- University of Minnesota College of Pharmacy, Department of Experimental and Clinical Pharmacology
| | - Joseph A Corbino
- University of Minnesota College of Pharmacy, Department of Experimental and Clinical Pharmacology
| | - Mackenzie L Cottrell
- University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Division of Pharmacotherapy and Experimental Therapeutics
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Nunes R, Araújo F, Barreiros L, Bártolo I, Segundo MA, Taveira N, Sarmento B, das Neves J. Noncovalent PEG Coating of Nanoparticle Drug Carriers Improves the Local Pharmacokinetics of Rectal Anti-HIV Microbicides. ACS APPLIED MATERIALS & INTERFACES 2018; 10:34942-34953. [PMID: 30234288 DOI: 10.1021/acsami.8b12214] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Antiretroviral drug nanocarriers hold great promise for developing anti-human immunodeficiency virus (HIV) rectal microbicides. However, challenges remain, namely, concerning which properties are more suited for enhancing colorectal distribution and retention of microbicide compounds. In this work, we developed and assessed the in vitro and in vivo performance of poly(lactic- co-glycolic acid) (PLGA)-based nanoparticles (NPs) as carriers for the model drug efavirenz (EFV). We particularly focused on the effect of noncovalent poly(ethylene glycol) coating of PLGA NPs (PEG-PLGA NPs) conferring a mucus-diffusive behavior on the pharmacokinetics (PK) of EFV following rectal administration to mice. Drug-loaded PLGA NPs and PEG-PLGA NPs (200-225 nm) were obtained by nanoprecipitation. Both types of systems were able to retain native antiretroviral activity of EFV in vitro, while featuring lower cytotoxicity against different epithelial cell lines and HIV target cells. Also, PLGA NPs and PEG-PLGA NPs were readily taken up by colorectal cell lines and mildly reduced EFV permeation while increasing membrane retention in Caco-2 and Caco-2/HT29-MTX cell monolayer models. When administered intrarectally to CD-1 mice in phosphate-buffered saline (pH 7.4), EFV-loaded PEG-PLGA NPs consistently provided higher drug levels in colorectal tissues and lavages, as compared to free EFV or drug-loaded PLGA NPs. Mean values for the area-under-the-curve between 15 min and 12 h following administration were particularly higher for PEG-PLGA NPs in distal and middle colorectal tissues, with relative bioavailability values of 3.7 and 29, respectively, as compared to free EFV (2.2 and 6.0 over PLGA NPs, respectively). Systemic exposure to EFV was reduced for all treatments. NPs were further shown safe after once-daily administration for 14 days, as assessed by histological analysis of colorectal tissues and chemokine/cytokine assay of rectal lavages. Overall, PEG-PLGA NPs demonstrated to be safe carriers for rectal microbicide drug delivery and able to provide enhanced local PK that could be valuable in preventing rectal HIV transmission.
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Affiliation(s)
- Rute Nunes
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde , Gandra 4585-116 , Portugal
- ICBAS-Instituto de Ciências Biomédicas Abel Salazar Universidade do Porto, Porto 4050-313 , Portugal
| | | | - Luisa Barreiros
- LAQV, REQUIMTE, Departamento de Ciências Quı́micas, Faculdade de Farmácia , Universidade do Porto , Porto 4050-313 , Portugal
| | - Inês Bártolo
- HIV Evolution, Epidemiology and Prevention, Instituto de Investigação do Medicamento (iMed.ULisboa), Faculdade de Farmácia , Universidade de Lisboa , Lisboa 1649-003 , Portugal
| | - Marcela A Segundo
- LAQV, REQUIMTE, Departamento de Ciências Quı́micas, Faculdade de Farmácia , Universidade do Porto , Porto 4050-313 , Portugal
| | - Nuno Taveira
- HIV Evolution, Epidemiology and Prevention, Instituto de Investigação do Medicamento (iMed.ULisboa), Faculdade de Farmácia , Universidade de Lisboa , Lisboa 1649-003 , Portugal
- Centro de Investigação Interdisciplinar Egas Moniz (CiiEM) , Instituto Universitário Egas Moniz , Monte de Caparica 2829-511 , Portugal
| | - Bruno Sarmento
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde , Gandra 4585-116 , Portugal
| | - José das Neves
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde , Gandra 4585-116 , Portugal
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Vincent KL, Moss JA, Marzinke MA, Hendrix CW, Anton PA, Gunawardana M, Dawson LN, Olive TJ, Pyles RB, Baum MM. Phase I trial of pod-intravaginal rings delivering antiretroviral agents for HIV-1 prevention: Rectal drug exposure from vaginal dosing with tenofovir disoproxil fumarate, emtricitabine, and maraviroc. PLoS One 2018; 13:e0201952. [PMID: 30133534 PMCID: PMC6104940 DOI: 10.1371/journal.pone.0201952] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 05/22/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Intravaginal rings (IVRs) can deliver antiretroviral (ARV) agents for HIV pre-exposure prophylaxis (PrEP), theoretically overcoming adherence concerns associated with frequent dosing. However, topical vaginal ARV drug delivery has not simultaneously led to sufficient rectal drug exposure to likely protect from HIV infection as a result of receptive anal intercourse (RAI). Unprotected RAI has a higher risk of infection per sex act and, for women, also can be associated with vaginal exposure during a single sexual encounter, especially in higher-risk subsets of women. The physiologically inflamed, activated, immune-cell dense colorectal mucosa is increasingly appreciated as the sexual compartment with highly significant risk; this risk is increased in the setting of co-infections. Ex vivo studies have shown that colorectal tissue and rectal fluid concentrations correlated with HIV protection. Given these important results, efforts to document colorectal compartment ARV drug concentration from pod-IVR delivery was assessed to determine if vaginal application could provide protective ARV levels in both compartments. METHODOLOGY/PRINCIPAL FINDINGS A crossover clinical trial (N = 6) evaluated 7 d of continuous TDF pod-IVR use, a wash-out phase, followed by 7 d with a TDF-FTC pod-IVR. A subsequent clinical trial (N = 6) consisted of 7 d of continuous TDF-FTC-MVC pod-IVR use. Rectal fluids were collected on Day 7 at IVR removal in all three ARV-exposures (two Phase 1 trials) and drug concentrations quantified by LC-MS/MS. Median rectal fluid concentrations of TFV, the hydrolysis product of the prodrug TDF, were between 0.66 ng mg-1 (TDF pod-IVR group) and 1.11 ng mg-1 (TDF-FTC pod-IVR group), but below the analytical lower limit of quantitation in 5/6 samples in the TDF-FTC-MVC pod-IVR group. Unexpectedly, median FTC (TDF-FTC pod-IVR, 20.3 ng mg-1; TDF-FTC-MVC pod-IVR, 0.18 ng mg-1), and MVC rectal fluid concentrations (0.84 ng mg-1) were quantifiable and higher than their respective in vitro EC50 values in most samples. Due to participant burden in these exploratory trials, rectal fluid was used as a surrogate for rectal tissue, where drug concentrations are expected to be higher. CONCLUSIONS/SIGNIFICANCE The concentrations of FTC and MVC in rectal fluids obtained in two exploratory clinical trials of IVRs delivering ARV combinations exceeded levels associated with in vitro efficacy in HIV inhibition. Unexpectedly, MVC appeared to depress the distribution of TFV and FTC into the rectal lumen. Here we show that vaginal delivery of ARV combinations may provide adherence and coitally independent dual-compartment protection from HIV infection during both vaginal and receptive anal intercourse.
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Affiliation(s)
- Kathleen Listiak Vincent
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - John A. Moss
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Mark A. Marzinke
- Department of Medicine (Division of Clinical Pharmacology), Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Pathology, Johns Hopkins University, Sheikh Zayed Tower, Baltimore, Maryland, United States of America
| | - Craig W. Hendrix
- Department of Medicine (Division of Clinical Pharmacology), Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Peter A. Anton
- Center for HIV Prevention Research, Division of Digestive Diseases and UCLA AIDS Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
| | - Manjula Gunawardana
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Lauren N. Dawson
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Trevelyn J. Olive
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Richard B. Pyles
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Marc M. Baum
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
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10
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Abstract
Background Cryopreservation of leukocytes isolated from the cervicovaginal and colorectal mucosa is useful for the study of cellular immunity (see Hughes SM et al. PLOS ONE 2016). However, some questions about mucosal biology and sexually transmitted infections are better addressed with intact mucosal tissue, for which there is no standard cryopreservation protocol. Methods and findings To find an optimal preservation protocol for mucosal tissues, we tested slow cooling (1°C/min) with 10% dimethylsulfoxide (designated “cryopreservation”) and fast cooling (plunge in liquid nitrogen) with 20% dimethylsulfoxide and 20% ethylene glycol (“vitrification”). We compared fresh and preserved human cervicovaginal and colorectal tissues in a range of assays, including metabolic activity, human immunodeficiency virus infection, cell phenotype, tissue structure by hematoxylin-and-eosin staining, cell number and viability, production of cytokines, and microbicide drug concentrations. Metabolic activity, HIV infectability, and tissue structure were similar in cryopreserved and vitrified vaginal tissues. However, vitrification led to poor cell recovery from the colorectal mucosa, with 90% fewer cells recovered after isolation from vitrified colorectal tissues than from cryopreserved. HIV infection rates were similar for fresh and cryopreserved ectocervical tissues, whereas cryopreserved colorectal tissues were less easily infected than fresh tissues (hazard ratio 0.7 [95% confidence interval 0.4, 1.2]). Finally, we compared isolation of cells before and after cryopreservation. Cell recoveries were higher when cells were isolated after freezing and thawing (71% [59–84%]) than before (50% [38–62%]). Cellular function was similar to fresh tissue in both cases. Microbicide drug concentrations were lower in cryopreserved explants compared to fresh ones. Conclusions Cryopreservation of intact cervicovaginal and colorectal tissues with dimethylsulfoxide works well in a range of assays, while the utility of vitrification is more limited. Cell yields are higher from cryopreserved intact tissue pieces than from thawed cryopreserved single cell suspensions isolated before freezing, but T cell functions are similar.
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Benítez-Gutiérrez L, Soriano V, Requena S, Arias A, Barreiro P, de Mendoza C. Treatment and prevention of HIV infection with long-acting antiretrovirals. Expert Rev Clin Pharmacol 2018; 11:507-517. [PMID: 29595351 DOI: 10.1080/17512433.2018.1453805] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Current antiretroviral therapy allows to achieve and sustain maximal suppression of HIV replication in most treated patients. As result, the life expectancy of HIV-infected persons has improved dramatically and is nowadays similar to that of the HIV-negative population. However, oral antiretrovirals have to be taken daily and indefinitely to avoid resumption of HIV replication and selection of drug resistance. Unfortunately, drug adherence is often suboptimal and tends to decline over time. Areas covered: New drugs, formulations and delivery systems are being developed for extended-release of antiretrovirals. At this time, intramuscular cabotegravir and rilpivirine, dapivirine vaginal rings and tenofovir alafenamide subdermal implants are the products in more advanced stages of clinical development. Their pharmacokinetics/dynamics and safety/efficacy are reviewed. Expert commentary: In the absence of eradicative therapy for individuals with HIV infection and protective vaccines for persons at risk, long-term antiretroviral therapy is the best approach for preventing disease progression in patients and halting transmissions, either as result of 'treatment as prevention' for HIV carriers or 'pre-exposure prophylaxis' for uninfected individuals at risk. In all these scenarios, the advent of long-acting antiretrovirals will expand options for overcoming the challenge of suboptimal drug adherence and reduce the burden of HIV infection.
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Affiliation(s)
- Laura Benítez-Gutiérrez
- a Internal Medicine Department , Puerta de Hierro University Hospital , Majadahonda , Spain.,b Laboratory of Internal Medicine , Puerta de Hierro Research Institute , Majadahonda , Spain
| | - Vicente Soriano
- c Infectious Diseases Unit , La Paz University Hospital & Autonomous University , Madrid , Spain
| | - Silvia Requena
- b Laboratory of Internal Medicine , Puerta de Hierro Research Institute , Majadahonda , Spain
| | - Ana Arias
- a Internal Medicine Department , Puerta de Hierro University Hospital , Majadahonda , Spain
| | - Pablo Barreiro
- c Infectious Diseases Unit , La Paz University Hospital & Autonomous University , Madrid , Spain
| | - Carmen de Mendoza
- b Laboratory of Internal Medicine , Puerta de Hierro Research Institute , Majadahonda , Spain
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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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Richardson-Harman N, Parody R, Anton P, McGowan I, Doncel G, Thurman AR, Herrera C, Kordy K, Fox J, Tanner K, Swartz G, Dezzutti CS. Analytical Advances in the Ex Vivo Challenge Efficacy Assay. AIDS Res Hum Retroviruses 2017; 33:395-403. [PMID: 27841671 PMCID: PMC5372762 DOI: 10.1089/aid.2016.0073] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The ex vivo challenge assay is being increasingly used as an efficacy endpoint during early human clinical trials of HIV prevention treatments. There is no standard methodology for the ex vivo challenge assay, although the use of different data collection methods and analytical parameters may impact results and reduce the comparability of findings between trials. In this analysis, we describe the impact of data imputation methods, kit type, testing schedule and tissue type on variability, statistical power, and ex vivo HIV growth kinetics. Data were p24 antigen (pg/ml) measurements collected from clinical trials of candidate microbicides where rectal (n = 502), cervical (n = 88), and vaginal (n = 110) tissues were challenged with HIV-1BaL ex vivo. Imputation of missing data using a nonlinear mixed effect model was found to provide an improved fit compared to imputation using half the limit of detection. The rectal virus growth period was found to be earlier and of a relatively shorter duration than the growth period for cervical and vaginal tissue types. On average, only four rectal tissue challenge assays in each treatment and control group would be needed to find a one log difference in p24 to be significant (alpha = 0.05), but a larger sample size was predicted to be needed for either cervical (n = 21) or vaginal (n = 10) tissue comparisons. Overall, the results indicated that improvements could be made in the design and analysis of the ex vivo challenge assay to provide a more standardized and powerful assay to compare efficacy of microbicide products.
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Affiliation(s)
| | - Robert Parody
- Alpha StatConsult, LLC, Damascus, Maryland
- School of Mathematical Sciences, Rochester Institute of Technology, Rochester, New York
| | - Peter Anton
- Department of Medicine, David Geffen School of Medicine at UCLA, Center for HIV Prevention Research, UCLA AIDS Institute, Los Angeles, California
| | - Ian McGowan
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Magee Womens Research Institute, Pittsburgh, Pennsylvania
| | - Gustavo Doncel
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, Virginia
| | | | - Carolina Herrera
- Division of Infectious Diseases, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Kattayoun Kordy
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Southern California, Los Angeles, California
| | - Julie Fox
- Guys and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Karen Tanner
- Department of Medicine, David Geffen School of Medicine at UCLA, Center for HIV Prevention Research, UCLA AIDS Institute, Los Angeles, California
| | - Glenn Swartz
- Advanced Bioscience Laboratories, Gaithersburg, Maryland
| | - Charlene S. Dezzutti
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Magee Womens Research Institute, Pittsburgh, Pennsylvania
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