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Perez-Molina JA, Crespillo-Andújar C, Zamora J, Fernández-Félix BM, Gaetano-Gil A, López-Bernaldo de Quirós JC, Serrano-Villar S, Moreno S, Álvarez-Díaz N, Berenguer J. Contribution of Low CD4 Cell Counts and High Human Immunodeficiency Virus (HIV) Viral Load to the Efficacy of Preferred First-Line Antiretroviral Regimens for Treating HIV Infection: A Systematic Review and Meta-Analysis. Clin Infect Dis 2023; 76:2027-2037. [PMID: 36975712 DOI: 10.1093/cid/ciad177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
We assessed whether low CD4 count and high viral load (VL) affect the response to currently preferred ART. We performed a systematic review of randomized, controlled clinical trials that analyzed preferred first-line ART and a subgroup analysis by CD4 count (≤ or >200 CD4/μL) or VL (≤ or >100 000 copies/mL). We computed the odds ratio (OR) of treatment failure (TF) for each subgroup and individual treatment arm. Patients with ≤200 CD4 cells or VL ≥100 000 copies/mL showed an increased likelihood of TF at 48 weeks: OR, 1.94; 95% confidence interval (CI): 1.45-2.61 and OR, 1.75; 95% CI: 1.30-2.35, respectively. A similar increase in the risk of TF was observed at 96 weeks. There was no significant heterogeneity regarding integrase strand transfer inhibitor or nucleoside reverse transcriptase inhibitor backbone. Our results show that CD4 <200 cells/μL and VL ≥100,000 copies/mL impair ART efficacy in all preferred regimens.
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Affiliation(s)
- Jose A Perez-Molina
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Clara Crespillo-Andújar
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Zamora
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain
- CIBERESP, Instituto de Salud Carlos III, Madrid, Spain
- Institute of Metabolism and Systems Research, WHO Collaborating Center for Global Women's Health, University of Birmingham, Birmingham, United Kingdom
| | - Borja M Fernández-Félix
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain
- CIBERESP, Instituto de Salud Carlos III, Madrid, Spain
| | - Andrea Gaetano-Gil
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain
- CIBERESP, Instituto de Salud Carlos III, Madrid, Spain
| | - Juan C López-Bernaldo de Quirós
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- HIV Unit, Hospital Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Gregorio Marañón, Madrid, Spain
| | - Sergio Serrano-Villar
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Santiago Moreno
- Infectious Diseases Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Juan Berenguer
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- HIV Unit, Hospital Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Gregorio Marañón, Madrid, Spain
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2
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Park SY, Faraci G, Murphy G, Pilcher C, Busch MP, Lee HY. Microdrop Human Immunodeficiency Virus Sequencing for Incidence and Drug Resistance Surveillance. J Infect Dis 2021; 224:1048-1059. [PMID: 33517458 DOI: 10.1093/infdis/jiab060] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/26/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Precise and cost-efficient human immunodeficiency virus (HIV) incidence and drug resistance surveillances are in high demand for the advancement of the 90-90-90 "treatment for all" target. METHODS We developed microdrop HIV sequencing for the HIV incidence and drug resistance assay (HIDA), a single-blood-draw surveillance tool for incidence and drug resistance mutation (DRM) detection. We amplified full-length HIV envelope and pol gene sequences within microdroplets, and this compartmental amplification with long-read high-throughput sequencing enabled us to recover multiple unique sequences. RESULTS We achieved greater precision in determining the stage of infection than current incidence assays, with a 1.2% false recency rate (proportion of misclassified chronic infections) and a 262-day mean duration of recent infection (average time span of recent infection classification) from 83 recently infected and 81 chronically infected individuals. Microdrop HIV sequencing demonstrated an increased capacity to detect minority variants and linked DRMs. By screening all 93 World Health Organization surveillance DRMs, we detected 6 pretreatment drug resistance mutations with 2.6%-13.2% prevalence and cross-linked mutations. CONCLUSIONS HIDA with microdrop HIV sequencing may promote global HIV real-time surveillance by serving as a precise and high-throughput cross-sectional survey tool that can be generalized for surveillance of other pathogens.
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Affiliation(s)
- Sung Yong Park
- Department of Molecular Microbiology and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Gina Faraci
- Department of Molecular Microbiology and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Gary Murphy
- Public Health England, London, United Kingdom
| | - Christopher Pilcher
- Department of Medicine, University of California, San Francisco, California, USA
| | - Michael P Busch
- Research and Scientific Programs, Vitalant Research Institute, San Francisco, California, USA.,Deparment of Laboratory Medicine, University of California, California, San Francisco, USA
| | - Ha Youn Lee
- Department of Molecular Microbiology and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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3
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Plaçais L, Boufassa F, Lécuroux C, Gardiennet E, Avettand-Fenoel V, Saez-Cirion A, Lambotte O, Noël N. Antiretroviral therapy for HIV controllers: Reasons for initiation and outcomes in the French ANRS-CO21 CODEX cohort. EClinicalMedicine 2021; 37:100963. [PMID: 34195579 PMCID: PMC8225698 DOI: 10.1016/j.eclinm.2021.100963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Less than 1% of Human Immunodeficiency Virus (HIV)-infected individuals are able to achieve spontaneous viral control without requiring antiretroviral therapy (ART). Whether these HIV controllers (HIC) are at risk of HIV-associated comorbidities and could benefit from ART is debated, but recent studies reported decreased T-cell activation upon ART initiation. We report the frequency of ART initiation, reasons to treat, treatment outcome on immunovirological parameters, and rate of side-effects and treatment discontinuation in the French cohort of HIC. METHODS Participants included in the French multicenter Agence Nationale de Recherche sur le SIDA et les Hépatites (ANRS) Cohorte des extremes (CODEX) cohort of HIC between July 6, 2007 and January 3, 2018 were prospectively followed. ART initiation, indication, discontinuation, non-Acquired ImmunoDeficiency Syndrome (AIDS)-defining events, side-effects, and immunovirological parameters were recorded. Undetectable HIC (u-HIC) were defined as participants with strictly undetectable viral loads based on routinely used assays throughout the follow-up and blipper HIC (b-HIC) as participants with possible detectable viral loads above the detection threshold during follow-up. FINDINGS Among 302 HIC followed for a median of 14.8 years [10.3-20.2], 90 (30%) received ART (7 u-HIC and 83 b-HIC). The main reasons for ART initiation were decreased CD4 T-cell counts (n = 36, 40%), loss of virological control (n = 13, 14%), and non-AIDS-defining events (n = 12, 13%). Sixteen (18%) participants experienced 17 grade 1-2 adverse events. In b-HIC, ART slightly increased the CD4/CD8 ratio (median +0.19, p < 0.0001) and decreased the frequency of circulating CD38+ HLA-DR.+ CD4 and CD8 lymphocytes (median -0.75%, p = 0.003, and -2%, p < 0.0001, respectively), but these changes were not observed for treated u-HIC. Thirteen (14%) participants discontinued ART (5 (38%) because of side-effects, and 10 remained HIC after treatment cessation (median follow-up: 305 days [235-728]). INTERPRETATION Only 30% of participants in this large cohort of HIC required ART during a median follow-up of 14.8 years. These results show that HIC status is very stable and vouch for a patient-centered treatment decision based on the individual benefit/risk balance.
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Affiliation(s)
- Léo Plaçais
- AP-HP, GHU Paris-Saclay, Hôpital Bicêtre, Service de Médecine Interne et Immunologie Clinique, Le Kremlin Bicêtre, 78, rue du Général Leclerc, 94275 CEDEX, France
- Inserm, CEA, Centre de Recherche en Immunologie des Infections Virales et des Maladies Auto-Immunes ImVA, Université Paris-Saclay, UMR1184, Le Kremlin Bicêtre 94270, France
| | - Faroudy Boufassa
- CESP, Centre for Research in Epidemiology and Population Health, Univ Paris-Saclay, Univ Paris Sud, UVSQ, Inserm UMRS 1018, Villejuif, France
| | - Camille Lécuroux
- Inserm, CEA, Centre de Recherche en Immunologie des Infections Virales et des Maladies Auto-Immunes ImVA, Université Paris-Saclay, UMR1184, Le Kremlin Bicêtre 94270, France
| | - Elise Gardiennet
- AP-HP, Laboratoire de Microbiologie Clinique, Hôpital Necker-Enfants Malades, Paris, France
- Faculté de Médecine, INSERM U1016, CNRS, UMR8104, Institut Cochin, Université de Paris, Paris, France
| | - Véronique Avettand-Fenoel
- AP-HP, Laboratoire de Microbiologie Clinique, Hôpital Necker-Enfants Malades, Paris, France
- Faculté de Médecine, INSERM U1016, CNRS, UMR8104, Institut Cochin, Université de Paris, Paris, France
| | - Asier Saez-Cirion
- Institut Pasteur, Unité HIV, Inflammation et Persistance, Paris, France
| | - Olivier Lambotte
- AP-HP, GHU Paris-Saclay, Hôpital Bicêtre, Service de Médecine Interne et Immunologie Clinique, Le Kremlin Bicêtre, 78, rue du Général Leclerc, 94275 CEDEX, France
- Inserm, CEA, Centre de Recherche en Immunologie des Infections Virales et des Maladies Auto-Immunes ImVA, Université Paris-Saclay, UMR1184, Le Kremlin Bicêtre 94270, France
- Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Nicolas Noël
- AP-HP, GHU Paris-Saclay, Hôpital Bicêtre, Service de Médecine Interne et Immunologie Clinique, Le Kremlin Bicêtre, 78, rue du Général Leclerc, 94275 CEDEX, France
- Inserm, CEA, Centre de Recherche en Immunologie des Infections Virales et des Maladies Auto-Immunes ImVA, Université Paris-Saclay, UMR1184, Le Kremlin Bicêtre 94270, France
- Faculté de Médecine, Université Paris Saclay, Le Kremlin Bicêtre, France
- Corresponding author at: AP-HP, GHU Paris-Saclay, Hôpital Bicêtre, Service de Médecine Interne et Immunologie Clinique, Le Kremlin Bicêtre, 78, rue du Général Leclerc, 94275 CEDEX, France.
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Smith SJ, Zhao XZ, Passos DO, Pye VE, Cherepanov P, Lyumkis D, Burke TR, Hughes SH. HIV-1 Integrase Inhibitors with Modifications That Affect Their Potencies against Drug Resistant Integrase Mutants. ACS Infect Dis 2021; 7:1469-1482. [PMID: 33686850 PMCID: PMC8205226 DOI: 10.1021/acsinfecdis.0c00819] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
![]()
Integrase strand transfer inhibitors
(INSTIs) block the integration
step of the retroviral lifecycle and are first-line drugs used for
the treatment of HIV-1/AIDS. INSTIs have a polycyclic core with heteroatom
triads, chelate the metal ions at the active site, and have a halobenzyl
group that interacts with viral DNA attached to the core by a flexible
linker. The most broadly effective INSTIs inhibit both wild-type (WT)
integrase (IN) and a variety of well-known mutants. However, because
there are mutations that reduce the potency of all of the available
INSTIs, new and better compounds are needed. Models based on recent
structures of HIV-1 and red-capped mangabey SIV INs suggest modifications
in the INSTI structures that could enhance interactions with the 3′-terminal
adenosine of the viral DNA, which could improve performance against
INSTI resistant mutants. We designed and tested a series of INSTIs
having modifications to their naphthyridine scaffold. One of the new
compounds retained good potency against an expanded panel of HIV-1
IN mutants that we tested. Our results suggest the possibility of
designing inhibitors that combine the best features of the existing
compounds, which could provide additional efficacy against known HIV-1
IN mutants.
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Affiliation(s)
- Steven J. Smith
- HIV Dynamics and Replication Program, Center for Cancer Research, National Cancer Institute, Frederick, Maryland 21702, United States
| | - Xue Zhi Zhao
- Chemical Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, Maryland 21702, United States
| | - Dario Oliveira Passos
- Laboratory of Genetics, The Salk Institute for Biological Studies, La Jolla, California 92037, United States
| | - Valerie E. Pye
- Chromatin Structure and Mobile DNA Laboratory, The Francis Crick Institute, London NW1 1AT, U.K
| | - Peter Cherepanov
- Chromatin Structure and Mobile DNA Laboratory, The Francis Crick Institute, London NW1 1AT, U.K
- St Mary’s Hospital, Department of Infectious Disease, Imperial College London, Section of Virology, Norfolk Place, London W2 1PG, U.K
| | - Dmitry Lyumkis
- Laboratory of Genetics, The Salk Institute for Biological Studies, La Jolla, California 92037, United States
- Department of Integrative Structural and Computational Biology, The Scripps Research Institute, La Jolla, California 92037, United States
| | - Terrence R. Burke
- Chemical Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, Maryland 21702, United States
| | - Stephen H. Hughes
- HIV Dynamics and Replication Program, Center for Cancer Research, National Cancer Institute, Frederick, Maryland 21702, United States
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5
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Smith SJ, Zhao XZ, Passos DO, Pye VE, Cherepanov P, Lyumkis D, Burke TR, Hughes SH. HIV-1 Integrase Inhibitors with Modifications That Affect Their Potencies against Drug Resistant Integrase Mutants. ACS Infect Dis 2021. [PMID: 33686850 DOI: 10.1021/acsinfecdis.0c00819/suppl_file/id0c00819_liveslides.mp4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
Abstract
Integrase strand transfer inhibitors (INSTIs) block the integration step of the retroviral lifecycle and are first-line drugs used for the treatment of HIV-1/AIDS. INSTIs have a polycyclic core with heteroatom triads, chelate the metal ions at the active site, and have a halobenzyl group that interacts with viral DNA attached to the core by a flexible linker. The most broadly effective INSTIs inhibit both wild-type (WT) integrase (IN) and a variety of well-known mutants. However, because there are mutations that reduce the potency of all of the available INSTIs, new and better compounds are needed. Models based on recent structures of HIV-1 and red-capped mangabey SIV INs suggest modifications in the INSTI structures that could enhance interactions with the 3'-terminal adenosine of the viral DNA, which could improve performance against INSTI resistant mutants. We designed and tested a series of INSTIs having modifications to their naphthyridine scaffold. One of the new compounds retained good potency against an expanded panel of HIV-1 IN mutants that we tested. Our results suggest the possibility of designing inhibitors that combine the best features of the existing compounds, which could provide additional efficacy against known HIV-1 IN mutants.
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Affiliation(s)
- Steven J Smith
- HIV Dynamics and Replication Program, Center for Cancer Research, National Cancer Institute, Frederick, Maryland 21702, United States
| | - Xue Zhi Zhao
- Chemical Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, Maryland 21702, United States
| | - Dario Oliveira Passos
- Laboratory of Genetics, The Salk Institute for Biological Studies, La Jolla, California 92037, United States
| | - Valerie E Pye
- Chromatin Structure and Mobile DNA Laboratory, The Francis Crick Institute, London NW1 1AT, U.K
| | - Peter Cherepanov
- Chromatin Structure and Mobile DNA Laboratory, The Francis Crick Institute, London NW1 1AT, U.K
- St Mary's Hospital, Department of Infectious Disease, Imperial College London, Section of Virology, Norfolk Place, London W2 1PG, U.K
| | - Dmitry Lyumkis
- Laboratory of Genetics, The Salk Institute for Biological Studies, La Jolla, California 92037, United States
- Department of Integrative Structural and Computational Biology, The Scripps Research Institute, La Jolla, California 92037, United States
| | - Terrence R Burke
- Chemical Biology Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, Maryland 21702, United States
| | - Stephen H Hughes
- HIV Dynamics and Replication Program, Center for Cancer Research, National Cancer Institute, Frederick, Maryland 21702, United States
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Schuettfort G, Cabello A, Cotter AG, Leuw PD, Górgolas M, Hamzah L, Herrmann E, Kann G, Khaykin P, Mena A, Stephan C, Haberl AE. Reasons for Choice of Antiretroviral Regimens in HIV Patients Presenting Late for Initial Treatment in Europe. AIDS Patient Care STDS 2021; 35:110-115. [PMID: 33835853 DOI: 10.1089/apc.2021.0011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The choice of an optimal antiretroviral therapy (ART) in naive patients presenting late for initial therapy with advanced HIV infection, that is, with a CD4 cell count <200/μL and/or an AIDS-defining disease (late presenters, LPs), is still a challenge, even for HIV specialists. At present, there is little information on the decision process and selection criteria that physicians must take into account when choosing the presumably optimal initial ART for LPs. This study analyzes reasons for the individual choice of first-line ART in HIV LPs. We conducted a prospective multi-center study to analyze the decision-making process of physicians treating naive HIV patients presenting with a CD4 cell count <200/μL and/or an AIDS-defining condition. Two European HIV treatment centers based in Frankfurt (Germany) and A Coruna (Spain) participated in the study. Physicians documented the reasons that led to their decision for a specific first-line ART regimen. A questionnaire was designed for the study. Decisions of the participating physicians were evaluated. A total of 52 treatment decisions were analyzed. Evaluation of the choice of antiretroviral treatment demonstrated that for the overall group of physicians, simplicity of the regimen was the most important selection criterion in 34.6% of cases. The presence of comorbidities was given as the decisive selection criterion in 26.9%, followed by experience with the chosen drugs in 21.2% of cases. In the group of physicians choosing an integrase strand transfer inhibitor (INSTI)-based regimen for first-line ART, the same selection criteria were identified as in the overall group; 33.3% of clinicians selected an INSTI-based regimen because of its simplicity. The presence of comorbidities was the second most frequent decisive criterion (31.0%), followed by personal experience with the prescribed ART (23.8%). In the protease inhibitor group, simplicity was also the most common selection criterion with 40%. Results of clinical trials were stated as the most important criterion for the selection of ART in 38% of all cases, followed by the expected adherence of the patient (22%). Among the physicians who used a non-nucleoside reverse transcriptase inhibitor-based regimen, patients' desire to have children was the most frequent criterion for selection of ART (60%). An ongoing pregnancy was the second most frequent selection criterion, followed by ART's simplicity (8%). For patients treated with a single-tablet regimen, simplicity of ART was comprehensibly the most important decisive criterion (54.5%). Experience with the chosen drugs was the decisive selection criterion in 24.2%, followed by comorbidities in 18.2% of cases. Physicians' selection of individual ART in patients presenting late for first-line treatment seems to be predominantly dependent on patient-centered factors such as adherence issues as well as the clinical experience of physicians with the prescribed drugs.
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Affiliation(s)
- Gundolf Schuettfort
- Department of Infectious Diseases, HIVCENTER, University Hospital Frankfurt, Frankfurt, Germany
| | - Alfonso Cabello
- Infectious Diseases Outpatient Clinic, Hospital Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Aoife G. Cotter
- Department of Infectious Diseases, HIV Molecular Research Group, UCD School of Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | - Miguel Górgolas
- Infectious Diseases Outpatient Clinic, Hospital Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Lisa Hamzah
- St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, Frankfurt, Germany
| | - Gerrit Kann
- Department of Infectious Diseases, HIVCENTER, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Alvaro Mena
- Department of Infectious Diseases, A Coruña University Hospital, A Coruña, Spain
| | - Christoph Stephan
- Department of Infectious Diseases, HIVCENTER, University Hospital Frankfurt, Frankfurt, Germany
| | - Annette E. Haberl
- Department of Infectious Diseases, HIVCENTER, University Hospital Frankfurt, Frankfurt, Germany
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7
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Rhee SY, Clutter D, Hare CB, Tchakoute CT, Sainani K, Fessel WJ, Hurley L, Slome S, Pinsky BA, Silverberg MJ, Shafer RW. Virological Failure and Acquired Genotypic Resistance Associated With Contemporary Antiretroviral Treatment Regimens. Open Forum Infect Dis 2020; 7:ofaa316. [PMID: 32904894 PMCID: PMC7462367 DOI: 10.1093/ofid/ofaa316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/27/2020] [Indexed: 12/20/2022] Open
Abstract
Background There are few descriptions of virologic failure (VF) and acquired drug resistance (HIVDR) in large cohorts initiating contemporary antiretroviral therapy (ART). Methods We studied all persons with HIV (PWH) in a California clinic population initiating ART between 2010 and 2017. VF was defined as not attaining virologic suppression, discontinuing ART, or virologic rebound prompting change in ART. Results During the study, 2315 PWH began ART. Six companion drugs were used in 93.3% of regimens: efavirenz, elvitegravir/c, dolutegravir, darunavir/r, rilpivirine, and raltegravir. During a median follow-up of 36 months, 214 (9.2%) PWH experienced VF (2.8 per 100 person-years) and 62 (2.7%) experienced HIVDR (0.8 per 100 person-years). In multivariable analyses, younger age, lower CD4 count, higher virus load, and atazanavir/r were associated with increased VF risk; lower CD4 count, higher virus load, and nevirapine were associated with increased HIVDR risk. Compared with efavirenz, dolutegravir, raltegravir, and darunavir were associated with reduced HIVDR risk. Risks of VF and HIVDR were not significantly associated with ART initiation year. Of the 62 PWH with HIVDR, 42 received an non-nucleoside RT inhibitor (NNRTI), 15 an integrase-strand transfer inhibitor (INSTI), and 5 a protease inhibitor (PI). Among those with HIVDR on an NNRTI or first-generation INSTI, 59% acquired dual class resistance and 29% developed tenofovir resistance; those receiving a PI or dolutegravir developed just M184V. Conclusions Despite the frequent use of contemporary ART regimens, VF and HIVDR continue to occur. Further efforts are required to improve long-term ART virological responses to prevent the consequences of ongoing HIV-1 replication including virus transmission and HIVDR.
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Affiliation(s)
- Soo-Yon Rhee
- Division of Infectious Diseases, Department of Medicine, Stanford University, Stanford, California, USA
| | - Dana Clutter
- Department of Infectious Diseases, Kaiser Permanente Northern California, South San Francisco, California, USA
| | - C Bradley Hare
- Department of Infectious Diseases, Kaiser Permanente Northern California, San Francisco, California, USA
| | - Christophe T Tchakoute
- Division of Epidemiology and Population Health, Department of Medicine, Stanford University, Stanford, California, USA
| | - Kristin Sainani
- Division of Epidemiology and Population Health, Department of Medicine, Stanford University, Stanford, California, USA
| | - W Jeffrey Fessel
- Department of Infectious Diseases, Kaiser Permanente Northern California, San Francisco, California, USA
| | - Leo Hurley
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Sally Slome
- Department of Infectious Diseases, Kaiser Permanente Northern California, Oakland, California, USA
| | - Benjamin A Pinsky
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Michael J Silverberg
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Robert W Shafer
- Division of Infectious Diseases, Department of Medicine, Stanford University, Stanford, California, USA
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8
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Treatment modification after starting cART in people living with HIV: retrospective analysis of the German ClinSurv HIV Cohort 2005-2017. Infection 2020; 48:723-733. [PMID: 32613529 PMCID: PMC7519003 DOI: 10.1007/s15010-020-01469-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 06/21/2020] [Indexed: 11/23/2022]
Abstract
Objective Combination antiretroviral therapy (cART) has markedly increased survival and quality of life in people living with HIV. With the advent of new treatment options, including single-tablet regimens, durability and efficacy of first-line cART regimens are evolving. Methods We analyzed data from the prospective multicenter German Clinical Surveillance of HIV Disease (ClinSurv) cohort of the Robert-Koch Institute. Kaplan–Meier and Cox proportional hazards models were run to examine the factors associated with treatment modification. Recovery after treatment initiation was analyzed comparing pre-cART viral load and CD4+ T-cell counts with follow-up data. Results We included 8788 patients who initiated cART between 2005 and 2017. The sample population was predominantly male (n = 7040; 80.1%), of whom 4470 (63.5%) were reporting sex with men as the transmission risk factor. Overall, 4210 (47.9%) patients modified their first-line cART after a median time of 63 months (IQR 59–66). Regimens containing integrase strand transfer inhibitors (INSTI) were associated with significantly lower rates of treatment modification (adjusted hazard ratio 0.44; 95% CI 0.39–0.50) compared to protease inhibitor (PI)-based regimens. We found a decreased durability of first-line cART significantly associated with being female, a low CD4+ T-cell count, cART initiation in the later period (2011–2017), being on a multi-tablet regimen (MTR). Conclusions Drug class and MTRs are significantly associated with treatment modification. INSTI-based regimens showed to be superior compared to PI-based regimens in terms of durability. Electronic supplementary material The online version of this article (10.1007/s15010-020-01469-6) contains supplementary material, which is available to authorized users.
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9
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High effectiveness of recommended first-line antiretroviral therapies in Germany: a nationwide, prospective cohort study. Infection 2020; 48:453-461. [PMID: 32394345 DOI: 10.1007/s15010-020-01428-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 04/13/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Current German/Austrian antiretroviral treatment guidelines recommend more than 20 combination regimens for first-line therapy, without a preference. Regimens include two nucleoside reverse transcriptase inhibitors (NRTIs) plus either an integrase strand transfer inhibitor (INSTI), a non-NRTI (NNRTI) or a boosted protease inhibitor (PI). The objective was to examine the outcomes of recommended first-line ART in Germany. METHODS This nationwide observational study included treatment-naïve chronically HIV-1 infected patients receiving one of the recommended first-line regimens. Patients were allocated to three arms (INSTI, NNRTI, PI) and were prospectively followed for 24 months. Delayed treatment initiation was defined by a baseline CD4 T-cell count of < 350/µl or CDC clinical stage C. RESULTS Among a total of 434 patients enrolled, virologic failure was rare and occurred in 4.3% (6/141) in the PI arm, in 3.3% (4/122) in the NNRTI arm and in 0.6% (1/171) in the INSTI arm (p = 0.10). De novo drug resistance mutations developed in only two patients in the NNRTI arm. Nonetheless, treatment modifications were frequent (51%) and mostly performed for strategic reasons. Retention on all initial compounds at month 24 was 64%, 49%, and 22% in the INSTI, NNRTI and PI arms respectively. Delayed treatment initiation was common (47%) and more frequently observed in patients in the PI arm. It was not associated with virological failure. CONCLUSION High efficacy and low virological failure rates were observed with recommended first-line regimens independent of delayed treatment initiation, chosen regimen and subsequent treatment modifications, demonstrating the validity of the current treatment guidelines.
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