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Chiappini E, Lisi C, Giacomet V, Erba P, Bernardi S, Zangari P, Di Biagio A, Taramasso L, Giaquinto C, Rampon O, Gabiano C, Garazzino S, Tagliabue C, Esposito S, Bruzzese E, Badolato R, Zanaboni D, Cellini M, Dedoni M, Mazza A, Pession A, Giannini AM, Salvini F, Dodi I, Carloni I, Cazzato S, Tovo PA, de Martino M, Galli L. Off-label use of combined antiretroviral therapy, analysis of data collected by the Italian Register for HIV-1 infection in paediatrics in a large cohort of children. BMC Infect Dis 2022; 22:55. [PMID: 35033018 PMCID: PMC8760752 DOI: 10.1186/s12879-022-07026-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 12/31/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early start of highly active antiretroviral therapy (HAART) in perinatally HIV-1 infected children is the optimal strategy to prevent immunological and clinical deterioration. To date, according to EMA, only 35% of antiretroviral drugs are licenced in children < 2 years of age and 60% in those aged 2-12 years, due to the lack of adequate paediatric clinical studies on pharmacokinetics, pharmacodynamics and drug safety in children. METHODS An observational retrospective study investigating the rate and the outcomes of off-label prescription of HAART was conducted on 225 perinatally HIV-1 infected children enrolled in the Italian Register for HIV Infection in Children and followed-up from 2001 to 2018. RESULTS 22.2% (50/225) of included children were receiving an off-label HAART regimen at last check. Only 26% (13/50) of off-label children had an undetectable viral load (VL) before the commencing of the regimen and the 52.0% (26/50) had a CD4 + T lymphocyte percentage > 25%. At last check, during the off label regimen, the 80% (40/50) of patients had an undetectable VL, and 90% (45/50) of them displayed CD4 + T lymphocyte percentage > 25%. The most widely used off-label drugs were: dolutegravir/abacavir/lamivudine (16%; 8/50), emtricitbine/tenofovir disoproxil (22%; 11/50), lopinavir/ritonavir (20%; 10/50) and elvitegravir/cobicistat/emtricitabine/ tenofovir alafenamide (10%; 10/50). At logistic regression analysis, detectable VL before starting the current HAART regimen was a risk factor for receiving an off-label therapy (OR: 2.41; 95% CI 1.13-5.19; p = 0.024). Moreover, children < 2 years of age were at increased risk for receiving off-label HAART with respect to older children (OR: 3.24; 95% CI 1063-7.3; p = 0.001). Even if our safety data regarding off-label regimens where poor, no adverse event was reported. CONCLUSION The prescription of an off-label HAART regimen in perinatally HIV-1 infected children was common, in particular in children with detectable VL despite previous HAART and in younger children, especially those receiving their first regimen. Our data suggest similar proportions of virological and immunological successes at last check among children receiving off-label or on-label HAART. Larger studies are needed to better clarify efficacy and safety of off-label HAART regimens in children, in order to allow the enlargement of on-label prescription in children.
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Affiliation(s)
- Elena Chiappini
- Paediatric Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Viale Pieraccini, 24, 50100, Florence, Italy.
| | - Catiuscia Lisi
- Paediatric Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Viale Pieraccini, 24, 50100, Florence, Italy
| | - Vania Giacomet
- Paediatric Infectious Diseases Unit, Department of Paediatrics, ASST FBF SACCO, University of Milan, Milan, Italy
| | - Paola Erba
- Paediatric Infectious Diseases Unit, Department of Paediatrics, ASST FBF SACCO, University of Milan, Milan, Italy
| | - Stefania Bernardi
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paola Zangari
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonio Di Biagio
- Infectious Disease Unit, Ospedale Policlinico San Martino, University of Genova, Genova, Italy
| | - Lucia Taramasso
- Infectious Disease Unit, Ospedale Policlinico San Martino, University of Genova, Genova, Italy
| | - Carlo Giaquinto
- Department of Women and Child Health, University of Padova, Padova, Italy
| | - Osvalda Rampon
- Department of Women and Child Health, University of Padova, Padova, Italy
| | - Clara Gabiano
- Paediatric Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Silvia Garazzino
- Paediatric Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Claudia Tagliabue
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Susanna Esposito
- Paediatric Clinic, Pietro Barilla Children's Hospital, University of Parma, Parma, Italy
| | - Eugenia Bruzzese
- Department of Translational Medical Sciences, Section of Paediatrics, University of Naples Federico II, Naples, Italy
| | - Raffaele Badolato
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Domenico Zanaboni
- Department On Internal Medicine and Therapeutics, IRCCS Policlinico "S. Matteo" Foundation, University of Pavia, Pavia, Italy
| | - Monica Cellini
- Department of Medical and Surgical Sciences, Section of Paediatric Hemato-Oncology, University of Modena and Reggio Emilia, Modena, Italy
| | - Maurizio Dedoni
- Department of Paediatrics, Ospedale Microcitemico, Cagliari, Italy
| | - Antonio Mazza
- Paediatric Unit, "S. Chiara" Hospital, Trento, Italy
| | - Andrea Pession
- Andrea Pession, Paediatric Unit, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
| | - Anna Maria Giannini
- Paediatric Infectious Diseases Unit, University Hospital Policlinico Giovanni XXIII, Bari, Italy
| | - Filippo Salvini
- Department of Paediatrics, University of Milan, Niguarda Hospital, Milan, Italy
| | - Icilio Dodi
- Paediatric Clinic, Pietro Barilla Children's Hospital, University of Parma, Parma, Italy
| | - Ines Carloni
- Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
| | | | - Pier Angelo Tovo
- Paediatric Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy
| | - Maurizio de Martino
- Paediatric Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Viale Pieraccini, 24, 50100, Florence, Italy
| | - Luisa Galli
- Paediatric Infectious Diseases Unit, Department of Health Sciences, Anna Meyer Children's University Hospital, University of Florence, Viale Pieraccini, 24, 50100, Florence, Italy
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Rosenberg YJ, Jiang X, Cheever T, Coulter FJ, Pandey S, Sack M, Mao L, Urban L, Lees J, Fischer M, Smedley J, Sidener H, Stanton J, Haigwood NL. Protection of Newborn Macaques by Plant-Derived HIV Broadly Neutralizing Antibodies: a Model for Passive Immunotherapy during Breastfeeding. J Virol 2021; 95:e0026821. [PMID: 34190597 PMCID: PMC8387040 DOI: 10.1128/jvi.00268-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/10/2021] [Indexed: 12/16/2022] Open
Abstract
Preventing human immunodeficiency virus (HIV) infection in newborns by vertical transmission remains an important unmet medical need in resource-poor areas where antiretroviral therapy (ART) is not available and mothers and infants cannot be treated prepartum or during the breastfeeding period. In the present study, the protective efficacy of the potent HIV-neutralizing antibodies PGT121 and VRC07-523, both produced in plants, were assessed in a multiple-SHIV (simian-human immunodeficiency virus)-challenge breastfeeding macaque model. Newborn macaques received either six weekly subcutaneous injections with PGT121 alone or as a cocktail of PGT121-LS plus VRC07-523-LS injected three times every 2 weeks. Viral challenge with SHIVSF162P3 was twice weekly over 5.5 weeks using 11 exposures. Despite the transient presence of plasma viral RNA either immediately after the first challenge or as single-point blips, the antibodies prevented a productive infection in all babies with no sustained plasma viremia, compared to viral loads ranging from 103 to 5 × 108 virions/ml in four untreated controls. No virus was detected in peripheral blood mononuclear cells (PBMCs), and only 3 of 159 tissue samples were weakly positive in the treated babies. Newborn macaques proved to be immunocompetent, producing transient anti-Env antibodies and anti-drug antibody (ADA), which were maintained in the circulation after passive broadly neutralizing antibody clearance. ADA responses were directed to the IgG1 Fc CH2-CH3 domains, which has not been observed to date in adult monkeys passively treated with PGT121 or VRC01. In addition, high levels of VRC07-523 anti-idiotypic antibodies in the circulation of one newborn was concomitant with the rapid elimination of VRC07. Plant-expressed antibodies show promise as passive immunoprophylaxis in a breastfeeding model in newborns. IMPORTANCE Plant-produced human neutralizing antibody prophylaxis is highly effective in preventing infection in newborn monkeys during repeated oral exposure, modeling virus in breastmilk, and offers advantages in cost of production and safety. These findings raise the possibility that anti-Env antibodies may contribute to the control of viral replication in this newborn model and that the observed immune responsiveness may be driven by the long-lived presence of immune complexes.
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Affiliation(s)
| | | | - Tracy Cheever
- Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Felicity J. Coulter
- Department of Molecular Microbiology & Immunology, Oregon Health & Science University, Portland, Oregon, USA
| | - Shilpi Pandey
- Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon, USA
| | | | - Lingjun Mao
- PlantVax Corporation, Rockville, Maryland, USA
| | - Lori Urban
- PlantVax Corporation, Rockville, Maryland, USA
| | | | - Miranda Fischer
- Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Jeremy Smedley
- Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Heather Sidener
- Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Jeffrey Stanton
- Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Nancy L. Haigwood
- Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon, USA
- Department of Molecular Microbiology & Immunology, Oregon Health & Science University, Portland, Oregon, USA
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Abstract
When addressing the compatibility of breastfeeding with certain maternal conditions, we need to differentiate between "contraindication" and "obstacle." Failure to distinguish between the two confuses new mothers and their families, and engenders misconceptions about breastfeeding advice by health professionals. Health conditions that may simply impede the initiation and duration of breastfeeding are often wrongly referred to as true contraindications to breastfeed, under the assumption that they might harm the health of the mother and/or that of the nursing infant. Here, we discuss several topics, including breast surgery, prolactinoma, concurrent new pregnancy, hormonal contraception, and use of medications and contrast agents, that continue to raise controversy. While most conditions appear to be compatible with breastfeeding, the major determinants of a woman's final choice of whether to nurse her infant or not are the attitude of health professionals and the state of mind of being an informed mother.
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Affiliation(s)
- Riccardo Davanzo
- Division of Pediatrics and Neonatology, Department of Mother and Child Health, Ospedale Madonna delle Grazie, Matera, Italy.,Task Force on Breastfeeding, Ministry of Health, Rome, Italy
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