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Dalwadi DA, Ozuna L, Harvey BH, Viljoen M, Schetz JA. Adverse Neuropsychiatric Events and Recreational Use of Efavirenz and Other HIV-1 Antiretroviral Drugs. Pharmacol Rev 2018; 70:684-711. [DOI: 10.1124/pr.117.013706] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Baxi SM, Greenblatt RM, Bacchetti P, Cohen M, DeHovitz JA, Anastos K, Gange SJ, Young MA, Aouizerat BE. Evaluating the association of single-nucleotide polymorphisms with tenofovir exposure in a diverse prospective cohort of women living with HIV. THE PHARMACOGENOMICS JOURNAL 2017; 18:245-250. [PMID: 28462920 DOI: 10.1038/tpj.2017.3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 12/20/2016] [Accepted: 01/18/2017] [Indexed: 12/19/2022]
Abstract
Higher exposure to tenofovir (TFV) increases the risk for kidney function decline, but the impact of genetic factors on TFV exposure is largely unknown. We investigated whether single-nucleotide polymorphisms (SNPs, n=211) in 12 genes are potentially involved in TFV exposure. Participants (n=91) from the Women's Interagency HIV Study, underwent a 24 h intensive pharmacokinetic sampling of TFV after witnessed dose and TFV area under the time-concentration curves (AUCs) were calculated for each participant. SNPs were assayed using a combination of array genotyping and Sanger sequencing. Linear regression models were applied to logarithmically transformed AUC. Those SNPs that met an a priori threshold of P<0.001 were considered statistically associated with TFV AUC. ABCG2 SNP rs2231142 was associated with TFV AUC with rare allele carriers displaying 1.51-fold increase in TFV AUC (95% confidence interval: 1.26, 1.81; P=1.7 × 10-5). We present evidence of a moderately strong effect of the rs2231142 SNP in ABCG2 on a 24 h TFV AUC.
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Affiliation(s)
- S M Baxi
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - R M Greenblatt
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - P Bacchetti
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - M Cohen
- CORE Center, Division of Infectious Diseases, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - J A DeHovitz
- Division of Infectious Diseases, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - K Anastos
- Departments of Medicine and Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - S J Gange
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - M A Young
- Department of Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - B E Aouizerat
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA.,Bluestone Center for Clinical Research, College of Dentistry, New York University, New York, NY, USA.,Department of Oral and Maxillofacial Surgery, College of Dentistry, New York University, New York, NY, USA
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He L, Pan X, Dou Z, Huang P, Zhou X, Peng Z, Zheng J, Zhang J, Yang J, Xu Y, Jiang J, Chen L, Jiang J, Wang N. The Factors Related to CD4+ T-Cell Recovery and Viral Suppression in Patients Who Have Low CD4+ T Cell Counts at the Initiation of HAART: A Retrospective Study of the National HIV Treatment Sub-Database of Zhejiang Province, China, 2014. PLoS One 2016; 11:e0148915. [PMID: 26900702 PMCID: PMC4764673 DOI: 10.1371/journal.pone.0148915] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 01/24/2016] [Indexed: 11/18/2022] Open
Abstract
Background Since China has a unique system of delivering HIV care that includes all patients’ records. The factors related to CD4+ T-cell recovery and viral suppression in patients who have low CD4+ T cell counts at the initiation of HAART are understudied in the China despite subsequent virological suppression (viral load < 50 copies/mL) is unknown. Methods The authors conducted a retrospective cohort study using data from the national HIV treatment sub-database of Zhejiang province to identify records of HIV+ patients. Patient records were included if they were ≥ 16 years of age, had an initial CD4 count < 100 cells/μL, were on continuous HAART for at least one year by the end of December 31, 2014; and achieved and maintained continued maximum virological suppression (MVS) (< 50 copies/ml) by 9 months after starting HAART. The primary endpoint for analysis was time to first CD4+ T cell count recovery (≥ 200, 350, 500 cells/μL). Cox proportional hazard regression was used to identify the risk factors for CD4+ T cell count recovery to key thresholds (200–350, 350–500, ≥ 500 cells/μL) by the time of last clinical follow-up (whichever occurred first), key thresholds (follow-up date for analysis), with patients still unable to reach the endpoints being censored by the end December 31, 2014 (follow-up date for analysis). Results Of the 918 patients who were included in the study, and the median CD4+ T cell count was 39 cells/μL at the baseline. At the end of follow-up, 727 (79.2%), 363 (39.5%) and 149 (16.2%) patients had return to ≥ 200, 350, and 500 cells/μL, respectively. Kaplan-Meier analysis demonstrated that the rate of patients with CD4+ count recovery to ≥ 200, 350, and 500 cells/μL after 1 year on HAART was 43.6, 8.6, and 2.5%, respectively, after 3 years on treatment was 90.8, 46.3, and 17.9%, respectively, and after 5 years on HAART was 97.1, 72.2, and 36.4%, respectively. The median time to return to 200–350, 350–500, ≥ 500cells/μL was 1.11, 3.33 and 6.91 years, respectively. Factors of age (aHR = 0.77, 95%CI 0.61–0.97), baseline CD4+ count (aHR = 1.60, 95%CI 1.37–1.86), initial regimens, changes in regimen (aHR = 0.58, 95%CI 0.49–0.69), and inclusion of a cotrimoxazole prophylaxis (aHR = 0.66, 95%CI 0.51–0.85) were associated with CD4+ T cell count recovery. Conclusion The proportion of patients with initially low CD4 counts after nine months of treatment and that achieved continuous virological suppression was greater than 70% for persons with CD4+ count ≥ 350. Conversely, only 35% of patients recovered to levels of 500 cells/μL after 5 years of treatment, and levels continued to rise significantly with further long-term HAART. Early HAART intervention will be necessary for achieving effective CD4+ T cell responses and optimal immunological function in HIV+ patients.
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Affiliation(s)
- Lin He
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Xiaohong Pan
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
- * E-mail: (XP); (NW)
| | - Zhihui Dou
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Peng Huang
- Department of Epidemiology & Biostatics, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xin Zhou
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Zhihang Peng
- Department of Epidemiology & Biostatics, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jinlei Zheng
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Jiafeng Zhang
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Jiezhe Yang
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Yun Xu
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Jun Jiang
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Lin Chen
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Jianmin Jiang
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
| | - Ning Wang
- National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- * E-mail: (XP); (NW)
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Baxi SM, Scherzer R, Greenblatt RM, Minkoff H, Sharma A, Cohen M, Young MA, Abraham AG, Shlipak MG. Higher tenofovir exposure is associated with longitudinal declines in kidney function in women living with HIV. AIDS 2016; 30:609-18. [PMID: 26558723 PMCID: PMC4782771 DOI: 10.1097/qad.0000000000000958] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Tenofovir disoproxil fumarate is a commonly used antiretroviral drug, but risk factors for tenofovir (TFV)-associated kidney disease are not fully understood. We used intensive pharmacokinetic studies in a cohort of HIV-infected women on TFV-based therapy to study the relationship between TFV exposure and subsequent kidney function. DESIGN This is a nested study within the Women's Interagency HIV Study, a multicenter, prospective cohort of HIV-infected women. Participants on TFV-based therapy underwent 24-h intensive pharmacokinetic sampling after witnessed dose. Kidney function was measured over the succeeding 7 years by serum creatinine [estimated glomerular filtration rate calculated by serum creatinine (eGFRcr)]. METHODS Multivariable linear mixed models evaluated the relationship of baseline TFV area under the-time concentration curves (AUCs) with subsequent changes in kidney function. Covariates included age, diabetes, hypertension, race, BMI, ritonavir use, duration of TFV exposure, current CD4 cell count, and HIV viral load. RESULTS Of the 105 participants, persons within the highest baseline TFV AUC tertile had significantly lower eGFRcr compared with those in the lowest tertile (mean ± standard error: 80 ± 4.3 vs. 104 ± 2.5 ml/min per 1.73 m, P < 0.0001). By year 7, this difference widened (72 ± 4.9 vs. 105 ± 2.9, P < 0.0001). After multivariable adjustment, TFV AUC in the highest tertile remained associated with lower eGFRcr relative to values in the lowest tertile at both baseline (-15 ml/min per 1.73 m, P = 0.0047) and year 7 (-23 ml/min per 1.73 m, P = 0.0002). CONCLUSION Through intensive TFV pharmacokinetic sampling, we found a strong association between greater TFV exposure and subsequent decline in kidney function. Variations in TFV drug exposure may partially account for subsequent nephrotoxicity in persons infected with HIV.
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Affiliation(s)
- Sanjiv M. Baxi
- Department of Medicine, University of California, San Francisco
- School of Public Health, University of California, Berkeley
| | - Rebecca Scherzer
- Department of Medicine, University of California, San Francisco
- General Internal Medicine Division, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, California
| | - Ruth M. Greenblatt
- Department of Clinical Pharmacy, University of California, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Howard Minkoff
- Division of Infectious Diseases, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Anjali Sharma
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Mardge Cohen
- CORE Center/Division of Infectious Diseases, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Mary A. Young
- Department of Medicine, Georgetown University Medical Center, Washington DC
| | - Alison G. Abraham
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Michael G. Shlipak
- Department of Medicine, University of California, San Francisco
- General Internal Medicine Division, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
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Hessol NA, Holman S, Minkoff H, Cohen MH, Golub ET, Kassaye S, Karim R, Sosanya O, Shaheen C, Merhi Z. Menstrual cycle phase and single tablet antiretroviral medication adherence in women with HIV. AIDS Care 2015; 28:11-21. [PMID: 26274806 DOI: 10.1080/09540121.2015.1069787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Suboptimal adherence to antiretroviral (ARV) therapy among HIV-infected individuals is associated with increased risk of progression to AIDS and the development of HIV resistance to ARV medications. To examine whether the luteal phase of the menstrual cycle is independently associated with suboptimal adherence to single tablet regimen (STR) ARV medication, data were analyzed from a multicenter cohort study of HIV-infected women who reported regular menstrual cycles and were taking an STR. In a cross-sectional analysis, suboptimal adherence to an STR among women in their follicular phase was compared with suboptimal adherence among women in their luteal phase. In two-way crossover analyses, whereby the same woman was assessed for STR medication adherence in both her follicular and luteal phases, the estimated exact conditional odds of non-adherence to an STR was measured. In adjusted logistic regression analysis of the cross-sectional data (N=327), women with ≤12 years of education were more than three times more likely to have suboptimal adherence (OR=3.6, p=.04) compared to those with >12 years of education. Additionally, women with Center for Epidemiological Studies Depression Scale (CES-D) scores ≥23 were 2.5-times more likely to have suboptimal adherence (OR=2.6, p=.02) compared to those with CES-D scores <23. In conditional logistic regression analyses of the crossover data (N=184), having childcare responsibilities was associated with greater odds of ≤95% adherence. Menstrual cycle phase was not associated with STR adherence in either the cross-sectional or crossover analyses. The lack of association between phase of the menstrual cycle and adherence to an STR in HIV-infected women means attention can be given to other more important risk factors for suboptimal adherence, such as depression, level of education, and childcare responsibilities.
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Affiliation(s)
- Nancy A Hessol
- a Departments of Clinical Pharmacy and of Medicine , University of California , 3333 California Street, Suite 420, San Francisco , CA 94143-0613 , USA
| | - Susan Holman
- b Department of Medicine, College of Medicine and Department of Community Health Sciences, School of Public Health , State University of New York Downstate Medical Center , 450 Clarkson Avenue, Brooklyn , NY , USA
| | - Howard Minkoff
- c Department of Obstetrics & Gynecology , Maimonides Medical Center , 967 48th Street, Brooklyn , NY , USA
| | - Mardge H Cohen
- d CORE Center , Cook County Health and Hospital System , 2225 W. Harrison Street, Chicago , IL , USA.,e Department of Medicine , Cook County Health and Hospital System and Rush University , 2225 W. Harrison Street, Chicago , IL , USA
| | - Elizabeth T Golub
- f Department of Epidemiology , Bloomberg School of Public Health , Johns Hopkins University, 615 N. Wolfe Street, Baltimore , MD , USA
| | - Seble Kassaye
- g Georgetown University School of Medicine , 2115 Wisconsin Avenue, NW, Washington DC , USA
| | - Roksana Karim
- h Department of Preventive Medicine , Keck School of Medicine, University of Southern California , 1540 Alcazar, Los Angeles , CA , USA
| | - Oluwakemi Sosanya
- i Division of Internal Medicine , Montefiore Medical Center , 3311 Bainbridge Avenue, Bronx , NY , USA
| | - Christopher Shaheen
- j Department of Clinical Pharmacy , University of California , 3333 California Street, San Francisco , CA , USA
| | - Zaher Merhi
- k Department of Obstetrics and Gynecology , New York University School of Medicine , 180 Varick Street, New York , NY , USA
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Abstract
PURPOSE OF REVIEW Long-acting injectable antiretroviral therapy (ART) formulations hold great promise in helping to close the significant gap between efficacy and effectiveness in HIV treatment by eliminating the requirement for lifelong daily pills. However, significant systems-level and individual challenges to implementation of long-acting ART in HIV treatment are anticipated. RECENT FINDINGS Studies of long-acting ART formulations are burgeoning, but the drugs are still in early phases of investigation and key knowledge gaps in pharmacokinetics and pharmacodynamics, as well as their effectiveness in settings with the largest burden of HIV disease and in key populations, remain. Extrapolating from the literature on implementation barriers to using long-acting contraception on a global scale, we explore the implementation barriers to rolling-out long-acting ART, including country approval and endorsements; prioritization of patient populations for preferred use, clinic infrastructure requirements, steady supply chains, decentralization of care, provider and patient training programs, and laboratory monitoring; and the need to examine patient preferences and conduct rigorous implementation science research to effectively scale-up this intervention. SUMMARY Long-acting ART for HIV treatment harbors exciting potential to shift treatment paradigms. Current knowledge gaps in the use of these agents remain, leading to multiple anticipated systems-level and individual-level barriers to implementation. Addressing these gaps and barriers will help fulfill the promise of these agents against the pandemic.
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Affiliation(s)
- Diane Havlir
- Department of Medicine, HIV/AIDS Division, University of California, San Francisco, San Francisco, California, USA
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Luetkemeyer AF, Rosenkranz SL, Lu D, Grinsztejn B, Sanchez J, Ssemmanda M, Sanne I, McIlleron H, Havlir DV, Haas DW. Combined effect of CYP2B6 and NAT2 genotype on plasma efavirenz exposure during rifampin-based antituberculosis therapy in the STRIDE study. Clin Infect Dis 2015; 60:1860-3. [PMID: 25722197 DOI: 10.1093/cid/civ155] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 02/18/2015] [Indexed: 01/11/2023] Open
Abstract
In STRIDE, slow metabolizer CYP2B6 and NAT2 genotypes were each associated with increased plasma efavirenz concentrations during antituberculosis therapy. Concentrations were greater on therapy than off therapy in 58% with CYP2B6 and 93% with NAT2 slow metabolizer genotypes. Individuals with slow metabolizer genotypes in both genes had markedly elevated concentrations.
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Affiliation(s)
- Anne F Luetkemeyer
- HIV/AIDS Division, San Francisco General Hospital, University of California, San Francisco
| | - Susan L Rosenkranz
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts
| | - Darlene Lu
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts
| | - Beatriz Grinsztejn
- Fundacao Oswaldo Cruz, Instituto de Pesquisa Clinica Evandro Chagas, Rio de Janeiro, Brazil
| | | | | | - Ian Sanne
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
| | - Diane V Havlir
- HIV/AIDS Division, San Francisco General Hospital, University of California, San Francisco
| | - David W Haas
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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Rosin C, Elzi L, Thurnheer C, Fehr J, Cavassini M, Calmy A, Schmid P, Bernasconi E, Battegay M. Gender inequalities in the response to combination antiretroviral therapy over time: the Swiss HIV Cohort Study. HIV Med 2014; 16:319-25. [PMID: 25329751 DOI: 10.1111/hiv.12203] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Gender-specific data on the outcome of combination antiretroviral therapy (cART) are a subject of controversy. We aimed to compare treatment responses between genders in a setting of equal access to cART over a 14-year period. METHODS Analyses included treatment-naïve participants in the Swiss HIV Cohort Study starting cART between 1998 and 2011 and were restricted to patients infected by heterosexual contacts or injecting drug use, excluding men who have sex with men. RESULTS A total of 3925 patients (1984 men and 1941 women) were included in the analysis. Women were younger and had higher CD4 cell counts and lower HIV RNA at baseline than men. Women were less likely to achieve virological suppression < 50 HIV-1 RNA copies/mL at 1 year (75.2% versus 78.1% of men; P = 0.029) and at 2 years (77.5% versus 81.1%, respectively; P = 0.008), whereas no difference between sexes was observed at 5 years (81.3% versus 80.5%, respectively; P = 0.635). The probability of virological suppression increased in both genders over time (test for trend, P < 0.001). The median increase in CD4 cell count at 1, 2 and 5 years was generally higher in women during the whole study period, but it gradually improved over time in both sexes (P < 0.001). Women also were more likely to switch or stop treatment during the first year of cART, and stops were only partly driven by pregnancy. In multivariate analysis, after adjustment for sociodemographic factors, HIV-related factors, cART and calendar period, female gender was no longer associated with lower odds of virological suppression. CONCLUSIONS Gender inequalities in the response to cART are mainly explained by the different prevalence of socioeconomic characteristics in women compared with men.
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Affiliation(s)
- C Rosin
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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Crawford KW, Wakabi S, Magala F, Kibuuka H, Liu M, Hamm TE. Evaluation of treatment outcomes for patients on first-line regimens in US President's Emergency Plan for AIDS Relief (PEPFAR) clinics in Uganda: predictors of virological and immunological response from RV288 analyses. HIV Med 2014; 16:95-104. [PMID: 25124078 DOI: 10.1111/hiv.12177] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Viral load (VL) monitoring is recommended, but seldom performed, in resource-constrained countries. RV288 is a US President's Emergency Plan for AIDS Relief (PEPFAR) basic programme evaluation to determine the proportion of patients on treatment who are virologically suppressed and to identify predictors of virological suppression and recovery of CD4 cell count. Analyses from Uganda are presented here. METHODS In this cross-sectional, observational study, patients on first-line antiretroviral therapy (ART) (efavirenz or nevirapine+zidovudine/lamivudine) from Kayunga District Hospital and Kagulamira Health Center were randomly selected for a study visit that included determination of viral load (HIV-1 RNA), CD4 cell count and clinical chemistry tests. Subjects were recruited by time on treatment: 6-12, 13-24 or >24 months. Logistic regression modelling identified predictors of virological suppression. Linear regression modelling identified predictors of CD4 cell count recovery on ART. RESULTS We found that 85.2% of 325 subjects were virologically suppressed (viral load<47 HIV-1 RNA copies/ml). There was no difference in the proportion of virologically suppressed subjects by time on treatment, yet CD4 counts were higher in each successive stratum. Women had higher median CD4 counts than men overall (406 vs. 294 cells/μL, respectively; P<0.0001) and in each time-on-treatment stratum. In a multivariate logistic regression model, predictors of virological suppression included efavirenz use [odds ratio (OR) 0.47; 95% confidence interval (CI) 0.22-1.02; P=0.057], lower cost of clinic visits (OR 0.815; 95% CI 0.66-1.00; P=0.05), improvement in CD4 percentage (OR 1.06; 95% CI 1.014-1.107; P=0.009), and care at Kayunga vs. Kangulamira (OR 0.47; 95% CI 0.23-0.92; P=0.035). In a multivariate linear regression model of covariates associated with CD4 count recovery, time on highly active antiretroviral therapy (ART) (P<0.0001), patient satisfaction with care (P=0.038), improvements in total lymphocyte count (P<0.0001) and haemoglobin concentration (P=0.05) were positively associated, whereas age at start of ART (P=0.0045) was negatively associated with this outcome. CONCLUSIONS High virological suppression rates are achievable on first-line ART in Uganda. The odds of virological suppression were positively associated with efavirenz use and improvements in CD4 cell percentage and total lymphocyte count and negatively associated with the cost of travel to the clinic. CD4 cell reconstitution was positively associated with CD4 count at study visit, time on ART, satisfaction with care at clinic, haemoglobin concentration and total lymphocyte count and negatively associated with age.
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Affiliation(s)
- K W Crawford
- U.S. Military HIV Research Program (MHRP), Global Health Programs, Walter Reed Army Institute of Research, Bethesda, MD, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
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Borand L, Madec Y, Laureillard D, Chou M, Marcy O, Pheng P, Prak N, Kim C, Lak KK, Hak C, Dim B, Nerrienet E, Fontanet A, Sok T, Goldfeld AE, Blanc FX, Taburet AM. Plasma concentrations, efficacy and safety of efavirenz in HIV-infected adults treated for tuberculosis in Cambodia (ANRS 1295-CIPRA KH001 CAMELIA trial). PLoS One 2014; 9:e90350. [PMID: 24608960 PMCID: PMC3946522 DOI: 10.1371/journal.pone.0090350] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 01/27/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To assess efavirenz plasma concentrations and their association with treatment efficacy and tolerance of efavirenz 600 mg daily in HIV-tuberculosis co-infected patients. METHODS HIV-infected adults with CD4+ T cell count ≤ 200/mm(3) received standard 6-month tuberculosis treatment and antiretroviral therapy including a daily-dose of 600 mg of efavirenz, irrespective of their body weight. Mid-dose blood samples were drawn both on tuberculosis treatment (week +2 and week +6 after antiretroviral therapy initiation, and week 22 of follow-up) and off tuberculosis treatment (week 50 of follow-up). Considered therapeutic range was 1,000 to 4,000 ng/mL. Multivariate analysis was performed to evaluate the association between efavirenz concentration below 1,000 ng/mL and virological failure. Linear regression was used to test the association between efavirenz exposure and CD4+ T cell gain. Severe side effects potentially related to efavirenz were described and their association with efavirenz exposure was tested by multivariate analysis. RESULTS Efavirenz plasma concentrations were available in 540 patients. Median [interquartile range] efavirenz concentrations were 2,674 ng/mL [1,690-4,533], 2,667 ng/mL [1,753-4,494] and 2,799 ng/mL [1,804-4,744] at week +2, week +6, week 22, respectively, and 2,766 ng/mL [1,941-3,976] at week 50. Efavirenz concentrations were lower at week 50 (off rifampicin) compared to week 22 (on rifampicin) (p<0.001). Late attendance to study visit and low hemoglobinemia were the only factors associated with an increased risk of efavirenz concentration below 1,000 ng/mL. Efavirenz concentration below 1,000 ng/mL was not associated with treatment failure. Efavirenz concentration above 4,000 ng/mL was associated with higher risk of central nervous system side effects (p<0.001) and of hepatotoxicity (p<0.001). CONCLUSION Body weight and tuberculosis treatment were not associated with low efavirenz concentrations or treatment failure, supporting the 600 mg daily-dose of efavirenz in HIV-tuberculosis co-infected patients. High efavirenz concentrations were related to a higher risk of central nervous system side effects and hepatotoxicity. TRIAL REGISTRATION ClinicalTrials.gov NCT01300481.
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Affiliation(s)
- Laurence Borand
- Institut Pasteur du Cambodge, Epidemiology and Public Health Unit, Phnom Penh, Cambodia
| | - Yoann Madec
- Institut Pasteur, Unité de Recherche et d'Expertise Epidémiologie des Maladies Emergentes, Paris, France
| | | | - Monidarin Chou
- Faculty of Pharmacy, University of Health Sciences, Phnom Penh, Cambodia
| | - Olivier Marcy
- Institut Pasteur du Cambodge, Epidemiology and Public Health Unit, Phnom Penh, Cambodia
| | - Phearavin Pheng
- Institut Pasteur du Cambodge, Epidemiology and Public Health Unit, Phnom Penh, Cambodia
| | - Narom Prak
- Khmer-Soviet Friendship Hospital, Phnom Penh, Cambodia
| | - Chindamony Kim
- Donkeo Provincial Hospital, Takeo, Cambodia
- Médecins Sans Frontières, Phnom Penh, Cambodia
| | - Khemarin Kim Lak
- Svay Rieng Provincial Hospital, Svay Rieng, Cambodia
- Cambodian Health Committee, Phnom Penh, Cambodia
| | | | - Bunnet Dim
- Médecins Sans Frontières, Phnom Penh, Cambodia
- Siem Reap Referral Hospital, Siem Reap, Cambodia
| | - Eric Nerrienet
- Institut Pasteur du Cambodge, HIV/Hepatitis Laboratory, Phnom Penh, Cambodia
| | - Arnaud Fontanet
- Institut Pasteur, Unité de Recherche et d'Expertise Epidémiologie des Maladies Emergentes, Paris, France
- Conservatoire National des Arts et Métiers, Paris, France
| | - Thim Sok
- Cambodian Health Committee, Phnom Penh, Cambodia
| | - Anne E. Goldfeld
- Cambodian Health Committee, Phnom Penh, Cambodia
- Program in Cellular and Molecular Medicine, Children's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - François-Xavier Blanc
- Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Hôpitaux Universitaires Paris Sud, Pneumology Department, Le Kremlin-Bicêtre, France
- UMR INSERM 1087 CNRS UMR_6291, l′Institut du Thorax, Service de Pneumologie, CHU de Nantes, DHU2020, Université de Nantes, France
| | - Anne-Marie Taburet
- Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Hôpitaux Universitaires Paris Sud, Clinical Pharmacy Department, Le Kremlin-Bicêtre, France
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11
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Baxi SM, Greenblatt RM, Bacchetti P, Scherzer R, Minkoff H, Huang Y, Anastos K, Cohen M, Gange SJ, Young M, Shlipak MG, Gandhi M. Common clinical conditions - age, low BMI, ritonavir use, mild renal impairment - affect tenofovir pharmacokinetics in a large cohort of HIV-infected women. AIDS 2014; 28:59-66. [PMID: 24275255 PMCID: PMC3956315 DOI: 10.1097/qad.0000000000000033] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Tenofovir is used commonly in HIV treatment and prevention settings, but factors that correlate with tenofovir exposure in real-world settings are unknown. DESIGN Intensive pharmacokinetic studies of tenofovir in a large, diverse cohort of HIV-infected women over 24 h at steady state were performed and factors that influenced exposure [assessed by areas under the concentration-time curves (AUCs)] identified. METHODS HIV-infected women (n = 101) on tenofovir-based therapy underwent intensive 24-h pharmacokinetic sampling. Data on race/ethnicity, age, exogenous steroid use, menstrual cycle phase, concomitant medications, recreational drugs and/or tobacco, hepatic and renal function, weight, and BMI were collected. Multivariable models using forward stepwise selection identified factors associated with effects on AUC. Glomerular filtration rates (GFRs) prior to starting tenofovir were estimated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation using both creatinine and cystatin-C measures. RESULTS The median (range) of tenofovir AUCs was 3350 (1031-13 911) ng × h/ml. Higher AUCs were associated with concomitant ritonavir use (1.33-fold increase, P = 0.002), increasing age (1.21-fold increase per decade, P = 0.0007), and decreasing BMI (1.04-fold increase per 10% decrease in BMI). When GFR was calculated using cystatin-C measures, mild renal insufficiency prior to tenofovir initiation was associated with higher subsequent exposure (1.35-fold increase when pre-tenofovir GFR <70 ml/min, P = 0.0075). CONCLUSION Concomitant ritonavir use, increasing age, decreasing BMI, and lower GFR prior to tenofovir initiation as estimated by cystatin C were all associated with elevated tenofovir exposure in a diverse cohort of HIV-infected women. Clinicians treating HIV-infected women should be aware of common clinical conditions that affect tenofovir exposure when prescribing this medication.
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Micheli JE, Chinn LW, Shugarts SB, Patel A, Martin JN, Bangsberg DR, Kroetz DL. Measuring the overall genetic component of nevirapine pharmacokinetics and the role of selected polymorphisms: towards addressing the missing heritability in pharmacogenetic phenotypes? Pharmacogenet Genomics 2013; 23:591-6. [PMID: 23982262 PMCID: PMC4048019 DOI: 10.1097/fpc.0b013e32836533a5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Nevirapine is an important component of highly active antiretroviral therapy used in the treatment of HIV infection. There is a considerable variation in the pharmacokinetics of nevirapine and this variation can impact the efficacy and toxicity of nevirapine. Although some of this variation can be attributed to environmental factors, the degree to which heritability influences nevirapine pharmacokinetics is unknown. This study aims to estimate how much variation in nevirapine pharmacokinetics is due to genetic factors and to investigate the contribution of selected polymorphisms to this variability. METHODS Two doses of immediate-release nevirapine were administered to European (n=11) and African American (n=6) participants recruited from the Research in Access to Care in the Homeless cohort. A repeated drug administration method was then used to determine the relative genetic contribution (r(GC)) to variability in nevirapine AUC(0-6 h). Nevirapine plasma levels were quantified using LC/MS/MS. Patients were also genotyped for selected polymorphisms in candidate genes that may influence nevirapine pharmacokinetics. RESULTS A significant r(GC) for nevirapine AUC(0-6 h) was found in Europeans (P=0.02) and African Americans (P=0.01). A trend toward higher nevirapine AUC(0-6 h) for the CYP2B6 516TT (rs3745274; Q172H) genotype was observed in European Americans (P=0.19). CONCLUSION This study demonstrates that there is a significant genetic component to variability in nevirapine pharmacokinetics. Although genetic variants such as CYP2B6 polymorphisms attributed to some of this variation, these data suggest that there may be additional genetic factors that influence nevirapine pharmacokinetics.
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Affiliation(s)
- Janine E Micheli
- Departments of aBioengineering and Therapeutic Sciences bEpidemiology cMedicine dThe Institute for Human Genetics, University of California, San Francisco, California eRagon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard University, Massachusetts General Hospital Center for Global Health, Harvard Medical School, Boston, Massachusetts, USA
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13
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Schoen JC, Erlandson KM, Anderson PL. Clinical pharmacokinetics of antiretroviral drugs in older persons. Expert Opin Drug Metab Toxicol 2013; 9:573-88. [PMID: 23514375 DOI: 10.1517/17425255.2013.781153] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Combination antiretroviral therapy has enabled HIV-infected persons to reach older ages in high numbers. Hepatic and renal changes that normally occur with advancing age occur earlier and with higher incidence in HIV-infected individuals. A limited number of prospective controlled studies have demonstrated small reductions (17 to 41%) in lopinavir, atazanavir and lamivudine clearance in older versus younger adults. A much larger number of retrospective studies in adults (age range ∼ 20 to 60 years), including all antiretroviral drugs, have evaluated age as a covariate for pharmacokinetics. Most studies did not detect substantial associations between drug exposures and age. AREAS COVERED This review summarizes antiretroviral drug pharmacokinetics in older persons. The authors review articles from PubMed (search terms: elderly, antiretroviral, pharmacokinetics) in addition to the bibliographies of those selected. EXPERT OPINION The evidence to date does not support major pharmacokinetic changes in adults between ∼ 20 and 60 years of age. However, additional prospective, well-controlled studies are needed in more persons > 60 years, including those with frailty and comorbidities, with assessment of unbound drug clearance, and incorporation of adherence, pharmacogenetics and concomitant medications. Until then, guidelines for drug-drug interactions and dosing in renal and hepatic impairment should be followed in older HIV-infected individuals.
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Affiliation(s)
- John C Schoen
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Anschutz Medical Campus, Aurora, CO, USA
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14
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Pharmacokinetics of phase I nevirapine metabolites following a single dose and at steady state. Antimicrob Agents Chemother 2013; 57:2154-60. [PMID: 23459477 DOI: 10.1128/aac.02294-12] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Nevirapine is one of the most extensively prescribed antiretrovirals worldwide. The present analyses used data and specimens from two prior studies to characterize and compare plasma nevirapine phase I metabolite profiles following a single 200-mg oral dose of nevirapine in 10 HIV-negative African Americans and a steady-state 200-mg twice-daily dose in 10 HIV-infected Cambodians. Nevirapine was assayed by high-performance liquid chromatography (HPLC). The 2-, 3-, 8- and 12-hydroxy and 4-carboxy metabolites of nevirapine were assayed by liquid chromatography-tandem mass spectrometry (LC/MS/MS). Pharmacokinetic parameters were calculated by noncompartmental analysis. The metabolic index for each metabolite was defined as the ratio of the metabolite area under the concentration-time curve (AUC) to the nevirapine AUC. Every metabolite concentration was much less than the corresponding nevirapine concentration. The predominant metabolite after single dose and at steady state was 12-hydroxynevirapine. From single dose to steady state, the metabolic index increased for 3-hydroxynevirapine (P < 0.01) but decreased for 2-hydroxynevirapine (P < 0.001). The 3-hydroxynevirapine metabolic index was correlated with nevirapine apparent clearance (P < 0.001). These findings are consistent with induction of CYP2B6 (3-hydroxy metabolite) and a possible inhibition of CYP3A (2-hydroxy metabolite), although these are preliminary data. There were no such changes in metabolic indexes for 12-hydroxynevirapine or 4-carboxynevirapine. Two subjects with the CYP2B6 *6*6 genetic polymorphism had metabolic indexes in the same range as other subjects. These results suggest that nevirapine metabolite profiles change over time under the influence of enzyme induction, enzyme inhibition, and host genetics. Further work is warranted to elucidate nevirapine biotransformation pathways and implications for drug efficacy and toxicity.
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Gandhi M, Greenblatt RM, Bacchetti P, Jin C, Huang Y, Anastos K, Cohen M, Dehovitz JA, Sharp GB, Gange SJ, Liu C, Hanson SC, Aouizerat B. A single-nucleotide polymorphism in CYP2B6 leads to >3-fold increases in efavirenz concentrations in plasma and hair among HIV-infected women. J Infect Dis 2012; 206:1453-61. [PMID: 22927450 DOI: 10.1093/infdis/jis508] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Efavirenz exhibits marked interindividual variability in plasma levels and toxicities. Prior pharmacogenetic studies usually measure exposure via single plasma levels, examine limited numbers of polymorphisms, and rarely model multiple contributors. We analyzed numerous genetic and nongenetic factors impacting short-term and long-term exposure in a large heterogeneous population of human immunodeficiency virus (HIV)-infected women. METHODS We performed 24-hour intensive pharmacokinetic studies in 111 women receiving efavirenz under actual-use conditions and calculated the area-under-the-concentration-time curve (AUC) to assess short-term exposure; the efavirenz concentration in hair was measured to estimate long-term exposure. A total of 182 single-nucleotide polymorphisms (SNPs) and 45 haplotypes in 9 genes were analyzed in relationship to exposure by use of multivariate models that included a number of nongenetic factors. RESULTS Efavirenz AUCs increased 1.26-fold per doubling of the alanine aminotransferase level and 1.23-fold with orange and/or orange juice consumption. Individuals with the CYP2B6 516TT genotype displayed 3.5-fold increases in AUCs and 3.2-fold increases in hair concentrations, compared with individuals with the TG/GG genotype. Another SNP in CYP2B6 (983TT) and a p-glycoprotein haplotype affected AUCs without substantially altering long-term exposure. CONCLUSIONS This comprehensive pharmacogenomics study showed that individuals with the CYP2B6 516TT genotype displayed >3-fold increases in both short-term and long-term efavirenz exposure, signifying durable effects. Pharmacogenetic testing combined with monitoring of hair levels may improve efavirenz outcomes and reduce toxicities.
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Affiliation(s)
- Monica Gandhi
- Department of Medicine, University of California, San Francisco, CA, USA.
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Nevirapine pharmacokinetics and risk of rash and hepatitis among HIV-infected sub-Saharan African women. AIDS 2012; 26:833-41. [PMID: 22301417 DOI: 10.1097/qad.0b013e328351a521] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To estimate nevirapine (NVP) pharmacokinetics and examine its association with rash and/or hepatotoxicity in women starting antiretroviral treatment in the AIDS Clinical Trials Group A5208/OCTANE study in Africa. DESIGN In HIV-infected, nonpregnant women with screening CD4 cell count less than 200 cells/μl randomized to NVP (twice daily, after 14-day once-daily lead-in period) and tenofovir/emtricitabine, single NVP blood samples were collected 14 and 28 days following randomization. Rash and hepatotoxicity that occurred during therapy, or within 7 days after the last dose of NVP, were defined as toxicity. METHODS NVP pharmacokinetics were modeled by population pharmacokinetic analysis. Individual Bayesian pharmacokinetic estimates were used to calculate clearance, 24-h area under the curve, and predicted plasma concentrations. RESULTS Median week 4 NVP clearance was 2 l/h. Among the 359 women, 194 (54%) developed a rash of any grade; 82 (23%) had grade 2+ and nine (3%) had grade 3+ rash. Median clearance was 1.7 l/h for participants exhibiting 3+ rash versus 2 l/h in women without 3+ rash (P = 0.046). The odds of developing 3+ rash was 50% higher for every 20% decrease in clearance (P = 0.046). NVP discontinuation due to rash/liver toxicity was significantly more common among women with pretreatment CD4 cell count more than 250 cells/μl (P = 0.003). CONCLUSION In this study, HIV-infected African women starting a NVP-based antiretroviral regimen had a lower NVP clearance compared to previous reports. Severe rash, but not hepatotoxicity, was associated with higher NVP exposure. Albeit observed in a small number of women, baseline CD4 cell count at least 250 cells/μl was significantly associated with NVP toxicity.
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Pharmacokinetic interactions between the hormonal emergency contraception, levonorgestrel (Plan B), and Efavirenz. Infect Dis Obstet Gynecol 2012; 2012:137192. [PMID: 22536010 PMCID: PMC3299227 DOI: 10.1155/2012/137192] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 12/19/2011] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Compare the Plan B levonorgestrel (LNG) area under the concentration- time curve (AUC(12)) prior to and with efavirenz (EFV). Design. Prospective, open-label, single-arm, equivalence study. METHODS Healthy HIV-negative subjects underwent 12 hr intensive pharmacokinetic (PK) sampling following single dose LNG alone and after 14 days of EFV. Geometric means, Geometric Mean Ratios, and 90% confidence intervals (CI) are reported for PK Parameters. T-tests were utilized. Clinical parameters and liver function tests (LFTs) were assessed. RESULTS 24 women enrolled and 21 completed the study. With EFV, LNG AUC(12) was reduced 56% (95% CI: 49%, 62%) from 42.9 to 17.8 ng∗hr/mL, and maximum concentration (C(max)) was reduced 41% (95% CI: 33%, 50%) from 8.4 to 4.6 ng/mL. LNG was well tolerated with no grade 3 or 4 treatment-related toxicities. CONCLUSIONS EFV significantly reduced LNG exposures. Higher LNG doses may be required with EFV. These results reinforce the importance of effective contraception in women taking EFV.
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Nonnucleoside Reverse Transcriptase Inhibitor Pharmacokinetics in a Large Unselected Cohort of HIV-Infected Women. J Acquir Immune Defic Syndr 2011. [DOI: 10.1097/qai.0b013e31823e4ead] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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What did we learn on host's genetics by studying large cohorts of HIV-1-infected patients in the genome-wide association era? Curr Opin HIV AIDS 2011; 6:290-6. [PMID: 21546832 DOI: 10.1097/coh.0b013e3283478449] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Genome-wide association studies (GWASs) performed in large cohorts of HIV-1-infected patients have shown that high throughput genomics can add valuable information in understanding disease progression. We report recent information gathered in the international field during the last few years and revisit the importance of well documented cohorts for genotype-phenotype association studies. RECENT FINDINGS The majority of GWASs in the HIV-1 field found that viral loads and disease progression are under the control of variants located in the major histocompatibility complex (MHC) in untreated patients. Although these experiments brought a new and more objective vision of genotype-phenotype correlations in HIV-1 disease, they also pointed out that less than 15% of the observed phenotypic variability can be explained as common genetic variants. Most of the studies have included mainly white patients and the few studies performed in Africans are underpowered but suggest that MHC is probably not the only genetic determinant influencing disease progression in this population. SUMMARY Although the first results of the GWASs in HIV disease look as a confirmation of previous findings, high throughput agnostic genomics entered the field of chronic infectious diseases and will probably unveil new genotype-phenotype associations in the future. Networks between existing cohorts leading to 'virtual mega-cohorts' will be necessary to increase the probability to discover new genetic pathways important for HIV disease. Finally, predictive models including genetic information for clinical usage is another challenge in HIV disease genetics.
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Abstract
Reducing the incidence of HIV remains one of our greatest public health challenges. However, there is growing optimism that preexposure prophylaxis (PrEP) could have a major impact on preventing incident HIV infection. Recently presented data on the use of oral PrEP in men who have sex with men (MSM) have provided proof-of-principle for this strategy. Additional clinical trials are evaluating whether PrEP provides similar protection to risk groups other than MSM, such as heterosexual persons and injection drug users. Still unanswered questions include optimal dosing strategies, long-term safety, maximizing adherence and minimizing costs, addressing drug resistance in the face of PrEP failure, optimizing access, and assessing effects on risk behavior. Future implementation will be guided by the results of clinical trials in progress. This article provides a review of the data on the potential strengths and limitations of PrEP as an HIV prevention strategy, identifies challenges to implementation of this approach, and outlines knowledge gaps.
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Affiliation(s)
- Theodoros Kelesidis
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Population pharmacokinetic-pharmacogenetic study of nevirapine in HIV-infected Cambodian patients. Antimicrob Agents Chemother 2010; 54:4432-9. [PMID: 20696882 DOI: 10.1128/aac.00512-10] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The aims of this ANRS12154 open-label, single-center, multiple-dose pharmacokinetic study were to characterize nevirapine pharmacokinetics in a Cambodian population of HIV-infected patients and to identify environmental and genetic factors of variability, focusing on the CYP2B6, CYP3A5, and ABCB1 (MDR1) genes. A total of 170 Cambodian HIV-infected patients were included. Nevirapine trough concentrations were measured after 18 and 36 months of starting antiretroviral treatment and in samples drawn during a dosing interval in a subset of 10 patients. All data were analyzed by nonlinear mixed-effects modeling. The effect of covariates was investigated using the population pharmacokinetic model. Patients carrying homozygous loss-of-function alleles CYP3A5 6986A>G, CYP2B6 516G>T, CYP2B6 1459C>T, and ABCB1 3435C>T represent 42.4%, 9.2%, 0%, and 18% of the population, respectively. The median nevirapine trough concentrations did not differ after 18 and 36 months of treatment (5,705 ng/ml [range, ≤50 to 13,871] and 5,709 ng/ml [range, ≤50 to 15,422], respectively). Interpatient and intrapatient variabilities of nevirapine apparent clearance were 28% and 17%, respectively. CYP2B6 516G>T and creatinine clearance were found to significantly affect nevirapine apparent clearance. The estimated nevirapine apparent clearances were 2.95 liters/h, 2.62 liters/h, and 1.86 liters/h for CYP2B6 516GG, CYP2B6 516GT, and CYP2B6 516TT genotypes, respectively. The impact of creatinine clearance was small. This study demonstrates that 95% of the patients had sustained nevirapine exposure well above the 3,000-ng/ml threshold. Nevirapine clearance was shown to be affected by CYP2B6 516G>T genetic polymorphism and creatinine clearance, although this explained only part of the interpatient variability, which remains low compared to that for other antiretroviral drugs.
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