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McCluskey SM, Muyindike WR, Nanfuka V, Omoding D, Komukama N, Barigye IT, Kansiime L, Tumusiime J, Aung TN, Stuckwisch A, Hedt-Gauthier B, Marconi VC, Moosa MYS, Pillay D, Giandhari J, Lessells R, Gupta RK, Siedner MJ. Population Effectiveness of Dolutegravir Implementation in Uganda: A Prospective Observational Cohort Study (DISCO), 48-Week Results. J Infect Dis 2024; 230:e622-e630. [PMID: 38748986 PMCID: PMC11420783 DOI: 10.1093/infdis/jiae260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/30/2024] [Accepted: 05/13/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Tenofovir/lamivudine/dolutegravir (TLD) is the preferred first-line antiretroviral therapy (ART) regimen for people with HIV (PWH), including those who were previously virologically suppressed on nonnucleoside reverse transcriptase inhibitors (NNRTIs). We sought to estimate the real-world effectiveness of the TLD transition in Ugandan public-sector clinics. METHODS We conducted a prospective cohort study of PWH aged ≥18 years who were transitioned from NNRTI-based ART to TLD. Study visits were conducted on the day of TLD transition and 24 and 48 weeks later. The primary end point was viral suppression (<200 copies/mL) at 48 weeks. We collected blood for retrospective viral load (VL) assessment and conducted genotypic resistance tests for specimens with VL >500 copies/mL. RESULTS We enrolled 500 participants (median age 47 years; 41% women). At 48 weeks after TLD transition, 94% of participants were in care with a VL <200 copies/mL (n = 469/500); 2% (n = 11/500) were lost from care or died; and only 2% (n = 9/500) had a VL >500 copies/mL. No incident resistance to DTG was identified. Few participants (2%, n = 9/500) discontinued TLD due to adverse events. CONCLUSIONS High rates of viral suppression, high tolerability, and lack of emergent drug resistance support use of TLD as the preferred first-line regimen in the region. CLINICAL TRIALS REGISTRATION NCT04066036.
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Affiliation(s)
- Suzanne M McCluskey
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Daniel Omoding
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Ian T Barigye
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lydia Kansiime
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Taing N Aung
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ashley Stuckwisch
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bethany Hedt-Gauthier
- Harvard Medical School, Boston, Massachusetts, USA
- Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Vincent C Marconi
- Emory University School of Medicine and Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Mahomed-Yunus S Moosa
- Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
| | - Deenan Pillay
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Jennifer Giandhari
- KwaZulu-Natal Research Innovation and Sequencing Platform, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Richard Lessells
- Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
| | - Ravindra K Gupta
- Cambridge Institute of Therapeutic Immunology & Infectious Diseases, University of Cambridge, Cambridge, United Kingdom
- Africa Health Research Institute, Durban, South Africa
| | - Mark J Siedner
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Africa Health Research Institute, Durban, South Africa
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Maphosa T, Dunga S, Makonokaya L, Woelk G, Maida A, Wang A, Ahimbisibwe A, Chamanga RK, Zimba SB, Kayira D, Machekano R. Unlocking the potential: exploring the impact of dolutegravir treatment on body mass index improvement in underweight adults with HIV in Malawi. BMC Public Health 2024; 24:1321. [PMID: 38755632 PMCID: PMC11097535 DOI: 10.1186/s12889-024-18818-x] [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: 12/27/2023] [Accepted: 05/09/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND The introduction of dolutegravir (DTG) in treating HIV has shown enhanced efficacy and tolerability. This study examined changes in weight gain and body mass index (BMI) at 6- and 12-months after post-initiating antiretroviral therapy (ART), comparing people living with HIV (PLHIV) on DTG-based regimens with those on non-DTG-based regimens in Malawi. METHODS Retrospective cohort data from 40 public health facilities in Malawi were used, including adult ART patients (aged ≥ 15 years) from January 2017 to March 2020. The primary outcomes were BMI changes/transitions, with secondary outcomes focused on estimating the proportion of mean weight gain > 10% post-ART initiation and BMI category transitions. Descriptive statistics and binomial regression were used to estimate the unadjusted and adjusted relative risks (RR) of weight gain of more than ( >) 10%. RESULTS The study included 3,520 adult ART patients with baseline weight after ART initiation, predominantly female (62.7%) and aged 25-49 (61.1%), with a median age of 33 years (interquartile range (IQR), 23-42 years). These findings highlight the influence of age, ART history, and current regimen on weight gain. After 12months follow up, compared to those aged 15-24 years, individuals aged 25-49 had an Adjusted RR (ARR) of 0.5 (95% Confidence Interval (CI): 0.35-0.70), suggesting a 50% reduced likelihood of > 10% weight gain after post-ART initiation. Similarly, those aged 50 + had an ARR of 0.33 (95% CI: 0.20-0.58), indicating a 67% decreased likelihood compared to the youngest age group 15-24 years. This study highlights the positive impact of DTG-based regimens, revealing significant transitions from underweight to normal BMI categories at 6- and 12-months post-initiation. CONCLUSION This study provides insights into weight gain patterns in patients on DTG-based regimens compared with those on non-DTG regimens. Younger individuals (15-24 years) exhibited higher odds of weight gain, suggesting a need for increased surveillance in this age group. These findings contribute to the understanding DTG's potential effects on weight gain, aiding clinical decision making. Further research is required to comprehensively understand the underlying mechanisms and long-term implications of weight gain in patients receiving DTG-based regimens.
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Affiliation(s)
- Thulani Maphosa
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi.
| | - Shalom Dunga
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | | | - Godfrey Woelk
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - Alice Maida
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Alice Wang
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | | | - Suzgo B Zimba
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Dumbani Kayira
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
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Loaiza JD, Chvatal-Medina M, Hernandez JC, Rugeles MT. Integrase inhibitors: current protagonists in antiretroviral therapy. Immunotherapy 2023; 15:1477-1495. [PMID: 37822251 DOI: 10.2217/imt-2023-0011] [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] [Indexed: 10/13/2023] Open
Abstract
Since HIV was identified as the etiological agent of AIDS, there have been significant advances in antiretroviral therapy (ART) that has reduced morbidity/mortality. Still, the viral genome's high mutation rate, suboptimal ART regimens, incomplete adherence to therapy and poor control of the viral load generate variants resistant to multiple drugs. Licensing over 30 anti-HIV drugs worldwide, including integrase inhibitors, has marked a milestone since they are potent and well-tolerated drugs. In addition, they favor a faster recovery of CD4+ T cells. They also increase the diversity profile of the gut microbiota and reduce inflammatory markers. All of these highlight the importance of including them in different ART regimens.
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Affiliation(s)
- John D Loaiza
- Grupo Inmunovirología, Facultad de medicina, Universidad de Antioquia, Medellín, 050010, Colombia
| | - Mateo Chvatal-Medina
- Grupo Inmunovirología, Facultad de medicina, Universidad de Antioquia, Medellín, 050010, Colombia
| | - Juan C Hernandez
- Infettare, Facultad de medicina, Universidad Cooperativa de Colombia, Medellín, 050012, Colombia
| | - Maria T Rugeles
- Grupo Inmunovirología, Facultad de medicina, Universidad de Antioquia, Medellín, 050010, Colombia
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4
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SeyedAlinaghi S, Afsahi AM, Moradi A, Parmoon Z, Habibi P, Mirzapour P, Dashti M, Ghasemzadeh A, Karimi E, Sanaati F, Hamedi Z, Molla A, Mehraeen E, Dadras O. Current ART, determinants for virologic failure and implications for HIV drug resistance: an umbrella review. AIDS Res Ther 2023; 20:74. [PMID: 37884997 PMCID: PMC10604802 DOI: 10.1186/s12981-023-00572-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
OBJECTIVE The purpose of this study is to investigate the incidence of determinants for virologic failure and to identify predisposing factors to enhance treatment efficacy. Tackling this global public health issue is the key to reducing the rate of virological failure and increasing the success of treatment for those living with HIV. METHODS This umbrella review delves into various aspects of current anti-retroviral therapy (ART) which is the primary treatment for human immunodeficiency virus (HIV) infection. Comprehensive searches were conducted in online databases including PubMed, Embase, Scopus, and Web of Science, up to May 26, 2023. Following the screening and selection of relevant articles, eligible articles were included in the data extraction. This study adhered to the PRISMA guideline to report the results and employed the NIH quality and bias risk assessment tool to ensure the quality of included studies. RESULTS In total, 40 review studies published from 2015 to 2023 were included. The bulk of these studies concurred on several major factors contributing to HIV drug resistance and virological failure. Key among these were medication adherence, baseline and therapeutic CD4 levels, the presence of co-infections, and the advanced clinical stage of the infection. CONCLUSION The resistance to HIV drugs and instances of determinants for virologic failure have a profound impact on the life quality of those infected with HIV. Primary contributors to this scenario include insufficient adherence to treatment, decreased CD4 T-cell count, elevated viral levels, and certain treatment regimens. Implementing appropriate interventions could address these issues. Sub-Saharan Africa exhibits elevated rates of determinants for virologic failure, attributed to the delay in HIV testing and diagnosis, and late initiation of antiretroviral therapy (ART). It is essential to undertake further research aimed at enhancing the detection of resistance in HIV patients and mitigating viral failure by addressing these underlying causes.
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Affiliation(s)
- SeyedAhmad SeyedAlinaghi
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Masoud Afsahi
- Department of Radiology, School of Medicine, University of California, San Diego (UCSD), San Diego, CA, USA
| | - Ali Moradi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Zohal Parmoon
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Pedram Habibi
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Pegah Mirzapour
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Dashti
- Department of Radiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Afsaneh Ghasemzadeh
- Department of Radiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Elaheh Karimi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Foziye Sanaati
- School of Nursing and Allied Medical Sciences, Maragheh University of Medical Sciences, Maragheh, Iran
| | - Zahra Hamedi
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ayoob Molla
- School of Medicine, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Esmaeil Mehraeen
- Department of Health Information Technology, Khalkhal University of Medical Sciences, Khalkhal, 5681761351, Iran.
| | - Omid Dadras
- Bergen Addiction Research, Department of Addiction Medicine, Haukland University Hospital, Bergen, Norway
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5
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Li M, Oliveira Passos D, Shan Z, Smith SJ, Sun Q, Biswas A, Choudhuri I, Strutzenberg TS, Haldane A, Deng N, Li Z, Zhao XZ, Briganti L, Kvaratskhelia M, Burke TR, Levy RM, Hughes SH, Craigie R, Lyumkis D. Mechanisms of HIV-1 integrase resistance to dolutegravir and potent inhibition of drug-resistant variants. SCIENCE ADVANCES 2023; 9:eadg5953. [PMID: 37478179 DOI: 10.1126/sciadv.adg5953] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 06/16/2023] [Indexed: 07/23/2023]
Abstract
HIV-1 infection depends on the integration of viral DNA into host chromatin. Integration is mediated by the viral enzyme integrase and is blocked by integrase strand transfer inhibitors (INSTIs), first-line antiretroviral therapeutics widely used in the clinic. Resistance to even the best INSTIs is a problem, and the mechanisms of resistance are poorly understood. Here, we analyze combinations of the mutations E138K, G140A/S, and Q148H/K/R, which confer resistance to INSTIs. The investigational drug 4d more effectively inhibited the mutants compared with the approved drug Dolutegravir (DTG). We present 11 new cryo-EM structures of drug-resistant HIV-1 intasomes bound to DTG or 4d, with better than 3-Å resolution. These structures, complemented with free energy simulations, virology, and enzymology, explain the mechanisms of DTG resistance involving E138K + G140A/S + Q148H/K/R and show why 4d maintains potency better than DTG. These data establish a foundation for further development of INSTIs that potently inhibit resistant forms in integrase.
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Affiliation(s)
- Min Li
- National Institute of Diabetes and Digestive Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | | | - Zelin Shan
- The Salk Institute for Biological Studies, La Jolla, CA, 92037, USA
| | - Steven J Smith
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, 21702, USA
| | - Qinfang Sun
- Center for Biophysics and Computational Biology, and Department of Chemistry, Temple University, Philadelphia, PA 19122, USA
| | - Avik Biswas
- The Salk Institute for Biological Studies, La Jolla, CA, 92037, USA
- Center for Biophysics and Computational Biology and Department of Physics, Temple University, Philadelphia, PA 19122, USA
| | - Indrani Choudhuri
- Center for Biophysics and Computational Biology, and Department of Chemistry, Temple University, Philadelphia, PA 19122, USA
| | | | - Allan Haldane
- Center for Biophysics and Computational Biology and Department of Physics, Temple University, Philadelphia, PA 19122, USA
| | - Nanjie Deng
- Department of Chemistry and Physical Sciences, Pace University, New York, NY, 10038, USA
| | - Zhaoyang Li
- National Institute of Diabetes and Digestive Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Xue Zhi Zhao
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, 21702, USA
| | - Lorenzo Briganti
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Mamuka Kvaratskhelia
- Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Terrence R Burke
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, 21702, USA
| | - Ronald M Levy
- Center for Biophysics and Computational Biology and Department of Physics, Temple University, Philadelphia, PA 19122, USA
| | - Stephen H Hughes
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Frederick, MD, 21702, USA
| | - Robert Craigie
- National Institute of Diabetes and Digestive Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Dmitry Lyumkis
- The Salk Institute for Biological Studies, La Jolla, CA, 92037, USA
- Department of Integrative Structural and Computational Biology, The Scripps Research Institute, La Jolla, CA, 92037, USA
- Graduate School of Biological Sciences, Section of Molecular Biology, University of California San Diego, La Jolla, CA 92093, USA
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6
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Ntamatungiro AJ, Eichenberger A, Okuma J, Vanobberghen F, Ndege R, Kimera N, Francis JM, Kagura J, Weisser M. Transitioning to Dolutegravir in a Programmatic Setting: Virological Outcomes and Associated Factors Among Treatment-Naive Patients With HIV-1 in the Kilombero and Ulanga Antiretroviral Cohort in Rural Tanzania. Open Forum Infect Dis 2023; 10:ofad321. [PMID: 37520425 PMCID: PMC10375425 DOI: 10.1093/ofid/ofad321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/23/2023] [Indexed: 08/01/2023] Open
Abstract
Background Virological outcome data after programmatic transition from non-nucleoside reverse transcriptase inhibitor (NNRTI)-based to dolutegravir (DTG)-based antiretroviral therapy (ART) regimens in sub-Saharan Africa (SSA) outside of clinical trials are scarce. We compared viral suppression and associated factors in treatment-naïve people living with HIV (PLHIV) starting DTG- based versus NNRTI-based ART. Methods We compared virological suppression at 12 months, after treatment initiation in the two cohorts of participants aged ≥15 years, initiating DTG- and NNRTI-based ART. Drug resistance was assessed among participants with viremia ≥50 copies/mL on DTG. Results Viral suppression was achieved for 165/195 (85%) and 154/211 (73%) participants in the DTG- and NNRTI- cohorts, respectively (P = 0.003). DTG-based ART was associated with >2 times the odds of viral suppression versus NNRTI-based ART (adjusted odds ratio, 2.10 [95% confidence interval {CI}, 1.12-3.94]; adjusted risk ratio, 1.11 [95% CI, 1.00-1.24]). HIV-1 genotypic resistance testing (GRT) before ART initiation was done in 14 of 30 viremic participants on DTG, among whom nucleoside reverse transcriptase inhibitor (NRTI), NNRTI, and protease inhibitors resistance was detected in 0 (0%), 2 (14%) and 1 (7%), respectively. No resistance was found in the 2 of 30 participants with available GRT at the time of viremia ≥50 copies/mL. Conclusions Virological suppression at 1 year was higher in participants initiating DTG- versus NNRTI-based ART. In those with viremia ≥50 copies/mL on DTG-based ART, there was no pretreatment or acquired resistance to the DTG co-administered NRTIs, although the number of samples tested was small.
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Affiliation(s)
- Alex J Ntamatungiro
- Correspondence: Alex J. Ntamatungiro, MS, Department of Interventions and Clinical Trials, Ifakara Health Institute, 5 Ifakara St, Plot 463 Mikocheni, PO Box 78373, Dar es Salaam, Tanzania (); Anna Eichenberger, MS, Department of Infectious Diseases, Bern University Hospital, Freiburgstrasse 16, 3010 Bern, Switzerland ()
| | - Anna Eichenberger
- Correspondence: Alex J. Ntamatungiro, MS, Department of Interventions and Clinical Trials, Ifakara Health Institute, 5 Ifakara St, Plot 463 Mikocheni, PO Box 78373, Dar es Salaam, Tanzania (); Anna Eichenberger, MS, Department of Infectious Diseases, Bern University Hospital, Freiburgstrasse 16, 3010 Bern, Switzerland ()
| | - James Okuma
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Fiona Vanobberghen
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Robert Ndege
- Division of Epidemiology and Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Namvua Kimera
- Department of Interventions and Clinical Trials, Ifakara Health Institute, Ifakara, Tanzania
| | - Joel M Francis
- Department of Family Medicine and Primary Care, University of the Witwatersrand, Johannesburg, South Africa
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Kantor R, Gupta RK. We should not stop considering HIV drug resistance testing at failure of first-line antiretroviral therapy. Lancet HIV 2023; 10:e202-e208. [PMID: 36610438 PMCID: PMC10067973 DOI: 10.1016/s2352-3018(22)00327-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 01/06/2023]
Abstract
HIV drug resistance is a major global hurdle to successful and sustained antiretroviral therapy. Global guidelines recommend testing for antiretroviral drug resistance and results are used to inform treatment regimen design for patients at different stages of therapy. Several clinical trials investigated optimal regimens after failure of first-line antiretroviral therapy, yielding data that advanced knowledge and informed care. However, further interpretation of data from these studies questioned the benefit of antiretroviral drug resistance testing for cases in which first-line treatment is not effective and, furthermore, that relying on the results of antiretroviral drug resistance testing could be misleading and unnecessary. In this Viewpoint, which is largely focused on high-income settings, we review these data, reflect on the potential problems with their interpretation, and call for caution in their extrapolation. Without negating the importance of the data, and recognising the varied circumstances related to HIV drug resistance testing in different global settings, we advise caution before changing current practice and recommendations. We believe that we should not universally stop considering HIV drug resistance testing at failure of first-line antiretroviral therapy.
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Affiliation(s)
- Rami Kantor
- Division of Infectious Diseases, Department of Medicine, Brown University, The Miriam Hospital, Providence, RI, USA.
| | - Ravindra K Gupta
- Cambridge Institute of Therapeutic Immunology and Infectious Diseases, University of Cambridge, Cambridge, UK; Africa Health Research Institute, Kwazulu-Natal, South Africa
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Matsuda EM, Campos IB, de Oliveira IP, Colpas DR, López-Lopes GIS, Chiavegato VO, Brígido LFDM. Lamivudine-based two-drug regimens with dolutegravir or protease inhibitor: Virological suppression in spite of previous therapy failure or renal dysfunction. Braz J Infect Dis 2023; 27:102757. [PMID: 36809850 PMCID: PMC10064429 DOI: 10.1016/j.bjid.2023.102757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/09/2023] [Accepted: 02/02/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Two-Drug Regimens (2DR) have proven effective in clinical trials but real-world data, especially in resource-limited settings, is limited. OBJECTIVES To evaluate viral suppression of lamivudine-based 2DR, with dolutegravir or ritonavir-boosted protease inhibitor (lopinavir/r, atazanavir/r or darunavir/r), among all cases regardless of selection criteria. PATIENTS AND METHODS A retrospective study, conducted in an HIV clinic in the metropolitan area of São Paulo, Brazil. Per-protocol failure was defined as viremia above 200 copies/mL at outcome. Intention-To-Treat-Exposed (ITT-E) failure was considered for those who initiated 2DR but subsequently had either (i) Delay over 30 days in Antiretroviral Treatment (ART) dispensation, (ii) ART changed or (iii) Viremia > 200 copies/mL in the last observation using 2DR. RESULTS Out of 278 patients initiating 2DR, 99.6% had viremia below 200 copies/mL at last observation, 97.8% below 50 copies/mL. Lamivudine resistance, either documented (M184V) or presumed (viremia > 200 copies/mL over a month using 3TC) was present in 11% of cases that showed lower suppression rates (97%), but with no significant hazard ratio to fail per ITT-E (1.24, p = 0.78). Decreased kidney function, present in 18 cases, showed of 4.69 hazard ratio (p = 0.02) per ITT-E for failure (3/18). As per protocol analysis, three failures occurred, none with renal dysfunction. CONCLUSIONS The 2DR is feasible, with robust suppression rates, even when 3TC resistance or renal dysfunction is present, and close monitoring of these cases may guarantee long-term suppression.
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Affiliation(s)
- Elaine Monteiro Matsuda
- Secretaria de Saúde de Santo André, Ambulatório de Doenças Infecciosas, São Paulo, SP, Brazil
| | - Ivana Barros Campos
- Instituto Adolfo Lutz, Centro Regional de Santo André, Santo André, SP, Brazil
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9
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Ntamatungiro AJ, Kagura J, Weisser M, Francis JM. Pre-treatment HIV-1 drug resistance in antiretroviral therapy-naive adults in Eastern Africa: a systematic review and meta-analysis. J Antimicrob Chemother 2022; 77:3231-3241. [PMID: 36225089 DOI: 10.1093/jac/dkac338] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/12/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pre-treatment HIV drug resistance (PDR) may result in increased risk of virological failure and acquisition of new resistance mutations. With recently increasing ART coverage and periodic modifications of the guidelines for HIV treatment, there is a need for an updated systematic review to assess the levels of the PDR among adults newly initiating ART in Eastern Africa. METHODS We conducted a systematic search for studies published between 1 January 2017 and 30 April 2022 in the MEDLINE Complete and CINAHL Complete, searched simultaneously using EBSCOhost, and Web of Science. To determine the overall PDR prevalence estimates, we extracted data from eligible articles and analysed prevalence estimates using Stata 14.2. RESULTS A total of 22 eligible observation studies were selected. The studies included a total of 5852 ART-naive people living with HIV. The overall pooled prevalence of PDR was 10.0% (95% CI: 7.9%-12.0%, I2 = 88.9%) and 9.4% (95% CI: 7.0%-11.9%, I2 = 90.4%) for NNRTIs, 2.6% (95% CI: 1.8%-3.4%, I2 = 69.2%) for NRTIs and 0.7% (95% CI: 0.3%-1.2%, I2 = 29.0%) for PIs. No major integrase strand transfer inhibitors (INSTI)-related mutations were identified. CONCLUSIONS We observed a moderate overall PDR prevalence among new ART initiators in this study. PDR to NNRTIs is more prevalent, underscoring the importance of the current WHO recommendation for replacement of NNRTIs by INSTIs. PDR to NRTIs was low but notable, which warrants continuous surveillance of pre-existing resistance to the dolutegravir co-administered NRTI in Eastern Africa.
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Affiliation(s)
- Alex J Ntamatungiro
- Ifakara Health Institute, Ifakara, Tanzania.,Division of Epidemiology and Biostatistics, University of the Witwatersrand, Johannesburg, South Africa
| | - Juliana Kagura
- Division of Epidemiology and Biostatistics, University of the Witwatersrand, Johannesburg, South Africa
| | - Maja Weisser
- Ifakara Health Institute, Ifakara, Tanzania.,Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Basel, Basel, Switzerland.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Joel M Francis
- Department of Family Medicine and Primary Care, University of the Witwatersrand, Johannesburg, South Africa
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Minimal Cross-resistance to Tenofovir in Children and Adolescents Failing ART Makes Them Eligible for Tenofovir-Lamivudine-Dolutegravir Treatment. Pediatr Infect Dis J 2022; 41:827-834. [PMID: 35895893 PMCID: PMC9508940 DOI: 10.1097/inf.0000000000003647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Fixed-dose combination of dolutegravir (DTG) with tenofovir disoproxil fumarate (TDF) and lamivudine (3TC) likely improves adherence and has a favorable resistance profile. We evaluated predicted efficacy of TLD (TDF-3TC-DTG) in children and adolescents failing abacavir (ABC), zidovudine (AZT), or TDF containing regimens. METHODS Drug resistance mutations were analyzed in a retrospective dataset of individuals <19 years of age, failing ABC (n = 293) AZT (n = 288) or TDF (n = 69) based treatment. Pol sequences were submitted to Stanford HIVdb v8.9. Genotypic susceptibility scores were calculated for various DTG-containing regimens. RESULTS Genotypes were assessed for 650 individuals with a median age of 14 years (IQR 10-17 years). More individuals failed a protease inhibitor (PI)-based (78.3%) than a non-nucleoside reverse transcriptase inhibitors (NNRTI)-based (21.7%) regimen. Most individuals in the AZT group (n = 288; 94.4%) failed a PI-based regimen, compared with 71.0% and 64.2% in the TDF (n = 69) and ABC group (n = 293). Genotypic sensitivity scores <2 to TLD were observed in 8.5% and 9.4% of ABC- and AZT-exposed individuals, compared with 23.2% in the TDF group. The M184V mutation was most often detected in the ABC group (70.6%) versus 60.0% and 52.4% in TDF and AZT groups. The presence of K65R was rare (n = 13, 2.0%) and reduced TLD susceptibility was commonly caused by accumulation of nucleoside reverse transcriptase inhibitor (NRTI) mutations. CONCLUSIONS Cross-resistance to TDF was limited, further reducing concerns about use of transition to TLD in children and adolescents. The NADIA trial has subsequently shown that patients failing a TDF/3TC/EFV regimen can safely be transitioned to a TLD regimen but we do not have data for patients failing an ABC/3TC/NNRTI or PI regimens. Frequent virological monitoring is recommended after switch to DTG, especially in children continuing ABC in the backbone. Clinical studies correlating predicted resistance with clinical outcomes, especially in settings without access to genotyping, are required.
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Schramm B, Temfack E, Descamps D, Nicholas S, Peytavin G, Bitilinyu-Bangoh JE, Storto A, Lê MP, Abdi B, Ousley J, Kalua T, Calvez V, Jahn A, Marcelin AG, Szumilin E. Viral suppression and HIV-1 drug resistance 1 year after pragmatic transitioning to dolutegravir first-line therapy in Malawi: a prospective cohort study. THE LANCET HIV 2022; 9:e544-e553. [DOI: 10.1016/s2352-3018(22)00136-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 05/02/2022] [Accepted: 05/11/2022] [Indexed: 12/12/2022]
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12
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Steegen K, Hans L. Compelling evidence for unconditional shift to dolutegravir. THE LANCET HIV 2022; 9:e523-e524. [DOI: 10.1016/s2352-3018(22)00164-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022]
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13
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Mens H, Fjordside L, Fonager J, Gerstoft J. Emergence of the G118R Pan-Integrase Resistance Mutation as a Result of Low Compliance to a Dolutegravir-Based cART. Infect Dis Rep 2022; 14:501-504. [PMID: 35893472 PMCID: PMC9326666 DOI: 10.3390/idr14040053] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/31/2022] [Accepted: 06/19/2022] [Indexed: 02/04/2023] Open
Abstract
HIV-1 resistance towards integrase inhibitors is a potential threat of the success of HIV-1 combination treatment. G118R is a rare drug resistance mutation conferring pan-integrase resistance. Here, we describe the occurrence of G118R in a HIV-1 subtype-B-positive individual with major compliance problems, detected while the patient was on dolutegravir-based cART. We speculate the pre-selection of M184I/V aided the occurrence of G118R in this case, and discuss the robustness of dolutegravir-based therapies.
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Affiliation(s)
- Helene Mens
- Rigshospitalet, Department of Infectious Diseases, 2100 Copenhagen, Denmark; (L.F.); (J.G.)
- Correspondence: ; Tel.: +45-354-504-36
| | - Lasse Fjordside
- Rigshospitalet, Department of Infectious Diseases, 2100 Copenhagen, Denmark; (L.F.); (J.G.)
| | - Jannik Fonager
- Viruses and Microbial Special Diagnostics, Statens Serum Institut, 2300 Copenhagen, Denmark;
| | - Jan Gerstoft
- Rigshospitalet, Department of Infectious Diseases, 2100 Copenhagen, Denmark; (L.F.); (J.G.)
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Pre-Treatment Integrase Inhibitor Resistance and Natural Polymorphisms among HIV-1 Subtype C Infected Patients in Ethiopia. Viruses 2022; 14:v14040729. [PMID: 35458459 PMCID: PMC9029575 DOI: 10.3390/v14040729] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/18/2022] [Accepted: 03/28/2022] [Indexed: 02/01/2023] Open
Abstract
Dolutegravir-based antiretroviral therapy (ART) has been scaled up in many developing countries, including Ethiopia. However, subtype-dependent polymorphic differences might influence the occurrence of HIV-drug-resistance mutations (HIVDRMs). We analyzed the prevalence of pre-treatment integrase strand transfer inhibitor (INSTI) HIVDRMs and naturally occurring polymorphisms (NOPs) of the integrase gene, using plasma samples collected as part of the national HIVDR survey in Ethiopia in 2017. We included a total of 460 HIV-1 integrase gene sequences from INSTI-naïve (n = 373 ART-naïve and n = 87 ART-experienced) patients. No dolutegravir-associated HIVDRMs were detected, regardless of previous exposure to ART. However, we found E92G in one ART-naïve patient specimen and accessory mutations in 20/460 (4.3%) of the specimens. Moreover, among the 288 integrase amino acid positions of the subtype C, 187/288 (64.9%) were conserved (<1.0% variability). Analysis of the genetic barrier showed that the Q148H/K/R dolutegravir resistance pathway was less selected in subtype C. Docking analysis of the dolutegravir showed that protease- and reverse-transcriptase-associated HIVDRMs did not affect the native structure of the HIV-1 integrase. Our results support the implementation of a wide scale-up of dolutegravir-based regimes. However, the detection of polymorphisms contributing to INSTI warrants the continuous surveillance of INSTI resistance.
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15
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Nyandiko W, Holland S, Vreeman R, DeLong AK, Manne A, Novitsky V, Ngeresa A, Chory A, Aluoch J, Orido M, Jepkemboi E, Sam SS, Caliendo AM, Ayaya S, Hogan JW, Kantor R. HIV-1 Treatment Failure, Drug Resistance, and Clinical Outcomes in Perinatally Infected Children and Adolescents Failing First-Line Antiretroviral Therapy in Western Kenya. J Acquir Immune Defic Syndr 2022; 89:231-239. [PMID: 34723922 PMCID: PMC8752470 DOI: 10.1097/qai.0000000000002850] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 10/19/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Long-term impact of drug resistance in perinatally infected children and adolescents living with HIV (CALWH) is poorly understood. We determined drug resistance and examined its long-term impact on failure and mortality in Kenyan CALWH failing first-line non-nucleoside reverse transcriptase inhibitor-based antiretroviral therapy (ART). SETTING Academic Model Providing Access to Healthcare, western Kenya. METHODS Participants were enrolled in 2010-2013 (timepoint 1) and a subsample re-enrolled after 4-7 years (timepoint 2). Viral load (VL) was performed on timepoint 1 samples, with genotyping of those with detectable VL. Primary endpoints were treatment failure (VL >1000 copies/mL) at and death before timepoint 2. Multinomial regression analysis was used to characterize resistance effect on death, failure, and loss-to-follow-up, adjusting for key variables. RESULTS The initial cohort (n = 480) was 52% (n = 251) female, median age 8 years, median CD4% 31%, 79% (n = 379) on zidovudine/abacavir + lamivudine + efavirenz/nevirapine for median 2 years. Of these, 31% (n = 149) failed at timepoint 1. Genotypes at timepoint 1, available on n = 128, demonstrated 93% (n = 119) extensive resistance, affecting second line. Of 128, 22 failed at timepoint 2, 17 died, and 32 were lost to follow-up before timepoint 2. Having >5 resistance mutations at timepoint 1 was associated with higher mortality [relative risk ratio (RRR) = 8.7, confidence interval (CI) 2.1 to 36.3] and loss to follow-up (RRR = 3.2, CI 1.1 to 9.2). Switching to second line was associated with lower mortality (RRR <0.05, CI <0.05 to 0.1) and loss to follow-up (RRR = 0.1, CI <0.05 to 0.3). CONCLUSION Extensive resistance and limited switch to second line in perinatally infected Kenyan CALWH failing first-line ART were associated with long-term failure and mortality. Findings emphasize urgency for interventions to sustain effective, life-long ART in this vulnerable population.
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Affiliation(s)
- Winstone Nyandiko
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Moi University College of Health Sciences, Eldoret, Kenya
| | | | - Rachel Vreeman
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Anthony Ngeresa
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ashley Chory
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Josephine Aluoch
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Millicent Orido
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Eslyne Jepkemboi
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | | | - Samuel Ayaya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Moi University College of Health Sciences, Eldoret, Kenya
| | - Joseph W Hogan
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Brown University, Providence, RI, USA
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Chimukangara B, Lessells RJ, Singh L, Grigalionyte I, Yende-Zuma N, Adams R, Dawood H, Dlamini L, Buthelezi S, Chetty S, Diallo K, Duffus WA, Mogashoa M, Hagen MB, Giandhari J, de Oliveira T, Moodley P, Padayatchi N, Naidoo K. Acquired HIV drug resistance and virologic monitoring in a HIV hyper-endemic setting in KwaZulu-Natal Province, South Africa. AIDS Res Ther 2021; 18:74. [PMID: 34656129 PMCID: PMC8520607 DOI: 10.1186/s12981-021-00393-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022] Open
Abstract
Background Introduction of tenofovir (TDF) plus lamivudine (3TC) and dolutegravir (DTG) in first- and second-line HIV treatment regimens in South Africa warrants characterization of acquired HIV-1 drug resistance (ADR) mutations that could impact DTG-based antiretroviral therapy (ART). In this study, we sought to determine prevalence of ADR mutations and their potential impact on susceptibility to drugs used in combination with DTG among HIV-positive adults (≥ 18 years) accessing routine care at a selected ART facility in KwaZulu-Natal, South Africa. Methods We enrolled adult participants in a cross-sectional study between May and September 2019. Eligible participants had a most recent documented viral load (VL) ≥ 1000 copies/mL after at least 6 months on ART. We genotyped HIV-1 reverse transcriptase and protease genes by Sanger sequencing and assessed ADR. We characterized the effect of ADR mutations on the predicted susceptibility to drugs used in combination with DTG. Results From 143 participants enrolled, we obtained sequence data for 115 (80%), and 92.2% (95% CI 85.7–96.4) had ADR. The proportion with ADR was similar for participants on first-line ART (65/70, 92.9%, 95% CI 84.1–97.6) and those on second-line ART (40/44, 90.9%, 95% CI 78.3–97.5), and was present for the single participant on third-line ART. Approximately 89% (62/70) of those on first-line ART had dual class NRTI and NNRTI resistance and only six (13.6%) of those on second-line ART had major PI mutations. Most participants (82%) with first-line viraemia maintained susceptibility to Zidovudine (AZT), and the majority of them had lost susceptibility to TDF (71%) and 3TC (84%). Approximately two in every five TDF-treated individuals had thymidine analogue mutations (TAMs). Conclusions Susceptibility to AZT among most participants with first-line viraemia suggests that a new second-line regimen of AZT + 3TC + DTG could be effective. However, atypical occurrence of TAMs in TDF-treated individuals suggests a less effective AZT + 3TC + DTG regimen in a subpopulation of patients. As most patients with first-line viraemia had at least low-level resistance to TDF and 3TC, identifying viraemia before switch to TDF + 3TC + DTG is important to avoid DTG functional monotherapy. These findings highlight a need for close monitoring of outcomes on new standardized treatment regimens. Supplementary Information The online version contains supplementary material available at 10.1186/s12981-021-00393-5.
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17
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Rojas J, de Lazzari E, Negredo E, Domingo P, Tiraboschi J, Ribera E, Abdulghani N, Puig J, Mateo MG, Podzamczer D, Gutierrez MM, Paredes R, Clotet B, Gatell JM, Blanco JL, Martínez E. Efficacy and safety of switching to dolutegravir plus lamivudine versus continuing triple antiretroviral therapy in virologically suppressed adults with HIV at 48 weeks (DOLAM): a randomised non-inferiority trial. Lancet HIV 2021; 8:e463-e473. [PMID: 34358497 DOI: 10.1016/s2352-3018(21)00100-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/25/2021] [Accepted: 04/28/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Simplified antiretroviral therapy (ART) regimens are desirable for people with HIV. We investigated the efficacy and safety of switching from triple ART to dual dolutegravir plus lamivudine therapy. METHODS DOLAM is a phase 4, randomised, open-label, non-inferiority trial, done at six HIV clinics in Catalonia, Spain. Adults with HIV-1 receiving a triple ART regimen, aged 18 years or older, with virological suppression, a CD4 nadir of at least 200 cells per μL, who were HBsAg-negative, and without previous viral failure or resistance mutations to study drugs were eligible. Participants underwent computer-generated randomisation, stratified by the class of the third drug, and were assigned (1:1) to switch to oral dolutegravir 50 mg and lamivudine 300 mg once daily or to continue triple ART for 48 weeks. The primary endpoint was the proportion of people with an HIV RNA value of at least 50 copies per mL at week 48 (US Food and Drug Administration snapshot algorithm, 8% non-inferiority margin). Both the primary and safety outcomes were evaluated in the intention-to-treat exposed population. The study is completed and was registered with EudraCT 201500027435. FINDINGS Between July 7, 2015, and Oct 31, 2018, 265 participants were randomly assigned to switch to dolutegravir plus lamivudine (n=131) or to maintain triple ART (n=134) and all received at least one dose. Nine (7%) participants in the dual therapy group and ten (7%) in the triple therapy group were excluded before 48 weeks, mostly due to treatment discontinuations or virological failure. Participants were predominantly male (116 [87%] of 134 in the triple ART group and 111 [85%] of 131 in the dolutegravir plus lamivudine group). The difference in the proportion of participants with HIV RNA values of at least 50 copies per mL at 48 weeks between the dual therapy group (three [2%] of 131) and triple therapy group (two [1%] of 134) was 0·8 percentage points (95% CI -3·3 to 5·2), showing non-inferiority of dolutegravir plus lamivudine dual therapy compared with triple ART. 73 (56%) of 131 participants allocated to dual therapy had 150 adverse effects, compared with 78 (58%) of 134 participants allocated to triple therapy who also had 150 adverse events (p=0·68). Drug discontinuation due to adverse effects occurred in four people in the triple therapy group and three people in the dual therapy group. INTERPRETATION Our findings show the efficacy and safety of dolutegravir plus lamivudine as a simplified therapy switch option for selected people with HIV with virological suppression on triple ART. FUNDING Instituto de Salud Carlos III, Red de Investigación en Sida, and ViiV Healthcare.
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Affiliation(s)
| | | | - Eugenia Negredo
- Hospital Germans Trias i Pujol, Badalona, Spain; Lluita Contra La Sida Foundation, Badalona, Spain; Universitat de Vic-Universitat Central de Catalunya, Barcelona, Spain
| | | | | | | | | | - Jordi Puig
- Hospital Germans Trias i Pujol, Badalona, Spain; Lluita Contra La Sida Foundation, Badalona, Spain
| | | | | | | | - Roger Paredes
- Hospital Germans Trias i Pujol, Badalona, Spain; Lluita Contra La Sida Foundation, Badalona, Spain; Universitat de Vic-Universitat Central de Catalunya, Barcelona, Spain; IrsiCaixa AIDS Research Institute, Badalona, Spain
| | - Bonaventura Clotet
- Hospital Germans Trias i Pujol, Badalona, Spain; Lluita Contra La Sida Foundation, Badalona, Spain; Universitat de Vic-Universitat Central de Catalunya, Barcelona, Spain; IrsiCaixa AIDS Research Institute, Badalona, Spain
| | - Jose M Gatell
- University of Barcelona, Barcelona, Spain; ViiV Healthcare, Brentford, UK
| | - Jose L Blanco
- Hospital Clínic-IDIBAPS, Barcelona, Spain; University of Barcelona, Barcelona, Spain
| | - Esteban Martínez
- Hospital Clínic-IDIBAPS, Barcelona, Spain; University of Barcelona, Barcelona, Spain.
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18
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de Lazzari E, Gonzalez-Cordon A, Inciarte A, Ugarte A, de la Mora L, Martinez-Rebollar M, Laguno M, Ambrosioni J, Torres B, Mallolas J, Blanco JL, Miro JM, Martinez E. Factors associated with the use and composition of two-drug regimens in a large single-centre HIV cohort. J Antimicrob Chemother 2021; 76:2988-2992. [PMID: 34293162 DOI: 10.1093/jac/dkab261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/25/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We aimed to assess the clinical characteristics associated with the use of two-drug regimens (2DRs) and the factors associated with specific antiretrovirals in 2DRs in a large single-centre HIV cohort. METHODS Retrospective analysis of demographics, HIV characteristics and AIDS events, antiretroviral prescription, virological failure and genotypic resistance testing, and laboratory results from all adult people with HIV (PWH) prospectively followed at the Hospital Clinic of Barcelona who were receiving a 3DR or a 2DR in January 2020. We assessed factors associated with the probability of receiving 2DRs relative to three-drug regimens (3DRs) using a logistic regression model, controlling for age, sex and year of HIV diagnosis. The same methodology was applied to identify factors associated with the prescription of integrase inhibitor-based regimens or PI-based regimens among PWH receiving 2DRs. RESULTS There were 3432 (88%) PWH receiving 3DRs and 463 (12%) receiving 2DRs. In the final adjusted model, ≥2 previous virological failures, previous resistance mutations, previous AIDS diagnosis, longer time on current regimen, higher total cholesterol or triglycerides and lower baseline haemoglobin were independent factors associated with 2DRs. The majority of 2DRs included an integrase inhibitor or/and a PI. We identified independent factors associated with the inclusion of integrase inhibitors (lower HDL cholesterol) or PIs (prior AIDS, prior genotypic resistance mutations and lower CD4/CD8 ratio) in the 2DR. CONCLUSIONS In this large single-centre HIV cohort, a worse cardiometabolic status or more archived resistance were key factors associated with inclusion of integrase inhibitors or PIs, respectively, in 2DRs.
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Affiliation(s)
- Elisa de Lazzari
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Alexy Inciarte
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ainoa Ugarte
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | | | | | - Juan Ambrosioni
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Berta Torres
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Josep Mallolas
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jose L Blanco
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jose M Miro
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Esteban Martinez
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
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Abstract
The HIV integrase (IN) strand transfer inhibitor (INSTI) bictegravir (BIC) has a long dissociation half-life (t1/2) from wild-type IN-DNA complexes: BIC 163 hr > dolutegravir (DTG) 96 hr > raltegravir (RAL) 10 hr > elvitegravir (EVG) 3.3 hr. In cells, BIC had more durable antiviral activity against wild-type HIV after drug washout than RAL or EVG. BIC also had a longer t1/2 and maintained longer antiviral activity after drug washout than DTG with the clinically relevant resistance IN mutant G140S+Q148H. Structural analyses indicate that BIC makes more contacts with the IN-DNA complex than DTG mainly via its bicyclic ring system which may contribute to more prolonged residence time and resilience against many resistance mutations.
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20
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Hyle EP, Scott JA, Sax PE, Millham LRI, Dugdale CM, Weinstein MC, Freedberg KA, Walensky RP. Clinical Impact and Cost-effectiveness of Genotype Testing at Human Immunodeficiency Virus Diagnosis in the United States. Clin Infect Dis 2021; 70:1353-1363. [PMID: 31055599 DOI: 10.1093/cid/ciz372] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/03/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND US guidelines recommend genotype testing at human immunodeficiency virus (HIV) diagnosis ("baseline genotype") to detect transmitted drug resistance (TDR) to nonnucleoside reverse transcriptase inhibitors (NNRTIs), nucleoside reverse transcriptase inhibitors (NRTIs), and protease inhibitors. With integrase strand inhibitor (INSTI)-based regimens now recommended as first-line antiretroviral therapy (ART), the of baseline genotypes is uncertain. METHODS We used the Cost-effectiveness of Preventing AIDS Complications model to examine the clinical impact and cost-effectiveness of baseline genotype compared to no baseline genotype for people starting ART with dolutegravir (DTG) and an NRTI pair. For people with no TDR (83.8%), baseline genotype does not alter regimen selection. Among people with transmitted NRTI resistance (5.8%), baseline genotype guides NRTI selection and informs subsequent ART after adverse events (DTG AEs, 14%). Among people with transmitted NNRTI resistance (7.2%), baseline genotype influences care only for people with DTG AEs switching to NNRTI-based regimens. The 48-week virologic suppression varied (40%-92%) depending on TDR. Costs included $320/genotype and $2500-$3000/month for ART. RESULTS Compared to no baseline genotype, baseline genotype resulted in <1 additional undiscounted quality-adjusted life-day (QALD), cost an additional $500/person, and was not cost-effective (incremental cost-effectiveness ratio: $420 000/quality-adjusted life-year). In univariate sensitivity analysis, clinical benefits of baseline genotype never exceeded 5 QALDs for all newly diagnosed people with HIV. Baseline genotype was cost-effective at current TDR prevalence only under unlikely conditions, eg, DTG-based regimens achieving ≤50% suppression of transmitted NRTI resistance. CONCLUSIONS With INSTI-based first-line regimens in the United States, baseline genotype offers minimal clinical benefit and is not cost-effective.
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Affiliation(s)
- Emily P Hyle
- Medical Practice Evaluation Center, Department of Medicine.,Division of Infectious Diseases, Massachusetts General Hospital.,Harvard Medical School, Boston.,Harvard University Center for AIDS Research, Cambridge
| | | | - Paul E Sax
- Harvard Medical School, Boston.,Division of Infectious Diseases and Department of Medicine, Brigham and Women's Hospital
| | | | - Caitlin M Dugdale
- Medical Practice Evaluation Center, Department of Medicine.,Division of Infectious Diseases, Massachusetts General Hospital.,Harvard Medical School, Boston
| | - Milton C Weinstein
- Harvard Medical School, Boston.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Department of Medicine.,Division of Infectious Diseases, Massachusetts General Hospital.,Harvard Medical School, Boston.,Harvard University Center for AIDS Research, Cambridge.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health.,Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Department of Medicine.,Division of Infectious Diseases, Massachusetts General Hospital.,Harvard Medical School, Boston.,Harvard University Center for AIDS Research, Cambridge.,Division of General Internal Medicine, Massachusetts General Hospital, Boston
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21
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Mikasi SG, Isaacs D, Ikomey GM, Shimba H, Cloete R, Jacobs GB. Short Communication: HIV-1 Drug Resistance Mutation Analyses of Cameroon-Derived Integrase Sequences. AIDS Res Hum Retroviruses 2021; 37:54-56. [PMID: 32640829 DOI: 10.1089/aid.2020.0022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
HIV-1 integrase (IN) is a primary target for combination antiretroviral therapy. Only a limited number of studies report on the emergence of resistance-associated mutations (RAMs) in Cameroon. We observed that 1.4% of sequence from treatment-naive patients had IN strand transfer inhibitor (INSTI) RAMs. These mutations confer resistance to raltegravir and elvitegravir. We also observed that 10.1% of the sequences have INSTI accessory RAMs. HIV-1 CRF02_AG was the predominant subtype (44.7%) in this study analyses. The occurrence of INSTI RAMs among the sequences at baseline needs to be monitored carefully.
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Affiliation(s)
- Sello Given Mikasi
- Division of Medical Virology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Darren Isaacs
- South African Medical Research Council Bioinformatics Unit, South African National Bioinformatics Institute, University of the Western Cape, Cape Town, South Africa
| | - George Mondinde Ikomey
- Centre for the Study and Control of Communicable Diseases, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaounde, Cameroon
| | - Henerico Shimba
- Division of Medical Virology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Bugando Medical Centre, Mwanza, United Republic of Tanzania
| | - Ruben Cloete
- Centre for the Study and Control of Communicable Diseases, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaounde, Cameroon
| | - Graeme Brendon Jacobs
- Division of Medical Virology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Hocqueloux L, Raffi F, Prazuck T, Bernard L, Sunder S, Esnault JL, Rey D, Le Moal G, Roncato-Saberan M, André M, Billaud E, Valéry A, Avettand-Fènoël V, Parienti JJ, Allavena C. Dolutegravir Monotherapy Versus Dolutegravir/Abacavir/Lamivudine for Virologically Suppressed People Living With Chronic Human Immunodeficiency Virus Infection: The Randomized Noninferiority MONotherapy of TiviCAY Trial. Clin Infect Dis 2020; 69:1498-1505. [PMID: 30601976 DOI: 10.1093/cid/ciy1132] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/29/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We investigated whether dolutegravir (DTG) monotherapy could be used to maintain virological suppression in people living with human immunodeficiency virus (HIV) on a successful dolutegravir-based triple therapy. METHODS MONCAY (MONotherapy of TiviCAY) was a 48-week, multicentric, randomized, open-label, 12% noninferiority margin trial. Patients with CD4 nadir >100/μL, plasma HIV-1 RNA <50 copies/mL for ≥12 months, and stable regimen with DTG/abacavir (ABC)/lamivudine (3TC) were 1:1 randomized to continue their regimen or to DTG monotherapy. The primary endpoint was the proportion of patients with HIV RNA <50 copies/mL at week 24 in intention-to-treat snapshot analysis. Virologic failure (VF) was defined as 2 consecutive HIV RNA >50 copies/mL within 2 weeks apart. RESULTS Seventy-eight patients were assigned to DTG monotherapy and 80 to continue DTG/ABC/3TC. By week 24, 2 patients in the DTG group experienced VF without resistance to the integrase strand transfer inhibitor (INSTI) class; 1 patient discontinued DTG/ABC/3TC due to an adverse event. The success rate at week 24 was 73/78 (93.6%) in the DTG arm and 77/80 (96.3%) in the DTG/ABC/3TC arm (difference, 2.7%; 95% confidence interval [CI], -5.0 to 10.8). During subsequent follow-up, 5 additional VFs occurred in the DTG arm (2 of which harbored emerging resistance mutation to INSTI). The cumulative incidence of VF at week 48 was 9.7% (95% CI, 2.8 to 16.6) in the DTG arm compared with 0% in the DTG/ABC/3TC arm (P = .005 by the log-rank test). The Data Safety Monitoring Board recommended to reintensify the DTG arm with standardized triple therapy. CONCLUSIONS Because the risk of VF with resistance increases over time, we recommend avoiding DTG monotherapy as a maintenance strategy among people living with chronic HIV infection. CLINICAL TRIALS REGISTRATION NCT02596334 and EudraCT 2015-002853-36.
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Affiliation(s)
- Laurent Hocqueloux
- Service des Maladies Infectieuses et Tropicales, CHR d'Orléans-La Source, Tours
| | - François Raffi
- Service des Maladies Infectieuses, CHU Hôtel Dieu and INSERM UIC 1413 Nantes University, Tours
| | - Thierry Prazuck
- Service des Maladies Infectieuses et Tropicales, CHR d'Orléans-La Source, Tours
| | - Louis Bernard
- Service des Maladies Infectieuses, CHU Bretonneau, Tours
| | - Simon Sunder
- Service des Maladies Infectieuses et Tropicales, CHG de Niort
| | - Jean-Luc Esnault
- Service des Maladies Infectieuses, CHD de Vendée, La Roche-sur-Yon
| | - David Rey
- Le Trait d'Union, Hôpitaux Universitaires de Strasbourg
| | - Gwenaël Le Moal
- Service des Maladies Infectieuses, CHU La Milétrie, Poitiers
| | | | - Marie André
- Service des Maladies Infectieuses, CHRU-Brabois, Nancy
| | - Eric Billaud
- Service des Maladies Infectieuses, CHU Hôtel Dieu and INSERM UIC 1413 Nantes University, Tours
| | - Antoine Valéry
- Département d'Informatique Médicale, CHR d'Orléans-La Source, France
| | - Véronique Avettand-Fènoël
- Laboratoire de Microbiologie clinique, CHU Necker and Université Paris Descartes, Sorbonne Paris Cité
| | - Jean-Jacques Parienti
- Unité de Biostatistique et de Recherche Clinique, CHU de Caen; EA2656 Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Université Caen Normandie, Caen, France
| | - Clotilde Allavena
- Service des Maladies Infectieuses, CHU Hôtel Dieu and INSERM UIC 1413 Nantes University, Tours
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Jóźwik IK, Passos DO, Lyumkis D. Structural Biology of HIV Integrase Strand Transfer Inhibitors. Trends Pharmacol Sci 2020; 41:611-626. [PMID: 32624197 PMCID: PMC7429322 DOI: 10.1016/j.tips.2020.06.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 12/12/2022]
Abstract
Integrase (IN) strand transfer inhibitors (INSTIs) are recent compounds in the antiretroviral arsenal used against HIV. INSTIs work by blocking retroviral integration; an essential step in the viral lifecycle that is catalyzed by the virally encoded IN protein within a nucleoprotein assembly called an intasome. Recent structures of lentiviral intasomes from simian immunodeficiency virus (SIV) and HIV have clarified the INSTI binding modes within the intasome active sites and helped elucidate an important mechanism of viral resistance. The structures provide an accurate depiction of interactions of intasomes and INSTIs to be leveraged for structure-based drug design. Here, we review these recent structural findings and contrast with earlier studies on prototype foamy virus intasomes. We also present and discuss examples of the latest chemical compounds that show promising inhibitory potential as INSTI candidates.
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Affiliation(s)
- Ilona K Jóźwik
- The Salk Institute for Biological Studies, 10010 North Torrey Pines Road, La Jolla, CA, 92037, USA
| | - Dario O Passos
- The Salk Institute for Biological Studies, 10010 North Torrey Pines Road, La Jolla, CA, 92037, USA
| | - Dmitry Lyumkis
- The Salk Institute for Biological Studies, 10010 North Torrey Pines Road, La Jolla, CA, 92037, USA; The Scripps Research Institute, 10550 North Torrey Pines Road, La Jolla, CA, 92037, USA.
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Marcelin AG, Grude M, Charpentier C, Bellecave P, Le Guen L, Pallier C, Raymond S, Mirand A, Bocket L, Fofana DB, Delaugerre C, Nguyen T, Montès B, Jeulin H, Mourez T, Fafi-Kremer S, Amiel C, Roussel C, Dina J, Trabaud MA, Le Guillou-Guillemette H, Vallet S, Signori-Schmuck A, Maillard A, Ferre V, Descamps D, Calvez V, Flandre P. Resistance to integrase inhibitors: a national study in HIV-1-infected treatment-naive and -experienced patients. J Antimicrob Chemother 2020; 74:1368-1375. [PMID: 30789205 DOI: 10.1093/jac/dkz021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 12/26/2018] [Accepted: 01/02/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To describe integrase strand transfer inhibitor (INSTI) resistance profiles and factors associated with resistance in antiretroviral-naive and -experienced patients failing an INSTI-based regimen in clinical practice. METHODS Data were collected from patients failing an INSTI-containing regimen in a multicentre French study between 2014 and 2017. Failure was defined as two consecutive plasma viral loads (VL) >50 copies/mL. Reverse transcriptase, protease and integrase coding regions were sequenced at baseline and failure. INSTI resistance-associated mutations (RAMs) included in the Agence Nationale de Recherches sur le SIDA genotypic algorithm were investigated. RESULTS Among the 674 patients, 359 were failing on raltegravir, 154 on elvitegravir and 161 on dolutegravir therapy. Overall, 90% were experienced patients and 389 (58%) patients showed no INSTI RAMs at failure. The strongest factors associated with emergence of at least one INSTI mutation were high VL at failure (OR = 1.2 per 1 log10 copies/mL increase) and low genotypic sensitivity score (GSS) (OR = 0.08 for GSS ≥3 versus GSS = 0-0.5). Patients failing dolutegravir also had significantly fewer INSTI RAMs at failure than patients failing raltegravir (OR = 0.57, P = 0.02) or elvitegravir (OR = 0.45, P = 0.005). Among the 68 patients failing a first-line regimen, 11/41 (27%) patients on raltegravir, 7/18 (39%) on elvitegravir and 0/9 on dolutegravir had viruses with emergent INSTI RAMs at failure. CONCLUSIONS These results confirmed the robustness of dolutegravir regarding resistance selection in integrase in the case of virological failure in routine clinical care.
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Affiliation(s)
- Anne-Genevieve Marcelin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP), AP-HP, Hôpital Pitié-Salpêtrière, Service de Virologie, Paris, France
| | - Maxime Grude
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP), AP-HP, Hôpital Pitié-Salpêtrière, Service de Virologie, Paris, France
| | - Charlotte Charpentier
- INSERM, IAME, UMR 1137, F-75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France; AP-HP, Hôpital Bichat, Laboratoire de Virologie, Paris, France
| | - Pantxika Bellecave
- CHU de Bordeaux, Laboratoire de Virologie, Université Bordeaux, CNRS UMR 5234, Bordeaux, France
| | - Laura Le Guen
- CHU de Nantes, Laboratoire de Virologie, Nantes, France
| | | | - Stéphanie Raymond
- INSERM U1043 Toulouse, F-31300 France and Laboratoire de Virologie, CHU Toulouse Purpan, Toulouse, France
| | | | | | - Djeneba Bocar Fofana
- Sorbonne Université, INSERM, Institut Pierre Louis, d'Epidémiologie et de Santé Publique (IPLESP), AP-HP, Hôpital Saint Antoine, Service de Virologie, Paris, France
| | | | - Thuy Nguyen
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP), AP-HP, Hôpital Pitié-Salpêtrière, Service de Virologie, Paris, France
| | | | - Hélène Jeulin
- Laboratoire de Virologie, CHRU de Nancy Brabois, Vandoeuvre-lès-Nancy, France
| | | | | | | | | | | | | | | | | | | | | | - Virginie Ferre
- CHU Nantes, Laboratoire de Virologie, CIC INSERM 143, Nantes, France
| | - Diane Descamps
- INSERM, IAME, UMR 1137, F-75018 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France; AP-HP, Hôpital Bichat, Laboratoire de Virologie, Paris, France
| | - Vincent Calvez
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP), AP-HP, Hôpital Pitié-Salpêtrière, Service de Virologie, Paris, France
| | - Philippe Flandre
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP), AP-HP, Hôpital Pitié-Salpêtrière, Service de Virologie, Paris, France
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El Bouzidi K, Kemp SA, Datir RP, Murtala-Ibrahim F, Aliyu A, Kwaghe V, Frampton D, Roy S, Breuer J, Sabin CA, Ogbanufe O, Charurat ME, Bonsall D, Golubchik T, Fraser C, Dakum P, Ndembi N, Gupta RK. High prevalence of integrase mutation L74I in West African HIV-1 subtypes prior to integrase inhibitor treatment. J Antimicrob Chemother 2020; 75:1575-1579. [PMID: 32105319 PMCID: PMC7225870 DOI: 10.1093/jac/dkaa033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/09/2020] [Accepted: 01/16/2020] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES HIV-1 integrase inhibitors are recommended as first-line therapy by WHO, though efficacy and resistance data for non-B subtypes are limited. Two recent trials have identified the integrase L74I mutation to be associated with integrase inhibitor treatment failure in HIV-1 non-B subtypes. We sought to define the prevalence of integrase resistance mutations, including L74I, in West Africa. METHODS We studied a Nigerian cohort of recipients prior to and during receipt of second-line PI-based therapy, who were integrase inhibitor-naive. Illumina next-generation sequencing with target enrichment was used on stored plasma samples. Drug resistance was interpreted using the Stanford Resistance Database and the IAS-USA 2019 mutation lists. RESULTS Of 115 individuals, 59.1% harboured CRF02_AG HIV-1 and 40.9% harboured subtype G HIV-1. Four participants had major IAS-USA integrase resistance-associated mutations detected at low levels (2%-5% frequency). Two had Q148K minority variants and two had R263K (one of whom also had L74I). L74I was detected in plasma samples at over 2% frequency in 40% (46/115). Twelve (26.1%) had low-level minority variants of between 2% and 20% of the viral population sampled. The remaining 34 (73.9%) had L74I present at >20% frequency. L74I was more common among those with subtype G infection (55.3%, 26/47) than those with CRF02_AG infection (29.4%, 20/68) (P = 0.005). CONCLUSIONS HIV-1 subtypes circulating in West Africa appear to have very low prevalence of major integrase mutations, but significant prevalence of L74I. A combination of in vitro and clinical studies is warranted to understand the potential implications.
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Affiliation(s)
- Kate El Bouzidi
- Division of Infection & Immunity, University College London, London, UK
- Institute for Global Health, University College London, London, UK
| | - Steven A Kemp
- Division of Infection & Immunity, University College London, London, UK
| | | | | | - Ahmad Aliyu
- Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Vivian Kwaghe
- University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Dan Frampton
- Division of Infection & Immunity, University College London, London, UK
| | - Sunando Roy
- Division of Infection & Immunity, University College London, London, UK
| | - Judith Breuer
- Division of Infection & Immunity, University College London, London, UK
| | - Caroline A Sabin
- Institute for Global Health, University College London, London, UK
| | - Obinna Ogbanufe
- U.S. Centers for Disease Control and Prevention, Diplomatic Drive, Abuja, Nigeria
| | - Man E Charurat
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David Bonsall
- Big Data Institute, University of Oxford, Oxford, UK
| | | | | | | | | | - Ravindra K Gupta
- Department of Medicine, University of Cambridge, Cambridge, UK
- Africa Health Research Institute, Durban, KZN, South Africa
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Abstract
BACKGROUND There is an increasing interest in two-drug regimens. We hypothesized that maintenance therapy with raltegravir and lamivudine would keep HIV-1 suppressed and be well tolerated. METHODS Virally suppressed HIV-1-infected adults without previous viral failures or known resistance mutations to integrase inhibitors or 3TC/FTC or chronic hepatitis B were randomized 2 : 1 to switch to fixed-dose combination 150 mg lamivudine/300 mg raltegravir twice daily or to continue therapy. Primary outcome was the proportion of patients free of therapeutic failure (defined as viral failure, change in treatment for any reason, consent withdrawal, loss to follow-up or death) at week 24. Secondary outcomes were changes in laboratory, body composition, sleep quality, adherence, and adverse effects. RESULTS There were 75 patients included: men 78%; median age 50 years; median CD4 622/μl. At week 24, 7 (9%) patients had therapeutic failure: raltegravir and lamivudine 2 (4%) vs. control 5 (20%). The difference in proportions of therapeutic failures raltegravir and lamivudine minus control was -0.159 (95% confidence interval: -0.353 to -0.012). There was a trend to more weight gain with raltegravir and lamivudine, but no significant changes in other secondary outcomes. Sixty-four percent of patients in each arm had at least one adverse effect. Two (6%) patients in control arm and 4 (7%) patients in raltegravir and lamivudine arm had severe adverse effects. CONCLUSION This pilot study suggests that switching to raltegravir along with lamivudine in patients with viral suppression maintains efficacy and is well tolerated. A larger study of longer duration is required to confirm these findings.
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27
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Blanco JL, Rojas J, Paredes R, Negredo E, Mallolas J, Casadella M, Clotet B, Gatell JM, de Lazzari E, Martinez E. Dolutegravir-based maintenance monotherapy versus dual therapy with lamivudine: a planned 24 week analysis of the DOLAM randomized clinical trial. J Antimicrob Chemother 2019; 73:1965-1971. [PMID: 29608685 DOI: 10.1093/jac/dky093] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 02/22/2018] [Indexed: 01/26/2023] Open
Abstract
Background No controlled comparisons between dolutegravir/lamivudine or dolutegravir maintenance therapy have been done. We hypothesized that these options would have similar efficacy to triple ART. Methods We used an open-label non-inferiority randomized controlled trial comprising two phases: phase A was established to test that experimental arms did not have an unacceptable (≥5%) failure rate; phase B was intended to include the full number of patients followed for 48 weeks. Treated HIV-1-infected adults with viral load <50 copies/mL for ≥12 months, no prior viral failure or resistance mutations to study drugs, nadir CD4 >200 cells/mm3, and hepatitis B virus surface antigen negative were randomized 1:1:1 to maintain triple therapy (control arm), or to switch to dolutegravir/lamivudine, or to dolutegravir monotherapy stratifying by anchor drug. Premature discontinuation was considered if viral failure or therapy interruption due to adverse events, concurrent illness, protocol deviation or patient's wish occurred. Blips were registered. Planned phase A results at 24 weeks are reported here. The study is registered at EudraCT: 201500027435. Results Ninety-one (control, n = 31; dual therapy, n = 29; monotherapy, n = 31) patients were randomized. Three patients (none previously exposed to integrase inhibitors) prematurely discontinued treatment due to viral failure: dolutegravir/lamivudine (n = 1), no resistance mutations (subject A); dolutegravir (n = 2), N155H, S147G and Q148R resistance mutations (subject B), and E138K, G140S and N155H resistance mutations (subject C). There were no discontinuations for other reasons. One patient (dolutegravir/lamivudine) experienced a blip in viral load. The Data Safety Monitoring Board recommended stopping the dolutegravir monotherapy arm. Conclusions In contrast to dolutegravir/lamivudine, a higher than expected risk of viral failure with development of cross-resistance integrase mutations occurred with dolutegravir maintenance monotherapy.
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Affiliation(s)
- Jose L Blanco
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jhon Rojas
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Roger Paredes
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Eugenia Negredo
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Josep Mallolas
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Maria Casadella
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - Jose M Gatell
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Elisa de Lazzari
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Esteban Martinez
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
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Steegen K, Van Zyl G, Letsoalo E, Claassen M, Hans L, Carmona S. Resistance in patients failing integrase strand transfer inhibitors: a call to replace raltegravir with dolutegravir in third-line treatment in South Africa. Open Forum Infect Dis 2019; 6:ofz377. [PMID: 31433056 PMCID: PMC6786511 DOI: 10.1093/ofid/ofz377] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/19/2019] [Indexed: 11/18/2022] Open
Abstract
Data on integrase resistance patterns in low- and middle-income countries (LMICs) is scarce. We assessed genotypic drug resistance in 43 patients with virological failure on integrase strand transfer inhibitors (INSTIs) containing regimens as part of the third-line treatment program in South Africa. Of the raltegravir (RAL) exposed patients 20/34 (59%) had ≥1 major INSTI mutation, including two (6%) with dolutegravir (DTG) cross-resistance. DTG resistance was detected in one out of four DTG-exposed patients. Replacing RAL with DTG may reduce the risk of INSTI mutations. We recommend DTG drug resistance monitoring when DTG is introduced at a larger scale in LMICs.
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Affiliation(s)
- Kim Steegen
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Services, Johannesburg, South Africa
| | - Gert Van Zyl
- National Health Laboratory Services, Johannesburg, South Africa
- Department of Medical Virology, Tygerberg and Stellenbosch University, South Africa
| | - Esrom Letsoalo
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Services, Johannesburg, South Africa
| | - Mathilda Claassen
- National Health Laboratory Services, Johannesburg, South Africa
- Department of Medical Virology, Tygerberg and Stellenbosch University, South Africa
| | - Lucia Hans
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Services, Johannesburg, South Africa
| | - Sergio Carmona
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Services, Johannesburg, South Africa
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Scutari R, Alteri C, Vicenti I, Di Carlo D, Zuccaro V, Incardona F, Borghi V, Bezenchek A, Andreoni M, Antinori A, Perno CF, Cascio A, De Luca A, Zazzi M, Santoro MM. Evaluation of HIV-1 integrase resistance emergence and evolution in patients treated with integrase inhibitors. J Glob Antimicrob Resist 2019; 20:163-169. [PMID: 31330378 DOI: 10.1016/j.jgar.2019.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/26/2019] [Accepted: 07/12/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES This study evaluated the emergence of mutations associated with integrase strand transfer inhibitors (INSTI) resistance (INSTI-RMs) and the integrase evolution in human immunodeficiency virus type 1 (HIV-1) infected patients treated with this drug class. METHODS The emergence of INSTI-RMs and integrase evolution (estimated as genetic distance between integrase sequences under INSTI treatment and before INSTI treatment) were evaluated in 107 INSTI-naïve patients (19 drug-naïve and 88 drug-experienced) with two plasma genotypic resistance tests: one before INSTI treatment and one under INSTI treatment. A logistic regression analysis was performed to evaluate factors associated with the integrase evolution under INSTI treatment. RESULTS The patients were mainly infected by B subtype (72.0%). Eighty-seven patients were treated with raltegravir, 13 with dolutegravir and seven with elvitegravir. Before INSTI treatment one patient harboured the major INSTI-RM R263K and three patients the accessory INSTI-RMs T97A. Under INSTI treatment the emergence of ≥1 INSTI-RM was found in 39 (36.4%) patients. The major INSTI-RMs that more frequently emerged were: N155H (17.8%), G140S (8.4%), Y143R (7.5%), Q148H (6.5%), and Y143C (4.7%). Concerning integrase evolution, a higher genetic distance was found in patients with ≥1 INSTI-RM compared with those without emergence of resistance (0.024 [0.012-0.036] vs. 0.015 [0.009-0.024], P=0.018). This higher integrase evolution was significantly associated with a longer duration of HIV-1 infection, a higher number of past regimens and non-B subtypes. CONCLUSIONS These findings confirm that major INSTI-RMs very rarely occur in INSTI-naïve patients. Under INSTI treatment, selection of drug-resistance follows the typical drug-resistance pathways; a higher evolution characterises integrase sequences developing drug-resistance compared with those without any resistance.
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Affiliation(s)
| | - Claudia Alteri
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | | | - Domenico Di Carlo
- University of Milan, Paediatric Clinical Research Center "Romeo and Enrica Invernizzi", Milan, Italy
| | | | | | - Vanni Borghi
- Infectious Diseases Clinics, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | | | | | - Andrea Antinori
- National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome, Italy
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Chimbetete C, Chirimuta L, Pascoe M, Keiser O. A case report of untreatable HIV infection in Harare, Zimbabwe. South Afr J HIV Med 2019; 20:885. [PMID: 31308964 PMCID: PMC6620492 DOI: 10.4102/sajhivmed.v20i1.885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 02/28/2019] [Indexed: 01/21/2023] Open
Abstract
Introduction Zimbabwe, like other resource limited countries, manages HIV infection using the public health approach with standard antiretroviral therapy (ART) regimens for first, second and third-line treatment. Third-line ART is the last available treatment option and is based on dolutegravir and darunavir use after HIV drug resistance testing. Patient Presentation We report here a 17-year-old patient on dolutegravir (DTG) and Darunavir based third-line antiretroviral therapy (ART) previously exposed to raltegravir who develops multidrug resistance HIV to the four ART classes available in Zimbabwe. Management and Outcome A trophism assay revealed that patient has CXCR4 trophic virus and hence will not benefit from Maraviroc. Patient is currently stable and receiving a holding regimen of abacavir, lamivudine and lamivudine. Conclusion This is the first documented case of multiclass resistance to the four available ART classes in Zimbabwe. The development and transmission of multiclass HIV drug resistance in resource limited settings has potential to undo the gains of national ART programs. There is need to ensure optimum adherence to ART even in the era of DTG.
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Affiliation(s)
- Cleophas Chimbetete
- Institute of Global Health, University of Geneva, Geneva, Switzerland.,Newlands Clinic, Harare, Zimbabwe
| | | | | | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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31
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Lanzafame M, Lattuada E, Rizzardo S, Piacentini D, Chiesi S, Mazzi R. Dolutegravir Monotherapy's Virological Efficacy in a Highly Treatment-Experienced Patient. AIDS Res Hum Retroviruses 2019; 35:359-360. [PMID: 30525872 DOI: 10.1089/aid.2018.0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Massimiliano Lanzafame
- 1 "Diagnosis and Therapy of HIV Infection" Unit, G.B. Rossi University Hospital, Verona, Italy
| | - Emanuela Lattuada
- 2 Infectious Diseases Unit, G.B. Rossi University Hospital, Verona, Italy
| | | | - Daniela Piacentini
- 2 Infectious Diseases Unit, G.B. Rossi University Hospital, Verona, Italy
| | - Sheila Chiesi
- 2 Infectious Diseases Unit, G.B. Rossi University Hospital, Verona, Italy
| | - Romualdo Mazzi
- 2 Infectious Diseases Unit, G.B. Rossi University Hospital, Verona, Italy
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Capetti A, Rizzardini G. Choosing appropriate pharmacotherapy for drug-resistant HIV. Expert Opin Pharmacother 2019; 20:667-678. [DOI: 10.1080/14656566.2019.1570131] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Amedeo Capetti
- Divisione Malattie Infettive, Aziende Socio Sanitarie Territoriale Fatebenefratelli Sacco, Milano, Italy
| | - Giuliano Rizzardini
- Divisione Malattie Infettive, Aziende Socio Sanitarie Territoriale Fatebenefratelli Sacco, Milano, Italy
- Faculty of Health Sciences, School of Clinical Medicine, Whitwaterstrand University, Johannesburg, South Africa
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Affiliation(s)
- Arne Kroidl
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich 80802, Germany.
| | - Joseph Eberle
- Max von Pettenkofer Institute & Gene Center, Virology, National Reference Center for Retroviruses, Medical Center of the University of Munich, Munich, Germany
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Ahmed N, Flavell S, Ferns B, Frampton D, Edwards SG, Miller RF, Grant P, Nastouli E, Gupta RK. Development of the R263K Mutation to Dolutegravir in an HIV-1 Subtype D Virus Harboring 3 Class-Drug Resistance. Open Forum Infect Dis 2018; 6:ofy329. [PMID: 30648124 PMCID: PMC6329901 DOI: 10.1093/ofid/ofy329] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 12/09/2018] [Indexed: 11/14/2022] Open
Abstract
Dolutegravir (DTG), a second-generation integrase strand-transfer inhibitor (INSTI), is equivalent or superior to current non-nucleotide reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), and first-generation INSTI-based antiretroviral regimens (ARVs). It has the potential to make big improvements in HIV control globally and within patients. This is perhaps the most "precious" HIV drug available. The integrase mutation R263K has been observed in tissue culture experiments and in patients treated with dolutegravir monotherapy in clinical trials. Globally, adherence and monitoring may be less than optimal and therefore DTG resistance more common. This is particularly important in low-middle-income countries, where patients may remain on failing regimens for longer periods of time and accumulate drug resistance. Data on this mutation in non-subtype B infections do not exist. We describe the first report of the R263K integrase mutation in a dolutegravir-exposed subtype D-infected individual with vertically acquired HIV. We have used deep sequencing of longitudinal samples to highlight the change in resistance over time while on a failing regimen. The case highlights that poorly adherent patients should not be offered dolutegravir even as part of a combination regimen and that protease inhibitors should be used preferentially.
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Affiliation(s)
- N Ahmed
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, United Kingdom
| | - S Flavell
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, United Kingdom
| | - B Ferns
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - D Frampton
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - S G Edwards
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, United Kingdom
| | - R F Miller
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, United Kingdom.,Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, United Kingdom
| | - P Grant
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - E Nastouli
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, London, United Kingdom.,Department of Population, Policy and Practice, UCL GOS Institute of Child Health, London, United Kingdom
| | - R K Gupta
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, United Kingdom.,Division of Infection and Immunity, University College London, London, United Kingdom
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Modica S, Rossetti B, Lombardi F, Lagi F, Maffeo M, D'Autilia R, Pecorari M, Vicenti I, Bruzzone B, Magnani G, Paolucci S, Francisci D, Penco G, Sacchini D, Zazzi M, De Luca A, Di Biagio A. Prevalence and determinants of resistance mutations in HIV-1-infected patients exposed to integrase inhibitors in a large Italian cohort. HIV Med 2018; 20:137-146. [PMID: 30461149 DOI: 10.1111/hiv.12692] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The aim of the study was to analyse the prevalence of integrase resistance mutations in integrase strand transfer inhibitor (INSTI)-experienced HIV-1-infected patients and its predictors. METHODS We selected HIV-1 integrase sequences from the Antiviral Response Cohort Analysis (ARCA) database, derived from INSTI-experienced patients between 2008 and 2017. Differences in the prevalence of resistance to raltegravir (RAL), elvitegravir (EVG) and dolutegravir (DTG) were assessed by χ2 test and predictors of resistance were analysed by logistic regression. RESULTS We included 462 genotypes from INSTI-exposed individuals: 356 'INSTI-failing' patients and 106 'previously INSTI-exposed' patients (obtained a median of 42 weeks after INSTI discontinuation [interquartile range (IQR) 17-110 weeks]). Overall, at least low-level resistance (LLR) to any INSTI (Stanford 8.5 algorithm) was detected in 198 (42.9%) cases. The most frequent INSTI resistance mutation was N155H, followed by Q148H/K/R, G140A/C/S, E138A/K/T and Y143C/H/R. Y143R and E138A were more prevalent in viral subtype B versus non-B [5.2 versus 1.5%, respectively (P = 0.04), and 3.1 versus 0%, respectively (P = 0.02)]. Overall, the Q148H/K/R plus G140A/C/S and/or E138A/K/T pattern, defining an intermediate level of resistance to DTG, was detected in 70 (15%) cases. Independent predictors of at least LLR to any INSTI were current use versus past use of INSTIs, a lower genotypic sensitivity score (GSS) for contemporary antiretroviral drugs used, and having an integrase sequence obtained in calendar year 2016 as compared to 2008-2009. CONCLUSIONS The results support integrase resistance testing in INSTI-experienced patients. Emergence of INSTI resistance is facilitated by the reduced genetic barrier of the regimen as a consequence of resistance to companion drugs. However, INSTI resistance may become undetectable by standard population sequencing upon INSTI discontinuation.
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Affiliation(s)
- S Modica
- Infectious Diseases Unit, Siena University Hospital, Siena, Italy.,Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - B Rossetti
- Infectious Diseases Unit, Siena University Hospital, Siena, Italy
| | - F Lombardi
- Institute of Clinical Infectious Diseases, Catholic University of the Sacred Heart, Rome, Italy
| | - F Lagi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - M Maffeo
- Infectious Diseases Unit, Siena University Hospital, Siena, Italy.,Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - R D'Autilia
- Department of Mathematics, University of Roma Tre, Rome, Italy
| | - M Pecorari
- Unit of Microbiology and Virology, Modena University Hospital, Modena, Italy
| | - I Vicenti
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - B Bruzzone
- Hygiene Unit, Policlinico San Martino Hospital, Genoa, Italy
| | - G Magnani
- Department of Infectious Diseases, S. Maria Nuova IRCCS Hospital, Reggio Emilia, Italy
| | - S Paolucci
- Molecular Virology Unit, Microbiology and Virology Department, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - D Francisci
- Infectious Diseases Clinic, Perugia University Hospital, Perugia, Italy
| | - G Penco
- Department of Infectious Diseases, Galliera Hospital, Genoa, Italy
| | - D Sacchini
- Clinic of Infectious Diseases, 'Guglielmo da Saliceto' Hospital, Piacenza, Italy
| | - M Zazzi
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - A De Luca
- Infectious Diseases Unit, Siena University Hospital, Siena, Italy.,Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - A Di Biagio
- Infectious Diseases Clinic, Policlinico San Martino Hospital, Genoa, Italy
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Lanzafame M, Rizzardo S, Piacentini D, Lattuada E, Chiesi S, Vento S. Dolutegravir monotherapy: an option for highly adherent HIV1-infected naive patients with relatively low zenith HIV-RNA? Infect Dis (Lond) 2018; 51:77-78. [PMID: 30317907 DOI: 10.1080/23744235.2018.1518585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Massimiliano Lanzafame
- a Diagnosis and Therapy of HIV Infection Unit , G.B. Rossi University Hospital , Verona , Italy
| | - Sebastiano Rizzardo
- b Infectious Diseases Unit , G.B. Rossi University Hospital , Verona , Italy
| | - Daniela Piacentini
- b Infectious Diseases Unit , G.B. Rossi University Hospital , Verona , Italy
| | - Emanuela Lattuada
- b Infectious Diseases Unit , G.B. Rossi University Hospital , Verona , Italy
| | - Sheila Chiesi
- c Department of Medicine , School of Medicine, Nazarbayev University , Astana , Kazakhstan
| | - Sandro Vento
- d University Medical Center , Astana , Kazakhstan
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