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Rubenstein E, Diemer M, Goldwirt L, Lascoux-Combe C, Chaix ML, Rami A, Ponscarme D, Lafaurie M, Denis B, De Castro N, Gras J, Liegeon G, Sellier PO, Deville L, Chevret S, Delaugerre C, Molina JM. Low cabotegravir trough concentrations without oral lead-in in patients with HIV-1 switching to long-acting cabotegravir and rilpivirine. AIDS 2024; 38:1267-1269. [PMID: 38814715 DOI: 10.1097/qad.0000000000003887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
In a cohort of 72 consecutive virologically-suppressed patients with HIV-1 switching to long-acting cabotegravir and rilpivirine, we observed low cabotegravir trough concentrations 1 and 3 months after the first injection, with a significant association with no oral lead-in at 1 month [odds ratio (OR) = 6.3 [95% confidence interval (CI) 1.7-29.5], P = 0.01] and three months (OR = 5.6 [95% CI 1.3-29.7], P = 0.03), and with high BMI at 1 month (OR = 1.3 [95% CI 1.1-1.6], P = 0.007).
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Affiliation(s)
- Emma Rubenstein
- Department of Infectious Diseases, Saint Louis and Lariboisiere Hospitals, Université Paris Cité
| | - Myriam Diemer
- Department of Infectious Diseases, Saint Louis and Lariboisiere Hospitals, Université Paris Cité
| | | | - Caroline Lascoux-Combe
- Department of Infectious Diseases, Saint Louis and Lariboisiere Hospitals, Université Paris Cité
| | | | - Agathe Rami
- Department of Infectious Diseases, Saint Louis and Lariboisiere Hospitals, Université Paris Cité
| | - Diane Ponscarme
- Department of Infectious Diseases, Saint Louis and Lariboisiere Hospitals, Université Paris Cité
| | - Matthieu Lafaurie
- Department of Infectious Diseases, Saint Louis and Lariboisiere Hospitals, Université Paris Cité
| | - Blandine Denis
- Department of Infectious Diseases, Saint Louis and Lariboisiere Hospitals, Université Paris Cité
| | - Nathalie De Castro
- Department of Infectious Diseases, Saint Louis and Lariboisiere Hospitals, Université Paris Cité
| | - Julien Gras
- Department of Infectious Diseases, Saint Louis and Lariboisiere Hospitals, Université Paris Cité
| | - Geoffroy Liegeon
- Department of Infectious Diseases, Saint Louis and Lariboisiere Hospitals, Université Paris Cité
| | - Pierre-Olivier Sellier
- Department of Infectious Diseases, Saint Louis and Lariboisiere Hospitals, Université Paris Cité
| | | | - Sylvie Chevret
- Department of Biostatistics, Saint Louis Hospital, Université Paris Cité Paris, France
| | | | - Jean-Michel Molina
- Department of Infectious Diseases, Saint Louis and Lariboisiere Hospitals, Université Paris Cité
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Teichner P, Chamay N, Elliot E, Pascual-Bernáldez M, Merrill D, Garris C, D'Amico R, Felizarta C, Torres E, Van Solingen-Ristea R, Baugh B, Patel P, Vannappagari V, Dakhia S, Polli JW, Garside L, Grove R, Thiagarajah S, Birmingham E, van Wyk J. Cabotegravir + Rilpivirine Long-Acting: Overview of Injection Guidance, Injection Site Reactions, and Best Practices for Intramuscular Injection Administration. Open Forum Infect Dis 2024; 11:ofae282. [PMID: 38882931 PMCID: PMC11179104 DOI: 10.1093/ofid/ofae282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 05/23/2024] [Indexed: 06/18/2024] Open
Abstract
Background Cabotegravir (CAB) + rilpivirine (RPV) dosed monthly or every 2 months is a complete long-acting (LA) regimen for the maintenance of human immunodeficiency virus type 1 virologic suppression. Across the phase 3/3b trials, the most frequently reported adverse events were injection site reactions (ISRs). Methods We present pooled ISR characteristics and outcomes for participants receiving CAB + RPV LA through week 96 of the FLAIR and ATLAS-2M studies, and survey results from healthcare providers (HCPs) giving injections (eg, injectors) in the ATLAS, FLAIR, and ATLAS-2M studies to determine optimal injection techniques. Surveys were anonymous, self-administered online questionnaires that queried provider demographics, injection experience, and techniques to minimize pre-/postinjection discomfort. Data were summarized using descriptive statistics. Results Overall, 8453 ISRs were reported by 801 participants receiving ≥1 injection of CAB LA/RPV LA. Most ISRs were mild to moderate in severity (grade 1-2, 99%), with a median duration of 3 days (interquartile range, 2-4 days), and rarely led to withdrawal (2%). Surveys were completed by 181 HCPs across 113 sites. Pushing the intramuscular injection at slow speed (66%), bringing the medication to room temperature (58%), and relaxing the gluteus muscle before injecting (53%) were ranked as effective preinjection/injection procedure practices for minimizing pain. Most injectors (60%) indicated that a prone position provided optimal patient comfort, and 41% had no preference on injection medication order. Conclusions Taken together, the data demonstrate favorable tolerability with CAB + RPV LA injections over the long term and simple techniques routinely used by injectors to help optimize the administration of CAB + RPV LA injections.
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Affiliation(s)
| | | | | | | | | | | | | | - Cecy Felizarta
- Private practice of Franco Felizarta, MD, Bakersfield, California, USA
| | - Emma Torres
- Service de maladies infectieuses et tropicales, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Bryan Baugh
- Janssen Research and Development, Titusville, New Jersey, USA
| | - Parul Patel
- ViiV Healthcare, Durham, North Carolina, USA
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Thoueille P, Saldanha SA, Schaller F, Choong E, Veuve F, Munting A, Cavassini M, Braun D, Günthard HF, Duran Ramirez JJ, Surial B, Furrer H, Rauch A, Ustero P, Calmy A, Stöckle M, Di Benedetto C, Bernasconi E, Schmid P, Marzolini C, Girardin FR, Buclin T, Decosterd LA, Guidi M. Population Pharmacokinetics of Cabotegravir Following Oral Administration and Long-Acting Intramuscular Injection in Real-World People with HIV. Clin Pharmacol Ther 2024; 115:1450-1459. [PMID: 38519844 DOI: 10.1002/cpt.3240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/25/2024] [Indexed: 03/25/2024]
Abstract
Long-acting cabotegravir has been studied mainly in the stringent framework of clinical trials, which does not necessarily reflect the situation of people with HIV (PWH) in routine clinical settings. The present population pharmacokinetic analysis aims to build real-world reference percentile curves of cabotegravir concentrations, accounting for patient-related factors that may affect cabotegravir exposure. The second objective is to simulate whether dosing interval adjustments of cabotegravir could be considered in specific subpopulations. Overall, 238 PWH contributed to 1,038 cabotegravir levels (186 during the initial oral administration phase and 852 after intramuscular injection). Cabotegravir pharmacokinetics was best described using a one-compartment model with distinct first order-absorption for oral and intramuscular administrations, and identical volume and clearance. Our model showed almost 40% faster absorption and 30% higher clearance than previously reported, resulting in a time to steady-state of 8 months and an elimination half-life of 4.6 weeks for long-acting cabotegravir. Sex and body mass index significantly influenced absorption, and bodyweight affected clearance. Model-based simulations showed that cabotegravir trough concentrations in females were 25% lower 4 weeks after the intramuscular loading dose, but 42% higher during the late maintenance phase. Finally, simulations indicated that in females, despite significantly higher cabotegravir concentrations, longer intervals between injections may not consistently ensure levels above the 4-fold protein-adjusted 90% inhibitory target concentration.
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Affiliation(s)
- Paul Thoueille
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Susana Alves Saldanha
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabian Schaller
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eva Choong
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - François Veuve
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Aline Munting
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Matthias Cavassini
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Dominique Braun
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Huldrych F Günthard
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Jessy J Duran Ramirez
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Bernard Surial
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andri Rauch
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pilar Ustero
- Division of Infectious Diseases, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marcel Stöckle
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Enos Bernasconi
- Division of Infectious Diseases, Ente Ospedaliero Cantonale, Lugano, University of Geneva, and University of Southern Switzerland, Lugano, Switzerland
| | - Patrick Schmid
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Catia Marzolini
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - François R Girardin
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thierry Buclin
- Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Laurent A Decosterd
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monia Guidi
- Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Centre for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland
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Han K, Patel P, McCallister S, Rinehart AR, Gandhi Y, Spreen W, Landovitz RJ, Delany-Moretlwe S, Marzinke MA, McKeon T, Budnik P, van Wyk J, Ford SL. Long-acting cabotegravir pharmacokinetics with and without oral lead-in for HIV PrEP. Antimicrob Agents Chemother 2024:e0147523. [PMID: 38709006 DOI: 10.1128/aac.01475-23] [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: 11/13/2023] [Accepted: 04/10/2024] [Indexed: 05/07/2024] Open
Abstract
Long-acting cabotegravir is approved for pre-exposure prophylaxis and combination HIV treatment, both initiated with optional short-term oral lead-in (OLI). We evaluated the impact of OLI on long-acting cabotegravir pharmacokinetics. Cabotegravir plasma concentrations were compared between HIV-positive participants initiating injections with (n = 278) or without (n = 110) OLI in phase III treatment study FLAIR and in HIV-negative participants using OLI (n = 263) in pivotal pre-exposure prophylaxis studies HPTN 083 and HPTN 084. Cabotegravir pharmacokinetic profiles were simulated in three populations (assigned-male-at-birth, 50%-assigned-female-at-birth, and assigned-female-at-birth) under three scenarios: first injection given (A) 1 or (B) 3 days after final OLI dose (OLI-injection gap) or (C) without OLI. The PK objective was 80% of participants achieving 4× in vitro protein-adjusted 90% maximal inhibitory concentration (PA-IC90) and 50% achieving 8× PA-IC90. Observed trough concentrations (Cτ) were similar with and without OLI (P > 0.3). With a 3-day OLI-injection gap, simulated pre-injection Cτ remained above PK objective. Approximately 1-2 weeks after the first injection, simulated PK profiles became nearly identical among all scenarios. Without OLI, it was predicted that 80% of participants achieve 4× PA-IC90 in 1.2, 1.8, and 2.8 days after the first injection in each population, respectively, and 50% achieve 8× PA-IC90 in 1.4, 2.1, and 3.8 days, respectively. Observed long-acting cabotegravir exposure was similar with or without OLI, supporting optional OLI use. Cabotegravir exposure was predicted to remain above PK objective for OLI-injection gaps of ≤3 days and rapidly achieve PK objective after first injection without OLI. Findings are consistent between assigned-male-at-birth and assigned-female-at-birth populations.This study is registered with ClinicalTrials.gov as NCT02720094.
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Affiliation(s)
| | - Parul Patel
- ViiV Healthcare, Durham, North Carolina, USA
| | | | | | | | | | - Raphael J Landovitz
- Center for Clinical AIDS Research and Education, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | | | - Todd McKeon
- ViiV Healthcare, Durham, North Carolina, USA
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Cossu MV, D'Avolio A, Gervasoni C, Giacomelli A, Cattaneo D, Moschese D. Switching to deltoid intramuscular injections maintains therapeutic trough concentrations of rilpivirine and cabotegravir in people with HIV. Antimicrob Agents Chemother 2024; 68:e0017524. [PMID: 38534104 PMCID: PMC11064637 DOI: 10.1128/aac.00175-24] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Affiliation(s)
- Maria Vittoria Cossu
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Antonio D'Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Cristina Gervasoni
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Andrea Giacomelli
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Dario Cattaneo
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Davide Moschese
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
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Bettonte S, Berton M, Battegay M, Stader F, Marzolini C. Development of a physiologically-based pharmacokinetic model to simulate the pharmacokinetics of intramuscular antiretroviral drugs. CPT Pharmacometrics Syst Pharmacol 2024; 13:781-794. [PMID: 38429889 PMCID: PMC11098154 DOI: 10.1002/psp4.13118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 03/03/2024] Open
Abstract
There is growing interest in the use of long-acting (LA) injectable drugs to improve treatment adherence. However, their long elimination half-life complicates the conduct of clinical trials. Physiologically-based pharmacokinetic (PBPK) modeling is a mathematical tool that allows to simulate unknown clinical scenarios for LA formulations. Thus, this work aimed to develop and verify a mechanistic intramuscular PBPK model. The framework describing the release of a LA drug from the depot was developed by including both the physiology of the injection site and the physicochemical properties of the drug. The framework was coded in Matlab® 2020a and implemented in our existing PBPK model for the verification step using clinical data for LA cabotegravir, rilpivirine, and paliperidone. The model was considered verified when the simulations were within twofold of observed data. Furthermore, a local sensitivity analysis was conducted to assess the impact of various factors relevant for the drug release from the depot on pharmacokinetics. The PBPK model was successfully verified since all predictions were within twofold of observed clinical data. Peak concentration, area under the concentration-time curve, and trough concentration were sensitive to media viscosity, drug solubility, drug density, and diffusion layer thickness. Additionally, inflammation was shown to impact the drug release from the depot. The developed framework correctly described the release and the drug disposition of LA formulations upon intramuscular administration. It can be implemented in PBPK models to address pharmacological questions related to the use of LA formulations.
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Affiliation(s)
- Sara Bettonte
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical ResearchUniversity Hospital BaselBaselSwitzerland
- Faculty of MedicineUniversity of BaselBaselSwitzerland
| | - Mattia Berton
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical ResearchUniversity Hospital BaselBaselSwitzerland
- Faculty of MedicineUniversity of BaselBaselSwitzerland
| | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical ResearchUniversity Hospital BaselBaselSwitzerland
- Faculty of MedicineUniversity of BaselBaselSwitzerland
| | | | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical ResearchUniversity Hospital BaselBaselSwitzerland
- Faculty of MedicineUniversity of BaselBaselSwitzerland
- Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUK
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and PathologyUniversity Hospital Lausanne and University of LausanneLausanneSwitzerland
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7
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Bettonte S, Berton M, Stader F, Battegay M, Marzolini C. Drug Exposure of Long-Acting Cabotegravir and Rilpivirine in Older People With Human Immunodeficiency Virus: A Pharmacokinetic Modeling Study. Open Forum Infect Dis 2024; 11:ofae171. [PMID: 38595957 PMCID: PMC11002946 DOI: 10.1093/ofid/ofae171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/19/2024] [Indexed: 04/11/2024] Open
Abstract
Background The life expectancy of people with human immunodeficiency virus (PWH) has significantly increased, thanks to combined antiretrovirals with improved potency and tolerability. One further step has been achieved with the development of long-acting (LA) injectable antiretrovirals, which allow for infrequent dosing. However, the pharmacokinetics of LA antiretrovirals has been poorly characterized in older PWH, as they are generally excluded from trials. We performed virtual studies using physiologically based pharmacokinetic (PBPK) modeling to determine the anticipated exposure of LA cabotegravir/rilpivirine in older individuals. Methods Our PBPK model was verified against available observed data for LA cabotegravir and rilpivirine. Cohorts of virtual individuals aged 20-50, 50-65, or 65-85 years were generated to simulate the exposure of LA cabotegravir/rilpivirine for each age group. The fold changes in trough concentration (Cmin) and in drug exposure (area under the time-concentration curve [AUC]) were determined for older relative to young individuals. Results The verified PBPK models predicted an increase in exposure within the 0.8-1.25 fold range for monthly LA cabotegravir/rilpivirine. The Cmin and AUC were predicted to be 29% and 26% higher in older compared with young adults for LA cabotegravir administered bimonthly (every 2 months) and 46% and 41% higher for LA rilpivirine bimonthly. The Cmin and AUC of LA cabotegravir and rilpivirine were predicted to be modestly increased in female compared with male individuals for all age groups. Conclusions LA cabotegravir/rilpivirine exposure and trough concentrations are predicted to be higher in older than in young PWH; thus, older adults could have a lower risk to present suboptimal concentrations during the dosing interval.
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Affiliation(s)
- Sara Bettonte
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Mattia Berton
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | | | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, University Hospital Lausanne and University of Lausanne, Lausanne, Switzerland
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8
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Gaur AH, Capparelli EV, Calabrese K, Baltrusaitis K, Marzinke MA, McCoig C, Van Solingen-Ristea RM, Mathiba SR, Adeyeye A, Moye JH, Heckman B, Lowenthal ED, Ward S, Milligan R, Samson P, Best BM, Harrington CM, Ford SL, Huang J, Crauwels H, Vandermeulen K, Agwu AL, Smith-Anderson C, Camacho-Gonzalez A, Ounchanum P, Kneebone JL, Townley E, Bolton Moore C. Safety and pharmacokinetics of oral and long-acting injectable cabotegravir or long-acting injectable rilpivirine in virologically suppressed adolescents with HIV (IMPAACT 2017/MOCHA): a phase 1/2, multicentre, open-label, non-comparative, dose-finding study. Lancet HIV 2024; 11:e211-e221. [PMID: 38538160 PMCID: PMC11213970 DOI: 10.1016/s2352-3018(23)00300-4] [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: 05/18/2023] [Revised: 10/06/2023] [Accepted: 11/13/2023] [Indexed: 04/07/2024]
Abstract
BACKGROUND Combined intramuscular long-acting cabotegravir and long-acting rilpivirine constitute the first long-acting combination antiretroviral therapy (ART) regimen approved for adults with HIV. The goal of the IMPAACT 2017 study (MOCHA [More Options for Children and Adolescents]) was to assess the safety and pharmacokinetics of these drugs in adolescents. METHODS In this phase 1/2, multicentre, open-label, non-comparative, dose-finding study, virologically suppressed adolescents (aged 12-17 years; weight ≥35 kg; BMI ≤31·5 kg/m2) with HIV-1 on daily oral ART were enrolled at 15 centres in four countries (Botswana, South Africa, Thailand, and the USA). After 4-6 weeks of oral cabotegravir (cohort 1C) or rilpivirine (cohort 1R), participants received intramuscular long-acting cabotegravir or long-acting rilpivirine every 4 weeks or 8 weeks per the adult dosing regimens, while continuing pre-study ART. The primary outcomes were assessments of safety measures, including all adverse events, until week 4 for oral cabotegravir and until week 16 for long-acting cabotegravir and long-acting rilpivirine, and pharmacokinetic measures, including the area under the plasma concentration versus time curve during the dosing interval (AUC0-tau) and drug concentrations, at week 2 for oral dosing of cabotegravir and at week 16 for intramuscular dosing of cabotegravir and rilpivirine. Enrolment into cohort 1C or cohort 1R was based on the participant's pre-study ART, meaning that masking was not done. For pharmacokinetic analyses, blood samples were drawn at weeks 2-4 after oral dosing and weeks 4-16 after intramuscular dosing. Safety outcome measures were summarised using frequencies, percentages, and exact 95% CIs; pharmacokinetic parameters were summarised using descriptive statistics. This trial is registered at ClinicalTrials.gov, NCT03497676, and is closed to enrolment. FINDINGS Between March 19, 2019, and Nov 25, 2021, 55 participants were enrolled: 30 in cohort 1C and 25 in cohort 1R. At week 16, 28 (97%, 95% CI 82-100) of the 29 dose-evaluable participants in cohort 1C and 21 (91%; 72-99) of the 23 dose-evaluable participants in cohort 1R had reported at least one adverse event, with the most common being injection-site pain (nine [31%] in cohort 1C; nine [39%] in cohort 1R; none were severe). One (4%, 95% CI 0-22) participant in cohort 1R had an adverse event of grade 3 or higher, leading to treatment discontinuation, which was defined as acute rilpivirine-related allergic reaction (self-limiting generalised urticaria) after the first oral dose. No deaths or life-threatening events occurred. In cohort 1C, the week 2 median cabotegravir AUC0-tau was 148·5 (range 37·2-433·1) μg·h/mL. The week 16 median concentrations for the every-4-weeks and every-8-weeks dosing was 3·11 μg/mL (range 1·22-6·19) and 1·15 μg/mL (<0·025-5·29) for cabotegravir and 52·9 ng/mL (31·9-148·0) and 39·1 ng/mL (27·2-81·3) for rilpivirine, respectively. These concentrations were similar to those in adults. INTERPRETATION Study data support using long-acting cabotegravir or long-acting rilpivirine, given every 4 weeks or 8 weeks, per the adult dosing regimens, in virologically suppressed adolescents aged 12 years and older and weighing at least 35 kg. FUNDING The National Institutes of Health and ViiV Healthcare.
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Affiliation(s)
- Aditya H Gaur
- St Jude Children's Research Hospital, Memphis, TN, USA.
| | | | | | - Kristin Baltrusaitis
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mark A Marzinke
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | - Adeola Adeyeye
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - John H Moye
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA
| | | | - Elizabeth D Lowenthal
- University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shawn Ward
- Frontier Science Foundation, Boston, MA, USA
| | | | | | | | | | | | | | | | | | - Allison L Agwu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | | | - Ellen Townley
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Alabama, Birmingham, AL, USA
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West RE, Oberly PJ, Riddler SA, Nolin TD, Devanathan AS. Development and validation of an ultra-high performance liquid chromatography-tandem mass spectrometry method to quantify antiretroviral drug concentrations in human plasma for therapeutic monitoring. J Pharm Biomed Anal 2024; 240:115932. [PMID: 38198884 PMCID: PMC10922569 DOI: 10.1016/j.jpba.2023.115932] [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: 11/10/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024]
Abstract
Antiretroviral therapy (ART) is highly effective for the treatment of HIV-1 infection. ART previously consisted of concomitant administration of many drugs, multiple times per day. Currently, ART generally consists of two- or three-drug regimens once daily as fixed-dose combinations. Drug monitoring may be necessary to ensure adequate concentrations are achieved in the plasma over the dosing interval and prevent further HIV resistance formation. Additionally, nonadherence remains an issue, highlighting the need to ensure sufficient ART exposure. Towards this effort, we developed and validated a highly selective ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method for the simultaneous quantification of a panel of nine antiretrovirals: abacavir, bictegravir, cabotegravir, dolutegravir, doravirine, emtricitabine, lamivudine, raltegravir, and tenofovir in human plasma. Using only 50 µL of plasma, a simple protein precipitation with acetonitrile with internal standards followed by reconstitution in 50 uL (high) or 400 uL (low) was performed. Analyte separation was achieved using a multistep UPLC gradient mixture of (A: 0.1% formic acid in water and B: acetonitrile) and a Waters CORTECS T3 (2.1 ×100 mm) column. The method was comprehensively validated according to the United States Food and Drug Administration Bioanalytical Guidelines over two clinically relevant ranges (1-250 ng/mL and 100-5000 ng/mL) with excellent linearity (R2 > 0.99 for all). The assay run time was 7.5 min. This method achieves acceptable performance of trueness (89.7-104.1%), repeatability, and precision (CV <15%), and allows for simultaneous quantification of guideline-recommended ART regimens. This method can be utilized for the therapeutic monitoring of antiretrovirals in human plasma.
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Affiliation(s)
- Raymond E West
- Center for Clinical Pharmaceutical Sciences, Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Oberly
- Center for Clinical Pharmaceutical Sciences, Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sharon A Riddler
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas D Nolin
- Center for Clinical Pharmaceutical Sciences, Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aaron S Devanathan
- Center for Clinical Pharmaceutical Sciences, Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.
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10
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Oka S, Holohan V, Shirasaka T, Choi JY, Kim YS, Chamay N, Patel P, Polli JW, Ford SL, Crauwels H, Garside L, D'Amico R, Latham C, van Solingen-Ristea R, Baugh B, van Wyk J. Asian participants' experience in phase 3/3b studies of long-acting cabotegravir and rilpivirine: Efficacy, safety, pharmacokinetic, and virological outcomes through week 96. HIV Med 2024; 25:381-390. [PMID: 38147871 DOI: 10.1111/hiv.13588] [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: 07/06/2023] [Accepted: 11/08/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVES Cabotegravir + rilpivirine (CAB + RPV) dosed monthly or every 2 months is the first complete long-acting (LA) regimen recommended by treatment guidelines for the maintenance of HIV-1 virological suppression. This post hoc analysis summarizes outcomes for Asian participants through week 96. METHODS Data from Asian participants naive to CAB + RPV randomized to receive dosing every 4 weeks (Q4W) or every 8 weeks (Q8W) in the FLAIR (NCT02938520) and ATLAS-2M (NCT03299049) phase 3/3b studies were pooled. The proportion of participants with plasma HIV-1 RNA ≥50 and <50 copies/mL (per FDA Snapshot algorithm), incidence of confirmed virological failure (CVF; two consecutive HIV-1 RNA ≥200 copies/mL), pharmacokinetics, safety, and tolerability through week 96 were assessed. RESULTS Overall, 41 Asian participants received CAB + RPV (Q8W, n = 17; Q4W, n = 24). At week 96, 83% (n = 34/41) of participants maintained HIV-1 RNA <50 copies/mL, none had HIV-1 RNA ≥50 copies/mL, and 17% (n = 7/41) had no virological data. No Asian participant met the CVF criterion. Drug-related adverse events occurred in 44% (n = 18/41) of participants; none were Grade ≥3. All injection site reactions were Grade 1 or 2; median duration was 2 days and most resolved within 7 days (90%, n = 390/435). CAB and RPV trough concentrations remained well above their respective protein-adjusted 90% inhibitory concentrations (CAB, 0.166 μg/mL; RPV, 12 ng/mL) through week 96. CONCLUSIONS CAB + RPV LA demonstrated high efficacy, with no participants having CVF, and an acceptable safety profile in Asian participants through week 96. These data support CAB + RPV LA as a complete regimen for the maintenance of HIV-1 virological suppression in Asian individuals.
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Affiliation(s)
- Shinichi Oka
- National Center for Global Health and Medicine, Tokyo, Japan
| | | | - Takuma Shirasaka
- AIDS Medical Center, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Jun Yong Choi
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Yeon-Sook Kim
- School of Medicine, Chungnam National University, Daejeon, South Korea
| | | | - Parul Patel
- ViiV Healthcare, Durham, North Carolina, USA
| | | | | | | | | | | | | | | | - Bryan Baugh
- Janssen Pharmaceuticals, Research & Development, Titusville, New Jersey, USA
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11
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Senkoro E, Bracchi M, Heskin J, Walters Y, Varadarajan M, Antoniadi C, Al-Shakarchi Y, Girometti N, Boffito M. Direct switch from an efavirenz-based regimen to intramuscular long-acting cabotegravir plus rilpivirine: A case report. Int J STD AIDS 2024; 35:311-313. [PMID: 37997937 DOI: 10.1177/09564624231217323] [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: 11/25/2023]
Abstract
Switching from oral antiretroviral treatment to intramuscular (IM) cabotegravir (CAB) + rilpivirine (RPV) has an optional oral lead-in to ensure tolerability. The British HIV Association guidelines advise against directly switching from oral antiretroviral (ART) combinations containing strong/moderate cytochrome inducers like efavirenz (EFV) to IM CAB + RPV. EFV has a prolonged elimination half-life, leading to a residual induction of UGT1A1 and CYP3A4 after discontinuation. These enzymes are responsible for CAB and RPV metabolism and their induction might lead to sub-optimal concentrations of CAB and RPV, risking drug resistance. When switching from EFV to oral CAB + RPV, the ATLAS and ATLAS 2M studies showed reduced RPV concentrations but with maintained viral suppression during the oral lead-in and subsequent long-acting injectable (LAI) phases. Also, a recent pharmacokinetic modelling study indicated reduced RPV concentrations, without viral implication, when switching from EFV to IM CAB + RPV. However, there are limited real-world data on direct switching from EFV-based therapy to long-acting IM CAB + RPV. We describe a case where oral intake was impossible in a critical care scenario, switching from emitricitabine/tenofovir-DF (FTC/TDF) 200/245 mg + 600 mg EFV to IM CAB + RPV for treatment optimisation.
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Affiliation(s)
- Elizabeth Senkoro
- HIV Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Chronic Disease Clinic, Ifakara Health Institute, Morogoro, Tanzania
| | - Margherita Bracchi
- HIV Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Joseph Heskin
- HIV Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Yasmin Walters
- HIV Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Maithili Varadarajan
- HIV Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Christina Antoniadi
- HIV Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Yaser Al-Shakarchi
- HIV Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nicolo Girometti
- HIV Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Marta Boffito
- HIV Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
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12
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Atoyebi S, Bunglawala F, Cottura N, Grañana-Castillo S, Montanha MC, Olagunju A, Siccardi M, Waitt C. Physiologically-based pharmacokinetic modelling of long-acting injectable cabotegravir and rilpivirine in pregnancy. Br J Clin Pharmacol 2024. [PMID: 38340019 DOI: 10.1111/bcp.16006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 11/25/2023] [Accepted: 01/06/2024] [Indexed: 02/12/2024] Open
Abstract
AIMS Long-acting cabotegravir and rilpivirine have been approved to manage HIV in adults, but data regarding safe use in pregnancy are limited. Physiologically-based pharmacokinetic (PBPK) modelling was used to simulate the approved dosing regimens in pregnancy and explore if Ctrough was maintained above cabotegravir and rilpivirine target concentrations (664 and 50 ng/mL, respectively). METHODS An adult PBPK model was validated using clinical data of cabotegravir and rilpivirine in nonpregnant adults. This was modified by incorporating pregnancy-induced metabolic and physiological changes. The pregnancy PBPK model was validated with data on oral rilpivirine and raltegravir (UGT1A1 probe substrate) in pregnancy. Twelve weeks' disposition of monthly and bimonthly dosing of long-acting cabotegravir and rilpivirine was simulated at different trimesters and foetal exposure was also estimated. RESULTS Predicted Ctrough at week 12 for monthly long-acting cabotegravir was above 664 ng/mL throughout pregnancy, but below the target in 0.5% of the pregnant population in the third trimester with bimonthly long-acting cabotegravir. Predicted Ctrough at week 12 for monthly and bimonthly long-acting rilpivirine was below 50 ng/mL in at least 40% and over 90% of the pregnant population, respectively, throughout pregnancy. Predicted medians (range) of cord-to-maternal blood ratios were 1.71 (range, 1.55-1.79) for cabotegravir and 0.88 (0.78-0.93) for rilpivirine between weeks 38 and 40. CONCLUSIONS Model predictions suggest that monthly long-acting cabotegravir could maintain antiviral efficacy throughout pregnancy, but that bimonthly administration may require careful clinical evaluation. Both monthly and bimonthly long-acting rilpivirine may not adequately maintain antiviral efficacy in pregnancy.
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13
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Han K, Gevorkyan H, Sadik Shaik J, Crauwels H, Leemereise C, Bontempo G, Win B, Chounta V, Seal C, DeMoor R, D'Amico R, Spreen WR, Ford SL. Pharmacokinetics and tolerability of cabotegravir and rilpivirine long-acting intramuscular injections to the vastus lateralis (lateral thigh) muscles of healthy adult participants. Antimicrob Agents Chemother 2024; 68:e0078123. [PMID: 38038460 PMCID: PMC10777827 DOI: 10.1128/aac.00781-23] [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: 06/26/2023] [Accepted: 10/04/2023] [Indexed: 12/02/2023] Open
Abstract
Cabotegravir + rilpivirine administered via intramuscular gluteal injections is the first complete long-acting (LA) regimen approved for maintaining HIV-1 virologic suppression. The vastus lateralis (lateral) thigh muscle could be a potential alternative site of administration in circumstances such as injection site fatigue, intolerability, or contraindication for gluteal administration. Cabotegravir and rilpivirine pharmacokinetics and participant tolerability were evaluated following single intramuscular injections to the lateral thigh. Healthy adult participants received 4 weeks of daily oral cabotegravir (30 mg) and rilpivirine (25 mg), followed by a 10- to 14-day washout and single 3 mL intramuscular injections of cabotegravir LA 600 mg and rilpivirine LA 900 mg to the lateral thigh. Safety, tolerability, and pharmacokinetics were evaluated through 52 weeks post injection. Pharmacokinetic parameters were estimated using non-compartmental analysis. Fifteen participants (female at birth, n = 6) enrolled. Median age was 33 years. Median weight was 93.6 kg. Median body mass index was 31.4 kg/m2. One participant withdrew due to pregnancy after oral dosing before receiving an injection. Plasma concentrations at Weeks 4 and 8 were 15.4- and 5.3-fold above the protein-adjusted 90% inhibitory concentration for cabotegravir and 4.7- and 2.4-fold for rilpivirine, respectively. The most common injection site reactions were pain [28/28 (100%)], induration [15/28 (54%)], and swelling [12/28 (42%)]; 94% were Grade 1 or 2. Cabotegravir and rilpivirine plasma pharmacokinetic profiles observed in this study support further evaluation of thigh administration in target populations of people living with HIV-1. Tolerability of cabotegravir + rilpivirine LA intramuscular lateral thigh injections was similar to gluteal administration.
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Affiliation(s)
- Kelong Han
- Department of Clinical Pharmacology, Modeling & Simulation, GSK, Collegeville, Pennsylvania, USA
| | - Hakop Gevorkyan
- California Clinical Trials Medical Group in affiliation with PAREXEL, Glendale, California, USA
| | - Jafar Sadik Shaik
- Department of Clinical Pharmacology & Pharmacometrics, Janssen Research & Development, Spring House, Pennsylvania, USA
| | - Herta Crauwels
- Department of Clinical Pharmacology, Janssen Research & Development, Beerse, Belgium
| | | | | | | | | | | | | | | | | | - Susan L. Ford
- Department of Clinical Pharmacology, Modeling & Simulation, GSK, Durham, North Carolina, USA
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14
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Thoueille P, Saldanha SA, Schaller F, Choong E, Munting A, Cavassini M, Braun D, Günthard HF, Kusejko K, Surial B, Furrer H, Rauch A, Rougemont M, Ustero P, Calmy A, Stöckle M, Marzolini C, Di Benedetto C, Bernasconi E, Schmid P, Piso RJ, Andre P, Girardin FR, Guidi M, Buclin T, Decosterd LA. Real-world trough concentrations and effectiveness of long-acting cabotegravir and rilpivirine: a multicenter prospective observational study in Switzerland. THE LANCET REGIONAL HEALTH. EUROPE 2024; 36:100793. [PMID: 38162253 PMCID: PMC10757247 DOI: 10.1016/j.lanepe.2023.100793] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/01/2023] [Accepted: 11/07/2023] [Indexed: 01/03/2024]
Abstract
Background The efficacy and tolerability of long-acting cabotegravir and rilpivirine were demonstrated in Phase III trials. However, low concentrations combined with other risk factors have been associated with an increased risk of virologic failure. This study aims to verify whether drug concentrations measured in a real-world setting are consistent with those previously reported. Methods SHCS-879 is a nationwide observational study within the Swiss HIV Cohort Study for the monitoring of people with HIV (PWH) on long-acting cabotegravir plus rilpivirine. Samples were collected from March 2022 to March 2023. Findings Overall, 725 samples were obtained from 186 PWH. Our data show a large inter-individual variability in cabotegravir and rilpivirine concentrations, with some individuals exhibiting repeatedly low concentrations. Rilpivirine trough concentrations were consistent with those from Phase III trials, while cabotegravir concentrations were lower. The first concentrations quartile was only slightly above the target of 664 ng/mL. Exploratory statistical analyses found 35% (p < 0·01) lower cabotegravir trough in males compared to females. Overall, 172 PWH (92%) remained suppressed and three experienced virologic failures (1·6%), of those, two had sub-optimal drug exposure. No association was found between low trough levels and detectable viral load. Interpretation Real-world cabotegravir concentrations are substantially lower than previously reported. However, these concentrations appear sufficient to ensure sustained virological suppression in almost every PWH. These reassuring data challenge the rather conservative thresholds adopted to date, which may raise unnecessary concerns. Yet, our study reveals that some PWH have repeatedly very low drug levels, for reasons that remain to be elucidated. Funding This work was funded by the Swiss National Science Foundation, grant number N◦ 324730_192449. This study received no support from pharmaceutical industries. This study was performed within the framework of the Swiss HIV Cohort Study, supported by the Swiss National Science Foundation (grant #201369), by SHCS project #879, and by the SHCS research foundation. The SHCS data were gathered by the Five Swiss University Hospitals, two Cantonal Hospitals, 15 affiliated hospitals and 36 private physicians (listed in http://www.shcs.ch/180-health-care-providers).
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Affiliation(s)
- Paul Thoueille
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Susana Alves Saldanha
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabian Schaller
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eva Choong
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Aline Munting
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Matthias Cavassini
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Dominique Braun
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Huldrych F. Günthard
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Katharina Kusejko
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Bernard Surial
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andri Rauch
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mathieu Rougemont
- Primary Care Medicine Division, University Hospital Geneva, Geneva, Switzerland
| | - Pilar Ustero
- Division of Infectious Diseases, Geneva University Hospitals, Faculty of Medicine, Geneva, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, Geneva University Hospitals, Faculty of Medicine, Geneva, Switzerland
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marcel Stöckle
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Catia Marzolini
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | | | - Enos Bernasconi
- Division of Infectious Diseases, Ente Ospedaliero Cantonale, Lugano, Switzerland
- University of Geneva, University of Southern Switzerland, Lugano, Switzerland
| | - Patrick Schmid
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Rein Jan Piso
- Department of Internal Medicine, Infectious Diseases and Hospital Epidemiology, Cantonal Hospital Olten, Switzerland
| | - Pascal Andre
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - François R. Girardin
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monia Guidi
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Centre for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Thierry Buclin
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Laurent A. Decosterd
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - The Swiss HIV Cohort Study
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Primary Care Medicine Division, University Hospital Geneva, Geneva, Switzerland
- Division of Infectious Diseases, Geneva University Hospitals, Faculty of Medicine, Geneva, Switzerland
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Division of Infectious Diseases, Ente Ospedaliero Cantonale, Lugano, Switzerland
- University of Geneva, University of Southern Switzerland, Lugano, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
- Department of Internal Medicine, Infectious Diseases and Hospital Epidemiology, Cantonal Hospital Olten, Switzerland
- Centre for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland
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15
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O’Shea JG, Cholli P, Heil EL, Buchacz K. Considerations for long-acting antiretroviral therapy in older persons with HIV. AIDS 2023; 37:2271-2286. [PMID: 37965737 PMCID: PMC10993170 DOI: 10.1097/qad.0000000000003704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
People with HIV (PWH) can now enjoy longer, healthier lives due to safe and highly effective antiretroviral therapy (ART), and improved care and prevention strategies. New drug formulations such as long-acting injectables (LAI) may overcome some limitations and issues with oral antiretroviral therapy and strengthen medication adherence. However, challenges and questions remain regarding their use in aging populations. Here, we review unique considerations for LAI-ART for the treatment of HIV in older PWH, including benefits, risks, pharmacological considerations, implementation challenges, knowledge gaps, and identify factors that may facilitate uptake of LA-ART in this population.
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Affiliation(s)
- Jesse G. O’Shea
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Preetam Cholli
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Emily L. Heil
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Kate Buchacz
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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16
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Landovitz RJ, Hanscom BS, Clement ME, Tran HV, Kallas EG, Magnus M, Sued O, Sanchez J, Scott H, Eron JJ, Del Rio C, Fields SD, Marzinke MA, Eshleman SH, Donnell D, Spinelli MA, Kofron RM, Berman R, Piwowar-Manning EM, Richardson PA, Sullivan PA, Lucas JP, Anderson PL, Hendrix CW, Adeyeye A, Rooney JF, Rinehart AR, Cohen MS, McCauley M, Grinsztejn B. Efficacy and safety of long-acting cabotegravir compared with daily oral tenofovir disoproxil fumarate plus emtricitabine to prevent HIV infection in cisgender men and transgender women who have sex with men 1 year after study unblinding: a secondary analysis of the phase 2b and 3 HPTN 083 randomised controlled trial. Lancet HIV 2023; 10:e767-e778. [PMID: 37952550 DOI: 10.1016/s2352-3018(23)00261-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/27/2023] [Accepted: 10/03/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Injectable cabotegravir was superior to daily oral tenofovir disoproxil fumarate plus emtricitabine for HIV prevention in two clinical trials. Both trials had the primary aim of establishing the HIV prevention efficacy of long-acting injectable cabotegravir pre-exposure prophylaxis (PrEP) compared with tenofovir disoproxil fumarate plus emtricitabine daily oral PrEP. Long-acting PrEP was associated with diagnostic delays and integrase strand-transfer inhibitor (INSTI) resistance. This report presents findings from the first unblinded year of the HIV Prevention Trials Network (HPTN) 083 study. METHODS The HPTN 083 randomised controlled trial enrolled HIV-uninfected cisgender men and transgender women at elevated HIV risk who have sex with men, from 43 clinical research sites in Africa, Asia, Latin America, and the USA. Inclusion criteria included: a negative HIV serological test at the screening and study entry, undetectable HIV RNA levels within 14 days of study entry, age 18 years or older, overall good health as determined by clinical and laboratory evaluations, and a creatinine clearance of 60 mL/min or higher. Participants were randomly allocated to receive long-acting injectable cabotegravir or daily oral tenofovir disoproxil fumarate plus emtricitabine PrEP. After study unblinding, participants remained on their original regimen awaiting an extension study. HIV infections were characterised retrospectively at a central laboratory. Here we report the secondary analysis of efficacy and safety for the first unblinded year. The primary outcome was incident HIV infection. Efficacy analyses were done on the modified intention-to-treat population using a Cox regression model. Adverse events were compared across treatment groups and time periods (blinded vs unblinded). This trial is registered with ClinicalTrials.gov, NCT02720094. FINDINGS Of the 4488 participants who contributed person-time to the blinded analysis, 3290 contributed person-time to the first unblinded year analysis between May 15, 2020, and May 14, 2021. Updated HIV incidence in the blinded phase was 0·41 per 100 person-years for long-acting injectable cabotegravir PrEP and 1·29 per 100 person-years for daily oral tenofovir disoproxil fumarate plus emtricitabine PrEP (hazard ratio [HR] 0·31 [95% CI 0·17-0·58], p=0·0003). HIV incidence in the first unblinded year was 0·82 per 100 person-years for long-acting PrEP and 2·27 per 100 person-years for daily oral PrEP (HR 0·35 [0·18-0·69], p=0·002). Adherence to both study products decreased after study unblinding. Additional infections in the long-acting PrEP group included two with on-time injections; three with one or more delayed injections; two detected with long-acting PrEP reinitiation; and 11 more than 6 months after their last injection. Infection within 6 months of cabotegravir exposure was associated with diagnostic delays and INSTI resistance. Adverse events were generally consistent with previous reports; incident hypertension in the long-acting PrEP group requires further investigation. INTERPRETATION Long-acting injectable cabotegravir PrEP retained high efficacy for HIV prevention in men and transgender women who have sex with men during the first year of open-label follow-up, with a near-identical HR for HIV risk reduction between long-acting injectable cabotegravir and daily oral tenofovir disoproxil fumarate plus emtricitabine PrEP during the first year after unblinding compared with the blinded period. Extended follow-up further defined the risk period for diagnostic delays and emergence of INSTI resistance. FUNDING Division of AIDS at the National Institute of Allergy and Infectious Diseases, ViiV Healthcare, and Gilead Sciences.
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Affiliation(s)
- Raphael J Landovitz
- Center for Clinical AIDS Research and Education, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | | | | | - Ha V Tran
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Esper G Kallas
- Department of Parasitic and Infectious Diseases, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Manya Magnus
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Omar Sued
- Fundación Huésped, Buenos Aires, Argentina
| | - Jorge Sanchez
- Centro de Investigaciones Tecnologicas, Biomedicas y Medioambientales, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Hyman Scott
- San Francisco Department of Public Health, San Francisco, CA, USA
| | - Joe J Eron
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carlos Del Rio
- Emory University School of Medicine and Grady Health System, Atlanta, GA, USA
| | - Sheldon D Fields
- Ross and Carol Nese College of Nursing, Pennsylvania State University, University Park, PA, USA
| | - Mark A Marzinke
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Matthew A Spinelli
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Ryan M Kofron
- Center for Clinical AIDS Research and Education, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Berman
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | | | | | - Peter L Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Anschutz Medical Campus, Aurora, CO, USA
| | - Craig W Hendrix
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adeola Adeyeye
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | | | | | - Myron S Cohen
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil
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17
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Orkin C, Schapiro JM, Perno CF, Kuritzkes DR, Patel P, DeMoor R, Dorey D, Wang Y, Han K, Van Eygen V, Crauwels H, Ford SL, Latham CL, St. Clair M, Polli JW, Vanveggel S, Vandermeulen K, D’Amico R, Garges HP, Zolopa A, Spreen WR, van Wyk J, Cutrell AG. Expanded Multivariable Models to Assist Patient Selection for Long-Acting Cabotegravir + Rilpivirine Treatment: Clinical Utility of a Combination of Patient, Drug Concentration, and Viral Factors Associated With Virologic Failure. Clin Infect Dis 2023; 77:1423-1431. [PMID: 37340869 PMCID: PMC10654860 DOI: 10.1093/cid/ciad370] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/19/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Previously reported post hoc multivariable analyses exploring predictors of confirmed virologic failure (CVF) with cabotegravir + rilpivirine long-acting (CAB + RPV LA) were expanded to include data beyond week 48, additional covariates, and additional participants. METHODS Pooled data from 1651 participants were used to explore dosing regimen (every 4 or every 8 weeks), demographic, viral, and pharmacokinetic covariates as potential predictors of CVF. Prior dosing regimen experience was accounted for using 2 populations. Two models were conducted in each population-baseline factor analyses exploring factors known at baseline and multivariable analyses exploring baseline factors plus postbaseline model-predicted CAB/RPV trough concentrations (4 and 44 weeks postinjection). Retained factors were evaluated to understand their contribution to CVF (alone or in combination). RESULTS Overall, 1.4% (n = 23/1651) of participants had CVF through 152 weeks. The presence of RPV resistance-associated mutations, human immunodeficiency virus-1 subtype A6/A1, and body mass index ≥30 kg/m2 were associated with an increased risk of CVF (P < .05 adjusted incidence rate ratio), with participants with ≥2 of these baseline factors having a higher risk of CVF. Lower model-predicted CAB/RPV troughs were additional factors retained for multivariable analyses. CONCLUSIONS The presence of ≥2 baseline factors (RPV resistance-associated mutations, A6/A1 subtype, and/or body mass index ≥30 kg/m2) was associated with increased CVF risk, consistent with prior analyses. Inclusion of initial model-predicted CAB/RPV trough concentrations (≤first quartile) did not improve the prediction of CVF beyond the presence of a combination of ≥2 baseline factors, reinforcing the clinical utility of the baseline factors in the appropriate use of CAB + RPV LA.
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Affiliation(s)
- Chloe Orkin
- SHARE Collaborative, Department of Immunobiology, Queen Mary University of London, London, United Kingdom
| | | | | | - Daniel R Kuritzkes
- Division of Infectious Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Parul Patel
- ViiV Healthcare, Durham, North Carolina, USA
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18
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Young IC, Pallerla A, Cottrell ML, Maturavongsadit P, Prasher A, Shrivastava R, De la Cruz G, Montgomery SA, Schauer A, Sykes C, Kashuba ADM, Benhabbour SR. Long-acting injectable multipurpose prevention technology for prevention of HIV and unplanned pregnancy. J Control Release 2023; 363:606-620. [PMID: 37797892 PMCID: PMC10841820 DOI: 10.1016/j.jconrel.2023.10.006] [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: 05/31/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/07/2023]
Abstract
Only condoms are proven to protect against both HIV and unplanned pregnancy, however, poor user acceptability and lack of partner cooperation impede effectiveness. We developed an injectable ultra-long-acting, biodegradable, and removable in-situ forming implant (ISFI) as multipurpose prevention technology (MPT). MPT ISFIs co-formulated an antiretroviral (dolutegravir (DTG)) or cabotegravir (CAB)), and a hormonal contraceptive (etonogestrel (ENG) or medroxyprogesterone acetate (MPA)). All formulations were well-tolerated in mice with no signs of chronic local or systemic inflammation. Plasma CAB and DTG concentrations were above 4× PA-IC90 for 90 days with zero-order and diffusion-controlled absorption, respectively, and no differences when co-formulated with either hormone. Plasma ENG and MPA concentrations were quantifiable for 90 days. Complete removal of CAB/MPA ISFIs resulted in MPA concentrations falling below the limit of quantification after 24 h post-removal, but incomplete CAB elimination from plasma. Collectively, we demonstrated the ability to co-formulate antiretrovirals with contraceptives in an ISFI that is well-tolerated with sustained plasma concentrations up to 90 days.
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Affiliation(s)
- Isabella C Young
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Aryani Pallerla
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mackenzie L Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Panita Maturavongsadit
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alka Prasher
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Roopali Shrivastava
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Amanda Schauer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Craig Sykes
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Angela D M Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S Rahima Benhabbour
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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19
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Nachega JB, Scarsi KK, Gandhi M, Scott RK, Mofenson LM, Archary M, Nachman S, Decloedt E, Geng EH, Wilson L, Rawat A, Mellors JW. Long-acting antiretrovirals and HIV treatment adherence. Lancet HIV 2023; 10:e332-e342. [PMID: 37062293 PMCID: PMC10734401 DOI: 10.1016/s2352-3018(23)00051-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/26/2023] [Accepted: 02/10/2023] [Indexed: 04/18/2023]
Abstract
Intramuscular injection of long-acting cabotegravir and rilpivirine is a novel, long-acting antiretroviral therapy (ART) combination approved for use as a fully suppressive regimen for people living with HIV. Long-acting cabotegravir with rilpivirine ART has reduced required dosing frequency from once daily to once every month or every 2 months injections. This new era of long-acting ART, which includes other antiretrovirals and formulations in various stages of clinical development, holds tremendous promise to change the standard of HIV treatment. Although long-acting ART has high potential to be revolutionary in the landscape of HIV care, prevention, and treatment cascade, more data are needed to substantiate its efficacy and cost-effectiveness among patients at risk of non-adherence and across age groups, pregnancy, and post partum. Advocacy efforts and policy changes to optimise a sustained, high-quality, equitable reach of long-acting ART, especially in low-income and middle-income countries where most people living with HIV reside, are needed to realise the full benefits of long-acting ART.
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Affiliation(s)
- Jean B Nachega
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Department of Infectious Diseases and Microbiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Center for Global Health, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Department of Epidemiology and Department International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, and Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rachel K Scott
- MedStar Health Research Institute and MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA
| | | | - Moherndran Archary
- Department of Pediatrics, King Edward VIII Hospital, University of Kwa Zulu Natal, Durban, South Africa
| | - Sharon Nachman
- Department of Pediatrics, Stony Brook Children's, SUNY Stony Brook University, Stony Brook, NY, USA
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Department of Medicine, and Institute for Public Health, Washington University, St Louis, MO, USA
| | | | - Angeli Rawat
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; School of Population and Public Heath, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John W Mellors
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
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20
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Marzinke MA, Fogel JM, Wang Z, Piwowar-Manning E, Kofron R, Moser A, Bhandari P, Gollings R, Bushman LR, Weng L, Halvas EK, Mellors J, Anderson PL, Persaud D, Hendrix CW, McCauley M, Rinehart AR, St Clair M, Ford SL, Rooney JF, Adeyeye A, Chariyalertsak S, Mayer K, Arduino RC, Cohen MS, Grinsztejn B, Hanscom B, Landovitz RJ, Eshleman SH. Extended Analysis of HIV Infection in Cisgender Men and Transgender Women Who Have Sex with Men Receiving Injectable Cabotegravir for HIV Prevention: HPTN 083. Antimicrob Agents Chemother 2023; 67:e0005323. [PMID: 36995219 PMCID: PMC10112247 DOI: 10.1128/aac.00053-23] [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: 01/13/2023] [Accepted: 02/15/2023] [Indexed: 03/31/2023] Open
Abstract
HPTN 083 demonstrated that injectable cabotegravir (CAB) was superior to oral tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) for HIV prevention in cisgender men and transgender women who have sex with men. We previously analyzed 58 infections in the blinded phase of HPTN 083 (16 in the CAB arm and 42 in the TDF-FTC arm). This report describes 52 additional infections that occurred up to 1 year after study unblinding (18 in the CAB arm and 34 in the TDF-FTC arm). Retrospective testing included HIV testing, viral load testing, quantification of study drug concentrations, and drug resistance testing. The new CAB arm infections included 7 with CAB administration within 6 months of the first HIV-positive visit (2 with on-time injections, 3 with ≥1 delayed injection, and 2 who restarted CAB) and 11 with no recent CAB administration. Three cases had integrase strand transfer inhibitor (INSTI) resistance (2 with on-time injections and 1 who restarted CAB). Among 34 CAB infections analyzed to date, diagnosis delays and INSTI resistance were significantly more common in infections with CAB administration within 6 months of the first HIV-positive visit. This report further characterizes HIV infections in persons receiving CAB preexposure prophylaxis and helps define the impact of CAB on the detection of infection and the emergence of INSTI resistance.
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Affiliation(s)
- Mark A. Marzinke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica M. Fogel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zhe Wang
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Estelle Piwowar-Manning
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryan Kofron
- Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Amber Moser
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pradip Bhandari
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryann Gollings
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lane R. Bushman
- Department of Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Lei Weng
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Elias K. Halvas
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John Mellors
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Peter L. Anderson
- Department of Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Deborah Persaud
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Craig W. Hendrix
- Department of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Marty St Clair
- ViiV Healthcare, Research Triangle Park, North Carolina, USA
| | - Susan L. Ford
- GlaxoSmithKline, Research Triangle Park, North Carolina, USA
| | | | - Adeola Adeyeye
- Prevention Science Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, USA
| | - Suwat Chariyalertsak
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Kenneth Mayer
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Roberto C. Arduino
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Myron S. Cohen
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Beatriz Grinsztejn
- Instituto de Pesquisa Clinica Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil
| | - Brett Hanscom
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Raphael J. Landovitz
- Center for Clinical AIDS Research and Education, University of California, Los Angeles, Los Angeles, California, USA
| | - Susan H. Eshleman
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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21
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Benaboud S, Solas C, Bouchet S, Gregoire M, Lemaitre F, Venisse N, Lê MP, Muret P, Parant F, Neant N, Boujafaar S, Lagoutte-Renosi J, Garraffo R, Peytavin G. Comment on: Population pharmacokinetics of the rilpivirine long-acting formulation after intramuscular dosing in healthy subjects and people living with HIV. J Antimicrob Chemother 2023; 78:853-854. [PMID: 36683308 DOI: 10.1093/jac/dkad009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- Sihem Benaboud
- EA7323, Evaluation des Thérapeutiques et Pharmacologie Périnatale et Pédiatrique, Université Paris Cité, Paris, France.,Service de Pharmacologie Clinique, Hôpital Cochin, AP-HP, Université Paris Cité, Paris, France
| | - Caroline Solas
- Laboratoire de Pharmacocinétique et Toxicologie, Aix-Marseille Univ, APHM, Unité des Virus Emergents (UVE) IRD 190, INSERM 1207, Laboratoire de Pharmacocinétique et Toxicologie, Hôpital La Timone, Marseille 13005, France
| | - Stephane Bouchet
- Service de Pharmacologie Médicale, CHU de Bordeaux, Bordeaux F-33000, France.,INSERM, Université de Bordeaux, BPH, U1219, Bordeaux F-33000, France
| | - Matthieu Gregoire
- Service de Pharmacologie Clinique, Nantes Université, Centre Hospitalier Universitaire de Nantes, Nantes, France.,Cibles et Médicaments des Infections et de l'Immunité, IICiMed, UR1155, Nantes Université, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Florian Lemaitre
- Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR S 1085, EHESP, Inserm, CHU Rennes, Université Rennes 1, Rennes F-35000, France.,INSERM, Centre d'Investigation Clinique 1414, Rennes F-35000, France.,Service de Pharmacologie Biologique, Centre Hospitalier Universitaire de Rennes, Université de Rennes 1, Rennes, France
| | - Nicolas Venisse
- INSERM CIC 1402, Université de Poitiers, CHU Poitiers, CNRS 7267 EBI, Poitiers F-86000, France.,Pôle Biologie-Pharmacie, Santé Publique, CHU de Poitiers, Poitiers, France
| | - Minh Patrick Lê
- AP-HP, Hôpital Bichat-Claude Bernard, Service de Pharmacologie, Paris 75018, France
| | - Patrice Muret
- Service de Pharmacologie Clinique et Toxicologie, CHU Besançon, Besançon, France.,Pharmacologie, Université Bourgogne Franche-Comté, Besançon, France
| | - Francois Parant
- CBAPS, UM Pharmaco-Tox, Laboratoire Analyse de Trace et Métaux Toxiques, CHU Lyon, Lyon, France
| | - Nadege Neant
- Laboratoire de Pharmacocinétique et Toxicologie, Aix-Marseille Univ, APHM, Unité des Virus Emergents (UVE) IRD 190, INSERM 1207, Laboratoire de Pharmacocinétique et Toxicologie, Hôpital La Timone, Marseille 13005, France
| | | | - Jennifer Lagoutte-Renosi
- Service de Pharmacologie Clinique et Toxicologie, CHU Besançon, Besançon, France.,Pharmacologie, Université Bourgogne Franche-Comté, Besançon, France
| | - Rodolphe Garraffo
- Pharmacologie, Hopital Pasteur, Centre Hospitalier Universitaire de Nice, Universite de Nice-Sophia-Antipolis, Nice 06200, France
| | - Gilles Peytavin
- Pharmacologie-Toxicologie, AP-HP, Hôpital Bichat-Claude Bernard & IAME, UMR 1137, Université Paris Cité, Paris, France
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22
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Patel P, Teichner P, Elliot E, Boffito M, Murray M, Polli JW, Baker M, Ford SL, Han K, Russu A, Crauwels H, D’Amico RD, Spreen WR, van Wyk J. Practical dosing guidance for the management of clinician-administered injections of long-acting cabotegravir and rilpivirine. Ther Adv Infect Dis 2023; 10:20499361231214626. [PMID: 38107552 PMCID: PMC10722954 DOI: 10.1177/20499361231214626] [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: 06/14/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023] Open
Abstract
Cabotegravir (CAB) and rilpivirine (RPV) is the first complete long-acting (LA) injectable regimen recommended by treatment guidelines for the maintenance of HIV-1 virologic suppression in people with HIV-1 who are virologically suppressed on a stable antiretroviral regimen that is administered monthly (Q1M) or every 2 months (Q2M). As an alternative regimen to lifelong daily oral antiretroviral therapy, Q1M or Q2M dosing schedules are associated with increased patient satisfaction and treatment preference. In addition, it may address challenges associated with daily oral dosing, including fear of treatment disclosure or stigma, anxiety related to oral dosing adherence, and the daily reminder of HIV disease status. Cabotegravir + RPV LA is administered by clinical staff as two intramuscular injections dosed Q1M or Q2M. In this review, we share practical dosing guidance for CAB+RPV LA injectable therapy, including how to initiate therapy, schedule injection visits, manage dosing interruptions due to missed or delayed injection visits, manage errors in dosing, and transition to alternative antiretroviral therapy after discontinuation. Practical guidance on the clinical management of CAB+RPV LA dosing, including a detailed discussion using case-based scenarios that may be encountered in clinical practice, is provided. The clinician-administered CAB+RPV LA regimen has dosing management considerations that are flexible and considerate of the patient and has the potential to provide a highly desirable and efficacious alternative to daily oral antiretroviral therapy for many people with HIV-1.
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Affiliation(s)
- Parul Patel
- ViiV Healthcare, 410 Blackwell Street, Durham, NC 27701, USA
| | | | | | - Marta Boffito
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Milena Murray
- Merck & Co, Inc, Rahway, NJ, USA
- Midwestern University and Northwestern Medicine, Chicago, IL, USA
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23
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Meyers K, Nguyen N, Zucker JE, Kutner BA, Carnevale C, Castor D, Sobieszczyk ME, Yin MT, Golub SA, Remien RH. The Long-Acting Cabotegravir Tail as an Implementation Challenge: Planning for Safe Discontinuation. AIDS Behav 2023; 27:4-9. [PMID: 36056997 PMCID: PMC11232485 DOI: 10.1007/s10461-022-03816-0] [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] [Accepted: 08/10/2022] [Indexed: 01/24/2023]
Abstract
The long-acting feature of cabotegravir, an integrase-inhibitor highly effective in preventing acquisition of HIV in adolescents and adults, is both its greatest strength and a challenge to its implementation. Cab-LA is administered at 8-week intervals (after an initial loading dose) but has a long, variable drug "tail" that may leave users vulnerable to future drug resistance if they contract HIV during this critical period. The potential for cab-LA to meaningfully contribute to ending the HIV Epidemic is hindered by, among other factors, limited resources to guide patients and providers on how to safely discontinue injections. We suggest three key strategies to overcome this specific challenge: (1) Comprehensive patient education and counseling about the drug tail; (2) Training and coaching PrEP care teams, including clinical and non-clinical staff, on communication around the tail; (3) Adherence support strategies, including monitoring of cabotegravir drug levels after discontinuation, for a personalized medicine approach to safe discontinuation.
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Affiliation(s)
- Kathrine Meyers
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, 701 W. 168th Street, HHSC 1102, 10032, New York, NY, USA.
| | - Nadia Nguyen
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, 701 W. 168th Street, HHSC 1102, 10032, New York, NY, USA
| | - Jason E Zucker
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Bryan A Kutner
- HIV Center for Clinical and Behavioral Studies, Division of Gender, Sexuality and Health, NY State Psychiatric Institute and Columbia University, New York, NY, USA
| | - Caroline Carnevale
- NYP HIV Prevention Program, New York-Presbyterian Hospital, New York, NY, USA
| | - Delivette Castor
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Magdalena E Sobieszczyk
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Michael T Yin
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Sarit A Golub
- Department of Psychology, Hunter College, City University of New York, New York, NY, USA
- Basic and Applied Social Psychology (BASP) PhD Program, Graduate Center of the City University of New York, New York, NY, USA
- Einstein-Rockefeller-CUNY Center for AIDS Research (ERC-CFAR), New York, NY, USA
| | - Robert H Remien
- HIV Center for Clinical and Behavioral Studies, State Psychiatric Institute, Columbia University, New York, NY, NY, USA
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24
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Liegeon G, Ghosn J. Long-acting injectable cabotegravir for PrEP: A game-changer in HIV prevention? HIV Med 2022. [PMID: 36468218 DOI: 10.1111/hiv.13451] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/22/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Long-acting injectable cabotegravir (CAB-LA) represents a new additional option for HIV prevention in people at substantial risk of HIV infection that may fill the gaps in pre-exposure prophylaxis (PrEP) uptake, adherence, and retention in users having difficulty with oral PrEP. Data from clinical trials demonstrated that CAB-LA was safe, highly effective, and well-accepted for HIV prevention. However, the occurrence of breakthrough HIV infections despite timely injections, HIV seroconversion timing and patterns, risk of selection and dissemination of resistance-associated mutations to integrase inhibitors, complexity of follow-up, logistical considerations, and its cost effectiveness compared with oral PrEP constitute significant issues for the integration of CAB-LA into clinical routine. FINDINGS These concerns need to be addressed before moving forward with large-scale implementation programmes. Pilot and implementation projects are required in the following areas: HIV testing algorithms, patient education, clinic procedures, protocols for switching and discontinuation, efficacy and safety in populations not included in clinical trials, and demedicalization processes. The development of models to increase the uptake of, adherence to, and persistence with and after CAB-LA injections will also be of paramount importance for success. Lessons learned from these projects will increase experience, staff expertise, and organizational and training capacities to support the roll-out of this new agent as part of HIV prevention programmes. CONCLUSION CAB-LA has not yet achieved its full potential in HIV prevention, and strong commitment from all stakeholders is required to push CAB-LA as a game-changer in HIV response.
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Affiliation(s)
- Geoffroy Liegeon
- Université Paris Cité, Paris, France.,Assistance publique - Hôpitaux de Paris, Département des maladies infectieuses, Hôpital Saint Louis et Lariboisière, Paris, France
| | - Jade Ghosn
- Université Paris Cité, Paris, France.,Assistance publique - hôpitaux de Paris, Service des maladies infectieuses, Hôpital Bichat Claude Bernard, Paris, France
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