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Lanzafame M, Lattuada E, Luise D, Delama A, Fait D, Vento S. Short Cycle, Intermittent Therapy: A Valuable Option in Selected, Virologically Suppressed People Living with HIV. AIDS Res Hum Retroviruses 2024; 40:69-72. [PMID: 37551977 DOI: 10.1089/aid.2022.0168] [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: 08/09/2023] Open
Abstract
The use of long-acting antiretroviral regimens will not be suitable for all people living with HIV for various reasons (previous virological failure with drugs of the same class, side effects, logistic difficulties, and costs). We think that short-cycle therapies could represent a feasible and valuable option for antiretroviral treatment optimization in selected individuals. So here we review clinical evidence about efficacy of short-cycle therapy in suppressed HIV-infected patients.
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Affiliation(s)
- Massimiliano Lanzafame
- Unit of Infectious Diseases, Department of Medical Area, "Santa Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Emanuela Lattuada
- Unit of Infectious Diseases, Specialist Department, "Santa Maria della Misericordia" Hospital, Rovigo, Italy
| | - Dora Luise
- Unit of Infectious Diseases, Department of medical Area, "San Bortolo" Hospital, Vicenza, Italy
| | - Andrea Delama
- Unit of Infectious Diseases, Department of Medical Area, "Santa Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Daniela Fait
- Unit of Infectious Diseases, Department of Medical Area, "Santa Chiara" Hospital, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Sandro Vento
- Faculty of Medicine, University of Puthisastra, Phnom Penh, Cambodia
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Lambert-Niclot S, Abdi B, Bellet J, Fofana D, De Truchis P, Amat K, Alvarez JC, Surgers L, Allavena C, Zaegell-Faucher O, Morlat P, Palich R, Gibowski S, Costagliola D, Girard PM, Landman R, Assoumou L, Morand-Joubert L. Four days/week antiretroviral maintenance strategy (ANRS 170 QUATUOR): substudies of reservoirs and ultrasensitive drug resistance. J Antimicrob Chemother 2023:7146011. [PMID: 37104815 DOI: 10.1093/jac/dkad119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND In a 4 days/week (4/7 days) maintenance strategy (ANRS-170 QUATUOR trial), the virological impact of an intermittent strategy was assessed by ultrasensitive virological analyses of reservoirs and resistance. METHODS HIV-1 total DNA, ultra-sensitive plasma viral load (USpVL) and semen VL were measured in the first 121 participants. Sanger and ultra-deep sequencing (UDS) were performed on the HIV-1 genome (Illumina technology) according to the ANRS consensus. A generalized estimation equation with a Poisson distribution was used to compare changes in the proportion of residual viraemia, detectable semen HIV RNA and HIV DNA within and between the two groups over time. RESULTS The proportion of participants with residual viraemia at Day 0 (D0) and Week 48 (W48) was 16.7% and 25.0% in the 4/7 days group and 22.4% and 29.7% in the 7/7 days group, respectively (+8.3% versus +7.3%, P = 0.971). The proportion of detectable DNA (>40 copies/106 cells) at D0 and W48 was 53.7% and 57.4% in the 4/7 days group and 56.1% and 51.8% in the 7/7 days group, respectively (+3.7% versus -4.3%, P = 0.358). Semen HIV RNA was detectable (≥100 copies/mL) in 2.2% of participants at D0 and 4.5% at W48 in the 4/7 days group versus 6.1% and 9.1% in the 7/7 days group, respectively (+2.3% versus +3.0%, P = 0.743). Emerging resistance at failure was more frequent in the 4/7 days group detected by Sanger sequencing: 3/6 participants versus 1/4 in the 7/7 days group, and similar with the UDS assay: 5/6 versus 4/4, respectively. CONCLUSIONS These findings support the potency of a 4/7 days maintenance strategy on virological suppression at the reservoirs and emergent resistance level, including minority variants.
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Affiliation(s)
- Sidonie Lambert-Niclot
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), 184 rue du Faubourg Saint-Antoine, 75571 Cedex 12, Paris, France
- AP-HP Hôpital Saint-Antoine, Laboratoire de Virologie, Paris, France
| | - Basma Abdi
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), 184 rue du Faubourg Saint-Antoine, 75571 Cedex 12, Paris, France
- AP-HP Hôpital Pitié-Salpêtrière, Virology Department, Paris, France
| | - Jonathan Bellet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), 184 rue du Faubourg Saint-Antoine, 75571 Cedex 12, Paris, France
| | - Djeneba Fofana
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), 184 rue du Faubourg Saint-Antoine, 75571 Cedex 12, Paris, France
- AP-HP Hôpital Saint-Antoine, Laboratoire de Virologie, Paris, France
| | - Pierre De Truchis
- Hôpitaux Universitaires Paris-Ile de France-Ouest, Hôpital Raymond Poincaré APHP, Université Versailles-Saint-Quentin, France, Infectious Diseases Department, Garches, France
| | - Karine Amat
- Institut de Médecine et Epidémiologie Appliquée, Hôpital Bichat, Université Paris 7, Paris, France
| | - Jean-Claude Alvarez
- Département de Pharmacologie-Toxicologie, Hôpital R Poincaré APHP, Inserm U-1173, Université Versailles-Saint-Quentin, Garches, France
| | - Laure Surgers
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), 184 rue du Faubourg Saint-Antoine, 75571 Cedex 12, Paris, France
- GHU APHP. Sorbonne Université, Service des Maladies Infectieuses et Tropicales, Hôpital Saint-Antoine, F75012, Paris, France
| | | | - Olivia Zaegell-Faucher
- CHU Sainte-Marguerite, Assistance Publique Hôpitaux de Marseille, Infectious Diseases Department, Marseille, France
| | - Philippe Morlat
- Hôpital Saint André, Internal Medicine and Infectious Diseases Department, CHU, Université de Bordeaux, Bordeaux, France
| | - Romain Palich
- AP-HP Hôpital Pitié-Salpêtrière, Infectious Diseases Department, Paris, France
| | | | - Dominique Costagliola
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), 184 rue du Faubourg Saint-Antoine, 75571 Cedex 12, Paris, France
| | - Pierre-Marie Girard
- GHU APHP. Sorbonne Université, Service des Maladies Infectieuses et Tropicales, Hôpital Saint-Antoine, F75012, Paris, France
| | - Roland Landman
- Infectious and Tropical Diseases Department, IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Hôpital Bichat, AP-HP, Infectious and Tropical Diseases, Paris, France
| | - Lambert Assoumou
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), 184 rue du Faubourg Saint-Antoine, 75571 Cedex 12, Paris, France
| | - Laurence Morand-Joubert
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique (IPLESP), 184 rue du Faubourg Saint-Antoine, 75571 Cedex 12, Paris, France
- AP-HP Hôpital Saint-Antoine, Laboratoire de Virologie, Paris, France
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Petit C. D’un protocole de soin au succès d’un essai clinique. Med Sci (Paris) 2022; 38:707-713. [DOI: 10.1051/medsci/2022109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Les innovations pour traiter l’infection par le virus de l’immunodéficience humaine (VIH) n’ont pas cessé depuis les premières monothérapies et, en 1996, les premières trithérapies. L’une d’elles vient d’être validée par l’essai ANRS QUATUOR. Elle consiste à prendre deux fois moins de médicaments, en rendant le traitement intermittent. À la demande des patients non adhérents à sa prescription standard, Jacques Leibowitch a encadré cette pratique dès 2002, en s’appuyant sur une étude transgressant le dogme de l’adhésion stricte au traitement quotidien. Ce concept de traitement à temps partiel provenait des travaux du groupe d’Anthony Fauci, mais il le revisitera pour le pousser à son apogée avec la cohorte Iccarre. Son intention strictement thérapeutique s’inscrivit initialement dans le cadre du protocole de soin Iccarre qui, en 2020, comptait 96 patients, majoritairement en réduction médicamenteuse de 70 % grâce à l’ultra-intermittence thérapeutique. Il a posé les bases de l’essai contrôlé QUATUOR dont le résultat, récemment publié, montre la non infériorité des traitements intermittents à 4 jours/7 de médicaments par rapport au traitement standard.
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Landman R, de Truchis P, Assoumou L, Lambert S, Bellet J, Amat K, Lefebvre B, Allavena C, Katlama C, Yazdanpanah Y, Molina JM, Petrov-Sanchez V, Gibowski S, Alvarez JC, Leibowitch J, Capeau J, Fellahi S, Duracinsky M, Morand-Joubert L, Costagliola D, Alvarez JC, Girard PM, LAMAURY I, BANI-SADR F, FORCE G, CHABROL A, CABY F, PATEY O, FRESARD A, GAGNEUX-BRUNON A, CHIROUZE C, DUVIVIER C, LOURENCO J, TOLSMA V, JANSSEN C, LEROLLE N, CATALAN P, RAMI A, DE PONTHAUD L, PICHANCOURT G, NASRI S, LANDOWSKI S, BOTTERO J, MFUTILA KAYKAY F, PIALOUX G, BOUCHAUD O, ABGRALL S, GATEY C, WEISS L, PAVIE J, SALMON-CERON D, ZUCMAN D, LELIEVRE JD, PALICH R, SIMON A, MEYOHAS MC, GRAS J, CABIE A, PIRCHER M, MORLAT P, HESSAMFAR M, NEAU D, CAZENAVE C, GENET C, FAUCHER JF, MAKHLOUFI D, BOIBIEUX A, BREGIGEON-RONOT S, LAROCHE H, SAUTEREAU A, REYNES J, MAKINSON A, RAFFI F, BOLLENGIER-STRAGIER O, NAQVI A, CUA E, ROSENTHAL E, ARVIEUX C, BUZELE R, REY D, BATARD ML, BERNARD L, DELOBEL P, PIFFAUT M, VERDON R, PIROTH L, BLOT M, LECLERCQ P, SIGNORI-SCHMUCK A, HULEUX T, MEYBECK A, MAY T, MIAILHES P, PERPOINT T, GREDER-BELAN A, ELHARRAR B, KHUONG MA, POUPARD M, BLUM L, MICHAU C, PRAZUCK T, PHILIBERT P, SLAMA L, HIKOMBO H, DARASTEANU I, GIRARD PM, ALVAREZ JC, MATHEZ D, DE TRUCHIS P, LANDMAN R, MEYNARD JL, MORAND-JOUBERT L, LAMBERT S, LE DU D, PERRONNE C, ASSOUMOU L, COSTAGLIOLA D, MELCHIOR JC, DURACINSKI M, PETROV-SANCHEZ V, AMAT K, BENALYCHERIF A, SYLLA B, GELLEY A, GIBOWSKI S, LE MEUT G, THIEBAUT R, CLUMECK N, LECLERCQ V, CECCHERINI-SILBERSTEIN F, DECOSTER L, LAMAURY I, BANI-SADR F, FORCE G, CHABROL A, CABY F, PATEY O, FRESARD A, GAGNEUX-BRUNON A, CHIROUZE C, DUVIVIER C, LOURENCO J, TOLSMA V, JANSSEN C, LEROLLE N, CATALAN P, RAMI A, DE PONTHAUD L, PICHANCOURT G, NASRI S, LANDOWSKI S, BOTTERO J, MFUTILA KAYKAY F, PIALOUX G, BOUCHAUD O, ABGRALL S, GATEY C, WEISS L, PAVIE J, SALMON-CERON D, ZUCMAN D, LELIEVRE JD, PALICH R, SIMON A, MEYOHAS MC, GRAS J, CABIE A, PIRCHER M, MORLAT P, HESSAMFAR M, NEAU D, CAZENAVE C, GENET C, FAUCHER JF, MAKHLOUFI D, BOIBIEUX A, BREGIGEON-RONOT S, LAROCHE H, SAUTEREAU A, REYNES J, MAKINSON A, RAFFI F, BOLLENGIER-STRAGIER O, NAQVI A, CUA E, ROSENTHAL E, ARVIEUX C, BUZELE R, REY D, BATARD ML, BERNARD L, DELOBEL P, PIFFAUT M, VERDON R, PIROTH L, BLOT M, LECLERCQ P, SIGNORI-SCHMUCK A, HULEUX T, MEYBECK A, MAY T, MIAILHES P, PERPOINT T, GREDER-BELAN A, ELHARRAR B, KHUONG MA, POUPARD M, BLUM L, MICHAU C, PRAZUCK T, PHILIBERT P, SLAMA L, HIKOMBO H, DARASTEANU I, GIRARD PM, ALVAREZ JC, MATHEZ D, DE TRUCHIS P, LANDMAN R, MEYNARD JL, MORAND-JOUBERT L, LAMBERT S, LE DU D, PERRONNE C, ASSOUMOU L, COSTAGLIOLA D, MELCHIOR JC, DURACINSKI M, PETROV-SANCHEZ V, AMAT K, BENALYCHERIF A, SYLLA B, GELLEY A, GIBOWSKI S, LE MEUT G, THIEBAUT R, CLUMECK N, LECLERCQ V, CECCHERINI-SILBERSTEIN F, DECOSTER L. A 4-days-on and 3-days-off maintenance treatment strategy for adults with HIV-1 (ANRS 170 QUATUOR): a randomised, open-label, multicentre, parallel, non-inferiority trial. THE LANCET HIV 2022; 9:e79-e90. [DOI: 10.1016/s2352-3018(21)00300-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 10/22/2021] [Accepted: 11/11/2021] [Indexed: 12/31/2022]
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Luise D, Lattuada E, Rizzardo S, Nicolè S, Lambertenghi L, Coledan I, Gambino S, Gottardo R, Lanzafame M, Vento S. Short-cycle therapy in HIV-infected adults: rilpivirine combination 4 days on/3 days off therapy. J Antimicrob Chemother 2021; 77:747-752. [PMID: 34849955 DOI: 10.1093/jac/dkab442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/29/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Short-cycle therapy (SCT) is the administration of ART for 4 or 5 consecutive days a week, followed by 3 or 2 days off therapy. Its benefits include improving patient satisfaction and reducing ART toxicity and costs. METHODS In this observational study we included HIV-infected adults with a three-drug ART containing rilpivirine, a history of long-term virological suppression and no evidence of resistance to previous drug regimens. Patients switched to a SCT of 4 days on/3 days off and were followed for 48 weeks with regular check-ups. The primary outcome was virological suppression; secondary outcomes were changes in CD4+ cells and rilpivirine plasma concentration, the occurrence of adverse events and resistance in the case of failure, and patient satisfaction. RESULTS At week 48 no virological failure was observed, with a virological suppression rate of 30/30 (100%). Three patients switched back to continuous therapy for other reasons, with an overall success rate of SCT of 30/33 (90.9%, 95% CI = 81.24% to 100%). The CD4+ mean value increased by +64 cells/mm3 (95% CI = -59 to +187 cells/mm3; P = 0.052). No adverse events were observed and the mean total score in the satisfaction questionnaire was 57.7/60 (96.22%). Rilpivirine plasma concentration was below the efficacy threshold in 71.3% of the samples, suggesting that the patients' characteristics, more than the drug's pharmacokinetics, played a role in maintaining virological suppression. CONCLUSIONS SCT with rilpivirine-containing regimens could be an effective alternative to continuous therapy in selected HIV-infected patients with previous long-term virological suppression.
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Affiliation(s)
- Dora Luise
- Infectious Diseases Unit, Vicenza Hospital, Vicenza, Italy
| | - Emanuela Lattuada
- Division of Infectious Diseases, Department of Diagnostic and Public Health, Integrated University Hospital of Verona, Verona, Italy
| | - Sebastiano Rizzardo
- Infectious Diseases Section, Internal Medicine Unit, Rovereto Hospital, Rovereto, Italy
| | - Stefano Nicolè
- Infectious Diseases Unit, Vicenza Hospital, Vicenza, Italy
| | - Lorenza Lambertenghi
- Division of Infectious Diseases, Department of Diagnostic and Public Health, Integrated University Hospital of Verona, Verona, Italy
| | - Ilaria Coledan
- Infectious Diseases Unit, Rovigo Hospital, Rovigo, Italy
| | - Silvia Gambino
- Infectious Diseases Unit, Bolzano Hospital, Bolzano, Italy
| | - Rossella Gottardo
- Division of Legal Medicine, Department of Diagnostic and Public Health, Integrated University Hospital of Verona, Verona, Italy
| | | | - Sandro Vento
- Faculty of Medicine, University of Puthisastra, Phnom Penh, Cambodia
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Calin R, Landowski S, Valantin MA, Tubiana R, Palich R, Agher R, Marcou M, Blanc C, Katlama C, de Truchis P. Efficacy of intermittent short cycles of integrase inhibitor-based maintenance ART in virologically suppressed HIV patients. J Antimicrob Chemother 2021; 75:1321-1323. [PMID: 31977046 DOI: 10.1093/jac/dkz555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 12/01/2019] [Accepted: 12/11/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Several studies have shown that NNRTI/PI-based triple therapy could be safely administered as a 4 days (4D) or 5 days (5D) a week maintenance strategy. We report here our experience of using an integrase inhibitor (INSTI)-based 4D/5D regimen in virologically suppressed HIV patients. METHODS This cohort study enrolled adult patients on ART with viral load (VL) <50 copies/mL for >1 year, who switched to an INSTI-based triple regimen given 4D/5D a week. The primary endpoint was the virological efficacy rate at Week (W) 48, with virological failure defined as confirmed VL ≥50 copies/mL. RESULTS A total of 73 patients were included (n = 28 for 4D, n = 45 for 5D): 54 men (74%), median (IQR) age 51 (45-57) years, ART duration 10 (6-18) years and duration of viral suppression 5 (2-9) years at baseline. As of 25 March 2019, the median follow-up was 21 (14-35) months, with a total of 161 patient-years of follow-up; all patients had reached the W24 visit, 66 (90%) W48 and 34 (47%) W96. Four patients discontinued the strategy: virological failure (n = 2) at W60 and W67, respectively, switch for renal toxicity (n = 1) at W28 and switch to rilpivirine/dolutegravir (n = 1) at W65. Overall the rate of virological success (95% CI) was 100% (94%-100%) at W24 and W48 and 93.7% (79.8%-98.2%) at W96. CONCLUSIONS While waiting for the final results of the large randomized QUATUOR ANRS-170 study, our real-life results suggest that the use of an intermittent maintenance triple-drug regimen given as a weekend (2 or 3 days) off is as effective with an INSTI-based regimen as with a PI or an NNRTI.
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Affiliation(s)
- Ruxandra Calin
- AP-HP, Pitié-Salpêtrière Hospital, Infectious Diseases Department, Paris, Sorbonne Université, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, F-75013 Paris, France
- AP-HP, GHUEP, Tenon Hospital, Sorbonne Université, Paris, France
| | - Stephanie Landowski
- AP-HP, Raymond-Poincaré Hospital, Infectious Diseases Department, Garches France, Saint-Quentin-en-Yvelines University, Paris-Versailles, France
| | - Marc-Antoine Valantin
- AP-HP, Pitié-Salpêtrière Hospital, Infectious Diseases Department, Paris, Sorbonne Université, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, F-75013 Paris, France
| | - Roland Tubiana
- AP-HP, Pitié-Salpêtrière Hospital, Infectious Diseases Department, Paris, Sorbonne Université, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, F-75013 Paris, France
| | - Romain Palich
- AP-HP, Pitié-Salpêtrière Hospital, Infectious Diseases Department, Paris, Sorbonne Université, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, F-75013 Paris, France
| | - Rachid Agher
- AP-HP, Pitié-Salpêtrière Hospital, Infectious Diseases Department, Paris, Sorbonne Université, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, F-75013 Paris, France
| | - Morgane Marcou
- AP-HP, Raymond-Poincaré Hospital, Infectious Diseases Department, Garches France, Saint-Quentin-en-Yvelines University, Paris-Versailles, France
| | - Christine Blanc
- AP-HP, Pitié-Salpêtrière Hospital, Infectious Diseases Department, Paris, Sorbonne Université, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, F-75013 Paris, France
| | - Christine Katlama
- Sorbonne Université, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Pitié-Salpêtrière Hospital, Infectious Diseases Department, F-75013 Paris, France
| | - Pierre de Truchis
- AP-HP, Raymond-Poincaré Hospital, Infectious Diseases Department, Garches France, Saint-Quentin-en-Yvelines University, Paris-Versailles, France
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Mulato A, Acosta R, Chang S, Martin R, Yant SR, Cihlar T, White K. Simulating HIV Breakthrough and Resistance Development During Variable Adherence to Antiretroviral Treatment. J Acquir Immune Defic Syndr 2021; 86:369-377. [PMID: 33196554 DOI: 10.1097/qai.0000000000002562] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/26/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Barriers to lifelong HIV-1 suppression by antiretrovirals include poor adherence and drug resistance; regimens with higher tolerance to missed doses (forgiveness) would be beneficial to patients. To model short-term nonadherence, in vitro experiments monitoring viral breakthrough (VB) and resistance development were conducted. METHODS HIV breakthrough experiments simulated drug exposures at full adherence or suboptimal adherence to bictegravir+emtricitabine+tenofovir alafenamide (BIC+FTC+TAF) or dolutegravir + lamivudine (DTG+3TC). MT-2 cells were infected with wild-type or low frequency M184V HIV-1, exposed to drug combinations, monitored for VB, and rebound virus was deep sequenced. Drug concentrations were determined using human plasma-free adjusted clinical trough concentrations (Cmin), at simulated Cmin after missing 1 to 3 consecutive doses (Cmin - 1 or Cmin - 2, and Cmin - 3) based on drug or active metabolite half-lives. RESULTS Cultures infected with wild-type or low frequency M184V HIV-1 showed no VB with BIC+FTC+TAF at drug concentrations corresponding to Cmin, Cmin - 1, or Cmin - 2 but breakthrough did occur in 26 of 36 cultures at Cmin - 3, where the M184V variant emerged in one culture. Experiments using DTG + 3TC prevented most breakthrough at Cmin concentrations (9/60 had breakthrough) but showed more breakthroughs as drug concentrations decreased (up to 36/36) and variants associated with resistance to both drugs emerged in some cases. CONCLUSIONS These in vitro VB results suggest that the high potency, long half-lives, and antiviral synergy provided by the BIC/FTC/TAF triple therapy regimen may protect from viral rebound and resistance development after short-term lapses in drug adherence.
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Hsu WT, Pan SC, Hsieh SM. 10-year outcome of temporary structured treatment interruption (STI) among HIV-1-infected patients: An observational study in a single medical center. J Formos Med Assoc 2019; 119:455-461. [PMID: 31409497 DOI: 10.1016/j.jfma.2019.07.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/17/2019] [Accepted: 07/31/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Lifelong antiretroviral therapy (ART) is recommended for HIV-1 infected patients but may lead to intolerance or poor adherence. Structured treatment interruption (STI) is a strategy for drug holiday or to boost HIV-specific immunity. But the long-term outcome of STI was never reported in literature. METHODS This is a single-center observational study. We followed the HIV-infected patients who already had a stable viral suppression and voluntarily started temporary STI with a fixed 12-week interval after counseling, evaluation and education. HIV-1-specific T cell response was also measured in some patients. RESULTS Totally 34 HIV-infected patients received temporary STI since July, 2006. 18 patients completed 10-year follow-up. All patients received protease inhibitors (PI)-based ART before and during temporary STI. The patients received temporary STI with a period of 36-85 weeks. All of them reached viral suppression after 12 weeks of restarting continuous ART. No viral rebound or opportunistic disease was recorded during follow-up. No adverse event or comorbidity was attributed to STI. The plasma viral load (PVL) at the end of STI was significantly lower than baseline PVL in patients with a longer duration of STI (≤36 weeks vs. >36 weeks, P = 0.005). The T cell response study revealed that cyclically increased HIV-1-specific T cell response after starting STI in patients with baseline CD4+ count >350/μL. CONCLUSION Temporary STI may not lead to worse long-term outcome among highly selected patients. The policy may partially control viral replication through reminding the HIV-1 specific T cell immunity.
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Affiliation(s)
- Wei-Ting Hsu
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taiwan
| | - Sung-Ching Pan
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taiwan
| | - Szu-Min Hsieh
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taiwan.
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Effects on immune system and viral reservoir of a short-cycle antiretroviral therapy in virologically suppressed HIV-positive patients. AIDS 2019; 33:965-972. [PMID: 30946150 DOI: 10.1097/qad.0000000000002169] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Atripla dose reduction decreases subclinical toxicity and maintains viral suppression in HIV+ individuals but the virological efficacy and immunological safety of this strategy needs to be further confirmed. METHODS Virologically suppressed HIV-infected adults on Atripla once-daily were randomized 1 : 1 to reduce therapy to 3 days a week (3W, n = 30) or to maintain it unchanged (once-daily, n = 31). HIV-1 reservoir (total and integrated HIV-1 DNA in CD4 cells) and immunological cell activation (CD38 and HLA-DR), senescence (CD57 and CD28), apoptosis (annexinV) as well as T-naive, effector memory (TEM) (CCR7, CD45RA) and stem cell memory (TSCM) (CD954 and CD27) populations were measured at baseline, 24 and 48 weeks. RESULTS No differences on activation, senescence or apoptosis of both CD4 and CD8 T cells were observed on follow-up. Nave CD4 T-cell proportion showed a significant decrease in the 3W group (mean ± SD): 24.6 ± 13.7 vs. 20.5 ± 12.9 (P = 0.002). No differences in both plasma viral load and HIV reservoir were detected on follow-up. CD4 TSCM levels at 48 weeks correlated with basal integrated HIV-1 DNA in the 3W group but not in the once-daily group. A post hoc analysis of data prior to the study entry revealed a higher viral load zenith and a trend to lower CD4 nadir in 3W vs. once-daily group. CONCLUSION No significant immunological or viral changes were induced in the 3W group confirming the virological efficacy and immunogical safety of this strategy. In-depth virological and immunological analyses are useful in providing additional information in antiretroviral switching studies (Clinical Trials.gov: NCT01778413).
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de Truchis P, Assoumou L, Landman R, Mathez D, Le Dû D, Bellet J, Amat K, Katlama C, Gras G, Bouchaud O, Duracinsky M, Abe E, Alvarez JC, Izopet J, Saillard J, Melchior JC, Leibowitch J, Costagliola D, Girard PM, Perronne C. Four-days-a-week antiretroviral maintenance therapy in virologically controlled HIV-1-infected adults: the ANRS 162-4D trial. J Antimicrob Chemother 2019; 73:738-747. [PMID: 29186458 DOI: 10.1093/jac/dkx434] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 10/25/2017] [Indexed: 11/12/2022] Open
Abstract
Background Intermittent treatment could improve the convenience, tolerability and cost of ART, as well as patients' quality of life. We conducted a 48 week multicentre study of a 4-days-a-week antiretroviral regimen in adults with controlled HIV-1-RNA plasma viral load (VL). Methods Eligible patients were adults with VL < 50 copies/mL for at least 1 year on triple therapy with a ritonavir-boosted PI (PI/r) or an NNRTI. The study protocol consisted of the same regimen taken on four consecutive days per week followed by a 3 day drug interruption. The primary outcome was the proportion of participants remaining in the strategy with VL < 50 copies/mL up to week 48. The study was designed to show an observed success rate of > 90%, with a power of 87% and a 5% type 1 error. The study was registered with ClinicalTrials.gov (NCT02157311) and EudraCT (2014-000146-29). Results One hundred patients (82 men), median age 47 years (IQR 40-53), were included. They had been receiving ART for a median of 5.1 (IQR 2.9-9.3) years and had a median CD4 cell count of 665 (IQR 543-829) cells/mm3. The ongoing regimen included PI/r in 29 cases and NNRTI in 71 cases. At 48 weeks, 96% of participants (95% CI 90%-98%) had no failure while remaining on the 4-days-a-week regimen. Virological failure occurred in three participants, who all resumed daily treatment and became resuppressed. One participant stopped the strategy. No severe treatment-related events occurred. Conclusions Antiretroviral maintenance therapy 4 days a week was effective for 48 weeks in 96% of patients, leading to potential reduction of long-term toxicities, high adherence to the antiretroviral regimen and drug cost saving.
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Affiliation(s)
- Pierre de Truchis
- Hôpitaux Universitaires Paris-Ile de France-Ouest, Hôpital Raymond Poincaré APHP, Garches, Université Versailles-Saint-Quentin, France
| | - Lambert Assoumou
- Sorbonne Universités, INSERM, UPMC Université Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Roland Landman
- Institut de Médecine et Epidémiologie Appliquée, Hôpital Bichat, Université Paris 7, Paris, France.,IAME, UMR 1137, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Hôpital Bichat-Claude Bernard, Service de Maladies Infectieuses et Tropicales, Paris, France
| | - Dominique Mathez
- Hôpitaux Universitaires Paris-Ile de France-Ouest, Hôpital Raymond Poincaré APHP, Garches, Université Versailles-Saint-Quentin, France
| | - Damien Le Dû
- Hôpitaux Universitaires Paris-Ile de France-Ouest, Hôpital Raymond Poincaré APHP, Garches, Université Versailles-Saint-Quentin, France
| | - Jonathan Bellet
- Sorbonne Universités, INSERM, UPMC Université Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Karine Amat
- Institut de Médecine et Epidémiologie Appliquée, Hôpital Bichat, Université Paris 7, Paris, France
| | - Christine Katlama
- Sorbonne Universités, INSERM, UPMC Université Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France.,APHP, Hôpital Pitié-Salpétrière, Service Maladies Infectieuses et Tropicales, Paris, France
| | - Guillaume Gras
- Centre Hospitalier Universitaire Bretonneau, Tours, France
| | - Olivier Bouchaud
- APHP, Centre Hospitalier Universitaire Avicenne, APHP, Bobigny 93, France
| | - Martin Duracinsky
- Université Paris Sorbonne-Diderot, EA 7334, APHP Hotel-Dieu, URC-ECO, Paris, France
| | - Emuri Abe
- APHP Hôpital R Poincaré, Département de Pharmacologie, Inserm U-1173, Université Paris-Ile de France Ouest, Garches 92, France
| | - Jean-Claude Alvarez
- APHP Hôpital R Poincaré, Département de Pharmacologie, Inserm U-1173, Université Paris-Ile de France Ouest, Garches 92, France
| | - Jacques Izopet
- INSERM U1043/CNRS5282, Université de Toulouse, CHU Purpan, Toulouse, France
| | - Juliette Saillard
- INSERM-ANRS, Agence Nationale pour la Recherche sur le Sida et les Hépatites, Paris, France
| | - Jean-Claude Melchior
- Hôpitaux Universitaires Paris-Ile de France-Ouest, Hôpital Raymond Poincaré APHP, Garches, Université Versailles-Saint-Quentin, France
| | - Jacques Leibowitch
- Hôpitaux Universitaires Paris-Ile de France-Ouest, Hôpital Raymond Poincaré APHP, Garches, Université Versailles-Saint-Quentin, France
| | - Dominique Costagliola
- Sorbonne Universités, INSERM, UPMC Université Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Pierre-Marie Girard
- Sorbonne Universités, INSERM, UPMC Université Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France.,Institut de Médecine et Epidémiologie Appliquée, Hôpital Bichat, Université Paris 7, Paris, France.,APHP, Hôpital Saint Antoine, Service Maladies Infectieuses, Paris, France
| | - Christian Perronne
- Hôpitaux Universitaires Paris-Ile de France-Ouest, Hôpital Raymond Poincaré APHP, Garches, Université Versailles-Saint-Quentin, France
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Churchill D, Waters L, Ahmed N, Angus B, Boffito M, Bower M, Dunn D, Edwards S, Emerson C, Fidler S, Fisher M, Horne R, Khoo S, Leen C, Mackie N, Marshall N, Monteiro F, Nelson M, Orkin C, Palfreeman A, Pett S, Phillips A, Post F, Pozniak A, Reeves I, Sabin C, Trevelion R, Walsh J, Wilkins E, Williams I, Winston A. British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2015. HIV Med 2018; 17 Suppl 4:s2-s104. [PMID: 27568911 DOI: 10.1111/hiv.12426] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | | | | | - Mark Bower
- Chelsea and Westminster Hospital, London, UK
| | | | - Simon Edwards
- Central and North West London NHS Foundation Trust, UK
| | | | - Sarah Fidler
- Imperial College School of Medicine at St Mary's, London, UK
| | | | | | | | | | | | | | | | - Mark Nelson
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | | | | | | | | | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Caroline Sabin
- Royal Free and University College Medical School, London, UK
| | | | - John Walsh
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Ian Williams
- Royal Free and University College Medical School, London, UK
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A maintenance 3-day-per-week schedule with the single tablet regimen efavirenz/emtricitabine/tenofovir disoproxil fumarate is effective and decreases sub-clinical toxicity. AIDS 2018; 32:1633-1641. [PMID: 29746294 DOI: 10.1097/qad.0000000000001843] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Antiretroviral drugs contained in single tablet Atripla have pharmacokinetic properties that could allow for longer than once-daily dosing. We hypothesized that simplifying Atripla once daily to 3-day per week would be feasible, able to maintain viral suppression and less toxic. METHODS Virologically suppressed (≥2 years) HIV+ adults on Atripla once daily, CD4 greater than 350 cells/μl at inclusion, and no prior documented virological failure or evidence of resistance mutations to efavirenz, tenofovir, or emtricitabine were randomized to maintain their once-daily (OD) regimen or to reduce it to 3 days (Mondays, Wednesdays, and Fridays) a week (3W) (A-TRI-WEEK pilot trial). Primary end-point was the proportion of patients free of treatment failure (noncompleter = failure) at 24 weeks. CD4 and CD8 cells, ultrasensitive HIV-1 RNA, Pittsburg Sleep Quality Index (PSQI), bone mineral density, plasma efavirenz levels, and fasting blood and urine chemistries were measured at baseline and 24 weeks. The study is registered at ClinicalTrials.gov, NCT01778413. RESULTS Sixty-one patients were randomized. All patients in both arms remained free of treatment failure (estimated difference 0%; 95% confidence interval -14.1 to 14.1). Ultrasensitive plasma HIV-1 RNA below detection threshold showed no difference between arms (70% in the 3W arm vs. 71% in the OD arm, P = 0.933) at 24 weeks. Total cholesterol and femur T-score significantly increased, whereas PSQI, plasma efavirenz, albumin/creatinine and beta-2-microglobulin in urine significantly decreased in the 3W arm relative to OD arm. CONCLUSION The A-TRI-WEEK study represents a proof of concept for the feasibility of three-day per week Atripla maintenance that should be further confirmed in a larger, well powered clinical trial.
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13
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Weekends-off efavirenz-based antiretroviral therapy in HIV-infected children, adolescents and young adults (BREATHER): Extended follow-up results of a randomised, open-label, non-inferiority trial. PLoS One 2018; 13:e0196239. [PMID: 29684092 PMCID: PMC5912750 DOI: 10.1371/journal.pone.0196239] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 04/09/2018] [Indexed: 11/19/2022] Open
Abstract
Background Weekends off antiretroviral therapy (ART) may help engage HIV-1-infected young people facing lifelong treatment. BREATHER showed short cycle therapy (SCT; 5 days on, 2 days off ART) was non-inferior to continuous therapy (CT) over 48 weeks. Planned follow-up was extended to 144 weeks, maintaining original randomisation. Methods BREATHER was an open-label, non-inferiority trial. Participants aged 8-24yrs with virological suppression on efavirenz-based first-line ART were randomised 1:1, stratified by age and African/non-African sites, to remain on CT or change to SCT. The Kaplan-Meier method was used to estimate the proportion of participants with viral rebound (confirmed VL≥50 copies/mL) under intent-to-treat at 48 weeks (primary outcome), and in extended follow-up at 96, 144, and 192 weeks. SCT participants returned to CT following viral rebound, 3 VL blips or discontinuation of efavirenz. Findings Of 199 participants (99 SCT, 100 CT), 97 per arm consented to extended follow-up. Median follow-up was 185.3 weeks (IQR 160.9–216.1). 69 (70%) SCT participants remained on SCT at last follow-up. 105 (53%) were male, baseline median age 14 years (IQR 12–18), median CD4 count 735 cells/μL (IQR 576–968). 16 SCT and 16 CT participants had confirmed VL≥50 copies/mL by the end of extended follow-up (HR 1.00, 95% CI 0.50–2.00). Estimated difference in percentage with viral rebound (SCT minus CT) by week 144 was 1.9% (90% CI -6.6–10.4; p = 0.72) and was similar in a per-protocol analysis. There were no significant differences between arms in proportions of participants with grade 3/4 adverse events (18 SCT vs 16 CT participants; p = 0.71) or ART-related adverse events (10 vs 12; p = 0.82). 20 versus 8 serious adverse events (SAEs) were reported in 16 SCT versus 4 CT participants, respectively (p = 0.005 comparing proportions between groups; incidence rate ratio 2.49, 95%CI 0.71–8.66, p = 0.15). 75% of SAEs (15 SCT, 6 CT) were hospitalisations for a wide range of conditions. 3 SCT and 6 CT participants switched to second-line ART following viral failure (p = 0.50). Conclusions Sustainable non-inferiority of virological suppression in young people was shown for SCT versus CT over median 3.6 years. Standard-dose efavirenz-based SCT is a viable option for virologically suppressed HIV-1 infected young people on first-line ART with 3-monthly VL monitoring. Trial registration EudraCT 2009-012947-40 ISRCTN 97755073 ClinicalTrials.gov NCT01641016
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14
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Tierrablanca LE, Ochalek J, Ford D, Babiker A, Gibb D, Butler K, Turkova A, Griffin S, Revill P. Economic evaluation of weekends-off antiretroviral therapy for young people in 11 countries. Medicine (Baltimore) 2018; 97:e9698. [PMID: 29384848 PMCID: PMC5805420 DOI: 10.1097/md.0000000000009698] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 11/07/2017] [Accepted: 01/01/2018] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To analyze the cost effectiveness of short-cycle therapy (SCT), where patients take antiretroviral (ARV) drugs 5 consecutive days a week and have 2 days off, as an alternative to continuous ARV therapy for young people infected with human immunodeficiency virus (HIV) and taking efavirenz-based first-line ARV drugs. METHODS We conduct a hierarchical cost-effectiveness analysis based on data on clinical outcomes and resource use from the BREATHER trial. BREATHER is a randomized trial investigating the effectiveness of SCT and continuous therapy in 199 participants aged 8 to 24 years and taking efavirenz-based first-line ARV drugs in 11 countries worldwide. Alongside nationally representative unit costs/prices, these data were used to estimate costs and quality adjusted life years (QALYs). An incremental cost-effectiveness comparison was performed using a multilevel bivariate regression approach for total costs and QALYs. Further analyses explored cost-effectiveness in low- and middle-income countries with access to low-cost generic ARV drugs and high-income countries purchasing branded ARV drugs, respectively. RESULTS At 48 weeks, SCT offered significant total cost savings over continuous therapy of US dollar (USD) 41 per patient in countries using generic drugs and USD 4346 per patient in countries using branded ARV drugs, while accruing nonsignificant total health benefits of 0.008 and 0.009 QALYs, respectively. Cost-effectiveness estimates were similar across settings with access to generic ARV drugs but showed significant variation among high-income countries where branded ARV drugs are purchased. CONCLUSION SCT is a cost-effective treatment alternative to continuous therapy for young people infected with HIV in countries where viral load monitoring is available.
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Affiliation(s)
| | | | - Deborah Ford
- Medical Research Council Clinical Trials Unit, University College London, London
| | - Ab Babiker
- Medical Research Council Clinical Trials Unit, University College London, London
| | - Diana Gibb
- Medical Research Council Clinical Trials Unit, University College London, London
| | | | - Anna Turkova
- Medical Research Council Clinical Trials Unit, University College London, London
- Great Ormond Street Hospital, London, UK
| | - Susan Griffin
- Centre for Health Economics, University of York, York
| | - Paul Revill
- Centre for Health Economics, University of York, York
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Ramos JV, Mmbaga BT, Turner EL, Rugalabamu LL, Luhanga S, Cunningham CK, Dow DE. Modality of Primary HIV Disclosure and Association with Mental Health, Stigma, and Antiretroviral Therapy Adherence in Tanzanian Youth Living with HIV. AIDS Patient Care STDS 2018; 32:31-37. [PMID: 29323556 DOI: 10.1089/apc.2017.0196] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Disclosing HIV status to children before adolescence is a major challenge facing families and healthcare providers. This study used a mixed methods approach to explore the youth perspective of how youth living with HIV (YLHIV) found out their status and to quantify the association of disclosure modality with mental health, stigma, adherence, and HIV outcomes in adolescence. Youth 11-24 years of age attending adolescent HIV clinic in Moshi, Tanzania were included. Adolescents answered questions, including when and how they found out they had HIV, mental health surveys (nine-item Patient Health Questionnaire, Strengths and Difficulties Questionnaire, and modified University of California Los Angeles trauma screen), modified Berger's stigma scale, and self-reported adherence. HIV-1 RNA and latest CD4 were obtained. In-depth interviews were conducted using a convenience sample. The majority of youth reported that they found out their HIV status on their own (80%). Youth attending the government site were less likely to be purposefully told their HIV status compared with those attending the referral site (p < 0.01). Depressive and emotional/behavioral symptoms, internal stigma, and incomplete adherence were significantly more likely among those who figured out their HIV status on their own as compared with those who were purposefully told. Youth discussed how they figured out their HIV status on their own during in-depth interviews. These findings demonstrated that youth who figured out their HIV status on their own had increased mental health symptoms and worse adherence to antiretroviral therapy (ART). It is imperative to implement disclosure protocols in early childhood to reduce mental health difficulties, internal stigma, and promote ART adherence in YLHIV.
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Affiliation(s)
- Julia V. Ramos
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Center, KCMC-Duke Collaboration, Moshi, Tanzania
| | - Elizabeth L. Turner
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | | | - Severa Luhanga
- Kilimanjaro Christian Medical Center, KCMC-Duke Collaboration, Moshi, Tanzania
| | - Coleen K. Cunningham
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Pediatrics, Infectious Diseases, Duke University, Durham, North Carolina
| | - Dorothy E. Dow
- Kilimanjaro Christian Medical Center, KCMC-Duke Collaboration, Moshi, Tanzania
- Duke Global Health Institute, Duke University, Durham, North Carolina
- Pediatrics, Infectious Diseases, Duke University, Durham, North Carolina
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Nalukwago S, Lancioni CL, Oketcho JB, Canaday DHE, Boom WH, Ojok L, Mayanja-Kizza H. The effect of interrupted anti-retroviral treatment on the reconstitution of memory and naive T cells during tuberculosis treatment in HIV patients with active pulmonary tuberculosis. Afr Health Sci 2017; 17:954-962. [PMID: 29937865 PMCID: PMC5870287 DOI: 10.4314/ahs.v17i4.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The reconstitution of cellular immune components contributes to clinical outcome of HIV and Mycobacterium tuberculosis (MTB) infection. Interruption of anti-retroviral therapy (ART) could lead to perturbations in reconstitution of T cells in HIV/ tuberculosis (TB) patients. OBJECTIVES To ascertain the effect of interrupted ART on reconstitution of CD4+ and CD8+ T sub-sets in TB patients. METHODS Participants with HIV (CD4>350 cells/µL) and TB were recruited under a larger phase 3 open label randomised controlled clinical trial. The CD45RO and CD62L markers were measured on CD4+ and CD8+ cells by flow cytometry. Samples were analysed at baseline, 3, 6, 12 months. RESULTS There was a significant increase of naive CD8+ cells (p = 0.003) and a decrease in effector CD8+ cells (p = 0.004) among participants in ART/TB treatment arm during the first 6 months. Withdrawing ART led to naive CD8+ cells reduction (p=0.02) to values close to baseline. An increase of naive CD8+ cells after 6 months of TB treatment in TB alone treatment arm (p=0.01) was observed. A trend towards increment of naive CD4+ sub sets in either treatment arms was observed. CONCLUSION Interrupting ART alters CD8+ but not CD4+ sub-sets in patients with less advanced HIV infection and TB.
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Affiliation(s)
| | - Christina L Lancioni
- Department of Paediatric infectious diseases, Oregon Health Sciences University, Portland Oregon
| | | | - Dave H e Canaday
- Division of Infectious Diseases, Case Western Reserve University
- Getriatric Research Center Clinical Core, Louis Stoves Cleveland VA Medicine Center
| | - W Henry Boom
- Division of Infectious Diseases, Case Western Reserve University
| | - Lonzy Ojok
- Department of pathology, Makerere University College of Veterinary Medicine, Animal resources and biosecurity, Kampala, Uganda
| | - Harriet Mayanja-Kizza
- School of Medicine, Makerere University College of Health Sciences, Mulago Hospital, Kampala, Uganda
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Weekends-off efavirenz-based antiretroviral therapy in HIV-infected children, adolescents, and young adults (BREATHER): a randomised, open-label, non-inferiority, phase 2/3 trial. Lancet HIV 2016; 3:e421-e430. [PMID: 27562743 PMCID: PMC4995440 DOI: 10.1016/s2352-3018(16)30054-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 05/24/2016] [Accepted: 05/26/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND For HIV-1-infected young people facing lifelong antiretroviral therapy (ART), short cycle therapy with long-acting drugs offers potential for drug-free weekends, less toxicity, and better quality-of-life. We aimed to compare short cycle therapy (5 days on, 2 days off ART) versus continuous therapy (continuous ART). METHODS In this open-label, non-inferiority trial (BREATHER), eligible participants were aged 8-24 years, were stable on first-line efavirenz with two nucleoside reverse transcriptase inhibitors, and had HIV-1 RNA viral load less than 50 copies per mL for 12 months or longer. Patients were randomly assigned (1:1) to remain on continuous therapy or change to short cycle therapy according to a computer-generated randomisation list, with permuted blocks of varying size, stratified by age and African versus non-African sites; the list was prepared by the trial statistician and randomisation was done via a web service accessed by site clinician or one of the three coordinating trials units. The primary outcome was the proportion of participants with confirmed viral load 50 copies per mL or higher at any time up to the 48 week assessment, estimated with the Kaplan-Meier method. The trial was powered to exclude a non-inferiority margin of 12%. Analyses were intention to treat. The trial was registered with EudraCT, number 2009-012947-40, ISRCTN, number 97755073, and CTA, number 27505/0005/001-0001. FINDINGS Between April 1, 2011, and June 28, 2013, 199 participants from 11 countries worldwide were randomly assigned, 99 to the short cycle therapy and 100 to continuous therapy, and were followed up until the last patient reached 48 weeks. 105 (53%) were men, median age was 14 years (IQR 12-18), and median CD4 cell count was 735 cells per μL (IQR 576-968). Six (6%) patients assigned to the short cycle therapy versus seven (7%) assigned to continuous therapy had confirmed viral load 50 copies per mL or higher (difference -1·2%, 90% CI -7·3 to 4·9, non-inferiority shown). 13 grade 3 or 4 events occurred in the short cycle therapy group and 14 in the continuous therapy group (p=0·89). Two ART-related adverse events (one gynaecomastia and one spontaneous abortion) occurred in the short cycle therapy group compared with 14 (p=0·02) in the continuous therapy group (five lipodystrophy, two gynaecomastia, one suicidal ideation, one dizziness, one headache and syncope, one spontaneous abortion, one neutropenia, and two raised transaminases). INTERPRETATION Non-inferiority of maintaining virological suppression in children, adolescents, and young adults was shown for short cycle therapy versus continous therapy at 48 weeks, with similar resistance and a better safety profile. This short cycle therapy strategy is a viable option for adherent HIV-infected young people who are stable on efavirenz-based ART. FUNDING UK National Institute for Health Research Health Technology Assessment; UK Medical Research Council; European Commission; PENTA Foundation; INSERM SC10-US19, France.
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Butler K, Inshaw J, Ford D, Bernays S, Scott K, Kenny J, Klein N, Turkova A, Harper L, Nastouli E, Paparini S, Choudhury R, Rhodes T, Babiker A, Gibb D. BREATHER (PENTA 16) short-cycle therapy (SCT) (5 days on/2 days off) in young people with chronic human immunodeficiency virus infection: an open, randomised, parallel-group Phase II/III trial. Health Technol Assess 2016; 20:1-108. [PMID: 27377073 PMCID: PMC4947878 DOI: 10.3310/hta20490] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND For human immunodeficiency virus (HIV)-infected adolescents facing lifelong antiretroviral therapy (ART), short-cycle therapy (SCT) with long-acting agents offers the potential for drug-free weekends, less toxicity, better adherence and cost savings. OBJECTIVES To determine whether or not efavirenz (EFV)-based ART in short cycles of 5 days on and 2 days off is as efficacious (in maintaining virological suppression) as continuous EFV-based ART (continuous therapy; CT). Secondary objectives included the occurrence of new clinical HIV events or death, changes in immunological status, emergence of HIV drug resistance, drug toxicity and changes in therapy. DESIGN Open, randomised, non-inferiority trial. SETTING Europe, Thailand, Uganda, Argentina and the USA. PARTICIPANTS Young people (aged 8-24 years) on EFV plus two nucleoside reverse transcriptase inhibitors and with a HIV-1 ribonucleic acid level [viral load (VL)] of < 50 copies/ml for > 12 months. INTERVENTIONS Young people were randomised to continue daily ART (CT) or change to SCT (5 days on, 2 days off ART). MAIN OUTCOME MEASURES Follow-up was for a minimum of 48 weeks (0, 4 and 12 weeks and then 12-weekly visits). The primary outcome was the difference between arms in the proportion with VL > 50 copies/ml (confirmed) by 48 weeks, estimated using the Kaplan-Meier method (12% non-inferiority margin) adjusted for region and age. RESULTS In total, 199 young people (11 countries) were randomised (n = 99 SCT group, n = 100 CT group) and followed for a median of 86 weeks. Overall, 53% were male; the median age was 14 years (21% ≥ 18 years); 13% were from the UK, 56% were black, 19% were Asian and 21% were Caucasian; and the median CD4% and CD4 count were 34% and 735 cells/mm(3), respectively. By week 48, only one participant (CT) was lost to follow-up. The SCT arm had a 27% decreased drug exposure as measured by the adherence questionnaire and a MEMSCap(™) Medication Event Monitoring System (MEMSCap Inc., Durham, NC, USA) substudy (median cap openings per week: SCT group, n = 5; CT group, n = 7). By 48 weeks, six participants in the SCT group and seven in the CT group had a confirmed VL > 50 copies/ml [difference -1.2%, 90% confidence interval (CI) -7.3% to 4.9%] and two in the SCT group and four in the CT group had a confirmed VL > 400 copies/ml (difference -2.1%, 90% CI -6.2% to 1.9%). All six participants in the SCT group with a VL > 50 copies/ml resumed daily ART, of whom five were resuppressed, three were on the same regimen and two with a switch; two others on SCT resumed daily ART for other reasons. Overall, three participants in the SCT group and nine in the CT group (p = 0.1) changed ART regimen, five because of toxicity, four for simplification reasons, two because of compliance issues and one because of VL failure. Seven young people (SCT group, n = 2; CT group, n = 5) had major non-nucleoside reverse transcriptase inhibitor mutations at VL failure, of whom two (n = 1 SCT group, n = 1 CT group) had the M184V mutation. Two young people had new Centers for Disease Control B events (SCT group, n = 1; CT group, n = 1). There were no significant differences between SCT and CT in grade 3/4 adverse events (13 vs. 14) or in serious adverse events (7 vs. 6); there were fewer ART-related adverse events in the SCT arm (2 vs. 14; p = 0.02). At week 48 there was no evidence that SCT led to increased inflammation using an extensive panel of markers. Young people expressed a strong preference for SCT in a qualitative substudy and in pre- and post-trial questionnaires. In total, 98% of the young people are taking part in a 2-year follow-up extension of the trial. CONCLUSIONS Non-inferiority of VL suppression in young people on EFV-based first-line ART with a VL of < 50 copies/ml was demonstrated for SCT compared with CT, with similar resistance, safety and inflammatory marker profiles. The SCT group had fewer ART-related adverse events. Further evaluation of the immunological and virological impact of SCT is ongoing. A limitation of the trial is that the results cannot be generalised to settings where VL monitoring is either not available or infrequent, nor to use of low-dose EFV. Two-year extended follow-up of the trial is ongoing to confirm the durability of the SCT strategy. Further trials of SCT in settings with infrequent VL monitoring and with other antiretroviral drugs such as tenofovir alafenamide, which has a long intracellular half-life, and/or dolutegravir, which has a higher barrier to resistance, are planned. TRIAL REGISTRATION Current Controlled Trials ISRCTN97755073; EUDRACT 2009-012947-40; and CTA 27505/0005/001-0001. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme (projects 08/53/25 and 11/136/108), the European Commission through EuroCoord (FP7/2007/2015), the Economic and Social Research Council, the PENTA Foundation, the Medical Research Council and INSERM SC10-US19, France, and will be published in full in Health Technology Assessment; Vol. 20, No. 49. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Karina Butler
- Department of Paediatric Infectious Diseases and Immunology, Our Lady's Hospital, Dublin, Ireland
| | - Jamie Inshaw
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), London, UK
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), London, UK
| | - Sarah Bernays
- Department of Social and Environmental Health Research, Faculty of Public Health Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Karen Scott
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), London, UK
| | - Julia Kenny
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), London, UK
- Infection, Immunity and Inflammation Programme, Institute of Child Health, London, UK
| | - Nigel Klein
- Infection, Immunity and Inflammation Programme, Institute of Child Health, London, UK
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), London, UK
| | - Lynda Harper
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), London, UK
| | - Eleni Nastouli
- Virology, University College London Hospital NHS Foundation Trust, London, UK
| | - Sara Paparini
- Department of Social and Environmental Health Research, Faculty of Public Health Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Rahela Choudhury
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), London, UK
| | - Tim Rhodes
- Department of Social and Environmental Health Research, Faculty of Public Health Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Abdel Babiker
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), London, UK
| | - Diana Gibb
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), London, UK
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Calcagno A, Di Perri G, Bonora S. What do we know about tailoring treatment with tenofovir? Pharmacogenomics 2016; 17:531-4. [DOI: 10.2217/pgs-2016-0003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Stefano Bonora
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
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Leibowitch J, Mathez D, de Truchis P, Ledu D, Melchior JC, Carcelain G, Izopet J, Perronne C, David JR. Four days a week or less on appropriate anti-HIV drug combinations provided long-term optimal maintenance in 94 patients: the ICCARRE project. FASEB J 2015; 29:2223-34. [PMID: 25833895 DOI: 10.1096/fj.14-260315] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 02/03/2015] [Indexed: 11/11/2022]
Abstract
Short, intraweekly cycles of anti-HIV combinations have provided intermittent, effective therapy (on 48 patients) (1). The concept is now extended to 94 patients on treatment, 4 days per week or less, over a median of 2.7 discontinuous treatment years per patient. On suppressive combinations, 94 patients volunteered to treatment, 5 and 4 days per week, or reduced stepwise to 4, 3, 2, and 1 days per week in 94, 84, 66, and 12 patients, respectively, on various triple, standard, antiviral combinations, or nonregistered, quadruple, antiviral combinations. Ninety-four patients on treatment 4 days per week aggregated 165 intermittent treatment years; no viral breakthrough was observed over 87 average treatment weeks per patient, 63 of 94 having passed 2.5 intermittent treatment years on any of the antiviral combinations prescribed. On the hyperintermittent treatment of 3, 2, and 1 days per week, HIV RNA surged >50 copies, 4 weeks apart, in 18 instances (6.8 viral escapes/100 hyperdiscontinuous maintenance years). Viral escapes could have been a result of erratic adherence (EA) to regimen or follow-up (3 patients)--drug taken at half of the daily recommended dosage (8 patients) and/or overlooked archival-resistant HIVs from antecedent treatment failures (6 patients). Aside from the above circumstances, HIV unexpectedly rebounded in 3 patients on 2 days per week treatment and 1 patient on 1 day per week treatment, posting 2.2 intrinsic viral escapes/100 highly discontinuous treatment years. All 18 escapes were eventually reversed by 7 days per week salvage combinations, and 11 of 18 patients have been back for a second course of intermittent therapy, 4 days per week or less. Both cell-activation markers on the surface of T lymphocytes and cell-bound HIV DNA levels remained stable or declined. CD4/CD8 ratios rose to ≥1 in 35% of patients, whereas CD4 counts went ≥500/µl in 75%. These values were previously 7 and 40%, respectively, on 7 days per week therapy. In our aging, long, HIV-enduring, multitreated patient cohort, treatment 4 days per week and less over 421 intermittent treatment years reduced prescription medicines by 60%--equivalent to 3 drug-free/3 virus-free remission year per patient--actually sparing €3 million on just 94 patients at the cost of 2.2 intrinsic viral failure/100 hyperintermittent treatment years. At no risk of viral escape, maintenance therapy, 4 days per week, would quasiuniversally offer 40% cuts off of current overprescriptions.
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Affiliation(s)
- Jacques Leibowitch
- *Hôpital Raymond-Poincaré, Garches, France; Pitié-salpétrière Hospital, Paris, France; Purpan Hospital, Toulouse, France; and Harvard T.H. Chan School of Pubic Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Dominique Mathez
- *Hôpital Raymond-Poincaré, Garches, France; Pitié-salpétrière Hospital, Paris, France; Purpan Hospital, Toulouse, France; and Harvard T.H. Chan School of Pubic Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Pierre de Truchis
- *Hôpital Raymond-Poincaré, Garches, France; Pitié-salpétrière Hospital, Paris, France; Purpan Hospital, Toulouse, France; and Harvard T.H. Chan School of Pubic Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Damien Ledu
- *Hôpital Raymond-Poincaré, Garches, France; Pitié-salpétrière Hospital, Paris, France; Purpan Hospital, Toulouse, France; and Harvard T.H. Chan School of Pubic Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean Claude Melchior
- *Hôpital Raymond-Poincaré, Garches, France; Pitié-salpétrière Hospital, Paris, France; Purpan Hospital, Toulouse, France; and Harvard T.H. Chan School of Pubic Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Guislaine Carcelain
- *Hôpital Raymond-Poincaré, Garches, France; Pitié-salpétrière Hospital, Paris, France; Purpan Hospital, Toulouse, France; and Harvard T.H. Chan School of Pubic Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Jacques Izopet
- *Hôpital Raymond-Poincaré, Garches, France; Pitié-salpétrière Hospital, Paris, France; Purpan Hospital, Toulouse, France; and Harvard T.H. Chan School of Pubic Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Christian Perronne
- *Hôpital Raymond-Poincaré, Garches, France; Pitié-salpétrière Hospital, Paris, France; Purpan Hospital, Toulouse, France; and Harvard T.H. Chan School of Pubic Health, Harvard Medical School, Boston, Massachusetts, USA
| | - John R David
- *Hôpital Raymond-Poincaré, Garches, France; Pitié-salpétrière Hospital, Paris, France; Purpan Hospital, Toulouse, France; and Harvard T.H. Chan School of Pubic Health, Harvard Medical School, Boston, Massachusetts, USA
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Foster C, Fidler S. Optimizing antiretroviral therapy in adolescents with perinatally acquired HIV-1 infection. Expert Rev Anti Infect Ther 2014; 8:1403-16. [DOI: 10.1586/eri.10.129] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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22
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6.0 Supporting patients on therapy. HIV Med 2013. [DOI: 10.1111/hiv.12119_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
BACKGROUND Retaining patients in clinical care is necessary to ensure successful antiretroviral treatment (ART) outcomes. Among patients who discontinue care, some reenter care at a later stage, whereas others are or will be lost from follow-up. We examined risk factors for health care interruptions and loss to follow-up within a cohort receiving ART in Uganda. METHODS Using a large hospital cohort providing free universal ART and HIV clinical care, we assessed characteristics and risk factors for treatment interruptions, defined as a 12-month absence from care at Mildmay, and loss to follow-up, defined as absence from care greater than 12 months without reengagement in care at Mildmay. We included patients aged 14 years and above. We assessed these outcomes over time using Kaplan-Meier analysis and multivariable regression. RESULTS Of 6970 eligible patients, 784 (11.2%) had a health care interruption of at least 12 months and 217 (3.1%) were lost to follow-up. Patients experiencing health care interruptions had higher baseline CD4 T-cell counts at ART initiation, defined as ≥ 250 cells per cubic millimeter [odds ratio (OR): 1.29, 95% confidence intervals (CI): 1.11 to 1.50], and lower levels of education (OR: 1.32, 95% CI: 1.09 to 1.61). Adolescents were much more likely to be lost to follow-up (OR: 3.11, 95% CI: 2.23 to 4.34). In contrast, having a partner (OR: 0.22, 95% CI: 0.16 to 0.31) or being sexually active at baseline (OR: 0.40, 95% CI: 0.28 to 0.55) was protective of loss to follow-up. CONCLUSIONS Within this cohort, long periods of unsupervised health care interruptions were common.
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Hernandez AV, Pasupuleti V, Deshpande A, Thota P, Collins JA, Vidal JE. Deficient reporting and interpretation of non-inferiority randomized clinical trials in HIV patients: a systematic review. PLoS One 2013; 8:e63272. [PMID: 23658818 PMCID: PMC3643946 DOI: 10.1371/journal.pone.0063272] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 04/03/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Non-inferiority (NI) randomized clinical trials (RCTs) commonly evaluate efficacy of new antiretroviral (ARV) drugs in human immunodeficiency virus (HIV) patients. Their reporting and interpretation have not been systematically evaluated. We evaluated the reporting of NI RCTs in HIV patients according to the CONSORT statement and assessed the degree of misinterpretation of RCTs when NI was inconclusive or not established. DESIGN Systematic review. METHODS PubMed, Web of Science, and Scopus were reviewed until December 2011. Selection and extraction was performed independently by three reviewers. RESULTS Of the 42 RCTs (n = 21,919; range 41-3,316) selected, 23 were in ARV-naïve and 19 in ARV-experienced patients. Twenty-seven (64%) RCTs provided information about prior RCTs of the active comparator, and 37 (88%) used 2-sided CIs. Two thirds of trials used a NI margin between 10 and 12%, although only 12 explained the method to determine it. Blinding was used in 9 studies only. The main conclusion was based on both intention-to-treat (ITT) and per protocol (PP) analyses in 5 trials, on PP analysis only in 4 studies, and on ITT only in 31 studies. Eleven of 16 studies with NI inconclusive or not established highlighted NI or equivalence, and distracted readers with positive secondary results. CONCLUSIONS There is poor reporting and interpretation of NI RCTs performed in HIV patients. Maximizing the reporting of the method of NI margin determination, use of blinding and both ITT and PP analyses, and interpreting negative NI according to actual primary findings will improve the understanding of results and their translation into clinical practice.
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Affiliation(s)
- Adrian V. Hernandez
- Health Outcomes and Clinical Epidemiology Section, Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
- Postgraduate School, Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru
- * E-mail:
| | - Vinay Pasupuleti
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Abhishek Deshpande
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Priyaleela Thota
- Health Outcomes and Clinical Epidemiology Section, Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Jaime A. Collins
- HIV/AIDS Unit, Department of Internal Medicine, Guillermo Almenara General Hospital, EsSalud, Lima, Peru
| | - Jose E. Vidal
- Department of Infectious Diseases, Emilio Ribas Institute of Infectious Diseases, São Paulo, Brazil
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Mann M, Lurie MN, Kimaiyo S, Kantor R. Effects of political conflict-induced treatment interruptions on HIV drug resistance. AIDS Rev 2013; 15:15-24. [PMID: 23449225 PMCID: PMC3774601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Thirty-four million people worldwide were living with the HIV by the end of 2010. Despite significant advances in antiretroviral therapy, drug resistance remains a major deterrent to successful, enduring treatment. Unplanned interruptions in antiretroviral therapy have negative effects on HIV treatment outcomes, including increased morbidity and mortality, as well as development of drug resistance. Treatment interruptions due to political conflicts, not infrequent in resource-limited settings, result in disruptions in health care, infrastructure, or treatment facilities and patient displacement. Such circumstances are ideal bases for antiretroviral therapy resistance development, but there is limited awareness of and data available on the association between political conflict and the development of HIV drug resistance. In this review we identify and discuss this association and review how varying antiretroviral therapy half-lives, genetic barriers, different HIV subtypes, and archived resistance can lead to lack of medication effectiveness upon post-conflict resumption of care. Optimized antiretroviral therapy stopping strategies as well as infrastructural concerns and stable HIV treatment systems to ensure continuity of care and rapid resumption of care must be addressed in order to mitigate risks of HIV drug resistance development during and after political conflicts. Increased awareness of such associations by clinicians as well as politicians and stakeholders is essential.
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Turkova A, Webb RH, Lyall H. When to start, what to start and other treatment controversies in pediatric HIV infection. Paediatr Drugs 2012; 14:361-76. [PMID: 23013459 DOI: 10.2165/11599640-000000000-00000] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Over the last decade there have been dramatic changes in the management of pediatric HIV infection. Whilst observational studies and several randomized control trials (RCTs) have addressed some questions about when to start antiretroviral therapy (ART) in children and what antiretrovirals to start, many others remain unanswered. In infants, early initiation of ART greatly reduces mortality and disease progression. Treatment guidelines now recommend ART in all infants younger than 1 or 2 years of age depending on geographical setting. In children >1 year of age, US, European (Paediatric European Network for Treatment of AIDS; PENTA) and WHO guidelines differ and debate is ongoing. Recent data from an RCT in Thailand in children with moderate immune suppression indicate that it is safe to monitor asymptomatic children closely without initiating ART, although earlier treatment was associated with improved growth. Untreated HIV progression in children aged over 5 years is similar to that in adults, and traditionally adult treatment thresholds are applied. Recent adult observational and modeling studies showed a survival advantage and reduction of age-associated complications with early treatment. The current US guidelines have lowered CD4+ cell count thresholds for ART initiation for children aged >5 years to 500 cells/mm3. Co-infections influence the choice of drugs and the timing of starting ART. Drug interactions, overlapping toxicities and adherence problems secondary to increased pill burden are important issues. Rapid changes in the pharmacokinetics of antiretrovirals in the first years of life, limited pharmacokinetic data in children and genetic variation in metabolism of many antiretrovirals make correct dosing difficult. Adherence should always be addressed prior to starting ART or switching regimens. The initial ART regimen depends on previous exposure, including perinatal administration for prevention of mother to child transmission (PMTCT), adherence, co-infections, drug availability and licensing. A European cohort study in infants indicated that treatment with four drugs produced superior virologic suppression and immune recovery. Protease inhibitor (PI)-based ART has the advantage of a high barrier to viral resistance. A recent RCT conducted in several African countries showed PI-based ART to be advantageous in children aged <3 years compared with nevirapine-based ART irrespective of previous nevirapine exposure. Another trial in older children from resource rich settings showed both regimens were equally effective. Treatment interruption remains a controversial issue in children, but one study in Europe demonstrated no short-term detrimental effects. ART in children is a rapidly evolving area with many new antiretrovirals being developed and undergoing trials. The aim of ART has shifted from avoiding mortality and morbidity to achieving a normal life expectancy and quality of life, minimizing toxicities and preventing early cancers and age-related illnesses.
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Affiliation(s)
- Anna Turkova
- Department of Paediatric Infectious Diseases, St Mary's Hospital, Imperial College NHS Trust, London, UK
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The needs for HIV treatment and care of children, adolescents, pregnant women and older people in low-income and middle-income countries. AIDS 2012; 26 Suppl 2:S105-16. [PMID: 23303433 DOI: 10.1097/qad.0b013e32835bddfc] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Success in diagnosing and treating HIV-infected adults has, where HIV care and treatment is available, turned HIV into a chronic, rather than life-limiting disease. Progress meeting the needs of HIV-infected children, perinatally and horizontally infected adolescents, pregnant women and older people has lagged behind. We review the special needs and barriers to scaling up care and antiretroviral therapy (ART) coverage in these populations. DESIGN AND METHODS A literature review combined with personal views and operational experience specifically from countries covered by the Evidence for Action programme. RESULTS Challenges include logistics of diagnosis and treatment in pregnancy, difficulties in early infant diagnosis, availability of appropriate paediatric formulations, management of adolescents, and comorbidities in older people. CONCLUSION Priorities for development need to focus upon the simplification of HIV care to allow provision for all ages at the primary healthcare level. Specific priorities include focused use of virological testing in infants, ongoing development of dispersible and scored fixed-dose ART combinations suitable for use across ages, development of 'adolescent-friendly' HIV services catering for perinatally and horizontally infected adolescents to improve adherence and reduce onward transmissions, simplification of referral pathways to ensure all pregnant women are tested for HIV and commenced on ART, and education of healthcare workers on the specific needs of HIV care in older patients. Each priority will be reviewed and potential solutions discussed.
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6.0 Supporting patients on therapy. HIV Med 2012. [DOI: 10.1111/j.1468-1293.2012.01029_7.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Gosuen GC, Turcato G, Salomao R, Lewi DS, Diaz RS. Decrease in lipoatrophy in a pilot study using a short-term treatment interruption strategy for 48 weeks in São Paulo, Brazil. AIDS Res Hum Retroviruses 2012; 28:747-8. [PMID: 22220684 DOI: 10.1089/aid.2011.0292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Gisele Cristina Gosuen
- Infectious Diseases Division, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Gilberto Turcato
- Infectious Diseases Division, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Reinaldo Salomao
- Infectious Diseases Division, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - David Salomao Lewi
- Infectious Diseases Division, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Ricardo Sobhie Diaz
- Infectious Diseases Division, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
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Patterns of antiretroviral therapy adherence and impact on HIV RNA among patients in North America. AIDS 2012; 26:1415-23. [PMID: 22767342 DOI: 10.1097/qad.0b013e328354bed6] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Adherence to antiretroviral therapies (ART) is the strongest predictor of viral suppression among individuals infected with HIV, however, limited data exists to understand the patterns of adherence that confer the greatest benefit across different ART regimens. DESIGN Longitudinal data pooled from 16 studies conducted between 1997 and 2009 across the United States. METHODS Adherence was measured using Medication Event Monitoring System. Percentage of time with sufficient drug concentrations (covered time) and the length of the longest treatment interruption during the 28 days prior to plasma HIV-RNA measurements were calculated. Logistic regression with generalized estimating equations was used to estimate medication-specific adherence estimates on detectable HIV-RNA (>400 copies/ml). RESULTS One thousand and eighty-eight participants with 3795 HIV-RNA measures were studied. Both lower covered time and greater longest interruption showed dose-response relationships with the odds of detectable HIV-RNA; however, estimates did not vary by medication regimen. Compared with 93-100% coverage, periods of 0-25% covered time had a three-fold increased risk of detectable HIV-RNA [odds ratio (OR) = 3.22, 95% confidence interval (CI): 2.48-4.19]. Similarly, compared to longest interruptions of 0-48 h, longest interruptions of 21-28 days had a nearly four-fold increased risk of detectable HIV-RNA (OR = 3.65, 95% CI: 2.77, 4.81). CONCLUSION We found that adherence was consistently strongly associated with treatment response across ART regimens. Of the patterns of adherence, longer interruptions may have greater impact than covered time. Future research should investigate additional methods for examining adherence patterns, understanding the determinants of consecutive missed doses and the evaluation of interventions designed to address interruptions in treatment.
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Standing genetic variation and the evolution of drug resistance in HIV. PLoS Comput Biol 2012; 8:e1002527. [PMID: 22685388 PMCID: PMC3369920 DOI: 10.1371/journal.pcbi.1002527] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 04/04/2012] [Indexed: 11/25/2022] Open
Abstract
Drug resistance remains a major problem for the treatment of HIV. Resistance can occur due to mutations that were present before treatment starts or due to mutations that occur during treatment. The relative importance of these two sources is unknown. Resistance can also be transmitted between patients, but this process is not considered in the current study. We study three different situations in which HIV drug resistance may evolve: starting triple-drug therapy, treatment with a single dose of nevirapine and interruption of treatment. For each of these three cases good data are available from literature, which allows us to estimate the probability that resistance evolves from standing genetic variation. Depending on the treatment we find probabilities of the evolution of drug resistance due to standing genetic variation between and . For patients who start triple-drug combination therapy, we find that drug resistance evolves from standing genetic variation in approximately 6% of the patients. We use a population-dynamic and population-genetic model to understand the observations and to estimate important evolutionary parameters under the assumption that treatment failure is caused by the fixation of a single drug resistance mutation. We find that both the effective population size of the virus before treatment, and the fitness of the resistant mutant during treatment, are key-parameters which determine the probability that resistance evolves from standing genetic variation. Importantly, clinical data indicate that both of these parameters can be manipulated by the kind of treatment that is used. For HIV patients who are treated with antiretroviral drugs, treatment usually works well. However, the virus can, and sometimes does, become resistant against one or more drugs. HIV drug resistance results from the acquisition of specific and well known mutations. It is currently unknown whether drug resistance mutations usually stem from standing genetic variation, i.e., they were already present at low frequency before treatment started, or whether they tend to occur during treatment. In the current manuscript, I make use of several large datasets and evolutionary modeling to estimate the probability that drug resistance mutations are present before treatment starts and lead to viral failure. I find that for the most common type of treatment with a combination of three drugs, drug resistance evolves from pre-existing mutations in 6% of the patients. With other types of treatment, this probability varies from 0 to 39%. I conclude that there is room for improvement in preventing the evolution of drug resistance from pre-existing mutations.
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Holodniy M, Brown ST, Cameron DW, Kyriakides TC, Angus B, Babiker A, Singer J, Owens DK, Anis A, Goodall R, Hudson F, Piaseczny M, Russo J, Schechter M, Deyton L, Darbyshire J. Results of antiretroviral treatment interruption and intensification in advanced multi-drug resistant HIV infection from the OPTIMA trial. PLoS One 2011; 6:e14764. [PMID: 21483491 PMCID: PMC3069000 DOI: 10.1371/journal.pone.0014764] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Accepted: 01/05/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Guidance is needed on best medical management for advanced HIV disease with multidrug resistance (MDR) and limited retreatment options. We assessed two novel antiretroviral (ARV) treatment approaches in this setting. METHODS AND FINDINGS We conducted a 2×2 factorial randomized open label controlled trial in patients with a CD4 count≤300 cells/µl who had ARV treatment (ART) failure requiring retreatment, to two options (a) re-treatment with either standard (≤4 ARVs) or intensive (≥5 ARVs) ART and b) either treatment starting immediately or after a 12-week monitored ART interruption. Primary outcome was time to developing a first AIDS-defining event (ADE) or death from any cause. Analysis was by intention to treat. From 2001 to 2006, 368 patients were randomized. At baseline, mean age was 48 years, 2% were women, median CD4 count was 106/µl, mean viral load was 4.74 log(10) copies/ml, and 59% had a prior AIDS diagnosis. Median follow-up was 4.0 years in 1249 person-years of observation. There were no statistically significant differences in the primary composite outcome of ADE or death between re-treatment options of standard versus intensive ART (hazard ratio 1.17; CI 0.86-1.59), or between immediate retreatment initiation versus interruption before re-treatment (hazard ratio 0.93; CI 0.68-1.30), or in the rate of non-HIV associated serious adverse events between re-treatment options. CONCLUSIONS We did not observe clinical benefit or harm assessed by the primary outcome in this largest and longest trial exploring both ART interruption and intensification in advanced MDR HIV infection with poor retreatment options. TRIAL REGISTRATION Clinicaltrials.gov NCT00050089.
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Affiliation(s)
- Mark Holodniy
- VA Palo Alto Health Care System, Palo Alto, California, United States of America
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Sheldon T. Brown
- James J. Peters VA Medical Center, Bronx, New York, United States of America
- Department of Medicine, Mt. Sinai School of Medicine, New York, New York, United States of America
| | - D. William Cameron
- University of Ottawa at The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Canadian HIV Trials Network, St Paul's Hospital, Vancouver, British Columbia, Canada
- * E-mail:
| | - Tassos C. Kyriakides
- VA Cooperative Studies Program Coordinating Center, West Haven, Connecticut, United States of America
| | - Brian Angus
- Nuffield Department of Medicine, The John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | | | - Joel Singer
- Canadian HIV Trials Network, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Douglas K. Owens
- VA Palo Alto Health Care System, Palo Alto, California, United States of America
- Department of Medicine, Stanford University, Stanford, California, United States of America
| | - Aslam Anis
- Canadian HIV Trials Network, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Ruth Goodall
- MRC Clinical Trials Unit, London, United Kingdom
| | - Fleur Hudson
- MRC Clinical Trials Unit, London, United Kingdom
| | - Mirek Piaseczny
- Canadian HIV Trials Network, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - John Russo
- VA Cooperative Studies Program Coordinating Center, West Haven, Connecticut, United States of America
| | - Martin Schechter
- Canadian HIV Trials Network, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Lawrence Deyton
- Department of Veterans Affairs, Office of Public Health and Environmental Hazards, Washington, D.C., United States of America
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