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Achilles SL, Kelly CW, Hoesley CJ, Blithe DL, Brown J, Richardson BA, Devlin B, Hendrix CW, Poloyac SM, Marzinke MA, Gundacker H, Singh D, Piper JM, Johnson S, Steytler J, Chen BA. Phase 1 randomized trials to assess safety, pharmacokinetics, and vaginal bleeding associated with use of extended duration dapivirine and levonorgestrel vaginal rings. PLoS One 2024; 19:e0304552. [PMID: 38838028 PMCID: PMC11152307 DOI: 10.1371/journal.pone.0304552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 05/14/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Vaginal rings formulated to deliver two drugs simultaneously have potential as user-controlled, long-acting methods for dual prevention of HIV and pregnancy. METHODS Two phase 1 randomized trials (MTN-030/IPM 041 and MTN-044/IPM 053/CCN019) respectively enrolled 24 and 25 healthy, HIV-negative participants to evaluate safety, pharmacokinetics, and vaginal bleeding associated with use of a vaginal ring containing 200mg dapivirine (DPV) and 320mg levonorgestrel (LNG) designed for 90-day use. MTN-030/IPM 041 compared the DPV/LNG ring to a DPV-only ring (200mg) over 14 days of use. MTN-044/IPM 053/CCN019 compared continuous or cyclic use of the DPV/LNG ring over 90 days of use. Safety was assessed by recording adverse events (AEs). DPV and LNG concentrations were quantified in plasma, cervicovaginal fluid, and cervical tissue. Vaginal bleeding was self-reported. RESULTS There were no differences in the proportion of participants with grade ≥2 genitourinary AEs or grade ≥3 AEs with DPV/LNG ring vs. DPV ring use (p = .22), or with DPV/LNG ring continuous vs. cyclic use (p = .67). Higher plasma DPV concentrations were observed in users of DPV/LNG compared to DPV-only rings (Cmax p = 0.049; AUC p = 0.091). Plasma DPV and LNG concentrations were comparable with continuous and cyclic use (Cmax p = 0.74; AUC p = 0.25). With cyclic use, median nadir plasma DPV concentration was approximately 300 pg/mL two days after removal and median t1/2 for cervicovaginal fluid DPV concentration was 5.76 hours (n = 3). Overall bleeding experiences did not differ between continuous and cyclic users (p = 0.12). CONCLUSIONS The extended duration DPV/ LNG rings were well tolerated and the observed DPV concentrations in plasma and cervicovaginal fluid when used continuously exceeded concentrations observed in previous DPV ring efficacy studies. LNG concentrations in plasma were comparable with other efficacious LNG-based contraceptives. Genital DPV concentrations had a short half-life and were thus not well sustained following ring removal.
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Affiliation(s)
- Sharon L. Achilles
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, United States of America
| | - Clifton W. Kelly
- Statistical Center for HIV/AIDS Research & Prevention, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
| | - Craig J. Hoesley
- University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, United States of America
| | - Diana L. Blithe
- National Institute of Child Health and Human Development, Contraceptive Development Program, DIPHR, NIH, Bethesda, Maryland, United States of America
| | - Jill Brown
- National Institute of Child Health and Human Development, Contraceptive Development Program, DIPHR, NIH, Bethesda, Maryland, United States of America
| | - Barbra A. Richardson
- Statistical Center for HIV/AIDS Research & Prevention, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
- Department of Biostatistics, University of Washington, Seattle, Washington, United States of America
| | - Brid Devlin
- International Partnership for Microbicides, Silver Spring, Maryland, United States of America
| | - Craig W. Hendrix
- Department of Medicine, Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Samuel M. Poloyac
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Mark A. Marzinke
- Department of Medicine, Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Holly Gundacker
- Statistical Center for HIV/AIDS Research & Prevention, Fred Hutchinson Cancer Center, Seattle, Washington, United States of America
| | - Devika Singh
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, United States of America
| | - Jeanna M. Piper
- National Institutes of Allergy and Infectious Disease, NIH, Bethesda, Maryland
| | - Sherri Johnson
- FHI 360, Durham, North Carolina, United States of America
| | - John Steytler
- International Partnership for Microbicides, Silver Spring, Maryland, United States of America
| | - Beatrice A. Chen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Magee-Womens Research Institute, Pittsburgh, Pennsylvania, United States of America
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Peebles K, Brown ER, Hendrix CW, Palanee-Phillips T, van der Straten A, Harkoo I, Reddy K, Mirembe BG, Jeenarain N, Hillier SL, Baeten JM, Barnabas RV. Brief Report: Dapivirine Ring HIV-1 Prevention Effectiveness for Women Engaged in Vaginal and Anal Intercourse: Insights From Mathematical Modeling. J Acquir Immune Defic Syndr 2023; 92:122-126. [PMID: 36184755 PMCID: PMC9839478 DOI: 10.1097/qai.0000000000003110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/13/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND The dapivirine vaginal ring reduces the risk of HIV-1 acquisition in acts of vaginal intercourse (VI), and although it does not offer HIV-1 protection in acts of anal intercourse (AI), it may provide some overall risk reduction for women for whom most sex acts are vaginal. We estimated the protective effect of the ring among women with high ring adherence engaged in both VI and AI. METHODS We developed a microsimulation model using data from the MTN-020/ASPIRE trial. Among women who reported any AI, we estimated the proportion of all sex acts that were AI. Model scenarios varied this proportion among women engaged in both VI and AI from 5% to 30%, including the trial-observed median proportion of 6.3% of all acts being AI. In primary analyses, dapivirine ring efficacy was model-calibrated at 70% for vaginal exposures and assumed to be 0% for anal exposures. RESULTS Among highly adherent women for whom 6.3% of sex acts were AI, the ring reduced HIV-1 risk by 53% (interquartile range: 44, 60), with a decline to 26% (interquartile range: 16, 36) among women for whom 30% of acts were AI. Ring effectiveness was less than 40% among women for whom AI accounted for greater than 16% of all sex acts, although this represented less than 5% of all women in the ASPIRE trial. CONCLUSIONS For most women, including those who engage in AI, because most HIV-1 risk occurs in acts of vaginal sex, the dapivirine vaginal ring can provide important HIV-1 protection.
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Affiliation(s)
- Kathryn Peebles
- Department of Global Health, University of Washington,
Seattle, United States
| | - Elizabeth R. Brown
- Vaccine and Infectious Disease and Public Health Sciences
Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Biostatistics, University of Washington,
Seattle, WA, USA
| | - Craig W. Hendrix
- Department of Medicine (Clinical Pharmacology), Johns
Hopkins University, Baltimore, MD, USA
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, University of
the Witwatersrand, Johannesburg, South Africa
| | | | - Ishana Harkoo
- Centre for the AIDS Program of Research in South Africa,
Durban, South Africa
| | - Krishnaveni Reddy
- RTI International, Women’s Global Health Imperative
(WGHI), San Francisco, CA, USA
| | - Brenda G. Mirembe
- Makerere University - Johns Hopkins University Research
Collaboration, Kampala, Uganda
| | | | - Sharon L. Hillier
- Department of Obstetrics, Gynecology and Reproductive
Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jared M. Baeten
- Department of Global Health, University of Washington,
Seattle, United States
- Department of Epidemiology, University of Washington,
Seattle, United States
- Department of Medicine, University of Washington,
Seattle, United States
| | - Ruanne V. Barnabas
- Department of Global Health, University of Washington,
Seattle, United States
- Department of Epidemiology, University of Washington,
Seattle, United States
- Department of Medicine, University of Washington,
Seattle, United States
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Rodríguez-Izquierdo I, Sepúlveda-Crespo D, Lasso JM, Resino S, Muñoz-Fernández MÁ. Baseline and time-updated factors in preclinical development of anionic dendrimers as successful anti-HIV-1 vaginal microbicides. WILEY INTERDISCIPLINARY REVIEWS. NANOMEDICINE AND NANOBIOTECHNOLOGY 2022; 14:e1774. [PMID: 35018739 PMCID: PMC9285063 DOI: 10.1002/wnan.1774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/05/2021] [Accepted: 12/09/2021] [Indexed: 12/12/2022]
Abstract
Although a wide variety of topical microbicides provide promising in vitro and in vivo efficacy, most of them failed to prevent sexual transmission of human immunodeficiency virus type 1 (HIV‐1) in human clinical trials. In vitro, ex vivo, and in vivo models must be optimized, considering the knowledge acquired from unsuccessful and successful clinical trials to improve the current gaps and the preclinical development protocols. To date, dendrimers are the only nanotool that has advanced to human clinical trials as topical microbicides to prevent HIV‐1 transmission. This fact demonstrates the importance and the potential of these molecules as microbicides. Polyanionic dendrimers are highly branched nanocompounds with potent activity against HIV‐1 that disturb HIV‐1 entry. Herein, the most significant advancements in topical microbicide development, trying to mimic the real‐life conditions as closely as possible, are discussed. This review also provides the preclinical assays that anionic dendrimers have passed as microbicides because they can improve current antiviral treatments' efficacy. This article is categorized under:Nanotechnology Approaches to Biology > Nanoscale Systems in Biology Therapeutic Approaches and Drug Discovery > Nanomedicine for Infectious Disease Toxicology and Regulatory Issues in Nanomedicine > Regulatory and Policy Issues in Nanomedicine
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Affiliation(s)
| | - Daniel Sepúlveda-Crespo
- Unidad de Infección Viral e Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Salvador Resino
- Unidad de Infección Viral e Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
| | - Ma Ángeles Muñoz-Fernández
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,Spanish HIV HGM BioBank, Madrid, Spain.,Section of Immunology, Laboratorio InmunoBiología Molecular, Hospital General Universitario Gregorio Marañón (HGUGM), Madrid, Spain
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4
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Palanee-Phillips T, Baum MM, Moss JA, Clark MR, Nuttall J, Romano JW. Drug-releasing vaginal rings for HIV/STI and pregnancy prevention: A review of recent advances and clinical applications. Expert Opin Drug Deliv 2021; 19:47-58. [PMID: 34958283 DOI: 10.1080/17425247.2022.2020242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Adolescent girls and young women (AGYW), as well as pre- and post-menopausal women globally would benefit from expanded choice to address their sexual and reproductive health (SRH) needs related to Human Immunodeficiency Virus (HIV), sexually transmitted infections (STIs) and pregnancy prevention. Lack of adequate preventative vaccines for HIV/STIs reinforces public health prioritization for options women may use independently to mitigate risk for infectious disease and unplanned pregnancy. Drug releasing intravaginal rings (IVR) represent one such technology that has garnered attention based on the modality's success recently as a pre-exposure prophylaxis (PrEP) delivery option and its impact on reduction in HIV risk. AREAS COVERED : This article provides a synopsis of three IVR technologies in active clinical development for prevention of HIV, STI, and unintended pregnancy demonstrating advancements in terms of compatibility with a wide range of drug types with a focus on dapivirine-based silicone rings (International Partnership for Microbicides (IPM), tenofovir-based polyurethane rings (CONRAD), and pod-based rings (Oak Crest Institute of Science). EXPERT OPINION The goals of IVR research are to reduce burdens of HIV/STIs and unplanned pregnancies. Through the evolution of IVR technologies, the potential exists to trigger integration of healthcare services through formulation of products with multiple indications.
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Affiliation(s)
- Thesla Palanee-Phillips
- Faculty of Health Sciences, Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Marc M Baum
- Oak Crest Institute of Science, Monrovia, CA, USA
| | - John A Moss
- Oak Crest Institute of Science, Monrovia, CA, USA
| | | | - Jeremy Nuttall
- International Partnership for Microbicides, Silver Spring, MD, USA
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5
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Krovi SA, Johnson LM, Luecke E, Achilles SL, van der Straten A. Advances in long-acting injectables, implants, and vaginal rings for contraception and HIV prevention. Adv Drug Deliv Rev 2021; 176:113849. [PMID: 34186143 DOI: 10.1016/j.addr.2021.113849] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/15/2021] [Accepted: 06/22/2021] [Indexed: 12/22/2022]
Abstract
Worldwide, women face compounding reproductive health risks, including human immunodeficiency virus (HIV), sexually-transmitted infections (STIs), and unintended pregnancy. Multipurpose prevention technologies (MPTs) offer combined protection against these overlapping risks in singular prevention products that offer potential for simplified use, lower burden, higher acceptability, and increased public health benefits. Over the past decade, substantial progress has been made in development of extended-release MPTs, which have further potential to grant sexual and reproductive health autonomy to women globally and to offer choice for women to accommodate varying needs during their reproductive lives. Here, we highlight the advances made in injectable, implant, and ring delivery forms, and the importance of incorporating end-user preferences early in the research and development of these products.
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Affiliation(s)
| | | | - Ellen Luecke
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Sharon L Achilles
- University of Pittsburgh, School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Ariane van der Straten
- Center for AIDS Prevention Studies, Dept of Medicine, University of California San Francisco, San Francisco, CA, USA; ASTRA Consulting, Kensington, CA, USA
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Al-Khouja A, Shieh E, Fuchs EJ, Marzinke MA, Bakshi RP, Hummert P, Ham AS, Buckheit KW, Breakey J, Weld ED, Chen H, Caffo BS, Buckheit RW, Hendrix CW. Examining the Safety, Pharmacokinetics, and Pharmacodynamics of a Rectally Administered IQP-0528 Gel for HIV Pre-Exposure Prophylaxis: A First-In-Human Study. AIDS Res Hum Retroviruses 2021; 37:444-452. [PMID: 33371779 DOI: 10.1089/aid.2020.0188] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A lubricating microbicide gel designed for rectal and vaginal use would provide a behaviorally congruent strategy to enhance pre-exposure prophylaxis adherence and reduce HIV infection risk. In this study, we report the first-in-human evaluation of such a gel containing 1% IQP-0528, an investigational antiretroviral. Seven HIV-1-negative participants received one 10 mL rectal dose of radiolabeled 1% IQP-0528 gel. We assessed safety; IQP-0528 pharmacokinetics in plasma, and rectal and vaginal tissue; ex vivo local pharmacodynamics (PD); and colorectal distribution. The 1% gel was determined to be safe with one mild event attributed to study product and no effects on rectal tissue histology. All concentrations measured in plasma and vaginal tissue were below the limit of quantitation. Median IQP-0528 concentrations in rectal tissue exceeded the in vitro EC95 against HIV-1 (0.07 ng/mg) by 3-5 h of dosing and remained above this concentration for at least 24 h, despite a 3-log reduction in concentration over this duration of time. Rectal tissue PD-assessed by ex vivo HIV challenge-demonstrated significant p24 antigen reduction 3-5 h postdose compared with baseline (p = .05), but not 24-26 h postdose (p = .75). Single-photon emission computed tomography/computed tomography imaging revealed that product distribution was localized to the rectosigmoid. The IQP-0528 gel possesses desirable features for a topical microbicide including: local safety with no systemic absorption, delivery of locally high IQP-0528 concentrations, and significant reductions in ex vivo HIV infectivity. However, the gel is limited by its rapid clearance and inability to penetrate vaginal tissues following rectal dosing. Clinical Trial Registration number: NCT03082690.
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Affiliation(s)
- Amer Al-Khouja
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eugenie Shieh
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Edward J. Fuchs
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark A. Marzinke
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rahul P. Bakshi
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pamela Hummert
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Jennifer Breakey
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ethel D. Weld
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Huan Chen
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Brian S. Caffo
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Craig W. Hendrix
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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7
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Crakes KR, Herrera C, Morgan JL, Olstad K, Hessell AJ, Ziprin P, LiWang PJ, Dandekar S. Efficacy of silk fibroin biomaterial vehicle for in vivo mucosal delivery of Griffithsin and protection against HIV and SHIV infection ex vivo. J Int AIDS Soc 2021; 23:e25628. [PMID: 33073530 PMCID: PMC7569169 DOI: 10.1002/jia2.25628] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 12/22/2022] Open
Abstract
Introduction The majority of new HIV infections occur through mucosal transmission. The availability of readily applicable and accessible platforms for anti‐retroviral (ARV) delivery is critical for the prevention of HIV acquisition through sexual transmission in both women and men. There is a compelling need for developing new topical delivery systems that have advantages over the pills, gels and rings, which currently fail to guarantee protection against mucosal viral transmission in vulnerable populations due to lack of user compliance. The silk fibroin (SF) platform offers another option that may be better suited to individual circumstances and preferences to increase efficacy through user compliance. The objective of this study was to test safety and efficacy of SF for anti‐HIV drug delivery to mucosal sites and for viral prevention. Methods We formulated a potent HIV inhibitor Griffithsin (Grft) in a mucoadhesive silk fibroin (SF) drug delivery platform and tested the application in a non‐human primate model in vivo and a pre‐clinical human cervical and colorectal tissue explant model. Both vaginal and rectal compartments were assessed in rhesus macaques (Mucaca mulatta) that received SF (n = 4), no SF (n = 7) and SF‐Grft (n = 11). In this study, we evaluated the composition of local microbiota, inflammatory cytokine production, histopathological changes in the vaginal and rectal compartments and mucosal protection after ex vivo SHIV challenge. Results Effective Grft release and retention in mucosal tissues from the SF‐Grft platform resulted in protection against HIV in human cervical and colorectal tissue as well as against SHIV challenge in both rhesus macaque vaginal and rectal tissues. Mucoadhesion of SF‐Grft inserts did not cause any inflammatory responses or changes in local microbiota. Conclusions We demonstrated that in vivo delivery of SF‐Grft in rhesus macaques fully protects against SHIV challenge ex vivo after two hours of application and is safe to use in both the vaginal and rectal compartments. Our study provides support for the development of silk fibroin as a highly promising, user‐friendly HIV prevention modality to address the global disparity in HIV infection.
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Affiliation(s)
- Katti R Crakes
- Department of Medical Microbiology & Immunology, School of Medicine, University of California Davis, Davis, CA, USA
| | - Carolina Herrera
- Department of Medicine, St. Mary's Campus Imperial College, London, United Kingdom
| | - Jessica L Morgan
- Department of Molecular Cell Biology, University of California Merced, Merced, CA, USA
| | - Katie Olstad
- California National Primate Research Center, University of California Davis, Davis, CA, USA
| | - Ann J Hessell
- Division of Pathobiology and Immunology, Oregon National Primate Research Center, Oregon Health and Sciences University, Beaverton, OR, USA
| | - Paul Ziprin
- Department of Surgery and Cancer, St. Mary's Campus Imperial College, London, United Kingdom
| | - Patricia J LiWang
- Department of Molecular Cell Biology, University of California Merced, Merced, CA, USA
| | - Satya Dandekar
- Department of Medical Microbiology & Immunology, School of Medicine, University of California Davis, Davis, CA, USA
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8
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Highly synergistic drug combination prevents vaginal HIV infection in humanized mice. Sci Rep 2020; 10:12995. [PMID: 32747682 PMCID: PMC7400648 DOI: 10.1038/s41598-020-69937-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/20/2020] [Indexed: 01/01/2023] Open
Abstract
The HIV-1 epidemic remains an urgent global health concern. Young women are disproportionately at risk of acquiring the virus. A range of highly effective, female-controlled, discrete vaginal products therefore is needed to help curb the epidemic. Oral tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) are effective in HIV-1 pre-exposure prophylaxis (PrEP) and form a promising basis for a vaginal product. Here, we evaluate TDF and FTC in combination with the broadly neutralizing antibody VRC01-N using a highly reproducible humanized mouse model. The agents were vaginally dosed individually and in combination, and the efficacy of HIV-1 prevention was analyzed using the established, rigorous median-effect model. Surprisingly, the triple combination showed a high degree of synergism, unprecedented for in vivo HIV-1 PrEP, leading to a possible fivefold dose reduction for some of the agents. Vaginal administration of the TDF-FTC-VRC01-N combination holds significant promise for HIV-1 PrEP.
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9
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Stannah J, Silhol R, Elmes J, Owen B, Shacklett BL, Anton P, McGowan I, van der Straten A, Dimitrov D, Baggaley RF, Boily MC. Increases in HIV Incidence Following Receptive Anal Intercourse Among Women: A Systematic Review and Meta-analysis. AIDS Behav 2020; 24:667-681. [PMID: 31486008 PMCID: PMC7018785 DOI: 10.1007/s10461-019-02651-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Receptive anal intercourse (RAI) carries a greater per-act risk of HIV acquisition than receptive vaginal intercourse (RVI) and may influence HIV epidemics driven by heterosexual sex. This systematic review explores the association between RAI and incident HIV among women, globally. We searched Embase and Medline through September 2018 for longitudinal studies reporting crude (cRR) or adjusted (aRR) relative risks of HIV acquisition by RAI practice among women. Of 27,563 articles identified, 17 eligible studies were included. We pooled independent study estimates using random-effects models. Women reporting RAI were more likely to acquire HIV than women not reporting RAI (pooled cRR = 1.56 95% CI 1.03–2.38, N = 18, I2 = 72%; pooled aRR = 2.23, 1.01–4.92, N = 5, I2 = 70%). In subgroup analyses the association was lower for women in Africa (pooled cRR = 1.16, N = 13, I2 = 21%) than outside Africa (pooled cRR = 4.10, N = 5, I2 = 79%) and for high-risk (pooled aRR = 1.69, N = 4, I2 = 63%) than general-risk women (pooled aRR = 8.50, N = 1). Interview method slightly influenced cRR estimates (p value = 0.04). In leave-one-out sensitivity analyses pooled estimates were generally robust to removing individual study estimates. Main limitations included poor exposure definition, incomplete adjustment for confounders, particularly condom use, and use of non-confidential interview methods. More and better data are needed to explain differences in risk by world region and risk population. Women require better counselling and greater choice in prevention modalities that are effective during RVI and RAI.
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10
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Abstract
HIV topical microbicides are products with anti-HIV activity, generally incorporating a direct-acting antiretroviral agent, that when applied to the vagina or rectum have the potential to prevent the sexual acquisition of HIV in women and men. Topical microbicides may meet the prevention needs of individuals and groups for whom oral daily forms of pre-exposure prophylaxis (PrEP) have not been acceptable. Microbicides can provide personal control over HIV prevention and offer the possibility of discreet use, qualities that may be particularly important for receptive partners in sexual relationships such as women and transgender women and men, who together account for the clear majority of new HIV infections worldwide. Although the promise of such a product emerged nearly three decades ago, proof of concept has been demonstrated only within the last decade. A robust pipeline of microbicidal gels, films, inserts, and rings has been evaluated in multiple studies among at-risk women and men, and refinement of products for ease of use, reversibility, and high safety is the priority for the field.
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Affiliation(s)
- Jared M Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington 98104, USA;
| | - Craig W Hendrix
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland 21205, USA;
| | - Sharon L Hillier
- Department of Obstetrics, Gynecology, and Reproductive Sciences and Department of Microbiology and Molecular Genetics, University of Pittsburgh, Magee-Womens Research Institute, Pittsburgh, Pennsylvania 15213, USA;
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11
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Faria MJ, Machado R, Ribeiro A, Gonçalves H, Real Oliveira MECD, Viseu T, das Neves J, Lúcio M. Rational Development of Liposomal Hydrogels: A Strategy for Topical Vaginal Antiretroviral Drug Delivery in the Context of HIV Prevention. Pharmaceutics 2019; 11:pharmaceutics11090485. [PMID: 31540519 PMCID: PMC6781289 DOI: 10.3390/pharmaceutics11090485] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/11/2019] [Accepted: 09/14/2019] [Indexed: 01/09/2023] Open
Abstract
HIV/AIDS stands as a global burden, and vaginal microbicides constitute a promising strategy for topical pre-exposure prophylaxis. Preceding the development of a microbicide containing tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC), in silico and in vitro studies were performed to evaluate the physicochemical characteristics of both drugs, and to study their biophysical impact in lipid model systems. Results from these pre-formulation studies defined hydrogels as adequate vehicles to incorporate TDF-loaded liposomes and FTC. After studying interactions with mucin, zwitterionic liposomes with a mean diameter of 134 ± 13 nm, an encapsulation TDF efficiency of approximately 84%, and a transition temperature of 41 °C were selected. The chosen liposomal formulation was non-cytotoxic to HEC-1-A and CaSki cells, and was able to favor TDF permeation across polysulfone membranes (Jss = 9.9 μg·cm-2·h-1). After the incorporation of TDF-loaded liposomes and FTC in carbomer hydrogels, the drug release profile was sustained over time, reaching around 60% for both drugs within 3-6 h, and best fitting the Weibull model. Moreover, liposomal hydrogels featured pseudoplastic profiles that were deemed suitable for topical application. Overall, the proposed liposomal hydrogels may constitute a promising formulation for the vaginal co-delivery of TDF/FTC.
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Affiliation(s)
- Maria J. Faria
- CF-UM-UP—Centro de Física das Universidades do Minho e Porto, Departamento de Física da Universidade do Minho, 4710-057 Braga, Portugal (T.V.)
| | - Raul Machado
- CBMA—Centro de Biologia Molecular e Ambiental, Departamento de Biologia, Universidade do Minho, 4710-057 Braga, Portugal;
- IB-S—Institute of Science and Innovation for Bio-Sustainability, Universidade do Minho, 4710-057 Braga, Portugal
| | - Artur Ribeiro
- CEB—Centro de Engenharia Biológica, Universidade do Minho, 4710-057 Braga, Portugal;
| | | | - Maria Elisabete C. D. Real Oliveira
- CF-UM-UP—Centro de Física das Universidades do Minho e Porto, Departamento de Física da Universidade do Minho, 4710-057 Braga, Portugal (T.V.)
| | - Teresa Viseu
- CF-UM-UP—Centro de Física das Universidades do Minho e Porto, Departamento de Física da Universidade do Minho, 4710-057 Braga, Portugal (T.V.)
| | - José das Neves
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-135 Porto, Portugal
- INEB—Instituto de Engenharia Biomédica, Universidade do Porto, 4200-135 Porto, Portugal
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, 4585-116 Gandra, Portugal
- Correspondence: (J.d.N.); (M.L.); Tel.: +351-22-040-8800 (J.d.N.); +351-25-360-4060 (M.L.)
| | - Marlene Lúcio
- CF-UM-UP—Centro de Física das Universidades do Minho e Porto, Departamento de Física da Universidade do Minho, 4710-057 Braga, Portugal (T.V.)
- CBMA—Centro de Biologia Molecular e Ambiental, Departamento de Biologia, Universidade do Minho, 4710-057 Braga, Portugal;
- Correspondence: (J.d.N.); (M.L.); Tel.: +351-22-040-8800 (J.d.N.); +351-25-360-4060 (M.L.)
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Yap PK, Loo Xin GL, Tan YY, Chellian J, Gupta G, Liew YK, Collet T, Dua K, Chellappan DK. Antiretroviral agents in pre-exposure prophylaxis: emerging and advanced trends in HIV prevention. ACTA ACUST UNITED AC 2019; 71:1339-1352. [PMID: 31144296 DOI: 10.1111/jphp.13107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 05/05/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Antiretroviral agents (ARVs) have been the most promising line of therapy in the management of human immunodeficiency virus (HIV) infections. Some of these ARVs are used in the pre-exposure prophylaxis (PrEP) to suppress the transmission of HIV. Prophylaxis is primarily used in uninfected people, before exposure, to effectively prevent HIV infection. Several studies have shown that ART PrEP prevents HIV acquisition from sexual, blood and mother-to-child transmissions. However, there are also several challenges and limitations to PrEP. This review focuses on the current antiretroviral therapies used in PrEP. KEY FINDINGS Among ARVs, the most common drugs employed from the class of entry inhibitors are maraviroc (MVC), which is a CCR5 receptor antagonist. Other entry inhibitors like emtricitabine (FTC) and tenofovir (TFV) are also used. Rilpivirine (RPV) and dapivirine (DPV) are the most common drugs employed from the Non-nucleoside reverse transcriptase inhibitor (NNRTIs) class, whereas, tenofovir disoproxil fumarate (TDF) is primarily used in the Nucleoside Reverse Transcriptase Inhibitor (NRTIs) class. Cabotegravir (CAB) is an analog of dolutegravir, and it is an integrase inhibitor. Some of these drugs are also used in combination with other drugs from the same class. SUMMARY Some of the most common pre-exposure prophylactic strategies employed currently are the use of inhibitors, namely entry inhibitors, non-nucleoside reverse transcriptase inhibitors, nucleoside reverse transcriptase inhibitors, integrase and protease inhibitors. In addition, we have also discussed on the adverse effects caused by ART in PrEP, pharmacoeconomics factors and the use of antiretroviral prophylaxis in serodiscordant couples.
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Affiliation(s)
- Pui Khee Yap
- School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Griselda Lim Loo Xin
- School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Yoke Ying Tan
- School of Health Sciences, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Jestin Chellian
- Department of Life Sciences, School of Pharmacy, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Gaurav Gupta
- School of Pharmacy, Suresh Gyan Vihar University, Jaipur, India
| | - Yun Khoon Liew
- Department of Life Sciences, School of Pharmacy, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Trudi Collet
- Innovative Medicines Group, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Qld, Australia
| | - Kamal Dua
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney (UTS), Ultimo, NSW, Australia.,Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute (HMRI) & School of Biomedical Sciences and Pharmacy, The University of Newcastle (UoN), Callaghan, NSW, Australia
| | - Dinesh Kumar Chellappan
- Department of Life Sciences, School of Pharmacy, International Medical University, Bukit Jalil, Kuala Lumpur, Malaysia
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13
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McBride JW, Boyd P, Dias N, Cameron D, Offord RE, Hartley O, Kett VL, Malcolm RK. Vaginal rings with exposed cores for sustained delivery of the HIV CCR5 inhibitor 5P12-RANTES. J Control Release 2019; 298:1-11. [PMID: 30731150 PMCID: PMC6414755 DOI: 10.1016/j.jconrel.2019.02.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/28/2019] [Accepted: 02/02/2019] [Indexed: 11/29/2022]
Abstract
Antiretroviral-releasing vaginal rings are at the forefront of ongoing efforts to develop microbicide-based strategies for prevention of heterosexual transmission of the human immunodeficiency virus (HIV). However, traditional ring designs are generally only useful for vaginal administration of relatively potent, lipophilic, and small molecular weight drug molecules that have sufficient permeability in the non-biodegradable silicone elastomer or thermoplastic polymers. Here, we report a novel, easy-to-manufacture 'exposed-core' vaginal ring that provides sustained release of the protein microbicide candidate 5P12-RANTES, an experimental chemokine analogue that potently blocks the HIV CCR5 coreceptor. In vitro release, mechanical, and stability testing demonstrated the utility and practicality of this novel ring design. In a sheep pharmacokinetic model, a ring containing two ¼-length excipient-modified silicone elastomer cores - each containing lyophilised 5P12-RANTES and exposed to the external environment by two large windows - provided sustained concentrations of 5P12-RANTES in vaginal fluid and vaginal tissue between 10 and 10,000 ng/g over 28days, at least 50 and up to 50,000 times the reported in vitro IC50 value.
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Affiliation(s)
- John W McBride
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK
| | - Peter Boyd
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK
| | | | | | - Robin E Offord
- Mintaka Foundation for Medical Research, Geneva, Switzerland
| | - Oliver Hartley
- Mintaka Foundation for Medical Research, Geneva, Switzerland; Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Vicky L Kett
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK
| | - R Karl Malcolm
- School of Pharmacy, Queen's University Belfast, Belfast BT9 7BL, UK.
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14
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Hendrix CW. HIV Antiretroviral Pre-Exposure Prophylaxis: Development Challenges and Pipeline Promise. Clin Pharmacol Ther 2018; 104:1082-1097. [PMID: 30199098 PMCID: PMC6925668 DOI: 10.1002/cpt.1227] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/20/2018] [Indexed: 12/17/2022]
Abstract
The US Food and Drug Administration (FDA) approved oral daily tenofovir/emtricitabine (Truvada) for pre-exposure prophylaxis of human immunodeficiency virus (HIV) infection in 2012 on the basis of two randomized controlled trials (RCTs), one in men who have sex with men (MSM) and another in HIV serodiscordant heterosexual couples. Subsequently, even greater efficacy has been demonstrated in MSM with rapid population-level incidence reductions in some locations. In contrast, studies of antiretroviral pre-exposure prophylaxis (PrEP) in heterosexual women showed only modest or no efficacy, largely attributed to low adherence. The mixed results of antiretroviral-based PrEP bear witness to unique drug development challenges at this complicated intersection of sexual behavior, public health, and drug development. Multiple innovative methods and formulation strategies followed to address unmet medical needs of persons struggling with daily oral PrEP adherence or preference for nonsystemic PrEP options. Clinical pharmacology plays essential roles throughout this PrEP development process, especially in early product development and through pharmacologically informed enhancement and interpretation of clinical trials.
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Affiliation(s)
- Craig W Hendrix
- 1Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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