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Murdock NA, Alajaji NE, Schaefer R, Boone CA, Campo RE, Dore GJ, Gandhi M, Gorospe JR, Gulick RM, Hodder SL, Liu J, Rhee MS, Rooney JF, Vannappagari V, Wilkin T, Miller V. Long-acting HIV Treatments: Study Design, Logistics, and Access. Open Forum Infect Dis 2024; 11:ofae337. [PMID: 38983711 PMCID: PMC11232696 DOI: 10.1093/ofid/ofae337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/12/2024] [Indexed: 07/11/2024] Open
Abstract
New long-acting HIV treatment products have the potential to change the HIV epidemic in the United States and globally. Phase 3 clinical trials of HIV treatments tend to underrepresent populations bearing a disproportionate burden of the HIV epidemic-including women, racial minorities, trans and gender-diverse people, older adults, the unhoused, people who inject drugs, those in rural areas, individuals with mental illness, and other marginalized groups. These populations commonly face significant challenges in adhering to daily HIV treatment regimens. Conducting clinical trials of long-acting treatment targeting specific unmet medical needs of these populations can improve understanding of optimal care approaches, broaden the indication for use of long-acting products, and inform treatment guidelines, all of which can influence reimbursement and access policies. Innovative trial designs and programmatic implementation can improve inclusivity for long-acting therapy. This article summarizes discussions of a multistakeholder workshop on study designs for long-acting HIV treatments.
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Affiliation(s)
- Nicholas A Murdock
- Forum for Collaborative Research, University of California, Berkeley, Washington, DC, USA
| | - Nayri E Alajaji
- Forum for Collaborative Research, University of California, Berkeley, Washington, DC, USA
| | - Robin Schaefer
- Forum for Collaborative Research, University of California, Berkeley, Washington, DC, USA
| | | | | | - Gregory J Dore
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Monica Gandhi
- Department of Medicine, University of California at San Francisco (UCSF), San Francisco, California, USA
| | - J Rafael Gorospe
- Office of AIDS Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Roy M Gulick
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Sally L Hodder
- West Virginia Clinical and Translational Science Institute, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Jonathan Liu
- University of Southern California, Los Angeles, California, USA
| | | | | | | | - Timothy Wilkin
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Veronica Miller
- Forum for Collaborative Research, University of California, Berkeley, Washington, DC, USA
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2
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Hickey MD, Grochowski J, Mayorga-Munoz F, Oskarsson J, Imbert E, Spinelli M, Szumowski JD, Appa A, Koester K, Dauria EF, McNulty M, Colasanti J, Havlir DV, Gandhi M, Christopoulos KA. Identifying Implementation Determinants and Strategies for Long-Acting Injectable Cabotegravir-Rilpivirine in People With HIV Who Are Virally Unsuppressed. J Acquir Immune Defic Syndr 2024; 96:280-289. [PMID: 38534179 PMCID: PMC11192618 DOI: 10.1097/qai.0000000000003421] [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: 10/06/2023] [Accepted: 02/13/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Early evidence suggests long-acting injectable cabotegravir and rilpivirine (LA-CAB/RPV) may be beneficial for people with HIV (PWH) who are unable to attain viral suppression (VS) on oral therapy. Limited guidance exists on implementation strategies for this population. SETTING Ward 86, a clinic serving publicly insured PWH in San Francisco. METHODS We describe multilevel determinants of and strategies for LA-CAB/RPV implementation for PWH without VS, using the Consolidated Framework for Implementation Research. To assess patient and provider-level determinants, we drew on pre-implementation qualitative data. To assess inner and outer context determinants, we undertook a structured mapping process. RESULTS Key patient-level determinants included perceived ability to adhere to injections despite oral adherence difficulties and care engagement challenges posed by unmet subsistence needs; strategies to address these determinants included a direct-to-inject approach, small financial incentives, and designated drop-in days. Provider-level determinants included lack of time to obtain LA-CAB/RPV, assess injection response, and follow-up late injections; strategies included centralizing eligibility review with the clinic pharmacist, a pharmacy technician to handle procurement and monitoring, regular multidisciplinary review of patients, and development of a clinic protocol. Ward 86 did not experience many outer context barriers because of rapid and unconstrained inclusion of LA-CAB/RPV on local formularies and ability of its affiliated hospital pharmacy to stock the medication. CONCLUSIONS Multilevel strategies to support LA-CAB/RPV implementation for PWH without VS are required, which may necessitate additional resources in some settings to implement safely and effectively. Advocacy to eliminate outer-context barriers, including prior authorizations and specialty pharmacy restrictions, is needed.
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Affiliation(s)
- Matthew D. Hickey
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Janet Grochowski
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Francis Mayorga-Munoz
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Jon Oskarsson
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Elizabeth Imbert
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Matthew Spinelli
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - John D. Szumowski
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Ayesha Appa
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Kimberly Koester
- Division of Prevention Science, University of California, San Francisco
| | - Emily F. Dauria
- Department of Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh
| | - Moira McNulty
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago
| | | | - Diane V Havlir
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Katerina A. Christopoulos
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
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Nguyen N, Lane B, Golub SA, Chastain C, Zucker J, King K, Terry M, Burdge J, Carnevale C, Muscarella A, Castor D, Kutner B, Meyers K. Long-acting injectable ART to advance health equity: a descriptive analysis of US clinic perspectives on barriers, needed support and programme goals for implementation from applications to the ALAI UP Project. J Int AIDS Soc 2024; 27 Suppl 1:e26282. [PMID: 38965977 PMCID: PMC11224578 DOI: 10.1002/jia2.26282] [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: 09/01/2023] [Accepted: 05/09/2024] [Indexed: 07/06/2024] Open
Abstract
INTRODUCTION Approval of the first long-acting injectable antiretroviral therapy (LAI ART) medication heralded a new era of HIV treatment. However, the years since approval have been marked by implementation challenges. The "Accelerating Implementation of Multilevel Strategies to Advance Long-Acting Injectable for Underserved Populations (ALAI UP Project)" aims to accelerate the systematic and equitable delivery of LAI ART. METHODS We coded and analysed implementation barriers according to the Consolidated Framework for Implementation Research (CFIR) domains, desired resources and programme goals from questionnaire short-answer responses by clinics across the United States responding to ALAI UP's solicitation to participate in the project between November 2022 and January 2023. RESULTS Thirty-eight clinics responded to ALAI UP's solicitation. The characteristics of LAI ART as an innovation (cost, complexity of procurement, dosing interval, limited eligibility) precipitated and interacted with barriers in other CFIR domains. Barriers included obtaining coverage for the cost of medication (27/38 clinics) (outer setting); need for new workflows and staffing (12/38) and/or systems to support injection scheduling/coordination (16/38), transportation and expanded clinic hours (13/38) (inner setting); and patient (10/38) and provider (7/38) education (individuals). To support implementation, applicants sought: technical assistance to develop protocols and workflows (18/38), specifically strategies to address payor challenges (8/38); additional staff for care coordination and benefits navigation (17/38); opportunities to share experiences with other implementing clinics (12/38); patient-facing materials to educate and increase demand (7/38); and support engaging communities (6/38). Clinics' LAI ART programme goals varied. Most prioritized delivering LAI ART to their most marginalized patients struggling to achieve viral suppression on oral therapy, despite awareness that current US Food and Drug Administration approval is only for virally suppressed patients. The goal for LAI ART reach after 1 year of implementation ranged from ≤10% of patients with HIV on LAI ART (17/38) to ≥50% of patients (2/38). CONCLUSIONS Diverse clinic types are interested in offering LAI ART and most aspire to use LAI ART to support their most vulnerable patients sustain viral suppression. Dedicated resources centred on equity and relevant to context and population are needed to support implementation. Otherwise, the introduction of LAI ART risks exacerbating, not ameliorating, health disparities.
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Affiliation(s)
- Nadia Nguyen
- Aaron Diamond AIDS Research CenterColumbia University Irving Medical CenterNew York CityNew YorkUSA
| | - Benjamin Lane
- Aaron Diamond AIDS Research CenterColumbia University Irving Medical CenterNew York CityNew YorkUSA
| | - Sarit A. Golub
- Hunter College of the City University of New YorkNew York CityNew YorkUSA
| | - Cody Chastain
- Division of Infectious DiseasesDepartment of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jason Zucker
- Division of Infectious DiseasesDepartment of MedicineColumbia University Irving Medical CenterNew York CityNew YorkUSA
| | - Katherine King
- New York City Department of Mental Health and HygieneNew York CityNew YorkUSA
| | - Marvell Terry
- Aaron Diamond AIDS Research CenterColumbia University Irving Medical CenterNew York CityNew YorkUSA
| | - Jennifer Burdge
- Division of Infectious DiseasesDepartment of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | - Anahit Muscarella
- Division of Infectious DiseasesDepartment of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Delivette Castor
- Division of Infectious DiseasesDepartment of MedicineColumbia University Irving Medical CenterNew York CityNew YorkUSA
| | - Bryan Kutner
- Albert Einstein College of MedicineBronxNew YorkUSA
| | - Kathrine Meyers
- Aaron Diamond AIDS Research CenterColumbia University Irving Medical CenterNew York CityNew YorkUSA
- Division of Infectious DiseasesDepartment of MedicineColumbia University Irving Medical CenterNew York CityNew YorkUSA
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Li Y, Choudhary M, Mellors JW. The Current Pipeline of Antiretroviral Therapy: Expanding Options and Filling Gaps. Infect Dis Clin North Am 2024:S0891-5520(24)00025-4. [PMID: 38876905 DOI: 10.1016/j.idc.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024]
Abstract
Highly effective antiretroviral therapy (ART) has transformed human immunodeficiency virus (HIV) care in the past 3 decades. 30 years ago, how many would have imagined that a single-tablet daily ART regimen containing different drug classes could achieve sustained HIV-1 suppression and halt disease progression to acquired immunodeficiency syndrome (AIDS)? Despite this remarkable achievement, challenges in HIV care remain that require further innovation for ART. In this review, we focus on newly approved antiretroviral agents and those undergoing phase 2/3 clinical trials. These new antiretrovirals hold great promise to expand treatment options and fill gaps in HIV care.
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Affiliation(s)
- Yijia Li
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Madhu Choudhary
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - John W Mellors
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Bacic Lima D, Solomon DA. Switching Human Immunodeficiency Virus Therapy: Basic Principles and Options. Infect Dis Clin North Am 2024:S0891-5520(24)00026-6. [PMID: 38871570 DOI: 10.1016/j.idc.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
The number of options for effective antiretroviral therapy (ART) is steadily increasing. Although older regimens may achieve the goal of virologic suppression, newer options can offer advantages in safety, tolerability, and convenience. In this article, we offer guiding principles for switching ART, highlighting reasons to pursue a switch and key factors to consider when selecting a new regimen.
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Affiliation(s)
- Danilo Bacic Lima
- Massachusetts General Hospital and Brigham & Women's Hospital; Infectious Diseases Division, Brigham and Women's Hospital, 75 Francis Street, PBB-A4, Boston, MA 02115, USA. https://twitter.com/danbacic
| | - Daniel Aran Solomon
- Infectious Diseases Division, Brigham and Women's Hospital, 75 Francis Street, PBB-A4, Boston, MA 02115, USA; Harvard Medical School.
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Collins LF, Koester KA, McNulty MC, Montgomery ET, Johnson MO, Neilands TB, Dilworth SE, Sauceda JA, Dance K, Erguera X, Diaz Tsuzuki M, Gutierrez JI, Christopoulos KA, Colasanti JA. Patient Attitudes Toward Self- or Partner-, Friend-, or Family-Administered Long-acting Injectable Antiretroviral Therapy: A Mixed-Methods Study Across 3 Urban Human Immunodeficiency Virus Clinics. Open Forum Infect Dis 2024; 11:ofae265. [PMID: 38854389 PMCID: PMC11161893 DOI: 10.1093/ofid/ofae265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/09/2024] [Indexed: 06/11/2024] Open
Abstract
Background Long-acting injectable (LAI) cabotegravir/rilpivirine (CAB/RPV) offers a novel drug delivery option for persons with human immunodeficiency virus (PWH) but requires administration every 4 or 8 weeks by a medical professional. Methods To facilitate LAI antiretroviral therapy (ART) scale-up, we evaluated patient interest in alternative administration approaches via a mixed-methods, serial cross-sectional study across 3 US HIV clinics. We surveyed PWH (December 2021 to May 2022) on appeal of self- or partner/friend/family-administered LAI-CAB/RPV; multivariable ordinal logistic regression explored associated characteristics. To contextualize survey results, we thematically analyzed semi-structured interview data collected from PWH (August 2020 to July 2021) on attitudes toward out-of-clinic LAI-ART administration. Results Among 370 surveyed PWH (median age, 46 years; 26% cisgender female, 59% Black, 56% sexual minority, 34% housing instability), self-administering LAI-CAB/RPV appealed to 67%. PWH who were White (adjusted odds ratio [aOR], 3.30 [95% confidence interval {CI}, 1.42-7.64]), stably housed (aOR, 2.16 [95% CI, 1.30-3.59]), or gay/bisexual (aOR, 1.81 [1.14-2.89]) were more likely to endorse self-administration. Fewer PWH (60%) reported partner/friend/family administration as appealing; adjusted models revealed similar sociodemographic preferences for this outcome. In 72 interviews, PWH noted that acceptability of out-of-clinic LAI-ART administration was qualified by convenience, prior injection experience, and potential fear of self-inflicted pain, dependence on others, and/or HIV disclosure. Conclusions In a multisite sample of PWH, self- and, to a lesser extent, partner/friend/family-administration of LAI-CAB/RPV appealed to most; however, was less appealing among populations more impacted by health disparities. Innovative LAI-ART delivery options could free up in-clinic resources to focus scale-up among marginalized populations.
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Affiliation(s)
- Lauren F Collins
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
| | - Kimberly A Koester
- Division of Prevention Science, Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, USA
| | - Moira C McNulty
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, Illinois, USA
- Chicago Center for HIV Elimination, University of Chicago, Chicago, Illinois, USA
| | - Elizabeth T Montgomery
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
- Women’s Global Health Imperative, RTI International, Berkeley, California, USA
| | - Mallory O Johnson
- Division of Prevention Science, Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, USA
| | - Torsten B Neilands
- Division of Prevention Science, Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, USA
| | - Samantha E Dilworth
- Division of Prevention Science, Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, USA
| | - John A Sauceda
- Division of Prevention Science, Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, USA
| | - Kaylin Dance
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
| | - Xavier Erguera
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Department of Public Health, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Manami Diaz Tsuzuki
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - José I Gutierrez
- Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Katerina A Christopoulos
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Department of Public Health, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
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Campbell CK, Kielhold K, Reynolds HE, Vincent W, Siconolfi DE, Ramos SD, Ogunbajo A, Kegeles SM, Storholm ED. LAI-ART Awareness, Willingness, Barriers and Facilitators among Black Sexual Minority Men Living with HIV in the US South. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:602. [PMID: 38791816 PMCID: PMC11121555 DOI: 10.3390/ijerph21050602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 05/02/2024] [Accepted: 05/04/2024] [Indexed: 05/26/2024]
Abstract
Black sexual minority men (BSMM) continue to bear a disproportionate burden of HIV in the United States, with the highest incidence and prevalence in the southern region of the country. In Texas, BSMM living with HIV (BSMM+) have the lowest rates of viral suppression of all SMM and have lower antiretroviral treatment (ART) adherence than white and Hispanic SMM. Long-acting injectable ART (LAI-ART) can potentially overcome several barriers to daily oral ART adherence (e.g., stigma, forgetfulness, pill fatigue). However, little is known about the knowledge, willingness, barriers, and facilitators regarding LAI-ART among BSMM+. From July 2022 to September 2023, we conducted in-depth, semi-structured interviews with 27 BSMM+ from the Houston and Dallas Metropolitan Areas, Texas. Data were analyzed using a thematic analysis approach. Most men knew about LAI-ART, but their understanding varied based on their existing sources of information. Some men were enthusiastic, some were cautious, and some reported no interest in LAI-ART. Barriers to LAI-ART included a lack of public insurance coverage of LAI-ART; fear of needles and side effects; the frequency of injection visits; the requirement of viral suppression before switching from oral ART to LAI-ART; and satisfaction with oral daily ART. Motivators of LAI-ART uptake included the eliminated burden of daily pills and reduced anxiety about possibly missing doses. BSMM+ may be among those who could most benefit from LAI-ART, though more research is needed to understand which factors influence their willingness and how the barriers to LAI-ART might be addressed, particularly among diverse communities of SMM of color.
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Affiliation(s)
- Chadwick K. Campbell
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA 92093, USA; (K.K.); (S.D.R.)
| | - Kirstin Kielhold
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA 92093, USA; (K.K.); (S.D.R.)
- School of Public Health, San Diego State University, San Diego, CA 92182, USA; (H.E.R.); (E.D.S.)
| | - Hannah E. Reynolds
- School of Public Health, San Diego State University, San Diego, CA 92182, USA; (H.E.R.); (E.D.S.)
| | - Wilson Vincent
- Department of Psychology and Neuroscience, Temple University, Philadelphia, PA 19122, USA;
| | | | - Stephen D. Ramos
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA 92093, USA; (K.K.); (S.D.R.)
- School of Public Health, San Diego State University, San Diego, CA 92182, USA; (H.E.R.); (E.D.S.)
| | | | - Susan M. Kegeles
- Department of Medicine, University of California San Francisco, San Francisco, CA 94158, USA;
| | - Erik D. Storholm
- School of Public Health, San Diego State University, San Diego, CA 92182, USA; (H.E.R.); (E.D.S.)
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Chang MH, Guo Y, Acbo A, Bao H, McSweeney T, Vo CA, Nori P. Antiretroviral Stewardship: Top 10 Questions Encountered by Stewardship Teams and Solutions to Optimize Therapy. Clin Ther 2024:S0149-2918(24)00081-X. [PMID: 38704295 DOI: 10.1016/j.clinthera.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/26/2024] [Accepted: 04/04/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Infectious disease pharmacists and physicians overseeing antimicrobial stewardship programs possess expertise and often advanced certification in management of antiretrovirals to treat HIV. Stewardship programs are responsible for managing facility formularies and must stay up to date with the latest antiretrovirals, including once daily formulations and depot injectables. Furthermore, stewardship program members need to understand drug-interactions, short-, and long-term toxicities of these regimens, including dyslipidemia and cardiovascular effects. Patients receiving chronic antiretroviral therapy may present to the acute care, ambulatory care, and long-term care settings. Like other antimicrobials, audit-and-feedback, drug monitoring, and dose-optimization are often required to prevent antiretroviral associated medication errors and minimize resistance. METHODS A narrative review was conducted on antiretroviral stewardship, addressing common clinical questions encountered by stewardship teams and best practices to optimize antiretroviral therapy and reduce the risk for treatment interruptions, resistance, drug interactions, long term toxicities, and other adverse effects. FINDINGS People living with HIV are often hospitalized and treated by medical teams without formal HIV training. For this reason, these patients are at greater risk for medication errors during hospitalization and between transitions of care. Many opportunities are present for antiretroviral stewardship to mitigate these errors. Frequent updates to simplify HIV regimen, maintain select patients on fixed-dose combination tablets, and strategies to minimize drug interactions make it difficult for even the seasoned clinician to keep up regularly. IMPLICATIONS Despite the availability of free online HIV resources and progress made in HIV management, significant opportunities for antiretroviral stewardship remain. Implementing electronic order entry updates, formulary upgrades, and formal pharmacy renal dose adjustments to optimize antiretroviral therapy will help clinicians harness these opportunities. Dedicated time and expertise for antiretroviral stewardship as part of local antimicrobial stewardship programs are needed.
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Affiliation(s)
- Mei H Chang
- Department of Pharmacy, Montefiore Health System, Bronx, New York.
| | - Yi Guo
- Department of Pharmacy, Montefiore Health System, Bronx, New York
| | - Antoinette Acbo
- Department of Pharmacy, Montefiore Health System, Bronx, New York
| | - Hongkai Bao
- Department of Pharmacy, Montefiore Health System, Bronx, New York
| | | | - Christopher A Vo
- Division of Infectious Diseases, Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York
| | - Priya Nori
- Division of Infectious Diseases, Department of Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York
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Manghani P, Monroe A, Castel A, Kumar P, Phunmongkol J, Denyer R, O’Connor L. Low Uptake of Long-Acting Injectables in the First 2.5 Years Following Approval Among a Cohort of People Living With HIV. Open Forum Infect Dis 2024; 11:ofae087. [PMID: 38756764 PMCID: PMC11097117 DOI: 10.1093/ofid/ofae087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Indexed: 05/18/2024] Open
Affiliation(s)
- Priyanka Manghani
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Anne Monroe
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Amanda Castel
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Princy Kumar
- Division of Infectious Diseases, Georgetown University School of Medicine, Washington, DC, USA
| | - Jennifer Phunmongkol
- Division of Infectious Diseases, Georgetown University School of Medicine, Washington, DC, USA
| | - Rachel Denyer
- Infectious Disease Division, Veterans Affairs Medical Center, Washington, DC, USA
- School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Lauren O’Connor
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
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10
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Mehtani NJ, Strough A, Strieff S, Zevin B, Eveland J, Riley ED, Gandhi M. Feasibility of Implementing a Low-Barrier Long-Acting Injectable Antiretroviral Program for HIV Treatment and Prevention for People Experiencing Homelessness. J Acquir Immune Defic Syndr 2024; 96:61-67. [PMID: 38346426 PMCID: PMC11009050 DOI: 10.1097/qai.0000000000003396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/23/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Long-acting (LA) antiretrovirals may provide meaningful benefit to people who use drugs and people experiencing homelessness (PEH) who face disproportionate structural and psychosocial barriers in adhering to daily oral HIV antiretroviral therapy or pre-exposure prophylaxis (PrEP), but their use in these populations has not been studied. SETTING The Maria X. Martinez Health Resource Center is a low-barrier (eg, no appointment) community-based clinic serving San Francisco PEH. METHODS A multidisciplinary care model with robust monitoring and outreach support was developed to provide LA antiretroviral therapy (ART) and LA-PrEP to eligible patients experiencing difficulties adhering to oral antiretrovirals. Feasibility was assessed by evaluating the rates of HIV viremia and on-time injections among patients receiving LA antiretrovirals over the first 24 months of program implementation. RESULTS Between November 2021 and November 2023, 33 patients initiated LA-ART or LA-PrEP (median age, 37 years; 27% transgender/nonbinary; 73% non-White; 27% street homeless; 52% sheltered homeless; 30% with opioid use disorder; 82% with methamphetamine use disorder). Among 18 patients with HIV, 14 initiated LA-ART injections with detectable viremia (median CD4 count, 340 cells/mm 3 ; mean log 10 viral load, 3.53; SD, 1.62), 8 had never previously been virally suppressed, and all but 1 achieved or maintained virologic suppression (mean, 9.67 months; SD, 8.30). Among 15 LA-PrEP patients, all remained HIV negative (mean, 4.73 months; SD, 2.89). Of 224 total injections administered, 8% were delayed >7 days. DISCUSSION The implementation of LA antiretrovirals is feasible in low-barrier, highly supportive clinical settings serving vulnerable PEH. Expansion of such programs will be critical in ending the HIV epidemic.
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Affiliation(s)
- Nicky J. Mehtani
- University of California, San Francisco; Department of Psychiatry & Behavioral Sciences
- San Francisco Department of Public Health, Whole Person Integrated Care
- University of California, San Francisco; Department of Medicine; Division of HIV, ID & Global Medicine
| | - Alix Strough
- San Francisco Department of Public Health, Whole Person Integrated Care
| | - Sarah Strieff
- San Francisco Department of Public Health, Whole Person Integrated Care
| | - Barry Zevin
- San Francisco Department of Public Health, Whole Person Integrated Care
| | - Joanna Eveland
- San Francisco Department of Public Health, Whole Person Integrated Care
| | - Elise D. Riley
- University of California, San Francisco; Department of Medicine; Division of HIV, ID & Global Medicine
| | - Monica Gandhi
- University of California, San Francisco; Department of Medicine; Division of HIV, ID & Global Medicine
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11
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Spinelli MA, Christopoulos KA, Moreira CV, Jain JP, Lisha N, Glidden DV, Burkholder GA, Crane HM, Shapiro AE, Jacobson JM, Cachay ER, Mayer KH, Napravnik S, Moore RD, Gandhi M, Johnson MO. Viral Suppression Trajectories Destabilized After Coronavirus Disease 2019 Among US People With Human Immunodeficiency Virus: An Interrupted Time Series Analysis. Clin Infect Dis 2024; 78:991-994. [PMID: 37963086 PMCID: PMC11006098 DOI: 10.1093/cid/ciad657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
We examined changes in the proportion of people with human immunodeficiency virus (PWH) with virologic suppression (VS) in a multisite US cohort before and since the coronavirus disease 2019 (COVID-19) pandemic. Overall, prior gains in VS slowed during COVID-19, with disproportionate impacts on Black PWH and PWH who inject drugs.
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Affiliation(s)
- Matthew A Spinelli
- Division of HIV, ID, and Global Medicine, University of California, SanFrancisco, California, USA
| | - Katerina A Christopoulos
- Division of HIV, ID, and Global Medicine, University of California, SanFrancisco, California, USA
| | - Carlos V Moreira
- Division of HIV, ID, and Global Medicine, University of California, SanFrancisco, California, USA
| | - Jennifer P Jain
- Division of Prevention Science, University of California, SanFrancisco, California, USA
| | - Nadra Lisha
- Department of Epidemiology and Biostatistics, University of California, SanFrancisco, California, USA
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, SanFrancisco, California, USA
| | - Greer A Burkholder
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham,Alabama, USA
| | - Heidi M Crane
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Adrienne E Shapiro
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Jeffrey M Jacobson
- Divsion of Infectious Diseases, Case Western Reserve University, Cleveland, Ohio, USA
| | - Edward R Cachay
- Division of Infectious Diseases, University of California, San Diego, California, USA
| | - Kenneth H Mayer
- Department of Medicine, Harvard University and the Fenway Institute/Fenway Health, Boston, Massachusetts, USA
| | - Sonia Napravnik
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Richard D Moore
- Division of Infectious Diseases, Johns Hopkins University, Baltimore, Maryland, USA
| | - Monica Gandhi
- Division of HIV, ID, and Global Medicine, University of California, SanFrancisco, California, USA
| | - Mallory O Johnson
- Division of Prevention Science, University of California, SanFrancisco, California, USA
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12
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Gandhi M, Hill L, Grochowski J, Nelson A, Koss CA, Mayorga-Munoz F, Oskarsson J, Shiels M, Avery A, Bamford L, Baron J, Short WR, Hileman CO. Case Series of People With HIV on the Long-Acting Combination of Lenacapavir and Cabotegravir: Call for a Trial. Open Forum Infect Dis 2024; 11:ofae125. [PMID: 38628952 PMCID: PMC11020301 DOI: 10.1093/ofid/ofae125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Indexed: 04/19/2024] Open
Abstract
Background Injectable cabotegravir (CAB)/rilpivirine (RPV) is the only combination long-acting (LA) antiretroviral regimen approved for HIV. RPV may not be effective among individuals with non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance, which has >10% prevalence in many countries. Lenacapavir (LEN) is an LA capsid inhibitor given every 6 months, but has not been studied in combination with other LA agents. Methods We assembled a case series from 4 US academic medical centers where patients with adherence challenges were prescribed LEN subcutaneously every 26 weeks/CAB (+/- RPV) intramuscularly every 4 or 8 weeks. Descriptive statistics, including viral load (VL) outcomes, were summarized. Results All patients (n = 34: 76% male; 24% cis/trans female; 41% Black; 38% Latino/a; median age [range], 47 [28-75] years; 29% and 71% on CAB every 4 or 8 weeks) reported challenges adhering to oral ART. The reasons for using LEN/CAB with or without RPV were documented or suspected NNRTI mutations (n = 21, 59%), integrase mutations (n = 5, 15%), high VL (n = 6, 18%), or continued viremia on CAB/RPV alone (n = 4, 12%). Injection site reactions on LA LEN were reported in 44% (32% grade I, 12% grade 2). All patients but 2 (32/34; 94%) were suppressed (VL <75 copies/mL) after starting LEN at a median (range) of 8 (4-16) weeks, with 16/34 (47%) suppressed at baseline. Conclusions In this case series of 34 patients on LEN/CAB, high rates of virologic suppression (94%) were observed. Reasons for using LEN/CAB included adherence challenges and underlying resistance, mostly to NNRTIs. These data support a clinical trial of LEN/CAB among persons with NNRTI resistance.
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Affiliation(s)
- Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Lucas Hill
- Division of Infectious Diseases and Global Public Health, University of California San Diego (UCSD), San Diego, California, USA
| | - Janet Grochowski
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Alexander Nelson
- Department of Specialty Pharmacy, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Catherine A Koss
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Francis Mayorga-Munoz
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Jon Oskarsson
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Mary Shiels
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Ann Avery
- Division of Infectious Diseases, MetroHealth Medical Center, and Case Western Reserve University (CWRU), Cleveland, Ohio, USA
| | - Laura Bamford
- Division of Infectious Diseases and Global Public Health, University of California San Diego (UCSD), San Diego, California, USA
| | - Jillian Baron
- Division of Infectious Diseases, Hospital of the University of Pennsylvania (UPenn), Philadelphia, Pennsylvania, USA
| | - William R Short
- Division of Infectious Diseases, Hospital of the University of Pennsylvania (UPenn), Philadelphia, Pennsylvania, USA
| | - Corrilynn O Hileman
- Division of Infectious Diseases, MetroHealth Medical Center, and Case Western Reserve University (CWRU), Cleveland, Ohio, USA
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13
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Sax PE, Thompson MA, Saag MS. Updated Treatment Recommendation on Use of Cabotegravir and Rilpivirine for People With HIV From the IAS-USA Guidelines Panel. JAMA 2024; 331:1060-1061. [PMID: 38427337 DOI: 10.1001/jama.2024.2985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- Paul E Sax
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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14
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Zaccarelli M. Reassessing the emphasis on limited options in antiretroviral treatment. AIDS 2024; 38:599-601. [PMID: 38416552 DOI: 10.1097/qad.0000000000003757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Mauro Zaccarelli
- STI, HIV and Migration Unit, San Gallicano Dermatological Institute, I.R.C.C.S., Rome, Italy
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15
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Wood BR, Kumarasamy N. Early adopters of long-acting injectable cabotegravir/rilpivirine: what lessons can we learn? AIDS 2024; 38:425-426. [PMID: 38300160 DOI: 10.1097/qad.0000000000003810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Affiliation(s)
- Brian R Wood
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
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16
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McCrimmon T, Collins LF, Perez-Brumer A, Bazzi AR, Shaffer VA, Kerrigan D, Alcaide ML, Philbin MM. Long-Acting Injectable Antiretrovirals for HIV Treatment: A Multi-Site Qualitative Study of Clinic-Level Barriers to Implementation in the United States. AIDS Patient Care STDS 2024; 38:61-69. [PMID: 38381949 DOI: 10.1089/apc.2023.0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
Long-acting injectable antiretroviral therapy (LAI ART) has the potential to address adherence obstacles associated with daily oral ART, leading to enhanced treatment uptake, adherence, and viral suppression among people living with HIV (PLWH). Yet, its potential may be limited due to ongoing disparities in availability and accessibility. We need a better understanding of the organizational context surrounding the implementation of LAI ART, and to inform its widespread rollout, we conducted 38 in-depth interviews with medical and social service providers who offer HIV care at private and hospital-based clinics across six US cities. Our findings highlight real-world implementation barriers outside of clinical trial settings. Providers described ongoing and anticipated barriers across three stages of LAI ART implementation: (1) Patient enrollment (challenges registering patients and limited insurance coverage), (2) medication delivery (insufficient personnel and resources), and (3) leadership and management (lack of interprofessional coordination and a lack of programming guidelines). Providers described how these barriers would have a disproportionate impact on under-resourced clinics, potentially exacerbating existing disparities in LAI ART access and adherence. Our findings suggest strategies that clinic leadership, policymakers, and other stakeholders can pursue to promote rapid and equitable LAI ART implementation in clinics across the United States. Resource and staffing investments could support clinics to begin, sustain, and scale up LAI ART delivery; additionally, the establishment of guidelines and tools could facilitate wider adoption of LAI ART across clinical settings. These efforts are crucial to promote resourced, standardized, and equitable implementation of LAI ART and maximize its potential to help end the HIV epidemic.
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Affiliation(s)
- Tara McCrimmon
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Lauren F Collins
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Amaya Perez-Brumer
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Angela R Bazzi
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, California, USA
| | - Victoria A Shaffer
- Department of Psychological Sciences, University of Missouri, Columbia, Missouri, USA
| | - Deanna Kerrigan
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, USA
| | - Maria L Alcaide
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Morgan M Philbin
- Division of Vulnerable Populations, Department of Medicine, University of California San Francisco, San Francisco, California, USA
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17
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Brock JB, Herrington P, Hickman M, Hickman A. Long-acting Injectable Cabotegravir/Rilpivirine Effective in a Small Patient Cohort With Virologic Failure on Oral Antiretroviral Therapy. Clin Infect Dis 2024; 78:122-124. [PMID: 37740255 DOI: 10.1093/cid/ciad511] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Indexed: 09/24/2023] Open
Abstract
We report 12 patients with persistent viremia on oral antiretroviral therapy who were initiated on injectable cabotegravir/rilpivirine (iCAB/RPV) without oral lead-in. All patients achieved viral suppression without any virologic rebound. iCAB/RPV may be considered as an option for patients unable to maintain suppression on oral antiretroviral therapy.
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Affiliation(s)
- James B Brock
- Department of Medicine, Division of Infectious Diseases, University of Mississippi Medical Center . Jackson, Mississippi, USA
| | - Peyton Herrington
- Department of Medicine, Division of Infectious Diseases, University of Mississippi Medical Center . Jackson, Mississippi, USA
| | - Melissa Hickman
- Department of Medicine, Division of Infectious Diseases, University of Mississippi Medical Center . Jackson, Mississippi, USA
| | - Aubri Hickman
- Department of Medicine, Division of Infectious Diseases, University of Mississippi Medical Center . Jackson, Mississippi, USA
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18
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Cannon L, Fehrman S, Pinzone M, Weissman S, O'Doherty U. Machine Learning Bolsters Evidence That D1, Nef, and Tat Influence HIV Reservoir Dynamics. Pathog Immun 2024; 8:37-58. [PMID: 38292079 PMCID: PMC10827039 DOI: 10.20411/pai.v8i2.621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/04/2023] [Indexed: 02/01/2024] Open
Abstract
Background The primary hurdle to curing HIV is due to the establishment of a reservoir early in infection. In an effort to find new treatment strategies, we and others have focused on understanding the selection pressures exerted on the reservoir by studying how proviral sequences change over time. Methods To gain insights into the dynamics of the HIV reservoir we analyzed longitudinal near full-length sequences from 7 people living with HIV between 1 and 20 years following the initiation of antiretroviral treatment. We used this data to employ Bayesian mixed effects models to characterize the decay of the reservoir using single-phase and multiphasic decay models based on near full-length sequencing. In addition, we developed a machine-learning approach utilizing logistic regression to identify elements within the HIV genome most associated with proviral decay and persistence. By systematically analyzing proviruses that are deleted for a specific element, we gain insights into their role in reservoir contraction and expansion. Results Our analyses indicate that biphasic decay models of intact reservoir dynamics were better than single-phase models with a stronger statistical fit. Based on the biphasic decay pattern of the intact reservoir, we estimated the half-lives of the first and second phases of decay to be 18.2 (17.3 to 19.2, 95%CI) and 433 (227 to 6400, 95%CI) months, respectively.In contrast, the dynamics of defective proviruses differed favoring neither model definitively, with an estimated half-life of 87.3 (78.1 to 98.8, 95% CI) months during the first phase of the biphasic model. Machine-learning analysis of HIV genomes at the nucleotide level revealed that the presence of the splice donor site D1 was the principal genomic element associated with contraction. This role of D1 was then validated in an in vitro system. Using the same approach, we additionally found supporting evidence that HIV nef may confer a protective advantage for latently infected T cells while tat was associated with clonal expansion. Conclusions The nature of intact reservoir decay suggests that the long-lived HIV reservoir contains at least 2 distinct compartments. The first compartment decays faster than the second compartment. Our machine-learning analysis of HIV proviral sequences reveals specific genomic elements are associated with contraction while others are associated with persistence and expansion. Together, these opposing forces shape the reservoir over time.
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Affiliation(s)
- LaMont Cannon
- Center for Biological Data Science, Virginia Commonwealth University, Richmond, Virginia
| | - Sophia Fehrman
- Center for Biological Data Science, Virginia Commonwealth University, Richmond, Virginia
| | - Marilia Pinzone
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sam Weissman
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Una O'Doherty
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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19
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Kimmel SD, Wurcel AG. Hit Me With Your Best Shot: Long-Acting Therapies to Improve HIV Viral Suppression. Ann Intern Med 2023; 176:1001-1002. [PMID: 37399553 DOI: 10.7326/m23-1427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023] Open
Affiliation(s)
- Simeon D Kimmel
- Sections of General Internal Medicine and Infectious Diseases, Department of Medicine, Boston Medical Center, and Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Alysse G Wurcel
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, and Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
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