1
|
Hsu RK, Fusco JS, Henegar CE, Vannappagari V, Clark A, Brunet L, Lackey PC, Pierone G, Fusco GP. Heavily treatment-experienced people living with HIV in the OPERA® cohort: population characteristics and clinical outcomes. BMC Infect Dis 2023; 23:91. [PMID: 36782125 PMCID: PMC9926692 DOI: 10.1186/s12879-023-08038-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 01/27/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Multi-class resistance, intolerance, and drug-drug interactions can result in unique antiretroviral (ART) combinations for heavily treatment-experienced (HTE) people living with HIV (PLWH). We aimed to compare clinical outcomes between HTE and non-HTE PLWH. METHODS Eligible ART-experienced PLWH in care in the OPERA® Cohort were identified in a cross-sectional manner on December 31, 2016 and observed from the date of initiation of the ART regimen taken on December 31, 2016 until loss to follow up, death, study end (December 31, 2018), or becoming HTE (non-HTE group only). In the absence of resistance data, HTE was defined based on the ART regimens used (i.e., exposed to ≥ 3 core agent classes or regimen suggestive of HTE). Time to virologic undetectability, failure, and immunologic preservation were assessed using Kaplan-Meier methods; cumulative probabilities were compared between the two groups. Regimen changes, incident morbidities, and death were described. RESULTS A total of 24,183 PLWH (2277 HTE PLWH, 21,906 non-HTE) were followed for a median of 28 months (IQR 21, 38). Viremic HTE PLWH (viral load [VL] ≥ 50 copies/mL) were less likely to achieve undetectability (VL < 50 copies/mL; 24-month cumulative probability: 80% [95% Confidence Interval 77-82]) than their non-HTE counterparts (85% [84-86]). No difference was observed in the probability of maintaining VLs < 200 copies/mL over the first 48 months after achieving suppression (< 50 copies/mL). HTE PLWH were less likely than non-HTE PLWH to maintain CD4 cell counts ≥ 200 cells/µL (24-month cumulative probability: 95% HTE [91-93]; 97% non-HTE [97-97]), and more likely to change regimens (45% HTE; 41% non-HTE). Incident non-AIDS defining event (ADE) morbidities were common in both populations, though more likely among HTE PLWH (45%) than non-HTE PLWH (35%). Incident ADE morbidities and deaths were uncommon among HTE (ADEs 5%; deaths 2%) and non-HTE (ADEs 2%; deaths 1%) PLWH. CONCLUSIONS HTE PLWH were at greater risk of unfavorable treatment outcomes than non-HTE PLWH, suggesting additional therapeutic options are needed for this vulnerable population.
Collapse
Affiliation(s)
- Ricky K. Hsu
- grid.240324.30000 0001 2109 4251NYU Langone Health Center, New York, NY USA ,grid.427827.c0000 0000 8950 9874AIDS Healthcare Foundation, New York, NY USA
| | - Jennifer S. Fusco
- Epividian, Inc., Raleigh, NC USA ,Epividian, Inc., 150 Fayetteville Street, Suite 2300, Raleigh, NC 27601 USA
| | | | | | - Andrew Clark
- grid.476798.30000 0004 1771 726XViiV Healthcare, Brentford, Middlesex, UK
| | | | - Philip C. Lackey
- grid.241167.70000 0001 2185 3318Wake Forest School of Medicine, Winston-Salem, NC USA
| | | | | |
Collapse
|
2
|
Hsu RK, Brunet L, Fusco JS, Henegar C, Vannappagari V, Clark A, Lackey PC, Pierone G, Fusco GP. 1264. Durability and effectiveness of fostemsavir in heavily treatment-experienced people with HIV. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Paired with other active antiretrovirals (ARVs), fostemsavir (FTR) may offer heavily treatment-experienced (HTE) people with HIV (PWH) options for continuing effective treatment. Durability and effectiveness of FTR-containing regimens in routine clinical care in the United States were assessed.
Methods
Electronic health record data from the OPERA® cohort were used to identify adults initiating FTR-containing regimens between 2JUL2020 (FDA approval) and 1SEP2021. Eligible PWH were followed from first FTR prescription (baseline) until FTR discontinuation, death, loss to follow up, or study end (28FEB2022). Durability was assessed as frequency of FTR discontinuation. Virologic outcomes assessed at 6 and 12 months (±3 months) included suppression (viral load [VL] < 50 copies/mL), virologic failure (2 consecutive VL ≥200 copies/mL or 1 VL ≥200 copies/mL + FTR discontinuation within 120 days after suppression), and viral blips (1 VL ≥50 copies/mL preceded and followed by VLs < 50 copies/mL). Analyses were stratified by baseline viral load (bVL < 50 copies/mL; bVL ≥50 copies/mL).
Results
Overall, 86 PWH initiated FTR (bVL < 50: 30; bVL ≥50: 55), with median follow up of 10.8 months (IQR: 6.8, 15.3). Compared to PWH with bVL ≥50, those with bVL < 50 were older and more likely to be white and have lived longer with HIV (Table 1). Over follow up, 20% discontinued FTR (Table 2). Most (82%) FTR discontinuations were switches to alternative regimens; the remaining were ARV interruptions (no ARVs for > 45 days). Among PWH with bVL < 50, most maintained suppression (6 months: 74%; 12 months: 82%; Figure). Among PWH with bVL ≥50 and with follow up VL during the period assessed, 33% were suppressed at 6 months, 36% were suppressed at 12 months, and 48% achieved suppression at any time over the entire follow up (Figure). In either group, ≤5 PWH experienced virologic failure or blip, though the proportion of PWH with multiple follow up VLs was low.
Conclusion
Despite a heterogenous population and diverse regimens, most HTE PWH remained on FTR at study end. Most PWH with bVL < 50 remained suppressed and half of PWH with bVL ≥50 achieved suppression over the entire study period. Virologic failure and blips were infrequent, although follow up was limited in this early evaluation of real-world FTR use.
Disclosures
Ricky K. Hsu, MD, Gilead: Honoraria|Merck: Honoraria|ViiV: Advisor/Consultant|ViiV: Grant/Research Support|ViiV: Honoraria Laurence Brunet, PhD, AIDS Healthcare Foundation: Client of my employer|EMD Serono: Client of my employer|Gilead Sciences: Client of my employer|Janssen: Client of my employer|Merck & Co: Client of my employer|TheraTechnologies: Client of my employer|ViiV Healthcare: Client of my employer Jennifer S. Fusco, BS, AIDS Healthcare Foundation: Client of my employer|EMD Serono: Client of my employer|Gilead Sciences: Client of my employer|Janssen: Client of my employer|Merck & Co.: Client of my employer|TheraTechnologies: Client of my employer|ViiV Healthcare: Client of my employer Cassidy Henegar, PhD, MSPH, GlaxoSmithKline: Stocks/Bonds|ViiV Healthcare: full-time employee Vani Vannappagari, MBBS, MPH, PhD, ViiV Healthcare: I am full time employee of ViiV Healthcare and receive GlaxoSmithKline stock as part of my compensation package|ViiV Healthcare: Stocks/Bonds Andrew Clark, MD, ViiV Healthcare: Employee|ViiV Healthcare: Stocks/Bonds Gerald Pierone, Jr., MD, Gilead: Grant/Research Support|GSK-VIIV: Grant/Research Support Gregory P. Fusco, MD, MPH, AIDS Healthcare Foundation: Client of employer|EMD: Grant/Research Support|Gilead Sciences: Client of employer|Janssen: Client of employer|Merck & Co.: Client of employer|Theratechnologies: Client of employer|ViiV Healthcare: Client of employer.
Collapse
Affiliation(s)
- Ricky K Hsu
- AIDS Healthcare Foundation\ NYU School of Medicine , New York, New York
| | | | | | | | | | - Andrew Clark
- ViiV Healthcare , Brentford, UK, Brentford, England , United Kingdom
| | | | | | | |
Collapse
|
3
|
Pierone G, Fusco JS, Brunet L, Vannappagari V, Sarkar S, Henegar C, van Wyk JA, Zolopa A, Fusco GP. 1284. Suppressed Switch to DTG/3TC 2-Drug Regimen Vs. BIC- or DTG-Based 3-Drug Regimens. Open Forum Infect Dis 2022. [PMCID: PMC9752627 DOI: 10.1093/ofid/ofac492.1115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Real-world effectiveness of fixed dose dolutegravir/lamivudine (DTG/3TC) two-drug regimens (2DR) during the first 24 months of availability in the US was compared to common three-drug regimens (3DRs) among suppressed antiretroviral therapy (ART)-experienced people living with HIV (PLWH). Methods Suppressed (viral load [VL] < 200 copies/mL) PLWH initiating DTG/3TC 2DR, bictegravir (BIC)-3DR, or DTG-3DR between 01MAY2019 and 31OCT2020 in the OPERA® Cohort were followed until 30APR2021 (potential for ≥6 months of follow-up). Univariate Poisson regression (incidence rates) and Cox proportional hazards marginal structural models were employed to assess confirmed virologic failure (2 viral loads [VLs] ≥200 copies/mL) or regimen discontinuation. Results Overall, 8037 PLWH were included in the analysis (Table). Virologic failure incidence rates were low, ranging from 0.66 (DTG/3TC) to 1.78 (DTG 3DR) per 100 person-years. Compared to DTG/3TC, only DTG 3DR was associated with an increase in the hazard of virologic failure. Discontinuation incidence rates ranged from 8.30 (BIC 3DR) to 24.9 (DTG 3DR) per 100 person-years. The discontinuation hazard was 69% greater with DTG 3DRs and 49% lower with BIC 3DRs compared to DTG/3TC. Regardless of regimen, most discontinuers were suppressed (VL< 200 copies/mL) at the time of discontinuation (DTG/3TC 2DR: 96%, BIC 3DR: 94%, DTG 3DR: 93%; all p >0.05). Discontinuations following an adverse diagnosis/side effect were uncommon with DTG/3TC 2DR (3%) and DTG 3DR (4%, p=0.5), and higher with BIC 3DR discontinuation (7%, p=0.02). The most common reason for DTG 3DR discontinuations was regimen simplification (21%); no reason was given for >50% of the discontinuations in each group.
![]() Conclusion Among ART-experienced, virologically suppressed PLWH, virologic failure was rare after switching to DTG/3TC 2DR, BIC 3DR or DTG 3DR. Most discontinuations were not attributed to the treatment (i.e., loss of suppression, adverse diagnosis, side effects), suggesting other reasons for discontinuation despite high levels of suppression and tolerability. Disclosures Gerald Pierone, Jr., MD, Gilead: Grant/Research Support|GSK-VIIV: Grant/Research Support Jennifer S. Fusco, BS, AIDS Healthcare Foundation: Client of my employer|EMD Serono: Client of my employer|Gilead Sciences: Client of my employer|Janssen: Client of my employer|Merck & Co.: Client of my employer|TheraTechnologies: Client of my employer|ViiV Healthcare: Client of my employer Laurence Brunet, PhD, AIDS Healthcare Foundation: Client of my employer|EMD Serono: Client of my employer|Gilead Sciences: Client of my employer|Janssen: Client of my employer|Merck & Co: Client of my employer|TheraTechnologies: Client of my employer|ViiV Healthcare: Client of my employer Vani Vannappagari, MBBS, MPH, PhD, ViiV Healthcare: I am full time employee of ViiV Healthcare and receive GlaxoSmithKline stock as part of my compensation package|ViiV Healthcare: Stocks/Bonds Supriya Sarkar, PhD, MPH, ViiV Healthcare: Salary|ViiV Healthcare: Stocks/Bonds Cassidy Henegar, PhD, MSPH, GlaxoSmithKline: Stocks/Bonds|ViiV Healthcare: full-time employee Andrew Zolopa, MD, ViiV Healthcare: full time employee|ViiV Healthcare: Stocks/Bonds Gregory P. Fusco, MD, MPH, AIDS Healthcare Foundation: Client of employer|EMD: Grant/Research Support|Gilead Sciences: Client of employer|Janssen: Client of employer|Merck & Co.: Client of employer|Theratechnologies: Client of employer|ViiV Healthcare: Client of employer.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Jean A van Wyk
- ViiV Healthcare Limited, Brentford, England, United Kingdom
| | - Andrew Zolopa
- ViiV Healthcare, Research Triangle Park, North Carolina
| | | |
Collapse
|
4
|
Fitch KV, McCallum SA, Erlandson KM, Overton ET, Zanni MV, Fichtenbaum C, Aberg JA, Fulda ES, Kileel EM, Moran LE, Bloomfield GS, Novak RM, Pérez-Frontera S, Abrams-Downey A, Pierone G, Kumarasamy N, Ruxrungtham K, Mngqibisa R, Douglas PS, Ribaudo HJ, Grinspoon SK. Diet in a global cohort of adults with HIV at low-to-moderate traditional cardiovascular disease risk. AIDS 2022; 36:1997-2003. [PMID: 35876637 PMCID: PMC9612704 DOI: 10.1097/qad.0000000000003344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To characterize diet quality across a global cohort of people with HIV (PWH). DESIGN Cross-sectional analysis. METHODS Leveraging REPRIEVE data from baseline across five Global Burden of Disease (GBD) regions, we analyzed participant responses to the Rapid Eating Assessment for Participants questionnaire. An overall diet quality score and scores for specific diet components were generated. Higher scores indicate better diet quality. RESULTS Among 7736 participants (median age 50 years, 30% women, median BMI 25.8 kg/m 2 ) overall diet quality score (max score 30) was optimal in 13% of participants and good, suboptimal or poor in 45%, 38%, and 4% of participants, respectively; saturated fat score (max score 18) was good, suboptimal, or poor in 38%, 40%, or 7% of participants, respectively. Diet quality scores differed across GBD region with the highest scores reported in the South Asia region [median 23 (21-25)] and lowest in the sub-Saharan Africa region [median 15 (12-18)]; 61% of participants in the South Asia region reported optimal diet quality compared with only 6% in the sub-Saharan Africa region. Higher atherosclerotic cardiovascular risk scores were seen with worsening diet quality. CONCLUSION Among PWH eligible for primary CVD prevention, diet quality was suboptimal or poor for almost half of participants, and there were substantial variations in diet quality reported by GBD region. TRIAL REGISTRATION NCT02344290.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Laura E. Moran
- Social & Scientific Systems, a DLH Company, Silver Spring, MD
| | - Gerald S. Bloomfield
- Duke Global Health Institute, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Sigrid Pérez-Frontera
- University of Puerto Rico, Medical Sciences Campus, School of Medicine, San Juan, PR
| | | | - Gerald Pierone
- AIDS Research and Treatment Center of the Treasure Coast, Vero Beach, FL, USA
| | | | - Kiat Ruxrungtham
- School of Global Faculty of Medicine Chulalongkorn University and HIV-NAT Research Collaboration, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Rosie Mngqibisa
- Enhancing Care Foundation (Wentworth Hospital), Durban, South Africa
| | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Heather J. Ribaudo
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | |
Collapse
|
5
|
Pierone G, Fusco JS, Vannappagari V, Brunet L, Weber RP, Aboud M, van Wyk J, Ragone L, Fusco GP. Dolutegravir/rilpivirine 2-drug regimen comparable to commonly prescribed 3-drug regimens up to 18-months in a real-world setting. Antivir Ther 2022. [DOI: 10.1177/13596535211073235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background This study compared the effectiveness and durability of DTG/RPV with commonly prescribed 3-drug regimens (3-DR) in people living with HIV (PLWH) in a real-world setting. Methods Antiretroviral therapy (ART)-experienced, virologically suppressed PLWH who initiated DTG/RPV or a 3-DR in 2018 were identified in the OPERA® database and followed through 6/30/2019. Virologic failure (two consecutive viral loads (VL) ≥ 200 copies/mL or single VL ≥ 200 copies/mL with regimen modification/discontinuation) and maintained virologic suppression (last VL test < 50 or < 200 copies/mL) were described. Kaplan–Meier methods were used to estimate time to virologic failure and treatment discontinuation. Risk of virologic failure was adjusted for age, sex, race/ethnicity, risk of infection, region, baseline CD4 cell count, history of substance abuse or syphilis, and mortality risk score at baseline in a Cox model. Results PLWH initiating DTG/RPV were older and more likely to be Hispanic or have comorbidities than 3-DR initiators. DTG/RPV users experienced fewer discontinuations (15%) and were more likely to be suppressed at study end (98%) than 3-DR users (28% and 96%, respectively). Virologic failure was uncommon; rates per 100 person-years did not differ between the DTG/RPV (1.45, 95% CI: 0.69, 3.03) and 3-DR (2.63, 95% CI: 2.21, 3.14) groups. The risk of virologic failure did not differ significantly between the groups in adjusted Cox models (adjusted hazard ratio 1.32, 95% CI: 0.61, 2.89). Conclusions The findings of this real-world OPERA® study suggest that DTG/RPV can be a viable alternative to standard 3-DRs for ART-experienced, virologically suppressed PLWH.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Leigh Ragone
- ViiV Healthcare, Research Triangle Park, NC, USA
| | | |
Collapse
|
6
|
Pierone G, Fusco JS, Brunet L, Henegar C, van Wyk JA, Sarkar S, Vannappagari V, Zolopa A, Wohlfeiler MB, Fusco G. 886. The Impact of the COVID-19 Pandemic on Clinical Follow-Up, Monitoring and Regimen Discontinuation for People Living with HIV in the US. Open Forum Infect Dis 2021. [PMCID: PMC8690744 DOI: 10.1093/ofid/ofab466.1081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background The COVID-19 pandemic has disrupted health care services for people living with HIV (PLWH). This study aimed to compare rates of clinical visits, viral load monitoring and antiretroviral therapy (ART) regimen discontinuation among virally suppressed PLWH in the US before and during the COVID pandemic. Methods The study population consisted of ART-experienced PLWH ≥18 years of age and active in care in the OPERA cohort within 2 years prior to 31OCT2020. Virally suppressed PLWH (i.e., viral load < 200 copies/mL) were included if they switched to either dolutegravir/lamivudine or a dolutegravir- or bictegravir-based 3-drug regimen between 01MAY2019 and 30APR2020. The study periods spanned from 01MAY2019 to 28FEB2020 (pre-COVID) and 01MAR2020 to 31OCT2020 (during COVID). Incidence rates of clinical visits, viral load measurements and regimen discontinuation were estimated using univariate Poisson regression for both study periods. In-person visits comprised any scheduled or walk-in outpatient, inpatient, emergency or laboratory visit. Telehealth visits comprised any phone or video encounters. Results The study included 4806 PLWH in the pre-COVID and 4992 in the COVID period. Rates of in-person visits were reduced almost 2-fold during COVID, while telehealth visits increased almost 9-fold, resulting in an overall reduction in any visits rates from 10.07 visits per person-year (95% CI: 9.93, 10.21) pre-COVID to 7.10 (95% CI: 7.01, 7.19) during COVID [Fig 1]. Rates of viral load measurements dropped from 2.99 viral loads per person-year (95% CI: 2.92, 3.07) pre-COVID to 1.97 (95% CI: 1.92, 2.02) during COVID [Fig 2]. Regimen discontinuation rates were also reduced from 14.3 discontinuations per 100 person-years pre-COVID (95% CI: 12.7, 16.1) to 9.6 (95% CI: 8.6, 10.8) during COVID [Fig 3]. In both study periods, virologic failures were detected in < 1% of PLWH with ≥ 1 viral load. Figure 1. Incidence rates for overall, in-person, and telehealth visits during the pre-COVID (open circle) and the COVID (filled circle) study periods ![]()
Incidence rates for viral load measurements during the pre-COVID (open circle) and the COVID (filled circle) study periods ![]()
Incidence rates for regimen discontinuation during the pre-COVID (open circle) and the COVID (filled circle) study periods ![]()
Conclusion The COVID pandemic has led to an important reduction in the frequency and type of clinical follow-up visits and viral load monitoring among virally suppressed PLWH in the US. A reduction in regimen discontinuation rates was also observed, presumably associated to less frequent follow-up. The long-term impact of the pandemic on HIV care remains uncertain. Disclosures Gerald Pierone, MD, Epividian (Board Member) Jennifer S. Fusco, BS, Epividian, inc (Employee) Laurence Brunet, PhD, Epividian, inc (Employee) Cassidy Henegar, PhD, GSK (Shareholder)ViiV Healthcare (Employee) Jean A. van Wyk, MB,ChB, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Supriya Sarkar, PhD, GSK (Shareholder)ViiV Healthcare (Employee) Vani Vannappagari, MBBS, MPH, PhD, ViiV Healthcare Limited (Employee) Andrew Zolopa, MD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Michael B. Wohlfeiler, MD, Epividian, inc (Board Member)ViiV Healthcare (Research Grant or Support) Gregory Fusco, MD, MPH, Epividian, inc (Employee)
Collapse
|
7
|
Pierone G, Henegar C, Fusco J, Vannappagari V, Aboud M, Ragone L, Fusco G. Two-drug antiretroviral regimens: an assessment of virologic response and durability among treatment-experienced persons living with HIV in the OPERA ® Observational Database. J Int AIDS Soc 2019; 22:e25418. [PMID: 31802641 PMCID: PMC6893210 DOI: 10.1002/jia2.25418] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 10/22/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Two-drug regimens (2-DR) have the potential to be a viable solution to the challenges of treatment complexity, cost, adverse effects and contraindications. We sought to describe the real-world use and effectiveness of 2-DR among persons living with HIV (PLHIV) in the United States. METHODS We analysed data for 10,190 treatment-experienced patients from the OPERA® Observational Database initiating a new 2-DR or three-drug regimen (3-DR) between 1 January 2010 and 30 June 2016. Multivariate Cox Proportional Hazards models were used to estimate the association among 2-DR or 3-DR initiation and virologic suppression (viral load (VL) <50 copies/mL), virologic failure (2 VLs > 200 copies/mL or 1 VL > 200 copies/mL + discontinuation) or regimen discontinuation. RESULTS Patients initiating a 2-DR (n = 1337, 13%) were older, and more likely to have a lower CD4 count, a history of AIDS and comorbid conditions than patients initiating a 3-DR. There was no difference between groups in time to virologic suppression (aHR: 1.00 (95% CI: 0.88, 1.13)) among viraemic patients (baseline VL ≥ 50 copies/mL, n = 4180), or time to virologic failure (aHR: 1.15 (95% CI: 0.90, 1.48)) among virologically stable patients (baseline VL < 50 copies/mL, n = 6010). However, time to discontinuation was shorter following 2-DR than 3-DR initiation (aHR: 1.51 (95% CI: 1.41, 1.61)). CONCLUSIONS In this large cohort of treatment-experienced patients, 2-DR prescriptions were common and more frequent among patients with significant comorbidity. Virologic response was similar, but duration of use was shorter with a 2-DR than a 3-DR, suggesting that 2-DRs may be a virologically effective treatment strategy for treatment-experienced PLHIV with existing comorbidities.
Collapse
|
8
|
Pierone G, Schulman K, Fusco JS, Vannappagari V, Aboud M, Ragone L, Fusco G. 2483. Characteristics and Outcomes Over First 12 Months of a Two-Drug Regimen (Dolutegravir/Rilpivirine) for Treatment of HIV-1 in the United States. Open Forum Infect Dis 2019. [PMCID: PMC6809477 DOI: 10.1093/ofid/ofz360.2161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background In 2017, the first complete antiretroviral regimen (ART) containing only two drugs, dolutegravir/rilpivirine (DTG/RPV), was approved for treatment of HIV-1 in virologically suppressed (<50 copies/mL) patients on a stable ART regimen for ≥6 months with no history of treatment failure/resistance to DTG or RPV. Our objective was to characterize early utilization/outcomes of DTG/RPV in a real-world population. Methods HIV-1+ individuals initiating DTG/RPV from January 1, 2018 to December 31, 2018 were identified in the OPERA Database. Outcomes were evaluated among the virologically suppressed subgroup who initiated in the first 6 months. Discontinuation (d/c) was defined as cessation of DTG/RPV. Virologic failure (VF) was defined as either 2 consecutive HIV viral loads (VL) ≥ 200 copies/mL OR 1 VL ≥200 copies/mL + d/c. Population was observed from DTG/RPV start (index) until the first of: (a) d/c, (b) death, or (c) study end (December 31, 2018). Demographic and clinical characteristics were described at index. Kaplan–Meier methods were used to describe d/c and VF. Results A total of 880 patients were prescribed DTG/RPV in the first 12 months; demographic and clinical characteristics are described in Figures 1 and 2. Most (76%) DTG/RPV users were virologically suppressed at initiation (n = 671). Among the 197 (22%) ART experienced, viremic initiators, a third had a baseline VL ≥ 50 but <200. Few patients were ART naïve (n = 12, 1%). Index VL was unavailable for 21 (5%) initiators. Comorbidity was prevalent: 59% had ≥1 endocrine disorders; 42% hypertension, and 33% mental disorders. For the virologically suppressed at initiation, with ≥6 months of follow-up (n = 340); median (IQR) days on DTG/RPV was 248 (204–299); 88% remained on DTG/RPV at study end. Among the 42 (12.4%) discontinued patients, 41% were virologically stable (<200 copies/mL) at d/c. Median (IQR) days to d/c was 58 (29–141) (Figure 3). Most patients (n = 288, 85%) had ≥ 1 VL during follow-up; 79% (n = 270) had ≥1 VL during the first 24 weeks. Among these, VF occurred in 1.5% patients. Median (IQR) time to VF was 5.1 (2.0–9.2) months (Figure 4). Conclusion While DTG/RPV initiators were primarily ART-experienced, virologically suppressed individuals older than 50 years of age challenged by significant comorbid conditions, the frequency of d/c or VF in the first 12 months was low. ![]()
![]()
![]()
![]()
Disclosures All authors: No reported disclosures.
Collapse
Affiliation(s)
| | | | | | | | - Michael Aboud
- ViiV Healthcare, Research Triangle Park, North Carolina
| | - Leigh Ragone
- ViiV Healthcare, Research Triangle Park, North Carolina
| | | |
Collapse
|
9
|
Lackey P, Mills A, Carpio F, Hsu R, DeJesus E, Pierone G, Henegar C, Fusco J, Fusco G, Wohlfeiler M. Virologic Effectiveness of Abacavir/Lamivudine with Darunavir/Ritonavir Versus Other Protease Inhibitors in Treatment-Experienced HIV-Infected Patients in Clinical Practice. Clin Drug Investig 2017; 37:51-60. [PMID: 27587070 PMCID: PMC5209413 DOI: 10.1007/s40261-016-0456-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background and Objectives The standard of care for HIV treatment is a three-drug regimen consisting of two nucleoside reverse transcriptase inhibitors (NRTIs) and either a non-nucleoside reverse transcriptase inhibitor, a protease inhibitor (PI) or an integrase strand transfer inhibitor. Darunavir boosted with ritonavir (DRV/r) is the only preferred PI in the US Department of Health and Human Services (DHHS) HIV treatment guidelines for antiretroviral-naïve patients, recommended in combination with tenofovir/emtricitabine for antiretroviral-naïve patients. For treatment-experienced and certain antiretroviral-naïve patients, abacavir and lamivudine (ABC/3TC) in combination with DRV/r is considered an effective and tolerable alternative, despite limited research on the effectiveness of this particular combination. This study evaluated virologic outcomes in treatment-experienced patients taking ABC/3TC + DRV/r compared to treatment-experienced patients taking ABC/3TC with any other PI. Methods Treatment-experienced HIV-infected patients initiating their first regimen containing ABC/3TC in combination with any PI in the year 2005 or later were selected from the Observational Pharmaco-Epidemiology Research and Analysis (OPERA®) cohort, a prospective observational cohort reflecting routine medical care. Viral load measurements taken during follow-up were compared between patients taking ABC/3TC + DRV/r and ABC/3TC with a PI other than DRV/r. Logistic regression models were fit to assess the association between regimen exposure and viral load suppression. Results A total of 151 patients initiating ABC/3TC + DRV/r and 525 patients initiating ABC/3TC + a non-darunavir PI were included. Patients in both treatment groups had comparable clinical indicators (viral load, CD4) at baseline. A regimen of ABC/3TC + DRV/r was more likely to be prescribed in the later years of the study period, leading to a shorter median follow-up in the DRV/r treatment group (as-treated analysis: 14 vs. 17 months, p = 0.04; intent-to-treat analysis: 33 vs. 68 months, p < 0.001). Multivariable logistic regression models accounting for year of regimen initiation, among other factors, indicated no statistically significant differences in achieving an undetectable viral load for patients taking DRV/r with ABC/3TC compared with other PIs, both in the as-treated (odds ratio [95 % confidence interval]: 0.84 [0.53–1.34]) and intent-to-treat analyses (0.82 [0.48–1.40]). Patients in both treatment groups also showed similar reductions in viral load (median darunavir vs. non-darunavir: −23.0 vs. −23.0 copies/mL; p = 0.72) and gains in CD4 T cell counts (median darunavir vs. non-darunavir: 106 vs. 108 cells/mm3; p = 0.59] while being treated with the regimen of interest. Conclusions Patients receiving ABC/3TC + DRV/r appear to experience similar treatment benefit to patients taking ABC/3TC with other PIs in terms of achieving suppression, as well as absolute reductions in viral load and CD4 lymphocyte gains.
Collapse
Affiliation(s)
- Philip Lackey
- Carolinas Healthcare System, Charlotte, NC, USA.,OPERA Clinical and Epidemiological Advisory Board, Epividian Inc., Durham, NC, USA
| | - Anthony Mills
- OPERA Clinical and Epidemiological Advisory Board, Epividian Inc., Durham, NC, USA.,Anthony Mills MD, Inc., Los Angeles, CA, USA
| | - Felix Carpio
- OPERA Clinical and Epidemiological Advisory Board, Epividian Inc., Durham, NC, USA.,Altamed Health Services, Los Angeles, CA, USA
| | | | - Edwin DeJesus
- OPERA Clinical and Epidemiological Advisory Board, Epividian Inc., Durham, NC, USA.,Orlando Immunology Center, Orlando, FL, USA
| | - Gerald Pierone
- OPERA Clinical and Epidemiological Advisory Board, Epividian Inc., Durham, NC, USA.,AIDS Research and Treatment Center of the Treasure Coast, Vero Beach, FL, USA
| | - Cassidy Henegar
- OPERA Database, Epividian, Inc., 4819 Emperor Blvd., Suite 400, Durham, NC, 27703, USA.
| | - Jennifer Fusco
- OPERA Clinical and Epidemiological Advisory Board, Epividian Inc., Durham, NC, USA.,OPERA Database, Epividian, Inc., 4819 Emperor Blvd., Suite 400, Durham, NC, 27703, USA
| | - Gregory Fusco
- OPERA Clinical and Epidemiological Advisory Board, Epividian Inc., Durham, NC, USA
| | - Mike Wohlfeiler
- OPERA Clinical and Epidemiological Advisory Board, Epividian Inc., Durham, NC, USA.,AIDS Healthcare Foundation, Los Angeles, CA, USA
| |
Collapse
|
10
|
Dejesus E, Elion R, Ramgopal M, Wade BH, Sloan L, Edelstein H, Pierone G, Slim J, Stephens J, Yan M, Tran-Muchowski C, Rhee M. Efficacy and Safety of Tenofovir Alafenamide versus Tenofovir Disoproxil Fumarate in HIV-infected, Virologically Suppressed Black and Non-Blacks Adults Through Week 48: Subgroup Analysis of a Randomized Switch Study. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.1210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Moti Ramgopal
- Midway Immunology and Research Center, Fort Pierce, FL
| | - Barbara H. Wade
- Center for the Prevention and Treatment of Infections, Pensacola, FL
| | - Louis Sloan
- North Texas Infectious Diseases Consultants PA, Dallas, TX
| | | | - Gerald Pierone
- AIDS Research and Treatment Center of the Treasure Coast, Vero Beach, FL
| | - Jihad Slim
- Saint. Michael's Medical Center, Newark, NJ
| | | | - Mingjin Yan
- Biostatistics, Gilead Sciences, Inc., Foster City, CA
| | | | | |
Collapse
|
11
|
Chiang Y, Pierone G, Al-Niaimi F. Dermal fillers: pathophysiology, prevention and treatment of complications. J Eur Acad Dermatol Venereol 2016; 31:405-413. [DOI: 10.1111/jdv.13977] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 07/20/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Y.Z. Chiang
- Department of Dermatology; Salford Royal Hospital; Manchester UK
| | - G. Pierone
- Facial rejuvenation Florida; Vero Beach FL USA
| | - F. Al-Niaimi
- Department of Surgery and Laser Unit; St. John's Institute of Dermatology; Guy's and St. Thomas’ Hospitals; London UK
| |
Collapse
|
12
|
Lackey P, Mills A, Carpio F, Hsu R, Dejesus E, Pierone G, Henegar C, Brouwer E, Fusco J, Fusco G, Wohlfeiler M. Virologic Effectiveness of Abacavir/Lamivudine With Darunavir Versus Other Protease Inhibitors in Treatment-Experienced HIV-Infected Patients in Clinical Practice. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
13
|
Pierone G, Urban T, Martin A, Mieras J, Kantor C. Successful Use of a Tipranavir/Ritonavir-Based Antiretroviral Regimen Following Development of Viral Resistance to Darunavir. HIV Clinical Trials 2015; 9:140-1. [DOI: 10.1310/hct0902-140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
14
|
Pierone G, Mieras J, Bulgin-Coleman D, Kantor C, Shearer J, Fontaine L, Fath M, Norton M. A Pilot Study of Switch to Lopinavir/Ritonavir (LPV/r) Monotherapy from Nonnucleoside Reverse Transcriptase Inhibitor–Based Therapy. HIV Clinical Trials 2014; 7:237-45. [PMID: 17162317 DOI: 10.1310/hct0705-237] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE This study evaluated the safety and efficacy of switching HIV-infected patients with stable viral suppression on nonnucleoside reverse transcriptase inhibitor/nucleoside reverse transcriptase inhibitor (NNRTI/NRTI) therapy to lopinavir/ritonavir (LPV/r) monotherapy. METHOD Eligible patients discontinued NNRTI and started LPV/r. Two weeks later NRTIs were stopped and LPV/r monotherapy was continued. Patients were seen every 4 weeks throughout the 48-week study. RESULTS Twelve of 18 (66%) participants met the primary endpoint with HIV RNA <75 copies/mL at week 48. Thirteen (72%) participants completed 48 weeks of LPV/r monotherapy, and 12 of 13 (92%) participants on treatment at week 48 had HIV RNA <75 copies/mL. Ten (55%) of 18 patients maintained HIV RNA <75 copies/mL at all time points. Two patients were withdrawn with virologic failure but demonstrated no evidence of virologic resistance. Three (17%) patients withdrew due to diarrhea, 2 with hyperglycemia at baseline developed diabetes mellitus, 7 (54%) required addition of or increase in lipid-lowering agents, but none had grade 3 or 4 hyperlipidemia. CONCLUSION Results from this pilot study suggest that LPV/r monotherapy may be an option for management of HIV infection. Larger, randomized trials are warranted to evaluate the safety, efficacy, and patient population who might benefit from LPV/r monotherapy.
Collapse
Affiliation(s)
- Gerald Pierone
- AIDS Research and Treatment Center of Treasure Coast, Ft. Pierce, Florida, USA.
| | | | | | | | | | | | | | | |
Collapse
|
15
|
Bassichis B, Blick G, Conant M, Condoluci D, Echavez M, Eviatar J, Gold MH, Hamilton T, Hanke WC, Humble G, LaMarca A, Daro-Kaftan E, Mest D, Pierone G. Injectable Poly-l-Lactic Acid for Human Immunodeficiency Virus–Associated Facial Lipoatrophy: Cumulative Year 2 Interim Analysis of an Open-Label Study (FACES). Dermatol Surg 2012; 38:1193-205. [DOI: 10.1111/j.1524-4725.2012.02474.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
16
|
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a deadly demyelinating disease of the brain, caused by reactivation of the polyomavirus JC (JCV). PML has classically been described in individuals with profound cellular immunosuppression such as patients with AIDS, haematological malignancies, organ transplant recipients or those treated with immunosuppressive or immunomodulatory medications for autoimmune diseases. METHODS AND CASE REPORTS: The authors describe five HIV seronegative patients with minimal or occult immunosuppression who developed PML including two patients with alcoholic cirrhosis, one with untreated dermatomyositis and two with idiopathic CD4(+) T cell lymphocytopenia. The authors performed a review of the literature to find similar cases. RESULTS The authors found an additional 33 cases in the literature. Of a total of 38 cases, seven (18.4%) had hepatic cirrhosis, five (13.2%) had renal failure, including one with concomitant hepatic cirrhosis, two (5.2%) were pregnant women, two (5.2%) had concomitant dementia, one (2.6%) had dermatomyositis, and 22 (57.9%) had no specific underlying diagnosis. Among these 22, five (22.7%) had low CD4(+) T cell counts (0.080-0.294x10(9)/l) and were diagnosed as having idiopathic CD4(+) lymphocytopenia, and one had a borderline CD4(+) T cell count of 0.308x10(9)/l. The outcome was fatal in 27/38 (71.1%) cases within 1.5-120 months (median 8 months) from onset of symptoms, and 3/4 cases who harboured JCV-specific T cells in their peripheral blood had inactive disease with stable neurological deficits after 6-26 months of follow-up. DISCUSSION These results indicate that PML can occur in patients with minimal or occult immunosuppression, and one can revisit the generally accepted notion that profound cellular immunosuppression is a prerequisite for the development of PML.
Collapse
Affiliation(s)
- Sarah Gheuens
- Division of Viral Pathogenesis, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA
| | | | | | | |
Collapse
|
17
|
Abstract
Previous studies of lopinavir/ritonavir (LPV/r) monotherapy have shown that over 70% of patients achieved HIV RNA levels <500 copies/mL over a follow-up period of 48 to 96 weeks, but the long-term durability is undetermined. Herein, the authors report 2 patients that started LPV/r monotherapy after virologic failure on an NNRTIbased regimen and have been successfully treated for greater than 7 years. Both patients demonstrated long-term control of viral replication over the course of treatment, although the first patient had 3 viral load blips and the second had 1 blip under 400 copies/mL. Both patients had increases in CD4+ lymphocyte counts. The first patient from 96 cells/μL to 378 cells/μL and the second patient from 71 cells/μL to 411 cells/μL. To the authors knowledge, these 2 cases represent the longest experience with LPV/r monotherapy and provide some measure of reassurance about the durability of LPV/r for control of HIV replication.
Collapse
Affiliation(s)
- Gerald Pierone
- Treasure Coast Infectious Disease Consultants, Vero Beach, Florida, Indian River Medical Center, Vero Beach, Florida,
| | - Jeffrey Mieras
- Treasure Coast Infectious Disease Consultants, Vero Beach, Florida, Indian River Medical Center, Vero Beach, Florida
| | - Amber Martin
- Treasure Coast Infectious Disease Consultants, Vero Beach, Floriad, Indian River Medical Center, Vero Beach, Florida
| | - Theresa Urban
- Treasure Coast Infectious Disease Consultants, Vero Beach, Florida, Indian River Medical Center, Vero Beach, Florida
| |
Collapse
|
18
|
Haubrich R, Berger D, Chiliade P, Colson A, Conant M, Gallant J, Wilkin T, Nadler J, Pierone G, Saag M, van Baelen B, Lefebvre E. Week 24 efficacy and safety of TMC114/ritonavir in treatment-experienced HIV patients. AIDS 2007; 21:F11-8. [PMID: 17413685 DOI: 10.1097/qad.0b013e3280b07b47] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Agents for the treatment of HIV-1-infected patients with resistance to current antiretroviral (ART) drugs are needed. METHODS TMC114-C202 was a randomized, partially blinded, dose-finding study in treatment-experienced HIV-1-infected patients with one or more primary protease inhibitor (PI) mutations and HIV-1 RNA > 1000 copies/ml. Patients were randomized to receive one of four TMC114 doses given with ritonavir (TMC114/r) or investigator-selected control PI drug(s) (CPI); all received an optimized background regimen. The primary intent-to-treat analysis compared the proportion of patients achieving a >or= 1 log10 copies/ml HIV-1 RNA reduction at week 24 between the treatment arms using the time-to-loss of virological response algorithm. RESULTS For 278 patients at baseline, mean HIV-1 RNA was 4.7 log10 copies/ml, median CD4 cell count was 106 cells/mul; HIV-1 isolates had a median of three primary PI mutations and a median fold change in lopinavir susceptibility of 80. Discontinuation rates were 23% for TMC114/r versus 64% for CPI. More patients in each TMC114/r dose group achieved >or= 1.0 log10 copies/ml reduction in HIV-1 RNA than in the CPI group (45-62% versus 14%; P <or= 0.003): patients taking TMC114/r twice daily had the greatest responses. HIV-1 RNA was < 50 copies/ml in 18-39% of TMC114/r patients versus 7% CPI (P < 0.001 for highest dose). Mean CD4 cell count increased by 59-75 versus 12 cells/mul (TMC114/r versus CPI: P <or= 0.005). Overall adverse event rates were similar in both arms, without significant differences among TMC114/r groups. CONCLUSIONS TMC114/r treatment resulted in greater virological and immunological responses in ART-experienced patients compared with CPI at 24 weeks.
Collapse
|
19
|
Gathe JC, Pierone G, Piliero P, Arasteh K, Rubio R, Lalonde RG, Cooper D, Lazzarin A, Kohlbrenner VM, Dohnanyi C, Sabo J, Mayers D. Efficacy and safety of three doses of tipranavir boosted with ritonavir in treatment-experienced HIV type-1 infected patients. AIDS Res Hum Retroviruses 2007; 23:216-23. [PMID: 17263650 DOI: 10.1089/aid.2006.0178] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The efficacy, safety, and pharmacokinetics of three doses of tipranavir/ritonavir (TPV/r) in highly treatment-experienced human immunodeficiency virus (HIV)-1-infected patients with protease inhibitor (PI)-resistant isolates were evaluated. A 24-week multicenter, double-blind, randomized, dose-finding trial was conducted. All patients were three-drug class experienced and had taken at least two PI-based regimens. All had at least one primary PI mutation and had plasma HIV-RNA > 1000 copies/ml. Patients remained on their background non-PI antiretroviral medications for the first 14 days. After this 14-day period of functional TPV/r monotherapy, the background antiretroviral medications were optimized based on treatment history and the screening genotype. A total of 216 patients were randomized. All groups [TPV/r 500 mg/100 mg (n = 73), 500 mg/200 mg (n = 72), and 750 mg/200 mg (n = 71) twice daily] achieved an approximate 1 log10 reduction in the median HIV-RNA at week 2. A significant reduction was sustained through 24 weeks in the TPV/r 500 mg/200 mg and 750 mg/200 mg groups. The 500 mg/200 mg dose achieved optimal median TPV trough concentrations and lower interpatient variability. The most frequently reported adverse events (AEs) were diarrhea, nausea, vomiting, fatigue, and headache. The TPV/r 750 mg/200 mg group had the highest rate of grade 3 or 4 laboratory abnormalities and study discontinuations due to AEs. All doses of TPV/r tested in this study were associated with HIV-1 viral load reductions through 24 weeks. The 500 mg/200 mg dose achieved the best efficacy, safety, and pharmacokinetic profile in this highly treatment-experienced population and was selected for the pivotal phase 3 studies.
Collapse
Affiliation(s)
- Joseph C Gathe
- Therapeutic Concepts, 4900 Fannin Street, Houston, TX 77004, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Gathe JC, Pierone G, Piliero P, Arasteh K, Rubio R, Lalonde RG, Cooper D, Lazzarin A, Kohlbrenner VM, Dohnanyi C, Sabo J, Mayers D. Efficacy and Safety of Three Doses of Tipranavir Boosted with Ritonavir in Treatment-Experienced HIV Type 1-Infected Patients. AIDS Res Hum Retroviruses 2007. [DOI: 10.1089/aid.2007.23.ft-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
21
|
Gathe J, Cooper DA, Farthing C, Jayaweera D, Norris D, Pierone G, Steinhart CR, Trottier B, Walmsley SL, Workman C, Mukwaya G, Kohlbrenner V, Dohnanyi C, McCallister S, Mayers D. Efficacy of the Protease Inhibitors Tipranavir plus Ritonavir in Treatment-Experienced Patients: 24-Week Analysis from the RESIST-1 Trial. Clin Infect Dis 2006; 43:1337-46. [PMID: 17051503 DOI: 10.1086/508353] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2006] [Accepted: 07/06/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Improved treatment options are needed for patients infected with multidrug-resistant human immunodeficiency virus type 1 (HIV-1). The nonpeptidic protease inhibitor tipranavir has demonstrated antiviral activity against many protease inhibitor-resistant HIV-1 isolates. The Randomized Evaluation of Strategic Intervention in multi-drug reSistant patients with Tipranavir (RESIST-1) trial is an ongoing, open-label study comparing the efficacy and safety of ritonavir-boosted tipranavir (TPV/r) with an investigator-selected ritonavir-boosted comparator protease inhibitor (CPI/r) in treatment-experienced, HIV-1-infected patients. METHODS Six hundred twenty antiretroviral-experienced patients were treated at 125 sites in North America and Australia. Before randomization, all patients underwent genotypic resistance testing, which investigators used to select a CPI/r and an optimized background regimen. Patients were randomized to receive TPV/r or CPI/r and were stratified on the basis of preselected protease inhibitor and enfuvirtide use. Treatment response was defined as a confirmed reduction in the HIV-1 load of > or = 1 log10 less than the baseline level without treatment change at week 24. RESULTS Mean baseline HIV-1 loads and CD4+ cell counts were 4.74 log10 copies/mL and 164 cells/mm3, respectively. At week 24, a total of 41.5% of patients in the TPV/r arm and 22.3% in the CPI/r arm had a > or = 1-log10 reduction in the HIV-1 load (intent-to-treat population; P<.0001). Mean increases in the CD4+ cell count of 54 and 24 cells/mm3 occurred in the TPV/r and CPI/r groups, respectively. Adverse events were slightly more common in the TPV/r group and included diarrhea, nausea, and vomiting. Elevations in alanine and aspartate aminotransferase levels and in cholesterol/triglyceride levels were more frequent in the TPV/r group. CONCLUSIONS TPV/r demonstrated superior antiviral activity, compared with investigator-selected, ritonavir-boosted protease inhibitors, at week 24 in treatment-experienced patients with multidrug-resistant HIV-1 infection.
Collapse
|
22
|
Borucki M, Holodniy M, Pierone G, Ruane P, Steinhart C, Williams S, Slom T, Palella F, Hare CB, Yoshida Y, Li XD, Pollard RB. The Safety and Tolerability of Z-100 in Patients Infected with HIV-1. Antivir Ther 2006. [DOI: 10.1177/135965350601100314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Z-100 is an extract of the Mycobacterium tuberculosis strain Aoyama B, which contains various polysaccharides. Aoyama B has previously been shown to induce a T helper 1-type cytokine response in various murine oncological models and has also demonstrated inhibitory activity against HIV-1 in vitro. This multicentre study primarily determined the safety of Z-100 in early HIV-1-infected patients who were treatment naive; were treatment experienced, but had elected to discontinue highly active antiretroviral therapy (HAART) 8 weeks or longer before the study; or were stable on their first or second HAART regimen for at least 12 weeks before the study. Thirty-two individuals participated in this study and self-injected either placebo, 20 μg or 40 μg Z-100 twice a week for 8 weeks. Z-100 was well tolerated and the safety profiles of the Z-100 treatment groups were not meaningfully different compared with the placebo group. Plasma levels of HIV-1 RNA were not statistically significantly different in any treatment group at the end of the treatment period. There were no statistically significant differences among the treatment groups in the change from baseline to week 8 for any of the biological endpoints including plasma levels of HIV-1 RNA; CD4+ and CD8+ T-cell counts; levels of macrophage inflammatory protein 1; soluble tumour necrosis factor receptor 1; C-reactive protein; interleukin-6; and granulocyte colony stimulating factor. Consequently, this trial demonstrates the safety of Z-100 in HIV-1 infected patients without evidence of any activity at the doses administered.
Collapse
Affiliation(s)
| | - Mark Holodniy
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Gerald Pierone
- Treasure Coast Infectious Disease Consultants, Vero Beach, FL, USA
| | - Peter Ruane
- Tower I.D. Medical Associates, Los Angels, CA, USA
| | | | | | - Trevor Slom
- St. John's Mercy Medical Center, St. Louis, MO, USA
| | - Frank Palella
- Northwestern University Medical School, Chicago, IL, USA
| | - C Bradley Hare
- Positive Health Program, Department of Medicine, University of California, San Francisco, CA, USA
| | | | - Xiao-Dong Li
- University of California Davis Medical Center, Sacramento, CA, USA
| | | |
Collapse
|
23
|
Borucki M, Holodniy M, Pierone G, Ruane P, Steinhart C, Williams S, Slom T, Palella F, Hare CB, Yoshidao Y, Li XD, Pollard RB. The safety and tolerability of Z-100 in patients infected with HIV-1. Antivir Ther 2006; 11:297-303. [PMID: 16759045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Z-100 is an extract of the Mycobacterium tuberculosis strain Aoyama B, which contains various polysaccharides. Aoyama B has previously been shown to induce a T helper 1-type cytokine response in various murine oncological models and has also demonstrated inhibitory activity against HIV-1 in vitro. This multicentre study primarily determined the safety of Z-100 in early HIV-1-infected patients who were treatment naive; were treatment experienced, but had elected to discontinue highly active antiretroviral therapy (HAART) 8 weeks or longer before the study; or were stable on their first or second HAART regimen for at least 12 weeks before the study. Thirty-two individuals participated in this study and self-injected either placebo, 20 microg or 40 microg Z-100 twice a week for 8 weeks. Z-100 was well tolerated and the safety profiles of the Z-100 treatment groups were not meaningfully different compared with the placebo group. Plasma levels of HIV-1 RNA were not statistically significantly different in any treatment group at the end of the treatment period. There were no statistically significant differences among the treatment groups in the change from baseline to week 8 for any of the biological endpoints including plasma levels of HIV-1 RNA; CD4+ and CD8+ T-cell counts; levels of macrophage inflammatory protein 1; soluble tumour necrosis factor receptor 1; C-reactive protein; interleukin-6; and granulocyte colony stimulating factor. Consequently, this trial demonstrates the safety of Z-100 in HIV-1 infected patients without evidence of any activity at the doses administered.
Collapse
|
24
|
Fichtenbaum CJ, Hadigan CM, Kotler DP, Pierone G, Sax PE, Steinhart CR, Tebas P. Treating morphologic and metabolic complications in HIV-infected patients on antiretroviral therapy. A consensus statement of an advisory committee of the International Association of Physicians in AIDS Care. IAPAC Mon 2005; 11:38-46. [PMID: 15971353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Clinicians are increasingly challenged by presentation of morphologic and metabolic complications in HIV-infected patients. These complications are associated with HIV infection and/or combination antiretroviral therapy. This Consensus Statement is intended to offer guidance to clinicians actively involved in HIV/AIDS care. PARTICIPANTS Seven clinicians with expertise in HIV medicine were invited by the International Association of Physicians in AIDS Care (IAPAC) to serve on an ad hoc Advisory Committee. CONSENSUS PROCESS IAPAC convened the Advisory Committee to develop a draft Consensus Statement. Each clinician was tasked with drafting a specific section of the Consensus Statement corresponding with his or her expertise around a morphologic and/or metabolic complication. Scientific and clinical research, and other data in published literature and abstracts from scientific conferences were considered by strength of evidence. This document represents the consensus agreement of the Advisory Committee.
Collapse
|
25
|
Squires K, Pozniak AL, Pierone G, Steinhart CR, Berger D, Bellos NC, Becker SL, Wulfsohn M, Miller MD, Toole JJ, Coakley DF, Cheng A. Tenofovir disoproxil fumarate in nucleoside-resistant HIV-1 infection: a randomized trial. Ann Intern Med 2003; 139:313-20. [PMID: 12965939 DOI: 10.7326/0003-4819-139-5_part_1-200309020-00006] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Resistance to antiretroviral agents remains a leading cause of treatment failure for patients infected with HIV-1. OBJECTIVE To describe the efficacy and safety of tenofovir disoproxil fumarate (tenofovir DF) compared with placebo in patients with detectable viral replication despite current antiretroviral therapy. DESIGN Randomized, double-blind, placebo-controlled study through 24 weeks. After 24 weeks, all patients received open-label tenofovir DF for the remainder of the 48-week study. SETTING 75 North American, European, and Australian HIV clinics. PATIENTS 552 HIV-1-infected adults who were receiving antiretroviral therapy and had stable HIV-1 RNA levels ranging from 400 to 10,000 copies/mL. MEASUREMENTS Change in HIV-1 RNA level (time-weighted average from baseline through week 24); proportion of patients with grade 3 or 4 laboratory abnormalities and adverse events; and genotypic HIV-1 resistance testing in a separate substudy at baseline, week 24, and week 48. RESULTS A statistically significant decrease in HIV-1 RNA level through week 24 (the primary end point) was observed in the tenofovir DF group versus the placebo group (-0.61 log10 copies/mL vs. -0.03 log10 copies/mL, respectively [P < 0.001]; difference, -0.58 log10 copies/mL [95% CI, -0.68 to -0.49 log10 copies/mL]). In a virologic substudy, 94% of 253 patients had plasma isolates expressing reverse transcriptase mutations associated with nucleoside resistance mutations at baseline. Through week 24, the incidence of clinical adverse events was similar between patients receiving placebo and those receiving tenofovir DF (14% vs. 13%). No evidence of tenofovir DF-related toxicity was seen through week 48. CONCLUSION In treatment-experienced patients with suboptimal viral suppression, tenofovir DF significantly reduced HIV-1 RNA level and had a safety profile similar to that of placebo.
Collapse
Affiliation(s)
- Kathleen Squires
- Keck School of Medicine, University of Southern California, Los Angeles, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Wheat LJ, Farthing C, Cohen C, Pierone G, Lalezari J, Pilson RS, Siemon-Hryczyk P. Efficacy and safety of twice-daily versus three-times daily saquinavir soft gelatin capsules as part of triple combination therapy for HIV-1 infection. Antivir Ther 2002; 7:199-209. [PMID: 12487388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
OBJECTIVE The objective of this study was to determine whether a triple therapy regimen incorporating twice-daily saquinavir is as effective as a three-times daily regimen. METHODS This was an open-label, Phase III, multicentre, 48-week study involving 837 HIV-1-infected patients randomised to one of the following: saquinavir soft gel capsule (SGC) 1200 mg three-times daily, plus two nucleoside reverse transcriptase inhibitors (NRTIs) (arm A); saquinavir SGC 1,600 mg twice-daily, plus two NRTIs (arm B); saquinavir SGC 1,200 mg twice-daily and nelfinavir 1,250 mg twice-daily, plus a single NRTI (arm C). The primary outcome measure was the virological response in arm A versus B and in arm A versus C with respect to the percentage of patients whose plasma HIV-1 RNA levels fell below the level of quantification for the Amplicor assay (<400 copies/ml) at weeks 24 and 48. RESULTS At 48 weeks, the percentage of patients with plasma HIV-1 RNA levels <400 copies/ml was 47.1% (arm A), 45.3% (arm B) and 42.7% (arm C) in the intention-to-treat analysis. The treatment difference between arm B-arm A was -1.8% (95% confidence intervals -10.1, 6.5) and for arm C-arm A was -4.5% (95% confidence intervals -12.7, 3.7) in the intention-to-treat analysis. These differences fell within the maximum allowable difference (+/- 12%) for arm B compared with arm A. At week 24, the percentage of patients with HIV-1 RNA levels <400 copies/ml was 59.6% (arm A), 57.6% (arm B) and 51.3% (arm C). CONCLUSIONS A twice-daily triple therapy regimen incorporating saquinavir SGC plus two NRTIs was of equivalent efficacy to the three-times daily regimen studied. All regimens were generally well tolerated.
Collapse
Affiliation(s)
- L Joseph Wheat
- Indiana University School of Medicine, Indianapolis, Ind, USA
| | | | | | | | | | | | | |
Collapse
|
27
|
Wheat LJ, Farthing C, Cohen C, Pierone G, Lalezari J, Pilson RS, Siemon-Hryczyk P, Baxter J, Beer V, Bellos NC, Bissett J, Braun J, Brosgart C, Burman W, Burnside A, Cervia J, Cheeseman S, Cimoch P, Cohen C, DeJesus E, Diaz L, Dieterich D, Dobkin J, Dretler R, El-Sadr W, Eng R, Farthing C, Feinberg J, Feleke G, Fessel J, Fish D, Galpin J, Gathe J, Gilson I, Gold M, Goodgame J, Goodrich J, Greenberg R, Greiger P, Grossman H, Grossman R, Hanna B, Hathaway B, Hoffman-Terry M, Jacobson S, Jemsek J, Jordan W, Kaplan M, Kostman J, Lalezari J, Landesman S, Lindquist C, MacArthur R, Madhava V, Marsh B, Martin D, Mathur-Wagh U, McMeeking A, Miao P, Mogyoros M, Murphy R, Mustafa M, Nadler J, Norris D, Onbirbak B, Parker RH, Pearce D, Pierone G, Poblete R, Poretz DM, Reyelt MC, Rivera-Vazquez C, Salvato P, Sands M, Schwartz R, Sension M, Skowron G, Slater L, Smith D, Stavola J, Steinhart C, Temesgen Z, Thompson M, Timpone J, Valentine FT, Vollmer K, Wada S, Ward D, Wheat LJ, Yangco B, Carey P, Jablonowski H, Theisen A, Lazzarin A, Ocana I. Efficacy and Safety of Twice-Daily versus Three-Times Daily Saquinavir Soft Gelatin Capsules as Part of Triple Combination Therapy for HIV-1 Infection. Antivir Ther 2002. [DOI: 10.1177/135965350200700310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective The objective of this study was to determine whether a triple therapy regimen incorporating twice-daily saquinavir is as effective as a three-times daily regimen. Methods This was an open-label, Phase III, multicentre, 48-week study involving 837 HIV-1-infected patients randomised to one of the following: saquinavir soft gel capsule (SGC) 1200 mg three-times daily, plus two nucleoside reverse transcriptase inhibitors (NRTIs) (arm A); saquinavir SGC 1600 mg twice-daily, plus two NRTIs (arm B); saquinavir SGC 1200 mg twice-daily and nelfinavir 1250 mg twice-daily, plus a single NRTI (arm C). The primary outcome measure was the virological response in arm A versus B and in arm A versus C with respect to the percentage of patients whose plasma HIV-1 RNA levels fell below the level of quantification for the Amplicor assay (<400 copies/ml) at weeks 24 and 48. Results At 48 weeks, the percentage of patients with plasma HIV-1 RNA levels <400 copies/ml was 47.1% (arm A), 45.3% (arm B) and 42.7% (arm C) in the intention-to-treat analysis. The treatment difference between arm B–arm A was -1.8% (95% confidence intervals -10.1, 6.5) and for arm C–arm A was -4.5% (95% confidence intervals -12.7, 3.7) in the intention-to-treat analysis. These differences fell within the maximum allowable difference (±12%) for arm B compared with arm A. At week 24, the percentage of patients with HIV-1 RNA levels <400 copies/ml was 59.6% (arm A), 57.6% (arm B) and 51.3% (arm C). Conclusions A twice-daily triple therapy regimen incorporating saquinavir SGC plus two NRTIs was of equivalent efficacy to the three-times daily regimen studied. All regimens were generally well tolerated.
Collapse
Affiliation(s)
- L Joseph Wheat
- Indiana University School of Medicine, Indianapolis, Ind., USA
| | - Charles Farthing
- AIDS HealthCare Foundation Research Center, Los Angeles, Calif., USA
| | - Calvin Cohen
- Community Research Initiative, Brookline, Mass., USA
| | - Gerald Pierone
- Treasure Coast Infectious Disease Specialists, Vero Beach, Fla., USA
| | - Jay Lalezari
- Quest Clinical Research, San Francisco, Calif., USA
| | | | | | | | - Victor Beer
- Beer Medical Group, Los Angeles, Calif., USA
| | | | - Jack Bissett
- Austin Infectious Disease Consultants, Austin, Tex., USA
| | | | - Carol Brosgart
- Alta Bates Medical Ctr, East Bay AIDS Center, Berkeley, Calif., USA
| | | | | | - Joe Cervia
- NY Hospital/Cornell Medical Center, New York, NY, USA
| | - Sarah Cheeseman
- University of Massachusetts Medical Center, Worcester, Mass., USA
| | - Paul Cimoch
- Orange County Center for Special Immunology, Fountain Valley, Calif., USA
| | - Calvin Cohen
- Community Research Initiative, Brookline, Mass., USA
| | - Edwin DeJesus
- IDC Research Initiative, Altamonte Springs, Fla., USA
| | - Leslie Diaz
- Stratogen Health of Palm Beach, Jupiter, Fla., USA
| | | | - Jay Dobkin
- Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Robin Dretler
- Infectious Disease Specialists of Atlanta, Decauter, Ga., USA
| | | | - Robert Eng
- VA New Jersey Health Care System III-ID, East Orange, NJ, USA
| | - Charles Farthing
- AIDS Healthcare Foundation Research Center, Los Angeles, Calif., USA
| | - Judith Feinberg
- University of Cincinnati Medical Center, AIDS Treatment Center, Cincinnati, OH, USA
| | | | - Jeffrey Fessel
- Kaiser Permanente Medical Center, HIV Research Unit, San Francisco, Calif., USA
| | - Douglas Fish
- Albany Medical College, Division of HIV Medicine, Albany, NY, USA
| | - Jeffrey Galpin
- Shared Medical Research Foundation, Sherman Oaks Hospital, Sherman Oaks, Calif., USA
| | | | - Ian Gilson
- Aurora Medical Group, Milwaukee, Wis., USA
| | - Marla Gold
- MCH Hahnermann University, Partnership Comprehensive Care Practice, Philadelphia, Pa., USA
| | | | | | | | | | | | - Ron Grossman
- Anderson Clinical Research, Inc., New York, NY, USA
| | | | - Bruce Hathaway
- ECU School of Medicine, Section of Infectious Diseases, Greenville, NC, USA
| | | | - Susan Jacobson
- Alta Bates Medical Center, East Bay AIDS Center, Berkeley, Calif., USA
| | | | | | - Mark Kaplan
- North Shore University Hospital, Center for AIDS Research, Manhasset, NY, USA
| | | | | | | | | | - Rodger MacArthur
- Wayne State University/Detroit Medical Center, Detroit, Mich., USA
| | | | - Bryan Marsh
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Usha Mathur-Wagh
- Peter Krueger Clinic/Beth Israel Medical Center, New York, NY, USA
| | | | - Peter Miao
- Sherman Oaks Hospital Research Institute, Sherman Oaks, Calif., USA
| | - Miguel Mogyoros
- Kaiser Permanente, Department of Infectious Diseases, Denver, Col., USA
| | | | | | - Jeffrey Nadler
- Hillsborough County Health Department of Health, Tampa, Fla., USA
| | | | - Brian Onbirbak
- HIV Wellness Center/University Medical Center, Las Vegas, Nev., USA
| | | | | | | | - Ronald Poblete
- New Jersey Community Research Initiative, Newark, NJ, USA
| | | | | | | | | | - Michael Sands
- Boulevard Comprehensive Care Center, Jacksonville, Fla., USA
| | | | - Michael Sension
- Urgent Care Center, North Broward Hospital District, Fort Lauderdale, Fla., USA
| | - Gail Skowron
- Roger Williams Medical Division of Infectious Disease, Providence, RI, USA
| | - Leonard Slater
- Oklahoma University Health Science Center, Oklahoma City, Okla., USA
| | - David Smith
- Research Medical Center/Antibiotic Research Assoc., Kansas City, Mont., USA
| | - Joseph Stavola
- NY Hospital/Cornell Medical Center, Department of Pediatrics, New York, NY, USA
| | | | | | | | | | - Fred T Valentine
- AIDS Clinical Trials Unit, NYU Medical Center, New York, NY, USA
| | - Kelly Vollmer
- Arizona Clinical Research Center Inc., Tucson, Ariz., USA
| | - Suzanne Wada
- University of Texas Southwestern Medical Center, Dallas, Tex., USA
| | - Douglas Ward
- Dupont Circle Physicians Group, Washington, DC, USA
| | - L Joseph Wheat
- Indiana University School of Medicine, Indianapolis, Ind., USA
| | | | - Peter Carey
- Royal Liverpool University Hospital, Liverpool, UK
| | - Helmut Jablonowski
- Medizinische Einrichtungen der Heinrich Heine Univ, Duesseldoft, Germany
| | - Albert Theisen
- Medizinische Einrichtungen der Heinrich Heine Univ, Duesseldorf, Germany
| | | | - Inma Ocana
- Vall d'Hebron Hospital, Barcelona, Spain
| | | |
Collapse
|
28
|
|
29
|
|