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Eshleman SH, Fogel JM, Piwowar-Manning E, Chau G, Cummings V, Agyei Y, Richardson P, Sullivan P, Haines CD, Bushman LR, Petropoulos C, Persaud D, Kofron R, Hendrix CW, Anderson PL, Farrior J, Mellors J, Adeyeye A, Rinehart A, St Clair M, Ford S, Rooney JF, Mathew CA, Hunidzarira P, Spooner E, Mpendo J, Nair G, Cohen MS, Hughes JP, Hosseinipour M, Hanscom B, Delany-Moretlwe S, Marzinke MA. Characterization of Human Immunodeficiency Virus (HIV) Infections in Women Who Received Injectable Cabotegravir or Tenofovir Disoproxil Fumarate/Emtricitabine for HIV Prevention: HPTN 084. J Infect Dis 2022; 225:1741-1749. [PMID: 35301540 PMCID: PMC9113509 DOI: 10.1093/infdis/jiab576] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/20/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND HIV Prevention Trials Network 084 demonstrated that long-acting injectable cabotegravir (CAB) was superior to daily oral tenofovir (TFV) disoproxil fumarate (TDF)/emtricitabine (FTC) for preventing human immunodeficiency virus (HIV) infection in sub-Saharan African women. This report describes HIV infections that occurred in the trial before unblinding. METHODS Testing was performed using HIV diagnostic assays, viral load testing, a single-copy RNA assay, and HIV genotyping. Plasma CAB, plasma TFV, and intraerythrocytic TFV-diphosphate concentrations were determined by liquid chromatography-tandem mass spectrometry. RESULTS Forty HIV infections were identified (CAB arm, 1 baseline infection, 3 incident infections; TDF/FTC arm, 36 incident infections). The incident infections in the CAB arm included 2 with no recent drug exposure and no CAB injections and 1 with delayed injections; in 35 of 36 cases in the TDF/FTC arm, drug concentrations indicated low or no adherence. None of the cases had CAB resistance. Nine women in the TDF/FTC arm had nonnucleoside reverse-transcriptase inhibitor resistance; 1 had the nucleoside reverse-transcriptase inhibitor resistance mutation, M184V. CONCLUSIONS Almost all incident HIV infections occurred in the setting of unquantifiable or low drug concentrations. CAB resistance was not detected. Transmitted nonnucleoside reverse-transcriptase inhibitor resistance was common; 1 woman may have acquired nucleoside reverse-transcriptase inhibitor resistance from study drug exposure.
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Affiliation(s)
- Susan H Eshleman
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica M Fogel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Estelle Piwowar-Manning
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gordon Chau
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Vanessa Cummings
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yaw Agyei
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul Richardson
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Philip Sullivan
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Casey D Haines
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lane R Bushman
- Department of Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | | | - Deborah Persaud
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryan Kofron
- Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Craig W Hendrix
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter L Anderson
- Department of Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | | | - John Mellors
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adeola Adeyeye
- Prevention Science Program, Division of Acquired Immunodeficiency Syndrome, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, USA
| | - Alex Rinehart
- ViiV Healthcare, Research Triangle Park, North Carolina, USA
| | - Marty St Clair
- ViiV Healthcare, Research Triangle Park, North Carolina, USA
| | - Susan Ford
- GlaxoSmithKline, Research Triangle Park, North Carolina, USA
| | | | | | - Portia Hunidzarira
- University of Zimbabwe Clinical Trials Research Centre, Harare, Zimbabwe
| | - Elizabeth Spooner
- HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa
| | | | - Gonasagrie Nair
- Center for Medical Ethics and Law, Stellenbosch University, Stellenbosch, South Africa
| | - Myron S Cohen
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - James P Hughes
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Mina Hosseinipour
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brett Hanscom
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | - Mark A Marzinke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Delany-Moretlwe S, Hughes JP, Bock P, Ouma SG, Hunidzarira P, Kalonji D, Kayange N, Makhema J, Mandima P, Mathew C, Spooner E, Mpendo J, Mukwekwerere P, Mgodi N, Ntege PN, Nair G, Nakabiito C, Nuwagaba-Biribonwoha H, Panchia R, Singh N, Siziba B, Farrior J, Rose S, Anderson PL, Eshleman SH, Marzinke MA, Hendrix CW, Beigel-Orme S, Hosek S, Tolley E, Sista N, Adeyeye A, Rooney JF, Rinehart A, Spreen WR, Smith K, Hanscom B, Cohen MS, Hosseinipour MC. Cabotegravir for the prevention of HIV-1 in women: results from HPTN 084, a phase 3, randomised clinical trial. Lancet 2022; 399:1779-1789. [PMID: 35378077 PMCID: PMC9077443 DOI: 10.1016/s0140-6736(22)00538-4] [Citation(s) in RCA: 154] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/12/2022] [Accepted: 03/14/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Oral pre-exposure prophylaxis has been introduced in more than 70 countries, including many in sub-Saharan Africa, but women experience considerable barriers to daily pill-taking, such as stigma, judgement, and the fear of violence. Safe and effective long-acting agents for HIV prevention are needed for women. We aimed to evaluate the safety and efficacy of injectable cabotegravir compared with daily oral tenofovir diphosphate plus emtricitabine (TDF-FTC) for HIV prevention in HIV-uninfected women. METHODS HPTN 084 was a phase 3, randomised, double-blind, double-dummy, active-controlled, superiority trial in 20 clinical research sites in seven countries in sub-Saharan Africa. Participants were eligible for enrolment if they were assigned female sex at birth, were aged 18-45 years, reported at least two episodes of vaginal intercourse in the previous 30 days, were at risk of HIV infection based on an HIV risk score, and agreed to use a long-acting reversible contraceptive method. Participants were randomly assigned (1:1) to either active cabotegravir with TDF-FTC placebo (cabotegravir group) or active TDF-FTC with cabotegravir placebo (TDF-FTC group). Study staff and participants were masked to study group allocation, with the exception of the site pharmacist who was responsible for study product preparation. Participants were prescribed 5 weeks of daily oral product followed by intramuscular injections every 8 weeks after an initial 4-week interval load, alongside daily oral pills. Participants who discontinued injections were offered open-label daily TDF-FTC for 48 weeks. The primary endpoints of the study were incident HIV infection in the intention-to-treat population, and clinical and laboratory events that were grade 2 or higher in all women who had received at least one dose of study product. This study is registered with ClinicalTrials.gov, NCT03164564. FINDINGS From Nov 27, 2017, to Nov 4, 2020, we enrolled 3224 participants (1614 in the cabotegravir group and 1610 in the TDF-FTC group). Median age was 25 years (IQR 22-30); 1755 (54·7%) of 3209 had two or more partners in the preceding month. 40 incident infections were observed over 3898 person-years (HIV incidence 1·0% [95% CI 0·73-1·40]); four in the cabotegravir group (HIV incidence 0·2 cases per 100 person-years [0·06-0·52]) and 36 in the TDF-FTC group (1·85 cases per 100 person-years [1·3-2·57]; hazard ratio 0·12 [0·05-0·31]; p<0·0001; risk difference -1·6% [-1·0% to -2·3%]. In a random subset of 405 TDF-FTC participants, 812 (42·1%) of 1929 plasma samples had tenofovir concentrations consistent with daily use. Injection coverage was 93% of the total number of person-years. Adverse event rates were similar across both groups, apart from injection site reactions, which were more frequent in the cabotegravir group than in the TDF-FTC group (577 [38·0%] of 1519 vs 162 [10·7%] of 1516]) but did not result in injection discontinuation. Confirmed pregnancy incidence was 1·3 per 100 person-years (0·9-1·7); no congenital birth anomalies were reported. INTERPRETATION Although both products for HIV prevention were generally safe, well tolerated, and effective, cabotegravir was superior to TDF-FTC in preventing HIV infection in women. FUNDING National Institute of Allergy and Infectious Diseases, ViiV Healthcare, and the Bill & Melinda Gates Foundation. Additional support was provided through the National Institute of Mental Health, the National Institute on Drug Abuse, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. ViiV Healthcare and Gilead Sciences provided pharmaceutical support.
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Affiliation(s)
- Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa.
| | - James P Hughes
- Statistical Centre for HIV/AIDS Research and Prevention, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Peter Bock
- Desmond Tutu TB Centre, University of Stellenbosch, Stellenbosch, South Africa
| | - Samuel Gurrion Ouma
- Kisumu Clinical Research Site, Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Portia Hunidzarira
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Dishiki Kalonji
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Noel Kayange
- Blantyre Clinical Research Site, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Joseph Makhema
- Botswana Harvard AIDS Institute Partnership (BHP), Gaborone, Botswana
| | - Patricia Mandima
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Carrie Mathew
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Elizabeth Spooner
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Juliet Mpendo
- International AIDS Vaccine Initiative, Uganda Virus Research Institute, Entebbe, Uganda
| | | | - Nyaradzo Mgodi
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | | | - Gonasagrie Nair
- Desmond Tutu Health Foundation, University of Cape Town, Cape Town, South Africa
| | - Clemensia Nakabiito
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Harriet Nuwagaba-Biribonwoha
- Eswatini Prevention Center, International Center for AIDS Care and Treatment Program at Columbia University Mailman School of Public Health, New York, NY, USA
| | - Ravindre Panchia
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Nishanta Singh
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Bekezela Siziba
- Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | | | | | - Peter L Anderson
- Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Susan H Eshleman
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark A Marzinke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Craig W Hendrix
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephanie Beigel-Orme
- Statistical Centre for HIV/AIDS Research and Prevention, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Sybil Hosek
- Department of Psychiatry, Stroger Hospital of Cook County, Chicago, IL, USA
| | | | | | - Adeola Adeyeye
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
| | | | | | | | | | - Brett Hanscom
- Statistical Centre for HIV/AIDS Research and Prevention, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Myron S Cohen
- University of North Carolina (UNC) at Chapel Hill, Chapel Hill, NC, USA
| | - Mina C Hosseinipour
- University of North Carolina (UNC) at Chapel Hill, Chapel Hill, NC, USA; UNC Project-Malawi, Lilongwe, Malawi
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Cohen MS, Nirula A, Mulligan MJ, Novak RM, Marovich M, Yen C, Stemer A, Mayer SM, Wohl D, Brengle B, Montague BT, Frank I, McCulloh RJ, Fichtenbaum CJ, Lipson B, Gabra N, Ramirez JA, Thai C, Chege W, Gomez Lorenzo MM, Sista N, Farrior J, Clement ME, Brown ER, Custer KL, Van Naarden J, Adams AC, Schade AE, Dabora MC, Knorr J, Price KL, Sabo J, Tuttle JL, Klekotka P, Shen L, Skovronsky DM. Effect of Bamlanivimab vs Placebo on Incidence of COVID-19 Among Residents and Staff of Skilled Nursing and Assisted Living Facilities: A Randomized Clinical Trial. JAMA 2021; 326:46-55. [PMID: 34081073 PMCID: PMC8176388 DOI: 10.1001/jama.2021.8828] [Citation(s) in RCA: 134] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Preventive interventions are needed to protect residents and staff of skilled nursing and assisted living facilities from COVID-19 during outbreaks in their facilities. Bamlanivimab, a neutralizing monoclonal antibody against SARS-CoV-2, may confer rapid protection from SARS-CoV-2 infection and COVID-19. OBJECTIVE To determine the effect of bamlanivimab on the incidence of COVID-19 among residents and staff of skilled nursing and assisted living facilities. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, single-dose, phase 3 trial that enrolled residents and staff of 74 skilled nursing and assisted living facilities in the United States with at least 1 confirmed SARS-CoV-2 index case. A total of 1175 participants enrolled in the study from August 2 to November 20, 2020. Database lock was triggered on January 13, 2021, when all participants reached study day 57. INTERVENTIONS Participants were randomized to receive a single intravenous infusion of bamlanivimab, 4200 mg (n = 588), or placebo (n = 587). MAIN OUTCOMES AND MEASURES The primary outcome was incidence of COVID-19, defined as the detection of SARS-CoV-2 by reverse transcriptase-polymerase chain reaction and mild or worse disease severity within 21 days of detection, within 8 weeks of randomization. Key secondary outcomes included incidence of moderate or worse COVID-19 severity and incidence of SARS-CoV-2 infection. RESULTS The prevention population comprised a total of 966 participants (666 staff and 300 residents) who were negative at baseline for SARS-CoV-2 infection and serology (mean age, 53.0 [range, 18-104] years; 722 [74.7%] women). Bamlanivimab significantly reduced the incidence of COVID-19 in the prevention population compared with placebo (8.5% vs 15.2%; odds ratio, 0.43 [95% CI, 0.28-0.68]; P < .001; absolute risk difference, -6.6 [95% CI, -10.7 to -2.6] percentage points). Five deaths attributed to COVID-19 were reported by day 57; all occurred in the placebo group. Among 1175 participants who received study product (safety population), the rate of participants with adverse events was 20.1% in the bamlanivimab group and 18.9% in the placebo group. The most common adverse events were urinary tract infection (reported by 12 participants [2%] who received bamlanivimab and 14 [2.4%] who received placebo) and hypertension (reported by 7 participants [1.2%] who received bamlanivimab and 10 [1.7%] who received placebo). CONCLUSIONS AND RELEVANCE Among residents and staff in skilled nursing and assisted living facilities, treatment during August-November 2020 with bamlanivimab monotherapy reduced the incidence of COVID-19 infection. Further research is needed to assess preventive efficacy with current patterns of viral strains with combination monoclonal antibody therapy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04497987.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/immunology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Neutralizing/therapeutic use
- Antiviral Agents/adverse effects
- Antiviral Agents/immunology
- Antiviral Agents/therapeutic use
- Assisted Living Facilities
- COVID-19/epidemiology
- COVID-19/prevention & control
- Double-Blind Method
- Drug Approval
- Female
- Health Personnel
- Humans
- Immunization, Passive
- Incidence
- Infusions, Intravenous
- Male
- Middle Aged
- SARS-CoV-2/isolation & purification
- Severity of Illness Index
- Skilled Nursing Facilities
- Young Adult
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Affiliation(s)
- Myron S. Cohen
- Institute of Global Health and Infectious Diseases, University of North Carolina at Chapel Hill
| | | | - Mark J. Mulligan
- New York University Langone Vaccine Center, Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York
| | | | - Mary Marovich
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| | - Catherine Yen
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| | | | | | - David Wohl
- Institute of Global Health and Infectious Diseases, University of North Carolina at Chapel Hill
| | | | - Brian T. Montague
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora
| | - Ian Frank
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | | | | | - Brad Lipson
- Florida Primary and Specialty Care, Boca Raton
| | - Nashwa Gabra
- Burke Internal Medicine & Research, Burke, Virginia
| | - Julio A. Ramirez
- Division of Infectious Diseases, University of Louisville School of Medicine, Louisville, Kentucky
| | | | - Wairimu Chege
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| | - Margarita M. Gomez Lorenzo
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| | | | | | | | - Elizabeth R. Brown
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | | | | | | | | | | | | | | | | | - Lei Shen
- Eli Lilly and Co, Indianapolis, Indiana
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Seneviratne HK, Tillotson J, Lade JM, Bekker LG, Li S, Pathak S, Justman J, Mgodi N, Swaminathan S, Sista N, Farrior J, Richardson P, Hendrix CW, Bumpus NN. Metabolism of Long-Acting Rilpivirine After Intramuscular Injection: HIV Prevention Trials Network Study 076 (HPTN 076). AIDS Res Hum Retroviruses 2021; 37:173-183. [PMID: 33191765 DOI: 10.1089/aid.2020.0155] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A long-acting injectable formulation of rilpivirine (RPV), a non-nucleoside reverse transcriptase inhibitor, is currently under investigation for use in human immunodeficiency virus (HIV) maintenance therapy. We previously characterized RPV metabolism after oral dosing and identified seven metabolites: four metabolites resulting from mono- or dioxygenation of the 2,6-dimethylphenyl ring itself or either of the two methyl groups located on that ring, one N-linked RPV glucuronide conjugate, and two O-linked RPV glucuronides produced via glucuronidation of mono- and dihydroxymethyl metabolites. However, as is true for most drugs, the metabolism of RPV after injection has yet to be reported. The phase II clinical trial HPTN 076 enrolled 136 HIV-uninfected women and investigated the safety and acceptability of long-acting injectable RPV for use in HIV pre-exposure prophylaxis. Through the analysis of plasma samples from 80 of these participants in the active product arm of the study, we were able to detect 2 metabolites after intramuscular injection of long-acting RPV, 2-hydroxymethyl-RPV, and RPV N-glucuronide. Of the total of 80 individuals, 72 participants exhibited detectable levels of 2-hydroxymethyl-RPV in plasma samples whereas RPV N-glucuronide was detectable in plasma samples of 78 participants. In addition, RPV N-glucuronide was detectable in rectal fluid, cervicovaginal fluid, and vaginal tissue. To investigate potential genetic variation in genes encoding enzymes relevant to RPV metabolism, we isolated genomic DNA and performed next-generation sequencing of CYP3A4, CYP3A5, UGT1A1 and UGT1A4. From these analyses, four missense variants were detected for CYP3A4 whereas one missense variant and one frameshift variant were detected for CYP3A5. A total of eight missense variants of UGT1A4 were detected, whereas two variants were detected for UGT1A1; however, these variants did not appear to account for the observed interindividual variability in metabolite levels. These findings provide insight into the metabolism of long-acting RPV and contribute to an overall understanding of metabolism after oral dosing versus injection. ClinicalTrials.gov Identifier: NCT02165202.
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Affiliation(s)
- Herana Kamal Seneviratne
- Division of Clinical Pharmacology, Department of Medicine, the Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph Tillotson
- Division of Clinical Pharmacology, Department of Medicine, the Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Julie M. Lade
- Department of Pharmacology and Molecular Sciences, the Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Sue Li
- Statistical Center for HIV/AIDS Research & Prevention (SCHARP), Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Subash Pathak
- Statistical Center for HIV/AIDS Research & Prevention (SCHARP), Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Jessica Justman
- ICAP at Columbia, Mailman School of Public Health, and Division of Infectious Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Nyaradzo Mgodi
- University of Zimbabwe–University of California, San Francisco (UZ-UCSF) Collaborative Research Programme, Harare, Zimbabwe
| | - Shobha Swaminathan
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | | | | | - Paul Richardson
- Department of Pathology, the Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Craig W. Hendrix
- Division of Clinical Pharmacology, Department of Medicine, the Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Namandje N. Bumpus
- Division of Clinical Pharmacology, Department of Medicine, the Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pharmacology and Molecular Sciences, the Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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5
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Bekker L, Li S, Pathak S, Tolley E, Marzinke M, Justman J, Mgodi N, Chirenje M, Swaminathan S, Adeyeye A, Farrior J, Hendrix C, Piwowar-Manning E, Richardson P, Eshelman S, Redinger H, Williams P, Sista N. Safety and tolerability of injectable Rilpivirine LA in HPTN 076: A phase 2 HIV pre-exposure prophylaxis study in women. EClinicalMedicine 2020; 21:100303. [PMID: 32280940 PMCID: PMC7139112 DOI: 10.1016/j.eclinm.2020.100303] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 02/18/2020] [Accepted: 02/18/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Daily oral TDF/FTC is protective against HIV infection when used for pre-exposure prophylaxis (PrEP). However, daily adherence to oral PrEP is difficult for many; therefore, finding alternative PrEP strategies remains a priority. HPTN 076 evaluated the long-acting injectable form of rilpivirine (RPV), known as RPV LA for safety, pharmacokinetics and acceptability. METHODS HPTN 076 (NTC 02165202) was a phase 2, double-blind, 2:1 randomized trial comparing the safety of 1200mg RPV LA (LA) to placebo (P). The study included a 28-day oral run-in phase of daily, self- administered oral RPV (25 mg), with directly observed oral dosing about six times. Of 136 enrolled sexually active, HIV-uninfected, low HIV-risk African (100) and US (36) adult women, injectable product was administered in two gluteal, intramuscular (IM) injections once every eight weeks to 122 participants following the oral run-in phase. A maximum of six injection time points occurred over a 48-week period. Acceptability, safety, tolerability and pharmacokinetic (PK) data were collected throughout the study. This paper includes primary endpoint data collected up to the week 52 post enrollment. FINDINGS The median age of the enrolled population was 31 years (IQR: 25,38), median weight 75 kg (IQR: 64, 89), median body mass index (BMI) 30 (IQR: 27, 35), 46% married, 94% Black and 60% unemployed. A total of 122 (80 LA, 42 P) women received at least one injection and 98 (64 LA, 34 P) received all six injections. During the injection phase, three women withdrew from the study (2 LA, 1 P) and 16 women discontinued study product (10 LA, 6 P). Fourteen women (11 LA and 3 P) discontinued oral study product and did not enter the injection phase. Study product discontinuations were not significantly different between the two arms throughout. Of the product discontinuations in the injection phase, 8% in LA and 5% in P arm were due to adverse events (AEs), including one randomized to the P arm with prolonged QTc interval on EKG. The proportion of women who experienced Grade 2 or higher AEs during the injection phase as the primary outcome was not significantly different between the two arms [73.8%, 95% CI: (63.2%, 82.1%) for LA and 73.8%, 95% CI: (58.9%, 84.7%), p>0.99]. Transient Grade ≥2 liver abnormalities occurred in 14% of women in the LA arm compared with 12% in P arm. Three LA women (4%) developed Grade 3 injection site reactions compared with none in P arm. In participants who received at least 1 injection, the geometric mean of overall RPV trough concentrations (Ctrough) was 62.2 ng/mL. In participants who received all six injections, the geometric mean of CTrough through the injection phase and after the last injection were 72.8 ng/mL and 100.9 ng/mL, respectively. At week 52 (eight weeks after last injection), the geometric mean of RPV Ctrough was 75.0 ng/mL. At the last injection visit (Week 44), 80 % of women who answered acceptability questions strongly agreed that they would think about using- and 68% that they would definitely use a PrEP injectable in the future. INTERPRETATION RPV LA IM injections every eight weeks in African and US women were safe and acceptable. Overall, despite more injection site reactions and pain in the participants receiving RPV LA the injections were well tolerated. Data from this study support the further development of injectable PrEP agents.
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Affiliation(s)
- L.G. Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, South Africa
| | - S. Li
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - S. Pathak
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | | | - N.M. Mgodi
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | - M. Chirenje
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre, Harare, Zimbabwe
| | | | | | | | | | | | | | | | - H. Redinger
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - P. Williams
- Johnson and Johnson Global Public Health, Belgium
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Tolley EE, Li S, Zangeneh SZ, Atujuna M, Musara P, Justman J, Pathak S, Bekker L, Swaminathan S, Stanton J, Farrior J, Sista N. Acceptability of a long-acting injectable HIV prevention product among US and African women: findings from a phase 2 clinical Trial (HPTN 076). J Int AIDS Soc 2019; 22:e25408. [PMID: 31651098 PMCID: PMC6813716 DOI: 10.1002/jia2.25408] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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: 04/18/2019] [Accepted: 10/02/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION High HIV incidence and low adherence to daily oral PrEP among women underscore the need for more acceptable and easier to use HIV prevention products. Global demand for injectable contraception suggests that new, long-acting, injectable formulations could meet this need. We examine acceptability of a long-acting injectable PrEP among HIV-uninfected women in Zimbabwe, South Africa and two United States phase 2 trial sites. METHODS Quantitative surveys were administered at the first, fourth and sixth injection visits. Focus group discussions (FGD) were conducted after the sixth injection visit. We compared the acceptability of injectable product attributes, prevention preferences and future interest in injectable PrEP by site and arm and ran longitudinal ordinal logistic regression models to identify determinants of future interest in injectable PrEP. RESULTS Between April 2015 and February 2017, the trial enrolled 136 (100 African, 36 US) women with a median age of 31 years. Most participants (>75%) rated injectable attributes as very acceptable. While few reported rash or other side effects, 56% to 67% reported injection pain, with nonsignificant differences over time and between arms. During FGDs, participants described initial fear of the injectable and variable experiences with pain. Most US and African participants preferred injectable PrEP to daily oral pills (56% to 96% vs. 4% to 25%). Future interest in using injectable PrEP was associated with acceptability of product attributes and was higher in African than US sites. In FGDs, participants described multiple reasons for trial participation, including a combination of monetary, health-related and altruistic motivations. While associated with future interest in use in univariate models, neither altruistic nor personal motivations remained significant in the multivariate model. CONCLUSIONS This study found that long-acting injectable PrEP is acceptable among African and US women experiencing product use. Acceptability of product attributes better predicted future interest in injectable use than experience of pain. This is reassuring as a single-dose regimen of a different product has advanced to phase 3 trials. Finally, the study suggests that future demand for an injectable PrEP by women may be greater in African than US settings, where the risk of HIV is highest.
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Affiliation(s)
| | - Sue Li
- Vaccine and Infectious Disease DivisionFred HutchSeattleWAUSA
| | | | | | | | | | - Subash Pathak
- Vaccine and Infectious Disease DivisionFred HutchSeattleWAUSA
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7
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McKinstry LA, Zerbe A, Hanscom B, Farrior J, Kurth AE, Stanton J, Li M, Elion R, Leider J, Branson B, El-Sadr WM. A Randomized-Controlled Trial of Computer-based Prevention Counseling for HIV-Positive Persons (HPTN 065). ACTA ACUST UNITED AC 2017; 8. [PMID: 28966842 PMCID: PMC5619875 DOI: 10.4172/2155-6113.1000714] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Decreasing the risk of HIV transmission from HIV-positive individuals is an important public health priority. We evaluated the effectiveness of a computer-based sexual risk reduction counseling intervention (CARE+) among HIV-positive persons enrolled in care. METHODS HIV-positive eligible participants (N=1075) were enrolled from 11 care sites in the Bronx, NY and Washington, DC and randomized 1:1 to either a tablet-based self-administered CARE+ intervention or standard of care (SOC). The primary outcome was the proportion of participants reporting any unprotected vaginal/anal sex at last sex, among all partners, HIV-negative or HIV-unknown-status partners and for primary and non-primary partners. RESULTS At baseline, 7% of participants in both arms reported unprotected sex with an HIV-negative or HIV-unknown-status partner, while 13% in the CARE+ arm and 17% in the SOC arm reported unprotected sex with any partner. Most participants (88%) were on antiretroviral therapy (ART) at baseline. There was no significant difference in changes over time in unprotected vaginal/anal sex between the CARE+ and SOC arms for any partners (p=0.67) or either HIV-negative or HIV-unknown-status partners (p=0.40). At the Month 12 visit, most participants (85%) either strongly agreed or agreed that computer counseling would be a good addition to in-person counseling by a provider. CONCLUSION The CARE+ intervention was not effective at reducing sexual risk behaviors among HIV-positive patients in care, most of whom were on ART. Further research may be warranted around the utility of computer-based counseling for HIV prevention.
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Affiliation(s)
- Laura A McKinstry
- Statistical Center for AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Allison Zerbe
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, USA
| | - Brett Hanscom
- Statistical Center for AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, USA
| | | | | | | | - Maoji Li
- Statistical Center for AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Rick Elion
- District of Columbia District of Health STD/HIV Research Program, Washington, USA
| | - Jason Leider
- North Bronx Health Care Network, New York, NY, USA
| | | | - Wafaa M El-Sadr
- ICAP at Columbia University, Mailman School of Public Health, New York, NY, USA
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8
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Buchacz K, Farrior J, Beauchamp G, McKinstry L, Kurth AE, Zingman BS, Gordin FM, Donnell D, Mayer KH, El-Sadr WM, Branson B. Changing Clinician Practices and Attitudes Regarding the Use of Antiretroviral Therapy for HIV Treatment and Prevention. J Int Assoc Provid AIDS Care 2016; 16:81-90. [PMID: 27708115 DOI: 10.1177/2325957416671410] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
As part of the HPTN 065 study in the Bronx, New York and Washington, the authors, we surveyed clinicians to assess for shifts in their practices and attitudes around HIV treatment and prevention. Antiretroviral therapy (ART)-prescribing clinicians at 39 HIV care sites were offered an anonymous Web-based survey at baseline (2010-2011) and at follow-up (2013). The 165 respondents at baseline and 141 respondents at follow-up had similar characteristics-almost 60% were female, median age was 47 years, two-thirds were physicians, and nearly 80% were HIV specialists. The percentage who reported recommending ART irrespective of CD4 count was higher at follow-up (15% versus 68%), as was the percentage who would initiate ART earlier for patients having unprotected sex with partners of unknown HIV status (64% versus 82%), and for those in HIV-discordant partnerships (75% versus 87%). In line with changing HIV treatment guidelines during 2010 to 2013, clinicians increasingly supported early ART for treatment and prevention.
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Affiliation(s)
- Kate Buchacz
- 1 Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Geetha Beauchamp
- 3 Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Laura McKinstry
- 3 Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Ann E Kurth
- 4 Yale University School of Nursing, New Haven, CT, USA
| | - Barry S Zingman
- 5 Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Fred M Gordin
- 6 Veterans Affairs Medical Center, George Washington University, Washington DC, USA
| | - Deborah Donnell
- 3 Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Kenneth H Mayer
- 7 Fenway Health, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Wafaa M El-Sadr
- 8 ICAP at Columbia University, Mailman School of Public Health, Columbia University and Harlem Hospital, New York, NY, USA
| | - Bernard Branson
- 1 Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA
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Gamble T, Corcoran P, Stanton J, Watkins P, Greene E, Farrior J, Elion R, Amenichi-Enahoro S, El-Sadr W. Geographic Utilization of Gift Cards Used for Financial Incentives to Encourage Viral Suppression: Findings from HPTN 065. AIDS Res Hum Retroviruses 2014. [DOI: 10.1089/aid.2014.5649.abstract] [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: 11/12/2022] Open
Affiliation(s)
| | - Padraig Corcoran
- Massachusetts Institute of Technology, Cambridge, MA, United States
| | | | | | | | | | - Richard Elion
- Whitman-Walker Health, Washington, DC, United States
| | | | - Wafaa El-Sadr
- Columbia University Mailman School of Public Health, ICAP, New York, NY, United States
- Harlem Hospital, New York, NY, United States
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Abstract
With the decline in primary cases of otosclerosis surgery, revision stapes operations are becoming a higher percentage of otosclerosis practice. Are the results from revision stapes surgery today comparable with those of surgeons trained prior to the present decline? A retrospective review of 559 consecutive stapes operations performed by the author revealed 109 revision operations. A retrospective review of these cases reveals that the most common cause for revision surgery was displaced prostheses and incus necrosis. The hearing results are dependent on the surgical pathology. In this series, the airborne gap was closed to less than 10 dB in 58% of cases, there were 64% of cases of displaced prostheses, and 57% of cases of incus necrosis, which is comparable with previously reported studies.
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Abstract
The complications of otitis media are frequently not considered in discussions of the medical or surgical management of this disease. Retrospective review of 135 cases in children treated surgically in an otologic referral practice between 1981 and 1989 revealed that perforation of the eardrum (57 cases) was the most common complication of otitis media, followed by cholesteatoma (54), mastoiditis (16), and atelectasis of the eardrum (eight). Coalescent mastoiditis was most common in children less than 6 years of age, whereas cholesteatoma and ossicular chain destruction occurred more frequently with increasing age. The presenting signs and symptoms of the complications and their management are presented to help alert the practitioner to the potentially severe complications of otitis media.
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Farrior J. Cholesteatoma of the external ear canal. Am J Otol 1990; 11:113-6. [PMID: 2181879] [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: 12/30/2022]
Abstract
Cholesteatoma arising in the external ear canal is uncommon. A variety of etiologic factors have been attributed to the development of cholesteatoma in the external ear canal. The various disease processes that cause excessive desquamation and cholesteatoma formation are reviewed and their management is presented.
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Abstract
Osteomyelitis of the temporal bone often begins with minor trauma and results in a persistent external otitis. I report my experience with ten patients managed with combined medical and surgical therapy, and discuss the progression of the disease process and how it affects the duration of antibiotic therapy and the indications for planned surgical debridement. Early recognition of osteomyelitis of the temporal bone, combined with the aggressive use of long-term antibiotic therapy, in addition to planned surgical debridement, will reduce morbidity and potential mortality.
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Abstract
The surgical management of glomus jugulare tumors involving the temporal bone and skull base is determined by the extent of the disease process. These highly vascular tumors also have the capability of producing vasoactive amines, which may complicate surgical management by causing widely fluctuating blood pressures. I present my experience in the evaluation and management of glomus tumors in 44 patients treated at the Farrior Clinic to alert physicians to the potential endocrine activity of tumors of the skull base.
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Abstract
With the four-sided point of the C-wire hand drill there is less risk of footplate mobilization during small fenestra stapedectomy. The small fenestra stapedectomy is thought to cause less trauma to the vestibule and to pose less risk of aspirating vestibular contents than the stapedectomy that totally removes the footplate.
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