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Leblanc JF, Custer B, Van de Laar T, Drews SJ, Germain M, Lewin A. HIV Pre-Exposure Prophylaxis, Blood Donor Deferral, Occult Infection, and Risk of HIV Transmission by Transfusion: A Fine Balance Between Evidence-Based Donor Selection Criteria and Transfusion Safety. Transfus Med Rev 2023; 37:150754. [PMID: 37741792 DOI: 10.1016/j.tmrv.2023.150754] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 09/25/2023]
Abstract
Pre- and postexposure prophylaxis for human immunodeficiency virus (HIV) are key to reducing the transmission of this virus. Furthermore, low-toxicity, long-acting formulations provide additional clinical benefits, in particular easier adherence to treatment and prevention. However, breakthrough HIV infections can occur despite the use of pre-exposure prophylaxis (PrEP), mainly due to suboptimal adherence or multi-drug resistant HIV strains. Albeit rare, PrEP breakthrough infections have also been reported in fully adherent patients. Should such breakthrough infection occur in an eligible blood donor, PrEP might suppress viremia and delay antibody seroconversion, thereby masking the infection and increasing the risk of transfusion transmission. This possibility has raised concerns in the blood transfusion community but remains little documented. Therefore, a literature search was performed to assess the state of knowledge on the risk of PrEP breakthrough infection, with a particular focus on the risk of HIV entering the blood supply. Evidently, PrEP breakthrough infections are rare, although the risk is not zero. Moreover, a fraction of individuals - including blood donors - do not disclose PrEP use according to various surveys and measurements of HIV PrEP analytes. Additionally, viremia and seroconversion may remain undetectable or close to the limit of detection for a long time after cessation of PrEP, particularly with long-acting antiretrovirals. Therefore, current recommendations to defer donors for at least 3 months after the last dose of oral PrEP or 2 years for long-acting PrEP appear justified, as they safeguard the blood supply and public trust toward the system. These recommendations help to safeguard blood safety and public trust in the blood supply.
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Affiliation(s)
| | - Brian Custer
- Vitalant Research Institute, San Francisco, CA, USA; Department of Laboratory Medicine, University of California, San Francisco, CA, USA
| | - Thijs Van de Laar
- Sanquin Research, Department of Donor Medicine Research, Amsterdam, The Netherlands; Onze Lieve Vrouwe Gasthuis, Laboratory of Medical Microbiology, Amsterdam, The Netherlands
| | - Steven J Drews
- Microbiology, Donation Policy and Studies, Canadian Blood Services, Edmonton, Alberta, Canada; Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Marc Germain
- Hema-Québec, Medical Affairs and Innovation, Montréal and Québec, Québec, Canada
| | - Antoine Lewin
- Hema-Québec, Medical Affairs and Innovation, Montréal and Québec, Québec, Canada; Université de Sherbrooke, Faculty of Medicine and Health Sciences, Sherbrooke, Québec, Canada.
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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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Thuo N, Polay M, Leddy AM, Ngure K, Chatterhee P, Gandhi M, Amico KR. Point-of-Care Test for Assessing Tenofovir Adherence: Feasibility and Recommendations from Women in an Oral PrEP Program in Kenya and Their Healthcare Providers. AIDS Behav 2021; 25:3617-3629. [PMID: 33893877 PMCID: PMC9271229 DOI: 10.1007/s10461-021-03255-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
Oral pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention modality when taken as recommended. Women in sub-Saharan Africa may have adherence challenges that remain undisclosed to providers. Real-time measures that identify non-adherence can allow for immediate exploration of adherence challenges, counseling and interventions. We conducted a formative qualitative study in Kenya to explore oral PrEP experiences and reactions to a point-of-care urine test (UT) identifying recent (past 4 days) non-adherence to tenofovir-based PrEP among female PrEP users (25 in-depth interviews; 4 focus groups) and health care provider (10 key informant interviews). Findings indicate that use of the UT would be highly feasible in the context of regular PrEP care, largely acceptable to clients and providers, and could improve adherence. Clients emphasized the need for transparent client-centered strategies in delivering results. This formative study informs the development of tools to implement this point-of-care UT in future interventional studies and clinical settings.
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Affiliation(s)
- Nicholas Thuo
- Centre for Clinical Research, Kenya Medical Research Institute, -PHRD, Thika Project, Nairobi, Kenya
| | - Madison Polay
- Health Behavior Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Anna M. Leddy
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, CA, USA
| | - Kenneth Ngure
- Centre for Clinical Research, Kenya Medical Research Institute, -PHRD, Thika Project, Nairobi, Kenya,Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Purba Chatterhee
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - K. Rivet Amico
- Health Behavior Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Perler BK, Reinhart EM, Montgomery M, Maynard M, Shapiro JM, Belenky P, Chan PA. Evaluation of the Microbiome in Men Taking Pre-exposure Prophylaxis for HIV Prevention. AIDS Behav 2021; 25:2005-2013. [PMID: 33394167 DOI: 10.1007/s10461-020-03130-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 01/04/2023]
Abstract
Tenofovir-based regimens as pre-exposure prophylaxis (PrEP) are highly effective at preventing HIV infection. The most common side-effect is gastrointestinal (GI) distress which may be associated with changes in the microbiome. Dysbiosis of the microbiome can have numerous health-related consequences. To understand the effect of PrEP on dysbiosis, we evaluated 27 individuals; 14 were taking PrEP for an average of 171 weeks. Sequencing of 16S rRNA was performed using self-collected rectal swabs. Mixed beta diversity testing demonstrated significant differences between PrEP and non-PrEP users with Bray-Curtis and unweighted UniFrac analyses (p = 0.05 and 0.049, respectively). At the genus level, there was a significant reduction in Finegoldia, along with a significant increase in Catenibacterium and Prevotella in PrEP users. Prevotella has been associated with inflammatory pathways, insulin resistance and cardiovascular disease, while Catenibacterium has been associated with morbid obesity and metabolic syndrome. Overall, these results suggest that PrEP may be associated with some degree of microbiome dysbiosis, which may contribute to GI symptoms. Long-term impact of these changes is unknown.
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Marzinke MA, Grinsztejn B, Fogel JM, Piwowar-Manning E, Li M, Weng L, McCauley M, Cummings V, Ahmed S, Haines CD, Bushman LR, Petropoulos C, Persaud D, Adeyeye A, Kofron R, Rinehart A, St Clair M, Rooney JF, Pryluka D, Coelho L, Gaur A, Middelkoop K, Phanuphak N, Cohen MS, Hendrix CW, Anderson P, Hanscom B, Donnell D, Landovitz RJ, Eshleman SH. Characterization of HIV infection in cisgender men and transgender women who have sex with men receiving injectable cabotegravir for HIV prevention: HPTN 083. J Infect Dis 2021; 224:1581-1592. [PMID: 33740057 DOI: 10.1093/infdis/jiab152] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/18/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION The HIV Prevention Trials Network (HPTN) 083 trial demonstrated that long-acting cabotegravir (CAB-LA) was more effective than tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for HIV prevention in cisgender men and transgender women who have sex with men. We characterized HIV infections that occurred in the blinded phase of HPTN 083. METHODS Retrospective testing included HIV testing, viral load testing, quantification of study drugs and HIV drug resistance testing. RESULTS Fifty-eight infections were evaluated, including 51 incident infections (12 CAB, 39 TDF/FTC). In many cases (5 CAB, 37 TDF/FTC), infection was associated with low or unquantifiable study drug concentrations. In four cases, infection occurred with on-time CAB-LA injections and expected plasma CAB concentrations. CAB exposure was associated with prolonged viral suppression and delayed antibody expression. In some cases, delayed HIV diagnosis resulted in CAB provision to participants with undetected infection, delayed antiretroviral treatment (ART), and emergence of drug resistance; most of these infections would have been detected earlier with viral load testing. CONCLUSIONS Early detection of HIV infection and prompt ART initiation could improve clinical outcomes in persons who become infected despite CAB-LA prophylaxis. Further studies are needed to elucidate the correlates of HIV protection in persons receiving CAB-LA.
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Affiliation(s)
- Mark A Marzinke
- Dept. of Pathology, Johns Hopkins Univ. School of Medicine, Baltimore, MD, USA
| | - Beatriz Grinsztejn
- Instituto de Pesquisa Clinica Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil
| | - Jessica M Fogel
- Dept. of Pathology, Johns Hopkins Univ. School of Medicine, Baltimore, MD, USA
| | | | - Maoji Li
- Fred Hutchinson Cancer Research Center, Seattle, WA, , USA
| | - Lei Weng
- Fred Hutchinson Cancer Research Center, Seattle, WA, , USA
| | | | - Vanessa Cummings
- Dept. of Pathology, Johns Hopkins Univ. School of Medicine, Baltimore, MD, USA
| | - Shahnaz Ahmed
- Dept. of Pathology, Johns Hopkins Univ. School of Medicine, Baltimore, MD, USA
| | - Casey D Haines
- Dept. of Pathology, Johns Hopkins Univ. School of Medicine, Baltimore, MD, USA
| | | | | | - Deborah Persaud
- Dept. of Pediatrics, Johns Hopkins Univ. School of Medicine, Baltimore, MD, USA
| | - Adeola Adeyeye
- Prevention Science Program, DAIDS, NIAID, NIH, Rockville, MD, USA
| | - Ryan Kofron
- Dept. of Medicine, Univ. of California at Los Angeles, Los Angeles, CA, USA
| | | | | | | | | | - Lara Coelho
- Instituto de Pesquisa Clinica Evandro Changas-Fiocruz, Rio de Janeiro, Brazil
| | - Aditya Gaur
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Keren Middelkoop
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Nittaya Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand; Center of Excellence in Transgender Health, Chulalongkorn University, Bangkok, Thailand
| | | | - Craig W Hendrix
- Dept. of Pathology, Johns Hopkins Univ. School of Medicine, Baltimore, MD, USA
| | | | - Brett Hanscom
- Fred Hutchinson Cancer Research Center, Seattle, WA, , USA
| | | | - Raphael J Landovitz
- Center for Clinical AIDS Research & Education, Univ. of California, Los Angeles, Los Angeles, CA, USA
| | - Susan H Eshleman
- Dept. of Pathology, Johns Hopkins Univ. School of Medicine, Baltimore, MD, USA
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Cohen MS, Landovitz RJ. Assessing the Role of Long-Acting Cabotegravir Preexposure Prophylaxis of Human Immunodeficiency Virus: Opportunities and Aspirations. J Infect Dis 2021; 223:1-3. [PMID: 32882042 DOI: 10.1093/infdis/jiaa555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Myron S Cohen
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Raphael J Landovitz
- Center for Clinical AIDS Research and Education, University of California, Los Angeles, Los Angeles, California, USA
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Chaix ML, Charreau I, Pintado C, Delaugerre C, Mahjoub N, Cotte L, Capitant C, Raffi F, Cua E, Pialoux G, Tremblay C, Meyer L, Molina JM. Effect of On-Demand Oral Pre-exposure Prophylaxis With Tenofovir/Emtricitabine on Herpes Simplex Virus-1/2 Incidence Among Men Who Have Sex With Men: A Substudy of the ANRS IPERGAY Trial. Open Forum Infect Dis 2018; 5:ofy295. [PMID: 30539039 PMCID: PMC6286447 DOI: 10.1093/ofid/ofy295] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 11/04/2018] [Indexed: 11/14/2022] Open
Abstract
We evaluated the impact of on-demand oral tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) for pre-exposure prophylaxis (PrEP) on herpes simplex virus (HSV)-1/2 incidence among men who have sex with men (MSM) enrolled in the ANRS IPERGAY trial. Serum samples were tested at baseline and at the last visit for HSV-1/2 antibodies. Overall HSV-1 incidence was 11.7 per 100 person-years; 16.2 and 7.8 per 100 person-years in the TDF/FTC and placebo arm, respectively (P = .19). Overall HSV-2 incidence was 7.6 per 100 person-years; 8.1 and 7.0 per 100 person-years in the TDF/FTC and placebo arm, respectively (P = .75). On-demand oral PrEP with TDF/FTC failed to reduce HSV-1/2 incidence in this population.
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Affiliation(s)
- Marie-Laure Chaix
- Virologie, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité, Centre National de la Recherche Scientifique Unité Mixte de Recherche, Institut Universitaire d'Hématologie, Sorbonne Paris Cité, Université Paris Diderot, Hôpital Saint Louis, France
| | | | - Claire Pintado
- Maladies Infectieuses, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, France
| | - Constance Delaugerre
- Virologie, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité, Centre National de la Recherche Scientifique Unité Mixte de Recherche, Institut Universitaire d'Hématologie, Sorbonne Paris Cité, Université Paris Diderot, Hôpital Saint Louis, France
| | - Nadia Mahjoub
- Virologie, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, France
| | - Laurent Cotte
- Maladies Infectieuses, Hôpital de la Croix Rousse, Centre Hospitalier et Universitaire de Lyon, France
| | | | - François Raffi
- Department of Infectious Diseases, University Hospital of Nantes and Centre d'Investigation Clinique, INSERM, Nantes
| | - Eric Cua
- Maladies Infectieuses, Hôpital de l'Archet, Centre Hospitalier de Nice, France
| | - Gilles Pialoux
- Maladies Infectieuses, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, France
| | - Cécile Tremblay
- Maladies Infectieuses, Centre Hospitalier de l'Université de Montréal, Canada
| | - Laurence Meyer
- INSERM Service Commun, Villejuif, France.,Université Paris-Sud, Université Paris-Saclay, France
| | - Jean-Michel Molina
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité, Centre National de la Recherche Scientifique Unité Mixte de Recherche, Institut Universitaire d'Hématologie, Sorbonne Paris Cité, Université Paris Diderot, Hôpital Saint Louis, France.,Maladies Infectieuses, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, France
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Cutrell A, Donnell D, Dunn DT, Glidden DV, Grobler A, Hanscom B, Stancil BS, Meyer RD, Wang R, Cuffe RL. HIV prevention trial design in an era of effective pre-exposure prophylaxis. HIV Clin Trials 2017; 18:177-188. [PMID: 29039265 DOI: 10.1080/15284336.2017.1379676] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Pre-exposure prophylaxis (PrEP) has demonstrated remarkable effectiveness protecting at-risk individuals from HIV-1 infection. Despite this record of effectiveness, concerns persist about the diminished protective effect observed in women compared with men and the influence of adherence and risk behaviors on effectiveness in targeted subpopulations. Furthermore, the high prophylactic efficacy of the first PrEP agent, tenofovir disoproxil fumarate/emtricitabine (TDF/FTC), presents challenges for demonstrating the efficacy of new candidates. Trials of new agents would typically require use of non-inferiority (NI) designs in which acceptable efficacy for an experimental agent is determined using pre-defined margins based on the efficacy of the proven active comparator (i.e. TDF/FTC) in placebo-controlled trials. Setting NI margins is a critical step in designing registrational studies. Under- or over-estimation of the margin can call into question the utility of the study in the registration package. The dependence on previous placebo-controlled trials introduces the same issues as external/historical controls. These issues will need to be addressed using trial design features such as re-estimated NI margins, enrichment strategies, run-in periods, crossover between study arms, and adaptive re-estimation of sample sizes. These measures and other innovations can help to ensure that new PrEP agents are made available to the public using stringent standards of evidence.
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Affiliation(s)
- Amy Cutrell
- a ViiV Healthcare , Research Triangle Park , Durham , NC , USA
| | - Deborah Donnell
- b Vaccine and Infectious Disease Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | | | - David V Glidden
- d University of California San Francisco, Epidemiology & Biostatistics Department , CA , USA
| | - Anneke Grobler
- e Clinical Epidemiology and Biostatistics Unit , Murdoch Childrens Research Institute , Melbourne , Australia.,f Centre for the AIDS Programme of Research in South Africa (CAPRISA) , Durban , South Africa
| | - Brett Hanscom
- b Vaccine and Infectious Disease Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | | | | | - Ronnie Wang
- h Pfizer Global Product Development , Groton , CT , USA
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Delaugerre C, Gatey C, Chaix ML, Molina JM. La prévention pré-exposition au VIH-1 par les antirétroviraux, la PrEP. Virologie (Montrouge) 2016; 20:147-57. [PMID: 33065894 DOI: 10.1684/vir.2016.0658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Due to the lack of vaccine, the HIV epidemic is still uncontrolled. Use of antiretrovirals (ARV) for prevention, successfully implemented to prevent mother-to-child transmission of HIV, is a new avenue to control the epidemic. One approach is to treat all patients diagnosed with HIV, and suppress viremia and transmission to their partner. Another strategy is the use of ARV as a pre-exposition prophylaxis (PrEP) in HIV-negative at risk individuals. Oral tenofovir (TDF) ± emtricitabine (FTC) is the elected drug regimen for PrEP, given its safety, its long intracellular half-life and a high diffusion into mucosal entry sites. PrEP was investigated in randomized trials of oral or local gel given daily or at time of sexual intercourse in high-risk populations. PrEP efficacy is strongly correlated to adherence and concentrations of ARV. Adverse events have been infrequent. Selection of FTC-resistant strains has been mainly reported in undiagnosed HIV-infected participants using PrEP. PrEP is now strongly recommended by WHO in prevention programs for HIV in order to control the epidemic by 2030.
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Wesdorp DJW, Knoester M, Braat AE, Coenraad MJ, Vossen ACTM, Claas ECJ, van Hoek B. Nucleoside plus nucleotide analogs and cessation of hepatitis B immunoglobulin after liver transplantation in chronic hepatitis B is safe and effective. J Clin Virol 2013; 58:67-73. [PMID: 23880162 DOI: 10.1016/j.jcv.2013.06.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 06/23/2013] [Accepted: 06/26/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND After orthotopic liver transplantation (OLT) in chronic hepatitis B (HBV), adequate prophylaxis for recurrence of HBV in the graft is mandatory. OBJECTIVES Evaluate safety of HBV prophylaxis with tenofovir and emtricitabine (TDF/FTC) after cessation of hepatitis B immunoglobulin (HBIG) after OLT in chronic HBV. STUDY DESIGN In 17 consecutive patients after OLT in chronic HBV we started TDF/FTC after cessation of HBIG. All had received HBIG >6 months. 15/17 were HBsAg negative and 16/17 had undetectable HBV-DNA. RESULTS After mean follow-up of 2 years 16/17 patients were alive, one died due to urosepsis. All 16 with undetectable HBV-DNA remained HBV-DNA negative. From 15 HBsAg negative patients at start, in one seroconversion to positive HBsAg occurred, without detectable HBV-DNA. Liver biochemistry remained within the normal ranges. There were no cases of drug discontinuation. No major side effects were reported. TDF/FTC use saves €16,262/year over standard-of-care (HBIG+LAM). This prospective follow-up study shows that in liver transplantation for chronic hepatitis B, after initial treatment including HBIG for at least 6 months combined with or followed by (dual) nucleos(t)ide analog therapy, TDF/FTC provides adequate prophylaxis against recurrent HBV infection without major side effects and leads to substantial cost savings over a regimen with HBIG. CONCLUSION Combined prophylaxis with TDF/ETV nucleoside plus nucleotide analogs and cessation of immunoglobulin after liver transplantation in chronic hepatitis B is safe and effective.
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Affiliation(s)
- D J W Wesdorp
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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