COPEDOL: a two-year observational study in pretreated HIV-1-infected patients switching to a dolutegravir-based regimen

OBJECTIVES

Dolutegravir is a second-generation integrase strand transfer inhibitor of particular interest as a rescue treatment for people living with HIV (PLWHIV) who develop resistance to multiple antiretrovirals (ART). We assessed the virological treatment response in patients switched to a dolutegravir-based regimen following failure of previous ART treatment in a real-world treatment setting.

PATIENTS AND METHODS

This was a multicenter, longitudinal, observational study with retrospective patient enrolment. Patients were enrolled between February 2017 and January 2018. Patients starting dolutegravir treatment between February 2014 and September 2016 were retrospectively included. Patients were followed up for 24 months after dolutegravir initiation. During this period, treatment with dolutegravir could be discontinued at any time at the physician's discretion. Treatment failure was either defined as a viral load ≥50 copies/mL at two consecutive blood samples or as clinical or biological safety issues. Overall, 459 patients were enrolled and 329 completed 24 months of treatment. The primary study outcome measures were treatment response and time to treatment response.

RESULTS

346/440 patients (78.6%) achieved a treatment response; 86 patients discontinued dolutegravir treatment (of whom 17 for failure to achieve or maintain viral suppression and 38 for tolerability issues). Acquired dolutegravir-resistance mutations were identified in five patients.

CONCLUSIONS

A sustained treatment response can be obtained with a dolutegravir-based treatment regimen in PLWHIV experiencing treatment failure, even in vulnerable patients with a long history of previous ART failure, infected with multidrug-resistant HIV strains, and with multiple comorbidities.

[General practice patients at risk of chronic obstructive pulmonary disease: epidemiologic survey of 3 411 patients]

OBJECTIVES

Describe patients at risk of chronic obstructive pulmonary disease (COPD) and analyze general practitioners' (GPs) management of COPD patients in France in 2003-2004.

METHODS

EDEN, a national epidemiological survey, recruited 2 378 GPs. Each GP was to include 3 consecutive patients (aged 36-80 years) who were current or former smokers and presented respiratory symptoms (any of expectoration, cough, or dyspnea) without asthma or previously diagnosed COPD. The physician completed a standardized, anonymous questionnaire for each patient, including measurement of peak expiratory flow (PEF).

RESULTS

The sample of 3 411 current smokers or former smokers with respiratory symptoms included twice as many men as women. The mean age was 58 years, with women significantly younger (p<0.0001). Men and older patients had more severe disease. Women were more often current smokers, but they smoked less than men. All patients had at least one respiratory symptom, but only 63.5% were seeing their GP for that reason. Overall, 56.5% patients reported repeated acute bronchitis, and 36.3% of these at least 3 episodes. PEF was measured in 87.7% of patients and the ratio of mean measured PEF/predicted PEF was 73.2%. GPs concluded that 92.1% of these patients had COPD, but prescribed respiratory function tests useful for only 73.8% and referred only 71.2% to a specialist.

CONCLUSION

Former and current smokers underestimated their respiratory symptoms, and so did the GPs. Accordingly, COPD is diagnosed later and at a more advanced stage. Increasing GPs' awareness of COPD would improve early detection in at-risk subjects.

Surveillance network for herpes simplex virus resistance to antiviral drugs: 3-year follow-up

Herpes simplex virus (HSV) infections are very common in the general population and among immunocompromised patients. Acyclovir (ACV) is an effective treatment which is widely used. We deemed it essential to conduct a wide and coordinated survey of the emergence of ACV-resistant HSV strains. We have formed a network of 15 virology laboratories which have isolated and identified, between May 1999 and April 2002, HSV type 1 (HSV-1) and HSV-2 strains among hospitalized subjects. The sensitivity of each isolate to ACV was evaluated by a colorimetric test (C. Danve, F. Morfin, D. Thouvenot, and M. Aymard, J. Virol. Methods 105:207-217, 2002). During this study, 3900 isolated strains among 3357 patients were collected; 55% of the patients were immunocompetent. Only six immunocompetent patients excreted ACV-resistant HSV strains (0.32%), including one female patient not treated with ACV who was infected primary by an ACV-resistant strain. Among the 54 immunocompromised patients from whom ACV-resistant HSV strains were isolated (3.5%), the bone marrow transplantation patients showed the highest prevalence of resistance (10.9%), whereas among patients infected by human immunodeficiency virus, the prevalence was 4.2%. In 38% of the cases, the patients who excreted the ACV-resistant strains were treated with foscarnet (PFA), and 61% of them developed resistance to PFA. The collection of a large number of isolates enabled an evaluation of the prevalence of resistance of HSV strains to antiviral drugs to be made. This prevalence has remained stable over the last 10 years, as much among immunocompetent patients as among immunocompromised patients.

[Adherence to antiretroviral treatments with a protease inhibitor in HIV-infected patients]

OBJECTIVE

Long-term therapeutic success of powerful antiretroviral treatments dependent on patient adherence. This study was conducted to assess the difficulties HIV-infected patients with advanced-stage disease encounter in adhering to antiretroviral treatments with a protease inhibitor.

PATIENTS AND METHODS

A prospective self-administered questionnaire survey was conducted at our outpatient clinic for 2 months. CD4 counts and HIV viral loads were also determined.

RESULTS

Seventy-one percent of the study population which included 262 responded to the questionnaire. The survey was made a median 215 days after initiating the antiprotease treatment with indinavir (71% of the cases), ritonavir (13%), saquinavir (6%), or a combination of protease inhibitors (10%). At onset of antiprotease treatment, mean CD4 count was 171+/-150/mm(3) and mean HIV viral load was 75,000 copies/ml. The treatment was considered to be difficult to take by 43% of the patients; 66% stated they had forgotten to take their drugs at least once a month. It was most difficult to take the drugs prescribed for the afternoon. Shifts of 1 hour were observed in 58% of patients. Non-adherence was frequent (1 failure to take drugs per week), observed in 13% of patients. Most often, the patients stated they had forgotten to take their drugs because of occupational or relational difficulties (52%). Non-adherence increased with duration of treatment. The drug most often associated with non-adherence was indinavir (73%). Age and sex did not influence adherence. Mean RNA HIV serum level was lower than at onset of the antiprotease treatment in the most non-adherent patients. At the time of the questionnaire, there was no difference in serum RNA HIV level or in the percentage of patients with an undetectable level between non-adherent and adherent patients.

CONCLUSION

This survey confirmed difficulties in adherence are frequent and worsen with time. No relationship was found between non-adherence and reduction in viral load, suggesting that a short-term effect of these very active drugs despite lack of perfect adherence. Other factors (pharmacology, sensitivity to antiretroviral drugs.) also play a major role in therapeutic success.

IgG subclass distribution in serum and various mucosal fluids of HIV type 1-infected subjects

We measured total IgG1, IgG2, IgG3, and IgG4 concentrations by ELISA in serum (S), total saliva (TS), cervicovaginal secretions (CVS), seminal secretions (SPE), and rectal secretions (RS) from either CDC II/III HIV-1-infected subjects or healthy volunteers. Human serum albumin was measured in parallel to calculate the relative coefficient of excretion (RCE). Levels of IgG1 and IgG3 directed against gp120 MN also were measured by ELISA in all samples, and the specific activity (SA) calculated. HIV-1-specific IgG2 and IgG4 were not compared, as total IgG2 and total IgG4 levels in HIV-1-infected subjects were found to be lower than in the healthy controls. Despite substantial interindividual variability, total IgG1 and IgG3 concentrations in all fluids were greater in the HIV-1-infected subjects than in the healthy controls. Calculations of RCE indicated predominantly a transudative origin for IgG subclasses in the different mucosal fluids, except for CVS, in which IgG1, IgG2, and IgG4 was produced locally. The transduction behavior of IgG3 in secretions appears to be different from that of other IgG subclasses. HIV-1-infected subjects were considered positive for IgG1 and IgG3 antibodies against gp120 MN if their antibody levels exceeded the maximum titer measured in the control group. Positive levels of anti-gp120 MN IgG1 were detected for 100% of HIV-1-infected individuals in S, CVS, and SPE, 97% in TS, and 75% in RS. Fewer subjects had positive levels of IgG3 to gp120 MN in their secretions (maximum 67% in CVS). Despite the low concentrations of total IgG3, mean SA values for IgG3 to gp120 MN were greater in secretions than in serum. No significant difference in the SA values for IgG1 to gp120 MN was observed between the different fluids. Only CVS had a local production of HIV-specific IgG1 Our results highlight the importance of an HIV-specific IgG1 and IgG3 immune response in mucosal fluids from HIV-1-infected subjects.

Comparison of the distribution of IgG and IgA antibodies in serum and various mucosal fluids of HIV type 1-infected subjects

We compared IgG and IgA distribution in serum, three different salivary samples, two different rectal secretion samples, cervicovaginal secretions, and seminal secretions from asymptomatic CDC stage II/III HIV-1-infected subjects (n = 44) and from HIV-1-seronegative volunteers (n = 52). In-house ELISAs were used to measure total IgG and total IgA levels, as well as HIV-specific anti-gp120 MN and anti-p24 LAI IgG and IgA. Human serum albumin was titrated in parallel to calculate the relative coefficient of excretion (RCE). In spite of substantial interindividual variability, total IgG concentrations in all fluids were found to be significantly greater in the HIV-1-infected group than in the seronegative subjects. Calculation of RCE values revealed three different types of mucosal secretion: secretions with no local Ig production, such as sperm; secretions with local production of IgA and transudative origin of IgG, such as salivary and rectal samples; and secretions with local production of both IgG and IgA, such as in cervicovaginal secretions. For all mucosal specimens from HIV-1-infected subjects, the response to HIV-1 was predominantly IgG, with highest titers observed in cervicovaginal secretions (although these were lower than serum levels). In contrast, the specific IgA response appeared weaker in the mucosa than in serum.

Detection and quantification of HIV-1 in semen: identification of a subpopulation of men at high potential risk of viral sexual transmission

BACKGROUND

To assess HIV burden in both acellular and cellular fractions of semen in men with different levels of blood plasma HIV RNA by a cross-sectional study.

PATIENTS

Fifty-two HIV-1-seropositive men (21 receiving antiretroviral therapy) with CD4 cell counts ranging from 1 to 1170 x 10(6)/l.

METHODS

Semen was separated into seminal plasma and fractions enriched in motile spermatozoa or non-spermatozoal cells. HIV RNA was quantified by the HIV-Monitor technique (Roche) in blood plasma, seminal plasma and spermatozoa fractions. HIV DNA or infectious virions in cellular fractions were detected by either PCR or qualitative viral culture.

RESULTS

HIV RNA was detected in 86.5% of seminal plasma specimens and in 14.6% of spermatozoa fractions; HIV DNA was detected in 57.1% of non-spermatozoal cell fractions. HIV RNA levels in blood plasma and seminal plasma were correlated (r5 = 0.56, P < 0.0001, Spearman's rank test). A majority of men had lower levels in seminal plasma than in blood plasma: one-third had HIV-positive seminal cell fractions. However, 20 men (38.5%) with HIV RNA levels in seminal plasma (median: 4.65 log10 copies/ml) comparable to or higher than those in blood plasma had all HIV-positive non-spermatozoal cells or spermatozoa fractions with a high frequency of positive cultures.

CONCLUSION

A high frequency of men had detectable HIV in semen. We identified a subpopulation demonstrating high levels of HIV RNA in seminal plasma, comparable to or higher than those in blood plasma, frequently associated with a substantial viral shedding in seminal cells, raising the possibility of viral production within the genital tract and suggesting heterogeneity in the potential of HIV sexual transmission among infected men.

Safety and immunogenicity of a live recombinant canarypox virus expressing HIV type 1 gp120 MN MN tm/gag/protease LAI (ALVAC-HIV, vCP205) followed by a p24E-V3 MN synthetic peptide (CLTB-36) administered in healthy volunteers at low risk for HIV infection. AGIS Group and L'Agence Nationale de Recherches sur Le Sida

A live recombinant canarypox vector expressing HIV-1 gpl20 MN tm/gag/protease LAI (ALVAC-HIV, vCP205) alone or boosted by a p24E-V3 MN synthetic peptide (CLTB-36) was tested in healthy volunteers at low risk for HIV infection for their safety and immunogenicity. Both antigens were well tolerated. ALVAC-HIV (vCP205) induced low levels of neutralizing antibodies against HIV-1 MN in 33% of the volunteers. None of them had detectable neutralizing antibodies against a nonsyncytium-inducing HIV-1 clade B primary isolate (Bx08). After the fourth injection of vCP205, CTL activity was detected in 33% of the volunteers and was directed against Env, Gag, and Pol. This activity was mediated by both CD4+ and CD8+ lymphocytes. On the other hand, the CLTB-36 peptide was poorly immunogenic and induced no neutralizing antibodies or CTLs. Although the ALVAC-HIV (vCP205) and CLTB-36 prime-boost regimen was not optimal, further studies with ALVAC-HIV (vCP205) are warranted because of its clear induction of a cellular immune response and utility as a priming agent for other subunit antigens such as envelope glycoproteins, pseudoparticles, or new peptides.

Development and standardization of methods to evaluate the antibody response to an HIV-1 candidate vaccine in secretions and sera of seronegative vaccine recipients

Enzyme-linked immunosorbent assays (ELISA) were developed to test, in serum and mucosal samples, total IgG, total IgA, serum albumin, and anti-gp120 MN and anti-p24 LAI IgG and IgA levels. These ELISAs were optimized according to reagents and experimental conditions. Inter- and intra-assay coefficients of variation ranged from 3.3% to 18.6%. The ELISA results were linear and precise, and for anti-HIV-1 IgG and IgA, the analytical recovery was close to 100%. For IgG and IgA titration against gp120 MN and p24 LAI, standards were made using pooled sera or gammaglobulins with assigned titres in ELISA units per ml (EU/ml). These standards were used to obtain a linear regression curve that could then be used to obtain the titres of experimental samples. The cut-offs for positivity were determined for sera and mucosal fluid using healthy controls. Validation conditions were defined for ELISAs, and samples that did not satisfy these conditions were retested. Measurement of total IgG and IgA allowed normalization and comparison of the results of specific immunoglobulin levels between different samples. Serum albumin was tested as a marker of transudation from serum to mucosal fluid, allowing calculation of the relative coefficient of excretion, which is one element required to determine the origin of the immunoglobulin detected in mucosal samples. These ELISAs were developed with samples from HIV-1-infected and healthy subjects. We now have the tools to study and understand mucosal immunity in seronegative subjects vaccinated with an HIV-1 candidate vaccine.

Detection of HIV-1 in seminal plasma and seminal cells of HIV-1 seropositive men

It is of critical importance to precisely understand the modalities of HIV presence in semen, especially with regard to procreation. In this study, paired blood and semen samples from 31 human immunodeficiency virus type 1 (HIV-1)-positive men were assessed for cell-free HIV-RNA load in blood plasma (BP) and seminal plasma (SP), and for detection of HIV by culture, PCR and RT-PCR in semen cellular fractions separated by centrifugation on Percoll gradient. HIV-RNA was detected in 94% of BP and 84% of SP samples. For 11 men (35%), HIV-RNA load in SP was equal or superior to that observed in blood. HIV-DNA presence was demonstrated (either by PCR or culture positivity) in 39% of the non-spermatozoal cells (NSC)-enriched fractions, and in one Percoll-selected sperm pellet. HIV-RNA was detected in 17% (4/23) of the sperm pellets. This positivity was associated with an HIV-RNA load in SP equal or superior to the HIV-RNA load in blood, a high rate of HIV-DNA detection in the NSC fraction, and a low CD4+ cell count. In such conditions, a significant viral production inside the genital tract is more likely to be present, and a close association between HIV and gametes might occur. Assisted procreation with selected spermatozoa should be preceded by accurate assessments of viral presence in blood, SP and semen cellular fractions.

[Search for a HIV vaccine]

A DIFFICULT SITUATION FOR A VACCINE: The human immunodeficiency virus has an exceptional capacity to mutate and macrophage reservoirs where it is harbored after penetration are highly inaccessible to antibodies. Use of a live vaccine would increase the risk of recurrent virulence and integration into the genome. UNKNOWN IMMUNOLOGY: Induction of cytotoxic cells appears to be essential, but investigations into this type of response are not well standardized and not easily quantifiable. Neutralizing antibodies would have a protective effect, but facilitating antibodies would have the opposite effect. SEVERAL POSSIBILITIES UNDER STUDY: These vaccine use live attenuated viruses with a more or less deleted genome, recombinant live viruses constructed from other viruses or bacteria, pseudo-particles, or recombinant proteins as well as vaccines synthetized from peptides or lipopeptides. An association of different vaccines would appear to be the best solution as live vectors usually induce cytotoxic cells while proteins or peptides induce production of neutralizing antibodies. RESPONSE TO VACCINES IS USUALLY WEAK: Both in animal models and in human volunteers, immune responses obtained to date have been quite variable and of short duration. Canarypox type recombinant vaccines followed by recombinant protein vaccines appear to give the best results at the present time. SEVERAL PROBLEMS: Anti-HIV vaccination protocols raise major ethical problems for the participating volunteers (ELISA test becomes positive, lack personal protection) and for the population involved in phase II/III trials. In addition, the virus rapidly penetrates via the mucosa without yielding sufficient mucosal immune response.