Evaluating Diversity in Randomized Clinical Trials of Dolutegravir-Based Antiretroviral Therapy Regimens: Pooled 48-Week Analyses by Race, Sex, and Regional Subgroups

Background

In HIV clinical trials, proportions of Black and female participants achieving virologic suppression (VS) are often lower compared with White and male participants. As the antiretroviral therapy (ART) landscape continues to evolve, addressing existing challenges in clinical trial diversity will be critical to effectively translate results into clinical practice. Here, we pooled data to evaluate the efficacy and safety of dolutegravir (DTG)-containing regimens by race, sex, and regional subgroups.

Methods

Three pooled analyses were conducted using 48-week results from phase 3/3b trials: DTG 3-drug vs non-DTG-containing 3- or 4-drug regimens in ART-naive participants (ARIA, FLAMINGO, SINGLE, SPRING-2), DTG-containing 2-drug vs 3-drug regimens in ART-naive participants (GEMINI-1, GEMINI-2), and DTG 3-drug vs non-DTG-containing 3- or 4-drug regimens in ART-experienced participants (SAILING, DAWNING). Proportions of participants with VS, safety, and change from baseline in CD4+ cell count were analyzed.

Results

Proportions of participants achieving VS were high among those receiving DTG vs comparator regimens. Proportions of participants achieving VS were generally lower in Black (vs non-Black), female (vs male), and US (vs non-US) subgroups. No new safety signals emerged from any subgroup in pooled analyses.

Conclusions

These analyses confirm that, across subgroups, DTG has robust efficacy and a good safety profile at week 48 relative to comparator regimens. Achieving VS may vary by participant characteristics, highlighting the urgent need for enrollment to reflect the demographics of global HIV populations more accurately. Future studies should strive to support participants throughout the trial to ensure optimal representation, inclusion, and retention.

Preexposure Prophylaxis for HIV Infection Integrated With Municipal- and Community-Based Sexual Health Services

IMPORTANCE

Several randomized clinical trials have demonstrated the efficacy of preexposure prophylaxis (PrEP) in preventing human immunodeficiency virus (HIV) acquisition. Little is known about adherence to the regimen, sexual practices, and overall effectiveness when PrEP is implemented in clinics that treat sexually transmitted infections (STIs) and community-based clinics serving men who have sex with men (MSM).

OBJECTIVE

To assess PrEP adherence, sexual behaviors, and the incidence of STIs and HIV infection in a cohort of MSM and transgender women initiating PrEP in the United States.

DESIGN, SETTING, AND PARTICIPANTS

Demonstration project conducted from October 1, 2012, through February 10, 2015 (last date of follow-up), among 557 MSM and transgender women in 2 STI clinics in San Francisco, California, and Miami, Florida, and a community health center in Washington, DC. Data were analyzed from December 18, 2014, through August 8, 2015.

INTERVENTIONS

A combination of daily, oral tenofovir disoproxil fumarate and emtricitabine was provided free of charge for 48 weeks. All participants received HIV testing, brief client-centered counseling, and clinical monitoring.

MAIN OUTCOMES AND MEASURES

Concentrations of tenofovir diphosphate in dried blood spot samples, self-reported numbers of anal sex partners and episodes of condomless receptive anal sex, and incidence of STI and HIV acquisition.

RESULTS

Overall, 557 participants initiated PrEP, and 437 of these (78.5%) were retained through 48 weeks. Based on the findings from the 294 participants who underwent measurement of tenofovir diphosphate levels, 80.0% to 85.6% had protective levels (consistent with ≥4 doses/wk) at follow-up visits. African American participants (56.8% of visits; P = .003) and those from the Miami site (65.1% of visits; P < .001) were less likely to have protective levels, whereas those with stable housing (86.8%; P = .02) and those reporting at least 2 condomless anal sex partners in the past 3 months (88.6%; P = .01) were more likely to have protective levels. The mean number of anal sex partners declined during follow-up from 10.9 to 9.3, whereas the proportion engaging in condomless receptive anal sex remained stable at 65.5% to 65.6%. Overall STI incidence was high (90 per 100 person-years) but did not increase over time. Two individuals became HIV infected during follow-up (HIV incidence, 0.43 [95% CI, 0.05-1.54] infections per 100 person-years); both had tenofovir diphosphate levels consistent with fewer than 2 doses/wk at seroconversion.

CONCLUSIONS AND RELEVANCE

The incidence of HIV acquisition was extremely low despite a high incidence of STIs in a large US PrEP demonstration project. Adherence was higher among those participants who reported more risk behaviors. Interventions that address racial and geographic disparities and housing instability may increase the impact of PrEP.

Impact of comorbidities and drug therapy on development of renal impairment in a predominantly African American and Hispanic HIV clinic population

Purpose

Renal impairment in human immunodeficiency virus (HIV)-infected patients could potentially be caused by many factors. HIV-related renal impairment risks have been little studied in African Americans and Hispanics. We investigated the impact of HIV itself, highly active antiretroviral therapy (HAART), comorbidities, and non-HIV-related drug treatment on glomerular filtration rate in a predominantly African American/Hispanic HIV-infected population who had received HAART for at least one year. This study was a retrospective electronic medical record database evaluation of renal impairment risks in a largely African American/Hispanic HIV population obtaining medical care at an HIV clinic in Dallas, Texas.

Methods

Proportional hazards models were used to investigate an association between an estimated glomerular filtration rate decrease >25% from baseline (ie, renal impairment) and demographics, antiretroviral/nonantiretroviral medications, comorbidities (hypertension, diabetes mellitus, hepatitis C virus [HCV] infection, hepatitis B virus [HBV] infection), CD4+ counts, viral load, and duration patients were monitored at the clinic (time on study).

Results

In total, 323 patients were evaluated: 82% males; 61% African American/12% Hispanic/19% Caucasian; mean age 37.9 years (standard deviation [SD] 8.5); 6% HBV-positive; 34% HCV-positive; 29% hypertensive; 3% diabetic; 52% tenofovir-treated; mean weight 75.4 kg (SD, 15.4); mean estimated glomerular filtration 114.5 mL/min/1.73 m² (SD, 36.7) using the Modification of Diet in Renal Disease (MDRD) calculation method; mean creatinine clearance (from which estimated glomerular filtration was extrapolated) by the Cockcroft-Gault calculation method 120.6 mL/min/1.73 m² (SD, 41.2); mean time on study 2.7 years (SD, 1.0 year). An estimated glomerular filtration rate decrease of >25% from baseline was significantly associated with time on study (P = 0.0017; hazards ratio [HR] = 0.999) and hypertension (HR = 1.706; P = 0.0158) by the MDRD method, and with age (HR = 1.039; P = 0.0077), weight (HR = 0.987; P = 0.0023), and time on study (HR = 0.999; P = 0.0043) by extrapolation of Cockcroft-Gault creatinine clearance calculation. No specific HAART agent was associated with significant renal impairment risk by the definition used in this study.

Conclusion

This retrospective database study showed time on study, hypertension, weight, and age to be the only significant predictors of an estimated glomerular filtration rate decrease >25% from baseline.

Comorbidities and challenges affecting African Americans with HIV infection

The significant disparities in health outcomes that exist among racial minorities in the United States are clearly evident in the HIV epidemic. HIV disproportionately affects minorities, African Americans in particular. Current treatment of HIV/AIDS is complicated by medical problems such as hepatitis, diabetes and dyslipidemia, which also disproportionately affect African Americans and can significantly impact the complexity of clinical care. In addition, untreated psychological problems such as depression and societal barriers to adequate medical care may decrease treatment adherence and increase HIV-related morbidity and mortality among African Americans. Consideration of these issues by healthcare providers is necessary to optimize care and improve treatment outcomes for African Americans with HIV infection.

Differences in perceptions of what constitutes having "had sex" in a population of people living with HIV/AIDS

The reduction of high-risk sexual behavior among HIV-infected individuals is a major aspect of prevention strategies to reduce HIV infection in the United States. These prevention efforts assume a common understanding between clinicians and HIV-infected individuals of the terms "sex" and what constitutes having "had sex." The purpose of this study was to determine what sexual behaviors HIV-infected individuals perceive as having had sex and to examine the variability of these perceptions. Surveys were done of 279 HIV-positive adults receiving services at an HIV-focused community health center in Dallas, TX. Responses from participants about whether they perceived a given behavior as constituting having had sex were analyzed by Chi-squared analysis. Overall, only 80.9% of respondents perceived penile-vaginal intercourse as "sex," while 76.9% said they "had sex" if someone had oral contact with their genitals. There were gender and ethnicity differences in what was perceived as having had sex. Females were significantly less likely than males to perceive anal intercourse as having had sex. Variability exists among HIV-positive individuals regarding what they perceive as having had sex. Results support the need for clinicians to more precisely ascertain sexual perceptions and risks to achieve HIV prevention goals.

Recognizing and managing common toxicities in patients receiving antiretroviral therapy

Each of the 3 traditional classes of antiretroviral drugs (nucleoside/nucleotide reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, and protease inhibitors [PIs]) has characteristic sets of toxicities that are not found with the other drug classes. On the other hand, lipodystrophy, which was thought to be specific to PIs, is now known to be common to all 3 classes of drugs. An understanding of the drug-specific, class-specific, and general toxicities and side effects of antiretroviral drugs will help the clinician tailor treatment regimens to individual patients.

Impact of an Educational Program on Efficacy and Adherence With a Twice-Daily Lamivudine/Zidovudine/Abacavir Regimen in Underrepresented HIV-Infected Patients

A 24-week open-label clinical trial was conducted in 195 HIV-infected adults commonly underrepresented in research (35% female, 71% African American, 21% Hispanic, and 20% injection drug users [IDUs]) to evaluate the effect of an HIV educational program on efficacy and adherence with a simple, compact, twice-daily triple nucleoside regimen containing a lamivudine (150 mg)/zidovudine (300 mg) combination (COM) tablet plus abacavir (ABC), 300 mg. At baseline, the patients' median plasma HIV-1 RNA level was 4.18 log10 copies/mL and the median CD4+ cell count was 379 cells/mm3. Patients were randomized 1:1 to 4 modules of the Tools for Health and Empowerment HIV education intervention plus routine counseling (EI + RC; n = 96) or to routine counseling alone (RC; n = 99). No differences between the EI + RC and RC treatment arms were observed with respect to the proportion of patients achieving plasma HIV-1 RNA levels <40 copies/mL (60% [33/55] vs. 55% [38/69]; P = 0.529) or <400 copies/mL (80% [44/55] vs. 80% [55/69]; P = 0.689) at week 24 (intent-to-treat observed analysis), increase in median CD4 cell count above baseline at week 24 (78.3 vs. 104.8 cells/mm3; P = 0.498), or mean overall adherence rates as measured by the Medication Event Monitoring System (MEMS) (70% vs. 74%). COM + ABC was generally well tolerated, and no association was observed between interruptions in treatment and the development of ABC hypersensitivity (5 suspected cases). In conclusion, in underrepresented patients, the EI used in this study did not affect the efficacy and adherence results with ABC + COM to any greater degree than did RC.

A preliminary study of African-American physician involvement in the care of HIV-infected patients

In 1995, questionnaires were sent to the mailing list of the National Medical Association (NMA). The mail responses were supplemented by questionnaires distributed at the NMA annual meeting. Of the 709 respondents, approximately 63% were primary care providers, pediatricians, or obstetrician-gynecologists; 72% were treating from zero to 10 human immunodeficiency virus (HIV) patients while 9% were treating > 90 HIV patients; and 12% had been treating HIV patients > 10 years. The majority of these patients were African American; male-to-male sex and injecting drugs were the two major risk factors. Complexity of HIV care and lack of reimbursement were the principal barriers to providing HIV care. The burden of providing HIV care is borne by a relatively small number of physicians, and African-American physicians are actively involved in this care. Programs are needed to increase the number of African-American providers treating HIV patients and to provide appropriate reimbursement for providing this care.

An assessment of Ryan White Title IIIb HIV early intervention programs in Region VI of the United States Public Health Service

A survey was conducted of 15 early intervention programs in Region VI of the United States Public Health Service (USPHS) to determine when human immunodeficiency virus (HIV)-infected clients assessed care. Data were collected from 672 HIV-infected patients who received medical care between March 1991 and July 1993. Eighty-four percent were male, 42% were white, 35% were African-American, 22% were Hispanic, and less than 1% defined themselves as "other." Information also was obtained on HIV risk factors and CD4 counts on entry to the facility. Thirty percent of patients had entry CD4 counts > 500/mm3, 55% had counts between 499 and 200/mm3, and 25% < 200/mm3. The distribution of entry CD4 counts were similar to those reported from two large, urban, public-hospital HIV clinics. The most common risk factor for all ethnicities was male-to-male sex (53%), followed by heterosexual exposure (17%), and injection drug use (16%). The results indicate that the majority of clients who initially present to Title IIIb "early intervention" programs in Region VI are of ethnic minority groups. Based on entry CD4 counts, patients in Title IIIb programs present late with one fourth at acquired immunodeficiency syndrome (AIDS)-defining levels. Regardless of ethnicity, male-to-male sex was the highest risk factor in this region. These findings have significant implications for the targeting of specific populations for outreach and for possibly reallocating funds for future planning of Ryan White Comprehensive AIDS Emergency Care Act programs.