Sachet water quality and product registration: a cross-sectional study in Accra, Ghana

The study's objectives were to assess the extent to which packaged water producers follow product registration procedures and to assess the relationship between product registration and drinking water quality in Accra, Ghana. Following preliminary analysis of a national water quality survey, 118 packaged sachet water samples were collected by sampling all brands sold by 66 vendors. A sample of vendors was selected from two high-income and two low-income areas of Accra, Ghana. Sachet packaging and labelling details were recorded and compared to a regulatory database to assess product registration. All samples were weighed and tested for faecal indicator bacteria and selected physico-chemical parameters. Product registration numbers and brand names could be matched to regulatory records for 77 of 118 sachets (65.2%). All samples tested were compliant with national water quality standards for faecal indicator bacteria and nitrate. Brand registration was not associated with any of the quality indicators considered. The results of this study suggest that while a substantial proportion of sachet water is sold without formal product registration, the microbial quality of the unlicensed water is consistently high in Accra, Ghana. Further examination of regulatory enforcement and monitoring will be needed to ensure sustained high water quality over time.

Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes

A summary of the latest evidence-based nutrition guidelines for the prevention and management of diabetes is presented. These guidelines are based on existing recommendations last published in 2011, and were formulated by an expert panel of specialist dietitians after a literature review of recent evidence. Recommendations have been made in terms of foods rather than nutrients wherever possible. Guidelines for education and care delivery, prevention of Type 2 diabetes, glycaemic control for Type 1 and Type 2 diabetes, cardiovascular disease risk management, management of diabetes-related complications, other considerations including comorbidities, nutrition support, pregnancy and lactation, eating disorders, micronutrients, food supplements, functional foods, commercial diabetic foods and nutritive and non-nutritive sweeteners are included. The sections on pregnancy and prevention of Type 2 diabetes have been enlarged and the weight management section modified to include considerations of remission of Type 2 diabetes. A section evaluating detailed considerations in ethnic minorities has been included as a new topic. The guidelines were graded using adapted 'GRADE' methodology and, where strong evidence was lacking, grading was not allocated. These 2018 guidelines emphasize a flexible, individualized approach to diabetes management and weight loss and highlight the emerging evidence for remission of Type 2 diabetes. The full guideline document is available at www.diabetes.org.uk/nutrition-guidelines.

Detection of Estrogen Receptor-Beta mRNA in Breast Cancer Using RT-PCR

The estrogen receptor (ER) is the most useful marker currently available for breast cancer, being used both to predict response to therapy and assess prognosis. Recently, a new form of the ER, known as ER-beta, was identified. In this preliminary study we show that ER-beta mRNA was expressed less frequently in breast cancers than ER-alpha. ER-alpha but not ER-beta levels correlated with ER protein as determined by ELISA. We conclude that ER-beta is expressed in approximately 50% of breast cancers but it does not appear to be detected by a widely available ELISA.

Abstract P5-10-02: High expression of BAD, PUMA, BOK and TRADD mRNA is associated with higher overall survival in ER+ and PR+ breast cancer patients

Background: Apoptosis signalling is controlled by a complex interaction of pro- and anti-apoptotic BCL2 proteins and its dysregulation is believed to be a major contributor to therapy responses and resistance in cancer. We previously demonstrated that inhibition of cell death in cancer cell is associated to poor outcome in colorectal cancer (Lindner et al., Cancer Res, 2012) and to lower cell death in triple negative breast cancer (TNBC) cells in vitro (Lucantoni et al., in review). In ER+ breast cancer, the anti-apoptotic protein BCL2 is commonly overexpressed, but its expression is associated with improved clinical outcome. The aim of this study was to assess whether system modelling of BCL2 protein interactions stratifies low- and high-risk breast cancer patients, and to determine the contribution of apoptosis signalling in different molecular subtypes of breast cancer.

Methods: Protein levels of BAK, BAX, BCL2 and BCL(X) were determined in fresh frozen, TNBC samples from the BREAST-PREDICT Irish Cancer Society Collaborative Research Centre cohort, using HeLa cells as standard in which absolute protein levels were previously determined. Clinical, protein level and gene expression datasets of 845 invasive breast carcinoma patients were accessed from The Cancer Genome Atlas project, and BCL2 protein profiles were calculated by linear regression based on the BREAST-PREDICT cohort. In both cohorts, profiles were used to calculate the stress dose required to induce mitochondrial apoptosis (η).

Results: In contrast to experiments with TNBC cells in which a high η indicated lower rates of cell death in vitro (Lucantoni et al., in review), we found that in breast cancer patients, η ≤ 0 was associated with lower overall survival (OS) compare to η > 0 (HR 2.1, 95%CI 1.3-3.3, p < 0.01). η > 0 was associated with lower levels of cleaved caspase 7 compared to η ≤ 0 (ANOVA & Tukey post-hoc; p < 0.1). Cleaved caspase 7 levels > mean were associated with improved OS compared to levels ≤ mean (HR 0.4, 95%CI 0.3-0.7, p = 0.001). High values of η were significantly associated with lower proliferation in ER/PR+ cancer (ANOVA & Tukey post-hoc; p < 0.01), but not in HER2+ or TNBC. Next we performed hierarchical cluster analysis (ConsensusClusterPlus; Monti et al, Machine Learning, 2003) with 61 additional mRNAs and proteins which are not implemented in our systems modelling approach. We found a subgroup with high BAD, PUMA, BOK and TRADD mRNA expression levels in ER/PR+ breast cancer patients, independently of the value of η. ER/PR+, but not HER2+ or TNBC, patients with an averaged expression of these 4 mRNA > mean had significant higher OS compared with patients with an averaged expression ≤ mean (HR 0.4, 95%CI 0.2-0.9, p = 0.02).

Conclusions: Impairment of apoptosis assessed solely on the levels of BAK, BAX, BCL2 and BCLX(L) proteins were not sufficient as prognostic marker in breast cancer patients. However, our analysis suggest that patients with ER/PR+ cancer cells potentially 'primed' towards apoptosis - via the expression of pro-apoptotic BAD, PUMA, BOK and TRADD - had a more favourable clinical outcome compared to patients with cancer cells lacking this priming.

Citation Format: Lindner AU, Lucantoni F, Vareslija D, Resler A, Gallagher WM, Hill A, Young L, Prehn JHM. High expression of BAD, PUMA, BOK and TRADD mRNA is associated with higher overall survival in ER+ and PR+ breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-10-02.

Co-initiated hyperbranched-polydendron building blocks for the direct nanoprecipitation of dendron-directed patchy particles with heterogeneous surface functionality

A synthetic strategy branched polymer building blocks that allow the rapid construction of patchy nanoparticles is presented. Hyperbranched polydendrons with mixtures of PEG and thiol-functional dendrons nanoprecipitate to form isolated zones that are imaged with gold nanoparticles.

Pressing diseases that represent promising targets for gene therapy

Over time, there has been a growing interest in the application of gene therapy within the healthcare industry as demonstrated by the nearly 3,000 clinical trials associated with gene therapy that are listed in clinicaltrials.gov. However, there are various difficulties associated with gene therapy that have limited the realization of licensed gene therapies to only a handful of treatments. Furthermore, efforts to develop gene therapeutics have been narrowly focused and most clinical trials have sought to develop treatments for cancer (64.6%), monogenic diseases (10.5%), infectious diseases (7.4%), and cardiovascular diseases (7.4%). In addition, nearly 70% of clinical trials have utilized viral-based delivery systems, despite various concerns associated with this strategy. Each of these factors highlights the lack of diversity in the development of gene therapeutics that should be addressed. In recent years, developments in gene manipulation and delivery such as CRISPR and non-viral vectors (e.g., liposomes) demonstrate promise for improving outcomes for gene therapy. The increased fidelity and capacity afforded by these technologies provide the potential to improve upon contemporary gene therapy approaches and enable the development of treatments for less-emphasized disorders. In this review, we provide a summary of gene delivery technology and discuss various developments in gene therapy technology. We conclude by proposing several genetic conditions that represent promising targets for gene therapy given recent developments in gene delivery and manipulation.

Changing prognosis in paroxysmal nocturnal haemoglobinuria disease subcategories: an analysis of the International PNH Registry

BACKGROUND

Paroxysmal nocturnal haemoglobinuria (PNH) is a rare disease. Although much progress has been made in the understanding of the pathophysiology of the disease, far less is known with respect to the clinical outcomes of patients with PNH. Few retrospective studies provide survival estimates, and even fewer have explored the clinical heterogeneity of the disease. Haemolytic and aplastic anaemia (AA) forms of the disease have been recognised as main disease categories, with the haemolytic form being associated with the worst prognosis by the largest studied cohort some years ago.

AIMS

To describe mortality and causes of death in PNH overall and by PNH classification and to evaluate risk factors associated with mortality.

METHODS

We analysed data of 2356 patients enrolled in the International PNH Registry with multivariate analyses, using time-dependent covariates. Patients were classified into haemolytic, AA/PNH syndrome or intermediate PNH.

RESULTS

Overall, 122 (5.2%) patients died after enrolment, the incidence according to subcategories being 5.1, 11.7, 2.0 and 4.8% for patients with haemolytic PNH, AA-PNH, intermediate and insufficient data respectively. Older age and decreased performance status also affected survival in multivariate analysis. Improved outcome of patients with haemolytic PNH suggests that eculizumab treatment in PNH may be associated with improved survival.

CONCLUSION

A detailed analysis of clinical presentations and causes of death in patients with PNH, overall and by disease subcategories, provide evidence that in the current era, patients with haemolytic PNH are no longer those who harbour the worst prognosis. This finding differs sharply from what has been previously reported.

A cross-sectional study to evaluate the association of hyperbilirubinaemia on markers of cardiovascular disease, neurocognitive function, bone mineral density and renal markers in HIV-1 infected subjects on protease inhibitors

BACKGROUND

Ongoing inflammation in controlled HIV infection contributes to non-AIDS comorbidities. High bilirubin appears to exhibit an anti-inflammatory effect in vivo. We therefore examined whether increased bilirubin in persons with HIV was associated with differences in markers of inflammation and cardiovascular, bone, renal disease, and neurocognitive (NC) impairment.

METHODS

This cross-sectional study examined inflammatory markers in individuals with stable HIV infection treated with two nucleoside reverse transcriptase inhibitors and a boosted protease inhibitor. Individuals recruited were those with a normal bilirubin (NBR; 0-17 μmol/L) or high bilirubin (>2.5 × upper limit of normal). Demographic and anthropological data were recorded. Blood and urine samples were taken for analyses. Pulse wave velocity (PWV) measurement, carotid intimal thickness (CIT), and calcaneal stiffness (CSI) were measured. Males were asked to answer a questionnaire about sexual function; NC testing was performed using CogState.

RESULTS

101 patients were screened, 78 enrolled (43 NBR and 35 HBR). Atazanavir use was significantly higher in HBR. Whilst a trend for lower CIT was seen in those with HBR, no significant differences were seen in PWV, bone markers, calculated cardiovascular risk (Framingham), or erectile dysfunction score. VCAM-1 levels were significantly lower in the HBR group. HBR was associated with lower LDL and triglyceride levels. NBR was associated with a calculated FRAX significantly lower than HBR although no associations were found after adjusting for tenofovir use. No difference in renal markers was observed. Component tests of NC testing revealed differences favouring HBR but overall composite scores were similar.

DISCUSSION

High bilirubin in the context of boosted PI therapy was found not to be associated with differences in with the markers examined in this study. Some trends were noted and, on the basis of these, a larger, clinical end point study is warranted.

InterPrEP: internet-based pre-exposure prophylaxis with generic tenofovir disoproxil fumarate/emtrictabine in London - analysis of pharmacokinetics, safety and outcomes

OBJECTIVES

The National Health Service in England (NHS England) does not provide pre-exposure prophylaxis (PrEP) against HIV, forcing people to purchase generic versions on the internet. However, there are concerns about the authenticity of medicines purchased online. We established an innovative service offering plasma tenofovir (TFV) and emcitrabine (FTC) therapeutic drug monitoring for people buying generic PrEP online, to ensure that drug concentrations in vivo were consistent with those of propriety brands and previously published data.

METHODS

TFV/FTC concentrations were measured by ultra-performance liquid chromatography ultraviolet detection. Evaluation of renal function and testing for HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) were also carried out, at baseline and every 3-6 months, with risk reduction advice.

RESULTS

A total of 293 individuals presented having purchased PrEP on the internet: 85% were white, 84% were taking daily PrEP, and 16% were event-driven. Most were on generic TFV disoproxil fumarate (TDF)/FTC from Cipla Ltd. Median (range) TFV and FTC plasma concentrations were 104 (21-597) ng/mL and 140 (17-1876) ng/mL, respectively. All concentrations were above our established plasma TFV and FTC targets, based on previously published data. Renal function was normal in all evaluable individuals and no new cases of HIV, HBV or HCV infection were seen.

CONCLUSIONS

In a population at high risk of HIV acquisition, who cannot yet access PrEP on the NHS, concentrations of TFV and FTC in generic formulations purchased over the internet were similar to (or slightly higher than) those measured in phase I studies with the original formulation from Gilead (Truvada™), which has demonstrated high levels of protection against HIV infection in previous PrEP clinical trials.

Impact of simulated three-dimensional perception on precision of depth judgements, technical performance and perceived workload in laparoscopy

Background

This study compared precision of depth judgements, technical performance and workload using two‐dimensional (2D) and three‐dimensional (3D) laparoscopic displays across different viewing distances. It also compared the accuracy of 3D displays with natural viewing, along with the relationship between stereoacuity and 3D laparoscopic performance.

Methods

A counterbalanced within‐subjects design with random assignment to testing sequences was used. The system could display 2D or 3D images with the same set‐up. A Howard–Dolman apparatus assessed precision of depth judgements, and three laparoscopic tasks (peg transfer, navigation in space and suturing) assessed performance (time to completion). Participants completed tasks in all combinations of two viewing modes (2D, 3D) and two viewing distances (1 m, 3 m). Other measures administered included the National Aeronautics and Space Administration Task Load Index (perceived workload) and the Randot^® Stereotest (stereoacuity).

Results

Depth judgements were 6·2 times as precise at 1 m and 3·0 times as precise at 3 m using 3Dversus2D displays (P < 0·001). Participants performed all laparoscopic tasks faster in 3D at both 1 and 3 m (P < 0.001), with mean completion times up to 64 per cent shorter for 3Dversus2D displays. Workload was lower for 3D displays (up to 34 per cent) than for 2D displays at both viewing distances (P < 0·001). Greater viewing distance inhibited performance for two laparoscopic tasks, and increased perceived workload for all three (P < 0·001). Higher stereoacuity was associated with shorter completion times for the navigating in space task performed in 3D at 1 m (r = − 0·40, P = 0·001).

Conclusion

3D displays offer large improvements over 2D displays in precision of depth judgements, technical performance and perceived workload.

Many advantages for 3D

Abstract P3-04-17: Global transcriptional repression by the coactivator SRC-1 mediates disease progression in treatment-resistant breast cancer

Despite the effectiveness of endocrine therapy in treating estrogen receptor (ER) positive breast cancer, nearly 40% of breast cancer patients may develop resistance which can lead to metastatic disease progression. Steroid receptor co-activator-1 (SRC-1), a key regulator of ER signalling, is overexpressed in 35% of breast cancer patients and is strongly associated with the development of endocrine resistant metastasis(1). Recent studies highlighted the ability of SRC-1 to also act as transcriptional repressor. SRC-1 can therefore bi-directionally regulate gene expression to promote the resistant phenotype (2).

This study employed a genome-wide multi-omics sequencing approach to determine the SRC-1 repression signature in endocrine resistance and elucidate the mechanism by which SRC-1 mediates this repression. RNA-sequencing identified 736 genes significantly downregulated by SRC-1, with common functional pathways such as differentiation, cell morphogenesis and extracellular matrix enriched in the gene set. Parallel global methylation sequencing analysis revealed distinct differentially methylated regions specific to SRC-1 repressed target genes. Mechanistic studies in endocrine resistant cells revealed a role for methylation proteins, DNMTs and MBD, in SRC-1 directed repression. Through combined analysis of our global sequencing data we identified a network hub of five differentiation genes directly repressed by SRC-1. High expression of this signature predicts enhanced recurrence free survival in tamoxifen treated patients (n=335, p=0.032). A reduction in expression of these genes was shown to have functional output on proliferation, migration and mammosphere formation. Finally, we use tumour explant models to show that targeting DNA methylation can be used to reverse the SRC-1 driven suppression of this differentiation hub.

Here we report a novel mechanism by which SRC-1 may be driving endocrine resistant tumorigenesis. Our genome-wide discovery approach revealed a global epigenetic re-programming pathway whereby concerted differential DNA methylation is potentiated by the activation of SRC-1 in the presence of tamoxifen in the endocrine resistant setting. This study suggests that therapeutic strategies of combined targeted epigenetic therapy with estrogen deprivation could be a successful strategy to prevent acquired resistance to endocrine therapy.

Citation Format: Ward E, Varešlija D, Fagan A, Hill A, Young L. Global transcriptional repression by the coactivator SRC-1 mediates disease progression in treatment-resistant breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-04-17.

Prone position ventilation in the Role 2 Afloat environment

Prone position ventilation is a life-saving technique for the management of hypoxic respiratory failure in ventilated patients. It has particular application in the isolated Role 2 Afloat (R2A) environment where both human and material resources are limited. It can be achieved with minimal training. This article describes the rationale behind prone position ventilation and equips the reader with the knowledge base that will allow the technique to be instigated.

Endovascular Repair of a Chronic AV Fistula Presenting as Post-Partum High Output Heart Failure

Introduction

Acute injury to the large vessels is the most feared of diagnoses for a spinal surgeon, but far more common is the delayed presentation of arteriovenous fistula (AVF) formation. The mean time to diagnosis of an AV fistula in this scenario is just over 1 month. Treatment can include both open and endovascular repair.

Report

This study presents a case of an otherwise healthy 39-year-old woman who initially presented with orthopnea, leg edema, and a presumptive diagnosis of post-partum cardiomyopathy. Cardiac investigations revealed high output cardiac failure and an abdominal CT scan confirmed an arterial venous fistula from the left common iliac artery to left common iliac vein. The patient maintained a cardiac output three times normal prior to her definitive treatment. This high flow physiology caused unique challenges for the endovascular procedure as the stent graft collapsed and distorted toward the iliac side wall. The AV fistula was eventually covered successfully and post-operative studies show no further fistula and normal cardiac function. This case demonstrates an unanticipated effect of very high flows of stent graft deployment.

Discussion

Extreme high flow AV fistulas can present as unexpected challenges to endovascular repair. These issues may be ameliorated by techniques such as controlled hypotension, adenosine, ventricular pacing, or proximal balloon occlusion.

•

This chronic AV fistula was diagnosed 12 years after lumbar discectomy.

•

Only after the normal physiological state of pregnancy, and its elevated high cardiac output requirements did the patient decompensate with orthopnea and edema.

•

This otherwise healthy 39-year-old woman had three times the cardiac output expected which was caused by her iliac artery to iliac vein fistula.

•

Endovascular treatment is a viable option to cover the fistula, but the high flows can collapse and distort the stent graft during deployment.

•

Controlled hypotension, adenosine, ventricular pacing or proximal balloon occlusion may be appropriate if extreme flows are anticipated.

Effect of Vitamin K on Vascular Health and Physical Function in Older People with Vascular Disease--A Randomised Controlled Trial

BACKGROUND AND AIMS

Vitamin K insufficiency is common and linked to an increased risk of cardiovascular disease and osteoporotic fractures. The aim of this study was to examine whether daily supplementation with oral vitamin K could improve vascular health and physical function in older people with established vascular disease.

METHODS AND RESULTS

A double blind, randomised, placebo-controlled trial. Participants aged ≤ 70 years with a history of vascular disease were randomised to receive 6 months of daily oral 100mcg vitamin K2 (MK7 subtype) or matching placebo with outcomes measured at 0, 3 and 6 months. The primary outcome was between-group difference in endothelial function assessed using flow-mediated dilatation of the brachial artery at 6 months. Secondary outcomes included carotid-radial pulse wave velocity, augmentation index, blood pressure, carotid intima-media thickness, C-reactive protein, B-type natriuretic peptide, cholesterol and desphospho-uncarboxylated matrix Gla protein levels. Handgrip strength and the Short Physical Performance Battery assessed physical function, while postural sway was measured using a 3-dimensional force platform.

RESULTS

80 participants were randomised, mean age 77 (SD 5) years; 44/80 were male. Vitamin K levels rose in the intervention arm compared to placebo (+48 pg/ml vs -6 pg/ml, p=0.03) at 6 months. Desphospho-uncarboxylated Matrix Gla protein levels fell in the intervention group compared to placebo at 6 months (-130 [SD 117] pmol/L vs +13 [SD 180] pmol/L, p<0.001). No change was seen in endothelial function (between group difference -0.3% [95%CI -1.3 to 0.8], p=0.62). A modest, non-significant improvement in pulse wave velocity was seen in the vitamin K group (-0.8m/s [95%CI -1.8 to 0.3], p=0.15) while all other vascular and physical function outcomes unchanged.

CONCLUSIONS

Six months of vitamin K2 supplementation did not improve markers of vascular health or physical function in older patients with vascular disease.

Abstract P2-05-03: Whole genome transcriptome analysis of sequential breast to brain metastasis uncovers new signalling pathways and druggable targets

The occurrence of brain metastasis (BM) in breast cancer (BC) is currently on the rise across all molecular subtypes with 10-30% reported incidence. The need to uncover the mechanisms underlying this clinically devastating complication is apparent, and in the current study we sought to identify BC cell mediators of BM.

In our cohort of metastatic patients (n=196) we found that BM developed in 13% of the cases. Despite the previous reports of negative ER status being a risk factor for BM, the ER+ve patients accounted for 42% of all diagnosed BM. To elucidate the gene alterations required for successful colonisation of the brain we undertook RNA sequencing (RNA-seq) of sequential breast to brain metastasis of known receptor status (n=7).This study presents the first whole transcriptome next-generation RNA-seq analysis of resected BM and their matching primary breast tumours.

We identified 500 differentially expressed genes (DEGs) (&lt; 0.05, fcThreshold &gt;±1.5), accounting for those that were both upregulated and downregulated in BM compared to the primary. Analysis of protein-coding genes identified collective ER-specific metastatic pathways. Additionally, common functional pathways altered included ECM, cell adhesion and neuronal differentiation. Our analysis of the BM transcriptomic landscape and verification in cell line models that preferentially metastasise to the brain has unravelled a complex network of driver genes, cooperating with stromal derived factors, responsible for the organ-specific behaviour of the metastatic cells. Genes such as ANTRX1, THBS2, FAP, VCAN and TIMP2 were found to be part of the invasion and migration network that drives the extravasation of the BM cells. Furthermore, an EMT stemness signalling network driven by ANTRX1and WNT pathway driven RUNX was prominent in the cells acquiring the ability to migrate to the brain. Additional work is being carried out on uncovering the adaptations that re-activate the dormant brain metastatic cells and the contribution of the neuronal niche in the facilitating the colonisation by the MBC.

This study highlights the requirement of unique gene sets for the invasion, migration and colonisation to the brain and that functional characterisation of the DEGs will enable the identification of novel molecular targets for prevention and treatment of breast cancer BM.

Citation Format: Varešlija D, Fagan A, Buckley P, Farrell M, Hill A, Young L. Whole genome transcriptome analysis of sequential breast to brain metastasis uncovers new signalling pathways and druggable targets. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-05-03.

Efficacy of protease inhibitor monotherapy vs. triple therapy: meta-analysis of data from 2303 patients in 13 randomized trials

OBJECTIVES

The aim of this analysis was to review the evidence and update a meta-analysis evaluating the efficacy and safety results from randomized controlled trials of ritonavir-boosted protease inhibitor (PI/r) monotherapy.

METHODS

A PubMed/EMBASE search was conducted to find randomized trials of PI/r monotherapy vs. triple therapy in patients with HIV-1 RNA suppression at baseline (<50 HIV-1 RNA copies/mL). Rates of virological suppression were analysed using switch-equals-failure and intensification-included endpoints [intent-to-treat (ITT)]. The rate of treatment-emergent resistance mutations, neurocognitive function endpoints, and cerebrospinal fluid (CSF) HIV-1 RNA were also analysed by treatment arm.

RESULTS

There were 2303 patients from 13 different randomized clinical trials of darunavir/r monotherapy (n = 784: MONET, MONOI, Monarch and PROTEA), lopinavir/r monotherapy (n = 829: OK pilot, OK-04, KalMo, KALESOLO, KRETA, MOST and DREAM), atazanavir/r monotherapy (n = 103: MODAT), or all three (n = 587: PIVOT). HIV-1 RNA plasma suppression was lower in the PI/r monotherapy arm compared with the triple therapy arm in the switch-equals-failure analysis [difference -8.3%; 95% confidence interval (CI) -11.9 to -4.8%], but not when intensification was included (difference 0.5%; 95% CI -2.5 to 3.6%). Rates of resistance mutations were similar between arms, as was overall neurocognitive function.

CONCLUSIONS

PI/r monotherapy showed a higher risk of plasma HIV-1 RNA elevations. However, there was no increased risk of treatment-emergent drug resistance, neurocognitive endpoints did not differ, and HIV-1 RNA suppression rates after intensification were similar between PI/r monotherapy and triple therapy.