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Sever B, Otsuka M, Fujita M, Ciftci H. A Review of FDA-Approved Anti-HIV-1 Drugs, Anti-Gag Compounds, and Potential Strategies for HIV-1 Eradication. Int J Mol Sci 2024; 25:3659. [PMID: 38612471 PMCID: PMC11012182 DOI: 10.3390/ijms25073659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/22/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Acquired immunodeficiency syndrome (AIDS) is an enormous global health threat stemming from human immunodeficiency virus (HIV-1) infection. Up to now, the tremendous advances in combination antiretroviral therapy (cART) have shifted HIV-1 infection from a fatal illness into a manageable chronic disorder. However, the presence of latent reservoirs, the multifaceted nature of HIV-1, drug resistance, severe off-target effects, poor adherence, and high cost restrict the efficacy of current cART targeting the distinct stages of the virus life cycle. Therefore, there is an unmet need for the discovery of new therapeutics that not only bypass the limitations of the current therapy but also protect the body's health at the same time. The main goal for complete HIV-1 eradication is purging latently infected cells from patients' bodies. A potential strategy called "lock-in and apoptosis" targets the budding phase of the life cycle of the virus and leads to susceptibility to apoptosis of HIV-1 infected cells for the elimination of HIV-1 reservoirs and, ultimately, for complete eradication. The current work intends to present the main advantages and disadvantages of United States Food and Drug Administration (FDA)-approved anti-HIV-1 drugs as well as plausible strategies for the design and development of more anti-HIV-1 compounds with better potency, favorable pharmacokinetic profiles, and improved safety issues.
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Affiliation(s)
- Belgin Sever
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Anadolu University, Eskisehir 26470, Türkiye;
- Medicinal and Biological Chemistry Science Farm Joint Research Laboratory, Faculty of Life Sciences, Kumamoto University, Kumamoto 862-0973, Japan;
| | - Masami Otsuka
- Medicinal and Biological Chemistry Science Farm Joint Research Laboratory, Faculty of Life Sciences, Kumamoto University, Kumamoto 862-0973, Japan;
- Department of Drug Discovery, Science Farm Ltd., Kumamoto 862-0976, Japan
| | - Mikako Fujita
- Medicinal and Biological Chemistry Science Farm Joint Research Laboratory, Faculty of Life Sciences, Kumamoto University, Kumamoto 862-0973, Japan;
| | - Halilibrahim Ciftci
- Medicinal and Biological Chemistry Science Farm Joint Research Laboratory, Faculty of Life Sciences, Kumamoto University, Kumamoto 862-0973, Japan;
- Department of Drug Discovery, Science Farm Ltd., Kumamoto 862-0976, Japan
- Department of Bioengineering Sciences, Izmir Katip Celebi University, Izmir 35620, Türkiye
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Leonard MA, Cindi Z, Bradford Y, Bourgi K, Koethe J, Turner M, Norwood J, Woodward B, Erdem H, Basham R, Baker P, Rebeiro PF, Sterling TR, Hulgan T, Daar ES, Gulick R, Riddler SA, Sinxadi P, Ritchie MD, Haas DW. Efavirenz Pharmacogenetics and Weight Gain Following Switch to Integrase Inhibitor-Containing Regimens. Clin Infect Dis 2021; 73:e2153-e2163. [PMID: 32829410 PMCID: PMC8492125 DOI: 10.1093/cid/ciaa1219] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/14/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Unwanted weight gain affects some people living with human immunodeficiency virus (HIV) who are prescribed integrase strand transfer inhibitors (INSTIs). Mechanisms and risk factors are incompletely understood. METHODS We utilized 2 cohorts to study pharmacogenetics of weight gain following switch from efavirenz- to INSTI-based regimens. In an observational cohort, we studied weight gain at 48 weeks following switch from efavirenz- to INSTI-based regimens among patients who had been virologically suppressed for at least 2 years at a clinic in the United States. Associations were characterized with CYP2B6 and UGT1A1 genotypes that affect efavirenz and INSTI metabolism, respectively. In a clinical trials cohort, we studied weight gain at 48 weeks among treatment-naive participants who were randomized to receive efavirenz-containing regimens in AIDS Clinical Trials Group studies A5095, A5142, and A5202 and did not receive INSTIs. RESULTS In the observational cohort (n = 61), CYP2B6 slow metabolizers had greater weight gain after switch (P = .01). This was seen following switch to elvitegravir or raltegravir, but not dolutegravir. UGT1A1 genotype was not associated with weight gain. In the clinical trials cohort (n = 462), CYP2B6 slow metabolizers had lesser weight gain at week 48 among participants receiving efavirenz with tenofovir disoproxil fumarate (P = .001), but not those receiving efavirenz with abacavir (P = .65). Findings were consistent when stratified by race/ethnicity and by sex. CONCLUSIONS Among patients who switched from efavirenz- to INSTI-based therapy, CYP2B6 genotype was associated with weight gain, possibly reflecting withdrawal of the inhibitory effect of higher efavirenz concentrations on weight gain. The difference by concomitant nucleoside analogue is unexplained.
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Affiliation(s)
| | - Zinhle Cindi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Yuki Bradford
- Department of Genetics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kassem Bourgi
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John Koethe
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Megan Turner
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jamison Norwood
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Rebecca Basham
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Paxton Baker
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Peter F Rebeiro
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Todd Hulgan
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric S Daar
- Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Roy Gulick
- Weill Cornell Medicine, New York, New York, USA
| | | | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marylyn D Ritchie
- Department of Genetics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David W Haas
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Meharry Medical College, Nashville, Tennessee, USA
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Li B, Veturi Y, Verma A, Bradford Y, Daar ES, Gulick RM, Riddler SA, Robbins GK, Lennox JL, Haas DW, Ritchie MD. Tissue specificity-aware TWAS (TSA-TWAS) framework identifies novel associations with metabolic, immunologic, and virologic traits in HIV-positive adults. PLoS Genet 2021; 17:e1009464. [PMID: 33901188 PMCID: PMC8102009 DOI: 10.1371/journal.pgen.1009464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 05/06/2021] [Accepted: 03/03/2021] [Indexed: 01/01/2023] Open
Abstract
As a type of relatively new methodology, the transcriptome-wide association study (TWAS) has gained interest due to capacity for gene-level association testing. However, the development of TWAS has outpaced statistical evaluation of TWAS gene prioritization performance. Current TWAS methods vary in underlying biological assumptions about tissue specificity of transcriptional regulatory mechanisms. In a previous study from our group, this may have affected whether TWAS methods better identified associations in single tissues versus multiple tissues. We therefore designed simulation analyses to examine how the interplay between particular TWAS methods and tissue specificity of gene expression affects power and type I error rates for gene prioritization. We found that cross-tissue identification of expression quantitative trait loci (eQTLs) improved TWAS power. Single-tissue TWAS (i.e., PrediXcan) had robust power to identify genes expressed in single tissues, but, often found significant associations in the wrong tissues as well (therefore had high false positive rates). Cross-tissue TWAS (i.e., UTMOST) had overall equal or greater power and controlled type I error rates for genes expressed in multiple tissues. Based on these simulation results, we applied a tissue specificity-aware TWAS (TSA-TWAS) analytic framework to look for gene-based associations with pre-treatment laboratory values from AIDS Clinical Trial Group (ACTG) studies. We replicated several proof-of-concept transcriptionally regulated gene-trait associations, including UGT1A1 (encoding bilirubin uridine diphosphate glucuronosyltransferase enzyme) and total bilirubin levels (p = 3.59×10−12), and CETP (cholesteryl ester transfer protein) with high-density lipoprotein cholesterol (p = 4.49×10−12). We also identified several novel genes associated with metabolic and virologic traits, as well as pleiotropic genes that linked plasma viral load, absolute basophil count, and/or triglyceride levels. By highlighting the advantages of different TWAS methods, our simulation study promotes a tissue specificity-aware TWAS analytic framework that revealed novel aspects of HIV-related traits. Transcriptome-wide association studies (TWAS) are a type of bioinformatics methodology for identifying complex trait-associated genes. There have been various TWAS methods, each developed under distinct biological assumptions of how genes contribute to complex traits. It is unclear, however, how powerful different TWAS methods are under a variety of biological scenarios. Here, we design an unbiased simulation strategy to evaluate the performance of multiple representative TWAS methods. We find that no one method fits all. Different TWAS methods are advantageous at dealing with different biological scenarios and answering different research questions. Thus, we propose a novel TWAS analytic framework that integrates and maximizes the performance of multiple TWAS methods, and validate its capability using a well-studied real-world dataset. In summary, our study provides quantitative evaluation of method performance to aid future TWAS experimental design and understanding of genes underlying complex human traits. The TWAS evaluation tool is made publicly available.
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Affiliation(s)
- Binglan Li
- Department of Biomedical Data Science, Stanford University, Stanford, California, United States of America
| | - Yogasudha Veturi
- Department of Genetics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Anurag Verma
- Department of Genetics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Yuki Bradford
- Department of Genetics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Eric S. Daar
- Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, United States of America
| | - Roy M. Gulick
- Weill Cornell Medicine, New York City, New York, United States of America
| | - Sharon A. Riddler
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Gregory K. Robbins
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jeffrey L. Lennox
- Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - David W. Haas
- Departments of Medicine, Pharmacology, Pathology, Microbiology & Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- Department of Internal Medicine, Meharry Medical College, Nashville, Tennessee, United States of America
| | - Marylyn D. Ritchie
- Department of Genetics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- * E-mail:
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Lévy Y, Lelièvre JD, Assoumou L, Aznar E, Pulido F, Tambussi G, Crespo M, Meybeck A, Molina JM, Delaugerre C, Izopet J, Peytavin G, Cardon F, Diallo A, Lancar R, Béniguel L, Costagliola D. Addition of Maraviroc Versus Placebo to Standard Antiretroviral Therapy for Initial Treatment of Advanced HIV Infection: A Randomized Trial. Ann Intern Med 2020; 172:297-305. [PMID: 32040959 DOI: 10.7326/m19-2133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patients diagnosed with advanced HIV infection have a poor prognosis despite initiation of combined antiretroviral therapy (c-ART). OBJECTIVE To assess the benefit of adding maraviroc, an antiretroviral drug with immunologic effects, to standard c-ART for patients with advanced disease at HIV diagnosis. DESIGN Randomized controlled trial. (ClinicalTrials.gov: NCT01348308). SETTING Clinical sites in France (n = 25), Italy (n = 5), and Spain (n = 20). PARTICIPANTS 416 HIV-positive, antiretroviral-naive adults with CD4 counts less than 0.200 × 109 cells/L and/or a previous AIDS-defining event (ADE). INTERVENTION C-ART plus placebo or maraviroc (300 mg twice daily with dose modification) for 72 weeks. MEASUREMENTS The primary end point was first occurrence of severe morbidity (new ADE, selected serious infections, serious non-ADE, immune reconstitution inflammatory syndrome, or death). Prespecified secondary outcomes included primary outcome components, biological and pharmacokinetic measures, and adverse events graded 2 or higher. RESULTS 409 randomly assigned participants (207 in the placebo group and 202 in the maraviroc group) who received more than 1 dose were included in the analysis. During 72 weeks of follow-up, incidence of severe morbidity was 11.1 per 100 person-years in the maraviroc group and 11.2 per 100 person-years in the placebo group (hazard ratio, 0.97 [95% CI, 0.57 to 1.67]). Incidence of adverse events graded 2 or higher was 36.1 versus 41.5 per 100 person-years (incidence rate ratio, 0.87 [CI, 0.65 to 1.15]). LIMITATIONS Sixty-four participants discontinued therapy during follow-up. The study was not designed to evaluate time-dependent outcomes or effect modification. CONCLUSION Addition of maraviroc to standard c-ART does not improve clinical outcomes of patients initiating therapy for advanced HIV infection. PRIMARY FUNDING SOURCE INSERM-ANRS (French National Agency for Research on AIDS).
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Affiliation(s)
- Yves Lévy
- Vaccine Research Institute, Institut National de la Santé et de la Recherche médicale (INSERM), and Assistance Publique Hôpitaux de Paris (APHP), Hôpital H. Mondor, Créteil, France (Y.L., J.L.)
| | - Jean-Daniel Lelièvre
- Vaccine Research Institute, Institut National de la Santé et de la Recherche médicale (INSERM), and Assistance Publique Hôpitaux de Paris (APHP), Hôpital H. Mondor, Créteil, France (Y.L., J.L.)
| | - Lambert Assoumou
- INSERM, Sorbonne Université, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP), Paris, France (L.A., R.L., L.B., D.C.)
| | - Esther Aznar
- Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica - Grupo de Estudio del SIDA, Madrid, Spain (E.A.)
| | - Federico Pulido
- Hospital Universitario 12 de Octubre, imas12, Universidad Complutense de Madrid (UCM), Madrid, Spain (F.P.)
| | - Giuseppe Tambussi
- Istituto di ricovero e cura a carattere scientifico-Ospedale San Raffaele, Milano, Italy (G.T.)
| | - Manuel Crespo
- Hospital universitario Vall d'Hebron, Barcelona, Spain (M.C.)
| | - Agnès Meybeck
- Service Universitaire des Maladies Infectieuses et du Voyageur, Centre Hospitalier de Tourcoing, Tourcoing, France (A.M.)
| | - Jean-Michel Molina
- INSERM U944, Université de Paris, Hôpital Saint-Louis, APHP, Paris, France (J.M., C.D.)
| | - Constance Delaugerre
- INSERM U944, Université de Paris, Hôpital Saint-Louis, APHP, Paris, France (J.M., C.D.)
| | - Jacques Izopet
- INSERM, U1043, Université Toulouse III Paul-Sabatier, Faculté de Médecine Toulouse-Purpan, Toulouse, France (J.I.)
| | - Gilles Peytavin
- Université Paris Diderot, Sorbonne Paris Cité, Laboratoire de Pharmacologie-Toxicologie, Hôpital Bichat-Claude Bernard, APHP, Paris, France (G.P.)
| | - Fanny Cardon
- ANRS, France Recherche Nord & Sud Sida-hiv Hépatites, Agence autonome de l'INSERM, Paris, France (F.C., A.D.)
| | - Alpha Diallo
- ANRS, France Recherche Nord & Sud Sida-hiv Hépatites, Agence autonome de l'INSERM, Paris, France (F.C., A.D.)
| | - Rémi Lancar
- INSERM, Sorbonne Université, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP), Paris, France (L.A., R.L., L.B., D.C.)
| | - Lydie Béniguel
- INSERM, Sorbonne Université, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP), Paris, France (L.A., R.L., L.B., D.C.)
| | - Dominique Costagliola
- INSERM, Sorbonne Université, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP), Paris, France (L.A., R.L., L.B., D.C.)
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The Use of the Restricted Mean Survival Time as a Treatment Measure in HIV/AIDS Clinical Trial: Reanalysis of the ACTG A5257 Trial. J Acquir Immune Defic Syndr 2019; 81:44-51. [PMID: 30789450 DOI: 10.1097/qai.0000000000001978] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The restricted mean survival time (RMST) measures have not been used as primary measure of efficacy in HIV/AIDS clinical trials. In this work, we aim to compare analysis based on the difference in RMST (Δ-RMST) measure and 2 other treatment-effect measures in a recent HIV equivalence trial, and to investigate the performance and characteristics of Δ-RMST-based analysis in a simulation study. SETTING AND METHODS We reanalyzed a recent HIV equivalence trial (ACTG A5257 trial) with hazard ratio and Δ-RMST, and then compared the results with the original analysis based on risk difference estimated by Kaplan-Meier curves (RDKM). In a simulation study, we investigated the performance and operating characteristics of Δ-RMST-based analysis in the setting of non-proportional hazards (PH) ratio. RESULTS In the ACTG A5257 trial, analyses based on Δ-RMST globally led to similar conclusions as the published finding based on RDKM. By contrast, analyses based on hazard ratio provided some discordant equivalence conclusions compared both with the initial analyses based on RDKM and the Δ-RMST. Results of simulation study indicate that the violation of the PH assumption has an impact on Δ-RMST-based analysis regarding the probability of declaring equivalence. CONCLUSIONS Although the RMST-based analysis is an alternative measure of efficacy in HIV/AIDS, clinical trials such an analysis can be strongly impacted by departures from the PH assumption.
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Feng Q, Zhou A, Zou H, Ingle S, May MT, Cai W, Cheng CY, Yang Z, Tang J. Quadruple versus triple combination antiretroviral therapies for treatment naive people with HIV: systematic review and meta-analysis of randomised controlled trials. BMJ 2019; 366:l4179. [PMID: 31285198 PMCID: PMC6613201 DOI: 10.1136/bmj.l4179] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the effects of four drug (quadruple) versus three drug (triple) combination antiretroviral therapies in treatment naive people with HIV, and explore the implications of existing trials for clinical practice and research. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES PubMed, EMBASE, CENTRAL, Web of Science, and the Cumulative Index to Nursing and Allied Health Literature from March 2001 to December 2016 (updated search in PubMed and EMBASE up to June 2018); and reference lists of eligible studies and related reviews. STUDY SELECTION Randomised controlled trials comparing quadruple with triple combination antiretroviral therapies in treatment naive people with HIV and evaluating at least one effectiveness or safety outcome. REVIEW METHODS Outcomes of interest included undetectable HIV-1 RNA, CD4 T cell count, virological failure, new AIDS defining events, death, and severe adverse effects. Random effects meta-analyses were conducted. RESULTS Twelve trials (including 4251 people with HIV) were eligible. Quadruple and triple combination antiretroviral therapies had similar effects on all relevant effectiveness and safety outcomes, with no point estimates favouring quadruple therapy. With the triple therapy as the reference group, the risk ratio was 0.99 (95% confidence interval 0.93 to 1.05) for undetectable HIV-1 RNA, 1.00 (0.90 to 1.11) for virological failure, 1.17 (0.84 to 1.63) for new AIDS defining events, 1.23 (0.74 to 2.05) for death, and 1.09 (0.89 to 1.33) for severe adverse effects. The mean difference in CD4 T cell count increase between the two groups was -19.55 cells/μL (-43.02 to 3.92). In general, the results were similar, regardless of the specific regimens of combination antiretroviral therapies, and were robust in all subgroup and sensitivity analyses. CONCLUSION In this study, effects of quadruple combination antiretroviral therapy were not better than triple combination antiretroviral therapy in treatment naive people with HIV. This finding lends support to current guidelines recommending the triple regimen as first line treatment. Further trials on this topic should be conducted only when new research is justified by adequate systematic reviews of the existing evidence. However, this study cannot exclude the possibility that quadruple cART would be better than triple cART when new classes of antiretroviral drugs are made available.
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Affiliation(s)
- Qi Feng
- Division of Epidemiology, Jockey Club School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Aoshuang Zhou
- Division of Epidemiology, Jockey Club School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, China
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Suzanne Ingle
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Margaret T May
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Weiping Cai
- Department of Infectious Disease, Guangzhou Eighth People's Hospital, Guangzhou, China
| | - Chien-Yu Cheng
- Division of Infectious Diseases, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
- School of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Zuyao Yang
- Division of Epidemiology, Jockey Club School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Jinling Tang
- Division of Epidemiology, Jockey Club School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
- Shenzhen Key Laboratory for Health Risk Analysis, Shenzhen Research Institute of the Chinese University of Hong Kong, Shenzhen, China
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Snedecor SJ, Radford M, Kratochvil D, Grove R, Punekar YS. Comparative efficacy and safety of dolutegravir relative to common core agents in treatment-naïve patients infected with HIV-1: a systematic review and network meta-analysis. BMC Infect Dis 2019; 19:484. [PMID: 31146698 PMCID: PMC6543679 DOI: 10.1186/s12879-019-3975-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/11/2019] [Indexed: 01/30/2023] Open
Abstract
Background Network meta-analyses (NMAs) provide comparative treatment effects estimates in the absence of head-to-head randomized controlled trials (RCTs). This NMA compared the efficacy and safety of dolutegravir (DTG) with other recommended or commonly used core antiretroviral agents. Methods A systematic review identified phase 3/4 RCTs in treatment-naïve patients with HIV-1 receiving core agents: ritonavir-boosted protease inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), or integrase strand inhibitors (INSTIs). Efficacy (virologic suppression [VS], CD4+ cell count change from baseline) and safety (adverse events [AEs], discontinuations, discontinuation due to AEs, lipid changes) were analyzed at Week 48 using Bayesian NMA methodology, which allowed calculation of probabilistic results. Subgroup analyses were conducted for VS (baseline viral load [VL] ≤/> 100,000copies/mL, ≤/> 500,000copies/mL; baseline CD4+ ≤/>200cells/μL). Results were adjusted for the nucleoside/nucleotide reverse transcriptase inhibitors (NRTI) combined with the core agent (except subgroup analyses). Results The NMA included 36 studies; 2 additional studies were included in subgroup analyses only. Odds of achieving VS with DTG were statistically superior to PIs (odds ratios [ORs] 1.78–2.59) and NNRTIs (ORs 1.51–1.86), and similar but numerically higher than other INSTIs. CD4+ count increase was significantly greater with DTG than PIs (difference: 23.63–31.47 cells/μL) and efavirenz (difference: 34.54 cells/μL), and similar to other core agents. INSTIs were more likely to result in patients achieving VS versus PIs (probability: 76–100%) and NNRTIs (probability: 50–100%), and a greater CD4+ count increase versus PIs (probability: 72–100%) and NNRTIs (probability: 60–100%). DTG was more likely to result in patients achieving VS (probability: 94–100%), and a greater CD4+ count increase (probability: 53–100%) versus other core agents, including INSTIs (probability: 94–97% and 53–93%, respectively). Safety outcomes with DTG were generally similar to other core agents. In patients with baseline VL > 100,000copies/mL or ≤ 200 CD4+cells/μL (18 studies), odds of achieving VS with DTG were superior or similar to other core agents. Conclusion INSTI core agents had superior efficacy and similar safety to PIs and NNRTIs at Week 48 in treatment-naïve patients with HIV-1, with DTG being among the most efficacious, including in patients with baseline VL > 100,000copies/mL or ≤ 200 CD4+cells/μL, who can be difficult to treat. Electronic supplementary material The online version of this article (10.1186/s12879-019-3975-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Matthew Radford
- ViiV Healthcare, GSK House, 980 Great West Rd, Brentford, Middlesex, TW8 9GS, UK
| | | | | | - Yogesh S Punekar
- ViiV Healthcare, GSK House, 980 Great West Rd, Brentford, Middlesex, TW8 9GS, UK.
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8
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Lu H, Cole SR, Hall HI, Schisterman EF, Breger TL, Edwards JK, Westreich D. Generalizing the per-protocol treatment effect: The case of ACTG A5095. Clin Trials 2019; 16:52-62. [PMID: 30326736 PMCID: PMC6693502 DOI: 10.1177/1740774518806311] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intention-to-treat comparisons of randomized trials provide asymptotically consistent estimators of the effect of treatment assignment, without regard to compliance. However, decision makers often wish to know the effect of a per-protocol comparison. Moreover, decision makers may also wish to know the effect of treatment assignment or treatment protocol in a user-specified target population other than the sample in which the trial was fielded. Here, we aimed to generalize results from the ACTG A5095 trial to the US recently HIV-diagnosed target population. METHODS We first replicated the published conventional intention-to-treat estimate (2-year risk difference and hazard ratio) comparing a four-drug antiretroviral regimen to a three-drug regimen in the A5095 trial. We then estimated the intention-to-treat effect that accounted for informative dropout and the per-protocol effect that additionally accounted for protocol deviations by constructing inverse probability weights. Furthermore, we employed inverse odds of sampling weights to generalize both intention-to-treat and per-protocol effects to a target population comprising US individuals with HIV diagnosed during 2008-2014. RESULTS Of 761 subjects in the analysis, 82 dropouts (36 in the three-drug arm and 46 in the four-drug arm) and 59 protocol deviations (25 in the three-drug arm and 34 in the four-drug arm) occurred during the first 2 years of follow-up. A total of 169 subjects incurred virologic failure or death. The 2-year risks were similar both in the trial and in the US HIV-diagnosed target population for estimates from the conventional intention-to-treat, dropout-weighted intention-to-treat, and per-protocol analyses. In the US target population, the 2-year conventional intention-to-treat risk difference (unit: %) for virologic failure or death comparing the four-drug arm to the three-drug arm was -0.4 (95% confidence interval: -6.2, 5.1), while the hazard ratio was 0.97 (95% confidence interval: 0.70, 1.34); the 2-year risk difference was -0.9 (95% confidence interval: -6.9, 5.3) for the dropout-weighted intention-to-treat comparison (hazard ratio = 0.95, 95% confidence interval: 0.68, 1.32) and -0.7 (95% confidence interval: -6.7, 5.5) for the per-protocol comparison (hazard ratio = 0.96, 95% confidence interval: 0.69, 1.34). CONCLUSION No benefit of four-drug antiretroviral regimen over three-drug regimen was found from the conventional intention-to-treat, dropout-weighted intention-to-treat or per-protocol estimates in the trial sample or target population.
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Affiliation(s)
- Haidong Lu
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephen R Cole
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - H Irene Hall
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Enrique F Schisterman
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Tiffany L Breger
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jessie K Edwards
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniel Westreich
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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9
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Gianotti N, Galli L, Galizzi N, Ripa M, Andolina A, Nozza S, Spagnuolo V, Poli A, Lazzarin A, Castagna A. Time spent with residual viraemia after virological suppression below 50 HIV-RNA copies/mL according to type of first-line antiretroviral regimen. Int J Antimicrob Agents 2018; 52:492-499. [PMID: 30009958 DOI: 10.1016/j.ijantimicag.2018.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 06/28/2018] [Accepted: 07/07/2018] [Indexed: 01/19/2023]
Abstract
PURPOSE To investigate if the regimen used when starting antiretroviral therapy (ART) affects the time spent with residual viraemia (RV) after achieving <50 HIV-RNA copies/mL. METHODS Retrospective cohort study on patients infected with human immunodeficiency virus (HIV), followed prospectively, who started ART with a boosted protease inhibitor (PI/r)-, a non-nucleoside reverse transcriptase inhibitor (NNRTI)- or an integrase inhibitor (InSTI)-based triple regimen, or a regimen with more than three drugs. RV was defined as any detectable polymerase chain reaction (PCR) signal <50 HIV-RNA copies/mL, as assessed by kinetic PCR or Abbott real-time PCR. The percentage of time spent with RV (%RV) was calculated as the cumulative follow-up time spent with RV on the observed follow-up, and was estimated using a generalized linear model. RESULTS Seven hundred and seventy-one patients (33%, 32%, 30% and 5% receiving PI/r-, NNRTI-, InSTI-based triple regimens, or a regimen with more than three drugs, respectively) were included in the analysis. After a median of 2.16 (interquartile range 1.27-3.16) years of follow-up, adjusted means of %RV were 37.9% [95% confidence interval (CI) 30.3-45.4%], 23.9% (95% CI 16-31.8%), 25.3% (95% CI 17.8-32.7%) and 45.5% (95% CI 34.6-56.4%) in the PI/r, NNRTI, InSTI and more than three drugs groups, respectively; %RV was significantly higher in patients who started ART with a regimen with more than three drugs (P=0.030), and was significantly lower in patients who started ART with an NNRTI-based regimen (P<0.0001) or an InSTI-based regimen (P=0.030) than in those who started ART with a PI/r-based regimen. %RV was independently associated with pre-ART HIV-RNA (P<0.0001), time to HIV-RNA <50 copies/mL (P<0.0001), NRTI backbone (P=0.037) and baseline HIV-RNA (P<0.0001). CONCLUSION First-line regimens based on PIs/r or on more than three drugs are associated with a greater percentage of time spent with RV after achieving virological suppression.
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Affiliation(s)
- Nicola Gianotti
- Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Laura Galli
- Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nadia Galizzi
- Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Marco Ripa
- Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Andolina
- Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Silvia Nozza
- Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vincenzo Spagnuolo
- Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Poli
- Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Adriano Lazzarin
- Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonella Castagna
- Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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10
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Haas DW, Bradford Y, Verma A, Verma SS, Eron JJ, Gulick RM, Riddler S, Sax PE, Daar ES, Morse GD, Acosta EP, Ritchie MD. Brain neurotransmitter transporter/receptor genomics and efavirenz central nervous system adverse events. Pharmacogenet Genomics 2018; 28:179-187. [PMID: 29847509 PMCID: PMC6010221 DOI: 10.1097/fpc.0000000000000341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE We characterized associations between central nervous system (CNS) adverse events and brain neurotransmitter transporter/receptor genomics among participants randomized to efavirenz-containing regimens in AIDS Clinical Trials Group studies in the USA. PARTICIPANTS AND METHODS Four clinical trials randomly assigned treatment-naive participants to efavirenz-containing regimens. Genome-wide genotype and PrediXcan were used to infer gene expression levels in tissues including 10 brain regions. Multivariable regression models stratified by race/ethnicity were adjusted for CYP2B6/CYP2A6 genotypes that predict plasma efavirenz exposure, age, and sex. Combined analyses also adjusted for genetic ancestry. RESULTS Analyses included 167 cases with grade 2 or greater efavirenz-consistent CNS adverse events within 48 weeks of study entry, and 653 efavirenz-tolerant controls. CYP2B6/CYP2A6 genotype level was independently associated with CNS adverse events (odds ratio: 1.07; P=0.044). Predicted expression of six genes postulated to mediate efavirenz CNS side effects (SLC6A2, SLC6A3, PGR, HTR2A, HTR2B, HTR6) were not associated with CNS adverse events after correcting for multiple testing, the lowest P value being for PGR in hippocampus (P=0.012), nor were polymorphisms in these genes or AR and HTR2C, the lowest P value being for rs12393326 in HTR2C (P=6.7×10(-4)). As a positive control, baseline plasma bilirubin concentration was associated with predicted liver UGT1A1 expression level (P=1.9×10(-27)). CONCLUSION Efavirenz-related CNS adverse events were not associated with predicted neurotransmitter transporter/receptor gene expression levels in brain or with polymorphisms in these genes. Variable susceptibility to efavirenz-related CNS adverse events may not be explained by brain neurotransmitter transporter/receptor genomics.
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Affiliation(s)
- David W. Haas
- Vanderbilt University School of Medicine, Nashville, TN
- Meharry Medical College, Nashville, TN
| | - Yuki Bradford
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Anurag Verma
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
- Institute for Biomedical Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Shefali S. Verma
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Joseph J. Eron
- University of North Carolina at Chapel Hill, Department of Medicine, Chapel Hill, NC
| | - Roy M. Gulick
- Weill Cornell Medicine, Department of Medicine, New York, NY
| | | | - Paul E. Sax
- Brigham and Women's Hospital and Harvard Medical School, Department of Medicine, Boston, MA
| | - Eric S. Daar
- Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | | | - Marylyn D. Ritchie
- Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
- Institute for Biomedical Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
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11
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Lok JJ, Yang S, Sharkey B, Hughes MD. Estimation of the cumulative incidence function under multiple dependent and independent censoring mechanisms. LIFETIME DATA ANALYSIS 2018; 24:201-223. [PMID: 28238045 PMCID: PMC5572121 DOI: 10.1007/s10985-017-9393-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 02/14/2017] [Indexed: 06/06/2023]
Abstract
Competing risks occur in a time-to-event analysis in which a patient can experience one of several types of events. Traditional methods for handling competing risks data presuppose one censoring process, which is assumed to be independent. In a controlled clinical trial, censoring can occur for several reasons: some independent, others dependent. We propose an estimator of the cumulative incidence function in the presence of both independent and dependent censoring mechanisms. We rely on semi-parametric theory to derive an augmented inverse probability of censoring weighted (AIPCW) estimator. We demonstrate the efficiency gained when using the AIPCW estimator compared to a non-augmented estimator via simulations. We then apply our method to evaluate the safety and efficacy of three anti-HIV regimens in a randomized trial conducted by the AIDS Clinical Trial Group, ACTG A5095.
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Affiliation(s)
- Judith J Lok
- Department of Biostatistics, Harvard School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA.
| | - Shu Yang
- Department of Statistics, North Carolina State University, Raleigh, NC, USA
| | | | - Michael D Hughes
- Department of Biostatistics, Harvard School of Public Health, 655 Huntington Avenue, Boston, MA, 02115, USA
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12
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Howe CJ, Dulin-Keita A, Cole SR, Hogan JW, Lau B, Moore RD, Mathews WC, Crane HM, Drozd DR, Geng E, Boswell SL, Napravnik S, Eron JJ, Mugavero MJ. Evaluating the Population Impact on Racial/Ethnic Disparities in HIV in Adulthood of Intervening on Specific Targets: A Conceptual and Methodological Framework. Am J Epidemiol 2018; 187:316-325. [PMID: 28992096 DOI: 10.1093/aje/kwx247] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 06/08/2017] [Indexed: 01/10/2023] Open
Abstract
Reducing racial/ethnic disparities in human immunodeficiency virus (HIV) disease is a high priority. Reductions in HIV racial/ethnic disparities can potentially be achieved by intervening on important intermediate factors. The potential population impact of intervening on intermediates can be evaluated using observational data when certain conditions are met. However, using standard stratification-based approaches commonly employed in the observational HIV literature to estimate the potential population impact in this setting may yield results that do not accurately estimate quantities of interest. Here we describe a useful conceptual and methodological framework for using observational data to appropriately evaluate the impact on HIV racial/ethnic disparities of interventions. This framework reframes relevant scientific questions in terms of a controlled direct effect and estimates a corresponding proportion eliminated. We review methods and conditions sufficient for accurate estimation within the proposed framework. We use the framework to analyze data on 2,329 participants in the CFAR [Centers for AIDS Research] Network of Integrated Clinical Systems (2008-2014) to evaluate the potential impact of universal prescription of and ≥95% adherence to antiretroviral therapy on racial disparities in HIV virological suppression. We encourage the use of the described framework to appropriately evaluate the potential impact of targeted interventions in addressing HIV racial/ethnic disparities using observational data.
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Affiliation(s)
- Chanelle J Howe
- Centers for Epidemiology and Environmental Health, Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island
| | - Akilah Dulin-Keita
- Center for Health Equity Research, Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island
| | - Stephen R Cole
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joseph W Hogan
- Center for Statistical Sciences, Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island
| | - Bryan Lau
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Richard D Moore
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Heidi M Crane
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington
| | - Daniel R Drozd
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington
| | - Elvin Geng
- Department of Medicine, School of Medicine, University of Washington, Seattle, Washington
| | | | - Sonia Napravnik
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joseph J Eron
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael J Mugavero
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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13
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Mollan KR, Tierney C, Hellwege JN, Eron JJ, Hudgens MG, Gulick RM, Haubrich R, Sax PE, Campbell TB, Daar ES, Robertson KR, Ventura D, Ma Q, Edwards DRV, Haas DW. Race/Ethnicity and the Pharmacogenetics of Reported Suicidality With Efavirenz Among Clinical Trials Participants. J Infect Dis 2017; 216:554-564. [PMID: 28931220 PMCID: PMC5853681 DOI: 10.1093/infdis/jix248] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 05/26/2017] [Indexed: 01/11/2023] Open
Abstract
Background We examined associations between suicidality and genotypes that predict plasma efavirenz exposure among AIDS Clinical Trials Group study participants in the United States. Methods Four clinical trials randomly assigned treatment-naive participants to efavirenz-containing regimens; suicidality was defined as reported suicidal ideation or attempted or completed suicide. Genotypes that predict plasma efavirenz exposure were defined by CYP2B6 and CYP2A6 polymorphisms. Associations were evaluated with weighted Cox proportional hazards models stratified by race/ethnicity. Additional analyses adjusted for genetic ancestry and selected covariates. Results Among 1833 participants, suicidality was documented in 41 in exposed analyses, and 34 in on-treatment analyses. In unadjusted analyses based on 12 genotype levels, suicidality increased per level in exposed (hazard ratio, 1.11; 95% confidence interval, .96-1.27) and on-treatment 1.16; 1.01-1.34) analyses. In the on-treatment analysis, the association was strongest among white but nearly null among black participants. Considering 3 metabolizer levels (extensive, intermediate and slow), slow metabolizers were at increased risk. Results were similar after baseline covariate-adjustment for genetic ancestry, sex, age, weight, injection drug use history, and psychiatric history or recent psychoactive medication. Conclusions Genotypes that predict higher plasma efavirenz exposure were associated with increased risk of suicidality. Strength of association varied by race/ethnicity.
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Affiliation(s)
| | - Camlin Tierney
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, and
| | | | - Joseph J Eron
- Center for AIDS Research and Departments of
- Medicine, University of North Carolina at Chapel Hill
| | | | - Roy M Gulick
- Weill Cornell Medicine, Department of Medicine, New York, and
| | | | - Paul E Sax
- Division of Infectious Diseases and Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Eric S Daar
- Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, David Geffen School of Medicine at UCLA, California; and
| | | | - Diana Ventura
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, and
| | - Qing Ma
- University at Buffalo, Department of Pharmacy Practice, New York
| | - Digna R. Velez Edwards
- Department of Obstetrics and Gynecology, Vanderbilt Genetics Institute, Vanderbilt University Medical Center
| | - David W Haas
- Department of Medicine, Vanderbilt University School of Medicine, and
- Department of Internal Medicine, Meharry Medical College, Nashville, Tennessee
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14
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Pharmacogenetics of efavirenz discontinuation for reported central nervous system symptoms appears to differ by race. Pharmacogenet Genomics 2017; 26:473-80. [PMID: 27509478 DOI: 10.1097/fpc.0000000000000238] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Efavirenz frequently causes central nervous system (CNS) symptoms. We evaluated genetic associations with efavirenz discontinuation for CNS symptoms within 12 months of treatment initiation. METHODS Patients had initiated efavirenz-containing regimens at an HIV primary care clinic in the Southeastern United States and had at least 12 months of follow-up data. Polymorphisms in CYP2B6 and CYP2A6 defined efavirenz metabolizer categories. Genome-wide genotyping enabled adjustment for population stratification. RESULTS Among 563 evaluable patients, 99 (17.5%) discontinued efavirenz within 12 months, 29 (5.1%) for CNS symptoms. The hazard ratio (HR) for efavirenz discontinuation for CNS symptoms in slow versus extensive metabolizers was 4.9 [95% confidence interval (CI): 1.9-12.4; P=0.001]. This HR in Whites was 6.5 (95% CI: 2.3-18.8; P=0.001) and 2.6 in Blacks (95% CI: 0.5-14.1; P=0.27). Considering only slow metabolizers, the HR in Whites versus Blacks was 3.1 (95% CI: 0.9-11.0; P=0.081). The positive predictive value of slow metabolizer genotypes for efavirenz discontinuation was 27% in Whites and 11% in Blacks. CONCLUSION Slow metabolizer genotypes were associated significantly with efavirenz discontinuation for reported CNS symptoms. This association was considerably stronger in Whites than in Blacks.
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15
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Kanters S, Vitoria M, Doherty M, Socias ME, Ford N, Forrest JI, Popoff E, Bansback N, Nsanzimana S, Thorlund K, Mills EJ. Comparative efficacy and safety of first-line antiretroviral therapy for the treatment of HIV infection: a systematic review and network meta-analysis. Lancet HIV 2016; 3:e510-e520. [PMID: 27658869 DOI: 10.1016/s2352-3018(16)30091-1] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 06/24/2016] [Accepted: 06/30/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND New antiretroviral therapy (ART) regimens for HIV could improve clinical outcomes for patients. To inform global guidelines, we aimed to assess the comparative effectiveness of recommended ART regimens for HIV in ART-naive patients. METHODS For this systematic review and network meta-analysis, we searched for randomised clinical trials published up to July 5, 2015, comparing recommended antiretroviral regimens in treatment-naive adults and adolescents (aged 12 years or older) with HIV. We extracted data on trial and patient characteristics, and the following primary outcomes: viral suppression, mortality, AIDS defining illnesses, discontinuations, discontinuations due to adverse events, and serious adverse events. We synthesised data using network meta-analyses in a Bayesian framework and included older treatments, such as indinavir, to serve as connecting nodes. We defined network nodes in terms of specific antivirals rather than specific ART regimens. We categorised backbone regimens and adjusted for them through group-specific meta-regression. We used the GRADE framework to interpret the strength of inference. FINDINGS We identified 5865 citations through database searches and other sources, of which, 126 articles related to 71 unique trials were included in the network analysis, including 34 032 patients randomly assigned to 161 treatment groups. For viral suppression at 48 weeks, compared with efavirenz, the odds ratio (OR) for viral suppression was 1·87 (95% credible interval [CrI] 1·34-2·64) with dolutegravir and 1·40 (1·02-1·96) with raltegravir; with respect to viral suppression, low-dose efavirenz was similar to all other treatments. Both low-dose efavirenz and integrase strand transfer inhibitors tended to be protective of discontinuations due to adverse events relative to normal-dose efavirenz. The most protective effect relative to efavirenz in network meta-analyses was that of dolutegravir (OR 0·26, 95% CrI 0·14-0·47), followed by low-dose efavirenz (0·39, 0·16-0·92). Owing to insufficient data, we could make no conclusions about serious adverse events. Low event rates also limited the quality of evidence with regard to mortality and AIDS defining illnesses. INTERPRETATION The efficacy and safety of ART has substantially improved with the introduction of newer drug classes of antiretrovirals that are now available to patients and HIV care providers. Their improved tolerance could be part of a larger solution to improve retention, which is a challenge, particularly in low-income and middle-income country settings. FUNDING The World Health Organization.
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Affiliation(s)
- Steve Kanters
- Precision Global Health, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - Meg Doherty
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | | | - Nathan Ford
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | - Jamie I Forrest
- Precision Global Health, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Evan Popoff
- Precision Global Health, Vancouver, BC, Canada
| | - Nick Bansback
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Edward J Mills
- Precision Global Health, Vancouver, BC, Canada; School of Public Health, University of Rwanda, Kigali, Rwanda.
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16
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Fogel JM, Hudelson SE, Ou SS, Hart S, Wallis C, Morgado MG, Saravanan S, Tripathy S, Hovind L, Piwowar-Manning E, Sabin D, McCauley M, Gamble T, Zhang XC, Eron JJ, Gallant JE, Kumwenda J, Makhema J, Kumarasamy N, Chariyalertsak S, Hakim J, Badal-Faesen S, Akelo V, Hosseinipour MC, Santos BR, Godbole SV, Pilotto JH, Grinsztejn B, Panchia R, Mayer KH, Chen YQ, Cohen MS, Eshleman SH. Brief Report: HIV Drug Resistance in Adults Failing Early Antiretroviral Treatment: Results From the HIV Prevention Trials Network 052 Trial. J Acquir Immune Defic Syndr 2016; 72:304-9. [PMID: 26859828 PMCID: PMC4911290 DOI: 10.1097/qai.0000000000000951] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Early initiation of antiretroviral treatment (ART) reduces HIV transmission and has health benefits. HIV drug resistance can limit treatment options and compromise use of ART for HIV prevention. We evaluated drug resistance in 85 participants in the HIV Prevention Trials Network 052 trial who started ART at CD4 counts of 350-550 cells per cubic millimeter and failed ART by May 2011; 8.2% had baseline resistance and 35.3% had resistance at ART failure. High baseline viral load and less education were associated with emergence of resistance at ART failure. Resistance at ART failure was observed in 7 of 8 (87.5%) participants who started ART at lower CD4 cell counts.
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Affiliation(s)
- Jessica M Fogel
- 1Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD; 2Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA; 3Frontier Science & Technology Research Foundation, Amherst, NY; 4Specialty Molecular Division, Lancet Laboratories and BARC-SA, Johannesburg, South Africa; 5Laboratory of AIDS and Molecular Immunology, Oswaldo Cruz Institute, Rio de Janeiro, Brazil; 6Y. R. Gaitonde Centre for AIDS Research and Education, Chennai, India; 7National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Agra, India; 8Science Facilitation Department, FHI 360, Washington, DC; 9Science Facilitation Department, FHI 360, Durham, NC; 10Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; 11Southwest CARE Center, Santa Fe, NM; 12College of Medicine-Johns Hopkins Project, Blantyre, Malawi; 13Botswana Harvard AIDS Institute, Gaborone, Botswana; 14YRGCARE Medical Centre, VHS, Chennai, India; 15Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand; 16Department of Medicine, University of Zimbabwe, Harare, Zimbabwe; 17Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa; 18Kenya Medical Research Institute, Center for Disease Control, Kisumu, Kenya; 19Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC; 20UNC Project-Malawi, Institute for Global Health and Infectious Diseases, Lilongwe, Malawi; 21Serviço de Infectologia, Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil; 22Department of Epidemiology and Biostatistics, National AIDS Research Institute (ICMR), Pune, India; 23Hospital Geral de Nova Iguacu and Laboratorio de AIDS e Imunologia Molecular-IOC/Fiocruz, Rio de Janeiro, Brazil; 24Instituto Nacional de Infectologia Evandro Chagas-INI-Fiocruz, Rio de Janeiro, Brazil; 25Perinatal HIV Research Unit, University of the Witwatersrand, Soweto HPTN CRS, S
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17
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Castel AD, Kalmin MM, Hart RLD, Young HA, Hays H, Benator D, Kumar P, Elion R, Parenti D, Ruiz ME, Wood A, D'Angelo L, Rakhmanina N, Rana S, Bryant M, Hebou A, Fernández R, Abbott S, Peterson J, Wood K, Subramanian T, Binkley J, Happ LP, Kharfen M, Masur H, Greenberg AE. Disparities in achieving and sustaining viral suppression among a large cohort of HIV-infected persons in care - Washington, DC. AIDS Care 2016; 28:1355-64. [PMID: 27297952 DOI: 10.1080/09540121.2016.1189496] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
One goal of the HIV care continuum is achieving viral suppression (VS), yet disparities in suppression exist among subpopulations of HIV-infected persons. We sought to identify disparities in both the ability to achieve and sustain VS among an urban cohort of HIV-infected persons in care. Data from HIV-infected persons enrolled at the 13 DC Cohort study clinical sites between January 2011 and June 2014 were analyzed. Univariate and multivariate logistic regression were conducted to identify factors associated with achieving VS (viral load < 200 copies/ml) at least once, and Kaplan-Meier (KM) curves and Cox proportional hazards models were used to identify factors associated with sustaining VS and time to virologic failure (VL ≥ 200 copies/ml after achievement of VS). Among the 4311 participants, 95.4% were either virally suppressed at study enrollment or able to achieve VS during the follow-up period. In multivariate analyses, achieving VS was significantly associated with age (aOR: 1.04; 95%CI: 1.03-1.06 per five-year increase) and having a higher CD4 (aOR: 1.05, 95% CI 1.04-1.06 per 100 cells/mm(3)). Patients infected through perinatal transmission were less likely to achieve VS compared to MSM patients (aOR: 0.63, 95% CI 0.51-0.79). Once achieved, most participants (74.4%) sustained VS during follow-up. Blacks and perinatally infected persons were less likely to have sustained VS in KM survival analysis (log rank chi-square p ≤ .001 for both) compared to other races and risk groups. Earlier time to failure was observed among females, Blacks, publically insured, perinatally infected, those with longer standing HIV infection, and those with diagnoses of mental health issues or depression. Among this HIV-infected cohort, most people achieved and maintained VS; however, disparities exist with regard to patient age, race, HIV transmission risk, and co-morbid conditions. Identifying populations with disparate outcomes allows for appropriate targeting of resources to improve outcomes along the care continuum.
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Affiliation(s)
- Amanda D Castel
- a Department of Epidemiology and Biostatistics , George Washington University Milken Institute School of Public Health , Washington , DC , USA
| | - Mariah M Kalmin
- a Department of Epidemiology and Biostatistics , George Washington University Milken Institute School of Public Health , Washington , DC , USA
| | | | - Heather A Young
- a Department of Epidemiology and Biostatistics , George Washington University Milken Institute School of Public Health , Washington , DC , USA
| | - Harlen Hays
- b Cerner Corporation , Kansas City , MO , USA
| | - Debra Benator
- c Veterans Affairs Medical Center , Washington , DC , USA
| | - Princy Kumar
- d Division of Infectious Diseases, Georgetown University , Washington , DC , USA
| | | | - David Parenti
- f Division of Infectious Disease , George Washington Medical Faculty Associates , Washington , DC , USA
| | - Maria Elena Ruiz
- g Division of Infectious Diseases, Department of Medicine , Washington Hospital Center , Washington , DC , USA
| | - Angela Wood
- h Family and Medical Counseling Service , Washington , DC , USA
| | - Lawrence D'Angelo
- i Burgess Adolescent Clinic, Children's National Medical Center , Washington , DC , USA
| | - Natella Rakhmanina
- j Special Immunology Service Pediatric Clinic Children's National Medical Center , Washington , DC , USA
| | - Sohail Rana
- k Department of Pediatric and Child Health , Howard University Hospital , Washington , DC , USA
| | - Maya Bryant
- l Howard University Hospital Adult Infectious Disease Clinic , Washington , DC , USA
| | | | | | | | - James Peterson
- a Department of Epidemiology and Biostatistics , George Washington University Milken Institute School of Public Health , Washington , DC , USA
| | - Kathy Wood
- p Cerner Corporation , Vienna , VA , USA
| | | | | | - Lindsey Powers Happ
- a Department of Epidemiology and Biostatistics , George Washington University Milken Institute School of Public Health , Washington , DC , USA
| | - Michael Kharfen
- r District of Columbia Department of Health , HIV/AIDS, Hepatitis, Sexually Transmitted Diseases, Tuberculosis Administration (HAHSTA) , Washington , DC , USA
| | - Henry Masur
- s Department of Critical Care Medicine , National Institutes of Health , Bethesda , MD , USA
| | - Alan E Greenberg
- a Department of Epidemiology and Biostatistics , George Washington University Milken Institute School of Public Health , Washington , DC , USA
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Tonk ECM, Gurwitz D, Maitland-van der Zee AH, Janssens ACJW. Assessment of pharmacogenetic tests: presenting measures of clinical validity and potential population impact in association studies. THE PHARMACOGENOMICS JOURNAL 2016; 17:386-392. [PMID: 27168098 PMCID: PMC5549182 DOI: 10.1038/tpj.2016.34] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 12/24/2015] [Accepted: 02/26/2016] [Indexed: 12/20/2022]
Abstract
The progressing discovery of genetic variants associated with drug-related adverse events has raised expectations for pharmacogenetic tests to improve drug efficacy and safety. To further the use of pharmacogenetics in health care, tests with sufficient potential to improve efficacy and safety, as reflected by good clinical validity and population impact, need to be identified. The potential benefit of pharmacogenetic tests is often concluded from the strength of the association between the variant and the adverse event; measures of clinical validity are generally not reported. This paper describes measures of clinical validity and potential population health impact that can be calculated from association studies. We explain how these measures are influenced by the strength of the association and by the frequencies of the variant and the adverse event. The measures are illustrated using examples of testing for HLA-B*5701 associated with abacavir-induced hypersensitivity and SLCO1B1 c.521T>C (*5) associated with simvastatin-induced adverse events.
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Affiliation(s)
- E C M Tonk
- Department of Clinical Genetics/EMGO Institute for Health and Care Research, Section Community Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - D Gurwitz
- Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - A-H Maitland-van der Zee
- Utrecht Institute of Pharmaceutical Sciences, Division of Pharmacoepidemiology &Clinical Pharmacology, Utrecht University, Utrecht, The Netherlands
| | - A C J W Janssens
- Department of Clinical Genetics/EMGO Institute for Health and Care Research, Section Community Genetics, VU University Medical Center, Amsterdam, The Netherlands.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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19
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Kearney MF, Wiegand A, Shao W, Coffin JM, Mellors JW, Lederman M, Gandhi RT, Keele BF, Li JZ. Origin of Rebound Plasma HIV Includes Cells with Identical Proviruses That Are Transcriptionally Active before Stopping of Antiretroviral Therapy. J Virol 2016; 90:1369-76. [PMID: 26581989 PMCID: PMC4719635 DOI: 10.1128/jvi.02139-15] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/05/2015] [Indexed: 12/28/2022] Open
Abstract
UNLABELLED Understanding the origin of HIV variants during viral rebound may provide insight into the composition of the HIV reservoir and has implications for the design of curative interventions. HIV single-genome sequences were obtained from 10 AIDS Clinical Trials Group participants who underwent analytic antiretroviral therapy (ART) interruption (ATI). Rebounding variants were compared with those in pre-ART plasma in all 10 participants and with on-ART peripheral blood mononuclear cell (PBMC)-associated DNA and RNA (CA-RNA) in 7/10 participants. The highest viral diversities were found in the DNA and CA-RNA populations. In 3 of 7 participants, we detected multiple, identical DNA and CA-RNA sequences during suppression on ART that exactly matched plasma HIV sequences. Hypermutated DNA and CA-RNA were detected in four participants, contributing to diversities in these compartments that were higher than in the pre-ART and post-ATI plasma. Shifts in the viral rebound populations could be detected in some participants over the 2- to 3-month observation period. These findings suggest that a source of initial rebound viremia could be populations of infected cells that clonally expanded prior to and/or during ART, some of which were already expressing HIV RNA before treatment was interrupted. These clonally expanding populations of HIV-infected cells may represent an important target for strategies aimed at achieving reservoir reduction and sustained virologic remission. IMPORTANCE Antiretroviral therapy alone cannot eradicate the HIV reservoir, and viral rebound is generally rapid after treatment interruption. It has been suggested that clonal expansion of HIV-infected cells is an important mechanism of HIV reservoir persistence, but the contribution of these clonally proliferating cells to the rebounding virus is unknown. We report a study of AIDS Clinical Trials Group participants who underwent treatment interruption and compared rebounding plasma virus with that found within cells prior to treatment interruption. We found several incidences in which plasma HIV variants exactly matched that of multiple proviral DNA copies from infected blood cells sampled before treatment interruption. In addition, we found that these cells were not dormant but were generating unspliced RNA transcripts before treatment was interrupted. Identification of the HIV reservoir and determining its mechanisms for persistence may aid in the development of strategies toward a cure for HIV. (This study was presented in part at the Conference on Retroviruses and Opportunistic Infections, Seattle, WA, February 23 to 26 2015.).
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Affiliation(s)
- Mary F Kearney
- HIV Dynamics and Replication Program, National Cancer Institute, Frederick, Maryland, USA
| | - Ann Wiegand
- HIV Dynamics and Replication Program, National Cancer Institute, Frederick, Maryland, USA
| | - Wei Shao
- Leidos Biomedical Research, Inc., Frederick National Laboratories for Cancer Research, Frederick, Maryland, USA
| | - John M Coffin
- Department of Molecular Biology and Microbiology, Tufts University, Boston, Massachusetts, USA
| | - John W Mellors
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Rajesh T Gandhi
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brandon F Keele
- Leidos Biomedical Research, Inc., Frederick National Laboratories for Cancer Research, Frederick, Maryland, USA
| | - Jonathan Z Li
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Lok JJ, Hughes MD. Evaluating predictors of competing risk outcomes when censoring depends on time-dependent covariates, with application to safety and efficacy of HIV treatment. Stat Med 2016; 35:2183-94. [PMID: 26763556 DOI: 10.1002/sim.6852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 10/21/2015] [Accepted: 11/30/2015] [Indexed: 11/08/2022]
Abstract
We propose a prediction model for the cumulative incidence functions of competing risks, based on a logit link. Because of a concern about censoring potentially depending on time-varying covariates in our motivating human immunodeficiency virus (HIV) application, we describe an approach for estimating the parameters in the prediction models using inverse probability of censoring weighting under a missingness at random assumption. We then illustrate the application of this methodology to identify predictors of the competing outcomes of virologic failure, an efficacy outcome, and treatment limiting adverse event, a safety outcome, among human immunodeficiency virus-infected patients first starting antiretroviral treatment. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Judith J Lok
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, MA, 65502115, U.S.A
| | - Michael D Hughes
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Huntington Avenue, Boston, MA, 65502115, U.S.A
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Swart M, Evans J, Skelton M, Castel S, Wiesner L, Smith PJ, Dandara C. An Expanded Analysis of Pharmacogenetics Determinants of Efavirenz Response that Includes 3'-UTR Single Nucleotide Polymorphisms among Black South African HIV/AIDS Patients. Front Genet 2016; 6:356. [PMID: 26779253 PMCID: PMC4703773 DOI: 10.3389/fgene.2015.00356] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 12/10/2015] [Indexed: 01/11/2023] Open
Abstract
Introduction: Efavirenz (EFV) is a non-nucleoside reverse transcriptase inhibitor prescribed as part of first-line highly active antiretroviral therapy (HAART) in South Africa. Despite administration of fixed doses of EFV, inter-individual variability in plasma concentrations has been reported. Poor treatment outcomes such as development of adverse drug reactions or treatment failure have been linked to EFV plasma concentrations outside the therapeutic range (1–4 μg/mL) in some studies. The drug metabolizing enzyme (DME), CYP2B6, is primarily responsible for EFV metabolism with minor contributions by CYP1A2, CYP2A6, CYP3A4, CYP3A5, and UGT2B7. DME coding genes are also regulated by microRNAs through targeting the 3′-untranslated region. Expanded analysis of 30 single nucleotide polymorphisms (SNPs), including those in the 3′-UTR, was performed to identify pharmacogenetics determinants of EFV plasma concentrations in addition to CYP2B6 c.516G>T and c.983T>C SNPs. Methods: SNPs in CYP1A2, CYP2B6, UGT2B7, and NR1I2 (PXR) were selected for genotyping among 222 Bantu-speaking South African HIV-infected patients receiving EFV-containing HAART. This study is a continuation of earlier pharmacogenetics studies emphasizing the role of genetic variation in the 3′-UTR of genes which products are either pharmacokinetic or pharmacodynamic targets of EFV. Results: Despite evaluating thirty SNPs, CYP2B6 c.516G>T and c.983T>C SNPs remain the most prominent predictors of EFV plasma concentration. Conclusion: We have shown that CYP2B6 c.516G>T and c.983T>C SNPs are the most important predictors of EFV plasma concentration after taking into account all other SNPs, including genetic variation in the 3′-UTR, and variables affecting EFV metabolism.
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Affiliation(s)
- Marelize Swart
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Jonathan Evans
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Michelle Skelton
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Sandra Castel
- Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Peter J Smith
- Division of Clinical Pharmacology, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
| | - Collet Dandara
- Division of Human Genetics, Department of Pathology and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town Cape Town, South Africa
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Llibre JM, Walmsley S, Gatell JM. Backbones versus core agents in initial ART regimens: one game, two players. J Antimicrob Chemother 2016; 71:856-61. [PMID: 26747092 DOI: 10.1093/jac/dkv429] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The advances seen in ART during the last 30 years have been outstanding. Treatment has evolved from the initial use of single agents as monotherapy. The ability to use HIV RNA as a surrogate marker for clinical outcomes allowed the more rapid evaluation of new therapies. This led to the understanding that triple-drug regimens, including a core agent (an NNRTI or a boosted PI) and two NRTIs, are optimal. These combinations have demonstrated continued improvements in their efficacy and toxicity as initial therapy. However, the need for pharmacokinetic boosting, with potential drug-drug interactions, or residual issues of efficacy or toxicity have persisted for some agents. Most recently, integrase strand transfer inhibitors, particularly dolutegravir, have shown unparalleled safety and efficacy and are currently the core agents of choice. Regimens that included only core agents or only backbone agents have not been as successful as combined therapy in antiretroviral-naive patients. It appears that at least one NRTI is needed for optimal performance and lamivudine and emtricitabine may be the ideal candidates. Several studies are ongoing of agents with longer dosing intervals, lower cost and new NRTI-saving strategies to address unmet needs.
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Affiliation(s)
- Josep M Llibre
- HIV Unit and 'Lluita contra la SIDA' Foundation, University Hospital Germans Trias I Pujol, Badalona, Spain Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sharon Walmsley
- Infectious Diseases, University Health Network, University of Toronto, Toronto, Canada
| | - Josep M Gatell
- Infectious Diseases & AIDS Units, Hospital Clinic/IDIBAPS, University of Barcelona, Barcelona, Spain
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Efavirenz a nonnucleoside reverse transcriptase inhibitor of first-generation: Approaches based on its medicinal chemistry. Eur J Med Chem 2016; 108:455-465. [DOI: 10.1016/j.ejmech.2015.11.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/12/2015] [Accepted: 11/17/2015] [Indexed: 11/21/2022]
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Schackman BR, Haas DW, Park SS, Li XC, Freedberg KA. Cost-effectiveness of CYP2B6 genotyping to optimize efavirenz dosing in HIV clinical practice. Pharmacogenomics 2015; 16:2007-18. [PMID: 26607811 PMCID: PMC4832977 DOI: 10.2217/pgs.15.142] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
AIMS To assess the cost-effectiveness of CYP2B6 genotyping to guide efavirenz dosing for initial HIV therapy in the USA. METHODS We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) microsimulation model to project quality-adjusted life expectancy and lifetime costs (2014 US dollars) for efavirenz-based HIV therapy with or without CYP2B6 genotyping. We assumed that with genotyping 60% of patients would be eligible to receive lower doses. RESULTS Current care without CYP2B6 genotyping has an incremental cost-effectiveness ratio >$100,000/QALY compared with genotype-guided dosing, even if lower dosing reduces efficacy. When we assumed generic efavirenz availability, conclusions were similar unless lower dosing reduces efficacy by 6% or more. CONCLUSION CYP2B6 genotyping can inform efavirenz dosing and decrease HIV therapy cost.
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Affiliation(s)
- Bruce R Schackman
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - David W Haas
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sanghee S Park
- Medical Practice Evaluation Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - X Cynthia Li
- Medical Practice Evaluation Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Health Policy & Management, Harvard TH Chan School of Public Health, Boston, MA, USA
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Comparative Safety and Neuropsychiatric Adverse Events Associated With Efavirenz Use in First-Line Antiretroviral Therapy: A Systematic Review and Meta-Analysis of Randomized Trials. J Acquir Immune Defic Syndr 2015; 69:422-9. [PMID: 25850607 DOI: 10.1097/qai.0000000000000606] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Efavirenz (EFV) is widely used for the treatment of antiretroviral-naive HIV-positive individuals, but there are concerns about the risk of adverse neuropsychiatric events. We systematically reviewed the safety of EFV in first-line therapy. METHODS Four databases were searched until October 2014 for randomized trials comparing EFV against non-EFV-based regimens for the treatment of antiretroviral-naive HIV-positive adults and children. The primary outcome was drug discontinuation as a result of any adverse event. Relative risks and proportions were pooled using random-effects meta-analysis. RESULTS Forty-two trials were included for review. A lower relative and absolute risk of discontinuations due to adverse drug reactions was seen with EFV compared to nevirapine. The relative and absolute risk of discontinuation was greater for EFV compared with low-dose EFV, rilpivirine, tenofovir, atazanavir, and maraviroc. The relative risk of discontinuation was greater for EFV compared with dolutegravir and raltegravir, but absolute risks were not significantly different. There was no difference in the risk of any severe clinical adverse events for any comparison. With the exception of dizziness, fewer than 10% of patients exposed to EFV experienced any other specific type of neuropsychiatric event. No suicides were reported. CONCLUSIONS This review found that over 90% of patients remained on an EFV-based first-line regimen after an average follow-up time of 78 weeks. The relative risk of discontinuations due to adverse events was higher for EFV compared with most other first-line options, but absolute differences were less than 5% for all comparisons.
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Genome-wide association study of virologic response with efavirenz-containing or abacavir-containing regimens in AIDS clinical trials group protocols. Pharmacogenet Genomics 2015; 25:51-9. [PMID: 25461247 DOI: 10.1097/fpc.0000000000000106] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Efavirenz and abacavir are components of recommended first-line regimens for HIV-1 infection. We used genome-wide genotyping and clinical data to explore genetic associations with virologic failure among patients randomized to efavirenz-containing or abacavir-containing regimens in AIDS Clinical Trials Group (ACTG) protocols. PARTICIPANTS AND METHODS Virologic response and genome-wide genotype data were available from treatment-naive patients randomized to efavirenz-containing (n=1596) or abacavir-containing (n = 786) regimens in ACTG protocols 384, A5142, A5095, and A5202. RESULTS Meta-analysis of association results across race/ethnic groups showed no genome-wide significant associations (P < 5 × 10) with virologic response for either efavirenz or abacavir. Our sample size provided 80% power to detect a genotype relative risk of 1.8 for efavirenz and 2.4 for abacavir. Analyses focused on CYP2B genotypes that define the lowest plasma efavirenz exposure stratum did not show associations nor did analysis limited to gene sets predicted to be relevant to efavirenz and abacavir disposition. CONCLUSION No single polymorphism is associated strongly with virologic failure with efavirenz-containing or abacavir-containing regimens. Analyses to better consider context, and that minimize confounding by nongenetic factors, may show associations not apparent here.
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Comparison of Three Different FDA-Approved Plasma HIV-1 RNA Assay Platforms Confirms the Virologic Failure Endpoint of 200 Copies per Milliliter Despite Improved Assay Sensitivity. J Clin Microbiol 2015; 53:2659-66. [PMID: 26063861 DOI: 10.1128/jcm.00801-15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 06/04/2015] [Indexed: 11/20/2022] Open
Abstract
Discrepancies between HIV-1 RNA results assayed by different FDA-approved platforms have been reported. Plasma samples collected from 332 randomly selected clinical trial participants during the second year of antiretroviral treatment were assayed with three FDA-approved platforms: UltraSensitive Roche Amplicor Monitor, v1.5 (Monitor), the Abbott RealTime HIV-1 test on the m2000 system (Abbott), and the Roche TaqMan HIV-1 test, v2.0 (TaqMan). Samples from 61 additional participants with confirmed HIV-1 RNA levels of >50 copies/ml during trial follow-up were also included. Endpoints were HIV-1 RNA quantification of ≤50 copies/ml versus >50 copies/ml at an individual-sample level (primary) and determination of confirmed virologic failure (VF) from longitudinal samples. A total of 389 participants had results obtained from all assays on at least one sample (median = 6). Proportions of results of >50 copies/ml were 19% (Monitor), 22% (TaqMan), and 25% (Abbott). Despite indication of strong agreement (Cohen's kappa, 0.76 to 0.82), Abbott was more likely to detect HIV-1 RNA levels of >50 copies/ml than Monitor (matched-pair odds ratio [mOR] = 4.2; modified Obuchowski P < 0.001) and TaqMan (mOR = 2.1; P < 0.001); TaqMan was more likely than Monitor (mOR = 2.6; P < 0.001). Despite strong agreement in classifying VF across assay comparisons (kappa, 0.75 to 0.92), at a 50-copies/ml threshold, differences in the probability of VF classification (in the same direction as primary) were apparent (all McNemar's P < 0.007). At a 200-copies/ml VF threshold, no differences between assays were apparent (all P > 0.13). Despite strong agreement among assays, significant differences were observed with respect to detecting HIV-1 RNA levels of >50 copies/ml and identifying VF at the 50-copies/ml threshold. This has important implications for the definition of VF in clinical trials and clinical practice.
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Duwal S, Winkelmann S, Schütte C, von Kleist M. Optimal Treatment Strategies in the Context of 'Treatment for Prevention' against HIV-1 in Resource-Poor Settings. PLoS Comput Biol 2015; 11:e1004200. [PMID: 25927964 PMCID: PMC4423987 DOI: 10.1371/journal.pcbi.1004200] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 02/18/2015] [Indexed: 12/15/2022] Open
Abstract
An estimated 2.7 million new HIV-1 infections occurred in 2010. `Treatment-for-prevention’ may strongly prevent HIV-1 transmission. The basic idea is that immediate treatment initiation rapidly decreases virus burden, which reduces the number of transmittable viruses and thereby the probability of infection. However, HIV inevitably develops drug resistance, which leads to virus rebound and nullifies the effect of `treatment-for-prevention’ for the time it remains unrecognized. While timely conducted treatment changes may avert periods of viral rebound, necessary treatment options and diagnostics may be lacking in resource-constrained settings. Within this work, we provide a mathematical platform for comparing different treatment paradigms that can be applied to many medical phenomena. We use this platform to optimize two distinct approaches for the treatment of HIV-1: (i) a diagnostic-guided treatment strategy, based on infrequent and patient-specific diagnostic schedules and (ii) a pro-active strategy that allows treatment adaptation prior to diagnostic ascertainment. Both strategies are compared to current clinical protocols (standard of care and the HPTN052 protocol) in terms of patient health, economic means and reduction in HIV-1 onward transmission exemplarily for South Africa. All therapeutic strategies are assessed using a coarse-grained stochastic model of within-host HIV dynamics and pseudo-codes for solving the respective optimal control problems are provided. Our mathematical model suggests that both optimal strategies (i)-(ii) perform better than the current clinical protocols and no treatment in terms of economic means, life prolongation and reduction of HIV-transmission. The optimal diagnostic-guided strategy suggests rare diagnostics and performs similar to the optimal pro-active strategy. Our results suggest that ‘treatment-for-prevention’ may be further improved using either of the two analyzed treatment paradigms. HIV-1 continues to spread globally. Antiviral treatment cannot cure patients, but it slows disease progression and may prevent HIV transmission by decreasing the amount of transmittable viruses in treated individuals. ‘Treatment-for-prevention’ argues for immediate treatment initiation and may reduce transmission by 96% (CI: 73–99%), according to the results of a large clinical study (HPTN052). In order to ensure long-lasting treatment success, early therapy initiation demands more sophisticated treatment strategies & exceeding funds. However, countries facing the highest HIV burden are among the poorest. Within this work, we provide a mathematical framework that allows assessing different treatment paradigms using optimal control theory together with stochastic modelling of within-host viral dynamics and drug resistance development. We use this framework to compute and evaluate two distinct optimal long-term treatment strategies for resource-constrained settings: (i) a diagnostic-guided and (ii) a pro-active treatment strategy. The cost of a strategy is evaluated from a national economic perspective, valuating a severe patient health status in terms of an economic loss. The optimal strategies are compared with current clinical treatment protocols and no treatment in terms of costs, life expectation and reduction of secondary cases. Our simulations indicate that the pro-active treatment strategy performs comparably to the diagnostic-guided treatment strategy. Both strategies perform better than current clinical protocols, suggesting directions for improvement.
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Affiliation(s)
- Sulav Duwal
- Department of Mathematics and Computer Science, Freie Universität Berlin, Germany
- Junior Research Group “Systems Pharmacology & Disease Control”
| | - Stefanie Winkelmann
- Department of Mathematics and Computer Science, Freie Universität Berlin, Germany
| | - Christof Schütte
- Department of Mathematics and Computer Science, Freie Universität Berlin, Germany
- Zuse Institute Berlin, Germany
| | - Max von Kleist
- Department of Mathematics and Computer Science, Freie Universität Berlin, Germany
- Junior Research Group “Systems Pharmacology & Disease Control”
- * E-mail:
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Illustration of a measure to combine viral suppression and viral rebound in studies of HIV therapy. J Acquir Immune Defic Syndr 2015; 68:241-4. [PMID: 25415292 DOI: 10.1097/qai.0000000000000423] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Viral load is an important tool for assessing antiretroviral treatment efficacy. However, the most common viral load end point, virologic failure, may be flawed. We illustrate an alternative end point that estimates the average time patients spent suppressed before rebound in the AIDS Clinical Trials Group A5095 trial. Patients averaged 644 days suppressed in the 3-drug arm and 686 days suppressed in the 4-drug arm, for a difference of 42 days in favor of the 4-drug regimen (95% confidence interval: -11 to 96). These results agree with results using virologic failure as the end point but better emphasize the separate suppression and rebound processes.
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Katz IT, Leister E, Kacanek D, Hughes MD, Bardeguez A, Livingston E, Stek A, Shapiro DE, Tuomala R. Factors associated with lack of viral suppression at delivery among highly active antiretroviral therapy-naive women with HIV: a cohort study. Ann Intern Med 2015; 162:90-9. [PMID: 25599347 PMCID: PMC4299931 DOI: 10.7326/m13-2005] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND A high delivery maternal plasma HIV-1 RNA level (viral load [VL]) is a risk factor for mother-to-child transmission and poor maternal health. OBJECTIVE To identify factors associated with detectable VL at delivery despite initiation of highly active antiretroviral therapy (HAART) during pregnancy. DESIGN Multicenter observational study. (ClinicalTrial.gov: NCT00028145). SETTING 67 U.S. AIDS clinical research sites. PATIENTS Pregnant women with HIV who initiated HAART during pregnancy. MEASUREMENTS Descriptive summaries and associations among sociodemographic, HIV disease, and treatment characteristics; pregnancy-related risk factors; and detectable VL (>400 copies/mL) at delivery. RESULTS Between 2002 and 2011, 671 women met inclusion criteria and 13.1% had detectable VL at delivery. Factors associated with detectable VL included multiparity (16.4% vs. 8.0% nulliparity; P = 0.002), black ethnicity (17.6% vs. 6.6% Hispanic and 6.6% white; P < 0.001), 11th grade education or less (17.6% vs. 12.1% had a high school diploma; P = 0.013), initiation of HAART in the third trimester (23.9% vs. 12.3% and 8.6% in the second and trimesters, respectively; P = 0.003), having an HIV diagnosis before the current pregnancy (16.1% vs. 11.0% during the current pregnancy; P = 0.051), and having the first prenatal visit in the third trimester (33.3% vs. 14.3% and 10.5% in the second and third trimesters, respectively; P = 0.002). Women who had treatment interruptions or reported poor medication adherence were more likely to have detectable VL at delivery. LIMITATION Data on many covariates were incomplete because women entered the study at varying times during pregnancy. CONCLUSION A total of 13.1% of women who initiated HAART during pregnancy had detectable VL at delivery. The timing of HAART initiation and prenatal care, along with medication adherence during pregnancy, were associated with detectable VL at delivery. Social factors, including ethnicity and education, may help identify women who could benefit from focused efforts to promote early HAART initiation and adherence. PRIMARY FUNDING SOURCE U.S. Department of Health and Human Services.
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Affiliation(s)
- Ingrid T. Katz
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Massachusetts General Hospital Center for Global Health, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Erin Leister
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Deborah Kacanek
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Michael D. Hughes
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Arlene Bardeguez
- University of Medicine and Dentistry of New Jersey, Newark, New Jersey, United States of America
| | - Elizabeth Livingston
- Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Alice Stek
- University of Southern California Keck School of Medicine, Los Angeles, California, United States of America
| | - David E. Shapiro
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Ruth Tuomala
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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Hammer SM, Ribaudo H, Bassett R, Mellors JW, Demeter LM, Coombs RW, Currier J, Morse GD, Gerber JG, Martinez AI, Spreen W, Fischl MA, Squires KE. A Randomized, Placebo-Controlled Trial of Abacavir Intensification in HIV-1–Infected Adults With Virologic Suppression on a Protease Inhibitor–Containing Regimen. HIV CLINICAL TRIALS 2015. [DOI: 10.1310/hct1105-312] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Moore CB, Verma A, Pendergrass S, Verma SS, Johnson DH, Daar ES, Gulick RM, Haubrich R, Robbins GK, Ritchie MD, Haas DW. Phenome-wide Association Study Relating Pretreatment Laboratory Parameters With Human Genetic Variants in AIDS Clinical Trials Group Protocols. Open Forum Infect Dis 2015; 2:ofu113. [PMID: 25884002 PMCID: PMC4396430 DOI: 10.1093/ofid/ofu113] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 12/02/2014] [Indexed: 01/11/2023] Open
Abstract
Background. Phenome-Wide Association Studies (PheWAS) identify genetic associations across multiple phenotypes. Clinical trials offer opportunities for PheWAS to identify pharmacogenomic associations. We describe the first PheWAS to use genome-wide genotypic data and to utilize human immunodeficiency virus (HIV) clinical trials data. As proof-of-concept, we focused on baseline laboratory phenotypes from antiretroviral therapy-naive individuals. Methods. Data from 4 AIDS Clinical Trials Group (ACTG) studies were split into 2 datasets: Dataset I (1181 individuals from protocol A5202) and Dataset II (1366 from protocols A5095, ACTG 384, and A5142). Final analyses involved 2547 individuals and 5 954 294 imputed polymorphisms. We calculated comprehensive associations between these polymorphisms and 27 baseline laboratory phenotypes. Results. A total of 10 584 (0.17%) polymorphisms had associations with P < .01 in both datasets and with the same direction of association. Twenty polymorphisms replicated associations with identical or related phenotypes reported in the Catalog of Published Genome-Wide Association Studies, including several not previously reported in HIV-positive cohorts. We also identified several possibly novel associations. Conclusions. These analyses define PheWAS properties and principles with baseline laboratory data from HIV clinical trials. This approach may be useful for evaluating on-treatment HIV clinical trials data for associations with various clinical phenotypes.
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Affiliation(s)
- Carrie B. Moore
- Vanderbilt University School of Medicine, Nashville, Tennessee
- The Center for Systems Genomics, The Pennsylvania State University, University Park
| | - Anurag Verma
- The Center for Systems Genomics, The Pennsylvania State University, University Park
| | - Sarah Pendergrass
- The Center for Systems Genomics, The Pennsylvania State University, University Park
| | - Shefali S. Verma
- The Center for Systems Genomics, The Pennsylvania State University, University Park
| | | | - Eric S. Daar
- Los Angeles Biomed Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | - Marylyn D. Ritchie
- The Center for Systems Genomics, The Pennsylvania State University, University Park
| | - David W. Haas
- Vanderbilt University School of Medicine, Nashville, Tennessee
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Patel DA, Snedecor SJ, Tang WY, Sudharshan L, Lim JW, Cuffe R, Pulgar S, Gilchrist KA, Camejo RR, Stephens J, Nichols G. 48-week efficacy and safety of dolutegravir relative to commonly used third agents in treatment-naive HIV-1-infected patients: a systematic review and network meta-analysis. PLoS One 2014; 9:e105653. [PMID: 25188312 PMCID: PMC4154896 DOI: 10.1371/journal.pone.0105653] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 07/22/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A network meta-analysis can provide estimates of relative efficacy for treatments not directly studied in head-to-head randomized controlled trials. We estimated the relative efficacy and safety of dolutegravir (DTG) versus third agents currently recommended by guidelines, including ritonavir-boosted atazanavir (ATV/r), ritonavir-boosted darunavir (DRV/r), efavirenz (EFV), cobicistat-boosted elvitegravir (EVG/c), ritonavir-boosted lopinavir (LPV/r), raltegravir (RAL), and rilpivirine (RPV), in treatment-naive HIV-1-infected patients. METHODS A systematic review of published literature was conducted to identify phase 3/4 randomized controlled clinical trials (up to August 2013) including at least one third agent of interest in combination with a backbone nucleoside reverse transcriptase inhibitor (NRTI) regimen. Bayesian fixed-effect network meta-analysis models adjusting for the type of nucleoside reverse transcriptase inhibitor backbone (tenofovir disoproxil fumarate/emtricitabine [TDF/FTC] or abacavir/lamivudine [ABC/3TC]) were used to evaluate week 48 efficacy (HIV-RNA suppression to <50 copies/mL and change in CD4+ cells/µL) and safety (lipid changes, adverse events, and discontinuations due to adverse events) of DTG relative to all other treatments. Sensitivity analyses assessing the impact of NRTI treatment adjustment and random-effects models were performed. RESULTS Thirty-one studies including 17,000 patients were combined in the analysis. Adjusting for the effect of NRTI backbone, treatment with DTG resulted in significantly higher odds of virologic suppression (HIV RNA<50 copies/mL) and increase in CD4+ cells/µL versus ATV/r, DRV/r, EFV, LPV/r, and RPV. Dolutegravir had better or equivalent changes in total cholesterol, LDL, triglycerides, and lower odds of adverse events and discontinuation due to adverse events compared to all treatments. Random-effects and unadjusted models resulted in similar conclusions. CONCLUSION Three clinical trials of DTG have demonstrated comparable or superior efficacy and safety to DRV, RAL, and EFV in HIV-1-infected treatment-naive patients. This network meta-analysis suggests DTG is also favorable or comparable to other commonly used third agents (ATV/r, LPV/r, RPV, and EVG/c).
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Affiliation(s)
- Dipen A. Patel
- Pharmerit International, Bethesda, Maryland, United States of America
| | - Sonya J. Snedecor
- Pharmerit International, Bethesda, Maryland, United States of America
| | - Wing Yu Tang
- Pharmerit International, Bethesda, Maryland, United States of America
| | | | | | | | - Sonia Pulgar
- GlaxoSmithKline, Research Triangle Park, North Carolina, United States of America
| | - Kim A. Gilchrist
- GlaxoSmithKline, Renaissance, Pennsylvania, United States of America
| | | | - Jennifer Stephens
- Pharmerit International, Bethesda, Maryland, United States of America
| | - Garrett Nichols
- GlaxoSmithKline, Research Triangle Park, North Carolina, United States of America
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Mollan KR, Smurzynski M, Eron JJ, Daar ES, Campbell TB, Sax PE, Gulick RM, Na L, O'Keefe L, Robertson KR, Tierney C. Association between efavirenz as initial therapy for HIV-1 infection and increased risk for suicidal ideation or attempted or completed suicide: an analysis of trial data. Ann Intern Med 2014; 161:1-10. [PMID: 24979445 PMCID: PMC4204642 DOI: 10.7326/m14-0293] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The relationship between efavirenz use and suicidality is not well-defined. OBJECTIVE To compare time to suicidality with efavirenz-containing versus efavirenz-free antiretroviral regimens for initial treatment of HIV. DESIGN Participant-level data were analyzed from 4 AIDS Clinical Trials Group, antiretroviral-naive studies conducted from 2001 to 2010. Within each study, participants were randomly assigned to an efavirenz-containing (n = 3241) or efavirenz-free (n = 2091) regimen. (ClinicalTrials.gov: NCT00013520 [A5095], NCT00050895 [A5142], NCT00084136 [A5175], and NCT00118898 [A5202]). SETTING AIDS Clinical Trials Group sites; 74% of participants enrolled in the United States. PATIENTS Antiretroviral-naive participants. INTERVENTION Efavirenz versus efavirenz-free regimens. MEASUREMENTS Suicidality was defined as suicidal ideation or attempted or completed suicide. Groups were compared with a hazard ratio and 95% CI estimated from a Cox model, stratified by study. RESULTS Seventy-three percent of participants were men, the median age was 37 years, and 32% had documented psychiatric history or received psychoactive medication within 30 days before entering the study. Median follow-up was 96 weeks. Suicidality incidence per 1000 person-years was 8.08 (47 events) in the efavirenz group and 3.66 (15 events) in the efavirenz-free group (hazard ratio, 2.28 [95% CI, 1.27 to 4.10]; P = 0.006). Incidence of attempted or completed suicide was 2.90 (17 events) and 1.22 (5 events) in the efavirenz and efavirenz-free groups, respectively (hazard ratio, 2.58 [CI, 0.94 to 7.06]; P = 0.065). Eight suicides in the efavirenz group and 1 in the efavirenz-free group were reported. LIMITATION There was not a standardized questionnaire about suicidal ideation or attempt. Efavirenz was open-label in 3 of 4 studies. CONCLUSION Initial treatment with an efavirenz-containing antiretroviral regimen was associated with a 2-fold increased hazard of suicidality compared with a regimen without efavirenz. PRIMARY FUNDING SOURCE National Institutes of Health.
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Howe CJ, Napravnik S, Cole SR, Kaufman JS, Adimora AA, Elston B, Eron JJ, Mugavero MJ. African American race and HIV virological suppression: beyond disparities in clinic attendance. Am J Epidemiol 2014; 179:1484-92. [PMID: 24812158 DOI: 10.1093/aje/kwu069] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Racial disparities in clinic attendance may contribute to racial disparities in plasma human immunodeficiency virus type 1 : HIV-1) RNA levels among HIV-positive patients in care. Data from 946 African American and 535 Caucasian patients receiving HIV care at the University of North Carolina Center for AIDS Research HIV clinic between January 1, 1999, and August 1, 2012, were used to estimate the association between African American race and HIV virological suppression (i.e., undetectable HIV-1 RNA) when racial disparities in clinic attendance were lessened. Clinic attendance was measured as the proportion of scheduled clinic appointments attended (i.e., visit adherence) or the proportion of six 4-month intervals with at least 1 attended scheduled clinic appointment (i.e., visit constancy). In analyses accounting for patient characteristics, the risk ratio for achieving suppression when comparing African Americans with Caucasians was 0.91 (95% confidence interval: 0.85, 0.98). Lessening disparities in adherence or constancy lowered disparities in virological suppression by up to 44.4% and 11.1%, respectively. Interventions that lessen disparities in adherence may be more effective in eliminating disparities in suppression than interventions that lessen disparities in constancy. Given that gaps in care were limited to be no more than 2 years for both attendance measures, the impact of lessening disparities in adherence may be overstated.
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de la Torre P, George J, Baxter JD. Nucleoside-sparing antiretroviral regimens. Curr Infect Dis Rep 2014; 16:410. [PMID: 24880455 DOI: 10.1007/s11908-014-0410-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Nucleoside reverse transcriptase inhibitors (NRTIs) were the first drugs approved for use as antiretroviral therapy in patients infected with HIV. Despite the introduction of other classes of antiretroviral drugs, they remain an important component of combination regimens as recommended by many treatment guidelines. They also continue to be used in prevention of disease from mother to child, postexposure prophylaxis, and more recently for preexposure prophylaxis. Unfortunately, the toxicities associated with this class of drugs can limit their use. Although NRTI-sparing regimens are not currently recommended for first-line therapy there is an increasing amount of data supporting their use in both treatment-naive and in treatment-experienced patients.
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Affiliation(s)
- Pola de la Torre
- Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA,
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Haas DW, Kwara A, Richardson DM, Baker P, Papageorgiou I, Acosta EP, Morse GD, Court MH. Secondary metabolism pathway polymorphisms and plasma efavirenz concentrations in HIV-infected adults with CYP2B6 slow metabolizer genotypes. J Antimicrob Chemother 2014; 69:2175-82. [PMID: 24729586 DOI: 10.1093/jac/dku110] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Efavirenz is widely prescribed for HIV-1 infection, and CYP2B6 polymorphisms 516G→T and 983T→C define efavirenz slow metabolizer genotypes. To identify genetic predictors of higher plasma efavirenz concentrations beyond these two common functional alleles, we characterized associations with mid-dosing interval efavirenz concentrations in 84 HIV-infected adults, all carrying two copies of these major loss-of-function CYP2B6 alleles. METHODS Study participants had been randomized to efavirenz-containing regimens in prospective clinical trials and had available plasma efavirenz assay data. Analyses focused on secondary metabolism pathway polymorphisms CYP2A6 -48T→G (rs28399433), UGT2B7 735A→G (rs28365062) and UGT2B7 802T→C (rs7439366). Exploratory analyses also considered 196 polymorphisms and 8 copy number variants in 41 drug metabolism/transport genes. Mid-dosing interval efavirenz concentrations at steady-state were obtained ≥8 h but <19 h post-dose. Linear regression was used to test for associations between polymorphisms and log-transformed efavirenz concentrations. RESULTS Increased efavirenz concentrations were associated with CYP2A6 -48T→G in all subjects (P = 3.8 × 10(-4)) and in Black subjects (P = 0.027) and White subjects (P = 0.0011) analysed separately; and with UGT2B7 735 G/G homozygosity in all subjects (P = 0.006) and in Black subjects (P = 0.046) and White subjects (P = 0.062) analysed separately. In a multivariable model, CYP2A6 -48T→G and UGT2B7 735 G/G homozygosity remained significant (P < 0.05 for each). No additional polymorphisms or copy number variants were significantly associated with efavirenz concentrations. CONCLUSIONS Among individuals with a CYP2B6 slow metabolizer genotype, CYP2A6 and possibly UGT2B7 polymorphisms contribute to even higher efavirenz concentrations.
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Affiliation(s)
- David W Haas
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Awewura Kwara
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Paxton Baker
- Vanderbilt University School of Medicine, Nashville, TN, USA
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Raffi F, Pozniak AL, Wainberg MA. Has the time come to abandon efavirenz for first-line antiretroviral therapy? J Antimicrob Chemother 2014; 69:1742-7. [PMID: 24603962 DOI: 10.1093/jac/dku058] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Efavirenz has been recommended as a preferred third agent together with two nucleos(t)ides for first-line combination antiretroviral therapy (ART) for >15 years. The availability of efavirenz in a fixed-dose combination makes it very attractive. However, because of (i) adverse events associated with efavirenz, (ii) a poorer overall efficacy of efavirenz compared with newer antiretrovirals, (iii) the ranking of efavirenz as FDA Pregnancy Category D and (iv) the relatively high prevalence of transmitted drug-resistance mutations, there is a need to reconsider the role of efavirenz in first-line ART. We review the available evidence that challenges efavirenz's current position in first-line HIV treatment guidelines. Apart from its animal teratogenic potential, and moderate neuropsychiatric adverse events associated with its use, efavirenz has recently been associated with an increased risk of suicidality when compared with other antiretroviral drugs. Most importantly, efavirenz has demonstrated overall inferior efficacy to various comparator drugs, which include rilpivirine, raltegravir and dolutegravir, in antiretroviral-naive patients. Furthermore, epidemiological data indicate that the prevalence of non-nucleoside reverse transcriptase inhibitor resistance has reached 5%-8% in various parts of the world, and minority transmitted non-nucleoside reverse transcriptase inhibitor resistance-associated mutations can have a negative impact on the outcome of first-line efavirenz-based ART. Based on considerations of efficacy, toxicity and resistance, it is time to reconsider the routine use of efavirenz in ART. This, of course, presupposes that other antiretrovirals will be available in place of efavirenz, and may not be applicable in certain developing country settings where this is not the case.
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Affiliation(s)
- Francois Raffi
- Division of Infectious Diseases, Nantes University Hospital, Nantes, France
| | - Anton L Pozniak
- HIV Department, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Mark A Wainberg
- Departments of Medicine and of Microbiology, Jewish General Hospital, McGill University, Montreal, Canada
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Howe CJ, Cole SR, Napravnik S, Kaufman JS, Adimora AA, Elston B, Eron JJ, Mugavero MJ. The role of at-risk alcohol/drug use and treatment in appointment attendance and virologic suppression among HIV(+) African Americans. AIDS Res Hum Retroviruses 2014; 30:233-40. [PMID: 24325326 DOI: 10.1089/aid.2013.0163] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The causes of poor clinic attendance and incomplete virologic suppression among HIV(+) African Americans (AAs) are not well understood. We estimated the effect of at-risk alcohol/drug use and associated treatment on attending scheduled appointments and virologic suppression among 576 HIV(+) AA patients in the University of Alabama at Birmingham (UAB) 1917 Clinic Cohort who contributed 591 interviews to the analysis. At interview, 78% of patients were new to HIV care at UAB, 38% engaged in at-risk alcohol/drug use or received associated treatment in the prior year, while the median (quartiles) age and CD4 count were 36 (28; 46) years and 321 (142; 530) cells/μl, respectively. In the 2 years after an interview, half of the patients had attended at least 82% of appointments while half had achieved virologic suppression for at least 71% of RNA assessments. Compared to patients who did not use or receive treatment, the adjusted risk ratio (aRR) for attending appointments for patients who did use but did not receive treatment was 0.97 (95% confidence limits: 0.92, 1.03). The corresponding aRR for virologic suppression was 0.94 (0.86, 1.03). Compared to patients who did not receive treatment but did use, the aRR for attending appointments for patients who did receive treatment and did use was 0.86 (0.78, 0.95). The corresponding aRR for virologic suppression was 1.07 (0.92, 1.24). Use was negatively associated with attendance and virologic suppression among patients not in treatment. Among users, treatment was negatively associated with attendance yet positively associated with virologic suppression. However, aRR estimates were imprecise.
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Affiliation(s)
- Chanelle J. Howe
- Department of Epidemiology, Center for Population Health and Clinical Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Stephen R. Cole
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Sonia Napravnik
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
- Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jay S. Kaufman
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Adaora A. Adimora
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
- Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Beth Elston
- Department of Epidemiology, Center for Population Health and Clinical Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Joseph J. Eron
- Division of Infectious Diseases, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michael J. Mugavero
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Gouskova NA, Cole SR, Eron JJ, Fine JP. Viral suppression in HIV studies: combining times to suppression and rebound. Biometrics 2014; 70:441-8. [PMID: 24446693 DOI: 10.1111/biom.12140] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 12/01/2013] [Accepted: 12/01/2013] [Indexed: 11/27/2022]
Abstract
In HIV-1 clinical trials the interest is often to compare how well treatments suppress the HIV-1 RNA viral load. The current practice in statistical analysis of such trials is to define a single ad hoc composite event which combines information about both the viral load suppression and the subsequent viral rebound, and then analyze the data using standard univariate survival analysis techniques. The main weakness of this approach is that the results of the analysis can be easily influenced by minor details in the definition of the composite event. We propose a straightforward alternative endpoint based on the probability of being suppressed over time, and suggest that treatment differences be summarized using the restricted mean time a patient spends in the state of viral suppression. A nonparametric analysis is based on methods for multiple endpoint studies. We demonstrate the utility of our analytic strategy using a recent therapeutic trial, in which the protocol specified a primary analysis using a composite endpoint approach.
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Affiliation(s)
- Natalia A Gouskova
- Department of Biostatistics, University of North Carolina at Chapel Hill Chapel Hill, North Carolina, 27599, U.S.A
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Cespedes MS, Kerns SL, Holzman RS, McLaren PJ, Ostrer H, Aberg JA. Genetic predictors of cervical dysplasia in African American HIV-infected women: ACTG DACS 268. HIV CLINICAL TRIALS 2013; 14:292-302. [PMID: 24334182 DOI: 10.1310/hct1406-292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine genome-wide associations in HIV-infected women with a history of cervical dysplasia compared with HIV-infected women with no history of abnormal Papanicolaou (Pap) tests. DESIGN Case-control study using data from women analyzed for the HIV Controllers Study and enrolled in HIV treatment-naïve studies in the AIDS Clinical Trials Group (ACTG). METHODS Genotyping utilized Illumina HumanHap 650 Y or 1MDuo platforms. After quality control and principal component analysis, ~610,000 significant single nucleotide polymorphisms (SNPs) were tested for association. Threshold for significance was P < 5 × 10(-8) for genome-wide associations. RESULTS No significant genomic association was observed between women with low-grade dysplasia and controls. The genome-wide association study (GWAS) analysis between women with high-grade dysplasia or invasive cervical cancer and normal controls identified significant SNPs. In the analyses limited to African American women, 11 SNPs were significantly associated with the development of high-grade dysplasia or cancer after correcting for multiple comparisons. The model using significant SNPs alone had improved accuracy in predicting high-grade dysplasia in African American women compared to the use of clinical data (area under the receiver operating characteristic curve for genetic and clinical model = 0.9 and 0.747, respectively). CONCLUSIONS These preliminary data serve as proof of concept that there may be a genetic predisposition to developing high-grade cervical dysplasia in African American HIV-infected women. Given the small sample size, the results need to be validated in a separate cohort.
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Affiliation(s)
| | | | | | - Paul J McLaren
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Harry Ostrer
- Albert Einstein College of Medicine, Bronx, New York
| | - Judith A Aberg
- New York University School of Medicine, New York, New York
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[Consensus Statement by GeSIDA/National AIDS Plan Secretariat on antiretroviral treatment in adults infected by the human immunodeficiency virus (Updated January 2013)]. Enferm Infecc Microbiol Clin 2013; 31:602.e1-602.e98. [PMID: 24161378 DOI: 10.1016/j.eimc.2013.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 04/08/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVE This consensus document is an update of combined antiretroviral therapy (cART) guidelines for HIV-1 infected adult patients. METHODS To formulate these recommendations a panel composed of members of the GeSIDA/National AIDS Plan Secretariat (Grupo de Estudio de Sida and the Secretaría del Plan Nacional sobre el Sida) reviewed the efficacy and safety advances in clinical trials, cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. The strength of the recommendations and the evidence which support them are based on a modification of the criteria of Infectious Diseases Society of America. RESULTS cART is recommended in patients with symptoms of HIV infection, in pregnant women, in serodiscordant couples with high risk of transmission, in hepatitisB co-infection requiring treatment, and in HIV nephropathy. cART is recommended in asymptomatic patients if CD4 is <500cells/μl. If CD4 are >500cells/μl cART should be considered in the case of chronic hepatitisC, cirrhosis, high cardiovascular risk, plasma viral load >100.000 copies/ml, proportion of CD4 cells <14%, neurocognitive deficits, and in people aged >55years. The objective of cART is to achieve an undetectable viral load. The first cART should include 2 reverse transcriptase inhibitors (RTI) nucleoside analogs and a third drug (a non-analog RTI, a ritonavir boosted protease inhibitor, or an integrase inhibitor). The panel has consensually selected some drug combinations, for the first cART and specific criteria for cART in acute HIV infection, in tuberculosis and other HIV related opportunistic infections, for the women and in pregnancy, in hepatitisB or C co-infection, in HIV-2 infection, and in post-exposure prophylaxis. CONCLUSIONS These new guidelines update previous recommendations related to first cART (when to begin and what drugs should be used), how to monitor, and what to do in case of viral failure or adverse drug reactions. cART specific criteria in comorbid patients and special situations are similarly updated.
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Murphy K, Hoover DR, Shi Q, Cohen M, Gandhi M, Golub ET, Gustafson DR, Pearce CL, Young M, Anastos K. Association of self-reported race with AIDS death in continuous HAART users in a cohort of HIV-infected women in the United States. AIDS 2013; 27:2413-23. [PMID: 24037210 PMCID: PMC3815041 DOI: 10.1097/01.aids.0000432537.92958.73] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 06/25/2013] [Accepted: 06/27/2013] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To assess the association of race with clinical outcomes in HIV-positive women on continuous HAART. DESIGN Prospective study that enrolled women from 1994 to 1995 and 2001 to 2002. SETTING Women's Interagency HIV Study, a community-based cohort in five US cities. PARTICIPANTS One thousand, four hundred and seventy-one HIV-positive continuous HAART users. MAIN OUTCOME MEASURES Times to AIDS and non-AIDS death and incident AIDS-defining illness (ADI) after HAART initiation. RESULTS In adjusted analyses, black vs. white women had higher rates of AIDS death [adjusted hazard ratio (aHR) 2.14, 95% confidence interval (CI) 1.30, 3.50; P = 0.003] and incident ADI (aHR 1.58, 95% CI 1.08, 2.32; P = 0.02), but not non-AIDS death (aHR 0.91, 95% CI 0.59, 1.39; P = 0.65). Cumulative AIDS death incidence at 10 years was 17.3 and 8.3% for black and white women, respectively. Other significant independent pre-HAART predictors of AIDS death included peak viral load (aHR 1.70 per log₁₀, 95% CI 1.34, 2.16; P < 0.001), nadir CD4⁺ cell count (aHR 0.65 per 100 cells/μl, 95% CI 0.56, 0.76; P < 0.001), depressive symptoms by Center for Epidemiology Studies Depression score at least 16 (aHR 2.10, 95% CI 1.51, 2.92; P < 0.001), hepatitis C virus infection (aHR 1.57, 95% CI 1.02, 2.40; P = 0.04), and HIV acquisition via transfusion (aHR 2.33, 95% CI 1.21, 4.49; P = 0.01). In models with time-updated HAART adherence, association of race with AIDS death remained statistically significant (aHR 3.09, 95% CI 1.38, 6.93; P = 0.006). CONCLUSION In continuous HAART-using women, black women more rapidly died from AIDS or experienced incident ADI than their white counterparts after adjusting for confounders. Future studies examining behavioral and biologic factors in these women may further the understanding of HAART prognosis.
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Affiliation(s)
- Kerry Murphy
- aAlbert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York bRutgers University, Piscataway, New Jersey cSchool of Health Sciences and Practice/New York Medical College, Valhalla, New York dCook County Health and Hospitals System eRush University, Chicago, Illinois fUniversity of California San Francisco, San Francisco, California gJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland hState University of New York/Downstate Medical Center, Brooklyn, New York, USA iUniversity of Gothenburg, Gothenburg, Sweden jUniversity of Southern California, Los Angeles, California kGeorgetown University, Washington, District of Columbia, USA
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Ribaudo HJ, Smith KY, Robbins GK, Flexner C, Haubrich R, Chen Y, Fischl MA, Schackman BR, Riddler SA, Gulick RM. Racial differences in response to antiretroviral therapy for HIV infection: an AIDS clinical trials group (ACTG) study analysis. Clin Infect Dis 2013; 57:1607-17. [PMID: 24046302 DOI: 10.1093/cid/cit595] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the United States, black individuals infected with human immunodeficiency virus (HIV) have higher rates of virologic failure on antiretroviral therapy (ART) and of death compared to white individuals. The cause for these disparities is uncertain. We sought to examine differences in virologic outcomes among antiretroviral-naive clinical trial participants starting randomized ART and to investigate factors to explain the differences. METHODS Individual-level data from participants initiating ART in 5 AIDS Clinical Trials Group studies were analyzed. Included studies were those conducted during 1998-2006 with a primary outcome of virologic failure. The primary outcome measure was time to virologic failure, regardless of ART changes. RESULTS A total of 2495 individuals (1151 black; 1344 white) were included with a median follow-up of 129 weeks. Compared to whites, blacks had an increased hazard of virologic failure (hazard ratio [HR]; 1.7; 95% confidence interval [CI], 1.4-1.9; P < .001), with no evidence of heterogeneity across regimens (P = .97); the association remained after adjustment for measured confounders (HR, 1.4; 95% CI, 1.2-1.6; P < .001). Increased hazard of virologic failure was associated with younger age, higher pretreatment HIV type 1 RNA level, lower pretreatment CD4 cell count, hepatitis C antibody, less education, and recent nonadherence to treatment. Sensitivity analyses with different endpoint definitions demonstrated similar results. CONCLUSIONS In this analysis, blacks had a 40% higher virologic failure risk than whites that was not explained by measured confounders. The observation was consistent over a range of regimens, suggesting that the difference may be driven by social factors; however, biological factors cannot be ruled out. Further research should identify the sources of racial disparities and develop strategies to reduce them.
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Affiliation(s)
- Heather J Ribaudo
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
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Johnson BA, Ribaudo H, Gulick RM, Eron JJ. Modeling clinical endpoints as a function of time of switch to second-line ART with incomplete data on switching times. Biometrics 2013; 69:732-40. [PMID: 23862631 DOI: 10.1111/biom.12064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 01/01/2013] [Accepted: 03/01/2013] [Indexed: 11/29/2022]
Abstract
Modeling clinical endpoints as a function of change in antiretroviral therapy (ART) attempts to answer one simple but very challenging question: was the change in ART beneficial or not? We conceive a similar scientific question of interest in the current manuscript except that we are interested in modeling the time of ART regimen change rather than a comparison of two or more ART regimens. The answer to this scientific riddle is unknown and has been difficult to address clinically. Naturally, ART regimen change is left to a participant and his or her provider and so the date of change depends on participant characteristics. There exists a vast literature on how to address potential confounding and those techniques are vital to the success of the method here. A more substantial challenge is devising a systematic modeling strategy to overcome the missing time of regimen change for those participants who do not switch to second-line ART within the study period even after failing the initial ART. In this article, we adopt and apply a statistical method that was originally proposed for modeling infusion trial data, where infusion length may be informatively censored, and argue that the same strategy may be employed here. Our application of this method to therapeutic HIV/AIDS studies is new and interesting. Using data from the AIDS Clinical Trials Group (ACTG) Study A5095, we model immunological endpoints as a polynomial function of a participant's switching time to second-line ART for 182 participants who already failed the initial ART. In our analysis, we find that participants who switch early have somewhat better sustained suppression of HIV-1 RNA after virological failure than those who switch later. However, we also found that participants who switched very late, possibly censored due to the end of the study, had good HIV-1 RNA suppression, on average. We believe our scientific conclusions contribute to the relevant HIV literature and hope that the basic modeling strategy outlined here would be useful to others contemplating similar analyses with partially missing treatment length data.
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Affiliation(s)
- Brent A Johnson
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia 30307, U.S.A
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Genome-wide association study of plasma efavirenz pharmacokinetics in AIDS Clinical Trials Group protocols implicates several CYP2B6 variants. Pharmacogenet Genomics 2013; 22:858-67. [PMID: 23080225 DOI: 10.1097/fpc.0b013e32835a450b] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Prior candidate gene studies have associated CYP2B6 516G→T [rs3745274] and 983T→C [rs28399499] with increased plasma efavirenz exposure. We sought to identify novel variants associated with efavirenz pharmacokinetics. MATERIALS AND METHODS Antiretroviral therapy-naive AIDS Clinical Trials Group studies A5202, A5095, and ACTG 384 included plasma sampling for efavirenz pharmacokinetics. Log-transformed trough efavirenz concentrations (Cmin) were previously estimated by population pharmacokinetic modeling. Stored DNA was genotyped with Illumina HumanHap 650Y or 1MDuo platforms, complemented by additional targeted genotyping of CYP2B6 and CYP2A6 with MassARRAY iPLEX Gold. Associations were identified by linear regression, which included principal component vectors to adjust for genetic ancestry. RESULTS Among 856 individuals, CYP2B6 516G→T was associated with efavirenz estimated Cmin (P=8.5×10). After adjusting for CYP2B6 516G→T, CYP2B6 983T→C was associated (P=9.9×10). After adjusting for both CYP2B6 516G→T and 983T→C, a CYP2B6 variant (rs4803419) in intron 3 was associated (P=4.4×10). After adjusting for all the three variants, non-CYP2B6 polymorphisms were associated at P-value less than 5×10. In a separate cohort of 240 individuals, only the three CYP2B6 polymorphisms replicated. These three polymorphisms explained 34% of interindividual variability in efavirenz estimated Cmin. The extensive metabolizer phenotype was best defined by the absence of all three polymorphisms. CONCLUSION Three CYP2B6 polymorphisms were independently associated with efavirenz estimated Cmin at genome-wide significance, and explained one-third of interindividual variability. These data will inform continued efforts to translate pharmacogenomic knowledge into optimal efavirenz utilization.
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Kumar P, DeJesus E, Huhn G, Sloan L, Small CB, Edelstein H, Felizarta F, Hao R, Ross L, Stancil B, Pappa K, Ha B. Evaluation of cardiovascular biomarkers in a randomized trial of fosamprenavir/ritonavir vs. efavirenz with abacavir/lamivudine in underrepresented, antiretroviral-naïve, HIV-infected patients (SUPPORT): 96-week results. BMC Infect Dis 2013; 13:269. [PMID: 23741991 PMCID: PMC3685599 DOI: 10.1186/1471-2334-13-269] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 05/24/2013] [Indexed: 01/11/2023] Open
Abstract
Background Rates of cardiovascular disease are higher among HIV-infected patients as a result of the complex interplay between traditional risk factors, HIV-related inflammatory and immunologic changes, and effects of antiretroviral therapy (ART). This study prospectively evaluated changes in cardiovascular biomarkers in an underrepresented, racially diverse, HIV-1-infected population receiving abacavir/lamivudine as backbone therapy. Methods This 96-week, open-label, randomized, multicenter study compared once-daily fosamprenavir/ritonavir 1400/100 mg and efavirenz 600 mg, both with ABC/3TC 600 mg/300 mg, in antiretroviral-naïve, HLA-B*5701-negative adults without major resistance mutations to study drugs. We evaluated changes from baseline to weeks 4, 12, 24, 48, and 96 in interleukin-6 (IL-6), high-sensitivity C-reactive protein (hs-CRP), soluble vascular adhesion molecule-1 (sVCAM-1), d-dimer, plasminogen, and fibrinogen. Biomarker data were log-transformed before analysis, and changes from baseline were described using geometric mean ratios. Results This study enrolled 101 patients (51 receiving fosamprenavir/ritonavir; 50 receiving efavirenz): 32% female, 60% African American, and 38% Hispanic/Latino; 66% (67/101) completed 96 weeks on study. At week 96, levels of IL-6, sVCAM-1, d-dimer, fibrinogen, and plasminogen were lower than baseline in both treatment groups, and the decrease was statistically significant for sVCAM-1 (fosamprenavir/ritonavir and efavirenz), d-dimer (fosamprenavir/ritonavir and efavirenz), fibrinogen (efavirenz), and plasminogen (efavirenz). Values of hs-CRP varied over time in both groups, with a significant increase over baseline at Weeks 4 and 24 in the efavirenz group. At week 96, there was no difference between the groups in the percentage of patients with HIV-1 RNA <50 copies/mL (fosamprenavir/ritonavir 63%; efavirenz 66%) by ITT missing-equals-failure analysis. Treatment-related grade 2–4 adverse events were more common with efavirenz (32%) compared with fosamprenavir/ritonavir (20%), and median lipid concentrations increased in both groups over 96 weeks of treatment. Conclusions In this study of underrepresented patients, treatment with abacavir/lamivudine combined with either fosamprenavir/ritonavir or efavirenz over 96 weeks, produced stable or declining biomarker levels except for hs-CRP, including significant and favorable decreases in thrombotic activity (reflected by d-dimer) and endothelial activation (reflected by sVCAM-1). Our study adds to the emerging data that some cardiovascular biomarkers are decreased with initiation of ART and control of HIV viremia. Trial registration ClinicalTrials.gov identifier NCT00727597
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Squires KE, Bekker LG, Eron JJ, Cheng B, Rockstroh JK, Marquez F, Kumar P, Thompson M, Campo RE, Mounzer K, Strohmaier KM, Lu C, Rodgers A, Jackson BE, Wenning LA, Robertson M, Nguyen BYT, Sklar, for the REALMRK Investigator P. Safety, tolerability, and efficacy of raltegravir in a diverse cohort of HIV-infected patients: 48-week results from the REALMRK Study. AIDS Res Hum Retroviruses 2013; 29:859-70. [PMID: 23351187 DOI: 10.1089/aid.2012.0292] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The racial diversity and gender distribution of HIV-infected patients make it essential to confirm the safety and efficacy of raltegravir in these populations. A multicenter, open-label, single-arm observational study was conducted in a diverse cohort of HIV-infected patients (goals: ≥25% women; ≥50% blacks in the United States), enrolling treatment-experienced patients failing or intolerant to current antiretroviral therapy (ART) and treatment-naive patients (limited to ≤20%). All patients received raltegravir 400 mg b.i.d. in a combination antiretroviral regimen for up to 48 weeks. A total of 206 patients received study treatment at 34 sites in the United States, Brazil, Dominican Republic, Jamaica, and South Africa: 97 (47%) were female and 153 (74%) were black [116 (56%) in the United States]. Of these, 185 patients were treatment experienced: 97 (47%) were failing and 88 (43%) were intolerant to current therapy; 21 patients (10%) were treatment naive. Among treatment-intolerant patients, 55 (63%) had HIV-1 RNA<50 copies/ml at baseline. Overall, 15% of patients discontinued: 13% of men, 18% of women, 14% of blacks, and 17% of nonblacks. At week 48, HIV RNA was <50 copies/ml in 60/94 (64%) patients failing prior therapy, 61/80 (76%) patients intolerant to prior therapy, and 16/21 (76%) treatment-naive patients. Response rates were similar for men vs. women and black vs. nonblack patients. Drug-related clinical adverse events were reported by 8% of men, 18% of women, 14% of blacks, and 9% of nonblacks. After 48 weeks of treatment in a diverse cohort of HIV-infected patients, raltegravir was generally safe and well tolerated with potent efficacy regardless of gender or race.
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Affiliation(s)
- Kathleen E. Squires
- Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Joseph J. Eron
- University of North Carolina, Chapel Hill, North Carolina
| | - Benjamin Cheng
- International HIV Partners, Lake Forest Park, Washington
| | | | | | | | | | | | | | | | - Chengxing Lu
- Merck Sharp & Dohme Corp., Whitehouse Station, New Jersey
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Zheng L, Rosenkranz SL, Taiwo B, Para MF, Eron JJ, Hughes MD. The design of single-arm clinical trials of combination antiretroviral regimens for treatment-naive HIV-infected patients. AIDS Res Hum Retroviruses 2013; 29:652-7. [PMID: 23228206 DOI: 10.1089/aid.2012.0180] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Single-arm clinical trials are useful to evaluate antiretroviral regimens in certain populations of HIV-infected treatment-naive patients for whom a randomized controlled trial is not feasible or desirable. They can also be useful to establish initial estimates of efficacy and safety/tolerability of novel regimens to inform the design of large phase III trials. In this article, we discuss key design considerations for such single-arm studies.
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Affiliation(s)
- Lu Zheng
- Statistical Data Analysis Center, Harvard School of Public Health, Boston, Massachusetts
| | - Susan L. Rosenkranz
- Statistical Data Analysis Center, Harvard School of Public Health, Boston, Massachusetts
| | - Babafemi Taiwo
- Division of Infectious Diseases, Northwestern University, Chicago, Illinois
| | - Michael F. Para
- Division of Infectious Diseases, Ohio State University, Columbus, Ohio
| | - Joseph J. Eron
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael D. Hughes
- Statistical Data Analysis Center, Harvard School of Public Health, Boston, Massachusetts
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