1
|
McGuire C, Atieno MA, Hoke T, Jeckonia P, K'orimba K, Lorenzetti L, Ngure K, Niyibeshaho MM, Njuguna N, Torjesen K, Fonner V. PrEP Method Switching: Will it Yield Greater Coverage of HIV Protection? Applying Lessons Learned from Family Planning to Guide Future Research in the Context of PrEP Choice. Curr HIV/AIDS Rep 2024; 21:282-292. [PMID: 39046639 PMCID: PMC11377463 DOI: 10.1007/s11904-024-00704-1] [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] [Accepted: 07/08/2024] [Indexed: 07/25/2024]
Abstract
PURPOSE OF REVIEW Despite the growing availability of oral PrEP, coverage remains suboptimal. Through the introduction of additional PrEP methods, including vaginal rings and long-acting injectable formulations, health systems globally are on the cusp of offering PrEP methods that vary by route of administration, efficacy, and frequency of use. With PrEP choice, it will be important to explore PrEP use patterns to better understand how the ability to choose and switch products affects coverage and continuation. In this review, we draw parallels with family planning (FP) by summarizing how method choice and product switching affected contraceptive coverage globally, synthesize what is known about PrEP product switching, and outline evidence gaps to help guide future research on PrEP switching in the context of choice. RECENT FINDINGS Decades of research in FP has demonstrated that product switching is common and can lead to more satisfaction and increases in contraceptive use. While research on PrEP product switching is nascent, findings suggest switching is common, and that providing more than one PrEP option can increase coverage. Key evidence gaps include understanding product switching in the context of full versus constrained choice, switching in the context of temporary need, and developing interventions that promote product switching for those who could benefit. Providing choice and allowing people to start, stop, and switch products according to their needs and desires is a core component of a rights-based approach to HIV prevention. More research is needed to better understand what drives use patterns, including switching, and how to leverage choice to improve coverage. Standard definitions -some of which have been proposed in this review-are needed to inform comparable measurement. Finally, there is a need to holistically frame PrEP use to acknowledge changes in need over the life course, thus making method switching a standard part of HIV prevention.
Collapse
Affiliation(s)
- Courtney McGuire
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA.
| | | | - Theresa Hoke
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
| | | | | | - Lara Lorenzetti
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
| | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, USA
| | | | | | | | - Virginia Fonner
- FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701, USA
| |
Collapse
|
2
|
Liegeon G, Delaugerre C, Molina JM. HIV Pre-Exposure Prophylaxis. Infect Dis Clin North Am 2024; 38:453-474. [PMID: 38871567 DOI: 10.1016/j.idc.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Pre-exposure prophylaxis (PrEP) of human immunodeficiency virus (HIV) represents the most significant breakthrough in the HIV prevention field over the past decade. PrEP is an effective strategy in preventing the transmission of HIV across all populations, providing high adherence. The current PrEP options include oral daily and on-demand tenofovir-based regimens, long-acting injections of cabotegravir, and a 1-month dapivirine vaginal ring. As a component of a multifaceted prevention approach, extensive deployment of PrEP holds the promise to significantly reduce the global HIV epidemic. Nonetheless, barriers still exist in terms of uptake, adherence, and persistence, while disparities in PrEP accessibility remain a concern.
Collapse
Affiliation(s)
- Geoffroy Liegeon
- Department of Infectious Diseases and Global Health, University of Chicago Medicine, Office L043 5841 South Maryland Avenue, Chicago 60637, IL, USA.
| | - Constance Delaugerre
- Virology Department, Assistance Publique - Hôpitaux de Paris, Hôpital Saint Louis, Paris, France; Paris Cité University, Paris, France; INSERM UMR 944, Paris, France
| | - Jean-Michel Molina
- Paris Cité University, Paris, France; INSERM UMR 944, Paris, France; Department of Infectious Diseases, Assistance Publique - Hôpitaux de Paris, Hôpitaux Saint Louis et Lariboisière, Paris, France
| |
Collapse
|
3
|
Bettonte S, Berton M, Stader F, Battegay M, Marzolini C. Effect of Obesity on the Exposure of Long-acting Cabotegravir and Rilpivirine: A Modeling Study. Clin Infect Dis 2024; 79:477-486. [PMID: 38309958 PMCID: PMC11327779 DOI: 10.1093/cid/ciae060] [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: 11/03/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Obesity is increasingly prevalent among people with human immunodeficiency virus (HIV, PWH). Obesity can reduce drug exposure; however, limited data are available for long-acting (LA) antiretrovirals. We performed in silico trials using physiologically based pharmacokinetic (PBPK) modeling to determine the effect of obesity on the exposure of LA cabotegravir and rilpivirine after the initial injection and after multiple injections. METHODS Our PBPK model was verified against available clinical data for LA cabotegravir and rilpivirine in normal weight/ overweight (body mass index [BMI] <30 kg/m2) and in obese (BMI >30 kg/m2). Cohorts of virtual individuals were generated to simulate the exposure of LA cabotegravir/rilpivirine up to a BMI of 60 kg/m2. The fold change in LA cabotegravir and rilpivirine exposures (area under the curve [AUC]) and trough concentrations (Cmin) for monthly and bimonthly administration were calculated for various BMI categories relative to normal weight (18.5-25 kg/m2). RESULTS Obesity was predicted to impact more cabotegravir than rilpivirine with a decrease in cabotegravir AUC and Cmin of >35% for BMI >35 kg/m2 and in rilpivirine AUC and Cmin of >18% for BMI >40 kg/m2 at steady-state. A significant proportion of morbidly obese individuals were predicted to have both cabotegravir and rilpivirine Cmin below the target concentration at steady-state with the bimonthly administration, but this was less frequent with the monthly administration. CONCLUSIONS Morbidly obese PWH are at risk of presenting suboptimal Cmin for cabotegravir/rilpivirine after the first injection but also at steady-state particularly with the bimonthly administration. Therapeutic drug monitoring is advised to guide dosing interval adjustment.
Collapse
Affiliation(s)
- Sara Bettonte
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Mattia Berton
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | | | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, University Hospital Lausanne and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
4
|
Camfield C, Evans YN, Kumbhakar RG. HIV preexposure prophylaxis in adolescents and young adults: an update. Curr Opin Pediatr 2024; 36:389-399. [PMID: 38655797 DOI: 10.1097/mop.0000000000001357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW This review provides an update of evidence for HIV preexposure prophylaxis (PrEP), including efficacy and safety of newly available medications. It discusses barriers to care that are unique to adolescents and young adults as well as interventions that may help increase uptake, adherence, and retention in care. RECENT FINDINGS Tenofovir alafenamide-emtricitabine and cabotegravir are both newly approved medications for the prevention of HIV and are well tolerated and effective for adolescents. These medications, along with tenofovir disoproxil-emtricitabine, offer a variety of PrEP options to choose from. SUMMARY Adolescents and young adults have many options when it comes to HIV prevention, but barriers persist in terms of uptake and adherence to PrEP and retention in care. Technology-based interventions, provider education, navigation support, and multiple access options are all tools to help increase PrEP use in young people.
Collapse
Affiliation(s)
- Caitlin Camfield
- Division of Adolescent Medicine, Department of Pediatrics, University of Washington & Seattle Children's Hospital
| | - Yolanda N Evans
- Division of Adolescent Medicine, Department of Pediatrics, University of Washington & Seattle Children's Hospital, Seattle, Washington, USA
| | - Raaka G Kumbhakar
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington
| |
Collapse
|
5
|
Sherman EM, Agwu AL, Ambrosioni J, Behrens GMN, Chu C, Collins LF, Jimenez HR, Koren DE, McGorman L, Nguyen NN, Nicol MR, Pandit NS, Pierre N, Scarsi KK, Spinner GF, Tseng A, Young JD, Badowski ME. Consensus recommendations for use of long-acting antiretroviral medications in the treatment and prevention of HIV-1: Endorsed by the American Academy of HIV Medicine, American College of Clinical Pharmacy, Canadian HIV and Viral Hepatitis Pharmacists Network, European AIDS Clinical Society, and Society of Infectious Diseases Pharmacists. Pharmacotherapy 2024; 44:494-538. [PMID: 39005160 DOI: 10.1002/phar.2922] [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: 12/01/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 07/16/2024]
Abstract
Five long-acting (LA) antiretrovirals (ARVs) are currently available in a limited number of countries worldwide for HIV-1 prevention or treatment-cabotegravir, rilpivirine, lenacapavir, ibalizumab, and dapivirine. Implementing use of LA ARVs into routine clinical practice requires significant changes to the current framework of HIV-1 prevention, treatment, and service provision. Given the novelty, complexity, and interdisciplinary requirements needed to safely and optimally utilize LA ARVs, consensus recommendations on the use of LA ARVs will assist clinicians in optimizing use of these agents. The purpose of these recommendations is to provide guidance for the clinical use of LA ARVs for HIV-1 treatment and prevention. In addition, future areas of research are also identified and discussed.
Collapse
Affiliation(s)
- Elizabeth M Sherman
- Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
- Division of Infectious Disease, Memorial Healthcare System, Hollywood, Florida, USA
| | - Allison L Agwu
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Juan Ambrosioni
- HIV Unit and Infectious Disease Service, Hospital Clinic and Fundació de Recerca Clínic Barcelona-IDIBAPS, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Georg M N Behrens
- Department of Rheumatology and Immunology, Hannover Medical School, Hannover, Germany
- German Center for Infection Research (DZIF), Partner Site Hannover-Braunschweig, Hannover, Germany
- Centre for Individualized Infection Medicine (CiiM), Hannover Medical School, Hannover, Germany
| | - Carolyn Chu
- University of California San Francisco, San Francisco, California, USA
| | - Lauren F Collins
- Division of Infectious Diseases, Emory School of Medicine, Grady Ponce de Leon Center, Atlanta, Georgia, USA
| | - Humberto R Jimenez
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey, USA
- Comprehensive Care Center, St. Joseph's University Medical Center, Paterson, New Jersey, USA
| | - David E Koren
- Temple University Health System, Philadelphia, Pennsylvania, USA
| | - Leslie McGorman
- American Academy of HIV Medicine, Washington, District of Columbia, USA
| | - Nancy N Nguyen
- Thomas J. Long School of Pharmacy, University of the Pacific, Stockton, California, USA
| | - Melanie R Nicol
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota, USA
| | - Neha Sheth Pandit
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland, USA
| | - Natacha Pierre
- Department of Population Health Nursing Science, College of Nursing, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kimberly K Scarsi
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Gary F Spinner
- Southwest Community Health Center, Bridgeport, Connecticut, USA
| | - Alice Tseng
- Immunodeficiency Clinic, University Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy D Young
- Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Melissa E Badowski
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| |
Collapse
|
6
|
Van Duyne R, Irollo E, Lin A, Johnson JA, Guillem AM, O’Brien EV, Merja L, Nash B, Jackson JG, Sarkar A, Klase ZA, Meucci O. Adult Human Brain Tissue Cultures to Study NeuroHIV. Cells 2024; 13:1127. [PMID: 38994979 PMCID: PMC11240386 DOI: 10.3390/cells13131127] [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: 04/15/2024] [Revised: 06/11/2024] [Accepted: 06/26/2024] [Indexed: 07/13/2024] Open
Abstract
HIV-associated neurocognitive disorders (HAND) persist under antiretroviral therapy as a complex pathology that has been difficult to study in cellular and animal models. Therefore, we generated an ex vivo human brain slice model of HIV-1 infection from surgically resected adult brain tissue. Brain slice cultures processed for flow cytometry showed >90% viability of dissociated cells within the first three weeks in vitro, with parallel detection of astrocyte, myeloid, and neuronal populations. Neurons within brain slices showed stable dendritic spine density and mature spine morphologies in the first weeks in culture, and they generated detectable activity in multi-electrode arrays. We infected cultured brain slices using patient-matched CD4+ T-cells or monocyte-derived macrophages (MDMs) that were exposed to a GFP-expressing R5-tropic HIV-1 in vitro. Infected slice cultures expressed viral RNA and developed a spreading infection up to 9 days post-infection, which were significantly decreased by antiretrovirals. We also detected infected myeloid cells and astrocytes within slices and observed minimal effect on cellular viability over time. Overall, this human-centered model offers a promising resource to study the cellular mechanisms contributing to HAND (including antiretroviral toxicity, substance use, and aging), infection of resident brain cells, and new neuroprotective therapeutics.
Collapse
Affiliation(s)
- Rachel Van Duyne
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
| | - Elena Irollo
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
| | - Angel Lin
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
| | - James A. Johnson
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
| | - Alain M. Guillem
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
| | - Erick V. O’Brien
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
| | - Laura Merja
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
| | - Bradley Nash
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
| | - Joshua G. Jackson
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
| | - Atom Sarkar
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
- Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, PA 19102, USA
- Global Neurosciences Institute, LLC, Philadelphia, PA 19107, USA
| | - Zachary A. Klase
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
- Center for Neuroimmunology and CNS Therapeutics, Institute for Molecular Medicine and Infectious Diseases, Drexel University College of Medicine, Philadelphia, PA 19102, USA
| | - Olimpia Meucci
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
- Center for Neuroimmunology and CNS Therapeutics, Institute for Molecular Medicine and Infectious Diseases, Drexel University College of Medicine, Philadelphia, PA 19102, USA
- Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
| |
Collapse
|
7
|
Thoueille P, Saldanha SA, Schaller F, Choong E, Veuve F, Munting A, Cavassini M, Braun D, Günthard HF, Duran Ramirez JJ, Surial B, Furrer H, Rauch A, Ustero P, Calmy A, Stöckle M, Di Benedetto C, Bernasconi E, Schmid P, Marzolini C, Girardin FR, Buclin T, Decosterd LA, Guidi M. Population Pharmacokinetics of Cabotegravir Following Oral Administration and Long-Acting Intramuscular Injection in Real-World People with HIV. Clin Pharmacol Ther 2024; 115:1450-1459. [PMID: 38519844 DOI: 10.1002/cpt.3240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/25/2024] [Indexed: 03/25/2024]
Abstract
Long-acting cabotegravir has been studied mainly in the stringent framework of clinical trials, which does not necessarily reflect the situation of people with HIV (PWH) in routine clinical settings. The present population pharmacokinetic analysis aims to build real-world reference percentile curves of cabotegravir concentrations, accounting for patient-related factors that may affect cabotegravir exposure. The second objective is to simulate whether dosing interval adjustments of cabotegravir could be considered in specific subpopulations. Overall, 238 PWH contributed to 1,038 cabotegravir levels (186 during the initial oral administration phase and 852 after intramuscular injection). Cabotegravir pharmacokinetics was best described using a one-compartment model with distinct first order-absorption for oral and intramuscular administrations, and identical volume and clearance. Our model showed almost 40% faster absorption and 30% higher clearance than previously reported, resulting in a time to steady-state of 8 months and an elimination half-life of 4.6 weeks for long-acting cabotegravir. Sex and body mass index significantly influenced absorption, and bodyweight affected clearance. Model-based simulations showed that cabotegravir trough concentrations in females were 25% lower 4 weeks after the intramuscular loading dose, but 42% higher during the late maintenance phase. Finally, simulations indicated that in females, despite significantly higher cabotegravir concentrations, longer intervals between injections may not consistently ensure levels above the 4-fold protein-adjusted 90% inhibitory target concentration.
Collapse
Affiliation(s)
- Paul Thoueille
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Susana Alves Saldanha
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabian Schaller
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eva Choong
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - François Veuve
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Aline Munting
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Matthias Cavassini
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Dominique Braun
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Huldrych F Günthard
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Jessy J Duran Ramirez
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Bernard Surial
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andri Rauch
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pilar Ustero
- Division of Infectious Diseases, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marcel Stöckle
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - Enos Bernasconi
- Division of Infectious Diseases, Ente Ospedaliero Cantonale, Lugano, University of Geneva, and University of Southern Switzerland, Lugano, Switzerland
| | - Patrick Schmid
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Catia Marzolini
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - François R Girardin
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thierry Buclin
- Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Laurent A Decosterd
- Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monia Guidi
- Service of Clinical Pharmacology, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Centre for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland
| |
Collapse
|
8
|
Schmidt D, Kollan C, Stoll M. Long-acting prescriptions and therapy for HIV-1 from market launch to the present in Germany (May 2021 to December 2023). Front Public Health 2024; 12:1404255. [PMID: 38873299 PMCID: PMC11171712 DOI: 10.3389/fpubh.2024.1404255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/07/2024] [Indexed: 06/15/2024] Open
Abstract
Background In Europe, the combination of cabotegravir (CAB) with rilpivirine (RPV) has been approved as a dual injection long-acting (LA) therapy for the treatment of human immunodeficiency virus type 1 (HIV-1) infections in adults since December 2020. Studies have shown that between 36 and 61% of people living with HIV (PLWHIV) prefer LA therapy. However, there are no real-world data on the number of people receiving LA therapy, in Germany or internationally. The aim of this study was to assess the current situation and trends in usage of LA therapy for the treatment of HIV-1 in Germany. Methods Based on pharmacy prescription data derived from Insight Health, the monthly number of prescriptions for oral CAB, CAB-LA, and RPV-LA over the entire period of availability in Germany was analyzed and evaluated (May 2021 to December 2023). The number of 1st and 2nd initiation injections and subsequent maintenance injections was calculated on the basis of the prescriptions for oral CAB initiation. Results The bimonthly schedule resulted in two growing cohorts from September 2021 with an estimated 14,523 CAB-LA prescriptions over the entire period. Accordingly, in December 2023, there were approximately 1,364 PLWHIV receiving LA therapy, of whom 1,318 were receiving maintenance therapy. Only treatments with bimonthly regimens were carried out. Accounting for people not covered by statutory health insurance (~13%), a total of ~1,600 PLWHIV were receiving LA therapy in Germany in December 2023. The average rounded annual cost of therapy in 2023 was €11,940 (maintenance therapy with initiation) and €10,950 (maintenance therapy without initiation). Conclusion To our knowledge, this is the first study of real-world use and number of people receiving LA therapy. A strength of our study is the nearly complete coverage of people with statutory health insurance in Germany. The predicted demand for LA therapy does not match the actual number of people receiving LA therapy. Although the number of PLWHIV receiving LA therapy increased steadily, they accounted for just under 2% of the estimated total number of people receiving HIV therapy in Germany in 2023, almost 2 years after the market launch. No significant increase in prescriptions is expected; on the contrary, the trend is leveling off and is unlikely to change drastically in the near future. Hence, the need for this mode of therapy in Germany appears to be limited. Follow-up studies at regular intervals on the further course would be useful and are recommended, as well as investigations into the possible reasons for the slow uptake to inform public health experts and possibly broaden treatment options.
Collapse
Affiliation(s)
- Daniel Schmidt
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Christian Kollan
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | | |
Collapse
|
9
|
Cossu MV, D'Avolio A, Gervasoni C, Giacomelli A, Cattaneo D, Moschese D. Switching to deltoid intramuscular injections maintains therapeutic trough concentrations of rilpivirine and cabotegravir in people with HIV. Antimicrob Agents Chemother 2024; 68:e0017524. [PMID: 38534104 PMCID: PMC11064637 DOI: 10.1128/aac.00175-24] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Affiliation(s)
- Maria Vittoria Cossu
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Antonio D'Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Cristina Gervasoni
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Andrea Giacomelli
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Dario Cattaneo
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Davide Moschese
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| |
Collapse
|
10
|
Bettonte S, Berton M, Battegay M, Stader F, Marzolini C. Development of a physiologically-based pharmacokinetic model to simulate the pharmacokinetics of intramuscular antiretroviral drugs. CPT Pharmacometrics Syst Pharmacol 2024; 13:781-794. [PMID: 38429889 PMCID: PMC11098154 DOI: 10.1002/psp4.13118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 03/03/2024] Open
Abstract
There is growing interest in the use of long-acting (LA) injectable drugs to improve treatment adherence. However, their long elimination half-life complicates the conduct of clinical trials. Physiologically-based pharmacokinetic (PBPK) modeling is a mathematical tool that allows to simulate unknown clinical scenarios for LA formulations. Thus, this work aimed to develop and verify a mechanistic intramuscular PBPK model. The framework describing the release of a LA drug from the depot was developed by including both the physiology of the injection site and the physicochemical properties of the drug. The framework was coded in Matlab® 2020a and implemented in our existing PBPK model for the verification step using clinical data for LA cabotegravir, rilpivirine, and paliperidone. The model was considered verified when the simulations were within twofold of observed data. Furthermore, a local sensitivity analysis was conducted to assess the impact of various factors relevant for the drug release from the depot on pharmacokinetics. The PBPK model was successfully verified since all predictions were within twofold of observed clinical data. Peak concentration, area under the concentration-time curve, and trough concentration were sensitive to media viscosity, drug solubility, drug density, and diffusion layer thickness. Additionally, inflammation was shown to impact the drug release from the depot. The developed framework correctly described the release and the drug disposition of LA formulations upon intramuscular administration. It can be implemented in PBPK models to address pharmacological questions related to the use of LA formulations.
Collapse
Affiliation(s)
- Sara Bettonte
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical ResearchUniversity Hospital BaselBaselSwitzerland
- Faculty of MedicineUniversity of BaselBaselSwitzerland
| | - Mattia Berton
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical ResearchUniversity Hospital BaselBaselSwitzerland
- Faculty of MedicineUniversity of BaselBaselSwitzerland
| | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical ResearchUniversity Hospital BaselBaselSwitzerland
- Faculty of MedicineUniversity of BaselBaselSwitzerland
| | | | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical ResearchUniversity Hospital BaselBaselSwitzerland
- Faculty of MedicineUniversity of BaselBaselSwitzerland
- Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUK
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and PathologyUniversity Hospital Lausanne and University of LausanneLausanneSwitzerland
| |
Collapse
|
11
|
Henderson AC, Cholli P, Lampe MA, Kourtis AP. Challenges, risks, and opportunities of antiretroviral drugs in women of reproductive potential. Expert Rev Anti Infect Ther 2024; 22:153-167. [PMID: 38517686 DOI: 10.1080/14787210.2024.2334054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/19/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION The HIV/AIDS epidemic has been one of the greatest challenges in global health, significantly affecting women of reproductive potential. Considerable advances in antiretroviral therapy for women living with HIV have contributed to improvements in quality of life, better reproductive and birth outcomes, and a reduced risk of perinatal transmission. AREAS COVERED Despite the progress made, persistent challenges in access and adherence to antiretroviral drugs may limit their benefits for some women. More pharmacokinetic and safety studies in pregnant and lactating women are urgently needed, as are prospective surveillance systems to evaluate associations between fetal and infant antiretroviral exposures, drug-drug interactions, and pregnancy outcomes. EXPERT OPINION Multipurpose technologies, such as combined HIV and other STI or unintended pregnancy prevention, and innovative delivery methods, such as the development of long-acting antiretrovirals, have the potential to reduce adherence challenges and enhance quality of life for women with HIV. Parallel advances in drug safety testing and surveillance are needed to ensure the health and safety of women with or at risk for HIV and children at risk for perinatal transmission.
Collapse
Affiliation(s)
- Alexis C Henderson
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Preetam Cholli
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Margaret A Lampe
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Athena P Kourtis
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| |
Collapse
|
12
|
Libman H, Krakower D, Taylor JL, Burns RB. How Would You Manage HIV Pre-exposure Prophylaxis in This Patient With Medical Comorbidities? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2024; 177:518-526. [PMID: 38588544 DOI: 10.7326/m24-0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Abstract
Despite advances in treatment, HIV infection remains an important cause of morbidity and mortality, with more than 30 000 new cases diagnosed in the United States each year. There are several interventions traditionally used to prevent HIV transmission, but these vary in effectiveness and there are challenges to their implementation. In 2014, the Centers for Disease Control and Prevention published initial guidance on the use of antiretroviral pre-exposure prophylaxis (PrEP) to prevent transmission of HIV infection in persons at risk based on multiple studies that showed it to be highly efficacious in various populations. It was updated in 2021 to reflect new drug options. The U.S. Preventive Services Task Force also recently updated its recommendations for PrEP, which strongly support its use in persons at risk. Despite its well-established effectiveness, the implementation of PrEP in clinical practice has been variable, especially among populations underserved by the medical system and marginalized by society. Fewer than one third of persons in the United States who are eligible for PrEP currently receive it. Here, 2 physicians experienced in HIV PrEP debate how best to identify patients who might benefit from PrEP, how to decide what regimen to use, and how to monitor therapy.
Collapse
Affiliation(s)
- Howard Libman
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (H.L., D.K., R.B.B.)
| | - Douglas Krakower
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (H.L., D.K., R.B.B.)
| | - Jessica L Taylor
- Boston University School of Medicine, Section of General Internal Medicine, Boston, Massachusetts (J.L.T.)
| | - Risa B Burns
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (H.L., D.K., R.B.B.)
| |
Collapse
|
13
|
Bettonte S, Berton M, Stader F, Battegay M, Marzolini C. Drug Exposure of Long-Acting Cabotegravir and Rilpivirine in Older People With Human Immunodeficiency Virus: A Pharmacokinetic Modeling Study. Open Forum Infect Dis 2024; 11:ofae171. [PMID: 38595957 PMCID: PMC11002946 DOI: 10.1093/ofid/ofae171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/19/2024] [Indexed: 04/11/2024] Open
Abstract
Background The life expectancy of people with human immunodeficiency virus (PWH) has significantly increased, thanks to combined antiretrovirals with improved potency and tolerability. One further step has been achieved with the development of long-acting (LA) injectable antiretrovirals, which allow for infrequent dosing. However, the pharmacokinetics of LA antiretrovirals has been poorly characterized in older PWH, as they are generally excluded from trials. We performed virtual studies using physiologically based pharmacokinetic (PBPK) modeling to determine the anticipated exposure of LA cabotegravir/rilpivirine in older individuals. Methods Our PBPK model was verified against available observed data for LA cabotegravir and rilpivirine. Cohorts of virtual individuals aged 20-50, 50-65, or 65-85 years were generated to simulate the exposure of LA cabotegravir/rilpivirine for each age group. The fold changes in trough concentration (Cmin) and in drug exposure (area under the time-concentration curve [AUC]) were determined for older relative to young individuals. Results The verified PBPK models predicted an increase in exposure within the 0.8-1.25 fold range for monthly LA cabotegravir/rilpivirine. The Cmin and AUC were predicted to be 29% and 26% higher in older compared with young adults for LA cabotegravir administered bimonthly (every 2 months) and 46% and 41% higher for LA rilpivirine bimonthly. The Cmin and AUC of LA cabotegravir and rilpivirine were predicted to be modestly increased in female compared with male individuals for all age groups. Conclusions LA cabotegravir/rilpivirine exposure and trough concentrations are predicted to be higher in older than in young PWH; thus, older adults could have a lower risk to present suboptimal concentrations during the dosing interval.
Collapse
Affiliation(s)
- Sara Bettonte
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Mattia Berton
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | | | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, University Hospital Lausanne and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
14
|
Bleasdale J, McCole M, Cole K, Hequembourg A, Morse GD, Przybyla SM. Perspectives on Injectable HIV Pre-Exposure Prophylaxis: A Qualitative Study of Health Care Providers in the United States. AIDS Patient Care STDS 2024; 38:177-184. [PMID: 38656214 PMCID: PMC11236283 DOI: 10.1089/apc.2024.0001] [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] [Indexed: 04/26/2024] Open
Abstract
The introduction of injectable HIV pre-exposure prophylaxis (PrEP) has the potential to significantly change the biomedical HIV prevention landscape. However, effective implementation will require health care providers to adopt, prescribe, and administer injectable PrEP within clinical settings. This study qualitatively examined challenges and benefit of injectable PrEP implementation from the perspective of health care providers. From April to August 2022, we conducted 19 in-depth interviews with current PrEP-prescribing health care providers in New York State, including 3 physician assistants, 5 physicians, and 11 nurse practitioners. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed to report semantic-level themes regarding injectable PrEP implementation. More than half of participants (61%) were aware of injectable PrEP; only 21% had experience prescribing it. Qualitative findings highlighted five themes. Three themes represented implementation challenges, including speculative concerns about side effects, appointment compliance, and practical and logistical considerations. The remaining two themes described benefits of injectable PrEP relative to oral PrEP, which included greater convenience and enhanced privacy. Findings from this qualitative study make significant applied contributions to the sparse knowledge on health care provider perspectives of injectable PrEP post-US Food and Drug Administration approval and their concerns and considerations regarding implementation in real-world clinical settings.
Collapse
Affiliation(s)
- Jacob Bleasdale
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA
- Southern HIV and Alcohol Research Consortium (SHARC), University of Florida, Gainesville, Florida, USA
| | - Meghan McCole
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York, USA
| | - Kenneth Cole
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York, USA
| | - Amy Hequembourg
- School of Nursing, University at Buffalo, Buffalo, New York, USA
| | - Gene D Morse
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York, USA
- Center for Integrated Global Biomedical Sciences, Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Sarahmona M Przybyla
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York, USA
| |
Collapse
|
15
|
Gaur AH, Capparelli EV, Calabrese K, Baltrusaitis K, Marzinke MA, McCoig C, Van Solingen-Ristea RM, Mathiba SR, Adeyeye A, Moye JH, Heckman B, Lowenthal ED, Ward S, Milligan R, Samson P, Best BM, Harrington CM, Ford SL, Huang J, Crauwels H, Vandermeulen K, Agwu AL, Smith-Anderson C, Camacho-Gonzalez A, Ounchanum P, Kneebone JL, Townley E, Bolton Moore C. Safety and pharmacokinetics of oral and long-acting injectable cabotegravir or long-acting injectable rilpivirine in virologically suppressed adolescents with HIV (IMPAACT 2017/MOCHA): a phase 1/2, multicentre, open-label, non-comparative, dose-finding study. Lancet HIV 2024; 11:e211-e221. [PMID: 38538160 PMCID: PMC11213970 DOI: 10.1016/s2352-3018(23)00300-4] [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: 05/18/2023] [Revised: 10/06/2023] [Accepted: 11/13/2023] [Indexed: 04/07/2024]
Abstract
BACKGROUND Combined intramuscular long-acting cabotegravir and long-acting rilpivirine constitute the first long-acting combination antiretroviral therapy (ART) regimen approved for adults with HIV. The goal of the IMPAACT 2017 study (MOCHA [More Options for Children and Adolescents]) was to assess the safety and pharmacokinetics of these drugs in adolescents. METHODS In this phase 1/2, multicentre, open-label, non-comparative, dose-finding study, virologically suppressed adolescents (aged 12-17 years; weight ≥35 kg; BMI ≤31·5 kg/m2) with HIV-1 on daily oral ART were enrolled at 15 centres in four countries (Botswana, South Africa, Thailand, and the USA). After 4-6 weeks of oral cabotegravir (cohort 1C) or rilpivirine (cohort 1R), participants received intramuscular long-acting cabotegravir or long-acting rilpivirine every 4 weeks or 8 weeks per the adult dosing regimens, while continuing pre-study ART. The primary outcomes were assessments of safety measures, including all adverse events, until week 4 for oral cabotegravir and until week 16 for long-acting cabotegravir and long-acting rilpivirine, and pharmacokinetic measures, including the area under the plasma concentration versus time curve during the dosing interval (AUC0-tau) and drug concentrations, at week 2 for oral dosing of cabotegravir and at week 16 for intramuscular dosing of cabotegravir and rilpivirine. Enrolment into cohort 1C or cohort 1R was based on the participant's pre-study ART, meaning that masking was not done. For pharmacokinetic analyses, blood samples were drawn at weeks 2-4 after oral dosing and weeks 4-16 after intramuscular dosing. Safety outcome measures were summarised using frequencies, percentages, and exact 95% CIs; pharmacokinetic parameters were summarised using descriptive statistics. This trial is registered at ClinicalTrials.gov, NCT03497676, and is closed to enrolment. FINDINGS Between March 19, 2019, and Nov 25, 2021, 55 participants were enrolled: 30 in cohort 1C and 25 in cohort 1R. At week 16, 28 (97%, 95% CI 82-100) of the 29 dose-evaluable participants in cohort 1C and 21 (91%; 72-99) of the 23 dose-evaluable participants in cohort 1R had reported at least one adverse event, with the most common being injection-site pain (nine [31%] in cohort 1C; nine [39%] in cohort 1R; none were severe). One (4%, 95% CI 0-22) participant in cohort 1R had an adverse event of grade 3 or higher, leading to treatment discontinuation, which was defined as acute rilpivirine-related allergic reaction (self-limiting generalised urticaria) after the first oral dose. No deaths or life-threatening events occurred. In cohort 1C, the week 2 median cabotegravir AUC0-tau was 148·5 (range 37·2-433·1) μg·h/mL. The week 16 median concentrations for the every-4-weeks and every-8-weeks dosing was 3·11 μg/mL (range 1·22-6·19) and 1·15 μg/mL (<0·025-5·29) for cabotegravir and 52·9 ng/mL (31·9-148·0) and 39·1 ng/mL (27·2-81·3) for rilpivirine, respectively. These concentrations were similar to those in adults. INTERPRETATION Study data support using long-acting cabotegravir or long-acting rilpivirine, given every 4 weeks or 8 weeks, per the adult dosing regimens, in virologically suppressed adolescents aged 12 years and older and weighing at least 35 kg. FUNDING The National Institutes of Health and ViiV Healthcare.
Collapse
Affiliation(s)
- Aditya H Gaur
- St Jude Children's Research Hospital, Memphis, TN, USA.
| | | | | | - Kristin Baltrusaitis
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mark A Marzinke
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | - Adeola Adeyeye
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - John H Moye
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA
| | | | - Elizabeth D Lowenthal
- University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shawn Ward
- Frontier Science Foundation, Boston, MA, USA
| | | | | | | | | | | | | | | | | | - Allison L Agwu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | | | - Ellen Townley
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; University of Alabama, Birmingham, AL, USA
| |
Collapse
|
16
|
Johnson LF, Myer L, Jamieson L, Meyer-Rath G, Delany-Moretlwe S, Joseph Davey D. The potential benefits of long-acting injectable cabotegravir in pregnant and breastfeeding women and their infants. AIDS 2024; 38:589-594. [PMID: 38016171 PMCID: PMC10906189 DOI: 10.1097/qad.0000000000003803] [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: 08/29/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Pregnant and breastfeeding women (PBW) in sub-Saharan Africa have high HIV incidence rates and associated risk of vertical transmission to their infants. Oral preexposure prophylaxis (PrEP) and injectable PrEP (long-acting cabotegravir, or CAB-LA) can potentially reduce this HIV transmission, but population-level impacts are uncertain. METHODS We extended a previously developed model of HIV and PrEP in South Africa to allow for variable PrEP duration and preference in PBW. We considered three potential scenarios for PrEP provision to PBW: oral PrEP only, CAB-LA only, and allowing oral/CAB-LA choice, with uptake and retention assumptions informed by South African data, each compared with a 'base' scenario without PrEP for PBW. RESULTS Without PrEP for PBW, the model estimates 1.31 million new infections will occur between 2025 and 2035 in South African adults and children, including 100 000 in PBW, 16 800 in infants at/before birth, and 35 200 in children through breastmilk. In the oral PrEP-only scenario, these numbers would reduce by 1.2% (95% CI: 0.7-1.7%), 8.6% (4.8-12.9%), 4.0% (2.1-5.8%), and 5.3% (3.0-8.2%) respectively. In the CAB-LA-only scenario, the corresponding reductions would be 6.1% (2.9-9.6%), 41.2% (19.8-65.0%), 12.6% (6.0-19.4%), and 29.5% (13.9-46.8%), respectively, and in the oral/CAB-LA choice scenario, similar reductions would be achieved [5.6% (3.4-8.0%), 39% (23.4-55.9%), 12.4% (7.4-16.8%) and 27.6% (16.5-39.9%) respectively]. CONCLUSION CAB-LA has the potential to be substantially more effective than oral PrEP in preventing HIV acquisition in PBW and vertical transmission, and can also modestly reduce HIV incidence at a population level.
Collapse
Affiliation(s)
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, Netherlands
- The South African Department of Science and Innovation/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
- The South African Department of Science and Innovation/National Research Foundation Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- Department of Global Health, Boston University, Boston, MA, USA
| | | | - Dvora Joseph Davey
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town
- Division of Infectious Diseases, Geffen School of Medicine, University of California Los Angeles, Los Angeles CA, USA
| |
Collapse
|
17
|
Oka S, Holohan V, Shirasaka T, Choi JY, Kim YS, Chamay N, Patel P, Polli JW, Ford SL, Crauwels H, Garside L, D'Amico R, Latham C, van Solingen-Ristea R, Baugh B, van Wyk J. Asian participants' experience in phase 3/3b studies of long-acting cabotegravir and rilpivirine: Efficacy, safety, pharmacokinetic, and virological outcomes through week 96. HIV Med 2024; 25:381-390. [PMID: 38147871 DOI: 10.1111/hiv.13588] [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: 07/06/2023] [Accepted: 11/08/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVES Cabotegravir + rilpivirine (CAB + RPV) dosed monthly or every 2 months is the first complete long-acting (LA) regimen recommended by treatment guidelines for the maintenance of HIV-1 virological suppression. This post hoc analysis summarizes outcomes for Asian participants through week 96. METHODS Data from Asian participants naive to CAB + RPV randomized to receive dosing every 4 weeks (Q4W) or every 8 weeks (Q8W) in the FLAIR (NCT02938520) and ATLAS-2M (NCT03299049) phase 3/3b studies were pooled. The proportion of participants with plasma HIV-1 RNA ≥50 and <50 copies/mL (per FDA Snapshot algorithm), incidence of confirmed virological failure (CVF; two consecutive HIV-1 RNA ≥200 copies/mL), pharmacokinetics, safety, and tolerability through week 96 were assessed. RESULTS Overall, 41 Asian participants received CAB + RPV (Q8W, n = 17; Q4W, n = 24). At week 96, 83% (n = 34/41) of participants maintained HIV-1 RNA <50 copies/mL, none had HIV-1 RNA ≥50 copies/mL, and 17% (n = 7/41) had no virological data. No Asian participant met the CVF criterion. Drug-related adverse events occurred in 44% (n = 18/41) of participants; none were Grade ≥3. All injection site reactions were Grade 1 or 2; median duration was 2 days and most resolved within 7 days (90%, n = 390/435). CAB and RPV trough concentrations remained well above their respective protein-adjusted 90% inhibitory concentrations (CAB, 0.166 μg/mL; RPV, 12 ng/mL) through week 96. CONCLUSIONS CAB + RPV LA demonstrated high efficacy, with no participants having CVF, and an acceptable safety profile in Asian participants through week 96. These data support CAB + RPV LA as a complete regimen for the maintenance of HIV-1 virological suppression in Asian individuals.
Collapse
Affiliation(s)
- Shinichi Oka
- National Center for Global Health and Medicine, Tokyo, Japan
| | | | - Takuma Shirasaka
- AIDS Medical Center, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Jun Yong Choi
- Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Yeon-Sook Kim
- School of Medicine, Chungnam National University, Daejeon, South Korea
| | | | - Parul Patel
- ViiV Healthcare, Durham, North Carolina, USA
| | | | | | | | | | | | | | | | - Bryan Baugh
- Janssen Pharmaceuticals, Research & Development, Titusville, New Jersey, USA
| | | |
Collapse
|
18
|
Pons-Faudoa FP, Di Trani N, Capuani S, Facchi I, Wood AM, Nehete B, DeLise A, Sharma S, Shelton KA, Bushman LR, Chua CYX, Ittmann MM, Kimata JT, Anderson PL, Nehete PN, Arduino RC, Grattoni A. Antiviral potency of long-acting islatravir subdermal implant in SHIV-infected macaques. J Control Release 2024; 366:18-27. [PMID: 38142963 PMCID: PMC10922355 DOI: 10.1016/j.jconrel.2023.12.031] [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: 08/21/2023] [Revised: 11/14/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
Treatment nonadherence is a pressing issue in people living with HIV (PLWH), as they require lifelong therapy to maintain viral suppression. Poor adherence leads to antiretroviral (ARV) resistance, transmission to others, AIDS progression, and increased morbidity and mortality. Long-acting (LA) ARV therapy is a promising strategy to combat the clinical drawback of user-dependent dosing. Islatravir (ISL) is a promising candidate for HIV treatment given its long half-life and high potency. Here we show constant ISL release from a subdermal LA nanofluidic implant achieves viral load reduction in SHIV-infected macaques. Specifically, a mean delivery dosage of 0.21 ± 0.07 mg/kg/day yielded a mean viral load reduction of -2.30 ± 0.53 log10 copies/mL at week 2, compared to baseline. The antiviral potency of the ISL delivered from the nanofluidic implant was higher than oral ISL dosed either daily or weekly. At week 3, viral resistance to ISL emerged in 2 out of 8 macaques, attributable to M184V mutation, supporting the need of combining ISL with other ARV for HIV treatment. The ISL implant produced moderate reactivity in the surrounding tissue, indicating tolerability. Overall, we present the ISL subdermal implant as a promising approach for LA ARV treatment in PLWH.
Collapse
Affiliation(s)
- Fernanda P Pons-Faudoa
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA
| | - Nicola Di Trani
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA
| | - Simone Capuani
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA
| | - Ilaria Facchi
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA
| | - Anthony M Wood
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA
| | - Bharti Nehete
- Department of Comparative Medicine, Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX 78602, USA
| | - Ashley DeLise
- Department of Comparative Medicine, Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX 78602, USA
| | - Suman Sharma
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Kathryn A Shelton
- Department of Comparative Medicine, Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX 78602, USA
| | - Lane R Bushman
- Deparment of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado- Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Corrine Ying Xuan Chua
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA
| | - Michael M Ittmann
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Jason T Kimata
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Peter L Anderson
- Deparment of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado- Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Pramod N Nehete
- Department of Comparative Medicine, Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX 78602, USA; The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX 77030, USA
| | - Roberto C Arduino
- Division of Infectious Diseases, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center, Houston, TX 77030, USA
| | - Alessandro Grattoni
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX 77030, USA; Department of Surgery, Houston Methodist Research Institute, Houston, TX 77030, USA; Department of Radiation Oncology, Houston Methodist Research Institute, Houston, TX 77030, USA.
| |
Collapse
|
19
|
Thoueille P, Cavassini M, Guidi M, Buclin T, Girardin FR, Decosterd LA, Marzolini C. Guidance for the Interpretation of Long-Acting Cabotegravir and Rilpivirine Concentrations Based on Real-World Therapeutic Drug Monitoring Data and Documented Failures. Open Forum Infect Dis 2024; 11:ofae023. [PMID: 38379570 PMCID: PMC10878054 DOI: 10.1093/ofid/ofae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/11/2024] [Indexed: 02/22/2024] Open
Abstract
The interpretation of long-acting cabotegravir and rilpivirine concentrations is complicated by the lack of consensus on the threshold to consider. Building on real-world therapeutic drug monitoring data and documented virologic failures, this article provides a reappraisal of the existing thresholds and guidance for the interpretation of cabotegravir and rilpivirine concentrations.
Collapse
Affiliation(s)
- Paul Thoueille
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Matthias Cavassini
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monia Guidi
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Centre for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Thierry Buclin
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - François R Girardin
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Laurent A Decosterd
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Catia Marzolini
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| |
Collapse
|
20
|
Kinsale TS, Cottrell ML, Li L, Brand R, Gatto G, Luecke E, Norton C, Krovi A, Dumond JB, Rao G, Yeshwante S, Van Horne B, Van Der Straten A, Kashuba ADM, Johnson LM. Pharmacokinetic Modeling to Guide Preclinical Development of an Islatravir-Eluting Reservoir-Style Biodegradable Implant for Long-Acting HIV PrEP. Pharmaceutics 2024; 16:201. [PMID: 38399255 PMCID: PMC10893066 DOI: 10.3390/pharmaceutics16020201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/15/2023] [Accepted: 12/22/2023] [Indexed: 02/25/2024] Open
Abstract
Long-acting injectable cabotegravir is more effective than daily oral PrEP at preventing HIV transmission due to improved adherence, but requires bi-monthly large-volume intramuscular injections. Subcutaneous (SC) contraceptive implants can be formulated with antiretrovirals for extended-duration HIV PrEP. Islatravir (ISL) is a first-in-class, investigational antiretroviral with pharmacologic properties well-suited for implant delivery. We performed preclinical studies for the development of a reservoir-style, poly(ε-caprolactone) ISL-eluting implant by conducting a single-dose SC ISL dose-ranging pharmacokinetic (PK) study of 0.1, 0.3, and 1 mg/kg in adult Wistar rats. Non-compartmental analysis was conducted, and dose proportionality assessed for ISL plasma and intracellular islatravir-triphosphate (ISL-tp). Population PK models estimated ISL's unit impulse response to deconvolve ISL-implant in vivo absorption rate (mg/day) and cumulative mass (mg) from published rat plasma PK (n = 10). Drug release was interpreted using four kinetic models. Dose proportionality was affirmed for ISL and ISL-tp. A first-order, two-compartment model fitted the SC ISL bolus data. Mean (SD) absorption rate from 0 to 154 days was 0.072 ± 0.024 mg/day, and cumulative mass at 154 days was 8.67 ± 3.22 mg. ISL absorption was well-described by zero-order (r2 = 0.95) and Ritger-Peppas (r2 = 0.98). Our zero-order ISL-release poly(ε-caprolactone) implant is projected to achieve clinical PK above ISL-tp's PrEP efficacy threshold. Continued development for HIV PrEP applications is warranted.
Collapse
Affiliation(s)
- Talisa S. Kinsale
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA; (T.S.K.); (J.B.D.); (G.R.); (S.Y.); (B.V.H.); (A.D.M.K.)
| | - Mackenzie L. Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA; (T.S.K.); (J.B.D.); (G.R.); (S.Y.); (B.V.H.); (A.D.M.K.)
| | - Linying Li
- Biomedical Technologies RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC 27709, USA; (L.L.); (C.N.); (A.K.)
| | - Rhonda Brand
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA;
| | - Greg Gatto
- Global Public Health Impact Center, RTI International, Research Triangle Park, NC 27709, USA; (G.G.); (E.L.)
| | - Ellen Luecke
- Global Public Health Impact Center, RTI International, Research Triangle Park, NC 27709, USA; (G.G.); (E.L.)
| | - Chasity Norton
- Biomedical Technologies RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC 27709, USA; (L.L.); (C.N.); (A.K.)
| | - Archana Krovi
- Biomedical Technologies RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC 27709, USA; (L.L.); (C.N.); (A.K.)
| | - Julie B. Dumond
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA; (T.S.K.); (J.B.D.); (G.R.); (S.Y.); (B.V.H.); (A.D.M.K.)
| | - Gauri Rao
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA; (T.S.K.); (J.B.D.); (G.R.); (S.Y.); (B.V.H.); (A.D.M.K.)
| | - Shekhar Yeshwante
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA; (T.S.K.); (J.B.D.); (G.R.); (S.Y.); (B.V.H.); (A.D.M.K.)
| | - Brian Van Horne
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA; (T.S.K.); (J.B.D.); (G.R.); (S.Y.); (B.V.H.); (A.D.M.K.)
| | - Ariane Van Der Straten
- Center for AIDS Prevention Studies (CAPS), Department of Medicine, University of California San Francisco, San Francisco, CA 94104, USA;
- ASTRA Consulting, Kensington, CA 94708, USA
| | - Angela D. M. Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA; (T.S.K.); (J.B.D.); (G.R.); (S.Y.); (B.V.H.); (A.D.M.K.)
| | - Leah M. Johnson
- Biomedical Technologies RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC 27709, USA; (L.L.); (C.N.); (A.K.)
| |
Collapse
|
21
|
Han K, Gevorkyan H, Sadik Shaik J, Crauwels H, Leemereise C, Bontempo G, Win B, Chounta V, Seal C, DeMoor R, D'Amico R, Spreen WR, Ford SL. Pharmacokinetics and tolerability of cabotegravir and rilpivirine long-acting intramuscular injections to the vastus lateralis (lateral thigh) muscles of healthy adult participants. Antimicrob Agents Chemother 2024; 68:e0078123. [PMID: 38038460 PMCID: PMC10777827 DOI: 10.1128/aac.00781-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/04/2023] [Indexed: 12/02/2023] Open
Abstract
Cabotegravir + rilpivirine administered via intramuscular gluteal injections is the first complete long-acting (LA) regimen approved for maintaining HIV-1 virologic suppression. The vastus lateralis (lateral) thigh muscle could be a potential alternative site of administration in circumstances such as injection site fatigue, intolerability, or contraindication for gluteal administration. Cabotegravir and rilpivirine pharmacokinetics and participant tolerability were evaluated following single intramuscular injections to the lateral thigh. Healthy adult participants received 4 weeks of daily oral cabotegravir (30 mg) and rilpivirine (25 mg), followed by a 10- to 14-day washout and single 3 mL intramuscular injections of cabotegravir LA 600 mg and rilpivirine LA 900 mg to the lateral thigh. Safety, tolerability, and pharmacokinetics were evaluated through 52 weeks post injection. Pharmacokinetic parameters were estimated using non-compartmental analysis. Fifteen participants (female at birth, n = 6) enrolled. Median age was 33 years. Median weight was 93.6 kg. Median body mass index was 31.4 kg/m2. One participant withdrew due to pregnancy after oral dosing before receiving an injection. Plasma concentrations at Weeks 4 and 8 were 15.4- and 5.3-fold above the protein-adjusted 90% inhibitory concentration for cabotegravir and 4.7- and 2.4-fold for rilpivirine, respectively. The most common injection site reactions were pain [28/28 (100%)], induration [15/28 (54%)], and swelling [12/28 (42%)]; 94% were Grade 1 or 2. Cabotegravir and rilpivirine plasma pharmacokinetic profiles observed in this study support further evaluation of thigh administration in target populations of people living with HIV-1. Tolerability of cabotegravir + rilpivirine LA intramuscular lateral thigh injections was similar to gluteal administration.
Collapse
Affiliation(s)
- Kelong Han
- Department of Clinical Pharmacology, Modeling & Simulation, GSK, Collegeville, Pennsylvania, USA
| | - Hakop Gevorkyan
- California Clinical Trials Medical Group in affiliation with PAREXEL, Glendale, California, USA
| | - Jafar Sadik Shaik
- Department of Clinical Pharmacology & Pharmacometrics, Janssen Research & Development, Spring House, Pennsylvania, USA
| | - Herta Crauwels
- Department of Clinical Pharmacology, Janssen Research & Development, Beerse, Belgium
| | | | | | | | | | | | | | | | | | - Susan L. Ford
- Department of Clinical Pharmacology, Modeling & Simulation, GSK, Durham, North Carolina, USA
| |
Collapse
|
22
|
Sliefert M, Maloba M, Wexler C, Were F, Mbithi Y, Mugendi G, Maliski E, Nicolay Z, Thomas G, Kale S, Maosa N, Finocchario-Kessler S. Challenges with pediatric antiretroviral therapy administration: Qualitative perspectives from caregivers and HIV providers in Kenya. PLoS One 2024; 19:e0296713. [PMID: 38194419 PMCID: PMC10775971 DOI: 10.1371/journal.pone.0296713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Current formulations of pediatric antiretroviral therapy (ART) for children with HIV present significant barriers to adherence, leading to drug resistance, ART ineffectiveness, and preventable child morbidity and mortality. Understanding these challenges and how they contribute to suboptimal adherence is an important step in improving outcomes. This qualitative study describes how regimen-related challenges create barriers to adherence and impact families. METHODS We conducted key informant interviews (KIIs) with 30 healthcare providers and 9 focus group discussions (FGDs) with a total of 72 caregivers, across three public hospitals in Siaya and Mombasa Kenya. The KIIs and FGDs were audio recorded, translated, and transcribed verbatim. The transcripts were hand coded based on emergent and a-priori themes. RESULTS Caregivers discussed major regimen-related challenges to adherence included poor palatability of current formulations, complex preparation, and administration (including measuring, crushing, dissolving, mixing), complex drug storage, and frequent refill appointments and how these regimen-related challenges contributed to individual and intrapersonal barriers to adherence. Caregivers discussed how poor taste led to child anxiety, refusal of medications, and the need for caregivers to use bribes or threats during administration. Complex preparation led to concerns and challenges about maintaining privacy and confidentiality, especially during times of travel. Providers corroborated this patient experience and described how these challenges with administration led to poor infant outcomes, including high viral load and preventable morbidity. Providers discussed how the frequency of refills could range from every 2 weeks to every 3 months, depending on the patient. Caregivers discussed how these refill frequencies interrupted work and school schedules, risked unwanted disclosure to peers, required use of financial resources for travel, and ultimately were a challenge to adherence. CONCLUSION These findings highlight the need for improved formulations for pediatric ART to ease the daily burden on caregivers and children to increase adherence, improve child health, and overall quality of life of families.
Collapse
Affiliation(s)
- Michala Sliefert
- University of Kansas Medical Center, Kansas City, KS, United States of America
| | - May Maloba
- Global Health Innovations, Nairobi, Kenya
| | - Catherine Wexler
- University of Kansas Medical Center, Kansas City, KS, United States of America
| | | | | | | | - Edward Maliski
- Oak Therapeutics, Lawrence, KS, United States of America
| | | | - Gregory Thomas
- University of Kansas, Lawrence, KS, United States of America
| | | | | | | |
Collapse
|
23
|
Thoueille P, Saldanha SA, Schaller F, Choong E, Munting A, Cavassini M, Braun D, Günthard HF, Kusejko K, Surial B, Furrer H, Rauch A, Rougemont M, Ustero P, Calmy A, Stöckle M, Marzolini C, Di Benedetto C, Bernasconi E, Schmid P, Piso RJ, Andre P, Girardin FR, Guidi M, Buclin T, Decosterd LA. Real-world trough concentrations and effectiveness of long-acting cabotegravir and rilpivirine: a multicenter prospective observational study in Switzerland. THE LANCET REGIONAL HEALTH. EUROPE 2024; 36:100793. [PMID: 38162253 PMCID: PMC10757247 DOI: 10.1016/j.lanepe.2023.100793] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/01/2023] [Accepted: 11/07/2023] [Indexed: 01/03/2024]
Abstract
Background The efficacy and tolerability of long-acting cabotegravir and rilpivirine were demonstrated in Phase III trials. However, low concentrations combined with other risk factors have been associated with an increased risk of virologic failure. This study aims to verify whether drug concentrations measured in a real-world setting are consistent with those previously reported. Methods SHCS-879 is a nationwide observational study within the Swiss HIV Cohort Study for the monitoring of people with HIV (PWH) on long-acting cabotegravir plus rilpivirine. Samples were collected from March 2022 to March 2023. Findings Overall, 725 samples were obtained from 186 PWH. Our data show a large inter-individual variability in cabotegravir and rilpivirine concentrations, with some individuals exhibiting repeatedly low concentrations. Rilpivirine trough concentrations were consistent with those from Phase III trials, while cabotegravir concentrations were lower. The first concentrations quartile was only slightly above the target of 664 ng/mL. Exploratory statistical analyses found 35% (p < 0·01) lower cabotegravir trough in males compared to females. Overall, 172 PWH (92%) remained suppressed and three experienced virologic failures (1·6%), of those, two had sub-optimal drug exposure. No association was found between low trough levels and detectable viral load. Interpretation Real-world cabotegravir concentrations are substantially lower than previously reported. However, these concentrations appear sufficient to ensure sustained virological suppression in almost every PWH. These reassuring data challenge the rather conservative thresholds adopted to date, which may raise unnecessary concerns. Yet, our study reveals that some PWH have repeatedly very low drug levels, for reasons that remain to be elucidated. Funding This work was funded by the Swiss National Science Foundation, grant number N◦ 324730_192449. This study received no support from pharmaceutical industries. This study was performed within the framework of the Swiss HIV Cohort Study, supported by the Swiss National Science Foundation (grant #201369), by SHCS project #879, and by the SHCS research foundation. The SHCS data were gathered by the Five Swiss University Hospitals, two Cantonal Hospitals, 15 affiliated hospitals and 36 private physicians (listed in http://www.shcs.ch/180-health-care-providers).
Collapse
Affiliation(s)
- Paul Thoueille
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Susana Alves Saldanha
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabian Schaller
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eva Choong
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Aline Munting
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Matthias Cavassini
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Dominique Braun
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Huldrych F. Günthard
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Katharina Kusejko
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Bernard Surial
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andri Rauch
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mathieu Rougemont
- Primary Care Medicine Division, University Hospital Geneva, Geneva, Switzerland
| | - Pilar Ustero
- Division of Infectious Diseases, Geneva University Hospitals, Faculty of Medicine, Geneva, Switzerland
| | - Alexandra Calmy
- Division of Infectious Diseases, Geneva University Hospitals, Faculty of Medicine, Geneva, Switzerland
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marcel Stöckle
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Catia Marzolini
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | | | - Enos Bernasconi
- Division of Infectious Diseases, Ente Ospedaliero Cantonale, Lugano, Switzerland
- University of Geneva, University of Southern Switzerland, Lugano, Switzerland
| | - Patrick Schmid
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Rein Jan Piso
- Department of Internal Medicine, Infectious Diseases and Hospital Epidemiology, Cantonal Hospital Olten, Switzerland
| | - Pascal Andre
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - François R. Girardin
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monia Guidi
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Centre for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Thierry Buclin
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Laurent A. Decosterd
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - The Swiss HIV Cohort Study
- Service and Laboratory of Clinical Pharmacology, Department of Laboratory Medicine and Pathology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Service of Infectious Diseases, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Switzerland
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Primary Care Medicine Division, University Hospital Geneva, Geneva, Switzerland
- Division of Infectious Diseases, Geneva University Hospitals, Faculty of Medicine, Geneva, Switzerland
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Division of Infectious Diseases, Ente Ospedaliero Cantonale, Lugano, Switzerland
- University of Geneva, University of Southern Switzerland, Lugano, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
- Department of Internal Medicine, Infectious Diseases and Hospital Epidemiology, Cantonal Hospital Olten, Switzerland
- Centre for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Geneva, Switzerland
| |
Collapse
|
24
|
Griffin DW, Hoy JF, McMahon JH. Long-acting cabotegravir PrEP: a time for cautious optimism. Lancet HIV 2023; 10:e756-e757. [PMID: 37952552 DOI: 10.1016/s2352-3018(23)00294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 10/31/2023] [Indexed: 11/14/2023]
Affiliation(s)
- David Wj Griffin
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, VIC, Australia.
| | - Jennifer F Hoy
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - James H McMahon
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, VIC, Australia; Department of Infectious Diseases, Monash Health, Melbourne, VIC, Australia
| |
Collapse
|
25
|
Rivera CG, Zeuli JD, Smith BL, Johnson TM, Bhatia R, Otto AO, Temesgen Z. HIV Pre-Exposure Prophylaxis: New and Upcoming Drugs to Address the HIV Epidemic. Drugs 2023; 83:1677-1698. [PMID: 38079092 DOI: 10.1007/s40265-023-01963-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 12/20/2023]
Abstract
Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) provides a critical intervention toward ending the HIV epidemic and protecting people with reasons to utilize PrEP. PrEP options continue to expand as new administration modalities offer the potential to tailor PrEP use for individual success. We have provided the evidence for new and emerging antiretroviral agents for PrEP (cabotegravir, lenacapavir, dapivirine, and broadly neutralizing antibodies), divided into pharmacology, animal model, and human data, accompanied by a summary and suggested place in therapy. Cabotegravir is a US Food and Drug Administration (FDA)-approved intramuscular injection given every 2 months with a strong body of evidence demonstrating efficacy for HIV PrEP, lenacapavir administered subcutaneously every 6 months is currently under investigation for HIV PrEP, dapivirine vaginal ring is an available PrEP option for women in certain areas of Africa, and broadly neutralizing monoclonal antibodies have been challenged in demonstrating efficacy in phase 1-2 study for HIV PrEP to date. Clinical literature for individual agents is discussed with data from major studies summarized in tables. This review provides a detailed overview of recently available and premier candidate PrEP drugs.
Collapse
Affiliation(s)
- Christina G Rivera
- Section of Infectious Diseases, HIV Program, Mayo Clinic, Rochester, MN, USA
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - John D Zeuli
- Section of Infectious Diseases, HIV Program, Mayo Clinic, Rochester, MN, USA
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Bradley L Smith
- Department of Pharmacy, Grady Health System, Atlanta, GA, USA
| | - Tanner M Johnson
- Section of Infectious Diseases, HIV Program, Mayo Clinic, Rochester, MN, USA
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Ramona Bhatia
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, USA
| | - Ashley O Otto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Zelalem Temesgen
- Section of Infectious Diseases, HIV Program, Mayo Clinic, Rochester, MN, USA.
- Section of Infectious Diseases, Mayo Clinic and Foundation, 200 First St. SW, Rochester, MN, 55905, USA.
| |
Collapse
|
26
|
O’Shea JG, Cholli P, Heil EL, Buchacz K. Considerations for long-acting antiretroviral therapy in older persons with HIV. AIDS 2023; 37:2271-2286. [PMID: 37965737 PMCID: PMC10993170 DOI: 10.1097/qad.0000000000003704] [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] [Indexed: 11/16/2023]
Abstract
People with HIV (PWH) can now enjoy longer, healthier lives due to safe and highly effective antiretroviral therapy (ART), and improved care and prevention strategies. New drug formulations such as long-acting injectables (LAI) may overcome some limitations and issues with oral antiretroviral therapy and strengthen medication adherence. However, challenges and questions remain regarding their use in aging populations. Here, we review unique considerations for LAI-ART for the treatment of HIV in older PWH, including benefits, risks, pharmacological considerations, implementation challenges, knowledge gaps, and identify factors that may facilitate uptake of LA-ART in this population.
Collapse
Affiliation(s)
- Jesse G. O’Shea
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Preetam Cholli
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Emily L. Heil
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Kate Buchacz
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
27
|
Landovitz RJ, Hanscom BS, Clement ME, Tran HV, Kallas EG, Magnus M, Sued O, Sanchez J, Scott H, Eron JJ, Del Rio C, Fields SD, Marzinke MA, Eshleman SH, Donnell D, Spinelli MA, Kofron RM, Berman R, Piwowar-Manning EM, Richardson PA, Sullivan PA, Lucas JP, Anderson PL, Hendrix CW, Adeyeye A, Rooney JF, Rinehart AR, Cohen MS, McCauley M, Grinsztejn B. Efficacy and safety of long-acting cabotegravir compared with daily oral tenofovir disoproxil fumarate plus emtricitabine to prevent HIV infection in cisgender men and transgender women who have sex with men 1 year after study unblinding: a secondary analysis of the phase 2b and 3 HPTN 083 randomised controlled trial. Lancet HIV 2023; 10:e767-e778. [PMID: 37952550 PMCID: PMC11375758 DOI: 10.1016/s2352-3018(23)00261-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/27/2023] [Accepted: 10/03/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Injectable cabotegravir was superior to daily oral tenofovir disoproxil fumarate plus emtricitabine for HIV prevention in two clinical trials. Both trials had the primary aim of establishing the HIV prevention efficacy of long-acting injectable cabotegravir pre-exposure prophylaxis (PrEP) compared with tenofovir disoproxil fumarate plus emtricitabine daily oral PrEP. Long-acting PrEP was associated with diagnostic delays and integrase strand-transfer inhibitor (INSTI) resistance. This report presents findings from the first unblinded year of the HIV Prevention Trials Network (HPTN) 083 study. METHODS The HPTN 083 randomised controlled trial enrolled HIV-uninfected cisgender men and transgender women at elevated HIV risk who have sex with men, from 43 clinical research sites in Africa, Asia, Latin America, and the USA. Inclusion criteria included: a negative HIV serological test at the screening and study entry, undetectable HIV RNA levels within 14 days of study entry, age 18 years or older, overall good health as determined by clinical and laboratory evaluations, and a creatinine clearance of 60 mL/min or higher. Participants were randomly allocated to receive long-acting injectable cabotegravir or daily oral tenofovir disoproxil fumarate plus emtricitabine PrEP. After study unblinding, participants remained on their original regimen awaiting an extension study. HIV infections were characterised retrospectively at a central laboratory. Here we report the secondary analysis of efficacy and safety for the first unblinded year. The primary outcome was incident HIV infection. Efficacy analyses were done on the modified intention-to-treat population using a Cox regression model. Adverse events were compared across treatment groups and time periods (blinded vs unblinded). This trial is registered with ClinicalTrials.gov, NCT02720094. FINDINGS Of the 4488 participants who contributed person-time to the blinded analysis, 3290 contributed person-time to the first unblinded year analysis between May 15, 2020, and May 14, 2021. Updated HIV incidence in the blinded phase was 0·41 per 100 person-years for long-acting injectable cabotegravir PrEP and 1·29 per 100 person-years for daily oral tenofovir disoproxil fumarate plus emtricitabine PrEP (hazard ratio [HR] 0·31 [95% CI 0·17-0·58], p=0·0003). HIV incidence in the first unblinded year was 0·82 per 100 person-years for long-acting PrEP and 2·27 per 100 person-years for daily oral PrEP (HR 0·35 [0·18-0·69], p=0·002). Adherence to both study products decreased after study unblinding. Additional infections in the long-acting PrEP group included two with on-time injections; three with one or more delayed injections; two detected with long-acting PrEP reinitiation; and 11 more than 6 months after their last injection. Infection within 6 months of cabotegravir exposure was associated with diagnostic delays and INSTI resistance. Adverse events were generally consistent with previous reports; incident hypertension in the long-acting PrEP group requires further investigation. INTERPRETATION Long-acting injectable cabotegravir PrEP retained high efficacy for HIV prevention in men and transgender women who have sex with men during the first year of open-label follow-up, with a near-identical HR for HIV risk reduction between long-acting injectable cabotegravir and daily oral tenofovir disoproxil fumarate plus emtricitabine PrEP during the first year after unblinding compared with the blinded period. Extended follow-up further defined the risk period for diagnostic delays and emergence of INSTI resistance. FUNDING Division of AIDS at the National Institute of Allergy and Infectious Diseases, ViiV Healthcare, and Gilead Sciences.
Collapse
Affiliation(s)
- Raphael J Landovitz
- Center for Clinical AIDS Research and Education, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | | | | | - Ha V Tran
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Esper G Kallas
- Department of Parasitic and Infectious Diseases, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Manya Magnus
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Omar Sued
- Fundación Huésped, Buenos Aires, Argentina
| | - Jorge Sanchez
- Centro de Investigaciones Tecnologicas, Biomedicas y Medioambientales, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Hyman Scott
- San Francisco Department of Public Health, San Francisco, CA, USA
| | - Joe J Eron
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carlos Del Rio
- Emory University School of Medicine and Grady Health System, Atlanta, GA, USA
| | - Sheldon D Fields
- Ross and Carol Nese College of Nursing, Pennsylvania State University, University Park, PA, USA
| | - Mark A Marzinke
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Matthew A Spinelli
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Ryan M Kofron
- Center for Clinical AIDS Research and Education, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Berman
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | | | | | - Peter L Anderson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, Anschutz Medical Campus, Aurora, CO, USA
| | - Craig W Hendrix
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adeola Adeyeye
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | | | | | - Myron S Cohen
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil
| |
Collapse
|
28
|
West RE, Oberly PJ, Riddler SA, Nolin TD, Devanathan AS. Development and validation of an ultra-high performance liquid chromatography-tandem mass spectrometry method for quantifying lenacapavir plasma concentrations: Application to therapeutic monitoring. J Chromatogr B Analyt Technol Biomed Life Sci 2023; 1230:123905. [PMID: 37866010 PMCID: PMC10842204 DOI: 10.1016/j.jchromb.2023.123905] [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: 07/01/2023] [Revised: 09/25/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023]
Abstract
Although current antiretroviral therapy (ART) effectively suppresses HIV in the blood, regimens may fail due to suboptimal treatment history and non-adherence to ART. In these scenarios, accumulation of viral resistance mutations to ART drug classes may occur. For these treatment-experienced people living with HIV (PLWH), activity against resistant viral strains is required; lack of therapeutic efficacy will result in continued viral replication and progression to acquired immunodeficiency syndrome. New treatment options have emerged. Lenacapavir is a first-in-class long-acting HIV-1 capsid inhibitor approved for the treatment of HIV in treatment-experienced patients. Lenacapavir is approved with an initiation regimen of oral and subcutaneous injection dosing followed by subcutaneous self-injection every 6 months. With infrequent dosing, therapeutic drug monitoring may be necessary to ensure adequate concentrations are consistently achieved in the plasma to assure treatment adherence and prevent further HIV resistance formation. To this end, we developed and validated a highly selective ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) method to quantify lenacapavir concentrations in human plasma. A simple protein precipitation with acetonitrile followed by supernatant dilution was performed. Lenacapavir and its stable labeled internal standard were separated at 1.90 min using a multi-step UPLC gradient. The assay for lenacapavir quantification was extensively validated according to the United States Food and Drug Administration Bioanalytical Guidelines over a clinically relevant range of 0.1 to 500 ng/mL with excellent linearity (R2 ≥ 0.9960). This analytical method achieves acceptable performance of trueness (89.7-104.1 %), repeatability, and precision (CV < 15 %). We applied this method to quantify a clinical sample and to determine the percent protein-unbound. This method can be utilized for the therapeutic monitoring of lenacapavir in human plasma for monitoring HIV treatment efficacy.
Collapse
Affiliation(s)
- Raymond E West
- Center for Clinical Pharmaceutical Sciences, Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Oberly
- Center for Clinical Pharmaceutical Sciences, Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sharon A Riddler
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas D Nolin
- Center for Clinical Pharmaceutical Sciences, Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aaron S Devanathan
- Center for Clinical Pharmaceutical Sciences, Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.
| |
Collapse
|
29
|
Young IC, Pallerla A, Cottrell ML, Maturavongsadit P, Prasher A, Shrivastava R, De la Cruz G, Montgomery SA, Schauer A, Sykes C, Kashuba ADM, Benhabbour SR. Long-acting injectable multipurpose prevention technology for prevention of HIV and unplanned pregnancy. J Control Release 2023; 363:606-620. [PMID: 37797892 PMCID: PMC10841820 DOI: 10.1016/j.jconrel.2023.10.006] [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: 05/31/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/07/2023]
Abstract
Only condoms are proven to protect against both HIV and unplanned pregnancy, however, poor user acceptability and lack of partner cooperation impede effectiveness. We developed an injectable ultra-long-acting, biodegradable, and removable in-situ forming implant (ISFI) as multipurpose prevention technology (MPT). MPT ISFIs co-formulated an antiretroviral (dolutegravir (DTG)) or cabotegravir (CAB)), and a hormonal contraceptive (etonogestrel (ENG) or medroxyprogesterone acetate (MPA)). All formulations were well-tolerated in mice with no signs of chronic local or systemic inflammation. Plasma CAB and DTG concentrations were above 4× PA-IC90 for 90 days with zero-order and diffusion-controlled absorption, respectively, and no differences when co-formulated with either hormone. Plasma ENG and MPA concentrations were quantifiable for 90 days. Complete removal of CAB/MPA ISFIs resulted in MPA concentrations falling below the limit of quantification after 24 h post-removal, but incomplete CAB elimination from plasma. Collectively, we demonstrated the ability to co-formulate antiretrovirals with contraceptives in an ISFI that is well-tolerated with sustained plasma concentrations up to 90 days.
Collapse
Affiliation(s)
- Isabella C Young
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Aryani Pallerla
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mackenzie L Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Panita Maturavongsadit
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alka Prasher
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Roopali Shrivastava
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Amanda Schauer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Craig Sykes
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Angela D M Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S Rahima Benhabbour
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| |
Collapse
|
30
|
Marzinke MA, Hanscom B, Wang Z, Safren SA, Psaros C, Donnell D, Richardson PA, Sullivan P, Eshleman SH, Jennings A, Feliciano KG, Jalil E, Coutinho C, Cardozo N, Maia B, Khan T, Singh Y, Middelkoop K, Franks J, Valencia J, Sanchez N, Lucas J, Rooney JF, Rinehart AR, Ford S, Adeyeye A, Cohen MS, McCauley M, Landovitz RJ, Grinsztejn B. Efficacy, safety, tolerability, and pharmacokinetics of long-acting injectable cabotegravir for HIV pre-exposure prophylaxis in transgender women: a secondary analysis of the HPTN 083 trial. Lancet HIV 2023; 10:e703-e712. [PMID: 37783219 PMCID: PMC10842527 DOI: 10.1016/s2352-3018(23)00200-x] [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: 04/21/2023] [Revised: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND The HIV Prevention Trials Network (HPTN) 083 trial showed that long-acting injectable cabotegravir was more effective than tenofovir disoproxil fumarate plus emtricitabine in preventing HIV in cisgender men and transgender women who have sex with men. We aimed to characterise the cohort of transgender women included in HPTN 083. METHODS HPTN 083 is an ongoing, phase 2b/3, randomised, multicentre, double-blind, double-dummy clinical trial done at 43 sites in seven countries (Argentina, Brazil, Peru, the USA, South Africa, Thailand, and Viet Nam). HIV-negative participants were randomly assigned (1:1) to receive injectable cabotegravir or tenofovir disoproxil fumarate plus emtricitabine. The study design and primary outcomes of the blinded phase of HPTN 083 have already been reported. An enrolment minimum of 10% transgender women was set for the trial. Here we characterise the cohort of transgender women enrolled from Dec 6, 2016, to May 14, 2020, when the study was unblinded. We report sociodemographic characteristics, use of gender affirming hormone therapy, and behavioural assessments of the transgender women participants. Laboratory testing and safety evaluations are also reported. The trial is registered at ClinicalTrials.gov, NCT02720094. FINDINGS HPTN 083 enrolled 570 transgender women (304 tenofovir disoproxil fumarate plus emtricitabine; 266 injectable cabotegravir). Transgender women were primarily from Asia (225 [39%]) and Latin America (205 [36%]); 330 (58%) reported using gender affirming hormone therapy. Intimate partner violence was common (270 [47%] reported emotional abuse and 172 [30%] reported physical abuse) and 323 (57%) reported a history of childhood sexual abuse. 159 (28%) transgender women disagreed that they were at risk for HIV, and 142 (25%) screened positive for depressive symptoms. During study follow-up, incidence of syphilis was 16·25% (95% CI 13·28-19·69), rectal gonorrhoea was 11·66% (9·14-14·66), and chlamydia was 20·61% (17·20-24·49). Frequency of adverse events was similar between the treatment groups. Nine seroconversions occurred among transgender women during the blinded phase of the study (seven in the tenofovir disoproxil fumarate plus emtricitabine group and two in the injectable cabotegravir group); overall incidence was 1·19 per 100 person-years (95% CI 0·54-2·25): 1·80 per 100 person-years (0·73-3·72) in the tenofovir disoproxil fumarate plus emtricitabine group and 0·54 per 100 person-years (0·07-1·95) in the injectable cabotegravir group (hazard ratio 0·34 [95% CI 0·08-1·56]). Cabotegravir concentrations did not differ by gender affirming hormone therapy use. INTERPRETATION HIV prevention strategies for transgender women cannot be addressed separately from social and structural vulnerabilities. Transgender women were well represented in HPTN 083 and should continue to be prioritised in HIV prevention studies. Our results suggest that injectable cabotegravir is a safe and effective pre-exposure prophylaxis option for transgender women. FUNDING National Institute of Allergy and Infectious Diseases and ViiV Healthcare.
Collapse
Affiliation(s)
| | | | - Zhe Wang
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | | | | | | | | | | | | | | | | | - Emilia Jalil
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Manguinhos, Rio de Janeiro, Brazil
| | - Carolina Coutinho
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Manguinhos, Rio de Janeiro, Brazil
| | | | | | | | - Yashna Singh
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Keren Middelkoop
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | | | | | | | | | | | | | - Myron S Cohen
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Raphael J Landovitz
- Center for Clinical AIDS Research and Education, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (INI-Fiocruz), Manguinhos, Rio de Janeiro, Brazil.
| |
Collapse
|
31
|
Landovitz RJ, Scott H, Deeks SG. Prevention, treatment and cure of HIV infection. Nat Rev Microbiol 2023; 21:657-670. [PMID: 37344551 DOI: 10.1038/s41579-023-00914-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 06/23/2023]
Abstract
The development of antiretroviral therapy for the prevention and treatment of HIV infection has been marked by a series of remarkable successes. However, the efforts to develop a vaccine have largely failed, and efforts to discover a cure are only now beginning to gain traction. In this Review, we describe recent progress on all fronts - pre-exposure prophylaxis, vaccines, treatment and cure - and we discuss the unmet needs, both current and in the coming years. We describe the emerging arsenal of drugs, biologics and strategies that will hopefully address these needs. Although HIV research has largely been siloed in the past, this is changing, as the emerging research agenda is marked by multiple cross-discipline synergies and collaborations. As the limitations of antiretroviral drugs as a means to truly end the epidemic are becoming more apparent, there is a great need for continued efforts to develop an effective preventative vaccine and a scalable cure, both of which remain formidable challenges.
Collapse
Affiliation(s)
- Raphael J Landovitz
- Center for Clinical AIDS Research and Education, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Hyman Scott
- Bridge HIV, San Francisco Department of Public Health, San Francisco, CA, USA
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Steven G Deeks
- Division of HIV, Infectious Diseases & Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA.
| |
Collapse
|
32
|
Ullah Nayan M, Sillman B, Hasan M, Deodhar S, Das S, Sultana A, Thai Hoang Le N, Soriano V, Edagwa B, Gendelman HE. Advances in long-acting slow effective release antiretroviral therapies for treatment and prevention of HIV infection. Adv Drug Deliv Rev 2023; 200:115009. [PMID: 37451501 DOI: 10.1016/j.addr.2023.115009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/21/2023] [Accepted: 07/12/2023] [Indexed: 07/18/2023]
Abstract
Adherence to daily oral antiretroviral therapy (ART) is a barrier to both treatment and prevention of human immunodeficiency virus (HIV) infection. To overcome limitations of life-long daily regimen adherence, long-acting (LA) injectable antiretroviral (ARV) drugs, nanoformulations, implants, vaginal rings, microarray patches, and ultra-long-acting (ULA) prodrugs are now available or in development. These medicines enable persons who are or at risk for HIV infection to be treated with simplified ART regimens. First-generation LA cabotegravir, rilpivirine, and lenacapavir injectables and a dapivirine vaginal ring are now in use. However, each remains limited by existing dosing intervals, ease of administration, or difficulties in finding drug partners. ULA ART regimens provide an answer, but to date, such next-generation formulations remain in development. Establishing the niche will require affirmation of extended dosing, improved access, reduced injection volumes, improved pharmacokinetic profiles, selections of combination treatments, and synchronization of healthcare support. Based on such needs, this review highlights recent pharmacological advances and a future treatment perspective. While first-generation LA ARTs are available for HIV care, they remain far from ideal in meeting patient needs. ULA medicines, now in advanced preclinical development, may close gaps toward broader usage and treatment options.
Collapse
Affiliation(s)
- Mohammad Ullah Nayan
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, NE, USA
| | - Brady Sillman
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, NE, USA
| | - Mahmudul Hasan
- Department of Pharmaceutical Science, University of Nebraska Medical Center, NE, USA
| | - Suyash Deodhar
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, NE, USA
| | - Srijanee Das
- Department of Pathology and Microbiology, University of Nebraska Medical Center, NE, USA
| | - Ashrafi Sultana
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, NE, USA
| | - Nam Thai Hoang Le
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, NE, USA
| | | | - Benson Edagwa
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, NE, USA.
| | - Howard E Gendelman
- Department of Pharmacology and Experimental Neuroscience, University of Nebraska Medical Center, NE, USA.
| |
Collapse
|
33
|
Leblanc JF, Custer B, Van de Laar T, Drews SJ, Germain M, Lewin A. HIV Pre-Exposure Prophylaxis, Blood Donor Deferral, Occult Infection, and Risk of HIV Transmission by Transfusion: A Fine Balance Between Evidence-Based Donor Selection Criteria and Transfusion Safety. Transfus Med Rev 2023; 37:150754. [PMID: 37741792 DOI: 10.1016/j.tmrv.2023.150754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 09/25/2023]
Abstract
Pre- and postexposure prophylaxis for human immunodeficiency virus (HIV) are key to reducing the transmission of this virus. Furthermore, low-toxicity, long-acting formulations provide additional clinical benefits, in particular easier adherence to treatment and prevention. However, breakthrough HIV infections can occur despite the use of pre-exposure prophylaxis (PrEP), mainly due to suboptimal adherence or multi-drug resistant HIV strains. Albeit rare, PrEP breakthrough infections have also been reported in fully adherent patients. Should such breakthrough infection occur in an eligible blood donor, PrEP might suppress viremia and delay antibody seroconversion, thereby masking the infection and increasing the risk of transfusion transmission. This possibility has raised concerns in the blood transfusion community but remains little documented. Therefore, a literature search was performed to assess the state of knowledge on the risk of PrEP breakthrough infection, with a particular focus on the risk of HIV entering the blood supply. Evidently, PrEP breakthrough infections are rare, although the risk is not zero. Moreover, a fraction of individuals - including blood donors - do not disclose PrEP use according to various surveys and measurements of HIV PrEP analytes. Additionally, viremia and seroconversion may remain undetectable or close to the limit of detection for a long time after cessation of PrEP, particularly with long-acting antiretrovirals. Therefore, current recommendations to defer donors for at least 3 months after the last dose of oral PrEP or 2 years for long-acting PrEP appear justified, as they safeguard the blood supply and public trust toward the system. These recommendations help to safeguard blood safety and public trust in the blood supply.
Collapse
Affiliation(s)
| | - Brian Custer
- Vitalant Research Institute, San Francisco, CA, USA; Department of Laboratory Medicine, University of California, San Francisco, CA, USA
| | - Thijs Van de Laar
- Sanquin Research, Department of Donor Medicine Research, Amsterdam, The Netherlands; Onze Lieve Vrouwe Gasthuis, Laboratory of Medical Microbiology, Amsterdam, The Netherlands
| | - Steven J Drews
- Microbiology, Donation Policy and Studies, Canadian Blood Services, Edmonton, Alberta, Canada; Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Marc Germain
- Hema-Québec, Medical Affairs and Innovation, Montréal and Québec, Québec, Canada
| | - Antoine Lewin
- Hema-Québec, Medical Affairs and Innovation, Montréal and Québec, Québec, Canada; Université de Sherbrooke, Faculty of Medicine and Health Sciences, Sherbrooke, Québec, Canada.
| |
Collapse
|
34
|
Joshi S, Namuddu C, Kasujja FX, Mirembe M, Homsy J, Seeley J, King R. PrEP uptake and persistence amongst HIV-negative women who exchange sex for money or commodities in Kampala, Uganda: A qualitative inquiry assessing the influence of pregnancy. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000434. [PMID: 37368866 PMCID: PMC10298783 DOI: 10.1371/journal.pgph.0000434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/10/2023] [Indexed: 06/29/2023]
Abstract
Pregnant young women who exchange sex for money or commodities are at elevated biological and social risk for HIV acquisition. PrEP serves as an effective means of HIV prevention, including during pregnancy. This study aimed to explore attitudes, experiences and challenges with PrEP to understand what motivates or limits PrEP uptake and adherence specifically during pregnancy among this population of young women. Semi-structured interviews were conducted with 23 participants, recruited from the Prevention on PrEP (POPPi) study in the Good Health for Women Project clinic in Kampala, Uganda. POPPi's inclusion criteria comprised of HIV-uninfected women, aged 15-24, who exchange sex for money or commodities. Interviews focused on experience with PrEP and pregnancy. Data were analyzed utilizing a framework analysis approach. Key themes were comprised of participant barriers to and facilitators of PrEP uptake and adherence. Reasons for PrEP initiation included desire for autonomy and agency, mistrust of partners, and social support. Participants expressed challenges with initiating or sustaining their use of PrEP, including pregnancy, PrEP access and perceived or felt stigma. During pregnancy, participants' primary motivators for altering PrEP use were either understanding of PrEP safety for their baby or changes in perceptions of their HIV risk. Many of these factors were similar across participants who had experience with pregnancy and those who did not. This study highlights the importance of addressing barriers to and facilitators of PrEP uptake and persistence, especially during pregnancy where risk is elevated, with a multi-level approach. Community-oriented education, stigma reduction activities alongside access to PrEP, can serve as means for adherence. The development of robust PrEP support services and guidelines regarding PrEP use during pregnancy among high-risk women, and strategies for their implementation, are of utmost importance for the control of HIV in key populations and the elimination of mother-to-child transmission of HIV.
Collapse
Affiliation(s)
- Shivali Joshi
- Institute for Global Health Sciences, University of California, San Francisco, (UCSF), San Francisco, California, United States of America
| | - Catherine Namuddu
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
| | - Francis Xavier Kasujja
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
| | - Miriam Mirembe
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
| | - Jaco Homsy
- Institute for Global Health Sciences, University of California, San Francisco, (UCSF), San Francisco, California, United States of America
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Rachel King
- Institute for Global Health Sciences, University of California, San Francisco, (UCSF), San Francisco, California, United States of America
| |
Collapse
|
35
|
Giraud EL, de Jong LAW, van den Hombergh E, Kaal SEJ, van Erp NP, Desar IME. Measuring Tumour Imatinib Concentrations in Gastrointestinal Stromal Tumours: Relevant or Redundant? Cancers (Basel) 2023; 15:cancers15112875. [PMID: 37296838 DOI: 10.3390/cancers15112875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/17/2023] [Accepted: 05/20/2023] [Indexed: 06/12/2023] Open
Abstract
Imatinib plasma trough concentrations are associated with efficacy for patients treated for advanced or metastatic KIT-positive gastrointestinal stromal tumours (GISTs). This relationship has not been studied for patients treated in the neoadjuvant setting, let alone its correlation with tumour drug concentrations. In this exploratory study we aimed to determine the correlation between plasma and tumour imatinib concentrations in the neoadjuvant setting, investigate tumour imatinib distribution patterns within GISTs, and analyse its correlation with pathological response. Imatinib concentrations were measured in both plasma and in three regions of the resected primary tumour: the core, middle part, and periphery. Twenty-four tumour samples derived from the primary tumours of eight patients were included in the analyses. Imatinib tumour concentrations were higher compared to plasma concentrations. No correlation was observed between plasma and tumour concentrations. Interpatient variability in tumour concentrations was high compared to interindividual variability in plasma concentrations. Although imatinib accumulates in tumour tissue, no distribution pattern of imatinib in tumour tissue could be identified. There was no correlation between imatinib concentrations in tumour tissue and pathological treatment response.
Collapse
Affiliation(s)
- Eline L Giraud
- Radboud University Medical Centre, Department of Pharmacy, 6500 HB Nijmegen, The Netherlands
| | - Loek A W de Jong
- Radboud University Medical Centre, Department of Pharmacy, 6500 HB Nijmegen, The Netherlands
| | - Erik van den Hombergh
- Radboud University Medical Centre, Department of Pharmacy, 6500 HB Nijmegen, The Netherlands
| | - Suzanne E J Kaal
- Radboud University Medical Centre, Department of Medical Oncology, 6500 HB Nijmegen, The Netherlands
| | - Nielka P van Erp
- Radboud University Medical Centre, Department of Pharmacy, 6500 HB Nijmegen, The Netherlands
| | - Ingrid M E Desar
- Radboud University Medical Centre, Department of Medical Oncology, 6500 HB Nijmegen, The Netherlands
| |
Collapse
|
36
|
Young IC, Thorson AL, Shrivastava R, Sykes C, Schauer AP, Cottrell ML, Kashuba ADM, Benhabbour SR. Dose-Ranging Plasma and Genital Tissue Pharmacokinetics and Biodegradation of Ultra-Long-Acting Cabotegravir In Situ Forming Implant. Pharmaceutics 2023; 15:1487. [PMID: 37242729 PMCID: PMC10222572 DOI: 10.3390/pharmaceutics15051487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/02/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
HIV continues to affect millions of men and women worldwide. The development of long-acting injectables for HIV prevention can overcome adherence challenges with daily oral prevention regimens by reducing dosing frequency and stigma. We previously developed an ultra-long-acting injectable, biodegradable, and removeable in situ forming implant (ISFI) with cabotegravir (CAB) that demonstrated protection after multiple rectal SHIV challenges in female macaques. Here, we sought to further characterize CAB ISFI pharmacokinetics (PK) in mice by assessing the effect of dose and number of injections on CAB PK, time to completion of CAB release and polymer degradation, long-term genital tissue PK, and CAB PK tail after implant removal. CAB concentrations in plasma were above the benchmark for protection for 11-12 months with proportionality between dose and drug exposure. CAB ISFI exhibited high concentrations in vaginal, cervical, and rectal tissues for up to 180 days. Furthermore, depots were easily retrievable up to 180 days post-administration with up to 34% residual CAB and near complete (85%) polymer degradation quantified in depots ex vivo. After depot removal, results demonstrated a median 11-fold decline in CAB plasma concentrations across all doses. Ultimately, this study provided critical PK information for the CAB ISFI formulation that could aid in its future translation to clinical studies.
Collapse
Affiliation(s)
- Isabella C. Young
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Allison L. Thorson
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Roopali Shrivastava
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Craig Sykes
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Amanda P. Schauer
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Mackenzie L. Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Angela D. M. Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Soumya Rahima Benhabbour
- Division of Pharmacoengineering and Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| |
Collapse
|
37
|
Weld ED, Parsons TL, Gollings R, McCauley M, Grinsztejn B, Landovitz RJ, Marzinke MA. Development and validation of a liquid chromatographic-tandem mass spectrometric assay for the quantification of cabotegravir and rilpivirine from dried blood spots. J Pharm Biomed Anal 2023; 228:115307. [PMID: 36842333 PMCID: PMC10065945 DOI: 10.1016/j.jpba.2023.115307] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/16/2023] [Accepted: 02/16/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Dried blood spots (DBS) have been utilized as a blood plasma alternative for therapeutic drug monitoring and pharmacologic analysis. There are analytical and physiochemical considerations in bridging drug concentrations from plasma to DBS. Recently, the long-acting antiretroviral cabotegravir (CAB) has been approved for HIV prevention, and a co-packaged regimen of long-acting CAB and rilpivirine (RPV) has been approved for HIV treatment. Measurement of these drugs in blood collected as DBS may offer increased capacity and flexibility in translational applications. METHODS Whole blood was spiked with CAB and RPV and spotted on DBS cards. Following extraction and addition of isotopically labeled internal standards, samples were subjected to liquid chromatographic-tandem mass spectrometric (LC-MS/MS) analysis. The method was validated according to regulatory recommendations, and the assay was evaluated in remnant samples from an HIV prevention trial in which paired DBS and plasma samples were collected. RESULTS DBS CAB and RPV concentrations were linear from 25 to 20,000 ng/mL and 2-2500 ng/mL, respectively. Precision, accuracy, and matrix effect results were acceptable. DBS RPV demonstrated stability under all tested conditions; DBS CAB showed mean biases of - 23.5% when stored at room temperature for 36 days, and - 18.0% at 40 °C and 100% humidity for two days. DBS measurements for CAB and RPV were an average 54.0% and 14.1% lower, respectively, as compared to paired plasma samples. Derived conversion factors of 1.79 and 1.16 were applied to DBS CAB and RPV measurements, respectively, to estimate plasma concentrations. Estimated plasma CAB and RPV concentrations showed mean biases of 2.2% and 0.6%, respectively. In a CAB clinical trial, application of the conversion factor resulted in agreement between estimated plasma CAB concentrations from DBS and plasma CAB concentrations (y = 1.08x - 79.2, r = 0.932; mean bias of -3.2%; 95% CI: -48.2% to 41.9%). CONCLUSIONS We developed and validated a novel LC-MS/MS assay for the quantification of CAB and RPV from DBS, and identified conversion factors to estimate plasma concentrations from spotted blood.
Collapse
Affiliation(s)
- Ethel D Weld
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Teresa L Parsons
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ryann Gollings
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas-Fiocruz, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Raphael J Landovitz
- Center for Clinical AIDS Research and Education, David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Mark A Marzinke
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
38
|
Abbate MTA, Ramöller IK, Sabri AH, Paredes AJ, Hutton AJ, McKenna PE, Peng K, Hollett JA, McCarthy HO, Donnelly RF. Formulation of antiretroviral nanocrystals and development into a microneedle delivery system for potential treatment of HIV-associated neurocognitive disorder (HAND). Int J Pharm 2023; 640:123005. [PMID: 37142137 DOI: 10.1016/j.ijpharm.2023.123005] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/06/2023]
Abstract
HIV/AIDS remains a major global public health issue. While antiretroviral therapy is effective at reducing the viral load in the blood, up to 50% of those with HIV suffer from some degree of HIV-associated neurocognitive disorder, due to the presence of the blood-brain barrier restricting drugs from crossing into the central nervous system and treating the viral reservoir there. One way to circumvent this is the nose-to-brain pathway. This pathway can also be accessed via a facial intradermal injection. Certain parameters can increase delivery via this route, including using nanoparticles with a positive zeta potential and an effective diameter of 200 nm or less. Microneedle arrays offer a minimally invasive, pain-free alternative to traditional hypodermic injections. This study shows the formulation of nanocrystals of both rilpivirine (RPV) and cabotegravir, followed by incorporation into separate microneedle delivery systems for application to either side of the face. Following an in vivo study in rats, delivery to the brain was seen for both drugs. For RPV, a Cmax was seen at 21 days of 619.17 ± 73.32 ng/g, above that of recognised plasma IC90 levels, and potentially therapeutically relevant levels were maintained for 28 days. For CAB, a Cmax was seen at 28 days of 478.31 ± 320.86 ng/g, and while below recognised 4IC90 levels, does indicate that therapeutically relevant levels could be achieved by manipulating final microaaray patch size in humans.
Collapse
Affiliation(s)
- Marco T A Abbate
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL
| | - Inken K Ramöller
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL
| | - Akmal H Sabri
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL
| | | | - Aaron J Hutton
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL
| | - Peter E McKenna
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL
| | - Ke Peng
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL
| | - Jessica A Hollett
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL
| | - Helen O McCarthy
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL
| | - Ryan F Donnelly
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, BT9 7BL
| |
Collapse
|
39
|
Fonner VA, Ridgeway K, van der Straten A, Lorenzetti L, Dinh N, Rodolph M, Schaefer R, Schmidt HMA, Nguyen VTT, Radebe M, Peralta H, Baggaley R. Safety and efficacy of long-acting injectable cabotegravir as preexposure prophylaxis to prevent HIV acquisition. AIDS 2023; 37:957-966. [PMID: 36723489 PMCID: PMC10090368 DOI: 10.1097/qad.0000000000003494] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 02/02/2023]
Abstract
OBJECTIVE HIV remains a significant burden, despite expanding HIV prevention tools. Long-acting injectable cabotegravir (CAB-LA) is a new preexposure prophylaxis (PrEP) product. We reviewed existing evidence to determine the efficacy and safety of CAB-LA as PrEP to inform global guidelines. DESIGN Systematic review and meta-analysis. METHODS We systematically reviewed electronic databases and conference abstracts for citations on CAB-LA from January 2010 to September 2021. Outcomes included HIV infection, adverse events, drug resistance, pregnancy-related adverse events, and sexual behavior. We calculated pooled effect estimates using random-effects meta-analysis and summarized other results narratively. RESULTS We identified 12 articles/abstracts representing four multisite randomized controlled trials. Study populations included cisgender men, cisgender women, and transgender women. The pooled relative risk of HIV acquisition comparing CAB-LA to oral PrEP within efficacy studies was 0.21 (95% confidence interval: 0.07-0.61), resulting in a 79% reduction in HIV risk. Rates of adverse events were similar across study groups. Of 19 HIV infections among those randomized to CAB-LA with results available, seven had integrase strand transfer inhibitor (INSTI) resistance. Data on pregnancy-related adverse events were sparse. No studies reported on sexual behavior. CONCLUSIONS CAB-LA is highly efficacious for HIV prevention with few safety concerns. CAB-LA may lead to an increased risk of INSTI resistance among those who have acute HIV infection at initiation or become infected while taking CAB-LA. However, results are limited to controlled studies; more research is needed on real-world implementation. Additional data are needed on the safety of CAB-LA during pregnancy (for mothers and infants) and among populations not included in the trials.
Collapse
Affiliation(s)
| | - Kathleen Ridgeway
- FHI 360 Global Health and Population Research, Durham, North Carolina
| | - Ariane van der Straten
- ASTRA Consulting and Center for AIDS prevention Studies (CAPS), Department of Medicine, San Francisco, California, USA
| | - Lara Lorenzetti
- FHI 360 Global Health and Population Research, Durham, North Carolina
| | - Nhi Dinh
- FHI 360 Global Health and Population Research, Durham, North Carolina
| | - Michelle Rodolph
- World Health Organization, Global HIV, Hepatitis and STIs Programmes, Geneva, Switzerland
| | - Robin Schaefer
- World Health Organization, Global HIV, Hepatitis and STIs Programmes, Geneva, Switzerland
| | - Heather-Marie A. Schmidt
- World Health Organization, Global HIV, Hepatitis and STIs Programmes, Geneva, Switzerland
- UNAIDS Regional Office for Asia and the Pacific, Bangkok, Thailand
| | | | - Mopo Radebe
- World Health Organization, Country Office, Pretoria, South Africa
| | | | - Rachel Baggaley
- World Health Organization, Global HIV, Hepatitis and STIs Programmes, Geneva, Switzerland
| |
Collapse
|
40
|
Nachega JB, Scarsi KK, Gandhi M, Scott RK, Mofenson LM, Archary M, Nachman S, Decloedt E, Geng EH, Wilson L, Rawat A, Mellors JW. Long-acting antiretrovirals and HIV treatment adherence. Lancet HIV 2023; 10:e332-e342. [PMID: 37062293 PMCID: PMC10734401 DOI: 10.1016/s2352-3018(23)00051-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/26/2023] [Accepted: 02/10/2023] [Indexed: 04/18/2023]
Abstract
Intramuscular injection of long-acting cabotegravir and rilpivirine is a novel, long-acting antiretroviral therapy (ART) combination approved for use as a fully suppressive regimen for people living with HIV. Long-acting cabotegravir with rilpivirine ART has reduced required dosing frequency from once daily to once every month or every 2 months injections. This new era of long-acting ART, which includes other antiretrovirals and formulations in various stages of clinical development, holds tremendous promise to change the standard of HIV treatment. Although long-acting ART has high potential to be revolutionary in the landscape of HIV care, prevention, and treatment cascade, more data are needed to substantiate its efficacy and cost-effectiveness among patients at risk of non-adherence and across age groups, pregnancy, and post partum. Advocacy efforts and policy changes to optimise a sustained, high-quality, equitable reach of long-acting ART, especially in low-income and middle-income countries where most people living with HIV reside, are needed to realise the full benefits of long-acting ART.
Collapse
Affiliation(s)
- Jean B Nachega
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Department of Infectious Diseases and Microbiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Center for Global Health, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Department of Epidemiology and Department International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Kimberly K Scarsi
- Antiviral Pharmacology Laboratory, College of Pharmacy, and Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rachel K Scott
- MedStar Health Research Institute and MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA
| | | | - Moherndran Archary
- Department of Pediatrics, King Edward VIII Hospital, University of Kwa Zulu Natal, Durban, South Africa
| | - Sharon Nachman
- Department of Pediatrics, Stony Brook Children's, SUNY Stony Brook University, Stony Brook, NY, USA
| | - Eric Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Department of Medicine, and Institute for Public Health, Washington University, St Louis, MO, USA
| | | | - Angeli Rawat
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; School of Population and Public Heath, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John W Mellors
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| |
Collapse
|
41
|
Marzinke MA, Fogel JM, Wang Z, Piwowar-Manning E, Kofron R, Moser A, Bhandari P, Gollings R, Bushman LR, Weng L, Halvas EK, Mellors J, Anderson PL, Persaud D, Hendrix CW, McCauley M, Rinehart AR, St Clair M, Ford SL, Rooney JF, Adeyeye A, Chariyalertsak S, Mayer K, Arduino RC, Cohen MS, Grinsztejn B, Hanscom B, Landovitz RJ, Eshleman SH. Extended Analysis of HIV Infection in Cisgender Men and Transgender Women Who Have Sex with Men Receiving Injectable Cabotegravir for HIV Prevention: HPTN 083. Antimicrob Agents Chemother 2023; 67:e0005323. [PMID: 36995219 PMCID: PMC10112247 DOI: 10.1128/aac.00053-23] [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: 01/13/2023] [Accepted: 02/15/2023] [Indexed: 03/31/2023] Open
Abstract
HPTN 083 demonstrated that injectable cabotegravir (CAB) was superior to oral tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) for HIV prevention in cisgender men and transgender women who have sex with men. We previously analyzed 58 infections in the blinded phase of HPTN 083 (16 in the CAB arm and 42 in the TDF-FTC arm). This report describes 52 additional infections that occurred up to 1 year after study unblinding (18 in the CAB arm and 34 in the TDF-FTC arm). Retrospective testing included HIV testing, viral load testing, quantification of study drug concentrations, and drug resistance testing. The new CAB arm infections included 7 with CAB administration within 6 months of the first HIV-positive visit (2 with on-time injections, 3 with ≥1 delayed injection, and 2 who restarted CAB) and 11 with no recent CAB administration. Three cases had integrase strand transfer inhibitor (INSTI) resistance (2 with on-time injections and 1 who restarted CAB). Among 34 CAB infections analyzed to date, diagnosis delays and INSTI resistance were significantly more common in infections with CAB administration within 6 months of the first HIV-positive visit. This report further characterizes HIV infections in persons receiving CAB preexposure prophylaxis and helps define the impact of CAB on the detection of infection and the emergence of INSTI resistance.
Collapse
Affiliation(s)
- Mark A. Marzinke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica M. Fogel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zhe Wang
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Estelle Piwowar-Manning
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryan Kofron
- Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Amber Moser
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pradip Bhandari
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryann Gollings
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lane R. Bushman
- Department of Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Lei Weng
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Elias K. Halvas
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John Mellors
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Peter L. Anderson
- Department of Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Deborah Persaud
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Craig W. Hendrix
- Department of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Marty St Clair
- ViiV Healthcare, Research Triangle Park, North Carolina, USA
| | - Susan L. Ford
- GlaxoSmithKline, Research Triangle Park, North Carolina, USA
| | | | - Adeola Adeyeye
- Prevention Science Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, USA
| | - Suwat Chariyalertsak
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Kenneth Mayer
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Roberto C. Arduino
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Myron S. Cohen
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Beatriz Grinsztejn
- Instituto de Pesquisa Clinica Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil
| | - Brett Hanscom
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Raphael J. Landovitz
- Center for Clinical AIDS Research and Education, University of California, Los Angeles, Los Angeles, California, USA
| | - Susan H. Eshleman
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
42
|
Smith J, Bansi-Matharu L, Cambiano V, Dimitrov D, Bershteyn A, van de Vijver D, Kripke K, Revill P, Boily MC, Meyer-Rath G, Taramusi I, Lundgren JD, van Oosterhout JJ, Kuritzkes D, Schaefer R, Siedner MJ, Schapiro J, Delany-Moretlwe S, Landovitz RJ, Flexner C, Jordan M, Venter F, Radebe M, Ripin D, Jenkins S, Resar D, Amole C, Shahmanesh M, Gupta RK, Raizes E, Johnson C, Inzaule S, Shafer R, Warren M, Stansfield S, Paredes R, Phillips AN. Predicted effects of the introduction of long-acting injectable cabotegravir pre-exposure prophylaxis in sub-Saharan Africa: a modelling study. Lancet HIV 2023; 10:e254-e265. [PMID: 36642087 PMCID: PMC10065903 DOI: 10.1016/s2352-3018(22)00365-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Long-acting injectable cabotegravir pre-exposure prophylaxis (PrEP) is recommended by WHO as an additional option for HIV prevention in sub-Saharan Africa, but there is concern that its introduction could lead to an increase in integrase-inhibitor resistance undermining treatment programmes that rely on dolutegravir. We aimed to project the health benefits and risks of cabotegravir-PrEP introduction in settings in sub-Saharan Africa. METHODS With HIV Synthesis, an individual-based HIV model, we simulated 1000 setting-scenarios reflecting both variability and uncertainty about HIV epidemics in sub-Saharan Africa and compared outcomes for each with and without cabotegravir-PrEP introduction. PrEP use is assumed to be risk-informed and to be used only in 3-month periods (the time step for the model) when having condomless sex. We consider three groups at risk of integrase-inhibitor resistance emergence: people who start cabotegravir-PrEP after (unknowingly) being infected with HIV, those who seroconvert while on PrEP, and those with HIV who have residual cabotegravir drugs concentrations during the early tail period after recently stopping PrEP. We projected the outcomes of policies of cabotegravir-PrEP introduction and of no introduction in 2022 across 50 years. In 50% of setting-scenarios we considered that more sensitive nucleic-acid-based HIV diagnostic testing (NAT), rather than regular antibody-based HIV rapid testing, might be used to reduce resistance risk. For cost-effectiveness analysis we assumed in our base case a cost of cabotegravir-PrEP drug to be similar to oral PrEP, resulting in a total annual cost of USD$144 per year ($114 per year and $264 per year considered in sensitivity analyses), a cost-effectiveness threshold of $500 per disability-adjusted life years averted, and a discount rate of 3% per year. FINDINGS Reflecting our assumptions on the appeal of cabotegravir-PrEP, its introduction is predicted to lead to a substantial increase in PrEP use with approximately 2·6% of the adult population (and 46% of those with a current indication for PrEP) receiving PrEP compared with 1·5% (28%) without cabotegravir-PrEP introduction across 20 years. As a result, HIV incidence is expected to be lower by 29% (90% range across setting-scenarios 6-52%) across the same period compared with no introduction of cabotegravir-PrEP. In people initiating antiretroviral therapy, the proportion with integrase-inhibitor resistance after 20 years is projected to be 1·7% (0-6·4%) without cabotegravir-PrEP introduction but 13·1% (4·1-30·9%) with. Cabotegravir-PrEP introduction is predicted to lower the proportion of all people on antiretroviral therapy with viral loads less than 1000 copies per mL by 0·9% (-2·5% to 0·3%) at 20 years. For an adult population of 10 million an overall decrease in number of AIDS deaths of about 4540 per year (-13 000 to -300) across 50 years is predicted, with little discernible benefit with NAT when compared with standard antibody-based rapid testing. AIDS deaths are predicted to be averted with cabotegravir-PrEP introduction in 99% of setting-scenarios. Across the 50-year time horizon, overall HIV programme costs are predicted to be similar regardless of whether cabotegravir-PrEP is introduced (total mean discounted annual HIV programme costs per year across 50 years is $151·3 million vs $150·7 million), assuming the use of standard antibody testing. With antibody-based rapid HIV testing, the introduction of cabotegravir-PrEP is predicted to be cost-effective under an assumed threshold of $500 per disability-adjusted life year averted in 82% of setting-scenarios at the cost of $144 per year, in 52% at $264, and in 87% at $114. INTERPRETATION Despite leading to increases in integrase-inhibitor drug resistance, cabotegravir-PrEP introduction is likely to reduce AIDS deaths in addition to HIV incidence. Long-acting cabotegravir-PrEP is predicted to be cost-effective if delivered at similar cost to oral PrEP with antibody-based rapid HIV testing. FUNDING Bill & Melinda Gates Foundation, National Institute of Allergy and Infectious Diseases of the National Institutes of Health.
Collapse
Affiliation(s)
- Jennifer Smith
- Institute for Global Health, University College London, London, UK
| | | | | | - Dobromir Dimitrov
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | | | | | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Marie-Claude Boily
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jens D Lundgren
- Department of Clinical Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Joep J van Oosterhout
- Partners in Hope, Lilongwe, Malawi; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Daniel Kuritzkes
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Robin Schaefer
- Global HIV, Hepatitis, and STIs Programmes, WHO, Geneva, Switzerland
| | - Mark J Siedner
- Department of Medicine, Harvard Medical School, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Clinical Research Department, Africa Health Research Institute, Mtubatuba, South Africa
| | | | - Sinead Delany-Moretlwe
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Raphael J Landovitz
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Center for Clinical AIDS Research and Education, University of California, Los Angeles, CA, USA
| | - Charles Flexner
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Jordan
- Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mopo Radebe
- Regional Office for Africa, WHO, Gauteng, South Africa
| | - David Ripin
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Sarah Jenkins
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Danielle Resar
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Carolyn Amole
- Infectious Diseases Program, Clinton Health Access Initiative, New York, NY, USA
| | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK; Clinical Research Department, Africa Health Research Institute, Mtubatuba, South Africa
| | - Ravindra K Gupta
- Clinical Research Department, Africa Health Research Institute, Mtubatuba, South Africa; Department of Medicine, University of Cambridge, Cambridge, UK
| | - Elliot Raizes
- US Department of Health and Human Services, Centers for Disease Control, Atlanta, GA, USA
| | - Cheryl Johnson
- Global HIV, Hepatitis, and STIs Programmes, WHO, Geneva, Switzerland
| | - Seth Inzaule
- Global HIV, Hepatitis, and STIs Programmes, WHO, Geneva, Switzerland
| | - Robert Shafer
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | | | - Sarah Stansfield
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Roger Paredes
- Department of Infectious Diseases, Irsi Caixa Institut de Recerca de la SIDA, Barcelona, Spain
| | | |
Collapse
|
43
|
Durham SH, Milam A, Waer D, Chahine EB. Cabotegravir: The First Long-Acting Injectable for HIV Preexposure Prophylaxis. Ann Pharmacother 2023; 57:306-316. [PMID: 35778802 DOI: 10.1177/10600280221102532] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Review the pharmacology, pharmacokinetics, efficacy, safety, and role of long-acting injectable cabotegravir (CAB-LA) in HIV preexposure prophylaxis (PrEP). DATA SOURCES A literature search was performed using PubMed and Google Scholar (2012 to April 2022) with the search terms cabotegravir, preexposure prophylaxis, and PrEP. Other resources included abstracts presented at recent conferences, the manufacturer's Web site, prescribing information, and review articles. STUDY SELECTION AND DATA EXTRACTION All English-language articles of studies assessing the efficacy and safety of CAB-LA for PrEP were included. DATA SYNTHESIS CAB-LA is the first long-acting injectable therapy approved for HIV-1 PrEP in both men and women. It is a suspension given intramuscularly every other month. CAB-LA has been shown to be more effective than daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) in preventing HIV-1 infection among high-risk individuals. Two phase 3 trials were stopped early on the basis of superior efficacy of CAB-LA. The most common adverse effects were injection site reactions (ISRs), although they tended to decrease over time, and few participants in clinical trials discontinued use due to ISRs. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE CAB-LA may be particularly useful for individuals with known adherence problems to oral therapy, those with renal impairment, and those with decreased bone mineral density. However, CAB-LA is more expensive than generic TDF/FTC and may be associated with weight gain. CONCLUSIONS CAB-LA is the first long-acting injectable agent for HIV PrEP. It is more effective than oral TDF/FTC, is well-tolerated aside from ISRs, and has few clinically significant drug-drug interactions.
Collapse
Affiliation(s)
- Spencer H Durham
- Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - Ashlee Milam
- Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - Dylan Waer
- Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - Elias B Chahine
- Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL, USA
| |
Collapse
|
44
|
Young IC, Massud I, Cottrell ML, Shrivastava R, Maturavongsadit P, Prasher A, Wong-Sam A, Dinh C, Edwards T, Mrotz V, Mitchell J, Seixas JN, Pallerla A, Thorson A, Schauer A, Sykes C, De la Cruz G, Montgomery SA, Kashuba ADM, Heneine W, Dobard CW, Kovarova M, Garcia JV, García-Lerma JG, Benhabbour SR. Ultra-long-acting in-situ forming implants with cabotegravir protect female macaques against rectal SHIV infection. Nat Commun 2023; 14:708. [PMID: 36759645 PMCID: PMC9911691 DOI: 10.1038/s41467-023-36330-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/24/2023] [Indexed: 02/11/2023] Open
Abstract
Ultra-long-acting delivery platforms for HIV pre-exposure prophylaxis (PrEP) may increase adherence and maximize public health benefit. We report on an injectable, biodegradable, and removable in-situ forming implant (ISFI) that is administered subcutaneously and can release the integrase inhibitor cabotegravir (CAB) above protective benchmarks for more than 6 months. CAB ISFIs are well-tolerated in female mice and female macaques showing no signs of toxicity or chronic inflammation. In macaques, median plasma CAB concentrations exceed established PrEP protection benchmarks within 3 weeks and confer complete protection against repeated rectal SHIV challenges. Implant removal via a small incision in 2 macaques at week 12 results in a 7- to 48-fold decrease in plasma CAB levels within 72 hours. Modeling to translate CAB ISFI dosing suggests that a 3 mL injection would exceed protective benchmarks in humans for over 5 months post administration. Our results support the clinical advancement of CAB ISFIs for ultra-long-acting PrEP in humans.
Collapse
Affiliation(s)
- Isabella C Young
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ivana Massud
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mackenzie L Cottrell
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Roopali Shrivastava
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Panita Maturavongsadit
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alka Prasher
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andres Wong-Sam
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Chuong Dinh
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tiancheng Edwards
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Victoria Mrotz
- Comparative Medicine Branch, Division of Scientific Resources, National Center for Emerging and Zoonotic Infection Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - James Mitchell
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Josilene Nascimento Seixas
- Infectious Diseases Pathology Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infection Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Aryani Pallerla
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Allison Thorson
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amanda Schauer
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Craig Sykes
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Gabriela De la Cruz
- Pathology Services Core, Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Stephanie A Montgomery
- Pathology Services Core, Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Angela D M Kashuba
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Walid Heneine
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Charles W Dobard
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Martina Kovarova
- International Center for the Advancement of Translational Science, Division of Infectious Diseases, Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Victor Garcia
- International Center for the Advancement of Translational Science, Division of Infectious Diseases, Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Gerardo García-Lerma
- Laboratory Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - S Rahima Benhabbour
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| |
Collapse
|
45
|
Sokhela S, Lalla-Edward S, Siedner MJ, Majam M, Venter WDF. Roadmap for Achieving Universal Antiretroviral Treatment. Annu Rev Pharmacol Toxicol 2023; 63:99-117. [PMID: 36662580 PMCID: PMC10807407 DOI: 10.1146/annurev-pharmtox-052020-094321] [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] [Indexed: 01/21/2023]
Abstract
Modern antiretroviral therapy safely, potently, and durably suppresses human immunodeficiency virus (HIV) that, if left untreated, predictably causes acquired immunodeficiency syndrome (AIDS), which has been responsible for tens of millions of deaths globally since it was described in 1981. In one of the most extraordinary medical success stories in modern times, a combination of pioneering basic science, innovative drug development, and ambitious public health programming resulted in access to lifesaving, safe drugs, taken as an oral tablet daily, for most of the world. However, substantial challenges remain in the fields of prevention, timely access to diagnosis, and treatment, especially in pediatric and adolescent patients. As HIV-positive adults age, treating their comorbidities will require understanding the course of different chronic diseases complicated by HIV-related and antiretroviral toxicities and finding potential treatments. Finally, new long-acting antiretrovirals on the horizon promise exciting new options in both the prevention and treatment fields.
Collapse
Affiliation(s)
- Simiso Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;
| | - Samanta Lalla-Edward
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;
| | - Mark J Siedner
- Harvard Medical School and Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mohammed Majam
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;
| | | |
Collapse
|
46
|
Gandhi RT, Bedimo R, Hoy JF, Landovitz RJ, Smith DM, Eaton EF, Lehmann C, Springer SA, Sax PE, Thompson MA, Benson CA, Buchbinder SP, Del Rio C, Eron JJ, Günthard HF, Molina JM, Jacobsen DM, Saag MS. Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2022 Recommendations of the International Antiviral Society-USA Panel. JAMA 2023; 329:63-84. [PMID: 36454551 DOI: 10.1001/jama.2022.22246] [Citation(s) in RCA: 196] [Impact Index Per Article: 196.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Importance Recent advances in treatment and prevention of HIV warrant updated recommendations to guide optimal practice. Objective Based on a critical evaluation of new data, to provide clinicians with recommendations on use of antiretroviral drugs for the treatment and prevention of HIV, laboratory monitoring, care of people aging with HIV, substance use disorder and HIV, and new challenges in people with HIV, including COVID-19 and monkeypox virus infection. Evidence Review A panel of volunteer expert physician scientists were appointed to update the 2020 consensus recommendations. Relevant evidence in the literature (PubMed and Embase searches, which initially yielded 7891 unique citations, of which 834 were considered relevant) and studies presented at peer-reviewed scientific conferences between January 2020 and October 2022 were considered. Findings Initiation of antiretroviral therapy (ART) is recommended as soon as possible after diagnosis of HIV. Barriers to care should be addressed, including ensuring access to ART and adherence support. Integrase strand transfer inhibitor-containing regimens remain the mainstay of initial therapy. For people who have achieved viral suppression with a daily oral regimen, long-acting injectable therapy with cabotegravir plus rilpivirine given as infrequently as every 2 months is now an option. Weight gain and metabolic complications have been linked to certain antiretroviral medications; novel strategies to ameliorate these complications are needed. Management of comorbidities throughout the life span is increasingly important, because people with HIV are living longer and confronting the health challenges of aging. In addition, management of substance use disorder in people with HIV requires an evidence-based, integrated approach. Options for preexposure prophylaxis include oral medications (tenofovir disoproxil fumarate or tenofovir alafenamide plus emtricitabine) and, for the first time, a long-acting injectable agent, cabotegravir. Recent global health emergencies, like the SARS-CoV-2 pandemic and monkeypox virus outbreak, continue to have a major effect on people with HIV and the delivery of services. To address these and other challenges, an equity-based approach is essential. Conclusions and Relevance Advances in treatment and prevention of HIV continue to improve outcomes, but challenges and opportunities remain.
Collapse
Affiliation(s)
- Rajesh T Gandhi
- Massachusetts General Hospital and Harvard Medical School, Boston
| | - Roger Bedimo
- University of Texas Southwestern Medical Center, Dallas
| | - Jennifer F Hoy
- The Alfred Hospital and Monash University, Melbourne, Australia
| | | | - Davey M Smith
- University of California San Diego School of Medicine
| | | | - Clara Lehmann
- University of Cologne and German Center for Infection Research (DZIF), Bonn-Cologne
| | - Sandra A Springer
- Yale University School of Medicine, New Haven, Connecticut
- The Veterans Administration Connecticut Healthcare System, West Haven
| | - Paul E Sax
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Carlos Del Rio
- Emory University School of Medicine and Grady Health System, Atlanta, Georgia
| | - Joseph J Eron
- The University of North Carolina School of Medicine at Chapel Hill
| | - Huldrych F Günthard
- University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Jean-Michel Molina
- University of Paris Cité, Saint-Louis and Lariboisière Hospitals, Assistance Publique Hopitaux de Paris, France
| | | | | |
Collapse
|
47
|
Bettonte S, Berton M, Marzolini C. What is the significance of the pharmacokinetic profile and potential drug-drug interactions of long-acting intramuscular cabotegravir and rilpivirine? Expert Opin Drug Metab Toxicol 2023; 19:243-247. [PMID: 37293864 DOI: 10.1080/17425255.2023.2223961] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/07/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Sara Bettonte
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Mattia Berton
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| |
Collapse
|
48
|
Meyers K, Nguyen N, Zucker JE, Kutner BA, Carnevale C, Castor D, Sobieszczyk ME, Yin MT, Golub SA, Remien RH. The Long-Acting Cabotegravir Tail as an Implementation Challenge: Planning for Safe Discontinuation. AIDS Behav 2023; 27:4-9. [PMID: 36056997 PMCID: PMC11232485 DOI: 10.1007/s10461-022-03816-0] [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] [Accepted: 08/10/2022] [Indexed: 01/24/2023]
Abstract
The long-acting feature of cabotegravir, an integrase-inhibitor highly effective in preventing acquisition of HIV in adolescents and adults, is both its greatest strength and a challenge to its implementation. Cab-LA is administered at 8-week intervals (after an initial loading dose) but has a long, variable drug "tail" that may leave users vulnerable to future drug resistance if they contract HIV during this critical period. The potential for cab-LA to meaningfully contribute to ending the HIV Epidemic is hindered by, among other factors, limited resources to guide patients and providers on how to safely discontinue injections. We suggest three key strategies to overcome this specific challenge: (1) Comprehensive patient education and counseling about the drug tail; (2) Training and coaching PrEP care teams, including clinical and non-clinical staff, on communication around the tail; (3) Adherence support strategies, including monitoring of cabotegravir drug levels after discontinuation, for a personalized medicine approach to safe discontinuation.
Collapse
Affiliation(s)
- Kathrine Meyers
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, 701 W. 168th Street, HHSC 1102, 10032, New York, NY, USA.
| | - Nadia Nguyen
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, 701 W. 168th Street, HHSC 1102, 10032, New York, NY, USA
| | - Jason E Zucker
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Bryan A Kutner
- HIV Center for Clinical and Behavioral Studies, Division of Gender, Sexuality and Health, NY State Psychiatric Institute and Columbia University, New York, NY, USA
| | - Caroline Carnevale
- NYP HIV Prevention Program, New York-Presbyterian Hospital, New York, NY, USA
| | - Delivette Castor
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Magdalena E Sobieszczyk
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Michael T Yin
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Sarit A Golub
- Department of Psychology, Hunter College, City University of New York, New York, NY, USA
- Basic and Applied Social Psychology (BASP) PhD Program, Graduate Center of the City University of New York, New York, NY, USA
- Einstein-Rockefeller-CUNY Center for AIDS Research (ERC-CFAR), New York, NY, USA
| | - Robert H Remien
- HIV Center for Clinical and Behavioral Studies, State Psychiatric Institute, Columbia University, New York, NY, NY, USA
| |
Collapse
|
49
|
Liegeon G, Ghosn J. Long-acting injectable cabotegravir for PrEP: A game-changer in HIV prevention? HIV Med 2022. [PMID: 36468218 DOI: 10.1111/hiv.13451] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/22/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Long-acting injectable cabotegravir (CAB-LA) represents a new additional option for HIV prevention in people at substantial risk of HIV infection that may fill the gaps in pre-exposure prophylaxis (PrEP) uptake, adherence, and retention in users having difficulty with oral PrEP. Data from clinical trials demonstrated that CAB-LA was safe, highly effective, and well-accepted for HIV prevention. However, the occurrence of breakthrough HIV infections despite timely injections, HIV seroconversion timing and patterns, risk of selection and dissemination of resistance-associated mutations to integrase inhibitors, complexity of follow-up, logistical considerations, and its cost effectiveness compared with oral PrEP constitute significant issues for the integration of CAB-LA into clinical routine. FINDINGS These concerns need to be addressed before moving forward with large-scale implementation programmes. Pilot and implementation projects are required in the following areas: HIV testing algorithms, patient education, clinic procedures, protocols for switching and discontinuation, efficacy and safety in populations not included in clinical trials, and demedicalization processes. The development of models to increase the uptake of, adherence to, and persistence with and after CAB-LA injections will also be of paramount importance for success. Lessons learned from these projects will increase experience, staff expertise, and organizational and training capacities to support the roll-out of this new agent as part of HIV prevention programmes. CONCLUSION CAB-LA has not yet achieved its full potential in HIV prevention, and strong commitment from all stakeholders is required to push CAB-LA as a game-changer in HIV response.
Collapse
Affiliation(s)
- Geoffroy Liegeon
- Université Paris Cité, Paris, France.,Assistance publique - Hôpitaux de Paris, Département des maladies infectieuses, Hôpital Saint Louis et Lariboisière, Paris, France
| | - Jade Ghosn
- Université Paris Cité, Paris, France.,Assistance publique - hôpitaux de Paris, Service des maladies infectieuses, Hôpital Bichat Claude Bernard, Paris, France
| |
Collapse
|
50
|
Jamieson L, Johnson LF, Nichols BE, Delany-Moretlwe S, Hosseinipour MC, Russell C, Meyer-Rath G. Relative cost-effectiveness of long-acting injectable cabotegravir versus oral pre-exposure prophylaxis in South Africa based on the HPTN 083 and HPTN 084 trials: a modelled economic evaluation and threshold analysis. Lancet HIV 2022; 9:e857-e867. [PMID: 36356603 PMCID: PMC9708606 DOI: 10.1016/s2352-3018(22)00251-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/29/2022] [Accepted: 08/31/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Long-acting injectable cabotegravir, a drug taken every 2 months, has been shown to be more effective at preventing HIV infection than daily oral tenofovir disoproxil fumarate and emtricitabine, but its cost-effectiveness in a high-prevalence setting is not known. We aimed to estimate the incremental cost-effectiveness of long-acting injectable cabotegravir compared with tenofovir disoproxil fumarate and emtricitabine in South Africa, using methods standard to government planning, and to determine the threshold price at which long-acting injectable cabotegravir is as cost-effective as tenofovir disoproxil fumarate and emtricitabine. METHODS In this modelled economic evaluation and threshold analysis, we updated a deterministic model of the South African HIV epidemic with data from the HPTN 083 and HPTN 084 trials to evaluate the effect of tenofovir disoproxil fumarate and emtricitabine and long-acting injectable cabotegravir provision to heterosexual adolescents and young women and men aged 15-24 years, female sex workers, and men who have sex with men. We estimated the average intervention cost, in 2021 US$, using ingredients-based costing, and modelled the cost-effectiveness of two coverage scenarios (medium or high, assuming higher uptake of long-acting injectable cabotegravir than tenofovir disoproxil fumarate and emtricitabine throughout) and, for long-acting injectable cabotegravir, two duration subscenarios (minimum: same pre-exposure prophylaxis duration as for tenofovir disoproxil fumarate and emtricitabine; maximum: longer duration than tenofovir disoproxil fumarate and emtricitabine) over 2022-41. FINDINGS Across long-acting injectable cabotegravir scenarios, 15-28% more new HIV infections were averted compared with the baseline scenario (current tenofovir disoproxil fumarate and emtricitabine roll-out). In scenarios with increased coverage with oral tenofovir disoproxil fumarate and emtricitabine, 4-8% more new HIV infections were averted compared with the baseline scenario. If long-acting injectable cabotegravir drug costs were equal to those of tenofovir disoproxil fumarate and emtricitabine for the same 2-month period, the incremental cost of long-acting injectable cabotegravir to the HIV programme was higher than that of tenofovir disoproxil fumarate and emtricitabine (5-10% vs 2-4%) due to higher assumed uptake of long-acting injectable cabotegravir. The cost per infection averted was $6053-6610 (tenofovir disoproxil fumarate and emtricitabine) and $4471-6785 (long-acting injectable cabotegravir). The cost per long-acting cabotegravir injection needed to be less than twice that of a 2-month supply of tenofovir disoproxil fumarate and emtricitabine to remain as cost-effective, with threshold prices ranging between $9·03 per injection (high coverage; maximum duration) and $14·47 per injection (medium coverage; minimum duration). INTERPRETATION Long-acting injectable cabotegravir could potentially substantially change HIV prevention. However, for its implementation to be financially feasible across low-income and middle-income countries with high HIV incidence, long-acting injectable cabotegravir must be reasonably priced. FUNDING United States Agency for International Development, The Bill & Melinda Gates Foundation.
Collapse
Affiliation(s)
- Lise Jamieson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, Netherlands.
| | - Leigh F Johnson
- Centre of Infectious Disease Epidemiology and Research (CIDER), University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Brooke E Nichols
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, Netherlands; Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mina C Hosseinipour
- Division of Infectious Diseases, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA; UNC Project, Lilongwe, Malawi
| | - Colin Russell
- Department of Medical Microbiology, Amsterdam University Medical Centre, Amsterdam, Netherlands; Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| |
Collapse
|