1
|
Gregson J, Rhee SY, Datir R, Pillay D, Perno CF, Derache A, Shafer RS, Gupta RK. Human Immunodeficiency Virus-1 Viral Load Is Elevated in Individuals With Reverse-Transcriptase Mutation M184V/I During Virological Failure of First-Line Antiretroviral Therapy and Is Associated With Compensatory Mutation L74I. J Infect Dis 2020; 222:1108-1116. [PMID: 31774913 PMCID: PMC7459140 DOI: 10.1093/infdis/jiz631] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/26/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND M184V/I cause high-level lamivudine (3TC) and emtricitabine (FTC) resistance and increased tenofovir disoproxil fumarate (TDF) susceptibility. Nonetheless, 3TC and FTC (collectively referred to as XTC) appear to retain modest activity against human immunodeficiency virus-1 with these mutations possibly as a result of reduced replication capacity. In this study, we determined how M184V/I impacts virus load (VL) in patients failing therapy on a TDF/XTC plus nonnucleoside reverse-transcriptase inhibitor (NNRTI)-containing regimen. METHODS We compared VL in the absence and presence of M184V/I across studies using random effects meta-analysis. The effect of mutations on virus reverse-transcriptase activity and infectiousness was analyzed in vitro. RESULTS M184I/V was present in 817 (56.5%) of 1445 individuals with virologic failure (VF). Virus load was similar in individuals with or without M184I/V (difference in log10 VL, 0.18; 95% confidence interval, .05-.31). CD4 count was lower both at initiation of antiretroviral therapy and at VF in participants who went on to develop M184V/I. L74I was present in 10.2% of persons with M184V/I but absent in persons without M184V/I (P < .0001). In vitro, L74I compensated for defective replication of M184V-mutated virus. CONCLUSIONS Virus loads were similar in persons with and without M184V/I during VF on a TDF/XTC/NNRTI-containing regimen. Therefore, we did not find evidence for a benefit of XTC in the context of first-line failure on this combination.
Collapse
Affiliation(s)
- J Gregson
- Department of Biostatistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S Y Rhee
- Department of Medicine, Stanford University, Stanford, California, USA
| | - R Datir
- Division of Infection and Immunity, UCL, London, United Kingdom
| | - D Pillay
- Division of Infection and Immunity, UCL, London, United Kingdom
- Africa Health Research Institute, Durban, South Africa
| | - C F Perno
- Department of Oncology and Haematoncology, University of Milan, Milan, Italy
| | - A Derache
- Africa Health Research Institute, Durban, South Africa
| | - R S Shafer
- Department of Medicine, Stanford University, Stanford, California, USA
| | - R K Gupta
- Africa Health Research Institute, Durban, South Africa
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
2
|
Bartlett AW, Lumbiganon P, Kurniati N, Sudjaritruk T, Mohamed TJ, Hansudewechakul R, Ly PS, Truong KH, Puthanakit T, Nguyen LV, Chokephaibulkit K, Do VC, Kumarasamy N, Yusoff NKN, Fong MS, Watu DK, Nallusamy R, Sohn AH, Law MG. Use and Outcomes of Antiretroviral Monotherapy and Treatment Interruption in Adolescents With Perinatal HIV Infection in Asia. J Adolesc Health 2019; 65:651-659. [PMID: 31395514 PMCID: PMC7007807 DOI: 10.1016/j.jadohealth.2019.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/22/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Antiretroviral monotherapy and treatment interruption are potential strategies for perinatally HIV-infected adolescents (PHIVA) who face challenges maintaining effective combination antiretroviral therapy (ART). We assessed the use and outcomes for adolescents receiving monotherapy or undergoing treatment interruption in a regional Asian cohort. METHODS Regional Asian data (2001-2016) were analyzed to describe PHIVA who experienced ≥2 weeks of lamivudine or emtricitabine monotherapy or treatment interruption and trends in CD4 count and HIV viral load during and after episodes. Survival analyses were used for World Health Organization (WHO) stage III/IV clinical and immunologic event-free survival during monotherapy or treatment interruption, and a Poisson regression to determine factors associated with monotherapy or treatment interruption. RESULTS Of 3,448 PHIVA, 84 (2.4%) experienced 94 monotherapy episodes, and 147 (4.3%) experienced 174 treatment interruptions. Monotherapy was associated with older age, HIV RNA >400 copies/mL, younger age at ART initiation, and exposure to ≥2 combination ART regimens. Treatment interruption was associated with CD4 count <350 cells/μL, HIV RNA ≥1,000 copies/mL, ART adverse event, and commencing ART age ≥10 years compared with age <3 years. WHO clinical stage III/IV 1-year event-free survival was 96% and 85% for monotherapy and treatment interruption cohorts, respectively. WHO immunologic stage III/IV 1-year event-free survival was 52% for both cohorts. Those who experienced monotherapy or treatment interruption for more than 6 months had worse immunologic and virologic outcomes. CONCLUSIONS Until challenges of treatment adherence, engagement in care, and combination ART durability/tolerability are met, monotherapy and treatment interruption will lead to poor long-term outcomes.
Collapse
Affiliation(s)
- Adam W. Bartlett
- Kirby Institute, University of New South Wales Sydney, New South Wales, Australia,Address correspondence to: Adam W. Bartlett, M.B.B.S., Kirby Institute, University of New South Wales, Level 6,Wallace Wurth Building, Sydney, New South Wales 2052, Australia, (A.W. Bartlett)
| | - Pagakrong Lumbiganon
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Nia Kurniati
- Cipto Mangunkusumo, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Tavitiya Sudjaritruk
- Department of Pediatrics, Faculty of Medicine, and Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | | | - Penh S. Ly
- National Centre for HIV/AIDS, Dermatology and STDs, Phnom Penh, Cambodia
| | | | - Thanyawee Puthanakit
- Department of Pediatrics, Faculty of Medicine and Research Unit in Pediatric and Infectious Diseases, Chulalongkorn University, Bangkok, Thailand
| | | | - Kulkanya Chokephaibulkit
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Viet C. Do
- Children’s Hospital 2, Ho Chi Minh City, Vietnam
| | | | | | | | - Dewi K. Watu
- Sanglah Hospital, Udayana University, Bali, Indonesia
| | | | - Annette H. Sohn
- TREAT Asia/amfAR - The Foundation for AIDS Research, Bangkok, Thailand
| | - Matthew G. Law
- Kirby Institute, University of New South Wales Sydney, New South Wales, Australia
| | | |
Collapse
|
3
|
Patten G, Schomaker M, Davies MA, Rabie H, van Zyl G, Technau K, Eley B, Boulle A, Van Dyke RB, Patel K, Sipambo N, Wood R, Tanser F, Giddy J, Cotton M, Nuttall J, Essack G, Karalius B, Seage G, Sawry S, Egger M, Fairlie L. What Should We Do When HIV-positive Children Fail First-line Combination Antiretroviral Therapy? A Comparison of 4 ART Management Strategies. Pediatr Infect Dis J 2019; 38:400-405. [PMID: 30882732 PMCID: PMC6355383 DOI: 10.1097/inf.0000000000002156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Managing virologic failure (VF) in HIV-infected children is especially difficult in resource-limited settings, given limited availability of alternative drugs, concerns around adherence, and the development of HIV resistance mutations. We aimed to evaluate 4 management strategies for children following their first episode of VF by comparing their immunologic and virologic outcomes. METHODS We included children (< 16 years of age) with VF from 8 International Epidemiologic Database to Evaluate AIDS Southern Africa cohorts, initiating combination antiretroviral therapy (cART) between 2004 and 2010, who followed one of the 4 management strategies: continuing on their failing regimen; switching to a second-line regimen; switching to a holding regimen (either lamivudine monotherapy or other non-cART regimen); discontinuing all ART. We compared the effect of management strategy on the 52-week change in CD4% and log10VL from VF, using inverse probability weighting of marginal structural linear models. RESULTS Nine hundred eighty-two patients were followed over 54,168 weeks. Relative to remaining on a failing regimen, switching to second-line showed improved immunologic and virologic responses 52 weeks after VF with gains in CD4% of 1.5% (95% confidence interval [CI], 0.2-2.8) and declines in log10VL of -1.4 copies/mL (95% CI, -2.0, -0.8), while switching to holding regimens or discontinuing treatment had worse immunologic (-5.4% (95% CI, -12.1, 1.3) and -5.6% (95% CI, -15.4, 4.1) and virologic outcomes (0.2 (95% CI, -3.6, 4.1) and 0.8 (95% CI, -0.6, 2.1), respectively. CONCLUSIONS The results provide useful guidance for managing children with VF. Consideration should be given to switching children failing first-line cART to second-line, given the improved virologic and immune responses when compared with other strategies.
Collapse
Affiliation(s)
- Gabriela Patten
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town, Cape Town, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town, Cape Town, South Africa
| | - Helena Rabie
- Tygerberg Academic Hospital, University of Stellenbosch, [Tygerberg, Cape Town, South Africa]
| | - Gert van Zyl
- Division of Medical Virology, Stellenbosch University and National Health Laboratory Service, Tygerberg, Cape Town, South Africa
| | - Karl Technau
- University of the Witwatersrand, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa
| | - Brian Eley
- Red Cross War Memorial Children’s Hospital, and the Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town, Cape Town, South Africa
| | - Russell B. Van Dyke
- Department of Pediatric, Tulane University, School of Medicine, New Orleans, United States
| | - Kunjal Patel
- Harvard T.H. Chan School of Public Health, Department of Epidemiology, Centre for Biostatistics in AIDS Research (CBAR), Boston, United States
| | - Nosisa Sipambo
- University of the Witwatersrand, Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute for Infectious Disease & Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Frank Tanser
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
| | | | - Mark Cotton
- Stellenbosch University and Tygerberg Children’s Hospital, Department of Paediatrics and Child Health Division of Paediatric Infectious Diseases, Cape Town, South Africa
| | - James Nuttall
- Red Cross War Memorial Children’s Hospital, and the Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Gadija Essack
- Tygerberg Academic Hospital, University of Stellenbosch, [Tygerberg, Cape Town, South Africa]
| | - Brad Karalius
- Harvard T.H. Chan School of Public Health, Department of Epidemiology, Centre for Biostatistics in AIDS Research (CBAR), Boston, United States
| | - George Seage
- Harvard T.H. Chan School of Public Health, Department of Epidemiology, Centre for Biostatistics in AIDS Research (CBAR), Boston, United States
| | - Shobna Sawry
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthias Egger
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town, Cape Town, South Africa
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | | |
Collapse
|
4
|
Patten G, Bernheimer J, Fairlie L, Rabie H, Sawry S, Technau K, Eley B, Davies MA. Lamivudine monotherapy as a holding regimen for HIV-positive children. PLoS One 2018; 13:e0205455. [PMID: 30308013 PMCID: PMC6181370 DOI: 10.1371/journal.pone.0205455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 09/25/2018] [Indexed: 01/19/2023] Open
Abstract
Background In resource-limited settings holding regimens, such as lamivudine monotherapy (LM), are used to manage HIV-positive children failing combination antiretroviral therapy (cART) to mitigate the risk of drug resistance developing, whilst adherence barriers are addressed or when access to second- or third-line regimens is restricted. We aimed to investigate characteristics of children placed on LM and their outcomes. Methods We describe the characteristics of children (age <16 years at cART start) from 5 IeDEA-SA cohorts with a record of LM during their treatment history. Among those on LM for >90 days we describe their immunologic outcomes on LM and their immunologic and virologic outcomes after resuming cART. Findings We included 228 children in our study. At LM start their median age was 12.0 years (IQR 7.3–14.6), duration on cART was 3.6 years (IQR 2.0–5.9) and median CD4 count was 605.5 cells/μL (IQR 427–901). Whilst 110 (48%) had no prior protease inhibitor (PI)-exposure, of the 69 with recorded PI-exposure, 9 (13%) patients had documented resistance to all PIs. After 6 months on LM, 70% (94/135) experienced a drop in CD4, with a predicted average CD4 decline of 46.5 cells/μL (95% CI 37.7–55.4). Whilst on LM, 46% experienced a drop in CD4 to <500 cells/μL, 18 (8%) experienced WHO stage 3 or 4 events, and 3 children died. On resumption of cART the average gain in CD4 was 15.65 cells/uL per month and 66.6% (95% CI 59.3–73.7) achieved viral suppression (viral load <1000) at 6 months after resuming cART. Interpretation Most patients experienced immune decline on LM. Its use should be avoided in those with low CD4 counts, but restricted use may be necessary when treatment options are limited. Managing children with virologic failure will continue to be challenging until more treatment options and better adherence strategies are available.
Collapse
Affiliation(s)
- Gabriela Patten
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | | | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, School of Clinical Medicine, Johannesburg, South Africa
| | - Helena Rabie
- Tygerberg Academic Hospital, University of Stellenbosch, Stellenbosch, South Africa
| | - Shobna Sawry
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, School of Clinical Medicine, Johannesburg, South Africa
| | - Karl Technau
- Empilweni Services and Research Unit, University of the Witwatersrand, Department of Paediatrics and Child Health, Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa
| | - Brian Eley
- Red Cross War Memorial Children’s Hospital, and the Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology & Research, University of Cape Town, Cape Town, South Africa
| | | |
Collapse
|
5
|
Agwu AL, Warshaw MG, McFarland EJ, Siberry GK, Melvin AJ, Wiznia AA, Fairlie L, Boyd S, Harding P, Spiegel HML, Abrams EJ, Carey VJ. Decline in CD4 T lymphocytes with monotherapy bridging strategy for non-adherent adolescents living with HIV infection: Results of the IMPAACT P1094 randomized trial. PLoS One 2017; 12:e0178075. [PMID: 28604824 PMCID: PMC5467803 DOI: 10.1371/journal.pone.0178075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 05/05/2017] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Management of persistently non-adherent youth living with HIV (YLHIV) with virologic failure (VF) on combination antiretroviral therapy (cART) remains challenging. One strategy has been using 3TC/ FTC monotherapy (3TC/FTC), which in the presence of the M184V resistance mutation, does not suppress viral replication nor select for additional drug resistance mutations, and reduces viral fitness with limited side effects. P1094 compared the immunologic outcome of continuing failing cART vs. switching to 3TC/FTC as a "bridging strategy" to subsequent suppressive cART for non-adherent YLHIV with pre-existing M184V resistance. MATERIALS & METHODS Participants with documented nonadherence, M184V mutation, CD4+ T cell count ≥100 cells/mm3 and VF (HIV-1 plasma RNA ≥400 copies/mL (2.6 log10 HIV-1 RNA) were enrolled and randomized to continue failing cART vs. switch to 3TC/FTC. The primary endpoint (time to ≥30% CD4+ T cell decline or development of CDC class C events) at 28-weeks were assessed by Kaplan-Meier (K-M) curves in an intent-to-treat analysis. RESULTS Thirty-three perinatally acquired YLHIV participants (16 continuing cART and 17 3TC/FTC) enrolled in the study. The median age, entry CD4+ T cell count, and viral load were 15 years (Inter-quartile range (IQR) 14-20), 472 cells/mm3 (IQR 384-651), and 4.0 log10HIV-1 RNA copies/ml (IQR 3.2-4.5), respectively. Five participants, all in the 3TC/FTC arm, reached the primary endpoint for absolute CD4+ T cell decline (p = 0.02, exact log-rank test comparing monotherapy to cART). The Kaplan-Meier estimate of probability of primary endpoint on 3TC/FTC at 28 weeks was 0.41 (standard error 0.14). There were no CDC class C events or deaths and no statistically significant difference in frequencies of adverse events between the arms. CONCLUSIONS Non-adherent participants randomized to 3TC/FTC were more likely than those maintained on failing cART to experience a confirmed decline in CD4+ count of ≥30%. Although this study suffers from limitations of small sample size and premature discontinuation, the randomized comparison to continuing failing cART indicates that 3TC/FTC provides inferior protection from immunologic deterioration for non-adherent youth with M184V resistance. Better alternatives to 3TC/FTC such as ART with higher barriers to resistance and novel adherence and treatment strategies for nonadherent youth are urgently needed. TRIAL REGISTRATION Clinical Trials.gov NCT01338025.
Collapse
Affiliation(s)
- Allison L. Agwu
- Johns Hopkins School of Medicine, Departments of Pediatrics and Internal Medicine, Division of Infectious Diseases, Baltimore, Maryland, United States of America
| | - Meredith G. Warshaw
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Elizabeth J. McFarland
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Pediatric Infectious Diseases, Aurora, Colorado, United States of America
| | - George K. Siberry
- Maternal Pediatric Infectious Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, United States of America
| | - Ann J. Melvin
- Seattle Children’s Hospital, Division of Pediatric Infectious Disease, Seattle, Washington, United States of America
| | - Andrew A. Wiznia
- Pediatric HIV Services, Jacobi Medical Center/Family Based Services, Bronx, New York, United States of America
| | - Lee Fairlie
- Wits Reproductive Health & HIV Research Institute, University of the Witwatersrand, Johannesburg, Republic of South Africa
| | - Sandra Boyd
- St. Jude Children's Research Hospital, Memphis, Tennessee, United States of America
| | - Paul Harding
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Pediatric Infectious Diseases, Aurora, Colorado, United States of America
| | - Hans M. L. Spiegel
- Kelly Government Solutions, Contractor to Division of AIDS, PMPRB/Prevention Sciences Program, Division of AIDS, NIAID, NIH, Rockville, Maryland, United States of America
| | - Elaine J. Abrams
- ICAP at Columbia, Mailman School of Public Health and College of Physicians & Surgeons, Columbia University, New York, New York, United States of America
| | - Vincent J. Carey
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | | |
Collapse
|