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Mugo NR, Mudhune V, Heffron R, Thomas KK, McLellan-Lemal E, Njoroge B, Peacock S, O’Connor SM, Nyagol B, Ouma E, Ridzon R, Wiener J, Isoherranen N, Erikson DW, Ouattara LA, Yousefieh N, Jacot TA, Haaland RE, Morrison SA, Haugen HS, Thurman AR, Allen SA, Baeten JM, Samandari T, Doncel GF. Randomized controlled phase IIa clinical trial of safety, pharmacokinetics and pharmacodynamics of tenofovir and tenofovir plus levonorgestrel releasing intravaginal rings used by women in Kenya. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1118030. [PMID: 37383290 PMCID: PMC10293630 DOI: 10.3389/frph.2023.1118030] [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: 12/12/2022] [Accepted: 04/11/2023] [Indexed: 06/30/2023] Open
Abstract
Introduction Globally, many young women face the overlapping burden of HIV infection and unintended pregnancy. Protection against both may benefit from safe and effective multipurpose prevention technologies. Methods Healthy women ages 18-34 years, not pregnant, seronegative for HIV and hepatitis B surface antigen, not using hormonal contraception, and at low risk for HIV were randomized 2:2:1 to continuous use of a tenofovir/levonorgestrel (TFV/LNG), TFV, or placebo intravaginal ring (IVR). In addition to assessing genital and systemic safety, we determined TFV concentrations in plasma and cervicovaginal fluid (CVF) and LNG levels in serum using tandem liquid chromatography-mass spectrometry. We further evaluated TFV pharmacodynamics (PD) through ex vivo CVF activity against both human immunodeficiency virus (HIV)-1 and herpes simplex virus (HSV)-2, and LNG PD using cervical mucus quality markers and serum progesterone for ovulation inhibition. Results Among 312 women screened, 27 were randomized to use one of the following IVRs: TFV/LNG (n = 11); TFV-only (n = 11); or placebo (n = 5). Most screening failures were due to vaginal infections. The median days of IVR use was 68 [interquartile range (IQR), 36-90]. Adverse events (AEs) were distributed similarly among the three arms. There were two non-product related AEs graded >2. No visible genital lesions were observed. Steady state geometric mean amount (ssGMA) of vaginal TFV was comparable in the TFV/LNG and TFV IVR groups, 43,988 ng/swab (95% CI, 31,232, 61,954) and 30337 ng/swab (95% CI, 18,152, 50,702), respectively. Plasma TFV steady state geometric mean concentration (ssGMC) was <10 ng/ml for both TFV IVRs. In vitro, CVF anti-HIV-1 activity showed increased HIV inhibition over baseline following TFV-eluting IVR use, from a median of 7.1% to 84.4% in TFV/LNG, 15.0% to 89.5% in TFV-only, and -27.1% to -20.1% in placebo participants. Similarly, anti-HSV-2 activity in CVF increased >50 fold after use of TFV-containing IVRs. LNG serum ssGMC was 241 pg/ml (95% CI 185, 314) with rapid rise after TFV/LNG IVR insertion and decline 24-hours post-removal (586 pg/ml [95% CI 473, 726] and 87 pg/ml [95% CI 64, 119], respectively). Conclusion TFV/LNG and TFV-only IVRs were safe and well tolerated among Kenyan women. Pharmacokinetics and markers of protection against HIV-1, HSV-2, and unintended pregnancy suggest the potential for clinical efficacy of the multipurpose TFV/LNG IVR. Clinical Trial Registration NCT03762382 [https://clinicaltrials.gov/ct2/show/NCT03762382].
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Affiliation(s)
- Nelly R. Mugo
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA, United States
- Center for Clinical Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Victor Mudhune
- HIV Research Division, Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Renee Heffron
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA, United States
- Department Epidemiology, University of Washington, Seattle, WA, United States
| | - Katherine K. Thomas
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA, United States
| | - Eleanor McLellan-Lemal
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Betty Njoroge
- Center for Clinical Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Sue Peacock
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA, United States
| | - Siobhán M. O’Connor
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Beatrice Nyagol
- HIV Research Division, Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Eunice Ouma
- HIV Research Division, Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Renee Ridzon
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jeffrey Wiener
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Nina Isoherranen
- Department of Pharmaceutics, University of Washington, Seattle, WA, United States
| | - David W. Erikson
- Endocrine Technologies Core, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR, United States
| | | | - Nazita Yousefieh
- CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Terry A. Jacot
- CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Richard E. Haaland
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Susan A. Morrison
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA, United States
| | - Harald S. Haugen
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA, United States
| | | | - Shannon A. Allen
- Office of HIV and AIDS, Bureau for Global Health, United States Agency for International Development, Washington, DC, United States
| | - Jared M. Baeten
- International Clinical Research Center, Department of Global Health, University of Washington, Seattle, WA, United States
- Department Epidemiology, University of Washington, Seattle, WA, United States
- Department of Medicine, University of Washington, Seattle, WA, United States
| | - Taraz Samandari
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention (United States), Kisumu, Kenya
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Thurman AR, Brache V, Cochon L, Ouattara LA, Chandra N, Jacot T, Yousefieh N, Clark MR, Peet M, Hanif H, Schwartz JL, Ju S, Marzinke MA, Erikson DW, Parikh U, Herold BC, Fichorova RN, Tolley E, Doncel GF. Randomized, placebo controlled phase I trial of the safety, pharmacokinetics, pharmacodynamics and acceptability of a 90 day tenofovir plus levonorgestrel vaginal ring used continuously or cyclically in women: The CONRAD 138 study. PLoS One 2022; 17:e0275794. [PMID: 36215267 PMCID: PMC9550080 DOI: 10.1371/journal.pone.0275794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 08/29/2022] [Indexed: 11/04/2022] Open
Abstract
Multipurpose prevention technologies (MPTs), which prevent sexually transmitted infection(s) and unintended pregnancy, are highly desirable to women. In this randomized, placebo-controlled, phase I study, women used a placebo or tenofovir (TFV) and levonorgestrel (LNG) intravaginal ring (IVR), either continuously or cyclically (three, 28-day cycles with a 3 day interruption in between each cycle), for 90 days. Sixty-eight women were screened; 47 were randomized to 4 arms: TFV/LNG or placebo IVRs used continuously or cyclically (4:4:1:1). Safety was assessed by adverse events and changes from baseline in mucosal histology and immune mediators. TFV concentrations were evaluated in multiple compartments. LNG concentration was determined in serum. Modeled TFV pharmacodynamic antiviral activity was evaluated in vaginal and rectal fluids and cervicovaginal tissue ex vivo. LNG pharmacodynamics was assessed with cervical mucus quality and anovulation. All IVRs were safe with no serious adverse events nor significant changes in genital tract histology, immune cell density or secreted soluble proteins from baseline. Median vaginal fluid TFV concentrations were >500 ng/mg throughout 90d. TFV-diphosphate tissue concentrations exceeded 1,000 fmol/mg within 72hrs of IVR insertion. Mean serum LNG concentrations exceeded 200 pg/mL within 2h of TFV/LNG use, decreasing quickly after IVR removal. Vaginal fluid of women using TFV-containing IVRs had significantly greater inhibitory activity (87-98% versus 10% at baseline; p<0.01) against HIV replication in vitro. There was a >10-fold reduction in HIV p24 antigen production from ectocervical tissues after TFV/LNG exposure. TFV/LNG IVR users had significantly higher rates of anovulation, lower Insler scores and poorer/abnormal cervical mucus sperm penetration. Most TFV/LNG IVR users reported no change in menstrual cycles or fewer days of and/or lighter bleeding. All IVRs were safe. Active rings delivered high TFV concentrations locally. LNG caused changes in cervical mucus, sperm penetration, and ovulation compatible with contraceptive efficacy. Trial registration: ClinicalTrials.gov #NCT03279120.
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Affiliation(s)
- Andrea R. Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
- * E-mail:
| | | | | | - Louise A. Ouattara
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Neelima Chandra
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Terry Jacot
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Nazita Yousefieh
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Meredith R. Clark
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Melissa Peet
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Homaira Hanif
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Jill L. Schwartz
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Susan Ju
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
| | - Mark A. Marzinke
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - David W. Erikson
- Endocrine Technologies Core (ETC), Oregon National Primate Research Center (ONPRC), Beaverton, OR, United States of America
| | - Urvi Parikh
- Department of Medicine, Division of Infectious Diseases and Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Betsy C. Herold
- Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Raina N. Fichorova
- Laboratory of Genital Tract Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Elizabeth Tolley
- Family Health International 360, Research Triangle, NC, United States of America
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA, United States of America
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Ouattara LA, Thurman AR, Jacot TA, Cottrell M, Sykes C, Blake K, Fang X, Ju S, Vann NC, Schwartz J, Doncel GF. Genital Mucosal Drug Concentrations and anti-HIV Activity in Tenofovir-Based PrEP Products: Intravaginal Ring vs. Oral Administration. J Acquir Immune Defic Syndr 2022; 89:87-97. [PMID: 34878438 PMCID: PMC8647693 DOI: 10.1097/qai.0000000000002820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 09/20/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To describe and compare systemic and local pharmacokinetics (PK) and cervicovaginal (CV) pharmacodynamics (PD) of oral tenofovir disoproxil fumarate (TDF) in combination with emtricitabine (FTC) with tenofovir (TFV) intravaginal ring (IVR). DESIGN Phase I, randomized, parallel-group study. Women (n = 22) used TDF/FTC oral tablets daily or TFV IVR continuously and were assessed at baseline and 14 days. METHODS TFV and FTC concentrations were measured in plasma, CV fluid (CVF), and CV tissue. TFV-diphosphate and FTC-triphosphate were assessed in CV tissue. In vitro PD antiviral activities of TFV and FTC (using in vivo concentration ranges) were modeled in the CVF and by infecting CV tissue explants ex vivo with HIV-1BaL. RESULTS Adverse events (AEs) were more common with oral TDF/FTC use (P < 0.01). The median CVF TFV concentrations were 106 ng/mL after use of TFV IVR vs. 102 ng/mL for TDF/FTC. The median TFV and TFV-diphosphate concentrations in CV tissue were >100-fold higher among IVR users. The median CVF FTC concentrations were 103 ng/mL. FTC and FTC-triphosphate were detected in all CV tissues from TDF/FTC users. HIV inhibitory activity of CVF increased significantly with treatment in both cohorts (P < 0.01) but was higher in TFV IVR users (P < 0.01). In vitro inhibition of tissue infection with ex vivo administration of TFV and FTC was dose dependent, with maximal efficacy achieved with 10 µg/mL TFV, 1 µg/mL FTC, and 0.1 µg/mL of TFV and FTC combined. CONCLUSIONS Both products were safe and increased mucosal HIV inhibitory activity. In addition to systemic protection, oral TDF/FTC displays a PK/PD profile compatible with CV mucosal antiviral activity. TFV IVR resulted in fewer AEs, lower TFV plasma concentrations, higher CVF and tissue TFV and TFV-DP concentrations, and greater anti-HIV activity in CVF.
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Affiliation(s)
| | - Andrea R. Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Terry A. Jacot
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | | | - Craig Sykes
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kimberly Blake
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Xi Fang
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Susan Ju
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Nikolas C. Vann
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Jill Schwartz
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Norfolk and Arlington, VA; and
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