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Papot E, Jacoby S, Arlinda D, Avihingsanon A, Azwa I, Borok M, Brown D, Cissé M, Dao S, Eriobu N, Kaplan R, Karyana M, Kumarasamy N, Lee J, Losso MH, Matthews GV, Perelis L, Perez-Casas C, Ruxrungtham K, Watkins M, Lane HC, Kelleher A, Law M, Polizzotto MN. Adaption of an ongoing clinical trial to quickly respond to gaps in changing international recommendations: the experience of D 2EFT. HIV Res Clin Pract 2022; 23:37-46. [PMID: 35938597 PMCID: PMC10029359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
A rapidly changing landscape of antiretrovirals and their procurement at scale has permitted the evaluation of new optimised second-line antiretroviral therapy (ART) in low- and middle-income countries. D2EFT is an open-label randomised controlled non-inferiority phase IIIB/IV trial in people living with HIV-1 (PWH) whose first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART is failing. At inception, it compared a standard of care of boosted darunavir with two nucleos(t)ide reverse transcriptase inhibitors (NRTIs) to the novel NRTI-sparing regimen of boosted darunavir with dolutegravir. Implemented in 2017, participating sites were across Africa, Asia and Latin America. Around the time of implementation, the World Health Organization updated its treatment guidelines and recommended scaling up tenofovir disoproxil fumarate-lamivudine-dolutegravir (TLD). This situation pushed D2EFT investigators to consider the impact of the roll-out of TLD on the D2EFT research question. The protocol team agreed it was important to study TLD in second-line when an NNRTI regimen was failing, and focused on options to expedite the work by studying the question within the existing trial and network. All key issues (statistical, programmatic and financial) were reviewed to assess the benefits and risks of adding a third arm to the ongoing study, as opposed to developing a new randomised clinical trial with the same control arm and within the same network. The development of a new trial was deemed to be longer than adding a third arm, and to create a challenging situation with two competing clinical trials at the same sites which would slow down recruitment and impair both trials. On the other hand, adding a third arm would be demanding in terms of operationalisation, increased sample size and statistical biases to control. The optimal strategy was deemed to be the addition of a third arm, arriving retrospectively at a simplified multi-arm multi-stage clinical trial design to achieve statistical validity. The D2EFT study maintains additional value in a quickly evolving second-line ART strategy allowed by the progress in global access to ART.
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Affiliation(s)
- Emmanuelle Papot
- Therapeutic and Vaccine Research Program, The Kirby Institute, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Simone Jacoby
- Therapeutic and Vaccine Research Program, The Kirby Institute, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Dona Arlinda
- Indonesia Research Partnership on Infectious Disease, Jakarta, Indonesia
| | - Anchalee Avihingsanon
- The HIV Netherlands Australia Thailand Research Collaboration, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Iskandar Azwa
- Infectious Diseases Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Margaret Borok
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Dannae Brown
- Global Medical, ViiV Healthcare, Abbotsford, Australia
| | - Mohamed Cissé
- Faculté des Sciences et techniques de la santé de l'Université Gamal Abdel Nasser de Conakry, University hospital of Donka, Conakry, Guinea
| | - Sounkalo Dao
- University Clinical Research Centre, Bamako, Mali
| | | | | | - Muhammad Karyana
- Indonesia Research Partnership on Infectious Disease, Jakarta, Indonesia
| | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site, Infectious Diseases Medical Centre, Voluntary Health Services, Chennai, India
| | - Johnnie Lee
- Global Medical Affairs, Global Public Health, Janssen Pharmaceutical companies of Johnson & Johnson, Plainfield, NJ, USA
| | - Marcelo H Losso
- Coordinación en Investigación Clínica Académica en Latinoamérica Fundación IBIS Buenos Aires, Buenos Aires, Argentina
| | - Gail V Matthews
- Therapeutic and Vaccine Research Program, The Kirby Institute, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Leonardo Perelis
- Coordinación en Investigación Clínica Académica en Latinoamérica Fundación IBIS Buenos Aires, Buenos Aires, Argentina
| | | | - Kiat Ruxrungtham
- The HIV Netherlands Australia Thailand Research Collaboration, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Melynda Watkins
- Product Development and Regulatory Affairs, Clinton Health Access Initiative, Boston, MA, USA
| | - H Clifford Lane
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Anthony Kelleher
- Immunovirology and Pathogenesis Program, The Kirby Institute, University of New South Wales Sydney, Sydney,Australia
| | - Matthew Law
- Biostatistics and Databases Program, The Kirby Institute, University of New South Wales Sydney, Sydney,Australia
| | - Mark N Polizzotto
- Therapeutic and Vaccine Research Program, The Kirby Institute, University of New South Wales Sydney, Sydney, NSW, Australia
- Department of Haematology, The Kinghorn Cancer Centre, St Vincent's Hospital, Darlinghurst, Australia
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Papot E, Kaplan R, Vitoria M, Polizzotto MN. Optimizing switching strategies to simplify antiretroviral therapy: the future of second-line from a public health perspective. AIDS 2021; 35:S153-S163. [PMID: 34848582 DOI: 10.1097/qad.0000000000003108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Emmanuelle Papot
- Therapeutic and Vaccine Research Program, The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | | | - Marco Vitoria
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Mark N Polizzotto
- Therapeutic and Vaccine Research Program, The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
- Department of Haematology, The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, Australia
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Badowski M, Pérez SE, Silva D, Lee A. Two's a Company, Three's a Crowd: A Review of Initiating or Switching to a Two-Drug Antiretroviral Regimen in Treatment-Naïve and Treatment-Experienced Patients Living with HIV-1. Infect Dis Ther 2020; 9:185-208. [PMID: 32193799 PMCID: PMC7237600 DOI: 10.1007/s40121-020-00290-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION As HIV has become a manageable chronic condition, a renewed and increased interest in challenging traditional three-drug HIV therapies and moving toward two-drug regimens (2DR) for initial or maintenance treatment in people living with HIV (PLWH) has developed. As PLWH are living longer, continual advancements in antiretroviral regimens have been a focus to provide optimal life-long therapy options. Although early studies may have shown poor outcomes in virologic suppression with 2DR, newer studies and treatment options have emerged to show promise in the management of HIV. The purpose of this review is to evaluate current literature and assess the efficacy of two-drug (2DR) antiretroviral therapy in treatment-naïve and -experienced people living with HIV. METHODS A systematic search was performed between January 2009 to January 2020, using EMBASE, MEDLINE, Google Scholar, and bibliographies. Combinations of the following search terms were used: HIV-1 infection, antiretroviral therapy, dual therapy, two-drug regimen, two-drug therapy, two-drug regimen, and 2DR. Included studies were those in the adult population with at least one active comparator, outcomes assessing HIV-1 RNA viral load while on treatment, and written in English. RESULTS Thirty-three studies were included, 13 where 2DRs were evaluated as initial therapy (3 studies with extension data) and 15 where 2DRs were evaluated as maintenance or switch therapy (2 studies with extension data). CONCLUSION Although 2DRs may not be appropriate in all patient populations, they are being utilized more frequently and have the potential to reduce costs, adverse effects, and drug interactions.
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Affiliation(s)
| | - Sarah E Pérez
- College of Pharmacy, University of New Mexico, Albuquerque, NM, USA
| | - David Silva
- College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Andrea Lee
- College of Pharmacy, University of Illinois, Chicago, IL, USA
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Huang Y, Huang X, Chen H, Wu H, Chen Y. Efficacy and Safety of Raltegravir-Based Dual Therapy in AIDS Patients: A Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2019; 10:1225. [PMID: 31749699 PMCID: PMC6842978 DOI: 10.3389/fphar.2019.01225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/23/2019] [Indexed: 11/13/2022] Open
Abstract
Background: The life expectancy for HIV-infected individuals has improved dramatically because of improvements in antiretroviral therapy (ART). Today, a simplified two-drug regimen enhances adherence and treatment satisfaction by reducing adverse effects. Therefore, we need more evidence to show the benefits and risks of simplified ART regimens from randomized controlled trials (RCTs). We compared the efficacy and safety of raltegravir-based simplified dual therapy (DT) and of traditional triple therapy (TT) for people living with HIV/AIDS (PLWHA). Methods: We carried out a systematic review of RCTs. After using a combination of the key words "HIV," "raltegravir," and "protease inhibitor" to search the English-language electronic databases from January 1, 2004, to September 11, 2019, we pooled data across eligible studies and estimated the summary effect sizes with Review Manager (version 5.3). Results: We included eight RCTs involving 4420 PLWHA: 2187 (49.5%) received raltegravir-based simplified DT, and 2144 (48.5%) received traditional TT. The proportion of viral suppression was 79% at 48 weeks and 74% at 96 weeks in the simplified regimen, and the proportion of viral suppression was 78% at 48 weeks and 71% at 96 weeks in the traditional TT group. Furthermore, the proportion of viral suppression in the simplified DT group was greater than that in the TT group at 24 weeks (risk ratio 1.11, 95% confidence interval 1.02-1.21; p = 0.01). The CD4 cell counts in the simplified DT group were significantly higher at 48 weeks and 96 weeks than those in the group that received the traditional TT. Regarding adverse events and mortality rates, the DT and TT groups were similar. However, there was better adherence in the DT group than in the TT group. Conclusion: We found that the simplified regimen was noninferior to TT regimen in regard to viral suppression. Furthermore, the simplified DT regimen had a better CD4 cell count and lower adverse events than the TT regimen.
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Affiliation(s)
- Yinqiu Huang
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China.,Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Xiaojie Huang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Yaokai Chen
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China.,Department of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
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Pasquau J, de Jesus SE, Arazo P, Crusells MJ, Ríos MJ, Lozano F, de la Torre J, Galindo MJ, Carmena J, Santos J, Tornero C, Verdejo G, Samperiz G, Palacios Z, Hidalgo-Tenorio C. Effectiveness and safety of dual therapy with rilpivirine and boosted darunavir in treatment-experienced patients with advanced HIV infection: a preliminary 24 week analysis (RIDAR study). BMC Infect Dis 2019; 19:207. [PMID: 30819101 PMCID: PMC6396540 DOI: 10.1186/s12879-019-3817-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 02/13/2019] [Indexed: 01/01/2023] Open
Abstract
Background The objective was to analyze the effectiveness and safety of dual therapy with rilpivirine plus boosted-darunavir (RPV + bDRV) in real-life patients. Methods Observational, retrospective, multi-center study in HIV+ patients who had received RPV + bDRV for 24 weeks to optimize/simplify their previous antiretroviral treatment. We determined the percentage of patients without virologic failure (2 consecutive viral loads > 50 copies/mL) at 24 weeks of treatment. Results The study included 161 patients from 15 hospitals with median age of 49 years; 29.3% had previous AIDS stage and median CD4+ lymphocyte nadir of 170 cells/uL. They had been diagnosed with HIV for a median of 17 years and had received 14 years of ART, with five previous treatment combinations, and 36.6% had a history of virological failure. The reasons for the switch were simplification/optimization (49.7%), toxicity/intolerance (17.4%), or inadequate effectiveness of previous ART (10.6%). Baseline VL of 50–1000 copies/mL was recorded in 25.5% of the patients. In the“intention-to-treat” analysis at 24 weeks, 87.6% of 161 patients continued the study treatment without virologic failure criteria. In the “on treatment” analysis (excluding patients who discontinued treatment with dual therapy for any reason other than virologic failure) the efficacy was 94.6% (141/149 patients). Conclusions Dual therapy with RPV + DRVb proved to be effective and safe in patients with advanced HIV infection, long exposure to ART, low CD4 nadir, previous virologic failure, and/or history of ineffective ART.
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Affiliation(s)
- Juan Pasquau
- Hospital Universitario Virgen de las Nieves, Granada, Spain.
| | | | | | | | | | | | | | | | - Jorge Carmena
- Hospital Universitario Doctor Peset, Valencia, Spain
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Huang Y, Huang X, Chen H, Wu H, Chen Y. Efficacy and Safety of Raltegravir-Based Dual Therapy in AIDS Patients: A Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2019. [PMID: 31749699 DOI: 10.3389/fphar.2019.01225/bibtex] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023] Open
Abstract
Background: The life expectancy for HIV-infected individuals has improved dramatically because of improvements in antiretroviral therapy (ART). Today, a simplified two-drug regimen enhances adherence and treatment satisfaction by reducing adverse effects. Therefore, we need more evidence to show the benefits and risks of simplified ART regimens from randomized controlled trials (RCTs). We compared the efficacy and safety of raltegravir-based simplified dual therapy (DT) and of traditional triple therapy (TT) for people living with HIV/AIDS (PLWHA). Methods: We carried out a systematic review of RCTs. After using a combination of the key words "HIV," "raltegravir," and "protease inhibitor" to search the English-language electronic databases from January 1, 2004, to September 11, 2019, we pooled data across eligible studies and estimated the summary effect sizes with Review Manager (version 5.3). Results: We included eight RCTs involving 4420 PLWHA: 2187 (49.5%) received raltegravir-based simplified DT, and 2144 (48.5%) received traditional TT. The proportion of viral suppression was 79% at 48 weeks and 74% at 96 weeks in the simplified regimen, and the proportion of viral suppression was 78% at 48 weeks and 71% at 96 weeks in the traditional TT group. Furthermore, the proportion of viral suppression in the simplified DT group was greater than that in the TT group at 24 weeks (risk ratio 1.11, 95% confidence interval 1.02-1.21; p = 0.01). The CD4 cell counts in the simplified DT group were significantly higher at 48 weeks and 96 weeks than those in the group that received the traditional TT. Regarding adverse events and mortality rates, the DT and TT groups were similar. However, there was better adherence in the DT group than in the TT group. Conclusion: We found that the simplified regimen was noninferior to TT regimen in regard to viral suppression. Furthermore, the simplified DT regimen had a better CD4 cell count and lower adverse events than the TT regimen.
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Affiliation(s)
- Yinqiu Huang
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Xiaojie Huang
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Hao Wu
- Center for Infectious Diseases, Beijing You'an Hospital, Capital Medical University, Beijing, China
| | - Yaokai Chen
- National Key Laboratory for Infectious Diseases Prevention and Treatment with Traditional Chinese Medicine, Chongqing Public Health Medical Center, Chongqing, China
- Department of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
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Churchill D, Waters L, Ahmed N, Angus B, Boffito M, Bower M, Dunn D, Edwards S, Emerson C, Fidler S, Fisher M, Horne R, Khoo S, Leen C, Mackie N, Marshall N, Monteiro F, Nelson M, Orkin C, Palfreeman A, Pett S, Phillips A, Post F, Pozniak A, Reeves I, Sabin C, Trevelion R, Walsh J, Wilkins E, Williams I, Winston A. British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2015. HIV Med 2018; 17 Suppl 4:s2-s104. [PMID: 27568911 DOI: 10.1111/hiv.12426] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | | | | | | | - Mark Bower
- Chelsea and Westminster Hospital, London, UK
| | | | - Simon Edwards
- Central and North West London NHS Foundation Trust, UK
| | | | - Sarah Fidler
- Imperial College School of Medicine at St Mary's, London, UK
| | | | | | | | | | | | | | | | - Mark Nelson
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | | | | | | | | | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Caroline Sabin
- Royal Free and University College Medical School, London, UK
| | | | - John Walsh
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Ian Williams
- Royal Free and University College Medical School, London, UK
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Stockdale AJ, Saunders MJ, Boyd MA, Bonnett LJ, Johnston V, Wandeler G, Schoffelen AF, Ciaffi L, Stafford K, Collier AC, Paton NI, Geretti AM. Effectiveness of Protease Inhibitor/Nucleos(t)ide Reverse Transcriptase Inhibitor-Based Second-line Antiretroviral Therapy for the Treatment of Human Immunodeficiency Virus Type 1 Infection in Sub-Saharan Africa: A Systematic Review and Meta-analysis. Clin Infect Dis 2018; 66:1846-1857. [PMID: 29272346 PMCID: PMC5982734 DOI: 10.1093/cid/cix1108] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/18/2017] [Indexed: 02/02/2023] Open
Abstract
Background In sub-Saharan Africa, 25.5 million people are living with human immunodeficiency virus (HIV), representing 70% of the global total. The need for second-line antiretroviral therapy (ART) is projected to increase in the next decade in keeping with the expansion of treatment provision. Outcome data are required to inform policy. Methods We performed a systematic review and meta-analysis of studies reporting the virological outcomes of protease inhibitor (PI)-based second-line ART in sub-Saharan Africa. The primary outcome was virological suppression (HIV-1 RNA <400 copies/mL) after 48 and 96 weeks of treatment. The secondary outcome was the proportion of patients with PI resistance. Pooled aggregate data were analyzed using a DerSimonian-Laird random effects model. Results By intention-to-treat analysis, virological suppression occurred in 69.3% (95% confidence interval [CI], 58.2%-79.3%) of patients at week 48 (4558 participants, 14 studies), and in 61.5% (95% CI, 47.2%-74.9%) at week 96 (2145 participants, 8 studies). Preexisting resistance to nucleos(t)ide reverse transcriptase inhibitors (NRTIs) increased the likelihood of virological suppression. Major protease resistance mutations occurred in a median of 17% (interquartile range, 0-25%) of the virological failure population and increased with duration of second-line ART. Conclusions One-third of patients receiving PI-based second-line ART with continued NRTI use in sub-Saharan Africa did not achieve virological suppression, although among viremic patients, protease resistance was infrequent. Significant challenges remain in implementation of viral load monitoring. Optimizing definitions and strategies for management of second-line ART failure is a research priority. Prospero Registration CRD42016048985.
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Affiliation(s)
- Alexander J Stockdale
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre
- Institute of Infection and Global Health, University of Liverpool
| | - Matthew J Saunders
- Section of Infectious Diseases and Immunity and Wellcome Trust–Imperial College Centre for Global Health Research, Imperial College London, United Kingdom
| | - Mark A Boyd
- Kirby Institute for Infection and Immunity, University of New South Wales, Sydney
- Lyell McEwin Hospital, University of Adelaide, South Australia, Australia
| | | | | | - Gilles Wandeler
- Institute of Social and Preventative Medicine, University of Bern
- Department of Infectious Diseases, Bern University Hospital, Switzerland
| | - Annelot F Schoffelen
- Department of Infectious Diseases, University Medical Centre Utrecht, The Netherlands
| | - Laura Ciaffi
- Unité Mixte de Recherche de l’Institut de Rech (UMI), Institute de Recherche pour le Développement, Institute National de la Santé et de la Recherche Medicale, University of Montpellier, France
| | - Kristen Stafford
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore
| | - Ann C Collier
- University of Washington School of Medicine, Seattle
| | - Nicholas I Paton
- Yong Loo Lin School of Medicine, National University of Singapore
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Jabłonowska E, Pulik P, Kalinowska A, Gąsiorowski J, Parczewski M, Bociąga-Jasik M, Mularska E, Pulik Ł, Siwak E, Wójcik K. Dual therapy based on raltegravir and boosted protease inhibitors - the experience of Polish centers. Arch Med Sci 2018; 14:860-864. [PMID: 30002705 PMCID: PMC6040130 DOI: 10.5114/aoms.2016.62445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 07/03/2016] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The aim of the study was to present the experience of Polish centers regarding dual therapy based on the integrase inhibitor raltegravir (RAL) and ritonavir-boosted protease inhibitors (PI/r) for treating treatment-naïve and -experienced HIV-infected patients. MATERIAL AND METHODS The paper concerns a retrospective multicenter study. The medical databases of six main Polish HIV centers from January 2009 to December 2014 were analyzed for the use of combined antiretroviral treatment consisting of RAL + PI/r. This study included 126 HIV-infected patients receiving RAL + PI/r therapy, of whom 17 patients were treatment-naive and 109 patients were treatment-experienced. RESULTS In treatment-experienced patients, the most common reasons for the introduction of a RAL + PI/r regimen were virologic failure and impaired renal function (45 of 109 patients). In the treatment-naïve group kidney disease was the cause of the RAL + PI/r regimen in 3 of 17 participants. In treatment-experienced patients, 80% of individuals still were on RAL + PI/r treatment after 12 months, 65% after 24 months and 53% of subjects after 60 months. In both groups, the simplification of the antiretroviral regimen was the most common reason for discontinuation of RAL + PI/r based therapy. CONCLUSIONS In antiretroviral-experienced patients the dual therapy based on RAL + PI/s is safe and effective. In antiretroviral-naïve patients the RAL + PI/r regimen is rarely used in Poland.
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Affiliation(s)
- Elżbieta Jabłonowska
- Clinic of Infectious Diseases and Hepatology, Medical University of Lodz, Lodz, Poland
| | - Piotr Pulik
- Hospital for Infectious Diseases, HIV Out-Patient Clinic, Warsaw, Poland
| | - Anna Kalinowska
- Department of Infectious Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Jacek Gąsiorowski
- Department of Infectious Diseases, Hepatology and Acquired Immune Deficiencies, Wroclaw Medical University, Wroclaw, Poland
| | - Miłosz Parczewski
- Department of Infectious and Tropical Diseases and Immune Deficiency, Pomeranian Medical University, Szczecin, Poland
| | - Monika Bociąga-Jasik
- Department of Infectious Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Elżbieta Mularska
- Outpatient Clinic for AIDS Diagnostics and Therapy Specialistic Hospital, Chorzow, Poland
| | - Łukasz Pulik
- Hospital for Infectious Diseases, HIV Out-Patient Clinic, Warsaw, Poland
| | - Ewa Siwak
- Hospital for Infectious Diseases, HIV Out-Patient Clinic, Warsaw, Poland
| | - Kamila Wójcik
- Clinic of Infectious Diseases and Hepatology, Medical University of Lodz, Lodz, Poland
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Evans D, Hirasen K, Berhanu R, Malete G, Ive P, Spencer D, Badal-Faesen S, Sanne IM, Fox MP. Predictors of switch to and early outcomes on third-line antiretroviral therapy at a large public-sector clinic in Johannesburg, South Africa. AIDS Res Ther 2018; 15:10. [PMID: 29636106 PMCID: PMC5891887 DOI: 10.1186/s12981-018-0196-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While efficacy data exist, there are limited data on the outcomes of patients on third-line antiretroviral therapy (ART) in sub-Saharan Africa in actual practice. Being able to identify predictors of switch to third-line ART will be essential for planning for future need. We identify predictors of switch to third-line ART among patients with significant viraemia on a protease inhibitor (PI)-based second-line ART regimen. Additionally, we describe characteristics of all patients on third-line at a large public sector HIV clinic and present their early outcomes. METHODS Retrospective analysis of adults (≥ 18 years) on a PI-based second-line ART regimen at Themba Lethu Clinic, Johannesburg, South Africa as of 01 August 2012, when third-line treatment became available in South Africa, with significant viraemia on second-line ART (defined as at least one viral load ≥ 1000 copies/mL on second-line ART after 01 August 2012) to identify predictors of switch to third-line (determined by genotype resistance testing). Third-line ART was defined as a regimen containing etravirine, raltegravir or ritonavir boosted darunavir, between August 2012 and January 2016. To assess predictors of switch to third-line ART we used Cox proportional hazards regression among those with significant viraemia on second-line ART after 01 August 2012. Then among all patients on third-line ART we describe viral load suppression, defined as a viral load < 400 copies/mL, after starting third-line ART. RESULTS Among 719 patients in care and on second-line ART as of August 2012 (with at least one viral load ≥ 1000 copies/mL after 01 August 2012), 36 (5.0% over a median time of 54 months) switched to third-line. Time on second-line therapy (≥ 96 vs. < 96 weeks) (adjusted Hazard Ratio (aHR): 2.53 95% CI 1.03-6.22) and never reaching virologic suppression while on second-line ART (aHR: 3.37 95% CI 1.47-7.73) were identified as predictors of switch. In a separate cohort of patients on third-line ART, 78.3% (47/60) and 83.3% (35/42) of those in care and with a viral load suppressed their viral load at 6 and 12 months, respectively. CONCLUSIONS Our results show that the need for third-line is low (5%), but that patients' who switch to third-line ART have good early treatment outcomes and are able to suppress their viral load. Adherence counselling and resistance testing should be prioritized for patients that are at risk of failure, in particular those who never suppress on second-line and those who have been on PI-based regimen for extended periods.
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Ségéral O, Nerrienet E, Neth S, Spire B, Khol V, Ferradini L, Sarun S, Mom C, Ngin S, Charpentier C, Men P, Mora M, Mean Chhi V, Ly P, Saphonn V. Positive Virological Outcomes of HIV-Infected Patients on Protease Inhibitor-Based Second-Line Regimen in Cambodia: The ANRS 12276 2PICAM Study. Front Public Health 2018; 6:63. [PMID: 29662875 PMCID: PMC5890147 DOI: 10.3389/fpubh.2018.00063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/16/2018] [Indexed: 12/19/2022] Open
Abstract
Background Assessment of virological outcomes among HIV-infected patients receiving protease (PR) inhibitor-based second-line regimen are uncommon in Cambodia. The objective of this study is to assess the virological effectiveness of this regimen as well as impact of adherence boosting for patients experiencing virological failure. Methods The 2PICAM study (Clinicaltrial: NCT01801618) is a cross-sectional study of HIV-infected adults on PR inhibitor-based second-line regimen since at least 6 months, conducted in 13 representative sites, comprising more than 90% of the target population. Adults with HIV RNA above 250 copies/mL (threshold of the assay) at inclusion received boosted adherence counseling during 3 months followed by HIV RNA control. For confirmed virological failure, genotype resistance test was performed and expert committee used results for therapeutic decision. Results Among the 1,317 adults enrolled, the median duration of second-line regimen was 5 years. At inclusion, 1,182 (89.7%) patients achieved virological success (<250 copies/mL) and 135 (10.3%) experienced a virological failure (>250 copies/mL). In multivariable analysis, factors associated with virological success were: CD4 cell count between 201 and 350/mm3 (OR: 4.66, 95% CI: 2.57–8.47, p < 0.0001) and >350/mm3 (OR: 6.67, 95% CI: 4.02–11.06, p < 0.0001), duration of PI-based regimen >2 years (OR: 1.64, 95% CI: 1.03–2.62, p = 0.037), ATV-containing regimen (0R: 1.65, 95% CI: 1.04–2.63, p = 0.034) and high level of adherence (OR: 2.41, 95% CI: 1.07–5.41, p = 0.033). After adherence counseling, 63 (46.7%) patients were rescued while 72 (53.3%) were not. For the 54 patients with genotype resistance tests available, high or intermediate levels of resistance to lopinavir, atazanavir, and darunavir were reported for 13 (24%), 12 (22.2%), and 2 (3.7%) patients, respectively. Change to an alternative PR inhibitor-based regimen was recommended for 17 patients and to third-line regimen, including integrase inhibitors for 12. Conclusion This study reports high rate of virological suppression of second-line regimen and importance of adherence boosting prior to deciding any change of ART regimen. Genotype resistance tests appear necessary to guide decisions. Such information was of great importance for National HIV Program to adapt guidelines and program needs for third-line regimen.
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Affiliation(s)
- Olivier Ségéral
- French Agency for Research on AIDS and Viral Hepatitis (ANRS), Paris, France.,University of Health Sciences (UHS), Phnom-Penh, Cambodia
| | - Eric Nerrienet
- Institut Pasteur, Paris, France.,France Expertise Internationale, Paris, France
| | - Sansothy Neth
- University of Health Sciences (UHS), Phnom-Penh, Cambodia
| | - Bruno Spire
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
| | - Vohith Khol
- National Center for HIV/AIDS, Dermatology and STD (NCHADS), Phnom Penh, Cambodia
| | | | - Saramony Sarun
- University of Health Sciences (UHS), Phnom-Penh, Cambodia
| | - Chandara Mom
- National Center for HIV/AIDS, Dermatology and STD (NCHADS), Phnom Penh, Cambodia
| | - Sopheak Ngin
- National Center for HIV/AIDS, Dermatology and STD (NCHADS), Phnom Penh, Cambodia
| | - Charlotte Charpentier
- INSERM, IAME, UMR 1137, Paris, France.,Univ Paris Diderot, Sorbonne Paris Cité, Paris, France.,AP-HP, Hôpital Bichat, Laboratoire de Virologie, Paris, France
| | | | - Marion Mora
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
| | - Vun Mean Chhi
- University of Health Sciences (UHS), Phnom-Penh, Cambodia
| | - Penhsun Ly
- National Center for HIV/AIDS, Dermatology and STD (NCHADS), Phnom Penh, Cambodia
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12
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Hakim JG, Thompson J, Kityo C, Hoppe A, Kambugu A, van Oosterhout JJ, Lugemwa A, Siika A, Mwebaze R, Mweemba A, Abongomera G, Thomason MJ, Easterbrook P, Mugyenyi P, Walker AS, Paton NI. Lopinavir plus nucleoside reverse-transcriptase inhibitors, lopinavir plus raltegravir, or lopinavir monotherapy for second-line treatment of HIV (EARNEST): 144-week follow-up results from a randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2018; 18:47-57. [PMID: 29108797 PMCID: PMC5739875 DOI: 10.1016/s1473-3099(17)30630-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 09/05/2017] [Accepted: 09/26/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Millions of HIV-infected people worldwide receive antiretroviral therapy (ART) in programmes using WHO-recommended standardised regimens. Recent WHO guidelines recommend a boosted protease inhibitor plus raltegravir as an alternative second-line combination. We assessed whether this treatment option offers any advantage over the standard protease inhibitor plus two nucleoside reverse-transcriptase inhibitors (NRTIs) second-line combination after 144 weeks of follow-up in typical programme settings. METHODS We analysed the 144-week outcomes at the completion of the EARNEST trial, a randomised controlled trial done in HIV-infected adults or adolescents in 14 sites in five sub-Saharan African countries (Uganda, Zimbabwe, Malawi, Kenya, Zambia). Participants were those who were no longer responding to non-NRTI-based first-line ART, as assessed with WHO criteria, confirmed by viral-load testing. Participants were randomly assigned to receive a ritonavir-boosted protease inhibitor (lopinavir 400 mg with ritonavir 100 mg, twice per day) plus two or three clinician-selected NRTIs (protease inhibitor plus NRTI group), protease inhibitor plus raltegravir (400 mg twice per day; protease inhibitor plus raltegravir group), or protease inhibitor monotherapy (plus raltegravir induction for first 12 weeks, re-intensified to combination therapy after week 96; protease inhibitor monotherapy group). Randomisation was by computer-generated randomisation sequence, with variable block size. The primary outcome was viral load of less than 400 copies per mL at week 144, for which we assessed non-inferiority with a one-sided α of 0·025, and superiority with a two-sided α of 0·025. The EARNEST trial is registered with ISRCTN, number 37737787. FINDINGS Between April 12, 2010, and April 29, 2011, 1837 patients were screened for eligibility, of whom 1277 patients were randomly assigned to an intervention group. In the primary (complete-case) analysis at 144 weeks, 317 (86%) of 367 in the protease inhibitor plus NRTI group had viral loads of less than 400 copies per mL compared with 312 (81%) of 383 in the protease inhibitor plus raltegravir group (p=0·07; lower 95% confidence limit for difference 10·2% vs specified non-inferiority margin 10%). In the protease inhibitor monotherapy group, 292 (78%) of 375 had viral loads of less than 400 copies per mL; p=0·003 versus the protease inhibitor plus NRTI group at 144 weeks. There was no difference between groups in serious adverse events, grade 3 or 4 adverse events (total or ART-related), or events that resulted in treatment modification. INTERPRETATION Protease inhibitor plus raltegravir offered no advantage over protease inhibitor plus NRTI in virological efficacy or safety. In the primary analysis, protease inhibitor plus raltegravir did not meet non-inferiority criteria. A regimen of protease inhibitor with NRTIs remains the best standardised second-line regimen for use in programmes in resource-limited settings. FUNDING European and Developing Countries Clinical Trials Partnership (EDCTP), UK Medical Research Council, Instituto de Salud Carlos III, Irish Aid, Swedish International Development Cooperation Agency, Instituto Superiore di Sanita, Merck, ViiV Healthcare, WHO.
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Affiliation(s)
- James G Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | - Cissy Kityo
- Joint Clinical Research Centre (JCRC) Kampala, Kampala, Uganda
| | - Anne Hoppe
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Joep J van Oosterhout
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi; Dignitas International, Zomba, Malawi
| | | | | | | | | | | | | | | | - Peter Mugyenyi
- Joint Clinical Research Centre (JCRC) Kampala, Kampala, Uganda
| | - A Sarah Walker
- MRC Clinical Trials Unit at University College London, London, UK
| | - Nicholas I Paton
- MRC Clinical Trials Unit at University College London, London, UK; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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13
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de Miguel R, Montejano R, Stella-Ascariz N, Arribas JR. A safety evaluation of raltegravir for the treatment of HIV. Expert Opin Drug Saf 2017; 17:217-223. [PMID: 29199485 DOI: 10.1080/14740338.2018.1411903] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Raltegravir (RAL) was the first commercialized agent from a new drug class with an innovative target, the integrase. Since its introduction in clinical practice RAL has become widely used for the treatment of HIV-1 infected patients. A decade after its approval, this article reviews key evidence from RAL with a special interest on safety outcomes. Areas covered: Pharmacologic, safety and efficacy data of RAL from clinical trials and post-commercialization published reports are hereby summarized after a literature review including PubMed search, relating proceedings and abstracts from relevant international HIV conferences, assessment reports from European and United States regulatory agencies and treatment guidelines (World Health Organization, United States Department of Health and Human Services and European AIDS Clinical Society), up to October 2017. Most frequent search terms were 'raltegravir', 'safety', 'adverse events', 'efficacy' and 'integrase-inhibitors'. Expert opinion: Despite the arrival of new integrase strand transfer inhibitors (INSTIs) with advantages in terms of dosing convenience (elvitegravir, ELV) and higher genetic barrier (dolutegravir, DTG), RAL has stood the test of time and its overall favourable safety profile, without significant appearance of unexpected adverse events, vouch for its relevance in the antiretroviral armamentarium.
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Affiliation(s)
- Rosa de Miguel
- a HIV Unit, Internal Medicine Service , Hospital Universitario La Paz-IdiPAZ , Madrid , Spain
| | - Rocio Montejano
- a HIV Unit, Internal Medicine Service , Hospital Universitario La Paz-IdiPAZ , Madrid , Spain
| | - Natalia Stella-Ascariz
- a HIV Unit, Internal Medicine Service , Hospital Universitario La Paz-IdiPAZ , Madrid , Spain
| | - Jose R Arribas
- a HIV Unit, Internal Medicine Service , Hospital Universitario La Paz-IdiPAZ , Madrid , Spain
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14
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Wallis CL, Godfrey C, Fitzgibbon JE, Mellors JW. Key Factors Influencing the Emergence of Human Immunodeficiency Virus Drug Resistance in Low- and Middle-Income Countries. J Infect Dis 2017; 216:S851-S856. [PMID: 29207000 PMCID: PMC5853971 DOI: 10.1093/infdis/jix409] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The emergence and spread of human immunodeficiency virus (HIV) drug resistance from antiretroviral roll-out programs remain a threat to long-term control of the HIV-AIDS epidemic in low- and middle-income countries (LMICs). The patterns of drug resistance and factors driving emergence of resistance are complex and multifactorial. The key drivers of drug resistance in LMICs are reviewed here, and recommendations are made to limit their influence on antiretroviral therapy efficacy.
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Affiliation(s)
- Carole L Wallis
- Bio Analytical Research Corporation-South Africa and Lancet Laboratories, Johannesburg, South Africa
| | - Catherine Godfrey
- HIV Research Branch, Therapeutics Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health
| | - Joseph E Fitzgibbon
- Drug Development and Clinical Sciences Branch, Therapeutics Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health
| | - John W Mellors
- HIV Research Branch, Therapeutics Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pennsylvania
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15
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Meeting the WHO 90% target: antiretroviral treatment efficacy in Poland is associated with baseline clinical patient characteristics. J Int AIDS Soc 2017; 20:21847. [PMID: 28715160 PMCID: PMC5577695 DOI: 10.7448/ias.20.1.21847] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Introduction: Modern combined antiretroviral therapies (cART) allow to effectively suppress HIV-1 viral load, with the 90% virologic success rate, meeting the WHO target in most clinical settings. The aim of this study was to analyse antiretroviral treatment efficacy in Poland and to identify variables associated with virologic suppression. Methods: Cross-sectional data on 5152 (56.92% of the countrywide treated at the time-point of analysis) patients on cART for more than six months with at least one HIV-RNA measurement in 2016 were collected from 14 Polish centres. Patients’ characteristics and treatment type-based outcomes were analysed for the virologic suppression thresholds of <50 and <200 HIV-RNA copies/ml. CART was categorized into two nucleos(t)ide (2NRTI) plus non-nucleoside reverse transcriptase (NNRTI) inhibitors, 2NRTI plus protease (PI) inhibitor, 2NRTI plus integrase (InI) inhibitor, nucleos(t)ide sparing PI/r+InI and three drug class regimens. For statistics Chi-square and U-Mann Whitney tests and adjusted multivariate logistic regression models were used. Results: Virologic suppression rates of <50 copies/mL were observed in 4672 (90.68%) and <200 copies/mL in 4934 (95.77%) individuals. In univariate analyses, for the suppression threshold <50 copies/mL higher efficacy was noted for 2NRTI+NNRTI-based combinations (94.73%) compared to 2NRTI+PI (89.93%), 2NRTI+InI (90.61%), nucleos(t)ide sparing PI/r+InI (82.02%) and three drug class regimens (74.49%) (p < 0.0001), with less pronounced but significant differences for the threshold of 200 copies/mL [2NRTI+NNRTI-97.61%, 2NRTI+PI-95.27%, 2NRTI+InI-96.61%, PI/r+InI- 95.51% and 86.22% for three drug class cART) (p < 0.0001). However, in multivariate model, virologic efficacy for viral load <50 copies/mL was similar across treatment groups with significant influence by history of AIDS [OR:1.48 (95%CI:1.01–2.17) if AIDS diagnosed, p = 0.046], viral load < 5 log copies/mL at care entry [OR:1.47 (95%CI:1.08–2.01), p = 0.016], baseline lymphocyte CD4 count ≥200 cells/µL [OR:1.72 (95%CI:1.04–2.78), p = 0.034] and negative HCV serology [OR:1.97 (95%CI:1.29–2.94), p = 0.002]. For viral load threshold <200 copies/mL higher likelihood of virologic success was only associated with baseline lymphocyte CD4 count ≥200 cells/µL [OR:2.08 (95%CI:1.01–4.35), p = 0.049] and negative HCV status [OR:2.84 (95%CI:1.52–5.26), p = 0.001]. Conclusions: Proportion of virologically suppressed patients is in line with WHO treatment target confirming successful application of antiretroviral treatment strategy in Poland. Virological suppression rates depend on baseline patient characteristics, which should guide individualized antiretroviral tre0atment decisions.
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16
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Kanters S, Socias ME, Paton NI, Vitoria M, Doherty M, Ayers D, Popoff E, Chan K, Cooper DA, Wiens MO, Calmy A, Ford N, Nsanzimana S, Mills EJ. Comparative efficacy and safety of second-line antiretroviral therapy for treatment of HIV/AIDS: a systematic review and network meta-analysis. Lancet HIV 2017; 4:e433-e441. [PMID: 28784426 DOI: 10.1016/s2352-3018(17)30109-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/30/2017] [Accepted: 06/01/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Selection of optimal second-line antiretroviral therapy (ART) has important clinical and programmatic implications. To inform the 2016 revision of the WHO ART guidelines, we assessed the comparative effectiveness and safety of available second-line ART regimens for adults and adolescents in whom first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens have failed. METHODS In this systematic review and network meta-analysis, we searched for randomised controlled trials and prospective and retrospective cohort studies that evaluated outcomes in treatment-experienced adults living with HIV who switched ART regimen after failure of a WHO-recommended first-line NNRTI-based regimen. We searched Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials for reports published from Jan 1, 1996, to Aug 8, 2016, and searched conference abstracts published from Jan 1, 2014, to Aug 8, 2016. Outcomes of interest were viral suppression, mortality, AIDS-defining illnesses or WHO stage 3-4 disease, discontinuations, discontinuations due to adverse events, and serious adverse events. We assessed comparative efficacy and safety in a network meta-analysis, using Bayesian hierarchical models. FINDINGS We identified 12 papers pertaining to eight studies, including 4778 participants. The network was centred on ritonavir-boosted lopinavir plus two nucleoside or nucleotide reverse transcriptase inhibitors. Ritonavir-boosted lopinavir monotherapy was the only regimen inferior to others. With the lower estimate of the 95% credible interval (CrI) not exceeding the predefined threshold of 15%, evidence at 48 weeks supported the non-inferiority of ritonavir-boosted lopinavir plus raltegravir to regimens including ritonavir-boosted protease inhibitor plus two NRTIs with respect to viral suppression (odds ratio 1·09, 95% CrI 0·88-1·35). Estimated efficacy of ritonavir-boosted darunavir (800 mg once daily) was too imprecise to determine non-inferiority. Overall, regimens did not differ significantly with respect to continuations, AIDS-defining illnesses or WHO stage 3-4 disease, or mortality. INTERPRETATION With the exception of ritonavir-boosted lopinavir plus raltegravir, the evidence base is unable to provide strong support to alternative second-line options to ritonavir-boosted protease inhibitor plus two NRTIs, and thus more trials are warranted. FUNDING WHO.
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Affiliation(s)
- Steve Kanters
- Precision Global Health, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Maria Eugenia Socias
- Precision Global Health, Vancouver, BC, Canada; Intersdisciplinary Graduate Program, University of British Columbia, Vancouver, BC, Canada
| | - Nicholas I Paton
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Meg Doherty
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | | | - Evan Popoff
- Precision Global Health, Vancouver, BC, Canada
| | - Keith Chan
- Precision Global Health, Vancouver, BC, Canada
| | - David A Cooper
- Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Matthew O Wiens
- Precision Global Health, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alexandra Calmy
- HIV/AIDS Unit, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Nathan Ford
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | - Sabin Nsanzimana
- Institute of HIV Disease Prevention and Control, Rwanda Biomedical Centre, Kigali, Rwanda; Basel Clinical Epidemiology and Biostatistics Institute and Swiss Tropical and Public Health Institute, University of Basel, Switzerland
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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Vitoria M, Ford N, Clayden P, Pozniak AL, Hill AM. When could new antiretrovirals be recommended for national treatment programmes in low-income and middle-income countries: results of a WHO Think Tank. Curr Opin HIV AIDS 2017; 12:414-422. [PMID: 28410249 PMCID: PMC5459586 DOI: 10.1097/coh.0000000000000380] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To discuss barriers and opportunities for the introduction of new antiretrovirals into national treatment programmes in low-income and middle-income countries to support further treatment scale-up. Invitees to a WHO Think Tank in February 2017 evaluated recently published results. RECENT FINDINGS There is not sufficient clinical experience of dolutegravir (DTG), tenofovir alafenamide (TAF) or efavirenz 400 mg (EFV400) to recommend their use in pregnancy. Outcomes from births and assessment of congenital anomalies need to be evaluated from several hundred pregnant women. Clinical experience of these treatments during rifampicin-based treatment for tuberculosis is also required. This could be difficult for TAF, which is currently contraindicated with TAF. Changes in second-line treatment from two nucleoside analogues + protease inhibitor plus ritonavir will require new randomized trials of alternative combinations. CONCLUSION Additional safety and efficacy data on DTG, TAF and EFV400 in some subpopulations are needed before a large introduction in national treatment programmes. There is currently limited support for the introduction of TAF as part of first-line antiretroviral treatment in low-income and middle-income settings. There was an overall agreement for 6-monthly reviews of safety and efficacy data, in parallel with a phased introduction of the new antiretrovirals.
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Affiliation(s)
| | - Nathan Ford
- World Health Organisation, Geneva, Switzerland
| | | | - Anton L. Pozniak
- St Stephens AIDS Trust, Chelsea and Westminster Hospital, London
| | - Andrew M. Hill
- Department of Translational Medicine, University of Liverpool, Liverpool, UK
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18
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La Rosa AM, Harrison LJ, Taiwo B, Wallis CL, Zheng L, Kim P, Kumarasamy N, Hosseinipour MC, Jarocki B, Mellors JW, Collier AC. Raltegravir in second-line antiretroviral therapy in resource-limited settings (SELECT): a randomised, phase 3, non-inferiority study. Lancet HIV 2016; 3:e247-58. [PMID: 27240787 PMCID: PMC4914044 DOI: 10.1016/s2352-3018(16)30011-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 03/15/2016] [Accepted: 03/16/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND For second-line antiretroviral therapy, WHO recommends a boosted protease inhibitor plus nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs). However, concerns about toxicity and cross-resistance motivated a search for regimens that do not contain NRTIs. We aimed to assess whether boosted lopinavir plus raltegravir would be non-inferior to boosted lopinavir plus NRTIs for virological suppression in resource-limited settings. METHODS A5273 was a randomised, open-label, phase 3, non-inferiority study at 15 AIDS Clinical Trials Group (ACTG) research sites in nine resource-limited countries (three sites each in India and South Africa, two each in Malawi and Peru, and one each in Brazil, Kenya, Tanzania, Thailand, and Zimbabwe). Adults with plasma HIV-1 RNA concentrations of at least 1000 copies per mL after at least 24 weeks on a regimen based on a non-NRTI inhibitor were randomly assigned (1:1) to receive oral ritonavir-boosted lopinavir (100 mg ritonavir, 400 mg lopinavir) plus 400 mg raltegravir twice a day (raltegravir group) or to ritonavir-boosted lopinavir plus two or three NRTIs selected from an algorithm (eg, zidovudine after failure with tenofovir and vice versa; NRTI group). Randomised group assignment was done with a computer algorithm concealed to site personnel, and stratified by HIV-1 RNA viral load, CD4 cell count, and intention to use zidovudine, with the groups balanced by each site. The primary endpoint was time to confirmed virological failure (two measurements of HIV-1 RNA viral load >400 copies per mL) at or after week 24 in the intention-to-treat population. Non-inferiority (10% margin) was assessed by comparing the cumulative probability of virological failure by 48 weeks. This trial was registered with ClinicalTrials.gov, NCT01352715. FINDINGS Between March 13, 2012, and Oct 2, 2013, we randomly assigned 515 participants: 260 to the raltegravir group and 255 to the NRTI group; two participants in the raltegravir group and one in the NRTI group were excluded from analyses because of ineligibility. By the end of follow-up (October, 2014), 96 participants had virological failure (46 in the raltegravir group and 50 in the NRTI group). By 48 weeks, the cumulative probability of virological failure was 10·3% (95% CI 6·5-14·0) in the raltegravir group and 12·4% (8·3-16·5) in the NRTI group, with a weighted difference of -3·4% (-8·4 to 1·5), indicating that raltegravir was non-inferior, but not superior, to NRTIs. 62 (24%) participants in the raltegravir group and 81 (32%) in the NRTI group had grade 3 or higher adverse events; 19 (7%) and 29 (11%), respectively, had serious adverse events. Three participants in each group died, all from HIV-related causes. INTERPRETATION In settings with extensive NRTI resistance but no available resistance testing, our data support WHO's recommendation for ritonavir-boosted lopinavir plus NRTI for second-line antiretroviral therapy. Ritonavir-boosted lopinavir plus raltegravir is an appropriate alternative, especially if NRTI use is limited by toxicity. FUNDING National Institutes of Health.
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Affiliation(s)
| | | | | | | | - Lu Zheng
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Peter Kim
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | | | - Mina C Hosseinipour
- University of North Carolina, Chapel Hill, NC, USA; UNC Project, Lilongwe, Malawi
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Vitoria M, Hill AM, Ford NP, Doherty M, Khoo SH, Pozniak AL. Choice of antiretroviral drugs for continued treatment scale-up in a public health approach: what more do we need to know? J Int AIDS Soc 2016; 19:20504. [PMID: 26842728 PMCID: PMC4740352 DOI: 10.7448/ias.19.1.20504] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 12/04/2015] [Accepted: 01/12/2016] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION There have been several important developments in antiretroviral treatment in the past two years. Randomized clinical trials have been conducted to evaluate a lower dose of efavirenz (400 mg once daily). Integrase inhibitors such as dolutegravir have been approved for first-line treatment. A new formulation of tenofovir (alafenamide) has been developed and has shown equivalent efficacy to tenofovir in randomized trials. Two-drug combination treatments have been evaluated in treatment-naïve and -experienced patients. The novel pharmacokinetic booster cobicistat has been compared to ritonavir in terms of pharmacokinetics, efficacy and safety. The objective of this commentary is to assess recent developments in antiretroviral drug treatment to determine whether new treatments should be included in new international guidelines. DISCUSSION The use of first-line treatment with tenofovir and efavirenz at the standard 600 mg once-daily dose should remain the first-choice standard of care treatment. Evidence supporting a switch to efavirenz 400 mg once daily or integrase inhibitors is sufficient to consider these drugs as alternative first-line options, but more data are needed on their use in pregnant women and people with TB co-infection. The use of new formulations of tenofovir is currently too preliminary to justify immediate adoption and scale-up across HIV programmes in low- and middle-income countries. The evidence supporting use of two-drug combinations is not considered strong enough to justify changed recommendations from use of standard triple drug combinations. Cobicistat does not offer significant safety advantages over ritonavir as a pharmacokinetic booster. CONCLUSIONS For continued scale-up of antiretroviral treatment in low- and middle-income countries, use of first-line triple combinations including efavirenz 600 mg once daily is supported by the largest evidence base. Additional studies are underway to evaluate new treatments in key populations, and these results may justify changes to these recommendations.
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Affiliation(s)
- Marco Vitoria
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland;
| | - Andrew M Hill
- Department of Pharmacology and Therapeutics, Liverpool University, Liverpool, UK
| | - Nathan P Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Meg Doherty
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Saye H Khoo
- Department of Pharmacology and Therapeutics, Liverpool University, Liverpool, UK
| | - Anton L Pozniak
- St Stephens AIDS Trust, Chelsea and Westminster Hospital, London, UK
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Amin J, Boyd MA, Kumarasamy N, Moore CL, Losso MH, Nwizu CA, Mohapi L, Kerr SJ, Sohn AH, Teppler H, Renjifo B, Molina JM, Emery S, Cooper DA. Correction: Raltegravir Non-Inferior to Nucleoside Based Regimens in SECOND-LINE Therapy with Lopinavir/Ritonavir over 96 Weeks: A Randomised Open Label Study for the Treatment Of HIV-1 Infection. PLoS One 2015; 10:e0140623. [PMID: 26451848 PMCID: PMC4599832 DOI: 10.1371/journal.pone.0140623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Park TE, Mohamed A, Kalabalik J, Sharma R. Review of integrase strand transfer inhibitors for the treatment of human immunodeficiency virus infection. Expert Rev Anti Infect Ther 2015; 13:1195-212. [PMID: 26293294 DOI: 10.1586/14787210.2015.1075393] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Integrase strand transfer inhibitors (INSTIs) are oral antiretroviral agents used against HIV infection. There are three agents available, including raltegravir, elvitegravir and dolutegravir, some of which are available as combination medications with other antiretroviral drugs. The efficacy and safety of INSTIs in treatment-naïve and experienced HIV-infected patients have been established by multiple studies. Based on the current practice guidelines, INSTI-based regimens are considered as one of the first-line therapies for treatment-naïve HIV-infected patients. There are new INSTIs in development to improve the resistance profile and to decrease the frequency of drug administration.
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Affiliation(s)
- Tae Eun Park
- a 1 Fairleigh Dickinson University, School of Pharmacy, 230 Park Avenue, M-SP1-01, Florham Park, NJ 07901, USA
| | - Abdilahi Mohamed
- a 1 Fairleigh Dickinson University, School of Pharmacy, 230 Park Avenue, M-SP1-01, Florham Park, NJ 07901, USA
| | - Julie Kalabalik
- a 1 Fairleigh Dickinson University, School of Pharmacy, 230 Park Avenue, M-SP1-01, Florham Park, NJ 07901, USA
| | - Roopali Sharma
- b 2 Long Island University Arnold & Marie Schwartz College of Pharmacy and Health Sciences, 450 Clarkson Avenue Box 36, Brooklyn, NY 11203, USA
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