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Mpofu R, Kawuma AN, Wasmann RE, Akpomiemie G, Chandiwana N, Sokhela SM, Moorhouse M, Venter WDF, Denti P, Wiesner L, Post FA, Haas DW, Maartens G, Sinxadi P. Determinants of early change in serum creatinine after initiation of dolutegravir-based antiretroviral therapy in South Africa. Br J Clin Pharmacol 2024; 90:1247-1257. [PMID: 38332460 DOI: 10.1111/bcp.16009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 02/10/2024] Open
Abstract
AIMS Dolutegravir increases serum creatinine by inhibiting its renal tubular secretion and elimination. We investigated determinants of early changes in serum creatinine in a southern African cohort starting first-line dolutegravir-based antiretroviral therapy (ART). METHODS We conducted a secondary analysis of data from participants in a randomized controlled trial of dolutegravir, emtricitabine and tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide fumarate (TAF) (ADVANCE, NCT03122262). We assessed clinical, pharmacokinetic and genetic factors associated with change in serum creatinine from baseline to Week 4 using linear regression models adjusted for age, sex, baseline serum creatinine, HIV-1 RNA concentration, CD4 T-cell count, total body weight and co-trimoxazole use. RESULTS We included 689 participants, of whom 470 had pharmacokinetic data and 315 had genetic data. Mean change in serum creatinine was 11.3 (SD 9.9) μmol.L-1. Factors that were positively associated with change in serum creatinine at Week 4 were increased log dolutegravir area under the 24-h concentration-time curve (change in creatinine coefficient [β] = 2.78 μmol.L-1 [95% confidence interval (CI) 0.54, 5.01]), TDF use (β = 2.30 [0.53, 4.06]), male sex (β = 5.20 [2.92, 7.48]), baseline serum creatinine (β = -0.22 [-0.31, -0.12]) and UGT1A1 rs929596 A→G polymorphism with a dominant model (β = -2.33 [-4.49, -0.17]). The latter did not withstand correction for multiple testing. CONCLUSIONS Multiple clinical and pharmacokinetic factors were associated with early change in serum creatinine in individuals initiating dolutegravir-based ART. UGT1A1 polymorphisms may play a role, but further research on genetic determinants is needed.
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Affiliation(s)
- Rephaim Mpofu
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Aida N Kawuma
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Roeland E Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Godspower Akpomiemie
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nomathemba Chandiwana
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Simiso Mandisa Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michelle Moorhouse
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Frank A Post
- King's College Hospital NHS Foundation Trust, London, UK
| | - David W Haas
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Internal Medicine, Meharry Medical College, Nashville, Tennessee, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- SAMRC/UCT Platform for Pharmacogenomics Research and Translation (PREMED) unit, Cape Town, South Africa
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Sokhela S, Venter WDF, Bosch B, Woods J, McCann K, Akpomiemie G, Chandiwana N, Mashabane N, Tembo A, Simmons B, Lalla-Edward S, Siedner MJ, Sinxadi P, Hermans L, Fairlie L, Vos A, Abrams E, Manne-Goehler JM, Moorhouse M, Clayden P, Norris S, Qavi A, Chersich M, Masenya M, Arulappan N, Hill A. Final 192-Week Efficacy and Safety Results of the ADVANCE Trial, Comparing 3 First-line Antiretroviral Regimens. Open Forum Infect Dis 2024; 11:ofae007. [PMID: 38529213 PMCID: PMC10962246 DOI: 10.1093/ofid/ofae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/23/2024] [Indexed: 03/27/2024] Open
Abstract
Background ADVANCE compared 3 World Health Organization-recommended first-line regimens in participants with HIV who were antiretroviral naive. Methods This randomized, open-label, noninferiority trial enrolled participants living with HIV with no antiretroviral exposure in the previous 6 months to 1 of the following arms: tenofovir alafenamide (TAF) / emtricitabine (FTC) + dolutegravir (DTG) (2 tablets), tenofovir disoproxil fumarate (TDF) / FTC + DTG (2 tablets), or a fixed-dose combination of TDF / FTC / efavirenz (EFV) (1 tablet). We report the final safety and efficacy data up to 192 weeks. Results Repeat consent from the original 351 participants randomized to each arm was obtained from 230 participants (66%) in the TAF/FTC + DTG arm, 209 (60%) in the TDF/FTC + DTG arm, and 183 (52%) in the TDF/FTC/EFV arm. At 192 weeks, 213 (61%) of the original 351 participants in the TAF/FTC + DTG arm, 195 (56%) in the TDF/FTC + DTG arm, and 172 (49%) in the TDF/FTC/EFV arm had confirmed RNA <50 copies/mL, with low virologic failure in all groups and no significant integrase inhibitor mutations in any arm. Mean weight gain was 8.9 kg (SD, 7.1) in the TAF/FTC + DTG arm, 5.9 kg (SD, 7.1) in the TDF/FTC + DTG arm, and 3.2 kg (SD, 8.1) in the TDF/FTC/EFV arm at 192 weeks from baseline and was greatest among women, those taking TAF, and those with lower baseline CD4 counts. The weight trajectory slowed after week 96. There were few clinical events and minor laboratory changes and differences among arms after 96 weeks. There were no significant differences in treatment-emergent hypertension or pregnancy outcomes by arm. Conclusions High viral suppression was seen across arms, with no resistance to DTG. Weight gain continued but slowed after 96 weeks, with few clinical events or laboratory changes.
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Affiliation(s)
- Simiso Sokhela
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Willem D F Venter
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bronwyn Bosch
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joana Woods
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kaitlyn McCann
- School of Public Health, Imperial College London, London, UK
| | - Godspower Akpomiemie
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nomathemba Chandiwana
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nkuli Mashabane
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Angela Tembo
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bryony Simmons
- LSE Health, London School of Economics and Political Science, Imperial College London, London, UK
| | - Samanta Lalla-Edward
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark J Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Harvard Medical School, Boston, Massachusetts, USA
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- SAMRC/UCT Platform for Pharmacogenomics Research and Translation, South African Medical Research Council, Cape Town, South Africa
| | - Lucas Hermans
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lee Fairlie
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alinda Vos
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Elaine Abrams
- Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, ICAP at Columbia University, Columbia University, New York, New York, USA
| | - Jennifer M Manne-Goehler
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Shane Norris
- South African Medical Research Council, Developmental Pathways for Health Research Unit, Department of Pediatrics, University of the Witwatersrand, Johannesburg, South Africa
| | - Ambar Qavi
- School of Public Health, Imperial College London, London, UK
| | - Matthew Chersich
- Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Masebole Masenya
- Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Natasha Arulappan
- Wits Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Hill
- Department of Translational Medicine, Liverpool University, Liverpool, UK
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Tovar Sanchez T, Mpoudi-Etame M, Kouanfack C, Delaporte E, Calmy A, Venter F, Sokhela S, Bosch B, Akpomiemie G, Tembo A, Pepperrell T, Simmons B, Casas CP, McCann K, Mirchandani M, Hill A. Risks of metabolic syndrome in the ADVANCE and NAMSAL trials. Front Reprod Health 2023; 5:1133556. [PMID: 37791109 PMCID: PMC10544962 DOI: 10.3389/frph.2023.1133556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 09/01/2023] [Indexed: 10/05/2023] Open
Abstract
Introduction The ADVANCE and NAMSAL trials evaluating antiretroviral drugs have both reported substantial levels of clinical obesity in participants. As one of the main risk factors for metabolic syndrome, growing rates of obesity may drive metabolic syndrome development. This study aims to evaluate the risk of metabolic syndrome in the ADVANCE and NAMSAL trials. Methods The number of participants with metabolic syndrome was calculated at baseline and week 192 as central obesity and any of the following two factors: raised triglycerides, reduced HDL-cholesterol, raised blood pressure and raised fasting glucose. Differences between the treatment arms were calculated using the χ2 test. Results Across all visits to week 192, treatment-emergent metabolic syndrome was 15% (TAF/FTC + DTG), 10% (TDF/FTC + DTG) and 7% (TDF/FTC/EFV) in ADVANCE. The results were significantly higher in the TAF/FTC + DTG arm compared to the TDF/FTC/EFV arm (p < 0.001), and the TDF/FTC + DTG vs. the TDF/FTC/EFV arms (p < 0.05) in all patients, and in females. In NAMSAL, the incidence of treatment-emergent metabolic syndrome at any time point was 14% (TDF/3TC + DTG) and 5% (TDF/3TC + EFV) (p < 0.001). This incidence was significantly greater in the TDF/3TC/DTG arm compared to the TDF/3TC/EFV arm in all patients (p < 0.001), and in males (p < 0.001). Conclusion In this analysis, we highlight treatment-emergent metabolic syndrome associated with dolutegravir, likely driven by obesity. Clinicians initiating or monitoring patients on INSTI-based ART must counsel for lifestyle optimisation to prevent these effects.
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Affiliation(s)
| | | | - Charles Kouanfack
- Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
- Day Stay Hospital, Central Hospital of Yaoundé, Henri-Dunant, Yaoundé, Cameroon
- ANRS Cameroon Site, Central Hospital of Yaoundé, Henri-Dunant, Yaoundé, Cameroon
| | - Eric Delaporte
- TransVIHMI, University of Montpellier, IRD, INSERMI, Montpellier, France
| | - Alexandra Calmy
- Division of Infectious Diseases, HIV-AIDS Unit, Genva University Hospitals, Geneva, Switzerland
| | - Francois Venter
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Simiso Sokhela
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bronwyn Bosch
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Godspower Akpomiemie
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Angela Tembo
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Toby Pepperrell
- School of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Bryony Simmons
- London School of Economics and Political Science, LSE Health, London, United Kingdom
| | | | - Kaitlyn McCann
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Manya Mirchandani
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Andrew Hill
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
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Sokhela S, Bosch B, Hill A, Simmons B, Woods J, Johnstone H, Madhi S, Qavi A, Ellis L, Akpomiemie G, Bhaskar E, Levi J, Falconer J, Mirchandani M, Perez Casas C, Moller K, Pilkington V, Pepperrell T, Venter WDF. Comparing Prospective Incident Severe Acute Respiratory Syndrome Coronavirus 2 Infection Rates During Successive Waves of Delta and Omicron in Johannesburg, South Africa. Open Forum Infect Dis 2022; 9:ofac587. [PMID: 36540387 PMCID: PMC9757672 DOI: 10.1093/ofid/ofac587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/31/2022] [Indexed: 12/23/2022] Open
Abstract
In high-risk individuals in Johannesburg, during the Delta coronavirus disease 2019 wave, 22% (125/561) were positive, with 33% symptomatic (2 hospitalizations; 1 death). During Omicron, 56% (232/411) were infected, with 24% symptomatic (no hospitalizations or deaths). The remarkable speed of infection of Omicron over Delta poses challenges to conventional severe acute respiratory syndrome coronavirus 2 control measures.
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Affiliation(s)
- Simiso Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bronwyn Bosch
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Hill
- Department of Pharmacology and Therapeutics, Liverpool University, Liverpool, United Kingdom
| | - Bryony Simmons
- LSE Health, London School of Economics and Political Science, London, United Kingdom
| | - Joana Woods
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Shabir Madhi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,South Africa and African Leadership in Vaccinology Expertise, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ambar Qavi
- School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Leah Ellis
- School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Godspower Akpomiemie
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Esther Bhaskar
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jacob Levi
- Department of Intensive Care Medicine, Royal Free Hospital NHS Trust, London, United Kingdom
| | - Jonathan Falconer
- Respiratory Department, Royal Brompton Hospital NHS Trust, London, United Kingdom
| | - Manya Mirchandani
- School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | | | - Karlien Moller
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Toby Pepperrell
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Willem Daniel Francois Venter
- Correspondence: Willem D. Francois Venter, FCP, Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terr., Johannesburg, 2193, South Africa ()
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Bosch B, Akpomiemie G, Chandiwana N, Sokhela S, Hill A, McCann K, Qavi A, Mirchandani M, Venter WDF. Weight and metabolic changes after switching from tenofovir alafenamide (TAF)/emtricitabine (FTC)+dolutegravir (DTG), tenofovir disoproxil fumarate (TDF)/FTC+DTG and TDF/FTC/efavirenz (EFV) to TDF/lamivudine (3TC)/DTG. Clin Infect Dis 2022; 76:1492-1495. [PMID: 36519389 DOI: 10.1093/cid/ciac949] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/01/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Abstract
Participants randomised to first-line tenofovir alafenamide (TAF)/emtricitabine (FTC)+dolutegravir (DTG), tenofovir disoproxil fumarate (TDF)/FTC+DTG or TDF/FTC/efavirenz (EFV) for 192 weeks were then switched to TDF/lamivudine (3TC)/DTG for 52 weeks. Participants switching either TAF/FTC+DTG or TDF/FTC/EFV to TDF/3TC/DTG showed statistically significant reductions in weight, low density lipoprotein, triglycerides, glucose and glycated haemoglobin.
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Affiliation(s)
- Bronwyn Bosch
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg , South Africa
| | - Godspower Akpomiemie
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg , South Africa
| | - Nomathemba Chandiwana
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg , South Africa
| | - Simiso Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand , Johannesburg , South Africa
| | - Andrew Hill
- Department of Pharmacology and Therapeutics, University of Liverpool , United Kingdom
| | | | - Ambar Qavi
- Faculty of Medicine, Imperial College , London , UK
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Griesel R, Sinxadi P, Kawuma A, Joska J, Sokhela S, Akpomiemie G, Venter F, Denti P, Haas DW, Maartens G. Pharmacokinetic and pharmacogenetic associations with dolutegravir neuropsychiatric adverse events in an African population. J Antimicrob Chemother 2022; 77:3110-3117. [PMID: 36031789 PMCID: PMC7613765 DOI: 10.1093/jac/dkac290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/04/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Dolutegravir has been associated with neuropsychiatric adverse events (NPAEs), but relationships between dolutegravir concentrations and NPAEs are unclear. OBJECTIVES To determine in an African population whether a concentration-response relationship exists between dolutegravir and treatment-emergent NPAEs, and whether selected loss-of-function polymorphisms in genes encoding UDP-glucuronosyltransferase-1A1 (the major metabolizing enzyme for dolutegravir) and organic cation transporter-2 (involved in neurotransmitter transport and inhibited by dolutegravir) are associated with NPAEs. METHODS Antiretroviral therapy-naive participants randomized to dolutegravir-based therapy in the ADVANCE study were enrolled into a pharmacokinetic sub-study. Primary outcome was change in mental health screening [modified mini screen (MMS)] and sleep quality from baseline to weeks 4, 12 and 24. Dolutegravir exposure was estimated using a population pharmacokinetic model. Polymorphisms analysed were UGT1A1 rs887829 and SLC22A2 rs316019. RESULTS Data from 464 participants were available for pharmacokinetic analyses and 301 for genetic analyses. By multivariable linear regression, higher dolutegravir exposure was associated with worsening sleep quality only at week 12 [coefficient = -0.854 (95% CI -1.703 to -0.005), P = 0.049], but with improved MMS score at weeks 12 and 24 [coefficient = -1.255 (95% CI -2.250 to -0.261), P = 0.013 and coefficient = -1.199 (95% CI -2.030 to -0.368), P = 0.005, respectively]. The UGT1A1 and SLC22A2 polymorphisms were not associated with change in MMS score or sleep quality. CONCLUSIONS Only at week 12 did we find evidence of a relationship between dolutegravir exposure and worsening sleep quality. However, higher dolutegravir exposure was associated with improved MMS scores, suggesting a possible beneficial effect.
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Affiliation(s)
- Rulan Griesel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Aida Kawuma
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - John Joska
- HIV Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Simiso Sokhela
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Godspower Akpomiemie
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francois Venter
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - David W Haas
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Internal Medicine, Meharry Medical College, Nashville, TN, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Sokhela S, Bosch B, Hill A, Simmons B, Woods J, Johnstone H, Akpomiemie G, Ellis L, Owen A, Casas CP, Venter WDF. Randomized clinical trial of nitazoxanide or sofosbuvir/daclatasvir for the prevention of SARS-CoV-2 infection. J Antimicrob Chemother 2022; 77:2706-2712. [PMID: 35953881 PMCID: PMC9384711 DOI: 10.1093/jac/dkac266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The COVER trial evaluated whether nitazoxanide or sofosbuvir/daclatasvir could lower the risk of SARS-CoV-2 infection. Nitazoxanide was selected given its favourable pharmacokinetics and in vitro antiviral effects against SARS-CoV-2. Sofosbuvir/daclatasvir had shown favourable results in early clinical trials. METHODS In this clinical trial in Johannesburg, South Africa, healthcare workers and others at high risk of infection were randomized to 24 weeks of either nitazoxanide or sofosbuvir/daclatasvir as prevention, or standard prevention advice only. Participants were evaluated every 4 weeks for COVID-19 symptoms and had antibody and PCR testing. The primary endpoint was positive SARS-CoV-2 PCR and/or serology ≥7 days after randomization, regardless of symptoms. A Poisson regression model was used to estimate the incidence rate ratios of confirmed SARS-CoV-2 between each experimental arm and control. RESULTS Between December 2020 and January 2022, 828 participants were enrolled. COVID-19 infections were confirmed in 100 participants on nitazoxanide (2234 per 1000 person-years; 95% CI 1837-2718), 87 on sofosbuvir/daclatasvir (2125 per 1000 person-years; 95% CI 1722-2622) and 111 in the control arm (1849 per 1000 person-years; 95% CI 1535-2227). There were no significant differences in the primary endpoint between the treatment arms, and the results met the criteria for futility. In the safety analysis, the frequency of grade 3 or 4 adverse events was low and similar across arms. CONCLUSIONS In this randomized trial, nitazoxanide and sofosbuvir/daclatasvir had no significant preventative effect on infection with SARS-CoV-2 among healthcare workers and others at high risk of infection.
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Affiliation(s)
- Simiso Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bronwyn Bosch
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Hill
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Bryony Simmons
- LSE Health, London School of Economics & Political Science, London, UK
| | - Joana Woods
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Godspower Akpomiemie
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Leah Ellis
- Imperial College London, School of Public Health, London, UK
| | - Andrew Owen
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Carmen Perez Casas
- Unitaid, Global Health Campus, Chem. du Pommier 40, 1218 Le Grand-Saconnex, Switzerland
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8
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Mokgethi NO, Christofides N, Machisa M, Akpomiemie G, Lalla-Edward S. Quality of life and associated factors among people receiving second-line anti-retroviral therapy in Johannesburg, South Africa. BMC Infect Dis 2022; 22:456. [PMID: 35550020 PMCID: PMC9103409 DOI: 10.1186/s12879-022-07429-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 04/22/2022] [Indexed: 12/02/2022] Open
Abstract
Background Studies which examine quality of life (QOL) provide important insights that are needed to understand the impacts of HIV/AIDS anti-retroviral treatment (ART), comorbid conditions and other factors on the daily activities of people living with HIV/AIDS (PLH). This study aimed to determine the inter-relationships between clinical factors, behavioural, socio-demographic variables and QOL among PLH. Methods The secondary analysis used data collected from 293 people living with HIV/AIDS (PLH) receiving second-line ART in Johannesburg in a clinical trial which evaluated the non-inferiority of ritonavir-boosted darunavir (DRV/r 400/100 mg) compared to ritonavir-boosted lopinavir (LPV/r) over a 48 week-period. Physical functioning, cognitive and mental QOL were measured using the Aids Clinical Trial Group questionnaire. Exploratory factor analyses were used to examine the structure, the relationships between and the construct validity of QOL items. Structural equation models which tested the a priori-hypothesised inter-relationships between QOL and other variables were estimated and goodness of fit of the models to the data was assessed. Results Patients on darunavir presented with lower pill burden. Older patients and women were more likely to report lower QOL scores. Pill burden mediated the effects of age, sex and treatment regimen on physical functioning QOL and adverse effects; the effects of age, sex, treatment regimen and adverse effects on cognitive QOL; and the effects of sex on mental QOL. Conclusion QOL among PLH is associated with socio-demographic and clinical factors. Therefore, QOL could be enhanced by considering PLH characteristics, clinical factors such as regimen side-effects profile, management of comorbid conditions and mitigating risks such as potential adverse drug-to-drug interactions among patients on ART. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07429-9.
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Affiliation(s)
- Nomcebo Oratile Mokgethi
- Epidemiology and Biostatistics, WHO, Bloemfontein, Free State, South Africa. .,School of Public Health, Wits University, Johannesburg, South Africa. .,Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | | | - Mercilene Machisa
- School of Public Health, Wits University, Johannesburg, South Africa.,Gender and Health Research Unit, South African Medical Research Council, Pretoria, South Africa
| | - Godspower Akpomiemie
- School of Public Health, Wits University, Johannesburg, South Africa.,Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Samantha Lalla-Edward
- School of Public Health, Wits University, Johannesburg, South Africa.,Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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9
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Griesel R, Maartens G, Chirehwa M, Sokhela S, Akpomiemie G, Moorhouse M, Venter F, Sinxadi P. Corrigendum to: CYP2B6 Genotype and Weight Gain Differences Between Dolutegravir and Efavirenz. Clin Infect Dis 2022; 74:755. [PMID: 35099526 DOI: 10.1093/cid/ciab804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Rulan Griesel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Simiso Sokhela
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Godspower Akpomiemie
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michelle Moorhouse
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francois Venter
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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10
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Griesel R, Kawuma AN, Wasmann R, Sokhela S, Akpomiemie G, Venter WDF, Wiesner L, Denti P, Sinxadi P, Maartens G. CONCENTRATION-RESPONSE RELATIONSHIPS OF DOLUTEGRAVIR AND EFAVIRENZ WITH WEIGHT CHANGE AFTER STARTING ANTIRETROVIRAL THERAPY. Br J Clin Pharmacol 2021; 88:883-893. [PMID: 34954840 PMCID: PMC7612404 DOI: 10.1111/bcp.15177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/28/2021] [Accepted: 12/01/2021] [Indexed: 12/03/2022] Open
Abstract
Aim Dolutegravir is associated with more weight gain than efavirenz in people starting antiretroviral therapy (ART). We investigated the concentration-response relationships of efavirenz and dolutegravir with weight gain. Methods We determined concentration-response relationships of dolutegravir and efavirenz (both combined with tenofovir disoproxil fumarate and emtricitabine) with changes in weight and fat distribution, derived from dual-energy x-ray absorptiometry scans, in a nested study of ART-naïve participants from a randomised controlled trial. Pharmacokinetic parameters used in analyses were efavirenz mid-dosing interval (MDI) concentrations and estimated dolutegravir area under the concentration-time curve (AUC0-24) using a population pharmacokinetic model developed in the study population. Study outcomes were percentage changes from baseline to week 48 in weight, and visceral and subcutaneous adipose tissue (VAT and SAT) mass. Results Pharmacokinetic data were available for 158 and 233 participants in the efavirenz arm and dolutegravir arms respectively; 57.0% were women. On multivariable linear regression there were independent negative associations between efavirenz concentrations and changes in both weight (P <0.001) and SAT mass (P = 0.002). Estimated dolutegravir AUC0-24 was not associated with change in weight (P = 0.109) but was negatively associated with change in VAT mass (P = 0.025). Conclusion We found an independent negative concentration-response relationship between efavirenz concentrations and weight change in ART-naïve participants. Dolutegravir concentrations were not independently associated with weight change. These findings suggest that weight gain differences between efavirenz and dolutegravir are driven by efavirenz toxicity impairing weight gain rather than by off-target effects of dolutegravir causing weight gain.
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Affiliation(s)
- Rulan Griesel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Aida N Kawuma
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Roeland Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Simiso Sokhela
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Godspower Akpomiemie
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - W D Francois Venter
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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11
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Jamieson L, Serenata C, Makhubele L, Sokhela S, Mashabane N, Akpomiemie G, Johnson LF, Venter WDF, Meyer-Rath G. Cost and cost-effectiveness of dolutegravir-based antiretroviral regimens: an economic evaluation of a clinical trial. AIDS 2021; 35:S173-S182. [PMID: 34848584 DOI: 10.1097/qad.0000000000003068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND HIV programmes world-wide currently make decisions regarding new antiretroviral therapy (ART) regimens with less side-effects and higher resistance barriers, which may improve adherence and viral suppression. Economic evaluation helps inform these decisions. METHODS We conducted an economic evaluation of three ART regimens included in the ADVANCE trial from the provider's perspective: tenofovir alafenamide (TAF)/emtricitabine (FTC)+dolutegravir (DTG) and tenofovir disoproxil fumarate (TDF)/FTC+DTG, compared with TDF/FTC/efavirenz (EFV). We used top-down and bottom-up cost analysis with resource utilization based on trial data and adjusted to emulate routine care. We estimated the cost-effectiveness of each regimen as cost per person virally suppressed or retained and per life-year saved, at 48 and 96 weeks. RESULTS Though the DTG-based trial arms were 2% more costly than TDF/FTC/EFV, both had slightly lower cost-per-outcome ($9783 and $9929/patient virally suppressed for TDF/FTC+DTG and TAF/FTC+DTG, respectively) than TDF/FTC/EFV ($10 365). The trial cost per additional virally suppressed patient, compared with TDF/FTC/EFV, was lower in the TDF/FTC+DTG arm ($2967) compared with TAF/FTC+DTG ($3430). In routine care, cost per virally suppressed patient was estimated as similar between TDF/FTC+DTG ($426) and TDF/FTC/EFV ($424) but more costly under TAF/FTC+DTG. Similar results were seen in the cost per additional person retained across scenarios. When modelled over 20 years, TDF/FTC+DTG was more cost-effective than TAF/FTC+DTG ($10 341 vs $41 958/life-year saved). CONCLUSION TDF/FTC+DTG had similar costs per outcome as TDF/FTC/EFV in the routine care scenario but TDF/FTC+DTG was more cost-effective when modelled over 20 years.
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Affiliation(s)
- Lise Jamieson
- Health Economics and Epidemiology Research Office (HE RO), Department of Internal Medicine, School of Clinical Medicine
| | - Celicia Serenata
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Lebogang Makhubele
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Simiso Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Nkuli Mashabane
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Godspower Akpomiemie
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Leigh F Johnson
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Willem D F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE RO), Department of Internal Medicine, School of Clinical Medicine
- School of Public Health, Boston University, Boston, MA, USA
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12
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Griesel R, Maartens G, Chirehwa M, Sokhela S, Akpomiemie G, Moorhouse M, Venter F, Sinxadi P. CYP2B6 Genotype and Weight Gain Differences Between Dolutegravir and Efavirenz. Clin Infect Dis 2021; 73:e3902-e3909. [PMID: 32960272 PMCID: PMC8653639 DOI: 10.1093/cid/ciaa1073] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/25/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Dolutegravir is associated with more weight gain than efavirenz. Loss-of-function polymorphisms in CYP2B6 result in higher efavirenz concentrations, which we hypothesized would impair weight gain among people living with human immunodeficiency virus (HIV; PLWH) starting efavirenz-based antiretroviral therapy (ART). METHODS We studied ART-naive participants from the ADVANCE study randomized to the efavirenz /emtricitabine/tenofovir disoproxil fumarate (TDF) and dolutegravir/emtricitabine/TDF arms. We compared changes in weight and regional fat on DXA from baseline to week 48 between CYP2B6 metabolizer genotypes in the efavirenz arm, and with the dolutegravir arm. RESULTS There were 342 participants in the dolutegravir arm and 168 in the efavirenz arm who consented to genotyping. Baseline characteristics were similar. Weight gain was greater in women than men. In the efavirenz arm CYP2B6 metaboliser genotype was associated with weight gain (P = .009), with extensive metabolizers gaining the most weight, and with changes in regional fat in women, but not in men. Weight gain was similar in CYP2B6 extensive metabolizers in the efavirenz arm and in the dolutegravir arm (P = .836). The following variables were independently associated with weight gain in all participants: baseline CD4 count, baseline human immunodeficiency virus type 1 (HIV-1) RNA, and CYP2B6 metaboliser genotype. CONCLUSIONS CYP2B6 metaboliser genotype was associated with weight gain in PLWH starting efavirenz-based ART. Weight gain was similar between CYP2B6 extensive metabolizers in the efavirenz arm and in the dolutegravir arm, suggesting that impaired weight gain among CYP2B6 slow or intermediate metabolizers could explain the increased weight gain on dolutegravir compared with efavirenz observed in ADVANCE and other studies.
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Affiliation(s)
- Rulan Griesel
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Maxwell Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Simiso Sokhela
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Godspower Akpomiemie
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michelle Moorhouse
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francois Venter
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Phumla Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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13
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Chandiwana NC, Chersich M, Venter WF, Akpomiemie G, Hill A, Simmons B, Lockman S, Serenata CM, Fairlie L, Moorhouse MA. Unexpected interactions between dolutegravir and folate: randomized trial evidence from South Africa. AIDS 2021; 35:205-211. [PMID: 33086234 PMCID: PMC7810415 DOI: 10.1097/qad.0000000000002741] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 07/03/2020] [Accepted: 07/07/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Dolutegravir exposure at conception was associated with a preliminary signal of increased infant neural tube defect risk. As low maternal folate levels are linked with neural tube defects, we aimed to assess serum folate concentrations in women starting dolutegravir. DESIGN We analysed serum folate concentrations from stored plasma among women enrolled in the South African ADVANCE trial. METHODS We compared changes in mean serum folate and occurrence of low serum folate (<14.0 nmol/l) at weeks 0, 12 and 24 across study arms. In ADVANCE, 1053 treatment-naïve participants were randomized to initiate tenofovir-alafenamide/emtricitabine + dolutegravir (TAF/FTC + DTG), tenofovir-disoproxil-fumarate (TDF)/FTC + DTG or TDF/FTC/efavirenz (EFV). RESULTS Analysis includes 406 females, mean age 31.5 years and baseline CD4+ cell count 356 cells/μl. At baseline, folate concentrations were similar across treatment arms. However, serum folate increased over 12 weeks in the TAF/FTC + DTG arm (+4.0 ± 8.1 nmol/l), while folate concentrations decreased slightly in the TDF/FTC + DTG arm (-1.8 ± 8.9 nmol/l) and decreased in the TDF/FTC/EFV arm (-5.9 ± 8.1 nmol/l). Women taking TDF/FTC/EFV had low folate concentrations at both 12 and 24 weeks compared with the other arms (P < 0.001). Of 26 women who became pregnant on study before week 24, folate concentrations increased between baseline and 12 weeks by a mean 2.4 ± 7.1 nmol/l in the TAF/FTC + DTG arm and 2.3 ± 8.4 nmol/l in the TDF/FTC + DTG arm, but decreased by -3.3 ± 8.1 with TDF/FTC/EFV arm. CONCLUSION Unexpectedly, no declines were noted in the dolutegravir-containing arms, and concentrations were considerably higher than in the EFV arm. The possibility that dolutegravir may block cellular uptake of folate warrants investigation.
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Affiliation(s)
| | - Matthew Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Andrew Hill
- Department of Translational Medicine, Liverpool University, Liverpool
| | - Bryony Simmons
- Department of Infectious Disease, Imperial College London, London, UK
| | - Shahin Lockman
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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14
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Venter WDF, Sokhela S, Simmons B, Moorhouse M, Fairlie L, Mashabane N, Serenata C, Akpomiemie G, Masenya M, Qavi A, Chandiwana N, McCann K, Norris S, Chersich M, Maartens G, Lalla-Edward S, Vos A, Clayden P, Abrams E, Arulappan N, Hill A. Dolutegravir with emtricitabine and tenofovir alafenamide or tenofovir disoproxil fumarate versus efavirenz, emtricitabine, and tenofovir disoproxil fumarate for initial treatment of HIV-1 infection (ADVANCE): week 96 results from a randomised, phase 3, non-inferiority trial. Lancet HIV 2020; 7:e666-e676. [PMID: 33010240 DOI: 10.1016/s2352-3018(20)30241-1] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/14/2020] [Accepted: 07/27/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND ADVANCE compared the efficacy and safety of two antiretroviral first-line combinations (dolutegravir combined with emtricitabine and either tenofovir disoproxil fumarate or tenofovir alafenamide), with a third regimen (efavirenz combined with emtricitabine and tenofovir disoproxil fumarate) previously recommended by WHO. Here, we report the 96-week data for the study. METHODS This randomised, open-label, non-inferiority phase 3 trial, was done at two research sites in Johannesburg, South Africa, after participant recruitment from 11 public health clinics also in Johannesburg. Eligible participants were aged 12 years or older with HIV-1 infection, who weighed at least 40 kg, had no antiretroviral exposure in the previous 6 months, with a creatinine clearance of more than 60 mL/min (>80 mL per min in individuals aged <19 years), and a plasma HIV-1 RNA concentration of 500 copies per mL or higher. Individuals who were pregnant or had tuberculosis were excluded. Participants were randomly assigned (1:1:1) by study staff using a computerised randomisation system. Randomisation was stratified by age (12 and <19 years and ≥19 years). Participants were randomly assigned to once-daily oral fixed-dose combination tenofovir alafenamide 25 mg and emtricitabine 200 mg, and once-daily oral dolutegravir 50 mg; once-daily oral fixed-dose combination tenofovir disoproxil fumarate 300 mg and emtricitabine 200 mg, and once-daily oral dolutegravir 50 mg; or once-daily oral fixed-dose combination of tenofovir disoproxil fumarate 300 mg, emtricitabine 200 mg, and efavirenz 600 mg. The primary efficacy endpoint was the proportion of participants who had a plasma HIV-1 RNA concentration of less than 50 copies per mL at week 48, which has been reported previously. Here, we report the key secondary efficacy endpoint of the proportion of participants who had a plasma HIV-1 RNA concentration of less than 50 copies per mL at the week 96 visit, assessed in all participants who received at least one dose of any study drug, with a prespecified non-inferiority margin of -10%. Safety data, including clinical, dual-energy X-ray absorptiometry and laboratory data, are also reported. This study was registered with ClinicalTrials.gov, NCT03122262. FINDINGS Between Jan 17, 2017, and May 14, 2018, we screened 1453 individuals, of whom 1053 were enrolled: 351 participants were randomly assigned to the tenofovir alafenamide, emtricitabine, and dolutegravir group, 351 to the tenofovir disoproxil fumarate, emtricitabine, and dolutegravir group, and 351 to the tenofovir disoproxil fumarate, emtricitabine, and efavirenz group. All participants received at least one dose of study medication and were included in the primary analysis. At week 96, 276 (79%) of 351 participants in the tenofovir alafenamide, emtricitabine, and dolutegravir group, 275 (78%) of 351 participants in the tenofovir disoproxil fumarate, emtricitabine, and dolutegravir group, and 258 (74%) of 351 participants in the tenofovir disoproxil fumarate, emtricitabine, and efavirenz group had achieved a plasma HIV-1 RNA concentration of less than 50 copies per mL. Non-inferiority was established in all three comparisons. The proportion of patients with protocol-defined virological failure at week 96 was low in all treatment groups. Participants in the tenofovir alafenamide, emtricitabine, and dolutegravir group had fewer changes in bone density than the two other treatment groups. Mean weight gain was substantial (7·1 kg [SD 7·4] in the tenofovir alafenamide, emtricitabine, and dolutegravir group; 4·3 kg [6·7] in the tenofovir disoproxil fumarate, emtricitabine, and dolutegravir group, and 2·3 kg [7·0] in the tenofovir disoproxil fumarate, emtricitabine, and efavirenz group), and was greater among women than men. Ten (3%) of 351 participants in the tenofovir disoproxil fumarate, emtricitabine, and efavirenz group discontinued due to treatment-related adverse events, of which liver dysfunction (n=4) and rash (n=4) were most common. INTERPRETATION Medium-term and long-term metabolic and clinical consequences of the considerable increase in bodyweight observed in participants given these antiretroviral regimens and the trajectory of this weight gain over time, especially among women, require further study. FUNDING USAID, Unitaid, South African Medical Research Council, ViiV Healthcare.
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Affiliation(s)
- Willem D F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Simiso Sokhela
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bryony Simmons
- Department of Infectious Disease, Imperial College London, London, UK
| | - Michelle Moorhouse
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Nkuli Mashabane
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Celicia Serenata
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Godspower Akpomiemie
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Masebole Masenya
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Ambar Qavi
- School of Public Health, Imperial College London, London, UK
| | - Nomathemba Chandiwana
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kaitlyn McCann
- School of Public Health, Imperial College London, London, UK
| | - Shane Norris
- South African Medical Research Council and Wits Developmental Pathways for Health Research Unit, Department of Pediatrics, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew Chersich
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Samanta Lalla-Edward
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alinda Vos
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Elaine Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY, USA; Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Natasha Arulappan
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Hill
- Department of Translational Medicine, Liverpool University, Liverpool, UK
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15
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Wadley AL, Venter WDF, Moorhouse M, Akpomiemie G, Serenata C, Hill A, Sokhela S, Mqamelo N, Kamerman PR. High individual pain variability in people living with HIV: A graphical analysis. Eur J Pain 2020; 25:160-170. [PMID: 32939898 DOI: 10.1002/ejp.1658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/02/2020] [Accepted: 09/06/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND People living with HIV (PLWH) frequently experience pain. Following calls to analyse individual-level data in addition to group-level data in pain studies, we compared individual and group-level changes in pain prevalence, intensity and number of pain sites over 48 weeks in a large cohort of PLWH. This is the largest ever cohort study of pain in PLWH, and is the first to report pain at the level of the individual. METHODS Participants included all participants with complete pain records from a randomized clinical trial (RCT) for the treatment of HIV (n = 787/1053). At weeks 0, 12, 24, 36 and 48 we assessed participants' pain in the last week; presence of pain, and if present, the intensity and locations of the pain. We used standard averaging methods to describe data at the group level, and unique graphical reporting methods to analyse data at the level of the individual. RESULTS Group-level data demonstrated a trend for pain prevalence to decline over time (19% week 0, 12% week 48). Worst pain intensity remained stable (median between 4/10 and 5/10), as did the number (median = 1) and common sites of pain across the 48 weeks. In contrast, individual-level data demonstrated high intra-individual variability with regards to the presence of pain, and the intensity and location of the pain. CONCLUSIONS While our group-level data were similar to previous longitudinal studies, an apparent reduction in pain over 48 weeks, the individual-level data showed large variability within individuals in that same time frame. SIGNIFICANCE This graphical analysis highlights the high variability in pain (pain prevalence, intensity and body sites) across time in people living with HIV, and how presenting averaged data hides this important variability. Our data support the reporting of individual-level data in human experimental and observational studies.
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Affiliation(s)
- Antonia Louise Wadley
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Willem D F Venter
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michelle Moorhouse
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Godspower Akpomiemie
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Celicia Serenata
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Hill
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Simiso Sokhela
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Noxolo Mqamelo
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Peter R Kamerman
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, South Africa.,School of Pharmacy and Biological Sciences, Faculty of Health Sciences, Curtin University, Perth, WA, Australia
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Venter WDF, Moorhouse M, Sokhela S, Fairlie L, Mashabane N, Masenya M, Serenata C, Akpomiemie G, Qavi A, Chandiwana N, Norris S, Chersich M, Clayden P, Abrams E, Arulappan N, Vos A, McCann K, Simmons B, Hill A. Dolutegravir plus Two Different Prodrugs of Tenofovir to Treat HIV. N Engl J Med 2019; 381:803-815. [PMID: 31339677 DOI: 10.1056/nejmoa1902824] [Citation(s) in RCA: 394] [Impact Index Per Article: 78.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Two drugs under consideration for inclusion in antiretroviral therapy (ART) regimens for human immunodeficiency virus (HIV) infection are dolutegravir (DTG) and tenofovir alafenamide fumarate (TAF). There are limited data on their use in low- and middle-income countries. METHODS We conducted a 96-week, phase 3, investigator-led, open-label, randomized trial in South Africa, in which we compared a triple-therapy combination of emtricitabine (FTC) and DTG plus either of two tenofovir prodrugs - TAF (TAF-based group) or tenofovir disoproxil fumarate (TDF) (TDF-based group) - against the local standard-of-care regimen of TDF-FTC-efavirenz (standard-care group). Inclusion criteria included an age of 12 years or older, no receipt of ART in the previous 6 months, a creatinine clearance of more than 60 ml per minute (>80 ml per minute in patients younger than 19 years of age), and an HIV type 1 (HIV-1) RNA level of 500 copies or more per milliliter. The primary end point was the percentage of patients with a 48-week HIV-1 RNA level of less than 50 copies per milliliter (as determined with the Snapshot algorithm from the Food and Drug Administration; noninferiority margin, -10 percentage points). We report the primary (48-week) efficacy and safety data. RESULTS A total of 1053 patients underwent randomization from February 2017 through May 2018. More than 99% of the patients were black, and 59% were female. The mean age was 32 years, and the mean CD4 count was 337 cells per cubic millimeter. At week 48, the percentage of patients with an HIV-1 RNA level of less than 50 copies per milliliter was 84% in the TAF-based group, 85% in the TDF-based group, and 79% in the standard-care group, findings that indicate that the DTG-containing regimens were noninferior to the standard-care regimen. The number of patients who discontinued the trial regimen was higher in the standard-care group than in the other two groups. In the per-protocol population, the standard-care regimen had equivalent potency to the other two regimens. The TAF-based regimen had less effect on bone density and renal function than the other regimens. Weight increase (both lean and fat mass) was greatest in the TAF-based group and among female patients (mean increase, 6.4 kg in the TAF-based group, 3.2 kg in the TDF-based group, and 1.7 kg in the standard-care group). No resistance to integrase inhibitors was identified in patients receiving the DTG-containing regimens. CONCLUSIONS Treatment with DTG combined with either of two tenofovir prodrugs (TAF and TDF) showed noninferior efficacy to treatment with the standard-care regimen. There was significantly more weight gain with the DTG-containing regimens, especially in combination with TAF, than with the standard-care regimen. (ADVANCE ClinicalTrials.gov number, NCT03122262.).
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Affiliation(s)
- Willem D F Venter
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Michelle Moorhouse
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Simiso Sokhela
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Lee Fairlie
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Nkuli Mashabane
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Masebole Masenya
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Celicia Serenata
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Godspower Akpomiemie
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Ambar Qavi
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Nomathemba Chandiwana
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Shane Norris
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Matthew Chersich
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Polly Clayden
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Elaine Abrams
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Natasha Arulappan
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Alinda Vos
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Kaitlyn McCann
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Bryony Simmons
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Andrew Hill
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
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Venter WDF, Moorhouse M, Sokhela S, Serenata C, Akpomiemie G, Qavi A, Mashabane N, Arulappan N, Sim JW, Sinxadi PZ, Wiesner L, Maharaj E, Wallis C, Boyles T, Ripin D, Stacey S, Chitauri G, Hill A. Low-dose ritonavir-boosted darunavir once daily versus ritonavir-boosted lopinavir for participants with less than 50 HIV RNA copies per mL (WRHI 052): a randomised, open-label, phase 3, non-inferiority trial. Lancet HIV 2019; 6:e428-e437. [PMID: 31202690 DOI: 10.1016/s2352-3018(19)30081-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 03/01/2019] [Accepted: 03/13/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Pilot studies suggest that ritonavir-boosted darunavir could show high efficacy at doses below those currently approved. We investigated whether switch to 400 mg of darunavir boosted with 100 mg ritonavir once daily could show equivalent efficacy to continuation of ritonavir-boosted lopinavir (a protease inhibitor commonly used in low-income and middle-income countries) for individuals with HIV RNA suppression. METHODS In the WRHI 052 study, a randomised, parallel-group, open-label, non-inferiority phase 3 trial, adults who were HIV-1 positive were enrolled in Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa. Eligible participants were 18 years or older, who tolerated ritonavir-boosted lopinavir in combination with two nucleoside analogues (standard of care) for 6 months or more, and had plasma HIV-1 RNA of less than 50 copies per mL within 60 days of enrolment. We randomly assigned participants (1:1), using a computer-generated randomisation plan, to switch to darunavir (400 mg) boosted with ritonavir (100 mg) once daily or remain on ritonavir-boosted lopinavir (800 mg [plus 200 mg ritonavir]), with nucleoside analogues left unchanged. The primary endpoint was the proportion of patients with less than 50 HIV-1 RNA copies per mL at week 48 (US Food and Drug Administration snapshot algorithm; non-inferiority margin -4%). Primary and safety analyses included participants receiving at least one dose of darunavir boosted with ritonavir. This trial is registered with ClinicalTrials.gov, number NCT02671383. FINDINGS Between June 30, 2016, and June 15, 2017, 148 participants were assigned to ritonavir-boosted darunavir 400 mg and 152 continued on their lopinavir-containing regimen. Four (3%) patients in the darunavir group and three (2%) in the lopinavir group discontinued before week 48. At week 48, darunavir was non-inferior to lopinavir for the primary outcome (142 [96%] of 148 participants on darunavir had <50 HIV-1 RNA copies per mL vs 143 [94%] of 152 participants on lopinavir; difference 1·9% [95% CI -3·4 to 7·3]), with a predefined margin of -4%. More participants taking darunavir (30 [20%] participants) had drug-related adverse events than those on lopinavir (eight [5%]), but the adverse events were generally asymptomatic and resolved when switching back to lopinavir. Elevated liver transaminase in three (1%; one symptomatic) darunavir participants led to study withdrawal; all transaminase elevations resolved on restarting lopinavir. INTERPRETATION Low-dose ritonavir-boosted darunavir might be a safe and efficacious switch option to maintain HIV suppression for patients on lopinavir. However, an adequately powered and designed study in viraemic participants is needed. FUNDING South African Medical Research Council, United States Agency for International Development, and US National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Willem D F Venter
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Michelle Moorhouse
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Simiso Sokhela
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Celicia Serenata
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Godspower Akpomiemie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ambar Qavi
- Faculty of Medicine, Imperial College London, London, UK
| | - Nonkululeko Mashabane
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Natasha Arulappan
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joel W Sim
- Faculty of Medicine, Imperial College London, London, UK
| | - Phumla Z Sinxadi
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ellisha Maharaj
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Carole Wallis
- BARC, Lancet Laboratories, Johannesburg, South Africa
| | - Tom Boyles
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - David Ripin
- Clinton Health Access Initiative, Boston, MA, USA
| | - Sarah Stacey
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Division of Infectious Diseases, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Gila Chitauri
- Division of Infectious Diseases, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Hill
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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Venter WDF, Kambugu A, Chersich MF, Becker S, Hill A, Arulappan N, Moorhouse M, Majam M, Akpomiemie G, Sokhela S, Poongulali S, Feldman C, Duncombe C, Ripin DHB, Vos A, Kumarasamy N. Efficacy and Safety of Tenofovir Disoproxil Fumarate Versus Low-Dose Stavudine Over 96 Weeks: A Multicountry Randomized, Noninferiority Trial. J Acquir Immune Defic Syndr 2019; 80:224-233. [PMID: 30640204 PMCID: PMC6358196 DOI: 10.1097/qai.0000000000001908] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/15/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Reducing doses of antiretroviral drugs, including stavudine (d4T), may lower toxicity, while preserving efficacy. There are substantial concerns about renal and bone toxicities of tenofovir disoproxil fumarate (TDF). SETTING HIV-1-infected treatment-naive adults in India, South Africa, and Uganda. METHODS A phase-4, 96-week, randomized, double-blind, noninferiority trial compared d4T 20 mg twice daily and TDF, taken in combination with lamivudine (3TC) and efavirenz (EFV). The primary endpoint was the proportion of participants with HIV-1 RNA <50 copies per milliliter at 48 weeks. Adverse events assessments included measures of bone density and body fat. The trial is registered on Clinicaltrials.gov (NCT02670772). RESULTS Between 2012 and 2014, 536 participants were recruited per arm. At week 96, trial completion rates were 75.7% with d4T/3TC/EFV (n = 406) and 82.1% with TDF/3TC/EFV (n = 440, P = 0.011). Noncompletion was largely due to virological failure [6.2% (33) with d4T/3TC/EFV versus 5.4% (29) with TDF/3TC/EFV; P = 0.60]. For the primary endpoint, d4T/3TC/EFV was noninferior to TDF/3TC/EFV (79.3%, 425/536 versus 80.8% 433/536; difference = -1.49%, 95% CI: -6.3 to 3.3; P < 0.001). Drug-related adverse event discontinuations were higher with d4T (6.7%, 36), than TDF (1.1%, 6; P < 0.001). Lipodystrophy was more common with d4T (5.6%, 30) than TDF (0.2%, 1; P < 0.001). Creatinine clearance increased in both arms, by 18.1 mL/min in the d4T arm and 14.2 mL/min with TDF (P = 0.03). Hip bone density measures, however, showed greater loss with TDF. CONCLUSIONS Low-dose d4T combined with 3TC/EFV demonstrated noninferior virological efficacy compared with TDF/3TC/EFV, but mitochondrial toxicity remained high. Little renal toxicity occurred in either arm. Implications of bone mineral density changes with TDF warrant investigation.
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Affiliation(s)
- Willem Daniel Francois Venter
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Kambugu
- Infectious Diseases, College of Health Sciences at Makerere University, Kampala, Uganda
| | - Matthew F. Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Andrew Hill
- Pharmacology Department, University of Liverpool, Liverpool, United Kingdom
| | - Natasha Arulappan
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michelle Moorhouse
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mohammed Majam
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Godspower Akpomiemie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Simiso Sokhela
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Selvamuthu Poongulali
- Chennai Antiviral Research and Treatment Clinical Research Site, YRGCARE Medical Centre, Voluntary Health Services, Chennai, India
| | - Charles Feldman
- Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Alinda Vos
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site, YRGCARE Medical Centre, Voluntary Health Services, Chennai, India
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19
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Daniel Francois Venter W, Chersich MF, Majam M, Akpomiemie G, Arulappan N, Moorhouse M, Mashabane N, Glencross DK. CD4 cell count variability with repeat testing in South Africa: Should reporting include both absolute counts and ranges of plausible values? Int J STD AIDS 2018; 29:1048-1056. [PMID: 29749876 DOI: 10.1177/0956462418771768] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although eligibility for antiretroviral treatment is no longer based on CD4 thresholds, CD4 testing remains important. Variation in CD4 cell count complicates initiation of antibiotic prophylaxis, differential diagnoses and assessments of immunological recovery. Five hundred and fifty-three HIV-positive antiretroviral-naïve adults, recruited from inner-city clinics, had three serial CD4 cell count tests. Test 1 was mostly done in a laboratory network supporting primary care clinics, while Tests 2 and 3 were performed in a tertiary-level laboratory. Reproducibility was assessed through Bland-Altman limits of agreement and coefficients of variation. Participants, a mean age of 34 years and mostly female (57%), had a median 203 CD4 cells/μL (Test 1). Seventeen per cent classified as having advanced HIV disease (CD4 cell count < 200 cells/µL) on Test 1 had a CD4 cell count > 200 cells/µL on Tests 2 and 3. Mean differences between tests were <10 cells/µL for all comparisons. Limits of agreement for Tests 1 and 2 were -106.9 to 112.7 and coefficient of variation 15. Corresponding figures for Tests 2 and 3 were -88.2 to 103.4, and 13. Means of tests were similar, suggesting no systematic measurement differences, despite testing being done at different times. Variations were, however, considerable in many instances, though smaller in testing done in the same laboratory. CD4 cut-offs must not be applied rigidly, but rather constitute one amongst many factors used to guide patient care. Moreover, given the difficulties in determining whether CD4 changes are due to HIV disease, or other biological and laboratory factors, CD4 laboratory reports should include a range of plausible values, not only the absolute count.
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Affiliation(s)
- Willem Daniel Francois Venter
- 1 Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Braamfontein, Johannesburg, South Africa
| | - Matthew F Chersich
- 1 Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Braamfontein, Johannesburg, South Africa
| | - Mohammed Majam
- 1 Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Braamfontein, Johannesburg, South Africa
| | - Godspower Akpomiemie
- 1 Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Braamfontein, Johannesburg, South Africa
| | - Natasha Arulappan
- 1 Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Braamfontein, Johannesburg, South Africa
| | - Michelle Moorhouse
- 1 Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Braamfontein, Johannesburg, South Africa
| | - Nonkululeko Mashabane
- 1 Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Braamfontein, Johannesburg, South Africa
| | - Deborah K Glencross
- 2 Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand and the National Health Laboratory Service, Johannesburg, South Africa
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Venter WDF, Majam M, Akpomiemie G, Arulappan N, Moorhouse M, Mashabane N, Chersich MF. Is laboratory screening prior to antiretroviral treatment useful in Johannesburg, South Africa? Baseline findings of a clinical trial. BMC Public Health 2017; 17:445. [PMID: 28832288 PMCID: PMC5498858 DOI: 10.1186/s12889-017-4353-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Screening for renal, hepatic and haematological disorders complicates the initiation of current first-line antiretroviral therapy (ART). Each additional test done adds substantial costs, both through direct laboratory expenses, but also by increasing the burden on health workers and patients. Evaluating the prevalence of clinically relevant abnormalities in different population groups could guide decisions about what tests to recommend in national guidelines, or in local adaptations of these. METHODS As part of enrolment procedures in a clinical trial, 771 HIV-positive adults, predominantly from inner-city primary health care clinics, underwent laboratory screening prior to ART. Participants had to be eligible for ART, based on the then CD4 eligibility threshold of 350 cells/μL, antiretroviral naïve and have no symptoms of peripheral neuropathy. RESULTS Participants were mostly female (57%) and a mean 34 years old. Creatinine clearance rates were almost all above 50 mL/min (99%), although 5% had microalbuminuria. Hepatitis B antigenaemia was common (8% of participants), of whom 40% had a raised AST/ALT, though only 2 had transaminase levels above 200 IU/L. Only 2% of participants had severe anaemia (haemoglobin <8 g/dl) and 1% neutropaenia (neutrophils <0.75 × 10^9/L). Costs per case detected of hepatitis B infection was USD135, but more than USD800 for a raised creatinine. CONCLUSIONS Hepatitis B continues to be a common co-infection in HIV-infected adults, and adds complexity to management of ART switches involving tenofovir. Routine renal and haematological screening prior to ART detected few abnormalities. The use of these screening tests should be assessed among patients with higher CD4 counts, who may even have fewer abnormalities. Formal evaluation of cost-effectiveness of laboratory screening prior to ART is warranted.
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Affiliation(s)
- Willem D F Venter
- Wits Reproductive Health and HIV Institute (WRHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Mohammed Majam
- Wits Reproductive Health and HIV Institute (WRHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Godspower Akpomiemie
- Wits Reproductive Health and HIV Institute (WRHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Natasha Arulappan
- Wits Reproductive Health and HIV Institute (WRHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michelle Moorhouse
- Wits Reproductive Health and HIV Institute (WRHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nonkululeko Mashabane
- Wits Reproductive Health and HIV Institute (WRHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew F Chersich
- Wits Reproductive Health and HIV Institute (WRHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Akinsanya OS, Wiseberg-Firtell JA, Akpomiemie G, Adeniyi OV, Kaswa RP. Evaluation of the prevention of mother-to-child transmission programme at a primary health care centre in South Africa. S Afr Fam Pract (2004) 2017. [DOI: 10.1080/20786190.2016.1254933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- OS Akinsanya
- Department of Public Health, University of Liverpool, Liverpool, UK
| | | | - G Akpomiemie
- Reproductive Health & HIV Institute, University of the Witswatersrand, Johannesburg, South Africa
| | - OV Adeniyi
- Department of Family Medicine, Walter Sisulu University, East London, South Africa
| | - RP Kaswa
- Department of Family Medicine, Walter Sisulu University, East London, South Africa
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Abstract
INTRODUCTION Updated guidelines from the WHO recommend antiretroviral treatment for adults with HIV at any CD4 count and daily oral pre-exposure prophylaxis (PrEP) for people at substantial risk of HIV infection. However, implementation challenges may hinder the ability of programmes to translate these recommendations into successful practice. This demonstration project is the first to integrate PrEP and immediate treatment (ITx) for female sex workers (FSWs) in South Africa to answer operational research questions. METHODS AND ANALYSIS This is a prospective cohort study where the main outcome is retention at 12 months. The study population is recruited into two arms across two urban sites: (1) PrEP for HIV-negative FSWs (n=400) and (2) ITx for HIV-positive FSWs with CD4 greater than national guidelines (n=300). We investigate process and other health indicators, uptake and use of PrEP and ITx through qualitative research, and evaluate cost-effectiveness analysis combined with estimates of impact through epidemiological modelling. ETHICS AND DISSEMINATION The Treatment And Prevention for female Sex workers in South Africa (TAPS) Project was designed as an implementation study before emtricitabine/tenofovir disoproxil fumarate was licenced as an indication for PrEP in South Africa. Therefore, clinical trial requirements for ethical and South African Medicines Control Council approvals were followed. Results will be disseminated to participants, local health officials and other stakeholders, as well as in peer-reviewed journals and at conferences.
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Affiliation(s)
- Gabriela B Gomez
- Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
- Department of Global Health and Amsterdam, Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Robyn Eakle
- Wits Reproductive Health and HIV Institute, London School of Hygiene and Tropical Medicine, London, UK
| | - Judie Mbogua
- Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
| | | | | | - Helen Rees
- Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
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