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Kapadia SN, Wu C, Mayer KH, Wilkin TJ, Amico KR, Landovitz RJ, Andrade A, Chen YQ, Chege W, McCauley M, Gulick RM, Schackman BR. No change in health-related quality of life for at-risk U.S. women and men starting HIV pre-exposure prophylaxis (PrEP): Findings from HPTN 069/ACTG A5305. PLoS One 2018; 13:e0206577. [PMID: 30586364 PMCID: PMC6306196 DOI: 10.1371/journal.pone.0206577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 12/11/2017] [Accepted: 10/16/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Tenofovir (TDF)-containing PrEP is effective for HIV prevention, but its effect on health-related quality of life (QOL) is unknown. Using data from HPTN 069/ACTG A5305, a randomized study of potential PrEP regimens comparing maraviroc alone, or together with TDF or emtricitabine (FTC), to TDF + FTC (control), we evaluated the impact of these regimens on QOL in at-risk HIV-uninfected U.S. women and men. METHODS QOL was measured at baseline (before starting medications) and every 8 weeks through week 48 using the EQ-5D-3L. Responses were converted to a scale from 0.0 (death) to 1.0 (perfect health), using published valuation weights. Mean scores were compared between groups at each time point using nonparametric testing. Multivariable linear regression was used to adjust for potential confounders. RESULTS We analyzed 186 women (median age 35 years, 65% black, 17% Hispanic) and 405 men (median age 30 years, 28% black, 22% Hispanic), including 9 transgender participants analyzed based on sex-at-birth. Mean baseline QOL was 0.91 for women and 0.95 for men. There were minimal changes in mean QOL over time for any regimen (women: p = 0.29; men: p = 0.14). There were no significant differences between participants who continued the regimen compared to participants who discontinued early (women: p = 0.61; men: p = 0.1). Mean QOL did not differ significantly by regimen at any time point, both unadjusted and after adjustment for age, race/ethnicity, adherence, and use of alcohol, marijuana, opiates, and other substances. CONCLUSIONS QOL in at-risk individuals starting candidate PrEP regimens in a clinical trial is similar to the general population and maintained over time. This finding did not vary among regimens or when adjusted for demographics, adherence, and substance use. Our findings are the first to show that starting a candidate PrEP regimen in at-risk HIV-uninfected U.S. women and men was not associated with significant changes in QOL. TRIAL REGISTRATION Clinicaltrials.gov NCT01505114.
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Affiliation(s)
- Shashi N. Kapadia
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, United States of America
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, United States of America
| | - Chunyuan Wu
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Kenneth H. Mayer
- Fenway Health, Department of Medicine, Beth Israel Deaconess Medical Center / Harvard Medical School, Boston, Massachusetts, United States of America
| | - Timothy J. Wilkin
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, United States of America
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
| | - Raphael J. Landovitz
- UCLA Center for Clinical AIDS Research & Education, University of California Los Angeles, Los Angeles, California, United States of America
| | - Adriana Andrade
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Ying Q. Chen
- Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Wairimu Chege
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | | | - Roy M. Gulick
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, United States of America
| | - Bruce R. Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, United States of America
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Lewis M, Mori J, Toma J, Mosley M, Huang W, Simpson P, Mansfield R, Craig C, van der Ryst E, Robertson DL, Whitcomb JM, Westby M. Clonal analysis of HIV-1 genotype and function associated with virologic failure in treatment-experienced persons receiving maraviroc: Results from the MOTIVATE phase 3 randomized, placebo-controlled trials. PLoS One 2018; 13:e0204099. [PMID: 30586365 PMCID: PMC6306210 DOI: 10.1371/journal.pone.0204099] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 09/07/2017] [Accepted: 04/17/2018] [Indexed: 11/29/2022] Open
Abstract
Detailed clonal phenotypic/genotypic analyses explored viral-escape mechanisms during maraviroc-based therapy in highly treatment-experienced participants from the MOTIVATE trials. To allow real-time assessment of samples while maintaining a blind trial, the first 267 enrolled participants were selected for evaluation. At failure, plasma samples from 20/50 participants (16/20 maraviroc-treated) with CXCR4-using virus and all 38 (13 maraviroc-treated) with CCR5-tropic virus were evaluated. Of those maraviroc-treated participants with CXCR4-using virus at failure, genotypic and phenotypic clonal tropism determinations showed >90% correspondence in 14/16 at Day 1 and 14/16 at failure. Phylogenetic analysis of clonal sequences detected pre-treatment progenitor CXCR4-using virus, or on-treatment virus highly divergent from the Day 1 R5 virus, excluding possible co-receptor switch through maraviroc-mediated evolution. Re-analysis of pre-treatment samples using the enhanced-sensitivity Trofile® assay detected CXCR4-using virus pre-treatment in 16/20 participants failing with CXCR4-using virus. Post-maraviroc reversion of CXCR4-use to CCR5-tropic occurred in 7/8 participants with follow-up, suggesting selective maraviroc inhibition of CCR5-tropic variants in a mixed-tropic viral population, not emergence of de novo mutations in CCR5-tropic virus, as the main virologic escape mechanism. Maraviroc-resistant CCR5-tropic virus was observed in plasma from 5 treated participants with virus displaying reduced maximal percent inhibition (MPI) but no evidence of IC50 change. Env clones with reduced MPI showed 1-5 amino acid changes specific to each V3-loop region of env relative to Day 1. However, transferring on-treatment resistance-associated changes using site-directed mutagenesis did not always establish resistance in Day 1 virus, and key 'signature' mutation patterns associated with reduced susceptibility to maraviroc were not identified. Evolutionary divergence of the CXCR4-using viruses is confirmed, emphasizing natural selection not influenced directly by maraviroc; maraviroc simply unmasks pre-existing lineages by inhibiting the R5 virus. For R5-viral failure, resistance development through drug selection pressure was uncommon and manifested through reduced MPI and with virus strain-specific mutational patterns.
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Affiliation(s)
- Marilyn Lewis
- The Research Network, Sandwich, Kent, United Kingdom
| | - Julie Mori
- hVIVO, Queen Mary BioEnterprise Innovation Centre, London, United Kingdom
| | - Jonathan Toma
- Monogram Biosciences, South San Francisco, California, United States of America
| | - Mike Mosley
- University of Oxford, Oxford, United Kingdom
| | - Wei Huang
- Monogram Biosciences, South San Francisco, California, United States of America
| | | | - Roy Mansfield
- Pfizer Global Research and Development, Sandwich Labs, Sandwich, Kent, United Kingdom
| | - Charles Craig
- The Research Network, Sandwich, Kent, United Kingdom
| | | | - David L. Robertson
- Evolution and Genomic Sciences, School of Biological Sciences, The University of Manchester, Manchester, United Kingdom
- MRC-University of Glasgow Centre for Virus Research, Glasgow, United Kingdom
| | | | - Mike Westby
- Centauri Therapeutics Limited, Discovery Park, Kent, United Kingdom
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Vincent KL, Moss JA, Marzinke MA, Hendrix CW, Anton PA, Pyles RB, Guthrie KM, Dawson L, Olive TJ, Butkyavichene I, Churchman SA, Cortez JM, Fanter R, Gunawardana M, Miller CS, Yang F, Rosen RK, Vargas SE, Baum MM. Safety and pharmacokinetics of single, dual, and triple antiretroviral drug formulations delivered by pod-intravaginal rings designed for HIV-1 prevention: A Phase I trial. PLoS Med 2018; 15:e1002655. [PMID: 30265679 PMCID: PMC6161852 DOI: 10.1371/journal.pmed.1002655] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 08/17/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Intravaginal rings (IVRs) for HIV pre-exposure prophylaxis (PrEP) theoretically overcome some adherence concerns associated with frequent dosing that can occur with oral or vaginal film/gel regimens. An innovative pod-IVR, composed of an elastomer scaffold that can hold up to 10 polymer-coated drug cores (or "pods"), is distinct from other IVR designs as drug release from each pod can be controlled independently. A pod-IVR has been developed for the delivery of tenofovir (TFV) disoproxil fumarate (TDF) in combination with emtricitabine (FTC), as daily oral TDF-FTC is the only Food and Drug Administration (FDA)-approved regimen for HIV PrEP. A triple combination IVR building on this platform and delivering TDF-FTC along with the antiretroviral (ARV) agent maraviroc (MVC) also is under development. METHODOLOGY AND FINDINGS This pilot Phase I trial conducted between June 23, 2015, and July 15, 2016, evaluated the safety, pharmacokinetics (PKs), and acceptability of pod-IVRs delivering 3 different ARV regimens: 1) TDF only, 2) TDF-FTC, and 3) TDF-FTC-MVC over 7 d. The crossover, open-label portion of the trial (N = 6) consisted of 7 d of continuous TDF pod-IVR use, a wash-out phase, and 7 d of continuous TDF-FTC pod-IVR use. After a 3-mo pause to evaluate safety and PK of the TDF and TDF-FTC pod-IVRs, TDF-FTC-MVC pod-IVRs (N = 6) were evaluated over 7 d of continuous use. Safety was assessed by adverse events (AEs), colposcopy, and culture-independent analysis of the vaginal microbiome (VMB). Drug and drug metabolite concentrations in plasma, cervicovaginal fluids (CVFs), cervicovaginal lavages (CVLs), and vaginal tissue (VT) biopsies were determined via liquid chromatographic-tandem mass spectrometry (LC-MS/MS). Perceptibility and acceptability were assessed by surveys and interviews. Median participant age was as follows: TDF/TDF-FTC group, 26 y (range 24-35 y), 2 White, 2 Hispanic, and 2 African American; TDF-FTC-MVC group, 24.5 y (range 21-41 y), 3 White, 1 Hispanic, and 2 African American. Reported acceptability was high for all 3 products, and pod-IVR use was confirmed by residual drug levels in used IVRs. There were no serious adverse events (SAEs) during the study. There were 26 AEs reported during TDF/TDF-FTC IVR use (itching, discharge, discomfort), with no differences between TDF alone or in combination with FTC observed. In the TDF-FTC-MVC IVR group, there were 12 AEs (itching, discharge, discomfort) during IVR use regardless of attribution to study product. No epithelial disruption/thinning was seen by colposcopy, and no systematic VMB shifts were observed. Median (IQR) tenofovir diphosphate (TFV-DP) tissue concentrations of 303 (277-938) fmol/10(6) cells (TDF), 289 (110-603) fmol/10(6) cells (TDF-FTC), and 302 (177.1-823.8) fmol/10(6) cells (TDF-FTC-MVC) were sustained for 7 d, exceeding theoretical target concentrations for vaginal HIV prevention. The study's main limitations include the small sample size, short duration (7 d versus 28 d), and the lack of FTC triphosphate measurements in VT biopsies. CONCLUSIONS An innovative pod-IVR delivery device with 3 different formulations delivering different regimens of ARV drugs vaginally appeared to be safe and acceptable and provided drug concentrations in CVFs and tissues exceeding concentrations achieved by highly protective oral dosing, suggesting that efficacy for vaginal HIV PrEP is achievable. These results show that an alternate, more adherence-independent, longer-acting prevention device based on the only FDA-approved PrEP combination regimen can be advanced to safety and efficacy testing. TRIAL REGISTRATION ClinicalTrials.gov NCT02431273.
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Affiliation(s)
- Kathleen L. Vincent
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas, United States of America
- * E-mail:
| | - John A. Moss
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Mark A. Marzinke
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Craig W. Hendrix
- Division of Clinical Pharmacology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Peter A. Anton
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
- Center for HIV Prevention Research, Division of Digestive Diseases and UCLA AIDS Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
| | - Richard B. Pyles
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Kate M. Guthrie
- The Centers for Behavioral & Preventive Medicine, The Miriam Hospital, Providence, Rhode Island, United States of America
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Lauren Dawson
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Trevelyn J. Olive
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Irina Butkyavichene
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Scott A. Churchman
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - John M. Cortez
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Rob Fanter
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Manjula Gunawardana
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Christine S. Miller
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Flora Yang
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
| | - Rochelle K. Rosen
- The Centers for Behavioral & Preventive Medicine, The Miriam Hospital, Providence, Rhode Island, United States of America
- Department of Behavioral & Social Sciences, Brown University School of Public Health, Providence, Rhode Island, United States of America
| | - Sara E. Vargas
- The Centers for Behavioral & Preventive Medicine, The Miriam Hospital, Providence, Rhode Island, United States of America
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Marc M. Baum
- Department of Chemistry, Oak Crest Institute of Science, Monrovia, California, United States of America
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Scabini S, Trunfio M, Pirriatore V, Imperiale D, Audagnotto S, Bertucci R, Ghisetti V, Cinnirella G, Cistaro A, Perna M, Calcagno A, Di Perri G. Antiviral activity of maraviroc plus mirtazapine in a low-risk HIV-negative patient with progressive multifocal leukoencephalopathy. Infez Med 2018; 26:160-163. [PMID: 29932090] [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] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
A case of progressive multifocal leukoencephalopathy (PML) is described in an HIV-negative patient with mixed connective-tissue disease (MCTD) on a minimally immunosuppressive treatment with hydroxychloroquine. The patient presented with right-sided weakness, episodes of disorientation and loss of short-term memory and of vision in her right eye. PML was diagnosed by JCV DNA on cerebrospinal fluid and radiological criteria. She was treated with off-label maraviroc and mirtazapine but died two months after hospital admission, despite a surprising decrease in the viral load of cerebrospinal fluid three weeks after starting therapy. Prompt diagnosis and antiviral treatment of PML even in low-risk patients are warranted. Future studies are required to define the therapeutic role of maraviroc (MVC) and mirtazapine in this setting.
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Affiliation(s)
- Silvia Scabini
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Italy
| | - Mattia Trunfio
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Italy
| | - Veronica Pirriatore
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Italy
| | - Daniele Imperiale
- Department of Neurology, Maria Vittoria Hospital, ASLTO2, Torino, Italy
| | - Sabrina Audagnotto
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Italy
| | - Roberto Bertucci
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Italy
| | - Valeria Ghisetti
- Laboratory of Microbiology and Molecular Biology, Amedeo di Savoia Hospital, ASLTO2, Torino, Italy
| | | | - Angelina Cistaro
- Positron Emission Tomography Centre IRMET, Affidea, Torino, Italy, Neuroimaging Steering Committee of AIMN, Italy
| | - Mariaelena Perna
- Department of Radiology, Giovanni Bosco Hospital, ASLTO2, Torino, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Italy
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