Cerebrospinal fluid analysis for HIV replication and biomarkers of immune activation and neurodegeneration in long-term atazanavir/ritonavir monotherapy treated patients

Background: Cerebrospinal fluid (CSF) viral escape is a concern in ritonavir-boosted protease inhibitors monotherapy. The aim was to assess HIV-RNA, biomarkers of immune activation and neurodegeneration, and atazanavir concentrations in CSF of patients on successful long-term atazanavir/ritonavir (ATV/r) monotherapy. Methods: This is a substudy of the multicentric, randomized, open-label, noninferiority trial monotherapy once a day with atazanavir/ritonavir (NCT01511809), comparing the ongoing ATV/r along with 2 nucleoside retrotranscriptase inhibitors (NRTIs) regimen to a simplified ATV/r monotherapy. Patients with plasma HIV-RNA < 50 copies/mL after at least 96 study weeks were eligible. We assessed HIV-RNA, soluble (s)CD14, sCD163, CCL2, CXCL10, interleukin-6, and YKL40 by enzyme-linked immunosorbent assay; neopterin, tryptophan, kynurenine, and neurofilament by immunoassays; and ATV concentrations by liquid chromatography–mass spectrometry in paired plasma and CSF samples. Variables were compared with Wilcoxon rank-sum or Fisher exact test, as appropriate. Results: HIV-RNA was detected in the CSF of 1/11 patients on ATV/r monotherapy (114 copies/mL), without neurological symptoms, who was successfully reintensified with his previous 2NRTIs, and in none of the 12 patients on ATV/r + 2NRTIs. CSF biomarkers and ATV concentrations did not differ between the 2 arms. Conclusions: CSF escape was uncommon in patients on long-term ATV/r monotherapy and was controlled with reintensification

Non-AIDS defining cancers in the D:A:D Study-time trends and predictors of survival : a cohort study

BACKGROUND:Non-AIDS defining cancers (NADC) are an important cause of morbidity and mortality in HIV-positive individuals. Using data from a large international cohort of HIV-positive individuals, we described the incidence of NADC from 2004-2010, and described subsequent mortality and predictors of these.METHODS:Individuals were followed from 1st January 2004/enrolment in study, until the earliest of a new NADC, 1st February 2010, death or six months after the patient's last visit. Incidence rates were estimated for each year of follow-up, overall and stratified by gender, age and mode of HIV acquisition. Cumulative risk of mortality following NADC diagnosis was summarised using Kaplan-Meier methods, with follow-up for these analyses from the date of NADC diagnosis until the patient's death, 1st February 2010 or 6 months after the patient's last visit. Factors associated with mortality following NADC diagnosis were identified using multivariable Cox proportional hazards regression.RESULTS:Over 176,775 person-years (PY), 880 (2.1%) patients developed a new NADC (incidence: 4.98/1000PY [95% confidence interval 4.65, 5.31]). Over a third of these patients (327, 37.2%) had died by 1st February 2010. Time trends for lung cancer, anal cancer and Hodgkin's lymphoma were broadly consistent. Kaplan-Meier cumulative mortality estimates at 1, 3 and 5 years after NADC diagnosis were 28.2% [95% CI 25.1-31.2], 42.0% [38.2-45.8] and 47.3% [42.4-52.2], respectively. Significant predictors of poorer survival after diagnosis of NADC were lung cancer (compared to other cancer types), male gender, non-white ethnicity, and smoking status. Later year of diagnosis and higher CD4 count at NADC diagnosis were associated with improved survival. The incidence of NADC remained stable over the period 2004-2010 in this large observational cohort.CONCLUSIONS:The prognosis after diagnosis of NADC, in particular lung cancer and disseminated cancer, is poor but has improved somewhat over time. Modifiable risk factors, such as smoking and low CD4 counts, were associated with mortality following a diagnosis of NADC

Increased dose of dolutegravir as a potential rescue therapy in multi-experienced patients.

BACKGROUND: The pilot Phase IIb VIKING study suggested that dolutegravir (DTG), an HIV integrase inhibitor (INI), is efficacious in INI-resistant patients at the 50 mg twice-daily dose. However, DTG response was most reduced in subjects carrying resistance-associated mutations at position G140 and Q148. These mutations can cause a 10-20-fold reduced susceptibility to DTG as well as a 96% lower odds of achieving HIV-1 RNA &lt;50 copies/ml at week 24 if compared with those with no mutations at these positions. METHODS: Five multi-experienced patients harbouring the mutation complex G140-Q148, resistant to at least three drug classes, and previously exposed to DTG 50 mg twice daily, were treated with an increased dose of DTG (100 mg twice daily) in association with an optimized background regimen (OBR) based on their individual viral genotyping assays. The blood concentration of DTG was measured in order to determine whether a solubility issue is related with this high dosage. RESULTS: Four out of five patients attained an HIV-1 RNA &lt;50 copies/ml at week 48 and no relevant adverse events were detected. The measured DTG blood concentration was that expected for the administered dosage, ruling out any solubility concerns. CONCLUSIONS: For the first time 100 mg twice daily of DTG was administered to five multi-experienced patients harbouring the mutation complex G140-Q148. Although a small number of patients were tested, the results show a potential for a high-dose regimen of DTG as a rescue therapy in patients harbouring integrase strand transfer inhibitor resistant viruses

A nucleoside-sparing regimen of dolutegravir plus ritonavir-boosted atazanavir in HIV-1-infected patients with virological failure: the DOLATAV study

Vincenzo Spagnuolo,1,2 Laura Galli,2 Andrea Poli,2 Alba Bigoloni,2 Luca Fumagalli,2 Nicola Gianotti,2 Silvia Nozza,2 Davide Ferrari,3 Massimo Locatelli,3 Adriano Lazzarin,2 Antonella Castagna1,2 1Vita-Salute San Raffaele University, Faculty of Medicine and Surgery, Milan, Italy; 2Clinic of Infectious Diseases, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy; 3Laboratory Medicine Service, IRCCS San Raffaele Hospital, Milan, Italy&nbsp; IntroductionThe increased exposure of dolutegravir (DTG) when given with atazanavir/ritonavir&nbsp;(ATV/r), as well as the acceptable safety profile, may suggest the use of this combination&nbsp;as a two-drug regimen both in virologically suppressed and treatment-failing&nbsp;subjects.1&ndash;5&nbsp; This nucleoside reverse transcriptase inhibitors (NRTIs)-sparing regimen, characterized&nbsp;by a high genetic barrier, may represent an option in patients who have failed&nbsp;previous regimens and developed pharmacoresistance mutations to NRTIs and nonnucleoside&nbsp;reverse transcriptase inhibitors (NNRTIs).&nbsp; However, no data on DTG plus boosted ATV in patients with virological failure&nbsp;are currently available.&nbsp; Therefore, the aim of the DOLATAV study was to investigate the efficacy, safety,&nbsp;and pharmacokinetics of ATV/r 300/100 mg once-daily plus DTG 50 mg once-daily &nbsp

Switching to unboosted atazanavir improves glucose tolerance in highly pretreated HIV-1 infected subjects

OBJECTIVE: To evaluate the 24-week effects on glucose tolerance of switching from a protease inhibitor (PI)-based to an unboosted atazanavir-including regimen in highly pretreated HIV-1 infected subjects with metabolic alterations. DESIGN: Prospective, open-label, single-center, 24-week pilot study. METHODS: Twenty-one subjects underwent an oral glucose tolerance test (OGTT) at baseline (BL) and after 24 weeks of unboosted atazanavir. Insulin sensitivity and beta-cell responsiveness were evaluated on the basis of static and dynamic data; fasting glucose, insulin, C-peptide, triglycerides (TG), total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-c), low-density lipoprotein-cholesterol (LDL-c), TC/HDL-c ratio, CD4+ cell count and HIV-1 RNA were measured. RESULTS: After 24 weeks of unboosted atazanavir, the 120-min glucose level was significantly lower than the one measured at BL (P=0.021); there were no statistically significant differences in the insulin concentration profile. The SI(oral), an OGTT-based index of insulin sensitivity, was significantly higher at week 24 (P=0.017); the indices of first- and second-phase beta-cell responsiveness did not significantly change. There was no significant difference between BL and 24-week fasting glucose, insulin or C-peptide levels, and consequently no change in fasting homeostasis model assessment indices of insulin sensitivity and beta-cell function. There were significant improvements in TG (P=0.009), TC (P=0.0001), LDL-c (P=0.019) and TC/HDL-c ratio (P=0.001), and a similar trend in HDL-c levels (P=0.069). No significant changes in the immunological and virological parameters were detected. CONCLUSIONS: Our results show that switching from a PI-based to an unboosted atazanavir-including regimen leads to a significant improvement in glucose tolerance in highly pretreated HIV-1 infected subjects with metabolic alterations

Impact of lamivudine monotherapy in failing patients with multidrug-resistant HIV: final 48 weeks results (MONO-AIFA FARM7PAZS3)

Purpose of the study: To assess the impact of lamivudine (3TC) monotherapy in failing patients with multidrug-resistant HIV and limited therapeutic options. Methods: Prospective, open-label, multicenter, randomised (1:1), pilot study. HIV-1 failing pts with M184V mutation, HBsAg negative were assigned to 3TC 300mg QD for 24 weeks followed by a new regimen for 24 weeks (Arm A) or to a new regimen for 48 weeks (Arm B). The new HAART regimen was decided before randomisation in both groups, based on clinical history, genotype and viral tropism. Primary endpoint was the proportion of pts with HIV-RNA&lt;50 copies/mL (VS) at week 48 (W48). ITT and OT analysis performed. Results described by median (IQR). Summary of results: 109 screened, 34 screening failures, 75 randomised, 72 initiated the assigned treatment [38 and 34 pts in Arm A and B, respectively]: 69% males; age: 47.4 (43.2-51.9) years; years of HIV infection: 17 (14-23); nadir CD4+: 150 (47-231) cells/μL. Similar baseline demographic and clinical characteristics were found in Arm A vs Arm B [CD4+: 413 (294-550) vs 377 227-520) cells/µL; HIV-RNA: 3.94 (2.89-4.43) vs 3.66 (2.78-4.20) log10copies/mL; number of mutations: 9 (5-13) vs 9 (3-19); R5-virus: 67% vs 50%; new regimen GSS: 2 (2-3) vs 2 (2-2); 60% vs 56% pts included in the new regimen at least two of the following drugs: DRV/r, MVC, RAL, ETR, T-20]. At W48, pts with VS were 15/38 (39%) vs 17/34 (50%) in Arm A and B, respectively (ITT: P=0.477). In Arm A, 25/38 (66%) completed the 24-weeks of monotherapy and 21 reached week 48 vs 27 pts in Arm B (P=0.045). Pts with VS were 15/21 (71%) vs 17/27 (63%) in Arm A and B, respectively (OT: P=0.758). VS according to nadir CD4+, screening HIVRNA and GSS of the new regimen shown in 1. SAEs occurred in 4 (11%) and 2 (6%) in Arm A and B, respectively; all but 1 in Arm A unrelated to the regimen; 4 CDC events: 3 oral candidiasis and 1 recurrence of CMV infection in Arm A; 1 oral candidiasis in Arm B. W48 CD4 change from baseline was: ITT:-4 (-108/+56) and 53 (-37/+110) cells/L (P=0.735); OT: 8 (-62/+58) and 68 (-24/+148) cells/L in arm A and B, respectively (P=0.500). Mutations associated with resistance at W48 were 4 (0-7) and 7 (2-13) in Arm A and B, respectively (P=0.031). R5 virus at W48: Arm A=55% vs Arm B=29% (P=0.124). Conclusions: Use of 3TC monotherapy was associated with greater discontinuation. It may be considered in patients without effective therapeutic options to favour virological efficacy of the subsequent regimen