Jan van Lunzen

Efficacy and safety of once-daily darunavir/ritonavir versus lopinavir/ritonavir in treatment-naive HIV-1-infected patients at week 48

Background:The present primary analysis of AntiRetroviral Therapy with TMC114 ExaMined In naive Subjects (ARTEMIS) compares the efficacy and safety of once-daily darunavir/ritonavir (DRV/r) with that of lopinavir/ritonavir (LPV/r) in treatment-naive patients. Methods:Patients with HIV-1 RNA at least 5000 copies/ml were stratified by HIV-1 RNA and CD4 cell count in a phase III, open-label trial, and randomized to receive DRV/r 800/100 mg qd or LPV/r 800/200 mg total daily dose (bid or qd) plus fixed-dose tenofovir and emtricitabine for 192 weeks. The primary objective was to demonstrate non-inferiority of DRV/r as compared with LPV/r in HIV-1 RNA less than 50 copies/ml per-protocol time-to-loss of virologic response at 48 weeks. Results:Six hundred and eighty-nine patients were randomized and treated; mean baseline HIV-1 RNA: 4.85 log10 copies/ml and median CD4 count: 225 cells/μl. At 48 weeks, 84% of DRV/r and 78% of LPV/r patients achieved HIV-1 RNA less than 50 copies/ml (estimated difference = 5.6 [95% confidence interval −0.1–11]%), demonstrating non-inferiority of DRV/r as compared with LPV/r (P < 0.001; per-protocol time-to-loss of virologic response). Patients with HIV-1 RNA at least 100 000 copies/ml had a significantly higher response rate with DRV/r (79%) versus LPV/r (67%; P < 0.05). Median CD4 cell count increases (non-completer = failure; cells/μl) were 137 for DRV/r and 141 for LPV/r. DRV/r had a lower incidence of possibly treatment-related grade 2–4 gastrointestinal-related adverse events (7 versus 14%) and treatment-related moderate-to-severe diarrhea (4 versus 10%) than LPV/r. Adverse events leading to discontinuation were DRV/r: 3% and LPV/r: 7%. Conclusion:DRV/r 800/100 mg qd was non-inferior to LPV/r 800/200 mg at 48 weeks, with a more favorable safety profile. Significantly higher response rates were observed with DRV/r in patients with HIV-1 RNA at least 100 000 copies/ml. DRV/r 800/100 mg offers a new effective and well tolerated once-daily, first-line treatment option for treatment-naive patients.

Expansion of HIV-specific T follicular helper cells in chronic HIV infection

HIV targets CD4 T cells, which are required for the induction of high-affinity antibody responses and the formation of long-lived B cell memory. The depletion of antigen-specific CD4 T cells during HIV infection is therefore believed to impede the development of protective B cell immunity. Although several different HIV-related B cell dysfunctions have been described, the role of CD4 T follicular helper (TFH) cells in HIV infection remains unknown. Here, we assessed HIV-specific TFH responses in the lymph nodes of treatment-naive and antiretroviral-treated HIV-infected individuals. Strikingly, both the bulk TFH and HIV-specific TFH cell populations were significantly expanded in chronic HIV infection and were highly associated with viremia. In particular, GAG-specific TFH cells were detected at significantly higher levels in the lymph nodes compared with those of GP120-specific TFH cells and showed preferential secretion of the helper cytokine IL-21. In addition, TFH cell expansion was associated with an increase of germinal center B cells and plasma cells as well as IgG1 hypersecretion. Thus, our study suggests that high levels of HIV viremia drive the expansion of TFH cells, which in turn leads to perturbations of B cell differentiation, resulting in dysregulated antibody production.

Once-daily dolutegravir versus darunavir plus ritonavir in antiretroviral-naive adults with HIV-1 infection (FLAMINGO): 48 week results from the randomised open-label phase 3b study

BACKGROUND Dolutegravir has been shown to be non-inferior to an integrase inhibitor and superior to a non-nucleoside reverse transcriptase inhibitor (NNRTI). In FLAMINGO, we compared dolutegravir with darunavir plus ritonavir in individuals naive for antiretroviral therapy. METHODS In this multicentre, open-label, phase 3b, non-inferiority study, HIV-1-infected antiretroviral therapy-naive adults with HIV-1 RNA concentration of 1000 copies per mL or more and no resistance at screening were randomly assigned (1:1) to receive either dolutegravir 50 mg once daily or darunavir 800 mg plus ritonavir 100 mg once daily, with investigator-selected tenofovir-emtricitabine or abacavir-lamivudine. Randomisation was stratified by screening HIV-1 RNA (≤100,000 or >100,000 copies per mL) and nucleoside reverse transcriptase inhibitor (NRTI) selection. The primary endpoint was the proportion of patients with HIV-1 RNA concentration lower than 50 copies per mL (Food and Drug Administration [FDA] snapshot algorithm) at week 48 with a 12% non-inferiority margin. This trial is registered with ClinicalTrials.gov, NCT01449929. FINDINGS Recruitment began on Oct 31, 2011, and was completed on May 24, 2012, in 64 research centres in nine countries worldwide. Of 595 patients screened, 484 patients were included in the analysis (242 in each group). At week 48, 217 (90%) patients receiving dolutegravir and 200 (83%) patients receiving darunavir plus ritonavir had HIV-1 RNA of less than 50 copies per mL (adjusted difference 7·1%, 95% CI 0·9-13·2), non-inferiority and on pre-specified secondary analysis dolutegravir was superior (p=0·025). Confirmed virological failure occurred in two (<1%) patients in each group; we recorded no treatment-emergent resistance in either group. Discontinuation due to adverse events or stopping criteria was less frequent for dolutegravir (four [2%] patients) than for darunavir plus ritonavir (ten [4%] patients) and contributed to the difference in response rates. The most commonly reported (≥10%) adverse events were diarrhoea (dolutegravir 41 [17%] patients vs darunavir plus ritonavir 70 [29%] patients), nausea (39 [16%] vs 43 [18%]), and headache (37 [15%] vs 24 [10%]). Patients receiving dolutegravir had significantly fewer low-density lipoprotein values of grade 2 or higher (11 [2%] vs 36 [7%]; p=0·0001). INTERPRETATION Once-daily dolutegravir was superior to once-daily darunavir plus ritonavir. Once-daily dolutegravir in combination with fixed-dose NRTIs represents an effective new treatment option for HIV-1-infected, treatment-naive patients. FUNDING ViiV Healthcare and Shionogi & Co.

MyD88-Dependent Immune Activation Mediated by Human Immunodeficiency Virus Type 1-Encoded Toll-Like Receptor Ligands

ABSTRACT Immune activation is a major characteristic of human immunodeficiency virus type 1 (HIV-1) infection and a strong prognostic factor for HIV-1 disease progression. The underlying mechanisms leading to immune activation in viremic HIV-1 infection, however, are not fully understood. Here we show that, following the initiation of highly active antiretroviral therapy, the immediate decline of immune activation is closely associated with the reduction of HIV-1 viremia, which suggests a direct contribution of HIV-1 itself to immune activation. To propose a mechanism, we demonstrate that the single-stranded RNA of HIV-1 encodes multiple uridine-rich Toll-like receptor 7/8 (TLR7/8) ligands that induce strong MyD88-dependent plasmacytoid dendritic cell and monocyte activation, as well as accessory cell-dependent T-cell activation. HIV-1-encoded TLR ligands may, therefore, directly contribute to the immune activation observed during viremic HIV-1 infection. These data provide an initial rationale for inhibiting the TLR pathway to directly reduce the chronic immune activation induced by HIV-1 and the associated immune pathogenesis.

Barriers to a cure for HIV: new ways to target and eradicate HIV-1 reservoirs

Antiretroviral therapy for HIV infection needs lifelong access and strict adherence to regimens that are both expensive and associated with toxic effects. A curative intervention will be needed to fully stop the epidemic. The failure to eradicate HIV infection during long-term antiretroviral therapy shows the intrinsic stability of the viral genome in latently infected CD4T cells and other cells, and possibly a sustained low-level viral replication. Heterogeneity in latently infected cell populations and homoeostatic proliferation of infected cells might affect the dynamics of virus production and persistence. Despite potent antiretroviral therapy, chronic immune activation, inflammation, and immune dysfunction persist, and are likely to have important effects on the size and distribution of the viral reservoir. The inability of the immune system to recognise cells harbouring latent virus and to eliminate cells actively producing virus is the biggest challenge to finding a cure. We look at new approaches to unravelling the complex virus-host interactions that lead to persistent infection and latency, and discuss the rationale for combination of novel treatment strategies with available antiretroviral treatment options to cure HIV.

Once daily dolutegravir (S/GSK1349572) in combination therapy in antiretroviral-naive adults with HIV: planned interim 48 week results from SPRING-1, a dose-ranging, randomised, phase 2b trial

BACKGROUND Dolutegravir (S/GSK1349572) is a new HIV-1 integrase inhibitor that has antiviral activity with once daily, unboosted dosing. SPRING-1 is an ongoing study designed to select a dose for phase 3 assessment. We present data from preplanned primary and interim analyses. METHODS In a phase 2b, multicentre, dose-ranging study, treatment-naive adults were randomly assigned (1:1:1:1) to receive 10 mg, 25 mg, or 50 mg dolutegravir or 600 mg efavirenz. Dose but not drug allocation was masked. Randomisation was by a central integrated voice-response system according to a computer-generated code. Study drugs were given with either tenofovir plus emtricitabine or abacavir plus lamivudine. Our study was done at 34 sites in France, Germany, Italy, Russia, Spain, and the USA beginning on July 9, 2009. Eligible participants were seropositive for HIV-1, aged 18 years or older, and had plasma HIV RNA viral loads of at least 1000 copies per mL and CD4 counts of at least 200 cells per μL. Our primary endpoint was the proportion of participants with viral load of less than 50 copies per mL at week 16 and we present data to week 48. Analyses were done on the basis of allocation group and included all participants who received at least one dose of study drug. This study is registered with ClinicalTrials.gov, number NCT00951015. FINDINGS 205 patients were randomly allocated and received at least one dose of study drug: 53, 51, and 51 to receive 10 mg, 25 mg, and 50 mg dolutegravir, respectively, and 50 to receive efavirenz. Week 16 response rates to viral loads of at most 50 copies per mL were 93% (144 of 155 participants) for all doses of dolutegravir (with little difference between dose groups) and 60% (30 of 50) for efavirenz; week 48 response rates were 87% (139 of 155) for all doses of dolutegravir and 82% (41 of 50) for efavirenz. Response rates between nucleoside reverse transcriptase inhibitor subgroups were similar. We identified three virological failures in the dolutegravir groups and one in the efavirenz group-we did not identify any integrase inhibitor mutations. We did not identify any dose-related clinical or laboratory toxic effects, with more drug-related adverse events of moderate-or-higher intensity in the efavirenz group (20%) than the dolutegravir group (8%). We did not judge that any serious adverse events were related to dolutegravir. INTERPRETATION Dolutegravir was effective when given once daily without a pharmacokinetic booster and was well tolerated at all assessed doses. Our findings support the assessment of once daily 50 mg dolutegravir in phase 3 trials.

Relations among CD4 lymphocyte count Nadir, antiretroviral therapy, and HIV-1 disease progression : Results from the euroSIDA study

The availability and widespread use of highly active antiretroviral therapy have led to marked decreases in the incidence of AIDS-defining illnesses and death (1-3). Highly active antiretroviral therapy substantially increases CD4 lymphocyte counts (4-6) and T-cell function (7-9). Speculation exists about the immune reconstitution and complete recovery of patients infected with HIV (10). The potential for immune reconstitution after severe immunodeficiency is of clinical significance because it may change the need for primary and secondary prophylaxis (11) and will ultimately help to determine the well-being of the patient. Viral load and CD4 cell counts have independently predicted HIV-1 disease progression (12). Clinical trials (13-15) have demonstrated that therapy-related changes in surrogate markers were associated with clinical benefit. However, the effect of a previous CD4 cell count nadir on clinical benefit in patients experiencing increases in CD4 cell count has not been addressed. In addition, an analysis of clinical benefit in patients whose CD4 cell counts have rebounded from very low levels compared with benefit in patients who do not experience such a rebound has not been reported. This information may be difficult to obtain through clinical trials and may be accessible only through large, standardized, monitored observational databases. We explored the relations among CD4 lymphocyte count, antiretroviral treatment, and clinical disease progression through an analysis of the EuroSIDA cohort study, which follows 7333 European patients infected with HIV-1. Our first objective was to investigate the effect of a previous CD4 cell count nadir on prognosis [rate of disease progression and relative hazard for disease progression] in patients who have a CD4 count of at least 200 cells/mm3. We wanted to determine whether HIV-1 disease progresses at the same rate in two types of patients: 1) patients whose previously low CD4 counts have increased to and remain greater than 200 cells/mm3 and 2) patients whose CD4 counts have never decreased to less than 150 cells/mm3 (Figure). Our second objective was to investigate the effect of a rebound in CD4 cell count after a patient has experienced severe immunosuppression. We did this by comparing the rate of disease progression in patients with current CD4 counts of at least 200 cells/mm3 who had a previous nadir of 50 cells/mm3 or less (group A, stratum 4) with the rate of progression in patients with current CD4 cell counts of 50 cells/mm3 or less (group B) (Figure). In addition, we investigated the effect of type of antiretroviral treatment on disease progression in both patient groups. Figure. Study design. solid-line graphs broken-line graph Methods The EuroSIDA study is a prospective, observational study of HIV-infected patients in 52 outpatient clinics across Europe (Appendix) (2, 16). Individual centers enrolled between 24 and 323 patients (13 centers enrolled>200 patients, 18 centers enrolled between 100 and 200 patients, and 21 centers enrolled<100 patients). Consecutive patients who made a regular appointment at least 2 weeks before recruitment were enrolled. Eligible patients were at least 16 years of age and had had a CD4 count less than 500 cells/mm3 in the previous 4 months. The EuroSIDA study has enrolled a total of 7333 patients who were recruited at three separate time points: May 1994 (cohort I; n=3121), December 1995 (cohort II; n=1369), and February 1997 (cohort III; n=2843). Information was collected on a standardized data collection form at baseline and every 6 months thereafter. This information included CD4 cell counts, starting and ending dates of each antiretroviral treatment, use of prophylaxis against opportunistic infections, and dates of diagnosis of all AIDS-defining diseases (according to the 1993 clinical definition of AIDS as determined by the Centers for Disease Control and Prevention). Members of the EuroSIDA coordinating office visited all centers to ensure that patients were selected correctly and that accurate data were provided. Statistical Analysis We identified two groups of patients. Patients in group A had CD4 counts of 200 cells/mm3 or greater; patients in group B had CD4 counts less than 50 cells/mm3. For example, a patient in group A who had a previous CD4 cell count nadir less than 50 cells/mm3 while enrolled in the study would have contributed data to group B for the period that the CD4 cell count was less than 50 cells/mm3. A single patient could thus contribute data to both groups, depending on the profile of CD4 cell counts. At recruitment, information on the four most recent CD4 counts was collected; these data were included in the analyses. Information on all CD4 cell counts measured after recruitment was also collected. We used a patient-years method of analysis to calculate incidence of AIDS-defining illness or death, unadjusted for potential confounding variables. We calculated 95% CIs using a normal approximation or a Poisson distribution when the number of events was small. For the analysis of events in group A (patients with CD4 counts 200 cells/mm3), patient follow-up was from the date on which the first CD4 count of at least 200 cells/mm3 was obtained (referred to as baseline) until the CD4 count decreased to less than 200 cells/mm3 or the patients progressed to death or to an AIDS-defining illness. For patients who had AIDS at baseline, follow-up was continued until development of a new AIDS-defining illness (recurrences of disease were not included). Patients whose CD4 cell count did not decrease to less than 200 cells/mm3 and who did not experience an event were censored at their last follow-up visit. This analysis was stratified according to the minimum CD4 cell count experienced before baseline. Four strata were defined: CD4 cell count nadirs of 150 cells/mm3 or greater (stratum 1), 100 to 149 cells/mm3 (stratum 2), 50 to 99 cells/mm3 (stratum 3), and 1 to 50 cells/mm3 (stratum 4). The incidence of disease in patients from group B (CD4 counts<50 cells/mm3) was calculated in the same way. Patient follow-up began at the date on which the first CD4 count less than 50 cells/mm3 was obtained and ended when the CD4 count increased above this level, when the patient died, or when HIV-1 disease progressed. If none of these events occurred, follow-up ended at the last office visit. To further investigate the relative hazard of disease progression according to CD4 cell count nadir in group A patients, we used Cox proportional-hazards models. We investigated the relation between disease progression and such demographic factors as age, exposure category, sex, and ethnicity. In addition, we considered the following factors at baseline: CD4 cell count, treatment regimen (no treatment, monotherapy, dual combination therapy, combination therapy with three or more drugs, or highly active antiretroviral therapy [defined as a minimum of one protease inhibitor or non-nucleoside reverse transcriptase inhibitor in combination with a minimum of two nucleoside reverse transcriptase inhibitors]), and whether AIDS had been diagnosed in a patient. With the exception of age, demographic factors were not related to disease progression in univariate models and were therefore not included in multivariate models. Variables were included in the multivariate model as fixed covariates. When measurements of CD4 cell count before recruitment to EuroSIDA were included, the analysis was left-censored at the date of recruitment. In the multivariate analysis, we also adjusted for calendar time (because of the strong relation between calendar time and the introduction of more effective therapies) and stratified by study center. We also adjusted for use of prophylaxis against Pneumocystis carinii pneumonia. All analyses were done by using SAS software, version 2 (SAS Institute, Inc., Cary, North Carolina), with one exception: The CIs were calculated on a hand calculator with the use of tables for the Poisson distribution when the number of events was small. Role of the Funding Source The sponsors of the EuroSIDA study did not influence the organization or execution of the study in general; were not involved in the design, execution, and interpretation of this analysis; and had no role in the decision to publish these findings. Results The patient samples on which the analyses are based are described in Table 1. Of a total of 7333 EuroSIDA patients, 5352 had a CD4 count of at least 200 cells/mm3 (group A) and 2514 patients had CD4 cell counts of 50 cells/mm3 or less (group B). Group A patients were stratified according to CD4 cell count nadir: Those in stratum 1 had a nadir of at least 150 cells/mm3; those in stratum 2 had a nadir of 100 to 149 cells/mm3; those in stratum 3 had a nadir of 50 to 99 cells/mm3; and those in stratum 4 had a nadir of less than 50 cells/mm3. When we compared patients from these four strata, the median baseline CD4 cell count was significantly higher in patients from stratum 1. Baseline viral loads were available for a subset of patients only. Median baseline values were greater for patients from stratum 4 and group B. Table 1. Patient Characteristics Table 2 lists the number of events, patient-years of follow-up, and incidence rates for each patient group and stratum. For patients in group A, the overall median duration of follow-up was 16 months; follow-up times decreased sharply as the nadir decreased. Patients in group B had a median follow-up duration of 6 months. The overall incidence for patients with CD4 counts of at least 200 cells/mm3 was 3.9 events per 100 patient-years of follow-up (95% CI, 3.5 to 4.3 events); within the four strata, patients from stratum 1 had the lowest incidence (3.7 events) and patients from strata 2, 3, and 4 had a higher incidence (6.0, 8.1, and 5.9 events, respectively). The incidence for patients from group B was 18-fold higher (72.9 events per 100 patient-years of follow-up [

Impact of CYP2B6 983T>C polymorphism on non-nucleoside reverse transcriptase inhibitor plasma concentrations in HIV-infected patients

OBJECTIVES The aim of this study was to investigate the frequency of CYP2B6 polymorphisms (according to ethnicity) and the influence of heterozygosity and homozygosity on plasma concentrations of efavirenz and nevirapine. METHODS Following written informed consent, 225 Caucasians and 146 Blacks were recruited from the German Competence Network for HIV/AIDS. Plasma concentrations of efavirenz and nevirapine were assessed by HPLC, and genotyping for 516G>T, 983T>C and 1459T>C polymorphisms in CYP2B6 was conducted by real-time PCR-based allelic discrimination. RESULTS The minor allele frequency for 516G>T, 983T>C and 1459T>C was 0.29, 0 and 0.08 in Caucasians and 0.34, 0.07 and 0.02 in Blacks, respectively. Two Black patients with the 983C allele receiving efavirenz were identified and both were withdrawn from therapy within 1 week of sampling due to toxicity. In multivariate analyses, efavirenz and nevirapine plasma concentrations were significantly associated with 983T>C (P < 0.0001 and P = 0.02, respectively), 516G>T (P < 0.0001 and P = 0.002, respectively) and time of drug analysis post-dose (P < 0.0001 for both). Body mass index was independently related to efavirenz (P = 0.04) but not nevirapine concentrations, and age was related to nevirapine (P = 0.05) but not efavirenz concentrations. Consistent with other studies, 1459C>T was not associated with plasma concentrations of either drug (P > 0.05 for both drugs). CONCLUSIONS This is the first report that the 983T>C genotype (part of the CYP2B6*18 haplotype) impacts on nevirapine plasma concentrations and the first study to assess the impact of 983C homozygosity on efavirenz concentrations. These data have implications for administration of non-nucleoside reverse transcriptase inhibitors to Black patients.

Comprehensive Analysis of Frequency and Phenotype of T Regulatory Cells in HIV Infection: CD39 expression of FoxP3+ T regulatory cells correlates with progressive disease.

ABSTRACT There are conflicting data about the frequency and role of regulatory T cells (Tregs) during the course of HIV infection. Peripheral blood of a large cohort of HIV-infected patients (n = 131) at different stages of disease, including 15 long-term nonprogressors and 21 elite controllers, was analyzed to determine the frequency and phenotype of Tregs, defined as CD4+, CD25high, CD127low, FoxP3high cells. A significantly increased relative frequency of Tregs within the CD4+ compartment of HIV+ patients compared to that of healthy controls (P < 0.0001) was observed. Additionally, the relative frequency of Tregs directly correlated with HIV viral load and inversely with CD4+ counts. However, the absolute Treg number was reduced in HIV-infected patients versus healthy controls (P < 0.0001), with the exception of elite controllers (P > 0.05). The loss of absolute Treg numbers coincided with rising markers of immune activation (P < 0.0006). The initiation of antiviral therapy significantly increased absolute Treg numbers (P < 0.0031). We find that the expression of CD39, a newly defined ectonucleotidase with immunomodulatory functions on Tregs, correlated with progressive HIV disease, HIV viral load, and immune activation. Of note, when tested in peripheral blood mononuclear cells of healthy volunteers, the in vitro capacity to suppress T-cell proliferation was limited to CD4+, CD25high, CD39+ T cells. Interestingly, Tregs of elite controllers exhibited not only the highest expression of CCR5, CTLA-4, and ICOS but also the lowest level of CD39. The data presented here reconcile the seemingly contradictory results of previous studies looking at Tregs in HIV and highlight the complexity of Treg-mediated immunoregulation during human viral infections.

Transfer of autologous gene-modified T cells in HIV-infected patients with advanced immunodeficiency and drug-resistant virus.

Drug toxicity and viral resistance limit the long-term efficacy of antiviral drug treatment for human immunodeficiency virus (HIV) infection. Thus, alternative therapies need to be explored. We tested the infusion of T lymphocytes transduced with a retroviral vector (M87o) that expresses an HIV entry-inhibitory peptide (maC46). Gene-modified autologous T cells were infused into ten HIV-infected patients with advanced disease and multidrug-resistant virus during anti-retroviral combination therapy. T-cell infusions were tolerated well, with no severe side effects. A significant increase of CD4 counts was observed after infusion. At the end of the 1-year follow-up, the CD4 counts of all patients were still around or above baseline. Gene-modified cells could be detected in peripheral blood, lymph nodes, and bone marrow throughout the 1-year follow-up, and marking levels correlated with the cell dose. No significant changes of viral load were observed during the first 4 months. Four of the seven patients who changed their antiviral drug regimen thereafter responded with a significant decline in plasma viral load. In conclusion, the transfer of gene-modified cells was safe, led to sustained levels of gene marking, and may improve immune competence in HIV-infected patients with advanced disease and multidrug-resistant virus.