Jordi Curto

Maraviroc Concentrations in Cerebrospinal Fluid in HIV-Infected Patients

Objective:To determine maraviroc (MVC) concentrations in cerebrospinal fluid (CSF) in HIV-infected patients. Methods:Twelve CCR5+ HIV-1 adult antiretroviral-experienced patients receiving MVC-containing regimens for at least 1 month were enrolled. Both CSF and blood samples were taken around 12 hours after the last MVC dose. liquid chromatography tandem mass spectrometry was used to determine MVC concentrations, and HIV-1 viral load was determined by real-time polymerase chain reaction, (LOD, 40 copies/mL). Results:Twelve blood and 12 CSF samples were collected. Median CD4 count was 281(120-759) cells per microliter, and median HIV-1 viral load was <40 copies per milliliter. Median time on MVC was 13.5 weeks (4-60). Nucleoside analogues (tenofovir/didanosine) were given in only 1 case. Median MVC concentrations in plasma were 124.75 (7.3-517) ng/mL. In all except one, CSF sample-receiving an erroneous MVC dose while taking concomitantly nevirapine-MVC concentrations [2.58 (<0.5-7.22) ng/mL] were within the EC90 range (0.06-10.70). Median MVC CSF: plasma ratio was 0.022 (0.004-0.17), and when the free MVC plasma concentration was used, 0.094 (2.58-27.44). CSF viral load was <40 copies per milliliter in all 9 patients with undetectable plasma viral load. Conclusions:MVC achieves concentrations within the EC90 range in CSF. All patients with undetectable plasma viral load although receiving nucleoside-sparing regimens including new drugs showed viral suppression in CSF.

How much fat loss is needed for lipoatrophy to become clinically evident

The objective of this study was to evaluate how much limb fat is needed to be lost for lipoatrophy to become clinically evident. Antiretroviral drug-naive patients from a randomized trial comparing stavudine or abacavir plus lamivudine and efavirenz, who had subjective assessment to detect clinically evident lipoatrophy (standardized questionnaire) and objective measurements of limb fat (dual X-ray absorptiometry) at baseline, 48 weeks, and 96 weeks were included. ROC curves were used to assess the sensitivity and specificity of several cut-off values of absolute and percent limb fat loss for diagnosing lipoatrophy. Of 54 patients included, 13 (24%) had subjective lipoatrophy at 96 weeks. After 96 weeks, median limb fat change was -2.3 kg (interquartile range: -5.2, +0.2) and 0.4 kg (interquartile range: -7.2, +3.4) in patients with and without lipoatrophy, respectively. Median percent limb fat change was -45.5% (interquartile range: -78.0, +3.7) and 5.5% (interquartile range: -62.8, +95.6), respectively. The cut-off values of absolute and percent limb fat loss showing the best sensitivity and specificity values were -1.5 kg (sensitivity, 77%; specificity, 76%) and -30% (sensitivity, 85%; specificity, 73%). At least 30% limb fat is needed to be lost in HIV-infected patients for lipoatrophy to become clinically evident.

Maraviroc concentrations in seminal plasma in HIV-infected patients.

To the Editors: Maraviroc (MVC) is the first CCR5-antagonist approved for HIV treatment and has shown potent antiviral activity in HIV-infected patients with confirmed CCR5+ tropism. Little is known about its penetration and antiviral activity in viral reservoirs. The male genital tract can act as a separate compartment, in which different viral resistance patterns may develop, mainly in patients receiving drugs with suboptimal penetration. Good penetration of antiretroviral (ARV) drugs to the seminal plasma, a suggested surrogate male genital tract marker, could be associated with a decrease in viral replication and plays an important role in the prevention of sexual transmission of HIV. We present a series of HIV-infected ARV-experienced patientsdmost receiving an MVC-containing nucleosidesparing regimendin whom MVC concentrations and viral loads (VLs) were determined in blood plasma (BP) and seminal plasma (SP). MVC concentration in cerebrospinal fluid concentration was also assessed in some patients, and the results will be reported elsewhere. Eleven asymptomatic adult HIVinfected ARV-pretreated patients without clinical evidence of sexually transmitted disease were enrolled in our HIV outpatient unit. All had been taking MVC as part of an ARV regimen for at least 4 weeks. MVC dosage was set according to the recommendations stated in the European Medicines Agency’s scientific report. In each patient, plasma samples were obtained by peripheral venous puncture and semen samples by selfmasturbation. All samples were centrifuged and frozen at 70(C until analysis. Both blood and semen samples were taken the same day, approximately 12 hours after the previous MVC dose, to obtain the lowest BP MVC concentrations. The study was approved by the hospital ethics committee and the Spanish Drug Agency, and the patients gave written informed consent to participate. Total MVC concentrations in BP and SP samples were analyzed by a validated liquid chromatography tandem mass spectrometry assay (Tandem Labs, West Trenton, NJ; the ion transition monitored was 514.1/389.1) The reverse-phase chromatography calibration range was 0.5–500 ng/mL in Liheparin plasma samples. The extraction procedure is based on protein precipitation with acetonitrile, using 50 mL of plasma. The internal standard was the stable isotope label for MVC. HIV-1 VL was quantified with a real-time polymerase chain reaction technique (Abbott Molecular, Inc, Des Plaines, IL; limit of detection, 40 copies/mL). Patient mean age was 47 years. Median HIV-1 VL was <40 (<40–1777) copies per milliliter, and median CD4 count was 264 (120–810) cells per microliter. Patients were receiving MVC for a median of 5 (4–60) weeks. The pharmacokinetic data, virologic data, and ARV regimens received are summarized in Table 1. Raltegravir (RGV) was given in 90.9% of cases, darunavir in 54.5%, and etravirine in 36.3%. Only 2 patients received nucleoside analogues (TDF/ddI and TDF), and one other received nevirapine (NVP). According to the recommendations, this last patient should have received 300 mg twice a day of MVC in combination with RGV and NVP, but he erroneously took 150 mg twice a day. MVC BP and SP concentrations were determined in 13 samples from 11 patients. All MVC BP concentrations were above the minimal therapeutic concentration required to suppress HIV; the median value was 123 ng/mL (31.7– 529 ng/mL). In all SP samples, MVC concentrations exceeded several fold the median serum-adjusted EC90 of 0.57 ng/ mL (0.06–10.7 ng/mL). The median MVC SP concentration was 197 ng/mL (15.8–1650 ng/mL), and the median MVC SP:BP ratio was 0.89 (0.06–31.4). HIV-1 VL in SP was analyzed in 11 samples from 9 patients and was undetectable in 8 of them. BP VL was detectable in 3 of 9 patients, at levels of 1777, 202, and 99 copies per milliliter, respectively. Virologic response was adequate, with a 1.9–2.8 log VL reduction after 4, 4, and 5 weeks of MVC-including regimens, and in all 3 patients, SP VL was <40 copies per milliliter. On the other hand, 2 patients had detectable VL in SP while achieving BP suppression. One (patient 9) had been taking MVC for 58 weeks and had undetectable VL in SP in a subsequent sample. The other (patient 4; the NVP patient taking a suboptimal MVC dose) had the lowest MVC SP concentrations; VL was <40 copies per milliliter in a subsequent SP sample, despite a similar MVC SP concentration, but with a higher MVC BP concentration. In another patient (patient 6) with detectable SP VL, the semen sample was brought several weeks after a transient therapy discontinuation, and the results coincided with a parallel increase in BP VL. In this study, MVC BP concentrations in all patients were in the expected range; that is, several times higher than the median serum-adjusted EC90. MVC SP concentrations were higher than the upper end of the EC90 range in all patients. MVC reached a median SP concentration of 89% of the BP plasma concentration, suggesting that MVC diffuses passively from blood to the seminal compartment through the blood– testis barrier. Moreover, as MVC protein binding in semen seems to be low, at around 9% (4%–25%), the free MVC concentrations (active drug) in SP would be still several times above the EC90. We also found a very important interindividual variability in MVC plasma and semen concentrations. MVC is a substrate of CYP3A and also substrate of P-glycoprotein (PGP), and a concomitant use of CYP3A inhibitors and/or inducers with MVCmay alter the concentrations of this drug. Absorption and efflux from different compartments are influenced by the activity of PGP, which may be also altered by protease inhibitors. However, we could not find a statistically significant relationship between the concomitant use of MVC and CYP3A and/or PGP modifiers. Previous studies have demonstrated differing patterns of ARV drug penetration into male genital secretions: good concentrations with nucleoside analogues and nevirapine, varying with PIs, and lower with EFV. New

Atherogenic properties of lipoproteins in HIV patients starting atazanavir/ritonavir or darunavir/ritonavir: a substudy of the ATADAR randomized study

OBJECTIVES To assess LDL subfraction phenotype and lipoprotein-associated phospholipase A2 (Lp-PLA2) in naive HIV-infected patients starting atazanavir/ritonavir or darunavir/ritonavir plus tenofovir/emtricitabine. METHODS This was a substudy of a multicentre randomized study. Standard lipid parameters, LDL subfraction phenotype (by gradient gel electrophoresis) and Lp-PLA2 activity (by 2-thio-PAF) were measured at baseline and weeks 24 and 48. Multivariate regression analysis was performed. Results are expressed as the median (IQR). RESULTS Eighty-six (atazanavir/ritonavir, n=45; darunavir/ritonavir, n=41) patients were included: age 36 (31-41) years; 89% men; CD4 319 (183-425) cells/mm(3); and Framingham score 1% (0%-2%). No differences in demographics or lipid measurements were found at baseline. At week 48, a mild but significant increase in total cholesterol and HDL-cholesterol was observed in both arms, whereas LDL cholesterol increased only in the darunavir/ritonavir arm and triglycerides only in the atazanavir/ritonavir arm. The apolipoprotein A-I/apolipoprotein B ratio increased only in the atazanavir/ritonavir arm. At week 48, the LDL subfraction phenotype improved in the darunavir/ritonavir arm (increase in LDL particle size and in large LDL particles), whereas it worsened in the atazanavir/ritonavir arm (increase in small and dense LDL particles, shift to a greater prevalence of phenotype B); the worsening was related to the greater increase in triglycerides in the atazanavir/ritonavir arm. No changes in total Lp-PLA2 activity or relative distribution in LDL or HDL particles were found at week 48 in either arm. CONCLUSIONS In contrast with what occurred in the atazanavir/ritonavir arm, the LDL subfraction phenotype improved with darunavir/ritonavir at week 48. This difference was associated with a lower impact on plasma triglycerides with darunavir/ritonavir.

Randomized trial of a multidisciplinary lifestyle intervention in HIV-infected patients with moderate-high cardiovascular risk

OBJECTIVE To assess the impact of a multidisciplinary lifestyle intervention on cardiovascular risk and carotid intima-media thickness (c-IMT) in HIV-infected patients with Framingham scores (FS) > 10%. DESIGN Randomized pilot study; follow-up 36 months. METHODS Virologically suppressed adult HIV-1-infected patients with FS >10% were randomized 1:1 to the intervention group (multidisciplinary lifestyle intervention) or control group (routine care). At baseline and months 12, 24 and 36, lipid parameters were analyzed and carotid ultrasound was performed to determine c-IMT and presence of plaques. Biomarkers were measured at baseline and month 36. The primary endpoints were lipid and FS changes at 36 months. RESULTS Fifty-four patients were included, 27 in each arm. Median age was 50.5 years, all patients but one were men, and FS was 16.5%. Relative to controls, total and LDL cholesterol had significantly decreased in the intervention group at 24 months (p = 0.039, p = 0.011, respectively). However, no differences between groups were found at month 36 in lipid variables, neither in FS. Tobacco use decreased in the intervention group (p = 0.031). At baseline, 74.5% of patients had subclinical atherosclerosis, and at month 36, we observed a progression in c-IMT that was greater in the intervention group (p = 0.030). D-dimer increased (p = 0.027) and soluble intercellular adhesion molecule-1 decreased (p = 0.018) at 36 months. CONCLUSIONS In this cohort of HIV-infected patients with FS>10% and a high percentage of subclinical atherosclerosis, a multidisciplinary lifestyle intervention resulted in a slight improvement in some cardiovascular risk factors and the FS during the first 2 years, but did not prevent c-IMT progression.

Effectiveness of efavirenz compared with ritonavir-boosted protease-inhibitor-based regimens as initial therapy for patients with plasma HIV-1 RNA above 100,000 copies/ml.

BACKGROUND There are no clinical trials in which the main objective is to compare the efficacy of efavirenz versus ritonavir-boosted protease inhibitor (PI/r)-based initial antiretroviral therapy (ART) in patients with high plasma HIV-1 RNA levels. This study aims to compare these regimens in this patient population in the setting of routine clinical practice. METHODS This was a multicentre, observational cohort study, including 596 consecutive treatment-naive patients with plasma HIV-1 RNA>100,000 copies/ml initiating efavirenz or PI/r-based ART between 2000 and 2010. The primary effectiveness end point was the percentage of patients with HIV-1 RNA<50 copies/ml at week 48 by intent-to-treat analysis. RESULTS Among a total of 596 patients, 57% initiated efavirenz and 43% PI/r-regimens (73% lopinavir and fosamprenavir [62% lopinavir, 11% fosamprenavir]). HIV-1 RNA suppression to <50 copies/ml at week 48 was higher in the efavirenz group (84% versus 74% [difference 10%, 95% CI 3.4%, 16.7%; P=0.002]). The percentage of virological failures was similar (efavirenz 4% versus PI/r 4%; P=0.686), but voluntary discontinuations and toxicity-related treatment changes were higher with PI/r (4% versus 1%; P=0.006 and 11% versus 6%; P=0.069, respectively). However, resistance selection at failure was higher in patients receiving efavirenz (89% versus 50%; P=0.203). Efavirenz was significantly more effective than lopinavir/r or fosamprenavir/r, whereas no significant differences were observed between efavirenz and darunavir/r or atazanavir/r. The high viral suppression in the efavirenz group was also evident in patients with very high viral loads (>500,000 copies/ml) and in those with low CD4(+) T-cell counts. CONCLUSIONS In routine clinical practice, the effectiveness of initial efavirenz-based regimens was at least similar to or even higher than various PI/r-based regimens in HIV-1-infected patients with plasma HIV-1 RNA>100,000 copies/ml.

Impact of antiretroviral therapy interruption on plasma biomarkers of cardiovascular risk and lipids: 144-week final data from the STOPAR study†

The aim of the study was to investigate changes in plasma biomarkers of cardiovascular risk and lipids in a CD4‐guided antiretroviral therapy interruption study.

Abacavir/lamivudine plus darunavir/ritonavir in routine clinical practice: a multicentre experience in antiretroviral therapy-naive and -experienced patients

OBJECTIVES To present clinical experience with a regimen including abacavir/lamivudine + darunavir/ritonavir in a cohort of HIV-1-infected patients. METHODS A retrospective, multicentre cohort study, including all consecutive adult HIV-1-infected patients who started abacavir/lamivudine + darunavir/ritonavir from April 2008 to December 2010 and had at least one follow-up visit. The primary endpoint was HIV-1 viral load (VL) <40 copies/mL at week 48. RESULTS One hundred and eighty-three patients (42 naive and 141 experienced) from 19 hospitals in Spain were studied. The median follow-up was 26.7 (0.5-58.6) months, 79.8% were men, the median age was 47.1 (21.4-80.5) years, 26.2% had AIDS and 38.8% were positive for hepatitis C virus. At baseline, the median CD4 count was 246 cells/mm(3) in naive patients and 393 cells/mm(3) in experienced patients and the median VL was 4.80 and <1.59 log copies/mL, respectively. At week 48, 81.8% of naive patients and 84.2% of experienced patients receiving the regimen reached a VL <40 copies/mL, whereas at 96 weeks this occurred in 90.5% and 92.8%, respectively. CD4 cell count increases at 48 and 96 weeks were +176.5 and +283.5 cells/mm(3) in naive patients and +74.9 and +93 cells/mm(3) in experienced patients, respectively. Overall, 86 (47%) patients discontinued the study regimen, in many cases possibly related to non-medical reasons, such as drug switches to reduce cost or changes in address due to economic constraints. Three patients died of causes unrelated to therapy and 19 (10.4%) discontinued the regimen due to adverse events. CONCLUSIONS In our cohort, abacavir/lamivudine + darunavir/ritonavir was safe, well tolerated and achieved high rates of virological suppression. In a proportion of patients, discontinuation of this effective regimen was possibly due to non-medical reasons.

Switching to Raltegravir in Virologically Suppressed in HIV-1-Infected Patients: A Retrospective, Multicenter, Descriptive Study

OBJECTIVES To describe the efficacy and tolerability of switching to raltegravir (RAL) in virologically suppressed HIV-1-infected patients during routine clinical practice. METHODS A total number of 263 subjects (189 men, median age 48.1 years) with HIV-1 RNA < 50 copies/mL for ≥ 6 months were switched to RAL (400 mg b.i.d). Reasons for change were toxicity (49.0%), drug interactions (6.1%) or convenience (28.6%) (switch from subcutaneous to oral treatment 22.4%, improvement of posology 3.4%). Patients were followed up to 24 months after switching to RAL. Primary end-points were tolerability and virological failure defined as two consecutive measures of HIV-1 RNA > 50 copies/mL. RESULTS After a median of 12.4 months (range 2.8-26.4 months), virological failure was observed in 6 (2.3%) patients (2.2 per 100 person-years [95%CI 0.9-4.6]), while AIDS occurred in 1, drug discontinuation in 4, 3 patients died and 10 were lost to follow-up. The median CD4+ T cell count increased from 460 cells/mm3 to 508.6 cells/mm3 (P < 0.001). CONCLUSIONS Switching to RAL in clinical practice was mainly driven by toxicity, convenience or interactions, they were well tolerated and secured virologic suppression in the vast majority of patients.

Clinical progression of severely immunosuppressed HIV-infected patients depends on virological and immunological improvement irrespective of baseline status

OBJECTIVES The aim of this study was to analyse factors associated with progression to AIDS/death in severely immunosuppressed HIV-infected patients receiving ART. METHODS This study included naive patients from the PISCIS Cohort with CD4 <200 cells/mm(3) at enrolment and who initiated ART consisting of two nucleoside analogues plus either a PI or an NNRTI between 1998 and 2011. The PISCIS Cohort is a multicentre, observational study of HIV-infected individuals aged >18 years followed at 14 participating hospitals in Catalonia and the Balearic Islands (Spain). Clinical and laboratory parameters were assessed every 3-4 months during follow-up. Cox regression models were used to assess the effect of CD4 and viral load on the risk of progression to AIDS/death, adjusting for baseline variables and confounders. RESULTS 2295 patients were included and, after 5 years, 69.9% reached CD4 ≥200 cells/mm(3), 64.4% had an undetectable viral load and 482 (21%) progressed to AIDS/death. The lowest rate of disease progression was found in patients who reached both immunological and viral responses during follow-up, regardless of their baseline situation (1.9% in baseline CD4 >100 cells/mm(3) and viral load <5 log copies/mL; 2.3% in baseline CD4 ≤100 cells/mm(3) and/or viral load >5 log copies/mL). Achieving a CD4 count ≥200 cells/mm(3) was the main predictor of decreased progression to AIDS/death. In those not reaching this CD4 threshold, virological response reduced disease progression by half. CONCLUSIONS Even in the worse baseline scenario of CD4 ≤100 cells/mm(3) and high baseline viral loads, positive virological and immunological responses were associated with dramatic decreases in progression.