Sidonie Lambert-Niclot

Efficacy of darunavir/ritonavir maintenance monotherapy in patients with HIV-1 viral suppression: a randomized open-label, noninferiority trial, MONOI-ANRS 136.

Background:Darunavir/ritonavir (darunavir/r) maintenance strategy, in patients with suppressed HIV RNA viremia, is a potential long-term strategy to avoid nucleoside analogue toxicities and to reduce costs. Methods:MONOtherapy Inhibitor protease is a prospective, open-label, noninferiority, 96-week safety and efficacy trial in virologically suppressed patients on triple therapy who were randomized to a darunavir/r triple drug regimen or darunavir/r monotherapy. The primary endpoint was the proportion of patients with HIV RNA less than 400 copies/ml at week 48; treatment failure was defined as two consecutive HIV RNA more than 400 copies/ml (time to loss of virologic response) or any change in treatment. The trial had 80% power to show noninferiority for the monotherapy arm (δ=−10%, 90% confidence interval). Results:A total of 242 patients were screened, 225 of whom were randomized. In the per protocol efficacy analysis, treatment success was 99% on darunavir/r triple drug versus 94% on darunavir/r monotherapy (δ = −4.9%, 90% confidence interval, from −9.1 to −0.8). Similar results were found in intent-to-treat population (92 versus 87.5%, δ = −4.5%, 90% confidence interval from −11.2 to 2.1). Three patients experienced virologic failure on darunavir/monotherapy and none on darunavir/r triple drug. No resistance to protease inhibitor emerged in patients with plasma viral load above 50 copies/ml. The two groups did not differ in the number of serious adverse events. Conclusion:Darunavir/r monotherapy exhibited efficacy rate over 85% with concordant results in the magnitude of difference with darunavir/r triple drug regimen in both intent-to-treat and per protocol analyses, but discordant conclusions with respect to the noninferiority margin. Patients failing on darunavir/r monotherapy had no emergence of new darunavir resistance mutations preserving future treatment options.

Detection of HIV-1 RNA in seminal plasma samples from treated patients with undetectable HIV-1 RNA in blood plasma

Five percent of 145 HIV-1 infected men enrolled in an assisted reproductive technology (ART) program harbored detectable HIV-1 RNA in semen, although they had no other sexually transmitted disease and their blood viral load was undetectable for at least 6 months under antiretroviral treatment. This result justifies measuring HIV-1 RNA in semen before the ART process and suggests that a residual risk of transmission has to be mentioned to the patients who would like to have unprotected sexual intercourse.

Factors Associated With Virological Failure in HIV-1–Infected Patients Receiving Darunavir/Ritonavir Monotherapy

BACKGROUND Our objective was to determine virological and clinical characteristics associated with virological failure in human immunodeficiency virus (HIV)-infected patients switching to darunavir/ritonavir (DRV/r) monotherapy. METHODS The main outcome was virologic rebound, defined as 2 consecutive measurements of HIV-1 plasma RNA viral load (VL) >50 copies/mL. A logistic model was used to investigate which variables were predictive of a virologic rebound at weeks 48 (W48) and 96 (W96). RESULTS Receiving DRV/r monotherapy was associated with virologic rebound at W48 (P = .016) and W96 (P = .002), comparable to triple therapy. In the DRV/r monotherapy group, at W48, having a VL >50 copies/mL at day 0 and even a baseline ultrasensitive VL >1 copy/mL were predictive factors to virologic rebound (P = .042 and P = .025, respectively). At W96, shorter time of prior antiretrovial therapy (ART) exposure (odds ratio [OR] = 2.93 per 5 years decrease; P = .006), higher HIV-1 DNA at day 0 (OR = 2.66 per 1 log(10) copies/10(6) cells increase; P = .04) and adherence <100% (OR = 3.84 vs 100%; P = .02) were associated with an increased risk of rebound. CONCLUSIONS Factors associated with virological failure in patients receiving DRV/r monotherapy were having an initial blip, shorter time of antiretroviral treatment before monotherapy, and an adherence <100% during monotherapy. The importance of prior duration exposure to ART was in agreement with the impact of HIV-1 blood reservoir and VL level at baseline.

Detection of HIV-1 RNA in seminal plasma samples from treated patients with undetectable HIV-1 RNA in blood plasma on a 2002-2011 survey.

Objectives:To estimate the frequency of detectable seminal HIV-1 viral load in men with repeatedly undetectable blood viral load, in the recent past years and over a 10-year period (2002–2011) in a large cohort of HIV-1-infected men from couples requesting assisted reproduction technologies. We also searched for an association between HIV-1 RNA seminal viral load, HIV-1 RNA plasma viral load measured by ultrasensitive assay, and blood HIV-1 DNA in a subgroup of 98 patients. Methods:Three hundred and four HIV-1 infected men have provided 628 paired blood and semen samples. In a subset of 98 patients for which a blood sample was available, residual viremia, HIV-1 RNA in semen and HIV-1 DNA were studied. Results:Twenty of 304 patients (6.6%) had detectable HIV-1 RNA in semen, ranging from 135 to 2365 copies/ml, corresponding to 23 samples, although they had concomitantly undetectable HIV-1 RNA in blood while they were under antiretroviral therapy. This prevalence was stable over time even in recent years. There was an association between HIV-1 RNA plasma viral load measured by ultrasensitive assay and HIV-1 DNA in blood, but both were not associated with seminal HIV-1 RNA viral load. Conclusion:It seems cautious individually to maintain the recommendations of safe sex and the recourse to ART, or at least to inform the couple of the residual potential risk, in serodiscordant couples desiring a child.

Factors associated with proviral DNA HIV-1 tropism in antiretroviral therapy-treated patients with fully suppressed plasma HIV viral load: implications for the clinical use of CCR5 antagonists

OBJECTIVES Most treated HIV-1 patients have undetectable viral loads and the strategies for managing long-term side effects may involve a new class of antiretroviral-like CCR5 antagonists. Tropism determination based on proviral DNA sequence is necessary for patients with a fully suppressed plasma viral load, as assays analysing DNA phenotypes have yet to be developed. We aimed to analyse HIV-1 tropism using proviral DNA sequencing and the associated factors, in a group of patients on antiretroviral (ARV) treatment with an undetectable viral load in plasma. METHODS Blood samples of 140 HIV-1-infected ARV-treated patients with a plasma viral load of <40 copies/mL were studied. All patients had never been treated with CCR5 antagonists. Co-receptor usage was determined using proviral DNA from the V3 env region sequence by Geno2Pheno (false positive rate 10%) and PSSM algorithms. RESULTS Among 140 patients treated using ARV therapy with a fully suppressed plasma viral load, at least 70% of patients had proviral R5-tropic virus. Among all the studied factors (time since HIV infection diagnosis, treatment duration, time since viral load undetectability, HIV subtype, current treatment, age, number of treatment types, sex, genotypic susceptibility score, and nadir and current CD4 cell counts), nadir CD4 T cell count alone was associated with tropism during a multivariate analysis. R5X4/X4 tropism was present in all nadir CD4 categories. CONCLUSIONS Proviral DNA tropism determination should be required, even for patients with a CD4 nadir cell count >350 cells/mm(3), before CCR5 antagonists are used in patients with a fully suppressed plasma viral load.

HIV-1 genome is often defective in PBMCs and rectal tissues after long-term HAART as a result of APOBEC3 editing and correlates with the size of reservoirs

OBJECTIVES Precise characterization of viruses present in reservoirs in long-term pretreated patients will be a major issue to consider in the context of viral eradication. We assessed the frequency of defective viruses present in cellular reservoirs. METHODS Peripheral blood mononuclear cells (PBMCs) and rectal biopsy samples were compared between five patients on successful long-term highly active antiretroviral therapy (HAART) (>7 years without blips) and five untreated patients. Molecular cloning and sequencing of the reverse transcriptase region were used to detect the presence of and quantify in-frame stop codons in HIV quasi-species. The relationship between the size of the reservoir and the frequency of defective genomes was assessed. RESULTS Defective genomes were systematically detected in all patients on long-term HAART in both compartments (PBMCs and rectal tissues), with a higher level of defective genomes per sample compared with PBMCs of untreated patients. A high level of defective genomes was correlated with a small size of HIV proviral DNA. Regarding the nucleotide context, guanine (G) to adenine (A) substitution at tryptophan positions was responsible for the appearance of 89% of all in-frame stop codons in the context of G-to-A hypermutation, likely reflecting APOBEC3 footprints on the viral genome. CONCLUSIONS We propose a scenario whereby defective genomes accumulate during HAART treatment, eventually reaching a viral extinction threshold. In the context of viral eradication, measurement of the relative amounts of defective and non-defective viruses (by molecular cloning and ultradeep sequencing) should be used as a new criterion for eradicating HIV.

Mutations associated with virological response to darunavir/ritonavir in HIV-1-infected protease inhibitor-experienced patients

OBJECTIVE The aim of the study was to identify a pattern of protease gene mutations associated with the virological response to darunavir/ritonavir-based regimens. PATIENTS AND METHODS We analysed 153 treatment-experienced patients receiving a darunavir/ritonavir salvage regimen as a sole protease inhibitor (PI). Virological response was defined as an HIV-1 RNA load of <200 copies/mL at month 3. The impact of individual protease gene mutations on the virological response to darunavir/ritonavir was examined, and the combination of mutations most strongly associated with the virological response was identified. RESULTS The baseline median HIV RNA level was 4.7 log(10) copies/mL and the median CD4 cell count was 142 cells/mm(3). At month 3, 55% of patients had a virological response and the median fall in viral load from baseline was 1.7 log(10) copies/mL. All the patients had detectable darunavir concentrations at month 3. Cochran-Armitage procedure identified eight mutations with a negative impact on the virological response, namely K14R, K20I, E34Q, I47V, I54M, K55R, T74P and I84V; and two mutations (E35D and V82A) with a positive impact. In multivariate analyses, our genotypic scores were highly predictive of the virological response at month 3, along with the baseline plasma viral load and enfuvirtide co-prescription to enfuvirtide-naive patients. CONCLUSIONS Among the eight mutations with a negative impact on the virological response, I47V, I54M, T74P and I84V were previously described as darunavir resistance-associated mutations. Some PI resistance mutations had a positive impact on the virological response. These findings might help to explain the potency of darunavir/ritonavir on PI-resistant HIV.

Primary genotypic resistance of HIV-1 to CCR5 antagonists in CCR5 antagonist treatment-naive patients

Resistance to CCR5 antagonists can be driven by mutations in gp120. Sequences from 323 anti-CCR5 naive patients were analyzed for the presence of previously described in-vivo or in-vitro resistance mutations to CCR5 antagonists located in the V3 loop of gp120. The V3 loop region was rather polymorphic, and 7.3% of patients showed viruses with combinations of mutations in V3 loop previously described to be involved in maraviroc resistance, a licensed CCR5 antagonist.

Similar Evolution of Cellular HIV-1 DNA Level in Darunavir/Ritonavir Monotherapy versus Triple Therapy in MONOI –ANRS136 Trial over 96 Weeks

Background A higher proportion of intermittent viremia (to have a HIV-1 RNA viral load>50 copies/mL not confirmed) was reported in the boosted protease inhibitor monotherapy arm in some studies including MONOI trial, and that could have an impact on the replenishment of the HIV-1 DNA reservoirs. The HIV-1 DNA level is an interesting marker which reflects the size of cellular HIV reservoir. Our objectives were to study the impact of 96 weeks of Darunavir/ritonavir monotherapy versus a triple standard combination on the HIV-1 blood reservoir and factors associated with HIV-1 plasma DNA at baseline in MONOI trial sub-study. Methodology/Principal Findings This sub-study is focused on 160 patients (79 patients in monotherapy arm and 81 in tritherapy arm) for whom blood cells were available both at baseline and at week 96 (W96). Baseline HIV-1 plasma DNA was associated with CD4 nadir, pre therapeutic HIV-1 RNA viral load and baseline HIV-1 RNA measured by ultrasensitive assay. A similar median delta HIV-DNA was observed between D0 and W96 in both arms; 0.35 log copies/106 leucocytes in monotherapy arm versus 0.51 log copies/106 leucocytes in tritherapy arm. Conclusion/Significance Despite a higher proportion of intermittent viremia in monotherapy arm, a similar evolution of cellular HIV-1 DNA level was observed between mono and triple therapy arm. Trial Registration ClinicalTrials. gov NCT00421551

Presence of HIV-1 R5 viruses in cerebrospinal fluid even in patients harboring R5X4/X4 viruses in plasma.

Background:HIV-1 viruses have the ability to use CCR5 or CXCR4 coreceptors either solely (R5 or X4) or in combination (R5X4). The CCR5 antagonists block HIV entry into the cell and are specifically active against HIV-1 R5 strains. The objectives of this study were to investigate the predicted tropism of viruses present in paired cerebrospinal fluid (CSF) and plasma in a group of 22 HIV-1-infected patients with neurological disorders and to search for eventual discordance of predicted virus tropism between both compartments. Methods:Paired CSF and plasma samples were selected from subjects harboring neurological disorders. V3 env was amplified and bulk sequenced, and HIV-1 coreceptor usage was determined from the V3 env region sequence by Geno2Pheno and position-specific scoring matrices (PSSM) algorithms. Results:The majority of subjects (19 of 22) had concordant virus predicted tropism in both compartments. All patients having R5-tropic viruses in plasma had R5-tropic viruses in CSF (17 of 22). Patients having R5X4/X4-tropic viruses in plasma could have R5X4/X4-using (2 of 22) or R5-tropic viruses (3 of 22) in CSF. The case of R5-tropic viruses in plasma and R5X4/X4-tropic viruses in CSF was never observed. Conclusions:The majority of these patients have R5-using viruses in CSF that is mainly concordant with the predicted tropism in plasma. However, R5X4/X4 tropism in plasma does not necessarily mean the same predicted tropism in CSF compartment. Then, clinical therapeutic trials testing the clinical response to the CCR5 antagonists in patients with neurological disorders could be envisaged to analyze the effects of this therapeutic class in this setting.