international perspectives of adherence and resistance to hiv antiretroviral therapy · 2019. 9....
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International Perspectives of Adherence and Resistance to HIV Antiretroviral Therapy
David Bangsberg, MD, MPH
Massachusetts General HospitalHarvard Medical School
Harvard Initiative for Global Health
October, 2008
Bell-shaped Adherence and Resistance CurveIn
crea
sing
pro
babi
lity
of se
lect
ing
mut
atio
n
Increasing Adherence
Inadequate Drug Pressure
To Select Resistant Virus
Drug PressureSelects
Resistant Virus
Complete Viral Suppression
Adherence and Prospective Accumulation of Drug Resistance Mutations in The REACH
Cohort
>1mo HAART 6 mo HAART
Genotype #1VL>50 copies
Genotype #2VL >50 copies
>3 mo pill count
Outcome: # IAS-USA primary or secondary drug resistant mutations at Genotype #2 not present at Genotype #1
>7 mo HAART w/o change in regimen
Bangsberg et al AIDS 2003:17:1325
New Drug Resistance Mutations Over 6 Months in by Adherence Quintile in Viremic Patients
REACH Cohort n=57
00.20.40.60.8
11.21.41.61.8
Adherence Quintile0-41% 42-57% 58-78% 79-91% 92-100%
p=0.0002
#New
DR
M
Bangsberg et al AIDS 2003:17:1325
Proportion VL>50 copies/ml by Adherence QuintileREACH Cohort n=148
00.10.20.30.40.50.60.70.80.9
1
Adherence Quintile0-41% 42-57% 58-78% 79-91% 92-100%
p=<0.0001
Prop
ortio
n V
L>50
Bangsberg et al AIDS 2003:17:1325
Resistance Risk by Adherence and Regimen Class
0 20 40 60 80 100
Percent AdherenceSingle PI
Res
istan
ce R
isk
NNRTI
Bangsberg et al J. Antimicrob Chem; 2002 53(5):696-9.
5%
30%
46%
65%
0%
48%
71%60%
0%
20%
40%
60%
80%
100%
0-49% 50-74% 75-95% >=95%
pi rpi
Ritonavir Boosted PIs Lead to Better Viral Suppression at Moderate Adherence LevelsViral Suppression <50 copies/ml for RTV Boosted and Unboosted PI
N=46 N=67 N=83 n=71
Bangsberg et al Int Conference on Adherence to HIV Treatment 2007
P=0.04
Resistance Risk by Adherence and Regimen Class
0 20 40 60 80 100
Percent AdherenceSingle PI Boosted PI
Res
istan
ce R
isk
Bangsberg et al J. Antimicrob Chem; 2002 53(5):696-9.
Why NNRTI Might Have A Different Adherence-Resistance Relationship
• NNRTI potent and exert high selective pressure• NNRTI act distant to the active site – little impact
on fitness• NNRTI resistance seen with single dose therapy
23.3 23.5
5.3 3.410.3
5.6 1.6 20
5
10
15
20
25
<=75 76-85 86-95 >95
Self-reported Adherence and Virological Failure
Adherence: Patient report of % daily doses taken at the right time
Maggiolo F et al. CID 2005;40:158–163.
Failu
re ra
te
PI-based
NNRTI-based
NNRTI Lead to Better Viral Suppression (<400 copies/ml) than Unboosted PIs at Moderate
Electronic Medication Monitor Adherencen=65
23%33%
67%83%
33%
100%86%
75%
0%
20%
40%
60%
80%
100%
120%
0-53 54-73 74-93 94-100
Adherence
Perc
ent V
L<4
00 c
opie
s/m
l
PINNRTI
p=0.01
Bangsberg CID 2006:43:939-41
Prevalence of NNRTI Resistance by AdherenceBangsberg AIDS 2006 20:223-232
0102030405060708090
100
0-53% 54-79% 80-94% 95-100%Adherence Quartile
% R
esis
tant p=0.03
N=54
Resistance Risk by Adherence and Regimen Class
0 20 40 60 80 100
Percent AdherenceSingle PI Boosted PI
Res
istan
ce R
isk
NNRTI
Bangsberg et al J. Antimicrob Chem; 2002 53(5):696-9.
Subjects selecting for viral mutations (NN = any mutation; PI = ≥ 1 major or ≥ 3 minor)
0
1
2
3
4
5
6
< 75% 75-95% > 95%
NN PI boosted PI
Adherence
%
Percent of patients selecting for mutations at by adherence level
Maggiolo et al HIV Clin Trials. 2007 Sep-Oct;8(5):282-92.
Resistance Risk by Adherence and Regimen Class
0 20 40 60 80 100
Percent AdherenceSingle PI
Res
istan
ce R
isk
NNRTI
Bangsberg et al J. Antimicrob Chem; 2002 53(5):696-9.
Patient Plasma
Replicative Capacity
Purify Viral RNA AAAA
AAAAAAAA
RT-PCR
HIV PR and RTSequences
Transfection
Pool of Patient-DerivedRecombinant Viruses Containing Luciferase
+Luciferase
+
PR-RT
Luciferase
A-MLV env
Luciferase Activity (Replication) of Sensitive “Wild-Type” Virus Decreases at Higher Drug Levels
100
1,000
10,000
100,000
1,000,000
10,000,000
1 10 100 1,000Drug concentration, nM
Luci
fera
se
0
WT Control (NL4-3)
Replication of Sensitive vs. Resistant Virus
Drug concentration, nM
100
1,000
10,000
100,000
1,000,000
10,000,000
1 10 100 1,000
Luci
fera
se
0
WT Control (NL4-3)Resistant (pt-derived)
Res
ista
nt:W
T ra
tio0.01
0.1
1
10
100
0 1 10 100 1,000Drug concentration(nM)
Resistant virus favored
Resistance:WT >1
Wildtype virus favoredResistance:WT <1
Sensitive HIV is More Fit than Resistant HIV at Lower Drug Concentrations and Becomes Less Fit at Higher Drug Concentration
100
1,000
10,000
100,000
1,000,000
10,000,000
1 10 100 1,000
Luci
fera
se
0
WT Control (NL4-3)
Resistant (pt-derived pol)
Low RC
High RC
Resistant : Wildtype Replication RatioComparing Resistant Subject IsolatesWith Sensitive Reference Strain
Bangsberg et al AIDS 2006 20:223-232
Methods
Derive average resistant/WT fitness curve
Convert adherence adjusted predicted in vivo concentrations to comparable in vitro concentrations
0.001 0.01 0.1 1 100.1
1
10
100
1000
10000 1 3 10 30 100Adherence (%)
Res
ista
nt/R
efer
ence
Efavirenz
0.001 0.01 0.1 1 100.1
1
10
100
1000
10000 Adherence (%)1 3 10 30 100
Res
ista
nt/R
efer
ence
Nevirapine
0.001 0.01 0.1 1 100.1
1
10
100
1000
10000
1 3 10 30 100Adherence (%)
Drug Concentration(protein adjusted, mg/L)
Res
ista
nt/R
efer
ence
Nelfinavir
Bangsberg et al. AIDS 2006; 20:223-231
Level of adherence above which the resistant virus is more fit than the wild-type virus is ~ 2% for efavirenz and nevirapine and ~ 85% for nelfinavir
0.001 0.01 0.1 1 100.1
1
10
100
1000
10000 1 3 10 30 100Adherence (%)
Res
ista
nt/R
efer
ence
Efavirenz
0.001 0.01 0.1 1 100.1
1
10
100
1000
10000 Adherence (%)1 3 10 30 100
Res
ista
nt/R
efer
ence
Nevirapine
0.001 0.01 0.1 1 100.1
1
10
100
1000
10000
1 3 10 30 100Adherence (%)
Drug Concentration(protein adjusted, mg/L)
Res
ista
nt/R
efer
ence
Nelfinavir
Bangsberg et al. AIDS 2006; 20:223-231
Impact of initial
mutations on resistance
Impact of initial
mutations on fitness (no
drug)
Resistance at low
adherence?
NNRTIs ++++ ↓ Yes
PI + ↓↓ No
3TC ++++ ↓↓ Yes
TNF, ZDV, ddI, ABC
+ ↓↓ No
T20 ++++ ↓↓ Yes
Integrase ++++ ↓↓ Possibly
Maraviroc, R5 inhibitors
? ? ?
Antiretroviral therapy in AfricaWarren Stevens, Steve Kaye, Tumani Corrah BMJ 2004;328:280-282
[In sub-Saharan Africa]….the potential short term gains from reducing individual morbidity and mortality may be far outweighed by the potential for the long term spread of drug resistance…. In Africa, a higher proportion of patients are likely to fall into the category of potential
poor adherers unless resource intensive adherence programmes are available.
Adherence to HIV Therapy in the Industrialized North
San FranciscoBangsberg AIDS 2000
67%
Pittsburgh Paterson Annals Int Med 2000
74%
Los AngelesLiu Annals Int Med 2001
63%
New York City Arnsten CID 2001
57%
HartfordMcNabb CID 2001
53%
Philadelphia Gross AIDS 2001
79%
Mbarara, Uganda
Adherence in Patients Purchasing Generic D4T/3TC/NVP in Uganda
N=36
MEMS Unannounced Pill Count
Self Report
93% (SD 16%)
92%(SD 16%)
94%(SD 16%)
Oyugi et al JAIDS 2004 36:1100-1102
Meta-Analysis of Barriers to Adherence in Africa and North America
Mills and Bangsberg JAMA 2006:296:679-690
• Systematic review of adherence – 28,689 patients in 228 studies
• North America• Brazil, Uganda, Cote d’Ivoire, South Africa,
Malawi, Bostwana, Costa Rica, Romania
Resource-Rich Country Summary54.7% (95CI: 48.0-61.3%)
Resource-Poor Country Summary77.1% (95CI:67.3%-85.6%)
Adherence Declines Over Time in A Resource-Limited SettingOyugi and Bangsberg AIDS 2007:21:965-971
Measure Mean (SD) Mean (SD) 0-12 Week 13-24 Week 3-day SR 0.93 ± 0.179 0.91 ± 0.216 P=0.04 30-day VAS 0.95 ± 0.101 0.90 ± 0.175 P=0.008 PC 0.90 ± 0.164 0.87 ± 0.197 P=0.002 MEMS 0.91 ± 0.152 0.82 ± 0.271 P<0.001 VL ≤400 71 (71/88) 80.7%70 (70/86) 81.4% NS
N=97
UARTO Adherence Over 12 Months on Free ARV Therapy n=274Bangsberg et al CROI 2008
0102030405060708090
100
3 months 6 months 9 months 12 months
Pill Count MEMS Self Report
Socioeconomic Ladder
San Francisco Africa
A Social Model of Adherence for sub-Saharan AfricaWare and Bangsberg International HIV Adherence Conference 2008
Improving Health
ResourceScarcity
ResourceScarcity
Improving Health
A Social Model of Adherence for sub-Saharan AfricaWare and Bangsberg International HIV Adherence Conference 2008
ResourceScarcity
ResourceScarcity
Adherencefulfills
responsibility to helpers and
preserverelationshipsas a resource
Relationshipsas resources to
overcome economic
obstacles to adherence
Social Capital
Improving Health
A Social Model of Adherence for sub-Saharan AfricaWare and Bangsberg International HIV Adherence Conference 2008
ResourceScarcity
ResourceScarcity
Adherencefulfills
responsibility to helpers and
preserverelationshipsas a resource
Relationshipsas resources to
overcome economic
obstacles to adherence
Social Capital
Improving Health
A Social Model of Adherence for sub-Saharan AfricaWare and Bangsberg International HIV Adherence Conference 2008
ResourceScarcity
ResourceScarcity
Adherencefulfills
responsibility to helpers and
preserverelationshipsas a resource
Relationshipsas resources to
overcome economic
obstacles to adherence
Social Capital
Improving Health
A Social Model of Adherence for sub-Saharan AfricaWare and Bangsberg International HIV Adherence Conference 2008
Social Structural:Patterns of Inequality,
e.g., stigma,gender inequality
Adherencefulfills
responsibility to helpers and
preserverelationshipsas a resource
Relationshipsas resources to
overcome economic
obstacles to adherence
Social Capital
Infrastructural:Few treatment sites
Distance to careCost/Availability of
Transportation
Cultural:Religious Beliefs
Respect for AuthorityImportance of
having children
Individual:HIV knowledgeMed side effects
Cognitive functionMental healthAlcohol Use
ResourceScarcity
ResourceScarcity
Improving Health
A Social Model of Adherence for sub-Saharan AfricaWare and Bangsberg International HIV Adherence Conference 2008
D4T/3TC/Nevirapine17 USD per month
Triomune
Stopping drugs with different half lives
0 24 483612Time (hours)
Dru
g co
ncen
trat
ion
Zone of potential replicationIC90
IC50
Last Dose
Day 1Day 1 Day 2Day 2
MONOTHERAPY
S. Taylor et al. 11th CROI Abs 131
NNRTI Resistance and Treatment DiscontinuationParienti et al CID 2004:38:1311-6
No. patients at Risk≤1 drug holiday 52 47 38 30 19 4>= 2 drug holidays 19 17 13 10 6 1
Frequency and Duration of Treatment Interruptions >48hrs over 24 weeks on Self-pay ART
Oyugi and Bangsberg AIDS 2007
Interruptions > 48 hours 199 interruptions 62 people (64%)
Mean # interruptions/person 2.0 ±2.9 (S.D) Mean duration (days) for those who have interruptions
11.5 ±9.2 (S.D)
Frequency and Duration of Treatment Interruptions >48hrs over 24 weeks on Self-pay ART
Oyugi and Bangsberg AIDS 2007
Interruptions > 48 hours 199 interruptions 62 people (64%)
Mean # interruptions/person 2.0 ±2.9 (S.D) Mean duration (days) for those who have interruptions
11.5 ±9.2 (S.D)
Correlates: Financial difficulty securing ARVs and pharmacy stockouts
Frequency and Duration of Treatment Interruptions >48hrs over 24 weeks on Self-pay ART
Oyugi and Bangsberg AIDS 2007
Interruptions > 48 hours 199 interruptions 62 people (64%)
Mean # interruptions/person 2.0 ±2.9 (S.D) Mean duration (days) for those who have interruptions
11.5 ±9.2 (S.D)
Correlates: Financial difficulty securing ARVs and pharmacy stockouts
90% of all missed doses occur during an interruption
MEMS-Defined 48 Hour Treatment Interruptions Predict Resistance to Self-pay
ART in UgandaOyugi and Bangsberg AIDS 2007
Resistant
Interruption >48 hours
Yes 8/32 (63%)
No 0/56 (0%)
P=0.04
Duration of MEMS Defined Treatment Interruption and Probability of NNRTI ResistanceParienti and Bangsberg PLoS One 2008
n=72
+ ControlsO Cases
Estimated95% confidence interval
Longer interval of treatment discontinuation in days
Est
imat
ed p
roba
bilit
y of
vira
l con
trol
Africans “don’t know what Western time is,”and “do not know what you are talking about,” when asked to take drugs at specific times.
Andrew Natsios USAID Administrator
How to Take ARVs on Time in Rural Uganda Without a Watch: John’s Adherence StoryMaier, Mwebesa, Emenyonu, Pepper, Bangsberg
PLOS 2006• No education• Works as a farmer. • Lives with his brother, sister-in-law, and three
nieces in a three room mud-walled house without electricity.
• Owns a lantern, bed, sofa, bike, and a radio, but no watch.
• HIV in April 2005 and started generic D4T/3TC/NVP (Triomune) after disseminated herpes zoster and Kaposi’s sarcoma
• CD4 count of 151
Electronic medication monitor record of time of bottle openings for am and pm doses.
Adherence
• 90% of doses within 10 minutes of 7:20• 90% of doses within 17 minutes of 7:20 pm• Overall adherence 98.9%
John’s Adherence: 0-9 and 10-18 monthsInitial MEMS assessment (August 2005 to April 2006 (9 months))
Subsequent MEMS assessment (May 2006 to January 2007 (9 months))
Summary• Most resistance has occurred in highly
adherent patients on partially suppressive regimens
• Potent regimens reduce resistance at all levels of adherence
• NNRTI resistance: low adherence and treatment discontinuation
• Internationally: stable drug supply and distribution
Summary• Most resistance has occurred in highly
adherent patients on partially suppressive regimens
• Potent regimens reduce resistance at all levels of adherence
• NNRTI resistance: low adherence and treatment discontinuation
• Internationally: stable drug supply and distribution
Summary• Most resistance has occurred in highly
adherent patients on partially suppressive regimens
• Potent regimens reduce resistance at all levels of adherence
• NNRTI resistance: low adherence and treatment discontinuation
• Internationally: stable drug supply and distribution
Summary• Most resistance has occurred in highly
adherent patients on partially suppressive regimens
• Potent regimens reduce resistance at all levels of adherence
• NNRTI resistance: low adherence and treatment discontinuation
• Internationally: stable drug supply and distribution
Andrew Moss, PhD UCSF Epi/Biostat
Ed AcostaHuyen Cao, MD
Univ of AlabamaCa Sate Health Department
Tom Coates, PhDEdwin Charlebois, MPH, PhD
UCLAUCSF EPI Center
Barry Bredt, PhD UCSF Center for AIDS Prevention
Richard Clark, MPH UCSF Epi/Biostat
Steven Deeks, MD UCSF Positive Health Program
Nneka EmenyonuRobert Grant, MD, MPH
UCSF Epi CenterUCSF Gladstone Institute
Norma Ware, PhDGwen Hammer, PhDRick Hecht, MD
Harvard Medical SchoolUCSF EPI CenterUCSF Positive Health Program
Mark Holodniy, MD Palo Alto VA
Jeff Martin, MDNeil Parkin, PhDJennifer FreeTravis Porco, PhD
UCSF EpidemiologyMonogram BioscienceUCSF Epi CenterSF Department of Public Health
Irene Andia, MMed Mbarara University
Elise Riley, PhD UCSF EPI Center
Neil Parkin, PhD Virologic
Richard Harrigan, PhD University of British Columbia
Andrew Zolopa, MD Stanford Positive Care Program
Funding: NIMH, NIAAA, The Doris Duke Charitable Foundation, Bill and Melinda Gates Foundation, University-Wide AIDS Research Program, UCSF Center for AIDS Research
Harvard Global Health Scholars Program
David Bangsberg, MD, MPHJason Harlow, MA, MPH
CDC, 2006
PubMed – HIV, 2008 (n=100)
Balanced Leadership: Resource-rich Resource-poorMentorship: Junior Apprentice Senior MentorKnowledge: Discover Deliver
Harvard Global Health ScholarTri-axial Framework
Program
• Didactic Training in research methods• Leadership training in international research• Individualized mentored research program
Application Process
• Announcement: July 2010• Deadline September: 2010• First Cohort: January, 2011