Genital secretions from HIV-1 infected women on effective antiretroviral therapy contain high drug concentrations and low amounts of cell-free virus
Anandi N. Sheth, MD
Emory University School of Medicine, Division of Infectious DiseasesEmory Center for AIDS Research
Atlanta, USA
Background
• Antiretroviral therapy (ART) is associated with reduced HIV transmission
• Genital HIV viral shedding is associated with sexual transmission
• HIV RNA found in female genital tract (FGT) secretions from women on ART with undetectable plasma HIV RNA
SQV (ND)LPV (8%)
FGT Antiretroviral Drug Penetration
Modified from Cohen et al, Ann Int Med 2007 and Taylor and Davies, Curr Opin HIV/AIDS 2010. Data: Min (JAIDS 2004), Dumond (AIDS 2007), Kwara (CID 2008) Patterson (AAC 2011), Clavel (AAC 2011)
500%
400%
300%
200%
100%
75%
50%
25%
0%
FGT
Con
cent
ratio
n or
AU
C (%
of
Plas
ma)
Blood exposure = FGT exposure
NRTIs NNRTIs PIs Entry inhibitors
Integrase inhibitors
3TC (411%)FTC (395%)
ZDV (235%)
TFV (75-110%)
ddI (21%)
ABC (8%)d4T (5%)
ETR (130%)
NVP (83%)
DLV (48%)
EFV (0.4%)
IDV (200%)
DRV (150%)
APV (52%)
RTV (26%)ATV (18%)
MVC (273%)RAL (230%)
Study Objectives• Characterize FGT HIV shedding over one menstrual
cycle among women on one ART regimen– Tenofovir (TFV), emtricitabine (FTC), atazanavir / ritonavir
(ATV/r)
• Evaluate factors associated with genital viral shedding
• Describe FGT drug penetration over menstrual cycle
• Investigate relationship between FGT drug penetration and viral shedding
Study Design
Menses 1–3 d 2–4 d 2–4 d 2–4 d 2–4 d 2–4 d
Screening visit
Study Visit 1
Study Visit 2
Study Visit 3
Study Visit 4
Study Visit 5
Study Visit 6
26 28242220181614121086420
Follicular phaseMenstrual cycle day
Luteal phase
20 HIV-infected women on ART• Undetectable plasma HIV-1 RNA within 90 days• Reported adherence• Regular menses• Excluded if active vaginal infection• Instructed to avoid sexual intercourse and douching
6 paired blood and FGT samplesHIV RNA, proviral DNA, antiretroviral drug concentrations
Methods• Cervicovaginal fluid (CVF) collected by two methods
– Lavage (10mL PBS) for HIV RNA and DNA– TearFlo strips (3) for antiretroviral drug concentrations
• HIV-1 detection– Ultrasensitive Roche Amplicor RNA and DNA assays– RNA limit of quantification (LOQ): 50 copies/mL, detectable
below LOQ reported– DNA limit of detection: 10 copies/sample
• Antiretroviral drug concentrations– 24 hours after previous dose (C24h)– HPLC-MS-MS (lower LOQ: 5 ng/mL)
• Data analysis: generalized estimating equations and mixed-effects linear models
Results
Demographic and Clinical Characteristics(N=20)
Characteristic n (%) or median (range)
Age in yearsAfrican American race
36 (26 – 48)19 (95)
HIV risk category – heterosexual sex 19 (95)Sexually active past 6 months 17 (85)
One sexual partner 16 (94)
Partner HIV negative 12 (71)
Years of HIV diagnosis 9 (1 – 17)Nadir CD4 (cells/mm3) 110 (2 – 320)Current CD4 (cells/mm3) 412 (71 – 1189)Months since first ART 90 (9 – 155)Months on current ART 14 (3 – 41)
HIV RNA and DNA Detection
Outcome#Visits (%)*
(N=119) #Patients (%)
(N=20)BLOOD
HIV RNA detected 69 (58) 16 (80)
HIV RNA ≥50 copies/mL 13 (11) 8 (40)
HIV proviral DNA detected 119 (100) 20 (100)
*119 (99%) visits completed, 8 (7%) semen contamination
HIV RNA and DNA Detection
Outcome#Visits (%)*
(N=119) #Patients (%)
(N=20)BLOOD
HIV RNA detected 69 (58) 16 (80)
HIV RNA ≥50 copies/mL 13 (11) 8 (40)
HIV proviral DNA detected 119 (100) 20 (100)FGT
HIV RNA detected 19 (16) 9 (45)
HIV RNA ≥500 copies/10mL lavage 0 ( 0) 0 ( 0)
HIV proviral DNA detected 42 (36) 14 (70)
*119 (99%) visits completed, 8 (7%) semen contamination
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6
HIV Detection by Visit Number in Menstrual Cycle
Visit number
HIV
RN
A or
DN
A de
tect
ed
(
% o
f pa
rtic
ipan
ts, 9
5% C
I)
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6
Genital tract RNA Blood RNA Genital tract DNA
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6
Genital tract RNA Blood RNA Genital tract DNA
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6
Genital tract RNA Blood RNA Genital tract DNA
Blood RNA
FGT RNA
FGT DNA
Factors Associated with FGT HIV Detection
FactorHIV RNA DetectionRate Ratio (95%CI)
HIV DNA DetectionRate Ratio (95%CI)
CVF leuks ≥200 cells/µL 2.38 (1.03–5.51) 2.41 (1.52–3.80)
CVF blood ≥200 cells/µL 2.29 (0.86 –6.05) 1.50 (0.98–2.30)
Proviral DNA in CVF 2.81 (1.39–5.64) ---
HIV RNA in plasma 0.92 (0.33–2.52) 2.01 (0.99–4.09)
Follicular phase 0.89 (0.43–1.89) 1.07 (0.71–1.62)
Factors Associated with FGT HIV Detection
FactorHIV RNA DetectionRate Ratio (95%CI)
HIV DNA DetectionRate Ratio (95%CI)
CVF leuks ≥200 cells/µL 2.38 (1.03–5.51) 2.41 (1.52–3.80)
CVF blood ≥200 cells/µL 2.29 (0.86 –6.05) 1.50 (0.98–2.30)
Proviral DNA in CVF 2.81 (1.39–5.64) ---
HIV RNA in plasma 0.92 (0.33–2.52) 2.01 (0.99–4.09)
Follicular phase 0.89 (0.43–1.89) 1.07 (0.71–1.62)
1.5
2.0
2.5
3.0
3.5
FTC TFV ATV/r
Antiretroviral Drug C24h (N=119)
FGT: Plasma C24h Geometric Mean Ratio, 95%CI
12.2 (8.71–17.0)
3.42 (2.17– 5.39)
2.49 (1.80–3.44)
Mea
n lo
g 10 c
once
ntra
tion
(ng/
mL)
, 95%
CI
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6
Genital tract RNA Blood RNA Genital tract DNA
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6
Genital tract RNA Blood RNA Genital tract DNAPlasmaFGT
1428 ng/mL (1035–1970)
560 ng/mL (433–724)
236 ng/mL (157–354)
67 ng/mL (53–85)
909 ng/mL (644–1283)
75 ng/mL (58–96)
1.5
1.7
1.9
2.1
2.3
2.5
2.7
2.9
3.1
3.3
3.5
1 2 3 4 5 6
1.5
1.7
1.9
2.1
2.3
2.5
2.7
2.9
3.1
3.3
3.5
1 2 3 4 5 6
Antiretroviral Drug C24h by Visit Number in Menstrual Cycle
FTC
1.5
1.7
1.9
2.1
2.3
2.5
2.7
2.9
3.1
3.3
3.5
1 2 3 4 5 6
TFV
ATV/r
Visit number
Mea
n lo
g 10 d
rug
conc
entr
atio
n, 9
5% C
I
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6
Genital tract RNA Blood RNA Genital tract DNA
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6
Genital tract RNA Blood RNA Genital tract DNAPlasmaFGT
1.9
2.1
2.3
2.5
2.7
2.9
3.1
3.3
Detected Not detected Detected Not detected
FGT Drug C24h by HIV Detection Status
1.9
2.1
2.3
2.5
2.7
2.9
3.1
3.3
Detected Not detected Detected Not detected
1.9
2.1
2.3
2.5
2.7
2.9
3.1
3.3
Detected Not detected Detected Not detected
FGT
mea
n lo
g 10 C
24h,
95%
CI
HIV RNA HIV DNA
FTC
ATV/r
HIV RNA HIV DNA
HIV RNA HIV DNA
TFV
Limitations
• Analysis of impact of vaginal infections occurring during study is ongoing
• Dilution of CVF by lavage may underestimate genital HIV RNA levels
• Drug concentrations represent troughs, not entire dosing interval
• Only extracellular concentrations measured
• Comparison of different CVF collection methods for drug concentrations is needed
Conclusions
• ART resulted in adequate FGT penetration of all drugs throughout menstrual cycle
• Compared to previous reports, FTC and TFV penetration similar, but ATV/r higher
• In presence of ART, unable to detect HIV RNA at a quantifiable amount in FGT
• Detection of low-level genital HIV RNA suggests local viral replication not completely inhibited
Implications
• High genital drug concentrations reassuring– Consistent with success seen with oral PrEP– Higher-than-expected FGT concentrations of ATV/r
should be explored further
• Presence of low-level FGT HIV RNA and proviral DNA suggests ART reduces, but may not completely eliminate, sexual transmission
AcknowledgementsCDC Division of HIV/AIDS
Prevention Laboratory Branch• Clyde Hart• Chou-Pong Pau• Tammy Evans-Strickfaden• Adebola Adesoye• L. Davis Lupo• Michael Omondi• Richard Haaland• Amy Martin• Ron Ballard• John Papp• Christi Phillips
Emory Center for AIDS Research• Igho Ofotokun• Kirk Easley• Chelsea Gatcliffe• Wendy Armstrong• Angela Caliendo• Jeff Lennox• Carlos del Rio• Shenique Harmon• Maria Rivas• Eva Williams• Tanisha Sullivan• Tammera Byrd• Aswani Vunnava• Sara Sanford• Nancy Sawyer• Ericka Patrick
Grady Infectious Diseases Program• Gina Bailey-Herring• Study participants and their providers
This research was supported in part by the Emory Center for AIDS Research (P30 AI050409)