Tools to Monitor HIV Infection in 2013 and Beyond.

Transcription

1 Tools to Monitor HIV Infection in 2013 and Beyond. Federico García, Servicio de Microbiología Univ. Hospital San Cecilio Granada, Spain Outline Address clinical questions: Ultra sensitive detection of resistance Importance of Low Level Viraemia (LLV) Resistance testing in LLV Dr Federico Garcia 1

2 Minor Variants & HIV: a new paradigm for best-practice clinical care? 100 Next Generation Sequencing % HIV variants Bulk Sequencing Challenges in HIV NGS sequencing Clinical relevance Automation Cost Bioinformatics Dr Federico Garcia 2

3 HIV NGS sequencing Clinical relevance Clear in naive NNRTI, post- PMTCT, possible for some experienced patients Reduced nº of amplicons Pooling strategies Robotics for sample preparation Nimbus for breaking & enriching Automation Cost Sample pooling Centralised testing Bulk/454 sample selection Bioinformatics Validated / Automated resistance interpretation software solutions Low Level Viraemia My patient has a plasma viral load of 27 copies/ml It`s not a blip, I have confirmed a VL of 34 c/ml in a follow-up test Dr Federico Garcia 3

4 LLV & Time to next visit Very low level vireamia. cell-to-cell virus transmission, less suscpetibly to inhition by ART (Sigal et al) Dr Federico Garcia 4

5 How low is low enough? British HIV Association IAS-USA Gesida-Spain DHHS 50 copies/ml 200 copies/ml The Clinical Perspective To address the clinical importance of any detectable viral load: a) Are patients with detectable viral load <50 c/ml at a higher risk of virological failure? b) Do patients with low level viraemia develop resistance? Dr Federico Garcia 5

6 VL <50 copies/ml & risk of VF? Study Design Pre T 0 CD4 Time (y) with VL<50 pre T 0 Years on HAART HAART regimen VL Categories: RNA RNA + (~10-39) VL months (T 1 ) Endpoints at (T 1 ) Pts with VL>50 Pts with VL>400 T 0 Dr Federico Garcia 6

7 Added Clinical Value Proportion with VL rebound Proportion with VL rebound Time since T0 (months) Time since T0 (months) Abbott Assay Confirmed (or last available) VL >50 cps log rank test p< Time to rebound Confirmed (or last available) VL >400 cps T0 VL cps TOVL RNA + (~10-49 cps) TOVL RNA - Proportion with VL rebound % 13% T0 VL cps/ml Rebound >50 cps/ml Rebound >400 cps/ml 11.3% 3.8% T0 RNA+ 4% 1.2% T0 RNA- Overall 17/63 (27%) patients had 1 RAM affecting drugs taken at time of rebound Doyle T et al. Clin Infect Dis 2012 Mar 1;54(5): Increased Risk of Virological Failure With RealTime, HIV-1 RNA levels cps and to a lesser extent ~10-39 cps predict VL rebound >50 cps and >400 cps at follow-up Abbott Assay Doyle T et al. Clin Infect Dis 2012 Mar 1;54(5): Dr Federico Garcia 7

8 Need for Validating Different Assays Abbott Assay Doyle T et al. Clin Infect Dis 2012 Mar 1;54(5): Roche Taqman v2.0 Assay Dr Federico Garcia 8

9 Study Design Pre T 0 CD4 Time (y) with VL<50 pre T 0 Years on HAART HAART regimen VL Categories: VL <20 VL VL months (T 1 ) Endpoints at (T 1 ) Pts with VL>50 Pts with VL>400 T 0 Added Clinical Value % patients >50 c/ml p< ,2 % (3/134) 20,2 % (19/94) 24,2% (15/62) Time to VF 0,8 0,6 0,4 0,2 p< T T T 0 <20 0,0 0 < ,00 5,00 10,00 15,00 Roche Taqman v2.0 Assay Alvarez et al. JClin Microbiol, May Dr Federico Garcia 9

10 Increased Risk of Virological Failure Roche Taqman v2.0 Assay Alvarez et al. JClin Microbiol, May Roche Taqman v1.0 Assay PLOS ONE, November 2012 Vol 7 Dr Federico Garcia 10

11 Siemens Ultrasensitive Assay Maggiolo et al. J Acquir Immune Defic Syndr 2012 Aug 15;60(5): Dr Federico Garcia 11

12 All these data are Suggestive of ongoing virus replication in at least a subset of patients with HIV-1 RNA detection below the 50 cps threshold HIV-1 RNA detection during first-line ART with consistent VL suppression <50 cps 1000 Plasma HIV-1 RNA <50 10 Study aim To investigate residual plasma HIV-1 RNA detection in patients receiving first-line ART and showing a VL persistently <50 cps during up to 15 years of follow-up Residual HIV-1 RNA Geretti et al. International Workshop on HIV & Hepatitis Viruses Drug Resistance 2013 Dr Federico Garcia 12

13 HIV-1 RNA detection in plasma Plasma HIV-1 RNA detected in 52/104 (50%) patients Years VL <50 cps/ml HIV-1 RNA Total cps/ml (n=31) 5-7 (n=33) (n=104) (n=40) P Median (range) 3 (1, 35) 3 (1, 10) 3 (1, 11) 3 (1, 35) Mean log 10 (SD) 0.6 (0.3) 0.5 (0.2) 0.5 (0.2) 0.5 (0.2) During long-term, seemingly suppressive ART, HIV-1 RNA remains detectable in plasma at levels ~ 3 cps Different population from that with levels ~10-49 cps Geretti et al. International Workshop on HIV & Hepatitis Viruses Drug Resistance 2013 Resistance Testing in LLV Dr Federico Garcia 13

14 Genotypic resistance in HIV-1 patients with persistent LLV Parra J, et al; Enf Infecc Microbiol Clin, 2009, 27 (2), Dr Federico Garcia 14

15 Swenson LC, et al. International HIV Resistance Meeting, Toronto, June 2013 Swenson LC, et al. International HIV Resistance Meeting, Toronto, June 2013 Dr Federico Garcia 15

16 Data confirm that Using different viral load assays, patients with detectable viral load ~10-50 copies/ml have a higher likelihood of subsequent virological rebound to > 50 cp/ml & > 400 copies/ml. In these patients virological rebound occurs at a significant shorter time. Resistance can be detected and can evolve during LLV episodes Single copy assays may help to better identify patients that can benefit from long-term suppressive cart. Factors as adherence, potency and genetic barrier of the regimen, drug levels, time with viral load below 50 copies/ml, history of treatment or even immune activation are also important to support clinical decisions. Acknowledgments Prof. Anna María Geretti Dr Federico Garcia 16

17 Dr Federico Garcia 17