Alexander Thielen 16th European Meeting on HIV & Hepatitis

Transcription

1 Dynamics of therapy options for HIV-1 infected patients with historical multi-drug resistance (MDR), based on deep-sequencing of proviral DNA First Results from the LOWER Study Alexander Thielen, Martin Däumer, Eva Wolf, Markus Bickel, Albrecht Stoehr, Heribert Knechten, Patrick Braun, Stefan Esser, Christoph Wyen, Silke Heldwein, Ivanka Krznaric, Markus Müller, Jürgen Brust, Jan-Christian Wasmuth, Heinz- August Horst, Stefanie Holm, Thomas Buhk, and Christian Hoffmann Alexander Thielen 16th European Meeting on HIV & Hepatitis

2 Background newly infected patients good treatable, nowadays switching therapies for patients with resistance problems relatively unproblematic but what about intensely pre-treated patients with multidrug resistance and with long-standing viral suppression? data is scarce, particularly when focusing on changes in drug resistance mutation patterns the LOWER study, a clinical Investigator-Initiated Study designed, planned and headed by Christian Hoffmann and financially supported by Janssen-Cilag

3 LOWER Limited Options in Patients with Extended Resistance to Antiretroviral Therapy: A National Survey of Triple Class Resistance 13 centers*, April-October 2017 Aachen (PZB, P. Braun/H. Knechten) Berlin (ZIB, I. Krznaric) Bonn (Uni, C. Boesecke/J. Rockstroh) Essen (Uni, S. Esser) Frankfurt (Infektiologikum, M. Bickel) Hamburg (ICH, C. Hoffmann), PI Hamburg (IFI, A. Stoehr) Hannover (Praxis Georgstrasse, S. Holm) Kiel (UKSH, H.A. Horst) Köln (Praxis Ebertplatz, C. Wyen) Mannheim (Onkologie Praxis, M. Brust) München (MVZ Karlsplatz, H. Jäger/E. Wolf) Stuttgart (GP, A. Ulmer) Virology: Kaiserslautern (M. Däumer): GRT from proviral DNA *Pool: approx % of all therapied HIV+ patients in Germany slide kindly provided by Ch. Hoffmann

4 The LOWER study Two complexes of questions: 1. In which situtation are patients with TCR? Immunologic-virologic situation, active substances and options, current regime current health status (ASDM), co-morbidity when did the TCR occur, reasons, risk factors therapy satisfaction, adherence (MARS) 2. Concordance of previous resistance tests with current resistance situation (from plasma RNA or proviral DNA in case of aviremic patients): which resistances can still be found? is de-escalation possible? 4

5 Material & methods targeted sample size: 250 patients key inclusion criteria: signed informed consent and documented evidence of major resistance-associated mutations (RAMs) to at least 3 ART classes of NRTIs, NNRTIs, PIs or INSTIs viremic & aviremic patients allowed

6 Material & methods Isolation of proviral DNA Historical resistance reports Amplification of PR, RT, IN, and V3 Library generation M184V N155H K103N L90M Deep sequencing Cumulative resistance Analysis & Apobec filtering L90M, K103N, M184V, N155H

7 Material & methods interpretation using for genotypic susceptibility / active drug score (ADS) calculation: susceptible score 1 limited susceptibility score 0.5 intermediate resistance score 0.5 resistant score 0

8 Patient characteristics Total n 243 Male gender 89.7 % Median age, years (range) 55.1 ( ) Median time since HIV diagnosis, years 24.6 HIV-1 subtype B 87.4 % Non-R5 tropic virus 51.1 % Median CD4 cells/µl (range) 566 ( ) CD4 < 200 cells/µl 4.9 % Prior AIDS-defining illness 53.7 % Current HIV-RNA < 50 copies/ml 87.2 % Median historic resistance mutations 11 (3-27)

9 Results 243 patients with documented extended resistance 208 (85.6%) had RAMs affecting NRTIs, NNRTIs and PIs 12 (4.9%) had RAMs affecting NRTIs, INSTIs and NNRTIs or PIs. 23 (9.5%) patients had RAMs affecting all four classes. Deep sequencing (DS) data available for 193 patients with viral suppression (VS), and another 30 patients with nonvirological suppression (NVS).

10 Results in comparison to historical reports, DS found 64.7% mutations with a DS cutoff of 2%, whereas a Sanger-like cutoff of 15% found only 47.2%. 80,00% Detection of historically reported mutations 70,00% 60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 0,00% 1% 2% 5% 10% 15% 20% 30% DS minority cutoff

11 Results detection rates differed between different targets 100,00% Detection rates for different genes 90,00% 80,00% 70,00% 60,00% 50,00% 40,00% 30,00% PR RT IN 20,00% 10,00% 0,00% 1% 2% 5% 10% 15% 20% 30% DS minority cutoff

12 Results

13 Results the median active drug score was similar for historical drug resistance tests and DS cutoffs <10% for Sanger-comparable cutoffs 10%, it increased to 3.0.

14 Results Genotypic susceptibility to all currently approved drugs increased from 6.7 (historical) to 11.5 (2% cutoff), and further to 14.1 (15% cutoff). 18,00 GSS to currently approved drugs 16,00 14,00 12,00 10,00 8,00 6,00 NNRTI INI PI NRTI 4,00 2,00 0,00 historical 1% 2% 5% 10% 15% 20% 30%

15 Results apparently more drug options mainly due to the nondetectability of RAMs 90,00% 80,00% 70,00% 60,00% 50,00% 40,00% 30,00% M184V M41L L90M T215Y D67N K103N 20,00% 10,00% 0,00% 1% 2% 5% 10% 15% 20% 30%

16 Conclusions proviral DS resistance testing detects between 40% and 70% of cumulative detected RAMs depending on the used cutoff. no specific pattern for loss of mutations found yet potential shift to more drug options seen unclear if this is due to a true turnover of the proviral archive or due to incapability of detection ADS calculated from historical mutations similar to proviral results with lower DS cutoffs, slight increase with Sanger like cutoffs

17 Thanks to Christian Hoffmann The partners in the LOWER centers Ulrich Meyer-Bunsen, Maravillas Fernandez del Moral and for financial support Kirsten Becker, Elisa Danner, Nina Engel, Anja Förster, Anna Memmer, Bettina Welter, Martin Däumer, Bernhard Thiele