Anandi N. Sheth, MD Emory University School of Medicine, Division of Infectious Diseases

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 ≥50 copies/mL 13 (11) 8 (40)

HIV proviral DNA detected 119 (100) 20 (100)FGT


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


0%

20%

40%

60%

80%

100%

1 2 3 4 5 6


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


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


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


1.9

2.1

2.3

2.5

2.7

2.9

3.1

3.3


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)

Documents

Anandi N. Sheth, MD Emory University School of Medicine, Division of Infectious Diseases