Low Viral Load Time on failure and number of mutations Resistance - PowerPoint PPT Presentation

Low Viral Load

Time on failure and number of mutations Resistance After AZT/3TC/ABC Failure: CNA 3005 100 90 M184V + any TAM(s) M184V only or WT Percentage of patients 80 76 75 67 60 60 56 44 40 40 33 25 24 20 10 0 0−8 9−16 17−24 25−32 33−40 41−48 n=39 n=34 n=28 n=24 n=20 n=16 Weeks on therapy after first genotype WT=wild type TAM=thymidine-associated mutations Melby et al. 8th CROI 2001 2 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

Mean Values of log(VL) and CD4 log(VL) CD4 4.5 420 4.4 400 4.3 380 4.2 360 4.1 340 CD4 abs log(VL) 4.0 320 3.9 300 3.8 280 3.7 260 3.6 240 3.5 220 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year 3 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

Targets for HIV drug therapy plasma RNA proviral DNA 4 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA  Tropism analysis  „...Empfehlung, auch Analysen aus proviralen DNA- Sequenzen für die Therapieentscheidung zu verwenden.“ pro-viral DNA can be used for tropism prediction  Einfachtestung ausreichend single testing is sufficient „Deutsch-Österreichische Leitlinien zur antiretroviralen Therapie der HIV-1 Infektion“ De Luca, A., et al.; Reviews in Antiviral Therapy& Infectious Diseases - Volume 2, Abstract: O_17 5 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA  Determination of viral load in blood cells  Information on control over HIV (?)  Determination of resistance with pro-viral DNA  If low viral load is (too) low  If no historic resistance data are available 6 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA – viral load  144 Weeks data of MONET  DRV/r Mono-Therapie vs. DRV/r+2NRTI  Patients with constantly HIV RNA <50 copies/mL  Steady HIV DNA Level over 144 weeks  Patients with HIV RNA >50 copies/mL and/or CD4 Nadir <200 cells /µL  Higher HIV DNA levels after 144 weeks Hill, A., Geretti, A.M., et al. 2012; Reviews in Antiviral Therapy& Infectious Diseases - Volume 2, Abstract: O_06 7 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA Comparison of plasma viral load (VL) Abbott- and Roche-System 100 50 log copies/mL Kopien/mL 10 Abbott m2000 Roche VL 1 1 2 3 4 5 6 Patients VL ABBOTT: target not detected in all 6 samples VL ROCHE: target detected in 3/6 samples (1 sample 51 copies/mL) 8 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA Viral load (VL) in plasma and pro-viral load (pVL) in cells 100000 10000 copien/mL log copies/mL 1000 Abbott m2000 Roche VL 100 Roche pVL 50 10 1 1 2 3 4 5 6 Patients pVL ROCHE: varies between 10 3 and 10 5 copies/mL pVL is independent in plasma and cells 9 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA Pro-viral load vs CD4 cell count 0,09 0,08 Ratio of proviral load and CD 4 cell count 0,07 0,06 0,05 0,04 0,03 0,02 0,01 0,00 1 2 3 4 5 6 Patients ratio of pVL (ROCHE) and CD4-cell count: CD4/copies longitudinal data from each individual patient needed  ratio between 0,01 und 0,08  individual differences 10 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA 50 VL Plasma ROCHE > 50: n = 2 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA Viral RNA is below 50 copies/ml (59/61pats), pro-viral DNA varies between 1.42x10 2 and 1.43 5 copies/ml Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

Longitudinal observation of pro-viral DNA • Number of patients with decline in pro-viral load: 12 (35%) • Number of patients with increase in pro-viral load: 22 (65%) Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

Mean Values of Mutation Counts per Sequence NRTI NNRTI PI All Arevir database 6.0 5.5 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year 14 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

Low Level Viremia Mutationen in Abhängigkeit von der Viruslast (n=2000) bei Therapie-erfahrenen Patienten (AREVIR) <200 und >10000 Kopien/mL wurden kaum resistente Viren beobachtet Kaiser et al.; not published 15 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

Low Level Viremia Resistenz in Abhängigkeit von der Viruslast 2009-2011 bei Therapie-erfahrenen Patienten (HIV-GRADE Interpretation) 90 80 70 Anzahl (%) 60 50 keine Resistenz 1 Klasse 40 2 Klassen 30 3 Klassen 20 10 0 Kopien/mL 200-400 1000-10000 >100000 <200 400-1000 10000-100000 n (1939) = 35 47 115 440 706 596 Ab >400 Kopien/mL ist der Anteil resistenter Viren signifikant 16 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

Pro-viral DNA - Resistance  Resistance analysis of pro-viral DNA information equal to historic resistance data from viral RNA? 17 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA - Resistance Conkordence of detected Mutations in RNA and DNA (TN und TE) Konkordanz der Mutationen in RNA und DNA (%) NRTIs Kokordanz der NRTI Mutationen in RNA und 120 Concordance of RNA and DNA: 100 80  NRTI Mutations: 83,3% (60-100%) DNA (%) 60  NNRTI Mutations: 69,6% (40-100%) 40 20  PI Mutations: 80,8% (50-100%) 0 41 67 69 70 74 75 184 210 215 219 detektierte NRTI Resistenz-Mutationen NNRTIs PIs 120 Konkordanz der PI Mutationen in RNA und DNA 120 Konkordanz der NNRTI Mutationen in RNA und DNA 100 100 80 80 (%) (%) 60 60 40 40 20 20 0 0 98 100 101 103 108 138 179 181 190 225 230 24 33 46 47 53 54 76 82 84 90 detektierte NNRTI Resistenz-Mutationen detektierte PI Resistenz-Mutationen detektierte Mutationen NRTI Mutationen zeigten die größte Übereinstimmung zwischen RNA und DNA 18 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA - Resistance Summary  23/39 samples (59%) with resistance mutations showed equal number of mutations in pro-viral DNA and viral RNA  16/39 samples (41%) showed a lower number of mutations in pro-viral DNA 19 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA - Resistance Resistance patterns of historic resistance tests and of pro-viral DNA in non detectable viral load samples 46,7 43,3 26,3 Historic data are superior – pro-viral DNA shows lower number of mutations Wirden et al., 2011; J Antimicrob Chemother; 66:709-712 20 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA - Resistance Resistance patterns of historic resistance tests and of pro-viral DNA in non detectable viral load samples Concordance of DNA and historic RNA Genotypes: NRTI Mutations: 20% more frequent in RNA NNRTI Mutations: 10% % more frequent in RNA PI Mutations: 10% more frequent in RNA Historic data are superior – pro-viral DNA shows lower number of mutations Delaugerre et al., 2012; HIV Medicine 21 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA - Resistance Correlation of number of variants and time of replication: longer replication – more variants in PBMCs Verhofstede et al., 2004; JAIDS; 35: 473-483 22 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA - Resistance  Resistance analysis of pro-viral DNA information equal to historic resistance data from viral RNA?  No 23 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA - Resistance  Proviral DNA analysis equal to HIV RNA analysis from the same sample? 24 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA - Resistance Proviral Resistance analysis in Therapy-naive Patients  Higher number of resistance mutations in proviral DNA (compared to plasma RNA) (n=69) Kabamba-Mukabi, B. et al., 2010; HIV Medicine, 11, 483-492  Plasma: 66% Mutations detected  CD4-Zellen: 90% Mutationen detected  Higher number of resistance mutations in proviral DNA (compared to plasma RNA) (n=31) Bon, I. et al., 2007; J Clin Virol; Apr;38(4):313-320  RTI Mutations: DNA: 7/31 - RNA: 2/31  PI Mutations: exclusively in DNA  Identical resistance profiles in RNA and DNA (n=44) Ghosn, J. et al., 2006; AIDS, Jan 9; 20(2):159-1970  25 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

pro-viral DNA - Resistance Pro-viral resistance analysis in Therapy-naive Patients More resistance mutations in pro-viral DNA compared to viral RNA in Therapy-naive Patients 26 Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer