Recent clinical trials reported on the findings of new antiretroviral combinations with a dramatic increase in the proportion of patients safely achieving virologic response despite harboring multidrug-resistant HIV-1 viruses.1 Among these investigations, the ANRS 139 TRIO trial reported that 86% of patients reached HIV-1 RNA <50 copies/mL at week 48 with a salvage regimen containing raltegravir, etravirine, and darunavir/ritonavir and optimized background therapy with nucleoside reverse transcriptase inhibitors (NRTIs) or enfuvirtide.2 This level of success may be compared with previous studies on treatment-naive patients receiving a triple combination regimen including raltegravir.3,4 However, as highly potent combinations were only recently introduced in treatment-experienced patients, data on the long-term efficacy and safety of these regimens are scarce. Consequently, we report here the 96-week efficacy and safety of raltegravir, etravirine, and darunavir/ritonavir in patients enrolled in the ANRS 139 TRIO trial.
METHODS AND STATISTICAL ANALYSIS
The ANRS 139 TRIO trial was a phase II noncomparative, multicenter trial with 103 treatment-experienced patients with multidrug-resistant HIV viruses. Details of the study eligibility criteria were reported elsewhere.2 In short, patients were included if they presented with HIV-1 RNA >1000 copies/mL, were on stable antiretroviral therapy for at least 8 weeks, were naive to the study drugs, and had the following resistance profile: ≥3 primary protease inhibitor (PI) mutations, ≥3 NRTI mutations, ≤3 darunavir mutations, and ≤3 nonnucleoside reverse transcriptase inhibitor mutations.2 All patients received raltegravir (one 400-mg tablet twice daily), etravirine (two 100-mg tablets twice daily), and darunavir/ritonavir (two 300-mg/100-mg tablets twice daily). An optimized background regimen with NRTIs or enfuvirtide was given at the physician's discretion. At week 48, patients were invited to participate in the extended follow-up until week 96 to assess the durability of efficacy and safety of this antiretroviral combination.
The protocol amendment was reviewed and approved by the Nord Ouest III, France ethics committee, and health authority. All patients participating in the extended follow-up signed an additional consent form. Follow-up study visits after week 48 were scheduled at weeks 60, 72, 84, and 96.
The protocol-defined endpoints were the proportions of patients with HIV-1 RNA <50 copies/mL at weeks 48 and 96 (virologic success), with virologic failure defined by HIV-1 RNA ≥50 copies/mL at week 24 (primary endpoint), or with viral rebound defined by 2 consecutive measurements of HIV-1 RNA ≥50 copies/mL between week 24 and week 96. Other endpoints were changes in HIV-1 RNA levels and CD4+ cell counts from baseline and incident clinical and biological events.
All patients participating in the extended follow-up were included in the statistical analysis. For patients discontinuing the trial, data were included up to the date of the final visit. For HIV-1 RNA analysis, missing data were imputed as >50 copies/mL (missing equal failure), while the analysis of CD4+ counts was performed on available data only.
The incidence of clinical and laboratory adverse events comprised all events occurring during the trial. The severity of clinical and laboratory abnormalities was graded according to the ANRS scale for grading the severity of adverse events in adults.
All statistical analyses were performed using SAS, version 9.1.3 service pack 2 (SAS Institute).
Of the 103 patients, 100 consented to participate in the extended follow-up. Among the 3 other patients, 1 died at week 40, 1 was unable to consent due to mental confusion and multiple injuries after an accident, and 1 refused to participate. Overall, 98 of the 100 enrolled patients completed follow-up until week 96, whereas 2 patients withdrew their participation due to reasons unrelated to the trial drugs.
Among the 100 patients enrolled, 89% were male with a median age of 45 years (IQR: 41–51), whereas 42% had a history of an AIDS-defining event at trial baseline (week 0). At week 0, the median plasma HIV-1 RNA level was 4.2 log10 copies/mL (IQR: 3.6–4.6) and median CD4+ cell count 258 cells/mm3 (IQR: 143–350), with 40% of patients displaying a CD4+ count <200 cells/mm3.
At week 48, 86% [95% Confidence Interval (95% CI): 79% to 93%] of patients achieved HIV-1 RNA <50 copies/mL in the missing equal failure analysis, and 86% (95% CI: 79%-93%) in the analysis on available data. At week 96, these proportions remained high at 88% (95% CI: 82% to 94%) and 91% (95% CI: 85% to 97%), respectively.
All patients, including those experiencing virologic failure, continued raltegravir-etravirine-darunavir/ritonavir until week 96. Regarding the optimized background therapy, 87 patients received NRTIs or enfuvirtide at week 0 and 78 at week 96. Virologic success did not differ whether patients received a backbone regimen (81%) or not (85%). Moreover, baseline characteristics such as HIV-1 RNA, CD4 count or genotypic sensitivity score were not related to virologic success at week 96.
Overall, 19 (19%) patients experienced virologic failure during the trial: 12 before week 48 (8 with HIV-1 RNA ≥50 copies/mL at week 24 and 4 with a viral rebound between week 24 and week 48) and 7 between week 48 and week 96, including 2 patients with missing data considered as failure (Table 1). Among the 12 patients who experienced virologic failure before week 48, HIV-1 RNA values were detectable in 6 between week 48 and week 96. Viral amplification was obtained for 2 patients (HIV-1 RNA <100 copies/mL in the other cases). In the first of these patients (Table 1, case n = 5) whose HIV-1 RNA measurement was never below 50 copies/mL throughout the entire study, the selection of the L10F mutation was observed in protease and associated with the disappearance of the major PI resistance mutation L76V. In the second patient (Table 1, case n = 6), the selection of the I15V mutation was associated with a switch from I54T to I54V on protease. Moreover, the L74I/M integrase mutation associated with the V72I and G163R mutations observed at week 24 conferred a potential resistance to raltegravir according to the ANRS algorithm. It should be noted that the selection of mutations associated with resistance to darunavir or etravirine was previously reported in both of these patients.5 In 5 patients with virologic failure after week 48, we demonstrated the selection of the L100I and K103N nonnucleoside reverse transcriptase inhibitor resistance mutations in 1 patient (Table 1, case n = 15; HIV-1 RNA <50 copies/mL at week 96), in addition to the minor protease resistance mutation K20M in another (Table 1, case n = 17; HIV-1 RNA = 100 copies/mL at week 96).
The mean change in HIV-1 RNA from baseline to week 96 was –2.3 log10 copies per mL (95% CI: −2.5 to −2.1). Median CD4+ cell counts increased from 258 cells/mm3 (IQR: 143–350) at baseline to 360 (IQR: 240–484) at week 48 and 385 (IQR: 248–541) at week 96, with the median gain being 110 cells/mm3 (IQR: 58–169) and 150 (IQR: 70–271), respectively. The proportion of patients with CD4+ cell count <200 cells/mm3 decreased from 40% (95% CI: 30 to 50) at week 0 to 14% (95% CI: 7 to 21) at week 48 and week 96.
Grade 3–4 laboratory adverse events were reported in 25 patients (24%), mostly during the week 0 to week 48 study period. No biological event resulted in treatment discontinuation. Median triglycerides levels were 2.5 mmol/L at week 0 and 2.2 mmol/L at week 96. Median total cholesterol and high-density lipoprotein were 5.3 and 1 mmol/L at week 0, and 5.4 and 1.1 mmol/L at week 96, respectively. Glucose levels were 5 and 5.1 mmol/L at week 0 and week 96, respectively.
Clinical adverse events were reported in 96 patients (93%), mostly during the weeks 0–48 study period. In 26 patients (25%), a grade 3–4 clinical event was observed, including 4 events considered to be related to study drugs, which occurred before week 48: 1 recurrent epidermal necrolysis leading to treatment discontinuation, 1 nephrolithiasis, 1 lipodystrophia, and 1 muscular spasm.
Two patients presented a new AIDS-defining event before week 48 (HIV encephalopathy and candida esophagitis), with another patient during the week 48–week 96 period (non-Hodgkin lymphoma and tuberculosis lymphadenopathy). The incidence of AIDS events was estimated to be 1.6 per 100 person-years of follow-up (95% CI: 0.3 to 4.7).
Five cases of cancer were reported: myeloma (week 0 to week 48), non Hodgkin lymphoma, Hodgkin lymphoma, anal carcinoma, and recurrence of a Castleman disease (week 48 to week 96). Three patients presented a myocardial ischemic event, including 1 who died due to myocardial infarction syndrome after aortobifemoral bypass surgery before week 48, whether another patient exhibited a possible cerebral transitory ischemic attack. No severe renal or hepatic events were reported. The incidence of non–AIDS-related serious events was estimated to be 4.3 per 100 person-years of follow-up (95% CI: 1.9 to 8.4).
This study confirms that in treatment-experienced patients, an antiretroviral regimen containing raltegravir, etravirine, and darunavir/ritonavir showed high efficacy, with a good safety profile. Long-term efficacy in this population seemed to be as high as that reported for treatment-naive patients receiving either PI-containing regimens associated with NRTIs6 or combinations containing new antiretroviral drugs, such as raltegravir.7,8 In our study, virologic failures mostly occurred during the first 48 weeks after treatment initiation. Only 7 patients for whom antiretroviral treatment was efficacious at week 48 presented a failure during the extended phase: 2 with missing data but a measure of HIV-1 RNA <50 copies/mL at the last control, 4 with HIV-1 RNA levels <200 copies/mL, and 1 with 2 measurements between 200 and 400 copies/mL.
No major raltegravir resistance mutation could be detected by direct sequencing, even at a late time-point. In our study, virologic failure was rarely associated with the selection of drug resistance mutations, although a few samples were able to be analyzed due to the low level of HIV-1 RNA.
In this study, CD4+ cell count continued to increase between week 48 and week 96, and the proportion of patients with CD4+ count <200 cells/mm3 was low at both time points. In addition, in these immunodeficient patients at risk of opportunistic diseases,9 new AIDS-defining events were rare, with only a small proportion of patients developing AIDS-defining malignancies. Four cases of non-AIDS malignancies were reported. Given that a longer response to immunodeficiency is an important risk factor of such malignancies,10 it is difficult to compare the study population to the general HIV population for the incidence of non-AIDS cancers.11 However, these numbers are small, and the cases are unlikely to be related to antiretroviral drugs prescribed.
In conclusion, the treatment combination of raltegravir, etravirine, and darunavir/ritonavir was shown to be highly potent and durable in terms of efficacy and safety for treatment-experienced patients with multidrug-resistant HIV.
We would like to thank all of the patients, investigators, collaborators, virologists, and pharmacists at the clinical sites for participating in the study.
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ANRS 139 TRIO TRIAL GROUP
In addition to the authors, the following investigators are involved in the trial: C.H. Belfort: J.P. Faller; C.H. Perpignan: H. Aumaitre; Hôpital Gilles, Corbeil: P. Chevojon; Hôpital Saint Louis, Paris: L. Gerard, JM. Molina, D. Sereni, F. Timsit; Hôpital Avicenne, Bobigny: M. Bentata, O. Bouchaud; Hôpital Hôtel Dieu, Paris: A. Compagnucci; Hôpital Saint-Jacques, Besançon: C. Drobacheff; Hôpital Pellegrin, Bordeaux: M. Dupon, JM. Ragnaud; Hôpital Necker-Enfants Malades, Paris: JP. Viard; CH, Annecy: J. Gaillat; Hôpital Bicêtre, Paris: C. Goujard; Hôpital Lariboisière, Paris: A. Rami; Hôpital Henri Duffaut, Avignon: G. Pichancourt; Hôpital Raymond Poincaré, Garches: P. De Truchis; Hôpital Paul Brousse, Villejuif: D. Vittecoq; Hôpital Tenon, Paris: G. Pialoux; Hôpital Antoine Béclère, Clamart: F. Boué; Hôpital européen Georges Pompidou, Paris: L. Weiss; Hôpital Cochin, Paris: D. Salmon-Ceron; Hôpital Henri Mondor, Créteil: Y. Lévy; Hôpital Pitié-Salpêtrière, Paris: C. Katlama, A. Simon; Hôpital Saint Antoine, Paris: D. Bollens; Hôpital de l'Hôtel Dieu, Angers: JM. Chennebault; Hôpital Saint André, Bordeaux: P. Morlat; Hôpital Edouard Herriot, Lyon: F. Jeanblanc; Hôpital Hôtel Dieu, Lyon: C. Trepo; Hôpital Sainte Marguerite, Marseille: I. Poizot-Martin; Hôpital Bichat, Paris: P.Yeni; Hôpital de l'Hôtel Dieu Nantes: F. Raffi; CH, la Roche sur Yon: P. Perré; Hôpital de l'Archet, Nice: J. Durant, E. Rosenthal; Hôpital Pontchaillou, Rennes: C. Michelet; Hôpital Bretonneau, Tours: F. Bastides; Hôpital Purpan, Toulouse: B. Marchou; Hôpital de la Côte de Nacre, Caen: R. Verdon; Hôpital de l'Hôtel Dieu, Clermont Ferrand: C. Jacomet; Hôpital du Bocage, Dijon: L. Piroth; Hôpital Albert Michallon, Grenoble: P. Leclercq; Hôpital Gustave Dron, Tourcoing: Y. Yazdanpanah; Hôpital Delafontaine, St Denis: M. A. Khuong; Centre Hospitalier, Mulhouse: G. Beck-Wirth; C. H. René Dubos, Pontoise: L. Blum.
The study team also included A. M. Taburet, pharmacologist; V. Dubar, protocol pharmacist; C. Jean Marie, A. Beuscart, and N. Agher, trial clinical research assistants; S. Couffin- Cadiergues and A. Diallo, representatives of ANRS.