Transmission of resistant HIV in patients with a known date of - - PowerPoint PPT Presentation

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Transmission of resistant HIV in patients with a known date of infection

Data from the HIV-1 Seroconverter Cohort

Bartmeyer B., Kuecherer C., Werning J., Hamouda O. for the German Seroconverter Study Group Robert Koch-Institute, Berlin, Germany

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Aim s

Monitoring the spread of resistant HIV

• trends of transmission, classes of resistance
• resistance mutations

Persistence and viral fitness of resistant HIV Impact of resistant HIV

• progression of disease
• treatment success

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Study design

• Prospective multi-centre national study (1997)
• Recruitment of patients by private physicians and clinics
• written informed consent of the patients
• Documented Seroconverters
• last negative and first positive HIV-test ≤ 3 years
• Acute Seroconverters
• HIV RNA+, EIA– or EIA+ and indeterminate WB

HIV-positive patients with reliably estimated date of infection

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Genotypic Resistance Analysis

• pol-population sequences

Direct sequencing

• Identification of resistance mutations:

(IAS-List 2007, Johnson et al; Shafer et al, 2007)

• Prediction of resistant phenotype
• Stanford algorithm

(http://hivdb.stanford.edu, Version 4.3.1,September 2007)

• Level of resistance to each drug:

sensitive: sensitiv + potentially resistant intermediate: low + intermediate high resistance

• Statistics

Fisher's Exact test, comparison of proportions and proportions for trend (Epicalc 2000)

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Patient characteristics

• Study Population

1563 (12/ 2007)

• Sex

92% men; 7% women

• MSM

82%

• IVDU

4%

• Heterosexuals

8%

• HPL

3%

• Subtype nonB

8%

• Genotyped (N)

1043 67%

• Primary mutations

143 (13.7% , CI 11.7-15.9)

• Sex

139 men, 4 women

• Age

33 (IQR, 18-61)

• CDC classification

96% A, 3% B, 0,7% C

• CD4 cell count (cells/ µl, median)

428 cells/ µl

• HIV RNA (copies/ ml, median)

102500 copies/ ml

• Duration first line regimen

140 d

479 patients with first line therapy

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Risk of transmission

50 100 150 200 250 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

year of seroconversion

patients

IVDA

• ccupational

heterosexual high prevalence countries MSM & bisexual

N=1563

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Time of observation 1996 - 2007

200 400 600 800 1000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

year of recruitment

patients N

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Prevalence 13,7% (CI 11,7 – 15,9); p=0.05

Transmission of resistant HIV

0,0 10,0 20,0 30,0 40,0 50,0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Date of infection

Percent %

N=1563 (genotyped: 1043)

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Risk of infection with resistant HIV

• Age -

Deviation measure is the 95% confidence interval according to Wilson

10 20 30 40 50 60 70 80 90 100

resistant susceptible percent of patients (%)

>40 yrs. of age 18 -40 yrs. of age

*

*p=0.03 (95%CI 1,05-2,38; OR 1,58)

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Resistance - Drug classes

0,00 2,00 4,00 6,00 8,00 10,00 NRTI NNRTI PI Dual Multi

Drug classes Percent

Genotyped: N=1043

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Trend – Drug classes

NRTI - Resistance

5 10 15 20 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

NNRTI p=0.18 NRTI p=0.02 PI p=0.007

NNRTI - Resistance

5 10 15 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

PI - Resistance

2 4 6 8 10 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

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63,1 19,4 15,5 41,5 58,5 55 45 84 15,7

10 20 30 40 50 60 70 80 90

N R T I P I N N R T I 1 N R T I > 1 N R T I 1 P I > 1 P I 1 N N R T I > 1 N N R T I % mono resistant HIV

• 88% single class resistance (103/117)
• 53% caused by singletons (54/103)
• PI- and NNRTI-singletons >NRTI

Resistance to single drug classes dominates

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Seroconverter-(HA)ART

(HA)ART-regimen with > 1% of total runtime, treatment-interruptions and time-gaps 778 Patients – 923.307 days of (HA)ART-lifetime

0% 20% 40% 60% 80% 100% 1 9 9 6 1 1 9 9 6 4 1 9 9 7 3 1 9 9 8 2 1 9 9 9 1 1 9 9 9 4 2 3 2 1 2 2 2 1 2 2 4 2 3 3 2 4 2 2 5 1 2 5 4 2 6 3 2 7 2 quarter of runtime Interruption Gap Other 2NRTI/1NNRTI/1PIr 3NRTI/1NNRTI 2NRTI/1NNRTI 3NRTI/1PIr 2NRTI/1PIr 2NRTI/2PI 2NRTI/1PI 1NRTI/1PI 3NRTI 2NRTI

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Seroconverter-(HA)ART

(HA)ART-regimen with > 1% of total runtime 777 Patients – 691.069 days of (HA)ART

0% 20% 40% 60% 80% 100% 1 9 9 6 1 1 9 9 7 1 1 9 9 8 1 1 9 9 9 1 2 1 2 1 1 2 2 1 2 3 1 2 4 1 2 5 1 2 6 1 2 7 1 quarter of runtime Other 2NRTI/1NNRTI/1PIr 3NRTI/1NNRTI 2NRTI/1NNRTI 3NRTI/1PIr 2NRTI/1PIr 2NRTI/2PI 2NRTI/1PI 1NRTI/1PI 3NRTI 2NRTI

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Seroconverter-(HA)ART

Firstline-regimen 628 patients – 193.164 days of (HA)ART-time

0% 20% 40% 60% 80% 100% 1 9 9 6 1 1 9 9 6 4 1 9 9 7 3 1 9 9 8 2 1 9 9 9 1 1 9 9 9 4 2 3 2 1 2 2 2 1 2 2 4 2 3 3 2 4 2 2 5 1 2 5 4 2 6 3 2 7 2 quarter of runtime

3NRTI/1NNRTI/1PIr 2NRTI/1NNRTI/1PIr 1NRTI/1NNRTI/1PIr 2NRTI/1NNRTI/1PI 1NRTI/1NNRTI/1PI 3NRTI/1NNRTI 2NRTI/1NNRTI 1NRTI/1NNRTI 2PIr 3NRTI/1PIr 2NRTI/1PIr 1NRTI/1PIr 2NRTI/2PI 1NRTI/2PI 3NRTI/1PI 2NRTI/1PI 1NRTI/1PI 3NRTI 2NRTI 1NRTI

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Seroconverter-(HA)ART

Only PI containing firstline-regimen 353 patients – 97.630 days of (HA)ART-time

0% 20% 40% 60% 80% 100%

19961 19964 19973 19982 19991 19994 20003 20012 20021 20024 20033 20042 20051 20054 20063 20072

quarter of runtime

TPV/r FPV/r APV/r APV LPV/ATV/r ATV/r ATV SQV/LPV/r LPV/r RTV IDV/r IDV/RTV IDV IDV/NFV NFV SQV/NFV SQV/r SQV/RTV SQV

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Seroconverter-(HA)ART

Only NNRTI containing firstline-regimen 192 patients – 72.773 days of (HA)ART-time

0% 20% 40% 60% 80% 100% 1 9 9 6 1 1 9 9 6 4 1 9 9 7 3 1 9 9 8 2 1 9 9 9 1 1 9 9 9 4 2 3 2 1 2 2 2 1 2 2 4 2 3 3 2 4 2 2 5 1 2 5 4 2 6 3 2 7 2 quarter of runtime

DLV EFV NVP

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First-line Therapy-Preferences

10 20 30 40 50 Acute Documented percentage of patients (%) 2 NRTI/1 NNRTI 2 NRTI/ 1 Pir

** p < 0.01 ** p < 0.01

10 20 30 40 50 Acute Documented percentage of patients (%) 2 NRTI/1 NNRTI 2 NRTI/ 1 P

** p < 0.01 ** p < 0.01

Documented: n=1086 Acute: n=435

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First line therapy

Characteristics susceptible resistant

N 247 47 Sex 236 male; 11 female 45 male, 2 female Age 32 (IQR: 18-63) 31(IQR: 18-61)

First line therapy

NRTI/NNRTI 92/247 (37%) 19/47 (40%)

First line therapy

NRTI/PIr 160/247 (65%) 25/47 (53%) CD4 cells/µl (median) initial 420 cells/µl (IQR:8-1319) 425 cells/µl (IQR:96-705) VL copies/ml (median) Initial 275 000 copies/ml (IQR: 500-10 000000) 130 000 copies/ml IQR: 120-10 000000) Duration of first line therapy (median) 162 d (IQR: 0-1774) 142 (IQR: 5-1639)

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Prediction of Phenotype

0% 20% 40% 60% 80% 100% ATV DRV FPV IDV LPV NFV SQV TPV 3TC ABC AZT D4T DDI FTC TDF EFV ETV NVP Susceptible Intermediate Resistant

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First-line Therapy

• NNRTI -

10 20 30 40 50 60 70 80 90 Susceptible Resistant

Nevirapin Efavirenz Delavirdin

Percent %

Susceptible: N=92 Resistant: N=19

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First-line Therapy

• Proteaseinhibitors -

Percent %

10 20 30 40 50 60 Susceptible Resistant

Atazanavir Fosamprenavir Fortovase Indinavir Invirase Nelfinavir Lopinavir/r Tipranavir

Susceptible: N=160 Resistant: N=25

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CD4 cell count 6 months after ART initiation

susceptible resistant

250 500 750 1000 1250

C D 4 c e l l s / µ l

Susceptible: n=139 CD4 cells/µl: 524 (median) Resistant: n=26 CD4 cells/µl: 618 (median) Mann-Whitney-U-Test p=0.6

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VL 6 months after ART initiation

susceptible resistant

0,0 25000,0 50000,0 75000,0

V L c

• p

i e s / m l

Susceptible: n=117 VL copies/ml: 250 (median) Resistant: n=21 VL copies/ml: 545 (median) Mann-Whitney-U-Test p=0.8

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Conclusion

Resistance

• 1/7 newly HIV infected patients with resistant HIV
• Decrease of NRTI and PI resistance
• Increase of NNRTI resistance
• Resistance to single drug classes predominant
• mainly singleton resistance mutations

HAART

• Reduction of STI since 2006
• Increase of NRTI/PIr-regimen (Second generation PI)
• more drug-combinations
• Longer run-time of NRTI/NNRTI regimen

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Aachen Augsburg Berlin Bielefeld Bochum Bonn Dortmund Dresden Duisburg Düsseldorf Frankfurt/M Frankfurt/O. Freudenstadt Halle/Saale

• Dres. Knechten, Habets

Klinikum Augsburg Ärzteforum Seestraße Augusta-Viktoria Krankenhaus (Vivantes)

• Dres. Bienieck, Cordes
• Dr. Claus
• Dr. Dobao
• Dres. Dupke, Carganico
• Dr. Fenske
• Dres. Freiwald, Rausch
• Dres. Gölz, Moll, Schleehauf
• Dr. Hintsche
• Dres. Jessen
• Dres. Krauthausen, Köppe
• Dr. Reuter
• Dres. Schlote, Lauenroth-Mai, Schuler
• Dr. Schmidt
• Dr. Schüler-Maué
• Dres. Schranz, Fischer

Krankenhaus Prenzlauer Berg Institut für Tropenmedizin Universitätsmedizin Berlin Charité Krankenhaus MARA II

• St. Joseph Hospital

Universitätsklinik Bonn Klinikum Dortmund Städtisches Krankenhaus Dresden-Neus

• Dr. Becker-Boost
• Dr. Kwirant

Universitätsklinik Düsseldorf Universitätsklinik Joh.-W.-Goethe-Universität

• Dr. Markus

Landratsamt Freudenstadt Universitätsklinik M.-Luther-Universität Hamburg Hannover Karlsruhe Koblenz Köln Leipzig Magdeburg Mainz München Münster Norderstedt Nürnberg Osnabrück Regensburg Remscheid Rostock Stuttgart Ulm Viernheim Wiesbaden ifi Allg.Krankenhaus St. Georg

• Dres. Adam, Weitner, Schewe
• Dr. Fenske
• Dr. Gellermann

Universitätsklinik Eppendorf

• Med. Hochschule Hannover
• Dres. Buch, Leugner

Landratsamt Karlsruhe Krankenhaus Kemperhof

• Dr. Bihari
• Dr. Ferdinand

Universitätsklinik Köln Universitätsklinik Leipzig Universitätsklinik Otto-v.-Guericke Universität Klinikum der Joh.-Gutenberg-Universität

• Dr. Malm
• Dres. Jäger, Jägel-Guedes
• Dr. Rieger

Städtisches Krankenhaus München Schwabing Technische Universität München Universitätsklinik Münster

• Dr. Soldan

Klinikum Nürnberg Städt. Klinik Natruper Holz Universitätsklinik Regensburg

• Dres. Steege, Walter
• Dr. Kreft

Universitätsklinik Rostock

• Dres. Schnaitmann, Schaffert, Trein, Ißler
• Dres. Ulmer, Frietsch, Müller

Justizvollzugsanstalt Stuttgart Universitätsklinik Ulm

• Dr. van Treek
• Dr. Starke

Private practitioners

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Acknowledgement

• Verbund HIV-Resistenz -

Robert Koch-Institute

Department of Infectious Disease Epidemiology HIV/AIDS, STI Unit

• Dr. Osamah Hamouda

Claudia Fleischhauer Johanna Werning Parvin Ghassim Christian Kollan Britta Klose

Project HIV Variability and Molecular Epidemiology

• Dr. Claudia Kücherer

Stefan Loschen Sabrina Neumann

University Düsseldorf

Clinic for Gastroenterology, Hepatology, Nephrology (Prof. Dr. med. Dieter Häusinger)

• Dr. Stefan Reuter

Krankenhaus der Augustinerinnen

Kliniken für Innere Medizin

PD Dr. med. Mark Oette

University Köln

Institute of Virology (Prof. Dr. rer. nat. Herbert Pfister)

• Dr. rer. nat. Rolf Kaiser
• Dr. Jens Verheyen

Eugen Schülter, Stiftung CESAR, Bonn

Paul Ehrlich-Institute

• PD. Dr. Barbara Schnierle

Birgit Krause Dorothea Binninger-Schinzel

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Funded by the German Ministry ofHealth

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Patients newly infected with T215 revertants

N=51 patients infected with T215 revertants Transmission group 48 MSM, 2 Heterosexuals Patient category

• 33 documented seroconverters, 9.2 months

mean test date difference [IQR 5;15]

• 17 „acute“ seroconverters

Follow-up

17/51 Follow-up samples mean f-up time 16.6 months [IQR 12;34; min 8, max 46] 10/17 had 1-2 additional TAMs No other RT or major PI mutations

HIV-1 T215 revertants Drug-naive course of infection

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5 10 15 20 25 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

%

T215 revertants resistant HIV 0,0 2,0 4,0 6,0 8,0 10,0 12,0 1

%

any NRTI

• ne NRTI

any TAM

• ne TAM

M41L K70R L210W T215YF T215ACDEGHILNSV K219QE D67NG T69DN V75ITMSA F77L M184VI

High prevalence of T215 revertants

• NRTI resistance mutations 1996-2007 -
• 1174 genotyped

148 resistant HIV 12,6 % [9,8;14,5]

• 51 T215 revertants

4,3 % revertant substitutions: T215ACDEGHILNSV 1 2 1 2

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Revertant substitutions in RT position 215

• 12/17 reversions persisted
• 2 mutated to another revertant substitution

(D ->E; C->S)

• 3 Reversion to wild type

19 13 6 6 3 2 11

D S A C E N L ADNT

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Persistence of T215 revertants

Clonal quasispecies analysis

M41 A62 K70 V75 V108 L210 T215 K219 First 2 10/10

• A
• 1.Fup

5 1/10

• R
• A

9/10

• A
• 2.Fup

12 1/9

• 8/9
• A
• First

23 10/10 L

• C
• Fup

34 10/10 L

• C
• First

17 4/7 L

• W

S

• 2/7

L

• W

C

• 1/7

L

• I

W C

• Fup

37 9/9 L

• W

S

• First

6 8/8 L

• D
• Fup

24 5/7 L

• D
• 1/7

L V

• D
• 1/7

L

• A
• D
• First

9/9

• S
• Fup

12 10/10

• S
• 5

4 1 3 2

Resistance-associated mutations reverse transcriptase clone no. Patient Duration infection

(months)

Sample

3 3

Transmission clusters

• f revertant HIV

(n=51)

0.01 C.ET.86.ET D.UG.94.94 2006-07-CS 1999-09-TS 2003-06-CS B.US.83.RF 2002-03-C 2007-05-D 2001-05-D 2004-01-C 2005-07-L 2007-11-D 2007-07-C 2002-08-E 2006-06-E 2005-03-S 2002-08-S 2006-11-S 2004-07-S 2006-03-S 2006-11-S 2006-07-S 2006-08-S 2006-11-S 2003-12-D 2005-06-D 2006-05-D 2006-10-D 2006-07-D 2006-06-C 2006-09-D 2005-05-D 2006-10-ADNT B.FR.83.HX B.US.86.JR 2004-03-E 2007-07-A 2004-04-A 2004-10-A 2004-04-A 2004-03-A 1997-12-S 2004-07-N 2006-05-N 2003-01-D 1997-06-D 2004-11-D 2006-02-D 2007-05-S 2004-09-DE 2006-01-D 2007-09-AT 1999-10-D 2006-04-S 2004-05-D 1997-07-D B.US.90.WE

2 1 10 3 4 5 6 7 8 9

example: 2006-07-A yy-mm-aa

Similar infection dates (< 4months)

• >transmission by a

common source or during acute infection Time difference between infection dates (> 1year)

• > persistence in vivo

100 100 100

Clade B

100 100 100 100 99,6 99,5 100 100 100 100 99,8

10 clusters

94,6

* * * * * * *

pol-NJ tree K2P,

• utgroup C

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Conclusion

• 1/7 newly HIV infected patients with resistant HIV
• Decrease of NRTI and PI resistance
• Increase of NNRTI resistance
• Resistance to single drug classes predominant
• mainly singleton resistance mutations
• Persistence of T215 revertants ≥ year in absence of transmitted

wild-type variants (up to almost 4 years, median 17 months

• Epidemically linked infection indicates:
• efficient transmission of HIV revertants
• during acute infection
• Transmission clusters of closely related HIV involving

infections which occured years a part argue also for long persistence in vivo