Resistencia a Fármacos Antirretrovirales: Controversias en 2009 I Congreso Nacional de GESIDA Madrid, 21-24 de Octubre de 2009 Resistencia a Fármacos Antirretrovirales: Controversias en 2009 Santiago Moreno Hospital Ramón y Cajal Madrid

Santiago Moreno Hospital Ramón y Cajal Madrid En la Reunión de Gesida del año 2000, hubo un serio debate Los estudios de resistencia SÍ son útiles para guiar el tratamiento antirretroviral Santiago Moreno Hospital Ramón y Cajal Madrid

Conclusiones Los estudios de resistencia SÍ son útiles porque, utilizados de modo adecuado, pueden ayudar a maximizar los beneficios del tratamiento antirretroviral

Papel Potencial de los Estudios de Resistencia Elección del tratamiento de inicio Monitorización de la resistencia primaria (transmitida) Evaluar el impacto de los polimorfismos en la respuesta al tratamiento Ayuda a entender la razón del fracaso virológico Virus resistentes, adherencia, PK, absorción, etc Elección del tratamiento de 2ª línea y siguientes Posibilidad de un fármaco de ser usado en un nuevo régimen Fármacos que pueden ser útiles a pesar de su uso previo Informa cuando no modificar el tratamiento

Genotipo vs Fenotipo vs Fenotipo Virtual Genotipo > Estándar Fenotipo = Estándar Genotipo = Fenotipo Fenotipo = Fenotipo Virtual

Indicaciones de los Estudios de Resistencia IAS-USA[1] DHHS[2] European[3] Primary/acute Recommend Postexposure prophylaxis -- Recommend* Chronic, tx naive Failure Pregnancy Pediatric *Test source patient especially if treated with antiretroviral drugs. 1. Hirsch MS, et al. Clin Infect Dis. 2008;47:266-285. 2. DHHS guidelines. Available at: http://www.aidsinfo.nih.gov. Accessed January 12, 2009. 3. EACS Guidelines Version 3. Available at: http://www.eacs.eu/guide/index.htm. Accessed October 24, 2008. 6 6

Indicaciones de los Estudios de Resistencia Gesida 2009 Antes del Inicio del TARV Mujeres embarazadas En cada fracaso del TARV Profilaxis post-exposición (caso fuente)

Aspectos Actuales de los Estudios de Resistencia Utilidad actual de los estudios de resistencia Resistencias primarias (transmitidas) Poblaciones minoritarias resistentes

Aspectos Actuales de los Estudios de Resistencia Utilidad actual de los estudios de resistencia Resistencias primarias (transmitidas) Poblaciones minoritarias resistentes

Estudio TRIO: Resultados a 24 semanas (ITT, M=F) 90% (95% CI: 85% to 96%) % Pts with HIV RNA <50 cp/ml (95% CI) Weeks 00 02 04 08 12 16 20 24 10 30 40 50 60 70 80 90 100 Yazdanpannah, et al. 17th IAC; Mexico City, Aug 3-8, 2008; Abst. ThAB0406. 10 10

Regímenes Ahorradores de Clases Raltegravir, Maraviroc y Etravirina Patients co-enrolled in EAPs for RAL, MVC, and ETR Class-sparing regimens prescribed according to tropism, genotype, and prior resistance tests RAL + MVC + ETR (n = 28) RAL + MVC or ETR (n = 20) PI/r + RAL + MVC or ETR (n = 28) PI/r + RAL (n = 19) BACKGROUND HIV-infected patients with limited antiretroviral (ARV) options were co-enrolled in expanded access programs of RAL, MVC and ETR. Salvage therapy was prescribed according to viral tropism, screening genotype and previous resistance tests. All the study patients (pts) received a RAL-based regimen: 28 pts received a NRTI- and PI-sparing regimen with RAL, MVC and ETR; 20 pts received a PI-sparing regimen based on RAL, MVC or ETR; 28 pts received a PI/r- and RAL-based regimen, with MVC or ETR; 19 pts received a PI/r- and RAL-based regimen. Data were collected at baseline (BL) and at 4, 12, 24, 36 and 48 weeks. CD4+ cell change was calculated between baseline and week 24 and this variable was considered as the outcome of this study. Generalized linear regression model was applied. Results are reported as median (Q1-Q3) or frequency (percentage). MAIN MESSAGES Investigators reported excellent rates of virologic success in all the four treatment groups, similar to those observed in naive patients. The NRTI- and PI-sparing regimen with RAL, MVC and ETR showed a greater immunological response than the other groups with a surprisingly robust short-term CD4 recovery. Reasons for this success may be related to the use of multiple active agents in this regimen, blocking consecutive targets of viral replication. Despite recent reports showing a negative interaction between MVC and RAL, the excellent CD4 recovery in pts receiving RAL, MVC and ETR could be related to the high doses of MVC, required in pts receiving ETR. Moreover, the avoidance of RTV and NRTI toxicity, may positively influence this outcome. Subjects with HIV RNA < 50 copies/mL (%) Mean CD4+ change (cells/mm3) Weeks Weeks Nozza et al. 9th ICDT; November 9-13, 2008; Glasgow, UK. Abstract P45. 11

Demanda de Estudios de Resistencia Hospital Ramón y Cajal Aproximadamente el 60% tenían estudios de resistencia previos % pacientes en fracaso (>50 copias/mL) Hernández-Novoa B. Congreso SEIMC, Madrid 2008

Resistencia a A.N.: Patrones de 3 TAMs 41 / 210 Pathway 70 / 219 Pathway M41L L210W T215Y D67N K70R K219Q/E/N 3 NAMs: > 4 NAMs: 11%* 12%* M41L D67N L210W T215Y 7%* D67N K70R T215F K219Q/E/N 8%*  L210W rarely associates with K70R (< 7%) or T215F (< 2%)**  L210W always found with T215Y (> 98%) or M41L (> 94%)** Therefore, L210W is diagnostic for 3 NAMS inclusive of M41L or L210W Miller M, et al. 14th IAC, Barcelona 2002. Abstract 1390.

Resistencia a Etravirina: Peso de las Mutaciones § Y181I 3 Y181V K101P 2.5 L100I Y181C M230L E138A 1.5 V106I G190S V179F V90I 1 V179D K101E K101H A98G V179T G190A Weight factor Mutation Total weighted score 0–2 Highest response 2.5–3.5 Intermediate response 4 Reduced response Vingerhoets J, et al. 17th IHDRW; Sitges, Spain, June 10-14, 2008; Poster 24.

Perfil de Resistencias de Tipranavir y Darunavir TPV DRV Different mutations Impact TPV and DRV activity L10V I13V K20M/R/V E35G M36I K43T M46L I54A/V Q58E H69K T74P V82L/T N83D V11I V32I I50V I54L G73S L76V L89V L33F I47V I54M I84V Mutations with most impact V82L/T I50V Mutations associated with increased susceptibility to TPV D30N, 41K, G48V, I50V* I50L, 53L/W/Y, I54L*, H69K, 76V* to DRV D30N, 12S, 61K, N88S * DRV mutations Elston et al. CROI 2007. Parkin CROI 2006.

Resistencia a Darunavir: Peso de las Mutaciones   FC>4 3-4 2-3 <2 50V 54M 76V 84V 32I 33F 47V 11I 54L 73S 89V Diminished response to Darunavir when 3 or more of these mutations where present at BL Antiviral Therapy 2006; 11: S83

Resistencia a Tipranavir: Peso de las Mutaciones Class Weight Range Mutations Increased response < 0 24I, 50L/V, 54L, 76V Minor mutations 1-2 10V, 36I, 43T, 46L, 84V Major mutations ≥ 3 47V, 54A/M/V, 58E, 74P, 82L/T, 83D Mutations associated with an increased response to APTIVUS/r were 24I, 50L/V, 54L, 76V. Minor mutations were10V, 36I, 43T, 46L, 84V while 47V, 54A/M/V, 58E, 74P, 82L/T, 83D were classed as major mutations. 33F, previously believed to be a key APTIVUS mutation, received a weight of 0 and was removed from the weighted score. 84V, a major mutation for all PIs (receives a weight of 25 in the Stanford score), received a weight of 2 in the revised analyses. Mutations 54L, 50V and 76V, all representing major mutations contributing resistance to fosamprenavir and darunavir, predicted improved response to APTIVUS. Only 47V (14%), 54A/M/V (64%) and 58E (16%) were major mutations seen in >10% of patients in the APTIVUS development program. Tipranavir score mutations 13V and 69K, which were seen more frequently in non-clade B patients in the BI-sponsored trial of naïve patients 1182.33 (13V: 17.2% B vs. 48.4% non-B and 69K: 4.0% B vs. 66.2% non-B), both received weights of 0 and were removed from the weighted score. Reference Scherer, J., et al. 11th Eur AIDS Conference (EACS). 2007. Madrid, Spain. Abs. P3.4/07 Score Response ≤ 3 Susceptible (S) > 3 ≤ 10 Partially susceptible (PS) > 10 Resistant (R) Scherer J. et al., 11th EACS Madrid 2007. Poster# P3.1/12 Schapiro et al., 11th EACS Madrid 2007. Poster # P3.4/16 17

Resistencia Cruzada por Mutaciones en la Integrasa seleccionadas por Raltegravir Mutations selected for by RAL resulted in resistance to structurally unrelated integrase inhibitors now in development MK-2048 more effective than other inhibitors in the presence of these resistance pathways L-810 and GS-9137 both lost substantial activity, especially with the Q148 pathway Hazuda DJ, et al. HIV Resistance Workshop 2007. Abstract 8.

Aspectos Actuales de los Estudios de Resistencia Utilidad actual de los estudios de resistencia Se utilizan, aunque en menor cantidad de pacientes Necesarios todavía para tomar decisiones terapéuticas en pacientes en fracaso Probable larga vida a los estudios genotípicos de resistencias

Aspectos Actuales de los Estudios de Resistencia Utilidad actual de los estudios de resistencia Resistencias primarias (transmitidas) Poblaciones minoritarias resistentes

Transmisión de virus resistentes The prevalence of phenotypic resistance* increased significantly during 1999-2000 compared to prior years 1995–98 1999–2000 P-value Highly resistant to: One or more drug 3.4 12.4% 0.002 NRTI 2.3 6.2% 0.07 NNRTI 1.9 7.1% 0.03 PI 0.4 8.0% <0.001 >2 drug classes (MDR) 1.1 6.2% 0.01 The transmission of resistant virus has increased significantly during 1999-2000 compared to previous years * virus with IC50 that was >10 x reference virus Little SJ. N Engl J Med 2002; 347(6): 385-394.

Prevalence of Resistant HIV Continues to Grow Prevalence of Primary Drug Resistance United Kingdom (Medium or high-level resistance) United States Due to varying methods in genotyping techniques, it is difficult to obtain a global sense of the spread of resistant HIV strains. However, it is clear from certain studies on the temporal trends of HIV resistance that it remains a growing threat to the sustainability of current therapies in controlling infection. Significant increases in primary drug resistance have been reported in regions such as the United Kingdom and the United States. Recent years have shown a rapid growth in resistance to antivirals in the United Kingdom and the United States.4,5 These data point to the need for development and use of new antiretroviral therapies that are effective against drug-resistant strains and can help reduce the spread of these challenging strains. Number Evaluated 11 55 101 97 90 23 Nucleoside or nucleotide reverse transcriptase inhibitors Non-nucleoside reverse transcriptase inhibitors Protese inhibitors Any antiretroviral drugs 3TC = lamivudine; PI = protease inhibitor. Cane et al. BMJ. 2005;331:1368–1373. Little et al. N Eng J Med. 2002;347:385–394.

Resistencia Primaria en 40 ciudades USA (2003) Ross L. HIV Clin Trials 2007: 8:1-8

CDC : Resistencia de VIH en Pacientes con Nuevos Diagnósticos Prevalence of Drug Resistance, % 1998[1] (n = 257) 1999[1] (n = 239) 2000[1] (n = 299) 2003-2004[2] (n = 633) 2003-2006[3] (n = 3130) Any drug 5.5 8.8 10.7 14.5 10.4 NRTI 5.1 7.1 7.7 3.6 NNRTI 0.4 2.1 1.7 8.4 6.9 PI 0.8 3.0 2.8 2.4 ≥ 2 drug classes 1.3 3.1 1.9 1. Bennett D, et al. CROI 2002. Abstract 372. 2. Bennett D, et al. CROI 2005. Abstract 674. 3. Wheeler W, et al. CROI 2007. Abstract 648.

Prevalencia de Resistencia Primaria en Europa (SPREAD) Spread Programma. AIDS 2008, 22:625–635

Resistencias Primarias en España CoRIS (2004-2008) Garcia F. I Congreso Gesida. Madird, 2009

Mutaciones de Resistencias Primarias CoRIS (2004-2008) Garcia F. I Congreso Gesida. Madird, 2009

Evolución de Resistencias Primarias CoRIS (2004-2008) % resistencia primaria Garcia F. I Congreso Gesida. Madird, 2009

Persistencia de la Resistencia Primaria en Ausencia de Presión Selectiva 14 patients with transmitted drug resistance deferred treatment Median follow-up for genotypic analysis of persistence of drug resistant virus: 108 weeks Mean time to detection of WT virus: 96 weeks (95% CI: 48-192) Estimated median time to loss of drug resistant virus: 4.1 years Conservative estimate based on lower 95% CI Little SJ, et al. J Virol. 2008;82:5510-5518

Transmission of highly resistant virus Tiempo hasta el fracaso virólogico en función de la sensibilidad Little SJ. N Engl J Med 2002;347:385-94

Las Resistencias Basales son Predictoras de Fracaso FTC 301A: Prospective study of 571 ART-naïve patients 16% (90/546) had baseline NRTI and/or NNRTI resistance Baseline Genotype Virologic Failure FTC / ddI / EFV (N=270) d4T / ddI / EFV (N=276) Wild type 4% 11% K103N 43% 71% Other NNRTI 14% 33% NRTI 12% 29% Any 10% 30% Transmission of a drug-resistant virus is often detected during baseline genotyping. In a prospective study of 571 newly infected ART-naïve patients, detection of drug-resistant variants during baseline genotyping before first-line HAART correlated with a higher occurrence of virologic failure.2 These data emphasize the importance of obtaining genotypic information to guide initial therapy for HIV. ART = antiretroviral therapy; FTC = emtricitabine; ddI = didanosine; EFV = efavirenz; d4T = stavudine. Borroto–Esoda et al. AIDS Res Hum Retroviruses. 2007;23:988-995. Saag et al. JAMA. 2004;292:180–190.

Análisis de Coste Efectividad de los Estudios de Resistencia Primaria Los estudios de resistencia en pacientes que van a iniciar su primer tratamiento es una estrategia coste-efectiva si la prevalencia basal de resistencias es >1% Sax PE. 2005; 41:1316–23

Indicaciones de los Estudios de Resistencia IAS-USA[1] DHHS[2] European[3] Primary/acute Recommend Postexposure prophylaxis -- Recommend* Chronic, tx naive Failure Pregnancy Pediatric *Test source patient especially if treated with antiretroviral drugs. 1. Hirsch MS, et al. Clin Infect Dis. 2008;47:266-285. 2. DHHS guidelines. Available at: http://www.aidsinfo.nih.gov. Accessed January 12, 2009. 3. EACS Guidelines Version 3. Available at: http://www.eacs.eu/guide/index.htm. Accessed October 24, 2008. 33 33

Indicaciones de los Estudios de Resistencia Gesida 2009 Antes del Inicio del TARV Mujeres embarazadas En cada fracaso del TARV Profilaxis post-exposición (caso fuente)

Aspectos Actuales de los Estudios de Resistencia Resistencias primarias (transmitidas) Se mantiene una prevalencia elevada en los pacientes con infección crónica: necesaria su monitorización La presencia de mutaciones de resistencia basales se asocian con fracaso terapéutico Recomendable, de momento, el uso de los estudios genotípicos basales

Aspectos Actuales de los Estudios de Resistencia Utilidad actual de los estudios de resistencia Resistencias primarias (transmitidas) Poblaciones minoritarias resistentes

Baseline Testing Significantly Underestimates Resistance PI Resistance NRTI Resistance NNRTI Resistance Selection and monitoring of therapeutic strategies rely on routine viral genotyping to detect emerging drug resistance. However, comparison of results from recent genotypic tests (yellow and pink bars) with combined results from patient histories (brown bars) reveals that baseline genotype testing can significantly underestimate drug resistance.6 This can be explained by the lack of accuracy with a single antiretroviral-drug-resistance test. Results from a single test report only the most prominent HIV strains at a cross-section of the disease continuum. Minority species are often present at levels undetectable by standard genotyping/phenotyping techniques. Thus, a patient’s resistance history should always be included in the therapeutic decision-making process. Prevalence of Mutation Prevalence of Mutation Prevalence of Mutation Longitudinal testing Cross sectional on therapy Cross sectional regardless of therapy Harrigan et al. J Infect Dis. 2005;191:1325–1330.

Técnicas Ultrasensibles para Detección de Variantes Minoritarias Detectan poblaciones minoritarias resistentes (0,05%) Distintos fundamentos y plataformas: PCR-alelo específica Secuenciación clonal “Ultradeep sequencing” Grandes avances técnicos

Detección de variantes minoritarias en pacientes naïve (Real Time PCR) One to three minority drug resistance mutation(s) identified in 34/205 (17%) newly diagnosed persons who had wild-type virus by conventional genotyping. At least one minority variant with a different drug resistance mutation among 30/303 (10%) samples with bulk genotype resistance mutations Johnson J, et al. PLoS Medicine 2008; 5: e158

Ultradeep vs Secuenciación Estándar en Pacientes del Ensayo FIRST 258 patients from FIRST trial underwent standard genotyping and ultradeep sequencing Significantly more mutations detected with ultradeep sequencing Presence of minority NNRTI mutations correlated with significantly higher risk of virologic failure HR: 3.38 (95% CI: 1.35-8.43; P = .009 for IAS NNRTI mutations) HR: 3.49 (95% CI: 1.65-7.36; P = .001 for Stanford database NNRTI mutations) Standard sequencing Ultradeep sequencing P < .0001 30.0 25.0 P < .0001 P = .0001 20.0 P < .0001 % With Resistance Mutations 15.0 10.0 P = .03 5.0 IAS Database Mutations (All Classes) Stanford Database Mutations (All Classes) PI NNRTI NRTI Stanford Mutations by Class Simen BB, et al. J Infect Dis 2009; 199:693–701

Poblaciones Minoritarias y Riesgo de Fracaso Virológico Simen BB, et al. J Infect Dis 2009; 199:693–701

PCR Alelo-Especifica Detecta Alta Prevalencia de K103N y M184V Ultrasensitive allele-specific real-time PCR (AS-PCR) used to determine key resistance mutations in patients with primary infection 74 patients who tested negative for K103N and M184V mutations by bulk sequencing resequenced using AS-PCR K103N in 4/74 patients (5.4%) M184V in 11/74 patients (14.9%) Detection of minority species did not correlate with therapeutic failure when patients were followed between 0.8 and 4.0 years Metzner KJ, et al. HIV Resistance Workshop 2007. Abstract 40.

H. Ramón y Cajal: Ultradeep Sequencing Poblaciones Minoritarias y Respuesta Criterios de Selección: Mala respuesta tras 24 semanas de TAR Tratamiento con fármacos de barrera genética baja (efavirenz, nevirapina, lamivudina) No mutaciones de resistencia en genotipado estándar Buena adherencia razonablemente demostrada (historia, médico, Farmacia) 15/25 pacientes se pueden evaluar con U-S La CV basal media fue 5.0 log (3.8-5.7) Hernández B. I Congreso Nacional de Gesida. Madrid, 2009.

H. Ramón y Cajal: Ultradeep Sequencing Poblaciones Minoritarias y Respuesta Todos presentaron variantes minoritarias resistentes en alguna medida La proporción media de variantes minoritarias resistentes de VIH-1 presentes al inicio de tratamiento fue de: K103N (AAC y AAT): 3.63% (0.05-12.70) Y181C: 0.00% (0.00-0.11) M184V: 3.63% (0.45-11.93) Se alcanzó CV indetectable (<1.7 log) tras la administración del tratamiento en todos los casos menos uno, en un tiempo de 9.1 meses (4.0-12.0). Hernández B. I Congreso Nacional de Gesida. Madrid, 2009.

H. Ramón y Cajal: Ultradeep Sequencing Poblaciones Minoritarias y Respuesta Hernández B. I Congreso Nacional de Gesida. Madrid, 2009.

Aspectos Actuales de los Estudios de Resistencia Poblaciones minoritarias resistentes Detectables en una gran proporción de pacientes mediante técnicas adecuadas En evaluación actualmente el significado clínico de su detección No recomendables en la actualidad para su uso rutinario