Three lessons of the PrEP (pre-exposure prophylaxis) clinical trials - that adherence is critical to effectiveness, that pharmacologic adherence measures are more reliable than self-report, and that daily pill-taking is difficult ?must be applied to the next phase of HIV prevention research. This phase will investigate oral PrEP roll-out and optimization in high incidence settings, as well as novel long-acting methods for preventing HIV infection, such as injectables or vaginal rings. The vaginal ring prevented HIV acquisition in two recent trials, but poor adherence to consistent ring insertion dampened overall effectiveness. Injectable PrEP with long-acting cabotegravir is of interest, but will require adequate drug levels to be effective, especially at the end of dosing intervals and with missed visits. Pharmacologic metrics integrate biology (pharmacokinetics, PK) and behavior (adherence) and will be crucial to interpreting effectiveness with real-world oral PrEP, rings and injectables. Our group has helped pioneer the use of small hair samples (which are easy to collect, store and ship) to monitor exposure (PK) and adherence to antiretrovirals (ARVs). During the first funding period of this R01, we made significant progress on our original aims, demonstrating that hair levels of ARVs, which monitor long-term exposure, are stronger predictors of treatment success than self-reported adherence (or plasma levels) in HIV-infected pregnant women, children, and adults. We have also shown preliminary utility of hair levels of tenofovir (TFV)/emtricitabine (FTC) to monitor adherence and toxicities with oral PrEP. This proposal will leverage three important trials to explore key knowledge gaps that will arise in the next phase of HIV prevention work: The Sustainable East Africa Research in Community Health (SEARCH) trial (Dr. Havlir, chair and co-I) has just launched a large study providing oral PrEP to at-risk individuals in 16 communities in Africa. The HIV Open-Label Prevention Extension (HOPE) study in the Microbicide Trials Network (MTN) (Dr. Baeten, chair and co-I) will assess open-label use of the dapivirine vaginal ring. The Long-Acting Antiretroviral Therapy in Non-adherent HIV-Infected Individuals Trial (A5359, Dr. Castillo- Mancilla, co-chair and co-I)) in the AIDS Clinical Trials Group (ACTG) will examine long-acting injectables in HIV-infected patients with a history of poor adherence. All 3 trials will collect hair and plasma for drug levels, and track robust outcomes, to allow us to 1) investigate hair levels as metrics of adherence with the vaginal ring and oral PrEP in Africa and examine patterns of adherence (e.g. daily, around periods of risk, just prior to visits) by combining data in plasma and hair; and 2) examine hair levels as easy-to-collect metrics for PK monitoring with the use of injectables. The overarching goal of this renewal is to develop an integrated package of highly predictive biologic adherence and pharmacokinetic measures spanning PrEP delivery methods and optimization strategies. Defining predictors and patterns of adherence to oral PrEP and rings, as well as metrics to monitor PK with injectables, will inform public health interventions in HIV prevention.

Public Health Relevance

Pre-exposure prophylaxis (PrEP) with oral tenofovir (TFV) disoproxil fumarate/emtricitabine (TDF/FTC) works, but measuring PrEP drug levels to assess adherence in the PrEP trials helped us understand that 1) drug levels measure adherence better than self-report; and 2) it is difficult to take a pill every day. New ways to prevent HIV will involve testing a vaginal ring that is inserted monthly or injections of a long-acting antiretroviral (like cabotegravir), but we must examine drug levels in the human body when studying these novel tools to truly understand how well they work. This study will look at drug levels in small hair samples in three important trials (studying oral PrEP in Africa; the dapivirine vaginal ring in Africa under real-world conditions; and injectable agents in the U.S.) to see if hair measures can monitor the effectiveness of HIV prevention delivered via exciting new modalities and in high-incidence settings.

Agency
National Institute of Health (NIH)
Institute
National Institute of Allergy and Infectious Diseases (NIAID)
Type
Research Project (R01)
Project #
5R01AI098472-08
Application #
9659279
Study Section
Behavioral and Social Consequences of HIV/AIDS Study Section (BSCH)
Program Officer
Zhang, Hao
Project Start
2011-12-15
Project End
2022-02-28
Budget Start
2019-03-01
Budget End
2020-02-29
Support Year
8
Fiscal Year
2019
Total Cost
Indirect Cost
Name
University of California San Francisco
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
094878337
City
San Francisco
State
CA
Country
United States
Zip Code
94118
Abaasa, Andrew; Hendrix, Craig; Gandhi, Monica et al. (2018) Utility of Different Adherence Measures for PrEP: Patterns and Incremental Value. AIDS Behav 22:1165-1173
Koss, Catherine A; Hosek, Sybil G; Bacchetti, Peter et al. (2018) Comparison of Measures of Adherence to Human Immunodeficiency Virus Preexposure Prophylaxis Among Adolescent and Young Men Who Have Sex With Men in the United States. Clin Infect Dis 66:213-219
Gandhi, Monica; Gandhi, Rajesh T; Stefanescu, Andrei et al. (2018) Cumulative Antiretroviral Exposure Measured in Hair Is Not Associated With Measures of HIV Persistence or Inflammation Among Individuals on Suppressive ART. J Infect Dis 218:234-238
Thaden, Joshua T; Gandhi, Monica; Okochi, Hideaki et al. (2018) Seroconversion on preexposure prophylaxis: a case report with segmental hair analysis for timed adherence determination. AIDS 32:F1-F4
Koss, Catherine A; Liu, Albert Y; Castillo-Mancilla, Jose et al. (2018) Similar tenofovir hair concentrations in men and women after directly-observed: dosing of TDF/FTC: implications for PrEP adherence monitoring. AIDS :
Cohen, Stephanie E; Sachdev, Darpun; Lee, Sulggi A et al. (2018) Acquisition of tenofovir-susceptible, emtricitabine-resistant HIV despite high adherence to daily pre-exposure prophylaxis: a case report. Lancet HIV :
Gandhi, Monica; Ofokotun, Igho; Bacchetti, Peter et al. (2018) Antiretroviral concentrations in hair strongly predict virologic response in a large HIV treatment-naive clinical trial. Clin Infect Dis :
Colby, Donn J; Kroon, Eugene; Sacdalan, Carlo et al. (2018) Acquisition of Multidrug-Resistant Human Immunodeficiency Virus Type 1 Infection in a Patient Taking Preexposure Prophylaxis. Clin Infect Dis 67:962-964
Phung, Nhi; Kuncze, Karen; Okochi, Hideaki et al. (2018) Development and validation of an assay to analyze atazanavir in human hair via liquid chromatography/tandem mass spectrometry. Rapid Commun Mass Spectrom 32:431-441
Tabb, Zachary J; Mmbaga, Blandina T; Gandhi, Monica et al. (2018) Antiretroviral drug concentrations in hair are associated with virologic outcomes among young people living with HIV in Tanzania. AIDS 32:1115-1123

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