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

▶
low viral load time on failure and number of mutations
SMART_READER_LITE
LIVE PREVIEW

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

Jan 21, 2024 316 likes •665 views

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 08

slide-1
SLIDE 1

Low Viral Load

slide-2
SLIDE 2

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

Resistance After AZT/3TC/ABC Failure: CNA 3005

Melby et al. 8th CROI 2001

Percentage of patients

10 24 25 33 40 56 90 76 75 67 60 44

20 40 60 80 100 0−8 9−16 17−24 25−32 33−40 41−48 M184V + any TAM(s) M184V only or WT Weeks on therapy after first genotype

n=16 n=39 n=34 n=28 n=24 n=20

WT=wild type TAM=thymidine-associated mutations

Time on failure and number of mutations

2

slide-3
SLIDE 3

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

Mean Values of log(VL) and CD4

3.5 3.6 3.7 3.8 3.9 4.0 4.1 4.2 4.3 4.4 4.5 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

log(VL) 220 240 260 280 300 320 340 360 380 400 420 CD4 abs

log(VL) CD4

3

slide-4
SLIDE 4

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

plasma RNA proviral DNA

4

Targets for HIV drug therapy

slide-5
SLIDE 5

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 5

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

slide-6
SLIDE 6

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 6

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
slide-7
SLIDE 7

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 7

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

slide-8
SLIDE 8

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 8

pro-viral DNA

1 10 100 1 2 3 4 5 6 log copies/mL Patients Abbott m2000 Roche VL

Comparison of plasma viral load (VL) Abbott- and Roche-System

50

VL ABBOTT: target not detected in all 6 samples VL ROCHE: target detected in 3/6 samples (1 sample 51 copies/mL)

Kopien/mL

slide-9
SLIDE 9

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 9

pro-viral DNA

1 10 100 1000 10000 100000 1 2 3 4 5 6 log copies/mL Patients Abbott m2000 Roche VL Roche pVL

50

Viral load (VL) in plasma and pro-viral load (pVL) in cells pVL ROCHE: varies between 103 and 105 copies/mL

pVL is independent in plasma and cells

copien/mL

slide-10
SLIDE 10

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 10

pro-viral DNA

0,00 0,01 0,02 0,03 0,04 0,05 0,06 0,07 0,08 0,09 1 2 3 4 5 6 Ratio of proviral load and CD4 cell count Patients

Pro-viral load vs CD4 cell count

ratio of pVL (ROCHE) and CD4-cell count: CD4/copies

  • ratio between 0,01 und 0,08
  • individual differences

longitudinal data from each individual patient needed

slide-11
SLIDE 11

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

VL Plasma ROCHE > 50: n = 2 50

pro-viral DNA

slide-12
SLIDE 12

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 1.42x102 and 1.435 copies/ml

slide-13
SLIDE 13

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

  • Number of patients with decline in pro-viral load: 12 (35%)
  • Number of patients with increase in pro-viral load: 22 (65%)

Longitudinal observation of pro-viral DNA

slide-14
SLIDE 14

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

Mean Values of Mutation Counts per Sequence

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year

NRTI NNRTI PI All

Arevir database

14

slide-15
SLIDE 15

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 15

Low Level Viremia

Mutationen in Abhängigkeit von der Viruslast (n=2000) bei Therapie-erfahrenen Patienten (AREVIR)

Kaiser et al.; not published

<200 und >10000 Kopien/mL wurden kaum resistente Viren beobachtet

slide-16
SLIDE 16

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 16

Low Level Viremia

<200 200-400 400-1000 1000-10000 10000-100000 >100000 10 20 30 40 50 60 70 80 90

keine Resistenz 1 Klasse 2 Klassen 3 Klassen

Kopien/mL Anzahl (%) n (1939) = 35 47 115 440 706 596

Resistenz in Abhängigkeit von der Viruslast 2009-2011 bei Therapie-erfahrenen Patienten (HIV-GRADE Interpretation) Ab >400 Kopien/mL ist der Anteil resistenter Viren signifikant

slide-17
SLIDE 17

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 17

Pro-viral DNA - Resistance

  • Resistance analysis of pro-viral DNA information

equal to historic resistance data from viral RNA?

slide-18
SLIDE 18

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 18

pro-viral DNA - Resistance

Concordance of RNA and DNA:

  • NRTI Mutations:

83,3% (60-100%)

  • NNRTI Mutations: 69,6% (40-100%)
  • PI Mutations:

80,8% (50-100%)

Conkordence of detected Mutations in RNA and DNA (TN und TE)

20 40 60 80 100 120 41 67 69 70 74 75 184 210 215 219

detektierte NRTI Resistenz-Mutationen Kokordanz der NRTI Mutationen in RNA und DNA (%)

NRTIs

20 40 60 80 100 120 98 100 101 103 108 138 179 181 190 225 230

detektierte NNRTI Resistenz-Mutationen Konkordanz der NNRTI Mutationen in RNA und DNA (%)

NNRTIs

20 40 60 80 100 120 24 33 46 47 53 54 76 82 84 90

detektierte PI Resistenz-Mutationen Konkordanz der PI Mutationen in RNA und DNA (%)

PIs

Konkordanz der Mutationen in RNA und DNA (%) detektierte Mutationen

NRTI Mutationen zeigten die größte Übereinstimmung zwischen RNA und DNA

slide-19
SLIDE 19

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 19

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

pro-viral DNA - Resistance

slide-20
SLIDE 20

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 20

pro-viral DNA - Resistance

Resistance patterns of historic resistance tests and

  • f pro-viral DNA in non detectable viral load samples

Wirden et al., 2011; J Antimicrob Chemother; 66:709-712

46,7 26,3 43,3

Historic data are superior – pro-viral DNA shows lower number of mutations

slide-21
SLIDE 21

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 21

pro-viral DNA - Resistance

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

Delaugerre et al., 2012; HIV Medicine

Historic data are superior – pro-viral DNA shows lower number of mutations Resistance patterns of historic resistance tests and

  • f pro-viral DNA in non detectable viral load samples
slide-22
SLIDE 22

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 22

pro-viral DNA - Resistance

Verhofstede et al., 2004; JAIDS; 35: 473-483

Correlation of number of variants and time of replication: longer replication – more variants in PBMCs

slide-23
SLIDE 23

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 23

pro-viral DNA - Resistance

  • Resistance analysis of pro-viral DNA information

equal to historic resistance data from viral RNA?

  • No
slide-24
SLIDE 24

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 24

pro-viral DNA - Resistance

  • Proviral DNA analysis equal to

HIV RNA analysis from the same sample?

slide-25
SLIDE 25

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 25

pro-viral DNA - Resistance

  • Higher number of resistance mutations in proviral DNA

(compared to plasma RNA) (n=69)

  • Plasma: 66% Mutations detected
  • CD4-Zellen: 90% Mutationen detected
  • Higher number of resistance mutations in proviral DNA

(compared to plasma RNA) (n=31)

  • RTI Mutations: DNA: 7/31 - RNA: 2/31
  • PI Mutations: exclusively in DNA
  • Identical resistance profiles in RNA and DNA (n=44)
  • Proviral Resistance analysis in Therapy-naive Patients

Kabamba-Mukabi, B. et al., 2010; HIV Medicine, 11, 483-492 Ghosn, J. et al., 2006; AIDS, Jan 9; 20(2):159-1970 Bon, I. et al., 2007; J Clin Virol; Apr;38(4):313-320

slide-26
SLIDE 26

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 26

pro-viral DNA - Resistance

More resistance mutations in pro-viral DNA compared to viral RNA in Therapy-naive Patients

Pro-viral resistance analysis in Therapy-naive Patients

slide-27
SLIDE 27

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 27

pro-viral DNA - Resistance

  • Korrelation of number of active drugs and length of LLV and risk of

akkumulation of resistance mutations

  • 47 patients under therapy with LLV (<1000 cop/mL; Median: 267

cop/mL)

  • 44% (8/18) of patients with ≥ 2 LLV Episodes (blips?) developed

resistance mutations

  • 16% developed virological failure

Pro-viral resistance analysis in therapy-experienced patients with LLV

Li, J.Z. et al., 2012; AAC, puplished online ahead of print 13 Aug 2012

Wenige aktive Substanzen + LLV LLV  Bildung und Archivierung von Resistenzmutationen

slide-28
SLIDE 28

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 28

pro-viral DNA - Resistance

  • 80 EDTA-samples of the RESINA cohort with results

from Plasma RNA

  • Therapy-naive: n=50 (VL: Median 102982 copies/mL)
  • Therapy-experienced: n=30 (VL: Median 10208 copies/mL)
  • Pro-virale DNA and Plasma RNA were isolated from all

samples

  • PR und RT Gene wurden analysiert

Pro-viral resistance analysis vs. Viral Resistance analysis

slide-29
SLIDE 29

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 29

pro-viral DNA - Resistance

  • 78/80 results from viral RNA (TN=50, TE=30)
  • 78/80 results from pro-viral DNA (TN=48, TE=30)
  • 9 samples with PR Mutations
  • 30 samples with RT Mutations
  • Mehr Mutationen bei TE Patienten
  • TN Patienten: vergleichsweise mehr Mutationen in proviraler DNA
  • TE Patienten: vergleichsweise mehr Mutationen in viraler RNA

RNA vs. DNA

TN (n=48) TE (n=30) PR RT PR RT n=1 n=5 n=8 n=25 RNA>DNA 1 4 11 RNA=DNA 1 2 2 13 RNA<DNA 2 2 1

slide-30
SLIDE 30

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 30

pro-viral DNA - Resistance

Concordance of RNA and DNA:

  • NRTI Mutations:

83,3% (60-100%)

  • NNRTI Mutations: 69,6% (40-100%)
  • PI Mutations:

80,8% (50-100%)

Concordance of detected Mutations in RNA and DNA (TN und TE)

20 40 60 80 100 120 41 67 69 70 74 75 184 210 215 219

detektierte NRTI Resistenz-Mutationen Kokordanz der NRTI Mutationen in RNA und DNA (%)

NRTIs

20 40 60 80 100 120 98 100 101 103 108 138 179 181 190 225 230

detektierte NNRTI Resistenz-Mutationen Konkordanz der NNRTI Mutationen in RNA und DNA (%)

NNRTIs

20 40 60 80 100 120 24 33 46 47 53 54 76 82 84 90

detektierte PI Resistenz-Mutationen Konkordanz der PI Mutationen in RNA und DNA (%)

PIs

Konkordanz der Mutationen in RNA und DNA (%) detektierte Mutationen

NRTI Mutationen zeigten die größte Übereinstimmung zwischen RNA und DNA

slide-31
SLIDE 31

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 31

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

pro-viral DNA - Resistance

slide-32
SLIDE 32

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 32

pro-viral DNA - Resistance

  • Gibt die Resistenzanalyse der proviralen DNA die

gleiche Menge an Informationen wie die Resistenzanalyse der viralen RNA? im Prinzip ja, aber..... (Frage an Radio Eriwan)

  • Bei hohen Viruslasten: virale RNA
  • Bei niedrigen Viruslasten: provirale DNA

und historische Resistenzdaten (wenn vorhanden)

slide-33
SLIDE 33

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer 33

Low Level Viremia

  • Viruslast <200 Kopien/mL
  • resistente Viren feststellbar - aber geringe Häufigkeit
  • Persistierende Viruslasten bis 200 Kopien/mL führten in einer

Gruppe von 10 Patienten zu keiner Resistenz

  • Vermutlich Ausschüttung aus zellulären Reservoirs
  • Viruslast zwischen 200 und 10000 Kopien/mL
  • Hohe Rate an Resistenzmutationen
  • Vermutlich anhaltende virale Replikation

Obermeier, M., Kaiser, R., Berg, T.; Antiviral Therapy 2012; 17 Suppl 1:A140 Kaiser et al.; not published Ehret, R. et al., 2012; Reviews in Antiviral Therapy& Infectious Diseases - Volume 2, Abstract: P_51 Obermeier, M., Kaiser, R., Berg, T.; Antiviral Therapy 2012; 17 Suppl 1:A140 Kaiser et al.; not published

Bei Anstieg der VL >200 Kopien/mL ist ein Resistenztest sinnvoll!

slide-34
SLIDE 34

Nadine Lübke, Rolf Kaiser, Monika Timmen-Wego, Finja Schweitzer

  • In 2000: majority of analyzed samples have VL > 10000 copies/ml,

many resistance mutations all drugs in the regimen replaced

  • In 2012: majority of analyzed samples have VL < 500 copies/ml

few resistance mutations single drugs of the regimen replaced

  • VL >50 copies/ml
  • Resistence test
  • side effects?
  • check options
  • select individualized regimen
  • We analyse a larger region of HIV and we analyse human factors

(HLA)

Summary

34