Genital secretions from HIV-1 infected women on
effective antiretroviral therapy contain high drug
concentrations and low amounts of cell-free virus
Anandi N. Sheth, MD
Emory University School of Medicine, Division of Infectious Diseases
Emory Center for AIDS Research
Atlanta, USA
Background
• Antiretroviral therapy (ART) is associated with
reduced HIV transmission
• Genital HIV viral shedding is associated with
sexual transmission
• HIV RNA found in female genital tract (FGT)
secretions from women on ART with
undetectable plasma HIV RNA
FGT Antiretroviral Drug Penetration
FGT Concentration or AUC (% of Plasma)
NRTIs
NNRTIs
Entry
inhibitors
PIs
Integrase
inhibitors
500%
400%
3TC (411%)
FTC (395%)
300%
200%
100%
MVC (273%)
ZDV (235%)
IDV (200%)
ETR (130%)
TFV
(75-110%)
RAL (230%)
DRV (150%)
Blood exposure = FGT exposure
NVP (83%)
75%
50%
25%
DLV (48%)
RTV (26%)
ddI (21%)
ATV (18%)
LPV (8%)
ABC (8%)
0%
d4T (5%)
APV (52%)
EFV (0.4%)
SQV (ND)
Modified from Cohen et al, Ann Int Med
2007 and Taylor and Davies, Curr Opin
HIV/AIDS 2010. Data: Min (JAIDS 2004),
Dumond (AIDS 2007), Kwara (CID 2008)
Patterson (AAC 2011), Clavel (AAC 2011)
Study Objectives
• Characterize FGT HIV shedding over one menstrual
cycle among women on one ART regimen
– Tenofovir (TFV), emtricitabine (FTC), atazanavir / ritonavir
(ATV/r)
• Evaluate factors associated with genital viral shedding
• Describe FGT drug penetration over menstrual cycle
• Investigate relationship between FGT drug penetration
and viral shedding
Study Design
20 HIV-infected women on ART
• Undetectable plasma HIV-1 RNA within 90 days
• Reported adherence
• Regular menses
• Excluded if active vaginal infection
• Instructed to avoid sexual intercourse and douching
Follicular phase
Menstrual
cycle day
0
2
4
Menses
Screening
visit
6
8
1–3 d
Study
Visit 1
Luteal phase
10
12
2–4 d
Study
Visit 2
14
16
2–4 d
Study
Visit 3
18
2–4 d
20
22
2–4 d
Study
Visit 4
Study
Visit 5
24
26
2–4 d
Study
Visit 6
6 paired blood and FGT samples
HIV RNA, proviral DNA, antiretroviral drug concentrations
28
Methods
• Cervicovaginal fluid (CVF) collected by two methods
– Lavage (10mL PBS) for HIV RNA and DNA
– TearFlo strips (3) for antiretroviral drug concentrations
• HIV-1 detection
– Ultrasensitive Roche Amplicor RNA and DNA assays
– RNA limit of quantification (LOQ): 50 copies/mL, detectable
below LOQ reported
– DNA limit of detection: 10 copies/sample
• Antiretroviral drug concentrations
– 24 hours after previous dose (C24h)
– HPLC-MS-MS (lower LOQ: 5 ng/mL)
• Data analysis: generalized estimating equations and
mixed-effects linear models
Results
Demographic and Clinical Characteristics
(N=20)
Characteristic
Age in years
African American race
n (%) or median (range)
36 (26 – 48)
19 (95)
HIV risk category – heterosexual sex
19 (95)
Sexually active past 6 months
17 (85)
One sexual partner
16 (94)
Partner HIV negative
12 (71)
Years of HIV diagnosis
9 (1 – 17)
Nadir CD4 (cells/mm3)
110 (2 – 320)
Current CD4 (cells/mm3)
412 (71 – 1189)
Months since first ART
90 (9 – 155)
Months on current ART
14 (3 – 41)
HIV RNA and DNA Detection
#Visits (%)*
(N=119)
#Patients (%)
(N=20)
HIV RNA detected
69 (58)
16 (80)
HIV RNA ≥50 copies/mL
13 (11)
8 (40)
119 (100)
20 (100)
Outcome
BLOOD
HIV proviral DNA detected
*119 (99%) visits completed, 8 (7%) semen contamination
HIV RNA and DNA Detection
#Visits (%)*
(N=119)
#Patients (%)
(N=20)
HIV RNA detected
69 (58)
16 (80)
HIV RNA ≥50 copies/mL
13 (11)
8 (40)
119 (100)
20 (100)
19 (16)
9 (45)
0 ( 0)
0 ( 0)
42 (36)
14 (70)
Outcome
BLOOD
HIV proviral DNA detected
FGT
HIV RNA detected
HIV RNA ≥500 copies/10mL lavage
HIV proviral DNA detected
*119 (99%) visits completed, 8 (7%) semen contamination
HIV Detection by Visit Number in Menstrual Cycle
100%
80%
Genital tract RNA
0%
Ge
100%
1
80%
60%
40%
20%
0%
100%
1
80%
100%
2
3
4
5
80%
60%
FGT RNA
Genital
tract RNA
40%
2
3
4
5
20%
20%
1
100%0%
1
2
3
100%
6
80%
FGT DNA
Blood RNA60% Genital
tract DNA
Genital tract0%
RNA
40%
6
ith HIVRNA detected (%)
20%
60%
cted (%)
Blood
Blood RNA
RNA
40%
Visits with HIVRNA detected (%)
HIV RNA or DNA detected
(% of participants, 95% CI)
60%
4
2
5
Visit number
6
40%
3
4
Visit number
Factors Associated with FGT HIV Detection
Factor
HIV RNA Detection HIV DNA Detection
Rate Ratio (95%CI) Rate Ratio (95%CI)
CVF leuks ≥200 cells/µL
2.38 (1.03–5.51)
2.41 (1.52–3.80)
CVF blood ≥200 cells/µL
2.29 (0.86 –6.05)
1.50 (0.98–2.30)
Proviral DNA in CVF
2.81 (1.39–5.64)
---
HIV RNA in plasma
0.92 (0.33–2.52)
2.01 (0.99–4.09)
Follicular phase
0.89 (0.43–1.89)
1.07 (0.71–1.62)
Factors Associated with FGT HIV Detection
Factor
HIV RNA Detection HIV DNA Detection
Rate Ratio (95%CI) Rate Ratio (95%CI)
CVF leuks ≥200 cells/µL
2.38 (1.03–5.51)
2.41 (1.52–3.80)
CVF blood ≥200 cells/µL
2.29 (0.86 –6.05)
1.50 (0.98–2.30)
Proviral DNA in CVF
2.81 (1.39–5.64)
---
HIV RNA in plasma
0.92 (0.33–2.52)
2.01 (0.99–4.09)
Follicular phase
0.89 (0.43–1.89)
1.07 (0.71–1.62)
Antiretroviral Drug C24h (N=119)
3.0
2.5
2.0
Visits with HIVRNA detected (%)
tract RNA
Blood
Genital
tra
GenitalGenital
tract RNA
Blood
RNA RNA
Genital
tract DNA
FGT
Plasma
Visits with HIVRNA detected (%)
Mean log10 concentration (ng/mL), 95% CI
3.5
1428 ng/mL
(1035–1970)
100% 100%
909 ng/mL
80%
80%
(644–1283)
560 ng/mL
(433–724)
60% 60%
40% 40%
236 ng/mL
(157–354)
20% 20%
0%
0%
75 ng/mL
1
(58–96)
1 2
2 ng/mL
3
67
(53–85)
3 4
4 5
Visit number
Visit number
1.5
FTC
FGT: Plasma C24h
Geometric Mean
Ratio, 95%CI
12.2
(8.71–17.0)
TFV
ATV/r
3.42
(2.17– 5.39)
2.49
(1.80–3.44)
5 6
Antiretroviral Drug C24h by Visit Number in Menstrual Cycle
Genital
tract
RNA Blood
Blood
RNA Genital
Genital
tract
DNA
Genital
RNA
RNA
tract
DNA
FGTtract
Plasma
3.5
3.3
100%
100%
3.3
3.1
Mean log10 drug concentration, 95% CI
Visits with HIVRNA detected (%)
Visits with HIVRNA detected (%)
3.5
2.9
3.1
2.7
2.7
2.5
FTC 60%
60%
2.5
2.3
2.1
2.3
2.1
40%
40%
1.9
1.7
1.9
1.7
20%
20%
1.5
1
2
3
TFV
2.9
80%
80%
4
1.5
5
1
6
2
3
4
5
6
3.5
3.3
0%0%
1 1
3.1
2 2
3 3
2.9
4 4
Visit
number
Visit
number
2.7
2.5
2.3
2.1
ATV/r
1.9
1.7
1.5
1
2
3
4
Visit number
5
6
5 5
6 6
FGT mean log10 C24h, 95%CI
FGT Drug C24h by HIV Detection Status
3.3
3.3
3.1
3.1
2.9
2.9
2.7
2.7
FTC
2.5
2.5
2.3
2.3
2.1
2.1
1.9
1.9
Detected
Not detected
Detected
HIV RNA
TFV
Not detected
Detected
HIV DNA
Not detected
HIV RNA
3.3
3.1
2.9
2.7
2.5
ATV/r
2.3
2.1
1.9
Detected
Not detected
HIV RNA
Detected
Not detected
HIV DNA
Detected
Not detected
HIV DNA
Limitations
• Analysis of impact of vaginal infections occurring
during study is ongoing
• Dilution of CVF by lavage may underestimate genital
HIV RNA levels
• Drug concentrations represent troughs, not entire
dosing interval
• Only extracellular concentrations measured
• Comparison of different CVF collection methods for
drug concentrations is needed
Conclusions
• ART resulted in adequate FGT penetration of all drugs
throughout menstrual cycle
• Compared to previous reports, FTC and TFV
penetration similar, but ATV/r higher
• In presence of ART, unable to detect HIV RNA at a
quantifiable amount in FGT
• Detection of low-level genital HIV RNA suggests local
viral replication not completely inhibited
Implications
• High genital drug concentrations reassuring
– Consistent with success seen with oral PrEP
– Higher-than-expected FGT concentrations of ATV/r
should be explored further
• Presence of low-level FGT HIV RNA and
proviral DNA suggests ART reduces, but may
not completely eliminate, sexual transmission
Acknowledgements
CDC Division of HIV/AIDS
Prevention Laboratory Branch
• Clyde Hart
• Chou-Pong Pau
• Tammy Evans-Strickfaden
• Adebola Adesoye
• L. Davis Lupo
• Michael Omondi
• Richard Haaland
• Amy Martin
• Ron Ballard
• John Papp
• Christi Phillips
Grady Infectious Diseases Program
• Gina Bailey-Herring
• Study participants and their providers
This research was supported in part by the
Emory Center for AIDS Research (P30
AI050409)
Emory Center for AIDS Research
• Igho Ofotokun
• Kirk Easley
• Chelsea Gatcliffe
• Wendy Armstrong
• Angela Caliendo
• Jeff Lennox
• Carlos del Rio
• Shenique Harmon
• Maria Rivas
• Eva Williams
• Tanisha Sullivan
• Tammera Byrd
• Aswani Vunnava
• Sara Sanford
• Nancy Sawyer
• Ericka Patrick