Anandi N. Sheth, MD Emory University School of Medicine, Division of Infectious Diseases

1. 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

2. 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

3. Entry inhibitors Integrase inhibitors NRTIs NNRTIs PIs MVC (273%) SQV (ND) LPV (8%) ATV (18%) RTV (26%) APV (52%) DRV (150%) IDV (200%) 3TC (411%) RAL (230%) FTC (395%) NVP (83%) ZDV (235%) EFV (0.4%) ETR (130%) TFV (75-110%) DLV (48%) ddI (21%) ABC (8%) d4T (5%) FGT Antiretroviral Drug Penetration 500% 400% 300% 200% 100% 75% 50% 25% 0% FGT Concentration or AUC (% of Plasma) Blood exposure = FGT exposure 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)

4. 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

5. Follicular phase Luteal phase Menstrual cycle day 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 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 Menses 1–3 d 2–4 d 2–4 d 2–4 d 2–4 d 2–4 d Study Visit 5 Study Visit 6 Study Visit 4 Study Visit 3 Study Visit 1 Study Visit 2 Screening visit 6 paired blood and FGT samples HIV RNA, proviral DNA, antiretroviral drug concentrations

6. 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

7. Results

8. Demographic and Clinical Characteristics(N=20)

9. HIV RNA and DNA Detection *119 (99%) visits completed, 8 (7%) semen contamination

10. HIV RNA and DNA Detection *119 (99%) visits completed, 8 (7%) semen contamination

11. HIV Detection by Visit Number in Menstrual Cycle Blood RNA HIV RNA or DNA detected (% of participants, 95% CI) FGT RNA FGT DNA Visit number

12. Factors Associated with FGT HIV Detection

13. Factors Associated with FGT HIV Detection

14. Antiretroviral Drug C24h(N=119) FGT Plasma 1428 ng/mL (1035–1970) 909 ng/mL(644–1283) 560 ng/mL (433–724) Mean log10 concentration (ng/mL), 95% CI 236 ng/mL (157–354) 75 ng/mL (58–96) 67 ng/mL(53–85) FGT: Plasma C24h Geometric Mean Ratio, 95%CI 12.2 (8.71–17.0) 3.42 (2.17– 5.39) 2.49 (1.80–3.44)

15. Antiretroviral Drug C24h by Visit Number in Menstrual Cycle FGT Plasma TFV FTC Mean log10 drug concentration, 95% CI ATV/r Visit number

16. FGT Drug C24h by HIV Detection Status TFV FTC FGT mean log10 C24h, 95%CI HIV RNA HIV DNA HIV RNA HIV DNA ATV/r HIV DNA HIV RNA

17. 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

18. 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

19. 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

20. 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 Acknowledgements • 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 • 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)