Background

1. Changes in bone mineral density over 48 weeks among participants randomised to either LPV/r+2-3N(t)RTI or LPV/r + raltegravir as second-line therapy: a sub-study of the SECONDLINE trial. Allison MARTIN1, Cecilia MOORE1, Patrick W.G. MALLON2,Jennifer HOY3,Sean EMERY1, Waldo BELLOSO4, Praphan PHANUPHAK5, Samuel FERRET6, David A. COOPER1, Mark A. BOYD1 on behalf of the Second Line study team 1The Kirby Institute, University of New South Wales, Sydney, Australia; 2UCD School of Medicine and Medical Science, Dublin, Ireland; 3The Alfred Hospital, Melbourne, Australia; 4CICAL, Buenos Aires, Argentina;5Thai Red Cross AIDS Research Center, Bangkok, Thailand; 6Hopital Saint-Louis, Paris, France.

2. Background • Loss of Bone Mineral Density occurs with cART • Greater loss with N(t)RTI- and PI-containing ART • Tenofovir disoproxil fumarate • Effect of integrase inhibitors on BMD is not well defined • The SECOND-LINE study permits an assessment of BMD changes associated with: • LPV/r+2-3N(t)RTI versus LPV/r+RAL (N(t)RTI-sparing arm) • Hypothesis: LPV/r+RAL would be associated with smaller reductions in BMD

3. Methods SECOND-LINE: open-label, non-inferiority RCT • 96 week multi-centre trial • 37 sites in Asia, Africa, Australia, Latin America and Europe • Patients failing first-line NNRTI + 2N(t)RTI ART randomised 1:1 to • LPV/r (400/100mg bd or 800/200mg qd) + 2-3N(t)RTI (current WHO-recommended 2nd-line ART) • LPV/r + RAL (400mg bd) • Primary objective of parent study • Proportion with plasma viral load <200 copies/mL at week 48

4. Methods • Eligible participants: • HIV-1 positive adults (aged ≥ 16 years) • received first-line cART comprised of a NNRTI + 2N(t)RTIs for ≥24 weeks with no change within 12 weeks prior to screening • evidence of virological failure, • 2 consecutive plasma viral load >500 copies per mL • no previous exposure to PI or InSTI

5. Methods The Bone Sub-study • 8 sites from 5 countries (South Africa, India, Malaysia, Thailand, Argentina) with access to DXA scanning participated in the bone sub-study • scans at baseline (week 0) and week 48 • recruitment open to all PHA screened at these sites from July 2010 to July 2011 • BMD of proximal femur and lumbar spine (L2-L4) measured by a standard protocol

6. Methods • Primary objective: to determine the difference in mean percent change in BMD at the proximal femur and lumbar spine by treatment arm from baseline to week 48 • Secondary objectives: • mean percent change from baseline in Z-score and T-score • proportion of participants with new osteopenia and osteoporosis by treatment arm • to explore the relationship between lumbar spine and proximal femur BMD change and baseline clinical demographics and cART

7. Methods • Baseline covariates included in the multivariate model: • Age, sex, ethnicity • BMI, smoking, blood pressure • HIV and ART markers • randomised treatment arm, CD4+ T-cell counts, plasma HIV RNA, prior and on-study use of TDF, prior and on-study duration of TDF use • Body composition parameters (fat and lean mass) • Other parameters influencing bone mass (e.g. hypogonadism, corticosteroids)

8. Screened (n=699) Consented to Sub-study (n=236) • 25 subjects not randomised • Ineligible (n=17) • Withdrawn (n=6) • Other: Death (n=1) • LFU (n=1) Results – Patient Disposition Randomised (n=211) Exited before analysis, never received study therapy (n=1) Analysis Population (n=210) LFU (n=1) Deaths (n=4) r/LPV + 2-3N(t)RTI (n=102) r/LPV + RAL (n=108) Deaths (n=1) Reached week 48 (n=97) Reached week 48 (n=107)

9. Baseline Characteristics

10. Baseline BMD and ART characteristics

11. Mean % change in BMD -2.0% -2.9% -4.2% -5.2% All analyses are adjusted for baseline imbalances in sex, BMI and smoking status

12. Mean change in T and Z score

13. New Cases of Osteopenia, and Osteoporosis at W48

14. Multivariate analysis - baseline predictors of percent change in BMD at proximal femur over 48 weeks * reference group

15. Multivariate analysis - baseline predictors of percent change in BMD at lumbar spine over 48 weeks * reference group

16. Summary • Study population comprising 52% women and 97% non-Caucasian participants, primarily from middle income countries • Significantly greater loss of BMD was observed in the LPV/r+2-3N(t)RTI group compared to LPV/r+RAL • Incidence of osteopenia and osteoporosis assessed at the proximal femur and lumbar spine was similar between groups • Use of tenofovir and low baseline BMI were predictive of reduced BMD at both proximal femur and spine

17. Conclusion • First study to examine changes in BMD in ART-experienced patients virologically failing first line regimens, with re-suppression of viremia • The loss of BMD was least in participants treated with raltegravir and greater in those exposed to tenofovir throughout the study • Magnitude of BMD reduction similar to that observed in ART naive patients initiating therapy • These data confirm that reduction in BMD secondary to ART remains a significant co-morbidity in the long term management of HIV.

18. Acknowledgements • SECONDLINE investigators: Dr Nagalingeswaran Kumarasamy, Prof Robin Wood, Dr Sharne Foulkes, Dr Lerato Mohapi, Dr Ploenchan Chetchotisakd, Prof Praphan Phanuphak, Dr Adeeba Kamarulzaman,  Dr Oscar Messina. • SECONDLINE team: Prof David Cooper, Prof Sean Emery, Dr Mark Boyd, Allison Humphries, Natalie Espinosa, Hila Haskelberg, Maria Arriaga, Sally Hough, Cecilia Moore, Dr Janaki Amin, Andrea Redgrave, Rosemary Robson • AMR: centralised Viral Load assays • Funding: This study was funded by a public-private partnership of the University of New South Wales, Merck & Co Inc, AbbVie Pty Ltd, NHMRC and the Foundation for AIDS Research (amFAR). The views expressed in this publication do not necessarily represent the position of the Australian government. The Kirby Institute is affiliated with the Faculty of Medicine, University of New South Wales.