Too many children are still being newly infected with HIV. The Global Plan is to eliminate new HIV infections among children by 2015 and keep their mothers alive. The rate of MTCT of HIV-1 has fallen to less than 2% in countries with the implementation of recommendations. The best documented factor that correlates to higher rates of transmission is the maternal level of plasma viremia. Therefore it is important to maximally inhibit HIV replication in order to prevent HIV-associated morbidity and mortality and to prevent MTCT. Durable viral suppression prolongs life by improving immune function and overall quality of life, lowering the risk of both AIDs-defining and non-AIDS-defining complications. Clinical data are more limited on antiretroviral drugs in pregnant women than in non-pregnant individuals due to concerns for maternal and fetal safety, ethical considerations, the difficulty in designing appropriate trials to assess the study objectives, and funding limitations. However there are sufficient data to base recommendations for drug choice for many of the available antiretroviral drugs. Preferred drugs must show durable viral suppression, increased CD4 cell count, and a favorable safety profile. In addition to the aforementioned characteristics of a preferred drug, preferred antiretroviral drugs for pregnant individuals must pay special attention to maternal toxicity, potential teratogenicity, and fetal safety, efficacy of reducing perinatal transmission, and pharmacokinetics data during the perinatal transmission of HIV. Currently the optimal initial antiretroviral regimens to treat antiretroviral-naïve patients in high resource regions consist of two nucleoside/tide reverse transcription inhibitors in combination with either a nonnucleoside reverse transcriptase inhibitor or a protease inhibitor boosted with RTV. Continually re-evaluation is recommended to challenge current paradigms. Treatment advances may lead to safer and even superior alternatives to current first-line therapy. The WHO current first-line therapy in less developed or developing regions includes the nonnucleoside reverse transcriptase inhibitor, EFV and considerations of poorer overall efficacy compared to newer drugs, toxicity, resistance, and adverse effects suggest that EFV should be reconsidered for use in first-line therapy. Although preferred protease inhibitors are as effective as EFV with fewer adverse effects, serious issues arise when patients are on concomitant medications with drug interactions. Currently raltegravir is the only integrase strand transfer inhibitor drug (INSTI) with data during pregnancy. Raltegravir is an attractive alternative or additional drug for pregnant women requiring medications with resistance, incomplete virologic response, or significant interactions with current first-line regimen drugs. Furthermore, based on recent data, raltegravir could provide pre-exposure prophylaxis in the fetus. DTG is a newer generation INSTI with clinical trials data showing safety and efficacy in nonpregnant adults. These studies suggest great promise for DTG and justify its role as first-line therapy for the nonpregnant population with relatively few drug interactions; in addition, it offers the only single tablet regimen for patient with or at risk for renal dysfunction. Although more data must be collected to ensure the safety and efficacy of INSTI as a first-line therapy in pregnant women, current studies show promise and with increasing experience INSTI agents may become part of the recommended first-line regimen for pregnant women.

Submitted by Ubirajara Cruz (ubirajara.cruz@gmail.com) on 2018-06-06T17:59:49Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) tese_fabio_silva.pdf: 1259622 bytes, checksum: 78c63552140cce462ad2758cdd968a0f (MD5) / Approved for entry into archive by Aline Batista (alinehb.ufpel@gmail.com) on 2018-06-08T11:37:05Z (GMT) No. of bitstreams: 2 tese_fabio_silva.pdf: 1259622 bytes, checksum: 78c63552140cce462ad2758cdd968a0f (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2018-06-08T11:37:05Z (GMT). No. of bitstreams: 2 tese_fabio_silva.pdf: 1259622 bytes, checksum: 78c63552140cce462ad2758cdd968a0f (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2017-08-30 / Sem bolsa / O vírus da imunodeficiência felina (FIV) apresenta estrutura molecular similar ao vírus da imunodeficiência humana (HIV) e pode assim causar síndrome de imunodeficiência adquirida em gatos, estando o tratamento antirretroviral indicado em animais acometidos por infecções recorrentes, neuropatias e gengivoestomatite crônica. Entretanto, a zidovudina, apresenta-se como o único fármaco anti-HIV recomendado para tratamento de gatos infectados pelo FIV, sendo a ação da maioria das drogas antirretrovirais desconhecida diante do agente. Dessa maneira, o presente trabalho teve como objetivo avaliar a ação terapêutica do fármaco raltegravir em gatos naturalmente infectados por FIV, mediante a análise de imunofenotipagem e carga viral plasmática pré, trans e pós terapia. A pesquisa foi conduzida a partir da avaliação de nove gatos com infecção por FIV provenientes da rotina de atendimento médico do Hospital de Clínicas Veterinária da UFPel durante o ano de 2016. Esses animais foram classificados em dois grupos: o grupo 1 (G1) composto de cinco animais FIV positivos submetidos ao tratamento com o fármaco raltegravir e o grupo 2 (G2) constituído de quatro animais FIV positivos não tratados com o antirretroviral. Cada animal foi submetido a 3 avaliações em momentos distintos, a 1ª avaliação (pré-terapia) foi realizada até 2 dias antes do início do tratamento, a 2ª avaliação (trans-terapia) entre o 10º e 12º dia de tratamento e a 3ª avaliação (pós-terapia) realizada até dois dias após a suspensão do medicamento. A dose de 40mg/ gato a cada 12h, via oral, administrada por 21 dias demonstrou-se tolerável e segura nos gatos, pois não induziu nenhuma reação adversa durante o tratamento. Contudo a contagem de linfócitos CD4+ e o quociente CD4+/CD8+ não demonstrou elevação de valores, assim como a carga viral plasmática não apresentou supressão após o tratamento com raltegravir pelo mesmo período. Sendo assim, não foi possível estabelecer atividade antiviral in vivo do antirretroviral raltegravir diante do FIV. / Feline immunodeficiency virus (FIV) presents molecular structure similar to the human immunodeficiency virus (HIV) and can cause acquired immunodeficiency syndrome in cats, this way the antiretroviral therapy is encouraged in animals affected by recurrent infections, neuropathy and chronic gingivostomatitis. However, zidovudine is the only anti-HIV drug recommended for the treatment of FIV infected cats, being unknown the action of most of the antiretroviral drugs against the virus. In that way, the present work had the objective of evaluating the therapeutic action of raltegravir in cats naturally infected by FIV, through immunofenotyping and plasma viral load before, trans and after-therapy. The research was conducted by evaluating 9 cats naturally infected by FIV from the medical routine of the Veterinary Clinics Hospital (UFPel) during the year of 2016. These animals were classified in two groups: group 1 (G1) composed by 5 FIV positive animals treated with raltegravir and group 2 (G2) with 4 FIV positive animals non-treated with the antiretroviral. Each animal was submitted to 3 evaluations in distinct moments, the first evaluation (before therapy) was performed until two days before the beginning of the treatment, the second evaluation (trans-therapy) was between the 10th and the 12th day of treatment and the third evaluation (after-therapy) was performed until two days after the suspension of the drug. The dose of 40mg/ cat q 12h, PO, administered for 21 days has showed to be tolerable and safe in the cats, because it did not induce any adverse reaction during the treatment. However, the CD4+ lymphocyte count and the CD4+/CD8+ quotient did not show elevation of values, as well as the plasma viral load did not present suppression after the treatment with raltegravir for the same period. Thus, it was not possible to establish in vivo antiviral activity of the antiretroviral raltegravir against FIV.

HIV protease inhibitors (PI) are core components of Highly Active Antiretroviral Therapy (HAART). HIV PIs are extremely effective at suppressing viral load, but have been linked to lipodystrophy and dyslipidemia, which are major risk factors for cardiovascular disease. Recent studies indicate that activation of endoplasmic reticulum (ER) stress is an important cellular mechanism underlying HIV PI-induced dysregulation of lipid metabolism. However, the exact role of ER stress in HIV PI-associated lipodystrophy and dyslipidemia remains to be identified. Hepatocytes and adipocytes are important players in regulating lipid metabolism and the inflammatory state. Dysfunction of these two cell types is closely linked to various metabolic diseases. In this dissertation research, we aimed to define the role of activation of ER stress in HIV PI-induced dysregulation of lipid metabolism in adipocytes and hepatocytes and further identifty the potential molecular mechanisms. Both cultured and primary mouse adipocytes and hepatocytes were used to examine the effect of individual HIV PIs on ER stress activation and lipid metabolism. The results indicated that HIV PIs differentially activate ER stress through depletion of ER calcium stores, activating the unfolded protein response (UPR). UPR activation further lead to an alteration of cellular differentiation through downstream transcription factor CHOP. At the same time, HIV PIs also altered adipogenesis via differential regulation of the adipogenic transcription factor PPARγ. HIV PI-induced ER stress was closely linked to dysregulation of autophagy activation through CHOP, and upstream ATF-4, signaling pathways. In hepatocytes, the integrase inhibitor raltegravir abrogated HIV PI-induced lipid accumulation by inhibiting ER stress activation and dysregulation of autophagy pathway. Our studies suggest that both ER stress and autophagy are involved in HIV PI-induced dysregulation of lipid metabolism in adipocytes and hepatocytes. The key components of ER stress and autophagy signaling pathways are potential therapeutic targets for HIV PI-induced metabolic side effects in HIV HAART-treated patients.

As HIV is now primarily a chronic condition, treatment is given life-long with changes as necessitated by alterations in tolerability and efficacy. Thus, personalized medicine may be useful in the prevention of unnecessary drug exposure and avoidable side effects. Three of the four currently available HIV integrase strand transfer inhibitors (INSTIs), raltegravir, elvitegravir, and dolutegravir, are widely utilized antiretrovirals in the USA and exhibit variations in outcomes among subjects. To interrogate differences among subjects receiving these drugs, we investigated the association of several single nucleotide polymorphisms (SNPs) with drug exposure, clinical outcomes, and subject-reported adverse events. HIV+ adults (≥18 years old) receiving an INSTI regimen were recruited (n=88). Subject genotypes were evaluated using an iPLEX PGx Panel. Genetic variations within our population, underwent multiple regression with covariates [age, sex, BMI, regimen duration, and baseline variables (as required) along with specific regimen in the comprehensive group] to detect significant (p=0.028) between abnormal dream occurrence and specific INSTI regimen with the raltegravir grouping presenting a higher frequency. This exploratory study also discovered several SNP-outcome associations when using INSTIs. Although these SNPs were found to have a role in predicting segments of adverse effect profiles, the clinical significance of these findings remains to be determined. Larger studies will be needed to confirm these exploratory findings with functional studies to understand pathogeneses. In conclusion, the associations found in this study strengthen the need for further assessment, within the HIV+ population, of factors contributing to unfavorable subject outcomes.

La variabilité pharmacocinétique liée à une élimination des médicaments par glucuronoconjugaison a été peu étudiée. Nous avons donc choisi d’étudier les caractéristiques pharmacocinétiques de deux médicaments glucuronoconjugués, l’acide mycophénolique (MPA, prodrogue, mycophénolate mofétil ou MMF) et le raltégravir, dans certaines situations cliniques spécifiques. Deux études cliniques ont été réalisées avec le MMF. En transplantation hépatique pédiatrique, des AUC0-12 de MPA supérieures à 30 mg.h/L ont été obtenues chez tous les enfants avec une dose de 600 mg/m² de MMF administrée par voie orale deux fois par jour. L’estimation de l’AUC0-12 par méthode non compartimentale étant particulièrement contraignante en pédiatrie, nous avons développé une stratégie de prélèvements limités permettant une estimation à partir de seulement trois prélèvements. Chez des patients adultes transplantés rénaux, nos travaux ont permis de caractériser le polymorphisme génétique des transporteurs ABCC2 et ABCB1 et l’albuminémie comme étant des facteurs de variabilité inter et intra-individuelle de la pharmacocinétique du MPA. Les concentrations intracellulaires moyennes de MPA dans les cellules mononuclées du sang périphérique étaient élevées et largement supérieures à la concentration de MPA inhibant 50% de l’activité de l’IMPDH. Nos premiers résultats concernant le raltégravir montrent que ses paramètres pharmacocinétiques sont caractérisés par une variabilité inter-individuelle importante chez des patients infectés par le VIH. Nous avons établi que le raltégravir ne se fixe pas du tout sur l’alpha-1-glycoprotéine acide mais se fixe à 60% sur l’albumine, cette fixation étant dépendante du pH plasmatique. Cependant, cette forte liaison du raltégravir à l’albumine n’empêche pas une bonne diffusion du médicament dans le compartiment séminal. En conclusion, les études de pharmacocinétique clinique que nous avons menées montrent que la variabilité de la pharmacocinétique de ces deux médicaments glucuronoconjugués est aussi importante que pour des médicaments métabolisés par le cytochrome P450 3A4. L’identification des facteurs de variabilité de ces médicaments contribue à l’optimisation des traitements. / Pharmacokinetic variability was poorly studied for drugs eliminated by glucuronidation. We therefore chose to study the pharmacokinetic parameters of two glucuronidated drugs, mycophenolic acid (MPA, prodrug, mycophenolate mofetil or MMF) and raltegravir, in specific clinical situations. Two clinical studies were conducted with MMF. In pediatric liver transplantation, MPA AUC0-12 above the target AUC of 30 mg.h/L were obtained in all children with a MMF dosing regimen of 600 mg/m² administered orally twice a day. As extensive AUC monitoring is laborious, especially in children, we developed a limited sampling strategy to calculate MPA AUC0-12 with only three samples. In adult renal transplantation, our work allowed us to characterize genetic polymorphism of ABCC2 and ABCB1 genes and serum albumin as factors of inter and intraindividual variability in MPA pharmacokinetics. We demonstrated that MPA concentrations in peripheral blood mononuclear cells were high and well above the concentration of MPA responsible for a 50%-inhibition of the activity of IMPDH. Our first results show that the raltegravir pharmacokinetics is characterized by a wide interindividual variability in HIV-infected patients. Raltegravir does not bind to alpha-1-acid glycoprotein but binds to 60% to albumin and this binding is pH-dependent. Despite this high protein binding, a good penetration into the seminal compartment was evidenced. In conclusion, these clinical pharmacokinetic studies demonstrated that the variability in the pharmacokinetics of these glucuronidated drugs is as important as the one exhibited by drugs metabolized by cytochrome P450 3A4. Identifying factors of variability of these glucuronidated drugs contributes to optimizing patient care.