Sarah T. Pruett, Vincent C. Marconi, Edward P. Acosta, Aswani Vunnava, Kirk A. Easley, Cecile Delille, Jeffrey L. Lennox, Richard F. Arrendale, Ighovwerha Ofotokun, Anandi N. Sheth, and Wendy S. Armstrong
Despite highly active antiretroviral therapy (HAART), human immunodeficiency virus-1 (HIV-1) continues to elude eradication. Even in the setting of plasma virologic suppression, HIV-1 RNA can be found in peripheral blood mononuclear cells (PBMCs), genital secretions, gastrointestinal lymphoid tissue, and cerebrospinal fluid (CSF).1,2 Limited penetration of antiretrovirals (ARVs) into these sites may play a role in viral persistence.2,3 HIV-1 invades the central nervous system (CNS) early after infection via macrophages, monocytes, and dendritic cells.4 Over time, HIV-associated neurocognitive disorders (HAND) can develop,5 contributing significantly to morbidity6 and early mortality.7 While severity of HAND has decreased, prevalence remains unchanged since the pre-HAART era: 36.2–44.8%,6 prompting a concern for suboptimal CNS control of HIV. This is supported by reports of elevated neopterin, an inflammatory biomarker, and measurable HIV RNA in the CSF of patients on long term HAART,8,9 both predictive markers for development of HIV-associated dementia.10,11 Some studies suggest that limited CNS penetration by ARVs is associated with HAND.12,13 Molecular size, lipophilicity, affinity for efflux pump transporters, and degree of plasma protein binding are factors that impact drug CNS penetration.14 Lipophilic drugs, including HIV protease inhibitors (PIs), are highly bound to plasma protein, predominantly alpha1-acid glycoprotein (AAG). The plasma unbound (free) drug component is considered pharmacologically active and readily crosses the blood–brain and blood–CSF barriers15,16 therefore highly bound drugs such as PIs may have limited CNS penetration. Two PIs, atazanavir (ATV) and darunavir (DRV), are recommended by the Department of Health and Human Services (DHHS) as part of first-line once daily regimens for ARV-naive patients when boosted with ritonavir (RTV) and given with a backbone of tenofovir disoproxil fumarate/emtricitabine (TDF/FTC).17 Both PIs have characteristics that could impede tissue and CNS penetration, including large molecular size and affinity for efflux pump transporters. However, they differ in their affinity for plasma AAG: ATV is 86% plasma protein bound in vitro whereas DRV is 95% bound.18,19 The degree to which they successfully penetrate the CNS remains unclear. Best et al showed low or undetectable CSF ATV levels in nearly 25% of study participants.20 but measured only total drug concentrations with a lower quantitation limit of 5 ng/mL. In contrast, 3 prior studies have shown that DRV can attain drug concentrations in the CSF exceeding IC50 21–23 ; however, the single study measuring unbound drug concentrations22 examined participants receiving twice daily DRV rather than the DHHS recommended once daily dosing schedule for patients without history of DRV resistance.17 Additionally, measuring random total drug concentrations rather than troughs limited all previous studies. To address these limitations, we evaluated the CSF penetration of once daily DRV relative to ATV, both boosted with RTV and administered with the same background TDF/FTC regimen. We hypothesized that ATV, a PI with lower degree of plasma protein binding, would achieve a higher CSF/plasma unbound drug concentration ratio than DRV. In addition, we compared unbound CSF PI concentrations to their drug-specific IC50 and assessed relationships with CSF HIV-1 RNA and neopterin.