Study Comparing Efficacy and Safety of Darunavir Boosted With Ritonavir to HART With 2 NRTI and Darunavir Boosted With Ritonavir in HIV-1 Infected Patients ANRS136

• Proportion of patients with virological success between W48 and W96, [ Time Frame: W96 ] [ Designated as safety issue: Yes ]
• Proportion of patients with HIV-1 RNA below 50 copies/mL, between 50 to 400 copies/mL and > 400 copies/ml from D0 to W96, [ Time Frame: W96 ] [ Designated as safety issue: Yes ]
• Time to virologic failure, [ Time Frame: between W0 and W96 ] [ Designated as safety issue: No ]
• PI genotypic resistance mutations occurring during the follow-up [ Time Frame: between W0 and W96 ] [ Designated as safety issue: Yes ]
• Change in proviral DNA at D0, W48 and W96, [ Time Frame: W0, W48 and W96 ] [ Designated as safety issue: No ]
• Change in CD4 count from D0 to W96. [ Time Frame: D0, W96 ] [ Designated as safety issue: No ]
• Comparing plasma HIV-1 RNA genotypic resistance with DNA genotypic resistance at entry [ Time Frame: D0 ] [ Designated as safety issue: No ]
• Quantification of HIV RNA in the genital compartment between D0 and W48 (sub-study with 40 patients enrolled, 20 patients in each arm of strategy). [ Time Frame: D0 and W48 ] [ Designated as safety issue: No ]
• Incidence of clinical endpoints [ Time Frame: W96 ] [ Designated as safety issue: Yes ]
• Modification of treatment strategies and withdrawal of study treatment. [ Time Frame: between D0 and W96 ] [ Designated as safety issue: Yes ]
• Tolerance of Darunavir (Grade 3 and 4 laboratory abnormalities and signs and symptoms). [ Time Frame: between D0 and W96 ] [ Designated as safety issue: Yes ]
• Change in lipidic and glucidic profile and distribution of fat tissue by DEXA-scan (sub-study in 160 patients enrolled). [ Time Frame: W0, W48 and W96 ] [ Designated as safety issue: No ]
• Self-reported adherence and symptom self-evaluation. [ Time Frame: W0, W4, W24, W48, W96 ] [ Designated as safety issue: No ]
• The proportion of patients with HIV RNA below 50 copies/mL in darunavir/r monotherapy arm after resuming 2 previous NRTIs in case of virological failure. [ Time Frame: between W0 and W96 ] [ Designated as safety issue: No ]
• Search for predictive factors of virological failure (level of proviral DNA, Cmin LPV, …). [ Time Frame: between W0 and W96 ] [ Designated as safety issue: No ]
• evaluation of the mineral bone density by DEXA-scan (sub-study in 160 patients enrolled). [ Time Frame: W96 ] [ Designated as safety issue: No ]

• Proportion of patients with virological success between W48 and W96,
• Proportion of patients with HIV-1 RNA below 50 copies/mL, between 50 to 400 copies/mL and > 400 copies/ml from D0 to W96,
• Time to virologic failure,
• PI genotypic resistance mutations occurring during the follow-up,
• Change in proviral DNA at D0, W48 and W96,
• Change in CD4 count from D0 to W96.
• Comparing plasma HIV-1 RNA genotypic resistance with DNA genotypic resistance at entry
• Quantification of HIV RNA in the genital compartment between D0 and W48 (sub-study with 40 patients enrolled, 20 patients in each arm of strategy).
• Incidence of clinical endpoints
• Modification of treatment strategies and withdrawal of study treatment.
• Tolerance of Darunavir (Grade 3 and 4 laboratory abnormalities and signs and symptoms).
• Change in lipidic and glucidic profile and distribution of fat tissue by DEXA-scan (sub-study in 120 patients enrolled).
• Self-reported adherence and symptom self-evaluation.
• The proportion of patients with HIV RNA below 50 copies/mL in darunavir/r monotherapy arm after resuming 2 previous NRTIs in case of virological failure.
• Search for predictive factors of virological failure (level of proviral DNA, Cmin LPV, …).

The purpose of this study is to evaluate whether a monotherapy of boosted darunavir is able to maintain the virological success until 48 weeks in comparison to a standard therapy 2 INTI + darunavir/r in HIV infected patients with full viral suppression.

The chronicity of the disease which will require treatment over decades, long-term adverse events associated with standard combined antiretroviral therapy, emphasize the need for simpler, alternative treatment strategies for HIV infection. The goal of antiretroviral therapy in 2006 is the durability of treatment with less toxicity and reduced exposure to drugs. Previous studies have shown that single boosted PI maintenance therapy such as lopinavir (LPV/r), were effective in maintaining virological efficacy. Furthermore, in case of virological failure, limited resistance has been described. darunavir/r, a new PI, has been shown to be highly potent, exhibits a high genetic barrier to resistance and appears to be well tolerated. This study aimed to evaluate whether darunavir/r can represent a potential strategy therapeutic as single therapy in patients who have full virologic suppression At entry, subjects with HIV RNA below 50 cp/ml switch from their current therapy which can be 2 NRTI and IP, 2 NRTI and NNRTI, 3 NRTI to darunavir/r with their 2 NRTIs for 8 weeks (Phase I). If patients remain below 50 cp/ml and has no intolerance to darunavir at week -4, they are included in the phase II and will be randomized either to receive darunavir/r alone or to continue 2 NRTI and darunavir/r for until W48 (Phase II). Patients will be monitored at W4, W8 and then every 8 weeks until W48 for the primary endpoint. To evaluate the durability and safety of this strategy, patients will be followed up to W96

• Drug: Darunavir
  during the 48 first weeks of the trial, (2x300mg) twice a day between W48 and W96, (2x400mg) once a day
  Other Name: Prezista
• Drug: ritonavir
  during the first 48 weeks, 100mg twice a day between W48 and W96, 100mg once a day
  Other Name: Norvir

• Experimental: 1
  Interventions:

  • Drug: Darunavir
  • Drug: ritonavir
• Active Comparator: 2
  Interventions:

  • Drug: Darunavir
  • Drug: ritonavir

• Lambert-Niclot S, Flandre P, Valantin MA, Soulie C, Fourati S, Wirden M, Sayon S, Pakianather S, Bocket L, Masquelier B, Dos Santos G, Katlama C, Calvez V, Marcelin AG. Similar evolution of cellular HIV-1 DNA level in darunavir/ritonavir monotherapy versus triple therapy in MONOI-ANRS136 trial over 96 weeks. PLoS One. 2012;7(7):e41390. Epub 2012 Jul 25.
• Katlama C, Valantin MA, Algarte-Genin M, Duvivier C, Lambert-Niclot S, Girard PM, Molina JM, Hoen B, Pakianather S, Peytavin G, Marcelin AG, Flandre P. Efficacy of darunavir/ritonavir maintenance monotherapy in patients with HIV-1 viral suppression: a randomized open-label, noninferiority trial, MONOI-ANRS 136. AIDS. 2010 Sep 24;24(15):2365-74.

Inclusion Criteria:

• Confirmed HIV-1 infection.
• Documented level of HIV-1 RNA at initiation of antiretroviral treatments
• Prior antiretroviral regimen, including at least 2 NRTIs combined to 1 PI or NNRTI or a third NRTI for at least 18 months prior to study entry.
• CD4 count of 200 cells per mm3 or greater.
• Viral load below 400 copies per ml within 18 months prior to entry and below 50 copies per mL at entry.
• Willing to use acceptable methods of contraception

Exclusion Criteria:

• Previous virological failure under prior PI-based regimen.
• Prior therapy in the darunavir.
• HIV-2 infected patients.
• Absence of documented level of HIV-1 RNA at initiation of antiretroviral treatments
• Hepatitis B or C infection within 90 days prior to study entry.
• Therapies including interferon, interleukin-2, cytotoxic chemotherapy or immunosuppressors at study entry.
• Serious acute illness requiring systemic treatment or hospitalization in the 14 days prior to study entry.
• Treatment for an active AIDS defining opportunistic infection within 30 days prior to screening
• Drug or alcohol use or any dependence that would interfere with compliance.
• Pregnancy or breastfeeding