1. Efavirenz (EFV) Concentrations in Pregnant Women Taking EFV-Based Antiretroviral Therapy (ART) with and without Rifampin-Containing Tuberculosis (TB) Treatment Helen McIlleron, Neil Martinson, Paolo Denti, Fildah Mashabela, Jennifer Hunt, Saba Shembe, Jennifer Hull, David W. Haas, Regina Msandiwa, Silvia Cohn, Sandra Meredith, Lubbe Wiesner, Richard Chaisson, Kelly E. Dooley, and the TSHEPISO Study Team

2. Background In South Africa, the current standard of care for pregnant women with HIV infection and < 350 CD4 cells/mm 3 is combination ART There are limited data on efavirenz (EFV) pharmacokinetics (PK) in pregnant women, though its use is increasing (Cressey et al., 2012) In Soweto, an estimated 0.8-2.2% of pregnant women with HIV also have active TB (Gounder et al. 2011; Kali et al. 2006) Rifampin, a key component of first-line TB treatment, reduces concentrations of many antiretroviral (ARV) drugs The combined effect of pregnancy and rifampin-containing TB treatment on EFV PK, virologic suppression and prevention of maternal-to-child transmission of HIV-1 (PMTCT) has not been studied

3. Study design TSHEPISO is a prospective cohort study among HIV-infected pregnant women with TB (n=250 CASES) and without TB (n=500 CONTROLS), currently enrolling in Soweto, South Africa Antenatal clinics and obstetrics ward at Chris Hani Baragwanath Hospital, women at 13-34 weeks gestation Impact of TB/HIV co-infection in pregnancy on maternal and infant outcomes being evaluated Women (n=150) with and without TB, on EFV-containing ART (600 mg QD) will enroll in an EFV PK/PD substudy, along with their infants  We report preliminary results from 76 women and 70 infants in the TSHEPISO EFV PK substudy to date

4. Study schema

5. EFV PK Substudy Blood samples for EFV PK analysis were collected: Maternal, up to 4 samples per occasion – 37 weeks gestation or at delivery – 6 weeks post-partum Infant – Cord blood at delivery – 7 days Viral load: Maternal, at delivery Infant, at 6 weeks

6. Methods: EFV PK Substudy Blood samples for EFV PK analysis were collected: – Maternal: 37 weeks gestation or delivery, then 6 weeks post-partum; up to 4 samples per occasion – Cord blood at delivery, infant sample at 7 days Plasma concentrations determined by LCMS/MS † CYP2B6 genotyping of maternal DNA § – Extensive = 516GG and 983TT – Intermediate = 516GT or 983CT – Slow = 516TT or (516GT and 983CT) or 983CC – Very Slow = 983CC Post-hoc Bayesian estimates of PK parameters from NLME modeling with allometric scaling, using NONMEM HIV-1 viral load collected at delivery for mothers, at 6 weeks for infants †Clinical Pharmacology Analytical Laboratory, University of Cape Town; §Pharmacogenomics Laboratory, Vanderbilt University, Nashville and University of the Witwatersrand, Johannesburg

7. Results: Study participants Cases (n=33)Controls (n=43) Age in years, median (IQR)29 (26-34)30 (26-32) Gestational age at enroll, median (IQR)29 (26-32)31 (24-33) CD4 cells/mm3 at enroll, median (IQR)288 (137-427)330 (260-382) HIV RNA copies/mL at enroll, N (%)* <20 >=20 9 (28%) 23 (72%) 25 (58%) 18 (42%) CYP2B6 metabolizer status, N (%) Extensive Intermediate Slow Very Slow 8 (26%) 20 (59%) 4 (15%) 1 (3%) 10 (24%) 19 (45%) 13 (31%) 1 (2%) Gestational age at delivery, median (IQR)38 (36-40)39 (38-40) Weeks on EFV at delivery, median (IQR)12 (5-18)21 (12-68) *p<0.05 in univariate analysis

8. EFV Population PK Model Central Compartment Central Compartment TV Ka= 0.417 h -1 TV V/F=469 L Absorption Compartment Absorption Compartment TV CL/F, by genotype: Extensive: 19.7 L/h Intermediate: 12.1 L/h Slow: 7.99 L/h Very Slow: 2.19 L/h BSV 35.6% F=1 (FIXED) BOV 32.2% Dose TV CL/F= 11.7 L/h BSV 65.5% BOV 33.9% For Slower metabolizers: CL/F -59% when on RIF co- treatment

9. EFV Population PK model features 1-compartment model Visits excluded if all EFV samples BLQ (13 PK samples in 10 participants) Allometric scaling with body weight applied to CL/F and V/F CL/F strongly influenced by CYP2B6 genotype Did not detect significant longitudinal variations in EFV PK (pre/post partum) Rifampicin co-treatment decreased EFV CL/F in slower metabolizers

10. Parameter Typical Value (%RSE) BSV (%RSE) BOV (%RSE) CL/F Fast [L/h]19.7 (9.6%) 35.6% (23.3%) CL/F Intermediate [L/h]12.1 (6.6%) CL/F Slow [L/h]7.99 (28.5%) CL/F Very Slow [L/h]2.19 (41.7%) V/F [L]469 (12.8%) RIF on CL/F (Slow-VSlow)-58.6% (25.9%) Ka [h -1 ]0.417 (47.7%) Bioavailability1 FIXED 32.2 (15.8%) PROP ERR [%]7.78% (10.8%) ADD ERR [ng/mL]0.124 (15.7%) B.J. Anderson and N.H. Holford, "Mechanism-based concepts of size and maturity in pharmacokinetics.," Annual review of pharmacology and toxicology, vol. 48, 2008, pp. 303-32. Population PK Model BSV: Between subject variability, BOV: Between-Occasion variability, %RSE: Relative Standard Error

11. *1 Very Slow has EFV value > upper limit of assay CYP2B6 and EFV PK estimates *

12. Maternal EFV PK estimates, by pregnancy status and rifampin co-treatment Pre/intrapartum (n=59) 6 weeks Post-partum (n=50) C min (mg/L)*1.4 (0.99, 1.89)1.68 (1.22, 2.78) % with C min <1 mg/L25.4%20.0% *Median (IQR) The population PK model post-hoc estimates were used to predict individual C min, reported here with the BLQ values that could not be included in the model Taking rifampin for TB treatment (n=30) Not taking rifampin (n=46) C min (mg/L)*1.76 (0.89, 3.13)1.52 (1.14, 2.02) % with C min <1 mg/L29.6%17.1%

13. Maternal EFV PK estimates, effect of genotype *Median (IQR) Note – 1 of 2 Very Slow with EFV > upper limit of quantitation, being re-assayed Extensive (n=18) Intermediate (n=38) Slow (n=13) Very Slow (n=2) C min (mg/L)* 0.87 (0.61, 1.24) 1.58 (1.26, 2.01) 4.33 (2.43, 5.98) 19.6, 19.8 % with C min <1 mg/L56.3%5.7%16.7%0%

14. Maternal EFV PK estimates, effect of genotype and RIF *Median (IQR) Fast (n=6 RIF, 13 no RIF) Intermediate (n=19 RIF, 20 no RIF) Slow (n=3 on RIF, 11 no RIF) Very Slow (n=1 RIF, 1 no RIF) Genotype /RIF C min (mg/L)* 0.79 (0.58, 0.85) 1.84 (1.29, 2.59) 7.00 (5.64, 7.12) 19.6 RIF treatment % with C min <1 mg/L100%12.5%0% C min (mg/L)* 1.2 (0.69, 1.48) 1.52 (1.26, 1.79) 3.98 (1.11, 5.24) 19.8 No RIF treatment % with C min <1 mg/L36.4%0%30.0%0%

15. Maternal EFV PK estimates, effect of weight and RIF *Median (IQR) <60 kg (n=15 RIF, 10 no RIF) >=60kg (n=22 RIF, 41 no RIF) Weight/ RIF C min (mg/L)* 1.91 (1.23, 3.71) 1.91 (0.86, 3.13) RIF treatment % with C min <1 mg/L20.0%31.6% C min (mg/L)* 1.33 (1.12, 1.64) 1.55 (1.13, 2.07) No RIF treatment % with C min <1 mg/L11.1% 16.7%

16. Cord blood and infant PK results Cord blood (n=45) – Median EFV concentration 1.15 (0.628 – 1.91) mg/L – Below the limit of quantification in 4/45 (8.9%) samples Infant blood (7 days) (n=57) – Median EFV concentration BLQ (BLQ - 0.079) mg/L – Below the limit of quantification in 35/57 (61.4%) samples Cord and maternal pre-partum concentrations were highly correlated (r=0.93) Infant 7-days blood concentrations were BLQ in most cases, but quantifiable values were related to larger cord blood concentrations.

17. Virologic outcomes Maternal viral load at delivery – 70% of cases and 83% of controls had VL<20 copies/mL at delivery (p=0.24) – Of those taking EFV for at least 12 weeks at delivery, 82% of cases and 93% of controls had VL<20 copies/mL (p=0.26) PMTCT – No transmission from women taking EFV at delivery

18. Limitations Single site Sparse sampling Not all participants presented for all sampling visits Observational study in complex setting, no DOT-ART Small sample size for subgroup comparisons

19. Summary Rich dataset including 76 women, 70 infants, PK and VL data from high burden HIV/TB setting Estimated C min among women pre/intrapartum and post-partum were not significantly different In a model that accounts for weight and CYP2B6 genotype, unable to show significant effect of rifampin on EFV PK (except among slow EFV metabolizers) Despite about 30% with C min <1 mg/L, VL suppressed in most women taking EFV for 3 months or more at the time of delivery, and no MTCT

20. Acknowledgements Perinatal HIV Research Unit Lala Maseko Joyce Netshivhale Abram Maubane Agnes Shilubane Matabogo Letutu Glenda Gray Chris Hani Baragwanath Hospital Jennifer Hull Eckhart Buchman Sthe Velaphi Sanjay Lala Khakhu Mathivha University of the Witwatersrand Wendy Stevens Sergio Carmona A special thanks to all study participants University of Cape Town Division of Clinical Pharmacology laboratory Marilyn Solomons Johns Hopkins University Chris Hoffmann Vanderbilt University Danielle Richardson Paul Leger Cara Sutcliffe Funding NIH/NICHD R01HD064354 (Chaisson) NIH K23 (Dooley) NIH/NIAID R01 AI-077505, NCATS UL1 TR-000011 (Haas)

21. Thank you