Switch From Etravirine to Doravirine as a Part of Antiretroviral Combination in Virologically Suppressed People Living With HIV (PLWH): the French Multicenter, Observational SWEED Study

The evolution of HIV infection from fatal to chronic has been enabled by advances in development and access of antiretroviral treatment (ART), which has also resulted in life expectancy of PLWH approaching that of those uninfected.In addition, over the past few years, new drugs and news regimens have offered improved efficacy, safety and tolerability. The 95-95-95 UNAIDS target, i.e. to diagnose 95% of PLWHIV (1st 95), provide ART to 95% of those diagnosed with HIV (2nd 95), and to reach viral suppression in 95% of patients on ART (3rd 95), is being achieved in several countries. Calls to add a fourth target, i.e. to improve the quality of life for PLWHIV, have grown stronger since the concept was introduced in 2016. The twin aims are long-term treatment durability and improved quality of life with a focus on personalized treatment.

Switching or simplifying ART in the setting of HIV suppression may improve pill burden, dosing frequency, safety, tolerability, and/or food requirements. At times, ART switch or simplification is elective, such as consolidating a multiple-tablet to a single-tablet regimen (STR). Other times, it is necessary to eliminate drug-drug interactions (DDIs) and/or minimize active or potential treatment-associated adverse events (AEs). The fundamental principle of switching or simplifying ART is to preserve virologic suppression without jeopardizing future ART options.

Etravirine, a second generation NNRTI, has been demonstrated to be effective on HIV strains with prior resistance mutations on reverse transcriptase impacting other NNRTIs, such as nevirapine, efavirenz or rilpivirine. It has even been used in salvage therapy, in association with darunavir and raltegravir, in uncontrolled patients with multiresistant strains. Etravirine is mostly prescribed twice daily, and is a strong enzymatic inducer providing many DDIs, complicating its use.

Doravirine, a last generation NNRTI, is approved in treatment-naïve and experienced HIV-infected individuals. In the DRIVE-FORWARD study, doravirine 100 mg QD, in combination with either TDF/FTC or ABC/3TC, achieved high virologic success at week 48 and was non-inferior to DRV/r + 2 NRTIs regardless of baseline HIV-RNA. In the DRIVE-AHEAD study, in treatment-naïve adults with HIV-1 infection, doravirine + 3TC/TDF administered once daily demonstrated a high antiviral potency with non-inferior efficacy to EFV/FTC/TDF regardless of baseline HIV-RNA, and a low rate of resistance, with only 1.6% of participants developing resistance to any study drug through W48. For virologically suppressed patients considering a change in therapy, switching to DOR/3TC/TDF was shown to be a well-tolerated option which was non-inferior to continuation of the previous regimen, with high rates of virologic suppression and low rates of virologic rebound. Long term results from the DRIVE-SHIFT trial showed that doravirine maintained virologic suppression and was generally well tolerated through 144 weeks of treatment. DOR/3TC/TDF as switch therapy showed a favorable lipid profile compared with previous regimens and results in minimal weight gain. The convenience achieved through switching to a DOR based regimen serves to achieve regimen simplification and could respond to patient demands for increased tolerability.

The DOR resistance profile is distinct from that of other NNRTIs with the in vitro selection of mutations at reverse transcriptase (RT) positions 106, 108, 188, 227, 230, 234 and 236. In vitro studies have also suggested that DOR has activity against viruses with certain mutations selected by other NNRTIs, including the K103N and Y181C mutations. In the DRIVE-SHIFT trial, conducted in virologically suppressed patients, 24 participants had a virus with baseline NNRTI mutations (K103N, Y181C and G190A) and 23/24 who switched to DOR/3TC/TDF remained virologically suppressed at the 48-week follow-up. This suggests that the most frequent NNRTI mutations at RT mutation positions 103, 181 and 190 probably not impact DOR activity in vivo.