The efficacy and safety of SUNLENCA in heavily treatment-experienced participants with multidrug resistant HIV-1 is based on 52-week data from CAPELLA, a randomized, placebo-controlled, double-blind, multicenter trial (NCT 04150068).
CAPELLA was conducted in 72 heavily treatment-experienced participants with multiclass resistant HIV-1. Participants were required to have a viral load ≥ 400 copies/mL, documented resistance to at least two antiretroviral medications from each of at least 3 of the 4 classes of antiretroviral medications (NRTI, NNRTI, PI and INSTI), and ≤ 2 fully active antiretroviral medications from the 4 classes of antiretroviral medications remaining at baseline due to resistance, intolerability, drug access, contraindication, or other safety concerns.
The trial was composed of two cohorts. Participants were enrolled into the randomized cohort (cohort 1, N=36) if they had a < 0.5 log10 HIV-1 RNA decline compared to the screening visit. Participants were enrolled into the non-randomized cohort (cohort 2, N=36) if they had a ≥ 0.5 log10 HIV-1 RNA decline compared to the screening visit or after cohort 1 reached its planned sample size.
In the 14-day functional monotherapy period, participants in cohort 1 were randomized in a 2:1 ratio in a blinded fashion to receive either SUNLENCA or placebo, while continuing their failing regimen. This period was to establish the virologic activity of SUNLENCA. After the functional monotherapy period, participants who had received SUNLENCA continued on SUNLENCA along with an OBR; participants who had received placebo during this period initiated SUNLENCA along with an OBR.
Participants in cohort 1 had a mean age of 52 years (range: 24 to 71), 72% were male, 46% were White, 46% were Black, and 9% were Asian. 29% percent of participants identified as Hispanic/Latino. The mean baseline plasma HIV-1 RNA was 4.3 log10 copies/mL (range: 2.3 to 5.4). 19% of participants had baseline viral loads greater than 100,000 copies/mL. The mean baseline CD4+ cell count was 161 cells/mm3 (range: 6 to 827). 75% of participants had CD4+ cell counts below 200 cells/mm3. The mean number of years since participants first started HIV treatment was 24 years (range: 7 to 33); the mean number of antiretroviral agents in failing regimens at baseline was 4 (range: 1 to 7). The percentage of participants in the randomized cohort with known resistance to at least 2 agents from the NRTI, NNRTI, PI and INSTI classes was 97%, 94%, 78% and 75%, respectively. In cohort 1, 53% of participants had no fully active agents, 31% had 1 fully active agent, and 17% had 2 or more fully active agents within their initial failing regimen, including 6% of participants were who were receiving fostemsavir, which was an investigational agent at the start of the CAPELLA trial.
Participants in cohort 2 initiated SUNLENCA and an OBR on Day 1.
Participants in cohort 2 had a mean age of 48 years (range: 23 to 78), 78% were male, 36% were White, 31% were Black, 33% were Asian, and 14% of participants identified as Hispanic/Latino. The mean baseline plasma HIV-1 RNA was 4.1 log10 copies/mL (range: 1.3 to 5.7). 19% of participants had baseline viral loads greater than 100,000 copies/mL. The mean baseline CD4+ cell count was 258 cells/mm3 (range: 3 to 1296). 53% of participants had CD4+ cell counts below 200 cells/mm3. The mean number of years since participants first started HIV treatment was 19 years (range: 3 to 35); the mean number of antiretroviral agents in failing regimens at baseline was 4 (range: 2 to 7). The percentage of participants in the non-randomized cohort with known resistance to at least 2 agents from the NRTI, NNRTI, PI and INSTI classes was 100%, 100%, 83% and 64%, respectively. In cohort 2, 31% of participants had no fully active agents, 42% had 1 fully active agent, and 28% had 2 or more fully active agents within their initial failing regimen, including 6% of participants who were receiving fostemsavir, which was an investigational agent at the start of the CAPELLA trial.
The primary efficacy endpoint was the proportion of participants in cohort 1 achieving ≥ 0.5 log10 copies/mL reduction from baseline in HIV-1 RNA at the end of the functional monotherapy period. The results of the primary endpoint analysis are shown in Table 13.
Table 13 Proportion of Participants Achieving a ≥ 0.5 log10 Decrease in Viral Load at the End of the Functional Monotherapy Period in the CAPELLA Trial (Cohort 1) | SUNLENCA (N=24) | Placebo (N=12) |
|---|
| Proportion of Participants Achieving a ≥ 0.5 log10 Decrease in Viral Load | 87.5% | 16.7% |
| Treatment Difference (95% CI) | 70.8% (34.9% to 90.0%)
|
The results at Weeks 26 and 52 are provided in Table 14 and Table 15.
Table 14 Virologic Outcomes (HIV-1 RNA < 50 copies/mL) at Weeks 26 and 52 with SUNLENCA plus OBR in the CAPELLA Trial (Cohort 1) | SUNLENCA plus OBR (N=36) |
|---|
| Week 26 | Week 52 |
|---|
| OBR = optimized background regimen |
| HIV-1 RNA < 50 copies/mL | 81% | 83% |
| HIV-1 RNA ≥ 50 copies/mL
| 19% | 14% |
| No virologic data in Week 26 or 52 Window | 0 | 3% |
| Discontinued Study Drug Due to AE or Death
| 0 | 0 |
| Discontinued Study Drug Due to Other Reasons and Last Available HIV-1 RNA < 50 copies/mL | 0 | 3% |
| Missing Data During Window but on Study Drug | 0 | 0 |
Table 15 Virologic Outcomes (HIV-1 RNA < 50 copies/mL) by Baseline Covariates at Weeks 26 and 52 with SUNLENCA plus OBR in the CAPELLA trial (Cohort 1) | SUNLENCA plus OBR (N=36) |
|---|
| Week 26 | Week 52 |
|---|
| ARV = antiretroviral; DRV=darunavir; DTG=dolutegravir; INSTI = integrase strand-transfer inhibitor; OBR = optimized background regimen; |
| Age (Years) | |
| < 50 | 100% (9/9) | 89% (8/9) |
| ≥ 50 | 74% (20/27) | 81% (22/27) |
| Gender | |
| Male | 77% (20/26) | 77% (20/26) |
| Female | 90% (9/10) | 100% (10/10) |
| Race | |
| Black | 81% (13/16) | 75% (12/16) |
| Non-Black | 84% (16/19) | 89% (17/19) |
| Baseline plasma viral load (copies/mL) | |
| ≤ 100,000 | 86% (25/29) | 86% (25/29) |
| > 100,000 | 57% (4/7) | 71% (5/7) |
| Baseline CD4+ (cells/mm3) | |
| < 200 | 78% (21/27) | 78% (21/27) |
| ≥ 200 | 89% (8/9) | 100% (9/9) |
| Baseline INSTI resistance profile | |
| With INSTI resistance | 85% (23/27) | 81% (22/27) |
| Without INSTI resistance | 63% (5/8) | 88% (7/8) |
| Number of fully active ARV agents in the OBR | |
| 0 | 67% (4/6) | 67% (4/6) |
| 1 | 86% (12/14) | 79% (11/14) |
| ≥ 2 | 81% (13/16) | 94% (15/16) |
| Use of DTG and/or DRV in the OBR | |
| With DTG and DRV | 83% (10/12) | 83% (10/12) |
| With DTG, without DRV | 83% (5/6) | 83% (5/6) |
| Without DTG, with DRV | 78% (7/9) | 89% (8/9) |
| Without DTG or DRV | 78% (7/9) | 78% (7/9) |
In cohort 1, at Weeks 26 and 52, the mean change from baseline in CD4+ cell count was 81 cells/mm3 (range: -101 to 522) and 82 cells/mm3 (range: -194 to 467), respectively.
In cohort 2, at Weeks 26 and 52, 81% (29/36) and 72% (26/36) of participants achieved HIV-1 RNA < 50 copies/mL, respectively, and the mean change from baseline in CD4+ cell count was 97 cells/mm3 (range: -103 to 459) and 113 cells/mm3 (range: -124 to 405), respectively.