Second-line Treatment of HIV-1 With Ritonavir Boosted Atazanavir or Darunavir With an Optimized NRTI Backbone (SUPPRESS)

• Proportion of subjects with HIV-1 RNA < 50 c/mL [ Time Frame: At week 24 ] [ Designated as safety issue: No ]
• Change from baseline in CD4 cell count [ Time Frame: Baseline (Week 0) and at week 48 ] [ Designated as safety issue: No ]
• Incidence rates of serious adverse event (SAEs) and adverse events (AEs) leading to discontinuation [ Time Frame: up to week 48 ] [ Designated as safety issue: Yes ]
• Incidence rates of antiretroviral resistance measured by newly emergent genotypic substitutions and phenotypic resistance to study drugs for virologic failure [ Time Frame: up to week 48 ] [ Designated as safety issue: Yes ]
• Proportion of subjects with HIV-1 RNA < 50 c/mL at Week 48 by baseline M184V presence or absence [ Time Frame: Week 48 ] [ Designated as safety issue: No ]

• Proportion of subjects with HIV-1 RNA < 50 c/mL [ Time Frame: At week 24 ] [ Designated as safety issue: No ]
• Change from baseline in CD4 cell count [ Time Frame: Baseline (Week 0) and at week 48 ] [ Designated as safety issue: No ]
• Incidence rates of serious adverse event (SAEs) and adverse events (AEs) leading to discontinuation [ Time Frame: up to week 48 ] [ Designated as safety issue: Yes ]
• Incidence rates of antiretroviral resistance measured by newly emergent genotypic substitutions and phenotypic resistance to study drugs for virologic failure [ Time Frame: up to week 48 ] [ Designated as safety issue: Yes ]

The purpose of this study is to determine the proportion of subjects with HIV-1 RNA < 50 c/mL at Week 48 in patients who failed their first line therapy containing a non-nucleoside reverse transcriptase inhibitor (NNRTI) or an integrase inhibitor

Allocation: Randomization will be stratified

• ATV = Atazanavir
• DRV = Darunavir
• RTV = Ritonavir

• Drug: Atazanavir
  Capsule, Oral, 300 mg, Once daily (QD), 48 weeks
  Other Name: REYATAZ®
• Drug: Darunavir
  Oral, Two 400 mg Tablets, Once daily (QD), 48 weeks
  Other Name: PREZISTA®
• Drug: Ritonavir
  Tablet, Oral, 100 mg, Once daily (QD), 48 weeks
  Other Name: NORVIR®
• Drug: Optimized NRTI backbone

  tablet/capsule, Noninvestigational products i.e. NRTI backbone will be administered according to their respective package inserts for 48 weeks

  NRTI backbone are:

  - Abacavir (300 mg), Tenofovir (300 mg), Didanosine (250 mg or 400 mg), Stavudine (30 mg or 40 mg), Emtricitabine (200 mg), Lamivudine (300 mg), Zidovudine (300 mg), EPZICOM® (600 mg Ziagen® + 300 mg Lamivudine), COMBIVIR® (150 mg Lamivudine + 300 mg Zidovudine)

  The following NRTI combinations are prohibited in this study:

  • Didanosine + Stavudine
  • Zidovudine + Stavudine
  • Lamivudine + Emtricitabine

• Experimental: Arm 1: ATV/RTV 300/100 mg QD + optimized NRTI backbone
  Interventions:

  • Drug: Atazanavir
  • Drug: Ritonavir
  • Drug: Optimized NRTI backbone
• Experimental: Arm 2: DRV/RTV 800/100 mg QD + optimized NRTI backbone
  Interventions:

  • Drug: Darunavir
  • Drug: Ritonavir
  • Drug: Optimized NRTI backbone

Inclusion Criteria:

1. Signed informed consent

2. HIV-1 infected patients with viremia (VL ≥ 500/mL) on or after their first NNRTI or INI-based cART regimen and meeting one of the two criteria below:

   • On 1st line Non-nucleoside reverse transcriptase inhibitor (NNRTI) or Integrase inhibitor (INI)-based Combination antiretroviral therapy (cART) with HIV-1 RNA ≥ 500 c/ML after being on the same therapy for at least 12 weeks
   • Off 1st line NNRTI or INI-based Combination antiretroviral therapy (cART) for at least 2 weeks after having been on antiviral therapy for at least 4 weeks and who are non-compliant and off first line cART without a history of virologic failure with resistance, with a : HIV-1 RNA ≥ 500 c/ML
3. Fully sensitive genotype and phenotype report for Atazanavir/Ritonavir (clinical cut-off of 5.2) and Darunavir/Ritonavir (clinical cut-off ranging from 10 to 90)
4. At least one NRTI other than Lamivudine (3TC) or emtricitabine (FTC) with full sensitivity (one "active" NRTI) by genotype and phenotype, ie, PhenoSense Genotype (GT), report must provide a "sensitive" net assessment of susceptibility. An NRTI or PI (reported with or without ritonavir) with a "partially sensitive" net assessment will not be considered "fully sensitive"

4. Mentally able to participate in the study 5. Men and women ≥ 18 years old

• Women of child bearing potential who engage in vaginal intercourse and who are not clinically sterilized must use highly effective methods of birth control during the study

Exclusion Criteria:

1. Screening HIV genotype showing presence at baseline of any of the following Protease inhibitor (PI) Mutation Patterns associated with genotypic resistance to Atazanavir sulfate/ Ritonavir or Darunavir/Ritonavir will lead to exclusion:

   1. Subjects with any darunavir associated mutations* at baseline (*V11I, V32I, L33F, I47V, I50V, I54L, I54M, T74P, L76V, I84V and L89V)
   2. Subjects with a major mutation to Atazanavir sulfate consisting of N88S
   3. Subjects with more than 3 of any of the following Atazanavir sulfate related mutations:D30N, M36I/V, M46I/L/T, I54V/L/T/M/A, A71V/T/I/G, G73S/A/C/T, V77I, V82A/F/T/S/I, I84V/A, N88D or L90M
2. Subjects with < 1 fully active NRTI on PhenoSense report, other than lamivudine and emtricitabine
3. Diagnosed with active tuberculosis
4. Chronic hepatitis B infection
5. Hepatitis C-positive patients who are not clinically stable or need treatment during the study period
6. Acute hepatitis in the 30 days prior to study entry
7. Any gastrointestinal disease or surgical procedure that may impact the absorption of study drug
8. Intractable diarrhea within 30 days prior to study entry
9. Presence of a newly diagnosed Human immunodeficiency virus (HIV)-related opportunistic infection or any medical condition requiring acute therapy at the time of enrollment
10. Subject's with Cushing's syndrome
11. Untreated hypothyroidism or hyperthyroidism
12. Recent therapy with agents with significant systemic myelosuppressive, neurotoxic, pancreatotoxic, hepatotoxic or cytotoxic potential within 3 months of study start
13. Subject's with obstructive liver disease
14. Active alcohol or illegal substance use
15. Inability to swallow capsules
16. Active peripheral neuropathy
17. Presence of cardiomypathy or any significant cardiovascular disease
18. Known, clinically significant cardiac conduction system disease

19. Physical and Laboratory Test Findings:

    • Moderate to severe hepatic insufficiency

    • Screening laboratory values as follows:

      • T4 < 4mcg/dL or >11mcg/dL and/or Thyroid-stimulating hormone (TSH) <0.5mU/L or >5.0mU/L
      • Calculated creatinine clearance < 60 cc/min
      • Hemoglobin < 8.0 g/dL
      • Total serum lipase ≥ 1.4 times the upper limit of normal (ULN)
      • Liver enzymes [Aspartate transaminase (AST), Alanine transaminase (ALT)] ≥ 5 times the ULN
      • Alkaline phosphatase > 5 times the ULN
      • Platelets < 50,000 cells/mm3
      • Positive blood screen for hepatitis B surface antigen (HBsAg)
      • Total serum bilirubin ≥ 1.5 times the ULN

20. Allergies and Adverse Drug Reaction:

    • Previously demonstrated hypersensitivity to any of the components of atazanavir or the other experimental agents in this study
    • Darunavir contains a sulfonamide moiety. Darunavir should be used with caution in patients with a known sulfonamide allergy
    • History of allergy to atazanavir, ritonavir, or darunavir
    • History of allergy to NRTIs included as NRTI backbone options in this study
    • History of clinically relevant severe drug reaction

21. Sex and Reproductive Status:

    • Women with a positive pregnancy test on enrollment prior to study drug administration
    • Women who become pregnant during the study will be taken off-protocol
    • Women using a prohibited contraceptive method
    • Women who are breastfeeding

22. Other Exclusion Criteria

    • Prisoners or subjects who are involuntarily incarcerated
    • Subjects who are compulsorily detained for treatment of wither a psychiatric or physical illness