LETTERS TO THE EDITOR
and the median CD4 count at study entry
Comparable
Pharmacokinetics of
Generic Indinavir
(Inhibisam) Versus
Brand Indinavir
(Crixivan) When
Boosted With Ritonavir
To the Editor:
The introduction of inexpensive
generic copies of antiretrovirals in re-
source-limited settings has the potential
to provide access to treatment for mil-
lions of HIV-infected individuals.1 The
generic antiretrovirals are expected to
provide the same efficacy and safety as
demonstrated for brand-name products;
however, assurance of bioequivalence
to brand formulations is also required.
In this context, studies demonstrating
comparable bioavailability of generic ver-
sions of antiretroviral drugs are of para-
mount importance to avoid the risk
of substandard antiretroviral therapy.2
In Argentina, generic protease inhibitors
are currently available to 16,000 HIV-
infected individuals through the Ministry
of Health. In this open-label crossover
study, we compare systemic exposure of
a generic formulation of indinavir (IDV)
(Inhibisam; Laboratorio Richmond, Bue-
nos Aires, Argentina) with brand IDV
(Crixivan; Merck & Co., Whitehouse
Station, NJ) in the context of ritonavir
(RTV)-boosted therapy.
The study included 10 adult patients
(median age = 33 years, interquartile ratio
[IQR]: 29–55 years) in Buenos Aires,
Argentina (9 men, 1 woman), who were
on their first highly active antiretroviral
therapy (HAART) regimen, including
twice-daily IDV/RTV (800/100 mg), and
remained virologically suppressed (<50
copies/mL) for a minimum of 24 weeks.
The median baseline plasma HIV-RNA
level was 5.27 log (IQR: 4.69–5.87 log),
From the *Fundación Huesped, Buenos Aires,
Argentina; and †British Columbia Centre for
Excellence in HIV/AIDS, Vancouver, British
Columbia, Canada.
J Acquir Immune Defic Syndr  Volume 38, Number 3, March 1 2005
IDV/RTV doses were administered in a
was 298 cells/mL (IQR: 70–536 cells/mL).
In general, liver function was normal
in these patients (median aspartate
aminotransferase [AST] = 24.5 U/L,
IQR: 22–27.8 U/L; median alanine
aminotransferase [ALT] = 19 U/L,
IQR: 16.5–34.5 U/L). Backbone double
nucleosides included combinations of
zidovudine (ZDV), lamivudine (3TC),
didanosine (ddI), stavudine (d4T), and
abacavir (ABV) at regular dosing in-
tervals. One patient’s IDV/RTV dose
was supplemented with ABC and nevir-
apine. Another patient was also being
treated with trimethoprim-sulfamethox-
azole (Septra) and fluconazole at the
time of both tests.
The average exposure of the 2
formulations was tested using a nonrep-
licated crossover design with each sub-
ject serving as his/her own control. Six of
10 volunteers were sequenced from
Inhibisam to Crixivan, whereas the
remaining 4 were sequenced from Crix-
ivan to Inhibisam. Blood samples were
taken immediately before the morning
dose of IDV/RTV and then at 0.5, 1, 2, 3,
4, 6, 8, 10, and 12 hours after the dose
was administered. Patients were reas-
sessed in the same way approximately 14
days later after switching formulations.
FIGURE 1. Mean plasma indinavir concentration for 2 sources of indinavir (IDV):
Inhibisam (open circles) and Crixivan (filled circles). Error bars indicate standard error.
P values are derived from the paired t test. The IDV/ritanovir dose was 800/100 mg
twice daily.
fasted state on the day of pharmacoki-
netic (PK) assessment. Adherence was
monitored by pill count.
Plasma IDV concentrations were
determined by a validated assay using
reverse phase high-pressure liquid chro-
matography coupled with tandem mass
spectroscopy. The upper and lower limits
of quantification for IDV were 79 ng/mL
and 11,800 ng/mL, respectively. Average
peak, trough, and area under the curve
for 0 to 12 hours (AUC0–12h) for the 2
formulations were compared using
a paired t test. The peak concentra-
tion was taken as the highest observed
concentration (Cmax), trough concentra-
tion was selected at 12 hours after
the dose was administered (C12h), and
the AUC0–12h was determined using the
linear trapezoid rule.
On average, IDV exposures were
slightly greater for the generic formula-
tion (Fig. 1); however, this was not statis-
tically significant. No sequencing bias
was detected. Generally, IDV expo-
sures were within the therapeutic limits,
although 1 patient exhibited a C12h below
the recommended minimum of 100 ng/mL
while taking Inhibisam. Similarly, 1 and
3 patients exceeded the maximum rec-
ommended Cmax of 10,000 ng/mL while
363
Letters to the Editor
taking Crixivan and Inhibisam, respec-
tively. After completion of the study, all
patients continued on the generic formu-
lation. Plasma HIV RNA levels remained
less than 50 copies/mL at a median
follow-up interval of 12 weeks in all
patients. There were no serious labora-
tory abnormalities or clinical adverse
events after switching IDV formulations.
Although our results suggest that
Inhibisam should provide suppression of
viral replication similar to that obtained
with Crixivan, selection of this study
sample within a cohort of ‘‘virologic
responders’’ may bias this assumption.
At least for patients who achieve viro-
logic success, Inhibisam seems to be
a suitable substitute for Crixivan. C12h
values, which strongly correlate with the
antiviral activity of IDV,3–5 were higher
than the recommended lower limits in
90% of cases in which Inhibisam was
used. Furthermore, the mean C12h values
of 1007 ng/mL and 1383 ng/mL found in
this study for Crixivan and Inhibisam,
respectively, compare favorably with
IDV C12h values reported previously for
IDV/RTV at a dose of 800/100 mg
administered twice daily.6–8
Of concern in this study was the
number of patients presenting with IDV
Cmax values in excess of the recommen-
ded safe limit. Notably, 3 patients pre-
sented with IDV Cmax values greater than
10,000 ng/mL while taking Inhibisam, as
did 1 patient while taking Crixivan.
Thus, 40% of the patients in this study
were at increased risk of nephrotox-
icity7,9 based on pharmacokinetic data
collected within a period of less than
1 month. This highlights the necessity of
impressing on patients the importance of
proper hydration while taking IDV/RTV.10
Generic antiretroviral drugs are
increasingly used in resource-limited
settings.11,12 Thousands of HIV-infected
patients from Latin America are cur-
rently exposed to generic versions of pro-
tease inhibitors, including IDV. Although
concern has been raised about the safety
and effectiveness of generic substitutes
in developing countries, little informa-
tion is available about the pharmacoki-
netic properties of these formulations.
This is the first independent evaluation of
the pharmacokinetics of a generic pro-
tease inhibitor in Argentina. In this series
of patients on stable antiretroviral ther-
apy, we provide evidence that Inhibisam
364
J Acquir Immune Defic Syndr
matched pharmacokinetic exposures to
Crixivan, at least in the context of RTV
boosting. Further work is warranted to
expand pharmacokinetic evaluations where
generic antiretrovirals are widely avail-
able to treat HIV-infected individuals.
Carlos Zala, MD*
Christopher S. Alexander, PhD†
Claudia Ochoa, MD*
Silvia Guillemi, MD†
Lillian S. Ting, BSc†
Simon Bonner, MSc†
Pedro Cahn, MD, PhD*
P. Richard Harrigan, PhD†
Julio S. G. Montaner, MD, FRCPC†
*Fundación Huesped
Buenos Aires, Argentina; and
†British Columbia Centre
for Excellence in HIV/AIDS
Vancouver, British Columbia
Canada
REFERENCES
1. Angerer T, Wilson D, Ford N, et al. Access and
activism: the ethics of providing antiretroviral
therapy in developing countries. AIDS. 2001;
15(Suppl 5):S81–S90.
2. Henney JE. Review of generic bioequivalence
studies. JAMA. 1999;282:1995.
3. Burger D, Hugen P, Reiss P, et al, for the
ATHENA Cohort Study Group. Therapeutic
drug monitoring of nelfinavir and indinavir in
treatment-naive HIV-1-infected individuals.
AIDS. 2003;17:1157–1165.
4. Fletcher CV, Anderson PL, Kakuda TN, et al.
Concentration-controlled compared with con-
ventional antiretroviral therapy for HIV in-
fection. AIDS. 2002;16:551–560.
5. Murphy RL, Sommadossi JP, Lamson M, et al.
Antiviral effect and pharmacokinetic interac-
tion between nevirapine and indinavir in per-
sons infected with human immunodeficiency
virus type 1. J Infect Dis. 1999;179:1116–
1123.
6. van Heeswijk RPG, Veldkamp AI, Hoetelmans
RMW, et al. The steady-state plasma pharma-
cokinetics of indinavir alone and in combina-
tion with a low dose of ritonavir in twice daily
dosing regimens in HIV-1-infected individuals.
AIDS. 1999;13(Suppl):F95–F99.
7. Burger D, Boyd M, Duncombe C, et al.
Pharmacokinetics and pharmacodynamics of
indinavir with or without low-dose ritonavir in
HIV-infected Thai patients. J Antimicrob
Chemother. 2003;51:1231–1238.
8. Burger DM, Hugen PW, Aarnoutse RE, et al. A
retrospective, cohort based survey of patients
using twice-daily indinavir plus ritonavir
combinations: pharmacokinetics, safety and
efficacy. J Acquir Immune Defic Syndr. 2001;
26:218–222.
9. Aarnoutse RE, Wasmuth JC, Fatkenheuer G,
et al. Administration of indinavir and low-dose
ritonavir (800/100 mg twice daily) with food
reduces nephrotoxic peak plasma levels of
indinavir. Antivir Ther. 2003;8:309–314.
 Volume 38, Number 3, March 1 2005
10. CrixivanÒ Product Monograph. Whitehouse
Station, NJ: Merck & Co.; 1996, 1997, 1998,
1999.
11. Coetzee D, Hildebrand K, Boulle A, et al.
Outcomes after two years of providing anti-
retroviral treatment in Khayelitsha, South
Africa. AIDS. 2004;18:887–895.
12. Kumarasamy N, Solomon S, Chaguturu SK,
et al. The safety, tolerability and effectiveness
of generic antiretroviral drug regimens for HIV-
infected patients in south India. AIDS. 2003;
17:2267–2269.
Prevalence and
Persistence of
Nonnucleoside
Reverse Transcriptase
Inhibitor Mutations
in the Female
Genital Tract
To the Editor:
As antiretroviral therapy (ART)
regimens containing nonnucleoside re-
verse transcriptase inhibitors (NNRTIs)
have gained increasing favor as a result
of their potent activity and favorable side
effect profile, there has been a corre-
sponding increase in NNRTI resistance
mutations detected in plasma. In fact,
NNRTI resistance among patients newly
infected with HIV is increasing at a rate
greater than protease inhibitor (PI) re-
sistance.1,2 A better appreciation of the
prevalence and persistence of resistant
HIV in the female genital tract, including
viruses with NNRTI-resistant mutations,
may allow a better understanding of the
sexual and vertical transmission of these
viruses.
The study population consisted
of 20 NNRTI-experienced HIV-positive
women who receive medical care at The
Miriam Hospital Immunology Center
(Providence, RI). The Miriam Hospital
Institutional Review Board approved
Research facilitated by the infrastructure and
resources provided by the Lifespan/Tufts/
Brown Center for AIDS Research, a National
Institutes of Health (NIH)–funded program P30
AI42853. Additional funds were provided by
NIH grant AI40350, 5U01AI046381 and the
Clinical Scientist Development Award from the
Doris Duke Charitable Foundation (B.R.).
q 2005 Lippincott Williams & Wilkins
J Acquir Immune Defic Syndr  Volume 38, Number 3, March 1 2005 Letters to the Editor

the study. All the women gave written
informed consent. The patients’ history,
counseling, and sexually transmitted
disease (STD) screening records were
obtained and testing had been performed
as described previously.3 HIV-seropositive
women failing ART with a plasma viral
load greater than 10,000 copies/mL were
eligible for enrollment.
HIV RNA was extracted from
plasma, Sno-strips, and cervicovaginal
lavage (CVL) samples using Qiagen
reagents (Valencia, CA). Reverse trans-
cription, polymerase chain reaction (PCR)
amplification of HIV sequences, and
sequencing of PCR products spanning
the pol gene were accomplished using
previously published methods.4 Se-
quences were analyzed using the HIVseq
program5 from the Stanford University
HIV drug resistance database. Quantita-
tive viral load analysis from blood and
genital compartments was performed by
the Nuclisens assay.
Reverse transcriptase (RT) and
protease sequences were amplified from
the plasma and genital samples of 8
of the 20 NNRTI-experienced subjects.
Thirty-eight percent of these patients
were black, 25% were Hispanic, and
38% had a history of intravenous drug
abuse. These 8 patients had an average
CD4 count of 223 cells/mL. They have
each taken at least 5 RT inhibitors,
including azidothymidine (AZT), lami-
vudine (3TC), and at least 1 NNRTI. The
average duration of ART was 6.9 years,
and the average duration of NNRTI ther-
apy was 1.6 years. Five of the 8 subjects
were not taking NNRTIs at the time of
analysis. These patients had not taken
NNRTIs for an average of 1.3 years
before this study.
NNRTI resistance mutations were
detected in genital secretions of all pa-
tients (Table 1). Mutations at the major
NNRTI resistance codon K103 were
found in the plasma and genital tract of
5 subjects, whereas K238N mutations
were found in the genital tract but not the
plasma of 2 subjects who were not
currently receiving NNRTI therapy. The
3TC resistance mutation M184V was
detected in the plasma and genital com-
partments of 6 subjects, whereas the
L63P protease gene polymorphism in
plasma was found in both compartments
of 7 subjects (data not shown). Virus
from most paired samples had similar
patterns of resistance; however, discor-
dant mutations from the plasma and
genital tract were also found in 5 of these
8 patients. Discordance between blood
and genital HIV resistance may imply
differing selective pressures in these
sources. Compartmentalization between
blood and the female genital tract has
also been demonstrated by the findings
of differing genotypic variants, genetic
complexity, and drug resistance muta-
tions from these sources.5–10 Reduced
antiretroviral drug concentrations in gen-
ital tissues may contribute to selection of
different viruses from these sources.11
Alternatively, the cellular environment of
the female genital tract may result in
different selective pressures compared
with virus found in blood.
From this cohort of NNRTI-
experienced women, mutations confer-
ring NNRTI resistance were isolated from
the genital tract of all subjects, including
all 5 patients not currently on NNRTI
therapy. The longest period analyzed off
NNRTI therapy was 33 months, during
which time the K238N mutation was
detected in the genital tract (subject 20).
The K103N mutation was detected in
the plasma and genital tract in subject 4,
who had not been on NNRTI treatment
for 23 months. A recent report suggests
that the K103N NNRTI resistance muta-
tion is one of the most common HIV
drug resistance mutations found during
primary infection and that this variant
can persist for years in the absence of drug
selection.12 Our results suggest that
NNRTI mutations also seem to be stable
in the female genital tract in the absence
of drug selection, implying that these
viruses have a relatively preserved fitness
in these settings. These findings high-
light the potential for further increases
in the sexual and vertical transmission
of HIV resistant to NNRTI and have
particular relevance to the design of
treatment for pregnant women previously
treated with NNRTI drugs.

TABLE 1. NNRTI Resistance Mutations in Plasma and the Female Genital Tract
RNA CD4 100 103 106† 179† 181† 188 190 238† NRTI/NNRTI Current NNRTI?
No. Source* Copies/mL Cells/mL L K V V Y Y G K Exposure (Ever) Time off NNRTI
1 Genital 1700 17 I N 3TC, ddI, AZT, d4T, ABC, TDF, EFV No
Plasma 620,000 I N 7 months
2 Genital 4800 404 N 3TC, TDF, AZT, ddI, ABC, NVP No
Plasma 5300 N 8 months
4 Genital 7000 362 N AZT, 3TC, ABC, d4T, EFV No
Plasma 24,063 N I 23 months
5 Genital 400,000 268 N D ddI, TDF, EFV, AZT, 3TC, d4T, ABC Yes
Plasma 11,000 N D
6 Genital 120,000 396 S AZT, 3TC, EFV Yes
Plasma 24,000 R/S I
8 Genital 1.6 3 106 181 A Q 3TC, d4T, EFV, AZT, ddC Yes
Plasma 170,000 Q
20 Genital 30 3 106 114 N ddI, TDF, AZT, 3TC, d4T, NVP No
Plasma 260,000 33 months
21 Genital 1 3 106 42 L N 3TC, TDF, AZT, ddI, ddC, ABC, EFV, NVP No
Plasma 15,000 L 6 months
*Genital viral load from Sno-strips, except from patient 6, which was from CVL.
†Boxed letters indicate discordance between plasma and genital mutations. No NNRTI resistance mutations were found at codons 98, 100, 101, 225 and 230. Single letters
correspond to standard amino acid abbreviations. ABC, abacavir; AZT, zidovudine; ddC, dideoxycytidine; ddl, didanosine; d4T, stauvudine; EFZ, efavirenz; NRTI, nucleoside reverse
transcriptase inhibitor; NVP, nevirapine; TDV, tenofovir; 3TC, lamivudine.

q 2005 Lippincott Williams & Wilkins 365

Letters to the Editor J Acquir Immune Defic Syndr
ACKNOWLEDGMENTS REFERENCES
1. Grant RM, Hecht FM, Warmerdam M, et al.
The authors thank Fred Lee for
expert technical assistance and Daniel Time trends in primary HIV-1 drug resistance
among recently infected persons. JAMA. 2002;
Boden for helpful discussions. 288:181–188.
2. Simon V, Vanderhoeven J, Hurley A, et al.
Evolving patterns of HIV-1 resistance to
Michael Newstein*
antiretroviral agents in newly infected individ-
Phyllis Losikoff*
uals. AIDS. 2002;16:1511–1519.
Angela Caliendo† 3. Cu-Uvin S, Caliendo AM, Reinert S, et al.
Jessica Ingersoll† Effect of highly active antiretroviral therapy
Jaclynn Kurpewski* on cervicovaginal HIV-1 RNA. AIDS. 2000;14:
415–421.
Dawn Hanley* 4. Boden D, Hurley A, Zhang L, et al. HIV-1 drug
Joselyn Cerezo* resistance in newly infected individuals. JAMA.
Bharat Ramratnam* 1999;282:1135–1141.
Susan Cu-Uvin* 5. Shafer RW, Jung DR, Betts BJ. Human immu-
*Division of Infectious Diseases nodeficiency virus type 1 reverse transcriptase
Department of Medicine and protease mutation search engine for queries.
Brown Medical School Nat Med. 2000;6:1290–1292.
6. Kovacs A, Wasserman SS, Burns D, et al.
Providence, RI; and
Determinants of HIV-1 shedding in the genital
†Department of Pathology and tract of women. Lancet. 2001;358:1593–
Laboratory Medicine 1601.
School of Medicine 7. Poss M, Martin HL, Kreiss JK, et al. Diversity
Emory University, in virus populations from genital secretions and
Atlanta, GA peripheral blood from women recently infected
ERRATUM
Due to an error, the wrong version of the article by Mynarcik et al was printed in the journal (JAIDS 2005;38:53–56). The
correct version is printed in this issue on pages 367–371.
366
 Volume 38, Number 3, March 1 2005
with human immunodeficiency virus type 1.
J Virol. 1995;69:8118–8122.
8. Overbaugh J, Anderson RJ, Ndinya-Achola JO,
et al. Distinct but related human immunodefi-
ciency virus type 1 variant populations in
genital secretions and blood. AIDS Res Hum
Retroviruses. 1996;12:107–115.
9. Si-Mohamed A, Kazatchkine MD, Heard I, et al.
Selection of drug-resistant variants in the
female genital tract of human immunodeficiency
virus type 1-infected women receiving antire-
troviral therapy. J Infect Dis. 2000;182:112–122.
10. Leigh Brown AJ, Frost SD, Mathews WC,
et al. Transmission fitness of drug-resistant
human immunodeficiency virus and the prev-
alence of resistance in the antiretroviral-
treated population. J Infect Dis. 2003;187:
683–686.
11. DePasquale MP, Brown AL, Cu-Uvin S, et al.
Differences in HIV-1 pol sequences from
female genital tract and blood during antire-
troviral therapy. J Acquir Immune Defic Syndr.
2003;34:37–44.
12. Little SJ, Koelsch KK, Ignacio CC. Persistence
of transmitted drug-resistant virus among
subjects with primary HIV infection deferring
antiretroviral therapy. Presented at: 11th CROI;
2004; Boston.
q 2005 Lippincott Williams & Wilkins