Strategic Timing of Antiretroviral Treatment
- Conditions
- HIV Infection
- Interventions
- Drug: All licensed antiretroviral medications
- Registration Number
- NCT00867048
- Lead Sponsor
- University of Minnesota
- Brief Summary
Objectives:
* To find out if the chance of developing a serious illness or of getting AIDS is less if patients start taking HIV medicines at a time when their cluster-of-differentiation-4 (CD4)+ cell count is still fairly high, instead of waiting until the CD4+ count is at the level where there is good evidence for starting medicines.
* To learn more about how a strategy of starting HIV medicines early might affect other aspects of care, such as the chances of developing other illnesses or resistance to HIV medicines, the frequency of doctor visits, the cost of medical care, and general health and satisfaction.
- Detailed Description
Background:
* Most guidelines agree that if the number of your CD4+ cells (cells in your blood which help fight infection) drops below 350 cells/mm3, or if you have symptoms of AIDS, you should start taking HIV medicines. There are randomized trials that support this recommendation. (Randomized trials are usually considered the strongest form of evidence to support treatment decisions. Other studies, like observational studies, provide evidence too, but the evidence is often considered to be weaker than evidence from randomized trials. A randomized trial gives the most certain information about how well a treatment works because randomization makes sure each group is similar except for the treatment they receive.) Some experts believe that HIV treatment should be started even when the number of CD4+ cells is above 350 cells/mm3. For example, guidelines issued in the US in December 2009 include a new recommendation for starting HIV medicines if your CD4+ cell count is between 350 and 500 cells/mm3. However, this recommendation is based on information from observational studies, not randomized trials. We are doing this study to find out if the chances of getting a serious illness or of getting AIDS are less if people start taking HIV medicines at a time when their CD4+ cell counts are still fairly high, instead of waiting to take HIV medicines at a CD4+ count where there is good evidence for starting medicines.
Objectives:
* To find out if the chance of developing a serious illness or of getting AIDS is less if patients start taking HIV medicines at a time when their CD4+ cell count is still fairly high, instead of waiting until the CD4+ count is at the level where there is good evidence for starting medicines.
* To learn more about how a strategy of starting HIV medicines early might affect other aspects of care, such as the chances of developing other illnesses or resistance to HIV medicines, the frequency of doctor visits, the cost of medical care, and general health and satisfaction.
Eligibility:
* Patients 18 years of age and older who are infected with HIV, have CD4+ cell counts of greater than 500 cells/mm3, and who have never had antiretroviral therapy to treat HIV.
Design:
* Initial screening visits (2) to draw blood for CD4+ cell counts and provide a full medical history
* Patients will be randomly split into two groups:
Early: Patients will begin receiving HIV medications from the start of the study.
Deferred: Patients will begin to take HIV medications when the CD4 drops below 350 cells/mm3, or they develop AIDS or other symptoms of HIV infection.
* HIV medications for each patient will be determined by the study doctors.
* Evaluations during the treatment period:
* Physical examination, including vital signs and body weight checks, and pregnancy test for women who can become pregnant.
* Questions about daily life, including sexual behaviors.
* Blood and urine tests.
* Heart tests with electrocardiogram.
* Patients will return for evaluations at 1 and 4 months after randomization, and every 4 months thereafter for the duration of the study.
Substudies will take advantage of the START randomization to compare outcomes in people starting ART early vs. later.
The purpose of this randomized study is to determine whether immediate initiation of antiretroviral treatment (ART) is superior to deferral of ART until the CD4+ declines below 350 cells/mm(3) in terms of morbidity and mortality in HIV-1 (subsequently referred to as HIV) infected persons who are antiretroviral naive with a CD4+ count above 500 cells/mm(3).
The study will enroll an estimated 4,000 participants. Participants will be followed for at least 3 years after enrollment, to a common closing date.
Substudies will take advantage of the START randomization to compare outcomes in people starting ART early vs. later. These will measure outcomes that do not require the entire sample size of START to determine whether early ART is related to a difference in these outcomes over the course of the study.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 4688
Not provided
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Early ART All licensed antiretroviral medications Initiate ART immediately following randomization Deferred ART All licensed antiretroviral medications Defer ART until the CD4+ count declines to \<350 cells/cu mm or AIDS develops
- Primary Outcome Measures
Name Time Method Composite Endpoint of AIDS, Serious Non-AIDS Diagnoses, and All-cause Mortality full follow-up, 9.3 years
- Secondary Outcome Measures
Name Time Method Death, All-cause Mortality full follow-up, 9.3 years Count of participants
Changes in Bone Mineral Density (in a Subset of Participants) Measure 1 4.5 years Mean percent change from baseline in bone mineral density at the spine. In the bone mineral density (BMD) substudy of START, participants underwent dual-enery x-ray absorptionmetry (DXA) to measure BMD at the spine and hip at baseline and annually. Analyses were by intention-to-treat principles.
Specific Non-AIDS Diagnoses full follow-up, 9.3 years Quality of Life- Mean Change From Baseline in a Visual Analog Scale (VAS) for Perceived Current Health 4.5 years Mean change from baseline of the VAS. This was a single data item where participants self-reported their perceived current state of health on a scale of 0-100 (0=worst possible and 100=best possible).
Large Artery Elasticity (in a Subset of Participants) 4.5 years Mean change from baseline in large arterial elasticity. In the Arterial Elasticity substudy of START, participants had non-invasive measurements of radial artery blood pressure waveforms recorded at baseline, study months 4, 8, and 12, and then annually. Small arterial elasticity (SAE) and large arterial elasticity (LAE) were derived from analysis of the diastolic pulse waveform. Analyses were by intention-to-treat principles.
AIDs or AIDs Related Death full follow-up, 9.3 years participant count
Transmission Risk Behavior Outcome 1 12 months Proportion of participants identifying as men who have sex with men (MSM) engaging in condomless sex with HIV serodifferent partners (CLS-D) at study month 12. Participant completed a self-reported questionnaire on transmission risk behavior during the "past two months" at the month 12 visit following randomization.
Changes in Bone Mineral Density (in a Subset of Participants) Measure 2 4.5 years Mean percent change from baseline in bone mineral density at the spine. In the bone mineral density (BMD) substudy of START, participants underwent dual-enery x-ray absorptionmetry (DXA) to measure BMD at the spine and hip at baseline and annually. Analyses were by intention-to-treat principles.
Change in Neurocognitive Function (in a Subset of Participants) 4.5 years Mean change from baseline of the QNPZ-8 score. In the Neurology substudy of START, participants were administered a neuropsychological test battery of 8 tests (grooved peg board, finger tapping, Color Trails 1 and 2, Semantic Verbal Fluency, WAIS III Digit Symbol, HVLT-R Learning, HVLT-R Delayed Recall). Test scores were standardized to z-scores using baseline values as reference such that baseline values had a mean of 0 and standard deviation of 1. Test scores were standardized to z-scores using baseline values as reference such that baseline values had a mean of 0 and standard deviation of 1. Z-scores \> 0 indicate improvement over baseline levels. The quantitative neuropsychological performance z-score (QNPZ-8) was the mean of the z-scores across the the 8 tests. Analyses were by intention-to-treat principles.
Transmission Risk Behavior Outcome 2 12 month visit Percentage of participants identifying as hetrosexual engaging in condomless sex with HIV serodifferent partners (CLS-D) at study month 12. Participant completed a self-reported questionnaire on transmission risk behavior during the "past two months" at the month 12 visit following randomization.
Small Artery Elasticity (in a Subset of Participants) 4.5 years Mean change from baseline in small arterial elasticity. In the Arterial Elasticity substudy of START, participants had non-invasive measurements of radial artery blood pressure waveforms recorded at baseline, study months 4, 8, and 12, and then annually. Small arterial elasticity (SAE) and large arterial elasticity (LAE) were derived from analysis of the diastolic pulse waveform. Analyses were by intention-to-treat principles.
Rate of Lung Function Decline (in a Subset of Participants) Among 4.5 years Rate of lung function decline (slope of forced expiratory volume (FEV1)) over follow-up among self-reported smokers at study entry. In the pulmonary substudy of START, participants had post-bronchodilator spirometry measures collected at baseline and annually. Analyses were by intention-to-treat principles.
Rate of Lung Function Decline (in a Subset of Participants) Among Non-smokers 4.5 years Rate of lung function decline (slope of forced expiratory volume (FEV1)) over follow-up among self-reported non-smokers at study entry. In the pulmonary substudy of START, participants had post-bronchodilator spirometry measures collected at baseline and annually. Analyses were by intention-to-treat principles.
Trial Locations
- Locations (218)
FUNCEI
🇦🇷Buenos Aires, Argentina
Fundacion IDEAA
🇦🇷Buenos Aires, Argentina
Sanpatong Hospital
🇹🇭Chiang Mai, Thailand
Chiangrai Prachanukroh Hospital
🇹🇭Chiang Rai, Thailand
Chonburi Regional Hospital
🇹🇭Chon Buri, Thailand
Lurie Children's Hospital
🇺🇸Chicago, Illinois, United States
Houston AIDS Research Team
🇺🇸Houston, Texas, United States
Texas Children's Hospital
🇺🇸Houston, Texas, United States
University Hospital Basel
🇨🇭Basel, Switzerland
VA Greater Los Angeles Healthcare System
🇺🇸Los Angeles, California, United States
UCLA CARE-4-Families (LABAC CRS)
🇺🇸Los Angeles, California, United States
University of Florida Health Services Center
🇺🇸Jacksonville, Florida, United States
Mt. Sinai Hospital
🇺🇸Chicago, Illinois, United States
University of North Texas Health Science Center
🇺🇸Fort Worth, Texas, United States
Bronx-Lebanon Hospital Center
🇺🇸Bronx, New York, United States
Infectious Diseases Associates NW FL, PA
🇺🇸Pensacola, Florida, United States
Hospital Rawson
🇦🇷Cordoba, Argentina
Temple University
🇺🇸Philadelphia, Pennsylvania, United States
University of Florida, Jacksonville
🇺🇸Jacksonville, Florida, United States
AIDS Research and Treatment Center of the Treasure Coast
🇺🇸Vero Beach, Florida, United States
Rigshospitalet, Infektionsmedicinsk ambulatorium 8622
🇩🇰Copenhagen, Denmark
St. Jude Children's Research Hospital
🇺🇸Memphis, Tennessee, United States
Holdsworth House Medical Practice
🇦🇺Darlinghurst, New South Wales, Australia
Royal Adelaide Hospital
🇦🇺Adelaide, South Australia, Australia
UT Southwestern Clinical Research Unit
🇺🇸Dallas, Texas, United States
Naval Medical Center Portsmouth
🇺🇸Portsmouth, Virginia, United States
CEIN
🇦🇷Neuquen, Argentina
Institute of Tropical Medicine
🇧🇪Antwerp, Belgium
Burwood Road General Practice
🇦🇺Burwood, New South Wales, Australia
Centre Clinic
🇦🇺St Kilda, Victoria, Australia
East Sydney Doctors
🇦🇺Darlinghurst, New South Wales, Australia
Taylor Square Private Clinic
🇦🇺Darlinghurst, New South Wales, Australia
Center for Infectious Diseases at the UFES
🇧🇷Vitoria, ES, Brazil
Westmead Hospital
🇦🇺Westmead, New South Wales, Australia
Centro de Referencia e Treinamento DST/Aids
🇧🇷Sao Paulo, SP, Brazil
Fundacion Arriaran
🇨🇱Santiago, Chile
University Hospital Plzen, CZ
🇨🇿Plzen, Czechia
Hospital La Princesa, Internal Medicine and Infectious Disease Service CRS
🇪🇸Madrid, Spain
H�pital Saint-Antoine
🇫🇷Paris, France
Hospital de la Santa Creu i Sant Pau
🇪🇸Barcelona, Spain
Hospital Universitari Germans Trias i Pujol
🇪🇸Badalona, Spain
Hospital Clinic de Barcelona
🇪🇸Barcelona, Spain
Hospital Joaquim Urbano
🇵🇹Oporto, Portugal
1 Military Hospital
🇿🇦Pretoria, South Africa
Khon Kaen University, Srinagarind Hospital
🇹🇭Khon Kaen, Thailand
Hospital Universitario Principe de Asturias
🇪🇸Alcala de Henares, Spain
Desmond Tutu HIV Foundation Clinical Trials Unit
🇿🇦Cape Town, South Africa
Durban International Clinical Research Site (WWH)
🇿🇦Durban, South Africa
San Juan Hospital
🇵🇷Rio Piedras, Puerto Rico
Hospital del Mar
🇪🇸Barcelona, Spain
University of Puerto Rico Pediatric Research Site
🇵🇷San Juan, Puerto Rico
Bern University Hospital
🇨🇭Bern, Switzerland
Sahlgrenska University Hospital
🇸🇪Gothenburg, Sweden
Unite VIH/SIDA Geneva
🇨🇭Geneva, Switzerland
Skane University Hospital
🇸🇪Malmo, Sweden
The James Cook University Hospital
🇬🇧Middlesbrough, Cleveland, United Kingdom
Durban International Clinical Research Site
🇿🇦Durban, South Africa
Guy's and St.Thomas' NHS Foundation Trust
🇬🇧London, United Kingdom
North Manchester General Hospital
🇬🇧Manchester, United Kingdom
Complejo Hospitalario Xeral Cies
🇪🇸Vigo, Spain
University Hospital Zurich
🇨🇭Zurich, Switzerland
Royal Berkshire Hospital
🇬🇧Reading, Berkshire, United Kingdom
Coventry and Warwickshire NHS partnership Trust
🇬🇧Coventry, West Midlands, United Kingdom
Queen Elizabeth Hospital Birmingham
🇬🇧Birmingham, West Midlands, United Kingdom
Southmead Hospital
🇬🇧Bristol, United Kingdom
Chelsea and Westminster Hospital
🇬🇧London, United Kingdom
Imperial College Healthcare NHS Trust
🇬🇧London, United Kingdom
UCSD Mother-Child-Adolescent Program
🇺🇸San Diego, California, United States
Naval Medical Center San Diego
🇺🇸San Diego, California, United States
Duke University
🇺🇸Durham, North Carolina, United States
San Antonio Military Health System
🇺🇸San Antonio, Texas, United States
MRC/UVRI Research Unit on AIDS
🇺🇬Entebbe, Uganda
Joint Clinical Research Center (JCRC)
🇺🇬Kampala, Uganda
University of Southern California
🇺🇸Alhambra, California, United States
Royal Perth Hospital
🇦🇺Perth, Western Australia, Australia
YRGCARE Medical Centre VHS, Chennai CRS
🇮🇳Chennai, Tamil Nadu, India
Boston Medical Center
🇺🇸Boston, Massachusetts, United States
Denver Public Health
🇺🇸Denver, Colorado, United States
Wayne State University
🇺🇸Detroit, Michigan, United States
Henry Ford Health System
🇺🇸Detroit, Michigan, United States
The Research + Education Group - Portland
🇺🇸Portland, Oregon, United States
The Research and Education Group at Portland VA Research Foundation
🇺🇸Portland, Oregon, United States
Lim 56/Hcfmusp
🇧🇷Sao Paulo, SP, Brazil
Groupe Hospitalier Pitie-Salpetri�re
🇫🇷Paris, France
Birmingham Heartlands Hospital
🇬🇧Birmingham, West Midlands, United Kingdom
St. George's Healthcare NHS Trust
🇬🇧London, United Kingdom
Gloucestershire Royal Hospital
🇬🇧Gloucester, United Kingdom
Hospital Escola Sao Francisco de Assis - UFRJ
🇧🇷Rio de Janeiro, RJ, Brazil
CHRU
🇿🇦Johannesburg, South Africa
Hospital Universitario y Politecnico La Fe
🇪🇸Valencia, Spain
Hospital Clinico San Carlos
🇪🇸Madrid, Spain
Hospital Universitari Mutua Terrassa
🇪🇸Terrassa, Spain
Hospital Universitario Doce de Octubre
🇪🇸Madrid, Spain
Hospital La Paz
🇪🇸Madrid, Spain
University of Illinois at Chicago
🇺🇸Chicago, Illinois, United States
H�pital de Bicetre
🇫🇷Le Kremlin-Bicetre, France
Gemeinschaftspraxis Jessen-Jessen-Stein
🇩🇪Berlin, Germany
George Washington Medical Faculty Associates
🇺🇸Washington, District of Columbia, United States
Community Research Initiative of New England
🇺🇸Boston, Massachusetts, United States
Newland Immunology Center of Excellence (NICE)
🇺🇸Southfield, Michigan, United States
Hennepin County Medical Center
🇺🇸Minneapolis, Minnesota, United States
Wake County Human Services
🇺🇸Raleigh, North Carolina, United States
Cornell CRS
🇺🇸New York, New York, United States
Regional Center for Infectious Disease
🇺🇸Greensboro, North Carolina, United States
The Ohio State University Medical Center
🇺🇸Columbus, Ohio, United States
St. Vincent's Hospital
🇦🇺Darlinghurst, New South Wales, Australia
Sexual Health and HIV Service - Clinic 2
🇦🇺Brisbane, Queensland, Australia
Melbourne Sexual Health Centre
🇦🇺Melbourne, Victoria, Australia
Otto-Wagner-Spital SMZ /Baumgartner Hoehe
🇦🇹Vienna, Austria
University Vienna General Hospital
🇦🇹Vienna, Austria
Universitaire Ziekenhuizen Gent
🇧🇪Ghent, Belgium
Universitair Ziekenhuis Gasthuisberg
🇧🇪Leuven, Belgium
SEI - Servi�os Especializados em Infectologia
🇧🇷Salvador, BA, Brazil
Ipec/Fiocruz
🇧🇷Rio de Janeiro, RJ, Brazil
Instituto de Infectologia Emilio Ribas - IIER
🇧🇷Sao Paulo, SP, Brazil
Arhus Universitetshospital, Skejby
🇩🇰Aarhus, Denmark
Faculty Hospital Na Bulovce, Prague, Czech Rep.
🇨🇿Prague, Czechia
Hvidovre University Hospital, Department of Infectious Diseases
🇩🇰Hvidovre, Denmark
Odense University Hospital
🇩🇰Odense, Denmark
West Tallinn Central Hospital Infectious Diseases
🇪🇪Tallinn, Estonia
Helsinki University Central Hospital, Div. of Infectious Diseases CRS
🇫🇮Helsinki, Finland
CHU C�te de Nacre
🇫🇷Caen, France
CHU de Besan�on - H�pital Jean-Minjoz
🇫🇷Besancon, France
H�pital Antoine Becl�re
🇫🇷Clamart, France
H�pital Henri Mondor
🇫🇷Creteil, France
H�pital H�tel Dieu
🇫🇷Paris, France
H�pital Europeen Georges Pompidou
🇫🇷Paris, France
H�pital Saint-Louis
🇫🇷Paris, France
EPIMED-Gesellschaft fur epidemiologische und klinische Forschung in der MedizinmbH
🇩🇪Berlin, Germany
Centre Hospitalier - H�pital Gustave Dron
🇫🇷Tourcoing, France
H�pital Foch
🇫🇷Suresnes, France
Medizinische Universitatsklinik - Bonn, Immunologische Ambulanz CRS
🇩🇪Bonn, Germany
Klinik I fur Innere Medizin der Universitat zu Koln, Studienburo fur Infektiologie u. HIV
🇩🇪Cologne, Germany
Universitatsklinikum Dusseldorf
🇩🇪Duesseldorf, Germany
Klinikum Dortmund gGmbH
🇩🇪Dortmund, Germany
Klinik fur Dermatologie, Venerologie, Allergologie
🇩🇪Essen, Germany
Universitatsklinikum Erlangen
🇩🇪Erlangen, Germany
Johann Wolfgang Goethe - University Hospital, Infektionsambulanz CRS
🇩🇪Frankfurt, Germany
ICH Study Center
🇩🇪Hamburg, Germany
Ifi - Studien und Projekte GmbH
🇩🇪Hamburg, Germany
Medizinische Hochschule Hannover
🇩🇪Hanover, Germany
Universitatsklinikum Heidelberg
🇩🇪Heidelberg, Germany
Klinikum der Universitat Munchen
🇩🇪Munich, Germany
Universitatsklinikum Hamburg-Eppendorf
🇩🇪Hamburg, Germany
Universitatsklinikum Regensburg
🇩🇪Regensburg, Germany
Attikon University General Hospital
🇬🇷Athens, Greece
Universitatsklinikum Wurzburg, Medizinische Klinik und Poliklinik II, Schwerpunkt Infektiologie CRS
🇩🇪Wuerzburg, Germany
Evangelismos General Hospital
🇬🇷Athens, Greece
Korgialenio-Benakio Hellenic Red Cross
🇬🇷Athens, Greece
Syngros Hospital
🇬🇷Athens, Greece
Hippokration University General Hospital of Athens
🇬🇷Athens, Greece
AHEPA University Hospital
🇬🇷Thessaloniki, Greece
Institute of Infectious Diseases
🇮🇳Pune, Maharashtra, India
Mater Misericordiae University Hospital
🇮🇪Dublin, Ireland
Tel Aviv Sourasky Medical Center
🇮🇱Tel Aviv, Israel
Rambam Medical Center
🇮🇱Haifa, Israel
Centre Hospitalier de Luxembourg
🇱🇺Luxembourg, Luxembourg
Lazzaro Spallanzani IRCSS
🇮🇹Rome, RM, Italy
Ospedale San Raffaele S.r.l.
🇮🇹Milan, MI, Italy
University Malaya Medical Centre
🇲🇾Kuala Lumpur, Federal Territory, Malaysia
Serefo/Cesac Mali
🇲🇱Bamako, Mali
Hospital Nacional Edgardo Rebagliati Martins
🇵🇪Lima, Peru
INCMNSZ (Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran)
🇲🇽Tlalpan, Mexico
University Hospital Centre Ibn Rochd
🇲🇦Casablanca, Morocco
Via Libre
🇵🇪Lima, Peru
Institute of Human Virology-Nigeria (IHVN)
🇳🇬Abuja, FCT, Nigeria
Oslo University Hospital, Ulleval
🇳🇴Oslo, Norway
Hospital Nacional Guillermo Almenara Irigoyen
🇵🇪Lima, Peru
Asociacion Civil Impacta Salud y Educacion - Sede San Miguel
🇵🇪Lima, Peru
Uniwersytecki Szpital Kliniczny
🇵🇱Bialystok, Poland
Hospital de Egas Moniz
🇵🇹Lisbon, Portugal
Wojewodzki Szpital Zakazny
🇵🇱Warsaw, Poland
EMC Instytut Medyczny SA
🇵🇱Wroclaw, Poland
Hospital Curry Cabral
🇵🇹Lisbon, Portugal
Hospital de Santa Maria
🇵🇹Lisbon, Portugal
Royal Bournemouth Hospital
🇬🇧Bournemouth, Dorset, United Kingdom
Sheffield Teaching Hospital NHS Foundation Trust
🇬🇧Sheffield, South Yorkshire, United Kingdom
Belfast Health and Social Care Trust (RVH)
🇬🇧Belfast, Northern Ireland, United Kingdom
Leicester Royal Infirmary
🇬🇧Leicester, Leicestershire, United Kingdom
Barts Health NHS Trust
🇬🇧London, United Kingdom
Lewisham and Greenwich NHS Trust
🇬🇧London, United Kingdom
University College London Medical School
🇬🇧London, United Kingdom
Yale University School of Medicine
🇺🇸New Haven, Connecticut, United States
Florida Department of Health in Orange County/Sunshine Care Center
🇺🇸Orlando, Florida, United States
Hillsborough County Health Deptment/University of South Florida
🇺🇸Tampa, Florida, United States
Walter Reed National Military Medical Center
🇺🇸Bethesda, Maryland, United States
National Institutes of Health Clinical Center
🇺🇸Bethesda, Maryland, United States
Wake Forest University Health Sciences
🇺🇸Winston-Salem, North Carolina, United States
Mayo Clinic
🇺🇸Rochester, Minnesota, United States
UNC AIDS Clinical Trials Unit
🇺🇸Chapel Hill, North Carolina, United States
AIDS Resource Center of Wisconsin
🇺🇸Milwaukee, Wisconsin, United States
Medical College of Wisconsin
🇺🇸Milwaukee, Wisconsin, United States
Virginia Commonwealth University
🇺🇸Richmond, Virginia, United States
New Jersey Medical School Adult Clinical Research Center
🇺🇸Newark, New Jersey, United States
University of Miami
🇺🇸Miami, Florida, United States
Orlando Immunology Center
🇺🇸Orlando, Florida, United States
Georgetown University
🇺🇸Washington, District of Columbia, United States
Washington DC VA Medical Center
🇺🇸Washington, District of Columbia, United States
Tulane University Medical Center
🇺🇸New Orleans, Louisiana, United States
Hospital Nacional Profesor Alejandro Posadas
🇦🇷El Palomar, Buenos Aires, Argentina
Hospital Interzonal General de Agudos Dr. Diego Paroissien
🇦🇷Isidro Casanova, Buenos Aires, Argentina
Hospital General de Agudos JM Ramos Mejia
🇦🇷Buenos Aires, Argentina
Hospital Italiano de Buenos Aires
🇦🇷Buenos Aires, Argentina
Cooper University Hospital
🇺🇸Camden, New Jersey, United States
CAICI (Instituto Centralizado de Assistencia e Investigacion Clinica Integral)
🇦🇷Rosario, Santa Fe, Argentina
Centre Hospitalier Universitaire St. Pierre (C.H.U. St. Pierre)
🇧🇪Brussels, Belgium
Asociacion Civil IMPACTA Salud y Educacion
🇵🇪Lima, Peru
Chulalongkorn University Hospital
🇹🇭Bangkok, Thailand
Bamrasnaradura Institute
🇹🇭Nonthaburi, Thailand
Brighton and Sussex University Hospitals NHS Trust
🇬🇧Brighton, East Sussex, United Kingdom
The Alfred Hospital
🇦🇺Melbourne, Victoria, Australia
Prahran Market Clinic
🇦🇺Melbourne, Victoria, Australia
Puerto Rico-AIDS Clinical Trials Unit (PR-ACTU)
🇵🇷San Juan, Puerto Rico
Siriraj Hospital
🇹🇭Bangkok Noi, Thailand
Ramathibodi Hospital
🇹🇭Bangkok, Thailand
Research Institute for Health Sciences (RIHES)
🇹🇭Chiang Mai, Thailand
Montefiore Medical Center
🇺🇸Bronx, New York, United States
Royal Free London NHS Foundation Trust
🇬🇧London, United Kingdom