Early vs Late Introduction of Antiretroviral Therapy in Naive HIV-infected Patients With Tuberculosis in Cambodia
Trial Snapshot
- Phase
- Phase 3
- Status
- Completed
- Sponsor
- Enrollment
- 661
- Locations
- 5
- Primary Endpoint
- Survival rate
Study Overview
Brief Summary
In Cambodia the prevalence of both tuberculosis (TB) and Human Immunodeficiency Virus (HIV) infection is high. Data suggest that aggressive management of HIV infection, which includes Anti-Retroviral Therapy (HAART) during treatment of TB, decreases both morbidity and mortality. On the other hand, the use of HAART for patients with TB may cause severe complications due to drug-drug interactions, and occasionally a temporary exacerbation of symptoms. These reactions may be particularly severe when HAART is started soon after the start of TB treatment.
The proposed study aims to determine the optimal time to initiate HAART in previously untreated HIV-infected adult patients with TB and low CD4 cell counts.
Detailed Description
In Cambodia the prevalence of both tuberculosis (TB) and Human Immunodeficiency Virus (HIV) infection is high. In 2000, there were approximately 75.000 newly diagnosed TB cases. In 2003, 1.9% of the population was infected with HIV. TB rates in Cambodia are more than double those observed in other developing countries and up to 30 times higher than those currently seen in the USA or Western Europe. It is estimated that over 8% of the newly diagnosed TB cases are co-infected with HIV, of which approximately 85% are severely immunosuppressed (CD4+ cell count < 200 x 106 cells/l).
Mortality rates were found to be 2-4 folds higher in HIV/TB co-infected patients than in TB alone. Data suggest that aggressive management of HIV infection, which includes Highly Active Anti-Retroviral Therapy (HAART) during treatment of TB decreases both morbidity and mortality by suppressing viral replication and improving immune function.
On the other hand, the use of HAART for patients with TB may cause severe complications due to drug-drug interactions, and occasionally a temporary exacerbation of symptoms, signs or radiographic manifestations of TB. Such events or 'paradoxical reactions' that occur among 7 - 36% of HIV/TB co-infected patients treated with HAART may be secondary to immune restitution. These reactions may be particularly severe when HAART is started soon after the start of TB treatment.
Most clinical teams recommend delaying the initiation of HAART to avoid the early side effects of TB treatment and simplify clinical management of the co-infected patient. However others argue that early initiation of HAART in TB patients with CD4 cell counts < 100 x 106 cells/l leads to a marked reduction of viral load despite frequent adverse events.
The proposed study aims to determine the optimal time to initiate HAART (defined as d4T + 3TC + efavirenz) in previously untreated HIV-infected adult patients with TB and low CD4 cell counts. The study is a multicentre prospective, randomized, open-label two-armed trial with no placebo. It is designed as a superiority trial to compare the "early arm" (HAART initiated 2 weeks after TB treatment onset) with the "late arm" (HAART initiated 2 months after TB treatment onset). Efficacy will be assessed by the survival rate in the two arms. Secondary objectives will include evaluation of (1) the safety of an early initiation of HAART in terms of drug interactions or paradoxical reactions, (2) the occurrence of opportunistic infections diagnosed during the follow-up period, (3) patients' adherence to TB treatment and HAART, (4) the rate of hospitalization for any cause during the trial; the measure of (5) the effectiveness of the TB treatment and HAART and (6) the predictive factors for the survival, the response to anti-TB therapy and HAART and the paradoxical reactions.
Study Design
- Study Type
- Interventional
- Allocation
- Randomized
- Intervention Model
- Parallel
- Primary Purpose
- Treatment
- Masking
- None
Eligibility Criteria
- Ages
- 18 Years to — (Adult, Older Adult)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •Age 18 or over
- •Positive HIV test result
- •CD4+ cell count under or equal to 200 cells per ml within 14 days prior the study entry
- •Positive AFB on any smear (sputum, lymph node drainage, stool, CSF, pleural fluid)
- •Naive to ART
- •TB treatment started less than one week prior enrolment
- •Negative gonadotrophin pregnancy test (blood) for women of childbearing potential (i.e. not surgically sterile or less than 2 years menopause)
- •Agreement from female candidates who are participating in sexual activity that could lead to pregnancy while receiving and for 6 weeks after stopping efavirenz to use two reliable methods of contraception, one of which including condom.
Exclusion Criteria
- •Suspected TB with negative AFB
- •Pregnant or breastfeeding women
- •Impaired hepatic function (icterus, elevated AST or ALT at least 5 times over the normal value)
- •Unable and/or unlikely to comprehend and/or be adherent to the protocol
- •Treated for a previous suspected or documented TB other than the ongoing infection which motivates enrolment in this trial
Arms & Interventions
1
Intervention: Early antiretroviral treatment (Procedure)
2
Intervention: Late antiretroviral treatment (Procedure)
Outcomes
Primary Outcomes
Survival rate
Time Frame: At the end of the study
Secondary Outcomes
- Type, frequency and severity of Adverse Events that occur during the trial and to their potential relations with the drugs, HIV or TB infection(During the overall study)
- Frequency of TB paradoxical reaction, defined as worsening or emergence of signs or symptoms of TB (e.g. fever, cough, shortness of breath, adenopathy or exacerbation of disease at other extra pulmonary sites) during appropriate TB treatment(During the overall study)
- Occurrence of opportunistic infections(During the overall study)
- Evaluation of ART treatment success(During the overall study)
- Frequency of Immune Reconstitution Inflammatory Syndrome(During the overall study)
- Patient's adherence to TB and ARV treatment evaluated based on interviews and pill counts at each study visit(During the overall study)
- Resistance to ARV treatment determined by genotyping HIV-1 strains among patients with detectable viral load on Day 0 and Week 50(Within 12 months of follow-up)
- Pharmacokinetic study to assess efavirenz plasma exposure will be assayed at regular time intervals(Within 12 months of follow-up)
- Survival Rate(50 weeks after enrolment)
- Evaluation of TB treatment success(During the overall study)