Evaluation of Two Anti-HIV Treatment Strategies in Resource-Limited South African Communities

NCT ID: NCT00255840

Last Updated: 2011-06-21

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: NA
• Total Enrollment: 812 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2006-07-31
• Study Completion Date: 2009-01-31

Brief Summary

The purpose of this study is to determine the effectiveness of several anti-HIV treatment strategies in resource-poor South African communities. The strategies being studied are using specially trained doctors or nurses to administer HIV care.

Detailed Description

The introduction of antiretroviral therapy (ART) for the treatment of HIV has dramatically improved morbidity and mortality for HIV infected people in the developed world. However, research data on the efficacy of ART regimens in developing countries, such as South Africa, are limited. There are an estimated 4.7 million HIV infected individuals in the South African population of about 40 million inhabitants. The greatest social impact may be achieved by treating an entire household affected by HIV to ensure maximum adherence to prescribed ART regimens and to minimize the sharing of antiretroviral drugs. This study will evaluate the effectiveness of ART given by an HIV-trained doctor compared to ART given by an HIV-trained primary health care nurse. Participants failing first-line therapy will receive a second-line regimen based on what medications are available at the clinic, with approval by the clinical safety team. Participants in this study will be recruited from resource-poor communities outside Johannesburg and Cape Town, South Africa.

This study will last 5 years. HIV infected people and other HIV infected members of their household 16 years of age and older will be enrolled. Study participants will receive first-line ART consisting of efavirenz (EFV) once daily, lamivudine (3TC) twice daily, and stavudine (d4T) twice daily. Women of childbearing potential who are unwilling to use acceptable forms of contraception and who have CD4 counts less than 250 cells/mm3 will receive 3TC twice daily; nevirapine (NVP) daily for 2 weeks, then twice daily; and d4T twice daily. Women who are pregnant at baseline, who become pregnant on study treatment, or who are unwilling to use acceptable methods of contraception and have CD4 counts of 250 cells/mm3 or more, or children who were previously exposed to NVP will receive 3TC twice daily, lopinavir/ritonavir (LPV/r) twice daily, and d4T twice daily. Participants will be randomly assigned to one of two arms. Arm 1 will receive ART under the monitoring care of an HIV-trained medical doctor, while Arm 2 will receive ART under the monitoring care of an HIV-trained primary health care nurse with training in HIV diagnosis and treatment. Participants who fail their first-line regimen will receive a second-line regimen but will remain in their treatment arms.

Study visits will occur at study entry; Weeks 2, 4, 8, and 12; and every 12 weeks thereafter. A physical exam, measurement of height and weight, tuberculosis (TB) and hepatitis B infection screening, blood collection, pill counts, and compliance/adherence and resource utilization counseling will occur at most visits. Participants will also be asked to complete quality of life and household cost questionnaires at selected visits. Study visits for participants who fail first-line treatment will occur at treatment failure, between Days 15 and 30, Week 4 post-treatment failure, every 4 weeks until Week 48 post-treatment failure, and every 12 weeks thereafter. A targeted physical exam, measurement of height and weight, TB infection screening, blood collection, pill counts, and compliance/adherence and resource utilization counseling will occur at most visits. Participants will also be asked to complete quality of life and household cost questionnaires at selected visits.

Conditions

HIV Infections

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: TREATMENT
• Blinding Strategy: NONE

Study Groups

A

Study-specified Antiretroviral regimen under care of HIV-trained medical doctor

Group Type: ACTIVE_COMPARATOR

Monitoring by an HIV-trained medical doctor

Intervention Type: BEHAVIORAL

Participants will receive care from an HIV-trained medical doctor

Efavirenz

Intervention Type: DRUG

600 mg tablet taken orally daily

Lamivudine

Intervention Type: DRUG

150 mg tablet taken orally daily

Lopinavir/Ritonavir

Intervention Type: DRUG

400 mg lopinavir/100mg ritonavir tablet taken orally twice daily

Nevirapine

Intervention Type: DRUG

200 mg tablet taken orally for 14 days before taking a 200 mg tablet orally twice daily

Stavudine

Intervention Type: DRUG

Tablet taken orally daily. Dosage depends on weight.

B

Study-specified Antiretroviral regimen under care of HIV-trained primary care nurse

Group Type: ACTIVE_COMPARATOR

Monitoring by an HIV-trained primary care nurse

Intervention Type: BEHAVIORAL

Participants will receive care from an HIV-trained primary care nurse

Efavirenz

Intervention Type: DRUG

600 mg tablet taken orally daily

Lamivudine

Intervention Type: DRUG

150 mg tablet taken orally daily

Lopinavir/Ritonavir

Intervention Type: DRUG

400 mg lopinavir/100mg ritonavir tablet taken orally twice daily

Nevirapine

Intervention Type: DRUG

200 mg tablet taken orally for 14 days before taking a 200 mg tablet orally twice daily

Stavudine

Intervention Type: DRUG

Tablet taken orally daily. Dosage depends on weight.

Interventions

Monitoring by an HIV-trained medical doctor

Participants will receive care from an HIV-trained medical doctor

Intervention Type: BEHAVIORAL

Monitoring by an HIV-trained primary care nurse

Participants will receive care from an HIV-trained primary care nurse

Intervention Type: BEHAVIORAL

Efavirenz

600 mg tablet taken orally daily

Intervention Type: DRUG

Lamivudine

150 mg tablet taken orally daily

Intervention Type: DRUG

Lopinavir/Ritonavir

400 mg lopinavir/100mg ritonavir tablet taken orally twice daily

Intervention Type: DRUG

Nevirapine

200 mg tablet taken orally for 14 days before taking a 200 mg tablet orally twice daily

Intervention Type: DRUG

Stavudine

Tablet taken orally daily. Dosage depends on weight.

Intervention Type: DRUG

Other Intervention Names

EFV; 3TC; LPV/RTV; NVP; d4T

Eligibility Criteria

Inclusion Criteria

• HIV-1 infected
• Current severe CDC Category B AIDS-defining illness (with the exception of a single episode of bacterial sepsis or a single episode of zoster), OR history of a severe CDC Category B or C AIDS-defining illness, OR one CD4 count less than 350 cells/mm3 within 6 months prior to study entry
• Antiretroviral naive. A participant who previously received 6 weeks or less of post-exposure prophylaxis or short course therapy for the prevention of mother-to-child transmission are not excluded. More information on this criterion can be found in the protocol.
• Willing to use acceptable forms of contraception
• Parent or guardian willing to provide informed consent, if applicable

Exclusion Criteria

• Current newly diagnosed CDC Category C AIDS-defining opportunistic infection or condition requiring acute therapy at the time of study entry. More information on this criterion can be found in the protocol.
• Therapy with agents with significant systemic myelosuppressive, neurotoxic, pancreatotoxic, hepatotoxic, or cytotoxic potential within 30 days prior to study entry
• Require certain medications
• Current alcohol or substance abuse that, in the opinion of the investigator, may interfere with the study
• Uncontrolled diarrhea (more than 6 stools per day for 7 consecutive days) within 30 days prior to study entry
• Diagnosis of or suspected acute hepatitis within 30 days prior to study entry
• Signs or symptoms of bilateral peripheral neuropathy of Grade 2 or greater at screening
• Inability to tolerate oral medication
• Any other clinical condition that, in the opinion of the investigator, may interfere with the study
• In the first trimester of pregnancy

• Minimum Eligible Age: 16 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

National Institute of Allergy and Infectious Diseases (NIAID)

NIH

Sponsor Role: collaborator

CIPRA SA

NETWORK

Sponsor Role: lead

Responsible Party

CIPRA SA

Principal Investigators

James McIntyre, MBChB, MRCOG

Role: PRINCIPAL_INVESTIGATOR

Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital

Ian Sanne, MBChB

Role: PRINCIPAL_INVESTIGATOR

University of the Witwatersrand, Thembaletu Clinic, Helen Joseph Hospital

Robin Wood, MBChB, FCP (SA)

Role: PRINCIPAL_INVESTIGATOR

Department of Medicine, University of Cape Town

References

Hosseinipour MC, Kazembe PN, Sanne IM, van der Horst CM. Challenges in delivering antiretroviral treatment in resource poor countries. AIDS. 2002;16 Suppl 4:S177-87. doi: 10.1097/00002030-200216004-00024. No abstract available.

Reference Type: BACKGROUND

PMID: 12699015 (View on PubMed)

Sanne I, van der Horst C. Research as a path to wide-scale implementation of antiretroviral therapy in Africa. J HIV Ther. 2004 Sep;9(3):65-8.

Reference Type: BACKGROUND

PMID: 15534564 (View on PubMed)

Wools-Kaloustian K, Kimaiyo S. Extending HIV care in resource-limited settings. Curr HIV/AIDS Rep. 2006 Nov;3(4):182-6. doi: 10.1007/s11904-006-0014-1.

Reference Type: BACKGROUND

PMID: 17032578 (View on PubMed)

Brehm JH, Koontz DL, Wallis CL, Shutt KA, Sanne I, Wood R, McIntyre JA, Stevens WS, Sluis-Cremer N, Mellors JW; CIPRA-SA Project 1 Study Team. Frequent emergence of N348I in HIV-1 subtype C reverse transcriptase with failure of initial therapy reduces susceptibility to reverse-transcriptase inhibitors. Clin Infect Dis. 2012 Sep;55(5):737-45. doi: 10.1093/cid/cis501. Epub 2012 May 22.

Reference Type: DERIVED

PMID: 22618567 (View on PubMed)

Orrell C, Cohen K, Conradie F, Zeinecker J, Ive P, Sanne I, Wood R. Efavirenz and rifampicin in the South African context: is there a need to dose-increase efavirenz with concurrent rifampicin therapy? Antivir Ther. 2011;16(4):527-34. doi: 10.3851/IMP1780.

Reference Type: DERIVED

PMID: 21685540 (View on PubMed)

Sanne I, Orrell C, Fox MP, Conradie F, Ive P, Zeinecker J, Cornell M, Heiberg C, Ingram C, Panchia R, Rassool M, Gonin R, Stevens W, Truter H, Dehlinger M, van der Horst C, McIntyre J, Wood R; CIPRA-SA Study Team. Nurse versus doctor management of HIV-infected patients receiving antiretroviral therapy (CIPRA-SA): a randomised non-inferiority trial. Lancet. 2010 Jul 3;376(9734):33-40. doi: 10.1016/S0140-6736(10)60894-X.

Reference Type: DERIVED

PMID: 20557927 (View on PubMed)

Other Identifiers

U19AI053217

Identifier Type: NIH

Identifier Source: secondary_id

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3U19AI053217-03S1

Identifier Type: NIH

Identifier Source: secondary_id

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3U19AI053217-04S1

Identifier Type: NIH

Identifier Source: secondary_id

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3U19AI053217-04

Identifier Type: NIH

Identifier Source: secondary_id

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CIPRA-SA Project 1

Identifier Type: -

Identifier Source: org_study_id