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When to Start Anti-HIV Drugs in Patients With Opportunistic Infections

Primary Purpose

HIV Infections, AIDS-Related Opportunistic Infections

Status
Completed
Phase
Phase 4
Locations
International
Study Type
Interventional
Intervention
Emtricitabine/tenofovir disoproxil fumarate
Lopinavir/ritonavir
Stavudine
Sponsored by
National Institute of Allergy and Infectious Diseases (NIAID)
About
Eligibility
Locations
Outcomes
Full info

About this trial

This is an interventional diagnostic trial for HIV Infections focused on measuring Anti-HIV Agents, Disease Progression, Drug Administration Schedule, Viral Load, HIV-1, Treatment Outcome, Survival Analysis, Treatment Naive

Eligibility Criteria

13 Years - undefined (Child, Adult, Older Adult)All SexesDoes not accept healthy volunteers

Note: Participants who enrolled in this study prior to Version 3.0 will be offered and allowed to switch to FTC/TDF if they wish. However, participants under the age of 18 cannot receive FTC/TDF through this study. Inclusion Criteria for Step 1: HIV-1 infected Currently being treated for OI (including Pneumocystis carinii pneumonia [PCP]; cryptococcal meningitis; disseminated histoplasmosis; disseminated Mycobacterium avium complex [MAC]; cytomegalovirus [CMV] retinitis; CMV encephalitis; toxoplasmic encephalitis; other atypical non-tuberculous, non-MAC mycobacterial infections; or other serious, invasive BIs). Participants who have tuberculosis (TB) alone are ineligible for this study. Participants with bacterial pneumonia or serious BI must have a CD4 count less than 200 cells/mm3 within 30 days prior to study entry. Participants with other serious OIs, including other AIDS-defining and -related OIs for which appropriate therapy other than ART exists are eligible, pending investigator approval. Participants' current OI treatment must have been started within 14 days prior to study entry, but may have been discontinued prior to study entry. Able to take oral medications Parent or guardian willing to provide informed consent, if applicable Willing to use acceptable methods of contraception Exclusion Criteria for Step 1: Any ART within 8 weeks prior to study entry 31 or more days of any ARV within 6 months prior to entry History of more than one virologic, immunologic, or clinical treatment failure while on a HAART regimen, or a history of more than one regimen change for unknown reasons Systemic cancer chemotherapy within 30 days prior to study entry Immunomodulators within 30 days prior to study entry, including growth factors, immune globulin, interleukins, and interferons (unless for hepatitis C virus or Kaposi's sarcoma) Investigational ARV agents at study entry Systemic investigational agents (except ARV drugs) within 30 days prior to study entry will be allowed at the study official's discretion Anticipated use of certain medications Kidney failure requiring dialysis Current drug or alcohol use that, in the opinion of the study official, would interfere with the study Treatment for current, first-treated, and diagnosed OI or BI for more than 14 days prior to study entry Known resistance to ART that prohibits administration of an effective ART regimen Current OI has recurred within 90 days prior to study entry. Recurrent BIs are not excluded. Pregnant or breastfeeding

Sites / Locations

  • University of California, Davis Medical Center
  • University of California, San Diego Antiviral Rese
  • San Francisco General Hospital
  • San Mateo County AIDS Program
  • Santa Clara Valley Medical Center
  • Stanford Univ
  • Willow Clinic
  • Harbor General/UCLA
  • University of Colorado Health Sciences Center, Denver
  • Univ of Miami
  • Emory University
  • Northwestern University
  • Cook County Hospital Core Center
  • Methodist Hospital of Indiana
  • Indiana University Hosp
  • Wishard Hospital
  • University of Maryland, Institute of Human Virology
  • Johns Hopkins University
  • Harvard (Massachusetts General Hospital)
  • Beth Israel Deaconess - West Campus
  • Brigham and Womens Hospital
  • Hennepin County Medical Clinic
  • St. Louis Connect Care
  • Washington University (St. Louis)
  • Beth Israel Medical Center
  • NYU/Bellevue
  • Columbia University
  • Community Health Network, Inc.
  • University of Rochester Medical Center
  • University of North Carolina
  • Duke University Medical Center
  • University of Cincinnati
  • Case Western Reserve University
  • MetroHealth Medical Center
  • Ohio State University
  • Presbyterian Medical Center - University of PA
  • University of Pennsylvania, Philadelphia
  • Rhode Island Hospital
  • The Miriam Hospital
  • Comprehensive Care Clinic
  • University of Texas, Southwestern Medical Center
  • Univ of Texas, Galveston
  • University of Washington (Seattle)
  • University of Puerto Rico
  • University of Witwatersrand

Outcomes

Primary Outcome Measures

Survival, recurrence of presenting OI/bacterial infection (BI) or incidence of new AIDS-defining events, and HIV-1 plasma viral load at Week 48

Secondary Outcome Measures

HIV-1 plasma viral load at all timepoints up to and including Week 48
CD4 counts at all timepoints up to and including Week 48
changes in ARV regimen for lack of efficacy
efficacy of treatment and clinical outcomes for specific OI/BI, including duration of and complications of treatment, incidence and duration of hospitalization, rate of relapse/recurrence, and incidence of IRIS and impact on outcomes in the two arms
safety and tolerability, measured by Grade 3 and 4 signs and symptoms and laboratory toxicities, ART and OI/BI treatment changes and dose modifications due to toxicities, and IRIS
HIV-1 drug resistance over time (genotype)
health care resource use, including total inpatient days and emergency room visits compared in the two groups
quality of life (QOL) and functional status outcomes, including overall self-reported QOL and functional status compared in the two groups at Week 48
adherence, including self-reported adherence to all ARVs over the study period, examined for relationship with primary study outcomes, including death, progression, and viral suppression

Full Information

First Posted
February 19, 2003
Last Updated
October 14, 2014
Sponsor
National Institute of Allergy and Infectious Diseases (NIAID)
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1. Study Identification

Unique Protocol Identification Number
NCT00055120
Brief Title
When to Start Anti-HIV Drugs in Patients With Opportunistic Infections
Official Title
A Phase IV Study of Antiretroviral Therapy for HIV Infected Adults Presenting With Acute Opportunistic Infections: Immediate Versus Deferred Initiation of Antiretroviral Therapy
Study Type
Interventional

2. Study Status

Record Verification Date
October 2014
Overall Recruitment Status
Completed
Study Start Date
March 2003 (undefined)
Primary Completion Date
September 2006 (Actual)
Study Completion Date
August 2007 (Actual)

3. Sponsor/Collaborators

Name of the Sponsor
National Institute of Allergy and Infectious Diseases (NIAID)

4. Oversight

5. Study Description

Brief Summary
The purpose of this study is to evaluate the effect of starting anti-HIV drugs in HIV infected patients who are being treated for opportunistic infections (OIs). This study will follow two patient groups: those who received anti-HIV drugs soon after being diagnosed with an OI and patients with OIs who deferred beginning anti-HIV drugs until after recovering from the OI.
Detailed Description
Despite the advent of highly active antiretroviral therapy (HAART), many HIV infected patients without access to antiretroviral therapy (ART) present with acute OIs. Such presentations pose a management problem, as there are currently no data available as to whether initiating HAART during the acute presentation is of benefit. Reports of an immune reconstitution inflammatory syndrome (IRIS) marked by increasing hypoxia or new pulmonary infiltrates have been associated with the initiation of ART in patients with AIDS. There is also concern as to drug interactions between ART and antimicrobials used to treat the presenting OI. This study will evaluate the possible benefits and costs of initiating ART in HIV infected patients who present with an AIDS-defining OI. There are 2 steps in this study. In Step 1, patients will be randomly assigned to one of two study arms. Arm A will receive ART within 2 weeks of starting therapy for the acute OI. Arm B will have ART deferred until Step 2, at least 4 weeks and no more than 32 weeks after beginning therapy for the acute OI. Only Arm B participants will enter Step 2, which will likely begin between Weeks 6 and 12. The study will make the following drugs available for construction of an antiretroviral (ARV) regimen: emtricitabine/tenofovir disoproxil fumarate (FTC/TDF), lopinavir/ritonavir (LPV/RTV), and stavudine (d4T). Use of other ARV drugs is at the discretion of the study official. Drug regimen additions and substitutions will be made on a case-by-case basis. Patients will be followed for 48 weeks and will have 10 study visits. All study visits will include a physical exam, medication history, and blood collection. Patients will be asked to complete questionnaires assessing health status and adherence at selected visits.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
HIV Infections, AIDS-Related Opportunistic Infections
Keywords
Anti-HIV Agents, Disease Progression, Drug Administration Schedule, Viral Load, HIV-1, Treatment Outcome, Survival Analysis, Treatment Naive

7. Study Design

Primary Purpose
Diagnostic
Study Phase
Phase 4
Interventional Study Model
Parallel Assignment
Masking
None (Open Label)
Allocation
Randomized
Enrollment
283 (Actual)

8. Arms, Groups, and Interventions

Intervention Type
Drug
Intervention Name(s)
Emtricitabine/tenofovir disoproxil fumarate
Intervention Type
Drug
Intervention Name(s)
Lopinavir/ritonavir
Intervention Type
Drug
Intervention Name(s)
Stavudine
Primary Outcome Measure Information:
Title
Survival, recurrence of presenting OI/bacterial infection (BI) or incidence of new AIDS-defining events, and HIV-1 plasma viral load at Week 48
Secondary Outcome Measure Information:
Title
HIV-1 plasma viral load at all timepoints up to and including Week 48
Title
CD4 counts at all timepoints up to and including Week 48
Title
changes in ARV regimen for lack of efficacy
Title
efficacy of treatment and clinical outcomes for specific OI/BI, including duration of and complications of treatment, incidence and duration of hospitalization, rate of relapse/recurrence, and incidence of IRIS and impact on outcomes in the two arms
Title
safety and tolerability, measured by Grade 3 and 4 signs and symptoms and laboratory toxicities, ART and OI/BI treatment changes and dose modifications due to toxicities, and IRIS
Title
HIV-1 drug resistance over time (genotype)
Title
health care resource use, including total inpatient days and emergency room visits compared in the two groups
Title
quality of life (QOL) and functional status outcomes, including overall self-reported QOL and functional status compared in the two groups at Week 48
Title
adherence, including self-reported adherence to all ARVs over the study period, examined for relationship with primary study outcomes, including death, progression, and viral suppression

10. Eligibility

Sex
All
Minimum Age & Unit of Time
13 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Note: Participants who enrolled in this study prior to Version 3.0 will be offered and allowed to switch to FTC/TDF if they wish. However, participants under the age of 18 cannot receive FTC/TDF through this study. Inclusion Criteria for Step 1: HIV-1 infected Currently being treated for OI (including Pneumocystis carinii pneumonia [PCP]; cryptococcal meningitis; disseminated histoplasmosis; disseminated Mycobacterium avium complex [MAC]; cytomegalovirus [CMV] retinitis; CMV encephalitis; toxoplasmic encephalitis; other atypical non-tuberculous, non-MAC mycobacterial infections; or other serious, invasive BIs). Participants who have tuberculosis (TB) alone are ineligible for this study. Participants with bacterial pneumonia or serious BI must have a CD4 count less than 200 cells/mm3 within 30 days prior to study entry. Participants with other serious OIs, including other AIDS-defining and -related OIs for which appropriate therapy other than ART exists are eligible, pending investigator approval. Participants' current OI treatment must have been started within 14 days prior to study entry, but may have been discontinued prior to study entry. Able to take oral medications Parent or guardian willing to provide informed consent, if applicable Willing to use acceptable methods of contraception Exclusion Criteria for Step 1: Any ART within 8 weeks prior to study entry 31 or more days of any ARV within 6 months prior to entry History of more than one virologic, immunologic, or clinical treatment failure while on a HAART regimen, or a history of more than one regimen change for unknown reasons Systemic cancer chemotherapy within 30 days prior to study entry Immunomodulators within 30 days prior to study entry, including growth factors, immune globulin, interleukins, and interferons (unless for hepatitis C virus or Kaposi's sarcoma) Investigational ARV agents at study entry Systemic investigational agents (except ARV drugs) within 30 days prior to study entry will be allowed at the study official's discretion Anticipated use of certain medications Kidney failure requiring dialysis Current drug or alcohol use that, in the opinion of the study official, would interfere with the study Treatment for current, first-treated, and diagnosed OI or BI for more than 14 days prior to study entry Known resistance to ART that prohibits administration of an effective ART regimen Current OI has recurred within 90 days prior to study entry. Recurrent BIs are not excluded. Pregnant or breastfeeding
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Andrew R. Zolopa, MD
Organizational Affiliation
Division of Infectious Diseases, Stanford University
Official's Role
Study Chair
Facility Information:
Facility Name
University of California, Davis Medical Center
City
Sacramento
State/Province
California
ZIP/Postal Code
95814
Country
United States
Facility Name
University of California, San Diego Antiviral Rese
City
San Diego
State/Province
California
ZIP/Postal Code
92103
Country
United States
Facility Name
San Francisco General Hospital
City
San Francisco
State/Province
California
ZIP/Postal Code
94110
Country
United States
Facility Name
San Mateo County AIDS Program
City
Stanford
State/Province
California
ZIP/Postal Code
94305-5107
Country
United States
Facility Name
Santa Clara Valley Medical Center
City
Stanford
State/Province
California
ZIP/Postal Code
94305-5107
Country
United States
Facility Name
Stanford Univ
City
Stanford
State/Province
California
ZIP/Postal Code
94305-5107
Country
United States
Facility Name
Willow Clinic
City
Stanford
State/Province
California
ZIP/Postal Code
94305-5107
Country
United States
Facility Name
Harbor General/UCLA
City
Torrance
State/Province
California
ZIP/Postal Code
90502-2052
Country
United States
Facility Name
University of Colorado Health Sciences Center, Denver
City
Denver
State/Province
Colorado
ZIP/Postal Code
80262-3706
Country
United States
Facility Name
Univ of Miami
City
Miami
State/Province
Florida
ZIP/Postal Code
33136-1013
Country
United States
Facility Name
Emory University
City
Atlanta
State/Province
Georgia
ZIP/Postal Code
30308
Country
United States
Facility Name
Northwestern University
City
Chicago
State/Province
Illinois
ZIP/Postal Code
60611-3015
Country
United States
Facility Name
Cook County Hospital Core Center
City
Chicago
State/Province
Illinois
ZIP/Postal Code
60612
Country
United States
Facility Name
Methodist Hospital of Indiana
City
Indianapolis
State/Province
Indiana
ZIP/Postal Code
46202-1261
Country
United States
Facility Name
Indiana University Hosp
City
Indianapolis
State/Province
Indiana
ZIP/Postal Code
46202-5250
Country
United States
Facility Name
Wishard Hospital
City
Indianapolis
State/Province
Indiana
ZIP/Postal Code
46202
Country
United States
Facility Name
University of Maryland, Institute of Human Virology
City
Baltimore
State/Province
Maryland
ZIP/Postal Code
21201
Country
United States
Facility Name
Johns Hopkins University
City
Baltimore
State/Province
Maryland
ZIP/Postal Code
21287-8106
Country
United States
Facility Name
Harvard (Massachusetts General Hospital)
City
Boston
State/Province
Massachusetts
ZIP/Postal Code
02114
Country
United States
Facility Name
Beth Israel Deaconess - West Campus
City
Boston
State/Province
Massachusetts
ZIP/Postal Code
02215
Country
United States
Facility Name
Brigham and Womens Hospital
City
Boston
State/Province
Massachusetts
ZIP/Postal Code
02215
Country
United States
Facility Name
Hennepin County Medical Clinic
City
Minneapolis
State/Province
Minnesota
ZIP/Postal Code
55455-0392
Country
United States
Facility Name
St. Louis Connect Care
City
St. Louis
State/Province
Missouri
ZIP/Postal Code
63108-2138
Country
United States
Facility Name
Washington University (St. Louis)
City
St. Louis
State/Province
Missouri
ZIP/Postal Code
63108-2138
Country
United States
Facility Name
Beth Israel Medical Center
City
New York
State/Province
New York
ZIP/Postal Code
10003
Country
United States
Facility Name
NYU/Bellevue
City
New York
State/Province
New York
ZIP/Postal Code
10016-6481
Country
United States
Facility Name
Columbia University
City
New York
State/Province
New York
ZIP/Postal Code
10021
Country
United States
Facility Name
Community Health Network, Inc.
City
Rochester
State/Province
New York
ZIP/Postal Code
14642-0001
Country
United States
Facility Name
University of Rochester Medical Center
City
Rochester
State/Province
New York
ZIP/Postal Code
14642-0001
Country
United States
Facility Name
University of North Carolina
City
Chapel Hill
State/Province
North Carolina
ZIP/Postal Code
27514
Country
United States
Facility Name
Duke University Medical Center
City
Durham
State/Province
North Carolina
ZIP/Postal Code
27710
Country
United States
Facility Name
University of Cincinnati
City
Cincinnati
State/Province
Ohio
ZIP/Postal Code
45267-0405
Country
United States
Facility Name
Case Western Reserve University
City
Cleveland
State/Province
Ohio
ZIP/Postal Code
44106-5083
Country
United States
Facility Name
MetroHealth Medical Center
City
Cleveland
State/Province
Ohio
ZIP/Postal Code
44109-1998
Country
United States
Facility Name
Ohio State University
City
Columbus
State/Province
Ohio
ZIP/Postal Code
43210
Country
United States
Facility Name
Presbyterian Medical Center - University of PA
City
Philadelphia
State/Province
Pennsylvania
ZIP/Postal Code
19104
Country
United States
Facility Name
University of Pennsylvania, Philadelphia
City
Philadelphia
State/Province
Pennsylvania
ZIP/Postal Code
19104
Country
United States
Facility Name
Rhode Island Hospital
City
Providence
State/Province
Rhode Island
ZIP/Postal Code
02906
Country
United States
Facility Name
The Miriam Hospital
City
Providence
State/Province
Rhode Island
ZIP/Postal Code
02906
Country
United States
Facility Name
Comprehensive Care Clinic
City
Nashville
State/Province
Tennessee
ZIP/Postal Code
37203
Country
United States
Facility Name
University of Texas, Southwestern Medical Center
City
Dallas
State/Province
Texas
ZIP/Postal Code
75235-9173
Country
United States
Facility Name
Univ of Texas, Galveston
City
Galveston
State/Province
Texas
ZIP/Postal Code
77555-0435
Country
United States
Facility Name
University of Washington (Seattle)
City
Seattle
State/Province
Washington
ZIP/Postal Code
98104
Country
United States
Facility Name
University of Puerto Rico
City
San Juan
ZIP/Postal Code
00936-5067
Country
Puerto Rico
Facility Name
University of Witwatersrand
City
Parktown
State/Province
Johannesburg
Country
South Africa

12. IPD Sharing Statement

Citations:
PubMed Identifier
11549544
Citation
Wislez M, Bergot E, Antoine M, Parrot A, Carette MF, Mayaud C, Cadranel J. Acute respiratory failure following HAART introduction in patients treated for Pneumocystis carinii pneumonia. Am J Respir Crit Care Med. 2001 Sep 1;164(5):847-51. doi: 10.1164/ajrccm.164.5.2007034.
Results Reference
background
PubMed Identifier
11504958
Citation
Bartlett JA, DeMasi R, Quinn J, Moxham C, Rousseau F. Overview of the effectiveness of triple combination therapy in antiretroviral-naive HIV-1 infected adults. AIDS. 2001 Jul 27;15(11):1369-77. doi: 10.1097/00002030-200107270-00006.
Results Reference
background
Citation
Hamill RJ. Immune restoration syndrome in AIDS and mycoses. Program and abstracts of the 41st Interscience Conference on Antimicrobial Agents and Chemotherapy; December 16-19, 2001; Chicago, IL. Abtract 1272.
Results Reference
background
PubMed Identifier
12803995
Citation
Nunez M, Asencio R, Valencia ME, Leal M, Gonzalez-Lahoz J, Soriano V. Rate, causes, and clinical implications of presenting with low CD4+ cell counts in the era of highly active antiretroviral therapy. AIDS Res Hum Retroviruses. 2003 May;19(5):363-8. doi: 10.1089/088922203765551719.
Results Reference
background
PubMed Identifier
21126955
Citation
Sax PE, Sloan CE, Schackman BR, Grant PM, Rong J, Zolopa AR, Powderly W, Losina E, Freedberg KA; Cepac US And Actg A5164 Investigators. Early antiretroviral therapy for patients with acute aids-related opportunistic infections: a cost-effectiveness analysis of ACTG A5164. HIV Clin Trials. 2010 Sep-Oct;11(5):248-59. doi: 10.1310/hct1105-248.
Results Reference
result
PubMed Identifier
20617176
Citation
Grant PM, Komarow L, Andersen J, Sereti I, Pahwa S, Lederman MM, Eron J, Sanne I, Powderly W, Hogg E, Suckow C, Zolopa A. Risk factor analyses for immune reconstitution inflammatory syndrome in a randomized study of early vs. deferred ART during an opportunistic infection. PLoS One. 2010 Jul 1;5(7):e11416. doi: 10.1371/journal.pone.0011416.
Results Reference
derived
PubMed Identifier
19440326
Citation
Zolopa A, Andersen J, Powderly W, Sanchez A, Sanne I, Suckow C, Hogg E, Komarow L. Early antiretroviral therapy reduces AIDS progression/death in individuals with acute opportunistic infections: a multicenter randomized strategy trial. PLoS One. 2009;4(5):e5575. doi: 10.1371/journal.pone.0005575. Epub 2009 May 18.
Results Reference
derived

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When to Start Anti-HIV Drugs in Patients With Opportunistic Infections

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