Chepetsa TB - Reducing TB Among HIV-Infected Malawians

August 15, 2017 updated by: Johns Hopkins University

Impact of a New Molecular Tuberculosis (TB) Test on TB/HIV Outcomes Among HIV-

The specific aims of this project are: (1) to compare the impact of using the routine screening and GeneXpert algorithms for TB case detection on Tuberculosis (TB)- and HIV-related outcomes; (2) to compare the impact of using the routine screening and GeneXpert algorithms for exclusion of TB prior to initiation of IPT and ART on TB- and HIV-related outcomes; and (3) to assess the relative cost-effectiveness of the routine screening and GeneXpert algorithms for TB case detection and exclusion of TB. The GeneXpert is a "disruptive technology"10 that could allow TB/HIV programs in resource-limited settings to leapfrog over solid and liquid culture-based TB diagnostic algorithms, and to remove a key barrier to scale up of ICF and IPT.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

HIV and tuberculosis (TB) are, along with malaria, the leading infectious causes of death worldwide and in sub-Saharan Africa.1 In 2008, there were 2 million deaths from AIDS and 1.8 million deaths from TB worldwide.2, 3 The HIV epidemic has fueled an increase in the incidence of, prevalence of and mortality due to TB in the past 3 decades. 15% of TB cases are HIV co-infected worldwide.34 78% of HIV-infected TB cases are in Africa.3 TB is the leading cause of death and opportunistic infection among persons living with HIV/AIDS (PLWHA). The HIV epidemic has challenged time-tested TB control methods that are now failing in high HIV prevalence settings.5 The World Health Organization (WHO) has recommended that the Three I's - intensified case-finding for TB (ICF), isoniazid preventive therapy (IPT) and infection control for TB - be targeted at PLWHA.6 ICF and IPT have not been adequately implemented in part due to the absence of sensitive, specific and rapid TB tests. The Cepheid GeneXpert System, a new diagnostic test for TB, is a self-contained sputum-processing and real-time PCR system to detect the M. tuberculosis complex as well as rifampin resistance.78 The GeneXpert is rapid, highly sensitive and specific, can be used as a point-of-care test, and has low human resource, laboratory and infection control requirements.7, 8 The WHO Strategic and Advisory Group for TB has endorsed recommendations for widespread use of the GeneXpert.9 WHO strongly recommended that the GeneXpert should be used as the initial diagnostic test in HIV-infected TB suspects and multidrug-resistant TB (MDR-TB) suspects.9 WHO also recommended that implementation of the GeneXpert be phased in within the context of comprehensive national and MDR-TB strategic plans.9 WHO recognized that several operational conditions need to be met for successful implementation, including but not limited to stable electrical supply, security against theft, trained personnel and annual calibration of the instrument by a commercial supplier.9 WHO also noted that it is important to document the impact and cost-effectiveness of the GeneXpert for TB case detection.9

Trial Concept The overall objective of this proposal is to conduct a cluster-randomized trial of the relative impact and cost-effectiveness of a routine TB screening algorithm -- symptom screening and point-of-care LED fluorescence sputum smear microscopy - versus a GeneXpert-based TB screening algorithm - symptom screening and point-of-care GeneXpert testing - on reducing morbidity and mortality due to TB among HIV-infected Malawians. 12 public sector clinics in southern Malawi will be randomized to 1 of 2 algorithms for TB case detection as part of ICF and for exclusion of TB prior to IPT and antiretroviral therapy (ART) initiation. In the clinics assigned to the GeneXpert algorithm, newly diagnosed HIV-infected patients will be screened for symptoms of TB and, if symptomatic, will provide sputum for GeneXpert point-of-care TB testing. Under the routine screening algorithm, patients at a clinic will be screened for symptoms of TB and, if symptomatic, will provide sputum for point-of-care LED fluorescence smear microscopy. The current standard of care in Malawi and most of Africa is symptom screening and sputum smear microscopy using Ziehl-Neelsen stain (not LED fluorescence microscopy) alone. There is not sufficient evidence at this time to demonstrate whether point-of-care LED microscopy versus GeneXpert testing is likely to be superior with respect to clinical impact and/or cost-effectiveness. Outcomes will be measured at the clinic level.

Study Type

Interventional

Enrollment (Actual)

1200

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Malawi
      • Blantyre, Malawi
    • Thyolo District
      • Blantyre, Thyolo District, Malawi

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

All HIV-infected men and women > 18 years of age with newly diagnosed HIV at the 12 study clinics will be asked to participate in the study.

Exclusion Criteria:

  • Patients will be excluded from participation if they have a current diagnosis of TB and/or if they are currently taking IPT, TB treatment and/or ART.
  • Patients will also be excluded from participation if they cannot speak English or Chichewa;
  • if they have a language or hearing impairment; or
  • if they are prisoners.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Other
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: GeneXpert
Point of care GeneXpert
Other: GeneXpert
Point of care GeneXpert
Other: LED Microscopy
Point of care LED Microscopy
Active Comparator: LED Microscopy
Point of care LED Microscopy
Other: LED Microscopy
Point of care LED Microscopy

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Time Frame
Survival of newly-diagnosed HIV-infected patients at 1 year
Time Frame: 4 years
4 years

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Johns Hopkins University

Investigators

  • Principal Investigator: Elizabeth Corbett, MD, Malawi Liverpool Wellcome Trust
  • Study Director: David Dowdy, MD. PhD, Johns Hopkins Unviversity
  • Principal Investigator: Lawrence Moulton, PhD, Johns Hopkins University

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

September 1, 2012

Primary Completion (Actual)

December 1, 2016

Study Completion (Actual)

December 30, 2016

Study Registration Dates

First Submitted

October 7, 2011

First Submitted That Met QC Criteria

October 11, 2011

First Posted (Estimate)

October 12, 2011

Study Record Updates

Last Update Posted (Actual)

August 18, 2017

Last Update Submitted That Met QC Criteria

August 15, 2017

Last Verified

August 1, 2017

More Information

Terms related to this study

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 1R01AI093316-01A1 (U.S. NIH Grant/Contract)

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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