Comparing PI-Based to a nNRTI-based ART for Clearance of Plasmodium Falciparum Parasitemia in HIV-Infected

An Open-Label, Proof of Concept, Randomized Trial Comparing a LPV/r-Based to an nNRTI-Based Antiretroviral Therapy Regimen for Clearance of Plasmodium Falciparum Subclinical Parasitemia in HIV-infected Adults With CD4+ Counts >200 and <500 Cells/mm^3

The purpose of this study was to see if antiretroviral therapy (ART) is safe and works at getting rid of malaria in blood and to see whether one type of ART is better than another. This study may offer information for further research in looking at whether ART plays a role in the prevention and treatment of malaria.

Study Overview

• Status: Completed
• Conditions: HIV-1 Infection; Pf Subclinical Parasitemia
• Intervention / Treatment: Drug: Lopinavir/ritonavir; Drug: Emtricitabine/tenofovir disoproxil fumarate; Drug: Efavirenz; Drug: Nevirapine; Drug: Trimethoprim/sulfamethoxazole

Detailed Description

A5297 was a Phase I/II, open-label, proof of concept, two-step, two-arm, randomized controlled clinical trial (RCT) to test the superiority of lopinavir/ritonavir (LPV/r)-based antiretroviral therapy (ART) to non-nucleoside reverse transcriptase (nNRTI)-based ART for clearance of Plasmodium falciparum (Pf) subclinical parasitemia (SCP).

The study consisted of two steps. At study Step 1 entry, participants were randomized 1:1 to either LPV/r-based ART or nNRTI-based ART for 15 days. In study Step 2, all participants received nNRTI-based ART and TMP/SMX prophylaxis for 15 days. The total study duration was 30 days.

Study visits occurred every 3 days in Step 1, and every 5 days in Step 2. At each study visit, 2 samples were taken for measurement of parasite density, except day 15 and day 30 at which 3 samples were taken.

Adverse events which occurred after randomization were also recorded. Signs/symptoms and diagnoses were evaluated at each visit, while safety labs (including Hemoglobin, hematocrit, white blood cell count (WBC), differential WBC, platelet count, and absolute neutrophil count (ANC), glucose, electrolytes (sodium, potassium, chloride, bicarbonate), total bilirubin, AST (SGOT), ALT (SGPT), albumin, alkaline phosphatase, and creatinine) were taken at day 15 and day 30, or if indicated at other study visits.

• Study Type: Interventional
• Enrollment (Actual): 52
• Phase: Phase 2; Phase 1

Contacts and Locations

Study Locations

• Kenya
  • Eldoret, Kenya, 30100
    • AMPATH at Moi Univ. Teaching Hosp. Eldoret CRS (12601)
  • Kericho, Kenya, 20200
    • Walter Reed Project - Kenya Med. Research Institute Kericho CRS (12501)
  • Kisumu, Kenya, 40100
    • Kisumu Crs (31460)
• Malawi
  • Blantyre, Malawi
    • College of Med. JHU CRS (30301)
• Uganda
  • Kampala, Uganda
    • Joint Clinical Research Centre (JCRC) (12401)

Participation Criteria

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:

• HIV-1 infection
• CD4+ count > 200 and < 500 cells/mm^3 obtained within 30 days prior to study entry at a DAIDS-approved laboratory.

• Pf SCP confirmed in a laboratory approved to conduct parasitemia microscopy. Note: Pf SCP defined as meeting all three of the following criteria within 72 hours prior to study entry:

  1. Microscopy confirmed parasitemia (see section 6.3.6 and the A5297 Manual of Procedures [MOPS])
  2. An oral temperature < 37.5°C.

  3. The absence of Grade 2 or greater signs or symptoms thought to be related to clinical malaria including:

     1. headache
     2. malaise or fatigue
     3. abdominal discomfort
     4. muscle or joint pain
     5. fever
     6. chills
     7. perspiration
     8. anorexia
     9. vomiting
     10. other signs or symptoms thought to be related to clinical malaria
• Certain laboratory values obtained within 14 days prior to study entry, as detailed in section 4.1.4 of the protocol.
• Hepatitis B surface antigen (HBsAg) negative within 30 days prior to entry.
• Female study volunteers of reproductive potential have a negative serum or urine pregnancy test performed within 72 hours prior to entry.
• All study volunteers agree not to participate in a conception process (eg, active attempt to become pregnant or to impregnate, sperm donation, in vitro fertilization) for study duration. If participating in sexual activity that could lead to pregnancy, must agree to use two reliable forms of contraceptive simultaneously while receiving protocol-specified medications. One form of contraceptive must be a barrier method if a participant receives EFV. Participants must agree to continue the use of two contraceptives for 6 months after stopping EFV and 6 weeks after stopping all other protocol-specified medications.
• Study volunteers who are not of reproductive potential are eligible without requiring the use of a contraceptive.
• Ability and willingness of participant or legal guardian/representative to provide informed consent.
• Willing and able to return to the clinic twice to three times a day for study visits.

Exclusion Criteria:

Step 1: Exclusion Criteria

• Previous history or current use of ART.
• Single dose NVP or dual therapies used for Prevention of mother-to-child transmission (PMTCT) within 2 years prior to entry.
• Use of any medication with antimalarial activity, including TMP/SMX (see list of prohibited medications in the A5297 Manual of Procedures (MOPS)), within 14 days prior to study entry.
• Confirmed or clinically suspected OIs (including but not limited to tuberculosis, clinical malaria, PCP), or other pulmonary or gastrointestinal infections for which potential participants did not complete treatment more than 30 days prior to enrollment or have signs and symptoms during screening.
• Breastfeeding.
• Known allergy/sensitivity or any hypersensitivity to components of study drugs or their formulation.
• Active drug or alcohol use or dependence that, in the opinion of the site investigator, would interfere with adherence to study requirements.
• Serious illness requiring systemic treatment and/or hospitalization within 30 days prior to entry.
• Results suggestive of active pulmonary disease from a chest x-ray performed within 30 days prior to study entry.

Study Plan

How is the study designed?

Design Details

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

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: LPV/r-based ART; Participants were prescribed to LPV/r-based antiretroviral therapy (ART) for 15 days, which includes lopinavir/ritonavir plus emtricitabine/tenofovir disoproxil fumarate; followed by an nNRTI-based ART, which includes efavirenz, nevirapine, plus emtricitabine/tenofovir disoproxil fumarate, and Trimethoprim/sulfamethoxazole prophylaxis to take from day 16 through day 30.	Drug: Lopinavir/ritonavir; Participants received two 200 mg/50 mg tablets of lopinavir/ritonavir orally twice daily.; Other Names: LPV/r; Drug: Emtricitabine/tenofovir disoproxil fumarate; Participants received one 200 mg/300 mg tablet of Emtricitabine/tenofovir disoproxil fumarate orally once daily.; Other Names: FTC/TDF; Drug: Efavirenz; Participants received one 600 mg tablet of efavirenz orally once daily.; Other Names: EFV; Drug: Nevirapine; If unable to take efavirenz, participants received on 200 mg tablet of nevirapine orally once daily.; Other Names: NVP; Drug: Trimethoprim/sulfamethoxazole; Participants received one 160 mg/800 mg tablet of trimethoprim/sulfamethoxazole orally once daily.; Other Names: TMP/SMX
Experimental: nNRTI-based ART; Participants were prescribed to nNRTI-based ART for 15 days, which includes efavirenz, nevirapine, plus emtricitabine/tenofovir disoproxil fumarate, followed by an nNRTI-based ART and Trimethoprim/sulfamethoxazole prophylaxis to take from day 16 through day 30.	Drug: Emtricitabine/tenofovir disoproxil fumarate; Participants received one 200 mg/300 mg tablet of Emtricitabine/tenofovir disoproxil fumarate orally once daily.; Other Names: FTC/TDF; Drug: Efavirenz; Participants received one 600 mg tablet of efavirenz orally once daily.; Other Names: EFV; Drug: Nevirapine; If unable to take efavirenz, participants received on 200 mg tablet of nevirapine orally once daily.; Other Names: NVP; Drug: Trimethoprim/sulfamethoxazole; Participants received one 160 mg/800 mg tablet of trimethoprim/sulfamethoxazole orally once daily.; Other Names: TMP/SMX

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Proportion of Participants With Plasmodium Falciparum (Pf) Subclinical Parasitemia (SCP) Clearance	Pf SCP clearance defined by polymerase chain reaction (PCR) < 10 parasites/µL on three consecutive occasions within a 24-hour period. If a participant had missing data on day 15, they were considered as not having clearance.	Day 15 (3 samples collected, separated by at least 5 hours and all three collected within 24-hours)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time to First Pf SCP Clearance	Time to clearance is defined by time to first measurement with PCR < 10 parasites/µL, and is evaluated as the point estimate and 95% CI for the day when 50% of participants cleared parasite.	From study entry up to day 30
Log10(Pf Parasite Density)	Pf parasite density was determined by PCR. If parasite density equals 0, the value is set to 0.01 before log10 transformation. The value 0.01 was chosen based on the smallest observed parasite density value of 0.017.	Entry, days 3, 6, 9, 12, 15, 20, 25, 30
Change in log10(Pf Parasite Density) From Entry to Day 30	Change is evaluated as log10(Pf parasite density) at day 30 minus log10(Pf parasite density) at entry. Change is evaluated in four groups: Randomized to nNRTI-based ART with continued Pf SCP at day 15; Randomized to nNRTI-based ART with clearance of Pf SCP at day 15; Randomized to LPV/r-based ART with continued Pf SCP at day 15; Randomized to LPV/r-based ART with clearance of Pf SCP at day 15	Entry, Day 30
Number of Participants With Uncomplicated Clinical Malaria	Uncomplicated clinical malaria is defined as the presence of non-severe fever/symptoms and parasitemia without organ complication.	From study entry to day 30
Number of Participants With Detectable Pf Gametocyte Density	Number of participants with detectable Pf gametocyte density as determined by PCR. Due to the large number of undetectable results, this outcome was measured as dichotomous.	Entry, days 3, 6, 9, 12, 15, 20, 25, 30
Change in log10(Pf Gametocyte Density) From Entry to Day 30	Change in log10(Pf gametocyte density) as evaluated using a Hodges-Lehmann estimate from entry to day 30 is evaluated in two groups: Randomized to nNRTI-based ART with continued Pf SCP at day 15; Randomized to LPV/r-based ART with continued Pf SCP at day 15 Analysis was not conducted in either group with clearance at day 15 due to the small sample size and high number of undetectable samples in both clearance groups at entry and day 30.	Entry, Day 30

Collaborators and Investigators

• Sponsor: AIDS Clinical Trials Group
• Collaborators: National Institute of Allergy and Infectious Diseases (NIAID)
• Investigators: Study Chair: Johnstone Kumwenda, FRCP, College of Medicine-Johns Hopkins Project; Study Chair: Douglas Shaffer, MD, MHS, Kenya Medical Research Institute/Walter Reed Project

Publications and helpful links

General Publications

• Shaffer D, Kumwenda J, Chen H, Akelo V, Angira F, Kosgei J, Tonui R, Ssali F, McKhann A, Hogg E, Stewart VA, Murphy SC, Coombs R, Schooley R; A5297 Team. Brief Report: No Differences Between Lopinavir/Ritonavir and Nonnucleoside Reverse Transcriptase Inhibitor-Based Antiretroviral Therapy on Clearance of Plasmodium falciparum Subclinical Parasitemia in Adults Living With HIV Starting Treatment (A5297). J Acquir Immune Defic Syndr. 2022 Feb 1;89(2):178-182. doi: 10.1097/QAI.0000000000002839.

Helpful Links

• DAIDS Table for Grading the Severity of Adult and Pediatric Adverse Events (DAIDS AE Grading Table), Version 1.0, December 2004
• Manual for Expedited Reporting of Adverse Events to DAIDS (DAIDS EAE Manual), Version 2.0, January 2010

Study record dates

Study Major Dates

• Study Start (Actual): January 10, 2014
• Primary Completion (Actual): June 19, 2016
• Study Completion (Actual): June 19, 2016

Study Registration Dates

• First Submitted: June 29, 2012
• First Submitted That Met QC Criteria: June 29, 2012
• First Posted (Estimate): July 3, 2012

Study Record Updates

• Last Update Posted (Actual): August 6, 2019
• Last Update Submitted That Met QC Criteria: July 23, 2019
• Last Verified: July 1, 2019

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Pathologic Processes; Infections; Systemic Inflammatory Response Syndrome; Inflammation; Sepsis; Parasitic Diseases; Parasitemia; Molecular Mechanisms of Pharmacological Action; Anti-Infective Agents; Antiviral Agents; Reverse Transcriptase Inhibitors; Nucleic Acid Synthesis Inhibitors; Enzyme Inhibitors; Anti-HIV Agents; Anti-Retroviral Agents; Protease Inhibitors; Cytochrome P-450 CYP3A Inhibitors; Cytochrome P-450 Enzyme Inhibitors; Cytochrome P-450 Enzyme Inducers; Antiprotozoal Agents; Antiparasitic Agents; Cytochrome P-450 CYP3A Inducers; HIV Protease Inhibitors; Viral Protease Inhibitors; Antimalarials; Folic Acid Antagonists; Cytochrome P-450 CYP2B6 Inducers; Cytochrome P-450 CYP2C9 Inhibitors; Anti-Dyskinesia Agents; Anti-Infective Agents, Urinary; Renal Agents; Cytochrome P-450 CYP2C19 Inhibitors; Cytochrome P-450 CYP2C8 Inhibitors; Tenofovir; Emtricitabine; Nevirapine; Ritonavir; Lopinavir; Emtricitabine, Tenofovir Disoproxil Fumarate Drug Combination; Efavirenz; Trimethoprim; Sulfamethoxazole
• Other Study ID Numbers: ACTG A5297; 1U01AI068636 (U.S. NIH Grant/Contract)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No