PK Study of Rifampicin Interactions With DMPA and Efavirenz in TB (PRIDE-HT)

An Open-Label, Non-Randomized Study of Pharmacokinetic Interactions Among Depot Medroxyprogesterone Acetate (DMPA), Rifampicin (RIF), and Efavirenz (EFV) in Women Co-infected With Human Immunodeficiency Virus (HIV) and Tuberculosis (TB)

This study was done to evaluate the effect of HIV and TB treatment on a commonly used birth control method. It enrolled women who were infected with HIV and TB and were taking efavirenz (EFV; Sustiva®; an anti-HIV medication), rifampicin (RIF; an anti-TB medication), and isoniazid (INH; an anti-TB medication). The purpose of this study was to find out the best frequency to give depot medroxyprogesterone acetate (DMPA; a hormonal birth control method that is given as a shot every 3 months) in these women. This study also tried to find out if a 150 mg injection of DMPA was effective in preventing ovulation, the process by which the ovaries (the ovaries are part of the female reproductive system) release an egg for fertilization, for 12 weeks in women who are taking EFV and RIF. Another purpose of this study was to find out if it is safe to take RIF, EFV and DMPA at the same time.

Study Overview

• Status: Completed
• Conditions: Tuberculosis; HIV-1 Infection
• Intervention / Treatment: Drug: Depot medroxyprogesterone acetate

Detailed Description

Globally, women comprise 52% of all people living with human immunodeficiency virus (HIV). Decisions about contraception in a population of women infected with both tuberculosis (TB) and HIV are of paramount importance. In the setting of the treatment of active TB, preventing pregnancy becomes even more important because it allows women to attain a level of health that will support healthy future pregnancies. Treatment options for TB may be limited in pregnancy because of concerns about teratogenicity. Millions of women around the world use depot medroxyprogesterone acetate (DMPA, trade name Depo-Provera) for prevention of pregnancy. DMPA is an intermediate-acting progesterone-only injectable contraceptive with a high efficacy rate. Unfortunately, DMPA's safety and effectiveness among women co-infected with TB and HIV is unknown since the interactions of TB treatment, combination ART (cART), and DMPA have not been well studied. The results of this study are likely to be applicable to women receiving RIF-containing TB treatment who are not being treated concurrently with EFV as well, given that addition of EFV to RIF is unlikely to increase induction of metabolizing enzymes significantly beyond the induction achieved with RIF alone.

The study population included premenopausal women, 18 to 46 years of age, who were co-infected with HIV and TB. To be eligible to enroll in the study, participants must have been on EFV 600 mg once daily plus two or more nucleoside reverse transcriptase inhibitors (NRTIs) for at least 28 days prior to study entry with no plans to change therapy for the 12 weeks of the study. Women must have been on the continuation phase of active TB treatment (with a minimum of 12 weeks remaining) taking RIF 8-12 mg/kg orally and INH 4-6 mg/kg orally on a 5-day or more per week schedule (or as directed by national guidelines for TB treatment). At study entry/week 0, DMPA 150 mg was administered intramuscularly as a single dose.

Study duration was 12 weeks. Visits occurred at weeks 0, 2, 4, 6, 8, 10, and 12. The key evaluations included physical examination, clinical assessments, hematology, chemistry, HIV RNA, pregnancy testing, plasma progesterone levels, and plasma DMPA concentration levels.

The sample size was 46 participants, of which 42 had to be evaluable. Participants who missed two successive visits prior to week 8 and those who did not complete the week 10 and week 12 clinic visits with available DMPA concentrations and progesterone levels were not evaluable and replaced in the sample size. The final number of participants enrolled was 62 participants, with only 42 evaluable.

• Study Type: Interventional
• Enrollment (Actual): 62
• Phase: Phase 2

Contacts and Locations

Study Locations

• Botswana
  • Gaborone, Botswana
    • Gaborone Prevention/Treatment Trials CRS (12701)
• Kenya
  • Kisumu, Kenya, 40100
    • Kenya Medical Research Institute/Center for Disease Control (KEMRI/CDC) CRS (31460)
• South Africa
  • Durban, South Africa, 4013 SF
    • Durban Adult HIV CRS (11201)
  • Johannesburg, South Africa
    • Univ. of Witwatersrand CRS (11101)
• Zimbabwe
  • Harare, Zimbabwe
    • UZ-Parirenyatwa CRS (30313)

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years to 44 years (Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

• HIV-1 infection.
• Current tuberculosis infection, confirmed or probable diagnosis.
• Currently stable on EFV-based cART for at least 28 days with no intention to change the regimen during the 12-week study period.
• Currently receiving RIF and Isoniazid (INH)-based TB therapy on at least 5 days per week schedule after completion of the intensive phase of TB treatment (minimum of 8 weeks of TB treatment) and expected to be on TB treatment for a minimum of 12 weeks after enrollment. [Does not exclude the use of ethambutol on study.]
• Premenopausal female with presumed normal ovarian function based on normal menstrual history and absence of previous ovarian dysfunction diagnosis.
• Last menstrual period (LMP) ≤35 days prior to study entry.
• Negative serum or urine-HCG pregnancy test within 30 days prior to study entry and negative pregnancy test at entry at any network-approved laboratory that operates in accordance with Good Clinical Practices and participates in appropriate external quality assurance programs.

• All participants must agree not to participate in a conception process (e.g., active attempt to become pregnant or in vitro fertilization) for the duration of the study. Women of reproductive potential, who are participating in sexual activity that could lead to pregnancy, must agree to use an additional reliable method of contraception while in the study. Acceptable forms of contraceptives include:

  • Condoms (male or female) with or without a spermicidal agent
  • Diaphragm or cervical cap with spermicide
  • Non-hormonal IUD
  • Bilateral tubal ligation
  • Male partner vasectomy

• Laboratory values within 30 days prior to study entry:

  • Absolute neutrophil count ≥500 cells/mm^3
  • Platelet count ≥50,000 platelets/mm^3
  • Hemoglobin ≥8.0 g/dL
  • Aspartate transaminase (AST) and alanine aminotransferase (ALT) <5 x upper limit of normal (ULN)
  • Creatinine ≤1.5 x ULN
  • Total bilirubin ≤2.0 x ULN
• Ability and willingness to provide written informed consent.

Exclusion Criteria:

• Receipt of DMPA or any other injectable contraceptive within 180 days prior to study entry.
• Receipt of other hormonal contraceptives within 30 days prior to study entry.
• Use of any drugs other than RIF and EFV known to: 1) induce CYP3A4 system within 30 days and to 2) inhibit the CYP3A4 system with one week prior to study entry. [Because ethambutol does not induce or inhibit the CYP3A4 system, its use is consistent with the language in the protocol.]
• ≤40 kg in weight.
• Bilateral oophorectomy.
• Less than 30 days postpartum at study entry.
• Hypersensitivity to DMPA, medroxyprogesterone acetate (MPA), or any of the other ingredients in DMPA.
• Any previous breast cancer diagnosis.
• Serious illness requiring systemic treatment and/or hospitalization within 21 days prior to study entry.
• Karnofsky performance score <70 within 14 days prior to study entry.
• Use of any immunosuppressant medication including systemic corticosteroids within 30 days prior to study entry.
• Active drug or alcohol use or dependence that, in the opinion of the site investigator, would interfere with adherence to study requirements.
• History of deep venous thrombosis or pulmonary emboli.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Arm A: Depot medroxyprogesterone acetate; At study entry/week 0, participants received depot medroxyprogesterone acetate (DMPA) 150 mg administered intramuscularly as a single dose and co-administered with rifampicin (RIF) and efavirenz (EFV).	Drug: Depot medroxyprogesterone acetate; Depot medroxyprogesterone acetate intramuscular injection; Other Names: DMPA

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percent of Participants With DMPA Concentrations Below 0.1 ng/mL at Week 12	The percent of participants with plasma DMPA concentrations below 0.1 ng/mL was calculated with an exact Clopper-Pearson 95% confidence interval. Suppression of ovulation generally occurs as long as the DMPA level is => 0.1 ng/mL.	Week 12
Percent of Participants With Progesterone Levels Above 1 ng/mL at Week 12	The percent of participants with plasma progesterone levels above 1 ng/mL was calculated with an exact Clopper-Pearson 95% confidence interval. Ovulation generally occurs when the progesterone level is > 5 ng/mL. If there were participants with plasma progesterone levels > 1 ng/mL, then the percent of participants with plasma progesterone levels > 5 ng/mL would have been calculated by study week.	Week 12

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percent of Participants With DMPA Concentrations Below 0.1 ng/mL at Weeks 2, 4, 6, 8, and 10	The percents of participants with plasma DMPA concentrations below 0.1 ng/mL at weeks 2, 4, 6, 8, and 10 were calculated with exact Clopper-Pearson 95% confidence intervals. Suppression of ovulation generally occurs as long as the DMPA level is => 0.1 ng/mL.	Weeks 2, 4, 6, 8, and 10
Cumulative Percentage of Participants With DMPA < 0.1 ng/mL	The cumulative percentage of participants having a DMPA concentration less than 0.1 ng/mL at week 12 was calculated using a Kaplan-Meier estimator with an associated standard error. The confidence interval was calculated using a log-log transformation. Suppression of ovulation generally occurs as long as the DMPA level is => 0.1 ng/mL.	Weeks 0, 2, 4, 6, 8, 10, and 12
DMPA AUC	Describe the DMPA plasma area under the curve (AUC) between 0 and 12 weeks, where AUC(0-12wks) was calculated using non-compartmental methods.The Week 0 time point was drawn prior to DMPA injection.	Weeks 0, 2, 4, 6, 8, 10, and 12
DMPA Cmin	Describe the DMPA minimum observed concentration (Cmin) between 0 and 12 weeks. The Week 0 time point was drawn prior to DMPA injection.	Weeks 0, 2, 4, 6, 8, 10, and 12
DMPA Cmax	Describe the DMPA maximum observed concentration (Cmax) between 0 and 12 weeks. The Week 0 time point was drawn prior to DMPA injection.	Weeks 0, 2, 4, 6, 8, 10, and 12
DMPA CL/F	Describe the apparent DMPA clearance (CL/F) between 0 and 12 weeks. The Week 0 time point was drawn prior to DMPA injection.	Weeks 0, 2, 4, 6, 8, 10, and 12
Percent of Participants Who Experienced a Grade 3 or Higher Sign/Symptom or Laboratory Abnormality	The percent of participants who experienced a grade 3 (severe) or higher sign/symptom or laboratory abnormality were calculated with an exact Clopper-Pearson 95% confidence interval. Events were graded (1=mild, 2=moderate, 3=severe, 4=life-threatening, 5=death) according to the DAIDS AE Grading Table (V1.0).	Weeks 2, 4, 6, 8, 10, and 12
DMPA Half-life	Describe the terminal elimination half-life of DMPA (t½) between 0 and 12 weeks, where t½ was calculated using nonlinear mixed-effects (NLME) modelling. The Week 0 time point was drawn prior to DMPA injection.	Weeks 0, 2, 4, 6, 8, 10, and 12
Time at Which Participant-specific Estimated Elimination Slopes for DMPA Level Cross the Threshold of 0.1 ng/mL	Describe the time at which DMPA levels drop below the threshold of 0.1 ng/mL, based on participant-specific estimated elimination slopes from nonlinear mixed-effects (NLME) models. The Week 0 time point was drawn prior to DMPA injection.	Weeks 0, 2, 4, 6, 8, 10, and 12

Collaborators and Investigators

• Sponsor: AIDS Clinical Trials Group
• Collaborators: National Institute of Allergy and Infectious Diseases (NIAID)
• Investigators: Study Chair: Rosie Mngqibisa, MBChB, MPH, Durban Adult HIV CRS; Study Chair: Susan E. Cohn, MD, MPH, Northwestern University; Study Chair: Jennifer Robinson, MD, MPH, Johns Hopkins University

Publications and helpful links

General Publications

• Haas DW, Mngqibisa R, Francis J, McIlleron H, Robinson JA, Kendall MA, Baker P, Mawlana S, Badal-Faesen S, Angira F, Omoz-Oarhe A, Samaneka WP, Denti P, Cohn SE; AIDS Clinical Trials Group A5338 Study Team. Pharmacogenetics of interaction between depot medroxyprogesterone acetate and efavirenz, rifampicin, and isoniazid during treatment of HIV and tuberculosis. Pharmacogenet Genomics. 2022 Jan 1;32(1):24-30. doi: 10.1097/FPC.0000000000000448.
• Mngqibisa R, Kendall MA, Dooley K, Wu XS, Firnhaber C, Mcilleron H, Robinson J, Cramer Y, Rosenkranz SL, Roa J, Coughlin K, Mawlana S, Badal-Faesen S, Schnabel D, Omoz-Oarhe A, Samaneka W, Godfrey C, Cohn SE; A5338 Study Team. Pharmacokinetics and Pharmacodynamics of Depot Medroxyprogesterone Acetate in African Women Receiving Treatment for Human Immunodeficiency Virus and Tuberculosis: Potential Concern for Standard Dosing Frequency. Clin Infect Dis. 2020 Jul 27;71(3):517-524. doi: 10.1093/cid/ciz863.

Helpful Links

• DAIDS Table for Grading the Severity of Adult and Pediatric Adverse Events (DAIDS AE Grading Table), Version 1.0, December 2004; Clarification, August 2009
• 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): November 3, 2015
• Primary Completion (Actual): June 15, 2017
• Study Completion (Actual): June 15, 2017

Study Registration Dates

• First Submitted: March 17, 2015
• First Submitted That Met QC Criteria: April 6, 2015
• First Posted (Estimate): April 9, 2015

Study Record Updates

• Last Update Posted (Actual): July 1, 2019
• Last Update Submitted That Met QC Criteria: June 13, 2019
• Last Verified: June 1, 2019

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Infections; Bacterial Infections; Bacterial Infections and Mycoses; Gram-Positive Bacterial Infections; Actinomycetales Infections; Mycobacterium Infections; Tuberculosis; Physiological Effects of Drugs; Antineoplastic Agents; Antineoplastic Agents, Hormonal; Contraceptive Agents, Hormonal; Contraceptive Agents; Reproductive Control Agents; Contraceptives, Oral; Contraceptive Agents, Female; Contraceptives, Oral, Synthetic; Contraceptives, Oral, Hormonal; Contraceptive Agents, Male; Medroxyprogesterone Acetate; Medroxyprogesterone
• Other Study ID Numbers: ACTG A5338; UM1AI068636 (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