The Intensified Treatment Monitoring Strategy to Prevent Accumulation of Drug Resistance (ITREMA) Trial (ITREMA)

Evaluation of an Intensified Treatment Monitoring Strategy to Prevent Accumulation and Spread of HIV-1 Drug Resistance in Low- and Middle-income Countries (ITREMA).

The ITREMA trial is an open-label randomized controlled trial (RCT) in which HIV-1 infected patients initiating first-line ART and already on first-line ART will be enrolled. Enrollment will continue until 600 patients have been randomized. Patients initiating ART will be randomized after six months of ART and patients already on ART will be randomized at 6 months after the last viral load measurement. Patients in both arms will receive study visits every three months for a total follow-up duration of 18 months after randomization to either of two study arms. The control arm will receive standard of care HIV-1 treatment monitoring during first-line ART in accordance with South African National Department of Health (NDoH) guidelines. The intervention arm will receive intensified treatment monitoring during first-line ART according to the treatment monitoring strategy under investigation.

Study Overview

• Status: Completed
• Conditions: HIV/AIDS
• Intervention / Treatment: Other: Standard of care monitoring; Other: Intensified monitoring

Detailed Description

This study will enroll adult HIV-1 infected patients who are about to initiate or have already initiated first-line ART. Patient enrollment and randomization will be performed at two different time points. Timing and criteria for enrollment and randomization are as follows:

1. ART naïve patients: Patients are eligible for enrollment initiation of treatment with first-line ART. Randomization is performed after availability of the first routine viral load measurement, performed at month 6 of treatment.
2. Patients on ART: Patients are eligible for enrollment after ≥ 1 year of virologically suppressive first-line ART and only if a last viral load with a result <1000 copies/mL was performed within the last 6 months. Randomization is performed 6 months after the last viral load (VL) result.

A total number of 600 patients will be randomized into two trial arms. The trial will be conducted on-site at one of the clinical facilities of Ndlovu Care Group (http://www.ndlovucaregroup.co.za/), one of the partners in the project. This facility, Ndlovu Medical Centre, is situated in the town of Elandsdoorn, Limpopo, South Africa, and provides medical service to local South African patients who are unable to pay medical insurance. The Ndlovu Care Group distributes antiretroviral medication in the framework of the South African Department of Health antiretroviral treatment programme. This clinic is currently providing ART to >3600 patients. Patients on ART return to the clinic monthly for collection of medication, pill count and adherence counselling, which allows intensification of monitoring without substantial change of the infrastructure or frequency of visits.

After randomisation, patients in both study arms will return for study follow-up visits on a three-monthly basis, at month 9, 12, 15, 18, 21 and 24 after start of ART or after the last VL measurement. In addition, patients will be called back for additional study visits (max. 2) in case of a detected viral load >1000 copies/ml during any of these visits. All visits in both arms, including aforementioned additional call back visits will coincide with standard of care medication collection visits to the clinic. In case of a switch to second-line therapy, patients in both arms will continue three-monthly follow-up visits in an observational manner, and guidelines for monitoring of second-line therapy are followed.

Control arm:

300 patients randomly assigned to this arm will be monitored in full concordance with current South African NDoH guidelines in use at the study site. Viral load measurements will be performed at month 12 and 24 after start of ART (for newly initiated patients) or at month 12 and 24 after the last viral load measurement (patients already on ART). If a viral load >1000 copies/ml is detected, the patient is called back for counseling for therapy adherence and repeat viral load measurement, 2 months after the initial viral load measurement. If the repeat viral load measurement is >1000 copies/ml after adherence counseling, this is taken to be indicative of therapy failure due to development of drug resistance and a switch to second line therapy is made, together with intensified adherence counseling, without verifying the cause of virological failure by performing drug level testing or drug resistance testing. If viral load drops to <1000 copies/ml after adherence counseling, the first line treatment is maintained.

Intervention arm:

300 patients randomly assigned to this arm will be monitored using the investigational intensified monitoring strategy. This strategy consists of 3-monthly viral load monitoring at month 9, 12, 15, 18, 21 and 24 (after start of ART in initiating patients or after the last viral load measurement in patients on ART). If a viral load measurement > 1000 copies/mL is detected, the patient will be called back for a follow-up study visit at the next monthly medication collection visit (4 weeks after detection of elevated viral load). Upon arrival drug level testing is performed, the viral load measurement is repeated, and a dried blood spot prepared and stored at room temperature. Procedures following this depend on the result of drug level testing:

• If drug levels are detected by drug level testing, the result of the viral load measurement is awaited. If the repeat viral load is >1000 copies/ml, the dried blood spot is shipped directly by courier to the World Health Organization (WHO) reference laboratory for drug resistance testing. The reference laboratory will provide feedback by means of a digital resistance report to the coordinating research physician. The patient will be called back for a second follow-up study visit at the next monthly medication visit (8 weeks after detection of elevated viral load), either for prescription of second-line therapy or continuation of first-line therapy, guided by the result of resistance testing.
• If drug level monitoring at the first follow-up visit indicates that drug levels are not detected, intensified counseling is performed at the same visit and first-line therapy will be maintained, regardless of the result of the repeat viral load measurement. The patient will not be called back and the next viral load will be performed at the next scheduled three-monthly time point. However, if the viral load result at this visit is again >1000 copies/ml, drug resistance testing will be performed regardless of the outcome of drug level testing.

• Study Type: Interventional
• Enrollment (Actual): 501
• Phase: Not Applicable

Contacts and Locations

Study Locations

• South Africa
  • Limpopo
    • Elandsdoorn, Limpopo, South Africa, 0485
      • Ndlovu Medical Centre

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 infected male or female patients
• For ART Naïve patients: Eligible for and intending to initiate ART at the clinical site
• For patients on ART: On ART ≥1 year. Last VL <6 months ago and <1000 copies/mL
• ≥18 years of age
• Able to understand and willing to give informed consent

Exclusion Criteria:

• Any serious unstable medical condition at study baseline
• Any criteria that in the opinion of the investigator indicate that the patient is unable to participate in the full study.

Study Plan

How is the study designed?

Design Details

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

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Control; Standard of Care monitoring	Other: Standard of care monitoring; Standard-of-care virological monitoring during first-line ART as described by WHO and South African National Department of Health ART guidelines, consisting of viral load monitoring at month 6 and 12 of ART and annually thereafter, followed-up by a repeat measurement within 3 months after a viral load >1000 copies/mL, during first-line antiretroviral treatment (ART) for HIV-1 infection as prescribed by South African national guidelines.
Experimental: Intervention; Intensified monitoring	Other: Intensified monitoring; Intensified virological monitoring during first-line ART with viral load monitoring at month 6 of ART and 3-monthly thereafter, followed-up consecutively by point-of-care qualitative drug level testing and drug resistance testing in case of a viral load >1000 copies/mL, during first-line antiretroviral treatment (ART) for HIV-1 infection as prescribed by South African national guidelines.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Drug resistance	Prevalence of drug resistance in patients with therapy failure in each arm	week 48
Drug resistance	Prevalence of drug resistance in patients with therapy failure in each arm	week 96
Unnecessary treatment switches	Number of virological failure cases without drug resistance in the intervention arm (averted unnecessary treatment switches) versus in the control arm (unnecessary treatment switches)	week 48
Unnecessary treatment switches	Number of virological failure cases without drug resistance in the intervention arm (averted unnecessary treatment switches) versus in the control arm (unnecessary treatment switches)	week 96

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time on failing regimen	Time during which viremia > 1000 copies/mL is maintained after the first instance of a viral load >1000 copies/ml	week 96
Loss of second line therapeutic options over time	The loss of second line therapeutic options over time due to accumulation of resistance mutations in the presence of a failing regimen.	week 96
Influence of genotypic resistance testing	Influence of genotypic resistance testing on the choice for a second line regimen by comparing chosen regimens in the intervention and control groups.	week 96

Collaborators and Investigators

• Sponsor: UMC Utrecht
• Collaborators: ZonMw: The Netherlands Organisation for Health Research and Development; Wits Reproductive Health and HIV Institute; Ndlovu Care Group
• Investigators: Principal Investigator: Annemarie MJ Wensing, MD, PhD, UMC Utrecht

Publications and helpful links

General Publications

• Hermans LE, Nijhuis M, Tempelman HA, Houts T, Schuurman R, Burger DM, Wensing AMJ, ter Heine R. Point-of-Care Detection of Nonadherence to Antiretroviral Treatment for HIV-1 in Resource-Limited Settings Using Drug Level Testing for Efavirenz, Lopinavir, and Dolutegravir: A Validation and Pharmacokinetic Simulation Study. J Acquir Immune Defic Syndr. 2021 Aug 1;87(4):1072-1078. doi: 10.1097/QAI.0000000000002681.

Study record dates

Study Major Dates

• Study Start (Actual): June 29, 2015
• Primary Completion (Actual): March 1, 2019
• Study Completion (Actual): May 1, 2022

Study Registration Dates

• First Submitted: September 28, 2017
• First Submitted That Met QC Criteria: November 23, 2017
• First Posted (Actual): November 30, 2017

Study Record Updates

• Last Update Posted (Actual): May 11, 2022
• Last Update Submitted That Met QC Criteria: May 10, 2022
• Last Verified: May 1, 2022

More Information

Terms related to this study

• Additional Relevant MeSH Terms: RNA Virus Infections; Virus Diseases; Infections; Blood-Borne Infections; Communicable Diseases; Sexually Transmitted Diseases, Viral; Sexually Transmitted Diseases; Lentivirus Infections; Retroviridae Infections; Immunologic Deficiency Syndromes; Immune System Diseases; Slow Virus Diseases; HIV Infections; Acquired Immunodeficiency Syndrome
• Other Study ID Numbers: 69/2015

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No