INSTI's For The Management of HIV-associated TB (INSIGHT)

A Phase 2b Study to Evaluate the Efficacy, Safety and PK of a Combination of Bictegravir, Emtricitabine, and Tenofovir Alafenamide Fumarate for Treatment of HIV-1 Infection in Patients With DS-TB on a Rifampicin-based Regimen

This study is being conducted to assess the antiretroviral activity of a fixed-drug, single tablet, combination of Bictegravir 50mg/ Emtricitabine 200mg/ Tenofovir alafenamide 25mg (Biktarvy®) dosed twice daily in HIV-1 infected, ART-naïve patients with TB co-infection receiving a rifampicin-based tuberculosis (TB) treatment regimen. This study will assess the activity of Bictegravir and dolutegravir-containing ART regimens in patients with drug-susceptible TB through 48 weeks

Study Overview

• Status: Active, not recruiting
• Conditions: HIV/AIDS; Tuberculosis, Pulmonary
• Intervention / Treatment: Combination product: Biktarvy®; Combination product: TLD- fixed-drug combination single tablet

Detailed Description

Primary objective: To characterize viral suppression rates (proportion of patients with suppressed viral load) at week 24 in the BIC arm

Secondary objectives:

To characterize viral suppression rates at weeks 12, 24 and 48 in the standard of care treatment (SOC) arm (currently, TDF 300mg/3TC 300mg/DTG 50mg) and at weeks 12 and 48 in the BIC/FTC/TAF arm.

To compare the pharmacokinetics (PK) of BIC when given twice daily and co-administered with Rifampicin during tuberculosis treatment vs when given alone after discontinuation of Rifampicin

To assess the incidence of TB associated IRIS in each arm, through week 24.

To characterize the tolerability of treatment in each arm by assessing frequency of clinician-initiated treatment interruptions or switches through week 48.

To assess frequency of ART drug resistance mutations in participants with detectable viral load at study visit weeks 24 and 48.

• Study Type: Interventional
• Enrollment (Actual): 122
• Phase: Phase 2

Contacts and Locations

• Study Contact: Name: Smita Maharaj; Phone Number: 0510 +27316550510; Email: Smita.Maharaj@caprisa.org
• Study Contact Backup: Name: Resha Boodhram, MSc; Phone Number: 0669 +27316550669; Email: resha.boodhram@caprisa.org

Study Locations

• South Africa
  • KwaZulu-Natal
    • Durban, KwaZulu-Natal, South Africa, 4001
      • CAPRISA Springfield Clinical Research Site

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 105 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Adults ≥ 18 years of age with Karnofsky score ≥ 70
• Confirmed rifampicin-susceptible tuberculosis and/or
• On first-line rifampicin-based tuberculosis treatment (not > 8 weeks at the time of enrolment)
• Documented HIV-1 infection, ART-naïve OR ART non-naïve (patients to have no exposure to ART medication at least ≥ 3 months at the time of enrollment)
• Estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73m2
• Alanine aminotransferase (ALT) ≤3 times the upper limit of normal (ULN)
• Total bilirubin ≤2.5 times ULN
• Creatinine ≤2 times ULN
• Hemoglobin ≥ 7.0 g/dL (6.5 g/dL for females)
• Platelet count ≥ 50,000/mm3
• Absolute Neutrophil Count (ANC) ≥650/mm3
• Able and willing to provide written informed consent
• Female patients agree to use both a barrier and a non-barrier form of contraception during the study, starting at least 14 days prior to enrolment

Exclusion Criteria:

• Pregnancy or breastfeeding (or planned pregnancy within 12 months of study entry)
• Prior use of antiretroviral drugs for pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP) < 3 months at the time of enrolment
• Hepatitis B surface antigen positive OR Hepatitis B virus (HBV) infection OR active systemic infections (other than HIV-1 infection) requiring systemic antibiotic or antifungal therapy current or within 30 days prior to baseline that could, in the opinion of the investigator, interfere with study procedures or assessment of study outcomes
• Participants with a CD4+ cell count of < 50 cells/ μl
• Any verified Grade 4 laboratory abnormality, with the exception of, Grade 4 triglycerides. A single repeat test is allowed during the Screening period to verify a result
• Patients on metformin (> 500mg, 12hourly)
• Patients with an uncontrolled psychiatric co-morbidity. Patients who, in the investigator's judgment, pose a significant suicidality risk. Recent history of suicidal behavior and/or suicidal ideation may be considered as evidence of serious suicide risk
• Other condition or circumstance deemed by clinician/investigators to be detrimental to patient safety or study conduct
• Unwilling to be part of the main pharmacokinetic (PK) study and have PK blood draws done (NB there is a semi-intensive PK substudy which is optional)

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: BIC arm; The Intervention Arm ART regimen is a fixed-drug combination of a single tablet co-formulated regimen containing Bictegravir 50mg Emtricitabine 200mg and tenofovir alafenamide 25mg (BIC/FTC/TAF; Biktarvy®) that will be taken twice a day during rifampicin-containing TB treatment and 2 weeks after stopping TB treatment, thereafter the BIC/FTC/TAF single tablet co-formulation will be taken once daily.	Combination product: Biktarvy®; Biktarvy® is a fixed dose combination, single tablet containing bictegravir (BIC), emtricitabine (FTC), and tenofovir alafenamide (TAF) for oral administration. BIC is an integrase strand transfer inhibitor (INSTI). FTC, a synthetic nucleoside analog of cytidine, is an HIV nucleoside analog reverse transcriptase inhibitor (HIV NRTI). TAF, an HIV NRTI, is converted in vivo to tenofovir, an acyclic nucleoside phosphonate (nucleotide) analog of adenosine 5'-monophosphate. Each tablet contains 50 mg of BIC (equivalent to 52.5 mg of bictegravir sodium), 200 mg of FTC, and 25 mg of TAF (equivalent to 28 mg of tenofovir alafenamide fumarate) and the following inactive ingredients: croscarmellose sodium, magnesium stearate, and microcrystalline cellulose.
Active Comparator: DTG Arm; Dolutegravir 50mg /Lamivudine 300mg/ Tenofovir 300mg (TLD- fixed-drug combination single tablet) plus Dolutegravir 50mg evening dose during TB treatment and for two weeks after completion of TB treatment, then TLD once daily thereafter- as per Standard of Care (SOC)	Combination product: TLD- fixed-drug combination single tablet; Standard of care Dolutegravir-based regimen; Other Names: Dolutegravir 50mg /Lamivudine 300mg/ Tenofovir 300mg

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Viral suppression rate	Viral suppression rate (HIV-1 RNA <50 copies/mL) at week 24 in the BIC arm (using the FDA snapshot algorithm)	Week 24

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Viral suppression rates	Viral suppression rates (HIV-1 RNA <50 copies/mL) in the DTG arm and at 12 and 48 weeks in the BIC arm	At weeks 12, 24 and 48
BIC Drug concentrations ("Area under the plasma concentration versus time curve (AUC)"	BIC drug levels (AUC) when given twice daily and co-administered with Rifampicin vs. during TB treatment vs when given alone after TB treatment completion	Week 4, 8 12, 24, 32 and 40
BIC Drug concentrations [Peak Plasma Concentration (Cmax)]	BIC drug levels (Cmax) when given twice daily and co-administered with Rifampicin vs. during TB treatment vs when given alone after TB treatment completion	Week 4, 8 12, 24, 32 and 40
BIC Drug concentrations [Trough/Minimum Plasma Concentration Ctrough)	BIC drug levels ( Ctrough) when given twice daily and co-administered with Rifampicin vs. during TB treatment vs when given alone after TB treatment completion	Week 4, 8 12, 24, 32 and 40
The incidence of TB associated IRIS	To assess the incidence of TB associated IRIS in each arm	Through week 24
The tolerability of treatment in each arm	To characterize the tolerability of treatment in each arm by assessing frequency of clinician-initiated treatment interruptions or switches through week 48	Through week 48
Frequency of ART drug resistance mutations	To assess frequency of ART drug resistance mutations in participants with detectable viral load	study visit weeks 24 and 48.

Collaborators and Investigators

• Sponsor: Centre for the AIDS Programme of Research in South Africa
• Collaborators: Johns Hopkins University; National Institute of Allergy and Infectious Diseases (NIAID); University of Cape Town; Medical Research Council, South Africa
• Investigators: Principal Investigator: Anushka Naidoo, PhD, Centre for the AIDS Programme of Research in South Africa (CAPRISA); Study Director: Kogieleum Naidoo, PhD, Centre for the AIDS Programme of Research in South Africa; Principal Investigator: Kelly Dooley, MD, Vanderbilt University Medical Center

Publications and helpful links

General Publications

• Naidoo A, Dooley KE, Naidoo K, Padayatchi N, Yende-Zuma N, Perumal R, Dorse G, Boodhram R, Osuala EC. INSTIs for the management of HIV-associated TB (INSIGHT study): a phase 2b study to evaluate the efficacy, safety and pharmacokinetics of a combination of bictegravir, emtricitabine and tenofovir alafenamide fumarate for the treatment of HIV-1 infection in patients with drug-susceptible tuberculosis on a rifampicin-based treatment regimen: a phase 2b open-label randomised controlled trial. BMJ Open. 2022 Nov 10;12(11):e067765. doi: 10.1136/bmjopen-2022-067765.

Study record dates

Study Major Dates

• Study Start (Actual): February 18, 2022
• Primary Completion (Actual): January 19, 2024
• Study Completion (Estimated): August 31, 2024

Study Registration Dates

• First Submitted: January 11, 2021
• First Submitted That Met QC Criteria: January 29, 2021
• First Posted (Actual): February 2, 2021

Study Record Updates

• Last Update Posted (Actual): April 3, 2024
• Last Update Submitted That Met QC Criteria: April 2, 2024
• Last Verified: April 1, 2024

More Information

Terms related to this study

• Keywords: HIV/AIDS; Biktarvy® is a fixed dose combination; TLD- fixed-drug combination single tablet; Dolutegravir 50mg; Tuberculosis, Pulmonary
• Additional Relevant MeSH Terms: RNA Virus Infections; Virus Diseases; Infections; Respiratory Tract Infections; Respiratory Tract Diseases; Blood-Borne Infections; Communicable Diseases; Sexually Transmitted Diseases, Viral; Sexually Transmitted Diseases; Lentivirus Infections; Retroviridae Infections; Immunologic Deficiency Syndromes; Immune System Diseases; Lung Diseases; Bacterial Infections; Bacterial Infections and Mycoses; Gram-Positive Bacterial Infections; Actinomycetales Infections; Mycobacterium Infections; Slow Virus Diseases; Urogenital Diseases; Genital Diseases; HIV Infections; Tuberculosis; Acquired Immunodeficiency Syndrome; Tuberculosis, Pulmonary; 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; HIV Integrase Inhibitors; Integrase Inhibitors; Tenofovir; Lamivudine; Dolutegravir
• Other Study ID Numbers: CAPRISA 093; 1R01AI152142-01 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Data generated under this project will be shared in accordance with CAPRISA, and NIH-SAMRC policies, including the NIH Data Sharing Policy. Research data that documents, supports, and validates research findings will be made available after the main findings from the final research data set have been accepted for publication.
• IPD Sharing Time Frame: Not longer than 12 months after first publication of results. In accordance with WHO stipulations, summary results or a link to summary results will be reported within the trial registration record within 12 months of the study completion date.
• IPD Sharing Access Criteria: Access to databases and associated software tools generated under the project will be available for educational, research, and non-profit purposes from bona-fide researchers and/or research organisations.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL

Drug and device information, study documents

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