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).
研究概览
详细说明
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:
- 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.
- 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.
研究类型
注册 (实际的)
阶段
- 不适用
联系人和位置
学习地点
-
-
Limpopo
-
Elandsdoorn、Limpopo、南非、0485
- Ndlovu Medical Centre
-
-
参与标准
资格标准
适合学习的年龄
接受健康志愿者
有资格学习的性别
描述
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.
学习计划
研究是如何设计的?
设计细节
- 主要用途:其他
- 分配:随机化
- 介入模型:并行分配
- 屏蔽:无(打开标签)
武器和干预
参与者组/臂 |
干预/治疗 |
---|---|
有源比较器:Control
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.
|
实验性的:Intervention
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.
|
研究衡量的是什么?
主要结果指标
结果测量 |
措施说明 |
大体时间 |
---|---|---|
Drug resistance
大体时间:week 48
|
Prevalence of drug resistance in patients with therapy failure in each arm
|
week 48
|
Drug resistance
大体时间:week 96
|
Prevalence of drug resistance in patients with therapy failure in each arm
|
week 96
|
Unnecessary treatment switches
大体时间:week 48
|
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
大体时间:week 96
|
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
|
次要结果测量
结果测量 |
措施说明 |
大体时间 |
---|---|---|
Time on failing regimen
大体时间:week 96
|
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
大体时间:week 96
|
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
大体时间:week 96
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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
|
合作者和调查者
赞助
合作者
调查人员
- 首席研究员:Annemarie MJ Wensing, MD, PhD、UMC Utrecht
出版物和有用的链接
研究记录日期
研究主要日期
学习开始 (实际的)
初级完成 (实际的)
研究完成 (实际的)
研究注册日期
首次提交
首先提交符合 QC 标准的
首次发布 (实际的)
研究记录更新
最后更新发布 (实际的)
上次提交的符合 QC 标准的更新
最后验证
更多信息
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