Human Immunodeficiency Virus
Conditions
Keywords
HIV
Brief summary
A randomised controlled trial to investigate three methods to reduce early mortality in adults, adolescents and children aged 5 years or older starting antiretroviral therapy (ART) with severe immuno-deficiency. The three methods are: (i) increasing the potency of ART with a 12 week induction period using 4 antiretroviral drugs from 3 classes (ii) augmented prophylaxis against opportunistic/bacterial infections and helminths for 12 weeks (iii) macronutrient intervention using ready-to-use supplementary food for 12 weeks.
Detailed description
REALITY is a open-label randomised trial of 1800 adults, adolescents and children aged 5 years or more with low CD4 counts about to initiate ART. The trial will have a factorial design with 3 randomisations, each to address one of the potential approaches to reduce early mortality in adults and children initiating ART with low CD4, namely: 1. Raltegravir for 12 weeks from ART initiation in addition to 3 standard ART (3-drug 2-class) versus standard of care first-line 3-drug 2-class ART (choice according to national guidelines for ART initiation); 2. Immediate enhanced opportunistic infections (OI) prophylaxis with isoniazid/pyridoxine and cotrimoxazole, plus 12 weeks fluconazole, 5 days azithromycin and a single dose of albendazole versus cotrimoxazole prophylaxis alone for the first 12 weeks followed by isoniazid and any prophylaxis and/or treatment prescribed at screening 3. supplementation with Ready to Use Supplementary Food (RUSF) for 12 weeks versus standard of care nutritional support to those with poor nutritional status according to local guidelines. All participants will receive cotrimoxazole throughout the trial. The primary objective of the trial is to identify effective, safe and acceptable interventions to reduce early mortality (all-cause) in HIV-infected adults, adolescents, and older children (5 years or more) initiating ART.
Interventions
DRUGRaltegravir
400mg twice daily for the first 12 weeks only in addition to 3 standard ARVs
DRUGFluconazole
100mg once daily for 12 weeks
DRUGAzithromycin
500mg once daily for 5 days
DRUGAlbendazole
a single dose 400mg
DRUGIsoniazid
300mg taken immediately in combination with cotrimoxazole
DIETARY_SUPPLEMENTReady to Use Supplementary Food
2x92g packets daily of high energy, low protein lipid-based paste for 12 weeks
Sponsors
Department for International Development, United Kingdom
Wellcome Trust
Medical Research Council
PENTA Foundation
Anna Griffiths, MRC
Study design
Allocation
RANDOMIZED
Intervention model
FACTORIAL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
5 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Aged 5 years or older * Documented HIV infection by HIV ELISA or HIV rapid test * Naive to ART * CD4 T-cell count \<100 cells/mm3 on blood test taken at screening for REALITY * Results of screening haematology and biochemistry tests available and no contraindications to planned ART according to national guidelines * Patient/carer provide informed consent (and children \<18 years assent, as appropriate according to their age and knowledge of HIV status) The lower age limit is because CD4 counts are less reliable predictors of immunodeficiency under 5 years: CD4 counts are recommended by guidelines in older children. No patient with a CD4 count above 100 cells/mm3 should have ART delayed in order to subsequently meet eligibility criteria. Rather, patients eligible for REALITY will be those testing HIV positive for the first time with a low CD4 count (i.e. those delaying presentation to care), or those who have defaulted before initiating ART and only return to care at an advanced stage of immuno-deficiency.
Exclusion criteria
* Contraindications to any proposed antiretroviral drugs (including integrase inhibitors), isoniazid, fluconazole, albendazole or azithromycin * Pregnant or breastfeeding or intending to become pregnant during the first 12 weeks of the study * Ever known to have previously received single-dose nevirapine for prevention of mother-to-child transmission (mother or child).
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| All-cause mortality over the first 24 weeks after starting ART | Week 24 |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Endpoint relating to anti-infection intervention | 0-48 weeks | Incidence of tuberculosis (TB), cryptococcal and candida disease, severe bacterial infections |
| Endpoint relating to anti-malnutrition intervention | 0-48 weeks | BMI, weight and body fat assessed by bioimpedance analysis (BIA), height (in children) and grip strength |
| Adherence to ART and acceptability of each strategy | Week 0-48 | Adherence to ART, OI drugs and RUSF will be assessed in all participants at each visit by pill counts and short nurse-administered questions. Every 12 weeks, a more detailed adherence questionnaire will be adminstered. |
| Endpoint relating to anti-HIV intervention | 0-48 weeks | Changes in CD4 cell count |
| Safety | Week 0-48 | * serious adverse events * grade 4 adverse events * adverse events leading to modification of ART or other study drugs |
| Hospital inpatient episodes and total days admitted | Week 0-48 | — |
| 48 week mortality (all-cause) | Week 48 | — |
Countries
Kenya, Malawi, Uganda, Zimbabwe
Outcome results
None listed