HIV-1-infection, Pregnancy Related
Conditions
Keywords
MTCT, Antiretroviral, Pregnancy, Africa
Brief summary
To evaluate dolutegravir (DTG) efficacy in women who present with untreated HIV in late pregnancy. An open-label, multi-centre randomised controlled trial of DTG vs efavirenz-based regimens for women commencing cART in late pregnancy. HIV positive pregnant women presenting with untreated HIV infection in late (≥28 weeks gestation) pregnancy will be randomised 1:1 to receive DTG (50mg once daily) + 2 nucleoside reverse transcriptase inhibitors (NRTIs) or EFV + 2 NRTIs (SoC)
Detailed description
This is an open-label, randomised controlled trial of DTG versus EFV -based regimens for 250 women commencing cART in late pregnancy, randomised 1:1 to DTG vs EFV-based cART. The purpose of this study is to inform treatment guidelines and for the first time specifically address the treatment needs of this group of women- hence the trial is powered for superiority over EFV. The primary endpoints is maternal VL at delivery, with secondary endpoints including safety and tolerability of DTG in both mother and infant, VL decline in breast milk, development of drug resistance, pharmacokinetics of DTG in mother-infant pairs, pharmacogenomics factors relating to efficacy or toxicity of DTG, and MTCT of HIV up to 72 weeks postpartum. Two sites have been selected - Infectious Diseases Institute, Makerere University, Kampala, Uganda and the University of Cape Town, South Africa - both have a strong track record of successfully delivering collaborative multidisciplinary research in PMTCT. Furthermore, health economics analysis to examine costs and cost-effectiveness of DTG in late-presenting pregnant women will be conducted The desired outcome of this project is to establish high quality evidence and operational guidance for use of DTG in late pregnancy. Late-presenting HIV-infected pregnant women are an important, but neglected group of vulnerable individuals in whom a randomised controlled intervention of HIV treatment has never previously been undertaken. This work will be done in relationship with WHO and the Clinton Health Access Initiative to ensure successful delivery of the project objectives.
Interventions
DRUGDolutegravir
Patients randomized to the study drug will be commenced on an antiretroviral regimen comprising DTG 50mg once daily in combination with 2 NRTIs
DRUGStandard of Care (EFV + 2 NRTI backbone)
Patients randomized to receive standard of care will receive the currently used antiretroviral regimens in keeping with national policy.
Sponsors
UNITAID
University of Cape Town
Liverpool School of Tropical Medicine
Infectious Diseases Institute, Uganda
Radboud University Medical Center
University of Liverpool
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
An open-label, multi-centre randomised controlled trial
Eligibility
Sex/Gender
FEMALE
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Evidence of a personally signed and dated informed consent document indicating that the participant has been informed of all pertinent aspects of the study. 2. Willing and able to comply with scheduled visits, treatment plan, laboratory tests, and other study procedures. 3. Women aged 18 years or older 4. Pregnant ( ≥28 weeks gestation by best available gestation estimation) 5. Untreated HIV infection in late pregnancy
Exclusion criteria
1. Received any antiretroviral drugs in previous 12 months 2. Ever received integrase inhibitors 3. Previous documented failure of an NNRTI-containing ART regimen, previous EFV-associated toxicity or other history of ARV use that would preclude randomisation based on investigator judgement 4. Serum haemoglobin \<8.0 g/dl 5. eGFR\<50 ml/min\* 6. Elevations in serum levels of alanine aminotransferase (ALT) \>5 times the upper limit of normal (ULN) or ALT \>3xULN and bilirubin \>2xULN (with \>35% direct bilirubin). 7. History or clinical suspicion of unstable liver disease (as defined by the presence of ascites, encephalopathy, coagulopathy, hyperbilirubinaemia, oesophageal or gastric varices or persistent jaundice). 8. Severe pre-eclampsia (e.g. HELLP), or other pregnancy related events such as renal or liver abnormalities (e.g. grade 2 or above proteinuria,, total bilirubin, ALT or AST)\* at the time of enrolment 9. Paternal objection for infant participation in DTG arm (where disclosure has taken - applies to Uganda site only 10. Medical, psychiatric or obstetric condition that might affect participation in the study based on investigator judgement 11. Receiving any of the following medications (current or within past 2 weeks): anti-epileptic drugs, TB therapy, or other drugs known to significantly interact with either DTG or EFV
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| HIV Viral Load at Delivery | by delivery | \<50 copies/ mL |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Plasma viral load | By delivery | \<1000 copies/ mL |
| Maternal viral load to 48 weeks | 48 weeks postpartum | Proportion \<50 and \<1000 copies/ mL |
| Maternal viral load to 72 weeks | 72 weeks postpartum | Proportion \<50 and \<1000 copies/ mL |
| Occurrence of MTCT | 48 weeks postpartum | Proportion of infants with HIV infection |
Other
| Measure | Time frame | Description |
|---|---|---|
| Safety of DTG in infant: Birth outcomes (Weight) | At birth | Weight |
| Safety of DTG in infant: Birth outcomes (Length) | At birth | Length |
| Safety of DTG in infant: Growth and development (Infant gross motor screening tool) | 24, 48 and 72 weeks postpartum | Infant gross motor screening tool |
| Drug toxicities as defined by DAIDS criteria | Each study visit up to 72 weeks postpartum | Safety questionnaire |
| Safety of DTG exposure to infant (Blood glucose) | Delivery and 6 weeks postpartum | Blood glucose |
| Safety of DTG exposure to infant | 6 weeks postpartum | ALT (U/mL) |
| Safety and tolerability of DTG exposure to infant: Maternal report (Safety questionnaire) | Delivery and all postnatal follow-up to 72 weeks | Safety questionnaire |
| Safety endpoint: Maternal mental health (Edinburgh Postnatal Depression Scale) | Enrolment, 4 weeks after ART initiation, every postnatal visit up to 72 weeks postpartum | Edinburgh Postnatal Depression Scale |
| Safety endpoint: Maternal mental health (Hospital Anxiety and Depression Scale) | Enrolment, 4 weeks after ART initiation, every postnatal visit up to 72 weeks postpartum | Hospital Anxiety and Depression Scale |
| Safety of DTG in infant: Birth outcomes (Surface examination for anomalies) | At birth | Surface examination for anomalies |
| Safety of DTG in infant: Birth outcomes (Ballard Score for Maturity) | At birth | Ballard Score for Maturity |
Countries
South Africa, Uganda
Outcome results
None listed