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Preservation and Expansion of T-cell Subsets Following HAART De-intensification to Atazanavir/Ritonavir (ATV/r)

Information source: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
ClinicalTrials.gov processed this data on August 23, 2015
Link to the current ClinicalTrials.gov record.

Condition(s) targeted: HIV Infections

Intervention: Early Initiation of Highly Active Anti-Retroviral Therapy (Procedure); Standard Care (Procedure)

Phase: N/A

Status: Completed

Sponsored by: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)

Official(s) and/or principal investigator(s):
Bret J Rudy, M.D., Study Chair, Affiliation: Children's Hospital of Philadelphia
John Sleasman, M.D., Study Chair, Affiliation: University of South Florida, Dept of Pediatrics

Summary

This study proposes to evaluate a pre-DHHS guideline of HAART initiation and then de-intensification management strategy in adolescents with mild immunosuppression and compare changes in CD4% from baseline to week 48 and then during de-intensification.

Clinical Details

Official title: Preservation and Expansion of T-cell Subsets Following HAART De-intensification to Atazanavir/Ritonavir (ATV/r) in Adolescents With CD4 + T Cells > 350 Cells/mm3 Initiating HAART

Study design: Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment

Primary outcome: Ability to maintain or enhance HAART-associated quantitative changes in CD4+ T cell percentages achieved during HAART following therapy de-intensification to ATV/r in adolescents and young adults who began treatment prior to meeting DHHS guidelines.

Secondary outcome:

Quantitative and qualitative changes in T cell subsets percentage in those initiating HAART prior to current guidelines followed by de-intensification and in subjects initiating HAART by current DHHS guidelines.

Ability to maintain decreases in T cell activation achieved during HAART following therapy de-intensification

Ability to maintain virologic control following de-intensification in adolescents treated with HAART prior to meeting DHHS guidelines.

Impact of early HAART initiation on thymic output

Determine the emergence of drug resistance in subjects who fail therapy de-intensification

Evaluate the safety of initiating ART prior to significant CD4+ T cell loss with respect to emergence of drug associated toxicity and drug resistance.

Monitor prevalence of genotypic drug resistance within an ARV naïve or minimally exposed adolescent and young adult population; evaluate the associations of subject demographic and clinical variables with presence of genotypic mutation

Detailed description: This is a randomized, proof of concept study of youth 18- 24 years of age with confirmed HIV after age 9 with CD4+ T cells above 350 cells/mm3 who are randomized 3: 1 to begin HAART consisting of TDF/FTC/ATV/r (preferred), AZT/3TC/ATV/r, or other recommended NRTI backbone with ATV/r upon entry or to begin treatment under current DHHS guidelines. Subjects in the experimental group who achieve virologic control by week 24 and maintain good control through 48 weeks will then de-intensify to ATV/r alone and will be followed for two years. Subjects randomized to the standard care arm will begin HAART with TDF/FTC/ATV/r (preferred), AZT/3TC/ATV/r, or other recommended ATV/r based HAART regimen according to current DHHS standard of care.

Eligibility

Minimum age: 18 Years. Maximum age: 24 Years. Gender(s): Both.

Criteria:

Inclusion Criteria 1. Age 18 yrs and 0 days to 24 yrs and 364 days; 2. CD4+ T cells > 350/mm3 and HIV RNA ≥ 1,000 copies/ml as determined by two consecutive measures within 6 months of entry with the second measure being collected at pre-entry; 3. Infected after age 9. HIV-1 infection should be documented by any licensed ELISA test kit and confirmed by Western blot, HIV-1 culture, HIV-1 antigen, plasma HIV-1 RNA, or a second antibody test by a method other than ELISA at any time prior to entry; Note: Subjects who are in acute seroconversion as evidenced by being ELISA negative (antibody negative) and DNA PCR or HIV-1 RNA positive or who are ELISA positive but Western Blot indeterminate are not eligible. 4. Subjects must be naïve to ARV medications except for women who have received HAART for prevention of maternal to child transmission (MTCT) that meet the following criteria: HAART (defined as three medications from two classes) given for no more than six months for prevention of MTCT, Evidence of viral suppression on the HAART regimen defined as a plasma RNA level below the level of detection for the assay used by the site either during the third trimester or around the time of delivery, A minimum of six months since HAART exposure for prevention of MTCT, and Exposure to HAART for a single pregnancy only; Note: Prior treatment with Trizivir for prevention of MCTC is also permitted as long as viral suppression is documented at the time of delivery or in the last trimester, whichever is most recent. 5. HIV genotype without major resistance mutations to ATV/r. The following genotypic mutations exclude subjects from participation in ATN 061: Major ATV mutations I50L; I84V; N88D/S, Major PI mutations including: D30N; V32I; L33I/F/V; M46I/L; I47V/A; G48V; I50V/L; I54V/L/A/M/T/S; L76V; V82A/F/T/S/L; L90M, Any major PI mutation as defined by the most current IAS-USA Drug Resistance Mutations Figures that would adversely affect a subject's future PI choices, Major RT mutations: Q151M and 69 insertion complex; Decisions regarding the selection of an NRTI backbone for subjects with NRTI resistance mutations other than those described above will be made by the site PI in consultation with the protocol chair or his designee. Whenever possible and not otherwise contraindicated, NRTI choices should be congruent with the protocol-specified preferred regimens. The site PI must provide a copy of the genotype analysis along with their proposed regimen for review; Note: Subjects who cannot go onto either FTC/TDF or AZT/3TC must have the regimen approved by the protocol team following pre-entry screening and prior to study entry. Note: All HIV-1 genotype profiles with ANY resistance mutations must be evaluated by a physician specializing in the care of HIV-infected patients prior to final determination of subject eligibility. Polymorphism mutations should NOT be reported since their clinical significance is unknown. All other (major and minor) mutations should be appropriately categorized and reported as indicated by the case report form. In circumstances where there are numerous such mutations or other concerns present, consultation with the protocol team by the evaluating physician via the ATN QNS is highly encouraged. 6. Calculated creatinine clearance ≥60 mL/min as estimated by the Cockcroft-Gault

equation: For men, (140 - age in years) x (body weight in kg) ÷ (serum creatinine in

mg/dL x 72) = CrCl (mL/min)*;*For women, multiply the result by 0. 85 = CrCl (mL/min); 7. For females with child-bearing potential, agreement to use one effective birth control method and willing to postpone pregnancy for the duration of the study (See

Section 9. 3 - criteria for class C drugs should be followed); and

8. Able to provide written informed consent/assent. Exclusion Criteria 1. Pregnancy; 2. On systemic immunosuppressive therapy or immune modulating therapy (short courses (<14 days) of prednisone for reactive airway disease [RAD] are permitted but not within 30 days prior to study entry); 3. Any history of an AIDS-defining illness (note: a history of a CD4 + T cell count below 200 cells/mm3 is not an exclusion criterion as long as all other inclusion/exclusion criteria are met); 4. Currently breast feeding; 5. Current treatment for active serious systemic bacterial infections; 6. Active hepatitis B infection as defined by Hepatitis B Ag positive; 7. Treatment with immune modulators including IL-2, intravenous gammaglobulin, and therapeutic or other experimental vaccines including HIV-1 vaccine given for primary prevention at any time; 8. History of cardiac conduction abnormalities including one or more of the following: Symptomatic heart block, Third-degree heart block, even if asymptomatic, Pre-excitation syndromes, Heart Rate <40 bpm, Ventricular pause length >3 seconds, QTc > 500 msec, and Cardiomyopathy; 9. Disallowed Medications (see Section 5. 3.2); 10. Active drug or alcohol use or dependence that, in the opinion of the site personnel, would interfere with adherence to the study; 11. History of chronic renal insufficiency or Grade 3 or greater serum creatinine; and 12. Any confirmed grade 3 or greater laboratory value at pre-entry (with the exception of grade 3 or greater lipids or platelets).

Locations and Contacts

University of Puerto Rico, San Juan 00927, Puerto Rico

Children's Hopsital of Los Angeles, Los Angeles, California 90027, United States

University of Southern California - IMPAACT Site, Los Angeles, California 90033, United States

University of California at San Francisco, San Francisco, California 94118, United States

Children's Hospital of Denver - IMPAACT Site, Aurora, Colorado 80045, United States

Children's National Medical Center, Washington, District of Columbia 20010, United States

Howard University - IMPAACT Site, Washington, District of Columbia 20060, United States

Children's Diagnostic and Treatment Center, Fort Lauderdale, Florida 33316, United States

University of Miami, Miami, Florida 33101, United States

University of Southern Florida College of Medicine, Tampa, Florida 33606, United States

Childrens Memorial Hospital, Chicago, Illinois 60614, United States

Stoger Hospital of Cook County, Chicago, Illinois 60612, United States

Tulane Medical Center, New Orleans, Louisiana 70112, United States

Johns Hopkins University - IMPAACT Site, Baltimore, Maryland 21287, United States

University of Maryland, Baltimore, Maryland 21201, United States

Children's Hospital of Michigan - IMPAACT Site, Detroit, Michigan 48201, United States

UMDNJ - IMPAACT Site, Newark, New Jersey 07103, United States

Montefiore Medical Center, Bronx, New York 10467, United States

Mount Sinai Medical Center, New York, New York 10128, United States

Duke Pediatric Infectious Diseases - IMPAACT Site, Durham, North Carolina 27710, United States

Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, United States

St. Jude Children's Research Hospital (Memphis) - IMPAACT Site, Memphis, Tennessee 38105, United States

St. Jude Childrens Research Hospital, Memphis, Tennessee 38105, United States

Additional Information

Description of Adolescent Trials Networks (ATN) and contact information

Starting date: October 2007
Last updated: May 15, 2014

Page last updated: August 23, 2015

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