59
|
Venter WDF, Moorhouse M, Sokhela S, Fairlie L, Mashabane N, Masenya M, Serenata C, Akpomiemie G, Qavi A, Chandiwana N, Norris S, Chersich M, Clayden P, Abrams E, Arulappan N, Vos A, McCann K, Simmons B, Hill A. Dolutegravir plus Two Different Prodrugs of Tenofovir to Treat HIV. N Engl J Med 2019; 381:803-815. [PMID: 31339677 DOI: 10.1056/nejmoa1902824] [Citation(s) in RCA: 424] [Impact Index Per Article: 84.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Two drugs under consideration for inclusion in antiretroviral therapy (ART) regimens for human immunodeficiency virus (HIV) infection are dolutegravir (DTG) and tenofovir alafenamide fumarate (TAF). There are limited data on their use in low- and middle-income countries. METHODS We conducted a 96-week, phase 3, investigator-led, open-label, randomized trial in South Africa, in which we compared a triple-therapy combination of emtricitabine (FTC) and DTG plus either of two tenofovir prodrugs - TAF (TAF-based group) or tenofovir disoproxil fumarate (TDF) (TDF-based group) - against the local standard-of-care regimen of TDF-FTC-efavirenz (standard-care group). Inclusion criteria included an age of 12 years or older, no receipt of ART in the previous 6 months, a creatinine clearance of more than 60 ml per minute (>80 ml per minute in patients younger than 19 years of age), and an HIV type 1 (HIV-1) RNA level of 500 copies or more per milliliter. The primary end point was the percentage of patients with a 48-week HIV-1 RNA level of less than 50 copies per milliliter (as determined with the Snapshot algorithm from the Food and Drug Administration; noninferiority margin, -10 percentage points). We report the primary (48-week) efficacy and safety data. RESULTS A total of 1053 patients underwent randomization from February 2017 through May 2018. More than 99% of the patients were black, and 59% were female. The mean age was 32 years, and the mean CD4 count was 337 cells per cubic millimeter. At week 48, the percentage of patients with an HIV-1 RNA level of less than 50 copies per milliliter was 84% in the TAF-based group, 85% in the TDF-based group, and 79% in the standard-care group, findings that indicate that the DTG-containing regimens were noninferior to the standard-care regimen. The number of patients who discontinued the trial regimen was higher in the standard-care group than in the other two groups. In the per-protocol population, the standard-care regimen had equivalent potency to the other two regimens. The TAF-based regimen had less effect on bone density and renal function than the other regimens. Weight increase (both lean and fat mass) was greatest in the TAF-based group and among female patients (mean increase, 6.4 kg in the TAF-based group, 3.2 kg in the TDF-based group, and 1.7 kg in the standard-care group). No resistance to integrase inhibitors was identified in patients receiving the DTG-containing regimens. CONCLUSIONS Treatment with DTG combined with either of two tenofovir prodrugs (TAF and TDF) showed noninferior efficacy to treatment with the standard-care regimen. There was significantly more weight gain with the DTG-containing regimens, especially in combination with TAF, than with the standard-care regimen. (ADVANCE ClinicalTrials.gov number, NCT03122262.).
Collapse
Affiliation(s)
- Willem D F Venter
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Michelle Moorhouse
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Simiso Sokhela
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Lee Fairlie
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Nkuli Mashabane
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Masebole Masenya
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Celicia Serenata
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Godspower Akpomiemie
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Ambar Qavi
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Nomathemba Chandiwana
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Shane Norris
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Matthew Chersich
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Polly Clayden
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Elaine Abrams
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Natasha Arulappan
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Alinda Vos
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Kaitlyn McCann
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Bryony Simmons
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| | - Andrew Hill
- From Ezintsha (W.D.F.V., M. Moorhouse, S.S., N.M., C.S., G.A., N.C., N.A., A.V.), Wits Reproductive Health and HIV Institute, Faculty of Health Sciences (W.D.F.V., M. Moorhouse, S.S., L.F., N.M., M. Masenya, C.S., G.A., N.C., M.C., N.A., A.V.), and the South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Pediatrics, School of Clinical Medicine, Faculty of Health Sciences (S.N.), University of the Witwatersrand, Johannesburg; the Faculty of Medicine, Imperial College London (A.Q., K.M., B.S.), and HIV i-Base (P.C.), London, and the Department of Translational Medicine, Liverpool University, Liverpool (A.H.) - all in the United Kingdom; ICAP at Columbia University, Mailman School of Public Health and Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York (E.A.); and the Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands (A.V.)
| |
Collapse
|