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Malik F, Crichton S, Plotnikova Y, Latysheva I, Samarina A, Pokorska-Śpiewak M, Gomez MN, Bailey H, Thorne C, Judd A, Turkova A, Collins IJ. Effectiveness and Safety of Direct-acting Antivirals for Treatment of Adolescents With HCV/HIV Coinfection: Real-world Data From Europe. Pediatr Infect Dis J 2024; 43:e155-e159. [PMID: 38315439 PMCID: PMC11003402 DOI: 10.1097/inf.0000000000004271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 02/07/2024]
Abstract
We evaluated the effectiveness and safety of direct-acting antivirals in adolescents with hepatitis C (HCV)/HIV coinfection using pooled individual patient-level data from 5 European cohorts. Of 122 participants in follow-up from November 2013 to August 2021, 19 were treated <18 years of age; of 15 with HCV RNA available at/after 12 weeks post-treatment, all had sustained virologic response with acceptable safety. This evidence addresses an important gap in knowledge of treatment outcomes in adolescents with HCV/HIV coinfection in real-life settings.
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Affiliation(s)
- Farihah Malik
- From the UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Siobhan Crichton
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Yulia Plotnikova
- Irkutsk AIDS Centre, Irkutsk Regional Centre for the Prevention and Control of AIDS and Infectious Diseases (IOC AIDS), Russia
| | - Inga Latysheva
- Republican Clinical Hospital of Infectious Diseases, Saint Petersburg, Russia
| | | | - Maria Pokorska-Śpiewak
- Department of Children’s Infectious Diseases, Medical University of Warsaw; Hospital of Infectious Diseases in Warsaw, Poland
| | - Marisa Navarro Gomez
- Pediatric Infectious Diseases, Hospital Gregorio Marañón, IISGM, UCM, CIBERINFEC ISCIII, Madrid, Spain
| | - Heather Bailey
- Institute for Global Health, University College London, London, United Kingdom
| | - Claire Thorne
- From the UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Ali Judd
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Intira Jeannie Collins
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
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Turkova A, Chan MK, Kityo C, Kekitiinwa AR, Musoke P, Violari A, Variava E, Archary M, Cressey TR, Chalermpantmetagul S, Sawasdichai K, Ounchanum P, Kanjanavanit S, Srirojana S, Srirompotong U, Welch S, Bamford A, Epalza C, Fortuny C, Colbers A, Nastouli E, Walker S, Carr D, Conway M, Spyer MJ, Parkar N, White I, Nardone A, Thomason MJ, Ferrand RA, Giaquinto C, Ford D. D3/Penta 21 clinical trial design: A randomised non-inferiority trial with nested drug licensing substudy to assess dolutegravir and lamivudine fixed dose formulations for the maintenance of virological suppression in children with HIV-1 infection, aged 2 to 15 years. Contemp Clin Trials 2024:107540. [PMID: 38636725 DOI: 10.1016/j.cct.2024.107540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/29/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND There is increasing interest in utilising two-drug regimens for HIV treatment with the goal of reducing toxicity and improve acceptability. The D3 trial evaluates the efficacy and safety of DTG/3TC in children and adolescents and includes a nested pharmacokinetics(PK) substudy for paediatric drug licensing. METHODS D3 is an ongoing open-label, phase III, 96-week non-inferiority randomised controlled trial(RCT) conducted in South Africa, Spain, Thailand, Uganda and the United Kingdom. D3 has enrolled 386 children aged 2- < 15 years, virologically suppressed for ≥6 months, with no prior treatment failure. Participants were randomised 1:1 to receive DTG/3TC or DTG plus two nucleoside reverse transcriptase inhibitors(NRTIs), stratified by region, age (2- < 6, 6- < 12, 12- < 15 years) and DTG use at enrolment (participants permitted to start DTG at enrolment). The primary outcome is confirmed HIV-1 RNA viral rebound ≥50 copies/mL by 96-weeks. The trial employs the Smooth Away From Expected(SAFE) non-inferiority frontier, which specifies the non-inferiority margin and significance level based on the observed event risk in the control arm. The nested PK substudy evaluates WHO weight-band-aligned dosing in the DTG/3TC arm. DISCUSSION D3 is the first comparative trial evaluating DTG/3TC in children and adolescents. Implications of integrating a PK substudy and supplying data for prompt regulatory submission, were carefully considered to ensure the integrity of the ongoing trial. The trial uses an innovative non-inferiority frontier for the primary analysis to allow for a lower-than-expected confirmed viral rebound risk in the control arm, while ensuring interpretability of results and maintaining the planned sample size in an already funded trial. TRIAL REGISTRATION International Standard Randomised Clinical Trial Number Register: ISRCTN17157458. European Clinical Trials Database: 2020-001426-57. CLINICALTRIALS gov: NCT04337450.
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Affiliation(s)
- Anna Turkova
- Medical Research Council Clinical Trials Unit at University College London, UK.
| | - Man K Chan
- Medical Research Council Clinical Trials Unit at University College London, UK
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | | | - Philippa Musoke
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwarsrand, Johannesburg, South Africa
| | - Ebrahim Variava
- Perinatal HIV Research Unit, University of the Witwarsrand, Johannesburg, South Africa
| | - Moherndran Archary
- Department of Paediatrics and Children Health, King Edward VIII Hospital, Enhancing Care Foundation, University of KwaZulu-Natal, Durban, South Africa
| | - Tim R Cressey
- AMS-IRD PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Suwalai Chalermpantmetagul
- AMS-IRD PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | | | | | | | | | - Steven Welch
- Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alasdair Bamford
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; University College London Great Ormond Street Institute of Child Health, London, UK
| | - Cristina Epalza
- Instituto de Investigación Sanitaria Hospital, 12 de Octubre (imas12), Madrid, Spain
| | - Clàudia Fortuny
- Infectious Diseases Department, Institut de Recerca Sant Joan de Déu, Sant Joan de Déu Children's Hospital, Barcelona, Spain; Department of Surgery and Medico-Surgical Specialties, Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Medical InnovationHealth Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Eleni Nastouli
- University College London Great Ormond Street Institute of Child Health, London, UK; University College London Hospitals NHS Trust, Advanced Pathogen Diagnostics Unit, London, UK
| | - Simon Walker
- Centre for Health Economics, University of York, Heslington, York, UK
| | - Dan Carr
- Department of Molecular and Clinical Pharmacology, University of Liverpool, UK
| | | | - Moira J Spyer
- Medical Research Council Clinical Trials Unit at University College London, UK; University College London Great Ormond Street Institute of Child Health, London, UK
| | - Nazia Parkar
- Medical Research Council Clinical Trials Unit at University College London, UK
| | - Iona White
- Medical Research Council Clinical Trials Unit at University College London, UK
| | | | - Margaret J Thomason
- Medical Research Council Clinical Trials Unit at University College London, UK
| | | | - Carlo Giaquinto
- Fondazione Penta ETS, Padova, Italy; University of Padova, Department of Women and Child Health, Padova, Italy
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit at University College London, UK
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3
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Cressey TR, Turkova A. Expanding options of child-friendly, single-tablet regimens for young children with HIV. Lancet HIV 2024:S2352-3018(24)00007-9. [PMID: 38621390 DOI: 10.1016/s2352-3018(24)00007-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 04/17/2024]
Affiliation(s)
- Tim R Cressey
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai 50200, Thailand.
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit, University College London, London, UK
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Chabala C, Wobudeya E, van der Zalm MM, Kapasa M, Raichur P, Mboizi R, Palmer M, Kinikar A, Hissar S, Mulenga V, Mave V, Musoke P, Hesseling AC, McIlleron H, Gibb D, Crook A, Turkova A. Clinical outcomes in children living with HIV treated for non-severe tuberculosis in the SHINE Trial. Clin Infect Dis 2024:ciae193. [PMID: 38592950 DOI: 10.1093/cid/ciae193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/23/2024] [Accepted: 04/05/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Children living with HIV(CLWH) are at high risk of tuberculosis(TB) and face poor outcomes, despite antiretroviral treatment(ART). We evaluated outcomes in CLWH and HIV-uninfected children treated for non-severe TB in the SHINE trial. METHODS SHINE was a randomized trial that enrolled children aged <16 years with smear-negative, non-severe TB who were randomized to receive 4 vs 6 months of TB treatment and followed for 72 weeks. We assessed TB relapse/recurrence, mortality, hospitalizations, grade ≥3 adverse events by HIV status, and HIV virological suppression in CLWH. RESULTS Of 1204 enrolled, 127(11%) were CLWH, of similar age (median(IQR) 3.6(1.2, 10.3) vs. 3.5(1.5, 6.9)years, p= 0.07), but more underweight (WAZ; -2.3(-3.3, -0.8) vs -1.0(-1.8, -0.2), p<0.01) and anemic (hemoglobin 9.5(8.7, 10.9) vs 11.5(10.4, 12.3)g/dl, p<0.01) compared to HIV-uninfected children. 68(54%) CLWH were ART-naïve; baseline median CD4 count 719(241-1134) cells/mm3, CD4% 16(10-26)%). CLWH were more likely to be hospitalized (aOR=2.4(1.3-4.6)) and die (aHR(95%CI) 2.6(1.2,5.8)). HIV status, age <3 years (aHR 6.3(1.5,27.3)), malnutrition (aHR 6.2(2.4,15.9)) and hemoglobin <7g/dl(aHR 3.8(1.3,11.5) independently predicted mortality. Among children with available VL, 45% and 61% CLWH had VL<1000copies/ml at weeks 24 and 48, respectively. There was no difference in the effect of randomized treatment duration (4 vs 6 months) on TB treatment outcomes by HIV status (p for interaction=0.42). CONCLUSIONS We found no evidence of a difference in TB outcomes between 4 and 6 months of treatment for CLWH treated for non-severe TB. Irrespective of TB treatment duration, CLWH had higher rates of mortality and hospitalization than HIV-uninfected counterparts.
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Affiliation(s)
- Chishala Chabala
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia
- University Teaching Hospital-Children's Hospital, Lusaka, Zambia
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Eric Wobudeya
- Makerere University-John Hopkins Hospital Research Collaboration, Mulago Hospital, Kampala, Uganda
| | - Marieke M van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Monica Kapasa
- University Teaching Hospital-Children's Hospital, Lusaka, Zambia
| | - Priyanka Raichur
- Byramjee Jeejeebhoy Medical College- Johns Hopkins University Clinical Research Site, Pune, India
| | - Robert Mboizi
- Makerere University-John Hopkins Hospital Research Collaboration, Mulago Hospital, Kampala, Uganda
| | - Megan Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Medical College- Johns Hopkins University Clinical Research Site, Pune, India
| | - Syed Hissar
- Indian Council of Medical Research - National Institute for Research in Tuberculosis, Chennai, India
| | - Veronica Mulenga
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia
- University Teaching Hospital-Children's Hospital, Lusaka, Zambia
| | - Vidya Mave
- Byramjee Jeejeebhoy Medical College- Johns Hopkins University Clinical Research Site, Pune, India
| | - Philippa Musoke
- Makerere University-John Hopkins Hospital Research Collaboration, Mulago Hospital, Kampala, Uganda
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Helen McIlleron
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Diana Gibb
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Angela Crook
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Anna Turkova
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
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Makumbi S, Bajunirwe F, Ford D, Turkova A, South A, Lugemwa A, Musiime V, Gibb D, Tamwesigire IK. Voluntariness of consent in paediatric HIV clinical trials: a mixed-methods, cross-sectional study of participants in the CHAPAS-4 and ODYSSEY trials in Uganda. BMJ Open 2024; 14:e077546. [PMID: 38431301 PMCID: PMC10910635 DOI: 10.1136/bmjopen-2023-077546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 02/13/2024] [Indexed: 03/05/2024] Open
Abstract
OBJECTIVES To examine the voluntariness of consent in paediatric HIV clinical trials and the associated factors. DESIGN Mixed-methods, cross-sectional study combining a quantitative survey conducted concurrently with indepth interviews. SETTING AND PARTICIPANTS From January 2021 to April 2021, we interviewed parents of children on first-line or second-line Anti-retroviral therapy (ART) in two ongoing paediatric HIV clinical trials [CHAPAS-4 (ISRCTN22964075) and ODYSSEY (ISRCTN91737921)] at the Joint Clinical Research Centre Mbarara, Uganda. OUTCOME MEASURES The outcome measures were the proportion of parents with voluntary consent, factors affecting voluntariness and the sources of external influence. Parents rated the voluntariness of their consent on a voluntariness ladder. Indepth interviews described participants' lived experiences and were aimed at adding context. RESULTS All 151 parents randomly sampled for the survey participated (84% female, median age 40 years). Most (67%) gave a fully voluntary decision, with a score of 10 on the voluntariness ladder, whereas 8% scored 9, 9% scored 8, 6% scored 7, 8% scored 6 and 2.7% scored 4. Trust in medical researchers (adjusted OR 9.90, 95% CI 1.01 to 97.20, p=0.049) and male sex of the parent (adjusted OR 3.66, 95% CI 1.00 to 13.38, p=0.05) were positively associated with voluntariness of consent. Prior research experience (adjusted OR 0.31, 95% CI 0.12 to 0.78, p=0.014) and consulting (adjusted OR 0.25. 95% CI 0.10 to 0.60, p=0.002) were negatively associated with voluntariness. Consultation and advice came from referring health workers (36%), spouses (29%), other family members (27%), friends (15%) and researchers (7%). The indepth interviews (n=14) identified the health condition of the child, advice from referring health workers and the opportunity to access better care as factors affecting the voluntariness of consent. CONCLUSIONS This study demonstrated a high voluntariness of consent, which was enhanced among male parents and by parents' trust in medical researchers. Prior research experience of the child and advice from health workers and spouses were negatively associated with the voluntariness of parents' consent. Female parents and parents of children with prior research experience may benefit from additional interventions to support voluntary participation.
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Affiliation(s)
- Shafic Makumbi
- Joint Clinical Research Centre, Mbarara, Uganda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Francis Bajunirwe
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Annabelle South
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | - Victor Musiime
- Joint Clinical Research Centre, Mbarara, Uganda
- Makerere University, Kampala, Uganda
| | - Diana Gibb
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Imelda K Tamwesigire
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
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du Cros P, Greig J, Alffenaar JWC, Cross GB, Cousins C, Berry C, Khan U, Phillips PPJ, Velásquez GE, Furin J, Spigelman M, Denholm JT, Thi SS, Tiberi S, Huang GKL, Marks GB, Turkova A, Guglielmetti L, Chew KL, Nguyen HT, Ong CWM, Brigden G, Singh KP, Motta I, Lange C, Seddon JA, Nyang'wa BT, Maug AKJ, Gler MT, Dooley KE, Quelapio M, Tsogt B, Menzies D, Cox V, Upton CM, Skrahina A, McKenna L, Horsburgh CR, Dheda K, Marais BJ. Standards for clinical trials for treating TB. Int J Tuberc Lung Dis 2023; 27:885-898. [PMID: 38042969 PMCID: PMC10719894 DOI: 10.5588/ijtld.23.0341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/21/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND: The value, speed of completion and robustness of the evidence generated by TB treatment trials could be improved by implementing standards for best practice.METHODS: A global panel of experts participated in a Delphi process, using a 7-point Likert scale to score and revise draft standards until consensus was reached.RESULTS: Eleven standards were defined: Standard 1, high quality data on TB regimens are essential to inform clinical and programmatic management; Standard 2, the research questions addressed by TB trials should be relevant to affected communities, who should be included in all trial stages; Standard 3, trials should make every effort to be as inclusive as possible; Standard 4, the most efficient trial designs should be considered to improve the evidence base as quickly and cost effectively as possible, without compromising quality; Standard 5, trial governance should be in line with accepted good clinical practice; Standard 6, trials should investigate and report strategies that promote optimal engagement in care; Standard 7, where possible, TB trials should include pharmacokinetic and pharmacodynamic components; Standard 8, outcomes should include frequency of disease recurrence and post-treatment sequelae; Standard 9, TB trials should aim to harmonise key outcomes and data structures across studies; Standard 10, TB trials should include biobanking; Standard 11, treatment trials should invest in capacity strengthening of local trial and TB programme staff.CONCLUSION: These standards should improve the efficiency and effectiveness of evidence generation, as well as the translation of research into policy and practice.
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Affiliation(s)
- P du Cros
- Burnet Institute, Melbourne, VIC, Monash Infectious Diseases, Monash Health, Melbourne, VIC, Australia
| | - J Greig
- Burnet Institute, Melbourne, VIC, Médecins Sans Frontières (MSF), Manson Unit, London, UK
| | - J-W C Alffenaar
- Sydney Infectious Diseases Institute (Sydney ID), and, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Westmead Hospital, Sydney, NSW
| | - G B Cross
- Burnet Institute, Melbourne, VIC, Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - C Cousins
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - C Berry
- Médecins Sans Frontières (MSF), Manson Unit, London, UK
| | - U Khan
- Interactive Research and Development Global, Singapore City, Singapore
| | - P P J Phillips
- UCSF Center for Tuberculosis, Division of Pulmonary and Critical Care Medicine, and
| | - G E Velásquez
- UCSF Center for Tuberculosis, Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - J Furin
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA
| | - M Spigelman
- Global Alliance for TB Drug Development, New York, NY, USA
| | - J T Denholm
- Victorian Tuberculosis Program, Melbourne Health, Melbourne, VIC, Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| | - S S Thi
- Eswatini National TB Control Program, Mbabane, Kingdom of Eswatini
| | - S Tiberi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, GlaxoSmithKline, London, UK
| | - G K L Huang
- Burnet Institute, Melbourne, VIC, Northern Health Infectious Diseases, Northern Health, Melbourne, VIC
| | - G B Marks
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - A Turkova
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - L Guglielmetti
- Médecins Sans Frontières (MSF), Paris, Sorbonne Université, Institut national de la santé et de la recherche médicale, Unité 1135, Centre d'Immunologie et des Maladies Infectieuses, Paris, Assistance Publique Hôpitaux de Paris (APHP), Groupe Hospitalier Universitaire Sorbonne Université, Hôpital Pitié-Salpêtrière, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries, Paris, France
| | - K L Chew
- Department of Laboratory Medicine, National University Hospital, Singapore City, Singapore
| | - H T Nguyen
- Research Department, Friends for International TB Relief, Ha Noi, Vietnam
| | - C W M Ong
- Infectious Diseases Translational Research Programme, Department of Medicine, National University of Singapore, Singapore City, Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore City, Institute of Healthcare Innovation & Technology, National University of Singapore, Singapore City, Singapore
| | - G Brigden
- The Global Fund, Geneva, Switzerland
| | - K P Singh
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia, Victorian Infectious Disease Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | - C Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, German Center for Infection Research (DZIF), TTU-TB, Borstel, Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - J A Seddon
- Department of Infectious Disease, Imperial College London, London, UK, Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - B-T Nyang'wa
- Public Health Department, Operational Center Amsterdam (OCA), MSF, Amsterdam, The Netherlands
| | - A K J Maug
- Damien Foundation Bangladesh, Dhaka, Bangladesh
| | - M T Gler
- De La Salle Medical and Health Sciences Institute, Dasmariñas, the Philippines
| | - K E Dooley
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M Quelapio
- Tropical Disease Foundation, Makati City, Manila, the Philippines, KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - B Tsogt
- Mongolian Anti-TB Coalition, Ulaanbaatar, Mongolia
| | - D Menzies
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & McGill International TB Centre, Montreal, QC, Canada
| | - V Cox
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town
| | - C M Upton
- TASK Applied Science, Cape Town, South Africa
| | - A Skrahina
- The Republican Scientific and Practical Center for Pulmonology and TB, Minsk, Belarus
| | - L McKenna
- Treatment Action Group, New York, NY
| | - C R Horsburgh
- Departments of Global Health, Epidemiology, Biostatistics and Medicine, Schools of Public Health and Medicine, Boston University, Boston MA, USA
| | - K Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa, Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - B J Marais
- Sydney Infectious Diseases Institute (Sydney ID), and, The Children's Hospital at Westmead, Sydney, NSW, WHO Collaborating Centre in Tuberculosis, The University of Sydney, Sydney, NSW, Australia
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7
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Galileya LT, Wasmann RE, Chabala C, Rabie H, Lee J, Njahira Mukui I, Hesseling A, Zar H, Aarnoutse R, Turkova A, Gibb D, Cotton MF, McIlleron H, Denti P. Evaluating pediatric tuberculosis dosing guidelines: A model-based individual data pooled analysis. PLoS Med 2023; 20:e1004303. [PMID: 37988391 PMCID: PMC10662720 DOI: 10.1371/journal.pmed.1004303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 10/02/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND The current World Health Organization (WHO) pediatric tuberculosis dosing guidelines lead to suboptimal drug exposures. Identifying factors altering the exposure of these drugs in children is essential for dose optimization. Pediatric pharmacokinetic studies are usually small, leading to high variability and uncertainty in pharmacokinetic results between studies. We pooled data from large pharmacokinetic studies to identify key covariates influencing drug exposure to optimize tuberculosis dosing in children. METHODS AND FINDINGS We used nonlinear mixed-effects modeling to characterize the pharmacokinetics of rifampicin, isoniazid, and pyrazinamide, and investigated the association of human immunodeficiency virus (HIV), antiretroviral therapy (ART), drug formulation, age, and body size with their pharmacokinetics. Data from 387 children from South Africa, Zambia, Malawi, and India were available for analysis; 47% were female and 39% living with HIV (95% on ART). Median (range) age was 2.2 (0.2 to 15.0) years and weight 10.9 (3.2 to 59.3) kg. Body size (allometry) was used to scale clearance and volume of distribution of all 3 drugs. Age affected the bioavailability of rifampicin and isoniazid; at birth, children had 48.9% (95% confidence interval (CI) [36.0%, 61.8%]; p < 0.001) and 64.5% (95% CI [52.1%, 78.9%]; p < 0.001) of adult rifampicin and isoniazid bioavailability, respectively, and reached full adult bioavailability after 2 years of age for both drugs. Age also affected the clearance of all drugs (maturation), children reached 50% adult drug clearing capacity at around 3 months after birth and neared full maturation around 3 years of age. While HIV per se did not affect the pharmacokinetics of first-line tuberculosis drugs, rifampicin clearance was 22% lower (95% CI [13%, 28%]; p < 0.001) and pyrazinamide clearance was 49% higher (95% CI [39%, 57%]; p < 0.001) in children on lopinavir/ritonavir; isoniazid bioavailability was reduced by 39% (95% CI [32%, 45%]; p < 0.001) when simultaneously coadministered with lopinavir/ritonavir and was 37% lower (95% CI [22%, 52%]; p < 0.001) in children on efavirenz. Simulations of 2010 WHO-recommended pediatric tuberculosis doses revealed that, compared to adult values, rifampicin exposures are lower in most children, except those younger than 3 months, who experience relatively higher exposure for all drugs, due to immature clearance. Increasing the rifampicin doses in children older than 3 months by 75 mg for children weighing <25 kg and 150 mg for children weighing >25 kg could improve rifampicin exposures. Our analysis was limited by the differences in availability of covariates among the pooled studies. CONCLUSIONS Children older than 3 months have lower rifampicin exposures than adults and increasing their dose by 75 or 150 mg could improve therapy. Altered exposures in children with HIV is most likely caused by concomitant ART and not HIV per se. The importance of the drug-drug interactions with lopinavir/ritonavir and efavirenz should be evaluated further and considered in future dosing guidance. TRIAL REGISTRATION ClinicalTrials.gov registration numbers; NCT02348177, NCT01637558, ISRCTN63579542.
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Affiliation(s)
- Lufina Tsirizani Galileya
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Training and Research Unit of Excellence, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Roeland E. Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Chishala Chabala
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Pediatrics, University of Zambia, School of Medicine, Lusaka, Zambia
- University Teaching Hospitals-Children’s Hospital, Lusaka, Zambia
| | - Helena Rabie
- Department of Pediatrics and Child Health and Family Center for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Janice Lee
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | | | - Anneke Hesseling
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Heather Zar
- Department of Pediatrics and Child Health, Red Cross War Memorial Children’s Hospital, and SA-MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Rob Aarnoutse
- Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Diana Gibb
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Mark F. Cotton
- Department of Pediatrics and Child Health and Family Center for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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8
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Matthews PC, Ocama P, Wang S, El-Sayed M, Turkova A, Ford D, Torimiro J, Garcia Ferreira AC, Miranda AE, De La Hoz Restrepo FP, Seremba E, Mbu R, Pan CQ, Razavi H, Dusheiko G, Spearman CW, Hamid S. Reply to: "Does currently recommended maternal antiviral prophylaxis against mother-to-child transmission of hepatitis B virus require enhancement?". JHEP Rep 2023; 5:100875. [PMID: 37822785 PMCID: PMC10563044 DOI: 10.1016/j.jhepr.2023.100875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 10/13/2023] Open
Affiliation(s)
- Philippa C. Matthews
- The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
- Division of Infection and Immunity, University College London, Gower St, London WC1E 6BT, UK
- Department of Infection, University College London Hospitals, 235 Euston Rd, London NW1 2BU, UK
| | - Ponsiano Ocama
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Su Wang
- Cooperman Barnabas Medical Center, Florham Park, NJ, USA
- Hepatitis B Foundation, Doylestown, PA, USA
| | - Manal El-Sayed
- Department of Paediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit, University College London, 90 High Holborn London WC1V 6LJ, UK
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit, University College London, 90 High Holborn London WC1V 6LJ, UK
| | - Judith Torimiro
- Chantal Biya International Reference Centre for Research on Prevention and Management of HIV/AIDS (CIRCB), Yaounde, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
| | - Ana Cristina Garcia Ferreira
- Ministry of Health, Health Surveillance Department, Department of Chronic Diseases and Sexually Transmitted Infections, SRTVN Quadra 701, Lote D, PO700 Building, CEP: 70719040, Brasília/DF, Brazil
| | - Angélica Espinosa Miranda
- Ministry of Health, Health Surveillance Department, Department of Chronic Diseases and Sexually Transmitted Infections, SRTVN Quadra 701, Lote D, PO700 Building, CEP: 70719040, Brasília/DF, Brazil
| | | | - Emmanuel Seremba
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robinson Mbu
- Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
| | - Calvin Q. Pan
- Division of Gastroenterology and Hepatology, NYU Langone Health, NYU Grossman School of Medicine, NY, USA
| | - Homie Razavi
- Center for Disease Analysis Foundation, 1120 W South Boulder Rd Suite 102, Lafayette, CO 80026, USA
| | - Geoffrey Dusheiko
- Liver Unit, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
| | - C. Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Saeed Hamid
- Department of Medicine, Aga Khan University, Karachi, Pakistan
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9
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Chabala C, Turkova A, Kapasa M, LeBeau K, Tembo CH, Zimba K, Weisner L, Zyambo K, Choo L, Chungu C, Lungu J, Mulenga V, Crook A, Gibb D, McIlleron H. Inadequate Lopinavir Concentrations With Modified 8-Hourly Lopinavir/Ritonavir 4:1 Dosing During Rifampicin-based Tuberculosis Treatment in Children Living With HIV. Pediatr Infect Dis J 2023; 42:899-904. [PMID: 37506295 PMCID: PMC10501348 DOI: 10.1097/inf.0000000000004047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Lopinavir/ritonavir plasma concentrations are profoundly reduced when co-administered with rifampicin. Super-boosting of lopinavir/ritonavir is limited by nonavailability of single-entity ritonavir, while double-dosing of co-formulated lopinavir/ritonavir given twice-daily produces suboptimal lopinavir concentrations in young children. We evaluated whether increased daily dosing with modified 8-hourly lopinavir/ritonavir 4:1 would maintain therapeutic plasma concentrations of lopinavir in children living with HIV receiving rifampicin-based antituberculosis treatment. METHODS Children with HIV/tuberculosis coinfection weighing 3.0 to 19.9 kg, on rifampicin-based antituberculosis treatment were commenced or switched to 8-hourly liquid lopinavir/ritonavir 4:1 with increased daily dosing using weight-band dosing approach. A standard twice-daily dosing of lopinavir/ritonavir was resumed 2 weeks after completing antituberculosis treatment. Plasma sampling was conducted during and 4 weeks after completing antituberculosis treatment. RESULTS Of 20 children enrolled; 15, 1-7 years old, had pharmacokinetics sampling available for analysis. Lopinavir concentrations (median [range]) on 8-hourly lopinavir/ritonavir co-administered with rifampicin (n = 15; area under the curve 0-24 55.32 mg/h/L [0.30-398.7 mg/h/L]; C max 3.04 mg/L [0.03-18.6 mg/L]; C 8hr 0.90 mg/L [0.01-13.7 mg/L]) were lower than on standard dosing without rifampicin (n = 12; area under the curve 24 121.63 mg/h/L [2.56-487.3 mg/h/L]; C max 9.45 mg/L [0.39-26.4 mg/L]; C 12hr 3.03 mg/L [0.01-17.7 mg/L]). During and after rifampicin cotreatment, only 7 of 15 (44.7%) and 8 of 12 (66.7%) children, respectively, achieved targeted pre-dose lopinavir concentrations ≥1mg/L. CONCLUSIONS Modified 8-hourly dosing of lopinavir/ritonavir failed to achieve adequate lopinavir concentrations with concurrent antituberculosis treatment. The subtherapeutic lopinavir exposures on standard dosing after antituberculosis treatment are of concern and requires further evaluation.
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Affiliation(s)
- Chishala Chabala
- From the Department of Paediatrics, University of Zambia, School of Medicine, Lusaka, Zambia
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Faculty of Health Sciences, Cape Town, South Africa
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Anna Turkova
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Monica Kapasa
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Kristen LeBeau
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Chimuka H. Tembo
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Kevin Zimba
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Lubbe Weisner
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Faculty of Health Sciences, Cape Town, South Africa
| | - Khozya Zyambo
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Louise Choo
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Chalilwe Chungu
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Joyce Lungu
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Veronica Mulenga
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Angela Crook
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Diana Gibb
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Helen McIlleron
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Faculty of Health Sciences, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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10
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Chandasana H, Thapar M, Hayes S, Baker M, Gibb DM, Turkova A, Ford D, Ruel T, Wiznia A, Fairlie L, Bwakura-Dangarembizi M, Mujuru H, Alvero C, Farhad M, Hazra R, Townley E, Buchanan A, Bollen P, Waalewijn H, Colbers A, Burger D, Acosta EP, Singh R. Population Pharmacokinetic Modeling of Dolutegravir to Optimize Pediatric Dosing in HIV-1-Infected Infants, Children, and Adolescents. Clin Pharmacokinet 2023; 62:1445-1459. [PMID: 37603217 PMCID: PMC10520196 DOI: 10.1007/s40262-023-01289-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND AND OBJECTIVE HIV treatment options remain limited in children. Dolutegravir is a potent and well-tolerated, once-daily HIV-1 integrase inhibitor recommended for HIV-1 infection in both adults and children down to 4 weeks of age. To support pediatric dosing of dolutegravir in children, we used a population pharmacokinetic model with dolutegravir data from the P1093 and ODYSSEY clinical trials. The relationship between dolutegravir exposure and selected safety endpoints was also evaluated. METHODS A population pharmacokinetic model was developed with data from P1093 and ODYSSEY to characterize the pharmacokinetics and associated variability and to evaluate the impact of pharmacokinetic covariates. The final population pharmacokinetic model simulated exposures across weight bands, doses, and formulations that were compared with established adult reference data. Exploratory exposure-safety analyses evaluated the relationship between dolutegravir pharmacokinetic parameters and selected clinical laboratory parameters and adverse events. RESULTS A total of N = 239 participants were included, baseline age ranged from 0.1 to 17.5 years, weight ranged from 3.9 to 91 kg, 50% were male, and 80% were black. The final population pharmacokinetic model was a one-compartment model with first-order absorption and elimination, enabling predictions of dolutegravir concentrations in the pediatric population across weight bands and doses/formulations. The predicted geometric mean trough concentration was comparable to the adult value following a 50-mg daily dose of dolutegravir for all weight bands at recommended doses. Body weight, age, and formulation were significant predictors of dolutegravir pharmacokinetics in pediatrics. Additionally, during an exploratory exposure-safety analysis, no correlation was found between dolutegravir exposure and selected safety endpoints or adverse events. CONCLUSIONS The dolutegravir dosing in children ≥ 4 weeks of age on an age/weight-band basis provides comparable exposures to those historically observed in adults. Observed pharmacokinetic variability was higher in this pediatric population and no additional safety concerns were observed. These results support the weight-banded dosing of dolutegravir in pediatric participants currently recommended by the World Health Organization.
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Affiliation(s)
- Hardik Chandasana
- Clinical Pharmacology, Modeling and Simulation, GSK, 1250 South Collegeville Road, Collegeville, PA, 19406, USA.
| | | | | | | | - Diana M Gibb
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Theodore Ruel
- University of California, San Francisco, San Francisco, CA, USA
| | - Andrew Wiznia
- Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Lee Fairlie
- Faculty of Health Sciences, Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Hilda Mujuru
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | | | - Mona Farhad
- Frontier Science Foundation, Brookline, MA, USA
| | - Rohan Hazra
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Ellen Townley
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Pauline Bollen
- Department of Pharmacy, Radboudumc Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hylke Waalewijn
- Department of Pharmacy, Radboudumc Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Angela Colbers
- Department of Pharmacy, Radboudumc Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David Burger
- Department of Pharmacy, Radboudumc Institute for Medical Innovation, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Rajendra Singh
- Clinical Pharmacology, Modeling and Simulation, GSK, 1250 South Collegeville Road, Collegeville, PA, 19406, USA
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11
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Turkova A, White E, Kekitiinwa AR, Mumbiro V, Kaudha E, Liberty A, Ahimbisibwe GM, Moloantoa T, Srirompotong U, Mosia NR, Puthanakit T, Kobbe R, Fortuny C, Kataike H, Bbuye D, Na-Rajsima S, Coelho A, Lugemwa A, Bwakura-Dangarembizi MF, Klein N, Mujuru HA, Kityo C, Cotton MF, Ferrand RA, Giaquinto C, Rojo P, Violari A, Gibb DM, Ford D. Neuropsychiatric manifestations and sleep disturbances with dolutegravir-based antiretroviral therapy versus standard of care in children and adolescents: a secondary analysis of the ODYSSEY trial. Lancet Child Adolesc Health 2023; 7:718-727. [PMID: 37562418 DOI: 10.1016/s2352-4642(23)00164-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/03/2023] [Accepted: 06/12/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Cohort studies in adults with HIV showed that dolutegravir was associated with neuropsychiatric adverse events and sleep problems, yet data are scarce in children and adolescents. We aimed to evaluate neuropsychiatric manifestations in children and adolescents treated with dolutegravir-based treatment versus alternative antiretroviral therapy. METHODS This is a secondary analysis of ODYSSEY, an open-label, multicentre, randomised, non-inferiority trial, in which adolescents and children initiating first-line or second-line antiretroviral therapy were randomly assigned 1:1 to dolutegravir-based treatment or standard-of-care treatment. We assessed neuropsychiatric adverse events (reported by clinicians) and responses to the mood and sleep questionnaires (reported by the participant or their carer) in both groups. We compared the proportions of patients with neuropsychiatric adverse events (neurological, psychiatric, and total), time to first neuropsychiatric adverse event, and participant-reported responses to questionnaires capturing issues with mood, suicidal thoughts, and sleep problems. FINDINGS Between Sept 20, 2016, and June 22, 2018, 707 participants were enrolled, of whom 345 (49%) were female and 362 (51%) were male, and 623 (88%) were Black-African. Of 707 participants, 350 (50%) were randomly assigned to dolutegravir-based antiretroviral therapy and 357 (50%) to non-dolutegravir-based standard-of-care. 311 (44%) of 707 participants started first-line antiretroviral therapy (ODYSSEY-A; 145 [92%] of 157 participants had efavirenz-based therapy in the standard-of-care group), and 396 (56%) of 707 started second-line therapy (ODYSSEY-B; 195 [98%] of 200 had protease inhibitor-based therapy in the standard-of-care group). During follow-up (median 142 weeks, IQR 124-159), 23 participants had 31 neuropsychiatric adverse events (15 in the dolutegravir group and eight in the standard-of-care group; difference in proportion of participants with ≥1 event p=0·13). 11 participants had one or more neurological events (six and five; p=0·74) and 14 participants had one or more psychiatric events (ten and four; p=0·097). Among 14 participants with psychiatric events, eight participants in the dolutegravir group and four in standard-of-care group had suicidal ideation or behaviour. More participants in the dolutegravir group than the standard-of-care group reported symptoms of self-harm (eight vs one; p=0·025), life not worth living (17 vs five; p=0·0091), or suicidal thoughts (13 vs none; p=0·0006) at one or more follow-up visits. Most reports were transient. There were no differences by treatment group in low mood or feeling sad, problems concentrating, feeling worried or feeling angry or aggressive, sleep problems, or sleep quality. INTERPRETATION The numbers of neuropsychiatric adverse events and reported neuropsychiatric symptoms were low. However, numerically more participants had psychiatric events and reported suicidality ideation in the dolutegravir group than the standard-of-care group. These differences should be interpreted with caution in an open-label trial. Clinicians and policy makers should consider including suicidality screening of children or adolescents receiving dolutegravir. FUNDING Penta Foundation, ViiV Healthcare, and UK Medical Research Council.
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Affiliation(s)
- Anna Turkova
- Medical Research Council Clinical Trials Unit at University College London, London, UK.
| | - Ellen White
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | | | - Vivian Mumbiro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | - Afaaf Liberty
- Perinatal HIV Research Unit, University of the Witwarsrand, Johannesburg, South Africa
| | | | - Tumelo Moloantoa
- Perinatal HIV Research Unit, University of the Witwarsrand, Johannesburg, South Africa
| | | | - Nozibusiso Rejoice Mosia
- Department of Paediatrics and Children Health, King Edward VIII Hospital, Enhancing Care Foundation, University of KwaZulu-Natal, Durban, South Africa
| | - Thanyawee Puthanakit
- HIVNAT, Thai Red Cross AIDS Research Center, Bangkok, Thailand; Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Thailand
| | - Robin Kobbe
- Institute for Infection Research and Vaccine Development, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; Department of Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Clàudia Fortuny
- Infectious Diseases Department, Institut de Recerca Sant Joan de Déu, Sant Joan de Déu Children's Hospital, Barcelona, Spain; Department of Surgery and Medico-Surgical Specialties, Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Hajira Kataike
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | | | | | - Alexandra Coelho
- INSERM/ANRS SC10-US19, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France
| | | | | | - Nigel Klein
- Infection, Immunity & Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, UK; Africa Health Research Institute, Kwazulu-Natal, South Africa
| | - Hilda A Mujuru
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Mark F Cotton
- Children's Infectious Diseases Clinical Research Unit, Family Center for Research with Ubuntu, Department of Paediatrics and Child Health, University of Stellenbosch, Cape Town, South Africa
| | - Rashida A Ferrand
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Carlo Giaquinto
- Department of Women and Child Health, Padova, University of Padova, Italy
| | - Pablo Rojo
- Pediatric Infectious Diseases Unit, Hospital 12 de Octubre, Madrid, Spain
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwarsrand, Johannesburg, South Africa
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit at University College London, London, UK
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12
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Barlow‐Mosha LN, Ahimbisibwe GM, Chappell E, Amuge PM, Nanduudu A, Kaudha E, Amukele T, Balamusani D, Kafufu B, Nimwesiga A, Kataike H, Namwanje R, Kasangaki G, Mulindwa A, Muzorah GA, Bbuye D, Musiime V, Mujyambere E, Ssenyonga M, Mulima D, Kyambadde RC, Namusanje J, Isabirye R, Nabalamba M, Nakirya BM, Kityo C, Kekitiinwa AR, Giaquinto C, Copp A, Gibb DM, Ford D, Musoke P, Turkova A. Effect of dolutegravir on folate, vitamin B12 and mean corpuscular volume levels among children and adolescents with HIV: a sub-study of the ODYSSEY randomized controlled trial. J Int AIDS Soc 2023; 26:e26174. [PMID: 37766505 PMCID: PMC10534059 DOI: 10.1002/jia2.26174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION Dolutegravir-based antiretroviral therapy (ART) is the preferred antiretroviral treatment for children and adolescents living with HIV. A large surveillance study in Botswana previously raised concerns about an association between pre-conception dolutegravir and neural tube defects. Before these concerns were subsequently resolved, we set up a sub-study to look at the effect of dolutegravir on levels of folate and vitamin B12 in children and adolescents within the randomized ODYSSEY trial, as folate and vitamin B12 are known to play a crucial role in neural tube development. METHODS We conducted the sub-study among Ugandan ODYSSEY participants and compared folate and vitamin B12 between children randomized to dolutegravir-based ART (DTG) and non-dolutegravir-based standard-of-care treatment (SOC). Plasma folate was measured at enrolment and week 4 on stored samples; in addition, plasma and red blood cell (RBC) folate and vitamin B12 were assayed at week ≥96 in prospectively collected samples. RBC mean corpuscular volume (MCV) was measured 24-weekly in all ODYSSEY participants. Samples analysed in the sub-study were collected between September 2016 and October 2020. RESULTS A total of 229 children aged ≥6 years were included in the sub-study with median age at trial enrolment of 12.3 (interquartile range [IQR] 9.0, 14.7) years, and CD4 count of 501 (IQR 228, 695); 112 (49%) children were male. Most participants (225/229, 98%) had plasma folate results at enrolment and 214 (93%) children had results available for RBC folate, vitamin B12 and plasma folate at week ≥96. MCV results were analysed on 679 children aged ≥6 years enrolled in ODYSSEY. At week 4, mean plasma folate was significantly higher in the dolutegravir arm than in SOC (difference [DTG-SOC] 1.6 ng/ml, 95% CI 0.8, 2.3; p<0.001), and this difference persisted to week ≥96 (2.7 ng/ml, 95% CI 1.7, 3.7; p<0.001). Mean RBC folate at ≥96 weeks was also higher in the DTG arm (difference 73 ng/ml, 95% CI 3, 143; p = 0.041). There was no difference in the treatment arms for vitamin B12 levels at ≥96 weeks or change in MCV through trial follow-up. CONCLUSIONS Plasma and RBC folate levels were higher in children and adolescents receiving dolutegravir-based ART than on other ART regimens. Further studies are needed to clarify the mechanisms of these interactions and the clinical implications of increased blood folate levels.
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Affiliation(s)
| | | | - Elizabeth Chappell
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and MethodologyLondonUK
| | | | | | | | - Timothy Amukele
- Department of PathologyICON Central Laboratories IncFarmingdaleNew YorkUSA
| | | | - Bosco Kafufu
- Infectious Diseases Institute Core LaboratoryKampalaUganda
| | | | - Hajira Kataike
- Makerere University‐Johns Hopkins University (MU‐JHU) Research CollaborationKampalaUganda
| | - Rosemary Namwanje
- Makerere University‐Johns Hopkins University (MU‐JHU) Research CollaborationKampalaUganda
| | - Gladys Kasangaki
- Makerere University‐Johns Hopkins University (MU‐JHU) Research CollaborationKampalaUganda
| | | | | | - Dickson Bbuye
- Baylor College of Medicine Children's Foundation‐UgandaKampalaUganda
| | - Victor Musiime
- Joint Clinical Research CentreKampalaUganda
- Department of Paediatrics and Child HealthMakerere University College of Health SciencesKampalaUganda
| | | | - Mark Ssenyonga
- Makerere University‐Johns Hopkins University (MU‐JHU) Research CollaborationKampalaUganda
| | | | | | | | - Richard Isabirye
- Makerere University‐Johns Hopkins University (MU‐JHU) Research CollaborationKampalaUganda
| | | | - Barbara Musoke Nakirya
- Makerere University‐Johns Hopkins University (MU‐JHU) Research CollaborationKampalaUganda
| | | | | | - Carlo Giaquinto
- Department of Women and Child HealthUniversity of PadovaPadovaItaly
| | - Andrew Copp
- UCL Great Ormond Street Institute of Child HealthLondonUK
| | - Diana M. Gibb
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and MethodologyLondonUK
| | - Deborah Ford
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and MethodologyLondonUK
| | - Philippa Musoke
- Makerere University‐Johns Hopkins University (MU‐JHU) Research CollaborationKampalaUganda
- Department of Paediatrics and Child HealthMakerere University College of Health SciencesKampalaUganda
| | - Anna Turkova
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and MethodologyLondonUK
| | - the ODYSSEY trial team
- Makerere University‐Johns Hopkins University (MU‐JHU) Research CollaborationKampalaUganda
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13
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Botha JC, Byott M, Spyer MJ, Grant PR, Gärtner K, Chen WX, Burton J, Bamford A, Waters LJ, Giaquinto C, Turkova A, Vavro CL, Nastouli E. Sensitive HIV-1 DNA Pol Next-Generation Sequencing for the Characterisation of Archived Antiretroviral Drug Resistance. Viruses 2023; 15:1811. [PMID: 37766218 PMCID: PMC10536450 DOI: 10.3390/v15091811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023] Open
Abstract
Modern HIV-1 treatment effectively suppresses viral amplification in people living with HIV. However, the persistence of HIV-1 DNA as proviruses integrated into the human genome remains the main barrier to achieving a cure. Next-generation sequencing (NGS) offers increased sensitivity for characterising archived drug resistance mutations (DRMs) in HIV-1 DNA for improved treatment options. In this study, we present an ultra-sensitive targeted PCR assay coupled with NGS and a robust pipeline to characterise HIV-1 DNA DRMs from buffy coat samples. Our evaluation supports the use of this assay for Pan-HIV-1 analyses with reliable detection of DRMs across the HIV-1 Pol region. We propose this assay as a new valuable tool for monitoring archived HIV-1 drug resistance in virologically suppressed individuals, especially in clinical trials investigating novel therapeutic approaches.
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Affiliation(s)
- Johannes C. Botha
- Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK (E.N.)
- Advanced Pathogen Diagnostics Unit, University College London Hospitals NHS Trust, London NW1 2PG, UK
| | - Matthew Byott
- Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK (E.N.)
- Advanced Pathogen Diagnostics Unit, University College London Hospitals NHS Trust, London NW1 2PG, UK
| | - Moira J. Spyer
- Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK (E.N.)
- Advanced Pathogen Diagnostics Unit, University College London Hospitals NHS Trust, London NW1 2PG, UK
| | | | - Kathleen Gärtner
- Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK (E.N.)
| | | | - James Burton
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Alasdair Bamford
- Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK (E.N.)
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
- Medical Research Council Clinical Trials Unit, University College London, London WC1E 6BT, UK
| | - Laura J. Waters
- Central and North West London NHS Foundation Trust, Mortimer Market, London WC1E 6JB, UK
| | - Carlo Giaquinto
- Department of Women and Child Health, University of Padova, 35122 Padova, Italy
- Fondazione Penta ETS, 35127 Padova, Italy
| | - Anna Turkova
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
- Medical Research Council Clinical Trials Unit, University College London, London WC1E 6BT, UK
| | | | - Eleni Nastouli
- Great Ormond Street Institute of Child Health, University College London, London WC1N 1EH, UK (E.N.)
- Advanced Pathogen Diagnostics Unit, University College London Hospitals NHS Trust, London NW1 2PG, UK
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14
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Quartagno M, Chan M, Turkova A, Ford D, White IR. The Smooth Away From Expected (SAFE) non-inferiority frontier: theory and implementation with an application to the D3 trial. Trials 2023; 24:556. [PMID: 37626423 PMCID: PMC10464088 DOI: 10.1186/s13063-023-07586-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND In a non-inferiority trial, the choice of margin depends on the expected control event risk. If the true risk differs from expected, power and interpretability of results can be affected. A non-inferiority frontier pre-specifies an appropriate non-inferiority margin for each value of control event risk. D3 is a non-inferiority trial comparing two treatment regimens in children living with HIV, designed assuming a control event risk of 12%, a non-inferiority margin of 10%, 80% power and a significance level (α) of 0.025. We consider approaches to choosing and implementing a frontier for this already funded trial, where changing the sample size substantially would be difficult. METHODS In D3, we fix the non-inferiority margin at 10%, 8% and 5% for control event risks of ≥9%, 5% and 1%, respectively. We propose four frontiers which fit these fixed points, including a Smooth Away From Expected (SAFE) frontier. Analysis approaches considered are as follows: using the pre-specified significance level (α=0.025); always using a reduced significance level (to achieve α≤0.025 across control event risks); reducing significance levels only when the control event risk differs significantly from expected (control event risk <9%); and using a likelihood ratio test. We compare power and type 1 error for SAFE with other frontiers. RESULTS Changing the significance level only when the control event risk is <9% achieves approximately nominal (<3%) type I error rate and maintains reasonable power for control event risks between 1 and 15%. The likelihood ratio test method performs similarly, but the results are more complex to present. Other analysis methods lead to either inflated type 1 error or badly reduced power. The SAFE frontier gives more interpretable results with low control event risks than other frontiers (i.e. it uses more reasonable non-inferiority margins). Other frontiers do not achieve power close (i.e. within 1%) to SAFE across the range of likely control event risks while controlling type I error. CONCLUSIONS The SAFE non-inferiority frontier will be used in D3, and the non-inferiority margin and significance level will be modified if the control event risk is lower than expected. This ensures results will remain interpretable if design assumptions are incorrect, while achieving similar power. A similar approach could be considered for other non-inferiority trials where the control event risk is uncertain.
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Affiliation(s)
- Matteo Quartagno
- MRC Clinical Trials Unit, Institute for Clinical Trials and Methodology, University College London, 90 High Holborn, London, WC1V 6LJ, UK.
| | - Man Chan
- MRC Clinical Trials Unit, Institute for Clinical Trials and Methodology, University College London, 90 High Holborn, London, WC1V 6LJ, UK
| | - Anna Turkova
- MRC Clinical Trials Unit, Institute for Clinical Trials and Methodology, University College London, 90 High Holborn, London, WC1V 6LJ, UK
| | - Deborah Ford
- MRC Clinical Trials Unit, Institute for Clinical Trials and Methodology, University College London, 90 High Holborn, London, WC1V 6LJ, UK
| | - Ian R White
- MRC Clinical Trials Unit, Institute for Clinical Trials and Methodology, University College London, 90 High Holborn, London, WC1V 6LJ, UK
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15
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Collins IJ, Turkova A. A step closer to optimal ART for all children. Lancet HIV 2023; 10:e487-e489. [PMID: 37541703 DOI: 10.1016/s2352-3018(23)00132-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 08/06/2023]
Affiliation(s)
- Intira Jeannie Collins
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London WC1V 6LJ, UK.
| | - Anna Turkova
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London WC1V 6LJ, UK
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16
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Matthews PC, Ocama P, Wang S, El-Sayed M, Turkova A, Ford D, Torimiro J, Garcia Ferreira AC, Espinosa Miranda A, De La Hoz Restrepo FP, Seremba E, Mbu R, Pan CQ, Razavi H, Dusheiko G, Spearman CW, Hamid S. Enhancing interventions for prevention of mother-to-child- transmission of hepatitis B virus. JHEP Rep 2023; 5:100777. [PMID: 37554925 PMCID: PMC10405098 DOI: 10.1016/j.jhepr.2023.100777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 08/10/2023] Open
Abstract
Prevention of mother-to-child transmission of hepatitis B virus (HBV) infection is a cornerstone of efforts to support progress towards elimination of viral hepatitis. Current guidelines recommend maternal screening, antiviral therapy during the third trimester of high-risk pregnancies, universal and timely HBV birth dose vaccination, and post-exposure prophylaxis with hepatitis B immunoglobulin for selected neonates. However, serological and molecular diagnostic testing, treatment and HBV vaccination are not consistently deployed, particularly in many high endemicity settings, and models predict that global targets for reduction in paediatric incidence will not be met by 2030. In this article, we briefly summarise the evidence for current practice and use this as a basis to discuss areas in which prevention of mother-to-child transmission can potentially be enhanced. By reducing health inequities, enhancing pragmatic use of resources, filling data gaps, developing advocacy and education, and seeking consistent investment from multilateral agencies, significant advances can be made to further reduce vertical transmission events, with wide health, societal and economic benefits.
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Affiliation(s)
- Philippa C. Matthews
- The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
- Division of Infection and Immunity, University College London, Gower St, London WC1E 6BT, UK
- Department of Infection, University College London Hospitals, 235 Euston Rd, London NW1 2BU, UK
| | - Ponsiano Ocama
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Su Wang
- Cooperman Barnabas Medical Center, Florham Park, NJ, USA
- Hepatitis B Foundation, Doylestown, PA, USA
| | - Manal El-Sayed
- Department of Paediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit, University College London, 90 High Holborn, London WC1V 6LJ, UK
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit, University College London, 90 High Holborn, London WC1V 6LJ, UK
| | - Judith Torimiro
- Chantal Biya International Reference Centre for Research on Prevention and Management of HIV/AIDS (CIRCB), Yaounde, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
| | - Ana Cristina Garcia Ferreira
- Ministry of Health, Health Surveillance Department, Department of Chronic Diseases and Sexually Transmitted Infections, SRTVN Quadra 701, Lote D, PO700 Building, CEP: 70719-040, Brasília/DF, Brazil
| | - Angélica Espinosa Miranda
- Ministry of Health, Health Surveillance Department, Department of Chronic Diseases and Sexually Transmitted Infections, SRTVN Quadra 701, Lote D, PO700 Building, CEP: 70719-040, Brasília/DF, Brazil
| | | | - Emmanuel Seremba
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Robinson Mbu
- Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
| | - Calvin Q. Pan
- Division of Gastroenterology and Hepatology, NYU Langone Health, NYU Grossman School of Medicine, NY, USA
| | - Homie Razavi
- Center for Disease Analysis Foundation, 1120 W South Boulder Rd Suite 102, Lafayette, CO 80026, USA
| | - Geoffrey Dusheiko
- Liver Unit, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
| | - C. Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Saeed Hamid
- Department of Medicine, Aga Khan University, Karachi, Pakistan
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17
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Frigati LJ, Gibb D, Harwell J, Kose J, Musiime V, Rabie H, Rangaraj A, Rojo P, Turkova A, Penazzato M. The hard part we often forget: providing care to children and adolescents with advanced HIV disease. J Int AIDS Soc 2023; 26:e26041. [PMID: 36943761 PMCID: PMC10029994 DOI: 10.1002/jia2.26041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 11/10/2022] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Many children and adolescents living with HIV still present with severe immunosuppression with morbidity and mortality remaining high in those starting antiretroviral therapy (ART) when hospitalized. DISCUSSION The major causes of morbidity and mortality in children living with HIV are pneumonia, tuberculosis, bloodstream infections, diarrhoeal disease and severe acute malnutrition. In contrast to adults, cryptococcal meningitis is rare in children under 5 years of age but increases in adolescence. In 2021, the World Health Organizations (WHO) consolidated guidelines for managing HIV disease and rapid ART included recommendations for children and adolescents. In addition, a WHO technical brief released in 2020 highlighted the various interventions that are specifically related to children and adolescents with advanced HIV disease (AHD). We discuss the common clinical presentations of children and adolescents with AHD with a focus on diagnosis, prevention and treatment, highlight some of the challenges in the implementation of the existing package of care, and emphasize the importance of additional research to address the needs of children and adolescents with AHD. CONCLUSIONS There are limited data informing these recommendations and an urgent need for further research on how to implement optimal strategies to ensure tailored approaches to prevent and treat AHD in children and adolescents. Holistic care that goes beyond a simple choice of ART regimen should be provided to all children and adolescents with AHD.
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Affiliation(s)
- Lisa Jane Frigati
- Department of Paediatrics and Child HealthStellenbosch University, Tygerberg Academic HospitalCape TownSouth Africa
| | - Diana Gibb
- Medical Research CouncilClinical Trials Unit at University CollegeLondonLondonUK
| | | | - Judith Kose
- Technical Strategy and InnovationThe Elizabeth Glaser Pediatric AIDS FoundationNairobiKenya
- Erasmus MCDepartment of ViroscienceErasmus UniversityRotterdamNetherlands
| | - Victor Musiime
- Department of Paediatrics and Child HealthMakerere UniversityKampalaUganda
- Research DepartmentJoint Clinical Research CentreKampalaUganda
| | - Helena Rabie
- Department of Paediatrics and Child HealthStellenbosch University, Tygerberg Academic HospitalCape TownSouth Africa
| | | | - Pablo Rojo
- Department of PediatricsHospital Universitario Doce de OctubreMadridSpain
| | - Anna Turkova
- Medical Research CouncilClinical Trials Unit at University CollegeLondonLondonUK
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18
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Gafar F, Wasmann RE, McIlleron HM, Aarnoutse RE, Schaaf HS, Marais BJ, Agarwal D, Antwi S, Bang ND, Bekker A, Bell DJ, Chabala C, Choo L, Davies GR, Day JN, Dayal R, Denti P, Donald PR, Engidawork E, Garcia-Prats AJ, Gibb D, Graham SM, Hesseling AC, Heysell SK, Idris MI, Kabra SK, Kinikar A, Kumar AKH, Kwara A, Lodha R, Magis-Escurra C, Martinez N, Mathew BS, Mave V, Mduma E, Mlotha-Mitole R, Mpagama SG, Mukherjee A, Nataprawira HM, Peloquin CA, Pouplin T, Ramachandran G, Ranjalkar J, Roy V, Ruslami R, Shah I, Singh Y, Sturkenboom MGG, Svensson EM, Swaminathan S, Thatte U, Thee S, Thomas TA, Tikiso T, Touw DJ, Turkova A, Velpandian T, Verhagen LM, Winckler JL, Yang H, Yunivita V, Taxis K, Stevens J, Alffenaar JWC. Global estimates and determinants of antituberculosis drug pharmacokinetics in children and adolescents: a systematic review and individual patient data meta-analysis. Eur Respir J 2023; 61:2201596. [PMID: 36328357 PMCID: PMC9996834 DOI: 10.1183/13993003.01596-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Suboptimal exposure to antituberculosis (anti-TB) drugs has been associated with unfavourable treatment outcomes. We aimed to investigate estimates and determinants of first-line anti-TB drug pharmacokinetics in children and adolescents at a global level. METHODS We systematically searched MEDLINE, Embase and Web of Science (1990-2021) for pharmacokinetic studies of first-line anti-TB drugs in children and adolescents. Individual patient data were obtained from authors of eligible studies. Summary estimates of total/extrapolated area under the plasma concentration-time curve from 0 to 24 h post-dose (AUC0-24) and peak plasma concentration (C max) were assessed with random-effects models, normalised with current World Health Organization-recommended paediatric doses. Determinants of AUC0-24 and C max were assessed with linear mixed-effects models. RESULTS Of 55 eligible studies, individual patient data were available for 39 (71%), including 1628 participants from 12 countries. Geometric means of steady-state AUC0-24 were summarised for isoniazid (18.7 (95% CI 15.5-22.6) h·mg·L-1), rifampicin (34.4 (95% CI 29.4-40.3) h·mg·L-1), pyrazinamide (375.0 (95% CI 339.9-413.7) h·mg·L-1) and ethambutol (8.0 (95% CI 6.4-10.0) h·mg·L-1). Our multivariate models indicated that younger age (especially <2 years) and HIV-positive status were associated with lower AUC0-24 for all first-line anti-TB drugs, while severe malnutrition was associated with lower AUC0-24 for isoniazid and pyrazinamide. N-acetyltransferase 2 rapid acetylators had lower isoniazid AUC0-24 and slow acetylators had higher isoniazid AUC0-24 than intermediate acetylators. Determinants of C max were generally similar to those for AUC0-24. CONCLUSIONS This study provides the most comprehensive estimates of plasma exposures to first-line anti-TB drugs in children and adolescents. Key determinants of drug exposures were identified. These may be relevant for population-specific dose adjustment or individualised therapeutic drug monitoring.
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Affiliation(s)
- Fajri Gafar
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen, The Netherlands
| | - Roeland E Wasmann
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Helen M McIlleron
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
- University of Cape Town, Institute of Infectious Disease and Molecular Medicine, Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Cape Town, South Africa
| | - Rob E Aarnoutse
- Radboud University Medical Center, Radboud Institute of Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - H Simon Schaaf
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Ben J Marais
- The Children's Hospital at Westmead, Sydney, Australia
- The University of Sydney, Sydney Institute for Infectious Diseases, Sydney, Australia
| | - Dipti Agarwal
- Ram Manohar Lohia Institute of Medical Sciences, Department of Paediatrics, Lucknow, India
| | - Sampson Antwi
- Komfo Anokye Teaching Hospital, Department of Child Health, Kumasi, Ghana
- Kwame Nkrumah University of Science and Technology, School of Medical Sciences, Department of Child Health, Kumasi, Ghana
| | | | - Adrie Bekker
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - David J Bell
- NHS Greater Glasgow and Clyde, Infectious Diseases Unit, Glasgow, UK
| | - Chishala Chabala
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia
- University Teaching Hospitals - Children's Hospital, Lusaka, Zambia
| | - Louise Choo
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Geraint R Davies
- Malawi Liverpool Wellcome Clinical Research Programme, Clinical Department, Blantyre, Malawi
- University of Liverpool, Institute of Infection, Veterinary and Ecological Sciences, Liverpool, UK
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- University of Oxford, Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Oxford, UK
| | - Rajeshwar Dayal
- Sarojini Naidu Medical College, Department of Pediatrics, Agra, India
| | - Paolo Denti
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Peter R Donald
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Ephrem Engidawork
- Addis Ababa University, College of Health Sciences, School of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Addis Ababa, Ethiopia
| | - Anthony J Garcia-Prats
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Pediatrics, Madison, WI, USA
| | - Diana Gibb
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Stephen M Graham
- University of Melbourne, Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Anneke C Hesseling
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Scott K Heysell
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Misgana I Idris
- University of Alabama at Birmingham, Department of Biology, Birmingham, AL, USA
| | - Sushil K Kabra
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India
| | - Agibothu K Hemanth Kumar
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Awewura Kwara
- University of Florida, Emerging Pathogens Institute, College of Medicine, Gainesville, FL, USA
| | - Rakesh Lodha
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | | | - Nilza Martinez
- Instituto Nacional de Enfermedades Respiratorias y Del Ambiente, Asunción, Paraguay
| | - Binu S Mathew
- Christian Medical College and Hospital, Department of Pharmacology and Clinical Pharmacology, Vellore, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins University, Department of Medicine and Infectious Diseases, Baltimore, MD, USA
| | - Estomih Mduma
- Haydom Lutheran Hospital, Center for Global Health Research, Haydom, Tanzania
| | | | | | - Aparna Mukherjee
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | - Heda M Nataprawira
- Universitas Padjadjaran, Hasan Sadikin Hospital, Faculty of Medicine, Department of Child Health, Division of Paediatric Respirology, Bandung, Indonesia
| | | | - Thomas Pouplin
- Mahidol University, Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Geetha Ramachandran
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Jaya Ranjalkar
- Christian Medical College and Hospital, Department of Pharmacology and Clinical Pharmacology, Vellore, India
| | - Vandana Roy
- Maulana Azad Medical College, Department of Pharmacology, New Delhi, India
| | - Rovina Ruslami
- Universitas Padjadjaran, Faculty of Medicine, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Bandung, Indonesia
| | - Ira Shah
- Bai Jerbai Wadia Hospital for Children, Department of Pediatric Infectious Diseases, Pediatric TB Clinic, Mumbai, India
| | - Yatish Singh
- Sarojini Naidu Medical College, Department of Pediatrics, Agra, India
| | - Marieke G G Sturkenboom
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Elin M Svensson
- Radboud University Medical Center, Radboud Institute of Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
- Uppsala University, Department of Pharmacy, Uppsala, Sweden
| | - Soumya Swaminathan
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
- World Health Organization, Public Health Division, Geneva, Switzerland
| | - Urmila Thatte
- Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Department of Clinical Pharmacology, Mumbai, India
| | - Stephanie Thee
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Berlin, Germany
| | - Tania A Thomas
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Tjokosela Tikiso
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Daan J Touw
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Anna Turkova
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Thirumurthy Velpandian
- All India Institute of Medical Sciences, Ocular Pharmacology and Pharmacy Division, Dr R.P. Centre, New Delhi, India
| | - Lilly M Verhagen
- Radboud University Medical Center, Radboud Center for Infectious Diseases, Laboratory of Medical Immunology, Section of Pediatric Infectious Diseases, Nijmegen, The Netherlands
- Radboud University Medical Center, Amalia Children's Hospital, Department of Paediatric Infectious Diseases and Immunology, Nijmegen, The Netherlands
- Stellenbosch University, Family Centre for Research with UBUNTU, Department of Paediatrics and Child Health, Cape Town, South Africa
| | - Jana L Winckler
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Hongmei Yang
- University of Rochester, School of Medicine and Dentistry, Department of Biostatistics and Computational Biology, Rochester, NY, USA
| | - Vycke Yunivita
- Universitas Padjadjaran, Faculty of Medicine, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Bandung, Indonesia
| | - Katja Taxis
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen, The Netherlands
| | - Jasper Stevens
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
- Both authors contributed equally and shared senior authorship
| | - Jan-Willem C Alffenaar
- The University of Sydney, Sydney Institute for Infectious Diseases, Sydney, Australia
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia
- Westmead Hospital, Sydney, Australia
- Both authors contributed equally and shared senior authorship
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Amuge P, Lugemwa A, Wynne B, Mujuru HA, Violari A, Kityo CM, Archary M, Variava E, White E, Turner RM, Shakeshaft C, Ali S, Nathoo KJ, Atwine L, Liberty A, Bbuye D, Kaudha E, Mngqibisa R, Mosala M, Mumbiro V, Nanduudu A, Ankunda R, Maseko L, Kekitiinwa AR, Giaquinto C, Rojo P, Gibb DM, Turkova A, Ford D. Once-daily dolutegravir-based antiretroviral therapy in infants and children living with HIV from age 4 weeks: results from the below 14 kg cohort in the randomised ODYSSEY trial. Lancet HIV 2022; 9:e638-e648. [PMID: 36055295 PMCID: PMC9646993 DOI: 10.1016/s2352-3018(22)00163-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Young children living with HIV have few treatment options. We aimed to assess the efficacy and safety of dolutegravir-based antiretroviral therapy (ART) in children weighing between 3 kg and less than 14 kg. METHODS ODYSSEY is an open-label, randomised, non-inferiority trial (10% margin) comparing dolutegravir-based ART with standard of care and comprises two cohorts (children weighing ≥14 kg and <14 kg). Children weighing less than 14 kg starting first-line or second-line ART were enrolled in seven HIV treatment centres in South Africa, Uganda, and Zimbabwe. Randomisation, which was computer generated by the trial statistician, was stratified by first-line or second-line ART and three weight bands. Dispersible 5 mg dolutegravir was dosed according to WHO weight bands. The primary outcome was the Kaplan-Meier estimated proportion of children with virological or clinical failure by 96 weeks, defined as: confirmed viral load of at least 400 copies per mL after week 36; absence of virological suppression by 24 weeks followed by a switch to second-line or third-line ART; all-cause death; or a new or recurrent WHO stage 4 or severe WHO stage 3 event. The primary outcome was assessed by intention to treat in all randomly assigned participants. A primary Bayesian analysis of the difference in the proportion of children meeting the primary outcome between treatment groups incorporated evidence from the higher weight cohort (≥14 kg) in a prior distribution. A frequentist analysis was also done of the lower weight cohort (<14 kg) alone. Safety analyses are presented for all randomly assigned children in this study (<14 kg cohort). ODYSSEY is registered with ClinicalTrials.gov, NCT02259127. FINDINGS Between July 5, 2018, and Aug 26, 2019, 85 children weighing less than 14 kg were randomly assigned to receive dolutegravir (n=42) or standard of care (n=43; 32 [74%] receiving protease inhibitor-based ART). Median age was 1·4 years (IQR 0·6-2·0) and median weight 8·1 kg (5·4-10·0). 72 (85%) children started first-line ART and 13 (15%) started second-line ART. Median follow-up was 124 weeks (112-137). By 96 weeks, treatment failure occurred in 12 children in the dolutegravir group (Kaplan-Meier estimated proportion 31%) versus 21 (48%) in the standard-of-care group. The Bayesian estimated difference in treatment failure (dolutegravir minus standard of care) was -10% (95% CI -19% to -2%; p=0·020), demonstrating superiority of dolutegravir. The frequentist estimated difference was -18% (-36% to 2%; p=0·057). 15 serious adverse events were reported in 11 (26%) children in the dolutegravir group, including two deaths, and 19 were reported in 11 (26%) children in the standard-of-care group, including four deaths (hazard ratio [HR] 1·08 [95% CI 0·47-2·49]; p=0·86). 36 adverse events of grade 3 or higher were reported in 19 (45%) children in the dolutegravir group, versus 34 events in 21 (49%) children in the standard-of-care group (HR 0·93 [0·50-1·74]; p=0·83). No events were considered related to dolutegravir. INTERPRETATION Dolutegravir-based ART was superior to standard of care (mainly protease inhibitor-based) with a lower risk of treatment failure in infants and young children, providing support for global dispersible dolutegravir roll-out for younger children and allowing alignment of adult and paediatric treatment. FUNDING Paediatric European Network for Treatment of AIDS Foundation, ViiV Healthcare, UK Medical Research Council.
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Affiliation(s)
- Pauline Amuge
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | | | - Ben Wynne
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Hilda A Mujuru
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, South Africa
| | | | - Moherndran Archary
- Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal, Durban, South Africa
| | - Ebrahim Variava
- Perinatal HIV Research Unit, University of the Witwatersrand, South Africa
| | - Ellen White
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Rebecca M Turner
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Clare Shakeshaft
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Shabinah Ali
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Kusum J Nathoo
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | - Afaaf Liberty
- Perinatal HIV Research Unit, University of the Witwatersrand, South Africa
| | - Dickson Bbuye
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | | | - Rosie Mngqibisa
- Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal, Durban, South Africa
| | - Modehei Mosala
- Perinatal HIV Research Unit, University of the Witwatersrand, South Africa
| | - Vivian Mumbiro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | | | - Lindiwe Maseko
- Perinatal HIV Research Unit, University of the Witwatersrand, South Africa
| | | | - Carlo Giaquinto
- Department of Women and Child Health, University of Padova, Italy; Penta Foundation, Padova, Italy
| | - Pablo Rojo
- Pediatric Infectious Diseases Unit, Hospital 12 de Octubre, Madrid, Spain
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit at University College London, London, UK.
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Turkova A, Waalewijn H, Chan MK, Bollen PDJ, Bwakura-Dangarembizi MF, Kekitiinwa AR, Cotton MF, Lugemwa A, Variava E, Ahimbisibwe GM, Srirompotong U, Mumbiro V, Amuge P, Zuidewind P, Ali S, Kityo CM, Archary M, Ferrand RA, Violari A, Gibb DM, Burger DM, Ford D, Colbers A. Dolutegravir twice-daily dosing in children with HIV-associated tuberculosis: a pharmacokinetic and safety study within the open-label, multicentre, randomised, non-inferiority ODYSSEY trial. Lancet HIV 2022; 9:e627-e637. [PMID: 35868341 PMCID: PMC9630157 DOI: 10.1016/s2352-3018(22)00160-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Children with HIV-associated tuberculosis (TB) have few antiretroviral therapy (ART) options. We aimed to evaluate the safety and pharmacokinetics of dolutegravir twice-daily dosing in children receiving rifampicin for HIV-associated TB. METHODS We nested a two-period, fixed-order pharmacokinetic substudy within the open-label, multicentre, randomised, controlled, non-inferiority ODYSSEY trial at research centres in South Africa, Uganda, and Zimbabwe. Children (aged 4 weeks to <18 years) with HIV-associated TB who were receiving rifampicin and twice-daily dolutegravir were eligible for inclusion. We did a 12-h pharmacokinetic profile on rifampicin and twice-daily dolutegravir and a 24-h profile on once-daily dolutegravir. Geometric mean ratios for trough plasma concentration (Ctrough), area under the plasma concentration time curve from 0 h to 24 h after dosing (AUC0-24 h), and maximum plasma concentration (Cmax) were used to compare dolutegravir concentrations between substudy days. We assessed rifampicin Cmax on the first substudy day. All children within ODYSSEY with HIV-associated TB who received rifampicin and twice-daily dolutegravir were included in the safety analysis. We described adverse events reported from starting twice-daily dolutegravir to 30 days after returning to once-daily dolutegravir. This trial is registered with ClinicalTrials.gov (NCT02259127), EudraCT (2014-002632-14), and the ISRCTN registry (ISRCTN91737921). FINDINGS Between Sept 20, 2016, and June 28, 2021, 37 children with HIV-associated TB (median age 11·9 years [range 0·4-17·6], 19 [51%] were female and 18 [49%] were male, 36 [97%] in Africa and one [3%] in Thailand) received rifampicin with twice-daily dolutegravir and were included in the safety analysis. 20 (54%) of 37 children enrolled in the pharmacokinetic substudy, 14 of whom contributed at least one evaluable pharmacokinetic curve for dolutegravir, including 12 who had within-participant comparisons. Geometric mean ratios for rifampicin and twice-daily dolutegravir versus once-daily dolutegravir were 1·51 (90% CI 1·08-2·11) for Ctrough, 1·23 (0·99-1·53) for AUC0-24 h, and 0·94 (0·76-1·16) for Cmax. Individual dolutegravir Ctrough concentrations were higher than the 90% effective concentration (ie, 0·32 mg/L) in all children receiving rifampicin and twice-daily dolutegravir. Of 18 children with evaluable rifampicin concentrations, 15 (83%) had a Cmax of less than the optimal target concentration of 8 mg/L. Rifampicin geometric mean Cmax was 5·1 mg/L (coefficient of variation 71%). During a median follow-up of 31 weeks (IQR 30-40), 15 grade 3 or higher adverse events occurred among 11 (30%) of 37 children, ten serious adverse events occurred among eight (22%) children, including two deaths (one tuberculosis-related death, one death due to traumatic injury); no adverse events, including deaths, were considered related to dolutegravir. INTERPRETATION Twice-daily dolutegravir was shown to be safe and sufficient to overcome the rifampicin enzyme-inducing effect in children, and could provide a practical ART option for children with HIV-associated TB. FUNDING Penta Foundation, ViiV Healthcare, UK Medical Research Council.
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Affiliation(s)
- Anna Turkova
- Medical Research Council Clinical Trials Unit, University College London, London, UK.
| | - Hylke Waalewijn
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Man K Chan
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Pauline D J Bollen
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Mark F Cotton
- Children's Infectious Diseases Clinical Research Unit, Family Center for Research with Ubuntu, Department of Paediatrics and Child Health, University of Stellenbosch, Cape Town, South Africa
| | | | - Ebrahim Variava
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Vivian Mumbiro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | - Peter Zuidewind
- Children's Infectious Diseases Clinical Research Unit, Family Center for Research with Ubuntu, Department of Paediatrics and Child Health, University of Stellenbosch, Cape Town, South Africa
| | - Shabinah Ali
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | - Moherndran Archary
- Department of Paediatrics and Child Health, King Edward VIII Hospital, Enhancing Care Foundation, University of KwaZulu-Natal, Durban, South Africa
| | | | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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21
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Lyons A, Thompson L, Chappell E, Ene L, Galli L, Goetghebuer T, Jourdain G, Noguera-Julian A, Kahlert CR, Königs C, Kosalaraksa P, Lumbiganon P, Marczyńska M, Marques L, Navarro M, Naver L, Okhonskaia L, Prata F, Puthanakit T, Ramos JT, Samarina A, Thorne C, Voronin E, Turkova A, Giaquinto C, Judd A, Collins IJ. Outcomes of etravirine-based antiretroviral treatment in treatment-experienced children and adolescents living with HIV in Europe and Thailand. Antivir Ther 2022; 27:13596535221092182. [PMID: 36029009 DOI: 10.1177/13596535221092182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Etravirine (ETR) is approved as a component of second or third-line antiretroviral treatment (ART) for children living with HIV. We assessed the outcomes of ETR-based ART in children in routine care in Europe and Thailand. METHODS Data on children aged <18 years at ETR start were pooled from 17 observational cohorts. Characteristics at ETR start, immunological and virological outcomes at 12 months, discontinuations, adverse events (AEs) and serious adverse events (SAEs) were described. Follow-up was censored at ETR discontinuation, death or last visit. RESULTS 177 children ever received ETR. At ETR start, median [IQR] age was 15 [12,16] years, CD4 count 480 [287, 713] cells/mm3, 70% had exposure to ≥3 ART classes and 20% had viral load (VL) <50 copies/mL. 95% received ETR in combination with ≥1 potent drug class, mostly protease inhibitor-based regimens. Median time on ETR was 24 [7, 48] months. Amongst those on ETR at 12 months (n=141), 69% had VL<50 copies/mL. Median CD4 increase since ETR start (n=83) was 147 [16, 267] cells/mm3. Overall, 81 (46%) discontinued ETR by last follow-up. Median time to discontinuation was 23 [8, 47] months. Common reasons for discontinuation were treatment simplification (19%), treatment failure (16%) and toxicity (12%). Eight children (5%) had AEs causally associated with ETR, all dermatological/hypersensitivity reactions. Two were SAEs, both Stevens-Johnson Syndrome in children on regimens containing ETR and darunavir and were causally related to either drugs; both resolved following ART discontinuation. CONCLUSION Children receiving ETR were predominantly highly treatment-experienced, over two-thirds were virally suppressed at 12 months.
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Affiliation(s)
- Alex Lyons
- MRC Clinical Trials Unit at UCL, 4919University College London, London, UK
| | - Lindsay Thompson
- MRC Clinical Trials Unit at UCL, 4919University College London, London, UK
| | - Elizabeth Chappell
- MRC Clinical Trials Unit at UCL, 4919University College London, London, UK
| | - Luminita Ene
- Clinical Department of Infectious Diseases (HIV Department), Dr. Victor Babeș Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | - Luisa Galli
- Infectious Disease Unit, Meyer Children's Hospital, Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Gonzague Jourdain
- Institut de recherche pour le développement (IRD)-PHPT, Marseille, France
- Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Antoni Noguera-Julian
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Sant Joan de Déu Hospital Research Foundation, Barcelona, Spain
| | - Christian R Kahlert
- Infectious Diseases and Hospital Epidemiology, Children's Hospital of Eastern Switzerland and Cantonal Hospital, St Gallen, Switzerland
| | - Christoph Königs
- Department for Children and Adolescents, Division for Stem Cell Transplantation and Immunology, University Hospital Frankfurt/Main, Frankfurt, Germany
| | - Pope Kosalaraksa
- Department of Pediatrics, Khon Kaen University, Khon Kaen, Thailand
| | | | - Magdalena Marczyńska
- Hospital of Infectious Diseases, 37803Medical University of Warsaw, Warsaw, Poland
| | - Laura Marques
- Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Marissa Navarro
- Hospital General Universitario "Gregorio Marañón", Madrid, Spain
- 16734Universidad Complutense, Madrid, Spain
- 559924Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
- Red de Investigación Translacional en Infectología Pediátrica, RITIP, Madrid, Spain
| | - Lars Naver
- Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Liubov Okhonskaia
- Federal Budgetary Institution "Republican Clinical Infectious Hospital" of the Ministry of Health of the Russian Federation, Saint-Petersburg, Russian Federation
| | | | - Thanyawee Puthanakit
- Department of Pediatrics, Faculty of Medicine, 26683Chulalongkorn University and HIVNAT, Thai Red Cross AIDS Research Center, Bangkok, Thailand
| | - Jose T Ramos
- Departamento de Salud Pública y Materno-infantil, Universidad Complutense, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Anna Samarina
- The City HIV Centre, St Petersburg City AIDS Center, St Petersburg, Russian Federation
| | - Claire Thorne
- University College London Great Ormond Street Institute of Child Health, London, UK
| | - Evgeny Voronin
- Federal Budgetary Institution "Republican Clinical Infectious Hospital" of the Ministry of Health of the Russian Federation, Saint-Petersburg, Russian Federation
| | - Anna Turkova
- MRC Clinical Trials Unit at UCL, 4919University College London, London, UK
- 4956Great Ormond Street Hospital, London, UK
| | - Carlo Giaquinto
- 561043Paediatric European Network for the Treatment of AIDS (Penta), Padova, Italy
| | - Ali Judd
- MRC Clinical Trials Unit at UCL, 4919University College London, London, UK
| | - Intira J Collins
- MRC Clinical Trials Unit at UCL, 4919University College London, London, UK
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22
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White IR, Choodari-Oskooei B, Sydes MR, Kahan BC, McCabe L, Turkova A, Esmail H, Gibb DM, Ford D. Combining factorial and multi-arm multi-stage platform designs to evaluate multiple interventions efficiently. Clin Trials 2022; 19:432-441. [PMID: 35579066 PMCID: PMC9373200 DOI: 10.1177/17407745221093577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Factorial-MAMS design platform designs have many advantages, but the practical advantages and disadvantages of combining the two designs have not been explored. METHODS We propose practical methods for a combined design within the platform trial paradigm where some interventions are not expected to interact and could be given together. RESULTS We describe the combined design and suggest diagrams that can be used to represent it. Many properties are common both to standard factorial designs, including the need to consider interactions between interventions and the impact of intervention efficacy on power of other comparisons, and to standard multi-arm multi-stage designs, including the need to pre-specify procedures for starting and stopping intervention comparisons. We also identify some specific features of the factorial-MAMS design: timing of interim and final analyses should be determined by calendar time or total observed events; some non-factorial modifications may be useful; eligibility criteria should be broad enough to include any patient eligible for any part of the randomisation; stratified randomisation may conveniently be performed sequentially; and analysis requires special care to use only concurrent controls. CONCLUSION A combined factorial-MAMS design can combine the efficiencies of factorial trials and multi-arm multi-stage platform trials. It allows us to address multiple research questions under one protocol and to test multiple new treatment options, which is particularly important when facing a new emergent infection such as COVID-19.
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23
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Waalewijn H, Chan MK, Bollen PDJ, Mujuru HA, Makumbi S, Kekitiinwa AR, Kaudha E, Sarfati T, Musoro G, Nanduudu A, Lugemwa A, Amuge P, Moore CL, Rojo P, Giaquinto C, Colbers A, Gibb DM, Ford D, Turkova A, Burger DM. Dolutegravir dosing for children with HIV weighing less than 20 kg: pharmacokinetic and safety substudies nested in the open-label, multicentre, randomised, non-inferiority ODYSSEY trial. Lancet HIV 2022; 9:e341-e352. [PMID: 35189082 PMCID: PMC9046096 DOI: 10.1016/s2352-3018(21)00292-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dolutegravir-based antiretroviral therapy is a preferred first-line treatment for adults and children living with HIV; however, very little pharmacokinetic data for dolutegravir use are available in young children. We therefore aimed to evaluate dolutegravir dosing and safety in children weighing 3 kg to less than 20 kg by assessing pharmacokinetic parameters and safety data in children taking dolutegravir within the ODYSSEY trial. METHODS We did pharmacokinetic substudies nested within the open-label, multicentre, randomised, non-inferiority ODYSSEY trial. We enrolled children from seven research centres in South Africa, Uganda, and Zimbabwe. Children weighing 3 kg to less than 14 kg received 5 mg dispersible tablets of dolutegravir according to WHO weight bands: 5 mg for children weighing 3 kg to less than 6 kg and younger than 6 months, 10 mg for children weighing 3 kg to less than 6 kg and aged 6 months or older, 15 mg for children weighing 6 kg to less than 10 kg, and 20 mg for children weighing 10 kg to less than 14 kg. Children weighing 14 kg to less than 20 kg received a 25 mg film-coated tablet once per day early in the trial or 25 mg dispersible tablets (five 5 mg tablets once per day) later in the trial. A minimum of eight children per weight band or dose was targeted for 24 h pharmacokinetic profiling at steady state. The primary pharmacokinetic parameter was the trough concentration 24 h after observed dolutegravir intake (Ctrough). Pharmacokinetic targets were based on adult dolutegravir Ctrough and the 90% effective concentration (EC90; ie, 0·32 mg/L). Safety was evaluated in eligible children consenting to pharmacokinetic substudies. FINDINGS Between May 25, 2017, and Aug 15, 2019, we enrolled 72 children aged between 3 months and 11 years. 71 children were included in the safety population and 55 (76%) of 72 children contributed 65 evaluable pharmacokinetic profiles. Geometric mean Ctrough in children on dispersible tablets in weight bands between 3 kg and less than 20 kg ranged between 0·53-0·87 mg/L, comparable to the adult geometric mean Ctrough of 0·83 mg/L. Variability was high with coefficient of variation percentages ranging between 50% and 150% compared with 26% in adults. Ctrough below EC90 was observed in four (31%) of 13 children weighing 6 kg to less than 10 kg taking 15 mg dispersible tablets, and four (21%) of 19 weighing 14 kg to less than 20 kg taking 25 mg film-coated tablets. The lowest geometric mean Ctrough of 0·44 mg/L was observed in children weighing 14 kg to less than 20 kg on 25 mg film-coated tablets. Exposures were 1·7-2·0 times higher on 25 mg dispersible tablets versus 25 mg film-coated tablets. 19 (27%) of 71 children had 29 reportable grade 3 or higher adverse events (13 serious adverse events, including two deaths), none of which were related to dolutegravir. INTERPRETATION Weight-band dosing of paediatric dolutegravir dispersible tablets provides appropriate drug exposure in most children weighing 3 kg to less than 20 kg, with no safety signal. 25 mg film-coated tablets did not achieve pharmacokinetic parameters in children weighing 14 kg to less than 20 kg, which were comparable to adults, suggesting dosing with dispersible tablets is preferable or a higher film-coated tablet dose is required. FUNDING Paediatric European Network for Treatment of AIDS Foundation, ViiV Healthcare, and UK Medical Research Council.
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Affiliation(s)
- Hylke Waalewijn
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Man K Chan
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, UK
| | - Pauline D J Bollen
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hilda A Mujuru
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | | | | | - Tatiana Sarfati
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, UK
| | - Godfrey Musoro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | | | - Pauline Amuge
- Baylor College of Medicine Children's Foundation, Kampala, Uganda
| | - Cecilia L Moore
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, UK
| | - Pablo Rojo
- University Hospital October 12, Madrid, Spain
| | - Carlo Giaquinto
- Department for Woman's and Child's Health, University of Padova, Padova, Italy
| | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, UK
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, UK
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit at University College London, University College London, London, UK
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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Turkova A, Wills GH, Wobudeya E, Chabala C, Palmer M, Kinikar A, Hissar S, Choo L, Musoke P, Mulenga V, Mave V, Joseph B, LeBeau K, Thomason MJ, Mboizi RB, Kapasa M, van der Zalm MM, Raichur P, Bhavani PK, McIlleron H, Demers AM, Aarnoutse R, Love-Koh J, Seddon JA, Welch SB, Graham SM, Hesseling AC, Gibb DM, Crook AM. Shorter Treatment for Nonsevere Tuberculosis in African and Indian Children. N Engl J Med 2022; 386:911-922. [PMID: 35263517 PMCID: PMC7612496 DOI: 10.1056/nejmoa2104535] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Two thirds of children with tuberculosis have nonsevere disease, which may be treatable with a shorter regimen than the current 6-month regimen. METHODS We conducted an open-label, treatment-shortening, noninferiority trial involving children with nonsevere, symptomatic, presumably drug-susceptible, smear-negative tuberculosis in Uganda, Zambia, South Africa, and India. Children younger than 16 years of age were randomly assigned to 4 months (16 weeks) or 6 months (24 weeks) of standard first-line antituberculosis treatment with pediatric fixed-dose combinations as recommended by the World Health Organization. The primary efficacy outcome was unfavorable status (composite of treatment failure [extension, change, or restart of treatment or tuberculosis recurrence], loss to follow-up during treatment, or death) by 72 weeks, with the exclusion of participants who did not complete 4 months of treatment (modified intention-to-treat population). A noninferiority margin of 6 percentage points was used. The primary safety outcome was an adverse event of grade 3 or higher during treatment and up to 30 days after treatment. RESULTS From July 2016 through July 2018, a total of 1204 children underwent randomization (602 in each group). The median age of the participants was 3.5 years (range, 2 months to 15 years), 52% were male, 11% had human immunodeficiency virus infection, and 14% had bacteriologically confirmed tuberculosis. Retention by 72 weeks was 95%, and adherence to the assigned treatment was 94%. A total of 16 participants (3%) in the 4-month group had a primary-outcome event, as compared with 18 (3%) in the 6-month group (adjusted difference, -0.4 percentage points; 95% confidence interval, -2.2 to 1.5). The noninferiority of 4 months of treatment was consistent across the intention-to-treat, per-protocol, and key secondary analyses, including when the analysis was restricted to the 958 participants (80%) independently adjudicated to have tuberculosis at baseline. A total of 95 participants (8%) had an adverse event of grade 3 or higher, including 15 adverse drug reactions (11 hepatic events, all but 2 of which occurred within the first 8 weeks, when the treatments were the same in the two groups). CONCLUSIONS Four months of antituberculosis treatment was noninferior to 6 months of treatment in children with drug-susceptible, nonsevere, smear-negative tuberculosis. (Funded by the U.K. Medical Research Council and others; SHINE ISRCTN number, ISRCTN63579542.).
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Affiliation(s)
- Anna Turkova
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Genevieve H Wills
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Eric Wobudeya
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Chishala Chabala
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Megan Palmer
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Aarti Kinikar
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Syed Hissar
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Louise Choo
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Philippa Musoke
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Veronica Mulenga
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Vidya Mave
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Bency Joseph
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Kristen LeBeau
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Margaret J Thomason
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Robert B Mboizi
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Monica Kapasa
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Marieke M van der Zalm
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Priyanka Raichur
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Perumal K Bhavani
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Helen McIlleron
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Anne-Marie Demers
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Rob Aarnoutse
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - James Love-Koh
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - James A Seddon
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Steven B Welch
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Stephen M Graham
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Anneke C Hesseling
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Diana M Gibb
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Angela M Crook
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
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25
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Turner RM, Turkova A, Moore CL, Bamford A, Archary M, Barlow-Mosha LN, Cotton MF, Cressey TR, Kaudha E, Lugemwa A, Lyall H, Mujuru HA, Mulenga V, Musiime V, Rojo P, Tudor-Williams G, Welch SB, Gibb DM, Ford D, White IR. Borrowing information across patient subgroups in clinical trials, with application to a paediatric trial. BMC Med Res Methodol 2022; 22:49. [PMID: 35184739 PMCID: PMC8858505 DOI: 10.1186/s12874-022-01539-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Clinical trial investigators may need to evaluate treatment effects in a specific subgroup (or subgroups) of participants in addition to reporting results of the entire study population. Such subgroups lack power to detect a treatment effect, but there may be strong justification for borrowing information from a larger patient group within the same trial, while allowing for differences between populations. Our aim was to develop methods for eliciting expert opinions about differences in treatment effect between patient populations, and to incorporate these opinions into a Bayesian analysis.
Methods
We used an interaction parameter to model the relationship between underlying treatment effects in two subgroups. Elicitation was used to obtain clinical opinions on the likely values of the interaction parameter, since this parameter is poorly informed by the data. Feedback was provided to experts to communicate how uncertainty about the interaction parameter corresponds with relative weights allocated to subgroups in the Bayesian analysis. The impact on the planned analysis was then determined.
Results
The methods were applied to an ongoing non-inferiority trial designed to compare antiretroviral therapy regimens in 707 children living with HIV and weighing ≥ 14 kg, with an additional group of 85 younger children weighing < 14 kg in whom the treatment effect will be estimated separately. Expert clinical opinion was elicited and demonstrated that substantial borrowing is supported. Clinical experts chose on average to allocate a relative weight of 78% (reduced from 90% based on sample size) to data from children weighing ≥ 14 kg in a Bayesian analysis of the children weighing < 14 kg. The total effective sample size in the Bayesian analysis was 386 children, providing 84% predictive power to exclude a difference of more than 10% between arms, whereas the 85 younger children weighing < 14 kg provided only 20% power in a standalone frequentist analysis.
Conclusions
Borrowing information from a larger subgroup or subgroups can facilitate estimation of treatment effects in small subgroups within a clinical trial, leading to improved power and precision. Informative prior distributions for interaction parameters are required to inform the degree of borrowing and can be informed by expert opinion. We demonstrated accessible methods for obtaining opinions.
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Gureva T, Turkova A, Yablokova E, Smirnova P, Sveshnikova O, Zolotaya O, Nikishova E, Heldal E, Hinderaker S, Seddon JA, Mariandyshev A. Fluoroquinolone preventive therapy for children exposed to MDR-TB. Int J Tuberc Lung Dis 2022; 26:171-173. [PMID: 35086631 PMCID: PMC8802561 DOI: 10.5588/ijtld.21.0443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- T Gureva
- Northern State Medical University, Arkhangelsk, Russian Federation
| | - A Turkova
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials &Methodology, London, UK
| | - E Yablokova
- Northern State Medical University, Arkhangelsk, Russian Federation
| | - P Smirnova
- Arkhangelsk Clinical Antituberculosis Dispensary, Arkhangelsk, Russian Federation
| | - O Sveshnikova
- Arkhangelsk Clinical Antituberculosis Dispensary, Arkhangelsk, Russian Federation
| | - O Zolotaya
- Arkhangelsk Clinical Antituberculosis Dispensary, Arkhangelsk, Russian Federation
| | - E Nikishova
- Northern State Medical University, Arkhangelsk, Russian Federation
| | - E Heldal
- Heart and Lung Patient Organization International, Oslo, Norway
| | | | | | - A Mariandyshev
- Northern State Medical University, Arkhangelsk, Russian Federation, Northern Arctic Federal University, Arkhangelsk, Russian Federation
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Malik F, Chulanov V, Pimenov N, Fomicheva A, Lundin R, Levina N, Thorne C, Turkova A, Indolfi G. Treatment and monitoring of children and adolescents with hepatitis C in Russia: Results from a multi-centre survey on policy and practice. J Virus Erad 2022; 8:100063. [PMID: 35198235 PMCID: PMC8844707 DOI: 10.1016/j.jve.2022.100063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/10/2022] [Accepted: 02/01/2022] [Indexed: 11/17/2022] Open
Abstract
Background The Russian Federation has the largest paediatric hepatitis C virus (HCV) disease burden in the World Health Organization European region with an estimated 118,000 children living with HCV viraemia. Direct-acting antivirals (DAAs) have been available for adults in Russia since 2015 and approved for treatment of adolescents aged ≥12 years since 2019. We evaluated DAA availability and uptake for HCV treatment of children and adolescents and clinical practices on diagnosis and management of paediatric HCV in Russia. Methods A survey was distributed to regional ministries of health in 85 administrative regions during September 2020. The survey consisted of 22 items collecting data on: type of facility, aggregate patient characteristics, HCV testing practices for children and pregnant women and HCV management and treatment practices for children. Results Survey responses were received from 37 of the 85 regions in Russia (response rate 44%). 2159 children and adolescents with chronic HCV were in follow-up; 1089 (50%) were female. Of 2080 children with available data on age-groups, 134 (6%) were <3 years, 336 (16%) 3-<6 years, 718 (35%) 6-<12 years and 892 (43%) 12-<18 years. 134 (15%) of 892 adolescents ≥12 years received DAAs, 96 (72%) glecaprevir/pibrentasvir, 26 (19%) sofosbuvir, 8 (6%) daclatasvir and 4 (3%) sofosbuvir/ledipasvir. Conclusions This study provides a baseline of DAA uptake in early stages of rollout for children and adolescents. The use of DAAs for treatment of adolescents in Russia presents a unique opportunity for HCV micro-elimination in this population.
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Turkova A, White E, Mujuru HA, Kekitiinwa AR, Kityo CM, Violari A, Lugemwa A, Cressey TR, Musoke P, Variava E, Cotton MF, Archary M, Puthanakit T, Behuhuma O, Kobbe R, Welch SB, Bwakura-Dangarembizi M, Amuge P, Kaudha E, Barlow-Mosha L, Makumbi S, Ramsagar N, Ngampiyaskul C, Musoro G, Atwine L, Liberty A, Musiime V, Bbuye D, Ahimbisibwe GM, Chalermpantmetagul S, Ali S, Sarfati T, Wynne B, Shakeshaft C, Colbers A, Klein N, Bernays S, Saïdi Y, Coelho A, Grossele T, Compagnucci A, Giaquinto C, Rojo P, Ford D, Gibb DM. Dolutegravir as First- or Second-Line Treatment for HIV-1 Infection in Children. N Engl J Med 2021; 385:2531-2543. [PMID: 34965338 PMCID: PMC7614690 DOI: 10.1056/nejmoa2108793] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Children with human immunodeficiency virus type 1 (HIV-1) infection have limited options for effective antiretroviral treatment (ART). METHODS We conducted an open-label, randomized, noninferiority trial comparing three-drug ART based on the HIV integrase inhibitor dolutegravir with standard care (non-dolutegravir-based ART) in children and adolescents starting first- or second-line ART. The primary end point was the proportion of participants with virologic or clinical treatment failure by 96 weeks, as estimated by the Kaplan-Meier method. Safety was assessed. RESULTS From September 2016 through June 2018, a total of 707 children and adolescents who weighed at least 14 kg were randomly assigned to receive dolutegravir-based ART (350 participants) or standard care (357). The median age was 12.2 years (range, 2.9 to 18.0), the median weight was 30.7 kg (range, 14.0 to 85.0), and 49% of the participants were girls. By design, 311 participants (44%) started first-line ART (with 92% of those in the standard-care group receiving efavirenz-based ART), and 396 (56%) started second-line ART (with 98% of those in the standard-care group receiving boosted protease inhibitor-based ART). The median follow-up was 142 weeks. By 96 weeks, 47 participants in the dolutegravir group and 75 in the standard-care group had treatment failure (estimated probability, 0.14 vs. 0.22; difference, -0.08; 95% confidence interval, -0.14 to -0.03; P = 0.004). Treatment effects were similar with first- and second-line therapies (P = 0.16 for heterogeneity). A total of 35 participants in the dolutegravir group and 40 in the standard-care group had at least one serious adverse event (P = 0.53), and 73 and 86, respectively, had at least one adverse event of grade 3 or higher (P = 0.24). At least one ART-modifying adverse event occurred in 5 participants in the dolutegravir group and in 17 in the standard-care group (P = 0.01). CONCLUSIONS In this trial involving children and adolescents with HIV-1 infection who were starting first- or second-line treatment, dolutegravir-based ART was superior to standard care. (Funded by ViiV Healthcare; ODYSSEY ClinicalTrials.gov number, NCT02259127; EUDRACT number, 2014-002632-14; and ISRCTN number, ISRCTN91737921.).
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Affiliation(s)
- Anna Turkova
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Ellen White
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Hilda A Mujuru
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Adeodata R Kekitiinwa
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Cissy M Kityo
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Avy Violari
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Abbas Lugemwa
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Tim R Cressey
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Philippa Musoke
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Ebrahim Variava
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Mark F Cotton
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Moherndran Archary
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Thanyawee Puthanakit
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Osee Behuhuma
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Robin Kobbe
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Steven B Welch
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Mutsa Bwakura-Dangarembizi
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Pauline Amuge
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Elizabeth Kaudha
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Linda Barlow-Mosha
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Shafic Makumbi
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Nastassja Ramsagar
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Chaiwat Ngampiyaskul
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Godfrey Musoro
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Lorna Atwine
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Afaaf Liberty
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Victor Musiime
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Dickson Bbuye
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Grace M Ahimbisibwe
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Suwalai Chalermpantmetagul
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Shabinah Ali
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Tatiana Sarfati
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Ben Wynne
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Clare Shakeshaft
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Angela Colbers
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Nigel Klein
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Sarah Bernays
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Yacine Saïdi
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Alexandra Coelho
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Tiziana Grossele
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Alexandra Compagnucci
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Carlo Giaquinto
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Pablo Rojo
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Deborah Ford
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
| | - Diana M Gibb
- From the Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology (A.T., E.W., S.A., T.S., B.W., C.S., D.F., D.M.G.), the University College London Great Ormond Street Institute of Child Health (N.K.), and the Department of Global Health and Development, London School of Hygiene and Tropical Medicine (S.B.), London, and Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.B.W.) - all in the United Kingdom; the University of Zimbabwe, Harare (H.A.M., M.B.-D., G.M.); Baylor College of Medicine, Fort Portal (A.R.K., P.A., D.B.), the Joint Clinical Research Center, Mbarara (A. Lugemwa, S.M., L.A.), and the Joint Clinical Research Center (C.M.K., E.K., V.M.), Makerere University-Johns Hopkins University Research Collaboration (P.M., L.B.-M., G.M.A.), and Makerere University (V.M.), Kampala - all in Uganda; the Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg (A.V., N.R., E.V., A. Liberty), the Family Centre for Research with Ubuntu, the Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg (M.F.C.), the Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal (M.A.), and the Africa Health Research Institute (O.B., N.K.), Durban - all in South Africa; the Program for HIV Prevention and Treatment-Institut de Recherche pour le Développement Research Unit, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai (T.R.C., S.C.), the Faculty of Medicine, Chulalongkorn University (T.P.), and HIV-NAT (HIV Netherlands Australia Thailand Research Collaboration), Thai Red Cross AIDS Research Center, Bangkok (T.P.), and Prapokklao Hospital, Chanthaburi (C.N.) - all in Thailand; the First Department of Medicine, Division of Infectious Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (R.K.); the Department of Pharmacy, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands (A. Colbers); the School of Public Health, University of Sydney, Sydney (S.B.); INSERM-ANRS SC10-US019, Essais Thérapeutiques et Maladies Infectieuses, Villejuif, France (Y.S., A. Coelho, A. Compagnucci); the Penta Foundation (T.G., C.G.), and the Department of Women and Child Health, University of Padua (C.G.) - both in Padua, Italy; and the Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Madrid (P.R.)
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Chabala C, Turkova A, Hesseling AC, Zimba KM, van der Zalm M, Kapasa M, Palmer M, Chirehwa M, Wiesner L, Wobudeya E, Kinikar A, Mave V, Hissar S, Choo L, LeBeau K, Mulenga V, Aarnoutse R, Gibb D, McIlleron H. Pharmacokinetics of first-line drugs in children with tuberculosis using WHO-recommended weight band doses and formulations. Clin Infect Dis 2021; 74:1767-1775. [PMID: 34420049 PMCID: PMC9155615 DOI: 10.1093/cid/ciab725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background Dispersible pediatric fixed-dose combination (FDC) tablets delivering higher doses of first-line antituberculosis drugs in World Health Organization–recommended weight bands were introduced in 2015. We report the first pharmacokinetic data for these FDC tablets in Zambian and South African children in the treatment-shortening SHINE trial. Methods Children weighing 4.0–7.9, 8.0–11.9, 12.0–15.9, or 16.0–24.9 kg received 1, 2, 3, or 4 tablets daily, respectively (rifampicin/isoniazid/pyrazinamide [75/50/150 mg], with or without 100 mg ethambutol, or rifampicin/isoniazid [75/50 mg]). Children 25.0–36.9 kg received doses recommended for adults <37 kg (300, 150, 800, and 550 mg/d, respectively, for rifampicin, isoniazid, pyrazinamide, and ethambutol). Pharmacokinetics were evaluated after at least 2 weeks of treatment. Results In the 77 children evaluated, the median age (interquartile range) was 3.7 (1.4–6.6) years; 40 (52%) were male and 20 (26%) were human immunodeficiency virus positive. The median area under the concentration-time curve from 0 to 24 hours for rifampicin, isoniazid, pyrazinamide, and ethambutol was 32.5 (interquartile range, 20.1–45.1), 16.7 (9.2–25.9), 317 (263–399), and 9.5 (7.5–11.5) mg⋅h/L, respectively, and lower in children than in adults for rifampicin in the 4.0–7.9-, 8–11.9-, and ≥25-kg weight bands, isoniazid in the 4.0–7.9-kg and ≥25-kg weight bands, and ethambutol in all 5 weight bands. Pyrazinamide exposures were similar to those in adults. Conclusions Recommended weight band–based FDC doses result in lower drug exposures in children in lower weight bands and in those ≥25 kg (receiving adult doses). Further adjustments to current doses are needed to match current target exposures in adults. The use of ethambutol at the current World Health Organization–recommended doses requires further evaluation.
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Affiliation(s)
- Chishala Chabala
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia.,University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa.,University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Anna Turkova
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Anneke C Hesseling
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Kevin M Zimba
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Marieke van der Zalm
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Monica Kapasa
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Megan Palmer
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Maxwell Chirehwa
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Lubbe Wiesner
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Eric Wobudeya
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Syed Hissar
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Louise Choo
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Kristen LeBeau
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Veronica Mulenga
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Robb Aarnoutse
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Diana Gibb
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Helen McIlleron
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Moore CL, Turkova A, Mujuru H, Kekitiinwa A, Lugemwa A, Kityo CM, Barlow-Mosha LN, Cressey TR, Violari A, Variava E, Cotton MF, Archary M, Compagnucci A, Puthanakit T, Behuhuma O, Saϊdi Y, Hakim J, Amuge P, Atwine L, Musiime V, Burger DM, Shakeshaft C, Giaquinto C, Rojo P, Gibb DM, Ford D. ODYSSEY clinical trial design: a randomised global study to evaluate the efficacy and safety of dolutegravir-based antiretroviral therapy in HIV-positive children, with nested pharmacokinetic sub-studies to evaluate pragmatic WHO-weight-band based dolutegravir dosing. BMC Infect Dis 2021; 21:5. [PMID: 33446115 PMCID: PMC7809782 DOI: 10.1186/s12879-020-05672-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 11/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dolutegravir (DTG)-based antiretroviral therapy (ART) is highly effective and well-tolerated in adults and is rapidly being adopted globally. We describe the design of the ODYSSEY trial which evaluates the efficacy and safety of DTG-based ART compared with standard-of-care in children and adolescents. The ODYSSEY trial includes nested pharmacokinetic (PK) sub-studies which evaluated pragmatic World Health Organization (WHO) weight-band-based DTG dosing and opened recruitment to children < 14 kg while dosing was in development. METHODS ODYSSEY (Once-daily DTG based ART in Young people vS. Standard thErapY) is an open-label, randomised, non-inferiority, basket trial comparing the efficacy and safety of DTG + 2 nucleos(t) ides (NRTIs) versus standard-of-care (SOC) in HIV-infected children < 18 years starting first-line ART (ODYSSEY A) or switching to second-line ART (ODYSSEY B). The primary endpoint is clinical or virological failure by 96 weeks. RESULTS Between September 2016 and June 2018, 707 children weighing ≥14 kg were enrolled; including 311 ART-naïve children and 396 children starting second-line. 47% of children were enrolled in Uganda, 21% Zimbabwe, 20% South Africa, 9% Thailand, 4% Europe. 362 (51%) participants were male; median age [range] at enrolment was 12.2 years [2.9-18.0]. 82 (12%) children weighed 14 to < 20 kg, 135 (19%) 20 to < 25 kg, 206 (29%) 25 to < 35 kg, 284 (40%) ≥35 kg. 128 (18%) had WHO stage 3 and 60 (8%) WHO stage 4 disease. Challenges encountered include: (i) running the trial across high- to low-income countries with differing frequencies of standard-of-care viral load monitoring; (ii) evaluating pragmatic DTG dosing in PK sub-studies alongside FDA- and EMA-approved dosing and subsequently transitioning participants to new recommended doses; (iii) delays in dosing information for children weighing 3 to < 14 kg and rapid recruitment of ART-naïve older/heavier children, which led to capping recruitment of participants weighing ≥35 kg in ODYSSEY A and extending recruitment (above 700) to allow for ≥60 additional children weighing between 3 to < 14 kg with associated PK; (iv) a safety alert associated with DTG use during pregnancy, which required a review of the safety plan for adolescent girls. CONCLUSIONS By employing a basket design, to include ART-naïve and -experienced children, and nested PK sub-studies, the ODYSSEY trial efficiently evaluates multiple scientific questions regarding dosing and effectiveness of DTG-based ART in children. TRIAL REGISTRATION NCT, NCT02259127 , registered 7th October 2014; EUDRACT, 2014-002632-14, registered 18th June 2014 ( https://www.clinicaltrialsregister.eu/ctr-search/trial/2014-002632-14/ES ); ISRCTN, ISRCTN91737921 , registered 4th October 2014.
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Affiliation(s)
- Cecilia L Moore
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom.
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Hilda Mujuru
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | | | | | | | - Tim R Cressey
- PHPT/IRD 174, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand.,Department of Immunology & Infectious Diseases, Harvard T. H Chan School of Public Health, Boston, USA.,Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Avy Violari
- Perinatal HIV Research Unit, Johannesburg, South Africa
| | - Ebrahim Variava
- Klerksdorp Tshepong Hospital Complex, Matlosana, South Africa
| | - Mark F Cotton
- Family Center for Research with Ubuntu, Cape Town, South Africa
| | | | | | - Thanyawee Puthanakit
- HIVNAT, Thai Red Cross AIDS Research Center and Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Osee Behuhuma
- Africa Health Research Institute, Hlabisa Hospital, Hlabisa, South Africa
| | | | - James Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Pauline Amuge
- Baylor College of Medicine Children's Foundation, Kampala, Uganda
| | | | | | - David M Burger
- Department of Clinical Pharmacy and Nijmegen Institute for Infection, Inflammation and Immunity (N4i), Radboud University, Nijmegen, The Netherlands
| | - Clare Shakeshaft
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | | | | | - Diana M Gibb
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
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Jacobs TG, Svensson EM, Musiime V, Rojo P, Dooley KE, McIlleron H, Aarnoutse RE, Burger DM, Turkova A, Colbers A. Pharmacokinetics of antiretroviral and tuberculosis drugs in children with HIV/TB co-infection: a systematic review. J Antimicrob Chemother 2020; 75:3433-3457. [PMID: 32785712 PMCID: PMC7662174 DOI: 10.1093/jac/dkaa328] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/29/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Management of concomitant use of ART and TB drugs is difficult because of the many drug-drug interactions (DDIs) between the medications. This systematic review provides an overview of the current state of knowledge about the pharmacokinetics (PK) of ART and TB treatment in children with HIV/TB co-infection, and identifies knowledge gaps. METHODS We searched Embase and PubMed, and systematically searched abstract books of relevant conferences, following PRISMA guidelines. Studies not reporting PK parameters, investigating medicines that are not available any longer or not including children with HIV/TB co-infection were excluded. All studies were assessed for quality. RESULTS In total, 47 studies met the inclusion criteria. No dose adjustments are necessary for efavirenz during concomitant first-line TB treatment use, but intersubject PK variability was high, especially in children <3 years of age. Super-boosted lopinavir/ritonavir (ratio 1:1) resulted in adequate lopinavir trough concentrations during rifampicin co-administration. Double-dosed raltegravir can be given with rifampicin in children >4 weeks old as well as twice-daily dolutegravir (instead of once daily) in children older than 6 years. Exposure to some TB drugs (ethambutol and rifampicin) was reduced in the setting of HIV infection, regardless of ART use. Only limited PK data of second-line TB drugs with ART in children who are HIV infected have been published. CONCLUSIONS Whereas integrase inhibitors seem favourable in older children, there are limited options for ART in young children (<3 years) receiving rifampicin-based TB therapy. The PK of TB drugs in HIV-infected children warrants further research.
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Affiliation(s)
- Tom G Jacobs
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - Elin M Svensson
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Victor Musiime
- Research Department, Joint Clinical Research Centre, Kampala, Uganda
- Department of Paediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Pablo Rojo
- Pediatric Infectious Diseases Unit. Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Kelly E Dooley
- Divisions of Clinical Pharmacology and Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rob E Aarnoutse
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - David M Burger
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - Anna Turkova
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Angela Colbers
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
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Lanyon C, Seeley J, Namukwaya S, Musiime V, Paparini S, Nakyambadde H, Matama C, Turkova A, Bernays S. "Because we all have to grow up": supporting adolescents in Uganda to develop core competencies to transition towards managing their HIV more independently. J Int AIDS Soc 2020; 23 Suppl 5:e25552. [PMID: 32869514 PMCID: PMC7459166 DOI: 10.1002/jia2.25552] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/04/2020] [Accepted: 05/29/2020] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Sustaining optimal adherence is the major challenge facing adolescents living with HIV (ALHIV), particularly in low-resource settings, where "second-line" is often the last accessible treatment option. We explored the knowledge and skills adolescents need in order to maintain improved adherence behaviours, and the specific ways clinicians and caregivers may support young people to do so more independently. METHODS We conducted individual, in-depth interviews with 20 ALHIV aged 10 to 18 years in Uganda in 2017 to 2018. All participants had recently commenced second-line treatment as part of a clinical trial. We used thematic qualitative analysis to examine adherence experiences and challenges while on first-line therapy, as well as specific supports necessary to optimise treatment-taking longer-term. RESULTS Adherence difficulties are exacerbated by relatively rapid shifts from caregiver-led approaches during childhood, to an expectation of autonomous treatment-taking with onset of adolescence. For many participants this shift compounded their ongoing struggles managing physical side effects and poor treatment literacy. Switching to second-line typically prompted reversion back to supervised adherence, with positive impacts on self-reported adherence in the immediate term. However, this measure is unlikely to be sustainable for caregivers due to significant caregiver burden (as on first line), and provided little opportunity for clinicians to guide and develop young people's capacity to successfully adopt responsibility for their own treatment-taking. CONCLUSIONS As ALHIV in sub-Saharan Africa are attributed increasing responsibility for treatment adherence and HIV management, they must be equipped with the core knowledge and skills required for successful, self-directed care. Young people need to be relationally supported to develop necessary "adherence competencies" within the supportive framework of a gradual "transition" period. Clinic conversations during this period should be adolescent-focussed and collaborative, and treatment-taking strategies situated within the context of their lived environments and support networks, to facilitate sustained adherence. The disclosure of adherence difficulties must be encouraged so that issues can be identified and addressed prior to treatment failure.
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Affiliation(s)
- Chloe Lanyon
- School of Public HealthUniversity of SydneySydneyNSWAustralia
| | - Janet Seeley
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
- MRC/UVRI and LSHTM Uganda Research UnitEntebbeUganda
- Africa Health Research Institute (AHRI)DurbanSouth Africa
| | | | - Victor Musiime
- Department of Paediatrics and Child HealthMakerere UniversityKampalaUganda
- Research DepartmentJoint Clinical Research CentreKampalaUganda
| | - Sara Paparini
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUnited Kingdom
| | | | | | - Anna Turkova
- Clinical Trials UnitUniversity College LondonLondonUnited Kingdom
| | - Sarah Bernays
- School of Public HealthUniversity of SydneySydneyNSWAustralia
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
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Rojo P, Carpenter D, Venter F, Turkova A, Penazzato M. The HIV drug optimization agenda: promoting standards for earlier investigation and approvals of antiretroviral drugs for use in adolescents living with HIV. J Int AIDS Soc 2020; 23 Suppl 5:e25576. [PMID: 32869500 PMCID: PMC7459170 DOI: 10.1002/jia2.25576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 06/10/2020] [Accepted: 06/22/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Most clinical trials for new antiretroviral (ARV) agents are conducted among narrowly defined adult populations. Only after safety and efficacy have been clearly demonstrated among adults living with HIV are trials including adolescents, children and infants conducted. This approach contributes to significant delays in the availability of optimal new ARV regimens for infants, children and adolescents. This commentary discusses issues related to the inclusion of adolescents aged 12 to 18 years in initial HIV clinical phase 3 trials of novel antiretrovirals (ARVs) or conducting parallel phase 3 clinical trials among adolescents. DISCUSSION The absorption, metabolic and excretion or elimination pathways for drugs do not significantly differ between adolescents and adults. In fact, dosing recommendations for ARVs are the same for adults and adolescents who meet the age and weight criteria. Although conducting clinical trials among adolescents present special challenges (e.g. consenting minors and concerns about trial completion and contraception), these challenges can be addressed to obtain high-quality trial results. Importantly, new agents and optimized combinations have more favourable dosing schedules and side-effect profiles and are more effective ARV agents with higher HIV drug resistance thresholds, which would be extremely beneficial to improve outcomes among HIV-positive adolescents. CONCLUSIONS Adolescents may not present with significantly different pharmacokinetic characteristics from those in adults. Including HIV-positive adolescents in phase 3 ARV clinical trials, either with adults or in specific adolescent studies conducted in parallel, would allow adolescents to access promising, more effective treatment for HIV years earlier than with the current stepwise approach.
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Affiliation(s)
- Pablo Rojo
- Pediatric Infectious Diseases UnitDepartment of PediatricsHospital 12 de OctubreUniversidad ComplutenseMadridSpain
| | - Deborah Carpenter
- Maternal and Child Health BranchDivision of Global HIV and TuberculosisCenter for Global HealthUS Centers for Disease Control and PreventionAtlantaGAUSA
| | - François Venter
- Wits Reproductive Health and HIV InstituteUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Anna Turkova
- MRC Clinical Trials Unit at UCLInstitute of Clinical Trials & MethodologyLondonUnited Kingdom
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Bollen PDJ, Moore CL, Mujuru HA, Makumbi S, Kekitiinwa AR, Kaudha E, Parker A, Musoro G, Nanduudu A, Lugemwa A, Amuge P, Hakim JG, Rojo P, Giaquinto C, Colbers A, Gibb DM, Ford D, Turkova A, Burger DM. Simplified dolutegravir dosing for children with HIV weighing 20 kg or more: pharmacokinetic and safety substudies of the multicentre, randomised ODYSSEY trial. Lancet HIV 2020; 7:e533-e544. [PMID: 32763217 PMCID: PMC7445428 DOI: 10.1016/s2352-3018(20)30189-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 04/14/2023]
Abstract
BACKGROUND Paediatric dolutegravir doses approved by stringent regulatory authorities (SRAs) for children weighing 20 kg to less than 40 kg until recently required 25 mg and 10 mg film-coated tablets. These tablets are not readily available in low-resource settings where the burden of HIV is highest. We did nested pharmacokinetic substudies in patients enrolled in the ODYSSEY-trial to evaluate simplified dosing in children with HIV. METHODS We did pharmacokinetic and safety substudies within the open-label, multicentre, randomised ODYSSEY trial (NCT02259127) of children with HIV starting treatment in four research centres in Uganda and Zimbabwe. Eligible children were randomised to dolutegravir in ODYSSEY and weighed 20 kg to less than 40 kg. In children weighing 20 kg to less than 25 kg, we assessed dolutegravir's pharmacokinetics in children given once daily 25 mg film-coated tablets (approved by the SRAs at the time of the study) in part one of the study, and 50 mg film-coated tablets (adult dose) or 30 mg dispersible tablets in part two of the study. In children weighing 25 kg to less than 40 kg, we also assessed dolutegravir pharmacokinetics within-subject on film-coated tablet doses of 25 mg or 35 mg once daily, which were approved by the SRAs for the children's weight band; then switched to 50 mg film-coated tablets once daily. Steady-state 24 h dolutegravir plasma concentration-time pharmacokinetic profiling was done in all enrolled children at baseline and 1, 2, 3, 4, 6, and 24 h after observed dolutegravir intake. Target dolutegravir trough concentrations (Ctrough) were based on reference adult pharmacokinetic data and safety was evaluated in all children in the corresponding weight bands who consented to pharmacokinetic studies and received the studied doses. FINDINGS Between Sept 22, 2016, and May 31, 2018, we enrolled 62 black-African children aged from 6 years to younger than 18 years (84 pharmacokinetic-profiles). In children weighing 20 kg to less than 25 kg taking 25 mg film-coated tablets, the geometric mean (GM) Ctrough (coefficient of variation) was 0·32 mg/L (94%), which was 61% lower than the GM Ctrough of 0·83 mg/L (26%) in fasted adults on dolutegravir 50 mg once-daily; in children weighing 25 kg to less than 30 kg taking 25 mg film-coated tablets, the GM Ctrough was 0·39 mg/L (48%), which was 54% lower than the GM Ctrough in fasted adults; and in those 30 kg to less than 40 kg taking 35 mg film-coated tablets the GM Ctrough was 0·46 mg/L (63%), which was 45% lower than the GM Ctrough in fasted adults. On 50 mg film-coated tablets or 30 mg dispersible tablets, Ctrough was close to the adult reference (with similar estimates on the two formulations in children in the 20 to <25 kg weight band), with total exposure (area under the concentration-time curve from 0 h to 24 h) in between reference values in adults dosed once and twice daily, where safety data are reassuring, although maximum concentrations were higher in children weighing 20 kg to less than 25 kg than in the twice-daily adult reference. Over a 24-week follow-up period in 47 children on 30 mg dispersible tablets or 50 mg film-coated tablets, none of the three reported adverse events (cryptococcal meningitis, asymptomatic anaemia, and asymptomatic neutropenia) were considered related to dolutegravir. INTERPRETATION Adult dolutegravir 50 mg film-coated tablets given once daily provide appropriate pharmacokinetic profiles in children weighing 20 kg or more, with no safety signal, allowing simplified practical dosing and rapid access to dolutegravir. These results informed the WHO 2019 dolutegravir paediatric dosing guidelines and have led to US Food and Drug Administration approval of adult dosing down to 20 kg. FUNDING Paediatric European Network for Treatment of AIDS Foundation, ViiV Healthcare, UK Medical Research Council.
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Affiliation(s)
- Pauline D J Bollen
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, Netherlands
| | - Cecilia L Moore
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Hilda A Mujuru
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | | | | | - Anna Parker
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Godfrey Musoro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | | | - Pauline Amuge
- Baylor College of Medicine Children's Foundation, Kampala, Uganda
| | - James G Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | | | - Angela Colbers
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, Netherlands.
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - David M Burger
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, Netherlands
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Wademan DT, Busakwe L, Nicholson TJ, van der Zalm M, Palmer M, Workman J, Turkova A, Crook AM, Thomason MJ, Gibb DM, Seeley J, Hesseling A, Hoddinott G. Acceptability of a first-line anti-tuberculosis formulation for children: qualitative data from the SHINE trial. Int J Tuberc Lung Dis 2019; 23:1263-1268. [PMID: 31931909 PMCID: PMC6903808 DOI: 10.5588/ijtld.19.0115] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 03/12/2019] [Indexed: 12/24/2022] Open
Abstract
SETTING: We conducted a qualitative exploration into the palatability and acceptability of a novel fixed-dose combination (FDC) anti-tuberculosis drug. This study was nested in the SHINE (Shorter treatment for minimal TB in children) trial, which compares the safety and efficacy of treating non-severe drug-susceptible tuberculosis (TB) with a 6 vs. 4 months anti-tuberculosis regimen in children aged 0-16 years. Participants were recruited in Cape Town, South Africa.OBJECTIVE: To describe the palatability and acceptability of a FDC of rifampicin, isoniazid and pyrazinamide among South African children and their caregivers in the SHINE trial.METHODS: We conducted 20 clinic observations of treatment administration, during which we conducted 16 semi-structured interviews with children and their caregivers. Data were organised thematically to report on experiences with administering and ingesting the FDC.RESULTS: Children and caregivers' experiences varied from delight to disgust. In general, participants said that the FDC compared favourably to other formulations. Pragmatic challenges such as dissolving the FDC and the time required to administer the FDC impeded caregivers' ability to integrate treatment into their daily routines. Drug manipulation was common among caregivers to improve TB treatment administration.CONCLUSION: This novel FDC appears acceptable for children, albeit with practical challenges to administration. Scale-up of FDC use should include supplementary intervention components to support caregivers.
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Affiliation(s)
- D T Wademan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - L Busakwe
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - T J Nicholson
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - M van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - M Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - J Workman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - A Turkova
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London
| | - A M Crook
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London
| | - M J Thomason
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London
| | - D M Gibb
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London
| | - J Seeley
- Department of Global Health, London School of Hygiene & Tropical Medicine, London, UK
| | - A Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - G Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
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Penazzato M, Townsend CL, Rakhmanina N, Cheng Y, Archary M, Cressey TR, Kim MH, Musiime V, Turkova A, Ruel TD, Rabie H, Sugandhi N, Rojo P, Doherty M, Abrams EJ. Prioritising the most needed paediatric antiretroviral formulations: the PADO4 list. Lancet HIV 2019; 6:e623-e631. [PMID: 31498110 DOI: 10.1016/s2352-3018(19)30193-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 05/22/2019] [Accepted: 06/03/2019] [Indexed: 06/10/2023]
Abstract
Despite considerable progress in paediatric HIV treatment and timely revision of global policies recommending the use of more effective and tolerable antiretroviral regimens, optimal antiretroviral formulations for infants, children, and adolescents remain limited. The Paediatric Antiretroviral Drug Optimization group reviews medium-term and long-term priorities for antiretroviral drug development to guide industry and other stakeholders on formulations most needed for low-income and middle-income countries. The group convened in December, 2018, to assess progress since the previous meeting and update the list of priority formulations. Issues relating to drug optimisation for neonatal prophylaxis and paediatric treatment, and those relating to the investigation of novel antiretrovirals in adolescents and pregnant and lactating women were also discussed. Continued focus on identifying, prioritising, and providing access to optimal antiretroviral formulations suitable for infants, children, and adolescents is key to ensuring that global HIV treatment targets can be met.
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Affiliation(s)
| | | | - Natella Rakhmanina
- The George Washington University, School of Medicine & Health Sciences, Washington, DC, USA; Children's National Medical Center, Washington, DC, USA; Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - Yao Cheng
- Medicines Patent Pool, Geneva, Switzerland
| | - Moherndran Archary
- Department of Paediatrics, University of KwaZulu-Natal, Durban, South Africa
| | - Tim R Cressey
- Program for HIV Prevention and Treatment - Institut de Recherche pour le Développement, Unit 174, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Department of Immunology and Infectious Diseases, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Maria H Kim
- Department of Pediatrics, Baylor International Pediatric AIDS Initiative, Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Abbott Fund Children's Clinical Centre of Excellence Malawi, Lilongwe, Malawi
| | - Victor Musiime
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda; Research Department, Joint Clinical Research Centre, Kampala, Uganda
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, UK
| | - Theodore D Ruel
- Division of Pediatric Infectious Diseases and Global Health, University of California, San Francisco, CA, USA
| | - Helena Rabie
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Pablo Rojo
- Pediatric Infectious Diseases Unit, Pediatric Department, Hospital 12 de Octubre, Universidad Complutense, Madrid, Spain
| | - Meg Doherty
- HIV Department, World Health Organization, Geneva, Switzerland
| | - Elaine J Abrams
- ICAP at Columbia University, New York, NY, USA; Department of Pediatrics, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
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Turkova A, Volynets GV, Crichton S, Skvortsova TA, Panfilova VN, Rogozina NV, Khavkin AI, Tumanova EL, Indolfi G, Thorne C. Advanced liver disease in Russian children and adolescents with chronic hepatitis C. J Viral Hepat 2019; 26:881-892. [PMID: 30803105 PMCID: PMC7155091 DOI: 10.1111/jvh.13093] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 12/11/2022]
Abstract
Russia has one of the highest prevalences of paediatric chronic hepatitis C infection (CHC). Our aim was to provide a detailed characterization of children and adolescents with CHC including treatment outcomes. Thus, an observational study of children with CHC aged <18 years was conducted in three hepatology centres from November 2014 to May 2017. Of 301 children (52% male), 196 (65%) acquired HCV vertically, 70 (23%) had a history of blood transfusion or invasive procedures, 1 injecting drug use and 34 (11%) had no known risk factors. Median age at HCV diagnosis was 3.1 [interquartile range, IQR 1.1, 8.2] and 10.8 [7.4, 14.7] at last follow-up. The most common genotype was 1b (51%), followed by 3 (37%). Over a quarter of patients (84, 28%) had raised liver transaminases. Of 92 with liver biopsy, 38 (41%) had bridging fibrosis (median age 10.4 [7.1, 14.1]). Of 223 evaluated by transient elastography, 67 (30%) had liver stiffness ≥5.0 kPa. For each year, increase in age mean stiffness increased by 0.09 kPa (95% CI 0.05, 0.13, P < 0.001). There was significant correlation between liver stiffness and biopsy results (Tau-b = 0.29, P = 0.042). Of 205 treated with IFN-based regimens, 100 (49%) had SVR24. Most children (191, 93%) experienced adverse reactions, leading to treatment discontinuation in 6 (3%). In conclusion, a third of children acquired HCV via nonvertical routes and a substantial proportion of those with liver biopsy had advanced liver disease. Only half of children achieved SVR24 with IFN-based regimens highlighting the need for more effective and better-tolerated treatments with direct-acting antivirals. Further studies are warranted in Russia on causes and prevention of nonvertical transmission of HCV in children.
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Affiliation(s)
- Anna Turkova
- MRC Clinical Trials Unit at UCLInstitute of Clinical Trials and MethodologyUniversity College LondonLondonUK
- Paediatric Infectious Diseases DepartmentGreat Ormond Street HospitalLondonUK
| | - Galina V. Volynets
- Veltischev Research and Clinical Institute of PediatricsPirogov Russian National Research Medical UniversityMoscowRussia
- Federal State Autonomous Institution National Scientific and Practical Center of Children's Health of the Ministry of Health of the Russian FederationMoscowRussia
| | - Siobhan Crichton
- MRC Clinical Trials Unit at UCLInstitute of Clinical Trials and MethodologyUniversity College LondonLondonUK
| | - Tamara A. Skvortsova
- Federal State Autonomous Institution National Scientific and Practical Center of Children's Health of the Ministry of Health of the Russian FederationMoscowRussia
- Centre of Children's GastroenterologyMorozovskaya Children's City Clinical HospitalMoscowRussia
| | - Victoria N. Panfilova
- Department of PediatricsInstitute of Postgraduate EducationKrasnoyarsk State Medical University of the Ministry of Health of the Russian FederationKrasnoyarskRussia
| | - Natalia V. Rogozina
- Department of Congenital InfectionsPediatric Research and Clinical Center for Infectious DiseasesSaint‐PetersburgRussia
| | - Anatoly I. Khavkin
- Veltischev Research and Clinical Institute of PediatricsPirogov Russian National Research Medical UniversityMoscowRussia
| | - Elena L. Tumanova
- Department of Pathological Anatomy of Pediatric FacultyPirogov Russian National Research Medical UniversityMoscowRussia
| | - Giuseppe Indolfi
- Pediatric and Liver UnitMeyer Children's University Hospital of FlorenceFlorenceItaly
| | - Claire Thorne
- University College London Institute of Child HealthUniversity College LondonLondonUK
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Seddon JA, Garcia-Prats AJ, Purchase SE, Osman M, Demers AM, Hoddinott G, Crook AM, Owen-Powell E, Thomason MJ, Turkova A, Gibb DM, Fairlie L, Martinson N, Schaaf HS, Hesseling AC. Levofloxacin versus placebo for the prevention of tuberculosis disease in child contacts of multidrug-resistant tuberculosis: study protocol for a phase III cluster randomised controlled trial (TB-CHAMP). Trials 2018; 19:693. [PMID: 30572905 PMCID: PMC6302301 DOI: 10.1186/s13063-018-3070-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 11/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multidrug-resistant (MDR) tuberculosis (TB) presents a challenge for global TB control. Treating individuals with MDR-TB infection to prevent progression to disease could be an effective public health strategy. Young children are at high risk of developing TB disease following infection and are commonly infected by an adult in their household. Identifying young children with household exposure to MDR-TB and providing them with MDR-TB preventive therapy could reduce the risk of disease progression. To date, no trials of MDR-TB preventive therapy have been completed and World Health Organization guidelines suggest close observation with no active treatment. METHODS The tuberculosis child multidrug-resistant preventive therapy (TB-CHAMP) trial is a phase III cluster randomised placebo-controlled trial to assess the efficacy of levofloxacin in young child contacts of MDR-TB cases. The trial is taking place at three sites in South Africa where adults with MDR-TB are identified. If a child aged < 5 years lives in their household, we assess the adult index case, screen all household members for TB disease and evaluate any child aged < 5 years for trial eligibility. Eligible children are randomised by household to receive daily levofloxacin (15-20 mg/kg) or matching placebo for six months. Children are closely monitored for disease development, drug tolerability and adverse events. The primary endpoint is incident TB disease or TB death by one year after recruitment. We will enrol 1556 children from approximately 778 households with an average of two eligible children per household. Recruitment will run for 18-24 months with all children followed for 18 months after treatment. Qualitative and health economic evaluations are embedded in the trial. DISCUSSION If the TB-CHAMP trial demonstrates that levofloxacin is effective in preventing TB disease in young children who have been exposed to MDR-TB and that it is safe, well tolerated, acceptable and cost-effective, we would expect that that this intervention would rapidly transfer into policy. TRIAL REGISTRATION ISRCTN Registry, ISRCTN92634082 . Registered on 31 March 2016.
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Affiliation(s)
- James A. Seddon
- Centre for International Child Health, Department of Paediatrics, Imperial College London, Norfolk Place, London, W2 1PG UK
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Anthony J. Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Susan E. Purchase
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Muhammad Osman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Anne-Marie Demers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Angela M. Crook
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Ellen Owen-Powell
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Margaret J. Thomason
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Anna Turkova
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Diana M. Gibb
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit at University College London, London, UK
| | - Lee Fairlie
- Wits Reproductive Health & HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - H. Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
| | - Anneke C. Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Clinical Building, Room 0085, PO Box 19063, Tygerberg, South Africa
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Turkova A, Bamford A. Treating young children co-infected with tuberculosis and HIV. Lancet HIV 2018; 6:S2352-3018(18)30326-6. [PMID: 30529030 DOI: 10.1016/s2352-3018(18)30326-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 11/13/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Anna Turkova
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials & Methodology, London WC1V 6LJ, UK; Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| | - Alasdair Bamford
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials & Methodology, London WC1V 6LJ, UK; Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; University College London Great Ormond Street Institute of Child Health, London, UK
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Collins IJ, Turkova A. Outcomes in children on raltegravir: a story of two halves. Lancet HIV 2018; 5:e676-e678. [PMID: 30527322 DOI: 10.1016/s2352-3018(18)30332-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 11/16/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Intira Jeannie Collins
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London WC1V 6LJ, UK.
| | - Anna Turkova
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London WC1V 6LJ, UK
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Harausz EP, Garcia-Prats AJ, Law S, Schaaf HS, Kredo T, Seddon JA, Menzies D, Turkova A, Achar J, Amanullah F, Barry P, Becerra M, Chan ED, Chan PC, Ioana Chiotan D, Crossa A, Drobac PC, Fairlie L, Falzon D, Flood J, Gegia M, Hicks RM, Isaakidis P, Kadri SM, Kampmann B, Madhi SA, Marais E, Mariandyshev A, Méndez-Echevarría A, Moore BK, Nargiza P, Ozere I, Padayatchi N, Ur-Rehman S, Rybak N, Santiago-Garcia B, Shah NS, Sharma S, Shim TS, Skrahina A, Soriano-Arandes A, van den Boom M, van der Werf MJ, van der Werf TS, Williams B, Yablokova E, Yim JJ, Furin J, Hesseling AC. Treatment and outcomes in children with multidrug-resistant tuberculosis: A systematic review and individual patient data meta-analysis. PLoS Med 2018; 15:e1002591. [PMID: 29995958 PMCID: PMC6040687 DOI: 10.1371/journal.pmed.1002591] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 05/18/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND An estimated 32,000 children develop multidrug-resistant tuberculosis (MDR-TB; Mycobacterium tuberculosis resistant to isoniazid and rifampin) each year. Little is known about the optimal treatment for these children. METHODS AND FINDINGS To inform the pediatric aspects of the revised World Health Organization (WHO) MDR-TB treatment guidelines, we performed a systematic review and individual patient data (IPD) meta-analysis, describing treatment outcomes in children treated for MDR-TB. To identify eligible reports we searched PubMed, LILACS, Embase, The Cochrane Library, PsychINFO, and BioMedCentral databases through 1 October 2014. To identify unpublished data, we reviewed conference abstracts, contacted experts in the field, and requested data through other routes, including at national and international conferences and through organizations working in pediatric MDR-TB. A cohort was eligible for inclusion if it included a minimum of three children (aged <15 years) who were treated for bacteriologically confirmed or clinically diagnosed MDR-TB, and if treatment outcomes were reported. The search yielded 2,772 reports; after review, 33 studies were eligible for inclusion, with IPD provided for 28 of these. All data were from published or unpublished observational cohorts. We analyzed demographic, clinical, and treatment factors as predictors of treatment outcome. In order to obtain adjusted estimates, we used a random-effects multivariable logistic regression (random intercept and random slope, unless specified otherwise) adjusted for the following covariates: age, sex, HIV infection, malnutrition, severe extrapulmonary disease, or the presence of severe disease on chest radiograph. We analyzed data from 975 children from 18 countries; 731 (75%) had bacteriologically confirmed and 244 (25%) had clinically diagnosed MDR-TB. The median age was 7.1 years. Of 910 (93%) children with documented HIV status, 359 (39%) were infected with HIV. When compared to clinically diagnosed patients, children with confirmed MDR-TB were more likely to be older, to be infected with HIV, to be malnourished, and to have severe tuberculosis (TB) on chest radiograph (p < 0.001 for all characteristics). Overall, 764 of 975 (78%) had a successful treatment outcome at the conclusion of therapy: 548/731 (75%) of confirmed and 216/244 (89%) of clinically diagnosed children (absolute difference 14%, 95% confidence interval [CI] 8%-19%, p < 0.001). Treatment was successful in only 56% of children with bacteriologically confirmed TB who were infected with HIV who did not receive any antiretroviral treatment (ART) during MDR-TB therapy, compared to 82% in children infected with HIV who received ART during MDR-TB therapy (absolute difference 26%, 95% CI 5%-48%, p = 0.006). In children with confirmed MDR-TB, the use of second-line injectable agents and high-dose isoniazid (15-20 mg/kg/day) were associated with treatment success (adjusted odds ratio [aOR] 2.9, 95% CI 1.0-8.3, p = 0.041 and aOR 5.9, 95% CI 1.7-20.5, p = 0.007, respectively). These findings for high-dose isoniazid may have been affected by site effect, as the majority of patients came from Cape Town. Limitations of this study include the difficulty of estimating the treatment effects of individual drugs within multidrug regimens, only observational cohort studies were available for inclusion, and treatment decisions were based on the clinician's perception of illness, with resulting potential for bias. CONCLUSIONS This study suggests that children respond favorably to MDR-TB treatment. The low success rate in children infected with HIV who did not receive ART during their MDR-TB treatment highlights the need for ART in these children. Our findings of individual drug effects on treatment outcome should be further evaluated.
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Affiliation(s)
- Elizabeth P Harausz
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.,Military HIV Research Program, Bethesda, Maryland, United States of America
| | - Anthony J Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Stephanie Law
- Montreal Chest Institute, McGill University, Montreal, Quebec, Canada
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Tamara Kredo
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - James A Seddon
- Centre for International Child Health, Imperial College, London, United Kingdom
| | - Dick Menzies
- Montreal Chest Institute, McGill University, Montreal, Quebec, Canada
| | - Anna Turkova
- Imperial College Healthcare NHS Trust, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Jay Achar
- Manson Unit, Médecins Sans Frontières (MSF), London, United Kingdom
| | | | - Pennan Barry
- California Department of Public Health, Sacramento, California, United States of America
| | - Mercedes Becerra
- Partners In Health, Harvard Medical School, and Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Edward D Chan
- Denver Veterans Affairs Medical Center, National Jewish Health, Denver, Colorado, United States of America
| | - Pei Chun Chan
- Division of Chronic Infectious Disease, Centers for Disease Control, Taipei, Taiwan
| | - Domnica Ioana Chiotan
- Epidemiological Surveillance Department, Romanian National TB Program, Bucharest, Romania
| | - Aldo Crossa
- New York City Department of Health and Mental Hygiene, New York, New York, United States of America
| | - Peter C Drobac
- Partners In Health, Harvard Medical School, and Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Lee Fairlie
- Wits Reproductive Health & HIV Institute (WRHI), University of the Witwatersrand, Johannesburg, South Africa
| | - Dennis Falzon
- Laboratories, Diagnostics and Drug Resistance Unit, Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Jennifer Flood
- California Department of Public Health, Sacramento, California, United States of America
| | - Medea Gegia
- Technical Support Coordination, Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Robert M Hicks
- Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Petros Isaakidis
- Médecins Sans Frontières (MSF)/Doctors Without Borders, Mumbai, India
| | - S M Kadri
- Disease Control, Directorate of Health Services, Kashmir, India
| | - Beate Kampmann
- Paediatric Infection & Immunity, Centre of International Child Health, Imperial College London, London, United Kingdom.,Vaccines & Immunity Theme, MRC Unit The Gambia, Banjul, The Gambia
| | - Shabir A Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, and Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - Else Marais
- Department of Clinical Microbiology and Infectious Diseases, University of the Witwatersrand and the National Health Laboratory Services, Johannesburg, South Africa
| | | | - Ana Méndez-Echevarría
- Pediatric, Infectious and Tropical Diseases Department, Hospital La Paz, Madrid, Spain
| | - Brittany Kathryn Moore
- Division of Global HIV and TB, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Parpieva Nargiza
- Republican Scientific Medical Center of Phtiziology and Pulmonology, Ministry of Health, Tashkent, Uzbekistan
| | - Iveta Ozere
- Riga Eastern Clinical University Hospital, Centre for Tuberculosis and Lung Diseases, Riga, Latvia
| | | | | | - Natasha Rybak
- Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Begoña Santiago-Garcia
- Pediatric Infectious Diseases Unit, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - N Sarita Shah
- Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Sangeeta Sharma
- Department of Pediatrics, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Tae Sun Shim
- Department of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Alena Skrahina
- The Republican Research and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - Antoni Soriano-Arandes
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Unit of International Health-Tuberculosis Drassanes-Vall Hebron, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Martin van den Boom
- Joint Tuberculosis, HIV & Viral Hepatitis Programme, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Marieke J van der Werf
- Disease Programme Tuberculosis, European Centre for Disease Prevention and Control, Stockholm, Sweden
| | | | - Bhanu Williams
- Northwick Park Hospital, London Northwest Healthcare NHS Trust, London, United Kingdom
| | - Elena Yablokova
- Northern State Medical University, Arkhangelsk, Russian Federation
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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Abstract
PURPOSE OF REVIEW Advances in diagnostic methods mean that co-infections are increasingly being detected in clinical practice, yet their significance is not always obvious. In parallel, basic science studies are increasingly investigating interactions between pathogens to try to explain real-life observations and elucidate biological mechanisms. RECENT FINDINGS Co-infections may be insignificant, detrimental, or even beneficial, and these outcomes can occur through multiple levels of interactions which include modulation of the host response, altering the performance of diagnostic tests, and drug-drug interactions during treatment. The harmful effects of chronic co-infections such as tuberculosis or Hepatitis B and C in association with HIV are well established, and recent studies have focussed on strategies to mitigate these effects. However, consequences of many acute co-infections are much less certain, and recent conflicting findings simply highlight many of the challenges of studying naturally acquired infections in humans. SUMMARY Tackling these challenges, using animal models, or careful prospective studies in humans may prove to be worthwhile. There are already tantalizing examples where identification and treatment of relevant co-infections seems to hold promise for improved health outcomes.
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Affiliation(s)
| | - Anna Turkova
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London
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Chabala C, Turkova A, Thomason MJ, Wobudeya E, Hissar S, Mave V, van der Zalm M, Palmer M, Kapasa M, Bhavani PK, Balaji S, Raichur PA, Demers AM, Hoddinott G, Owen-Powell E, Kinikar A, Musoke P, Mulenga V, Aarnoutse R, McIlleron H, Hesseling A, Crook AM, Cotton M, Gibb DM. Shorter treatment for minimal tuberculosis (TB) in children (SHINE): a study protocol for a randomised controlled trial. Trials 2018; 19:237. [PMID: 29673395 PMCID: PMC5909210 DOI: 10.1186/s13063-018-2608-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 03/15/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) in children is frequently paucibacillary and non-severe forms of pulmonary TB are common. Evidence for tuberculosis treatment in children is largely extrapolated from adult studies. Trials in adults with smear-negative tuberculosis suggest that treatment can be effectively shortened from 6 to 4 months. New paediatric, fixed-dose combination anti-tuberculosis treatments have recently been introduced in many countries, making the implementation of World Health Organisation (WHO)-revised dosing recommendations feasible. The safety and efficacy of these higher drug doses has not been systematically assessed in large studies in children, and the pharmacokinetics across children representing the range of weights and ages should be confirmed. METHODS/DESIGN SHINE is a multicentre, open-label, parallel-group, non-inferiority, randomised controlled, two-arm trial comparing a 4-month vs the standard 6-month regimen using revised WHO paediatric anti-tuberculosis drug doses. We aim to recruit 1200 African and Indian children aged below 16 years with non-severe TB, with or without HIV infection. The primary efficacy and safety endpoints are TB disease-free survival 72 weeks post randomisation and grade 3 or 4 adverse events. Nested pharmacokinetic studies will evaluate anti-tuberculosis drug concentrations, providing model-based predictions for optimal dosing, and measure antiretroviral exposures in order to describe the drug-drug interactions in a subset of HIV-infected children. Socioeconomic analyses will evaluate the cost-effectiveness of the intervention and social science studies will further explore the acceptability and palatability of these new paediatric drug formulations. DISCUSSION Although recent trials of TB treatment-shortening in adults with sputum-positivity have not been successful, the question has never been addressed in children, who have mainly paucibacillary, non-severe smear-negative disease. SHINE should inform whether treatment-shortening of drug-susceptible TB in children, regardless of HIV status, is efficacious and safe. The trial will also fill existing gaps in knowledge on dosing and acceptability of new anti-tuberculosis formulations and commonly used HIV drugs in settings with a high burden of TB. A positive result from this trial could simplify and shorten treatment, improve adherence and be cost-saving for many children with TB. Recruitment to the SHINE trial begun in July 2016; results are expected in 2020. TRIAL REGISTRATION International Standard Randomised Controlled Trials Number: ISRCTN63579542 , 14 October 2014. Pan African Clinical Trials Registry Number: PACTR201505001141379 , 14 May 2015. Clinical Trial Registry-India, registration number: CTRI/2017/07/009119, 27 July 2017.
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Affiliation(s)
- Chishala Chabala
- University Teaching Hospital, Children’s Hospital, Private Bag RW IX, Ridgeway, Lusaka, Zambia
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - Margaret J. Thomason
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - Eric Wobudeya
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
| | - Syed Hissar
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | | | - Megan Palmer
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Monica Kapasa
- University Teaching Hospital, Children’s Hospital, Private Bag RW IX, Ridgeway, Lusaka, Zambia
| | - Perumal K. Bhavani
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Sarath Balaji
- India Institute of Child Health and Hospital for Children, Chennai, India
| | | | - Anne-Marie Demers
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Ellen Owen-Powell
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Philippa Musoke
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
| | - Veronica Mulenga
- University Teaching Hospital, Children’s Hospital, Private Bag RW IX, Ridgeway, Lusaka, Zambia
| | - Rob Aarnoutse
- Radbound University Medical Center, Nijmegen, The Netherlands
| | | | - Anneke Hesseling
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Angela M. Crook
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - Mark Cotton
- Family Infectious Diseases Clinical Research Unit, Stellensbosch University, Cape Town, South Africa
| | - Diana M. Gibb
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
| | - on behalf of the SHINE trial team
- University Teaching Hospital, Children’s Hospital, Private Bag RW IX, Ridgeway, Lusaka, Zambia
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, High Holborn, London, WC1V 6LJ UK
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
- Byramjee Jeejeebhoy Government Medical College, Pune, India
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
- India Institute of Child Health and Hospital for Children, Chennai, India
- Radbound University Medical Center, Nijmegen, The Netherlands
- University of Cape Town, Cape Town, South Africa
- Family Infectious Diseases Clinical Research Unit, Stellensbosch University, Cape Town, South Africa
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Turkova A, Chappell E, Chalermpantmetagul S, Negra MD, Volokha A, Primak N, Solokha S, Rozenberg V, Kiselyova G, Yastrebova E, Miloenko M, Bashakatova N, Kanjanavanit S, Calvert J, Rojo P, Ansone S, Jourdain G, Malyuta R, Goodall R, Judd A, Thorne C. Tuberculosis in HIV-infected children in Europe, Thailand and Brazil: paediatric TB-HIV EuroCoord study. Int J Tuberc Lung Dis 2018; 20:1448-1456. [PMID: 27776584 DOI: 10.5588/ijtld.16.0067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Centres participating in the Paediatric European Network for Treatment of AIDS (PENTA), including Thailand and Brazil. OBJECTIVE To describe the incidence, presentation, treatment and treatment outcomes of tuberculosis (TB) in human immunodeficiency virus (HIV) infected children. DESIGN Observational study of TB diagnosed in HIV-infected children in 2011-2013. RESULTS Of 4265 children aged <16 years, 127 (3%) were diagnosed with TB: 6 (5%) in Western Europe, 80 (63%) in Eastern Europe, 27 (21%) in Thailand and 14 (11%) in Brazil, with estimated TB incidence rates of respectively 239, 982, 1633 and 2551 per 100 000 person-years (py). The majority (94%) had acquired HIV perinatally. The median age at TB diagnosis was 6.8 years (interquartile range 3.0-11.5). Over half (52%) had advanced/severe World Health Organization stage immunodeficiency; 67 (53%) were not on antiretroviral therapy (ART) at TB diagnosis. Preventive anti-tuberculosis treatment was given to 23% (n = 23) of 102 children diagnosed with HIV before TB. Eleven children had unfavourable TB outcomes: 4 died, 5 did not complete treatment, 1 had recurrent TB and 1 had an unknown outcome. In univariable analysis, previous diagnosis of acquired immune-deficiency syndrome, not being virologically suppressed on ART at TB diagnosis and region (Brazil) were significantly associated with unfavourable TB outcomes. CONCLUSION Most TB cases were from countries with high TB prevalence. The majority (91%) had favourable outcomes. Universal ART and TB prophylaxis may reduce missed opportunities for TB prevention.
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Affiliation(s)
- A Turkova
- Medical Research Council Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials & Methodology, London, UK
| | - E Chappell
- Medical Research Council Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials & Methodology, London, UK
| | - S Chalermpantmetagul
- Research Unit, Program for HIV Prevention and Treatment (Program for HIV Prevention and Treatment/Institut de Recherche pour le Développement Unités Mixtes Internationales 174), Chiang Mai, Thailand
| | - M Della Negra
- Instituto de Infectologia Emilio Ribas, São Paolo, São Paolo, Brazil
| | - A Volokha
- Kyiv City Centre for Prevention and Control of AIDS, Kyiv, Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
| | - N Primak
- Kryvyi Rih City Centre for Prevention and Control of AIDS, Kryvyi Rih, Ukraine
| | - S Solokha
- Donetsk Regional Centre for Prevention and Control of AIDS, Donetsk, Ukraine
| | - V Rozenberg
- Irkutsk Regional Centre for Prevention and Control of AIDS and Infectious Diseases, Irkutsk, Ukraine
| | - G Kiselyova
- Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
| | - E Yastrebova
- St Petersburg City Centre for Prevention and Control of AIDS and Infectious Diseases, St Petersburg, Russian Federation
| | - M Miloenko
- Republican Clinical Hospital of Infectious Diseases, St Petersburg, Russian Federation
| | - N Bashakatova
- Marioupol City Centre for Prevention and Control of AIDS, Marioupol, Ukraine
| | - S Kanjanavanit
- Nakornping Hospital, Chiang Mai, Thailand; ***Hospital 12 de Octubre, Universidad Complutense, Madrid, Spain
| | - J Calvert
- Medical Research Council Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials & Methodology, London, UK
| | - P Rojo
- Donetsk Regional Centre for Prevention and Control of AIDS, Donetsk, Ukraine
| | - S Ansone
- Riga East University Hospital, Latvian Centre of Infectious Diseases, Riga, Latvia
| | - G Jourdain
- Research Unit, Program for HIV Prevention and Treatment (Program for HIV Prevention and Treatment/Institut de Recherche pour le Développement Unités Mixtes Internationales 174), Chiang Mai, Thailand
| | - R Malyuta
- Perinatal Prevention of AIDS Initiative, Odessa, Ukraine
| | - R Goodall
- Medical Research Council Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials & Methodology, London, UK
| | - A Judd
- Medical Research Council Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials & Methodology, London, UK
| | - C Thorne
- Institute of Child Health, UCL, London, UK
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Tierrablanca LE, Ochalek J, Ford D, Babiker A, Gibb D, Butler K, Turkova A, Griffin S, Revill P. Economic evaluation of weekends-off antiretroviral therapy for young people in 11 countries. Medicine (Baltimore) 2018; 97:e9698. [PMID: 29384848 PMCID: PMC5805420 DOI: 10.1097/md.0000000000009698] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 11/07/2017] [Accepted: 01/01/2018] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To analyze the cost effectiveness of short-cycle therapy (SCT), where patients take antiretroviral (ARV) drugs 5 consecutive days a week and have 2 days off, as an alternative to continuous ARV therapy for young people infected with human immunodeficiency virus (HIV) and taking efavirenz-based first-line ARV drugs. METHODS We conduct a hierarchical cost-effectiveness analysis based on data on clinical outcomes and resource use from the BREATHER trial. BREATHER is a randomized trial investigating the effectiveness of SCT and continuous therapy in 199 participants aged 8 to 24 years and taking efavirenz-based first-line ARV drugs in 11 countries worldwide. Alongside nationally representative unit costs/prices, these data were used to estimate costs and quality adjusted life years (QALYs). An incremental cost-effectiveness comparison was performed using a multilevel bivariate regression approach for total costs and QALYs. Further analyses explored cost-effectiveness in low- and middle-income countries with access to low-cost generic ARV drugs and high-income countries purchasing branded ARV drugs, respectively. RESULTS At 48 weeks, SCT offered significant total cost savings over continuous therapy of US dollar (USD) 41 per patient in countries using generic drugs and USD 4346 per patient in countries using branded ARV drugs, while accruing nonsignificant total health benefits of 0.008 and 0.009 QALYs, respectively. Cost-effectiveness estimates were similar across settings with access to generic ARV drugs but showed significant variation among high-income countries where branded ARV drugs are purchased. CONCLUSION SCT is a cost-effective treatment alternative to continuous therapy for young people infected with HIV in countries where viral load monitoring is available.
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Affiliation(s)
| | | | - Deborah Ford
- Medical Research Council Clinical Trials Unit, University College London, London
| | - Ab Babiker
- Medical Research Council Clinical Trials Unit, University College London, London
| | - Diana Gibb
- Medical Research Council Clinical Trials Unit, University College London, London
| | | | - Anna Turkova
- Medical Research Council Clinical Trials Unit, University College London, London
- Great Ormond Street Hospital, London, UK
| | - Susan Griffin
- Centre for Health Economics, University of York, York
| | - Paul Revill
- Centre for Health Economics, University of York, York
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Judd A, Chappell E, Turkova A, Le Coeur S, Noguera-Julian A, Goetghebuer T, Doerholt K, Galli L, Pajkrt D, Marques L, Collins IJ, Gibb DM, González Tome MI, Navarro M, Warszawski J, Königs C, Spoulou V, Prata F, Chiappini E, Naver L, Giaquinto C, Thorne C, Marczynska M, Okhonskaia L, Posfay-Barbe K, Ounchanum P, Techakunakorn P, Kiseleva G, Malyuta R, Volokha A, Ene L, Goodall R. Long-term trends in mortality and AIDS-defining events after combination ART initiation among children and adolescents with perinatal HIV infection in 17 middle- and high-income countries in Europe and Thailand: A cohort study. PLoS Med 2018; 15:e1002491. [PMID: 29381702 PMCID: PMC5790238 DOI: 10.1371/journal.pmed.1002491] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 12/13/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Published estimates of mortality and progression to AIDS as children with HIV approach adulthood are limited. We describe rates and risk factors for death and AIDS-defining events in children and adolescents after initiation of combination antiretroviral therapy (cART) in 17 middle- and high-income countries, including some in Western and Central Europe (W&CE), Eastern Europe (Russia and Ukraine), and Thailand. METHODS AND FINDINGS Children with perinatal HIV aged <18 years initiating cART were followed until their 21st birthday, transfer to adult care, death, loss to follow-up, or last visit up until 31 December 2013. Rates of death and first AIDS-defining events were calculated. Baseline and time-updated risk factors for early/late (≤/>6 months of cART) death and progression to AIDS were assessed. Of 3,526 children included, 32% were from the United Kingdom or Ireland, 30% from elsewhere in W&CE, 18% from Russia or Ukraine, and 20% from Thailand. At cART initiation, median age was 5.2 (IQR 1.4-9.3) years; 35% of children aged <5 years had a CD4 lymphocyte percentage <15% in 1997-2003, which fell to 15% of children in 2011 onwards (p < 0.001). Similarly, 53% and 18% of children ≥5 years had a CD4 count <200 cells/mm3 in 1997-2003 and in 2011 onwards, respectively (p < 0.001). Median follow-up was 5.6 (2.9-8.7) years. Of 94 deaths and 237 first AIDS-defining events, 43 (46%) and 100 (42%) were within 6 months of initiating cART, respectively. Multivariable predictors of early death were: being in the first year of life; residence in Russia, Ukraine, or Thailand; AIDS at cART start; initiating cART on a nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen; severe immune suppression; and low BMI-for-age z-score. Current severe immune suppression, low current BMI-for-age z-score, and current viral load >400 c/mL predicted late death. Predictors of early and late progression to AIDS were similar. Study limitations include incomplete recording of US Centers for Disease Control (CDC) disease stage B events and serious adverse events in some countries; events that were distributed over a long time period, and that we lacked power to analyse trends in patterns and causes of death over time. CONCLUSIONS In our study, 3,526 children and adolescents with perinatal HIV infection initiated antiretroviral therapy (ART) in countries in Europe and Thailand. We observed that over 40% of deaths occurred ≤6 months after cART initiation. Greater early mortality risk in infants, as compared to older children, and in Russia, Ukraine, or Thailand as compared to W&CE, raises concern. Current severe immune suppression, being underweight, and unsuppressed viral load were associated with a higher risk of death at >6 months after initiation of cART.
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Affiliation(s)
| | - Ali Judd
- MRC Clinical Trials Unit, University College London (UCL), London, United Kingdom
- * E-mail:
| | - Elizabeth Chappell
- MRC Clinical Trials Unit, University College London (UCL), London, United Kingdom
| | - Anna Turkova
- MRC Clinical Trials Unit, University College London (UCL), London, United Kingdom
| | - Sophie Le Coeur
- Institut National d'Etude Demographique (INED), Mortality, Health and Epidemiology Unit, Paris, France
- Institut de Recherche pour le Developpement (IRD), UMI 174/PHPT, Chiang Mai, Thailand
| | - Antoni Noguera-Julian
- Unitat d’Infectologia, Servei de Pediatria, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
| | | | - Katja Doerholt
- St George’s Healthcare NHS Trust, London, United Kingdom
| | - Luisa Galli
- Department of Health Sciences, Pediatric Unit, University of Florence, Florence, Italy
| | - Dasja Pajkrt
- Department of Pediatric Infectious Diseases, Emma Children’s Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Intira J. Collins
- MRC Clinical Trials Unit, University College London (UCL), London, United Kingdom
| | - Diana M. Gibb
- MRC Clinical Trials Unit, University College London (UCL), London, United Kingdom
| | | | - Marisa Navarro
- Hospital General Universitario "Gregorio Marañón", Madrid, Spain
| | - Josiane Warszawski
- Institut National de la Santé et de la Recherche (INSERM), Paris, France
| | - Christoph Königs
- University Hospital Frankfurt, Department of Paediatrics, Goethe University, Frankfurt, Germany
| | - Vana Spoulou
- University of Athens Medical School, Athens, Greece
| | | | - Elena Chiappini
- Department of Health Sciences, Pediatric Unit, University of Florence, Florence, Italy
| | - Lars Naver
- Karolinska University Hospital, Stockholm, Sweden
| | - Carlo Giaquinto
- Paediatric European Network for the Treatment of AIDS (PENTA), Padova, Italy
| | - Claire Thorne
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | | | | | | | | | | | - Galina Kiseleva
- Shupyk National Medical Academy of Postgraduate Education, Kiev, Ukraine
| | - Ruslan Malyuta
- Perinatal Prevention of AIDS Initiative, Odessa, Ukraine
| | - Alla Volokha
- Shupyk National Medical Academy of Postgraduate Education, Kiev, Ukraine
| | | | - Ruth Goodall
- MRC Clinical Trials Unit, University College London (UCL), London, United Kingdom
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47
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Melvin AJ, Warshaw M, Compagnucci A, Saidi Y, Harrison L, Turkova A, Tudor-Williams G. Hepatic, Renal, Hematologic, and Inflammatory Markers in HIV-Infected Children on Long-term Suppressive Antiretroviral Therapy. J Pediatric Infect Dis Soc 2017; 6:e109-e115. [PMID: 28903520 PMCID: PMC5907869 DOI: 10.1093/jpids/pix050] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 06/03/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Data on long-term toxicity of antiretroviral therapy (ART) in HIV-infected children are sparse. PENPACT-1 was an open-label trial in which HIV-infected children were assigned randomly to receive protease inhibitor (PI)- or nonnucleoside reverse-transcriptase inhibitor (NNRTI)-based ART. METHODS We examined changes in clinical, immunologic, and inflammatory markers from baseline to year 4 in the subset of children in the PENPACT-1 study who experienced viral suppression between week 24 and year 4 of ART. Liver enzyme, creatinine, and cholesterol levels and hematologic parameters were assessed during the trial. Cystatin C, high-sensitivity C-reactive protein (hs-CRP), interleukin 6 (IL-6), d-dimer, and soluble CD14 (sCD14) were assayed from cryopreserved specimens. RESULTS Ninety-nine children (52 on PI-based and 47 on NNRTI-based ART) met inclusion criteria. The median age at initiation of ART was 6.5 years (interquartile range [IQR], 3.7-13.4 years), and 22% were aged <3 years at ART initiation; 56% of the PI-treated children received lopinavir/ritonavir, and 70% of NNRTI-treated children received efavirenz initially. We found no evidence of significant clinical toxicity in either group; growth, liver, kidney, and hematologic parameters either remained unchanged or improved between baseline and year 4. Total cholesterol levels increased modestly, but no difference between the groups was found. IL-6 and hs-CRP levels decreased more after 4 years in the NNRTI-based ART group. The median change in IL-6 level was -0.35 pg/ml in the PI-based ART group and -1.0 in the NNRTI-based ART group (P = .05), and the median change in hs-CRP level was 0.25 µg/ml in the PI-based ART group and -0.95 µg/ml in the NNRTI-based ART group (P = .005). CONCLUSION These results support the safety of prolonged ART use in HIV-infected children and suggest that suppressive NNRTI-based regimens can be associated with lower levels of systemic inflammation.
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Affiliation(s)
- Ann J Melvin
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Washington and Seattle Children’s Research Institute
| | - Meredith Warshaw
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | | | | | - Linda Harrison
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Anna Turkova
- Medical Research Council, Clinical Trials Unit, London, United Kingdom; and
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48
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Turkova A, Kampmann B. Short course treatment for MDR TB: jumping the gun? Thorax 2017; 72:773. [PMID: 28442556 DOI: 10.1136/thoraxjnl-2017-210163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Anna Turkova
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, London, UK
| | - Beate Kampmann
- Imperial College London, UK and MRC Unit The Gambia, West Africa
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49
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Turkova A, Tebruegge M, Brinkmann F, Tsolia M, Mouchet F, Kampmann B, Seddon JA. Management of child MDR-TB contacts across countries in the WHO European Region: a survey of current practice. Int J Tuberc Lung Dis 2017; 21:774-777. [PMID: 28633701 DOI: 10.5588/ijtld.16.0949] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The World Health Organization European Region has one of the highest rates of multidrug-resistant tuberculosis (MDR-TB) in the world, resulting in many vulnerable children being exposed each year. Evidence for preventive therapy following MDR-TB exposure is limited and current guidance is conflicting. An internet-based survey was performed to determine clinical practice in this region. Seventy-two clinicians from 25 countries participated. Practices related to screening and decision-making were highly variable. Just over half provided preventive therapy for children exposed to MDR-TB; the only characteristic associated with provision was practice within the European Union (adjusted OR 4.07, 95%CI 1.33-12.5).
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Affiliation(s)
- A Turkova
- Medical Research Council Clinical Trials Unit at University College London, London, Department of Paediatric Infectious Diseases, Great Ormond Street Hospital, London
| | - M Tebruegge
- Academic Unit of Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, Southampton Respiratory Biomedical Research Unit, Southampton University Hospital NHS Foundation Trust, Southampton, Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - F Brinkmann
- Department of Paediatric Pulmonology, Children's Hospital, Ruhr University Bochum, Bochum, Germany
| | - M Tsolia
- Second University Department of Paediatrics, National and Kapodistrian University of Athens School of Medicine, 'P. & A. Kyriakou' Children's Hospital, Athens, Greece
| | - F Mouchet
- Department of Paediatrics, Centre Hospitalière Universitaire Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - B Kampmann
- Medical Research Council Unit, The Gambia, Banjul, The Gambia, Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK
| | - J A Seddon
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK
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50
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Smirnova PA, Turkova A, Nikishova EI, Seddon JA, Chappell E, Zolotaya OA, Mironuk OM, Maryandyshev AO. Multidrug-resistant tuberculosis in children in northwest Russia: an observational cohort study. Eur Respir J 2016; 48:1496-1499. [PMID: 27587542 DOI: 10.1183/13993003.00354-2016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 07/06/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Polina A Smirnova
- Child and Adolescent Specialised Centre, Arkhangelsk Regional Tuberculosis Dispensary, Arkhangelsk, Russian Federation.,Both authors contributed equally
| | - Anna Turkova
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK .,Both authors contributed equally
| | - Elena I Nikishova
- Dept of Phthisiopulmonology, Northern State Medical University, Arkhangelsk, Russian Federation
| | - James A Seddon
- Dept of Academic Paediatrics, Imperial College London, London, UK
| | - Elizabeth Chappell
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Olga A Zolotaya
- Child and Adolescent Specialised Centre, Arkhangelsk Regional Tuberculosis Dispensary, Arkhangelsk, Russian Federation
| | - Oxana M Mironuk
- Child and Adolescent Specialised Centre, Arkhangelsk Regional Tuberculosis Dispensary, Arkhangelsk, Russian Federation
| | - Andrey O Maryandyshev
- Dept of Phthisiopulmonology, Northern State Medical University, Arkhangelsk, Russian Federation
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