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Higgins E, Palaniappan N, Nabi Z, Elliott K, Miles L, Lad R, Nixon L, Canham J, Hurt C, Heiberg C, Beasley M, Jones T, Webster R, Evans M. Does variation in swallowing organs-at-risk (SWOAR) delineation impact on predicted swallowing dysfunction for PATHOS trial patients? Clin Oncol (R Coll Radiol) 2022. [DOI: 10.1016/j.clon.2022.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Dickinson L, Walimbwa S, Singh Y, Kaboggoza J, Kintu K, Sihlangu M, Coombs JA, Malaba TR, Byamugisha J, Pertinez H, Amara A, Gini J, Else L, Heiberg C, Hodel EM, Reynolds H, Myer L, Waitt C, Khoo S, Lamorde M, Orrell C. Infant exposure to dolutegravir through placental and breastmilk transfer: a population pharmacokinetic analysis of DolPHIN-1. Clin Infect Dis 2020; 73:e1200-e1207. [PMID: 33346335 PMCID: PMC8423479 DOI: 10.1093/cid/ciaa1861] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 09/01/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Rapid reduction of HIV viral load is paramount to prevent peripartum transmission in women diagnosed late in pregnancy. We investigated dolutegravir population pharmacokinetics in maternal plasma, cord, breastmilk and infant plasma of DolPHIN-1 participants (NCT02245022) presenting with untreated HIV late in pregnancy (28-36 weeks gestation). METHODS Pregnant women from Uganda and South Africa were randomised (1:1) to daily dolutegravir (50 mg) or efavirenz-based therapy. Dolutegravir pharmacokinetic sampling (0-24 hours) was undertaken 14 days after treatment initiation and within 1-3 weeks of delivery, with matched maternal and cord samples at delivery. Mothers switched to efavirenz and maternal and infant plasma and breastmilk samples taken 24, 48 or 72 hours post-switch. Nonlinear mixed effects (NONMEM v. 7.4) was used to describe dolutegravir in all matrices and to evaluate covariates. RESULTS Twenty-eight women and 22 infants were included. Maternal dolutegravir was described by a two-compartment model linked to a fetal and breastmilk compartment. Cord and breastmilk to maternal plasma ratios were 1.279 (1.209-1.281) and 0.033 (0.021-0.050), respectively. Infant dolutegravir was described by breastmilk-to-infant and infant elimination rate constants. No covariate effects were observed. Predicted infant dolutegravir half-life and time to protein adjusted-IC90 (0.064 mg/L) for those above this threshold were 37.9 hours (22.1-63.5) and 108.9 hours [(18.6-129.6); 4.5 days (0.8-5.4); n=13]. CONCLUSIONS Breastfeeding contributed relatively little to infant plasma exposures but a median of 4.5 days additional prophylaxis to some of the breastfed infants was observed following maternal dolutegravir cessation (3-15 days postpartum), which waned with time postpartum as transplacental dolutegravir cleared.
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Affiliation(s)
- Laura Dickinson
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Stephen Walimbwa
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Yashna Singh
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Julian Kaboggoza
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Kenneth Kintu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Mary Sihlangu
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Julie-Anne Coombs
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Thokozile R Malaba
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Josaphat Byamugisha
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Henry Pertinez
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Alieu Amara
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Joshua Gini
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Laura Else
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Christie Heiberg
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - Eva Maria Hodel
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Helen Reynolds
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Catriona Waitt
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Saye Khoo
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
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Sanne I, Orrell C, Fox M, Conradie F, Ive P, Zeinecker J, Cornell M, Heiberg C, Ingram C, Panchia R, Rassool M, Gonin R, Stevens W, Truter H, Dehlinger M, van der Horst C, McIntyre J, Wood R. Nurse versus doctor management of HIV-infected patients receiving antiretroviral therapy (CIPRA-SA): a randomised non-inferiority trial. Lancet 2010; 376:33-40. [PMID: 20557927 PMCID: PMC3145152 DOI: 10.1016/s0140-6736(10)60894-x] [Citation(s) in RCA: 185] [Impact Index Per Article: 13.2] [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: 11/27/2022]
Abstract
BACKGROUND Expanded access to combination antiretroviral therapy (ART) in resource-poor settings is dependent on task shifting from doctors to other health-care providers. We compared outcomes of nurse versus doctor management of ART care for HIV-infected patients. METHODS This randomised non-inferiority trial was undertaken at two South African primary-care clinics. HIV-positive individuals with a CD4 cell count of less than 350 cells per microL or WHO stage 3 or 4 disease were randomly assigned to nurse-monitored or doctor-monitored ART care. Patients were randomly assigned by stratified permuted block randomisation, and neither the patients nor those analysing the data were masked to assignment. The primary objective was a composite endpoint of treatment-limiting events, incorporating mortality, viral failure, treatment-limiting toxic effects, and adherence to visit schedule. Analysis was by intention to treat. Non-inferiority of the nurse versus doctor group for cumulative treatment failure was prespecified as an upper 95% CI for the hazard ratio that was less than 1.40. This study is registered with ClinicalTrials.gov, number NCT00255840. FINDINGS 408 patients were assigned to doctor-monitored ART care and 404 to nurse-monitored ART care; all participants were analysed. 371 (46%) patients reached an endpoint of treatment failure: 192 (48%) in the nurse group and 179 (44%) in the doctor group. The hazard ratio for composite failure was 1.09 (95% CI 0.89-1.33), which was within the limits for non-inferiority. After a median follow-up of 120 weeks (IQR 60-144), deaths (ten vs 11), virological failures (44 vs 39), toxicity failures (68 vs 66), and programme losses (70 vs 63) were similar in nurse and doctor groups, respectively. INTERPRETATION Nurse-monitored ART is non-inferior to doctor-monitored therapy. Findings from this study lend support to task shifting to appropriately trained nurses for monitoring of ART. FUNDING National Institutes of Health; United States Agency for International Development; National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Ian Sanne
- Faculty of Health Sciences, University of the Witwatersrand
| | | | - Matthew Fox
- Center for Global Health and Development, Boston University
| | | | - Prudence Ive
- Faculty of Health Sciences, University of the Witwatersrand
| | | | | | | | | | | | | | | | - Wendy Stevens
- Faculty of Health Sciences, University of the Witwatersrand
| | - Handré Truter
- Faculty of Health Sciences, University of the Witwatersrand
| | | | | | - James McIntyre
- Faculty of Health Sciences, University of the Witwatersrand
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Sanne I, Orrell C, Fox M, Conradie F, Ive P, Zeinecker J, Cornell M, Heiberg C, Ingram C, Panchia R, Rassool M, Gonin R, Stevens W, Truter H, Dehlinger M, van der Horst C, McIntyre J, Wood R. Nurse versus doctor management of HIV-infected patients receiving antiretroviral therapy (CIPRA-SA): a randomised non-inferiority trial. Lancet 2010. [PMID: 20557927 PMCID: PMC3145152 DOI: 10.1016/s0140-6736%2810%2960894-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Expanded access to combination antiretroviral therapy (ART) in resource-poor settings is dependent on task shifting from doctors to other health-care providers. We compared outcomes of nurse versus doctor management of ART care for HIV-infected patients. METHODS This randomised non-inferiority trial was undertaken at two South African primary-care clinics. HIV-positive individuals with a CD4 cell count of less than 350 cells per microL or WHO stage 3 or 4 disease were randomly assigned to nurse-monitored or doctor-monitored ART care. Patients were randomly assigned by stratified permuted block randomisation, and neither the patients nor those analysing the data were masked to assignment. The primary objective was a composite endpoint of treatment-limiting events, incorporating mortality, viral failure, treatment-limiting toxic effects, and adherence to visit schedule. Analysis was by intention to treat. Non-inferiority of the nurse versus doctor group for cumulative treatment failure was prespecified as an upper 95% CI for the hazard ratio that was less than 1.40. This study is registered with ClinicalTrials.gov, number NCT00255840. FINDINGS 408 patients were assigned to doctor-monitored ART care and 404 to nurse-monitored ART care; all participants were analysed. 371 (46%) patients reached an endpoint of treatment failure: 192 (48%) in the nurse group and 179 (44%) in the doctor group. The hazard ratio for composite failure was 1.09 (95% CI 0.89-1.33), which was within the limits for non-inferiority. After a median follow-up of 120 weeks (IQR 60-144), deaths (ten vs 11), virological failures (44 vs 39), toxicity failures (68 vs 66), and programme losses (70 vs 63) were similar in nurse and doctor groups, respectively. INTERPRETATION Nurse-monitored ART is non-inferior to doctor-monitored therapy. Findings from this study lend support to task shifting to appropriately trained nurses for monitoring of ART. FUNDING National Institutes of Health; United States Agency for International Development; National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Ian Sanne
- Faculty of Health Sciences, University of the Witwatersrand
| | | | - Matthew Fox
- Center for Global Health and Development, Boston University
| | | | - Prudence Ive
- Faculty of Health Sciences, University of the Witwatersrand
| | | | | | | | | | | | | | | | - Wendy Stevens
- Faculty of Health Sciences, University of the Witwatersrand
| | - Handré Truter
- Faculty of Health Sciences, University of the Witwatersrand
| | | | | | - James McIntyre
- Faculty of Health Sciences, University of the Witwatersrand
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