Results of antiretroviral treatment interruption and intensification in advanced multi-drug resistant HIV infection from the OPTIMA trial

BACKGROUND

Guidance is needed on best medical management for advanced HIV disease with multidrug resistance (MDR) and limited retreatment options. We assessed two novel antiretroviral (ARV) treatment approaches in this setting.

METHODS AND FINDINGS

We conducted a 2×2 factorial randomized open label controlled trial in patients with a CD4 count≤300 cells/µl who had ARV treatment (ART) failure requiring retreatment, to two options (a) re-treatment with either standard (≤4 ARVs) or intensive (≥5 ARVs) ART and b) either treatment starting immediately or after a 12-week monitored ART interruption. Primary outcome was time to developing a first AIDS-defining event (ADE) or death from any cause. Analysis was by intention to treat. From 2001 to 2006, 368 patients were randomized. At baseline, mean age was 48 years, 2% were women, median CD4 count was 106/µl, mean viral load was 4.74 log(10) copies/ml, and 59% had a prior AIDS diagnosis. Median follow-up was 4.0 years in 1249 person-years of observation. There were no statistically significant differences in the primary composite outcome of ADE or death between re-treatment options of standard versus intensive ART (hazard ratio 1.17; CI 0.86-1.59), or between immediate retreatment initiation versus interruption before re-treatment (hazard ratio 0.93; CI 0.68-1.30), or in the rate of non-HIV associated serious adverse events between re-treatment options.

CONCLUSIONS

We did not observe clinical benefit or harm assessed by the primary outcome in this largest and longest trial exploring both ART interruption and intensification in advanced MDR HIV infection with poor retreatment options.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00050089.

Study conduct, monitoring and data management in a trinational trial: the OPTIMA model

The OPTions In Management with Antiretrovirals (OPTIMA) Trial, a collaboration between three governmental agencies in the USA, UK and Canada is a large-scale, multicenter, randomized controlled trial designed to compare the relative efficacy of different therapeutic strategies in HIV disease. The collaboration of three coordinating centers introduced unique data management issues including: a) use of different data systems for managing "country" trial data; b) two-way data transfer between the coordinating centers and the center where OPTIMA data is merged and analysis files are generated; and c) translation of certain data forms (mainly patient completed questionnaires) into French and Spanish. The involvement of three data centers provided a challenge in planning, designing and executing data management procedures in OPTIMA. Processes were implemented to ensure the trial's successful execution at the trinational level, without disregarding country-specific requirements and regulations. The OPTIMA model required a significant time and resource investment on behalf of all agencies involved, but allowed for autonomy and a sense of joint ownership of data in different countries.

Diabetes teaching--outcome analysis

A comprehensive database has been maintained on patients attending the St. Paul's Hospital Diabetes Teaching and Treatment Centre (DTTC) since 1984. In November 1995, four sets of patients, all of whom had returned to the Centre, were identified for an outcome study. The sets were: insulin-dependent diabetes mellitus (IDDM), diet-treated non-insulin-dependent diabetes mellitus (NIDDM), oral agent-treated NIDDM, insulin-treated NIDDM. Data on glycosylated hemoglobin (A1c) values, percent ideal body weight (%IBW), home blood glucose monitoring (HBGM/week were analysed for all sets; data on hypoglycemic events/month were analysed only for the group with IDDM. Results demonstrated that patients in all groups performed significantly more HBGM over time. Downward change in %IBW in the diet-treated and oral agent groups was significant. Upward change in %IBW was significant in the IDDM group. Hypoglycemic events did not significantly increase in IDDM patients even though A1c improved. Most notably, the A1c values improved in all four groups up to 8 years after the first DTTC visit. Implications for practice are suggested.