A Pragmatic, Randomized Controlled Trial of Oral Antivirals for the Treatment of Chronic Hepatitis C: The PRIORITIZE Study

BACKGROUND AND AIMS

Multiple direct-acting antiviral (DAA) regimens are available to treat HCV genotype 1 infection. However, comparative effectiveness from randomized controlled trials of DAA regimens is unavailable.

APPROACH AND RESULTS

We conducted a pragmatic randomized controlled trial (NCT02786537) to compare the effectiveness of DAAs for HCV genotype 1a or 1b on viral response, safety, tolerability, and medication nonadherence. Adults with compensated liver disease, HCV genotype 1, not pregnant or breastfeeding, and with health insurance likely to cover ledipasvir/sofosbuvir (LDV/SOF) were recruited from 34 US viral hepatitis clinics. Participants were randomized (± ribavirin) to LDV/SOF, elbasvir/grazoprevir (EBR/GZR), and paritaprevir/ritonavir/ombitasvir+dasabuvir (PrOD; treatment arm stopped early). Primary outcomes included sustained viral response at 12 weeks (SVR12), clinician-recorded adverse events, patient-reported symptoms, and medication nonadherence. Between June 2016 and March 2018, 1,609 participants were randomized. Among 1,128 participants who received ≥1 dose of EBR/GZR or LDV/SOF (± ribavirin), SVR12 was 95.2% (95% CI, 92.8%-97.6%) and 97.4% (95% CI, 95.5%-99.2%), respectively, with a difference estimate of 2.2% (-0.5% to 4.7%), falling within the "equivalence" interval (-5% to 5%). While most (56%) participants experienced adverse events, few were serious (4.2%) or severe (1.8%). In the absence of ribavirin, discontinuations due to adverse events were rare. Patient-reported symptoms and medication nonadherence were similar. Study limitations were dropout due to insurance denial and loss to follow-up after treatment, limiting the ability to measure SVR12.

CONCLUSIONS

This pragmatic trial demonstrated high SVR12 for participants treated with EBR/GZR and LDV/SOF with few adverse effects. Overall, the two regimens were equivalent in effectiveness. The results support current HCV guidelines that do not distinguish between ribavirin-free EBR/GZR and LDV/SOF.

Forage tree legumes. IV. Productivity of leucaena/grass mixtures

A field experiment was conducted in a wet tropical environment (Ciawi, West Java, Indonesia) to assess the forage yields of mixtures of leucaena and grasses over a 1 year period in plots which had been established 2 years earlier. The tree legume Leucaena leucocephala cv. Cunningham (plant density 1 m x 0.5 m), cut at either 30 cm or 100 cm, was interplanted with either a short grass (Setaria sphacelata var. splendida) or a tall grass (Pennisetum purpureum). Mineral nutrients were non-limiting. Highest leaf production was in the setaria monoculture (20.8 t ha-l yr-l) and the low-cut leucaena/setaria mixture (18.5 t ha-l yr-1), with the grass dominating production (> 88%) in the latter because of the ability of setaria to gain preferential access to light penetrating between the rows of leucaena early in each growth period. Leucaena shoot production in the low-cut leucaena treatments was reduced from a mean of 8.8 t ha-1 yr-1 in the monocultures to 1.5 t ha-l yr-1 in the mixtures. For the high-cut leucaena treatments, grass leaf yields were lower from the mixtures than from the monocultures but leucaena shoot yields were only reduced from monoculture yields in the mixture with pennisetum. The mixture of setaria and high-cut leucaena produced a considerable yield of setaria leaf (6.2 t ha-1 yr-l) with no reduction in leucaena leaf yields and intercepted a significantly greater percentage of total incident light (64%) than the other three mixtures (42-42%).