Empirical treatment against cytomegalovirus and tuberculosis in HIV-infected infants with severe pneumonia: study protocol for a multicenter, open-label randomized controlled clinical trial

Respiratory infections in low and middle-income countries

OBJECTIVES

To investigate the epidemiology, aetiology, diagnostics and management of childhood pneumonia in low and middle income countries (LMICs).

DESIGN

Review of published english literature from 2019 to February 2024.

RESULTS

Lower respiratory tract infections (LRTIs) still result in significant mortality in children under 5 years of age in LMICs. Important studies have reported a change in the pathogenesis of LRTIs over the last 5 years with respiratory syncytial virus (RSV) resulting in a large burden of disease. SARS-CoV-2 had a significant direct and indirect impact in children in LMICs. Mycobacterium tuberculosis (MTB) remains a priority pathogen in all children. Nucleic acid amplification and rapid antigen tests have improved diagnostic accuracy for MTB and other bacterial pathogens. Point of care diagnostics may overcome some limitations, but there is a need for better cost-effective diagnostics. Access to shorter courses of TB treatment are now recommended for some children, but child friendly formulations are lacking. The role of chest X-ray in TB has been recognized and included in guidelines, and lung ultrasound to diagnose LRTI is showing promise as a lower cost and accessible option.

CONCLUSION

Advances in diagnostics and large multi-centre studies have provided increased understanding of the causative pathogens of LRTIs in LMICs. Increased access to preventive strategies such as vaccines, treatment modalities including antivirals, and addressing upstream factors such as poverty are essential if further declines in LRTIs in LMICs are to be realised.

Statistical analysis plan for the "empirical treatment against cytomegalovirus and tuberculosis in HIV-infected infants with severe pneumonia" clinical trial

BACKGROUND

The EMPIRICAL trial aims to assess safety and efficacy of an empirical treatment against cytomegalovirus (CMV) and tuberculosis (TB) compared to standard of care (SoC), on adverse events and 15-day and 1-year mortality among infants living with HIV hospitalized with severe pneumonia in Africa.

METHODS AND DESIGN

The EMPIRICAL trial (NCT03915366) is an international multicenter phase II-III, open-label randomized factorial clinical trial conducted in six African countries. The trial has four randomization arms in a 1:1:1:1 fashion with patients allocated to (i) TB-Treatment plus SoC, (ii) valganciclovir plus SoC, (iii) both TB-Treatment and valganciclovir plus SoC, and (iv) SoC only.

DISCUSSION

This paper describes the statistical analysis plan (SAP) for the trial which, per the study publication plan, needs to be published prior to the database lock and final analysis results. The SAP includes details of the analyses to be undertaken and unpopulated tables that will be reported to address primary and secondary endpoints. The database will be locked on 31st January 2025.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03915366 (registered on April 16, 2019), Universal Trial Number: U111-1231-4736, Pan African Clinical Trial Registry: PACTR201994797961340.

Penta Network: State-of-the-Art Research in Pediatric Human Immunodeficiency Virus

The Penta Network has made significant strides in pediatric human immunodeficiency virus (HIV) research, initially focusing on clinical trials for children in Europe, before expanding globally to countries with high HIV prevalence. Key contributions include the ODYSSEY trial, which established dolutegravir as a superior treatment for children and the Early-treated Perinatally HIV-infected Individuals: Improving Children's Actual Life with Novel Immunotherapeutic Strategies consortium, aimed at developing strategies for HIV remission. The ongoing empirical and thrive projects address advanced HIV disease, particularly severe pneumonia and postdischarge mortality in children. Going beyond clinical trials, the Penta Network also plays a key role in bringing stakeholders and industry together to achieve better antiretroviral formulations for children.

HIV-associated tuberculosis in infants, children, and adolescents younger than 15 years: an update on the epidemiology, diagnosis, prevention, and treatment

PURPOSE OF REVIEW

HIV-associated tuberculosis (TB) remains a major driver of morbidity and mortality in children and adolescents younger than 15 years (CLWH). The purpose of this review is to highlight recent findings in the areas of prevention, diagnosis, and treatment of HIV-associated TB in CLWH and to highlight knowledge and implementation gaps.

RECENT FINDINGS

We found that despite access to antiretroviral therapy (ART), high rates of HIV-associated TB are still reported, and with an unacceptably high mortality. There are no advances in screening for TB, but shorter courses of rifapentine-based TB preventive therapy are becoming available. The use of algorithms in TB diagnosis can potentially simplify the therapeutic decision making. There are more data supporting the use of dolutegravir (DTG) with rifampicin and a need to study unadjusted DTG especially in the youngest children. Short course therapy for nonsevere pulmonary TB is currently implemented and programmatic outcome should be studied in CLWH. Low uptake of ART and poor suppression remains an important driver of HIV-associated TB.

SUMMARY

Although screening and diagnosis remains challenging, there are several advances in the prevention and treatment of HIV-associated TB. Effective implementation of these strategies is needed to advance the outcomes of CLWH.

Twice-Daily Dosing of Dolutegravir in Infants on Rifampicin Treatment: A Pharmacokinetic Substudy of the EMPIRICAL Trial

BACKGROUND

We evaluated dolutegravir pharmacokinetics in infants with human immunodeficiency virus (HIV) receiving dolutegravir twice daily (BID) with rifampicin-based tuberculosis (TB) treatment compared with once daily (OD) without rifampicin.

METHODS

Infants with HIV aged 1-12 months, weighing ≥3 kg, and receiving dolutegravir BID with rifampicin or OD without rifampicin were eligible. Six blood samples were taken over 12 (BID) or 24 hours (OD). Dolutegravir pharmacokinetic parameters, HIV viral load (VL) data, and adverse events (AEs) were reported.

RESULTS

Twenty-seven of 30 enrolled infants had evaluable pharmacokinetic curves. The median (interquartile range) age was 7.1 months (6.1-9.9), weight was 6.3 kg (5.6-7.2), 21 (78%) received rifampicin, and 11 (41%) were female. Geometric mean ratios comparing dolutegravir BID with rifampicin versus OD without rifampicin were area under curve (AUC)0-24h 0.91 (95% confidence interval, .59-1.42), Ctrough 0.95 (0.57-1.59), Cmax 0.87 (0.57-1.33). One infant (5%) receiving rifampicin versus none without rifampicin had dolutegravir Ctrough <0.32 mg/L, and none had Ctrough <0.064 mg/L. The dolutegravir metabolic ratio (dolutegravir-glucuronide AUC/dolutegravir AUC) was 2.3-fold higher in combination with rifampicin versus without rifampicin. Five of 82 reported AEs were possibly related to rifampicin or dolutegravir and resolved without treatment discontinuation. Upon TB treatment completion, HIV viral load was <1000 copies/mL in 76% and 100% of infants and undetectable in 35% and 20% of infants with and without rifampicin, respectively.

CONCLUSIONS

Dolutegravir BID in infants receiving rifampicin resulted in adequate dolutegravir exposure, supporting this treatment approach for infants with HIV-TB coinfection.

First-Line Antituberculosis Drug Concentrations in Infants With HIV and a History of Recent Admission With Severe Pneumonia

Optimal antituberculosis therapy is essential for favorable clinical outcomes. Peak plasma concentrations of first-line antituberculosis drugs in infants with living HIV receiving WHO-recommended dosing were low compared with reference values for adults, supporting studies on increased doses of first-line TB drugs in infants.