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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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