Enhanced prophylaxis plus antiretroviral therapy for advanced HIV infection in Africa
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Background: In sub-Saharan Africa, among patients with advanced human immunodeficiency virus (HIV) infection, the rate of death from infection (including tuberculosis and cryptococcus) shortly after the initiation of antiretroviral therapy (ART) is approximately 10%. Methods: In this factorial open-label trial conducted in Uganda, Zimbabwe, Malawi, and Kenya, we enrolled HIV-infected adults and children 5 years of age or older who had not received previous ART and were starting ART with a CD4+ count of fewer than 100 cells per cubic millimeter. They underwent simultaneous randomization to receive enhanced antimicrobial prophylaxis or standard prophylaxis, adjunctive raltegravir or no raltegravir, and supplementary food or no supplementary food. Here, we report on the effects of enhanced antimicrobial prophylaxis, which consisted of continuous trimethoprim-sulfamethoxazole plus at least 12 weeks of isoniazid-pyridoxine (coformulated with trimethoprim-sulfamethoxazole in a single fixed-dose combination tablet), 12 weeks of fluconazole, 5 days of azithromycin, and a single dose of albendazole, as compared with standard prophylaxis (trimethoprim-sulfamethoxazole alone). The primary end point was 24-week mortality. Results: A total of 1805 patients (1733 adults and 72 children or adolescents) underwent randomization to receive either enhanced prophylaxis (906 patients) or standard prophylaxis (899 patients) and were followed for 48 weeks (loss to follow-up, 3.1%). The median baseline CD4+ count was 37 cells per cubic millimeter, but 854 patients (47.3%) were asymptomatic or mildly symptomatic. In the Kaplan-Meier analysis at 24 weeks, the rate of death with enhanced prophylaxis was lower than that with standard prophylaxis (80 patients [8.9% vs. 108 [12.2%]; hazard ratio, 0.73; 95% confidence interval [CI], 0.55 to 0.98; P = 0.03); 98 patients (11.0%) and 127 (14.4%), respectively, had died by 48 weeks (hazard ratio, 0.76; 95% CI, 0.58 to 0.99; P = 0.04). Patients in the enhanced-prophylaxis group had significantly lower rates of tuberculosis (P = 0.02), cryptococcal infection (P = 0.01), oral or esophageal candidiasis (P = 0.02), death of unknown cause (P = 0.03), and new hospitalization (P = 0.03). However, there was no significant between-group difference in the rate of severe bacterial infection (P = 0.32). There were nonsignificantly lower rates of serious adverse events and grade 4 adverse events in the enhanced-prophylaxis group (P = 0.08 and P = 0.09, respectively). Rates of HIV viral suppression and adherence to ART were similar in the two groups. Conclusions: Among HIV-infected patients with advanced immunosuppression, enhanced antimicrobial prophylaxis combined with ART resulted in reduced rates of death at both 24 weeks and 48 weeks without compromising viral suppression or increasing toxic effects.
Hakim , J , Musiime , V , Szubert , A J , Mallewa , J , Siika , A , Agutu , C , Walker , S , Pett , S L , Bwakura-Dangarembizi , M , Lugemwa , A , Kaunda , S , Karoney , M , Musoro , G , Kabahenda , S , Nathoo , K , Maitland , K , Griffiths , A , Thomason , M J , Kityo , C , Mugyenyi , P , Prendergast , A J , Walker , A S , Gibb , D M , REALITY Trial Team & O'Hare , B A-M 2017 , ' Enhanced prophylaxis plus antiretroviral therapy for advanced HIV infection in Africa ' , New England Journal of Medicine , vol. 377 , no. 3 , pp. 233-245 . https://doi.org/10.1056/NEJMoa1615822
New England Journal of Medicine
Copyright © 2017 Massachusetts Medical Society. This work has been made available online in accordance with the publisher’s policies. This is the final published version of the work, which was originally published at https://doi.org/10.1056/NEJMoa1615822
DescriptionSupported by the Joint Global Health Trials Scheme of the Medical Research Council (MRC), the U.K. Department for International Development, and the Wellcome Trust through a grant (G1100693),with additional support from the PENTA Foundation. The MRC Clinical Trials Unit at University College London is supported by grants from the MRC (MC-UU-12023/23 and MC-UU-12023/26). Dr. Prendergast is funded by a grant (108065/Z/15/Z) from the Wellcome Trust, which also funds the Malawi–Liverpool–Wellcome Trust Clinical Research Program at the University of Malawi College of Medicine through a grant (101113/Z/13/Z) and the Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Program through a grant (077092).
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