Plain English Summary
Background and study aims
Hepatitis B virus (HBV) is a virus which causes long term liver damage in people all over the world. It is very common in much of sub-Saharan Africa and southeast Asia. Some countries have more than 10% of the entire population with the virus. Zambia is a country with a high HBV prevalence approximately 10%. HBV causes liver cirrhosis and liver cancer after several decades of infection, but now this is preventable. We know that the best way to treat people who have active HBV infection is to give them powerful drugs that stop the virus replicating. The old drugs that used to be used to treat hepatitis B (such as lamivudine) are very cheap but they are not very powerful and many people develop resistance to them so that they stop working after a period of time. The new drugs that are used to treat hepatitis B are more powerful and most people do not develop resistance. However the new drugs may have more side effects in the long term and they are much more expensive.
In many infections we know that starting treatment with a powerful drug and then reducing the treatment to a weaker drug is very effective. In London a pilot study of this approach has been tried in patients with hepatitis B with success in most cases. Specifically we took people who had been treated with the expensive new drug tenofovir and who were responding to treatment and we changed them to treatment with the weaker, cheaper, probably safer drug lamivudine. The great majority responded very well.
We now want to find out if this way of treating hepatitis B works in Lusaka, Zambia.
Who can participate?
80 Zambian adults, both sexes and aged 18 years or more, with HBV infection, already with evidence of some liver damage (using a marker in blood called ALT).
What does the study involve?
You will take tenofovir, the best single drug currently available, for 12 months to suppress the virus, then step down to lamivudine treatment. Our evidence suggests that after a period of complete viral suppression lamivudine failure may be much less likely. You will be monitored very closely during the 6 months after stepping down to lamivudine.
What are the possible benefits and risks of participating?
The main benefit is that you will receive at least 18 months of powerful antiviral therapy. The principal risks are associated with the liver biopsy (bleeding, but only 1 in 3000 have this problem), and the possibility that the infection may flare up aggressively at the end of the study. Our past experience suggests that this is very uncommon. If successful, this approach could lead to a much more affordable treatment approach for Africans with HBV infection, of whom there are many tens of thousands.
Where is the study run from?
This is a single centre study run from the University Teaching Hospital in Lusaka.
When is the study starting and how long is it expected to run for?
January 2014 to December 2015
Who is funding the study?
UK Medical Research Council
Who is the main contact?
Professor Graham Foster, principal investigator
Professor Paul Kelly and Dr Bright Nsokolo, chief investigators in Lusaka
Prof Graham Foster
Barts & The London School of Medicine
Queen Mary University of London
4 Newark Street
+44 (0)20 7882 7242
Step-down affordable treatment for chronic hepatitis B infection in Africa: feasibility of treatment strategy
That a treatment regime of tenofovir for 48 weeks followed by lamivudine for 24 weeks effectively suppresses hepatitis B virus (HBV) replication in more than 50% of patients.
University of Zambia Biomedical Research Ethics Committee, 24th May 2013, 005-02-13
Single group evaluation of feasibility of treatment strategy
Primary study design
Secondary study design
Non randomised controlled trial
Patient information sheet
Not available in web format, please use the contact details below to request a patient information sheet
Hepatitis B infection
Patients will be given Tenofovir 300mg daily (orally) for 52 weeks and then lamivudine 100mg (orally) daily for 26 weeks. Patients will be followed up for 6 months after starting lamivudine.
Primary outcome measures
Proportion of patients who successfully step down to lamivudine mono therapy with virological control of replication throughout
Secondary outcome measures
1. Proportion of patients who, even if there is virological rebound, achieve successful control on re-introduction of tenofovir
2. Accuracy of ALT monitoring in comparison with viral load monitoring
3. Accuracy of HBsAg quantification compared to viral load monitoring
The primary and secondary outcomes will be assessed by virological measurements in blood samples obtained every 3 months.
Overall trial start date
Overall trial end date
Participant inclusion criteria
1. HBV viral load >105 copies/ml
2. Alanine aminotransferase (ALT) >1.3 times upper limit of normal (which sets the criterion at 45 i.u./l)
3. Evidence of inflammation on liver biopsy
4. May be either e antigen negative (n=40) or positive (n=40)
Target number of participants
Participant exclusion criteria
1. Histological or radiological evidence of cirrhosis
2. HIV infection
3. History of alcohol abuse or histological evidence of alcoholic liver disease
4. History of any long-term drug ingestion
5. Histological evidence of metabolic liver disease (haemochromatosis, Wilsons disease, a1-antitrypsin deficiency) or autoimmune liver disease [antibodies to M2 antigen, Perinuclear antineutrophil cytoplasmic antibodies (p-ANCA), nuclear antigens, microsomes or smooth muscle]
6. Histological or radiological evidence of schistosomiasis
7. Histological evidence of hepatitis D virus (HDV) infection
8. Virological evidence of active hepatitis C virus (HCV) or hepatitis E virus (HEV) infection
Recruitment start date
Recruitment end date
Countries of recruitment
Trial participating centre
Blizard Institute, Barts & The London School of Medicine
Queen Mary University of London (UK)
Barts & The London School of Medicine Joint R&D office
+44 (0)20 7882 7273
Medical Research Council (UK), MR/K007394/1
Funding Body Type
Funding Body Subtype
Results and Publications
Publication and dissemination plan
Not provided at time of registration
Intention to publish date
Participant level data
Not provided at time of registration
Results - basic reporting