Plain English Summary
Background and study aims
At the moment, there is no cure for HIV, the virus that causes AIDS, but there are medicines called anti-retrovirals (ARVs) that can control HIV and keep people well for a long time. Unfortunately in many African countries patients only come for treatment when they are very sick and HIV has already had a big effect on their bodies. Often patients have malnutrition, diarrhoea, infections such as tuberculosis, serious lung infections (pneumonia) and other severe infections. This means that many more people die during the first 3 months after starting ARVs compared to richer countries. The aim of this study is to find out whether or not giving extra treatments during the first 3 months of taking ARVs will help sick people with HIV and prevent some of them from dying early, or whether giving extra treatments doesn’t make any difference and makes it harder to take ARVs. The extra treatments are:
1. An extra ARV drug added to the three standard ARVs (i.e., four ARVs in total)
2. A single pill containing cotrimoxazole (septrin) and isoniazid (to fight TB), plus fluconazole (to fight thrush) and azithromycin (to fight bacterial infections) and albendazole (to kill worms). All of these are medicines which fight against common infections in sick people with HIV
3. Extra food supplements to provide high energy food
Who can participate?
People aged 5 years and older who are HIV positive and also have low immunity measured by a blood test called the CD4 count, and therefore have a higher risk of getting sick.
What does the study involve?
Participants receive three ARVs and cotrimoxazole, together with any other medicines they are already taking or need for treatment of any infections. In addition, they are randomly allocated to receive or not receive each of the three extra treatments (ARVs, medicines to fight other infections, and nutritional supplements) for the first 3 months. After the first 3 months they continue to take three standard ARVs to fight HIV, cotrimoxazole (septrin) to help to protect against infections long-term, and isoniazid to protect against TB. Participants have regular clinic visits to see a nurse and a doctor and blood samples are taken to check for any side effects of the medicines. They are followed carefully for any side effects and responses to the treatments. Some of the blood is used to work out how much of the ARVs are actually getting into their blood where they can fight the HIV virus. After almost 1 year (48 weeks), participants leave the study and their care is provided by their country’s national health system, including provision of ARVs in line with the national programme.
What are the possible benefits and risks of participating?
Studies in rich countries have shown that taking four ARVs produces a very strong response to HIV so we want to see if taking an extra fourth ARV for the first 3 months of treatment reduces the risk of dying after people start ARVs. The risks are that there could be side-effects to this extra medicine, or that taking four medicines may be more difficult than three – if people don’t take all their ARVs all the time, the HIV virus can develop resistance to the drugs which stops them working over the longer term. The potential benefits are that the immune system may respond better both initially and over the long term if a fourth ARV is used in the first 3 months. Similarly, whilst adding other extra medicines to fight infections could reduce the risk of dying from these infections, it might also increase the risk of other side-effects, some of which can be serious, and might also make it harder to take all the ARVs. This study is designed to find out whether the potential benefits outweigh the potential risks.
Where is the study run from?
The study will enrol 1800 people in four countries: Kenya, Malawi, Uganda and Zimbabwe. It is co-ordinated by the Medical Research Council in London (UK)
When is the study starting and how long is it expected to run for?
September 2012 to August 2015
Who is funding the study?
The study is funded by the UK Medical Research Council, the Department for International Development and the Wellcome Trust (UK)
Who is the main contact?
Dr Margaret Thomason
m.thomason@ucl.ac.uk
Trial website
Contact information
Type
Scientific
Primary contact
Prof Diana Gibb
ORCID ID
Contact details
Medical Research Council Clinical Trials Unit
Aviation House
125 Kingsway
London
WC2B 6NH
United Kingdom
-
diana.gibb@ucl.ac.uk
Additional identifiers
EudraCT number
ClinicalTrials.gov number
NCT01825031
Protocol/serial number
G1100693
Study information
Scientific title
Reduction of Early mortALITY in HIV-infected African adults and children starting antiretroviral therapy: a randomised controlled trial
Acronym
REALITY
Study hypothesis
To identify effective, safe and acceptable interventions to reduce early mortality in HIV-infected adults, adolescents, and older children (5 years or more) initiating antiretroviral therapy (ART).
Hypotheses:
1. Addition of 12 weeks of an integrase inihibitor (raltegravir) to initial antiretroviral therapy will reduce mortality, compared to standard of care first-line 3-drug 2-class ART.
2. Addition of enhanced OI prophylaxis with immediate isoniazid/pyridoxine (and cotrimoxazole), 12 weeks fluconazole, plus single-dose albendazole and 5 days of azithromycin at ART initiation, will reduce mortality, compared to standard of care cotrimoxazole prophylaxis plus continuation of any pre-existing prophylaxis (i.e. only starting cotrimoxazole) for the first 12 weeks followed by isoniazid prophylaxis from 12 weeks onwards.
3. Supplementation with Ready-to-Use Supplementary Food (RUSF) will reduce mortality, compared to standard of care nutritional support to those with poor nutritional status according to local guidelines
Ethics approval
Ethical approval was granted by the appropriate national ethics committees in Kenya, Malawi, Uganda and Zimbabwe as well as University College London Ethics Committee (UK)
Study design
2x2x2 open-label factorial multi-centre randomised controlled trial conducted in four countries
Primary study design
Interventional
Secondary study design
Randomised controlled trial
Trial setting
Hospitals
Trial type
Treatment
Patient information sheet
Not available in web format, please use the contact details to request a patient information sheet
Condition
Human Immunodeficiency Virus (HIV)
Intervention
Three methods to reduce early mortality following antiretroviral therapy (ART) initiation:
1. Increasing the potency of ART with a 12 week induction period using 4 antiretroviral drugs from 3 classes
2. Augmented prophylaxis against opportunistic/bacterial infections and helminths for 12 weeks
3. Macronutrient intervention using ready-to-use supplementary food for 12 weeks
Each intervention will be compared with standard care, which in previously untreated patients presenting late with very low CD4 counts is to initiate ART with 3 drugs from 2 classes, together with cotrimoxazole prophylaxis and macronutrient intervention only for those with low BMI (or low weight-for-height/mid-upper arm circumference in children).
Intervention type
Drug
Phase
Phase III
Drug names
Albendazole, azithromycin, cotrimoxazole, fluconazole, isoniazid, pyridoxine, raltegravir
Primary outcome measure
Mortality over the first 24 weeks after starting anti-retroviral therapy
Secondary outcome measures
1. Mortality in 48 weeks after starting anti-retroviral therapy
2. Safety:
2.1. Serious adverse events
2.2. Grade 4 adverse events
2.3. Adverse events leading to modification of ART or other study drugs
3. Endpoints relating to the specific mechanisms of action of each intervention
3.1. Anti-HIV: CD4 levels
3.2. Anti-infection: incidence of tuberculosis, cryptococcal and candida disease, severe bacterial infections
3.3. Nutritional: body mass index (BMI), weight and body fat assessed by bioimpedance analysis (BIA), height (in children), grip strength
4. Hospital inpatient episodes and total days admitted
5. Adherence to ART and acceptability of each strategy measured by pill counts and questionnaire
Overall trial start date
01/09/2012
Overall trial end date
31/08/2015
Reason abandoned (if study stopped)
Eligibility
Participant inclusion criteria
1. Aged 5 years or older (the lower age limit is because CD4 counts are less reliable predictors of immunodeficiency under 5 years: CD4 counts are recommended by WHO guidelines in older children)
2. Documented HIV infection by HIV ELISA
3. Naive to ART except for drugs given or received to prevent mother-to-child transmission
4. CD4 T-cell count <100 cells/mm3 on blood test taken at screening for REALITY
5. Results of screening haematology and biochemistry tests available
6. Patient/carer provide informed consent (and children <18 years assent, as appropriate according to their age and knowledge of HIV status)
Participant type
Patient
Age group
Mixed
Gender
Both
Target number of participants
1800
Participant exclusion criteria
1. Contraindications to any proposed antiretroviral drugs (including integrase inhibitors), isoniazid, fluconazole, albendazole or azithromycin
2. Pregnant or breastfeeding or intending to become pregnant during the first 12 weeks of the study
Recruitment start date
18/06/2013
Recruitment end date
10/04/2015
Locations
Countries of recruitment
Kenya, Malawi, Uganda, Zimbabwe
Trial participating centre
Joint Clinical Research Centre
Fort Portal
-
Uganda
Trial participating centre
Joint Clinical Research Centre
Mbarara
-
Uganda
Trial participating centre
Joint Clinical Research Centre
Mbale
-
Uganda
Trial participating centre
Joint Clinical Research Centre
Gulu
-
Uganda
Trial participating centre
University of Zimbabwe Clinical Research Centre (UZCRC)
Harare
-
Zimbabwe
Trial participating centre
University of Malawi
Department of Medicine
Blantyre
-
Malawi
Trial participating centre
Moi University Clinical Research Centre (MUCRC)
Eldoret
-
Kenya
Trial participating centre
KEMRI Wellcome Trust Centre
Kilifi
-
Kenya
Sponsor information
Organisation
Medical Research Council (UK)
Sponsor details
2nd Floor
David Phillips Building
Polaris House
North Star Avenue
Swindon
SN2 1FL
United Kingdom
Sponsor type
Research council
Website
Funders
Funder type
Government
Funder name
Global Health Trials Scheme [Department for International Development, Medical Research Council & Wellcome Trust] (UK) ref: G1100693/1
Alternative name(s)
Funding Body Type
Funding Body Subtype
Location
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
Basic results (scientific)
Publication list
1. 2017 results in: https://www.ncbi.nlm.nih.gov/pubmed/28723333
2. 2018 results in: https://www.ncbi.nlm.nih.gov/pubmed/29653915
3. 2018 results in: https://www.ncbi.nlm.nih.gov/pubmed/30513108
4. 2018 results in: https://www.ncbi.nlm.nih.gov/pubmed/29514234 (added 01/10/2019)
5. 2018 results in: https://www.ncbi.nlm.nih.gov/pubmed/29514235 (added 01/10/2019)