Clinical trial NCT02744040: Modulating the Impact of Critical Events in Early HIV Infection: Effect of ART Initiation and Alcohol Use
Official title: Modulating the Impact of Critical Events in Early HIV Infection: Effect of ART Initiation and Alcohol Use
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: HIV Infection
Keywords: HIV reservoir
alcohol
ART
Lead sponsor: Fred Hutchinson Cancer Center
Sponsor class: OTHER
Collaborators: name: University of California, San Francisco
name: University of Washington
name: Asociación Civil Impacta Salud y Educación, Peru
name: Université de Montréal
name: Seattle Children's Hospital
name: National Institute on Drug Abuse (NIDA)
First posted: 2016-04-20
Enrollment: 151
Sex: MALE
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: The overall objective is to determine the influence of timing of ART initiation and alcohol consumption on HIV disease course. ART initiation immediately after HIV infection largely results in smaller HIV reservoir and lower HIV-associated systemic inflammation, which has been linked to non-AIDS morbidity and mortality. Immediate ART also reduces HIV-associated bacterial translocation and may prevent intestinal microbiome dysbiosis, that has been linked to increased systemic inflammation. Immediate intervention is not, however, generally feasible and more information is required about the consequences of starting ART at later time-points, but still early after acquisition. The study will be conducted in Lima, Peru, in a cohort of 180 MSM and transgender women (TW) with acute (Ab-, HIV RNA+) or recent (≤ 3 months) HIV infection. Alcohol use disorder (AUDIT score ≥8) is present in \~50% of HIV + participants in our cohort, four times higher than that seen among males in the general Peruvian population. Although the role of alcohol use in HIV pathogenesis and disease course remains unclear, some studies show a correlation with accelerated disease progression. The effects of alcohol resemble early post-infection changes in bacterial translocation and pro-inflammatory cytokines induced by HIV and their impact on HIV disease course before and after ART initiation remain unexplored.

Specific Aim 1: To determine the relative long-term benefits of immediate vs. early vs. delayed ART initiation at 24 weeks after diagnosis. The investigators will study outcomes after 2 and 4 years in MSM and TW diagnosed with acute or recent HIV infection.

Specific Aim 2: To determine the impact of alcohol use on the relative long-term benefits of immediate vs. early vs. delayed initiation of ART.

Detailed description: Specific Aims: Recent studies suggest that very early initiation of ART (prior to seroconversion) does not prevent the establishment of HIV reservoirs, which eventually expand when ART is discontinued. Early ART initiation is, however, associated with preservation of CD4+ T cells and lower levels of total HIV DNA and cell-associated RNA as well as preservation of gut Th17 cells, thereby averting a major driver of HIV-related immune activation and limiting the size of the HIV reservoir. When, by contrast, ART is initiated in Fiebig III (FIII) or later, many HIV-associated changes have already occurred, including seeding of HIV reservoirs, damage to GI mucosa, and initiation of inflammatory cascades. Since ART initiation within weeks of HIV acquisition is not a viable public health strategy, it is important to more completely understand the relative long-term benefits of initiating ART at very early times after infection (FI-II) as opposed to after a short (during FIII-V) or longer delay (at 24 weeks). Since the possibility that high-level alcohol use can mitigate the benefits of early ART is emerging as a potentially important public health issue, the investigators will evaluate the impact of time of ART initiation as well as alcohol use on HIV pathogenesis in Peruvian men who have sex with men (MSM) and TW, in whom high-level alcohol use is common. They will study outcomes after 2 and 4 years in MSM and TW diagnosed with acute (Ab-, HIV RNA+) or recent (≤3 months) HIV infection. Three groups based on time since estimated date of detectible HIV infection (EDDI) to ART initiation will be studied: a) EDDI-to-ART: ≤ 30 days b) EDDI-to-ART: 31-90 days and c) EDDI-to-ART: \>90 days

The overarching hypotheses are: 1. Initiation of ART soon after HIV infection will dampen perturbations of GI microbiota, reduce HIV-induced inflammatory changes, and decrease seeding of the reservoir. Initiation of ART within 30 days will have the greatest benefit. 2. Irrespective of the time of ART initiation, alcohol use will compound the negative effects of HIV.

SPECIFIC AIM 1) To determine the relative long-term benefits of immediate vs. early vs. delayed initiation of ART. Initiation of ART within 30 days of infection, while theoretically appealing, is infeasible in clinical practice because antibody-based tests, used almost world-wide, are unable to diagnose very early infection. Six months of ART initiated shortly after seroconversion can improve many immune parameters, although not to the near normal level seen when ART is initiated earlier.. Longer-term follow-up of seropositive participants who started ART \~2-8 months after HIV acquisition compared to those initiating ART within 30 days is needed to see whether markers of inflammation and residual viral load might continue to improve after 6 months, decreasing the difference between the groups. Methods: the investigators will evaluate the 3 groups using specimens from equivalent times after ART initiation for a total of 4 years of ART, comparing viral load, CD4 counts, time to reach undetectable VL, the GI microbiota, and inflammatory markers. Specimens from uninfected and chronically infected subjects are available as controls for some outcomes. They will model the size and persistence of the viral reservoir across all ART-compliant study subjects, measuring total HIV DNA, integrated HIV DNA and multi-spliced HIV RNA via TILDA (Tat/Rev Induced Limiting Dilution Assay) assay. In a subset of individuals from each group, the proviral integration sites will be defined at ART initiation and after 2 and 4 years to assess the maintenance of the reservoir by proliferating CD4 cells.

SPECIFIC AIM 2) To determine the impact of high-level alcohol use on the relative long-term benefits of immediate vs. early vs. delayed ART initiation. High-level alcohol use results in changes in the GI microbiome, increasing dysbiosis and gut permeability, and these changes are associated with up-regulation of inflammatory pathways.. Dysbiosis is present in many HIV-infected patients. Methods: Investigators will compare outcomes between subjects by their reported alcohol use or by assessing alcohol use blood biomarkers (Phosphatidylethanol; PEth) at specified timepoints.. Finally, among ART-adherent subjects with persistent viral suppression, the investigators will assess inflammatory markers and HIV reservoirs in those with and without high-level alcohol use at 2 and 4 years after ART initiation.

Eligibility criteria: Inclusion Criteria:

* Men who have sex with men or transgender women HIV-infected with prior participation in SABES study in Lima Peru OR Established HIV infection OR HIV uninfected

Exclusion Criteria:

* counter-indication for use of study antiretroviral drugs

Primary outcomes:
measure: Baseline HIV DNA Reservoir: Total HIV DNA
timeFrame: Baseline
measure: Two Phase Decay of HIV DNA Reservoir: Total HIV DNA
timeFrame: 4 years from ART initiation
measure: Baseline HIV DNA Reservoir: Integrated HIV DNA
timeFrame: Baseline
measure: Two Phase Decay of HIV DNA Reservoir: Integrated HIV DNA
timeFrame: 4 years from ART initiation
measure: Baseline HIV DNA Reservoir: TILDA Stimulation
timeFrame: Baseline
measure: Two Phase Decay of HIV DNA Reservoir: TILDA Stimulation
timeFrame: 4 years from ART initiation
measure: HIV DNA Integration Sites
timeFrame: 4 years from ART initiation
measure: GI Microbiome
timeFrame: 4 years from ART initiation
measure: Levels of Inflammatory Markers
timeFrame: 4 years from ART initiation
measure: Impact of Alcohol Use
timeFrame: 4 years from ART initiation
measure: HIV RNA Viral Load
timeFrame: 4 years from ART initiation
measure: CD4 Count
timeFrame: 4 years from ART initiation
measure: Time to Undetectable HIV Viral Load
timeFrame: 4 years from ART initiation
Secondary outcomes:
Other outcomes:
Locations:
city: Lima
country: Peru
facility: Asociación Civil Impacta Salud y Educación
Study officials:
affiliation: Fred Hutchinson Cancer Center
name: Ann Duerr
role: PRINCIPAL_INVESTIGATOR
References:
citation: Massanella M, Ignacio RAB, Lama JR, Pagliuzza A, Dasgupta S, Alfaro R, Rios J, Ganoza C, Pinto-Santini D, Gilada T, Duerr A, Chomont N. Long-term effects of early antiretroviral initiation on HIV reservoir markers: a longitudinal analysis of the MERLIN clinical study. Lancet Microbe. 2021 May;2(5):e198-e209. doi: 10.1016/s2666-5247(21)00010-0. Epub 2021 Mar 23.