HIV/AIDS Clinical Trial
Official title:
Evaluation of Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Alafenamide (E/C/F/TAF) Switch Followed by Sofosbuvir/Velpatasvir (SOF/VEL) Antiviral HCV Therapy Followed by Bictegravir/Emtricitabine/Tenofovir Alafenamide (B/F/TAF) Simplification in HIV-HCV Co-Infected Subjects on Opioid Substitution Therapy - A Pilot Feasibility Study
The study hypothesis is to determine the feasibility of switching HIV-HCV co-infected patients receiving methadone or buprenorphine/naloxone as opioid substitution therapy with suppressed HIV RNA viral load on current antiretroviral therapy to elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF, Genvoya™) followed by 12 weeks of HCV antiviral therapy with sofosbuvir/velpatasvir (SOF/VEL, Epclusa™), followed then by switch to bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF, Biktarvy™) for an additional 48 weeks.
This clinical study is a phase IV, prospective, open-label study that is being conducted in
25 participants over the age of 18 on stable antiretroviral therapy with documented HIV viral
suppression who have received opioid substitution therapy (OST) for at least three months.
The study is designed to assess the feasibility of the switch from a participant's current
antiretroviral therapy (ART) regimen to Genvoya, followed shortly thereafter by initiation of
Epclusa for treatment of HCV co-infection with subsequent optimization of the ART regimen to
Biktarvy in patients co-infected with HIV and HCV receiving methadone or
buprenorphine/naloxone as OST. Participants will be recruited from the Infectious Diseases
Clinic (IDC) in Regina, a tertiary referral site that cares for a large number of patients
living with HIV and viral hepatitis.
Eligible participants will have baseline investigations performed, including measures of
renal parameters and bone mineral densitometry, and will be switched from their current
antiretroviral regimen to Genvoya for the first 12 weeks of the study. Various reasons for
switching may play a role in clinician decision-making, including simplification, improved
tolerability, an improved metabolic risk profile, etc. The primary drawbacks to Genvoya in
clinical practice include the potential for drug-drug interactions due to the presence of
cobicistat, and the relatively low so-called "genetic barrier" of resistance, meaning that
sub-optimal adherence may be more likely to result in antiretroviral resistance. Participants
must already be fully suppressed at the time of screening to be enrolled in the study, as
well as having been stable on OST for at least three months, in order to reduce the risk of
poor adherence.
After the switch to Genvoya occurs, participants will be seen at weeks 1 and 4 to assess for
adverse events, including any changes in OST dosing. Laboratory testing will be performed as
per standard of care with CD4 counts and HIV viral loads checked at weeks 4 and 12 to ensure
stable virologic suppression following switch of ART. After 12 weeks of Genvoya, provided
that participants remain stably suppressed in terms of their HIV, they will then receive 12
weeks of Epclusa to treat their chronic HCV infection while continuing to take Genvoya.
Participants are allowed to have any HCV genotype and may have stage 0-4 liver fibrosis as
assessed by transient elastography, but may not have decompensated cirrhosis or
hepatocellular carcinoma. Participants will be followed at weeks 13, 16 and 24 with clinical
assessments performed, and repeat HCV viral loads at weeks 16 and 24 (end of HCV treatment)
as per standard of care. Participants will be seen at weeks 36 and 48 and have their HCV
viral loads performed to determine whether they have achieved a sustained virologic response
12 and 24 weeks following end of HCV therapy, which defines HCV cure. Bone mineral
densitometry will be performed at week 48 to determine any interval change in bone mineral
density has occurred between study initiation and week 48.
After the 48 weeks of treatment with Genvoya, participants who agree will be switched to a
modern unboosted ARV regimen consisting of Biktarvy through a 48 week extension phase.
Biktarvy is approved by Health Canada as an unboosted integrase-inhibitor based single-tablet
regimen with once-daily dosing and a small pill size, which facilitates adherence to
treatment. Due to the presence of bictegravir, Biktarvy is likely to have a higher "genetic
barrier" of resistance than Genvoya, and the lack of boosting significantly decreases the
risk of drug-drug interactions. During the extension phase, participants will be seen at
weeks 49, 52, 60, 72. 84 and 96 for clinical assessments with HIV viral loads, CD4 counts and
standard of care laboratory testing. Bone mineral densitometry will be performed at week 96
to determine any interval change in bone mineral density has occurred between study
initiation and week 96.
At each visit, participants will see a study coordinator and have vital signs performed, a
review of their concurrent medications including any changes in their methadone dosing,
review for any adverse events, and weight and height measurements. Laboratory investigations
and urine drug screens will be performed as per current standards of care. Validated
questionnaires assessing whether the participant is having any symptoms or signs of opioid
withdrawal or overdose as well as determining treatment satisfaction with their new
antiretroviral regimen. will be administered at each visit. Each visit is anticipated to take
approximately 60-90 minutes, and the appointment for bone mineral density testing will take
no longer than 2 hours to complete with waiting time included. All study medication will be
provided during study period but not after study completion.
At study conclusion, demographic and other baseline variables will be summarized using
percentage, mean, median, standard deviation and interquartile range as appropriate. The
proportion of subjects achieving the various endpoints and the associated 95% confident
interval will be calculated. Adverse events will be summarized by grade and relationship to
treatment in addition to presenting the data in a listing format.
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