HIV Infections Clinical Trial
Official title:
Impact of Episodic Acyclovir Therapy on Ulcer Duration and HIV Shedding From Genital Ulcers Among Men in South Africa
The purpose of this study is to determine if acyclovir episodic treatment has an effect in ulcer healing and if it should be added to the syndromic management of genital ulcer disease.
Background and Objectives: Herpes simplex virus type 2 (HSV-2) is the primary cause of
genital ulcer and one of the most prevalent sexually transmitted infections (STI) worldwide.
HSV-2 has been recognized as a risk factor for HIV in multiple studies. A substantial shift
in the aetiology of genital ulcer disease (GUD) towards genital herpes has been noted in
many countries in Africa, especially those with mature HIV epidemics. Some countries guided
by the predominance of HSV-2 as the aetiology of GUD in their country, are changing
syndromic guidelines to include acyclovir as part of the treatment for GUD. Little data is
available to support this decision in terms of its effect on clinical course and its
cost-effectiveness. Yet, substantial investment would be needed in poor countries to add
acyclovir to their essential drug list. Studies to determine the appropriateness of episodic
acyclovir therapy for HSV-2 in the developing world are needed.
Episodic therapy with acyclovir both as a treatment modality and as an HIV-prevention
strategy is appealing, in terms of cost and sustainability. However, it is not clear which
will be its impact under field conditions in which there would be delay in symptom
recognition and treatment initiation, and whether these conditions could be optimized
through patient education. We propose to conduct a randomized placebo-controlled trial of
the effect of HSV-2 episodic therapy on symptomatic herpes and on HIV shedding from genital
ulcers. This study will help answer the question if acyclovir therapy for herpes should be
added into the syndromic management of genital ulcer disease. Acyclovir has an acceptable
profile for widespread STI treatment and is now relatively inexpensive and well-tolerated.
Given that HSV-2 is the leading cause of GUD in the developing world, this approach could
have great public health importance, by providing a safe, acceptable, and cost-effective
method to treat genital ulcer disease and potentially reduce HIV transmission. If acyclovir
therapy reduces HIV shedding, its incorporation into syndromic management would provide and
effective way to scale it up as a public health intervention.
Methods: We plan an individually randomized double blind placebo-control trial of the WHO
and US CDC recommended dose of 3-times daily acyclovir for a 5-day treatment course. The
trial will be conducted at two primary health care clinics in Johannesburg, South Africa. A
total of 600 men presenting to the clinic with GUD will be enrolled in the study. Consenting
participants will be randomized to receive either acyclovir plus syndromic management or
placebo plus syndromic management. Syndromic management for genital ulcer disease will
consist of one dose antibiotics to cover for syphilis and chancroid. Participants will be
followed for a month; during follow-up visits duration of ulcers, ulcer number and size will
be evaluated and ulcer, blood and semen samples collected to test for HIV RNA viral loads
among HIV-positives and for HSV-2 shedding.
Timeline: Duration of the project is 2 years
Expected Outcomes: The main outcome of the study will be the evaluation of the impact of
acyclovir therapy on ulcer healing. We will also measure the impact of acyclovir therapy on
HIV and HSV-2 viral load from genital ulcers and HIV viral load in semen.
;
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double-Blind, Primary Purpose: Treatment
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