Study to Assess the Effects of Cabotegravir (CAB) and Rilpivirine (RPV) Long-Acting (LA) Injections Following Sub-cutaneous (SC) Administration Compared With Intramuscular (IM) Administration in Adult Participants Living With Human Immunodeficiency Virus (HIV-1) Infection in the FLAIR Study

Human Immunodeficiency Virus Type 1 (HIV-1) Clinical Trial

Official title:

An Amendment to the FLAIR Study to Evaluate the Pharmacokinetics, Safety, Tolerability, Maintenance of Virological Suppression and Patient Reported Outcomes for Participants Receiving Cabotegravir (CAB 200 mg/mL) and Rilpivirine (300 mg/mL) Long-Acting Injections Following Sub-cutaneous (SC) Administration in the Anterior Abdominal Wall SC Tissue Compared With Intramuscular (IM) Administration in the Gluteus Medius Muscle in Adult Participants Living With HIV-1 Infection in the FLAIR Study

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT05896748
• Other study ID #: 201584-001
• Status: Completed
• Phase: Phase 3
• Start date: November 8, 2022
• Est. completion date: September 14, 2023

Study information

• Verified date: December 2023
• Source: ViiV Healthcare
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

This study will assess the pharmacokinetics, safety, tolerability, maintenance of virological suppression and patient reported outcomes for participants receiving CAB and RPV LA injections following SC administration in the anterior abdominal wall SC tissue compared with IM administration in the gluteus medius muscle in adult participants living with HIV-1 infection in the FLAIR study (NCT02938520).

Recruitment information / eligibility

• Status: Completed
• Enrollment: 93
• Est. completion date: September 14, 2023
• Est. primary completion date: April 18, 2023
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Capable of giving signed informed consent (FLAIR and Sub-study specific informed consent)
• Eligible participants must have been on CAB LA + RPV LA regimen for a minimum of 12 months while on the FLAIR study. Any disruptions in dosing during FLAIR must be discussed with the Medical Monitor for a final determination of eligibility into the sub-study.
• Plasma HIV-1 RNA <50 c/mL at Sub-Study Screening.
• History of Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) vaccination (or booster dosing) is allowed prior to sub study screening and will be allowed during the conduct of the sub-study as long as the vaccine (or boosters) are not administered within 14 days of virologic load (VL) assessments.
• HIV-1 infected antiretroviral therapy (ART)-naive men or women aged 18 years or greater at the time of signing the informed consent.
• HIV-1 infection as documented by Screening plasma HIV-1 RNA >=1000 cubic (c)/mL
• Antiretroviral-naive (less than or equal to (<=10) days of prior therapy with any antiretroviral agent following a diagnosis of HIV-1 infection). Any previous exposure to an HIV integrase inhibitor or non-nucleoside reverse transcriptase inhibitor will be exclusionary
• Female Participants: A female participant is eligible to participate if she is not pregnant at Screening and first day of Induction Phase (as confirmed by a negative serum human chorionic gonadotrophin [hCG] test), not lactating, and at least one of the following conditions applies

1. Non-reproductive potential defined as:

• Pre-menopausal females with one of the following:
• Documented tubal ligation;
• Documented hysteroscopic tubal occlusion procedure with follow-up confirmation of bilateral tubal occlusion;
• Hysterectomy; Documented Bilateral Oophorectomy;
• Postmenopausal defined as 12 months of spontaneous amenorrhea [in questionable cases a blood sample with simultaneous follicle stimulating hormone (FSH) and estradiol levels consistent with menopause. Females on hormone replacement therapy (HRT) and whose menopausal status is in doubt will be required to use one of the highly effective contraception methods if they wish to continue their HRT during the study. Otherwise, they must discontinue HRT to allow confirmation of post-menopausal status prior to study enrollment.

2. Reproductive potential and agrees to follow one of the options listed in the Modified List of Highly Effective Methods for Avoiding Pregnancy in Females of Reproductive Potential (FRP) from 30 days prior to the first dose of study medication, throughout the study, and for at least 30 days after discontinuation of all oral study medications and for at least 52 weeks after discontinuation of CAB LA and RPV LA.

• The investigator is responsible for ensuring that participants understand how to properly use these methods of contraception.
• All participants in the study should be counseled on safer sexual practices including the use and benefit/risk of effective barrier methods (example [e.g.,] male condom) and on the risk of HIV transmission to an uninfected partner.
• In France, a participant will be eligible for inclusion in this study only if either affiliated to or a beneficiary of a social security category.

Exclusion Criteria:

• More than 1 plasma HIV-1 RNA measurement 50 c/mL to <200 c/mL (virologic blip) within 24 weeks prior to sub-study Screening visit that was investigated and found NOT to be associated with alternative causes including recent vaccinations received within 4 weeks of the viral blip or NOT associated with intercurrent illness that developed within 2-4 weeks of the viral blip.
• All viral blips that occurred within 24 weeks prior to screening should be discussed with the Medical Monitor to assess whether such a participant can enroll into the sub-study.
• Any Suspected Virologic Failure (HIV-RNA 200 c/mL) as defined during FLAIR study.
• Participants planning to require oral bridging during participation in the FLAIR sub study.
• The participant has a tattoo or any dermatological condition overlying the abdominal or gluteal regions which may interfere with interpretation of injection site reactions.
• Any condition which, in the opinion of the Investigator, may interfere with the absorption, distribution, metabolism or excretion of the study drugs or render the participant unable to receive study medication.
• Any woman of childbearing potential who is pregnant at screening will be excluded from entering the sub-study.
• Any women of childbearing potential who gets pregnant while on the sub-study will have to be withdrawn from the sub-study but will be allowed to transition back to the parent FLAIR study if a pregnancy specific Informed Consent Form (ICF) is signed, and commercial access is not available at the time of pregnancy
• Women who are pregnant, breastfeeding, or plan to become pregnant or breastfeed during the study.
• Any evidence at Screening of an active Centers for Disease and Prevention Control (CDC) Stage 3 disease, except cutaneous Kaposi's sarcoma not requiring systemic therapy or historic or current cluster of differentiation 4+ (CD4+) cell count <200 cells/ cubic millimeter (mm^3) are not exclusionary.
• Participants with known moderate to severe hepatic impairment.
• Any pre-existing physical or mental condition (including substance abuse disorder) which, in the opinion of the Investigator, may interfere with the participant's ability to comply with the dosing schedule and/or protocol evaluations or which may compromise the safety of the participant.
• Participants determined by the Investigator to have a high risk of seizures, including participants with an unstable or poorly controlled seizure disorder. A participant with a prior history of seizure may be considered for enrollment if the Investigator believes the risk of seizure recurrence is low. All cases of prior seizure history should be discussed with the Medical Monitor prior to enrollment.
• Participant who, in the investigator's judgment, poses a significant suicide risk. Participant's recent history of suicidal behavior and/or suicidal ideation should be considered when evaluating for suicide risk.
• The participant has a tattoo or other dermatological condition overlying the gluteus region which may interfere with interpretation of injection site reactions.
• Evidence of Hepatitis B virus (HBV) infection based on the results of testing at Screening for Hepatitis B surface antigen (HBsAg), Hepatitis B core antibody (anti HBc), Hepatitis B surface antibody (anti-HBs) and HBV Deoxyribonucleic acid (DNA) as

follows:

• Participants positive for HBsAg are excluded;
• Participants negative for anti-HBs but positive for anti-HBc (negative HBsAg status) and positive for HBV DNA are excluded.
• Asymptomatic individuals with chronic hepatitis C virus (HCV) infection will not be excluded, however Investigators must carefully assess if therapy specific for HCV infection is required; participants who are anticipated to require HCV treatment prior to Week 48 of the Maintenance Phase must be excluded. HCV treatment on study may be permitted post Week 48, following consultation with the Medical Monitor. Participants

with HCV co-infection will be allowed entry into Phase 3 studies if:

• Liver enzymes meet entry criteria;
• HCV Disease has undergone appropriate work-up, HCV is not advanced, and will not require treatment prior to the Week 48 visit. Additional information (where available) on participants with HCV co-infection at screening should include results from any liver biopsy, fibroscan, ultrasound, or other fibrosis evaluation, history of cirrhosis or other decompensated liver disease, prior treatment, and timing/plan for HCV treatment.
• In the event that recent biopsy or imaging data is not available or is inconclusive, the Fib-4 score will be used to verify eligibility.
• A Fib-4 score > 3.25 is exclusionary;
• Fib-4 scores 1.45 - 3.25 requires Medical Monitor consultation. Fibrosis 4 Score Formula: (Age * AST)/ (Platelets * [square root of ALT]).
• Unstable liver disease (as defined by any of the following: presence of ascites, encephalopathy, coagulopathy, hypoalbuminemia, esophageal or gastric varices, or persistent jaundice), known biliary abnormalities (with the exception of Gilbert's syndrome or asymptomatic gallstones or otherwise stable chronic liver disease per investigator assessment).
• History of liver cirrhosis with or without hepatitis viral co-infection.
• Ongoing or clinically relevant pancreatitis.
• All participants will be screened for syphilis (rapid plasma reagin [RPR]). Participants with untreated syphilis infection, defined as a positive RPR without clear documentation of treatment, are excluded. Participants with a positive RPR test who have not been treated may be rescreened at least 30 days after completion of antibiotic treatment for syphilis.
• Ongoing malignancy other than cutaneous Kaposi's sarcoma, basal cell carcinoma, or resected, non-invasive cutaneous squamous cell carcinoma, or cervical, anal or penile intraepithelial neoplasia; other localized malignancies require agreement between the investigator and the study Medical Monitor for inclusion of the participant prior to enrollment.
• Any condition which, in the opinion of the Investigator, may interfere with the absorption, distribution, metabolism or excretion of the drug or render the participant unable to receive study medication.
• History or presence of allergy or intolerance to the study drugs or their components or drugs of their class. In addition, if heparin is used during pharmacokinetic (PK) sampling, participants with a history of sensitivity to heparin or heparin-induced thrombocytopenia must not be enrolled.
• Current or anticipated need for chronic anti-coagulation.
• ALT >=3 times upper limit normal (ULN).
• Clinically significant cardiovascular disease, as defined by history/evidence of congestive heart failure, symptomatic arrhythmia, angina/ischemia, coronary artery bypass grafting (CABG) surgery or percutaneous transluminal coronary angioplasty (PTCA) or any clinically significant cardiac disease.
• Exposure to an experimental drug and/or experimental vaccine within 28 days or 5 half-lives of the test agent, or twice the duration of the biological effect of the test agent, whichever is longer, prior to the first dose of investigational product (IP).
• Treatment with any of the following agents within 28 days of Screening:
• radiation therapy;
• cytotoxic chemotherapeutic agents;
• tuberculosis (TB) therapy, with the exception of treatment of latent TB with isoniazid;
• Immunomodulators that alter immune responses (such as chronic systemic corticosteroids, interleukins, or interferons).
• Treatment with an HIV-1 immunotherapeutic vaccine within 90 days of Screening.
• Treatment with any agent, except recognized ART as allowed above, with documented activity against HIV-1 within 28 days of the first dose of IP.
• Use of medications which are associated with Torsades de Pointes
• Any evidence of primary resistance to non-nuclease reverse transcriptase inhibitors (NNRTIs) (except for K103N which is allowed), or any known resistance to Integrase inhibitors from historical resistance test results.
• Participants who are human leukocyte antigen (HLA)-B*5701 positive and are unable to use an NRTI backbone that does not contain abacavir (participants who are HLA-B*5701 positive may be enrolled if they use a nuclease reverse transcriptase inhibitors (NRTI) backbone that does not contain abacavir; HLA-B*5701 positive participants may be excluded from the study if local provision of an alternate NRTI backbone is not possible).
• Any verified Grade 4 laboratory abnormality. A single repeat test is allowed during the Screening Phase to verify a result.
• Any acute laboratory abnormality at Screening, which, in the opinion of the Investigator, would preclude the participant's participation in the study of an investigational compound.
• Participant has estimated creatinine clearance <50 mL/minute (min)/1.73 meter square (m^2) via the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation.
• Participants who are currently participating in or anticipate to be selected for any other interventional study.

Related Conditions & MeSH terms

• Acquired Immunodeficiency Syndrome
• HIV Infections
• Human Immunodeficiency Virus Type 1 (HIV-1)
• Immunologic Deficiency Syndromes

Intervention

Drug:
• Cabotegravir - Injectable Suspension (CAB LA)
It is a sterile white to slightly pink suspension containing 200 mg/mL of CAB as free acid for administration by intramuscular (IM) injection. Each vial is for single-dose use containing a withdrawable volume of 2.0 mL, and does not require dilution prior to administration. CAB LA is composed of cabotegravir free acid, polysorbate 20, polyethylene glycol 3350, mannitol, and water for injection.
• Rilpivirine - Injectable Suspension (RPV LA)
It is a sterile white suspension containing 300 mg/mL of RPV as the free base. The route of administration is by intramuscular (IM) injection. Each vial contains a nominal fill of 2.0 mL, and does not require dilution prior to administration. RPV LA requires refrigeration and must be protected from light. RPV LA is composed of RPV free base, poloxamer 338, sodium dihydrogen phosphate monohydrate, citric acid monohydrate, glucose monohydrate, sodium hydroxide, water for injection.

Locations

Country	Name	City	State
Canada	GSK Investigational Site	Toronto	Ontario
Japan	GSK Investigational Site	Osaka
Japan	GSK Investigational Site	Tokyo
South Africa	GSK Investigational Site	Bloemfontein	Free State
South Africa	GSK Investigational Site	Durban
South Africa	GSK Investigational Site	Wentworth	KwaZulu- Natal
Spain	GSK Investigational Site	Barcelona
Spain	GSK Investigational Site	Barcelona
Spain	GSK Investigational Site	Bilbao
Spain	GSK Investigational Site	Elche
Spain	GSK Investigational Site	Ferrol
Spain	GSK Investigational Site	Granada
Spain	GSK Investigational Site	La Laguna-Tenerife
Spain	GSK Investigational Site	Madrid
Spain	GSK Investigational Site	Madrid
Spain	GSK Investigational Site	Madrid
Spain	GSK Investigational Site	Murcia
Spain	GSK Investigational Site	Murcia
Spain	GSK Investigational Site	Palma De Mallorca
Spain	GSK Investigational Site	San Sebastian de los Reyes
Spain	GSK Investigational Site	Santa Cruz de Tenerife
Spain	GSK Investigational Site	Santander
United Kingdom	GSK Investigational Site	Birmingham
United Kingdom	GSK Investigational Site	Leeds
United Kingdom	GSK Investigational Site	London
United States	GSK Investigational Site	Austin	Texas
United States	GSK Investigational Site	Bellaire	Texas
United States	GSK Investigational Site	Dallas	Texas
United States	GSK Investigational Site	Fort Worth	Texas
United States	GSK Investigational Site	Macon	Georgia

Sponsors (3)

Lead Sponsor	Collaborator
ViiV Healthcare	GlaxoSmithKline, Janssen Pharmaceuticals

Countries where clinical trial is conducted

United States,  Canada,  Japan,  South Africa,  Spain,  United Kingdom, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Concentrations at the end of the dosing interval (Ctau) of CAB LA and RPV LA following administration of SC injection		Week 4: Pre-dose; Week 8: Pre-dose and Week 12: Pre-dose
Primary	Maximum plasma concentration (Cmax) CAB LA and RPV LA following administration of SC injection		Week 1; Week 5 and Week 9
Primary	Area under the plasma concentration-time curve (AUC[0-tau]) of CAB LA and RPV LA following administration of SC injection		Week 4: Pre-dose; Week 8: Pre-dose and Week 12: Pre-dose
Primary	Ctau of CAB LA and RPV LA following administration of IM injection		Up to Week 17
Primary	Cmax of CAB LA and RPV LA following administration of IM injection		Up to Week 17
Primary	AUC(0-tau) of CAB LA and RPV LA following administration of IM injection		Up to Week 17
Secondary	Number of Participants With Adverse Events (AEs) of special interest following administration of SC injection		Up to Week 12
Secondary	Number of Participants With Injection Site Reactions (ISRs) following administration of SC injection		Up to Week 12
Secondary	Number of Participants With Severity of AEs of special interest following administration of SC injection		Up to Week 12
Secondary	Number of Participants With Severity of ISRs following administration of SC injection		Up to Week 12
Secondary	Percentage of participants who discontinue treatment due to ISRs following administration of SC injection		Up to Week 12
Secondary	Percentage of participants who discontinue treatment due to AEs of special interest following administration of SC injection		Up to Week 12
Secondary	Number of Participants With Non-serious Adverse Events (Non-SAEs) and Serious Adverse Events (SAEs) following administration of SC injection		Up to Week 12
Secondary	Change from Baseline in hematology parameters following administration of SC injection: Basophils, Eosinophils, Lymphocytes, Monocytes, Neutrophils and Platelet Count (Giga cells per Liter)		Baseline and Up to Week 12
Secondary	Change from Baseline in hematology parameter following administration of SC injection: Red Blood Cell Count (Trillion cells per liter)		Baseline and Up to Week 12
Secondary	Change from Baseline in hematology parameter following administration of SC injection: Hemoglobin (Grams per liter)		Baseline and Up to Week 12
Secondary	Change from Baseline in hematology parameter following administration of SC injection: Hematocrit (Proportion of red blood cells in blood)		Baseline and Up to Week 12
Secondary	Change from Baseline in hematology parameter following administration of SC injection: Mean Corpuscular Volume (Femtoliters)		Baseline and Up to Week 12
Secondary	Change from Baseline in chemistry parameters following administration of SC injection: Creatinine, Total Bilirubin (Micromoles per liter)		Baseline and Up to Week 12
Secondary	Change from Baseline in chemistry parameters following administration of SC injection: Glucose, Potassium, Sodium, Blood urea nitrogen, Carbon dioxide, Chloride, Phosphate (Millimoles per liter)		Baseline and Up to Week 12
Secondary	Change from Baseline in chemistry parameters following administration of SC injection: Alanine Aminotransferase (ALT), Alkaline Phosphatase (ALP), Aspartate Aminotransferase (AST), and Creatine phosphokinase (International units per liter)		Baseline and Up to Week 12
Secondary	Change from Baseline in chemistry parameter following administration of SC injection: Albumin (Grams per liter)		Baseline and Up to Week 12
Secondary	Change from Baseline in chemistry parameters following administration of SC injection: Lipase (Units per liter)		Baseline and Up to Week 12
Secondary	Change from Baseline in chemistry parameters following administration of SC injection: Creatinine Clearance (Milliliter per minute)		Baseline and Up to Week 12
Secondary	Change from Baseline in Fasting Lipid Panels following administration of SC injection: Total Cholesterol, High Density Lipoprotein (HDL) Cholesterol, Low Density Lipoprotein (LDL) Cholesterol, Triglycerides (Millimoles per liter)		Baseline and Up to Week 12
Secondary	Proportion of Participants With Plasma HIV-1 RNA <50 copies at Week 12 Following Administration of SC Injection		At Week 12
Secondary	Percentage of Participants With Plasma HIV-1 Ribonucleic Acid (RNA) greater than equal to (>=)50 Copies/milliliter (mL) at Week 12 Following Administration of SC Injection		At Week 12
Secondary	Percentage of participants with protocol defined confirmed virologic failure (CVF) of >=200 c/mL at week 12 Following Administration of SC injection		At Week 12
Secondary	Number of Participants With Treatment emergent Phenotypic Resistance Following Administration of SC injection		Up to Week 12
Secondary	Number of Participants With Treatment emergent Genotypic Resistance Following Administration of SC injection		Up to Week 12
Secondary	Number of participants with post-injection pain assessment using Numeric Rating Scale (NRS) following administration of SC Injection (scores on a scale)	The pain NRS is 11-point scale (0-10) ranging from 0=no pain and 10=extreme pain.	Up to Week 12
Secondary	Number of participants with post-injection pain assessment using NRS following CAB LA and RPV LA IM administration (scores on a scale)	The pain NRS is 11-point scale (0-10) ranging from 0=no pain and 10=extreme pain	Up to Week 13
Secondary	Change From Baseline in Total Treatment Satisfaction Score using HIV Treatment Satisfaction Status Questionnaire (HIVTSQs) Following Administration of SC Injection (scores on a scale)	The HIVTSQs treatment satisfaction questionnaire comprises of 1-12 questions and the total treatment satisfaction score is computed with items 1-11 and summed to produce a score with a possible range of 0 to 66. Higher scores represent greater treatment satisfaction.	Baseline and Up to Week 9
Secondary	Change From Baseline in individual item scores using HIVTSQs Following Administration of SC Injection (scores on a scale)	HIVTSQs (status version) is a 12 item questionnaire. The individual item scores are rated as 6 (very satisfied, convenient, flexible, etc.) to 0 (very dissatisfied, inconvenient, inflexible, etc.). Higher scores represent greater treatment satisfaction.	Baseline and Up to Week 9
Secondary	Change from Baseline in Total treatment satisfaction score using the HIV Treatment Satisfaction Change Questionnaire (HIVTSQc) Following Administration of SC Injection (scores on a scale)	The HIVTSQc is a 1-12 items questionnaire. Each item is scored -3 to 3. Total treatment satisfaction change score is computed using items 1 to 11 and are summed to produce a score with a possible range of -33 to 33. Higher the score, greater the improvement in satisfaction with treatment; the lower the score, the greater the deterioration in satisfaction with treatment. A score of 0 will represent no change.	Baseline and Up to Week 9
Secondary	Change From Baseline in individual item scores using HIVTSQc Following Administration of SC Injection (scores on a scale)	HIVTSQc is a 12 item questionnaire. The individual item scores on HIVTSQs scale are rated as 6 (very satisfied, convenient, flexible, etc.) to 0 (very dissatisfied, inconvenient, inflexible, etc.). Higher scores represent greater satisfaction with each aspect of treatment.	Baseline and Up to Week 9
Secondary	Change From Baseline in Total Treatment Satisfaction Score using HIVTSQs Following Administration of IM Injection (scores on a scale)	The HIVTSQs treatment satisfaction questionnaire comprises of 1-12 questions and the total treatment satisfaction score is computed with items 1-11 and summed to produce a score with a possible range of 0 to 66. Higher scores represent greater treatment satisfaction.	Baseline and Up to Week 17
Secondary	Change From Baseline in individual item scores using HIVTSQs Following Administration of IM Injection (scores on a scale)	HIVTSQs is a 12 item questionnaire. The individual item scores on HIVTSQs scale are rated as 6 (very satisfied, convenient, flexible, etc.) to 0 (very dissatisfied, inconvenient, inflexible, etc.). Higher scores represent greater satisfaction with each aspect of treatment.	Baseline and Up to Week 17
Secondary	Number of participants with Perception of Injection (PIN) Questionnaire Following Administration of SC Injection (scores on a scale)	The PIN questionnaire explores the bother of pain at the injection site and ISR, anxiety before and after injection, willingness to receive an HIV injectable treatment the following visit and satisfaction with the mode of treatment administration of individuals receiving injection and perceptions of individuals associated with receiving injections. This measure contains 21 items that measure pain at injection site, local site reactions, impact on functioning and willingness to pursue injectable treatment outside of a clinical trial. Scores range from 1 to 5, and questions are phrased in such a way as to ensure that 1 always equated with the most favorable perception of vaccination, and 5 the most unfavorable.	Baseline and Up to Week 9
Secondary	Number of participants with PIN Questionnaire Following Administration of IM Injection (scores on a scale)	The PIN questionnaire explores the bother of pain at the injection site and ISR, anxiety before and after injection, willingness to receive an HIV injectable treatment the following visit and satisfaction with the mode of treatment administration of individuals receiving injection and perceptions of individuals associated with receiving injections. This measure contains 21 items that measure pain at injection site, local site reactions, impact on functioning and willingness to pursue injectable treatment outside of a clinical trial. Scores range from 1 to 5, and questions are phrased in such a way as to ensure that 1 always equated with the most favorable perception of vaccination, and 5 the most unfavorable.	Up to Week 13
Secondary	Number of Participants With Their Treatment Preference Assessed Using Preference Questionnaire Following Administration of SC injections	The "Preference" questionnaire will include a single item question evaluating preference of HIV treatment and the attributes supporting this preference.	At Week 9
Secondary	Number of Participants With Their Treatment Preference Assessed Using Preference Questionnaire Following Administration of IM injections	The "Preference" questionnaire will include a single item question evaluating preference of HIV treatment and the attributes supporting this preference.	At Week 17