Pilot, Randomized Study Assessing Safety, Tolerability and Efficacy of Simplified LPV/r Maintenance Therapy in HIV Patients on the 1st PI-Based Regimen

Objectives To compare the efficacy and safety of an individualized treatment-simplification strategy consisting of switching from a highly-active anti-retroviral treatment (HAART) with a ritonavir-boosted protease inhibitor (PI/r) and 2 nucleoside reverse-transcriptase inhibitors (NRTIs) to lopinavir/ritonavir (LPV/r) monotherapy, with intensification by 2 NRTIs if necessary, to that of continuing their HAART. Methods This is a one-year, randomized, open-label, multi-center study in virologically-suppressed HIV-1-infected adults on their first PI/r-containing treatment, randomized to either LPV/r-monotherapy or continue their current treatment. Treatment efficacy was determined by plasma HIV-1 RNA viral load (VL), time-to-virologic rebound, patient-reported outcomes (PROs) and CD4+T-cell-count changes. Safety was assessed with the incidence of treatment-emergent adverse events (AE). Results Forty-one patients were randomized to LPV/r and 39 to continue their HAART. No statistically-significant differences between the two study groups in demographics and baseline characteristics were observed. At day-360, 71(39:LPV/r;32:HAART) patients completed treatment, while 9(2:LPV/r;7:HAART) discontinued. In a Last Observation Carried Forward Intent-to-Treat analysis, 40(98%) patients on LPV/r and 37(95%) on HAART had VL<200copies/mL (P = 0.61). Time-to-virologic rebound, changes in PROs, CD4+ T-cell-count and VL from baseline, also exhibited no statistically-significant between-group differences. Most frequent AEs were diarrhea (19%), headache (18%) and influenza (16%). Four (10%) patients on LPV/r were intensified with 2 NRTIs, all regaining virologic control. Eight serious AEs were reported by 5(2:LPV/r;3:HAART) patients. Conclusion At day-360, virologic efficacy and safety of LPV/r appears comparable to that of a PI+2NRTIs HAART. These results suggest that our individualized, simplified maintenance strategy with LPV/r-monotherapy and protocol-mandated NRTI re-introduction upon viral rebound, in virologically-suppressed patients merits further prospective long-term evaluation. Trial Registration ClinicalTrials.gov NCT00159224

A variety of new approaches designed to address the problems associated with HAART are currently being explored. These include strategic treatment interruptions to reduce time on therapy, toxicity and cost, the employment of a biphasic, induction/maintenance approach to therapy, where a standard, potent three drug regimen is used to suppress the virus followed by the use of a simpler regimen to maintain viral control while reducing side effects and cost and the use of drug class-sparing regimens to reduce or reverse toxicities such as fat redistribution, dyslipidemia and/or insulin resistance.
This study will assess the safety, tolerability and antiviral activity of a simplified PI-based treatment regimen (Kaletra,™) compared to conventional HAART regimens in patients infected with HIV-1 who are on their first boosted-PI The potency of the antiviral activity of Kaletra ™ has been clearly demonstrated in a wide spectrum of patients in a number of different clinical trials. [6][7][8][9] The durable viral suppression seen after 4 years of therapy 10 proves that it can provide effective, long-term treatment for people with HIV-1. It is active in subjects who have failed other PIs and in subjects with high viral load or low CD 4 count.
Data from one of these trials (M97-720), 6  is not associated with significant toxicity or genotypic/phenotypic resistance.
The proposed study will involve 100 HIV-1-infected subjects on their first PIbased antiretroviral therapy and will compare the safety, tolerability and efficacy of monoclass therapy with lopinavir/ritonovir to that of treatment regimens which include 2 NRTIs. The study will be conducted in accordance with good clinical practices and the protocol. All applicable clinical research regulations and guidelines as well as all applicable local regulations will be adhered to.

Primary Objective
The primary objective of this study is to assess the efficacy, and safety of the strategy of switching to a simplified lopinavir/ritonavir-based treatment regimen with intensification by reinitiation of 2 NRTI's if necessary, compared to the strategy of continuing on a current regimen comprising 2 NRTIs plus a ritonavir-boosted PI in patients infected with HIV-1 who are on their first PI-based anti-retroviral therapy.

Secondary Objectives
The secondary objectives of the study are to: . • Evaluate the resistance profile of the simplified treatment vs. the control group.
• Evaluate the comparative cost of both arms at the end of the study period.

Study Design and Procedures
This is a pilot, prospective, randomized, open-label, comparative, multi-center study in HIV-infected adults on their first PI-based anti-retroviral therapy.
Approximately 100 subjects will be enrolled at sites in Canada, Argentina, and Mexico.
At the first visit (Screening/Baseline Visit), subjects will undergo screening procedures as listed in Section 3.2 and will be randomly assigned to receive either lopinavir/ritonavir as monotherapy (study group) or to continue on their current anti-retroviral treatment regimen (control group) for the next 360 days.
The measurements made during the screening period, as described in Section 3.2, will serve as baseline measurements for the study. Subjects will return to the clinic on Day 15 for check-up, assessment of their compliance to the treatment regimen and to report adverse events. Return visits will be scheduled for Day 30 and then every 30 days until Day 180. After day 180, subjects will return for visits at Day 240, 300 and 360. The procedures to be carried out at these visits are summarized in Table 1.
Direct costs only related to the study medication will be captured. If as expected, no significant differences in outcomes/effectiveness are observed, a cost minimization analysis will be performed as per standard methodology. If the QOL estimates show a difference in effectiveness between the treatment regimens, we will additionally perform a cost utility analysis and estimate the incremental cost per life year gained.
The planned duration of the study is 360 days (12 months). Subject must have had no previous exposure to other regimens. • Subject has a viral load <50 copies/ml at the time of baseline evaluation for at least 6 months. • Subject has a CD4 cell count ≥ 100 cells/mm3.
• Vital signs, physical examination and laboratory results do not exhibit evidence of acute illness. • Subject has not been treated for an active opportunistic infection within 30 days of screening.
• If female, subject has a negative pregnancy test and agrees to use, for the duration of the study, a barrier method of birth control that has a history of proven reliability as judged by the investigator.
• Subject does not require and agrees not to take, for the duration of the study, any medication that is contraindicated with any of the antiretroviral drugs in their treatment regimen. The subject agrees not to take any medication, including over-the-counter medicine, alcohol, or recreational drugs without the knowledge and permission of the principal investigator.

Exclusion Criteria
• Subject has current uncontrolled substance abuse or psychiatric illness that could preclude compliance with the protocol.
• Subject has a viral load of > 50 copies/ml • Subject is HBsAg + • Subject has active tuberculosis or an opportunistic infection.
• Subject has liver failure as evidenced by ALT / AST > 5 x Upper Limit of Normal (ULN).
• Female subject is pregnant or lactating.
• Subject has received an investigational drug within 30 days prior to the initiation of the study.
• Subject has modified his/her antiretroviral therapy during the 3 months prior to baseline or is intending to do so during the course of the study.

Screening Procedures
After the subject signs and dates the study-specific informed consent, he/she will undergo the following screening procedures: • Complete medical history, including smoking, alcohol and drug history and prior medications. • Urine or serum pregnancy test for females of reproductive potential.
• Complete physical examination, including height, weight and abdominal circumference measured at the umbilicus level while standing.
• Vital signs including systolic and diastolic blood pressures, pulse, respiration rate and body temperature.
• Plasma HIV RNA level, measured using the Roche Amplicor assay.
• CD 4 cell count. The results of all clinical evaluations during screening must be within clinically acceptable limits as defined by the test laboratory and reviewed by the investigator. Subjects will not be included in the study if laboratory or other screening results are unacceptable.

Study Visits
The timing of study visits and the procedures that will be carried out at each visit are summarized in Table 1  Screening procedures as described in Section 3.2 will be performed during a period of two to three weeks before the Baseline Visit (Day-1), the day prior to the initiation of study treatment.

Day 15
• Physical examination including weight and abdominal circumference in the upright position. • Vital signs, viral load, QOL questionnaire and concomitant medications as for Screening/Baseline Visit.

Day 30
• Physical examination as for Day 15 • Vital signs, viral load, CD 4

Study Duration
It is estimated that the duration of this study will be 12 months. Enrolment of subjects will take 18 months and each subject randomized to receive lopinavir/ritonavir monotherapy will be treated for 360 days.

Discontinuation of Study
See Section 7.4.

Premature Withdrawal of Subjects
Each subject has the right to withdraw from the study at any time. The investigator may discontinue any subject's participation if the investigator deems it necessary for any reason, including adverse events, safety concerns, and failure to comply with the protocol. The participation of any female subject who becomes pregnant during the course of the study will be discontinued.
In the case of premature discontinuation from the study, a termination visit will be completed.
Any subject who discontinues study participation with an unresolved clinically significant laboratory abnormality or adverse event will be followed for 30 days after the last dose of lopinavir/ritonavir or until satisfactory clinical resolution is achieved.

Treatments Administered
Subjects randomized to the monotherapy group will be provided with co-formulated lopinavir/ritonavir 133.3/33.3 mg (Kaletra™) soft gel capsules manufactured by Abbott Laboratories. They will be instructed to take 3 capsules BID orally with food. Subjects randomized to the control group will continue on their current treatment regimen.

Prior and Concomitant Therapy
Subjects will be provided with a list of medications that should not be taken during the study. They will be advised to avoid taking any medication that is contraindicated.
Any medication (including over-the-counter medicines such as aspirin, antacids, vitamins, mineral supplements and herbal preparations) that the subject is receiving at the time of enrollment, or receives during the study, must be recorded together with the dates of administration and dosages. Any previous antiretroviral therapy should be recorded along with the dates of administration. Any vaccine administered to the subject should be listed as a concurrent medication.

Treatment Compliance
All subjects will receive ongoing counseling regarding the importance of compliance with their medication. They will be instructed to return the container of study drug, whether empty or containing drug, to the study coordinator at all study visits following the Screening/Baseline Visit.. . A pill count at every visit will be used to assess compliance with treatment.

Primary Efficacy Variable
The primary efficacy variable will be the percentage of subjects with plasma HIV RNA level < 200 copies/ml at Day 360.

Secondary Efficacy Variables
The secondary efficacy variables will be: 1. Percentage of subjects with plasma HIV RNA < 50 copies/mL at Day 360.
3. The mean change from baseline to each visit in HIV RNA level and CD 4 cell count.
4. The emergence of resistant strains. The investigator will follow all adverse events to satisfactory clinical resolution.
The investigator will rate the severity of the adverse event according to the following definition: Spontaneous and elective abortions will be reported as serious adverse events.
Please note that a severe adverse event/experience is not necessarily serious, as the term severe is a measure of intensity while a serious adverse event is determined based on the aforementioned regulatory criteria.

Toxicity Management
For the purpose of medical management, all adverse events and laboratory abnormalities that occur during the study must be evaluated by the investigator.
Appendix C contains "Clinical Toxicity Grades." This table is to be used in the grading of adverse events. All adverse events and laboratory abnormalities will be followed to satisfactory clinical resolution. The following guidelines should be used for study drug-related toxicity management for all subjects. The same form will be used to record Adverse Events and HIV-Related Events.
HIV-Related Events that are serious in nature, as defined in Section 6.2, must be reported in the same manner as Serious Adverse Events.

Subject Management
Study participants with a single viral rebound >50 copies/mL will continue on their randomized ARV therapy. The investigator will work with the patient to 25 resolve possible adherence problems. Viral load will be retested after not less than 7 and not more than 30 days. If the second viral load is <50, the patient will resume the normal study visit schedule; if it is between 50 and 200, viral load will be retested weekly until either <50 or >200. If any retest viral load is >200, patients in the 3-drug HAART continuation arm will be considered to have met a study endpoint of virologic failure, and treatment will be modified at the discretion of the investigator or the treating physician. In the monotherapy arm, if any retest viral load is > 200 copies/ml, intensification with two NRTI's is allowed (either the same NRTIs as before randomization or different ones) and the subject will be considered still on randomized treatment. These patients will resume the study visit schedule starting from baseline and have viral load retested at days 15, 30, etc. After intensification, viral load results >50 will be handled as described above. Patients who have intensified will be considered to have reached the study endpoint of virologic failure if they have one viral load >50 after intensification and a consecutive viral load >200; therapy will then be modified at the discretion of the investigator or the treating physician.  The primary efficacy outcome variable is rate of virologic control defined as the proportion of patients with viral load count less than 200 copies / mL at 360 days. Between-group differences with respect to this variable will be assessed with the Chi-Square Statistic and the relative risk with 95% confidence intervals.
Multiple logistic regression will be used to adjust the between group differences for potential confounders including patient's age and baseline characteristics. Similar analyses will be performed for the secondary efficacy variable of proportion of patients with viral load less than 50 copies/mL at 360 days. For both the <200 and <50 copies/mL outcomes, both intent-to-treat and on-treatment analyses will be performed.
The secondary efficacy variable of time to virologic rebound will be analyzed with the Kaplan Meier survival function and Breslow-Day log-rank test to compare the two groups. Cox'x proportional hazards model will be used to adjust the between group differences with respect to the rate of virologic rebound, for potential confounders including patient's age and baseline characteristic.
The Student's t-test for independent samples will be used to assess between group differences with respect to the change in viral load and CD4 cell counts between the baseline and final assessments.
Multiple linear regression will be used to adjust the between group differences with respect to these outcome variables for potential confounders including patient's age and baseline characteristics.
The emergence of resistance strains will be described for those patients that experience treatment failure only. The presence of resistant mutations will be described as the percentage of patients with treatment failure that are infected with a resistant HIV mutation.

Safety
Safety will be assessed by the incidence of adverse events including lipid abnormalities. The relative risk will be used to assess the between group differences with respect to the incidence of adverse events. Ninety-five percent confidence intervals will be used to assess the statistical significance and precision of the relative risk estimate. All adverse events will be described using the MedDra or WHO classification system 7.3 Level of Significance to be Used All statistical tests will be considered as significant if the alpha level is below 5%. However, alpha levels below 10% will be considered as indicating a trend,

Criteria for Termination of the Study
For reasonable cause, the Sponsor or any regulatory agencies may terminate this study at any time.

Procedure for Handling Missing, Unused, and Spurious Data
No imputations or replacement of missing data will be performed.
Observations will be censored at the time of last follow up. The last observation carried forward approach will NOT be used.

Procedures for Reporting Deviations from the Original Statistical Plan
Any deviations will be reported as amendments to the statistical analysis plan.

Criteria for Selection of Subjects to be Included in the Analyses
The primary analyses will be according to the Intent to Treat (ITT) principle that will be based on all patients enrolled in the study and have taken at least one dose of the study medications. Patients that do not adhere to the study protocol and are not compliant with the study treatment regimen (> 80% of medications) will be excluded from the as per protocol analysis.

Direct Access to Source Data/Documents
Upon the request of the regulatory authority, IRB/IEC members, or auditors, the investigators will make all requested trial-related documents available for direct access.

Informed Consent
It is the responsibility of the investigator to ensure that each subject is given adequate explanation of the aims, methods, anticipated benefits and potential risks of this study and voluntarily signs and dates the IRB/IECapproved informed consent form prior to study participation. The investigator must also explain that subjects have the right to refuse to participate in the study or to withdraw at any time for any reason.
The investigator will document in the subject's medical record that informed consent was obtained prior to the performance of any study related procedure and will retain the original consent form with the study records. A copy of the signed and dated consent form should be given to the subject. Appendix G contains the elements of informed consent.

Conduct of the Study
The study will be conducted in accordance with the protocol, applicable clinical research regulations and guideline, and all applicable local regulations.

Data Handling and Record Keeping
Case Report Forms (CRFs) will be used to store information collected during this study. CRFs will be completed for each subject enrolled in this study. All case report forms will be legible and completed in ink. Any necessary corrections will be made by drawing a single line through the incorrect entry and writing in the revision, and will be initialed and dated by the investigator or his/her designee.
Data will not be obliterated by blacking out, use of correction fluid, or by erasing the original entry. If the reason for the correction is not obvious, a brief explanation (e.g., transcription error) will accompany the change. All information written on the CRFs will also be reflected in the subjects' source documents.

Data Quality Assurance
In order to maintain the integrity of study data, information collected on CRFs and laboratory results will be verified by the investigator. This will be documented by the investigator´s signature.
The investigator will keep a screening/enrollment log and complete identification information on each subject to be used for the purpose of long-term follow up if needed.

Appendices Appendix A. Protocol Synopsis
Protocol Title: A Pilot, Randomized , Open-Label Study Assessing Safety, Tolerability, Efficacy of a Simplified Lopinavir/Ritonavir-Based Induction/Maintenance Therapy in HIV-Infected Subjects on their First Protease Inhibitor-Based Regimen.
Study Objectives:

Primary:
The primary objective of this study is to assess the efficacy, and safety of the strategy of switching to a simplified lopinavir/ritonavir-based treatment regimen with intensification by reinitiation of 2 NRTI's if necessary, compared to the strategy of continuing on a current regimen comprising 2 NRTIs plus a ritonavir-boosted PI in patients infected with HIV-1 who are on their first PI-based anti-retroviral therapy. Secondary: • To evaluate the resistance profile of the simplified treatment vs. the control group. • Evaluate the comparative cost of both arms at the end of the study period

Patient Population:
HIV-infected male and female subjects aged >18 years who are on their first protease inhibitor-based treatment regimen.

Study Design:
A pilot , prospective, randomized, open label, comparative, multi-center study.

Appendix E Documents Required Prior to Initiation of the Study
Prior to the beginning of the clinical study, the investigators will be asked to provide the following documentation.
• An original Investigator-signed Protocol Agreement page.
• A current curriculum vitae for the investigator. If subinvestigators will participate in the study, a curriculum vitae is required for each additional individual.
• A copy of the signed and dated approval letter from the Institutional Review Board (IRB)/Independent Ethics Committee (IEC), with regard to protocol, informed consent, and any advertisement(s).
• A list of IRB/IEC committee members, including their occupations and institutional affiliations.
• An approved copy of the IRB/IEC informed consent document to be used in this study.
• A list of normal reference ranges and values for all laboratory tests specified by the protocol for all laboratories utilized.
• A current copy of the laboratory(ies) certification(s) or the certification number(s), the name of the certifying authority, the period of certification, and the Laboratory Director's curriculum vitae. d) To identify all subinvestigators who will also supervise drug administration. e) To report adverse effects to the principal investigator promptly. In the event of a serious or unexpected adverse event, to notify the principal investigator immediately by telephone.

Appendix G Elements of Informed Consent
A signed consent must be obtained prior to any study-specific activities and must include the following items: a. A statement that the study involves research, and explanation of the purpose of the research and the expected duration of the patient's participation, a description of the procedures to be followed, and identification of any procedures that are experimental and/or invasive. e. A description of any benefits to the patient or to others which may reasonably be expected from the research. If the patient is to be compensated for participating in the study, the consent form must describe what the compensation consists of (to assure neither coercion nor undue influence).
f. A disclosure of appropriate alternative procedures or courses of treatment, if any, that might be advantageous to the patient, and the potential risks and benefits.
g. A statement that the investigator and the Institutional Review Board (IRB)/Independent Ethics Committee (IEC), will be granted direct access to the subject's original medical records for verification of clinical trial procedures and/or data, without violating the confidentiality of the subject, to the extent permitted by the applicable laws and regulations and that, by signing a written informed consent form, the subject or the subject's legally acceptable representative is authorizing such access.
A statement that records identifying the subject will be kept confidential and, to the extent permitted by the applicable laws and/or regulations, will not be made publicly available. If the results of the trial are published, the subject's identity will remain confidential.
h. An explanation of whom to contact for answers to pertinent questions about the research and research patients' rights, and whom to contact in the event of a research-related injury to the patient. (NOTE: It is preferable to identify as the contact some person other than the investigator. The guidance of the IRB/IEC may be required.) i. A statement that participation is voluntary, that refusal to participate will involve no penalty or loss of benefits to which the patient is otherwise entitled, and that the patient may discontinue participation at any time without penalty or loss of benefits to which the patient is otherwise entitled. j. A statement that a signed and dated copy of the consent form will be given to the patient. k. A statement of the agreement to participate (e.g., "I agree to participate ..."). l. A place for signature and date of signature for the research patient (or legally authorized representative) and for the person who explained the nature of the study to the patient (investigator or investigator's representative). m. *A statement that the particular treatment or procedures may involve risks to the patient (or to the embryo, fetus or nursing infant, if the patient is or may become pregnant) that are currently unforeseeable. n. A statement of anticipated circumstances or reasons under which the patient's participation may be terminated by the investigator without regard to patient's consent. o. A statement of any additional costs to the patient that may result from participation in the research. p. A statement regarding the consequences of a patient's decision to withdraw from the research and procedures for orderly termination of participation by the patient. q. A statement that significant new findings developed during the course of the research which may relate to the patient's willingness to continue participation will be provided to the patient (or the patient's legally acceptable representative) in a timely manner. r. A statement of the approximate number of patients involved in the study.
Therefore, it would be of interest to see whether trough PI levels can be correlated with virologic efficacy in this study, particularly for the Kaletra monotherapy arm. While this component of the study will be optional, it will be encouraged for all patients. Separate informed consent will be sought for the PK substudy at the time patients consent to participate in the main study. For patients in both arms who consent to this procedure, an additional pre-dose trough plasma sample will be drawn at the study visits at baseline and days 15, 30, 90, 180, and 360. Plasma will be stored frozen and shipped to the laboratory of the British Columbia Centre for Excellence in HIV/AIDS in Vancouver, B.C. for measurement of PI levels.

Objectives
1. To determine whether virologic efficacy in Kaletra monotherapy and other PIbased regimens is associated with trough plasma PI levels.
2. To determine whether trough LPV levels differ between patients who are taking Kaletra with or without concomitant nucleosides.
3. To determine whether suboptimal LPV trough levels are more likely to be associated with virologic failure in patients taking Kaletra monotherapy than in those taking 2 nucleosides plus Kaletra.

Substudy procedures
At the study visits at baseline and days 15, 30, 90, 180 and 360, consenting patients will be requested to attend the clinic before their morning dose of PI medication. The time of the previous PI dose will be recorded and an additional 3-5 mL blood sample will be collected in an EDTA tube along with the usual study blood tests. Blood samples will be stored at 4°C until processing. Plasma will be separated by centrifugation within 24 Protocol N°: ACA-ARGE-04-001, incorporating amendment # 1 dated April 12, 2005 Version Number:8 -April 12,2005 55 hours of collection and stored at -70 ºC. Frozen plasma samples will be shipped to laboratory of the British Columbia Centre for Excellence in HIV/AIDS in Vancouver, B.C. where PI levels will be analyzed by a validated assay using HPLC coupled with tandem mass spectrometry.

Statistics
Consent to take part in the PK substudy will be sought from all participants in the main study; therefore, up to 100 patients (50 in each arm) will participate in the PK substudy.
Using Student's t-test, LPV trough levels will be compared between patients randomized to Kaletra monotherapy, and those randomized to continue PI-based triple therapy who are taking Kaletra as their PI. In addition, trough PI levels will be entered as a covariate into the univariate and multivariate analysis for the efficacy endpoint of the main study (as described in section 7.2.1 of the study protocol).