Lopinavir/Ritonavir Monotherapy after 24 Weeks of Second-Line Antiretroviral Therapy in Africa: A Randomized Controlled Trial (Sara)
Gilks CF., Walker AS., Dunn DT., Gibb DM., Kikaire B., Reid A., Musana H., Mambule I., Kasirye R., Robertson V., Ssali F., Spyer M., Pillay D., Yirrell D., Kaleebu P.
Background Boosted protease inhibitor (bPI) monotherapy (bPImono) potentially has substantial cost, safety and operational benefits. It has never been evaluated as second-line antiretroviral therapy (ART) in Africa. Methods After 24 weeks of lopinavir/ritonavir- containing second-line therapy, DART participants were randomized to remain on combination therapy (CT), or change to bPI-mono maintenance (SARA trial; ISRCTN53817258). Joint primary end points were CD4 + T-cell changes 24 weeks later and serious adverse events (SAEs); retrospectively assayed viral load (VL) was a secondary end point. Analyses were intention-to-treat. Results A total of 192 participants were randomized to CT ( n =95) or bPImono ( n =97) and followed for median 60 weeks (IQR 45–84). Participants received median 4.0 years (IQR 3.5–4.4) first-line ART. Median CD4 + T-cell count at first-line failure was 86 cells/mm 3 (47–136), increasing to 245 cells/mm 3 (173–325) after 24-week induction when 77% had VL<50 copies/ml. Overall, 44 (23%) were receiving second-line therapy with bPI and nucleoside reverse transcriptase inhibitors (NRTI) only, and 148 (77%) with bPI plus non-NRTI (NNRTI) with or without NRTI. At 24 weeks after randomization to CT versus bPImono, mean CD4 + T-cell increase was 42 (CT, n =85) versus 49 cells/mm 3 (bPImono, n =88; adjusted difference 13 [95% CI -15, 43], P =0.37; non-inferior compared with predetermined non-inferiority margin [-33]). Virological suppression was greater for CT versus bPImono (trend P =0.009): 77% (70/91) versus 60% (56/94) were <50 copies/ml, and 5% (5) versus 14% (13) were ≥1,000 copies/ml, respectively. A total of 0 (0%) versus 5 (5%) participants had major protease inhibitor mutations and 3 (3%) versus 0 (0%) new NNRTI/NRTI mutations were detected during follow-up. Two participants (1 CT and 1 bPImono) died >24 weeks after randomization, and 5 (2 CT and 3 bPImono) experienced SAEs ( P =0.51). Conclusions bPImono following a 24-week second-line induction was associated with similar CD4 + T-cell response, but increased low-level viraemia, generally without protease inhibitor resistance. Longer-term trials are needed to provide definitive evidence about effectiveness in Africa.