Study design and participant characteristics of a randomized controlled trial of directly administered antiretroviral therapy in opioid treatment programs

<p>Abstract</p> <p>Background</p> <p>HIV-infected drug users are at higher risk of non-adherence and poor treatment outcomes than HIV-infected non-drug users. Prior work from our group and others suggests that directly administered antiretroviral therapy (DAART) delivered in opioid treatment programs (OTPs) may increase rates of viral suppression.</p> <p>Methods/Design</p> <p>We are conducting a randomized trial comparing DAART to self-administered therapy (SAT) in 5 OTPs in Baltimore, Maryland. Participants and investigators are aware of treatment assignments. The DAART intervention is 12 months. The primary outcome is HIV RNA < 50 copies/mL at 3, 6, and 12 months. To assess persistence of any study arm differences that emerge during the active intervention, we are conducting an 18-month visit (6 months after the intervention concludes). We are collecting electronic adherence data for 2 months in both study arms. Of 457 individuals screened, a total of 107 participants were enrolled, with 56 and 51 randomly assigned to DAART and SAT, respectively. Participants were predominantly African American, approximately half were women, and the median age was 47 years. Active use of cocaine and other drugs was common at baseline. HIV disease stage was advanced in most participants. The median CD4 count at enrollment was 207 cells/mm³, 66 (62%) had a history of an AIDS-defining opportunistic condition, and 21 (20%) were antiretroviral naïve.</p> <p>Conclusions</p> <p>This paper describes the rationale, methods, and baseline characteristics of subjects enrolled in a randomized clinical trial comparing DAART to SAT in opioid treatment programs.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov: <a href="http://www.clinicaltrials.gov/ct2/show/NCT00279110">NCT00279110</a></p

Breast cancer management pathways during the COVID-19 pandemic: outcomes from the UK ‘Alert Level 4’ phase of the B-MaP-C study

Abstract: Background: The B-MaP-C study aimed to determine alterations to breast cancer (BC) management during the peak transmission period of the UK COVID-19 pandemic and the potential impact of these treatment decisions. Methods: This was a national cohort study of patients with early BC undergoing multidisciplinary team (MDT)-guided treatment recommendations during the pandemic, designated ‘standard’ or ‘COVID-altered’, in the preoperative, operative and post-operative setting. Findings: Of 3776 patients (from 64 UK units) in the study, 2246 (59%) had ‘COVID-altered’ management. ‘Bridging’ endocrine therapy was used (n = 951) where theatre capacity was reduced. There was increasing access to COVID-19 low-risk theatres during the study period (59%). In line with national guidance, immediate breast reconstruction was avoided (n = 299). Where adjuvant chemotherapy was omitted (n = 81), the median benefit was only 3% (IQR 2–9%) using ‘NHS Predict’. There was the rapid adoption of new evidence-based hypofractionated radiotherapy (n = 781, from 46 units). Only 14 patients (1%) tested positive for SARS-CoV-2 during their treatment journey. Conclusions: The majority of ‘COVID-altered’ management decisions were largely in line with pre-COVID evidence-based guidelines, implying that breast cancer survival outcomes are unlikely to be negatively impacted by the pandemic. However, in this study, the potential impact of delays to BC presentation or diagnosis remains unknown

Directly administered antiretroviral therapy for HIV-infected individuals in opioid treatment programs: results from a randomized clinical trial.

Data regarding the efficacy of directly administered antiretroviral therapy (DAART) are mixed. Opioid treatment programs (OTPs) provide a convenient framework for DAART. In a randomized controlled trial, we compared DAART and self-administered therapy (SAT) among HIV-infected subjects attending five OTPs in Baltimore, MD.HIV-infected individuals attending OTPs were eligible if they were not taking antiretroviral therapy (ART) or were virologically failing ART at last clinical assessment. In subjects assigned to DAART, we observed one ART dose per weekday at the OTP for up to 12 months. SAT subjects administered ART at home. The primary efficacy comparison was the between-arm difference in the average proportions with HIV RNA <50 copies/mL during the intervention phase (3-, 6-, and 12-month study visits), using a logistic regression model accounting for intra-person correlation due to repeated observations. Adherence was measured with electronic monitors in both arms.We randomized 55 and 52 subjects from five Baltimore OTPs to DAART and SAT, respectively. The average proportions with HIV RNA <50 copies/mL during the intervention phase were 0.51 in DAART and 0.40 in SAT (difference 0.11, 95% CI: -0.020 to 0.24). There were no significant differences between arms in electronically-measured adherence, average CD4 cell increase from baseline, average change in log10 HIV RNA from baseline, opportunistic conditions, hospitalizations, mortality, or the development of new drug resistance mutations.In this randomized trial, we found little evidence that DAART provided clinical benefits compared to SAT among HIV-infected subjects attending OTPs.ClinicalTrials.gov NCT00279110 NCT00279110&quest;term&hairsp;&equals;&hairsp;NCT00279110&rank&hairsp;&equals;&hairsp;1

Average CD4 cell count (A) and change from baseline in CD4 cell count (B) over time, stratified by study arm.

<p>Directly administered antiretroviral therapy (DAART) is shown with square markers and solid lines and self-administered therapy (SAT) is shown with diamond markers and dashed lines. Individual-level data are shown at each time point (o indicating SAT and+indicating DAART).</p

Study outcomes in a randomized trial comparing directly administered antiretroviral therapy with self-administered therapy in opioid treatment programs, Baltimore, Maryland, 2006–2010.

<p>SAT, self-administered therapy; DAART, directly administered therapy; CI, confidence interval.</p>a<p>Difference in proportions (binary outcomes) or means (continuous outcomes) between DAART and SAT.</p>b<p>Primary outcome.</p>c<p>Electronic adherence data available for 51 and 52 SAT and DAART participants, respectively.</p>d<p>Adherence is (doses recorded/doses expected in the monitoring period)*100.</p

Baseline characteristics of HIV-infected participants in a randomized trial comparing directly administered antiretroviral therapy with self-administered therapy in opioid treatment programs, Baltimore, Maryland, 2006–2010.

<p>SAT, self-administered therapy; DAART, directly administered therapy; PI, protease inhibitor; NRTI, nucleoside reverse transcriptase inhibitor; NNRTI, non-nucleoside reverse transcriptase inhibitor.</p>a<p>Center for Epidemiologic Studies Depression (CES-D) short form scale <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0068286#pone.0068286-Andresen1" target="_blank">[14]</a>. Higher values indicate more numerous or severe depressive symptoms (range 0 to 30).</p>b<p>Alcohol Use Disorders Identification Test (AUDIT) score <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0068286#pone.0068286-Saunders1" target="_blank">[15]</a> of 8 or more is associated with hazardous drinking.</p

Virologic failure and acquisition of antiretroviral drug resistance mutations in a randomized trial comparing directly administered antiretroviral therapy with self-administered therapy in opioid treatment programs, Baltimore, Maryland, 2006–2010.

<p>SAT, self-administered therapy; DAART, directly administered therapy; CI, confidence interval.</p

HIV RNA suppression, at cutoffs of <50 (A) and <400 copies/mL (B), at baseline, 3-, 6-, 12-, and 18-month follow-up visits, stratified by study arm, with missing values ignored.

<p>Directly administered antiretroviral therapy (DAART) is shown with square markers and solid lines and self-administered therapy (SAT) is shown with diamond markers and dashed lines.</p

Study screening, enrollment, and disposition.

<p>Censored subjects had not reached the indicated study visit prior to the administrative closure of the study. DAART, directly administered antiretroviral therapy; SAT, self-administered therapy.</p