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Nucleoside analogs plus ritonavir in stable antiretroviral therapy-experienced HIV-infected children: a randomized
S A Nachman1, K Stanley, R Yogev
1Department of Pediatrics, State University of New York at Stony Brook, 11794-8111, USA. snachman@mail.som.sunysb.edu
Insights
Switching to ritonavir-containing antiretroviral therapy improved virologic response in children with human immunodeficiency virus (HIV). Ritonavir combined with two nucleoside analogs showed better results than one nucleoside analog at 48 weeks.
Area of Science:
- Pediatric Infectious Diseases
- Virology
- Clinical Pharmacology
Background:
- Protease inhibitors are standard for adult HIV treatment, but their role in stable pediatric HIV is unclear.
- Evaluating new antiretroviral therapy (ART) regimens is crucial for children with HIV.
Purpose of the Study:
- To assess the safety, tolerance, and virologic outcomes of switching ART in clinically stable, protease inhibitor-naive children with HIV.
- To compare different ART regimens including ritonavir in pediatric HIV patients.
Main Methods:
- A multicenter, phase 2, randomized, open-label trial (Pediatric AIDS Clinical Trials Group 338) involving 297 children (aged 2-17 years).
- Patients were randomized to zidovudine/lamivudine, zidovudine/lamivudine/ritonavir, or ritonavir/stavudine.
- Plasma HIV-1 RNA levels were measured at weeks 12 and 48.
Main Results:
- At week 12, ritonavir-containing regimens achieved significantly higher undetectable HIV RNA levels (52-54%) compared to zidovudine/lamivudine (12%).
- At week 48, 42% of children on ritonavir plus two nucleosides had undetectable HIV RNA, versus 27% on ritonavir plus one nucleoside (P=.04).
- 70% of children continued their ritonavir-containing regimens through week 48.
Conclusions:
- Changing ART to a ritonavir-containing regimen improved virologic response at 12 weeks compared to dual nucleoside analogs.
- Ritonavir in combination with two nucleoside analogs led to more undetectable HIV RNA levels at 48 weeks in children with HIV.
Context:
Although protease inhibitors are used routinely in adults with human immunodeficiency virus (HIV) infection, the role of these drugs in the treatment of clinically stable HIV-infected children is not clear.
Objective:
To evaluate the safety, tolerance, and virologic response produced by a change in antiretroviral therapy in HIV-infected children who were clinically and immunologically stable while receiving previous therapy.
Design:
The Pediatric AIDS Clinical Trials Group 338, a multicenter, phase 2, randomized, open-label controlled trial conducted from February 6 to April 30, 1997 (patient entry period); patients were followed up for 48 weeks.
Setting:
Pediatric HIV research clinics in the United States and Puerto Rico.
Patients:
Two hundred ninety-seven antiretroviral-experienced, protease inhibitor-naive, clinically stable HIV-infected children aged 2 to 17 years.
Interventions:
Children were randomized to receive zidovudine, 160 mg/m2 3 times per day, plus lamivudine, 4 mg/kg 2 times per day (n = 100); the same regimen plus ritonavir, 350 mg/m2 2 times per day (n = 100); or ritonavir, 350 mg/m2 2 times per day, and stavudine, 4 mg/kg 2 times per day (n = 97).
Main Outcome Measure:
Plasma HIV-1 RNA levels at study weeks 12 and 48, compared among the 3 treatment groups.
Results:
At study week 12, 12% of patients in the zidovudine-lamivudine group had undetectable plasma HIV RNA levels (<400 copies/mL) compared with 52% and 54% of patients in the 2- and 3-drug ritonavir-containing groups, respectively (P<.001). Through study week 48, 70% of children continued receiving their ritonavir-containing regimen. At study week 48, 42% of children receiving ritonavir plus 2 nucleosides compared with 27% of those receiving ritonavir and a single nucleoside had undetectable HIV RNA levels (P = .04); however, similar proportions in each group continuing initial therapy had HIV RNA levels of less than 10000 copies/mL (58% vs 48%, respectively; P = .19).
Conclusions:
In our study, change in antiretroviral therapy to a ritonavir-containing regimen was associated with superior virologic response at study week 12 compared with change to a dual nucleoside analog regimen. More children receiving ritonavir in combination with 2 compared with 1 nucleoside analog had undetectable HIV RNA levels at study week 48.
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