A General Framework for Designing and Evaluating Active-Controlled Trials with Non-Inferiority Objectives

Active-controlled trials with non-inferiority objectives are often used when effective interventions are available, but new options may offer advantages or meet public health needs. In these trials, participants are randomized to an experimental intervention or an active control. The traditional non-inferiority criterion requires that the new intervention preserve a substantial proportion of the active control effect. A key challenge is the absence of a placebo arm, which necessitates reliance on historical data to estimate the active control effect and assumptions about how well this effect applies to the target population. Another challenge arises when the active control is highly effective, as the new intervention may still be valuable even if it does not meet the traditional criterion. This has motivated alternative criteria based on sufficient efficacy relative to a hypothetical placebo. In this work, we propose a general framework for designing and evaluating non-inferiority trials that integrates all existing analytical methods and accommodates both traditional and alternative success criteria. The framework enables the systematic comparison of methods in terms of type I error, power, and robustness to misspecification of the active control effect. We illustrate its applicability in the design of a future HIV prevention trial with a highly effective active control. In this application, our framework identifies methods that provide greater efficiency and robustness than commonly used approaches and demonstrates practical advantages of the alternative non-inferiority criterion. Overall, this framework offers a comprehensive toolkit for rigorous non-inferiority trial design, supporting method selection and the evaluation of new interventions.