A Randomised, Phase 3 Non-inferiority Study of DOR/3TC/TDF Compared to DTG/TAF/FTC in Participants Infected With HIV-1 Starting First-line Antiretroviral Therapy

One of the major concerns, voiced by researchers, clinicians, and participants, is that data is severely limited to inform participants with side effects, or those wanting to avoid these side effects, as to evidence-based alternatives. As a result, there are no evidence-based regimens available for participants who have begun experiencing weight gain as a side effect on treatment or wanting to avoid weight gain on initiation of antiretrovirals which is now an almost routine side effect for women or Black participants.

Switching to efavirenz-based regimens, while plausibly associated with weight mitigation in efavirenz slow-metabolizers, is accompanied by unacceptable metabolic, organ and neuropsychiatric side effects in the slow metabolizers likely to experience weight loss. There is minimal data on weight changes for switches from integrase inhibitors and having evidence-based options would dramatically add to treatment possibilities for participants. There is some evidence that the use of TDF and doravirine may mitigate the weight gain seen with TAF/integrase inhibitors combinations.

Doravirine is a compelling replacement for the integrase inhibitors similarly well tolerated, and with a high resistance barrier and better lipid profile as compared to other drugs in the non-nucleoside reverse-transcriptase inhibitor class14. In a recent network meta-analysis, DOR/3TC/TDF was found to exhibit superiority in virological suppression to traditional first line non-DTG containing regimes with more tolerable side effects, and a decrease in severe adverse events.

The DOR/3TC/TDF combination would be a major step forward for current treatment guidelines if found to be equivalent in terms of virological suppression and showed a meaningful difference in weight gain, as well as in cardiometabolic outcomes. This potentially offers clinicians and high risk participants an evidence-based alternative to TAF/integrase inhibitor combinations.

We propose a head-to-head, non-inferiority, randomized study with DTG/TAF/FTC, against a formulation of DOR/3TC/TDF, in antiretroviral-naïve overweight participants, with differences in viral suppression as the primary end points weight gain and metabolic changes-being secondary endpoints of interest at 48 Weeks.

Inclusion criteria

Each participant must meet all the following criteria to be enrolled in this study.

• ≥18 years old, male or female.
• Documented laboratory diagnosis of infection with HIV-1 (positive enzyme-linked immunosorbent assay HIV-1 antibody test) at screening, with no baseline DOR resistance (please see Table 2 below).
• Is ART naïve.
• BMI≥ 25 kg/cm2.
• VL >500 copies/ml.
• Must sign an ICF indicating that he or she understands the purpose of, and procedures required for the study and is willing to participate in the study.
• Female participants of childbearing potential (WOCBP) are eligible to participate if willing to use highly effective contraception methods from enrolment, for the duration of the study.

Exclusion criteria

Participants meeting any of the following criteria will be excluded from the study:

• Is currently participating in any other interventional study or participated in a study with an investigational drug within 60 days of screening.
• Is pregnant, breastfeeding or intends to become pregnant or breastfeed during the study.
• Has active TB co-infection and requires anti-TB treatment.
• Has unstable liver disease (as defined by the presence of ascites, encephalopathy, coagulopathy, hypalbuminaemia, oesophageal or gastric varices, or persistent jaundice), cirrhosis, known biliary abnormalities (with the exception of Gilbert's syndrome or asymptomatic gallstones); Child-Pugh C.
• Has pre-existing physical or mental condition (including substance abuse disorder and suicide risk) which, in the opinion of the Investigator, may interfere with the participant's ability to comply with the dosing schedule and/or protocol evaluations or which may compromise the safety of the participant.
• Clinically unstable in the investigator's opinion (any pre-existing medical or laboratory abnormalities must be deemed to be stable by the investigator prior to study enrolment).
• Has estimated creatinine clearance <60mL/min per Cockcroft-Gault formula.
• Is taking, and is unable to discontinue, any of the following prohibited medications: carbamazepine, oxcarbazepine, phenobarbital, phenytoin; the antimycobacterial rifampicin, rifapentine; St. John's Wort (Hypericum perforatum); mitotane; enzalutamide; lumacaftor.