Determination of Adequate Tuberculosis Regimen in Patients Hospitalized With HIV-associated Severe Immune Suppression

Settings: 5 African (Cameroon, Guinea, Uganda, Zambia, Mozambique) and 1 South-East Asian (Cambodia) countries.

Sample size : 1330 patients (665 in each arm). Follow-up : 48 weeks after entry in the trial (TB treatment initiation).

All participants will initiate antiretroviral therapy (ART) 2 weeks after starting TB treatment. In each country, the chosen ART regimen will be the same in both arms. According to the first-line regimen recommended in each country, the ART combination will be TDF/3TC/EFV 600 mg, or TDF/3TC + double-dose DTG.

The primary objective is to estimate the impact of an intensified initial phase of TB treatment on mortality at 48 weeks among HIV-infected adults and adolescents hospitalized for TB with CD4 ≤ 100 cells/μL in comparison with standard TB treatment.

The secondary objectives are to estimate the impact of an intensified initial phase of TB treatment, in comparison with the standard TB regimen, on:

• Mortality at weeks 8 and 24
• Adverse events, including

• All grade 3 and 4 events
• Selected grade 2 events of interest
• Drug-related adverse events
• AIDS-defining illnesses
• Paradoxical TB-associated immune reconstitution inflammatory syndrome (IRIS)
• TB treatment success
• TB recurrence
• ART response in terms of virological success and immunological response
• Adherence to TB treatment and ART
• Peak plasma concentrations of rifampicin and isoniazid (and its N-acetyl-metabolite) at day 3, day 7 and week 2
• Plasma concentrations of efavirenz and dolutegravir at week 4 (i.e. 2 weeks after the onset of ART).

A pharmacokinetic sub-study of rifampicin and isoniazid will be carried out in 72 voluntary patients (6 patients/arm/country) at the second week of the main study.

Inclusion criteria

• Patient (and legally designed representative of minor patient) able to correctly understand the trial and to sign the informed consent
• Aged ≥ 15 years
• Confirmed HIV-1 infection as documented at any time prior to trial entry per national HIV testing procedures
• CD4 count ≤ 100 cells/μL
• Hospitalized for a newly diagnosed TB, defined by:

• Any positive Xpert® MTB/RIF specimen (sputum, urine, pus, other),
• Or a positive urine lipoarabinomannan (LAM) test,
• Or an abnormal chest X-ray compatible with active TB

EXCLUSION CRITERA

• Initiation of TB drugs for more than 7 days
• History of TB treatment during the last 6 months
• Central neurological symptoms, including but not restrictive to TB meningitis
• Suspected TB pericarditis
• Documented Mycobacterium tuberculosis strain resistant to rifampicin using rapid molecular testing (Xpert® MTB/RIF)
• Any concomitant medication or known hypersensitivity contraindicating any component of the TB treatment
• HIV-2 co-infection
• Current treatment with ART containing protease inhibitors
• Any contraindication to efavirenz and dolutegravir
• Severe associated diseases requiring corticosteroids or for which corticosteroids are contra-indicated
• Impaired hepatic function with ALT (SGPT) > 5 times the upper limit of normal (ULN) value
• Creatinine clearance < 30 mL/min/1.73m2 (according to either the MDRD or the CKD-EPI formula)
• Pregnancy or breastfeeding