POC Strategies to Improve TB Care in Advanced HIV Disease

NCT04122404 | Completed

• 1 other identifier: OP_861
• Study Type: interventional
• Target: 425
• Locations: 1 country
• Sites: 3

Brief Summary

Tuberculosis (TB) remains the major cause of morbidity and mortality among patients with HIV. Sub-optimal diagnostics contributes towards poor patient outcome and there is an urgent need to identify non-sputum-based point-of-care diagnostic tests. The urine based lateral flow lipoarabinomannan TB diagnostic test (LF-LAM) is a simple, inexpensive point-of-care test. In 2015, the World Health Organization endorsed LF-LAM for conditional use among patients with advanced HIV, but uptake of the test in clinical practices has been poor. The investigators aim to identify point-of-care (POC) strategies that can improve TB case detection and clinical outcomes among patients with advanced HIV. The project includes a main study and two sub-studies. The main study is a multicenter stepped wedge cluster-randomized controlled trial of LF-LAM implementation among patients with advanced HIV with 8-weeks follow-up. LF-LAM will be added to standard care and implemented stepwise at three hospitals in Ghana. Education in national TB treatment guidelines in collaboration with the Tuberculosis Control programme in Ghana, and Clinical audit of clinical staff with feedback, will be used to assess and strengthen LF-LAM implementation. The primary outcome time to TB treatment, for which a sample size of 690 participants will provide \>90% power to detect a minimum of 7 days reduction. Secondary outcomes are: TB related morbidity, TB case detection, time to TB diagnosis and overall early mortality at 8 weeks. The HIV-associated TB epidemiology including genotypic analyses of M. tuberculosis isolates obtained through the main study will be described. In sub study A, focused ultrasound of lungs, heart and abdomen will be performed in a sub cohort of 100 participants. In sub study B, the investigators will establish a biobank and data warehouse for storage of blood, urine and sputum samples collected from participants that enter the study at Korle-Bu Teaching hospital. It is expected that LF-LAM will lead to earlier diagnosis and treatment of TB. Findings may further guide scaling-up of LF-LAM. The HIV-associated epidemic including genotypic properties and resistance properties which is important for improved management will be detailed. The investigators further expect to evaluate the potential of bedside ultrasound as a clinical tool in management of HIV/TB co-infected patients. The unique Ghanaian HIV-cohort and biobank may facilitate rapid evaluation of future prognostic biomarkers and new point-of-care TB diagnostic tests.

Conditions

Extrapulmonary Tuberculosis; Tuberculosis, Pulmonary; Human Immunodeficiency Virus (HIV); Acquired Immunodeficiency Syndrome

Keywords

Point-of-care systems; Tuberculosis/Diagnosis; Biomarkers/Urin; Lipopolysaccharides/urine; Audit intervention; Diagnostic tests/Routine; Ultrasound; Bedside; Biobank; Stepped wedge cluster randomised trial; Multicenter study; Audit and feedback; Ghana; Adult; Hospitalization

Outcome Measures

Primary Outcomes (1)

• Time to TB treatment initiation

  Time to TB treatment initiation defined by time from TB diagnosis suspected to start of anti-tuberculous treatment provided.

  8 weeks follow up

Secondary Outcomes (4)

• TB related morbidity

  8 weeks follow up

• TB case detection

  8 weeks follow up

• Time to TB diagnosis

  8 weeks follow up

• Time to all-cause mortality.

  8 weeks follow up

Study Arms (2)

Intervention

OTHER

Routine TB diagnostic care (sputum smear microscopy, sputum Xpert MTB/Rif / sputum Xpert MTB/Rif Ultra, sputum culture) + Intervention Intervention: LF-LAM is made available at the study site for the clinical staff to use; Training of clinical staff in national TB guidelines and LF-LAM use together with staff from the National TB Programme in Ghana

Diagnostic Test: LF-LAM

Standard of care

NO INTERVENTION

Routine TB diagnostic care (sputum smear microscopy, sputum Xpert MTB/Rif / sputum Xpert MTB/Rif Ultra, sputum culture)

Interventions

LF-LAM DIAGNOSTIC_TEST

Open label multi-center stepped wedge cluster-randomized controlled trial with implementation of LF-LAM. All clusters (i.e. HIV/ART clinic attached wards) start with standard of care and are then randomized to switch to the intervention phase at predefined time points.

Also known as: Lateral flow urine lipoarabinomannan assay, Determine TM TB LAM Ag test

Intervention

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• HIV-positive
• years and above
• Able to give informed consent
• Admitted at the wards attached to the research site ART/HIV-clinic
• Eligible for LF-LAM testing (defined by WHO in the LF-LAM policy update 2019): CD4-cell-count ≤200 cells/μL (the last measured CD4-cell-count); or a WHO clinical stage 3 or 4 event at presentation for care; or seriously ill defined by WHO (respiratory rate \> 30/min, temperature \> 39°C, heart rate \> 120/min or unable to walk unaided); or a positive WHO TB symptom screening including one of the following symptoms: current cough, fever, weight loss, or night sweats

You may not qualify if:

• Anti-tuberculous treatment including preventive treatment with Isoniazide within the last 60 days
• Earlier participation in the same study

Sponsors & Collaborators

• University of Southern Denmark: lead
• Odense University Hospital: collaborator
• National Tuberculosis Control Programme, Ghana: collaborator
• Odense Patient Data Explorative Network: collaborator
• University of Ghana: collaborator
• Tema General Hospital, Ghana: collaborator
• Lekma Hospital, Ghana: collaborator
• Korle-Bu Teaching Hospital, Ghana: collaborator

Study Sites (3)

Korle Bu Teaching Hospital

Accra, Ghana

Location

Tema General Hospital

Tema, Ghana

Location

Lekma Hospital

Teshie, Ghana

Location

Related Publications (1)

• Zifodya JS, Kreniske JS, Schiller I, Kohli M, Dendukuri N, Schumacher SG, Ochodo EA, Haraka F, Zwerling AA, Pai M, Steingart KR, Horne DJ. Xpert Ultra versus Xpert MTB/RIF for pulmonary tuberculosis and rifampicin resistance in adults with presumptive pulmonary tuberculosis. Cochrane Database Syst Rev. 2021 Feb 22;2(2):CD009593. doi: 10.1002/14651858.CD009593.pub5.

  PMID: 33616229 DERIVED

MeSH Terms

Conditions

Tuberculosis, Extrapulmonary; Tuberculosis, Pulmonary; Acquired Immunodeficiency Syndrome; Tuberculosis; Disease

Condition Hierarchy (Ancestors)

Mycobacterium Infections; Actinomycetales Infections; Gram-Positive Bacterial Infections; Bacterial Infections; Bacterial Infections and Mycoses; Infections; Respiratory Tract Infections; Lung Diseases; Respiratory Tract Diseases; HIV Infections; Blood-Borne Infections; Communicable Diseases; Sexually Transmitted Diseases, Viral; Sexually Transmitted Diseases; Lentivirus Infections; Retroviridae Infections; RNA Virus Infections; Virus Diseases; Slow Virus Diseases; Genital Diseases; Urogenital Diseases; Immunologic Deficiency Syndromes; Immune System Diseases; Pathologic Processes; Pathological Conditions, Signs and Symptoms

Study Officials

• Johanna Åhsberg, MD

  Dept. of Infectious Diseases, Odense University Hosp., Univ. of Southern Denmark

  PRINCIPAL INVESTIGATOR

• Isik Somuncu Johansen, Prof

  Dept. of Infectious Diseases, Odense University Hosp., Univ. of Southern Denmark

  STUDY DIRECTOR

• Margaret Lartey, Prof

  School of Medicine and Dentistry, University of Ghana

  STUDY CHAIR

• Stephanie Bjerrum, MD

  Dept. of Infectious Diseases, Odense University Hosp., Univ. of Southern Denmark

  STUDY CHAIR

• Åse Bengaard Andersen, Prof

  Dept. of Infectious Diseases, Odense University Hosp., Univ. of Southern Denmark

  STUDY CHAIR

• Ernest Kenu, MD

  Dept. of Epidemiology and Disease Control, Univ. of Ghana

  STUDY CHAIR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: DIAGNOSTIC
• Intervention Model: SEQUENTIAL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Principal Investigator

Model Details: Open label multi-center stepped wedge cluster-randomized controlled implementation trial of the use of urine-based LF-LAM in addition to routine sputum-based TB diagnostic tests to guide initiation of TB treatment among adult hospitalized patients with advanced HIV. The design offers a randomised method of evaluation of the intervention at cluster level. Applying the stepped wedge design ensures that all participating HIV/ART clinic attached wards will have received the intervention at the end of the study period, and provides the basis for the LF-LAM test to become an integrated part of TB health care services also after the project finishes. Clinic staff will be trained on how to use and interpret the LF-LAM test and in TB diagnostic guidelines as outlined by WHO. An Audit and feedback study will identify leaky steps in the TB diagnostic pathway and further strengthen the implementation and possible impact of the LF-LAM test.

Study Record Dates

• First Submitted: October 8, 2019
• First Posted: October 10, 2019
• Study Start: October 14, 2019
• Primary Completion: January 30, 2022
• Study Completion: January 30, 2022
• Last Updated: May 23, 2022

Record last verified: 2022-05

Data Sharing

• IPD Sharing: Will not share

Locations

GH (3)