Effects of Prednisolone on Disease Progression in Antiretroviral-Untreated HIV Infection: A 2-Year Randomized, Double-Blind Placebo-Controlled Clinical Trial

Abstract

Background: HIV-disease progression correlates with immune activation. Here we investigated whether corticosteroid treatment can attenuate HIV disease progression in antiretroviral-untreated patients.

Methods: Double-blind, placebo-controlled randomized clinical trial including 326 HIV-patients in a resource-limited setting in Tanzania (clinicaltrials.gov NCT01299948). Inclusion criteria were a CD4 count above 300 cells/μl, the absence of AIDS-defining symptoms and an ART-naïve therapy status. Study participants received 5 mg prednisolone per day or placebo for 2 years. Primary endpoint was time to progression to an AIDS-defining condition or to a CD4-count below 200 cells/μl.

Results: No significant change in progression towards the primary endpoint was observed in the intent-to-treat (ITT) analysis (19 cases with prednisolone versus 28 cases with placebo, p = 0.1407). In a per-protocol (PP)-analysis, 13 versus 24 study participants progressed to the primary study endpoint (p = 0.0741). Secondary endpoints: Prednisolone-treatment decreased immune activation (sCD14, suPAR, CD38/HLA-DR/CD8+) and increased CD4-counts (+77.42 ± 5.70 cells/μl compared to -37.42 ± 10.77 cells/μl under placebo, p < 0.0001). Treatment with prednisolone was associated with a 3.2-fold increase in HIV viral load (p < 0.0001). In a post-hoc analysis stratifying for sex, females treated with prednisolone progressed significantly slower to the primary study endpoint than females treated with placebo (ITT-analysis: 11 versus 21 cases, p = 0.0567; PP-analysis: 5 versus 18 cases, p = 0.0051): No changes in disease progression were observed in men.

Conclusions: This study could not detect any significant effects of prednisolone on disease progression in antiretroviral-untreated HIV infection within the intent-to-treat population. However, significant effects were observed on CD4 counts, immune activation and HIV viral load. This study contributes to a better understanding of the role of immune activation in the pathogenesis of HIV infection.

Trial registration: ClinicalTrials.gov NCT01299948.

Fig 1. CONSORT statement 2010 flow diagram.

The number of participants enrolled, randomized, allocated to study medication, followed-up and analyzed is shown. Study participants who progressed to the endpoint of the study (CD4 < 200 or CDC stage-C disease) received HAART. In some cases, study participants also received HAART when they progressed to CD4 < 350 in combination with WHO stage 3-disease. This was in accordance to the National Tanzanian treatment recommendations Update in 2008 (1 case in the placebo arm and 3 cases in the prednisolone arm). In addition, one patient in the placebo arm and 2 study participants in the prednisolone arm received HAART without fulfilling either the study endpoint or the criteria listed in the National Treatment recommendation update.

Fig 2. Study drug adherence and loss to follow-up.

A, B: Study drug adherence calculated from pill counts of returned, unused study medication in female (A) and male (B) study participants. P-values were calculated by 2way ANOVA C: Loss to follow-up during the two-year study. P value was calculated by log-rank (Mantel-Cox) analysis.

Fig 3. CD4 counts of study participants with loss of follow-up.

A: Baseline (BL) CD4 counts from study participants who were later lost to follow up (lost) and who fulfilled (fulfilled) the study. P value was calculated by Mann-Whitney test. B: CD4 counts prior to loss to follow up (loss) or to progression to the primary endpoint (HAART). Red bars (placebo) and blue bars (prednisolone) represent medians. P values were calculated by Kruskal-Wallis test with multiple comparisons.

Fig 4. Effects of prednisolone on HIV disease progression: Primary Study Endpoint.

Kaplan-Meyer estimate of progression to combined study endpoint (onset of CDC stage-C-condition or drop of CD4 counts below 200) within the intent-to-treat (ITT) population (A) or the per protocol (PP) population (B). C: Progression to AIDS-defining condition. All study participants who received HAART, but did not reach the study endpoint were censored for the KM analysis. D-F and G-I: Post-hoc analyses for female study participants (D-F) and for male study participants (H-I) for progression to combined endpoint within the ITT population (D, G), progression to combined endpoint within the PP population (E, H), and progression to AIDS-defining condition (F, I). A-I: P values were calculated by log-rank (Mantel-Cox) analysis.

Fig 5. Disease progression in male and female study participants.

Kaplan-Meyer estimate of progression to combined study endpoint (onset of CDC stage-C-condition or drop of CD4 counts below 200) within the intent-to-treat (ITT) population of study participants treated with placebo (A) or prednisolone (B) stratified by sex. P values were calculated by log-rank (Mantel-Cox) analysis.

Fig 6. Progression to HAART as treated.

Kaplan-Meyer estimate of progression to HAART as treated within the intent-to-treat (ITT) population (A) or the per protocol (PP) population (B). Separate analyses for female study participants (B, E) and for male study participants (C, F) for progression to HART as treated. P values were calculated by log-rank (Mantel-Cox) analysis.

Fig 7. Study participants at risk.

Number of study participants at risk within the intent-to-treat (ITT) population (A) or the per protocol (PP) population (B). Separate analyses for female study participants (C, D) and for male study participants (E, F).

Fig 8. Effects of prednisolone on CD4 counts and CD4/CD8 ratio.

A: Mean CD4 ± S.D. P-values were determined by 2way ANOVA. B: Mean CD4 changes ± S.D. relative to baseline and linear regression of the data. 2-year gains/losses were calculated from slope of linear regression. C: Mean ± S.D. CD4/CD8-ratio and linear regression. B, C: P values on the right indicate non-zero hypotheses for the slope. P-value on the left for difference between the two data sets was calculated by 2way ANOVA. D-F and G-I: Post-hoc analyses for female study participants (D-F) and for male study participants (H-I) for absolute CD4 counts (D, G), CD4 relative CD4 changes (E, H), and CD4/CD8 ratio (F, I).

Fig 9. Effects of prednisolone on immune activation and HIV viral load.

A, E, I: Concentration of sCD14 was determined by ELISA from n = 134 (placebo) and n = 136 (prednisolone) available plasma samples collected at baseline, 3, 6 and 12 months. A: all sexes, E: females (n_Plac = 106, n_Pred = 110), I: males (n_Plac = 28, n_Pred = 26). B, F, J: Concentration of sUPAR was determined by ELISA from n = 122 (placebo) and n = 124 (prednisolone) available plasma samples collected at baseline, 3, 6 and 12 months. B: all sexes, F: females (n_Plac = 95, n_Pred = 102), J: males (n_Plac = 27, n_Pred = 22). A, B, E, F, I, J: Data as means ± S.D. P-values were determined by 2-way ANOVA (difference between the two treatments over the whole time period) or by Wilcoxon matched-pairs signed test (changes between Baseline and month 12). C, G, K: CD38/HLA-DR expression was determined by flow cytometry from n = 22 (placebo) and n = 30 (prednisolone) available frozen PBMC samples collected at baseline and 12 months. C: all sexes, G: females (n_Plac = 19, n_Pred = 27), K: males (n_Plac = 3, n_Pred = 3). P-values were determined by Wilcoxon matched-pairs signed test (changes between Baseline and month 12). D, H, L: HIV viral load was determined from n = 86 (placebo) and n = 80 (prednisolone) available plasma pairs at baseline and month 12. D: all sexes, H: females (n_Plac = 70, n_Pred = 66), L: males (n_Plac = 16, n_Pred = 14). P-values were determined by Wilcoxon matched-pairs signed test (changes between Baseline and month 12) and by Mann-Whitney test (comparison of month 12 placebo versus month 12 prednisolone).