The Bring BPaL2Me Trial - Comparing Nurse-Led RR-TB Treatment in Primary Care to Physician-Led, Hospital-Based RR-TB Treatment: A Cluster Randomized, Non-Inferiority Trial

NIH RePORTER · NIH · R01 · $681,271 · view on reporter.nih.gov ↗

Abstract

This administrative supplement supports the BringBPaL2Me Trial in order to fully meet trial aims. In South Africa (SA), Mycobacterium tuberculosis (TB) is managed within primary care clinics (PCCs), where nurses treat drug-susceptible TB and TB/HIV coinfection with treatment outcomes rivaling the best in the world. A PCC management strategy offers a more convenient, patient-centered, differentiated model of care that integrates TB and HIV treatment within the same setting. A diagnosis of rifampicin-resistant TB (RR-TB), however, upends this model, requiring referral to a hospital-based, physician-led outpatient treatment center. Hospital-based, physician-led models add significant patient-associated costs, with estimates suggesting 81% of RR-TB patients experience catastrophic costs even in a decentralized outpatient model. There is hope, however, to move RR-TB care into PCCs and in many settings this involves nurse-led management. The BringBPaL2Me Trial is a multi- principal investigator, multi-site, cluster randomized, non-inferiority trial (CR-NIT), to compare nurse-led RR- TB treatment in PCCs to standard of care physician-led RR-TB treatment at district hospitals in the provinces of KwaZulu-Natal (KZN), Gauteng (GP) and Eastern Cape (EC), SA. Clusters include 10 PCCs affiliated with 5 decentralized outpatient programs at RR-TB district hospitals (n=70 clusters). We estimate the need to screen 3,800 RR-TB positive patients to enroll 2,800, or 49 RR-TB participants per PCC cluster. We estimate 60-70% will be HIV co-infected. The interclass correlation is 0.024 based on our prior CRT enrolling 3,000 patients in KZN and EC. The non-inferiority margin is set at 5% with the assumption of 90% treatment success in the physician-led arm. Treatment will include either a 6-month RR-TB regimen (i.e., bedaquiline, pretomanid, linezolid and levofloxacin, or BPaL-L) or fluroquinolone-resistant TB (i.e., BPaL) regimen. The BringBPaL2Me primary aim is to conduct a 5-year, analyst and clinical safety review committee blinded, multi-site, CR-NIT to evaluate 1) treatment outcome; 2) safety; and 3) patient associated catastrophic costs with the following hypotheses: 1) Outpatient nurse-led treatment in PCCs will be non-inferior to outpatient physician-led treatment at hospital-based outpatient sites among RR-TB patients, regardless of HIV co-infection, as determined by a successful treatment outcome [H1]; 2) The proportion of severe adverse events (SAEs) identified will not significantly differ by blinded, independent review [H2]; 3) Patient associated catastrophic costs (i.e., costs 20% or more of household income) will be lower in nurse-led treatment [H3]. Our secondary aims include: 1) time to event analysis for a) RR-TB treatment initiation; b) smear/culture conversion; and, as applicable, c) HIV treatment initiation; d) HIV viral suppression; and e) AE and SAE symptom resolution; 2) characterization of provider adherence to guidelines for: a) dosing require...

Key facts

NIH application ID
11071583
Project number
3R01AI177135-02S1
Recipient
JOHNS HOPKINS UNIVERSITY
Principal Investigator
Denise Evans
Activity code
R01
Funding institute
NIH
Fiscal year
2024
Award amount
$681,271
Award type
3
Project period
2023-03-10 → 2028-02-29