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Evaluating Pharmacokinetic Interactions With Vaginal Ring Contraceptives and ART

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
ClinicalTrials.gov Identifier: NCT01903031
Recruitment Status : Completed
First Posted : July 19, 2013
Results First Posted : January 4, 2018
Last Update Posted : January 4, 2018
Sponsor:
Collaborator:
Information provided by (Responsible Party):

Study Description
Brief Summary:

This study was done to look at a method of hormonal birth control, called the NuvaRing, and specific anti-HIV medications, called antiretrovirals (ARVs). Some studies of women who use a hormonal birth control method (specifically oral pills, patches, and injections) and take ARVs have shown that ARVs interact with the hormones released by the birth control medication. These interactions may cause the birth control to be less effective at preventing pregnancy. There is also concern that hormonal birth control can increase HIV spreading to others, but more studies are needed to determine if this is true. The investigators did not know whether the NuvaRing and ARVs interact when they are used together, so this study looked to see if certain ARVs (efavirenz and atazanavir/ritonavir) interact with the two hormones released by NuvaRing. This will help us to determine if NuvaRing is safe and effective for women with HIV infection who are taking ARVs. The study also included HIV-infected women who were not on ARVs but used the NuvaRing to show us what the hormone levels are like in a similar group of women not on ARVs.

Vaginal rings are also currently being studied to deliver anti-HIV medications that may prevent HIV acquisition, and to provide birth control over a longer period of time (more than 1 month). Since vaginal rings will become more commonly used to administer medications, the investigators wanted to better understand the potential for drug interactions with drugs given vaginally. This study will also help us understand the potential for drug interactions between ARVs given orally, and other drugs given through vaginal rings, like the NuvaRing. Additionally, this study will help us understand how hormones released from a vaginal ring affect the amount of HIV virus in the genital tract, the bacterial make-up (microbiome) of the female genital tract, and the immune system within the genital tract, all of which may affect the chances of spreading HIV.


Condition or disease Intervention/treatment Phase
HIV-1 Infection Device: Nuvaring Drug: EFV Drug: ATV/r Drug: TDF Drug: NRTIs Phase 2

Detailed Description:
This was a 28 day study from study entry through the final clinic visit. Post-entry visits were scheduled at Days 7, 14, 21 and 28. The Nuvaring was put in place at study entry and removed on day 21. A single PK blood sample was collected for assay of ENG and EE at entry (day 0, prior to NuvaRing placement), and on days 7, 14, and 21 after placement of the NuvaRing. For participants on the ARV arms, intensive, 8-hour PK sampling, for assay of EFV (efavirenz) and ATV/RTV (atazanavir/ritonavir) respectively, was performed at study entry (day 0, prior to NuvaRing placement) and 21 days later. ARV sampling was performed at pre-dose (hour 0), and 1, 3, 4, 5, and 8 hours post-dose. Safety was assessed at each study visit.

Study Design

Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 84 participants
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Evaluating Pharmacokinetic Interactions With Vaginal Ring Contraceptives and Antiretroviral Therapy (ART)
Actual Study Start Date : December 30, 2014
Primary Completion Date : October 3, 2016
Study Completion Date : October 10, 2016

Resource links provided by the National Library of Medicine

U.S. FDA Resources

Arms and Interventions

Arm Intervention/treatment
Experimental: NuvaRing and no ART
Once NuvaRing is inserted into the vagina, the ring should remain in place (not be removed) continuously for 3 weeks (21 days).
Device: Nuvaring
NuvaRing is made of ethylene vinylacetate copolymers (28% and 9% vinylacetate) and magnesium stearate, is latex free, and contains 11.7 mg etonogestrel and 2.7 mg ethinyl estradiol. NuvaRing has an outer diameter of 54 mm and a cross-sectional diameter of 4mm. Once NuvaRing is inserted into the vagina, the ring should remain in place (not be removed) continuously for 3 weeks (21 days). After being in place for the first 21 days of the study, the ring may be removed after the day 21 study visit evaluations have been completed.
Other Name: Etonogestrel/ethinyl estradiol vaginal ring
Experimental: NuvaRing with EFV plus ≥2 NRTIs
Once NuvaRing is inserted into the vagina, the ring should remain in place (not be removed) continuously for 3 weeks (21 days). EFV is a non-nucleoside reverse transcriptase inhibitor taken at a dose of 600 mg once daily.
Device: Nuvaring
NuvaRing is made of ethylene vinylacetate copolymers (28% and 9% vinylacetate) and magnesium stearate, is latex free, and contains 11.7 mg etonogestrel and 2.7 mg ethinyl estradiol. NuvaRing has an outer diameter of 54 mm and a cross-sectional diameter of 4mm. Once NuvaRing is inserted into the vagina, the ring should remain in place (not be removed) continuously for 3 weeks (21 days). After being in place for the first 21 days of the study, the ring may be removed after the day 21 study visit evaluations have been completed.
Other Name: Etonogestrel/ethinyl estradiol vaginal ring
Drug: EFV
Participants received EFV 600 mg daily with two or more NRTIs
Other Name: Efavirenz
Drug: NRTIs
Participants received two or more NRTIs in Arm B and one or more NRTIs in Arm C
Other Name: Nucleoside Reverse Transcriptase Inhibitor
Experimental: NuvaRing with ATV/r plus TDF + ≥1 NRTIs
Once NuvaRing is inserted into the vagina, the ring should remain in place (not be removed) continuously for 3 weeks (21 days). ATV/r is a combination protease inhibitor taken at a dose of 300/100 mg once daily. TDF is a nucleoside reverse transcriptase inhibitor taken at a dose of 300 mg daily.
Device: Nuvaring
NuvaRing is made of ethylene vinylacetate copolymers (28% and 9% vinylacetate) and magnesium stearate, is latex free, and contains 11.7 mg etonogestrel and 2.7 mg ethinyl estradiol. NuvaRing has an outer diameter of 54 mm and a cross-sectional diameter of 4mm. Once NuvaRing is inserted into the vagina, the ring should remain in place (not be removed) continuously for 3 weeks (21 days). After being in place for the first 21 days of the study, the ring may be removed after the day 21 study visit evaluations have been completed.
Other Name: Etonogestrel/ethinyl estradiol vaginal ring
Drug: ATV/r
Participants received ATV/r 300 mg/ 100 mg daily with tenofovir and one or more additional NRTIs
Other Name: Atazanavir/Ritonavir
Drug: TDF
Participants received 300 mg of tenofovir in Arm C
Other Name: Tenofovir Disoproxil Fumarate
Drug: NRTIs
Participants received two or more NRTIs in Arm B and one or more NRTIs in Arm C
Other Name: Nucleoside Reverse Transcriptase Inhibitor


Outcome Measures

Primary Outcome Measures :
  1. Etonogestrel Concentrations at Study Day 21 [ Time Frame: Day 21 ]
    This evaluates the effect of EFV and ATV/r on etonogestrel by measuring etonogestrel concentrations on all three study arms 21 days after NuvaRing administration. The PK blood sample for measurement of etonogestrel on study day 21 was taken before the NuvaRing was removed. The assay lower limit of quantification for etonogestrel was 250 pg/mL; values < 250 were assigned a value of half the lower limit (ie, 125 pg/mL).

  2. Ethinyl Estradiol Concentrations at Study Day 21 [ Time Frame: Day 21 ]
    This evaluates the effect of EFV and ATV/r on ethinyl estradiol by measuring ethinyl estradiol concentrations on all three study arms 21 days after NuvaRing administration. The PK blood sample for measurement of ethinyl estradiol on study day 21 was taken before the NuvaRing was removed. The assay lower limit of quantification for ethinyl estradiol was 5 pg/mL ; values < 5 were assigned a value of half the lower limit (ie, 2.5 pg/mL).


Secondary Outcome Measures :
  1. Etonogestrel Concentrations Obtained on Study Days 7 and 14 [ Time Frame: Study days 7 and 14 ]
    This evaluates the effect of EFV and ATV/r on etonogestrel by measuring etonogestrel concentrations on all three study arms 7 and 14 days after NuvaRing administration. The assay lower limit of quantification for etonogestrel was 250 pg/mL; values < 250 were assigned a value of half the lower limit (ie, 125 pg/mL).

  2. Ethinyl Estradiol Concentrations Obtained on Study Days 7 and 14. [ Time Frame: Study days 7 and 14 ]
    This evaluates the effect of EFV and ATV/r on ethinyl estradiol by measuring ethinyl estradiol concentrations on all three study arms 7 and 14 days after NuvaRing administration. The assay lower limit of quantification for ethinyl estradiol was 5 pg/mL; values < 5 were assigned a value of half the lower limit (ie, 2.5 pg/mL).

  3. Efavirenz (EFV) Pharmacokinetics (PK) Area Under Curve (AUC)(0-24h), Cmin, Cmax, Tmax, and CL/F Calculated Based on Intensive EFV PK Samples Obtained From Individual Participants Enrolled in Arm B (NuvaRing With EFV Arm Plus 2 or More NRTIs) [ Time Frame: Intensive EFV PK samples at pre-dose, 1, 3, 4, 5, and 8 hours post-dose on study day 0 (before vaginal ring placement) and on study day 21 (3 weeks after vaginal ring placement). ]

    AUC(0-24h) defines area under the concentration-time curve over the doing period of 24 hours; Cmin defines minimum concentration in the dosing period of 24 hours; Cmax defines maximum concentration in the dosing interval of 24 hours; Tmax defines time to maximum concentration since dose is initiated; CL/F defines apparent oral clearance.

    Pharmacokinetics data are not available as of November 2017. To minimize variability, pharmacokinetics assays were batched. Due to batching, sample shipment could not begin until after the study follow-up completion. Given that this was a multi-center international study, shipment of samples took several months to complete. Therefore, samples are in the process of being tested. Upon completion of the testing, the results will be reviewed for data completeness and quality. After resolution of any issues and finalization of the database, the analysis can be conducted and the results will then be posted to ClinicalTrials.gov.


  4. ATV and RTV PK AUC(0-24h), Cmin, Cmax, Tmax, and CL/F Calculated Based on Intensive ATV and RTV PK Samples Obtained From Individual Participants Enrolled in Arm C (Nuvaring With ATV/r Plus TDF and One or More NRTIs). [ Time Frame: Intensive ATV and RTV PK samples at pre-dose, 1, 3, 4, 5, and 8 hours post-dose on study day 0 (before vaginal ring placement) and on study day 21 (3 weeks after vaginal ring placement) ]

    AUC(0-24h) defines area under the concentration-time curve over the doing period of 24 hours; Cmin defines minimum concentration in the dosing period of 24 hours; Cmax defines maximum concentration in the dosing interval of 24 hours; Tmax defines time to maximum concentration since dose is initiated; CL/F defines apparent oral clearance.

    Pharmacokinetics data are not available as of November 2017. To minimize variability, pharmacokinetics assays were batched. Due to batching, sample shipment could not begin until after the study follow-up completion. Given that this was a multi-center international study, shipment of samples took several months to complete. Therefore, samples are in the process of being tested. Upon completion of the testing, the results will be reviewed for data completeness and quality. After resolution of any issues and finalization of the database, the analysis can be conducted and the results will then be posted to ClinicalTrials.gov.


  5. Proportion of Participants With Plasma HIV-1 RNA Levels <40 Copies/mL [ Time Frame: Study day 0 and study day 21 ]
    This evaluates the short-term impact of Nuvaring on virologic suppression in participants who have been administered Nuvaring alone or together with EFV or ATV/r by measuring proportion of participants with plasma HIV-1 RNA levels <40 copies/mL at study day 0 (before vaginal ring placement) and study day 21 (three weeks after vaginal ring placement). An FDA-approved HIV-1 RNA assay was required.

  6. Percentage of Participants With Signs and Symptoms of Grade 2 or Higher Deemed Possibly, Probably or Definitely Related to Study Treatment [ Time Frame: From day 0 to day 28 ]
    This evaluates toxicity and safety of NuvaRing alone, NuvaRing with EFV, and NuvaRing with ATV/r. Signs/symptoms were graded using the DAIDS AE Grading Table was used. Participants with sign(s)/symptom(s) of grade 2 (moderate), 3 (severe), 4 (potentially life-threatening) or 5 (death) are included in the percentage. Relationship to study treatment was determined by the study co-chairs and DAIDS clinical representative.

  7. Proportion of Participants With Progesterone Levels Greater Than 5 ng/mL. [ Time Frame: Study days 0, 7, 14, 21 and 28 ]
    This evaluates alterations in progesterone levels due to the potential PK interaction between NuvaRing and the ARVs EFV and ATV/r by examining progesterone levels at study days 0 (before vaginal ring placement), 7, 14, and 21 (before vaginal ring removal), and study day 28, without regard to menstrual cycle status at study entry.


Eligibility Criteria

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Ages Eligible for Study:   16 Years and older   (Child, Adult, Senior)
Sexes Eligible for Study:   Female
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Documented HIV-1 infection.
  • Participants must have been receiving either 1) EFV 600 mg daily with 2 or more NRTIs, 2) ATV/r 300 mg/ 100 mg daily with TDF 300 mg and 1 or more additional NRTIs, or 3) no ART. ART regimens should have been stable for 30 days prior to study entry with no plans to change therapy during the first 28 days of this study. Participants receiving no ART should have had no plans to initiate ART during the first 28 days of the study.

NOTE: Participants must have had access to their ART regimens through their primary care providers. ART medications were not supplied by this study.

  • For participants on ART, documentation of plasma HIV-1 RNA ≤400 copies/mL was obtained within 60 days prior to study entry.
  • For participants not on ART, CD4+ cell count must have been ≥350 cells/mm^3, obtained within 60 days prior to study entry.
  • Laboratory values within 60 days prior to study entry:

    • Platelet count ≥50,000 platelets/mm^3
    • Hemoglobin ≥8.0 g/dL
    • Aspartate transaminase (SGOT) and alanine aminotransferase (SGPT) <5 x upper limit of normal (ULN)
    • Creatinine ≤1.5 x ULN
    • Total bilirubin ≤2.0 x ULN
  • Last menstrual period ≤6 months prior to study entry. If last menstrual period >6 months prior to study entry without another cause for amenorrhea, such as recent pregnancy, serum follicle-stimulating hormone (FSH) must have been checked and be ≤40 mIU/mL to be eligible for enrollment.
  • Premenopausal females with at least one functioning ovary.
  • Documentation of Pap smear within 1 year prior to study entry.
  • Negative serum or urine-HCG pregnancy test with a sensitivity of ≤25 mIU/mL within 60 days prior to study entry and within 24 hours prior to study entry
  • All participants must have agreed not to participate in a conception process (eg, active attempt to become pregnant or in vitro fertilization) for the duration of the study. Because it was unknown if ARVs adversely affect the efficacy of NuvaRing as a contraceptive method, participants of reproductive potential, who were participating in sexual activities that could lead to pregnancy, must have agreed to use an additional reliable form of contraception while in the study. Acceptable additional methods of contraception included:

    • Condoms (male or female)
    • Non-hormonal intrauterine device (IUD)

Other hormonal forms of contraception were not allowed during the study period.

Condoms should have been used to prevent transmission of HIV and sexually transmitted diseases between sexual partners.

NOTE: Participants with bilateral tubal ligation or non-hormonal IUD were eligible to be enrolled.

Exclusion Criteria:

  • Received depot medroxyprogesterone acetate (DMPA) within 4 months prior to study entry.
  • Received other hormonal therapies (eg, oral contraceptive agents, hormone- containing vaginal ring, contraceptive patch, hormone replacement therapy, anabolic therapies, including nandrolone decanoate or megestrol acetate) within 30 days prior to study entry.
  • Breastfeeding.
  • Less than 6 weeks postpartum at study entry.
  • Use of any prohibited medications within 30 days prior to study entry.
  • Initiated, discontinued, or changed doses of drugs that are CYP substrates or known to have drug interactions with ethinyl estradiol or etonogestrel within 30 days prior to study entry.
  • Bilateral oophorectomy.
  • For women older than 35 years of age, smoking 15 or more cigarettes per day.
  • History of invasive cancer of the reproductive tract; known or suspected malignancy of the breast, or known increased risk for breast cancer; undiagnosed abnormal vaginal bleeding; liver tumors; or serious ocular disorders at any time prior to study entry.
  • Chronic immunosuppressive conditions other than HIV.
  • Use of systemic or inhaled corticosteroids such as for acute therapy for Pneumocystis pneumonia (PCP) or asthma exacerbation and prednisone ≥10 mg (or equivalent) for any reason other than a stable or tapering dose.
  • History of deep venous thrombosis or pulmonary embolism.
  • History of cerebral vascular or coronary artery disease.
  • Severe uncontrolled hypertension within 60 days prior to study entry.
  • Diabetes with vascular involvement.
  • Clinically active cervical or vaginal infection at study entry. NOTE: Gonorrhea, chlamydia, and trichomonas testing was performed during screening using techniques available at the local sites and documented in source documentation and case report forms (CRFs). Testing for bacterial vaginosis, performed using techniques available at the local sites, was only necessary if the participant was symptomatic and the provider felt treatment might be necessary. Women with genital herpes lesions waited to be screened until the herpetic lesions had healed.
  • Acute infections or other opportunistic diseases requiring medication within 14 days prior to study entry.
Contacts and Locations

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01903031


  Show 21 Study Locations
Sponsors and Collaborators
AIDS Clinical Trials Group
National Institute of Allergy and Infectious Diseases (NIAID)
More Information

Additional Information:
Responsible Party: AIDS Clinical Trials Group
ClinicalTrials.gov Identifier: NCT01903031     History of Changes
Other Study ID Numbers: ACTG A5316
UM1AI068636 ( U.S. NIH Grant/Contract )
First Posted: July 19, 2013    Key Record Dates
Results First Posted: January 4, 2018
Last Update Posted: January 4, 2018
Last Verified: January 2018

Additional relevant MeSH terms:
Tenofovir
Reverse Transcriptase Inhibitors
Estradiol
Ethinyl Estradiol
Desogestrel
Contraceptive Agents
Etonogestrel
Antiviral Agents
Anti-Infective Agents
Nucleic Acid Synthesis Inhibitors
Enzyme Inhibitors
Molecular Mechanisms of Pharmacological Action
Anti-Retroviral Agents
Anti-HIV Agents
Estrogens
Hormones
Hormones, Hormone Substitutes, and Hormone Antagonists
Physiological Effects of Drugs
Reproductive Control Agents
Contraceptive Agents, Female
Contraceptives, Oral, Synthetic
Contraceptives, Oral
Progestins