Effect of Once-Weekly Azithromycin vs Placebo in Children With HIV-Associated Chronic Lung Disease : The BREATHE Randomized Clinical Trial

Key Points

Question

What is the effect of weekly azithromycin on morbidity in children with HIV-associated chronic lung disease?

Findings

In this randomized clinical trial that included 347 children aged 6 to 19 years, azithromycin did not improve lung function. The rate of acute respiratory exacerbations was 12.1 events per 100 person-years in the azithromycin group and 24.7 events per 100 person-years in the control group; the hospitalization rate was 1.3 events per 100 person-years in the azithromycin group and 7.1 events per 100 person-years in the placebo group.

Meaning

These findings suggest that prophylactic azithromycin has no effect on lung function in children with HIV-associated chronic lung disease but it is associated with a lower rate of acute respiratory exacerbations.

Abstract

This randomized clinical trial examines whether prophylactic azithromycin is effective in preventing worsening of lung function and in reducing acute respiratory exacerbations in children with HIV-associated chronic lung disease taking antiretroviral therapy.

Abstract

Importance

HIV-associated chronic lung disease (HCLD) in children is associated with small airways disease, is common despite antiretroviral therapy (ART), and is associated with substantial morbidity. Azithromycin has antibiotic and immunomodulatory activity and may be effective in treating HCLD through reducing respiratory tract infections and inflammation.

Objective

To determine whether prophylactic azithromycin is effective in preventing worsening of lung function and in reducing acute respiratory exacerbations (AREs) in children with HCLD taking ART.

Design, Setting, and Participants

This double-blind, placebo-controlled, randomized clinical trial (BREATHE) was conducted between 2016 and 2019, including 12 months of follow-up, at outpatient HIV clinics in 2 public sector hospitals in Malawi and Zimbabwe. Participants were randomized 1:1 to intervention or placebo, and participants and study personnel were blinded to treatment allocation. Participants included children aged 6 to 19 years with perinatally acquired HIV and HCLD (defined as forced expiratory volume in 1 second [FEV ₁] z score < −1) who were taking ART for 6 months or longer. Data analysis was performed from September 2019 to April 2020.

Intervention

Once-weekly oral azithromycin with weight-based dosing, for 48 weeks.

Main Outcomes and Measures

All outcomes were prespecified. The primary outcome was the mean difference in FEV ₁ z score using intention-to-treat analysis for participants seen at end line. Secondary outcomes included AREs, all-cause hospitalizations, mortality, and weight-for-age z score.

Results

A total of 347 individuals (median [interquartile range] age, 15.3 [12.7-17.7] years; 177 boys [51.0%]) were randomized, 174 to the azithromycin group and 173 to the placebo group; 162 participants in the azithromycin group and 146 placebo group participants had a primary outcome available and were analyzed. The mean difference in FEV ₁ z score was 0.06 (95% CI, −0.10 to 0.21; P = .48) higher in the azithromycin group than in the placebo group, a nonsignificant difference. The rate of AREs was 12.1 events per 100 person-years in the azithromycin group and 24.7 events per 100 person-years in the placebo groups (hazard ratio, 0.50; 95% CI, 0.27 to 0.93; P = .03). The hospitalization rate was 1.3 events per 100 person-years in the azithromycin group and 7.1 events per 100 person-years in the placebo groups, but the difference was not significant (hazard ratio, 0.24; 95% CI, 0.06 to 1.07; P = .06). Three deaths occurred, all in the placebo group. The mean weight-for-age z score was 0.03 (95% CI, −0.08 to 0.14; P = .56) higher in the azithromycin group than in the placebo group, although the difference was not significant. There were no drug-related severe adverse events.

Conclusions and Relevance

In this randomized clinical trial specifically addressing childhood HCLD, once-weekly azithromycin did not improve lung function or growth but was associated with reduced AREs; the number of hospitalizations was also lower in the azithromycin group but the difference was not significant. Future research should identify patient groups who would benefit most from this intervention and optimum treatment length, to maximize benefits while reducing the risk of antimicrobial resistance.

Trial Registration

ClinicalTrials.gov Identifier: NCT02426112