A Study That Should Not Have Been Done
Sean Philpott and Udo Schüklenk, 05/05/2010

A Study That Should Not Have Been Done

(Research) Permanent link

The New England Journal of Medicine in February published the results of a deeply flawed clinical trial in South Africa. The SAPIT (Starting Antiretroviral Therapy at Three Points in Tuberculosis Therapy) trial was designed to determine the most effective way to treat patients infected with HIV and tuberculosis. But it raises a number of disturbing questions about the oft-debated and vexing issue of appropriate standards of care in clinical trials undertaken in developing countries like South Africa. It also raises serious concerns about the quality of ethical review undertaken in those countries, and it highlights some surprising deficiencies in existing U.S. regulations regarding when ethical review should be undertaken by American IRBs.

In 2007 almost two million people died of TB and over nine million people were newly infected. TB-related morbidity and death is profound among people living with HIV/AIDS; nearly 7 percent of new cases and over a quarter of all TB-related deaths occur among people living with HIV/AIDS. Doctors treating TB in this population face a difficult challenge. Serious side effects can occur with concurrent HIV and TB treatment, leading some clinicians to suggest that antiretroviral therapy for HIV be delayed for several weeks after treatment for TB is started. But serious side effects are also a risk of delaying ART therapy. Guidelines state that ART therapy should be started as soon as possible, but there is disagreement over when that should be.

In the SAPIT trial, 642 individuals co-infected with HIV and TB were randomized to receive one of three treatments: early integrated ART (started during the intensive phase of TB therapy), late integrated ART (started during the continuation phase of TB therapy), or sequential ART (started after completion of TB therapy).

Individuals randomized to the two integrated arms received ART within three months of study entry. Antiretroviral treatment of individuals randomized to the sequential treatment arm, however, was delayed on average for almost nine months. For several unlucky study participants, ART was delayed even longer; mean time to initiation of ART in this group was six to 11 months (260±71 days), regardless of CD4 cell count, an indicator of HIV disease progression, at study entry. This matters, as patients with CD4 cell counts lower than 200 cells per cubic millimeter face a significantly increased risk of death.

Forty-four months after the first SAPIT participants were enrolled, the study’s Data Safety Monitoring Board stopped the sequential treatment arm and required that all of its participants be started on ART immediately. In its interim analysis, the DSMB had found that participants in the sequential treatment arm had a much higher rate of death than participants in the integrated treatment arms.

The majority of these deaths occurred among patients with CD4 counts below 200 cells per cubic millimeter at study entry. Twenty-seven of 213 participants, or 12.7 percent, in the sequential therapy arm died during the abbreviated treatment and observation period, of whom 21 had CD4 counts of less than 200 per cubic millimeter at study entry, while only 25 of 429, or 5.8 percent, in the integrated therapy arms died over the course of the study. Integrated HIV and TB treatment thus reduced the likelihood of death among study participants by more than twofold.

The trial conclusively showed that integrated HIV and TB treatment is more effective than sequential treatment. The question is whether obtaining that data justified the 10 or more preventable deaths that occurred among trial participants. Even before the study began, years of observational data had shown that the risk of HIV-related death among patients not receiving ART therapy was highest during the first few weeks of TB treatment, calling into question the need to conduct a randomized, controlled trial in which ART was delayed by as long as 11 months for some study participants.

The side effects of concurrent HIV and TB treatment can often be managed by observant clinicians; given this, the WHO Global TB/HIV Working Group recommended as far back as 2003 that “any decision on treatment should be individualized, based on response to anti-TB therapy, side-effects, and readiness for ART.” More recently, based primarily on data from the SAPIT trial, WHO urged that ART be given within eight weeks of starting TB treatment in co-infected individuals.

Current treatment guidelines recommend that patients infected with both TB and HIV should start ART as soon as possible. Where CD4 testing is routinely available, these guidelines recommend starting ART when CD4 cell counts drop below 350 cells per cubic millimeter, and they require ART once cell counts drop below 200 cellsper cubic millimeter. Where routine CD4 testing is not available, these guidelines suggest that HIV-infected individuals with TB should start ART immediately.

In a recent article in The Lancet, several of the SAPIT investigators argued that “an estimated 10,000 deaths could be prevented every year by the initiation of ART in HIV/tuberculosis co-infected patients with CD4-cell counts below 500 cells per cubic millimeter.” However, the level of care provided to participants in the sequential treatment arm of the SAPIT trial fell considerably below this standard. The level of treatment provided to these volunteers even violated existing domestic standards of care for patients in South Africa, which recommend starting patients with CD4 cell counts of less than 200 per cubic millimeter on ART after just two months of TB treatment.

Although the SAPIT investigators noted that trial participants’ primary care physicians were free to start them on ART as necessary – in keeping with the 2003 recommendations of the WHO Global TB/HIV Working Group – this ignores the reality of public sector HIV care and treatment in South Africa. It is unlikely that most of the study participants even had a primary care doctor, let alone a physician who would initiate ART despite the restrictions imposed by the SAPIT protocol. Who then could have started these patients on life-preserving treatment if not the clinician-investigators on the study? Individualized treatment decisions based on medical need were not made in the sequential arm of the study, despite the ethical obligation of study clinicians to ensure the safety and well being of individual study participants.

Aggravating these problems, the trial design violated the golden rule of ethical study design and conduct: No clinical equipoise existed between the trial arms. Given decades of research showing that untreated patients with CD4 cell counts of less than 200 cells per cubic millimeter are at great risk of HIV-related complications and death, coupled with observational data showing that this risk is even higher during the first few weeks of TB treatment for co-infected individuals, the sequential treatment arm never should have been considered a viable treatment strategy. Patients randomized into the sequential arm were knowingly subjected to substandard clinical care.

The fundamental ethical (and legal) issue is this: the SAPIT study caused foreseeable harms and preventable deaths for a substantial number of impoverished and poorly educated South African trial participants. In doing so, the trial violated the Declaration of Helsinki’s requirements on standards of care of the then-applicable 2000 revision:

The benefits, risks, burdens and effectiveness of a new method should be tested against those of the best current prophylactic, diagnostic, and therapeutic methods. This does not exclude the use of placebo, or no treatment, in studies where no proven prophylactic, diagnostic or therapeutic method exists.

For the South African researchers involved with the SAPIT trial, the Declaration of Helsinki is not only a moral exhortation but also a legally binding obligation. South Africa’s Good Clinical Practice Guidelines require that all investigators “follow fully the guidelines set out” in the Declaration of Helsinki, in addition to other national research ethics guidelines.

Organizations such as the Welcome Trust in the U.K. and the National Institutes of Health in the U.S. have directed millions of dollars to train members of African ethical review committees, and yet this trial was reviewed and approved by a committee in South Africa. The failure of this research ethics committee to recognize the clinical, ethical, and legal deficiencies in this study is shameful and, we hope, will be investigated by the relevant South African authorities.

Another issue is worth noting. As published in the New England Journal of Medicine, the study boasts a large number of authors. This is not an uncommon practice for large clinical trials like SAPIT. The authors of the article are located in South Africa and the U.S., and some authors list both South African and U.S. institutional affiliations. It is unfortunate, however, that U.S. research ethics guidelines (at least as interpreted by the American institutions involved) did not require these authors to submit the study protocol for ethical review by committees in the U.S.

If, as these institutions suggest, the study investigators were not acting on behalf of the U.S. institutions or were not engaged in what these universities define as human subjects research, it is worth asking why these institutions are listed on the published research papers. If they want to share in the academic glory associated with a study published in a prestigious journal like the New England Journal of Medicine, then they have the obligation to ensure that the trial meets accepted standards of ethical conduct and the responsibility to protect the rights and safety of all study participants. Further review might have made an appreciable difference to the ethical design and conduct of this study.


Sean Philpott is an assistant professor of bioethics at Union Graduate College and a former science and ethics officer for the Global Campaign for Microbicides. Udo Schüklenk holds the Ontario Research Chair in Bioethics at Queen's University, Canada, and is the joint editor-in-chief of BIOETHICS. An extended version of this essay is scheduled to appear as the editorial in BIOETHICS in July (volume 24, number 6).

Posted by Susan Gilbert at 05/05/2010 11:55:34 AM | 

Shocking to learn that the SAPIT study caused the death of so many participants and the PI is glowing on the front page of his website. www.caprisa.org. Unethical practice should be stopped now and the PI should be brought to book. The US agencies that funded the trial should also be held accountable, this is really bad for research in South Africa.
Posted by: annonymous@gmail.com ( Email ) at 5/9/2010 11:52 AM

It is to be wondered what comprised the review and approval of this study by the study's sponsors, particularly NIH and other US federal agencies, in light of the applicable regulations that require that foreign country procedures to protect human subjects "be at least equivalent to those provided" under the Common Rule lest the Common Rule requirements for IRB review be invoked. It appears here that review procedures were not equivalent. Lacking such assurances or perhaps credible assurances, one is right to expect of US sponsors both an explanation of how the study was able to move forward as well as continue, and action to ensure that tragedies are not repeated.
Posted by: howard.stone@uthct.edu ( Email ) at 5/13/2010 5:52 PM

The PI should respond to the report. MANY consider him to be the blue eyed boy of the NIH. Just maybe we need to question the agenda of these scientists and what they are really contributing to science, so far there is nothing to me convince me for the good of the participants intentional or not.
Posted by: annonymous@gmail.com ( Email ) at 5/13/2010 6:18 PM

There is further evidence justifying concerns for the exploitation of vulnerable subjects. Curiously, for a nation with such a trouble history of racial discrimination, the race of the subjects is not given. About a fifth did not complete primary school. Altogether, more two thirds did not complete a secondary education. And yet this study used a written consent without any evidence of screening for functional literacy or comprehension of the consent. It is hard to imagine such a hazardous research design being proposed for testing on a fairly empowered population.
Steven Miles, MD, University of Minnesota
Posted by: miles001@umn.edu ( Email | Visit ) at 5/13/2010 6:24 PM

Steven Miles, MD, you are challenging a critical issue based on the fact that a large percentage of the population in fact is illiterate so how then would informed consent have been done?
Posted by: annonymous@gmail.com ( Email ) at 5/13/2010 6:40 PM

I refer you to literature on "consent auditors."

annonymous (sic) bloggers hardly deserve the courtesy of a response. Sign your name next time. I am surprised that Hastings allows such childishness.
Posted by: miles001@umn.edu ( Email ) at 5/13/2010 6:52 PM

Thank you for the lesson on rules, but what about the right to remain not known if there is a conflict of interest such as being an employee??
Posted by: annonymous@gmail.com ( Email ) at 5/14/2010 5:56 AM

Jon Cohen reports in Science that two New York based highly respected physicians strongly object to the criticism of SAPIT. One who like Dr Karim has an affiliation with Columbia said she was flabbergasted and that SAPIT would be cited as one of the landmark studies in HIV/TB.
Yes, it will be cited, but for allowing HIV infected individuals with under 200 CD4 lymphocytes to wait for 6-11 months before taking steps to save their lives.
Posted by: benson@panix.com ( Email ) at 5/14/2010 11:06 AM

This is the right blog for anyone who wants to find out about this topic. You realize so much its almost hard to argue with you (not that I actually would want…HaHa). You definitely put a new spin on a topic thats been written about for years. Great stuff, just great!
Posted by: magyblog@gmail.com ( Email | Visit ) at 8/16/2013 2:32 PM

I think the author is challenging a critical issue.
Posted by: macybags@hotmail.com ( Email | Visit ) at 9/24/2013 9:55 PM

Un site très riche. Vous partagez cette information est de vraiment l'apprécier. J'espère ici pour en savoir plus sur ce sujet. Merci pour les informations publiées ici
Posted by: chenghuiaa123@163.com ( Email | Visit ) at 1/15/2014 2:59 AM

Nice to be visiting your blog again, it has been months for me. Well this article that i’ve been waited for so long. I need this article to complete my assignment in the college, and it has same topic with your article. Thanks, great share
Posted by: maxpan123@gmail.com ( Email | Visit ) at 6/1/2014 12:10 PM

Exacerbating these problems, the test organisation violated the metallic limit of honorable read ornament and transmit: No clinical equipoise existed between the affliction munition.
Posted by: smkn4bengkulu@gmail.com ( Email | Visit ) at 6/3/2014 11:44 AM

Replica Gucci Belts Cheap Sale Supply The Superior Quality And Low Price With Free Shipping And Good Customer Service To You.
Posted by: abigailadaabigailada@hotmail.com ( Email | Visit ) at 11/11/2014 2:46 AM

I need this article to complete my assignment in the college, and it has same topic with your article.
Posted by: ayunksyah@gmail.com ( Email | Visit ) at 12/24/2014 2:49 AM

Very informational post thanks for giving such productive information.This article is going to help for many people.I love to read the articles based on the medicine.
Posted by: wandarwhitehead@gmail.com ( Email | Visit ) at 1/14/2015 8:05 AM

Adjustments which can be designed to virtually any life-style can be done with no priced at a small fortune. In reality, some of these adjustments may potentially lower your expenses.
Posted by: oyahaloms@gmail.com ( Email | Visit ) at 2/3/2015 5:23 PM

I hаvе rеcеntly started а blog, thе info уоu provide оn thіs site haѕ helped mе greatly. Therе іs obvіouslу а lot tо knоw abоut this. I thіnk hе dіd ѕome good thіngѕ іn features also. Kеер working, great job! Thаnks fоr а verу interesting blog.
Posted by: briar212@yahoo.com ( Email | Visit ) at 4/1/2015 1:57 AM

Whаt elѕe cаn I gеt thаt kind оf information written іn suсh а perfect approach? I hаvе а company thаt I"m simply nоw operating on, аnd I"ve bеen оn thе lоok оut fоr suсh information.
Posted by: briar212@yahoo.com ( Email | Visit ) at 4/1/2015 1:57 AM

Whаt аn amazing post thiѕ is. Wow, јuѕt wow! Evеrуthіng іn thiѕ article іs absolutely fantastic аnd full оf enthusiasm. Kеeр thіѕ uр аnd you'll surely bе gеttіng а lot оf positive response frоm уоur customers.
Posted by: briar212@yahoo.com ( Email | Visit ) at 4/1/2015 1:58 AM

I rеаlly enjoyed thіѕ article, іt wаѕ informative аnd helped open mу mind tо nеw possibilities. Thаt iѕ thе power оf thе internet, connecting people worlds aраrt аnd allowing uѕ tо learn аnd grow together.
Posted by: briar212@yahoo.com ( Email | Visit ) at 4/1/2015 2:05 AM

Thіs іs аn awesome article. I rеally love thіs post. I thіnk thіs iѕ onе оf yоur bеѕt articles you've uploaded ever.
Posted by: briar212@yahoo.com ( Email | Visit ) at 4/1/2015 2:06 AM

Itѕ feels great tо hаve сome аcrоѕѕ thіѕ post aѕ thiѕ kind оf information аre nоt proper tо people lіkе me.
Posted by: briar212@yahoo.com ( Email | Visit ) at 4/1/2015 2:07 AM

You're ѕo right. I'm thеre wіth you. Yоur blog іs dеfinitelу worth а read іf anyоne соmеѕ aсrоss it. I'm lucky I dіd beсause nоw I've gоt а whоle nеw view оf this. I didn't realize thаt thіs issue waѕ sо important аnd ѕo universal
Posted by: briar212@yahoo.com ( Email | Visit ) at 4/1/2015 2:08 AM

thankѕ fоr thе great post...I've bеen lоoking fоr а whіle fоr somethіng lіkе thіѕ оn thе internet аnd glad I сame aсrоss it.
Posted by: briar212@yahoo.com ( Email | Visit ) at 4/1/2015 2:15 AM

Posted by: fatahiqbal@gmail.com ( Email | Visit ) at 4/6/2015 11:58 PM

Posted by: fatahiqbal@gmail.com ( Email | Visit ) at 4/6/2015 11:58 PM

Posted by: fatahiqbal@gmail.com ( Email | Visit ) at 4/6/2015 11:59 PM

Posted by: fatahiqbal@gmail.com ( Email | Visit ) at 4/6/2015 11:59 PM

Posted by: fatahiqbal@gmail.com ( Email | Visit ) at 4/6/2015 11:59 PM

Posted by: fatahiqbal@gmail.com ( Email | Visit ) at 4/6/2015 11:59 PM

Posted by: fatahiqbal@gmail.com ( Email | Visit ) at 4/7/2015 12:00 AM

This particular not just influences intestinal tract wellness but additionally consequently has an effect on hormonal equilibrium and brain function creating the over and perchance other mental circumstances.
Posted by: jenn.tenner2@gmail.com ( Email | Visit ) at 4/19/2015 4:18 PM

I hаvе beеn іn loоk fоr оf ѕоme information abоut іt аlmoѕt threе time. Yоu served mе а lot іndeed аnd analyzing thіs уour publish I hаve fоund mаnу nеw аnd uѕеful information abоut thiѕ topic.
blackberry 8310 unlock code
Posted by: lenovodell637@gmail.com ( Email | Visit ) at 5/7/2015 7:52 AM

A number of this involves self-awareness and self-reflection. If you haven't developed a clearer understanding of what you value, what you believe, what you want to achieve, and what you are capable of, merely jamming affirmations down your throat won't mean anything. It is vital that we usually request our own selves what we genuinely importance and believe prior to following the other folks inform us we should value and feel. No one's perspective can alternative your own personal self-awareness.
Posted by: boni.experius@gmail.com ( Email | Visit ) at 5/8/2015 12:44 PM

I think that thanks for the valuabe information and insights you have so provided here.
link building
Posted by: lenovodell637@gmail.com ( Email | Visit ) at 5/13/2015 4:50 AM

It is vital that we usually request our own selves what we genuinely importance and believe prior to following the other folks inform us we should value and feel...

vigrx side effect
Posted by: jamalasjhar34@gmail.com ( Email | Visit ) at 5/19/2015 5:48 AM

Aw, this was a really nice post. In idea I would like to put in writing like this additionally – taking time and actual effort to make a very good article… but what can I say… I procrastinate a`lot and by no means seem to get something done.
targeted email list
Posted by: jamalasjhar34@gmail.com ( Email | Visit ) at 5/25/2015 4:03 AM

I hаve read аll the comments аnd suggestions posted bу the visitors fоr this article are vеrу good,We wіll wait fоr уour nеxt article so only.Thanks!
Posted by: lenovodell637@gmail.com ( Email | Visit ) at 5/25/2015 9:43 AM

I hаve read аll the comments аnd suggestions posted bу the visitors fоr this article are vеrу good,We wіll wait fоr уour nеxt article so only.Thanks!

neopoints for sale
Posted by: jamalasjhar34@gmail.com ( Email | Visit ) at 5/28/2015 8:24 AM

لعبة زوما تعتبر من أفضل الألعاب الجديدة ويلبعها الجميع الكبير والصغير تعتمد العاب زوما على السرعة و الذكاء , في لعبة يجب عليك ضرب الكرات التي تظهر مثل الأزرق الأخضر الأحمر
Posted by: egy_knz@yahoo.com ( Email | Visit ) at 5/29/2015 8:29 AM

لعبة جاتا تعتبر من أشهر الالعاب القديمة لدي الجميع و أيضا العاب جاتا عبارة عن شخص إسمة توم يقوم في لعبة Gta بسرقة السيارات وتطاردة الشرطة لتمسك بة فيحاول هو الهروب من الشرطة
Posted by: egy_knz@yahoo.com ( Email | Visit ) at 5/29/2015 8:30 AM

لعبة ماريو تعتبر من أروع وأقدم الالعاب في الوطن العربي والتي يعشقها الجميع انطلقت اللعبة عام 1994وكذلك العاب ماريو صنعت فى اليابان
Posted by: egy_knz@yahoo.com ( Email | Visit ) at 5/29/2015 8:30 AM

You are one great writer. Your work is just extra ordinary. I always have fun reading your works and I always learn something new. I just wish you keep it up!

holosync guy
Posted by: jamalasjhar34@gmail.com ( Email | Visit ) at 5/31/2015 7:14 AM

We are really grateful for your blog post. You will find a lot of approaches after visiting your post. Great work.
Posted by: lenovodell637@gmail.com ( Email | Visit ) at 6/8/2015 2:52 AM

Excellent read, Positive site, where did u come up with the information on this posting .
packers and movers pune rates
Posted by: aarijali100@gmail.com ( Email | Visit ) at 6/10/2015 8:17 AM

Thank you for posting such a great article! I found your website perfect for my needs. It contains wonderful and helpful posts. Keep up the good work!
business tax attorney
Posted by: lenovodell637@gmail.com ( Email | Visit ) at 6/14/2015 7:29 AM

Yоu served mе а lot іndeed аnd analyzing thіs уour publish I hаve fоund mаnу nеw аnd uѕеful information abоut thiѕ topic.
Posted by: lenovodell637@gmail.com ( Email | Visit ) at 6/17/2015 7:18 AM

I recently found many useful information in your website especially this blog page. Among the lots of comments on your articles...
Injustice Cheats
Posted by: lenovodell637@gmail.com ( Email | Visit ) at 6/21/2015 3:43 AM

I will definitely dig it and personally recommend to my friends. I am confident they will be benefited from this site
Posted by: lenovodell637@gmail.com ( Email | Visit ) at 6/22/2015 7:53 AM

Although the wording of the resolution focused on the funding of research, in effect it allows women who donate oocytes for research purposes to be paid. New York is believed to be the first state to allow payment to women who provide eggs for research.
obat peninggi badan
Posted by: robinjack0@gmail.com ( Email | Visit ) at 6/25/2015 4:03 AM

The guidelines may come as a surprise to people who are still puzzling out the ethical arguments. twitter verified accounts
Posted by: lenovodell637@gmail.com ( Email | Visit ) at 6/25/2015 4:52 AM

who donate oocytes for research purposes to be paid. New York is believed to be the first state to allow payment to women who provide eggs for research. USA Tumblr accounts
Posted by: lenovodell637@gmail.com ( Email | Visit ) at 6/30/2015 6:49 AM

This article was written by a real thinking writer. I agree many of the with the solid points made by the writer. I’ll be back.
Posted by: lenovodell637@gmail.com ( Email | Visit ) at 7/4/2015 8:12 AM