Effectiveness of pegylated interferon-α combined with antiretroviral therapy on HIV reservoir clearance in acute HIV infection: study protocol for a randomised controlled trial at a tertiary infectious disease hospital in Beijing, China

Abstract

Introduction

HIV cure remains one of the major unsolved global health challenges. The persistence of the HIV reservoir is the key barrier to achieving viral eradication. The acute HIV infection (AHI) is crucial for reservoir establishment, making early intervention essential for long-term viral remission. Pegylated interferon-α (Peg-IFN-α) exhibits potent antiviral and immunomodulatory properties that may enhance reservoir clearance when combined with antiretroviral therapy (ART). This study aims to evaluate the efficacy and safety of Peg-IFN-α combined with ART in promoting reservoir reduction and immune reconstitution in individuals with AHI.

Methods and analysis

This randomised, parallel-controlled, open-label clinical trial will enrol 68 participants with confirmed AHI. Eligible participants will be randomly assigned (1:1) to receive Peg-IFN-α plus ART or ART alone. All participants will continue ART for a total of 48 weeks. The primary outcome is the percentage reduction in total HIV-1 DNA at week 48. Secondary outcomes include HIV-1 DNA reduction at week 12, CD4⁺ T-cell recovery, cytokine profiles and safety endpoints. Statistical analysis will be performed using the intention-to-treat principle. Recruitment commenced in April 2025 and is expected to complete by December 2027.

Ethics and dissemination

This study has been approved by the Ethics Committee of Beijing You’an Hospital, Capital Medical University (approval no. LL-2024-150-K). Written informed consent will be obtained from all participants before enrolment. The results will be disseminated through peer-reviewed publications, academic conferences and communications with the clinical and scientific community. De-identified datasets will be available to qualified researchers on reasonable request following publication.

Trial registration number

ChiCTR2500100011.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This is a prospective, randomised, parallel-controlled trial with 1:1 allocation using sealed-envelope concealment generated by an independent statistical centre.

• The primary endpoint is based on an objective laboratory measurement (total HIV-1 DNA quantification), and outcome assessors are blinded to group assignment, reducing the risk of measurement bias.

• Comprehensive serial biomarker assessments at 10 scheduled visits over 48 weeks, including HIV-1 DNA, HIV RNA, T-cell subsets, cytokine profiles and safety indicators, allow longitudinal characterisation of viral reservoir dynamics.

• The relatively small sample size (n=68) may limit statistical power for detecting differences in secondary endpoints and subgroup analyses.

• The single-centre, open-label design may restrict generalisability, although standardised laboratory endpoints and blinded outcome assessment mitigate potential performance bias.

Introduction

HIV primarily targets CD4⁺ T lymphocytes, leading to progressive immune dysfunction and ultimately AIDS.¹ Although antiretroviral therapy (ART) effectively suppresses viral replication, it cannot eradicate latently infected cells that persist within host tissues, forming the HIV reservoir—the principal barrier to achieving a cure.² These latent reservoirs evade both immune surveillance and ART due to the absence of viral protein expression, yet can reactivate at any time, resulting in viral rebound, chronic immune activation and sustained multi-organ damage.^{3 4} The acute phase of HIV infection (AHI) represents a critical window for reservoir establishment: the size of the viral reservoir seeded during this period largely determines the long-term reservoir burden, and early intervention may limit reservoir formation and preserve immune function.²

Interferons (IFNs) are a class of cytokines with antiviral, pro-inflammatory and immunomodulatory properties that induce an antiviral state by upregulating IFN-stimulated genes (ISGs). Research has shown that IFNs suppress HIV-1 replication through multiple mechanisms, including direct antiviral activity mediated by host proteins, enhancement of adaptive immune responses such as HIV-specific CD8⁺ T cell activation and antibody-dependent cell-mediated cytotoxicity and augmentation of innate immune responses involving natural killer and dendritic cells.⁵ During AHI, IFN-α plays a protective role in viral control; in humanised mouse models, depletion of plasmacytoid dendritic cells significantly reduces IFN-α production and increases viral replication.⁶ Similarly, administration of IFN-α2a in Simian Immunodeficiency Virus-infected rhesus macaques during acute infection upregulated antiviral gene expression and prevented systemic viral dissemination.⁷ However, the timing of IFN intervention is critical: prolonged IFN-I signalling during chronic infection drives immune exhaustion, impairs CD4⁺ and CD8⁺ T cell function and paradoxically accelerates disease progression.⁸ These findings indicate that the therapeutic window for IFN-based intervention is confined to the acute phase, before sustained IFN-I signalling transitions from protective to pathogenic.

Clinical studies using both pegylated IFN-α (Peg-IFN-α) subtypes support the potential of Peg-IFN-α in HIV reservoir management. Early work with Peg-IFN-α2a demonstrated that 12 weeks of treatment (180 µg/week) significantly reduced HIV-1 RNA levels in treatment-naïve individuals, with the antiviral effect correlating with ISG induction.⁹ Azzoni et al¹⁰ further showed that Peg-IFN monotherapy suppressed HIV replication and decreased integrated HIV-1 DNA levels in virologically suppressed patients. More recently, Armani-Tourret et al¹¹ found that combining Peg-IFN-α2a with the latency-reversing agent panobinostat altered the composition of the HIV-1 latent reservoir and increased the immunological vulnerability of latently infected cells. Subsequent studies by the same research group transitioned to Peg-IFN-α2b: Papasavvas et al¹² conducted a pilot clinical trial in which 20 ART-suppressed individuals received Peg-IFN-α2b (1 µg/kg/week) for 20 weeks, demonstrating safety, immune activation and a significant decrease in HIV-1 RNA-positive cells in gut-associated lymphoid tissue. Importantly, a post-hoc analysis comparing the two subtypes across three clinical trials confirmed comparable HIV suppression by Peg-IFN-α2a and Peg-IFN-α2b during analytical treatment interruption.¹³ However, the ANRS-112 INTERPRIM trial,¹⁴ which combined Peg-IFN-α with ART in acute HIV-1 infection incorporating treatment interruptions, found no significant virological benefit—possibly attributable to the interruption design and ART regimen used. Taken together, these studies demonstrate that both Peg-IFN-α subtypes exert antiviral and immunomodulatory effects on HIV reservoirs, with the therapeutic strategy and timing of intervention being more critical determinants of outcome than the specific IFN-α subtype employed.

Based on the available evidence, we hypothesise that a 12-week Peg-IFN-α regimen initiated during AHI, combined with continuous ART, can induce detectable reductions in the HIV latent reservoir. We designed a randomised controlled trial evaluating Peg-IFN-α2b (Pegberon, Xiamen Amoytop Biotech, China) combined with ART vs ART alone. Peg-IFN-α2b (Pegberon) has been approved in China for the treatment of chronic hepatitis B and has demonstrated favourable long-term safety and immunomodulatory efficacy in large-scale clinical studies.¹⁵ The ART backbone consists of dolutegravir (DTG)-based or bictegravir (BIC)-based integrase strand transfer inhibitor (INSTI) triple therapy, given their rapid viral suppression, favourable safety profile and high genetic barrier to resistance. This study aims to evaluate whether Peg-IFN-α2b combined with ART in AHI can enhance HIV reservoir clearance and facilitate immune reconstitution, providing clinical evidence to optimise treatment strategies for people with AHI.

Methods

Trial design

This trial is a randomised, parallel-controlled, open-label clinical study with blinded outcome assessment, designed and reported in accordance with the Consolidated Standards of Reporting Trial guidelines. The study population consists of patients with confirmed AHI, identified from the high-risk HIV cohort at Beijing You’an Hospital, Capital Medical University. Following informed consent, eligible participants will be randomly assigned in a 1:1 ratio to receive either Peg-IFN-α combined with ART for 12 weeks or ART alone. Participants will be followed for a total of 48 weeks to assess changes in HIV reservoir dynamics and immune reconstitution-related parameters. The primary objectives are to evaluate the efficacy of Peg-IFN-α combined with ART in clearing the HIV reservoir, as well as its safety and impact on immune reconstitution in patients with AHI. The study workflow is illustrated in figure 1.

Figure 1.

Flowchart of recruitment, randomisation and assessment of patients with AHI. ART, antiretroviral therapy; Peg-IFN-α, pegylated interferon-α.

Patient recruitment commenced in April 2025, and the study is expected to be completed by December 2027.

Participants

Inclusion criteria

1. Meet the diagnostic criteria for AHI as specified in the Chinese Guidelines for the Diagnosis and Treatment of AIDS (2024 Edition).¹⁶

2. Age between 18 and 60 years.

3. ART-naïve.

4. Willing to participate in the clinical study, capable of understanding and providing written informed consent.

Exclusion criteria

1. Co-infection with viral hepatitis.

2. History or current diagnosis of liver cirrhosis or liver cancer.

3. Pregnant or lactating women, or those planning to conceive in the near future.

4. History of severe cardiac disease, including unstable or uncontrolled conditions within the past 6 months.

5. Uncontrolled diabetes, hypertension, thyroid disorders, retinopathy or other clinically significant ophthalmic diseases, autoimmune disorders or epilepsy.

6. Laboratory abnormalities meeting any of the following criteria: neutrophil count <2×10⁹/L; platelet count <100×10⁹/L or evidence of acute severe liver injury, such as alanine aminotransferase>10 × the upper limit of normal or total bilirubin >34 µmol/L.

7. Co-existing opportunistic infections associated with HIV.

8. Diagnosis of malignant tumours or contraindications to IFN therapy (eg, IFN hypersensitivity, severe pulmonary disease).

9. History of psychiatric disorders.

10. History of alcohol abuse, substance abuse or drug misuse.

11. Any other conditions deemed inappropriate for inclusion by the investigator.

Removal criteria

Participants found to have falsified data or concealed their true personal circumstances during the study will be removed.

Withdrawal criteria

1. Investigator-initiated withdrawal: participants may be withdrawn by the investigator if they exhibit poor compliance, develop comorbidities or complications or experience adverse drug events that make continued participation unsuitable.

2. Participant-initiated withdrawal: participants may withdraw from the trial at any time, including cases where they stop medication or testing without explicitly requesting withdrawal. Efforts should be made to document the reasons for withdrawal whenever possible.

Interventions

Participants will be randomised 1:1 into the following two groups, as illustrated in figure 2.

Figure 2.

Randomisation, intervention and follow-up plan. ART, antiretroviral therapy; Peg-IFN-α, pegylated interferon-α.

Peg-IFN-α+ART group

Participants in this group will receive a combination of Peg-IFN-α2b (Pegberon, Xiamen Amoytop Biotech, China) and ART for the first 12 weeks, followed by ART alone for an additional 36 weeks, resulting in a total ART duration of 48 weeks. ART will be administered according to internationally recommended regimens, comprising an INSTI-based triple therapy with either DTG or BIC as the core agent. Peg-IFN-α2b will be administered subcutaneously once weekly at a fixed dose of 180 μg for participants weighing ≥75 kg and 135 μg for those weighing <75 kg, in accordance with the approved prescribing information.

ART-only group

Participants in this group will receive ART alone for a total duration of 48 weeks, following the same DTG-based or BIC-based triple therapy regimen as described above.

Follow-up

Participants in both groups will undergo a 48-week follow-up period consisting of 10 scheduled visits after screening and enrolment. At each visit, a series of clinical assessments will be conducted, including vital signs monitoring, physical examination and routine laboratory tests such as haematology, serum biochemistry, urinalysis, thyroid function and antibody profiling. Key immunological and virological evaluations will include CD4⁺ and CD8⁺ T-cell counts, plasma HIV RNA levels (viral load), total HIV-1 DNA quantification, inflammatory cytokine profiling and assessments of T-cell function and phenotypic markers. Psychological status will be evaluated using standardised anxiety and depression scales. In addition, 12-lead ECGs will be performed. Concomitant medications and adverse events (AEs) will be systematically recorded at each visit. A detailed summary of all scheduled assessments throughout the study is provided in table 1.

Table 1.

Clinical study flowchart

Study duration	Screening period	Baseline*	Treatment period					Follow-up period
Timepoints	–90d to –1d	0w	1w	2w	4w	8w	12w	16w	24w	36w	48w
Visit points	1	2	3	4	5	6	7	8	9	10	11
Window period	–	–	±3d	±3d	±7d	±14d	±14d	±14d	±14d	±30d	±30d
Informed consent	X
Screening of inclusion and exclusion criteria	X	X
Demographic data	X	X
Medical history	X	X
Vital signs	X	X	X	X	X	X	X	X	X	X	X
Physical examination	X	X	X	X	X	X	X	X	X	X	X
Complete blood count	X	X	X	X	X	X	X	X	X	X	X
Blood biochemistry	X	X	X	X	X	X	X	X	X	X	X
Urine analysis	X	X	X	X	X	X	X	X	X	X	X
Urine pregnancy test†	X								X		X
Thyroid function and antibody tests	X	X‡	X‡	X‡	X‡	X‡	X‡		X		X
Hepatitis B panel	X
HCV antibody	X
T-cell subsets		X	X	X	X	X	X	X	X	X	X
HIV-1 DNA		X	X	X	X	X	X	X	X	X	X
HIV RNA		X	X	X	X	X	X	X	X	X	X
Inflammatory cytokines		X	X	X	X	X	X	X	X	X	X
T-cell phenotypes		X	X	X	X	X	X	X	X	X	X
T-cell function		X	X	X	X	X	X	X	X	X	X
Anxiety/depression scales		X					X				X
12-lead ECG	X	X	X	X	X	X	X		X		X
Adverse events (AEs)		X	X	X	X	X	X	X	X	X	X
Concomitant medications	X	X	X	X	X	X	X	X	X	X	X

*Laboratory and examination results conducted within 30 days prior to enrollment can be used as baseline data without the need for repeat testing.

†Applicable only to women of childbearing age.

‡Only applicable to the Peg-IFN-α combined with ART group in the acute HIV phase.

ART, antiretroviral therapy; Peg-IFN-α, pegylated interferon-α.

AE management

An AE is defined as any unfavourable and unintended medical occurrence in a participant after receiving a study drug, regardless of whether a causal relationship with the treatment can be established. AEs are graded using the Common Terminology Criteria for Adverse Events (V.5.0, National Cancer Institute).¹⁷ All AEs will be meticulously recorded, and investigators will assess their potential association with the study intervention and implement appropriate management strategies. All Grade ≥3 AEs and serious adverse events (SAEs) will be reported to the ethics committee within 24 hours of the investigator becoming aware.

A range of adverse reactions is expected to occur during Peg-IFN-α therapy, based on prior clinical experience and pharmacological profiles. During the early stages of treatment, flu-like symptoms are the most frequently observed. Throughout the treatment period, reductions in white blood cell and platelet counts of varying degrees may occur. Prolonged IFN therapy may lead to decreased appetite, weight loss, hair loss, thyroid dysfunction and psychological or emotional abnormalities. The research team has extensive experience in managing Peg-IFN-α-related adverse reactions and has established predefined protocols to address potential complications.

Data monitoring and auditing

To promote protocol adherence and minimise performance bias, all laboratory specimens are processed and analysed at the centralised Clinical Research Center of Beijing You’an Hospital by personnel blinded to group assignment. Sample collection schedules and processing protocols are standardised across both groups.

Data monitoring will be conducted by the Clinical Research Center of Beijing You’an Hospital, which is independent of the study investigators. The centre will regularly review study progress, data integrity and participant safety. No interim analyses are planned, and the data monitoring committee will not have access to unblinded data before the completion of the study. Any unexpected SAEs will be promptly reported to the ethics committee according to institutional policy.

The study may be audited by the Ethics and Quality Control Committee of Beijing You’an Hospital to ensure compliance with Good Clinical Practice (GCP) and institutional regulations. Audits will be performed independently from the investigators, and audit findings will be reported directly to the hospital’s ethics committee.

Outcomes

The primary outcome is the percentage decrease in total HIV-1 DNA at week 48. Total HIV-1 DNA will be quantified by real-time quantitative PCR (qPCR) using the SUPBIO total HIV-1 DNA Quantitative PCR Kit (SUPBIO, Guangzhou, China) in accordance with the manufacturer’s instructions.

Secondary outcomes include the percentage decrease in total HIV-1 DNA at week 12, CD4⁺ T-cell growth rates at weeks 12 and 48, cytokine levels at weeks 12 and 48, HIV RNA suppression rates at weeks 12 and 48 and AE rate at week 48.

Sample size calculation

The sample size was determined using the superiority test module for two-sample means in PASS 2023 software. Based on prior real-world clinical data, the estimated percentage reduction in HIV-1 DNA was 0.7±0.30 in the Peg-IFN-α+ART group and 0.30±0.15 in the ART-only group. With a significance level (α) of 0.025, power (1−β) of 80%, a superiority margin of 0.2 and a 1:1 allocation ratio, the calculated sample size was 30 participants per group. Considering a 10% dropout rate, the final required sample size is 34 participants per group, totalling 68 participants.

Randomisation

Randomisation and allocation concealment will be conducted by an independent statistical centre using computer-generated random numbers with permuted block randomisation (block size of 4, undisclosed to enrolling investigators). Each participant will be assigned a sequentially numbered, opaque, sealed envelope prepared by the statistical centre prior to trial initiation. The envelope will be opened by the enrolling investigator only after written confirmation of participant eligibility, with the group assignment determined by the allocation specified within.

Statistical methods

All randomised participants will be included in the full-analysis set based on the intention-to-treat principle. The safety set (SS) comprises all participants who received at least one dose of study treatment and had post-treatment safety data recorded. AE incidence will be calculated using the SS population as the denominator.

For continuous variables, descriptive statistics will be presented by treatment group, including the number of participants (n), arithmetic mean, SD, minimum and maximum values. Categorical variables will be summarised as counts and percentages for each treatment group, followed by statistical analysis. Between-group comparisons for normally distributed continuous variables will be conducted using the independent-sample t-test, while the Mann-Whitney U test will be applied for non-normally distributed continuous variables. Missing data will be handled using multiple imputation where appropriate. All statistical analyses will be performed using R (V.4.4.3, R Foundation for Statistical Computing, Vienna, Austria), with a two-sided p value <0.05 considered statistically significant.

Declarations

Ethics and dissemination

This study has been approved by the Ethics Committee of Beijing You’an Hospital, Capital Medical University (Approval No. LL-2024-150-K). All participants will provide written informed consent prior to enrolment. The trial is conducted in accordance with the principles of the Declaration of Helsinki and GCP guidelines. Participant confidentiality will be strictly protected, and all data will be anonymised before analysis.

Consent and confidentiality

Written informed consent will be obtained from all participants by trained investigators before enrolment. Participants will be informed about sample use and future HIV-related studies requiring additional consent. All identifiable data will be replaced with coded identifiers and stored securely in password-protected institutional servers.

Ancillary and post-trial care

No ancillary or post-trial care is planned. Participants will continue to receive standard medical care after study completion, and any harm associated with trial participation will be handled according to institutional and national regulations.

Protocol amendments

Any important protocol modifications, including changes to study objectives, design, eligibility criteria or procedures, will be submitted to the Ethics Committee of Beijing You’an Hospital for approval prior to implementation. All amendments will also be updated in the trial registry and communicated to relevant stakeholders, including investigators and participants, when applicable.

Dissemination plan

Study findings will be disseminated through peer-reviewed journal publications and presented at relevant national and international conferences, including the Conference on Retroviruses and Opportunistic Infections and the International AIDS Society Conference. A summary of findings will be communicated to study participants. Trial results will be updated in the clinical trial registry on study completion. De-identified datasets and analytic codes may be shared with qualified researchers on reasonable request following publication, in compliance with institutional and ethical requirements.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s)