Daily Isoniazid to Prevent Tuberculosis in Infants Born to Mothers With HIV

• Time to Development of Tuberculosis (TB) Disease or Death Among HIV-infected Children [ Time Frame: Through to week 96 ] [ Designated as safety issue: No ]
  Criteria for diagnosis with TB disease: Definite-isolation of Mycobacterium TB (M.tb) or +ve stain on cerebrospinal fluid (CSF); Probable- +ve acid fast bacilli (AFB) stain on fluids/tissues other than CSF and sufficient clinical criteria/radiographic evidence suggestive of TB; Possible-abnormal chest radiograph suggestive of pulmonary TB (PTB) and either a +ve tuberculin skin test (TST) or minimum score on algorithm for clinical TB. Records reviewed by Endpoint Review Group. Results report percent of participants reaching TB disease/death by week 96 calculated using the Kaplan-Meier method.
• Time From Randomization to Development of TB Infection or Death Among Perinatally Exposed, HIV-uninfected Children [ Time Frame: Through to week 96 ] [ Designated as safety issue: No ]
  Criteria for diagnosis with TB infection were outlined in the protocol. TB infection included TB disease (see primary outcome measure 1 for definition) and latent TB infection. Latent TB infection was diagnosed by a positive tuberculin skin test (TST) based on a purified protein derivative (PPD) performed at week 96. Participant records were reviewed by an Endpoint Review Group to verify that participants had met the criteria for TB infection. Results report percent of participants reaching TB infection or death by week 96 calculated using the Kaplan-Meier method.

• Time from randomization to development of tuberculosis (TB) disease among HIV infected children, as observed at Week 96
• time from randomization to development of TB disease among perinatally-exposed, HIV uninfected children, as observed at Week 96

• Time From Randomization to Development of TB Infection or Death Among HIV-infected Children [ Time Frame: Through to week 96 ] [ Designated as safety issue: No ]
  Criteria for diagnosis with TB infection were outlined in the protocol. TB infection included TB disease (see primary outcome measure 1 for definition) and latent TB infection. Latent TB infection was diagnosed by a positive TST based on a PPD performed at week 96. Participant records were reviewed by an Endpoint Review Group to verify that participants had met the criteria for TB infection. Results report percent of participants reaching TB infection or death by week 96 calculated using the Kaplan-Meier method.
• Time From Randomization to HIV Disease Progression or Death Among HIV-infected Children [ Time Frame: Through to week 96 ] [ Designated as safety issue: No ]
  HIV disease progression was defined as any advancement in Centers for Disease Control (CDC) disease category from entry or death. If a participant was CDC disease category C at entry progression was defined as death. Results report percent of participants with HIV progression or death by week 96 calculated using the Kaplan-Meier method.
• Time From Randomization to Development of TB Disease or Death Among Perinatally Exposed, HIV-uninfected Children [ Time Frame: Through to week 96 ] [ Designated as safety issue: No ]
  Criteria for diagnosis with TB disease were: Definite-isolation of M.tb or positive stain on CSF; Probable-positive AFB stain on fluids/tissues other than CSF and sufficient clinical criteria/radiographic evidence suggestive of TB; Possible-abnormal chest radiograph suggestive of PTB and either a +ve TST or minimum score on algorithm to diagnose clinical TB. All records were reviewed by an Endpoint Review Group to verify that participants had met the criteria for TB disease. Results report percent of participants reaching TB disease/death by week 96 calculated using the Kaplan-Meier method.
• Time From Randomization to Development of TB Disease Among HIV Infected and Perinatally Exposed, HIV-uninfected Children [ Time Frame: Through to week 96 ] [ Designated as safety issue: No ]
  Criteria for diagnosis with TB disease were: Definite-isolation of M.tb or positive stain on CSF; Probable-positive AFB stain on fluids/tissues other than CSF and sufficient clinical criteria/radiographic evidence suggestive of TB; Possible-abnormal chest radiograph suggestive of PTB and either a +ve TST or minimum score on algorithm to diagnose clinical TB. All records were reviewed by an Endpoint Review Group to verify that participants had met the criteria for TB disease. Results report percent of participants reaching TB disease/death by week 96 calculated using the Kaplan-Meier method.
• Time From Randomization to Development of TB Infection Among HIV-infected and Perinatally Exposed, HIV-uninfected Children [ Time Frame: Through to week 96 ] [ Designated as safety issue: No ]
  Criteria for diagnosis with TB infection were outlined in the protocol. TB infection included TB disease (see primary outcome measure 1 for definition) and latent TB infection. Latent TB infection was diagnosed by a positive TST based on a PPD performed at week 96. Participant records were reviewed by an Endpoint Review Group to verify that participants had met the criteria for TB infection. Results report percent of participants reaching TB infection by week 96 calculated using the Kaplan-Meier method.
• Time From Randomization to Death Among HIV-infected and Perinatally Exposed, HIV-uninfected Children [ Time Frame: Through to week 96 ] [ Designated as safety issue: Yes ]
  Deaths from any cause were included. Results report percent of participants dying by week 96 calculated using the Kaplan-Meier method.
• Time From Randomization to First New Grade 3 or Worse Adverse Event Among HIV-infected and Perinatally Exposed, HIV-uninfected Children [ Time Frame: Through to week 96 ] [ Designated as safety issue: Yes ]
  Signs, symptoms and laboratory values were graded according to the Division of AIDS Adverse Event Grading System. Any event of grade 3 or higher not present at entry that occurred after randomization was classified as a new event. Results report percent of participants with a new event by week 96 calculated using the Kaplan-Meier method.

• Time from Week 96 to development of TB infection, and time from Week 96 to development of TB disease among HIV infected and perinatally-exposed, HIV uninfected children
• time from randomization to death as observed at Week 96, and time from Week 96 to death among HIV infected and perinatally-exposed, HIV uninfected children
• population pharmacokinetics (PK) model of isoniazid (INH) among HIV infected and perinatally-exposed, HIV uninfected children
• time from randomization to development of TB infection among HIV infected children, as observed at Week 96
• time from randomization to a new AIDS-defining illness or death as observed at Week 96, and time from Week 96 to AIDS-defining illness or death among HIV infected children
• time from randomization to development of TB disease among perinatally-exposed, HIV uninfected children, as observed at Week 96

Tuberculosis (TB) is highly endemic in sub-Saharan Africa. The increased burden of TB in settings with high prevalence of the Human Immunodeficiency Virus (HIV) is associated with high rates of transmission of Mycobacterium tuberculosis (M.tb) to both adults and children. Children infected with TB have a higher risk of developing severe disease than adults with TB. The purpose of this study was to determine if the antibiotic isoniazid (INH) prevented TB infection in infants born to HIV-infected mothers.

Tuberculosis (TB) and the Human Immunodeficiency Virus (HIV) are major public health problems in southern Africa, and the incidence of TB in South Africa is among the highest in the world. TB is caused by the highly contagious bacterium Mycobacterium tuberculosis. The use of Isoniazid (INH) prophylaxis in adults has been associated with reduced risk of TB disease in high-risk populations. Delay in initiating INH prophylaxis in children has resulted in more cases of childhood TB infection. This study evaluated the effectiveness of INH prophylaxis in preventing TB infection in infants born to HIV-infected mothers in southern Africa.

Infants were randomly assigned to receive either INH or placebo by mouth daily, beginning between the 91st and 120th day of life, and at least 90 days after Bacille Calmette-Guerin (BCG) vaccination. At sites in South Africa, HIV-infected infants received daily trimethoprim/sulfamethoxazole (TMP/SMX) as Pneumocystis jiroveci pneumonia (PCP) prophylaxis until at least 1 year of age; HIV-uninfected infants received TMP/SMX until at least 6 months of age.

The study was to follow participants for 192 weeks. Study visits occurred at study entry and every 12 weeks until week 192. A physical exam and blood collection occurred at each study visit. Infants were assessed for peripheral neuropathy every 12 weeks until week 96 and for TB at weeks 96, 144, and 192. The study also assessed medication adherence.

As of November 12, 2008, follow-up was revised. All participants were permanently discontinued from study follow-up by February 28, 2009 and no later than May 31, 2009. Only clinical evaluations were performed for all participants. For HIV-infected participants, the study drug was stopped at the next scheduled visit. For HIV-uninfected subjects, the study drug was discontinued immediately.

• HIV Infection
• Tuberculosis
• Pneumocystis Jiroveci Pneumonia

• Drug: Isoniazid (INH)
  Antibiotic for the prevention and treatment of TB
• Drug: Trimethoprim/Sulfamethoxazole (TMP/SMX)
  Antibiotic for the prevention and treatment of pneumocystis pneumonia (PCP)
• Drug: Isoniazid Placebo (PL)
  Isoniazid placebo and TMP/SMX

• Experimental: HIVneg/INH
  Perinatally exposed, HIV-uninfected (HIVneg) children receiving Isoniazid (INH)10-20 mg/kg orally once a day for 96 weeks + Trimethoprim/Sulfamethoxazole (TMP/SMX) 5 mg/kg of TMP component orally once a day until HIV status is confirmed and child is no longer at risk of acquiring HIV through breastfeeding
  Interventions:

  • Drug: Isoniazid (INH)
  • Drug: Trimethoprim/Sulfamethoxazole (TMP/SMX)
• Placebo Comparator: HIVneg/PL
  Perinatally exposed, HIV-uninfected (HIVneg) children receiving Isoniazid placebo (PL) orally once a day for 96 weeks + TMP/SMX 5 mg/kg of TMP component orally once a day until HIV status is confirmed and child is no longer at risk of acquiring HIV through breastfeeding
  Intervention: Drug: Isoniazid Placebo (PL)
• Experimental: HIVpos/INH
  HIV-infected (HIVpos) children receiving Isoniazid (INH) 10-20 mg/kg orally once a day for 96 weeks + TMP/SMX 5 mg/kg of TMP component orally once a day until one year of age. TMP/SMX may have been continued after one year of age according to WHO guidelines.
  Interventions:

  • Drug: Isoniazid (INH)
  • Drug: Trimethoprim/Sulfamethoxazole (TMP/SMX)
• Placebo Comparator: HIVpos/PL
  HIV-infected (HIVpos) children receiving Isoniazid placebo (PL) orally once a day for 96 weeks + TMP/SMX 5 mg/kg of TMP component orally once a day until one year of age. TMP/SMX may have been continued after one year of age according to WHO guidelines.
  Intervention: Drug: Isoniazid Placebo (PL)

• Cotton MF, Schaaf HS, Lottering G, Weber HL, Coetzee J, Nachman S; PACTG 1041 Team. Tuberculosis exposure in HIV-exposed infants in a high-prevalence setting. Int J Tuberc Lung Dis. 2008 Feb;12(2):225-7.
• Cotton M, Kim S, Rabie H, Coetzee J, Nachman S for the PACTG 1041 Team. A window into a public program for prevention of mother to child transmission of HIV: evidence from a prospective clinical trial. The Southern African Journal of HIV Medicine 10(4): 16-19, 2009.
• Chintu C, Mwaba P. Tuberculosis in children with human immunodeficiency virus infection. Int J Tuberc Lung Dis. 2005 May;9(5):477-84. Review.
• Corbett EL, Watt CJ, Walker N, Maher D, Williams BG, Raviglione MC, Dye C. The growing burden of tuberculosis: global trends and interactions with the HIV epidemic. Arch Intern Med. 2003 May 12;163(9):1009-21. Review.
• de Jong BC, Israelski DM, Corbett EL, Small PM. Clinical management of tuberculosis in the context of HIV infection. Annu Rev Med. 2004;55:283-301.
• Toossi Z. Virological and immunological impact of tuberculosis on human immunodeficiency virus type 1 disease. J Infect Dis. 2003 Oct 15;188(8):1146-55. Epub 2003 Sep 30. Review.
• Madhi SA, Nachman S, Violari A, Kim S, Cotton MF, Bobat R, Jean-Philippe P, McSherry G, Mitchell C; P1041 Study Team. Primary isoniazid prophylaxis against tuberculosis in HIV-exposed children. N Engl J Med. 2011 Jul 7;365(1):21-31.

Inclusion Criteria:

• Mother is HIV-infected. Hard copy documentation of the mother's HIV infection is unnecessary if a positive DNA PCR from her infant is available.
• Received Bacille Calmette-Guerin (BCG) vaccine up to and including the 30th day of life and at least 90 days prior to study entry
• Able to complete all study requirements
• Physician assessment of age-appropriate neurodevelopment in which the chronological age is corrected for gestational age for prematurely born infants
• Parent or legal guardian able and willing to provide signed informed consent
• Plan to live in the study area for at least 4 years
• For inclusion in HIV-infected stratum, infant must have a positive HIV-1 DNA PCR; for inclusion in HIV-uninfected stratum, infant must have a negative HIV-1 DNA PCR performed at >= 4 weeks of age

Exclusion Criteria:

• Previous diagnosis of TB infection, TB disease or current treatment for TB infection or TB disease
• Previous receipt of INH
• Contact with a known acid fast bacilli (AFB) sputum smear or culture-positive case of TB before study entry
• Current acute or recurrent (3 or more prior episodes) lower respiratory tract disease
• Chronic persistent diarrhea
• Failure to thrive
• Contraindications for use of INH or TMP/SMX
• Require certain medications
• Known or suspected immune system diseases other than HIV
• Current or previous diagnosis of or treatment for cancer
• Current immunosuppressive therapy greater than 1 mg/kg/day of prednisone or equivalent
• Anticipated long-term oral or intravenous corticosteroid therapy (greater than 3 weeks). Those receiving nonsteroidal anti-inflammatory agents and inhaled corticosteroids are not excluded.
• Grade 3 or greater AST/SGOT, ALT/SGPT, ANC, hemoglobin, platelet count, rash, neuropathy, or myopathy at screening
• Any Grade 4 clinical or laboratory toxicity within 14 days prior to study entry
• Other acute or chronic conditions that, in the opinion of the investigator, may interfere with the study

• National Institute of Allergy and Infectious Diseases (NIAID)
• Comprehensive International Program of Research on AIDS
• Secure the Future Foundation