Transcript TB screening - Makerere University

TB APPRISE:
A RANDOMIZED DOUBLE-BLIND PLACEBO-CONTROLLED TRIAL TO
EVALUATE THE SAFETY OF IMMEDIATE (ANTEPARTUM-INITIATED)
VERSUS DEFERRED (POSTPARTUM-INITIATED) ISONIAZID
PREVENTIVE THERAPY AMONG HIV-INFECTED WOMEN IN HIGH TB
INCIDENCE SETTINGS
IMPAACT P1078
Chair: Amita Gupta
Vice Chairs: Adriana Weinberg,
Timothy Sterling (TBTC), Gerhard Theron
Statisticians: Grace Montepiedra, Lisa Aaron
Sponsors: NIAID, NICHD
Complications Committee Chair: Sharon Nachman
1
TB: a major global problem for maternal child
health and HIV morbidity
• Globally 9.2 million new cases of TB, with women accounting for 3.6
million cases and 700,000 deaths
• TB most common HIV-1 related illness and cause of mortality in
women of reproductive age (15-49 years) in Asia and Africa
• Women account for up to 70% of HIV-infected adults in sub-Saharan
Africa
• HIV and TB are independent risk factors for maternal mortality
• Maternal TB/HIV important risk factor for poor pediatric birth
outcomes, TB and all-cause mortality
• Research on optimal methods for early detection and prevention of TB
in HIV-infected women needed as it will benefit both maternal and
child health
4/13/2015
(WHO global report 2009 Pillay 2004;
Khan 1999; Cotton 2007; Gupta 2007, 2010) 1.
2
INH preventive therapy in HIV-infected adults
• 12 TB prevention trials: 5 trials INH vs placebo and 3 trials
INH vs. other TB preventive regimens
• TB preventive therapy associated with lower incidence of
active TB
–
–
–
–
Overall: RR 0.68 (95% CI 0.54 to 0.85)
TST+ individuals RR 0.38 (95% CI 0.25 to 0.57)
TST - individuals RR 0.89 (95% CI 0.64 to 1.24)
No reduction in overall all cause-mortality but reduction in
mortality in TST+ RR 0.74
• NONE INCLUDED PREGNANT WOMEN AT ENTRY AND NONE
INCLUDED HAART
4/13/2015
Akolo Cochrane meta-analysis 2010
1. 3
New WHO guidelines for HIV-infected persons
• INH 300mg daily for at least 6 months to all HIVinfected persons in TB endemic countries,
NOW INCLUDES PREGNANT WOMEN
• Tuberculin skin testing not required
• Recommend pyridoxine (vitamin B6) 25mg daily
with INH
http://whqlibdoc.who.int/publications/2011/9789241500708_eng.pdf
WHO December 2010
4
TB screening
• No longer uses TST…
• Screening includes:
– History of fever
– Night sweats
– Weight loss (self reported)
– Cough
• The protocol has been updated to include
these screening measures plus:
– Failure of adequate weight gain in pregnancy
– Duration of symptoms
5
2010 WHO IPT Guidelines Statement for Pregnant
Women Living with HIV
• Pregnant women living with HIV are at risk of TB
– impact to maternal and perinatal outcomes
• The guideline group stressed the importance of
screening pregnant women living with HIV for TB using
clinical algorithm.
– …concluded that existing evidence and experience in
the pre-HIV and HIV era suggest that IPT is safe in
pregnant women.
• Therefore, the guideline group strongly recommend that
pregnancy should not exclude women living with HIV
from symptom based TB screening and receiving IPT.
WHO December 2010
6
Unanswered Questions
• What is optimal timing of IPT in pregnant and
postpartum women
• Urgent need for prospective data on:
– Safety
– Tolerability
– Adherence
– And effectiveness in combination with ARVs
7
INH safety in pregnancy and post-partum
– FDA category C
– INH data from pre-HIV and pre-HAART era
– Teratogenicity: none based on existing human data
– Association of INH and hemorrhagic disease in newborn suggested in one
study but not confirmed in other reports (some recommend prophylactic
vitamin K recommended at birth but generally not done)
– Hepatotoxicity
• Abnormal liver enzymes (AST/ALT) :1-25%
• Symptomatic liver disease 5.2 per 1000 patients in a study where
20,838 given INH for 12 mo.
• 20 deaths in CA, 4 were in women who had started INH in pregnancy
(Mouldings 1989)
• 2.5 fold increased hepatoxicity and 4-fold increased death in pregnant
women but not statistically significant (Francks 1989)
• Risk factors pregnancy, first 3 months postpartum, possibly HIV, alcohol,
underlying liver disease including chronic Hep B, age, ?HAART
– Breast milk: safe. Concentration 6.4-25%
4/13/2015
Francks 1989; Mouldings 1989; Brost 1995; Ouyang 2009; Singh 2008
1. 8
Antepartum INH
Pros
– More likely to prevent
maternal and infant TB
– Compliance and followup may be better
Cons
– Potential increased
toxicities for mother and
fetus/infant when
started in antepartum
EVIDENCE NEEDED TO CONVINCE PROVIDERS AND PROGRAMS
HIV-infected pregnant woman, ≥14 through ≤34 weeks gestation
TB Screening, Rule out active TB
Active TB Suspected OR Documented
NO
Woman meets other eligibility criteria
ARM A: Immediate INH
INH x 28 weeks, then
Placebo for INH
Enrollment and
Randomization
YES
Refer to local TB
program for
evaluation and
TB treatment; not
eligible for study
ARM B: Deferred INH
Placebo for INH until week 12
postpartum, then INH x 28 weeks
Study drugs (INH/Placebo for INH), open label Pyridoxine (vitamin B6)
and open label prenatal multivitamin terminated at 40 weeks postpartum
End of study, 48 weeks postpartum
All women and their infants will receive local standard of care for HIV, PMTCT
WHO TB symptom screen on all women at each visit
Study Schema cont’d
• Sample Size
– 950 pregnant women (475/arm)
– Allows for 10% loss to follow up
• Stratification:
 Gestational age
– Ia: 14 wks to <24 wks (at least 30%)
– Ib: 24 wks to ≤34 wks
 HAART
– IIa:on HAART at study entry
– IIb: not on HAART at entry
• Randomization balanced at each CRS
4/13/2015
1. 11
Primary Objective and Endpoint
• To compare safety of immediate vs. deferred INH
preventive therapy in HIV-infected pregnant
women enrolled at 14 to ≤34 weeks gestation.
Safety of INH will be assessed by comparing rates
of Grade ≥3 events possibly, probably, definitely
related to INH/placebo or permanent drug
discontinuation between women in the
immediate and deferred arms by 48 weeks
postpartum
4/13/2015
1. 12
Secondary Objectives
– Safety and toxicity of INH on fetus and infants
– Compare TB incidence and all-cause mortality in HIV-infected women
and their infants
– Evaluate INH resistance
– Assess INH and ART PK and pharmacogenomic variants
– Performance characteristics of IGRA (Quantiferon Gold in Tube,
enhanced ELISPOT) with TST in women and infants
– Assess adherence to INH/placebo during pregnancy and postpartum
13
Key Inclusion criteria
• HIV+
• Pregnant ≥18 years
– if IRB approves and appropriate consent ≥ 13
years
• 14-34 weeks gestation
• AST (SGOT), ALT (SGPT), and total bilirubin
below 1.25 times the upper limit of normal
(ULN)
4/13/2015
1. 14
Key Exclusion criteria
•
•
•
•
•
•
•
•
Positive TB symptom screen or suspected active TB
Acute hepatitis within 90 days prior to entry
Grade ≥1 peripheral neuropathy using BPNS tool
Known active TB exposure within past 12 weeks
INH>30 days in past year
Heavy alcohol exposure
AIDS defining illness treated less than 14 days
Any clinical significant diagnosis that site
investigator feels would compromise participation
4/13/2015
1. 15
Schedule of evaluations
Mothers
• Screening
– Assess for eligibility and active TB with WHO TB symptom screen, targeted
physical, risk exposure
– CD4 and screening labs
• Entry (after randomization)
–
–
–
–
start INH/placebo, open label prenatal MVI and Vitamin B6
PBMC collection for TB ELISPOT
Blinded QGIT
Sample for Hep B and C testing
• Q4 week visit until delivery
• Delivery (TST and abstraction of delivery data)
• Q4 week post partum until week 48 postpartum (week 12 visit important)
• Suspected active TB
Infants
• Birth
• Week 4, 8, 12, 24, 36, 48 of life
• Suspected active TB or mom diagnosed with TB
4/13/2015
1. 16
Details of study evaluations
• Entry will occur within 30 days of screening
• TB screen at each visit
• Safety labs: ALT at every scheduled visit until week 40
postpartum
• At approved sites
– Stored cells at entry, 12 and 44 weeks postpartum for
immunology studies
– Intensive PK for 36 women (restricted to women on HAART)
• Sample collection for population PK during pregnancy and
pharmacogenomic variant associated with toxicity risk
(nested case-control)
• Urine sample at suspected TB visit and end of study
• Infant PBMC and plasma stored samples at 12, 24, 44
weeks and at TB visit, urine at 24, 48 and suspected TB
4/13/2015
1. 17
Stage of development
• Undergoing Regulatory and budget rereview in
response to April 2011 DSMB recommendations
• Anticipate Version 1.0 by July 1st
• 13 Interested sites: 8052 - Soweto (Johannesburg, South Africa)
•
•
•
•
•
•
•
•
•
•
•
•
8950 - Stellenbosch University (Cape Town, South Africa)
12701 - Gaborone Prevention / Treatment Trials (Gaborone, Botswana)
12702 - Molepolole Prevention/Treatment Trials (Molepolole, Botswana)
20201 - Durban Pediatric (Durban, South Africa)
30301 - Blantyre College of Medicine (Blantyre, Malawi)
30303 - St. Mary's (Chitungwiza, Zimbabwe)
30306 - Seke North (Chitungwiza, Zimbabwe)
30313 - UZ-Parirenyatwa (Harare, Zimbabwe)
30273 - George Clinic (Lusaka, Zambia)
30293 - Makerere University (Kampala, Uganda)
31441 - BJ Medical College (Pune, India)
12901- KCM (Moshi, Tanzania)
18