Infant Peri-Exposure Prophylaxis to Prevent HIV-1 Transmission by Breastfeeding: Mechanisms & Safety
Condition: Growth and Development
Study type: Observational

Summary: 
      General objective

        -  To assess the long-term safety and efficacy of one-year infant prophylaxis using
           lamivudine (3TC) or lopinavir/ritonavir (LPV/r) to prevent post-natal transmission
           through breastfeeding.

        -  To investigate the biological mechanisms involved in postnatal HIV transmission.

      Specific objectives

        -  To compare the long-term safety of infant prophylaxis using either 3TC versus LPV/r on
           child development (growth, somatic and mental health), mortality, adrenal function,
           liver function, full blood count and mitochondrial toxicity.

        -  To estimate the final efficacy data of 50 weeks of infant prophylaxis using either LPV/r
           or 3TC, since some mothers may have resumed breastfeeding after the trial.

        -  To profile miRNA in breast milk according to maternal HIV status and HIV transmission.

        -  To determine the influence of maternal milk on infant gut inflammation in an in vitro
           3D-intestinal model (CACO-2 cells).

      The study population will comprise all ANRS 12174 PROMISE-PEP trial participants who
      completed the 50 week follow-up and are not HIV infected. An estimate of 881 mother-child
      pairs from the ANRS 12174 PROMISE- PEP will be recruited.

      This study is structured in two parts. The 'clinical & biological safety' component involves
      a cross sectional survey. A clinical and neuropsychological examination of participants will
      be conducted. In addition one venous blood sample will be collected to evaluate children HIV
      status, full blood count, liver & adrenal function and mitochondrial toxicity. Capillary hair
      follicles will be collected from 100 children in Zambia to study their genome integrity.

      The 'mechanisms' component includes biological assays to be conducted on breast milk samples
      previously collected from HIV infected, transmitting or non-infected mothers enrolled at ANRS
      12174 PROMISE-PEP trial.

      Primary endpoint: Long term survival, mortality rate, measurements of infant growth (length
      and weight), somatic and neuropsychological development of the 5 year old children enrolled
      in the ANRS 12174 PROMISE- PEP trial.

      Secondary endpoints: HIV seroconversion since last PROMISE PEP trial visit, full blood count,
      liver function, adrenal function, serum lactate. Number of mitochondrial DNA copies per cell
      & percentage of mitochondrial DNA deletion for mitochondrial toxicity. Number of micronuclei
      & number of Ɣ-tubulin spot per cell to study genomic toxicity.
    

Detailed description: 
      Background Besides optimal efficacy, Prevention of mother-to-child transmission of HIV(PMTCT)
      strategies must have a very good safety profile (1). Indeed, very large quantities of
      children will be exposed to these strategies, and the vast majority of them will not
      eventually be infected. Because in utero HIV exposure followed by one year of antiretroviral
      treatment (i.e at the time of infant embryogenesis and maturation) may have long-term
      consequences, such as hampering child development, an evaluation of safety beyond the end of
      prophylaxis is necessary to get a comprehensive knowledge of the true benefits/risks balance
      of PMTCT strategies.

      A recent review of the state of the art identified several knowledge gaps in the current
      understanding of Mother To Child Transmission (2). The role of HIV breast milk cell
      reservoirs in the HIV transmission through breastfeeding is still unclear. The effect of
      immune factors present in breast milk of HIV infected mothers on HIV population dynamics is
      also unknown as well as the permeability of infant's gut mucosa and the mechanisms involved
      on HIV transmission.

      The ANRS 12174 randomized controlled trial (ClinicalTrials.gov Identifier: NCT00640263)
      evaluated 3TC and LPV/r as infant Prep drugs for 50 weeks in HIV uninfected babies at day 7,
      with monthly follow-up. In addition, breast milk samples were collected four times during
      follow-up with infant plasma and cell pellets collected at weeks 6, 22 and 38, and infants
      Dried Blood Spots (DBS) every 3 months. The final results showed that both 3TC and LPV/r
      achieved very low rates of transmission with an excellent clinical tolerance and no
      difference between arms in terms of efficacy or safety. In total, 1103 infants completed the
      final visit.

      This study presents a unique opportunity to i) investigate the mechanisms of HIV-1 post-natal
      transmission, iii) to assess long-term safety of LPV/r and 3TC and ii) to estimate the final
      efficacy of infant peri-exposure prophylaxis (PreP), since some children were still exposed
      at the end of the study.

      The study will be conducted at the four ANRS 12174 PROMISE-PEP trial sites, namely East
      London (South Africa), Ouagadougou (Burkina Faso), Lusaka (Zambia) and Mbale (Uganda).

      Clinical and Biological safety component At enrolment, children will be assessed for
      hospitalisation events since the end of the ANRS 12174 PROMISE-PEP trial, mortality rate,
      growth, neurodevelopment, mitochondrial and genomic toxicity, and blood biochemical
      parameters such as full blood count, liver function and the level of adrenal hormones. All
      biological assays and explorations in this study will be carried out blindly, Mitochondrial
      DNA depletion study: DBS will be collected from all children at enrolment. Samples will be
      randomized and only 50 samples from Burkina Faso, Uganda and Zambia will be analysed (N=150)
      as it give us enough power to detect the statistical inferences within the population.

      Genome integrity study:The genome integrity assessment will include 50 children from each of
      the two PROMISE-PEP arms selected by randomization. (n=100 in total). The Zambian site is the
      only one with the necessary expertise and laboratory equipment for freezing cells. Therefore,
      the genome integrity study will only be conducted at this site. As a source of adherent
      cells, plucked hairs will be collected and frozen in 10% dimethylsulfoxide (DMSO) solution.

      Children will be assessed through a battery of tests; the Kaufman Assessment Battery for
      Children - Second edition (KABC-II), the Movement Assessment Battery for Children - Second
      Edition (M-ABC2), the Test of Variables of Attention (TOVA)-visual, the Strengths and
      Difficulties Questionnaire (SDQ25) designed to evaluate the main neuropsychological domains
      considered to be affected in HIV pediatric disease. Children will be evaluated when they are
      over 5 years of age.

      The 'mechanisms' component includes biological assays to be conducted on breast milk samples
      previously collected from HIV infected, transmitting or not transmitting mothers enrolled at
      ANRS 12174 PROMISE-PEP trial. Two studies will be conducted.

        -  The first study will investigate the specific microRNAs found in exosomes present in
           breast milk that are linked to regulation immune pathways. We propose to investigate the
           different miRNA profile in human breast milk in correlation to HIV status and HIV
           transmission. We also hypothesize that the involved pathways on may be linked with the
           local mucosal immunity of the mother breast but also with the gut mucosal immunity of
           the recipient child.

        -  The second study will focus on the effect of breast milk effect on the cytokine profile
           of infant's intestinal cells. We aim to determine 1/ the enterocyte cytokine profile
           exposed to breast milk compounds; 2/ the influence of milk on the transcytosis of
           T-lymphocytes, both HIV-infected and HIV negative.
    

Observational model: Case-Only
Time perspective: Cross-Sectional
Sampling method: Non-Probability Sample
Study population: 
        The study population will comprise all ANRS 12174 PROMISE-PEP trial participants who
        completed the 50 week follow-up and are not HIV infected. There are 1101 children
        fulfilling the inclusion criteria over the four African sites with an estimation of 80% of
        them being recruited on PROMISE M&S study (N=881).
      
Biospecimen description: 
      plasma
    
Keywords: HIV; Neuropsychological tests; PMTCT; PreP