Tuberculosis Preventive Therapy Among Latent Tuberculosis Infection in HIV-infected Individuals

Study Overview
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Brief Summary
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The investigators want to know if ultra-short, effective treatment for latent tuberculosis (TB) infection (LTBI) could dramatically reduce the global incidence of active TB or not. The investigators hypothesize that short-course (4-week) daily isoniazid/rifapentine (INH/RPT) (1HP) is not inferior to standard -course (12 weeks) INH/RPT weekly regimen (3HP) for the prevention of TB in human immunodeficiency virus (HIV)-infected individuals.

Detailed Description
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This study is a multicenter, randomized, open-label, phase III clinical trial comparing a 4-week daily INH/RPT regimen (1HP) to a 12-weekly INH/RPT (3HP) for the treatment of LTBI in HIV-infected participants without evidence of active TB. The primary objective will be efficacy of active TB prevention. The study will also assess safety and tolerability of the regimens, adherence to the treatments, and patterns of antibiotic resistance among Mycobacterium tuberculosis (MTB) isolates in participants who fail on these prophylactic regimens. Under this study, there is one substudy entitled, Pharmacokinetic study of rifapentine, dolutegravir, and tenofovir alafenamide in HIV-infected individual with latent tubersulosis infection. There will be a subgroup of patients who will participate in this pharmacokinetic study of rifapentine and dolutegravir (DTG) / tenofovir alafenamide (TAF). Randomization is based on cluster of differentiation 4 (CD4) categories : < 200, 200-350, > 500 cells/mm3 and VL <50 or >50 copies/ml.

Official Title
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Implementation for Tuberculosis Preventive Therapy Among Latent Tuberculosis Infection in HIV-infected Individuals Using Novel Regimen of Isoniazid/Rifapentine Daily (4 Weeks) Compared to Isoniazid/Rifapentine Weekly (12 Weeks)

Conditions
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HIV-infected Participants With Latent TB Infection in High TB Burden Country

Intervention / Treatment
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* Drug: Isoniazid/Rifapentine daily (4 weeks) plus pyridoxine (vitamin B6)
* Drug: Isoniazid/Rifapentine 12-weekly plus pyridoxine (vitamin B6)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Documented HIV-1 infection by standard HIV test or plasma HIV-1 RNA viral load and received ART within 12 months. Participants received ART more than 12 months would be allowed if CD4 cell counts is less than 350 cells/mm3 18 years and older Evidence of latent TB infection, either by TST ≥5 mm or positive interferon gamma release assay (IGRA) or history of close contact with active pulmonary TB* within 3 months prior entry visit or residing in a high TB burden area** NOTE * close contact is referred to person living/sharing in the same room with active pulmonary TB participants for > 4 hours/day ** high TB burden areas are defined as areas with an estimated or reported TB prevalence of 100 to 300/100,000, according to the WHO. Thailand is included in high TB burden areas. Laboratory values obtained within 30 days prior to entry Absolute neutrophil count (ANC) >750 cells/mm3 Hemoglobin >7.4 g/dL Platelet count >50,000/mm3 Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT]) and alanine aminotransferase (ALT) (serum glutamic pyruvic transaminase [SGPT]) <3x upper limit of normal (ULN) Total bilirubin <2.5 X ULN Chest radiograph or chest computed tomography (CT) scan without evidence of active tuberculosis, unless one has been performed within 90 days prior to entry. Female participants who are participating in sexual activity that could lead to pregnancy must agree to use one reliable non-hormonal form of contraceptive (i.e., condoms, IUD, diaphragm) during RPT treatment and contraception should be remain to 6 weeks post RPT NOTE Female participants who are not of reproductive potential or whose male partner(s) have undergone successful vasectomy with documented azoospermia or have documented azoospermia are eligible without requiring the use of contraceptives. Participant-reported history is acceptable documentation of menopause, hysterectomy, or bilateral oophorectomy or bilateral tubal ligation. All participants must agree not to participate in a conception process (e.g., active attempt to become pregnant or to impregnate, donate sperm, in vitro fertilization) while receiving RPT and for 6 weeks after stopping this drug. Body weight > 40 kg Ability and willingness of participant to provide informed consent Exclusion Criteria: Treatment for active or latent TB (pulmonary or extrapulmonary) within 2 years prior to study entry or presence of any confirmed or probable active TB at screening. History of Isoniazid (INH) or Rifampicin (RIF)/Rifabutin (RFB) resistant TB at any time prior to study entry or known exposure to INH or RIF/RFB resistant TB (e.g., household member of a person with MDR or XDR TB) at any time prior to study entry. Treatment for >14 consecutive days with a rifamycin or >30 consecutive days with INH at any time during the 2 years prior to enrollment. Current or planned use of protease inhibitor-based ART. Currently on a salvage ART regimen, defined as a regimen started due to confirmed HIV virologic failure on a prior ART regimen or due to known HIV drug resistance. History of liver cirrhosis at any time prior to study entry. Evidence of acute hepatitis, such as abdominal pain, jaundice, dark urine, and/or light stools within 90 days prior to entry. Diagnosis of porphyria at any time prior to study entry. Peripheral neuropathy ≥Grade 2 according to the Division of AIDS (DAIDS) Toxicity Table, within 90 days prior to study entry. Known allergy/sensitivity or any hypersensitivity to components of study drug(s) or their formulation. Active drug or alcohol use or dependence that, in the opinion of the site investigator, would interfere with adherence to study requirements. Acute or serious illness requiring systemic treatment and/or hospitalization within 30 days prior to entry. Pregnancy or breastfeeding

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: This study is a multicenter, randomized, open-label, phase III clinical trial comparing a 4-week daily INH/RPT regimen (1HP) to a 12-weekly INH/RPT (3HP) for the treatment of LTBI in HIV-infected participants without evidence of active TB.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: 1HP<br>4-week daily regimen of weight-based RPT and INH, plus pyridoxine (vitamin B6) | Drug: Isoniazid/Rifapentine daily (4 weeks) plus pyridoxine (vitamin B6)<br>* Isoniazid/Rifapentine daily (4 weeks) plus pyridoxine (vitamin B6)<br>|
| Active Comparator: 3HP<br>12-weekly INH/RPT regimen, plus pyridoxine (vitamin B6) | Drug: Isoniazid/Rifapentine 12-weekly plus pyridoxine (vitamin B6)<br>* Isoniazid/Rifapentine 12-weekly plus pyridoxine (vitamin B6)<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| efficacy in preventing active TB (proportion of participants that do not have active TB by the end of the study) | proportion of participants that do not have active TB by the end of the study | 3 years | 
| safety of the regimens (proportion of participants that do not have any side effects throughout the study period) | proportion of participants that do not have any side effects throughout the study period | 3 years | 
| tolerability to the regimens (proportion of participants that can complete the treatment course) | proportion of participants that can complete the treatment course | 3 years | 
| prevalence of drug resistance of MTB | proportion of participants with drug resistance to MTB | 3 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| severity of the condition | proportion of participants that have side effects of grade more than or equal to 3 signs | 3 years | 
| presence of symptoms | proportion of participants that have symptoms during the study period | 3 years | 
| level of CBC | assess the level of CBC | 3 years | 
| level of ALT | assess the level of ALT | 3 years | 
| level of AST | assess the level of AST | 3 years | 
| level of total bilirubin | assess the level of total bilirubin | 3 years | 
| level of ALK | assess the level of ALK | 3 years | 
| level of creatinine | assess the level of creatinine | 3 years | 
| death | time from randomization to death from any cause (TB and non TB events) | 3 years | 
| when TB culture becomes positive | how much time does it take to have positive TB culture | 3 years | 
| when TB is confirmed by clinical examination | how much time does it take to have TB diagnosed via clinical examination | 3 years | 
| adherence to LTBI treatment | proportion of pills missed during treatment period based on self report | 3 years | 
| consistency of taking LTBI treatment | proportion of pills missed during treatment period based on clinical assessment | 3 years | 
| treatment discontinuation | proportion of participants with permanent LTBI treatment discontinuation due to all causes | 3 years | 
| discontinuation of study due to adverse drug reactions | Proportion of participants that have discontinued the study because of adverse drug reactions | 3 years | 
| CD4 count | CD4 count at baseline | 3 years | 
| CD4 count to confirmed or probable TB | CD4 count at time from randomization to culture-confirmed or probable TB | 3 years | 
| time it takes for TB to be confirmed by IGRA | how much time does it take to confirm TB diagnosis via IGRA | 3 years | 
| TST result at baseline | TST result at day 0 | day 0 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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people living with HIV (PLHIV)