Effect on growth of exposure to maternal antiretroviral therapy in breastmilk versus extended infant nevirapine prophylaxis among HIV-exposed perinatally uninfected infants in the PROMISE randomized trial

Background Malnutrition is highly prevalent in HIV-exposed perinatally uninfected infants (HEUs) increasing the risk of morbidity and mortality throughout the life course. We set out to compare the effect of postnatal exposure to maternal antiretroviral therapy (mART) in breastmilk versus infant Nevirapine prophylaxis (iNVP) on somatic growth of HEUs in the randomized PROMISE trial. Methods and findings We randomized 2431 mothers with HIV and their 2444 HEUs from six African countries and India 6-14 days after delivery to mART or iNVP for prevention of breastmilk HIV transmission. The mART regimen contained tenofovir/emtricitabine (99%) plus lopinavir/ ritonavir. Infant growth parameters were compared at postnatal week 10, 26, 74 and 104 using World Health Organization (WHO) z-scores for length-for-age (LAZ), weight-for-age (WAZ), and head circumference-for-age (HCAZ). Week 26 LAZ was the primary endpoint measure. Student T-tests compared mean LAZ, WAZ, and HCAZ; estimated mean and 95% confidence interval (CI) are presented. Maternal and infant baseline characteristics were comparable between study arms. The estimated median breastfeeding duration was 70 weeks. After a mean follow-up of 88 weeks, mean LAZ and WAZ were below the WHO reference population mean at all timepoints, whereas mean HCAZ was not. The mART and iNVP arms did not differ for the primary outcome measure of LAZ at week 26 (p-value = 0.39; estimated mean difference (95%CI) of -0.05 (-0.18, 0.07)) or any of the other secondary growth outcome measures or timepoints (all p-values≥0.16). Secondary analyses of the primary outcome measure adjusting for week 0 LAZ and other covariates did not change these results (all pvalues ≥0.09). However, infants assigned to mART were more likely to have stunting compared to iNVP infants at week 26 (odds ratio (95% CI): 1.28 (1.05, 1.57)). Conclusions In HEUs, growth effects from postnatal exposure to mART compared to iNVP were comparable for measures on length, weight and head circumference with no clinically relevant differences between the groups. Despite breastfeeding into the second year of life, length and weight were below reference population means at all ages in both arms. Further investment is needed to optimize postnatal growth of infants born to women with HIV. PROMISE was a randomized open-label trial to evaluate the relative efficacy and safety of several proven ARV strategies to prevent vertical HIV transmission and optimize maternal health and child survival among healthy women who did not meet local criteria to initiate ART in settings with varying standards of care [13–15]. Fig 1 presents the overall PROMISE trial schema in countries where maternal ART was not standard at the time, illustrating the three sequential PROMISE components; Antepartum, Postpartum and Maternal Health (S1 Fig). The Postpartum randomization for breastfeeding mother-infant pairs was conducted at 14 health facility-based research sites in seven countries: India, Malawi, South Africa, Tanzania, Uganda, Zambia and Zimbabwe. There was no apparent difference in premature study discontinuation for reasons other than death; 23 in the mART arm (2% of 1,227 randomized) and 15 in the iNVP arm (1% of 1217) (p = 0.81). The median (Q1-Q3) follow-up in both arms was to 104 weeks of age (74–105), with a mean of 88 weeks. Most infants still breastfed (93.7% (95%CI: 92.6%, 94.6%)) at 26 weeks of age. The estimated median (Q1-Q3) duration of breastfeeding and, hence, postnatal ARV exposure was 70 weeks (56–82) and not different in both study arms. As previously reported [16], 14 breastfed infants acquired HIV infection during postnatal follow-up (7/1219 mother-infant pairs in the maternal ART arm and 7/1211in the infant NVP arm). Women were recruited with their uninfected infants to the Postpartum Component between 2011 and 2015 after completing the Antepartum Component or when first identified as HIV-infected during active labor (“late presenters”). Maternal inclusion criteria included the intent to breast feed, a CD4 count >350 cells/mm3 at enrollment and above the country specific threshold for initiation of ART, hemoglobin ≥7.0 grams/dL, white blood cell count (WBC) ≥1500 cells/mm3, absolute neutrophil count (ANC) ≥750 cells/mm3, platelets ≥50,000 cells/mm3, alanine aminotransferase (ALT) ≤2.5x upper limit of normal, and estimated creatinine clearance of ≥60mL/min (Cockcroft-Gault equation for women). Inclusion criteria for infants included age ≤14 days, negative HIV nucleic acid test on a specimen drawn prior to the week 1 visit, hemoglobin ≥10 grams/dL, WBC ≥1,500 cells/mm3, ANC ≥750 cells/mm3, platelets ≥50,000 cells/mm3, and ALT ≤2.5x ULN. Mothers were excluded if they required ART for their own health. For multiple births, a mother-infant pair was enrolled only if all infants could be enrolled. Infants were excluded for life-threatening conditions or circumstances that would make long-term follow-up unlikely in the judgment of the site physician or when birthweight was <2000g. In utero ARV exposure for infants in the Postpartum Component differed by duration and regimen. At study entry in pregnancy, women with their unborn infant(s) were randomized to receive either prophylaxis with Zidovudine (plus single dose Nevirapine and a 1-week tail of Tenofovir/Emtricitabine) or triple ART (with Zidovudine/Lamivudine plus ritonavir boosted Lopinavir or Tenofovir/Emtricitabine plus ritonavir boosted Lopinavir) from the time of registration at variable gestational ages. Women presenting late for antenatal care in labor or post-delivery received no prior ARVs. Mother-infant pairs were randomized in the Postpartum Component in a 1:1 ratio at 6–14 days post-delivery to mART with Tenofovir/Emtricitabine plus (preferred) Lopinavir-ritonavir or to iNVP using age-based daily NVP dosing (Fig 1). A web-based, central computer randomization system on the IMPAACT Data Management Center’s portal was used. The system used permuted block allocation with stratification by country and the antepartum/intrapartum maternal ARV prophylaxis. A site staff member enrolled participants by answering eligibility and stratification questions in the randomization system, and if passed, the system randomized the participant and generated a coded study identification number which the site pharmacist compared to a master list and dispensed the corresponding study drug. In the Postpartum Component, the randomly assigned postpartum ARV regimen (mART or iNVP) was continued for the duration of breastfeeding plus 42 days (two weeks following breastfeeding cessation, defined as no breastmilk exposure for >28 days) or through age 18 months, whichever came first, unless stopped for infant HIV infection, toxicity or other medical reason. All study infants received standard-of-care iNVP during the first six weeks of life and cotrimoxazole prophylaxis thereafter, per local guidelines. On July 6, 2015 PROMISE sites were notified that all maternal participants should be offered life-long ART for their health based on the results of the Strategic Timing of AntiRetroviral Treatment (START) study [19] which demonstrated a significant benefit to beginning ART early, including in those with high CD4 counts. Analyses are thus based on data collected at visits through the date of notification. Length, weight and head circumference were measured by trained study personnel using standard methods at birth and weeks 1, 6, 10, 14, 26, 38, 50, 62, 74, 86, 98 and 104 of life. Measurements of length and weight were performed using standardized rigid length boards and calibrated weighing scales. Mothers received infant feeding counselling throughout the study and were supported to breastfeed exclusively for the first six months of life followed by the gradual introduction of appropriate foods and fluids. The timing of cessation of breastfeeding was determined by the mother. Breastfeeding status and infant illnesses were recorded at each visit. The full PROMISE 1077BF protocol can be accessed on the protocol website at https://www.impaactnetwork.org/studies/1077BF.asp. The study was funded by the National Institutes of Health (ClinicalTrials.gov number {“type”:”clinical-trial”,”attrs”:{“text”:”NCT01061151″,”term_id”:”NCT01061151″}}NCT01061151). Written informed consent was obtained from each maternal study participant for her and her child’s participation. Study conduct adhered to international guidelines and was reviewed every six months by an independent Data and Safety Monitoring Board. Ethics committees and institutional review boards that approved this study include—MUJHU/Kampala, Uganda: The Joint Clinical Research Centre (JCRC) IRB, the National Drug Authority and the Uganda National Council of Science and Technology (UNCST) in Uganda and the Johns Hopkins Medical Institutions (JHMI) IRB in the U.S.; Wits RHI Shandukani CRS and Soweto IMPAACT CRS, Johannesburg, South Africa: University of Witwatersrand Human Ethics Research Committee (Medical), Medicines Control Council (South African Health Products Regulatory Authority in February 2018); FAM-CRU CRS, Cape town, South Africa: Health Research Ethics Committee (HREC), Faculty of Health Sciences, Stellenbosch University and Medicines Control Council (South African Health Products Regulatory Authority in February 2018); Durban Paediatric HIV CRS, Durban, South Africa: University of KwaZulu-Natal (UKZN) Biomedical Research Ethics Committee, Medicines Control Council (South African Health Products Regulatory Authority in February 2018); George CRS, Lusaka, Zambia: University of North Carolina (UNC) at Chapel Hill Biomedical IRB and University of Zambia Biomedical Research Ethics Committee (UNZABREC); Harare, Seke North and St. Mary’s sites, Zimbabwe: Medical Research Council of Zimbabwe(MRCZ), Research Council of Zimbabwe (RCZ), Medicine Control Authority of Zimbabwe (MCAZ), Joint Parirenyatwa group of Hospitals/University of Zimbabwe College of Health Sciences Research Ethics Committee(JREC); Byramjee Jeejeebhoy Medical College (BJMC) CRS, Pune, India: BJ Government College CTU Ethics Committee and Johns Hopkins IRB; Blantyre, Malawi: College of Medicine Research and Ethics Committee (COMREC) in Malawi, Pharmacy, Medicines and Poisons Board and Johns Hopkins Medical Institutions (JHMI) IRB in the U.S.; Lilongwe, Malawi: National Health Sciences Research Committee (NHSRC) in Malawi Pharmacy, Medicines and Poisons Board, and University of North Carolina, Chapel Hill (UNC-CH) Office of Human Research Ethics IRB in the U.S and Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania: Kilimanjaro Christian Medical College Ethics Committee, National Health Research Ethics Committee and Tanzania Medicines and Medical Devices Authority. Age and sex-appropriate World Health Organization z-scores were computed for LAZ, WAZ and HCAZ based on the SAS macro for z-score calculations for children aged <61 months [20]. The primary objective comparison timepoint was Week 26 and primary outcome measure was LAZ at Week 26; LAZ at weeks 10, 74, and 104, as well as WAZ and HCAZ at weeks 10, 26, 74, and 104 were secondary outcome measures. Mean z-scores for each anthropometric measure were compared at these timepoints between the assigned study arms—mART versus iNVP. Primary analyses were carried out using an intent to treat approach (analyzed as randomized), as were secondary analyses on additional growth outcome measures. Selected subgroup and restricted/as-treated analyses were performed as secondary analyses. Except for accrual and baseline summaries the unit of analysis was the infant. Twins were analyzed separately. Mean age adjusted z-scores were compared with a Student’s t-test. Modification of the mART versus iNVP effect by subgroups (interaction tests) were assessed via linear regression. Comparisons of other data applied Wilcoxon/Kruskal-Wallis for continuous data, X2/exact tests for categorical data, as appropriate. Treatment effects for binary outcomes were summarized with odds ratios from logistic regression. P-values and tests were two-sided and nominal with a significance level set at 0.05. The z-scores were also compared for LAZ stunting, WAZ underweight and HCAZ using a binary categorization with the following standard deviation (SD) cut offs: z-score < -2 SD and ≥-2 SD [21]. The individual level data cannot be made publicly available due to the ethical restrictions in the study’s informed consent documents and in the International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) Network’s approved human subjects protection plan; public availability may compromise participant confidentiality. However, data are available to all interested researchers upon request to the IMPAACT Statistical and Data Management Centre’s data access committee by email to [email protected] or [email protected]. This committee reviews and responds to requests for data, obtains necessary approvals from IMPAACT leadership and the NIH, arranges for signature of a Data Use Agreement, and releases the requested data.