Suvaporn Anugulruengkitt , Piyarat Suntarattiwong , Pradthana Ounchanum ,

1. Safety and nevirapine concentrations of 6-week triple antiretroviral prophylaxis in high risk HIV-exposed infants Suvaporn Anugulruengkitt, PiyaratSuntarattiwong, PradthanaOunchanum, UssaneeSrirompotong, WatsamonJantarabenjakul, JiratchayaSophonphan, SuntiPunnahitanon, ChitsanuPancharoen, KulkanyaChokephaibulkit, Tim R. Cressey, ThanyaweePuthanakit Faculty of Medicine, Chulalongkorn University Funding by a CIPHER grant from the International AIDS Society

2. No conflicts of interest to declare

3. Background Antiretroviral prophylaxis regimens in neonates with high risk of infection No lead-in No lead-in • Research gap • Safety of neonatal combination prophylaxis • Nevirapine pharmacokinetic study (Approximate 12-15 mg in term infants) • 1 Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: WHO 2016. • 2 Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. DHHS 2016. • 3 BHIVA guideline 2018 Consultation version., 4 LolekhaR, et al. Asian Biomedicine 2017;11:127-144.

4. Objectives Primary objective To compare the rates of adverse events of 6-week ZDV/3TC/NVP and 4-week ZDV neonatal prophylaxis regimen Secondary objective To describe nevirapine concentrations during the first 4 weeks of life among HIV-exposed high risk infants

5. Study design and methods • Prospective, multicenter, observational study • Study sites: 5 participating sites in Thailand • Population: 200 perinatally HIV-exposed infants • Inclusion criteria • Neonates born to HIV positive pregnant women • Age <7 days at enrollment • Gestational age >34 weeks • Birth weight >1500 g • Caregiver gives informed consent • Exclusion criteria • Infants with life-threatening conditions • Breast-fed infants

6. Study procedures and assessment Baseline (<7 days) 4 months High risk group (n=100) Maternal VL >50 c/mL or Maternal no ANC or ART <12 weeks 1 month 2 months ZDV/3TC/NVP ZDV Low risk group (n=100) Maternal VL ≤50 c/mL, Maternal adequate ART (good compliance and ART ≥12 weeks) CBC, AST, ALT HIV DNA PCR Assessment Effects from neonatal ARV Recovery • Laboratory abnormalitieswere graded using DAIDS NVP concentrations (n=50) NVP population PK parameters were performed by nonlinear mixed-effects regression models

7. Results: Demographic data

8. Results: Demographic data p value calculated by Chi-Square test and t-test

9. Results: Laboratory adverse events at age 1 and 2 months During follow-up period, 188 infants (94%), 93 infants of ZDV/3TC/NVP group and 95 of ZDV group, had follow-up until complete study +According to DAIDS Grading toxicity table 2014 *p-value calculated by Chi-Square test

10. Results: Frequency and severity of anemia at age 1 and 2 months P=0.01 By 4 months of age, all infants with anemia grade 3 had either normalized or improved to grade 1

11. Results: Hematological parameters A: Median of hemoglobin (g/dL) by age B: Median of neutrophil counts (x 109/L) by age X represents cut-off of anemia and neutropenia by age Whisker ends represents interquartile range

12. Secondary outcomes: NVP concentrations • To describe nevirapine concentrations during the first 4 weeks of life among HIV-exposed high risk neonates Data of 50 high-risk infants(NVP subgroup) • 2 infants were excluded due to their mother receiving a NVP-contained antiretroviraltherapy • 48 infants, 135 samples • Prematurity 25% (n=12) • Median (range) GA: 38 (34-40) weeks • Median (range) BW: 2,803 (1,570-3,888) g • BW ≥2500 g • Mean (SD) NVP 13 (2.1) mg • BW <2500 g • Mean (SD) NVP 9 (2.0) mg

13. Secondary outcomes: NVP concentrations Box and whisker plot of predicted NVP trough concentrations (C24) (mg/L) over the first month by age All infants maintained NVP concentrations above the prophylactic target threshold of 0.1 mg/L during the first 4 weeks Prophylactic target level 0.1 mg/L No correlations of NVP concentrations and adverse events (hepatitis/rash)

14. Discussion: Rates of anemia from neonatal combination prophylaxis This study United States1997-2009 (N=148) • Smith C, et al. PLoS One 2015;10(5):1-10. P=0.46 69% 66% P=0.04 63% 39% Higher grade 2 anemia

15. Discussion: Anemia and neutropenia from neonatal combination prophylaxis Hemoglobin levels This study Canada 1997-2013 (N=293) • KakkarFW, et al. J Int AIDS Soc2016; 19(1):20520. The lower hemoglobin levels were observed in combination regimen received infants at age 1 month but was no longer observed at age 2 and 4-6 months Neutrophil levels Low neutrophil counts were resolved by 4-6 months of age

16. Strength and limitations Strength Limitations The lower dose of ZDV and NVP may bias towards lower risk of side effects compared with WHO dosing regimens In NVP concentrations study, we did not include preterm GA <34 weeks who may require lead-in dosing due to potential for supratherapeutic levels • A large study with complete follow-up 94% retention on safety of combination prophylaxis regimen of 6-week ZDV/3TC/NVP in high risk HIV-exposed infants includes infants received ZDV alone prophylaxis as a comparison group • Pharmacokinetic data of NVP in high risk HIV-exposed neonates

17. Conclusions • Six-weeks of ZDV/3TC/NVP in HIV-exposed infants did not significant increase the risk of toxicity compared with an ZDV regimen. • Administration of 4 mg/kg of NVP from birth without lead-in provided adequate NVP concentrations for prophylaxis during the first 4 weeks of life without significant toxicity.

18. Acknowledgement Siriraj hospital Prof. KulkanyaChokephaibulkit KananongSuankanokan Pediatric Infectious Diseases, KCMH and Center of Excellence in Pediatric Infectious Diseases and Vaccine Assoc.Prof. ChitsanuPanchareon Assoc.Prof. ThanyaweePuthanakit WatsamonJantarabenjakul SineenartChautrakarn JesdapornSrisamer RachaneekornNadsasarn OrawanAnunsittichai JiratchayaSophonphan QSNICH PiyaratSuntarattiwong PugpenSirikutt YossawadeeNa Nakorn NaruemonPimsiri KhonKaen Hospital UssaneeSrirompotong PatamawadeeSudsaard SiripunNuanbuddee Pediatrics Department, KCMH Asst.Prof. SuntiPunnahitanon Faculty of Associated Medical Sciences Bioanalytical Testing, Chiang Mai University Chiang RaiPrachanukroh Hospital PradthanaOunchanum AreeratKongponoi Timothy R. Cressey YardpiroonTawon Research lab, TRC, AIDS research center SasiwimolUbolyam PatcharinEamyoung ThatriIampornsin Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) Grants, International AIDS Society Marissa Vicari Tamara Torri Samantha Hodgetts All study participants

20. Results: Demographic data Among 100 high risk neonates: - Maternal VL ≥50 copies/mL 48 - No VL testing 20 - ART <12 weeks before delivery 14 - No ANC 10 - Poor compliance 5 - Incident case 2 - Infant’s birth injury 1 • Among 48 mothers whose VL ≥50 c/mL • Median (IQR) VL 796 c/mL (192-16,398) • VL ≥50-999 c/mL n=27 • VL ≥1000 c/mL n=21 Among 100 low risk neonates: - Maternal VL <50 copies/mL 96 - No VL test but ART ≥ 12 weeks 3 - Physician preference 1 pvalue calculated by Chi-Square test

21. Serious adverse events; possible related to ARV 1 case of rash suspected from NVP hypersensitivity - Onset of rash at day of life 4 - Admit due to culture-negative neonatal sepsis - Lab: AST 20 U/L, ALT 16 U/L, eosinophil 70/μL NVP level(6 hours post-dose): 6.41 mg/L - NVP was discontinued, rash was resolved 2 days later - The result came back of NVP C24 at day 1 and 2 were 1.13 and 1.91 mg/L, respectively

22. Clinical adverse events; not related to ARV prophylaxis Serious adverse events • Acute gastroenteritis (3) • Acute febrile illness with moderate dehydration • Acute meningoencephalitis with status epilepticus • Ballooning posterior urethral valve • Cholestatic jaundice • Congenital tuberculosis • Left pinna infection • TB meningitis • Urinary tract infection Adverse events • URI (7) • Acute diarrhea (2) • Latent TB infection (2) • Atopic dermatitis • ASD secundum • BCGitis • Cephalhematoma • Fever from whole cell pertussis vaccine • Hydronephrosis • Oral candidiasis • Overfeeding 18 events in ZDV/3TC/NVP prophylaxis and 14 events in ZDV prophylaxis (p = 0.44)

23. Secondary outcome: HIV transmission rate in high-risk infants Exclude 34 infants with no definite data of high risk • Maternal VL not tested (n=20) • Maternal ART duration <12 weeks (n=14) 100 High-risk neonates 6 Loss to follow-up 60 High-risk neonates negative HIV DNA PCR 2 times but at age <4 months negative HIV DNA PCR at birth In-utero HIV infection 59 Uninfected Rate of HIV transmission 1.7% (95% CI: 0.3%-8.9%)

24. Case summary of infants with elevated transaminase

25. Secondary outcomes: NVP concentrations • There were no statistical differences of predicted NVP C24 among term and preterm infants (p=0.963) • Maternal EFV-based ART was tested for inclusion in the model but was found not to influence infant NVP pharmacokinetic parameters *Using independent t-test

26. Discussion: NVP concentrations level NVP 4 mg/kg, OD (Mean 13 mg, SD 2.2) WHO: NVP 15 mg, OD Prophylactic target level 0.1 mg/L Without significant toxicity, no correlation with adverse events Cressey TR et al. J Acquir Immune DeficSyndr2017;75(5):554-560.