Risk Factors for Non-Adherence and Loss to Follow-Up in a Three-Year Clinical Trial in Botswana

Background Participant non-adherence and loss to follow-up can compromise the validity of clinical trial results. An assessment of these issues was made in a 3-year tuberculosis prevention trial among HIV-infected adults in Botswana. Methods and Findings Between 11/2004–07/2006, 1995 participants were enrolled at eight public health clinics. They returned monthly to receive bottles of medication and were expected to take daily tablets of isoniazid or placebo for three years. Non-adherence was defined as refusing tablet ingestion but agreeing to quarterly physical examinations. Loss to follow-up was defined as not having returned for appointments in ≥60 days. Between 10/2008–04/2009, survey interviews were conducted with 83 participants identified as lost to follow-up and 127 identified as non-adherent. As a comparison, 252 randomly selected adherent participants were also surveyed. Multivariate logistic regression analysis was used to identify associations with selected risk factors. Men had higher odds of being non-adherent (adjusted odds ratio (AOR), 2.24; 95% confidence interval [95%CI] 1.24–4.04) and lost to follow-up (AOR 3.08; 95%CI 1.50–6.33). Non-adherent participants had higher odds of reporting difficulties taking the regimen or not knowing if they had difficulties (AOR 3.40; 95%CI 1.75–6.60) and lower odds associated with each year of age (AOR 0.95; 95%CI 0.91–0.98), but other variables such as employment, distance from clinic, alcohol use, and understanding study requirements were not significantly different than controls. Among participants who were non-adherent or lost to follow-up, 40/210 (19.0%) reported that they stopped the medication because of work commitments and 33/210 (15.7%) said they thought they had completed the study. Conclusions Men had higher odds of non-adherence and loss to follow-up than women. Potential interventions that might improve adherence in trial participants may include:targeting health education for men, reducing barriers, clarifying study expectations, educating employers about HIV/AIDS to help reduce stigma in the workplace, and encouraging employers to support employee health. Trial Registration ClinicalTrials.gov NCT00164281


Study Medications
Isoniazid (dosed per weight according to TB Program Guidelines) daily for 6  HIV. [1] The annual risk of developing active TB in HIV-positive individuals coinfected with M. tuberculosis is estimated to be 5-10% compared to a lifetime risk of 10% in HIVnegative individuals. [2][3][4][5] Results from clinical trials in Uganda, Zambia, and Kenya, and a meta-analysis of four clinical trials in Haiti, Kenya, USA, and Uganda have been published demonstrating that isoniazid (INH) prevents TB in HIV-infected persons in settings of high TB prevalence. [6][7][8][9] The meta-analysis estimated an overall efficacy (1 -Risk Ratio) of 50% for all HIV-infected patients regardless of TST status, and 70% in those with a positive TST. The risk ratios for active TB in the INH treatment and placebo groups by tuberculin skin test (TST) status are summarized in Table 1

Duration of IPT
A recent trial in Zambia demonstrated that the protective effect of limited IPT may not be prolonged. [12] TB case rates became indistinguishable between IPT-treated and placebo-treated patients 36 months after therapy. This has led to speculation that the 6-month regimen may be insufficient for conferring long-term protection against TB, either because M. tuberculosis reinfection occurs in settings with high TB prevalence or because six months of INH is inadequate for the complete sterilization that may be necessary to prevent the transition from infection to disease in advanced stages of immunodeficiency.

Rationale for IPT in Botswana
In 1999, approximately 29% of the population 15-49 years of age in Botswana was estimated to be living with HIV infection. [13] The TB case rate has more than doubled in Botswana during the 1990s (from 202/100,000 in 1989 to 521/100,000 in 1999) and is now among the highest rates in the world. [14] The strong association between HIV prevalence and the TB rate in Botswana is clear. Approximately 85% of hospitalized TB patients in Gaborone and Francistown during 1997-98, [15] and 73% of TB patients diagnosed in an outpatient setting in Gaborone during 1997-99 were also HIV-positive [16]. Preliminary results from an autopsy study conducted at Nyangabgwe Hospital in Francistown, Botswana, during 1997-1998 suggest that TB may account for 36% of deaths in adults dying of AIDS. [17] Although no systematic studies have been performed, evidence suggests that the vast majority of adults in Botswana are asymptomatically infected with M. tuberculosis.
Since TST may not be an accurate indicator of TB infection among HIV-positive patients, studies of HIV-negative adults in a population provide some indication of the

Study Endpoints.
The primary endpoint will be active TB (pulmonary or extrapulmonary) occurring after the participant initiates coded medication and before the end of the 36 months of study medication. Secondary endpoints will be 1) the combined endpoint of definite and probable TB (possible TB being excluded), 2) the combined endpoint of active TB and deaths in which TB was not excluded as a cause, 3) the combined endpoint of active TB and deaths, 4) adverse events, and 5) death. Outcome variables will be CD4 cell count and PPD positivity. These variables may assist the development of future IPT algorithms, and in clinical management of subjects. Clinical progression of HIV disease will also be reported.
When participants reach an endpoint other than death (and including completion of study medication), they will continue to be followed off study medication on a quarterly basis for the duration of the Study. Persons completing 36 months of study medication will continue to be followed for an average of 2.5 years as in the Zambia follow-up study [12]. This will provide important insights into the long-term effects of active tuberculosis in PLWH which are thought to 10 of 43 TB Preventive Therapy Protocol Samandari et al. March 2008 be grave even in the face of completion of anti-tuberculosis therapy as well as any possible TB outcomes among those who complete 36 months of the study medication. Cases of TB occurring after the 36-month period of study medication will not be included in the primary analysis. Given that in PLWH smear-negative and culture negative TB are common, a blinded independent assessment of patients' data may be necessary when insufficient or inconclusive endpoint data are available with the use of an endpoint committee.

Study Population and Eligibility
Participants must be HIV-positive, at least 18 years of age (the age cutoff in Botswana for being able to request a HIV test without parental permission), and consent to participation in the study. In addition, participants must have a Karnofsky performance score of ≥60 (indicating that they are in not in bed >50% of the day, do not require assistance for activities of daily living, and do not require frequent medical care [24]).
Participants may be either TST-positive or -negative, and may be taking antiretroviral treatment.
Exclusion criteria will include active pulmonary or extrapulmonary TB (by positive AFB smear or culture), a history of TB in the last three years, a history of IPT, exposure to a person with known INH-resistant TB, active hepatitis or other liver disease (AST or ALT greater than or equal to 2.5 times ULN and/or total bilirubin greater than or equal to 1.5 times the upper limit of normal), current therapy with warfarin, carbamazepine or phenytoin, or a self-reported history of non-adherence with other chronic therapies. All enrollees will receive a baseline chest radiograph. A study physician may permit an individual to be included in the study with an abnormal chest radiograph in such situations where the abnormality is not consistent with active TB or reflects residual scarring from a history of documented treated TB over 3 years ago or documented treated pneumonia. If a woman is found to be pregnant at the time of enrollment, she will be referred to the MTCT program and encouraged to return 6 weeks postpartum for reconsideration for enrollment. This is consistent with the national IPT program guidelines, in that pregnant women are not given IPT. If pregnancy occurs during trial follow-up, the woman will again be referred to MTCT, but will be continued in the trial.
After enrollment, criteria for withdrawal from the study will be the subject's voluntary withdrawal, death, or determination of ineligibility after enrollment. Subjects that develop medical complications of AIDS, are suspected to have had INH toxicity, or develop nontuberculous disease will continue to be followed for the 36-month duration of the study. During the course of the study, death certificate records and electronic TB register data will be periodically examined for those that made permanent moves from Gaborone or Francistown and those who did not return for any follow-ups. Participants who are determined to be ineligible for the study may remain eligible for the government IPT program, and will be reevaluated for such.

Study Design and Flow
Appendix 1 shows the algorithm for enrollment into the government IPT program. The staff at ten selected centers in Gaborone and Francistown will be instructed to screen PLWH, first using the published national guidelines (Appendix 1 2. An enrollment questionnaire (Appendix 3) will be administered 3. TST, chest radiograph, CD4 count, complete blood count, pregnancy test, and blood chemistry will be performed Study visit 2 (day 2 or 3 after enrollment) 1. The chest radiograph, laboratory results, and TST will be read and results will be recorded on Appendix 4 2. If still considered eligible, subjects will then be randomized to receive six months of INH followed by placebo or to receive continuous INH (as described in 3.6). All subjects will receive pyridoxine to reduce the risk of peripheral neuropathy.
3. The study nurse, who is blinded to the result of randomization, will provide a one month supply of the study medications (a bottle containing 128 tablets of 100 mg isoniazid), and schedule the subject to return in two weeks. Subjects will be advised to return to the clinic if they develop any illnesses or symptoms while on medications, including but not limited to cough, fever, night sweats, nausea, or vomiting, pruritis, or rash.
Study visit 3 (after two weeks of the study medications) 1. The subject will be evaluated for adverse medication effects such as rash or jaundice, and have blood drawn for repeat liver function tests. Results will be recorded on Appendix 5.
2. An additional two-week supply of study medications will be provided

Study visit 4 (after four weeks of the study medications)
If there were no significant abnormalities on the blood drawn during study visit 3, The subject returns to the clinic monthly to be evaluated for active TB, side effects, adherence, and for a refill of study medications. Results of any evaluations will be recorded using Appendix 6.
Study visit 9 (after six months of the study medications) 1. Subjects who had been randomized to six months of INH will be switched to placebo in a blinded fashion, while subjects who had been randomized to continuous INH will continue receive INH.
2. Both groups will continue to receive pyridoxine, return to the clinic monthly to pick up medication refills, and attend study clinic visits every three months to be screened for side effects of INH, AIDS progression, TB symptoms and TB exposure. During other months a new bottle of study medications will be provided, and participants will have a more detailed interview only if they report complaints. Furthermore, every six months a participant acceptability form will be completed to ensure that the participant is able to follow the medication regimen, and continues to comprehend the goals of the trial. Participants still in the study but off study medications (e.g., those who suffered a prolonged illness or adverse symptoms requiring discontinuation of study drugs for more than 4 weeks) will be followed every three months.

Follow-up
Study visit 5 (after two months of the study medications) is the first of the routine followup study clinic visits. All subjects will be followed monthly while taking study medication and quarterly if no longer taking study medication for 36 months. If a study participant has not reached a study endpoint by the 36 th month, she/he will be invited to return for quarterly visits 14  when contact with all participants will cease and new data collection ends). During these followup visits, the subject will be evaluated for active TB, clinical progression of HIV disease, other adverse events including drug toxicity, and adherence. Results will be recorded using Appendix 6. Unless contraindications are identified, subjects will be given a one-month supply of medications from the study clinic at each follow-up visit. Subjects will also receive safe sex counseling at each visit. Due to the recent Botswana government policy of free antiretrovirals, should a subject meet criteria for anti-retroviral therapy, he/she will be referred to the Ministry of Health's ARV clinic services.

Active tuberculosis.
Screening for the development of active TB will be done with a symptom screen (Appendix 6). If the symptom screen is positive, the subject will be told to halt INH until active TB is excluded. The subject will then undergo chest radiography, and AFB smear and culture using a liquid culture system. Active TB includes definite, probable and possible TB. "Definite TB" is when one or more cultures are positive for TB or there are two positive sputum smears and clinical evidence consistent with TB. "Probable TB" is when one or more smears are positive or there is histology suggestive of TB (e.g., granulomata) with clinical evidence consistent with TB. "Possible TB" is when there is absent or negative smear or histology and absent or negative culture for TB and clinical evidence consistent with TB including a clinical response to anti-TB therapy. A "false positive" is when there is one culture positive for TB with clinical evidence inconsistent with TB. "Unlikely TB" is when there is a case not falling under any of the above four categories (i.e., not definite, probable, possible or false positive).. . The protocol for recognizing adverse events will be facilitated by a checklist incorporated in the data forms present in the subject's chart. Physicians will also use their discretion to order additional tests, as necessary.

Clinical progression of HIV disease
For Grade 1 toxicity: if laboratory abnormalities are present, tests will be repeated one week after the abnormal values were noted. Medication may be continued.
For Grade 2 toxicity: If laboratory abnormalities are present, tests will be repeated every 2-3 days. Medication may be continued. If subjects develop persistent (i.e., more than two months') hepatic enzyme elevations, they will continue on medication and be monitored by symptoms and quarterly liver function tests.
For any Grade 3 toxicity, or Grade 4 toxicity for hemoglobin: Medication will be discontinued. The subject will be monitored and receive organ-specific supportive care as his/her condition warrants.
All serious, unexpected, and at least possibly related to study interventions adverse events will be promptly reported to the Botswana and CDC ethics committees. At the time of annual continuing review of the protocol, a summary listing of all adverse events (including anticipated) will be reported to both committees. All adverse events will be reported to the Data and Safety Monitoring Board.
Given the high estimated prevalence of chronic hepatitis B infection in sub-Saharan Africa, the greater risk of death from liver disease among persons co-infected with hepatitis viruses 34  HIV and the implication of continuous IPT, all persons who develop grade 2 or higher liver function abnormalities will be tested for evidence of active hepatitis B and hepatitis C infections.
To determine whether there is a greater risk for hepatitis among these persons as compared to those who do not develop grade 2 or higher liver function tests, two participants without evidence of hepatic enzyme elevations but with a similar medication profile will be selected as controls for each case.

Adherence.
A subject will be encouraged at enrollment and at each follow-up to take all medications as prescribed. In order to encourage adherence, subjects will be asked to bring any remaining medication to every follow-up visit. Pill counts will be done, results recorded (Appendix 6), and reasons for discrepancies will be explored. Results of pill counts will be recorded, but the subject will not be removed from the study even if nonadherence is suspected.
"Enablers" will be provided to the study participants in order to maintain their willingness to continue to participate. The enablers will include cash (30 Pulas = US$5) for each visit as compensation for transport to and from the clinics. Other enablers such as caps, T-shirts and participant mini-workshops for coping with HIV/AIDS will be provided at significant milestones in the study. Additional reimbursements to participants will be provided for unscheduled, required study-related visits for such instances as when a blood sample was lost or clotted.
In order to estimate overall adherence, annually a random selection of 20% of study participants will be consented to provide urine samples to assay for INH metabolites. The samples will be sent to a laboratory unaffiliated with the study. The laboratory will report the aggregate number will remain blinded as to whether a certain study participant is taking the placebo or the active investigational agent.
A case control analysis will be conducted anonymously to identify factors associated with nonadherence among study participants. More specifically, the objectives will be to determine differences in knowledge, attitudes and beliefs between the cases and controls and reasons for stopping study medication. Cases will be participants who stopped taking the study medication yet agreed to continue keeping quarterly appointments as well as persons who were lost to follow up. Controls will be those who continued to take the study medication. The study will be conducted in two stages: 1) formative research (focus groups, key informant interviews, and cognitive interviews) and 2) a survey study. This assessment will be conducted by a contracted third party in order to enhance openness by study participants. This degree of openness may not occur if study participants were interviewed by study nurses whom they know. Cases will include any participant meeting the above-stated criteria and 2 controls will be interviewed for each case interviewed. A reimbursement of P60 (~$10) will be provided to those participating in these interviews as they may take up to 2 hours.

Loss to follow-up.
If a subject is late for a follow-up visit, study nurses will attempt to locate the subject by calling or visiting the subject's home, and will record the reason for loss to For those subjects who are not located, the Electronic TB Register and death certificate review will be conducted at periodically during the course of the study. For those subjects who are hospitalized, chart review will be conducted. For those subjects who died, a verbal autopsy will be conducted by the study physician (Appendix 8).

Death.
A significant effort will be made to determine the cause of death for all enrolled subjects. In order to improve retention in the study as well as the promptness of death notifications and determining the cause of death, P1,000 (=$167) will be given as an enabler to family members in the form of a contribution towards the cost of a participant's funeral. Three sources of information will be utilized to determine the likelihood that a subject expired from TB: the opinion of the clinician responsible for the subject's care, a verbal autopsy questionnaire will be administered to a household relative of the deceased, detailing symptoms pertinent to the likely cause of death (Appendix 8), and a necropsy will be sought. Death of a subject will be classified according to the following The IPT Study will stock INH in 100 mg scored tablets. Nearly all subjects in the study will weigh at least 60 kg and will take three tablets daily. Should a subject weigh less than 30 kg, the dosage will be based upon a rule of 5 mg/kg. Subjects will also be provided pyridoxine, 25 mg daily. Subjects randomized to receive placebo will receive the same number of pyridoxine tablets plus tablets identical in appearance and number to INH. Sputum specimens for mycobacteria will undergo digestion, decontamination, and centrifugation, and the sediment will be used for AFB or fluorescent smear and culture inoculation. Cultures will be incubated for up to six weeks to observe for growth. Specimens from any subject who develops active TB will undergo INH susceptibility testing using the

Chest radiography:
Chest radiographs are required at enrollment and anytime the subject offers symptoms consistent with TB. These will be done on-site at the study clinic, and will be interpreted by a radiologist who will only know that the film was ordered for "rule-out TB" (not as part of a research study).

Tuberculin skin testing:
A positive TST is defined as ≥5 mm induration to 2 TU of PPD using the Mantoux method [28]. The optimal time for reading the TST is 48-72 hours after PPD administration; however, if a subject's reaction is read beyond 72 hours and is >5 mm, this will be considered positive. BCG vaccination is given as a single dose to more than 90% of children at birth in Botswana, [14] but reports suggest its affect on TST reactivity is variable and wanes over time. [29] Therefore, we will use standard TST interpretation criteria in the determination of a positive TST. [

Blood tests.
Hemoglobin, hematocrit, platelet, and white blood cell count with differential will be done with the Coulter counter (Coulter Diagnostics). Liver function tests will be done according to the clinic routine.

Drug Susceptibility Testing (DST).
All culture positive TB isolates will be tested for sensitivity to isoniazid, rifampicin, ethambutol, streptomycin. Isoniazid susceptibility testing is routinely performed at both low (0.2 µ/L) and a high (1.0 µ/L) levels of drug concentration.

Spoligotyping, Mycobacterial Interspersed Repetitive Unit Typing (MIRU) and/or Restriction
Fragment Length Polymorphism (RFLP) using IS6110 fingerprint testing will be conducted on any M. tuberculosis isolates according to standard methods at the CDC's Atlanta facility. [30] The purpose of this is to identify clusters within the IPT facilities which suggest recent transmission, as well as to estimate the relative burden of recent transmission compared with reactivation of latent M. tuberculosis infection. This information will assist TB Control Programme efforts. The presence of mutations of katG and inhA will be investigated on these specimens as mutations in these genes have been associated with isoniazid resistant MTB.

Randomization
Randomization schedules will be prepared to assure an allocation ratio of 1:1 (limited or continuous INH). Randomization of drug and placebo assignment will be achieved by using the permuted-block randomization method in which one of ten 5-digit codes (to which study clinicians will be blinded) will be pre-assigned to all potential patient identification numbers by clinic site prior to the launch of the study. Each of the proposed 10 study clinic sites will have a

Interim Analysis
Safety and efficacy data will be reviewed by an independent Data and Safety Monitoring Board (DSMB). The DSMB will be comprised of four members who are not involved with enrolling participants into the trial. The DSMB will be permitted to seek additional expertise, including pharmaceutical representatives (although these will not be voting members Data monitoring will use the Lan-DeMets method as a guideline for early stopping. A single interim analysis will be scheduled for 24 months from the start of enrollment. This time was selected because half of subjects will average 18 months of follow-up, which is the time to which some trials have shown that the protective effect of INH becomes indistinguishable from that of placebo [12]. However, if the incidence of adverse events is noted to be high, an earlier interim analysis may occur before the scheduled 24 month analysis. The DMSB will receive trial results from the principle investigator (TS), who will not communicate interim results to any other investigator. The primary criterion for stopping the trial before the scheduled completion will include sufficient primary endpoints (active TB) which demonstrate a difference between the 6-month and continuous arm of IPT that is significant at the P<0.001 level. The DSMB might also advise modifying the trial under several circumstances:

SAMPLE SIZE ESTIMATES
Assumptions: 1. Subjects will be equally allocated to limited and continuous INH. 4. Up to 21% of subjects may be unable to take INH or be lost to follow-up; this proportion should not vary significantly between study treatment groups.
Using EpiInfo 6.04 (CDC, Atlanta GA) "sample size function, cohort or cross-sectional study" with confidence level of 95%, power of 80%, and a frequency of disease of 10% among those in the placebo arm (i.e., 6 months isoniazid followed by placebo or "unexposed"), if 6 month IPT results in a rate of 3.0, the study requires 474 subjects per arm. Based upon the observed attrition rate in the trial by December 2005 (21%), and because stratification will be done based on TST status (positive, (5mm, and negative, <5mm) and CD4 counts ((200 cells/mm3 and >200 cells/mm3) we assume that 60% will have TST (5mm), the estimated sample size was inflated and rounded up to 1,000 in each arm.

DATA COLLECTION, ANALYSIS AND MANAGEMENT
Clindex software (Fortress Medical Systems, Inc.) will be used to store information received from case report forms. Only the patient's study identification code and no personal identifiers will be kept in this database. Access software (Microsoft, Inc.) will be used to store personal identifiers. The latter database will be accessible only to clinicians who may contact the study population.The data will be double entered into a password-protected database. Discrepancies in entry will be resolved by the study nurses and data clerks. Informed consents with both names and the unique identifier will be stored in locked cabinets in the BOTUSA office in The treatment groups will be compared with chi-square tests or Fisher's exact tests for categorial variables, and with Students-t tests and/or Wilcoxon rank sum tests for continuous variables. Time-to-event analyses will be performed with proportionalhazards regression. The proportion assumption will be checked. Both unadjusted and adjusted analyses will be performed to estimate odds ratios for the incidence of TB, mortality, and progression of HIV disease. Primary analyses will be performed on an intention-to-treat basis. All randomized participants (i.e. those starting coded medication) will be included in the intention-to-treat analysis, including those who missed substantial amounts of treatment or had been given the wrong treatment. All P-values will be two-sided. For dichotomous variables, relative risks with 95% confidence intervals (CI) will be calculated.
Step implementation.

Strategy formulation
Between March 10-20, 2003, a needs assessment was conducted with key informants in order to: (1) notify key informants about the study and determine their willingness to assist BOTUSA with participant recruitment; (2) determine methods for educating and recruiting study participants; (3) determine methods for educating health care providers at the government clinics and counselors at NGOs about the study and for assisting with participant recruitment; (4) determine methods for ensuring participant adherence.

Channel and material selection
Based on the needs assessment results, the following draft materials will be developed: • • Posters will be placed in clinics and NGO waiting areas to increase awareness about the study. The target audience is potential participants, clinic, NGO, and VCT staff.
• A pamphlet that will contain condensed information about the study, eligibility requirements, and contact information. The target audience is potential study participants.
• A booklet that will contain detailed information about participation in the study, including information about transportation issues, monthly clinic visits, and adherence issues.
• The target audience is study participants.
• A calendar/reminder card that will be used by participants to assist with adherence to treatment and monthly monitoring clinic visits. The target audience is study participants.
• Two fact sheets: one targeted at clinic nurses and will contain information about the study, referral procedures, and contact information; the other targeted at NGOs, VCTs and will contain information about the study, referral procedures, and contact information.
• A staff schedule that is targeted at clinic nurses and will provide information about the BOTUSA staff schedule at the study clinic.

Material development (formative evaluation)
The draft IEC materials will be developed based on the needs assessment results and feedback from the IPT study coordinators. Formative evaluation will be utilized to ascertain the opinions, reactions, and beliefs of the target audience regarding: acceptability, feasibility, usability, readability, and comprehension of the IEC materials. The formative evaluation will address content, format, and design issues. The formative evaluation will use two approaches: focus groups and interviews.
29 of 43 TB Preventive Therapy Protocol Samandari et al. March 2008

Focus groups
Two focus groups will be conducted in each of the study sites -Gaborone and Francistown (total of 4 focus groups). Participants will be recruited from the target audience by BOTUSA study staff using standardized recruitment procedures. Each focus group will consist of 8-10 participants from the target audience. The focus groups will be conducted by a moderator from BOTUSA and the Botswana National TB Program. The focus group moderator will conduct the focus groups using a standardized guide (script) translated into Setswana

Interviews
Ten interviews will be conducted with health care workers and counselors regarding the content, format, and design of the fact sheets. The interviews will be conducted by a moderator from BOTUSA and the Botswana National TB Program.
Both the focus groups and the interviews will be conducted in Setswana or English and taperecorded. The recordings will be transcribed and translated into English for analysis by CDC.
Information from the interviews will be analyzed in aggregate form by CDC. No identifying information will be collected.
Assurance will be given to participants that the information discussed in the focus group or interview will be kept confidential, anonymous, and that their participation is voluntary -they may withdraw at any time. At no time during the data collection process will participants be asked to provide personal, or unique, identifying information (i.e., information such as birth date, social security number, first and last names address, etc.). The data collected will be reported on an aggregate basis -not an individual level -and all summary information will be provided to CDC in a manner that prohibits identification of individual participants.

Implementation
The IEC materials will be finalized based on the results of formative evaluation conducted with the target audiences and will be submitted to CDC IRB for approval. Final products will be available in English and Setswana. Consent will be read to any potential subject if illiterate and consent will be by witnessed "X" on the consent form.

PROTECTION OF HUMAN SUBJECTS
Pilot testing of the consent will be conducted by administering the consent to 4 members of our staff who are similar to those who are to enrolled, and then administering a questionnaire to test comprehension (Appendix 9 correct. In order to ensure that study participants continue to understand the objectives of the study and what it means to take coded medication, the comprehension will be re-administered every six months. If subjects fail the test they will not be terminated from the study but the study nurses will review issues that were not fully understood.
All potential participants are first asked a number of questions parallel to those required for entry into the National IPT Programme. For this phase, which includes a physical examination and a blood draw, a verbal consent is obtained. Until the results of the blood studies and chest radiograph return, the participant is given written materials related to the Trial as well as a copy of the consent form. When the potential participant returns and is found to meet eligibility criteria, a full written consent is obtained from the study participant. fatality rate is about 10 percent, with poorer prognosis associated with an onset of symptoms after more than 2 months of therapy. [26,27] At follow-up, research staff will attempt to detect any of these side effects early by measuring liver transaminases two weeks after IPT is initiated, and then by symptom screening. Study physicians may decide to perform liver function tests to diagnose INH-induced hepatitis.

Risks and Methods to Minimize Risk
Metabolism of phenytoin or carbamazepine may be impaired by INH, resulting in toxicity and isoniazid may slow the metabolism of warfarin. Absorption of INH is impaired by antacids that contain aluminum or antidiarrheals that contain kaolin. Therefore, concurrent medications that a subject may be taking are noted on the enrollment form so that the medical officer can make appropriate interventions to avoid medication interactions, and patients taking warfarin, carbamazepine or phenytoin therapy will be excluded from the study.
Other physical risks include those of the blood draw, which will be minimized by sterile technique, and the chest x ray, which delivers a negligible radiation dose. Methods to maintain data confidentiality are detailed above in the section, "Data collection, analysis and management" (5.0), and include the use of unique study identification number as the only personal identifier in the computerized database, a password-protected database, locked cabinets for participant records for which only the data manager and the principle investigator have access and participant identifiers to which only clinicians caring for patients, the data manager and the principle investigator have access.
The subject also incurs the inconvenience of participating in a long-term study, and traveling for follow-up visits. As mentioned in section 3.3.4, enablers will be provided including the cost of transportation to and from the clinics. In addition, the BOTUSA Project employs drivers and has vehicles that can be used when a subject needs transport not convenient through the public transport system.

Anticipated Benefits and Methods to Maximize Benefit
The results of this investigation will potentially benefit the subject, the AIDS Control Programme in Botswana, and PLWH in other settings with a high prevalence of TB.
Benefits to the subject include screening for pregnancy, allowing for prompt referral to the MTCT program. The INH will reduce the subjects' risk of TB. The initial enrollment investigations and the follow-up will enable early identification and management of medical conditions. Subjects enrolled in the study will also have immediate access to any other treatments that become standard of care in Botswana (such as cotrimoxazole

Community Advisory Board
A community advisory board will be established in Gaborone and in Francistown. The membership will consist of approximately 10 individuals drawn from members of local and traditional government, advocacy organizations for people living with HIV/AIDS, community health professionals, social welfare institutions, academia, and the media. Community advisory boards are necessary for this trial in order to: enhance the acceptability and ethical propriety of the IPT trial; build community awareness of the IPT trial through its membership drawn from a broad spectrum of organizations in the community; identify and address community concerns regarding the IPT trial; build communication networks to support the IPT trial and report on progress of the trial to the wider community.

Participant Advisory Group
A participant advisory group (PAG) will be established in Gaborone and in Francistown. The membership will consist of approximately 10 individuals drawn from a diverse representation of all participating subjects. The PAG will be convened to enhance the quality, cultural appropriateness, and acceptability of IPT Trial procedures for study participants. The PAG will advise study investigators about recruitment venues and materials, methods and materials used to obtain fully informed consent, the conduct of study procedures, and the dissemination of study results. Study personnel will communicate with the PAG progress being made in the study.

FUNDING AND RESOURCES
BOTUSA will cover the costs incurred as part of research study, such as the cost of the research medications, liver function and pregnancy tests, the CD4 count enumeration, tuberculin skin testing instruction and equipment, computers and programmers for data management, transport of specimens and/or subjects, and will provide personnel necessary for on-site implementation and management of the study: two nurses, one doctor ( time), and one laboratory technician in each city (Gaborone and Francistown).
BOTUSA will also provide full-time epidemiologist support.
The Government of Botswana will provide the VCT and MTCT clinic staff and facilities, INH and other TB drugs, HIV counseling and testing, chest radiography, the TB laboratory space and equipment, access to and maintenance for the National Electronic TB Register, and will pay for routine services to the subject, such as evaluation and treatment for opportunistic infections. In the event of any injury to a study participant, she/he will receive the standard of medical care available to all citizens of Botswana.