Safety and Immunogenicity of 4 Intramuscular Double Doses and 4 Intradermal Low Doses vs Standard Hepatitis B Vaccine Regimen in Adults With HIV-1 A Randomized Controlled Trial

Context Alternative schedules more immunogenic than the standard hepatitis B vaccine regimen are needed in patients with human immunodeficiency virus 1 (HIV-1) infection. Objective To compare the safety and immunogenicity of 4 intramuscular double-dose and 4 intradermal low-dose regimens vs the standard hepatitis B vaccine regimen. Design, Setting, and Participants An open-label, multicenter, 1:1:1 parallel-group, randomized trial conducted between June 28, 2007, and October 23, 2008 (date of last patient visit, July 3, 2009) at 33 centers in France with patients enrolled in French National Agency for Research on AIDS and Viral Hepatitis trials in adults with HIV-1 infection who were hepatitis B virus (HBV) seronegative and having CD4 cell counts of more than 200 cells/mu L. Intervention Patients were randomly assigned to receive 3 intramuscular injections of the standard dose (20 mu g) of recombinant HBV vaccine at weeks 0, 4, and 24 (IM20 x 3 group, n=145); 4 intramuscular double doses (40 mu g [2 injections of 20 mu g]) of recombinant HBV vaccine at weeks 0, 4, 8, and 24 (IM40 x 4 group, n=148); or 4 intradermal injections of low doses (4 mu g [1/5 of 20 mu g]) of recombinant HBV vaccine at weeks 0, 4, 8, and 24 (ID4 x 4 group, n=144). Main Outcome Measures Percentage of responders at week 28, defined as patients with hepatitis B surface antibody (anti-HBs) of at least 10 mIU/mL in patients who received at least 1 dose of vaccine. Patients with missing anti-HBs titer measurement at the final follow-up visit at week 28 were considered as nonresponders in the primary (efficacy) analysis. Results A total of 437 patients were randomized to the 3 study groups, of whom 11 did not receive any vaccine. Of these, 396 had available anti-HBs titers at week 28. The percentage of responders at week 28 was 65% (95% confidence interval [CI], 56%-72%) in the IM20 x 3 group (n=91), 82% (95% CI, 77%-88%) in the IM40 x 4 group (n=119) (P < .001 vs IM20 x 3 group), and 77% (95% CI, 69%-84%) in the ID4 x 4 group (n=108) (P=.02 vs IM20 x 3 group). No safety signal and no effect on CD4 cell count or viral load were observed. Conclusion In adults with HIV-1, both the 4 intramuscular double-dose regimen and the 4 intradermal low-dose regimen improved serological response compared with the standard HBV vaccine regimen.