PD-1 Inhibition to Determine CNS Reservoir of HIV-Infection
Phase: PHASE1
Conditions: HIV Infections
Sponsor: National Institute of Neurological Disorders and Stroke (NINDS)

Protocol Title:  PD-1 inhibi2on to determine CNS reservoir of HIV-infec2on 
NCT#: NCT03239899 
Document Date:  1/09/2022 

 
 
 
  
Protocol Title: PD-1 inhibition to determine CNS reservoir of HIV-infection 
Abbreviated Title: HIV CNS PD-1 
Protocol Number: 17-N-0145 
Date of This Submission/Version1/9/2022/Amendment o 
 
Principal Investigator 
Lauren Reoma, 
MD 
NINDS/OCD 
Bldg. 10, 
2A23J 
301-435-7531 
lauren.reoma@nih.gov 
 
 
 
Total requested accrual    
  (20) Patients       
   (0) Healthy Volunteers  
 
  
 
Project Uses Ionizing Radiation:  □No  
 
√ Yes  
  
 
□□Medically-indicated only 
  
 
√ Research-related only (attach RSC/RDRC documentation) 
  
 
□□Both  
 
IND/IDE  
 
 
□ No  
 
√ Yes  
  
Drug/Device/#_IND 133900____________________ 
  
Sponsor: __NINDS________________________ 
 
Durable Power of Attorney  
 
√ No  
 
□Yes  
 
Multi-institutional Project 
 
√ No  
 
□Yes 
 
 
 
 
 
 
Institution#1_________________    FWA #_________  
Date of IRB approval ______________  
 
 
 
Institution#2_________________    FWA #_________  
Date of IRB approval ______________  
 
Data and Safety Monitoring Board  
□No  
 
√Yes  
 
Technology Transfer Agreement No  
 
 
√ Yes  
 
Samples are being stored  
 
□No 
  
√ Yes  
 
Flesch-Kincaid reading level of consent form: 8.8 
 
 

 
 
 
 
 
 
 
 
 
 
 
page 2 of 49 
Précis: 
Objective 
In this Phase I, proof-of-concept study, we aim to determine the safety and tolerability of 
pembrolizumab, an FDA-approved monoclonal antibody against programmed cell death protein 
(PD)-1, in viremically suppressed human immunodeficiency virus-1 (HIV) positive patients. We are 
examining the correlation of immune activation and suppression markers in viremically 
suppressed HIV positive patients with the effects of pembrolizumab on immune restoration 
function (e.g. CD4 count, HIV viral load) and immune activation (e.g. HIV-specific T-cell responses). 
 
Study Population 
HIV is estimated to infect 37.6 million people globally, with 690,000 deaths and 1.5 million new 
infections occurring yearly. There is no cure. Opportunistic infections and neoplasms contribute 
to a large portion of mortality and morbidity within the HIV-positive population. Even in well-
controlled, viremically suppressed patients, neurologic complications including HIV-associated 
neurocognitive disorder, continue to contribute to disease morbidity and mortality.  
 
There is evidence that HIV reservoirs contribute to the inability to cure HIV infection. In the brain, 
macrophages and astrocytes harbor HIV. It is theorized that the brain is a potential reservoir for 
replication competent HIV. PD-1 expression is elevated in patients with HIV compared to 
uninfected controls. Upregulated PD-1 expression is associated with higher viral load and 
increased mortality in infections. PD-1 co-expression on regulatory T-cells has been shown to 
correlate with disease progression in perinatally-infected HIV-positive children. Drugs targeting 
the PD-1 pathway in HIV infection have shown upregulation of T-cell responses that are 
potentially critical to eradication of infection. Pembrolizumab is an attractive option due to its 
mechanism of action, although it has been rarely used in the HIV population. 
 
Design 
In this single-center, single-arm, open label, baseline-versus-treatment phase I clinical trial, twelve 
patients with HIV-1 infection receive a one-time dose of 200mg pembrolizumab with a baseline 
study period of 3 weeks, a one-day treatment phase, and a 6-month post treatment phase. 
Outcome measures are collected every 3 to 6 weeks for the duration of the study. 
 
Outcome Measures 
The primary outcome is the safety and tolerability of pembrolizumab, which is measured by 
clinical exam, laboratory studies and adverse event tabulations using the Common Terminology 
Criteria for Adverse Events (CTCAE) v5.0.  
 
In addition, viral and immunologic outcome measures investigating the impact of 
pembrolizumab on HIV-1 biology and its effects on immune function is measured in the CSF and 
periphery, including single copy HIV analysis, CD4+ T-cell count, PD-1 lymphocyte expression and 
T-cell phenotype analysis, T-cell proliferation against HIV-proteins, CSF cytokine analysis and/or 
CSF antibody profiling (LIPS). These additional studies offer indirect proof of a HIV viral reservoir 
in the CNS as well as potential efficacy of pembrolizumab in reversing immune exhaustion 
against latent HIV 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
page 3 of 49 
 
Table of Contents  
List of Abbreviations ............................................................................................................................ 6 
1. 
Introduction and Background ............................................................................................ 7 
1.1 
HIV .................................................................................................................................................................... 7 
1.2 
HIV Persistence and HIV Reservoir .................................................................................................... 7 
1.3 
The Berlin Patient ...................................................................................................................................... 7 
1.4 
Antibody responses to HIV-Tat protein ............................................................................................ 9 
1.5 
HIV and anti-PD-1 ..................................................................................................................................... 9 
1.6 
HIV and Pembrolizumab ..................................................................................................................... 11 
1.7 
Pembrolizumab ....................................................................................................................................... 13 
1.8 
Pembrolizumab and Pharmacokinetics ........................................................................................ 13 
1.9 
Pembrolizumab and Safety ................................................................................................................ 14 
1.10 
Pembrolizumab and Drug Dosage .................................................................................................. 17 
1.11 
Pembrolizumab and Fetal Toxicity ................................................................................................. 17 
1.12 
Pembrolizumab and Breastfeeding ................................................................................................ 17 
1.13 
Pembrolizumab and the Blood Brain Barrier ............................................................................ 17 
1.14 
PD-1, Pembrolizumab, and latent HIV reservoirs ..................................................................... 18 
1.15 
Results at the time of quadrennial review ................................................................................... 18 
2. 
Study Objectives .................................................................................................................... 19 
2.1 
Primary objectives .................................................................................................................................. 19 
2.2 
Secondary objectives ............................................................................................................................. 19 
2.3 
Exploratory objectives .......................................................................................................................... 19 
3. 
Subjects ..................................................................................................................................... 19 
3.1 
Description of study populations ..................................................................................................... 19 
3.2 
Inclusion criteria ..................................................................................................................................... 19 
3.3 
Exclusion criteria .................................................................................................................................... 20 
4. 
Study Design and Methods ................................................................................................. 21 
4.1 
Study overview ......................................................................................................................................... 21 
4.2 
Recruitment ............................................................................................................................................... 23 
4.3 
Screening .................................................................................................................................................... 24 
4.4 
Baseline ....................................................................................................................................................... 25 
4.5 
Study Procedures .................................................................................................................................... 26 
4.6 
Neurologic Evaluations ........................................................................................................................ 27 
4.7 
Laboratory evaluations ........................................................................................................................ 27 
4.7.a 
Safety blood draw: ....................................................................................................................... 27 
4.7.b 
Additional research blood draw: ........................................................................................... 27 
4.7.c 
Lumbar puncture: ........................................................................................................................ 28 
4.7.d 
Leukapheresis: .............................................................................................................................. 29 
4.8 
Neuroimaging evaluations ................................................................................................................. 29 
4.8.a 
Magnetic resonance imaging (MRI): .................................................................................... 29 
4.8.b 
Positron Emission Tomography/ Computed Tomography (PET-CT): .................. 29 
4.9 
Drug dosing ............................................................................................................................................... 30 
4.10 
Drug administration ............................................................................................................................. 30 
4.11 
End of participation ............................................................................................................................... 30 
4.12 
Disease community engagement ..................................................................................................... 30 
5. 
Management of Data and Samples ................................................................................... 30 

 
 
 
 
 
 
 
 
 
 
 
page 4 of 49 
5.1 
Storage ........................................................................................................................................................ 30 
5.2 
Data and sample sharing plan .......................................................................................................... 31 
6. 
Additional Considerations ................................................................................................. 31 
6.1 
Research with investigational drugs or devices ........................................................................ 31 
6.2 
Gene therapy ............................................................................................................................................. 31 
6.3 
MRI ................................................................................................................................................................ 31 
6.4 
PET/CT ........................................................................................................................................................ 32 
7. 
Risks and Discomforts ......................................................................................................... 32 
7.1 
Risks of neurological evaluation ...................................................................................................... 33 
7.2 
Risks of blood drawing ......................................................................................................................... 33 
7.3 
Risk of intravenous line ........................................................................................................................ 33 
7.4 
Risks of MRI ............................................................................................................................................... 33 
7.5 
Risks of intravenous gadolinium contrast ................................................................................... 33 
7.6 
Risks of lumbar puncture .................................................................................................................... 34 
7.7 
Risks of sedation ...................................................................................................................................... 34 
7.8 
Risks of PET/CT scanning ................................................................................................................... 34 
7.9 
Risks of Fluorine-18-fluorodeoxyglucose ..................................................................................... 35 
7.10 
Risks of Radiation Exposure ............................................................................................................... 35 
7.11 
Risks of Premedication ......................................................................................................................... 35 
7.12 
Risks of Leukapheresis .......................................................................................................................... 35 
8. 
Subject Safety Monitoring .................................................................................................. 35 
8.1 
Expected Adverse Events ..................................................................................................................... 36 
8.2 
Monitoring of adverse events ............................................................................................................ 36 
8.3 
Toxicity tables/ criteria to be used ................................................................................................. 36 
8.4 
Treatment of adverse events .............................................................................................................. 37 
8.5 
Criteria for Infusion-Related Toxicity ............................................................................................ 37 
8.6 
Criteria for individual subject withdrawal .................................................................................. 37 
9. 
Outcome Measures ............................................................................................................... 38 
9.1 
Primary outcome measures ............................................................................................................... 38 
9.2 
Secondary outcome measures ........................................................................................................... 38 
10. 
Statistical Considerations ................................................................................................... 38 
10.1 
General design .......................................................................................................................................... 38 
10.2 
Analytical plan ......................................................................................................................................... 38 
10.3 
Sample size and power considerations ......................................................................................... 39 
11. 
Human Subjects Protection ............................................................................................... 39 
11.1 
Subject selection ...................................................................................................................................... 39 
11.2 
Justification for exclusion of children ............................................................................................ 39 
11.3 
Justification for exclusion of other vulnerable subjects ......................................................... 40 
11.4 
Justification for sensitive procedures ............................................................................................. 40 
11.5 
Safeguards for vulnerable populations and sensitive procedures .................................... 40 
12. 
Anticipated Benefit ............................................................................................................... 40 
13. 
Consent Documents and Process ..................................................................................... 40 
13.1 
Designation of those obtaining consent ........................................................................................ 40 
13.2 
Consent procedures ................................................................................................................................ 40 
13.3 
Consent documents ................................................................................................................................ 42 
14. 
Data and Safety Monitoring ............................................................................................... 42 

 
 
 
 
 
 
 
 
 
 
 
page 5 of 49 
14.1 
Data and safety monitor ...................................................................................................................... 42 
14.2 
Data and safety monitoring plan ..................................................................................................... 42 
14.3 
Criteria for stopping the study or suspending enrollment or procedures ..................... 43 
15. 
Quality Assurance (QA) ....................................................................................................... 43 
15.1 
Quality assurance monitor ................................................................................................................. 43 
15.2 
Quality assurance plan ......................................................................................................................... 43 
16. 
Reporting of Unanticipated Problems, Adverse Events and Protocol Deviations
 
44 
17. 
Alternatives to Participation ............................................................................................. 44 
18. 
Privacy ...................................................................................................................................... 44 
19. 
Confidentiality ........................................................................................................................ 44 
19.1 
For research data and investigator medical records .............................................................. 44 
19.2 
For stored samples ................................................................................................................................. 45 
20. 
Conflict of Interest ................................................................................................................ 45 
20.1 
Distribution of NIH guidelines .......................................................................................................... 45 
20.2 
Conflict of interest .................................................................................................................................. 45 
21. 
Technology Transfer ............................................................................................................ 45 
22. 
Research and Travel Compensation ............................................................................... 45 
23. 
References ............................................................................................................................... 47 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
page 6 of 49 
List of Abbreviations  
 
 
AE 
Adverse Event/Adverse Experience 
ALT/SGPT 
serum glutamic-pyruvic transaminase 
AML 
Acute Myeloid Leukemia 
ART 
Antiretroviral Therapy 
AST/SGOT 
serum glutamic-oxaloacetic transaminase 
CNS 
Central Nervous System 
CRF 
Case Report Form 
CSF 
Cerebrospinal Fluid 
CT 
Computed Tomography  
CTCAE Common Terminology Criteria for Adverse Events (CTCAE) v5.0 
DoH 
Declaration of Helsinki  
DSMB   Data and Safety Monitoring Board 
ELISA 
Enzyme-Linked Immunosorbent Assay 
FDG 
2-deoxy-2(12F) fluoro-D-glucose 
G-CSF granulocyte colony-stimulating factor  
HAND HIV-associated neurocognitive disorder 
HIV 
Human Immunodeficiency Virus 
HLA 
Human Leukocyte Antigen 
HTLV 
Human T-Lymphotropic Virus 
IEC 
Independent or Institutional Ethics Committee 
IL-8 
interleukin-8  
IP-10 
interferon y-induced protein 10 
irAE       immune-related Adverse Events 
IRB 
Institutional Review Board 
LIPS 
Luciferase Immunoprecipitation System 
MCP-1 monocyte chemotactic protein 1 
MIP-1β macrophage inflammatory protein-1β  
MRI 
Magnetic Resonance Imaging 
N 
Number (refers to number of participants/sample size) 
NIAID National Institute of Allergy and Infectious Diseases  
NIH 
National Institutes of Health 
NINDS National Institute of Neurological Disorders and Stroke 
PBMC peripheral blood mononuclear cells  
PD-1 
Programmed Cell Death Protein 
PD-L1 Programmed Cell Death Protein Ligand 1 
PD-L2 Programmed Cell Death Protein Ligand 2 
PET 
Positron Emission Tomography 
PI 
Principal Investigator 
QA 
Quality Assurance 
QC 
Quality Control 
RNA 
Ribonucleic Acid 
SAE 
Serious Adverse Event/Serious Adverse Experience 
SIV 
Simian Immunodeficiency Virus 
SMC      Safety Monitoring Committee 
SST 
Serum Separator Tube 

 
 
 
 
 
 
 
 
 
 
 
page 7 of 49 
 
 
1. Introduction and Background 
 
1.1 HIV 
In 2020, there were an estimated 37.6 million people living globally with HIV infection[2]. In the 
last year alone, 690,000 adults and children died from AIDS and 1.5 million people were newly 
infected with HIV. The introduction of the first antiretroviral drug zidovudine in 1987, followed by 
combination antiretroviral therapy in 1996, signaled the first change in the HIV/AIDS epidemic 
and led to a marked shift in disease outcomes with an expected decrease in the incidence of 
patients affected by HIV-related opportunistic infections and AIDS-related deaths. However, 
nearly thirty years after the advent of ART, with 73% of people living with HIV on antiretroviral 
therapy, patients continue to be affected by opportunistic infections, HIV-associated 
neurocognitive disorders (HAND) and major depressive disorder (MDD). Cognitive disorders, with 
their non-acute onset and relatively mild initial clinical presentations, can lead to gradual, but 
ultimately significant, functional deterioration even in those patients who have suppressed virus 
and are on antiretroviral therapy. 
 
1.2 HIV Persistence and HIV Reservoir 
Although control of chronic HIV infection can be achieved with optimum ART[3] there is no cure 
for the disease. HIV continues to persist in latently infected CD4+ T cells and is integrated into the 
host cell nucleus until cell death. Tissue reservoirs contribute to chronic persistence where the 
virus evades the immune system. In well-controlled HIV-positive patients,  HIV is usually 
undetectable in the CSF although non-specific immune activation can be detected indicating 
continuing response to the underlying infection.[4] While studies from the pre-antiretroviral era 
clearly show that HIV can infect cells within the central nervous system (CNS), including microglia, 
astrocytes and macrophages,[5], CNS reservoir remains a site of active investigation. Recent 
investigations reporting CSF escape detail a rate of approximately 6%, with neurosymptomatic 
escape associated with concurrent low-level viremia or plasma suppression.[6] In the CHARTER 
cohort, a longitudinal study of 401 individuals living with HIV-1 on ART, up to 13% of individuals 
had detectable HIV in CSF.[7, 8] 
 
Currently there are no methods to detect HIV in the brain of living patients and very few autopsy 
brains are available from HIV-positive patients who are viremically suppressed and on ART at the 
time of death. These factors limit our ability to conclude whether or not the brain itself is a 
reservoir for latent HIV infection. An indirect method to detect the CNS viral reservoir would be 
to monitor immune responses directed against HIV antigens in the CSF and compare to those 
present in blood.   
 
1.3 The Berlin Patient 
In 2008, a patient in Berlin, Germany with HIV-1 infection for 10 years on stable ART developed 
acute myeloid leukemia (AML) requiring stem cell transplantation.[9] An HLA-identical donor was 
screened for homozygosity for the CCR5 delta32 allele, which confers resistance to HIV infection 
with a truncated CCR5 protein that is not expressed on the cell-surface. To date, this Berlin patient 
is the only known patient with an HIV sterile cure. Although this is the only true HIV cure to date, 

 
 
 
 
 
 
 
 
 
 
 
page 8 of 49 
a small population of HIV-positive individuals known as “elite controllers” or “long term non-
progressors” are able to maintain high CD4+ counts and low HIV-1 RNA viral loads off of ART. Elite 
controllers typically have strong HIV-specific CD8+ T-cell proliferative and cytotoxic responses 
against HIV proteins, such as gag or nef, or HIV-infected CD4+ T cells.[10] Although stem cell 
transplantation has failed to afford any patient other than the Berlin patient with a sterile HIV 
cure, new methods to enhance HIV specific T-cell responses against Gag and Nef are being 
developed to target the HIV-reservoir with the goal of developing cure strategies.[11] 
 
Elite controllers have also been shown to have lower levels of macrophage inflammatory protein-
1β (MIP-1β), interferon y-induced protein 10 (IP-10), and monokine induced by interferon-y 
(MIG), with CD4+ T-cell counts inversely correlating with plasma cytokine MIP-1β levels.[12] 
Increased levels CSF cytokine IP-10, along with interleukin-8 (IL-8), monocyte chemotactic protein 
(MCP)-1, and granulocyte colony-stimulating factor (G-CSF), has been implicated in HIV-
associated neurocognitive disorder (HAND). 
 
Studies on the Berlin patient and elite controllers show that the HIV antibody profiles of these 
groups differ from non-controllers and can be used to monitor curative intervention. [13] In the 
Berlin patient, the only known patient with a functional cure of HIV, there are no HIV directed 
antibodies against p24, matrix, nucleocapsid, integrase, protease or gp120 proteins. Low level 
antibody responses continued to be seen 5 years’ post-cure against reverse transcriptase, tat and 
gp41 in the Berlin patient. LIPS assay in a subset of exceptionally strong elite controllers showed 
low antibody responses against p24, matrix and gp120.[10] In follow up studies, loss of antibodies 
to p24 were uniquely associated with the cured state (Figure 1).[13]  
 
 
 

 
 
 
 
 
 
 
 
 
 
 
page 9 of 49 
 
Figure 1: Antibody profiles against HIV antigens in the Berlin Patient and other HIV-
infected subjects.  
The antibody levels against each of the 9 HIV proteins were determined in the uninfected 
subjects (n = 10), the 5 serial samples from the Berlin Patient, elite controllers (n = 10), and 9 
HIV subjects (n = 9) from before (no ART) and after ART. The antibody levels are plotted on 
the y-axis using a log10 scale and the median value in each group is shown by a solid horizontal 
line. Only statistically significant P values between the Berlin Patient and other groups are 
shown and were calculated using the Mann– Whitney U test. For comparison between the 
Berlin Patient and HIV (no ART) and HIV (ART) groups, P values less than .008 are denoted by 
an asterisk. Abbreviations: ART, antiretroviral therapy; HIV, human immunodeficiency virus. 
Figure from publication cited in reference #[13]. 
 
1.4 Antibody responses to HIV-Tat protein  
We have previously measured antibody responses to HIV-Tat protein in the CSF and found that 
its correlated with viral load in the CSF and the degree of immunosuppression (Figure 2).[14]  
Measuring antibody responses to Tat could be particularly informative since once the HIV proviral 
DNA is formed Tat protein is formed unchecked even in the presence of adequate ART. The 
production of Tat in the brain under such circumstances can be recognized in brain macrophages 
even when p24 cannot be detected [15].  
 
Indeed, further work from our group showed that – in a cohort of 68 HIV-positive, virally 
suppressed individuals on ART – tat was detected in 36.8% of collected samples.[16] Exosome 
analysis revealed that 34.4% of samples were strongly positive for tat protein and /or TAR RNA, 
with retained tat-transactivation activity in 66.7% of samples.[16] Indeed – tat concentration 
increased in 4 out of 5 positive individuals after initiation of ART, indicating that tat pathways 
are not inhibited by current ART, highlighting a potential useful marker of CSF HIV-1 
reservoir.[16] . 
 
A small study of in vivo work with HIV-1 tat demonstrated an induction of PD-L1 expression on 
APC/dendritic cells through TNF-alpha and TLR-4 mechanisms, potentially offering a new route of 
exhaustion in chronic non-progressors driven by continued tat transactivation.[17]  
 
1.5 HIV and anti-PD-1 
A hallmark of chronic viral illness is the impairment of antigen-specific T-cell responses, with 
upregulation of programmed cell death protein 1 (PD-1). The presence of inflammatory cytokines 
and continued expression of tat up-regulate the expression of PD-1 and PD-L1 expression, which 
in turn downregulates the T-cell effector responses (Figure 2). 
 

 
 
 
 
 
 
 
 
 
 
 
page 10 of 49 
 
 
 
 
Figure 2: PD-1 CD8+ T-cell Effector Response  
This schematic shows the relationship between PD-1 upregulation on CD8+ cytotoxic T-cells, 
the drive for anergy in the cell through the PD-1 receptor pathway, and the relationship of 
tat transactivation to the PD-1 pathway even in the presence of optimal cART with 
suppression of HIV virion. 
 
Upregulated PD-1 expression is associated with higher viral load and increased mortality in 
infections.[1] PD-1 co-expression on regulatory T-cells has been shown to correlate with disease 
progression in perinatally-infected HIV-positive children.[18]  PD-1 is a member of the B7-CD28 
superfamily expressed on activated T cells, NK cells, as well as B-cells, natural killer cells and all 
antigen-presenting cells.[19] This immune checkpoint is involved in inducing tolerance as well as 
modulating the magnitude of the antigen-specific immune response to infection.[19]  
 
Animal studies in SIV infected lymphoid tissue and in HIV blood have shown that checkpoint 
inhibitors PD-1 and TGIT remain elevated on CD8+ T-cells, correlating with disease 
progression.[20] Furthermore, checkpoint inhibition remained high even in the presence of viral 
suppression, and check-point antibody blockade restored viral-specific T-cells responses against 
SIV and/or HIV.[20] 
 
PD-1 further modulates T-cell activity via interaction with its ligand PD-L1, and blocking this 
interaction has been proven to enhance T-cell specific responses for viral control.[21] In one 
study, increased frequencies of PD-1+CD8+ T cells correlated with HIV progression and antibody 
blockade of PD-L1 restored viral-specific CD8+ T cell effector responses, suggesting novel curative 
HIV targets to reverse T-cell exhaustion.[20] This T-cell response was noted to be particularly 
robust in a subset of patients against HIV gag protein. Case studies have shown transient increases 
in HIV-specific responses, increased inflammatory cytokines, as well as potential for decrease in 

 
 
 
 
 
 
 
 
 
 
 
page 11 of 49 
cell-associated proviral HIV-DNA in individual patients treated with anti-PD1 therapy for oncologic 
indications [22, 23] This indicates that clinical trials are needed to determine if an anti-PD1 
approach in HIV is able to target the CSF HIV-1 reservoir. 
 
 
 
1.6 HIV and Pembrolizumab 
Although there are now several anti-PD1 monoclonal antibodies that are FDA approved for 
varying cancer treatments, Pembrolizumab was the first anti-PD-1 agent to be approved by the 
FDA as a fully humanized, highly selective, IgG4-kappa monoclonal antibody against PD-1.[19] 
Original trials have supported the use of pembrolizumab in melanoma treatment trials among 
other cancers [24], and it has more recently been expanded as off-label in infections such as BK 
encephalitis and CNS JC virus reactivation.[25] 
 
An open-label, non-randomized, phase 1 multicenter study evaluated the safety of 200mg IV 
pembrolizumab every 3 weeks for up to 35 doses in 30 participants with HIV and advanced cancers 
in three CD4 count defined cohorts.[26] In this study, pembrolizumab was found to have a similar 
safety profile in patients with cancer, HIV on ART and CD4 count greater than 100 as compared to 
the non-HIV patients with cancer. One participant with pretreatment KS herpesvirus viremia 
developed a B-cell lymphoproliferation after anti-PD1 therapy and died, suggesting a potential 
association. Most adverse events at least possibly related to pembrolizumab were low grade, and 
20% were grade 3. Immune-related adverse events (irAEs) included hypothyroidism, pneumonitis, 
rash, elevated liver enzymes, and musculoskeletal event. HIV was controlled in all participants.  
 
A small, phase I safety study of PD-L1 inhibition, the ligand to PD-1 and not the receptor, in HIV 
positive patients (N=8) measured HIV gag-specific CD8+ T cell responses correlated to HIV RNA 
and CD4+ counts before and after treatment.[27, 28] There were no major adverse treatment-
related adverse events in this study, but was discontinued early due to retinal toxicity in animal 
studies. A case of hypophysitis was also seen after a few months in this study and could not be 
excluded as being related to study drug.[28]  
 
A phase ½, double-blind, placebo-controlled, ascending multiple dose study of anti-PD1 antibody 
cemiplimab was halted early after two treatment related adverse events after enrollment of 5 
participants.[29] Stopping criteria was stringent. One participant experienced sub-clinical 
hyperthyroidism after 1 dose and a second (with baseline grade 1 elevation in AST/ALT) 
experienced an asymptomatic grade 3 elevation in AST/ALT. Both participants returned to 
baseline function without intervention, but the study was halted on the advice of their DSMB. 
 
Since 2003, there have been six interventional clinical trials looking at checkpoint inhibitors in 
otherwise healthy, aviremic, on ART individuals living with HIV (Table 1). Two of these trials are at 
the NIH and have enrolled half of their target cohorts, and only one trial targets the CNS reservoir 
(NCT03239899). All but one trial has targeted the PD-1 pathway. Most safety events self-resolved 
or resolved with treatment in the trials that were halted for reasons of safety.  
 
Table 1: Checkpoint Trials In HIV 
Organization 
Status 
Trial Number 
Target 
Description 
Outcome 

 
 
 
 
 
 
 
 
 
 
 
page 12 of 49 
NINDS 
Recruiting 
NCT03239899 PD1 
PD-1 Inhibition to 
Determine 
CNS 
Reservoir of HIV-
Infection 
Ongoing, 
no 
concerning AEs 
to date 
NIAID 
Recruiting 
NCT03367754 PD1 
A Single Dose of 
Pembrolizumab in 
HIV-Infected People 
Ongoing, 
no 
concerning AEs 
to date 
ACTG 
Completed 
NCT03787095 PD1 
Safety 
and 
Immunotherapeutic 
Activity of an Anti-
PD-1 Antibody 
(Cemiplimab) 
in HIV-1-infected 
Participants 
on 
Suppressive cART 
Halted 
for 
reasons 
of 
safety – grade 2 
hyperthyroidism 
and 
grade 
3 
ALT/AST 
elevation 
AbbVie 
Recruiting 
NCT04223804 PD1 
A Study to Evaluate 
the 
Safety, 
Pharmacokinetics 
and 
Pharmacodynamics 
of 
ABBV-181 
(Budigalimab) 
in 
Adult 
Participants 
With HIV-1 
Ongoing, 
no 
data to date 
ACTG 
Completed 
NCT02028403 PD-L1 
Safety and Immune 
Response of BMS-
936559 
in HIV-
Infected 
People 
Taking Combination 
Antiretroviral 
Therapy 
Halted 
for 
reasons 
of 
safety in animal 
study – retinal 
findings 
in 
macaques. At 36 
week follow up, 
asymptomatic 
hypophysitis in 
one participant 
with 
eventual 
return 
to 
baseline 
BMS 
Completed 
NCT03407105 CTLA-4 A 
Dose-Escalation 
Study of MDX-010 
Administered 
Monthly 
as 
Immunotherapy in 
Subjects 
Infected 
With 
Human 
Immunodeficiency 
Virus (HIV) 
Completed. 
N=24. 
One 
grade 2 facial 
palsy. No AEs 
greater 
than 
grade 2. 
 

 
 
 
 
 
 
 
 
 
 
 
page 13 of 49 
 
Drug safety data on pembrolizumab is extensive in the cancer population, but it should be noted 
that the populations in which it is most studied are patients with metastatic lung cancer or 
metastatic melanoma who have previously received multiple chemotherapeutic and/or 
immunosuppressive drugs. This population is more at risk for adverse events due to the serious 
nature of their disease and multi-organ involvement of their metastatic cancers. Also, prior 
therapies and chronic illness complicate the adverse event reporting in these patients. The safety 
data that is available suggests that risks are not increased in participants living with HIV receiving 
pembrolizumab compared to the general population. 
 
1.7 Pembrolizumab 
Pembrolizumab (Keytruda) is FDA approved for the treatment of 15 different oncologic 
indications as of January 2020.[30] It is a humanized IgG4 kappa monoclonal antibody that blocks 
the interaction between PD-1 and its ligands PD-L1 and PD-L2 with an approximate molecular 
weight of 149 kDa, manufactured by Merck. It has a terminal half-life of 28 days and steady-state 
concentrations are reached after repeat dosing with an every 3-week regimen of doses between 
2 to 10mg/kg every 3 weeks in solid tumours.[30]  
 
1.8 Pembrolizumab and Pharmacokinetics 
Based on patients who received doses of 1 to 10mg/kg every 2 weeks or 2 to 10mg/kg every 3 
weeks, the clearance of drug was 0.22L/day and the mean elimination half-life was 26 days. 
Steady state concentrations were reached by 18 weeks with repeat dosing every 3 weeks. Renal 
impairment and mild hepatic impairment had no clinically important effect on the clearance of 
pembrolizumab. Updated guidance recommends a flat dose of 200mg every 3 weeks for most 
indications.[30]  

 
 
 
1.9 Pembrolizumab and Safety 
 
Table 1: Immune-mediated adverse reactions by solid tumor type with adverse time to onset.[31] 
 
 
Adverse 
Reaction 
Melanoma 
Average time to 
adverse 
reaction onset 
after starting 
treatment 
AE 
Grade 
2 
AE 
Grade 
≥3 
Non-Small 
Cell Lung 
Cancer  
Average time to 
adverse 
reaction onset 
after starting 
treatment 
AE 
Grade 2 
AE 
Grade ≥3 
Hypo-
thyroidism 
8.1% 
3.3 months 
(range 5 days to 
18.9 months) 
 
0.1% 
6.9% 
 (14.6% in 
HNSCC 
Trial 4) 
4.2 months (20 
days to 11.2 
months) 
5.5% 
0.2% 
(0.5% 
HNSCC 
trial 4) 
Hyper-
thyroidism 
3.3% 
1.4 months 
(range 1 day to 
21.9 months) 
0.6% 
0.1% 
1.8% 
1.8 months (2 
days to 3.4 
months) 
0.7% 
0.3% 
Pneumonitis 
2.0% 
4.3 months 
(range 2 days to 
19.3 months) 
 
 
3.5% 
1.7 months 
(range 4 days to 
12.9 months) 
1.1% 
1.9% 
Colitis 
2% 
3.4 months 
(range 10 days 
to 9.7 months) 
0.5% 
1.2% 
0.7% 
1.6 months 
(range 28 days 
to 2.2 months) 
0.2% 
0.4% 
Hepatitis 
1.0%  
26 days (range 8 
days to 21.4 
months) 
0.1% 
0.8% 
0% 
 
 
 
Hypophysitis 
0.8%  
3.3 months 
(range 1 day to 
7.2 months) 
0.3% 
0.4% 
0.2% 
(n=1) 
3.7 months 
 
0.2% 
Nephritis and 
Renal 
Dysfunction 
0.4%  
5.1 months 
(range 12 days 
to 12.8 months) 
0.2% 
0.3% 
0% 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
page 15 of 49 
Type 1 
Diabetes 
Mellitus 
0.1% (n=3) 
(all trials 1-3 
combined 
melanoma 
and NCSLC) 
 
 
 
 
 
 
 
Other 
immune-
mediated: 
including 
cardiac 
toxicities 
<1% 
 
 
 
<1% 
 
 
 
Immune 
Arthritis 
1.6% 
 
 
 
 
 
 
 
Infusion 
Reaction 
0.1% (all 
trials 1-3 
combined 
melanoma 
and NCSLC) 
 
 
 
 
 
 
 
Total Adverse 
Events 
19.4% 
 
1.7% 
2.9% 
14.1% (or 
21.8% 
including 
trial 4 
data) 
 
7.5% 
3.0% (or 
3.3% 
including 
trial 4 
data) 

 
 
 
 
With repeat dosing for solid tumor immunotherapy, side effects were overall well tolerated in the 
majority of cancer patients but immune mediated adverse reactions could be seen (Table 1).[31, 
32] The major serious adverse reactions that can occur secondary to exposure and repeat 
exposure to pembrolizumab are autoimmune in nature (Table 1). There has also been a reported 
case of reactivated tuberculosis following pembrolizumab treatment.[33] Patients receiving anti-
CTLA 4 and/or anti-PD-1 therapy have developed cardiotoxic side effects, with one patient 
receiving 
pembrolizumab 
experiencing 
cardiac 
arrest 
attributed 
to 
a 
Takotsubo 
cardiomyopathy.[34] 
 
In patients with metastatic melanoma, the following laboratory abnormalities were increased 
from baseline with 2mg/kg every 3 weeks dosing of pembrolizumab (Table 2)[31, 32]. 
 
 
Table 2: Laboratory abnormalities in patients with metastatic melanoma in >20% of 
patients after receiving repeat dosage pembrolizumab[31, 32] 
 
Laboratory Test 
All Grades Adverse Event 
(%) 
Adverse Event Grade ≥ 3 
(%) 
Chemistry 
 
 
Hyperglycemia 
45 
4.2 
Hyponatremia 
28 
4.6 
Hypoalbuminemia 
27 
2.4 
Hypertriglyceridemia 
43 
2.6 
Increased AST 
27 
2.6 
Increased ALT 
23 
3.1 
Hypocalcemia 
24 
 
Hematology 
 
 
Anemia 
35 
3.8 
Lymphopenia 
33 
6 
 
Common clinical abnormalities in patients include fatigue, gastrointestinal side effects, fever, joint 
aches, and itching/rashes (Table 3).  
 
 
Table 3: Clinical Adverse reactions in patients with NSCLC in ≥ 10% of patients after 
receiving repeat dosage pembrolizumab.[31] 
 
Clinical Symptom 
All Grades Adverse Event (%) 
Adverse Event Grade 3 
(%) (no higher AEs) 
Fatigue 
44 
4 
Pyrexia 
12 
1 
Peripheral Edema 
10 
0 
Decreased Appetite 
25 
1 
Dyspnea 
23 
4 
Cough 
29 
˂1 
Nausea 
18 
1 
Diarrhea 
15 
1 
Constipation 
15 
˂1 

 
 
 
 
 
 
 
 
 
 
 
page 17 of 49 
Vomiting 
12 
1 
Arthralgia 
15 
1 
Back Pain 
10 
2 
Rash 
18 
˂1 
Pruritis 
12 
0 
 
1.10 
Pembrolizumab and Drug Dosage 
 
Pembrolizumab is FDA approved for intravenous infusion over 30 minutes at a dose of 200mg 
every 3 weeks for most of its 15 oncologic indications.{(FDA),  #450} A pooled analysis from three 
trials of pembrolizumab in melanoma that evidenced a flat-exposure-toxicity relationship across 
the dose range of 1 to 10mg/kg every 2 to 3 weeks identified no new major safety 
concerns.{Barone, 2017 #453}  
 
1.11 
Pembrolizumab and Fetal Toxicity 
Pembrolizumab is an abortifactant. Animal models link the PD-1 pathways to maintenance of 
pregnancy through immune tolerance pathways. Although mouse models have not shown fetal 
malformations, there was an increase in fetal loss in mice where PD-1 was blockaded. Fetal 
exposure to pembrolizumab is hypothesized to increase the risk of the fetus to immune mediated 
disorders. Patients of reproductive potential should be advised to use two forms of highly 
effective contraception during drug administration and for at least 4 months following the last 
drug dose.{(FDA),  #450} 
 
1.12 
Pembrolizumab and Breastfeeding 
It is not known if pembrolizumab is excreted in breast milk. Nursing mothers are advised to 
discontinue pembrolizumab.{(FDA),  #450}  
 
1.13 
Pembrolizumab and the Blood Brain Barrier 
There is no literature on the specifics of pembrolizumab and trafficking across the blood brain 
barrier. Although it is likely that peripheral antibody is trafficked into the CNS through adsorptive 
transcytosis, receptor mediated transcytosis and disrupted tight junctions, inherent mechanisms 
also exist to remove pembrolizumab, an Fc-containing mAb, from CNS space and therefore the 
CSF bioavailability would be expected to be distinct from the periphery.{Chacko, 2013 #454} 
Unpublished work from our group (Figure 3) shows that CSF PD-1+ CD8+ and CSF PD-1+CD4+ T-
cell levels recover in a manner distinct from the peripheral PD-1+CD8+, PD-1+CD4+ T-cell 
populations, suggesting that while peripheral administration of pembrolizumab decreases CSF as 
well as peripheral PD1+ T-cell surface expression on CD4+ and CD8+ T-lymphocytes, the CNS 
immune space is independently regulated and distinct from the peripheral space.  
 

 
 
 
 
 
 
 
 
 
 
 
page 18 of 49 
 
 
Figure 3: PD-1+ CD4+ and PD-1+CD8+ T-cell response in response to peripheral 
pembrolizumab administration in the CSF compared to peripheral blood.  
This timeline represents the course of PD-1+ T-cell suppression (CD4+ and CD8+ T-cells) 
demonstrated by flow cytometry in one patient with HIV-PML who was treated with systemic 
2mg/kg pembrolizumab at two timepoints (red stars). Peripheral suppression continued 
when CSF PD-1+ expression began to rebound which is consistent with our groups larger 
population of non-HIV PML patients treated with anti-PD-1 therapies (data not shown). 
 
 
1.14 
PD-1, Pembrolizumab, and latent HIV reservoirs 
Reservoirs in HIV contribute to disease morbidity and provide a source of virus that is not able to 
be effectively targeted by current antiretroviral therapy, eliminating the possibility of a disease 
cure. Although HIV has been identified in the CNS, limitations on current studies have not allowed 
for conclusive evidence of a CNS reservoir. Targeted immune therapies against check-point 
inhibitors such as PD-1 will potentially release anergic T-cells, increasing the host adaptive and 
innate immune responses against the latent sites of HIV infection. Evidence of this response in 
HIV infection, and the potential efficacy as well as safety profile of pembrolizumab, will allow for 
further targeted therapies for curative intervention. We hypothesize that the number of adverse 
events related to a one-time dose of pembrolizumab in HIV infected patients will be less than 
reported rates in the cancer population. This would offer evidence of an equivalent or improved 
safety profile in the HIV-population compared to the FDA-approved drug indicated cancer 
populations. 
 
1.15 
Results at the time of quadrennial review  
 
Since the approval of this protocol, 13 patients have enrolled. To date, 6 of the enrolled patients 
have completed participation in the study.  Some preliminary study results were presented at 
the Conference on Retroviruses and Opportunistic Infections (CROI) in 2021: 
• 
https://www.croiconference.org/abstract/effects-of-pd-1-blockade-on-hiv-reservoirs-in-
blood-during-art/ 
• 
https://www.croiconference.org/abstract/pembrolizumab-treatment-is-associated-
with-decreased-cell-associated-hiv-dna-in-csf/ 
 

 
 
 
 
 
 
 
 
 
 
 
page 19 of 49 
A full interim analysis of the first six participants is currently underway and those results are 
pending. 
 
2. Study Objectives  
 
2.1 Primary objectives 
a. The primary goal of the study is to determine the safety of a single dose of 
pembrolizumab in HIV-positive patients. 
 
2.2 Secondary objectives 
a. To examine if pembrolizumab changes the CSF expression of HIV-specific 
antibody responses and/or CSF cytokine profiles 
b. To determine the effect of pembrolizumab on CSF PD-1 expression  
 
2.3 Exploratory objectives 
a. To determine if laboratory correlates of active HIV-1 replication, such as viral RNA 
and CD4+ T-cell counts, correlate with the effects of pembrolizumab on markers 
of immune activation 
b. To explore the effect of pembrolizumab on 18FDG-PET/CT. 
c. To explore the effect of pembrolizumab on MRI brain studies 
d. To determine the effect of pembrolizumab on HIV-specific T-cell responses  
 
3. Subjects 
3.1 Description of study populations  
The study population will consist of 12 subjects with a diagnosis of HIV-1 infection. We 
anticipate enrolling up to 20 patients to allow for up to 8 dropouts. Participants who 
withdraw voluntarily, not due to toxicity, after initiation of the baseline phase but before 
receiving drug are considered dropouts. Patients who voluntarily drop out after receiving 
study drug are considered non-completers. Patients who no longer wish to participate in the 
research portion of the study after receiving pembrolizumab are offered the option of 
remaining in the study to continue safety evaluations. Patients who withdraw are removed 
from any further study or safety procedures.  
 
3.2 Inclusion criteria 
□ 
18 years or older 
□ 
Diagnosis of HIV-1 infection, with positive HIV 1 antibody testing 
□ 
HIV RNA ≤40 copies/mL in plasma in the last 12 or greater months  
□ 
CD4 count above 350 cells/uL 
□ 
Antiretroviral therapy for 12 months prior to trial 
□ 
Fully vaccinated against SARS-CoV-2. Fully vaccinated is defined as:  
o Two weeks out from the second dose of a two-dose vaccine series (Moderna, 
Pfizer-BioNTech); or 
o Two weeks out from a single-dose vaccine (Johnson & Johnson/Janssen) 

 
 
 
 
 
 
 
 
 
 
 
page 20 of 49 
□ 
Patient must be willing and able to comply with all the aspects of trial design and 
follow-up. 
□ 
Patients must be able to provide informed consent 
□ 
Women of childbearing potential must agree to use contraception (defined as 
two forms of effective birth control), from the time of enrollment until 4 months 
after the last exposure to pembrolizumab 
□ 
Participants who are physically able to father a child must agree to use 2 effective 
methods of contraception (birth control) from the time you enroll in the study 
until 4 months after your last exposure to pembrolizumab 
o Effective methods of contraception for this study include:  
1. hormonal contraception (birth control pills, birth control 
patches, injected hormones, hormonal implants or vaginal 
ring),  
2. Intrauterine device, 
3. Barrier methods (condom or diaphragm) combined with 
spermicide, and  
4. Surgical sterilization (hysterectomy, tubal ligation, or 
vasectomy). 
o If you have had a hysterectomy, tubal ligation, or vasectomy (or have a 
partner with a hysterectomy, tubal ligation or vasectomy), you do not have 
to use 2 methods of birth control.  
 
3.3 Exclusion criteria 
□ 
Clinically significant medical disorders that might expose the patient to undue risk 
of harm confound study outcomes or prevent the patient from completing the 
study as identified on screening studies and by patient history. Examples of such 
conditions include known cardiac disease such as congestive heart failure, chronic 
obstructive pulmonary disease, uncontrolled hypertension, kidney disease, liver 
disease, endocrine disease, pulmonary disease, heart disease, progressive CNS 
disease such as Parkinson’s disease, dementia, prior tuberculosis infection or 
ongoing CNS opportunistic infection.  
□ 
Patient has received immunomodulatory/immunosuppressive therapy (including 
IV steroids but excluding local injections) in the preceding 6 months. 
□ 
Patient with known autoimmunity that would include but is not limited to 
disorders such as hypo/hyperthyroidism, myasthenia gravis, diabetes mellitus 
type 1, hemolytic anemia, and immune mediated hepatitis (but excluding 
patients with hypothyroidism already on thyroid replacement therapy). 
□ 
Prior history of cancer (excluding non-invasive squamous and basal cell 
carcinoma) 
□ 
Any opportunistic infection in the prior 2 years (excluding thrush) including latent 
TB or a positive TB Quantiferon Gold test 
□ 
Patient has received other investigational drugs within 3 months before 
enrollment 
□ 
Positive serological or PCR evidence of active or prior infection with HTLV-1/II, 
Hepatitis B or C. Patients with hepatitis B core (+), surface antibody (+), surface 

 
 
 
 
 
 
 
 
 
 
 
page 21 of 49 
antigen (–) and hepatitis B DNA (-) are eligible to participate in the study (provided 
they are on tenofovir, lamivudine or TAF). Participants with prior hepatitis C who 
are hepatitis C antibody (+) but hepatitis C RNA (-) with normal liver enzymes and 
no evidence of cirrhosis on clinical liver ultrasound are eligible to participate in 
the study. 
□ 
Metal in the body which would make having an MRI scan unsafe, such as 
pacemakers, stimulators, pumps, aneurysm clips, metallic prostheses, artificial 
heart valves, cochlear implants or shrapnel fragments, or history of welding or 
metal worker 
□ 
Claustrophobia 
□ 
Inability to lie comfortably on the back for up to two hours. 
□ 
Abnormal anti-thyroid panel (anti-TPO and anti-TG) test at screening visit. 
□ 
Abnormal screening/baseline blood tests exceeding any of the limits defined 
below or as deemed exclusionary by the investigators on review: 
o AST and ALT values >1.1x ULN 
o Fasting triglyceride > 300 mg/dL. 
o Total bilirubin >1.1 x ULN (unless participant is taking atazanavir or has Gilbert 
syndrome) 
o Creatinine Clearance or eGFR <60 ml/minute (adjusted for race) 
o Hemoglobin < 10 g/dL 
o Absolute neutrophil count < 1000/µL 
o Platelet count <130,000/mm3 (if platelet clumping is present on hematology 
slide review, platelet count <100,000/mm3 is considered exclusionary to 
study) 
o Hemoglobin A1c ≥ 6% 
o Thyroid-stimulating hormone (TSH) and adrenocorticotropic hormone 
(ACTH) within normal limits. If TSH is not within normal limits then the 
participant may be eligible if thyroxine (T4) is within normal limits. 
Participants are not excluded if they are on a stable dose of replacement 
thyroid medication; dose may be adjusted as needed. 
□        An employee or staff of the NIH 
4. Study Design and Methods 
 
4.1 Study overview  
The study is a single center, single arm, and open label, baseline versus treatment trial of 
pembrolizumab in HIV patients. Twelve patients with viremically suppressed HIV-1 infection will 
receive a single dose IV pembrolizumab 200mg infusion; the treatment phase will be followed by 
a post-treatment follow-up for an additional 52 weeks. Study-related evaluations may be done in 
an outpatient setting unless inpatient setting is indicated at the NIH Clinical Center as outlined in 
Table 4. Telehealth may be used for conducting routine visits to the NIH Clinical Center. 
 
In the event that circumstances beyond our control preclude the travel of one or more of the 
study participants to the NIH Clinical Center for a visit, or otherwise would put their health at 
greater risk (i.e. epidemic or pandemic), we will endeavor to establish capabilities for remote visits 
(through an NIH approved platform). Specifically, for safety visits, the study team will arrange for 

 
 
 
 
 
 
 
 
 
 
 
page 22 of 49 
local laboratory studies to be done, and conduct a telehealth visit with the participant. 
Unscheduled visits, due to safety, may also be conducted remotely through telehealth and/or 
offsite laboratory and radiologic studies and/or in conjunction with a local physician with the 
guidance of the study PI. The laboratory studies may be performed through LabCorp, Quest, or 
with the local physician, and results will be sent to the study team for safety monitoring and 
oversight. Radiology studies will be arranged through a local, non-study physician, or directly by 
the study team, at a site close to the participants home area if travel to the NIH is not possible. In 
the event that subjects are unable to come to the Clinical Center because of safety issues or travel 
restrictions, required in person procedures, physical exams, neurologic exams, research blood 
draws, lumbar punctures, or MRIs, will be conducted at the next planned study visit time point or 
as soon as is safe and feasible. 
 
Patients have up to 9 visits at the NIH Clinical Center, with visits on Weeks 12 and 18 as optional 
travel visits. On weeks 12, and 18 patients may have an interval history over the phone and 
present to an NIH-contracted lab (either Quest and/or LabCorp) for safety blood draws. Offsite 
study visits are allowed if subject is able to access Quest and/or LabCorp for blood draws within 
the +/- 1-week study visit timepoint and is not able to come to the NIH Clinical Center. Offsite 
study visits are allowed at screening and all study timepoints after week 3 in the event of an 
epidemic or pandemic that limits participant travel to the NIH Clinical Center. In the event of an 
epidemic or pandemic affecting the week 24 MRI and lumbar puncture timepoints, these studies 
can be moved to the week 52 visit. If the week 52 is missed due to a pandemic or epidemic, a 
make-up final study visit comprising all the expected week 52 procedures (including potential LP 
and MRI from a missed week 24 visit) will be allowed as soon as the participant is able to safely 
travel to the NIH Clinical Center. During a pandemic or epidemic affecting patient travel, serial 
missed research collections will not be considered major study deviations and will be reported to 
the IRB at the time of continuing review. 
 
Visits to the off-site Quest and/or LabCorp are coordinated by the study team, and the patient 
presents to the site for phlebotomy and urine collection only for safety laboratory work listed in 
Table 6. For off-site week 12 and 18 visits, the study team arranges a phone call with the patient 
to assess the interval history within the +/- 1-week interval.  Study visits are accepted within a +/- 
1-week window and brain FDG-PET/CT is accepted within a +/- 2-week window of the time points 
noted in Table 4. Each visit is expected to last no longer than 8 hours. 
 
 
Table 4: Study Timeline 
 
 
Screening 
(Week -52 to 0) 
Week -12 to 0 
Week 0 
Week 3 
Week 6 
Week 12 
Week 18 
 
Week 24 
 
Week 52 
 
 
 
 
 
 
 
 
 
 
Medical history 
√ 
√ 
 
 
 
 
 
 
 
Interval history 
 
 
√ 
√ 
√ 
√ 
√ 
√ 
√ 

 
 
 
 
 
 
 
 
 
 
 
page 23 of 49 
 
         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 *For women of child-bearing potential only 
 #In the event of an epidemic or pandemic, the timing of these study procedures are 
optional and can be performed when the subject is safely able to travel to the Clinical 
Center, at least once before participant is able to go off study. For the MRI and lumbar 
puncture, if they are missed at the week 24 timepoint due to an epidemic/pandemic, 
they can be moved to the week 52 visit. If this is unable to be completed at week 52, a 
make-up final study visit will be allowed as soon as the participant is able to safely 
travel to the NIH Clinical Center. 
##Optional 
 
4.2 Recruitment 
Patients are recruited from the Section of Infections of the Nervous System protocol 13-N-0149 
and through advertisement to the general public, and through the recruitment plan stipulated in 
protocol 13-N-0149.  
 
Additionally, recruitment of HIV+ subjects is done from existing clinic OP-8 NIAID protocols, and 
referrals from the ID clinics at Washington Hospital Center, Family Medical & Counseling Services, 
CHARTER/NNTC sites, P30 sites, ACTG sites, and other physicians (Appendix E).  Flyers may be 
posted on bulletin boards at grocery stores, community centers, bookstores, NIH Clinical Center, 
libraries or placed in advocacy group offices, in doctor’s office waiting rooms, libraries, retail 
establishments with approval of the venue or in accord with their policy.  Flyers may be made 
available at outreach exhibits, speaking engagements, support group meetings, professional 
meetings, association/trade meetings with approval of the venue or in accord with their policy. 
Flyers may be given directly to those requesting study information. Flyers may be posted 
electronically on websites such as such as NIH or NIMH websites, advocacy support group 
websites and local community online or print publications, such as Capitol Hill Community News. 
Flyers may be sent electronically to those requesting study information. IRB-approved 
advertisements may be placed in local print publications of newspapers, magazines and support 
or health care organizations, including Washington Post, Express, Washingtonian, Bethesda 
Physical exam 
 
√ 
√ 
√ 
√# 
## 
## 
√# 
√# 
Neurologic 
exam 
 
√ 
√ 
√ 
√# 
## 
## 
√# 
√# 
Pregnancy 
testing* 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
√ 
Research Blood 
Draw 
 
√ 
√ 
√ 
√# 
## 
## 
√# 
√# 
Safety Blood 
Draw 
√ 
√ 
 
√ 
√ 
√ 
√ 
√ 
√ 
Lumbar 
Puncture 
 
√ 
 
√ 
 
 
 
## 
# 
Leukapheresis 
 
## 
 
## 
 
 
 
## 
 
MRI 
 
√ 
 
√ 
 
 
 
√# 
# 
FDG-PET/CT 
 
√ 
 
√ 
 
 
 
 
 
Pembrolizumab 
200mg therapy 
 
 
√ 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
page 24 of 49 
Magazine, Washington Examiner, Military papers, Washington Jewish Week, NAMI Advocate, 
MHA, CHADD, and/or the NIH Record/CC News. 
 
IRB-approved advertisements may be placed in national print publications of newspapers and 
magazines, including New York Times, Newsweek, Time, Oprah. IRB-approved advertisements are 
posted on the sides of Metro and Ride On buses, within the Metro Rail system, in bus shelters, on 
billboards, on scrolling digital boards in the Washington DC-Virginia-Maryland area. 
  
Based on current and historical referral patterns, we anticipate this will permit the study to screen 
an average of 1-2 subjects per month.  
 
4.3 Screening 
 
Screening activities performed prior to obtaining informed consent 
Minimal risk activities that may be performed before the subject has signed a consent include the 
following:  
• 
Email, written, in person or telephone communications with prospective subjects.  
• 
Review of existing medical records to include H&P, laboratory studies, etc.   
• 
Review of existing MRI, x-ray, or CT images. 
 
Request for Waiver of Consent for Screening Activities 
Prior to the subject signing the consent for this study pre-screening activities listed above may be 
performed. We request a waiver of consent for these activities as they involve only minimal risk 
to the subjects. A waiver will not adversely affect the rights and welfare of the subjects given that 
the activities are only intended to determine suitability for screening for participation in research 
protocols.  These activities could not practicably be carried out without the waiver as central 
recruiting services, utilized in the NIH Clinical Center, perform pre-screening activities for multiple 
studies and obtaining consent for each one is beyond their resources.  The subjects will be 
provided with additional pertinent information after participation as they will be informed 
whether or not they are eligible to sign a consent for additional screening. 
 
Screening activities performed after a consent for screening has been signed 
The following activities will be performed only after the subject has signed the consent this study: 
• 
Assessments performed another NIH protocol within the timeframes may also be used to 
determine eligibility once a participant has signed the consent. 
 
Consent under 17-N-0145 is obtained before any study procedures, including screening 
procedures, are done.  Screening can occur at any time during the life-cycle of the protocol. 
Screening participants did not start the baseline phase until after the SMC’s 90-day post-study 
drug SMC safety review whereby further enrollment was allowed by the SMC in October 2019.  In 
July 2021, the data and safety monitoring entity was changed from an SMC to a data and safety 
monitoring board (DSMB).  Screening can occur within 52 weeks of the baseline visit and include 
the following procedures and laboratory evaluations: 
a. History (Appendix F is used to obtain history) 
b. Clinical blood draw 
o Table 5: Screening laboratory evaluations 
Laboratory Testing 

 
 
 
 
 
 
 
 
 
 
 
page 25 of 49 
CBC/diff/plts 
Hem A1c 
PT/PTT 
Pregnancy test (urine or serum) 
Fasting Lipid panel 
Anti-thyroid panel (anti-TPO and anti-TG) 
Acute Care Panel/Hepatic Panel/Mineral Panel 
amylase/lipase 
TSH 
CRP 
HIV RNA Viral Load 
TBNK 
Adrenocorticotropic Hormone 
ESR 
Anti-nuclear antibody 
Anti-ENA 
TB Quantiferon gold 
Hepatitis scr (HBsAG, Anti HBs,Anti HBc, Anti HCV, 
Anti HAV, HCV RNA Quant) 
HTLV - ½ 
 
 
4.4 Baseline 
The following evaluations take place within a 12-week period of time and include: 
a. 
History and physical examination 
b. 
Standardized neurological examination 
c. 
Clinical blood draw and laboratory testing  
o Table 6: Baseline laboratory evaluations 
Laboratory Testing 
CBC/diff/plts 
Hem A1c 
PT/PTT 
Pregnancy test (urine or serum) 
Fasting Lipid panel 
Acute Care Panel/Hepatic Panel/Mineral Panel 
amylase/lipase 
TSH 
CRP 
HIV RNA Viral Load 
TBNK 
Adrenocorticotropic Hormone 
ESR 
Anti-nuclear antibody 

 
 
 
 
 
 
 
 
 
 
 
page 26 of 49 
Anti-ENA 
 
d. 
Research blood draw 
e. 
MRI brain with and without contrast  
f. 
Brain FDG-PET/CT 
g. 
Lumbar Puncture 
 
4.5 Study Procedures 
Each study visit and procedure occur as indicated in Table 4 and Appendix A. These time points 
are approximated.  To accommodate for patient scheduling needs or clinical necessity, study 
visits are accepted within a +/- 1-week window of the time points noted. Clinical history, 
physical and neurological examination are expected to last no more than 2 hours and are for 
clinical care and research. The week 3 neurological and physical examination are required and 
the week 52 timepoint (or its equivalent ending) should be completed.   Lumbar puncture is 
expected to last no more than 1 hour and are for clinical care and research. The lumbar 
puncture is required at baseline and at the week 3 timepoint. The third lumbar puncture is 
optional and could be deferred to the week 52 timepoint as the long-term antibody/immune 
response at the 24 and 52 week mark are likely to be similar. Leukapheresis is optional and may 
be performed at baseline, week 3 and week 24. Interim examinations do not impact outcome 
measures and are highly unlikely to impact subject safety. If interim examinations cannot be 
completed, this will not adversely affect the study or safety of the participants. Brain FDG-
PET/CT are accepted within a +/- 2-week window of the time points noted due to scheduling 
restraints and prior brain FDG-PET/CT within 12 months is accepted as the baseline scan. FDG-
PET/CT lasts no more than 3 hours. FDG-PET/CT scan at baseline and week 3 is for clinical care 
and research. MRI studies of the brain are performed at baseline, week 3 and 24 for both clinical 
care and research. Brain MRI is expected to last no more than 2 hours. For women of 
childbearing potential, urine or serum pregnancy testing is performed at screening, baseline, on 
the day of pembrolizumab administration, and at each follow up visit. Blood draws occur 
approximately every three to six weeks for the first 36 weeks of the trial (64 weeks), with a 1-
year safety visit, not to exceed Clinical Center guidelines. Safety labs can be drawn according to 
the trial schedule with an NIH contracted commercial laboratory if preferred by the patient at 
visits week 12 and 18. Blood draw is expected to last no more than 1 hour. We draw no more 
than 30 teaspoons of blood at any one time.  We draw no more than 5.86 cups or 277 teaspoons 
of blood during the entire study.  As specified in Table 4, blood draws are for both clinical care 
and research at the time points noted. All laboratory results are reviewed by NIH clinicians in a 
timely manner upon receipt. Visits at week 12 and 18 include a phone visit for interval history 
from an NIH clinician if the patient chooses not to come to the NIH clinical center. Screening 
may be done remotely. Baseline and visits at week 0, 3, 6, 24, and 52 must be at the NIH clinical 
center. Screening visits occurred prior to the 90-day SMC review, but participants did not begin 
baseline timepoint until after a 90-day post-drug safety review that allowed further study drug 
dosing of participants.  
 
Two forms of contraception are required from study enrollment until 4 months’ post-study drug 
when pregnancy is possible. In light of the potential risk of pembrolizumab to a developing fetus, 
participants are counseled at each study visit concerning the importance of consistently using two 
forms of effective birth control. 
 

 
 
 
 
 
 
 
 
 
 
 
page 27 of 49 
Participation is staggered with interim review of safety and futility. An initial cohort of 4 study 
patients who have completed week 0 – study drug visit, and an SMC review of the sentinel 90-day 
post-drug safety data was required prior to additional subject enrollment. Given that the SMC 
review was favorable, the trial continued to enroll the remaining study subjects. Futility was 
evaluated at the sentinel safety data review prior to continuing study enrollment. 
 
4.6 Neurologic Evaluations 
History and physical examination is performed at baseline and visits specified in Appendix A along 
with neurological examination. This procedure lasts approximately 1-2 hours. 
 
4.7 Laboratory evaluations 
4.7.a 
Safety blood draw: 
Blood is obtained at each visit specified in Appendix A for patient safety.  
 
 
Table 7: Safety laboratory testing 
Laboratory Testing 
CBC/diff/plts 
Hem A1c 
PT/PTT 
Pregnancy test (urine or serum) 
Fasting Lipid panel 
Acute Care Panel/Hepatic Panel/Mineral Panel 
amylase/lipase 
TSH 
CRP 
HIV RNA Viral Load 
Adrenocorticotropic Hormone 
ESR 
Anti-nuclear antibody 
Anti-ENA 
CD4/CD8 counts* 
 
• 
Or lymphocyte TBNK, interchangeable laboratory evaluations. 
4.7.b 
Additional research blood draw:  
Research blood is collected at the baseline visit and subsequent study visits listed in 
Appendix A. This is used for immunophenotypic analysis and to characterize the cell 
mediated and humoral immune responses, as well as virology. Any remaining serum or 
plasma is preserved at less than -60 degrees C for future immunological testing.   
 
Additionally, up to 120 ml of whole blood in syringe with preservative-free heparin (or an 
equivalent amount in standard research tubes) may be drawn at each research blood time 
point for immunologic and virologic testing. When 120mL of whole blood is drawn, it 
occurs on a day separate from other research laboratory testing to comply with clinical 
center blood draw limits and guidelines if the amount of research blood in additional to 

 
 
 
 
 
 
 
 
 
 
 
page 28 of 49 
clinical lab blood draw is expected to exceed Clinical Center guidelines, or the amount of 
whole blood in the syringe to be drawn on the same day is adjusted to abide by clinical 
center blood draw guidelines. No more than 550mL is drawn in any 8-week period. 
Lymphocytes are isolated from this sample and are used to quantify viral RNA expression 
and/or T-cell responses to HIV antigens, as well as other virologic and immune testing. 
This includes but is not limited to immune testing and may include measurement of 
circulating bulk T, B-lymphocyte and NK cell populations and peripheral blood as well as 
enumeration of HIV-specific CD8+ T cells by HIV tetramers and/or cytokine secretion and 
the capacity of CD8+ T-cells to proliferate in response to HIV antigens. Any remaining 
lymphocytes are cryopreserved and stored in liquid nitrogen for additional ancillary 
immunological and virologic testing. 
 
Table 8: Research Laboratory Testing 
Blood Lymphocyte Phenotype TBNK 
Flow Cytometry (CSF and blood) 
Blood HIV-specific T-cell responses 
Luciferase Immunoprecipitation Assay (LIPS) – mandatory 
at CSF paired timepoints, optional at non-CSF paired 
study visits 
Single copy HIV RNA analysis - mandatory at CSF paired 
timepoints, optional at non-CSF paired study visits 
 
4.7.c 
Lumbar puncture:   
A lumbar puncture is done before drug administration at the baseline visit and at week 3 
study visit as listed in Appendix A. There is an optional lumbar puncture at the 24-week 
study visit. Up to 25 mL of CSF is collected and may be evaluated for HIV-1 RNA, cell count 
and differential, total protein, glucose, IgG indices, flow cytometry and the presence of 
HIV-1 antibodies, standard CSF pathogens, CSF immune profile, and/or cytokine profile. 
Additional testing can be performed as necessary for clinical or research confirmation. 
Lymphocytes may be isolated from the CSF and used for virologic and immune testing as 
described in additional research blood draw. This procedure lasts from 30 minutes to 2 
hours.  The lumbar puncture is usually done on an inpatient or day hospital floor of the 
Clinical Center.  The procedure may be performed under fluoroscopic guidance by a 
credentialed neuroradiologist in Diagnostic Radiology, if there is a patient medical or 
scheduling need to do so. This involves a small amount of ionizing radiation (0.023 rem 
per year) per procedure. This is substantially less than the limits imposed by the guidelines 
of the NIH Radiation Safety Committee (5.0 rem per year for adults).  All persons of child-
bearing potential will have a pregnancy test performed within 24 hours prior to any LP 
being performed under fluoroscopy. Sedation with low-dose benzodiazepines may be 
used for subjects with anxiety during the LP. 
 

 
 
 
 
 
 
 
 
 
 
 
page 29 of 49 
4.7.d 
Leukapheresis: 
The patient may undergo leukapheresis (generally, 2 liters of whole blood will be 
processed to target a yield of 1-2 x10e9 mononuclear cells) in the Department of 
Transfusion Medicine (DTM) Dowling Apheresis Clinic according to DTM standard 
operating procedures. The procedure requires dual venous access and takes 
approximately 3-4 hours to complete. The procedures are carried out in such a way that 
the extracorporeal volume is no more than 15% of the blood volume in adults. 
Lymphocytes are isolated from this sample and used to characterize HIV biology including 
assessment of live virus reservoir when possible, as well as other virologic and immune 
testing. This includes but is not limited to immune testing and may include measurement 
of circulating bulk T, B-lymphocyte and NK cell populations and peripheral blood as well 
as enumeration of HIV-specific CD8+ T cell killing and/or cytokine secretion and the 
capacity of CD8+ T-cells to proliferate in response to HIV antigens. Any remaining 
lymphocytes will be cryopreserved and stored in liquid nitrogen for additional ancillary 
immunological and virologic testing. 
 
 
4.8 Neuroimaging evaluations 
4.8.a 
Magnetic resonance imaging (MRI):  
MRI of the brain is completed at the baseline visit (for applicable participants), week 3 
and week 24 Study Visits. MRI is performed with FDA-approved contrast (typically 
gadobutrol) of the cerebrum MRI of the brain lasts 1-2 hours. A macrocyclic gadolinium 
chelate is used in this study, and NIH Clinical Center Radiology and Imaging Sciences 
guidelines for gadolinium administration are followed.  
 
Under certain circumstances, participants in this study may receive a linear chelate. 
Examples of situations in which this may occur include the following: (1) prior sensitivity 
to all macrocyclic agents; (2) participation in a longitudinal study in which a linear chelate 
was previously given, there is a clear advantage to maintaining the same gadolinium 
protocol, and T1 signal change in the basal ganglia or dentate nuclei was not observed; 
(3) after consultation with, and approval by, a radiologist credentialed at the NIH Clinical 
Center.  
 
An 
FDA 
approved 
gadolinium 
guide 
is 
available 
on 
the 
FDA 
website: 
https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-
communication-fda-warns-gadolinium-based-contrast-agents-gbcas-are-retained-body. 
Participants are given a copy of the gadolinium guide. 
 
Sedation with a low-dose benzodiazepine may be used for subjects with anxiety during 
the MRI. 
4.8.b 
Positron Emission Tomography/ Computed Tomography (PET-CT):  
Brain 18FDG-PET/CT is completed at the baseline visit and repeated at the 3-week study 
visit to assess for CNS and HIV-reservoir site inflammation. PET/CT is performed with FDA-
approved glucose analog 2-deoxy-2(12F) fluoro-D-glucose (FDG). For patients who have 

 
 
 
 
 
 
 
 
 
 
 
page 30 of 49 
had a brain FDG-PET/CT in the prior 12 months, this scan can serve as the baseline 
neuroimaging study. FDG-PET/CT of the brain lasts no more than 3 hours. 
4.9 Drug dosing 
Pembrolizumab is dosed at the recommended 200mg, per FDA guidelines for approved 
conditions. Prior data on our HIV-positive patients with progressive multifocal 
leukoencephalopathy (PML) who received pembrolizumab for the treatment of JC virus 
reactivation show that PD-1 saturation on T-cells is present for up to 4-6 weeks post 2mg/kg 
infusion (data not published). 
4.10 
Drug administration 
Pembrolizumab 200mg is administered as a one-time intravenous infusion over 30 minutes 
during the treatment phase of the study. In our experience the study drug is very well 
tolerated with 650mg of oral acetaminophen and 25mg oral diphenhydramine 30 minutes 
prior to infusion. Unless there is a contraindication to one or either of these medications, all 
study subjects receive pre-medication 30 minutes prior to the pembrolizumab infusion due 
to the 0.1% risk of infusion reactions seen in clinical trials.[31] Post-infusion, patients are 
observed for safety purposes in the clinical center and admitted overnight if indicated for 
drug-related infusion side effects to be discharged the following day. 
4.11 
End of participation 
Following the completion of study procedures or withdrawal from the study, patients will 
receive ongoing care by their primary neurologist or infectious disease physician. Patients 
who self-referred to NINDS (for example, by finding the study listing on the NIH Clinical 
Center website) will be given a list of outside neurologists and/or infectious disease specialist 
after the initial evaluation if they do not have outside HIV management. Should any patient 
decide to discontinue participation, information relevant for the management of the 
patient’s condition will be discussed with the patient and the primary physician, and any 
treatment recommendations will be made. All patients will be discharged to their primary 
care physician for long-term management. Patients will be given study results that are 
pertinent to their ongoing clinical care. 
4.12 
Disease community engagement  
We plan to continue to engage the community and to disseminate trial results by engaging 
and presenting data to the ACTG community, to the NIMH Center Series, to the NIAID VRC 
HIV Cure Meetings, to the NIH Intramural Neuro-HIV retreat, at CROI and at the AAN. 
5. Management of Data and Samples 
5.1 Storage 
All collected samples, including serum; blood, CSF, and peripheral blood mononuclear cells 
(PBMC) derived from patients, are coded and stored in secured freezers on the NIH campus or at 
the NCI at Frederick Central Repository.  NIH samples are transferred and retained at the end of 
the study under a repository protocol. Loss or destruction of samples will be reported to the IRB. 
Study data is collected and stored in a 21 CFR Part 11 compliant database.  

 
 
 
 
 
 
 
 
 
 
 
page 31 of 49 
 
5.2 Data and sample sharing plan 
 
Data and samples may also be shared with collaborating laboratories at NIH or outside of NIH 
and/or submitted to NIH-designated repositories and databases if consent for sharing was 
obtained. Repositories receiving data and/or samples from this protocol may be open-access or 
restricted access. The intent is for all samples to be analyzed in laboratories on the NIH campus 
or associated contract laboratories.  Cell lines may be shared with other laboratories in a manner 
similar to that described previously. 
 
Samples and data are stripped of identifiers and may be coded (“de-identified”) or unlinked from 
an identifying code (“anonymized”). When coded data is shared, the key to the code is not be 
provided to collaborators, but remains at NIH.    Submission to non-NIH sponsored or supported 
databases and repositories will be submitted for prospective IRB approval. 
 
Imaging data without any personal or identifying information attached may be shared with other 
investigators or public data repositories in the spirit of the Final NIH Statement on Sharing 
Research Data (http://grants.nih.gov/grants/guide/notice-files/NOT-OD-03-032.htmL).  This 
provides the research community with open access to datasets contributed by labs around the 
world.  Information is either unlinked or coded, with demographics limited to age (accurate to the 
year), sex (male, female), group membership (e.g., disease/treatment state) and handedness.  For 
coded data, the investigators retain the key to the code, which is maintained on secured 
computers at NIH.  Data is transferred using secure file transfer protocols. 
 
For subjects enrolled in 13-N-0149, data and samples may be shared between investigators of 13-
N-0149 and the present study.  The data and samples may be shared with patients names and 
identifying information.  Sharing these data and samples helps minimize patients need to repeat 
procedures if data or samples are already collected, as they are co-enrolled in both studies.  
 
Required approvals from the collaborating institution is obtained and materials are shipped in 
accordance with NIH and federal regulations.    
6. Additional Considerations 
6.1 Research with investigational drugs or devices 
This study involves the use of Pembrolizumab, an FDA-approved medication for the treatment of 
non-resectable or metastatic melanoma, as well as refractory non-small cell lung cancer. This 
study was granted IND 133900 on May 25th, 2017. 
 
6.2 Gene therapy 
This study does not involve gene therapy 
 
6.3 MRI 
The following MRI scanners (NIH CC Radiology and Imaging Sciences Department) are used in this 
study: 
 
3.0 Tesla (Siemens) 

 
 
 
 
 
 
 
 
 
 
 
page 32 of 49 
• 
Device model: Prisma  
• 
Description of each component: FDA-approved head coil, pulse sequences, software and 
monitoring equipment 
• 
This device is classified as an FDA approved device (#K173592).  This device is being used 
as marketed. 
 
3.0 Tesla (Philips) 
• 
Device model: Achieva  
• 
Description of each component: FDA-approved head coil, pulse sequences, software and 
monitoring equipment 
• 
This device is classified as an FDA approved device (#K190461).  This device is being used 
as marketed. 
 
6.4 PET/CT 
The PET/CT is classified as an FDA approved device.  This device is being used as marketed, and as 
per FDA approved indications.  
7. Risks and Discomforts 
The most common adverse reactions to pembrolizumab (reported in ≥ 20% of cancer patients) 
include fatigue, cough, nausea, pruritus, rash, decreased appetite, constipation, arthralgia and 
diarrhea.[32] These are further elaborated on in Tables 3 and 4.[31, 32] 
 
As pembrolizumab is a humanized monoclonal IgG4 kappa immunoglobulin there is a potential 
risk of allergic reactions, including anaphylaxis.  If infusion toxicities occur, the infusion will be 
stopped.  The patient will be examined by a study investigator at the time of event.   
 
All patients are informed as to the 15-20% risk of the development of autoimmunity that was seen 
in patients with either melanoma or non-small cell lung cancer on repeat dosing as listed in table 
1.[31] There is also a theoretical risk of immune reconstitution inflammatory syndrome, although 
no reports exist in the literature to date. 
 
These immune-mediated adverse reactions that may require corticosteroid treatment and/or 
other supportive therapies. They include the following autoimmune conditions.  
 
o Pneumonitis 
o Colitis  
o Hepatitis  
o Hypophysitis  
o Nephritis  
o Hyperthyroidism and Hypothyroidism 
 
All patients are advised to report new or worsening cough, chest pain, shortness of breath, 
diarrhea, severe abdominal pain, jaundice, nausea, vomiting, easy bruising or bleeding, persistent 
or unusual headache, extreme weakness, dizziness, fainting, vision changes, bleeding in the urine, 
urinary pain, hair loss, heat or cold intolerance, changes in sweating patterns, severe fatigue, or 

 
 
 
 
 
 
 
 
 
 
 
page 33 of 49 
changes in weight loss or weight gain as these are frequent symptoms of the above listed 
autoimmune conditions. 
 
All male participants are advised that pembrolizumab may cause fetal harm. Sexually active 
participants are instructed to use highly effective contraception, with participants agreeing to use 
two methods of control including one barrier method, during and for 4 months after the last dose 
of pembrolizumab, if there is even a remote possibility of fathering a pregnancy.  
 
7.1 Risks of neurological evaluation 
There may be minimal discomfort associated with the clinical examination. 
7.2 Risks of blood drawing 
There may be some discomfort and bruising at the site of needle entry. There is a very small risk 
of fainting.  
7.3 Risk of intravenous line 
There may be some discomfort and bruising at the site of needle entry. Some people may feel 
light-headed or faint. There is a small risk of bleeding, infection or local inflammation of the skin 
and/or vein with possible pain and/or swelling. 
7.4 Risks of MRI 
People are at risk for injury from the MRI magnet if they have pacemakers or other implanted 
electrical devices, brain stimulators, dental implants, aneurysm clips (metal clips on the wall of a 
large artery), metallic prostheses (including metal pins and rods, heart valves, and cochlear 
implants), permanent eyeliner or tattoos, implanted delivery pump, or shrapnel fragments. 
Welders and metal workers are also at risk for injury because of possible small metal fragments 
in the eye, of which they may be unaware. All subjects are screened for these conditions prior to 
the study, and if they have any, they will not receive an MRI scan.   
 
7.5 Risks of intravenous gadolinium contrast 
Symptoms from the contrast infusion are usually mild and may include feeling hot, burning, or 
coldness in the arm during the injection, a metallic taste, headache, allergic reactions and nausea. 
In an extremely small number of individuals, more severe symptoms have been reported including 
shortness of breath, wheezing, hives, and lowering of blood pressure. Unless specifically allowed 
by the protocol, participants will not receive gadolinium-based contrast agents for research 
purposes if they have previously had an allergic reaction to them. Individuals with a history of 
anaphylaxis to other agents or chronic asthma requiring treatment will not receive gadolinium 
under this protocol unless they have previously received gadolinium and tolerated it well. 
Participants are asked about such allergic reactions and history of asthma before a contrast agent 
is administered.  
 
People with kidney disease are at risk for a serious reaction to gadolinium contrast called 
“nephrogenic systemic fibrosis,” which has resulted in a very small number of deaths. If subjects 
are 60 years old or greater or have diabetes, kidney disease or liver disease, blood work to assess 
kidney function will be performed within 4 weeks before any MRI scan with gadolinium contrast. 
Participants may not receive gadolinium for a research MRI scan if kidney function is not normal. 
There is no evidence for the potential of gadolinium-related toxicity in people with normal kidney 

 
 
 
 
 
 
 
 
 
 
 
page 34 of 49 
function. This protocol follows NIH Clinical Center guidelines for kidney-function screening related 
to gadolinium administration. 
 
Most of the gadolinium contrast is eliminated in the urine. However, recent studies have found 
very small amounts of residual gadolinium in the body, including the brain, by imaging and at 
autopsy. Macrocyclic gadolinium-containing contrast agents are substantially less likely to leave 
gadolinium behind than linear agents. The use of macrocyclic vs. linear agents in this study is 
delineated in the procedures section above. There is presently no evidence that the retained 
gadolinium is associated with any adverse effects.    
 
 
7.6 Risks of lumbar puncture 
Adverse effects associated with lumbar punctures include brief pain or tingling paresthesia 
radiating down the lower extremity due to the needle brushing against a nerve.  Should this occur, 
the needle can be repositioned.  Mild lower back pain at the site of needle insertion following the 
procedure can occur; this can be managed with over the counter non-steroidal anti-inflammatory 
agents if needed.  In approximately one third of patients, a post-dural puncture headache may 
develop and persist for a few days; in one in 50 to 200 lumbar punctures the post-dural puncture 
headache can last longer than 7 days.  Generally, this headache is not severe and resolves 
spontaneously within days - 2 weeks.  Should the headache persist or be severe, a blood patch 
can be performed.  An extremely rare complication of lumbar puncture includes temporary 
double vision related to abducens nerve palsy, and infection. Strict aseptic technique is followed. 
Collecting additional 10-15 mL of CSF per procedure represents negligible risk [35]. In humans the 
rate of CSF synthesis is approximately 21.5 mL/hour [36], or approximately 500mL/24hours, which 
represents roughly 4 times the total volume of CSF in an adult patient. Therefore, the volume of 
20-25mL of CSF that would be collected for both diagnostic and research purposes will be 
replenished in its entirety within approximately 1-1.5 hours after collection. 
 
 
7.7 Risks of sedation  
Subjects may be sedated for the MRI or lumbar puncture. Benzodiazepines cause sedation. Other 
possible side effects include confusion, dizziness and agitation. Monitoring is required in clinic 
after benzodiazepine administration and staff ensure that patient has a designated ride home, 
either through staff-arranged taxi or with a driver designated by the patient.  
 
 
7.8 Risks of PET/CT scanning 
There are no known physical hazards to subjects from being inside the PET/CT scanner, which 
detects injected radioactivity within the body.  Additionally, the scanning procedures are 
conducted in the presence of trained staff, should subjects experience any discomfort and require 
medical attention.  Subjects can communicate with the staff while in the scanner and can 
withdraw from the study at any time, if they wish to do so.  Occasionally subjects become anxious 
during the scanning procedure, in which case, they can request the operator to stop the scanning 
and to be removed from the scanning bed. 
 

 
 
 
 
 
 
 
 
 
 
 
page 35 of 49 
7.9 Risks of Fluorine-18-fluorodeoxyglucose 
Fluorine-18-labeled fluorodeoxyglucose (FDG) is a radioactive glucose analog used for metabolic 
imaging.  After intravenous injection, FDG is taken in organs proportionally in regard to glucose 
metabolism.  The brain has the highest uptake of FDG.  Imaging is recommended to begin after 
an uptake period of 1 hour.  The principal route of excretion of FDG is through the urinary system. 
The dose of FDG administered is approximately 10 mCi per scan.   
 
7.10 
Risks of Radiation Exposure  
PET/CT scans require exposure to radiation.  All tests requiring subject exposure to ionizing 
radiation are considered potentially hazardous.  A detailed breakdown of the radiation exposure 
risks expected for the subjects enrolled in this protocol are included in the NIH 88-23(a) 
Application for Authorization to Use Radiation in Research Involving Human Subjects.  The 
radiation received conforms to the NIH Radiation Safety Committee guidelines for subjects 
participating in research studies, defined as a 5-rem effective dose in 12 consecutive months.  The 
total radiation exposure from two PET/CT from this protocol in one year is 1.39 rem. Lumbar 
puncture may be done in the radiology department under fluoroscopic guidance for patient 
medical or scheduling needs. The total radiation exposure during the two procedures is 0.05 rem 
and for three procedures is 0.075 which is below the guideline of 5 rem per year allowed for 
research subjects by the NIH Radiation Safety Committee. 
 
The total radiation exposure that a participant may receive through participation in this study is 
1.47 rem, which is below the guideline of 5 rem per year allowed for research subjects by the NIH 
Radiation Safety Committee. 
 
7.11 
Risks of Premedication 
Premedication with standard dose diphenhydramine (Benadryl) and acetaminophen (Tylenol) is 
provided to study participants prior to receiving study drug. The risks of receiving 
diphenhydramine include drowsiness, dry mouth, urinary retention and constipation. The risks of 
receiving acetaminophen include allergic reaction, skin rash and liver injury. 
 
7.12 
Risks of Leukapheresis 
The potential risks associated with leukapheresis include lightheadedness, dizziness, possible 
fainting, tingling around the mouth and in the fingers and toes, nausea, chills, vomiting, mild 
muscle cramps, loss of <1 pint of blood, or pain, bruising, or discomfort at the needle insertion 
sites. Most procedures are performed without an incident. Blood components removed during 
leukapheresis are generally replaced by the body within a few hours or a few days. Temporary or 
permanent nerve damage may occur at the needle placement sites. There is also a risk of 
infection. These are very rare. To date, there have been no cases of permanent nerve damage or 
infection with apheresis at the NIH. 
8. Subject Safety Monitoring 
The NIH PI and DSMB are responsible for the safety of the participants and for monitoring and 
reporting any unanticipated problems or adverse events. The study personnel closely monitor 
patient safety during study procedures. Credentialed clinical staff monitor all contrast-enhanced 
MRI scans in accordance with NIH NMR Center policies.  

 
 
 
 
 
 
 
 
 
 
 
page 36 of 49 
The PI is responsible for overall study safety monitoring. The DSMB serves as the IND sponsor’s 
medical monitor and makes the final determinations of relatedness on behalf of the sponsor 
(NINDS). The DSMB is charged with reviewing all AEs at a bi-yearly meeting. The DSMB will be 
given reports as soon as possible but within 24 hours of a known grade 3 or higher AE, or an SAE, 
on an “ad hoc” basis. The DSMB will provide feedback to the study PI and NINDS within 7 days of 
received “ad hoc” reports, as well as after each bi-yearly meeting. Participants will be removed 
from the study if they are unable to cooperate with the study procedures, if a medical exclusionary 
condition develops, or if the principal investigator judge’s discontinuation to be in the 
participant’s best medical interest. If a patient experiences neurologic decline or other clinical 
conditions requiring immunomodulatory and immunosuppressive drugs including steroids during 
the trial, they will be discontinued from the trial and will receive standard medical care.   
8.1 Expected Adverse Events 
There is a potential for autoimmunity with cancer dosing protocols using pembrolizumab. The 
most frequently and consistently experienced adverse reactions (in at least 20% of patients taking 
the drug for refractory cancers) reported are fatigue, cough, nausea, pruritus, rash, decreased 
appetite, constipation, arthralgia and diarrhea. 
 
8.2 Monitoring of adverse events 
Patients will be instructed to contact the study investigators and/or seek medical care if they have 
any questions or concerns.  The patient will be instructed to contact the investigator immediately 
should he/she manifest any new sign or symptom or change in their condition during the period 
extending from the time of dosing to and including the final study visit at Week 52. Adverse events 
will be documented according to the criteria outlined in Section 25.4.  
 
Additionally, the patient is instructed to contact the investigator immediately if she becomes 
pregnant or if he believes that he has fathered a child.  Testing would be performed to verify that 
the subject or subject’s partner was pregnant.  If the pregnancy test were positive, the study 
subject and their partner would be offered consultation with an OB/GYN at the NIH for counseling. 
Subjects and their pregnant partners would be instructed to contact the investigator with any 
abnormalities experienced during their pregnancy, in the event of fetal loss, or if fetal 
malformations were present. Additionally, information on any live-birth children up to 12-week 
post-partum would be collected when possible.  
 
Patients are physically examined by the investigators or patient’s physicians approximately every 
3 to 6 weeks for the study duration until study visit week 24, except at visit week 12 and 18 as 
noted in Appendix A. Laboratory safety monitoring occurs every 3 to 6 weeks for the until study 
visit week 24 as listed in Appendix A.  
 
8.3 Toxicity tables/ criteria to be used 
Toxicity is assessed according to the U.S. Department of Health and Human Services, National 
Institutes of Health, National Cancer Institute Common Terminology Criteria for Adverse Events 
(CTCAE) v5.0. Available from: 
https://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/CTCAE_v5_Quick_
Reference_5x7.pdf 
 
 

 
 
 
 
 
 
 
 
 
 
 
page 37 of 49 
8.4 Treatment of adverse events 
Treatment of any AE is according to current available best treatment. Treatment of infusion 
reactions and immune-related adverse events will be treated based on standard of care using 
Merck protocol guidelines as a reference, included in Section 25.3, Appendix C. The applied 
measures will be recorded in the patient’s chart. All AEs occurring from the time of study drug 
dosing through the study follow-up period of 1+ years are documented, recorded, and reported 
as outlined in section 25.4.  
 
8.5 Criteria for Infusion-Related Toxicity 
If infusion-related toxicities occur, study drug will be discontinued.  If infusion related toxicity 
occurs, subjects will be monitored until toxicity resolves to less than Grade 1.   
 
8.6 Criteria for individual subject withdrawal   
A subject will permanently discontinue from the study if the subject desires to discontinue study 
drug monitoring under this protocol. Patients have the right to withdraw from the study at any 
time and for any reason. The investigator also has the right to withdraw patients from the study 
in the event of an intercurrent illness, adverse events, protocol violations, administrative reasons, 
or if it is in the best interest of the participant. However, all subjects wishing to withdraw from 
the study after receiving study drug will be invited to stay in the study to be monitored with clinical 
safety measures only (including clinical blood draws, neurologic and physical examinations, as 
well as MRI and FDG-PET studies), forgoing all further research testing from that timepoint 
forward. Patients who wish to withdraw fully from the study will be considered non-completers 
and will not be followed after the point of study withdrawal. Subjects who withdraw prior to 
receiving study drug will be considered dropouts and can be replaced.  
 
In the event that the subject or partner of an enrolled subject becomes pregnant within 4 months 
of the subject receiving study drug, information about the subject, the subject’s partner’s 
pregnancy, the outcome of the pregnancy, and the status of the infant at 8 to 12 weeks of age 
will also be collected. Participants will receive counseling with an OB/GYN consult. 
 
The reasons for discontinuation of the study drug must be recorded in the subject’s Clinical Center 
patient file. Patients withdrawing before receiving trial drug are discontinued from the study 
without further follow up. Patients withdrawing after receiving trial drug are offered clinical 
follow up for the study duration of 26 weeks, and, if they choose to remain enrolled will be 
followed and all adverse events up to 1 year will be reported and documented in the Clinical 
Center records. If discontinuation or withdrawal was because of an adverse event grade 3 or 
higher, the patient will be offered to stay in the trial for clinical follow up only until the event is 
resolved or stabilized for up to 1 year if patient received study drug. Patients who decline clinical 
follow up when offered will be withdrawn from the trial with no further follow up. 
 
Participants who withdraw voluntarily after initiation of the study but before receiving study drug 
are considered dropouts. These subjects can be replaced.  
 
Patients who voluntarily withdraw after receiving study drug but before the 3-week study visit 
will be considered non-completers.  

 
 
 
 
 
 
 
 
 
 
 
page 38 of 49 
9. Outcome Measures 
9.1 Primary outcome measures 
Frequency of grade 3 and higher AE that are definitely or probably causal to pembrolizumab. 
 
9.2 Secondary outcome measures 
i. 
Change in HIV-specific antibody responses in the CSF and serum using LIPS assay. 
ii. 
Change in CSF cytokine profile post-study drug. 
iii. 
Peripheral CD4+ counts.  
iv. 
HIV RNA in plasma and CSF.  
v. 
Change in FDG-PET/CT metabolic uptake in the CNS.  
vi. 
Change in PD-1 expression in the CSF and blood cells. 
10.  Statistical Considerations 
 
10.1 
General design 
This is a proof-of-concept, single-arm, phase 1 safety study of pembrolizumab given as a single 
dose of 200mg.  Each participant is followed for a total of 52-64 weeks for evaluation. This study 
will also collect CSF and plasma data at baseline and week 3 after treatment to assess 
immunologic responses against HIV after PD-1 blockade.   
 
10.2 
Analytical plan 
The primary objective of the study is to describe the safety of pembrolizumab in patients with 
HIV.  The analytical plan will be descriptive and will only include data starting at the baseline data 
point.  Proportions of adverse events will be reported along with exact 95% confidence intervals 
using the Clopper-Pearson approach (the binomial test function in R will be used for the 
calculations).  Any AE will also be reported. 
 
The secondary objective of the study is to assess the effects of pembrolizumab on various 
immunologic responses.  Paired t-tests (one-sided at 5% significance) will be used to test fold 
increase (on log scale) of the assays before and after treatment.  For example, for the antibodies 
to Tat, we will test the null hypothesis that the mean log-fold-increase will be log (1.2) versus the 
alternative that there is no increase in Tat over the 3-week post-treatment period.  In addition, 
95% confidence interval for the log fold change will be calculated to describe the variability of the 
endpoint.  As a sensitivity analysis, we will also perform a one-sided Wilcoxon signed rank test for 
the null hypothesis that the log-fold-change is symmetric about log (1.2) at 5% significance.  The 
signed rank test does not require normality of the log-fold-change (as the t-test does) and will 
ensure the test results are robust. 
 
We will also use the Berlin patient’s antibody levels as a benchmark for the post-treatment 
antibodies of the study participants.  Specifically, we will calculate the 95% confidence interval for 
each antibody mean and compare the interval to the Berlin patient’s average values for the 
antibody against each of the following proteins: gp41, gp120, matrix, p24, nucleocapsid, reverse 
transcription, integrase, protease, and tat.  
 

 
 
 
 
 
 
 
 
 
 
 
page 39 of 49 
Other secondary endpoints will be analyzed in a similar manner.  For change in PD-1 expression, 
change in CSF cytokine, and change in FDG-PET/CT uptake, paired t test and signed rank test will 
be conducted.  For all variables, 95% confidence intervals for the log change will be calculated.  
When data are available for the Berlin patient, we will also compare the confidence interval of 
these secondary endpoints to that of the Berlin patient. 
 
10.3 
Sample size and power considerations 
We plan to enroll a total 20 subjects and expect 12 patients will receive study drug to have 
complete follow up for safety (12 months) and CSF measurements (3 weeks).  
 
The sample size of this study was determined based feasibility, while aiming to enable the study 
team to collect data to decide on the next steps—in two ways: (1) the primary analysis will provide 
descriptive statistics of the AE rates, and (2) the secondary analysis will provide estimate of 
variability of the antibodies.  These data are useful for the planning of a proof of concept phase 2 
study where safety will continue to be monitored. 
 
In addition, we aim to be able to identify any unexpected severe AEs that may warrant trial 
stopping.  Specifically, with 12 patients, there is about 86% probability to detect any unexpected 
severe AEs that occurs at a rate of 15% or higher.  This probability calculation provides an 
assurance for detecting SAEs that are unexpected that may occur at a high rate (i.e. 15%).  We 
note that this is not intended to serve as a hypothesis test, but rather a monitoring mechanism. 
 
We will use the data to assess the variability in the antibody response and detect possible signals.  
For example, for the anti-Tat antibody analysis, we assume that the standard deviation of a log-
fold-increase is 0.25, based on Burbelo et al.[13]  Under this assumption, the one-sided t-test at 
5% level (described above) will have 81% power to conclude that the mean log-fold-increase in 
less than 1.2 under the alternative of a unity fold change.  Under the same assumption, a 5% 
Wilcoxon signed rank test (one-sided) has 74% power.  These calculations indicate that the pilot 
will be able to provide data on the variability in these antibodies and therefore to understand the 
treatment effects (clinically important difference divided over variability), if not demonstrate 
statistical significance.  
11.   Human Subjects Protection 
 
11.1 
Subject selection 
All adult patients with HIV-1 fulfilling all inclusion criteria and for whom none of the exclusion 
criteria are applicable, irrespective of gender or race are included in the trial. Patients 18 years 
and older are included in the trial as long as they are willing and able to comply with all the 
aspects of testing and treatment.  
 
11.2 
Justification for exclusion of children  
Due to the complex nature of this clinical trial, the greater than minimal risk, and the off-label use 
of pembrolizumab, children are not allowed to participate in this trial.   
 

 
 
 
 
 
 
 
 
 
 
 
page 40 of 49 
11.3 
Justification for exclusion of other vulnerable subjects  
Due to the complex nature of this clinical trial, and the off-label use of pembrolizumab, those who 
are not able to provide informed consent are not allowed to participate in this trial because the 
goals of the study can be achieved without by enrolling only those with capacity to consent, 
therefore the risks outweigh the benefits for this population.  
 
11.4 
Justification for sensitive procedures  
There are no sensitive procedures in this trial. 
 
11.5 
Safeguards for vulnerable populations and sensitive procedures  
Because pembrolizumab is rated as a category D drug in pregnancy with evidence of adverse 
effects in animal reproductive studies and absence of controlled studies in humans, participants 
are required to use appropriate methods of contraception for the trial. Women over age 55 who 
have not had a period for one year are considered menopausal and do not need pregnancy testing 
or contraception.  Women under the age of 55 are excluded unless there is a history of surgical 
menopause, tubal ligation or other history of surgical and/or medical sterility.   
 
 
12.  Anticipated Benefit 
Indirect benefit(s):  This study does not offer direct benefit to participants but is likely to yield 
generalizable knowledge about HIV viral reservoirs and will inform future clinical trials aimed at 
curative interventions. 
13.   Consent Documents and Process 
 
13.1 
Designation of those obtaining consent 
Study investigators designated as able to obtain consent in the study personnel page, obtain 
informed consent.  All study investigators obtaining informed consent have completed the NIMH 
HSPU ‘Elements of Successful Informed Consent’ training.   
 
13.2 
Consent procedures  
 
The informed consent document will be provided as a physical or electronic document to the 
participant for review prior to consenting. A designated study investigator will carefully explain 
the procedures and tests involved in this study, and the associated risks, discomforts and benefits. 
In order to minimize potential coercion, as much time as is needed to review the document will 
be given, including an opportunity to discuss it with friends, family members and/or other 
advisors, and to ask questions of any designated study investigator. A signed informed consent 
document will be obtained prior to any research activities taking place.  
 
In the event that circumstances beyond our control preclude the travel to the NIH Clinical Center 
for a visit, or otherwise would put their health at greater risk (i.e. epidemic or pandemic), we will 
endeavor to establish capabilities for remote consent. The initial consent process as well as re-

 
 
 
 
 
 
 
 
 
 
 
page 41 of 49 
consent, when required, may take place in person or remotely (e.g., via telephone or other NIH 
approved remote platforms used in compliance with policy, including HRPP Policy 303) per 
discretion of the designated study investigator with the agreement of the participant. 
 
A physical copy of the consent form may be sent to the subject if a telephone consent process is 
used. The consent interview may then be conducted when the subject can read the consent form 
during the discussion. Whether in person or remote, the privacy of the subject will be maintained. 
Consenting investigators (and participant, when in person) will be located in a private area (e.g., 
clinic consult room). When consent is conducted remotely, the participant will be informed of the 
private nature of the discussion and will be encouraged to relocate to a more private setting if 
needed. If the consent process is occurring remotely, participants and investigators will view 
individual copies of the approved consent document on screens at their respective locations; the 
same screen may be used when both the investigator and the participant are co-located but this 
is not required. 
 
Note: When required, the witness signature will be obtained similarly as described for the 
investigator and participant below. 
 
Consent will be documented with required signatures on the physical copy of the consent 
(which includes the printout of an electronic document sent to the participant), or on the 
electronic document. The process for documenting signatures on an electronic document is 
described below. 
When an electronic document is used for the documentation of consent, this study will use the 
iMedConsent platform which is 21 CFR, Part 11 compliant to obtain the required signatures. 
During the consent process, participants and investigators will view the same document 
simultaneously in their respective locations.  
The identity of the participant will be determined by a prompt which will require the provision 
of information from an official identification document, prior to obtaining the signature. Both 
the investigator and the participant will sign the electronic document using a finger, stylus or 
mouse. 
A copy of the informed consent document signed and dated by the subject are given to the 
subject. Confirmation of a subject’s informed consent is documented in the subject’s medical 
records prior to any testing under this protocol. 
The initial consent process as well as re-consent, when required, may take place in person or 
remotely (e.g., via telephone or other NIH approved remote platforms) per discretion of the 
designated study investigator and with the agreement of the participant. During the consent 
process, participants and investigators will view the same approved consent document 
simultaneously in their respective locations. 
Whether in person or remote, the privacy of the subject will be maintained. Consenting 
investigators (and participant, when in person) will be located in a private area (e.g., clinic consult 

 
 
 
 
 
 
 
 
 
 
 
page 42 of 49 
room). When consent is conducted remotely, the participant will be informed of the private 
nature of the discussion and will be encouraged to relocate to a more private setting if needed. 
 
The investigator obtaining consent documents the consent process in the participant’s medical 
record. All instances of use of the CC Short Written Consent Form are reported to the IRB at the 
time of annual review. Interpreters are present for other protocol procedures as necessary. 
 
 
 
13.3 
Consent documents 
The consent form contains all required elements. The consent form is attached in iRIS. 
14.   Data and Safety Monitoring 
 
14.1 
Data and safety monitor 
 Data and safety is monitored by a Data and Safety Monitoring Board (DSMB). 
 
14.2 
Data and safety monitoring plan 
 Parameters that will be monitored for the study as a whole: 
a. MRI brain 
b. FDG-PET/CT 
c. Clinical and laboratory data  
 
The clinical data, including clinical laboratory parameters and physical examination with MRI 
results are reviewed by the study investigators weekly in a clinical care meeting. If a clinical 
care meeting is not able to be scheduled due to holiday, conflicting schedules, or inclement 
weather, the PI will review the clinical data within one week of the patient’s visit. Additionally, 
research data will be reviewed within one week of acquisition in weekly laboratory meeting, 
or at the clinical care meeting.   
   
The DSMB serves as the sponsor’s medical monitor and will make the final determinations of 
relatedness on behalf of the IND sponsor (NINDS). The DSMB is charged with reviewing all AEs 
at a bi-yearly meeting. This meeting may take place in person, as a tele-conference, web-
meeting or via email. The DSMB will operate under the rules of an approved charter. 
Reviewers will have access to unblinded and interim study data and will be given a pre-
meeting report a week prior to the scheduled interim bi-yearly meetings. After the bi-yearly 
interim meetings and the 90-day safety meeting, the DSMB chair will provide a report to the 
study PI and NINDS Office of the Clinical Director within 14 days. 
 
The DSMB will be given reports within 24 hours of a known grade 3 or higher AE, or SAE, on 
an ad hoc basis. The DSMB will be given reports within 7 days of any known grade 2 AE 
involving the following irAE diagnoses: Pneumonitis, Colitis, Hepatitis, Hypophysitis, 
Nephritis, Hyperthyroidism and/or Hypothyroidism. The DSMB will provide feedback to the 
study PI and the IND sponsor (NINDS) within 7 days of received ad hoc notifications.  
 

 
 
 
 
 
 
 
 
 
 
 
page 43 of 49 
14.3 
Criteria for stopping the study or suspending enrollment or procedures 
The study will be stopped/suspended and DSMB review will be triggered if one or more 
subjects develop: 
o Any SAEs deemed to be possibly, probably, or definitely attributable to study 
medication by the Investigator and/or the data and safety monitoring board. 
o One grade 4 AE or lab abnormality deemed to be possibly or probably related to 
the study medication by the Investigator and/or the safety monitoring 
committee. 
o Two grade 3 AEs or lab abnormalities that are similar in nature and deemed to be 
possibly or probably related to the study medication by the Investigator and/or 
safety monitoring committee. 
o An anaphylactic reaction deemed to be at least possibly related to the study 
medication by the Investigator and/or the safety monitoring committee. 
o A pattern of significant symptoms, physical findings, or laboratory abnormalities 
(adverse events) that, although individually minor, collectively represent a safety 
concern in the opinion of the investigator and/or the safety monitoring 
committee and are judged to be at least possibly related to study medication. If 
this pattern is noted by the investigator during the infusion of study treatment, it 
should be stopped immediately and the subject should be further evaluated and 
treated. 
 
The FDA will be notified immediately if the study is suspended for reasons of safety. In the event 
that the study is stopped or suspended, the DSMB will convene to review the interim study data 
until the time of stoppage or suspension. The study will resume only in the event that DSMB 
review determines an adverse event meeting the stopping criteria (significant symptoms, physical 
findings and/or laboratory abnormalities) to be unlikely due to or unrelated to study drug.  
15.   Quality Assurance (QA) 
 
15.1 
Quality assurance monitor 
The PI and the IND sponsor’s Contract Research Organization (CRO) perform quality assurance 
monitoring for this study.  
 
15.2 
Quality assurance plan 
The PI and co-investigators meet monthly to review quality control on all data. Additionally, 
clinical data (including clinical labs and physical exam) collected on individual subjects is reviewed 
by study investigators within one week of each visit.  A Contract Research Organization (CRO) 
provides on-site monitoring of this protocol.  An initial visit was conducted by the CRO, following 
final approval of the protocol by the IRB and FDA.  During the site initiation visit, the study team 
and the monitor determined the frequency of monitoring visits.  The sponsor via the CRO, is 
responsible for providing adequate oversight of the investigation to ensure adequate protection 
of the rights, welfare, and safety of human subjects and the quality and integrity of the resulting 
data.  The purpose of the QA audit is to assess compliance with applicable regulatory 
requirements, good clinical practice guidelines, NINDS policy, as well as to provide 
recommendations for improving the management of clinical research data.   

 
 
 
 
 
 
 
 
 
 
 
page 44 of 49 
16. Reporting of Unanticipated Problems, Adverse Events and Protocol 
Deviations 
 
Reportable events will be tracked and reported in compliance with Policy 801.  
17.   Alternatives to Participation  
 
FDA approved medications to treat HIV infection is combination antiretroviral therapy. Patients 
will continue antiretroviral therapy on this trial. There is no FDA approved drug therapy for 
evaluation of a viral reservoir in HIV infection. The alternative to participate is therefore to remain 
on FDA approved therapy with no additional medication. The study drug is FDA approved for the 
treatment of specific refractory cancers, but not for the evaluation of HIV reservoirs. 
18.   Privacy 
 
Participant confidentiality and privacy is strictly held in trust by the participating investigators 
and their staff. This confidentiality is extended to cover testing of biological samples and genetic 
tests in addition to the clinical information relating to participants. Therefore, the study 
protocol, documentation, data, and all other information generated will be held in strict 
confidence. 
 
All research activities are conducted in as private a setting as possible. 
19.   Confidentiality 
 
To further protect the privacy of study participants, a Certificate of Confidentiality has been 
issued by the National Institutes of Health (NIH).  This certificate protects identifiable research 
information from forced disclosure. It allows the investigator and others who have access to 
research records to refuse to disclose identifying information on research participation in any 
civil, criminal, administrative, legislative, or other proceeding, whether at the federal, state, or 
local level. By protecting researchers and institutions from being compelled to disclose 
information that would identify research participants, Certificates of Confidentiality help achieve 
the research objectives and promote participation in studies by helping assure confidentiality 
and privacy to participants. 
 
19.1 
For research data and investigator medical records 
Each participant receives a unique study ID number at the time of enrollment. A master list 
correlating the unique numbers with personal health information such as names, addresses, and 
contact information will exist but will only be accessible to investigators on this protocol in order 
to minimize the risk of compromising confidentiality. These data are kept in password-protected 
computers on the NIH campus. De-identified results from clinical trials will be posted on 
cctrials.gov 

 
 
 
 
 
 
 
 
 
 
 
page 45 of 49 
19.2 
For stored samples 
Data and samples are stored in secured areas. Samples kept at NIH are stored in a coded fashion 
in a locked room. Clinical data is stored on a secure NINDS server. Identifiable information is not 
released without the patient’s signed release form, except when authorized by law.  
20.   Conflict of Interest 
 
20.1 
Distribution of NIH guidelines 
NIH guidelines on conflict of interest have been distributed to all investigators.   
 
20.2 
Conflict of interest  
 There are no conflicts-of-interest to report. 
21.   Technology Transfer 
 
A technology transfer agreement is in place for this protocol. 
 
The independence of this study from any actual or perceived influence is critical.  Therefore, any 
actual conflict of interest of persons who have a role in the design, conduct, analysis, 
publication, or any aspect of this trial will be disclosed and managed. Furthermore, persons who 
have a perceived conflict of interest will be required to have such conflicts managed in a way 
that is appropriate to their participation in the design and conduct of this trial.  The study 
leadership in conjunction with the Technology Transfer office of NINDS has established policies 
and procedures for all study group members to disclose all conflicts of interest and will establish 
a mechanism for the management of all reported dualities of interest. 
 
Samples and data derived from this protocol may be analyzed in conjunction with outside 
collaborators, and in these instances materials and data transfer agreements will be obtained, 
or existing agreements will be followed. 
22.   Research and Travel Compensation  
 
Participants are compensated for research-related discomfort and inconveniences in accord with 
NIH guidelines. NIH provides partial travel to and from the Clinical Center in Bethesda, Maryland 
within the United States per established policy. Compensation rates are comparable to those at 
NIH and an escort fee is not provided. Compensation is prorated for parts completed if subjects 
do not complete the study.  
 
 
 
Table 9. Subject Reimbursement.   
 
Inconvenience 
units 
Pay for 
inconvenience  
Time 
(h) 
Pay 
for 
time  
Total 
Occurrences 
Pay 
 
Pay for Study 
Completion 
FDG-PET/CT 
15 
150.00 
3 
40.00 
2 
190.00 
380.00 

 
 
 
 
 
 
 
 
 
 
 
page 46 of 49 
MRI 
10 
100.00 
2 
30.00 
3 
130.00 
390.00 
Lumbar puncture 
12 
120.00 
2 
30.00 
3 
150.00 
450.00 
Antecubital 
venous catheter 
3 
30.00 
 
 
5 
30.00 
150.00 
Leukapheresis 
17.5 
175.00 
 
 
3 
175.00 
525.00 
Gadolinium 
administration 
2 
20.00 
 
 
3 
20.00 
60.00 
Blood Draw 
3 
30.00 
1 
20.00 
9 
50.00 
450.00 
Clinic Visit 
4 
40.00 
1 
20.00 
9 
60.00 
540.00 
Total 
 
 
 
 
 
 
2945.00 

 
 
 
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