Defining Antiretroviral Pharmacology Within HIV-1 Reservoirs of Males and Females
Phase: PHASE4
Conditions: HIV
Sponsor: Emory University

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Defining Antiretroviral Pharmacology Within HIV-1 Reservoirs of Males and Females 
Protocol date: September 8, 2020 
NCT number: NCT02924389 
 
PRINCIPAL INVESTIGATOR 
 
Cecile Delille Lahiri, M.D. 
 
 
 
 
 
Assistant Professor of Medicine 
 
 
Division of Infectious Diseases 
 
 
 
Emory University School of Medicine 
 
 
 
 
 
 
 
CO-INVESTIGATORS 
 
 
 
 
 
 
 
 
Ighovwerha Ofotokun, M.D., M.Sc.  
Associate Professor of Medicine  
Division of Infectious Diseases 
Emory University School of Medicine 
 
Anandi Sheth, M.D. 
Assistant Professor of Medicine 
Division of Infectious Diseases 
Emory University School of Medicine 
 
Lisa Haddad, M.D, MS, MPH 
Assistant Professor 
Department of Gynecology and Obstetrics 
Emory University School of Medicine 
 
Lisa Flowers, M.D. 
Professor 
Department of Gynecology and Obstetrics 
Emory University School of Medicine 
 
 

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CONTENTS 
 
Section 
 
 
 
 
 
 
 
Page(s) 
 
ABBREVIATIONS 
 
 
 
 
 
 
3-4 
 
ABSTRACT 
 
 
 
 
 
 
 
5 
 
LAY SUMMARY 
 
 
 
 
 
 
6 
 
1.  Study Aims & Hypotheses  
 
 
 
 
7 
 
2.  Introduction 
 
 
 
 
 
 
8-9 
 
3.  Study Design 
 
 
 
 
 
 
10-13 
 
4.  Selection/Enrollment of Participants 
 
 
 
13-15 
 
5.  Clinical and Laboratory Evaluation 
 
 
 
15-16 
 
6.  Statistical Considerations  
 
 
 
 
16-17 
 
7.  Data Collection & Monitoring 
 
 
 
 
18 
 
8.  Human Subjects 
 
 
 
 
 
 
19-20 
 
9.  Data Safety & Monitoring Plans  
 
 
 
20 
 
10.  Sponsor  
 
 
 
 
 
 
20 
 
11.  Biohazard Containment  
 
 
 
 
20 
 
12.  References 
 
 
 
 
 
 
20-22  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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ABBREVIATIONS 
 
AAUCMB = average area under the curve minus baseline 
 
ARV = antiretroviral 
 
AUC = area under the curve 
 
BP = blood plasma 
 
CL/F = oral clearance of drug 
 
Cmax = maximum drug concentration 
 
Cmin = minimum drug concentration 
 
CNS = central nervous system 
 
CSF = cerebrospinal fluid 
 
DTG = dolutegravir 
 
DTG Ct24h = DTG total concentration 24 hours post dosing 
 
Emax = maximum drug effect 
 
EC90 = DTG Ct24h required to produce 90% of the maximum drug effect 
 
EC95 = DTG Ct24h required to produce 95% of the maximum drug effect 
 
HAART = highly active antiretroviral therapy 
 
HPLC-MS/MS = high performance liquid chromatography – tandem mass spectroscopy 
 
INSTI = integrase strand transfer inhibitor 
 
LPV/RTV = lopinavir/ritonavir 
 
PBMCs = peripheral blood mononuclear cells 
 
PK = pharmacokinetic 
 
PD = pharmacodynamic 
 
RT-PCR = real time-polymerase chain reaction 
 
TDF/FTC = tenofovir disoproxil fumarate/emtricitabine 
 
Tmax = time to Cmax 
 
Tmin = time to Cmin 
 

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T1/2 = half life 
 
VD = viral dynamic 
 
WIHS = Women’s Interagency HIV Study 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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ABSTRACT 
Emerging evidence indicates that sites outside of blood plasma, such as peripheral blood mononuclear cells 
(PBMCs) and gut-associated lymphoid tissue, remain reservoirs for HIV and play critical roles in viral persistence 
despite long-term potent combination antiretroviral therapy (cART). Suboptimal ARV drug concentrations within 
these reservoirs are thought to contribute to our inability to fully eradicate HIV. In addition, host factors such as 
sex have been found to impact ARV drug exposure within these sites and effect key outcomes such as time to 
virologic suppression. Our understanding of reservoir site pharmacology and the impact on sex is limited due to 
several barriers: 1) Difficulty in sampling reservoir sites intensively and 2) Scarcity of women enrolled in HIV 
clinical research studies. Optimal drug concentrations are ideally determined early in drug development by dose-
ranging studies that require intensive blood plasma sampling; this methodology is impractical to employ within 
tissue sites. To mitigate these barriers, we propose to study the pharmacology of the integrase strand transfer 
inhibitor dolutegravir (DTG) within three body compartments: blood plasma, PBMCs, and rectal tissue using a 
novel integrated population pharmacokinetic-viral dynamic (PK-VD) modeling approach. This PK-VD modeling 
strategy generates concentration-response relationships with limited sampling and dosing simulations ideally 
suited to reservoir sites. Additionally, we will prioritize the exploration of sex differences by leveraging our 
extensive research infrastructure, including the clinical core of the Emory Center for AIDS Research (CFAR), the 
Atlanta Clinical and Translational Science Institute (ACTSI), and the motivated cohort of the Atlanta Women’s 
Interagency HIV Study (WIHS). We hypothesize that integrated population PK-VD modeling will show that 
optimal drug doses needed to suppress HIV will be higher in PBMC and rectal tissue reservoirs compared to 
blood plasma and will be different between males and females.  
 
Our proposed aims are: 1) Compare descriptive data generated from our DTG PK-VD blood plasma model to 
existing dose-ranging study data for validation, 2) Extend the development of DTG PK-VD models to PBMC and 
rectal tissue reservoirs, and 3) Investigate sex differences in DTG PK-VD in all three body sites.  To accomplish 
this, 20 HIV-infected males and 20 HIV infected females (total n = 40) will be enrolled in a 168 day (6 month) 
longitudinal study whereby blood plasma, PBMCs, and rectal tissue will be serially sampled during six (6) study 
visits to measure DTG concentrations, HIV-1 RNA viral load, and perform 3 different assays to measure the HIV 
reservoir, including total cell-associated HIV DNA,  2-LTR unintegrated HIV DNA circles, and a modified rapid 
low cell quantitative viral outgrowth assay (QVOA). From these data, integrated population PK-VD models will 
be constructed and dosing simulations used to determine optimal drug exposure needed to attain virologic 
suppression at all three sites within males and females. With support from a multi-disciplinary team of mentors, 
completion of this work will uniquely position me for an independent research career integrating pharmacologic 
interventions within HIV cure stratagems. 
 
Duration 
Enrollment is expected to take 36 months, with completion of all study visits in 40 months.  Data collection will 
be completed after sample collection of the last enrolled participant at their Day 168 visit. 
Sample size 
A sample size of 20 HIV-infected women and 20 HIV-infected men will be enrolled in this study. 
 
Population 
HIV-1 infected women enrolled in the Emory Women’s Interagency HIV Study (WIHS), Ponce de Leon Center, 
or other community HIV clinic and men enrolled at the Ponce de Leon Center or other community HIV clinic. 

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LAY SUMMARY 
 
Even with strong HIV medications, there is no known cure for HIV infection.  When a person is infected with HIV, 
studies have shown that the virus enters many different parts of the body, including the brain, lymph nodes, the 
gut (including the rectum), and special cells in the blood.  HIV medications are very good at getting into blood 
plasma and killing the virus, but may have limited ability to get into some of these other places.   In sites such as 
special blood cells and the gut, the virus can hide from HIV medications. 
 
The dose of HIV medication needed for good HIV control is decided by studies that look at drug levels in the 
blood plasma of patients.  While the dose of medication may be good enough to control HIV infection in blood 
plasma, it may not be good enough to control HIV infection in these other hard-to-reach sites.   
 
The purpose of this study is to find out how well the HIV medication dolutegravir (DTG/Tivicay), a FDA approved 
HIV medication for the treatment of HIV infections, gets into different parts of the body:  including blood plasma, 
special blood cells, and rectal tissue.  Specifically, we want to compare how fast dolutegravir (DTG) lowers the 
HIV viral load in these three different sites. In addition, we want to see if there are any differences in how 
dolutegravir acts in males and females. Results of this study will give us more information about HIV medications 
and their limitations.  In the future, this could help us create better HIV medications that can get into these hard-
to-reach places and eventually cure HIV infection. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1. STUDY AIMS AND HYPOTHESES 
 
1.1 Aim 1 
 
The primary aim of this study is to validate the integrated population PK-VD model that 
quantitatively describes the relationship between DTG exposure and HIV viral decay in BP.  
 
Twenty (20) HIV-infected women and twenty (20) men will undergo BP sampling for HIV-1 RNA and 
DTG concentrations following first dose oral administration of Triumeq ( DTG 50 mg/Abacavir, ABC 600 
mg/ Lamivudine, 3TC 300 mg) or DTG (50 mg) plus standard dose of co-formulated tenofovir disoproxil 
fumarate (TDF)/ emtricitibine (FTC) on days 14, 42, 168, and repeat intensive sampling over 24 hours 
following observed dosing at day 84 for steady state parameter estimates.  Integrated population PK-
VD modeling and simulation will be used to estimate the EC90, defined as the DTG Ct24h (DTG total 
concentration 24 hours post dosing) required to produce 90% of the maximum drug effect (Emax), and 
other PK-VD parameters.   
 
 
Hypothesis:  A population PK-VD model with exposure-response simulations will show that optimal 
DTG doses needed for virologic suppression are higher in PBMCs and rectal tissue compared to BP.  
 
1.2 Aim 2 
 
The second aim of this study is to develop an integrated population PK-VD model to describe 
the relationship between DTG exposure and HIV viral decay in PBMCs and rectal tissue 
reservoir sites.   
HIV-1 infected subjects initiating therapy with a DTG-based HAART regimen will undergo collection of 
PBMCs at Baseline and on Days 14, 42, 84, and 168.   Rectal tissue will be collected within 7 days of 
ART initiation, and on Days 42, 84, and 168 for DTG concentrations and quantitation of the HIV 
reservoir by measuring HIV RNA, total cell-associated HIV DNA, 2-LTR DNA circles, and by performing 
a modified QVOA.   Integrated population modeling and simulation will be used to estimate EC90 at 
each site.   
Hypothesis:   A population PK-VD model will accurately estimate DTG EC90, Emax (concentration 
required for maximum effect), and optimal dose needed for virologic suppression in BP. 
1.3 Aim 3 
The third aim is exploratory and will investigate sex differences in DTG penetration into blood 
plasma, PBMC and rectal tissue reservoirs as well as its impact on the rectal microbiome.   
Integrated population modeling and simulation will be used to estimate EC90 at each site. 
Hypothesis:  A population PK-VD model with exposure-response simulations will show that DTG 
exposure differs between males and females and is associated with both viral dynamic changes within 
PBMC and rectal tissue reservoirs as well changes within the rectal microbiome.   
 
 
 
 

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INTRODUCTION 
 
1.4 Background 
 
Emerging evidence suggests that sites such as gut tissue and peripheral blood mononuclear cells 
(PBMCs) remain reservoirs for HIV-1 and play critical roles in viral persistence despite combination 
antiretroviral therapy (cART)[1-11].  Leading theories to explain barriers to HIV eradication from 
reservoirs include 1) ongoing proliferation of latently infected cells invulnerable to cART and 2) 
continuing viral replication due to suboptimal antiretroviral (ARV) tissue concentrations[8, 12, 13].  
In response, the HIV cure agenda has focused on strategies such as “shock and kill”, whereby 
latently infected cells are activated (“shocked”), making them susceptible to killing by immune 
attack and/or cART[14].  To achieve killing by cART, drugs must be capable of penetrating 
reservoirs.  This approach requires a clear understanding of drug pharmacokinetics (PK) and HIV 
viral dynamics (VD) specifically in these affected sites.  Drug and host characteristics, including 
factors modulated by patient’s sex [15-18], result in drug distribution and disposition that differs 
between blood plasma (BP) and other body compartments [19, 20]. For example, lower ARV 
concentrations in lymphatic tissues were found to be associated with persistent HIV replication 
[13].  Likewise, sex differences have been noted in PK parameters of multiple ARV drugs within 
BP[21-25] and PBMCs[26-29], with females showing more rapid HIV viral load decay and shorter 
time to plasma virologic suppression than males[25, 29]. Most of these prior studies are limited by 
examination of sex differences only in secondary analyses.  Improved understanding of ARV 
PK-VD within HIV reservoirs of males and females will have far-reaching public health 
implications by informing the development of sex-specific pharmacologic HIV cure 
strategies.   
A key obstacle to reservoir PK-VD assessment is the challenge of repeated tissue sampling, which 
is necessary to establish pharmacologic parameters in traditional dose-ranging studies. This is 
further compounded by paucity of PK-VD data in women who account for >50% of the 36.9 million 
people living with HIV worldwide[30], yet represent < 18% of participants in clinical studies of HIV 
cure[31]. Integrated population PK-VD modeling uses mathematical modeling and dose-ranging 
simulations to simultaneously describe drug exposure and VDs and generate concentration-
response relationships. We have recently shown that a PK-VD modeling and simulation tool can 
accurately predict the PK-VD relationship for a fixed dose of LPV/RTV in a small number of 
patients[32]. We propose to test this novel PK-VD modeling approach to generate concentration-
response relationships using limited tissue sampling combined with dosing simulations for 
dolutegravir (DTG) to test a more practical approach for pharmacologic assessment of deep-
seated reservoirs.  Leveraging our extensive translational research infrastructure supported by the 
clinical core of the Emory Center for AIDS Research, the Atlanta Clinical and Translational Science 
Institute, and access to the motivated female cohort in the Atlanta Women’s HIV Interagency 
Study, we will apply integrated PK-VD models to assess relationships between DTG exposure and 
HIV viral dynamics in 3 compartments, BP, PBMCs, and rectal tissue, in HIV-infected females and 
males.  DTG was chosen because of its potent antiviral activity, excellent safety profile, and 
published robust dose-ranging study data in BP.   
 
1.5 Potential significance 
 
1. We will investigate the utility of a novel strategy, integrated population PK-VD modeling, to predict 
DTG exposure needed for virologic suppression in BP. This model differs from early phase PK-PD 
models in that it utilizes data from participants on fixed-dose drug instead of different doses. In 
place, dosing simulations will be employed to predict optimal dose needed for virologic suppression.  
This approach will complement efforts to generate PK-VD data for clinical decision making for drugs 
where data are lacking.   
 

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2. Applying this model to predict PK-VD parameters in PBMCs and rectal mucosa is innovative. 
 
3. The recruitment of women, via the resources of an established cohort of women in the Atlanta WIHS, 
will be a priority enabling the study of sex differences. This will provide novel PK-VD data on females in 
an area where relevant sex-specific data are not available.   
 
4. Using multiple different assays to measure the HIV reservoir, including HIV RNA, total cell 
associated HIV DNA, 2-LTR DNA circles, and modified QVOAs allows a multi-faceted mechanism to 
evaluate the reservoir so that we can better understand the overall size, replication competence of 
latent virus, and the cell subset origin of latent virus.  Together, this information provides key insight into 
understanding where the viral reservoir is located, which subsets harbor the virus, which latent cells are 
capable of producing replication-competent virus, and differences across tissues and sex. 
 
 
 
2. STUDY DESIGN 
 
3.1  Study design overview 
The primary aim of this study is to determine whether DTG plasma PK-VD parameters can be 
accurately estimated using an integrated population PK-VD model with data derived from subjects 
initiating a uniform dose of a DTG-based HAART regimen compared to a standard dose-ranging study. 
It will be descriptive in nature and will involve HIV-infected women and men prospectively recruited 
from the Atlanta WIHS cohort, the Ponce de Leon Center, and community HIV clinics.  Population PK-
VD modeling will be applied. Subjects will undergo intensive blood sampling over a period of 6 months 
following HAART initiation, as shown in Figure 1. Plasma DTG concentration will be measured by 
HPLC-MS/MS and plasma HIV RNA will be quantified by RNA extraction, reverse transcription 
polymerase chain reaction (RT-PCR), and PCR amplification. DTG concentrations and viral dynamic 
data will be modeled to generate blood plasma DTG EC90, Emax, and other PK-VD metrics of interest.  
DTG was selected because of the abundance of dose ranging PK-PD data available in the literature for 
validation. A 6-month study duration suffices as DTG based HAART regimens are very potent and have 
steep viral decay slopes with most HIV-infected individuals achieving undetectable plasma viral loads at 
or before this time point on DTG-based therapy [33]. 
The second aim will be exploratory:  we will expand the integrated population PK-VD approach to test 
its utility in the estimation of PK-VD parameters including EC90 and Emax in two other reservoir sites: 
PBMCs and rectal tissue. PBMCs will be collected at Baseline and Days 14, 42, 84, and 168. Rectal 
tissue will be collected within 7 days of ART initiation and on Days 42, 84, and 168, as shown in Figure 
1. Intracellular and rectal tissue DTG concentrations and HIV RNA will be quantified using similar 
techniques as for blood plasma, but validated for these tissues. As measurement of HIV RNA only 
provides a very limited view of the total HIV reservoir, we will also measure the reservoir using three 
additional assays:  total cell associated HIV DNA, 2-LTR DNA circles, and a modified QVOA. 
Aim 3 seeks to investigate sex differences in penetration of DTG into blood plasma and PBMC and 
rectal tissue reservoirs, as well as differences in the rectal microbiome. 

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3.2  Study entry and initial screening 
 
• 
If a person agrees to participate and provides informed consent, a screening evaluation will occur at 
the clinical core of the Emory Center for AIDS Research (CFAR) at the Grady IDP or at the Grady 
Hospital CRN, a core equipped with state-of-the-art facilities for clinical research. Screening will include 
informed consent, a review of medical and medication history, and assessment for eligibility. HIV status 
will be verified with documentation of HIV ELISA test confirmed with western blot or plasma HIV-RNA. 
Screening laboratory tests, if not already available within 90 days prior to screening, will be conducted 
at the Grady clinical laboratories on a fee-for-service basis and will include complete blood count (CBC) 
with platelet and differentials, and full chemistry. Consecutive potential participants in the Atlanta WIHS 
cohort will be screened until 40 eligible participants are enrolled (20 females and 20 males).  
Participants will receive $20 in compensation after completion of the screening visit.  A preliminary 
consent-only visit may also be conducted if necessary. 
• 
It is important to know that for this study, the study drug, dolutegravir (DTG/Tivicay) is FDA approved 
for the treatment of HIV infections and can be given in combination with other antiretrovirals (ARVs), as 
a standard therapy for HIV. It is also important to know that this study will not provide nor will the study 
pay for the study medication. Participants will receive from their provider a prescribed supply of the 
drug, Tivicay® (dolutegravir/DTG), with either Triumeq, or Truvada or Descovy as determined by their 
primary HIV provider. It will be taken by mouth as prescribed and its dose and its administration will be 
determined by your provider. Participants will also be responsible for bringing these medications with 
them to their study visits. 
3.3 Study visits 
Visit 1:  Baseline, Pre-dose  
This visit will take place at the Grady IDP clinic and will involve a targeted history and physical, review 
of reproductive and sexual history, urine dipstick pregnancy test (women) and pre-dose collection of 
blood plasma, PBMC sampling, and HIV RNA quantification. Subjects will initiate HAART regimen with 
either Triumeq, DTG 50 mg daily plus Truvada (tenofovir disoproxil fumarate/emtricitabine, TDF/FTC) 

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300/200 mg daily, or DTG 50 mg daily plus Descovy (emtricitibine/tenofovir alafenamide) 200/25 mg 
daily. Eligibility to start these regimens will be determined by their primary HIV provider and participants 
are responsible for acquiring the medication and bringing them to the study visits.   Specimens will be 
processed within one hour to separate the plasma component and PBMCs and stored at -80°C until 
analyzed for DTG drug concentrations.     
In addition, either at this visit or within 7 days of ART initiation, participants will undergo anoscopy with 
rectal tissue sampling.  Rectal mucosa fluid will be collected first using two dry sterile cotton swabs and 
stored at -80°C for future rectal microbiome analysis using 16S sequencing. Any digital image of the 
biopsy site may also be taken during the anoscopy procedure to follow healing of the site over time.  
These de-identified images may be shared with investigators not listed on the study. 
 Four (4) to 8 pieces of rectal tissue will be collected via punch biopsy during anoscopy for 
measurement of DTG concentrations, HIV-1 RNA, total cell associated HIV DNA, 2-LTR DNA circles, 
and modified QVOA. Half of the rectal tissue will be flash-frozen in liquid nitrogen and cryopreserved at 
-80°C until analysis.  The other half will be placed fresh in phosphate-buffered saline and transported to 
the Laboratory of Biochemical Pharmacology (under the supervision of Drs. Gavegnano and Schinazi) 
at room temperature within 24 hours of collection for processing and analysis.   
Participants will receive $30 for the blood draw and $50 for the rectal biopsy, for a total of $80 
compensation for their time and inconvenience if they complete all procedures. 
The Screening and Baseline visits can occur on the same day if acceptable to the participant. 
 
Visits 2, 3 :  Post-dose population sampling of blood plasma, PBMCs, and rectal tissue. 
Visit 2 will occur 14 days after visit 1. 
Visit 3 will occur 42 days after visit 1. 
During visits 2-3, participants will have a focused history and physical exam.  Participants will undergo 
post-dose population sampling of blood plasma and PBMCs at visits 2-3.  Rectal mucosa fluid and 
tissue will be collected at visit 4 for future rectal microbiome analysis and measurement of DTG 
concentrations, HIV-1 RNA, total cell-associated HIV DNA, 2-LTR DNA circles, and modified QVOA.  
Participants will receive $30 for visits requiring only a blood draw, and an additional $50 in 
compensation at any visit with rectal tissue collection (up to 8 punch biopsies), for a total of $80. A 
digital image of rectal biopsy sites may be taken during the anoscopy procedure to examine healing of 
the site and these images may be shared with investigators not listed on the study. 
Visit 4: Steady state 24 hour PK-VD sampling 
Visit 4 will occur 84 days (12 weeks) after visit 1. 
This visit will involve an 8-hour stay either at the Grady or the Emory site of the Georgia Clinical and 
Translational Science Alliance (CTSA) for intensive blood plasma and PBMC sampling for ARV 
concentrations and HIV RNA quantification. 
During visit 4, participants will have a focused history and physical exam and provide urine for 
pregnancy testing and blood for CD4+ T cells (add-on: CD3), CBC (add-ons: BI smear w/diff; RBC 
morphology) with differential and comprehensive chemistries. 
Visit 4 will represent steady-state PK. DTG has an elimination half-life of 14 hours [34], therefore steady 
state plasma concentration is achieved after 5 days of oral administration. Adherence to previous DTG 
doses will be documented. Participants are responsible for bringing in their prescribed medication. 
Blood samples will be drawn 15 minutes prior to DTG administration (time 0) and 1, 2, 3, 4, 6, 8 and 24 
hours following observed drug intake to provide steady-state PK-VD data. HIV-RNA sampling will be 
done once as subjects are expected to be virologically suppressed in the blood plasma at this stage of 
HAART therapy. In addition, each participant will undergo PBMC and rectal mucosa fluid collection and 

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tissue sampling (up to 8 punch biopsies) 24 hours post-dose for measurement of rectal microbiome, 
DTG concentrations,HIV-1 RNA, total HIV-associated HIV DNA, 2-LTR DNA circles, and modified 
QVOA. Participants will be compensated $150 for this visit. 
Visit 5: 
Visit 5 will occur 168 days (6 months) after visit 1. During visit 5, participants will have a focused history 
and physical exam.  Participants will undergo post-dose population sampling of blood plasma and 
PBMCs.  Rectal mucosa fluid and tissue will be collected for future rectal microbiome analysis and 
measurement of DTG concentrations, HIV-1 RNA, total cell-associated HIV DNA, 2-LTR DNA circles, 
and modified QVOA.  A digital image of rectal biopsy sites may be taken during the anoscopy 
procedure to examine healing of the site and these images may be shared with investigators not listed 
on the study. 
Participants will be compensated $30 for the blood draw and $50 for the rectal biopsy, for a total of $80 
compensation if they complete all procedures. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Table 1 illustrates the schedule of events during each study visit: 
 
Table 1. SCHEDULE OF EVENTS 
 
Screening 
visit 
Baseline 
Visita  (pre-
dose) 
Day 14 
Day 42 
Day 84 (24 hr 
visit, steady 
state) 
Day 168 
Screening and Baseline Evaluation 
Informed 
consent 
 
 
 
 
 
 
Documentation 
of HIV status 
 
 
 
 
 
 
Targeted H&P 
 
 
 
 
 
 
Chem 14c 
 
 
 
 
 
 
CBC w/ diffc (add-
ons: BI smear w/diff; 
RBC morphology) 
 
 
 
 
 
 
CD4 T cell count 
(add-on: CD3) 
 
 
 
 
 
 
Determine DTG EC90 in blood plasma 
Plasma DTG 
concentration 
 
 
 
 
 
 
 
 
 
Plasma HIV-1 
RNA  
 
 
 
 
 
 
 
 
 
 
Determine DTG EC90 in PBMCs and rectal tissue (RT)b 
DTG 
concentrations 
 
 
 
 
 
 
 
 
 
HIV-1 RNA 
 
 
 
 
 
 
 
 
 
 
Total cell-
associated DNA 
 
 
 
 
 
 
 
 
 
2-LTR DNA 
circles 
 
 
 
 
 
 
 
 
 
Modified QVOA 
 
 
 
 
 
 
 
 
 
Examine rectal mucosa microbiome 
Rectal mucosa 
microbiome 
analysis 
 
 
 
 
 
 
 
 
 
 
aDay = Number of days since initiation of cART with DTG-based regimen.  Day 0 = day of 1st dose cART 
bRectal tissue assays will be performed in all participants within 7 days of first dose, and on Days 42, 84, and 168. 
cCBC with diff and Chem 14 will only be done at screening visit if they have not been done in last 90 days. 
 
NOTE: Pregnancy tests will continue to be performed at each visit. 
 
4.  SELECTION AND ENROLLMENT OF PARTICIPANTS 
 
4.1 Inclusion criteria 
• 
Age ≥ 18 years 

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• 
No ARVs in the last 6 months (from date of screening)  
• 
No documented or suspected resistance to integrase inhibitors (dolutegravir, elvitegravir, 
raltegravir, or bictegravir).  
• 
Creatinine Clearance >50 mL/min, as calculated by the Cockcroft-Gault equation within 90 days 
of screen 
• 
Liver function testing, including alanine aminotransferase (ALT), aspartate aminotransferase 
(AST), and alkaline phosphatase < 5 times upper limit of normal within 90 days of screen 
• 
Intact gastrointestinal tract 
• 
Able and willing to give informed consent 
• 
Willing and eligible to initiate ARV therapy with Triumeq, DTG + Truvada (TDF/FTC), or DTG + 
Descovy (FTC/TAF) 
• 
Agree to receive from their provider and pay for a prescribed supply of the drug, Tivicay® 
(dolutegravir/DTG), with either Triumeq, or Truvada or Descovy as determined by their primary 
HIV provider. 
o Agree to take the prescribed medication by mouth. 
o Agree that they (the participant) is responsible for bringing these medications with them 
to their study visits. 
• 
Willing to undergo serial blood and rectal tissue sampling 
• 
Female participants’ must be willing to have a pregnancy test done at each visit.  
Female participants of childbearing potential (FCB) must agree to either commit to continued 
abstinence from heterosexual intercourse or to use a reliable form of birth control such as oral 
contraceptive pills, intrauterine device, Nexplanon, DepoProvera, permanent sterilization, or 
another acceptable method, as determined by the investigator for the duration of the study.  
FCB are defined as sexually mature women who have not undergone hysterectomy or bilateral 
oophorectomy or have not been naturally postmenopausal for at least 24 consecutive months 
(i.e have had menses at any time in preceding 24 months) 
 
4.2 Exclusion criteria 
• 
Pregnant or attempting to conceive now or during the course of the study 
• 
Self-reported or documented current anal or rectal disease prohibiting safe anoscopy and 
biopsies, in investigator’s opinion. 
• 
Taking concurrent medications that interfere with DTG (see Table 2) 
• 
Bleeding diathesis 
• 
Platelet count <50,000 mm3 
• 
Medical condition that interferes with conduct of study, in investigator’s opinion 
 
4.3 Study enrollment procedures 
 
The study protocol and protocol consent form will be approved by the Emory University institutional 
review board (IRB) and the Grady Health System Research Oversight Committee prior to 
implementation of this study. 
 
Candidates will be notified of the study via a flier (Appendix A).  Once a candidate has been 
identified, the details of the study will be carefully discussed with them.  Prior to undergoing any 
study procedure, the candidate will be asked to read and sign the study protocol consent form that 
was approved by the Emory IRB.  The subject will be given a copy of the signed informed consent 
form for their records, and a second copy will be kept in the subject’s research record. 
 
4.4 Prohibited and precautionary medications 
 

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Any participant actively taking any of the prohibited or precautionary medications listed in Table 2 
will not be eligible to participate in this study. 
 
Table 2:  Prohibited and precautionary medications 
 
Concomitant drug 
class:  drug name 
Effect of concentration 
on Dolutegravir and/or 
concomitant drug 
Clinical comment 
HIV antiviral agents 
Non-nucleoside 
reverse transcriptase 
inhibitor (NNRTI): 
etravirine 
 Dolutegravir 
Do not coadminister 
without also giving 
darunavir/ritonavir, 
atazanavir/ritonavir, or 
lopinavir/ritonavir 
NNRTI:  Efavirenz 
 Dolutegravir 
Dose adjustment of 
DTG to 50 mg bid for 
treatment naïve  
NNRTI:  Nevirapine 
 Dolutegravir 
Avoid coadministration:  
insufficient data for 
dosing 
recommendations  
 
Protease inhibitors:  
Fosamprenavir/ritonavir 
Tipranavir/ritonavir 
 Dolutegravir 
Dose adjustment of 
DTG to 50 mg bid for 
treatment naïve 
Other agents 
Psychotropic agents: 
Oxcarbazepine 
Phenytoin 
Phenobarbital 
Carbamazepine 
St. John’s Wort 
 Dolutegravir 
Avoid coadministration:  
insufficient data for 
dosing 
recommendations 
Medications with 
polyvalent cations: 
Cation-containing 
antacids or laxatives 
Sucralfate 
Buffered medications 
 Dolutegravir 
Must administer 
Dolutegravir 2 hours 
before or 6 hours after 
these medications 
Hypoglycemic: 
Metformin 
 Metformin 
Consider metformin 
dose reductions 
Antibiotic: 
Rifampin 
 Dolutegravir 
Dose adjustment of 
DTG to 50 mg bid for 
treatment naïve 
Adapted from Table 5 in Tivicay (dolutegravir) [package insert]. ViiV Healthcare:  Research Triangle Park, 
NC; 2014 [34]. 
 

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5. Definitions for Schedule of Events- timing of study visits 
 
5.1.1 Screening Visit 
Screening evaluations will determine eligibility and will occur prior to the participants’ enrollment into 
the study. 
5.1.2 On Study Visits 
The first on-study visit will occur after the screening visit, but within a month (30 days) of screening 
visit (unless otherwise specified). All other on-study visits that occur after the first on-study visit will 
occur 14 days, 42 days, 84 days, and 168 days after the first visit. 
The window period for visits on day 14 can be +/- 3 days. 
The window period for visits on day 42 and 84 can be +/- 7 days. 
The window period for the visit on day 168 can be +/- 14 days. 
Please see Table 1 for schedule of clinical and laboratory evaluations. 
 
5.2 Definitions of evaluations 
5.2.1 Consent Form 
A signed and dated consent form approved by the Emory IRB is required prior to 
participation in this study. 
 
5.2.2 Documentation of HIV 
HIV-1 infection, as documented by any licensed serologic test confirmed by western blot or 
by positive plasma HIV-1 RNA performed by any laboratory that has a CLIA certification. 
 
5.2.3 Medication History 
Current medications will be recorded from the patient’s self-report and medical record 
including doses, dosing frequency, and duration of treatment. 
 
5.2.4 Screening Clinical Assessment  
Screening clinical assessment will include a review of medical diagnoses, current 
medications, and eligibility criteria.   
 
5.2.5 Screening Laboratory Evaluations 
At screening, most recent HIV-1 RNA PCR (if available) and CD4 T-cell counts will be 
recorded from the medical record.  Absolute CD4+/CD8+ counts and percentages 
performed by flow cytometry at a CLIA-certified or equivalent laboratory will be recorded.  
Study eligibility will be determined based on medical history review and laboratory testing as 
described below:   
• 
Urine collected at this visit in all female participants will be tested by dipstick for beta-
hCG to assess for pregnancy.  If this test indicates pregnancy, the patient will be 
notified and referred to their primary care provider in the clinic for further evaluation.   
• 
Platelet count within the last 90 days will be reviewed from the medical record.  
Participants with platelets <50,000 are not eligible to participate. 
• 
Renal and liver function testing within the last 90 days will be reviewed from the 
medical record.  Participants with creatinine clearance <50 mL/min by Cockcroft-

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Gault equation or AST, ALT, alkaline phosphatase > five (5) times upper limit of 
normal are not eligible to participate. 
 
5.2.6 HIV-1 RNA in plasma, PBMCs, and rectal tissue 
 
HIV-1 RNA will be quantified in cryopreserved plasma, PBMCs, and rectal tissue by RNA 
extraction, reverse transcription polymerase chain reaction (RT-PCR), and PCR 
amplification using assays validated for each site at the Emory CFAR virology core on a fee-
for-service basis. 
 
5.2.7 HIV-1 total cell associated DNA, 2-LTR DNA circles, and modified QVOA in PBMCs and 
rectal tissue 
Total-cell associated HIV DNA , 2-LTR DNA circles, and modified rapid-low cell QVOA will 
be quantified by Dr. Christina Gavegnano within the Laboratory of Biochemical Pharmacology 
under the supervision of Dr. Raymond Schinazi on a fee-for-service basis.  For total HIV DNA 
and 2-LTR DNA circle assays, PBMCs, at a minimum of 1.0 x 105 cells, will be subjected to total 
cell lysis with an NP-40 based detergent while rectal tissue will be homogenized and then 
dissolved.  Quantitation of 2-LTR DNA circles will be performed using real-time PCR and 
Taqman technology (Applied Biosystems), as previously described.  Plasmids containing LTR 
sequences will be used as standards for quantitation (NL4-3, subtype B).  Total-cell associated 
HIV DNA will be performed using the Abbott Real-time HIV-1 DNA assay.  The modified rapid-
low cell QVOA is a culture-based assay that detects the outgrowth of replication-competent 
virus. Ex-vivo PBMCs will be subjected to density gradient centrifugation to obtain total PBMC 
populations and sorted using fluorescent activated cell sorting (FACS).  For PBMCs from tissue, 
cells will be subjected to tissue homogenization and purification of live, single cell supsensions 
using existing methods in the BSL 2/3 Laboratory of Biochemical Pharmacology (OctoMacs Pro; 
Miltenyi Biotec methodology).  Sorted cells are cultured with EC99 of cART (Raltegravir/(-)-
FTC/efavirenz) for 72 hours to prevent virus harbored in sorted cells from spreading.  
CD3/CD28 and IL-15 are added to induce activation of latent virus from sorted memory cultures; 
24 hours post reactivation, cells are stained with anti-p24 fluorescein isothiocyanate mAb and 
non-dividing p24+ cells are quantified with FACS to measure reservoir size.  Supernatant is 
harvested and virus is quantified with p24 ELISA prior to infection with naïve PBMCs at limiting 
dilutions of inoculates to determine replication competence.   
Total cell-associated HIV DNA and 2-LTR DNA circles quantitation will be performed on 
cryopreserved PBMCs and rectal tissue.  The modified QVOA will be performed in both 
cryopreserved PBMCs and fresh rectal tissue.  Fresh rectal tissue will be placed in phosphate-
buffered saline and transported at room temperature to the Laboratory of Biochemical 
Pharmacology within 24 hours of collection for processing.   
5.2.8 Dolutegravir concentrations in plasma, PBMCs, and rectal tissue 
DTG concentrations will be measured from blood plasma, PBMCs, and rectal tissue under  
Dr. Edward Acosta’s supervision at the University of Alabama-Birmingham Antiviral 
Laboratory using HPLC-MS/MS, as previously described [35]. To decrease variability, 
samples will be analyzed in duplicate and resulted as the average. 
 
5.2.9 Any Digital images of biopsy sites will be examined from 2 consecutive visits with digital 
imaging analysis software.  The percentage of the biopsy that has healed over time will be 
calculated as an exploratory analysis to better understand mucosal healing after injury.   
 
5.2.10 Rectal fluid microbiome  
Rectal microbiome analysis will be performed at a future date using 16S sequencing. 

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6. STATISTICAL CONSIDERATIONS 
 
6.1 Primary endpoint 
To estimate the EC90 of dolutegravir in blood plasma using an integrated Pharmacokinetic (PK) – 
Viral Dynamic (VD) model. 
 
6.2 Secondary endpoints 
To estimate the EC90 of dolutegravir in PBMCs and rectal tissue using an integrated 
Pharmacokinetic (PK) – Viral Dynamic (VD) model. 
 
To compare the PK-VD determined EC90 of dolutegravir in blood plasma, PBMCs, and rectal tissue 
between males and females. 
 
6.3 Sample size justification 
 
For our primary endpoint, we plan to enroll a total of 40 HIV-1 infected persons (20 men and 20 
women into this study.  As our primary endpoint is descriptive, our goal is to attain an accurate 
parameter estimate by achieving a sufficiently narrow confidence interval.  Based on a coefficient 
of variation of 25% [36], a sample size of 17 HIV-1 infected women gives us 80% certainty that the 
90% confidence interval for DTG EC90 will be no wider than 0.20 units [37].   
 
 
6.4 Analyses 
6.4.1 Demographic and clinical characteristics 
Baseline demographic and clinical characteristics will be summarized by descriptive 
statistics. 
 
6.4.2 Primary objective analysis:  Estimate EC90 of DTG in blood plasma using integrated PK-VD 
modeling 
 
Pharmacokinetics:  PK data will be used to plot plasma concentration-time curves for DTG 
at steady-state to determine total drug exposure (AUC) and other PK parameters, including 
peak concentration (Cmax), minimum concentration (Cmin), time to Cmax (tmax), time to Cmin 
(tmin), half-life (t1/2), and estimated clearance (CL/F).  
 
Viral dynamics:  Viral dynamic determinant of response will be AAUCMB, defined as the 
decrease in log10 time-averaged under the viral load-time curve from 0 to Day 168 (AUC0-
week-12) minus baseline.  
 
PK-VD Modeling:  Population analysis will be used to develop the overall PK-VD model.  
Because this is a longitudinal study with repeated measures, an expectation-maximization 
algorithm will be used on a parametric non-linear mixed-effects model to determine 
maximum likelihood estimates for model parameters, as developed by Shumitzky and 
Walker [38, 39].  This will be implemented using ADAPT software (version 5, MLEM module) 
[40]. Baseline covariates, including age, race, body mass index, menstrual cycle, and use of 
hormonal contraception will be evaluated for their ability to explain inter-individual variability 
in base model parameters. Prediction-corrected visual checks [41] will be used for model 
evaluation. 
 
EC90 estimate:  To estimate EC90, exposure-response simulations using a wide range of 
DTG doses will be conducted:  The DTG Cmin (exposure) will be linked to the VD 

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determinant of response, AAUCMB. Median estimates will be reported in ng/mL with 
interquartile range.  90% confidence intervals will be constructed for the EC90 parameter 
using the bootstrap method, as described by Miller [42]. 
6.4.3 Secondary objectives analyses:  Estimate EC90 of DTG in PBMCs and rectal tissue using 
integrated PK-VD modeling 
 
Analyses similar to those described in 6.4.2 for the primary objective will be used here. 
 
7.  DATA COLLECTION AND MONITORING 
 
7.1 Records to be kept 
Case report forms (CRFs) will be provided for each subject to collect demographic, clinical, and 
laboratory data at study entry, and additional clinical data at study visits. These data will be 
collected from the screening clinical assessment, the subject’s medical record, the study entry 
physical examination, and the subject’s medication diary.  Subjects will not be identified by name on 
any CRFs.  Subjects will be identified by the participant identification number (PID), which will be 
provided by the study investigator upon registration. 
 
7.2  Role of Data Management 
 
7.2.1  Instructions regarding the recording of study data on CRFs will be provided by the study 
investigator 
 
7.2.1  The study investigator will be responsible for assuring the quality of computerized data.  
This role extends from protocol development to generation of the final study databases. 
Data will be entered into Emory Redcap, a secure web application for building and 
managing online surveys and databases.   
 
7.3  Clinical Site Monitoring and Record Availability 
7.3.1  The Emory University IRB, the OHRP, FDA, , or other government regulatory authorities 
may perform clinical site monitoring.  Clinical research sites monitoring may include the 
review of the individual participant records, including consent forms, CRFs, supporting 
data, laboratory specimen records, and medical records (physicians’ progress notes, 
nurses’ notes, individuals’ hospital charts) to ensure protection of study participants, 
compliance with the protocol, and accuracy and completeness of records.  The monitors 
may also inspect sites’ regulatory files to ensure that regulatory requirements are being 
followed. 
 
7.3.2 The investigator will make study documents (e.g., consent forms, CRFs) and pertinent 
hospital or clinic records readily available for inspection by the local IRB or the OHRP for 
confirmation of the study data. 

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8.   HUMAN SUBJECTS 
 
8.1 Responsibilities of the Investigator 
In implementing this protocol, the investigators will adhere to the basic principles of “Good Clinical 
Practice” as outlined in CFR 312, subpart D, “Responsibilities of Sponsors and Investigators,” 
CFR 21, part 50 and CFR 21, part 56 and Section 4 of ICH Harmonized Tripartite Guideline for 
GCP.   
 
8.2  IRB Review and Informed Consent 
This protocol and the informed consent document and any subsequent modifications will be 
reviewed and approved by the Emory University IRB. A signed and dated, Emory IRB-approved 
consent form will be obtained from the subject (or parent, legal guardian, or person with power of 
attorney for subjects who cannot consent for themselves). The consent form will describe the 
purpose of the study, the procedures to be followed, and the risks and benefits of participation. A  
copy of the signed consent form will be given to the subject, parent, or legal guardian, and this will 
be documented in the subject’s record. 
8.3  Subject Confidentiality 
All laboratory specimens, evaluation forms, reports, and other records that leave the site will be 
identified only by coded number to maintain subject confidentiality. All records will be kept locked. 
All computer entry and networking programs will be done with coded numbers only. Clinical 
information will not be released without written permission of the subject, except as necessary for 
monitoring by IRB or the OHRP. 
8.4  Study Discontinuation 
A study participant may elect to discontinue participation in the study at any time.  The study may 
be discontinued at any time by the IRB, the OHRP, or other government agencies as part of their 
duties to ensure that research subjects are protected. 
8.5 Risks to Human Subjects 
The risks to study participants include side effects of Triumeq, DTG and TDF/FTC or DTG and 
FTC/TAF, risk of venipuncture for blood sampling, and risk of rectal tissue biopsies.  DTG was 
approved by the FDA for use in combination with other ARV agents for treatment of HIV-1 infection 
in treatment-experienced or ARV-naïve persons in 2013.  Subjects will be initiating a DTG-based 
regimen as part of treatment for HIV-infection and therefore will not assume additional ARV-related 
risk above and beyond standard of care.  Clinical evaluation and safety laboratory testing will be 
performed to monitor participants for development of ARV-related adverse events.  Recently, DHHS 
guidelines have released updated recommendations for the use of DTG in females of child-bearing 
potential (FCB) due to the potential risk of neural tube defects in infants born to women taking DTG-
based regimens[43]. Given this new information, FCB must agree to either commit to continued 
abstinence from heterosexual intercourse or to use a reliable form of birth control such as oral 
contraceptive pills, intrauterine device, Nexplanon, DepoProvera, permanent sterilization, or 
another acceptable method, as determined by the investigator for the duration of the study.  
Pregnancy tests will continue to be performed each study visit.  Common risks of venipuncture 
include discomfort, bleeding, and bruising.  When repeated blood draws are necessary, it will be 
attempted through peripheral IV to minimize venipuncture.   

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Common risks of rectal biopsies include discomfort and bleeding.  Rare (<1%) complications of 
anoscopy with rectal biopsies include infection, anal tears, or colonic perforation.  
Adverse events will be reported per Emory IRB protocol. 
9.  Data safety and monitoring plans 
 
Grade 3 and 4 adverse events and study conduct will be reviewed regularly by study investigators.  
Standard Emory IRB guidelines for reporting adverse events will be followed.  Adverse Events and 
Serious Adverse Events will be reported to the IRB per Emory’s guidelines for reportable events.  
 
 
10. SPONSORS 
 
The NIH/NIAID is sponsoring this study. 
 
 
11. BIOHAZARD CONTAINMENT 
 
As the transmission of HIV and other blood-borne pathogens can occur through contact with 
contaminated needles, blood, and blood products, appropriate blood and secretion precautions will be 
employed by all personnel in the drawing of blood and handling of all specimens for this study, as 
currently recommended by the Centers for Disease Control and Prevention and the National Institutes of 
Health. 
All infectious specimens will be transported using packaging mandated in the Code of Federal 
Regulations, 42 CFR Part 72. 
 
 
 
 

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12. REFERENCES 
1. 
Chun, T.W., et al., Quantification of latent tissue reservoirs and total body viral load in HIV-1 
infection. Nature, 1997. 387(6629): p. 183-8. 
2. 
Chun, T.W., et al., Persistence of HIV in gut-associated lymphoid tissue despite long-term 
antiretroviral therapy. J Infect Dis, 2008. 197(5): p. 714-20. 
3. 
Chun, T.W., et al., Presence of an inducible HIV-1 latent reservoir during highly active antiretroviral 
therapy. Proc Natl Acad Sci U S A, 1997. 94(24): p. 13193-7. 
4. 
Di Stefano, M., et al., Intracellular and cell-free (infectious) HIV-1 in rectal mucosa. J Med Virol, 
2001. 65(4): p. 637-43. 
5. 
Finzi, D., et al., Identification of a reservoir for HIV-1 in patients on highly active antiretroviral 
therapy. Science, 1997. 278(5341): p. 1295-300. 
6. 
Imamichi, H., et al., Lack of compartmentalization of HIV-1 quasispecies between the gut and 
peripheral blood compartments. J Infect Dis, 2011. 204(2): p. 309-14. 
7. 
Lampinen, T.M., et al., Association of antiretroviral therapy with detection of HIV-1 RNA and DNA in 
the anorectal mucosa of homosexual men. AIDS, 2000. 14(5): p. F69-75. 
8. 
Palmer, S., L. Josefsson, and J.M. Coffin, HIV reservoirs and the possibility of a cure for HIV infection. J 
Intern Med, 2011. 270(6): p. 550-60. 
9. 
Poles, M.A., et al., Lack of decay of HIV-1 in gut-associated lymphoid tissue reservoirs in maximally 
suppressed individuals. J Acquir Immune Defic Syndr, 2006. 43(1): p. 65-8. 
10. 
Wong, J.K., et al., Recovery of replication-competent HIV despite prolonged suppression of plasma 
viremia. Science, 1997. 278(5341): p. 1291-5. 
11. 
Zalar, A., et al., Macrophage HIV-1 infection in duodenal tissue of patients on long term HAART. 
Antiviral Res, 2010. 87(2): p. 269-71. 
12. 
Cory, T.J., et al., Overcoming pharmacologic sanctuaries. Curr Opin HIV AIDS, 2013. 8(3): p. 190-5. 
13. 
Fletcher, C.V., et al., Persistent HIV-1 replication is associated with lower antiretroviral drug 
concentrations in lymphatic tissues. Proc Natl Acad Sci U S A, 2014. 111(6): p. 2307-12. 
14. 
Archin, N.M. and D.M. Margolis, Emerging strategies to deplete the HIV reservoir. Curr Opin Infect 
Dis, 2014. 27(1): p. 29-35. 
15. 
Clark, R., Considerations for the antiretroviral management of women in 2008. Womens Health 
(Lond Engl), 2008. 4(5): p. 465-77. 
16. 
Floridia, M., et al., Gender differences in the treatment of HIV infection. Pharmacol Res, 2008. 58(3-
4): p. 173-82. 
17. 
Nicastri, E., et al., Sex issues in HIV-1-infected persons during highly active antiretroviral therapy: a 
systematic review. J Antimicrob Chemother, 2007. 60(4): p. 724-32. 
18. 
Ofotokun, I., S.K. Chuck, and J.E. Hitti, Antiretroviral pharmacokinetic profile: a review of sex 
differences. Gend Med, 2007. 4(2): p. 106-19. 
19. 
Di Mascio, M., et al., Antiretroviral tissue kinetics: in vivo imaging using positron emission 
tomography. Antimicrob Agents Chemother, 2009. 53(10): p. 4086-95. 
20. 
Solas, C., et al., Discrepancies between protease inhibitor concentrations and viral load in reservoirs 
and sanctuary sites in human immunodeficiency virus-infected patients. Antimicrob Agents 
Chemother, 2003. 47(1): p. 238-43. 
21. 
Venuto, C.S., et al., Sex differences in atazanavir pharmacokinetics and associations with time to 
clinical events: AIDS Clinical Trials Group Study A5202. J Antimicrob Chemother, 2014. 69(12): p. 
3300-10. 
22. 
Regazzi, M., et al., Sex differences in nevirapine disposition in HIV-infected patients. AIDS, 2003. 
17(16): p. 2399-400. 

Dolutegravir in Reservoirs    
 
V10:  9/8/2020 
23
23. 
Pai, M.P., et al., Sex-related differences in the pharmacokinetics of once-daily saquinavir soft-gelatin 
capsules boosted with low-dose ritonavir in patients infected with human immunodeficiency virus 
type 1. Pharmacotherapy, 2004. 24(5): p. 592-9. 
24. 
Kile, D.A., et al., A population pharmacokinetic-pharmacogenetic analysis of atazanavir. AIDS Res 
Hum Retroviruses, 2012. 28(10): p. 1227-34. 
25. 
Fletcher, C.V., et al., Sex-based differences in saquinavir pharmacology and virologic response in AIDS 
Clinical Trials Group Study 359. J Infect Dis, 2004. 189(7): p. 1176-84. 
26. 
Pruvost, A., et al., Pilot pharmacokinetic study of human immunodeficiency virus-infected patients 
receiving tenofovir disoproxil fumarate (TDF): investigation of systemic and intracellular 
interactions between TDF and abacavir, lamivudine, or lopinavir-ritonavir. Antimicrob Agents 
Chemother, 2009. 53(5): p. 1937-43. 
27. 
Moyle, G., et al., Steady-state pharmacokinetics of abacavir in plasma and intracellular carbovir 
triphosphate following administration of abacavir at 600 milligrams once daily and 300 milligrams 
twice daily in human immunodeficiency virus-infected subjects. Antimicrob Agents Chemother, 
2009. 53(4): p. 1532-8. 
28. 
Harris, M., et al., Intracellular carbovir triphosphate levels in patients taking abacavir once a day. 
AIDS, 2002. 16(8): p. 1196-7. 
29. 
Anderson, P.L., et al., Antiviral dynamics and sex differences of zidovudine and lamivudine 
triphosphate concentrations in HIV-infected individuals. AIDS, 2003. 17(15): p. 2159-68. 
30. 
UNAIDS. Global AIDS Response Progress Reporting. 2015  August 15, 2015]; Available from: 
http://www.unaids.org/en/resources/documents/2015/GARPR_2015_guidelines. 
31. 
Johnston, R.E. and M.M. Heitzeg, Sex, age, race and intervention type in clinical studies of HIV cure: a 
systematic review. AIDS Res Hum Retroviruses, 2015. 31(1): p. 85-97. 
32. 
Wang, K., et al., Integrated population pharmacokinetic/viral dynamic modelling of 
lopinavir/ritonavir in HIV-1 treatment-naive patients. Clin Pharmacokinet, 2014. 53(4): p. 361-71. 
33. 
Stellbrink, H.J., et al., Dolutegravir in antiretroviral-naive adults with HIV-1: 96-week results from a 
randomized dose-ranging study. AIDS, 2013. 27(11): p. 1771-8. 
34. 
Tivicay (dolutegravir) [package insert], 2014, ViiV Healthcare: Research Triangle Park, NC. 
35. 
Else, L., et al., Validation of a rapid and sensitive high-performance liquid chromatography-tandem 
mass spectrometry (HPLC-MS/MS) assay for the simultaneous determination of existing and new 
antiretroviral compounds. J Chromatogr B Analyt Technol Biomed Life Sci, 2010. 878(19): p. 1455-
65. 
36. 
Song, I., Chen Shuguang, Lou Y, et al.  , Pharmacokinetic (PK) and Pharmacodynamic (PD) 
Relationship of S/GSK1349572, a Next Generation Integrase Inhibitor (INI), in HIV-1 Infected 
Patients, in International AIDS Society, 5th Conference on HIV Pathogenesis, Treatment, and 
Prevention2009: Cape Town, South Africa. 
37. 
Kelley, K., Sample size planning for the coefficient of variation from the accuracy in parameter 
estimation approach. Behav Res Methods, 2007. 39(4): p. 755-66. 
38. 
Walker, S., An EM algorithm for nonlinear random effects models. Biometrics, 1996. 52(3): p. 934-
44. 
39. 
A, S., Advanced methods of pharmacokinetic and pharmacodynamic systems analysis. EM algorithms 
and two stage methods in pharmacokinetic population analysis, ed. D.Z. D'Argenio. Vol. 2. 1995, 
New York: Plenum Press. 
40. 
D'Argenio, D.Z., Schumitzky A, Wang X., ADAPT 5 user's guide:  pharmacokinetic/pharmacodynamic 
systems analysis software.  . Biomedical Simulations Resource. 2009, Los Angeles. 

Dolutegravir in Reservoirs    
 
V10:  9/8/2020 
24
41. 
Bergstrand, M., et al., Prediction-corrected visual predictive checks for diagnosing nonlinear mixed-
effects models. AAPS J, 2011. 13(2): p. 143-51. 
42. 
Miller, D.P., Bootstrap 101:  Obtain Robust Confidence Intervals for Any Statistic, in SUGI 29 2004: 
Montreal, Canada. 
43. 
Recommendations Regarding the Use of Dolutegravir in Adults and Adolescents with HIV Who are 
Pregnant or of Child-Bearing Potential. AIDS Info, Department of Health and Human Services 2018 
May 30, 2018 June 1, 2018]; Available from: 
https://aidsinfo.nih.gov/news/2109/recommendations-regarding-the-use-of-dolutegravir-in-
adults-and-adolescents-with-hiv-who-are-pregnant-or-of-child-bearing-potential.