A Phase I/II Pilot Study of Dipyridamole as a Modulator of Immune Activation and Systemic Inflammation in HIV-1-Infected Subjects on Antiretroviral Therapy- DAIDS-ES ID 11987
Phase: PHASE1
Conditions: HIV Infection
Sponsor: Sharon Riddler

 
 
 
 
DAIDS-ES ID 11987 
 
A Phase I/II Pilot Study of Dipyridamole as a Modulator of Immune Activation and 
Systemic Inflammation in HIV-1-Infected Subjects on Antiretroviral Therapy 
 
 
 
Sponsored by: 
 
The National Institute of Allergy 
and Infectious Diseases (U01 AI110410) 
 
 
 
 
 
Non-IND Study 
 
 
 
Co-Principal Investigators: 
Bernard J. Macatangay, MD 
 
Sharon A. Riddler, MD 
 
 
Co-Investigators: 
Kaleab Abebe, PhD 
 
Aryan Aiyer, MD 
 
Edwin K. Jackson, PhD 
 
Ian McGowan, MD, PhD, FRCP 
 
Deborah McMahon, MD 
 
John Mellors, MD 
 
Charles Rinaldo, PhD 
 
Theresa Whiteside, PhD 
 
Alison Morris, MD, MS 
 
 
 
Matthew R. Gingo, MD, MS  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
Final Version 2.0  
05 Feb 2015 
 
 
 
 
 
 
 

 
 
TABLE OF CONTENTS 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page 
 
PROTOCOL TEAM ROSTER…………………………………………………………………     4 
GLOSSARY OF TERMS……………………………………………………………………… 
 7 
PROTOCOL SUMMARY AND STUDY SCHEMA……………………………………….… 
 8 
1.0 
HYPOTHESES AND STUDY OBJECTIVES………………………………………. 
10 
1.1 
Hypotheses……………………………………………………………………. 
10 
1.2 
Primary Objective…………………………………………………………….. 
10 
1.3 
Secondary Objectives ………………………………………………………...    10 
 
1.4 
Exploratory Objectives……………………………………………………….. 
11 
2.0 
INTRODUCTION………………………………………………………………………. 11 
2.1 
Background……………………………………………………………………. 
11 
2.2 
Rationale………………………………………………………………………..    12 
 
2.3 
Description of Study Product………………………………………………….   14 
3.0 
STUDY DESIGN……………………………………………………………………….. 16 
4.0 
SELECTION AND ENROLLMENT OF SUBJECTS………………………………… 16 
4.1 
Inclusion Criteria……………………………………………………………….. 17 
4.2 
Exclusion Criteria………………………………………………………………. 19 
4.3 
Study Enrollment Procedures………………………………………………… 21 
4.4 
Coenrollment Guidelines……………………………………………………… 21 
5.0 
STUDY TREATMENT …………………………………………………………………..  21 
5.1 
Regimens, Administration, and Duration……………………………………. 21 
5.2 
Study Product Formulation and Storage……………………………………. 21 
5.3 
Pharmacy: Product Supply, Acquisition, and Accountability……………… 22 
5.4 
Concomitant Medications…………………………………………………….. 22 
 
5.5 
Adherence Assessment………………………………………………………. 22 
6.0 
CLINICAL AND LABORATORY EVALUATIONS…………………………………… 23 
6.1 
Schedule of Events (SOE)……………………………………………………. 23 
6.2 
Timing of Evaluations…………………………………………………………. 25 
6.3 
Instructions for Evaluations…………………………………………………… 26 
7.0 
CLINICAL MANAGEMENT ISSUES…………………………………………………. 33 
7.1 
Toxicity………………………………………………………………………….. 34 
7.2 
Pregnancy Management………………………………………………………. 36 
 
7.3 
Unblinding……………………………………………………………………….. 37 
8.0 
CRITERIA FOR DISCONTINUATION………………………………………………… 37 
8.1 
Permanent Treatment Discontinuation………………………………………. 37 
8.2 
Premature Study Discontinuation…………………………………………….. 37 
9.0 
STATISTICAL CONSIDERATIONS…………………………………………………… 38 
9.1 
General Design Issues…………………………………………………………  38 
9.2 
Endpoints………………………………………………………………………… 38 
9.3 
Randomization and Stratification……………………………………………… 39 
9.4 
Sample Size and Accrual………………………………………………………. 39 
9.5 
Primary Analysis………………………………………………………………… 40 
9.6 
Secondary Analyses……………………………………………………………  40 
9.7 
Monitoring………………………………………………………………………..  41 
10.0 
PHARMACOLOGY PLAN………………………………………………………………  42 
11.0 
DATA COLLECTION AND MONITORING AND ADVERSE EVENT REPORTING 42 
11.1 
Records to Be Kept…………………………………………………………….. 42 

 
 
11.2 
Role of Data Management…………………………………………………….. 42 
11.3 
Clinical Site Monitoring and Record Availability…………………………….. 43 
11.4 
Expedited Adverse Event Reporting………….………………………..……. 43 
 
11.5 
Unanticipated Problems………………………………………………………... 44 
12.0 
HUMAN SUBJECTS…………………………………………………………..….…….. 45 
12.1 
Institutional Review Board (IRB) Review and Informed Consent…………  45 
12.2 
Protocol Registration…………………………………….……………………   45 
 
12.3 
Risk-Benefit Statement…………………………………………………….....    46 
 
12.4 
Informed Consent Process…………………………………………….….....  47 
 
12.5 
Participant Confidentiality…………………………….……………………..... 48 
 
12.6 
Special Populations……………………………………….…………………… 49 
 
12.7 
Compensation………………………………...…………….………………….. 49 
 
12.8 
Communicable Disease Reporting……………………….…..……………… 50 
12.9 
Study Discontinuation ……………………………………………………….. .  50 
13.0 
PUBLICATION OF RESEARCH FINDINGS …………………….……………….… 50 
14.0 
BIOHAZARD CONTAINMENT…………………………………………………..…..… 50 
15.0 
REFERENCES………………………………………………………….………..…….. 51 
 
 
  

 
 
PROTOCOL TEAM ROSTER 
 
Co-Principal Investigators: 
Bernard J.C. Macatangay, MD 
Division of Infectious Diseases 
Keystone Building  
3520 Fifth Avenue, Suite 510  
Pittsburgh, PA  15213 
Phone:  (412) 383-1272 
Fax:  (412) 383-2900 
E-mail:  macatangaybj@upmc.edu 
 
Sharon A. Riddler, MD 
Division of Infectious Diseases 
Keystone Building  
3520 Fifth Avenue, Suite 510  
Pittsburgh, PA  15213 
Phone:  (412) 383-1741 
Fax:  (412) 383-2900 
E-mail:  riddler@pitt.edu 
 
Co-Investigators: 
Aryan Aiyer, MD 
HVI at University Center 
120 Lytton Avenue, Suite 100B 
Pittsburgh, PA 15213 
Phone: (412) 641-8870 
E-mail: aiyeran@upmc.edu  
 
Edwin K. Jackson, PhD 
Pharmacology and Chemical Biology 
Bridgeside Point Building, Room 514 
100 Technology Drive 
Pittsburgh, PA  15219 
Phone: 412-648-1505 
Fax: 412-624-5070 
E-mail: edj@pitt.edu  
 
Ian McGowan, MD, PhD, FRCP 
University of Pittsburgh Medical Center 
Magee-Womens Research Institute 
204 Craft Ave., Room B505 
Pittsburgh, PA 15213  
Phone: 412-641-4710  
Email: mcgowanim@mwri.magee.edu  
 
Deborah McMahon, MD 
Division of Infectious Diseases 
Keystone Building  
3520 Fifth Avenue, Suite 510  
Pittsburgh, PA  15213 
4 
 

 
 
Phone:  (412) 383-1717 
Fax:  (412) 383-2900 
E-mail: mcmahond@pitt.edu  
 
John Mellors, MD 
Division of Infectious Diseases  
University of Pittsburgh School of Medicine 
Scaife Hall, Suite 818 
3550 Terrace Street  
Pittsburgh, PA 15261  
Phone:  (412) 624-8512  
Fax:  (412) 383-7982  
E-mail:  mellors@dom.pitt.edu  
 
Charles Rinaldo, PhD 
Infectious Diseases & Microbiology 
Graduate School of Public Health 
A419 Crabtree Hall 
130 DeSoto Street 
Pittsburgh PA 15261 
Phone: (412) 624-3928 
Fax: (412) 624-4953 
E-mail: rinaldo@pitt.edu  
 
Theresa Whiteside, PhD 
Hillman Cancer Center, Suite 1.32d 
5117 Centre Avenue 
Pittsburgh, PA 15213 
Phone: (412) 624-0096 
Fax: (412) 624-0264 
E-mail: whitesidetl@upmc.edu 
 
Alison Morris, MD, MS 
628 NW MUH 
3459 Fifth Avenue 
Pittsburgh, PA 15213 
Phone: 412-624-8209 
Fax:  412-624-2260 
E-mail: morrisa@upmc.edu  
 
Matthew R. Gingo, MD, MS 
628 NW MUH 
3459 Fifth Avenue 
Pittsburgh, PA 15213 
Phone: 412-624-3045 
Fax:  412-624-2260 
E-mail: gingomr@upmc.edu  
 
DAIDS Clinical Representative: 
Karin Klingman, MD 
5 
 

 
 
Medical Officer, HIVRB 
Division of AIDS/NIAID/NIH 
5601 Fishers Lane, 9E40A, MSC 9830  
Rockville, MD 20852 
Phone: 240-627-3067 
E-mail:  kklingman@niaid.nih.gov 
 
Regulatory Specialist: 
Patricia Peters, RPh 
Keystone Building  
3520 Fifth Avenue, Suite 510  
Pittsburgh, PA  15213 
Phone:  (724) 515-6006 
Fax:  (724) 515-6007 
E-mail:  petersp@dom.pitt.edu  
 
Statistician: 
Kaleab Z. Abebe, PhD 
Center for Research on Health Care Data Center  
200 Meyran Ave., Suite 300 
Pittsburgh, PA 15213 
Phone: 412-246-6931 
Fax: 412-586-9672 
E-mail: abebekz@upmc.edu  
 
Data Manager: 
James Gavel, BS 
Keystone Building  
3520 Fifth Avenue, Suite 510  
Pittsburgh, PA  15213 
Phone:  (412) 383-4029 
Fax:  (412) 383-2900 
E-mail:  gaveljj@upmc.edu 
 
Investigational Drug Pharmacist: 
Staci Ziobert, PharmD 
Investigational Drug Service Coordinator 
UPMC Presbyterian Shadyside 
Room 326B Scaife Hall 
200 Lothrop Street 
Pittsburgh, PA 15213 
Phone: 412-647-3178 
Fax: 412-647-9651 
E-mail: zioberts@upmc.edu 
 
 
6 
 

 
 
 
GLOSSARY OF TERMS 
 
ADO 
 
 
 
Adenosine 
AE 
 
 
 
Adverse Event 
ART 
 
 
 
antiretroviral therapy 
ASA 
 
 
 
Aspirin 
ALT 
 
 
 
Alanine aminotransferase 
AST 
 
 
 
Aspartate aminotransferase 
ATS 
 
 
 
American Thoracic Society 
CrCL  
 
 
calculated creatinine clearance 
CRHC DC 
 
 
Center for Research on Health Care Data Center 
CLIA  
 
 
Clinical Laboratory Improvement Amendments 
COPD  
 
 
Chronic Obstructive Pulmonary Disease 
CRF 
 
 
 
Case Report Form 
CRP 
 
 
 
C-reactive protein 
CVD 
 
 
 
Cardiovascular disease 
DHHS  
 
 
Division of Health and Human Services 
DP 
 
 
 
Dipyridamole 
EAE 
 
 
 
Expedited adverse event 
E/CIA  
 
 
Enzyme or chemiluminescence immunoassay  
FEV1  
 
 
Forced exhaled volume in 1 second 
FMD 
 
 
 
Flow-mediated dilation 
FVC 
 
 
 
Forced vital capacity 
HAART 
 
 
Highly active antiretroviral therapy 
hsCRP  
 
 
High Sensitivity C-Reactive Protein 
IDS 
 
 
 
Investigational Drug Service 
IDSMB  
 
 
Institutional Data Safety and Monitoring Board  
LFT 
 
 
 
Liver function test 
MOPS  
 
 
Manual of Procedures 
NNRTI  
 
 
Nonnucleoside reverse transcriptase inhibitor 
NRTI  
 
 
Nucleoside reverse transcriptase inhibitor 
PI 
 
 
 
Protease inhibitor 
SAE 
 
 
 
Serious adverse event 
SUSAR 
 
 
Suspected, unexpected, serious, adverse reaction 
 
 
 
7 
 

 
 
PROTOCOL SUMMARY 
 
A Phase I/II Pilot Study of Dipyridamole as a Modulator of Immune Activation and 
Systemic Inflammation in HIV-1-Infected Subjects on Antiretroviral Therapy 
 
Short Title: Dipyridamole for immune activation in HIV 
 
DESIGN  
This is a Phase 1/2, randomized, double blind, two-arm, partial cross-over, 
single-site, pilot study evaluating the effect of oral dipyridamole (DP) on 
immune activation and inflammation in HIV-1-infected, ART-treated 
subjects with HIV-1 RNA  less than 50 copies/mL. The change from 
baseline to week 12 in the plasma levels of sCD163 and sCD14, and IL-6  
will be assessed within and compared between study arms, as will 
secondary endpoints related to immune activation, inflammation, gut 
mucosal changes, pulmonary function and brachial artery flow-mediated 
dilation (FMD).  
 
Subjects will be randomized 1:1 to DP 100 mg 4 times a day or matching 
placebo. Following week 12, subjects in the DP arm will continue DP for an 
additional 12 weeks (for total 24 weeks) and subjects in the placebo arm 
will cross over to DP 100 mg 4 times a day for 12 weeks.   
  
Evaluations will be scheduled at Entry (week 0) and Weeks 2, 4, 8, 12, 14, 
16, 20, 24, and 28. 
 
DURATION 
Subjects will be in the study for 28 weeks. 
 
SAMPLE SIZE 
40 subjects, 20 per arm. Rectal Tissue Subset: 20 subjects, 10 per arm. 
 
POPULATION 
HIV-1-infected male and female subjects, 18 years of age or older, on ART 
with HIV-1 RNA <50 copies/mL for a minimum of 12 months. 
 
STRATIFICATION Subjects will be stratified by CD4+ T-cell counts (≤ 500 versus > 500 
cells/mm3, and by enrollment into the Rectal Tissue Subset)  
 
REGIMEN 
Arm A:  Dipyridamole 100 mg 4 times daily for 24 weeks 
 
Arm B:  Dipyridamole placebo 1 capsule 4 times daily for 12 weeks, then 
Dipyridamole 100 mg 4 times daily for 12 weeks. 
 
 
 
 
 
 
 
 
 
 
 
8 
 

 
 
STUDY SCHEMA: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
9 
 

 
 
1.0 
HYPOTHESES AND STUDY OBJECTIVES 
 
1.1 
Hypotheses  
 
Dipyridamole (DP) will decrease the levels of monocyte and macrophage activation (as 
measured by the plasma levels of sCD163 and sCD14) and systemic inflammation (as 
measured by plasma IL-6) in antiretroviral treated HIV-1-infected individuals with HIV-1 
RNA <50 copies/mL. 
 
1.2 
Primary Objective 
 
1.2.1 To compare changes in monocyte and macrophage activation and systemic 
inflammation, as measured by plasma levels of sCD163, sCD14, and IL-6 after 
12 weeks of DP treatment to placebo. 
 
1.3   
Secondary Objectives 
 
1.3.1  To compare changes in the level of T cell immune activation as measured by the 
proportion of CD8+ and CD4+ T cells co-expressing HLA-DR and CD38 and the 
proportion of CD8+ and CD4+ T cell co-expressing CD69 and CD25, after 12 
weeks of DP treatment to placebo. 
 
 1.3.2 To compare changes in cellular markers of monocyte and macrophage 
activation, as measured by tissue factor and CD16 expression in monocytes after 
12 weeks of DP treatment to placebo. 
 
1.3.3 To compare changes in the levels of systemic inflammatory biomarkers 
(sTNFαR, TNFα, hsCRP) and levels of coagulation (D-dimer, tissue factor) after 
12 weeks of DP treatment to placebo. 
 
1.3.4 To compare changes in brachial artery flow-mediated dilation (FMD) 12 weeks 
after treatment with DP to placebo. 
 
1.3.5 To evaluate the safety and tolerability of DP administered for up to 24 weeks in 
HIV-1-infected adults. 
 
1.3.6 To assess persistence of changes in immune activation and levels of systemic 
inflammation, including the primary endpoint measures, after 24 weeks of DP 
treatment and 4 weeks after discontinuation of therapy. 
 
1.3.7 To assess whether DP reduces the proportion of cycling CD4+ and CD8+ T cells 
as measured by Ki-67 expression at baseline and after treatment with DP. 
 
1.3.8 To correlate plasma DP levels to urine adenosine, plasma IL-6, and cellular and 
soluble markers of immune activation. 
 
1.3.9 To evaluate changes in residual plasma HIV-1 RNA using single copy assay 
(SCA) before and after DP treatment.  
 
 
 
10 
 

 
 
1.4       Exploratory Objectives 
 
1.4.1 To evaluate the changes in T cell activation in rectosigmoid tissue by measuring 
the proportion of CD4+ and CD8+ T cells co-expressing CD38 and HLA-DR at 
baseline and after treatment with DP. 
 
1.4.2 To explore the frequency of gut-homing CD4+ T cells by measuring blood and 
tissue CCR9+ β7high T cells at baseline and after treatment with DP. 
 
1.4.3 To explore the frequency and phenotype of T cells, B cells, and monocytes 
expressing CD73 in peripheral blood as well as T cells and B cells expressing 
CD73 in gut tissue at baseline and after DP treatment. 
 
1.4.4 To measure levels of purines involved in the adenosine (ADO) suppression 
pathway before and after DP treatment. 
 
1.4.5 To correlate expression of CD73 in the different immune cells with levels of ADO 
and other purines involved in the ADO suppression pathway as well as with 
levels of cellular immune activation and inflammation. 
 
1.4.6 To correlate the levels of ADO and other purines in the ADO suppression 
pathway with levels of cellular immune activation and inflammation. 
 
1.4.7 To explore correlations between CD73-expressing immune cells, Th17 cells, and 
regulatory T cells. 
 
1.4.8 To explore levels of residual viral expression before and after DP treatment by 
through single copy assays and measurement of cell-associated HIV-1 RNA and 
DNA in blood and GALT. 
 
1.4.9 To explore the effect DP treatment has on pulmonary function by comparing 
change in pre- and post-bronchodilator forced expired volume in 1 second (FEV1) 
after 12 and 24 weeks of DP treatment. 
 
2.0 
INTRODUCTION 
 
2.1 
Background 
 
Although effective antiretroviral therapy (ART) has significantly increased the life 
expectancy of individuals with HIV-1 infection, mortality rates are still higher compared to 
the HIV-1 uninfected population.1-3 In HIV-1 infection, despite virologic suppression, the 
levels of cellular immune activation and inflammation rarely return to levels observed in 
HIV-1 seronegative individuals.4,5 It is believed that the non-AIDS-associated morbidity 
and mortality is due, in part, to the consequences of this persistent immune activation 
and elevated levels of systemic inflammation.6  Furthermore, the levels of inflammation 
are higher in ART-treated individuals with incomplete immune reconstitution compared 
to those with good CD4+ T cell recovery.7,8 Although persistent viremia has been 
proposed to be the major cause of immune activation and inflammation in HIV-1 
infection, in virally suppressed individuals, chronic inflammation has also been 
hypothesized to be due to a number of different factors including depletion of CD4+ T 
cells in the gut mucosa leading to the continued translocation of microbial products into 
11 
 

 
 
the circulation,9,10 reactivation of other viruses such as cytomegalovirus,11,12 or 
dysregulation of T cell homeostasis.13 A number of clinical trials are currently assessing 
these possible causes, as well as evaluating various immunotherapeutic agents as 
strategies to decrease the inflammation. 
 
In increased inflammatory states, adenosine (ADO) is produced by both intracellular and 
extracellular mechanisms, the latter being the more significant source of ADO 
generation.14 ADO limits cellular damage by activating the adenosine receptors, 
A2A/2BR, leading to increased intracellular cAMP and a subsequent anti-inflammatory 
effect.15  ADO is a highly potent immunoregulatory nucleoside that is produced by cells 
during conditions of stress such as during trauma, hypoxia, and inflammation in order to 
limit the tissue damage,15-17 with levels increasing from nano-molar to micro-molar 
concentrations during inflammatory states.14,16,18  Extracellular generation of ADO is 
facilitated by the ectoenzymes CD39 and CD73. ATP released by cells during 
inflammation is hydrolyzed by CD39 to 5’-AMP, which in turn is hydrolyzed by CD73 to 
ADO.19 Once ADO is generated, it binds to specific cell receptors in order to mediate its 
effects.  Of these receptors, the A2AR is expressed on most lymphoid cells where ligation 
causes an increase in cAMP production thereby allowing the lymphocytes to regulate the 
immune response.15,20 ADO is then transported intracellularly down its concentration 
gradient by nucleoside transporters where it is degraded by ADO deaminase or 
rephosphorylated by ADO kinase.21 During T cell activation, A2AR signaling may allow T 
cell proliferation but cytokine production is strongly inhibited.22 In vitro studies show that 
A2AR signaling also protects CD4+ T cells from activation-induced cell death by blocking 
the extrinsic apoptotic pathway.23 Apart from regulating T lymphocytes, ADO through the 
A2AR signaling, prevents excessive macrophage activation leading to a decrease in the 
expression of TNFα and nitric oxide24 and a switch to the production of the anti-
inflammatory cytokine IL-10.25 Indeed, recent in vitro studies using T cells from both 
normal controls (NC) and HIV-1+ subjects demonstrated the ability of exogenous ADO to 
inhibit both T cell secretion of TNFα and IL-2 secretion as well as T cell immune 
activation.  
 
It has been shown that the levels of CD73-expressing CD4+ T cells are markedly 
reduced in the peripheral blood of HIV-1-infected patients regardless of viral 
suppression, and that ADO decreases T cell immune activation in a concentration 
dependent manner.26 The decreased levels of ADO, due to the low numbers of 
CD4+CD73+ T cells, fails to counter HIV-1-associated persistent immune activation and 
subsequent increased inflammation.  It is hypothesized that an intervention increasing 
extracellular ADO will lead to decreased immune activation in HIV-1-infected subjects. 
 
2.2 
Rationale 
 
As the HIV-1 infected population ages, there is increased risk for the development of 
non-AIDS-related chronic diseases. Identifying specific immunologic pathway(s) that 
regulates the elevated levels of immune activation and inflammation is paramount in the 
prevention of these chronic diseases and in increasing the life expectancy of those living 
with HIV-1. Furthermore, identification of specific pathways will lead to the development 
of more effective immunotherapeutic strategies that target and regulate these pathways.  
 
Dipyridamole (DP) is an FDA-approved medication used as an adjunct to anticoagulants 
in preventing post-operative thromboembolic complications following heart surgery, and 
has been studied with aspirin in stroke prevention.27,28 It increases extracellular ADO by 
12 
 

 
 
blocking equilibrative nucleoside transporters which facilitate the transport of ADO down 
its concentration gradient.29,30 Moreover, it is able to further increase cAMP levels by 
inhibiting phosphodiesterase that prevents the breakdown of cAMP.29,31 In a clinical 
study by Gamboa et al., DP was shown to enhance the delivery of ADO into the 
interstitium, allowing ADO to exert is effects.32 In another clinical study, pretreatment 
with DP potentiated the vasodilatory effects of ADO, with the magnitude of ADO-induced 
vasodilation directly correlating with plasma DP concentrations.33 The anti-inflammatory 
effect of DP is evident in an earlier study by Brozna et al., which showed DP inhibiting 
LPS-induced superoxide anion release and tissue factor (TF) expression in peripheral 
blood monocytes.34 In a more recent study, DP blocked the generation of monocyte 
chemotactic protein-1 by LPS-treated monocytes.35  
 
Animal studies on the anti-inflammatory effect of DP were validated in a clinical trial by 
Ramakers et al.30 In this randomized, double-blind study, healthy male subjects received 
either extended-release DP (200mg twice daily) or placebo for 7 days. The subjects then 
received a 2ng/kg dose of endotoxin. DP treatment caused an 89% reduction in 
nucleoside transporter activity as well as an increase in endogenous ADO concentration, 
with the DP levels strongly correlating with peak ADO concentrations (r=0.82; P<0.01). 
DP augmented the LPS-induced increase in levels of the anti-inflammatory cytokine, IL-
10. Furthermore, the decline of TNFα and IL-6 levels was accelerated in DP-treated 
subjects.  
 
Chronic obstructive lung disease (COPD) is an important co-morbidity in HIV that may 
also be the consequence of immune activation and systemic inflammation. COPD, 
characterized by irreversible airflow obstruction and inflammation36, is the fourth leading 
cause of death in the United States.  COPD is defined by the Global Initiative for 
Obstructive Lung Diseases as “a preventable and treatable disease…characterized by 
airflow obstruction that is not fully reversible” and is generally defined by forced 
expiratory volume in one second (FEV1)/forced vital capacity (FVC)<0.70, with the 
severity of airflow obstruction measured by degree of decrease in FEV1
36.  HIV is an 
independent risk factor for COPD, and there has been a three-fold increase in 
obstructive lung disease deaths in HIV since the introduction of antiretroviral therapy 
(ART)37-39. We see an average rate of decline in FEV1 in our cohorts of stable HIV-
infected outpatients (including non-smokers and those without any lung disease) of 
approximately 75-98ml/year, which is far greater than that seen in both non-smoking and 
smoking HIV-uninfected individuals who typically experience a 20-60ml/year decline. In 
addition, FEV1 is an independent predictor of mortality in the HIV-uninfected 
population,40 and we have similarly found that FEV1 is related to mortality in our cohort of 
237 HIV+ individuals followed for an average of 3.2 years, with those dying having 
FEV1/FVC of 0.69 (SD 0.15) compared to 0.77 (SD 0.10) in survivors (p=0.031). Decline 
in FEV1 in HIV may be related to local and systemic inflammation as we see increases in 
lung and blood cytokines, markers of immune activation, and co-infections in HIV+ 
individuals with lung dysfunction. The inflammation may be exaggerated by smoking, but 
does not depend on smoke exposure.  We have recently shown that worse airflow 
obstruction is associated with increased immune activation and inflammation including 
increases in IL-6, hsCRP, and activated T-cells.41 In a separate analysis, we have also 
found correlations of FEV1 with IL-8 and endothelin-1 (ET1), and confirmed associations 
with IL-6. Based on these observations, inflammation is important in HIV pulmonary 
dysfunction. We will measure FEV1 in participants as an exploratory outcome to see if 
DP may be a potential therapeutic option for HIV-1 infected individuals where few 
therapeutic options exist. 
13 
 

 
 
 
Administration of DP in HIV-1-infected individuals will be ideal in further investigating 
whether deficiencies in ADO signaling pathway play an important role in the persistent 
immune activation and systemic inflammation in chronic HIV-1 infection. This pilot 
clinical trial will evaluate the effect of DP, an FDA-approved drug with a known 
mechanism of action, on immune activation and inflammation of HIV-1 infected 
individuals on effective ART. 
 
 
2.3 
Description of Study Product 
 
Dipyridamole42 is an antiplatelet agent chemically described as 2,2',2'',2'''-[(4,8-
Dipiperidinopyrimido[5,4-d ]pyrimidine-2,6-diyl)dinitrilo]-tetraethanol. It has the following 
structural formula: 
 
 
 
 
 
Mechanism of Action:  
DP inhibits the uptake of adenosine into platelets, endothelial cells and erythrocytes in 
vitro and in vivo; the inhibition occurs in a dose-dependent manner at therapeutic 
concentrations (0.5-1.9 µg/mL). This inhibition results in an increase in local 
concentrations of adenosine which acts on the platelet A2-receptor thereby stimulating 
platelet adenylate cyclase and increasing platelet cyclic-3',5'-adenosine monophosphate 
(cAMP) levels. Via this mechanism, platelet aggregation is inhibited in response to 
various stimuli such as platelet activating factor (PAF), collagen and adenosine 
diphosphate (ADP).  
 
DP inhibits phosphodiesterase (PDE) in various tissues. While the inhibition of cAMP-
PDE is weak, therapeutic levels of DP inhibit cyclic-3',5'-guanosine monophosphate-
PDE (cGMP-PDE), thereby augmenting the increase in cGMP produced by nitric oxide.  
  
Pharmacokinetics: 
Following an oral dose of DP tablets, the average time to peak concentration is about 75 
minutes. The decline in plasma concentration following a dose of DP tablets fits a two-
14 
 

 
 
compartment model. The alpha half-life (the initial decline following peak concentration) 
is approximately 40 minutes. The beta half-life (the terminal decline in plasma 
concentration) is approximately 10 hours. DP is highly bound to plasma proteins. It is 
metabolized in the liver where it is conjugated as a glucuronide and excreted with the 
bile.  Drug interactions with HIV medications, including protease inhibitors, are not 
predicted. 
 
Indications for DP: 
DP (Persantine®) tablets are indicated as an adjunct to warfarin anticoagulants in the 
prevention of postoperative thromboembolic complications of cardiac valve replacement. 
The recommended oral dose is 75-100 mg four times daily as an adjunct to the usual 
warfarin therapy. 
 
Precautions and Adverse Reactions: 
DP has a vasodilatory effect and should be used with caution in patients with severe 
coronary artery disease (e.g., unstable angina or recently sustained myocardial 
infarction). Chest pain may be aggravated in patients with underlying coronary artery 
disease who are receiving DP. Elevations of hepatic enzymes and hepatic failure have 
been reported in association with DP administration. DP should be used with caution in 
patients with hypotension since it can produce peripheral vasodilation. 
 
DP has been reported to increase the plasma levels and cardiovascular effects of 
adenosine and may counteract the anticholinesterase effect of cholinesterase inhibitors, 
thereby potentially aggravating myasthenia gravis.  
 
Adverse reactions at therapeutic doses are usually minimal and transient. With long-term 
use of DP tablets, initial side effects usually disappear. The following reactions in Table 
1 were reported in two heart valve replacement trials comparing DP tablets and warfarin 
therapy to either warfarin alone or warfarin and placebo: 
 
Table 1 Adverse Reactions Reported in 2 Heart 
Valve Replacement Trials 
Adverse 
Reaction 
Dipyridamole 
Tablets/Warfarin 
Placebo/ 
Warfarin 
Number of 
Patients 
147 
170 
Dizziness 
13.6% 
8.2% 
Abdominal 
distress 
6.1% 
3.5% 
Headache 
2.3% 
0.0% 
Rash 
2.3% 
1.1% 
 
Other reactions from uncontrolled studies include diarrhea, vomiting, flushing and 
pruritus. In addition, angina pectoris has been reported rarely and there have been rare 
reports of liver dysfunction. On those uncommon occasions when adverse reactions 
have been persistent or intolerable, they have ceased on withdrawal of the medication. 
 
When DP tablets were administered concomitantly with warfarin, bleeding was no 
greater in frequency or severity than that observed when warfarin was administered 
alone. In rare cases, increased bleeding during or after surgery has been observed. The 
15 
 

 
 
guidelines from the American Society of Gastrointestinal Endoscopy state that low risk 
endoscopic procedures, including flexible sigmoidoscopy with biopsies, may be 
performed on patients using standard-dose DP or ASA-DP combinations. 43 
 
In post-marketing reporting experience, there have been rare reports of hypersensitivity 
reactions (such as rash, urticaria, severe bronchospasm, and angioedema), larynx 
edema, fatigue, malaise, myalgia, arthritis, nausea, dyspepsia, paresthesia, hepatitis, 
thrombocytopenia, alopecia, cholelithiasis, hypotension, palpitation, and tachycardia. 
 
3.0 
STUDY DESIGN 
 
The proposed study is a randomized, placebo-controlled, two-arm, partial cross-over, 
single-site, pilot study comparing the effect of 12 weeks of DP or placebo on immune 
activation and inflammation.  The study will enroll approximately 40 HIV-1-infected 
subjects, age 18 years or older, who have been on ART for at least 12 months prior to 
study entry and have HIV-1 RNA <50 copies/mL for at least 12 months prior to study 
entry.  Subjects will be randomized equally to two regimens: 
 
Arm A: Dipyridamole 100 mg four times daily for 24 weeks 
 
or  
 
Arm B: Dipyridamole placebo capsule four times daily for 12 weeks, then 
Dipyridamole 100 mg four times daily for 12 weeks. 
 
Each subject will be enrolled for 28 weeks.  Accrual is expected to be completed in 
approximately 18 months.   
 
In addition, this study will include Rectal Tissue evaluations in 20 subjects (10 per arm).  
Flexible sigmoidoscopy with biopsies will be done at Entry/Week 0 and Weeks 12, 24, 
and 28.   
 
The primary endpoints will be change from baseline to week 12 in plasma levels of 
sCD163, sCD14, and IL-6.  Secondary endpoints will include changes in immune 
activation as measured in blood (%HLA-DR+CD38+CD8+ and CD4+ T-cells and 
%CD69+CD25+ CD8+ and CD4+ T-cells) and rectal tissue (HLA-DR+CD45RO+CD4+ 
T-cells, gut-homing CD4+ T-cells), cell-associated HIV-1 RNA and total DNA, and safety 
and tolerability of DP in HIV-1-infected adults. 
 
Assessment of the primary and secondary endpoints at Week 24 will be conducted to 
gather additional longitudinal data.  Arm A subjects will provide data on the durability of 
the effect of DP on immune activation, as well as safety and tolerability.  Arm B subjects 
will receive DP from week 12 to week 24 and will enhance the power of the study to 
detect an effect of DP as well provide additional safety and tolerability data. 
 
4.0 
SELECTION AND ENROLLMENT OF SUBJECTS 
 
The inclusion and exclusion criteria in Sections 4.1 and 4.2 will be utilized to ensure the 
appropriate selection of study subjects. Potential subjects will primarily be recruited from 
the University of Pittsburgh HIV/AIDS primary care clinic.  They will be identified by their 
primary care doctor or clinical team, including subjects who have previously expressed 
16 
 

 
 
interest in participating in a clinical research study by signing the IRB-approved HIPPA-
compliant Research Registry consent document for sharing of health information.  
Interested persons will be provided with information by the research recruiter/educator 
who will include the potential subject’s primary clinician in the discussion to participate.  
Subjects may also be referred to the study from other local HIV care providers, research 
projects, and health and social service providers.  All recruitment materials will be 
approved by the University of Pittsburgh Institutional Review Board prior to use.  
Informed consent for participation will be obtained by a physician investigator.  Eligible 
participants who agree to rectal tissue biopsies will be enrolled in the tissue subset. 
 
4.1 
Inclusion Criteria 
 
Subjects must meet all of the following criteria to be eligible for inclusion in the study. 
 
4.1.1 
HIV-1 infection, documented by any licensed rapid HIV test or HIV enzyme or 
chemiluminescence immunoassay (E/CIA) test kit at any time prior to study entry 
and confirmed by a licensed Western blot or a second antibody test by a method 
other than the initial rapid HIV and/or E/CIA, or by HIV-1 antigen, plasma HIV-1 
RNA viral load.  
 
WHO (World Health Organization) and CDC (Centers for Disease Control and 
Prevention) guidelines mandate that confirmation of the initial test result must 
use a test that is different from the one used for the initial assessment. A reactive 
initial rapid test should be confirmed by either another type of rapid assay or an 
E/CIA that is based on a different antigen preparation and/or different test 
principle (e.g., indirect versus competitive), or a Western blot or a plasma HIV-1 
RNA viral load. 
 
4.1.2 
Men and women age 18 years or older. 
 
4.1.3 
On ART for at least 12 months prior to study entry with a regimen that includes 
three or more antiretroviral medications.  Ritonavir used as a pharmacokinetic 
enhancer for another protease inhibitor will not be counted as an antiretroviral 
medication. 
 
4.1.4 Plasma HIV-1 RNA <50 copies/mL by any standard clinical assay at screening 
and for a minimum of 12 months prior to entry, confirmed by by at least two 
measurements prior to study entry, one of which must be at least 48 weeks prior 
to study entry and one measurement that was obtained between 61 days and 48 
weeks prior to study entry.  All plasma HIV-1 RNA measurements in the 12 
months prior to study entry must be <50 copies/mL (with the exception that a 
single detectable measurement of ≤ 200 copies/mL is permitted if the RNA levels 
immediately before and after are <50 copies/mL). 
 
4.1.5 Stable ART regimen for at least 8 weeks prior to study entry and no plans to 
change ART regimen for at least 6 months following study entry. 
 
4.1.6 Ability and willingness of subject to provide informed consent. 
 
4.1.7 In the opinion of the investigator, no medical, mental health or other condition 
that precludes participation. 
17 
 

 
 
 
4.1.8 Laboratory values obtained within 60 days prior to entry: 
• 
Hemoglobin ≥10.0 g/dL 
• 
Platelet count ≥100,000/mm3 
• 
INR ≤ 1.5 (for rectal tissue subset only) 
• 
PTT <2x ULN (for rectal tissue subset only)   
• 
AST and ALT < 2.5 x upper limit of normal (ULN) 
• 
Total bilirubin < 2.5 x ULN (except if hyperbilirubinemia is secondary to 
atazanavir). 
• 
Creatinine ≤ 1.5 x ULN 
• 
Hepatitis B surface antigen negative 
• 
Hepatitis C antibody negative (note: subject with HCV Ab positive is eligible if 
Hepatitis C RNA PCR (viral load) is undetectable) 
 
4.1.9 For women of reproductive potential, negative serum or urine pregnancy test, 
with a sensitivity of ≤ 50 mIU/mL, at screening and within 72 hours prior to study 
entry.  
 
4.1.10 Female study volunteers of reproductive potential include women who have not 
been post-menopausal for at least 24 consecutive months, (i.e., who have had 
menses within the preceding 24 months, or women who have not undergone 
surgical sterilization, specifically hysterectomy and/or bilateral oophorectomy). 
 
If participating in sexual activity that could lead to pregnancy, female subjects 
must agree to use one form of contraceptive as listed below while receiving 
protocol-specified treatment and for 4 weeks after stopping the treatment. 
 
• 
Condoms (male or female) with or without a spermicidal agent. Condoms are 
recommended because their appropriate use is the only contraception 
method effective for preventing HIV transmission.  
• 
Diaphragm or cervical cap with spermicide 
• 
Intrauterine device (IUD) 
• 
Hormone-based contraceptive 
 
NOTE: If the subject is taking a concomitant medication with stricter 
contraceptive requirements than what are listed in the protocol for the study 
drugs (such as in the case of efavirenz), then refer to the pregnancy category 
and product labeling for the concomitant medication with the strictest 
contraceptive requirements.  
 
4.1.11 If the female subject is not of reproductive potential (girls who have not reached 
menarche, women who have been post-menopausal for at least 24 consecutive 
months, or women who have undergone surgical sterilization, e.g., hysterectomy, 
bilateral oophorectomy, or bilateral tubal ligation or salpingectomy), she is eligible 
without requiring the use of a contraceptive. Self- report is acceptable 
documentation of sterilization, other contraceptive methods, and menopause. 
 
4.1.12 Rectal Tissue Subset only: Willing to abstain from receptive anal intercourse and 
practices involving insertion of anything in the rectum (drug, enema, penis, or sex 
18 
 

 
 
toy) for 72 hours prior to rectal biopsy and for 7 days post-biopsy to minimize risk 
of bleeding complications.  
 
4.2 Exclusion Criteria 
 
Subjects who meet any of the following criteria will be excluded from the study: 
 
4.2.1 Pregnancy or breast-feeding. 
 
4.2.2 Known allergy/sensitivity or any hypersensitivity to components of study drug(s) 
or their formulation. 
 
4.2.3 Known cardiovascular disease (history of MI, coronary artery bypass graft 
surgery, percutaneous coronary intervention, stroke, transient ischemic attack, 
peripheral arterial disease with ABI <0.9 or claudication). 
 
4.2.4 Uncontrolled type II diabetes mellitus.   
 
4.2.5 Known chronic inflammatory conditions such as, but not limited to, rheumatoid 
arthritis, systemic lupus erythematosus, sarcoidosis, inflammatory bowel disease 
(i.e., Crohn’s disease or ulcerative colitis), chronic pancreatitis, or autoimmune 
hepatitis, myositis, or myopathy. 
 
4.2.6 History of asthma requiring medical treatment within 2 years prior to study entry 
with the exception of the use of albuterol inhaler for mild intermittent asthma. 
 
4.2.7 Serious illness requiring systemic treatment and/or hospitalization within 14 days 
prior to entry. 
 
4.2.8 Use of any of the following medications for more than 3 consecutive days within 
the 60 days prior to study entry: 
 
• 
Immunosuppressives (e.g., azathioprine, , cyclosporine, mycophenolate, 
sirolimus, sulfasalazine, tacrolimus) 
• 
Immune modulators (e.g., cytokines [e.g., IL-2], granulocyte colony 
stimulating factor, growth hormone, tumor necrosis factor antagonists, 
thalidomide) 
• 
Antineoplastic agents 
• 
Anticoagulants (e.g., warfarin and heparin) 
• 
Anti-platelet drugs (e.g., clopidogrel) 
  
4.2.9 Use of any of the following medications for more than 3 consecutive days within 
the 30 days prior to study entry: 
 
• 
Corticosteroids [physiologic replacement doses are allowed] 
• 
NSAIDs (nonsteroidal anti-inflammatory drugs) 
• 
Aspirin 
 
4.2.10 Vaccinations within 1 week prior to the pre-entry or study entry visits.  
 
19 
 

 
 
NOTE: Routine standard of care vaccinations including hepatitis A and/or B, 
influenza, pneumococcal, and tetanus are permitted if administered at least 7 
days before pre-entry and entry evaluations.   
 
4.2.11 Participation on any HIV immunotherapy or therapeutic vaccination trials within 6 
months prior to study entry. 
 
4.2.12 Active drug or alcohol use or dependence that, in the opinion of the site 
investigator, would interfere with adherence to study requirements. 
 
4.2.13  Use of investigational therapies within 30 days prior to study entry. 
 
4.2.14  Rectal Tissue Subset only:  
• 
Abnormalities of the colorectal mucosa or significant colorectal symptom(s), 
which in the opinion of the study investigator represent a contraindication to 
biopsy (including but not limited to presence of any unresolved injury, 
infectious or inflammatory condition of the local mucosa, and presence of 
symptomatic external hemorrhoids. 
 
NOTE: Abnormalities of the colorectal mucosa will be assessed at the time of 
the enrollment flexible sigmoidoscopy.  If no significant colorectal 
abnormalities or symptoms are present then the participant will undergo the 
enrollment procedures.  If abnormalities are present then no biopsies will be 
performed and the participant will not be enrolled into the rectal tissue subset 
but will continue participation in the main study. 
 
• 
Active untreated gonorrhea, or chlamydia infection within 30 days prior to 
study entry (subjects diagnosed with rectal gonorrhea or chlamydia infection 
at screening may be treated during the screening period provided the 
treatment is at least 30 days prior to entry).  
 
4.2.15 Exclusions for spirometry testing (for participants enrolled under Version 2.0): 
Participants will not undergo pre- and post-bronchodilator spirometry if they have 
any of the following: 
 
• 
Abdominal or cataract surgery within 3 months. 
• 
Myocardial infarction or stroke within the past 3 months. 
• 
Acute onset of shortness of breath, cough, fever or heart condition such as 
tachycardia, angina or arrhythmias with 4 weeks prior to enrollment. 
• 
Increasing respiratory symptoms or febrile (temperature >100.4°F [38°C]) 
within 4 weeks of study entry. 
• 
Uncontrolled hypertension defined as systolic > 160 mm Hg or diastolic > 100 
mm Hg from an average of two or more readings.  Participant with controlled 
hypertension may undergo spirometry. 
• 
Prior history of adverse reaction to albuterol 
 
4.3 
Study Enrollment Procedures 
 
Prior to implementation of this protocol, and any subsequent full version amendments, 
the protocol and the protocol consent form(s) will be approved by the University of 
20 
 

 
 
Pittsburgh Institutional Review Board (IRB). Upon receiving final approval, all required 
protocol registration documents will be submitted to the DAIDS Protocol Registration 
Office (DAIDS PRO) at the Regulatory Support Center (RSC).The DAIDS PRO will 
review the submitted protocol registration packet to ensure that all of the required 
documents have been received.  
 
4.4 
Coenrollment Guidelines  
 
Coenrollment into observational studies is permitted provided maximum blood draw 
volumes are not exceeded.  
 
5.0 
STUDY TREATMENT  
 
5.1 
Regimens, Administration, and Duration 
 
Study treatment is defined as DP 100 mg capsules and matching placebo, and will be 
provided by the study. Subjects will be asked to bring back their study product bottles for 
pill counts for all post-entry visits. 
 
5.1.1 Regimens 
 
At study entry, subjects will be randomized to one of the following arms: 
 
Arm A: Dipyridamole 100 mg 4 times daily for 24 weeks 
 
Arm B:  Dipyridamole placebo 1 capsule 4 times daily for 12 weeks, then 
Dipyridamole 100 mg 4 times daily for 12 weeks. 
 
 
5.1.2 Administration 
 
DP capsules (and Placebo capsules) should be taken orally 4 times daily with or 
without food.   
 
5.1.3 Study Treatment Duration 
 
 
Subjects will remain on study treatment until Week 24. 
 
5.2 
Study Product Formulation and Storage  
 
DP 100 mg and placebo for DP are provided as capsules. 
 
Store at a controlled room temperature of 25°C (77°F); excursions permitted to 15°-30°C 
(59°-86°F); protect from excessive moisture. 
 
5.3 
Pharmacy: Product Supply, Acquisition, and Accountability 
 
5.3.1 Study Product Supply 
 
DP and placebo for DP will be supplied by the Investigational Drug Service (IDS) 
of the University of Pittsburgh Medical Center. 
 
21 
 

 
 
5.3.2 Study Product Accountability 
 
The IDS pharmacist will maintain complete records of all study products received 
and subsequently dispensed. All unused study products must be returned to IDS 
and will be destroyed after the study is completed or terminated.  
 
5.4 
Concomitant Medications 
 
5.4.1 Required Medications 
 
Subjects must be on combination ART (not provided by the study) as specified in 
the inclusion criteria (4.1.3).  
 
 
5.5 
Adherence Assessment  
 
Pill counts and self-report adherence interviews for DP will be used to assess adherence 
during the treatment period. Subjects will be asked to bring in the bottles of study 
medication so that pill counts may be performed.   
 
 
 
22 
 

 
 
 
6.0 
CLINICAL AND LABORATORY EVALUATIONS 
6.1 
Schedule of Events (SOE) 
Evaluation 
Screening 
Pre-Entry1 
Entry 
Week 
Premature 
Treatment and/or 
Study 
Discontinuation 
2 
4 
8 
12 
14 
16 
20 
24 
28 
 
Documentation of HIV-1 infection 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History/Medication 
History 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Complete Physical Exam 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Targeted Physical Exam 
 
X 
X 
 
X 
X 
X 
 
X 
X 
X 
X 
X 
Clinical Assessments 
 
 
X 
 
X 
X 
X 
 
X 
X 
X 
X 
X 
Concomitant Medications 
 
X 
X 
 
X 
X 
X 
 
X 
X 
X 
X 
X 
Hematology 
X 
 
X 
 
 
 
X 
 
 
 
X 
 
X 
Liver Function Tests/Blood 
Chemistries 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Fasting Lipid Panel 
 
 
X 
 
 
 
X 
 
 
 
X 
 
X 
Plasma HIV-1-1 RNA 
X 
 
X 
 
 
 
X 
 
 
 
X 
 
X 
CD4+/CD8+ 
X 
 
X 
 
 
 
X 
 
 
 
X 
 
X 
Pregnancy Test 
X 
 
X 
 
X 
X 
X 
 
X 
X 
X 
X 
X 
Prothrombin time/INR/PTT2 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Hepatitis B and C 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Stored Plasma for 
Immunology/Virology5 
 
X 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Stored PBMC for 
Immunology/Virology5 
 
X 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
Urine adenosine level (stored) 5 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
Serum for Dipyridamole 
concentration (stored) 
 
 
 
 
X 
X 
X 
 
X 
X 
X 
 
X 
Brachial Artery FMD 
 
 
X 
 
X 
 
X 
 
 
 
X 
 
X3 
Rectal swabs for GC/CT NAAT2 
X 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
HSV Serology2 
 
 
X 
 
 
 
 
 
 
 
 
 
 
Flexible sigmoidoscopy (rectal 
biopsy)2, 5 
 
 
X 
 
 
 
X 
 
 
 
X 
X 
 
Adherence self-report 
 
 
 
 
X 
 
X 
 
X 
 
X 
 
 
23 
 

 
 
 
Evaluation 
Screening 
Pre-Entry1 
Entry 
Week 
Premature 
Treatment and/or 
Study 
Discontinuation 
2 
4 
8 
12 
14 
16 
20 
24 
28 
 
Medication Adherence 
Assessment 4 
 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
Telephone assessment of 
tolerability/adherence 
 
 
 
X 
 
 
 
X 
 
 
 
 
 
Pre- and post-bronchodilator 
spirometry 6 
 
 
X 
 
X 
 
X 
 
 
 
X 
 
 
1 Pre-Entry evaluations must be completed within 14 days prior to study entry.  
2 Rectal Tissue sub-group only. 
3 Only if ≥ 4 weeks since the last FMD assessment and on study medication ≤72 hours prior to visit. 
4 Capsule counts to take place at all post-entry visits. 
5 See Section 6.3.9 for specific assays. 
6  For participants enrolled under Version 2.0 
 
24 
 

 
 
 
6.2 
Timing of Evaluations 
 
6.2.1 Screening and Pre-Entry Evaluations  
 
Screening and pre-entry evaluations must occur prior to the subject’s starting any 
study medications, treatments, or interventions. 
 
Screening 
Screening evaluations to determine eligibility must be completed within 60 days 
prior to study entry unless otherwise specified. 
 
Pre-Entry  
Pre-entry evaluations must be completed at least 24 hours after screening 
evaluations have been completed and within 14 days prior to study entry.  
 
6.2.2 Entry Evaluations 
 
Entry evaluations must occur at least 24 hours after pre-entry evaluations unless 
otherwise specified. All entry evaluations must be completed before study drug is 
started.  In order to facilitate scheduling of procedures, subjects may have the 
FMD test or the rectal biopsies performed on a separate day within 3 days after 
randomization (but prior to starting study medication). 
 
6.2.3 Post-Entry Evaluations 
 
On-Study Evaluations  
All on-study evaluations must be scheduled as per Section 6.1 with a +7 day 
window for all visits.  In order to facilitate scheduling of procedures, subjects may 
have the FMD test or the rectal biopsies performed on a separate day within the 
visit window.   
 
6.2.4 Discontinuation Evaluations  
 
Evaluations for Randomized Subjects Who Do Not Start Study Treatment 
Subjects who are randomized but do not start study treatment within 72 hours will 
be taken off study with no further evaluations required. All case report forms 
(CRFs) must be completed for the period up to and including week 0.  
 
Premature Treatment Discontinuation Evaluations  
Subjects who prematurely discontinue study treatment will have a study 
discontinuation visit as per Section 6.1 and then be taken off study. 
 
6.2.5 Pregnancy 
 
If a woman becomes pregnant while on study, study product will be discontinued 
immediately and no further study assessments will be performed except safety 
labs. See Section 7.2 regarding patient management. All pregnancies should be 
followed by monthly telephone contact until the final outcome can be determined. 
25 
 

 
 
 
In the event that the pregnancy has not been completed by the final study visit, 
then the subject will be contacted through monthly phone calls and review of 
medical records, if possible, until the pregnancy outcome can be ascertained. 
Intrapartum complications and/or pregnancy outcome will be recorded on the 
CRFs.  
 
6.3 
Instructions for Evaluations 
 
All clinical and laboratory information required by this protocol is to be present in the 
source documents. Sites must refer to the Source Document Guidelines on the DAIDS 
Web site for information about what must be included in the source document: 
http://www3.niaid.nih.gov/research/resources/DAIDSClinRsrch/PDF/SourceDocAppndx.
pdf. All stated evaluations are to be recorded on the CRF and keyed into the database 
unless otherwise specified. This includes events that meet the International Conference 
on Harmonization (ICH) definitions for a serious adverse event. 
 
• 
Results in death 
• 
Life-threatening 
• 
Requires inpatient hospitalization or prolongation of existing hospitalization 
• 
Results in persistent or significant disability/incapacity  
• 
Congenital anomaly/birth defect 
• 
Other important medical event (may not be immediately life-threatening or result in 
death or hospitalization but may jeopardize the subject or may require intervention to 
prevent one of the events listed above.  
 
To grade diagnoses, signs and symptoms, and laboratory results, sites must refer to the 
DAIDS Table for Grading the Severity of Adult and Pediatric Adverse Events (DAIDS AE 
Grading Table), Version 1.0, December 2004 (Clarification, August 2009), which can be 
found on the DAIDS RSC Web site: http://rsc.tech-res.com/safetyandpharmacovigilance     
 
6.3.1 Definition of Fasting 
Subjects must be evaluated in a fasting state for those evaluations indicated as 
“fasting”.  
 
NOTE: Fasting is defined as nothing to eat or drink except water and required 
prescription medications for at least 8 hours. Drinking black decaffeinated coffee 
without sweetener or creamer is permissible, but is not advised.  Subjects will be 
asked whether they have fasted, and if not, they should be scheduled to return in 
a fasting state within 7 days.  
 
Although subjects must be fasting, they will be specifically instructed to take all 
medications according to their regular schedules and with the usual amounts of 
water, to the extent that they can tolerate them in a fasting condition. Drugs that 
need to be taken with food may be brought to the clinic and taken with food after 
the FMD evaluation and the fasting specimen collection.  
 
In order to minimize diurnal variation, fasting samples for individual subjects 
should be obtained consistently in either the morning or the afternoon throughout 
26 
 

 
 
 
the study, if possible.  
 
6.3.2 Documentation of HIV-1 
 
Please refer to Section 4.1.1 regarding assay requirements for HIV-1 
documentation. HIV-1 documentation is not recorded on the CRF. 
 
6.3.3 Medical History 
 
The medical history must include all HIV-related and AIDS-defining diagnoses 
(Centers for Disease Control and Prevention [CDC] category B and C), and the 
following non-HIV diagnoses: diabetes mellitus,  dyslipidemia, hypertension, 
hypotension, MI, coronary artery disease (not MI), congestive heart failure, 
stroke, malignancy, renal insufficiency, liver disease, pulmonary embolism, deep 
vein thrombosis, peripheral artery disease (including peripheral artery 
revascularization), chronic obstructive pulmonary disease (COPD), and asthma.  
Any allergies to any medications and their formulations must be documented in 
the source documentation. 
 
HIV-1 RNA History 
Pre-ART HIV-1 RNA: Record on the CRF the documented date and level of the 
subject’s pre-ART viral load. If documentation is not available, then subject 
recollection will suffice.   
 
Record on the CRF the documented date and viral load of the subject’s first HIV-
1 RNA level that was below the assay lower limit. Also, record the duration of 
time prior to study entry the subject has had continued HIV-1 RNA levels that 
were below assay lower limits. If documentation is unavailable, then subject 
recollection will suffice.  
 
All known HIV-1 RNA levels obtained within 1 year prior to study entry should be 
documented and recorded on the CRF.   
 
CD4+ T-cell History 
Nadir CD4+ T-cell Count:  The subject’s nadir CD4+ T-cell count (absolute value 
and date) should be documented when possible with a copy of the nadir CD4+ T-
cell count report. If this documentation is not available, then subject recollection 
will suffice. For subjects who do not know the exact nadir value and for whom 
there is no source documentation, then recall of the categorical nadir (e.g., < 50, 
< 100, < 200 cells/mm3) will suffice.  
 
All known CD4+ T-cell counts obtained within 1 year prior to study entry should 
be documented and recorded on the CRF.   
 
6.3.4 Medication History 
 
A medication history must be present, including start and stop dates, in the 
source documents and on the CRFs, including:   
27 
 

 
 
 
 
Complete HIV-1 treatment history of any ARV medication (estimated if the exact 
dates cannot be obtained), immune-based therapy, and HIV-related vaccines, 
including blinded study medications. 
 
All prescription medications and non-prescription drugs, including herbal 
supplements or vitamin supplements taken within 30 days prior to study entry. 
 
6.3.5 Clinical Assessments 
 
Complete Physical Examination 
A complete physical examination is performed at Screening and is to include at a 
minimum an examination of the skin, head, mouth, and neck; auscultation of the 
chest; cardiac exam; abdominal exam; examination of the extremities for edema. 
The complete physical exam will also include signs and symptoms, diagnoses, 
height, weight, and vital signs (temperature, pulse, respiration rate, and blood 
pressure).  
 
Targeted Physical Exam 
A targeted physical examination is performed at Entry and all other study visits to 
include weight and vital signs (temperature, pulse, respiration rate, and blood 
pressure) and is to be driven by any previously identified or new signs or 
symptoms, or any diagnoses that the subject has experienced within 30 days 
prior to entry/since the last visit. 
 
Height 
Height will be recorded on the CRF at the screening visit only. 
 
Weight 
Weight will be recorded on the CRF at each targeted physical exam.  
 
Signs and Symptoms 
At entry, all grades that occurred within 30 days before study entry must be 
recorded; post-entry, only new signs and symptoms Grade ≥ 2 must be recorded 
on CRFs. Record on CRFs all signs and symptoms that led to a change in 
treatment, regardless of grade. The source document must include date of onset 
and date of resolution. 
 
Diagnoses 
After entry, record all HIV-related and AIDS-defining diagnoses (Centers for 
Disease Control and Prevention [CDC] category B and C), and the following non-
HIV diagnoses: diabetes mellitus,  dyslipidemia, hypertension, hypotension, MI, 
coronary artery disease (not MI), congestive heart failure, stroke, malignancy, 
renal insufficiency, liver disease, pulmonary embolism, deep vein thrombosis, 
peripheral artery disease (including peripheral artery revascularization), chronic 
obstructive pulmonary disease (COPD), and asthma.   
 
Each diagnosis must include: 
28 
 

 
 
 
 
a) Date of diagnosis, and date of resolution 
b) Method of diagnosis 
 
Concomitant Medications 
Record new, or discontinued concomitant medications including immune-based 
therapy, blinded study treatment, prescription drugs, nonprescription drugs, 
alternative therapies, and dietary supplements since the last visit. 
 
Study Drug Modifications 
Record all study drug modifications, including initial doses, subject-initiated 
and/or protocol-mandated modifications, and inadvertent and deliberate 
interruptions. Record any permanent discontinuation of treatment on the CRF. 
More than three consecutive missed days will be considered an interruption and 
should be recorded on the CRF.  
 
Antiretroviral Therapy  
All modifications to ART medications including initial doses, subject-initiated 
modifications (more than three consecutive missed days), modifications, and 
permanent discontinuation will be recorded on the CRFs.  
 
6.3.6 Laboratory Evaluations 
 
At screening and entry all protocol required laboratory values must be recorded 
on CRFs. For post-entry assessments, record on CRFs all Grade ≥ 2 laboratory 
values. All laboratory toxicities that led to a change in treatment, regardless of 
grade, must be recorded on CRFs. Record on CRFs all values for serum 
creatinine, AST, ALT, and fasting lipid panel regardless of grade.  
 
Hematology 
Hemoglobin, hematocrit, white blood cell count (WBC), differential WBC, and 
platelet count.  
 
Liver Function Tests/Chemistries 
Total bilirubin (and indirect bilirubin if subject is receiving atazanavir), ALT 
(SGPT), AST (SGOT), and alkaline phosphatase, blood urea nitrogen (BUN), 
creatinine, glucose, sodium, potassium, chloride, and CO2/bicarbonate. 
 
Fasting Lipid Panel  
Total cholesterol, HDL-c, calculated LDL-c (if triglycerides <400 mg/dL) and 
triglycerides.  
 
Hepatitis Testing (at Screening) 
Hepatitis B surface antigen, Hepatitis C antibody (if indicated, Hepatitis C RNA 
PCR). 
 
 
 
29 
 

 
 
 
Prothrombin time/INR/PTT 
Prothrombin time/INR and PTT are required at pre-entry for rectal tissue subset 
only. 
 
Rectal GC/CT NAAT 
Rectal swab for GC/CT NAAT will be obtained for rectal tissue subset only 
 
HSV Antibody 
Serum for HSV antibody testing will be obtained at Entry visit for the rectal tissue 
subset only 
 
Pregnancy Test 
For women of reproductive potential as defined in section 4.1.11, serum or urine 
β-HCG (urine test must have a sensitivity of at least 50 mIU/mL) must be 
performed as indicated in section 6.1: 
• At the screening visit. 
• At the study entry visit. 
• Every 4 weeks during study participation. 
 
6.3.7 Immunologic Studies 
 
CD4+ 
Obtain absolute CD4+ T-cell count and percentage within 60 days prior to entry 
from a laboratory that possesses a CLIA certification or equivalent.  
 
Evaluations for CD4+/CD8+ T-cell counts and percentages will be performed in 
the same laboratory at the entry visit and throughout the course of the study. 
 
Because of the diurnal variation in CD4+ and CD8+ T-cell counts, determinations 
for individual subjects should be obtained consistently in either the morning or 
the afternoon throughout the study, if possible. 
 
6.3.8 Virologic Studies 
 
Plasma HIV-1 RNA 
All measurement of HIV-1 RNA will be performed by a laboratory that possesses 
a CLIA certification or equivalent. Screening HIV-1 RNA must be performed 
within 60 days prior to study entry. Eligibility will be determined based on the 
screening value.   
 
30 
 

 
 
 
6.3.9 Stored Samples 
 
Blood and rectal tissue will be processed immediately after collection and stored 
for future analysis.  Results of these tests do not have clinical relevance and will 
not be reported to participants. 
 
Stored Specimens for Cellular Immune Activation  
 
PBMC will be stored for batched analysis: 
 
Immunology Lab: 
 
Markers of cellular immune activation 
Cell cycling (Ki67) 
Immunoregulatory cell subsets (frequency and phenotype) 
CD39 and CD73 expression in lymphocytes and monocytes 
 
Stored Specimens for Markers of Inflammation, Coagulation and Activation 
 
Plasma specimens for batch measurement (Immunology Lab): 
 
Soluble markers of immune activation, inflammation, and 
coagulation 
 
Stored Specimens for Adenosine and DP Pharmacokinetics 
 
Plasma and Urine Specimens for HPLC‐tandem mass spectrometry (Jackson 
Lab) of: 
 
Adenosine, inosine, guanosine 
5’‐AMP and 3,5’‐cAMP 
Plasma creatinine 
Dipyridamole assay  
 
Stored Specimens for Virology: 
 
PBMC and Plasma (Mellors Lab): 
 
 
 
 
Cell‐associated HIV‐1 DNA  
Cell‐associated HIV‐1 RNA 
HIV-1 RNA Single copy assay  
 
 
 
Rectal Mucosa: 
 
 
 
Tissue mononuclear cells for immune activation (Mucosal Immunology Lab): 
: 
 
 
 
 
Markers of cellular immune activation 
Immunoregulatory cell subsets 
Expression of CD39 and CD73 in lymphocytes and monocytes 
31 
 

 
 
 
 
 
 
 
 
Tissue mononuclear cells for virology (Mellors Lab): 
 
 
 
 
 
Cell‐associated HIV‐1 DNA  
Cell‐associated HIV‐1 RNA 
 
Refer to the protocol laboratory processing chart (LPC) for details of collection, 
processing, and storage. 
 
6.3.10 Brachial Artery FMD 
 
The brachial FMD assessment will be performed and interpreted at the University 
of Pittsburgh Department of Epidemiology Ultrasound Research Lab (URL) as 
per Section 6.1.  
 
Subjects who are prematurely discontinuing the study should have a brachial 
FMD test only if it has been ≥4 weeks since the last FMD assessment.  
 
Considerations for the Brachial Artery FMD Scanning: 
1. Subjects should fast and abstain from exercise and smoking for at least 8 
hours prior to the study visit and be afebrile (afebrile (oral T < 38 degrees C), 
at the visit; otherwise these assessments must be rescheduled.  
 
a) Subjects should be fasting (nothing but water or black decaffeinated 
coffee for 8 hours prior to evaluation; drinking black decaffeinated coffee 
is considered an exception but is not advised). 
 
2. No blood pressure (BP) measurements or venipuncture are permitted in the 
right arm before the ultrasound scan.  
 
3. FMD assessments should be done in the morning, approximately at the same 
time.  
 
Brachial artery size in response to an endothelium-dependent stimulus will be 
evaluated by ultrasonographic measurement of the brachial artery.  Baseline 
brachial artery diameter will be measured using 2-D ultrasonography.  A blood 
pressure cuff will be placed proximal to the brachial artery and will be inflated to 
suprasystolic pressure (cuff inflation will be 40mmHg above the systolic blood 
pressure) for 5 minutes.  After 5 minutes, the cuff will be deflated. Brachial artery 
diameter will be measured by 2-D ultrasonography at 1 minute following cuff 
deflation to measure brachial artery diameter response to reactive hyperemia, 
which is an endothelium-dependent vasomotor stimulus.   
 
For quality control purposes, a subset of participants may be asked to have a 
second FMD at Weeks 4, 12, or 24. 
 
32 
 

 
 
 
6.3.11 Rectal Exam and Rectal Specimen Collection 
 
Rectal tissues will be obtained from subjects at Enrollment and at Weeks 12, 24, 
and 28. These study visits will take place at the Magee Womens Hospital CTRC.  
Procedures will be performed by qualified physicians who perform rectal biopsies 
on a regular basis. All subjects in the Tissue Subset will be instructed to abstain 
from receptive anal intercourse and all rectal products for 72 hours prior to rectal 
biopsy, and for 7 days post-biopsy to minimize risk of bleeding complications.  
Subjects will be contacted by telephone 24-48 hours after sample collection to 
assess for any AEs.  
 
The subject will be positioned in the left lateral decubitus position for the following 
procedures:  
• 
Rectal swab for GC/CT 
• 
Visual and digital rectal exam:  The examiner will conduct a visual 
examination of the anus and surrounding area and note any abnormality.  
The examiner will then insert a lubricated gloved finger into the anal canal 
and sweep around the internal anal circumference. 
• 
Enema: A 125 mL saline enema will be inserted through the anus and the 
contents gently squeezed into the rectum.  The subject will hold the fluid in 
the rectum for 5 minutes then expel it.  
• 
Flexible sigmoidoscopy and biopsy: A flexible sigmoidoscope will be inserted 
to approximately 10-20 cm, where approximately 17-21 biopsies will be taken 
using large-cup biopsy forceps. 
 
6.3.12 Medication Adherence Assessment  
 
A standardized assessment to monitor adherence and pill counts will be 
administered. Subjects will be instructed to return pill bottles for DP to the study 
site, and pill counts will be undertaken by the study nurse or designee and 
recorded on the CRFs. 
 
6.3.13 Pre- and post-bronchodilator spirometry (for participants enrolled under Version 
2.0) 
 
 
Participants will be asked to withhold use of any short-acting bronchodilators for 
at least 4 hours prior to testing and long acting bronchodilators for at least 12 
hours prior to testing. At least 3 acceptable forced vital capacity maneuvers 
should be performed according to ATS standards: a maximal inspiration followed 
by a maximal forced expiratory effort which lasts for at least seconds. The 
participant should be seated. Ensure that the 3 best FEV1 values are within 5% 
of each other. Participants will then be given 4puffs (360ug) of albuterol from a 
metered dose inhaler through a spacer. Three acceptable forced vital capacity 
maneuvers will again be performed according to ATS standards. Refer to the 
Manual of Procedures (MOPS) for detailed instructions.  
 
7.0 
CLINICAL MANAGEMENT ISSUES 
 
33 
 

 
 
 
Criteria for subject management, dose interruptions, modifications, and discontinuation 
of treatment will be mandated only for toxicities attributable to DP. 
 
The grading system is located in the DAIDS Table for Grading the Severity of Adult and 
Pediatric Adverse Events Version 1.0 - December 2004 (Clarification dated August 
2009), which can be found on the Division of AIDS Regulatory Support Center Web site: 
http://rsc.tech-res.com/safetyandpharmacovigilance/.  
 
The management of toxicities suspected to be due to ART should be according to 
standard clinical practice.   
 
7.1 
Toxicity  
 
7.1.1 General Reactions 
 
• 
Grade 1 or 2 
 
Subjects who develop a Grade 1 or 2 AE or toxicity, except as stated 
in Section 7.2 may continue study treatment at the discretion of the 
investigator. If a subject chooses to discontinue study treatment, the 
subject will be followed until the toxicity resolves.   
 
• 
Grade 3 
 
Subjects who develop a Grade 3 AE that is not specifically addressed 
below and is judged by the investigator to be study drug-related should 
have the study drug held. Subjects should be followed closely and if 
the AE does not return to Grade ≤ 2 within 4 weeks, the study drug 
must be permanently discontinued with subject evaluations as per 
Section 6.2.4.  
 
If the study drug is resumed and the same Grade 3 AE recurs within 4 
weeks of reintroduction, and the investigator considers this AE related 
to the study drug, the drug must be permanently discontinued.  
 
With a Grade 3 AE that is judged not related to the study drug by the 
investigator, the study drugs may be continued at the discretion of the 
site investigator with close follow up.  
 
Subjects experiencing Grade 3 AEs requiring permanent 
discontinuation of study treatment should be followed closely for 
resolution of the AE to Grade ≤ 2. 
 
Subjects with Grade 3 asymptomatic laboratory abnormalities in 
cholesterol, creatine kinase (CK) or triglycerides may continue study 
treatment. 
 
• 
Grade 4 
34 
 

 
 
 
 
Subjects who develop a Grade 4 AE that is not specifically addressed 
below and is judged by the site investigator to be study drug-related 
should have the specific study drug held. Clinical assessments and 
laboratory testing will be completed as described for Grade 3 toxicity. 
Subjects experiencing Grade 4 AEs should be followed closely with 
additional clinical assessments and laboratory testing as clinically 
indicated until resolution of the AE.  
 
7.1.2 AST/ALT Elevations  
 
• 
Grade 2 Asymptomatic 
 
 
For subjects who develop asymptomatic Grade 2 AST or ALT 
elevations, DP may continue and the AST and ALT should be repeated 
within 2 weeks. 
 
• 
Grade 2 Symptomatic 
 
 
For symptomatic Grade 2 or greater elevations of AST or ALT for 
subjects on DP, the study drug should be held until symptoms have 
resolved and further evaluations, as indicated, have been conducted. If 
symptoms resolve and AST or ALT returns to < Grade 2, then DP may 
be resumed with close follow up. 
 
• 
Grade 3 
 
 
Subjects who develop a Grade 3 AST or ALT that is judged by the 
investigator to be related to DP should have the DP held. The subject 
should be followed closely and if the AE does not return to Grade ≤ 2 
within 4 weeks, the DP must be permanently discontinued with subject 
evaluations as per Section 6.2.4.  
 
 
If the study drug is resumed and the same Grade 3 AE recurs within 4 
weeks of reintroduction, and the investigator again considers this AE 
related to the DP, the drug must be permanently discontinued.  
 
• 
Grade 4 
 
 
Subjects who develop a Grade 4 AST or ALT AE that is judged to be 
related to DP by the investigator will have the drug permanently 
discontinued, with clinical assessments and laboratory testing as 
described for Grade 3 toxicity. Subjects experiencing Grade 4 AEs 
should be followed closely with additional clinical assessments and 
laboratory testing as clinically indicated. 
 
7.1.3 Hypotension  
 
35 
 

 
 
 
• 
Grade 2 
 
 
Subjects who develop a symptomatic hypotension that resolves with 
oral fluids (Grade 2) may continue study medication and will be 
instructed to maintain adequate hydration.  Recurrence of Grade 2 
hypotension should prompt consideration of discontinuation of study 
treatment.  
 
• 
Grade 3 
 
 
Subjects who develop Grade 3 or 4 hypotension that is judged by the 
investigator to be related to DP will have study treatment permanently 
discontinued. 
 
7.1.4 Headache 
 
• 
Grade 1 
 
Subjects who develop Grade 1 headache may continue study 
medications. 
 
• 
Grade 2 
 
 
Subjects who develop Grade 2 headache may continue study 
medication and may be treated with over the counter analgesics 
(acetaminophen preferred, NSAIDS should be avoided and may not be 
taken for > 3 consecutive days).   
 
• 
Grade 3 
 
 
Subjects who develop Grade 3 or 4 headache that is judged by the 
investigator to be related to DP will have study treatment permanently 
discontinued. 
 
7.2 
Pregnancy Management 
 
If the pregnancy test is positive at entry, then the subject must not start study treatment. 
No further evaluations are necessary, provided that the subject did not initiate study 
drug. 
 
Subjects who become pregnant after study entry must discontinue study treatment 
immediately. These subjects should be seen for a premature treatment discontinuation 
evaluation within 7 days. No further study evaluations except for safety labs will occur. 
These subjects will complete a study termination visit per Section 6.1.  Study staff will 
request permission to contact pregnant participants by telephone monthly regarding 
pregnancy outcomes and/or obstetrical complications during and at the end of 
pregnancy.  
 
36 
 

 
 
 
Pregnancies that occur on study should be reported to The Antiretroviral Pregnancy 
Registry. More information is available at www.apregistry.com. Phone: 800-258-4263; 
Fax: 800-800-1052. Intrapartum complications and/or pregnancy outcome will be 
recorded to The Antiretroviral Pregnancy Registry as well as on study case report forms, 
if possible. 
 
7.3 
Unblinding 
 
It is not expected that subject unblinding will be necessary for management of toxicity.  If 
deemed medically appropriate, unblinding will be requested from the Data Center.   
   
8.0 
CRITERIA FOR DISCONTINUATION 
 
8.1 
Permanent Treatment Discontinuation 
 
• 
Requirement for prohibited concomitant medications except vaccinations (see the 
Manual of Procedures). 
• 
Requirement for precautionary concomitant medications at the discretion of the 
investigator (see the Manual of Procedures) 
• 
Drug-related toxicity as per Section 7.1 
• 
Study drug is discontinued for 7 consecutive days for reasons other than toxicity at 
the discretion of the investigator. If study drug is discontinued for reasons other than 
toxicity, but the underlying reason for the d i s c o n t i n u a t i o n  l a t e r  resolves, 
study drug may be resumed at the discretion of the investigator. 
• 
Pregnancy or breast-feeding 
• 
Request by subject to terminate treatment. 
• 
Clinical reasons believed to be life threatening by the physician, even if not 
addressed in the toxicity Section of the protocol. 
 
 
8.2 
Premature Study Discontinuation 
 
• 
Subject repeatedly noncompliant with study treatment as prescribed. 
• 
Request by the subject to withdraw or not able to attend study visits as required by 
study. 
• 
Request of the primary care provider if s/he thinks the study is no longer in the best 
interest of the subject. 
• 
Subject judged by the investigator to be at significant risk of failing to comply with the 
provisions of the protocol as to cause harm to self or seriously interfere with the 
validity of the study results. 
• 
At the discretion of the institutional review board (IRB), Office for Human Research 
Protections (OHRP), NIAID, investigator, or IDSMB. 
 
9.0 
STATISTICAL CONSIDERATIONS 
 
9.1 
General Design Issues 
 
This study is a randomized, placebo-controlled,  two-arm, single-site, pilot study that will 
37 
 

 
 
 
evaluate whether 12 weeks of treatment with DP, decreases markers of immune 
activation and systemic inflammation in HIV-1 infected subjects virally suppressed on 
ART. DP will be administered to subjects for up to 24 weeks. Follow-up continues to 
week 28. The targeted sample size will be 40 subjects (20 of these subjects will be 
enrolled in the rectal tissue subset). 
 
9.2 
Endpoints 
 
9.2.1 Primary Endpoints 
 
• 
Change in Plasma level of sCD14 from baseline to week 12. 
• 
Change in Plasma level of sCD163 and IL-6 from baseline to week 12. 
 
9.2.2 Secondary Endpoints 
 
 
• 
Changes from entry to week 12 and 24 (as applicable)  in the following: 
 
o %HLA-DR+ CD38+ expression in CD8+ and CD4+ T-cells 
 
o %CD69+CD25+ expression in CD4+ and CD8+ T-cells  
 
o CD16 and tissue factor expression in monocytes  
 
o Plasma levels of biomarkers of systemic inflammation (sTNFαR, 
TNFα, hsCRP) and coagulation (D-dimer, tissue factor) 
 
o Percent brachial artery FMD 
 
o Proportion of cycling CD4+ and CD8+ T cells as measured by Ki-67 
expression 
 
• 
Grade 2 or higher AEs, treatment discontinuations 
 
• 
Correlation of plasma DP level to urine adenosine, plasma IL-6, and soluble 
and cellular markers of immune activation 
 
 
9.2.3 Exploratory Endpoints 
 
• 
Changes from entry to week 12 and 24 (as applicable)  in the following: 
 
o Rectal tissue: %CD38+/DR+ CD4+ and CD8+ T-cells by flow 
cytometry 
 
o Blood and rectal tissue CCR9+ β7high T-cells 
 
o Frequency and numbers of CD73 expressing T cells B cells and 
monocytes in peripheral blood and gut 
38 
 

 
 
 
 
o Purine and adenosine levels in blood 
 
o Plasma HIV-1 RNA using single copy assay (SCA)   
 
o Cell-associated HIV-1 RNA and DNA in blood and rectal tissue 
 
o Pre- and post-bronchodilator FEV1 
 
9.3 
Randomization and Stratification 
 
At study entry, subjects will be allocated at a 1:1 ratio to the two arms using blocked 
randomization.  In addition, randomization will be stratified by CD4 cell count at 
screening (<500 cells/mm3 or ≥500 cells/mm3), and enrollment into the rectal tissue 
subset.   
 
9.4 
Sample Size and Accrual 
 
There will be 40 subjects (20 per arm) randomized to either DP 100 mg 4 times daily or 
matching placebo, and it is assumed that no more than 10% of participants will be 
excluded from the primary analysis due to any reason.  sCD14 will be the main primary 
outcome, while sCD163 and IL-6 will be treated as other key outcomes of interest.  As a 
result, the hypothesis for sCD14 will be tested at the 5% significance level and will be 
the basis for our power analysis. sCD163 and IL-6 will also be tested at the 5% 
significance level each.  Based on the assumption that none of the 40 subjects are 
excluded from the primary analysis for any reason, we will have 80% power to detect 
standardized mean difference of 0.909 between treatment arms for the sCD14. In terms 
of clinically meaningful effects, this translates to a difference of 0.49 x 106 pg/mL in 
sCD14 between arms at 12 weeks assuming similar standard deviation seen in 
preliminary data (standard deviation is 0.54 x 106 pg/mL for sCD14).  In the more 
realistic situation that 10% of subjects are excluded (18 per arm), we will have 80% 
power to detect standardized mean difference of 0.961 between treatment arms for the 
primary outcome. In terms of clinically meaningful effects, this translates to a difference 
of 0.52 x 106 pg/mL in sCD14 between arms at 12 weeks assuming similar standard 
deviations seen in preliminary data.    
 
Because the ANCOVA model will adjust for baseline sCD14 as well as CD4 cell count 
(neither of which are expected to be related to treatment arm), it’s likely that there will be 
sufficient power to detect even smaller effects than what is expected. 
 
It is anticipated that subjects will accrue to the study at a rate of 2-3 subjects per month. 
At this rate, the study should fully accrue within 18 months after the first subject enrolls. 
 
9.5 
Primary Analyses 
 
As this is a pilot study of biologic activity, our primary analysis of efficacy will be an as-
treated analysis, limited to subjects who have data for baseline and week 12, and remain 
on study treatment through week 12 with no more than 7 consecutive days of medication 
39 
 

 
 
 
missed, and did not change ART or use prohibited medications or have virologic failure 
during this time period.  To preserve the study power in the case of greater than 10% 
missing data due to discontinuation/non-adherence, additional subjects may enroll, at 
discretion of the protocol team, to replace subjects who are discontinued or non-
adherent to study product or scheduled study visits prior to week 12. Therefore the total 
sample size may exceed 40 at the end of the study. 
 
Changes from baseline to week 12 in sCD14, sCD163, and IL-6 (as well as all 
secondary and exploratory outcomes) will be summarized by means, medians, standard 
deviations, and 95% confidence intervals for each treatment arm.  We will compare the 
two study arms at baseline with respect to clinical characteristics as well as subject 
demographics.  Any baseline covariates that cause imbalance at the 5% significance 
level will be included in the primary analyses.  Our primary analysis will utilize an 
Analysis of Covariance (ANCOVA) model of the primary outcomes, which compares the 
outcomes at 12 weeks between arms (placebo/DP) after adjusting for baseline activation 
(or plasma level) and CD4 cell count.  If any of the primary outcomes violate 
assumptions of normality, suitable transformations will be investigated.  If no 
transformation can be used, between-arm comparisons on 12 week change in sCD14, 
sCD163, and IL-6 will be assessed by the Wilcoxon rank sum test. 
 
Statistical significance for the primary analysis of sCD14 will be tested using a two-sided 
alpha = 0.05. The other key outcomes of sCD163 and IL-6 will each be tested at 0.05 as 
well. 
  
9.6 
Secondary Analyses 
 
Changes from baseline to week 12 and week 24 in other secondary and exploratory 
endpoints including  measurements of immune activation, systemic inflammation, and 
residual virus in blood and rectal tissue, change in pre- and post-bronchodilator FEV1, 
and percent FMD (see 9.2.2 and 9.2.3) will be summarized by means, medians, 
standard deviations, and 95% CIs for each of the treatment arms.  As in the primary 
analysis, between-arm comparisons will be made using either an ANCOVA model or the 
Wilcoxon rank sum test.  For secondary outcomes with more frequent measurements 
(i.e. baseline, 4, 12 week), longitudinal models such as Generalized Estimating 
Equations (GEE) will be used to compare the trajectories across time between treatment 
arms. Included in the model will be predictor variables for week, treatment group, and 
their interaction. 
 
The study design allows for an additional 12 weeks of follow up in which the placebo arm 
crosses over to DP 100 mg 4 times daily for 12 weeks. As an exploratory measure, the 
trajectories of T cell activation and IL-6 expression for these subjects will be analyzed 
using a generalized linear mixed model with covariates for week (defined as time since 
initiating placebo/DP), drug (placebo/DP), and their interaction. The effects of long-term 
and short-term DP on T cell activation will be quantified using an ANCOVA model, 
similar to the primary analysis. 
 
Safety will be evaluated by summarizing the number and frequency of Grade ≥ 2 
adverse events within each study arm.  Comparisons between study arms will be done 
40 
 

 
 
 
using Fisher’s exact test at each study visit. 
 
Statistical significance for each of the secondary analyses will be tested using the 
nominal 5% type I error rate.    
 
9.7 
Monitoring 
 
Accrual and a summary of all Grade ≥ 2 signs and symptoms, all Grade ≥ 2 laboratory 
abnormalities and all reported AEs will be reviewed by the study team monthly. This 
summary will be pooled over the study arms. In addition, baseline characteristics as well 
as early study treatment and study discontinuations, pooled over study arms, will be 
reviewed regularly by the team. The Center for Research in Health Care Data Center 
(CRHC DC) will also prepare a quarterly report of all Grade ≥ 2 signs and symptoms, all 
Grade ≥ 2 laboratory abnormalities and reported AEs by study arm, to be reviewed 
quarterly [or as requested] by the DAIDS clinical representative or designee.  
 
Approximately 6 months after enrollment of the first subject, (or, if earlier, when 50% of 
subjects have been enrolled), an interim review of the study will occur.  An Institutional 
Data Safety and Monitoring Board (IDSMB) convened by the University of Pittsburgh will 
function as a Study Monitoring Committee (SMC) for the study and will review accrual, 
toxicity summaries, and off-treatment and off-study rates and reasons broken down by 
study arms. In addition, longitudinal changes in CD4+ T-cell count and HIV-1 RNA levels 
will be reviewed. Note that immune activation measurements, including the primary 
endpoints, will be run in batch after follow-up is concluded. The first IDSMB review will 
occur when 30% of the subjects are enrolled or at 1 years, whichever is earlier.  IDSMB 
reviews will occur at least annually after the first review or at more frequent intervals as 
determined by the IDSMB.  An interim IDSMB review may also be conducted if a reason 
is identified by the DAIDS clinical representative, study investigators, or study statistician 
in consultation with the team. 
 
The specific responsibilities of the IDSMB are to: 
 
1. Review the research protocol, informed consent documents and plans for data and 
safety monitoring; 
2. Evaluate the progress of the study, including periodic assessments of data quality and 
timeliness, subject recruitment, accrual and retention, subject  risk versus benefit, 
adverse events, unanticipated problems, performance of the trial site, and other 
factors that can affect study outcome; 
3. Consider factors external to the study when relevant information becomes available, 
such as scientific or therapeutic developments that may have an impact on the safety 
of the subjects or the ethics of the study; 
4. Review clinical center performance, make recommendations and assist in the 
resolution of problems reported by the PIs; 
5. Protect the safety of the study subjects; 
6. Report on the safety and progress of the study; 
7. Make recommendations to the PIs concerning continuation, termination or other 
modifications of the study based on the observed beneficial or adverse effects of the 
treatment under study; 
41 
 

 
 
 
8. Monitor the confidentiality of the study data and the results of monitoring;  
9. Assist the PIs by commenting on any problems with study conduct, enrollment, 
sample size and/or data collection. 
 
The IDSMB will include experts in infectious disease, immunology, and biostatistics.  
Members will consist of persons independent of the investigators who have no financial, 
scientific, or other conflict of interest with the study.  Written documentation attesting to 
absence of conflict of interest will be required. 
 
The University of Pittsburgh Office of Clinical Research, Health Sciences will provide the 
logistical management and support of the IDSMB.  A safety officer (chairperson) will be 
identified at the first meeting.  This person will be the contact person for serious adverse 
event reporting.  Procedures for this will be discussed at the first meeting. 
 
The first meeting will take place before initiation of the study to discuss the protocol, 
approve the commencement of the study, and to establish guidelines to monitor the 
study.  The follow-up meeting frequency of the IDSMB will be determined during the first 
meeting.  An emergency meeting of the IDSMB will be called at any time by the 
Chairperson should questions of patient safety arise.    
 
10.0 
PHARMACOLOGY PLAN 
 
 
 
Not applicable 
 
 
 
 
11.0 
DATA COLLECTION AND MONITORING AND ADVERSE EVENT REPORTING 
 
11.1 
Records to Be Kept 
 
Case report forms (CRF) will be completed for each subject. Subjects must not be 
identified by name on any CRFs. Subjects will be identified by the patient identification 
number (PID). 
 
11.2 
Role of Data Management 
 
11.2.1 Instructions concerning the recording of study data on CRFs will be provided by 
the CRHC Data Center.  
 
11.2.2 It is the responsibility of the CRHC Data Center to assure the quality of 
computerized data for this study. This role extends from protocol development to 
generation of the final study databases. 
 
42 
 

 
 
 
11.3 
Clinical Site Monitoring and Record Availability 
 
11.3.1 Site monitors under contract to the NIAID will visit the clinical research site to 
review the individual subject 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 
subjects, compliance with the protocol, and accuracy and completeness of 
records. The monitors also will inspect the site‘s regulatory files to ensure that 
regulatory requirements are being followed and the site pharmacy to review 
product storage and management. 
 
11.3.2 The site investigator will make study documents (e.g., consent forms, drug 
distribution forms, CRFs) and pertinent hospital or clinic records readily available 
for inspection by the local IRB, the site monitor, the NIAID, and the OHRP, or 
their designees for confirmation of the study data. 
 
11.4 
Expedited Adverse Event Reporting 
 
11.4.1 Reporting Requirements for this Study 
 
Requirements, definitions and methods for expedited reporting of Adverse 
Events (AEs) are outlined in Version 2.0 of the DAIDS EAE Manual, which is 
available on the RSC website: http://rsc.tech-
res.com/safetyandpharmacovigilance 
 
All serious adverse events which are unexpected, fatal or life-threatening, and 
related or possibly related to the research intervention will be reported to the 
University of Pittsburgh IRB within 24 hours of the investigator learning of the 
event. All serious adverse events, regardless of relationship to the research 
intervention, will be reported to the IDSMB within 24 hours. An emergency 
meeting may be called as determined by the IDSMB Chair. Other AEs that must 
be reported in an expedited manner are: congenital anomalies or abnormal 
pregnancy outcomes after week 20 of gestation, regardless of attribution to 
study agent(s). 
 
All other adverse events that meet the IRB reporting requirements as per 
Section 11.5 will be reported to the IRB within 10 working days of the 
investigator learning of the event. All adverse events, regardless of relationship 
to the research intervention, will be reported to the IDSMB during regular 
reporting intervals (to be determined after the first initial meeting and depending 
upon risk).   
 
The study agents for which expedited reporting are required are: dipyridamole 
and placebo for dipyridamole. 
 
The DAIDS Medical Officer (MO) will receive a copy of all AEs submitted to the 
IRB in an expedited fashion.  In addition to the events described above, the 
43 
 

 
 
 
DAIDS MO will receive all Grade 3 and 4 AEs that are attributed to study 
procedures graded as per Section 11.4.2. 
 
11.4.2 Grading Severity of Events 
 
The most current Division of AIDS Table for Grading the Severity of Adult and 
Pediatric Adverse Events (DAIDS AE Grading Table) is used and is available on 
the RSC website: http://rsc.tech-res.com/safetyandpharmacovigilance 
 
11.4.3 Expedited AE Reporting Period 
 
The expedited AE reporting period for this study will be from the time the 
participant starts study agent until the end of the study follow-up for that 
participant..  After the protocol-defined AE reporting period, unless otherwise 
noted, only SUSARs as defined in Version 2.0 of the EAE Manual, will be 
reported to the IRB and IDSMB if the study staff become aware of the events on 
a passive basis (from publicly available information). A copy of these reports will 
also be sent to the DAIDS Medical Officer. 
 
11.5  Unanticipated Problems 
 
Unanticipated problems, as defined by the OHRP include any incident, experience, or 
outcome that meets all of the following criteria: 
 
1.  Unexpected (in terms of nature, severity, or frequency) given (a) the research 
procedures that are described in the protocol-related documents, such as the IRB-
approved research protocol and informed consent document; and (b) the 
characteristics of the subject population being studied; 
2.  Related or possibly related to participation in the research (in this guidance 
document, “possibly related” means there is a reasonable possibility that the 
incident, experience, or outcome may have been caused by the procedures involved 
in the research); and 
3.  Suggests that the research places subjects or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously 
known or recognized. 
 
Upon becoming aware of any AE, the investigator will assess whether the AE represents 
an unanticipated problem by applying the criteria described above. If the investigator 
determines that the AE represents an unanticipated problem, the PI will report it the 
University of Pittsburgh IRB within 10 working days as per the IRB Policies and 
Procedures Manual, Section XVII and to the IDSMB during regular reporting intervals. In 
addition, incidents, experiences and outcomes that occur during the conduct of this 
study that represent unanticipated problems but are not considered AEs may require 
reporting under the HHS regulations at 45 CFR 46.103(a) and 46.103(b)(5). Further 
details and examples of such scenarios are described in the OHRP policy 
(http://www.hhs.gov/ohrp/policy/advevntguid.html#Q1). Unanticipated problems involving 
risks to participants or others will be reported as detailed in the DAIDS Critical Event 
Policy 
44 
 

 
 
 
(http://www.niaid.nih.gov/LabsAndResources/resources/DAIDSClinRsrch/Pages/Safety.
aspx). 
 
12.0 
HUMAN SUBJECTS  
 
12.1 
Institutional Review Board (IRB) Review and Informed Consent 
 
This protocol and the informed consent documents and any subsequent 
modifications will be reviewed and approved by the University of Pittsburgh IRB. 
A signed consent form will be obtained from the subject. 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 consent form will be given to the 
subject, and this fact will be documented in the subject’s record 
 
 
12.2 
Protocol Registration 
 
Prior to implementation of this protocol, and any subsequent full version 
amendments, the Pitt CRS will have the protocol and the protocol consent 
form(s) approved by the University of Pittsburgh IRB.  Upon receiving final 
approval, all required protocol registration documents will be submitted to the 
DAIDS PRO at the Regulatory Support Center (RSC).  The DAIDS PRO will 
review the submitted protocol registration packet to ensure that all of the required 
documents have been received.   
 
The site-specific informed consent forms (ICFs) WILL NOT be reviewed or 
approved by the DAIDS PRO, and the site will receive an Initial Registration 
Notification when the DAIDS PRO receives a complete registration packet.  
Receipt of an Initial Registration Notification indicates successful completion of 
the protocol registration process.  The site will not receive any additional 
notifications from the DAIDS PRO for the initial protocol registration.  A copy of 
the Initial Registration Notification should be retained in the site's regulatory files. 
 
Upon receiving final IRB and any other applicable approval(s) for an amendment, 
the study site will implement the amendment immediately.  The site is required to 
submit an amendment registration packet to the DAIDS PRO at the RSC.  The 
DAIDS PRO will review the submitted protocol registration packet to ensure that 
all the required documents have been received.  The site-specific ICFs WILL 
NOT be reviewed or approved by the DAIDS PRO, and the site will receive an 
Amendment Registration Notification when the DAIDS PRO receives a complete 
registration packet.  A copy of the Amendment Registration Notification should be 
retained in the site's regulatory files.  
 
For additional information on the protocol registration process and specific 
documents required for initial and amendment registrations, refer to the current 
version of the DAIDS Protocol Registration Manual, available at http://rsc.tech-
res.com/protocolregistration. 
45 
 

 
 
 
 
 
12.3 
Risk-Benefit Statement 
 
12.3.1 Risks 
 
General  
Phlebotomy may lead to discomfort, feelings of dizziness or faintness, 
and/or bruising, swelling and/or infection.  Disclosure of STI status may 
cause sadness or depression in volunteers.  Participation in clinical 
research includes the risks of loss of confidentiality and discomfort with 
the personal nature of questions.   
 
Brachial Artery Flow-Mediated Dilation (FMD) 
Brachial artery FMD is a painless imaging test that has no known short or 
long-term risks. The test uses ultrasound and does not involve radiation 
exposure. The test may be mildly uncomfortable because a blood 
pressure cuff is applied tightly to the arm.    
 
 
Dipyridamole  
Adverse reactions at therapeutic doses are usually minimal and transient. 
On long-term use, initial side effects usually disappear. In two heart valve 
replacement trials, the following reactions were reported when DP tablets 
were given with warfarin: dizziness (13.6%), abdominal distress (6.1%), 
headache (2.3%), and rash (2.3%). Other reactions from uncontrolled 
studies include diarrhea, vomiting, flushing and pruritus. In addition, 
angina pectoris has been reported rarely and there have been rare 
reports of liver dysfunction. On those uncommon occasions when 
adverse reactions have been persistent or intolerable, they have ceased 
on withdrawal of the medication. 
 
When DP tablets were administered concomitantly with warfarin, bleeding 
was no greater in frequency or severity than that observed when warfarin 
was administered alone. In rare cases, increased bleeding during or after 
surgery has been observed. 
 
In post-marketing reporting experience, there have been rare reports of 
hypersensitivity reactions (such as rash, urticaria, severe bronchospasm, 
and angioedema), larynx edema, fatigue, malaise, myalgia, arthritis, 
nausea, dyspepsia, paresthesia, hepatitis, thrombocytopenia, alopecia, 
cholelithiasis, hypotension, palpitation, and tachycardia. 
 
Enema 
The main risk from having an enema is temporary discomfort, bloating 
and flatulence.   
 
Flexible Sigmoidoscopy 
46 
 

 
 
 
Flexible sigmoidoscopy is a commonly practiced medical procedure and 
the endoscopic procedures done in this trial will not involve any unusual 
risks or discomforts.  The risks associated with these procedures include 
mild discomfort and the feeling of having a “bloated stomach”.  Mild rectal 
irritation, urgency to move bowels, or hypotension may also occur. 
 
Endoscopic biopsies are painless, begin to heal within 2 hours, and are 
completely healed within 3-5 days.  On extremely rare occasions, the 
endoscopic procedure or biopsies may lead to pain, infection (sepsis), 
bleeding or perforation of the gastrointestinal tract.  Perforation secondary 
to mucosal biopsy occurs approximately once out of every 8,000 
procedures.  If this extremely rare complication occurs, antibiotics and 
surgery to repair the tear may be necessary.  
 
Risk of bleeding due to DP: DP does not appear to increase the risk of 
bleeding and the Standards of Practice Committee of the American 
Society for Gastrointestinal Endoscopy does not recommend 
discontinuation of the drug prior to low risk endoscopic procedures, 
including flexible sigmoidoscopy with biopsy.  
Pre- and post-bronchodilator spirometry and albuterol administration: 
Spirometry is a routine diagnostic procedure and involves a very low level 
of risk. A person taking a lung function test may feel a sensation of 
dyspnea and cough, faintness or feeling of light-headedness. These 
sensations subside rather quickly after completing the testing. All lung 
function tests will be performed sitting down so as to protect against injury 
from falling. Albuterol is a well-tolerated bronchodilator to be inhaled 
during the lung function testing. Common side effects of albuterol include 
heart palpitations, increased heart rate, chest pain, shakiness, 
nervousness, headache, dizziness, sore throat, and runny nose. Rarely, 
albuterol may cause an immediate hypersensitivity allergic reaction.  
 
12.3.2 Benefits 
 
There are no direct benefits for participation in this pilot study.  Subjects and 
others may benefit in the future from information learned from this study.  
Specifically, information learned in this study may lead to a better understanding 
of the causes of persistent immune activation and systemic inflammation in 
chronic HIV-1 infection.  Subjects will be referred for treatment for any incidental 
findings detected during screening and other study-related examinations.   
 
12.4 
Informed Consent Process 
 
It is the responsibility of the study site investigator to ensure that the Elements of 
Informed Consent (21 CFR 50.25, 45 CFR 46.116, and ICH GCP 4.8.10) and 
Health Insurance Portability Accountability Act (HIPAA) guidelines are followed 
and documented in the source document file.  Written informed consent will be 
obtained from each study subject prior to screening.  In obtaining and 
47 
 

 
 
 
documenting informed consent, the investigators and their sub-investigators will 
comply with applicable local and US regulatory requirements and will adhere to 
GCP and to the ethical principles that have their origin in the Declaration of 
Helsinki.  Study staff must document the informed consent process in 
accordance with the Requirements for Source Documentation in DAIDS Funded 
and/or Sponsored Clinical Trials available at:  
 
(http://www.niaid.nih.gov/LabsAndResources/resources/DAIDSClinRsrch/Docum
ents/sourcedocpolicy.pdf).     
 
Subjects will be provided with copies of the informed consent forms if they are 
willing to receive them.  The informed consent process will cover all elements of 
informed consent required by research regulations.  In addition, the process will 
specifically address the following topics of importance to this study: 
 
• 
The unknown safety and unproven efficacy of the study products 
• 
The importance of adherence to the study visit and procedures schedule  
• 
The potential medical risks of study participation (and what to do if such risks 
are experienced) 
• 
The real yet limited benefits of study participation  
• 
The distinction between research and clinical care 
• 
The right to withdraw from the study at any time  
 
The informed consent process will include an assessment of each potential subject’s 
understanding prior to enrollment and randomization of concepts identified by the 
protocol team as essential to the informed consent decision.  Subjects who are not 
able to demonstrate adequate understanding of key concepts after exhaustive 
educational efforts will not be enrolled in the study.  
 
If during the trial a consent revision where new information that might affect the 
research subject’s willingness to participate is presented, subjects will be informed of 
the revisions.  If a research subject terminates the study and consent form revision 
occurs after their participation has ended, they do not need to sign the revised 
consent form. 
 
12.5 
Participant Confidentiality 
 
All study procedures will be conducted in private and every effort will be made to 
protect subject privacy and confidentiality to the extent possible.  All study-related 
information will be stored securely at the study site.  All subject information will 
be stored in locked file cabinets in areas with access limited to study staff.  Data 
collection, process and administrative forms, laboratory specimens and other 
reports will be identified by a coded number only to maintain subject 
confidentiality.  Forms, lists, logbooks, appointment books and any other listings 
that link subject ID numbers to other identifying information will be stored in a 
separate, locked file in an area with limited access.  All local databases will be 
secured with password-protected access systems.  Subjects’ study information 
48 
 

 
 
 
will not be released without their written permission, except as necessary for 
review, monitoring, and/or auditing by: 
 
• 
Representatives of the US Federal Government, including  the US OHRP, 
NIH, and/or contractors of the NIH  
• 
University of Pittsburgh IRB 
 
Authorized representatives of QUEST Diagnostics, Inc. will have access to 
limited identifiable information (including first and last name, date of birth, gender, 
and medical record number) for the purpose of analyzing biological samples 
obtained for this research study.  Subjects who decline to allow this use of 
identifiers will have samples sent to QUEST using only a coded number. 
 
12.6 
Special Populations 
 
This section outlines considerations made for the inclusion or exclusion of special 
populations in this study. 
 
12.6.1 Pregnant Women 
 
Women who test positive for pregnancy at screening or enrollment visits 
will not be eligible to participate in this study.   
 
A urine pregnancy test will be performed on all women of childbearing 
potential at the Screening, Entry, and every 4 weeks during the study.  
Investigators will discontinue study product among subjects who test 
positive for pregnancy.  All potential female subjects of childbearing 
potential will be required to be currently using a reliable method of 
contraception as outlined in the inclusion criteria.  
 
12.6.2 Children 
 
The NIH has mandated that children be included in research trials when 
appropriate.  This study meets Justifications for Exclusion criteria for 
younger children as set forth by the NIH.  Specifically, “insufficient data 
are available in adults to judge potential risk in children” and “children 
should not be the initial group to be involved in research studies.”  This 
study does not plan to enroll children or adolescents under 18 years of 
age. 
 
12.7 
Compensation 
 
Pending IRB approval, subjects will be compensated for their time and effort in 
this study, and/or be reimbursed for travel to study visits and time away from 
work according to standard practice at the University of Pittsburgh.  
Reimbursement amounts will be specified in the informed consent form. 
 
12.8 
Communicable Disease Reporting 
49 
 

 
 
 
 
Study staff will comply with all applicable local requirements to report 
communicable diseases identified among study subjects to local health 
authorities.  Subjects will be made aware of all reporting requirements during the 
study informed consent process. 
 
12.9 
Study Discontinuation 
 
This study may be discontinued at any time by NIAID, the OHRP,  the University 
of Pittsburgh IRB, the IDSMB or the Principal Investigators. 
 
13.0 
PUBLICATION OF RESEARCH FINDINGS 
 
Publication of the results of this trial will be governed by University of Pittsburgh policies.  
 
14.0 
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 shipping 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 dangerous goods materials, including diagnostic specimens and infectious 
substances, must be transported using packaging mandated by CFR 42 Part 72. Please 
refer to instructions detailed in the International Air Transport Association (IATA) 
Dangerous Goods Regulations. 
50 
 

 
 
15.0 
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53