HERV-K Suppression Using Antiretroviral Therapy in Volunteers With Amyotrophic Lateral Sclerosis (ALS)
Phase: PHASE1
Conditions: Amyotrophic Lateral Sclerosis
Sponsor: National Institute of Neurological Disorders and Stroke (NINDS)

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
Protocol number:  15-N-0126 
Version:  13.0 
 
CNS IRB Protocol Template (rev 11.20.14) 
 
 
 
 
 
 
page 1 of 41 
 
 
Protocol Title: HERV-K Suppression Using Antiretroviral Therapy in Volunteers with Amyotrophic Lateral 
Sclerosis (ALS) 
Abbreviated Title: ART in ALS 
Protocol Number:  15-N-0126 
Date of this Submission/Version:  July 13, 2021 (M) 
 
Total requested accrual  
(200) Participants   
 
 (0) Healthy Volunteers   
  
 
Project Uses Ionizing Radiation:  o No   
x Yes 
  
 
o Medically-indicated only 
  
 
x Research-related only 
  
 
o Both 
 
IND/IDE 
 
 
x No   
oYes (attach FDA documentation) 
  
Drug/Device/#_____________________ 
  
Sponsor: __________________________ 
 
 
Durable Power of Attorney  
 
x No   
o Yes  
 
Multi-institutional Project 
 
x No   
o Yes  
 
 
 
 
 
Data and Safety Monitoring Board  
x No   
o Yes  
 
Technology Transfer Agreement  
o No   
 xYes  
Agreement type and number _Please refer to Study Application in iRIS____ Expiration Date_____ 
 
Samples are being stored  
 
o No   
x Yes  
 
Flesch-Kincaid reading level of standard consent form:  8.8 
Flesch-Kincaid reading level of blood draw only consent form: 7.6 
 
 
 
 
 
 
 
 
 
 
 
 
 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
Protocol number:  15-N-0126 
Version:  13.0 
 
 
CNS IRB Protocol Template (rev 11.20.14) 
 
 
 
 
 
 
page 2 of 41 
 
Précis: 
Objective 
In this Phase I, proof-of-concept study, we aim to determine whether an antiretroviral regimen approved 
to treat human immunodeficiency virus (HIV) infection would also suppress levels of Human Endogenous 
Retrovirus-K (HERV-K) found to be activated in a subset of participants with amyotrophic lateral sclerosis 
(ALS). We propose to measure the of blood levels of HERV-K by quantitative PCR before, during, and after 
treatment with an antiretroviral regimen. We will evaluate the safety of the antiretroviral regimen for 
participants with ALS and also explore clinical and neurophysiological outcomes of ALS symptoms, quality 
of life, and pulmonary function.  
 
Study Population 
We will study a subset of ALS participants who have a ratio of HERV-K:RPP30 greater than or equal to 13.  
About 30% of ALS participants may have detectable levels of HERV-K; about 20% of participants with ALS 
have a level >1000 copies/ml. To show whether the HERV-K could be suppressed, we will recruit from the 
approximately 20% of participants with the high levels so that the antiretroviral effect can be determined.  
 
Design 
This is an open-label study of a combination antiretroviral therapy for 24 weeks in up to 25 HIV-negative, 
HTLV-negative ALS participants with high ratio of HERV-K:RPP30. The study duration for each participant 
will be up to 72 weeks. Participants will be followed regularly for safety, clinical, and neurophysiological 
outcomes. 
 
Outcome Measures 
The primary outcome measure will be the percent decline in blood HERV-K concentration measured by 
quantitative PCR.  Percent decline for a participant is measured by: 100 x (screening visit – week 24 visit 
measurement) / screening visit. The safety of antiretrovirals in volunteers with ALS as measured by the 
frequency and type of AEs, the ability to remain on assigned treatment (tolerability), physical 
examinations, laboratory test results, vital signs, and weight/body mass index (BMI). Efficacy will be 
explored by measuring the change in mean scores of: the ALS Functional Rating Scale-Revised (ALSFRS-R), 
the ALS Specific Quality of Life Inventory-Revised (ALSSQOL-R), the ALS Cognitive Behavioral Screen (ALS-
CBS), vital capacity and maximal inspiratory pressure as measured by handheld spirometer, electrical 
impedance myography (EIM), the change in neurofilament levels in blood and/or CSF, and the change in 
urine p75ECD levels. 
 
 
 
 
 
 
 
 
 
 
 
 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
Protocol number:  15-N-0126 
Version:  13.0 
 
 
CNS IRB Protocol Template (rev 11.20.14) 
 
 
 
 
 
 
page 3 of 41 
 
Table of Contents 
1. 
Introduction ................................................................................................................................................. 6 
2. 
Study Objectives ....................................................................................................................................... 14 
2.1. 
Primary Objectives ........................................................................................................................ 14 
2.2. 
Secondary Objectives .................................................................................................................... 15 
2.3. 
Exploratory Objectives: ................................................................................................................ 15 
3. 
Subjects ....................................................................................................................................................... 15 
3.1. 
Description of study populations .............................................................................................. 15 
3.2. 
Inclusion Criteria ............................................................................................................................ 15 
3.3. 
Exclusion Criteria ........................................................................................................................... 16 
4. 
Study Design and Methods .................................................................................................................... 17 
4.1. 
Study Overview ............................................................................................................................... 17 
4.2. 
Recruitment ...................................................................................................................................... 17 
4.3. 
Screening ........................................................................................................................................... 17 
4.4. 
Study Visits ....................................................................................................................................... 18 
4.5. 
Research Procedures .................................................................................................................... 20 
4.6. 
End of Participation ....................................................................................................................... 22 
5. 
Management of Data and Samples ..................................................................................................... 23 
5.1. 
Storage ............................................................................................................................................... 23 
5.2. 
Data ..................................................................................................................................................... 23 
6. 
Additional Considerations .................................................................................................................... 23 
6.1. 
Research with investigational drugs or devices .................................................................. 23 
6.2. 
Gene Therapy ................................................................................................................................... 24 
7. 
Risks and Discomforts ............................................................................................................................ 24 
8. 
Subject Safety Monitoring ..................................................................................................................... 27 
9. 
Outcome Measures .................................................................................................................................. 30 
9.1. 
Primary outcome measures ........................................................................................................ 30 
9.2. 
Secondary outcome measures ................................................................................................... 30 
9.3. 
Exploratory outcome measures ................................................................................................ 30 
10. 
Statistical Analysis .............................................................................................................................. 30 
10.1. 
Analysis of data/ study outcomes ............................................................................................. 30 
10.2. 
Power analysis ................................................................................................................................. 31 
11. 
Human Subjects Protection ............................................................................................................. 32 
11.1. 
Subject selection ............................................................................................................................. 32 
11.2. 
Justification for the exclusion of children .............................................................................. 32 
11.3. 
Justification for the exclusion of those who lack consent capacity ............................... 32 
11.4. 
Justification for sensitive procedures ..................................................................................... 32 
11.5. 
Safeguards for vulnerable populations and sensitive procedures ................................ 32 
12. 
Anticipated Benefit ............................................................................................................................. 33 
13. 
Consent Documents and Process ................................................................................................... 33 
13.1. 
Consent procedures ....................................................................................................................... 33 
13.1.1. 
Telephone Consent ................................................................................................................................. 33 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
Protocol number:  15-N-0126 
Version:  13.0 
 
 
CNS IRB Protocol Template (rev 11.20.14) 
 
 
 
 
 
 
page 4 of 41 
 
13.2. 
Consent documents ........................................................................................................................ 33 
14. 
Data and Safety Monitoring ............................................................................................................. 34 
14.1. 
Data and safety monitor ............................................................................................................... 34 
14.2. 
Data and safety monitoring plan ............................................................................................... 34 
14.3. 
Criteria for stopping the study or suspending enrollment or procedures ................. 34 
15. 
Quality Assurance ............................................................................................................................... 34 
15.1. 
Quality assurance monitor .......................................................................................................... 34 
15.2. 
Quality assurance plan ................................................................................................................. 34 
16. 
Reporting of Unanticipated Problems, Adverse Events and Protocol Deviations ......... 34 
17. 
Alternatives to Participation ........................................................................................................... 35 
18. 
Privacy .................................................................................................................................................... 35 
19. 
Confidentiality ...................................................................................................................................... 35 
19.1. 
For research data and investigator medical records ......................................................... 35 
19.2. 
For stored samples ......................................................................................................................... 35 
19.3. 
Special precautions ........................................................................................................................ 35 
20. 
Conflict of Interest .............................................................................................................................. 36 
20.1. 
Distribution of NIH guidelines ................................................................................................... 36 
20.2. 
Conflict of interest .......................................................................................................................... 36 
21. 
Technology Transfer .......................................................................................................................... 36 
22. 
Research and Travel Compensation ............................................................................................. 36 
23. 
References ............................................................................................................................................. 36 
24. 
Consent Forms ...................................................................................................................................... 38 
25. 
Appendix A. Adverse Event definitions ........................................................................................ 39 
26. 
Appendix B. Cover Letter for Telephone Consent .................................................................... 41 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
Protocol number:  15-N-0126 
Version:  13.0 
 
 
CNS IRB Protocol Template (rev 11.20.14) 
 
 
 
 
 
 
page 5 of 41 
 
List of Abbreviations 
 
AE 
 
 
Adverse Event/Adverse Experience 
ALS 
 
 
Amyotrophic Lateral Sclerosis 
ALSFRS-R 
 
ALS Functional Rating Scale-Revised 
ALSSQOL-R 
 
ALS Specific Quality of Life Inventory-Revised 
ALS-CBS 
 
ALS Cognitive Behavioral Screen 
ART 
 
 
Antiretroviral Therapy 
BMI 
 
 
Body Mass Index 
CRF 
 
 
Case Report Form 
CSF 
 
 
Cerebrospinal Fluid 
DNA 
 
 
Deoxyribonucleic Acid 
EIM 
 
 
Electrical impedance myography 
EMG 
 
 
Electromyography 
fALS 
 
 
Familial ALS 
FDA 
 
 
Food and Drug Administration 
HERV 
 
 
Human Endogenous Retrovirus 
HIV 
 
 
Human Immunodeficiency Virus 
HTLV 
 
 
Human T-Lymphotropic Virus 
IEC 
 
 
Independent or Institutional Ethics Committee 
IRB 
 
 
Institutional Review Board 
LP 
 
 
Lumbar Puncture 
MIP 
 
 
Maximal Inspiratory Pressure 
N 
 
 
Number (refers to number of participants/sample size) 
NCS 
 
 
Nerve Conduction Study 
NIAID  
 
National Institute of Allergy and Infectious Diseases  
NIH 
 
 
National Institutes of Health 
NINDS  
 
National Institute of Neurological Disorders and Stroke 
NRTI 
 
 
Nucleoside Reverse Transcriptase Inhibitor  
PCR 
 
 
Polymerase Chain Reaction 
PI 
 
 
Principal Investigator 
QA 
 
 
Quality Assurance 
QC 
 
 
Quality Control 
RNA 
 
 
Ribonucleic Acid 
RT 
 
 
Reverse Transcriptase 
SAE 
 
 
Serious Adverse Event/Serious Adverse Experience 
sALS 
 
 
Sporadic ALS 
SOD1  
 
Superoxide Dismutase 1 
TAF 
 
 
Tenofovir alafenamide 
TARDP  
 
TAR-DNA-binding protein 
 
 
 
 
 
 
 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
Protocol number:  15-N-0126 
Version:  13.0 
 
 
CNS IRB Protocol Template (rev 11.20.14) 
 
 
 
 
 
 
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1. Introduction 
ALS 
Amyotrophic Lateral Sclerosis (ALS) is a rare, usually fatal degenerative disorder of large motor neurons 
of the cerebral cortex, brain stem and spinal cord that results in progressive wasting and paralysis of 
voluntary muscles. It has a prevalence of 3.9 cases/100,000 persons in the United States and the lifetime 
risk for individuals is 1/600 to 1/1000. ALS affects individuals of nearly all ages, genders, races, and 
geographic locations.1 The median age of onset is 55 years. There is a slight male predominance (3:2 
men:women) in sporadic ALS. Age and gender are the only risk factors consistently seen in epidemiological 
studies.1 Fifty percent of people with ALS will die within three years of onset of symptoms and 90% die 
within five years.2 The only available pharmacotherapy for ALS, riluzole, prolongs survival by only 60-90 
days.3 
 
Essential features of ALS are progressive signs and symptoms of lower motor neuron dysfunction (atrophy, 
cramps, and fasciculations) associated with corticospinal tract signs (spasticity, enhanced and pathological 
reflexes) typically in the absence of sensory findings.4 There is relative sparing of muscles of eye 
movement and the urinary sphincters. The course is relentless; strength, respiratory function and overall 
function invariably decrease with time. Hypoxia and pneumonia account for the majority of deaths in 
patients with ALS.5 
 
The majority of ALS cases are sporadic (sALS); 10% are familial (fALS). Mutations in specific genes or loci 
have been identified in ~40% familial and ~10% of sporadic cases.6 Those most frequently detected involve 
C9ORF72, superoxide dismutase-1 (SOD1) and the TAR-DNA-binding protein (TARDBP). C9ORF72 is 
strongly associated with ALS cases in which motor neuron degeneration is accompanied by 
frontotemporal dementia.7 Clusters of cases were also reported in football and soccer players, suggesting 
the possibility of trauma as a triggering event. Pathophysiological processes implicated in ALS include: 
toxicity from excess excitation of the motor neuron by transmitters such as glutamate, free radical-
mediated oxidative cytotoxicity, neuroinflammation, mitochondrial dysfunction, autoimmune processes, 
cytoskeletal abnormalities, and aberrant activation of cyclo-oxygenase. 
 
ALS and Viruses 
It was also suggested that a virus may be associated with ALS, in part because of the marked similarities 
in the histopathologic and neuroanatomic findings in ALS and poliomyelitis.8 Both are motor neuron 
diseases causing asymmetric-onset weakness that then spreads to other areas and eventually leading to 
diffuse muscle paralysis.  Additionally, post-polio syndrome occurs many years after infection and 
produces progressive weakness similar to ALS.  However, it is improbable that a virus or a post-viral 
syndrome is the primary cause of ALS.  A concrete link to a viral infection has never been documented in 
ALS; however, the research investigating such a link led to several noteworthy findings.  
 
The first demonstration of a possible viral association with ALS was in 1975 when reverse transcriptase 
(RT), an enzyme essential for replication of retroviruses (e.g., human immunodeficiency virus [HIV] or 
Human T-lymphotropic virus [HTLV]), was found post-mortem in two Guamanian ALS patients’ brains but 
not in brains from two control individuals.9 Subsequent studies showed approximately 53% (n=131) of ALS 
patients have detectable serum levels of RT compared with 12% (n=152) of controls (Table 1).  
Interestingly, relatives related by blood to patients with ALS are more likely than unrelated controls to 
have detectable RT.  To date, there are no reported genetic testing results for these unaffected controls 
with detectable RT levels to see if they share a genetic mutation associated with ALS. 
 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
Protocol number:  15-N-0126 
Version:  13.0 
 
 
CNS IRB Protocol Template (rev 11.20.14) 
 
 
 
 
 
 
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Table 1. Summary of Published Data on ALS and Serum Reverse Transcriptase 
Author 
Subjects (number) 
RT in serum Screened Retroviruses 
Andrews et al. 10 
ALS (56) 
 
Controls (58) 
 
59% 
 
5% 
 
HIV, HTLV, HFV, HRV5 
Steele et al. 
ALS (30) 
 
Unrelated controls (44) 
Related controls (14) 
 
47% 
 
18% 
43% 
 
NR 
MacGowan 
ALS (23) 
 
Controls (21) 
 
56% 
 
19% 
 
HIV 
McCormick et al. 
ALS (22) 
 
Controls (14) 
 
50% 
 
7% 
 
HIV HTLV 
RT, reverse transcriptase. HTLV, Human T-Lymphotrophic Virus. HFV, Human Foamy Virus. HRV, Human 
Retrovirus-5. NR, not reported 
 
Human Endogenous Retroviruses (HERV) 
The reason for some ALS patients having detectable levels of the RT enzyme in brain and serum is unclear.  
The studies that have looked for retroviruses have not been able to detect them (Table 1).  However, RT 
may not be produced by an exogenous/acquired retrovirus and could be associated with an endogenous 
retrovirus instead.  When retroviruses infect humans, they incorporate their genetic information into a 
host’s DNA.  Through ancestral retroviral infections, and the successive sharing of these retroviral genetic 
elements with infected persons’ progeny, 8-9% of our human genome is now made of retroviral elements.  
These elements closely resemble viruses and thus are termed human “endogenous” retroviruses (HERV) 
in contrast to exogenous, infectious retroviruses such as HIV or HTLV.  Some of these elements may form 
viral particles although there is no evidence that these endogenous retroviruses remain infectious or are 
the primary etiologic agent of any disease.  Research studies have shown that some diseases are 
associated with an increased expression of endogenous retroviral elements, e.g., in rheumatoid arthritis 
or systemic lupus erythematosus; however, the significance of these findings is uncertain.11,12   
 
Of the HERV families, HERV-K and HERV-W have gained the most attention due to the presence of a 
complete open-reading frame (cORF) and the ability to form virus-like particles.  We analyzed serum 
samples from 190 different participants: 72 with ALS, 53 with frontotemporal dementia (a 
neurodegenerative condition often associated with ALS), 26 with Alzheimer’s dementia, 9 from family 
members of ALS patients, and 30 healthy controls. All samples were obtained from neurologists at Emory 
University. We analyzed the samples in a blinded fashion so that we did not know the diagnosis until after 
determining the results. The methods are described in Section 9.2.  Six of 72 samples from patients with 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
Protocol number:  15-N-0126 
Version:  13.0 
 
 
CNS IRB Protocol Template (rev 11.20.14) 
 
 
 
 
 
 
page 8 of 41 
 
sporadic ALS had very high levels (>1000 RNA copies/ml) of HERV-K gag RNA expression as measured by 
quantitative polymerase chain reaction (PCR). There was no detectable HERV-K in samples from healthy 
controls or patients with either frontotemporal dementia or Alzheimer’s dementia (Figure 1). Low level 
activation was found in first-degree blood relatives of ALS patients similar to the finding reported for 
reverse transcriptase detection. 
 
 
 
 
 
 
 
 
 
 
 
 
We also confirmed the presence of HERV-K in post-mortem brain samples from ALS patients. Using 
samples from both patients and healthy controls, we determined that the entire HERV-K genome (Figure 
2A) and spliced transcripts were expressed in both sets. Initial observations suggested that the 4.5 kb 
spliced env transcript was exclusively expressed in brains from ALS patients (3 of 11). Expression of HERV-
K transcripts was further confirmed by quantitative PCR which showed that transcripts for all three genes, 
gag, pol and env, were elevated in the ALS brain samples (Figure 2B and C). There was good correlation 
between the expression of each of these genes confirming that the entire viral genome is expressed in 
these patients. This is consistent with our previous observation where HERV-K pol RNA transcript was 
expressed in the brain of sporadic ALS patients but not in those with Parkinson’s disease13. No particular 
clinical phenotype was associated with the expression of HERV-K in ALS patients. 
 
To determine the cell types in which HERV-K was expressed, we immunostained brain tissue from ALS 
patients using an antibody to the HERV-K env. We found expression of the env protein in 3 of 5 individuals 
(Figure 2D and E), with strong expression in the large pyramidal neurons of the cortex (Figure 2F). The 
expression was exclusively in the neuronal cytoplasm and was concentrated in foci at the cell membrane 
(Figure 2F). Anterior horn neurons in the spinal cord also showed immunostaining for HERV-K env. These 
cells had a dysmorphic appearance (Figure 2G). No immunostaining was noted in the glial cells or in the 
white matter (Figure 2H). 
 
It is likely that reverse transcriptase is a less specific finding than the RNA transcripts of HERV-K and thus 
fewer ALS patients have HERV-K compared to those with reverse transcriptase activity.  To date, there is 
no clear phenotypic differences in those ALS patients with or without elevated levels of HERV-K; however, 
the sample size of current data is limited to make such conclusions.   
 
 
 
 
 
 
 
 
Figure 
1: Detection 
of HERV-K 
in 
plasma. 
Quantitative RT-PCR was used to detect HERV-K 
transcripts in 140 ul of plasma from patients with ALS 
(n=72), healthy controls (HC; n=30), frontotemporal 
dementia (FTD; n=53), Alzheimer’s disease (AD; n=29) 
and healthy first degree relatives of patients with ALS 
(rALS n=9). Highest levels are seen in a subgroup of 
ALS patients. 
 
rALS 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
Protocol number:  15-N-0126 
Version:  13.0 
 
 
CNS IRB Protocol Template (rev 11.20.14) 
 
 
 
 
 
 
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Other markers of HERV-K activity: 
We have found that some patients with ALS have antibodies to HERV-K and there is dysregulation of HERV-
K in the lymphocytes in these patients. The significance of this immune response is not clear. We are thus 
validating these assays and developing an ELISA to monitor antibody responses in these patients. We will 
also develop a cell-based assay to monitor HERV-K expression in peripheral blood lymphocytes. Once 
developed we will determine the immune response to HERV-K in the context of this current study. 
 
Neurofilament levels in ALS: 
Recent studies have shown that phosphorylated heavy and light chain neurofilament levels can be 
measured in CSF and blood. These levels correlate with disease severity and rate of progression.14 
Neurofilament release in the CSF and blood is an indicator of neuronal injury and even though it may not 
be specific for ALS, it could be a useful marker for monitoring the effects of treatment in this population. 
 
Urine p75ECD in ALS: 
Urine p75ECD has been shown recently to correlate well with ALS disease progression including with the 
clinical rating scale, the revised ALSFRS.15 
 
Human Immunodeficiency Virus and Motor Neuron Disease: 
ALS occasionally affects patients with HIV infection with the first case described as early as 1985.16 To 
date, at least 30 cases of HIV-associated ALS patients have been reported.17 With comorbid HIV, there 
were several unique characteristics of ALS that appear in some cases: younger age at onset, more rapid 
progression, and elevated CSF protein; however, the significance of these apparent differences is not 
entirely certain because the number of patients is limited and the phenotypic variability is rather high. 
Figure 2: HERV-K expression in brain of ALS patients.. 
Total RNA was extracted from frozen brain tissue with 
RNeasy Plus mini kit. The RNA extracts were treated 
with RNase-free DNase. Reverse transcription was 
performed with 1μg RNA using Superscript III first 
stand kit. Quantitative PCR was done using Applied 
Biosystems Vii 7. (A) HERV-K genome showing regions 
amplified by PCR  
 (B) All HERV-K genes were significantly elevated in 
ALS patients (n=11) compared to controls (n=16). The 
amount of RNA in brain samples was expressed as 
relative levels to control samples after normalization 
with 18s RNA. (C) Full-length HERV-K RNA, 7.5 kb, and 
spliced products 4.5 kb and 2.5 kb were detected by 
reverse transcription PCR in brain tissue. 4.5 kb 
product representing the env was present in ALS 
samples only. (D) Immunostaining for HERV-K env in 
ALS cortical neurons in layer V, (E) in pyramidal 
neurons, (F) in the cytoplasm with focal accumulation 
at the cell membrane and in (G) anterior horn 
neurons in spinal cord. (H) White matter and (I) 
secondary antibody control show no immunostaining. 
Scale bar=50 µm 
 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
Protocol number:  15-N-0126 
Version:  13.0 
 
 
CNS IRB Protocol Template (rev 11.20.14) 
 
 
 
 
 
 
page 10 of 41 
 
The most striking and likely significant feature of HIV-associated ALS is that some patients improved when 
treated with antiretroviral therapy. Motor and respiratory strength improved, and in some patients, 
strength returns to normal and is sustained for years.18-20 This improvement in ALS symptoms that some 
patients have when treated with HIV medications is remarkable. 
 
In a small case series, HIV infection was newly diagnosed at the time of ALS symptom presentation for 
38% of patients. The severity of immunosuppression was variable, with CD4 counts ranging from 2 to 618 
cells/mm3, and HIV viral load ranged from undetectable to 7.8x104 copies/ml. Because of the somewhat 
unique clinical characteristics and the potential for a clinical response to antiretroviral therapy (ART), ALS 
is often named “ALS-like” when it affects a patient with comorbid HIV even though patients meet El 
Escorial criteria for an ALS diagnosis.  Alternatively, some authors have referred to it as “motor neuron 
disease.” 
 
Response to Antiretroviral Therapy: 
All patients with HIV-associated ALS who clinically improved or became stabilized were treated with ART. 
The response to ART typically coincides with reduced plasma HIV viral load and increased CD4 count. 
However, despite continued ART, normal CD4 counts and an undetectable plasma viral load, three 
patients experienced a clinical relapse after a period of initial improvement (15 months in one and 24 
months in two).17 Based on a small sample size, prognosis is not related to the age at onset, the initial CD4 
cell count or viral load, or the duration of known HIV seropositivity.17 Corticosteroids and intravenous 
immunoglobulin were not beneficial.  ART is the only class of drugs associated with stabilization or even 
improvement in ALS patients.  
 
ALS in HIV-infected patients may be primarily from HIV infection of the motor neuron, an unknown 
complication that mimics ALS, or there may be a mere coincidence. However, the likelihood that the ALS-
like presentation in these patients is caused by at least a shared etiology with patients with ALS and 
without HIV is suggested by the fact that the neurological manifestations of ALS either with or without 
HIV are indistinguishable in many cases. The patients may be younger and the course of disease without 
treatment may be worse; however, the clinical phenotype is indistinguishable. A retrovirus as a cause of 
a subset of ALS cases is supported by the response to ART in 52% of HIV-associated ALS cases. This is quite 
controversial. HIV does not infect neurons.21 Thus, selective damage to motor neurons may occur by 
neurotoxic viral proteins or cytokines produced as a consequence of the viral infection.22 Autopsy studies 
failed to connect HIV, or any virus, directly to motor neurons and muscle fiber loss16,23,24 although the 
possibility exists that in these rare cases, HIV may transactivate an endogenous retrovirus25 which would 
explain the response to ART in these patients.  
 
Treatment of ALS with ART 
Two pilot studies of monotherapy in patients with ALS and negative for HIV were unsuccessful. Zidovudine 
was used for 12 patients with ALS at a dose of 500 mg daily. Only interim results were published with 
patients completing between 2-10 months of therapy. The authors did not feel there was a significant 
change in the disease course with zidovudine since 5/12 patients died at the time of publication. They 
noted that zidovudine was well tolerated among the patients and that serum CK levels decreased during 
treatment although no other outcome measures were reported.26 Indinavir was tested in a double-blind 
placebo-controlled trial27 powered to measure safety and feasibility. Four of 23 participants receiving 
indinavir developed nephrolithiasis, and only 12 patients in the treatment group completed the 9-month 
trial. The authors cite disease progression and inability to travel as the two primary reasons why 
participants could not complete the trial. In the intention-to-treat analysis, there was a faster rate of 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
Protocol number:  15-N-0126 
Version:  13.0 
 
 
CNS IRB Protocol Template (rev 11.20.14) 
 
 
 
 
 
 
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decline in the ALSFRS, a symptom scale used in most ALS clinical trials, in the treatment group compared 
to the placebo group. 
 
In a recent study in Australia, called the Lighthouse Study, 35 patients were treated with combination ART, 
Triumeq (abacavir, dolutegravir and lamivudine) for a period of six months. The patients were enrolled at 
four different sites. Serum samples from 10 patients were made available to us from one site. We have 
analyzed these samples for HERV-K using a newly developed digital PCR assay in our lab. The advantage 
of this assay as compared to the qPCR assay is that it is highly accurate, many of the steps are automated 
hence it is highly reproducible as well. Data from those 10 patients shows that in 4/10 patients there was 
a drop in HERV-K levels. These were also the patients with the highest viral load (Figure 3). The clinical 
significance of this drop in viral load is not clear. 
 
 
 
 
 
 
 
 
Rationale Summary 
It is well established that a subset of patients with ALS have detectable blood levels of HERV-K viral load, 
and both the titer levels and proportion of patients with detectable levels are greater in patients with ALS 
compared to healthy controls and to those with other neurologic diseases. The clinical significance of this 
HERV-K viral load to disease pathogenesis and phenotype is entirely uncertain. It is also well established 
that HIV-infected patients who develop an ALS-like syndrome may have lasting improvement in strength 
and function when treated with antiretroviral therapies. This study will allow an initial clinical investigation 
to explore the concept that the HERV-K viral load is susceptible to suppression similar to levels of HIV RNA 
when treated with antiretroviral therapies. 
 
Rationale for Using Antiretroviral Therapy 
We have tested approximately 30 antiretroviral therapies for activity against HERV-K. 27 We synthesized 
the HERV-K genome, pseudotyped it with VSV-glycoprotein, and then infected two different cells lines. 
The infection was monitored using viral replication by quantitative PCR. We found that the virus could 
replicate in these cells efficiently. In a separate set of experiments, we infected the cells in the presence 
of reverse transcriptase inhibitors including abacavir and zidovudine. Some drugs suppressed HERV-K viral 
loadlevels in a dose-responsive manner.  To determine if protease inhibitors could impact HERV-K 
expression, we transfected HeLa cells with the HERV-K plasmid and then exposed the cells to a panel of 
protease inhibitors. We found that darunavir had the most potent effect against HERV-K (Figure 3). Of 
note in Figure 3, indinavir has limited activity against HERV-K; this was the agent studied in one of the 
prior pilot studies of antiretroviral therapy in ALS.   
 
 
 
Figure 3: Effect of ART on serum HERV-K levels in ALS 
patients. HERV-K levels were measured by digital PCR. Four 
patients with the highest viral load also showed a drop in 
viral load following treatment with Triumeq for six months. 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
Protocol number:  15-N-0126 
Version:  13.0 
 
 
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We calculated the IC90 (the drug concentration required for 90% suppression, a standard for determining 
antiretroviral drug efficacy) for each of the drugs and compared it to that reported in the literature for 
effects on HIV replication (Table 2). It appears that the effects of zidovudine and abacavirare similar 
against both viruses, while lopinavir has very limited effect; however, the effects of darunavir appeared 
to be 3-10 fold less potent compared to the effect on HIV although the effects are still in the nM range 
(Table 2). In addition to the protease inhibitor (darunavir boosted with ritonavir) with the highest impact 
on HERV-K replication, we propose using an integrase inhibitor (dolutegravir) because it penetrates into 
the CNS, is effective against a broad range of retroviruses (less specific for HIV) and it could prevent 
infection of new cells by blocking viral integration. 
 
Rationale for tenofovir alafenamide fumerate (TAF) 
A recent study shows that the IC50 for tenofovir against HERV-K was 3.9 uM while that of abacavir was 
14.6 uM and zidivudine was 15.9uM, suggesting that tenofovir was the most efficacious drug against 
HERV-K.28 While the penetration of tenofovir across the blood brain barrier is poor, a new form of the 
drug, tenofovir alafenamide fumerate (TAF) has several hundred-fold higher concentrations in the brain. 
We thus propose to use TAF instead of zidovudine, which also has a better side effect profile. 
 
Rationale for dolutegravir 
Dolutegravir is a newer integrase inhibitor with similar properties to raltegravir; however it has much 
better CNS penetration and thus is more appropriate for this study. 
 
Table 2: IC90 for Antiretroviral Therapies Targeting HIV and HERV-K 
Drugs  
HIV IC90  
HERV-K IC90  
TAF 
Unknown 
Unknown 
Darunavir  
2.7nM to 13nM 
50± 20nM 
   
Lopinavir  
IC50  17nM (no serum) 
IC50  102nM  (50% serum) 
0.8µM ±0.2 µM  
Dolutegravir  
Unknown 
Unknown 
 
 
Figure 4. Relative suppression of HERV-K gag 
RNA 
transcript 
expression 
by 
protease 
inhibitors.  Darunavir has the most suppressive 
activity of the comparison drugs. 
 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
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Version:  13.0 
 
 
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Rationale for Experimental Therapeutics in ALS 
Riluzole, a drug that has multiple mechanisms of action including inhibition of release of glutamate at pre-
synaptic terminals, was reported in two controlled studies to extend survival by three months for patients 
with ALS although without a concomitant improvement in strength. This is currently the only FDA-
approved agent for use in ALS. Trials of thalidomide, tamoxifen, dexpramipexole, IGF-1, gabapentin, brain-
derived neurotrophic factor (BDNF), xaliproden, topiramate, celecoxib, creatine, lithium, talampanel, and 
ceftriaxone, among others, were shown to be ineffective in treating ALS.  
 
Because there are no ALS therapies with strong benefit on the disease course, there is a need for trials to 
explore novel pathways in ALS.  This study is an early-phase proof-of-concept trial that may help open 
pathways for additional novel experimentation in ALS. 
 
24-week Treatment Duration Rationale 
We anticipate that suppression of reverse transcriptase to undetectable levels will require treatment for 
several months. By having a 24-week duration of medications, we expect to observe sustained 
suppression in HERV-K viral load if it can occur with the ART regimen.  
 
Description of anti-retroviral regimen 
 
Table 3. Antiretroviral regimen 
Name 
Dose 
Frequency 
Route of 
Administration 
Food Considerations 
Trade 
name 
Darunavir1 
600 
mg 
Twice 
daily 
PO 
Should be taken with meals 
Prezista® 
Ritonavir1 
100mg 
Twice 
daily 
PO 
Should be taken with meals 
Norvir® 
Dolutegravir  
50 mg 
Once daily 
PO 
May be taken without 
regard to meals 
Tivicay® 
TAF 
25 mg 
Once daily 
PO 
May be taken without 
regard to meals 
Vemlidy® 
1Darunavir must always be administered with ritonavir. 
Table 3 describes the dose, frequency, route of administration of the combination antiretroviral 
medication regimen. 
 
Table 4. Alternative formulations for study medications available for patients with dysphagia 
Name 
Chewable tablet 
Oral suspension 
Frequency 
Darunavir 
n/a 
6ml of 100 mg/ml 
solution (600 mg) 
Twice daily 
Ritonavir 
n/a 
1.25 ml of 80 mg/ml 
solution (100 mg) 
Twice daily 
Dolutegravir 
n/a 
Dissolved 
crushed 
tablet in water 
Once daily 
TAF 
n/a 
Dissolved crushed 
tablet in water 
Once daily 
Table 4 describes alternative formulations available for patients with dysphagia who cannot tolerate the 
formulations from Table 3.   
 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
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Darunavir is an orally-administered protease inhibitor, the most effective class of drugs against HIV.  As a 
protease inhibitor, it prevents the cleavage of protein precursors that are required to produce new viral 
particles.  It was FDA-approved to treat HIV in 2006. 
 
Because darunavir is extensively metabolized by CYP3A it is always combined with ritonavir, another 
protease inhibitor that inhibits CYP3A.  When a single dose of ritonavir-boosted darunavir is given, there 
is an approximate 14-fold increase in the systemic exposure of darunavir.   
 
Dolutegravir is an orally-administered integrase inhibitor that blocks the integration of viral DNA into host 
cell chromosomes.  Inhibiting integration prevents propogation of viral infection.  It was FDA-approved to 
treat HIV in 2013.  No dosage adjustment is necessary for patients with mild-moderate hepatic or renal 
impairment.  Dolutegravir is available in 50mg film-coated tablets.  
 
Darunavir with boosted ritonavir and another integrase inhibitor, raltegravir, were studied extensively in 
clinical trials.  8-12% of patients with HIV have not had virologic suppression during trials lasting up to 212 
weeks.  During this time, 66-70% of patients starting either medicine remained on the medicine and on 
study until completion and remained virologically suppressed (Table 5).   
 
Tenofovir alafenamide is a nucleotide reverse transciptase inhibitor that blocks the enzyme required for 
replication of retroviruses.  It was FDA approved to treated HIV in 2016.  No dosage adjustments are 
recommeneded for patients with mild-severe renal impairment or mild hepatic impairment.  It is available 
only as a 25mg tablet to be taken once daily and there is no liquid formulation available.   
 
For antiretroviral therapies, the CNS penetration effectiveness (CPE) ranking is a validated measure of 
CSF:plasma concentrations for each drug with a score of 4 for the most CNS penetrating and 1 for least.  
The CPE scores for , darunavir + ritonavir, and dolutegravir are 3 and 4 respectively indicating that all have 
strong penetration into the CNS.29 The CPE score for TAF is currently not reported in the literature.   
 
Table 5. Clinical trial results in treatment-naïve, HIV-positive subjects 
 
Concomitant 
medications 
Study 
duration 
(weeks) 
Virologic success 
(lower limit of 
detection in 
copies/ml) 
Virologic 
failure 
Discontinued 
study 
Darunavir 
(+ritonavir)30 
FTC/TDF 
192 
70% (<50) 
12% 
18% 
Dolutegravir30 
FTC/TDF 
96 
81% (<50) 
5% 
2% 
TAF 
FTC/EVG/COBI 
48 
92% 
4% 
6% 
FTC, emtricitabine.  TDF, tenofovir.  3TC, lamivudine.  IDV, indinavir. EVG, elvitegravir. COBI, cobicistat. 
NR, not reported 
 
Study Progress Update as of April 11, 2019 
Since approval of Amendment C on March 4, 2019, we have pre-screened several potential participants.  
We have had one enrollment as of April 11, 2019.  
2. Study Objectives 
2.1. Primary Objectives 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
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The primary objective is to assess whether an antiretroviral regimen of darunavir + ritonavir, dolutegravir, 
and TAF for 24 weeks will suppress blood levels of HERV-K RNA below the limit of detection (1000 
copies/ml) in patients with HERV-K-positive ALS. 
 
2.2. Secondary Objectives 
The secondary objectives of this study are: 
1. To assess the safety of an antiretroviral regimen of darunavir + ritonavir, dolutegravir, and TAF in 
patients with ALS. 
2. The percent decline in blood HERV-K concentration: 100% x (screening visit – week 24 visit 
measurement)/screening visit measurement. 
 
2.3. Exploratory Objectives: 
The exploratory objectives will guide decisions on future studies of antiretroviral therapy in ALS patients. 
• 
Evaluate the efficacy of ART on clinical biomarkers of ALS that measure symptoms, neurophysiologic 
outcomes, respiratory function, and quality of life. 
• 
Evaluate whether known genetic variability associated with ALS accounts for variable suppression of 
HERV-K viral load in blood levels by ART. 
• 
Evaluate effect of ART on HERV-K antibody levels in blood and/or CSF and effects on intracellular 
HERV-K expression in peripheral blood lymphocytes. These assays are currently under development 
in our laboratory and will be applied to stored samples once available.  
3. Subjects 
3.1. Description of study populations  
Participants may be included with a diagnosis of clinically probable, laboratory-supported clinically 
probable, or clinically definite ALS. By including participants with probable ALS rather than only definite 
ALS, we will allow participants to enroll earlier in the course of illness. This is a common inclusion method 
for ALS clinical trials because the median time from symptom onset to clinically-definite ALS is over 12 
months. More than 25% of ALS patients die without meeting the El Escorial criteria for clinically definite 
ALS.31  
 
Participants will be recruited from a small subset of ALS patients who have elevated levels of the HERV-
K:RPP30 greater than or equal to 13 at the time of screening.  By using this small, specific population for 
our study, we will limit the generalizability of our results. However, this is a proof-of-concept study and 
using this limited population with the highest HERV-K levels will afford the best opportunity to test the 
concept that antiretrovirals can suppress the HERV-K levels. 
 
Accrual ceiling:  200 
Target number of completers:  up to 25 for a goal of 20  
Withdrawals/dropouts will be replaced as defined in Section 10. 
 
3.2. Inclusion Criteria 
Subjects must meet all of the following inclusion criteria to be eligible to participate in this study: 
1. Age 18 years or older at the time of the screening visit. 
2. Able to provide informed consent and comply with study procedures. 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
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3. ALS diagnosed as probable, laboratory-supported probable or definite according to the World 
Federation of Neurology El Escorial revised criteria32 as determined by a neurologist with 
neuromuscular subspecialty training. 
4. A ratio of HERV-K:RPP30 greater than or equal to 13 measured by quantitative PCR at the screening 
visit. 
5. Duration of disease less than 2 years, or if greater than 2 years, disease progression at a rate that in 
the judgement of the investigator would allow for completion of the study.  
6. If taking riluzole or edaravone, must be on a stable dose for at least 30 days prior to the screening 
visit, or stopped taking riluzole or edaravone at least 30 days prior to the screening visit. 
7. Subject has a competent caregiver who can and will be responsible for administering study drug. If 
there is no caregiver, another qualified individual must be available to do this. 
8. Subject has established care with a neurologist and will maintain this clinical care throughout the 
study. 
9. Subject has had neuroimaging within the last 24 months for participants enrolling at the NIH Clinical 
Center. 
3.3. Exclusion Criteria 
A participant will be excluded if he or she has any of the following: 
1. Dependence on daytime mechanical ventilation (invasive or non-invasive, including Continuous 
Positive Airway Pressure (CPAP) or Bilevel Positive Airway Pressure (BiPap) at the time of the screening 
visit. 
2. Participation in any other investigational drug trial or using investigational drug (within 4 weeks prior 
to the Day 0 visit and thereafter).  
3. History of severe sulfonamide allergy (i.e. anaphylaxis). 
4. History of positive test or positive result at screening for HIV or HTLV-1. 
5. Participants must not be able to become pregnant (e.g., post-menopausal for at least one year, 
surgically sterile, or using adequate methods of contraception) or breastfeed for the duration of the 
study. Adequate methods of contraception include: implanted contraception, intrauterine device in 
place for at least 3 months, or barrier method in conjunction with spermicide. Participants of 
childbearing potential must have a negative pregnancy test at screening and be non-lactating. 
6. Presence of any of the following clinical conditions at the time of screening: 
a. Drug abuse or alcoholism 
b. Unstable medical disease (such as unstable angina or chronic obstructive pulmonary disease), 
or active infectious disease (such as Hepatitis C or tuberculosis), or current malignancy 
c. Unstable psychiatric illness defined as psychosis or untreated major depression within 90 days 
of the screening visit 
d. Dementia 
e. Diabetes mellitus 
f. Hemophilia 
7. Use of contraindicated medications:  amiodarone, dronedarone, lovastatin, simvastatin, rifampin, 
rifapentine, rifabutin, cisapride, pimozide, midazolam, triazolam, dihydroergotamine, ergonovine, 
ergotamine, methylergonovine, St. John’s wort, alfuzosin, salmeterol, sildenafil for pulmonary arterial 
hypertension, oxcarbazepine, phenobarbital, phenytoin or dofetilide. 
8. Safety Laboratory Criteria at the screening visit: 
a. Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) greater than 3.0 times 
the upper limit of normal. 

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Date:  July 13, 2021 
 
 
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b. Serum creatinine, serum phosphorous, total bilirubin, triglycerides, amylase, or lipase greater 
than 2.0 times the upper limit of normal. 
c. Estimated glomerular filtration rate <60mg/dl. 
d. Platelet concentration of <100,000/ µl. 
e. PT and PTT >1.2 times the upper limit of normal for participants enrolling at the NIH Clinical 
Center. 
f. Hemoglobin <10mg/dL. 
g. Positive Hepatitis B Surface Antigen and Hepatitis C Virus Antigen 
4. Study Design and Methods 
4.1. Study Overview 
This is a single-center, single-arm, open-label, baseline-versus-treatment study of darunavir, dolutegravir, 
ritonavir, and TAF in ALS patients. Up to 25 patients with ALS and with a ratio of HERV-K:RPP30 greater 
than or equal to 13  will receive the antiretroviral regimen for 24 weeks.  The goal is to have 20 participants 
complete the study through week 24.  The treatment phase will be followed by a post-treatment follow-
up for an additional 24 weeks.  The study duration for each participant could be up to 72 weeks (i.e. when 
24 weeks elapses between initial blood draw and the screening visit). Study evaluations will be completed 
as outlined in Section 4.5.  For participant convenience, some of the visits may be completed as an 
inpatient or outside of NIH.  
 
4.2. Recruitment 
Participants will be recruited from physician referral, self-referral, and through advertisement.  Referring 
providers may share the contact details with the potential participant who then may contact the 
coordinator directly. 
 
Potential participants will be pre-screened for this study. Available records may be reviewed to evaluate 
eligibility for this study. We anticipate the following documentation to be available for pre-screening 
review: demographic information, the ALS diagnosis category, medications, and comorbid medical 
conditions. We anticipate that some patients may have been screened for HIV and HTLV during their 
diagnostic workup for ALS and these results may be available during the pre-screening review.  
 
Potential participants who meet eligibility criteria based on the pre-screening review will be offered 
enrollment onto this study.  
 
4.3. Screening 
After signing on to the Blood Draw Only Consent, participants will undergo a venipuncture with removal 
of up to 20 ml of whole blood to check the HERV-K:RPP30 ratio.  Subjects may have research blood drawn 
as outpatients at the NIH’s CRC in Bethesda, MD or at an offsite location for convenience of the 
participant.  The offsite location will provide venipuncture as a fee-for-service and will not be considered 
an outside research institution. Tubes and pre-paid shipping materials would be provided if blood samples 
are being drawn locally and will be transported to the NIH Clinical Center lab of Dr. Avindra Nath, where 
an assay will be performed to measure the HERV-K:RPP30 ratio. This bloodwork will be done for research 
purposes only.  If blood is collected outside of NIH, the participant will be signed on to the Blood Draw 
Only Consent via telephone (See section 14.2 for the consenting process). If participant has had their 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
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HERV-K:RPP30 ratio measured as part of another study, those results may be used in place of this 
screening process. 
 
Participants who are still eligible after the results are available will sign the consent for the full study and 
complete their screening at NIH.  The screening visit will take place at a maximum of 24 weeks from the 
date of the screening HERV-K blood draw.  During the screening and enrollment visit, participants will 
review and sign the study consent before any procedures are performed.  Vital signs (blood pressure, 
pulse rate, temperature), height, and weight will be measured. A comprehensive medical history will be 
taken including details of medical illness, vaccinations, current medications, allergies, social and family 
histories, and participation in other research trials. Each participant will have a general and neurologic 
examination.  Prior neuroimaging will be reviewed.  Vital capacity and maximal inspiratory pressure will 
be measured with a handheld spirometer. Laboratory evaluations will include tests for research and safety 
labs as detailed in Section 4.5. The ALSFRS-R, ALSSQOL-R, optional ALS-CBS, lumbar puncture and 
neurophysiologic measurements will be completed. 
 
During times that participant participation in the Clinical Center is restricted or when participant travel to 
the Clinical Center is not safe, for example during times of pandemics, protocol screening and study visits 
will continue offsite.  The study team will use the most recent exam by the participant’s community 
neurologist as the baseline neurological exam, vital signs, and weight.  Safety and research labs as outlined 
in Section 4.5 may be collected offsite. The labs will be collected at a location that will provide 
venipuncture as a fee-for-service and will not be considered an outside research institution. NIH will cover 
the cost of the blood draw and laboratory tests. The study team will arrange a telehealth or telephone 
visit with the participant to get informed consent, a medical history, and administer the ALSFRS-R, 
ALSSQOL-R, and optional ALS-CBS. Participants that enroll offsite will continue the study offsite through 
Week 48.  Vital capacity, maximal inspiratory pressure, neurophysiologic measurements, lumbar puncture 
will be omitted for these participants.   
 
An assessment of all inclusion and exclusion criteria will be completed using an eligibility criteria and 
eligibility will be documented in the participant’s NIH Clinical Center chart.  
 
4.4. Study Visits 
Day 0 
The study medications will be prescribed by the NIH Clinical Center pharmacy.  These will be:  darunavir 
600 mg, ritonavir 100 mg, dolutegravir 50mg, and TAF 25 mg.  Darunavir and ritonavir will be taken twice 
daily.  Dolutegravir and TAF will be taken once daily.  No titration will be needed at the beginning of 
medication administration, and no tapering is needed at the end of medication administration. 
 
If participants are not local, the medications may be mailed to the participant once all screening studies 
have resulted. 
 
On-treatment phase 
Participants will have on-treatment phase visits at Weeks 1, 4, 8, 12, 16, 20 and 24. If the participant elects 
to not travel to NIH for their study visit for Weeks 1, 4, 8, 16, or 20, vital signs, weight, and physical exam 
will be omitted. Safety and research labs as outlined in Section 4.5 may be collected offsite and the study 
team will arrange a phone call with the participant to assess the interim history within the study visit 
window. The labs will be collected at a location that will provide venipuncture as a fee-for-service and will 

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
Protocol number:  15-N-0126 
Version:  13.0 
 
 
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not be considered an outside research institution. NIH will cover  the cost of the blood draw and laboratory 
tests. During the on-treatment phase, the following procedures will be conducted for NIH visits:  vital 
signs, weight, physical examination, and laboratory evaluations for safety monitoring and research as 
indicated in Section 4.5.  
 
At each on-treatment phase visit, participants will talk with a member of the NIH study team about 
adherence to study medications. Subjects will be asked about their health and the use of any concomitant 
medications since screening or the previous study visit.  They will also be asked if they are experiencing 
any AEs.  Subjects experiencing any AEs or potential toxicity may be evaluated during unscheduled study 
visits. 
 
At each NIH visit when participants are taking study drugs, participants will be asked to bring the study 
medications and empty study medication bottles.   
 
If participant is unable to travel for Weeks 12 and 24 safety and research labs as outlined in Section 4.5 
may be collected offsite and the study team will arrange a phone call with the participant to assess the 
interim history within the study visit window. The labs will be collected at a location that will provide 
venipuncture as a fee-for-service and will not be considered an outside research institution. NIH will cover 
the cost of the blood draw and laboratory tests. ALSFRS-R, ALSSQOL-R, ALS-CBS will be done as indicated 
in Section 4.5. Vital capacity, maximal inspiratory pressure, neurophysiologic measurements, lumbar 
puncture, and research urine will be omitted. This will only be done if participant is not able to travel or 
initially enrolled offsite in order for the study to meet its objectives. 
 
Final study medication visit 
The final study medication visit will be at Week 24 and will include:  vital capacity, maximal inspiratory 
pressure, ALSFRS-R, ALSSQOL-R, ALS-CBS, neurophysiologic measurements, lumbar puncture, and the 
Week 24 lab work if completed at NIH.  
 
If participant is unable to travel for the final study medication visit, safety and research labs as outlined in 
Section 4.5 may be collected offsite and the study team will arrange a telehealth or telephone visit with 
the participant to assess the interim history and administer the ALSFRS-R, ALSSQOL-R, and ALS-CBS as 
outlined in Section 4.5.  The labs will be collected at a location that will provide venipuncture as a fee-for-
service and will not be considered an outside research institution. NIH will cover the cost of the blood 
draw and laboratory tests. Vital capacity, maximal inspiratory pressure, neurophysiologic measurements, 
lumbar puncture, and research urine will be omitted if participant is unable to travel to NIH or initially 
enrolled offsite. 
 
The final study medication visit procedures may be completed over multiple days for participant 
convenience. Subjects will return any unused medications. 
 
Follow-up and Final Study Visits 
The Week 28 visit will include ALSFRS-R and blood collection for research.  This visit may be done either 
at the Clinical Center or offsite. 
Participants will return to clinic at Week 36 for an additional visit after medication administration is 
completed for comprehensive evaluations detailed in Section 4.5.  The Week 36 visit will include vital 
signs, weight, medical history, physical examination, vital capacity, maximal inspiratory pressure,  ALSFRS-

PI name:  Avindra Nath 
 
Date:  July 13, 2021 
 
 
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R, neurophysiologic measurements, and laboratory evaluations for safety and research as indicated in 
Section 4.5. 
 
If participant is unable to travel for the Week 36, safety and research labs as outlined in Section 4.5 may 
be collected offsite. The labs will be collected at a location that will provide venipuncture as a fee-for-
service and will not be considered an outside research institution. NIH will cover the cost of the blood 
draw and laboratory tests. The study team will arrange a telehealth or telephone visit with the participant 
to assess the interim history and administer the ALSFRS-R.  Vital capacity, maximal inspiratory pressure, 
neurophysiologic measurements will be omitted if participant is unable to travel to NIH or initially enrolled 
offsite. 
 
Week 48, the final study visit, will include an optional ALSFRS-R assessment completed by telephone. 
 
The window periods for the visit schedules are as follows: 
 
 
 
- Day 0 (no window) 
 
 
 
- Week 1 (+/- 3 days) 
 
 
 
- Weeks 4, 8, 12, 16, 20, 24 (+/- 7 days) 
 
 
 
- Week 28, 36, 48 (+/- 10 days) 
 
Recontact of Subjects After Week 48 
Follow up visits after Week 48 may be allowed to follow participants clinically for evaluation and/or 
resolution of AEs. 
 
4.5. Research Procedures 
History and Physical 
All participants who appear to be eligible based on the screening assessments and laboratory test results 
will undergo a physical exam and have their medical history collected to determine their eligibility for the 
study. In addition, participants will have physical exams performed at NIH visits on weeks 1, 4, 8, 12, 16, 
20, 24, and 36. For offsite visits, the participant’s interval history will be assessed over the phone.  A 
targeted clinical physical exam will be performed for individuals as necessary to evaluate AEs.  
 
Drug Accountability and Compliance 
At each NIH visit when participants are taking study drugs (Weeks 1-24), participants will be asked to bring 
the study medications and empty study medication bottles.  Participants and caregivers will be asked 
about compliance with the study drug schedule at each study visit.   
 
Specimen Collection 
a) Acute care, hepatic and mineral panels, and CBC with differential will be performed to monitor 
clinical status, document drug-related benefits, and detect any potential drug-related toxicities. These 
tests will be carried out during screening and every subsequent study visit. 
 
b) Creatine Kinase, Amylase, and Lipase 
These parameters will be measured at screening and at weeks 1, 12, 24, and 36. 
 
c) Hemoglobin A1c, Fasting Lipid Profile, and Urinalysis 
These parameters will be measured at screening and at weeks 12, 24, and 36. 

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d) HIV and HTLV Testing 
HIV and HTLV antibodies will be measured by blood draw at screening. Previous HIV and HTLV testing 
results from within one year of the screening visit are acceptable. 
 
e) Hepatitis B and C Testing 
These parameters will be measured at the screening visit. 
 
f) Serum/Urine Pregnancy Test 
The pregnancy test will be measured by a standard assay at every scheduled study visit for women of 
childbearing potential. 
 
g) Research Samples  
Research blood and HERV-K:RPP30 ratios will be collected at screening, unless collected as part of another 
study, and every subsequent study visit.  HERV-K:RPP30 ratios will be measured by quantitative PCR in the 
laboratory of Dr. Avindra Nath.  Levels of urine p75ECD will be measured from research urine collected at 
screening and Weeks 12, 24, 28, and 36 if the participant is seen at the Clinical Center. 
 
h) ALS genetics panel 
 If the participant is able to come to the Clinical Center, somatic mutation analysis will be 
performed.  Whole exome and/or whole genome sequencing including testing for hexanucleotide repeat 
expansion in C9ORF72 will be performed in the laboratory of Dr. Bryan Traynor or a CLIA certified 
laboratory at the participants first study visit at the Clinical Center. 
 
 
i) 
PT, PTT 
These parameters will be measured at the screening visit. 
 
Nerve conduction studies (NCS) and Electromyography (EMG) (Optional) 
NCS and EMG are standard diagnostic tests that have been used for many decades to diagnose disorders 
of muscle, nerves, and nerve roots.  Nerve conduction studies are performed using an electrical stimulator 
to activate the nerve and recording the nerve response in wire leads taped to the skin.  Needle EMG is 
performed by using a specialized EMG needle to record electrical signals within the muscle. It will be an 
optional procedure at screening that may be performed for questions of ALS diagnosis by the neurologist 
performing the neurophysiology evaluation. 
 
Muscle ultrasound (Optional) 
Muscle ultrasound is performed to gain a better understanding of the muscle architecture and pathology.  
The test is performed by placing an ultrasound probe covered with ultrasound gel on the skin.  An image 
of the muscle or nerve can be seen and evaluated. Muscle ultrasound may be done in select cases.   It will 
be an optional procedure at screening that may be performed for questions of ALS diagnosis by the 
neurologist performing the neurophysiology evaluation. 
 
Electrical impedance myography (EIM) 
EIM is a device (Myolex, Inc) that uses a high frequency, low intensity electrical current via a surface 
electrode to measure the consequent voltage.  This produces measurements of resistance, reactance and 
a calculated phase angle.  This is used to follow muscle pathology but is not a diagnostic test. It will be 

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measured at screening and weeks 12, 24, and 36 if the participant is seen at the Clinical Center.  The 
quantitative data generated from the EIM will be used as an exploratory outcome measure. 
 
Vital Capacity and Maximal Inspiratory Pressure 
Forced Vital Capacity (FVC) and maximal inspiratory pressure (MIP) will be measured. The FVC and MIP 
will be calculated as the percentage of the predicted vital capacity for a participant’s height, gender, and 
age. The FVC and MIP will be completed at screening and weeks 12, 24, and 36 if the participant is seen 
at the Clinical Center. 
 
Questionnaires 
a) ALSFRS-R 
The ALSFRS-R is a validated, reproducible, and reliable functional measure that assesses participant 
function across four domains: bulbar, fine motor, gross motor, and respiratory. It can be performed both 
in person and by telephone and is highly correlated with survival. The ALSFRS-R takes approximately 5 
minutes to complete and will be measured at screening and weeks 12, 24, 28, 36, and optionally at week 
48. 
 
b) ALSSQOL-R 
The Amyotrophic Lateral Sclerosis Specific Quality of Life Instrument-Revised (ALSSQOL-R) is a 50-item 
inventory that measures overall quality of life and six specific domains for patients with ALS. The test is 
completed by the patient with ALS and takes approximately 15-20 minutes to complete and will be 
completed at screening and week 24. 
 
c) ALS-CBS   
The Amyotrophic Lateral Sclerosis Cognitive Behavioral Screen is a validated screening tool that attempts 
to identify ALS patients at risk for cognitive and/or behavioral impairment by evaluating four areas: 
initiation and retrieval, concentration, attention, and tracking-monitoring. The questionnaire will take 
approximately 5 minutes to complete.  It will be an optional measurement at screening and week 24.  
 
Lumbar puncture 
A lumbar puncture will be completed during the screening evaluations as well as within the time frame of 
the Week 24 visit if the participant is seen at the Clinical Center.  The procedure may be completed under 
fluoroscopy or at bedside.  Up to 30 cc of CSF will be collected with each LP.  CSF tests will include cell 
count, glucose, and protein, and research specimens will be stored for future testing (for example, 
neurofilament levels). 
 
4.6. End of Participation 
Participants will continue care with their providers after this study.   
 
Early Termination Visit 
Participants requiring discontinuation as well as those who elect to discontinue study drugs prior to 
treatment completion for medical or personal reasons should have an end of treatment visit scheduled 
as soon as possible after study drugs are discontinued.  Additionally, participants will be given the option 
of being followed as outlined in Section 4.5 for safety or research labs until the end of the participant’s 
planned final study visit.  
 

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Any participant who chooses to be followed after discontinuation of study drugs will be followed closely 
for resolution of active laboratory abnormalities or AEs which are considered related to the study agents.  
Participants who discontinue treatment early and opt not to be followed will be removed from the study 
after it is deemed safe to do so (i.e., abnormal test results return to a safe range). 
 
Sharing of Information with Participants 
Results of genetic testing will not be disclosed to participants unless it may have a direct medical or 
reproductive implication for the participant or family.  In that case, genetic counseling will be provided to 
participants to discuss these implications in more detail. 
 
Results of other procedures will be shared with the participant and with the participant’s ALS physician if 
follow up is necessary.  Should there be a clinical need to communicate urgently with the participant or 
his/her physician, this will be pursued via telephone communication in addition to the written 
communication. 
5. Management of Data and Samples 
5.1. Storage 
All collected samples, including blood, urine, and CSF will be coded and stored in secured freezers on the 
NIH campus. NIH samples will be transferred and retained at the end of the study under a repository 
protocol after the appropriate IRB approval is received.  Only study investigators will have access to the 
stored samples and data.  Any loss or destruction of samples will be reported to the IRB. 
5.2. Data 
 This protocol is not subject to the Genomic Data Sharing (GDS) policy. It does not generate “large-scale” 
human genomic data as defined in the NIH Supplemental Information to the GDS Policy. 
Data and samples may be shared with collaborating laboratories at NIH or outside of NIH and/or 
submitted to NIH-designated repositories and databases if consent for sharing was obtained in the original 
consent form. 
 
Samples and data will be stripped of identifiers and may be coded (“de-identified”) or unlinked from an 
identifying code (“anonymized”). When coded data is shared, the key to the code will not be provided to 
collaborators but will remain at NIH.  Data and samples may be shared with investigators and institutions 
with an FWA or operating under the Declaration of Helsinki (DoH) and reported at the time of continuing 
review.  Sharing with investigators without an FWA or not operating under the DoH will be submitted for 
prospective IRB approval.  Submissions to NIH-sponsored or supported databases and repositories will be 
reported at the time of Continuing Review.  Submission to non-NIH sponsored or supported databases 
and repositories will be submitted for prospective IRB approval. 
 
Required approvals from the collaborating institution will be obtained and materials will be shipped in 
accordance with NIH and federal regulations. 
6. Additional Considerations 
6.1. Research with investigational drugs or devices 
This protocol is a clinical investigation of drug products that are lawfully marketed in the United States 
and are exempt from the requirements of IND as described in 21 CFR 312.2(b). The investigation is not 

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intended to be reported to FDA as a well-controlled study in support of a new indication for use nor 
intended to be used to support any other significant change in the labeling for the drugs; the drugs that 
are undergoing investigation, are lawfully marketed as a prescription drug products; the investigation is 
not intended to support a significant change in the advertising for the product; the investigation does not 
involve a route of administration or dosage level or use in a patient population or other factor that 
significantly increases the risks (or decreases the acceptability of the risks) associated with the use of these 
drug products; the investigation is conducted in compliance with the requirements for 
institutional review set forth in part 56 and with the requirements for informed consent set forth in part 
50; and the investigation is conducted in compliance with the requirements of 312.7. 
 
6.2. Gene Therapy 
This protocol does not involve gene therapy. 
7. Risks and Discomforts 
Risks associated with use of darunavir 
Based on clinical trials,33 the most commonly reported adverse drug reactions with darunavir in 
combination with ritonavir are:  diarrhea (16%), nausea (7%), headache (6%), and abdominal pain (6%).  
Drug-induced hepatitis was reported with darunavir at a rate of 0.5% of patients receiving combination 
darunavir + ritonavir; pre-existing liver dysfunction is a risk factor. Severe skin reactions were reported in 
0.4% of patients in clinical trials receiving darunavir (Stevens-Johnson Syndrome was diagnosed in 0.1% 
of cases). Rash of mild-to-moderate severity occurred in 10.3% of participants with a discontinuation rate 
of 0.5%. 
 
Darunavir has a sulfonamide moiety and must be used with caution in patients with a known sulfonamide 
allergy; the incidence and severity of rash were similar in participants with and without a history of 
sulfonamide allergy. 
 
Other rare, serious side effects include increased bleeding in patients with hemophilia, diabetes 
mellitus/hyperglycemia, and increased cholesterol. 
 
In a clinical trial of darunavir versus lopinavir (both combined with ritonavir, emtricitabine, and tenofovir), 
5% of participants discontinued darunavir because of AE or death in comparison with 13% of subjects 
discontinuing lopinavir. 
 
Risks associated with use of dolutegravir 
Based on clinical trials,30 the most commonly-reported adverse drug symptoms with dolutegravir are:  
insomnia (3%), headache (2%), and fatigue (2%). The most commonly-reported adverse drug-related 
laboratory abnormalities are: elevated CK (7%), increased lipase (7%), increased liver function tests (4-
5%), hyperglycemia (6%), increased bilirubin (3%), and neutropenia (4%). 
 
The most serious complications associated with dolutegravir are potentially life-threatening and fatal skin 
reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis.  Patients with underlying 
hepatitis B or C may have worsening development of transaminase elevations.  
 
Other rare (<2%) significant side effects include: abdominal pain and discomfort, myositis, pruritic, 
hepatitis, renal impairment, and suicidal ideation/behavior. 

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In a clinical trial of dolutegravir versus efavirenz (both combined with emtricitabine and tenofovir), 4% of 
participants discontinued dolutegravir because of AE or death compared with 14% of subjects 
discontinuing efavirenz. 
 
Risks associated with use of ritonavir 
Note: The dose of ritonavir used for clinical trials as monotherapy is 600 mg twice daily.  The dose used 
for this study is 100 mg twice daily.  Potential risks are presented here for the full dose because the risks 
for the 100 mg dose are described in clinical trial information together with the other protease inhibitors 
with which it is always prescribed (i.e., the risks of darunavir include the risk of ritonavir). 
 
Potentially fatal skin reactions have occurred with ritonavir.34  Pancreatitis has occurred that was life-
threatening and fatalities were reported.  PR interval prolongation with 2nd and 3rd degree heart blocks 
have occurred.  Hepatic reactions included significant elevations in liver function tests (>5x ULN) and 
hepatitis, with pre-existing liver disease being a risk factor. 
 
Other rare (<2%) significant side effects include: diabetes mellitus/hyperglycemia, fat redistribution, 
myopathy and abnormal bleeding in patients with hemophilia. 
 
Common (>5%) side effects with ritonavir include diarrhea (68%), nausea (57%), fatigue (46%), vomiting 
(32%), abdominal pain (26%), arthralgia (18%), dizziness (15%), elevated triglycerides (9%), myalgia (9%), 
flatulence (8%), urticaria (8%), elevated liver function tests (8%), blurred vision (6%), and edema (6%). 
 
Risks associated with TAF 
Most common adverse reactions (incidence ≥5%; all grades) were headache, abdominal pain, fatigue, 
cough, nausea and back pain. Cases of acute renal failure and Fanconi syndrome have been reported with 
the use of tenofovir prodrugs. Tenofovir but not TAF has been associated with rare cases of lactic acidosis 
and hepatotoxicity with steatosis. 
 
Risks of medication interactions with the study drugs 
The study drugs, particularly the protease inhibitors, have the potential for significant interactions with a 
number 
of 
medications. 
 
A 
list 
of 
significant 
interactions 
is 
found 
at:  
http://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf.  The document contains 
tables for drug-drug interactions with the protease inhibitors darunavir and ritonavir, reverse 
transcriptase inhibitor tenofovir, and the integrase inhibitor dolutegravir.  
 
Risks of blood draw 
There may be some discomfort and bruising at the site of venipuncture. There is a very small risk of 
fainting. Infection in the area of needle entry is rare. 
 
Risks of Nerve conduction studies (optional) 
The risks of the electrical stimulation using commercial isolated stimulators are low. Most subjects find 
electrical nerve shocks to be mildly uncomfortable; it is usually perceived as a brief stinging or tapping 
sensation. The intensities required for nerve conduction studies are usually well tolerated. Risk is 
minimized by using the lowest intensity possible to obtain the nerve response. 
 
Risks of Electromyography (optional) 

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The risks of EMG are low, and consist of local discomfort, bleeding and bruising at the site of needle 
insertion. Needle puncture carries a small risk of infection. Sterile needles are used to minimize this risk. 
 
Risks of Nerve and muscle ultrasonography (optional) 
There are no known medical risks and minimal discomfort associated with this test. 
 
Risks of Electrical Impedance Myography 
EIM device is placed on the muscle and a high frequency current is delivered to the skin. There is no 
sensation related to the application of the high frequency impulse.  The only discomforts would be 
pressure of placing the EIM on the skin. 
 
Risks of vital capacity and maximal inspiratory pressure testing  
There is minimal risk associated with vital capacity and maximal inspiratory pressure testing.  Participants 
may feel short of breath or lightheaded during testing. 
 
Risks of ALS questionnaires (ALSFRS-R, ALSQOL-R, ALS-CBS)  
Some patients may feel frustrated or stressed when answering questions.  There are no other risks with 
the questionnaires. 
 
Risks of lumbar puncture 
Subjects may experience a brief pain or tingling sensation in their legs during the procedure if the needle 
brushes against a nerve. If this happens, the needle will be adjusted. Following the LP, some people have 
a mild backache at the site of needle insertion. About one-third of people have a headache for a few days 
following the procedure. Usually the headache is not severe and improves without treatment other than 
mild pain relievers. Headaches lasting longer than seven days develop in 1 in 50 to 200 LPs and usually 
improve gradually over two weeks. In rare cases, headaches have persisted longer. Prolonged headaches 
may be due to persistent leakage of CSF from the area of the LP and may require a “blood patch.” For a 
blood patch, venous blood will be removed from the patient and then injected into the area of the back 
where the lumbar puncture was performed to seal off the CSF leak. We will not perform an LP if 
neuroimaging suggests that the patient is at increased risk of herniation. If the LP is done under 
fluoroscopy, there is also a small amount of radiation exposure. Conscious sedation is associated with a 
small risk of respiratory depression and an even smaller risk of cardiac arrhythmias. Patients will be 
monitored closely for possible side effects and treated with medications or intubation, if necessary. The 
LP will be performed by trained clinicians and every precaution will be taken to minimize the risks 
associated with this procedure. Lumbar puncture may be done in the radiology department under 
fluoroscopic guidance for patient medical or scheduling needs. The radiation exposure during this study 
is 0.049 rem, which is well below the guideline of 5 rem per year allowed for research subjects by the NIH 
Radiation Safety Committee. 
 
Risks of genetic testing 
Genetic testing can provide information about how illness is passed on within a family. This knowledge 
may affect participants’ emotional wellbeing. They might feel differently about their life if they learned 
that they or their children were at increased risk of a disease, especially if there were no treatments. Their 
children, brothers or sisters may find out that they are at risk for health problems because of information 
found out about the participants, which might affect the participants’ relationships with family members.  
Other family members may also be affected by uncovering risks they have but did not want to know about. 
This information can cause stress, anxiety, or depression.   

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Some genetic testing can also determine if people are directly related. These tests sometimes show that 
people were adopted or that their biological parent is someone other than their legal parent. If these facts 
were not known previously, they could be troubling.  Genetic counseling is available at the NIH to help 
participants understand the nature and implications of genetic findings. 
 
Because of the emotional risk, some participants do not want to know the results of genetic testing. It is 
our policy to not disclose the results of genetic testing unless it may have direct medical or reproductive 
implications for participants or the participants’ families. 
 
Results of genetic testing will not be shared with participants unless they have direct implications for 
participants’ health (are clinically actionable). Participants will be contacted if a clinically actionable gene 
variant is discovered. Clinically actionable findings for the purpose of this study are defined as disorders 
appearing in the American College of Medical Genetics and Genomics recommendations for the return of 
incidental findings that is current at the time of primary analysis. If participants state that they would like 
to obtain the results, confirmatory testing will be conducted at a CLIA-certified laboratory either at NIH or 
elsewhere which will be paid for by the IC. If the research finding is verified by the CLIA-certified 
laboratory, the participant will be offered the opportunity to receive genetic counseling from an NIH 
genetic counselor (at our expense) to explain the results. Participants have the option to receive a referral 
to a local genetic healthcare provider (at their expense). This is the only time during the course of the 
study that incidental findings will be returned. No interrogations regarding clinically actionable findings 
will be made after the primary analysis. 
 
Genetic information will be kept confidential to the extent possible. The results of genetic testing will be 
kept in a locked and secured manner at the NIH.    
 
Problems, such as with insurance or employment discrimination, may occur if they disclose information 
about themselves or agree to have their research records released.  We will not release any information 
about participants to any physician, insurance company or employer unless they sign a document allowing 
release of the information. 
8. Subject Safety Monitoring 
The Principal Investigator (PI) and study personnel will be responsible for monitoring individual subjects 
during participation in study procedures. 
 
Parameters to be monitored 
Previous experience demonstrated a low human toxicity profile for darunavir, ritonavir, dolutegravir, and 
TAF. The most frequently and consistently experienced adverse reactions reported are headache, 
insomnia, abdominal pain or cramping, hyperglycemia, increased amylase and lipase, abnormalities in 
liver function tests and elevated CK levels. Hematologic abnormalities such as decreased absolute 
neutrophil count and thrombocytopenia are also expected adverse events.  
 
In particular, given the rare risk of severe skin and hypersensitivity reactions (Stevens-Johnson syndrome 
and toxic epidermal necrolysis; rash with fever, fatigue, malaise, conjunctivitis or other constitutional 
symptoms), the patient will be instructed to immediately discontinue all the study medications and 
contact the study investigators should a severe skin reaction or hypersensitivity symptoms occur. 

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Additionally, female participants will be instructed to contact the investigator immediately if she believes 
that she is pregnant. Testing will be performed to verify that the participant is pregnant. If the pregnancy 
test is positive, the participant would be instructed to immediately stop taking the study drug. 
 
Medical events typical for the clinical course of ALS (i.e., typical neurological signs/symptoms that a 
patient experienced during pre-treatment baseline and their worsening as would be expected from the 
natural history of ALS) can be regarded as expected events in the course of the current trial.  
Because the clinical course of ALS is known to be a steady decline in neurologic and respiratory function, 
we expect participants to have certain ALS-specific events that will not be attributed to study drugs.  
Examples of these events include: 
1. Increased motor weakness, either defined by changes in neurophysiological measurements, 
by participant’s self report, or by physical examination.  Careful attention to the pattern of 
weakness will be important because ALS causes both upper and lower motor neuron patterns 
of weakness.   
2. Dyspnea.  Dyspnea is a known complication of ALS and may be noted by a decline in vital 
capacity or participant’s self report.   
3. Dysphagia.  Dysphagia is also a known complication of ALS and is typically reported by 
patients.  Dysphagia may be noticed because of the pill burden during study drug 
administration.  Participants who may not be able to tolerate the pill burden may opt for 
alternative study drug administration methods as described in Table 4. 
4. Cognitive changes.  10-15% of patients with ALS reach criteria for frontotemporal dementia 
at some point in their disease course.35  Milder forms of cognitive impairment may develop 
during the course of the study.  If cognitive impairment progresses to the point that the 
participant would not be able to safely remain in the study or would not be able to continue 
to provide informed consent, the participant may be removed from the study. 
 
The participants will be instructed to contact the study investigators and/or seek medical care if they have 
any questions or concerns. Participants will be instructed to contact the investigator immediately should 
they manifest any new signs or symptoms or change in their condition during the period extending from 
the time of consent up to and including the final study visit at Week 36. After this period of time, 
participants should report to the investigator only AEs they perceive as possibly related to their 
participation in this study.  
 
Definitions of AEs and SAEs and assessments of AE severity and causality are listed in Appendix A. 
 
Laboratory monitoring will occur according to the schedule described in Section 4.5. In the event of 
unexplained clinically significant abnormal laboratory test values, the tests should be repeated 
immediately and followed up until they have returned to the normal range and/or an adequate 
explanation of the abnormality is found.  If a clear explanation is established it should be recorded. 
 
Toxicity tables/ criteria to be used 
The Investigator will grade the severity of each AE according to the “Division of Aids Table for Grading the 
Severity of Adult and Pediatric Adverse Events” Version 2.1, July 2017 which can be found at:  
http://rsc.tech-
res.com/Document/safetyandpharmacovigilance/Table_for_Grading_Severity_of_Adult_Pediatric_Adve
rse_Events.pdf  

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Some grade 1 lab parameters on the DAIDS Toxicity Table [Fibrinogen, Calcium (low), Phosphate (low), 
Uric Acid (males only, elevated)] fall within the NIH lab reference range for normal values. These normal 
values will not be reported as grade 1 adverse events. The grade 1 values for these tests will be reported 
as follows: 
 
• 
Fibrinogen: 100 - 176 mg/dL 
• 
Phosphate (low): There is no grade 1 reportable value  
• 
Calcium (low): 1.95 - 2.04 mmol/L 
• 
Uric Acid (males): 8.7 – 10.0 mg/dL  
 
Criteria for stopping procedures in an individual 
A participant must permanently discontinue study drug treatment for any of the following reasons: 
 
1. The participant becomes pregnant (pregnancy test will be performed for female patients with 
child bearing potential during each study visit as indicated in Section 4.5). If a patient becomes 
pregnant, treatment must be immediately discontinued. The pregnancy must be reported to 
the IRB immediately. Information about the participant, the participant’s pregnancy, and the 
outcome of the pregnancy will also be collected. 
2. The participant desires to discontinue study drug treatment under this protocol.  
3. If the participant develops a severe skin or hypersensitivity reaction to a study drug(s) he will 
be instructed to immediately discontinue all study drugs and contact the study investigators 
who will coordinate the management. 
4. Laboratory safety criteria may be used as a stopping criterion when the abnormal laboratory 
result continues after one week of cessation of study drugs.  Participants may resume the 
study drugs if the laboratory abnormality resolves within one week.   
a. ALT, AST, amylase, or lipase more than three times the upper limit of normal. 
b. Hemoglobin reduction of >25% of baseline value or Hemoglobin <7.5mg/dl. 
c. Absolute granulocyte count reduction of >50% of baseline value or absolute granulocyte 
count of <1000 cells/mm3 
d. Any other highly abnormal laboratory finding that is deemed critical by an investigator. 
5. The participant has greater than 30% weight loss compared to weight at baseline. 
6. The participant has rapid muscle weakness beyond what is expected for the natural course of 
ALS.  
 
There will be no dose reductions in the study drugs due to intolerance or toxicity, and all four study drugs 
will be held/discontinued even if the AE is likely attributable to only one study drug. 
 
The reasons for discontinuation of the study drugs must be recorded in the participant’s Clinical Center 
patient file. If discontinuation was because of an AE, the patient will be followed until the event is resolved 
or stabilized. If the discontinuation was because of pregnancy, the participant will be followed until after 
the birth. 
 
Criteria for individual subject withdrawal from the study 
Participants have the right to withdraw from the study at any time and for any reason. The investigator 
also has the right to withdraw participants from the study in the event of an intercurrent illness, AEs, 
treatment failure, protocol violations, administrative reasons, or other reasons.  

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9. Outcome Measures 
9.1. Primary outcome measures 
The primary outcome measure will be the percent decline in blood HERV-K concentration measured by 
quantitative PCR.  Percent decline for a patient is measured by: 100 x (screening visit – week 24 visit 
measurement) / screening visit. 
 
9.2. Secondary outcome measures 
1. The safety of antiretrovirals in volunteers with ALS as measured by the frequency and type of AEs, 
the ability to remain on assigned treatment (tolerability), physical examinations, laboratory test 
results, vital signs, and weight/body mass index (BMI). 
2. The percent decline in blood HERV-K concentration: 100% x (screening visit – week 24 visit 
measurement)/screening visit measurement.  
 
9.3. Exploratory outcome measures 
Efficacy will be explored by measuring the change in mean scores of: 
a. ALSFRS-R 
b. ALSSQOL-R 
c. ALS-CBS 
d. vital capacity and maximal inspiratory pressure 
e. EIM 
f. neurofilament levels. 
g. urine p75ECD 
 
Variability in HERV-K viral loads suppression with ART will be evaluated by genetic exome sequencing 
surveying mutations in specific genes or loci associated with ALS. 
10. Statistical Analysis 
10.1. Analysis of data/ study outcomes 
The design of this clinical trial is one-group pre-test and post-test design. Thus, each participant will have 
a pre-treatment measurement (screening) and a post-treatment measurement. 
 
Planned analyses 
A one-sample t-test with significance level of 0.05 will be used to test the null hypothesis: the Mean 
reduction percent is zero. For each patient, the reduction percent is calculated as 100 x (screening visit – 
week 24 visit measurement) / screening visit. The secondary and exploratory outcomes will be 
summarized using descriptive statistics without conducting statistical inference. 
 
Analysis cohorts 
Suppression analysis data set.  The analysis set for antiviral activity analyses will include participants who 
were enrolled into the study and received at least 24 weeks of study drug. 
 
Safety analysis data set. The analysis set for safety analyses will include participants who received at least 
one dose of study drugs. 

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Efficacy analysis data set. The analysis set for efficacy analyses will include participants who received at 
least 24 weeks of study drug.  Efficacy analyses will be limited to descriptions of any changes that may 
occur in results of:  vital capacity, maximal inspiratory pressure, ALSFRS-R, ALSSQOL-R, ALS-CBS, EIM, and 
neurofilament levels or urine p75 levels.   
 
Missing data plan 
Missing data can impact interpretation of the study data. Values for missing data will not be imputed.  Any 
participant with missing data due to premature discontinuation of the study drugs (see Section 10.5 
below) will be considered a failure at the time points on, or following, the date of discontinuation.  
 
Where appropriate, safety data for participants not completing the study will be included in summary 
statistics. For example, if a participant received study drugs, the participant will be included in a summary 
of adverse event.  If safety laboratory results for a participant are missing for any reason at a time point, 
the participant will be excluded from the calculation of summary statistics for that time point. If the 
participant is missing a pre-dose value, then the participant will be excluded from the calculation of 
summary statistics for the pre-dose value and the change from pre-dose values. 
 
10.2. Power analysis 
Accrual number request 
Sample size:   
Pilot data on ARV in ALS patients indicates that in those patients with greater than 1000 HERV-K copies 
per ml serum at screening (n=5), there is an average percent decline in serum concentration of 38% with 
a standard deviation of 50%. Only individuals with greater than 1000 copies per ml at screening will be 
recruited into the current study. The average percent decline of 38% is close to the estimated minimally 
biologically meaningful percent decline of 50%.  
 
To calculate the number of subjects needed, we will power using an inflated standard deviation, due to 
the issues with using standard deviation from a small pilot to power a study. Browne (1995) indicates that 
using an 80% percent UCL on standard deviation will provide a sample size sufficient to achieve planned 
power in at least 80% percent of trials, and we will use that adjustment here.36 Therefore, the resulting 
conservative standard deviation is 76%. We estimated that untreated, these individuals will have a 0% 
decline from baseline.  
 
Achieving 85% power for this test using our minimally relevant difference of 50% decline and SD of 76% 
would require data from 23 subjects. 20 subjects would allow us to detect a decline of 54% (Table 6). 
 
Table 6. One-sample two-sided t-test power calculations 
Effect 
Size 
(Percent Decline) 
Standard  
Deviation 
Alpha 
Power 
N 
50% 
76% 
0.05 
0.85 
23 
54% 
76% 
0.05 
0.85 
20 
 
We anticipate screening 200 subjects in order to obtain 20 participants who meet eligibility criteria.  This 
will include participants who begin study drug and who discontinue study drugs without the meeting the 

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primary outcome before Week 24 (and who will be replaced) and subjects who are screened but do not 
enroll in the treatment phase of the study. 
 
Dropouts 
Participants who withdraw voluntarily (not due to toxicity or meeting the primary outcome) after 
initiation of the study but before week 24 will be considered dropouts. These participants should have a 
follow-up visit as close as possible to the date of the last dose of the study.  These participants will be 
given the option of being followed as outlined in Section 4.5 for safety or research labs until the end of 
the participant’s planned final study visit.  
 
Patients who voluntarily stop study drugs before 24 weeks will be considered non-completers.  They will 
have the option to remain in the study and continue the protocol-specific evaluations.  
11. Human Subjects Protection 
11.1. Subject selection 
The investigational nature and objectives of this trial, the procedures and treatments involved, as well as 
the attendant risks, discomforts, and potential benefits will be carefully explained to the patient. A signed 
consent form will be obtained by the PI or an associate investigator. It will be carefully explained to 
patients that they may withdraw from the study at any time, for any reason. 
 
All adult ALS patients fulfilling all inclusion criteria and for whom none of the exclusion criteria are 
applicable, irrespective of gender or race, are included in the trial. Patients 18 years and older will be 
included in the trial as long as they are willing and able to comply with all the aspects of testing and 
treatment.  
 
11.2. Justification for the exclusion of children 
Children less than 18 years old are excluded from the trial. Since ALS is exceptionally rare in the second 
decade, pediatric cases might not be representative of the typical pathophysiology of the condition.  
 
11.3. Justification for the exclusion of those who lack consent capacity  
Due to the complex nature of this clinical trial, and the off-label use of the study medications, those who 
are cannot provide informed consent will not be allowed to participate in this trial.  
 
11.4. Justification for sensitive procedures 
Genetic testing will be completed as part of this protocol. Approximately 40% of familial ALS and 10% of 
sporadic ALS cases are associated with a known genetic mutation. It is likely that other genetic mutations 
account for even larger percentages of familial and sporadic ALS cases. Patients with a C9ORF72 mutation 
are more likely to have associated frontotemporal dementia; however, there are few other phenotypic 
differences between cases with genetic mutations. Therefore, it will be difficult to look for genetic 
differences that could account for the variability in suppression of the HERV-K RNA without assessing for 
the known genetic mutations. 
 
11.5.  Safeguards for vulnerable populations and sensitive procedures 

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Because there are no adequate and well-controlled studies in pregnant women for darunavir, 
dolutegravir, and TAF, participants able to become pregnant will be required to use appropriate methods 
of contraception for the trial duration and all participants able to become pregnant will be evaluated with 
a pregnancy test at each study visit. Male participants will not be required to use contraception during 
the study.  Women 55 and over who have not had a period for one year will be considered menopausal 
and will not need pregnancy testing or contraception. Women under age 55 will undergo pregnancy 
testing and will be required to use appropriate methods of contraception for the trial duration, unless 
there is a history of hysterectomy, bilateral oophorectomy, or medically-documented ovarian failure. 
Adequate methods of contraception include:  implanted contraception, intrauterine device in place for at 
least 3 months, or barrier method in conjunction with spermicide. Women of childbearing potential must 
have a negative pregnancy test at screening and be non-lactating. 
12. Anticipated Benefit 
There is no expected direct benefit to participants in this study.  The study will likely yield generalizable 
knowledge about how antiretroviral medications affect HERV-K levels in a specific subset of patients with 
ALS. 
13. Consent Documents and Process 
13.1. Consent procedures  
All participants will receive a verbal explanation in terms suited to their comprehension of the purposes, 
procedures and potential risks of the study and of their rights as research participants. Participants will 
have the opportunity to carefully review both of the written consent forms and ask questions regarding 
this study prior to signing.  
 
13.1.1. 
Telephone Consent 
Telephone or telehealth consent may be done for participants having the screening blood collected 
outside of NIH or for continued enrollment onto the Standard Consent when participant participation at 
the Clinical Center is restricted.  
 
For participants having the screening blood collected outside of NIH, the participant will be provided with 
a cover letter (Appendix B) and a copy of the Blood Draw Only Consent form.  The study team will also 
send a copy of the Standard Consent form without the signature page as a reference to the rest of the 
study if the participant qualifies.  The Standard Consent form with signature page will be sent to 
participants continuing their enrollment but restricted from traveling to the Clinical Center to complete 
their screening visit.   
 
Once the consent forms are received, the study team will arrange for a telephone call or telehealth visit 
with an Investigator authorized to obtain consent and the participant to review the study and the consent 
form and to answer any questions.  Once the participant agrees to participate, the participant will sign 
and date their copy of the consent form.  The Investigator will document the consent process. The 
participant will return their signed copy to the Investigator.  Once the copy with the participant signature 
is received, the Investigator will sign and date the consent form and send a copy to the participant.  The 
telephone consent process will be documented. 
 
13.2. Consent documents 

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The Blood Draw Only and Standard consent forms contain all required elements.   The Blood Draw Only 
consent allows for only the screening blood draw from consenting participants.   
14. Data and Safety Monitoring 
14.1. Data and safety monitor 
This study will be monitored by an Independent Monitoring Committee (IMC).  The IMC will be Drs. Camilo 
Toro and Mary Wright.  Camilo Toro, MD is a neurologist with the Undiagnosed Diseases Network 
(National Human Genome Research Institute) who has extensive expertise in the evaluation of 
neuromuscular disorders including ALS.  Mary Wright, MD, MPH is an infectious diseases physician with 
National Institutes of Allergy and Infectious Diseases who has extensive experience with antiretroviral 
therapies.   
 
14.2. Data and safety monitoring plan  
The IMC will review the study prior to initiation, twice a year thereafter, and at the end of the study. The 
IMC may convene additional reviews as necessary.  The IMC will review the study data to evaluate the 
safety, study progress, and conduct of the study.  All serious adverse events and all unanticipated 
problems will be reported by the PI to the IMC at the same time they are submitted to the IRB.  The PI will 
notify the IMC at the time pausing criteria are met and obtain a recommendation concerning continuation, 
modification, or termination of the study.  The PI will submit the written IMC summary reports with 
recommendations to the IRB. 
 
14.3. Criteria for stopping the study or suspending enrollment or procedures 
Enrollment in the study will be halted if a study drug-related SAE occurs in more than one patient, or AEs 
at a higher frequency than expected based on the available data.  
15. Quality Assurance 
15.1. Quality assurance monitor 
The NINDS Quality Assurance (QA) Audit Committee will perform QA monitoring for this study. 
 
15.2. Quality assurance plan 
This protocol will undergo random review by the NINDS Quality Assurance (QA) Audit Committee as 
outlined in the NINDS QA Standard Operating Procedure.  The purpose of the QA audit is to assess 
compliance with applicable regulatory requirements, good clinical practice guidelines, NINDS/NIH 
policies, as well as to provide recommendations for improving the management of clinical research data.  
The protocol will be audited according to the decision algorithm as described in the NINDS SOP.  As such, 
this protocol is classified as “more than minimal risk” and thus will be audited with a target frequency of 
once during the first year following IRB approval, and then approximately every three years thereafter. 
16. Reporting of Unanticipated Problems, Adverse Events and Protocol 
Deviations 
Reportable events will be tracked and submitted to the IRB as outlined in Policy 801. 

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17. Alternatives to Participation 
This is not a treatment protocol and the only alternative is the off-label use of the study medications 
outside of the study. 
18. Privacy 
All research activities will be conducted in as private a setting as possible. 
19. Confidentiality 
Participant confidentiality and privacy is strictly held in trust by the participating investigators and the 
study team. This confidentiality is extended to cover testing of biological samples and genetic tests in 
addition to the clinical information relating to participants. Therefore, the study protocol, documentation, 
data, and all other information generated will be held in strict confidence.  
 
The study monitor, representatives of the Institutional Review Board (IRB), and/or regulatory agencies 
may inspect all documents and records required to be maintained by the investigator, including but not 
limited to, medical records (office, clinic, or hospital) and pharmacy records for the participants in this 
study. The clinical study site will permit access to such records. 
 
The study participant’s contact information will be securely stored at each clinical site for internal use 
during the study. At the end of the study, all records will continue to be kept in a secure location for as 
long a period as dictated by the reviewing IRB, Institutional policies, or sponsor requirements. 
 
To further protect the privacy of study participants, a Certificate of Confidentiality has been issued by the 
National Institutes of Health (NIH). This certificate protects identifiable research information from forced 
disclosure. It allows the investigator and others who have access to research records to refuse to disclose 
identifying information on research participation in any civil, criminal, administrative, legislative, or other 
proceeding, whether at the federal, state, or local level. By protecting researchers and institutions from 
being compelled to disclose information that would identify research participants, Certificates of 
Confidentiality help achieve the research objectives and promote participation in studies by helping 
assure confidentiality and privacy to participants. 
 
19.1. For research data and investigator medical records 
Each participant will receive a unique study ID number at the time of enrollment. A master list correlating 
the unique numbers with personal health information such as names, addresses, and contact information 
will exist but will only be accessible to investigators on this protocol in order to minimize the risk of 
compromising confidentiality. These data will be kept in password-protected computers on the NIH 
campus. 
19.2. For stored samples 
Data and samples will be stored in secured areas. Samples kept at NIH will be stored in a coded fashion in 
a locked room in the SINS lab.  
19.3. Special precautions 

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Samples and data will be stored using codes that we assign. Data will be kept in password-protected 
computers.  Samples will be kept in locked storage. Only study investigators will have access to the 
samples and data. 
 
19.4. For genetic samples 
Genetic samples will be stripped of identifiers and will be coded (“de-identified”) or unlinked from an 
identifying code (“anonymized”). Genetic samples will be stored in secured freezers on the NIH campus. 
Only study investigators will have access to the stored samples and data/results. Access to the “key” of 
the code is in password protected databases where access is limited to the study team. The Key will not 
be provided to collaborators or third parties but will remain at NIH.  The data/results of the genetic tests 
will not pose a high risk in the identification of participants or their families as the data will be coded. Any 
loss or destruction of samples will be reported to the IRB. Samples may be shared with collaborating 
laboratories at NIH or outside of NIH and/or submitted to NIH-designated repositories and databases if 
consent for sharing was obtained in the original consent form. See Section 5.2 Data for additional 
information regarding the sharing of genetic data. 
20. Conflict of Interest 
20.1. Distribution of NIH guidelines 
NIH guidelines on conflict-of-interest were distributed to all investigators.  
 
20.2. Conflict of interest  
There are no conflicts-of-interest to report. 
21. Technology Transfer 
Technology transfer agreement(s) for this protocol are described in the Data and Sample Sharing 
spreadsheet. See  Study Application in iRIS. 
22. Research and Travel Compensation  
Patients will not be compensated for their participation in this study. Participants will be reimbursed for 
travel and subsistence will be offered consistent with NIH guidelines. Participants will not receive financial 
compensation from any commercial product developed from this research. 
23. References 
1. 
Prevalence of Amyotrophic Lateral Sclerosis—United States, 2010–2011.  CDC Website.  
http://www.cdc.gov/mmwr/pdf/ss/ss6307.pdf.  Updated July 25, 2014.  Accessed August 
29, 2014. 
2. 
Lilienfeld DE, Chan E, Ehland J, et al. Rising mortality from motoneuron disease in the 
USA, 1962-84. Lancet. 1989;1(8640):710-713. 
3. 
Bensimon G, Lacomblez L, Meininger V. A controlled trial of riluzole in amyotrophic 
lateral sclerosis. ALS/Riluzole Study Group. N Engl J Med. 1994;330(9):585-591. 
4. 
Cudkowicz M, Qureshi M, Shefner J. Measures and markers in amyotrophic lateral 
sclerosis. NeuroRx. 2004;1(2):273-283. 

PI name:  Avindra Nath 
 
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5. 
Corcia P, Pradat PF, Salachas F, et al. Causes of death in a post-mortem series of ALS 
patients. Amyotroph Lateral Scler. 2008;9(1):59-62. 
6. 
Lattante S, Conte A, Zollino M, et al. Contribution of major amyotrophic lateral sclerosis 
genes to the etiology of sporadic disease. Neurology. 2012;79(1):66-72. 
7. 
DeJesus-Hernandez M, Mackenzie IR, Boeve BF, et al. Expanded GGGGCC 
hexanucleotide repeat in noncoding region of C9ORF72 causes chromosome 9p-linked 
FTD and ALS. Neuron. 2011;72(2):245-256. 
8. 
Karpati G, Dalakas MC. Viral hide-and-seek in sporadic ALS: a new challenge. Neurology. 
2000;54(1):6-7. 
9. 
Viola MV, Frazier M, White L, Brody J, Spiegelman S. RNA-instructed DNA polymerase 
activity in a cytoplasmic particulate fraction in brains from Guamanian patients. J Exp Med. 
1975;142(2):483-494. 
10. 
Andrews WD, Tuke PW, Al-Chalabi A, et al. Detection of reverse transcriptase activity in 
the serum of patients with motor neurone disease. J Med Virol. 2000;61(4):527-532. 
11. 
Perl A, Colombo E, Dai H, et al. Antibody reactivity to the HRES-1 endogenous retroviral 
element identifies a subset of patients with systemic lupus erythematosus and overlap 
syndromes. Correlation with antinuclear antibodies and HLA class II alleles. Arthritis 
Rheum. 1995;38(11):1660-1671. 
12. 
Ziegler B, Gay RE, Huang GQ, Fassbender HG, Gay S. Immunohistochemical localization 
of HTLV-I p19- and p24-related antigens in synovial joints of patients with rheumatoid 
arthritis. Am J Pathol. 1989;135(1):1-5. 
13. 
Douville R, Liu J, Rothstein J, Nath A. Identification of active loci of a human endogenous 
retrovirus in neurons of patients with amyotrophic lateral sclerosis. Ann Neurol. 
2011;69(1):141-151. 
14. 
Poesen K, De Schaepdryver M, Stubendorff B, et al. Neurofilament markers for ALS 
correlate with extent of upper and lower motor neuron disease. Neurology. 
2017;88(24):2302-2309. 
15. 
Shepheard SR, Chataway T, Schultz DW, Rush RA, Rogers ML. The extracellular domain 
of neurotrophin receptor p75 as a candidate biomarker for amyotrophic lateral sclerosis. 
PLoS One. 2014;9(1):e87398. 
16. 
Nath A, Jankovic J, Pettigrew LC. Movement disorders and AIDS. Neurology. 
1987;37(1):37-41. 
17. 
Jia Y, Wu T, Jelinek CA, et al. Development of protein biomarkers in cerebrospinal fluid 
for secondary progressive multiple sclerosis using selected reaction monitoring mass 
spectrometry (SRM-MS). Clin Proteomics. 2012;9(1):9. 
18. 
Sinha S, Mathews T, Arunodaya GR, et al. HIV-1 clade-C-associated "ALS"-like disorder: 
first report from India. J Neurol Sci. 2004;224(1-2):97-100. 
19. 
Moulignier A, Moulonguet A, Pialoux G, Rozenbaum W. Reversible ALS-like disorder in 
HIV infection. Neurology. 2001;57(6):995-1001. 
20. 
Anand KS, Wadhwa A, Garg J, Mahajan RK. Amyotrophic Lateral Sclerosis-Like 
Presentation in a HIV-Positive Patient. J Int Assoc Provid AIDS Care. 2014. 
21. 
McArthur JC, Steiner J, Sacktor N, Nath A. Human immunodeficiency virus-associated 
neurocognitive disorders: Mind the gap. Ann Neurol. 2010;67(6):699-714. 
22. 
Nath A. Human immunodeficiency virus (HIV) proteins in neuropathogenesis of HIV 
dementia. J Infect Dis. 2002;186 Suppl 2:S193-198. 

PI name:  Avindra Nath 
 
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Protocol number:  15-N-0126 
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23. 
Galassi G, Gentilini, M., Ferrari, S., Ficarra, G., Zonari, P., Mongiardo, N., Di Rienzo. B. 
Motor neuron disease and HIV-1 infection in a 30-year-old HIV-positive heroin abuser: a 
causal relationship? Clin Neuropathol. 1998;17:131. 
24. 
Simpson DM, Morgello, S., Citak, K., Corbo, M., Latov, N. Motor neuron disease 
associated with HIV-1 and anti-asialo GM1 antibody 
Muscle Nerve. 1994;17:1091. 
25. 
Gonzalez-Hernandez MJ, Cavalcoli JD, Sartor MA, et al. Regulation of the HERV-K 
(HML-2) transcriptome by the HIV-1 Tat protein. J Virol. 2014. 
26. 
Westarp ME, Bartmann P, Rossler J, et al. Antiretroviral therapy in sporadic adult 
amyotrophic lateral sclerosis. Neuroreport. 1993;4(6):819-822. 
27. 
Scelsa SN, MacGowan DJ, Mitsumoto H, et al. A pilot, double-blind, placebo-controlled 
trial of indinavir in patients with ALS. Neurology. 2005;64(7):1298-1300. 
28. 
Contreras-Galindo R, Dube D, Fujinaga K, Kaplan MH, Markovitz DM. Susceptibility of 
Human Endogenous Retrovirus Type K to Reverse Transcriptase Inhibitors. J Virol. 
2017;91(23). 
29. 
Letendre S. Central nervous system complications in HIV disease: HIV-associated 
neurocognitive disorder. Top Antivir Med. 2011;19(4):137-142. 
30. 
Raltegravir 
Prescribing 
Information. 
 
Merck 
website.  
http://www.merck.com/product/usa/pi_circulars/i/isentress/isentress_pi.pdf. 
Updated 
August 2014.  Accessed September 15, 2014. 
31. 
Traynor BJ, Codd MB, Corr B, Forde C, Frost E, Hardiman OM. Clinical features of 
amyotrophic lateral sclerosis according to the El Escorial and Airlie House diagnostic 
criteria: A population-based study. Arch Neurol. 2000;57(8):1171-1176. 
32. 
Brooks BR, Miller RG, Swash M, Munsat TL, World Federation of Neurology Research 
Group on Motor Neuron D. El Escorial revisited: revised criteria for the diagnosis of 
amyotrophic lateral sclerosis. Amyotroph Lateral Scler Other Motor Neuron Disord. 
2000;1(5):293-299. 
33. 
Darunavir 
Prescribing 
Information. 
 
Prezista 
website.  
https://www.prezista.com/sites/default/files/pdf/us_package_insert.pdf.  Updated April 
2014.  Accessed September 15, 2014. 
34. 
Ritonavir 
Prescribing 
Information. 
 
Abbvie 
website.  
http://www.rxabbvie.com/pdf/norvirtab_pi.pdf.  Updated November 2013.  Accessed 
September 15, 2014. 
35. 
Goldstein LH, Abrahams S. Changes in cognition and behaviour in amyotrophic lateral 
sclerosis: nature of impairment and implications for assessment. Lancet Neurol. 
2013;12(4):368-380. 
36. 
Browne RH. On the Use of a Pilot Sample for Sample-Size Determination. Statistics in 
Medicine. 1995;14(17):1933-1940. 
 
24. Consent Forms 
Blood Draw Only Consent 
Standard  
 
 

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25.  Appendix A. Adverse Event definitions 
Definition of Adverse Event (AE) 
An AE “is any unfavorable and unintended diagnosis, symptom, sign (including an abnormal laboratory 
finding), syndrome or disease which either occurs during the study, having been absent at baseline, or, if 
present at baseline, appears to worsen.” An AE is a term that is a unique representation of a specific event 
used for medical documentation and scientific analyses. 
 
Severity of Adverse events 
Grade refers to the severity of the AE. The DAIDS toxicity table displays Grades 1 through 4 with unique 
clinical descriptions of severity for each AE based on this general guideline: 
Grade 1 Mild AE 
Grade 2 Moderate AE 
Grade 3 Severe AE 
Grade 4 Potentially life-threatening AE (SAE) 
 
Grade 1:  Symptoms 
causing no or 
minimal interference 
with usual social & 
functional activities 
Grade 2:  Symptoms 
causing greater than 
minimal interference 
with usual social & 
functional activities 
Grade 3:  
Symptoms causing 
inability to 
perform usual 
social & functional 
activities 
Grade 4:  Symptoms causing 
inability to perform basic self-
care functions OR Medical or 
operative intervention 
indicated to prevent 
permanent impairment, 
persistent disability, or death  
 
Definition of Serious Adverse Event (SAE) 
A serious adverse event is any untoward medical occurrence or effect at any dose, that: 
• 
results in death,  
• 
is life threatening,  
• 
results in persistent or significant disability/incapacity,  
• 
requires in-patient hospitalization‡ or prolongation of existing hospitalization, 
• 
results in cancer, 
• 
is a congenital anomaly/birth defect in the offspring of a study participant, 
• 
is deemed, by the investigator, an important or serious medical event that may jeopardize the patient 
or may require intervention to prevent one of the other outcomes listed above should be considered 
serious (i.e., intensive treatment in an emergency room or at home for allergic bronchospasm; blood 
dyscrasias or convulsions that do not result in hospitalization; or development of drug dependency or 
drug abuse.) 
 
Assessment of causality 
Every effort should be made by the investigator to explain each AE and assess its causal relationship, if 
any, to the study medication. The degree of certainty with which an adverse event can be attributed to 
the study medication (or alternative causes, e.g., natural history of the underlying diseases, concomitant 
therapy, etc.) will be determined by how well the event can be understood in terms of one or more of the 
following: 
• 
Reaction of similar nature previously observed with this type of medication. 
• 
The event reported in the literature for similar types of medication. 
• 
Subject’s underlying clinical state or other medical conditions (defined further in Section 8.1). 

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• 
Concomitant agents and/or therapies. 
 
The causal relationship, if any, to study medication will be defined by one of the following terms: 
 
Assessment 
Definition 
Definitely 
There is suspicion of a relationship between study medication and AE (without 
determining the extent of probability); there are no other more likely causes and 
study medication is suspected to have contributed to the AE. 
Probable 
AE cannot be reasonably explained by other factors (i.e., clinical condition, 
environmental/toxic factors or other treatments). 
Possible 
AE can be reasonably explained by other factors (as mentioned above). 
Unlikely 
AE occurs within an unusual time frame of administration of study medication and 
can also be reasonably explained by other factors (as mentioned above). 
Unrelated 
There is no suspicion that there is a relationship between study medication and AE; 
there are other more likely causes and study medication is not suspected to have 
contributed to the AE. 
 
 
 

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26. Appendix B. Cover Letter for Telephone Consent 
 
 
Dear _, 
 
 
Thank you for your interest in our study: 15-N-0126 “HERV-K Suppression Using Antiretroviral 
Therapy in Volunteers with Amyotrophic Lateral Sclerosis (ALS).” 
 
Per our previous conversation we are sending you the Blood Draw Only Consent.  This is the 
form that, once signed, gives us permission to collect your blood for research purposes.  Please 
do not sign this form until we talk on the telephone.  We are also sending you a copy of the 
Standard Consent.  This form does not have a signature page and is a reference for the entire 
study. 
 
We are scheduled to discuss these documents on _ at _.  Please take the time before then to 
review the consent forms so that you may gather your thoughts and questions for us to discuss 
prior to you signing.   
 
A member of the study team will contact you on the number you have provided us at the scheduled 
time above.     
 
If you have any questions, you may contact 
 
Amanda Wiebold, RN  
301-594-5194 
amanda.wiebold@nih.gov  
 
 
Sincerely, 
Amanda Wiebold, RN 
Research Nurse Specialist 
NINDS Section of Infections of the Nervous System