Chemoprevention With Monthly IPTp With Dihydroartemisinin-piperaquine for Malaria in HIV-infected Pregnant Participants on Daily Cotrimoxazole in Kenya and Malawi: a Multi-centre Placebo-controlled Trial
Phase: PHASE3
Conditions: Pregnancy; HIV; Malaria
Sponsor: Liverpool School of Tropical Medicine

IMPROVE-2 Protocol (v2.0-11Jul19) 
 
Title page 
 
 
Page 1 of 112 
 
Chemoprevention with monthly IPTp with dihydroartemisinin-piperaquine for malaria in HIV-
infected pregnant participants on daily cotrimoxazole in Kenya and Malawi: a multi-centre placebo-
controlled trial 
Short Title: Improving PRegnancy Outcomes with PReVEntive therapy in Africa-2 (IMPROVE-2) 
 
Trial Identifiers: 
Kenya SERU 
178/3784 
Malawi COMREC 
01/19/2578 
UK LSTM REC 
17-005 
KPPB 
[#####] 
PMPB 
[#####] 
Clinicaltrials.gov 
[#####] 
 
Chief Investigator: Prof Feiko ter Kuile, MD, PhD, LSTM, Address: Liverpool School of Tropical 
Medicine, Pembroke Place, Liverpool L3 5QA, UK, Mobile: +44 (0)7846 377 369 (UK), +254 (0)708 
739 228 (Kenya); Email: feiko.terkuile@lstmed.ac.uk 
Co-Principal Investigators: 
Malawi: Dr Mwayiwawo Madanitsa, MD, PhD, College of Medicine, University of Malawi, Private 
Bag 360, Chichiri, Blantyre 3, Mobile: +265(0) 999 616 537; E-mail: mmadanitsa@medcol.mw, 
mwayi.madanitsa@gmail.com 
Kenya: a) Dr Hellen Barsosio, MD, KEMRI Centre for Global Health Research (CGHR) and CDC 
Collaboration, P.O. Box 1578, Kisumu 40100. Mobile: +254 719 436 833; E-mail: 
hellen.barsosio@lstmed.ac.uk  
b) Dr Simon Kariuki, PhD, KEMRI Centre for Global Health Research (CGHR) and CDC Collaboration, 
P.O. Box 1578, Kisumu 40100. Mobile: + 254 725 389 246; E-mail: SKariuki@kemricdc.org 
Co-investigators: See page 10 for investigators and page 74 for the role of investigators 
 
Funder: Joint Global Health Trials Scheme, Medical Research Council/Wellcome Trust/DFID, UK; 
and the European and Developing Countries Clinical Trials Partnership (EDCTP) 
Sponsor: Liverpool School of Tropical Medicine (LSTM); Pembroke Place, Liverpool L3 5QA, UK, 
Phone: +44 0151 7053794; Email: lstmgov@lstmed.ac.uk 
 
Revision chronology: 
Version and date 
of protocol 
Details of Changes 
Authors (see also page 10) Signature Chief Investigator 
v1.0-17Apr19 
Original 
HB, MM, CB, EMH, JD, FtK 
 
v2.0-11Jul19 
Amendment 
HB, MM, JD, FtK 
 
 
 
 
 
 
Confidentiality Statement: This document contains confidential information that must not be disclosed to anyone 
other than the sponsor, the investigator team, host institution, relevant ethics committee and regulatory authorities 

IMPROVE-2 Protocol (v2.0-11Jul19) 
 
Description of amendments 
 
 
 
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DESCRIPTION OF AMENDMENTS 
DETAILS OF KEY CHANGES TO PROTOCOL VERSION 
 
Version 2.0-11Jul19 
1.  The addition of safety halting rules that trigger a DSMB review (10.2.5, Safety halting rules, page 
54).

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 TABLE OF CONTENT  
1 
Abbreviations ................................................................................................................................. 8 
2 
Administrative information .......................................................................................................... 10 
2.1 
Title ....................................................................................................................................... 10 
2.2 
Investigators and collaborators ............................................................................................ 10 
2.2.1 
Chief Investigator .......................................................................................................... 10 
2.2.2 
Co-Principal investigators ............................................................................................. 10 
2.2.3 
Co-investigators ............................................................................................................ 10 
2.2.4 
Collaborators ................................................................................................................. 10 
2.2.5 
Institutions .................................................................................................................... 10 
2.3 
Trial registration and protocol summaries ........................................................................... 11 
2.3.1 
Trial Registration data ................................................................................................... 11 
2.3.2 
Lay summary ................................................................................................................. 13 
2.3.3 
Short technical protocol summary ................................................................................ 14 
2.3.4 
Long technical protocol summary ................................................................................. 15 
3 
Introduction ................................................................................................................................. 20 
3.1 
The burden malaria and HIV and viral infections in pregnancy ............................................ 20 
3.1.1 
Malaria and HIV in pregnancy ....................................................................................... 20 
3.1.2 
Viral co-infections in pregnancy .................................................................................... 20 
3.2 
Malaria prevention in HIV-infected women ......................................................................... 20 
3.2.1 
Antifolate resistance ..................................................................................................... 20 
3.2.2 
Chemoprevention with Dihydroartemisinin-Piperaquine (DP)..................................... 21 
3.2.3 
DP and other viral infections ......................................................................................... 21 
3.2.4 
Recent changes in first-line combination antiretroviral therapy (cART) from efavirenz 
(EFV) to dolutegravir (DTG) based cARTs ...................................................................................... 22 
3.3 
Drug-drug interactions .......................................................................................................... 24 
3.3.1 
Drug-drug interaction between DP and dolutegravir ................................................... 24 
3.4 
Safety of study drugs in pregnancy ....................................................................................... 24 
3.4.1 
CTX ................................................................................................................................ 24 
3.4.2 
Dihydroartemisinin-Piperaquine ................................................................................... 24 
3.4.3 
Dolutegravir (DTG) ........................................................................................................ 25 
4 
Justification for the study ............................................................................................................. 26 
4.1 
Why is this study needed now? ............................................................................................ 26 
4.2 
Other relevant research ongoing elsewhere ........................................................................ 26 
4.2.1 
HIV-infected women ..................................................................................................... 26 
4.2.2 
HIV-uninfected women ................................................................................................. 26 
4.3 
Hypotheses ........................................................................................................................... 26 
5 
Aim & Objectives .......................................................................................................................... 27 
5.1 
Primary objective .................................................................................................................. 27 
5.2 
Secondary objectives ............................................................................................................ 27 
6 
Trial Design & design considerations ........................................................................................... 27 
6.1 
Overview of design ............................................................................................................... 27 
6.2 
Design considerations ........................................................................................................... 28 
6.2.1 
Rational for a fixed dose rather than a dose based on bodyweight ............................. 28 
6.2.2 
Rationale for nested pharmacokinetic studies ............................................................. 28 
6.2.3 
Design as a superiority trial ........................................................................................... 28 
7 
Methods: Participants, interventions, and outcomes .................................................................. 29 
7.1 
Study setting ......................................................................................................................... 29 

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7.1.1 
Kenya ............................................................................................................................. 29 
7.1.2 
Malawi ........................................................................................................................... 29 
7.2 
Eligibility criteria.................................................................................................................... 30 
7.2.1 
Inclusion criteria ............................................................................................................ 30 
7.2.2 
Exclusion criteria ........................................................................................................... 30 
7.3 
Interventions ......................................................................................................................... 30 
7.3.1 
Trial Medications and interventions ............................................................................. 30 
7.3.2 
Criteria for discontinuing or modifying allocated interventions for a given trial 
participant ..................................................................................................................................... 33 
7.3.3 
Antiretroviral regimens ................................................................................................. 34 
7.3.4 
Permitted and prohibited concomitant medication and care ...................................... 35 
7.3.5 
Strategies to improve adherence to study protocol and medication ........................... 35 
7.3.6 
Removal of participants from study .............................................................................. 36 
7.4 
Outcome measures ............................................................................................................... 37 
7.4.1 
Primary outcome .......................................................................................................... 37 
7.4.2 
Secondary outcome measures ...................................................................................... 37 
7.5 
Participants timeline ............................................................................................................. 38 
7.5.1 
Timeline ......................................................................................................................... 38 
7.5.2 
Antenatal booking visit ................................................................................................. 38 
7.5.3 
Interim monthly scheduled visits .................................................................................. 39 
7.5.4 
Unscheduled visits during pregnancy ........................................................................... 40 
7.5.5 
Delivery visit .................................................................................................................. 40 
7.5.6 
Postnatal visits .............................................................................................................. 41 
7.6 
Sample size and power ......................................................................................................... 42 
7.6.1 
Primary outcome .......................................................................................................... 42 
7.6.2 
Power calculations for key secondary outcomes .......................................................... 42 
7.6.3 
Sample size for cardiac monitoring study ..................................................................... 43 
7.7 
Recruitment and retention ................................................................................................... 43 
7.7.1 
Recruitment procedures ............................................................................................... 43 
7.7.2 
Planned recruitment rate .............................................................................................. 43 
7.7.3 
Rate of loss to follow-up ............................................................................................... 43 
7.7.4 
Problems with compliance and Strategies for retention .............................................. 43 
8 
Methods: Assignment of interventions ........................................................................................ 44 
8.1 
Allocation .............................................................................................................................. 44 
8.2 
Blinding and unblinding ........................................................................................................ 44 
8.2.1 
Blinding ......................................................................................................................... 44 
8.2.2 
Emergency unblinding .................................................................................................. 45 
9 
Methods Data collection, management and analysis .................................................................. 45 
9.1 
measurement of efficacy outcomes and safety .................................................................... 45 
9.1.1 
Efficacy .......................................................................................................................... 45 
9.1.2 
Safety ............................................................................................................................ 46 
9.1.3 
Pharmacokinetic studies and drug-drug interactions ................................................... 47 
9.1.4 
Laboratory assays .......................................................................................................... 47 
9.2 
Data collection methods & storage ...................................................................................... 48 
9.2.1 
Data management ........................................................................................................ 48 
9.3 
Statistical methods ................................................................................................................ 49 
9.3.1 
General principles ......................................................................................................... 49 
9.3.2 
Analyses populations .................................................................................................... 49 
9.3.3 
Primary outcome analyses ............................................................................................ 49 
9.3.4 
Secondary outcomes analyses ...................................................................................... 50 
9.3.5 
Subgroup analyses ........................................................................................................ 50 

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9.3.6 
Safety ............................................................................................................................ 50 
9.3.7 
Interim sample size re-estimation and/or interim analyses and criteria for termination 
of the trial ..................................................................................................................................... 50 
10 
Methods: Monitoring ................................................................................................................... 51 
10.1 
Data monitoring and trial oversight committees ................................................................. 51 
10.1.1 
Data Monitoring and Ethics Committee (DMEC) .......................................................... 51 
10.1.2 
Trial Steering Committee (TSC) ..................................................................................... 51 
10.2 
Safety Monitoring and reporting .......................................................................................... 52 
10.2.1 
Definitions ..................................................................................................................... 52 
10.2.2 
Identifying, managing adverse events .......................................................................... 53 
10.2.3 
Assessment of causality ................................................................................................ 53 
10.2.4 
Reporting adverse event procedures ............................................................................ 53 
10.2.5 
Safety halting rules ........................................................................................................ 54 
10.3 
Trial monitoring and auditing ............................................................................................... 55 
10.3.1 
Trial monitoring ............................................................................................................. 55 
10.3.2 
Auditing ......................................................................................................................... 55 
10.3.3 
Role of sponsor ............................................................................................................. 55 
10.4 
Other quality control measures ............................................................................................ 55 
10.4.1 
Safety monitors ............................................................................................................. 55 
10.4.2 
Trial monitoring ............................................................................................................. 55 
10.4.3 
Training ......................................................................................................................... 55 
10.4.4 
Quality assurance/control of laboratory tests .............................................................. 56 
11 
Ethics and dissemination .............................................................................................................. 56 
11.1 
Declaration of Helsinki .......................................................................................................... 56 
11.2 
Research ethics and regulatory approval ............................................................................. 56 
11.2.1 
Review process .............................................................................................................. 56 
11.2.2 
Protocol amendments................................................................................................... 56 
11.2.3 
Sanctioning of the protocol by hospitals ...................................................................... 56 
11.2.4 
Regulatory approval ...................................................................................................... 57 
11.3 
Informed consent procedures .............................................................................................. 57 
11.3.1 
Consent procedures ...................................................................................................... 57 
11.4 
Protection of privacy and confidentiality .............................................................................. 58 
11.4.1 
Privacy ........................................................................................................................... 58 
11.4.2 
Privacy of individual ...................................................................................................... 58 
11.4.3 
Confidentiality of data .................................................................................................. 58 
11.5 
Declaration of interest .......................................................................................................... 58 
11.6 
Access to source data/documents ........................................................................................ 58 
11.7 
Risks and benefits ................................................................................................................. 58 
11.7.1 
Risks to study participants ............................................................................................ 58 
11.7.2 
Benefits to study participants ....................................................................................... 59 
11.7.3 
Risk to the population ................................................................................................... 60 
11.7.4 
Other ethical considerations ......................................................................................... 60 
11.8 
Ancillary and post-trial care .................................................................................................. 60 
11.8.1 
Health care during the trial ........................................................................................... 60 
11.8.2 
Trial insurance ............................................................................................................... 60 
11.8.3 
Post-trial care ................................................................................................................ 60 
11.9 
Expenses reimbursement and incentives ............................................................................. 61 
11.10 
Dissemination and application of the results ................................................................... 61 
11.10.1 
Result dissemination and publication policy ............................................................ 61 
11.10.2 
Impact ....................................................................................................................... 62 
11.10.3 
Authorship and publications ..................................................................................... 63 

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11.10.4 
Data Sharing Statement ............................................................................................ 63 
12 
Timeframe and duration of the study .......................................................................................... 64 
12.1 
Timeline ................................................................................................................................. 64 
12.1.1 
Project Gantt chart ........................................................................................................ 64 
13 
References .................................................................................................................................... 65 
14 
Financial aspects and conflict of interest ..................................................................................... 73 
14.1 
Funding for the trial .............................................................................................................. 73 
14.2 
Provision of study drugs ........................................................................................................ 73 
15 
Budget & budget justification ...................................................................................................... 73 
16 
Appendices ................................................................................................................................... 74 
16.1 
Appendix I. Role of Investigators and collaborators ............................................................. 74 
16.1.1 
Definition investigator and collaborator ....................................................................... 74 
16.1.2 
Protocol development: authors’ contributions ............................................................ 74 
16.1.3 
Role Investigators .......................................................................................................... 74 
16.1.4 
Collaborators ................................................................................................................. 75 
16.2 
Appendix II. Terms of reference oversight committees ....................................................... 76 
16.2.1 
Trial Management Group (TMG) .................................................................................. 76 
16.2.2 
Trial Steering Committee (TSC) ..................................................................................... 76 
16.2.3 
Data Monitoring and Ethics Committee (DMEC) .......................................................... 78 
16.3 
Appendix III. Declaration of Helsinki ..................................................................................... 80 
16.4 
Appendix IV. Budget and budget justification ...................................................................... 83 
16.4.1 
Budget ........................................................................................................................... 83 
16.4.2 
Budget Justification ....................................................................................................... 83 
16.5 
Appendix V. Participant information sheets and informed consent statements ................. 84 
16.5.1 
Participant Information Sheet: Main trial (all participants) (English) ........................... 84 
16.5.2 
Consent statement for screening and participation in the main trial (all participants) 
(English) 84 
16.5.3 
Consent Statement for long term storage of samples and use for future research (all 
participants) (English) ................................................................................................................... 84 
16.5.4 
Participant Information Sheet for cardiac safety monitoring (subgroup) (English) ..... 84 
16.5.5 
Consent Statement for cardiac safety monitoring (sub-group) (English) ..................... 84 
16.6 
Appendix VI. Description of other clinical and laboratory methods..................................... 85 
16.6.1 
Pharmacokinetic studies of drug-drug interactions between piperaquine and standard 
antiretroviral therapy.................................................................................................................... 85 
16.6.2 
Impact of antimalarial resistance on protective efficacy .............................................. 86 
16.6.3 
Impact on maternal antibody, trans-placental antibody transfer and multi-pathogen 
neonatal cell-mediated immune responses ................................................................................. 87 
16.6.4 
Impact on infant adaptive and innate-like immunity ................................................... 87 
16.6.5 
Impact on biomarkers of placental function and adverse birth outcomes .................. 88 
16.6.6 
Impact on arboviral co-infections ................................................................................. 89 
16.6.7 
Use of mobile phone Unstructured Supplementary Service Data (USSD) platform to 
enhance protocol adherence and monitoring of tolerance ......................................................... 89 
16.6.8 
Performance of a highly sensitive diagnostic test for malaria ...................................... 90 
16.7 
Appendix VII. Product characteristics ................................................................................... 91 
16.7.1 
Dihydroartemisinin-piperaquine product insert (D-ARTEPP, Guilin Pharma) .............. 91 
16.7.2 
Dihydroartemisinin-piperaquine product insert (Eurartesim, AlfaSigma) .................... 93 
16.7.3 
Cotrimoxazole ............................................................................................................... 99 
16.7.1 
Fixed dose combination of TLD (TDF/3TC/DTG) ......................................................... 101 
16.8 
Appendix VIII. SPIRIT 2013 checklist clinical trial protocol ................................................. 107 

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16.9 
Appendix IX. Questionnaires ............................................................................................... 112 

IMPROVE-2 Protocol (v2.0-11Jul19) 
 
Abbreviations 
 
 
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1 ABBREVIATIONS  
3TC 
Lamivudine 
95% CI 
95 per cent Confidence Interval 
ACT 
Artemisinin-Based Combination Therapy 
AE 
Adverse Event  
AIDS  
Acquired Immunodeficiency Syndrome 
AL  
Artemether-Lumefantrine 
ANC 
Antenatal Care 
ART 
Antiretroviral Therapy 
AUC 
Area Under the Curve 
AZT 
Zidovudine 
cART 
Combination Antiretroviral Therapy 
CDC 
US Centers for Disease Control and Prevention 
CHW 
Community Health Worker 
CHEW 
Community Health Extension Worker 
Cmax 
Maximum Drug Concentration 
COM 
College of Medicine, University of Malawi 
CRF 
Case Record Form 
CRO 
Contract Research Organization 
CT 
Counselling and Testing 
CTX 
Cotrimoxazole 
CYP450 
Cytochrome P450 
DHA  
Dihydroartemisinin 
DBS 
Dried Blood Spot (On Filter Paper) 
DP 
Dihydroartemisinin-Piperaquine 
DMEC 
Data Monitoring and Ethics Committee 
DS 
Double Strength  
DTG 
Dolutegravir 
ECG 
Electrocardiogram 
EDCTP 
European And Developing Countries Clinical Trials Partnership 
EFV 
Efavirenz 
ELISA 
Enzyme-Linked Immunosorbent Assay 
EMTCT 
Elimination of Mother to Child Transmission 
ERG 
Evidence Review Group from WHO 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GLM 
Generalised Linear Model 
GMP 
Good Manufacturing Practice 
Hb 
Haemoglobin 
HIV  
Human Immunodeficiency Virus 
IRB  
Institutional Review Board 
IRS 
Indoor Residual Spraying 
IPTp 
Intermittent Preventive Treatment in Pregnancy 
ITNs  
Insecticide Treated Nets 
ITT 
Intention to Treat 
KCMC 
Kilimanjaro Christian Medical Centre 
KEMRI 
Kenya Medical Research Institute 
LBW 
Low Birthweight 

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LLINS 
Long-Lasting Insecticide Treated Nets 
LSHTM 
London School of Hygiene and Tropical Medicine 
LSTM  
Liverpool School of Tropical Medicine 
MDA 
Mass Drug Administration 
MoH 
Ministry of Health 
MPAC 
Malaria Policy Advisory Committee 
MRC 
Medical Research Council, UK 
MTCT 
Mother to Child Transmission 
NMCP 
National Malaria Control Programme 
NVP 
Nevirapine 
PCR 
Polymerase Chain Reaction 
PD 
Pharmacodynamics 
PK 
Pharmacokinetics 
PMTCT 
Prevention of Mother to Child Transmission 
PT 
Preterm 
PQ 
Piperaquine  
RCT 
Randomised Controlled Trial 
RDT  
Rapid Diagnostic Test 
REC 
Research Ethics Committee 
SAE 
Serious Adverse Event 
SGA 
Small for Gestational Age 
SMX-TMP 
Sulfamethoxazole-Trimethoprim  
SOP 
Standard Operating Procedure 
SP 
Sulphadoxine-Pyrimethamine 
SS 
Single Strength 
STI 
Sexually Transmitted Infection 
T1/2 
Plasma Half-Life 
QTc 
Rate Corrected Time Qt Interval on Electrocardiogram (ECG) 
QTcB 
Rate Corrected Time Qt Interval on ECG Using Bazett’s Correction 
QTcF 
Rate Corrected Time Qt Interval on ECG Using Fridericia’s Correction 
TDF 
Tenofovir Disoproxil Fumarate 
TLD 
Tenofovir Disoproxil Fumarate /Lamivudine/Dolutegravir Fixed Dose 
TLE 
Tenofovir Disoproxil Fumarate /Lamivudine/Efavirenz Fixed Dose 
Tmax 
Time to Maximum Plasma Concentration 
TSC 
Trial Steering Committee 
VHV 
Village Health Volunteer 
VHW 
Village Health Worker 
VHEV 
Village Health Extension Volunteer 
VHEW 
Village Health Extension Worker 
WHO  
World Health Organization 
 
 

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2 ADMINISTRATIVE INFORMATION 
2.1 
TITLE 
Chemoprevention with monthly IPTp with dihydroartemisinin-piperaquine for malaria in HIV-
infected pregnant participants on daily cotrimoxazole in Kenya and Malawi: a multi-centre placebo-
controlled trial (IMPROVE-2) 
2.2 
INVESTIGATORS AND COLLABORATORS 
2.2.1 Chief Investigator 
2.2.2 Co-Principal investigators 
Prof Feiko ter Kuile, MD, PhD1,2 
Dr Hellen Barsosio, MD (Kenya)1,2 
 
Dr Simon Kariuki, PhD2 (Kenya) 
 
Dr Mwayiwawo Madanitsa, MD, PhD3 (Malawi) 
2.2.3 Co-investigators 
 
Prof Duolao Wang, PhD1 
Prof Victor Mwapasa, MD, MPH, PhD3 
Mr James Dodd, MSC1 
Prof Kamija Phiri, MD, PhD3 
Dr Titus Kwambai, MD2 
Prof Ken Maleta, MD, PhD3 
Dr George Githuka, MD, MSc4 
Dr Clifford Banda3 
2.2.4 Collaborators 
 
Dr George Warimwe5 
Prof Karen Barnes, PhD10 
Dr Charles Nyaigoti5 
Dr Ann Moormann, PhD11 
Prof Philip Bejon, MD, PhD5 
Prof Kevin Kain, MD, PhD12 
Dr Aaron Samuels, MD6 
Prof Stephen Rogerson, MBBS, PhD13 
Dr Meghna Desai, PhD6 
Dr Gonzalo Domingo, MD, PhD14 
Dr Julie Gutman, MD, MSc6 
Dr David Bell, PhD15 
Dr Jenny Hill, PhD1 
Dr Pascal Voiriot, MD16 
Dr Emily Adams, PhD1 
Dr Cristiana Cairo, PhD17 
Ass. Prof Dr Michael Alifrangis, PhD7 
Prof Miriam Laufer, PhD17 
Assist Prof Matthew Chico, MPH8 
Prof. Wilson Mandala18 
Mrs Silke Fernandes8 
Mr Manota Mphande19 
Prof Kara Hanson8 
Dr Maureen Kimani, MD, MPH5 
Dr Eva Maria Hodel, PhD1,4 
Dr Kigen Bartilol, MD MMeD (Obs/Gyn)5 
2.2.5 Institutions 
 
1 Liverpool School of Tropical Medicine, UK 
11 University of Massachusetts, Worcester, USA 
2 Kenya Medical Research Institute, Kenya 
12 University of Toronto, Canada 
3 College of Medicine, University of Malawi, Malawi 
13 University of Melbourne, Melbourne, Australia 
4 National AIDS and STI’s Control Programme, Kenya 
14 PATH, Seattle, Washington, USA 
5 KEMRI-Wellcome Trust Research Programme 
15 Intellectual Ventures Lab., Washington, USA 
6 CDC, Atlanta, Georgia, USA 
16 Cardiabase, Banook Group, Nancy, France 
7 University of Copenhagen, Denmark 
17 University of Maryland, Baltimore 
8 London School of Hygiene and Trop. Medicine, UK 
18 Malawi University of Science and Technology 
9 University of Tampere, Finland 
19 Logic Bay Systems Ltd, Malawi 
10 University of Cape, South Africa 
 

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2.3 
 TRIAL REGISTRATION AND PROTOCOL SUMMARIES  
2.3.1 Trial Registration data 
Data Category 
Information 
Primary registry and trial 
identifying number 
Clinicaltrials.gov: [#####] 
 
Date of registration in 
primary registry 
[#####] 
Secondary 
identifying 
numbers 
Kenya SERU 
#178/3784 
Malawi COMREC 
#01/19/2578 
UK LSTM REC 
#17-005 
KPPB 
[#####] 
PMPB 
[#####] 
 
Source(s) of monetary 
or material support 
Joint Global Health Trials Scheme, Medical Research Council/Wellcome 
Trust/DFID, UK; and the European and Developing Countries Clinical Trials 
Partnership (EDCTP) 
Primary sponsor 
Liverpool School of Tropical Medicine (LSTM); Pembroke Place, Liverpool L3 
5QA, UK, Phone: +44 0151 7053794; Email: lstmgov@lstmed.ac.uk 
Secondary sponsor(s)  
NA 
Contact 
for 
public 
queries 
Prof Feiko ter Kuile, LSTM, Pembroke Place, Liverpool, L3 5QA, UK, E-mail: 
feiko.terkuile@lstmed.ac.uk 
Contact for 
scientific 
queries 
Prof Feiko ter Kuile, LSTM, Pembroke Place, Liverpool, L3 5QA, UK, E-mail: 
feiko.terkuile@lstmed.ac.uk 
Public title 
Improving PRegnancy Outcomes with PReVEntive therapy in Africa-2 
(IMPROVE-2) 
Scientific title 
Chemoprevention with monthly IPTp with dihydroartemisinin-piperaquine for 
malaria in HIV-infected pregnant participants on daily cotrimoxazole in Kenya 
and Malawi: a multi-centre placebo-controlled trial 
Countries of recruitment Malawi; Kenya 
Health condition(s) or 
problem(s) studied 
Pregnancy; HIV; Malaria 
Intervention(s) 
CTX-alone: Daily, one double-strength tablet of 160mg of sulfamethoxazole and 
800mg of trimethoprim plus monthly placebo-DP, given as a fixed dose of 3 
placebo-DP tablets daily for three days until delivery 
CTX-DP: Daily, one double-strength tablet of 160mg of sulfamethoxazole and 
800mg of trimethoprim plus monthly DP, given as a fixed dose of 3 tablets (40 
mg of dihydroartemisinin and 320 mg of piperaquine) daily for three days until 
delivery. 
Study type 
Interventional 
Allocation: randomised; intervention model: parallel assignment; arms: 2; 
allocation ratio: 1:1; stratified by site (hospital) and HIV-status (known-positive 
and newly-diagnosed). Masking: Placebo controlled  
Primary purpose: Treatment and prevention 
Phase-III 
Date first enrolment 
[dd mmm yyyy] 
Target sample size 
898 (449 per arm) (359 contributors and 90 non-contributors)   
Recruitment status 
Not yet recruiting 

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Data Category 
Information 
Primary Objective 
To determine if monthly IPTp-DP in HIV-infected pregnant women receiving 
daily CTX is safe and superior to daily CTX-alone for controlling malaria infection 
in areas with high antifolates resistance to SP and CTX in Malawi and Kenya. 
Key inclusion criteria 
• 
HIV-infected pregnant women between 16-28 weeks’ gestation 
• 
Viable singleton pregnancy  
• 
On or eligible for cARTs and CTX 
• 
A resident of the study area 
• 
Willing to adhere to scheduled and unscheduled study visit procedures 
• 
Willing to deliver in a study clinic or hospital 
• 
Provide written informed consent 
Key exclusion criteria 
• 
Multiple pregnancies (i.e. twin/triplets) 
• 
HIV-negative or HIV status unknown 
• 
Known heart ailment 
• 
Severe malformations or non-viable pregnancy if observed by ultrasound 
• 
Participants with advanced HIV-disease at WHO clinical stage 3 and 4 
• 
Confirmed or suspected TB infection, 
• 
Unable to give consent 
• 
Known allergy or contraindication to any of the study drugs 
Primary outcome(s) 
Cumulative incidence of malaria infection detected from 2 weeks after the first 
day of the first dose of the first course to delivery inclusive 
Key secondary outcomes  
Efficacy outcomes 
 
• 
Composite of foetal loss and neonatal mortality. 
• 
SGA-LBW-PT composite. 
• 
The individual components of the above composites 
• 
Neonatal length and stunting. 
• 
Incidence of clinical malaria. 
• 
Incidence of malaria infection detected by microscopy and PCR (not for 
point of care). 
• 
Placental malaria by microscopy, PCR and histology (past and active 
infections).  
Safety outcomes 
• 
QTc-prolongation. 
• 
Congenital malformations. 
• 
Other SAEs and AEs. 
Tolerance 
• 
History of vomiting study drug (<60 min). 
• 
Dizziness. 
• 
Gastrointestinal complaints.  
Antimicrobial 
activity 
and resistance 
• 
Frequency of molecular markers of drug resistance in Plasmodium 
falciparum infections during pregnancy and delivery. 
 
 

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2.3.2 Lay summary 
Context of the research: In malaria-endemic Africa, HIV and malaria conspire to increase the risks of 
pregnancy loss, preterm delivery, and growth retardation resulting in small babies. HIV-negative 
women in these areas receive intermittent preventive therapy in pregnancy (IPTp) with the 
antimalarial sulphadoxine-pyrimethamine (SP) to mitigate these effects. HIV-infected women receive 
daily prevention with cotrimoxazole (CTX), an antibiotic which also has antimalarial activity. However, 
the malaria parasite is increasingly resistant to SP and CTX. Recent trials with IPTp with mefloquine, 
when provided in addition to daily CTX, suggested that chemoprevention with an effective 
antimalarial markedly improves the protection against malaria in HIV-infected women compared to 
daily CTX alone. However, mefloquine was not well tolerated and other antimalarials are needed. 
The long-acting antimalarial dihydroartemisinin-piperaquine (DP) is well tolerated and has shown 
great promise in trials in HIV-negative women in Uganda and Kenya. Chemoprevention with monthly 
DP has also been explored in a small study (N=200) of HIV-infected women on daily CTX in Uganda. 
Unfortunately, the study was inconclusive because malaria transmission was low. It also showed a 
drug-drug interaction with the anti-retroviral efavirenz (EFV), which markedly reduced the protective 
drug levels of DP. Since this first trial, the preferred first-line combination antiretroviral therapy (cART) 
recommended by WHO for use in the 2nd and 3rd trimester changed to dolutegravir (DTG) based cARTs. 
No such drug-drug interaction is expected between DTG and DP. We will, therefore, assess the safety 
and efficacy of malaria chemoprevention with monthly DP in HIV-infected women on daily CTX and 
DTG-based cARTs. 
Aim: To determine whether monthly IPTp-DP in HIV-infected pregnant women on cARTs and daily CTX 
improves current policies to control malaria in areas with high resistance to CTX and high prevalence 
of malaria in East & Southern Africa. 
Methods: This is a 2-arm multi-centre trial involving 898 (449 per arm) women in 8 hospitals in Kenya 
and Malawi comparing daily CTX alone versus daily CTX plus monthly DP. The primary outcome is the 
incidence of malaria infection. This study is conducted alongside a sister trial among HIV-negative 
women (IMPROVE trial) also evaluating monthly DP. 
Potential benefits and risks to participants: CTX and DP are currently thought to be safe for the mother 
and foetus during the second and third trimesters of pregnancy. The drugs have not yet been given 
concurrently in HIV-infected women on DTG-based cARTs, and the study will, therefore, include a 
nested cardiac monitoring component and a pharmacokinetic component to ensure women have 
adequate and safe drug levels.  Examinations will be non-invasive, except for blood sampling which 
may cause minor discomfort. Participants experiencing illness between visits will be seen and treated 
free of charge as part of the study. 
Potential applications: The study is designed to inform WHO policy in countries experiencing high 
levels of malaria parasite resistance and may potentially pave the way for new strategies to combat 
malaria in HIV-infected pregnant women hopefully resulting in healthier pregnancies and newborns. 

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2.3.3 Short technical protocol summary  
Background: Pregnant women represent a vulnerable population for malaria. HIV-infected women are 
particularly at risk. In HIV-infected pregnant women, WHO recommends daily cotrimoxazole (CTX), an 
antifolate drug, for malaria chemoprevention and prophylaxis against opportunistic infection. 
However, there is cross-resistance with sulphadoxine-pyrimethamine (SP), and high levels of 
antifolate resistance threatens the antimalarial effect of CTX. Recent trials with intermittent 
preventive therapy (IPT) with mefloquine in HIV-infected women on daily CTX, suggested that 
chemoprevention with an effective antimalarial markedly improves the protection against malaria 
compared to daily CTX alone. However, mefloquine was not well tolerated.  
The long-acting combination of dihydroartemisinin–piperaquine (DP) is well tolerated and has shown 
great promise as IPTp in HIV-negative women in East-Africa. Chemoprevention with monthly DP has 
also been explored in HIV-infected pregnant women on daily CTX in Uganda. Unfortunately, the study 
was inconclusive because malaria transmission was too low and a clinically relevant drug interaction 
with efavirenz (EFV) was found reducing the exposure to DP. WHO now recommends dolutegravir 
(DTG) based combination antiretroviral therapy (ARTs) as the preferred firstline regimen including for 
pregnant women in the 2nd and 3rd trimester of pregnancy for the prevention of mother-to-child 
transmission of HIV. As a result, many countries in Africa are now transitioning to DTG-based 
combination antiretroviral therapy (cARTs). No such drug-drug interaction is expected between DTG 
and DP. We will, therefore, assess the safety and efficacy of malaria chemoprevention with monthly 
DP in HIV-infected women on daily CTX and DTG-based cARTs.  
Objectives and methods: This is a 2-arm, individually-randomized, multi-centre, placebo-controlled 
superiority trial comparing the safety and efficacy of daily CTX plus monthly DP (‘CTX-DP’) versus daily 
CTX plus monthly placebo-DP (i.e. ‘CTX-alone’, control arm) to reduce malaria and the adverse effects 
of malaria in 898 (449 per arm) HIV-infected pregnant women on DTG-based cARTs. The study will be 
conducted in 8 hospitals in Kenya and Malawi in high SP-resistance areas with a high prevalence of 
malaria. These are the same sites where the sister trial in HIV-uninfected women is being conducted 
in Kenya and Malawi (IMPROVE trial). Both the mother and baby will be followed for 6-8 weeks after 
delivery. The study is powered at 80% (alpha=0.05) to detect ≥50% relative risk reduction (RR=0.50) 
in the primary outcome (cumulative incidence of malaria infection) from 12% in the CTX-alone arm 
(control arm) to 6% in in the interventions arm allowing for 20% non-contributors. The trial includes a 
pharmacokinetic assessment, cardiac monitoring for safety, assessment of antimalarial drug and the 
impact on immune responses to malaria and other pathogens. 
 

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2.3.4 Long technical protocol summary 
Title: Chemoprevention with monthly IPTp with dihydroartemisinin-piperaquine for malaria in HIV-
infected pregnant participants on daily cotrimoxazole in Kenya and Malawi: a multi-centre placebo-
controlled trial(IMPROVE-2). 
Background and rationale: In malaria-endemic Africa, HIV and malaria conspire to increase the risks 
of adverse pregnancy outcomes. For HIV-infected pregnant women, WHO recommends daily 
cotrimoxazole (CTX) for chemoprevention for malaria and prophylaxis against opportunistic infection. 
However, there is cross-resistance with SP, and high levels of antifolate resistance threaten the 
antimalarial effect of CTX. Recent trials in HIV-infected pregnant women who received daily CTX plus 
IPTp with mefloquine, suggested that chemoprevention with an effective antimalarial markedly 
reduces the risk of malaria compared to daily CTX alone. However, mefloquine was not well tolerated. 
The long-acting combination of dihydroartemisinin–piperaquine (DP) is well tolerated and has shown 
great promise as IPTp in HIV-negative women in East-Africa. Chemoprevention with monthly DP has 
also been explored in HIV-infected women on daily CTX in Uganda. Unfortunately, the study was 
inconclusive as malaria transmission was too low. Furthermore, a clinically relevant drug-drug 
interaction between DP and efavirenz (EFV) was found to reduce DP drug levels. Following the 
recommendation from WHO, many countries in Africa are transitioning from EFV-based to 
dolutegravir (DTG) based combination antiretroviral therapy (cARTs). WHO now recommends DTG-
based cARTS as the preferred first-line cART regimen in the 2nd and 3rd trimester of pregnancy. No such 
drug-drug interaction is expected between DTG and DP. We will therefore assess the safety and 
efficacy of malaria chemoprevention with monthly DP in HIV-infected women on daily CTX and DTG-
based cARTs. We will therefore assess the safety and efficacy of malaria chemoprevention with 
monthly IPTp with DP in women on daily CTX and DTG-based cARTs and daily CTX. 
Overall aim: To provide WHO with evidence on whether monthly IPTp-DP can improve current policies 
to control malaria in HIV-infected pregnant women on daily CTX in areas with high levels of parasite 
resistance and malaria in East and Southern Africa. 
Primary objective: To determine if monthly IPTp-DP in HIV-infected pregnant women receiving daily 
CTX is safe and superior to daily CTX-alone for controlling malaria infection in areas with high 
antifolates resistance to SP and CTX in Malawi and Kenya. 
Hypotheses: Monthly IPTp-DP in women receiving daily CTX is superior to daily CTX-alone in controlling 
malaria infection during pregnancy in HIV infected women on antiretroviral therapy. 
Overview Study Design: This multi-centre trial will be conducted in antenatal clinics in 8 hospitals in 
Kenya and Malawi located in areas with high prevalence of HIV and malaria and with high anti-folate 
resistance of the malaria parasite. These are the same sites where the sister trial in HIV-uninfected 
women (all gravidae) is being conducted in Kenya and Malawi (IMPROVE trial: NCT03208179). Overall, 
898 (449 per arm) HIV-infected pregnant women who are 16 to 28 weeks pregnant assessed by 
ultrasound dating, will be randomised to receive one of the two interventions. Permuted block 
randomisation stratified by site (i.e. hospital) and HIV-status (known-positive and newly-diagnosed) 
will be used. Allocation concealment will be ensured by using sequentially numbered, sealed, opaque 
envelopes. The study will include pharmacokinetic studies and cardiac monitoring in a sub group of 
women. Other components include molecular marker studies of antimalarial resistance. We will also 
look at the impact on biomarkers of placental function and trans-placental antibody transfer and 
multi-pathogen neonatal cell mediated immune responses. 

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Study Interventions: Daily CTX for all trial participants receiving cARTs in addition to: a) monthly-DP 
(‘CTX-DP’), or b) monthly DP-placebo (‘CTX-alone’) (control). 
Follow-up procedures: Monthly visits during pregnancy, and then at delivery. Mother and newborn 
follow-up at 7 days and 6-8 weeks post-partum. 
Primary outcome: The cumulative incidence of malaria infection detected from 2 weeks after the first 
day of the first dose of the first course to delivery inclusive, defined as the presence of peripheral 
(maternal) or placental (maternal) Plasmodium infection detected by either molecular diagnostics 
(henceforth referred to as PCR), microscopy, RDT or placental histology (active infection). 
Sample size: 898 (449 per arm), allowing for 20% loss to follow-up. 
Data Analysis: Log-binomial regression will be used to analyse the primary outcome, controlled for 
site and gravidity.   
Primary partner institutions: KEMRI, Kenya; College of Medicine, University of Malawi, Malawi; 
Liverpool School of Tropical Medicine (LSTM); London School of Hygiene and Tropical Medicine 
(LSHTM); US Centers for Disease Control and Prevention (CDC); University of Bergen, Norway. 
Funding: Joint Global Health Trials Scheme, Medical Research Council/Wellcome Trust/DFID, UK; and 
the European and Developing Countries Clinical Trials Partnership (EDCTP). 
Sponsor: Liverpool School of Tropical Medicine (LSTM); Pembroke Place, Liverpool L3 5QA, UK, Phone: 
+44 0151 7053794; Email: lstmgov@lstmed.ac.uk. 

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Table 1: Summary Table of Study Design and Schedule of Assessment 
Phase 
Recruitment 
Phase 
Enrolment 
Antenatal follow-up 
Delivery 
Postnatal follow-up mother and 
newborn 
Visit type number 
#1 
#1 
#2a 
#3 
#4a 
#5 
#6 
#7 
#8 
Visit type description 
Screening b 
Enrolment & 
baseline 
Scheduled 
monthly 
ANC visit 
Unscheduled 
antenatal 
visits 
Home visit 
or phone 
call 
Maternal and 
birth outcome 
assessment 
1 week 
Postnatal 
6-8 
weeks 
Postnatal 
Unscheduled 
postnatal 
visits 
Recruitment 
 
 
 
 
 
 
 
 
 
   Pre-screening eligibility 
X 
 
 
 
 
 
 
 
 
   Prior consent discussion 
X 
 
 
 
 
 
 
 
 
Enrolment 
 
 
 
 
 
 
 
 
 
   Eligibility screen 
 
X 
 
 
 
 
 
 
 
   Informed consent 
 
X 
 
 
 
 
 
 
 
   Study code issued 
 
X 
 
 
 
 
 
 
 
   Randomisation 
 
X 
 
 
 
 
 
 
 
   Allocation 
 
X 
 
 
 
 
 
 
 
Interventions d 
 
 
 
 
 
 
 
 
 
   CTX-DP  
 
DP 
Day: 0,1,2 
DP: 
Day 0,1,2 
 
 
 
 
 
 
   CTX-alone (Placebo-DP) 
 
DPplac: 
Day 0,1,2 
DPplac: 
Day 0,1,2 
 
 
 
 
 
 
Assessments 
 
 
 
 
 
 
 
 
 
Clinical measures 
 
 
 
 
 
 
 
 
 
   Copy Clinic/Lab data from ANC card 
   and ANC and other clinic registers 
 
X 
X 
X g 
 
X 
X 
X 
X g 
   Study CRF 
 
X 
X 
X g 
X 
X 
X 
X 
X g 
   Physical Exam. 
 
X 
X 
X g 
 
X 
X 
X 
X g 
   Maternal anthropometricss 
 
X 
X 
 
 
X 
X 
X 
 
   Ultra Sound Scane 
 
X 
 
 
 
 
 
 
 
   Drug vomiting questionnairef & AE 
 
X f 
X f 
 
 
X 
X 
X 
X 
   Newborn anthropometricsm 
 
 
 
 
 
X 
X 
X 
 
   Cardiac monitoring ECGc 
 
X 
X 
 
 
 
 
 
 
   Drug adherence and tolerance 
 
 
 
 
X 
 
 
 
 
Samples 
 
 
 
 
 
 
 
 
 
   Blood sample g-l 
 
VP h l 
VP i,l 
Xg 
 
VP h /CB j 
HP k 
HP k 
HPg 
   Placental samples m 
 
 
 
 
 
X m 
 
 
 

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Visit type 1: Pre-screening interview, Screening, Consent, Enrolment, Randomisation, and Allocation. First IPTp treatment dose given under direct observation. 
Visit type 2: Monthly scheduled ANC follow up visits for assessment.  
Visit type 3 and 8: Unscheduled follow-up visits in between scheduled follow-up visits due to acute illness or other health concerns 
Visit type 4: Telephone contact to assess drug adherence and tolerance will be conducted after each dose. Women without access to a mobile phone will be visited at 
home to monitor adherence. In addition, all participants will be visited at home at least once for random spot checks of adherence and to determine the availability, 
use of LLITNs the previous night, and integrity of LLITNs on a random basis. 
Visit type 5: Delivery visit. To be conducted as soon as possible after birth without interrupting the initiation of breastfeeding or any necessary care required to the 
mother or newborn. A surface examination shall be conducted to assess for external congenital abnormalities. 
Visits type 6 and 7: Routine postnatal care, physical examination and follow-up of the mother-newborn pair. 
a. Scheduled visits spaced approximately one month apart. The range of monthly visits will be 3 to 7 visits depending on the gestational age of the woman at 
enrolment and delivery. Since recruitment is restricted to 16-28 weeks gestation, a median of 4 to 5 monthly visits is expected. 
b. Pre-study screening can take place any time women start visiting the ANC; i.e. even prior to 16 weeks gestation, but the intervention can only start at 16 weeks. 
c. 
Cardiac safety monitoring: In a subgroup of 160 women (80808080 in each arm), a total of six ECGs will be taken per woman as three sets of two ECGs (one 
before and one after the course); One ECG prior to 1st dose and one 4-6 hours after the 3rd dose of the 3-day DP course at enrolment and then twice more spaced 
at least one month apart over the course of the pregnancy, just before and 4h after a monthly DP dose. 
d. Drug administration: The first dose (day-0) of each monthly course to be given under direct observation and subsequent 2 doses are to be taken at home (day-1 
and day-2). Women will be called or receive text messages to remind them of or verify drug intake.  
e. Baseline ultra sound scans in all women to assess the gestational age.  
f. 
Vomiting and other adverse events (AEs) occurring within 30 minutes of the first dose will be assessed. Subsequent AEs will be captured in all women through 
passive surveillance and 1/3 of women through home visits for random spot checks (~1/3 of women). Participants will be encouraged to report to the study clinic 
for any subsequent AEs that may arise after each study visit at any time before the next study visit. 
g. 
Unscheduled visit in between scheduled visits as part of continuous passive surveillance for acute illness or any other health problems. If a visit is for acute illness, 
a venepuncture (Mother, upto 6mL) or heelprick (HP, newborn) blood sample (~250-500 µL) will be taken for malaria RDT/smear, Hb, and DBS for malaria, and 
plasma for detection PCR and antibody assays for viral pathogens. A maternal 5 mL urine sample will also be taken for detection of urinary tract infections and 
arboviruses. 
h. Blood sample on enrolment & delivery by venepuncture (VP) (up to 12 mL): All women all sites: haemoglobin level, HIV test (unless known to be HIV+), maternal 
HIV viral load, syphilis, baseline tests before starting cARTs (biochemistry and full-blood count), malaria smear, dried blood spots (DBS) for molecular malaria 
diagnostics (not for point of care, DBS for multi-pathogen antibody assays and drug resistance), detection PCR and antibody assays for viral pathogens. Sub-group: 
Drug levels; antibody and cell mediated immune responses to malaria and other pathogens; biomarkers of placental function, inflammation and gestational age; 
malaria diagnostics, and drug levels. DBS, plasma, serum and red cell pellets will be stored. 
i. 
Blood sample scheduled monthly visits by venepuncture (up to 12 mL): Same assays as for baseline, except for syphilis. Maternal HIV viral load testing will be 
done once in the third trimester (and/or delivery).  
j. 
Blood sample umbilical cord blood (CB) (~up to 300 mL): Haemoglobin level, malaria molecular diagnostics, antibody and cell mediated immune responses to 
malaria and other pathogens), detection PCR and antibody assays for viral pathogens, and drug levels. DBS, blood smear, plasma and red cell pellets will be stored. 
k. 
Blood sample newborn by heel prick (HP) (~250-500 µL) in all babies at week 1 postnatal visit (mRDT, malaria smear, DBS for molecular malaria diagnostics), week 
6 postnatal visit (infant HIV PCR DNA viral detection at week 6-8), mRDT, malaria smear, DBS for molecular malaria diagnostics). At sick visits infants with fever or 

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other symptoms heel prick samples collected for malaria RDT, microscopy and dried blood spot, and in a subgroup of asymptomatic infants for immunological 
assays. 
l. 
Blood sample ECG component by venepuncture 2 ml blood sample taken 4-6 hours after last dose of the initial course and then monthly just before the first dose 
and 4h after the third dose of a monthly course of DP (cMax) for biochemistry, blood sugars and drug levels (subgroup of 240 women in ECG component) 
m. Placental samples at delivery/termination of pregnancy: placental section for histopathology, amnion roll, placental impression smear, maternal placental blood 
for malaria diagnostics (not for point of care), drug levels, and cord blood (i.e. newborn’s side) (see cord blood sample). 
n. Maternal anthropometric measurements: Enrolment: height; All visits: bodyweight, and MUAC. Infant anthropometric measurements at birth, 1, and 6-8 weeks 
post-partum: bodyweight and length, head, abdominal, mid-upper arm circumference.  

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3 INTRODUCTION 
3.1 
THE BURDEN MALARIA AND HIV AND VIRAL INFECTIONS IN PREGNANCY 
3.1.1 Malaria and HIV in pregnancy 
The double burden of HIV infection and malaria is borne heaviest in sub-Saharan Africa, where they 
conspire to threaten maternal and newborn health. Pregnancy increases the susceptibility of women 
to malaria with devastating consequences for mother and foetus.1 The burden of human 
immunodeficiency virus (HIV) on maternal health has been superimposed on that of malaria, 
particularly in malaria-endemic regions in Africa where women account for approximately 57% of all 
people living with HIV2,3 and where approximately 12% of women are co-infected with HIV and malaria 
during pregnancy.4,5 HIV-infected women are at particular risk and consistently experience more 
peripheral and placental malaria, higher parasite densities, and more febrile illnesses, severe anaemia, 
and adverse birth outcomes than their HIV-uninfected counterparts, particularly in multigravidae5,6 
and, in some studies, increased mother-to-child transmission of HIV (MTCT).6,7 Thus, HIV alters the 
typical gravidity-specific pattern of malaria immunity and risk by shifting the burden from, primarily, 
primigravidae and secundigravidae to all pregnant women.6 Similar to malaria, maternal HIV infection 
increases the risk of miscarriage, stillbirth, and other adverse birth outcomes2,7,8 and the combination 
of pregnancy, HIV and malaria poses a triple threat to maternal health and foetal development.9  
The World Health Organization (WHO) currently recommends a three-pronged approach for the 
control of malaria in pregnancy; case-management of symptomatic malaria; providing long lasting 
insecticide-treated bed nets (LLITNs) to reduce exposure to infective mosquito bites; and intermittent 
preventive treatment of malaria in pregnancy (IPTp) for prevention of malaria in HIV-negative 
pregnant  women and daily cotrimoxazole (CTX) in HIV-infected women.4,10,11 IPTp consists of the 
administration of treatment doses of sulfadoxine-pyrimethamine (IPTp-SP) during the second and 
third trimesters of pregnancy at every scheduled antenatal visit at least a month apart.4,10,11  
3.1.2 Viral co-infections in pregnancy 
In East and Southern Africa, maternal viral infections including cytomegalovirus (CMV), Epstein-Barr-
virus (EBV), measles virus, Respiratory syncytial virus (RSV) and several mosquito vector-borne viruses 
such as Dengue, Chikungunya, Zika, Yellow Fever, Rift Valley Fever12are co-endemic with malaria and 
HIV, and are each known to be associated with pregnancy loss and pre-term delivery13-15 and may 
compound the adverse pregnancy outcomes associated with malaria and HIV. The impact of maternal 
viral co-infections or the potential effect of antimalarials on some of these viral infections has not yet 
been documented.  
3.2 
MALARIA PREVENTION IN HIV-INFECTED WOMEN 
3.2.1 Antifolate resistance 
Sulphadoxine-pyrimethamine (SP), an anti-folate drug, is the only antimalarial currently 
recommended by the WHO for IPTp. However, IPTp-SP is contraindicated in HIV-infected pregnant 
women receiving daily CTX, both of which are sulpha-based anti-folate drugs, due to their overlapping 
mechanisms of action and synergistic risk of adverse drug reactions when used in combination.11 CTX 
has some anti-malarial properties, and in HIV-infected pregnant women, plays a dual role as both 
prophylaxis against opportunistic infections and malaria and, has been associated with reduced 
incidence of  malaria infection and maternal anaemia16 and  improved pregnancy outcomes.17 

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However, because SP and CTX as anti-folate drugs are thought to share the same drug targets, the 
increasing resistance of the malaria parasite to SP, also threatens the efficacy daily CTX for malaria 
prophylaxis in HIV-infected women.18-21 Recent IPTp trials in HIV-infected women who received the 
combination of daily CTX plus an additional 3 courses of IPTp with mefloquine, suggested that 
chemoprevention with an effective antimalarial markedly improves the protection against malaria 
compared to daily CTX alone. However, IPTp-MQ was poorly tolerated and was associated with 
increased viral load and MTCT of HIV.22,23 There remains a need for enhanced chemoprevention of 
malaria in HIV-infected pregnant women.2,9,24,25 
3.2.2 Chemoprevention with Dihydroartemisinin-Piperaquine (DP) 
3.2.2.1 
IPTp with DP in HIV-negative women 
Unlike IPTp with mefloquine, amodiaquine or chloroquine based combinations,26-28 the long-acting 
combination of dihydroartemisinin–piperaquine (DP) is well tolerated and has shown great promise 
as IPTp in HIV-negative women in two recently completed trials conducted in Uganda29and Kenya.30,31 
A recent meta-analysis of these two trials suggests a 73% (95% CI 43 to 88) and 75% (37 to 90) 
reduction in clinical malaria and malaria infection during pregnancy respectively, a 65% (95% CI 30 to 
83) reduction in placental malaria, and a non-significant reduction in adverse pregnancy outcomes of 
17% (-10 to 38).32  
3.2.2.2 
Experience to date with IPTp with DP in HIV-positive women 
IPTp with DP has only been evaluated in a single trial (n~200) in Uganda comparing daily CTX alone to 
daily CTX plus monthly DP. This trial showed no statistical difference in the risk of malaria during 
pregnancy or at delivery.33 The study was inconclusive because of the small sample size and the very 
low malaria transmission in the study area following the successful introduction of Indoor Residual 
Spraying (IRS)34; the rate of placental malaria in the CTX arm was approximately 10-fold lower than 
the risk observed in HIV-infected daily CTX recipients in the previous years in this same study area.33 
Furthermore, a clinically relevant drug-drug interaction between DP and efavirenz (EFV) was found to 
reduce DP drug levels by 38%. Based on this study alone, it would be wrong to conclude that HIV-
infected women require no additional antenatal malaria prevention beyond daily CTX because the 
power of this study was undermined by the low prevalence of the primary outcome, which was 
unexpected and beyond the control of the investigators.24  
Encouragingly, the addition to CTX of monthly DP was well tolerated, which is a necessary 
precondition for any candidate prevention measure. Furthermore, there were no indications that the 
piperaquine-associated corrected QT prolongations were worse in HIV-infected women receiving CTX 
and EFV-based combination antiretroviral therapy (cART) than in HIV-uninfected women receiving DP 
and were also not associated with pregnancy status or, importantly, with the number of previous IPTp 
courses taken.35 
3.2.3 DP and other viral infections 
A recent study showed chloroquine, a quinoline-based anti-malarial demonstrated in-vitro 
prophylactic and therapeutic effects on Chikungunya virus36 as well as conferred protection against 
Zika virus infection in pregnant mice.37 Piperaquine, has a similar chemical structure as chloroquine, 
but its impact on arboviruses has not yet been explored. Additionally, artemisinins have been shown 
to have robust inhibitory effects against some viruses such as CMV and EBV.38,39 If DP is shown to 
inhibit the growth of arboviruses and other maternal viral co-infections, they may lead the way for 
integrated approaches towards the prevention of malaria and arboviral and other viral infections in 
HIV-uninfected and infected pregnant women with monthly DP and use of insecticide-treated nets. 

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3.2.4 Recent changes in first-line combination antiretroviral therapy (cART) from 
efavirenz (EFV) to dolutegravir (DTG) based cARTs 
Following the recent recommendations by WHO in 2018, a transition is occurring in 2018-2019 from 
EFV-based cARTs to dolutegravir (DTG) based cARTs in sub-Saharan Africa, which in many countries 
may be completed by 2020.40-43 DTG is associated with fewer drug-drug interactions, is more effective 
than EFV-based regimens in suppressing viral load in late pregnancy44,45 and has a higher genetic 
barrier to resistance than EFV. In its most recent guidelines from December 2018,43 WHO is now 
recommending the use of DTG-based combinations (TDF+3TC (or FTC) + DTG) as the preferred first-
line regimen in the 2nd or 3rd trimester and breastfeeding women (see highlighted text in Table 2: WHO 
updated preferred first-line regimens in pregnant and breastfeeding women and women of 
childbearing potential, page 23).43 Because the safety of dolutegravir at the time of conception and in 
early first trimester pregnancy remains to be established,46 WHO continues to recommend EFV-based 
cARTs (TDF+3TC (or FTC)+EFV47) in the first trimester and for women of children bearing age who wish 
to become pregnant or do not have access to ‘consistent and reliable contraception’, unless a woman 
chooses to use DTG-based cARTs ‘after informed choice’ (see 3.4.3, Dolutegravir, page 25).  
Many countries in sub-Saharan Africa are recommending the continued use of EFV in pregnant women 
because of concerns about the complexity of WHO’s regimen. However, several countries are in the 
process of reviewing their cART and PMTCT guidelines in the light of these updated recommendations 
from WHO43 and recent findings from the DOLPHIN-II trial showing that DTG-based combinations are 
much more effective than EFV-based combination in rapidly suppressing viral load below the level of 
detection when initiated late in pregnancy.44,45 It is therefore anticipated that more countries in sub-
Saharan Africa will consider WHO guidelines and use DTG-based regimens as the preferred first-line 
cART during the 2nd and 3rd trimester of pregnancy. The Malawian48 PMTCT guidelines were reviewed 
in March 2019 and will now include the use of DTG-based cART regimens in the 2nd and 3rd trimester 
of pregnancy (Clifford Banda, personal communications). Kenya is scheduled to review their guidelines 
in late 2019, and currently recommends EFV-based combinations in women of child-bearing potential 
including during pregnancy.49 However, the Kenyan PMTCT guidelines also state that: a) ‘DTG is safe 
during pregnancy and breastfeeding if initiated 8 weeks after conception (although women need to 
be counseled on the risk of becoming pregnant while breastfeeding and provided with effective 
contraception)’ and b) ‘Women and adolescent girls of childbearing potential may opt to remain on 
DTG and should be supported in their decision and offered effective contraception as well as 
counseling on the potential risk of birth defects when DTG is used around the time of conception.’49  
 

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Table 2: WHO updated preferred first-line regimens in pregnant and breastfeeding women and women of childbearing potential 
 
Source: World Health Organisation, Updated recommendations on first-line and second-line antiretroviral regimens and 
post-exposure prophylaxis and recommendations on early infant diagnosis of HIV: Interim Guidelines. Supplement to the 
2016 consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. December 2018. 
HIV treatment. Geneva: World Health Organisation. Table 1, Preferred and alternative first-line regimens in adults and 
adolescents, page 21 of WHO’s guidelines.43 The authors of this protocol added the highlights. 

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3.3 
DRUG-DRUG INTERACTIONS  
3.3.1 Drug-drug interaction between DP and dolutegravir 
There are no previous studies of DP and DTG-based cART regimens. DTG is associated with fewer drug-
drug 
interactions 
than 
efavirenz40,50 
because 
it 
is 
metabolized 
primarily 
by 
UDP 
glucuronosyltransferase (UGT)1A1 and is not an inducer nor inhibitor of CYP isoenzymes50 minimizing 
the risk of clinically relevant drug-drug interactions that would decrease the concentrations of 
piperaquine which is mainly metabolised by CYP3A4 (and to a lesser extent by CYP2C9 and CYP2C19). 
Previous drug-drug interaction studies between dolutegravir and artemether-lumefantrine or 
artesunate-amodiaquine showed that dolutegravir did not significantly change the maximum 
concentration in plasma, the time to maximum concentration, and the area under the concentration-
time curve (AUC) for artemether, dihydroartemisinin, lumefantrine, and desbutyl-lumefantrine, nor 
did it significantly alter the AUC for artesunate, dihydroartemisinin, amodiaquine, and 
desethylamodiaquine.51  
It is less clear if there is potential for DP to affect dolutegravir concentrations. Dihydroartemisinin does 
not induce or inhibit UGT1A1, and piperaquine is a weak inducer. Nevertheless, coadministration of 
dolutegravir with artesunate-amodiaquine resulted in 42 and 24% approximate decreases in the DTG 
trough concentrations and the AUC, respectively.51 The mechanisms for these interactions are unclear. 
These decreases in DTG concentrations are unlikely to be of clinical significance since for all subjects 
who received DTG with artesunate-amodiaquine trough concentrations were comparable to or above 
1,100 ng/ml (10) trough concentrations observed in prior dolutegravir phase 3 adult trials.51 
Furthermore, through concentrations of 300 ng/ml52 or 150ng/mL (the 5th percentile of the DTG 
trough concentration distribution) and are associated with good efficacy of DTG.52 The combinations 
were well tolerated with no serious adverse events.  
Nevertheless, since DP, like artesunate-amodiaquine, is a 4-aminoquinoline ACT and no previous 
pharmacokinetic studies of DP and DTG-based cART regimens have been conducted, we propose to 
investigate this through a pharmacokinetic sub-study as part of the current IMPROVE-2 study. 
3.4 
SAFETY OF STUDY DRUGS IN PREGNANCY 
3.4.1 CTX 
CTX has been used for many years as prophylaxis for opportunistic infections in pregnancy as part of 
routine HIV care.  
3.4.2 Dihydroartemisinin-Piperaquine 
3.4.2.1 
Experience with DP in pregnancy 
There is also increasing experience with DP in pregnancy, both for treatment (case management) and 
chemoprevention (IPTp). Treatment with DP has been shown to be safe in the 2nd and 3rd trimester of 
pregnancy.29,30,53-59 A single course DP is safe for use in the 2nd and 3rd trimesters, is recommended by 
WHO for treatment of malaria in the 2nd and 3rd trimester and has been first-line treatment for this 
indication in Papua, Indonesia, for over 10 years.  
In addition to the extensive experience using this drug for treatment in pregnancy, approximately 
3,282 women have received either 3-course or monthly IPTp-DP in Kenya,30 Uganda,29,60 our recently 
completed IPTp-DP trial in Indonesia (STOPMIP-Indonesia,61 ISRCTN34010937) and in our ongoing 
IMPROVE trial in HIV-negative women. The three recent trials in Uganda and Kenya showed that 

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monthly IPTp with DP was well tolerated with no noticeable differences to SP in side effect profiles. 
There is also no indication that IPTp-DP is associated with an increased risk of congenital malformation 
or pregnancy loss. The existing evidence in Africa suggests a 61% [95% CI 13-83] reduction in the risk 
of foetal loss compared to SP in HIV-negative women.29,30,32 The single trial to date in HIV-infected 
women showed IPTp-DP to be well tolerated (N=184).62  
3.4.2.2 
Piperaquine-associated QTc prolongation 
The main safety concern with DP is a dose-dependent QTc prolongation associated with piperaquine, 
like that observed with other antimalarials like chloroquine, but less severe than with halofantrine 
and quinine. Because of its slow elimination, monthly doses of DP could result in dose accumulation 
of piperaquine. However,  the experience in over 2,200 HIV-uninfected pregnant women who received 
either 3-course or monthly IPTp-DP in Kenya, Uganda, Malawi and Indonesia29,30,63-65 (Clinicaltrials.gov 
NCT02793622 and NCT03009526) does not suggest that the known piperaquine associated QTc 
prolongation increases with the number of previous courses received, i.e. the magnitude of QTc 
prolongation was similar after 3 to 5 courses to the prolongation observed after the 1st course and 
similar to that observed in patients treated for acute malaria. This is likely because piperaquine-
associated QTc prolongation is transient and lasts for a few days only. This is also consistent with 
experience with ITP in Ugandan children provided with 18 monthly courses of DP from 6 to 24 months 
of age the magnitude of transient QTc prolongation remained constant and was similar after ≥12 
monthly courses compared to a single course.66 
There is less experience (n=184) with IPTp with DP when provided to HIV-infected women who receive 
daily CTX and cARTS, although in the single previous study with IPTp-DP in HIV-infected women on 
EFV-based cART, all pre- and post-dosing QTc intervals were within normal limits (<450 msec).67 
3.4.3 Dolutegravir (DTG) 
The DTG-based fixed combination cART tenofovir/lamivudine/dolutegravir (TLD) is recommended by 
WHO for use in the 2nd and 3rd trimester of pregnancy (see Table 2: WHO updated preferred first-line 
regimens in pregnant and breastfeeding women and women of childbearing potential, page 23). This 
is based on the lower costs and superior efficacy of TLD, relative to EFV-based combination, in rapidly 
suppressing viral load and the available safety data from approximately 2,000 pregnancies initiating 
DTG-based ARTs in the ongoing Tsepamo birth study in Botswana. This Tsepamo study showed that 
the rate of adverse birth outcomes and congenital malformations were similar among pregnant 
women who initiated DTG-based and EFV-based cART at least eight weeks after conception. 9, 90  
There are concerns however about the use of DTG-based cARTs in women of childbearing age because 
results from the Tsepamo birth study in Botswana also indicated that DTG was associated with an 
increased risk of neural tube defect when used at the time of conception. This resulted in the WHO 
updated treatment guidelines from December 2018. These new guidelines recommend that women 
of children bearing potential should only be offered DTG-based cARTs if they are using effective 
contraception, or choose to use DTG after informed choice. More recent collective data involving 
monitoring of 198 pregnancies from prospective antiretroviral pregnancy exposure registries (APR and 
EPPICC) as well as data from 3 other studies with 104 pregnancy outcomes identified no birth defect 
signal, either in defect prevalence of defect type. In addition, among the birth defects reported after 
DTG exposure during pregnancy or at the time of conception, none involved neural tube defects.  
These data provide some reassurance to women whose pregnancies have already been exposed to 
DTG or who have limited options. They also highlight the importance of continuing prospective 
monitoring of pregnancies exposed to DTG around the time of conception. 

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4 JUSTIFICATION FOR THE STUDY 
4.1 
WHY IS THIS STUDY NEEDED NOW? 
IPT with DP has great promise to reduce the burden of malaria during pregnancy in HIV-negative 
women in Africa, but because of the drug-drug interaction with EFV, the benefits are lost in HIV-
infected women receiving EFV-based cARTs. A recent WHO Malaria Policy Advisory Committee 
(MPAC) recommendations based on WHO Evidence Review Group (ERG) on malaria in pregnancy from 
October 2017 25,68 highlighted the need for alternative strategies for chemoprevention in HIV-infected 
women as CTX provides only partial protection against malaria; and the need for PK/PD studies of 
antimalarials in pregnancy to advice on dosage modification including in HIV-infected women on 
different cART regimens. The proposed IMPROVE-2 trial will address these gaps and will determine 
the efficacy of monthly IPTp-DP when added to daily CTX on antenatal malaria infection. 
4.2 
OTHER RELEVANT RESEARCH ONGOING ELSEWHERE 
4.2.1 HIV-infected women 
We are aware of one other EDCTP2-funded trial similar to IMPROVE2 to be conducted in Mozambique 
and Gabon between 2018 and 2023: A randomised double-blind placebo-controlled trial to evaluate 
the safety and efficacy of DHA-PPQ for IPTp in HIV-infected pregnant women receiving CTXp and ARV 
drugs and using LLITNs (MAMAH)69. A search of WHO’s trial registry indicated no other registered IPTp-
DP, or DP prophylaxis trials in HIV positive pregnant women are ongoing in Africa. 
4.2.2 HIV-uninfected women 
However, five studies with IPTp with DP in HIV-negative women are ongoing or have been completed 
involving a total of 4,519 HIV-negative participants who received or will receive IPTp with DP in Africa. 
This includes 3,120 IPTp-DP recipients in our own (sister) trial in involving a total of 4,680 women in 
Kenya, Malawi and Tanzania (IMPROVE trial). The IMPROVE trial (separate stand-alone protocol) and 
IMPROVE-2 trial (this protocol) are conducted in the same sites in Kenya and Malawi. We are also 
aware of two smaller trials comparing monthly IPTp-DP and IPTp-SP in a high SP resistance area in 
eastern Uganda, published recently,60 and in Malawi (PMI-funded, Julie Gutman, CDC, personal 
communications, Clinicaltrials.gov NCT03009526, approximately 602 women, 301 per arm). These five 
trials involving over 4,500 IPTp-DP recipients will be sufficient to address the impact of IPTp-DP versus 
IPTp-SP on adverse birth outcomes in a prospective meta-analysis of individual participant data. 
We are also aware of one other study in Africa looking at the cardiac safety of single course (rather 
than repeat course) of IPTp with DP in pregnancy (n=100) in north-eastern Tanzania (Matthew Chico 
et al, LSHTM; Clinicaltrials.gov NCT02909712).  
Lastly, our STOPMIP-Indonesia trial,65 comparing IPTp-DP with screening strategies involved a further 
681 women on monthly IPTp-DP, but the efficacy results cannot be extrapolated to Africa because the 
study is conducted in low transmission areas where P. falciparum and P. vivax co-exist, and the control 
arm does not involve IPTp-SP. 
4.3 
HYPOTHESES 
We propose to conduct a 2-arm trial in HIV-infected women on anti-retroviral drugs and daily CTX, 
comparing the current strategy with CTX alone, against a new intervention consisting of monthly IPTp 
with DP. The study has the following hypothesis: Monthly IPTp-DP in women receiving daily CTX is 

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superior to daily CTX-alone in controlling malaria infection during pregnancy in HIV infected women 
on antiretroviral therapy. 
5 AIM & OBJECTIVES 
The overall aim of the study is to provide WHO with evidence on whether monthly IPTp-DP can 
improve current policies to control malaria in HIV-infected pregnant women on daily CTX in areas with 
high levels of parasite resistance and malaria in East and Southern Africa. 
5.1 
PRIMARY OBJECTIVE 
To determine if monthly IPTp-DP in HIV-infected pregnant women receiving daily CTX is safe and 
superior to daily CTX-alone for controlling malaria infection in areas with high antifolates resistance 
to SP and CTX in Malawi and Kenya.  
5.2 
SECONDARY OBJECTIVES 
1. To determine if monthly IPTp-DP in HIV-infected pregnant women receiving daily CTX is safe 
and superior to daily CTX-alone for preventing adverse pregnancy outcomes due to malaria. 
2. To determine the effect of co-administration of DP and current first-line cARTs on the 
pharmacokinetic properties of piperaquine, first line cARTs and CTX 
3. To determine if the level of SP drug resistance, assessed by molecular markers, affects the 
potential impact of CTX. 
4. To determine the safety of monthly-DP in pregnant women receiving daily CTX and cARTs by 
conducting nested cardio monitoring studies. 
5. To determine if monthly IPTp-DP in HIV-infected pregnant women receiving daily CTX affects 
the risk of mother-to-child transmission of HIV infection. 
6. To determine if monthly IPTp-DP in HIV-infected pregnant women receiving daily CTX reduces 
the risk of viral infections. 
7. To determine the impact of the interventions and prenatal exposure to HIV and/or malaria on 
adaptive and innate-like immune responses 
6 TRIAL DESIGN & DESIGN CONSIDERATIONS 
6.1 
OVERVIEW OF DESIGN 
This will be a multi-centre, 2-arm, parallel, placebo-controlled, individually randomised, phase-3, 
superiority trial in 898 (449 per arm) HIV-infected pregnant women receiving daily CTX and cARTs to 
compare the efficacy of monthly IPTp-DP (‘CTX-DP’) against monthly placebo-DP (‘CTX-alone’) 
(allocation ratio 1:1). The study will be conducted in about 8 sites in high malaria endemic and high 
HIV endemic areas in southern Malawi and western Kenya. These are the same sites in Malawi and 
Kenya where the trial in HIV-negative women (IMPROVE) will be conducted.  
HIV-infected pregnant women (all gravidae) attending for antenatal care (ANC) between 16-28 weeks’ 
gestation irrespective of CTX or cART use, assessed by ultrasound dating, will be eligible. Participants 
will be seen monthly until delivery. Mothers and infants will be followed-up for 6 to 8 weeks post-
partum. Sub-studies of cardiac-safety and pharmacokinetics will be conducted. 

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The trial is powered at 80% (alpha=0.05) to detect a 50% reduction in the cumulative incidence of 
malaria infection and will take 24 months to complete. 
6.2 
DESIGN CONSIDERATIONS 
6.2.1 Rational for a fixed dose rather than a dose based on bodyweight 
There are pragmatic benefits to using a fixed dose rather than a dose based on bodyweight, but the 
risk is that heavier women are under-dosed as they receive less drug per kg bodyweight. However, 
the data from the two Ugandan trials in pregnant women, both of which used a fixed monthly dose of 
3x3 tablets per day, showed that in contrast to expectations, women with a lower BMI have lower 
(rather than higher) piperaquine concentrations compared to those with higher BMI, despite the fact 
that women with the lower BMI received more drug per kg bodyweight.29,33,35,70,71 Women with a lower 
BMI appear to eliminate piperaquine more quickly, resulting in lower plasma drug concentrations 
relative to the dose in mg/kg received. This was observed in both HIV-infected women (all on EFV-
based cARTs) and HIV-uninfected pregnant women. In HIV-uninfected women, women in the higher 
weight-based category achieved adequate drug concentrations with the fixed dose of 960 mg and the 
fixed-dose regimen was very effective and only 3 out of 373 women got malaria in the monthly IPTp-
DP arm (Rada Savic and Erika Wallender, UCSF, personal communications). which reflected a >90% 
reduction in malaria compared to the monthly SP arm.72 Models predict that HIV-infected women on 
DTG-based regimens (i.e. assuming no drug-drug interaction affecting piperaquine concentrations) 
will achieve the same adequate trough levels with a fixed dose of 3 tablets per day (960 mg/day) as 
observed in HIV-uninfected women (courtesy of Rada Savic and Erika Wallender, UCSF, personal 
communications). This has important potential policy implications as it suggests that women in the 
heavier bodyweight categories (60-80kg and >80kg) are likely to achieve adequate piperaquine 
concentrations with a fixed monthly dose of 3x3 tablets, avoiding the need for a more complex weight-
based loading dose or weekly regimens. 
6.2.2 Rationale for nested pharmacokinetic studies 
Because no previous studies have looked at the combination DP and DTG-based cARTs, there is a need 
for further PK profiling of piperaquine-DTG drug-drug interactions to verify the pharmacological model 
predictions. This includes an assessment of the effect of the cARTs on piperaquine pharmacokinetics, 
and the effect of repeated piperaquine dosing on the steady state concentration of the cARTs and 
CTX. 
6.2.3 Design as a superiority trial 
Daily cotrimoxazole is cheap, well tolerated, safe, widely available and with the double benefit of 
conferring protection against malaria and opportunistic infections in HIV-infected participants. In 
contrast, DP will be more expensive, result in more adverse effects, and confer a greater pill burden 
during implementation as it will be given in addition to daily CTX and cART in this population. 
Therefore, the health benefits need to be sufficiently greater than observed with daily CTX-alone to 
outweigh the burden of an additional monthly 3-day DP regimen and the additional cost associated 
with the drug and implementing a new policy in HIV-infected pregnant participants. 

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7 METHODS: PARTICIPANTS, INTERVENTIONS, AND OUTCOMES 
7.1 
STUDY SETTING 
For the study to have a high likelihood of showing a differential impact, it must be conducted in areas 
with moderate to intense malaria transmission and high SP resistance, which is a proxy of CTX 
resistance. The prevalence of placental infection detected by PCR and histopathology among 
paucigravidae in the SP arms of our recent trials in HIV-negative participants was 50% in Kenya30 and 
57% in Malawi.73 These high rates in both countries suggest both a failure of SP to clear or prevent 
infections and high transmission intensity. In the sites in Kenya and Malawi, the prevalence of the 
quintuple mutant is >98% and approximately 6-9% of participants in 2013 were infected with parasites 
carrying the sextuple dhfr/dhps mutation (Pfdhps-A581G in combination with the quintuple mutant). 
The National Malaria Control Programmes (NMCP) in these two countries regard SP resistance as a 
major threat to the existing IPTp-SP policy.  
 
The study will be conducted in antenatal clinics and delivery units of Government or private (e.g. 
mission) hospitals and clinics with at least 30 new antenatal attendants per month in areas with year-
round malaria transmission. The final choice of sites will depend on the available infrastructure and 
absence of planned malaria control interventions in the catchment area that might have a major 
impact on the malaria transmission intensity during the study period (e.g. planned mass campaigns to 
reduce malaria transmission such as indoor residual spraying [IRS]).  
7.1.1 Kenya 
The study is part of a multi-year collaboration between LSTM and the Kenya Medical Research 
Institute (KEMRI), Kisumu, western Kenya, and the US Centers for Diseases Control and Prevention 
(CDC)-Kenya, and will be conducted in approximately 3 to 5 Hospitals and satellite ANC clinics in the 
counties of the previous Western and Nyanza Provinces; including, but not limited to Busia, Siaya, 
Kisumu, Homa Bay and Migori counties in high malaria transmission areas in western Kenya.  
7.1.1.1 
Suggested primary hospitals 
Ahero sub-county hospital, Rabuor sub-county hospital and Akala sub-county hospital and the 
corresponding satellite clinics that refer patients to these hospitals. 
7.1.1.2 
Backup and expansion hospitals and clinics  
Homa Bay County Referral Hospital, Rongo sub-county hospital, Migori County Referral Hospital, St 
Mary's Hospital, Mumias, Mukumu Mission Hospital, Kakamega, Kisumu District Hospital, Pap Onditi 
sub-county hospital, Sondu sub-county hospital, Busia District Hospital, Nyamira District Hospital, 
Bondo County Hospital, Siaya County Referral Hospital, Madiany County Hospital, Kisumu County 
Referral Hospital, Jaramogi Oginga Odinga Teaching and Referral Hospital, Rachounyo sub county 
hospital, Kendu Bay sub-county hospital and Kendu Adventist hospital. This list is not exclusive and 
another hospital may be considered for inclusion in western Kenya if they fulfil the entry criteria for 
size and malaria transmission and control. 
7.1.2 Malawi 
The sites in southern Malawi will include 3 to 5 district hospitals and satellite ANC clinics where several 
pregnancy studies have been conducted. The Research Support Centre from the College of Medicine 
(CoM), University of Malawi, and supported by Malawi-Liverpool-Wellcome Trust Clinical Research-
Programme linked with the CoM in Blantyre will be the coordination institutions providing 
administrative and laboratory support. 

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7.1.2.1 
Suggested primary hospitals 
Mangochi District Hospital, Zomba Central Hospital, Chikwawa District Hospital, Madziabango and 
Mpemba Health Centers and, the corresponding satellite clinics that refer patients to these facilities. 
7.1.2.2 
Backup and expansion hospitals and clinics  
These included, but are not limited to Machinga District Hospital, Lungwena Health Center, Makanjira 
Health Center, Monkeybay Community Hospital, Domasi Rural Hospital, Mfera Health Center, 
Chapananga Health Center, Balaka District Hospital, Chiradzulu District Hospital, Mwanza District 
Hospital and Ntcheu District Hospital. This list is not exclusive as other hospitals may be considered 
for inclusion in southern Malawi if they fulfil the entry criteria for size and malaria transmission and 
control. 
7.2 
ELIGIBILITY CRITERIA 
7.2.1 Inclusion criteria 
Includes: HIV-infected pregnant participants between 16-28 (both inclusive) weeks gestation, 
singleton pregnancy, on or eligible for DTG-based cARTs and CTX, resident of the study area, willing 
to adhere to scheduled and unscheduled study visit procedures, willing to deliver in a study clinic or 
hospital.  
7.2.2 Exclusion criteria 
Includes: Multiple pregnancies (i.e. twin/triplets), HIV-negative or HIV-status unknown, known heart 
ailment, severe malformations or nonviable pregnancy observed by ultrasound, unable to give 
consent, confirmed or suspected TB infection, known allergy or contraindication to any of the study 
drugs. 
7.3 
INTERVENTIONS 
7.3.1 Trial Medications and interventions 
7.3.1.1 
Study arms 
At enrolment, all participants will be randomly allocated to receive one of two regimens: 
Table 3: Dosing regimen per course 
Study arm Drug regimen 
Number of tablets once daily per 
course (In addition to daily CTX) 
Day-0 
Day-1 
Day-2 
CTX-alone Daily CTX plus monthly placebo-DP 
3  
3  
3  
CTX-DP 
Daily CTX plus monthly DP 
3  
3  
3  
CTX-alone: Daily, one double-strength tablet of 160mg of sulfamethoxazole and 800mg of 
trimethoprim plus monthly placebo-DP, given as a fixed dose of 3 placebo-DP tablets daily for three 
days until delivery. 
CTX-DP: Daily, one double-strength tablet of 160mg of sulfamethoxazole and 800mg of 
trimethoprim plus monthly DP, given as a fixed dose of 3 tablets (40 mg of dihydroartemisinin and 
320 mg of piperaquine) daily for three days until delivery. 
 

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All participants will (continue to) receive daily cotrimoxazole (CTX) (one double-strength tablet of 
160mg of sulfamethoxazole and 800mg of trimethoprim) and anti-retroviral drugs (see section  
7.3.1.4, Other concomitant intervention, page 31).  
7.3.1.2 
Placebos  
The study will be placebo-controlled such that each woman will receive an identical number of tablets 
per day (3) for an identical number of days (3) at enrolment and monthly after that. 
7.3.1.3 
Methods of drug administration  
7.3.1.3.1 Enrolment 
The first-day dose of each DP will be given in the clinic under direct observation (day-0). Participants 
will be given clean water for swallowing the tablets and will then be observed for thirty minutes. 
Participants will be given the remaining day-1 and day-2 doses to take at home, with instructions to 
take one set of the pre-packaged tablets on each of the two days. If vomiting occurs in the ANC during 
the 30 min observation period on day-0, the full dose will be repeated. If the participant vomits again 
after the repeat dose, she will be instructed to take the next daily dose the following day. Women will 
be given instructions when going home that if she vomits her drugs within 30 minutes on either day-
1 or day-2, she should come back to the clinic or a replacement dose can be brought to her home for 
30 min observed dosing of that day’s drug. If intolerance continues, she will not be given DP again for 
that course but receive her next course of DP or DP-placebo during the next monthly visit according 
to the normal schedule.  
Methods to monitor adherence to the 3-day dose regimen are described in section 7.3.5, Strategies 
to improve adherence to study protocol and medication, page 35. 
7.3.1.3.2 Monthly DP dose 
Participants will be given each subsequent monthly DP course using the same procedures as for the 
enrolment course; i.e. the first daily dose is given in the clinic under supervision and the remaining 
two daily doses will be taken at home. Methods to monitor adherence to the monthly dose are 
described in section 7.3.5, Strategies to improve adherence to study protocol and medication, page 
35. 
7.3.1.4 
Other concomitant intervention 
All participants will (continue to) receive daily cotrimoxazole and anti-retroviral drugs consisting of 
the fixed combination tenofovir/lamivudine/dolutegravir (TLD) containing Tenofovir (TDF, 300mg) 
and Lamivudine (3TC, 300mg) and dolutegravir (DTG, 50mg). In addition, all participants will receive a 
long-lasting insecticide-treated net (LLIN) on enrolment as part of routine antenatal care. The study 
will ensure the clinics have access to the standard (low-dose of folic acid (0.4mg) as some clinics still 
use high-dose folic acid (5mg) which may interact with CTX (an antifolate drug).  
7.3.1.5 
Manufacturing, regulatory approval and supply of study drugs 
7.3.1.5.1  Dihydroartemisinin-piperaquine and matching placebo 
Dihydroartemisinin-piperaquine and matching placebo will be sourced for this study from Guilin 
Pharma, based in China which is GMP certified manufacturer of  D-ARTEPP®, which is produced as 
40/320, 60/480 and 80/640 dihydroartemisinin/piperaquine tablet strengths (see section 16.7 
Appendix VII. Product characteristics, page 91). Alternatively, it will be sourced from Alfasigma 
(formerly Sigma-Tau), Rome, Italy who manufacture DP as Eurartesim® (which makes adult tablet 
containing 40 mg of dihydroartemisinin and 320 mg of piperaquine).  

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7.3.1.5.2 Cotrimoxazole (CTX) 
CTX is usually provided to HIV-infected participants at government clinics for free. Where required, 
CTX will be purchased from either Durbin PLC, South Harrow, Middlesex, UK, or other international 
specialist medical suppliers of quality controlled products that distribute pharmaceuticals worldwide 
or as generic by other GMP manufacturers (e.g. Universal or Cosmos, Nairobi). Cotrimoxazole is 
approved for use in Kenya and Malawi under various brand names.  
7.3.1.6 
Product labelling, shipment and accountability  
7.3.1.6.1 Labelling and shipment 
Each manufacturer will be responsible for the labelling of the active drug and placebo and will arrange 
shipment to the respective countries. The study will cover the shipment costs and customs clearance 
fees. The manufacturers will also provide the certificate of good manufacturing practice (GMP), 
certificates of analysis for active drug and placebo, where appropriate, the most recent Investigator 
Brochure, and the summary of product characteristics (SmPC) and the Public Assessment Report (PAR) 
(released by FDA / EMA), a certificate of donation, and an invoice. All of these are required by the 
countries to obtain regulatory clearance and an import license for the study drug. 
7.3.1.6.2 Packaging 
Blister packs or envelopes with the study arm specific active drug and placebo combinations will be 
prepared by the manufacturers or an equivalent organisation or the study pharmacist, such that one 
box or envelope contains all the study drugs for that participant. Each box or envelope will contain 
smaller envelopes each containing a blister pack for a specific course. The specific study drug blisters 
will be kept in the box/envelope until dispensing. Packaging used for all treatment arms will be 
identical, labelled and blinded to the contents. The study drugs will be prepared and shipped in at 
least two different batches, to avoid any shelf life limitations. 
7.3.1.6.3  Product storage   
All study drugs will be stored in a secure area with access limited to investigators and authorised study 
site personnel, and under appropriate storage conditions. 
7.3.1.6.4  Product accountability 
The site-PI will be responsible for establishing a system for the correct handling of study drug to ensure 
that: 
1. Deliveries of study drug from the sponsor are correctly received by a responsible person (e.g. 
pharmacist assistant) 
2. Accurate records are maintained for the receipt of study drug, for the dispensing of study drug to 
subjects and for the returned study drug. 
3. Certificates of delivery and return must be signed preferably by the investigator or authorised 
personnel and copies retained in the trial site file. 
4. The study drug is to be handled and stored safely and properly and in agreement with the given 
storage instructions. 
5. The study drug is to be prescribed only by the principal investigator, co-investigators or study site 
personnel authorised to do so by the principal investigator. 
6. The study drug is dispensed only to study subjects in accordance with the protocol.  
7. Subjects must return all unused medication and empty containers to the investigator. 
8. At the end of the study, delivery records must be reconciled with records of usage and returned 
stock. Any discrepancies must be accounted for in writing. 

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9. Once accounted for, any returned and unused study treatment at the site will be returned to the 
sponsor for destruction or destroyed locally upon agreement with the sponsor. Drug destruction 
certificates will be issued that refers to the subject study numbers for subject-specific medication 
that was destroyed. 
7.3.1.6.5  Pharmacist, pharmacist assistant or dispenser 
All efforts will be made for the preparation, packaging and labelling of the blinded study drug to be 
performed and documented in accordance with Good Manufacturing Practice (GMP).  
7.3.2 Criteria for discontinuing or modifying allocated interventions for a given 
trial participant 
7.3.2.1 
Malaria infection or symptomatic malaria 
7.3.2.1.1  Malaria infection diagnosed at enrolment visit 
 
Participants who are febrile or have a recent history of fever or other symptoms of malaria during the 
enrolment visit will not be excluded. They will follow the standard enrolment and randomisation 
procedures during that initial visit. In addition, a malaria RDT will be taken. In Kenya, the policy is to 
screen all women for malaria by RDT or microscopy regardless of the presence of symptoms as part 
of routine care. In Malawi, this is restricted to symptomatic women. Participants who have 
uncomplicated malaria confirmed by RDT, regardless of the presence of symptoms, will be treated 
with a 3-day course of artemether-lumefantrine (AL) for clinical malaria as per national guidelines and 
will not yet be given DP. The first study specific antimalarial drugs (i.e. the DP or placebo-DP) will then 
be given during the next scheduled monthly visit approximately four weeks later. This guarantees that 
both arms (included the CTX-only arm) will receive an active ACT when diagnosed with malaria 
infection at enrolment. This will be recorded on the CRF. Participants with negative RDT will be given 
study drug as per randomisation arm. 
7.3.2.1.2  Febrile participants during scheduled visits  
Similarly, participants in any group who attend a scheduled study appointment with fever and malaria 
confirmed by RDT will be treated with a 3-day course of AL for clinical malaria. If their scheduled 
monthly dose of DP or placebo-DP falls within the same three AL treatment days, their DP dose will 
be delayed until the day after the completion of the last dose of AL. After the delayed course of DP 
has been taken, they will then continue with monthly DP approximately four weeks later. This will be 
recorded on the CRF. Participants with negative RDT will continue with the original schedule as per 
randomisation arm. 
7.3.2.1.3  Unscheduled visits 
Participants diagnosed with symptomatic uncomplicated malaria during the course of the study will 
also be treated with AL and where appropriate the next monthly dose of DP or placebo-DP delayed 
using the same schedule as described in 7.3.2.1.2 Febrile participants during scheduled visits. This will 
be recorded on the CRF. 
7.3.2.2 
Allergy to study medication or other safety reasons 
Other reasons leading to withdrawal from study interventions include suspected or confirmed allergic 
reaction to the study drug or for safety reasons as judged by the investigator, study safety monitor or 
DMEC. See also paragraph 7.3.6, Removal of participants from therapy and/or assessment. 

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7.3.3 Antiretroviral regimens 
7.3.3.1 
The rationale for switching cARTs 
The counselling and cARTs will be provided by these routine HIV care clinics in each country; the 
PMTCT/ART clinics in Malawi and the PMTCT/patient support centres (PSC) in Kenya. The study will 
be conducted during a period when countries are in transition from EFV-based cARTs to DTG-based 
cARTs in the general population (Malawi) or in restricted populations excluding women of child-
bearing potential.  
At enrolment, if women in Malawi and Kenya are not yet on DTG-based cARTs (TLD) they will be 
started on, or switched to (see 7.3.3.2), daily TLD at the time of enrolment, as per WHO’s guidelines 
for preferred first-line treatment in the 2nd and 3rd trimester.  
Approximately two weeks post-partum (a period of lactational amenorrhoea when women are 
unlikely to conceive), women will be counselled by the PMTCT/ART clinics (Malawi) or PMTCT/patient 
support centres (PSC) (Kenya) about their options for preferred first-line treatment in women of 
childbearing potential. These options currently vary between Malawi and Kenya, and we will, 
therefore, follow the existing or upcoming national guidelines at that time in each country. A letter 
from the secretary of Health and Population In Malawi was recently (March 21, 2019) circulated to all 
health care providers about an upcoming HIV policy update. This suggests that in Malawi, the new 
national guidelines will include the provision of a routine counselling visit in the first few weeks post-
partum and the option for women of childbearing potential to continue on/use TLD without a 
requirement for contraception. In Kenya, current guidelines stipulate that this routine counselling visit 
takes place around two weeks postpartum. EFV-based regimens are currently the preferred first-line 
treatment for women of childbearing age in Kenya, but it is anticipated that these guidelines may be 
revised. Currently, the Kenyan guidelines also state that ‘women and adolescent girls who are on 
effective contraception may opt to use DTG and should be supported in their decision.‘49  
All cARTs will be provided by the PMTCT/ART (Malawi) and PMTCT/PSC (Kenya) clinic teams within 
each study health facilities. The study staff will liaise closely with these clinics to ensure the women 
receive the appropriate cART postpartum according to the prevailing national guidelines. 
7.3.3.2 
Method of switching from TLE to TLD during pregnancy and from TLD to TLE after delivery 
For known HIV-positive women on TLE, we will use a straightforward switch from the fixed 
combination of TLE (Tenofovir/Lamivudine/Efavirenz) to TLD (Tenofovir/Lamivudine/Dolutegravir) 
during pregnancy and from TLD to TLE, in the first few weeks postpartum (about two weeks according 
to the Kenyan national guidelines). The straightforward switch is based on the switching guidelines 
provided by British HIV Association guidelines 2016 (page 72),74 which state that ‘Mathematical 
modelling suggests that dolutegravir concentrations achieved target minimum effective 
concentrations by 3 days following efavirenz discontinuation (6 days in efavirenz poor metabolisers). 
Importantly, there was no time point where both the efavirenz and dolutegravir concentrations were 
predicted to be sub-therapeutic.75 On that basis, straightforward (with no dose adjustment) 
substitution of efavirenz with dolutegravir is recommended’.74 In Kenya, straightforward switching is 
implemented in individuals with evidence of adequate viral load suppression (<400 copies/mL). If the 
most recent viral load was >=400 copies/mL a different switching protocol applies in Kenya to 
differentiate between cART adherence problem and acquired drug resistance. This will be an exclusion 
criterion. 

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7.3.4 Permitted and prohibited concomitant medication and care 
7.3.4.1 
Routine care and permitted concomitant medication 
All participants will be offered routine antenatal care according to local policy and the principles of 
‘focused antenatal care’. This includes the provision of insecticide-treated bed nets (ITNs) free of 
charge, and screening of malaria at enrolment if this is the local policy (e.g. in western Kenya). Routine 
antenatal care also includes screening at the first appointment for syphilis, anaemia and HIV, and the 
provision of appropriate treatment for these conditions. Participants confirmed as HIV-negative prior 
to enrolment will be excluded from the trial and referred to routine care for assessment or for 
enrolment in the sister IMPROVE trial in HIV-negative women.  
Participants will be counselled to avoid concomitant medications not prescribed by the study clinic, 
specifically antimalarial drugs or drugs that may be associated with QTc prolongation. All concomitant 
medications taken during the study will be recorded in the appropriate sections of the CRF with 
indication, dose information, and dates of administration.  
All routine medication used for antenatal care is permitted, with the exception listed under the 
paragraph 7.3.4.2, Prohibited medication, page 35. Permitted medication includes the use of AL (first 
line) and quinine or amodiaquine-artesunate (second line) for treatment of uncomplicated malaria, or 
artesunate or quinine for severe malaria as per national guidelines. As part of their antenatal care 
participants will be given iron and folic acid supplements (folic acid dose 0.4 mg to 0.6 mg / day) and 
tetanus vaccination if applicable. Where this is local policy, helminth infections will be treated 
presumptively with albendazole 400 mg single dose or mebendazole 400mg for hookworm, 
trichuriasis and ascariasis after the first trimester. 
7.3.4.2 
Prohibited medication 
Prohibited medication includes antimalarial drugs not prescribed within the trial protocol, and other 
drugs with antimalarial properties including SP, unless prescribed by the study staff. It also includes 
high dose folic acid supplementation (>1.5. mg/day such as the commonly used 5 mg tablets per day). 
Randomised participants who take prohibited medications will remain in the trial and will be included 
in the primary, intention-to-treat analysis, but excluded from the per-protocol analysis. 
7.3.5 Strategies to improve adherence to study protocol and medication 
7.3.5.1 
Adherence to study protocol and medication  
Adequate education on the number of tablets to be taken at home on days 1 and 2 of each monthly 
course will be provided at each contact point during scheduled and unscheduled visit. Where feasible, 
a take-away pictorial drug administration chart will be provided to aid adherence to the dose and the 
visit schedule. Where feasible, study participants will be reminded about any follow-up visits through 
mobile phone contact. Where participants cannot be reached by mobile phones, home visits will be 
arranged where feasible. All information will be recorded on the appropriate sections of the CRF. 
Subjects judged to be non-compliant may continue in the study but will be counselled on the 
importance of taking their study medication as prescribed. 
7.3.5.2 
Monitoring adherence 
Adherence will be monitored by mobile phone interviews and/or text messages after each daily dose 
of each monthly course. Women without access to a mobile phone will be visited at home to monitor 
adherence. Further exploratory evaluation of the use of mobile phone technology utilising an 
Unstructured Supplementary Service Data (USSD) platform to monitor adherence and safety events, 
shall be implemented in some sites. 

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In addition, all participants will be visited by a fieldworker at least once to check whether they have 
taken the tablets and whether they have had any problems. This visit shall also serve to determine the 
availability, use of LLITNs the previous night, and integrity of LLITNs on a random basis.  
7.3.5.3 
Strategies for retention  
During screening and consent procedures, participants will be asked whether they live in the 
catchment area, are willing to adhere to the study protocol, and deliver in a study clinic or hospital. 
Specifically, potential participants will be asked whether they will be willing and able to comply with 
the frequent follow-up schedule and whether they need to travel out of the study area for an extended 
period during the follow-up period. The ‘study catchment area’ will be defined for each study site 
before the start of the study. All participants will be reimbursed for transportation costs to and from 
the clinic.  
GPS position and otherwise, detailed directions to participants’ homes as well as contact information, 
including mobile phone information, will be recorded at enrolment. If participants do not return for 
scheduled follow-up visits, the study team will call them and ask them to come to the clinic for 
evaluation, offering transport reimbursement, or if participants do not have access to a mobile phone, 
study staff may visit their house to help arrange transport to the clinic if the participants are willing to 
come to the clinic, or, alternately, a study staff member may go to their home for clinical evaluation 
and to assess if they still wish to participate in the study. The participants’ travel costs will be 
reimbursed. All information will be recorded on the appropriate sections of the CRF. Subjects judged 
to be non-compliant may continue in the study but should be counselled on the importance of taking 
their study medication as prescribed. 
7.3.6 Removal of participants from study 
7.3.6.1 
Removal of participants from therapy and/or assessment 
Participants can discontinue from the study for any one of the following reasons: 
1. Screening error resulting in incorrect enrolment (found that subject did not meet required 
inclusion / exclusion criteria) 
2. Withdrawal of consent at any stage or subject not willing to continue in the study   
3. Suspected or confirmed allergic reaction to the study drug (removal from therapy only) 
4. Safety reasons as judged by the investigator, study safety monitor or DMEC (removal from 
therapy only) 
Where feasible, the participants who discontinue from the study treatment or from the study entirely 
will be asked about the reason(s) for their discontinuation and the presence of adverse events. 
Participants have the right to unconditionally withdraw from participation in the study without 
providing a reason. If a subject discontinues, data captured will contribute to the analysis up to the 
day prior to discontinuation, unless the subject indicates that she withdraws consent for any data 
captured up to that point. Every effort will be made to follow-up participants who discontinue due to 
drug related adverse events to determine the birth outcome. If a subject discontinues due to drug-
related adverse events, all the assessments that would have been carried out at the next scheduled 
visit will be conducted at day 28 where reasonably possible (unless consent is withdrawn). This will be 
recorded in the CRFs. The study drug will be returned by the subject. Subjects that have discontinued 
the study prematurely will not be replaced. 

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7.3.6.2 
Discontinuation from storage of samples for future studies 
The applicability of long-term storage of study samples for future research shall be in respect to the 
regulations of the country-specific ethics board. When a subject’s consent for long-term storage is 
withdrawn, the stored sample will be destroyed, and the withdrawal noted in the CRF. If the request 
is received after the dataset has been anonymised, the stored sample can no longer be withdrawn. 
7.4 
OUTCOME MEASURES  
7.4.1 Primary outcome 
7.4.1.1 
Cumulative incidence of malaria infection 
The primary outcome will be the cumulative incidence of malaria infection detected from 2 weeks 
after the first day of the first dose of the first course to delivery inclusive, defined as the presence of 
peripheral (maternal) or placental (maternal) Plasmodium infection detected by either molecular 
diagnostics (henceforth referred to as PCR), microscopy, RDT or placental histology (active infection).  
7.4.2 Secondary outcome measures 
7.4.2.1 
Efficacy   
1. Incidence of malaria infection in the peripheral blood during pregnancy defined as the 
composite of malaria detected in the peripheral blood by RDT (for point of care), or 
microscopy (not for point of care), or by PCR (not for point of care), excluding enrolment and 
delivery. 
2. The individual components of the composite malaria infection endpoints 
3. Incidence of clinical malaria. 
4. Malaria infection at delivery, detected in maternal peripheral or placental blood by either 
molecular diagnostics, microscopy, RDT or placental histology (active infection). 
5. Placental malaria by histology (active, past, and active and past infections pooled) 
6. Placental malaria by any measure  
7. Maternal peripheral malaria infection at delivery by any measure  
8. Placental inflammation or chorioamnionitis 
9. Adverse pregnancy outcome: the composite of foetal loss (spontaneous abortion or stillbirth), 
or singleton live births born small-for-gestational-age (SGA), or with low birthweight (LBW), 
or preterm (PT) (SGA-LBW-PT), or subsequent neonatal death by day 28. Small for gestational 
age will be defined using the new INTERGROWTH population reference’s 10th percentile.76 
10. Composite of foetal loss and neonatal mortality. 
11. SGA-LBW-PT composite. 
12. The individual components of the above composites 
13. Neonatal length and stunting. 
14. Evidence of arboviral infections  
7.4.2.2 
Safety  
1. QTc-prolongation. 
2. Congenital malformations. 
3. Maternal mortality 
4. Other SAEs and AEs. 
5. Mother to child transmission of HIV 

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7.4.2.3 
Tolerance 
1. History of vomiting study drug (<30 min). 
2. Dizziness. 
3. Gastrointestinal complaints.  
7.4.2.4 
Antimicrobial activity and resistance 
1. Frequency of molecular markers of drug resistance in Plasmodium falciparum infections 
during pregnancy and delivery. 
7.4.2.5 
Pharmacokinetic parameters 
1. Standard pharmacokinetic parameters for dolutegravir, piperaquine and CTX. 
7.5 
PARTICIPANTS TIMELINE 
7.5.1 Timeline 
The total duration of the trial is 24 months. Actual participant recruitment and follow up is expected 
to take up to 19 months (12 months recruitment plus 7 months of mother-infant follow-up until the 
child is 6 weeks old) (see 12.1, Timeline, page 64). 
7.5.2 Antenatal booking visit 
If a woman makes first contact with the study team between 16 and 28 weeks gestation (inclusive), 
the first study visit will immediately follow eligibility screening. If a woman makes first contact before 
16 weeks gestation, she will be invited to be enrolled into the study at the next clinic visit when she 
would have reached the eligible gestational age where all screening and enrolment procedures will be 
conducted.  
7.5.2.1 
Enrolment 
After informed consent has been signed, participants will be randomly allocated to either of the two 
study arms (see section 8.1, Allocation, page 44) and issued with a trial identifier with their unique 
study identification number.  
At this stage study staff will ask the participant for a home or mobile telephone number if they have 
one, and home address or a description of the location of their home, and for their verbal consent to 
be called or visited at home whenever they do not attend scheduled appointments. 
7.5.2.2 
Baseline assessment 
A baseline assessment will be conducted for each participant comprising demographic information, 
socioeconomic information, ITN and IRS use, medical and obstetric history, and clinical assessment. 
Any relevant information already collected during the screening process or at previous antenatal 
appointments for the same pregnancy will be copied from the antenatal cards and HIV care and 
treatment cards onto the CRF, so that questions, tests and examinations are not unnecessarily 
duplicated, unless for quality control. 
Study-relevant information recorded at the first visit will include age; area of residence; prior use of 
ITNs/IRS; the number of previous known pregnancies and number of previous births and 
corresponding pregnancy outcomes. Clinical assessment will include screening for TB and 
opportunistic infections, height and body weight, mid-upper arm circumference, fundal height, 
reported date of last menstrual period and estimated gestation. An ultrasound scan will be done to 
determine the gestational age. 

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7.5.2.3 
Biological samples 
A venous (up to 12 mL) will be taken and used for both routine and study-specific testing as described 
in Table 1: Summary Table of Study Design and Schedule of Assessment, page 17. This will be obtained 
after consent for eligibility screening has been obtained but before consent for enrolment in the trial; 
participants who have not been tested for HIV and syphilis in their current pregnancy will be tested 
for HIV and syphilis, and all participants will be tested for anaemia and haemoglobin levels. 
Participants not previously tested for syphilis in this pregnancy will be tested and treated if positive. 
The same blood sample will be prepared for study-specific diagnostic testing for malaria (e.g. not for 
point-of-care in Malawi, and for mRDT screening in Kenya). A filter-paper sample will be prepared and 
stored for parasite genetic studies. Additionally, baseline assessment tests will be done at enrolment 
for those starting first-line cARTs (newly diagnosed HIV positive at enrolment) as per the national 
guidelines and could include full blood count, biochemistry for electrolytes, liver and renal function 
test. Where feasible maternal viral load tests will be conducted for all women at enrolment. If this was 
done as part of routine care in the previous 3 months, including any CD4 count, the information will 
be copied from clinic registers. 
In a subgroup of participants enrolled in the nested cardiac monitoring study, an additional 2 mL of 
whole blood will be required for drug level assessment, full blood count, biochemistry for electrolytes, 
liver and renal function test, 4-6 hours after the 3rd dose of DP loading dose. 
All samples collected will be recorded on case report forms and will include participant ID, type, date, 
time of sample collection and any other relevant information required by the laboratories. No names 
will be recorded on any of the biological samples or corresponding CRFs.  
7.5.2.4 
Study intervention 
The first course of study drug will be administered to asymptomatic participants at the visit as 
described in section 7.3, Interventions, page 30. If participants have malaria, they will be treated as 
described in section 7.3.2.1. Malaria infection diagnosed at enrolment visit, page 33. 
7.5.2.5 
Routine antenatal care and treatment of illness 
Routine antenatal care and treatment of any illness identified at this visit will be provided as described 
in section 7.3.4.1, Routine care and permitted concomitant medication, page 35. This will include the 
provision of an ITN if the woman does not already have one, and advice on sleeping under the net for 
the entire duration of the pregnancy. 
7.5.2.6 
Recording of morbidity and medication taken 
All participants will be asked about any symptoms or illnesses they have had in the last month, and 
any medication taken.  These will be recorded in the adverse events section of the CRF. All AEs shall 
also be evaluated for seriousness and reported accordingly. 
7.5.3 Interim monthly scheduled visits   
Subsequent clinic visits will be scheduled monthly after the first visit.  The range of monthly visits will 
be 3 to 7 visits depending on the gestational age of the woman at enrolment and delivery. Since 
recruitment is restricted to 16-28 weeks gestation, a median of 4 to 5 monthly visits is expected. 
7.5.3.1 
Serial ultrasound scans 
A subgroup of participants in selected sites shall be requested to undergo two more additional 
ultrasound scans at interim monthly visits at the approximate gestational ages of 25-28 weeks and 32-
35 weeks (or otherwise at the nearest scheduled monthly visit) (subject to funding). 

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7.5.3.2 
Biological samples 
A venous (up to 12 mL) will be taken for the same assays as the baseline sample and for maternal viral 
load during the third trimester visits as described in Table 1: Summary Table of Study Design and 
Schedule of Assessment, page 17. Where appropriate viral load assay result will be copied from clinic 
registers if they were done, or are scheduled to be done, in the third trimester as part of routine care. 
The samples taken for malaria diagnostics, including malaria smears and PCR will be taken for later 
diagnostic analysis and not for patient care. A standard malaria RDT will be taken from participants 
with fever or a history of fever in the last 48 hours for patient care (7.3.2.1.2, Febrile participants 
during scheduled visits, page 33).  
At each scheduled visit, the subgroup of women enrolled in the cardiac monitoring study will have an 
additional 2mL of whole blood drawn 4-6 hours after the third dose of a monthly course; for the 
assessment of drug levels, full blood count, and biochemistry for electrolytes, liver and renal function 
tests. The sample will be drawn just after the respective ECGs have been taken at these time points.  
7.5.3.3 
Study intervention 
The monthly DP or placebo will be administered at these visits as described in section 7.3.1.1, Study 
arms, page 30. If women are symptomatic with evidence of malaria confirmed by RDT they will be 
treated as described in section 7.3.2.1.2, Febrile participants during scheduled visits, page 39.  
7.5.3.4 
Routine antenatal care and treatment of illness 
Routine antenatal care and treatment of any other illness identified at this visit will also be provided 
as appropriate. 
7.5.3.5 
Recording of morbidity and medication 
Participants will be asked about any symptoms or illnesses they have had since the start of pregnancy, 
and any medication is taken, and these will be appropriately documented in the CRFs. 
7.5.4 Unscheduled visits during pregnancy 
Participants will be encouraged to visit the clinic if they feel unwell between scheduled appointments. 
Participants who present between appointments will be examined by study staff. Presenting 
symptoms, axillary temperature and blood pressure will be recorded. A venous blood sample (upto 
6mL) will be taken for Hb measurement (if clinically indicated) and malaria RDT for point of care (if 
clinically indicated), and a malaria smear and dried blood spot for later analysis of malaria. A 5mL urine 
sample will also be taken for detection of urinary tract infections if clinically indicated and for viral 
infections. Any illness will be treated as appropriate and according to standard local care. The date of 
attendance, diagnosis and treatment will be recorded on the CRF, and any adverse events reported 
according to standard procedures. 
7.5.5 Delivery visit 
Participants will be encouraged to deliver on the maternity wards of the participating clinics, in which 
case they will be assisted to deliver by regular clinic midwives, and a specially trained staff will visit 
them on the ward and perform relevant examinations shortly after delivery. Participants who deliver 
at home will be identified using a network of community health workers such as health surveillance 
staff or village health volunteers/workers and will be requested to report to the health facility within 
48 hours, to collect, as far as possible, the same information. Infants will be referred to the PMTC 
teams in the hospital to initiate cART prophylaxis in line with the existing national guidelines as soon 
as the first contact with the mother and infant after delivery. The current infant prophylaxis consists 

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of 12 weeks in which zidovudine (AZT, Retrovir) and nevirapine (NVP) are given for the first six weeks, 
followed by six weeks of daily NVP. 
7.5.5.1 
Biological sampling mother 
A similar venous (up to 12 mL) blood sample (~250 µL) will be taken as for the scheduled follow-up 
visits for the same assays as described in Table 1: Summary Table of Study Design and Schedule of 
Assessment. 
7.5.5.2 
 Placental sampling 
A blood sample will be collected from the delivered placenta by making an incision on the maternal 
side and collecting the pooled blood. This sample will be tested for malaria using standard microscopy 
of blood smear and PCR, and drug levels. 
A 2cm x 2cm x 1cm specimen of placental tissue will be taken from the maternal side for 
histopathology testing for current and past malarial infection. An amnion roll will be included in the 
collection of the placental sample for histological evaluation of chorio and/ or amnionitis. 
7.5.5.3 
Umbilical cord sampling 
An umbilical cord blood sample will be taken for haemoglobin level, malaria molecular diagnostics, 
antibody and cell mediated immune responses to malaria and other pathogens such as viral infections 
and drug levels. We will collect up to 300ml of cord blood where feasible. At term, the maternal blood 
that flows through the placenta is approximately 600-700ml/min77. At the time of delivery, delayed 
cord clamping as per obstetrics standard of care allows blood to flow from the placenta to the baby 
and thus reducing placental volume by approximately half. Where feasible, we will collect the 
remaining cord blood in a blood transfusion bag which can be up to approximately 300mL. 
7.5.5.4 
Examination of the baby 
All babies shall be examined for vital status, jaundice and the presence of congenital abnormalities. 
Birthweight, using digital scales, head circumference, length, and umbilical abdominal circumference 
shall be measured.  
7.5.6 Postnatal visits 
7.5.6.1 
Seven-day postnatal visit 
Participants and their babies will be seen at the clinic by a study nurse around seven days after birth. 
The baby will be examined for the presence of jaundice and for any congenital anomalies that may 
have been missed at delivery and basic anthropometric measures taken. A heelprick sample (about 
500 microL) will be taken in all babies with fever or other symptoms for testing by RDT, microscopy 
and DBS, and in a subgroup of asymptomatic babies for assays to assess immune responses to malaria 
and other infectious diseases. All treatment in symptomatic infants will be provided based on the RDT 
results. Standard postnatal advice and healthcare will be provided as needed for mother and baby 
including infant ARV prophylaxis and mother adherence to cART during breastfeeding, and any 
treatment and clinical findings for the baby recorded on the CRF. Routine postnatal care will be 
provided for the participants.  
Participants who do not attend this appointment will be visited at home if possible. Any infant deaths 
occurring before the visit will be recorded; the date and probable cause of death will be ascertained 
by verbal autopsy.  

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7.5.6.2 
Six,- to eight-week postnatal visit 
Participants and their babies will be seen again at the clinic around six to eight weeks after birth, at 
their baby’s second vaccination visit. The baby will be examined for the presence of congenital 
anomalies that may have been missed at delivery or the first visit.  
A similar heel prick sample (about 500 microL) as on day 7 will be taken again for malaria diagnosis 
and for immunological assays with treatment provided based on the RDT results. Part of the sample 
will be used for DNA PCR for HIV virus detection at 6 weeks in line with national and/or WHO 
guidelines. Standard postnatal advice and healthcare will be provided as needed for mother and baby, 
and any treatment and clinical findings for the baby recorded on the CRF. Routine postnatal care will 
be provided for the participants.  
Participants who do not attend the scheduled appointment will be visited at home if possible. Any 
infant deaths occurring before the visit will be recorded; the date and probable cause of death will be 
ascertained by verbal autopsy. 
7.5.6.3 
Unscheduled postnatal visits 
Participants will be encouraged to attend the clinic if they or their baby become unwell during the 
follow-up postnatal period. Physical examinations and relevant blood samples will be conducted to 
guide management. Any illness will be treated as appropriate and according to standard local care. 
The date of attendance, diagnosis and treatment will be recorded on the CRF, and any adverse events 
reported according to standard procedures. Clinical care will also be provided for participants who 
attend because of their own illness, but this will not be recorded as part of the study.  
In a sub-group of participants seen during sick visits, dried blood spots or red pellets will be taken and 
analysed for detection of molecular markers of anti-malarial resistance. 
7.6 
SAMPLE SIZE AND POWER 
7.6.1 Primary outcome 
The primary outcome will be the cumulative incidence of malaria infection detected from 2 weeks 
after the first day of the first dose of the first course to delivery inclusive, defined as the presence of 
peripheral (maternal) or placental (maternal) Plasmodium infection detected by either molecular 
diagnostics (henceforth referred to as PCR), microscopy, RDT or placental histology (active infection). 
A sample size of 898 (449 per arm) (359 contributors and 90 non-contributors) is required to detect a 
50% reduction (RR=0.50) from 12% in the CTX-alone arm (control arm) to 6% in the intervention arm 
with 80% power (alpha=0.05) allowing for 20% non-contributors (N=90). The effect size of 50% is more 
conservative than the 68% pooled effect size observed in fixed effects meta-analysis from the three 
completed trials to date that compared IPTp-DP vs IPTp-SP in HIV-negative women (95% CI 61% to 
73%, I-squared=0%, P<0.0001).29,30,72 
7.6.2 Power calculations for key secondary outcomes 
7.6.2.1 
Adverse pregnancy outcome 
A key secondary outcome is ‘adverse pregnancy outcome’ defined as the composite of foetal loss 
(spontaneous abortion or stillbirth), or singleton live births born small-for-gestational-age (SGA), or 
with low birthweight (LBW), or preterm (PT) (SGA-LBW-PT), or subsequent neonatal death by day 28. 
The sample size of 718 contributors (359 per arm) provides 80% power to detect a 27.6% reduction 
(RR=0.724) in adverse pregnancy outcomes from 34.5% with CTX-alone (control) to 25.0% in the DP 
arm (alpha=0.05). The 34.5% proportion for this outcome in the control arm (CTX-alone) is based on 

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data from our recently completed pregnancy trials in Malawi78 and Kenya.30 The frequency of this 
outcome was 23.0% in HIV-negative women receiving IPTp-SP. It was assumed that this outcome is at 
least 1.5 times more common in HIV-infected women on cART (i.e. 1.5x23.0=34.5%), based on a recent 
meta-analysis comparing the risk of low birthweight and pre-term delivery in HIV-infected vs HIV-
negative women.8  
 
7.6.3 Sample size for cardiac monitoring study 
Overall, 80 women will be recruited per arm (160 in total). Each woman will have a total of six ECGs 
taking as three sets of two ECGs; one before and one 4-6h after the first course at enrolment and then 
again one before and one 4-6h after two of the subsequent monthly courses spaced at least one 
month apart throughout the pregnancy. The research question of interest concerns the QTC 
prolongation at enrolment. Previous studies have shown that most of the piperaquine related QTc 
prolongation occurs after the first course of DP with a subsequent decline in QTc prolongation with 
subsequent monthly courses.60,79 However, since the study is placebo-controlled, women from both 
arms will need to be recruited. A sample size of 80 in the CTX-DP and 80 in the CTX-alone arm will 
provide 90% power to detect a 10ms difference in QTc prolongation (e.g. 30 vs 20ms) after the first 
course (two-sided α=0.05, standard deviation 18.3ms, t-test for independent samples, allowing for 
10% non-contributors [e.g. due to missing ECG at Tmax on Day-2]). The standard deviation of 18.3ms 
is based on our recent observations in our recently completed trial in Indonesia (ter Kuile et al., 
unpublished observations). 
7.7 
RECRUITMENT AND RETENTION 
7.7.1 Recruitment procedures 
Eligible women who are resident in the study area will be recruited when they start attending 
antenatal care in one of the ANC clinics in the participating hospitals. The study will provide staff and 
dedicated study staff to deal with the additional workload. Where required, the trial will fund minor 
improvements in the infrastructure, such as the refurbishment of a dedicated study room, or pay rent 
to the hospital to use facilities. 
7.7.2 Planned recruitment rate 
Recruitment of 898 (449 per arm) women (all gravidae) from 2 countries will require 12 months, with 
an additional seven months to complete pregnancy plus infant follow-up. The recruitment rate of 37 
HIV-positive women per month is feasible in the hospitals where the larger sister trial is ongoing in 
Malawi and Kenya.  
7.7.3 Rate of loss to follow-up 
This trial will be conducted by the same study teams and use similar outcomes as in the previous trials 
in these countries.30,78,80 The sample size allows for 20% loss to follow-up, which is conservative as the 
primary endpoint is the cumulative incidence of malaria infection and most women are expected to 
contribute observation time to this endpoint during pregnancy even if observations at the time of 
delivery may be missed. 
7.7.4 Problems with compliance and Strategies for retention  
7.7.4.1 
Strategies for retention  
During screening, women will be asked whether they live in the catchment area, are willing to adhere 
to the study protocol, and deliver in a study clinic or hospital. GPS position and otherwise, detailed 

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directions to participants’ homes as well as contact information, including mobile phone information, 
will be recorded at enrolment. If women do not return for scheduled follow-up visits, the study team 
will call them and ask them to come to the clinic for evaluation, offering transport reimbursement, or 
if women do not have access to a mobile phone, study staff may visit their house to help arrange 
transport to the clinic if the women are willing to come to the clinic, or, alternately, a study staff 
member may go to their home for clinical evaluation and to assess if they still wish to participate in 
the study. The women’s travel costs will be reimbursed. All information will be recorded on the 
appropriate sections of the CRF. Subjects judged to be non-compliant may continue in the study but 
should be counselled on the importance of taking their study medication as prescribed. 
7.7.4.2 
Drug adherence 
The first dose of each course will be given under supervision of study staff on day 0, and the remaining 
2 doses for days 1 and 2 will be taken at home by the study participants. Participants will be reminded 
through mobile phone contact to take the assigned tablets for the second and third dose. A sub-
sample of participants will be visited at home by random spot checks (some on Day 1 and other 
participants on Day 2, with Day 0 being the first day of treatment) to assess adherence to the study 
drugs. In our previous trial in western Kenya documented adherence using this method was very high 
(>95%).30 Adherence to dosing will be assessed by questionnaire during each monthly scheduled visit, 
and by random spot checks at home or by mobile phone. Where feasible a drug administration 
pictorial chart will be provided to aid adherence in between scheduled visits. 
8 METHODS: ASSIGNMENT OF INTERVENTIONS 
8.1 
ALLOCATION 
Balanced randomisation will be used using permuted block randomisation methods stratified by site 
(i.e. hospital) and two HIV-status groups (known-positive and newly-diagnosed). A statistician at LSTM 
in the UK will generate the randomisation lists using dummy coding (e.g. A, B), and another 
independent statistician who is not involved in the study will assign the dummy codes to each of the 
two study arms. The list with the allocation sequence will then be forwarded to the trial pharmacists 
based in Kenya and Malawi who will then prepare sequentially numbered, sealed, opaque boxes or 
envelopes for each participant with the randomisation assignments. Contained within each of these 
envelopes or boxes will be the pre-packed investigational product for the entire duration of the study 
for that participant. These opaque boxes/envelopes will be opened sequentially upon enrolment of a 
study participant in each site. Stratification by HIV-status (known-positive vs newly-diagnosed) is 
essential to ensure balanced distribution among study arms as women newly diagnosed with HIV will 
not yet be on daily cotrimoxazole and may thus have a higher risk of malaria at enrolment. The latter 
is an important determinant of the primary outcome of malaria infection. Minimisation or distance 
randomisation using central randomisation services by internet is not feasible because of the 
unreliable internet connections and telephone services in some of the proposed sites.  
8.2 
BLINDING AND UNBLINDING 
8.2.1 Blinding 
The study will placebo-controlled involving a placebo for DP, which will be identical in size, shape and 
colour to the active DP tablet to ensure blinding of all investigators and study staff during allocation 
and for the duration of the trial. To further minimise bias, we will use an objective primary outcome 
measure and mask all laboratory staff to the treatment assignment of individual women. The trial 

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statistician will also be blinded regarding the treatment code when he develops the statistical analysis 
plan and writes the statistical programmes, which will be validated and completed using dummy 
randomisation codes. The actual allocation will only be provided to the study team after locking of the 
database for the primary outcome, and after the statistical analysis plan has been signed off by the 
Chief Investigator, the trial statistician, and by the independent Data Monitoring and Ethics 
Committee (DMEC) and a signed copy has been e-mailed to them for their records.  
8.2.2 Emergency unblinding 
Emergency unblinding will be on an individual basis to ensure the blinding of other participants is not 
affected. Emergency unblinding will be considered in these instances: suspected unexpected serious 
adverse reaction to the study drug (SUSAR), serious adverse reaction to the study drug, or serious 
expected adverse drug-drug interactions between the study drug and other drugs provided to the 
participant undergoing treatment, as judged by the study physician or study safety monitor. The first 
alert will be raised by the study physician within 24 hours of becoming aware of the event in an 
expedited report on the SAE form (10.2.4.1, Expedited reporting, page 53) to the chief investigator, 
ethics committees, safety monitor, sponsor and DMEC chair. The final decision for emergency 
unblinding will be advised by the country Principal investigator and/or the Chief investigator in 
consultation with the safety monitor and/or DMEC chair. The trial pharmacist in each country will be 
responsible for the safekeeping of the treatment allocation of each participant and will be contacted 
by phone and email by the principal investigator and/or chief investigator if emergency unblinding will 
be advised. Furthermore, the allocation code for each participant is also kept by the independent 
statistician at LSTM in the UK who is not involved in the study as an investigator. This independent 
statistician will be available when emergency unblinding is requested by the DMEC chair. The date, 
reason and name of the person breaking the code must be documented. If so clinically indicated, the 
subject will be withdrawn from receiving further study drug. Other than the written or verbal 
disclosure of the code in any of the confidential correspondence about the participant between the 
principal or chief investigator and the safety monitor or the DMEC chair, the actual allocation will NOT 
be disclosed to the participant and/or other study personnel including other site personnel, monitors, 
corporate sponsors or project office staff. 
9 METHODS DATA COLLECTION, MANAGEMENT AND ANALYSIS 
9.1 
MEASUREMENT OF EFFICACY OUTCOMES AND SAFETY 
9.1.1 Efficacy 
9.1.1.1 
Malaria infection 
In febrile participants (women and their new-borns) or those with a history of fever in the last 48 
hours, RDTs will be used for point-of-care diagnosis at all scheduled and unscheduled visits, with RDT-
positivity defined as either pLDH or HRP2 antigen positivity. For all participants, including those who 
are asymptomatic, samples will be taken for the later determination of the presence of malaria 
infection by PCR or LAMP, microscopy, and RDTs. This will be conducted in central laboratories (i.e. 
not at point of care and not for participant’s care). At delivery, additional samples will be collected for 
placental histology (active and past malaria infections) and later detection of the presence of malaria 
infection in cord blood.  

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9.1.1.2 
SGA-LBW-PT 
New-borns will be weighed within 24 hours of delivery using digital scales (± 10 gr) and LBW defined 
as < 2,500g. If the birthweight cannot be obtained within 24 hours, birthweights obtained up to day 7 
inclusive can be used and a correction factor to adjust for the physiological fall in birthweight will be 
applied. Gestational age will be assessed using ultrasound dating at enrolment and preterm (PT) 
defined as <37 weeks gestation also within 24 hours, and otherwise within 96 hours. Small for 
gestational age (SGA) will be defined as birthweight below the tenth percentile for a given gestational 
age and sex, using the new INTERGROWTH-21st reference population.76 This will also allow the 
calculation of z-scores.  
9.1.1.3 
Pregnancy outcome and neonatal death 
Foetal loss will be assessed monthly at scheduled ANC visits. If women do not turn-up they will be 
contacted by mobile phone and/or visited at home to document this. Foetal loss before 28 weeks 
gestation will be defined as induced or spontaneous miscarriage, and foetal loss at or after 28 weeks 
gestation as stillbirth. Neonatal death will be assessed at the 6-week follow-up visit. Neonatal 
mortality will be defined an infant death within 28 days if the date of birth and date of death are 
known, and otherwise within 1 month (30 days) if one of these dates are not exactly known. 
9.1.2 Safety 
9.1.2.1 
Congenital abnormalities, neonatal jaundice and vital status  
The presence of congenital abnormalities and jaundice will be assessed at delivery, day 7, and at 1 
month. The vital status of participants will be recorded at each scheduled and unscheduled visit, and 
through follow-up phone calls and home visits if participants do not attend the scheduled visit. 
Maternal mortality will be defined as the death of a woman while pregnant or within 42 days of 
termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause 
related to or aggravated by the pregnancy or its management but not from accidental or incidental 
causes.  A verbal autopsy questionnaire will attempt to determine the cause of death.  
9.1.2.2 
Mother to child transmission of HIV 
The occurrence of mother to child transmission of HIV will be assessed at delivery and at week 6-8 
post-natal visit. Maternal viral load will be measured, at enrolment, third trimester visit and/or 
delivery visit. Infant blood samples for DNA PCR for HIV virus detection will done at 6-8 weeks in line 
with national and/or WHO guidelines for both study arms. Where available results will be obtained 
from clinic registers if these assays are done as part of routine care to avoid duplication. 
9.1.2.3 
Routine monitoring cART tolerance and safety 
As part of routine care, women initiating cART will be monitored closely as part of their routine HIV 
care for development of adverse drug events and to identify and address barriers to adherence. This 
includes a complete medical history taken, a thorough physical examination and appropriate laboratory 
investigations, which includes viral load, haemoglobin assessment (or full blood count where available), 
and renal and liver function tests. As this is part of routine care, and related to the study, this will be 
conducted by routine clinic staff, not by study staff. The information will be copied for the routine clinic 
registers. 
9.1.2.4 
Procedures for cardiac monitoring 
9.1.2.4.1 Overview 
Cardiac monitoring will be conducted in the first 160 women (80 in each arm) who provide informed 
consent to join this component of the study. The objective of this cardiac monitoring sub-study is 

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twofold; 1) to determine whether there is a difference in QTc prolongation between the CTX-alone 
arm and the CTX-DP arm. 2) to determine whether the magnitude of DP related QTc prolongation on 
the ECG, observed between the pre-treatment value (day 0) and the QTc time 4-6 hours after the 3-
day IPTp-DP course (peak piperaquine levels) increases with each subsequent course, and to 
determine if this is different compared to HIV-negative women getting monthly IPT with DP. A venous 
sample for drug levels will be taken at the same time to determine the relationship between 
piperaquine level and magnitude of QTc prolongation and determine the impact of monthly dosing on 
hepatic and renal function.  
9.1.2.4.2 Electrocardiogram (ECG) 
Each woman will have a total of six ECGs taking as three sets of two ECGs; one before and one 4-6h 
after the first course at enrolment and then again one before and one 4-6h after two of the 
subsequent monthly courses spaced at least one month apart throughout the pregnancy. ECG will be 
conducted by study staff at the clinic and results read by local clinicians; Approximately half of ECGs 
will also be read off-site by an experienced cardiologist (Cardiabase, Banook Group, Nancy, France). 
The following stopping rules will be applied as a contraindication for subsequent IPTp courses with 
DP. 1) Confirmed QT values >480ms & QTc>500ms combined with a heart rate of <65bpm and >60ms 
increase in QTc relative to baseline, or 2) any QT>480ms combined with a heart rate of <65bpm in a 
woman with syncope or seizures within 24 hours of the monthly dose. In such events, women will 
continue in the study but will on receive daily CTX. The results of the external expert reading of ECGs 
will be available on a secure server (provided by the study or by the external experts, e.g. by 
Cardiabase). The external experts and the site Principal Investigator will be alerted by e-mail as soon 
as the ECGs and results respectively have been uploaded onto the server. In the event of any findings 
with clinical significance, participants shall be traced and requested to report to the study clinic as 
soon as possible for repeat ECG and communication of the findings and appropriate clinical 
management. 
9.1.2.4.3 Plasma piperaquine levels, full blood count, renal function and liver function  
A few minutes after the last ECG (i.e. 4-6 hours after the last dose of each course), a 2 ml venous blood 
sample will be obtained for piperaquine, cARTs and CTX drug levels to determine the relationship 
between drug level and magnitude of QTc prolongation. The sample will also be used to determine the 
impact of monthly dosing on full blood count, renal and hepatic function. Furthermore, at delivery, 
maternal placental blood and a cord blood sample will be used for the same drug levels to quantify 
drug exposure to placental parasites and the neonate, respectively. 
9.1.3 Pharmacokinetic studies and drug-drug interactions 
We will conduct pharmacokinetic studies in a subset of the first 80 of the 160 women undergoing 
cardiac monitoring who provide informed consent for the additional sampling. The blood sample will 
be used to measure drug levels of piperaquine, cotrimoxazole, DTG and other cARTs to determine the 
pharmacokinetic profile of these drugs and any clinically relevant drug-drug interactions when co-
administered. All these women will also take part in the cardiac monitoring study to determine the 
association between QTc prolongation and drug levels (for further details, see 16.6.1, Pharmacokinetic 
studies of drug-drug interactions between piperaquine and standard antiretroviral therapy, page 85).  
9.1.4 Laboratory assays 
A detailed description of the assays and analyses are provided in section 16.6, Appendix VI. Description 
of other clinical and laboratory methods, from page 85 onwards. Some laboratory assays will be 
conducted at collaborating institutions in Australia, United States of America, Canada, United 
Kingdom, and Europe.  

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9.2 
DATA COLLECTION METHODS & STORAGE 
9.2.1 Data management 
9.2.1.1 
Methodologies for data collection / generation 
This will be combined with the data management of the larger sister trial in HIV-negative women. In 
brief: A combination of paper-based and electronic record forms will be used. For the questionnaires 
that are administered in paper format, the study will utilise HP Teleform software to design the paper-
based CRFs for semi-automated transcribing into an electronic database using scanning and Optical 
Character Recognition, intelligent document recognition and data validation using checksum 
algorithms, cross-field validation, and human verification of information against source documents. 
Once validated, the data will be transferred to the target database along with a PDF of the original 
image of the CRFs, such that there is an electronic copy of all paper-based documents. For the 
electronic-only data capture, such as home visits to administer drug adherence questionnaires, we 
will use tablets with integrated sim cards to transfer encrypted data to the ODK servers at LSTM, UK. 
This has worked well in previous studies.  
9.2.1.2 
Data quality and standards 
The quality of questionnaire data collection and data entry will be maximised through training of field 
staff in the standardised questionnaire administration methodology. Field staff will be trained in the 
methodology for collecting data and will be expected to demonstrate competence before conducting 
fieldwork. All electronic CRFs and data validations processes for data captured through Teleform will 
incorporate range and consistency checks. 
9.2.1.3 
Managing, storing and curating data 
Verified and validated data from both countries will be stored via the cloud on a secure, highly fault 
tolerant, storage area network servers at KEMRI and at LSTM in Liverpool, which is accessed by a series 
of blade servers configured in a high availability cluster. The PIs from each site will have access to their 
site data on the central server. All country PIs will have full access to their country level data. Locally, 
data will be backed-up on a continuous basis on a secure off-site server in Liverpool, and on encrypted 
standalone hard drives.  
Once the data validation phase is completed by the central data manager in Liverpool, the database 
will be locked and transferred to a statistical programmer at LSTM who will do further syntax-driven 
consistency checks and syntax-driven data cleaning (e.g. in Stata). The statistical programmer will have 
access to the PDF copies of the source data. He/she will then prepare the database for data analysis 
by the trial statistician by creating the final variables for data analysis, such as the creation of the 
composite endpoints. The final cleaned database will be available as SAS, STATA and in SPSS format, 
with an embedded data dictionary. 
9.2.1.4 
Metadata standards and data documentation 
The full study protocol, supporting documents including the data management Standard Operating 
Procedures (SOPs) and the full individual participant level database will be made publicly available 
once the study findings have been published. The data manager and statistical programmer will 
produce a document summarising the methods used to generate the data with a full description of all 
procedures, analyses, data capture tools, coding and description of variables. This document will be 
published alongside the research database.  

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9.2.1.5 
Data preservation strategy and standards 
The majority of the data collected will be captured using scannable paper-based forms. The scanned 
PDF copies will be used for archiving, and the original paper questionnaires kept in a dedicated 
lockable data storage room in country and then destroyed after a minimum period subject to the 
prevailing laws in each country. The research data will be stored in the long-term in the original 
electronic format, in a unified large database and a public database that contains all research data 
other than participant identifiable data. The public database will be updated when needed if software 
becomes obsolescent to achieve long-term preservation. The data will be preserved in this way for 10 
years or longer if still being accessed at that stage. 
9.3 
STATISTICAL METHODS 
9.3.1 General principles 
All statistical analyses will be described in detail in the Statistical Analysis Plan (SAP) and finalised and 
signed before unblinding the study. One interim analysis and/or one sample size re-estimation will be 
conducted as described in section 7.6.1, Sample size and power, page 42 and section 9.3.7, Interim 
sample size re-estimation and/or interim analyses and criteria for termination of the trial, page 50. 
The study is designed as a superiority trial, so all tests will be two-sided and unless otherwise defined, 
P-values <0.05 will be used to define statistical significance for analysis involving comparisons 
between the control arm and the intervention arm for the primary and secondary outcomes. The 
analysis will be done using Stata. 
9.3.2 Analyses populations  
Primary analyses will be based on the Intention-to-treat (ITT) population and secondary supportive 
analyses will be done on the Per-protocol (PP) population. The safety analysis will be performed on 
the safety population. These analytical populations are defined as follows: 1) The ITT population 
consists of all randomised subjects with valid informed consent; 2) The PP population is a subset of 
the ITT population, where subjects with major protocol deviations will be excluded. Major protocol 
deviations will be defined in the Statistical Analysis Plan (SAP). 3) The safety population is a subset of 
the ITT population, consisting of all randomised subjects who receive at least one dose or a partial 
dose of study drug.  
9.3.3 Primary outcome analyses  
The generalised linear model (GLM) with the log-link function and binomial distribution (log-binomial 
regression) will be used to analyse the primary outcome. The GLM model will have the treatment arm 
as the only predictor variable and the balancing factors site and HIV-status (known-positive and newly-
diagnosed) as covariates, from which the risk ratio (RR) and its 95% confidence intervals (CI) of having 
a primary outcome will be derived. Covariate-adjusted analyses for the primary outcome will also be 
conducted by adding other pre-specified covariates into the above unadjusted GLM analysis to derive 
the adjusted RR (95% CI). Imputation for baseline missing covariates will be made for covariate-
adjusted analysis. These same covariates will be included in subgroup analyses. Assessment of the 
homogeneity of treatment effect by a subgroup variable will be conducted by a GLM with the 
treatment, subgroup variable, and their interaction term as predictors, and the P-value presented for 
the interaction term. In the case that convergence with the interaction models cannot be achieved, 
this will be done by separate GLM models for each category of a subgroup, and the difference between 
subgroup compared using the Altman-Bland method.81 In addition, the risk difference (RD) of the 
primary outcome will be derived from the overall and country stratified GLM models with binomial 
distribution function, and identity link functions, respectively. 

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9.3.4 Secondary outcomes analyses 
All secondary outcomes will be analysed as a superiority design and two-sided 95% CIs for the 
treatment differences in these outcomes between two treatment groups will be calculated and 
presented. Secondary outcome analyses will be based on the ITT population unless specified. The 
secondary outcomes will also be analysed using the same GLMs will treatment arm as the only 
predictor variable and the balancing factors site and HIV-status (known-positive and newly-diagnosed) 
as covariates. The point estimate of the treatment effects with their two-sided 95% CI will be derived 
via the specification of a GLM model for each secondary outcome depending on its distribution. For a 
binary outcome such as the components of the primary outcome, similar analysis to the primary 
outcome analysis will be performed and the treatment effects measured as RR and RD will be 
generated. For a continuous outcome like birthweight, a Gaussian distribution will be assumed, and 
an identity link function will be used. Correspondingly the mean difference and its 95%CI between two 
arms will be calculated. For a count outcome such as the number of SAEs or number of malaria 
infections or clinical malaria episodes after enrolment, Poisson distribution and log link function will 
be used (or negative binormal distribution if overdispersion is found), from which incidence rate ratio 
(IRR) and its two-sided 95% CI will be computed.  
9.3.5 Subgroup analyses  
We will perform subgroup analyses of the primary outcome and its components on a series of pre-
specified baseline characteristics of women including study country, gravidity (paucigravidae [1st and 
2nd] vs multigravidae [3rd+]), malaria status (positive-negative, based on a composite of microscopy 
and PCR), socio-economic status (terciles), HIV-status (known-positive and newly-diagnosed) season 
(terciles of average rainfall last 6 months before delivery)  and viral load (1,000 copies/ml), and study 
site (i.e. hospital) characteristics: malaria transmission intensity (terciles), expressed as prevalence of 
PCR positivity on enrolment across two arms; and degree of SP parasite resistance (as a proxy for CTX 
resistance), expressed as prevalence of the Pdhps-A581G mutation as a proxy ‘sextuple’ dhfr/dhps 
mutant parasites using (e.g. >30% Pdhps-A581G). We will also conduct subgroup analysis for the effect 
of the number of monthly doses received (e.g. median). The definition of subgroups in the statistical 
analysis plan will supersede those in the protocol. The treatment effect within each category of the 
above-selected variables will be estimated and the interaction effect between treatment and each 
variable assessed to explore effect modification. The modifying effects of bednets cannot be assessed 
as all women will receive LLINs on enrolment as part of the national policy.  
9.3.6 Safety 
For the safety analysis, women in the DP arm will be considered by arm and by both DP arms pooled 
(overall) and by the number of DP courses received to explore dose-responses, and the mean QTc 
change before the 1st dose and after the last dose of each course compared using GLM.  
9.3.7 Interim sample size re-estimation and/or interim analyses and criteria for 
termination of the trial 
9.3.7.1 
Sample size re-estimation 
One interim sample size-estimation will be conducted when approximately 50% of participants have 
been recruited to verify if the trial is not under-powered based on potential differences between the 
observed event and dropout rate pooled across the two arms (i.e. blinded) and the estimates of these 
pooled rates used in the sample size calculations, which were based on historical data from the study 
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conducted blinded; i.e. the effect size will not be taken into consideration as no details by arm will be 
provided to the statistician conducting the sample size re-estimation  
9.3.7.2 
Interim analysis 
At the discretion of the DMEC, an interim analysis will be conducted on the primary outcome when 
approximately 75% of participants have enrolled or at a time point suggested by the TSC or DMEC. 
The interim analysis will be performed by an independent statistician, blinded for the treatment 
allocation. The statistician will report to the independent DMEC. The DMEC will have unblinded access 
to all data and will discuss or report the results of the interim-analysis with the Trial Steering 
Committee (TSC), e.g. in a joint meeting. The TSC decides on the continuation of the trial and will 
report to the ethics committees. 
The Lan-DeMets spending function with O’Brien-Fleming type boundaries will be employed to 
preserve the overall one-sided type I error rate for efficacy at the final analysis. If the stopping 
boundary is crossed at the interim analysis and the RR is less than 0.5, it will be concluded that the 
study has demonstrated that the efficacy of the intervention is superior to that of IPTp-SP in the 
prevention of the primary outcome. The trial recruitment can then be stopped unless the DMEC 
advises otherwise  Statistics will not be the sole basis for the decision to stop or continue and the 
DMEC can advise to continue recruiting in the trial, or stop recruiting but continue to complete the 
intervention as per randomisation in the remaining active participants, even if statistically the 
stopping boundary is crossed, e.g. in order to continue collecting more safety information or data for 
further sub-group analyses etc. The trial can also be stopped in case of futility. 
A detailed plan for interim analysis, the provisional stopping rules and how the stopping rules will be 
applied, will be drawn up prior to the start of the interim analysis and documented in the study 
statistical analysis plan. 
10 METHODS: MONITORING 
10.1 DATA MONITORING AND TRIAL OVERSIGHT COMMITTEES 
10.1.1 Data Monitoring and Ethics Committee (DMEC) 
Since the study is a clinical trial an independent Data Monitoring and Ethics Committee (DMEC) will 
be set up. The DMEC will be critical to ensure that the subjects are protected from harm, while also 
ensuring that the study integrity is not compromised. The DMEC will consist of 3 to 4 independent 
members knowledgeable in the conduct of clinical trials. They will meet regularly (e.g. twice yearly or 
more frequently if so required) during data collection period to provide a review of blinded (and if 
requested unblinded) data to ensure the safety, rights and well-being of trial participants. In addition, 
regular review of the quality of the study data will be conducted at each meeting of the DMEC.  
The roles and membership of the DMEC are described in more detail in Appendix II. Terms of reference 
oversight committees, section 16.2.3, page 78. 
10.1.2 Trial Steering Committee (TSC)  
The trial will also have a Trial Steering Committee (TSC) which will advise on the study amendments, 
monitor progress and quality of the trial, ensure participants’ rights and safety are adhered to, review 
relevant new information from other sources and consider recommendations from the DMEC. The 
role and membership of the TSC are also described in more detail in section 16.2.2, Appendix II. Terms 
of reference oversight committees, page 76. 

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10.2 SAFETY MONITORING AND REPORTING 
The principles of ICH GCP require that both investigators and sponsors follow specific procedures 
when notifying and reporting adverse events or reactions in clinical trials. 
10.2.1 Definitions 
The following definitions apply to this protocol: 
10.2.1.1 Adverse Event (AE) 
Any untoward medical occurrence in a patient or clinical trial subject administered a medicinal 
product and which does not necessarily have a causal relationship with this treatment. 
10.2.1.2 Adverse Reaction (AR) 
Any untoward and unintended response to an investigational medicinal product related to any dose 
administered. 
Comment: All adverse events judged by either the reporting investigator or the sponsor as having a 
reasonable causal relationship to a medicinal product would qualify as adverse reactions. The 
expression ‘reasonable causal relationship’ means to convey, in general, that there is evidence or 
argument to suggest a causal relationship. 
10.2.1.3 Serious Adverse Event (SAE) or Serious Adverse Reaction (SAR) 
Any adverse event or adverse reaction that results in death, is life-threatening*, requires 
hospitalisation or prolongation of existing hospitalisation, results in persistent or significant disability 
or incapacity, or is a congenital anomaly or birth defect. 
Comment: Medical judgement should be exercised in deciding whether an adverse event/reaction 
should be classified as serious in other situations. Important adverse events/reactions that are not 
immediately life-threatening or do not result in death or hospitalisation but may jeopardise the 
subject or may require intervention to prevent one of the other outcomes listed in the definition 
above should also be considered serious. 
*Life-threatening in the definition of a serious adverse event or serious adverse reaction refers to an 
event in which the subject was at risk of death at the time of the event. It does not refer to an event 
which hypothetically might have caused death if it were more severe. 
10.2.1.4 Suspected Unexpected Serious Adverse Reaction (SUSAR) 
An adverse reaction that is both unexpected (not consistent with the applicable product information) 
and also meets the definition of a Serious Adverse Event/Reaction.  
10.2.1.5 Intensity 
The intensity of each AE recorded in the case report form should be assigned to a grade (1-5), which 
will be determined following the MedDRA definitions set forth by the International Council for 
Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH). Use of these 
standardised guidelines will allow for uniform reporting. The grades are defined as follows: 
▪ 
Grade 1: Mild AE 
▪ 
Grade 2: Moderate AE 
▪ 
Grade 3: Severe AE  
▪ 
Grade 4: Life-threatening or disabling AE 
▪ 
Grade 5: Death related to AE 

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10.2.2 Identifying, managing adverse events 
Participants who develop adverse events because of the study interventions or other treatments will 
be identified at scheduled and unscheduled follow-up visits and referred to the designated hospital 
for evaluation and treatment according to local guidelines.  Mild adverse events will be noted in the 
participant’s case report form; no further action will be taken by study staff except in the case of 
vomiting, in which case the study medication may need to be re-administered.  In the case of any SAE, 
subjects will be referred to the hospital for management. Transportation to the hospital will be 
provided where feasible, or transport reimbursed. All participants with SAEs will undergo a record 
review to identify potential adverse consequences of study participation.  
10.2.3 Assessment of causality 
The investigator is obligated to assess the relationship between the investigational product and the 
occurrence of each AE/SAE. The investigator will use clinical judgment to determine the relationship.  
Alternative causes, such as the natural history of the underlying diseases, concomitant therapy, other 
risk factors, and the temporal relationship of the event to the investigational product will be 
considered and investigated.  The investigator will also consult the drug information and the DMEC as 
needed in the determination of his/her assessment. 
There may be situations when an SAE has occurred, and the investigator has minimal information to 
include in the initial report. However, it is very important that the investigator always assess causality 
for every event prior to transmission of the SAE report.  The investigator may change his/her opinion 
of causality in light of follow-up information, amending the SAE case report form accordingly.  
10.2.4 Reporting adverse event procedures 
All SAEs will be reported to the in-country principal investigator or an assigned representative within 
24 hours of the staff becoming aware of it, using an SAE form, which should be completed and sent 
electronically. The SAE form asks for the nature of the event, date of onset, severity, corrective 
therapies given, outcome and causality (i.e. unrelated, unlikely, possible, probably, definitely). The 
responsible study clinician should assign the causality of the event.  
10.2.4.1 Expedited reporting 
SAEs that are unexpected and are at least ‘possibly related’ to the study drug require expedited 
reporting within 24 hours of the country principal investigator or assigned representative becoming 
aware of it (e-mail notification); i.e. this will be a maximum of 48 hours after the event occurred or 
the study team were made aware of the event (including the 24 hours required for the field staff to 
report to the principal investigator/representative). Additional information will be sent within 14 
additional days (full SAE report) if the reaction had not resolved at the time of e-mail notification.  
10.2.4.2 Scheduled reporting 
Other SAEs and AEs will be reported annually (or more frequently if so required by the DMEC or ethics 
committees) in an aggregated report. AEs that will not be reported include common illnesses that do 
not result in hospitalization, including but not limited to clinical malaria, respiratory, gastrointestinal, 
and skin diseases unless they are considered at least possibly related to the intervention. 
10.2.4.3 Recipients of reports 
The study will comply with local regulations about reporting of SAEs to their local Research Ethics 
Committee and/or Research & regulatory offices. In addition to the primary ethics committees, we 
will report safety data to the DMEC, and the sponsor. In addition, and if so requested by the 
manufacturer, the sponsor will forward the reports to the manufacturer of DP. A copy of the final 

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study report will be provided to all study hospitals, ethics committees, TSC, DMEC, to local regulators, 
and, if so requested, to the manufacturer. 
Figure 1: Safety reporting assessment flowchart82 
 
IMP: Investigational Medicinal Product 
*See definition of SAE in section 10.2.1 
**Assessed in line with the current approved Investigator’s Brochure (IB) 
10.2.5 Safety halting rules 
A concern for study participant safety would arise if an excess number of women in the experimental 
arm (CTX-DP) have clinically relevant QTC prolongation. If the following halting rule is met, study 
enrollment may be suspended until DSMB review. 
 

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1. Three or more participants have developed clinically significant QTc prolongation defined as 
1) Confirmed QT values >480ms & QTc>500ms combined with a heart rate of <65bpm and 
>60ms increase in QTc relative to baseline, or 2) any QT>480ms combined with a heart rate 
of <65bpm in a woman with syncope or seizures within 24 hours of the monthly dose (see 
section 9.1.2.4.2, Electrocardiogram (ECG), page 47). 
10.3 TRIAL MONITORING AND AUDITING 
10.3.1 Trial monitoring 
External clinical trial monitoring visits are provided by the sponsor at trial initiation, and then regularly 
(at least yearly) thereafter and at trial closeout, or more frequently if so required; e.g. if the trial 
fieldwork is about 24 months, this means that each site is visited approximately 4 times by external 
monitors. The results from each monitoring visit will help inform whether more frequent or earlier 
repeat visits are required. The frequency of these visits appeared appropriate for our experienced 
study sites in recent trials and the feedback was highly appreciated by the study teams. 
10.3.2 Auditing 
The independent clinical monitoring process will be audited by a study staff from the sponsor’s 
research office at LSTM in Liverpool, UK. The auditor will accompany the clinical monitor during at 
least one of the site visits. After this visit, it will be determined by the sponsor if more auditing visits 
are required. 
10.3.3 Role of sponsor 
 
The Sponsor reserves the right to suspend temporarily or prematurely discontinue this study at any 
time for reasons including, but not limited to, safety or ethical issues or severe non-compliance. If the 
sponsor determines such action is needed, it will discuss this with the investigator. When feasible, the 
sponsor will provide advance notification to the investigator of the impending action prior to it taking 
effect. The sponsor will promptly inform the ethics committees and provide the reason for the 
suspension or termination. 
10.4 OTHER QUALITY CONTROL MEASURES 
10.4.1 Safety monitors 
A local paediatrician and/or obstetrician will act as trial safety monitors, one per country. 
10.4.2 Trial monitoring 
Each of the partner’s institutions have their own internal quality control teams who will conduct 
internal monitoring regularly, and to help prepare for external monitoring visits. The study will be 
externally monitored regularly by a monitor appointed by the sponsor’s research office at LSTM in 
Liverpool, UK. The frequency will be at least yearly, but after each visit, the frequency of subsequent 
monitoring visits will be evaluated by the sponsor to see if more frequent monitoring is required. 
10.4.3 Training 
The country Principal Investigators are responsible for the conduct of the study at the study sites, 
including delegation of specified study responsibilities, and training of study staff. Each site will 
maintain a record of all individuals involved in the study (medical, nursing and other staff) and will 
ensure that all persons assisting with the trial receive the appropriate training about the protocol, the 
investigational product(s) and their trial-related duties and functions, including formal certified GCP 

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training. During the study, the regular spot checks will be conducted to assess the performance of the 
study site staff members and re-training provided where necessary. 
10.4.4 Quality assurance/control of laboratory tests 
Regular audits of laboratory performance will be completed by experienced supervisors according to 
standard operating procedures. All malaria blood smears will be read by two different microscopists 
blinded to the allocation and each other’s results, any significantly discordant results based on 
positive/negative results or difference in parasites above a defined threshold will be verified by a third 
expert microscopist. All malaria molecular analyses will include a set of positive P. falciparum controls 
and a set of randomly distributed negative controls on the PCR plates. If one or more of the negative 
controls are PCR positive the PCR run will be discarded. Ten percent of all histopathology slides will 
undergo external validation. 
11 ETHICS AND DISSEMINATION 
11.1 DECLARATION OF HELSINKI 
The trial will be conducted in compliance with the principles of the Declaration of Helsinki (1996) (See 
16.3, Appendix III. Declaration of Helsinki, page 80), the principles of GCP and in accordance with all 
applicable regulatory requirements in Kenya and Malawi.  
11.2 RESEARCH ETHICS AND REGULATORY APPROVAL 
11.2.1 Review process 
This protocol, the informed consent document, patient information sheets will be reviewed and 
approved by the Research Ethics Committees at KEMRI, Nairobi, Kenya (SERU), and the College of 
Medicine in Malawi (COMREC) (or if requested at the national level, by the Malawian National Health 
Science Research Committee). In addition, the protocol will require approval from the Research and 
Ethics Committee of Liverpool School of Tropical Medicine, Liverpool (LSTM). 
11.2.2 Protocol amendments 
If it is necessary for the protocol to be amended, the protocol amendment will be submitted to the 
research ethics committees at LSTM (sponsor) and the primary ethics committees in each country for 
approval before implementation in that country. Any change to the informed consent form, except 
for layout, spelling errors and formatting, must also be approved by the sponsor and the primary 
ethics committee in each country, before the revised form is used. 
No change will be made to the approved protocol without the agreement of the sponsor. The Chief 
Investigator, or a delegated person, will distribute amendments on behalf of the sponsor to each 
principal investigator, who in turn is responsible for the distribution of these documents to the staff 
at his/her study site. 
11.2.3 Sanctioning of the protocol by hospitals 
Where this is a requirement of participating hospitals, the approved protocol will subsequently be 
submitted to the participating hospitals' review committees or representatives for subsequent 
sanctioning of the protocol and procedures by the hospital. 

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11.2.4 Regulatory approval 
Regulatory approval will be sought from the national regulators in Kenya and Malawi from the 
Pharmacy and Poisons Board; Pharmacy, Medicines and Poisons Board. CTX and DP are currently 
approved under various brand names in each of the two countries as outlined below: 
11.2.4.1 Dihydroartemisinin-piperaquine 
Dihydroartemisinin-piperaquine is registered for use as case-management for clinical malaria in both 
Kenya and Malawi. The main brands registered are DuoCotecxin (from Beijing Holley-Cotec 
Pharmaceutical Ltd, China), D-ARTEPP® from Guilin Pharma, a GMP and WHO pre-qualified, 
pharmaceutical company based in China, and Eurartesim®, a GMP manufactured product from 
AlfaSigma (formerly Sigma-Tau) approved by the European Medicines Agency (EMA), the European 
regulator for the case-management of malaria.  
11.2.4.2 Cotrimoxazole (CTX) 
CTX is approved in Kenya and Malawi under various brand names. 
11.2.4.3 Fixed dose combinations of cART 
The DTG-based formulations are approved as fixed dose combination of TLD (TDF/3TC/DTG) and 
available under various brands manufactured by Mylan Pharma, Cipla, Hetero labs limited, Aurobindo 
Pharma, Macleods Pharmaceuticals Limited and Laurus Labs Limited. Of these, by April 2019, TLD 
manufactured by Mylan, Hetero labs limited, Aurobindo and Macleods and Laurus labs limited are 
approved or tentatively approved antiretrovirals by the US FDA for use in association with Presidential 
Emergency Plan for AIDS Relief (PEPFAR).83 
11.3 INFORMED CONSENT PROCEDURES 
Informed consent will be obtained before participants are enrolled in the study. See section 7.5.2.1, 
and 16.5, Appendix V. Participant information sheets and informed consent statements, page 84 for 
further details. 
11.3.1 Consent procedures 
Written, informed consent will be obtained in the local vernacular language. The consent process shall 
be initiated at the time of enrolment into the study and shall continue throughout the participant’s 
participation. Participants meeting the initial eligibility criteria will have the study explained to them 
by a member of the study team. If the participant meets the study enrolment criteria, the full consent 
process will follow, with a written consent form provided. A copy of the informed consent document 
will be given to the participant for their records unless they state that they do not wish to have a copy. 
For illiterate participants, an independent witness will be present during the informed consent process 
and will sign the consent form as a witness, while the participant will be asked to indicate consent by 
use of thumbprint. The participant may withdraw consent at any time throughout the course of the 
study, and this will be made clear in the informed consent process. A copy of the informed consent 
document will be given to the caregiver for their records unless they state that they do not wish to 
have a copy.  
All individuals will be informed that there is no requirement to join the study and that standard 
medical care will remain the same regardless of study enrolment. If the participant chooses not to be 
enrolled in the study, they will be allowed to continue with routine care provided by the health facility 
without any consequences to the expected level of care provided.  

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Participants will be given the option to take the patient information sheet and consent statement 
home to provide them with the opportunity to discuss this with their partner and family members 
prior to deciding if they want to join the study. 
11.4 PROTECTION OF PRIVACY AND CONFIDENTIALITY 
11.4.1 Privacy 
Personal and medical information relating to research participants will be treated as confidential. The 
risk of disclosure will be minimized by secure storage of documents and use of linked data by replacing 
personal identifiers with a unique study code to conceal the identity of the participant. 
11.4.2 Privacy of individual 
Individual data such as RDT tests for malaria, syphilis and anaemia will be reported to the participant 
at point of care, to relevant study staff and where appropriate will be recorded in the participants’ 
medical record book in addition to study CRFs. 
11.4.3 Confidentiality of data 
All information regarding the participants will remain confidential to the extent allowed by law. 
Unique numerical identifiers will be used for data entry.  All screening forms and case report forms 
will be kept in a secured location with access limited to authorized study staff. Unique numerical 
identifiers will be used for the computer-based data entry and blood samples. Publications will contain 
only aggregate data. No identifying information will be included to ensure individual patient 
anonymization of all data and results made public.  
11.5 DECLARATION OF INTEREST 
None of the principal investigators have paid consultancies with the pharmaceutical companies 
involved in the trial or other competing interest for the overall trial or in each study site.  
11.6 ACCESS TO SOURCE DATA/DOCUMENTS 
In addition to the clinical monitors, authorised representatives of the sponsor/CRO, an IEC/IRB or 
regulatory authority may visit the study site to perform audits or inspections, including source data 
verification. The investigator agrees to allow the sponsor and CRO representatives, including the 
monitor and study safety monitor, the DMEC, the IRB/IEC and regulatory authority direct access to 
source data and other relevant documents. 
11.7 RISKS AND BENEFITS 
11.7.1 Risks to study participants 
11.7.1.1 Safety of the study drugs in pregnancy 
All three drugs (CTX, DP and TLD) are currently thought to be safe for the mother and foetus during 
the second and third trimesters of pregnancy and have been used in research settings with favourable 
safety profiles within the proposed doses to be used in the trial. For more details of the safety of the 
study drugs in pregnancy and drug-drug interactions see 3.4, Safety of study drugs in pregnancy, page 
24 and section 3.3, Drug-drug interactions, page 24. 

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All adverse events, including those associated with the study medication, will be recorded and 
monitored throughout the trial. The trial may be stopped or temporarily suspended by the sponsor at 
any stage due to any arising safety concerns.  
11.7.1.2 Blood and tissue sampling 
All examinations undertaken as part of this study will be non-invasive, except for blood sampling. 
Wherever possible, blood sampling will be minimised. Blood samples of no more than 12 mL will be 
taken before enrolment, for eligibility screening/study-specific baseline testing. The sample will be 
taken at the screening stage. A similar blood sample shall be collected at all scheduled visits, and 
aliquoted, where necessary, into respective sample tubes for study investigations. An additional 2 ml 
venous blood sample is taken from participants participating in the cardiac safety study on day 2, 4-6 
hours after administration of the 3rd intervention dose, and for two more times during pregnancy, 4-
6 hours after a selected monthly course of DP. 
A maternal blood sample (no more than 12 mL) will be taken at scheduled visits and at birth, and 
where possible routine care and study-specific samples will be combined in a single blood draw.  
Blood sampling may be inconvenient to the participants and may cause minor discomfort and bruising. 
In some aspects of the trial, blood sampling has the potential to directly benefit the participants or 
their babies, as any malaria infection or anaemia detected because of the sampling will be treated. In 
other aspects of the trial, such as parasite genetics, CTX (or antifolate) and piperaquine resistance 
markers will not be of direct benefit to the individual woman, but the potential knowledge gained will 
eventually be used to benefit all pregnant participants and their babies in areas with similar 
characteristics in sub-Saharan Africa.      
The volume of blood collected from each participant will be small, a maximum of 100 ml per woman 
over the course of the study. Only well-trained nursing and laboratory staff will be employed on the 
trial. Only new disposable needles and lancets will be used for blood sampling procedures, and these 
will be safely discarded immediately after their use. There no direct risks to the participants while 
collecting cord blood and placental samples. In the event of a needle stick to study staff during blood 
and tissue sampling, HIV post exposure prophylaxis (PEP) will be provided at the trial sites at the cost 
of the trial. 
11.7.2 Benefits to study participants 
By taking part in this trial, participants will receive either placebo-DP or active DP in addition to their 
daily CTX and cART. All these regimens have either been the routine standard of care (daily CTX) or 
have the potential to have significantly increased effectiveness on birth outcome (DP). Participants 
who do not attend scheduled appointments will receive reminders and active follow-up. Participants 
experiencing illness between visits will be seen and treated free of charge as part of the study though 
this is already routine practice in some of the participating countries, such as in Malawi. As a minimum, 
the participant will benefit from frequent reminders to attend the monthly ANC schedule, reduced 
waiting times, and ensured availability of study drugs and routine care. Where participants are 
diagnosed with malaria or an STI (e.g. syphilis) during scheduled and unscheduled visits, treatment 
will be provided as per the nationally recommended standard of care. This will be recorded for 
participants who received treatment during follow up.  

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11.7.3 Risk to the population 
11.7.3.1 DP resistance 
Monthly DP will also exert some drug pressure on piperaquine. Artemisinin-based combination 
therapies, including DP, have demonstrable parasite resistance in South East Asia and there is concern 
that resistance will spread to or develop within Africa.84 Importantly we will monitor for signs that 
drug pressure is selecting for resistant parasite strains as outlined in section. We will determine if any 
mutations within these known drug resistance candidates increase because of exposure to either daily 
CTX (antifolate resistance) or DP (piperaquine) or the artemisinin(dihydro-artemisinin). 
11.7.4 Other ethical considerations 
11.7.4.1  Inclusion of young people under the age of 18 
This study will include young participants aged <18y. Young pregnant participants, in tandem with the 
respective country laws of age of emancipation, will be considered emancipated, therefore being 
legally able to consent on their own behalf, and to be included in a clinical trial. It is important to 
include young participants in the trial, as adolescents are known to be particularly susceptible to 
malaria in pregnancy and are therefore one of the groups that may benefit the most from any 
improvements to practice to prevent adverse outcomes related to malaria in pregnancy. 
11.7.4.2 Long term samples storage for future studies and shipment of samples to external 
laboratories 
With respect to applicable country regulations, written informed consent will be sought from 
participants participating in the trial for long term storage of their samples for future research. 
Informed consent shall be sought from all participants for the shipping of their samples to external 
laboratories for relevant analyses. 
11.8 ANCILLARY AND POST-TRIAL CARE 
11.8.1 Health care during the trial 
All care directly related to the proper and safe conduct of the trial, and the treatment of immediate 
adverse events related to trial procedures will be provided free of charge by the study in the study 
hospitals. The provision of ancillary care beyond that immediately required for the conduct of the trial 
will not be covered by the trial.  
11.8.2 Trial insurance 
The sponsor will take out trial insurance such that participants enrolled in the study are covered by 
indemnity for negligent harm and non-negligent harm associated with the protocol. This will include 
cover for additional health care, compensation or damages whether awarded voluntarily by the 
Sponsor, or by claims pursued through the courts. The liability of the manufacturer of the trial drug  
DP is limited to those claims arising from faulty manufacturing of the commercial product and not to 
any aspects of the conduct of the study. 
11.8.3 Post-trial care 
The study budget is not able to fund post-study care or implementation of monthly DP as policy. 
However, the investigators work in close collaboration with local and international policymakers (e.g. 
WHO) and funders (e.g. President's Emergency Plan for AIDS Relief [PEPFAR], President’s Malaria 
Initiative [PMI]) to ensure those policymakers and funders are informed early of germane research 
findings. 

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11.9 EXPENSES REIMBURSEMENT AND INCENTIVES 
The study will provide payment for all study drugs, study procedures, study-related visits and 
reasonable medical expenses that are incurred in study clinics or hospitals because of the study, 
including expenses for transport for any study related visits including unscheduled visits in between 
scheduled visits to study clinics. The study will not cover the costs of any non-malaria or non-study 
related events, including scheduled or unscheduled surgery or trauma-related events (e.g. accidents, 
burns etc.) if this is not deemed to be related to the study by the principal investigators or their 
representative. 
11.10 
DISSEMINATION AND APPLICATION OF THE RESULTS 
11.10.1 
Result dissemination and publication policy 
11.10.1.1 Dissemination to local stakeholders, global policy makers, academic beneficiaries and the 
general public 
Our research findings will be communicated to country level stakeholders including the study 
participants, reproductive health and malaria programmes/national Ministries of Health, and the 
research partner institutions in Kenya and Malawi, and to other national and international research 
partners, NGOs, technical agencies and implementing partners, donor organizations, WHO, UNICEF 
and the general public. We will use multiple communication strategies to reach each target audience 
as outlined below. 
11.10.1.2 Local Stakeholders 
Communications with stakeholders involved in the trials and nested studies (i.e. study participants, 
health providers and trial staff), Ministries of Health and their technical and implementing partners, 
and donors in Kenya and Malawi will be through face-to-face meetings and local forum presentations 
at village, district, regional, county and national levels as may be applicable. The results of the trial 
and nested studies will be communicated through a dissemination meeting to all national level 
stakeholders held in one of the two trial countries, preferably linking to the national interagency and 
multidisciplinary technical committees on malaria, reproductive health, and HIV/AIDS (see 11.10.2, 
Impact, page 62). Policy briefs describing the results in clear, jargon-free language targeting country 
Table 4: Reimbursement of expenses and incentives provided by the study 
To Who 
What 
Approximate Amount 
Hospital 
Improvement of infrastructure where required 
up to ~$10,000/hospital 
 
Training of routine staff adult ward 
~ $3,000/hospital 
 
Study procedure costs and study drugs and 
admission fees for inpatients 
~ $100,000/hospital 
Participant 
(mother or 
infant) 
Travel expenses for the participant  
Up to ~$10 per round trip* 
Compensation for each day they are scheduled to 
come to the ANC, out-patient clinic or delivery unit 
and need to stay or wait for more than 4 hours  
Up to ~$ 3 per day 
(excluding any travel 
expenses) 
*In exceptional cases, higher amounts of travel expenses can be reimbursed if distance requires. 
This would need to be decided on a case by case basis, courtesy of the site PI/coordinator. 

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policy makers will be disseminated to facilitate policy adoption and subsequent implementation, as 
appropriate. 
11.10.1.3 Academic beneficiaries 
Communication of trial results to academic beneficiaries will be achieved through standard academic 
channels including open-access, peer-reviewed journal publications, articles in science review 
magazines such as International Innovation, symposia, conferences, and the dissemination workshop 
to multidisciplinary malaria technical committees (which include academics) in Malawi and Kenya. The 
full de-identified individual patient level dataset from the trial will be made publicly accessible via the 
WWARN platform (http://www.wwarn.org/working-together/sharing-data/accessing-data). The trial 
publications will also be disseminated via institutional websites of partners, and to all partners of the 
LSTM-led Malaria in Pregnancy Consortium by e-mail, their website, and the MiP library, which is the 
most comprehensive and reliable database of literature on malaria in pregnancy currently available 
(http://library.mip-consortium.org/). The research will also be disseminated to all academics within 
each of the participating institutions through monthly and annual dissemination seminars that are 
held routinely for information sharing and to encourage networking, cross disciplinary working, and 
development of new initiatives. The Chief Investigator will be responsible for ensuring dissemination 
in the UK, Drs Meghna Desai and Julie Gutman for dissemination in the US, and the country PIs (Kenya: 
Hellen Barsosio and Simon Kariuki), (Malawi: Mwayiwawo Madanitsa, supported by Victor Mwapasa, 
Ken Maleta) for dissemination in Kenya and Malawi, respectively. 
11.10.1.4 WHO and Roll Back Malaria (RBM) Partnership 
Results of the trial are expected to be presented to WHO at a WHO-convened ERG meeting in 2020 or 
2021 for consideration for policy. If the intervention is recommended for global policy, the research 
team will support WHO to prepare and disseminate policy guidance information aimed at policy users 
in sub-Saharan Africa. The results will also be disseminated to the Roll Back Malaria (RBM) Partnership 
MiP Working Group, responsible for generating consensus among RBM Partners, including national 
malaria and reproductive health programmes, technical agencies and donors, on key strategic issues 
and best practices for ensuring effective delivery and scale-up of interventions for the prevention and 
control of MiP. 
11.10.1.5 General Public 
Communication to a broader audience and the public will be via press releases and TV opportunities 
in the news media in the UK, Kenya and Malawi, news items on websites including partner websites 
and online networks such as Global Health Network https://globalhealthtrials.tghn.org, and 
publication portals including the MiP library. 
11.10.2 
Impact 
11.10.2.1 Likelihood to result in major advances for the field of malaria control in pregnancy 
The context for the trial is highly significant and timely. Several multi-centre trials for the control of 
malaria in pregnancy have been completed in the last decade. However, very few studies have looked 
at malaria prophylaxis for HIV-infected pregnant women. It is thought that antifolate cross-resistance 
with IPTp-SP and CTX may have a negative impact on daily CTX for malaria prophylaxis in this 
population, suggested by the recent trials that showed that adding an effective antimalarial 
(mefloquine) markedly improved the chemoprevention of malaria compared to daily CTX alone.80 
However, mefloquine was not well tolerated and cannot be considered as IPTp for chemoprevention 
in pregnancy. The results of the recently completed exploratory trials of IPTp with DP in Kenya and 
Uganda in HIV-negative women29,30are promising and DP has now emerged as the leading, and so far 

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only, suitable candidate to replace SP for use in IPTp in HIV-negative women or in addition to daily 
CTX in HIV-positive women.85  
11.10.2.2  Improving public health, economic and societal impacts 
The ultimate beneficiaries of this research will be mothers and their infants in Kenya and Malawi, and 
other countries experiencing high levels of antifolate resistance, whose quality of life, health, and 
creative output will have been enhanced. Malaria poses a substantial economic and social burden in 
endemic countries, with costs arising at the household level through direct costs of seeking care and 
indirect (productivity) losses; and at the aggregate level by reducing economic growth. Malaria in 
pregnancy is estimated to be responsible for 35% of preventable low birthweight, which is a strong 
predictor of infant mortality, childhood morbidity and productivity in adult life.13 Identifying more 
effective means of preventing malaria in pregnancy for these participants can reduce part of this 
burden and enhance the effectiveness of public investments in malaria control. 
Approximately 10 to 19% of the pregnancies in East and Southern Africa occur among HIV-infected 
women. We estimate that each year approximately 620,000 to 1 million HIV-infected pregnancies will 
benefit from a switch to the new intervention if found to be superior to daily CTX. These are the 
pregnancies among HIV-infected women that occur in highly antifolate resistant areas in east and 
southern Africa where the quintuple dhfr/dhps haplotype has reached saturation, representing 
approximately 24% of all pregnancies in HIV-infected women in malaria-endemic Africa. About one-
third of these occur in settings with appreciable levels of the sextuple haplotype which severely 
compromises the effectiveness of antifolate drugs such as SP (Patrick Walker, Imperial College, 
unpublished observations).  
11.10.2.3 Contribution to strengthening the capacity in sub-Saharan Africa to conduct clinical trials 
The development of research capacity of African institutions is central to the achievement of the 
research objectives and includes training in trial methodologies, including in Good Clinical Practice, 
and strengthening of the quality assurance/control procedures. The multi-centre trial in both 
countries will enhance the visibility of the two African research institutions and the potential to 
improve research quality and the rate at which pivotal research findings can be translated into policy, 
thereby increasing its impact. The trial will furthermore result in the training of a cohort of one 
Malawian Post-Doc and two African PhD students, contributing skilled research staff to the national 
workforce. Health worker capacity in the feasibility study sites in Kenya will also be strengthened 
through training, thereby advancing knowledge, improving skills and increasing the effectiveness of 
public health services for pregnant participants. 
11.10.3 
Authorship and publications 
Potential authors include all professionals that have participated in the trial for a minimum of six 
months. Authorship of any presentations or publications arising from this study will also be governed 
by the principles for authorship criteria of the International Committee of Medical Journal Editors has 
designed.86 Disputes regarding authorship will be settled by the publications committee, with further 
involvement of the independent chair of the TSC if so required. The manufacturers of the study 
medications will be provided with a draft of the manuscript but will have no role in review, data 
interpretation, or writing of the article. 
11.10.4 
Data Sharing Statement 
Biological samples and data will be shared using material and data transfer agreements with the 
collaborating institutions (see 2.2.4 Collaborators, page 10) to minimise the risk of unauthorised 
analysis beyond the scope of the agreed parameters. 

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The full protocol will be available on request to any interested professional and may be published in 
a peer reviewed journal or deposited in an online repository. Individual, de-identified participant data 
will be made available for meta-analyses as soon as the data analysis is completed, with the 
understanding that results of the meta-analysis will not be published prior to the results of the 
individual trial without prior agreement of the investigators. No later than five years after the 
publication of the trial a fully de-identified data set of the complete patient-level data will be available 
for sharing purposes, such as via the WWARN repository platform (http://www.wwarn.org/working-
together/sharing-data/accessing-data). All requests for data for secondary analysis will be considered 
by a Data Access Committee to ensure that use of data is within the terms of consent and ethics 
approval.  
12 TIMEFRAME AND DURATION OF THE STUDY 
12.1 TIMELINE 
The total duration of the project is 48 months, including 36 months for the preparation and conduct of 
the trial, and 1 additional year for the PhD students to write up their theses. The 36 months trial period 
includes 12 months for trial preparation and 19 months field work (12 months recruitment plus 7 
months of mother-infant follow-up until the child is 6 weeks old), and 5 months for completion of 
laboratory assays, data analysis and reporting. The 12 months for trial preparation are needed for 
ethical and regulatory clearances, trial insurance, trial registration, study drug shipment and packing, 
establishment of a DMEC, development of 
case-record forms (CRFs) and standard operating 
procedures (SOPs), and community sensitisation and staff training. The study will include 1 interim 
analysis of efficacy and safety data when approximately 75% of the patients have been enrolled. 
12.1.1 Project Gantt chart 
 
Year 1 
Year 2 
Year 3 
Year 4* 
 
Q
1 
Q
2 
Q
3 
Q
4 
Q
1 
Q
2 
Q
3 
Q
4 
Q
1 
Q
2 
Q
3 
Q
4 
Q
1 
Q
2 
Q
3 
Q
4 
Activity 
  
 
 
 
  
 
 
 
  
 
 
 
  
 
 
  
Protocol development 
  
 
 
 
  
 
 
 
  
 
 
 
  
 
 
  
IRB approval / Annual 
Review 
  
  
 
 
  
 
 
 
  
 
 
 
  
 
 
  
Regulatory approval/ 
Annual Review 
  
  
 
 
  
 
 
 
  
 
 
 
  
 
 
  
CRF and SOP development   
  
 
 
  
 
 
 
  
 
 
 
  
 
 
  
Drug and placebo 
preparation 
  
  
 
 
  
 
 
 
  
 
 
 
  
 
 
  
Drug shipment 
  
  
 
 
  
 
 
 
  
 
 
 
  
 
 
  
Enrolment 
  
 
  
 
  
 
 
 
  
 
 
 
  
 
 
  
Study 
  
 
  
  
  
  
  
 . 
  
  
 
 
  
 
 
  
Closure 
  
 
 
 
  
 
 
 
  
 
  
 
  
 
 
  
Analysis 
  
 
 
 
  
 
 
 
  
 
  
 
  
 
 
  

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Manuscript and results 
dissemination 
  
 
 
 
  
 
 
 
  
 
  
 . 
  
 
 
  
 
 
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14 FINANCIAL ASPECTS AND CONFLICT OF INTEREST 
14.1 FUNDING FOR THE TRIAL 
Funding to conduct the trial is provided by: 
1. The Joint Global Health Trials Scheme of the UK Medical Research Council (MRC/ Wellcome 
Trust of Great Britain (WT) and the UK Department of International Development (DFID). 
2. The European and Developing Countries Clinical Trials Partnership (EDCTP 2) which is funded 
by the European Union (EU), European Participating States and third parties including Product 
Development Partners (PDPs), Private Sector Industry, and International Development 
Partners.  
The funders had no role in the design of this trial and will not have any during the execution, analysis, 
interpretation of the data, or decision to submit the results. 
14.2 PROVISION OF STUDY DRUGS 
DP and DP placebo will be provided at reduced rates either by Guilin Pharma, based in China, or 
Alfasigma (formerly Sigma-Tau). CTX will be purchased a GMP manufacturer identified in section 
7.3.1.5. Fixed-dose formulations of DTG-based combination will be obtained from the local 
Governments or a GMP manufacturer identified in section 7.3.1.5. When so requested by 
manufacturers, the study will provide copies of safety reports of SAEs and AEs to the manufacturers 
(expedited where required). The manufacturers will not be involved in the design of the trial.  
15 BUDGET & BUDGET JUSTIFICATION 
See 16.4,  Appendix IV. Budget and budget justification, page 83. 
 

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16 APPENDICES 
16.1 APPENDIX I. ROLE OF INVESTIGATORS AND COLLABORATORS 
16.1.1 Definition investigator and collaborator 
16.1.1.1 Investigators 
Investigators are directly involved with the field research and, except for the trial statisticians, and live 
and work in Kenya and Malawi.  
16.1.1.2 Collaborators 
Collaborators are not involved with any of the field work and are either PhD supervisors living 
overseas, provide purely technical support, or support the study with the laboratory assays in their 
overseas laboratories. Each home institutions will sign MOUs in the form of MTA and/or DTAs with 
the overseas collaborators before samples or data can be shipped overseas. 
16.1.2 Protocol development: authors’ contributions 
Hellen Barsosio (HB), Mwayiwawo Madanitsa (MM) and Feiko terKuile (FtK) wrote the first draft of 
the protocol. All investigators contributed to the refinement of the study protocol and approved the 
final versions.  
16.1.3 Role Investigators 
16.1.3.1 Chief Investigator 
Prof Feiko ter Kuile (MD, PhD), is a Professor of Tropical Epidemiology from the Liverpool School of 
Tropical Medicine (LSTM) based at KEMRI in Kisumu. He is the Chief Investigator and grant holder and 
will carry overall responsibility for the coordination of the trial and for the linkages with the sponsor, 
funders and with international partners involved. He will also liaise with WHO. 
16.1.3.2 Co-principal investigators 
Dr Hellen Barsosio (MD, MSc), is a research medical officer with KEMRI/CDC/Liverpool collaboration, 
based in Kisumu, Kenya. She will be the co-Principal Investigator for Kenya and as overall trial 
Manager. She will also liaise with the local hospitals, the ethics committees, the regulators and the 
MoH in country. She will be supervised locally by Dr Simon Kariuki, the KEMRI-CDC Malaria Branch 
Chief and internationally by Prof Feiko ter Kuile. 
Dr Mwayiwawo Madanitsa (MD, PhD), is a postdoctoral research fellow with COM and LSTM, based 
at COM in Blantyre, Malawi. He will act as the co-Principal Investigator for Malawi and as overall trial 
Manager. He will a l s o  liaise with the local hospitals, the ethics committees, the regulators and the 
MoH in country. He will be supervised locally by Professor Victor Mwapasa and internationally by FtK. 
Dr Simon Kariuki (PhD), is the KEMRI/CDC Malaria Branch Chief and will be the co-Principal Investigator 
for Kenya. Dr Kariuki the KEMRI-CDC Malaria Branch Chief and oversees all research studies that fall 
under the Malaria Branch. He will supervise Dr Hellen Barsosio in addition to providing local support 
with regulators and the MoH in country.  
16.1.3.3 Co-investigators 
Prof Duolao Wang, PhD is Professor of Medical Statistics at the Liverpool School of Tropical Medicine 
and will be the trial statistician. 

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James Dodd, MSc at the Liverpool School of Tropical Medicine is a statistician who will be involved 
with the data merging and analysis under supervision of Prof Duolao Wang. 
George Githuka, MD, MSc from NASCOP, MoH, Kenya will provide technical advice and oversight of 
the PMTCT transmission component and cART guidelines in Kenya. 
Clifford Banda (MD, MSc) is a medical officer from the CoM, Malawi with a special interest in clinical 
pharmacology and will be responsible for the conduct of the pharmacokinetic component of the study 
Prof Victor Mwapasa (MD, MPH, PhD) is a Professor of Public Health and Dean of Research and 
Postgraduate Studies at the CoM. He will serve as the co-investigator in Malawi and provide site co-
leadership and liaison with administrative and policy stakeholders of the trial and co-lead the capacity 
development activities at the College of Medicine, University of Malawi. 
Prof Kamija Phiri (MD, PhD) is Professor in Clinical Epidemiology, Public Health Department, and Dean 
of the School of Public Health & Family Medicine, and Director, of the Training & Research Unit of 
Excellence (TRUE), College of Medicine, University of Malawi. He has over 10 years’ experience in 
clinical research and will provide site co-leadership for the study site in Zomba, Malawi.  
Prof Ken Maleta (MD PhD) is Professor in Community Health, College of Medicine, University of 
Malawi. He is a nutritional and growth expert and will support the activities in the Mangochi site in 
Malawi. 
16.1.4 Collaborators 
Non-engaged collaborators are not classified as investigators and have an advisory and supporting 
role and are not directly involved with the research activities on site. 
 

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16.2 APPENDIX II. TERMS OF REFERENCE OVERSIGHT COMMITTEES  
16.2.1 Trial Management Group (TMG) 
16.2.1.1 Purpose  
The TMG is responsible for the administrative management and day to day running of the trial. 
16.2.1.2 Membership 
1. Overall trial manager (Dr Hellen Barsosio) 
2. Other co-Principal Investigators (4x) or representatives 
3. Country trial Coordinators (4x) 
4. Lead Data manager 
5. Lead administrators 
6. Chief Investigator (ad hoc) 
7. Others who are involved in the day to day running of the trial are invited ad hoc 
16.2.1.3 Responsibilities:  
• 
Study planning 
• 
Organisation of the Trial Steering Committee and Data Monitoring and Ethics Committee 
(DMEC) meetings 
• 
Provide risk report to regulators, manufactures and ethics committees 
• 
SUSAR [Serious unexpected suspected adverse events] reporting  
• 
Responsible for the trial master file 
• 
Budget administration and contractual issues 
• 
Advice for lead investigators 
• 
The organisation of central data management and sample collection 
16.2.2 Trial Steering Committee (TSC) 
16.2.2.1 Membership TSC 
16.2.2.1.1 Independent members 
1. Chair: Dr Laurence Slutsker, PATH, is the director of malaria and neglected tropical diseases, at 
the Center for Malaria Control and Elimination, PATH. He is malaria and HIV expert, and member 
of the Malaria Policy Advisory Committee (MPAC) at WHO and chair of WHO’ Evidence Review 
Group for malaria in pregnancy  
2. Associate Professor Miriam Laufer, (PhD), University of Maryland, School of Medicine, Baltimore, 
USA (paediatrician, and malaria epidemiologist and public health expert with specific expertise in 
pregnancy, WHO ERG member); 
3. Professor Grant Dorsey, MD, PhD University of California, San Francisco (malaria epidemiologist 
and expert on intermittent DP, CI of the previous trials in Uganda.29,60  
4. Professor Per Ashorn, MD, PhD, Department of Maternal, Child, and Adolescent Health, World 
Health Organization, Geneva, Switzerland (paediatrician, infectious disease and growth and 
nutrition expert and CI of previous intervention trials in pregnancy participants using intermittent 
azithromycin combined with IPTp). 
5. Dr Matt Cairns, from LSHTM, will be TSC statistician.  

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16.2.2.1.2 Trial members 
• 
Prof Feiko ter Kuile, Chief Investigator 
• 
Dr Hellen Barsosio, representing the co-Principal Investigators 
• 
Prof Duolao Wang, trial statistician 
• 
The other co-PIs, co-investigators, collaborators and the trial statistician will attend the 
meetings if and when required.  
16.2.2.1.3 Observers 
• 
EDCTP 
• 
MRC 
16.2.2.2 Roles and Responsibilities TSC 
The TSC is a trial governing body which includes a majority of its members who are independent of 
the trial management group. The TSC concentrates on the progress of the trial and ensures that the 
trial is conducted to the standards set out in the Guidelines for Good Clinical Practice with 
consideration given to participant safety and provision of informed consent. 
− 
To evaluate the progress of the trial in relation to the timeliness, data quality and other factors 
that can affect the overall objectives of the trial 
− 
To ensure participant rights and safety are adhered to and that the protocol demands freely 
given informed consent 
− 
To review relevant information from other sources 
− 
To consider the recommendations of the Data Monitoring and Ethics Committee (DMEC) and 
in light of it to inform the Chief Investigator and TMG the need to make changes to the trial 
protocol  
− 
To ensure that the trial results are disseminated appropriately, and consideration be given to 
the implementation of the results into policy 
16.2.2.3 Operational TSC 
The CI will present the full protocol to the TSC as an agenda before the start-up of data collection. The 
TSC members shall review the timeline set out in the protocol for participant recruitment, informed 
consent documents and plans for data safety monitoring.  
The TSC shall see that the finalised protocol is sent to the sponsor and funders before the start of 
participant recruitment and data collection. 
The TSC in its first meeting shall approve the nominated members of the DMEC and establish the 
DMEC which shall meet regularly to review and report on the data quality and the results of interim 
analyses. 
In all their deliberations the TSC should consider any deviations from the trial protocol, participant 
safety and information provided to the participants and consenting procedures. 
16.2.2.4 Frequency of Meetings 
The TSC shall have a start-up meeting to discuss the protocol and establish the DMEC. A second 
meeting shall take place before the initiation of the trial to finalise the protocol and approve the 
commencement of the trial. After that, the TSC will generally meet once a year in the life span of the 
trial and one meeting at the closure of the trial. 

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The Chair and at least 2 of the three independent members together with the CI and trial co-ordinator 
shall constitute the quorum. If so required, in addition, a member of the funder can be invited to 
attend the meetings.  
16.2.2.5 Trial Reports and actions TSC meeting 
The TSC shall provide at each meeting a summary report of their findings and recommendations which 
must be submitted to the funder, the Sponsor and the TMG.  
If the TSC makes a recommendation that the trial should be stopped or suspended, the Sponsor will 
take the necessary action to ensure that new recruitment to the trial is stopped whilst the TSC report 
is evaluated and the Research Ethics Committee is informed. 
16.2.3 Data Monitoring and Ethics Committee (DMEC) 
16.2.3.1 Membership DMEC (preliminary) 
1. Professor Andy Stergachis, Professor of Pharmacy and Global Health, and pharmaco-
epidemiologist, University of Washington will chair the DMEC. He chairs the safety working group 
of the Malaria in Pregnancy Consortium since 2008 and chaired several DMECs related to similar 
malaria in pregnancy trials.  
2. Professor Ib Christian Bygbjerg, from the Institute for Public Health, University of Copenhagen, 
Denmark 
3. Dr Billy Ngasala, from Department of Parasitology and Medical Entomology, Muhimbili University 
of Health and Allied Sciences (MUHAS), Tanzania 
4. Dr Kathleen Wannemuehler (kpw9@cdc.gov), Centers for Disease Control and Prevention (CDC), 
Atlanta, USA (Statistician) 
16.2.3.2 Role DMEC 
The DMEC consist of 3-4 members (including one or more clinicians and one statistician, all with 
experience in clinical trials). 
The DMEC shall assess the data regularly (before the annual TSC meeting) to review the data and the 
interim analysis. The assessment could be via email or another electronic medium annually before the 
TSC meeting.  In the first year of recruitment more frequent assessment (bi-annually) is recommended 
for this trial. 
The members should be the only personnel to see the results separated by treatment group during 
the trial. They are independent and look at the trial from an ethical point of view of the participant 
safety, future participants and society in general. It is their responsibility to prevent participants being 
exposed to any excess risks by recommending to the Trial Steering Committee (TSC) for the trial 
suspension or termination early if the safety or efficacy results are sufficiently convincing.  The trial 
statistician is usually invited to attend part of the DMEC meeting to present the most current data 
from the trial. This will be blinded, unless the DMEC specifically requests for an unblinded analysis. 
16.2.3.3 Responsibilities DMEC 
− 
To determine how frequently interim analysis of trial data should be undertaken. 
− 
To consider the blinded or unblinded interim data from the trial and relevant information from 
other sources. 
− 
To consider any requests for unblinding and release of interim trial data and to recommend 
to the TSC on the importance of this.  
− 
To report (following each DMEC meeting) to the TSC and to recommend whether the trial 
should continue, the protocol be modified or the trial be stopped. 

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A full confidential report should be submitted in writing to the TSC at the end of each DMEC meeting 
 

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16.3 APPENDIX III. DECLARATION OF HELSINKI 
WORLD MEDICAL ASSOCIATION DECLARATION OF HELSINKI 
Recommendations guiding physicians in biomedical research involving human subjects. Adopted by 
the 18th World Medical Assembly, Helsinki, Finland, June 1964. Amended by the 29th World Medical 
Assembly, Tokyo, Japan, October 1975, 35th World Medical Assembly, Venice, Italy, October 1983, 41st 
World Medical Assembly Hong Kong, September 1989 and the 48th General Assembly, Somerset 
West, Republic of South Africa, October 1996 
INTRODUCTION 
It is the mission of the physician to safeguard the health of the people.  His or her knowledge and 
conscience are dedicated to the fulfilment of this mission. 
The Declaration of Geneva of the World Medical Association binds the physician with the words, "The 
health of my patient will be my first consideration", and the International Code of Medical Ethics 
declares that, "A physician shall act only in the patient's interest when providing medical care which 
might have the effect of weakening the physical and mental condition of the patient." 
The purpose of biomedical research involving human subjects must be to improve diagnostic, 
therapeutic and prophylactic procedures and the understanding of the aetiology and pathogenesis of 
disease. 
In current medical practice most diagnostic, therapeutic or prophylactic procedures involve hazards.  
This applies especially to biomedical research. 
Medical progress is based on research which ultimately must rest in part on experimentation involving 
human subjects. 
In the field of biomedical research, a fundamental distinction must be recognized between medical 
research in which the aim is essentially diagnostic or therapeutic for a patient, and medical research, 
the essential object of which is purely scientific and without implying direct diagnostic or therapeutic 
value to the person subjected to the research. 
Special caution must be exercised in the conduct of research which may affect the environment, and 
the welfare of animals used for research must be respected. 
Because it is essential that the results of laboratory experiments be applied to human beings to further 
scientific knowledge and to help suffering humanity, the World Medical Association has prepared the 
following recommendations as a guide to every physician in biomedical research involving human 
subjects.  They should be kept under review in the future. It must be stressed that the standards as 
drafted are only a guide to physicians all over the world.  Physicians are not relieved from criminal, 
civil and ethical responsibilities under the laws of their own countries. 
Basic principles 
1. Biomedical research involving human subjects must conform to generally accepted scientific 
principles and should be based on adequately performed laboratory and animal experimentation 
and on a thorough knowledge of the scientific literature. 
2. The design and performance of each experimental procedure involving human subjects should be 
clearly formulated in an experimental protocol which should be transmitted for consideration, 
comment and guidance to a specially appointed committee independent of the investigator and 

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the sponsor provided that this independent committee is in conformity with the laws and 
regulations of the country in which the research experiment is performed. 
3. Biomedical research involving human subjects should be conducted only by scientifically qualified 
persons and under the supervision of a clinically competent medical person.  The responsibility 
for the human subject must always rest with a medically qualified person and never rest on the 
subject of the research, even though the subject has given his or her consent. 
4. Biomedical research involving human subjects cannot legitimately be carried out unless the 
importance of the objective is in proportion to the inherent risk to the subject. 
5. Every biomedical research project involving human subjects should be preceded with careful 
assessment of predictable risks in comparison with foreseeable benefits to the subject or to 
others. Concern for the interests of the subject must always prevail over the interests of science 
and society. 
6. The right of the research subject to safeguard his or her integrity must always be respected.  Every 
precaution should be taken to respect the privacy of the subject and to minimize the impact of 
the study on the subject's physical and mental integrity and on the personality of the subject. 
7. Physicians should abstain from engaging in research projects involving human subjects unless they 
are satisfied that the hazards involved are believed to be predictable.  Physicians should cease any 
investigation if the hazards are found to outweigh the potential benefits. 
8. In publication of the results of his or her research, the physician is obliged to preserve the accuracy 
of the results.  Reports of experimentation not in accordance with the principles laid down in this 
Declaration should not be accepted for publication. 
9. In any research on human beings, each potential subject must be adequately informed of the 
aims, methods, anticipated benefits and potential hazards of the study and the discomfort it may 
entail.  He or she should be informed that he or she is at liberty to abstain from participation in 
the study and that he or she is free to withdraw his or her consent to participation at any time.  
The physician should then obtain the subject's freely-given informed consent, preferably in 
writing. 
10. When obtaining informed consent for the research project, the physician should be particularly 
cautious if the subject is in a dependent relationship to him or her or may consent under duress.  
In that case the informed consent should be obtained by a physician who is not engaged in the 
investigation and who is completely independent of this official relationship. 
11. In case of legal incompetence, informed consent should be obtained from the legal guardian in 
accordance with national legislation.  Where physical or mental incapacity makes it impossible to 
obtain informed consent, or when the subject is a minor, permission from the responsible relative 
replaces that of the subject in accordance with national legislation.  Whenever the minor child is 
in fact able to give a consent, the minor's consent must be obtained in addition to the consent of 
the minor's legal guardian. 
12. The research protocol should always contain a statement of the ethical considerations involved 
and should indicate that the principles enunciated in the present Declaration are complied with. 
Medical research combined with professional care (Clinical Research) 
1. In the treatment of the sick person, the physician must be free to use a new diagnostic and 
therapeutic measure, if in his or her judgement it offers hope of saving life, re-establishing health 
or alleviating suffering. 
2. The potential benefits, hazards and discomfort of a new method should be weighed against the 
advantages of the best current diagnostic and therapeutic methods. 

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3. In any medical study, every patient - including those of a control group, if any - should be assured 
of the best proven diagnostic and therapeutic method.  This does not exclude the use of inert 
placebo in studies where no proven diagnostic or therapeutic method exists. 
4. The refusal of the patient to participate in a study must never interfere with the physician-patient 
relationship. 
5. If the physician considers it essential not to obtain informed consent, the specific reasons for this 
proposal should be stated in the experimental protocol for transmission to the independent 
committee (I,2). 
6. The physician can combine medical research with professional care, the objective being the 
acquisition of new medical knowledge, only to the extent that medical research is justified by its 
potential diagnostic or therapeutic value for the patient. 
Non-therapeutic biomedical research involving human subjects (Non-clinical biomedical research) 
1. In the purely scientific application of medical research carried out on a human being, it is the duty 
of the physician to remain the protector of the life and health of that person on whom biomedical 
research is being carried out. 
2. The subjects should be volunteers -- either healthy persons or patients for whom the experimental 
design is not related to the patient's illness. 
3. The investigator or the investigating team should discontinue the research if in his/her or their 
judgement it may, if continued, be harmful to the individual. 
4. In research on man, the interest of science and society should never take precedence over 
considerations related to the well-being of the subject. 
 
 

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16.4  APPENDIX IV. BUDGET AND BUDGET JUSTIFICATION  
16.4.1 Budget 
 
Generic site budget estimates and summaries 
  Item Description 
Total Cost Euro 
 Total Cost USD* 
  
  PERSONNEL 
  
  
  
 
Actual costs 
437,340 € 
 $       491,640  
 
 
Unit costs 
91,860 € 
 $       103,260  
 
  Subtotal cost Personnel 
529,200 € 
 $       594,900  
  
  GOODS AND SERVICES 
  
  
  
  Certificates on Financial Statements 
6,000 € 
 $            6,720  
  
  Equipment 
3,900 € 
 $            4,380  
  
 
Consumables and supplies 
43,560 € 
 $         48,960  
 
 
Training 
2,100 € 
 $            2,400  
 
  Subtotal cost Goods and Services 
55,560 € 
 $         62,460  
  
  PATIENT ADMINISTRATION 
  
  
  
  Patient costs 
114,180 € 
 $       128,340  
  
  Subtotal costs Patient Administration 
114,180 € 
 $       128,340  
  
  
 TRAVEL 
  
  
  
  In-country work-related travel 
39,000 € 
 $         43,800  
  
  Subtotal Travel 
39,000 € 
 $         43,800  
  
  TOTAL DIRECT COST 
  
  
  
  Total Direct Costs 
737,940 € 
 $       829,500  
  
  Indirect Costs (25%) 
184,485 € 
 $       207,375  
  
  TOTAL COSTS 
922,425 € 
 $   1,036,875  
  
  
*The original budget is in Euros and subject to exchange rate fluctuations with the US Dollar 
and local currency 
* The above are generic budget estimates across Kenya and Malawi and specific costs will 
be subject to minimal variation between countries   
  
16.4.2 Budget Justification 
Funding has been approved for fieldwork starting in 2019 and an additional year to support 
completion of capacity development training. The overall budget includes central sponsorship 
support, trial insurance and trial monitoring, a central safety register, data management support and 
for trial coordination, international travel and academic capacity training. The budget also includes 
indirect costs.  
 

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16.5 APPENDIX V.  PARTICIPANT INFORMATION SHEETS AND INFORMED CONSENT 
STATEMENTS 
16.5.1 Participant Information Sheet: Main trial (all participants) (English) 
See separate document for participant information sheets and informed consent statements 
16.5.2 Consent statement for screening and participation in the main trial (all 
participants) (English)  
See separate document for participant information sheets and informed consent statements 
16.5.3 Consent Statement for long term storage of samples and use for future 
research (all participants) (English) 
See separate document for participant information sheets and informed consent statements 
16.5.4 Participant Information Sheet for cardiac safety monitoring (subgroup) 
(English) 
 
See separate document for participant information sheets and informed consent statements 
16.5.5 Consent Statement for cardiac safety monitoring (sub-group) (English) 
See separate document for participant information sheets and informed consent statements 
 
 

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16.6 APPENDIX VI. DESCRIPTION OF OTHER CLINICAL AND LABORATORY METHODS 
This section ‘Appendix VI. Description of other clinical and laboratory methods’ of the appendix, 
describes the clinical and laboratory-based assays for some secondary outcomes conducted in 
subgroups of participants in specific study sites or otherwise in a random sample of participants in all 
sites. The volume and timing of these samples are described in ‘Table 1: Summary Table of Study 
Design and Schedule of Assessment, page 16, and in section 7.5 ‘Participants timeline’, page 38 
onwards. The purpose if this appendix text is to describe the assays and measures of the procedures 
in more detail. 
16.6.1 Pharmacokinetic studies of drug-drug interactions between piperaquine and 
standard antiretroviral therapy 
Collaborating institutions and contact persons:  Dr Eva Maria Hodel (University of Liverpool/LSTM); Dr 
Clifford George Banda (COM, University of Malawi); Division of Clinical Pharmacology and Toxicology 
Laboratory-University Hospital (CHUV), Lausanne, Switzerland; Prof Karen Barnes (Division of Clinical 
Pharmacology, University of Cape Town. 
Rationale and study aim: Because no previous studies have looked at the combination DP and DTG-
based cARTs, there is a need for further PK profiling of piperaquine-DTG drug-drug interactions to 
verify the pharmacological model predictions. This includes an assessment of the effect of the cARTs 
on piperaquine pharmacokinetics, and the effect of repeated piperaquine dosing on the steady state 
concentration of the cARTs and CTX. 
Design: We will conduct sparse pharmacokinetic/dynamic studies among approximately 80 women 
enrolled in the main trial (40 in each arm) who are on DTG-based cARTs and daily CTX. These women 
will also be part of the cardiac monitoring component.  
Methods: Venous blood samples (2 ml) will be collected at baseline before the first dose and 4 hours 
after the last dose of the 3-day DP regimen, and then at approximately four weeks intervals to 
measure the CTX, cART and piperaquine trough levels just before the next monthly DP dose. Each 
woman will also contribute two piperaquine peak samples taken approximately four hours after a 
monthly course. At delivery, paired maternal plasma, placental blood, and umbilical cord blood 
samples collected at delivery will be assessed for piperaquine concentrations in approximately.  
Laboratory assays: Collected blood samples will be centrifuged to obtain plasma which will be stored 
in a −80 °C freezer until shipment on dry ice to the Division of Clinical Pharmacology and Toxicology 
laboratory at the University Hospital (CHUV) in Lausanne, Switzerland for analysis. Plasma 
concentrations of cotrimoxazole, dihydroartemisinin, efavirenz, dolutegravir, two nucleoside reverse 
transcriptase inhibitors co-administered with dolutegravir and the antimalarial drug piperaquine, will 
be determined by a multiplex liquid chromatography coupled to tandem triple-stage mass 
spectrometry (LC-MS/MS) assay.  
Pharmacokinetic analysis peripheral blood: We will measure CTX, DP and standard ART concentrations 
to characterise efficacy (troughs) and safety (peaks) of DP. The effect of piperaquine on dolutegravir 
and CTX mean steady-state (SS) concentrations will be assessed by comparing ARTs steady-state 
concentration in women in the piperaquine arm and those in the CTX-only arm (Placebo-DP). 
Piperaquine concentrations will also be compared against those in HIV-negative women from the 
ongoing IMPROVE trial. 
Placental circulation: Concentrations will be compared with those in 25 HIV-negative women (i.e. not 
on cARTs) from the ongoing IMPROVE trial to assess the impact of cART on the plasma concentrations 

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of piperaquine that penetrates the placental circulation. Each sample will be 200 μL of venous blood 
(citrate).  
Defining minimum inhibitory concentrations: To assess the association between piperaquine’s PK 
profile and efficacy, we will use a matched nested case-control method, where a ‘case’ is defined 
women with evidence of malaria infection at delivery and a ‘control’ as women who are negative for 
malaria at delivery by PCR and placental histology. Exposure will be defined as trough levels collected 
at different scheduled follow-up visits. 
16.6.2 Impact of antimalarial resistance on protective efficacy 
Collaborating institutions and contact persons: Ass. Prof Dr Michael Alifrangis, University of 
Copenhagen 
Objective: 1. To evaluate the contribution of recrudescence and reinfection to prevalent and incidence 
of malaria infection throughout pregnancy; 2. To investigate the prevalence of molecular antimalarial 
resistance markers in parasite isolates. 
Rationale: The use of DP, a slowly eliminated antimalarial, for IPTp may pose as a source of drug 
pressure that may drive the emergence of piperaquine resistance in sub-Saharan Africa. The presence 
of high-grade sulphadoxine-pyrimethamine resistant parasites markers may also be predictive of the 
efficacy of cotrimoxazole resistance. To evaluate this, we will conduct molecular studies to detect 
malaria infections from enrolment to delivery, differentiate these as new or recrudescent infections 
and determine their molecular resistance status to artemisinins and piperaquine and CTX and 
sulphadoxine-pyrimethamine. 
Methods 
Diagnostic qPCR: Dry blood spots or redcell pellets will be prepared at enrolment, all scheduled and 
unscheduled (sick) visits and at delivery. DNA will be extracted using chelex-100 extraction87 or Qiagen 
DNA extraction for further qPCR targeting the high-copy telomere-associated repetitive element 2 
(limit of detection 0.15 parasites/μl blood).88  
Genotyping to distinguish recrudescent and re-infections: qPCR positive samples from participants at 
two sequential monthly visits will be used for PCR genotyping of the polymorphic P.falciparum genes 
MSP2, GLURP and MSP1; interpretation of results will be performed using standardised 
methodologies.89  
Molecular markers of antimalarial drug resistance: All P. falciparum-qPCR positive samples collected 
will be used for the evaluation of artemisinin, piperaquine, and antifolate resistance molecular 
markers. All PCR positive samples at enrolment will be examined for SNPs in the genes Pfdhfr, Pfdhps, 
K13 and Pfmdr-1 and plasmepsin 2,3. A high-throughput next-generation platform for targeted 
sequencing using Illumina®-basedtechnology90will be applied as the main method. After index PCR, 
the gene fragments will be sequenced using the Illumina Miseq® platform available through 
collaboration with researchers at the Danish Technical University, Denmark. In addition, direct Sanger 
sequencing methods will be applied to a subset of samples targeting mainly K13 to confirm novel 
findings and as a gold standard comparison using published PCR methods [6] and after PCR, also send 
for commercial sequencing. A PCR sequence-specific oligonucleotide probe (SSOP)-ELISA91 will be 
deployed as a reference method to the Illumina methodology regarding Pfdhfr and Pfdhps data.  
Data analysis: The degree of antifolate resistance in the parasite population will be expressed as the 
frequency of the Pfdhps-A437G, K540E, or A581G mutations, which predict the frequency of 
quadruple, quintuple, and sextuple Pfdhfr–Pfdhps mutant haplotypes, respectively. In addition, we 

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will assess prevalence of molecular markers associated with tolerance/resistance to artemisinin and 
piperaquine (K13 and Pfmdr1, plasmepsin-2). These molecular data will be used as potential effect 
modifiers in the impact analysis of the main trial. 
16.6.3 Impact on maternal antibody, trans-placental antibody transfer and multi-
pathogen neonatal cell-mediated immune responses 
Collaborating institutions and contact persons: Ass Prof Ann Moormann, University of Massachusetts, 
Worcester, USA and Prof Stephen Rogerson, University of Melbourne, Australia.  
Objective: To determine the impact of the interventions and of malaria and HIV during pregnancy on 
maternal immunity, transfer of maternal antibodies and the development of cell-mediate immunity 
in infants to other pathogens, in addition to malaria. 
Rationale: Maternal antibodies may protect pregnant participants from malaria, but placental malaria 
has been associated with impaired transfer of maternal antibodies and hypergammaglobulinemia.92,93 
This negatively impacts the newborn's ability to be protected against malaria as well as viral 
infections.92,94 The scope of this lack of maternal antibody protection tends to be studied one or two 
infections at a time. Using multiplex methods,95,96 we will be able to simultaneously measure the 
impact of the study interventions on a panel of antibody titres and cell-mediated immune responses 
to multiple pathogens within the same study participants using extremely low volumes of peripheral 
blood.  
Methods 
Samples will be taken at all scheduled clinic visits, delivery and 1, and 6-8 weeks infant visit (heel prick) 
for: 
a) Serology profiling: Using a Luminex, multiplex suspension bead-based assay to simultaneously 
measure antibody titers to a panel of individual antigens or immunologic peptides against malaria (ie 
MSP1, AMA1, CSP, LSA1, etc), EBV, CMV, RSV, measles virus, tetanus toxoid, arboviruses etc.95 We will 
use a Systems Serology approach to identify protective antibodies.96 
b) Cell-mediated immunity: Using multi-parameter flow cytometry and potentially single cell RNAseq97 
we will efficiently and comprehensively interrogate immunity specific to pathogens and EPI vaccine-
induced responses. 
16.6.4 Impact on infant adaptive and innate-like immunity 
Collaborating institutions and contact persons:  Dr Cristiana Cairo and Prof Miriam Laufer, University 
of Maryland), Baltimore, USA. 
Objective: To determine the impact on adaptive and innate-like immune cell subsets of infants that 
are likely affected by prenatal exposure to HIV and/or malaria. 
Rationale: Prevention of mother to child transmission strategies successfully avert congenital 
infection, but early studies showed that HIV exposed uninfected infants (HEU) are more susceptible 
to common infections than their unexposed counterparts and have higher mortality rate. Even after 
widespread availability of combination antiretroviral therapy (cART), differences in morbidity and 
mortality between HIV exposed and unexposed infants were still reported, though significantly less 
pronounced than in early studies. The immunologic alterations that are responsible for this 
phenomenon among HEU infants have not been identified conclusively, due to confounding variables 
and conflicting results between studies. In addition, pregnancy associated malaria, particularly 
placental malaria, also perturbs some immune cell subsets in neonates, and infants born to women 

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with placental infection are at increased risk of malaria in the first year of life. We will study adaptive 
and innate-like immune cell subsets that are likely affected by prenatal exposure to HIV and/or malaria 
and compare this between study arms. 
Methods: Cord blood samples will be collected from 600 participants. Cord blood mononuclear cells 
(CBMC) will be isolated and cryopreserved in the vapor phase of liquid nitrogen at the University of 
Malawi College of Medicine by trained laboratory technicians. CBMC specimens will be shipped to the 
University of Maryland Baltimore for analyses requiring equipment that is not available in Malawi. At 
the University of Maryland School of Medicine, the specimens will be thawed and used for analyses 
of innate-like and adaptive immune cell subsets (including Mucosal Associated Invariant T cells, Th17 
cells and T regulatory cells). In particular, we will characterize: (1) T cell differentiation and activation 
state ex vivo; (1) Activation of T cell cytokine production and proliferation in response to live BCG (the 
vaccine against TB, administered at birth in sub-Saharan Africa) in vitro. In order to collect the data 
described above, we will use polychromatic flow cytometry (14 parameters per panel).  
16.6.5 Impact on biomarkers of placental function and adverse birth outcomes 
Collaborating institutions and contact persons: Prof Kevin Kaine, University of Toronto, Canada 
Objective: To determine the impact on biomarkers and pathways regulating placental development 
and function and that are predictive of adverse birth outcomes. e.g. fetal growth restriction (FGR), 
preterm birth (PTB) in a prospective study of pregnant participants at high risk of malaria. 
Rationale: Normal placental development is essential to support the growth of the fetus throughout 
pregnancy. Malaria in early pregnancy can disrupt the normal the vasculogenic processes in the first 
trimester needed to regulate de novo formation and growth of blood vessels.98 Angiogenic processes 
beginning in the second trimester induce remodeling of the underlying architecture of the placenta to 
allow for increased blood flow and surface area for nutrient exchange required for exponential fetal 
growth in the 3rd trimester.98,99 Healthy birth outcomes require tight regulation of these vasculogenic, 
angiogenic, and inflammatory pathways and disruptions to these critical axes that can result in 
placental dysfunction and poor birth outcomes. For example, placental vascular dysfunction is 
associated with multiple pregnancy pathologies including gestational diabetes, preeclampsia, and 
malaria in pregnancy.100-102 The early identification of pregnancies at risk of adverse birth outcomes 
would enable risk stratification for increased monitoring and interventions to improve outcome. We 
propose to externally validate a panel of biomarkers to examine these markers in the context of risk 
factors contributing to FGR and PTB, including malaria infection in pregnancy, and determine the 
impact of the two different interventions on these biomarkers. 
Methods Venous blood samples (minimum required volume of 250 μL) collected from participants at 
study enrolment, scheduled antenatal visits and delivery will be processed via a custom multiplex 
Luminex®-based assay to quantify plasma levels of markers of placental function, inflammation and 
development including Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2), Angiopoietin-Like 3 (AngptL3), 
Vascular Endothelial Growth Factor (VEGF), Soluble fms-like tyrosine kinase 1 (sFlt-1), soluble Tumor 
Necrosis Factor Receptor 2 (sTNFR2), Placental Growth Factor (PGF), Interleukin-18 Binding Protein 
(IL-18BP), soluble Intercellular Adhesion Molecule-1 (sICAM-1), soluble Endoglin (sEndoglin), C-
reactive protein (CRP), Chitinase-3-Like Protein-1 (CHI3L1), complement components including C5a 
(C5a), and brain derived neurotrophic factor (BDNF), and inflammatory biomarkers such as C-reactive 
protein (CRP). Proteins were selected based on evidence of a critical role of each protein in 
inflammatory pathways and placental vasculogenesis, as well as associations with birth and fetal 
outcomes.   

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16.6.6 Impact on arboviral co-infections  
Collaborating institutions and contact persons:  Dr George Warimwe, Dr Charles Nyaigoti and Prof 
Philip Bejon, KEMRI-Wellcome Trust, Kenya  
Objectives: 1) To determine the effect of malaria-arboviral co-infections on adverse pregnancy 
outcomes in HIV infected women, 2) To evaluate the impact of piperaquine on arboviral co-infections. 
Rationale: Mosquito-borne viruses (arboviruses) are gaining notoriety as pathogens associated with 
adverse outcomes in pregnancy including microcephaly with Zika virus13,103, neurological 
complications seen with Chikungunya104, miscarriages seen with Rift Valley fever virus (RVFV)105 and 
pre-term delivery and still births seen with Dengue virus co-infection in India.13 Concurrent arboviral-
malaria infections  have been documented in sub-Saharan Africa.106,107 However, the impact of these 
co-infections on adverse pregnancy outcomes are unknown. It’s also unclear whether anti-malarials 
used in prevention and treatment of malaria confers protection against arboviral co-infections. A 
recent study showed chloroquine inhibited Zika virus replication in-vitro cells and conferred 
protection against Zika virus infection in pregnant mice37,108 Piperaquine is structurally similar to 
chloroquine. We will determine the impact of piperaquine on arboviral co-infections by comparing 
the incidence of arboviral infections between the CTX-DP and the CTX-alone arm. 
Methods: All participants will be included. We will test for the presence of arbovirus and protective 
antibodies in all women at enrolment, some scheduled visits, sick visits and delivery in venous blood 
and urine samples at sick febrile visits. Arboviruses of interest will include: flaviviruses, alpha viruses, 
bunyaviruses and other viruses. Blood samples will be collected in EDTA bottles and plasma stored at 
-80 °C, before being shipped to and analysed in KEMRI. Serological assays will include IgG and IgM 
ELISAs and virus neutralising assays. The presence of virus will be determined by qRT-PCR assays using 
primers and probes targeting a broad range of flaviviruses, alphaviruses and bunyaviruses, and a 
randomly selected fraction processed by agnostic deep sequencing protocols to identify emerging 
viral pathogens not included in the directed PCRs/serological assays.  
16.6.7 Use of mobile phone Unstructured Supplementary Service Data (USSD) 
platform to enhance protocol adherence and monitoring of tolerance 
Collaborating institutions and contact persons:  Prof Wilson Mandala, Malawi University of Science 
and Technology, Malawi; Mr Manota Mphande, Logic Bay Systems, Malawi 
Objectives: 1) To enhance adherence to study drug and study schedule using a mobile phone USSD 
platform, 2) To enhance monitoring of tolerance and safety assessment of study drugs using a mobile 
phone USSD platform, 2 
Rationale: In resource limited settings where polypharmacy is prevalent, mobile health technology is 
an essential platform to monitor and facilitate treatment adherence and enhance safety monitoring 
through a real time interactive platform to ensure improved outcomes.109,110  We will explore to use 
of a USSD platform to boost the standard mobile phone contacting methods used in the trial. 
Methods: Approximately, 100 participants will be included in an exploratory evaluation. If the 
exploratory evaluation is successful, we will explore, subject to funding, how the USSD platform can 
be scaled up to other women in the trial. In the exploratory evaluation, mothers will be registered on 
the USSD platform utilizing their existing mobile phone and Subscriber Identity Module (SIM); their 
own number or otherwise one identified by the mother as her main contact number. Mothers will 
receive a series of periodic messages pertaining to appointment schedules, treatment adherence and 
reporting of adverse events. Participant data shall be secured through relevant data security standards 

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of the information and communications technology regulator, and with the mobile network service 
provider. Data shall only be accessible by research staff.  
16.6.8 Performance of a highly sensitive diagnostic test for malaria 
Collaborating institutions and contact persons: Christine Bachman, from Intellectual Ventures Limited, 
Washington, USA; and Dr Gonzalo Domingo, from PATH, Seattle, Washington, USA, and Dr Emily 
Adams, LSTM, UK 
Objective: To evaluate the diagnostic performance of novel diagnostic devices and highly sensitive 
diagnostic test for malaria in pregnant women. 
Rationale: Current RDTs have limited sensitivity to detect placental malaria in asymptomatic pregnant 
women. New diagnostic tests are under development with lower limits of detection, including, but 
not limited to, automated readers of RDTs and an experimental, highly-sensitive RDT (HSRDT). We will 
determine the diagnostic performance of new diagnostic tests in samples taken from the pregnant 
women included in the trial and compare them against the PCR results obtained in the trial as a 
reference standard. Since these new diagnostics tests are still experimental they can be used for 
research only, but not yet for clinical care.  
Methods: The RDT and HSRDT will be run on site on a 5 to 100 microlitre taken from the blood samples 
collected from participants. The RDTs will be read visually and also by placing the cartridge into 
automated readers. The results from the RDT Reader will be blinded to the health care worker and 
because these involve proto-types they cannot be used for patient care.  
Also, a 75 microlitre aliquot of blood will be stored frozen in cryovials for a later multiplex quantitative 
ELISA (Q-ELISA) and standard RDTs (not for patient care) at PATH (Seattle, USA). The Q-ELISA assay 
contains spots for HRP2 and pan-malaria LDH. The capture and detection of antibodies are 
orthologous to those on the RDTs and therefore allow confirmation of antigenemia. All experimental 
assays shall be conducted for research purposes only within the clinical setting of the trial but will not 
inform care. 
A total of 1,500 samples will be tested using the HSRDT and Q-Elisa providing 0.06 confidence interval 
at 0.95 confidence level for a 90% expected sensitivity, and a 1,500 sample for the comparison against 
the developmental readers. The primary outcome will be the sensitivity of the various diagnostic 
methods compared to qPCR or standard RDTs, including the threshold of detection of the 
experimental assays. Secondary outcomes will include other standard measures of diagnostic 
accuracy (specificity, positive predictive value, and negative predictive value) against PCR positivity.  

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16.7 APPENDIX VII. PRODUCT CHARACTERISTICS 
16.7.1 Dihydroartemisinin-piperaquine product insert (D-ARTEPP, Guilin Pharma) 
 
 
 
 

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16.7.2 Dihydroartemisinin-piperaquine product insert (Eurartesim, AlfaSigma) 
 

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# 
16.7.3 Cotrimoxazole 
 
 
 

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16.7.1 Fixed dose combination of TLD (TDF/3TC/DTG) 
The summary of product characteristics for TLD is provided below using the package insert for TLD 
from Cipla is shown for illustrative purposes but other generic brands may be considered subject to 
local policy. 
 
 
 
 

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16.8 APPENDIX VIII. SPIRIT 2013 CHECKLIST CLINICAL TRIAL PROTOCOL  
SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and related documents* 
 
Section/item 
Item 
No 
Description 
Addressed 
on 
page number 
Administrative information 
Title 
1 
Descriptive title identifying the study design, population, interventions, and, if applicable, trial acronym 
1, 10 
Trial registration 
2a 
Trial identifier and registry name. If not yet registered, name of intended registry 
1, 11 
2b 
All items from the World Health Organization Trial Registration Data Set 
11 
Protocol version 
3 
Date and version identifier 
1 
Funding 
4 
Sources and types of financial, material, and other support 
1, 31, 83 
Roles 
and 
responsibilities 
5a 
Names, affiliations, and roles of protocol contributors 
1, 10, 74 
5b 
Name and contact information for the trial sponsor 
1, 10 
 
5c 
Role of study sponsor and funders, if any, in study design; collection, management, analysis, and 
interpretation of data; writing of the report; and the decision to submit the report for publication, including 
whether they will have ultimate authority over any of these activities 
55 
 
5d 
Composition, roles, and responsibilities of the coordinating centre, steering committee, endpoint 
adjudication committee, data management team, and other individuals or groups overseeing the trial, if 
applicable (see Item 21a for data monitoring committee) 
 
76 to 78 
Introduction 

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Background 
and 
rationale 
6a 
Description of research question and justification for undertaking the trial, including summary of relevant 
studies (published and unpublished) examining benefits and harms for each intervention 
26to 27 
 
6b 
Explanation for choice of comparators 
26 
Objectives 
7 
Specific objectives or hypotheses 
26 to 27 
Trial design 
8 
Description of trial design including type of trial (eg, parallel group, crossover, factorial, single group), 
allocation ratio, and framework (eg, superiority, equivalence, noninferiority, exploratory) 
27  
Methods: Participants, interventions, and outcomes 
Study setting 
9 
Description of study settings (eg, community clinic, academic hospital) and list of countries where data will 
be collected. Reference to where list of study sites can be obtained 
29 
Eligibility criteria 
10 
Inclusion and exclusion criteria for participants. If applicable, eligibility criteria for study centres and 
individuals who will perform the interventions (eg, surgeons, psychotherapists) 
30 
Interventions 
11a 
Interventions for each group with sufficient detail to allow replication, including how and when they will 
be administered 
30 
11b 
Criteria for discontinuing or modifying allocated interventions for a given trial participant (eg, drug dose 
change in response to harms, participant request, or improving/worsening disease) 
33 
11c 
Strategies to improve adherence to intervention protocols, and any procedures for monitoring adherence 
(eg, drug tablet return, laboratory tests) 
35 
11d 
Relevant concomitant care and interventions that are permitted or prohibited during the trial 
31 35 
Outcomes 
12 
Primary, secondary, and other outcomes, including the specific measurement variable (eg, systolic blood 
pressure), analysis metric (eg, change from baseline, final value, time to event), method of aggregation (eg, 
median, proportion), and time point for each outcome. Explanation of the clinical relevance of chosen 
efficacy and harm outcomes is strongly recommended 
37 
Participant timeline 13 
Time schedule of enrolment, interventions (including any run-ins and washouts), assessments, and visits 
for participants. A schematic diagram is highly recommended (see Figure) 
38 to 42 

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Sample size 
14 
Estimated number of participants needed to achieve study objectives and how it was determined, including 
clinical and statistical assumptions supporting any sample size calculations 
42 
Recruitment 
15 
Strategies for achieving adequate participant enrolment to reach target sample size 
43 
Methods: Assignment of interventions (for controlled trials) 
Allocation: 
 
 
44 
Sequence 
generation 
16a 
Method of generating the allocation sequence (eg, computer-generated random numbers), and list of any 
factors for stratification. To reduce predictability of a random sequence, details of any planned restriction 
(eg, blocking) should be provided in a separate document that is unavailable to those who enrol 
participants or assign interventions 
44 
Allocation 
concealment 
mechanism 
16b 
Mechanism of implementing the allocation sequence (eg, central telephone; sequentially numbered, 
opaque, sealed envelopes), describing any steps to conceal the sequence until interventions are assigned 
44 
Implementation 
16c 
Who will generate the allocation sequence, who will enrol participants, and who will assign participants to 
interventions 
44 
Blinding (masking) 
17a 
Who will be blinded after assignment to interventions (eg, trial participants, care providers, outcome 
assessors, data analysts), and how 
44 
 
17b 
If blinded, circumstances under which unblinding is permissible, and procedure for revealing a participant’s 
allocated intervention during the trial 
45 
Methods: Data collection, management, and analysis 
Data 
collection 
methods 
18a 
Plans for assessment and collection of outcome, baseline, and other trial data, including any related 
processes to promote data quality (eg, duplicate measurements, training of assessors) and a description 
of study instruments (eg, questionnaires, laboratory tests) along with their reliability and validity, if known. 
Reference to where data collection forms can be found, if not in the protocol 
45 
 
18b 
Plans to promote participant retention and complete follow-up, including list of any outcome data to be 
collected for participants who discontinue or deviate from intervention protocols 
43 

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Data management 
19 
Plans for data entry, coding, security, and storage, including any related processes to promote data quality 
(eg, double data entry; range checks for data values). Reference to where details of data management 
procedures can be found, if not in the protocol 
48 to 49 
Statistical methods 
20a 
Statistical methods for analysing primary and secondary outcomes. Reference to where other details of 
the statistical analysis plan can be found, if not in the protocol 
49 to 51 
 
20b 
Methods for any additional analyses (eg, subgroup and adjusted analyses) 
50 
 
20c 
Definition of analysis population relating to protocol non-adherence (eg, as randomised analysis), and any 
statistical methods to handle missing data (eg, multiple imputation) 
49 
Methods: Monitoring 
Data monitoring 
21a 
Composition of data monitoring committee (DMC); summary of its role and reporting structure; statement 
of whether it is independent from the sponsor and competing interests; and reference to where further 
details about its charter can be found, if not in the protocol. Alternatively, an explanation of why a DMC is 
not needed 
78 
 
21b 
Description of any interim analyses and stopping guidelines, including who will have access to these interim 
results and make the final decision to terminate the trial 
51 
Harms 
22 
Plans for collecting, assessing, reporting, and managing solicited and spontaneously reported adverse 
events and other unintended effects of trial interventions or trial conduct 
52 
Auditing 
23 
Frequency and procedures for auditing trial conduct, if any, and whether the process will be independent 
from investigators and the sponsor 
54 
Ethics and dissemination 
Research 
ethics 
approval 
24 
Plans for seeking research ethics committee/institutional review board (REC/IRB) approval 
56 
Protocol 
amendments 
25 
Plans for communicating important protocol modifications (eg, changes to eligibility criteria, outcomes, 
analyses) to relevant parties (eg, investigators, REC/IRBs, trial participants, trial registries, journals, 
regulators) 
56 

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Consent or assent 
26a 
Who will obtain informed consent or assent from potential trial participants or authorised surrogates, and 
how (see Item 32) 
57 
 
26b 
Additional consent provisions for collection and use of participant data and biological specimens in 
ancillary studies, if applicable 
57 and 84 
Confidentiality 
27 
How personal information about potential and enrolled participants will be collected, shared, and 
maintained in order to protect confidentiality before, during, and after the trial 
58 
Declaration 
of 
interests 
28 
Financial and other competing interests for principal investigators for the overall trial and each study site 58 
Access to data 
29 
Statement of who will have access to the final trial dataset, and disclosure of contractual agreements that 
limit such access for investigators 
58 
Ancillary and post-
trial care 
30 
Provisions, if any, for ancillary and post-trial care, and for compensation to those who suffer harm from 
trial participation 
60 
Dissemination 
policy 
31a 
Plans for investigators and sponsor to communicate trial results to participants, healthcare professionals, 
the public, and other relevant groups (eg, via publication, reporting in results databases, or other data 
sharing arrangements), including any publication restrictions 
61 
 
31b 
Authorship eligibility guidelines and any intended use of professional writers 
63 
 
31c 
Plans, if any, for granting public access to the full protocol, participant-level dataset, and statistical code 
63 
Appendices 
Informed 
consent 
materials 
32 
Model consent form and other related documentation given to participants and authorised surrogates 
Separate 
document 
Biological 
specimens 
33 
Plans for collection, laboratory evaluation, and storage of biological specimens for genetic or molecular 
analysis in the current trial and for future use in ancillary studies, if applicable 
15 and 39 
 

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16.9 APPENDIX IX. QUESTIONNAIRES 
The questionnaires are provided as a separate document.