Bone Loss and Immune Reconstitution in HIV/AIDS (BLIR-HIV)
Phase: PHASE2
Conditions: HIV Infection, Bone Loss, Osteopenia, Osteoporosis
Sponsor: Emory University

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
08/18/10, 12/02/10, 04/15/11, 08/25/11, 04/09/12, 5/31/12,  
7/9/12; 6/25/2014 
1 
 
 
Bone Loss and Immune Reconstitution in HIV/AIDS (BLIR-HIV) 
Protocol Version 6.0 
June 25, 2014 
 
NCT01228318 
 
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
08/18/10, 12/02/10, 04/15/11, 08/25/11, 04/09/12, 5/31/12,  
7/9/12; 6/25/2014 
2 
 
 
 
 
Bone Loss and Immune Reconstitution in HIV/AIDS (BLIR-HIV) 
Emory University School of Medicine  
IRB Protocol Number:  
Version 6.0 
 
Sponsor: NIH Grant (#1R01AR059364-01 and 1R01AG40013-1A1). 
 
PRINCIPAL INVESTIGATORS 
                        
 
 
 
 
Igho Ofotokun, M.D., MSc. 
Associate Professor of Medicine 
Staff Physician, Grady Health Care System 
Division of Infectious Diseases 
Emory University School of Medicine 
49 Jesse Hill Jr. Drive 
Atlanta, GA 30303 
E-mail: iofotok@emory.edu 
Phone:404-616-0659 
Fax: 404-616-0592 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
08/18/10, 12/02/10, 04/15/11, 08/25/11, 04/09/12, 5/31/12,  
7/9/12; 6/25/2014 
3 
CO-INVESTIGATORS 
1. M. Neale Weitzmann, Ph.D. mweitzm@emory.edu 
2. Jeffrey L. Lennox, M.D. 
jlennox@emory.edu 
3. Carlos del Rio, M.D.  
cdelrio@emory.edu 
4. Wendy Armstrong, M.D. 
wsarmst@emory.edu 
5. Molly Eaton, M.D. 
 
meato01@emory.edu 
6. Clifford Gunthel, M.D.  
cgunthe@emory.edu 
7. Melody Palmore, M.D. 
mpalmor@emory.edu 
8. Kirk A. Easley, M.S.  
keasle2@emory.edu 
9. Anandi Sheth, M.D. 
 
ansheth@emory.edu 
 
 
 
 
 
 
  
  
 
 
 
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
08/18/10, 12/02/10, 04/15/11, 08/25/11, 04/09/12, 5/31/12,  
7/9/12; 6/25/2014 
4 
 CONTENTS 
 
 
 
Page 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ........................................................ 5 
 
ABSTRACT……..…………………………………………………………………………………………7 
 
LAY SUMMARY……..……………………………………………………………………………………8 
 
STUDY SCHEMA……..…………………………………………………………………………………..9 
1.0 
HYPOTHESIS AND STUDY OBJECTIVES................................................................... 10 
1.1 
Hypothesis ......................................................................................................... 10 
1.2 
Primary Endpoints ............................................................................................. 10 
1.3 
Secondary Endpoints ........................................................................................ 10 
2.0 
INTRODUCTION .......................................................................................................... 12 
2.1 
Preliminary Data: Animal model ......................................................................... 12 
2.2 
Preliminary Data: Human ................................................................................... 13 
2.3 
Long Acting Antiresorptive Agents ..................................................................... 14 
2.4 
Study Rationale ................................................................................................. 14 
3.0 
STUDY DESIGN ........................................................................................................... 15 
3.1       Overview ........................................................................................................... 15 
3.2       Subject Population and Recruitment.................................................................. 15 
3.3       Study Intervention ............................................................................................. 15 
4.0 
SELECTION AND ENROLLMENT OF SUBJECTS ....................................................... 16 
4.1 
Inclusion Criteria ................................................................................................ 16 
4.2 
Exclusion Criteria ............................................................................................... 18 
4.3 
Study Enrollment Procedures ............................................................................ 19 
 
5.0 
STUDY TREATMENT ................................................................................................... 19 
 
5.1 
Concomitant Medications .................................................................................. 20 
 
5.4 
Required Medications ........................................................................................ 20 
 
5.5 
Prohibited Medications ...................................................................................... 20 
6.0 
CLINICAL AND LABORATORY EVALUATIONS .......................................................... 27 
6.1 
Schedule of Events ............................................................................................ 27 
6.2 
Definitions for Schedule of Events – Timing of Evaluations ............................... 28 
6.3 
Definitions of Evaluations .................................................................................. 29 
 
7.0 
CLINICAL MANAGEMENT ISSUES ............................................................................. 33 
7.1 
General Consideration .................................................................................................. 33 
7.2 
Potential Risk ................................................................................................................ 33 
7.3 
Minimization of Risk ...................................................................................................... 33 
7.4 
Toxicity Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 
7.5 
Vitamin D Deficiency/Low Serum Calcium Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  34 
7.6 
Development of Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 
7.7 
Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
08/18/10, 12/02/10, 04/15/11, 08/25/11, 04/09/12, 5/31/12,  
7/9/12; 6/25/2014 
5 
 
8.0 
CRITERIA FOR DISCONTINUATION ........................................................................... 34 
8.1 
Permanent Treatment Discontinuation .......................................................................... 34 
8.2 
Premature Study Discontinuation .................................................................................. 34 
9.0 
STATISTICAL CONSIDERATIONS .............................................................................. 34 
9.1 
Summary of endpoints ....................................................................................... 35 
9.2 
Detailed Description of Endpoints ...................................................................... 36 
9.3 
Sample Size Calculations .................................................................................. 37 
9.4 
Statistical Analyses ............................................................................................ 39 
10.0 
EXPECTED OUTCOME AND INTERPRETATION OF DATA ....................................... 41 
11.0 
DATA COLLECTION, MONITORING AND ADVERSE EVENTS REPORTING ............ 43 
11.1 
Records to Be Kept ........................................................................................... 43 
11.2 
Role of Data Management ................................................................................. 43 
11.3 
Clinical Site Monitoring and Record Availability ................................................. 43 
11.4 
Expedited Adverse Event Reporting .................................................................. 44 
12.0 
HUMAN SUBJECTS ..................................................................................................... 46 
12.1 
Responsibilities of the Investigator .................................................................... 46 
12.2 
IRB Review and Informed Consent .................................................................... 46 
12.3 
Subject Confidentiality ....................................................................................... 46 
12.4 
Data Safety Monitoring ...................................................................................... 46 
12.5 
Study Discontinuation ........................................................................................ 47 
12.5 
Potential Benefit of the Proposed Research to the Subjects and Others ............ 47 
13.0 
Publications................................................................................................................... 47 
14.0 
BIOHAZARD CONTAINMENT ...................................................................................... 47 
15.0 
STUDY DURATION/TIMELINE ..................................................................................... 47 
16.0 
STUDY SPONSOR ....................................................................................................... 48 
17.0 
REFERENCES ............................................................................................................. 49 
 
 
 
 
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
08/18/10, 12/02/10, 04/15/11, 08/25/11, 04/09/12, 5/31/12,  
7/9/12; 6/25/2014 
6 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
 
Abbreviation   
 
Definition 
AE 
  
 
Adverse event 
AIDS   
 
 
Acquired Immune Deficiency Syndrome 
ALT  
 
 
 
Alanine transaminase 
ANC   
 
 
Absolute neutrophil count 
ART 
  
 
Antiretroviral therapy 
AST   
 
 
Aspartate transaminase 
ATV 
 
 
 
Atazanavir 
BID 
  
 
Twice daily 
BM 
  
 
Bone marrow 
BMD 
  
 
Bone marrow density 
BUN 
  
 
Blood urea nitrogen 
CBC   
 
 
Complete blood count 
CD40L  
 
 
CD40 ligand 
CLIA 
  
 
Clinical Laboratory Improvement Amendments 
CM 
  
 
Condition medium 
CRF 
  
 
Case report form 
CTx 
  
 
C-terminal telopeptide 
DAIDS 
  
 
Division of Acquired Immune Deficiency Syndrome (U.S.) 
DEXA 
  
 
Dual-energy x-ray absorptiometry 
DHHS 
  
 
Department of Health and Human Services 
EAE 
  
 
Expedited adverse event 
ELISA 
  
 
Enzyme-linked immunosorbent assay 
FACS 
  
 
Fluorescence activated cell sorting 
FDA 
  
 
Food and Drug Administration (U.S) 
FTC 
  
 
Emtricitabine 
GCP 
  
 
Good clinical practice 
GI  
 
 
 
Gastrointestinal 
HAART  
 
 
Highly active anti-retroviral therapy 
H & P  
 
 
History and Physical 
HEENT 
  
 
Head, eyes, ears, nose, and throat 
HIV  
 
 
 
Human immunodeficiency virus 
I.P. 
 
 
 
Intraperitoneally 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
08/18/10, 12/02/10, 04/15/11, 08/25/11, 04/09/12, 5/31/12,  
7/9/12; 6/25/2014 
7 
IRB 
  
 
Institutional review board 
IRIS 
  
 
Immune reconstitution inflammatory syndrome 
IV  
 
 
 
Intravenous 
KO 
 
 
 
Knock out 
LFT 
  
 
Liver function test 
LN 
  
 
Lymph node 
µCT 
 
 
 
Micro-computed tomograpy 
OHRP 
  
 
Office for Human Research Protections 
OI 
  
 
Opportunistic infection 
OPG 
  
 
Osteoprotegerin 
PBMC 
  
 
Peripheral blood mononuclear cells 
PCP 
  
 
Primary care physician 
PI  
 
 
 
Protease inhibitors 
PID 
  
 
Patient identifier (number) 
PO  
 
 
 
By mouth 
RANK  
 
 
Receptor activator of NF-B 
RANKL 
 
 
RANK ligand 
RTI  
  
 
Reverse transcriptase inhibitors 
RTV 
  
 
Ritonavir 
SAE 
  
 
Serious adverse event 
SGOT 
  
 
Aspartate aminotransferase 
SGPT 
  
 
Alanine aminotransferase 
SID 
 
 
 
Study ID 
TDF 
 
 
 
Tenofovir disoproxil fumarate 
Tg 
 
 
 
Transgenic 
ULN   
 
 
Upper limit of normal 
WK 
 
 
 
Week 
WT 
 
 
 
Wild type 
X-HIGM 
 
 
X-linked hyper-IgM syndrome 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
08/18/10, 12/02/10, 04/15/11, 08/25/11, 04/09/12, 5/31/12,  
7/9/12; 6/25/2014 
8 
ABSTRACT 
RATIONALE 
With the increasing age of people living with HIV/AIDS, age-induced osteoporosis is 
likely to be compounded by HIV/AIDS and HAART-associated bone loss. 
Mechanistically, osteoclasts, the cells responsible for bone resorption form under the 
influence of the key osteoclastogenic cytokine Receptor- Activator of NF-B 
(RANKL). The osteoclastogenic and proresorptive activities of RANKL are moderated 
by its physiological decoy receptor osteoprotegerin (OPG). Imbalance in the ratio of 
RANKL to OPG alters osteoclastic bone resorption and lead to osteoporosis. 
Activated T- and B-cells are a major source of RANKL, while normal physiological B-
cells are a major source of OPG. T-cells regulate the production of OPG by B-cells. 
Thus changes in the immune system induced by HIV/AIDS and/or by HAART could 
affect B-cell and T-cells RANKL and OPG production. Indeed, data from our group 
shows that in an animal model of HIV/AIDS, the HIV-1 Transgenic rat, the 
development of osteoporosis is recapitulated as observed in HIV-infected patients, 
and B-cell OPG and RANKL production are concurrently downregulated and 
upregulated respectively. Furthermore, preliminary data in HIV-infected subjects 
suggests dramatic acute upswing in bone resorption following HAART initiation that 
peaks at 12 weeks and then declining. Based on these findings, we hypothesize 
HAART associated bone loss is driven by immune reconstitution. Because this effect 
of HAART is dramatic in magnitude but short in duration, we propose to apply 
antiresorptive agent (zoledronic acid, reclast®) to specifically spare patients from this 
dramatic but acute bone damage. 
 
DESIGN 
In a prospective, blinded placebo-controlled randomized trial, treatment naïve HIV-
infected subjects initiating HAART will be assigned to HAART + zoledronic acid or 
HAART + placebo. Serial assessment of serum levels of bone markers, cellular 
expression of OPG/RANKL and other cytokines, cellular immune activation markers, 
serum bone regulating hormones, and bone mineral density (BMD) by DXA scan will 
be undertaking at pre-defined time points from baseline through week 144 of HAART.  
 
In the primary analysis, changes in serum CTx level, BMD, and cellular OPG/RANKL 
expression from baseline through week 24 will be quantitated and subsequently 
compared between treatment arms. In addition, the impact of zelodronic acid 
administration on these covariates will be assessed at various study time points. The 
relationship between OPG/RANKL expression, immune activation, serum bone 
regulating hormonal levels, and bone turnover will be evaluated.      
 
DURATION 
144 weeks after the enrollment of the last participant. Completion of enrollment is  
expected within 2 years of study initiation. 
 
SAMPLE SIZE 120 subjects will be screened for eligibility to enter the study, from which 94 subjects 
(47 per study arm) will be enrolled and followed in the study. Note that an informed 
consent is signed by each subject screened. 
 
POPULATION  Treatment naïve HIV-1 infected ambulatory men and women, age >30 < 50 years.

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
08/18/10, 12/02/10, 04/15/11, 08/25/11, 04/09/12, 5/31/12,  
7/9/12; 6/25/2014 
9 
 
Lay Summary 
 
Other studies have shown that HIV-infection and HAART treatment lead to increased bone loss. The 
reason for this is not clear. Recent data from animal studies generated by our group suggest bone 
loss in HIV-infection may be due to imbalance between two proteins (OPG and RANKL) in the body 
that regulate bone structure.  This study will therefore examine whether this is the case in humans. 
Furthermore, will examine whether bone loss resulting from HAART use is due to restoration of the 
immune function. 
 
We will measure the amount of these proteins in HIV-patients starting treatment with HAART to see if 
they change over time. We will also examine whether changes in this protein and bone loss that occur 
during HAART treatment can be prevented by the bone protective medication, zoledronic acid 
(reclast®).  
 
Individuals who volunteer to participate in this study will undergo thorough medical evaluation, serial 
blood draws for bone regulating proteins and other measurements, and total body DXA scans (DXA 
scan is a special type of X-ray that measures bone density). They will also begin HAART for treatment 
of HIV-infection and receive one dose of bone protecting medication or its saline solution placebo. 
The duration of the study from entry to completion will be approximately 144 weeks.    
   
 
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
08/18/10, 12/02/10, 04/15/11, 08/25/11, 04/09/12, 5/31/12,  
7/9/12; 6/25/2014 
10
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
11 
 
1.0  
HYPOTHESIS AND STUDY OBJECTIVES  
 
1.1 
Hypothesis: 
 
 
We hypothesize that HAART-associated acute bone loss is mediated through either direct effect 
on bone cells, or through indirect effect on metabolism related to disease reversal and/or 
immune reconstitution, and because this effect is acute and dramatic in nature, it may be 
reversible by a single dose of the long-acting antiresoptive agent (zoledronic acid).  
 
1.2 
Primary Endpoints:  
The focus of this study is to quantify the effect of HAART on bone turnover at the cellular level, to 
determine whether HAART-mediates bone effects through immune-reconstitution and 
perturbation of cellular (B and T cell subsets) balance in OPG/RANKL production, and to assess 
the effectiveness of antiresorptive agent in blocking HAART induced acute change in bone 
turnover. Because human data on cellular expression of OPG/RANKL in the setting of 
antiretroviral naiveté is currently limited, the study is powered to assess HAART induced acute 
changes in the plasma levels of markers of bone turnover.  
 
1.2.1 To assess HAART induced acute change in bone turnover by quantitating the change 
from baseline to week 144 in plasma level of marker of bone resorption (CTx) among 
treatment naïve HIV-infected subjects treated with atazanavir based HAART regimen. 
 
1.2.2 To quantitate the inhibitory effect of the long acting inhibitor of bone resorption 
(zoledronic acid) on HAART-induced change in the marker of bone resorption (CTx) at 
24 weeks of HAART therapy.  
 
1.3 
Secondary Endpoints: 
1.3.1 To quantitate the change from baseline at weeks 2, 8, 12, 16, 20, 24, 36, 48, 72, 96, 
120, and 144 in cells (lymphocyte subsets; B- and T-cell frequency and number/ml) and 
their production of OPG and RANKL, among treatment naïve HIV-infected subjects 
treated with atazanavir based HAART regimens. 
 
1.3.2 To evaluate the inhibitory effect of single dose zoledronic acid on HAART associated 
changes in other markers of bone turnover (Osteocalcin, P1NP, (bone formation 
markers) and TRAP5b (a marker of osteoclast activity) and BMD at appropriate study 
evaluation time points.  
 
1.3.3 To quantitate the inhibitory effect of antiresorptive (zoledronic acid) on HAART-induced 
change in cellular (lymphocyte subsets; B- and T-cell) production of OPG and RANKL at 
weeks, 2, 8, 12, 16, 20, 24, 36, 48, 72, 96, 120 and 144 of HAART therapy. 
 
1.3.4 To correlate changes in serum, and cellular (lymphocyte subsets; B- and T-cell) 
expression of OPG and RANKL with markers of bone turnover and BMD at appropriate 
study evaluation time points. 
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
12 
 
1.3.5 To correlate changes in bone regulatory hormones (PTH, estrogen, testosterone, vitamin 
D) and inflammatory cytokines ( IL-1, IL-6, TNF) with serum and cellular expression of 
OPG/RANKL, markers of bone turnover, and BMD at appropriate study evaluation time 
points. 
 
1.3.6 To correlate changes in lymphocyte subsets; (B- and T-cell (CD4 and CD8) with bone 
turnover markers and BMD.

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
13 
 
2.0. INTRODUCTION: Introduction of HAART has led to marked reduction in HIV/AIDS morbidity and 
mortality. However, serious metabolic complications including bone loss, osteoporosis and fractures 
(1) are now becoming increasingly common. With increasing age of people living with HIV/AIDS, age-
associated osteoporosis is likely to be significantly compounded by HIV/AIDS-associated bone loss 
leading to an epidemic of fractures in this population. The contributions to osteoporosis of direct and 
indirect effects of HIV/AIDS and of HAART, and the mechanisms involved are poorly understood. 
Only recently has the depth of integration 
between the immune and skeletal systems 
begun to be appreciated. The skeleton is a 
dynamic organ that is continually regenerated 
by the process of homeostatic bone remodeling 
(2).  Osteoclasts (OCs), the cells responsible 
for bone resorption, form from cells of the 
monocytic lineage in the bone marrow (BM) 
under the influence of the key osteoclastogenic 
cytokine Receptor- Activator of NF-B 
(RANKL). The activity of RANKL is moderated 
by its physiological decoy receptor 
osteoprotegerin (OPG) (3). We now appreciate 
from both human and animal studies that any 
increase in the ratio of RANKL to OPG 
accelerates the rate of osteoclastic bone 
resorption leading to the development of 
osteoporosis. Our group recently reported that 
in rodents B cells are critical stabilizers of peak 
bone mineral density (BMD) in vivo as cells of 
the B lymphocyte lineage, under the control of 
T cells, in part through CD40/CD40 ligand 
(CD40L) costimulation, account for up to 64% 
of total bone marrow (BM) OPG concentrations, 
with mature B cells alone contributing 45% of 
total BM OPG (4). Thus, a putative mechanism 
of HIV/AIDS and/or HAART related bone loss 
may be an imbalance in RANKL/OPG 
production as a consequence of T-cell and/or 
B-cell disruption/disregulation.  
 
2.1. Studies in animal model of HIV/AIDS 
suggest that B cells play a role in maintenance 
of bone homeostasis: The HIV-1 Transgenic 
(Tg) rat is a model of HIV-1/AIDS that 
recapitulates many of the features of the human 
disease. Preliminary data from our group 
demonstrated that like their human 
counterparts, HIV-1 Tg rats develop severe osteoporosis and display significant decrements in bone 
BMD (Figure 1) and in cortical and trabecular bone volume (Figure 2), as a consequence of elevated 
osteoclastic bone resorption (Figure 3).  Mechanistically, this osteoclastic bone loss appears to be 
driven by enhanced production of RANKL, the key osteoclastogenic cytokine, and amplified by a 
decrement in production of OPG, the key physiological suppressor of RANKL activity (Figure 4). Our 
preliminary studies suggest that this cytokine imbalance stems from a switch in production of OPG to 
production of RANKL by B cells, an immune cell that we have recently demonstrated to play a critical 
Figure 2: µCT Showing Three dimensional 
Reconstructions of femurs from WT and HIV-1 Tg rats.   
Figure 3: Elevated biochemical markers of bone 
resorption in HIV-1 Tg rats. *p=0.002 (t test), n=4 
rats/group: Age = 9 months 
Figure 1: HIV-1 Tg rats develop osteoporosis 
*P<0.004 (Mann-Whitney), n=5 WT/6 HIV, Age=15 months 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
14 
 
role in the regulation of basal bone homeostasis. Thus, our data suggest that disruption of B cells 
function, either due to direct viral action, or indirectly as a consequence of T cell disruption, is a critical 
factor in bone loss in HIV/AIDS in vivo. 
 
2.2.  HAART induces bone turnover: Besides the 
osteopenia associated with disruption of bone 
homeostasis in treatment-naive patients, the initiation of 
antiretroviral therapy has been consistently associated 
with a 2-3% reduction in BMD over the first 48-96 weeks of 
therapy (5-7), suggesting that the underlying cause of 
osteoporotic bone changes in HIV may be multi-factorial, 
and may include pharmacologic, immune or viral factors. 
In a recent meta-analysis of cross-sectional studies, HIV-
infected subjects receiving PIs had a higher prevalence of 
osteoporosis compared to those receiving non-PI 
regimens (8). By contrast, other studies of PI-treated HIV-
infected subjects have shown relatively stable or increased BMD over time (11-13),suggesting that 
individual PIs can have heterogeneous effects on bone, data supported by in vitro experiments (9, 
10). Recently, the effect of PI-based, NNRTI-based, or PI/NNRTI-based regimens on BMD in 71 
naïve patients was evaluated. At baseline, 31% were osteopenic and 3% osteoporotic. At week 48, 
there was an overall median decrease in BMD that was significant at 
both the lumbar spine and the femoral neck (4.1% and 2.8%, 
respectively). Greater decrements were noted in the PI containing 
regimens than in the NNRTI/NRTI regimen (14). In Gallant et al., BMD 
reductions were greater in those randomized to tenofovir (TDF) 
compared to those randomized to stavudine (d4T) (5). Whether HIV-
associated osteoporotic changes are a direct consequence of the 
pharmacological agents themselves or a consequence of disease 
modification/metabolic realignments to therapy (such as immune 
reconstitution) or both, is presently unclear.  
 
2.3.  HAART stimulates a rapid increase in bone 
resorption and disregulated OPG Production. In a recent 
pilot study (Emory IRB protocol #IR800007234), we 
examined biochemical markers of bone resorption (C-
terminal Telopeptide of collagen (CTx)) and serum OPG 
concentrations in HIV/AIDS patients (n=10) at baseline 
and prospectively at 2, 12 and 24 weeks of treatment with 
lopinovir/ritonavir + tenofovir/emtricitabine. Within 2 weeks 
of HAART initiation the percentage change from baseline 
of serum CTx rose by an average of 50%, reaching a 
statistically significant 115% increase by 12 weeks of 
treatment (some patients reached a 300% increase in 
bone resorption) and slowly declined reaching 70% by 24 weeks (Figure 5). In contrast, within 2 
weeks of HAART initiation OPG levels declined by 11%, consistent with enhanced bone resorption at 
this time point. Interestingly, by 12 weeks OPG levels had rebounded to ~18% above baseline levels, 
and then declined to 7% above baseline by 24 weeks 
(Figure 6). These data suggest that a decline in production 
of OPG shortly after HAART initiation may contribute to an 
initial wave of bone loss, potentially due to T cell and B 
cell activation and reconsitution, while a compensatory response to elevated bone resorption leading 
0
2 
12
24
-100
0
100
200
300
Time (Weeks)
*
0 Wks (Repeated Measures ANOVA, Tukey-Kramer Multiple Comparisons Test)
C-Terminal Telopeptide
 (% Change from Baseline)
0
2 
12
24
-100
-50
0
50
100
Time (Weeks)
*p=0.18 (Repeated Measures ANOVA
Osteoprotegerin
 (% Change from Baseline)
Figure 6: Changes in Serum OPG with HAART 
*p=0.18 (Repeated Measure ANOVA) 
iminished 
9 months  
Figure 5: Changes in Serum CTx with 
HAART, *p=0.05 vs wks (Repeated 
Measures ANOVA) 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
15 
 
to realignment in OPG production, may counteract bone resorption, thus slowing bone loss during 
medium to long term HAART treatment, as the immune system attains a more physiological state. 
Importantly, the observation that these changes occurred within the initial 24 weeks of therapy 
offers a unique opportunity for the exploration of early intervention to prevent antiretroviral 
induced bone loss.  Virtually all previous studies have focused on long time points, and 
consequently these dramatic resorptive events immediately following HAART administration have not 
been previously documented. The magnitude of these changes in bone resorption may have a 
profound impact on long term skeletal health in these patients. We thus propose a short-term (6 
months to 1 year) intervention arm to provide a proof of concept that this resorptive effect can, and 
should be, prevented pharmacologically. 
 
2.4. Long-Acting Antiresorptive Agents. Bisphosphonates including zoledronic acid are pyrophosphate 
analogues that inhibit bone resorption by binding to hydroxyapatite crystals. Several oral formulations 
of this class of compound are currently licensed for the treatment of osteoporosis. However, oral 
bisphosphonate use in the setting of HIV-infection may be limited by gastrointestinal side effects and 
contribution to an already high pill burden of HAART and other medications used for prophylaxis or 
treatment of opportunistic infections. Zoledronic acid on the other hand, is an intravenous third-
generation, long-acting bisphosphonate that can be administered annually. This compound has been 
shown to improve bone density and reduce fracture risk in subjects with osteoporosis [15, 16]. Two 
recent studies have also demonstrated that annual zoledronate infusion was well tolerated and led to 
significant increases in bone density in HIV-infected individuals with osteoporosis or osteopenia [17, 
18]. Denosumab is another long-acting parenteral agent that offers a novel approach to bone loss 
prevention. It is unique in the sense that is a fully humanized monoclonal antibody against RANKL, a 
cytokine, as noted above that is essential for the formation, function, and survival of osteoclasts. By 
binding RANKL, denosumab prevents the interaction of RANKL with its receptor, RANK, on 
osteoclasts and osteoclast precursors and reversibly inhibits osteoclast-mediated bone resorption 
[19]. Bi-annual subcutaneous administration of denosumab has been shown to be well tolerated and 
to reduce bone turnover and increase bone mineral density in human subjects [20 - 24]. Because 
HAART associated bone loss occurs early during therapy, and because zoledronate and denosumab 
have very long half-lives that span the window of rapid bone turnover during early phase of 
antiretroviral therapy, they may offer a convenient approach to aborting the rapid bone loss 
associated with HAART initiation in HIV-infected patients. However, in this proof-of-concept study, 
zoledronic acid will be used because it is currently approved in the U.S. by the Food and Drug 
Administration for the treatment of osteoporosis.  
 
2.5. Study Rationale: This proposal therefore aims to explore in further detail the cellular mechanism 
of HAART-associated bone turnover among HIV-infected subjects initiating antiretroviral therapy. We 
plan to evaluate the pharmacologic role of HAART therapy and the potential role of immune-
reconstitution following HAART on the homeostatic balance between RANKL and OPG in the serum 
and its production by B cells and T cells, cell types dramatically impacted by HIV-1 infection, and by 
HAART, and correlate these data with bio-markers of bone turnover and BMD in HIV-infected 
patients.  
 
Furthermore, we will investigate whether a single parenteral dose of zoledrononic acid, can prevent or 
slow the early rapid bone turnover seen among HIV-infected patients initiating HAART.  Such finding 
would be significant and could potentially offer an opportunity to reverse or slow the progression of 
osteopenia and osteoporosis in the setting of HAART with a convenient single dose administration of 
this or similar agent. 
Understanding, the risks to the skeleton associated with HIV/AIDS, and of HAART regimens, is 
imperative if we are to recognize the risk factors and treat patients appropriately to prevent premature 
or accelerated bone loss. With the mean survival time for HIV-infected individuals continuing to rise, 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
16 
 
damage sustained by the skeleton due to AIDS and/or HAART is likely to lead to an epidemic of 
osteoporosis and bone fractures among AIDS patients in the future, as age-associated declines in 
BMD exacerbate an already impoverished skeleton. While it may take some time before a consensus 
is reached as to the chronic use of antiosteoporotic agents in a population that may have to be treated 
for many decades, the utilization of an acute antiresorptive treatment to rescue patients from intensive 
skeletal damage associated with the early phase of HAART administration, could rapidly be 
implemented as part of the standard of care for these patients, dramatically improving long term 
skeletal health. 
 
3. STUDY DESIGN:  
 
3.1. Study Overview:  
 
In a prospective, blinded placebo-controlled, randomized study design, treatment naïve HIV-infected 
subjects initiating HAART will be assigned to HAART plus zoledronic acid or HAART plus placebo. 
Longitudinal blood sampling (seperated into plasma and PBMC) will be performed at pre-defined time 
points. Serial assessment of serum levels of bone markers, cellular expression of OPG/RANKL and 
other cytokines, cellular immune activation markers, serum bone regulating hormones, and bone 
mineral density (BMD) by DXA scan will be undertaking at pre-defined time points from baseline 
through week 144 of HAART.  
 
3.2. 
Subject Population and Recruitment:  
 
A total of 94 HIV-infected subjects (47 subjects per arm) will be recruited from the Grady 
Health Care System Infectious Diseases Program out-patient Clinic (Grady IDP). The Grady 
IDP manages over 4,500 HIV-infected patients and sees more than 50 antiretroviral naïve 
HIV-infected patients per month. HIV sero-positive patients may also be recruited from other 
areas where these populations may be found such as county health departments, private 
physician practices and community organizations.  
  
 
3.3. 
Study Intervention:  
 
3.3.1. Screening:  
 
Study related activities will include a screening visit to determine eligibility. This visit will 
entail informed consenting, review of medical records, detailed medical history and 
physical examination. Definitive proof of HIV-infection by ELISA test, western blot 
and/or plasma HIV-RNA PCR (viral load) will be documented. Urine pregnancy test will 
be performed for female subjects with childbearing potential. 
 
3.3.2. Study Entry 
 
Upon confirmation of eligibility and within 60 days of the screening visit, the subject will 
be enrolled into the study. Thereafter 87 mL of peripheral blood will be obtained via 
veni-puncture of a peripheral vein and collected into EDTA tubes. EDTA-Plasma is 
suitable for all ELISA Endpoints required in the specific aim of this proposal.  
 
Plasma and mononuclear cells will be recovered from collected blood samples by 
centrifugation using CPT tubes. Plasma will be stored at -80C until analyzed in the 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
17 
 
laboratory. PBMC will be processed immediately for FACS analysis and lymphocyte 
recovery (B and T cells) using immunomagnetic isolation procedures.   
 
Baseline plasma HIV-1 RNA viral load, CD4 T cell counts, and safety blood parameters 
(including chemistry panel, liver function tests, and complete blood cell counts) will be 
performed. Urine pregnancy test will be performed again for female subjects with 
childbearing potential. Subjects will be sent to have baseline DXA scans performed at 
the radiology unit of the Emory University Hospital. In addition, blood sample (1 
tablespoon) for DNA testing (optional) will be collected at one time point, usually at the 
time of enrollment. 
 
Following antiretroviral adherence counseling by trained and experienced medication 
counselors, subjects will be blindely randomized to one of two study arms; 
   
(a)  
HAART: Atazanavir (ATV)/ritonavir (RTV) + tenofovir 
  
 
(TDF)/emtricitabine (FTC) plus zoledronic acid 
  
(b) 
HAART (ATV/RTV + TDF/FTC) plus placebo 
 
3.3.3. Follow-up/safety Data  
 
Follow-up visits will occur at weeks 2, 4, 8, 12, 16, 20, 24, 36, 48, 72, 96, 120, and 144. 
During each visit, targeted physical examination driven by signs and symptoms will be 
performed. This will include vital signs: temperature, pulse, respiratory rate, blood 
pressure, weight, and height.  
 
At each visit, 87 mL of peripheral blood will be obtained via veni-puncture of a 
peripheral vein and collected into EDTA tubes following an overnight fast. Plasma and 
mononuclear cells will be recovered from collected blood samples by centrifugation 
using ACCUSPIN SYSTEM-HISTOPAQUE-1077 tubes. Plasma will be stored at -80C 
until analyzed in the laboratory. PBMC will be processed immediately for FACS 
analysis and lymphocyte recovery (B and T cells) using immunomagnetic isolation 
procedures.  DXA scan will also be performed at weeks 12, 24, 48, 96 and 144. 
 
As per standard of care at the Grady IDP, at weeks  4,16, 24, 36, 48, 72, 96, 120, and 
144 safety blood parameters, plasma HIV-1 RNA viral load, and CD4 T-cell counts will 
be performed and also at permanent study discontinuation.  
 
In addition, during each study visit, adherence to HAART treatment (as determined by 
pill counts or by using a previously validated questionnaire [25], and recording of 
adverse clinical events will be performed.   
 
Subjects with virologic failure will be evaluated with HIV-1 genotype and for change in 
antiretroviral treatment as per standard of care at the Grady IDP. Virologic failure for 
the purpose of this study will be defined as a confirmed plasma HIV-1 RNA level >1000 
copies/mL 16 weeks after randomization and before week 24 or >200 copies/mL 24 
weeks or more after randomization. 
 
4 
SELECTION AND ENROLLMENT OF SUBJECTS 
 
4.1 Inclusion Criteria 
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
18 
 
4.1.1 HIV-1 infection, as documented by any licensed serologic test and confirmed by a 
western blot or by a positive plasma HIV-1 RNA performed by any laboratory that 
has a CLIA certification.  
 
4.1.2 Meets Grady IDP clinical criteria for antiretroviral therapy initiation, and subject and 
his/her provider are agreeable to subject initiating therapy with a regimen consisting 
of ATV/RTV + FTC/TDF as part of his/her routine HIV management.  
  
4.1.3 Ambulatory men and women age > 30< 50 years. 
 
4.1.4 Ability and willingness of subject or legal guardian/representative to give written 
informed consent. 
 
4.1.5 ARV drug-naïve (defined as 10 days of ART at any time prior to entry).   
 
4.1.6 Screening HIV-1 RNA ≥1000 copies/mL obtained within 90 days prior to study entry 
by any FDA-approved test for quantifying HIV-1 RNA at any laboratory that has a 
CLIA certification.  
 
4.1.7 Laboratory values obtained within 90 days prior to study entry.  
 
Absolute neutrophil count (ANC) 500/mm3 
 
Hemoglobin 8.0 g/dL 
 
Platelet count 40,000/mm3 
 
Aspartate aminotransferase (AST), alanine aminotransferase (ALT), and 
alkaline phosphatase  3  ULN 
 
Total bilirubin 2.5 x ULN 
 
Calcium >8.0 mg/dL 
 
Serum vitamin D level >12ng/mL 
 
CrCl ≥50 mL/min as estimated by the Cockcroft-Gault equation.   
 
4.1.8 Absence of non-HIV related active immunological or bone disorders such as;  
 
Bone marrow or organ transplantation 
 
Inflammatory bowel disease (ulcerative colitis, crohn’s disease) 
 
Multiple Myeloma 
 
Osteogensis imperfect 
 
Osteomalacia 
 
Osteosacroma 
 
Paget’s disease 
 
Postmenopausal osteoporosis 
 
Rheumatoid arthritis 
 
Systemic lupus erythmatosus 
 
Thyroid disorders (hyper/hypothyroidism) 
 
4.1.9 Contraception requirements 
 
4.1.9.1 
Female Subjects of Reproductive Potential: 
Female subjects of reproductive potential, who are participating in 
sexual activity that could lead to pregnancy, must agree to use at least 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
19 
 
one reliable method of contraception while participating in the study.  
Acceptable methods of contraception include: 
 
Condoms (male or female) with or without a spermicidal agent 
 
Diaphragm or cervical cap with spermicide 
 
Intrauterine device (IUD) 
 
Hormone-based contraceptive (must contain at > 35 mcg of ethinyl 
  
estradiol) 
 
4.1.9.2 
Female Subjects Who Are Not of Reproductive Potential 
Women who are not of reproductive potential or whose male partner(s) 
has azoospermia are eligible to start study drugs without requiring the 
use of contraceptives.  Any statement of self-reported sterility or that of 
her partner’s must be entered in the source documents.   
 
NOTE: Acceptable documentation of lack of reproductive potential is the 
woman’s self-reported history of surgical sterilization, menopause, or 
male partner’s azoospermia. 
 
4.2 Exclusion Criteria 
 
4.2.1 The patient is pregnant  or breast feeding  
 
4.2.2 The patient has physical or biochemical evidence or a medical history of 
malignancy. 
 
4.2.3 The patient is currently (within the past 8 weeks) taking any systemic medication 
with known influence on the immune or skeletal system (e.g. immune modulation 
therapy, glucocorticoids, steroid hormones, other bisphosphonates). 
 
4.2.4 The patient has osteoporosis defined as T-score <-2.5 at the hip, or spine, or history 
of osteoporotic fracture.  
 
4.2.5 The patient has prior or current use of zoledronic acid (reclast®) 
 
4.2.6 The patient has a recent (within the past 6 months) or planned (within the next 6 
months) invasive dental procedure.  
 
4.2.7 The patient has any condition that, in the opinion of the investigators, would 
compromise the subject’s ability to participate in the study. 
 
4.2.8 The patient has a serious illness requiring systemic treatment and/or hospitalization 
until subject either completes therapy or is clinically stable on therapy, in the opinion 
of the investigators, for at least 7 days prior to study entry.   
 
4.2.9 The patient has discontinued, for at least 30 days prior to randomization, any 
medications (per protocol) that are prohibited with study ARV’s and zoledronic acid. 
 
4.2.10 The patient is currently imprisoned or involuntarily incarcerated in a medical facility 
for psychiatric or physical illness.   

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
20 
 
 
Exclusion criteria are primarily centered on immunological aspects with bone related 
aspects secondary. This is because in our model immunological function is proximal 
to bone function. Consequently, use of vitamin D or calcium supplementation will not 
be exclusion criteria, but will be added as covariates in our analysis.  
 
4.3 Study Enrollment Procedures 
 
4.3.1 Prior to implementation of this study, the protocol and protocol consent form will be 
approved by the Emory University institutional review board (IRB) and the Grady 
Health System Research Oversight Committee. Once a candidate for study entry 
has been identified, details will be carefully discussed with him/her. The candidate 
will be asked to read and sign the approved protocol consent form that was 
approved by the Emory University IRB prior to undergoing any study procedures. A 
copy of the signed informed consent form will be given to the subject, and the 
original copy will be kept in subject’s record.  
 
5 
STUDY TREATMENT  
 
5.1 
Regimens, Administration, and Duration 
 
5.1.1 
Regimens 
 
Subjects will be randomized to one of the following two treatment arms:  
 
ARM A: 
Atazanavir (ATV) 300 mg PO QD + Ritonavir (RTV) 100 mg PO 
QD + Tenofovir (TDF) / Emtricitabine (FTC) 200/300 mg PO QD 
plus single dose Zoledronic acid 5 mg in a 100 mL ready to 
infuse solution. 
 
ARM B: 
ATV 300 mg PO QD + RTV 100 mg PO QD + TDF/FTC 200/300 
mg PO QD plus single Zoledronic Acid 5mg placebo in 100 mL 
ready to infuse solution. 
 
5.1.2 
Administration and Dispensing 
 
5.1.2.1 
ATV will be administered orally as one 300 mg capsule once 
daily with food and is to be taken with RTV 100 mg once daily. 
 
5.1.2.2 
TDF/FTC will be administered orally as one 300/200 mg 
coformulated tablet (Truvada®) once daily with food.  
 
5.1.2.3 
Zoledronic acid will be administered intravenously as 5 mg/100 
mL infusion given over 30 minutes.  
 
5.1.3 
  Duration 
 
Subjects will participate in this study for approximately 144 weeks.   
 
5.2 
Study Product Formulation and Preparation 
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
21 
 
HAART (ATV, RTV or FTC/TDF) will be administered as standard of care for HIV-
infection management and is not provided by the study. Key study protocol products 
provided by the study are listed below.   
 
5.2.1 
Zoledronic acid 
 
 
Zoledronic acid (reclast®) is available in bottles (each bottle contain 5 
mg/100 mL. NDC 0078-0435-61) 
 
 
Product will be kept in a secured location. It will be stored at 25°C 
(77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled 
Room Temperature]. 
 
5.3 
Pharmacy: Product Supply, Distribution, and Accountability 
 
5.3.1 
Study Product Acquisition 
 
5.3.1.1 
HAART will be acquired by subject as part of their standard of 
care through their payor source. 
 
5.3.1.2 
Zoledronic acid/placebo is provided by Novartis 
 
5.3.2 
Study Product Accountability 
 
The Emory University Clinical Trial Unit pharmacists assigned to this 
protocol will be required to maintain complete records of all study products 
received from the supporting pharmaceutical companies and subsequently 
dispensed. All unused study products will be destroyed or returned after the 
study is completed or terminated. 
 
5.4 
Concomitant Medications 
 
To avoid drug interaction and adverse events, the manufacturer’s most recent 
package inserts of the study allowed antiretroviral agents, zoledronic acid, and the 
concomitant agent will be referred to whenever a concomitant medication is initiated 
or dose of a concurrent medication is changed. 
 
5.4.1 
Required Medications 
 
No concomitant medications are required by the protocol. 
 
5.4.2 
Prohibited Medications are listed below. 
 
 
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
22 
 
 
Table 1: Prohibited Medications 
Medication Category 
Zoledronate 
ATV 
RTV 
Alpha1-adrenoreceptor 
antagonist 
 
 
Alfuzosin HCL 
Antiarrhythmics 
 
 
amiodarone, bepridil, 
flecainide, 
propafenone, 
quinidine 
Antifungal 
 
 
voriconazole 
Antihistamines 
 
 
astemizole, 
terfenadine 
Antimycobacterials 
 
rifampin 
rifampin 
Antineoplastics 
 
irinotecan 
 
Ergot Derivatives 
 
dihydroergotamine, 
ergotamine, 
ergonovine, 
methylergonovine 
dihydroergotamine, 
ergotamine, 
ergonovine, 
methylergonovine 
GI Motility 
 
cisapride 
cisapride 
Herbal Products 
 
St. John’s wort 
(Hypericum 
perforatum) 
St. John’s wort 
(Hypericum 
perforatum) 
HMG-CoA Reductase 
Inhibitors 
 
lovastatin, 
simvastatin 
lovastatin, 
simvastatin 
Neuroleptic 
 
pimozide 
pimozide 
PDE5-inhibitors 
 
 
Sildenafil* 
(Revatio®) only 
when used for the 
treatment of 
pulmonary arterial 
hypertension (PAH) 
Sedative/hypnotics1 
 
triazolam, orally 
administered 
midazolam 
triazolam, orally 
administered 
midazolam 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
23 
 
 
5.4.3 
Precautionary medications may include, but may not be limited to:  
Table 2: Precautionary Medications 
Medication Category 
Zoledronic acid 
ATV 
RTV 
Clinical comment 
Aminiglycosides 
 
 
 
Caution is advised when bisphosphonates are 
administered with aminoglycosides, since these 
agents may have an additive effect to lower serum 
calcium level for prolonged periods. This effect has 
not been reported in zoledronate clinical trials. 
Anesthetic  
 
 
meperidine 
Dose increase and long-term use of meperidine with 
RTV is not recommended due to the ↑ concentrations 
of metabolite which has analgesic and/or CNS 
stimulant activity (e.g., seizures).  
Antiarrhythmics  
 
Amiodarone, 
bepridil, lidocaine 
(systemic), 
quinidine 
disopyramide, 
lidocaine, 
mexilitine 
Antiarrhythmics concentrations are ↑ by PIs. Caution 
is warranted and TDM (if available) is recommended 
for these agents when co-administered with PIs.  
Anticoagulant 
 
warfarin 
(↑ levels) 
warfarin 
(↓ levels) 
Initial frequent monitoring of the INR is indicated 
when warfarin is co-administered with PIs.  
Anticonvulsants 
 
 
↑carbamazepine 
↑clonazepam 
↑ethosuximide 
 
↓divalproex 
↓lamotrigine 
↓phenytoin 
Clinical monitoring of anticonvulsant concentrations 
and its dose titration is recommended to achieve the 
desired clinical response. 
Antidepressants 
 
Trazodone. 
trycyclics 
bupropion, 
nefazodone, 
SSRIs, tricyclics, 
trazodone, 
desipramine 
If these drugs are used with a PI, the combination 
should be used with caution and the lowest possible 
dose should be prescribed initially. Serum drug 
concentrations should be monitored when possible 
and used to titrate dose to obtain the desired clinical 
effect. Adverse events of nausea, dizziness, 
hypotension, and syncope have been observed 
following co-administration of trazodone and RTV.  
Anti-HCV agent 
 
 
 
For treatment of hepatitis C, interferon should not 
exceed a dose of 10 million IU/ week, and pegylated 
interferon should not exceed 180µg/wk.  It is 
recommended that participants not start hepatitis C 
treatment during the first year on-study; however, if 
treatment is started, participants will continue to be 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
24 
 
followed on-study and on-study treatment.  
Antiemetic  
 
 
dronabinol 
(↑ levels) 
A dose ↓ of dronabinol may be needed when co-
administered with RTV.  
Antifungal  
 
↑ketoconazole 
↑itraconazole 
↑ketoconazole 
↑itraconazole 
Due to the effect of RTV on ketoconazole or 
itraconazole, high doses (>200 mg/day) are not 
recommended. 
 
Plasma concentrations of voriconazole 
may be ↓ in the presence of DRV/r. Voriconazole 
should not be administered to patients receiving 
DRV/r unless an assessment of the benefit/risk ratio 
justifies the use of voriconazole. 
Anti-infective  
 
↑clarithromycin 
↑clarithromycin 
Co-administration of ATV with clarithromycin ↑ 
clarithromycin levels, which could result in QTc 
prolongation.  Dose reduction of clarithromycin by 
50% should be considered. 
With DRV/r, no dose adjustment of the combination is 
required for patients with normal renal function. For 
patients with renal impairment, refer to PI package 
insert for appropriate dosing. 
Antimycobacterial 
 
↑rifabutin 
↑rifabutin 
A rifabutin dose reduction of up to 75% (e.g., 150 mg 
every other day or 3 times per week) is 
recommended when co-administered with a RTV-
boosted PI. 
Antiparasitics  
 
 
atovaquone 
Clinical significance is unknown; however, ↑ in 
Atovaquone dose may be needed. 
Antihypertensives 
 
felodipine, 
nifedipine, 
nicardipine, 
verapamil 
Diltiazem, 
nifedipine, 
verapamil, 
Metoprolol, 
timolol 
Antihypertensive levels are ↑. Caution is warranted 
and clinical monitoring of patients is recommended. A 
dose ↓ may be needed for these drugs when co-
administered with RTV boosted PIs. 
 
Co-administration of ATV with diltiazem resulted in a 
2-fold ↑ in the steady state concentration of diltiazem.  
A 50% dose reduction in diltiazem may be necessary. 
 
Caution should be used when ATV is co-administered 
with drugs known to increase the PR interval (e.g., 
diltiazem).   
Bile sequestering resins  
 
 
 
Co-administration of PIs with bile sequestering resins 
(cholestyramine, colestipol) are discouraged because 
their use can be associated with ↑ triglyceride levels, 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
25 
 
and their effects on antiviral drug absorption have not 
been studied.  
Bronchodilator 
 
 
↓theophylline 
 
 
Long-acting beta-
adrenoceptor 
agonist: 
↑salmeterol.  
↑ dosage of theophylline may be required with RTV; 
TDM should be considered.  
 
Concurrent administration of salmeterol and RTV is 
not recommended. The combination may result in 
increased risk of cardiovascular adverse events 
associated with salmeterol, including QT 
prolongation, palpitations and sinus tachycardia. 
 
Digoxin 
 
 
↑Digoxin 
Caution should be exercised when co-administering 
RTV containing regimen with digoxin, with 
appropriate monitoring of serum digoxin levels.  
Gastric acid reducing 
agents 
 
↓ ATV levels 
 
Any drug or buffered product (e.g., antacids, H2 
blockers, proton pump inhibitors) that reduces gastric 
acid may reduce the plasma concentrations of ATV.   
- 
Note: If co-administered with an antacid (e.g., 
Maalox®, Mylanta®), ATV/RTV should be 
administered together at least 2 hours before 
and 1 hour after a dose of the antacid.  Since 
there are limited data on the effect 
simultaneous co-administration of both H2 
blockers (e.g., famotidine, cimetidine) and 
TDF have on ATV levels it is recommended 
that whenever possible ATV/RTV should be 
administered at least 2 hours before and at 
least 10 hours after a dose of the H2 
blocker. The proton-pump inhibitor dose 
should not exceed a dose comparable to 
omeprazole 20 mg and must be taken 
approximately 12 hours prior to the 
REYATAZ 300 mg and ritonavir 100 mg 
dose. 
Grapefruit juice 
 
 
 
Participants should avoid grapefruit juice throughout 
the study period, and especially within 72 hours prior 
to study visits when PI trough levels are obtained.  

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
26 
 
Loop Diuretics 
 
 
 
Caution should also be exercised when zoledronate 
is used in combination with loop diuretics due to an 
increased risk of hypocalcemia. 
Nephrotoxic Drugs 
 
 
 
Caution is indicated when zoledronate is used with 
other potentially nephrotoxic drugs. 
PDE5-inhibitors:  
 
↑sildenafil, 
↑tadalafil, 
↑vardenafil. 
↑sildenafil, 
↑tadalafil, 
↑vardenafil 
Particular caution should be exercised when 
prescribing these agents to participants receiving 
RTV-boosted PI regimens.  Co-administration of RTV 
with any of these agents is expected to substantially 
increase their concentrations which may cause 
hypotension, syncope, visual changes, and prolonged 
erection.  When co-administered with any PI:   
- 
Sildenafil should not exceed a maximum 
single dose of 25 mg in a 48-hour period. 
- 
Tadalafil should not exceed a maximum 
single dose of 10 mg in a 72-hour period 
when co-administered with any potent 
inhibitors of CYP3A4, such as RTV. 
- 
Vardenafil should not exceed a maximum 
single dose of 2.5 mg in a 72-hour period 
when co-administered with RTV.  When co-
administered with other PIs, caution should 
be exercised when dosing vardenafil. 
HMG-CoA Reductase 
Inhibitor  
 
↑rosuvastatin, ↑ 
atorvastatin 
↑rosuvastatin, ↑ 
atorvastatin 
Caution should be used when taking these agents as 
the risk of myopathy, including rhabdomyolysis, may 
be increased. They should be used at the lowest 
possible dose with careful monitoring and dose 
titration, and when possible, alternative agents should 
be considered. 
Hormonal contraceptives 
 
↓ or ↑ethinyl 
estradiol, 
 
↓or ↑ 
norgestimate 
↓ethinyl estradiol 
The effectiveness of estrogen-based contraceptives 
when co-administered with RTV-boosted PI regimens 
is unknown. Alternative or additional contraceptive 
measures should be used when estrogen-based oral 
contraceptives and RTV-boosted PI regimens are co-
administered 
Immuno-suppressants 
 
↑cyclosporine, 
↑tacrolimus, 
↑sirolimus 
↑cyclosporine, 
↑tacrolimus, 
↑sirolimus 
TDM is recommended for immunosuppressant agents 
when co-administered with a RTV-boosted PI. 
Inhaled Steroid: 
fluticasone 
 
↑fluticasone 
↑fluticasone 
Concomitant use of inhaled fluticasone propionate 
and RTV-boosted PI may increase plasma 
concentrations of fluticasone, resulting in significantly 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
27 
 
 
5.5 
Adherence Assessment  
 
Antiretroviral adherence will be assessed by pill counts during each study visit or by a brief adherence 
reduced serum cortisol concentrations. Alternatives 
should be considered, particularly for long term use. 
Narcotic Analgesic 
 
 
↓methadone 
Dose adjustments of methadone may be required for 
participants on RTV-boosted PI regimens.  
Participants on RTV-boosted regimens should be 
closely monitored for symptoms of opiate withdrawal. 
Nephrotoxic agents: 
e.g., amphotericin B, 
aminoglycosides, 
cidofovir, acyclovir, 
ganciclovir, vancomycin  
 
 
Co-administration of agents with nephrotoxic potential 
(e.g., amphotericin B, aminoglycosides, cidofovir, 
acyclovir, ganciclovir, vancomycin) or that are renally 
excreted with TDF may increase serum drug 
concentrations of TDF and/or increase the 
concentrations of the other renally excreted agents. 
TDF (or FTC/TDF fixed-dose combination) should be 
avoided in participants with concurrent or recent use 
of a nephrotoxic agent, in accordance with the 
Viread® package insert 
Neurolepltics 
 
 
↑perphenazine, 
↑risperidone, 
↑thioridazine 
A dose decrease may be needed for these drugs 
when co-administered with RTV containing regimen. 
Niacin 
 
 
 
Niacin increases the risk of insulin resistance even in 
non-diabetic individuals. It should therefore be 
avoided as first-line therapy in participants receiving 
PIs. 
Sedatives/ 
hypnotics 
 
 
↑buspirone, 
↑clonazepam, 
↑diazepam, 
↑estazolam, 
↑flurazepam, 
↑zolpidem 
A dose decrease may be needed for these drugs 
when co-administered with RTV. 
Steroids 
 
 
Dexamethasone, 
prednisone 
Systemic dexamethasone induces CYP3A and can 
thereby decrease DRV plasma concentrations. This 
may result in loss of therapeutic effect to DRV. 
Thalidomide 
 
 
 
In multiple myeloma patients, the risk of renal 
dysfunction may be increased when zoledronate is 
used in combination with thalidomide. 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
28 
 
questionnaire at intervals during the study. 
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
29 
 
6 
CLINICAL AND LABORATORY EVALUATIONS 
 
6.1 Schedule of Events 
 
Schedule of Events: Table 3 
 
                   Follow up weeks → 
Screening 
Entry 
2 
4 
 8 
12 
 16 
 20 
 24 
36  
 48 
72 
96 
120 
144 
Prem. D/C 
Clinical Parameters 
Documentation of HIV-1 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical/Medication History 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical Assessment 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Physical Exam (complete) 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Exam (targeted) 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Concomitant medication 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Adherence Assessment 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Study Specific Intervention 
HAART (ATV/r + FTC/TDF) 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Zoledronic acid 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study Specific Specimens 
Fasting Blood (plasma) 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Fasting Blood (PBMC) 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
DEXA-Scan 
x 
 
 
 
 
x 
 
 
x 
 
x 
 
x 
 
x 
 
HIV Treatment Outcome Labs 
Plasma HIV-1 RNA 
x 
x 
 
x 
 
 
x 
 
x 
x 
x 
x 
x 
x 
x 
x 
CD4+/CD8+ 
x 
x 
 
x 
 
 
x 
 
x 
x 
x 
x 
x 
x 
x 
x 
Safety Lab. Tests 
Hematology (complete CBC) 
x 
x 
x 
 
 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
Liver Function Tests (chem14)* 
x 
x 
x 
 
 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
Serum vitamin D 
x 
x 
x 
 
 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
Serum intact Parathyroid 
hormone (iPTH) 
 
x 
x 
 
 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
Calculated CrCl 
x 
x 
x 
 
 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
Urinalysis 
x 
x 
x 
 
 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
Pregnancy Testing 
x 
x 
 
 
 
 
 
 
x 
 
x 
 
x 
 
x 
 
†Stored blood for genetic testing 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*Chem 14 includes serum calcium, protein, albumin, liver function test, blood urea nitrogen, creatinine, glucose, bicarbonate, chloride, and sodium.  
 
Perm. D/C = premature study discontinuation  
 
†Blood sample for genetic testing can be collected anytime during the study visits if not collected at entry.  

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
30 
 
6.2 Definitions for Schedule of Events – Timing of Evaluations 
 
6.2.1 Screening Evaluations  
 
Screening evaluations will occur prior to the participant’s starting any study medications. 
Screening 
Screening evaluations to determine eligibility will be completed within 60 days prior to study 
entry, unless otherwise specified. 
   
NOTE: 
Screening plasma HIV-1 RNA will be obtained and performed locally within 90 
  
 
days prior to study entry. 
In addition to data being collected on participants who enroll into the study, demographic, 
clinical, and laboratory data on screening failures will be captured in a screening log and 
entered into the study database. 
6.2.2 Entry Evaluations 
 
Entry evaluations will occur within 60 days of screening (unless otherwise specified) and 
completed prior to the initiation of study medications.  Randomization will occur at the entry 
visit, and subjects will begin treatment within 7 days after randomization. 
 
6.2.3 Post-Entry Evaluations 
 
On-Treatment Evaluations 
 
On-treatment evaluations will occur after entry.  Study visits will be scheduled on the weeks 
listed in the Schedule of Events (Table 3) and within the windows specified below. 
 
 
The week 2 and 4 visit will occur +/- 3 days. 
 
The weeks 8, 12, 16, and 20 visits will occur +/- 7 days of the week indicated. 
 
Beginning at week 24, visits will occur +/- 14 days of the week indicated. 
Event-Driven Evaluations 
 
Confirmation of Virologic Failure Evaluations 
 
For participants who have a sample suggesting virologic failure, a confirmatory plasma HIV-1 
RNA test will be performed within 2 weeks after the initial HIV-1 RNA sample that indicated 
virologic failure as per standard of care at the Grady IDP.  If confirmation cannot be obtained 
within 2 weeks, the next viral load obtained will be considered the confirmatory one.  
Participants who meet criteria for the first episode of confirmed virologic failure will undergo 
real-time genotypic resistance testing as per standard of care (not provided by the study). 
Participants with confirmed virologic failure will be evaluated for antiretroviral regimen 
change, and may continue in the study. 
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
31 
 
6.2.4 Discontinuation Evaluations 
 
Evaluations for Registered Participants Who Do Not Start Study Treatment 
 
Registered participants who do not start study treatment will be discontinued from the study, 
and will be replaced by new participants. All CRFs will be completed and entered into the 
study database for the period up to discontinuation and including week 0. 
 
Premature Treatment Discontinuation Evaluations 
 
Premature discontinuation of study treatment is defined as permanently stopping all study 
treatment prior to study completion. 
 
All participants who discontinue their study regimens before the end of the study will come in 
for a premature discontinuation of study regimen visit within 14 days after stopping their 
antiretroviral therapy. 
 
Study Completion Evaluations 
 
Final Visit 
 
All registered participants, who either complete the study or who prematurely discontinue 
participation in the study, will be requested to report to the clinic to have the final visit 
evaluations performed. 
 
6.3 Definitions of Evaluations 
 
6.3.1 Documentation of HIV 
 
HIV-1 infection will be documented by any serologic test and confirmed by a positive western 
blot or plasma HIV-1 RNA performed by any laboratory that has a CLIA certification. 
 
6.3.2 Medical History 
 
A medical history will be recorded in source documents.  
 
Any allergies to any medications and their formulations will be documented and entered on 
the CRFs. 
 
6.3.3 Medication History 
 
A medication history including HIV treatment history, current HIV treatment, and treatment 
history of any prescription medication taken for the treatment or prophylaxis of opportunistic 
infections will be recorded in source documents including start and stop dates. 
 
All medications including prescription, non-prescription, alternative therapies, and dietary 
supplements taken within 30 days of the screening visit, and all medications currently taken 
will be recorded on the CRFs, including start and stop dates. 
 
6.3.4 Concomitant Medications 
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
32 
 
Any changes in concomitant medications since the previous visit will be recorded in the 
source documents and CRFs, including start and stop dates. . 
 
6.3.5 Clinical Assessments 
 
Complete Physical Exam 
 
A complete physical examination will be performed at screening only and will  include at a 
minimum an examination of the skin, HEENT (head, eyes, ears, nose, and throat), mouth, 
and neck; auscultation of the chest; cardiac exam; abdominal exam; examination of the 
extremities; neurologic exam, and Karnofsky performance test. The complete physical exam 
will also include signs and symptoms, diagnoses, height, weight, and vital signs (axillary or 
oral temperature [Fahrenheit], pulse, and blood pressure). 
 
Targeted Physical Exam 
 
A targeted physical examination will be performed at every visit beginning at entry and is to 
be driven by any previously identified or new signs or symptoms including diagnoses that the 
participant has experienced since the last visit.  It is to include weight, vital signs (axillary or 
oral temperature [Fahrenheit], pulse, and blood pressure). 
 
Signs and Symptoms 
 
At entry, all grades that occurred 30 days before entry will be recorded.  Post-entry and at the 
time of confirmation of virologic failure, only signs and symptoms Grade 3 will be recorded. 
All signs and symptoms that led to a change in treatment, regardless of grade will be 
recorded. The source document will include date of onset and date of resolution. 
 
Signs and symptoms will be graded according to the Division of AIDS Table for Grading the 
Severity of Adult and Pediatric Adverse Events (DAIDS AE Grading Table), Version 1.0, 
December 2004, which can be found on the DAIDS RCC Web site: http://rcc.tech-
res.com/tox_tables.htm. 
 
Diagnoses 
 
At screening and entry, all HIV-related and non-HIV-related confirmed and probable 
diagnoses will be recorded in the source documents.  During the study, all confirmed and 
probable diagnoses made since the last visit will be reviewed and recorded in the source 
documents, including current status at the time of study visit. 
 
The following will be recorded on the source documents: HIV-related diagnoses, HIV-related 
malignancies, AIDS-defining events, IRIS events, tuberculosis at any site, hepatitis, 
pancreatitis, coronary artery disease (myocardial infarction or angina), diabetes mellitus, and 
death.  Any other diagnosis that is, in the opinion of the clinical investigators, associated with 
study medications, will be recorded on the source documents.  The source document will 
include date of diagnosis and date of resolution.  
Concomitant Medications 
 
All changes in the following medications will be recorded on the CRFs: ARV medications, 
medications for treatment or prophylaxis of HIV infection or complications, interferon, 
ribavirin, lipid-lowering drugs, oral hypoglycemics, and insulin. 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
33 
 
 
At each study visit, all concomitant medications taken since the last visit will be recorded in 
the source documents. For lipid-lowering drugs, oral hypoglycemics (including any drug used 
to treat diabetes), and insulin, the source document will include start dates and stop dates.  
 
Study Treatment Modifications 
 
All study drug modifications will be recorded, including initial doses, participant-initiated 
and/or protocol-mandated modifications, and inadvertent and deliberate interruptions at each 
visit. Any permanent discontinuation of treatment will be recorded.  Treatment interruption is 
failure for any cause to take study drugs for more than 48 hours. 
 
6.3.6 Laboratory Evaluations 
 
Laboratory tests will be graded according to the Division of AIDS Table for Grading the 
Severity of Adult and Pediatric Adverse Events (DAIDS AE Grading Table), Version 1.0, 
December 2004, which can be found on the DAIDS RCC Web site: http://rcc.tech-
res.com/tox_tables.htm.  
 
At screening and entry, all laboratory values will be recorded. For post-entry assessments, all 
Grade 3 laboratory values will be recorded. All laboratory toxicities that led to a change in 
treatment, regardless of grade, will be recorded. 
 
All the following laboratory results (regardless of grade) will be recorded on the CRFs each 
time they are performed, according to the protocol Schedule of Events: 
 
 
Complete blood count 
 
Chemistry profile (including albumin and calcium) 
 
Serum vitamin D 
 
Serum intact parathyroid hormone (iPTH) 
 
HIV-1 RNA PCR 
 
CD4+/CD8+ T-cell counts 
 
Creatinine 
 
Calculated Creatinine Clearance* 
 
*(See https://www.fstrf.org/common/utilities/calculators/ccc.html for the Cockcroft-Gault 
equation). 
Hematology 
Hemoglobin, hematocrit, white blood cell count (WBC), differential WBC, absolute neutrophil 
count (ANC), and platelet count will be performed in real time at the local laboratory. 
Blood Chemistries 
 
Blood urea nitrogen (BUN), creatinine, and electrolytes (sodium, potassium, chloride, and 
bicarbonate) will be performed in real time at the local laboratory.  

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
34 
 
 
Liver Function Tests (LFTs) 
 
Total bilirubin, AST (SGOT), ALT (SGPT), and alkaline phosphatase will be performed in real 
time at the local laboratory. 
 
Plasma HIV-1 RNA 
 
Screening HIV-1 RNA will be performed locally using Abbott HIV-1 Real Time assay within 90 
days prior to study entry by a local laboratory certified for that assay. 
Eligibility will be determined based on the screening value. The screening value for all 
registered participants will be > 1000 copies/ml.  
 
HIV-1 RNA quantitation will be measured from entry forward in real time using the Abbott 
Real Time HIV-1 Monitor assay. 
CD4+/CD8+ 
 
CD4+/CD8+ counts and percentages performed by flow cytometry at a CLIA-certified or 
equivalent lab will be recorded in the source document and on the CRFs at each visit. 
 
6.3.7 DEXA Scan 
 
A single, total-body DEXA scan will be performed +/-14 days at screening and at weeks 12, 
24, 48, 96 and 144. 
 
 
Since food in the stomach can alter weight and body composition results, fasting 8 
hours prior to the DEXA scan is preferable. If a participant must take food with 
medications or for medical reasons, it should be a small snack (toast or crackers) with, 
at most, 8 oz of fluid at least 2 hours before the scan. 
 
 
DEXA scans will be performed on the same machine using the same software for each 
individual participant for the duration of the study.  
 
 
Screening for pregnancy prior to the DEXA scans will be performed in compliance with 
the requirements of the radiology department. 
 
6.3.8 Collection of samples to be used as a source of DNA for future analyses 
 
A Blood sample (~10mL) may be collected from each participant after their consent. 
Participants who consent will be asked to contribute DNA to be archived in the following 
manner. 
 
Whole blood will be collected to fill a 2 x 7.5 mL plastic Sarstedt brand K3 EDTA Monovettes, 
following manufacturer’s instructions for use (Product Number 01.1605.100). If possible, this 
specimen will be obtained at the entry visit or at 1 other scheduled visit if not obtained at 
entry. After filled with blood, Monovettes will be stored at –80oC until analysis.  
 
 
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
35 
 
7 
CLINICAL MANAGEMENT ISSUES 
7.1 
General Consideration 
 
All participants will remain under the care of their primary care physicians (PCP) throughout the 
study period. Patients will undergo routine clinical and laboratory evaluations and monitoring for 
complications of antiretroviral therapy under the care of their PCP as per the standard of care at 
the Grady IDP.  Parameters assessed for HIV-infected patients during routine clinic visits at the 
Grady IDP Clinic include general health, vital signs, complete CBC with differential, clinical 
chemistries, and immunologic studies (CD4+ and CD8+ lymphocyte counts).  Patients’ PCPs 
will have access to research records if considered necessary for patients’ care.   
7.2 
Potential Risk 
 
In addition to starting antiretroviral therapy as part of subjects’ standard treatment for HIV-
infection, subjects will also be exposed to either a single dose of i.v. zoledronic acid. Zoledronic 
acid is approved by the Food and Drug Administration (FDA) for the treatment of osteoporosis 
and has been used with success in the setting of HIV-infection and antiretroviral therapy [15 - 
19]. Subjects will be monitored closely for complications related to these agents and managed 
appropriately as per standard of care for managing these complications.  
 
Subjects enrolled into this study will be exposed to the risk of needle puncture during blood 
sample collection. The risks associated with vein punctures are uncommon and may include 
small blood clots in a vein, and infection at the site of needle puncture. Other uncommon risks 
also include pain, bruising, soreness, and reaction to tapes at the site of needle insertion. Some 
people may experience a fainting spell with needle puncture. These risks occur only on rare 
occasions and the likelihood for serious harm is extremely low. 
 
Bone densitometry by DXA is a completely non-invasive procedure that is routinely used for 
medical purposes. It utilizes extremely low levels of X-rays that is equal to or less than the 
natural environmental radiation the average person receives in the United States annually.  The 
principal risk associated with a radiation dose is the possibility of developing a radiation-induced 
cancer later in life or harm to the fetus in a pregnant woman.  There are however currently no 
studies that show an increase in the risk of genetic mutation in the next generation of offspring. 
The risk from radiation exposure from DXA scan is considered to be negligible when compared 
to everyday risks, thus there is consequently no credible risk of injury from this procedure. 
 
7.3 
Minimization of Risk 
 
 
 
 
The blood will be drawn by research personnel with experience in this procedure.  Universal  
 
 
precautions will be employed in all instances involving human specimens and samples  
 
 
processed assumed infectious and blood processed under at least BSL2 conditions. Women  
 
 
who may be pregnant will be excluded from participation in this study because of possible  
 
 
effects of radiation exposure on their unborn child.  
 
7.4 
Toxicity Management 
 
Toxicities related to study intervention will be graded according to the Division of AIDS Table for  
Grading the Severity of Adult and Pediatric Adverse Events, Version 1.0, December 2004,  
located at the Division of AIDS Regulatory Compliance Center Web Site: http://rcc.tech-

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
36 
 
res.com/tox_tables.htm. Study related toxicity will be recorded by treatment arms, monitored 
closely by study team, and management by the standard care at the Grady IDP.   
 
7.5 
Vitamin D Deficiency/Low Serum Calcium Levels 
 
Serum intact parathyroid hormone, calcium and vitamin D levels will be monitored periodically  
as outlined in the schedule of event. Subject found to have albumin corrected calcium levels <  
9.0 mg/dL will be placed on calcium replacement therapy. Similarly, subject with serum vitamin  
level < 20 ng/dLwill be started on vitamin D replacement therapy per standard of care.  
 
7.6 
Development of Osteoporosis 
 
 
 
DXA scans will be monitored at multiple pre-defined time points during the study.  If a subject  
 
 
develops a T-score of <-2.5 at any point after entry into the study, it will be necessary that the  
 
 
subject be unblinded in order that this condition can be appropriately managed. Unblinding will  
 
 
be conducted in a manner that keeps the study team (clinical, basic science, and statistical)  
 
blinded. Subjects will be referred for appropriate treatment by their primary care physician.  
  
Subjects treated with calcium and/or vitamin D may remain in the study and be followed per 
  
study protocol until study completion.  Subjects treated with a bisphosphonate or related drugs 
  
with bone modifying effects, however, will be permanently discontinued from the study. 
 
7.7 
Pregnancy 
 
Women who become pregnant while on study will be followed for safety evaluation until the  
completion of all study visits. Blood draw at each visit will be limited to safety lab (chem.14,  
CBC, CD4 T-cell counts, HIV-1 RNA, serum vitamin D, serum intact parathyroid hormone  
(iPTH)) as per the standard of care for the management of pregnant patient on HAART at the  
Ponce Clinic and according to national (US Public Health or other) guidelines. Collection of  
blood for study specific end points (fasting PBMC & plasma) and DXA scan will be discontinued. 
 
 
 
 
8 CRITERIA FOR DISCONTINUATION 
 
8.1 
Permanent Treatment Discontinuation 
 
Requirement for prohibited concomitant medications (see section 5.4). 
 
Pregnancy or breast-feeding. 
 
Completion of treatment as defined in the protocol. 
 
Request by participant to terminate treatment. 
 
Clinical reasons believed life threatening by the clinician, even if not addressed in the toxicity 
section of the protocol. 
 
Subject judged by the investigator to be at significant risk of failing to comply with the provisions 
of the protocol as to cause harm to self or seriously interfere with the validity of the study 
results. 
 
At the discretion of the IRB, FDA or other government regulatory authorities, Office for Human 
Research Protections (OHRP), investigator, or pharmaceutical supporter. 
 
8.2 
Premature Study Discontinuation 
 
Failure by the participant to attend three consecutive clinic visits. 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
37 
 
 
Request by the participant to withdraw. 
 
Request of the primary care provider if s/he thinks the study is no longer in the 
  
best interest of the participant. 
 
Participant judged by the clinician to be at significant risk of failing to comply 
  
with the provisions of the protocol as to cause harm to self or seriously interfere 
     with the validity of the study results. 
 
At the discretion of the IRB, FDA or other government regulatory authorities, 
  
OHRP, investigator, or pharmaceutical supporter.  
9.0 
STATISTICAL CONSIDERATIONS 
 
9.1 
General Design Issues 
 
This is a single center, prospective, blinded placebo-controlled, randomized study designed to 
evaluate the mechanism of HAART induced bone loss in HIV-infected individuals, and to assess 
if this effect of HAART on bone can be reversed by long acting inhibitors of bone resorption.  
 
9.2 
Summary of Endpoints 
 
9.2.1 Serum viremia: HIV-1 RNA PCR by commercially available Abbott HIV-1 Real Time 
assay. 
 
9.2.2 Bone mineral density by DXA –scan: lumbar spine (L1-L4) and left proximal femur, 
femur neck and left hip. 
 
9.2.3 Serum biochemical markers of bone formation and resorption by ELISA   
 
 
Markers of bone formation (Osteocalcin and P1NP).  
 
Markers of bone resorption (CTx and TRAP5b). 
 
9.2.4 Quantitation of plasma cytokines and bone regulating hormones by ELISA. 
 
 
RANKL (Osteoclast Inducer) 
 
OPG  (Osteoclast Suppressor) 
 
TNF  (Inflammatory Marker)  
 
IL-6  (Inflammatory Marker)  
 
IL-1  (Inflammatory Marker)  
 
PTH  (2 Hyperparathyroid  Marker) 
 
Vitamin D 
 
Testosterone  
 
17Estradiol 
 
9.2.5 Metabolic Function Markers 
 
 
Liver function assessed by serum levels of total bilirubin, AST (SGOT), ALT (SGPT), 
and alkaline phosphatase will be performed in real time at the local laboratory. 
 
 
Renal function assessed by creatinine clearance (Cockcroft-Gault equation). 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
38 
 
 
9.2.6 Quantitation of B cell and T cell numbers and percentage in PBMC by flow cytometry. 
 
9.2.6.1 T cell Subsets: (% and total/ml)  
 
CD3+, CD4+, CD8+, CD4+ CD25+ FoxP1+ 
 
Memory & Naive T cells Markers:  
 
Memory (CD4+ CD45RO+ CD27+) 
 
Naive (CD4+ CD45RO- CD27+; 
 
 
CD4 Activation Markers:  
 
CD4+ CD69+; CD4+ CD25+ FoxP1- 
 
 
T cell Proliferation: 
 
CD3+ Ki67+; CD4+ Ki67+; CD8+ Ki67+ 
 
 
T Cell Cytokine Expression:  
 
CD4+ RANKL; CD4+ OPG; CD4+ TNF; CD4+ IL-17; CD4+ 
CD40L, CD4+ IL-4; CD4+ IFN, CD4+ CD25+ FoxP1+ RANKL, 
CD4+ CD25+ FoxP1 OPG 
 
CD8+ RANKL; CD8+ OPG; CD8+ TNF  
 
9.2.6.2 Monocytes/M/OC Precursors (% and total/ml) --- CD14  
 
Osteoclast Precursors: (% and total/ml) --- c-Fms+ RANK+  
 
Monocyte Proliferation:---- CD14+ Ki67+ 
 
Monocyte Cytokine Expression: ---- CD14 + TNF  
 
9.2.6.3 B Cell Subsets (% and total/ml) 
 
CD19+, CD20+, B220  
 
 
Memory and Naïve B cells Markers 
 Memory (CD19+CD27+) &  
 Naïve (CD19+CD27-)  
 Immature transitional (CD10 CD21 CD27 CD27 B220)  
 Mature plasma cells (CD19low, CD38+ CD27++)  
 
 
B cell Proliferation:  
 CD19+ Ki67+; CD21+ Ki67+ 
 
 
B Cell Activation Markers:  
 CD10-, CD21low CD27+  
 
 
B Cell Cytokine Expression:  
 Memory: CD19+CD27+ RANKL; CD19+CD27+ OPG  
 Naïve: CD19+CD27- RANKL; CD19+CD27- OPG 
 Others: CD10 CD21 CD27 RANKL; CD10 CD21 CD27 OPG 
o Immature transitional B cells (CD10++CD21low  CD27-)  
o Naïve mature B cells (CD10-, CD21hi CD27-)  
o Activated mature B cells(CD10-, CD21low CD27+) 
o Exhausted tissue-like memory B cells (CD10-, CD21low CD27-) 
o Resting memory B cells (CD10-, CD21hi CD27+)  

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
39 
 
o Short-lived plasmablasts (Ki-67+CD19+CD10- CD20-CD21low 
CD27++) 
o Mature plasma cells (CD19low, CD38+ CD27++) 
o Memory subsets (CD19+CD27+B220+ and CD19+CD27+B220-) 
 
9.2.7 Quantitation of total plasma and peripheral blood B cell and T cell OPG & RANKL 
mRNA by real time RT-PCR and protein production by ELISA.  
 
9.2.8 Number, frequency and quantitation of OPG and RANKL production by B cell 
subsets and by T cell subsets (CD4 and CD8) by intracellular staining. 
 
9.3 
Detailed Description of Endpoints:  
In its current design the study is powered to detect changes in plasma levels of the bone 
marker CTx following HAART initiation and the inhibitory effect of bone resorption 
inhibitors on these changes. However, a major focus of this study is to understand the 
cellular (lymphocytic OPG/RANKL expression) changes associated with HIV/HAART 
induced bone loss and how these changes can be pharmacologically modified.    
   
9.3.1    Primary Endpoints:  
 
 
To assess HAART induced acute change in bone turnover by quantitating  
 
 
the change from baseline to week 24 in plasma level of marker of bone  
 
 
resorption (CTx) among treatment naïve HIV-infected subjects treated  
 
 
with atazanavir based HAART regimen. 
 
9.3.2 To quantitate the inhibitory effect of the long acting inhibitor of bone resorption 
(zoledronic acid) on HAART-induced change in the marker of bone resorption 
(CTx) at 24 weeks of HAART therapy.  
 
9.4 
Secondary Endpoints: 
 
9.4.1 To quantitate the change from baseline at weeks 2, 8, 12, 16, 20, 24, 36,48, 72, 96, 120, 
144 in cellular (lymphocyte subsets; B- and T-cell frequency and number/ml) and their 
production of OPG and RANKL, among treatment naïve HIV-infected subjects treated 
with atazanavir based HAART regimens. 
 
9.4.2 To evaluate the inhibitory effect of single dose zoledronic acid on HAART associated 
changes in other markers of bone turnover (Osteocalcin, P1NP, (bone formation 
markers) and TRAP5b (a marker of osteoclast activity) and BMD at appropriate study 
evaluation time points.  
 
9.4.3 To quantitate the inhibitory effect of antiresorptive (zoledronic acid) on HAART-induced 
change in cellular (lymphocyte subsets; B- and T-cell) production of OPG and RANKL at 
weeks, 2, 8, 12, 16, 20, 24, 36, 48, 72, 96, 120, and 144 of HAART therapy. 
 
9.4.4 To correlate changes in serum, and cellular (lymphocyte subsets; B- and T-cell) 
expression of OPG and RANKL with markers of bone turnover and BMD at appropriate 
study evaluation time points. 
 
9.4.5 To correlate changes in bone regulatory hormones (PTH, estrogen, testosterone, vitamin 
D) and inflammatory cytokines ( IL-1, IL-6, TNF) with serum and cellular expression of 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
40 
 
OPG/RANKL, markers of bone turnover, and BMD at appropriate study evaluation time 
points. 
 
9.4.6 To correlates changes in lymphocyte subsets; (B- and T-cell (CD4 and CD8) with bone 
turnover markers and BMD. 
 
9.5 Randomization and Stratification 
 
Subjects will be blindly assigned in equal proportions to one of the two treatment arms using 
permuted block randomization with stratification by screening HIV-1 RNA (<100,000; >100,000 
copies/mL). The purpose of the stratification is to ensure balance between treatment arms in 
terms of HIV-1 RNA status at screening. Additionally, to ensure balanced treatment allocation as 
well as balance across the three study arms in relation to age, randomization will also be stratified 
by subjects’ age (<40; > 40 years); and by sex (defined as sex at birth).  
 
9.6 Sample Size Estimation:  
 
As osteoclastic differentiation and activity is largely a function of the RANKL/OPG ratio we 
speculate that these cytokines will be related to plasma levels of the markers of bone resorption 
such as CTx. As there are no comparable published studies of the impact of HAART on cellular 
expression of bone regulating cytokines in treatment naïve HIV-infected subjects, Power 
estimation is based on preliminary data from a recent unpublished study from our group. In this 
study, we examined biochemical markers of bone resorption CTx and serum OPG concentrations 
in treatment naïve HIV/AIDS patients (n=9) at baseline and prospectively at 2, 12 and 24 weeks of 
treatment with lopinovir/ritonavir + tenofovir/emtricitabine. The observed mean serum CTx level at 
baseline was 3.29 ug/L. The observed change of serum CTx from baseline to 24 weeks was 2.06 
µg/L, approximately a 60% increase (observed SD of change = 1.37 µg/L).  Because the sample 
size for the above referenced unpublished work is small, and as such variability around mean 
change is wide, we have assumed a more conservative change in serum CTx with HAART in the 
design of the current study. Table 4 shows sample size required to detect changes in serum CTx 
from baseline to week 24. Setting  level at 0.05 and using a 2-sided one-sample t-test on the 
difference of means, a sample size of 31 subjects in the HARRT arm will achieve 90% statistical 
power to detect a mean change of 0.85 (20% change from baseline; effect size = 0.6) in serum 
CTx from baseline to week 24. The standard deviation estimate for the change used in the power 
calculation is 1.4. 
 
Table 4: Power needed to detect increase in CTx from baseline to week 24 of HAART in 
treatment naïve HIV patients 
 
Power 
Mean change (µg/L) 
% change 
Effect size 
Sample size 
1 
90% 
0.40 
10% 
0.3 
131 
2 
85% 
0.40 
10% 
0.3 
112 
3 
80% 
0.40 
10% 
0.3 
99 
4 
90% 
0.55 
14% 
0.4 
71 
5 
85% 
0.55 
14% 
0.4 
61 
6 
80% 
0.55 
14% 
0.4 
53 
7 
90% 
0.70 
17% 
0.5 
44 
8 
85% 
0.70 
17% 
0.5 
38 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
41 
 
9 
80% 
0.70 
17% 
0.5 
34 
10 
90% 
0.85 
20% 
0.6 
31 
11 
85% 
0.85 
20% 
0.6 
27 
12 
80% 
0.85 
20% 
0.6 
24 
 
Similarly as shown in table 5, a sample size of 31 subjects per arm will achieve a statistical power 
of 90% to detect a difference of 1.20 ug/L in serum CTx between HAART alone or HARRT + 
zoledronic acid at week 24 of HAART (=0.05; using a 2-sided 2-sample t-test). Observed change 
in serum CTx from baseline to 24 weeks (2.06 µg/L) was used to estimate mean change for the 
HAART + placebo group. Observed SD (1.4 µg/L) was used as an estimate of standard deviation 
for both groups. Given an attrition rate of 50% in due to the prolonged duration of the study, 94 
total subjects may be needed to achieve the desired sample size (47 in each of 2 groups). The 
sample size was estimated by PASS 2008 software. No formal interim analyses are planned for 
this trial. 
 
Table 5: Power estimation for mean difference in serum CTx between treatment arms 
 
Power 
Mean increase: 
HAART/Placebo 
Mean increase: 
HAART/Reclast 
Detectable 
difference (µg/L) 
Sample size (per 
group) 
1 
90% 
2.00 
2.80 
0.80 
66 
2 
85% 
2.00 
2.80 
0.80 
56 
3 
80% 
2.00 
2.80 
0.80 
50 
4 
90% 
2.00 
3.00 
1.00 
43 
5 
85% 
2.00 
3.00 
1.00 
37 
6 
80% 
2.00 
3.00 
1.00 
32 
7 
90% 
2.00 
3.20 
1.20 
30 
8 
85% 
2.00 
3.20 
1.20 
26 
9 
80% 
2.00 
3.20 
1.20 
23 
 
9.7 Statistical Analyses:  
 
9.7.1 
General Analysis Consideration: 
 
Unless otherwise specified, analyses will be carried out with an intention-to-treat (ITT) 
approach where subjects will be analyzed as randomized.  All analyses will use a 5% type 
I error for significance testing and present data with 95% confidence intervals.  
 
Continuous variables (e.g., OPG and RANKL, etc) will be summarized with standard 
descriptive statistics and represented graphically with displays such as scatterplots while 
categorical variables will be described by frequency tables. The appropriate distributional 
assumptions will be checked. The data will be transformed for the analysis, if necessary.  
Prior to implementation of simple linear regression to investigate the relationship between 
outcomes and predictor variables of interest, all assumptions will be assessed. 
Scatterplots and residual analyses will be used to help assess nonlinearity of the 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
42 
 
relationship and the appropriateness of the assumptions of normality for each outcome 
and constant variance of the outcome.  If these assumptions are violated, alternative 
methods such as data transformations (e.g., natural log) or the use of nonparametric 
regression such as Spearman rank correlation coefficient, kernel smoothing, spline fitting 
and LOESS techniques will be used.   
 
9.7.2 
Baseline and cross-sectional analyses:  
 
Mean CTx level, BMD, OPG and RANKL will be compared between groups at baseline 
using ANOVA to ensure comparability between groups. Standard demographic and clinical 
variables (viral load, CD4 count, age, sex, race, etc.) will also be compared between 
groups at baseline. 
 
Cross-sectional analyses will be performed with baseline CTx level, BMD, OPG and 
RANKL variables. Simple linear regression will be used to investigate the relationship 
between these outcomes and predictor variables of interest, such as age, gender, race 
and BMI.  
 
Additionally, a cross-sectional analysis will be performed comparing baseline markers of 
bone turnover of HIV-positive patients in this study to similar data collected from an HIV-
negative cohort study (Emory University IRB Study # 00027210). Analysis of covariance 
(ANCOVA) will be used to compare the HIV-negative patients and HIV-positive patients. 
Initially, we will assume that each outcome (e.g., CTx, BMD, OPG and RANKL) can be 
expressed as a linear function of age (X, covariate) with possible different slopes and 
intercepts for each subgroup. Assuming a common linear slope model is justified by our 
analyses, an age-adjusted mean will be estimated for each outcome (CTx, BMD, OPG and 
RANKL). An age-adjusted mean of the HIV-negative or HIV-positive group will be defined 
as the predicted response value obtained by evaluating the regression equation for each 
group at the mean age for the 2 groups. 
 
9.7.3 
Initial exploratory analyses of CTx versus RANKL over time, by treatment group: 
 
The rate of change in longitudinally obtained measurements will be determined by a linear 
mixed effects model (a random-coefficients model) in which the regression of CTx on time 
is assumed to be linear, with a random intercept and slope for each patient (fit for each 
treatment group). The same regression model will be fit for RANKL. We expect to see a 
linear relationship over time for CTx and RANKL for the HAART treatment group but we 
not expect to see a linear relationship for the other two treatment groups. Assuming there 
will be a linear relationship with time for the two endpoints (CTx and RANKL) for the 
HAART group we will fit the random coefficients model in which the regression of CTx on 
RANKL is assumed to be linear with a random intercept and slope for each patient.   
 
To estimate the correlation between the rates of change in CTx and RANKL, a bivariate 
linear random-effects will be fit allowing estimation of the correlation between the true 
underlying intercepts and slopes for CTx and RANKL. 
 
9.7.4 
Change over time in markers of bone turnover and BMD, within and between groups: 
 
Mean change in bone markers and BMD from baseline to weeks 2, 8, 12, 16, 20, 24, 36, 
48, 72, 96, 120, and 144 their 95% confidence intervals will be estimated for each of the 
treatment arm. Change over time will be assessed using an analysis of repeated 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
43 
 
measures data to properly account for the correlation between multiple observations from 
the same patient. Two commonly used models to analyze such data will be employed: the 
mixed-effects model and the generalized estimating equations (GEE) approach proposed 
by Liang and Zeger (1986). Both approaches allow for covariate adjustment. The results 
will be summarized with adjusted means and 95% confidence intervals for continuous 
outcomes. The GEE methodology can also be used to perform logistic regression of 
repeated binary responses within patients. 
 
Repeated-measures analyses, using mixed linear models will be performed for bone 
markers (listed in section 9.2) and percent change from baseline with a means model 
using SAS Proc Mixed (version 9) providing separate estimates of the means by time on 
study (2, 8, 16 weeks etc) and treatment group.  A compound symmetry variance-
covariance form among the repeated measurements from each treatment group will be 
assumed for each outcome, and robust estimates of the standard errors of parameters 
(Diggle et al.) will be used to perform statistical tests and construct confidence intervals.  
The model-based means are unbiased with unbalanced and missing data, as long as the 
missing data are non-informative (missing at random – see Shih JW). Statistical tests will 
be 2-sided. A P value ≤ 0.05 will be considered statistically significant for the main effects 
(time effect and treatment group effect) and the statistical interaction between treatment 
group and time on study from the repeated measures analysis for each outcome. A 
Bonferroni adjustment will be used for the pairwise comparisons at each time point if there 
is a statistically significant interaction between treatment and time on study since the main 
effects are not directly interpretable in the presence of a statistical interaction. Results 
from these models will focus on the magnitude of the differences. Data will be summarized 
using adjusted means plus 95% confidence intervals and observed mean differences plus 
95% confidence intervals.  Since the sample sizes will be small for each subgroup we will 
focus the interpretation on the magnitude of the mean differences and confidence 
intervals.  
 
A potential problem in any of the above analyses is missing data, as missing data may 
cause the usual statistical analysis of complete or all available data to be subject to bias. 
Every effort will be made to minimize missing data on outcomes and covariates. The 
required follow-up for this clinical trial is 144-weeks and we expect listed lost to follow-up 
(<10%) for the primary endpoints. There are no universally applicable methods for 
handling missing data. If missing data becomes an issue then we will conduct sensitivity 
analyses to encompass different scenarios of assumptions and discuss consistency or 
 
9.7.5 
Amendment to Statistical Analysis:  
 
This double-blind, placebo-controlled, 2-group parallel clinical study was originally 
designed as a fixed sample size ITT trial and each patient was to be followed for 144 
weeks after randomization. We have decided to change the design of the study and follow 
all randomized subjects for the first 24 weeks at which point the study will be unblinded to 
study team, data analyzed and findings published. We will however continue to follow all 
enrolled patients as a cohort for the originally planned 144 weeks study duration. 
 
 
10 EXPECTED OUTCOMES AND INTERPRETATION OF DATA 
 
Based on our preliminary data in rats we hypothesis that a switch in B cell OPG to RANKL production 
during HIV/AIDS progression will lead to increased osteoclastic bone resorption and diminished BMD. The 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
44 
 
expected outcome is thus that HIV-infected individuals will display diminished BMD that correlates 
positively with decreased total plasma and B cell OPG, and increased indices of bone resorption (CTx and 
TRAP5b). Diminished BMD is expected to correlate positively with increased plasma and B cell and/or T 
cell RANKL and the latter positively with bone resorption markers. We further anticipate that baseline CD4 
T-cell counts and plasma HIV-RNA PCR (both surrogates of disease severity) will correlate positively 
(possible linearly) with the magnitude of bone loss and with indices of bone resorption (CTx and TRAP5b) 
and with plasma and B cell and/or T cell RANKL production. We expect that plasma HIV-RNA PCR will 
correlate negatively with plasma OPG and B cell OPG production and with total B cell (and/or T cell) 
number.  
 
Based on our preliminary data in human, we also expect acute exacerbation of bone turnover following 
initiation of HAART. Thus pre-existing diminished BMD associated with HIV-infection will be further 
diminished at the onset of antiretroviral therapy. We speculate that the mechanism of HAART induced 
bone loss may be mediated through either direct effect on bone cells, or through indirect effect on 
metabolism related to disease reversal and immune reconstitution. We therefore expect HAART related 
bone loss to correlates positively with decreased total plasma and B cell OPG, and increased indices of 
bone resorption (CTx and TRAP5b). Diminished BMD in the setting of HAART is also expected to correlate 
positively with increased plasma and B cell and/or T cell RANKL and the latter positively with bone 
resorption markers. Because the effect of HAART on bone homeostasis occurs early in therapy, we 
anticipate a complete reversal or amelioration of this effect with long-acting inhibitors of bone resorption. 
 
An additional outcome that is consistent with our hypothesis is that a specific B cell population or 
subpopulation may correlate with decreased OPG production and/or increased RANKL production. For 
example there is reported to be a relative increase in immature translational B cells, activated mature B 
cells, exhausted memory B cells and plasmablasts with HIV viremia and these cells may account for 
RANKL production. By contrast naïve mature B cells, resting memory B cells and CD27+ B220- are 
diminished and could account for decreased OPG production. Alternatively, altered cell function and not 
absolute number could explain these differences. We may also find that specific subtypes of B cells make 
both RANKL and OPG or that different cell types make either RANKL or OPG. If such outcomes correlate 
strongly the percentage of the relevant B cell subtypes may be a useful diagnostic marker for predicting, 
and intervening to prevent, the future development of bone loss in HIV patients.   
 
T cells are known to secrete RANKL and could contribute RANKL to the final state, although the decline in 
T cells with viremia would be expected to eventually moderate any such effect. Consequently RANKL 
production may correlate positively with T cell numbers but negatively with viremia. As T cells are known to 
regulate B cells functions, including OPG production and given their importance as a target of HIV action, 
our basic analysis of T cell number and function may provide important information relevant to our 
hypothesis and to inform future studies. 
 
11 DATA COLLECTION, MONITORING AND ADVERSE EXPERIENCE REPORTING 
 
11.1 
Records to Be Kept 
 
CRFs will be provided for each subject. Subjects will not be identified by name on any CRFs. 
Subjects will be identified by the participant identification number (PID) and study identification 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
45 
 
number (SID) provided by the study Data Manager upon registration. 
 
11.2 
Role of Data Management 
 
11.2.1 Instructions concerning the recording of study data on CRFs will be provided by the 
study Data Management Coordinator. 
 
11.2.2 It will be the responsibility of the Data Management Coordinator to assure the quality of 
computerized data. This role extends from protocol development to generation of the 
final study databases. 
 
11.2.3 A centralized, secured, web-based relational database for data acquisition and storage 
will be developed for the BLIR-HIV clinical trial.  Study investigators and biostatistics 
personnel will work jointly to develop paper versions of Case Report Forms (CRF’s) for 
the study.  The data will be entered into electronic case report forms (eCRF) and saved 
in a database using web services.  Microsofts’ Structured Query Language (MS SQL) 
server 2000 database will be used for data collection and storage.  All data will be 
maintained in a database that is fully compliant with Emory University’s HIPAA policy 
and is subject to audit by the University Compliance Office.  Data checks will be done at 
time of data entry and a data audit trail will track changes made to the database.  Data 
validation including valid codes, chronological date checks, value ranges and integrity 
checks will be performed on eCRF as data are entered.  A comparison tool will be used 
to ensure data quality and accuracy.  Database edit checking programs will check data 
for data completeness of each CRF, check for validity between forms, and check 
whether these data were collected and key-entered in the study protocol’s prescribed 
time frame.  Data access and security rules will be established for all study personnel.  
Data reports will be generated each month to identify missing or extreme values using 
the database query engine and SAS software tools.  These reports will be sent to the 
study coordinator who will verify data with source documents; errors will then be 
corrected and logged in the master database. 
 
11.2.4 The data entry screens of the application will mimic the paper Case Report Forms for 
efficient data entry. The data entry forms will be GUI – based- with list boxes, radio-
buttons, check boxes, and formats for data fields.  The GUI-based forms will make data 
entry simple, fast and minimize error. 
 
11.3 
Clinical Site Monitoring and Record Availability 
 
11.3.1 Clinical site monitors may be performed by the Emory University IRB, FDA or other 
government regulatory authorities, OHRP, or pharmaceutical supporters. Clinical 
research sites monitor may include the review of the individual participant records, 
including consent forms, CRFs, supporting data, laboratory specimen records, and 
medical records (physicians’ progress notes, nurses’ notes, individuals’ hospital charts) 
to ensure protection of study participants, compliance with the protocol, and accuracy 
and completeness of records. The monitors may also inspect sites’ regulatory files to 
ensure that regulatory requirements are being followed and sites’ pharmacies to review 
product storage and management. 
 
11.3.2 The investigator will make study documents (e.g., consent forms, drug distribution forms, 
CRFs) and pertinent hospital or clinic records readily available for inspection by the local 
IRB, the OHRP, or the pharmaceutical supporter or the supporter’s designee for 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
46 
 
confirmation of the study data. 
 
11.4 
Expedited Adverse Event Monitoring and Reporting  
 
Adverse events (AEs) will be reported on an expedited basis at the standard level during the 
protocol-defined expedited adverse event (EAE) Reporting Period, which is the entire study 
duration for an individual subject (from study enrollment until study completion or 
discontinuation of the subject from study participation for any reason). 
 
11.4.1 AE Reporting 
 
Any AE that is reported to either the investigators or their designated research 
associates by a study subject or by medical staff caring for the subject and which meets 
the criteria will be documented.   
 
In addition, clinical investigators will monitor subjects for AEs and laboratory 
abnormalities during each study visit. Any AE will be reported to the Emory University 
IRB within 10 days of the event, and any serious adverse event (SAE) will be reported to 
the IRB within 24-48 hours of the event.  The standard Emory IRB reporting guidelines 
for AE and SAE reporting, as documented at 
http://www.emory.edu/IRB/guidelines_adverse_event.php, will be followed.   
 
A SAE is an adverse drug experience that results in any of the following outcomes: 
 Death. 
 Life-threatening situation - The subject was at risk of death at the time of the 
adverse event/experience.  It does not refer to the hypothetical risk of death if the 
AE were more severe or were to progress. 
 Inpatient hospitalization or prolongation of existing hospitalization. 
 Persistent or significant disability/incapacity - Any AE having an outcome that is 
associated with a substantial disruption of the ability to carry out normal life 
functions, including the ability to work.  This is not intended to include transient 
interruption of daily activities. 
 Congenital anomaly/birth defects - Any structural abnormality in subject’s 
offspring that occurs after intrauterine exposure to treatment. 
 Important medical events/experiences that may not result in death, be life-
threatening, or require hospitalization may be considered a serious adverse 
event/experience when, based upon appropriate medical judgment, they may 
jeopardize the subject and may require medical or surgical intervention to 
prevent one of the outcomes listed above, i.e., death, a life-threatening adverse 
event/experience, inpatient hospitalization or prolongation of existing 
hospitalization, a persistent or significant disability/incapacity, or a congenital 
anomaly/birth defect.  Examples of such medical events/experiences include 
allergic bronchospasm requiring intensive treatment in an emergency room or at 
home, blood dyscrasias or convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug abuse. 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
47 
 
 Spontaneous and elective abortions will be reported to the Emory IRB as serious 
adverse events.  
 
Severity of AEs will be rated according to the following definitions: 
 
Table 8. Severity of Adverse Events Rating 
Mild: 
The adverse event is transient and easily tolerated by 
the subject. 
Moderate: 
The adverse event causes the subject discomfort and 
interrupts the subject’s normal activities. 
Severe: 
The adverse event causes considerable interference 
with the subject’s normal activities and may be 
incapacitating or life-threatening. 
 
The following definitions will be used to assess the relationship of the AE to study 
drugs: 
 
Table 9. Relationship of Adverse Events to Study Medications  
Probably 
Related: 
An adverse event has a strong temporal relationship 
to study drug or recurs on re-challenge, and another 
etiology is unlikely or significantly less likely. 
Possibly 
Related: 
An adverse event has a strong temporal relationship 
to the study drug, and an alternative etiology is 
equally or less likely compared to the potential 
relationship to study drug. 
Probably Not 
Related: 
An adverse event has little or no temporal 
relationship to the study drug and/or a more likely 
alternative etiology exists. 
Not Related: 
An adverse event is due to an underlying or 
concurrent illness or effect of another drug and is not 
related to the study drug (e.g., has no temporal 
relationship to study drug or has much more likely 
alternative etiology). 
If the adverse event is in, the investigator’s opinion, possibly or probably related, or not 
related to study drug, then an alternate etiology will be provided by the investigator. 
  
It should however be noted that a SAE/experience is not necessarily serious, as the term 
severe is a measure of intensity while a serious adverse event is determined based on 
the aforementioned regulatory criteria. 
 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
48 
 
All AEs and laboratory abnormalities will be graded according to the Division of AIDS 
Table for Grading the Severity of Adult and Pediatric Adverse Events (DAIDS AE 
Grading Table), Version 1.0, December 2004, which can be found on the DAIDS RCC 
Web site: http://rcc.tech-res.com/tox_tables.htm.  All AEs will be followed to satisfactory 
clinical resolution as previously described in section 7.1.   
 
12 HUMAN SUBJECTS 
 
12.1 
Responsibilities of the Investigator 
 
In implementing this protocol, the investigators will adhere to the basic principles of “Good 
Clinical Practice” as outlined in CFR 312, subpart D, “Responsibilities of Sponsors and 
Investigators,” CFR 21, part 50 and CFR 21, part 56 and Section 4 of ICH Harmonized Tripartite 
Guideline for GCP.  
 
12.2 
IRB Review and Informed Consent  
 
This protocol and the informed consent document and any subsequent modifications will be 
reviewed and approved by the Emory University IRB. A signed consent form will be obtained 
from the subject (or parent, legal guardian, or person with power of attorney for subjects who 
cannot consent for themselves). The consent form will describe the purpose of the study, the 
procedures to be followed, and the risks and benefits of participation. A copy of the consent 
form will be given to the subject, parent, or legal guardian, and this fact will be documented in 
the subject’s record. 
 
12.3 
Subject Confidentiality 
 
All laboratory specimens, evaluation forms, reports, and other records that leave the site will be 
identified by coded number only to maintain subject confidentiality. All records will be kept 
locked. All computer entry and networking programs will be done with coded numbers only. 
Clinical information will not be released without written permission of the subject, except as 
necessary for monitoring by IRB, the OHRP, or the pharmaceutical supporter or the supporter’s 
designee. 
 
12.4 
Data Safety Monitoring 
 
Summaries of deaths, AEs (Grade 3 or 4), and targeted AEs across arms as well as study 
conduct (in terms of off-study rates, off-treatment rates, and data completeness) will be 
reviewed on a regular basis by the study investigators. Any AE will be reported to the Emory 
University IRB within 10 days of the event, and any serious adverse event (SAE) will be 
reported to the IRB within 24-48 hours of the event.  The standard Emory IRB reporting 
guidelines for AE and SAE reporting, as documented at 
http://www.emory.edu/IRB/guidelines_adverse_event.php, will be followed.    
 
The tolerability of zoledronic acid in HIV infected patients on HAART was recently documented in 
two large randomized clinical trials [17, 18]. No SAEs or acute AEs specifically due to the study drug 
infusion are expected in the current study.  However, additional safety monitoring will be performed 
annually by an independent Medical Safety Monitor.  Based on the 3 year accrual expectation for 
the study, it is anticipated that the study will undergo 3 reviews by the Medical Safety Monitor.  
The first will occur approximately one year after the accrual of the first subject.  The Data 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
49 
 
Coordinating Center (DCC) will produce a safety report for the Medical Safety Monitor to 
review.  The safety report will summarize AEs, SAEs, and lab toxicities by blinded treatment 
group.  The DCC will work with the Medical Safety Monitor to complete a ‘final assessment’ 
following the review of each safety report.  As part of the final assessment the Medical Safety 
Monitor will conclude ‘the study can continue as no safety concerns have been identified at the 
time of the review’ or ‘the study cannot continue as currently designed’.  The final assessment 
by the Medical Safety Monitor will be provided to the study PI who will make the findings 
available as appropriate to the Emory IRB, the FDA, and the NIH. 
 
 
12.5 
Study Discontinuation 
 
The study may be discontinued at any time by the IRB, the pharmaceutical supporter, the 
OHRP, or other government agencies as part of their duties to ensure that research subjects 
are protected.  
 
12.6 
Potential Benefits of the Proposed Research to the Subjects and Others  
 
The immediate benefit of the study to the subjects is uncertain at this time, however, 
osteoporotic patients may be identified and treated early. The knowledge gained in this research 
proposal is very important as the underlying mechanisms that cause osteoporosis in treatment 
naïve HIV/AIDS patients remains completely unknown. As the mean age of the HIV/AIDS 
population continues to trend upwards impaired bone turnover is likely to lead to an onslaught of 
fractures in the future as age-associated effects on bone mass combine with virally induced 
factors compounding bone loss.  A considerable amount of pre-clinical data has been generated 
in mice to support our hypothesis that the B cell plays a cardinal role in protection against 
osteoporosis and that B cell aberrations associated with HIV effects on the immune system may 
be the driving force behind HIV-associated osteoporosis.  However, this pre-clinical information 
has not yet been translated to humans.  This research project is an important first step into 
human investigation of B cells and their role in HIV/HAART associated osteoporosis. The 
potential benefit of long-acting inhibitors of bone resorption in the setting of HIV/HAART related 
bone loss will be tested.  The risk to the individual subject is minimal to moderate while the 
benefit to the future standard of care of HIV/AIDS patients may be very large.  
 
13 PUBLICATION OF RESEARCH FINDINGS 
 
Any presentation, abstract, or manuscript will be made available for review by the pharmaceutical 
supporters and other sponsors (if requested) prior to submission. 
 
14 BIOHAZARD CONTAINMENT 
 
As the transmission of HIV and other blood-borne pathogens can occur through contact with contaminated 
needles, blood, and blood products, appropriate blood and secretion precautions will be employed by all 
personnel in the drawing of blood and shipping and handling of all specimens for this study, as currently 
recommended by the Centers for Disease Control and Prevention and the National Institutes of Health. 
 
All infectious specimens will be transported using packaging mandated in the Code of Federal Regulations, 
42 CFR Part 72, and as specified by individual carrier guidelines, e.g., Federal Express, Airborne Express, 
for specific instructions. 
 
15 STUDY DURATION/TIMELINE    

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
50 
 
 
Subjects enrolled in this study will be followed for a total period of 144 weeks. We anticipate the duration of 
this study from beginning of accruement to completion to be 5 years.  
 
16 STUDY SPONSOR  
 
This study is sponsored by the grant awarded by National Institute of Health (#1R01AR059364-01 and 
1R01AG40013-1A1). Study medication (zoledronic acid: reclast®) is provided by Novartis.  
 
17 FUTURE DIRECTION 
 
The fact that treatment naïve HIV-1 patients develop low BMD, compounded by treatment with Specific 
formulations of HAART is now well established. However, the mechanisms responsible remain undefined 
and enigmatic. Based on our pre-clinical preliminary studies we anticipated that we will ratify a specific 
mechanism underlying the bone loss present in treatment naïve HIV/AIDS patients involving an imbalance 
in the RANKL/OPG ratio, a direct consequence of a switch in OPG to RANKL production by B cells and 
possible RANKL production though activated T cells. We further hope to identify specific populations of B 
cells responsible for this effect. Should this be the outcome future investigations will test the utility of 
utilizing changes in B cell number, function or subsets, as a diagnostic test for the development of 
osteoporosis and for increased fracture risk in those groups of patients. Long term goals will be the 
restoration of bone protective immune cell populations and/or restoration of normal bone turnover, using 
pharmacological or other means.   

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
51 
 
18.  REFERENCES 
1. Guaraldi G, Ventura P, Albuzza M, Orlando G, Bedini A, Amorico G, Esposito R 2001 Pathological 
fractures in AIDS patients with osteopenia and osteoporosis induced by antiretroviral therapy. Aids 
15(1):137-8. 
2. Manolagas SC, Jilka RL 1995 Bone marrow, cytokines, and bone remodeling. Emerging insights into 
the pathophysiology of osteoporosis. N Engl J Med 332(5):305-11. 
3. Teitelbaum SL 2000 Bone resorption by osteoclasts. Science 289(5484):1504-8. 
4. Li Y, Toraldo G, Li A, Yang X, Zhang H, Qian WP, Weitzmann MN 2007 B cells and T cells are critical 
for the preservation of bone homeostasis and attainment of peak bone mass in vivo. Blood 
109(9):3839-3848. 
5. Gallant JE, Staszewski S, Pozniak AL, DeJesus E, Suleiman JM, Miller MD, Coakley DF, Lu B, Toole 
JJ, Cheng AK 2004 Efficacy and safety of tenofovir DF vs stavudine in combination therapy in 
antiretroviral-naive patients: a 3-year randomized trial. Jama 292(2):191-201. 
6. Mallon PW, Miller J, Cooper DA, Carr A 2003 Prospective evaluation of the effects of antiretroviral 
therapy on body composition in HIV-1-infected men starting therapy. Aids 17(7):971-9. 
7. Tebas P, Umbleja  T, Dube  MP, Parker R, Mulligan K, Roubenoff R, Robbins G, Grinspoon S 2007 
Initiation of ART is associated with bone loss independent of the specific ART regimen: Results of 
ACTG A5005s. 14th Conference on Retroviruses and Opportunistic Infections:837. 
8. Brown TT, Qaqish RB 2006 Antiretroviral therapy and the prevalence of osteopenia and osteoporosis: a 
meta-analytic review. AIDS 20(17):2165-74. 
9. Wang MW, Wei S, Faccio R, Takeshita S, Tebas P, Powderly WG, Teitelbaum SL, Ross FP 2004 The 
HIV protease inhibitor ritonavir blocks osteoclastogenesis and function by impairing RANKL-induced 
signaling. J Clin Invest 114(2):206-13. 
10. Fakruddin JM, Laurence J 2003 HIV envelope gp120-mediated regulation of osteoclastogenesis via 
receptor activator of nuclear factor kappa B ligand (RANKL) secretion and its modulation by certain HIV 
protease inhibitors through interferon-gamma/RANKL cross-talk. J Biol Chem 278(48):48251-8. 
11. Dube MP, Qian D, Edmondson-Melancon H, Sattler FR, Goodwin D, Martinez C, Williams V, Johnson 
D, Buchanan TA 2002 Prospective, intensive study of metabolic changes associated with 48 weeks of 
amprenavir-based antiretroviral therapy. Clin Infect Dis 35(4):475-81. 
12. Mondy K, Yarasheski K, Powderly WG, Whyte M, Claxton S, DeMarco D, Hoffmann M, Tebas P 2003 
Longitudinal evolution of bone mineral density and bone markers in human immunodeficiency virus-
infected individuals. Clin Infect Dis 36(4):482-90. 
13. Nolan D, Upton R, McKinnon E, John M, James I, Adler B, Roff G, Vasikaran S, Mallal S 2001 Stable or 
increasing bone mineral density in HIV-infected patients treated with nelfinavir or indinavir. Aids 
15(10):1275-80. 
14. Duvivier C, Kolta S, Assoumou L, Ghosn J, Rozenberg S, Murphy RL, Katlama C, Costagliola D 2009 
Greater decrease in bone mineral density with protease inhibitor regimens compared with 
nonnucleoside reverse transcriptase inhibitor regimens in HIV-1 infected naive patients. Aids 27(7):817-
24. 
15. Black DM, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA, et al. Once-yearly zoledronic acid for 
treatment of postmenopausal osteoporosis. N Engl J Med 2007; 356:1809–1822. 
16. Reid IR, Brown JP, Burckhardt P, Horowitz Z, Richardson P, Trechsel U, et al. Intravenous zoledronic 
acid in postmenopausal women with low bone mineral density. N Engl J Med 2002; 346:653–661. 
17. Bolland MJ, Grey AB, Horne AM, Briggs SE, Thomas MG, Ellis- Pegler RB, et al. Annual zoledronate 
increases bone density in highly active antiretroviral therapy-treated human immunodeficiency virus-
infected men: a randomized controlled trial. J Clin Endocrinol Metab 2007; 92:1283–1288. 
18. Huang J, Meixner L, Fernandez S, McCutchan JA. A double-blinded, randomized controlled trial of 
zoledronate therapy for HIV-associated osteopenia and osteoporosis. AIDS. 2009;23(1):51-7. 
19. Delmas PD. Clinical potential of RANKL inhibition for the management of postmenopausal osteoporosis 
and other metabolic bone diseases. J Clin Densitom 2008;11:325-38. 
20. Cummings SR, San Martin J, McClung MR, et al. Denosumab for prevention of fractures in 

PI: Igho Ofotokun, MD, MSc. 
Associate Professor of Medicine, Emory University. 
iofotok@emory.edu.  
52 
 
postmenopausal women with osteoporosis. N Engl J Med. 2009 Nov 5;361(19):1914. 
21. Bone HG, Bolognese MA, Yuen CK, et al. Effects of denosumab on bone mineral density and bone 
turnover in postmenopausal women. J Clin Endocrinol Metab 2008;93:2149-57. 
22. Lewiecki EM, Miller PD, McClung MR, et al. Two-year treatment with denosumab (AMG 162) in a 
randomized phase 2 study of postmenopausal women with low BMD. J Bone Miner Res 2007;22:1832-
41. 
23. McClung MR, Lewiecki EM, Cohen SB, et al. Denosumab in postmenopausal women with low bone 
mineral density. N Engl J Med 2006;354:821-31. 
24. Miller PD, Bolognese MA, Lewiecki EM, et al. Effect of denosumab on bone density and turnover in 
postmenopausal women with low bone mass after long-term continued, discontinued, and restarting of 
therapy: a randomized blinded phase 2 clinical trial. Bone 2008;43:222-9. 
25. Chesney MA, Ickovics JR, Chambers DB, et al. Self-reported adherence to antiretroviral medications 
among participants in HIV clinical trials: the AACTG adherence instruments. Patient Care Committee & 
Adherence Working Group of the Outcomes Committee of the Adult AIDS Clinical Trials Group 
(AACTG). AIDS Care 2000; 12:255–66.