Safety and Efficacy of Sirolimus for HIV Reservoir Reduction in Individuals on Suppressive Antiretroviral Therapy
Phase: PHASE1
Conditions: HIV-1 Infection
Sponsor: Advancing Clinical Therapeutics Globally for HIV/AIDS and Other Infections

A5337 
 
Safety and Efficacy of Sirolimus for HIV Reservoir 
Reduction in Individuals on Suppressive Antiretroviral 
Therapy 
 
A Multicenter Trial of the AIDS Clinical Trials Group (ACTG) 
 
 
DAIDS ES # 11981 
 
 
This file contains the current ACTG A5337 protocol, which 
includes the following document:  
 
• Letter of Amendment #1, dated 26 January 2017 
• Clarification Memorandum #2, dated 20 December 2016 
• Clarification Memorandum #1, dated 4 October 2016 
• Protocol Version 2.0, dated 18 July 2016  
 

 
 
Letter of Amendment #1 
          Page 1 of 2 
26 January 2017 
ACTG A5337 Protocol Version 2.0 
 
Letter of Amendment #1 for: 
 
A5337 
 
Safety and Efficacy of Sirolimus for HIV Reservoir Reduction in Individuals on 
Suppressive Antiretroviral Therapy 
 
A Limited Center Trial of the AIDS Clinical Trials Group (ACTG) 
 
DAIDS ES # 11981 
 
Letter of Amendment Date: 26 January 2017 
 
 
ACTG Network Coordinating Center 
Social & Scientific Systems, Inc. 
 
 
 
 
Phone: (301) 628-3000 
8757 Georgia Avenue, 12th Floor 
 
 
 
 
Fax: 
(301) 628-3302 
Silver Spring, MD  20910 
 
LETTER OF AMENDMENT 
 
 
DATE:  
January 26, 2017 
 
TO: 
 
ACTG CTU Principal Investigators, CRS Leaders, and CTU/CRS Coordinators 
 
FROM: 
A5337 Protocol Team  
 
SUBJECT: 
Letter of Amendment #1 for Protocol A5337, Version 2.0, 07/18/16, entitled 
“Safety and Efficacy of Sirolimus for HIV Reservoir Reduction in Individuals on 
Suppressive Antiretroviral Therapy.”  
 
The following information impacts the A5337 study and must be forwarded to your 
institutional review board (IRB)/ethics committee (EC) as soon as possible for their 
information and review. Sites must follow the guidance of their IRB/EC.  
 
The following information may also impact the Sample Informed Consent. Your IRB/EC will 
be responsible for determining the process of informing participants of the contents of this 
Letter of Amendment (LOA). 
 
Sites are still required to submit an LOA registration packet to the DAIDS Protocol 
Registration Office (PRO) at the Regulatory Support Center. Sites will receive a registration 

 
Letter of Amendment #1 
          Page 2 of 2 
26 January 2017 
ACTG A5337 Protocol Version 2.0 
notification for the LOA once the DAIDS PRO verifies that all the required LOA registration 
documents have been received and are complete. An LOA registration notification from the 
DAIDS PRO is not required prior to implementing the LOA. A copy of the LOA registration 
notification along with this letter and any IRB/EC correspondence should be retained in the 
site’s regulatory files. 
 
The main purpose of this amendment is to allow sirolimus study medication to be continued in 
study participants while awaiting the results of a prompt Safety Monitoring Committee (SMC) 
review of specific adverse events. 
 
9.5  
Monitoring, second paragraph 
At the earlier of a) approximately 6 months after the first participant begins study treatment and 
b) after 12 participants have reached 12 weeks of study treatment, a Study Monitoring 
Committee (SMC) will be convened to review the study data and progress according to ACTG 
Standard Operating Procedures. The SMC will review accrual, participant characteristics, AE 
summaries (and listings detailing each team decision as to the relationship of the AE to study 
treatment), sirolimus dosages and trough levels (in particular for any participant with a Grade 3 
or higher AE), CD4+ cell counts and HIV-1 RNA levels/suppression over time, off-treatment and 
off-study rates (and reasons) and completeness of sample availability. In addition, if there are 
any Grade 4 AEs or greater than three Grade 3 AEs attributed to study treatment in two or more 
participants per section 9.2.1.1, sirolimus use in all participants will be stopped and an SMC 
safety review will be conducted and a conference call held if deemed necessary by the 
SMC within 7 business days of receiving the safety report from the team. Sirolimus use 
in participants will continue while the SMC safety review is conducted. The SMC review 
will include an assessment of the safety of the continued use of sirolimus by study 
participants as well as deliberations regarding other modifications to the study to assure 
the safety of the participants. With respect to monitoring AEs, any lipid laboratory 
value/abnormality will be considered as a single event, rather than separate events for each 
individual test (including fasting triglycerides, LDL, and total cholesterol). An SMC review will 
also be triggered if more than 25% of participants (evaluating at least 12 participants, e.g., 
greater than 3 of 12) discontinue study treatment due to AEs or other side effects attributable to 
study drug; the therapeutic duration of the trial might be reduced to 12 weeks or otherwise 
modified following SMC review. Subsequent SMC reviews will be approximately every 6 
months. In addition, the core team or the SMC, at any time it thinks appropriate, may ask for the 
SMC to independently review all available safety data. 

Clarification Memorandum #2 
          Page 1 of 2 
20 December 2016 
ACTG A5337 Protocol Version 2.0 
 
 
Clarification Memorandum #2 for: 
 
A5337 
 
Safety and Efficacy of Sirolimus for HIV Reservoir Reduction in Individuals on 
Suppressive Antiretroviral Therapy 
 
A Limited Center Trial of the AIDS Clinical Trials Group (ACTG) 
 
DAIDS ES # 11981 
 
Clarification Memorandum Date: 20 December 2016 
 
 
ACTG Network Coordinating Center 
Social & Scientific Systems, Inc. 
 
 
 
 
 
Phone: (301) 628-3000 
8757 Georgia Avenue, 12th Floor 
 
 
 
 
 
Fax:  
(301) 628-3302 
Silver Spring, MD 20910 
 
 
CLARIFICATION MEMO 
 
 
DATE:  
December 20, 2016 
 
TO: 
ACTG CTU Principal Investigators, CRS Leaders, and CTU/CRS Coordinators 
 
FROM: 
A5337 Protocol Team 
 
SUBJECT: 
Clarification Memo #2 for Protocol A5337, Version 2.0, 07/18/16, entitled, “Safety 
and Efficacy of Sirolimus for HIV Reservoir Reduction in Individuals on 
Suppressive Antiretroviral Therapy”  
 
This clarification memo does not result in a change in the protocol informed consent 
document. The Division of AIDS does not require you to forward it to your institutional 
review board (IRB); however, as always, you must follow your IRB's policies and 
procedures. If IRB review of clarification memos is required at your site, please submit 
this document for review. 
 
Each site should file a copy of this clarification memo with the protocol for reference. 
 
The protocol clarification contained in this memo should be implemented immediately. 
These updates will be included in the next version of the A5337 protocol if it is amended 
at a future date. 
 
The following is a clarification (in bold) to protocol A5337, Version 2.0, 07/18/16: 
 

 
Clarification Memorandum #2 
          Page 2 of 2 
20 December 2016 
ACTG A5337 Protocol Version 2.0 
 
 
 
9.5  
Monitoring, second paragraph 
 
At the earlier of a) approximately 6 months after the first participant begins study 
treatment and b) after 12 participants have reached 12 weeks of study treatment, 
a Study Monitoring Committee (SMC) will be convened to review the study data 
and progress according to ACTG Standard Operating Procedures. The SMC will 
review accrual, participant characteristics, AE summaries (and listings detailing 
each team decision as to the relationship of the AE to study treatment), sirolimus 
dosages and trough levels (in particular for any participant with a Grade 3 or 
higher AE), CD4+ cell counts and HIV-1 RNA levels/suppression over time, off-
treatment and off-study rates (and reasons) and completeness of sample 
availability. In addition, sirolimus use in all participants will be stopped and an 
SMC safety review will be promptly convened if there are any Grade 4 AEs or 
greater than three Grade 3 AEs attributed to study treatment in two or more 
participants per section 9.2.1.1. With respect to monitoring AEs, any lipid 
laboratory value/abnormality will be considered as a single event, rather 
than separate events for each individual test (including fasting 
triglycerides, LDL, and total cholesterol). An SMC review will also be triggered 
if more than 25% of participants (evaluating at least 12 participants, e.g., greater 
than 3 of 12) discontinue study treatment due to AEs or other side effects 
attributable to study drug; the therapeutic duration of the trial might be reduced to 
12 weeks or otherwise modified following SMC review. Subsequent SMC reviews 
will be approximately every 6 months. In addition, the core team or the SMC, at 
any time it thinks appropriate, may ask for the SMC to independently review all 
available safety data.  
 

Clarification Memorandum #2 
          Page 1 of 2 
4 October 2016 
ACTG A5337 Protocol Version 2.0 
 
 
Clarification Memorandum #1 for: 
 
A5337 
 
Safety and Efficacy of Sirolimus for HIV Reservoir Reduction in Individuals on 
Suppressive Antiretroviral Therapy 
 
A Limited Center Trial of the AIDS Clinical Trials Group (ACTG) 
 
DAIDS ES # 11981 
 
Clarification Memorandum Date: 4 October 2016 
 
 
ACTG Network Coordinating Center 
Social & Scientific Systems, Inc. 
 
 
 
 
 
Phone: (301) 628-3000 
8757 Georgia Avenue, 12th Floor 
 
 
 
 
 
Fax:  
(301) 628-3302 
Silver Spring, MD 20910 
 
 
CLARIFICATION MEMO 
 
 
DATE:  
October 4, 2016 
 
TO: 
ACTG CTU Principal Investigators, CRS Leaders, and CTU/CRS Coordinators 
 
FROM: 
A5337 Protocol Team 
 
SUBJECT: 
Clarification Memo #1 for Protocol A5337, Version 2.0, 07/18/16, entitled, “Safety 
and Efficacy of Sirolimus for HIV Reservoir Reduction in Individuals on 
Suppressive Antiretroviral Therapy”  
 
This clarification memo does not result in a change in the protocol informed consent 
document. The Division of AIDS does not require you to forward it to your institutional 
review board (IRB); however, as always, you must follow your IRB's policies and 
procedures. If IRB review of clarification memos is required at your site, please submit 
this document for review. 
 
Each site should file a copy of this clarification memo with the protocol for reference. 
 
The protocol clarifications contained in this memo should be implemented immediately. 
These updates will be included in the next version of the A5337 protocol if it is amended 
at a future date. 
 
 
The following are clarifications (in bold) to protocol A5337, Version 2.0, 07/18/16: 

 
Clarification Memorandum #2 
          Page 2 of 2 
4 October 2016 
ACTG A5337 Protocol Version 2.0 
 
 
4.2.16 Herpes-zoster or varicella-zoster viral infection requiring treatment within 
90 days prior to study entry or currently on suppressive therapy for herpes-
zoster (varicella-zoster). 
 
NOTE: Suppressive therapy for herpes simplex viruses 1 or 2 is not 
exclusionary. 
 
5.1 
Regimens, Administration and Duration 
 
Participants taking a non-PI, non-NNRTI containing regimen, and those on a 
non-PI, RPV-based regimen, will initially receive: 
 
• 
Sirolimus 0.025 mg/kg/day administered orally once daily with or without 
food. See Table 2. 
 
Participants taking an NNRTI containing regimen (with the exception of RPV) will 
initially receive: 
 
• 
Sirolimus 0.05 mg/kg/day administered orally once daily with or without food. 
See Table 3. 
 
In order to achieve therapeutic levels, therapy will be initiated with the dosage 
noted above and dosing will be subsequently adjusted based on trough blood 
sirolimus concentrations to achieve target concentrations between 5 and 10 
ng/mL (see Table 4). A detailed dosing table based on the adjustment algorithm 
in Table 4 can be found on the A5337 PSWP. 
 
NOTE: If there is a change in ART regimen between entry and week 12, the 
site must contact the A5337 core team (actg.corea5337@fstrf.org) as soon 
as possible to reassess the initial sirolimus dose based on current ART 
regimen/classification at week 12. 
  
6.2.3 Event Driven Evaluations 
Confirmation visit to confirm CD4+ cell count <300 cells/mm3 or >50% CD4+ 
decrease from study entry value or HIV-1 RNA >200 copies/mL (see sections 
7.1.4 and 7.1.5) should be scheduled within 1 week of receipt of the abnormal lab 
value.  If confirmed CD4+ cell count <300 cells/mm3 or >50% CD4+ decrease 
from study entry value or HIV-1 RNA >200 copies/mL, the study team should be 
promptly contacted and sirolimus should not be started or should be stopped if 
already started. 
 
NOTE: If study entry CD4+ cell count is not available, monitoring for >50% 
decrease should be done relative to the week 12 CD4+ cell count. If neither 
entry nor week 12 CD4+ cell count is available, monitoring for >50% 
decrease should be done relative to the screening CD4+ cell count. 

 
 
 
 
 
A5337 
 
 
Safety and Efficacy of Sirolimus for HIV Reservoir Reduction in Individuals on 
Suppressive Antiretroviral Therapy  
 
 
A Limited Center Trial of the AIDS Clinical Trials Group (ACTG) 
 
 
Sponsored by: 
 
The National Institute of Allergy 
and Infectious Diseases 
 
 
Industry Support Provided by: 
 
ViiV Healthcare 
 
 
 
 
The ACTG HIV Reservoirs and Viral Eradication  
Transformative Science Group: 
 
 
Joseph Eron, MD, Chair 
  
Protocol Co-Chairs:   
Timothy J. Henrich, MD 
Priscilla Hsue, MD 
 
 
Protocol Vice Chair:  
Steven G. Deeks, MD 
 
DAIDS Clinical Representative: 
Catherine Godfrey, MD 
 
Clinical Trials Specialist: 
Elizabeth Hawkins, MA 
 
 
 
 
 
Version 2.0 
July 18, 2016 
 
 

A5337 
 
 
Version 2.0 
 
 
07/18/16 
 
 
 
 
CONTENTS 
 
 
Page 
 
SITES PARTICIPATING IN THE STUDY .................................................................................... 4 
PROTOCOL TEAM ROSTER ..................................................................................................... 5 
STUDY MANAGEMENT ............................................................................................................. 8 
GLOSSARY OF PROTOCOL-SPECIFIC TERMS ..................................................................... 10 
SCHEMA .................................................................................................................................. 11 
1.0 
HYPOTHESES AND STUDY OBJECTIVES.................................................................. 13 
1.1 
Hypotheses ........................................................................................................ 13 
1.2 
Primary Objectives ............................................................................................. 13 
1.3 
Secondary Objectives ........................................................................................ 13 
1.4 
Exploratory Objectives ....................................................................................... 13 
2.0 
INTRODUCTION ........................................................................................................... 14 
2.1 
Background ........................................................................................................ 14 
2.2 
Rationale ........................................................................................................... 20 
3.0 
STUDY DESIGN ........................................................................................................... 25 
4.0 
SELECTION AND ENROLLMENT OF PARTICIPANTS ............................................... 26 
4.1 
Inclusion Criteria ................................................................................................ 26 
4.2 
Exclusion Criteria ............................................................................................... 28 
4.3 
Study Enrollment Procedures............................................................................. 30 
4.4 
Coenrollment Guidelines .................................................................................... 31 
5.0 
STUDY TREATMENT ................................................................................................... 32 
5.1 
Regimens, Administration and Duration ............................................................. 32 
5.2 
Study Product Formulation and Preparation ....................................................... 33 
5.3 
Pharmacy: Product Supply, Distribution, and Accountability .............................. 34 
5.4 
Concomitant Medications ................................................................................... 34 
6.0 
CLINICAL AND LABORATORY EVALUATIONS ........................................................... 36 
6.1 
Schedule of Events ............................................................................................ 36 
6.2 
Timing of Evaluations ......................................................................................... 39 
6.3 
Instructions for Evaluations ................................................................................ 41 
7.0 
CLINICAL MANAGEMENT ISSUES .............................................................................. 49 
7.1 
Toxicity .............................................................................................................. 49 
7.2 
Management of Specific Toxicities ..................................................................... 51 
7.3 
Management of HPV-Related Disease ............................................................... 52 
7.4  
Pregnancy Outcomes and Obstetrical History Reporting .................................... 52 
8.0 
CRITERIA FOR DISCONTINUATION ........................................................................... 52 
8.1 
Permanent and Premature Treatment Discontinuation ....................................... 52 
8.2 
Premature Study Discontinuation ....................................................................... 53 

A5337 
 
 
Version 2.0 
 
 
07/18/16 
CONTENTS (Cont’d) 
Page 
 
9.0 
STATISTICAL CONSIDERATIONS ............................................................................... 53 
9.1 
General Design Issues ....................................................................................... 53 
9.2 
Outcome Measures ............................................................................................ 53 
9.3 
Randomization and Stratification ........................................................................ 55 
9.4 
Sample Size and Accrual ................................................................................... 55 
9.5 
Monitoring .......................................................................................................... 55 
9.6 
Analyses ............................................................................................................ 56 
10.0 
PHARMACOLOGY PLAN .............................................................................................. 58 
10.1 
Pharmacology Study Design .............................................................................. 58 
10.2 
Primary and Secondary Data, Modeling and Data Analysis ............................... 58 
11.0 
DATA COLLECTION AND MONITORING AND ADVERSE EVENT REPORTING ........ 59 
11.1 
Records to Be Kept ............................................................................................ 59 
11.2 
Role of Data Management ................................................................................. 59 
11.3 
Clinical Site Monitoring and Record Availability .................................................. 59 
11.4 
Expedited Adverse Event Reporting to DAIDS ................................................... 59 
12.0 
PARTICIPANTS ............................................................................................................ 60 
12.1 
Institutional Review Board (IRB) Review and Informed Consent ........................ 60 
12.2 
Participant Confidentiality ................................................................................. 61 
12.3 
Study Discontinuation ........................................................................................ 61 
13.0 
PUBLICATION OF RESEARCH FINDINGS .................................................................. 61 
14.0 
BIOHAZARD CONTAINMENT ...................................................................................... 61 
15.0 
REFERENCES .............................................................................................................. 62 
 
APPENDIX I: SAMPLE INFORMED CONSENT  
 

 
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A5337 
Version 2.0 
 
 
07/18/16 
SITES PARTICIPATING IN THE STUDY 
 
A5337 is a limited center study open to select US clinical research sites (CRSs) that ideally 
have rapid sirolimus testing available within 72 hours via liquid chromatography/tandem mass 
spectrometry (LC tandem MS), but laboratory results may be dependent on the testing 
laboratory’s standard operating procedures. Refer to the Site tab on the protocol’s 
webpage on the ACTG Member website for the list of eligible sites. 
 
 
 
 
 
 
 

5 
A5337 
Version 2.0 
 
 
07/18/16 
 
PROTOCOL TEAM ROSTER 
 
Co-Chairs 
Timothy J. Henrich, MD 
Assistant Professor of Medicine 
Department of Experimental Medicine 
University of California San Francisco 
San Francisco General Hospital Campus, 
Building 3 
San Francisco, CA 
Phone: 415-206-5518  
E-mail: timothy.henrich@ucsf.edu 
 
Priscilla Hsue, MD 
University of California, San Francisco  
San Francisco General Hospital  
Room 5G1 
Cardiology SFGH 
1001 Potrero Avenue 
San Francisco, CA 94110 
Phone: 415-206-8257  
Fax: 415-206-5447 
E-mail: phsue@medsfgh.ucsf.edu 
 
Vice Chair 
Steven G. Deeks, MD 
UCSF, Positive Health Program 
SFGH Building 80, Ward 84 
996 Potrero Avenue 
San Francisco, CA 94110 
Phone: 415-476-4082 x330 
Fax: 415-476-6953  
E-mail: sdeeks@php.ucsf.edu 
 
Virologist 
Daniel R. Kuritzkes, MD 
Division of Infectious Diseases 
Brigham and Women’s Hospital 
65 Landsdowne St, Rm 449 
Cambridge, MA 02139 
Phone: 617-768-8398 
Fax: 617-768-8738 
E-mail: dkuritzkes@partners.org 
 
 
 
Immunologist 
Michael M. Lederman, MD 
Case Western Reserve University 
University Hospitals Cleveland 
11100 Euclid Ave 
Cleveland, OH 44106 
Phone: 216-844-8786 
Fax: 216-844-5523 
E-mail:  
lederman.michael@clevelandactu.org 
 
DAIDS Clinical Representative  
Catherine Godfrey, MD 
TRP, DAIDS, NIAID, NIH, HIV Research 
Branch,  
5601 Fishers Lane 
Room 9E49 
MSC 9830, Bethesda, MD 20852-9830 
Phone: 240-627-3074 
Fax: 301-432-9282 
E-mail: cgodfrey@niaid.nih.gov 
 
Clinical Trials Specialist 
Elizabeth Hawkins, MA 
ACTG Network Coordinating Center 
Social & Scientific Systems, Inc. 
8757 Georgia Avenue, 12th Floor 
Silver Spring, MD 20910-3714 
Phone: 301-628-3335 
Fax: 301-628-3302 
E-mail:  ehawkins@s-3.com 
 
Senior Statistician 
Ronald J. Bosch, PhD 
Center for Biostatistics in AIDS Research 
Harvard School of Public Health 
651 Huntington Ave 
Boston, MA 02115 
Phone: 617-432-3024 
Fax: 617-432-2843 
E-mail: ronbosch@sdac.harvard.edu 
 
 

 
6 
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PROTOCOL TEAM ROSTER (Cont'd) 
07/18/16 
 
Statistician 
Justin Ritz, MS 
Statistical and Data Analysis Center 
Harvard School of Public Health 
FXB Building, Room 510 
Boston MA 02115 
Phone: 617-432-3034  
Fax: 617-432-3163 
E-mail: jritz@sdac.harvard.edu 
 
Data Manager 
Apsara Nair, MS 
Frontier Science and Technology  
Research Foundation 
4033 Maple Road 
Amherst, NY 14226 
Phone: 716-834-0900 x7293  
Fax: 716-834-8432 
E-mail: nair@fstrf.org 
 
DAIDS Pharmacist 
Nayri Khairalla, BS, PharmD 
Pharmaceutical Affairs Branch 
OCSO, DAIDS, NIAID, NIH  
5601 Fishers Lane 
Room 9D46 
Rockville, MD 20852 
Phone: 301-761-6659 
Fax: 240-627-3112 
E-mail: Nayri.khairalla@nih.gov. 
 
Pharmacologist  
Francesca Aweeka, PharmD 
Clinical Pharmacy 
University of California, San Francisco 
P.O. Box 0622, C152 
521 Parnassus Avenue 
San Francisco, CA 94143-0622 
Phone: 415-476-0339 
Fax: 415-476-0307 
E-mail: faweeka@sfghsom.ucsf.edu 
 
Investigators  
Corey S. Cutler MD, MPH 
Department of Medical Oncology 
Dana-Farber Cancer Institute 
450 Brookline Avenue 
Boston, MA 02115 
Phone: 617-632-5946 
Fax: 617-632-5168 
E-mail: corey_cutler@dfci.harvard.edu 
 
Sulggi A. Lee, MD PhD 
University of California, San Francisco 
San Francisco General Hospital 
995 Potrero Avenue, Bldg 80, Box 0874 
San Francisco, CA 94110 
Phone: 415-735-5127 
Fax: 415-476-6953  
E-mail: sulggi.lee@ucsf.edu 
 
Rafick Sekaly, PhD 
Vaccine Gene Therapy Institute-Florida 
VGTI-FL, 9801 SW Discovery Way 
Port St. Lucie, FL 34987 
Phone: 772-345-5668 
Fax: 772-345-5752 
E-mail: rpsekaly@vgti-fl.org 
 
Field Representatives 
Susan Pedersen, RN, BSN 
The UNC Global HIV Prevention and 
Treatment Clinical Trials Unit  
130 Mason Farm Road,  
Campus Box 7215 
Chapel Hill, NC 27599 
Phone: 919-966-6713 
Fax: 919-966-8928 
E-mail: spederse@med.unc.edu 
 
Becky Straub, RN, BSN, MPH 
The UNC Global HIV Prevention and 
Treatment Clinical Trials Unit 
130 Mason Farm Road  
Campus Box 7215 
Chapel Hill, NC 27599 
Phone: 919-843-9975 
Fax: 919-966-8928 
E-mail: bstraub@med.unc.edu 
 

 
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PROTOCOL TEAM ROSTER (Cont'd) 
07/18/16 
 
Laboratory Technologist 
David L. Shugarts, MA 
Infectious Diseases Clinical Trials Lab 
University of Colorado Denver 
12700 E. 19th Ave. Room 11006 
Bldg. P15 RC-2 
Aurora, CO 80045 
Phone: 303-724-2981 
Fax: 303-724-2985  
E-mail: david.shugarts@ucdenver.edu 
 
Community Scientific Subcommittee (CSS) 
Representatives 
Danielle Campbell, MPHc 
University of California, Los Angeles CARE 
Center 
8810 S. Mary Avenue 
Los Angeles, CA 90002 
Phone: 310-910-8341 
E-mail: daniellecampbell@cdrewu.edu 
 
Michael Dorosh, MA 
University of Colorado 
38 West Maple Avenue 
Denver, CO 80223-1839 
Phone: 303-777-5737 
Fax: 720-920-7110 
E-mail: michael@ontheten.org 
 
Laboratory Data Manager 
Christopher Hensel 
Frontier Science and Technology  
Research Foundation 
4033 Maple Road 
Amherst, NY 14226-1056 
Phone:  716-834-0900   
Fax: 716-833-0655 
E-mail: chensel@fstrf.org  
 
 
 
 
 
 
 
 
 
 
Industry Representatives 
Belinda Ha, PhD 
ViiV Healthcare 
Five Moore Drive 
Research Triangle Park, NC 27709 
Phone: 919-483-8284 
E-mail: belinda.f.ha@viivhealthcare.com 
 
Andrew R. Zolopa, MD 
ViiV Healthcare 
Five Moore Drive 
Research Triangle Park, NC 27709-3398 
Phone: 919-315-8183  
E-mail: 
Andrew.r.zolopa@viivhealthcare.com 
 
 

 
8 
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07/18/16 
 
STUDY MANAGEMENT 
 
All questions concerning this protocol should be sent to actg.corea5337@fstrf.org via e-mail. 
The appropriate team member will respond with a "cc" to actg.corea5337@fstrf.org.  A response 
should generally be received within 24 hours (Monday-Friday). 
 
Protocol E-mail Group 
Sites should contact the User Support Group at the Data Management Center (DMC) as soon 
as possible to have the relevant personnel at the site added to the 'prota5337' e-mail group. 
Include the protocol number in the e-mail subject line. 
• 
Send an e-mail message to actg.user.support@fstrf.org. 
 
Clinical Management  
For questions concerning entry criteria, toxicity management, concomitant medications, and 
coenrollment, contact the protocol team.  
• 
Send an e-mail message to actg.corea5337@fstrf.org. Include the protocol number, patient 
identification number (PID), and a brief relevant history. 
 
Laboratory 
For questions specifically related to immunology laboratory tests, contact the protocol 
immunologist.  
• 
Send an e-mail message to actg.corea5337@fstrf.org (ATTN: Michael Lederman, MD). 
 
For questions specifically related to virology laboratory tests, contact the protocol virologist.  
• 
Send an e-mail message to actg.corea5337@fstrf.org (ATTN: Daniel Kuritzkes, MD).  
 
For questions specifically related to pharmacology laboratory tests, contact the protocol 
pharmacologist.  
• 
Send an e-mail message to actg.corea5337@fstrf.org (ATTN: Francesca Aweeka, PharmD). 
 
Data Management 
• 
For nonclinical questions about transfers, inclusion/exclusion criteria, case report 
forms (CRFs), randomization/registration, and other data management issues, contact 
the data manager. CRFs completion guidelines and participant completed CRFs can 
be downloaded from the FSTRF website at www.fstrf.orgFor transfers, reference the 
Study Participant Transfer SOP 119, and contact Apsara Nair, MS directly.  
• 
For other questions, send an e-mail message to actg.corea5337@fstrf.org (ATTN: Apsara 
Nair, MS).   
• 
Include the protocol number, PID, and a detailed question. 
 
Participant  Registration  
For participant registration questions or problems and study identification number (SID) lists.  
Send an e-mail message to rando.support@fstrf.org. Call the Statistical and Data Analysis 
Center (SDAC)/DMC Randomization Desk at 716-834-0900 extension 7301. 
 
 
Computer and Screen Problems  
Contact the SDAC/DMC programmers. 

 
9 
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Version 2.0 
 
STUDY MANAGEMENT (Cont'd) 
07/18/16 
 
• 
Send an e-mail message to actg.support@fstrf.org or call 716-834-0900 x7302. 
 
Protocol Document Questions 
For questions concerning the protocol document, contact the clinical trials specialist.  
• 
Send an e-mail message to actg.corea5337@fstrf.org (ATTN: Elizabeth Hawkins, MA). 
 
Copies of the Protocol 
To request a hard copy of the protocol, send an e-mail message to ACTGNCC@s-3.com 
(ATTN: Diane Delgado). Electronic copies can be downloaded from the ACTG Web site 
(https://www.actgnetwork.org). 
 
Product Package Inserts and/or Investigator Brochures 
To request copies of product package inserts or investigator brochures, contact the DAIDS 
Regulatory Support Center (RSC) at RIC@tech-res.com or call 301-897-1708. 
 
Protocol Registration 
For protocol registration questions, send an e-mail message to Protocol@tech-res.com or call 
301-897-1707.  
 
Protocol Activation 
For questions related to protocol activation, contact the Elizabeth Hawkins at 
ehawkins@s-3.com or ACTG Site Coordination group at actgsitecoordination@s-3.com. 
 
Study Product 
For questions or problems regarding study product, dose, supplies, records, and 
returns, call Nayri Khairalla, BS, PharmD, protocol pharmacist, at 301-761-6659.  
 
Study Drug Orders 
Call the Clinical Research Products Management Center (CRPMC) at 301-294-0741. 
 
Expedited Adverse Event (EAE) Reporting/Questions  
Contact DAIDS through the RSC Safety Office at DAIDSRSCSafetyOffice@tech-res.com or call 
1-800-537-9979 or 301-897-1709; or fax 1-800-275-7619 or 301-897-1710.  
 
Phone Calls 
Sites are responsible for documenting any phone calls made to A5337 team members. 
• 
Send an e-mail to actg.corea5337@fstrf.org. 
 
Protocol-Specific Web Page 
Additional information about management of the protocol can be found on the protocol-specific 
web page (PSWP). 

 
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GLOSSARY OF PROTOCOL-SPECIFIC TERMS 
 
5FU 
 
Fluorouracil 
AUC 
 
area under the curve 
BCG 
 
Bacillus Calmette-Guerin 
BOOP  
bronchiolitis obliterans organizing pneumonia  
CCR5  
C-C chemokine receptor type 5 
Cmax 
 
maximum concentration 
CM 
 
central memory 
CMV  
cytomegalovirus 
EBV 
 
Epstein-Barr virus 
E/CIA  
chemiluminescence immunoassay  
EM 
 
effector memory 
eGFR  
estimated glomerular filtration rate  
HHV 
 
human herpes virus 
HSCT  
hematopoietic stem cell transplantation 
IFN 
 
interferon 
IL-2 
 
interleukin 2  
KS 
 
Kaposi sarcoma 
MHC  
major histocompatibility complex 
mTOR  
mammalian target of rapamycin 
PD-1  
programmed cell death protein 1 
PK 
 
pharmacokinetic 
SCA 
 
single-copy assay 
SD 
 
standard deviation 
SMC  
Study Monitoring Committee 
TCM 
 
central memory T cells 
TM 
 
transitional memory 
Tmax 
 
time to peak concentration  
TST 
 
tuberculin skin test 

 
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SCHEMA 
 
A5337 
 
Safety and Efficacy of Sirolimus for HIV Reservoir Reduction in Individuals on Suppressive 
Antiretroviral Therapy  
 
DESIGN 
A5337 is a phase I/II, open label, single arm, pilot study to 
evaluate the safety of sirolimus and its efficacy with 
respect to its effects on HIV-1 reservoir size and immune 
function. This study will assess the effects of sirolimus on 
HIV-1-specific CD8+ T-cell function, HIV transcription, and 
residual viral production. Measurement of additional 
inflammatory markers, immunological studies, and 
reservoir size will be performed on stored specimens if the 
initial findings appear promising. 
 
DURATION 
44 weeks (12-week pre-sirolimus treatment lead-in period, 
followed by 20 weeks of sirolimus treatment and an 
additional 12 weeks off sirolimus treatment). 
 
SAMPLE SIZE 
30 participants  
 
POPULATION 
HIV-infected men and women ≥18 years of age, 
maintained on suppressive antiretroviral therapy (ART) for 
≥24 months with CD4+ cell count ≥350 cells/mm3.  
Participants  may not be on a PI-based or cobicistat-
based regimen 3 months prior to and at any time after 
study entry and must remain on ART during sirolimus 
study treatment. 
 
STRATIFICATION 
By class of antiretroviral (ARV) regimen   
 
REGIMEN  
▪ For participants on a non-protease inhibitor (PI), non-
non-nucleoside reverse transcriptase inhibitor (NNRTI) 
regimen, and for those on a non-PI, rilpivirine (RPV) based 
regimen:  
 
 
Sirolimus 0.025 mg/kg/day initial dose for 20 weeks  
 
▪For participants who are on an NNRTI regimen with the 
exception of RPV:   
 
Sirolimus 0.05 mg/kg/day initial dose for 20 weeks. 
 
Dosing will be adjusted based on trough sirolimus 
concentrations to achieve target concentrations between 5 
and 10 ng/mL. 

 
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Study Design Schematic 
Sirolimus from week 12 through 
week 32  
Week 44 (final visit) 
HIV-infected individuals ≥18 years of age who have 
been virologically suppressed on non-PI continuous 
ART for ≥24 months with CD4+ cell count ≥350 
cells/mm3 
Week 0: Lead-in prior to sirolimus 
Week 12: Sirolimus (weight-based 
dosing for goal trough level of 5-10 
ng/mL) 
Stratified by ARV regimen 
Week 32 (stop sirolimus) 

 
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1.0 
HYPOTHESES AND STUDY OBJECTIVES  
 
1.1 
Hypotheses 
 
1.1.1 Sirolimus will be safe and tolerated in participants on non-protease inhibitor (PI) 
suppressive antiretroviral therapy (ART).  
 
1.1.2 Sirolimus will improve HIV-specific cellular immunity and reduce T-cell activation, 
which in turn will cause decreases in viral transcription/cell-associated RNA 
levels and levels of low-level residual viremia. 
 
1.1.3 Sirolimus will cause down-regulation of programmed cell death protein (PD-1) 
and suppression of homeostatic proliferation of the latent reservoir, leading to 
reductions in cell-associated HIV-1 DNA levels. 
 
1.2 
Primary Objectives 
 
1.2.1 To assess the safety of sirolimus in HIV-infected participants receiving non PI-
based suppressive ART.  
 
1.2.2 To evaluate changes in the frequency (%) of HIV-1 Gag-specific CD8+ cells after 
20 weeks of sirolimus therapy. 
 
1.2.3 To assess changes in CD4+ cell-associated HIV-1 RNA and plasma HIV-1 RNA 
by single-copy assay (SCA) at baseline and at week 20 of sirolimus therapy. 
 
1.3 
Secondary Objectives 
 
1.3.1 To assess the impact of sirolimus on measures of reservoir size including HIV-1 
DNA levels in CD4+ cells and RNA levels by conventional assay. 
 
1.3.2 To assess the impact of sirolimus on CD4+ cell counts. 
 
1.3.3 To assess the impact of sirolimus on HIV-1-specific CD4+ cell responses and 
HIV-1-specific CD8+ cell responses. 
 
1.3.4 To assess the impact of sirolimus on T-cell activation and proliferation (% CD4+ 
and CD8+ cells CD38+/HLA-DR+, CD25+, PD-1+, Ki67+ and PD-L1 expression). 
 
1.4 
Exploratory Objectives 
 
1.4.1 To assess the pharmacokinetic (PK) interactions between sirolimus therapy and 
antiretroviral (ARV) drug levels. 
 
1.4.2 To perform ex vivo flow cytometric phenotyping of activation/proliferation in CD4+ 
and CD8+ central memory (CM), transitional memory (TM), effector memory 
(EM) and naïve populations as defined by CCR7 and CD27 expression. 
 

 
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1.4.3 To measure the effects of sirolimus on homeostatic proliferation, gene 
expression and transcriptional regulation. 
 
1.4.4 To assess the impact of sirolimus on soluble markers of inflammation, including 
IL-6, IL-7 and IL-15. 
 
1.4.5 To measure the effects of sirolimus on HIV-1-specific antibody levels, the breadth 
of antibody responses, and B cell phenotype, rearrangements, and class 
switching.  
 
1.4.6 To assess the relationship between human papillomavirus (HPV) DNA levels and 
HPV-related disease from anal swabs and anal Pap smears prior to and at 
completion of sirolimus therapy, and to assess the relationship between HPV and 
immune activation and reservoir size. 
 
1.4.7  To evaluate whether the use of sirolimus is associated with more frequent 
reactivation or suppression of human herpes viruses (i.e., cytomegalovirus 
[CMV], Epstein Barr virus [EBV], herpes simplex viruses [HSV] and human 
herpes viruses [HHV] 6, 7, and 8) as measured in longitudinally collected 
oral swabs. 
 
 
2.0 
INTRODUCTION  
 
2.1 
Background 
 
Despite complete or near complete inhibition of viral replication with standard therapies, 
replication-competent HIV persists indefinitely in all individuals. Chronic inflammation 
and/or immune dysfunction also persist during effective therapy [1]. Theoretically, host 
immune environment may contribute to HIV persistence through at least five 
independent mechanisms: (a) activating viral replication in latently-infected T cells 
(leading to HIV replication, assuming ART is not fully effective), (b) increasing the 
availability of susceptible target cells (making de novo infection more likely), (c) inhibiting 
the function of the adaptive immune system, (d) stimulating directly or indirectly the 
proliferation and expansion of memory T cells harboring replication competent HIV, 
and/or (e) stimulating intracellular signaling pathways (eg, PD-1) that may cause and 
maintain latent infection. The potential role of immune-based therapeutics as a 
component of a curative strategy is now recognized as a key research question in the 
field1.  
 
This study evaluates an intervention that may have an impact on HIV viral reservoirs, 
which has implications for viral eradication and ultimately ART-free remission of HIV. To 
date, few interventions have led to significant reductions in the size of the cellular HIV-1 
reservoir. In addition, this study investigates the viral and immune pathogenesis of HIV-1 
infection and related complications. The pathogenesis/immunology-oriented approach in 
this study of sirolimus treatment in HIV patients will help to identify underlying 
mechanisms of mammalian target of rapamycin (mTOR) inhibition, including the 
potential role of inflammation and immune activation, linking them to HIV disease 

 
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characteristics and reservoir size. In addition, A5337 may potentially provide important 
infrastructure by which to test the effects of using mTOR inhibition to target HIV viral 
reservoirs. Data obtained from this study will provide critical insights into a number of 
fundamental questions regarding the pathogenesis of long-term antiretroviral-treated HIV 
disease. Although the primary objective is to prepare for future clinical trials aimed at 
HIV-1 reservoir reduction using sirolimus and other drugs, the knowledge gained from 
this study could have broader implications, including the potential effects of anti-
inflammatory agents in preventing inflammation-associated non-AIDS events. The 
results from this pilot study will be used to generate preliminary data for future grants 
and later phase clinical trials. 
 
2.1.1 Sirolimus, T-cell activation and immunomodulatory effects 
Sirolimus (rapamycin) is a naturally occurring macrolide antibiotic that inhibits 
mTOR, a key regulatory kinase that controls cell-cycle progression [2] and has 
complex effects on T-cell activation and function [3]. As a consequence, 
progression from G1 to S phase is blocked in activated T cells. In contrast to 
other immune suppressing agents such as cyclosporine, the inhibitory effect of 
sirolimus on cell-cycle progression appears to be limited to T cells that are 
activated by cytokines and does not occur in T cells activated directly by antigen-
TCR engagement [4, 5]. Sirolimus has also been shown to inhibit class switching 
in B cells and promote cross-strain protection when used concomitantly with 
influenza vaccination [6].  
 
2.1.2 Clinical use of sirolimus therapy 
Sirolimus is approved for the prophylaxis of organ rejection in patients aged 13 
years and older receiving renal transplants [7, 8]. However, sirolimus is used in 
other settings such as prophylaxis of graft-versus-host-disease after allogeneic 
hematopoietic stem cell transplantation (HSCT) [9-13] and as a treatment for 
Kaposi sarcoma (KS) in HIV-infected patients as detailed below and in solid-
organ transplant patients [14-16]. Sirolimus is often used in combination with 
other immunosuppressive medications, such as cyclosporine or calcineurin 
inhibitors, and as a result, a large proportion of safety and efficacy data are in the 
setting of concomitant therapies or in populations with significant underlying 
morbidity. 
 
2.1.3 Sirolimus use in the setting of HIV and hepatitis C virus (HCV) infections   
Sirolimus may have utility in the management of HIV infection [17]. Reductions in 
HIV-associated T-cell activation should lead to a reduction in HIV replication, as 
has been observed with other immunosuppressant drugs. Sirolimus also can 
reduce HIV replication in vitro, possibly due to its impact in modulating the pro-
inflammatory aspects of interleukin 2 (IL-2) on cytokine stimulated T cells [18] 
and/or by reducing HIV transcription [19]. Sirolimus reduces C-C chemokine 
receptor type 5 (CCR5) expression on T cells, which may make them less 
susceptible to HIV infection [20-22]. Sirolimus may also attenuate the increased 
T-cell cycling seen in untreated HIV infection [23] and in persons with 
immunologic failure on suppressive ART [24]. 
 

 
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In a recent pilot study involving seven HIV-infected adults with KS, sirolimus was 
well tolerated and resulted in partial KS remissions in three individuals [14]. The 
drug has also been used in transplantation studies. No increased risk of 
opportunistic infections has been noted in HIV-infected allogeneic HSCT 
recipients receiving sirolimus for prevention of graft-versus-host disease [25]. 
Among 150 HIV-infected individuals receiving solid organ transplant [26], our 
group has shown that sirolimus exposure was safe.  
 
A small report of the effects of sirolimus treatment in HIV-infected liver transplant 
recipients showed significantly better control of both HIV and HCV replication in 
the patients receiving sirolimus monotherapy, with two of six patients showing 
complete clearance of HCV [15]. Complete HCV clearance upon conversion to 
sirolimus therapy has also been described in HIV-infected patients undergoing 
liver transplant [27]. 
 
2.1.4 Sirolimus and cytomegalovirus (CMV) and HPV infection   
A comprehensive review of the literature of CMV coinfection in renal transplant 
recipients shows that sirolimus and everolimus (a sirolimus derivative) may 
decrease the incidence and severity of clinical CMV disease [28]. A recent report 
showed a significant increase in (CMV-specific) effector-type CD8+ and CD4+ 
cell counts in patients undergoing everolimus dual therapy, which may partially 
explain the reported low incidence of CMV-related pathology in everolimus-
treated patients [29].  
 
A relationship between the mTOR pathway and HPV-related disease has been 
described, and promising in vitro studies suggest a role for future therapeutic 
efforts for HPV-associated tumors via inhibition of the E6 and E7 oncoprotein 
[30]. Early clinical studies suggest that inhibition of this pathway induces in vitro 
regression of cutaneous warts and may play a role in the therapy of cervical 
cancer and HPV-associated head and neck cancers [31, 32]. Reduction of 
persistent HPV infection may reduce the HPV-related burden of disease in the 
anogenital tract. Cutaneous warts have also been shown to resolve in the setting 
of conversion from tacrolimus or tacrolimus and cyclosporine to sirolimus in a 
transplant patient.   
  
Oncogenic HPV, in particular HPV 16, induces a local inflammatory response as 
evidenced by increased isolation of soluble markers of inflammation [33]. There 
are no data on whether this local response contributes to the systemic 
inflammatory response. It is plausible, however, that this local inflammation may 
contribute to an increased HIV-1 reservoir size.  
 
As part of this study we will evaluate whether the use of sirolimus is 
associated with more frequent reactivation or suppression of HHV as 
measured in longitudinally-collected oral swabs. Shedding of HHV DNA is 
frequently detected in saliva of healthy individuals and more frequently in 
HIV-infected adults and persistent replication of HHV (in particular CMV) 
has been repeatedly associated with increased systemic inflammation and 
cellular activation. As an alternative hypothesis, since persistent 

 
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inflammation can also be a trigger for HHV reactivation, reduction in 
inflammation and improvement of effector immune responses after 
sirolimus administration might be associated with decrease in HHV 
replication as seen with clinical KS. 
 
Sirolimus may be associated with suppression of CMV due to two potential 
factors: 1) increased CMV-specific effector immune responses as detailed 
in study rationale which may explain the low incidence of CMV-related 
pathology in mTOR inhibitor-treated participants, and 2) reduction in oral 
and systemic cytokine-driven immune activation and inflammation leading 
to lower levels of oral or genital CMV secretion. Given an existing body of 
literature showing potential benefits of mTOR inhibition on CMV infection, 
we have extrapolated from this information to hypothesize that there will be 
less CMV shedding from both oral and genital tissues in the setting of 
sirolimus use. Alternatively, CMV shedding may increase due to immune 
suppressive effects of sirolimus. 
 
2.1.5 Safety of sirolimus in HIV-uninfected patients 
 
The boxed warning in the FDA sirolimus labeling has been updated to state 
that increased susceptibility to infection and the possible development of 
lymphoma and other malignancies may result from immunosuppression 
[7].  Although other cancers such as non-melanoma skin cancers were 
previously thought to be associated with sirolimus, the current body of 
evidence suggests that this is no longer the case. Overall, current 
observations suggest that approved use of sirolimus in organ transplant 
recipients may reduce the burden or recurrence of non-melanoma skin 
cancers. There is a paucity of data on the use of sirolimus as non-
melanoma skin cancer prophylaxis in non-transplant populations, but there 
is growing evidence that mTOR inhibitors may be effective in treating other 
solid tumors of the skin, such as KS [34-36]. 
 
Serious adverse events (AEs) in populations treated with sirolimus monotherapy 
for various solid tumors were primarily limited to hyperglycemia, gastrointestinal 
disease (including apthous ulcers, mucositis, and diarrhea), infection (including 
pneumonia, cellulitis, urinary tract infections), dyspnea and anemia [15, 37, 38]. 
Although minor AEs of this nature have been noted in a majority of subjects 
taking sirolimus or related drugs as monotherapy [38], the high prevalence of 
AEs were likely due to the lack of drug level monitoring. In our clinical 
experience, the prevalence of AEs is lower in clinical practice settings where 
drug levels are monitored, although it is unclear if concomitant 
immunosuppressive medications may contribute to these findings through 
additive effects. 
 
AEs associated with sirolimus use in the setting of transplantation include [7]: 
• 
Increased susceptibility to infection, including activation of latent Epstein-Barr 
viral infection, and the possible development of lymphoma, as discussed 
above. 

 
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• 
Hypersensitivity reactions including anaphylactic/anaphylactoid reactions, 
angioedema, exfoliative dermatitis, and hypersensitivity vasculitis have been 
associated with the administration of sirolimus but are rare. The concomitant 
use of sirolimus with other drugs known to cause angioedema, such as ACE-
inhibitors, may increase the risk of developing angioedema. 
• 
Impaired or delayed wound healing in patients receiving sirolimus, including 
lymphocele and wound dehiscence, has been reported. 
• 
Proteinuria. 
• 
Fluid accumulation, including peripheral edema, lymphedema, pleural 
effusion, ascites, and pericardial effusions (including hemodynamically 
significant effusions and tamponade requiring intervention in children and 
adults) in patients receiving sirolimus. 
• 
Increased serum cholesterol and triglycerides requiring treatment occurred 
more frequently in patients treated with sirolimus compared to placebo 
controls.  
• 
Interstitial lung disease (including pneumonitis, bronchiolitis obliterans 
organizing pneumonia [BOOP] and pulmonary fibrosis) with no identified 
infectious etiology have occurred in patients receiving immunosuppressive 
regimens including sirolimus. In some cases, the interstitial lung disease has 
resolved upon discontinuation or dose reduction of sirolimus and the risk may 
be increased as the trough sirolimus concentration increases. Underlying 
lung disease may increase risks of pulmonary toxicity in lung transplant 
patients. 
 
2.1.6 Sirolimus and pregnancy 
Sirolimus is pregnancy Category C [7]. Sirolimus is embryo/fetotoxic in rats when 
given in doses approximately 0.2 to 0.5 times the human doses (adjusted for 
body surface area). Embryo/fetotoxicity was manifested as mortality and reduced 
fetal weights but no teratogenesis was evident. There are no adequate and well- 
controlled studies in pregnant women.  
 
2.1.7 Sirolimus and fertility 
Sirolimus plays a central inhibitory role in a stem cell factor (SCF)/c-kit-
dependent process in spermatogonia via the phos3phoinositide3-kinase (PI3-
K)/(AKT)/p70S6K pathway and has been shown to have effects on both male 
and female fertility [39]. Testosterone has been shown to decrease during 
sirolimus use whereas follicle stimulating hormone and luteinizing hormone 
increase [40]. Furthermore, six patients (four men and two women), all of whom 
had either fathered or conceived children and who were receiving sirolimus for 
rejection prophylaxis pre-kidney transplant, developed gonadal dysfunction and 
infertility on average 5-12 months after transplantation. Sirolimus was 
discontinued, and all four male patients demonstrated full recovery of the 
oligo/azoospermia and restoration of fertility. Both women developed 
amenorrhea during therapy; amenorrhea resolved in only one patient after 
discontinuation of therapy [41]. Transient oligospermia or azoospermia have also 
been reported in two other male patients in the setting of sirolimus use for renal 
transplantation [42,43].  

 
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2.1.8 Sirolimus pharmacokinetics and pharmacodynamics 
Sirolimus is a substrate for both CYP3A4 and P-gp. Sirolimus is extensively 
metabolized in the intestinal wall and liver and undergoes counter-transport from 
enterocytes of the small intestine into the gut lumen. Inhibitors of CYP3A4 and P-
gp increase sirolimus concentrations. Inducers of CYP3A4 and P-gp decrease 
sirolimus concentrations. After a single dose of (C14) sirolimus oral solution in 
healthy volunteers, the majority (91%) of radioactivity was recovered from the 
feces, and only a minor amount (2.2%) was excreted in urine. The mean ±SD 
terminal elimination half-life (t½) of sirolimus after multiple dosing in stable renal 
transplant patients was estimated to be about 62 ±16 hours. Following 
administration of rapamune oral solution, the mean times to peak concentration 
(tmax) of sirolimus are approximately 1 hour and 2 hours in healthy subjects and 
renal transplant patients, respectively [7]. The systemic availability of sirolimus is 
low, and was estimated to be approximately 14% after the administration of 
rapamune oral solution. In healthy subjects, the mean bioavailability of sirolimus 
after administration of the tablet is approximately 27% higher relative to the 
solution. Sirolimus tablets are not bioequivalent to the solution [7]. 
2.1.9 Sirolimus dosing 
According to FDA package inserts [7], sirolimus is to be administered orally once 
daily consistently with or without food and is extensively partitioned into formed 
blood elements. Sirolimus is often dosed by weight and requires monitoring 
during initial therapy until steady-state levels of drug are achieved on a 
maintenance dose. Loading doses are sometimes used to more rapidly reach 
desired trough concentrations when used as prophylaxis to reduce solid organ 
transplant rejection. Once the sirolimus maintenance dose is adjusted, patients 
should continue on the new maintenance dose for at least 7 to 14 days before 
further dosage adjustment with concentration monitoring. It is recommended that 
the maintenance dose of sirolimus be reduced by approximately one-third in 
patients with mild or moderate hepatic impairment and by approximately one-half 
in patients with severe hepatic impairment. It is not necessary to modify the 
sirolimus loading dose. Dosage adjustment is not needed in patients with 
impaired renal function. At doses of 2 mg/day and 5 mg/day, sirolimus 
significantly reduced the incidence of organ rejection in low- to moderate-
immunologic risk renal transplant patients at 6 months following transplantation 
compared with either azathioprine or placebo [7]. 
2.1.10 Sirolimus metabolism and drug-drug interactions  
Sirolimus is usually avoided with concomitant use of strong inducers (e.g., 
rifampin and rifabutin) and strong inhibitors (e.g., ketoconazole, voriconazole, 
itraconazole, erythromycin, and clarithromycin) of CYP3A4 and P-gp. Grapefruit 
juice is also contraindicated during sirolimus therapy. Drugs that could increase 
sirolimus blood concentrations include cimetidine, cisapride, clotrimazole, 
diltiazem, fluconazole, PIs (including those used to treat HIV and HCV), 
metoclopramide, nicardipine, troleandomycin and verapamil (verapamil levels 
may also increase when given with sirolimus). Drugs that could decrease 
sirolimus concentrations include carbamazepine, phenobarbital, phenytoin, 
rifapentine, NNRTIs and St. John's wort. 
 

 
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2.2 
Rationale 
Table 1. HIV-1 Persistence and the Potential Benefits of Sirolimus on HIV-1 Reservoirs 
Obstacle to HIV 
Reservoir Reduction 
Potential Effect of 
Sirolimus 
Immune Evaluation 
Potential Beneficial Impact on 
HIV-1 Reservoir Size 
Related  
Objectives 
Ongoing viral 
replication in 
activated reservoir 
Decreased immune 
activation (cytokine 
mediated); 
reduction of CCR5 
expression 
Markers of immune 
activation and/or 
proliferation, 
soluble markers of 
inflammation 
Decreased transcription/ 
translation and CA-RNA; 
decreased CA-DNA 
1.2.3 (P) 
1.3.1 (S) 
1.3.4 (S) 
1.4.4 (E) 
Blunted immune 
mediated clearance 
Increased CD8+ 
central and effector 
memory response; 
improved HIV-1-
specific CD8+ cell 
immunity; 
generation of novel 
immune responses; 
CD4+ cell 
differentiation to 
regulatory 
CD25+Fox-P3+ 
cells; enhanced 
viral specific 
humoral immunity 
and inhibits class 
switching in B cells 
HIV-1-specific 
CD8+ cell 
immunity; HIV-1-
specific CD4+ T-
cell immunity; 
transcriptional 
profiling; HIV-
specific Ab 
quantitation and B 
cell phenotyping 
Increased clearance of HIV-
infected cells (decreased CA-
DNA, RNA and residual 
viremia), plasma RNA 
1.2.2 (P) 
1.3.1 (S) 
1.3.3 (S) 
1.4.5 (E) 
Negative regulators; 
immune exhaustion 
Decreased PD-1 
and dysfunctional 
T-cell signatures 
PD1; PD-L1  
Decreased CA-DNA and other 
markers of reservoir size 
1.2.2 (P) 
1.3.1 (S) 
1.3.4 (S) 
Homeostatic 
proliferation 
Decreased 
proliferation of 
latent reservoir 
T-cell immune 
subset activation 
and proliferation; 
homeostatic prolif.-
regulating 
cytokines; STAT-
mediated signaling 
Decreased CA-DNA and other 
markers of reservoir size 
1.3.4 (S) 
1.4.2 (E) 
1.4.3 (E) 
Objective: P = primary, S = secondary, E = exploratory 
 
2.2.1 Rationale for the potential effect on HIV latency  
Given that the cell-cycle effects of sirolimus appear to be limited to T cells that 
are activated by cytokines, and data indicating that generalized T-cell activation 
in HIV disease is cytokine rather than antigen-driven [23], the mechanism of 
action of sirolimus may be particularly beneficial in HIV infection. Also, in contrast 
to cyclosporine, major histocompatibility complex (MHC) class I or class II 
restricted antigen presentation by dendritic cells is not inhibited by sirolimus, at 
least in vitro [44], which may preserve the capacity of the immune system to 
generate novel T-cell responses, prevent CD8+ cell exhaustion, and allow the 
preservation of an intact adaptive immune response [45]. Sirolimus also appears 
to enhance T regulatory cell function in humans, which may have both beneficial 
and harmful effects on immune function [46, 47]. 
 
Inhibition of mTOR will likely prevent differentiation of naïve T cells and central 
memory T (TCM) cells to the different CD4+ effector T-cell lineages as the latter 

 
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differentiation steps are metabolically demanding. Sirolimus inhibits STAT-
mediated signaling and thus could inhibit homeostatic proliferation characterized 
by cytokines, such as IL-7 and IL-15, which is in part responsible for the 
maintenance of the pool of latently infected cells. These combined effects could 
collectively decrease HIV burden by preventing the generation of cells that might 
be more likely to support HIV replication, and by preventing homeostatic 
proliferation of latently-infected TCM cells. Indeed clonal expansion of resting T 
cells may be an important mechanism for HIV persistence.  Two separate groups 
have recently shown identical HIV integration sites in a limited number of genes 
which accounted for a large proportion of the infected T cells in those patients 
[48, 49].  
 
2.2.2 Rationale for other potential mechanisms through which sirolimus may reduce 
HIV-1 reservoirs 
We have recently identified additional potential avenues through which sirolimus 
treatment could potentially reduce the HIV-1 reservoir in virally suppressed 
patients. We have shown that ex vivo sirolimus treatment of purified and 
stimulated CD4+ and CD8+ cells from chronically infected patients on ART 
results in the down-regulation of PD-1 expression and expansion of central 
memory subsets [Chomont N and Sekaly RP, unpublished data]. PD-1 is 
involved in the triggering of a dysfunctional T-cell signature and plays a role in 
the establishment and maintenance of the HIV-1 reservoir [50,51]. Sirolimus 
treatment has also been shown to down-regulate PD-L1 expression (ligand for 
PD-1) on both myeloid- and monocyte-derived dendritic cells, further expanding 
the possibility of potential rescue of CD8+ effector function [52]. Furthermore, our 
preliminary data have shown that CD8+ cells from HIV-1 elite controllers show a 
transcriptional profile that is characterized by the down-regulation of the mTOR 
signal transduction pathway, a phenotype that is generated by exposure of T 
cells to sirolimus. It is possible that decreased activation of mTOR signaling in 
the T cells of elite controllers is partially responsible for superior viral control and 
reduced reservoir size in these patients. Therefore, we will explore expression 
of genes in the mTOR pathway in study participants prior to receiving and 
while on sirolimus.  
 
Taken together, these findings suggest that sirolimus has anti-HIV effects by 
improving HIV-1 cellular immunity while reducing overall cytokine-mediated 
inflammation and T-cell activation and proliferation; sirolimus therapy may have 
significant effects on the latent HIV-1 reservoir. 
 
2.2.3 Rationale for the impact of sirolimus on HIV DNA levels during ART  
In order to determine the potential role of sirolimus and other immune-
suppressing agents in accelerating the decay of the HIV reservoir, we analyzed 
cellular and plasma HIV-1 RNA and DNA levels in a cohort of ARV-treated adults 
who underwent renal transplantation [53]. All individuals in this cohort were on 
ART, had a CD4+ cell count ≥200 cells/mm3 and had undetectable plasma HIV-1 
RNA using conventional assays. The decision as to which regimen was used 
was not standardized across subjects. Most subjects received a combination 

 
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regimen that included cyclosporine, tacrolimus or sirolimus, mycophenolate, 
and/or prednisone.  
 
From this cohort, we identified those subjects (n=91) who were on a stable ART 
regimen at study entry and who did not interrupt ART for more than 3 days in the 
post-transplant period. The median pre-transplant CD4+ cell count was 510 
cells/mm3. Immunosuppressive drugs used at week 12 included cyclosporine 
(21%), tacrolimus (74%), sirolimus (9%), mycophenolate mofetil (73%), and 
prednisone (76%). Of note, the calcineurin inhibitor (cyclosporine or tacrolimus) 
was discontinued in 9% of subjects due to toxicity, and replaced by sirolimus. At 
any study time point, a maximum of nine subject received sirolimus treatment.  
 
Predictors of HIV reservoir size (which included CD4+ cell count and exposure to 
various immunosuppressive drugs as time-dependent covariates) over the 2-year 
period post-transplant were examined using univariate and multivariate linear 
repeated measures models. Subjects were censored at the time of virologic 
failure or graft loss. All variables with p<0.1 from the univariate model were 
included in an initial multivariate model. For normality of the response variable, 
log10 (for plasma HIV-1 RNA) and reciprocal (for cell-associated RNA and 
proviral DNA) transformations were used. In the multivariate model, higher 
baseline plasma HIV RNA level (p<0.0001) and white race (p=0.01) were 
associated with increased plasma HIV-1 RNA levels post-transplant.  

 
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Sirolimus use (p=0.04) and longer duration of follow-up post-transplant 
(marginally; p=0.06) were associated with a decreased proviral DNA level in the 
multivariate model (model adjusted for baseline HIV DNA, baseline CD4+ cell 
count, time-varying sirolimus use, and study week); higher baseline proviral HIV 
DNA (p<0.0001) and lower CD4+ cell count (p=0.001) were associated with 
increased proviral HIV DNA level post-transplant. Sirolimus use was also 
significantly associated with lower proviral DNA in univariate analysis (p=0.02). 
 
Figure 2: Proviral HIV DNA level over time by sirolimus exposure. 
 
 
 
Log Proviral HIV DNA
Figure 1:  HIV-1 DNA levels by sirolimus use post-transplant. 
Sample sizes represent HIV-1 DNA measurements at all time points. 

 
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As compared to subjects on other immune-modulating drugs such as 
cyclosporine and tacrolimus, the relative difference in HIV DNA levels was 
approximately 0.3 log10 copies/mL (see Figure 1). Figure 2 shows the proviral 
HIV DNA level over time by sirolimus exposure. No significant predictors of cell-
associated RNA post-transplant were identified in the multivariate model (data 
not shown). These post-hoc analyses have several limitations, including the lack 
of consistent use of sirolimus monotherapy among the study population. As a 
result, the findings may have been influenced by various uncontrollable biases, 
and further data regarding sirolimus use and viral reservoirs from the kidney 
transplant population are not available. Taken together, a proof-of-concept study 
of sirolimus in HIV-infected individuals on suppressive ART is warranted to 
elucidate the safety and efficacy of mTOR inhibition on latent reservoirs and anti-
HIV immune responses and inflammation. 
 
2.2.4 Rationale for the safety of sirolimus in HIV-infected individuals   
There is growing evidence suggesting that long-term sirolimus monotherapy in 
HIV-infected individuals on ART is safe. For example, seven participants with KS 
underwent up to 12 cumulative months of sirolimus therapy while on suppressive 
ART [14]. During therapy, no significant increases in viral load measurements 
were observed and CD4+ cell declines were mild and transient for a majority of 
study participants (total counts from all participants remained above 300 
cells/uL). CD4+ cell counts returned to pre-sirolimus levels on therapy, and 
treatment was well tolerated overall. Although all participants had at least one 
AE, most were mild (Grade 1) with Grade 3 AEs occurring in two participants. 
One AE was a dental abscess that likely was present before sirolimus initiation 
and one participant had lower extremity superficial venous thrombosis. Another 
participant required oral antibiotic treatment for pneumonia (Grade 2 AE), but 
recovered and continued on sirolimus throughout the study [14]. Another study of 
HIV individuals undergoing liver transplantation observed ten individuals who 
received sirolimus therapy to prevent graft rejection. Two participants stopped 
sirolimus therapy secondary to wound infection or thrombocytopenia [15]. 
However, these participants were on concurrent immunosuppressive therapies in 
addition to sirolimus (cyclosporine/tacrolimus) which made it difficult to ascribe 
specific events to a single drug. A more recent, large prospective study of renal 
transplantation in HIV-infected individuals on ART included 68 participants on 
sirolimus immunosuppressive therapy, including some who tolerated years of 
immunosuppression [54]. Although there was a high rate of graft rejection noted 
in the study population, AEs to immunosuppression or changes in viral or 
immunologic parameters were not addressed in detail.  
 
2.2.5 Rationale for the exclusion of patients on PI-based therapies and potential drug-
drug interactions 
Sirolimus, which is metabolized by the cytochrome P450 system, has significant 
drug-drug interactions, predominately with the PI class of ARV drugs. PIs 
significantly increase the area under the curve (AUC) and maximum 
concentration (Cmax) of sirolimus and therefore will be prohibited in this study. 
NNRTIs can potentially lead to decreased levels of sirolimus, but dosage 
adjustment up for sirolimus and careful monitoring of sirolimus levels as 

 
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proposed will be sufficient to overcome potential interactions [55,56]. In the 
recent sirolimus monotherapy study for KS, the three participants who were on 
suppressive NNRTI regimens without PIs had maximum drug trough levels of 7 
to 13, all of which are in or near the accepted, safe therapeutic range used for 
transplant rejection [14]. Furthermore, these participants were on steady-state 
doses of sirolimus that mirror those of HIV-negative participants not on ART. The 
exact effects of sirolimus on NNRTI or NRTI levels are not well described, but all 
participants, even those on PI-based regimens with inconsistent drug levels, had 
stable, sustained viral control during sirolimus treatment [14].  
 
2.2.6 Rationale for stability of virologic and immunologic measurements while on 
suppressive ART 
HIV-specific CD8+  cells frequently decline after initiation of ART [57] but recent 
unpublished data from ACTG 5281 suggest that these T-cell frequencies stabilize 
on suppressive ART and demonstrate little change over 14 weeks of observation 
[J. Jacobson, personal communication]. Furthermore, no significant changes in 
the levels of cell-associated RNA in patients on suppressive ART have been 
observed when measured at intervals 2 weeks to 2 months apart [J. Mellors, 
personal communication]. Although the prevalence of detectable low level 
residual plasma viremia varies between studies incorporating the use of the 
single-copy RNA assay, stability of residual viremia on suppressive ART has 
been demonstrated in several studies [58]. These findings support the 
assumption that there would be no change or zero mean change in these 
measurements in a placebo arm if one were to be incorporated. 
 
2.2.7  Rationale for evaluation of anal dysplasia  
The most important risk factor for HPV-related anogenital dysplasia in HIV-
infected individuals is persistent HPV infection. If sirolimus reduces the amount 
or the presence of oncogenic HPV DNA, it is possible that regression of HPV-
associated lesions will follow. Anal disease is being assessed because of ease of 
evaluation. 
 
 
3.0 
STUDY DESIGN  
A5337 is a phase I/II open-label, single-arm, pilot study of sirolimus therapy for 20 weeks 
in 30 HIV-infected individuals suppressed on non-PI continuous ART for ≥24 months 
prior to study entry with CD4+ cell count ≥350 cells/mm3. Continuous ART is defined as 
active therapy for the 24-month period prior to study entry with no treatment interruption 
longer than 7 consecutive days. 
 
There is a 12-week pre-sirolimus lead-in period to define the steady-state level of HIV-1 
pre-intervention, given planned paired analysis of primary outcomes before and after 
sirolimus treatment. Study entry is considered the time at which the 12 week pre-
sirolimus period commences. Sirolimus therapy will be initiated at study week 12. In 
order to achieve therapeutic levels, therapy will be initiated with lead-in dose of 0.025 
mg/kg/day for participants on a non-PI, non-NNRTI regimen (e.g., raltegravir) and for 
those on a non-PI, RPV-based regimen, and with 0.05 mg/kg/day for participants on an 

 
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NNRTI regimen with the exception of RPV. Doses will be adjusted based on trough 
blood sirolimus concentrations to achieve target concentrations between 5 and 10 ng/mL 
as described in section 5.1, Table 4.   
 
Sirolimus levels will be checked by FDA-approved clinical laboratory assays in a Clinical 
Laboratory Improvement Amendments (CLIA) certified laboratory. For safety and ease of 
dosing, participants will be recruited and followed only at medical centers that have 
rapid sirolimus testing available via liquid chromatography/tandem mass spectrometry 
(LC tandem MS), which enables accurate and consistent measures of levels across 
study sites. Sites without this capability are permitted to ship to Quest Diagnostic 
Laboratories for LC tandem MS testing. Results from local laboratories or from Quest 
should be available ideally within 72 hours. As there is more than one commercial assay 
available, interpretation will be based on the local site laboratory result. Results which 
are quickly available after sample receipt ensures accurate and consistent measures of 
levels across study sites. In addition, samples will be stored weekly for ARV drug level 
testing. Given the relatively small size of this pilot study and the stable plasma viral loads 
from previous sirolimus monotherapy studies in participants on ART, there are no plans 
to alter ART doses during the study. Drug level testing will be performed post study. 
Safety outcomes will be defined as the rate of new Grade ≥3 AEs, including 
signs/symptoms, lab toxicity or clinical event, that is definitely, probably or possibly 
related to study treatment, as judged by the core team, or by change (confirmed >50% 
decline or to <300 cells/mm3) in CD4+ cell counts while on sirolimus.   
 
 
4.0 
SELECTION AND ENROLLMENT OF PARTICIPANTS  
 
4.1 
Inclusion Criteria 
 
4.1.1 HIV-1 infection, documented by any licensed rapid HIV test or HIV enzyme or 
chemiluminescence immunoassay (E/CIA) test kit at any time prior to study entry 
and confirmed by a licensed Western blot or a second antibody test by a method 
other than the initial rapid HIV and/or E/CIA, or by HIV-1 antigen, plasma HIV-1 
RNA viral load. 
 
WHO (World Health Organization) and CDC (Centers for Disease Control and 
Prevention) guidelines mandate that confirmation of the initial test result must 
use a test that is different from the one used for the initial assessment. A reactive 
initial rapid test should be confirmed by either another type of rapid assay or an 
E/CIA that is based on a different antigen preparation and/or different test 
principle (e.g., indirect versus competitive), or a Western blot or a plasma HIV-1 
RNA viral load. 
 
4.1.2    Currently on continuous ART for ≥24 months prior to study entry. This is defined 
as continuous active therapy for the 24-month period prior to study entry with no 
treatment interruption longer than 7 consecutive days.  
  
4.1.3    CD4+ cell count ≥350 cells/mm3 obtained within 60 days prior to study entry at 
any US laboratory that has a CLIA certification or its equivalent, or at any 

 
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network-approved non-US laboratory that operates in accordance with Good 
Clinical Laboratory Practices (GCLP) and participates in appropriate external 
quality assurance programs. 
  
4.1.4    Plasma HIV-1 RNA below the level of quantification (e.g., <20, <40, <50, or <75 
copies/mL depending on the assay) for ≥24 months by an FDA-approved assay 
at any US laboratory that has a CLIA certification or its equivalent, or at any 
network-approved non-US laboratory that operates in accordance with GCLP 
and participates in appropriate external quality assurance programs. Participants 
must have at least one documented HIV-1 RNA below the level of quantification 
obtained 12-24 months prior to screening HIV-1 RNA and one HIV-1 RNA less 
than the level of quantification obtained within 12 months prior to the screening 
HIV-1 RNA by an FDA-approved assay (see section 4.1.5)  
  
NOTE: One month = 30 days. 
 
Two plasma HIV-1 RNA measurements above the limit of quantification but <500 
copies/mL (“two blips”) in the 24 months prior to screening are allowed if 
directly preceded and followed by HIV-1 RNA below assay limit. The screening 
value may serve as the subsequent below-assay-limit value following a 
blip. 
 
4.1.5   Plasma HIV-1 RNA level of <40 copies/mL obtained by the Abbott real time assay 
or <20 copies/mL by the Roche COBAS TaqMan HIV-1 Test, Version 2.0 assay 
within 60 days prior to study entry at any laboratory that has a CLIA certification 
or its equivalent. 
  
4.1.6 For females of reproductive potential (defined as women who have not been 
postmenopausal for at least 24 consecutive months or documentation that the 
woman has undergone hysterectomy, bilateral oophorectomy, or salpingectomy), 
negative serum or urine pregnancy test within 48 hours prior to study entry. 
 
NOTE: Participant-reported history is acceptable documentation of 
hysterectomy and bilateral oophorectomy, tubal ligation, tubal micro-inserts, 
vasectomy and menopause. 
 
4.1.7 Females of reproductive potential who are participating in sexual activity that 
could lead to pregnancy must agree to initiate effective contraceptives before 
sirolimus therapy, continue use during sirolimus therapy and maintain use for at 
least 12 weeks after sirolimus therapy has been stopped. 
 
Female participants and/or their male partners MUST agree to use 
appropriately at least one of the following: 
• 
Condoms (male or female) with or without a spermicidal agent 
• 
Diaphragm or cervical cap with spermicide 
• 
Intrauterine device (IUD) 

 
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• 
Tubal ligation 
• 
Hormone-based contraceptive  
 
NOTE: 
• 
Sexual activity with an infertile partner is not sexual activity that can lead to 
pregnancy. 
• 
Females on hormone-based contraceptives at study entry must have been on 
the same method for at least 90 days prior to study entry. 
 
4.1.8 Men and women ≥18 years of age. 
 
4.1.9 Ability and willingness of participant or legal guardian/representative to provide 
informed consent. 
 
4.1.10  Laboratory evaluations obtained within 60 days prior to entry by any US 
laboratory that has a CLIA certification or its equivalent, or at any network-
approved non-US laboratory that operates in accordance with GCLP and 
participates in appropriate external quality assurance programs. 
• 
White blood cell (WBC) ≥3000/mm3  
• 
Platelet count ≥125,000/mm3  
• 
ANC >1300/mm3 
• 
Aspartate aminotransferase (AST) <1.25 x ULN 
• 
Alanine aminotransferase (ALT) <1.25 x ULN 
• 
Calculated creatinine clearance (CrCl) ≥60 mL/min as estimated by the 
Cockcroft-Gault equation: 
 
For men, (140 – age in years) x (body weight in kg) ÷ (serum 
 
creatinine in mg/dL x 72) = CrCl (mL/min)* 
 
*For women, multiply the result by 0.85 = CrCl (mL/min) 
 
NOTE: A program to assist in calculations is available on the DMC 
 
website at: http://www.fstrf.org/ACTG/ccc.html 
• 
Fasting or non-fasting triglyceride level ≤350 mg/dL  
• 
Fasting or non-fasting LDL <160 mg/dL 
• 
Urine protein to urine creatinine ratio ≤1 g/g from random urine collection 
 
4.2 
Exclusion Criteria 
 
4.2.1 Serious illness requiring systemic treatment and/or hospitalization until 
participant either completes therapy or is clinically stable on therapy in the 
opinion of the site investigator for at least 30 days prior to study entry.  
 
4.2.2 Documentation of any CDC Category C AIDS-indicator condition or 
oropharyngeal candidiasis (thrush) within 90 days prior to study entry. 
(http://www.cdc.gov/mmwr/preview/mmwrhtml/00018871.htm) 
 
4.2.3 Intended modification of ART during the study.  
 

 
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4.2.4 Latent tuberculosis (TB) infection defined as a positive purified protein derivative 
(PPD) ≥5 mm or positive interferon-gamma release assay (IGRA) at any time in 
the past or evidence of latent TB on the screening chest x-ray without 
subsequent isoniazid or equivalent antibiotic prophylaxis.   
 
NOTE: Prophylaxis must have been completed at least 48 weeks prior to study 
entry. 
 
4.2.5 TB disease within 48 weeks prior to study entry requiring treatment. Participants 
with a history of active TB must have completed treatment at least 48 weeks prior 
to study entry.  
 
4.2.6 History of or current (within 90 days prior to study entry) active hepatitis B (HBV) 
infection defined as positive HBV surface antigen test or positive HBV DNA in 
participants with isolated HBcAb positivity. 
 
4.2.7 HCV RNA-positive within 90 days prior to study entry. 
 
NOTE: Participants who are HCV antibody negative within 90 days prior to 
study entry are eligible for the study. Those who are not taking HCV therapy and 
who are HCV antibody-positive but HCV RNA negative within 90 days prior to 
study entry are eligible for the study.   
 
4.2.8 Previously diagnosed myelodysplasia syndrome. 
 
4.2.9  History of lymphoproliferative disease prior to study entry. 
 
4.2.10 Clinically significant lung disease on the screening chest x-ray that, in the opinion 
of the site investigator, places the participant at increased risk of lung toxicity 
(e.g.,history of pulmonary fibrosis, interstitial lung disease or pulmonary 
lymphoproliferative disease). 
 
4.2.11 Any prior or current diagnosis of solid tumor or hematologic malignancies, 
excluding a history of fully excised or resolved non-melanoma skin 
cancers without evidence of prior or current metastasis. 
 
4.2.12 History of congestive heart failure as defined by physician documentation in the 
medical record at any time prior to screening that required medication for heart 
failure or that required medical management within 2 years prior to study entry.  
 
4.2.13 Detectable Epstein-Barr virus (EBV) in blood by polymerase chain reaction 
(PCR) within 90 days prior to study entry at any US laboratory that has a CLIA 
certification or its equivalent. 
 
4.2.14 Active infection other than HIV that required receipt of systemic antibiotic therapy 
by intravenous infusion within 90 days prior to study entry.  
 

 
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4.2.15 Life-threatening fungal infection that in the opinion of the site investigator 
requires treatment within 48 weeks prior to study entry. 
 
4.2.16 Herpes-zoster or varicella-zoster viral infection requiring treatment within 90 days 
prior to study entry or currently on suppressive therapy. 
 
4.2.17 History of major hypersensitivity reaction to macrolide drugs including 
angioedema, anaphylaxis, drug-induced dermatitis or hypersensitivity vasculitis. 
 
4.2.18 Currently pregnant or breastfeeding, or planning to become pregnant prior to or 
during the study. 
 
4.2.19 Use of immunomodulators (e.g., interleukins, interferons and cyclosporine), HIV 
vaccine, systemic cytotoxic chemotherapy, or investigational therapy within 90 
days prior to study entry. 
 
4.2.20 Active drug or alcohol use or dependence that in the opinion of the site 
investigator would interfere with adherence to study requirements. 
 
4.2.21 Vaccination (e.g., pneumococcal polysaccharide/influenza vaccine) within 14 
days prior to study entry.  
 
NOTE: If participants receive influenza vaccination for routine clinical care 
during or prior to the screening visit, they may be rescreened 14 days after 
vaccination.    
 
4.2.22 On a PI-based ART or cobicistat-boosted regimen within 90 days prior to study 
entry or plans to change to a PI-based or cobicistat-boosted regimen during the 
study.  
 
NOTE: Prior PI-based or cobicistat-boosted regimens are allowed. 
 
4.2.23 Anal or perianal administration of anti-HPV therapies (e.g., imiquimod, 5FU, 
veregen) for 90 days prior to study entry or plans to initiate anti-HPV therapies 
during the study. 
 
4.3 
Study Enrollment Procedures 
 
4.3.1 Prior to implementation of this protocol and any subsequent full version 
amendments, each site must have the protocol and the protocol consent form 
approved, as appropriate, by their local institutional review board (IRB)/ethics 
committee (EC) and any other applicable regulatory entity (RE). Upon receiving 
final approval, sites will submit all required protocol registration documents to the 
DAIDS Protocol Registration Office (PRO) at the Regulatory Support Center 
(RSC). The DAIDS PRO will review the submitted protocol registration packet to 
ensure that all of the required documents have been received. Protocol activation 
may be required before each site can enroll any participants. 
Site-specific informed consent forms (ICFs) will be reviewed and approved by the 

 
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DAIDS PRO and sites will receive an Initial Registration Notification from the 
DAIDS PRO that indicates successful completion of the protocol registration 
process. A copy of the Initial Registration Notification should be retained in the 
site's regulatory files. 
 
Upon receiving final IRB/EC and any other applicable RE approvals for an 
amendment, sites should implement the amendment immediately. Sites are 
required to submit an amendment registration packet to the DAIDS PRO at the 
RSC. The DAIDS PRO will review the submitted protocol registration packet to 
ensure that all the required documents have been received. Site-specific ICFs 
will not be reviewed and approved by the DAIDS PRO and sites will receive an 
Amendment Registration Notification when the DAIDS PRO receives a complete 
registration packet. A copy of the Amendment Registration Notification should be 
retained in the site's regulatory files. 
 
For additional information on the protocol registration process and specific 
documents required for initial and amendment registrations, refer to the current 
version of the DAIDS Protocol Registration Manual. 
 
Once a candidate for study entry has been identified, details will be carefully 
discussed with the participant. The participant (or, when necessary, the legal 
guardian if the participant is under guardianship) will be asked to read and sign 
the approved protocol consent form.  
 
For participants from whom a signed informed consent has been obtained, an 
ACTG Screening Checklist must be entered through the Data Management 
Center (DMC) Participant Enrollment System.  
 
For candidates from whom informed consent has been obtained, but who are 
deemed ineligible or who do not enroll into the protocol, an ACTG Screening 
Failure Results form must be completed and keyed into the database.  
 
4.3.2 Protocol Activation 
 
Prior to enrollment, sites must complete the Protocol Activation Checklist 
found on the ACTG Member website. This checklist must be approved prior 
to any screening of participants for enrollment.  
 
4.3.3 Participant Registration 
 
Participants who meet eligibility criteria for A5337 will be registered to A5337 
according to standard ACTG DMC procedures.  
 
4.4 
Coenrollment Guidelines  
 
• 
A5128, “Plan for Obtaining Informed Consent to Use Stored Human Biological 
Materials (HBM) for Currently Unspecified Analyses”: Coenrollment in A5128 is 
encouraged and does not require permission from the A5337 protocol chairs. 

 
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• 
A5321, Decay of HIV-1 Reservoirs in Subjects  on Long-Term Antiretroviral  
Therapy: The ACTG HIV Reservoirs Cohort Study, and/or A5322, Long-Term 
Follow-up of Older HIV-infected Adults in the ACTG: Addressing Issues of Aging, 
HIV Infection and Inflammation, do not require permission from the A5337 
protocol chairs provided that sites can remain within site-specific blood volume 
limits 
• 
A5332 (REPRIEVE), Randomized Trial to Prevent Vascular Events in HIV, is 
allowed as long as participants are not enrolled in any of the REPRIEVE 
immunology substudies. 
• 
A5351s, Effect of Immune-Modulatory Interventions on Cytomegalovirus 
Replication during Suppressive Antiretroviral Therapy.  Coenrollment in 
A5351s is encouraged and does not require permission from the A5337 
protocol chairs. 
• 
For specific questions and approval for coenrollment in other studies, sites 
should first check the A5337 PSWP or contact the protocol team via e-mail as 
described in the Study Management section.   
 
 
5.0 
STUDY TREATMENT  
 
5.1 
Regimens, Administration and Duration 
 
Eligible participants will be stratified at study entry by class of ART regimen as follows: 
 
Participants taking a non-PI, non-NNRTI containing regimen, and those on a non-PI, 
RPV-based regimen, will initially receive: 
 
• 
Sirolimus 0.025 mg/kg/day administered orally once daily with or without food. See 
Table 2. 
 
Participants taking an NNRTI containing regimen (with the exception of RPV) will 
initially receive: 
 
• 
Sirolimus 0.05 mg/kg/day administered orally once daily with or without food. See 
Table 3. 
 
In order to achieve therapeutic levels, therapy will be initiated with the dosage noted 
above and dosing will be subsequently adjusted based on trough blood sirolimus 
concentrations to achieve target concentrations between 5 and 10 ng/mL (see Table 4).  
A detailed dosing table based on the adjustment algorithm in Table 4 can be found on 
the A5337 PSWP. 

 
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Table 2. Sirolimus Dosing at 0.025mg/kg 
Weight 
Initial daily dose  
25% increase* 
25% reduction* 
50 to 70 kg 
1.5 mg 
2 mg 
1 mg 
71 to 90 kg 
2.0 mg 
2.5 mg 
1.5 mg 
91 to 110 kg** 
2.5 mg 
3 mg  
2.0 mg  
*Dose adjustment based on sirolimus trough level.  
**For participants weighing >110 kg, the sirolimus dose needs to be clarified by the team.  
 
 
Table 3. Sirolimus Dosing at 0.05mg/kg 
Weight 
Initial daily dose 
25% increase* 
25% reduction* 
50 to 70 kg 
3 mg 
4 mg 
2 mg 
71 to 90 kg 
4 mg 
5 mg 
3 mg 
91 to 110 kg** 
5 mg 
6.5 mg 
4 mg  
*Dose adjustment based on sirolimus trough level  
**For participants weighing >110 kg, the sirolimus dose needs to be clarified by the team.  
 
Table 4. Sirolimus Dose Adjustment Algorithm 
Sirolimus level 
Dose adjustment* 
<5 ng/mL 
Increase dose by 25%,  
5-10 ng/mL 
Continue current dose 
>10, <15 ng/mL 
Reduce dose by 25% 
>15, <20/ng/mL 
Hold dose for 48 hours, then decrease dose by 25% 
>20/ng/mL 
Hold dose until next level check, if <12 ng/mL, then 
restart study drug at 50% prior dose 
*Round dose up to closest sirolimus 0.5mg tablet. Sirolimus tablets cannot be split, crushed or 
chewed. 
 
Participants will initiate study treatment at week 12 and continue for 20 weeks. 
Participants will be followed off-treatment for an additional 12 weeks for a total of 44 
weeks. Treatment must be initiated within 72 hours of week 12 (day 0) evaluations (see section 
6.2.3). 
 
5.2 
Study Product Formulation and Preparation 
 
Sirolimus tablets are obtained from Greenstone LLC. The inactive ingredients 
include sucrose, lactose, polyethylene glycol 8000, calcium sulfate, 
microcrystalline cellulose, pharmaceutical glaze, talc, titanium dioxide, 

 
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magnesium stearate, povidone, poloxamer 188, polyethylene glycol 20,000, 
glyceryl monooleate, carnauba wax, di-alpha tocopherol and other ingredients.  
 
Sirolimus tablets 0.5 mg will be provided. These tablets also contain yellow iron 
(ferric) oxide and brown iron (ferric) oxide. They should be stored at 20° to 25°C 
[USP Controlled Room Temperature] (68° to 77°F). Dispense in a tight, light-
resistant container as defined in the USP. 
 
5.3 
Pharmacy: Product Supply, Distribution, and Accountability 
 
5.3.1 Study Product Acquisition/Distribution 
 
Sirolimus will be available through the NIAID Clinical Research Products 
Management Center (CRPMC). The site pharmacist should obtain the study 
product(s) for this protocol by following the instructions in the manual Pharmacy 
Guidelines and Instructions for DAIDS Clinical Trials Networks.  
 
Any study product not provided by the study must comply with the NIAID 
(DAIDS) policy that outlines the process for authorizing the use of study products 
not marketed in the US in NIAID (DAIDS)-supported and/or –sponsored clinical 
trials.  
 
5.3.2 Study Product Accountability 
 
The site pharmacist is required to maintain complete records of all study products 
received from the NIAID CRPMC and subsequently dispensed. All unused study 
products in US CRSs must be returned to the NIAID CRPMC (or as otherwise 
directed by the sponsor) after the study is completed or terminated. The 
procedures to be followed are in the manual Pharmacy Guidelines and 
Instructions for DAIDS Clinical Trials Networks.  
 
5.4 
Concomitant Medications 
 
Whenever a concomitant medication or study agent is initiated or a dose changed, 
investigators must review the concomitant medication’s and study agent’s most recent 
package insert, Investigator’s Brochure, or updated information from DAIDS to obtain the 
most current information on drug interactions, contraindications, and precautions. 
 
Additional drug information may be found on the updated ACTG Precautionary and 
Prohibited Medications Database located at: 
http://tprc.pharm.buffalo.edu/home/di_search/ 
 
5.4.1 Required Medications 
 
Continuous ART, defined as active therapy with no treatment interruption longer 
than 7 consecutive days and a total duration off ART of no more than 7 days, is 
required through week 44. Changes in the regimen are allowed as long as a PI-
based or cobicistat-boosted regimen is not initiated. 

 
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5.4.2 Prohibited Medications 
 
These medications should be discontinued prior to study entry week 0 and are 
prohibited through week 32: 
• 
Verapamil or diltiazem 
• 
Protease inhibitors 
• 
Medications known to be potent CYP3A inhibitors, (e.g., ritonavir, cobicistat, 
ketoconazole, or erythromycin) 
• 
Anal or perianal administration of anti-HPV therapies (e.g., imiquimod, 5FU, 
veregen) 
• 
Use of immunomodulators such as interleukins, interferons, and cyclosporin, 
HIV vaccine, systemic cytotoxic chemotherapy or investigational therapy 
 
• 
Tacrolimus, mycophenalate mofetil, TNF-modulating medications, plaquenil 
or monoclonal antibodies targeting lymphocytes 
• 
HPV vaccine 
• 
Standard-of-care vaccines (e.g., pneumococcal polysaccharide or influenza 
vaccine within 14 days prior to study entry or 14 days prior to any post-entry 
study visit)   
 
 
5.4.3 Precautionary Medications 
 
 
 
 
 
A list of precautionary medications can be found on the A5337 PSWP. 
 
 

 
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6.0 
CLINICAL AND LABORATORY EVALUATIONS 
 
6.1 
Schedule of Events 
 
Evaluation 
Screening 
Entry 
Sirolimus 
Initiation 
Post-Entry Evaluations 
Premature 
Treatment or Study 
Discontinuation 
Confirmation of CD4 
Decrease 
Confirmation of 
Virologic Failure 
Week 
0 
12 
13 
14 
16 
20 
24 
32 
44 
Days Post-Sirolimus Initiation 
0 
4 
11 
28 
56 
84 
140 
224 
Window 
Within 60 
days prior 
to entry  
 
±1 week 
±1 day (same 
days as PK) 
±1 week (same 
days as PK) 
±2 
weeks 
Documentation of HIV 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Medical & Medication History 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
Clinical Assessment 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Complete Physical Exam 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Targeted Physical Exam 
 
X 
X 
 
X 
X 
X 
X 
X 
 
X 
X 
X 
Hematology 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Liver Function Tests 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Blood Chemistry 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Calculated Creatinine Clearance 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Urinalysis 
X 
 
X 
 
 
X 
X 
X 
 
 
 
 
 
Pregnancy Testing  
X 
X 
X 
if indicated 
 
 
 
Hepatitis Serology (see section 6.3.5) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Assessment for Reactivation of Latent 
EBV 
X 
 
 
 
 
 
X 
X 
X 
X 
X 
 
 
CD4+/CD8+  
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
 

 
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Evaluation 
Screening 
Entry 
Sirolimus 
Initiation 
Post-Entry Evaluations 
Premature 
Treatment or Study 
Discontinuation 
Confirmation of CD4 
Decrease 
Confirmation of 
Virologic Failure 
Week 
0 
12 
13 
14 
16 
20 
24 
32 
44 
Days Post-Sirolimus Initiation 
0 
4 
11 
28 
56 
84 
140 
224 
Window 
Within 60 
days prior 
to entry  
 
±1 week 
±1 day (same 
days as PK) 
±1 week (same 
days as PK) 
±2 
weeks 
Cryopreserved PBMCs for HIV-1 
Gag-specific CD8+ and CD4+ cell 
Immunity 
 
X 
X 
X 
 
X 
 
X 
X 
X 
X 
 
 
Stored Plasma for Inflammatory and 
Coagulation Markers 
 
X 
X 
X 
 
X 
 
X 
X 
X 
X 
 
 
Cryopreserved PBMCs for Markers of 
T-cell Activation and Proliferation 
 
X 
X 
X 
 
X 
 
X 
X 
X 
X 
 
 
Cryopreserved PBMCs for 
Exploratory Studies 
 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
 
 
Stored Plasma for Antibody 
Quantitation 
 
X 
X 
X 
 
 
 
X 
X 
X 
X 
 
 
Plasma HIV-1 RNA  
X 
X 
X 
 
 
X 
X 
X 
X 
X 
X 
 
X 
HIV-1 Drug Resistance Genotyping 
(see section 6.3.7) 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Cryopreserved PBMCs for Inducible 
RNA  Assay 
 
 
X 
 
 
 
 
X 
X 
X 
X 
 
 
Cryopreserved PBMCs for Cell-
Associated RNA and DNA  
 
X 
X 
X 
 
X 
 
X 
X 
X 
X 
 
 
Stored Plasma for Residual Viremia 
by Single-Copy RNA Assay 
 
X 
X 
X 
 
X 
 
X 
X 
X 
X 
 
 
Stored Whole Blood for Gene 
Expression Assay 
 
 
X 
X 
 
X 
 
X 
X 
X 
 
 
 
Stored Plasma and PBMCs for Future 
Unspecified Testing 
 
X 
X 
X 
 
X 
 
X 
X 
X 
X 
 
 
Tuberculosis Test  (see section 
6.3.11) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Chest Radiograph 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Anal Swabs/Anal Pap Test 
 
 
X 
 
 
 
 
 
X 
 
 
 
 
Oral Swabs 
 
X 
X 
X 
 
X 
 
X 
X 
X 
X 
 
 

 
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6.1.1 Pharmacokinetic Evaluations 
 
See section 6.3.12 for additional details. 
 
Pharmacokinetic (PK) Sampling 
Evaluation 
 
Weeks 12-16 
Weeks 18-32 
Week 
12 
13 
13 
14 
14 
15 
15 
16 
16 
18 
20 
24 
28 
32 
Day 
0 
4 
7 
11 
14 
18 
21 
25 
28 
Window 
±1 day (timed with other study visits as in section 6.1 
±1 week (timed with other study visits as in 
section 6.1) 
PK Whole Blood Samples  
for Trough Sirolimus Real-
time Monitoring (see 
section 6.3.12 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Stored Plasma for ARV PK 
(see section 6.3.12) 
X 
X 
 
X 
 
 
 
 
X 
X 
 
X 
X 
X 

 
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6.2 
Timing of Evaluations 
 
6.2.1 Screening Evaluations  
 
Screening evaluations must occur before any study medications, treatments or 
interventions. 
 
Screening evaluations to determine eligibility must be completed within 60 days prior 
to study entry, unless otherwise specified.  
 
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 Failure Results form and entered into the ACTG database.  
 
6.2.2 Entry Evaluations 
 
Entry evaluations, including collection of all entry specimens, must occur at least 48 
hours after screening evaluations, unless otherwise specified, and prior to the 
participant’s starting any study medications, treatments, or interventions.  
 
6.2.3 Post-Entry Evaluations 
 
Prior to starting sirolimus, laboratory measurements from the week 12 visit must be 
assessed to ensure that the criteria detailed in section 4.1.6 and 4.1.10 continue to 
be satisfied, as well as week 12 CD4+ cell count >300 cells/mm3.  If any criterion is 
not satisfied, the study team should be promptly contacted and sirolimus should not 
be started. In addition, concomitant medications must be re-assessed at the week 12 
visit to ensure that the participant has not received any prohibited medications since 
study entry. If so, the study team should be promptly contacted and sirolimus should 
not be started. 
 
Participants must begin study treatment within 72 hours after receipt of results from 
the study week 12 evaluations.  
 
Site staff is encouraged to contact participants at least 14 days prior to scheduled 
study visits (not PK-only visits) to remind participants not to receive any 
vaccinations prior to their visit.  A reminder can also be given that prohibited 
medications are not allowed at any time while on study. 
 
For stored samples, all sites must have established procedures for regular 
reconciliation and verification of specimens, which must be followed throughout the 
study per the Lab Processing Chart (LPC). Collection of sample aliquots is of 
particular importance at the pre-sirolimus time points (entry and week 12) and at the 
study week 32 time point. In the event that the required volume or number of sample 
aliquots is not obtained at any time point, designated site clinic and/or lab staff must 
immediately inform the study team, who will provide guidance on how to respond to 
the problem.   

 
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In addition to following this guidance from the study team, designated site clinic and 
lab staff will work together to document the problem, take appropriate corrective and 
preventive action, and document all action taken. Reconciliation must be performed 
for all specimen types that are received by the laboratory and stored in the LDMS.  
 
For other evaluations, if an evaluation is not completed at a scheduled visit, effort 
should be made to obtain the evaluation as soon as possible.  If unsuccessful, 
complete the evaluation at the next study visit if not already included as part of the 
regularly scheduled visit. 
 
NOTE: Sites must contact the A5337 core team prior to the scheduled week 12 visit, 
ideally at least 2 weeks before, for confirmation that a participant may begin study 
treatment based on availability of stored samples at study entry. This confirmation 
must be documented in the source document prior to initiation of sirolimus. 
 
On-Treatment Evaluations (weeks 12 through 32)  
The window for week 12 is ±1 week and for weeks 13 through 16 is ±1 day as visits 
will be timed with the PK evaluations. The window for weeks 20 through 32 is ±1 
week.  
 
NOTE: Starting with week 12, days should be counted from the first date of actual 
sirolimus dosing. Day 0 is the date of the first dose of sirolimus. 
 
Post-Treatment Evaluations (week 44)  
The week 44 visit is the final study visit. The window for the week 44 visit is ±2 
weeks.  
 
Event Driven Evaluations 
Confirmation visit to confirm CD4+ cell count <300 cells/mm3 or >50% CD4+ 
decrease from study entry value or HIV-1 RNA >200 copies/mL (see sections 7.1.4 
and 7.1.5) should be scheduled within 1 week of receipt of the abnormal lab value.  If 
confirmed CD4+ cell count <300 cells/mm3 or >50% CD4+ decrease from study entry 
value or HIV-1 RNA >200 copies/mL, the study team should be promptly contacted 
and sirolimus should not be started or should be stopped if already started. 
 
6.2.4 Discontinuation Evaluations 
 
Evaluations for Registered Participants Who Do Not Start Study Treatment 
Site personnel should notify the protocol team (actg.corea5337@fstrf.org) within 48 
hours of any participant who is registered and does not begin treatment at week 12. 
All case report forms must be completed and keyed for the period up to and including 
week 12.  Participants who do not start study treatment at week 12 will be taken off 
the study and will be replaced after completing all week 12 evaluations listed on the 
SOE. 
 

 
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Premature Treatment Discontinuation Evaluations  
Participants who prematurely discontinue the study treatment prior to week 32 will 
have the Premature Treatment Discontinuation visit per the SOE, performed as soon 
as possible, and then continue study follow-up through week 44. Participants should 
have all PK sampling performed until the next scheduled dosing visit; then PK 
sampling should be discontinued. Participants will be followed on study/off study 
treatment. 
 
Site personnel should notify the protocol core team (actg.corea5337@fstrf.org) within 
48 hours of any participant who prematurely discontinues the study treatment. 
 
Premature Study Discontinuation Evaluations 
Participants who prematurely discontinue the study will have the Premature Study 
Discontinuation visit per the SOE, performed as soon as possible prior to being taken 
off the study.  
 
Site personnel should notify the protocol core team (actg.corea5337@fstrf.org) within 
48 hours of any participant who prematurely discontinues the study. 
 
6.3 
Instructions for Evaluations 
 
All clinical and laboratory information required by this protocol is to be present in the source 
documents. Sites must refer to the Source Document Guidelines on the DAIDS Web site for 
information about what must be included in the source document: 
http://www.niaid.nih.gov/labsandresources/resources/daidsclinrsrch/documents/sourcedoca
ppndx.pdf 
 
All stated evaluations are to be recorded on the CRF and keyed into the database unless 
otherwise specified. This includes events that meet the International Council on 
Harmonisation (ICH) definitions for a serious adverse event: 
 
• 
Results in death 
• 
Life-threatening 
• 
Requires inpatient hospitalization or prolongation of existing hospitalization 
• 
Results in persistent or significant disability/incapacity  
• 
Congenital anomaly/birth defect 
• 
Other important medical event (may not be immediately life-threatening or result in death 
or hospitalization but may jeopardize the patient or may require intervention to prevent 
one of the events listed above.   
 
To grade diagnoses, signs and symptoms, and laboratory results, sites must refer to the 
DAIDS Table for Grading the Severity of Adult and Pediatric Adverse Events (DAIDS AE 
Grading Table), Version 2.0, November 2014 which can be found on the DAIDS RSC Web 
site: http://rsc.tech-res.com/safetyandpharmacovigilance/.   
 

 
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6.3.1 Documentation of HIV-1 
 
Section 4.1.1 specifies assay requirements for HIV-1 documentation. HIV-1 
documentation is not recorded on the CRF. 
 
6.3.2 Medical History 
 
The medical history must include all diagnoses within the 30 days prior to study entry 
identified by the ACTG criteria for clinical events and other diagnoses, as well as the 
following diagnoses, regardless of when the diagnosis was made, and recorded on a 
CRF. For current criteria, refer to the appendix identified on the study CRF.   
 
• 
AIDS-defining conditions 
• 
Bone fractures (verbal history accepted) 
• 
Coronary heart disease 
• 
Cancer  
• 
Myelodysplastic, myeloproliferative  or lymphoproliferative disorders 
• 
Diabetes 
• 
Tuberculosis 
• 
Non-tuberculus mycobacterial infection 
• 
Chronic hepatitis B 
• 
Chronic hepatitis C 
• 
Human papilloma virus (HPV; including cervical dysplasia/neoplasia and 
anogenital warts) 
• 
Kidney disease 
• 
Obstructive or restrictive lung disease 
• 
Interstitial lung disease 
• 
Endocrine disorders including fertility disorders 
• 
Thyroid disease 
• 
Treatment for HPV-related disease 
 
Any allergies to any medications and their formulations must also be documented. 
Document the pre-ART HIV-1 RNA level and CD4+ count, if available.  If pre-
ART HIV-1 RNA level or CD4+ count documentation is not available, then 
collect and record what the participant remembers.  Document the date of first 
undetectable HIV-1 RNA level prior to sustained viral load suppression (may be 
estimated if exact date not available) and the date(s) of any previous virologic 
failure on ART.  The medical history evaluation will be assessed at the 
screening and entry visit and recorded on the CRFs at the study entry visit.  
 
6.3.3 Medication History 
 
A medication history must be present, including start and stop dates. The table below 
lists the medications that must be included in the history.  

 
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Medication Category 
Timeframe 
Antiretroviral therapy 
Complete history 
(start and stop dates required 
only for ART taken within past 2 
years and date of first use of 
ART) 
Immune-based therapy 
(e.g., interleukins, interferons, 
cyclosporine, TNF-modulating 
drugs/monoclonal antibodies) 
Complete history 
HIV-1-related vaccines 
Complete history 
Drugs for treatment or 
prevention of opportunistic 
infections 
Complete history 
Prescription and non-
prescription drugs 
All cardiac or renal medications 
taken currently and within 12 
months prior to study entry 
(including HMG-CoA reductase 
inhibitors, calcium channel 
blockers) 
 
All other medications within 3 
months prior to study entry 
Dietary supplements 
Within 3 months prior to study 
entry 
Any prohibited medications. See 
section 5.4.2. 
30 days prior to study entry 
 
6.3.4 Clinical Assessments 
 
Complete Physical Exam 
A complete physical examination to include at a minimum an examination of the skin, 
head, mouth, and neck; auscultation of the chest; cardiac exam; abdominal exam; 
examination of the lower extremities for edema. The complete physical exam will 
also include signs and symptoms, diagnoses and vital signs (temperature, pulse, 
respiration rate, pulse oximetry and blood pressure). 
 
Targeted Physical Exam 
A targeted physical examination to include vital signs (temperature, pulse, respiration 
rate, pulse oximetry and blood pressure); examination of the skin, head, mouth, and 
neck; auscultation of the chest; cardiac exam; and is to be driven by any previously 
identified or new signs or symptoms and diagnoses that the participant has 
experienced since the last visit. Assessment of new pulmonary symptoms, including 
cough, shortness of breath and dyspnea on exertion will be included in the targeted 
exam. 

 
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Height 
Height will be recorded at entry.  
 
Weight 
Weight will be recorded at entry and all subsequent study visits. 
 
Signs and Symptoms 
At entry, all grades of signs and symptoms that occurred within 30 days before entry 
must be recorded; post-entry, all grades of Grade ≥2 must be recorded. Record on 
the CRF and key within 48 hours all signs and symptoms regardless of grade that 
led to a change in study treatment or a change in ART. All Grade 3 or higher 
sign/symptom, any sign/symptom regardless of grade that led to a change in study 
treatment, or that met ICH, EAE or SAE guidelines, are defined by the protocol as 
reportable events that will require more detailed event reporting and keying within 48 
hours. 
 
Diagnoses 
After entry, record all diagnoses identified by the ACTG criteria for clinical events and 
other diseases. Diagnoses must be recorded and keyed within 48 hours of the 
evaluation. 
 
Concomitant Medications 
After entry, record new or discontinued concomitant prescription and nonprescription 
drugs since the last visit. 
 
ART Medication Modifications 
At entry, record all ongoing ART. After entry, record all modifications in ART, 
including initial doses and/or missed doses (defined as more than 2 consecutive 
doses), inadvertent and deliberate interruption, and discontinuation.  
 
Study Treatment Modifications 
Record on the CRF and key within 48 hours all modifications in sirolimus dosing, 
including initial doses and/or missed doses, inadvertent and deliberate interruption 
and permanent discontinuation.  
 
6.3.5 Laboratory Evaluations 
 
Refer to the A5337 Laboratory Processing Chart (LPC) posted on the PSWP for 
processing, shipping, and storage information. 
 
The screening and entry protocol-required laboratory values, regardless of grade, 
must be recorded. For post-entry assessments, record on the CRF and key within 
48 hours, lipid values, glucose, hematology, liver function tests, calculated CrCl, 
serum creatinine values regardless of grade and all other Grade ≥3 laboratory 
values. In addition, record on the CRF and key within 48 hours all laboratory 
values regardless of grade that led to a change in study treatment or a change in 
ART. All Grade 3 or higher laboratory values, any laboratory value regardless of 

 
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grade that led to a change in study treatment, or that met ICH, EAE or SAE 
guidelines, are defined by the protocol as reportable events that will require more 
detailed event reporting and keying within 48 hours. 
 
Hematology 
Hemoglobin, hematocrit, white blood cell count (WBC) with differential, absolute 
neutrophil count (ANC), platelets. 
 
Liver Function Tests 
Total bilirubin, direct bilirubin, indirect bilirubin, albumin, AST (SGOT), ALT (SGPT), 
alkaline phosphatase, creatine kinase (CK). 
 
Blood Chemistries 
Glucose, triglycerides, cholesterol (total, LDL), electrolytes (e.g., sodium, potassium, 
chloride, bicarbonate), lactate dehydrogenase (LDH), creatinine, blood urea nitrogen 
(BUN), total protein, albumin, globulin (globulin may need to be calculated from the 
total protein and albumin). Lipid levels may be drawn non-fasting (see section 7.2.5 
for management of elevated levels). 
 
Calculated CrCl 
Estimated each time that a serum creatinine level is determined. To estimate 
calculated CrCl, use the Cockcroft and Gault equation (see section 4.1.10). 
 
Urinalysis 
Random urinalysis for urine protein to urine creatinine ratio. 
 
Pregnancy Test 
For women with reproductive potential: At screening (before chest x-ray) negative 
serum or urine pregnancy test with a sensitivity range of ≤25 mIU/mL, 48 hours prior 
to study entry and again at week 12 with results available before initiation of study 
drug, and at any time during the study when pregnancy is suspected. 
 
Hepatitis Serology 
For participants with known HBV immunity, prior documentation of positive HBsAb 
is acceptable. If documentation is not available, HBsAb, HBsAg, and HBcAb will be 
obtained at screening. Negative HBV tests (i.e., negative HBsAb, HBsAg, and 
HBcAb) performed within 6 months prior to enrollment need not be repeated. If the 
last negative test result is more than 6 months prior to enrollment, then testing 
should be performed at screening.  Results must be available prior to study entry so 
that participants who have active HBV can be excluded from participating in the 
study.  
 
Participants who have positive HBcAb but negative HBsAg and HBsAb (isolated 
HBcAb positive status) must have HBV DNA PCR performed and confirmed as 
negative for participant to be eligible for A5337. HBV DNA PCR will not be provided 
by A5337.  
 

 
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HCV antibody test (and HCV RNA if the HCV Ab test is positive) should be obtained 
at screening. Results must be available prior to study entry. 
 
Assessment for Reactivation Latent EBV 
Performed on serum or plasma using a clinical quantitative PCR-based test at a 
laboratory that has CLIA certification or its equivalent (see section 7.1.6) and results 
from all testing recorded on a CRF. 
 
6.3.6 Immunologic Studies 
 
CD4+/CD8+ 
Obtain absolute CD4+/CD8+ count and percentages within 60 days prior to entry and 
per the SOE at any US laboratory that possesses a CLIA certification or its 
equivalent, or at any network-approved non-US laboratory that operates in 
accordance with GCLP and participates in appropriate external quality assurance 
programs.  
 
During the study, all laboratories must possess a CLIA certification or equivalent and 
must be certified for protocol testing by the DAIDS Immunology Quality Assurance 
(IQA) Program. 
 
Cryopreserved PBMCs for HIV-1 Gag-specific CD8+  and CD4+ cell Immunity 
PBMC for flow cytometric testing of the frequency of HIV-1 Gag-specific and other 
non-specific responses in CD8+ and CD4+ cells by intracellular staining for IFN-
gamma will be stored for analysis. In addition, HLA genotyping will be performed 
(entry visit only). 
 
Stored Plasma for Inflammatory and Coagulation Markers 
Plasma for soluble markers of inflammation (including IL-6, IL-7, IL-15) will be stored 
for analyses.  
 
Cryopreserved PBMCs for Markers of T-cell Activation and Proliferation 
Testing for T-cell activation and proliferation (% CD4+ and CD8+ cells CD38+/HLA-
DR+, CD25+, PD-1+, PD-L1, Ki67+) will be performed concomitantly to the primary 
immunologic objectives. 
 
Cryopreserved PBMCs for Exploratory Studies 
B cell phenotyping, rearrangements and class switching determination will also be 
performed on cryopreserved cells as an exploratory objective. 
 
Stored Plasma for Antibody Quantitation 
Plasma will be stored for HIV-1-specific antibody quantitation including the use of 
assays that measure antibody levels, avidity and the breadth of antibody responses 
in peptide microarrays. 
 

 
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6.3.7 Virologic Studies  
 
Plasma HIV-1 RNA 
Screening HIV-1 RNA must be performed within 60 days prior to study entry by the 
Abbott RealTime HIV-1 assay or Roche COBAS TaqMan HIV-1 Test, Version 2.0 
assay at any laboratory that possesses a CLIA certification or its equivalent.  
 
After screening, all plasma HIV-1 RNAs should be performed by the Abbott 
RealTime HIV-1 assay at any laboratory that possesses a CLIA certification or its 
equivalent. Shipping should be done in an expeditious manner, preferably the day 
the sample is obtained.  
 
HIV-1 Drug Resistance Genotyping 
 
 
Resistance genotyping will be performed in those individuals with confirmed  
 
 
HIV-1 RNA >200 copies/mL on two consecutive assessments using the sample  
 
 
from the first of the two time points with HIV-1 RNA >200 copies/mL. Upon  
 
 
confirmation of virologic failure, a sample from the first time point having a  
 
 
viral load at least 1000 copies/mL will be sent for HIV-1 drug resistance   
 
 
genotyping. 
 
6.3.8 Viral Reservoir Studies 
 
Cryopreserved PBMCs for Inducible RNA  Assay 
The quantitative inducible RNA assay will be performed on resting CD4+ cells 
obtained from cryopreserved PBMC.  
 
Cryopreserved PBMCs for Cell-Associated RNA and DNA  
The cell-associated HIV-1 RNA and DNA will be performed on cryopreserved PBMC.  
 
NOTE: Extraction, purification and quantification of cell-associated RNA and DNA 
will take place simultaneously on the same cryopreserved PBMC aliquot. 
 
Stored Plasma for Residual Viremia by Single-Copy RNA Assay 
Refer to the LPC for blood volumes.   
 
6.3.9 Gene Expression Studies 
Whole blood will be stored for gene expression assays.  
 
6.3.10 Stored Samples for Future Unspecified Assays  
 
Plasma and PBMCs will be collected, processed, and stored for future unspecified 
immunologic and exploratory aims, if the allowed maximum blood volume is not 
exceeded.  
 

 
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6.3.11 Procedures 
 
Tuberculosis Test 
Purified protein derivative tuberculin skin testing (TST) will be performed at screening 
for participants with either no prior or negative TB testing. Participants with prior 
positive TB screening tests do not need to have repeat TB testing. TST sites will be 
evaluated for induration between 48 and 72 hours after the PPD dose is 
administered. An induration of ≥5 mm will be considered positive. TB screening may 
also be performed by blood tests (also called interferon-gamma release assays or 
IGRAs), and is the screening of choice for individuals who have received Bacillus 
Calmette–Guérin (BCG) vaccine. TB results do not need to be recorded on a CRF. 
 
Chest Radiograph 
At screening (after pregnancy test) a posterior-anterior (PA) and lateral chest x-ray 
will be performed and reviewed by site staff for evidence of lung disease including 
active or latent tuberculosis. Chest x-ray results do not need to be recorded on a 
CRF. 
 
Anal Swabs/Anal Pap Test 
Refer to the A5337 Anal Swab Instruction Sheet posted on the PSWP for processing 
and shipping information. 
 
 
 
Anal swabs will be collected for HPV DNA quantification. Specimens will be frozen 
 
 
and stored.   
 
 
 
Anal Pap tests will be performed at a laboratory that has CLIA certification 
 
 
or its equivalent and the result will be recorded on a CRF. No specimens  
 
 
need to be collected if anal Pap tests were done as part of routine medical care  
 
 
outside the study ±4 weeks of the scheduled study visit and tested in a CLIA certified 
 
 
laboratory, but results need to be recorded. 
 
 
 
Oral Swabs 
Oral swabs will be collected to evaluate whether the use of sirolimus is 
associated with more frequent reactivation or suppression of HHV.  Refer to 
the A5337 LPC posted on the PSWP for processing and shipping information. 
 
6.3.12 Pharmacokinetic Samples 
 
PK Monitoring of Sirolimus 
Trough sirolimus levels (whole blood) will be collected 4 days after administration of 
the first dose of sirolimus and will be analyzed and reported in real time. Trough 
samples will then be drawn twice a week (approximately days 4 and 7 of each week) 
for up to 4 weeks until two consecutive drug levels fall within 5-10 ng/mL.  Once two 
consecutive levels fall within 5-10 ng/mL (which may be achieved before the 4-week 
time point after sirolimus is initiated), trough samples will be drawn every 4 weeks 
until study week 32 (see section 6.1.1). 
 

 
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The windows for PK sampling are ±1 day through week 16 and ±1 week for weeks 
18 through 32. 
 
Stored Plasma for PK Exposure Estimates of ARVs 
In addition to real-time sirolimus testing, stored plasma will be collected for batched 
analysis of ARV drug concentrations.  
 
PK Dosing Restrictions 
Participants having PK sampling should be instructed to hold their morning doses of 
sirolimus and ARVs so a trough sample can be collected.  Once trough samples 
have been collected, participants can take their normal morning doses of sirolimus 
and ARVs. For participants taking EFV, the evening dose can be taken and the time 
of the last dose recorded when participants come to the clinic for PK blood draws.  
  
PK Data Collection 
For sirolimus and ARV PK collection visits, food intake, and date, time and amount of 
the last three doses of sirolimus and ARVs will be recorded on the CRF. 
 
 
7.0 
CLINICAL MANAGEMENT ISSUES  
 
Criteria for participant management, dose interruptions, modifications and discontinuation 
of treatment will be mandated only for toxicities attributable to sirolimus. 
 
The grading system for drug toxicities is located in the Division of AIDS Table for Grading 
the Severity of Adult and Pediatric Adverse Events, Version 2.0, November 2014, which 
can be found on the DAIDS RSC Web site: http://rsc.tech-
res.com/safetyandpharmacovigilance/.  
 
NOTE: The protocol core team must be notified by e-mail at actg.corea5337@fstrf.org within 
48 hours regarding toxicities that result in a change in study treatment (including permanent 
discontinuation) during the study-defined 20-week treatment period.  
 
7.1 
Toxicity  
 
7.1.1 Grade 1 or 2 Toxicity 
 
Participants who develop a Grade 1 or 2 AE or toxicity felt to be related to study 
drug may continue study treatment. If a participant chooses to discontinue study 
treatment, the site should notify the protocol core team at actg.corea5337@fstrf.org 
within 48 hours and follow the participant on study/off study treatment. 
 
7.1.2 Grade 3 Toxicity 
 
• 
If the investigator has compelling evidence that the AE has NOT been caused by 
the study drug, dosing may continue. Participants who develop a Grade 3 AE or 
toxicity, except as stated in the following sections, should have sirolimus 

 
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withheld, and the A5337 core team consulted. The participant should be 
reevaluated weekly until the AE returns to Grade <2, at which time the study drug 
may be reintroduced at the discretion of the investigator or according to standard 
practice.  
• 
If the same Grade 3 AE recurs within 4 weeks, the study drug must be 
permanently discontinued if the investigator considers the AE related to study 
drug. However, if the same Grade 3 AE recurs after 4 weeks, the management 
scheme outlined above may be repeated. 
• 
Participants experiencing Grade 3 AEs requiring permanent discontinuation of 
study drug should be followed weekly until resolution of the AE and should be 
encouraged to complete the early discontinuation evaluations and continue in on-
study follow-up. 
 
7.1.3 Grade 4 Toxicity 
 
• 
Participants who develop a Grade 4 symptomatic AE or toxicity will have study 
drug permanently discontinued and should notify the protocol core team at 
actg.corea5337@fstrf.org within 48 hours. Participants experiencing Grade 4 
AEs requiring permanent discontinuation of study drug should be followed weekly 
until resolution of the AE or return to baseline and encouraged to complete the 
early discontinuation evaluations and continue on-study follow-up. 
 
• 
Participants with Grade 4 asymptomatic laboratory abnormalities may continue 
study drug if the investigator has compelling evidence that the toxicity is NOT 
related to the study drug.  
 
7.1.4 CD4+ Decrease 
 
Study drug will be discontinued in participants who exhibit CD4+ cell count 
decrease to <300 cells/mm3 or decreases >50% from study entry value on two 
consecutive assessments. 
 
7.1.5 Detectable HIV-1 RNA 
 
Study drug will be discontinued in participants who have HIV-1 RNA >200 
copies/mL on two consecutive assessments.  
 
7.1.6 Detectable EBV in Blood 
 
Sirolimus will be discontinued if EBV DNA is detected.  
 
7.1.7 CMV viremia 
 
CMV viremia without evidence of end-organ involvement will not require study drug 
termination.  
 

 
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7.2 
Management of Specific Toxicities 
 
7.2.1 Hepatotoxicity 
 
Liver function test (LFT) monitoring will be performed as detailed in section 6.0. In the 
event that there is an increase in ALT or AST to >5 x ULN, sirolimus will be stopped 
and LFT blood testing will be repeated every 2 weeks until the values have returned 
to normal range.  
 
7.2.2 Pulmonary Toxicity 
 
All potential participants will have a chest x-ray and pulse oximetry measured prior 
to starting sirolimus therapy. Respiratory symptoms such as shortness of breath or 
coughing will be monitored at each study visit. If participants develop serious 
unexplained cough or shortness of breath suggestive of interstitial lung disease, they 
will be told not to take the next dose of study medication. An additional evaluation 
should be performed at the discretion of the site investigator, which may include 
pulse oximetry, physical examination, imaging including chest x-ray, chest computed 
tomography (CT scan) and possible referral to a pulmonologist or other specialist. 
 
NOTE:  Sirolimus will be held for Grade 2 dyspnea.  At the discretion of the site 
investigator, in consultation with the protocol team, study treatment may be withheld 
or discontinued for Grade 1 pulmonary toxicity. Once the dyspnea has resolved 
sirolimus may be restarted with caution. If dyspnea recurs, sirolimus must be 
discontinued.    
 
7.2.3 Myelosuppression 
 
Sirolimus will be held for neutrophil toxicity (ANC <1000 cells/µL) and 
thrombocytopenia (<100,000/mm3) until repeat testing confirms these results. At the 
discretion of the site investigator and in consultation with the protocol team, study 
treatment may be permanently discontinued.    
 
7.2.4 Nephrotoxicity 
 
Any participant with a calculated CrCl <50 mL/min or a reduction in CrCl by 30% or 
more should have the value confirmed within 7 days. Sirolimus will be discontinued if 
confirmed calculated CrCl decreases by >30% after initiation of treatment or falls 
below 50 mL/min/1.73 m2. 
 
Urine protein to creatinine ratios will also be checked per the SOE. Sirolimus will be 
discontinued if the ratio is >1 g/g. 
 
7.2.5 Hypertriglyceridemia/Hyperlipidemia 
 
Elevated triglycerides or lipid levels Grade ≥3 from a non-fasting blood draw should 
be repeated after an 8-hour fast. Only levels done in a fasting state should be used 

 
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to determine toxicity management. Participants with asymptomatic Grade <3 
triglyceride, total cholesterol, or LDL cholesterol elevations may continue study 
drugs, at the discretion of the site investigator. See sections 7.1.2 and 7.1.3 for 
management of Grade 3 and 4 toxicities.  
 
7.3 
Management of HPV-Related Disease 
 
Management of anal HPV-related disease is at the discretion of the participant’s primary 
care physician, but if at all possible, treatment of anal dysplasia should be delayed until the 
end of the study. 
 
7.4  
Pregnancy Outcomes and Obstetrical History Reporting 
 
Female participants who become pregnant while on study must discontinue study 
medication and study evaluations, but will be encouraged to remain on study so that 
pregnancy outcome data can be collected. Women will remain on study and complete the 
premature study discontinuation visit 1 week after stopping treatment; the off-study CRF 
must be completed at the end of the pregnancy. The outcome and the AEs for the 
participant and infant will be recorded on an outcome CRF. If a woman does not wish to 
remain on study follow-up at the time of study discontinuation, site staff should request 
permission to contact her regarding pregnancy and infant outcomes at the end of 
pregnancy. If the information is obtained, pregnancy outcomes for the participant and infant 
will be submitted. 
 
Pregnancies that occur on study in participants receiving ART should be reported by the 
CRS to the Antiretroviral Pregnancy Registry. More information is available at 
www.apregistry.com. Phone: 800-258-4263; Fax: 800-800-1052.  
 
 
8.0 
CRITERIA FOR DISCONTINUATION 
 
8.1 
Permanent and Premature Treatment Discontinuation 
 
• 
Drug-related toxicity (see section 7.1 and 7.2). 
• 
Requirement for prohibited concomitant medications (see section 5.4). 
• 
Completion of treatment as defined in the protocol. 
• 
Pregnancy or breastfeeding. 
• 
Request by participant to terminate treatment. 
• 
Clinical reasons believed life threatening by the physician, even if not addressed in the 
toxicity section of the protocol. 
• 
Any two consecutive CD4+ cell counts <300 mm3 or >50% decrease from study entry 
value. 
• 
Any two consecutive HIV-1 RNA levels >200 copies/mL. 
• 
Participant repeatedly noncompliant missing >3 doses of study drug a week for 2 or 
more weeks. 
• 
Participant misses two consecutive PK monitoring blood draws. 

 
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• 
Participant misses two consecutive clinic visits. 
 
8.2 
Premature Study Discontinuation 
 
• 
ART is permanently discontinued. 
• 
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 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, NIAID, Office for Human Research Protections (OHRP), and 
other government agencies as part of their duties to ensure that research participants 
are protected or the industry supporter or its designee. 
 
 
9.0 
STATISTICAL CONSIDERATIONS  
 
9.1 
General Design Issues 
 
A5337 is a phase I/II open-label, single-arm, pilot study to evaluate the safety, immunologic, 
virologic and pharmacologic effects of sirolimus in HIV-infected participants receiving 
effective ART who have HIV-1 RNA <40 copies/mL and CD4+ T-cell counts ≥350 cells/mm3. 
Each participant will receive 20 weeks of sirolimus starting 12 weeks after study entry, 
followed by an additional 12 weeks off sirolimus, for a total duration of 44 weeks. Sirolimus 
will be dose-adjusted based on frequent measurements of sirolimus drug levels to achieve 
desired target levels. Accrual of the targeted 30 participants is anticipated to take 8-12 
months. Note that the primary outcome measures are through week 32 while the study has 
an additional 12 weeks of post-treatment follow-up. 
 
9.2 
Outcome Measures 
 
9.2.1 Primary Outcome Measures 
 
9.2.1.1 Safety 
 
Occurrence of a new Grade ≥3 AE, including signs/symptoms, lab toxicity or 
clinical event, that is definitely, probably or possibly related to study 
treatment, as judged by the core team, or by change (confirmed >50% 
decline or to <300 cells/mm3) in CD4+ cell counts while on sirolimus.   
 
9.2.1.2 Efficacy – Immunologic 
 
Frequency of HIV-1 Gag-specific CD8+ cells by intracellular staining for 
IFN-gamma at baseline and at week 32 (20 weeks on sirolimus). 
 

 
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9.2.1.3 Efficacy – Virologic 
 
CD4+ T-cell-associated HIV-1 RNA and plasma HIV-1 RNA by SCA at 
baseline and at week 32 (20 weeks on sirolumus) 
 
9.2.2 Secondary Outcome Measures 
 
9.2.2.1 CD4+ cell counts at baseline and at weeks 14, 16, 20, 24, 32 (2, 4, 8, 12, 
20 weeks on sirolimus) and 44 
 
9.2.2.2 HIV-1 RNA levels by conventional assay at baseline and at weeks 16, 20, 
24, 32 (4, 8, 12, 20 weeks on sirolimus) and 44 
 
9.2.2.3 HIV-1-specific CD4+ cell responses and HIV-1-specific CD8+ cell 
responses (other than gag) at baseline and at weeks 13, 16, 24, 32 (1, 4, 
12, 20 weeks on sirolimus) and 44 
 
9.2.2.4 T-cell activation and proliferation (% CD4+ and CD8+ cells CD38+/HLA-
DR+, CD25+, PD-1+, Ki67+ and PD-L1 expression) at baseline and at 
weeks 13, 16, 24, 32 (1, 4, 12, 20 weeks on sirolimus) and 44 
 
9.2.2.5 HIV-1 DNA levels in CD4+ cells at baseline and at weeks 13, 16, 24, 32 (1, 
4, 12, 20 weeks on sirolimus) and 44 
 
9.2.3 Exploratory Outcome Measures  
 
9.2.3.1 Ex vivo flow cytometric phenotyping of activation/proliferation in CD4 and 
CD8 central memory (CM), transitional memory (TM), effector memory 
(EM) and naïve (N) populations as defined by CCR7 and CD27 expression 
 
9.2.3.2 Downstream signaling of homeostatic proliferation-regulating cytokines, 
such as IL-7 and IL-15, in CD4 and CD8 memory subsets and correlate 
preferential induction of phosphorylation of STAT-5 with changes in 
reservoir size 
 
9.2.3.3 Soluble markers including IL-6, IL-7 and IL-15 
 
9.2.3.4 HIV-1 specific antibody levels, the breadth of antibody responses and B-cell 
phenotype, rearrangements and class switching 
 
9.2.3.5 HPV typing and quantification of HPV DNA from rectal swabs at week 12 
(baseline) and week 32 (20 weeks on sirolimus) and pathologic evaluation 
for anal dysplasia from anal Pap tests prior to and after sirolimus 
administration. 
 
9.2.3.6 Pharmacokinetic exposure of sirolimus and ARVs in the context of 
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9.2.3.7 Measurements of CMV, EBV, HSV and HHV in oral swabs prior to and 
after sirolimus administration 
 
9.3 
Randomization and Stratification 
 
There is no randomization in this study. Eligible participants will be registered at study entry 
and stratified by ART regimen which determines initial dose of treatment. 
 
9.4 
Sample Size and Accrual 
 
Regarding the assessment of safety/toxicity (see section 9.2.1.1), the sample size of 30 
sirolimus-treated participants will provide >90% probability of observing a sirolimus-related 
adverse event that would occur in 8% or more of treated participants.  
The primary efficacy analyses will evaluate paired baseline and post-sirolimus therapy 
immunologic and virologic measurements to detect changes; these measures are assumed 
stable on long-term suppressive ART (see section 2.2.6). Allowing 17% sample size 
adjustment for lost to follow-up and treatment discontinuation for the planned as-treated 
analyses (i.e., n=25 participants assumed evaluable), the study will have 80% power to 
detect a 0.59 standard deviation (SD) effect size based on a two-sided, alpha=0.05, 1-arm t-
test. This effect size translates (under assumed normality) into a probability of 0.72 that a 
participant receiving sirolimus will have an observed increase in HIV-specific CD8 immunity 
(see section 9.2.1.2).  Similarly, power would be 80% to detect a corresponding decrease in 
cell-associated RNA (see section 9.2.1.3). The null hypothesis is that the probability is 0.5 
(equally likely to observe increase or decrease). For residual viremia (SCA, see section 
9.2.1.3), effect size is slightly larger due to anticipated left-censoring below assay limits. 
From numerical simulation based on a 1-arm t-test (imputing half the lower limit for SCA 
results below assay limits), power is estimated to be 80% to detect an underlying effect size 
of 0.67 SD; this 80% power corresponds to assuming that the probability is 0.5 (50%) for a 
baseline (pre-entry, entry) SCA to be below assay limit compared to 0.75 (75%) after 
treatment. The assumption that 50% of SCA results will be below assay limits at baseline is 
supported by findings from ACTG A5276s in which 56% of 668 SCA measurements after 
192 and 208 weeks of suppressive ART on 334 participants were below assay limits (<1 
copy/mL). Analyses will also jointly evaluate efficacy measurements at the multiple post-
treatment time points (e.g., the change from baseline to the average of the weeks 16, 24, 
and 32 measurements [4, 12, 20 weeks on sirolimus]), which could increase statistical 
power. 
 
9.5 
Monitoring 
 
Accrual, baseline characteristics, conduct of the study (including premature treatment and 
study discontinuations, and reasons, and summaries of sirolimus dosages and trough 
levels), interruptions of ART >2 days, virologic failures (defined as HIV-1 RNA >200 
copies/mL on two consecutive assessments), two consecutive CD4 counts below 300 
cells/mm3 (or >50% decrease from study entry) and all reported toxicities and events will be 
monitored during the study with reports sent to the core team on a regular basis. In addition, 

 
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assessment of the availability of stored samples for planned assays will be reviewed 
regularly. The core protocol team will review the individual safety data frequently (at least 
monthly) to assess relation of all reported toxicities and AEs to study treatment, including in 
this assessment the site investigator’s opinion on their relation to study treatment as 
reported on the case report forms. 
 
At the earlier of a) approximately 6 months after the first participant begins study treatment 
and b) after 12 participants have reached 12 weeks of study treatment, a Study Monitoring 
Committee (SMC) will be convened to review the study data and progress according to 
ACTG Standard Operating Procedures. The SMC will review accrual, participant 
characteristics, AE summaries (and listings detailing each team decision as to the 
relationship of the AE to study treatment), sirolimus dosages and trough levels (in particular 
for any participant with a Grade 3 or higher AE), CD4+ cell counts and HIV-1 RNA 
levels/suppression over time, off-treatment and off-study rates (and reasons) and 
completeness of sample availability. In addition, sirolimus use in all participants will be 
stopped and an SMC safety review will be promptly convened if there are any Grade 4 AEs 
or greater than three Grade 3 AEs attributed to study treatment in two or more participants 
per section 9.2.1.1. An SMC review will also be triggered if more than 25% of participants 
(evaluating at least 12 participants, e.g., greater than 3 of 12) discontinue study treatment 
due to AEs or other side effects attributable to study drug; the therapeutic duration of the 
trial might be reduced to 12 weeks or otherwise modified following SMC review. Subsequent 
SMC reviews will be approximately every 6 months. In addition, the core team or the SMC, 
at any time it thinks appropriate, may ask for the SMC to independently review all available 
safety data.  
 
9.6 
Analyses 
 
Baseline will defined as the average of entry and week 12 measurements (or will be based 
on one if the other is missing).  
 
9.6.1 Primary Analyses 
 
For the primary safety analysis, ≥Grade 3 AEs attributed to study treatment and 
confirmed CD4+ declines (see section 9.2.1.1) will be summarized. In addition, all 
other reported AEs ≤Grade 2 attributed to study treatment as well as all reported 
events ≥Grade 2 (regardless of treatment relatedness) will be summarized. All 
participants who have been exposed to study treatment will be included in the 
analysis.  
 
For the primary immunologic (see section 9.2.1.2) and virologic (see section 9.2.1.3) 
efficacy outcomes, post-treatment changes will be evaluated comparing 
measurements pre-treatment (averaged) to the measurement 20 weeks after starting 
study treatment, testing the null hypothesis of no difference pre-treatment versus 
post-treatment using a paired t-test. Log-transformations may be applied for the 
virologic outcomes.  To address anticipated left-censoring of SCA measurements, a 
value one half the lower assay limit will be imputed. If feasible with the modest 
sample size, censored-data longitudinal data methods that statistically address the 

 
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issue of left-censoring (SCA measurements below assay limits) will also be used to 
evaluate and estimate treatment effects [59]. Mean and quartile plots will summarize 
the immunologic and virologic measurements at each visit. Because the aim of this 
pilot study is to investigate the biologic effects of sirolimus, the analyses will be as-
treated, limited to participants who have data at baseline and week 32 (20 weeks 
on sirolimus) and who remained on study treatment and ART (and without virologic 
failure) through week 32. A supplemental analysis will be based on changes from 
baseline to the last available time point for a participant while on study treatment 
and ART (and without virologic failure). 
 
If there is evidence that there is a significant difference between the week 0 and 
week 12 levels of the primary immunologic and virologic efficacy measurements, 
based on paired t-tests between these two time points, then the primary analysis will 
instead be based on a comparison of slopes pre- versus post-treatment (see 9.6.2). 
Both sets of results, from the paired t-test analyses and the comparison of slopes 
analyses, will be reported in the presentation of the study findings.  
 
9.6.2 Secondary Analyses 
 
Additional analyses of safety will summarize the magnitude of CD4+ cell changes 
baseline to post-treatment time points (mean, quartiles). Analyses will also 
summarize the number of participants who exhibit on two consecutive 
measurements HIV RNA >200 copies/mL on conventional assay. Tolerability will be 
assessed by the number of participants who prematurely discontinue study 
treatment and the reasons for discontinuation. 
 
Analyses of secondary virologic and immunologic outcomes will parallel the primary 
analyses outlined in section 9.6.1. Graphical approaches will summarize the virologic 
and immunologic measurements over time. Supplemental analyses will compare the 
change in the slope-over-time pre-treatment (pre-entry to start of treatment) versus 
post-treatment (start of treatment through week 20 while on treatment) and also may 
examine the change from baseline to the average of the week 16, 24 and 32 (4, 12, 
20 weeks on sirolimus) measurements. Soluble markers (e.g., IL-6 levels) will be log-
transformed. 
 
Analyses will also summarize changes in immunologic and virologic measures after 
discontinuation of study treatment. 
 
Associations between changes in the various immunologic and virologic 
measurements will be evaluated using scatterplots and correlations coefficients. 
 
The relationship between anal HPV, particularly HPV 16, and immunological 
measurements of activation and virological measurements of HIV reservoir size will 
be correlated.   
 
The effect of study treatment on anal dysplasia will be described by evaluating the 
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normal or abnormal according to standard clinical criteria.   
 
 
10.0 
PHARMACOLOGY PLAN 
 
10.1 
Pharmacology Study Design 
 
Pharmacology Objective: To assess the pharmacokinetic (PK) interactions between 
sirolimus therapy and ARV drug levels. 
 
Sirolimus trough drug levels will be drawn on participants 4 days after the initial dose until 
two consecutive sirolimus levels are within the goal range of 5-10 ng/mL. Once two 
consecutive levels fall within 5-10 ng/mL (which may be achieved before the 4-week time 
point after sirolimus is initiated), trough samples will be drawn every 4 weeks until week 32 
(see section 6.1.1). Monitoring will be done by individual sites that have or use a laboratory 
that has a CLIA certification or its equivalent. For safety and ease of dosing, participants 
will be recruited and followed only at medical centers that have rapid sirolimus testing 
available or are able to ship samples to Quest laboratory for rapid turnaround of results 
based on liquid chromatography tandem mass spectrometry analysis which enables 
accurate and consistent measures of levels across study sites. Results should be available 
within 72 hours if shipped to Quest or local laboratory. Sirolimus dose will not be adjusted 
until study drug has been taken for a minimum of 1 week.  
 
In addition, samples will be collected and stored for batched analysis of ARV measurements 
following study completion. ARV trough levels will be collected just prior to initiating sirolimus 
to serve as baseline evaluations. These samples will be collected just prior to morning 
dosing. Participants will be asked to hold their morning doses to allow trough collections. 
 
10.2 
Primary and Secondary Data, Modeling and Data Analysis 
 
Real-time analysis for sirolimus will be used for participant monitoring only. Batched 
sample analysis of ARVs will be performed post-hoc using standardized analytical methods. 
This monitoring will allow the assessment of the PK of sirolimus therapy on ARV drug levels 
and evaluate the effects of ARVs on sirolimus levels. These analyses will inform potential 
required dose adjustments if further clinical trials are planned. However, these levels will not 
be used to dictate dose adjustment or clinical changes. 
 
Batched analysis of ARVs will be carried out using LC tandem MS. As participants will be 
taking various non-PI ARVs, analysis for ARVs will focus on the most common ARVs 
prescribed to optimize comparisons (e.g., efavirenz, tenofovir, integrase inhibitors). ARV 
levels will be compared prior to and following sirolimus initiation and to historical ARV PK 
data. Sirolimus levels will be compared across ARV regimens and to historical data, if 
available. 
 

 
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11.0 
DATA COLLECTION AND MONITORING AND ADVERSE EVENT REPORTING 
 
11.1 
Records to Be Kept 
 
Case report forms (CRFs) will be provided for each participant. Participants must not be 
identified by name on any CRFs. Participants will be identified by the patient identification 
number (PID) and study identification number (SID) provided by the ACTG DMC 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 
ACTG DMC. Each CRS is responsible for keying the data in a timely fashion. 
 
11.2.2 It is the responsibility of the ACTG DMC to assure the quality of computerized data 
for each ACTG study. This role extends from protocol development to generation of 
the final study databases. 
 
11.3 
Clinical Site Monitoring and Record Availability 
 
11.3.1 Site monitors under contract to the NIAID will visit participating clinical research sites 
to review the individual participant records, including consent forms, CRFs, 
supporting data, laboratory specimen records, and medical records (physicians’ 
progress notes, nurses’ notes, participants’ hospital charts), to ensure protection of 
study participants, compliance with the protocol and accuracy and completeness of 
records. The monitors also will 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 site investigator will make study documents (e.g., consent forms, drug 
distribution forms, CRFs) and pertinent hospital or clinic records readily available for 
inspection by the local IRB, the site monitors, industry supporter, the NIAID and the 
OHRP, for confirmation of the study data. 
 
11.4 
Expedited Adverse Event Reporting to DAIDS 
11.4.1 Adverse Event Reporting to DAIDS 
Requirements, definitions and methods for expedited reporting of Adverse Events 
(AEs) are outlined in Version 2.0 of the DAIDS EAE Manual, which is available on 
the RSC website at   http://rsc.tech-res.com/safetyandpharmacovigilance/. 
The DAIDS Adverse Events Reporting System (DAERS), an internet-based reporting 
system, must be used for expedited AE reporting to DAIDS.  In the event of system 
outages or technical difficulties, expedited AEs may be submitted via the DAIDS EAE 
Form. For questions about DAERS, please contact NIAID CRMS Support at 

 
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CRMSSuport@niaid.nih.gov. Site queries may also be sent from within the DAERS 
application itself. 
Sites where DAERS has not been implemented will submit expedited AEs by 
documenting the information on the current DAIDS EAE Form. This form is available 
on the RSC website: http://rsc.tech-res.com/safetyandpharmacovigilance/.  For 
questions about EAE reporting, please contact the RSC 
(DAIDSRSCSafetyOffice@tech-res.com). 
11.4.2  Reporting Requirements for this Study 
 
The SAE Reporting Category, as defined in Version 2.0 of the DAIDS EAE Manual, 
will be used for this study from the time of enrollment through week 44. After this 
time, the SUSAR Reporting Category will be used. 
 
The study agent for which expedited reporting is required is sirolimus. 
 
All cancers except basal cell cancer of the skin are to be reported as expedited 
events. 
 
11.4.3 Grading Severity of Events 
 
The Division of AIDS Table for Grading the Severity of Adult and Pediatric Adverse 
Events (DAIDS AE Grading Table), Version 2.0, November 2014, must be used and 
is available on the DAIDS RSC Web site at http://rsc.tech-
res.com/safetyandpharmacovigilance/. 
 
11.4.4 Expedited AE Reporting Period 
 
The EAE reporting period for this study is the entire study duration for an individual 
participant (from study enrollment until study completion or discontinuation of the 
participant from study participation for any reason). 
 
After the protocol-defined AE reporting period, unless otherwise noted, only 
suspected unexpected serious adverse reactions (SUSARs) as defined in Version 
2.0 of the EAE Manual will be reported to DAIDS if the study staff become aware of 
the events on a passive basis (e.g., from publicly available information). 
 
 
12.0 
PARTICIPANTS 
 
12.1 
Institutional Review Board (IRB) Review and Informed Consent 
 
This protocol, the informed consent document (Appendix I) and any subsequent 
modifications will be reviewed and approved by the IRB responsible for oversight of the 
study. A signed consent form will be obtained from the participant (or legal guardian or 
person with power of attorney for participants who cannot consent for themselves). The 

 
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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 participant 
or legal guardian and this fact will be documented in the participant’s record. 
 
12.2 
Participant Confidentiality 
 
All laboratory specimens, evaluation forms, reports, and other records that leave the site will 
be identified by coded number only to maintain participant 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 participant, 
except as necessary for monitoring by the ACTG, IRB, NIAID, OHRP, other government 
agencies as part of their duties to ensure that research participants are protected and 
industry supporter or designee. 
 
12.3 
Study Discontinuation 
 
The study may be discontinued at any time by the ACTG, IRB, NIAID, industry supporter, 
OHRP, or other government agencies as part of their duties to ensure that research 
participants are protected.  
 
 
13.0 
PUBLICATION OF RESEARCH FINDINGS 
 
Publication of the results of this trial will be governed by ACTG policies.  Any presentation, 
abstract, or manuscript will be made available for review by the industry supporter prior to 
submission.  
 
 
14.0 
BIOHAZARD CONTAINMENT 
 
As the transmission of HIV and other blood-borne pathogens can occur through contact with 
contaminated needles, blood, and blood products, appropriate blood and secretion 
precautions will be employed by all personnel in the drawing of blood and shipping and 
handling of all specimens for this study, as currently recommended by the Centers for 
Disease Control and Prevention and the National Institutes of Health. 
 
All dangerous goods and materials, including diagnostic specimens and infectious 
substances, must be transported using packaging mandated by CFR 42 Part 72. Please 
refer to instructions detailed in the International Air Transport Association (IATA) Dangerous 
Goods Regulations.  

 
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15.0 
REFERENCES 
 
1. Deeks SG, Autran B, Berkhout B, et al. Towards an HIV cure: a global scientific strategy. 
Nat Rev Immunol 2012;12:607-14. 
2. Isotani S, Hara K, Tokunaga C, Inoue H, Avruch J, Yonezawa K. Immunopurified 
mammalian target of rapamycin phosphorylates and activates p70 S6 kinase alpha in 
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25. Henrich T, Hu Z, Li J, et al. Long-Term Reduction in Peripheral Blood HIV-1 Reservoirs 
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Bemelman FJ. Everolimus-Treated Renal Transplant Recipients Have a More Robust 
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Treated Patients. Transplantation 2013;95:184-91. 
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trial of the NCIC Clinical Trials Group (NCIC CTG IND 199). Gynecol Oncol 
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32. Coppock JD, Wieking BG, Molinolo AA, Gutkind JS, Miskimins WK, Lee JH. Improved 
clearance during treatment of HPV-positive head and neck cancer through mTOR 
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33. Mhatre M, McAndrew T, Carpenter C, Burk RD, Einstein MH, Herold BC. Cervical 
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34. Rukasz D, Krajewska M, Augustyniak-Bartosik H, et al. Effective treatment of 
Kaposi sarcoma with everolimus in a patient with membranous 
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35. Detroyer D, Deraedt K, Schoffski P, et al. Resolution of diffuse skin and systemic 
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37. Bissler JJ, McCormack FX, Young LR, et al. Sirolimus for angiomyolipoma in tuberous 
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38. van den Eertwegh AJ, Karakiewicz P, Bavbek S, et al. Safety of Everolimus by 
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40. Boobes Y, Bernieh B, Saadi H, Raafat Al Hakim M, Abouchacra S. Gonadal dysfunction 
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44. Araki K, Turner AP, Shaffer VO, et al. mTOR regulates memory CD8 T-cell 
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45. Baan CC, van der Mast BJ, Klepper M, et al. Differential effect of calcineurin inhibitors, 
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46. Coenen JJ, Koenen HJ, van Rijssen E, Hilbrands LB, Joosten I. Rapamycin, and not 
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47. Dyavar Shetty R, Velu V, Titanji K, et al. PD-1 blockade during chronic SIV infection 
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48. Wagner TA; Proliferation of Cells With HIV Integrated Into Regulatory Genes Is a 
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Biometrics 1999;55:625-9. 
 

 
 
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APPENDIX I 
SAMPLE INFORMED CONSENT 
 
DIVISION OF AIDS  
AIDS CLINICAL TRIALS GROUP (ACTG) 
SAMPLE INFORMED CONSENT 
For protocol A5337 
 
Safety and Efficacy of Sirolimus for HIV Reservoir Reduction in Individuals on Suppressive 
Antiretroviral Therapy 
 
 
SHORT TITLE FOR THE STUDY: (A5337) Sirolimus Study  
 
 
 
INTRODUCTION 
 
 
When a person becomes infected with HIV (the virus that causes AIDS), his/her immune system 
(the system that helps fight infection) is weakened (partly because the number of CD4+ cells 
goes down). Despite successful treatment with antiretroviral therapy (ART), latent reservoirs 
(infected cells that are not actively producing HIV) remain present in the blood and contribute to 
ongoing immune system activation and inflammation in the body. Ongoing inflammation may 
contribute to HIV persisting in cells in your body even though you are taking medications to treat 
HIV. 
 
You are being asked to take part in this research study because you: 
• 
are infected with HIV 
• 
have  been on continuous anti-HIV medicines with no detectable HIV for 24 months or 
longer 
• 
have a CD4+ cell count of 350 or greater   
 
This study is sponsored by the National Institutes of Health (NIH). The doctor in charge of this 
study at this site is: (insert name of Principal Investigator). Before you decide if you want to be a 
part of this study, we want you to know about the study.  
 
This is a consent form. It gives you information about this study. The study staff will talk with you 
about this information. You are free to ask questions about this study at any time.  If you agree 
to take part in this study, you will be asked to sign this consent form. You will get a copy to 
keep. 
 
 
WHY IS THIS STUDY BEING DONE? 
 
The purpose of this study is to find out about the safety of sirolimus in individuals with HIV 
infection who are also being treated with ART. We want to learn whether sirolimus will decrease 
inflammation and immune activation in the body, whether sirolimus will change the level of HIV 
in your blood, and how sirolimus interacts with ART in the blood.  Sirolimus is approved by the 
Food and Drug Administration (FDA) to prevent organ rejection in patients aged 13 years and 
older receiving kidney transplants. Sirolimus has also been used for the prevention of 

 
 
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complications after stem cell transplants and as a treatment for certain kinds of cancers in HIV-
infected patients.  
 
 
WHAT DO I HAVE TO DO IF I AM IN THIS STUDY? 
 
If you decide to take part in this research study, you will be asked to sign this consent form and 
schedule a screening visit to determine if you can join the study.  If you enter the study, you will 
have laboratory and clinical evaluations performed and then be followed for 12 weeks before 
you start taking sirolimus.  The reason for the 12-week delay in starting sirolimus is to provide 
an estimate of the level of HIV-1 in your body while you are taking your anti-HIV medications. 
After this, you will be seen in the clinic about 15 times. 
 
Screening visit 
• 
Your HIV infection will be confirmed. If there is no record available, you will have another 
HIV test. You may have to sign a separate consent form before having this test. A separate 
consent form may be given to you by the staff at your site. 
• 
You will have a physical exam and will be asked about your health and medicines you have 
taken in the past or are taking now. 
• 
You will have blood drawn for routine safety blood tests and to measure your CD4+ cell 
count (cells that fight infection) and HIV-1 viral load (the amount of virus in your blood). You 
will be given the test results when they are available. 
• 
You will have blood drawn to test for hepatitis and for the Epstein-Barr virus (EBV), a virus of 
the herpes family. You will be given the test results when they are available. 
• 
If you are a woman able to become pregnant, you will be asked to give a urine or blood 
sample to see if you are pregnant. You will not be able to enroll in this study if you are 
pregnant. You will be told the result of the test when it becomes available.   
• 
You will be asked to provide a urine sample. 
• 
You will have a skin test or blood test to test for tuberculosis unless you have had a positive 
tuberculosis test in the past. If you have the skin test, you will get a small shot that contains 
purified protein derivative (PPD). The needle is gently placed under the top layer of skin, 
causing a bump (welt) to form. This usually goes away in a few hours.  After 48-72 hours, 
you must return to have the area checked to see if you have had a strong reaction to the 
test.  
• 
You will have a chest x-ray. 
 
If you do not enroll into the study 
If you decide not to take part in this study or if you do not meet the eligibility requirements, we 
will still use some of your information. As part of this screening visit, some demographic (for 
example, age, sex, race), clinical (for example, disease condition, diagnosis), and laboratory (for 
example, CD4+ cell count, viral load) information is being collected from you so that ACTG 
researchers may help determine whether there are patterns or common reasons why people do 
not join a study. 
 
Entry visit 
If you qualify for the study, you will come to the clinic after the screening visit for the first entry 
visit. You will have a brief physical exam and be asked about your medical history and any 
medicines you have taken. You will have blood drawn for routine tests, CD4+ cell count, viral 

 
 
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load, and for samples to be stored for future testing for this study.  If you are a woman able to 
become pregnant, you will be asked to give a urine or blood sample to see if you are pregnant. 
You will not be able to enroll in this study if you are pregnant. You will be told the result of the 
test when it becomes available.   
 
A swab of your mouth will be taken that you can do yourself.  You should not drink hot 
beverages (e.g., tea or coffee) 1 hour before you collect the sample. You will be given a 
cotton swab and asked to rub the tip repeatedly over the inside of both cheeks, along the 
upper and lower gum lines, inside and outside of the teeth, around the hard palate and 
across the soft palate (or roof of your mouth), and with the back of your throat (back 
wall) as you can tolerate.   
 
Week 12 post-entry visit  
Approximately 12 weeks after entry, you will come in for a visit before starting sirolimus therapy. 
During this visit: 
• 
You will have a brief physical exam and blood drawn for routine safety blood tests, CD4+ 
cell count and viral load and some of your blood will be stored for future testing for this 
study. 
• 
If you are a woman able to become pregnant, you will be asked to give a urine or blood 
sample to see if you are pregnant. You will not be able to enroll in this study if you are 
pregnant. You will be told the result of the test when it becomes available.   
• 
You will be asked to provide a urine sample. 
• 
You will have an anal swab and anal Pap test. A doctor or nurse will insert a swab (like a 
long Q-tip) into your anus. The end of the swab will be rubbed against the skin inside the 
anus. This sample will be tested for human papillomavirus (HPV). You will not receive 
the result of the HPV test as the specimen will be frozen and stored.  A second swab or 
a soft brush will be inserted into your anus for an anal Pap test. This sample will be 
tested for pre-cancers of the anus. These are areas that have been damaged by HPV 
and might turn into cancer someday. You will receive the result of the Pap test. If you 
have had a recent Pap test, we can use those results so this test will not have to be 
repeated. 
• 
You will take a swab of your mouth. 
 
On Study Visits After Entry 
You will begin taking sirolimus by mouth once a day for the next 20 weeks, in addition to the 
anti-HIV medicines your doctor has prescribed.  You may take the sirolimus medication with or 
without food.  Sirolimus will be supplied by the study; the anti-HIV medicines will not be supplied 
by the study.   
 
During the study visits: 
• 
Four days after you take your first dose of sirolimus, blood will be drawn to measure 
sirolimus levels in your blood. Blood samples will then be drawn twice a week 
(approximately days 4 and 7 of each week) for up to 4 weeks until two levels in a row show 
an adequate sirolimus level. Your dose may need to be adjusted up or down depending on 
the test results. Once the sirolimus level is at a steady level, blood samples will be drawn 
once every two weeks until 6 weeks of sirolimus treatment, after which samples will be 
drawn every 4 weeks.   
• 
You will have a brief physical exam performed at five of the visits. 

 
 
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• 
You will have blood drawn for routine safety blood tests at seven of the visits and for CD4+ 
cell count for six of the visits and some of your blood will be stored for future testing for this 
study. 
• 
You will have blood drawn to check your viral load at five of the visits. 
• 
You will have blood drawn to test for EBV at five of the visits. 
• 
You will have a urine sample collected at three of the visits. 
• 
You will have another anal swab and anal Pap test at week 32. 
• 
You will take a swab of your mouth five other times during the study. 
 
Immunologic/Virologic Failure 
If your CD4+ T-cell count is below 300 or it drops to less than half of what it was when you 
entered the study, or if your viral load is over 200, you will have another test done to check the 
findings. If your CD4+ T cell count is still down and/or your viral load is still up and you are still 
taking study drug, you will be required to stop the study drug. You will be followed on study off 
treatment until the final study visit at week 44. You will have the sirolimus test done one more 
time at your next study visit, and then stop having these tests.  
 
Pregnancy 
If you become pregnant, you will have to stop taking the study drug but we will ask you to stay in 
the study to be followed on study/off treatment until study completion. If you do not wish to 
continue to be followed on study/off treatment, the study staff will ask your permission to contact 
you regarding the outcome of your pregnancy. 
 
Premature Treatment/Study Discontinuation 
If you stop taking the study drug before the study-defined 20-week treatment period, you will be 
asked to return to the clinic to complete some evaluations. 
• 
You will have a brief physical exam and blood drawn for routine safety blood tests, CD4+ 
cell count, viral load and EBV test, and some of your blood will be stored for future testing 
for this study. 
• 
You will take a swab of your mouth. 
 
Other 
If you agree, some of your blood that is left over after all required study testing is done may be 
stored (with usual protectors of identity) and used for future ACTG-approved HIV-related 
research.  
 
Please indicate below “yes” or “no” and initial and date whether you approve the use of these 
stored samples. Note that you can withdraw your consent for research on stored specimens at 
any time you want and the specimens will be discarded. Your refusal or withdrawal of consent 
for the storage of these samples will not affect your study participation since storage of leftover 
samples is not a requirement for the study. 
 
______________________ Yes, I agree.       ____________________ No, I do not agree. 
 
 

 
 
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If you agree, we would like to draw one extra tube of blood for future tests that are not known at 
this time. It will be stored (with usual protectors of identity). We will do this whenever we store 
blood for required study testing.  
 
Please indicate below “yes” or “no” and initial and date whether you approve the use of these 
stored samples. Note that you can withdraw your consent for research on stored specimens at 
any time you want and the specimens will be discarded. Your refusal or withdrawal of consent 
for the extra blood draw will not affect your study participation since this the extra blood draw is 
not a requirement for the study. 
 
 
______________________ Yes, I agree.       ____________________ No, I do not agree 
 
Future Use of Stored Samples  
 
If you agree to let researchers store and use your leftover samples for future research, 
the following will happen: 
• 
After all routine tests required for your care are finished, instead of discarding your 
leftover samples we will save them in what is called a “tissue bank” for possible 
future research. We also will collect and save information from your medical record, 
including things like laboratory results.  
• 
We may give your leftover samples and certain medical information about you (for 
example, diagnosis, blood pressure, age if less than 85) to other scientists working 
with the AIDS Clinical Trials Group or other companies such as data centers 
including to a government health research database, but we will not give them your 
name, address, phone number, or any other information that would identify you. 
Results from tests done with your leftover samples will not be given to you or your 
doctor. Researchers from this study, as well as other researchers from other places 
and institutions will have access to these leftover samples and associated health 
information for future research studies.  However, only approved and qualified 
researchers will have access to your de-identified information. 
• 
Sometimes leftover samples are used for genetic research (about diseases that are 
passed on in families). Even if we use the sample for genetic research, we will not put 
the results in your medical record. The research will not change the care you receive. 
Your sample and any information about you will be kept until it is used up or 
destroyed. It may be used to develop new drugs, tests, treatments or products. In 
some instances these may have potential commercial value. Your personal health 
information cannot be used for additional research without additional approval from 
either you or a review committee.  
• 
Your leftover samples will be kept indefinitely. If you decide later that you do not want 
your leftover samples and information to be used for future research, you can notify 
the investigator in writing at [insert address], and we will destroy any remaining 
identifiable leftover samples and information if they are no longer needed for your 
care. However, if any research has already been done using portions of your leftover 
samples, the data will be kept and analyzed as part of those research studies. 
 

 
 
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• 
You will not receive any direct benefit for allowing the use and storage of leftover 
samples for future research.  
 
• 
You will not receive any results from any of the tests done with your samples and 
related health information.  
 
• 
You will not be contacted in the future for any results of studies done using your 
leftover samples and information. 
 
What risks are involved with donating samples for research? 
 
A federal law, called the Genetic Information Nondiscrimination Act (GINA), generally 
makes it illegal for health insurance companies, group health plans, and most employers 
to discriminate against you based on your genetic information. This law generally will 
protect you in the following ways: 
 
• 
Health insurance companies and group health plans may not request your genetic 
information that we get from this research. 
• 
Health insurance companies and group health plans may not use your genetic 
information when making decisions regarding your eligibility or premiums. 
• 
Employers with 15 or more employees may not use your genetic information that 
we get from this research when making a decision to hire, promote, or fire you or 
when setting the terms of your employment. 
  
Be aware that this new federal law does not protect you against genetic discrimination by 
companies that sell life insurance, disability insurance, or long-term care insurance, nor 
does it protect you against genetic discrimination by all employers. 
 
What about confidentiality? 
 
Allowing the use and storage of leftover samples may involve a loss of privacy, but 
information about you will be handled as confidentially as possible. Study data will be 
physically and electronically secured.  As with any use of electronic means to store 
information, there is a risk of breach of security.  Your name will not be used in any 
published reports from research performed using your sample. The AIDS Clinical Trials 
Group data manager and select staff members will have access to information about you 
but they will not release any identifying information about you to researchers using your 
leftover samples.  
 
Genetic information that results from this study does not have medical or treatment 
importance at this time.  So, researchers have decided that there will be no sharing of 
results with you or your doctor.  However, there is a risk that information about taking 
part in genetic studies using your leftover samples and information may influence 
insurance companies and/or employers regarding your health. To further safeguard your 
privacy, genetic information obtained in this study will not be placed in your medical 
record. Moreover, there is a chance in genetic research that even with all the security 
measures in place, someone using your samples, genetic information, and the databases 
may still find out who you are or “re-identify you.”  This person may also find out 

 
 
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information about you, your family, or people with similar genetic makeup.  However, 
these risks today are very small but may increase with time since science and 
technology are developing rapidly. 
 
Taking part in a genetic study may also have a negative impact or unintended 
consequences on family or other relationships. If you do not share information about 
taking part in this study, you will reduce this risk. Although your name will not be with 
the sample, it will have other facts about you such as the sequence of certain genes in 
your cells.  These facts are important because they will help us learn how HIV persists 
based on these facts.  Thus it is possible that study finding could one day help people of 
the same race, ethnicity, or sex as you.  However, it is also possible through these kinds 
of studies that genetic traits might come to be associated with your group.  In some 
cases, this could reinforce harmful stereotypes.  
 
______________________ Yes, I agree.       ____________________ No, I do not agree. 
 
 
HOW MANY PEOPLE WILL TAKE PART IN THIS STUDY? 
 
 About 30 people will take part in this study 
 
 
HOW LONG WILL I BE IN THIS STUDY? 
 
You will be in this study for about 44 weeks (11 months).   
 
 
WHY WOULD THE DOCTOR TAKE ME OFF THIS STUDY EARLY? 
 
The study doctor may need to take you off the study early without your permission if: 
• 
You stop your anti-HIV medicines or you need to take anti-HIV medicines that are not 
allowed on the study. 
• 
The study is stopped or canceled.  
• 
Your study doctor thinks the study is no longer in your best interest. 
• 
Your study doctor thinks you may to be at significant risk of failing to comply with the study 
requirements as to cause harm to yourself or seriously interfere with the validity of the study 
results. 
• 
Your primary care physician requests you be taken off the study. 
 
The study doctor may also need to take you off the study drug without your permission if: 
• 
Continuing the study medicine may be harmful to you. 
• 
You need a treatment that you may not take while on the study. 
• 
You become pregnant or are breastfeeding. 
• 
Your CD4 count or your viral load worsens. 
• 
You have detectable EBV in your blood.  
• 
You are not able to take the study medicine as required by the study. 
• 
You miss sirolimus level testing 2 times in a row.  

 
 
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• 
You miss more than 3 doses of sirolimus a week for 2 or more weeks. 
• 
You miss 2 consecutive clinic visits. 
 
If you must stop taking the study drug before the study is over, the study doctor will ask you to 
continue to be part of the study and return for some study visits and procedures. 
 
If you must permanently stop taking sirolimus before your study participation is over, the study 
staff will discuss other options that may be of benefit to you. After you have completed your 
study participation, the study will not be able to continue to provide you with sirolimus that you 
received on the study. If continuing to take this or similar drugs/agents would be of benefit to 
you, the study staff will discuss how you may be able to obtain them. 
 
 
WHAT ARE THE RISKS OF THE STUDY? 
 
The drugs used in this study may have side effects, some of which are listed below.  Please 
note that these lists do not include all the side effects seen with these drugs.  These lists include 
the more serious or common side effects with a known or possible relationship. It is very 
important that you tell your study doctor of any changes in your medical condition while taking 
part in the study. At any time during the study, if you believe you are experiencing any of these 
side effects, you have the right to ask questions on possible and/or known risks.  
 
There is a risk of serious and/or life threatening side effects when non-study medications are 
taken with the study drugs. For your safety, you must tell the study doctor or nurse about all 
medications you are taking before you start the study and you must ask approval for taking any 
new medication while you are on the study. Also, you must tell the study doctor or nurse before 
enrolling in any other clinical trials while on this study. 
 
Sirolimus (Rapamune) 
 
The following serious side effects may have been associated with the use of sirolimus: 
• 
Increased risk of getting infections 
• 
Increased risk of getting certain cancers 
• 
Serious allergic reactions. Tell your doctor or get medical help right away if you get any 
of the following symptoms of an allergic reaction: 
-Swelling of your face, eyes, or mouth, hands, feet, ankles, or lower legs 
-Trouble breathing or wheezing 
-Throat tightness 
-Chest pain or tightness 
-Feeling dizzy or faint 
-Rash or peeling of your skin 
-Itching 
• Poor wound healing 
• Increased risk for viral infection 
• Lung or breathing problems. This can sometimes lead to death. Tell your doctor if you 
have a new or worsening cough, difficulty breathing or any new breathing 
problems. 
• Unusual bleeding or bruising 

 
 
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• Other changes in blood test results that may show problems with the liver, kidneys, 
cholesterol and triglycerides (lipids or fat) levels, low red blood cell count (anemia), low 
platelet count (cells that help blood to clot) 
 
Common side effects with the use of sirolimus include:        
• 
Swelling (edema). Fluid may collect in your hands and feet and in various tissues of your 
body. 
• 
Hypertension (high blood pressure) 
• 
Abdominal pain 
• 
Diarrhea 
• 
Headache 
• 
Fever 
• 
Urinary tract infection 
• 
Nausea 
• 
Arthralgia (joint pain) 
• 
High blood sugar (diabetes) 
 
Potential Impact on Fertility 
Sirolimus may decrease sperm counts while you are taking the drug. However, sperm counts 
have been shown to increase to normal levels several months after sirolimus is stopped. 
Sirolimus has also been associated with the absence of menstruation (monthly period) that 
develops in some women while they are taking the drug, and there has been at least one report 
of a female patient who had permanent loss of menstruation after she stopped taking sirolimus. 
Fertility problems are usually identified 5 to 12 months after patients start taking the drug, and 
you will not be asked to take sirolimus for more than 4 months. The long-term effects of 
sirolimus on fertility and the ability to become pregnant after taking sirolimus are not well 
understood and you may be at risk for temporary or long-term infertility if you enroll in this study 
and take study medication. 
 
Immunologic/Virologic Failure 
You may have a decrease in your CD4+ cell count and/or an increase in your viral load. 
 
Risk of Blood Draw 
Taking blood may cause some discomfort, bleeding, bruising and/or swelling where the needle 
enters the body and in rare cases it may result in fainting.  There is a small risk of infection.  
 
Anal Swabs 
The swabs can be uncomfortable, and occasionally there can be some bleeding. 
 
Oral Swabs 
You may feel some discomfort or experience a gagging sensation when the back of your 
throat is touched with the swab, but the test only lasts a few seconds. 
 
 

 
 
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ARE THERE RISKS RELATED TO PREGNANCY? 
 
It is not known if the drug or drug combinations in this study harm unborn babies. If you are a 
woman and having sex that could lead to pregnancy, you must agree not to become pregnant. 
 
If you are a woman and participating in sexual activity that could lead to pregnancy, you and/or 
your male partner must use one form of birth control that you discuss with the study staff. You 
must start one method of birth control before you start taking your study drug and while you are 
taking your study drug. You must continue to use this method until 12 weeks after you stop the 
study drug. 
 
• 
Condoms (male or female) with or without a spermicidal agent. Condoms are recommended 
because their appropriate use is the only contraceptive method effective for preventing HIV 
transmission.  
• 
Diaphragm or cervical cap with spermicide 
• 
Intrauterine device (IUD) 
• 
Hormone-based contraceptive 
• 
Tubal ligation 
 
If you can become pregnant, you must have a pregnancy test before you enter this study and 
before you start taking sirolimus. The test must show that you are not pregnant. If you think you 
may be pregnant at any time during the study, tell your study staff right away. The study staff 
will talk to you about your choices. In addition, pregnancy complications and/or pregnancy 
outcomes that will not include any information that can identify you will be reported to the 
Antiretroviral Pregnancy Registry.  
 
 
ARE THERE BENEFITS TO TAKING PART IN THIS STUDY? 
 
This study is intended to gather information about how sirolimus acts on your immune system, 
not to treat your HIV infection. If you take part in this study, it is likely that there will be no direct 
benefit to you but information learned from this study may lead to the development of other 
studies that may help others who have HIV. 
 
 
WHAT OTHER CHOICES DO I HAVE BESIDES THIS STUDY? 
 
Instead of being in this study you have the choice of: 
 
• 
Treatment with prescription drugs available to you. 
• 
Treatment with experimental drugs, if you qualify.  
• 
No treatment 
 
Please talk to your doctor about these and other choices available to you. Your doctor will 
explain the risks and benefits of these choices. 
 
 

 
 
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WHAT ABOUT CONFIDENTIALITY? 
 
We will do everything we can to protect your privacy. In addition to the efforts of the study staff 
to help keep your personal information private, we have gotten a Certificate of Confidentiality 
from the U.S. Federal Government. This certificate means that researchers cannot be forced to 
tell people who are not connected with this study, such as the court system, about your 
participation. Also, any publication of this study will not use your name or identify you 
personally.   
 
People who may review your records include the ACTG, Office for Human Research Protections 
(OHRP) or other government agencies as part of their duties (insert name of site) IRB (a group 
that protects the rights and well-being of people in research), National Institutes of Health (NIH), 
study staff, study monitors, the drug company supporting this study and their designees. Having 
a Certificate of Confidentiality does not prevent you from releasing information about yourself 
and your participation in the study. 
 
Even with the Certificate of Confidentiality, if the study staff learns of possible child abuse and/or 
neglect or a risk of harm to yourself or others, we will be required to tell the proper authorities. 
 
A description of this clinical trial will be available on www.clinicaltrials.gov, as required by U.S. 
law. This website will not include information that can identify you. At most, the website will 
include a summary of the results. You can search this website at any time.  
 
 
WHAT ARE THE COSTS TO ME? 
 
Taking part in this study may lead to added costs to you and your insurance company. In some 
cases it is possible that your insurance company will not pay for these costs because you are 
taking part in a research study. There will be no cost to you for the sirolimus, study-related 
visits, physical examinations, laboratory tests, or other study procedures. Anti-HIV medicines 
will not be provided by the study. 
 
 
WILL I RECEIVE ANY PAYMENT? 
 
[Sites please indicate whether you will provide payment to participants] 
 
 
WHAT HAPPENS IF I AM INJURED? 
 
If you are injured as a result of being in this study, you will be given immediate treatment for 
your injuries. The cost for this treatment will be charged to you or your insurance company. 
There is no program for compensation either through this institution or the National Institutes of 
Health. You will not be giving up any of your legal rights by signing this consent form. 
 
 

 
 
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WHAT ARE MY RIGHTS AS A RESEARCH PARTICIPANT? 
 
Taking part in this study is completely voluntary. You may choose not to take part in this study 
or leave this study at any time. Your decision will not have any impact on your participation in 
other studies conducted by NIH and will not result in any penalty or loss of benefits to which you 
are otherwise entitled. 
 
We will tell you about new information from this or other studies that may affect your health, 
welfare, or willingness to stay in this study. If you want the results of the study, let the study staff 
know. 
 
 
WHAT DO I DO IF I HAVE QUESTIONS OR PROBLEMS? 
 
For questions about this study or a research-related injury, contact: 
 
• 
name of the investigator or other study staff 
• 
telephone number of above  
 
For questions about your rights as a research participant, contact: 
 
• 
name or title of person on the Institutional Review Board (IRB) or other organization 
appropriate for the site 
• 
telephone number of above 
 
 

 
 
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SIGNATURE PAGE 
 
If you have read this consent form (or had it explained to you), all your questions have been 
answered and you agree to take part in this study, please sign your name below. 
 
 
____________________________ 
________________________________________ 
Participant’s Name (print) 
Participant’s Signature and Date 
 
 
____________________________ 
________________________________________ 
Participant’s Legal Representative (print) Legal Representative’s Signature and Date 
(As appropriate) 
 
___________________________ 
_________________________________________ 
Study Staff Conducting 
Study Staff’s Signature and Date 
Consent Discussion (print)  
 
____________________________ 
_________________________________________ 
Witness’s Name (print) 
Witness’s Signature and Date 
(As appropriate)