Pilot Trial to Examine the Feasibility, Acceptability and Impact of an Intervention Using a New Urine-based Tenofovir Adherence Assay
Phase: NA
Conditions: Risk Reduction
Sponsor: University of California, San Francisco

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 1 of 93 
 
 
 
 
 
 
 
 
 
Protocol Signature Page 
 
I will conduct the study in accordance with the provisions of this protocol and all applicable 
protocol-related documents. I agree to conduct this study in compliance with United 
States (US) Health and Human Service regulations (45 CFR 46); applicable U.S. Food 
and Drug Administration regulations; standards of the International Conference on 
Harmonization Guideline for Good Clinical Practice (E6); Institutional Review 
Board/Ethics Committee determinations; all applicable in-country, state, and local laws 
and regulations; and other applicable requirements (e.g., US National Institutes of Health, 
Division of AIDS) and institutional policies. 
 
 
 
 
 
 
_November 11, 2021 
Signature of Investigator of Record 
Date (Month/Day/Year) 
 
 
  
Monica Gandhi MD, MPH  
 
Investigator of Record (PRINT NAME) 
 
 
Full Protocol Title:  Point-of-care Urine Monitoring of Adherence (PUMA): Testing a 
Real Time Urine Assay of Tenofovir in PrEP 
 
DAIDS Protocol Number: DAIDS ES-ID 38665 
DAIDS Protocol Version: 6.0 
Protocol Date: November 11, 2021 
 
NCT03935464

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 2 of 93 
 
 
 
 
Protocol Signature Page 
 
I will conduct the study in accordance with the provisions of this protocol and all applicable 
protocol-related documents. I agree to conduct this study in compliance with United 
States (US) Health and Human Service regulations (45 CFR 46); applicable U.S. Food 
and Drug Administration regulations; standards of the International Conference on 
Harmonization Guideline for Good Clinical Practice (E6); Institutional Review 
Board/Ethics Committee determinations; all applicable in-country, state, and local laws 
and regulations; and other applicable requirements (e.g., US National Institutes of Health, 
Division of AIDS) and institutional policies. 
 
 
 
 
 
 
November 11, 2021 
Signature of Investigator of Record 
Date (Month/Day/Year) 
 
 
Nelly Mugo, MBChB, MMeD, MPH 
Site Principal Investigator (PRINT NAME) 
 
 
Full Protocol Title:  Point-of-care Urine Monitoring of Adherence (PUMA): Testing a 
Real Time Urine Assay of Tenofovir in PrEP 
 
DAIDS Protocol Number: DAIDS ES-ID 38665 
DAIDS Protocol Version:   6.0 
Protocol Date: November 11, 2021 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 3 of 93 
 
 
 
 
STUDY PROTOCOL 
 
 
Point-of-care Urine Monitoring of Adherence (PUMA): 
Testing a Real-Time Urine Assay of Tenofovir in PrEP 
 
Pilot trial to examine the feasibility, acceptability and impact on longer-term 
adherence of an intervention using a new urine-based tenofovir adherence 
assay 
 
 
 
 
 
 
 
 
 
Funded by: 
US National Institute of Allergy and Infectious Diseases 
 
 
 
 
 
VERSION 6.0 
 
November 11, 2021 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 4 of 93 
 
 
 
 
 
 
PROTOCOL TEAM 
 
 
University of California, San Francisco (UCSF), USA 
Monica Gandhi MD, MPH (PI) 
Purba Chatterjee (Research coordinator) 
David Glidden PhD (biostatistician) 
 
Kenya Medical Research Institute, Nairobi, Kenya 
Nelly Rwamba Mugo MBChB, MMed, MPH (Site PI) 
 
Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya 
Kenneth Ngure MPH, PhD (Site Co-PI) 
 
NIH:  
Pablo F. Belaunzaran, M.D. 
Medical Officer 
HIV Research Branch 
DAIDS/NIAID/NIH 
5601 Fishers Lane, Room 9E40 
Rockville, MD 20852 
Phone: 240-292-4423 
E-mail: belaunzaranzapabf@niaid.nih.gov 
 
University of Washington, Seattle, USA 
Jared Baeten MD, PhD (Co-I) 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 5 of 93 
 
 
 
 
 
 
TABLE OF CONTENTS 
1. STUDY SUMMARY AND SCHEMA ....................................................................
1.1. LAY SUMMARY .................................................................................................................. 7 
1.2. STUDY SUMMARY .............................................................................................................. 7 
1.3. SCHEMA .......................................................................................................................... 10 
2.  CONSORT DIAGRAM……………………………………………………...………………………10 
3. BACKGROUND .......................................................................................
3.1. SIGNIFICANCE .................................................................................................................. 11 
3.2. INNOVATION ..................................................................................................................... 18 
3.3. PRELIIMINARY DATA………….L………………………………………………………..……….17 
3.4. FDA/CDRH AND THE NONSIGNIFICANT RISK (NSR) DESIGNATION FOR THE DEVICE………...….23 
3.5. STUDY RATIONALE ........................................................................................................... 25 
4. STUDY OBJECTIVES ...............................................................................
4.1. PRIMARY OBJECTIVES ...................................................................................................... 26 
5. STUDY PROCEDURES .................................................................................
5.1. OVERVIEW ....................................................................................................................... 26 
5.2. STUDY DESIGN ................................................................................................................ 26 
5.3. LOCATION AND SETTING ................................................................................................. 287 
5.4. POPULATION & ELIGIBILITY ................................................................................................ 28 
5.5. SERVICES AND INTERVENTION ........................................................................................... 29 
5.6. RECRUITMENT AND ENROLLMENT ...................................................................................... 31 
5.7. RANDOMIZATION .............................................................................................................. 32 
5.8. GENERAL STUDY PROCEDURES ........................................................................................ 32 
5.9. STANDARD-OF-CARE ARM FOLLOW UP PROCEDURES ......................................................... 33 
5.10. INTERVENTION ARM FOLLOW UP PROCEDURES ................................................................ 34 
5.11. DATA COLLECTED AND TESTING DURING CLINICAL VISITS ................................................. 34 
6. STUDY OUTCOMES AND ANALYSES .....................................................................
6.1. PRIMARY OUTCOMES ....................................................................................................... 36 
6.2. DATA COLLECTION FOR PRIMARY OUTCOMES………………………………………………….35 
6.3. SAMPLE SIZE AND POWER .................................................................................................... 38 
6.4. STATISTICAL ANALYSES .................................................................................................... 38 
7. PARTICIPANT REIMBURSEMENT ........................................................................
8. SAFETY ..........................................................................................
8.1. RISKS TO HUMAN SUBJECTS ............................................................................................. 40 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 6 of 93 
 
 
8.2. ADEQUACY OF PROTECTION AGAINST RISKS ...................................................................... 41 
8.3. POTENTIAL BENEFITS OF THE PROPOSED RESEARCH ......................................................... 42 
8.4. ENSURING PATIENT CONFIDENTIALTY AND SAFETY .............................................................. 42 
8.5. PREGNANCY AMONG HIV-NEGATIVE WOMEN ...................................................................... 42 
8.6. HIV TESTING .................................................................................................................... 43 
8.7. SOCIAL HARM CONSIDERATIONS FOR PREP AND PREP ADHERENCE TESTING....................... 43 
9. TIMELINE ............................................................................................................................. 43 
10. LIMITATIONS ..................................................................................................................... 44 
11. STUDY LEADERSHIP PLAN ................................................................................................. 45 
12. EXTERNAL MONITORING PLAN FOR PUMA STUDY……………………………………….44 
13. RESOURCE SHARING & DISSEMINATION PLAN .............................................................. 46 
14. ETHICAL CONSIDERATIONS ............................................................................................... 48 
15. PROTOCOL REGISTRATION ............................................................................................ 48 
16. REFERENCES………………………………………………………………………………………………………48 
APPENDIX I:  ENROLLMENT INFORMED CONSENT FOR CLIENTS .................................... 62 
APPENDIX II:  CONSENT FORM FOR INTERVIEWS OF HEALTH CARE PROVIDERS ......... 70 
STUDY TITLE:  POINT-OF-CARE URINE MONITORING OF ADHERENCE (PUMA):  
TESTING A REAL-TIME URINE ASSAY OF TENOFOVIR IN PREP ........................................ 72 
APPENDIX III: QUALITATIVE GUIDE FOR IN-DEPTH INTERVIEWS FOR WOMEN ............. 78 
APPENDIX IV:  FOCUS GROUP DISCUSSION GUIDE FOR CLIENTS .................................... 80 
APPENDIX V: QUALITATIVE GUIDE FOR IN-DEPTH INTERVIEWS (IDIS) FOR PROVIDERS 
.................................................................................................................................................83 
APPENDIX VI:  SOP FOR PERFORMING AND INTERPRETING URINE TENOFOVIR 
ADHERENCE ASSAY .................................................................................................................. 86 
APPENDIX VII: SOP FOR COLLECTION AND STORAGE OF HAIR SAMPLES ................... 865 
APPENDIX VIII: FDA DESIGNATION OF THE URINE TENOFOVIR ASSAY AS NSR ............90 
APPENDIX IX: KEMRI IRB APPROVAL OF PUMA TRIAL DATED 10/16/19 ........................... 93 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 7 of 93 
 
 
 
 
Abbreviations 
 
AIDS 
Acquired Immunodeficiency Virus 
AE 
Adverse Event 
ART 
Antiretroviral Therapy 
ARVs 
Antiretrovirals 
ARC 
AIDS Related Complex 
CDC 
Centers for Disease Control and Prevention (US) 
DAIDS 
Division of AIDS (NIH) 
DBS 
Dried Blood Spots 
EC 
Ethics Committee 
FDA 
Food and Drug Administration (US) 
FTC 
Emtricitabine 
FTC-TP 
Emtricitabine-triphosphate 
HAL 
Hair Analytical Laboratory 
HIV 
Human Immunodeficiency Virus 
HTTP 
Hypertext Transfer Protocol (presentation of web data) 
IRB 
Institutional Review Board 
KEMRI 
Kenya Medical Research Institute 
LC-MS/MS 
Liquid chromatography/tandem mass spectrometry 
LFA 
Lateral flow assay 
MSM 
Men who have sex with men 
NIH 
National Institutes of Health (US) 
PrEP 
Pre-exposure prophylaxis 
POC 
Point of care 
RCT 
Randomized controlled trial 
REDCap 
Research Electronic Data Capture 
SAS 
st Software 
SDC 
Serodiscordant couples 
SOC 
Standard of care 
STI 
Sexually transmitted infection 
TDF 
Tenofovir disoproxil fumarate 
TFV 
Tenofovir 
TFV-DP 
Tenofovir diphosphate 
UCSF 
University of California, San Francisco 
UNAIDS 
Joint United Nations Program on HIV/AIDS 
US 
United States 
UW 
University of Washington 
VCT 
Voluntary counseling and testing 
WHO 
World Health Organization 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 8 of 93 
 
 
 
 
1 
1. STUDY SUMMARY AND SCHEMA 
2 
3 
1.1. Lay Summary 
4 
Pre-exposure prophylaxis (PrEP) with oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) 
5 
prevents HIV infection if taken every day. However, previous PrEP trials demonstrated that many 
6 
women in Africa at risk for HIV who are not in couples (with an HIV-positive partner) need help 
7 
remembering to take the pill every day. Also, patients on PrEP may not always report their 
8 
adherence to the pill accurately and “objective” measures of adherence (where PrEP drug levels 
9 
were measured) are far superior to self-report. We have reason to believe that telling a patient 
10 
his/her  PrEP  drug  levels,  and  subsequent  counseling  on  adherence,  can  motivate  better 
11 
adherence in the future. The usual ways to measure PrEP drug levels are very complicated and 
12 
require expensive equipment and trained laboratory staff. However, our group has now developed 
13 
a new and innovative way to measure adherence to PrEP (specifically tenofovir, TFV) via an 
14 
antibody-based test (“immunoassay”) in urine that can be performed cheaply at the point-of-care 
15 
(POC) by any healthcare worker (like a urine pregnancy test). A few drops of the patient’s urine 
16 
is dropped into the test and tells the provider “yes” or “no” if the patient has been taking PrEP 
17 
recently. This protocol is for a pilot trial where we randomize women on PrEP (who are not in 
18 
serodiscordant couples) at Thika Clinic to having information from the urine assay delivered to 
19 
them (or not delivered to them in the control group) in order to provide feedback on adherence 
20 
from this test in a supportive, motivating manner and enhance adherence counseling. The pilot 
21 
trial will assess if the urine tool is acceptable to participants, feasible for the clinic to perform, and 
22 
if providing feedback on adherence from the urine tool to the participant increases longer-term 
23 
adherence, as assessed by measuring PrEP drug levels in small hair samples. Good adherence 
24 
to PrEP will eventually lead to fewer HIV infections worldwide. 
25 
26 
1.2. Study Summary 
27 
Worldwide expansion of pre-exposure prophylaxis (PrEP) will be critical to ending the HIV 
28 
epidemic. The original PrEP clinical trials showed us that 1) adherence is critical to effectiveness; 
29 
2) daily PrEP adherence was difficult to maintain, especially among women not in serodiscordant 
30 
relationships; 3) objective adherence measures (e.g. measuring PrEP drug levels) are more 
31 
reliable than self-reported adherence; and 4) real-time monitoring of PrEP drug levels with 
32 
feedback to the patient could improve subsequent adherence. Objective measures of PrEP 
33 
adherence, especially point-of-care measures that enable real-time assessment, intervention and 
34 
feedback,  will  be  important  for  both  interpreting  and  optimizing  effectiveness  during  PrEP 
35 
implementation. Our group has developed a novel point of care urine-based measure of PrEP 
36 
adherence which has been validated among HIV-uninfected volunteers who were administered 
37 
TDF/FTC.1-5 The test has now been developed into a lateral flow assay (LFA), allowing real-time 
38 
monitoring.4,5 This test is cheap, easy to perform and can be done at the point-of-care. However, 
39 
this tool has not yet been tested among participants on PrEP in a trial to see if real-time monitoring 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 9 of 93 
 
 
 
 
40 
of adherence using the urine assay is feasible, acceptable and motivates improvements in long- 
41 
term adherence as assessed by hair levels. 
42 
43 
Pharmacologic measures of adherence to TDF/FTC-based PrEP, where tenofovir (TFV) drug 
44 
levels are measured in a matrix such as plasma,6  dried blood spots (DBS),7  or hair (studied 
45 
extensively as an adherence metric by our group)8-48   capture drug ingestion and predict 
46 
outcomes more accurately than self-reported adherence.13-15,17,19,20  Pharmacologic adherence 
47 
monitoring is especially important in PrEP, where a surrogate biomarker of response (e.g. HIV 
48 
viral loads during HIV treatment) is not available. However, current methods to analyze PrEP 
49 
drug levels in any matrix, including easily accessible urine,49  require liquid chromatography- 
50 
tandem mass  spectrometry (LC-MS/MS),  which cannot  be performed in real-time because 
51 
expensive equipment and trained laboratory staff are needed. Antibody-based tests allow for 
52 
point-of-care testing. 
53 
54 
The UCSF Hair Analytical Laboratory (directed by Dr. Monica Gandhi) has now developed a 
55 
collaboration with Alere™ (recently bought by Abbott Rapid Diagnostics), a company with vast 
56 
expertise in point-of-care (POC) diagnostics, to develop one of the first immunoassays that 
57 
detects TFV in urine. The test is sensitive, specific, precise, and quantitates TFV levels in urine 
58 
as accurately as LC-MS/MS,1,2,4  or enzyme-linked immunoassay5  allowing for low-cost POC 
59 
adherence monitoring.  The  first  iteration of  the  lateral flow  immunoassay  (LFA)  has  been 
60 
developed4 and allows for real-time testing, giving the provider qualitative yes/no information on 
61 
recent adherence to PrEP. This novel POC adherence assay has the potential to address key 
62 
knowledge gaps in PrEP implementation to both interpret and improve adherence. 
63 
64 
Aim: 
To perform a pilot randomized controlled trial (RCT) in Kenya to assess the 
65 
acceptability  of  the  urine  POC  TFV  assay  to  participants,  the  feasibility  of 
66 
administering  the  test  for  providers,  and  the  impact  of  real-time  adherence 
67 
monitoring/feedback via the POC test on increasing PrEP adherence over time (as 
68 
established by a long-term metric of adherence using hair levels). 
69 
Hypothesis:  Providing real-time monitoring/feedback via the POC assay will be acceptable, 
70 
feasible, and improve adherence over time among adherence-challenged women 
71 
on PrEP in Kenya. 
72 
Approach: 
Given known PrEP adherence challenges among women not in serodiscordant 
73 
couples and the likely need for daily drug-taking among women for efficacy,50 we 
74 
will conduct a pilot randomized controlled trial by randomizing women not in 
75 
serodiscordant  couples  on  PrEP  in  Kenya  to  standard  of  care  adherence 
76 
counseling (n=60) vs real-time adherence feedback and enhanced adherence 
77 
counseling using information from the POC urine assay (n=60). Using mixed- 
78 
methods, we will assess the acceptability of the test to participants and the 
79 
feasibility  of  administering  the  test  for  providers  via  triangulating  data  from 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 10 of 93 
 
 
 
 
80 
structured surveys and qualitative interviews. The effect of the feedback on long- 
81 
term adherence over time measured via tenofovir (TFV) levels in hair samples will 
82 
be assessed. 
83 
At study end, we will have conducted a field test of a novel lateral flow assay to detect TFV in 
84 
urine as the first POC low-cost objective adherence metric available for participants on PrEP. The 
85 
assay will launch a novel modality for adherence intervention. Moreover, study findings will inform 
86 
a  larger-scale  PrEP  demonstration  trial  assessing  the  impact  of  real-time  adherence 
87 
monitoring/feedback via the assay on seroconversion rates. The pilot trial proposed here will 
88 
examine the acceptability, feasibility and impact of this novel tenofovir adherence assay in urine 
89 
on a longer-term metric of adherence for the first time in any population. 
90 
91 
1.3. Schema 
92 
 
Purpose: 
To determine if providing real-time monitoring/feedback via a POC 
tenofovir urine assay will be acceptable to women, feasible for providers, 
and improve adherence over time using a long-term metric of adherence 
among women on PrEP in Thika, Kenya. 
Design: 
A pilot randomized controlled trial of women receiving PrEP will be 
randomized (1:1) to standard of care adherence counseling (n=60) vs 
real-time adherence feedback and enhanced adherence counseling 
using information from the POC urine assay (n=60) 
Population: 
HIV-uninfected women ≥18 years old receiving PrEP in Kenya 
Study Size: 
a  minimum  of  100  and  not  exceeding  120  participants  equally 
randomized to each arm. 
POC Testing: 
Urine tenofovir testing by lateral flow assay 
Outcome 
Measurement: 
The primary outcomes for this study will be acceptability to participants, 
feasibility for providers, and impact of the POC adherence test on 
measures of tenofovir in hair samples 12 months after randomization. 
Study Duration: 
24 months, including enrollment period, and 12 months of follow-up per 
participant. 
Primary Objectives: 
To test the acceptability to participants, feasibility for providers, and 
impact on a longer-term metric of adherence among participants 
(assessed via tenofovir levels in hair) of implementing POC urine 
tenofovir testing and providing real-time feedback among women 
receiving PrEP in Thika, Kenya. 
Study Site: 
The Thika Clinic, which is located in an urban center about 40 kilometers 
outside of Nairobi, has been a center of excellence for PrEP delivery in 
Kenya and a longstanding clinical research partner with KEMRI and the 
University of Washington. 
93 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 11 of 93 
 
 
 
 
94 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
95 
96 
97 
98 
99 
100 
101 
102 
103 
104 
105 
106 
107 
2. CONSORT DIAGRAM 
 
3. BACKGROUND 
 
3.1. Significance 
 
Lessons from the PrEP trials and demonstration projects indicate a need for real-time 
monitoring of PrEP adherence using a pharmacologic measure. 
Massive advances in HIV biomedical prevention strategies have allowed the end of AIDS to 
finally come into sight.51 Along with treatment as prevention,52-55 pre-exposure prophylaxis 
(PrEP) with oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) 56-59 is one of the most 
effective strategies to prevent HIV acquisition among at-risk individuals. PrEP, now broadly 
recommended by the Centers for Disease Control and Prevention (CDC)60 and the World 
Health Organization (WHO),61 is in an exciting phase of global implementation. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 12 of 93 
 
 
 
 
108 
109 
110 
111 
112 
113 
114 
115 
116 
117 
118 
119 
120 
 
 
 
 
 
 
 
 
 
 
 
121 
122 
123 
124 
125 
126 
127 
128 
129 
130 
131 
132 
133 
134 
135 
136 
137 
 
The PrEP trials and demonstration projects to date; however, have highlighted four major lessons 
that should be addressed in order to increase the effectiveness of this important prevention 
strategy during implementation (Figure 1). First, there is a profound relationship between 
adherence and effectiveness.62 Second, taking a pill every day for prevention (e.g. maintaining 
adherence) is difficult, especially among certain key groups such as heterosexual women who 
are not in a relationship with an HIV-positive man. Third, pharmacologic measures – where drug 
levels of PrEP drugs are assayed in a biomatrix – predict the efficacy of PrEP more accurately 
than self-reported adherence.63-69 Fourth, real-time monitoring of PrEP drug levels, as in other 
disease states,70-90 may improve subsequent PrEP drug-taking.91-95 We have now developed one 
of the first point-of-care tools to assess PrEP adherence objectively1,3,96,97 with the potential to 
address all four lessons. 
 
 
 
The first two points – that adherence is necessary for PrEP effectiveness and daily adherence is 
hard to maintain – are well documented.98 Although PrEP was effective in placebo-controlled trials 
among men-who-have-sex-with-men (MSM) and transgender women,56 among intravenous drug 
users,59 and among both men and women in serodiscordant couples,57,58,99 there was no efficacy 
of oral PrEP observed in two large trials (FEM-PrEP and VOICE) conducted among young 
sexually active women in Africa who were not in serodiscordant relationships.63,65 Low rates of 
adherence to TDF/FTC were largely responsible for the lack of efficacy in FEM-PrEP65 and 
VOICE,63 where pharmacologic measures of adherence were critical to study interpretation.66 
Women in both trials self-reported >95% adherence to study drug, but random plasma tenofovir 
(TFV) levels among women on active drug were detectable in fewer than 30% of 
participants.63,65 
 
The third point – that pharmacologic measures predict the efficacy of PrEP better than self-report 
– was true not only in the placebo-controlled trials, but also in open-label extension studies of 
PrEP, where adherence has generally been higher than in the original trials. Pharmacologic 
measures  examine  drug  concentrations  in  a  biomatrix  such  as  plasma,6   peripheral  blood 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 13 of 93 
 
 
 
 
138 
139 
140 
141 
142 
143 
144 
145 
146 
147 
148 
149 
150 
151 
152 
153 
154 
155 
156 
157 
158 
159 
160 
161 
162 
163 
164 
165 
166 
167 
168 
169 
170 
171 
172 
173 
174 
175 
176 
177 
mononuclear cells (PBMCs),98 hair,31 or dried blood spots (DBS).7,100 Substantial discordance 
between self-reported measures of adherence and drug detection in trials and demonstration 
projects34,35,38,56,58,63,65,66,101-105 have highlighted the crucial importance of incorporating objective 
pharmacologic measures of adherence when interpreting PrEP effectiveness.69,98,101,102 For 
instance, in the iPrEx trial, the efficacy of TDF/FTC rose from 44% to an estimated 92% among 
those with detectable blood drug levels.56 
 
The fourth and final point, gleaned from the VOICE,91,94 iPrEx open label extension (OLE) 
study,95,106 and a demonstration project among MSM in Los Angeles,107 is that real time monitoring 
of PrEP drug ingestion is acceptable and motivating to patients and could improve subsequent 
PrEP adherence.91-95 However, a knowledge gap exists regarding the impact of this unique 
adherence intervention because no truly point-of-care (POC) pharmacologic measure of PrEP 
adherence has existed until now.97 Therefore, a low-cost, low-technology method to assess 
objective adherence via drug detection in real-time could address the four major lessons from 
PrEP studies (Figure 1) and optimize outcomes during PrEP roll-out by allowing for immediate 
feedback, enhanced adherence counseling, and targeted adherence interventions, including 
counseling to address specific barriers and addressing structural barriers.. 
 
Pharmacologic adherence measures in past were expensive; we have now developed a 
cheap, point-of care test. 
Plasma levels of PrEP drugs6 assess short-term adherence (~1-4 days) and were measured in 
every placebo-controlled PrEP trial to interpret effectiveness.56-59,63,65,69,102,108,109 TFV-diphosphate 
(TFV-DP) and FTC-triphosphate (FTC-TP) concentrations in DBS7 reflect longer-term adherence 
and multiple PrEP demonstration projects have used PrEP metabolite levels in DBS to assess 
adherence.34,37,38,106,110,111 Our UCSF group has developed methods to analyze PrEP drugs in 
hair,31 which assess adherence over weeks to months.8 Hair TFV levels have the best 
discriminatory ability as a single measure to predict long-term adherence39 and have been used 
to interpret PrEP adherence in multiple settings.32-35,37-39,41-44,46,48 
The current techniques to measure PrEP or PrEP metabolites, however, all  require liquid 
chromatography/tandem mass spectrometry (LC-MS/MS) or other spectrometry112 machines, all 
of which are expensive. Moreover, the techniques to extract drug and assess levels via any 
sensitive spectrometry-based method, even using small benchtop machines, are laborious and 
require specialized personnel. Most of the urine assays developed to date also all involve LC- 
MS/MS49,1-115 and, therefore, cannot be performed at the clinical point-of-care. Antibody-based 
tests (lateral flow immunoassays)116,117 are low-cost, enable drug detection to occur within 
minutes, and are easy to perform.118 
 
We have now developed one of the first such antibody-based (immunoassays) for TFV. Our 
immunoassay is highly specific (100%), sensitive (96%) and provide TFV levels in urine which 
correlate strongly with LC-MS/MS-measured levels (r=0.95) in a study of volunteers administered 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 14 of 93 
 
 
 
 
178 
179 
180 
181 
182 
183 
184 
185 
186 
187 
188 
189 
190 
191 
192 
193 
194 
195 
196 
197 
198 
199 
200 
201 
202 
203 
204 
205 
206 
207 
208 
209 
210 
daily TDF/FTC.1 In a larger study where TDF/FTC was administered to HIV-noninfected 
volunteers at 2, 4 and 7 doses a week, the assay showed the same excellent performance 
characteristics and we were able to establish the adherence cut-off (specifically 1500 
nanograms/milliliter) for TFV in urine for the POC assay.2 This cut-off minimizes misclassification 
of adherence and the assay has now being translated to a corresponding lateral flow assay4 in a 
strip format (like a urine pregnancy test, Figure 6) to use for this pilot trial. The lateral flow assay 
has high accuracy compared to the laboratory based enzyme-linked immunoassay (ELISA). See 
the preliminary data section (Section 3.3) for more details on the lateral flow assay.4,5 
 
Real-time feedback of pharmacologic adherence metrics during PrEP will likely increase 
adherence. 
In VOICE, at least 50% of women on active drug had undetectable TFV in all plasma tested,91 but 
over-reported adherence, even at the last study visit where accurate reporting would not affect 
study participation.93 Further qualitative work to understand non-adherence in VOICE was 
performed through the Microbicides Trials Network (MTN)-003D study91 which recruited 
participants with pharmacokinetic (PK) data consistent with low (0% of plasma samples having 
detectable TFV), inconsistent, or high adherence for retrospective disclosure of plasma TFV 
results and subsequent capture of reactions. Women with low adherence first expressed surprise 
at the PK results, then acknowledged they were true and revealed reasons for non-drug-taking 
during in-depth interviews. Women in all three categories stated that real-time monitoring and 
feedback in future trials would improve adherence.91 Women also said self-report would be more 
honest if presented with objective adherence metrics.94 
 
In the open-label extension (OLE) study of iPrEx, drug level testing was performed in plasma and 
DBS.106 The results of plasma drug levels over prior weeks were shared with individuals at a later 
visit, which was reported as highly acceptable.106 Those with detectable drug in plasma 
appreciated receiving validation of adherence and those without drug detection were not 
surprised.106 An in-depth qualitative analysis from iPrEx OLE confirmed the acceptability of drug 
level feedback (Figure 2)95 and, for those who were not adherent, the motivating effect of 
receiving such feedback on subsequent adherence.95 The results of these interviews led authors 
to conclude that 1) drug level feedback should be provided as quickly as possible, so new 
methods should be sought to provide rapid feedback; and 2) drug level feedback will encourage 
frank adherence discussion and should be provided in the context of adherence counseling.95 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 15 of 93 
 
 
 
 
 
 
211 
212 
213 
214 
215 
216 
217 
218 
219 
220 
221 
222 
223 
224 
225 
226 
227 
228 
229 
230 
231 
232 
233 
234 
235 
236 
237 
 
A demonstration project in Los Angeles MSM107 demonstrated high acceptability of plasma TFV 
level adherence feedback, with a trend towards greater adherence in those who received drug 
level results with enhanced adherence counselling. MSM found drug-level feedback highly 
acceptable, with participants competing to achieve the highest drug level result.107,119 Finally, a 
study which provided urine drug-level results to MSM in Philadelphia (not at the point-of-care) 
was also highly acceptable.120,121 In spite of these encouraging results, participants in these two 
studies requested that drug-level feedback should be provided as close as possible to the 
clinical visit to help motivate subsequent adherence. 
 
Finally, in the phase III placebo controlled trial of the dapivirine vaginal ring for HIV prevention,122 
plasma was collected quarterly and assayed for dapivirine levels.92 The data center provided 
feedback on drug levels to study and site leadership (but not at the individual level) to help 
motivate staff and counsel participants to use the ring. From 2013 to 2015, the proportion of 
participants in the active arm with dapivirine blood levels  consistent with good adherence 
increased from 63% to 84% (p<0.0001).92 This study demonstrated the feasibility and possible 
impact of drug level monitoring with even general (albeit not specific nor real-time) feedback to 
staff and participants.92 
 
Cumulatively, these findings have led to a widespread call for drug-level monitoring and feedback 
as close to real-time as possible during PrEP implementation. The HIV Prevention Trials Network 
(HPTN)-082 study, an open-label PrEP study of high-risk sexually active young women (ages 16- 
25) in Africa,111 included drug level feedback (using PrEP metabolite concentrations in DBS) at 8 
and 13 weeks for those randomized to an enhanced adherence support arm. Since drug level 
testing in DBS using LC-MS/MS cannot be performed in real time; however, feedback was 
delayed by at least a month, which could have led to the negative results of this study.123 The next 
iteration of the study (PrEP-SMART) will try providing real-time feedback of adherence via the 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 16 of 93 
 
 
 
 
238 
239 
240 
241 
242 
243 
244 
245 
246 
247 
248 
249 
250 
251 
252 
253 
254 
255 
256 
257 
258 
259 
260 
261 
262 
263 
264 
265 
266 
267 
268 
269 
270 
271 
272 
273 
274 
275 
276 
277 
urine assay we have developed. Only a truly real-time assay for monitoring PrEP drug-taking and 
providing feedback on the spot will allow for immediate counseling and intervention. 
 
Finally, the hypothesis that real-time monitoring and feedback on adherence may increase 
adherence among those on PrEP must be seen in the context of other structural and perceived 
barriers to PrEP use, including erroneous assumptions of one’s risk, transportation barriers, 
economic barriers, lack of peer support, depression, etc. However, the ability of the POC TFV 
assay to provide an objective metric of adherence in real-time to providers serving clients on PrEP 
can eventually allow adherence interventions to be tailored to an individual’s specific barriers (e.g. 
transportation vouchers if transportation is an issue; treatment of depression; discussion of risk; 
adherence clubs; contingency management etc). Moreover, enhanced adherence counseling 
itself is a tailored intervention in that the counseling takes into account the individual’s particular 
concerns about and barriers to adherence. If a provider relies on an individual’s self-reported 
adherence and that adherence reporting is inaccurate (e.g. inflated), an opportunity for a tailored 
adherence intervention and/or enhanced adherence counseling will be lost. An objective metric 
of adherence will allow providers to know if a patient is not taking PrEP and, thereby, tailor the 
adherence counseling and subsequent interventions appropriately.” 
 
Real-time monitoring of adherence and feedback in other disease states improves 
adherence and outcomes. 
Beyond the field of HIV prevention and even HIV treatment, other chronic diseases states are 
threatened by adherence difficulties. Patients adhere to life-saving cardiovascular and diabetes 
medications approximately 50% of the time.124 Hypertension and diabetes treatment have 
surrogate markers of adherence monitoring (e.g. blood pressure control and glucose or 
hemoglobin A1c levels, respectively) which can allow for monitoring and feedback. Real-time 
monitoring, accompanied by feedback to patients on results, have led to increases in adherence 
(as evidenced by increases in drug levels)70-72 and better outcomes73-79 in a variety of disease 
states.80-82 For instance, urine monitoring for anti-hypertensives,83-86,125 with subsequent feedback 
to patients on drug levels, increases both urine anti-hypertensive drug levels and blood pressure 
control.83 Another major field in which real-time monitoring and feedback is performed is in the 
context of screening for prescribed opioids (as well as for substance use).87-90 Immunoassays are 
the recommended first-line screening modality for opioid or substance use, since antibody-based 
tests allow for POC testing and rapid response at the clinical point-of-care.88,87-90,118 
 
Potential utility of PrEP adherence monitoring in urine and addressing “white-coat” 
adherence. 
Urine is a suitable matrix for POC testing for PrEP adherence since urine collection is 
noninvasive,49 preferred among youth over blood sampling,126,127 and TFV levels in urine correlate 
with adherence to TDF.49 Urine levels reflect plasma levels,128 assessing recent adherence,129 
which may be particularly useful when daily PrEP adherence is necessary, as in women.50 Plasma 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 17 of 93 
 
 
 
 
278 
279 
280 
281 
282 
283 
284 
285 
286 
287 
288 
289 
290 
291 
292 
293 
294 
295 
296 
297 
298 
299 
300 
301 
302 
303 
304 
305 
306 
307 
308 
309 
310 
311 
312 
313 
314 
315 
316 
317 
and urine PrEP drug levels reflect only short-term exposure, and thus monitoring via these 
matrices may be susceptible to “white coat adherence”. White-coat adherence is a phenomenon 
where adherence improves transiently before a clinic or a study visit.130 Despite this theoretical 
concern, this phenomenon has not yet been observed in PrEP. Indeed, plasma levels of TFV/FTC 
served as the “gold standard” adherence metric in every one of the placebo-controlled trials of 
TDF/FTC-based PrEP.3,4,57,59-63,79 Across these trials, plasma PrEP levels provided robust and 
critical information for interpreting trial results. For example, in iPrEx56 and Partners PrEP,58 
plasma levels demonstrated that the use of PrEP was associated with >90% protection against 
HIV, and in FEM-PrEP65 and VOICE,63 plasma TFV/FTC levels showed that very low adherence 
explained the trials’ results, further emphasizing that a white coat effect was not widespread in 
those trials. Our group found no evidence of white-coat adherence when examining a combination 
of long and short-term adherence metrics (assessed via PrEP drug levels in hair and plasma 
samples) in VOICE.35 In iPrEx OLE, there was no evidence of “white coat adherence” despite 
participants knowing drug level results were being monitored. Moreover, qualitative data from 
those who received plasma TFV level feedback found feedback “motivating” – not to impress 
study coordinators before a visit – but to maintain long-term adherence (last quote, Figure 2).95 
 
In research studies, a combination of short- and long-term metrics may provide the most 
complete detail to examine patterns of adherence35,39,41,48,131 and enables examination for the 
phenomenon of white-coat adherence. In this study, we plan to combine urine and hair PrEP 
measures to adjudicate white coat effects and confirm the benefit of the urine assay on 
adherence over time. Hair levels measure cumulative drug adherence over time and are not 
influenced by short-term fluctuations in adherence (analogous to a hemoglobin A1c level 
compared to a single glucose level in diabetes monitoring).8 Therefore, in this study, we will be 
able to distinguish between white coat adherence and long-term adherence occurring at each 
time point by comparing the urine and hair levels of tenofovir, respectively (for instance, good 
urine levels but low hair levels are suggestive of white-coat adherence). Another way to minimize 
the concern in future studies or the clinic is to perform unannounced urine assays125,132-                      
135 and then follow those with adherence challenges more closely (via differentiated service 
delivery136), both with a combination of short-term and longer-term metrics (e.g. drug levels in 
hair, DBS) and interventions. 
 
 
 
 
Women at risk need PrEP and need adherence support 
Adolescent girls and young women in sub-Saharan Africa have unacceptably high HIV incidence 
rates.137,138 PrEP has the potential to dramatically reduce HIV incidence in this population.139,140 
However, among women not in serodiscordant couples (FEM-PrEP65; VOICE63), adherence was 
too low to result in PrEP effectiveness. Recent demonstration projects show higher adherence 
among women at risk in Africa than in the initial randomized trials early on, with subsequent 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 18 of 93 
 
 
 
 
318 
319 
320 
321 
322 
323 
324 
325 
326 
327 
328 
329 
330 
331 
332 
333 
334 
335 
336 
337 
338 
339 
340 
341 
342 
343 
344 
345 
346 
347 
348 
349 
350 
351 
352 
353 
354 
355 
356 
357 
 
adherence waning.141 The recently completed HPTN 082 Evaluation of Daily Oral PrEP as a 
Primary  Prevention  Strategy  for  Young  African  Women  Study  (n=427)  found  that  25%  of 
participants had tenofovir diphosphate (TFV‐DP, measured in dried blood spots) levels consistent 
with 4 doses a week (albeit women may need dosing 7 doses a week) at 3-months with only 9% 
of women with similar levels at 12 months.142 Pharmacokinetic modeling indicates that, due to 
differences in TFV exposure in vaginal versus rectal tissues,50 women likely require higher levels 
of adherence, specifically 6-7 doses PrEP/week.143 These data highlight the importance of 
bringing novel adherence interventions to women on PrEP, which is why we chose to study 
women in our initial pilot study of this important new assay. 
 
3.2. Innovation 
Although pharmacologic adherence measures of PrEP are available, no POC method to assess 
adherence to PrEP via drug detection has yet been scaled. We have developed the first PrEP 
immunoassay, which is now available as a point-of-care test,{Gandhi, 2020 #1196} allowing for 
real-time adherence monitoring. The primary innovation of this study is that we propose to test 
the acceptability, feasibility and utility of this novel low-cost real-time metric of adherence to PrEP 
for the first time. 
 
Further innovations for HIV prevention and treatment will result from this proposal. Since TFV- 
based regimens (TDF or tenofovir  alafenamide or  TAF) are the backbone of antiretroviral 
treatment (ART) for HIV infection worldwide, providing a low-cost tool to monitor TFV drug-taking 
behavior at the clinical point-of-care should launch an entirely new field of adherence intervention 
for HIV treatment as well as prevention. Not only can real-time feedback on adherence itself 
improve adherence, but providing practitioners real-time knowledge on how a patient is 
adhering to PrEP or ART at a visit can allow for interventions to be triggered before 
prevention or treatment effectiveness is further compromised.144 In the context of treatment, 
a low-cost POC assay may help avert virologic failure and drug resistance between more 
expensive viral load measurements.145-147 
 
3.3. Preliminary data 
Development and validation of the novel urine-based tenofovir lateral flow assay 
How lateral flow assays allow for immediate drug detection 
Immunoassays use antibodies  to detect drug.116 Lateral flow immunoassays  (LFA) can be 
performed at the POC using a variety of testing platforms, such as a rapid strip test. LFAs are 
easy-to-perform, provide results quickly, and are cheap compared to standard methods to detect 
drug, specifically liquid chromatography-tandem mass spectrometry (LC-MS/MS).118 To develop 
immunoassays,153 antibodies are raised in rabbits against derivatives of the drug of interest. 
Purified antibodies with specific binding to the drug derivative are then isolated. Inhibition of signal 
needs to then be demonstrated with adding the drug of interest into the antigen-antibody mix to 
create dose-response curves. The most well-known LFA is the over-the-counter urine pregnancy 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 19 of 93 
 
 
 
 
358 
359 
360 
361 
 
 
 
 
 
 
 
 
 
 
362 
363 
364 
365 
366 
367 
368 
369 
370 
371 
372 
373 
374 
375 
376 
377 
378 
379 
380 
381 
382 
383 
384 
385 
386 
 
test. Figure 3 illustrates the steps of raising an antibody against tenofovir and creating an 
immunoassay that can eventually be translated into a lateral flow assay to be used at the point- 
of-care. 
 
 
 
Alere™ Diagnostics (now Abbott Rapid Diagnostic Division (ARDx)) has long-standing 
experience and expertise in developing point-of-care immunoassays.118,154-164 ARDx has 
developed immunoassays for the diagnosis of HIV,156-160 influenza A/B,155 tuberculosis,154 Crohn’s 
disease;161 for quantification of beta-type natriuretic peptide (BNP),162 D-dimer,163 and CD4 cell 
count;164 and for the simultaneous screening of multiple therapeutic analgesics and substances 
in urine.118 The Hair Analytical Laboratory (HAL) at UCSF and its predecessor (the UCSF Drug 
Studies Unit), with vast expertise in LC-MS/MS-based methods to analyze drugs in a variety of 
matrices, including antiretrovirals (ARVs) in hair,9,10,30 formed a collaboration with ARDx in 2016. 
 
Development of the novel immunoassay for quantification of TFV in urine. 
To initiate assay development, scientists from the UCSF HAL30 and ARDx first scrutinized the 
molecular structure of TFV to identify unique derivatives with structural distinction from 
endogenous nucleotides. We then constructed four possible immunogens (TFV derivatives) and 
each one was injected into three rabbits (12 rabbits total) (Figure 3). The rabbits were injected 
with boosters and bled monthly, with subsequent testing of serum by enzyme-linked 
immunosorbent assay (ELISA).165 After 5 months of monthly bleeds, each of the three rabbits 
injected with one of the immunogens developed a polyclonal antibody demonstrating very specific 
binding to TFV by ELISA. Inhibition of the signal of the antibody-antigen mix was then seen with 
the addition of increasing concentrations of TFV to create dose response curves. 
 
Figure 4 shows the dose-response curve for TFV levels in urine developed from the antibody 
purified from one of the rabbits.166 The strong inverse relationship between dose and urine 
concentrations of TFV shows appropriate assay characteristics. Based on these results, the 
purified antibody was deemed suitable for development into a POC assay. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 20 of 93 
 
 
  rho 0.92  
Figure 5: Correlation of urine immunoassay TFV levels with 
LC-MS/MS levels in TARGET urine samples with drug 
detectable in both assays (n=274). 
 
 
 
 
387 
388 
389 
390 
391 
392 
393 
394 
395 
396 
397 
398 
399 
400 
401 
402 
403 
404 
405 
406 
407 
408 
409 
410 
411 
412 
413 
414 
 
We have now published data showing the excellent performance characteristics of the ELISA- 
based immunoassay with this antibody compared to the gold-standard method of quantitating 
TFV levels in urine, specifically LC-MS/MS. Compared to quantification of TFV in urine via LC- 
MS/MS, the quantification of TFV levels in urine via the ELISA test demonstrate high sensitivity, 
specificity, accuracy, and precision.1,2 The high correlation of ELISA-immunoassay results of TFV 
in urine with those from the gold standard of LC-MS/MS is shown in Figure 5. 
 
Development of the TFV assay into a point-of-care LFA platform. 
The translation of the plate-based immunoassay to an LFA is a well-established process, and the 
Abbott Rapid Diagnostics Division is a leading diagnostic company with extensive experience in 
developing POC assays. The lateral flow assay (LFA) prototype has now been developed by 
Abbott for testing in this pilot trial.4 as described below: 
The LFA test strip components include 
a sample pad onto which the test 
sample (e.g. urine) is applied; a 
conjugate pad coated with tenofovir 
specific 
antibodies 
conjugated 
to 
colloidal 
gold 
nanoparticles; 
a 
nitrocellulose membrane striped with a 
test line consisting of a tenofovir 
antigen and a control line consisting of 
anti-rabbit antibody; and an absorbent 
pad designed to draw the sample 
across the reaction membrane by 
capillary action. These components are 
all affixed to inert backing material and 
packaged within 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 21 of 93 
 
 
 
 
415 
416 
417 
418 
419 
420 
421 
422 
423 
424 
425 
426 
427 
428 
429 
430 
431 
432 
433 
434 
435 
436 
437 
438 
 
a plastic casing (Figure 6). 
 
A photograph of the fully-developed LFA is shown in Figure 6. The urine first encounters the 
colored particles labeled with tenofovir antibody, so free tenofovir in the urine sample will bind the 
antibodies, preventing them from binding to the antigen line (test line) containing the tenofovir 
antigen. The presence of tenofovir in the urine, therefore, results in no color signal on the test 
line. Absence of tenofovir in the urine causes the antibodies to migrate to the antigen pad and 
bind strongly to the tenofovir antigen, resulting in a dark test line. This competitive assay, 
therefore, demonstrates a colored line in samples negative for tenofovir and no line in samples 
positive for tenofovir (Figure 6).This LFA requires 2-3 drops of urine to be dropped into the divot 
at the end and takes <2 minutes to yield results. The test on the left in Figure 6 shows a urine 
sample without tenofovir present. The test on the right shows a urine sample taken 8 hours after 
an HIV-noninfected volunteer was administered TDF/FTC 300mg/200mg. A single test therefore 
provides qualitative information (yes/no) on recent adherence 
 
As detailed below, laboratory staff at the Thika Clinic will be trained in the interpretation of this 
test since the presence of a tenofovir test line indicating a “negative results’ is counterintuitive. 
Neither the research provider nor the participant will need to interpret the test. The laboratory staff 
on site will perform the test, interpret the test, and deliver the results to the research provider for 
providing feedback to participants in the intervention arm only. Of note, the test shown in Figure 
6 is the prototype of the first test Abbott Rapid Diagnostics has produced. The final test for 
marketing (like urine pregnancy tests) will have an overlaid window so that a “positive test” for 
tenofovir shows up as a “plus sign” and a “negative test” for tenofovir shows up as a “minus sign”. 
 
 
 
 
Figure 6: Fully developed LFA for tenofovir testing 
 
 
 
 
 
 
 
 
 
 
 
 
439 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 22 of 93 
 
 
 
 
440 
441 
442 
443 
444 
445 
446 
447 
448 
449 
450 
451 
452 
453 
454 
455 
456 
457 
458 
459 
460 
461 
462 
463 
464 
465 
466 
467 
468 
469 
470 
471 
472 
473 
474 
475 
476 
477 
478 
Validation of the point of care tenofovir LFA against gold-standard quantification (LC- 
MS/MS) 
Using urine samples collected from a directly observed therapy (DOT) study (TARGET, 
NCT0301260)167 in which 30 HIV-noninfected volunteers from Thailand received directly- 
observed TDF 300mg/FTC 200mg at 7, 4 and 2 doses per week (to simulate high, moderate and 
low adherence levels, respectively), we modeled an appropriate adherence benchmark for the 
lateral flow assay. We found that a urine concentration of 1500 nanograms (ng)/milliliter (mL) of 
tenofovir in the urine balanced high specificity for adherence with good sensitivity for non- 
adherence.2 
 
To evaluate the performance of the LFA, urine samples were then aliquoted for measurement by 
both LC-MS/MS and the LFA. For the LC-MS/MS-based method,1 tenofovir is separated from one 
thousand-times diluted urine via reverse-phase high-performance LC and quantified by MS/MS 
using electrospray positive ionization in multiple reaction monitoring mode (TFV, 287.9/175.9 m/z 
(Q1/Q3)). The lower limit of quantification (LLOQ) of the LC-MS/MS-based assay is 500 ng/mL. 
For the LFA, 2-3 drops of urine are applied from the urine sample on to the LFA and, after 
approximately two minutes, the lines on the LFA window are read. We then calculated the 
sensitivity, specificity and accuracy of the LFA compared to LC-MS/MS by cross-tabulating values 
above/below the 1500ng/mL threshold by the two different assays.168 
 
Of 637 urine samples collected among the participants in the TARGET DOT study, 300 were 
randomly selected to be tested by both the LFA and the gold standard method of LC-MS/MS for 
validation. The accuracy of the LFA compared to LC-MS/MS was 97% (95% confidence interval 
(CI): 95% to 99%). Among the 213 tenofovir-negative samples by LC-MS/MS (≤1500ng/mL), 206 
were also negative by the LFA, indicating 97% specificity (95% CI: 93% to 99%). Of the 87 
tenofovir-positive samples  by  LC-MS/MS (>1500ng/ml), 86 were also positive by the LFA, 
indicating 99% sensitivity (95% CI: 94% to 100%). Therefore, our validation results showed high 
sensitivity and high specificity of the LFA compared to the gold standard method of quantification 
(LC-MS/MS) at a cut-off of 1500ng/mL of tenofovir in urine.4 
 
Validation of the tenofovir LFA against the enzyme-linked immunoassay (ELISA): 
This section details the data on the comparison between the LFA and the standard enzyme-linked 
immunoassay (ELISA) in diverse patient populations.5 This analysis used stored urine samples 
from the TRIUMPH study, an ongoing U.S. demonstration project of PrEP in transgender women 
and men, and the Partners PrEP study, a clinical trial of PrEP among heterosexual men and 
women. We calculated the sensitivity, specificity and accuracy of the LFA compared to ELISA 
using urine samples in the two different studies by cross-tabulating values above/below the 
1500ng/mL threshold defined for the LFA by the two different assays. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 23 of 93 
 
 
 
 
479 
480 
481 
482 
483 
484 
485 
486 
487 
488 
489 
490 
491 
492 
493 
494 
495 
496 
497 
498 
499 
500 
501 
502 
503 
504 
505 
506 
507 
508 
509 
510 
511 
512 
513 
514 
515 
516 
517 
Overall, 684 urine samples were tested from 324 participants in the two cohorts. In Partners PrEP, 
454 samples from 278 participants (41% women and 59% men) were tested; the median age was 
33 years (interquartile range (IQR) of 28-39). In IBrEATHe, 231 samples from 46 individuals (50% 
transgender women on estrogen and 50% transgender men on testosterone) were tested; the 
median age was 31 years (IQR 25-40). Of the 505 samples with tenofovir levels greater than or 
equal to the cut-off of 1500ng/ml using laboratory-based ELISA, 505 of the POC test results were 
also positive, yielding 100% sensitivity (one-sided 97.5% confidence interval (CI):99.3%). Of the 
179 samples with TFV levels below the cut-off, 176 were negative with the POC test, yielding 
98.3% specificity (95% CI:95.2%-99.7%). The accuracy of the POC LFA across the two studies 
was 99.6% compared to ELISA (95% CI:98.7%-99.9%). Therefore, in a large, diverse sample of 
men and women (both cisgender and transgender) taking TDF/FTC-based PrEP, the sensitivity, 
specificity, and accuracy of a the novel LFA were all over 98% when compared to the laboratory- 
based ELISA method.5 
 
Hair levels of tenofovir will serve as the long-term adherence metric in PUMA: prior work 
by the UCSF HAL examining hair ARV concentrations in the context of HIV treatment and 
prevention. 
Along with acceptability and feasibility, we will also examine the impact of the intervention on hair 
levels of TFV and FTC as a longer-term metric of adherence. Over the past decade, we have 
gained extensive expertise in the Hair Analytical Laboratory (HAL) at UCSF in developing 
methods for the extraction and quantification of ARVs9-11,15,26,30,31 and anti-TB drugs169-172 in hair 
using LC-MS/MS as long-term metrics of adherence.8 We have found no substantial differences 
in the median and range concentrations of ARVs in hair from participants of different race/ethnicity 
or with different hair colors. Experimental work in the HAL found little change in hair levels when 
performing coloring, permanent or straightening procedures on hair samples. Hair collection is 
highly acceptable (>95%) in PrEP32,38 and other studies in Africa/Asia.12,16-19,22,25,173 39 We have 
demonstrated a strong linear relationship between adherence to TDF and hair concentrations of 
TFV,31 enabling TDF dosing patterns to be estimated from hair levels in a variety of PrEP settings. 
32-35,37-39,41-44,46,48 We have also shown a strong correlation between hair TFV levels and DBS levels 
of TFV-DP, both long-term metrics of adherence.33 We further demonstrated that hair levels of 
ARVs increase within individuals following adherence interventions (relevant for this study).27,28 
 
3.4. FDA/CDRH and the Nonsignificant Risk (NSR) Designation for this Investigational 
Device for Tenofovir Testing 
We obtained pre-trial consultation advice from the Food and Drug Administration’s (FDA's) Center 
for Devices and Radiological Health (CDRH) regarding the our use of the novel point of care urine 
tenofovir assay in this newly funded PUMA study (R01 AI143340) through NIAID. The FDA 
verified that the urine tenofovir assay is not Investigational Device Exempt (IDE) because we are 
returning test results to participants in the intervention arm of the trial. Per FDA regulations (21 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 24 of 93 
 
 
 
 
518 
519 
520 
521 
522 
523 
524 
525 
526 
527 
528 
529 
530 
531 
532 
533 
534 
535 
536 
537 
538 
539 
540 
541 
542 
543 
544 
545 
546 
547 
548 
549 
550 
551 
552 
553 
554 
555 
556 
557 
CFR 812), the alternative determinations applicable to our studies are either Nonsignificant Risk 
(NSR) or Significant Risk (SR). 
 
Under FDA 21 CFR 812.3(m), a Significant Risk (SR) device is defined as an investigational 
device that “Is intended as an implant and presents a potential for serious risk to the health, safety, 
or welfare of a subject; is purported or represented to be for use supporting or sustaining human 
life and presents a potential for serious risk to the health, safety, or welfare of a subject; Is for a 
use of substantial importance in diagnosing, curing, mitigating, or treating disease, or otherwise 
preventing impairment of human health and presents a potential for serious risk to the health, 
safety, or welfare of a subject; or otherwise presents a potential for serious risk to the health, 
safety, or welfare of a subject.” The urine assay does not meet these criteria as it is completely 
noninvasive and merely tests levels of tenofovir in urine samples. Although test results will be 
shared with patients, which excludes it from the exempt category, no clinical decisions will be 
made based on the results. While the assay will be used to measure medication adherence, the 
collection of adherence information does not present a potential for serious risk to the health, 
safety, or welfare of the subject. Therefore the urine assay meets the criteria under the IDE 
Nonsignificant Risk Medical Device study with additional details provided here: 
 
1) The non-invasive urine assay will be used to detect the absence or presence of tenofovir 
(the metabolite of TDF) in urine to improve adherence counseling. TDF is used in HIV 
treatment regimens worldwide and is also the only agent (in combination with 
emtricitabine) approved for pre-exposure prophylaxis (PrEP) worldwide. The threshold of 
the assay was designed to distinguish between people who have taken TDF within the 
prior four days (“adherent”) versus those who have not (“non-adherent”) taken TDF within 
the prior four days. Participants who are considered “adherent” by the assay in the 
intervention arm of PUMA will be informed of the result and continue to receive standard 
adherence counseling. Participants who are considered “non-adherent” by the assay will 
receive enhanced adherence counseling with positive messaging (detailed below). 
 
2) The antibody that was developed against tenofovir for this novel assay is highly selective. 
As above, the assay has been demonstrated to have very high sensitivity and specificity 
in our recently concluded clinical validation studies against both the gold standard of 
measuring drug levels, LC-MS/MS,  and the laboratory-based method of performing 
immunoassays (enzyme-linked immunosorbent assay or ELISA). Therefore, this test has 
a very low rate of false positivity and we have designed it to have a very low false negative 
rate. In the unlikely situation of false positive results (where the results indicate “adherent” 
when the participant is not taking their medication), participants will continue to receive 
standard adherence counseling. In the very unlikely event of false negative results (where 
the results indicate “non-adherent” when the participant is taking their medication) the 
participant  will  receive  enhanced  adherence  counseling  (which  does  not  meet  the 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 25 of 93 
 
 
 
 
558 
559 
560 
561 
562 
563 
564 
565 
566 
567 
568 
569 
570 
571 
572 
573 
574 
575 
576 
577 
578 
579 
580 
581 
582 
583 
584 
585 
586 
587 
588 
589 
590 
591 
592 
593 
594 
595 
596 
597 
definition of “significant risk”) in the intervention arm of PUMA. Therefore, participant 
access to standard adherence counseling will not be affected by a false positive result. 
We do not anticipate any adverse consequences for participants who receive enhanced 
adherence counseling due to being wrongly classified as non-adherent (a very rare event). 
The feedback and adherence counseling will be delivered in a supportive non-judgemental 
manner (Figure 8 and Section 5.5). 
 
The FDA confirmed with our study team on October 3, 2019 that they  approve the NSR 
designation of the urine device (Email dated October 3, 2019 from Kellie B. Kelm PhD, Acting 
Director, Division of Chemistry and Toxicology Devices | OHT7: Office of In Vitro Diagnostics and 
Radiological Health, Office of Product Evaluation and Quality, CDRH | Food and Drug 
Administration states “Since the therapies that will be given are approved, given at approved 
doses and the adherent patients get standard adherence counseling and the non-adherent 
patients get enhanced adherence counseling with positive messaging, the impact of a false 
negative and false positive are minimal. We would agree these studies using an investigational 
device appear to be non-significant risk”. This designation of NSR for the urine assay by the FDA 
is provided in Appendix VIII. 
 
Finally, the study staff at Thika Clinic will follow the abbreviated requirements at 21 CFR 812.2(b), 
which require devices to be clearly labeled as investigational, under study, and marked clearly to 
specify that no clinical decisions should be based on the outcome of the results. All research 
participants in PUMA will signed written informed consent forms prior to participation that cite the 
urine test as investigational (Appendix I). The results of this trial will help inform the use of the 
test in routine clinical care in the future. 
 
3.5. Study Rationale 
Women not in serodiscordant couples (SDC) in sub-Saharan Africa (SSA) have demonstrated 
difficulty adhering to PrEP, as seen in the divergent results between the FEM-PrEP65 and VOICE63 
trials (where efficacy for women not in SDC was nil) and the Partners PrEP study58 (where efficacy 
for women in mutually-disclosed SDC was high). Women in serodiscordant partnerships, as in 
the Partners PrEP trial, who are aware of the HIV positive status of their partners, have been 
shown to have higher rates of adherence. Therefore, a focus in the PUMA trial on women not in 
serodiscordant relationships will allow selection for a possibly more adherence-challenged 
population, which is helpful when evaluating the effect of adherence interventions. 
 
The reason to conduct this trial in Kenya is that Kenya has one of the highest HIV burdens in 
SSA, with women accounting for >50% of new infections. We therefore propose to conduct a 
pilot RCT to evaluate acceptability, feasibility and impact on PrEP adherence over time of 
real-time monitoring/feedback via the urine assay among women not in SDC in Kenya. Of 
note, the theoretical effect of real-time monitoring of adherence on subsequent adherence in 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 26 of 93 
 
 
 
 
598 
599 
600 
601 
602 
603 
604 
605 
606 
607 
608 
609 
610 
611 
612 
613 
614 
615 
616 
617 
618 
619 
620 
621 
622 
623 
624 
625 
626 
627 
628 
629 
630 
631 
632 
633 
634 
635 
636 
637 
VOICE and iPrEx OLE was assessed using qualitative methods, but this aim will address a key 
knowledge gap to assess whether true POC monitoring/feedback has an impact on a quantitative 
measure (i.e. hair levels). This pilot will provide needed data for a larger trial evaluating the 
assay’s impact on HIV acquisition rates in the context of PrEP. 
 
4. STUDY OBJECTIVES 
Our central hypothesis is that providing real-time monitoring/feedback via the POC assay will be 
acceptable to participants, feasible to research providers, and improve adherence over time. 
 
4.1. Primary Objectives: To test the acceptability to participants, feasibility for providers, and 
impact on a longer-term metric of adherence among participants (assessed via tenofovir hair 
levels) of implementing POC urine tenofovir testing and providing real-time feedback and 
enhanced adherence counseling among women receiving PrEP in Thika, Kenya. 
 
5. STUDY PROCEDURES 
 
5.1. Overview 
Given known PrEP adherence challenges among women not in serodiscordant couples and the 
likely need for daily drug-taking among women for efficacy, we will conduct a pilot RCT by 
randomizing women on PrEP in Kenya  not in serodiscordant couples to standard of care 
adherence counseling (n=50 - 60) vs real-time adherence feedback using information from the 
POC urine assay (n=50 - 60). Acceptability, feasibility and the effect of the feedback on long-term 
adherence over time measured via TFV hair levels will be assessed. 
 
Short-term adherence may improve with feedback from the assay, but hair concentrations do not 
reflect “white coat” adherence and only increase if overall adherence over time increases. Since 
hair levels are not susceptible to “white coat adherence”, collecting both urine-based metrics of 
adherence and hair-based metrics (at every visit for every participant, although only the 
intervention arm participants and their research providers will receive the results of the urine 
assay) will help provide data on the frequency of “white coast adherence” in this setting. The 
procedure for hair collection has been described.14,15,23,32 We have demonstrated high rates of 
acceptability for hair collection in multiple African-based studies.12,16-19,22,25,173 Samples are kept at 
room temperature prior to shipment without biohazard precautions. The assays for measuring 
TFV/FTC in hair in the UCSF HAL29,31-42,174,175 have been approved by the Division of AIDS Clinical 
Pharmacology and Quality Assurance (CPQA) program.176 
 
5.2. Study Design 
Under the 2016 Kenya PrEP guidelines,177 all persons initiating PrEP undergo clinical assessment 
to ask  about symptoms of acute HIV infection, receive rapid HIV-1 and creatinine testing 
(estimated creatinine clearance >60 mL/min is required to start PrEP), and adherence counseling. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 27 of 93 
 
 
 
 
638 
639 
640 
641 
642 
643 
 
 
 
 
 
 
 
 
 
 
 
 
644 
645 
646 
647 
648 
649 
650 
651 
652 
653 
654 
655 
656 
657 
658 
659 
660 
661 
662 
663 
664 
665 
666 
Patients who qualify for and initiate PrEP are subsequently seen in 1 month, in 3 months, and 
then every 3 months for repeat HIV testing, continued risk assessment, and adherence counseling 
for daily PrEP under the standard of care (SOC). For this pilot RCT, we will recruit women ≥18 
years old on PrEP at Thika at the visit that occurs 3 months after PrEP initiation (per the 2016 
Kenya PrEP guidelines). Patients will be enrolled and randomized in a 1:1 fashion at that visit 
 
 
 
(month 0 or baseline visit of study) using sealed opaque envelopes to the intervention arm versus 
the SOC arm (Figure 7). A minimum of 100 and not exceeding 120 women will be recruited, with 
about 50 - 60 randomized to the intervention arm and about 50 - 60 to the SOC arm (Figure 7). 
We anticipate that randomizing established patients (at their second PrEP follow up visit since 
PrEP visits are to occur 1 and 3 months after PrEP initiation per Kenya guidelines) will minimize 
attrition during the study. 
 
Upon randomization, study visits will occur at 0 (baseline visit), 3, 6, 9 and 12 months after study 
enrollment. Each visit will include rapid testing for HIV, pregnancy testing if the participants 
requests it or is unsure of being pregnant (per standard of care), and creatinine measurement 
(per 2016 Kenya PrEP guidelines), as well as adherence counseling. As per the 2016 Kenya 
PrEP guidelines, any other laboratory testing or assessments will be performed per the history 
and physical examination. Self-reported time since last PrEP dose taken will be collected via a 
visual analog scale, as will self-reported adherence over the previous 3 and 30 days.178 Urine 
samples will be collected at every visit for participants in both arms, but stored only for participants 
in the standard-of-care arm (to be tested locally, in batches by laboratory staff not involved in daily 
study conduct). Urine samples will only be tested via the tenofovir assay in real-time for 
participants in the intervention arm by laboratory staff at the Thika Clinic. The results of the urine 
assay for intervention arm participants will then be recorded by the laboratory staff and conveyed 
to the research providers of intervention arm participants who will proceed to immediately provide 
feedback to participants using counseling guides prepared prior to the trial (and informed by the 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 28 of 93 
 
 
 
 
667 
668 
669 
670 
671 
672 
673 
674 
675 
676 
677 
678 
679 
680 
681 
682 
683 
684 
685 
686 
687 
688 
689 
690 
691 
692 
693 
694 
695 
696 
697 
698 
699 
700 
701 
702 
703 
704 
705 
results of the formative work to qualitatively  assess  how to provide supportive counseling 
message for either yes adherence or no adherence, Section 3.4). 
 
Hair samples will be collected at each study visit (months 0, 3, 6, 9 and 12) for storage and testing 
at the end of the study for all participants. (Please see Section 3.1 for a discussion of how white- 
coat adherence patterns can be assessed by collecting both short-term and long-term adherence 
metrics). Feasibility and acceptability assessments will be conducted at study end for research 
providers (feasibility) and participants in the intervention arm (acceptability), respectively. Plasma 
and DBS for TFV and TFV-DP level measurement, respectively, will be collected at each visit in 
each arm as additional adherence metrics and stored for future analysis in the UCSF Hair 
Analytical Laboratory (HAL) after seeking independent funding for those concentrations. 
 
Participants will be followed over a 12-month study (baseline visit which is month 0, months 3, 6, 
9 and 12) period to assess the study outcome measures. This study will follow all aspects of 
Kenya’s PrEP guidelines, except patients randomized to the intervention arm will receive point- 
of-care adherence testing by the urine tenofovir assay. 
 
5.3. Location and Setting 
The setting is the THIKA Partners in Prevention Research Site and Clinic, THIKA Section 9,  
Oau Road, next to Thika Nursing Home.The Thika Clinic serves an urban center about 40 
kilometers outside of Nairobi and is a center of excellence for PrEP delivery and research in 
Kenya. Over the past decade, the Thika clinical team established a multi-disciplinary site focused 
on HIV-1 and sexually transmitted disease prevention research (more than two dozen projects), 
and on provision of clinical care (HIV-1 testing, HIV-1 comprehensive care, HIV-1 prevention 
services). The experienced community outreach team at the Thika site has established successful 
recruitment strategies for research studies, including collaborating with existing HIV-1 testing 
centers and community-based mobilization for women to engage in HIV-1 prevention studies. The 
Thika clinic is a center of excellence for PrEP in Kenya and is leading the training of other clinics 
as part of Kenya’s national PrEP scale-up program. 
 
5.4. Population & Eligibility 
The eligibility criteria for this study are the following: 
• 
Female 
• 
Adult, age ≥18 years old 
• 
HIV-1 uninfected based on a negative HIV-1 rapid test 
• 
Not currently enrolled in an HIV-1 prevention clinical trial 
• 
Not currently in a serodiscordant relationship 
• 
Already taking PrEP and will be enrolled at the 3-month follow-up visit following PrEP 
initiation 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 29 of 93 
 
 
 
 
706 
707 
708 
709 
710 
711 
712 
713 
714 
715 
716 
717 
718 
719 
720 
721 
722 
723 
724 
725 
726 
727 
728 
729 
730 
731 
732 
733 
734 
735 
736 
737 
738 
739 
740 
741 
742 
743 
744 
745 
 
• 
Willing to be randomized to point-of-care tenofovir drug testing 
• 
Willing/able to provide informed consent to participate in the study 
• 
No contraindication to use of TDF or FTC 
• 
Note: Women who are pregnant or breastffeeding at screening/enrollment are still 
eligible 
 
Eligibility criteria are meant to approximate HIV-1 uninfected women at risk who have recently 
initiated PrEP. 
 
5.5. Services and Intervention 
 
Standard-of-care PrEP arm 
Participants will receive HIV-1 counseling, condoms, risk reduction counseling, and syndromic 
management of sexually transmitted infections according to local guidelines at the baseline 
enrollment visit and during all follow-up visits. All distribution of PrEP will be done with typical 
counseling and monitoring during the 12-month study period. The participants in this arm will 
undergo urine collection for storage only and will NOT receive the point-of-care urine tenofovir 
assay. Per the standard of care when providing PrEP, creatinine is checked every 6 months, 
urinalysis every 6 months, and a urine pregnancy test for women is performed as indicated by 
clinical care. 
 
POC Urine Tenofovir PrEP arm (Intervention) 
As with the SOC PrEP arm, participants will receive HIV-1 counseling, condoms, risk reduction 
counseling, creatinine testing, urinalyses, pregnancy testing, and syndromic management of 
sexually transmitted infections according to the 2016 Kenya PrEP guidelines (Table 1). In 
addition, participants will have clinic-based point-of-care testing for urine tenofovir performed by 
the POC urine assay at the baseline visit (month 0) and then at each quarterly visit (month 3, 6, 
9, 12) during the 12-month study period. The POC rapid strip test (Figure 6) will provide 
information on YES vs. NO recent PrEP adherence among intervention arm participants. 
 
PrEP medication provision and pharmacy control 
Tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) are reverse transcriptase inhibitors 
that have been approved for the treatment of HIV-1 infection in humans in Kenya, Uganda, and 
the United States with other antiretrovirals. A fixed-dose, oral co-formulation of FTC/TDF is used 
in Kenya for PrEP and provided by the Kenya Ministry of Health as part of PrEP roll-out. This drug 
is not provided as a study drug, but as part of routine care for the participants in this study. 
 
At Thika, TDF/FTC is stored in accordance with the drug manufacturer’s recommendations. The 
pharmacy and storage facility has locked, climate-controlled environments, with controlled 
humidity and temperature to remain within limits allowed by the manufacturer for drug storage. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 30 of 93 
 
 
 
 
746 
747 
748 
749 
750 
751 
752 
753 
754 
755 
756 
757 
758 
759 
760 
761 
762 
763 
764 
765 
766 
767 
768 
769 
770 
771 
772 
773 
774 
775 
776 
777 
Dispensing will be sufficient to last until the next visit (e.g. 90 days) with extra pills (20) dispensed 
to allow for a generous visit window. 
 
Counseling on TDF/FTC, its side effect profile, how to take the medication, what to do if side 
effects are experienced, and the importance of not sharing medication to optimize potential 
efficacy is performed routinely at each PrEP visit as per the 2016 Kenya PrEP guidelines. 
 
Point of care urine monitoring test 
The point-of-care urine-based adherence test is shown in Figure 6 and will be performed for 
participants in the intervention arm only (urine will be collected and stored without testing until the 
end of the study for participants in the standard of care arm). The laboratory staff at the Thika 
Clinic will be trained in the interpretation of this test. As detailed at length in Section 3.3, this 
competitive assay demonstrates a colored line in samples negative for tenofovir and no line in 
samples positive for tenofovir (Figure 6) so the laboratory staff will be carefully trained on the 
interpretation of the test prior to the start of the trial by the PI of the study, the site PIs, and the 
laboratory manager of the Thika Clinic. Neither the research provider nor the participant will need 
to interpret the test. The laboratory technologist on site will aid the provider in urine sample 
collection, perform the test, interpret the test, mark on the test if it is positive or negative, and 
deliver the results to the research provider for participants in the intervention arm only. The results 
will be delivered to the research providers for the intervention arm participants from the trained 
laboratory staff in the form of “yes” versus “no” for recent adherence to tenofovir. The research 
providers will then immediately deliver the appropriate messaging and counseling based on the 
urine test results for participants in the study. Of note, pictures of each urine tenofovir assay for 
participants in the intervention arm will be uploaded into the research database for quality 
assurance monitoring. After the picture of the test is uploaded into the research database, the 
used urine test will be discarded in an appropriate manner. 
 
Feedback to the participants on their tenofovir test results will be delivered in a supportive manner 
by the research providers. The messages to provide feedback on adherence will be adapted from 
HPTN082179 (Figure 8), for which Dr. Baeten serves as co-investigator. The counseling messages 
for this trial will first be piloted in a small group of women on PrEP at Thika for refinement prior to 
actual implementation. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 31 of 93 
 
 
 
 
778 
779 
780 
781 
782 
783 
784 
785 
786 
787 
788 
789 
790 
791 
792 
793 
794 
795 
796 
797 
798 
799 
800 
801 
802 
803 
804 
805 
806 
807 
808 
809 
810 
811 
812 
813 
814 
815 
816 
817 
Enhanced 
adherence 
counseling (EAC) to the 
women in the intervention 
arm will be delivered by 
healthcare providers at 
the Thika Clinic (nurses, 
doctors, 
clinical 
psychologist) 
 
with 
extensive experience in 
counseling 
 
and 
behavioral interventions. 
When 
asking 
about 
particular   barriers   and 
ways the Thika clinic providers can help in supporting the participant in adherence, counseling 
messages during EAC will be tailored to the individual’s circumstances. 
 
Both study arms 
For retention efforts in the study, participants will be contacted every 3 months if they do not 
appear for their quarterly PrEP visits for follow-up of safety issues, HIV-1 assessment, PrEP refills, 
and to ask if they want to continue participation in the study. Moreover, all participants will be 
contacted at the end of the study (even if they did not participate in all study visits) to obtain hair 
samples for measurement of long-term PrEP adherence  and for  acceptability interviews if 
applicable. 
 
5.6. Recruitment and Enrollment 
The Thika site has established local recruitment and screening methods that operationalize 
protocol-specified requirements for eligibility determination in a manner that is tailored to and most 
efficient for the local study setting and target study population. To reduce any bias towards 
participants who might be more adherent to PrEP or be amenable to adherence testing, 
enrollment will target areas with low PrEP uptake. 
 
Recruitment strategies will include partnering with existing voluntary counseling and testing (VCT) 
centers, outreach workers and community organizations, such as churches, and community 
mobilization around women’s VCT promotion. Recruitment materials will educate women about 
PrEP. Screening and enrollment may occur on the same day or may be split across days, 
depending on the preferences of the potential participant. Informed consent for study participation 
and enrollment in the study may proceed on the same day when eligibility is determined. 
 
A member of the study team will approach individuals within the PrEP clinic at the Thika Clinical 
research site and at community sites associated with Thika at their 3 month routine follow-up visit 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 32 of 93 
 
 
 
 
818 
819 
820 
821 
822 
823 
824 
825 
826 
827 
828 
829 
830 
831 
832 
833 
834 
835 
836 
837 
838 
839 
840 
841 
842 
843 
844 
845 
846 
847 
848 
849 
850 
851 
852 
following PrEP initiation. They will describe the study and ask for voluntary participation. They will 
explain the purpose of the study and review the study eligibility criteria with the participant. They 
will also address any questions  about study  participation.  The eligible adults  interested in 
participating in the study will be asked to sign the informed consent form to participate (see 
Appendix I). Those people who decide not to participate in the study  will  experience  no 
detrimental impact on their routine care at the clinic. Those who want to voluntarily participate will 
be taken to a private area of the clinic to be asked several demographic and clinical questions. 
 
The major talking points will be the following: 
• 
The study is for HIV-uninfected women who recently initiated PrEP. 
• 
The purpose of the study is to investigate whether feedback of urine drug levels may help 
improve long-term adherence to PrEP. 
• 
If adherence to PrEP is very good, then you will have a lower chance of becoming infected 
with HIV. 
• 
If you are eligible to participate in the study, then the study team will randomly assign you 
– by chance (like a coin flip) – to either the “regular care group” or the “intervention group.” 
If you are in the “regular care group”, then you will receive all the same treatment that you 
would normally receive, including the HIV medications for PrEP. If you are in the 
“intervention group”, then you will receive all the same treatment that you would normally 
receive, including HIV medications for PrEP but in addition, you will have PrEP drug level 
testing every three months with a simple urine dipstick test. 
 
After enrollment, the participant will be randomized to either the control arm or the intervention 
arm in a 1:1 fashion. 
 
5.7. Randomization 
The study design will be an open-label, randomized, implementation trial with 2 study arms. We 
will enroll healthy HIV-uninfected adults (≥18 years old). We will enroll a minimum of 100 and not 
exceeding 120 women receiving PrEP, about 50 - 60 participants in each study arm. 
 
Randomization will be done in variable-sized blocks using opaque envelopes opened at the time 
of randomization. Randomization will occur in a 1:1 fashion to alternate the intervention arm and 
the standard of care arm. Randomization will be done at the enrollment visit. 
 
The allocation of participants for the 2 study arms will be the following: 
 
Standard of Care Arm 
Intervention Arm 
Total 
Total 
50 - 60 
50 - 60 
100 - 120 
853 
854 
 
5.8. General Study Procedures 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 33 of 93 
 
 
 
 
855 
856 
857 
858 
859 
860 
861 
862 
863 
864 
865 
866 
867 
868 
869 
870 
871 
872 
873 
874 
875 
876 
877 
878 
879 
880 
881 
882 
883 
884 
885 
886 
887 
888 
889 
890 
891 
892 
893 
894 
Specific study procedures will take place at screening and enrollment, and then quarterly for both 
the standard-of-care arm as well as the intervention arm for up to 12 months. At screening, 
eligibility information will be collected. Subjects who meet the eligibility criteria will then be enrolled 
in the study. 
 
Once written consent is obtained, a member of the study team will collect demographic and health 
questions, related to age, birthdate, income, employment history, prior HIV testing, medical 
conditions, and current symptoms. They  will also obtain each participant’s  phone number, 
address, and relevant contact information. After obtaining the baseline demographic and clinical 
data, they will determine the study group randomization of the participant. 
 
A Research Nurse will then meet the participant in the same clinical exam room, and administer 
a brief clinical questionnaire. The nurse will coordinate the necessary blood draws for the 
participant, so each participant will only have one blood draw for each clinical visit. As part of 
PrEP initiation, several standard of care laboratory tests would have been completed prior to trial 
entry including HIV-1 testing, serum creatinine, Hepatitis B surface antigen, urine pregnancy test. 
For this study, additional information will be collected on medical history, physical exam findings, 
and STI syndromic assessment and additional testing will be done as part of standard of care 
PrEP follow-up. 
 
PrEP delivery will be according to the 2016 Kenya PrEP guidelines, including measurement of 
renal function (estimated creatinine clearance >60 mL/min to start PrEP and periodic monitoring 
over time, aligned to the visit schedule of the study), standard clinical assessment to avoid 
continuing PrEP during acute HIV-1 infection, and adherence counseling. Subjects will then be 
randomized at enrollment (Month 0 but the 3—month visit on PrEP) in a 1:1 fashion, as described 
above. Participants in either arm will be provided 3 months of PrEP medication, corresponding to 
enough to last until the next clinic-based visit. Participants in both arms will be counseled on PrEP 
discontinuation according to Kenya national guidelines. 
 
At each study visit, we will offer counseling for participants for HIV-1 testing (pre- and post- 
testing), HIV-1 infection risk reduction best practices, condom promotion and provision, 
adherence to PrEP medication, as well as other HIV-1 prevention strategies. 
 
Participant contact tracing for retention at all study visits will be done, particularly to establish 
PrEP continuation and HIV-1 status. 
 
5.9. Standard-of-Care Arm Follow up Procedures 
Participants in the standard-of-care arm will be directed to the regular clinical waiting area to be 
seen and evaluated by the study team every 3 months until the study end (month #12). The study 
team will prescribe PrEP and additional medications as appropriate, and provide adherence 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 34 of 93 
 
 
 
 
895 
896 
897 
898 
899 
900 
901 
902 
903 
904 
905 
906 
907 
908 
909 
910 
911 
912 
913 
914 
915 
916 
917 
918 
919 
counseling as appropriate. The standard-of-care includes rapid testing for HIV-1 before 
dispensing PrEP. If any participants have become HIV-infected, then confirmatory testing will be 
performed and participants will receive standard HIV care, including initiation of antiretroviral 
therapy. Urine and hair samples will be collected and stored at the baseline visit and at months 
3, 6, 9 and 12 for all standard-of-care arm participants but not tested (until study end). 
 
5.10. Intervention Arm Follow up Procedures 
Participants in the intervention arm will receive the same treatment and evaluations as 
participants in the standard-of-care arm (Table 1). In addition, participants will have baseline and 
quarterly testing for tenofovir by the POC urine assay test. The results of the test will be provided 
to the participant by the healthcare research provider and will be used to inform enhanced 
adherence counseling as above. An image of the point-of-care urine adherence assay is shown 
in Figure 6. The laboratory staff at the Thika site will interpret the test (to deliver the information 
to the research healthcare provider) and then take a picture of each urine test after development 
and upload to our centralized database. 
 
5.11. Data Collected and Testing during Clinical Visits 
We will use structured interviews on HIV-1 testing practices and self-reported PrEP adherence 
(e.g., frequency, ability, self-rating, missed doses). Table 1 provides a summary of clinical visits 
and testing in both study arms. There will be a window of 20 days around study visits to allow for 
late visits due to life circumstances. 
 
 
12 
 Table 1. Timeline of Visits and Laboratory Testing  
 
Enrollment 
Month 3 
Month 6 
Month 9 Mont
 Screening and Enrollment  
Review eligibility criteria 
X 
Obtain informed consent 
X 
Randomization 
X 
Collect sociodemographic information 
X 
 Research Assistant tasks  
Collect and update contact information 
X 
X 
X 
X 
X
Conduct baseline questionnaire 
X 
Conduct quarterly questionnaires 
X 
X 
X 
X
Conduct exit study questionnaire 
X
Perform PrEP pill counts 
X 
X 
X 
X 
X
 Point-of-care and Laboratory Testing  
Hemoglobin (for research study) 
X 
X 
X 
X 
X
POC   urine   tenofovir   assay   with   feedback 
(Intervention Arm) 
X 
X 
X 
X 
X

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 35 of 93 
 
 
 
 
 
Urine collected and stored (Standard of Care 
arm) 
X 
X 
X 
X 
X 
 Specimen Collection and Storage  
Stored plasma (10 ml) 
X 
X 
X 
X 
X 
Dried blood spot for TFV-DP 
X 
X 
X 
X 
X 
Hair sample for TFV 
X 
X 
X 
X 
X 
920 
921 
922 
923 
924 
925 
926 
927 
928 
929 
930 
931 
932 
933 
934 
935 
936 
937 
938 
939 
940 
941 
942 
943 
944 
945 
946 
947 
948 
949 
950 
951 
952 
953 
954 
955 
956 
*For the standard of care when providing PrEP, all paticipants in the study will receive a medical 
history and interval updates, physical examination, rapid HIV-1 testing, PrEP or other drug side 
effect screen, pill counts for PrEP drugs, PrEP dispensing for a 3-month supply, and standard 
adherence and risk reduction counseling at every visit. Per the standard of care when providing 
PrEP, creatinine is checked every 6 months, urinalysis every 6 months, and a urine pregnancy 
test for women is performed as indicated by clinical care.  All research providers at the Thika 
Clinic are trained clinicians in PrEP provision so they will be performing both the research 
procedures and the standard-of-care clinical procedures for PrEP. 
 
For date collection, we will use electronic data capture (REDCap Cloud), which is currently in 
use at the Thika site. 
 
5.12. Participant Retention and Withdrawal 
The Thika site will develop retention methods tailored to and most efficient for the local study 
setting. Retention activities may include explanation of the study visit schedule and procedural 
requirements during the informed consent process and re-emphasis at each study visit, collection 
and updating of locator information, and use of appropriate and timely visit reminder mechanisms 
(including phone calls and text messages). Visits can be missed, but, to provide complete 
information at the end of the study, efforts will be made to have a final follow-up visit for each 
participant. This study does not allow for home visits. 
 
Participants may voluntarily withdraw from the study for any reason, at any time. If the participant 
decides to leave the study before her last scheduled study visit, the participant will be requested 
to have a final study visit with the procedures listed in Table 1. The site Investigator also may 
withdraw participants from the study in order to protect their safety and/or if they are unwilling or 
unable to comply with required study procedures. Participants may also be withdrawn if the study 
is stopped or canceled. Reasons for withdrawal will be recorded. 
 
5.13. PrEP Discontinuation and Seroconversion 
PrEP Discontinuation. PrEP continuation will be according to Kenya PrEP guidelines. Use of 
PrEP may be interrupted by the site Investigator due to safety concerns for the participant or if 
the participant is unable or unwilling to comply with study procedures. All treatment interruptions 
will be documented. 
 
Seroconversion will be determined by local HIV-1 testing guidelines. For an initially HIV-1 
uninfected participant who seroconverts, she will be exited from the study and referred to HIV 
primary care for confirmation of the positive result and initiation of HIV care. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 36 of 93 
 
 
 
 
957 
958 
959 
960 
961 
962 
963 
964 
965 
966 
967 
968 
969 
970 
971 
972 
973 
974 
975 
976 
977 
978 
979 
980 
981 
982 
983 
984 
985 
986 
987 
988 
989 
990 
991 
992 
993 
994 
995 
996 
 
6. STUDY OUTCOMES AND ANALYSES 
6.1. Primary Outcomes 
The three primary outcomes for this study will be 1) acceptability of POC urine tenofovir testing 
among women receiving PrEP in Kenya; 2) feasibility to provide feedback on the POC urine 
tenofovir assay to participants for healthcare providers, and 3) long-term metrics of adherence as 
assessed via hair concentrations of TFV and FTC assessed at the 12-month study visit after 
enrollment. 
 
6.2. Data Collection for Primary Outcomes: 
 
Acceptability for participants taking PrEP: We will conduct a mixed-methods assessment of 
the intervention arm participants’ (all women on PrEP) experiences with real-time monitoring and 
feedback at the end of the study. A quantitative survey and a qualitative interview guide for in- 
depth interviews of participants will draw from the Information-Motivation-Behavioral skills (IMB) 
model.180-187 Quantitative data collection will occur via standardized interviewer-administered 
questionnaires. Items to be assessed include the following: 1) Feelings about receiving their PrEP 
adherence results in real time; 2) Likelihood of participating in other studies using a similar design; 
3) Likelihood of wanting to receive results of urine testing outside of a study while they are on 
PrEP; 4) Concern about the privacy and security of the data regarding their urine results; 5) 
Grading of the potential impact of knowing their urine TFV results on subsequent medication 
adherence; 6) Advantages and disadvantages of being told about their adherence in real time; 7) 
Likelihood of taking PrEP just before later study visits because they knew the urine test was being 
conducted; 8) Preferences regarding a yes/no assay versus an assay that provides information 
on “high”, “moderate” or “low” adherence. A 5-point Likert item format will be used to assess 
graded items (such as the likelihood of wanting continued urine testing in the context of PrEP; 
feelings about the urine testing, ranging from negative to positive; concerns about privacy, ranging 
from low to high; the potential impact of real-time feedback on subsequent adherence, ranging 
from low to high). Other items (advantages and disadvantages of being told about adherence 
results) will provide pre-specified options with one “other” option for open-ended text fields. 
 
Qualitative data collection for the acceptability outcome will include serial in-depth interviews 
using pre-piloted semi-structured guides (n=20 women from the intervention arm) and focus group 
discussions (n=4 groups with 5-10 women), conducted by experienced social scientists acting in 
the roles of facilitator and note taker under Dr. Ngure’s supervision. The semi-structured interview 
guide will elicit feelings about the adherence metric and counseling messages, concerns 
regarding privacy, advantages and disadvantages of receiving such results, the likely impact of 
this monitoring test on sustained adherence to PrEP or just short-term adherence. Although the 
guide will provide a framework for discussion participants will be encouraged to share their own 
thoughts regarding the feedback from the POC tenofovir assay. The in-depth interview will be 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 37 of 93 
 
 
 
 
997 
998 
999 
1000 
1001 
1002 
1003 
1004 
1005 
1006 
1007 
1008 
1009 
1010 
1011 
1012 
1013 
1014 
1015 
1016 
1017 
1018 
1019 
1020 
1021 
1022 
1023 
1024 
1025 
1026 
1027 
1028 
1029 
1030 
1031 
1032 
1033 
1034 
1035 
1036 
conducted at the end of the study (month 12). The focus group discussions will also be conducted 
at study exit. Interviews will be conducted using the participants’ preferred language and by 
consensus in the focus group discussions. The sampling for the qualitative interviews to include 
a range of possible perspectives (stratified-purposive sampling), to allow for stratification by study 
arm and other relevant factors that may emerge during the interviews. For instance, women will 
be purposefully sampled based on age group (≤ or > 25 years) given unique adherence barriers 
among young women.63,188,189 
 
Feasibility for research healthcare providers: Under the supervision of Dr. Ngure, who has led 
qualitative work in Thika for the past decade,190-196 we will assess the feasibility of the intervention 
by interviewing research healthcare providers, who will be administering this test at the clinical 
point of care in the future. The urine test takes 2 minutes and should be feasible in the context of 
busy clinic visits. We will examine provider perceptions of the assay using in-depth interviews. 
These key informant interviews (up to 8) will be performed at the end of this study with the 
healthcare providers (nurses, doctors, counselors) who delivered the counseling messages to 
intervention arm participants after receiving the results of the POC urine TFV assay from the 
trained Thika laboratory staff. We aim to understand acceptance, barriers, facilitators, and 
confidence regarding PrEP adherence testing using this POC assay in the context of PrEP. The 
semi-structured interview guide will draw from the Unified Theory of Acceptance and Use of 
Technology (UTAUT) model.{Ventkatesh, #603} This model incorporates factors that influence 
technology acceptance (in this case, of the POC immunoassay): perceived usefulness 
(performance expectancy), complexity to use (effort expectancy), stigma/social harm (social 
influence), and benefits (facilitating PrEP adherence among patients). These interviews will also 
elicit barriers and facilitators to delivering the TFV assay-informed counseling messages. 
Suggestions on how to optimize delivery of PrEP adherence testing will be documented. 
 
Storage and Retention of qualitative data sets: 
The qualitative discussions for both the Acceptability and Feasibility data collection procedures 
will be recorded, transcribed, and translated into English by the study team. All source documents 
including audio-recordings and notes for qualitative data will be stored in secure and lockable 
cabinets in accordance with the DAIDS Storage and Retention of Clinical Research Records 
Policy. 
 
Impact on hair concentrations (long-term adherence). 
Small hair samples (~50-100 strands) will be collected at study visits using previously described 
methods.23 TFV concentrations in hair samples will serve as the metric for cumulative, long-term 
adherence to PrEP. TFV and FTC are measured in hair samples at the Hair Analytical Laboratory 
at the University of California San Francisco (UCSF) using validated methods. The Hair Analytical 
Laboratory (HAL), and its predecessor (the UCSF Drug Studies Unit), have vast expertise (since 
1977)  in  LC-MS/MS-based  methods  to  analyze  drugs  in  a  variety  of  matrices,  including 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 38 of 93 
 
 
 
 
1037 
1038 
1039 
1040 
1041 
1042 
1043 
1044 
1045 
1046 
1047 
1048 
1049 
1050 
1051 
1052 
1053 
1054 
1055 
1056 
1057 
1058 
1059 
1060 
1061 
1062 
1063 
1064 
1065 
1066 
1067 
1068 
1069 
1070 
1071 
1072 
1073 
1074 
1075 
antiretrovirals (ARVs) in hair.9,10,30 The trial will assess whether TFV levels in hair increase over 
time with delivery of the feedback results and the opportunity to perform enhanced adherence 
counseling. Moreover, the combination of short-term adherence metrics (urine tenofovir assay) 
and long-term adherence metrics (hair TFV assay) in this study will enable us to determine if there 
are white-coat patterns of adherence.35,39,41 For example, positive urine TFV assays but low 
concentrations of TFV in hair (in intervention arm participants or in both arms, as assessed at the 
end of the study) are suggestive of white-coat adherence patterns. PrEP refills will be measured 
through data from the clinic’s electronic pharmacy system. 
 
6.3. Sample Size and Power 
We also assess sample size based on the long-term adherence outcome of this pilot RCT, an 
increase in hair levels of TFV with the real-time feedback/monitoring in the intervention arm 
compared to the SOC arm. For the hair level outcome, we consider the simplified situation of 
estimating difference in hair level changes between intervention and control arms using a single 
post-intervention level from each person. In this scenario, and assuming the person-to-person 
variability in TFV hair levels observed in a similar population (women in Africa not in SDC) in 
VOICE,35 then the standard deviation for the difference between a baseline and follow-up (log) 
TFV hair level is 1.2. We estimate the power for detect a difference using a two-sample t-test 
formula using the standard deviation the formula for two-sample t-test with 50 enrollees per arm, 
then we can detect a difference of 0.68 (log TFV) between two arm with 80% power and a 
difference of 0.79 (log TFV) with 90% power on a 0.05 level. This translate to differences of 2.0 
fold and 2.2 fold in TFV levels, respectively. Clinical differences could be appreciably smaller so 
it is not our objective to find statistical significance in hair outcome but, instead, to examine the 
feasibility of the intervention and to generate suggestive data on effects on long term adherence 
assessed by hair levels of TFV. 
 
6.4. Statistical analyses 
Acceptability 
For the questions on the acceptability survey with graded answers, frequency distributions of the 
Likert scale data will be summarized. The results of the survey question regarding the advantages 
and disadvantages of real-time monitoring of adherence will be tabulated, including manually 
reviewing and assigning open-ended responses under the “other” option to appropriate pre- 
specified options. Qualitative interviews from the participants will be recorded, transcribed, and 
translated into English by the study team. The transcripts will be reviewed separately by two 
investigators for completeness and initial theme generation. Coding and analysis will be 
performed with Dedoose, using an integrated inductive-deductive approach informed by 
grounded theory.197,198 Our approach permits us to organize our codes around themes in the semi- 
structured interview guides, while also leaving room for new codes to emerge. We will then review 
the results of our coding for consistency of text segmentation and code application with continued 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 39 of 93 
 
 
 
 
1076 
1077 
1078 
1079 
1080 
1081 
1082 
1083 
1084 
1085 
1086 
1087 
1088 
1089 
1090 
1091 
1092 
1093 
1094 
1095 
1096 
1097 
1098 
1099 
1100 
1101 
1102 
1103 
1104 
1105 
1106 
1107 
1108 
1109 
1110 
1111 
1112 
1113 
1114 
1115 
inter-coder agreement. Inconsistent results will be reviewed by the coders until consensus on 
grouped themes is reached. 
 
Feasibility 
The feasibility of this intervention will be assessed by the proportion of women retained in the 
study at 12 months, the mean number of missed visits, and the proportion of planned urine 
assessments completed and messages delivered in the intervention arm. Uncertainty around 
these observed proportions will be described using 95% confidence intervals. For the interview 
data from providers to assess feasibility, we will use similar qualitative methods to analyze the 
data as described under Acceptability. 
 
Long-term adherence metric 
 
Our analysis (of the adherence outcome) will be a (censored) mixed effects linear regression 
model, also known as a mixed tobit model, to estimate the effect of the intervention versus SOC 
on logarithmically transformed levels of TFV in hair. Since large relative differences between very 
low hair levels are less clinically important than similar relative differences between higher levels, 
we will censor undetectable levels at the lower detection limit, and we will also add the detection 
limit to all levels before log-transformation. These steps reduce the influence of minor differences 
between levels at or near the detection limit, while preserving the approximate interpretation of 
back-transformed regression coefficients as fold-effects. The predictor variable for intervention 
will equal zero for everyone at the baseline (0-month) visit (where hair  levels  reflect pre- 
randomization baseline) and then will change for those in the intervention arm to equal 1 at all 
subsequent visits. A random intercept term will account for within-person correlation across the 
multiple visits; time point will be included as a categorical variable to account for systematic 
changes over time. We incude the pre-intervention TFV hair levels in the tobit model Correlations 
between self-reported adherence and pill counts over 30 days and hair levels will also be 
calculated. 
 
Analyses will be by intention-to-treat. PrEP tenofovir drug levels in hair will be compared between 
arms using repeated measures mixed effects tobit model with baseline hair TFV included as a 
baseline covariate. The hypothesis of statistically significantly higher TFV levels will be tested at 
the month 12 time point. PrEP discontinuation, defined as missing a refill, will be analyzed as a 
time-to-event outcome using Cox proportional hazards regression with the pre-intervention TFV 
hair levels as a baseline factor in the model. If PrEP is discontinued by the treating clinician for 
safety reasons (but not adherence reasons), follow-up thereafter will be censored. Adjusted 
analyses will be performed to control for potential confounders based on our prior work assessing 
correlates of PrEP use: demographics (e.g., age, educational level), sexual behaviors (e.g., 
condom use, outside partnerships), medical status (e.g., depression), and beliefs (e.g., risk 
perception, PrEP efficacy). Stata package “st” and “metobit” will be used for analyses. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 40 of 93 
 
 
 
 
1116 
1117 
1118 
1119 
1120 
1121 
1122 
1123 
1124 
1125 
1126 
1127 
1128 
1129 
1130 
1131 
1132 
1133 
1134 
1135 
1136 
1137 
1138 
1139 
1140 
1141 
1142 
1143 
1144 
1145 
1146 
1147 
1148 
1149 
1150 
1151 
1152 
1153 
1154 
1155 
 
7. PARTICIPANT REIMBURSEMENT 
Study participants will be reimbursed for time of visits, inconvenience of study procedures, and 
transport expenses. The reimbursement per screening or follow-up visit will be 200 Kenyan 
Shillings (KSh). The reimbursement will be collected after the participant has completed their 
study visit. The participants will be told, “You will receive a transportation reimbursement and an 
additional 200 Kenyan shillings for your time and effort.” 
 
8. SAFETY 
8.1. Risks to Human Subjects 
Multinational studies, including the Thika site, which conducted Partners PrEP Study and Partners 
Demonstration Project demonstrated that PrEP (including FTC/TDF) was safe for use in 
heterosexual men and women from Kenya and Uganda. There were no statistically significant 
differences in the frequency of deaths, serious adverse events, adverse events overall, or key 
laboratory adverse events (specifically, creatinine elevation and phosphorus decrease) for those 
receiving PrEP compared to those receiving placebo in the Partners PrEP study. 
 
For the purposes of this study, only serious adverse events (SAEs), and adverse events felt 
related to PrEP adherence testing will be documented. SAEs felt to be related to PrEP will result 
in temporary hold of PrEP. In the case of temporary holds, the hold will continue until the event is 
stabilized or resolved. If the event resolves, PrEP may be reinitiated at the discretion of the 
Investigator, resuming safety monitoring. The severity of clinical symptoms will be scored using 
the DAIDS Table (July 2017 2.1 Version; https://rsc.niaid.nih.gov/clinical-research-sites/daids-  
adverse-event-grading-tables) for Grading the Severity of Adult and Pediatric AEs. Reporting on 
adverse events to the medical officer and relevant IRBs will be according to relevant regulations. 
Moreover, the study will be alert to any unanticipated problems which might arise in the conduct 
of the study (e.g. social harms) and take steps to minimize such problems (as detailed in Section 
8.2). If any unanticipated problems arise, these will be reported to the relevant IRBs (KEMRI and 
UCSF) immediately. 
 
Participants may feel pain or discomfort from phlebotomy if selected for a blood sample archive. 
Participants may become embarrassed, worried, or anxious when answering behavioral or 
demographic questions. We have trained counselors who are available through the study to help 
participants deal with any feelings or questions they may have. The study staff will make every 
effort to protect participant privacy and confidentiality while in the study. However, it is possible 
that participants' involvement in the study could become known to others, and that social harms 
may result (i.e., because participants could become known as participating in a trial involving 
those at risk of HIV). For example, participants could be treated unfairly or discriminated against, 
or could have problems being accepted by their families and/or communities. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 41 of 93 
 
 
 
 
1156 
1157 
1158 
1159 
1160 
1161 
1162 
1163 
1164 
1165 
1166 
1167 
1168 
1169 
1170 
1171 
1172 
1173 
1174 
1175 
1176 
1177 
1178 
1179 
1180 
1181 
1182 
1183 
1184 
1185 
1186 
1187 
1188 
1189 
1190 
1191 
1192 
1193 
1194 
1195 
 
8.2. Adequacy of Protection Against Risks 
Recruitment and Informed Consent 
The study protocol, consent forms, and project materials have been reviewed and approved by 
KEMRI Scientific and Research Unit (SERU) in Kenya (KEMRI IRB approval in Appendix IX). All 
consent forms and participant education materials will be available in English and Swahili, as 
appropriate. In developing the Swahili consent form, the English document will be translated into 
Swahili, and a separate person will back-translate the document into English. This process of 
back-translation of the Swahili consent form will help ensure a satisfactory translation. Throughout 
the recruitment and informed consent process, we will adhere to ethical norms that are standard 
to the study setting. 
 
During the course of the study, confidentiality will be preserved and the data will be maintained in 
a secure cabinet in the research office. The logbook containing the study identification numbers, 
completed consent forms, and completed data forms will remain on the premises and stored in a 
locked cabinet. The online data will be stored in REDCap, which is a password protected data 
management service. All computers with access to the data will be password protected. All data 
will be analyzed using the participants’ study identification number and not their identifiable 
information. 
 
Protection Against Risk 
We will take several steps to minimize risks for participating in the proposed research project. 
First, the research assistant will emphasize the voluntary nature of study participation and that 
participants are free to withdraw from the study at any time and without impact to their routine 
medical care. At any point during interviews, participants (women taking PrEP and healthcare 
providers) can decide to not answer any question they are uncomfortable answering and may 
choose to leave the interview or focus group sessions at any time. Second, the study protocol, 
consent forms, and project materials will be reviewed and approved by the Institutional Review 
Board in Kenya prior to commencing the study or recruiting participants. Ethical review boards 
have a Federal-Wide Assurance number. In addition, the consent forms will be translated to 
Swahili and then back translated into English to ensure accuracy. Third, we intend to minimize 
any potential breach of confidentiality by conducting interviews in a private space, maintaining 
study data in a locked office, entering data onto a secure website, and ensuring that all research 
computers are password protected. 
 
We will take several steps to minimize the clinical risks in the proposed research project. First, to 
minimize risks of discomfort, bleeding, and infection during the blood draws, we will always use 
sterile needles and syringes, practicing good technique, and conducting the procedures in a 
designated space. Second, to mitigate the risks of anxiety related to care and treatment related 
to HIV risk, we will be able to refer participants to accessible counselors and social workers. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 42 of 93 
 
 
 
 
1196 
1197 
1198 
1199 
1200 
1201 
1202 
1203 
1204 
1205 
1206 
1207 
1208 
1209 
1210 
1211 
1212 
1213 
1214 
1215 
1216 
1217 
1218 
1219 
1220 
1221 
1222 
1223 
1224 
1225 
1226 
1227 
1228 
1229 
1230 
1231 
1232 
1233 
1234 
Of note, the study team has extensive experience with counseling about HIV-1 risk and HIV-1 
serodiscordancy, PrEP (and ART), and strategies for HIV-1 prevention in general. The risks from 
the anticipated activities will be no greater than in our previous studies; in fact, given the proven 
prevention benefits of PrEP and now national roll-out in Kenya, risks are anticipated to be less 
than in some of our prior studies. We feel the risks associated with the study are small. The 
benefits are consistent with clinical care benefits and cultural expectations and they follow the 
established standard with IRB approval in our other studies. We therefore believe the balance of 
benefit and risk is appropriate 
 
Participants will be asked to inform the clinic staff if they feel they have been injured because of 
taking part in the study. Injuries may also be identified during laboratory testing, medical histories, 
and physical examinations. Treatment for adverse events related to study participation will be 
provided by the treatment clinic. If treatment is required that is beyond the capacity of the clinic, 
the clinic staff will refer the participant to appropriate services or organizations that can provide 
care for the injury. 
 
8.3. Potential Benefits of the Proposed Research 
Participants will be receiving PrEP as part of the standard of care. Potential benefits to the 
proposed research include allowing the participant to voice their opinion about the acceptability 
of this novel point-of-care test. Participants may feel useful to in helping researchers learn 
potentially new ways to measure and improve adherence to PrEP. Participants and others also 
may benefit in the future from information learned from this study on this novel urine-based 
adherence assay. There may be no other direct benefits to participants in this study 
 
8.4. Ensuring patient confidentiality and safety 
We will have several mechanisms in place to ensure participant confidentiality and safety. First, 
we will provide extensive training to the research team regarding the study protocol, consent form, 
the importance of maintaining participant confidentiality and safety. Laboratory technologists on- 
site at Thika responsible for interepreting the tenofovir urine assay will be extensively trained. 
Second, we will be in regular communication with the Thika clinic to ensure that we are not 
disrupting patient flow or treatment. Third, we will review our data on a regular basis to make 
certain that our proposed research projects are not causing harm or adverse events. The Principal 
Investigator will notify the Institutional Review Boards of any breaches in confidentiality, study 
protocol, or adverse events attributable to this study within ten days of the event. An Independent 
Study Monitor will review procedures for the study every 3 months with full details provided in 
Section 12. 
 
8.5. Pregnancy among HIV-negative women 
Animal and human date, including from the Partners PrEP Study and Partners Demonstration 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 43 of 93 
 
 
 
 
1235 
1236 
1237 
1238 
1239 
1240 
1241 
1242 
1243 
1244 
1245 
1246 
1247 
1248 
1249 
1250 
1251 
1252 
1253 
1254 
1255 
1256 
1257 
1258 
1259 
1260 
1261 
1262 
1263 
1264 
1265 
1266 
1267 
1268 
1269 
1270 
1271 
1272 
1273 
Project, suggest safety of FTC/TDF when used by HIV-1 infected women during pregnancy and 
breastfeeding.{Joseph Davey, 2020 #1219}. For this study, PrEP will not be discontinued when 
pregnancy is detected. Moreover, per the 2016 Kenya PrEP treatment guidelines, urine 
pregnancy testing of all women of reproductive age will be conducted at the start of PrEP and 
when indicated for clinical care (Table 1, footnote). 
 
8.6. HIV testing 
HIV-1 testing is an essential component of PrEP delivery to protect patient safety – specifically, 
to prevent the initiation of PrEP among persons who have already acquired HIV-1 and to prevent 
continuation of PrEP if HIV-1 is acquired while receiving PrEP. In clinical trials and delivery 
projects of PrEP, the greatest risk of HIV-1 infection is at the time of initiation – either because of 
unrecognized chronic HIV-1 infection prior to HIV-1 testing as part of PrEP start or recent (acute) 
HIV-1 infection acquired just prior to PrEP initiation. Such testing will be routine in this study at 
PrEP initiation and at each PrEP visit (Table 1) according to the 2016 Kenya PrEP guidelines. 
Kenya recommends testing according to the national HIV-1 testing algorithm, which uses third- 
generation HIV-1 antibody based tests, done in sequence (i.e., if a positive first test, then perform 
a second test for confirmation, and a third as tie-breaker). 
 
8.7. Social harm considerations for PrEP and PrEP adherence testing 
PrEP use at this point is considered one of the most effective biomedical prevention interventions 
for HIV risk and the benefits far outweigth the risk, which is why PrEP is part of standard clinical 
guidelines in Kenya and around the world. For this study, we have considered the risk of the 
adherence counseling provided by the urine-based test. The formative work we are performing 
now to ask women about how they would like the test information delivered in a supportive, 
motivating manner (Section 5.5) based on how counseling was delivered in HPTN-082 (Figure 
8) is vital to minimizing any risk of social harm from delivering the information. Moreover, the very 
low risk of misclassification of test results due to the urine assay’s high performance 
characteristics (low risk of false positives or false positives) is also helpful to minimizing any risk 
(please see Section 3.4). 
 
The 24-hour helpline that Thika clinic has, and which we have used for prior studies, will be 
available in case of anxiety, social harm, depression, or a positive HIV test. In the event of a 
clinical need (e.g., side effects, anxiety, symptoms of a sexually transmitted infection), participants 
will be requested to return to the clinic for care. 
 
9. TIMELINE 
The Study Aims will be completed in two years from the initiation of the study, according to the 
timeline detailed in Table 2. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 44 of 93 
 
 
Table 2. Timeline for Research Activities. 
Year 1 
Year 2 
Q1 
Q2 
Q3 
Q4   Q1   Q2 
Q3 
Q4 
RCT of PrEP Adherence 
Qualitative Acceptability/Feasibility 
studies 
 
 
1274 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1275 
1276 
1277 
1278 
1279 
1280 
1281 
1282 
1283 
1284 
1285 
1286 
1287 
1288 
1289 
1290 
1291 
1292 
1293 
1294 
1295 
1296 
1297 
1298 
1299 
1300 
. 
 
 
 
 
 
 
IRB approval, Training & Preparation 
X 
Enrollment Period 
X 
X 
Follow-up Period 
X 
X 
X 
X 
Laboratory Testing 
X 
X 
X 
 
 
Data collection 
X 
X 
Data analyses and manuscripts 
X 
X 
X 
 
 
10. LIMITATIONS 
Urine levels, like those in plasma, represent short-term PrEP adherence. Therefore, adherence 
monitoring via these matrices may be susceptible to “white coat adherence”, where adherence 
improves transiently before a clinic or a study visit.130. We have designed this study to capture 
information on both short-term adherence (via the urine assay) and long-term adherence (via the 
hair assay) to evaluate for white-coat adherence patterns.35,39,41 For instance, positive urine TFV 
assays but low concentrations of TFV in hair are suggestive of white-coat adherence patterns 
where short-term adherence is high, but long-term adherence is low. In intervention arm 
participants, short-term adherence may improve with feedback from the assay, but hair 
concentrations do not reflect “white coat” adherence and will only increase if overall adherence 
over time increases. Therefore, the careful design of the study and including both short-term and 
long-term adherence patterns will help us evaluate whether white-coat adherence is observed. 
Of note, we have elected to collect and store urine samples in the standard-of-care arm 
participants as well in order to analyze TFV detection at the end of the study in these samples. 
Hair levels will also be analyzed at the end of the study in SOC arm participants. This will enable 
us to compare whether the intervention arm participants (who knew urine tenofovir testing would 
be performed and the information delivered to them) had higher rates of “white coat adherence” 
than those in the standard-of-care arm. 
 
Another limitation is that we focus only on daily PrEP in this study. Intermittent PrEP has efficacy 
among MSM,199,200 although there is no evidence for on-demand PrEP with heterosexual risk 
in men and in women. Updated CDC guidelines for MSM still recommend daily use.201 World 
Health Organization guidelines endorse daily use. Therefore, this study has relevance to the 
way in which PrEP should be administered in women worldwide. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 45 of 93 
 
 
 
 
1301 
1302 
1303 
1304 
1305 
1306 
1307 
1308 
1309 
1310 
1311 
1312 
1313 
1314 
1315 
1316 
1317 
1318 
1319 
1320 
1321 
1322 
1323 
1324 
1325 
1326 
1327 
 
Finally, the extensive validation data we have now published and summarize in Section 3.3 
shows the high performance characteristics of the assay. Our work evaluating the assay’s 
performance in diverse populations using stored urine samples (e.g. Partners PrEP, 
manuscript in preparation) verifies its utility across real-world settings. We do not have specific 
information on the effect of concomitant medications on its performance (e.g. anti-TB drugs), 
although these are not expected to significantly affect the results of a yes/no tenofovir 
adherence assay. 
 
11. STUDY LEADERSHIP PLAN 
We have assembled an interdisciplinary team for this protocol. Dr. Monica Gandhi from UCSF 
has conducted research on metrics of adherence in HIV treatment and prevention and in HIV and 
women for over 15 years and is the clinical director of the UCSF HAL. Dr. Nelly Mugo has 
extensive experience in PrEP roll-out in Kenya and in PrEP implementation and clinical trials at 
Thika Clinic. Dr. Kenneth Ngure, an expert in qualitative methods, has led the qualitative work 
for most of the PrEP and treatment trials conducted at Thika. Dr. David Glidden, biostatistician, 
conducted the analysis of pharmacologic measures for most of the major PrEP trials. Dr. Jared 
Baeten is a world-renowned expert in PrEP, served as the PI of the Partners PrEP clinical trial, 
is the PI of the Partners Demonstration Project, Partners Scale-UP Project and has vast expertise 
in HIV prevention interventions in resource constrained settings. 
 
12. EXTERNAL MONITORING PLAN FOR PUMA STUDY- QUALITY ASSURANCE AND 
QUALITY CONTROL 
The International Clinical Research Center (ICRC) at the University of Washington will provide 
regular study monitoring for the Thika site in the PUMA study. The Study Monitor will be a Senior 
Research Manager at ICRC. The Research Manager will have Masters in Public Health and/or a 
Certified Clinical Research Associate (CCRA) certification and will be experienced in site 
monitoring activities. 
 
1328 
1329 
1330 
1331 
12.1. Goals and Objectives: Monitoring is necessary to assure adequate protection of the rights 
of human subjects and the safety of all participants involved in clinical investigations and the 
quality and integrity of the resulting data submitted. 
The objectives of the monitoring procedures are: 
 
1332 
1333 
• 
To ensure that the study is carried out in accordance with the approved protocol 
• 
To identify any problems and suggest / seek solutions 
 
1334 
1335 
1336 
1337 
12.2. Clinical Monitoring Activities 
The ICRC Study Monitor will conduct on-site monitoring visits twice annually over the course of 
the 24-month study (12 months of enrollment and 12 months of follow-up). Monitoring visits will 
start no more than 3-months after study initiation. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 46 of 93 
 
 
 
 
1338 
1339 
1340 
1341 
The Study Monitor will review standard operating procedures (SOPs) and other study-related 
documentation on-site and will conduct an in-depth review of a subset of enrolled participants’ 
records. Through this detailed review, monitoring will focus on the following key processes of the 
study: 
 
1342 
1343 
1344 
1345 
1346 
1347 
1348 
1349 
1350 
1351 
1352 
1353 
1354 
1355 
1356 
1357 
1358 
1359 
1360 
1361 
1362 
1363 
1364 
1365 
1366 
1367 
1368 
1369 
1370 
1371 
1372 
1373 
1374 
• 
Informed consent process 
• 
Study eligibility criteria met for all participants 
• 
Timely completion of study CRFs 
• 
Sample collection and handling in accordance to Protocol and SOP(s) 
• 
Review of data management procedure 
• 
Reporting of adverse events and protocols violations according to SOP(s) 
• 
Follow up assessments and procedures 
• 
Product accountability 
• 
Regulatory documents on file 
 
 
12.3. Clinical Monitoring Report 
The Study Monitor will submit a written monitoring report to the study PI, the site PIs, the co-I 
and the Thika research team no more than 14 days after the monitoring visit. In this report, the 
Study Monitor will assess the following items: 
• 
Regulatory review 
• 
Records review 
• 
Site Operations Assessment 
• 
Status of previous findings 
• 
Action items 
 
This report will be reviewed in detail with the Thika Research Team at the end of the Monitoring 
Visit. The Study Monitor will request a written response to any identified “Action Items” within 14 
days of the report being submitted, which will include how the team responded to any of the 
Action Items. 
 
13. RESOURCE SHARING & DISSEMINATION PLAN 
13.1. Resource Sharing: 
For all data generated during the course of this project, we will follow the prevailing standards and 
guidelines in documenting and depositing data sets. We will make quality-controlled raw data as 
well as processed data used in publications available. As described in the grant application, 
protocols and workflows will be implemented exactly as described and documented such that 
other groups will be able to precisely reproduce results from the raw data. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 47 of 93 
 
 
 
 
1375 
1376 
1377 
1378 
1379 
1380 
1381 
1382 
1383 
1384 
1385 
1386 
1387 
1388 
1389 
1390 
1391 
1392 
1393 
1394 
1395 
1396 
1397 
1398 
1399 
1400 
1401 
1402 
1403 
1404 
1405 
1406 
1407 
1408 
1409 
1410 
1411 
1412 
1413 
The study personnel assigned to the project, including KEMRI-based, UCSF-based and 
University of Washington-based investigators, will disseminate results from this research through 
presentations at public lectures, scientific institutions and meetings, and/or publication in major 
journals. The institutions and Principal Investigators will adhere to the NIH Grants Policy on 
Sharing of Unique Research Resources including the Sharing of Biomedical Research 
Resources: Guidelines for Recipients of NIH Grants and Contracts on Obtaining and 
Disseminating Biomedical Research Resources. Study records may be reviewed by the U.S. 
Office of Human Research Protections. 
 
13.2. Data Sharing Plan 
Intellectual property and data generated under this project will be administered in accordance with 
NIH policies, including the NIH Data Sharing Policy and Implementation Guidance of March 5, 
2003. Materials generated under the project will be disseminated in accordance with KEMRI, 
UCSF, University of Washington, and NIH policies. Depending on such policies, materials may 
be transferred to others under the terms of a material transfer agreement. Access to databases 
and associated software tools generated under the project will be available for educational, 
research, and non-profit purposes. Such access will be provided using web-based applications, 
as appropriate. Publication of data shall occur during the project, if appropriate, or at the end of 
the project, consistent with normal scientific practices. Research data that documents, supports, 
and validates research findings will be made available after the main findings from the final 
research data set have been accepted for publication. Such research data will be modified to 
prevent the disclosure of personal identifiers to remain in compliance with the Protection of 
Human Subjects guidelines. 
 
13.3. Publications 
We will disseminate the results from this research as broadly as possible. Of note, drafts of 
publications will be shared with our NIH program office and medical officer prior to submission. 
First, we will publish our results in Open Access journals, if appropriate. Second, we will post 
author PDFs of our manuscripts on our respective websites in accordance with the copyright rules 
of the journals. Third, we will practice posting our manuscripts on Internet archives (such as 
arxiv.org) when possible. 
 
13.4. Presentations 
We expect that all the research personnel will attend national conferences periodically and 
present the results from this research to the scientific community. Because of the multidisciplinary 
nature of the work, different group members will present at various conferences, such as the 
Conference on Retrovirus and Opportunistic Infections, International AIDS Society, and Kenya- 
based conferences, which focus on the appropriate aspects of our research. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 48 of 93 
 
 
 
 
1414 
1415 
1416 
1417 
1418 
1419 
1420 
1421 
1422 
1423 
1424 
1425 
1426 
1427 
1428 
1429 
1430 
1431 
1432 
1433 
1434 
1435 
1436 
1437 
1438 
1439 
1440 
1441 
1442 
1443 
1444 
1445 
1446 
1447 
1448 
1449 
1450 
1451 
1452 
1453 
1454 
The study team for this award is committed to public dissemination of results of clinical trial, to 
trial participants, local stakeholders in Kenya, the global scientific community, and US, Kenyan, 
and global policymakers. Dissemination of study results will follow principles of good participatory 
practice. The clinical trial has now been registered with Clinicaltrials.gov prior to initiation 
(NCT0393546) and results will be updated there in a timely fashion. Results will be published in 
conference abstracts and peer-reviewed journals. Study results will be disseminated through 
presentations to local stakeholders and policymakers in Kenya, including the Ministry of Health. 
 
14. ETHICAL CONSIDERATIONS 
The study protocol, consent forms, and project materials have been reviewed and approved by 
the KEMRI IRB (Appendix IX). The FDA has reviewed and approved the urine tenofovir test as 
qualifying for a Nonsignificant risk (NSR) indication for an investigational device (Section 3.4 and 
Appendix VIII) 
 
All participants will provide written informed consent before participation in the trial or in qualitative 
interviews in their preferred language. Participants will be informed the purpose of the study, the 
procedures to be followed and the risks and benefits of participation. The consents forms will be 
translated into Swahili and then back-translated to ensure accuracy. Specifically the participants 
will be informed that this novel study will answer a critical questions on acceptability, performance 
and barriers of objective PrEP adherence testing in the context of implementation of PrEP. 
 
Collection and analyses of socio-demographic information and biological samples taken for 
clinical purposes will be covered by ethics approval. Informed consent will be obtained from 
potential participants to participate in the study and to store blood and hair samples. These 
biological specimens will be handled by trained staff and labeled with a unique identifier for each 
participant. The results will be transmitted to the clinics in an electronic format but only accessed 
by authorized and trained clinic staff. Only key members of the data team will have access to the 
electronic data, which will be password protected. Once enrolled into the study participants will 
be able to withdraw at any point. The link between participant names and codes, used for samples 
and data, will be destroyed five years after the study is completed, 
 
15. PROTOCOL REGISTRATION 
Prior to implementation of this protocol, and any subsequent full version amendments, 
each site must have the protocol and the protocol informed consent form(s) 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 
(DAIDS PRO) at the Regulatory Support Center (RSC). The DAIDS PRO will review the 
submitted protocol registration packet to ensure that all of the required documents have 
been received. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 49 of 93 
 
 
 
 
1455 
1456 
1457 
1458 
1459 
1460 
1461 
1462 
1463 
1464 
1465 
1466 
1467 
1468 
1469 
1470 
1471 
1472 
1473 
1474 
1475 
1476 
1477 
1478 
1479 
1480 
1481 
1482 
1483 
1484 
1485 
1486 
1487 
1488 
1489 
1490 
1491 
1492 
1493 
1494 
1495 
1496 
1497 
1498 
1499 
1500 
1501 
Site-specific informed consent forms (ICFs) WILL NOT be reviewed or approved by the 
DAIDS PRO, and sites will receive an Initial Registration Notification when the DAIDS 
PRO receives a complete registration packet. Receipt of an Initial Registration 
Notification indicates successful completion of the protocol registration process. Sites will 
not receive any additional notifications from the DAIDS PRO for the initial protocol 
registration. A copy of the Initial Registration Notification should be retained in the site's 
regulatory files. 
 
Upon receiving final IRB/EC and any other applicable RE approval(s) 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 ICF(s) 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. 
 
 
 
16. REFERENCES 
 
1. 
Gandhi M, Bacchetti P, Rodrigues WC, et al. Development and Validation of an 
Immunoassay for Tenofovir in Urine as a Real-Time Metric of Antiretroviral Adherence. 
EClinical Medicine (Published by The Lancet); https://doiorg/101016/jeclinm201808004. 
2018. 
2. 
Gandhi M, Bacchetti P, Spinelli MA, et al. Brief Report: Validation of a Urine Tenofovir 
Immunoassay for Adherence Monitoring to PrEP and ART and Establishing the Cutoff for 
a Point-of-Care Test. J Acquir Immune Defic Syndr. 2019;81(1):72-77. 
3. 
Spinelli MA, Glidden DV, Rodrigues WC, et al. Low tenofovir level in urine by a novel 
immunoassay is associated with seroconversion in a PrEP demonstration project. AIDS. 
2019(5):867-872. 
4. 
Gandhi M, Wang G, King R, et al. Development and validation of the first point-of-care 
assay to objectively monitor adherence to HIV treatment and prevention in real-time in 
routine settings. AIDS. 2020;34(2):255-260. 
5. 
Spinelli MA, Rodrigues WC, Wang G, Vincent M, Glidden DV, Okochi H, Stalter R, 
Defechereux P, Deutsch M, Grant RM, Ngure K, Mugo NR, Baeten JM, Gandhi M. High 
accuracy of a real-time urine antibody-based tenofovir point-of-care test compared to 
laboratory-based ELISA in diverse populations. JAIDS 2020 (in press) 
6. 
Hendrix CW, Andrade A, Bumpus NN, et al. Dose Frequency Ranging Pharmacokinetic 
Study of Tenofovir-Emtricitabine After Directly Observed Dosing in Healthy Volunteers to 
Establish Adherence Benchmarks (HPTN 066). AIDS Res Hum Retroviruses. 
2016;32(1):32-43. 
7. 
Castillo-Mancilla JR, Zheng JH, Rower JE, et al. Tenofovir, emtricitabine, and tenofovir 
diphosphate in dried blood spots for determining recent and cumulative drug exposure. 
AIDS Res Hum Retroviruses. 2013;29(2):384-390. 
8. 
Gandhi M, Greenblatt RM. Hair it is: the long and short of monitoring antiretroviral 
treatment. Ann Intern Med. 2002;137(8):696-697. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 50 of 93 
 
 
 
 
1502 
1503 
1504 
1505 
1506 
1507 
1508 
1509 
1510 
1511 
1512 
1513 
1514 
1515 
1516 
1517 
1518 
1519 
1520 
1521 
1522 
1523 
1524 
1525 
1526 
1527 
1528 
1529 
1530 
1531 
1532 
1533 
1534 
1535 
1536 
1537 
1538 
1539 
1540 
1541 
1542 
1543 
1544 
1545 
1546 
1547 
1548 
1549 
1550 
1551 
9. 
Huang Y, Gandhi M, Greenblatt RM, Gee W, Lin ET, Messenkoff N. Sensitive analysis of 
anti-HIV drugs, efavirenz, lopinavir and ritonavir, in human hair by liquid chromatography 
coupled 
with 
tandem 
mass 
spectrometry. 
Rapid 
Commun 
Mass 
Spectrom. 
2008;22(21):3401-3409. 
10. 
Huang Y, Yang Q, Yoon K, et al. Microanalysis of the antiretroviral nevirapine in human 
hair from HIV-infected patients by liquid chromatography-tandem mass spectrometry. 
Anal Bioanal Chem. 2011;401(6):1923-1933. 
11. 
Gandhi M, Greenblatt RM, Bacchetti P, et al. A single-nucleotide polymorphism in 
CYP2B6 leads to >3-fold increases in efavirenz concentrations in plasma and hair among 
HIV-infected women. J Infect Dis. 2012;206(9):1453-1461. 
12. 
van Zyl GU, van Mens TE, McIlleron H, et al. Low lopinavir plasma or hair concentrations 
explain second line protease inhibitor failures in a resource-limited setting. J Acquir 
Immune Defic Syndr. 2011;56(4):333-339. 
13. 
Prasitsuebsai W, Kerr SJ, Truong KH, et al. Using Lopinavir Concentrations in Hair 
Samples to Assess Treatment Outcomes on Second-Line Regimens Among Asian 
Children. AIDS Res Hum Retroviruses. 2015;31(10):1009-1014. 
14. 
Gandhi M, Ameli N, Bacchetti P, et al. Protease inhibitor levels in hair strongly predict 
virologic response to treatment. AIDS. 2009;23(4):471-478. 
15. 
Gandhi M, Ameli N, Bacchetti P, et al. Atazanavir concentration in hair is the strongest 
predictor of outcomes on antiretroviral therapy. Clin Infect Dis. 2011;52(10):1267-1275. 
16. 
Cohan D, Natureeba P, Koss CA, et al. Efficacy and safety of lopinavir/ritonavir versus 
efavirenz-based antiretroviral therapy in HIV-infected pregnant Ugandan women. AIDS. 
2015;29(2):183-191. 
17. 
Koss CA, Natureeba P, Mwesigwa J, et al. Hair concentrations of antiretrovirals predict 
viral suppression in HIV-infected pregnant and breastfeeding Ugandan women. AIDS. 
2015;29(7):825-830. 
18. 
Chawana TD, Gandhi M, Nathoo K, et al. Defining a Cutoff for Atazanavir in Hair Samples 
Associated With Virological Failure Among Adolescents Failing Second-Line Antiretroviral 
Treatment. J Acquir Immune Defic Syndr. 2017;76(1):55-59. 
19. 
Pintye J, Bacchetti P, Teeraananchai S, et al. Brief Report: Lopinavir Hair Concentrations 
Are the Strongest Predictor of Viremia in HIV-Infected Asian Children and Adolescents on 
Second-Line Antiretroviral Therapy. J Acquir Immune Defic Syndr. 2017;76(4):367-371. 
20. 
Baxi SM, Greenblatt RM, Bacchetti P, et al. Nevirapine Concentration in Hair Samples Is 
a Strong Predictor of Virologic Suppression in a Prospective Cohort of HIV-Infected 
Patients. PLoS One. 2015;10(6):e0129100. 
21. 
Gandhi M, Ofokotun I, Bacchetti P, et al. Antiretroviral concentrations in hair strongly 
predict virologic response in a large HIV treatment-naive clinical trial. Clin Infect Dis. 
2019;5:1044-1047. 
22. 
Gandhi M, Mwesigwa J, Aweeka F, et al. Hair and Plasma Data Show That Lopinavir, 
Ritonavir, and Efavirenz All Transfer From Mother to Infant In Utero, But Only Efavirenz 
Transfers via Breastfeeding. J Acquir Immune Defic Syndr. 2013;63(5):578-584. 
23. 
Hickey MD, Salmen CR, Tessler RA, et al. Antiretroviral concentrations in small hair 
samples as a feasible marker of adherence in rural Kenya. J Acquir Immune Defic Syndr. 
2014;66(3):311-315. 
24. 
Olds PK, Kiwanuka JP, Nansera D, et al. Assessment of HIV antiretroviral therapy 
adherence by measuring drug concentrations in hair among children in rural Uganda. 
AIDS Care. 2015;27(3):327-332. 
25. 
Bartelink IH, Savic RM, Mwesigwa J, et al. Pharmacokinetics of lopinavir/ritonavir and 
efavirenz in food insecure HIV-infected pregnant and breastfeeding women in Tororo, 
Uganda. Journal of Clinical Pharmacology. 2014;54(2):121-132. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 51 of 93 
 
 
 
 
1552 
1553 
1554 
1555 
1556 
1557 
1558 
1559 
1560 
1561 
1562 
1563 
1564 
1565 
1566 
1567 
1568 
1569 
1570 
1571 
1572 
1573 
1574 
1575 
1576 
1577 
1578 
1579 
1580 
1581 
1582 
1583 
1584 
1585 
1586 
1587 
1588 
1589 
1590 
1591 
1592 
1593 
1594 
1595 
1596 
1597 
1598 
1599 
1600 
1601 
26. 
Gandhi M, Yang Q, Bacchetti P, Huang Y. Short communication: A low-cost method for 
analyzing nevirapine levels in hair as a marker of adherence in resource-limited settings. 
AIDS Res Hum Retroviruses. 2014;30(1):25-28. 
27. 
Gwadz M, Cleland CM, Applegate E, et al. Behavioral Intervention Improves Treatment 
Outcomes Among HIV-Infected Individuals Who Have Delayed, Declined, or Discontinued 
Antiretroviral Therapy: A Randomized Controlled Trial of a Novel Intervention. AIDS 
Behav. 2015;19(10):1801-1817. 
28. 
Hickey MD, Salmen CR, Omollo D, et al. Implementation and Operational Research: 
Pulling the Network Together: Quasiexperimental Trial of a Patient-Defined Support 
Network Intervention for Promoting Engagement in HIV Care and Medication Adherence 
on Mfangano Island, Kenya. J Acquir Immune Defic Syndr. 2015;69(4):e127-134. 
29. 
Gandhi M, Gandhi RT, Stefanescu A, et al. Cumulative Antiretroviral Exposure Measured 
in Hair Is Not Associated With Measures of HIV Persistence or Inflammation Among 
Individuals on Suppressive ART. J Infect Dis. 2018;218:234-238. 
30. 
Phung N, Kuncze K, Okochi H, et al. Development and Validation of an Assay to Analyze 
Atazanavir in Human Hair Via Liquid Chromatography-Tandem Mass Spectrometry (LC- 
MS/MS). Rapid Commun Mass Spectrom. 2018;Mar 15;32(5):431-441. 
31. 
Liu AY, Yang Q, Huang Y, et al. Strong relationship between oral dose and tenofovir hair 
levels in a randomized trial: hair as a potential adherence measure for pre-exposure 
prophylaxis (PrEP). PLoS One. 2014;9(1):e83736. 
32. 
Baxi SM, Liu A, Bacchetti P, et al. Comparing the novel method of assessing PrEP 
adherence/exposure using hair samples to other pharmacologic and traditional measures. 
J Acquir Immune Defic Syndr. 2015;68(1):13-20. 
33. 
Gandhi M, Glidden DV, Liu A, et al. Strong Correlation Between Concentrations of 
Tenofovir (TFV) Emtricitabine (FTC) in Hair and TFV Diphosphate and FTC Triphosphate 
in Dried Blood Spots in the iPrEx Open Label Extension: Implications for Pre-exposure 
Prophylaxis Adherence Monitoring. J Infect Dis. 2015;212(9):1402-1406. 
34. 
Gandhi M, Glidden DV, Mayer K, et al. Association of age, baseline kidney function, and 
medication exposure with declines in creatinine clearance on pre-exposure prophylaxis: 
an observational cohort study. Lancet HIV. 2016;3(11):e521-e528. 
35. 
Koss CA, Bacchetti P, Hillier SL, et al. Differences in Cumulative Exposure and Adherence 
to Tenofovir in the VOICE, iPrEx OLE, and PrEP Demo Studies as Determined via Hair 
Concentrations. AIDS Res Hum Retroviruses. 2017;33(8):778-783. 
36. 
Saberi P, Neilands TB, Ming K, et al. Strong Correlation Between Concentrations of 
Antiretrovirals in Home-Collected and Study-Collected Hair Samples: Implications for 
Adherence Monitoring. J Acquir Immune Defic Syndr. 2017;76(4):e101-e103. 
37. 
Gandhi M, Murnane PM, Bacchetti P, et al. Hair levels of preexposure prophylaxis drugs 
measure adherence and are associated with renal decline among men/transwomen. 
AIDS. 2017;31(16):2245-2251. 
38. 
Koss CA, Hosek SG, Bacchetti P, et al. Comparison of Measures of Adherence to Human 
Immunodeficiency Virus Preexposure Prophylaxis Among Adolescent and Young Men 
Who Have Sex With Men in the United States. Clin Infect Dis. 2018;66(2):213-219. 
39. 
Abaasa A, Hendrix C, Gandhi M, et al. Utility of Different Adherence Measures for PrEP: 
Patterns and Incremental Value. AIDS Behav. 2018;22(4):1165-1173. 
40. 
Seifert SM, Castillo-Mancilla JR, Erlandson K, et al. Adherence biomarker measurements 
in older and younger HIV-infected adults receiving tenofovir-based therapy. J Acquir 
Immune Defic Syndr. 2017;Mar 1:77(3):295-298. 
41. 
Baxi SM, Vittinghoff E, Bacchetti P, et al. Comparing pharmacologic measures of tenofovir 
exposure in a U.S. pre-exposure prophylaxis randomized trial. PLoS One. 
2018;13(1):e0190118. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 52 of 93 
 
 
 
 
1602 
1603 
1604 
1605 
1606 
1607 
1608 
1609 
1610 
1611 
1612 
1613 
1614 
1615 
1616 
1617 
1618 
1619 
1620 
1621 
1622 
1623 
1624 
1625 
1626 
1627 
1628 
1629 
1630 
1631 
1632 
1633 
1634 
1635 
1636 
1637 
1638 
1639 
1640 
1641 
1642 
1643 
1644 
1645 
1646 
1647 
1648 
1649 
42. 
Markowitz M, Grossman H, Anderson PL, et al. Newly Acquired Infection With Multidrug- 
Resistant HIV-1 in a Patient Adherent to Preexposure Prophylaxis. J Acquir Immune Defic 
Syndr. 2017;76(4):e104-e106. 
43. 
Thaden JT, Gandhi M, Okochi H, Hurt CB, McKellar MS. Seroconversion on preexposure 
prophylaxis: a case report with segmental hair analysis for timed adherence determination. 
AIDS. 2018;32(9):F1-F4. 
44. 
Colby DJ, Kroon E, Sacdalan C, et al. Acquisition of Multidrug-Resistant Human 
Immunodeficiency Virus Type 1 Infection in a Patient Taking Preexposure Prophylaxis. 
Clin Infect Dis. 2018;31:962-964. 
45. 
Koss CA, Liu AY, Castillo-Mancilla J, et al. Similar tenofovir hair concentrations in men 
and women after directly observed dosing of tenofovir disoproxil fumarate/emtricitabine: 
implications for preexposure prophylaxis adherence monitoring. AIDS. 2018;32(15):2189- 
2194. 
46. 
Cohen SE, Sachdev D, Lee SA, et al. Acquisition of tenofovir-susceptible, emtricitabine- 
resistant HIV despite high adherence to daily pre-exposure prophylaxis: a case report. 
Lancet HIV. 2018:doi: 10.1016/S2352-3018(1018)30288-30281. [Epub ahead of print]. 
47. 
Murnane PM, Bacchetti P, Currier JS, et al. Tenofovir concentrations in hair strongly 
predict virologic suppression in breastfeeding women. AIDS. 2019;33(10):1657-1662. 
48. 
Velloza J, Bacchetti P, Hendrix CW, et al. Short- and Long-Term Pharmacologic Measures 
of HIV Pre-exposure Prophylaxis Use Among High-Risk Men Who Have Sex With Men in 
HPTN 067/ADAPT. J Acquir Immune Defic Syndr. 2019;82(2):149-158. 
49. 
Koenig HC, Mounzer K, Daughtridge GW, et al. Urine assay for tenofovir to monitor 
adherence in real time to tenofovir disoproxil fumarate/emtricitabine as pre-exposure 
prophylaxis. HIV Med. 2017;18(6):412-418. 
50. 
Cottrell ML, Yang KH, Prince HM, et al. A Translational Pharmacology Approach to 
Predicting Outcomes of Preexposure Prophylaxis Against HIV in Men and Women Using 
Tenofovir Disoproxil Fumarate With or Without Emtricitabine. J Infect Dis. 2016;214(1):55- 
64. 
51. 
Havlir D, Beyrer C. The beginning of the end of AIDS? N Engl J Med. 2012;367(8):685- 
687. 
52. 
Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early 
antiretroviral therapy. N Engl J Med. 2011;365(6):493-505. 
53. 
Cohen MS, Chen YQ, McCauley M, et al. Antiretroviral Therapy for the Prevention of HIV- 
1 Transmission. N Engl J Med. 2016;375(9):830-839. 
54. 
Rodger AJ, Cambiano V, Bruun T, et al. Sexual Activity Without Condoms and Risk of HIV 
Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using 
Suppressive Antiretroviral Therapy. JAMA. 2016;316(2):171-181. 
55. 
Bavinton B, Grinsztejn B, Phanuphak N, et al. HIV treatment prevents HIV transmission in 
male serodiscordant couples in Australia, Thailand and Brazil. International AIDS 
Conference July 2017; Paris, France. 
56. 
Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV 
prevention in men who have sex with men. The New England Journal of Medicine. 
2010;363(27):2587-2599. 
57. 
Thigpen MC, Kebaabetswe PM, Paxton LA, et al. Antiretroviral preexposure prophylaxis 
for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367(5):423-434. 
58. 
Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in 
heterosexual men and women. The New England Journal of Medicine. 2012;367(5):399- 
410. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 53 of 93 
 
 
 
 
1650 
1651 
1652 
1653 
1654 
1655 
1656 
1657 
1658 
1659 
1660 
1661 
1662 
1663 
1664 
1665 
1666 
1667 
1668 
1669 
1670 
1671 
1672 
1673 
1674 
1675 
1676 
1677 
1678 
1679 
1680 
1681 
1682 
1683 
1684 
1685 
1686 
1687 
1688 
1689 
1690 
1691 
1692 
1693 
1694 
1695 
1696 
1697 
1698 
1699 
59. 
Choopanya K, Martin M, Suntharasamai P, et al. Antiretroviral prophylaxis for HIV infection 
in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, 
double-blind, placebo-controlled phase 3 trial. Lancet. 2013;381(9883):2083-2090. 
60. 
Centers for Disease Control (CDC). Preexposure Prophylaxis for the Prevention of HIV in 
the United States: A Clinical Practice Guideline - 2017 Update (published April 2018);  
https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf. (Accessed April 
23, 2018). 
61. 
World Health Organization (WHO). Updated recommendations on first-line and second- 
line antiretroviral regimens and post-exposure prophylaxis and recommendations on early 
infant 
diagnosis 
of 
HIV: 
interim 
guidance;  
http://www.who.int/hiv/pub/guidelines/ARV2018update/en/ (Accessed November 2018). 
62. 
Amico KR. Adherence to preexposure chemoprophylaxis: the behavioral bridge from 
efficacy to effectiveness. Curr Opin HIV AIDS. 2012;7(6):542-548. 
63. 
Marrazzo JM, Ramjee G, Richardson BA, et al. Tenofovir-based preexposure prophylaxis 
for HIV infection among African women. N Engl J Med. 2015;372(6):509-518. 
64. 
Corneli AL, McKenna K, Perry B, et al. The science of being a study participant: FEM- 
PrEP participants' explanations for overreporting adherence to the study pills and for the 
whereabouts of unused pills. J Acquir Immune Defic Syndr. 2015;68(5):578-584. 
65. 
Van Damme L, Corneli A, Ahmed K, et al. Preexposure prophylaxis for HIV infection 
among African women. N Engl J Med. 2012;367(5):411-422. 
66. 
van der Straten A, Brown ER, Marrazzo JM, et al. Divergent adherence estimates with 
pharmacokinetic and behavioural measures in the MTN-003 (VOICE) study. J Int AIDS 
Soc. 2016;19(1):20642. 
67. 
Baker Z, Javanbakht M, Mierzwa S, et al. Predictors of Over-Reporting HIV Pre-exposure 
Prophylaxis (PrEP) Adherence Among Young Men Who Have Sex With Men (YMSM) in 
Self-Reported Versus Biomarker Data. AIDS Behav. 2017. 
68. 
Agot K, Taylor D, Corneli AL, et al. Accuracy of Self-Report and Pill-Count Measures of 
Adherence in the FEM-PrEP Clinical Trial: Implications for Future HIV-Prevention Trials. 
AIDS Behav. 2015;19(5):743-751. 
69. 
Blumenthal J, Haubrich R. Pre-exposure prophylaxis for HIV infection: how antiretroviral 
pharmacology helps to monitor and improve adherence. Expert Opin Pharmacother. 
2013;14(13):1777-1785. 
70. 
Checchi KD, Huybrechts KF, Avorn J, Kesselheim AS. Electronic medication packaging 
devices and medication adherence: a systematic review. JAMA. 2014;312(12):1237-1247. 
71. 
Labovitz DL, Shafner L, Reyes Gil M, Virmani D, Hanina A. Using Artificial Intelligence to 
Reduce the Risk of Nonadherence in Patients on Anticoagulation Therapy. Stroke. 
2017;48(5):1416-1419. 
72. 
Bain EE, Shafner L, Walling DP, et al. Use of a Novel Artificial Intelligence Platform on 
Mobile Devices to Assess Dosing Compliance in a Phase 2 Clinical Trial in Subjects With 
Schizophrenia. JMIR Mhealth Uhealth. 2017;5(2):e18. 
73. 
Burke LE, Zheng Y, Ma Q, et al. The SMARTER pilot study: Testing feasibility of real-time 
feedback for dietary self-monitoring. Prev Med Rep. 2017;6:278-285. 
74. 
Margolis KL, Asche SE, Bergdall AR, et al. Effect of home blood pressure telemonitoring 
and pharmacist management on blood pressure control: a cluster randomized clinical trial. 
JAMA. 2013;310(1):46-56. 
75. 
Kerby TJ, Asche SE, Maciosek MV, O'Connor PJ, Sperl-Hillen JM, Margolis KL. 
Adherence to blood pressure telemonitoring in a cluster-randomized clinical trial. J Clin 
Hypertens (Greenwich). 2012;14(10):668-674. 
76. 
Frias J, Virdi N, Raja P, Kim Y, Savage G, Osterberg L. Effectiveness of Digital Medicines 
to Improve Clinical Outcomes in Patients with Uncontrolled Hypertension and Type 2 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 54 of 93 
 
 
 
 
1700 
1701 
1702 
1703 
1704 
1705 
1706 
1707 
1708 
1709 
1710 
1711 
1712 
1713 
1714 
1715 
1716 
1717 
1718 
1719 
1720 
1721 
1722 
1723 
1724 
1725 
1726 
1727 
1728 
1729 
1730 
1731 
1732 
1733 
1734 
1735 
1736 
1737 
1738 
1739 
1740 
1741 
1742 
1743 
1744 
1745 
1746 
1747 
1748 
Diabetes:  Prospective,  Open-Label,  Cluster-Randomized  Pilot  Clinical  Trial.  J  Med 
Internet Res. 2017;19(7):e246. 
77. 
Lind M, Polonsky W, Hirsch IB, et al. Continuous Glucose Monitoring vs Conventional 
Therapy for Glycemic Control in Adults With Type 1 Diabetes Treated With Multiple Daily 
Insulin Injections: The GOLD Randomized Clinical Trial. JAMA. 2017;317(4):379-387. 
78. 
Beck RW, Riddlesworth T, Ruedy K, et al. Effect of Continuous Glucose Monitoring on 
Glycemic Control in Adults With Type 1 Diabetes Using Insulin Injections: The DIAMOND 
Randomized Clinical Trial. JAMA. 2017;317(4):371-378. 
79. 
Givertz MM, Stevenson LW, Costanzo MR, et al. Pulmonary Artery Pressure-Guided 
Management of Patients With Heart Failure and Reduced Ejection Fraction. J Am Coll 
Cardiol. 2017;70(15):1875-1886. 
80. 
Patteet L, Morrens M, Maudens KE, Niemegeers P, Sabbe B, Neels H. Therapeutic drug 
monitoring of common antipsychotics. Ther Drug Monit. 2012;34(6):629-651. 
81. 
Schoretsanitis G, Paulzen M, Unterecker S, et al. TDM in psychiatry and neurology: A 
comprehensive summary of the consensus guidelines for therapeutic drug monitoring in 
neuropsychopharmacology, update 2017; a tool for clinicians(). World J Biol Psychiatry. 
2018;19(3):162-174. 
82. 
Hiemke C, Bergemann N, Clement HW, et al. Consensus Guidelines for Therapeutic Drug 
Monitoring in Neuropsychopharmacology: Update 2017. Pharmacopsychiatry. 2018;51(1- 
02):e1. 
83. 
Gupta P, Patel P, Strauch B, et al. Biochemical Screening for Nonadherence Is Associated 
With Blood Pressure Reduction  and Improvement in Adherence. Hypertension. 
2017;70(5):1042-1048. 
84. 
Helfer AG, Michely JA, Weber AA, Meyer MR, Maurer HH. Orbitrap technology for 
comprehensive metabolite-based liquid chromatographic-high resolution-tandem mass 
spectrometric urine drug screening - exemplified for cardiovascular drugs. Anal Chim Acta. 
2015;891:221-233. 
85. 
Patel P, Gupta PK, White CM, Stanley AG, Williams B, Tomaszewski M. Screening for 
non-adherence to antihypertensive treatment as a part of the diagnostic pathway to renal 
denervation. J Hum Hypertens. 2016;30(6):368-373. 
86. 
Lawson AJ, Shipman KE, George S, Dasgupta I. A Novel 'Dilute-and-Shoot' Liquid 
Chromatography-Tandem 
Mass 
Spectrometry 
Method 
for 
the 
Screening 
of 
Antihypertensive Drugs in Urine. J Anal Toxicol. 2016;40(1):17-27. 
87. 
Jamison RN, Martel MO, Huang CC, Jurcik D, Edwards RR. Efficacy of the Opioid 
Compliance Checklist to Monitor Chronic Pain Patients Receiving Opioid Therapy in 
Primary Care. J Pain. 2016;17(4):414-423. 
88. 
Standridge JB, Adams SM, Zotos AP. Urine drug screening: a valuable office procedure. 
Am Fam Physician. 2010;81(5):635-640. 
89. 
Oliva EM, Bowe T, Tavakoli S, et al. Development and applications of the Veterans Health 
Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid 
safety and prevent overdose and suicide. Psychol Serv. 2017;14(1):34-49. 
90. 
Group E-MS. Study protocol of the ESUB-MG cluster randomized trial: a pragmatic trial 
assessing the implementation of urine drug screening in general practice for 
buprenorphine maintained patients. BMC Fam Pract. 2016;17:24. 
91. 
van der Straten A, Montgomery ET, Musara P, et al. Disclosure of pharmacokinetic drug 
results to understand nonadherence. AIDS. 2015;29(16):2161-2171. 
92. 
Husnik MJ, Brown ER, Marzinke M, et al. Implementation of a Novel Adherence Monitoring 
Strategy in a Phase III, Blinded, Placebo-Controlled, HIV-1 Prevention Clinical Trial. J 
Acquir Immune Defic Syndr. 2017;76(3):330-337. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 55 of 93 
 
 
 
 
1749 
93. 
Mensch BS, Brown ER, Liu K, et al. Reporting of Adherence in the VOICE Trial: Did 
1750 
Disclosure  of  Product  Nonuse  Increase  at  the  Termination  Visit?  AIDS  Behav. 
1751 
2016;20(11):2654-2661. 
1752 
94. 
Musara P, Montgomery ET, Mgodi NM, et al. How Presentation of Drug Detection Results 
1753 
Changed Reports of Product Adherence in South Africa, Uganda and Zimbabwe. AIDS 
1754 
Behav. 2017. 
1755 
95. 
Koester KA, Liu A, Eden C, et al. Acceptability of drug detection monitoring among 
1756 
1757 
1758 
1759 
1760 
1761 
1762 
1763 
1764 
1765 
1766 
1767 
1768 
1769 
1770 
1771 
1772 
1773 
1774 
1775 
1776 
1777 
1778 
1779 
1780 
1781 
1782 
1783 
1784 
1785 
1786 
1787 
1788 
1789 
1790 
1791 
1792 
1793 
1794 
1795 
1796 
participants 
in 
an 
open-label 
pre-exposure 
prophylaxis 
study. 
AIDS 
Care. 
2015;27(10):1199-1204. 
96. 
Gandhi M, Bacchetti P, Spinelli IM, et al. Validation of a Urine Tenofovir Immunoassay for 
Adherence Monitoring to PrEP and ART and Establishing the Cut-Off for a Point-of-Care 
Test. J Acquir Immune Defic Syndr. 2019. 
97. 
Gandhi M, Wang G, King R, et al. Development and Validation of the First Point-of-Care 
Assay to Objectively Monitor Adherence to HIV Treatment and Prevention in Real-Time in 
Routine Settings. AIDS 2019 (in press). 
98. 
Anderson PL, Glidden DV, Liu A, et al. Emtricitabine-tenofovir concentrations and pre- 
exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med. 
2012;4(151):151ra125. 
99. 
Baeten JM, Celum C. Antiretroviral preexposure prophylaxis for HIV prevention. N Engl J 
Med. 2013;368(1):83-84. 
100. 
Anderson PL, Liu AY, Castillo-Mancilla JR, et al. Intracellular Tenofovir-Diphosphate and 
Emtricitabine-Triphosphate in Dried Blood Spots following Directly Observed Therapy. 
Antimicrob Agents Chemother. 2018;62(1). 
101. 
Liu A, Glidden DV, Anderson PL, et al. Patterns and correlates of PrEP drug detection 
among MSM and transgender women in the Global iPrEx Study. J Acquir Immune Defic 
Syndr. 2014;67(5):528-537. 
102. 
Donnell D, Baeten JM, Bumpus NN, et al. HIV protective efficacy and correlates of 
tenofovir blood concentrations in a clinical trial of PrEP for HIV prevention. J Acquir 
Immune Defic Syndr. 2014;66(3):340-348. 
103. 
Musinguzi N, Muganzi CD, Boum Y, 2nd, et al. Comparison of subjective and objective 
adherence measures for preexposure  prophylaxis against HIV  infection  among 
serodiscordant couples in East Africa. AIDS. 2016;30(7):1121-1129. 
104. 
Hosek SG, Landovitz RJ, Kapogiannis B, et al. Safety and Feasibility of Antiretroviral 
Preexposure Prophylaxis for Adolescent Men Who Have Sex With Men Aged 15 to 17 
Years in the United States. JAMA Pediatr. 2017;171(11):1063-1071. 
105. 
Glidden DV, Amico KR, Liu AY, et al. Symptoms, Side Effects and Adherence in the iPrEx 
Open-Label Extension. Clin Infect Dis. 2016;62(9):1172-1177. 
106. 
Grant RM, Anderson PL, McMahan V, et al. Uptake of pre-exposure prophylaxis, sexual 
practices, and HIV incidence in men and transgender women who have sex with men: a 
cohort study. Lancet Infect Dis. 2014;14(9):820-829. 
107. 
Landovitz RJ, Beymer M, Kofron R, et al. Plasma Tenofovir Levels to Support Adherence 
to TDF/FTC Preexposure Prophylaxis for HIV Prevention in MSM in Los Angeles, 
California. J Acquir Immune Defic Syndr. 2017;76(5):501-511. 
108. 
Van Damme L, Corneli A. Antiretroviral preexposure prophylaxis for HIV prevention. N 
Engl J Med. 2013;368(1):84. 
109. 
Musinguzi N, Muganzi CD, Boum Y, 2nd, et al. Comparison of subjective and objective 
adherence measures for preexposure  prophylaxis against HIV  infection  among 
serodiscordant couples in East Africa. AIDS. 2016;30(7):1121-1129. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 56 of 93 
 
 
 
 
1797 
1798 
1799 
1800 
1801 
1802 
1803 
1804 
1805 
1806 
1807 
1808 
1809 
1810 
1811 
1812 
1813 
1814 
1815 
1816 
1817 
1818 
1819 
1820 
1821 
1822 
1823 
1824 
1825 
1826 
1827 
1828 
1829 
1830 
1831 
1832 
1833 
1834 
1835 
1836 
1837 
1838 
1839 
1840 
1841 
1842 
1843 
1844 
1845 
110. 
Gross IM, Hosek S, Richards MH, Fernandez MI. Predictors and Profiles of Antiretroviral 
Therapy Adherence Among African American Adolescents and Young Adult Males Living 
with HIV. AIDS Patient Care STDS. 2016;30(7):324-338. 
111. 
Celum CL, Delany-Moretlwe S, Hosek S, et al. Risk Behavior, Perception and Reasons 
for PrEP among Young African Women in HPTN 082. Abstract #1049. 25th Conference 
on Retroviruses and Opportunistic Infections (CROI); March 4-7, 2018; Boston, MA. 
112. 
Rosen EP, Thompson CG, Bokhart MT, et al. Analysis of Antiretrovirals in Single Hair 
Strands for Evaluation of Drug Adherence with Infrared-Matrix-Assisted Laser Desorption 
Electrospray Ionization Mass Spectrometry Imaging. Anal Chem. 2016;88(2):1336-1344. 
113. 
Simiele M, Carcieri C, De Nicolo A, et al. A LC-MS method to quantify tenofovir urinary 
concentrations in treated patients. J Pharm Biomed Anal. 2015;114:8-11. 
114. 
Calcagno A, Cusato J, Marinaro L, et al. Clinical pharmacology of tenofovir clearance: a 
pharmacokinetic/pharmacogenetic study on plasma and urines. Pharmacogenomics J. 
2016;16(6):514-518. 
115. 
Lalley-Chareczko L, Clark D, Zuppa AF, et al. A case study of chewed Truvada((R)) for 
PrEP maintaining protective drug levels as measured by a novel urine tenofovir assay. 
Antivir Ther. 2017;22(7):639-641. 
116. 
DePriest AZ, Black DL, Robert TA. Immunoassay in healthcare testing applications. J 
Opioid Manag. 2015;11(1):13-25. 
117. 
Pecoraro V, Banfi G, Germagnoli L, Trenti T. A systematic evaluation of immunoassay 
point-of-care testing to define impact on patients' outcomes. Ann Clin Biochem. 
2017;54(4):420-431. 
118. 
Bang HI, Jang MA, Lee YW. Evaluation of the Triage TOX Drug Screen Assay for 
Detection of 11 Drugs of Abuse and Therapeutic Drugs. Ann Lab Med. 2017;37(6):522- 
525. 
119. 
Landovitz R. Personal communication. March 7, 2019. 
120. 
Hunt T, Lalley-Chareczko L, Daughtridge G, Swyryn M, Koenig H. Challenges to PrEP 
use and perceptions of urine tenofovir adherence monitoring reported by individuals on 
PrEP. AIDS Care. 2019:1-4. 
121. 
Lalley-Chareczko L, Clark D, Conyngham C, et al. Delivery of TDF/FTC for Pre-exposure 
Prophylaxis to Prevent HIV-1 Acquisition in Young Adult Men Who Have Sex With Men 
and Transgender Women of Color Using a Urine Adherence Assay. J Acquir Immune 
Defic Syndr. 2018;79(2):173-178. 
122. 
Baeten JM, Palanee-Phillips T, Brown ER, et al. Use of a Vaginal Ring Containing 
Dapivirine for HIV-1 Prevention in Women. N Engl J Med. 2016;375(22):2121-2132. 
123. 
Celum C, Mgodi N, Bekker LG, Hosek S, Donnell D, Anderson P, Dye B, Pathak S, Agyei 
Y, Fogel J, Marzinke M, Makgamathe K, Kassim S, Mukaka S, Noble H, Adeyeye A, 
Delany-Moretlwe S. PrEP use in young African women in HPTN 082: Effect of drug level 
feedback. IAS 2019, 21-24 July, Mexico City, MX. 
124. 
Naderi SH, Bestwick JP, Wald DS. Adherence to drugs that prevent cardiovascular 
disease: meta-analysis on 376,162 patients. Am J Med. 2012;125(9):882-887 e881. 
125. 
Correa NB, de Faria AP, Ritter AM, et al. A practical approach for measurement of 
antihypertensive medication adherence in patients with resistant hypertension. J Am Soc 
Hypertens. 2016;10(6):510-516 e511. 
126. 
Marrazzo JM, Scholes D. Acceptability of urine-based screening for Chlamydia 
trachomatis in asymptomatic young men: a systematic review. Sex Transm Dis. 
2008;35(11 Suppl):S28-33. 
127. 
Hadland SE, Levy S. Objective Testing: Urine and Other Drug Tests. Child Adolesc 
Psychiatr Clin N Am. 2016;25(3):549-565. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 57 of 93 
 
 
 
 
1846 
1847 
1848 
1849 
1850 
1851 
1852 
1853 
1854 
1855 
1856 
1857 
1858 
1859 
1860 
1861 
1862 
1863 
1864 
1865 
1866 
1867 
1868 
1869 
1870 
1871 
1872 
1873 
1874 
1875 
1876 
1877 
1878 
1879 
1880 
1881 
1882 
1883 
1884 
1885 
1886 
1887 
1888 
1889 
1890 
1891 
1892 
1893 
128. 
Drain PK, Kubiak RW, Siriprakaisil O, et al. Urine Tenofovir Concentrations Correlate with 
Plasma and 
Relates to 
TDF 
Adherence: A 
Randomized 
Directly-observed 
Pharmacokinetic Trial (TARGET Study). Clin Infect Dis. 2019. 
129. 
Kearney BP, Ramanathan S, Cheng AK, Ebrahimi R, Shah J. Systemic and renal 
pharmacokinetics of adefovir and tenofovir upon coadministration. Journal of Clinical 
Pharmacology. 2005;45(8):935-940. 
130. 
Podsadecki TJ, Vrijens BC, Tousset EP, Rode RA, Hanna GJ. "White coat compliance" 
limits the reliability of therapeutic drug monitoring in HIV-1-infected patients. HIV clinical 
trials. 2008;9(4):238-246. 
131. 
Anderson PL. Pharmacologic Measures of Adherence and Relationship to Drug 
Response. Conference of Retroviruses and Opportunistic Infections (CROI); Oral 
symposium; Boston, MA; February 22–25. 2016; Abstract 96. 
132. 
Musinguzi N, Muwonge T, Thomas K, Baeten JM, Bangsberg DR, Haberer JE. Does 
Adherence Change When No One is Looking? Comparing Announced and Unannounced 
Tenofovir Levels in a PrEP Trial. AIDS Behav. 2016;20(11):2639-2643. 
133. 
Raymond JF, Bucek A, Dolezal C, et al. Use of Unannounced Telephone Pill Counts to 
Measure Medication Adherence Among Adolescents and Young Adults Living With 
Perinatal HIV Infection. J Pediatr Psychol. 2017;42(9):1006-1015. 
134. 
Pence BW, Gaynes BN, Adams JL, et al. The effect of antidepressant treatment on HIV 
and depression outcomes: results from a randomized trial. AIDS. 2015;29(15):1975-1986. 
135. 
Fredericksen R, Feldman BJ, Brown T, et al. Unannounced telephone-based pill counts: 
a valid and feasible method for monitoring adherence. AIDS Behav. 2014;18(12):2265- 
2273. 
136. 
Macdonald V, Verster A, Baggaley R. A call for differentiated approaches to delivering HIV 
services to key populations. J Int AIDS Soc. 2017;20(Suppl 4):21658. 
137. 
UNAIDS. 
Global 
AIDS 
update. 
2016;  
http://www.unaids.org/en/resources/documents/2016/Global-AIDS-update-2016. 
Accessed June 3, 2016. 
138. 
UNAIDS 
Global 
AIDS 
Update 
2019.  
https://www.unaids.org/en/resources/documents/2019/2019-global-AIDS-update. 
139. 
Anderson SJ, Cherutich P, Kilonzo N, et al. Maximising the effect of combination HIV 
prevention through prioritisation of the people and places in greatest need: a modelling 
study. Lancet. 2014;384(9939):249-256. 
140. 
Abbas UL, Glaubius R, Mubayi A, Hood G, Mellors JW. Antiretroviral therapy and pre- 
exposure prophylaxis: combined impact on HIV transmission and drug resistance in South 
Africa. J Infect Dis. 2013;208(2):224-234. 
141. 
Celum CL, Delany-Moretlwe S, Baeten JM, et al. HIV pre-exposure prophylaxis for 
adolescent girls and young women in Africa: from efficacy trials to delivery. J Int AIDS 
Soc. 2019;22 Suppl 4:e25298. 
142. 
Celum C, Mgodi N, Bekker L, et al. PrEP adherence and effect of drug level feedback 
among young African women in HPTN 082 (Oral Abstract # TUAC0301). International 
AIDS Society (IAS) Conference on HIV Science; 2019; Mexico City, Mexico. 
143. 
Bekker LG, Roux S, Sebastien E, et al. Daily and non-daily pre-exposure prophylaxis in 
African women (HPTN 067/ADAPT Cape Town Trial): a randomised, open-label, phase 2 
trial. Lancet HIV. 2018;5(2):e68-e78. 
144. 
Spinelli MA, Glidden DV, Anderson PL, et al. Brief Report: Short-Term Adherence Marker 
to PrEP Predicts Future Nonretention in a Large PrEP Demo Project: Implications for 
Point-of-Care Adherence Testing. J Acquir Immune Defic Syndr. 2019;81(2):158-162. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 58 of 93 
 
 
 
 
1894 
1895 
1896 
1897 
1898 
1899 
1900 
1901 
1902 
1903 
1904 
1905 
1906 
1907 
1908 
1909 
1910 
1911 
1912 
1913 
1914 
1915 
1916 
1917 
1918 
1919 
1920 
1921 
1922 
1923 
1924 
1925 
1926 
1927 
1928 
1929 
1930 
1931 
1932 
1933 
1934 
1935 
1936 
1937 
1938 
1939 
1940 
1941 
1942 
1943 
145. 
Myer L, Dunning L, Lesosky M, et al. Frequency of Viremic Episodes in HIV-Infected 
Women Initiating Antiretroviral Therapy During Pregnancy: A Cohort Study. Clin Infect Dis. 
2017;64(4):422-427. 
146. 
Myer L, Redd AD, Mukonda E, et al. ART detection and resistance during viraemic 
episodes in pregnancy and breastfeeding. Conference on Retroviruses and Opportunistic 
Infections. 2018; Mar 4-7; Boston, MA. Abstract #140. 
147. 
Nachega JB, Sam-Agudu NA, Mofenson LM, Schechter M, Mellors JW. Achieving Viral 
Suppression in 90% of People Living with HIV on Antiretroviral Therapy in Low- and 
Middle-Income Countries: Progress, Challenges, and Opportunities. Clin Infect Dis. 
2018;Jan 8. doi: 10.1093/cid/ciy008. [Epub ahead of print] 
148. 
Nel A, Bekker LG, Bukusi E, et al. Safety, Acceptability and Adherence of Dapivirine 
Vaginal Ring in a Microbicide Clinical Trial Conducted in Multiple Countries in Sub- 
Saharan Africa. PLoS One. 2016;11(3):e0147743. 
149. 
Nel A, Van Niekerk N, Van Baelen B, Rosenberg Z. HIV Incidence and Adherence in 
DREAM: An Open-Label Trial of Dapivirine Vaginal Ring. Abstract #144LB. 25th 
Conference on Retroviruses and Opportunistic Infections (CROI); March 4-7, 2018; 
Boston, MA. 
150. 
Brown E, Philips-Palanee T, Marzinke M, et al. Residual dapivirine ring levels indicate 
higher adherence to vaginal ring is associated with HIV-1 protection. AIDS 2016, Durban, 
South Africa, July 18-22, 2016; Abstract TUAC0105LB 
151. 
Baeten J, Palanee-Phillips T, Mgodi N, et al. HIgh Uptake and Reduced HIV-1 Incidence 
in an Open-Label Trial of the Dapivirine Ring. Abstract #143LB. 25th Conference on 
Retroviruses and Opportunistic Infections (CROI); March 4-7, 2018; Boston, MA. 
152. 
Spence P, Nel A, van Niekerk N, Derrick T, Wilder S, Devlin B. Post-use assay of vaginal 
rings (VRs) as a potential measure of clinical trial adherence. J Pharm Biomed Anal. 
2016;125:94-100. 
153. 
Findlay JW, Smith WC, Lee JW, et al. Validation of immunoassays for bioanalysis: a 
pharmaceutical industry perspective. J Pharm Biomed Anal. 2000;21(6):1249-1273. 
154. 
Patel K, Nagel M, Wesolowski M, et al. Evaluation of a Urine-Based Rapid Molecular 
Diagnostic Test with Potential to be used at Point-of-Care for Pulmonary Tuberculosis: 
Cape Town Cohort. J Mol Diagn. 2017. 
155. 
Trabattoni E, Le V, Pilmis B, et al. Implementation of Alere i Influenza A & B point of care 
test for the diagnosis of influenza in an emergency department. Am J Emerg Med. 2017. 
156. 
Chang M, Steinmetzer K, Raugi DN, et al. Detection and differentiation of HIV-2 using the 
point-of-care Alere q HIV-1/2 Detect nucleic acid test. J Clin Virol. 2017;97:22-25. 
157. 
Murray TY, Sherman GG, Nakwa F, et al. Field Evaluation of Performance of Alere and 
Cepheid Qualitative HIV Assays for Pediatric Point-of-Care Testing in an Academic 
Hospital in Soweto, South Africa. J Clin Microbiol. 2017;55(11):3227-3235. 
158. 
van Tienen C, Rugebregt S, Scherbeijn S, Gotz H, GeurtsvanKessel C. The performance 
of the Alere HIV combo point-of-care test on stored serum samples; useful for detection 
of early HIV-1 infections? Sex Transm Infect. 2017. 
159. 
Jani IV, Meggi B, Vubil A, et al. Evaluation of the Whole-Blood Alere Q NAT Point-of-Care 
RNA Assay for HIV-1 Viral Load Monitoring in a Primary Health Care Setting in 
Mozambique. J Clin Microbiol. 2016;54(8):2104-2108. 
160. 
Hsiao NY, Dunning L, Kroon M, Myer L. Laboratory Evaluation of the Alere q Point-of- 
Care System for Early Infant HIV Diagnosis. PLoS One. 2016;11(3):e0152672. 
161. 
Delefortrie Q, Schatt P, Grimmelprez A, et al. Comparison of the Liaison(R) Calprotectin 
kit with a well established point of care test (Quantum Blue - Buhlmann-Alere(R)) in terms 
of analytical performances and ability to detect relapses amongst a Crohn population in 
follow-up. Clin Biochem. 2016;49(3):268-273. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 59 of 93 
 
 
 
 
1944 
1945 
1946 
1947 
1948 
1949 
1950 
1951 
1952 
1953 
1954 
1955 
1956 
1957 
1958 
1959 
1960 
1961 
1962 
1963 
1964 
1965 
1966 
1967 
1968 
1969 
1970 
1971 
1972 
1973 
1974 
1975 
1976 
1977 
1978 
1979 
1980 
1981 
1982 
1983 
1984 
1985 
1986 
1987 
1988 
1989 
1990 
1991 
1992 
1993 
162. 
Khezri BS, Carlsson L, Larsson A. Evaluation of the Alere NT-proBNP Test for Point of 
Care Testing. J Clin Lab Anal. 2016;30(4):290-292. 
163. 
Helmersson-Karlqvist J, Karlsson B, Fredriksson A, Larsson A. Evaluation of the Alere D- 
dimer test for point of care testing. J Thromb Thrombolysis. 2014;38(2):250-252. 
164. 
Larson B, Schnippel K, Ndibongo B, Long L, Fox MP, Rosen S. How to estimate the cost 
of point-of-care CD4 testing in program settings: an example using the Alere Pima 
Analyzer in South Africa. PLoS One. 2012;7(4):e35444. 
165. 
The enzyme-linked immunosorbent assay 
(ELISA). Bull World Health Organ. 
1976;54(2):129-139. 
166. 
Gandhi M, Rodriguez W, Spinelli M, et al. Development of a Point-of-Care Immunoassay 
for Detecting Tenofovir in Urine as a Real-Time Metric of PrEP Adherence (oral abstract). 
13th International Conference on HIV Treatment and Prevention Adherence 2018. IAPAC 
meeting; June 8-10, 2018, Miami, Florida. 
167. 
Cressey TR, Siriprakaisil O, Klinbuayaem V, et al. A randomized clinical pharmacokinetic 
trial of Tenofovir in blood, plasma and urine in adults with perfect, moderate and low PrEP 
adherence: the TARGET study. BMC Infect Dis. 2017;17(1):496. 
168. 
Agresti A., Kateri M. (2011) Categorical Data Analysis. In: Lovric M. (eds) International 
Encyclopedia of Statistical Science. Springer, Berlin, Heidelberg 
169. 
Gerona R, Wen A, Chin AT, et al. Quantifying Isoniazid Levels in Small Hair Samples: A 
Novel Method for Assessing Adherence during the Treatment of Latent and Active 
Tuberculosis. PLoS One. 2016;11(5):e0155887. 
170. 
Gerona R, Wen A, Koss C, Bacchetti P, Gandhi M, Metcalfe J. A multi-analyte panel for 
non-invasive pharmacokinetic monitoring of second-line anti-tuberculosis drugs. Int J 
Tuberc Lung Dis. 2016;20(7):991-992. 
171. 
Metcalfe J, Gerona R, Wen A, Bacchetti P, Gandhi M. An LC-MS/MS-based method to 
analyze the anti-tuberculosis drug bedaquiline in hair. Int J Tuberc Lung Dis. 
2017;21(9):1069-1070. 
172. 
Mave V, Kinikar A, Kagal A, et al. Isoniazid concentrations in hair and plasma area-under- 
the-curve exposure among children with tuberculosis. PLoS One. 2017;12(12):e0189101. 
173. 
Tabb ZJ, Mmbaga BT, Gandhi M, et al. Antiretroviral drug concentrations in hair are 
associated with virologic outcomes among young people living with HIV in Tanzania. 
AIDS. 2018;Feb 12 [Epub ahead of print]. 
174. 
Colby D, Kroon E, Sacdalan C, et al. Acquisition of multidrug resistant HIV-1 infection in 
a patient taking preexposure prophylaxis. Clinical Infectious Diseases 2018 (in press). 
175. 
Thaden JT, Gandhi M, Okochi H, Hurt CB, McKellar MS. Seroconversion On PrEP: A 
Case Report with Segmental Hair Analysis for Timed Adherence Determination. AIDS 
2018 (in press). 
176. 
DiFrancesco R, Tooley K, Rosenkranz SL, et al. Clinical pharmacology quality assurance 
for HIV and related infectious diseases research. Clin Pharmacol Ther. 2013;93(6):479- 
482. 
177. 
National AIDS & STI Control Programme. Guidelines on the use of antiretroviral drugs for 
treating and preventing HIV infection in Kenya. In: Ministry of Health, Kenya; 2016. 
178. 
Amico KR, Fisher WA, Cornman DH, et al. Visual analog scale of ART adherence: 
association with 3-day self-report and adherence barriers. J Acquir Immune Defic Syndr. 
2006;42(4):455-459. 
179. 
Celum CL, Mgodi N, Bekker LG, et al. Adherence 3 months after PrEP Initation among 
Young African Women in HPTN 082. Conference on Retroviruses and Opportunistic 
Infections (CROI), Seattle, Washingon, March 4-7 2019 (abstract 995). 
180. 
Dubov A, Altice FL, Fraenkel L. An Information-Motivation-Behavioral Skills Model of PrEP 
Uptake. AIDS Behav. 2018. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 60 of 93 
 
 
 
 
1994 
1995 
1996 
1997 
1998 
1999 
2000 
2001 
2002 
2003 
2004 
2005 
2006 
2007 
2008 
2009 
2010 
2011 
2012 
2013 
2014 
2015 
2016 
2017 
2018 
2019 
2020 
2021 
2022 
2023 
2024 
2025 
2026 
2027 
2028 
2029 
2030 
2031 
2032 
2033 
2034 
2035 
2036 
2037 
2038 
2039 
2040 
2041 
2042 
181. 
Norton WE, Amico KR, Fisher WA, et al. Information-motivation-behavioral skills barriers 
associated with intentional versus unintentional ARV non-adherence behavior among 
HIV+ patients in clinical care. AIDS Care. 2010;22(8):979-987. 
182. 
Rongkavilit C, Naar-King S, Kaljee LM, et al. Applying the information-motivation- 
behavioral skills model in medication adherence among Thai youth living with HIV: a 
qualitative study. AIDS Patient Care STDS. 2010;24(12):787-794. 
183. 
Peltzer K, Friend-du Preez N, Ramlagan S, Anderson J. Antiretroviral treatment 
adherence among HIV patients in KwaZulu-Natal, South Africa. BMC Public Health. 
2010;10:111. 
184. 
Ware NC, Wyatt MA, Bangsberg DR. Examining theoretic models of adherence for validity 
in resource-limited settings. A heuristic approach. J Acquir Immune Defic Syndr. 2006;43 
Suppl 1:S18-22. 
185. 
Starks TJ, Millar BM, Lassiter JM, Parsons JT. Preintervention Profiles of Information, 
Motivational, and Behavioral Self-Efficacy for Methamphetamine Use and HIV Medication 
Adherence Among Gay and Bisexual Men. AIDS Patient Care STDS. 2017;31(2):78-86. 
186. 
Konkle-Parker DJ, Amico KR, McKinney VE. Effects of an intervention addressing 
information, motivation, and behavioral skills on HIV care adherence in a southern clinic 
cohort. AIDS Care. 2014;26(6):674-683. 
187. 
Fisher JD, Amico KR, Fisher WA, Harman JJ. The information-motivation-behavioral skills 
model of antiretroviral adherence and its applications. Curr HIV/AIDS Rep. 2008;5(4):193- 
203. 
188. 
Corneli AL, Deese J, Wang M, et al. FEM-PrEP: adherence patterns and factors 
associated with adherence to a daily oral study product for pre-exposure prophylaxis. J 
Acquir Immune Defic Syndr. 2014;66(3):324-331. 
189. 
Amico KR, Stirratt MJ. Adherence to preexposure prophylaxis: current, emerging, and 
anticipated bases of evidence. Clin Infect Dis. 2014;59 Suppl 1:S55-60. 
190. 
Ngure K, Heffron R, Curran K, et al. I Knew I Would Be Safer. Experiences of Kenyan HIV 
Serodiscordant Couples Soon After Pre-Exposure Prophylaxis (PrEP) Initiation. AIDS 
Patient Care STDS. 2016;30(2):78-83. 
191. 
Ngure K, Heffron R, Mugo N, et al. Feasibility and acceptability of HIV self-testing among 
pre-exposure prophylaxis users in Kenya. J Int AIDS Soc. 2017;20(1):21234. 
192. 
Ngure K, Kimemia G, Dew K, et al. Delivering safer conception services to HIV 
serodiscordant couples in Kenya: perspectives from healthcare providers and HIV 
serodiscordant couples. J Int AIDS Soc. 2017;20(Suppl 1):21309. 
193. 
Ngure K, Mugo N, Celum C, et al. A qualitative study of barriers to consistent condom use 
among HIV-1 serodiscordant couples in Kenya. AIDS Care. 2012;24(4):509-516. 
194. 
Ngure K, Trinidad SB, Beima-Sofie K, et al. The role of male partners in women's 
participation in research during pregnancy: a case study from the partners demonstration 
project. Reprod Health. 2017;14(Suppl 3):160. 
195. 
Ngure K, Vusha S, Mugo N, et al. "I never thought that it would happen ... " Experiences 
of HIV seroconverters among HIV-discordant partnerships in a prospective HIV prevention 
study in Kenya. AIDS Care. 2016;28(12):1586-1589. 
196. 
Ngure K, Baeten JM, Mugo N, et al. My intention was a child but I was very afraid: fertility 
intentions and HIV risk perceptions among HIV-serodiscordant couples experiencing 
pregnancy in Kenya. AIDS Care. 2014;26(10):1283-1287. 
197. 
Glaser BG, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative 
Research.  Chicago, IL: Aldine Publishing Co, 1967. 
198. 
Charmaz K. Constructing Grounded Theory: A Practical Guide Through Qualitative 
Analysis. Sage Publications, Thousand Oaks, CA, 2006. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 61 of 93 
 
 
 
 
2043 
2044 
2045 
2046 
2047 
2048 
2049 
2050 
2051 
2052 
2053 
2054 
2055 
199. 
Molina JM, Capitant C, Spire B, et al. On-Demand Preexposure Prophylaxis in Men at 
High Risk for HIV-1 Infection. N Engl J Med. 2015;373(23):2237-2246. 
200. 
Antoni G, Tremblay C, Charreau I, et al. On-demand PrEP with TDF/FTC remains highly 
effective among MSM with infrequent sexual intercourse: a sub-study of the ANRS 
IPERGAY trial. International AIDS Conference July 2017; Paris, France. 
201. 
Iman N, Carpenter C, Mayer K, Fisher A, Stein M, Danforth S. Hierarchical pattern of 
mucosal candida infections in HIV-seropositive women. American Journal of Medicine. 
1990;89:142-146. 
202. 
Baeten JM, Donnell D, Mugo NR, et al. Single-agent tenofovir versus combination 
emtricitabine plus tenofovir for pre-exposure prophylaxis for HIV-1 acquisition: an update 
of data from a randomised, double-blind, phase 3 trial. Lancet Infect Dis. 
2014;14(11):1055-1064. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 62 of 93 
 
 
 
 
2056 
2057 
2058 
2059 
2060 
2061 
2062 
2063 
2064 
2065 
2066 
 
Appendix I:  Enrollment Informed Consent for Clients 
Informed Consent for Participants 
Study Title:  Point-of-care Urine Monitoring of Adherence (PUMA): Testing a Real-Time 
Urine Assay of Tenofovir in PrEP 
 
Protocol version 6.0 
November 11, 2021 
 
INVESTIGATORS 
 
Investigator 
Title 
Institution 
Telephone 
Kenneth Ngure 
MPH, PhD 
Jomo Kenyatta University of 
Agriculture and Technology 
067 2222561 
Nelly Mugo 
MBChB, 
MMed, MPH 
Kenya 
Medical 
Research 
Institute 
020 2736744 
Monica Gandhi 
MD 
University of California, San 
Francisco 
001 415-260-6709 
Jared Baeten 
MD, PhD 
University of Washington 
001 206-520-3808 
2067 
2068 
2069 
2070 
2071 
2072 
2073 
2074 
2075 
2076 
2077 
2078 
2079 
2080 
2081 
2082 
2083 
2084 
2085 
2086 
 
24 HOUR EMERGENCY TELEPHONE NUMBER:  Tel: 0736464299 
 
STUDY SUMMARY 
Pre-exposure prophylaxis (PrEP) with oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) 
prevents HIV infection if taken every day. However, previous PrEP trials demonstrated that many 
women in Africa at risk for HIV who are not in couples (with an HIV-positive partner) need help 
remembering to take the pill every day. Also, patients on PrEP may not always report their 
adherence to the pill accurately and “objective” measures of adherence (where PrEP drug levels 
were measured) are far superior to self-report. We also know that telling a patient his/her PrEP 
drug levels can be motivating for better adherence in the future. The usual ways to measure PrEP 
drug levels are very complicated and require expensive equipment and trained laboratory staff. 
However, our group has now developed a new and innovative way to measure adherence to PrEP 
using a drug level (specifically tenofovir, TFV) via an antibody-based test (“immunoassay”) in 
urine that can be performed cheaply at the point-of-care (POC) by any healthcare worker (like a 
urine pregnancy test). A few drops of the patient’s urine is dropped into the test and tells the 
provider “yes” or “no” if the patient has been taking PrEP recently. This protocol is for a pilot trial 
where we randomize women on PrEP at Thika Clinic to having information from the investigational 
urine assay delivered to them (or not delivered to them in the control group) in order to provide 
feedback on adherence from this test in a supportive, motivating manner and enhance adherence 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 63 of 93 
 
 
 
 
2087 
2088 
2089 
2090 
2091 
2092 
2093 
2094 
2095 
2096 
2097 
2098 
2099 
2100 
2101 
2102 
2103 
2104 
2105 
2106 
2107 
2108 
2109 
2110 
2111 
2112 
2113 
2114 
2115 
2116 
2117 
2118 
2119 
2120 
2121 
2122 
2123 
2124 
2125 
2126 
counseling. Women on PreP who are not in a couple with someone who has HIV (called a 
“serodiscordant couple”, where one person has HIV and the other does not) will be enrolled. The 
pilot trial will assess if the urine tool is acceptable to participants, feasible for the clinic to perform, 
and if providing feedback on adherence from the urine tool to the participant increases future 
adherence to PrEP (measured by  a longer-term  adherence metric  with hair  levels). Good 
adherence to PrEP will eventually lead to fewer HIV infections worldwide. 
 
INFORMED CONSENT 
We are asking you to participate in a research study. This study is sponsored by the Kenya 
Medical Research Institute, the University of California, San Francisco (UCSF), the University of 
Washington, and funded by the National Institutes of Health (USA). If you decide to take part in 
this study you will be asked to sign this consent form or make your mark in front of a witness. We 
will give you a copy of this form. This consent form might contain some words that are unfamiliar 
to you. Please ask us to explain anything you may not understand. A description of this clinical 
trial will be available on http://www.ClinicalTrials.gov. NCT03935464 
 
CLINICAL TRIALS WEBSITE 
A description of this clinical trial will be available on http://www.ClinicalTrials.gov. 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. 
 
PURPOSE OF THE STUDY 
Studies have shown that the medications used to treat HIV infection can also be used to prevent 
passing the virus. This concept is called pre-exposure prophylaxis, or PrEP. These studies have 
also learned that PrEP is safe (meaning that it does not produce significant health problems in 
persons who take them) when taken by HIV-uninfected men and women. You have now initiated 
PrEP to help protect you from HIV infection. 
 
Many studies have shown that PrEP has to be taken regularly for it to be effective. It can 
sometimes be difficult to take PrEP regularly and support is provided at every visit to ask about 
adherence (or regular PrEP taking) when you are on PrEP. Studies have shown it can be useful 
for people to see a test that shows that the PrEP drug has entered your system after you take it. 
We have now developed a new assay that tests your urine to show you that you have taken PrEP 
recently – the test shows up as “positive” if you have taken PrEP recently. The purpose of this 
study is to assess the acceptability of this test to measure PrEP drug-taking at your visit. Through 
a method similar to tossing a coin, you will be assigned to a group that: (1) comes to the clinic 
every three months and gets PrEP by your health provider in the usual way; (2) comes to the 
clinic every three months and gets both PrEP and your urine tested for PrEP drug levels 
(specifically tenofovir) by a health provider. If you are in the second group, you will be shown your 
PrEP drug level test and you and your provider can talk about how to help you take the drug every 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 64 of 93 
 
 
 
 
2127 
2128 
2129 
2130 
2131 
2132 
2133 
2134 
2135 
2136 
2137 
2138 
2139 
2140 
2141 
2142 
2143 
2144 
2145 
2146 
2147 
2148 
2149 
2150 
2151 
2152 
2153 
2154 
2155 
2156 
2157 
2158 
2159 
2160 
2161 
2162 
2163 
2164 
2165 
day if you need any support. Approximately,  100 - 120participants who are using PrEP will be 
enrolled in this study and will be in the study for up to 12 months. 
 
YOUR PARTICIPATION IS VOLUNTARY (YOU MAY DECIDE NOT TO BE IN THE STUDY, OR 
TO LEAVE THE STUDY AT ANY TIME) 
Before you learn about this study, it is important that you know the following: 
• 
You do not have to be in this study if you do not want to. 
• 
You may decide not to be in the study, or to being in the study at any time, without losing 
your regular medical care. 
• 
If you decide not to be in the study, you can still join other research studies later, if available 
and you qualify. 
• 
You may be asked about joining other studies. Due to the time commitment from being in 
this study, you may not be eligible to join this study if you are in other studies. If you do not 
agree to join these other studies, you may still take part in this study. 
• 
If you decide to enroll in this study, after your enrollment visit you will be in the study up to 
12 months. 
• 
The answers you provide to survey questions will remain confidential and identifying 
information about you will not be shared. 
 
ENROLLMENT PROCEDURES 
The enrollment tests for this study will include questions and tests done from samples of blood 
and urine. The enrollment procedures will include the following: 
 
• 
The study staff will ask you where you live and other questions about you and your sexual 
practices. 
• 
We will counsel you about HIV and other infections passed during sex, and how to avoid 
these infections including the use of condoms and other contraceptives. We will provide you 
with free condoms at your screening visit as well as at each visit throughout the study. 
• 
Even if you have recently been tested for HIV, we will need to repeat the HIV test today as 
part of the study and part of the routine procedures to be on PrEP. 
• 
We will ask you questions about your medical history, you will have a physical examination, 
and you will undergo an assessment for sexually transmitted infections (STIs) 
• 
You will be asked to give us permission to obtain a urine sample for laboratory tests 
(although you will receive the results of the tenofovir urine assay only if the coin flip puts you 
in the arm of the study where you are given feedback on the test) 
• 
You will have blood drawn which is use for both clinical care and for research tests in this 
study 
• 
Additionally, along with urine, we will ask for a small hair sample (about 50-100 strands, less 
than you lose from your head each day). We will test for PrEP drug levels in the hair sample 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 65 of 93 
 
 
 
 
2166 
2167 
2168 
2169 
2170 
2171 
2172 
2173 
2174 
2175 
2176 
2177 
2178 
2179 
2180 
2181 
2182 
2183 
2184 
2185 
2186 
2187 
2188 
2189 
2190 
2191 
2192 
2193 
2194 
2195 
2196 
2197 
2198 
2199 
2200 
2201 
2202 
2203 
at the end of the study. Your hair will not be stored in any way but destroyed after testing for 
the PrEP drug levels 
• 
In this research study, you will come to the clinic every 3 months which is standard for 
anyone on PrEP in Kenya. 
• 
Additionally, you will continue to be offered PrEP to be taken as one pill once each day to 
prevent HIV infection. The PrEP medication will be provided by this clinic, free of charge. 
• 
If you agree to take part in the study, you will also have a physical examination. During the 
examination, the study nurse will check for any signs of infection or other illnesses. If you 
have an active illness that requires medical attention or treatment, then you will be referred 
to receive the care you need. 
 
FOLLOW-UP PROCEDURES 
• 
You will be asked questions about your health and medical history, including whether you 
have any clinical symptoms, your sexual practices and other behaviors, and your feelings 
about taking medications for HIV prevention. 
• 
Risk counseling is part of every PrEP visit. We encourage you to talk with study staff about 
ways to avoid HIV and other infections passed during sex. You will be offered condoms. 
• 
Get medical care or referrals for medical care and other services if you need them. 
• 
Give updated information on where you live and how to keep in contact with you. The study 
staff will use this information to remind you of scheduled visits. If you miss a visit, the study 
staff will try to contact you by telephone. They may try to reach you through the contact 
people that you list. If they talk to these people, they will not tell them why they are trying to 
reach you. 
• 
Women will be asked whether they think they may be pregnant. A urine pregnancy test may 
be done if unsure about being pregnant. Women who are pregnant will not be excluded from 
the study. 
• 
If your HIV test is negative you can continue to receive PrEP medication. The pharmacy 
staff will provide you with new bottles with pills to last until your next visit. 
• 
You will be asked to give us permission to obtain a urine sample for laboratory tests 
(although you will receive the results of the tenofovir urine assay only if the coin flip puts you 
in the arm of the study where you are given feedback on the test) 
• 
You will have blood drawn which is use for both clinical care (for instance, to check that your 
kidneys are fine) and for research tests in this study 
• 
Additionally, along with urine, we will ask for a small hair sample (about 50-100 strands, less 
than you lose from your head each day). We will test for PrEP drug levels in the hair sample 
at the end of the study. Your hair will not be stored in any way but destroyed after testing for 
the PrEP drug levels. 
At any time in the study: 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 66 of 93 
 
 
 
 
2204 
2205 
2206 
2207 
2208 
2209 
2210 
2211 
2212 
2213 
2214 
2215 
2216 
2217 
2218 
2219 
2220 
2221 
2222 
2223 
2224 
2225 
2226 
2227 
2228 
2229 
2230 
2231 
2232 
2233 
2234 
2235 
2236 
2237 
2238 
2239 
2240 
2241 
2242 
2243 
 
• 
If you or the study staff thinks you may have any health problems, you may need to undergo 
a physical exam and may need to provide blood or other samples for testing. 
• 
You can have extra counseling and testing for HIV if needed between scheduled visits, 
either with your partner or by yourself. 
• 
If you decide to leave the study before your last scheduled study visit, we will ask you to 
have a final study visit with all the exams and tests listed above. 
 
Long interviews 
At the end of the study for those of you who were in the arm of the study where you got feedback 
on the urine test, the staff may invite you to answer more questions about the urine test and how 
you liked it. Some interviews will be done individually and some will be done as a group session 
with other people who are participating in the study. At any point during interviews, participants 
(women taking PrEP) can decide to not answer any question they are uncomfortable answering 
and may choose to leave the interview or focus group sessions at any time. The interviews will 
be recorded and transcribed, with notes taken during the session, to make sure we remember 
everything you tell us (removing any mention of names or any identifying information). This sound 
recording will be stored in a secure lockable cabinet. 
 
Pregnancy 
If you become pregnant during this study you will be referred for antenatal care and continue in 
the study. 
 
IF YOU BECOME HIV INFECTED 
During the course of the study we will provide you with condoms, PrEP, and other materials to 
help prevent getting HIV. However, it is possible to become HIV infected on PrEP although this is 
very rare if people take their HIV medications regularly. 
 
If you have a positive HIV test during the study: 
• 
The study staff will talk with you about this test result and what this means for you. 
• 
You will stop the taking the PrEP medication 
• 
You will then be referred to an HIV provider who will confirm the positive test result and start 
HIV care. You will not be in this urine test study anymore. 
 
SPECIMEN STORAGE AND USE OF SAMPLES AND DATA FOR FUTURE STUDIES 
The hair samples will be shipped to UCSF for testing of tenofovir levels and then destroyed. The 
urine samples will be tested at the Thika Clinic and then destroyed (if you are in the part of the 
study where you will see your urine test, that urine test will be destroyed at the end of the study). 
Some of the blood taken at study visits will beretained and stored in Thika clinic for future research 
by us and by other researchers. We will use these samples only for research related to analyzing 
PrEP medication levels in blood samples. A total of 60 milliliters (4 tablespoons) of blood will be 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 67 of 93 
 
 
 
 
2244 
2245 
2246 
2247 
2248 
2249 
2250 
2251 
2252 
2253 
2254 
2255 
2256 
2257 
2258 
2259 
2260 
2261 
2262 
2263 
2264 
2265 
2266 
2267 
2268 
2269 
2270 
2271 
2272 
2273 
2274 
2275 
2276 
2277 
2278 
2279 
2280 
2281 
2282 
collected over the course of entire study from you. Before your samples leave the clinic, they will 
be assigned a code and your name will not be on them. Your name will be linked to the code only 
at this clinic and only for five years after the study is completed. After that time, the link between 
your name and the code on your data and samples will be destroyed. An Institutional Review 
Board or Independent Ethics Committee, which watches over the safety and rights of research 
participants, must approve any future research studies using your data and samples. If you agree 
to store your samples, we will keep them for as long as sample remains that can be used for 
future research. If you do not want to have your samples saved for future research, you can still 
be in this study and your samples will be destroyed once testing for this study is completed. If you 
agree to store your samples now, but change your mind before the end of the study, let the study 
staff know and we will make sure that your samples do not get stored for future research. We will 
not sell your data or samples. Tests done on your samples may lead to a new invention or 
discovery. We have no plans to share any money or other benefits resulting from this invention 
or discovery with you. Future research from this study will never involve genetic sequencing 
(called “whole genome sequencing”). 
 
PROCEDURE and RISKS 
PROCEDURE 
This study will involve looking at a new urine assay for adherence and blood draws for research 
(and also clinical care). Please note that this urine assay is being tested during this study for its 
utility and is therefore still considered an “investigational” test. 
 
RISKS 
 
You may feel discomfort or pain when your blood is drawn. You may feel dizzy or faint. You may 
have a bruise where the needle goes into your arm. There is a small risk of bleeding or infection 
after the blood draw. You may feel slight pulling at your scalp when your hair sample is cut. 
 
The study staff will make every effort to protect your privacy and confidentiality during the entire 
study period. However, it is possible that others may learn of your participation and as a result, 
may treat you unfairly or discriminate against you. For example, you could have problems getting 
or keeping a job, or being accepted by your family or community. 
 
You may become embarrassed, worried, or anxious when talking about your sexual practices, 
ways to protect against HIV and other infections transmitted during sex, and your HIV test results 
in the course of usual clinical care on PrEP. You may become worried or anxious while waiting 
for your test results. If you become infected with HIV, knowing this could make you worried or 
anxious. Trained counselors will help you deal with any feelings or questions you may have. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 68 of 93 
 
 
 
 
2283 
2284 
2285 
2286 
2287 
2288 
2289 
2290 
2291 
2292 
2293 
2294 
2295 
2296 
2297 
2298 
2299 
2300 
2301 
2302 
2303 
2304 
2305 
2306 
2307 
2308 
2309 
2310 
2311 
2312 
2313 
2314 
2315 
2316 
2317 
2318 
2319 
2320 
2321 
2322 
You may feel embarrassed, worried, or anxious when talking about your experiences with PrEP 
adherence testing using the urine assay. Counselors are available through the study to help you 
deal with any feelings or questions you have. The study staff will make every effort to protect your 
privacy and confidentiality during the interviews or group discussions. During group discussions, 
all participants will be reminded for the need for confidentiality, however, group discussions will 
not be fully confidential since all members of the group discussion will hear the discussions. 
For more information about risks of this study, ask the study provider. 
BENEFITS 
Since this is a pilot study, there are no direct benefits anticipated from the study intervention. 
PrEP adherence testing using this new urine assay has the potential of improving adherence to 
PrEP, which will then lower people’s risk of becoming infected with HIV. Your participation in this 
study will contribute to understanding about PrEP adherence testing and counseling in Kenya, 
which may help others in the future. 
 
NEW FINDINGS 
You will be told any new information learned during this study that is important for your health or 
might cause you to change your mind about staying in the study. You will be told when the results 
of the study may be available, and how to learn about them. 
 
COSTS TO YOU 
There is no cost to you for being in this study. Treatments available to you from the study will be 
given free of charge. 
 
REASONS WHY YOU MAY BE WITHDRAWN FROM THE STUDY 
You may be removed from the study without your consent for the following reasons: 
 
• The study is stopped or canceled. 
• The study staff feel that staying in the study would be harmful to you. 
 
ALTERNATIVES TO PARTICIPATION 
You can always receive PrEP through the government program even if you are not in this urine 
assay study. There may be other studies going on here or in the community that you may be 
eligible for. If you wish, we will tell you about other studies that we know about. 
 
REIMBURSEMENT 
You will receive a transportation reimbursement and an additional 200 Kenyan shillings for your 
time and effort. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 69 of 93 
 
 
 
 
2323 
2324 
2325 
2326 
2327 
2328 
2329 
2330 
2331 
2332 
2333 
2334 
2335 
2336 
2337 
2338 
2339 
2340 
2341 
2342 
2343 
2344 
2345 
2346 
2347 
2348 
2349 
2350 
2351 
2352 
2353 
2354 
2355 
2356 
2357 
2358 
2359 
2360 
2361 
2362 
 
CONFIDENTIALITY 
Efforts will be made to keep your personal information confidential. However, absolute 
confidentiality cannot be guaranteed. Your personal information may be disclosed if required by 
law. Any sample from you or information about you will be identified only by code. The link 
between your name and code will be kept in a secure location at the clinic only. Any publication 
of this study will not use your name or identify you personally. 
 
Your study records may be reviewed by study staff and representatives of: 
 
• 
The University of California, San Francisco 
• 
The University of Washington, including study monitors 
• 
The United States National Institutes of Health 
• 
Kenya Medical Research Institute (KEMRI) 
• 
US Office for Human Research Protections. 
• 
Pharmacy and Poisons Board (PPB-ECCT) 
• 
National Commission for Science, Technology and Innovation (NACOSTI) 
 
In addition, other local, US, and international regulatory entities may review participant records. 
This research is covered by a Certificate of Confidentiality from the National Institutes of Health. 
This means that the researchers cannot release or use information, documents, or samples that 
may identify you in any action or suit unless you say it is okay. They also cannot provide them as 
evidence unless you have agreed. This protection includes federal, state, or local civil, criminal, 
administrative, legislative, or other proceedings. The Certificate of Confidentiality does not stop 
you from willingly releasing information about your involvement in this research. It also does not 
prevent you from having access to your own information. 
 
RESEARCH-RELATED INJURY 
The study staff will monitor your health while you are in this study. If you have any health problems 
between visits, or if you have a medical emergency that requires immediate care, please contact 
the study staff. 
 
If you are injured from participating in this study, you will be offered care at the study clinic, free 
of charge. It is important that you tell the members of the team of researchers at this clinic if you 
feel that you have been injured because of taking part in this study. There is not a program of 
monetary compensation through this institution. If you require medical care that the study clinic 
cannot provide, the study doctors will refer you to the appropriate services or organizations that 
can provide care for the injury. You do not give up any legal rights by signing this consent form. 
 
The U.S. National Institutes of Health (NIH) does not have a mechanism to provide direct 
compensation for research related injury. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 70 of 93 
 
 
 
 
2363 
2364 
2365 
2366 
2367 
2368 
2369 
2370 
2371 
2372 
2373 
2374 
2375 
2376 
2377 
 
 
PROBLEMS OR QUESTIONS 
If you ever have any questions about this study, you should contact Dr. Kenneth Ngure at the 
Thika Study clinic at Tel 06721305/2222561. For research related injury, please call the 24-hour 
emergency number: 0736464299. If you have questions about your rights as a participant, contact 
the secretary of the KEMRI Scientific and Ethics Review Unit, P.O. Box 54840-00200, Nairobi, 
Telephone number 020272-2541, 0722205901, 0733-400003. Email address: seru@kemri.org. 
 
STATEMENT OF CONSENT AND SIGNATURES 
I have read this form or had it read to me. I have discussed the information with study staff. My 
questions have been answered. I understand that my decision whether or not to take part in the 
study is voluntary. I understand that if I decide to join the study I may withdraw at any time. By 
signing this form, I do not give up any rights that I have as a research participant. 
 
 
Participant Name (print) 
 
Participant Signature/Thumbprint 
 
Date 
 
Study Staff Conducting Study 
Consent Discussion (print) 
 
Staff Signature 
 
Date 
 
Witness Name (print) 
 
Witness Signature 
 
Date 
2378 
2379 
2380 
2381 
 
SPECIMEN STORAGE AND USE OF YOUR DATA AND SAMPLES FOR FUTURE STUDIES 
Please initial and date one option: 
2382 
  
 
2383 
2384 
  
 
2385 
2386 
I DO agree to store my data and samples for future research into PrEP adherence 
 
I DO NOT agree to store my data and samples for future research into PrEP 
adherence 
2387 
2388 
2389 
With regard to shipment of my specimens/information to UCSF, in USA (Please initial and date 
one option) 
2390 
  
 
2391 
I DO agree to allow my biological samples to be shipped to UCSF for specialized 
tests (tenofovir levels in hair) and used for future research tests 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 71 of 93 
 
 
 
 
2392 
2393 
 
I DO NOT agree to allow my biological samples to be shipped to UCSF for 
2394 
2395 
2396 
2397 
2398 
specialized tests and used for future research tests 
 
With regard to giving permission for audio recording during long interviews (Please initial and date 
one option) 
2399 
  
 
2400 
I DO agree to audio recording during the qualitative interviews 
2401 
 
I DO NOT agree to audio recording during the qualitative interviews 
2402 
2403 
2404 
2405 
With  regard  to  giving  permission  to  have  my  fingerprint  taken  for  purposes  of  biometric 
identification (Please initial and date one option) 
2406 
 
I DO agree to have my finger print taken 
2407 
2408 
 
I DO NOT agree to have my fingerprint taken 
2409 
 
 
Participant Name (print) 
 
Participant Signature/Thumbprint 
 
Date 
 
Study Staff Conducting Study 
Consent Discussion (print) 
 
Staff Signature 
 
Date 
 
Witness Name (print) 
 
Witness Signature 
 
Date 
2410 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 72 of 93 
 
 
 
 
2411 
2412 
2413 
2414 
2415 
2416 
2417 
2418 
2419 
Appendix II:  CONSENT FORM FOR INTERVIEWS OF HEALTH CARE PROVIDERS 
 
Study Title:  Point-of-care Urine Monitoring of Adherence (PUMA): Testing a Real-Time 
Urine Assay of Tenofovir in PrEP 
 
Protocol version 6.0 
November 11, 2021 
 
INVESTIGATORS 
 
Investigator 
Title 
Institution 
Telephone 
Kenneth Ngure 
MPH, PhD 
Jomo Kenyatta University of 
Agriculture and Technology 
067 22561 
Nelly Mugo 
MBChB, 
MMed, MPH 
Kenya 
Medical 
Research 
Institute 
020 2736744 
Monica Gandhi 
MD 
University of California, San 
Francisco 
001 415-260-6709 
Jared Baeten 
MD, PhD 
University of Washington 
001 206-520-3808 
2420 
2421 
2422 
2423 
2424 
2425 
2426 
2427 
2428 
2429 
2430 
2431 
2432 
2433 
2434 
2435 
2436 
2437 
2438 
2439 
2440 
2441 
 
24 HOUR EMERGENCY TELEPHONE NUMBER:  Tel: 0736464299 
 
Study overview 
Researchers at the University of California, San Francisco and the Kenya Medical Research 
Institute (KEMRI) are conducting a study to understand what health care providers think about a 
new test to monitor PrEP adherence during clinic visits. You are being asked to take part in this 
study because you are a health care provider who works with PrEP clients at the Thika clinic and 
you contributed to the pilot trial where women on PrEP were provided with urine tenofovir 
adherence assay results. Please note that the utility of this new urine assay is being examined in 
this study and the urine assay is still considered an investigational tool. Researchers from KEMRI 
are now conducting in-depth interviews with PrEP providers at the Thika clinic at the end of the 
PUMA trial in order to understand their perceptions of this new test. 
 
The study interviewer will explain the study to you. Research studies include only people who 
choose to take part. You are not required to take part in the research study. However, your 
participation is appreciated as it will contribute to the development of an intervention that may 
providers help their patients adhere to PrEP. Please take your time to make your decision about 
participating. 
 
 
Why is this study being done? 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 73 of 93 
 
 
 
 
2442 
2443 
2444 
2445 
2446 
2447 
2448 
2449 
2450 
2451 
2452 
2453 
2454 
2455 
2456 
2457 
2458 
2459 
2460 
2461 
2462 
2463 
2464 
2465 
2466 
2467 
2468 
2469 
2470 
2471 
2472 
2473 
2474 
2475 
2476 
2477 
2478 
2479 
2480 
2481 
The purpose of this study is to understand what providers think about a new point-of-care test 
that can be used to monitor PrEP adherence during clinic visits. We are interested in learning 
what providers think of this test after seeing it being administered during the PUMA pilot trial, how 
they would use this test in their practice, and whether they think it would help clients improve their 
PrEP adherence. This information will be used to address providers’ concerns and preferences 
as this test is rolled out. 
 
How many people will take part in this study? 
Approximately 8 health care providers at the Thika clinic, will participate in this study. 
 
Your participation is voluntary 
Before you learn about the questions you will be asked in this study, it is important that you know 
the following: 
• 
You do not have to be in this study if you do not want to. 
• 
If you choose not to be in this study, it will not affect your work at Thika clinic. 
• 
The answers you provide will remain confidential and identifying information about you will 
not be shared. 
• 
You may decide not to answer the questions, or to stop the questions at any time, without 
penalty. 
• 
If you decide not to answer the questions, you can still provide clinical guidance to our 
research studies later, if available and if you qualify. 
 
What will happen if I take part in this research study? 
IN-DEPTH INTERVIEW: 
• 
The interview should last no more than 30-60 minutes and will take place in a private 
space at the Thika clinic. 
• 
The interviewer will audio record the interview and take notes to make sure we remember 
and understand everything you tell us. After the interview, someone will transcribe the 
recorded interview and remove any mention of names or other identifying information. The 
recordings will be stored under locked conditions accordance to the DAIDS Policy on 
Storage and Retention of Clinical Research Records policy, following the strictest of any 
applicable laws, regulations, policies or other requirements for record retention. 
• 
The interviewer will show you a picture of the new test that was used to measure PrEP 
adherence in the study and remind you how it can be used to provide women with 
feedback on their adherence during their regular clinic visits. You will have seen this test 
during the study. The test tells you if a patient took her PrEP recently (yes/no). The 
interviewer will ask for your thoughts about this test. Specifically, we are interested in 
knowing what you think about the test itself, whether you thought it helped clients on PrEP 
adhere to their medication, and how you might use it in your own practice in the future. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 74 of 93 
 
 
 
 
2482 
2483 
2484 
2485 
2486 
2487 
2488 
2489 
2490 
2491 
2492 
2493 
2494 
2495 
2496 
2497 
2498 
2499 
2500 
2501 
2502 
2503 
2504 
2505 
2506 
2507 
2508 
2509 
2510 
2511 
2512 
2513 
2514 
2515 
2516 
2517 
2518 
2519 
2520 
2521 
 
What side effects or risks can I expect from being in the study? 
You may feel embarrassed, worried, or anxious when talking about your opinions about this new 
test to the study staff. The study  staff will make every  effort to protect your  privacy  and 
confidentiality while you are answering the questions 
 
What are the benefits to taking part in this study? 
There will be no direct benefit to you from participating in this study. However, the information you 
provide will help inform the development of an intervention that may improve clients’ adherence 
to PrEP and help them protect their health. 
 
What are the costs of taking part in this study? 
There are no costs associated with participation in this study and there is no payment for 
participation in the study. 
 
Will information about me be kept private? 
We will do our best to make sure that the personal information gathered for this study is kept 
private. The KEMRI study team will conduct the interviews. The researchers will keep information 
about you as confidential as possible, but complete confidentiality cannot be guaranteed. On rare 
occasions, your personal information may be disclosed if required by law. Also, sometimes the 
law makes us report certain things to appropriate authorities, especially if we learn that you plan 
to hurt yourself or others. In that case, we have to do what the law says. While our questions may 
not ask you specifically about those things, please keep this is mind as you choose what to share 
with us. 
 
We will share data collected during this study in aggregate form only, and any data shared will 
not include your name or identifying information. Your answers will have no impact on your work 
at Thika clinic. All of the information you provide will be kept in a locked cabinet (for papers) or a 
password-protected and encrypted computer folder (for electronic files). Your name will not 
appear on any interview materials. Instead, we will keep track of your information with a unique 
numbered code. The link between your name and this code will be destroyed approximately five 
years after the study is completed. The transcript of your interview/group discussion will not have 
your name on it and will be used only in analysis together with all the other transcripts. 
 
Your responses to the questions may be reviewed by study staff and representatives of: 
• 
The University of California, San Francisco 
• 
The University of Washington, including study monitors 
• 
The United States National Institutes of Health 
• 
Kenya Medical Research Institute (KEMRI) 
• 
US Office for Human Research Protections. 
• 
Pharmacy and Poisons Board (PPB-ECCT) 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 75 of 93 
 
 
 
 
2522 
2523 
2524 
2525 
2526 
2527 
2528 
2529 
2530 
2531 
2532 
2533 
2534 
2535 
2536 
2537 
2538 
2539 
2540 
2541 
2542 
2543 
 
• 
National Commission for Science, Technology and Innovation (NACOSTI) 
 
We plan to apply the lessons we learn from the interviews to the development of an intervention 
to improve PrEP adherence among clients at risk for HIV. We will also share the lessons we learn 
at conferences and meetings, as well as in written articles. We will report results about the group 
as a whole and never about you individually. Your identifying information or the identifying 
information of any other participant will never appear in any of these materials. 
 
Who can answer my questions about this study? 
If you ever have any questions about this study, you should contact Kenneth Ngure at the Thika 
Partners in Health, Research and Development clinic at Tel 06721305/2222561. 
 
If you have questions about your rights as a research participant, you should contact the Secretary 
of the KEMRI Ethics Review Committee, P. O. Box 54840-00200, Nairobi. Telephone number: 
020272-2541, 0717719477, 0722-205901, 0733-400003. Email address: seru@kemri.org 
 
STATEMENT OF CONSENT AND SIGNATURES 
I have read this consent form or had it read to me. I have discussed the information with study 
staff. My questions have been answered. I understand that my decision whether or not to take 
part in this study is voluntary. I understand that if I decide to answer the questions, I may withdraw 
at any time. By signing this form, I do not give up any rights that I have as a research participant. 
 
 
Participant Name (print) 
 
Participant Signature/Thumbprint 
 
Date 
 
Study Staff Conducting Study 
Consent Discussion (print) 
 
Staff Signature 
 
Date 
 
Witness Name (print) 
 
Witness Signature 
 
Date 
2544 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 76 of 93 
 
 
 
 
2545 
2546 
2547 
2548 
2549 
2550 
2551 
2552 
2553 
PERMISSION FOR AUDIO RECORDING 
(Please check the appropriate response below) 
 
□ I give permission for the long interview and group discussions that I will participate in to be 
recorded. 
 
□ I do NOT give permission for the long interview and group discussions that I will participate in 
to be recorded. 
 
 
Participant Name (print) 
 
Participant Signature/Thumbprint 
 
Date 
 
Study Staff Conducting Study 
Consent Discussion (print) 
 
Staff Signature 
 
Date 
 
Witness Name (print) 
 
Witness Signature 
 
Date 
2554 
2555 
2556 
2557 
2558 
2559 
2560 
2561 
2562 
2563 
2564 
2565 
2566 
2567 
2568 
2569 
2570 
2571 
2572 
 
 
KENYA MEDICAL RESEARCH INSTITUTE ETHICS REVIEW COMMITTEE 
P.O.BOX 54840-00200 
NAIROBI 
TELEPHONE 2722541 
 
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO HUMAN SUBJECTS DIVISION 
3333 CALIFORNIA ST., SUITE 315 
SAN FRANCISCO, CA, 94143 
BOX 0962 
TELEPHONE 011-1-415-476-1814 
 
PERMISSION FOR AUDIO RECORDING 
(Please check the appropriate response below) 
 
□ I give permission for the long interview and group discussions that I will participate in to be 
recorded. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 77 of 93 
 
 
 
 
2573 
2574 
2575 
□ I do NOT give permission for the long interview and group discussions that I will participate in 
to be recorded. 
 
 
Participant Name (print) 
 
Participant Signature/Thumbprint 
 
Date 
 
Study Staff Conducting Study 
Consent Discussion (print) 
 
Staff Signature 
 
Date 
 
Witness Name (print) 
 
Witness Signature 
 
Date 
2576 
2577 
2578 
2579 
2580 
2581 
2582 
2583 
2584 
2585 
2586 
2587 
2588 
 
 
KENYA MEDICAL RESEARCH INSTITUTE ETHICS REVIEW COMMITTEE 
P.O.BOX 54840-00200 
NAIROBI 
TELEPHONE 2722541 
 
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO HUMAN SUBJECTS DIVISION 
3333 CALIFORNIA ST., SUITE 315 
SAN FRANCISCO, CA, 94143 
BOX 0962 
TELEPHONE 011-1-415-476-1814 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 78 of 93 
 
 
 
 
2589 
2590 
2591 
2592 
2593 
2594 
2595 
2596 
2597 
2598 
2599 
2600 
2601 
2602 
2603 
2604 
2605 
2606 
2607 
2608 
2609 
2610 
2611 
2612 
2613 
2614 
2615 
2616 
2617 
2618 
2619 
2620 
 
Appendix III: QUALITATIVE GUIDE FOR IN-DEPTH INTERVIEWS FOR WOMEN 
 
Qualitative component: Exploring HIV adherence testing experiences among HIV-1 uninfected 
women. 
 
Target group: Participants enrolled in the intervention arm of the PUMA Study at Thika. 
 
Objectives: 
1. Learn opinions of HIV-uninfected participants on PrEP adherence testing. 
2. Gain  an  understanding  of  how  participants  performed  the  PrEP  adherence  testing 
including any challenges experienced. 
 
Approach: 
Focus group discussions will consist of HIV-uninfected women not in serodiscordant relationships; 
Four focus group discussions of 5-10 participants each will be conducted. 
 
INTRODUCTION 
 
What kinds of PrEP adherence tests are you aware of? 
Probe: 
• 
Clinic based PrEP adherence testing? 
• 
How is PrEP adherence testing performed? 
 
Topic 1: Acceptability 
What do you think about Urine testing for PrEP drugs? What are the advantages? What 
are the disadvantages? 
Possible probes: 
• 
What would be the advantages or benefits? 
• 
What would be the challenges or disadvantages? 
• 
Are there any reasons that would make you not perform a test? 
• 
Possible concerns with urine testing for PrEP drugs? 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 79 of 93 
 
 
 
 
2621 
2622 
2623 
2624 
2625 
2626 
2627 
2628 
2629 
2630 
2631 
2632 
2633 
2634 
2635 
2636 
2637 
2638 
2639 
2640 
2641 
2642 
2643 
2644 
2645 
2646 
2647 
2648 
 
Topic 2: Usability 
How was your experience with urine drug-level testing? 
Possible probes: 
• 
What challenges did you experience in performing urine drug-level testing? 
• 
Have you shared your results with others? 
• 
Have you used the 24 hour helpline? 
 
Topic 3: PrEP adherence testing preferences 
What would you prefer urine drug testing at home or clinic-based testing? 
Possible probes: 
• 
What would you prefer, adherence testing at home or clinic based testing? What 
are your reasons? 
• 
What are the things that would make you prefer PrEP adherence testing? 
• 
How did you find the every 3 month testing schedule? 
 
Topic 4: Closing discussion 
Possible probes: 
• 
When people test for adherence, what are some ways to help them have better 
PrEP adherence? 
• 
Probe about helping via phone calls, packaging inserts that could provide helpful 
messages, what kind of preparation should people have before they have 
adherence testing to prepare for the results, etc. 
• 
What would make it easier for you or others to perform adherence testing? 
• 
Do you like the test that says yes/no on adherence or would you prefer a test that 
gives you an idea of high, moderate or low adherence? 
• 
Any other thoughts or suggestions on adherence testing that you would like to 
share? 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 80 of 93 
 
 
 
 
2649 
2650 
2651 
2652 
2653 
2654 
2655 
2656 
2657 
2658 
2659 
2660 
2661 
2662 
2663 
2664 
2665 
2666 
2667 
2668 
2669 
2670 
2671 
2672 
2673 
2674 
2675 
2676 
2677 
2678 
2679 
2680 
2681 
2682 
2683 
2684 
2685 
2686 
2687 
2688 
 
Appendix IV:  Focus Group Discussion Guide for Clients 
Introduction 
Discussion leader will introduce herself and the moderator [and anyone else present from the 
study team] to the group. 
 
Thank you for coming today to participate in this focus group. We have asked you to participate 
in this discussion because you are currently taking PrEP for the prevention of HIV. We’re 
conducting this focus group to get your input on a point-of-care test that measures a person’s 
adherence to PrEP by measuring the amount of tenofovir found in the person’s blood, urine, or 
saliva. Tenofovir is one of the drugs found in your PrEP. The goal of this focus group is to 
understand your feelings about this type of test. 
 
We really appreciate you taking the time to talk with us today. The focus group should take about 
1 hour. We are going to audio record the conversation in order to capture all the details and 
summarize them later on. For that reason, please do not use your name, other people’s names, 
or organization names, including clinic names, to ensure we maintain the confidentiality of the 
focus group. We will also be taking notes during the discussion to use as a reference. After we’ve 
transcribed the focus group discussion, we will delete the audio recording. Please remember that 
participation in the focus group is completely voluntary, and you may decide to not answer any 
question as you wish, and you can leave at any time. 
 
Please feel free to think out loud and answer questions as honestly as possible. I encourage all 
of you to participate in the conversation. And remember that there are no right or wrong answers. 
 
Are there any questions before we begin? 
Do I have everyone’s permission to record this discussion? [If everyone answers yes, turn on 
audio recorder.] 
Does anyone not want to participate? If you would like to leave, please do so at this time. 
 
Discussion Guide 
 
 
 
1. Has your provider ever talked to you about the need to take your PrEP regularly? Do you 
ever bring it up? How are those conversations? 
2. What’s it like to answer questions about taking PrEP? Do you think your answers are pretty 
accurate? What are some reasons why you might not tell the truth? 
3. What are some of the strategies your provider uses in the clinic to monitor or assess your 
adherence to your PrEP? What are the strengths and weaknesses  of the existing 
strategies? 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 81 of 93 
 
 
 
 
2689 
2690 
2691 
2692 
2693 
2694 
2695 
2696 
2697 
2698 
2699 
2700 
2701 
4. What happens in the clinic when your provider learns that your adherence is less than 
perfect? 
 
Now, I’d like to give you a little more information about the test that we’ll be discussing today. 
[Project image of test strips onto screen] This is a simple screening test that would measure 
whether a person has enough tenofovir in their system that would meet the threshold for protection 
from acquiring HIV. The test would just indicate a positive or negative result, indicating that a 
person is adherent to their medication or not adherent to their medication. The test strips shown 
on the screen are an example of what the test would look like. They would be used on urine 
samples, and results would appear within 5 minutes. Does everyone understand how this test 
would work before we continue? 
[Ensure the group understands how the test works before moving on.] 
 
2702 
5. What are your initial thoughts about a test like this? 
2703 
6. Would you want to use this test if it were optional and free at your clinic? Would you want 
2704 
it to be part of your care? If yes, how would it fit in with care for you or others on PrEP? 
2705 
What if your doctor asked you to use it? Some of you had this testing performed and how 
2706 
did you like it or feel about it? 
2707 
7. How would you feel about using this test on your own (for example, in your home or 
2708 
another private location) instead of using it in the clinic with your provider present? Think 
2709 
about the differences between the two in terms of convenience, privacy, client-provider 
2710 
relationship, effects on your mental health, etc. If you were to use this test on your own, 
2711 
under what circumstances would you use it (e.g., when and why would you use it?)? 
2712 
8. Do you think there would be any benefits or negative effects if your doctor tested you for 
2713 
adherence as a part of routine care? If yes, what are they and why? 
2714 
9. Do you think there are some types of clients who might benefit more from this type of test? 
2715 
If yes, what types? Are there some types of clients who might be negatively affected by 
2716 
being tested for adherence? If yes, what types? 
2717 
2718 
2719 
2720 
2721 
2722 
2723 
2724 
2725 
2726 
2727 
2728 
10. If you’re interested in being tested for adherence, how frequently would you want to be 
tested? Why? 
11. If you were tested and your results showed that you had low adherence, how would it 
affect your pill-taking behavior and your relationship with your provider? How do you think 
it would affect your mental health? 
[Probe: Think about both the short-term and the long-term effects on your behavior and 
your relationship.] 
12. Overall, what are your final thoughts on being tested for adherence? 
13. Do you like this yes/no test for adherence or would you want a test that tells you if you 
have had high, medium or low adherence? 
14. Do you have any other concerns or thoughts about this test that we have not yet 
discussed? 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 82 of 93 
 
 
 
 
2729 
2730 
2731 
2732 
2733 
2734 
2735 
 
Closure 
 
 
 
Discussion leader will close the focus group around 55 to 60 minutes after it began. She will ask 
for any further points from the participants that were not discussed. 
 
Finally, the discussion leader will conclude the focus group and thank the participants for their 
time. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 83 of 93 
 
 
 
 
2736 
2737 
2738 
2739 
2740 
2741 
2742 
2743 
2744 
2745 
2746 
2747 
2748 
2749 
2750 
2751 
2752 
2753 
2754 
2755 
2756 
2757 
2758 
2759 
2760 
2761 
2762 
2763 
2764 
2765 
2766 
2767 
2768 
2769 
2770 
2771 
2772 
2773 
2774 
2775 
 
Appendix V: Qualitative Guide for In-Depth Interviews (IDIs) for Providers 
 
Introduction 
 
 
[~5 minutes] 
 
Interviewer will introduce herself to the provider. 
 
Thank you for coming today to participate in this interview. We have asked you to participate in 
this discussion because you provide care and treatment services for individuals who are at higher 
risk for acquiring HIV. We’re conducting this interview to get your input on a point-of-care test that 
we used in the PUMA study. As you know, this test can measure a person’s adherence to pre- 
exposure prophylaxis (PrEP) by measuring whether tenofovir is found in the person’s urine. The 
goal of this interview is to understand your feelings about this test and to discover potential 
applications and use cases for this test. 
 
We really appreciate you taking the time to talk with us today. The interview should take about 
30-60 minutes. We are going to audio record the conversation in order to capture all the details 
and summarize them later on. For that reason, please do not use your name, other people’s 
names, or organization names to ensure we maintain the confidentiality of the interview. We will 
also be taking notes during the discussion to use as a reference. After we’ve transcribed the 
interview, we will delete the audio recording. Please remember that participation in the interview 
is completely voluntary, and you may decide to not answer any question as you wish, and you 
can leave at any time. 
 
Please feel free to think out loud and answer questions as honestly as possible. And remember 
that there are no right or wrong answers. 
 
Are there any questions before we begin? 
Do I have your permission to record this discussion? [If provider answers yes, turn on audio 
recorder.] 
 
Discussion Guide 
 
 
1. To begin, please tell me about your role in the PrEP program. 
Probes: 
a. What do you do on a day-to-day basis? 
b. How do you interact with patients on PrEP? 
2. How long have you been in this role? (years/months) 
3. How do you monitor or assess PrEP adherence at Thika clinic? If at all? 
4. How easy or difficult is PrEP adherence for your PrEP clients? 
a. Would you say non-adherence is common? 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 84 of 93 
 
 
 
 
2776 
2777 
2778 
2779 
2780 
2781 
2782 
2783 
2784 
2785 
2786 
2787 
2788 
2789 
2790 
2791 
 
 
 
 
 
 
2792 
2793 
2794 
2795 
2796 
2797 
2798 
2799 
2800 
2801 
2802 
2803 
2804 
2805 
2806 
2807 
2808 
5. How comfortable are women in reporting adherence challenges with PrEP to you or other 
providers in the clinic? Please explain. 
6. Does the clinic provide counsel or support around PrEP adherence- trying to take PrEP every 
day? Please tell me about that. 
a. Please give some examples of the support services are provided. (For example, do 
providers spend time counselling patients on the importance of taking PrEP every day? 
If so, how often is this done?) 
b. What do you think about the quality of support provided to PrEP clients to improve 
their adherence? Is it helpful? Are clients responsive to this support? 
 
II. 
Present the urine assay strip picture 
[Interviewer to bring out the rapid strip urine picture below and show it to the provider] 
Interviewer: This is a new test that was developed that can be used to measure people’s 
adherence to PrEP during their clinic visit. We used this in the PUMA study and half of the clients 
received counseling based on the results of this test and half of the clients received standard-of 
care counseling. 
 
 
You saw that all the client has to do was to provide a urine sample, and the provider then dips 
this strip into the urine sample (up to the test line indicated) and the strip will tell the provider the 
results at that moment (within about 5 minutes). 
The strip tells the provider whether the client has taken their PrEP drugs (yes/no) in the last 4 
days. A colored line at the top of the test when dipped into urine means no (has NOT taken PrEP 
drugs in the last 3 days) and no colored line means YES (has taken PrEP drugs in the past 3 
days). 
• 
If the test shows no colored line, it means that person has taken PrEP in the past 4 days 
(YES) 
• 
If the test shows a colored line, this means that the person hasn’t been able to take their 
PrEP pills for a while (NO) 
• 
Please note that this is the opposite of other rapid tests that we are familiar with, such as 
pregnancy tests. 
 
III. Elicit feedback about the test 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 85 of 93 
 
 
 
 
2809 
2810 
2811 
2812 
2813 
2814 
2815 
2816 
2817 
2818 
2819 
2820 
2821 
2822 
2823 
2824 
2825 
2826 
2827 
2828 
2829 
2830 
2831 
2832 
2833 
2834 
2835 
2836 
2837 
2838 
2839 
2840 
2841 
 
General thoughts on clarity of test: Now I’m going to ask you about what you thought about 
this new test. 
1. What were you first thoughts about this test? 
a. What do you like about it? 
b. What do you dislike about it? 
2. How clear were the results to you? Or was it confusing? What makes these results clear or 
confusing? 
 
Applications of PrEP Adherence Testing 
1. Do you think there would be any benefits or negative effects of using this test on your HIV- 
negative clients? If yes, what are they and why? 
2. Would you consider using this test on all of your HIV-negative clients or just a subset? If 
just a subset, which ones and why? [Probe: If you think the test would be best for only a 
subset, how would you minimize stigmatization of that subset of clients?] 
3. For the HIV-negative clients whom you would use this test on, how frequently would you 
test them and why? 
4. If you received test results for an HIV-negative client that showed less than perfect PrEP 
adherence, how would you use the results to support your clinical decision making? Would 
you do anything differently than what you are currently doing for poor adherence? Why? 
 
Feasibility and Acceptability of PrEP Adherence Testing 
5. Do you believe implementing this type of test would be feasible in your clinic or in another 
setting? Why or why not? 
6. Do you think providers need training to deliver these test results? Why/why not? 
7. How do you think this test could be implemented? That is, who would do the test? Where 
would the test be done? Who would give the results? When would the results be given? 
 
IV. Conclusion 
8. We have reached the end of our interview. Do you have any other concerns or thoughts 
about this test that we have not yet discussed? Is there anything that we didn’t ask that 
we should have asked? 
 
[Interviewer]: Thank you again for participating in our study! 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 86 of 93 
 
 
 
 
2842 
2843 
2844 
2845 
2846 
2847 
2848 
2849 
2850 
2851 
2852 
2853 
2854 
2855 
2856 
2857 
2858 
2859 
2860 
2861 
2862 
2863 
2864 
2865 
2866 
2867 
2868 
2869 
 
 
 
2870 
2871 
2872 
2873 
2874 
2875 
2876 
2877 
2878 
2879 
 
Appendix VI:  SOP for Performing and Interpreting Urine Tenofovir Adherence Assay 
SOP for Performing and Interpreting Urine Tenofovir Adherence Assay 
1. Present client with a cup and ask them to please provide a urine sample. Of note, there is no 
need to clean the urethra prior to urine collection. The client can just urinate into the cup (about 
5-10mL). Please ask them to urinate into the toilet if they have excess urine after filling the cup 
to the line. 
2. Please ask the client to screw the lid on to the urine cup after collection and bring it back out to 
the provider. 
3. The provider (using gloves) should use the dropper provided with the urine test to drip 3-4 
drops of urine from the urine cup into the divot of the urine test strip (indicated by blue arrow on 
below picture). 
4. After putting the urine drops on the urine strip test, please lay it on a paper towel and let it 
develop for 3-5 minutes 
5. Please take the sheet provided (table 
shown below) and write in the participant 
ID in the first column. 
6. The control line should turn positive no 
matter what the adherence line shows. 
Please mark the sheet provided in the 
second column with a “Y” for yes if the 
control line turns positive. If the control 
line does not turn positive, please mark 
“N” for no and use another test. 
 
Urine rapid strip assay picture 
 
 
Participant ID number 
Dark control line present (Y/N) 
Test  line present (Y/N) 
 
7. The test line will appear if the client is NOT taking his/her PrEP and be absent (not appear) if 
the client is taking his/her PrEP. Please mark the sheet provided in the third column with a “Y” 
for yes if the test line turns positive. If the control line does not turn positive, please mark “N” for 
no. 
8. Please take a picture of the rapid strip test with the participant ID label next to it so that we can 
record the results for the future. (Pictures for QC will be eventually emailed to the UCSF Hair 
Analytical Laboratory at Karen.kuncze@ucsf.edu). 
9. Please discard the urine test strip after marking the sheet and taking the picture 
Appendix VII: SOP for Collection and Storage of Hair Samples 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 87 of 93 
 
 
 
 
2880 
2881 
2882 
2883 
2884 
2885 
2886 
 
Materials: Scissors, alcohol wipe, piece of aluminum foil (folded), tape, participant ID labels, and 
Ziplock bag (or any sealable plastic bag). 
 
Video demonstration on how to collect hair for study: 
Collecting 50-100 hairs, http://www.youtube.com/watch?v=F1Fd0b2IlaQ 
 
2887 
2888 
1. Ready your scissors, the hair collection packet (aluminum foil envelope inside Ziplock bag), 
the thin piece of tape for labeling the hair sample, and the participant ID label for outside the 
2889 
envelope. 
2890 
2. Clean the scissor blades using the alcohol wipe prior to each use and allow the blades to 
2891 
completely dry. 
2892 
3. Lift up the top layer of hair from the occipital region of the scalp (back of the scalp). You may 
2893 
want to use a clip to hold up the top layer of hair. 
2894 
NOTE: Hair samples from other parts of the body cannot be used. 
2895 
4. Isolate a thatch of hair (approximately 100 strands of hair) from underneath this top layer of 
2896 
hair from the occipital region with your fingers. 
2897 
5. Cut the hair sample off the subject’s head as close to the scalp as possible. 
2898 
6. Unfold the piece of aluminum foil and place the cut thatch of hair inside the piece of foil keeping 
2899 
your fingers over the distal end of the hair sample so that you know which end to label (the 
2900 
distal end is the end farthest from the scalp). 
2901 
7. Use tape or a thin label to secure the DISTAL end of the hair thatch to the inside of the 
2902 
aluminum foil, leaving the proximal end free (the proximal end is the end closest to the scalp). 
2903 
NOTE: Please make sure the label is on the very edge of the hair, leaving most of the hair sample free. 
2904 
NOTE: Thin hair and short hair may become dislodged. You may choose to mark the distal end of the 
2905 
hair with nail polish or white-out as an extra precaution if you think the hair might be dislodged. 
2906 
Or a hairpin to pin down the distal end of the hair.  It is very important to know which side is 
2907 
which for the laboratory (which side is farthest from the scalp and which side is closest) so 
2908 
labeling is important when possible! 
2909 
NOTE: If the distal end of the hair sample cannot be labeled, such as if the hair is very short and/or 
2910 
curly, then let the hair fall directly into the piece of foil and no need to label the distal end. 
2911 
8. Refold the foil over to completely enclose the thatch of hair. 
2912 
9. Place a participant label on the outside of the folded piece of foil or a label with the patient’s 
2913 
ID number, date of collection and study name. 
2914 
10. Place the folded piece of foil inside the Ziplock bag and seal the bag. 
2915 
11. Place another participant ID label on the outside of the Ziploc bag. 
2916 
12. Pictures of the hair collection process for different styles of hair are shown below. 
2917 
13. Hair samples should be stored at room temperature and in a dark place at each processing 
2918 
lab prior to shipment to the testing lab. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 88 of 93 
 
 
CURLY HAIR 
STRAIGHT HAIR 
 
 
2919 
2920 
2921 
2922 
2923 
2924 
2925 
2926 
2927 
2928 
2929 
2930 
2931 
2932 
2933 
2934 
2935 
2936 
2937 
2938 
2939 
2940 
2941 
2942 
2943 
2944 
2945 
2946 
2947 
2948 
2949 
2950 
2951 
2952 
2953 
2954 
2955 
Materials required: Scissors, piece of tin foil, patient 
labels (2), Ziplock bag, and alcohol swabs. 
Suggest making these “hair kits” ahead of time. 
 
 
 
 
 
 
 
 
 
 
Step 1: Clean the blades of a pair of scissors 
with an alcohol pad and  allow  blades to 
completely dry. 
Clean off blades of scissors between patients. 
 
 
 
 
 
 
Step 2: Lift up the top layer of hair from the occipital region of the scalp. Isolate a small thatch of 
hair (~50-100 fibers of hair) from underneath this top layer. 
Can use hair clip to keep top layer of hair away if easier. Can also cut from more than one place 
if the participant would like that, although 50-100 strands of hair is not cosmetically noticeable. 
 
Step 3: Cut the small hair sample as close to the scalp as possible 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 89 of 93 
 
 
SHORT HAIR 
Can let hair fall directly into piece of tin foil when very short/cropped (no need to 
label end since too short) 
BRAIDED HAIR 
Cut hair thatch from in-between braids or dread locks 
 
 
2956 
2957 
2958 
2959 
2960 
2961 
2962 
2963 
2964 
2965 
2966 
2967 
2968 
2969 
2970 
2971 
2972 
2973 
2974 
2975 
2976 
2977 
2978 
2979 
2980 
2981 
2982 
2983 
2984 
2985 
2986 
2987 
2988 
2989 
2990 
2991 
2992 
2993 
2994 
2995 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 90 of 93 
 
 
 
 
2996 
 
 
2997 
2998 
2999 
3000 
3001 
3002 
3003 
3004 
3005 
3006 
3007 
3008 
3009 
3010 
3011 
3012 
3013 
 
 
Step 4: Keep your fingers on the part of the hair that was 
FURTHEST away from the scalp and put the hair sample down 
on an unfolded piece of tin foil. 
 
 
 
 
 
 
 
Step 5: Put a thin label over the end of the hair sample 
that was FURTHEST away from the scalp. 
If hair very short just let it fall into the piece of tin foil 
and no need to label the distal end. Make sure the 
label is thin so you don’t cover the hair sample and put 
it at the very end. 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 91 of 93 
 
 
 
 
3014 
3015 
3016 
3017 
3018 
3019 
3020 
3021 
3022 
3023 
3024 
3025 
3026 
3027 
3028 
3029 
3030 
3031 
3032 
3033 
3034 
Step 6: Refold the foil over to completely enclose 
the hair and place a participant D label on the folded 
piece of foil 
 
 
 
 
 
 
 
 
 
Step 7: Place the folded piece of foil inside the 
plastic (e.g. Ziplock) bag and seal the bag. Put 
another patient ID label on the outside of the bag 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 92 of 93 
 
 
 
 
3035 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3036 
3037 
 
Appendix VIII: FDA DESIGNATION OF THE URINE TENOFOVIR ASSAY AS NSR 

PUMA Study- M. Gandhi, Post-NIH CSRC review 
Protocol Version 6.0 
November 11, 2021 
Page 93 of 93 
 
 
 
 
3038 
3039 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3040 
 
APPENDIX IX: KEMRI IRB APPROVAL OF PUMA TRIAL DATED 10/16/19