Phase II-b Randomized Double-Blind Placebo-Controlled Trial of Lactobacillus Crispatus CTV-05 (LACTIN-V) to Prevent the Recurrence of Bacterial Vaginosis
Phase: PHASE2
Conditions: Bacterial Vaginosis
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)

Phase II-b Randomized Double-Blind Placebo-Controlled 
Trial of Lactobacillus crispatus CTV-05 (LACTIN-V) to Prevent 
the Recurrence of Bacterial Vaginosis  
A Study of the Sexually Transmitted Infection Clinical Trials Group  
(STI CTG) 
DMID Protocol Number: 14-0029 
DMID Funding Mechanism: 
Contract Number: HHSN272201 3000141 
Task Order Number: HHSN27200003 
Pharmaceutical Support Provided by: Osel, Inc. 
IND Sponsor: 
Division of Microbiology and Infectious Diseases 
National Institute of Allergy and Infectious Diseases 
National Institutes of Health 
5601 Fishers Lane 
Bethesda, MD 20892 
Principal Investigator: Craig R. Cohen, MD, MPH 
DMID Clinical Project Manager: Jonathan Glock, MPH 
DMID Medical Monitor: Soju Chang, MD 
 DMID Medical Officer: Jill Long, MD, MPH   
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STATEMENT OF COMPLIANCE 
The study will be carried out in accordance with Good Clinical Practice (GCP) as required by the 
following  
• 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies 
(45 CFR Part 46; 21 CFR Part 50, 21 CFR Part 56, and 21 CFR Part 312) 
• 
ICH E6; 62 Federal Register 25691 (1997)  
• 
NIH Clinical Terms of Award 
All key personnel (all individuals responsible for the design and conduct of this study) have 
completed Human Subjects Protection Training. 

 
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SIGNATURE PAGE 
The signature below constitutes the approval of this protocol and the attachments, and provides 
the necessary assurances that this trial will be conducted according to all stipulations of the 
protocol, including all statements regarding confidentiality, and according to local legal and 
regulatory requirements and applicable US federal regulations and ICH guidelines. 
 
Site Investigator: 
 
Signed: 
 
Date: 
 
 
Name 
Title 
 
 
 
 

 
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TABLE OF CONTENTS 
Page 
STATEMENT OF COMPLIANCE ................................................................................................. i 
SIGNATURE PAGE .................................................................................................................... ii 
LIST OF ABBREVIATIONS ........................................................................................................ vi 
PROTOCOL SUMMARY .......................................................................................................... viii 
SCHEMATIC OF STUDY DESIGN: ........................................................................................... ix 
1.0 
KEY ROLES ....................................................................................................................... 1 
2.0 
BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE ...................................... 4 
2.1 
Background Information .......................................................................................... 4 
2.2 
Rationale ................................................................................................................ 6 
2.3 
Potential Risks and Benefits ................................................................................... 8 
2.3.1 
Potential Risks ............................................................................................ 8 
2.3.2 
Known Potential Benefits........................................................................... 11 
3.0 
OBJECTIVES ................................................................................................................... 12 
3.1 
Study Objectives ................................................................................................... 12 
3.2 
Study Outcome Measures .................................................................................... 12 
3.2.1 
Primary Efficacy Outcome Measure .......................................................... 12 
3.2.2 
Primary Safety Outcome Measure ............................................................. 12 
3.2.3 
Secondary Efficacy Outcome Measures .................................................... 13 
4.0 
STUDY DESIGN .............................................................................................................. 14 
5.0 
STUDY ENROLLMENT AND WITHDRAWAL .................................................................. 15 
5.1 
Subject Inclusion Criteria ...................................................................................... 15 
5.2 
Subject Exclusion Criteria ..................................................................................... 16 
5.3 
Treatment Assignment Procedures ....................................................................... 17 
5.3.1 
Randomization Procedures ....................................................................... 17 
5.3.2 
Masking Procedures .................................................................................. 17 
5.3.3 
Reasons for Withdrawal ............................................................................ 17 
5.3.4 
Handling of Withdrawals ............................................................................ 18 
5.3.5 
Termination of Study ................................................................................. 19 
6.0 
STUDY PRODUCT .......................................................................................................... 20 
6.1 
Study Product Description .................................................................................... 20 
6.1.1 
Acquisition ................................................................................................. 20 
6.1.2 
Formulation, Packaging, and Labeling....................................................... 20 
6.2 
Dosage, Preparation, and Administration of Study Product ................................... 22 
6.3 
Accountability Procedures for the Study Investigational Product ........................... 22 
6.4 
Assessment of Subject Compliance with Study Product ....................................... 22 
6.5 
Concomitant Medications/Treatments ................................................................... 22 

 
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7.0 
STUDY SCHEDULE ......................................................................................................... 24 
7.1 
Screening Visit 0 (Day -30 to Day -5) .................................................................... 24 
7.1.1 
Rescreening Visit ...................................................................................... 26 
7.2 
Enrollment Visit 1 (Day 1) ..................................................................................... 27 
7.3 
Follow-up Study Visit 2, Week 4, Day 28 (Allowable Days 21-35) ......................... 30 
7.4 
Follow-up Study Visit 3, Week 8, Day 56 (Allowable Days 49-63) ......................... 31 
7.5 
Follow-Up Study Visit 4, Week 12, Day 84 (Allowable Days 77-91) ...................... 31 
7.6 
Telephone Interview, Visit 5, Week 16, Day 112 (Allowable Days 105-119) .......... 33 
7.7 
Telephone Interview, Visit 6, Week 20, Day 140 (Allowable Days 133-146) .......... 33 
7.8 
Final Study Visit 7, Week 24, Day 168 (Allowable Days 161-175) ......................... 34 
7.9 
Study Product Discontinuation/Early Termination Visit .......................................... 35 
7.10 
Unscheduled Visit ................................................................................................. 36 
8.0 
STUDY PROCEDURES/EVALUATIONS ......................................................................... 39 
8.1 
Clinical Evaluations ............................................................................................... 39 
8.2 
Laboratory Evaluations ......................................................................................... 39 
8.2.1 
Clinical Laboratory Evaluations ................................................................. 39 
8.2.2 
Special Assays or Procedures ................................................................... 39 
8.2.3 
Specimen Preparation, Handling, and Shipping ........................................ 39 
9.0 
ASSESSMENT OF SAFETY ............................................................................................ 40 
9.1 
Specification of Safety Parameters ....................................................................... 40 
9.2 
Methods and Timing for Assessing, Recording, and Analyzing Safety 
Parameters ........................................................................................................... 40 
9.2.1 
Adverse Events ......................................................................................... 40 
9.2.2 
Serious Adverse Events ............................................................................ 41 
9.2.3 
Procedures to be followed in the Event of Abnormal Laboratory Test 
Values or Abnormal Clinical Findings ........................................................ 42 
9.3 
Reporting Procedures ........................................................................................... 42 
9.3.1 
Serious Adverse Events ............................................................................ 42 
9.3.2 
Regulatory Reporting for Studies Conducted Under DMID-Sponsored 
IND ............................................................................................................ 43 
9.3.3 
Reporting of Pregnancy ............................................................................. 43 
9.4 
Type and Duration of Follow-up of Subjects after Adverse Events ........................ 44 
9.5 
Halting Rules ........................................................................................................ 44 
9.6 
Safety Oversight (ISM plus DSMB) ....................................................................... 44 
10.0 CLINICAL MONITORING ................................................................................................. 45 
10.1 
Site Monitoring Plan .............................................................................................. 45 
11.0 STATISTICAL CONSIDERATIONS .................................................................................. 46 
11.1 
Introduction ........................................................................................................... 46 
11.2 
Study Objectives and Outcome Measures ............................................................ 46 
11.3 
Study Hypotheses ................................................................................................. 46 
11.4 
Sample Size Considerations ................................................................................. 47 
11.5 
Planned Interim Analyses ..................................................................................... 47 

 
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11.5.1 Safety Review ........................................................................................... 47 
11.5.2 Efficacy Review ......................................................................................... 47 
11.6 
Final Analysis Plan ............................................................................................... 47 
11.6.1 General Principles ..................................................................................... 47 
11.6.2 Data Analysis Populations ......................................................................... 48 
11.6.3 Safety Analyses ........................................................................................ 49 
11.6.4 Efficacy Analyses ...................................................................................... 50 
12.0 SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/ DOCUMENTS ................. 53 
13.0 QUALITY CONTROL AND QUALITY ASSURANCE ........................................................ 54 
14.0 ETHICS/PROTECTION OF HUMAN SUBJECTS ............................................................ 55 
14.1 
Ethical Standard ................................................................................................... 55 
14.2 
Institutional Review Board .................................................................................... 55 
14.3 
Informed Consent Process ................................................................................... 55 
14.4 
Exclusion of Women, Minorities, and Children (Special Populations) .................... 55 
14.5 
Subject Confidentiality .......................................................................................... 56 
14.6 
Study Discontinuation ........................................................................................... 56 
14.7 
Future Use of Stored Specimens .......................................................................... 56 
15.0 DATA HANDLING AND RECORD KEEPING ................................................................... 57 
15.1 
Data Management Responsibilities ....................................................................... 57 
15.2 
Data Capture Methods .......................................................................................... 57 
15.3 
Types of Data ....................................................................................................... 57 
15.4 
Timing/Reports ..................................................................................................... 58 
15.5 
Study Records Retention ...................................................................................... 58 
15.6 
Protocol Deviations ............................................................................................... 58 
16.0 PUBLICATION POLICY ................................................................................................... 59 
17.0 LITERATURE REFERENCES .......................................................................................... 60 
APPENDICES ........................................................................................................................... 63 
 
Appendix A 
Schedule of Events 
 
Appendix B 
Division of AIDS Table for Grading the Severity of Adult and Pediatric  
 
 
 
Adverse Events, December 2004; Addendum 1: Female Genital Grading   
 
 
Table for Use in Microbicide Studies, November 2007 
 
Appendix C 
 DAIDS Toxicity Table for Grading the Severity of Adult and Pediatric  
 
 
 
Adverse Events, Version 1.0 - December 2004 (Clarification dated August  
 
 
2009)  

 
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LIST OF ABBREVIATIONS 
AE 
Adverse Event 
ATP 
According to Protocol 
βHCG 
BV 
Beta Human Chorionic Gonadotropin  
Bacterial Vaginosis 
CAPRISA 
CAR 
CC 
cfu 
CMH 
CI 
CRF 
CROMS 
DAIDS 
DHHS 
DMID 
Centre for the AIDS Programme of Research in South Africa 
Clinical Agents Repository 
Complete Case 
Colony Forming Units 
Cochran-Mantel-Haenszel 
Confidence Interval 
Case Report Form 
Clinical Research Operations and Management Support 
Division of AIDS, NIAID, NIH, DHHS 
Department of Health and Human Services 
Division of Microbiology and Infectious Diseases, NIAID, NIH, DHHS 
DSMB 
Data and Safety Monitoring Board 
ELISA 
FDA 
GCP 
Enzyme-linked Immunosorbent Assay 
Food and Drug Administration 
Good Clinical Practice 
GMP 
ICF 
Good Manufacturing Practice 
Informed Consent Form 
ICH 
ICMJE 
IDES 
IEC 
International Conference on Harmonisation 
International Committee of Medical Journal Editors 
Internet Data Entry System 
Independent or Institutional Ethics Committee 
IRB 
Institutional Review Board 
ISM 
Independent Safety Monitor 
ITT 
LACTIN-V 
LOCF 
MedDRA 
MetroGel 
mITT 
MOP 
Intent-to-treat 
Lactobacillus crispatus CTV-05 
Last Observation Carried Forward 
Medical Dictionary for Regulatory Activities 
MetroGel vaginal gel 
Modified Intent-to-Treat 
Manual of Procedures 
N 
Number (typically refers to participants) 
NIAID 
National Institute of Allergy and Infectious Diseases, NIH, DHHS 
NIH 
National Institutes of Health 
OCRA 
Office of Clinical Research Affairs, DMID, NIAID, NIH, DHHS 

 
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OHRP 
Office for Human Research Protections 
ORA 
Office of Regulatory Affairs, DMID, NIAID, NIH, DHHS 
OSEL 
pH 
PI 
Office of Science and Engineering Laboratories 
Potential Hydrogen 
Principal Investigator 
PP 
qPCR 
RR 
rUTI 
SAE 
SDCC 
Per Protocol 
Quantitative Polymerase Chain Reaction  
Rate Ratio 
Recurrent Urinary Tract Infection 
Serious Adverse Event 
Statistical and Data Coordinating Center 
SMC 
Safety Monitoring Committee 
SOP 
STAR 
STI 
STI-CTG 
US 
UTI 
Standard Operating Procedure 
Sexually Transmitted Infections Treatment and Research  
Sexually Transmitted Infection 
Sexually Transmitted Infections Clinical Trials Group 
United States 
Urinary Tract Infection 
 

 
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PROTOCOL SUMMARY 
Title:  
Phase II-b Randomized Double-Blind Placebo-Controlled Trial 
of Lactobacillus crispatus CTV-05 (LACTIN-V)  to Prevent the 
Recurrence of Bacterial Vaginosis 
Phase: 
II-b 
Population: 
228 non-pregnant, pre-menopausal women age 18 to 45 years 
diagnosed with bacterial vaginosis (BV) 
Number of Sites: 
Study Duration: 
Four U.S. sites  
72 weeks after enrollment of the first participant  
Participant Participation 
Duration: 
24 weeks per participant 
Description of Agent: 
 
 
 
 
 
 
Primary Objectives 
 
 
 
 
 
 
Secondary Objectives 
 
 
 
 
 
 
 
 
 
 
 
Exploratory Objective  
 
 
 
Description of Study Design:  
Time to Complete Enrollment: 
Lactobacillus (L.) crispatus CTV-05 (LACTIN-V) contains a 
naturally occurring vaginal strain of L. crispatus CTV-05, 
preserved as a powder applied by a vaginal applicator.  
LACTIN-V at 2 x 109 cfu/dose or matching placebo will be 
administered by vaginal applicator once daily for 5 consecutive 
days, followed by twice weekly for 10 consecutive additional 
weeks. 
1) To estimate the efficacy of repeated doses of LACTIN-V (2 x 
109 cfu/dose) as compared to placebo in preventing BV 
recurrence by 12 weeks following treatment of BV with 
MetroGel vaginal gel (MetroGel) 
2) To assess the safety of LACTIN-V over 24 weeks by 
comparing the incidence of AEs between individuals 
randomized to LACTIN-V or placebo 
1) To investigate the colonization of LACTIN-V (presence of L. 
crispatus CTV-05 in the vaginal specimen) and fluctuations 
over 12 weeks, in relation to menses and sexual intercourse 
2) To evaluate user acceptability and tolerability of LACTIN-V 
over 12 weeks, including perceptions around method of 
delivery and dosing  
3) To measure long-term colonization of LACTIN-V at 24 
weeks (12 weeks after last dosing) 
4) To estimate the long-term efficacy of repeated doses of 
LACTIN-V (2 x 109 cfu/dose) as compared to placebo in 
preventing BV recurrence at 24 weeks (12 weeks after last 
dosing) 
To estimate the efficacy of repeated doses of LACTIN-V (2 x 109 
cfu/dose) as compared to placebo in preventing repeated (more 
than one) episodes of BV recurrence up to 12 weeks following 
treatment of BV with MetroGel  
See schematic 
48 weeks 

 
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SCHEMATIC OF STUDY DESIGN: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Screening Visit 
Eligible women with Amsel criteria ≥3 and  
Nugent score 4-10  
Eligible women will start 5-day treatment with MetroGel 
Enroll and randomize 2:1 
LACTIN-V 
Self-administered once x5 days 
then twice weekly x10 weeks 
PLACEBO 
Self-administered once x5 days 
then twice weekly x10 weeks 
Follow-up visits at weeks 4, 8, 12, and 24 
Telephone interview at weeks 16 and 20 
Confirm eligibility and enroll within 2 days after 
completing MetroGel 

 
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1.0 
KEY ROLES 
DMID Clinical Project Manager 
Jonathan Glock, MPH 
HHS, NIH, NIAID, DMID, STD Branch 
5601 Fishers Lane 
Rockville, MD  20892 
(240) 627-3258 
jglock@niaid.nih.gov 
 
Principal Investigator 
Craig Cohen, MD, MPH 
550 16th Street (Mission Bay Campus, 
GHS Building) 
San Francisco, CA 94158 
(415) 476-5874 
Craig.Cohen@ucsf.edu 
 
Co- Principal Investigator 
Anke Hemmerling, MD, PhD, MPH 
550 16th Street (Mission Bay Campus, 
GHS Building) 
San Francisco, CA 94158 
(415) 476-5878 
Anke.Hemmerling@ucsf.edu 
 
DMID Medical Monitor 
Soju Chang, MD 
HHS, NIH, NIAID, DMID, OCRA 
5601 Fishers Lane 
Rockville, MD  20892 
(240) 292-4178 
changsoju@niaid.nih.gov 
 
DMID Medical Officer 
Jill Long, MD, MPH 
HHS, NIH, NIAID, DMID, STD Branch 
5601 Fishers Lane 
Rockville, MD  20892 
(240) 627-3305 
jill.long@nih.gov 
 

 
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Clinical Operations Manager 
Sean McCarthy 
STAR STI-CTG Coordinating Center 
Social & Scientific Systems, Inc. 
8757 Georgia Avenue, 12th Floor  
Silver Spring MD 20910 
(301) 628-3394 
smccarthy@s-3.com 
 
SDCC Project Manager 
Jason Thompson, MS 
The Emmes Corporation 
401 N. Washington Street, Suite 700 
Rockville, MD 20850 
(301) 251-1161 x2708 
jthompson@emmes.com 
 
SDCC Data Manager 
Hannah Kwak 
The Emmes Corporation 
401 N. Washington Street, Suite 700 
Rockville, MD 20850 
(301) 251-1161 x239 
hkwak@emmes.com 
 
SDCC Statistician 
Michael R. Wierzbicki, PhD 
The Emmes Corporation 
401 N. Washington Street, Suite 700 
Rockville, MD 20850 
(301) 251-1161 x181 
mwierzbicki@emmes.com 
 
Site Principal Investigators: 
San Francisco General Hospital 
Misa Peron-Burdick, MD 
Department of OB/GYN, Ward 6D 
San Francisco General Hospital 
1001 Potrero Street 
San Francisco, CA 94110 
(415) 206-2937 
misa.perron-burdick@ucsf.edu 
 

 
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Stroger Hospital of Cook County 
Audrey French, MD 
1900 West Polk Street, Room 1243 
Chicago, IL 60612 
(312) 864-4578 
afrench@cookcountyhhs.org 
 
University of California, San Diego 
Antiviral Research Center (UCSD 
AVRC) 
Sheldon Morris, MD, MPH 
220 Dickinson Street, Suite A 
San Diego, CA 92103 
(619) 543-4761 
shmorris@ucsd.edu 
 
Washington University Infectious 
Disease Clinical Research Unit 
Hilary Reno, MD, PhD 
620 South Taylor, Suite 200 
St. Louis, MO 63110 
(314) 747-5496 
hreno@dom.wustl.edu 
 
Industry Representatives: 
Executive Chairman 
Peter Lee, MD 
Osel, Inc. 
320 Logue Avenue 
Mountain View, CA 94043 
(650) 964-4679 
plee@oselinc.com 
 
Director of Product Development 
Thomas Parks, PhD 
Osel, Inc. 
320 Logue Avenue 
Mountain View, CA 94043 
(650) 964-4679 
tparks@oselinc.com 
 

 
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2.0 
BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE 
 
2.1 
Background Information 
 
Bacterial vaginosis (BV), characterized by an imbalanced vaginal flora deficient in 
naturally occurring acid-producing lactobacilli, is one of the most frequent vaginal 
infections and affects about 15–50% of reproductive aged women globally [1]. Many 
women are unaware of their condition. BV has been associated with significant 
gynecologic and obstetric complications, such as pelvic inflammatory disease [2], 
endometritis [3] and post-operative infections, including post-cesarean endometritis [4] 
and post-hysterectomy vaginal cuff cellulitis [5]. Strong associations have also been 
reported between BV and pre-term delivery, miscarriage [6], and amniotic fluid infections 
[7]. Studies have linked BV to both female HIV-1 acquisition, and female-to-male HIV 
transmission [8-10]. A recent study showed that the presence of lactobacilli decrease the 
odds for fetal inflammatory responses to placental colonization with pathogens [11]. 
Following standard antibiotic treatment of BV, 20–75% of women relapse within 1–3 
months [12, 13]. The high risk of recurrence and sequelae suggests that investigational 
studies of new agents like live biotherapeutic products [14] may be effective for the 
improved treatment and prevention of BV.  
 
Reconstituting a normal, Lactobacillus-predominant vaginal flora has been promoted for 
many years as a microbial defense against pathogens. The vaginal live biotherapeutic  
product Lactobacillus (L.) crispatus CTV-05 (LACTIN-V) was developed by Osel, Inc. in 
Mountain View, California, and is designed to replenish the vaginal lactobacilli population 
following conventional antibiotic treatment with MetroGel® (topical metronidazole gel 
0.75%). The product contains a naturally occurring vaginal strain of L. crispatus CTV-05, 
preserved as a powder applied by a vaginal applicator. Since the Lactobacillus strain 
used in LACTIN-V is a commensal organism normally present in the vagina associated 
with vaginal health, the product has an excellent pre-clinical and clinical safety profile.   
 
Early studies of LACTIN-V administered the product in gelatin-coated capsules. After the 
completion of a Phase I safety trial testing low doses of 106 and 108 cfu/dose or placebo, 
a Phase II multisite placebo-controlled trial tested a dose of 5 x 108 cfu of LACTIN-V 
administered in a gelatin capsule in 149 women with BV following standard antibiotic 
treatment. The product was dosed for 5 consecutive days followed by a weekly dose 
over 10 additional weeks. After 4 months, colonization efficiency in the LACTIN-V group 
reached 42% in the intent-to-treat (ITT) cohort and 59% in the according-to-protocol 
(ATP) cohort. Although not statistically significant, the time to first BV recurrence was 
longer in the LACTIN-V arm (118.7 days) compared to the placebo arm (98.7 days, p = 
0.37). The proportion of women in the LACTIN-V treatment group successfully colonized 
with L. crispatus CTV-05 experienced fewer episodes of recurrent symptomatic BV 
(12.5%) than those who were not colonized (36%), or those in the placebo group (30%). 
The product had a good safety profile with mostly mild (Grade 1 severity) adverse events 
(AEs) including vaginal discharge, odor and pruritus, each affecting less than 40% of 
participants. AEs were evenly distributed between LACTIN-V and placebo arms (Osel, 
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LACTIN-V has also been evaluated as a therapeutic agent to prevent recurrent urinary 
tract infections (rUTI). In a Phase II study in 100 women who received antibiotic 
treatment for cystitis, those who additionally received 108 cfu of LACTIN-V administered 
in a gelatin capsule over 5 consecutive days followed by a weekly dose over 10 
additional weeks had a reduction in rUTI from 27% in the placebo arm to 15% in the 
LACTIN-V arm (response rate [RR] = 0.5, 95% confidence interval [CI] 0.2-1.2) in 
comparison to the placebo arm. Among women receiving LACTIN-V who had detected 
high levels of vaginal colonization with L. crispatus, the reduction of rUTI reached 
statistical significance (RR=0.07, 95% CI 0.02-0.3). Interestingly, high levels of pre-
existing endogenous L. crispatus strains in women receiving placebo did not provide 
protection against rUTI [15]. 
 
Our research team at the University of California, San Francisco (UCSF) and Osel 
hypothesized that the efficacy of LACTIN-V to prevent BV recurrence could be improved 
by increasing the vaginal colonization rate of L. crispatus CTV-05. In order to achieve 
this, a vaginal applicator was developed capable of delivering a higher dose of LACTIN-
V powder (up to 2 x 109 cfu/dose) directly to the vagina without the impediment of a 
gelatin capsule, which was found to dissolve slowly in the vaginal environment. The new 
dosage form was first studied in a small Phase I escalating dose trial at UCSF to assess 
safety, tolerability and acceptability of three doses [5 X 108 cfu/dose (150mg), 1 X 109 
cfu/dose (300mg), 2 x 109 cfu/dose (600mg)] of LACTIN-V (IND No. 11363).  Four 
healthy women were randomized 3:1 to receive LACTIN-V or placebo at each dose 
level.  The product was found to be safe and well tolerated at all three doses. All AEs 
were Grade 1 and 2 severity and evenly distributed between LACTIN-V and placebo 
groups [16]. This study was followed by a Phase II-a trial of 24 women diagnosed with 
BV randomized 3:1 to LACTIN-V (2 x 109 cfu/dose) vs. an inert placebo administered 
daily for 5 days, and once weekly for 2 weeks. Participants completed a 5-day treatment 
course with MetroGel and within 24-72 hours initiated a regimen of high-dose LACTIN-V 
or inert placebo, administered once daily for 5 consecutive days and then once weekly 
over 2 additional weeks. After 4 weeks, colonization efficiency in the LACTIN-V group 
reached 61% (95%CI: 36%-83%) in the ITT cohort and 78% (95%CI: 40%-97%) in the 
ATP cohort [17]. We also explored the effect of endogenous lactobacilli and BV-
associated bacteria on vaginal colonization with the exogenous L. crispatus CTV-05 
using DNA extraction from vaginal swabs and bacterium-specific quantitative 
polymerase chain reaction (qPCR) assays. The median vaginal concentrations of BV-
associated bacteria (Megasphaera, Atopobium spp., Leptotrichia, Sneathia, Gardnerella 
(G.) vaginalis, Lactobacillus iners, Clostridium-like bacteria, BVAB1-3) declined after 
metronidazole treatment. In participants who subsequently colonized with L. crispatus 
CTV-05, this trend was maintained throughout the study. Participants who did not 
colonize with CTV-05 saw a resurgence of G. vaginalis, Leptotrichia/Sneathia species, 
A. vaginae, and BVAB2 concentration during the course of the study. This provides 
supporting evidence that these bacteria are important in the pathogenesis of BV and 
may impede the success of treatment with both antibiotics and live biotherapeutic 
products [18]. 
 
Collecting a larger body of data on colonization and efficacy of unmodified Lactobacillus 
strains to prevent BV recurrence will greatly contribute to the efforts of developing 
unmodified as well as genetically modified Lactobacillus strains as a multipurpose 

 
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technology for the prevention of HIV-1 and other genital tract infections. In the completed 
Centre for the AIDS Programme of Research in South Africa (CAPRISA)-004 trial that 
tested vaginally delivered 1% tenofovir gel for HIV-1 prevention [19], participants with 
recurrent symptoms of vaginal irritation and inflammation had a higher risk of HIV-1 
acquisition even in the 1% tenofovir gel arm (Karim SA, personal communication). In 
addition, a strong link has been shown between high-diversity cervicovaginal microbiota 
with low Lactobacillus levels and genital inflammation in a study of South African 
women. This genital inflammation was accompanied by increased numbers of activated 
HIV-infectable CD4+ cells in the cervix, providing a potential cellular link to increased 
HIV acquisition risk [20]. Thus, normalization of vaginal flora through use of exogenous 
vaginal Lactobacillus crispatus, and subsequent reduction of inflammation in the genital 
tract, could potentially enhance HIV-1 prevention associated with tenofovir gel use and 
other topical pre-exposure prophylaxis therapies under development [21].  
 
In the Phase II-a clinical trial, 19 (79%) of 24 participants agreed or strongly agreed that 
they would use the product again indicating that satisfaction of the product was high. 
Four women with persistent symptomatic BV at study exit were significantly less satisfied 
with the product (p=0.03); only two of these four women would use the product again.  
Efficacy, improved vaginal health, and being a ‘natural’ alternative to antibiotics were 
mentioned as positive attributes, and messiness and leakage arose as a negative 
attribute of the product [17]. In order to address participant concerns for messiness and 
leakage, Osel has increased the potency of LACTIN-V. Thus, while 600mg of powder 
was used in the Phase II-a trial, a lesser amount of powder is required to deliver the 
same dose of CTV-05 (2 x 109 cfu). Overall, these results suggest that women are highly 
interested in live biotherapeutics and future studies testing these products should include 
an acceptability component with both quantitative and qualitative components to fully 
characterize women’s satisfaction with the product.  
 
CTV-05 is a strain of L. crispatus, a gram-positive rod isolated from the vagina of a 
healthy woman. L.crispatus is found naturally in the vaginas of healthy women and is 
commonly found as a component of the natural human intestinal flora.  It is a facultative 
anaerobe, homofermentor of lactic acid, fastidious in its growth, and capable of H2O2 
production.  Unlike most commercially available strains of Lactobacillus, CTV-05 
adheres well to vaginal epithelial cells and is capable of colonizing the vaginal 
epithelium.   
 
LACTIN-V administered as a capsule has been tested in four trials (LV 001-004) with a 
dose level up to 5 x 108 cfu/capsule. Since the dose of 5 x 108 cfu/capsule resulted in 
colonization rates lower than desired, several changes to the study product were made. 
The higher dose of 2 x 109 cfu/dose delivered via vaginal applicator as dried powder 
directly into the upper vaginal vault has been tested in a Phase 1 trial (LV-005) in 12 
healthy women and subsequently in a Phase II-a trial (LV-006) in 24 women with BV. 
 
2.2 
Rationale 
 
This Phase II-b trial is designed to provide a screening evaluation for the hypothesis 
that, following a 5-day course of MetroGel to treat BV, LACTIN-V administered at 2 x 109 
cfu/dose using a vaginal applicator reduces the 12-week incidence of BV recurrence by 

 
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≥50% when compared to placebo. Based on the achieved colonization rate of L. 
crispatus CTV-05 at 2 x 109 cfu/dose of LACTIN-V, coupled with prior data from the 
Phase II-a clinical trial suggesting that vaginal colonization with L. crispatus CTV-05 was 
associated with a reduced risk of BV recurrence, the next logical step is to perform a 
larger Phase II-b trial.  
 
We plan to enroll 228 women in a 2:1 ratio of LACTIN-V to placebo to estimate the 
effectiveness of 2 x 109 cfu/dose of LACTIN-V to prevent the recurrence of BV following 
standard antibiotic treatment with MetroGel and establish longer term safety and 
acceptability data up to 24 weeks.  
 
The study will be conducted at domestic sites with a known track record of recruiting 
participants in other BV studies to enable enrollment of all 228 women over 48 weeks. 
This will allow the study to complete study follow up 18 months after the first woman 
enrolls in the trial. This timeline assumes that all sites initiate enrollment at about the 
same time.  
 
2.2.1 Rationale for BV Enrollment Criteria  
 
We are planning to enroll women with untreated BV (asymptomatic or 
symptomatic) as diagnosed during the screening visit defined by at least three of 
the following four Amsel criteria AND a Nugent score ≥4 on a Gram stain in the 
laboratory using the Nugent scoring system. 
 
The current 2015 CDC Sexually Transmitted Diseases Treatment Guidelines 
specify on page 69 that the clinical Amsel criteria can be used for the diagnosis 
of BV, and require three of the following symptoms or signs [22]: 
 
• 
Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal 
walls;  
• 
Vaginal pH >4.5;  
• 
Positive whiff-amine test, defined as the presence of a fishy odor when a drop 
of 10% potassium hydroxide (KOH) is added to a sample of vaginal 
discharge;  
• 
Presence of clue cells (>20%) on microscopy.  
 
Detection of three of these criteria has been correlated with results by Gram stain 
[23, 24]. 
 
The recent 2013 Food and Drug Administration (FDA) draft guidance for the use 
of metronidazole gel suggests all four Amsel criteria for inclusion, and states that 
a Nugent score of four or higher is recommended for inclusion [25]. 
 
Recent studies enrolling participants with BV since 2012 routinely combined 
Amsel criteria and Nugent scores for BV diagnosis at enrollment and follow up 
(see Table 2.2.1). 

 
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Table 2.2.1: 
 
Author 
Year 
Enrollment Criteria 
  
  
Amsel 
Only 
Nugent  
Only 
Combination of 
Amsel (A) and Nugent (N) 
Bradshaw [26] 
2013 
  
  
≥3 A and N=4-10 
Cruciani [27] 
2013 
  
  
≥3 A and N=4-10 
Donders [28] 
2013 
  
  
≥3 A and N=4-10 
Bradshaw [29] 
2012 
  
  
N = 7-10 or ≥3 A and N=4-10 
Balkus [30] 
2012 
  
  
≥3 A and N=7-10 
Weissenbacher 
[31] 
2012 
A=4 
Schwebke [32] 
2011 
A=4 
 
Marrazzo [33] 
2012 
  
  
≥3 A and N=4-10 
Madhivanan 
[34] 
2014 
  
  
≥3 A and N=7-10 
 
In practice intermediate (N=4-6) and high Nugent scores (N=7-10) are almost 
exclusively linked to Amsel criteria no lower than three. A study conducted by 
Schwebke et al [35] showed this and the data of our previous LV-006 Phase II-a 
study confirms this finding (Hemmerling 2010, subanalysis unpublished). For all 
96 BV measurements (24 enrolled participants at four time points), Nugent 
scores of 4-10 correlated with Amsel criteria of 3 or 4. The same data set showed 
that whenever Amsel criteria reached 4 (19 of 96 measurements), the 
corresponding Nugent score was 8 or higher, never corresponding with lower 
intermediate Nugent score of 4-6.   
 
After weighing recent FDA guidance, CDC guidelines, our data from previous 
studies, and reviewing recent BV enrollment practices of other studies, we 
propose to adopt the same enrollment criteria as the vast majority of recent 
studies: a combined requirement of at least 3 of 4 Amsel criteria and a Nugent 
score of 4-10.  
 
2.3 
Potential Risks and Benefits 
 
2.3.1 Potential Risks 
 
2.3.1.1 LACTIN-V and Placebo  
 
The study product contains a naturally occurring strain of L. crispatus 
CTV-05. To date, there has been considerable amount of experience 
using LACTIN-V at concentrations up to 2 x 109 cfu/dose without any 
apparent related adverse effects, with the exception of a short duration 
of asymptomatic vaginal discharge.  No serious adverse events have 
been reported in Protocol No. LV-001, LV-002 and LV-004 using 
LACTIN-V at 5 x 106 and 5 x 108 cfu/dose, and no subject left the 
protocol due to an adverse event.  No type of severe or severe-related 

 
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adverse event has been experienced by more than one subject.  In 
Protocol No. LV-003, using LACTIN-V at 5 x 108 cfu/dose, one subject 
in the placebo control substance group experienced three 
simultaneous SAEs unrelated to LACTIN-V. Two subjects in the 
LACTIN-V group discontinued study treatment due to AEs; one subject 
became pregnant and the other reported nausea and diarrhea, which 
required treatment.   
 
Safety results of the recently completed Phase II-a trial (LV-006) 
assessing colonization efficiency, safety, tolerability and acceptability 
of LACTIN-V at 2 x 109 cfu/ dose in 24 women with BV show that no 
AE Grade 3 or higher and no SAE was observed during the clinical 
phase of the study.  Based on the DAIDS Toxicity Table Addendum for 
Vaginal Microbicide Studies (November 2007) [36] designed to 
standardize AE assessment, a total of 120 total AEs were reported, 
108 (90%) of which were Grade 1 and 12 (10.0%) were Grade 2 
severity. The most common genitourinary AEs included vaginal 
discharge of study product (46%), abdominal pain (46%) and dysuria 
(21%). AEs were evenly distributed between LACTIN-V and placebo 
groups. All enrolled women (n=24) reported at least one AE.  A single 
participant receiving placebo discontinued herself from study product 
due to a moderate AE (vaginal irritation).   
 
Risks from the administration of LACTIN-V are low since colonization 
with this type of organism is strongly associated with improved vaginal 
health.  No systemic risks are anticipated since this is an organism that 
is applied topically and not expected to be absorbed. These risks will 
be explained in the written informed consent form.  No pregnant 
women, fetuses, prisoners, children, persons with an active STI or 
humans undergoing in vitro fertilization are included in this study. 
 
Adverse effects that may be associated with LACTIN-V include those 
seen with other vaginally administered products, and include: 
Most likely:  
• 
Vaginal, genital or menstrual symptoms: vaginal discharge 
 
Less likely:  
• 
Gastrointestinal symptoms: abdominal (stomach area) pain, 
constipation, diarrhea, nausea, vomiting 
• 
Urinary symptoms: needing to urinate urgently, needing to urinate 
at night and pain with urination 
• 
Vaginal, genital or menstrual symptoms: genital itching, bleeding 
between menstrual periods, delayed menstrual periods, vaginal 
odor, vaginal burning sensation, vaginal irritation, vaginal bleeding, 
vaginal dryness, genital swelling, rash, vaginal candidiasis (yeast 
infection) 
• 
Other symptoms: lower back pain 
 

 
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Rare but potentially life-threatening:  
• 
Allergic reaction (including anaphylaxis) to the study product 
 
2.3.1.2 MetroGel vaginal gel 
 
MetroGel vaginal gel is indicated in the treatment of bacterial 
vaginosis. It is contraindicated in patients with a prior history of 
hypersensitivity to metronidazole, parabens, other ingredients of the 
formulation, or other nitroimidazole derivatives. 
 
Rare but serious* 
• 
Convulsive Seizures and Peripheral Neuropathy: Convulsive 
seizures and peripheral neuropathy, the latter characterized mainly 
by numbness or paresthesia of an extremity, have been reported in 
patients treated with oral or intravenous metronidazole. The 
appearance of abnormal neurologic signs demands the prompt 
discontinuation of metronidazole vaginal gel therapy. 
Metronidazole vaginal gel should be administered with caution to 
patients with central nervous system diseases. 
• 
Psychotic Reactions: Psychotic reactions have been reported in 
alcoholic patients who were using oral metronidazole and 
disulfiram concurrently. Metronidazole vaginal gel should not be 
administered to patients who have taken disulfiram within the last 
two weeks. 
 
*MetroGel vaginal gel affords minimal peak serum levels and systemic 
exposure (AUCs) of metronidazole compared to 500 mg oral 
metronidazole dosing. Although these lower levels of exposure are 
less likely to produce the common reactions seen with oral  
metronidazole, the possibility of these and other reactions cannot be 
excluded presently.  Data from well-controlled trials directly comparing 
metronidazole administered orally to metronidazole administered 
vaginally are not available. 
 
2.3.1.3 Study Procedures  
 
Participants may experience discomfort when having pelvic exams 
and/or undergoing phlebotomy for this study. During phlebotomy, they 
also may feel dizzy or faint, or develop a bruise, swelling or infection 
where the needle is inserted. 
 
2.3.1.4 Disclosure of Sexually Transmitted Infections  
 
Participants may become embarrassed, worried, or anxious when 
receiving HIV and STI counseling. They may become worried or 
anxious while waiting for their HIV and STI test results.  
 

 
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2.3.1.5 Procedures for Minimizing Potential Risks 
 
Allergic reactions (including anaphylaxis): Participants with a known 
allergy to components of the study product will be excluded from 
enrollment.  If an allergy or sensitivity occurs during the course of the 
study, the participant will be advised to immediately discontinue study 
product use and seek medical attention. This event will be recorded on 
an AE form. 
 
STI testing: Participants will receive counseling prior to testing. 
Counselors will prepare them for possible feelings of anxiety and the 
ramifications of a positive test result. All results will be kept confidential 
by the study physician/nurse and will be maintained in a limited access 
database. 
 
2.3.2 
Known Potential Benefits 
 
There may be no direct benefits to participants in this study. However, 
participants and others may benefit in the future from information learned from 
this study. Information learned in this study may lead to the development of a 
safe and effective live biotherapeutic product that can prevent the recurrence of 
BV. Participants will have HIV testing and pelvic exam performed during 
screening. Participants will be screened for a number of STIs and a prescription 
will be provided, if applicable, following CDC STD Treatment Guidelines. 
Participants testing positive for BV during screening will receive study-supplied 
MetroGel.  
 

 
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3.0 
OBJECTIVES 
3.1 
Study Objectives 
 
3.1.1 Primary Objectives 
1) To estimate the efficacy of repeated doses of LACTIN-V (2 x 109 cfu/dose) as 
compared to placebo in preventing BV recurrence by 12 weeks following 
treatment of BV with MetroGel 
2) To assess the safety of LACTIN-V over 24 weeks by comparing the incidence 
of AEs between individuals randomized to LACTIN-V or placebo 
 
3.1.2 Secondary Objectives 
1) To investigate the colonization of LACTIN-V (presence of L. crispatus CTV-05 
in the vaginal specimen) and fluctuations over 12 weeks, in relation to 
menses and sexual intercourse 
2) To evaluate user acceptability and tolerability of LACTIN-V over 12 weeks, 
including perceptions around method of delivery and dosing  
3) To measure long-term colonization of LACTIN-V at 24 weeks (12 weeks after 
last dosing) 
4) To estimate the long-term efficacy of repeated doses of LACTIN-V (2 x 109 
cfu/dose) as compared to placebo in preventing BV recurrence at 24 weeks 
(12 weeks after last dosing) 
 
3.1.3 Exploratory Objective 
To estimate the efficacy of repeated doses of LACTIN-V (2 x 109 cfu/dose) as  
compared to placebo in preventing repeated (more than one) episodes of BV  
recurrence up to 12 weeks following treatment of BV with MetroGel 
 
3.2 
Study Outcome Measures 
 
3.2.1 Primary Efficacy Outcome Measure 
The proportion of participants with a positive BV diagnosis in each study arm by 
Visit 4 (Week 12, Day 84) 
 
BV recurrence is defined by Amsel criteria 3-4 and Nugent score 4-10. Following 
FDA draft guidance all BV diagnoses during follow-up visits are considered 
incident, as they occur at least 22-30 days after the commencement of MetroGel 
treatment and consequently are treatment failures or new infections [25].  For the 
purpose of this trial, treatment failure and new infection will both be considered 
recurrent BV. 
 
3.2.2 Primary Safety Outcome Measure 
The proportion of participants reporting product-related AEs and SAEs in each 
study arm through Visit 7 (Week 24, Day 168) 
 

 
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3.2.3 Secondary Efficacy Outcome Measures 
 
Secondary Outcome Measure 1  
The proportion of participants experiencing successful colonization with L. 
crispatus CTV-05 following dose of study product through Visit 4 (Week 12, Day 
84) in the LACTIN-V arm, overall and by occurrence of menses and intercourse 
 
Secondary Outcome Measure 2 
The proportion of participants experiencing successful colonization with L. 
crispatus CTV-05 following dose of study product at Visit 7 (Week 24, Day 168) 
in the LACTIN-V arm, overall and by occurrence of menses and intercourse 
 
Secondary Outcome Measure 3 
Tolerability of LACTIN-V and the applicator will be measured by: 
1. The proportion of participants who discontinue study product early in each 
study arm due to adverse events 
 
Acceptability of LACTIN-V and the applicator will be measured by: 
1. The proportion of participants who are compliant with the complete dose 
regimen in each study arm as assessed by participant reporting and 
applicator staining  
2. Self-administered questionnaires about acceptability of the study product in 
each study arm 
 
Secondary Outcome Measure 4 
The proportion of participants with a positive BV diagnosis in each study arm by 
Visit 7 (Week 24, Day 168) 
 
Exploratory Outcome Measure 
The statistical parameterizations of the exploratory objective will include, but are 
not limited to, the following: 
1. The number of BV recurrences per 12 weeks of follow-up 
2. The probability of BV recurrence during the 12 weeks of follow-up 

 
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4.0 STUDY DESIGN 
This is a Phase II-b multicenter randomized double-blind placebo-controlled trial to assess the 
efficacy of repeated doses of LACTIN-V compared to placebo in preventing BV recurrence in 
women diagnosed with BV. The study will also assess the safety of LACTIN-V by comparing the 
incidence of AEs between women randomized to LACTIN-V or placebo. The study plans to 
enroll 228 sexually-experienced, pre-menopausal women age 18 to 45 years. Women will be 
randomized 2:1 to receive LACTIN-V or placebo. 
  
Women will be consented and will have a history and physical examination to include a pelvic 
exam with STI diagnostics and testing for BV.  Potentially eligible women with Amsel criteria ≥3 
will have a vaginal smear sent to a central laboratory for Gram stain evaluation by Nugent 
score.  Blood will be obtained for HIV and syphilis serologies, a vaginal swab for gonorrhea, 
chlamydia and trichomonas molecular testing, and urine for βhCG. Potentially eligible women 
will start a standard 5-day course of MetroGel.  
 
Women will return to the study clinic within 2 days after completing the 5-day course of 
MetroGel to re-evaluate eligibility criteria and review the BV test results from the screening visit. 
Women with Amsel criteria ≥3 and Nugent score 4-10 will be instructed to administer the 
LACTIN-V  or placebo at home for 5 consecutive days and then twice weekly for 10 weeks.   
LACTIN-V (or placebo) will be administered at 2 x 109 cfu/dose by vaginal applicator. 
 
Women will complete a memory aid to record times of product application, menses, sexual 
intercourse, concomitant medications, condom use and any AEs. Reminders will be sent to 
women in order to increase adherence with all doses and prior to scheduled follow-up visits. 
Women will complete either a paper or electronic memory aid. If the electronic version of the 
memory aid is utilized by the participant, the study clinic will be alerted of any potential AEs 
reported by the participant for follow-up and reporting as deemed necessary. 
 
Follow-up visits are scheduled 4, 8, 12 and 24 weeks after enrollment. A memory aid to gauge 
symptoms and AEs will be reviewed, a questionnaire to collect clinical, including AEs, data will 
be administered and a pelvic exam will be performed to detect genital tract AEs. Vaginal swabs 
for wet mount evaluation (Amsel criteria) and Gram stain evaluation (Nugent score) will be 
collected. A vaginal swab for L. crispatus (including CTV-05) identification will be collected. 
Vaginal applicators will be collected at Visits 2, 3, and 4 and stained with Trypan Blue upon 
return to the site as a proxy for product use. Telephone interviews will be scheduled between 
the 12 and 24 week visits, at 16 and 20 weeks after enrollment. 

 
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5.0 STUDY ENROLLMENT AND WITHDRAWAL 
The study plans to enroll 228 non-pregnant, pre-menopausal women age 18 to 45 years 
diagnosed with symptomatic or asymptomatic BV. Eligibility criteria for participation in the study 
are described in detail in sections 5.1 and 5.2.  A screening consent form will be used for 
procedures to determine eligibility and an enrollment consent form will be used for study 
participation if eligibility is confirmed. Pregnant women, men and children are excluded from 
study participation (see section 14.4). 
 
5.1 
Subject Inclusion Criteria 
Participants must meet all of the inclusion criteria in order to be eligible to participate in 
the study: 
1. Capable of reading and writing English and voluntarily provide written informed 
consent to participate in the study and comply with all study procedures 
2. Untreated BV (asymptomatic or symptomatic) as diagnosed during the screening 
visit defined by >3 Amsel criteria  
Note: Amsel criteria include the following:  
• 
Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal 
walls;  
• 
Vaginal pH >4.5;  
• 
Positive whiff-amine test, defined as the presence of a fishy odor when a drop of 
10% potassium hydroxide (KOH) is added to a sample of vaginal discharge;  
• 
Presence of clue cells (>20% on microscopy). 
3. Untreated BV (asymptomatic or symptomatic) as confirmed in the laboratory using 
the Nugent scoring system (Nugent Score ≥4) 
4. Otherwise healthy pre-menopausal women 18–45 years of age on the day of 
screening 
5. Regular predictable menstrual cycles or amenorrheic for at least 3 months due to 
use of a long-acting progestin or continuous use of oral contraceptives 
6. Willing to be asked questions about personal medical health and sexual history 
7. Willing to apply study agent vaginally and comply with study examinations 
8. Agree to abstain from sexual intercourse during the first 5 consecutive days of study 
product administration, 12 hours prior to study visits and for 12 hours after each 
study product application  
9. Agree to abstain from the use of any other intravaginal product throughout the trial 
period from the time of screening through Visit 7 (Week 24, Day 168)  
Note: Intravaginal products include contraceptive creams such as Gynol II, gels, 
foams, sponges, lubricants not approved by the study investigators, and douches.   
Limit use of tampons during menstruation to unscented products. 
10. Must be of non-childbearing potential or if of childbearing potential, must agree to 
use a reliable method of birth control for the duration of the study  
Note: Reliable methods of birth control include tubal ligation, male partner with a  
vasectomy, a steroidal contraceptive (oral, patch, injectable or implantable), IUD,  
condoms or abstinence. 

 
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5.2 
Subject Exclusion Criteria 
 
Participants meeting any of the following criteria at screening, or when assessed at the 
enrollment visit, will be excluded from the study: 
1. Urogenital infection at screening 
Note: Urogenital infection includes urinary tract infection, Trichomonas (T.) vaginalis, 
Neisseria (N.) gonorrhoeae, Chlamydia (C.) trachomatis, Treponema (T.) pallidum, 
or vulvo-vaginal candidiasis.  
2. Diagnosis of two or more outbreaks of N. gonorrhoeae, C. trachomatis, T. pallidum, 
T. vaginalis, or herpes simplex virus (herpes genitalis) within 6 months prior to 
screening 
3. Positive for syphilis or HIV at screening 
4. Current pregnancy or within 2 months of last pregnancy and/or currently 
breastfeeding** 
5. Vaginal or systemic antibiotic or antifungal therapy (other than MetroGel given as 
part of study procedures) within 21 days of screening or within 30 days of 
enrollment**  
6. Use of disulfiram within past 2 weeks or other contraindication to use of MetroGel** 
7. Any condition requiring regular periodic use of systemic antibiotics during 
participation in the trial 
8. Active genital herpes lesion (if not resolved by enrollment)** 
9. Investigational drug use other than LACTIN-V within 30 days or 10 half-lives of the 
drug, whichever is longer, of enrollment visit**  
10. Other planned participation in an investigational drug study while participating in this 
study** 
11. Menopause defined as more than 12 consecutive months of amenorrhea without 
another known cause including pregnancy  
12. IUD insertion or removal, pelvic surgery, cervical cryotherapy or cervical laser 
treatment within the last 2 months prior to screening 
13. Use of vaginal ring (eg, NuvaRing) within 3 days of screening or during the course of 
the study** 
14. Failure to complete 5 days of MetroGel with the last dose taken no later than 48 
hours prior to randomization*** 
15. Use of new long-acting hormonal treatments. Participant may be enrolled if stable 
(>3 months) on existing therapy as determined by the principal investigator** 
16. Known allergy to any component of LACTIN-V/placebo or MetroGel or to 
nitroimidazole derivatives or latex (condoms) 
17. Any social, medical, or psychiatric condition including history of drug or alcohol 
abuse that in the opinion of the investigator would make it unlikely for the participant 
to comply with the study 
 
** Note: Criteria will be assessed at screening and enrollment. 
*** Note: Criteria will be assessed at enrollment. 

 
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5.3 
Treatment Assignment Procedures 
 
5.3.1 Randomization Procedures 
Women will be randomized at the enrollment visit 1 upon completion of the initial 
standardized antibiotic treatment with 0.75% topical MetroGel.   
Women will be randomly assigned to receive LACTIN-V at 2 x 109 cfu/dose or 
placebo in a 2:1 ratio. The 2:1 randomization was selected to increase precision 
of the estimated effectiveness of LACTIN-V to prevent recurrence of BV 12 
weeks after treatment with MetroGel.  
The list of randomized treatment assignments will be prepared by statisticians at 
The Emmes Corporation and provided to Fisher Bioservices. Fisher Bioservices 
will label each box of study treatment applicators sequentially with a treatment 
number according to the randomization scheme in a 2:1 (LACTIN-V to placebo) 
ratio.  
 
Instructions for use of the enrollment module are included in the 
AdvantageEDCSM User’s Guide.   
 
5.3.2 Masking Procedures 
At the time of enrollment, the site pharmacist will select the next available box of 
study product applicators in sequential order and will distribute to masked study 
personnel with no labels that identify the product or applicators as LACTIN-V or 
placebo.  No masking procedures are required for the MetroGel.   
 
The site pharmacist, participants, study personnel who perform study 
assessments, data entry personnel at the sites, and laboratory personnel 
performing study assays will be masked to treatment assignment. The Data and 
Safety Monitoring Board (DSMB) may receive data in aggregate and presented 
by treatment group, but without the treatment group identified. The DSMB may 
be unmasked to individual study treatment assignments, as needed, to 
adequately assess safety issues. Refer to the MOP for unmasking procedures, 
including emergency unblinding procedures. 
 
5.3.3 Reasons for Withdrawal 
 
5.3.3.1 Screening Failures 
Participants with the following diagnoses at the screening visit (Visit 0) 
will be considered screening failures and will be treated or referred for 
appropriate follow-up.  All screening failures will be replaced unless the 
diagnosis allows for Rescreening. 
 
• 
A diagnosis of a UTI, yeast vaginitis or an STI (T. vaginalis, N. 
gonorrhoeae, C. Trachomatis, T.pallidum), or vulvo-vaginal 
candidiasis) 
• 
Any diagnosis other than BV requiring antibiotics 

 
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A history of herpes genitalis does not exclude participants from 
participation as long as no active lesions are present at the enrollment 
visit and the participant experienced no more than one active outbreak 
of herpes genitalis within 6 months prior to screening. 
 
Participants diagnosed with a UTI at the screening visit (Visit 0) may 
choose to return to clinic for rescreening at least 21 days after 
completing antibiotic treatment. Participants diagnosed with an STI or 
participants with yeast vaginitis at the screening visit may be re-
screened at least 21 days after completing antibiotic treatment. 
Participants with active genital herpes lesions at enrollment are 
ineligible but can be re-screened after the outbreak has subsided. All 
screening procedures must be repeated unless otherwise clinically 
indicated.  
 
Participants who are eligible after screening but are subsequently 
deemed ineligible at the enrollment visit or do not return for the 
enrollment visit are considered screen-failures. 
 
5.3.3.2 Withdrawal after Enrollment 
 
Participants may withdraw or be withdrawn for any of the reasons given 
below.  The reason for withdrawal will be recorded in the data collection 
form.  
• 
Participant withdraws consent 
• 
Pregnancy or breastfeeding 
• 
Adverse event which requires discontinuation of the treatment 
regimen or results in inability to comply with study procedures 
• 
Discretionary decision by the site investigator  
• 
At the discretion of the IRB, FDA, NIH, or other government 
agencies as part of their duties to ensure that research participants 
are protected, or the industry supporter or its designee 
• 
Study is terminated 
 
5.3.4 Handling of Withdrawals 
 
All randomized participants who are discontinued from receiving further study 
product will continue to be followed through Visit 7 (Week 24, Day 168). Once a 
participant is randomized, she will not be replaced.  Withdrawals and drop-outs 
will not be replaced. 
 
If withdrawal of consent or study product discontinuation occurs after study 
treatment is initiated, the participant will be asked to continue scheduled study 
procedures including safety evaluations, if possible, and be given appropriate 
care under medical supervision if symptoms of any AE related to participation in 

 
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the study are continuing.  The participant will be followed until the AE is resolved 
or until the participant’s condition becomes stable. 
 
Participants who withdraw their consent for further participation in the study after 
their study treatment ends or discontinue study product early will be reminded of 
the importance of continuing in the study for safety evaluations. Participants will 
be encouraged to complete the Early Termination evaluations described in 
section 7.9 if they choose not to complete the remaining study visits.   
 
Participants who enroll in the study but do not return for study visits after a 
minimum of three attempts to contact them over a 2-week period will be 
considered lost to follow-up. 
 
5.3.5 Termination of Study  
 
Study closure may occur due to DSMB review, or at the discretion of the 
Institutional Review Board (IRB), FDA, DMID, and other government agencies as 
part of their duties to ensure that research participants are protected or the 
industry supporter or its designee. 
 

 
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6.0 
STUDY PRODUCT 
6.1 
Study Product Description 
 
LACTIN-V (Lactobacillus crispatus CTV-05)  
LACTIN-V contains a naturally occurring vaginal strain of Lactobacillus (L.) crispatus 
CTV-05, preserved as a powder and applied by a vaginal applicator. 
 
MetroGel vaginal gel (metro nidazo le gel) 
MetroGel vaginal gel is the intravaginal dosage form of the synthetic antibacterial agent, 
metronidazole, USP at a concentration of 0.75%. Metronidazole is a member of the 
imidazole class of antibacterial agents and is classified therapeutically as an 
antiprotozoal and antibacterial agent. Chemically, metronidazole is a 2-methyl-5-nitro 
imidazole-1-ethanol.  
 
At the Screening visit, eligible participants will receive MetroGel for the treatment of BV 
as described in section 7.0.  Participants who receive MetroGel, but do not complete the 
full MetroGel treatment, do not return for the Enrollment visit, or are otherwise found 
ineligible to be randomized to study treatment will not be enrolled into the study and will 
not be followed for safety or for AEs. 
 
6.1.1 Acquisition 
 
LACTIN-V and placebo 
Osel, Inc. will provide LACTIN-V and placebo. Upon request by DMID, LACTIN-V 
and placebo will be transferred to the following address:  
 
DMID Clinical Agents Repository (CAR) 
Fisher BioServices 
20439 Seneca Meadows Parkway 
Germantown, MD 20876 
Tel: (240) 477-1350 
Fax: (240) 477-1360 
Email: DMID.CAR@ThermoFisher.com 
 
MetroGel vaginal gel 
MetroGel vaginal gel will be purchased and supplied by the DMID CAR. 
 
LACTIN-V, placebo and MetroGel vaginal gel will be shipped from the DMID 
CAR to the study site upon request and approval by DMID. 
 
6.1.2 Formulation, Packaging, and Labeling 
 
LACTIN-V and placebo 
Each applicator will contain a LACTIN-V powder formulation containing L. 
crispatus CTV-05 at a potency of 2 x 109 cfu/dose.  LACTIN-V powder contains 
trehalose, xylitol, sodium ascorbate, colloidal silicon dioxide  and maltodextrin.  A 

 
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matching placebo formulation without L. crispatus CTV-05 is supplied in an 
identical applicator containing placebo powder.  
 
LACTIN-V or placebo pre-filled applicators will be individually packaged in heat-
sealed foil pouches, each containing one desiccant packet.  Each participant will 
receive one box containing 25 applicators. Each foil pouch and box will be 
labeled with the study number and unique participant number.  
 
The foil pouches and boxes will be labeled by the Osel Study Product Supplier.  
Each label will contain the study number and the FDA-required cautionary 
statement “Caution- New drug -Limited by Federal Law to Investigational Use.”  
The label of each box of study product applicators will also include the unique 
participant number and the statements: “Store at home in a cool, dry place out of 
reach of children (at room temperature).” 
 
MetroGel vaginal gel 
MetroGel vaginal gel is a gelled purified water solution, containing metronidazole 
at a concentration of 7.5 mg/g (0.75%). The gel is formulated at pH 4.0. The gel 
also contains carbomer 934P, edetate disodium, methylparaben, propylparaben, 
propylene gycol and sodium hydroxide.  
 
MetroGel vaginal gel is supplied in a 70 gram tube. Each participant will receive 
one box of MetroGel vaginal gel sufficient for the 5-day course of treatment. 
 
6.1.3 Product Storage and Stability 
 
LACTIN-V and placebo 
 
LACTIN-V and placebo applicators will be shipped overnight in an appropriate 
container on frozen gel packs and immediately placed into temperature-
controlled conditions (2–8°C) upon arrival. 
 
The study sites will store LACTIN-V and placebo applicators at 2-8°C.  
 
Participants will be instructed to store study product boxes in a cool, dry place, 
out of reach of children. 
 
MetroGel vaginal gel 
Store at controlled room temperature 15° to 30 °C (59 ° to 8 6 °F). Protect from 
freezing. 
 

 
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6.2 
Dosage, Preparation, and Administration of Study Product 
 
LACTIN-V and placebo 
Eligible participants will be instructed on how to insert the pre-filled applicator (LACTIN-V 
at 2 x 109 cfu/dose, or the placebo control substance) and will administer the first dose 
under direct supervision by the study clinician before leaving the clinic (Day 1). Study 
personnel will verify that each carton contains all 24 remaining applicators and this will 
be recorded on the appropriate Case Report Form (CRF).  Participants will be instructed 
to administer one dose once a day at bedtime for the next 4 days (beginning on Day 2), 
and then two times a week for 10 weeks. The remaining 20 applicators will be used for 
the two doses each week during weeks 2 through 11. 
 
MetroGel vaginal gel 
Participants will be instructed to administer one dose once a day at bedtime for 5 days 
initiated as soon as possible (ideally within 5 days of diagnosis at the screening or 
follow-up visit for symptomatic participants, or within 24 days of the screening visit for 
asymptomatic participants (see section 7.0 for additional details).  
 
6.3 
Accountability Procedures for the Study Investigational Product 
 
 
After receipt of the study product, the site Principal Investigator (PI) is responsible for 
 
distribution and disposition of these study products, and has ultimate responsibility for 
 
drug accountability. The PI may delegate this responsibility to the site pharmacist 
 
(or designee).  The site pharmacist (or designee) must maintain study product 
 
records and document logs of receipt, accountability, and storage temperature 
 
conditions. These study product accountability and dispensing logs must be maintained 
 
in the study file.  Upon completion of the study and after the final monitoring visit, 
 
unused applicators will be retained until monitored and released for disposition as 
 
per the Sponsor. Used LACTIN-V or placebo applicators will be collected and stained to 
 
determine if the participant used the study product and then disposed of after 
 
evaluation. For detailed information regarding final disposition of study product see 
 
the protocol-specific MOP.   
 
6.4 
Assessment of Subject Compliance with Study Product  
 
Compliance with study product will be assessed by participant self-report and applicator 
staining as described in the MOP. 
 
6.5 
Concomitant Medications/Treatments 
 
The study requires documentation of all medications (name, dose, route, frequency of 
dosing, and reason for use) taken by participants 30 days prior to screening through Visit 
7 (Week 24, Day 168) or early termination, whichever occurs first.  
 
The following medications are permitted throughout the study: 
• 
Vitamins and other nutritional supplements   
• 
Hormonal  contraceptives 

 
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• 
Cough medicine 
• 
Non-steroidal anti-inflammatory drugs 
• 
Prescription and over-the counter medications for allergies and asthma 
• 
Herbal, naturopathic, and traditional preparations (eg, Chinese traditional 
medications)  
• 
Externally applied topical medications (except genital area)  
• 
Antibiotics prescribed during the trial, including for MetroGel for BV  
 
The following medications are prohibited throughout the study, and participants will be 
instructed to not use them throughout the study up to Visit 7 (Week 24, Day 168): 
 
• 
Immune suppressants 
• 
Investigational drug preparations other than the study product 
• 
Intravaginal medications/preparations and topical medications/preparations other 
than the study product applied to the external genitalia  
 
Any other medication/treatment not listed as permitted or prohibited is subject to the judgment of 
the investigator. 

 
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7.0 
STUDY SCHEDULE 
7.1 
Screening Visit 0 (Day -30 to Day -5) 
The purpose of the screening visit is to identify participants who satisfy all eligibility 
criteria, including the diagnosis of symptomatic or asymptomatic bacterial vaginosis. 
Participants who agree to be screened will be asked to sign the screening informed 
consent form that will describe the purpose of the screening, the procedures to be 
followed, and the risks and benefits of screening and will include a separate section for 
consent to store samples for future use.  A copy of the consent form will be given to the 
participant and this fact will be documented in the medical record. A separate consent 
form will be completed during the enrollment visit after study eligibility is established. 
 
Participants will be asked to provide contact information (ie, address, email address, 
home/cell phone number, emergency contact), which will be recorded on appropriate 
form.  
 
At the screening visit (Visit 0) the woman's menstrual cycle history will be evaluated to 
ensure regular menstrual cycles (or amenorrhea due to long-acting contraceptives). 
Depending on the timing of her menstrual cycle, the screening procedure will be as 
follows: 
1. If she has just finished her menstrual cycle or is within the first half of her cycle with 
12 days or more expected until the onset of the next menstrual cycle, (latest 
screening visit on the 16th day of a regular 28-day cycle), she will proceed with 
screening, and will be able to complete screening, the treatment course of BV with 5 
days of topical MetroGel, the Enrollment Visit (Visit 1) (in case of eligibility confirmed 
by the laboratory results of the screening visit) within 48 hours of her last MetroGel 
administration, and the 5 days of continuous product use starting during the 
enrollment visit  (Visit 1).  
2. If she is menstruating at the time of the screening visit she will be asked to return for 
the screening visit as soon as possible after her menstrual cycle ends.  
3. If she is in the second half of her cycle with less than 12 days expected before the 
onset of the next menstrual bleeding, she will proceed with screening, but will be 
instructed to wait until after her next period before starting the 5-day treatment 
course of MetroGel.   
 
The screening visit must also be timed depending on her availability to return for the 
enrollment visit (visit 1) within 12-48 hours after the termination of the 5-day course of 
MetroGel. MetroGel treatment for women with symptomatic BV should be initiated as 
soon as possible (ideally within 5 days of diagnosis at the screening visit). For women 
diagnosed with asymptomatic BV at the screening visit, MetroGel should be initiated 
according to her menstrual cycle and within 24 days of the screening visit to ensure the 
time window between screening and enrollment is not more than 30 days.  
 
Women must start MetroGel treatment on a Tuesday, Wednesday, Thursday, Friday or 
Saturday (NOT Sunday or Monday) in order to return for enrollment and within 12-48 
hours after the 5th dose of her MetroGel treatment on the subsequent weekday Monday 
– Friday. 

 
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Table 7.1  
 
TUE 
WED 
THU 
FRI 
SAT 
SUN 
MON 
TUE 
WED 
THU 
FRI 
SAT 
SUN 
MON 
TUE 
5 day MetroGel 
Break 
 12-48 
 hours 
Enrollment  
5 days study product 
 
 
 
 
 
5 day MetroGel 
Break 
 12-48 
 hours 
Enrollment  
5 days study product 
 
 
 
 
 
5 day MetroGel 
Break 
 12-48 
 hours 
Enrollment  
5 days study product 
 
 
 
 
 
5 day MetroGel 
Break 
 12-48 
 hours 
Enrollment  
5 days study product 
 
 
 
 
 
5 day MetroGel 
Break 
 12-48 
 hours 
Enrollment  
5 days study product 
 
Participants who give informed consent will undergo the following procedures and 
assessments at the Screening Visit: 
1. Assessment of eligibility 
2. Detailed structured interview to obtain demographic information, medical, 
gynecological and sexual history to include assessment of STI and HIV risk  
3. Review of concomitant medications 
4. Acceptability questionnaire to determine participant’s experiences with BV and use of 
vaginal products in the past 
5. Complete physical and pelvic examination by a study physician or nurse that will 
include vital signs, including temperature, height and weight, and examination of 
respiratory and cardiovascular systems 
6. The pelvic examination will be conducted in the following order: 
a. Examination of the external genitalia 
b. Speculum insertion and examination of vagina, fornices and cervix with naked 
eye.  Water will be used to ease speculum insertion.  No lubricant should be 
used as it could contain chlorhexidine which may kill Lactobacillus. 
c. Vaginal swab for vaginal pH 
d. Vaginal swab for wet mount taken from the posterior fornix for trichomoniasis, 
yeast vaginitis, and clue cells and for amine test (whiff test)  
e. Vaginal swab for Gram stain (Nugent scoring system) 
f. Vaginal swabs (no more than two) for storage and future identification of vaginal 
bacteria, and possible multiomic (e.g. proteomics, metabolomics, etc.) testing 
g. Cervical (or vaginal) swabs for nucleic acid amplification of N. gonorrhoeae, C. 
trachomatis, and T. vaginalis 
7. Clean catch urine dipstick; urinalysis if abnormal results indicate 
8. Rapid urine βhCG pregnancy test. If the test is positive, the screening visit will be 
terminated as the woman is not eligible.  
9. Blood draw for Syphilis serology testing and HIV testing by standardized algorithms 
10. If the examiner suspects or confirms a UTI, vulvo-vaginal candidiasis, or an STI 
(T.vaginalis, N. gonorrhoeae, C.trachomatis, T. pallidum), the woman will be referred 
to standard of care treatment and may be invited for rescreening (see section 7.1.1). 
11. All clinical and laboratory findings at the time of the evaluation will be recorded on 
the CRF. These findings will include observations present on the pelvic exam, such 

 
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as genital findings including location; presence or absence and character of vaginal 
or cervical discharge or lesions; and results of any on-site tests. 
12. Participants diagnosed with BV by Amsel criteria ≥3 who agree to be treated with 
MetroGel and meet all eligibility criteria will be invited to return for the enrollment visit 
immediately after the completion of MetroGel, pending confirmation of BV diagnosis 
by Nugent score 4-10 and laboratory test results for STIs and HIV. 
13. Participants with confirmed BV by Amsel criteria ≥3 will be given 0.75% topical 
MetroGel to apply vaginally once daily in the evening for 5 consecutive days. Should 
the woman be in the first half of her menstrual cycle and her period is not expected 
for the next 12 days, she should start MetroGel on the evening of the screening visit. 
It also needs to be timed in accordance with her availability to return for the 
enrollment visit (Visit 1) within 12-48 hours after the completion of the 5-day course 
of MetroGel. See scheduling sequences in Table 7.1. MetroGel treatment for women 
with symptomatic BV should be initiated as soon as possible (ideally within 5 days of 
diagnosis at the Screening Visit). For women diagnosed with asymptomatic BV at the 
screening visit, MetroGel treatment needs to be initiated according to her menstrual 
cycle and within 24 days of the screening visit to ensure the time window between 
screening and enrollment is not more than 30 days.  
14. Participants will be advised to return for the enrollment visit within 12-48 hours after 
completion of MetroGel treatment. 
15. Non-spermicidal condoms will be dispensed. 
At screening, women with evidence of any STI diagnosed according to the study site’s 
protocol will be referred to standard of care treatment in compliance with current CDC 
STD Treatment Guidelines. If laboratory test results received after the screening visit 
determine ineligibility, the woman will be managed as clinically indicated for her 
respective condition and contacted to cancel her scheduled enrollment visit.  She will not 
be eligible for rescreening until 21 days after resolution of the abnormality (see section 
7.1.1). 
 
7.1.1 Rescreening Visit 
 
At least 21 days after completion of successful treatment for UTI or STI, 
participants will be invited for rescreening. At rescreening, the following 
procedures will be repeated to determine the diagnosis of bacterial vaginosis and 
eligibility for enrollment into the study. 
 
1. Detailed structure interview to obtain demographic information and medical, 
gynecological and sexual history to include assessment of STI and HIV risk 
2. Review of concomitant medications 
3. Complete physical and pelvic examination by a study physician or nurse that 
will include vital signs, including temperature, height and weight, and 
examination of respiratory and cardiovascular systems 
4. The pelvic examination will be conducted in the following order: 
a. Examination of the external genitalia 
b. Speculum insertion and examination of vagina, fornices and cervix with 
naked eye. Water will be used to ease speculum insertion. No lubricant 

 
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should be used as it could contain chlorhexidine which may kill 
Lactobacillus. 
c. Vaginal swab for vaginal pH 
d. Vaginal swab for wet mount taken from the posterior fornix for 
trichomoniasis, yeast vaginitis, and clue cells and for amine test (whiff 
test) 
e. Vaginal swab for Gram stain (Nugent scoring system) 
f. Vaginal swabs (no more than two) for storage and future identification of 
vaginal bacteria, and possible multiomic (e.g. proteomics, metabolomics, 
etc.) testing 
g. Cervical (or vaginal) swabs for nucleic acid amplification of N. 
gonorrhoeae, C. trachomatis, and T. vaginalis 
5. Clean catch urine dipstick; urinalysis if abnormal results indicate 
6. Rapid urine βhCG pregnancy test  
7. Blood draw for Syphilis serology testing and HIV testing by standardized 
algorithms if re-screening occurs more than 90 days after initial screening 
visit 
 
7.2 
Enrollment Visit 1 (Day 1) 
 
Only women who are diagnosed at the screening visit with BV (by Amsel criteria ≥3 and 
have a Nugent score 4-10 on the vaginal specimen collected at the screening visit) and 
complete a 5-day course of MetroGel are eligible to enroll in the study.  These women 
will be scheduled to return for the enrollment visit within 12-48 hours after completing the 
5th dose of MetroGel treatment. 
 
Once eligibility is determined from screening tests, the woman will be asked to sign the 
enrollment consent form which will describe the purpose of the study, the procedures to 
be followed, the risks and benefits of the study, and will include a separate section for 
consent to store samples for future use. A copy of the consent form will be given to her 
and this fact will be documented in her medical record.  
 
After signing the enrollment consent form, she will be asked to verify previously reported 
contact information which will be recorded on the appropriate form.  
 
At the enrollment visit, her menstrual cycle history will be re-evaluated to ensure regular 
menstrual cycles (or amenorrhea with long-acting contraceptives) and that menstruation 
will not be expected during the next 5 days when the use of the study product for 5 
consecutive days (days 1-5) has to occur. If she is not currently having menstrual 
bleeding and her period is not to be expected within the next 5 days, she will proceed 
with the enrollment visit. Before commencing with the enrollment exam, eligibility should 
be confirmed by reviewing the medical history and ALL results of the screening visit 
(including all laboratory results which must be complete). In addition, it must be 
confirmed that she completed MetroGel treatment on 5 consecutive days, and that the 
5th dose was administered within 48 hours before the enrollment visit.  
 

 
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If still eligible, participants will undergo the following procedures at the enrollment visit 
(Day 1): 
1. Detailed confirmation of demographic information, medical, gynecological and sexual 
history obtained to include assessment of STI and HIV risk  
2. Review of concomitant medications 
3. Symptom-directed physical and pelvic examination by a study physician or nurse that 
will include vital signs, including temperature, height and weight, and examination of 
respiratory and cardiovascular systems 
4. The pelvic examination will be conducted in the following order: 
a. Examination of the external genitalia 
b. Speculum insertion and examination of vagina, fornices and cervix with naked 
eye.  Water will be used to ease speculum insertion.  No lubricant should be 
used as it could contain chlorhexidine which may kill Lactobacillus. 
c. Vaginal pH 
d. Vaginal swab for wet mount taken from the posterior fornix for yeast vaginitis and 
clue cells and for amine test (whiff test)  
e. Vaginal swab for Gram stain (Nugent scoring system) 
f. Vaginal swabs (no more than two) for storage and future identification of vaginal 
bacteria, and possible multiomic (e.g. proteomics, metabolomics, etc.) testing 
g. Vaginal swabs for L. crispatus identification with qPCR 
If indicated, cervical (or vaginal) swabs for nucleic acid amplification of N. 
gonorrhoeae, C. trachomatis, and T. vaginalis 
Women with findings on pelvic exam at the enrollment visit, including active 
genital herpes lesions or for other reasons will be considered screening failures, 
will not be enrolled and will be referred for further evaluation. 
5. If indicated, clean catch urine dipstick; urinalysis if abnormal results indicate 
6. Rapid urine βhCG pregnancy test. If the test is positive, the enrollment visit will be 
terminated as the woman is not eligible.  
7. All clinical and laboratory findings at the time of the evaluation will be recorded on 
the CRF. These findings will include observations present on the pelvic exam such 
as genital findings including location; presence or absence, and character of vaginal 
or cervical discharge or lesions; and results of any on-site tests. 
8. If the clinician suspects the participant developed an STI since the screening visit, 
appropriate tests will be conducted and if needed the woman will be referred to 
standard of care treatment in compliance with current CDC STD Treatment 
Guidelines. The participant cannot be enrolled at this time but could be invited for 
rescreening after completion of treatment, if indicated.  
9. Randomization and enrollment into AdvantageEDCSM  
10. LACTIN-V/placebo and applicator will be dispensed to participants. Participants will 
self-administer the first dose of LACTIN-V/placebo in the clinic during this visit. 
Participants will then be instructed to administer one dose of LACTIN-V/or placebo 
once a day at bedtime for the next 4 days (beginning on Day 2) and then twice 
weekly for 10 weeks. Participants will be instructed to transport the pre-filled 
applicators while avoiding exposure to high temperatures. 

 
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11. Participants will be given a memory aid or a web link (with a username and 
temporary password) and instructed to make an entry following each insertion of a 
pre-filled applicator beginning with the first application at Visit 1 (Day 1). Any 
symptoms that occur during the study up until Visit 7 (Week 24, Day168) will be 
recorded on the memory aid. Participants not using the web link will be reminded to 
return with the paper memory aid at each study visit where it will be reviewed. 
12. Participants will be instructed to abstain from sexual intercourse during the first 5 
days of study product administration, for 12 hours after the weekly study product 
applications and 12 hours before study Visit 2 (Week 4, Day 28), Visit 3 (Week 8, 
Day 56), Visit 4 (Week 12, Day 84) and Visit 7 (Week 24, Day 168).  
13. Participants will receive non-spermicidal lubricated condoms for their male sexual 
partners who will be encouraged to use condoms from Visit 1 (Day 1) through Visit 7 
(Week 24, Day 168) if they engage in vaginal intercourse. 
14. Participants will be instructed not to use scented tampons or any other vaginal 
products through Visit 7 (Week 24, Day 168). 
15. Participants will be advised to return for Visit 2 (Week 4, Day 28), Visit 3 (Week 8, 
Day 56) and Visit 4 (Week 12, Day 84) with allowable scheduling within 7 days of the 
target date. Depending on the time of the enrollment and the average length of the 
woman’s menstrual cycle, careful attention should be paid to the approximate time of 
her next menstrual period when scheduling those visits. Later adjustments of those 
dates may be necessary.  
16. Participants will be asked to collect all used applicators and store them as described 
in the MOP.  
17. Participants will be asked to return all used applicators at their next visit.  
 
Participants immediately diagnosed with yeast on the wet mount (with or without 
discharge or vaginitis symptoms) during the enrollment visit will be referred for standard 
treatment. They will not be randomized and will not be invited for rescreening.  
 
If available test results at the enrollment visit suggest a UTI, cervicitis, vulvovaginitis, or 
active genital herpes lesion, the woman will be managed as clinically indicated and not 
randomized at this time, but invited for rescreening after completion of treatment. 
 
The antibiotics administered to treat BV need time to eliminate pathogens and the 
vaginal flora needs time to naturally replenish its lactobacilli population. By standard 
definition, a treatment of BV is only considered to have failed if Amsel criteria or Nugent 
score on Gram stain diagnose BV to persist at 22-30 days after the initiation of the 
antibiotic treatment. As a result, women who continue to have BV during the enrollment 
visit will not be re-treated with MetroGel at the time of enrollment, as additional time is 
needed for BV to resolve after antibiotic treatment. Thus, they are not considered 
treatment failures at this time (approximately 2 days after termination of antibiotic 
treatment). 
 
Participants diagnosed with an STI after randomization (when showing symptoms at 
subsequent visits that are confirmed with laboratory testing) will be referred for standard 
treatment and continue to receive study product.  
 

 
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7.3 
Follow-up Study Visit 2, Week 4, Day 28 (Allowable Days 21-35) 
 
The following procedures and assessments will be performed at Visit 2, Week 4, Day 28: 
1. Participants will return on Day 28. Staff will review the memory aid with the 
participant. The participant will be asked about symptoms, concomitant medications 
and any medical problems since the last visit, which will be recorded on the 
appropriate CRF. The participant will be asked to provide exact dates and times of 
the study product administration. 
2. Medical, gynecological and sexual history to include assessment of STI and HIV risk 
3. Symptom-directed physical and pelvic examination by a study physician or nurse that 
will include vital signs, including temperature, and examination of respiratory and 
cardiovascular systems, as well as assessment of symptoms and adverse events 
4. The pelvic examination will be conducted in the following order: 
a. Examination of the external genitalia 
b. Speculum insertion and examination of vagina, fornices and cervix with naked 
eye.  Water will be used to ease speculum insertion. No lubricant should be used 
as it could contain chlorhexidine which may kill Lactobacillus. 
c. Vaginal pH 
d. Vaginal swab for wet mount taken from the posterior fornix for yeast vaginitis and 
clue cells and for amine test (whiff test)  
e. Vaginal swab for Gram stain (Nugent scoring system) 
f. Vaginal swabs (no more than two) for storage and future identification of vaginal 
bacteria, and possible multiomic (e.g. proteomics, metabolomics, etc.) testing 
g. Vaginal swabs for L. crispatus identification with qPCR 
h. If indicated, cervical (or vaginal) swab for nucleic acid amplification of N. 
gonorrhoeae, C. trachomatis, and T.  vaginalis 
5. If indicated, clean catch urine dipstick; urinalysis if abnormal results indicate  
6. If indicated, urine βhCG pregnancy test 
7. All clinical and laboratory findings at the time of the evaluation will be recorded on 
the CRF. These findings will include observations present on the pelvic exam such 
as genital findings including location; presence or absence, and character of vaginal 
or cervical discharge or lesions; and results of any on-site tests. 
8. Participants will be reminded not to use scented tampons or any other vaginal 
products through Visit 7 (Week 24, Day 168).   
9. Participants will be reminded to abstain from sexual intercourse for 12 hours after 
each study product application and for 12 hours before the remaining study visits at 
Visit 3 (Week 8, Day 56), Visit 4 (Week 12, Day 84) and Visit 7 (Week 24, Day 168).  
10. Participants will receive non-spermicidal lubricated condoms for their male sexual 
partners.  Participants will be encouraged to use condoms if they engage in vaginal 
intercourse through Visit 7 (Week 24, Day 168). 
11. Participants will be asked if they still have the remaining applicators for the twice 
weekly doses stored at home. If not, they will receive additional pre-filled applicators 
to administer twice weekly through week 11. Participants will be instructed to 
transport the pre-filled applicators while avoiding exposure to high temperatures. 

 
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12. Participants will be instructed to collect all used applicators and store them as 
described in the MOP and to return all used applicators at their next visit, Visit 3 
(Week 8, Day 56). 
13. Applicators used since the last study visit will be collected. Applicators will be stained 
and tested as described in the MOP. 
14. An appointment for the follow-up visit will be scheduled. Depending on the time of 
the enrollment and the average length of the participant’s menstrual cycle, careful 
attention should be paid to the approximate time of the participant’s next menstrual 
period when scheduling those visits. Later adjustments of those dates may be 
necessary. 
Women with vaginal discharge or vaginitis symptoms who were diagnosed with yeast on 
the wet mount during the follow-up visit will be referred for standard treatment and 
continue to receive study product. 
  
If the test results at the follow-up visit suggest a urinary tract infection, cervicitis or 
vulvovaginitis, the participant will be referred for standard treatment and continue to 
receive study product. 
 
If the clinician suspects the woman to have developed an STI since the last visit, 
appropriate tests will be conducted and if needed the woman will be referred to standard 
of care treatment in compliance with current CDC STD Treatment Guidelines. The 
participant should be treated in case of positive findings and continue to use study 
product. 
 
Women who develop symptomatic BV confirmed by wet mount Amsel criteria ≥3 (with or 
without confirmatory Gram stain) at least 4 weeks after the last MetroGel treatment will 
be retreated with MetroGel. This practice follows CDC treatment guidelines and FDA 
recommendations. The 5-day course of MetroGel will begin as soon as possible.  
Women will skip their regularly scheduled dose of study product until 24 hours after their 
last dose of MetroGel when study product dosing will continue twice weekly. Women 
diagnosed with asymptomatic BV during the follow-up visit will not be retreated with 
MetroGel.  
 
7.4 
Follow-up Study Visit 3, Week 8, Day 56 (Allowable Days 49-63) 
The same procedures and assessments performed at Study Visit 2, Week 4, Day 28 will 
also be done at this visit. 
 
7.5 
Follow-Up Study Visit 4, Week 12, Day 84 (Allowable Days 77-91) 
The following procedures and assessments will be performed at Visit 4, Week 12, Day 
84: 
1. Participants will return on Day 84. Staff will review the memory aid with the 
participant. The participant will be asked about symptoms, concomitant medications 
and any medical problems since the last visit, which will be recorded on the 
appropriate CRF. The participant will be asked to provide exact dates and times of 
the study product administration.   
2. Medical, gynecological and sexual history to include assessment of STI and HIV risk 

 
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3. Symptom-directed physical and pelvic examination by a study physician or nurse that 
will include vital signs, including temperature, and examination of respiratory and 
cardiovascular systems, as well as assessment of symptoms and adverse events 
4. The pelvic examination will be conducted in the following order: 
a. Examination of the external genitalia 
b. Speculum insertion and examination of vagina, fornices and cervix with naked 
eye.  Water will be used to ease speculum insertion.  No lubricant should be 
used as it could contain chlorhexidine which may kill Lactobacillus. 
c. Vaginal pH 
d. Vaginal swab for wet mount taken from the posterior fornix for yeast vaginitis and 
clue cells and for amine test (whiff test)  
e. Vaginal swab for Gram stain (Nugent scoring system) 
f. Vaginal swabs (no more than two) for storage and future identification of vaginal 
bacteria, and possible multiomic (e.g. proteomics, metabolomics, etc.) testing   
g. Vaginal swabs for L. crispatus identification with qPCR 
h. If indicated, cervical (or vaginal) swab for nucleic acid amplification of N. 
gonorrhoeae, C. trachomatis, and T. vaginalis 
5. If indicated, clean catch urine dipstick; urinalysis if abnormal results indicate 
6. If indicated, urine βhCG pregnancy test 
7. All clinical and laboratory findings at the time of the evaluation will be recorded on 
the CRF. These findings will include observations present on the pelvic exam such 
as genital findings including location; presence or absence, and character of vaginal 
or cervical discharge or lesions; and results of any on-site tests. 
8. Participants will be asked to answer a detailed self-administered questionnaire 
assessing the acceptability of the study product and the applicator to evaluate the 
possible change of attitudes over time.   
9. Participants will be reminded not to use scented tampons or any other vaginal 
products through Visit 7 (Week 24, Day 168).   
10. Participants will be reminded to abstain from sexual intercourse for 12 hours before 
study Visit 7 (Week 24, Day 168).  
11. Participants will receive non-spermicidal lubricated condoms for their male sexual 
partners.  Participants will be encouraged to use condoms if they engage in vaginal 
intercourse through Visit 7 (Week 24, Day 168). 
12. Applicators used since the last study visit will be collected. Applicators will be stained 
and tested as described in the MOP. 
13. An appointment for a telephone interview at Visit 5 (Week 16, Day 112) and at Visit 6 
(Week 20, Day 140) will be scheduled. 
14. An appointment for the next follow-up visit, Visit 7 (Week 24, Day 168) will be 
scheduled. Depending on the time of the enrollment and the average length of the 
participant’s menstrual cycle, careful attention should be paid to the approximate 
time of the participant’s next menstrual period when scheduling those visits. Later 
adjustments of those dates may be necessary. 
Women with vaginal discharge or vaginitis symptoms who were diagnosed with yeast on 
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If the test results at the follow-up visit suggest a urinary tract infection, cervicitis or 
vulvovaginitis, the participant will be referred for standard treatment.  
 
If the clinician suspects the woman to have developed an STI since the last visit, 
appropriate tests will be conducted and if needed the woman will be referred to standard 
of care treatment in compliance with current CDC STD Treatment Guidelines. The 
participant should be treated in case of positive findings. 
 
Women who develop symptomatic BV confirmed by wet mount Amsel criteria ≥3 (with or 
without confirmatory Gram stain) at least 4 weeks after the last MetroGel treatment will 
be retreated with MetroGel. This practice follows CDC treatment guidelines and FDA 
recommendations. The 5-day course of MetroGel will begin as soon as possible.  
Women will skip their regularly scheduled dose of study product until 24 hours after their 
last dose of MetroGel when study product dosing will continue twice weekly. Women 
diagnosed with asymptomatic BV during the follow-up visit will not be retreated with 
MetroGel.  
 
7.6 
Telephone Interview, Visit 5, Week 16, Day 112 (Allowable Days 105-119) 
 
Between Visit 4 (Week 12, Day 84) and Visit 7 (Week 24, Day 168), communication with 
participants will be continued by monthly telephone interviews.  
1. Participants will be called for a prearranged telephone interview at Day 112. Staff will 
review the memory aid with the participant. The participant will be asked about 
symptoms, concomitant medications, last menses, sexual activity and any medical 
problems since the last visit, which will be recorded on the appropriate CRF.  
2. Participants are invited to present at the clinic for an unscheduled visit if the site 
investigator deems it necessary after reviewing any medical problems or symptoms. 
3. Participants will be reminded not to use scented tampons or any other vaginal 
products through Visit 7 (Week 24, Day 168).   
4. Participants will be reminded to abstain from sexual intercourse for 12 hours before 
the last study visit, Visit 7 (Week 24, Day 168). 
5. An appointment for the next telephone interview at Visit 6 (Week 20, Day 140) will be 
confirmed or rescheduled if necessary. 
6. An appointment for the final visit, Visit 7 (Week 24, Day 168) will be confirmed. 
Depending on the time of the enrollment and the average length of the participant’s 
menstrual cycle, careful attention should be paid to the approximate time of the 
participant’s next menstrual period when scheduling those visits. Later adjustments 
of those dates may be necessary. 
 
If the participant fails to cancel the appointment and reschedule, and is unreachable 
during the agreed upon time for the telephone interview, the study team will make three 
attempts to reach the participant to reschedule the telephone interview.  
 
7.7 
Telephone Interview, Visit 6, Week 20, Day 140 (Allowable Days 133-146) 
 
The same assessments and instructions at Telephone Interview, Visit 5, Week 16, Day 
112 will also be done during this telephone interview.  

 
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7.8 
Final Study Visit 7, Week 24, Day 168 (Allowable Days 161-175) 
 
The following procedures and assessments will be performed at Visit 7, Week 24, Day 
168.  
1. Participants will return on Day 168. Staff will review the memory aid with the 
participant. The participant will be asked about symptoms, concomitant medications 
and any medical problems since the last visit, which will be recorded on the 
appropriate CRF.   
2. Medical, gynecological and sexual history to include assessment of STI and HIV risk 
3. Symptom-directed physical and pelvic examination by a study physician or nurse that 
will include vital signs, including temperature, and examination of respiratory and 
cardiovascular systems, as well as assessment of symptoms and adverse events 
4. The pelvic examination will be conducted in the following order: 
a. Examination of the external genitalia 
b. Speculum insertion and examination of vagina, fornices and cervix with naked 
eye.  Water will be used to ease speculum insertion.  No lubricant should be 
used as it could contain chlorhexidine which may kill Lactobacillus. 
c. Vaginal pH 
d. Vaginal swab for wet mount taken from the posterior fornix for yeast vaginitis and 
clue cells and for amine test (whiff test)  
e. Vaginal swab for Gram stain (Nugent scoring system) 
f. Vaginal swabs (no more than two) for storage and future identification of vaginal 
bacteria, and possible multiomic (e.g. proteomics, metabolomics, etc.) testing 
g. Vaginal swabs for L. crispatus identification with qPCR 
h. If indicated, cervical (or vaginal) swab for nucleic acid amplification of N. 
gonorrhoeae, C. trachomatis, and T. vaginalis 
5. If indicated, clean catch urine dipstick; urinalysis if abnormal results indicate 
urinalysis 
6. If indicated, urine βhCG pregnancy test. 
7. All clinical and laboratory findings at the time of the evaluation will be recorded on 
the CRF. These findings will include observations present on the pelvic exam such 
as genital findings including location; presence or absence, and character of vaginal 
or cervical discharge or lesions; and results of any on-site tests. 
 
Women with vaginal discharge or vaginitis symptoms who were diagnosed with yeast on 
the wet mount during the follow-up visit will be referred for standard treatment.  
 
If the test results at the follow-up visit suggest a urinary tract infection, cervicitis or 
vulvovaginitis, the participant will be referred for standard treatment.  
 
If the clinician suspects the woman to have developed an STI since the last visit, 
appropriate tests will be conducted and if needed the woman will be referred to standard 
of care treatment in compliance with current CDC STD Treatment Guidelines. The 
participant should be treated in case of positive findings. 
 

 
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Women who develop symptomatic BV confirmed by wet mount Amsel criteria ≥3 (with or 
without confirmatory Gram stain) at least 4 weeks after the last MetroGel treatment will 
be retreated with MetroGel. This practice follows CDC treatment guidelines and FDA 
recommendations. The 5-day course of MetroGel will begin as soon as possible.  
Women will skip their regularly scheduled dose of study product until 24 hours after their 
last dose of MetroGel when study product dosing will continue twice weekly. Women 
diagnosed with asymptomatic BV during the follow-up visit will not be retreated with 
MetroGel.  
 
7.9 
Study Product Discontinuation/Early Termination Visit 
 
Study product discontinuation and early termination evaluations will be performed as 
described below. Women who must discontinue taking the study product, for reasons 
described in section 5.3.3.2, before the end of the study-defined treatment period, will be 
asked to stay in the study to be followed on study/off treatment until study completion. 
Women who terminate their participation in the study early will be asked to have one 
final study visit but could return to be followed on study/off treatment until study 
completion if circumstances of the termination change. 
1. Staff will review the memory aid with the participant if the participant declines to 
return for follow-up visits.  The participant will be asked about symptoms, 
concomitant medications and any medical problems since the last visit, which will be 
recorded on the appropriate CRF. The participant will be asked to provide exact 
dates and times of the study product administration.   
2. Medical, gynecological and sexual history to include assessment of STI and HIV risk 
3. Symptom-directed physical and pelvic examination by a study physician or nurse that 
will include vital signs, including temperature, and examination of respiratory and 
cardiovascular systems, as well as assessment of symptoms and adverse events 
4. The pelvic examination will be conducted in the following order: 
a. Examination of the external genitalia 
b. Speculum insertion and examination of vagina, fornices and cervix with naked 
eye.  Water will be used to ease speculum insertion.  No lubricant should be 
used as it could contain chlorhexidine which may kill Lactobacillus. 
c. Vaginal pH 
d. Vaginal swab for wet mount taken from the posterior fornix for yeast vaginitis and 
clue cells and for amine test (whiff test)  
e. Vaginal swab for Gram stain (Nugent scoring system) 
f. Vaginal swabs (no more than two) for storage and future identification of vaginal 
bacteria, and possible multiomic (e.g. proteomics, metabolomics, etc.) testing 
g. If indicated, cervical (or vaginal) swab for nucleic acid amplification of N. 
gonorrhoeae, C. trachomatis, and T. vaginalis 
h. Other tests as deemed necessary by the site investigator in response to 
symptoms presented at this visit 
5. If indicated, clean catch urine dipstick; urinalysis if abnormal results indicate  
6. If indicated, urine βhCG pregnancy test 
7. All clinical and laboratory findings at the time of the evaluation will be recorded on 
the CRF. These findings will include observations present on the pelvic exam such 

 
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as genital findings including location; presence or absence, and character of vaginal 
or cervical discharge or lesions; and results of any on-site tests. 
8. Applicators used since the last study visit will be collected.  Any remaining unused 
applicators will also be collected.  
9. Administer acceptability questionnaire 
10. Dispense condoms to subjects who discontinue study product but remain in follow 
up. 
11. If the clinician suspects the participant developed an STI since the last visit, 
appropriate tests will be conducted and if needed the woman will be referred to 
standard of care treatment in compliance with current CDC STD Treatment 
Guidelines. 
 
7.10 Unscheduled Visit  
 
An unscheduled visit following a participant’s request or the site investigator’s 
recommendation should be recorded on the appropriate CRF. The following procedures 
and assessments may be performed at the unscheduled visit: 
1. Staff will review the memory aid with the participant. The participant will be asked 
about symptoms, concomitant medications and any medical problems since the last 
visit, which will be recorded on the appropriate CRF. Additionally, the participant will 
be asked to provide exact dates and times of the study product administration.   
2. Medical, gynecological and sexual history to include assessment of STI and HIV risk 
3. Symptom-directed physical and pelvic examination by a study physician or nurse that 
will include vital signs, including temperature, and examination of respiratory and 
cardiovascular systems, as well as assessment of symptoms and adverse events 
4. The pelvic examination will be conducted in the following order: 
a. Examination of the external genitalia 
b. Speculum insertion and examination of vagina, fornices and cervix with naked 
eye.  Water will be used to ease speculum insertion.  No lubricant should be 
used as it could contain chlorhexidine which may kill Lactobacillus. 
c. Vaginal pH 
d. Vaginal swab for wet mount taken from the posterior fornix for yeast vaginitis and 
clue cells and for amine test (whiff test)  
e. Vaginal swab for Gram stain (Nugent scoring system) 
f. Vaginal swabs (no more than two) for storage and future identification of vaginal 
bacteria, and possible multiomic (e.g. proteomics, metabolomics, etc.) testing 
g. Vaginal swabs for L. crispatus identification with qPCR 
h. If indicated, cervical (or vaginal) swab for nucleic acid amplification of N. 
gonorrhoeae, C. trachomatis, and T. vaginalis 
i. 
Other tests as deemed necessary by the site investigator in response to 
symptoms presented at this visit 
5. If indicated, clean catch urine dipstick; urinalysis if abnormal results indicate 
6. If indicated, βhCG pregnancy test 
7. All clinical and laboratory findings at the time of the evaluation will be recorded on 
the CRF. These findings will include observations present on the pelvic exam such 

 
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as genital findings including location; presence or absence, and character of vaginal 
or cervical discharge or lesions; and results of any on-site tests. 
8. The applicators used since the last study visit will be collected. Applicators will be 
stained and tested as described in the MOP. 
9. An additional unscheduled visit as deemed necessary by the site investigator to 
ensure short-term surveillance will be planned.  
10. If the site investigator decides together with the participant that study product use 
can continue, participants will be asked if they still have the remaining applicators for 
the twice weekly doses stored at home. If not, they will receive additional pre-filled 
applicators to administer twice weekly through week 11. Participants will be 
instructed to transport the pre-filled applicators while avoiding exposure to high 
temperatures. 
11. Participants will be reminded not to use scented tampons or any other vaginal 
products through Visit 7 (Week 24, Day 168).   
12. Participants will be reminded to abstain from sexual intercourse for 12 hours after 
each study product application and 12 hours before the remaining study visits.  
13. Participants will receive non-spermicidal lubricated condoms for their male sexual 
partners.  Participants will be encouraged to use condoms if they engage in vaginal 
intercourse through Visit 7 (Week 24, Day 168). 
14. Participants will be instructed to collect all used applicators and store them as 
described in the MOP and to return all used applicators at their next visit. 
15. An appointment for the next regular follow-up visit will be scheduled. Depending on 
the time of the enrollment and the average length of the participant’s menstrual 
cycle, careful attention should be paid to the approximate time of the participant’s 
next menstrual period when scheduling those visits. Later adjustments of those dates 
may be necessary. 
 
Women with vaginal discharge or vaginitis symptoms who were diagnosed with yeast on 
the wet mount during the follow-up visit will be referred for standard treatment and 
continue to receive study product.  
 
If the test results at the follow-up visit suggest a urinary tract infection, cervicitis or 
vulvovaginitis, the participant will be referred for standard treatment and continue to 
receive study product. 
 
If the clinician suspects the woman to have developed an STI since the last visit, 
appropriate tests will be conducted and if needed the woman will be referred to standard 
of care treatment in compliance with current CDC STD Treatment Guidelines. The 
participant should be treated in case of positive findings and continue to use study 
product. 
 

 
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Women who develop symptomatic BV confirmed by wet mount Amsel criteria ≥3 (with or 
without confirmatory Gram stain) at least 4 weeks after the last MetroGel treatment will 
be retreated with MetroGel. This practice follows CDC treatment guidelines and FDA 
recommendations. The 5-day course of MetroGel will begin as soon as possible.  
Women will skip their regularly scheduled dose of study product until 24 hours after their 
last dose of MetroGel when study product dosing will continue twice weekly. Women 
diagnosed with asymptomatic BV during the follow-up visit will not be retreated with 
MetroGel.  
 

 
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8.0 
STUDY PROCEDURES/EVALUATIONS 
 
8.1 
Clinical Evaluations 
 
The following assessments and procedures will be performed: 
• 
Sociodemographic and participant contact information 
• 
Medical, gynecological and sexual history 
• 
Review of concomitant medications 
• 
Physical exam to include vital signs 
• 
Pelvic exam 
• 
Acceptability questionnaire 
 
8.2 
Laboratory Evaluations 
 
8.2.1 Clinical Laboratory Evaluations 
At each clinical site, the following tests will be performed using approved 
standard in-house tests: 
• 
Pregnancy will be tested by standard rapid urine βhCG assays.   
• 
Urine will be tested by urine dipstick for evidence of urinary tract infection, 
with follow-up urine culture for positives.   
• 
HIV testing will be conducted using standardized algorithms.*   
• 
Syphilis will be tested by rapid plasma reagin with a confirmatory 
agglutination.*   
*NOTE: The total blood required is approximately 15mL (3 teaspoons). 
• 
Cervical (or vaginal) swabs will be tested for N. gonorrhoeae, C. trachomatis 
and T. vaginalis by nucleic acid amplification.  
The following test will be performed by a central laboratory for all clinical sites: 
• 
Gram-stained vaginal smear by Nugent's scoring system for diagnosis of BV  
 
8.2.2 Special Assays or Procedures 
Vaginal specimens will be analyzed for vaginal colonization with L. crispatus 
using qPCR assays and will be performed by a central laboratory at UCSF.  
At UCSF, and at UCSF expense, a vaginal specimen will be stored for future 
testing of other bacteria associated with BV (cultivable and uncultivable) by 16S 
rRNA qPCR pending the availability of non-STI CTG research funds. 
 
8.2.3 Specimen Preparation, Handling, and Shipping 
8.2.3.1 Instructions for Specimen Preparation, Handling, and Storage 
Instructions for specimen preparation, handling, and storage will be 
described in the MOP. 
8.2.3.2 Specimen Shipment 
Instructions for specimen shipment will be described in the MOP. 

 
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9.0 
ASSESSMENT OF SAFETY 
9.1 
Specification of Safety Parameters 
 
All AEs and SAEs will be collected through Study Visit 7, Week 24, Day 168. 
 
9.2 
Methods and Timing for Assessing, Recording, and Analyzing Safety Parameters 
 
9.2.1 Adverse Events 
 
ICH (International Conference on Harmonisation) E6 defines an AE as any 
untoward medical occurrence in a patient or clinical investigation subject 
administered a pharmaceutical product regardless of its causal relationship to the 
study treatment.  An AE can therefore be any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of medicinal (investigational) product.  The occurrence of 
an AE may come to the attention of study personnel during study visits and 
interviews of a study participant presenting for medical care, or upon review by a 
study monitor.  
 
All AEs including local and systemic reactions not meeting the criteria for “serious 
adverse events” should be captured on the appropriate CRF and will include: 
• 
Vaginal bleeding other than menstruation 
• 
Abnormal vaginal discharge 
• 
Abnormal vaginal odor 
• 
Genital itching 
• 
Genital burning 
• 
External genital irritation  
• 
External genital swelling 
• 
Nausea  
• 
Vomiting 
• 
Abdominal pain/cramps 
• 
Diarrhea 
• 
Constipation 
• 
Genital rash 
• 
Pain/burning with urination 
• 
Frequent urination 
• 
Blood in urine 
• 
Headache 
 
Information to be collected includes event description, time of onset, clinician’s 
assessment of severity, relationship to study product (assessed only by those 
with the training and authority to make a diagnosis), and time of 
resolution/stabilization of the event.  All AEs occurring while on study must be 
documented appropriately regardless of relationship.  All AEs will be followed to 
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Any medical condition that is present at the time that the participant is screened 
should be considered as baseline and not reported as an AE.  However, if it 
deteriorates at any time during the study, it should be recorded as an AE. 
All AEs must be graded for severity and relationship to study product. The  
FDA defines an AE as any untoward medical occurrence associated with the use 
of a drug in humans, whether or not considered drug related. 
Severity of Event:  All AEs will be assessed by the clinician using a protocol 
defined grading system.  For events not included in the protocol defined grading 
system, than the following guidelines will be used to quantify intensity.  
 
• 
Mild:  Events require minimal or no treatment and do not interfere with the 
participant’s daily activities. 
• 
Moderate:  Events result in a low level of inconvenience or concern with the 
therapeutic measures. Moderate events may cause some interference with 
functioning. 
• 
Severe:  Events interrupt a participant’s usual daily activity and may require 
systemic drug therapy or other treatment. Severe events are usually 
incapacitating. 
 
Changes in the severity of an AE should be documented to allow an assessment 
of the duration of the event at each level of intensity to be performed.  AEs 
characterized as intermittent require documentation of onset and duration of 
each episode. 
 
Relationship to Study Products:  The clinician’s assessment of an AE’s 
relationship to test article is part of the documentation process, but it is not a 
factor in determining what is or is not reported in the study.  If there is any doubt 
as to whether a clinical observation is an AE, the event should be reported.  All 
AEs must have their relationship to study product assessed using the terms:  
related or not related.  In a clinical trial, the study product must always be 
suspect.  To help assess, the following guidelines are used. 
 
• 
Related: There is a reasonable possibility that the study product caused the 
AE. Reasonable possibility means that there is evidence to suggest a causal 
relationship between the study product and the AE. 
• 
Not Related: There is not a reasonable possibility that the administration of 
the study product caused the event. 
 
9.2.2 Serious Adverse Events 
 
An AE or SAE reaction is considered “serious” if, in the view of either the 
investigator or sponsor, it results in any of the following outcomes:  
• 
Death 
• 
A life-threatening adverse event*  
• 
Inpatient hospitalization or prolongation of existing hospitalization  
• 
A persistent or significant incapacity or substantial disruption of the ability to 
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• 
A congenital anomaly/birth defect.   
• 
Important medical events that may not result in death, be life-threatening, or 
require hospitalizations may be considered serious when, based upon 
appropriate medical judgment they may jeopardize the participant and may 
require medical or surgical intervention to prevent one of the outcomes listed 
in this definition.  Examples of such medical events include allergic 
bronchospasm requiring intensive treatment in an emergency room or at 
home, blood dyscrasias or convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug abuse. 
• 
*Life-threatening adverse event. An AE is considered “life-threatening” if, in 
the view of either the investigator or sponsor, its occurrence places the 
participant at immediate risk of death.  It does not include an AE that, had it 
occurred in a more severe form, might have caused death. 
 
All SAEs will be: 
• 
Recorded on the appropriate SAE form and eCRF 
• 
Followed through resolution by a study physician 
• 
Reviewed and evaluated by the study chairs, relevant IRBs, DMID and the 
DSMB 
 
9.2.3 Procedures to be followed in the Event of Abnormal Laboratory Test Values or 
Abnormal Clinical Findings 
The site principal investigator or appropriate sub-investigator is responsible for 
reporting all AE/SAEs that are observed or reported during the study, regardless 
of their relationship to study product.  AE/SAEs, abnormal laboratory values, or 
abnormal clinical findings will be documented, reported, and followed 
appropriately.  
For grading abnormal gynecological events, refer to Appendix B, Division of 
AIDS Table for Grading the Severity of Adult and Pediatric Adverse Events, 
December 2004; Addendum 1: Female Genital Grading Table for Use in 
Microbicide Studies, November 2007. 
For grading abnormal laboratory and clinical events, refer to Appendix C, DAIDS 
Toxicity Table for Grading the Severity of Adult and Pediatric Adverse Events, 
Version 1.0 - December 2004 (Clarification dated August 2009). 
To meet FDA approved Clinical Data Interchange Standards Consortium 
(CDISC) data standards, Appendix B and Appendix C were revised to remove 
Grade 4 toxicities and combine them with Grade 3 toxicities. 
 
9.3 
Reporting Procedures 
 
9.3.1 Serious Adverse Events 
AEs will be followed until resolution even if this extends beyond the study-
reporting period.  Resolution of an AE is defined as the return to pretreatment 
status or stabilization of the condition with the expectation that it will remain 
chronic.  
 

 
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Any AE that meets a protocol-defined serious criterion must be submitted 
immediately (within 24 hours of site awareness) on an SAE form to the DMID 
Pharmacovigilance Group, at the following address:  
DMID Pharmacovigilance Group 
Clinical Research Operations and Management Support (CROMS) 
6500 Rock Spring Dr. Suite 650 
Bethesda, MD 20814, USA 
SAE Hot Line: 1-800-537-9979 (US) or 1-301-897-1709 (outside US) 
SAE FAX Phone Number: 1-800-275-7619 (US) or 1-301-897-1710 (outside US) 
SAE Email Address: PVG@dmidcroms.com 
 
Other supporting documentation of the event may be requested by the DMID 
Pharmacovigilance Group and should be provided as soon as possible.  
 
The DMID medical monitor and clinical protocol manager will be notified of the 
SAE by the DMID Pharmacovigilance Group.  The DMID medical monitor will 
review and assess the SAE for regulatory reporting and potential impact on study 
subject safety and protocol conduct.  
 
At any time after completion of the study, if the investigator becomes aware of an 
SAE that is suspected to be related to study product, the investigator will report 
the event to the DMID Pharmacovigilance Group.  
 
9.3.2 Regulatory Reporting for Studies Conducted Under DMID-Sponsored IND 
 
Following notification from the site principal investigator or appropriate sub-
investigator, DMID, the Investigational New Drug (IND) sponsor, will report any 
suspected adverse reaction that is both serious and unexpected.  DMID will 
report an AE as a suspected adverse reaction only if there is evidence to suggest 
a causal relationship between the drug and the AE.  DMID will notify FDA and all 
participating site principal investigators (i.e., all principal investigators to whom 
the sponsor is providing drug under its IND(s) or under any principal 
investigator’s IND(s) in an IND safety report of potential serious risks from clinical 
trials or any other source, as soon as possible, but in no case later than 15 
calendar days after the sponsor determines that the information qualifies for 
reporting as specified in 21 CFR Part 312.32.  DMID will also notify FDA of any 
unexpected fatal or life-threatening suspected adverse reaction as soon as 
possible, but in no case later than 7 calendar days after the sponsor’s initial 
receipt of the information.  Relevant follow-up information to an IND safety report 
will be submitted as soon as the information is available.  Upon request from 
FDA, DMID will submit to FDA any additional data or information that the agency 
deems necessary, as soon as possible, but in no case later than 15 calendar 
days after receiving the request. 
 
9.3.3 Reporting of Pregnancy 
 

 
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Pregnancies occurring in study participants will be reported on the Pregnancy 
Report form.  Efforts will be made to follow all pregnancies reported during the 
course of the study to pregnancy outcome pending the participant’s permission. 
 
9.4 
Type and Duration of Follow-up of Subjects after Adverse Events 
 
AEs and SAEs will be followed from the time of study treatment through resolution even 
if this extends beyond the study-reporting period. Resolution of an AE/SAE is defined 
as the return to pretreatment status or stabilization of the condition with the expectation 
that it will remain chronic. 
 
Follow-up procedures, evaluations, and outcomes will be recorded on the appropriate 
data collection form. 
 
9.5 
Halting Rules 
 
Study enrollment and dosing will be halted and an ad hoc DSMB review will be 
performed if any of the following occur at any time during the study: 
1) One or more participants experience a treatment-related SAE. 
2) Two or more participants experience treatment-related vulvar and/or vaginal 
ulceration, abscess, or necrosis.  
3) Four or more participants experience a treatment-related severe (Grade 3) systemic 
adverse event.  
4) An overall pattern of symptomatic, clinical, or laboratory events that the DMID, 
medical monitor or DSMB consider associated with study product and that may 
collectively represent a serious potential concern for safety. 
A decision to reinitiate the study and proceed with study treatments will be made based 
on the recommendation of the DSMB and DMID. 
 
9.6 
Safety Oversight (ISM plus DSMB) 
 
An Independent Safety Monitor (ISM) at each clinical research site will oversee the 
safety of research subjects at that site, and will provide independent written evaluation of 
SAEs and related Grade 3 AEs to the DMID Clinical Project Manager and DMID Medical 
Monitor. The ISM will serve as an independent consultant for the site PI on subject-
related issues. The ISM will communicate with the site PI and study PIs to resolve any 
issues. 
 
Safety oversight will be under the direction of a DSMB, consisting of at least 3 voting 
members. The DSMB will meet after a third of the 228 participants complete Study Visit 
2 (Week 4), and then annually to assess safety and efficacy data on each arm of the 
study. The DSMB will review aggregate safety data for increased rate of occurrence of 
serious suspected adverse reactions. If halting rules are initiated, more frequent 
meetings may be held. The DMSB will operate under the rules of a DMID-approved 
charter that will be written at the organizational meeting of the DSMB. At this time, each 
data element that the DSMB needs to assess will be clearly defined. The DSMB will 
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10.0 CLINICAL MONITORING 
10.1 Site Monitoring Plan 
Site monitoring is conducted to ensure that the human subject protections, study and 
laboratory procedures, study intervention administration, and data collection processes 
are of high quality and meet sponsor, ICH/GCP guidelines and applicable regulations, 
and that the study is conducted in accordance with the protocol, protocol-specific MOP 
and applicable sponsor standard operating procedures.  DMID, the sponsoring agency, 
or its designee will conduct site-monitoring visits as detailed in the clinical monitoring 
plan. 
 
Site visits will be made at standard intervals as defined by DMID and may be made more 
frequently as directed by DMID.  Monitoring visits will include, but are not  limited to, 
review of regulatory files, accountability records, CRFs or eCRFs, informed consent 
forms, medical and laboratory reports, and protocol and GCP compliance.  Site monitors 
will have access to the study site, study personnel, and all study documentation 
according to the DMID-approved site monitoring plan.  Study monitors will meet with site 
principal investigators to discuss any problems and actions to be taken and document 
visit findings and discussions. 
 

 
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11.0 STATISTICAL CONSIDERATIONS 
11.1 Introduction 
 
This is a Phase II-b multicenter randomized double-blind placebo-controlled trial to 
assess the safety and efficacy of repeated doses of LACTIN-V in comparison with 
placebo in preventing BV recurrence in women diagnosed with BV.  The study plans to 
enroll 228 sexually-experienced, pre-menopausal women age 18 to 45 years who are 
using a reliable method of birth control.  Potentially eligible women will start a standard 
5-day course of MetroGel.  After completing the 5-day course of MetroGel, eligible 
participants will be randomized 2:1 to receive LACTIN-V or matching placebo.  There will 
be five clinic visits and two telephone interviews over 24 weeks. 
 
11.2 Study Objectives and Outcome Measures 
 
As described in section 3.1 and 3.2, the primary study objectives are to compare 
LACTIN-V with placebo following a 5-day treatment course with MetroGel to treat BV 
with respect to safety and efficacy.  The primary safety outcome measure is the 
proportion of participants reporting AEs and SAEs considered product-related following 
dose of study product in each study arm through Visit 7 (Week 24, Day 168).  The 
primary efficacy outcome measure is the proportion of participants who experience BV 
recurrence (i.e. positive BV diagnosis) in each study arm by Visit 4 (Week 12, Day 84). 
 
Following FDA guidelines [25], all BV diagnoses during follow-up visits are considered 
incident, as they occur at least 22-30 days after the commencement of MetroGel 
treatment and consequently are treatment failures or new infections.  For the purpose of 
this trial, treatment failure and new infection will both be considered recurrent BV. 
 
11.3 Study Hypotheses 
 
There are two planned formal tests of hypotheses which compare LACTIN-V to placebo, 
with respect to the primary safety and efficacy outcome measures.  The first hypothesis 
test compares the proportion of participants in each study arm who experience AEs or 
SAEs considered product related following the first dose of study product through Visit 7 
(Week 24, Day 168).  The second hypothesis test compares the proportion of 
participants in each study arm who experience BV recurrence by Visit 4 (Week 12, Day 
84).   
 
The null hypothesis for each comparison is that there is no difference in proportions 
between study arms, with a two-sided alternative.  The test for the primary safety 
hypothesis will be conducted using the Fisher’s exact test at the 5% two-sided level of 
significance without adjustment for multiplicity.  The test for the primary efficacy 
hypothesis will be conducted using the Pearson’s chi-square test at the 5% two-sided 
level of significance without adjustment for multiplicity.  No adjustments for multiplicity 
will be used as this is a Phase II-b trial which will provide screening evidence about 
safety and efficacy for a subsequent Phase III trial. 
 

 
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The primary safety hypothesis will be tested in the safety data analysis population. The 
primary efficacy analysis will be conducted in the Complete Case analysis population, 
and repeated as a secondary analysis in the modified intent-to-treat and Per Protocol 
analysis populations.  See Section 11.6.2 for definitions of and rationales for use of the 
analysis populations. 
 
11.4 Sample Size Considerations 
 
Sample size calculations are based on the assumption of detecting a 50% reduction in 
the cumulative proportion of participants who experience BV recurrence by 12 weeks 
post-administration of study product among participants receiving LACTIN-V compared 
to those receiving placebo in a complete case analysis at the 0.05 significance level.  
The proportion of participants among controls who will experience BV recurrence at 12 
weeks is assumed to be 30%.  We assume a LACTIN-V to placebo allocation ratio of 2:1 
and 10% of subjects drop-out from the Complete Case population.  Given logistical and 
feasibility constraints on the sample size and that this is a Phase II-b trial which will 
provide screening evidence about safety and efficacy for a subsequent Phase III trial, 
this trial is powered at the 70% level.  Given the assumptions above, a sample size of 
228 participants is required to detect a 50% reduction in the cumulative proportion of 
participants experiencing recurrence in the Complete Case population with 70% power 
using the Pearson Chi-Square test.   
 
11.5 Planned Interim Analyses 
 
11.5.1 Safety Review  
 
As described in Section 9.6, the DSMB will meet and review safety data and 
enrollment data after one-third (N = 76) enrolled participants have completed 
Visit 2 (Day 28) and then annually thereafter.  The study will be monitored to 
determine if any of the safety halting rules described above in Section 9.5 are 
met.  The halting rules do not utilize any statistical criteria and no formal 
hypothesis testing is planned to occur for the safety and enrollment data reviews. 
 
11.5.2 Efficacy Review 
 
There is no planned interim analysis of efficacy data for this study. 
 
11.6 Final Analysis Plan 
 
11.6.1 General Principles 
 
Tabulations will be used extensively to summarize the data.  Summary statistics 
displayed for continuous data will include measures of central tendency such as 
the mean or median, and measures of dispersion such as the standard deviation 
or inter-quartile range.  Summary statistics for discrete data will include 
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In presenting statistical inferences, the statistical claim (i.e. null and alternative 
hypotheses) will be clearly stated, the method used for hypothesis testing or 
confidence interval estimation will be described and appropriately referenced, 
and the assumptions underlying the methods will be validated. 
 
Analytical and/or graphical methods for assessing goodness of model fit may be 
performed.   
 
More details of the analyses to be performed will be included in a separate 
Statistical Analysis Plan. 
 
11.6.2 Data Analysis Populations 
 
The safety population will include all randomized participants who received study 
treatment. 
 
The Modified Intent-To-Treat (mITT) population will include all randomized 
participants who met all inclusion/exclusion criteria, received study product, and 
returned for at least one post-baseline visit.   
 
The Complete Case (CC) population will include all participants in the mITT 
population who were followed up until the first diagnosis of BV or through Visit 4 
(Week 12, Day 84), or discontinued from the study as a treatment failure.  The 
CC population will be used as the primary efficacy analysis population for the test 
of LACTIN-V to placebo. 
 
The Per-Protocol (PP) population will include all randomized participants who 
met all inclusion/exclusion criteria, complied with the assigned study product, 
were followed up until the first diagnosis of BV or through Visit 4, or discontinued 
from the study as a treatment failure. 
 
A participant is compliant with the assigned study product if she takes at least 
75% of the scheduled doses prior to the first diagnosis of BV or through Visit 4 
(Week 12, Day 84). 
 
Prior to unblinding, a blinded case review committee will review participants with 
a reported concomitant infection/disease/procedure that may interfere with study 
product, use of concomitant medications or products that may interfere with study 
product, significant protocol deviations, and other events that may impact study 
product effectiveness or study analyses.  On a case-by-case basis, the case 
review committee will determine if each participant will be included in PP 
population, if and when a participant should be censored or removed from PP 
analyses, and/or any other analytical requirements for the participant. 
 
For the primary efficacy analysis participants who discontinue for reasons other 
than lack of treatment effect, as well as participants with a missing or non-
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excluded from the CC and PP populations, but included in the mITT population 
using imputation methods noted in Section 11.6.4.1. 
 
11.6.3 Safety Analyses 
 
Solicited AEs will be analyzed by taking the most severe response over the 
follow-up period, dichotomizing into a binary variable (none versus mild, 
moderate, or severe) and using standard techniques, such as exact confidence 
intervals, to summarize the event rates.   
 
Standard summary statistics, including 95% confidence intervals will be 
computed.  Additionally, graded results may either be analyzed as a binary 
variable (normal, abnormal) or multinomial variable (Grade 0, Grade 1, Grade 2, 
Grade 3) using either logistic regression or ordinal logistic regression respectively 
to make treatment group comparisons. 
 
Unsolicited AEs will be coded by MedDRA® for preferred term and system organ 
class. The proportion of participants and exact 95% confidence intervals of AEs 
in aggregate, as well as by MedDRA® categories, will be computed.  The 
number of SAEs will be reported by a detailed listing showing the type, 
MedDRA® coding, relevant dates (treatment dosing dates and AE onset and 
resolution dates), severity, relatedness, and outcome for each event. 
 
11.6.3.1 
Analysis of Primary Safety Outcome Measure 
 
The primary safety outcome measure is the proportion of participants 
reporting product-related AEs and SAEs in each study arm through 
Visit 7 (Week 24, Day 168). 
 
The outcome will be assessed in the safety analysis population.  The 
outcome will be reported by study arm.  The point estimates for the 
arm-specific proportions and difference in proportions along with the 
corresponding standard errors will be reported.  Fisher’s exact test at 
the 5% two-sided level of significance level without adjustment for 
multiplicity will be used for the comparison of proportions between 
study arms.   
 
As described in Section 11.6.3, additional descriptive analyses of 
adverse event data and clinical safety laboratory values will be 
performed. 
 
11.6.3.2 
Analysis of Secondary Safety Outcome Measure 
The secondary safety outcome measure is the tolerability of LACTIN-
V measured by the proportion of participants who discontinue study 
product due to adverse events in each study arm.   
 
The outcome will be assessed in the safety analysis population.  The 
outcome will be reported by study arm.  The point estimates for the 

 
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arm-specific proportions and difference in proportions along with the 
corresponding standard errors will be reported.  Fisher’s exact test at 
the 5% two-sided level of significance level without adjustment for 
multiplicity will be used for the comparison of proportions between 
study arms. 
 
11.6.4 Efficacy Analyses 
 
11.6.4.1 
Analysis of Primary Efficacy Outcome Measure 
 
The primary efficacy outcome measure is the proportion of 
participants with a positive BV diagnosis in each study arm by Visit 4 
(Week 12, Day 84) after study product administration. 
 
As described in Section 3.1.2, the Amsel Criteria and Nugent criteria 
will be used to determine diagnosis of BV recurrence.  Cumulative 
proportion of BV recurrence by Visit 4 is defined as follows: the 
numerator is the number of participants who experience recurrence at 
least once through Visit 4 in the particular analysis population and the 
denominator is the number of participants included in the particular 
analysis population. 
 
The primary efficacy outcome measure will be assessed in the CC 
population.  Use of the mITT population has previously been 
recommended by the FDA where missing values from participants 
who drop out early are imputed using Last Observation Carried 
Forward (LOCF) [25].  However, this includes participants who 
dropped out after completing at least one-follow-up visit, but before 
their first positive diagnosis.  LOCF would classify such participants as 
‘not recurrent.’  Thus, it is possible that the estimated proportions of 
treatment successes in a study arm could be larger than they are in 
reality.  Thus LOCF could result in an over-optimistic estimate of 
treatment effect, conflicting with the following rational for using an ITT 
analysis population stated in ICH E9 [37]:  “[ITT analysis] tends to 
avoid over-optimistic estimates of efficacy resulting from a per 
protocol analysis, since the non-compliers included in the [ITT] 
analysis set will generally diminish the estimated treatment effect.”   
To assess the effect of the choice of analysis population on the 
primary analysis, the analysis will be repeated as a secondary 
analysis in the mITT and PP populations.  The mITT population 
includes participants who discontinue for reasons other than lack of 
treatment effect, as well as participants with a missing or non-
evaluable Amsel or Nugent result with no positive result at another 
visit.  The missing results will be imputed using LOCF.  To assess the 
effect of missing data and the method of imputation on the primary 
analysis, a sensitivity analysis will be performed.  The details of the 
sensitivity analysis will be detailed in the Statistical Analysis Plan. 
 

 
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As described in Section 11.3, a test of hypothesis will be performed. 
The analysis will be based on comparisons of cumulative proportion of 
BV recurrence between study groups by the Visit 4 using the Pearson 
Chi-Square test (or, if more appropriate, Fisher’s Exact Test) for 
differences in proportions between two independent groups.  The 
point estimates for the within-arm proportions, odds ratio, and 
corresponding two-sided level 95% confidence interval will be 
reported.  A secondary time-to-event analysis of the primary efficacy 
outcome measure will be performed.  Details of the analysis will be 
included in the Statistical Analysis Plan. 
 
11.6.4.2 
Analysis of Secondary Efficacy Outcome Measures 
 
All secondary efficacy outcomes measures will be assessed in the 
mITT, CC, and PP populations separately.   
 
The secondary efficacy outcome measures are as follows: 
1. The proportion of participants experiencing successful 
colonization with L. crispatus CTV-05 following dose of study 
product through Visit 4 (Week 12, Day 84) in the LACTIN-V arm, 
overall and stratified by occurrence of menses and intercourse. 
2. The proportion of participants experiencing successful 
colonization with L. crispatus CTV-05 following dose of study 
product at Visit 7 (Week 24,Day 168) in the LACTIN-V arm, overall 
and stratified by occurrence of menses and intercourse 
3. A) The proportion of participants compliant with the dose regimen 
in each study arm as assessed by participant reporting and 
applicator staining 
B) Summaries from a self-administered questionnaire about 
acceptability of the study product in each study arm 
4. The proportion of participants with a positive BV diagnosis in each 
study arm by Visit 7 (Week 24, Day 168) 
 
Secondary outcome measures 1 and 2 will be reported within the 
LACTIN-V arm and across time.  The point estimates for the overall 
proportions and stratified proportions, along with the corresponding 
standard errors, will be reported.  A secondary time-to-event analysis 
of secondary outcome measure 1 will also be performed, which will be 
described in the Statistical Analysis Plan. 
 
Secondary Outcome 3A will be reported by study arm.  The point 
estimates for the arm-specific proportions and difference in 
proportions along with the corresponding standard errors will be 
reported.  Pearson’s chi-square test or, if more appropriate, Fisher’s 
exact test, at the 5% two-sided level of significance level without 
adjustment for multiplicity will be used for the comparisons of 
proportions between study arms. 
 

 
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For Secondary Outcome 3B, responses to the self-administered 
questionnaire will be summarized by study arm.  Categorical 
responses will be summarized using contingency tables and/or odds 
ratios, while continuous responses will be summarized using 
measures of central tendency such as the mean or median, and 
measures of dispersion such as the standard deviation or inter-
quartile range. 
 
The analysis of Secondary Outcome 4 will be based on comparisons 
of cumulative proportion of BV recurrence between study groups by 
the Visit 7 using the Pearson Chi-Square test or Fisher’s Exact Test 
for differences in proportions between two independent groups.  The 
point estimates for the within-arm proportions, odds ratio, and 
corresponding two-sided level 95% confidence interval will be 
reported.  A secondary time-to-event analysis of secondary outcome 
measure 4 will also be performed, which will be described in the 
Statistical Analysis Plan. 
 
11.6.4.3 
Analysis of Exploratory Efficacy Outcome 
 
The statistical parameterizations of the exploratory objective will 
include, but are not limited to, the following: 
• 
The number of positive BV diagnoses per 12 weeks of follow-
up 
• 
The probability of positive BV diagnoses during the 12 weeks 
of follow-up 
 
For the first parameterization, a Poisson regression model will be fit to 
estimate the 12-week incidence of positive BV diagnoses in each of 
the treatment arms and to compare the incidence in the LACTIN-V 
arm to that in the placebo arm.  
 
For the second parameterization, a repeated measures logistic 
regression model will be fit to estimate the probability of positive BV 
diagnoses in each of the treatment arms and to compare the 
probability of recurrence in the LACTIN-V arm to that in the placebo 
arm.  
 
As the exploratory analyses include participants who received 
additional MetroGel treatment after experiencing symptomatic BV at a 
particular follow-up visit, a sensitivity analysis will be performed to 
assess the effect of the additional treatment on the outcome.  Details 
of the sensitivity analysis will be provided in the Statistical Analysis 
Plan. 
 
 

 
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12.0 SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/ 
DOCUMENTS 
Each participating site will maintain appropriate medical and research records for this trial, in 
compliance with ICH E6, Section 4.9 and regulatory and institutional requirements for the 
protection of confidentiality of participants.  Each site will permit authorized representatives of 
the DMID, its designees, and appropriate regulatory agencies to examine (and when required 
by applicable law, to copy) clinical records for the purposes of quality assurance reviews, audits, 
and evaluation of the study safety and progress.  These representatives will be permitted 
access to all source data, which include, but are not limited to, hospital records, clinical and 
office charts, laboratory notes, memoranda, evaluation checklists, pharmacy dispensing 
records, recorded data from automated instruments, copies or transcriptions certified after 
verification as being accurate and complete, microfiches, photographic negatives, microfilm or 
magnetic media, x-rays, and participant files and records kept at the pharmacy, at the 
laboratories, and medico-technical departments involved in the clinical trial.  Data collection 
forms will be derived from the eCRFs and be provided by the Statistical and Data Coordinating 
Center (SDCC). 
 
 

 
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13.0 QUALITY CONTROL AND QUALITY ASSURANCE 
The SDCC will implement quality control procedures beginning with the data entry system and 
generate data quality control checks that will be run on the database. Any missing data or data 
anomalies will be communicated to the site(s) for prompt clarification and resolution. 
 
The investigational sites are responsible for conducting routine quality control (QC) and quality 
assurance (QA) activities to internally monitor study progress and protocol compliance.  All sites 
will follow Sexually Transmitted Infections Treatment and Research (STAR) STI-CTG Standard 
Operating Procedures. A Clinical Quality Management Plan (CQMP) is in place for ensuring 
compliance with the protocol, applicable federal regulations, and Good Clinical Practice 
guidelines.  
 
The Principal Investigator will provide direct access to all trial-related sites, source 
data/documents, and reports for the purpose of monitoring and auditing by the sponsor, and 
inspection by local and regulatory authorities.  
 
The Principal Investigator will ensure all study personnel are appropriately trained and 
applicable documentations are maintained on site.  
 

 
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14.0 ETHICS/PROTECTION OF HUMAN SUBJECTS 
14.1 Ethical Standard 
The investigator will ensure that this study is conducted in full conformity with the 
principles set forth in the Belmont Report: Ethical Principles and Guidelines for the 
Protection of Human Subjects of Research of the US National Commission for the 
Protection of Human Subjects of Biomedical and Behavioral Research (April 18, 1979) 
and codified in 45 CFR Part 46 and/or the ICH E6; 62 Federal Regulations 25691 
(1997). 
 
14.2 Institutional Review Board 
Each participating institution will provide for the review and approval of this protocol and 
the associated informed consent documents and recruitment material by an appropriate 
independent ethics committee (IEC) or IRB registered with the OHRP.  Any amendments 
to the protocol or consent materials will also be approved before they are placed into 
use. 
 
14.3 Informed Consent Process 
Informed consent is a process that is initiated prior to the participant’s agreeing to 
participate in the study and continuing throughout the participant’s study participation.  
Extensive discussion of risks and possible benefits of this therapy will be provided to the 
participant and their families.  For this study, separate screening and enrollment consent 
forms will be used. Consent forms describing in detail the study interventions, products, 
study procedures, and risks are given to the participant and written documentation of 
informed consent is required prior to starting intervention or administering study product.  
Consent forms will be IRB-approved and the participant will be asked to read and review 
the document. Upon reviewing the document, the investigator will explain the research 
study to the participant and answer any questions that may arise.  The participants will 
sign the informed consent document prior to any procedures being done specifically for 
the study. The participants should have the opportunity to discuss the study with their 
surrogates or think about it prior to agreeing to participate.  The participants may 
withdraw consent at any time throughout the course of the trial.  A copy of the informed 
consent document will be given to the participants for their records.  The rights and 
welfare of the participants will be protected by emphasizing to them that the quality of 
their medical care will not be adversely affected if they decline to participate in this study. 
 
14.4 Exclusion of Women, Minorities, and Children (Special Populations) 
This trial will enroll adult women who meet the participant inclusion criteria regardless of 
religion or ethnic background.   
The following populations will be excluded from study participation:  
• 
Pregnant women 
Pregnant women are not eligible for this study because there are no current 
recommendations for the use of LACTIN-V during pregnancy.  

 
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• 
Men 
Men are not eligible for this study as the study evaluates the uterine cervix and 
vagina for changes associated with the use of LACTIN-V. 
• 
Children 
The NIH has mandated that children (defined as anyone under the age of 21) be 
included in research trials when appropriate. This study will enroll children aged 18 to 
20 who are able to give informed consent. This study meets "Justifications for 
Exclusion" criteria for younger children as set forth by the NIH. Specifically, 
"insufficient data are available in adults to judge potential risk in children" and 
"children should not be the initial group to be involved in research studies."  
 
14.5 Subject Confidentiality 
Participant confidentiality is strictly held in trust by the participating investigators, their 
staff, and the sponsor(s) and their agents.  This confidentiality is extended to cover 
testing of biological samples and genetic tests in addition to the clinical information 
relating to participating participants. 
 
The study protocol, documentation, data, and all other information generated will be held 
in strict confidence.  No information concerning the study or the data will be released to 
any unauthorized third party without prior written approval of the sponsor. 
 
The study monitor or other authorized representatives of the sponsor may inspect all 
documents and records required to be maintained by the investigator, including but not 
limited to, medical records (office, clinic, or hospital) and pharmacy records for the 
participants in this study.  The clinical study site will permit access to such records. 
 
14.6 Study Discontinuation 
If the trial is discontinued, participants who sign the informed consent form, and are 
randomized and treated will continue to be followed for safety assessments.  No further 
study product will be administered. 
 
14.7 Future Use of Stored Specimens  
Vaginal swabs (no more than two) will be collected at each visit and stored for future 
use. These swabs will be in addition to the swabs being collected to test for sexually 
transmitted infections and bacterial vaginosis. The additional swabs may be used for 
future testing and identification of vaginal bacteria. Samples will be kept confidential and 
coded with a unique ID. Upon request and ethical approval, these samples may also be 
made available to other researchers to test for the bacteria, and possible multiomic (e.g. 
proteomics, metabolomics, etc.) testing. Storage of samples is optional and not a 
requirement for the study. Participants will be asked to consent separately to have their 
specimens stored. Consent can be withdrawn at any time and refusal or withdrawal of 
consent will not affect study participation. 

 
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15.0 DATA HANDLING AND RECORD KEEPING 
The investigator is responsible for ensuring the accuracy, completeness, legibility, and 
timeliness of the data reported.   
 
Data collection forms will be derived from the eCRFs and provided by the SDCC to the sites to 
record and maintain data for each participant enrolled in the study.  All source documents 
should be completed in a neat, legible manner to ensure accurate interpretation of data.  
Permanent ink is required to ensure clarity of reproduced copies.  When making a change or 
correction, the original entry should be crossed out with a single line, and the change should be 
initialed and dated.  Do not erase, overwrite, or use correction fluid or tape on the original.  
Data reported in the eCRF should be consistent with the data collection form/source documents 
or the discrepancies should be documented.   
 
The sponsor and/or its designee will provide guidance to investigators on making corrections to 
the data collection forms and eCRFs. 
 
15.1 Data Management Responsibilities 
 
All source documents and laboratory reports must be reviewed by the clinical team and 
data entry staff, who will ensure that they are accurate and complete.  Adverse events 
must be graded, assessed for severity and causality, and reviewed by the site principal 
investigator (PI) or designee. 
 
Data collection is the responsibility of the clinical trial staff at the site under the 
supervision of the site PI.  During the study, the investigator must maintain complete and 
accurate documentation for the study. 
 
The Emmes Corporation will serve as the Statistical and Data Coordinating Center for 
this study and will be responsible for data management, quality review, analysis, and 
reporting of the study data. 
 
15.2 Data Capture Methods 
 
Clinical data (including, but not limited to, AE/SAEs, concomitant medications, and 
reactogenicity data) and clinical laboratory data will be entered into a 21 CFR Part 11-
compliant Internet Data Entry System, AdvantageEDCSM, provided by The Emmes 
Corporation.  The data system includes password protection and internal quality checks, 
such as automatic range checks, to identify data that appear inconsistent, incomplete, or 
inaccurate.  Clinical data will be entered directly from the source documents.  
 
15.3 Types of Data 
 
Data for this study will include clinical, efficacy, safety, laboratory and outcome 
measures (eg, AEs, SAEs, and reduction of BV reoccurrence). 
 

 
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15.4 Timing/Reports 
A final report will be prepared following the availability of all the safety and laboratory 
data.  Interim statistical reports may be generated as deemed necessary and 
appropriate by DMID.  Safety and laboratory data summary reports may be generated 
for the DSMB. 
 
15.5 Study Records Retention 
 
Study documents should be retained for a minimum of 2 years after the last approval of 
a marketing application in an ICH region and until there are no pending or contemplated 
marketing applications in an ICH region or at least 2 years have elapsed since the formal 
discontinuation of clinical development of the investigational product. These documents 
should be retained for a longer period, however, if required by local regulations.  No 
records will be destroyed without the written consent of the sponsor, if applicable.  It is 
the responsibility of the sponsor to inform the investigator when these documents no 
longer need to be retained. 
 
15.6 Protocol Deviations 
 
A protocol deviation is any noncompliance with the clinical trial protocol, Good Clinical 
Practice (GCP), or MOP requirements. The noncompliance may be either on the part of 
the participant, the investigator, or the study site staff.  As a result of deviations, 
corrective actions are to be developed by the site and implemented promptly.  
 
These practices are consistent with ICH E6: 
 
4.5 
Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3 
 
5.1 
Quality Assurance and Quality Control, section 5.1.1 
 
5.20 
Noncompliance, sections 5.20.1, and 5.20.2. I 
 
It is the responsibility of the site to use continuous vigilance to identify and report 
deviations within 5 working days of identification of the protocol deviation, or within 5 
working days of the scheduled protocol-required activity.  All deviations must be 
promptly reported to DMID, via the SDCC’s AdvantageEDCSM.  
 
All deviations from the protocol must be addressed in study subject data collection 
forms.  A completed copy of the DMID-approved Protocol Deviation Form must be 
maintained in the regulatory file, as well as in the participant’s source document.  
Protocol deviations must be sent to the local IRB/IEC per their guidelines. The site 
PI/study staff is responsible for knowing and adhering to their IRB/IEC requirements 
 

 
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59 
16.0 PUBLICATION POLICY 
Following completion of the study, the Investigator is expected to publish the results of this 
research in a scientific journal.  Publication of the results of this study will be governed by 
STICTG policies and the International Committee of Medical Journal Editors (ICMJE) member 
journals, which have adopted a trials-registration policy as a condition for publication.   
 
This policy requires that all clinical trials be registered in a public trials registry such as 
ClinicalTrials.gov  which is sponsored by the National Library of Medicine.  Other biomedical 
journals are considering adopting similar policies.  It is the responsibility of DMID to register this 
trial in an acceptable registry.  Any clinical trial starting enrollment after 01 July 2005 must be 
registered on or before patient enrollment.  For trials that began enrollment prior to this date, the 
ICMJE member journals will require registration by 13 September 2005, before considering the 
results of the trial for publication 
 
The ICMJE defines a clinical trial as any research project that prospectively assigns human 
participants to intervention or comparison groups to study the cause-and-effect relationship 
between a medical intervention and a health outcome.  Studies designed for other purposes, 
such as to study pharmacokinetics or major toxicity (eg, Phase 1 trials), would be exempt from 
this policy. 
 
Any presentation, abstract, or manuscript will be made available by the Investigator to the STI-
CTG Manuscript Review Committee, DMID, and Osel Inc. for review prior to submission. 
 

 ____________________________________________________________________________________________ 
60 
 
17.0 LITERATURE REFERENCES 
1. 
Allsworth JE and Peipert JF. Prevalence of bacterial vaginosis: 2001-2004 National Health 
and Nutrition Examination Survey data. Obstet Gynecol 2007;109(1):114-20. 
 
2. 
Eschenbach DA, Hillier S, Critchlow C, et al. Diagnosis and clinical manifestations of 
bacterial vaginosis. Am J Obstet Gynecol 1988;158(4):819-28. 
 
3. 
Hillier SL, Kiviat NB, Hawes SE, et al. Role of bacterial vaginosis-associated 
microorganisms in endometritis. Am J Obstet Gynecol 1996;175(2):435-41. 
 
4. 
Watts DH, Krohn MA, Hillier SL, et al. Bacterial vaginosis as a risk factor for post-cesarean 
endometritis. Obstet Gynecol 1990;75(1):52-8. 
 
5. 
Soper DE. Bacterial vaginosis and postoperative infections. Am J Obstet Gynecol. 1993 
Aug;169(2 Pt 2):467-9. 
 
6. 
Kurki T, Sivonen A, Renkonen OV, et al. Bacterial vaginosis in early pregnancy and 
pregnancy outcome. Obstet Gynecol 1992;80(2):173-7. 
 
7. 
Hillier SL, Martius J, Krohn M, et al. A case-control study of chorioamnionic infection and 
histologic chorioamnionitis in prematurity. N Engl J Med 1988;319(15):972-8. 
 
8. 
Taha TE, Hoover DR, Dallabetta GA, et al. Bacterial vaginosis and disturbances of vaginal 
flora: association with increased acquisition of HIV. AIDS 1998;12(13):1699-706. 
 
9. 
Myer L, Denny L, Telerant R, et al. Bacterial vaginosis and susceptibility to HIV infection in 
South African women: a nested case-control study. J Infect Dis 2005;192(8):1372-80. 
 
10. Cohen CR, Lingappa JR, Baeten JM, et al. Bacterial vaginosis associated with increased 
risk of female-to-male HIV-1 transmission: a prospective cohort analysis among African 
couples. PLoS Med. 2012;9(6):e1001251. doi: 10.1371/journal.pmed.1001251. Epub 2012 
Jun 26. 
 
11. Fichorova RN, Onderdonk AB, Yamamoto H, et al. Maternal microbe-specific modulation of 
inflammatory response in extremely low-gestational-age newborns. MBio 2011;2(1). 
 
12. Bradshaw CS, Morton AN, Hocking J, et al. High recurrence rates of bacterial vaginosis 
over the course of 12 months after oral metronidazole therapy and factors associated with 
recurrence. J Infect Dis 2006;193(11):1478-86. 
 
13. Bukusi EA, Thomas KK, Nguti R, Cohen CR, et al. Topical Penile Microbicide Use by Men 
to Prevent Recurrent Bacterial Vaginosis in Sex Partners: A Randomized Clinical Trial. Sex 
Transm Dis. 2011 Jun;38(6):483-9. 
 
14. Bolton M van der Straten A and Cohen CR. Probiotics: potential to prevent HIV and 
sexually transmitted infections in women. Sex Transm Dis 2008;35(3):214-25. 
 

 
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61 
15. Stapleton AE, Au-Yeung M, Hooton TM, et al. Randomized, Placebo-Controlled Phase 2 
Trial of a Lactobacillus crispatus Probiotic Given Intravaginally for Prevention of Recurrent 
Urinary Tract Infection. Clin Infect Dis 2011;52(10):1212-7. 
 
16. Hemmerling A, Harrison W, Schroeder A, et al. Phase 1 dose-ranging safety trial of 
Lactobacillus crispatus CTV-05 for the prevention of bacterial vaginosis. Sex Transm Dis 
2009;36(9):564-9. 
 
17. Hemmerling A, Harrison W, Schroeder A, et al. Phase 2a Study Assessing Colonization 
Efficiency, Safety and Acceptability of Lactobacillus crispatus CTV-05 (LACTIN-V) in 
Women with Bacterial Vaginosis. Sex Transm Dis 2010;37(12):745-50. 
 
18. Ngugi BM, Hemmerling A, Bukusi EA, et al. Effects of BV-Associated Bacteria and Sexual 
Intercourse on Vaginal Colonization with the Probiotic Lactobacillus crispatus CTV-05. Sex 
Transm Dis. 2011 Nov;38(11):1020-7. doi: 10.1097/OLQ.0b013e3182267ac4. 
 
19. Abdool Karim Q, Abdool Karim SS, Frohlich JA, et al. Effectiveness and safety of tenofovir 
gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science. 
2010;329(5996):1168-1174.  
 
20. Anahtar MN, Byrne EH, Koherty KE, et al. Cervicovaginal bacteria are a major modulator of 
host inflammatory responses in the female genital tract. Immunity 2015;42(5):965-76. 
 
21. Cohen CR, Moscicki  AB, Scott ME, et al. Increased levels of immune activation in the 
genital tract of healthy young women from sub-Saharan Africa. AIDS 2010;24(13):2069-74. 
 
22. CDC Sexually Transmitted Treatment Guidelines.  
http://www.cdc.gov/std/tg2015/tg-2015-print.pdf 
 
23. Schwebke JR, Hillier SL, Sobel JD, et al. Validity of the vaginal gram stain for the diagnosis 
of bacterial vaginosis. Obstet Gynecol 1996;88(4 Pt 1):573–6. 
 
24. Amsel R, Totten PA, Spiegel CA, et al. Nonspecific vaginitis. Diagnostic criteria and 
microbial and epidemiologic associations. Am J Med 1983;74:14–22. 
 
25. FDA Draft Guidance for the Use of Metronidazole Gel. 
http://www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/u
cm345807.pdf 
 
26. Bradshaw CS, Vodstrcil LA, Hocking JS, et al. (2013). Recurrence of bacterial vaginosis is 
significantly associated with post-treatment sexual activities and hormonal contraceptive 
use. Clinical Infectious Diseases, 56(6), 777. 
 
27. Cruciani F, Wasinger V, Turroni S, et al. (2013). Proteome profiles of vaginal fluids from 
women affected by bacterial vaginosis and healthy controls: Outcomes of rifaximin 
treatment.  J of Antimicrobial Chemo 68(11), 2648.  
 

 
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62 
28. Donders GG, Guaschino S, Peters K, et al. (2013). A multicenter, double-blind, 
randomized, placebo-controlled study of rifaximin for the treatment of bacterial vaginosis 
Int. J. Gynaecol Obstet, 120(2):131-136. doi: 10.1016/j.ijgo.2012.08.022 
 
29. Bradshaw CS, Pirotta M, Guingand DD, et al. (2012). Efficacy of oral metronidazole with 
vaginal clindamycin or vaginal probiotic for bacterial vaginosis: Randomized placebo-
controlled double-blind trial. PLoS One, 7(4) doihttp://0-
dx.doi.org.library.touro.edu/10.1371/journal.pone.0034540 
 
30. Balkus JE, Jaoko W, Mandaliya K, et al. (2012). The posttrial effect of oral periodic 
presumptive treatment for vaginal infections on the incidence of bacterial vaginosis and 
Lactobacillus colonization. Sex Transm Dis., 39(5):361-5. doi: 
10.1097/OLQ.0b013e31824790d7  
 
31. Weissenbacher ER, Donders G, Unzeitig V, et al. Fluomizin Study Group. (2012). 
A comparison of dequalinium chloride vaginal tablets and clindamycin vaginal cream in the 
treatment of bacterial vaginosis. a single-blind, randomized clinical trial of efficacy and 
safety. 2012;73(1):8-15.doi:10.1159/000332398.Epub 2011 Dec 24. 
 
32. Schwebke JR, Desmond RA. (2011). Tinidazole vs metronidazole for the treatment 
of bacterial vaginosis. Am J Obstet Gynecol, 204(3):211.e1-6. doi: 
10.1016/j.ajog.2010.10.898 
 
33. Marrazzo JM, Fiedler TL, Srinivasan S, et al. (2012). Extravaginal reservoirs of 
vaginal bacteria as risk factors for incident bacterial vaginosis. J Infect Dis., 205(10):1580-8. 
doi: 10.1093/infdis/jis242 
 
34. Madhivanan P, Raphael E, Rumphs A, et al. (2014). Characterization of 
culturable vaginal Lactobacillus species among women with and 
without bacterial vaginosis from the United States and India: a cross-sectional study. J Med 
Microbiol. 63(Pt 7):931-5. doi: 10.1099/jmm.0.073080-0 
 
35. Schwebke JR, Hillier SL, Sobel JD, et al. Validity of the vaginal gram stain for the diagnosis 
of bacterial vaginosis. Obstet Gynecol 1996;88(4 Pt 1):573–6. 
 
36. Division of AIDS Table for Grading the Severity of Adult and Pediatric Adverse Events, 
December 2004; Addendum 1: Female Genital Grading Table for Use in Microbicide 
Studies, November 2007 
 
37. International Conference on Harmonisation (ICH) E9. 
http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Efficacy/E9/Step4/
E9_Guideline.pdf 
 
 

 
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63 
APPENDICES 
Appendix A  
 
Schedule of Events 
 
Appendix B  
 
Division of AIDS Table for Grading the Severity of Adult and  
 
 
 
 
Pediatric Adverse Events, December 2004; Addendum 1: Female   
 
 
 
Genital Grading Table for Use in Microbicide Studies, November   
 
 
 
2007 
 
Appendix C 
 
DAIDS Toxicity Table for Grading the Severity of Adult and Pediatric  
 
 
 
Adverse Events, Version 1.0 - December 2004 (Clarification dated  
 
 
 
August 2009

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64 
  
 
 
Appendix A 
Schedule of Events 
 
Study Treatment 
 
Study Follow Up  
 
Evaluation 
Screening 
Visit 0 
Day -30 to -5
Enrollment Visit 1 
Day 1 
Study Visit 2  
Day 28 (Week 4) 
Study Visit 3  
Day 56 (Week 8) 
Study Visit 4  
Day 84 (Week 12) 
Phone Visit 5   
Day 112 
(Week 16)
Phone Visit 6   
Day 140  
(Week 20) 
Study Visit 7   
Day 168  
(Week 24) 
Unscheduled Visit 
Study Product  
Discontinuation 
Early  Termination 
Visit 
Visit window 
 
 
 
± 1 week 
 
Signed consent form 
X 
X 
 
 
 
 
 
 
 
 
 
Assessment of eligibility criteria 
X 
X 
 
 
 
 
 
 
 
 
 
Demographics 
X 
X 
 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
 
Detailed medical, gynecological and sexual history 
X 
 
 
 
 
 
 
 
 
 
 
Dispense MetroGel  
X 
 
(X) 
(X) 
(X) 
 
 
 
 
 
 
Dispense LACTIN-V/placebo and applicators 
 
X 
(X) 
(X) 
 
 
 
 
 
 
 
Dispense condoms 
X 
X 
X 
X 
X 
 
 
 
X 
X 
 
Dispense memory aid or instructions on using web 
based memory aid 
 
X 
 
 
 
 
 
 
 
 
 
Brief  medical, gynecological and sexual history 
 
X 
X 
X 
X 
 
 
X 
X 
X 
X 
Review of concomitant medications  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Study intervention 
 
X 
X 
X 
X 
 
 
 
 
 
 
Physical 
Examination 
Complete 
X 
 
 
 
 
 
 
 
 
 
 
Symptom-directed 
 
X 
X 
X 
X 
 
 
X 
X 
X 
X 
Vital signs 
X 
X 
X 
X 
X 
 
 
X 
X 
X 
X 
Pelvic examination 
X 
X 
X 
X 
X 
 
 
X 
X 
X 
X 
Review memory aid and symptoms 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Reminder to abstain from sexual intercourse 
 
X 
X 
X 
X 
X 
X 
 
X 
 
 

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65 
 
Study Treatment 
 
Study Follow Up  
 
Evaluation 
Screening 
Visit 0 
Day -30 to -5
Enrollment Visit 1 
Day 1 
Study Visit 2  
Day 28 (Week 4) 
Study Visit 3  
Day 56 (Week 8) 
Study Visit 4  
Day 84 (Week 12) 
Phone Visit 5   
Day 112 
(Week 16)
Phone Visit 6   
Day 140  
(Week 20) 
Study Visit 7   
Day 168  
(Week 24) 
Unscheduled Visit 
Study Product  
Discontinuation 
Early  Termination 
Visit 
Reminder not to use vaginal products 
 
X 
X 
X 
X 
X 
X 
 
X 
 
 
Reminder to collect and return used applicators 
 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 
Assessment of adverse events 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Clinical 
Laboratory 
Clean catch urine dipstick 
X 
(X) 
(X) 
(X) 
(X) 
 
 
(X) 
(X) 
(X) 
(X) 
Urinalysis 
(X) 
(X) 
(X) 
(X) 
(X) 
 
 
(X) 
(X) 
(X) 
(X) 
Rapid urine βhCG pregnancy test 
X 
X 
(X) 
(X) 
(X) 
 
 
(X) 
(X) 
(X) 
(X) 
HIV and syphilis serology (total blood 
required is approximately 15mL (3 
teaspoons)  
X 
 
 
 
 
 
 
 
 
 
 
Vaginal swab for N. gonorrhoeae, C. 
trachomatis, T. vaginalis 
X 
(X) 
(X) 
(X) 
(X) 
 
 
(X) 
 (X) 
(X) 
(X) 
Research 
Laboratory 
Vaginal swab for pH 
X 
X 
X 
X 
X 
 
 
X 
X 
X 
X 
Vaginal swab for wet mount, amine test 
X 
X 
X 
X 
X 
 
 
X 
X 
X 
X 
Vaginal swab for Gram stain  
X 
X 
X 
X 
X 
 
 
X 
X 
X 
X 
Vaginal swab for storage and future 
identification of vaginal bacteria  
X 
X 
X 
X 
X 
 
 
X 
 X 
X 
   X 
Vaginal swab for qPCR (L. crispatus 
identification) 
 
X 
X 
X 
X 
 
 
X 
 X 
X 
   X 
Other 
Procedures 
Acceptability questionnaire 
X 
 
 
 
X 
 
 
 
 
X 
X 
Staining of used applicators 
 
 
X* 
 
 
 
 
 
 
Telephone interview 
 
 
 
 
 
X 
X 
 
 
 
 
 
(X) if indicated 
X* per site discretion

 
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APPENDIX B 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS PUBLISH DATE: DECEMBER 2004 
 
Addendum 1 
 
Female Genital Grading Table for Use in Microbicide Studies 
NOTE: For protocols utilizing this Addendum, when the same parameter appears in both this Female Genital Grading Table and 
the main DAIDS AE Grading Table, use the grading scheme in this table. 
 
 
 
November 2007  
Page 1 of 12  
Version 1.0 
 
 
 
INDIVIDUAL SIGNS/SYMPTOMS 
PARAMETER 
GRADE 0 
NORMAL 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GENERAL 
Odor 
No complaint 
Mild-moderate unpleasant 
odor 
Severe unpleasant odor 
NA 
PAIN AND TENDERNESS 
(Specify Area: Vulvar/Perineum, Vagina, Cervix (including cervical motion tenderness), Uterus, Adnexae, 
Pelvic/Lower Abdominal, or Ovulatory) 
*Note – if both pain and tenderness are present, only report the one with the most severe grade 
Pain* 1 
None 
Pain causing no or 
minimal interference with 
usual social & functional 
activities 
Pain causing greater than 
minimal interference with 
usual social & functional 
activities or the need for 
non-narcotic medication 
Pain causing inability to 
perform usual social & 
functional activities or the 
need for narcotic 
medication OR 
hospitalization (other than 
emergency room visit) 
indicated 
Tenderness* 1 
None 
Mild tenderness 
Moderate 
tenderness 
Severe tenderness 
Dyspareunia (pain 
with sexual 
activity) 
None 
Pain causing no or 
minimal interference with 
sexual function 
Pain causing greater 
than minimal 
interference with sexual 
function 
NA 
Dysmenorrhea/cramping 
with menses 
None 
Pain causing no or 
minimal interference with 
usual social & functional 
activities 
Pain causing greater than 
minimal interference with 
usual social & functional 
activities or the need for 
non-narcotic medication 
Pain causing inability to 
perform usual social or 
functional activities or the 
need for narcotic 
medication 
1 If pain or tenderness is included in the grading of another category (e.g., PID), it should not be graded again in the pain or 
tenderness category 

 
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APPENDIX B (Cont'd) 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS PUBLISH DATE: DECEMBER 2004 
Addendum 1 
Female Genital Grading Table for Use in Microbicide Studies 
NOTE: For protocols utilizing this Addendum, when the same parameter appears in both this Female Genital Grading Table and the main DAIDS AE Grading 
Table, use the grading scheme in this table. 
 
 
November 2007  
Page 2 of 12  
Version 1.0 
 
INDIVIDUAL SIGNS/SYMPTOMS 
PARAMETER 
GRADE 0 
NORMAL 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GENITOURINARY SIGNS/SYMPTOMS – VULVA 
Vulvar/vaginal itching 
None 
Itching causing no, mild, 
or moderate interference 
with usual social & 
functional activities 
Itching causing inability to 
perform usual social & 
functional activities; may 
require intervention such 
as antihistamine or 
bathing to provide relief 
NA 
Vulvar edema 
None 
Mild, non-pitting edema 
Moderate, 1-2+ 
pitting edema 
3+ pitting edema, severe 
enough to require urinary 
drainage, or weeping 
edema ± skin breakdown 
Vulvar erythema 
None 
Erythema covering < 50% 
of vulvar surface 
Erythema covering ≥ 50% 
of vulvar surface 
NA 
Vulvar lesions (findings 
seen only by 
colposcopy should not 
be included here) 
Normal variants including 
skin tags, moles, scars, 
etc. 
Blisters, ulcerations, 
or pustules - no 
treatment indicated 
Blisters, ulcerations or 
pustules, with treatment 
indicated 
Severe epithelial disruption 
with hospitalization 
indicated (other than 
emergency room visit) 
Vulvar rash 
None 
Rash covering < 50% of 
vulvar surface 
Rash covering ≥ 50% of 
vulvar surface 
Severe epithelial disruption 
with hospitalization 
indicated (other than 
emergency room visit) 
Bartholin’s or Skene's 
gland 
No findings 
Cyst with no 
inflammation 
Cyst or abscess with 
outpatient intervention 
indicated 
Cyst or abscess with 
hospitalization indicated, 
(other than emergency 
room visit) including 
necrotizing fasciitis from 
Bartholin’s abscess 
GENITOURINARY SIGNS/SYMPTOMS – VAGINA 
** Note – if vaginal discharge is present both by history and on examination, only report the one with the most severe grade 
Vaginal edema 
None 
Mild-moderate 
engorgement 
Loss of ruggae and 
friability 
NA 
Vaginal erythema 
None 
Erythema covering < 50% 
of vaginal surface 
Erythema covering ≥ 50% 
of vaginal surface 
NA 
Vaginal dryness 
No complaint 
Dryness causing no or 
minimal interference with 
usual sexual, social, & 
functional activities 
Dryness causing greater 
than minimal interference 
with usual sexual, social, 
& functional activities 
NA 
 
 

 
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APPENDIX B (Cont'd) 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS PUBLISH DATE: DECEMBER 2004 
Addendum 1 
Female Genital Grading Table for Use in Microbicide Studies 
NOTE: For protocols utilizing this Addendum, when the same parameter appears in both this Female Genital Grading Table and the main DAIDS AE Grading 
Table, use the grading scheme in this table. 
 
 
November 2007  
Page 3 of 12  
Version 1.0 
 
INDIVIDUAL SIGNS/SYMPTOMS 
 
PARAMETER 
 
GRADE 0 
NORMAL 
 
GRADE 1 
MILD 
 
GRADE 2 
MODERATE 
 
GRADE 3 
SEVERE 
Vaginal discharge by 
participant report ** 
Participant's usual 
amount of discharge, 
regardless of color or 
quantity 
Mild-moderate increase in 
amount above participant 
baseline - no sanitary 
protection required 
Profuse increase in 
discharge requiring pad 
use or other hygienic 
intervention 
NA 
Vaginal discharge as 
observed by clinician ** 
(red or brown discharge 
should be reported under 
bleeding, not discharge) 
Slight amount of 
discharge, any color 
Mild-moderate increase in 
amount 
Significant increase in 
amount with pooling in 
vagina on examination 
NA 
Vaginal abrasions or 
lacerations  
(including probable 
applicator injuries) 
None 
Superficial disruptions 
and disruptions extending 
through the mucosa with 
minimal impact on life 
Large disruptions 
extending through the 
mucosa or large 
superficial disruptions, 
hospitalization not 
indicated 
Large disruptions 
extending through the 
mucosa or large 
superficial disruptions 
including lacerations, 
hospitalization 
indicated(other than 
emergency room visit) 
Vaginal lesions (findings 
seen only by 
colposcopy should not 
be included here) 
Normal variants including 
skin tags, moles, scars, 
etc. 
Blisters, ulcerations, 
or pustules, no 
treatment indicated 
Blisters, ulcerations, or 
pustules with treatment 
indicated 
Severe epithelial disruption 
requiring hospitalization 
(other than emergency 
room visit) 
Vaginal and Cervical 
masses  
(polyps, myomas, or 
possible malignancy) 
None or normal variants 
such as Nabothian cyst 
or Gartner duct cyst 
Polyp or myoma or 
undiagnosed mass 
without symptoms 
Polyp, myoma, or 
undiagnosed mass 
causing mild symptoms, 
e.g., bleeding/pain not 
requiring more than mild 
analgesia 
Polyp, myoma, or 
undiagnosed mass 
causing severe 
symptoms, e.g., 
bleeding/pain 
affecting bladder and 
bowel function, or 
visible cervical cancer 
GENITOURINARY SIGNS/SYMPTOMS – CERVIX 
Cervical edema and 
friability 
None 
Edema without 
friability 
Friable cervix 
NA 
Cervical erythema 
None 
Erythema covering < 
50% of cervix 
Erythema covering ≥ 50% 
of cervix 
NA 
Cervical discharge 
White or clear discharge 
Small amount of 
purulent discharge at 
Purulent discharge 
extending onto cervix or 
i
NA 

 
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APPENDIX B (Cont'd) 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS PUBLISH DATE: DECEMBER 2004 
Addendum 1 
Female Genital Grading Table for Use in Microbicide Studies 
NOTE: For protocols utilizing this Addendum, when the same parameter appears in both this Female Genital Grading Table and the main DAIDS AE Grading 
Table, use the grading scheme in this table. 
 
 
November 2007  
Page 4 of 12  
Version 1.0 
Visible cervical 
lesions (findings seen 
only by colposcopy 
should not be 
included here) 
Normal variants including 
skin tags, moles, scars, 
etc. 
Blisters, ulcerations, 
or pustules, no 
treatment indicated 
Blisters, ulcerations, or 
pustules with treatment 
indicated 
NA 
 
 
INDIVIDUAL SIGNS/SYMPTOMS 
 
PARAMETER 
 
GRADE 0 
NORMAL 
 
GRADE 1 
MILD 
 
GRADE 2 
MODERATE 
 
GRADE 3 
SEVERE 
GENITOURINARY SIGNS/SYMPTOMS – UTERUS 
Uterine 
masses/enlargement 
based on bimanual 
examination 
Normal to 8 week size, 
no palpable myomas 
Enlarged uterus and 
mild symptoms, e.g., 
bleeding/pain requiring 
mild analgesics 
Enlarged uterus/myoma 
with moderate pain or 
symptoms, e.g., bleeding 
Mass causing severe 
bleeding/pain or with 
impact on bowel/bladder 
function or requires 
transfusion or surgery 
Polyp, submucosal 
fibroid, or thickened 
endometrium detected 
by transvaginal 
ultrasound (new or 
increasing in size from 
prior exam) 
None or 
unchanged/reduced in 
size from prior exam 
New myomas < 6 cm 
diameter (single or 
multiple) or diameter 
increased < 6 cm since 
prior exam 
New myomas ≥ 6 cm 
diameter (single or 
multiple) or diameter 
increased ≥ 6 cm since 
prior exam 
Hospitalization (other than 
emergency room visit)  
and/or surgery indicated 
GENITOURINARY SIGNS/SYMPTOMS – ADNEXA 
Not pregnancy- or 
infection-related adnexal 
masses based on 
bimanual exam (use if no 
ultrasound done; if 
ultrasound done, use 
ultrasound categories 
below) 
None, ≤ 4 cm, normal 
size ovary 
> 4 cm with minimal 
or no symptoms 
> 4 cm with severe 
symptoms, e.g., pain, but 
hospitalization not 
indicated (see footnote 
#1) 
> 4 cm with severe 
symptoms, e.g., pain and 
hospitalization indicated 
(other than emergency 
room visit) (see footnote 
#1) 
Hydrosalpinx based on 
ultrasound 
None 
Asymptomatic, 
suspected 
hydrosalpinx 
Hydrosalpinx with pain, 
but without evidence of 
infection or ectopic 
pregnancy 
Signs/symptoms of 
infection with 
hospitalization (other than 
emergency room visit) 
and/or surgery indicated 
Adnexal mass based on 
ultrasound 
None 
Simple cyst, 
asymptomatic 
Simple cyst, 
symptomatic 
Malignant mass suspicious 
for malignancy 

 
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APPENDIX B (Cont'd) 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS PUBLISH DATE: DECEMBER 2004 
Addendum 1 
Female Genital Grading Table for Use in Microbicide Studies 
NOTE: For protocols utilizing this Addendum, when the same parameter appears in both this Female Genital Grading Table and the main DAIDS AE Grading 
Table, use the grading scheme in this table. 
 
 
November 2007  
Page 5 of 12  
Version 1.0 
 
 
INDIVIDUAL SIGNS/SYMPTOMS 
PARAMETER 
GRADE 0 
NORMAL 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GENITOURINARY SIGNS/SYMPTOMS – ABDOMEN 
Abdominal mass not 
palpable on pelvic exam 
of unknown diagnosis 
None or known 
(pre-existing) mass 
unchanged in size 
New mass or increased 
size of known mass 
requiring mild analgesia 
with minimal impact 
New mass or increased 
size of known mass with 
moderate symptoms 
Mass causing severe 
bleeding/ pain with impact 
on bladder/bowel function 
or with hospitalization 
(other than emergency 
room visit) indicated or 
malignancy 
GENITOURINARY SIGNS/SYMPTOMS – URINARY TRACT 
Urinary frequency 
None 
Up to 2 times 
participant’s normal 
frequency 
> 2 times participant’s 
normal frequency 
NA 
Dysuria 
None 
Superficial only 
Deep ± superficial 
Inability to void due to pain 
Hematuria 
None 
Microscopic, no 
intervention indicated 
(beyond evaluation for 
infection) 
Gross blood in urine or 
medical intervention/ 
evaluation indicated 
(beyond evaluation for 
infection) 
Persistent bleeding with 
transfusion, hospitalization 
(other than emergency 
room visit) or intervention 
indicated to obtain 
hemostasis (endoscopy, 
interventional radiology, or 
operative) 

 
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APPENDIX B (Cont'd) 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS PUBLISH DATE: DECEMBER 2004 
Addendum 1 
Female Genital Grading Table for Use in Microbicide Studies 
NOTE: For protocols utilizing this Addendum, when the same parameter appears in both this Female Genital Grading Table and the main DAIDS AE Grading 
Table, use the grading scheme in this table. 
 
 
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Version 1.0 
 
COMPOSITE SIGNS/SYMPTOMS 
(Use instead of individual categories if 2 or more signs/symptoms are present) 
 
PARAMETER 
 
GRADE 0 
NORMAL 
 
GRADE 1 
MILD 
(Use if all signs/ 
symptoms would 
individually be 
Grade 0 or 1) 
 
GRADE 2 
MODERATE (Use if one 
or more signs/symptoms 
would individually be Grade 
2 and all others Grade 0 or 
1) 
 
GRADE 3 
SEVERE 
(Use if one or more 
signs/symptoms would 
individually 
be Grade 3) 
NO ORGANISM IDENTIFIED BUT INADEQUATE TESTING PERFORMED 
Vulvovaginitis 
(combinations of pain, 
itching, erythema, 
edema, rash, 
tenderness, or 
discharge) 
None 
Mild signs/symptoms 
Moderate signs/symptoms Severe signs/ 
symptoms 
Cervicitis (combinations of 
dyspareunia, erythema, 
edema, tenderness, and 
discharge) 
None 
Mild signs/ 
symptoms 
Moderate signs/ 
symptoms 
Severe signs/ 
symptoms 
PID (if Gonorrhea or 
Chlamydia identified use 
that category) 
None 
NA 
Cervicitis with mild uterine 
tenderness, ± mild cervical 
motion tenderness, no 
signs of peritoneal 
irritation 
More diffuse tenderness, 
any signs of peritoneal 
irritation, or indications for 
hospitalization (other than 
emergency room visit)  
including tubo-ovarian 
NO ORGANISM IDENTIFIED AFTER APPROPRIATE TESTING PERFORMED 
Vulvovaginitis 
(combinations of pain, 
itching, erythema, 
edema, rash, 
tenderness, or 
discharge) 
None 
Mild signs/ 
symptoms 
Moderate signs/ 
symptoms 
Severe signs/ 
symptoms 
Cervicitis (combinations of 
dyspareunia, erythema, 
edema, tenderness, and 
discharge) 
None 
Mild signs/ 
symptoms 
Moderate signs/ 
symptoms 
Severe signs/ 
symptoms 
PID (if Gonorrhea or 
Chlamydia identified use 
that category) 
None 
NA 
Cervicitis with mild uterine 
tenderness, ± mild cervical 
motion tenderness, no 
signs of peritoneal 
irritation 
More diffuse tenderness, 
any signs of peritoneal 
irritation, or indications for 
hospitalization (other than 
emergency room visit) 
including tubo-ovarian 
abscess 

 
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APPENDIX B (Cont'd) 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS PUBLISH DATE: DECEMBER 2004 
Addendum 1 
Female Genital Grading Table for Use in Microbicide Studies 
NOTE: For protocols utilizing this Addendum, when the same parameter appears in both this Female Genital Grading Table and the main DAIDS AE Grading 
Table, use the grading scheme in this table. 
 
 
November 2007  
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Version 1.0 
INFECTIONS AND DYSPLASIA 
 
PARAMETER 
 
GRADE 0 
NORMAL 
 
GRADE 1 
MILD 
 
GRADE 2 
MODERATE 
 
GRADE 3 
SEVERE 
GENITOURINARY INFECTIONS 
Genital herpes 
No lesions 
Characteristic ulcerative 
or vesicular lesions 
confirmed by culture, 
PCR, Tzanck prep or 
other diagnostic test of 
lesion or previous type- 
specific serology, 
covering < 25% of vulva, 
vagina, or cervix 
Same criteria as mild 
but covering 25-50% of 
vulvar, vaginal, or 
cervical surface 
Same criteria as mild 
but covering > 50% of 
vulvar, vaginal, or 
cervical surface and/or 
symptoms of significant 
systemic involvement, 
e.g., encephalitis, 
hepatitis 
Candida 
Absence of symptoms 
regardless of candida test 
results 
Positive culture, wet 
mount, or other 
laboratory test for yeast, 
with mild symptoms 
Positive culture, wet 
mount, or other 
laboratory test for yeast, 
with moderate to severe 
symptoms 
NA 
Trichomonas 
Negative 
NA 
Positive wet mount, 
culture, PCR or other 
licensed test, excluding 
pap smear, showing T. 
vaginalis, regardless of 
symptoms 
NA 
Bacterial Vaginosis (BV) 
Negative 
Asymptomatic BV 
diagnosed by Amsel 
criteria, wet mount, Gram 
stain, or licensed 
diagnostic test 
Symptomatic confirmed by 
wet mount, Gram stain, or 
any licensed diagnostic 
test 
NA 
Chlamydia 
Negative 
NA 
Positive culture or other 
diagnostic test for 
Chlamydia, asymptomatic 
or with mild uterine or 
cervical motion 
tenderness (no signs of 
peritoneal irritation) 
Positive test for 
Chlamydia with 
abdominal or uterine or 
adnexal tenderness on 
examination, with or 
without adnexal mass, 
diffuse tenderness, any 
signs of peritoneal 
irritation, or indications for 
hospitalization (other than 
emergency room visit) 
including tubo-ovarian 
abscess 
 

 
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APPENDIX B (Cont'd) 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS PUBLISH DATE: DECEMBER 2004 
Addendum 1 
Female Genital Grading Table for Use in Microbicide Studies 
NOTE: For protocols utilizing this Addendum, when the same parameter appears in both this Female Genital Grading Table and the main DAIDS AE Grading 
Table, use the grading scheme in this table. 
 
 
November 2007  
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Version 1.0 
INFECTIONS AND DYSPLASIA 
 
PARAMETER 
 
GRADE 0 
NORMAL 
 
GRADE 1 
MILD 
 
GRADE 2 
MODERATE 
 
GRADE 3 
SEVERE 
Gonorrhea 
Negative 
NA 
Positive culture or other 
diagnostic test for 
Gonorrhea, asymptomatic 
or with mild uterine or 
cervical motion 
tenderness (no signs of 
peritoneal irritation) 
Positive test for 
Gonorrhea with 
abdominal or uterine or 
adnexal tenderness on 
examination, with or 
without adnexal mass, 
diffuse tenderness, any 
signs of peritoneal 
irritation, or indications for 
hospitalization (other than 
emergency room visit)  
including tubo-ovarian 
abscess or disseminated 
gonococcal infection 
Urinary tract infection (by 
urinalysis and urine 
culture) 
Negative 
5-10 WBC/hpf on 
urinalysis with a 
negative culture per 
protocol definition (with 
or without symptoms) 
> 10 WBC/hpf on 
urinalysis OR a positive 
culture per protocol 
definition (with or without 
symptoms) 
Pyelonephritis or sepsis 
(septicemia) due to urinary 
tract infection 
Syphilis 
Negative treponemal or 
non- treponemal test or 
both positive with known 
treatment and stable titers 
(< 4 fold increase) 
NA 
Syphilis diagnosed by a 
positive treponemal test 
along with a positive non- 
treponemal test and no 
previous treatment or a 
four- fold rise in titer on 
th
t
l t
t
Criteria for Grade 
2 Syphilis in the presence 
of neurologic symptoms or 
a positive CSF VDRL or 
FTA-ABS 
GENITAL DYSPLASIA 
Condyloma (specify site: 
cervical, vaginal, vulvar, 
perianal) 
None 
Condylomata causing no 
or mild interference with 
daily function 
Condylomata causing 
moderate interference 
with daily function 
Condylomata causing 
severe interference with 
daily function, secondary 
infection, or hospitalization 
(other than emergency 
room visit) indicated 
Condyloma (specify site: 
cervical, vaginal, vulvar, 
perianal) 
None 
Condylomata causing no 
or mild interference with 
daily function 
Condylomata causing 
moderate interference 
with daily function 
Condylomata causing 
severe interference with 
daily function, secondary 
infection, or hospitalization 
(other than emergency 
room visit) indicated 
 

 
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APPENDIX B (Cont'd) 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS PUBLISH DATE: DECEMBER 2004 
Addendum 1 
Female Genital Grading Table for Use in Microbicide Studies 
NOTE: For protocols utilizing this Addendum, when the same parameter appears in both this Female Genital Grading Table and the main DAIDS AE Grading 
Table, use the grading scheme in this table. 
 
 
November 2007  
Page 9 of 12  
Version 1.0 
INFECTIONS AND DYSPLASIA 
PARAMETER 
GRADE 0 
NORMAL 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
 
Intraepithelial Neoplasia 
by biopsy (VIN, CIN, 
VAIN) 
None 
Intraepithelial  
Neoplasia 1 (IN1) 
Intraepithelial 
Neoplasia 2 (IN2) 
Carcinoma in situ (CIS) or 
Invasive carcinoma 
Pap (use this category only 
if treatment performed 
without diagnostic testing, 
otherwise use biopsy 
category above) 
nl PAP 
ASCUS or LSIL 
HSIL 
Carcinoma in situ or 
carcinoma 

 
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APPENDIX B (Cont'd) 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS PUBLISH DATE: DECEMBER 2004 
Addendum 1 
Female Genital Grading Table for Use in Microbicide Studies 
NOTE: For protocols utilizing this Addendum, when the same parameter appears in both this Female Genital Grading Table and the main DAIDS AE Grading 
Table, use the grading scheme in this table. 
 
 
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Version 1.0 
 
UTERINE BLEEDING AND PREGNANCY COMPLICATIONS 
 
PARAMETER 
 
GRADE 0 
NORMAL 
 
GRADE 1 
MILD 
 
GRADE 2 
MODERATE 
 
GRADE 3 
SEVERE 
ABNORMAL UTERINE BLEEDING UNRELATED TO PREGNANCY 
Menorrhagia 2 (prolonged 
and/or heavy menstrual 
bleeding) 
Participant report of 
normal bleeding relative to 
her baseline 
Increase from usual with 
no or minimal 
interference with usual 
social & functional 
activities (including 
sexual functioning) 
Increase from usual with 
moderate interference 
with usual social & 
functional activities 
(including sexual) 
Incapacitating or severe 
interference  with usual 
social & functional 
activities (including 
sexual functioning), 
transfusion indicated 
Metrorrhagia 2 
(intermenstrual or 
frequent bleeding) 
None or any 
expected 
nonmenstrual 
bleeding 
Increase from usual with 
no or minimal 
interference  with usual 
social & functional 
activities (including 
sexual functioning) 
Increase from usual with 
moderate interference 
with usual social & 
functional activities 
(including sexual) 
Incapacitating or severe 
interference with usual 
social & functional 
activities (including 
sexual functioning), 
transfusion indicated 
Unexplained infrequent 
bleeding (excludes 
expected absence of 
menses due to hormonal 
contraception or 
pregnancy/ postpartum) 
Participant report of 
normal or expected 
bleeding frequency 
No menses for 1-3 
months (missed menses) 
No menses for > 3 
months (oligomenorrhea/ 
amenorrhea) 
NA 
Postcoital bleeding 
None 
Occasional (< 25% of 
coital acts) OR Increase 
from usual with no or 
minimal interference with 
usual social functioning 
(including sexual 
functioning) 
Frequent (25-75% of 
coital acts) OR Increase 
from usual with moderate 
interference with usual 
social functioning 
(including sexual) 
Consistent (> 75% of 
coital acts) OR 
Incapacitating or severe 
interference with usual 
social functioning 
(including sexual 
functioning), transfusion 
indicated 
 
 
 
 
2  If both Menorrhagia and Metrorrhagia are present, a single adverse event should be reported as “Menometrorrhagia” and graded per the Menorrhagia 
grading scale. 

 
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APPENDIX B (Cont'd) 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS PUBLISH DATE: DECEMBER 2004 
Addendum 1 
Female Genital Grading Table for Use in Microbicide Studies 
NOTE: For protocols utilizing this Addendum, when the same parameter appears in both this Female Genital Grading Table and the main DAIDS AE Grading 
Table, use the grading scheme in this table. 
 
 
November 2007  
Page 11 of 12  
Version 1.0 
 
UTERINE BLEEDING AND PREGNANCY COMPLICATIONS 
 
PARAMETER 
 
GRADE 0 
NORMAL 
 
GRADE 1 
MILD 
 
GRADE 2 
MODERATE 
 
GRADE 3 
SEVERE 
 
COMPLICATIONS OF PREGNANCY 
First trimester bleeding 
None 
Spotting or bleeding less 
than menses with 
continuation of 
pregnancy 
Bleeding like menses or 
heavier with continuation 
of pregnancy 
Spontaneous abortion, 
or profuse bleeding 
with dizziness or 
orthostatic hypotension, 
transfusion indicated 
Postabortal 
endometritis/salpingitis 
None 
Low grade fever and 
uterine tenderness, 
resolved with oral 
antibiotics 
Moderate symptoms, 
requiring ≤ 3 days of 
parenteral antibiotics 
Severe symptoms 
requiring > 3 days of IV 
antibiotics or development 
of tubo-ovarian abscess or 
diffuse peritonitis or 
severe uterine infection for 
which operative 
intervention indicated 
Postpartum hemorrhage 
EBL < 500 cc for vaginal 
delivery or < 1000 cc 
after CS or reported as 
normal 
EBL 500-1000 for vaginal 
delivery or 1000-1500 for 
CS or reported as slightly 
increased 
EBL > 1000 for vaginal 
delivery or > 1500 for CS, 
with or without mild 
dizziness, no transfusion 
required 
Hemorrhage at a level 
for which transfusion of 
packed cells or any 
amount of other blood 
components is indicated  
Postpartum endometritis 
None 
Low grade fever and 
uterine tenderness, 
resolved with oral 
antibiotics 
Moderate symptoms, 
treated by ≤ 3 days of 
parenteral antibiotics 
Severe symptoms treated 
with > 3 days of IV 
antibiotics or addition of 
heparin or infection for 
which operative 
intervention is indicated 
Chorioamnionitis 
None 
Fever (38°C –38.4°C or 
100.4°F– 100.9°F) with 
two or more: FHR> 160 
BPM, maternal HR> 120, 
uterine tenderness 
between contractions or 
purulent AF or preterm 
labor 
Same as Grade 1 plus 
fever 38.5°C –40°C or 
101°F –104°F 
Criteria for Grade 2 plus 
fetal distress or fever > 
40°C or 104°F or either 
fetal demise or maternal 
symptoms of shock 

 
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APPENDIX B (Cont'd) 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS PUBLISH DATE: DECEMBER 2004 
Addendum 1 
Female Genital Grading Table for Use in Microbicide Studies 
NOTE: For protocols utilizing this Addendum, when the same parameter appears in both this Female Genital Grading Table and the main DAIDS AE 
Grading Table, use the grading scheme in this table. 
 
 
November 2007  
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Version 1.0 
 
 
UTERINE BLEEDING AND PREGNANCY COMPLICATIONS 
 
PARAMETER 
 
GRADE 0 
NORMAL 
 
GRADE 1 
MILD 
 
GRADE 2 
MODERATE 
 
GRADE 3 
SEVERE 
Episiotomy infection 
None 
Mild erythema, 
edema, and 
tenderness of wound 
Fever > 38°C or 
100.4°F with erythema, 
edema, and tenderness 
of wound 
Fever with wound 
dehiscence or 
debridement required or 
signs shock or necrotizing 
fasciitis 
Second/third trimester 
bleeding 
None 
Bleeding less than 
menses 
Bleeding like menses or 
greater, but not requiring 
intervention 
Bleeding or coagulopathy  
requiring delivery or 
other intervention, e.g., 
transfusion, or fetal 
demise 
Preterm rupture of 
membranes 
None 
NA 
Preterm rupture with 
hospitalization but not 
resulting in delivery at 
less than 37 weeks’ 
gestation 
Delivery at < 37 weeks 
gestation or ≤ 2500 
grams birth weight 
Preterm contractions 
None 
Preterm contractions 
which resolve without 
medical intervention 
Preterm contractions 
with cervical change 
which result in medical 
intervention but not 
resulting in preterm 
delivery 
Delivery at < 37 weeks 
gestation or ≤ 2500 
grams birth weight 
Poor fetal growth 
At or above 10th 
percentile 
Fetal growth < 10th 
percentile but ≥ 3rd 
percentile for gestational 
age by ultrasound or 
newborn exam 
NA 
Fetal growth < 3rd 
percentile for gestational 
age by ultrasound or 
newborn exam 
 

 
 
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APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
 
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The Division of AIDS Table for Grading the Severity of Adult and Pediatric Adverse Events (“DAIDS AE Grading 
Table”) is a descriptive terminology which can be utilized for Adverse Event (AE) reporting. A grading (severity) 
scale is provided for each AE term. 
 
This clarification of the DAIDS Table for Grading the Severity of Adult and Pediatric AE’s provides 
additional explanation of the DAIDS AE Grading Table and clarifies some of the parameters. 
 
I. 
Instructions and Clarifications 
 
Grading Adult and Pediatric AEs 
The DAIDS AE Grading Table includes parameters for grading both Adult and Pediatric AEs. When a single set of 
parameters is not appropriate for grading specific types of AEs for both Adult and Pediatric populations, separate 
sets of parameters for Adult and/or Pediatric populations (with specified respective age ranges) are given in the 
Table. If there is no distinction in the Table between Adult and Pediatric values for a type of AE, then the single 
set of parameters listed is to be used for grading the severity of both Adult and Pediatric events of that type. 
Note: In the classification of adverse events, the term “severe” is not the same as “serious.” Severity is 
an indication of the intensity of a specific event (as in mild, moderate, or severe chest pain). The term 
“serious” relates to a participant/event outcome or action criteria, usually 
associated with events that pose a threat to a participant’s life or functioning. 
 
Addenda 1-3 Grading Tables for Microbicide Studies 
For protocols involving topical application of products to the female genital tract, male genital area or rectum, 
strong consideration should be given to using Appendices I-III as the primary grading scales for these areas. The 
protocol would need to specifically state that one or more of the Appendices would be 
primary (and thus take precedence over the main Grading Table) for items that are listed in both the 
Appendix and the main Grading Table. 
• 
Addendum 1 - Female Genital Grading Table for Use in Microbicide Studies - PDF 
• 
Addendum 2 - Male Genital Grading Table for Use in Microbicide Studies - PDF 
• 
Addendum 3 - Rectal Grading Table for Use in Microbicide Studies - PDF 
 
Grade 5  
For any AE where the outcome is death, the severity of the AE is classified as Grade 5.    
 
Estimating Severity Grade for Parameters Not Identified in the Table 
In order to grade a clinical AE that is not identified in the DAIDS AE grading table, use the category 
“Estimating Severity Grade” located on Page 3. 
 
Determining Severity Grade for Parameters “Between Grades” 
If the severity of a clinical AE could fall under either one of two grades (e.g., the severity of an AE could be either 
Grade 2 or Grade 3), select the higher of the two grades for the AE. If a laboratory value that is graded as a 
multiple of the ULN or LLN falls between two grades, select the higher of the two grades for the AE. For example, 
Grade 1 is 2.5 x ULN and Grade 2 is 2.6 x ULN for a parameter. If the lab value is 
2.53 x ULN (which is between the two grades), the severity of this AE would be Grade 2, the higher of the two 
grades. 
 
Values Below Grade 1  
Any laboratory value that is between either the LLN or ULN and Grade 1 should not be graded.  

 
 
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APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
 
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Determining Severity Grade when Local Laboratory Normal Values Overlap with Grade 1 Ranges 
In these situations, the severity grading is based on the ranges in the DAIDS AE Grading Table, even when 
there is a reference to the local lab LLN. 
 
For example: Phosphate, Serum, Low, Adult and Pediatric > 14 years (Page 20) Grade 1 range is 2.50 mg/dL - < 
LLN. A particular laboratory’s normal range for Phosphate is 2.1 – 3.8 mg/dL. A participant’s actual lab value is 
2.5.  In this case, the value of 2.5 exceeds the LLN for the local lab, but will be graded as Grade 1 per DAIDS AE 
Grading Table. 
. 
 
II.   Definitions of terms used in the Table: 
 
Basic Self-care Functions 
Adult 
Activities such as bathing, dressing, toileting, transfer/movement, 
continence, and feeding. 
Young Children 
Activities that are age and culturally appropriate (e.g., feeding self with 
culturally appropriate eating implement). 
LLN 
Lower limit of normal 
Medical Intervention 
Use of pharmacologic or biologic agent(s) for treatment of an AE. 
NA 
Not Applicable 
Operative Intervention 
Surgical OR other invasive mechanical procedures. 
ULN 
Upper limit of normal 
Usual Social & Functional 
Activities 
Adult 
Adaptive tasks and desirable activities, such as going to work, 
shopping, cooking, use of transportation, pursuing a hobby, etc. 
Young Children 
Activities that are age and culturally appropriate (e.g., social 
interactions, play activities, learning tasks, etc.). 
 

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APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
ESTIMATING SEVERITY GRADE 
Clinical adverse event NOT 
identified elsewhere in this 
DAIDS AE Grading Table 
Symptoms causing no or 
minimal interference with 
usual social & functional 
activities 
Symptoms causing greater 
than minimal interference with 
usual social & functional 
activities 
Symptoms causing inability to 
perform usual social & 
functional activities OR 
Medical or operative 
intervention indicated to 
prevent permanent 
impairment, persistent 
disability, or death 
SYSTEMIC 
Acute systemic allergic 
reaction 
Localized urticaria (wheals) 
with no medical intervention 
indicated 
Localized urticaria with medical 
intervention indicated OR Mild 
angioedema with no medical 
intervention indicated 
Generalized urticaria OR 
Angioedema with medical 
intervention indicated OR 
Symptomatic mild 
Bronchospasm OR Acute 
anaphylaxis OR Life- 
threatening bronchospasm OR 
Laryngeal edema 
Chills 
Symptoms causing no or 
minimal interference with usual 
social & functional activities 
Symptoms causing greater 
than minimal interference with 
usual social & functional 
activities 
Symptoms causing inability to 
perform usual social & 
functional activities 
Fatigue 
Malaise 
Symptoms causing no or 
minimal interference with 
usual social & functional 
activities 
Symptoms causing greater 
than minimal interference with 
usual social & functional 
activities 
Symptoms causing inability to 
perform usual social & 
functional activities 
Fever (nonaxillary) 
37.7 – 38.6°C 
38.7 – 39.3°C 
> 39.4  
Pain (indicate body site) DO 
NOT use for pain due to 
injection (See Injection Site 
Reactions: Injection site 
pain) See also Headache, 
Arthralgia, and Myalgia 
Pain causing no or minimal 
interference with usual 
social & functional activities 
Pain causing greater than 
minimal interference with 
usual social & functional 
activities 
Pain causing inability to 
perform usual social & 
functional activities OR 
Hospitalization (other than 
emergency room visit) 
indicated 

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February 19, 2016 
____________________________________________________________________________________________  
APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Unintentional weight loss 
NA 
5 – 9% loss in body weight 
from baseline 
> 10% loss in body weight from 
baseline OR Aggressive 
intervention indicated [e.g., tube 
feeding or total parenteral 
nutrition (TPN)] 
 INFECTION 
Infection (any other than HIV 
infection) 
Localized, no systemic 
antimicrobial treatment 
indicated AND Symptoms 
causing no or minimal 
interference with usual social 
& functional activities 
Systemic antimicrobial 
treatment indicated OR 
Symptoms causing greater 
than minimal interference with 
usual social & functional 
activities 
Systemic antimicrobial 
treatment indicated AND 
Symptoms causing inability to 
perform usual social & 
functional activities OR 
Operative intervention (other 
than simple incision and 
drainage) indicated 
 INJECTION SITE REACTIONS 
Injection site pain (pain without 
touching) Or Tenderness (pain 
when area is touched) 
Pain/tenderness causing no 
or minimal limitation of use of 
limb 
Pain/tenderness limiting use of 
limb OR Pain/tenderness 
causing greater than minimal 
interference with usual social 
& functional activities 
Pain/tenderness causing 
inability to perform usual social 
& functional activities OR 
Hospitalization (other than 
emergency room visit) indicated 
for management of 
pain/tenderness 
Injection site reaction (localized) 
Adult > 15 years 
Erythema OR Induration of 
5x5 cm – 9x9 cm (or 25 cm
2 – 
81cm2) 
Erythema OR Induration OR 
Edema > 9 cm any diameter 
(or > 81 cm2) 
Ulceration OR Secondary 
infection OR Phlebitis OR 
Sterile abscess OR Drainage 
OR Necrosis (involving dermis 
and deeper tissue) 
Pediatric ≤ 15 years 
Erythema OR Induration OR 
Edema present but ≤ 2.5 cm 
diameter 
Erythema OR Induration OR 
Edema > 2.5 cm diameter but 
< 50% surface area of the 
extremity segment (e.g., upper 
arm/thigh) 
Erythema OR Induration OR 
Edema involving ≥ 50% surface 
area of the extremity segment 
(e.g., upper arm/thigh) OR 
Ulceration OR Secondary 
infection OR Phlebitis OR 
Sterile abscess OR Drainage 
OR Necrosis (involving dermis 
and deeper tissue) 
 

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February 19, 2016 
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APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Pruritis associated with 
injection 
See also Skin: Pruritis (itching 
- no skin lesions) 
Itching localized to injection 
site AND Relieved 
spontaneously or with 
< 48 hours treatment 
Itching beyond the injection 
site but not generalized OR 
Itching localized to injection 
site requiring48 
hours treatment 
Generalized  itching causing 
inability to perform usual social 
& functional activities 
 
SKIN - DERMATOLOGICAL 
Alopecia 
Thinning detectable by study 
participant (or by caregiver  for 
young children and disabled  
adults) 
Thinning or patchy hair loss 
detectable by health care 
provider 
Complete hair loss 
Cutaneous  reaction - rash 
Localized  macular rash 
Diffuse macular, 
maculopapular, or morbilliform  
rash OR Target lesions 
Diffuse macular, 
maculopapular, or morbilliform  
rash with vesicles or limited 
number of bullae OR 
Superficial ulcerations of 
mucous  membrane limited to 
one site 
Hyperpigmentation 
Slight or localized 
Marked or generalized 
NA 
Hypopigmentation 
Slight or localized 
Marked or generalized 
NA 
Pruritis (itching - no skin 
lesions) 
(See also Injection Site 
Reactions: Pruritis associated 
with injection) 
Itching causing  no or minimal 
interference with usual social 
& functional activities 
Itching causing greater than 
minimal interference  with 
usual social & functional 
activities 
Itching causing inability to 
perform usual social & 
functional activities 
CARDIOVASCULAR 
Cardiac  arrhythmia (general) 
(By ECG or physical exam) 
Asymptomatic AND No 
intervention indicated 
Asymptomatic AND Non-
urgent medical intervention  
indicated 
Symptomatic AND medical 
intervention indicated 
Cardiac- ischemia/infarction 
NA 
NA 
Symptomatic ischemia (stable 
angina) OR Testing consistent 
with ischemia OR Unstable 
angina OR Acute myocardial 
infarction 
 
 

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APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Hemorrhage (significant acute 
blood loss) 
NA 
Symptomatic AND No 
transfusion indicated 
 Symptomatic AND 
Transfusion of  packed RBCs  
indicated 
Hypertension 
Adult > 17 years (with repeat 
testing at same visit) 
140 – 159 mmHg systolic OR 
90 – 99 mmHg diastolic 
160 – 179 mmHg systolic OR 
100 – 109 mmHg diastolic 
≥ 180 mmHg systolic OR ≥ 
110 mmHg diastolic OR 
Hospitalization indicated 
(other than emergency room 
visit) 
Correction: in Grade 2 to 160 - 179 from > 160-179 (systolic) and to ≥ 100 -109 from > 100-109 (diastolic) and in Grade 3 to 
≥ 180 from > 180 (systolic) and to ≥ 110  from > 110 (diastolic). 
Pediatric ≤ 17 years (with 
repeat testing at same visit) 
NA 
91st – 94th percentile adjusted 
for age, height, and gender 
(systolic and/or diastolic) 
≥ 95th percentile adjusted for 
age, height, and gender 
(systolic and/or diastolic) OR 
Hospitalization indicated 
(other than emergency room 
visit) 
Hypotension 
NA 
Symptomatic, corrected with 
oral fluid replacement 
Symptomatic, IV fluids 
indicated OR Use of 
vasopressors or mechanical 
assistance to maintain blood 
pressure 
Pericardial effusion 
Asymptomatic, small effusion 
requiring no intervention 
Asymptomatic, moderate or 
larger effusion requiring no 
intervention 
Effusion with non-life 
threatening physiologic 
consequences OR Effusion 
with non-urgent intervention 
indicated OR Life-threatening 
consequences (e.g., 
tamponade) OR Urgent 
intervention indicated) 
Prolonged PR interval 
Adult > 16 years 
PR interval 0.21 – 0.25 sec 
PR interval > 0.25 sec 
Type II 2nd degree AV block 
OR Ventricular pause > 3.0 
sec OR Complete AV block 
Pediatric ≤ 16 years 
1st degree AV block (PR > 
normal for age and rate) 
Type I 2nd degree AV 
block 
Type II 2nd degree AV 
block OR Complete AV block 

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February 19, 2016 
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APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Prolonged QTc 
Adult > 16 years 
Asymptomatic, QTc interval 
0.45 – 0.47 sec OR Increase 
interval < 0.03 sec above 
baseline 
Asymptomatic, QTc interval 
0.48 – 0.49 sec OR Increase 
in interval 0.03 – 0.05 sec 
above baseline 
Asymptomatic, QTc interval ≥ 0.50 
sec OR Increase in interval ≥ 0.06 
sec above baseline OR Life-
threatening consequences (e.g., 
Torsade de pointes or other 
associated serious ventricular 
dysrhythmia) 
Pediatric ≤ 16 years 
Asymptomatic, QTc interval 
0.450 – 0.464 sec 
Asymptomatic, QTc interval 
0.465 – 0.479 sec 
 Asymptomatic, QTc interval ≥ 
0.480 sec OR Life-threatening 
consequences, (e.g., Torsade de 
pointes or other associated serious 
ventricular dysrhythmia) 
Thrombosis/embolism 
NA 
Deep vein thrombosis AND No 
intervention indicated (e.g., 
anticoagulation, lysis filter, 
invasive procedure) 
Deep vein thrombosis AND 
Intervention indicated (e.g., 
anticoagulation, lysis filter, invasive 
procedure) OR Embolic event (e.g., 
pulmonary embolism, life-
threatening thrombus) 
Vasovagal episode 
(associated with a procedure 
of any kind) 
Present without loss of 
consciousness 
Present with transient loss of 
consciousness 
NA 
Ventricular dysfunction 
(congestive heart failure) 
NA 
Asymptomatic diagnostic 
finding AND intervention 
indicated 
New onset with symptoms OR 
Worsening symptomatic congestive 
heart failure OR Life-threatening 
congestive heart failure 
 GASTROINTESTINAL 
Anorexia 
Loss of appetite without 
decreased oral intake 
Loss of appetite associated 
with decreased oral intake 
without significant weight loss 
Loss of appetite associated with 
significant weight loss OR Life-
threatening consequences OR 
Aggressive intervention indicated 
[e.g., tube feeding or total 
parenteral nutrition (TPN)] 
Comment: Please note that, while the grading scale provided for Unintentional Weight Loss may be used as a guideline when grading 
anorexia, this is not a requirement and should not be used as a substitute for clinical judgment. 
Ascites 
Asymptomatic 
Symptomatic AND 
Intervention indicated (e.g., 
diuretics or therapeutic 
paracentesis) 
Symptomatic despite intervention 
OR Life-threatening consequences 

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February 19, 2016 
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APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Cholecystitis 
NA 
Symptomatic AND Medical 
intervention indicated 
Radiologic, endoscopic, or 
operative intervention 
indicated OR Life-
threatening consequences 
(e.g., sepsis or perforation) 
Constipation 
NA 
Persistent constipation 
requiring regular use 
of dietary 
modifications, 
laxatives, or enemas 
Obstipation with manual 
evacuation indicated OR 
Life-threatening 
consequences (e.g., 
obstruction) 
Diarrhea 
Adult and Pediatric ≥ 1 
year 
Transient or intermittent 
episodes of unformed stools 
OR Increase of ≤ 3 stools over 
baseline per 24-hour period 
Persistent episodes of 
unformed to watery stools OR 
Increase of 
4 – 6 stools over baseline per 
24-hour period 
Bloody diarrhea OR 
Increase of ≥ 7 stools per 
24-hour period OR IV fluid 
replacement indicated OR 
Life-threatening 
consequences (e.g., 
hypotensive shock) 
Pediatric < 1 year 
Liquid stools (more unformed 
than usual) but usual number of 
stools 
Liquid stools with increased 
number of stools OR Mild 
dehydration 
Liquid stools with moderate 
dehydration OR Liquid stools 
resulting in severe 
dehydration with aggressive 
rehydration indicated OR 
Hypotensive shock 
Dysphagia- 
Odynophagia 
Symptomatic but able to eat 
usual diet 
Symptoms causing altered 
dietary intake without 
medical intervention 
indicated 
Symptoms causing severely 
altered dietary intake with 
medical intervention 
indicated OR Life-
threatening reduction in oral 
intake 
Mucositis/stomatitis (clinical 
exam) Indicate site (e.g., larynx, 
oral) See Genitourinary for 
Vulvovaginitis.   
See also Dysphagia- 
Odynophagia and Proctitis 
Erythema of the mucosa 
Patchy pseudomembranes or 
ulcerations 
Confluent 
pseudomembranes or 
ulcerations OR Mucosal 
bleeding with minor trauma 
OR Tissue necrosis OR 
Diffuse spontaneous 
mucosal bleeding OR Life-
threatening consequences 

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APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Nausea 
Transient (< 24 hours) or 
intermittent nausea with no or 
minimal interference with oral 
intake 
Persistent nausea resulting in 
decreased oral intake for 24 – 
48 hours 
Persistent nausea resulting in 
minimal oral intake for > 48 
hours OR Aggressive 
rehydration indicated (e.g., IV 
fluids) OR Life-threatening 
consequences (e.g., 
hypotensive shock) 
Pancreatitis 
NA 
Symptomatic AND 
Hospitalization not indicated 
(other than emergency room 
visit) 
Symptomatic AND 
Hospitalization indicated 
(other than emergency room 
visit) OR Life-threatening 
consequences (e.g., 
circulatory failure, 
hemorrhage, sepsis) 
Proctitis (functional- 
symptomatic) Also see 
Mucositis/stomatitis for clinical 
exam 
Rectal discomfort AND No 
intervention indicated 
Symptoms causing greater 
than minimal interference with 
usual social & functional 
activities OR Medical 
intervention indicated 
Symptoms causing inability to 
perform usual social & 
functional activities OR 
Operative intervention 
indicated OR Life-threatening 
consequences (e.g., 
perforation)  
Vomiting 
Transient or intermittent vomiting 
with no or minimal interference 
with oral intake 
Frequent episodes of vomiting 
with no or mild dehydration 
Persistent vomiting resulting in 
orthostatic hypotension OR 
Aggressive rehydration 
indicated (e.g., IV fluids) or 
Life-threatening 
consequences (e.g., 
hypotensive shock) 
 
 

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APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
NEUROLOGIC 
Alteration in personality-
behavior or in mood (e.g., 
agitation, anxiety, depression, 
mania, psychosis) 
Alteration causing no or minimal 
interference with usual social & 
functional activities 
Alteration causing greater than 
minimal interference with 
usual social & functional 
activities 
Alteration causing inability to 
perform usual social & 
functional Activities OR 
Behavior potentially harmful to 
self or others. 
Altered Mental Status For 
Dementia, see Cognitive and 
behavioral/attentional 
disturbance (including dementia 
and attention deficit disorder) 
Changes causing no or minimal 
interference with usual social & 
functional activities 
Mild lethargy or somnolence 
causing greater than minimal 
interference with usual social 
& functional activities 
Confusion, memory 
impairment, lethargy, or 
somnolence causing inability 
to perform usual social & 
functional activities OR 
Delirium OR obtundation, OR 
coma 
Ataxia 
Asymptomatic ataxia detectable 
on exam OR Minimal ataxia 
causing no or minimal 
interference with usual social & 
functional activities 
Symptomatic ataxia causing 
greater than minimal 
interference with usual social 
& functional activities 
Symptomatic ataxia causing 
inability to perform usual 
social & functional activities 
OR Disabling ataxia causing 
inability to perform basic self-
care functions 
 
 

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February 19, 2016 
____________________________________________________________________________________________  
APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Cognitive and 
behavioral/attentional 
disturbance (including 
dementia and attention 
deficit disorder) 
Disability causing no 
or minimal interference 
with usual social & 
functional activities OR 
Specialized resources 
not indicated 
Disability causing 
greater than minimal 
interference with usual 
social & functional 
activities OR 
Specialized resources 
on part-time basis 
i di
t d
Disability causing inability to perform usual social & 
functional activities OR Specialized resources on a 
full-time basis indicated OR Disability causing 
inability to perform basic self-care functions OR 
Institutionalization indicated 
CNS ischemia (acute) 
NA 
NA 
Transient ischemic attack OR Cerebral vascular 
accident (CVA, stroke) with neurological deficit 
Developmental delay – 
Pediatric ≤ 16 years 
Mild developmental 
delay, either motor or 
cognitive, as 
determined by 
comparison with a 
developmental 
screening tool 
appropriate for the 
setting 
Moderate 
developmental delay, 
either motor or 
cognitive, as 
determined by 
comparison with a 
developmental 
screening tool 
appropriate for the 
setting 
Severe developmental delay, either motor or 
cognitive, as determined by comparison with a 
developmental screening tool appropriate for the 
setting OR Developmental regression, either motor 
or cognitive, as determined by comparison with a 
developmental screening tool appropriate for the 
setting 
Headache 
Symptoms causing no 
or minimal interference 
with usual social & 
functional activities 
Symptoms causing 
greater than minimal 
interference with usual 
social & functional 
activities 
Symptoms causing inability to perform usual social & 
functional activities OR Symptoms causing inability 
to perform basic self-care functions OR 
Hospitalization indicated (other than emergency 
room visit) OR Headache with significant impairment 
of alertness or other neurologic function 
Insomnia 
NA 
Difficulty sleeping 
causing greater than 
minimal interference 
with usual social & 
functional activities 
Difficulty sleeping causing inability to perform usual 
social & functional activities OR Disabling insomnia 
causing inability to perform basic self-care functions 
Neuromuscular 
weakness (including 
myopathy & 
neuropathy) 
Asymptomatic with 
decreased strength on 
exam OR Minimal 
muscle weakness 
causing no or minimal 
interference with usual 
social & functional 
activities 
Muscle weakness 
causing greater than 
minimal interference 
with usual social & 
functional activities 
Muscle weakness causing inability to perform usual 
social & functional activities OR Disabling muscle 
weakness causing inability to perform basic self-care 
functions OR Respiratory muscle weakness 
impairing ventilation 
  
 

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February 19, 2016 
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APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Neurosensory alteration 
(including paresthesia 
and painful neuropathy) 
Asymptomatic with 
sensory alteration on 
exam or minimal 
paresthesia causing no 
or minimal interference 
with usual social & 
functional activities 
Sensory alteration or 
paresthesia causing greater 
than minimal interference with 
usual social & functional 
activities 
Sensory alteration or paresthesia 
causing inability to perform usual social 
& functional activities OR Disabling 
sensory alteration or paresthesia 
causing inability to perform basic self-
care functions 
Seizure: (new onset) 
NA 
1 seizure 
> 1 seizure 
– Adult ≥ 18 years 
See also Seizure: 
(known pre-existing 
seizure disorder) 
Seizure: (known pre- 
existing seizure disorder) 
– Adult ≥ 18 years For 
worsening of existing 
epilepsy the grades 
should be based on an 
increase from previous 
level of control to any of 
these levels. 
NA 
Increased frequency of pre-
existing seizures (non-
repetitive) without change in 
seizure character OR 
Infrequent break- through 
seizures while on stable 
medication in a previously 
controlled seizure disorder 
Change in seizure character from 
baseline either in duration or quality 
(e.g., severity or focality) OR Seizures of 
any kind which are prolonged, repetitive 
(e.g., status epilepticus), or difficult to 
control (e.g., refractory epilepsy) 
Seizure 
Seizure, generalized 
Seizure, generalized 
Seizure, generalized onset with or 
without secondary generalization, lasting 
> 20 minutes OR Seizure, generalized 
onset with or without secondary 
generalization, requiring intubation and 
sedation 
– Pediatric < 18 
onset with or without 
onset with or without 
years 
secondary 
generalization, lasting < 
5 minutes with < 24 
hours post ictal state 
secondary generalization, 
lasting 5 – 20 minutes with < 24 
hours post ictal state 
Syncope (not associated 
with a procedure) 
NA 
Present 
NA 
Vertigo 
Vertigo causing no or 
minimal interference with 
usual social & functional 
activities 
Vertigo causing greater than 
minimal interference with usual 
social & functional activities 
Vertigo causing inability to perform usual 
social & functional activities OR 
Disabling vertigo causing inability to 
perform basic self-care functions 
 
 

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APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
RESPIRATORY 
Bronchospasm (acute) 
FEV1 or peak flow reduced 
to 70 – 80% 
FEV1 or peak flow 50 – 69% 
FEV1 or peak flow 25 – 49% OR 
Cyanosis OR FEV1 or peak flow 
< 25% OR Intubation 
Dyspnea or respiratory distress 
Adult ≥ 14 years 
Dyspnea on exertion with no 
or minimal interference with 
usual social & functional 
activities 
Dyspnea on exertion causing 
greater than minimal 
interference with usual social & 
functional activities 
Dyspnea at rest causing inability 
to perform usual social & 
functional activities OR 
Respiratory failure with ventilatory 
support indicated 
Pediatric < 14 years 
Wheezing OR minimal 
increase in respiratory rate 
for age 
Nasal flaring OR Intercostal 
retractions OR Pulse oximetry 
90 – 95% 
Dyspnea at rest causing inability 
to perform usual social & 
functional activities OR Pulse 
oximetry < 90% OR Respiratory 
failure with ventilatory support 
indicated 
 MUSCULOSKELETAL 
Arthralgia See also 
Arthritis 
Joint pain causing no or 
minimal interference with 
usual social & functional 
activities 
Joint pain causing greater than 
minimal interference with usual 
social & functional activities 
Joint pain causing inability to 
perform usual social & functional 
activities OR Disabling joint pain 
causing inability to perform basic 
self-care functions 
Arthritis See also 
Arthralgia 
Stiffness or joint swelling 
causing no or minimal 
interference with usual social 
& functional activities 
Stiffness or joint swelling 
causing greater than minimal 
interference with usual social & 
functional activities 
Stiffness or joint swelling causing 
inability to perform usual social & 
functional activities OR Disabling 
joint stiffness or swelling causing 
inability to perform basic self-care 
functions 
Bone Mineral Loss 
Adult ≥ 21 years 
BMD t-score -2.5 to -1.0 
BMD t-score < -2.5 
Pathological fracture (including 
loss of vertebral height) OR 
Pathologic fracture causing life-
threatening consequences 
Pediatric < 21 years 
BMD z-score -2.5 to -1.0 
BMD z-score < -2.5 
Pathological fracture (including 
loss of vertebral height) OR 
Pathologic fracture causing life-
threatening consequences 
 

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DMID14-0029 
 
Version 3.0 
 
February 19, 2016 
____________________________________________________________________________________________  
APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Myalgia (non-injection site) 
Muscle pain causing no 
or minimal interference 
with usual social & 
functional activities 
Muscle pain causing 
greater than minimal 
interference with usual 
social & functional 
activities 
Muscle pain causing inability to perform 
usual social & functional activities OR 
Disabling muscle pain causing inability to 
perform basic self-care functions 
Osteonecrosis 
NA 
Asymptomatic with 
radiographic findings 
AND No operative 
intervention indicated 
Symptomatic bone pain with radiographic 
findings OR Operative intervention 
indicated OR Disabling bone pain with 
radiographic findings causing inability to 
perform basic self-care functions 
GENITOURINARY 
Cervicitis (symptoms) (For use in 
studies evaluating topical study 
agents) For other cervicitis see 
Infection: Infection (any other 
than HIV infection) 
Symptoms causing no 
or minimal interference 
with usual social & 
functional activities 
Symptoms causing 
greater than minimal 
interference with usual 
social & functional 
activities 
Symptoms causing inability to perform 
usual social & functional activities and 
basic self-care functions. 
Cervicitis (clinical exam) (For 
use in studies evaluating topical 
study agents) For other cervicitis 
see Infection: Infection (any 
other than HIV infection) 
Minimal cervical 
abnormalities on 
examination (erythema, 
mucopurulent 
discharge, or friability) 
OR Epithelial disruption 
< 25% of total surface 
Moderate cervical 
abnormalities on 
examination (erythema, 
mucopurulent discharge, 
or friability) OR Epithelial 
disruption of 25 – 49% 
total surface 
Severe cervical abnormalities on 
examination (erythema, mucopurulent 
discharge, or friability) OR Epithelial 
disruption > 50% total surface 
Inter-menstrual bleeding (IMB) 
Spotting observed by 
participant OR Minimal 
blood observed during 
clinical or colposcopic 
examination 
Inter-menstrual bleeding 
not greater in duration or 
amount than usual 
menstrual cycle 
Inter-menstrual bleeding greater in duration 
or amount than usual menstrual cycle OR 
Hemorrhage with life-threatening 
hypotension OR Operative intervention 
indicated 
Urinary tract obstruction (e.g., 
stone) 
NA 
Signs or symptoms of 
urinary tract obstruction 
without hydronephrosis 
or renal dysfunction 
Signs or symptoms of urinary tract 
obstruction with hydronephrosis or renal 
dysfunction OR Obstruction causing life-
threatening consequences 
  
 

28-Dec-04/Clarification Aug 09 
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DMID14-0029 
 
Version 3.0 
 
February 19, 2016 
____________________________________________________________________________________________  
APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Vulvovaginitis (symptoms) 
(Use in studies evaluating 
topical study agents) For other 
vulvovaginitis see Infection: 
Infection (any other than HIV 
infection)
Symptoms causing no or 
minimal interference with 
usual social & functional 
activities 
Symptoms causing 
greater than minimal 
interference with usual 
social & functional 
activities 
Symptoms causing inability to perform 
usual social & functional activities OR 
basic self-care functions 
Vulvovaginitis (clinical exam) 
(Use in studies evaluating 
topical study agents) For other 
vulvovaginitis see Infection: 
Infection (any other than HIV 
infection) 
Minimal vaginal 
abnormalities on 
examination OR Epithelial 
disruption < 25% of total 
surface 
Moderate vaginal 
abnormalities on 
examination OR Epithelial 
disruption of 25 - 49% 
total surface 
Severe vaginal abnormalities on 
examination OR Epithelial disruption 
>50% total surface 
 OCULAR/VISUAL 
Uveitis 
Asymptomatic but 
detectable on exam 
Symptomatic anterior 
uveitis OR Medical 
intervention indicated 
Posterior or pan-uveitis OR Operative 
intervention indicated OR Disabling 
visual loss in affected eye(s) 
Visual changes (from 
baseline) 
Visual changes causing no 
or minimal interference 
with usual social & 
functional activities 
Visual changes causing 
greater than minimal 
interference with usual 
social & functional 
activities 
Visual changes causing inability to 
perform usual social & functional 
activities OR Disabling visual loss in 
affected eye(s) 
 ENDOCRINE/METABOLIC 
Abnormal fat accumulation 
(e.g., back of neck, breasts, 
abdomen) 
Detectable by study 
participant (or by caregiver 
for young children and 
disabled adults) 
Detectable on physical 
exam by health care 
provider 
Disfiguring OR Obvious changes on 
casual visual inspection 
Diabetes mellitus 
NA 
New onset without need 
to initiate medication OR 
Modification of current 
medications to regain 
glucose control 
New onset with initiation of medication 
indicated OR Diabetes uncontrolled 
despite treatment modification OR 
Life-threatening consequences (e.g., 
ketoacidosis, hyperosmolar non- 
ketotic coma) 
  
 

28-Dec-04/Clarification Aug 09 
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Version 1.0/Clarification 1 
 
 
DMID14-0029 
 
Version 3.0 
 
February 19, 2016 
____________________________________________________________________________________________  
APPENDIX C 
DIVISION OF AIDS TABLE FOR GRADING THE SEVERITY OF 
ADULT AND PEDIATRIC ADVERSE EVENTS  
VERSION 1.0, DECEMBER, 2004; CLARIFICATION AUGUST 2009  
Basic Self-care Functions – Adult: Activities such as bathing, dressing, toileting, transfer/movement, continence, and feeding. 
Basic Self-care Functions – Young Children: Activities that are age and culturally appropriate (e.g., feeding self with culturally appropriate eating 
implement). 
Usual Social & Functional Activities – Adult: Adaptive tasks and desirable activities, such as going to work, shopping, cooking, use of 
transportation, pursuing a hobby, etc. 
Usual Social & Functional Activities – Young Children: Activities that are age and culturally appropriate (e.g., social interactions, play activities, 
learning tasks, etc.). 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Gynecomastia 
Detectable by study 
participant or caregiver (for 
young children and disabled 
adults) 
Detectable on physical exam 
by health care provider 
Disfiguring OR Obvious on 
casual visual inspection 
Hyperthyroidism 
Asymptomatic 
Symptomatic causing greater 
than minimal interference with 
usual social & functional 
activities OR Thyroid 
suppression therapy indicated 
Symptoms causing inability to 
perform usual social & 
functional activities OR 
Uncontrolled despite treatment 
modification OR Life-
threatening consequences 
(e.g., thyroid storm) 
Hypothyroidism 
Asymptomatic 
Symptomatic causing greater 
than minimal interference with 
usual social & functional 
activities OR Thyroid 
replacement therapy indicated 
Symptoms causing inability to 
perform usual social & 
functional activities OR 
Uncontrolled despite treatment 
modification OR Life-
threatening consequences 
(e.g., myxedema coma) 
Lipoatrophy 
(e.g., fat loss from the face, 
extremities, buttocks) 
Detectable by study 
participant (or by caregiver for 
young children and disabled 
adults) 
Detectable on physical exam 
by health care provider 
Disfiguring OR Obvious on 
casual visual inspection 
 

 
DMID14-0029 
 
Version 3.0 
 
February 19, 2016 
 ____________________________________________________________________________________________ 
APPENDIX C 
DAIDS Toxicity Table for Grading the Severity of Adult and Pediatric Adverse Events,  
Version 1.0 - December 2004 (Clarification dated August 2009) 
 
NOTE: For protocols utilizing this Addendum, when the same parameter appears in both this Female 
Genital Grading Table and the main DAIDS AE Grading Table, use the grading scheme in this 
table. 
 
 
 
Page 1 of 6 
 
LABORATORY 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
HEMATOLOGY 
Standard International Units are listed in italics 
Absolute CD4+ count – Adult 
and Pediatric > 13 years 
(HIV NEGATIVE ONLY) 
300 – 400/mm3 300 – 400/µL 
200 – 299/mm3 200 – 299/µL 
< 199/mm3 < 199/µL 
Absolute lymphocyte count – 
Adult and Pediatric > 13 
years (HIV NEGATIVE ONLY) 
600 – 650/mm3 0.600 x 109 – 
0.650 x 10
9/L 
500 – 599/mm3 0.500 x 109 – 
0.599 x 10
9/L 
< 499/mm3 < 0.499 x 10
9/L 
Comment:  Values in children ≤ 13 years are not given for the two parameters above because the absolute counts are variable. 
Absolute neutrophil count (ANC) 
Adult and Pediatric, > 7 days 1,000 – 1,300/mm3 1.000 x 
109 – 1.300 x 109/L 
750 – 999/mm3 0.750 x 109 – 
0.999 x 109/L 
< 749/mm3 < 0.749 x 109/L 
Infant∗†, 2 – ≤ 7 days 
1,250 – 1,500/mm3 1.250 x 
109 – 1.500 x 109/L 
1,000 – 1,249/mm3 1.000 x 
109 – 1.249 x 109/L 
< 999/mm3 < 0.999 x 109/L 
Infant∗†, ≤1 day 
4,000 – 5,000/mm3 4.000 x 
109 – 5.000 x 109/L 
3,000 – 3,999/mm3 3.000 x 
109 – 3.999 x109/L 
< 2,999/mm3 < 2.999 x 109/L 
Comment:  Parameter changed from “Infant, < 1 day” to “Infant, ≤1 day” 
Fibrinogen, decreased 
100 – 200 mg/dL 1.00 – 2.00 
g/L OR 0.75 – 0.99 x LLN 
75 – 99 mg/dL 0.75 – 0.99 g/L 
OR 0.50 – 0.74 x LLN 
< 74 mg/dL < 0.74 g/L OR < 
0.49 x LLN OR Associated 
with gross bleeding 
 
 
 

 
DMID14-0029 
 
Version 3.0 
 
February 19, 2016 
 ____________________________________________________________________________________________  
APPENDIX C (Cont'd) 
DAIDS Toxicity Table for Grading the Severity of Adult and Pediatric Adverse Events,  
Version 1.0 - December 2004 (Clarification dated August 2009) 
Page 2 of 6 
LABORATORY 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Hemoglobin (Hgb) 
Comment: The Hgb values in mmol/L have changed because the conversion factor used to convert g/dL to mmol/L has been 
changed from 0.155 to 0.6206 (the most commonly used conversion factor). For grading Hgb results obtained by an analytic 
method with a conversion factor other than 0.6206, the result must be converted to g/dL using the appropriate conversion factor 
for that lab. 
Adult and Pediatric ≥ 57 
days (HIV POSITIVE ONLY) 
8.5 – 10.0 g/dL 5.24 – 6.23 
mmol/L 
7.5 – 8.4 g/dL 4.62–5.23 
mmol/L 
< 7.4 g/dL < 4.61 mmol/L 
Adult and Pediatric ≥ 57 
days (HIV NEGATIVE ONLY) 
10.0 – 10.9 g/dL 6.18 – 6.79 
mmol/L OR Any decrease 2.5 
– 3.4 g/dL 1.58 – 2.13 mmol/L 
9.0 – 9.9 g/dL 5.55 - 6.17 
mmol/L OR Any decrease 3.5 
– 4.4 g/dL 2.14 – 2.78 mmol/L 
< 8.9 g/dL < 5.54 mmol/L OR 
Any decrease ≥ 4.5 g/dL > 
2.79 mmol/L 
Comment:  The decrease is a decrease from baseline 
Infant∗†, 36 – 56 days (HIV 
POSITIVE OR NEGATIVE) 
8.5 – 9.4 g/dL 5.24 – 5.86 
mmol/L 
7.0 – 8.4 g/dL 4.31 – 5.23 
mmol/L 
< 6.9 g/dL < 4.30 mmol/L 
Infant∗†, 22 – 35 days (HIV 
POSITIVE OR NEGATIVE) 
9.5 – 10.5 g/dL 5.87 - 6.54 
mmol/L 
8.0 – 9.4 g/dL 4.93 – 5.86 
mmol/L 
< 7.9 g/dL < 4.92 mmol/L 
Infant∗†, ≤ 21 days (HIV 
POSITIVE OR NEGATIVE) 
12.0 – 13.0 g/dL 7.42 – 8.09 
mmol/L 
10.0 – 11.9 g/dL 6.18 – 7.41 
mmol/L 
< 9.9 g/dL < 6.17 mmol/L 
Correction: Parameter changed from “Infant < 21 days” to “Infant ≤ 21 days” 
International Normalized Ratio 
of prothrombin time (INR) 
1.1 – 1.5 x ULN 
1.6 – 2.0 x ULN 
> 2.1 x ULN 
Methemoglobin 
5.0 – 10.0% 
10.1 – 15.0% 
> 15.1% 
Prothrombin Time (PT) 
1.1 – 1.25 x ULN 
1.26 – 1.50 x ULN 
> 1.51 x ULN 
Partial Thromboplastin Time 
(PTT) 
1.1 – 1.66 x ULN 
1.67 – 2.33 x ULN 
> 2.34 x ULN 
Platelets, decreased 
100,000 – 124,999/mm3 
100.000 x 109 – 124.999 x 
109/L 
50,000 – 99,999/mm3 50.000 x 
109 – 99.999 x 109/L 
< 49,999/mm3 <  49.999 x 
109/L 
WBC, decreased 
2,000 – 2,500/mm3 2.000 x 
109 – 2.500 x 109/L 
1,500 – 1,999/mm3 1.500 x 
109 – 1.999 x 109/L 
< 1,499/mm3 < 1.499 x 109/L 
 
 
 

 
DMID14-0029 
 
Version 3.0 
 
February 19, 2016 
 ____________________________________________________________________________________________  
APPENDIX C (Cont'd) 
DAIDS Toxicity Table for Grading the Severity of Adult and Pediatric Adverse Events,  
Version 1.0 - December 2004 (Clarification dated August 2009) 
Page 3 of 6 
LABORATORY 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
CHEMISTRIES 
Standard International Units are listed in italics 
Acidosis 
NA 
pH < normal, but ≥ 7.3 
pH < 7.3  
Albumin, serum, low 
3.0 g/dL – < LLN 
30 g/L – < LLN 
2.0 – 2.9 g/dL 
20 – 29 g/L 
< 2.0 g/dL 
< 20 g/L 
Alkaline Phosphatase 
1.25 – 2.5 x ULN† 
2.6 – 5.0 x ULN† 
> 5.1 – 10.0 x ULN† 
Alkalosis 
NA 
pH > normal, but ≤ 7.5 
pH > 7.5  
ALT (SGPT) 
1.25 – 2.5 x ULN 
2.6 – 5.0 x ULN 
> 5.1 x ULN 
AST (SGOT) 
1.25 – 2.5 x ULN 
2.6 – 5.0 x ULN 
> 5.1 x ULN 
Bicarbonate, serum, low 
16.0 mEq/L – < LLN 
16.0 mmol/L – < LLN 
11.0 – 15.9 mEq/L 
11.0 – 15.9 mmol/L 
> 8.0 mEq/L 
> 8.0 mmol/L 
Comment:  Some laboratories will report this value as Bicarbonate (HCO3) and others as Total Carbon Dioxide (CO2). These 
are the same tests; values should be graded according to the ranges for Bicarbonate as listed above. 
Bilirubin (Total) 
 
Adult and Pediatric > 
14 days 
1.1 – 1.5 x ULN 
1.6 – 2.5 x ULN 
> 2.6 x ULN 
 
Infant∗†, ≤ 14 days 
(non-hemolytic) 
NA 
20.0 – 25.0 mg/dL 
342 – 428 µmol/L 
> 25.1 mg/dL 
> 429 µmol/L 
 
Infant∗†, ≤ 14 days 
(hemolytic) 
NA 
NA 
> 20.0 mg/dL 
> 342 µmol/L 
Calcium, serum, high 
 
Adult and Pediatric 
≥ 7 days 
10.6 – 11.5 mg/dL 
2.65 – 2.88 mmol/L 
11.6 – 12.5 mg/dL 
2.89 – 3.13 mmol/L 
> 12.6 mg/dL 
> 3.14 mmol/L 
 
Infant∗†, < 7 days 
11.5 – 12.4 mg/dL 
2.88 – 3.10 mmol/L 
12.5 – 12.9 mg/dL 
3.11 – 3.23 mmol/L 
> 13.0 mg/dL 
> 3.245 mmol/L 
Calcium, serum, low 
 
Adult and Pediatric 
≥ 7 days 
7.8  – 8.4 mg/dL 
1.95 – 2.10 mmol/L 
7.0  – 7.7 mg/dL 
1.75 – 1.94 mmol/L 
< 6.1 mg/dL 
< 1.53 mmol/L 
 
Infant∗†, < 7 days 
6.5 – 7.5 mg/dL 
1.63 – 1.88 mmol/L 
6.0 – 6.4 mg/dL 
1.50 – 1.62 mmol/L 
< 5.50 mg/dL 
< 1.38 mmol/L 
Comment:  Do not adjust Calcium, serum, low or Calcium, serum, high for albumin 
 

 
DMID14-0029 
 
Version 3.0 
 
February 19, 2016 
 ____________________________________________________________________________________________  
APPENDIX C (Cont'd) 
DAIDS Toxicity Table for Grading the Severity of Adult and Pediatric Adverse Events,  
Version 1.0 - December 2004 (Clarification dated August 2009) 
Page 4 of 6 
LABORATORY 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Cardiac troponin I (cTnI) 
NA 
NA 
Levels consistent with 
myocardial infarction or 
unstable angina as defined by 
the manufacturer 
Cardiac troponin T (cTnT) 
NA 
NA 
≥ 0.20 ng/mL 
OR 
Levels consistent with 
myocardial infarction or 
unstable angina as defined by 
the manufacturer 
Cholesterol (fasting) 
Adult ≥ 18 years 
200 – 239 mg/dL 
5.18 – 6.19 mmol/L 
240 – 300 mg/dL 
6.20 – 7.77 mmol/L 
> 300 mg/dL 
> 7.77 mmol/L 
Pediatric < 18 years 
170 – 199 mg/dL 
4.40 – 5.15 mmol/L 
200 – 300 mg/dL 
5.16 – 7.77 mmol/L 
> 300 mg/dL 
> 7.77 mmol/L 
Creatine Kinase 
3.0 – 5.9 x ULN† 
6.0 – 9.9 x ULN† 
> 10.0 x ULN† 
Creatinine 
1.1 – 1.3 x ULN† 
1.4 – 1.8 x ULN† 
> 1.9 x ULN† 
Glucose, serum, high 
Nonfasting 
116 – 160 mg/dL 
6.44 – 8.88 mmol/L 
161 – 250 mg/dL 
8.89 – 13.88 mmol/L 
> 251 mg/dL 
> 13.89 mmol/L 
Fasting 
110 – 125 mg/dL 
6.11 – 6.94 mmol/L 
126 – 250 mg/dL 
6.95 – 13.88 mmol/L 
> 251 mg/dL 
> 13.89 mmol/L 
Glucose, serum, low 
Adult and Pediatric 
≥ 1 month 
55 – 64 mg/dL 
3.05 – 3.55 mmol/L 
40 – 54 mg/dL 
2.22 – 3.06 mmol/L 
< 40 mg/dL 
< 2.21 mmol/L 
Infant∗†, < 1 month 
50 – 54 mg/dL 
2.78 – 3.00 mmol/L 
40 – 49 mg/dL 
2.22 – 2.77 mmol/L 
< 40 mg/dL 
< 2.21 mmol/L  
Lactate 
ULN - < 2.0 x ULN 
without acidosis 
≥ 2.0 x ULN without 
acidosis 
Increased lactate with pH < 
7.3  
 
 

 
DMID14-0029 
 
Version 3.0 
 
February 19, 2016 
 ____________________________________________________________________________________________  
APPENDIX C (Cont'd) 
DAIDS Toxicity Table for Grading the Severity of Adult and Pediatric Adverse Events,  
Version 1.0 - December 2004 (Clarification dated August 2009) 
Page 5 of 6 
LABORATORY
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Comment: Added ULN to Grade 1 parameter 
LDL cholesterol (fasting) 
Adult ≥ 18 years 
130 – 159 mg/dL 
3.37 – 4.12 mmol/L 
160 – 190 mg/dL 
4.13 – 4.90 mmol/L 
>190 mg/dL 
> 4.91 mmol/L 
Pediatric > 2 - < 18 years 
110 – 129 mg/dL 
2.85 – 3.34 mmol/L 
130 – 189 mg/dL 
3.35 – 4.90 mmol/L 
≥ 190 mg/dL 
≥ 4.91 mmol/L 
Lipase 
1.1 – 1.5 x ULN OR 
Refers to ULN 
1.6 – 3.0 x ULN 
> 3.1 x ULN 
Magnesium, serum, low 
1.2  – 1.4 mEq/L 
0.60 – 0.70 mmol/L 
0.9 – 1.1 mEq/L 
0.45 – 0.59 mmol/L 
< 0.89 mEq/L 
< 0.44 mmol/L 
Pancreatic amylase 
1.1 – 1.5 x ULN 
1.6 – 2.0 x ULN 
> 2.1 x ULN 
Phosphate, serum, low 
Adult and Pediatric 
> 14 years 
2.5 mg/dL – < LLN 
0.81 mmol/L – < LLN 
2.0 – 2.4 mg/dL 
0.65 – 0.80 mmol/L 
< 1.9 mg/dL 
< 0.64 mmol/L 
Pediatric 1 year – 14 years 
3.0 – 3.5 mg/dL 
0.97 – 1.13 mmol/L 
2.5 – 2.9 mg/dL 
0.81 – 0.96 mmol/L 
< 2.4 mg/dL 
< 0.80 mg/dL 
< 2.21 mmol/L 0.80 mmol/L 
Pediatric < 1 year 
3.5 – 4.5 mg/dL 
1.13 – 1.45 mmol/L 
2.5 – 3.4 mg/dL 
0.81 – 1.12 mmol/L 
< 2.4 mg/dL 
< 0.80 mmol/L 
Potassium, serum, high 
5.6 – 6.0 mEq/L 
5.6 – 6.0 mmol/L 
6.1 – 6.5 mEq/L 
6.1 – 6.5 mmol/L 
> 6.6 mEq/L 
> 6.6 mmol/L 
Potassium, serum, low 
3.0 – 3.4 mEq/L 
3.0 – 3.4 mmol/L 
2.5 – 2.9 mEq/L 
2.5 – 2.9 mmol/L 
< 2.4 mEq/L 
< 2.4 mmol/L 
Sodium, serum, high 
146 – 150 mEq/L 
146 – 150 mmol/L 
151 – 154 mEq/L 
151 – 154 mmol/L 
> 155 mEq/L 
> 155 mmol/L 
Sodium, serum, low 
130 – 135 mEq/L 
130 – 135 mmol/L 
125 – 129 mEq/L 
125 – 129 mmol/L 
< 121 mEq/L 
< 121 mmol/L
Triglycerides (fasting) 
NA 
500 – 750 mg/dL 
5.65 – 8.48 mmol/L 
> 751 mg/dL 
> 8.49 mmol/L 
 
 
 

 
DMID14-0029 
 
Version 3.0 
 
February 19, 2016 
 ____________________________________________________________________________________________  
APPENDIX C (Cont'd) 
DAIDS Toxicity Table for Grading the Severity of Adult and Pediatric Adverse Events,  
Version 1.0 - December 2004 (Clarification dated August 2009) 
Page 6 of 6 
 
LABORATORY 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
Uric acid 
7.5 – 10.0 mg/dL 
0.45 – 0.59 mmol/L 
10.1 – 12.0 mg/dL 
0.60 – 0.71 mmol/L 
> 12.1 mg/dL 
> 0.72 mmol/L 
URINALYSIS 
Standard International Units are listed in italics 
Hematuria (microscopic) 
6 – 10 RBC/HPF 
> 10 RBC/HPF 
Gross, with or without clots OR with RBC casts 
Proteinuria, random 
collection 
1 + 
2 – 3 + 
4 + 
Proteinuria, 24 hour collection 
Adult and Pediatric 
≥ 10 years 
200 – 999 mg/24 h 
0.200 – 0.999 g/d 
1,000 – 1,999 mg/24 h 
1.000 – 1.999 g/d 
> 2,000 mg/24 h 
> 2.000 g/d 
Pediatric > 3 mo - 
< 10 years 
201 – 499 mg/m2/24 h 
0.201 – 0.499 g/d 
500 – 799 mg/m2/24 h 
0.500 – 0.799 g/d 
> 800 mg/m2/24 h 
> 0.800 g/d