Phase 2 Placebo-controlled Randomized Trial of LACTIN-V (Lactobacillus Crispatus CTV-05) Among Women at High Risk of HIV Acquisition in Durban, South Africa
Phase: PHASE2
Conditions: Bacterial Vaginosis, HIV Infections
Sponsor: University of California, San Francisco

Page 1 of 124
Phase 2 placebo-controlled randomized trial of 
LACTIN-V (Lactobacillus crispatus CTV-05) 
among women at high risk of HIV acquisition 
in Durban, South Africa
Funding Mechanism: NICHD Grant
1R01HD098978
Pharmaceutical Support Provided by: Osel, Inc.
Trial Sponsor: University of 
California, San Francisco 
(USA)
NCT05022212
South Africa
Co- Principal Investigator:  Vaneshree Govender, MBBCh Co- 
Principal Investigator:  Thumbi Ndung’u, BVM, PhD
International
Principal Investigator: Craig R. Cohen, MD, MPH
Co- Principal Investigator: Douglas S. Kwon, MD, PhD
Co- Principal Investigator: Krista Dong, MD
Protocol Number: LV-007
Version 4.3
  03 September 2021

[Type here]
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Page 2 of 124
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

Guidelines for Good Practice in the Conduct of Clinical Trials with Human Participants in
South Africa. Department of Health, 2006.
All key personnel (all individuals responsible for the design and conduct of this study) have 
completed Human Subjects Protection Training.

Page 3 of 124
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.
Co-Principal Investigator (SOUTH AFRICA):
Signed:   
Date: 03 September, 2021
  Vaneshree Govender, MBBCh 
Co-Principal Investigator (SOUTH AFRICA):
Signed:   
Date: 03 September, 2021
  Thumbi Ndung’ u, BVM, PhD 
Principal Investigator (USA):
Signed:
Date: 03 September, 2021
Craig R. Cohen, MD, MPH 
Co-Principal Investigator (USA):
Signed:
Date: 03 September, 2021
Doug S. Kwon, MD, Ph D
Co-Principal Investigator (USA):
Signed:   
 Date: 03 September, 2021
Krista Dong, MD

Page 4 of 124
TABLE OF CONTENTS
STATEMENT OF COMPLIANCE ............................................................................................................2
SIGNATURE PAGE .......................................................................................................................... 3
TABLE OF CONTENTS .......................................................................................................................... 4
LIST OF ABBREVIATIONS....................................................................................................................  7
PROTOCOL SUMMARY.......................................................................................................................   9
SCHEMATIC OF STUDY DESIGN:...................................................................................................10
1.0
KEY ROLES...........................................................................................................................11
Key Investigators...............................................................................................................................11
Others................................................................................................................................................13
2.0      BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE..........................................14
2.1 Background Information the vaginal microbiome and its influence on risk of HIV 
infection/transmission........................................................................................................................ 14
2.2 Background Information on Bacterial Vaginosis..........................................................................16
2.3 Preliminary Studies on increased HIV acquisition and mucosal inflammation in young South 
African women...................................................................................................................................16
2.4 Preliminary Studies on LACTIN-V for Bacterial Vaginosis...........................................................18
2.5 Rationale …………………………………………………………………………………………………21
2.6 Potential Risks and Benefits......................................................................................................  23
3.0
HYPOTHESIS AND OBJECTIVES......................................................................................  27
3.1 Study Hypothesis ......................................................................................................................  27
3.2 Summary of Methods ................................................................................................................  27
3.3 Study Objectives .......................................................................................................................  27
3.4 Study Outcome Measures.........................................................................................................  27
4.0
STUDY DESIGN...................................................................................................................  30
5.0
STUDY ENROLMENT AND WITHDRAWAL.............................................................................  34
5.1 Subject Inclusion Criteria...........................................................................................................  34
5.2 Subject Exclusion Criteria..........................................................................................................  34
5.3 Treatment Assignment Procedures ...........................................................................................  36
6.0 
STUDY PRODUCT.....................................................................................................................  39
6.1 Study Product Description.........................................................................................................  39
6.2 Dosage, Preparation, and Administration of Study Product.......................................................  41
6.3 Accountability Procedures for the Study Investigational Product ...............................................  41
6.4 Assessment of Subject Compliance with Study Product ...........................................................  42
6.5 Concomitant Medications/Treatments.......................................................................................  42
7.0
STUDY SCHEDULE.............................................................................................................  43
7.1 Enrolment Visit 1 .......................................................................................................................  43
7.2 Check-in Visit 2 (Day 4).............................................................................................................  45

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7.3 Randomization Visit 3 (Day 8) ...................................................................................................45
7.4 Check-In Visits 4 – 10................................................................................................................47
7.5 Follow-up Visit 11 (Day 36) (Allowable window:  Days 33 - 43).................................................48
7.6 Check-In Visits 12 –18...................................................................................................................50
7.7 Final Study Visit 19, Day 64 (Allowable window: Days 57  - 71)...............................................50
7.8 Study Product Discontinuation/Early Termination Visit..............................................................52
7.9 Unscheduled Visit......................................................................................................................53
8.0
STUDY PROCEDURES/EVALUATIONS .................................................................................55
8.1 Clinical Evaluations ...................................................................................................................55
8.2 Laboratory Evaluations..............................................................................................................55
9.0
ASSESSMENT OF SAFETY.....................................................................................................57
9.1 Specification of Safety Parameters............................................................................................57
9.1 Methods and Timing for Assessing, Recording, and Analyzing Safety Parameters……………..57 
9.3 Reporting Procedures ...............................................................................................................59
9.4 Type and Duration of Follow-up of Subjects after Adverse Events............................................61
9.5 Halting Rules.............................................................................................................................61
9.6 Safety Oversight (DSMB) ..........................................................................................................61
10.0
MONITORING......................................................................................................................63
10.1 Site Monitoring Plan ................................................................................................................63
11.0
STATISTICAL CONSIDERATIONS..........................................................................................64
11.1 Introduction..............................................................................................................................64
11.2 Study Objectives and Outcome Measures ..............................................................................64
11.3 Sample Size Considerations ...................................................................................................65
11.4 Safety Analysis........................................................................................................................65
11.5 Statistical Analysis Plan ..........................................................................................................66
12.0  SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/ DOCUMENTS.....................68
13.0  QUALITY CONTROL AND QUALITY ASSURANCE ...............................................................69
14.0 ETHICS/PROTECTION OF HUMAN SUBJECTS...................................................................70
14.1 Ethical Standard......................................................................................................................70
14.2 Institutional Review Board.......................................................................................................70
14.3 Informed Consent Process ......................................................................................................70
14.4 Exclusion of Women, Minorities, and Children (Special Populations)......................................71
14.5 Subject Confidentiality.............................................................................................................71
14.6 Study Discontinuation..............................................................................................................71
15.0
DATA HANDLING AND RECORD KEEPING .....................................................................72
15.1 Data Management Responsibilities.........................................................................................72
15.2 Data Capture Methods ............................................................................................................72
15.3 Types of Data..........................................................................................................................72
15.4 Timing/Reports........................................................................................................................73
15.5 Study Records Retention ........................................................................................................73

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15.6 Protocol Deviations .................................................................................................................73
16.0 PUBLICATION POLICY ...............................................................................................................74
17.0 SPONSOR INDEMNIFICATION FOR SITES AND INVESTIGATORS………………………  75
18.0 LITERATURE REFERENCES ................................................................................................76
19.0 APPENDICES ...............................................................................................................................81
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 2.1-July 2017  
Appendix D
Coordination between FRESH and LACTIN-V studies

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LIST OF ABBREVIATIONS
AE
Adverse Event
ATP
According to Protocol
βHCG 
BV 
CAPRISA 
CAR
CC
cfu 
CMH
CDC
CI 
CONRAD
CRF
CROMS DAIDS 
DHHS DMID
Beta Human Chorionic Gonadotropin 
Bacterial Vaginosis
Centre for the AIDS Programme of Research in South Africa 
Clinical Agents Repository
Complete Case Colony 
Forming Units
Cochran-Mantel-Haenszel 
Centers for Disease Control and Prevention
Confidence Interval
Contraceptive Research and Development 
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 
GMP 
ICF 
ICH 
ICMJE
IDES 
IEC
Enzyme-linked Immunosorbent Assay 
Food and Drug Administration
Good Clinical Practice
Good Manufacturing Practice Informed 
Consent Form
International Conference for 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
LBP
LOCF
MedDRA 
Metronidazole
mITT 
MOP
Intent-to-treat
Lactobacillus crispatus CTV-05 
Live Biotherapeutic Product
Last Observation Carried Forward
Medical Dictionary for Regulatory Activities 
Metronidazole oral tablets
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

Page 8 of 124
OHRP
Office for Human Research Protections
ORA
Office of Regulatory Affairs, DMID, NIAID, NIH, DHHS
OSEL
pH 
PI 
PP
qPCR 
RR 
rUTI 
SAE 
SAHPRA
SDCC
SMC
SOP 
STAR 
STI
STI-CTG
 
UCSF
UKZN
US
UTI
WHO
Office of Science and Engineering Laboratories Potential 
Hydrogen
Principal Investigator 
Per Protocol
Quantitative Polymerase Chain Reaction 
Rate Ratio
Recurrent Urinary Tract Infection 
Serious Adverse Event
South African Health Products Regulatory Authority
Statistical and Data Coordinating Center
Safety Monitoring Committee
Standard Operating Procedure
Sexually Transmitted Infections Treatment and Research
Sexually Transmitted Infection
Sexually Transmitted Infections Clinical Trials Group 
University of California, San Francisco
University of KwaZulu-Natal
United States
Urinary Tract Infection
World Health Organization

Page 9 of 124
PROTOCOL SUMMARY
Title:
Phase 2 placebo-controlled randomized trial of LACTIN-V 
(Lactobacillus crispatus CTV-05) among women at high risk of 
HIV acquisition in Durban, South Africa
Phase:
2
Population:
Non-pregnant women age 18 – 23.
Enrolment will be continued until 60 women are randomized into 
the study
Number of Sites:
One site in Durban, South Africa: 
FRESH Clinic: Umlazi, KZN
Study Duration:
Participant Participation: 
Duration:
90 weeks after enrolment of the first participant
10 weeks (64 days) per participant
Description of Agent:
Primary Objectives:
Description of Study Design: 
Time to Complete Enrolment: 
Keywords:
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 3 consecutive 
additional weeks.
1: Determine the effect of repeat dosing of LACTIN-V (2 x 109 
cfu/dose) on genital tract inflammation in young South African 
women at risk of HIV.
2: Determine the ability of LACTIN-V to promote a Lactobacillus-
dominant vaginal microbiota in young South African women at risk 
of HIV.
3: Determine the safety and acceptability of LACTIN-V in a 
population of young South African women at risk for HIV.
See schematic 
65 weeks
Vaginal microbiome, lactobacilli, HIV risk, vaginal mucosa

Page 10 of 124
SCHEMATIC OF STUDY DESIGN:
Enrolment Visit 1
Day 1
Check-In Visit 2
Day 4
Randomization 
Visit 3
Day 8
Be assigned to receive LACTIN-V or 
placebo (the inactive substance) by 
randomization (chance)

Confirm completion of Metronidazole treatment.

Have physical exam, medical, gynaecological and sexual history, 
gynaecological exam, vaginal swabs, urine test, pregnancy test.
Find out if you are eligible for the study:

Be invited to participate if prior FRESH Lab results (Gram Stain, STI testing) 
confirm that you are eligible.

Have physical exam, as well as medical, gynaecological and sexual history, 
and answer questionnaire.

Start 7-day course of oral Metronidazole. Check-In Visit 2 on Day 4.
Dosing Visits
Visit 4, Day 11
Visit 5, Day 15
Visit 6, Day 18
Visit 7, Day 22
Visit 8, Day 25
Visit 9, Day 29
Visit 10, Day 32
LACTIN-V
PLACEBO
Follow-up Visits
Visit 11, Day 36
Follow-up Visits
Visit 12, Day 39
Visit 13, Day 43
Visit 14, Day 46
Visit 15, Day 50
Visit 16, Day 53
Visit 17, Day 57
Visit 18, Day 60
Final Visit
Visit 19, Day 64

Have physical exam, gynaecological medical and sexual history, 
gynaecological exam, vaginal swabs, urine test, pregnancy test

Answer questions about symptoms, medications, and sexual history

Have physical exam, medical, gynaecological and sexual history, gynaecological 
exam, vaginal swabs, urine test, pregnancy test

Answer questions about symptoms, medications, and sexual history

Administer study product at clinic

At Visit 4, take 1 dose home to be administered before bed the next day (Study 
Day 12)

Administer first dose at clinic based on randomization. Take 2 doses home 
to be administered before bed the following two days (Study Day 9 and 10).

Page 11 of 124
1.0
KEY ROLES
Key Investigators
SOUTH AFRICA:
Co-Principal Investigator
Vaneshree Govender, MBBCh
FRESH
Shop 109A, Umlazi Mega City, 
50 Griffiths Mxenge Highway 
Umlazi, 4066
South Africa
+27 (0) 31 003 5414
+27 (0) 84 759 6461 (mobile)
The Aurum Institute
Department: Research Management
Division: Clinical Research
29 Queens Road, Parktown,
Johannesburg
South Africa, 2193
+27 (0) 10 590 1300
VGovender@auruminstitute.org
Co-Principal Investigator
Thumbi Ndungu, DVM, PhD
HIV Pathogenesis Programme (HPP) 
Nelson R Mandela School of Medicine 
University of KwaZulu-Natal
719 Umbilo Road 
Durban
South Africa
+27 (0) 31 260 4618
Ndungu@ukzn.ac.za
Co-Investigator
Siphesihle Reward Ngcobo, MBChB
Ekasi Medical Centre
Umlazi Mega City, 
50 Griffiths Mxenge Highway, 
Umlazi, 4066
South Africa
+27 (0) 31 902 8808
+27 (0) 61 448 6836 (mobile)
sihler312@gmail.com 
INTERNATIONAL:
Principal Investigator
Craig Cohen, MD, MPH
550 16th Street (Mission Bay Campus)
San Francisco, CA 94158 
(415) 476-5874
Craig.Cohen@ucsf.edu
Co- Principal Investigator
Douglas S. Kwon, MD, PhD
The Ragon Institute of MGH, MIT and Harvard
400 Technology Square  893
Cambridge, MA 02139, USA
+1 (857) 268-7079
dkwon@mgh.harvard.edu

Page 12 of 124
Co-Principal Investigator
Krista Dong, MD
The Ragon Institute of MGH, MIT and Harvard
/ FRESH
Shop 109A, Umlazi Mega City, 
50 Griffiths Mxenge Highway 
Umlazi, 4066
South Africa
+27 (0) 31 906 0394
woodil.iteach@gmail.com 
kdong@mgh.harvard.edu
Co- Investigator
Anke Hemmerling, MD, PhD, MPH 550
   
16th Street 
(Mission Bay Campus, GHS Building)
  San Francisco, CA 94158
+ 1 (415) 476-5878
A2nke.Hemmerling@ucsf.edu
Co- Investigator
 
Caroline Mitchell, MD, MPH
Vincent Center for Reproductive Biology
Assistant Professor, Obstetrics, Gynecology &
Reproductive Biology
caroline.mitchell@mgh.harvard.edu
Protocol Statistician
  
Musie Ghebremichael, PhD
The Ragon Institute of MGH, MIT and Harvard
400 Technology Square 870
Cambridge, MA 02139
+1 (857) 268-7079
Musie_Ghebrimichael@dfci.harvard.edu
Co- Investigator
  
Laurel Lagenaur, PhD
Osel, Inc.
320 Logue Avenue
Mountain View, CA 94043
+1 (240) 760-6649
llagenaur@oselinc.com
Co- Investigator
  
Thomas Parks, PhD 
Osel, Inc.
320 Logue Avenue
Mountain View, CA 94043
+1 (650) 396-7626
tparks@oselinc.com

Page 13 of 124
Others
Monitoring
TCD Global
Tracy Southwood MD
Design House, 121 Amkor Road, 
Centurion 0157, Gauteng
PO Box 15775,
Lyttelton 0140, Gauteng, South Africa 
TEL +27 (0) 31 764 1413
FAX +27 (0) 86 668 8657
Tracy.Southwood@Tcd-global.com
Regulatory Support
Wilberto Robles 
Women Care Global
701 Palomar Airport Road 
Suite 300
Carlsbad CA 
92011
(858) 314-4025, ext. 300
wrobles@wcgcares.org
Data Management
DF Net Research Inc. 
Darryl Pahl, CEO
140 Lakeside Ave, Suite 310
Seattle, WA 98122 
USA
+1.206.322.5931 Phone
+1.206.322.5932 Fax
darryl@dfnetresearch.com
www.dfnetresearch.com
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

Page 14 of 124
2.0    BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE
2.1  
Background Information the vaginal microbiome and its influence on risk of HIV 
infection/transmission
HIV incidence in parts of sub-Saharan Africa (SSA), especially KwaZulu-Natal, 
South Africa remains very high due to biological, behavioral and unknown factors: 
SSA is the region most heavily affected by HIV worldwide with 67% of new infections 
among 15-24 year old women.1 The glaring geographic and gender disparities in HIV risk 
have been attributed to multiple causes, including differences in the genital tract immune 
milieu;2 hormonally-dependent differences in the genital epithelium;3 developmental 
factors; structural factors; and sociocultural factors.4, 5 The FRESH (Females Rising 
through Education, Support, and Health) cohort consists of 300 HIV uninfected young 
women age 18-23 living in Umlazi, South Africa. In this region, <1% of 14 year old girls 
are HIV positive but over 60% of 24 year old women are HIV infected.6 The 
development, evaluation, and testing of safe and highly acceptable female-controlled 
HIV prevention methods that are effective against HIV and other STIs are an urgent 
priority. Significant challenges remain for the field, including the reduced efficacy of 
tenofovir vaginal gel in women with a non-Lactobacillus-dominant vaginal microbiota 
compared to women with a Lactobacillus-dominant vaginal microbiota.7 Current 
approaches such as vaginal rings, gels and films for HIV prevention face adherence 
issues and significant obstacles to maintain and finance an uninterrupted large scale 
distribution chain.8, 9, 10 A durable, self- renewing intervention such as vaginal live 
biotherapeutic product (LBP) Lactobacillus could avoid some of the persistent obstacles 
for female-controlled HIV prevention.
Antiretroviral-based prevention strategies demonstrate biologic effectiveness but 
face challenges with real world efficacy. Oral PrEP with tenofovir or Truvada has been 
shown to be effective in MSM and HIV sero-discordant couples, and its efficacy is not 
affected by the vaginal microbiota.11, 12 Vaginal tenofovir pre-exposure prophylaxis has 
been shown to reduce the risk of HIV acquisition, among adherent women.13 However, in 
cohorts of young women, neither oral nor topical PrEP has demonstrated consistent 
effectiveness–largely due to low rates of adherence to the intervention.14, 15, 16 In addition, 
genital tract inflammation17 and dysbiotic microbial communities7 have been associated 
with attenuation of the protective effect. More recently, the world community has adopted 
the UNAIDS 90-90-90 platform, advocating for increased testing, treatment and viral 
suppression as the way to contain the HIV epidemic.18 However, in a large scale 
treatment-as-prevention trial conducted in Kenya and Uganda in which 80% of the people 
living with HIV in the intervention arm were virally suppressed, HIV incidence decreased 
over three years but remained at 0.7% and was not statistically different in the control 
communities.19 Thus, the development of a vaccine and other biomedical prevention 
products remain a high global priority to end the intractable HIV epidemic, especially 
among adolescent and young women in sub-Saharan Africa.20
The vaginal microbiome influences risk of HIV infection/transmission: Early in the 
epidemic, bacterial vaginosis (BV) was associated with prevalent HIV21, 22 and subsequent 
studies showed associations with incident HIV in women.23 - 27 BV was also associated 
with transmission of HIV to the fetus28 and a four-fold increased risk to male sexual

Page 15 of 124
partners.29 In a case-control analysis of participants from several studies in eastern and 
southern Africa, the quantity of several BV-associated microbial taxa (measured by 
qPCR) was associated with a 2-4 fold increased odds for incident HIV.30 Using next- 
generation sequencing techniques, we have demonstrated a 4-fold increased risk for HIV 
acquisition in women with a diverse, non-Lactobacillus-dominant vaginal microbiome 
(whether or not it meets criteria for BV) compared to a L. crispatus dominant 
cervicotype.31 These results suggest that L. crispatus may significantly reduce the risk of 
HIV acquisition in women at high risk of infection.
Genital mucosal inflammation increases the risk for HIV acquisition: Among women 
enrolled in the CAPRISA 004 topical tenofovir PrEP trial, those with genital tract 
inflammation (defined as 3 of 9 cytokines with a concentration in the upper quartile found 
in vaginal fluid) demonstrated higher HIV incidence and lower efficacy for topical tenofovir 
(3%) than women without genital inflammation (57% efficacy).17, 32 Women in the FRESH 
cohort with diverse vaginal microbial communities, who had the highest risk for HIV 
acquisition, also had the highest quantities of vaginal proinflammatory cytokines, and the 
highest numbers of activated cervical CD4+ T cells.33, 31 These data suggest that the 
mechanism underlying the association between the female genital microbiota and HIV 
acquisition is mucosal inflammation; thus a microbial intervention to decrease the risk of 
female HIV acquisition should decrease mucosal inflammatory markers in the genital tract.
Vaginal colonization with L. crispatus reduces the risk of HIV acquisition through 
several potential mechanisms of action: Although vaginal colonization with H2O2- 
producing Lactobacillus species is associated with decreased incidence of HIV 24, not all 
Lactobacillus species are equal in this regard. Women with a L. crispatus cervicotype had 
the lowest rates of HIV acquisition, as well as the lowest concentrations of 
proinflammatory cytokines in vaginal fluid and 
the lowest numbers of CD4+ HIV-target cells 
in the endocervix. 33, 31 Unfortunately, only a 
small fraction of the population had this 
microbial phenotype (8/94, 9%). The far more 
prevalent L. iners did not confer the same 
anti-inflammatory effect, nor protection 
against HIV infection. In the FRESH cohort, 
when participants transition from a higher CT 
(more diverse) to a lower CT (less diverse, 
more Lactobacillus-dominant) the 
concentrations of genital cytokines dropped.33 
Cervicovaginal lavage (CVL) from women 
with BV has lower SLPI, higher 
proinflammatory cytokines, and lower anti- 
HIV activity compared to CVL of women with 
Lactobacillus dominant microbiota.34 In the
presence of the proinflammatory stimulus of BV, 
colonization with H2O2-producing Lactobacillus 
species, like L. crispatus, is associated with 
lower quantities of vaginal cytokines.35 Vaginal 
inoculation of gnotobiotic mice with L. crispatus 
is associated with significantly lower numbers
Figure 1: Graphical representation of our hypothesis 
that L. crispatus protects agains HIV acquisition 
through three complimentary pathways: 1) decreased 
inflammation in genital mucosa; 2) reduced number of 
activated CD4+ T-cells in endocervix; and 3) reduction of 
infectious viral particles in genital secretions.

Page 16 of 124
of activated CD4+ T cells in the genital tract compared to Prevotella bivia.33 In vitro, several 
L. crispatus strains demonstrated anti-viral effects on HIV, as well as inhibition of viral 
replication in tissue.36 Cervicovaginal secretions from women with L. crispatus dominant 
microbiota demonstrate increased HIV-trapping activity compared to L. iners-dominated 
communities.37 Acidic vaginal secretions characteristic of a Lactobacillus-dominant microbial 
community both trap and inhibit HIV.38, 39 We will explore these three potential mechanisms 
of action (Figure 1) in the proposed LACTIN-V clinical trial.
2.2 
Background Information on Bacterial Vaginosis
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.40 Many women are unaware of 
their condition. BV has been associated with significant gynaecological and obstetric 
complications, such as pelvic inflammatory disease 41 , endometritis 42 and post-operative 
infections, including post-cesarean endometritis 43 and post-hysterectomy vaginal cuff 
cellulitis. 44 Strong associations have also been reported between BV and pre-term delivery, 
miscarriage 45, and amniotic fluid infections. 46 Studies have linked BV to both female HIV-1 
acquisition, and female-to-male HIV transmission.47-49 A recent study showed that the 
presence of lactobacilli decrease the odds for fetal inflammatory responses to placental 
colonization with pathogens. 50 Following standard antibiotic treatment of BV, 20–75% of 
women relapse within 1–3 months. 51-52 The high risk of recurrence and sequelae suggests 
that investigational studies of new agents like live biotherapeutic products 53 may be effective 
for the improved treatment and prevention of BV.
Reconstituting a normal, Lactobacillus-predominant microbiome 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 metronidazole. 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 and with vaginal health, the product has an 
excellent pre-clinical and clinical safety profile.
2.3 
Preliminary Studies on increased HIV acquisition and mucosal inflammation in 
young South African women
Lactobacillus-deficient cervicovaginal bacterial communities are associated with increased 
HIV acquisition and mucosal inflammation in young South African women: We recently 
characterized cervicovaginal microbiota in a prospective cohort study of healthy HIV-
uninfected South African women monitored with high frequency HIV testing. Sequencing of 
the bacterial 16S rRNA gene revealed the presence of four distinct cervicovaginal bacterial 
cervicotypes, or “cervicotypes” (CTs), two of which had low diversity and were dominated by 
either L. crispatus (CT1, 11% of participants) or Lactobacillus iners (CT2, 32%), and two high 
diversity CTs dominated by Gardnerella vaginalis (CT3, 28%) or a bacterial genus other than

Page 17 of 124
A
D
Lactobacillus or Gardnerella (CT4, 28%) (Fig. 2A). 31 The most abundant taxa in CT4 were 
anaerobic genera including Prevotella, Gardnerella, Sneathia and Megasphaera. Individuals 
with CT4 communities were at over 4-fold higher risk of acquiring HIV compared to those 
with L. crispatus dominance (Fig. 2B).7 They further had elevated genital cytokine levels31 
(Fig. 2C) and 17-fold increased numbers of cervical HIV target cells (Fig. 2D) 31, providing a 
plausible biological mechanism for the observed increase in infection. We identified specific 
bacterial taxa linked with HIV infection, showing that Prevotella melaninogenica,
Prevotella bivia and Sneathia sanguinegens, among other anaerobes, were significantly 
more abundant in individuals who subsequently acquired HIV. 31 This association was 
significant in women without co-infection with STIs, confirming a clear association between 
bacteria and both inflammation and HIV acquisition.
Using cytobrush samples from the FRESH cohort we demonstrated that women with a more 
diverse, non-Lactobacillus dominant microbiome (CT4) had significantly higher numbers of 
HIV target cells. In addition, these women had increased concentrations of Th17 cytokines, 
suggesting higher numbers of Th17+ T cells. 31 Women with the highest levels of vaginal 
proinflammatory cytokines had higher number of activated (CD38+ HLA- DR+) CCR5+CD4+ 
T cells vs. women with the lowest levels (p = 0.0361) (Fig. 3). Antigen presenting cells from 
women with CT4 had significant upregulation of multiple proinflammatory cytokine gene 
B
C
Figure 2: Cervicovaginal microbiome is associated with genital inflammation and increased HIV acquisition. A) Bacterial 
16s rRNA gene sequencing reveals 4 cervicovaginal community types (“CTs”) in women in FRESH. B) Kaplan-Meier curve 
showing HIV infections in each CT group over time. Acquisition curves for CT2 (n=65 individuals), CT3 (n=57) and CT4 (n=54) 
were compared with the acquisition curve for CT1 (n=23). Log-rank (Mantel-Cox) test-based p values and Mantel-Haenszel 
hazard ratios (HR) are displayed. C) Principal component 1 (PC1) of 28 measured cytokines shows increased soluble markers 
of genital inflammation in women with more diverse cervicovaginal bacterial communities. D) Flow cytometry analysis of 
HIV target cell numbers in in cytobrushes from 169 individuals, grouped by CT. Data are summarized as median and IQR. 
Kruskal-Wallis test with Dunn’s post hoc analyses (*p<0.05).

Page 18 of 124
such as IL1A (5.8-fold), IL1B (4.3-fold), TNF (6.5-fold), IL10 (10.6-fold), IFNB1 (23.4-fold), 
IL23A (7.3-fold), and IL6 (8.9-fold) vs. CT1 or CT2. 33 None of these difference in subset 
numbers or transcription were seen when comparing immune cells from peripheral blood.
  
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 55, 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. 
56 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. 57
2.4 
Preliminary Studies on LACTIN-V for Bacterial Vaginosis
LACTIN-V contains Lactobacillus crispatus CTV-05, 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.
Early studies of LACTIN-V administered the product in gelatin-coated capsules. 
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. After the completion of a Phase 1 safety trial testing low 
doses of 106 and 108 cfu/dose or placebo, a Phase 2 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.
B
Figure 3. Women with less genital 
inflammation or with L. crispatus 
dominant microbiota have lower 
numbers of cervical HIV target cells. 
A. Women in FRESH cohort with the 
lowest quintile of vaginal cytokines 
had fewer activated cervical CD4+ T 
cells than women in the highest 
quintile of inflammation.
B. 
Women 
with 
L. 
crispatus-
dominant microbiota (CT1) had 17-
fold lower number of activated CD4+ 
T cells vs. those with a diverse vaginal 
microbial community (CT4)
A

Page 19 of 124
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, personal communication).
LACTIN-V has also been evaluated as a therapeutic agent to prevent recurrent urinary 
tract infections (rUTI). In a Phase 2 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. 58
Later studies of LACTIN-V administered the product in pre-filled vaginal applicators. 
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, without 
the impediment of a gelatin capsule, which was found to dissolve slowly in the vaginal 
environment.
Under BB-IND 11363 (NCT00635622), the new dosage form was first studied in a small 
Phase 1 (LV-005) escalating dose trial at the University of California, San Francisco (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). Twelve 
healthy women were randomized 3:1 to use study product for 5 consecutive days, returned 
for follow-up on Days 7 and 14, and had phone interviews on Days 2 and 35. The DAIDS 
Toxicity Table Addendum for Vaginal Microbicide Studies (November 2007)59 was used to 
grade severity of genitourinary (GU) abnormalities, and colposcopic findings were assessed 
following the 2004 WHO/CONRAD manual.60 All 12 participants took 5 doses and completed 
study follow-up. Overall, 45 adverse events (AEs) occurred, 31 (69%) of which were GU 
AEs. GU AEs appeared evenly distributed between the 3 dose levels of LACTIN-V and the 
placebo arms. No grade 3 or 4 AEs or serious adverse events (SAEs) occurred. All three 
dose levels of LACTIN-V were safe and acceptable. 61
This study was followed by a Phase 2a trial (LV-006) to assess colonization efficiency, 
safety, tolerability, and acceptability of L. crispatus CTV-05. 62

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Twenty-four participants (African American: 9; White: 12; Other: 3) diagnosed with BV were 
randomized 3:1 to use 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 
topical metronidazole (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. They returned for follow-up on Days 10 and 28.
Safety results: Of the 120 AEs that occurred, 108 (90%) were mild and only 12 (10%) were 
moderate in severity; no grade 3 or 4 AEs or SAEs occurred, and no deep epithelial 
disruption was seen during colposcopic evaluation. 62 Furthermore, AEs were evenly 
distributed between the LACTIN-V and placebo groups.
Efficiency of colonization: Sixty-one percent of the 18 women randomized to the LACTIN- V 
group were colonized with L. crispatus CTV-05 at Day 10 and/or Day 28. Among LACTIN-V 
users with complete adherence to the study regimen, 78% were colonized at Day 10 and/or 
Day 28. 62
Effect of endogenous bacteria on vaginal colonization of exogenous L. crispatus CTV-05: 
The median vaginal concentrations of seven BV-associated bacteria declined in all 
participants between screening, when metronidazole treatment for BV was started, and 
enrolment. In participants who subsequently colonized with L. crispatus CTV-05, this trend 
was maintained at the Day 28 Visit when levels of six species were below limits of detection, 
with up to 7-log10 reductions in median values. In contrast, among participants who did not 
colonize with CTV-05, the concentrations of BV-associated bacterial DNA, especially those 
known to create a biofilm in the vagina [i.e., A. vaginae (p=0.04) and G. vaginalis (p=0.19)], 
resurged between enrolment and Day 28. Overall, this study provides evidence that vaginal 
colonization with a L. crispatus LBP can reduce colonization with diverse microbes, and 
potentially decrease inflammation and HIV risk. 63 We will evaluate the effect of LACTIN-V on 
the vaginal microbiome, expecting a shift to a L. crispatus dominant cervicotype.
Our Phase 2b clinical trial of LACTIN-V to prevent recurrent BV (NCT02766023) completed 
follow-up in February 2019. The trial was designed to provide a screening evaluation for the 
hypothesis that, following a 5-day treatment with MetroGel® (topical metronidazole) to treat 
BV, LACTIN-V administered at 2 x 109 cfu/dose using a vaginal applicator reduces the 12-
week incidence of BV recurrence when compared to placebo. The primary objectives of this 
study were: 1) to estimate the efficacy of 5 daily doses in week 1 followed by twice weekly 
dosing in weeks 2-11 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. A total of 228 women underwent randomization: 152 
to the Lactin-V group and 76 to the placebo group; of these participants, 88% in the 
Lactin-V group and 84% in the placebo group could be evaluated for the primary 
outcome. In the intention-to-treat population, recurrence of bacterial vaginosis by week 
12 occurred in 46 participants (30%) in the Lactin-V group and in 34 participants (45%) 
in the placebo group (risk ratio after multiple imputation for missing responses, 0.66; 
95%.

Page 21 of 124
2.5 
Rationale
The human vaginal microbiota has long been considered a factor impacting an individual’s 
risk for acquiring sexually transmitted infections (STIs) such as HIV, but the extent of this 
contribution and the underlying mechanisms had not been well defined. We recently 
demonstrated that young South African women with vaginal microbial communities 
dominated by Lactobacillus crispatus had a 4-fold lower rate of HIV acquisition, reduced 
numbers of mucosal CD4+ T cells and lower levels of genital tract proinflammatory cytokines 
compared with women with communities deficient in Lactobacillus species.33, 31
In longitudinal samples, genital tract proinflammatory cytokine concentrations increased 
when the cervical microbial community shifted from Lactobacillus dominance to a more 
diverse community dominated by other species 33, suggesting a cause/effect link between 
vaginal bacteria and genital tract inflammation. This link was further supported by the 
observation that germ-free mice intravaginally inoculated with high-risk bacteria had 
increased numbers of mucosal CD4+ T cells in their female genital tract compared to mice 
inoculated with L. crispatus. 31
The syndrome of vaginal dysbiosis known as bacterial vaginosis (BV) is characterized by a 
diverse, non-Lactobacillus dominant microbial community, similar to communities associated 
with an increased risk for HIV in our study. Standard treatment with antibiotics leads to a 
decrease in the presence of BV-associated microbes, but re-colonization with Lactobacillus 
species is often slow, and recurrence of BV is common.64, 65 In Kenyan women, monthly 
treatment with antibiotics to reduce BV and decrease risk for STIs was successful in 
reducing recurrence of BV by 10%,66 and was associated with an overall reduction in 
bacterial STI. 67 During the trial there was a 36% increase in the proportion of women with a 
Lactobacillus-dominant vaginal microbiota, 54 but this did not persist after stopping oral 
metronidazole. 68
Given the apparent protection from infections afforded by a Lactobacillus-dominant vaginal 
microbiota and the limited efficacy of antibiotics in establishing such a community, a different 
intervention strategy may be necessary. L. crispatus CTV-05 (LACTIN-V) under 
development as a live biotherapeutic product (LBP) has shown excellent tolerability and 
close to 80% colonization in Phase 1 and 2a studies in the US. 61, 62
We hypothesize that use of LACTIN-V by young women at high risk for HIV will 
decrease genital tract inflammation associated with increased HIV acquisition. We 
propose a randomized, placebo-controlled trial of this product in young South African 
women with a non-Lactobacillus-dominant microbiota to assess whether this intervention 
reduces proinflammatory cytokines and HIV target cells in the lower genital tract, leads to a 
persistent Lactobacillus-dominant vaginal microbial community, and is safe and acceptable 
in this population of young women at high risk for HIV.
We will conduct a randomized, placebo-controlled trial of the vaginal live biotherapeutic 
product LACTIN-V in a cohort of 60 young South African women. The trial will enrol women 
with a non-Lactobacillus dominant microbiota, will provide oral metronidazole 400 mg twice 
daily for seven days to all women, and will then randomize women 2:1 to LACTIN-V vs. 
placebo. Within 8-48 hours of taking the final metronidazole dose, women will receive the 
study product for five consecutive days, followed by twice weekly for three additional weeks. 
Women will be followed during the dosing (4 weeks) and post-dosing phase (4 weeks) for a 
total of 64 days.

Page 22 of 124
The FRESH cohort consists of HIV-uninfected young women age 18-23 living in Umlazi, 
South Africa. In this region, <1% of 14 year old girls are HIV positive but over 60% of 24 
year old women are HIV infected. 6 Since the study inception in 2012, over 1400 women 
have been enrolled. FRESH follows women for 9-months with twice weekly HIV viral load 
PCR testing. Paired blood and genital mucosal sampling occurs every three months with 
specific collection of cervical and vaginal swabs, cervical cytobrush and cervicovaginal 
lavage (CVL). Questionnaires are collected at each visit detailing symptomatic and sexual 
behavior data, diet, vaginal hygiene practices, contraceptive use, medical history and 
demographic factors. All participants undergo regular STI testing. Currently, over 6,000 CVL 
and cytobrushes, and 13,000 swabs have been stored from the study. We have also begun 
to culture, store, perform whole genome sequencing (WGS) on bacterial isolates to provide 
a detailed characterization of genomic and strain level variation within the cervicovaginal 
microbiome of these participants. Enrolment is ongoing with 300 new participants enrolled 
each year. Baseline characterization of cervicovaginal bacterial communities by 16s rRNA 
gene sequencing is performed on all participants.
Women who have a non-Lactobacillus-dominant vaginal microbiota community type and 
meet the inclusion and exclusion criteria will be offered enrolment in the LACTIN-V trial.
Funding for the core sample collection in FRESH has been secured from the Bill & Melinda 
Gates Foundation, Gilead Sciences Inc., and the Ragon Institute to cover the funding period 
of this grant proposal. Therefore, this study leverages an existing major site investment to 
enrol female participants, characterize their baseline vaginal microbiome and mucosal 
immune factors and perform detailed analysis on specimens collected as part of this cohort. 
There is no overlap between the work in this proposal and any other grants. The proposed 
Phase 2 trial of LACTIN-V within the FRESH cohort provides an unprecedented opportunity 
to study the effects of a L. crispatus on host-microbial interactions and genital tract 
inflammation.
LACTIN-V—if determined to be a safe and effective live biotherapeutic product (LBP)—has 
the potential to offer women a sustained, coitally independent, multi-purpose prevention 
product that promotes vaginal health and provides protection from HIV and potentially other 
STIs. By exploring the effects of LACTIN-V on genital tract mucosal immune markers 
associated with increased HIV susceptibility in young women, the ability of LACTIN-V to 
colonize the vagina and support a L. crispatus-dominant cervicotype in the female genital 
tract, and the safety of LACTIN-V in young South African women, we aim to provide critical 
data to aid in the continued development of vaginally administered LACTIN-V to prevent 
HIV-acquisition in women. The use of a safe LBP is an important paradigm shift in the 
development of HIV prevention technologies. LACTIN-V serves as an attractive alternative 
to the use of antiretroviral drug formulations currently under development. In addition, we 
will use molecular diagnostic technology to detect the effect of L. crispatus CTV-05 on the 
vaginal microbiota during follow-up.

Page 23 of 124
2.6
Potential Risks and Benefits
2.6.1 Potential Risks
2.6.1.1    Biological Risks: 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 severe or severe-related 
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 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 2a trial (LV-006) assessed colonization 
efficiency, safety, tolerability and acceptability of LACTIN-V at 2 x 109 cfu/ dose in 24 women 
with BV. No Grade 3 AEs or SAEs were observed during the clinical phase of the study. 
Based on the DAIDS Toxicity Table Addendum for Vaginal Microbicide Studies (November 
2007) 69 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 women 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

Page 24 of 124

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
Rare but potentially life-threatening:

Allergic reaction (including anaphylaxis) to the study product
2.6.1.2    Metronidazole
Metronidazole 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.
2.6.1.3
Biological Risk: Study Procedures
Participants may experience discomfort and slight vaginal bleeding when having pelvic 
exams for this study.
2.6.1.4   Biological Risk: Non-spermicidal lubricated condoms
Participants may be at a slightly increased risk of pregnancy, when using the study-provided 
non-spermicidal condoms, especially if the condom is not used correctly.
2.6.1.5
Social and Psychological Risks
Social Risks. (1) Participants may experience discord in their intimate relationships 
(boyfriend/sexual partner(s)) as a result of the request to abstain from sex for 12 hours 
following study product administration and for 24 hours prior to 3 separate scheduled pelvic 
examinations. (2) Participants may also experience tension between themselves and their 
co-enrollees in the FRESH cohort who were unable to join the LACTIN-V study for any 

Page 25 of 124
reason - e.g., not meeting the eligibility criteria or due to the limited study enrolment target.
Psychological Risks. (1) Participants may become embarrassed, worried, or anxious when 
receiving STI counseling. They may become worried or anxious while waiting for their STI 
test results. (2) Participants may experience anxiety from not knowing which Study Product
they are receiving, LACTIN-V or the placebo drug. (3) Participants may experience shyness 
or embarrassment when sharing details of sexual practices and/or undergoing pelvic exams.
2.6.1.6
Legal and Financial Risks
There are no legal or financial risks related to study participation. All study costs are paid by 
the study sponsor.
2.6.1.7
Procedures for Minimizing Potential Risks
Biological risks. Participants will be under the care of a specialist physician and experienced 
professional nurses, who will closely monitor participant health and safety throughout the 
trial. Allergic reactions (including anaphylaxis): Participants with a known allergy to 
components of the study product will be excluded from enrolment. 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. All such events will be reported 
as an AE.
Psychological risks. Questions about sensitive information, such as sexual practices and 
STIs will be asked by counselors and nurses who have years of experience working with this 
demographic of young women and counsel in such a way to minimize stigma associated 
with sharing such intimate information. Adequate preparation and education of participants 
around sexual health and STIs will be provided. Similarly, careful education about the need 
for blinding, randomization and use of a placebo agent will be provided. Participants will 
receive counseling prior to STI 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.
Social risks. Study staff will provide counseling and guidance to participants around 
communication with intimate partners. The importance of abstaining from sex will be 
explained (to minimize factors that could affect efficacy of the study product) and a calendar 
outlining the specific dates/times that abstinence has been requested will be provided to 
each participant. Participants will participate in focused discussions and may engage in role-
play exercises to practice communication with their intimate partners. To mitigate tension 
and jealousy with co-enrollees in the FRESH cohort, all FRESH participants will be provided 
information about the study, including the eligibility and exclusion criteria and the targeted 
enrolment for the LACTIN-V study.
2.6.2
Potential Benefits

Page 26 of 124
2.6.2.1 Possible direct benefits to study participants 
There may be no direct benefits to participants in this study.
2.6.2.2
Benefits related to clinical care
Participants will be screened for urinary tract infection, pregnancy, bacterial vaginosis and a 
number of STIs and referred for treatment, if clinically indicated. (Treatment for UTI will 
consider the urine test result, symptoms, and medical history.) Participants with a non-
Lactobacillus-dominant microbiota will receive study-supplied oral Metronidazole treatment. 
As needed, women will be provided long acting injectable contraceptives during the study.
Participants will be under the care of a specialist physician and experienced professional 
nurses, who will closely monitor participant health and safety throughout the trial.
2.6.2.3
Benefits related to public health
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 help normalize the vaginal microbiome to a Lactobacillus-
dominant state, and potentially decrease the risk of HIV acquisition.
2.6.2.4
Financial benefits
Participants will not directly benefit financially from this study, but will be remunerated for their 
time and transportation cost. In addition, lunch and refreshments will be provided at all study 
visits.
2.6.2.5
Prospects of tested intervention being available to the study population if proven 
effective
Should LACTIN-V be proven effective for reducing the risk of HIV acquisition in women 
following a definitive Phase 3 efficacy trial, the study sponsor UCSF and the drug developer 
Osel, Inc. would plan to obtain a new drug approval from the South African Health Products 
Regulatory Authority (SAHPRA).

Page 27 of 124
3.0
HYPOTHESIS AND OBJECTIVES
3.1 
Study Hypothesis
We hypothesize that use of LACTIN-V by young women at high risk for HIV will decrease 
genital tract inflammation associated with increased HIV acquisition. We propose 
randomized, placebo-controlled trial of this product in young South African women with a 
non Lactobacillus-dominant microbiota to assess whether this intervention reduces 
proinflammatory cytokines and HIV target cells in the lower genital tract, leads to a persistent 
Lactobacillus-dominant vaginal microbial community, and is safe and acceptable in this 
population of young women at high risk for HIV.
3.2
Summary of Methods
We will conduct a randomized, placebo-controlled trial of the vaginal live biotherapeutic 
product LACTIN-V in 60 young South African women. The trial will enrol women with a non-
Lactobacillus dominant microbiota, will provide oral metronidazole 400 mg twice daily for 
seven days to all women, and will then randomize women 2:1 to LACTIN-V vs. placebo. 
Within 8-48 hours of the final metronidazole dose, women will receive the study product for 
five consecutive days, followed by twice weekly for three additional weeks. Women will be 
followed during the dosing (4 weeks) and post-dosing phase (4 weeks) for a total of 64 days.
3.3
Study Objectives
3.3.1
Primary Objectives
1)
Determine the effect of repeat dosing of LACTIN-V (2 x 109 cfu/dose) on 
genital tract inflammation in young South African women at risk of HIV.
2)
Determine the ability of LACTIN-V to promote a Lactobacillus-dominant 
vaginal microbiota in young South African women at risk of HIV.
3)
Determine the safety and acceptability of LACTIN-V in a population of 
young South African women at risk for HIV.
3.4
Study Outcome Measures
3.4.1
Primary/ Secondary Outcome Measures
Primary / Secondary Outcome Measures for Objective 1 (effect on genital tract 
proinflammatory cytokines and HIV target cells)
The proportion of participants with decreased genital tract proinflammatory cytokines and 
HIV target cells at 6 and 10 weeks of follow up, compared to levels at the baseline FRESH 
Study Visit, and Randomization Visit on Day 8 of the study (after treatment with 
Metronidazole is completed).
Our outcome will be a change after 4 weeks of treatment with LACTIN-V in comparison to

Page 28 of 124
placebo, for the following:
i.
a decrease of the concentrations of proinflammatory cytokines in genital fluid 
that have been associated with risk for HIV acquisition,
ii.
a decrease in the number of activated HIV target cells (i.e. CD4+/CCR5+/HLA-
DR+/CD38+ T cells) in the endocervix and
iii.
an increase the anti-HIV effect of vaginal secretions relative to placebo.
Primary / Secondary Efficacy Outcome Measures for Objective 2 (promoting Lactobacillus-
dominant microbiota)
1:
The proportion of participants with increased Lactobacillus-dominant vaginal 
microbiota in young South African women, compared to levels at randomization 
(Day 8) after completion of metronidazole. Measured will be overall Lactobacillus 
species, as well as Lactobacillus crispatus, Lactobacillus jensenii, Lactobacillus 
gasseri, and Lactobacillus iners.
Our primary outcome is the presence of Lactobacillus-dominant vaginal microbial 
cervicotypes after 4 weeks of treatment with LACTIN-V, and following the post- dosing 
phase at Day 64.
Secondary outcomes include comparison of L. crispatus vs. L. iners prevalence 
between treatment groups, persistence of colonization after stopping therapy, effect of 
sex and/or vaginal hygiene practices on colonization by lactobacilli, and stability of 
vaginal microbial communities over time in the treatment vs. placebo group.
2:
The proportion of participants with a positive BV diagnosis in each study arm by Day 
64.
BV is defined Nugent score 7-10. Following FDA guidance all BV diagnoses during 
follow-up visits are considered incident, as they occur at least 22-30 days after the 
commencement of Metronidazole treatment and consequently are treatment failures 
or new infections.70 For the purpose of this trial, treatment failure and new infection 
will both be considered recurrent BV.
3:
The proportion of participants experiencing successful colonization with L. crispatus 
CTV-05 following dose of study product through final visit (approximately Day 36 and 
64) in the LACTIN-V arm.
4:
The proportion of subjects with cervicotypes I-IV compared by study arm.
Primary / Secondary Outcome Safety Measures for Objective 3 (safety and acceptability)
Safety of LACTIN-V and the applicator will be measured by:

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The proportion of participants reporting product-related AEs and SAEs through
the final visit that are likely related to use of study product compared by study 
arm, in particular Grade 3 AEs and SAEs.
Acceptability of LACTIN-V and the applicator will be measured by standardized 
questionnaire about acceptability of the study product and participants’ stated 
willingness to use this type of product in the future, in each study arm.

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4.0
STUDY DESIGN
This is a Phase 2 randomized double-blind placebo-controlled trial to assess the impact of the live 
biotherapeutic product LACTIN-V containing Lactobacillus crispatus CTV-05 on the vaginal 
microbiome of young women in South Africa at high risk of HIV acquisition.
The study will also assess the safety of LACTIN-V by comparing the incidence of AEs between 
women randomized to LACTIN-V or placebo.
We will conduct a randomized, placebo-controlled trial of LACTIN-V in a cohort of young South 
African women with a non-Lactobacillus dominant microbiota, who are sexually experienced, age 
18 to 23 years. Enrolment will be continued until 60 women will be randomized into the study.
Eligible women will be treated with oral metronidazole 400 mg twice daily for seven days and will 
then be randomized 2:1 to LACTIN-V vs. placebo.
Within 8-48 hours of taking the final metronidazole dose, women will receive the study product for 
five consecutive days, followed by a twice weekly dose for three additional weeks.
After enrolment and metronidazole treatment, women will be followed throughout the 4 weeks of 
dosing and the 4 weeks of post-dosing phase for a total of 10 weeks (until approximately Day 64).
The primary outcome (Objective 1) focuses on the ability of the L. crispatus CTV-05 to acutely 
decrease genital tract inflammation (as a marker of HIV susceptibility). This will be assessed by 
collecting cervicovaginal fluid and endocervical immune cells at randomization (Day 8), after 4 weeks 
of treatment with the LACTIN-V vs. placebo (Day 36), and after 4 weeks of post-dosing phase (Day 
64).
Direct anti-HIV activity will be assessed with in vitro HIV infection assays using vaginal fluid samples 
from randomization and after treatment: Randomization Visit (Day 8), Follow-up Visit (Day 36), and 
Final Visit at Day 64.
A secondary outcome (Objective 2) is to assess the ability of the L. crispatus CTV-05 to establish 
durable vaginal colonization as with the potential as a self-sustaining prevention strategy. This will 
be assessed by characterization of the vaginal microbiome at the baseline FRESH Study Visit, and 
the end of treatment (Day 36) and at the Final Visit (Day 64), after 4 additional weeks during the 
post-treatment phase.
Finally, while LACTIN-V has been shown to be safe and well tolerated in US women, we will assess 
the safety and tolerability (Objective 3) in this cohort of young South African women up to Week 9 
(4 weeks post-dosing phase).
The Umlazi site of the FRESH study enrols approximately 300 women per year into the cohort. 
During the baseline Screening Visit of the FRESH enrolment process, new cohort members will 
learn about the parallel LACTIN-V clinical trial, including the findings from the FRESH study which 
demonstrated the association of a L. crispatus cervicotype with a reduced risk of HIV acquisition.

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At the FRESH Study Visit conducted in Week 5 of the FRESH protocol, a vaginal smear is 
collected sent to the site laboratory for Gram stain evaluation by Nugent score. For STI diagnostics, 
a vaginal swab for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas and Mycoplasma 
genitalium molecular testing will be collected, as well as a urine sample for a Point-of-care (POC) 
urine testing and a β- hCG-based pregnancy test. Test results for STIs as well as the Gram Stain 
are expected to arrive within one week.
Any women who enrolled in the FRESH study who express interest in the LACTIN-V trial and during 
the Week 5 FRESH Study Visit were diagnosed with a Nugent score of 4-10 on vaginal Gram Stain, 
and without any positive tests for the STIs listed in the exclusion criteria, will be contacted by study 
staff about their preliminary eligibility for the LACTIN-V trial, and will be offered concurrent 
enrolment in the LACTIN-V study.
In consideration of their menstrual cycle (they should not be bleeding at the time of enrolment and 
during the first five days of product administration), a LACTIN-V Enrolment Visit is scheduled at 
least 7 days out, not to exceed 30 days from the FRESH Week 5 Visit to ensure a high likelihood 
that the test results of that visit are still relevant.
Women will return to the study clinic for enrolment into the LACTIN-V study. During the informed 
consent procedure, they will learn details about the LACTIN-V study.
At the Enrolment Visit 1 (Day 1), participants will complete a medical history and undergo a 
physical examination. Enrolled participants will receive oral Metronidazole 400mg tablets, and are 
instructed to immediately start the 7-day course (twice daily), to be completed within 8-48 hours of 
the Randomization Visit on Day 8. A Check-In Visit 2 (Day 4) is scheduled to provide additional 
guidance for the metronidazole administration. 
At the Randomization Visit 3 (Day 8), a gynaecological exam will be conducted to collect baseline 
vaginal microbiome data, including cervical swabs, cervicovaginal lavage fluid and an endocervical 
cytobrush to assess the microbial composition, cytokines and mucosal HIV target cells. A gram 
stain and a vaginal swab for L. crispatus (including CTV-05) identification will be collected. Only 
participants who completed their 7-day course of oral Metronidazole will be randomized and receive 
study product.
The 11 doses of LACTIN-V at 2 x 109 cfu/dose or placebo are scheduled to be administered by 
vaginal applicator for 5 consecutive days and then twice weekly for 3 weeks, throughout Week 1-4 
of the study. The first dose of study product is administered as part of the Randomization Visit on 
Day 8. Participants will be instructed to take the second and third dose on subsequent Days 9 and 
10 at home before bedtime. All other doses will remain at the clinic site, where the women are 
attending regular twice-weekly visits as participants of the FRESH study. During these FRESH 
visits, they will be handed the remaining LACTIN-V applicators to administer on site according to 
schedule in a form of directly observed therapy.
During the study, participants will be counselled to use the provided lubricated or unlubricated non-
spermicidal condoms during vaginal intercourse. Study staff will provide condoms that have been 
tested to not interfere with lactobacilli growth.71 In addition, participants are counselled to avoid 
vaginal intercourse during the 12 hours before scheduled gynaecological exams, as this activity 
could lead to microabrasions notable at speculum exam, and could interfere with a correct 
determination of symptoms related to study product administration.

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Further, participants will be counselled to avoid sexual intercourse for 12 hours after study product 
administration to ensure that the product will remain inside the vagina.
Brief Check-in Follow-up Visits 4 - 10 (Days 11, 15, 18, 22, 25, 29 and 32) without physical and 
gynaecological exams to assess adherence, menstrual cycle, sexual activity, condom use, 
concomitant medications, and AEs, and to administer subsequent doses of study product are 
scheduled to coincide with regular clinic visits as part of the FRESH schedule (twice weekly either 
Monday/Thursday or Tuesday/Friday).
Week 1:
Day 8    (where the doses for Day 9 & 10 are handed to participants to take at 
home)
Day 11  (where the dose for Day 12 is handed to participants to take at home)
Week 2:
Day 15 and 18   (Doses 6 and 7) administered in clinic
Week 3:
Day 22 and 25.  (Doses 8 and 9) administered in clinic
Week 4:
Day 29 and 32.  (Doses 10 and 11) administered in clinic
At the beginning of Week 5, at the end of the dosing phase, a Follow-up Visit 11 is scheduled for 
Day 36. This visit will include a physical and gynaecological exam to collect vaginal microbiome 
data, including cervical swabs, cervicovaginal lavage fluid and an endocervical cytobrush to assess 
the microbial composition, cytokines and mucosal HIV target cells. A gram stain and a vaginal swab 
for L. crispatus (including CTV-05) identification will be collected.
Should symptoms or the sexual history suggest the acquisition of an STI, testing for STIs will be 
included. Acceptability will be assessed using a questionnaire.
During Week 5 – 8, study staff will continue to check in with participants twice weekly for brief Check- 
in Follow-up Visits 12 – 18 (Days 39, 43, 46, 50, 53, 57 and 60) without physical and 
gynaecological exams to assess menstrual cycle, sexual activity, condom use, concomitant 
medications, and AEs. These are scheduled to coincide with regular clinic visits as part of the FRESH 
schedule (twice weekly either Monday/Thursday or Tuesday/Friday).
Week 5:
Day 39
Week 6:
Day 43 and 46
Week 7:
Day 50 and 53
Week 8:
Day 57 and 60
The Final Visit 19 (Day 64) 4 weeks post dosing will include a physical and gynaecological exam to 
collect vaginal microbiome data, including cervical swabs, cervicovaginal lavage fluid and an 
endocervical cytobrush to assess the microbial composition, cytokines and mucosal HIV target 
cells. A gram stain and a vaginal swab for L. crispatus (including CTV-05) identification will be 
collected. Should symptoms or the sexual history suggest the acquisition of an STI, testing for STIs 
will be included.

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Electronic reminders per cell phone will be sent to women prior to each scheduled visit. See 
complete listing of all study visits in the timeline below:
Wk
Monday 
(Tuesday)
Tuesday 
(Wednesday)
Wednesday 
(Thursday)
Thursday 
(Friday)
Friday 
(Saturday)
Saturday 
(Sunday)
Sunday 
(Monday)
0
Day 1
Enrolment Visit 1 
Informed Consent 
Metronidazole
1 & 2
2
Metronidazole 
3 & 4
3
Metronidazole 
5 & 6
4
Visit 2 
Check-in & 
dispense
Metronidazole 
7 & 8
5
Metronidazole 
9 & 10
6
Metronidazole 
11 & 12
7
Metronidazole 
13 & 14
1
8
Randomization 
Visit 3 
Gynaecol. exam
Dose 1, on site
9
Dose 2, at home
10
Dose 3, at home
11
Visit 4
AE Check
Dose 4, on site
12
Dose 5, at home
13
14
2
15
Visit 5
AE Check
Dose 6, on site
16
17
18
Visit 6
AE Check
Dose 7, on site
19
20
21
3
22
Visit 7
AE  Check 
Dose 8, on site
23
24
25
Visit 8
AE  Check 
Dose 9, on site
26
27
28
4
29
Visit 9
AE Check
Dose 10, on site
30
31
32
Visit 10
AE Check
Dose 11, on site
33
34
35
5
36
Visit 11
Gynaecol. exam
37
38
39
Visit 12
AE Check
40
41
42
6
43
Visit 13
AE Check
44
45
46
Visit 14
AE Check
47
48
49
7
50
Visit 15
AE Check
51
52
53
Visit 16
AE Check
54
55
56
8
57
Visit 17
AE Check
58
59
60
Visit 18
AE Check
61
62
63
9
64
Visit 19
Gynaecol. exam

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5.0
STUDY ENROLMENT AND WITHDRAWAL
The study plans to enrol non-pregnant women, age 18 to 23 years, diagnosed with a non-
Lactobacillus dominant microbiota (diagnosed by Nugent 4 – 10).
Enrolment will be continued until 60 women have been randomised into the study. Eligibility criteria 
for participation in the study are described in detail in sections 5.1 and 5.2.
The consent process will be completed during the Enrolment Visit 1 (Day 1) to determine eligibility. 
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.
FRESH study participant.
2.
Capable of reading and writing English or isiZulu and voluntarily provide written 
informed consent to participate in the study and comply with all study procedures
3.
HIV-negative
4.
 Nugent score 4-10 on vaginal Gram stain
5.
 Otherwise healthy women, 18–23 years of age on the day of enrolment
6.
Regular predictable menstrual cycles or amenorrhoeic for at least 3 months due 
to use of a long-acting progestin.
7.
Willing to complete 7-day course of oral metronidazole.
8.
Willing to be asked questions about personal medical health and sexual history
9.
Willing to apply study agent vaginally and comply with study examinations
10. Willing to self-administer Study Product on dosing days that do not coincide 
with regular FRESH study visits.
11. Agree to try to abstain from sexual intercourse 12 hours prior to study visits that 
include a gynaecological exam (Randomization Visit 3, Follow-up Visit 11, Final 
Visit 19).
12. Agree to try to abstain from sexual intercourse for 12 hours after study product 
administration to ensure that the product will remain inside the vagina.
13. Agree to abstain from the use of any other vaginal product throughout the trial 
period from the time of enrolment through the end of the study.
Note: Intravaginal products include contraceptive creams such as Gynol II, gels, 
foams, sponges, lubricants not approved by the study investigators, tampons and 
douches.
14.   Must be stable on a reliable method of long-acting birth control and agree to   
remain on, for the duration of the study (if of childbearing potential) or, of non-
childbearing potential (permanently sterile).
5.2
Subject Exclusion Criteria
Participants meeting any of the following criteria when assessed at the Enrolment Visit, will 
be excluded from the study: 

Page 35 of 124
1.
Urogenital infection (as tested during the FRESH Week 5 Study Visit, reported 
within 30 days of detection at the LACTIN-V Enrolment Visit). 
Note: Urogenital infection includes urinary tract infection, Trichomonas (T.)
vaginalis, Neisseria (N.) gonorrhoeae, Chlamydia (C.) trachomatis, Mycoplasma
genitalium.
2.
Diagnosis of two or more outbreaks of N. gonorrhoeae, C. trachomatis, T. 
vaginalis, Mycoplasma genitalium, or herpes simplex virus (herpes genitalis) 
within 6 months prior to enrolment.
3.
Subject is ineligible if menstrual cycle length is less than 21 days
4.
Subject is ineligible if deep epithelial disruption is observed on genital 
examination noted on or before the Randomization Visit
5.
Positive for HIV (as tested during the FRESH Week 5 Study Visit, within 30 days 
of the LACTIN-V Enrolment Visit).
6.
Current pregnancy or within 2 months of last pregnancy
7.
Vaginal or systemic antibiotic or antifungal therapy within 21 days of enrolment
8.
Use of disulfiram within past 2 weeks or other contraindication to use of 
metronidazole
9.
Any condition requiring regular periodic use of systemic antibiotics during 
participation in the trial
10. Investigational drug use other than LACTIN-V within 30 days or 10 half- lives of 
the drug, whichever is longer, of Enrolment Visit
11. Other planned participation in an investigational drug study while participating in 
this study
12. IUD insertion or removal, pelvic surgery, cervical cryotherapy or cervical laser 
treatment within the last 2 months prior to enrolment
13. Use of vaginal ring (e.g, NuvaRing) within 3 days of enrolment or during the 
course of the study
14. Hysterectomy
15. Unwilling to complete 7 days of oral metronidazole (twice daily) with the last 
dose taken no later than 48 hours prior to randomization (minimum of 12 of 14 
doses required)
16. Use of new long-acting hormonal treatments. Participant may be enrolled if 
stable (at least 1 month) on existing therapy as determined by the principal 
investigator (PI)
17. Known allergy to any component of LACTIN-V/placebo or metronidazole or to 
nitroimidazole derivatives or latex (condoms)
18. Any social, medical, or psychiatric condition including history of drug or alcohol 
abuse that in the opinion of the investigator would make it difficult for the 
participant to comply with study procedures
19. Any serious or chronic illness, deemed incompatible with study participation by 
the study doctor, including immunosuppression due to cancer chemotherapy, 
systemic corticosteroids.

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5.3
Treatment Assignment Procedures
5.3.1
Randomization Procedures
Women will be randomized at the Randomization Visit 3 (Day 8) upon completion of 
the initial standardized antibiotic treatment with 2 x 400 mg daily over 7 days of oral 
metronidazole.
Women will be randomly assigned to receive LACTIN-V at 2 x 109 cfu/dose or 
placebo in a 2:1 ratio. Enrolment will be continued until 60 women are randomized.
The list of randomized treatment assignments will be prepared by a statistician not 
involved with the study, and provided to the pharmacy, who will label the applicator 
pouches and cartons. Each carton will contain 11 study treatment applicators and 
be sequentially numbered according to the randomization scheme in a 2:1 
(LACTIN-V to placebo) ratio.
Disenrolled participants before randomization will be replaced until 60 women are 
randomized into the study. Once randomized, participants will not be disenrolled.
Participants who test HIV-positive after randomization, will discontinue study product, 
but continue follow-up and attend all remaining study visits to monitor for adverse 
events.  HIV-specific care, including the provision of antiretroviral treatment and 
ongoing management will be provided by the FRESH Study.
5.3.2
Blinding Procedures
At the time of randomization, 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 metronidazole treatment.
The participants, study personnel who perform study assessments, data entry 
personnel at the sites, and laboratory personnel performing study assays will be 
blinded 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.   Withdrawal after Enrolment
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.
At Randomization Visit 3:

A diagnosis of a UTI, an active herpes genitalis lesion, or symptomatic 
vulvo-vaginal candidiasis

Page 37 of 124

Any diagnosis other than BV requiring antibiotics

Failure to complete 7-day course of Metronidazole
Disenrolled participants before randomization will be replaced until 60 women are 
randomized into the study. Once randomized, participants will not be disenrolled.
At any Study Visit 3 – 19 after Enrolment Visit 1:

Participant withdraws consent

Pregnancy

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 at UKZN and UCSF, SAHPRA, 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
Disenrolled participants before randomization will be replaced until 60 women are 
randomized into the study. Once randomized, participants will not be disenrolled. All 
randomized participants who are discontinued from receiving further study product 
will continue to be followed through the Final Visit 19.
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 AEs related to participation in the study are 
continuing. The participant will be followed until the AE is resolved or until the 
participant’s condition becomes stable.
Pregnant women will discontinue study product and continue to be followed through 
the Final Visit 19 in Week 9. All samples will be collected except those directly 
collected at the cervix.
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 enrol 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

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Study closure may occur due to DSMB review, or at the discretion of the 
Institutional Review Board (IRB) at the University of KwaZulu-Natal (UKZN) 
and UCSF, SAHPRA, NIH, and other government agencies as part of their 
duties to ensure that research participants are protected, or at the discretion of 
the industry supporter or its designee.

Page 39 of 124
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 isolated from an African American woman in Seattle. LACTIN-V, preserved as a powder, 
is applied by a vaginal applicator at a potency of 2 x 109 cfu/dose. The LACTIN-V powder 
contains trehalose, xylitol, sodium ascorbate, colloidal silicon dioxide and maltodextrin. A 
matching placebo formulation without L. crispatus CTV-05 is supplied in an identical 
applicator containing placebo powder.
Metronidazole
Metronidazole is the oral dosage form of the synthetic antibacterial agent, metronidazole, at 
a concentration of 400mg per tablet. Metronidazole is a member of the nitro 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 Enrolment Visit 1, eligible participants will receive oral metronidazole for their non-
Lactobacillus-dominant microbiota. Participants who receive metronidazole, but do not 
complete their full metronidazole treatment, do not return for the Randomization Visit 3, or 
are otherwise found ineligible to be randomized to study treatment will be not be randomized 
and will be withdrawn from the study.
6.1.1    Acquisition
LACTIN-V and placebo
Osel, Inc. will provide LACTIN-V and placebo. LACTIN-V and placebo will be 
transferred from List Biological Laboratories, Inc. to the following address:
The Aurum Institute
Department: Research Management
Division: Clinical Research
29 Queens Road, Parktown, Johannesburg, South Africa, 2193
Contact Number: +27 (0) 10 590 1300
Contact person: Jayajothi Moodley (Pharmacist)
Metronidazole
Metronidazole oral tablets will be purchased and supplied in South Africa.
6.1.2
Formulation, Packaging, and Labeling
LACTIN-V and placebo
Each applicator will contain a LACTIN-V powder formulation containing L.crispatus 

Page 40 of 124
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 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 carton containing 11 applicators. Each foil pouch and box will be labeled 
with the study number and unique participant number.
The applicator pouches and cartons will be labeled by the research pharmacist at the 
Aurum Institute.
Each label will contain the study number. The label of each box of study product 
applicators will also include the unique participant number and the statements: “Store 
in a cool, dry place out of reach of children (at room temperature).”
Metronidazole oral tablets
Metronidazole oral tablets contain metronidazole at a concentration of 500 mg per 
tablet. Metronidazole is supplied in a box with 14 tablets. Each participant will receive 
one box of Metronidazole 400 mg sufficient for the 7-day course of treatment with 
oral tablets to be taken twice daily.
6.1.3
Product Storage and Stability
LACTIN-V and placebo
LACTIN-V and placebo applicators will be shipped in an appropriate container on 
frozen gel packs and immediately placed into temperature- controlled conditions (2–
8°C) upon arrival. During transit, temperature will be recorded using a temperature 
logger.
Following the randomization code provided by an independent statistician, the 
research pharmacist at the Aurum Institute will label all applicators and package 
them in the cartons, each containing 11 applicators. The cartons will be stored at 2-
8°C.
On the day of randomization (Randomization Visit 3), the study product will be 
transported from the research pharmacy to the site.
Cartons will be stored at the research site in a cool, dry place at room temperature 
until dispensed.
Participants will take home applicators for Days 2, 3 and 5, and will be instructed to 
store applicators in a cool, dry place at room temperature, and to avoid heat. 
Applicators should be kept out of reach of children.
Metronidazole oral tablets
Store at room temperature 15° to 30°C (59° to 86 °F). Protect from freezing, and 

Page 41 of 124
store out of reach of children.
6.2
Dosage, Preparation, and Administration of Study Product
LACTIN-V and placebo
At Randomization Visit 3 (Day 8), eligible participants will be instructed on how to insert the 
pre-filled applicator (LACTIN-V or the placebo) and will administer the first dose under direct 
supervision by the study clinician before leaving the clinic. Study personnel will verify that 
each carton contains the 10 remaining applicators, and this will be recorded on the 
appropriate Case Report Form (CRF).
Also, at the Randomization Visit 3, participants will be handed two applicators for the next 
two days (Day 9 and 10) and will be instructed to administer them at home before bedtime. 
They will return to the clinic on Day11 and receive one applicator for immediate 
administration, and the applicator for Day 12 to take home. The applicator cartons will be 
stored on site, and during Week 1-4, applicators will be dispensed twice weekly to study 
participants for immediate administration.
Metronidazole oral tablets
Participants will be instructed to administer one tablet twice daily (one in the morning and 
one in the evening) initiated depending on the day set for enrolment. The 7-day course 
needs to be planned according to the requirement of completing the course within 8-48 
hours of the Randomization Visit 3 (see Section 7.0 for additional details).
6.3 
Accountability Procedures for the Study Investigational Product
The study PI has ultimate responsibility for the storage, dispensing accountability, and 
destruction of study products. For this protocol, the responsibility for study product 
management is being delegated to the research pharmacist.
The research pharmacist is responsible for storage at the research pharmacy and for 
distribution of product to the site. After receipt of the study product at the site, the site 
Principal Investigator (PI) is responsible for distribution and disposition of the study product 
to study participants and has ultimate responsibility for drug accountability. Both, the 
research pharmacist (or designee) and the site PI 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. 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 ensured by directly observed administration in the 
clinic and through participant self-reporting for doses taken at home (Day 9, 10 and 12).

Page 42 of 124
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 enrolment through the final 
visit (Day 64) or early termination, whichever occurs first.
The following medications are permitted throughout the study:

Vitamins and other nutritional supplements

Hormonal contraceptives

Cough medicine

Non-steroidal anti-inflammatory drugs

Prescription and over-the counter medications for allergies and asthma

Herbal, naturopathic, and traditional preparations (e.g., 
Chinese traditional medications)

Externally applied topical medications (except genital area)

Antibiotics prescribed during the trial, including Metronidazole for BV
The following medications are prohibited throughout the study, and participants will be 
instructed to not use them throughout the study up to the Final Visit 19 (Day 64):

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.

Page 43 of 124
7.0
STUDY SCHEDULE
7.1
Enrolment Visit 1
The purpose of the Enrolment Visit 1 is to complete the informed consent process and 
identify participants who satisfy all eligibility criteria.
Women who are part of the FRESH study cohort can be recruited for the LACTIN-V study. 
Potentially eligible participants will be approached during the regular Week 5 FRESH Study 
Visit that includes a pelvic exam and mucosal sampling. Women will receive information 
about the opportunity to co-enrol in LACTIN-V. Should they be interested in participating in 
the LACTIN-V study, they will be told that some of the test results routinely collected at the 
Week 5 FRESH Study Visit will be used to assess their eligibility for LACTIN-V, and that they 
would be contacted should they meet the following eligibility criteria:
1. non-Lactobacillus dominated vaginal microbiota as determined by Nugent score 
4-10 on vaginal Gram stain
2. negative STI testing results
3. on stable long acting injectable contraception, either on Depot 
Medroxyprogesterone Acetate (DepoProvera) or norethisterone enanthate 
(NetEn), or an IUD or implant for at least 3 months.
Interested women who meet these eligibility criteria for LACTIN-V will be contacted after 
review of the laboratory results, usually within 7-10 days. In accordance with their menstrual 
cycle and expected onset of the next menses, they will be invited and scheduled for a 
LACTIN-V Enrolment Visit that will take place on a date at least 12 days before the next 
expected menses, and no later than 30 days after the Week 5 FRESH Study Visit.
Eligible women who agree to be enrolled in LACTIN-V will be asked to sign the informed 
consent form available in English and isiZulu that will describe the purpose of the study, the 
procedures to be followed, and the risks and benefits of the study, and will include a 
separate section for consent to store samples for future use. An Assessment of 
Understanding form, available in English and isiZulu, will be completed to ensure that study 
participants retained the most important aspects of the provided information. 
A copy of the consent form will be given to the participant and this fact will be documented in 
the medical record.
Participants will be asked to provide contact information (i.e., address, email address, 
home/cell phone number, emergency contact), which will be recorded on the appropriate 
contact form, which will be kept away from other study forms in a locked cabinet.
At the Enrolment Visit (Visit 1) the woman's menstrual cycle history will be evaluated to 
ensure regular menstrual cycles (or amenorrhea due to long-acting contraceptives).
Participants who give informed consent will undergo the following procedures and 
assessments at the Enrolment Visit 1:
1.
Assessment of eligibility
2.
Detailed structured interview to obtain demographic information, 
medical, gynaecological and sexual history
3.
Review of concomitant medications
4.
Complete physical examination by a study physician or nurse that will include vital 

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signs,  including  temperature,  height  and  weight,  and  examination  of   
respiratory and cardiovascular systems
5.
Clean catch urine dipstick. If test results suggest a UTI, the woman will be 
managed as clinically indicated and not randomized at this time.
6.
Rapid urine βhCG pregnancy test. If the test is positive, the Enrolment 
Visit 1 will be terminated as the woman is not eligible.
7. All findings at the time of the evaluation will be recorded on the CRF.
8. Subjects who meet all eligibility criteria will be given the first 6 of a total of 14 
oral tablets of 400 mg Metronidazole to take twice daily in the morning and 
evening for the next 3 days (total of 7 consecutive days). They will take the 
first dose in the clinic.
9. Participants will be invited to return for the Check-In Visit 3 on Day 4 (to 
coincide with their next regular FRESH visit) to receive the remaining 8 doses 
for the last 4 days of the 7-day Metronidazole treatment.
10. Participants will be invited to return for the Randomization Visit 3 within 8-
48 hours after completion of Metronidazole treatment.
11. Non-spermicidal condoms will be dispensed.
12. Enrolment into the study database
All women in the FRESH cohort come to the clinic twice weekly for HIV testing and life skills 
training. Depending on a woman’s placement within the FRESH cohort, she is either 
attending Monday/ Thursday sessions or Tuesday/ Friday sessions.
Randomization Visits will take place either Monday or Tuesday. Consequently, the 7- 
day Metronidazole course will have to be timed to start on the day of the Enrolment 
Visit 1, exactly one week prior to the Randomization Visit 3 (see Table 7.1).
Table 7.1
FRESH COHORT with regular clinic visits MONDAYS & THURSDAYS
MON
TUE
WED
THU
FRI
SAT
SUN
MON
TUE WED THU
FRI
SAT
SUN
MON
7-day oral Metronidazole (400mg per tablet, twice daily)
RANDO 
MIZATI 
ON DOSE 
1
DOSE 2
DOSE 3
CHECK
- IN 
VISIT, 
DOSE 4
DOSE 5
CHECK- IN 
VISIT
FRESH COHORT with regular clinic visits TUESDAYS & FRIDAYS
TUE
WED
THU
FRI
SAT
SUN
MON
TUE
WED
THU FRI
SAT
SUN
MON
TUE
7-day oral Metronidazole (400mg per tablet, twice daily)
RANDO 
MIZATI 
ON DOSE 
1
DOSE 2
DOSE 3
CHECK
- IN 
VISIT, 
DOSE 4
DOSE 5
CHECK- IN 
VISIT
7.1.1. Rescreening Visit
Because of the complex enrolment logistics into two parallel studies, FRESH and 
LACTIN-V, no rescreening will be offered to ineligible volunteers.

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7.2 
Check-in Visit 2 (Day 4)
Coinciding with the second regular weekly visit of the FRESH study, a brief Check-in 
Visit will be conducted, during which directly observed product administration of the 
fourth dose of oral Metronidazole will occur, and the remaining doses 5- 7 will be 
handed to the participants to take at home on subsequent days.
7.3 
Randomization Visit 3 (Day 8)
Before commencing with the physical and gynaecological exam, eligibility for 
randomization should be confirmed by reviewing the medical history and all laboratory 
results.
Only women who had negative STI tests and a Nugent score 4-10 on the vaginal 
specimen collected at the Week 5 FRESH Study Visit, are enrolled in LACTIN-V and 
completed a full 7-day course of oral Metronidazole (at least 12 of 14 doses, last dose 
within 8-48 hours of Randomization Visit 3) will proceed to be randomized. Women who 
did not complete a full 7-day course of oral Metronidazole and took less than 12 of 14 
doses, or took the last dose more than 48 hours before the Randomization Visit 3, will be 
withdrawn from the study.
Participants will be asked to verify previously reported contact information which will be 
recorded on the appropriate form.
Additionally, 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 Randomization Visit 3.
Participants will undergo the following procedures at the Randomization Visit 3 (Day 8):
1.
Review of concomitant medications
2.
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 Gram stain (Nugent scoring system)
e.
Two Vaginal swabs for complete mucosal sampling including 
identification of vaginal bacteria, lactobacilli species, cytokines 
and HIV target cells as well as multiomic (e.g. proteomics, 
metabolomics, etc.) testing
f.
Cervical (or vaginal) swabs for nucleic acid amplification of N. 
gonorrhoeae, and C. trachomatis.

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g.   A cervicovaginal lavage sample
h.   Vaginal swabs for L. crispatus identification with qPCR
i.   Vaginal swab for prostate specific antigen testing as a proxy for recent 
exposure to semen
Women with findings on pelvic exam at the Randomization Visit 3, including active genital 
herpes lesions, cervicitis, vulvovaginitis or for other reasons will be considered screening 
failures, will not be enrolled and will be referred for further evaluation.
3.
Rapid urine βhCG pregnancy test. If the test is positive, the Randomization Visit 3 
will be terminated as the woman is not eligible.
4.
Clean catch urine dipstick. If test results and clinical screening suggest a UTI, the 
woman will be managed as clinically indicated and not randomized at this time.
5.
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.
6.
If the clinician suspects the participant developed an STI since the Week 5 FRESH 
Study Visit, appropriate tests will be conducted and if needed the woman will be 
referred to standard of care treatment in compliance with current Centers for 
Disease Control and Prevention (CDC) STI and South African Department of Health 
STI Treatment Guidelines.72 The participant cannot be randomized at this time.
7.
Randomization
8.
The carton corresponding to the randomization code that contains study product 
(LACTIN-V or placebo) will be retrieved from the research pharmacy, and the first 
three applicators 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 the second and the third dose of LACTIN-V/or 
placebo once a day at bedtime for the next two days (Day 9, and Day 10) and 
return to the clinic for a brief Check-In Visit on Day 11, when she will receive the 
fourth dose to take directly, and the fifth dose to take at home on Day 12. The 
remaining Doses 6-11 will be administered in the clinic twice weekly for 3 weeks.
9.
Participants will be counselled to try to abstain from sexual intercourse during the 
first 5 days of study product administration. During the twice weekly visits, 
participants will be counselled to try to abstain from sexual intercourse 12 hours 
after administering the study product, as well as, 12 hours before each study visit 
that includes a gynaecological exam (Visit 11 on Day 36, and Visit 19 on Day 64). 
The twice weekly brief Check-In Visits 4 – 10 and 12 - 18 are visits without a 
gynaecological exam.
10. Participants will receive non-spermicidal lubricated condoms for their male sexual 
partners who will be encouraged to use condoms throughout the study if they 
engage in vaginal intercourse.
11. Participants will be counselled not to use tampons or any other vaginal products 
throughout the study.
12. Participants will be advised to return for the following brief Check-In Visits for a 
check of symptoms, AEs, sexual activity and menses as well as on site study 
product administration:
a.
Check-In Visit 4 (Day 11), Dose 4 (Dose 5 to take home for Day 12)

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b.
Check-In Visit 5 (Day 15), Dose 6
c.   Check-In Visit 6 (Day 18), Dose 7
d.
Check-In Visit 7 (Day 22), Dose 8
e.
Check-In Visit 8 (Day 25), Dose 9
f.    Check-In Visit 9 (Day 29), Dose 10
g.
Check-In Visit 10 (Day 32), Dose 11
Further, they will be advised to return for the following visits after the completion of the 
dosing phase:
h.
Follow-Up Visit 11 (Day 36), including gynaecological exam
i.    Check-In Visit 12 (Day 39)
j.    Check-In Visit 13 (Day 43)
k.   Check-In Visit 14 (Day 46)
l.    Check-In Visit 15 (Day 50)
m. Check-In Visit 16 (Day 53)
n.
Check-In Visit 17 (Day 57)
o.
Check-In Visit 18 (Day 60)
p.
and the Final Visit (Day 64), including gynaecological exam
These visits are timed to coincide with the regular twice weekly visits of the FRESH study.
13. Depending on the time of the enrolment 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 gynacological visits. Later adjustments of 
those dates may be necessary.
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 in compliance with current CDC STI Treatment Guidelines72, and continue to 
receive study product.
7.4 
Check-In Visits 4 – 10
Coinciding with the regular twice weekly visits of the FRESH study, brief Check-in Visits 
will be conducted, during which directly observed product administration of the remaining 
doses will occur (Doses 4 – 11).
a.
Check-In Visit 4 (Day 11), Dose 4 (Dose 5 to take home for Day 12)
b.
Check-In Visit 5 (Day 15), Dose 6
c.
Check-In Visit 6 (Day 18), Dose 7
d.
Check-In Visit 7 (Day 22), Dose 8
e.
Check-In Visit 8 (Day 25), Dose 9
f.
Check-In Visit 9 (Day 29), Dose 10
g.
Check-In Visit 10 (Day 32), Dose 11
The following short assessments will be performed at these Check-In Visits 4 – 10:

Page 48 of 124
1.
 Staff will review symptoms, concomitant medications, last menses, sexual 
activity and any medical problems since the last visit, which will be recorded on 
the appropriate CRF.
2.
 The participant will be asked to provide exact dates and times of those study
product administrations that took place at home (Dose 2,3 and 5 only).
3.
Staff will hand the appropriate dose (4, 6- 11) to the participant from the carton 
stored on site, labeled with the participant’s study ID.
4.
In Week 1 only, staff will hand the fifth dose to the participant from the carton on 
site, to take home and self-administer the next day (Day 12)
5.
Staff will document the study product administration on the appropriate CRF.
6.
Participants will be reminded not to use tampons or any other vaginal products 
throughout the study.
7.
Participants will be encouraged to use the provided non-spermicidal condoms if 
they engage in vaginal intercourse throughout the study.
8.
Participants will be counselled to try to abstain from sexual intercourse for 12 
hours after each study product application and for 12 hours before those study 
visits that include a gynaecological exam.
9.
An appointment for the next Check-In, Follow-Up or Final Visit will be confirmed or 
rescheduled if necessary. Depending on the time of the enrolment 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 she 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.
7.5 
Follow-up Visit 11 (Day 36) (Allowable window: Days 33 - 43)
The following procedures and assessments will be performed at the Follow-Up Visit 11, 
Day 36:
1.
Participants will return on Day 36 (Monday or Tuesday). With staff they will 
review symptoms, concomitant medications, and any medical problems since the 
last visit, which will be recorded on the appropriate CRF.
2.
Focused medical, gynaecological and sexual history since the last visit to include 
assessment of STI risk.
3.
Symptom-directed physical and pelvic examination by a study physician or nurse 
that will include vital signs, including temperature, 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 Gram stain (Nugent scoring system)

Page 49 of 124
e.
Two Vaginal swabs for complete mucosal sampling including identification 
of vaginal bacteria, lactobacilli species, cytokines and HIV target cells as 
well as multiomic (e.g. proteomics, metabolomics, etc.) testing
f.
Vaginal swab for prostate specific antigen testing as a proxy for recent 
exposure to semen
g.
Vaginal swab for STI testing if indicated by symptoms
h.
A cervicovaginal lavage sample
i.
Vaginal swabs for L. crispatus identification with qPCR
If indicated, cervical (or vaginal) swabs for nucleic acid 
amplification of N. gonorrhoeae, and C. trachomatis.
5.
Dipstick on clean catch urine; if abnormal, urinalysis (UA) will be performed. 
6.
Rapid 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 tampons or any other 
vaginal products throughout the study.
9.
Participants will be counselled to try to abstain from sexual intercourse for 
12 hours before the Final Visit 19 (Day 64).
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 throughout the study.
11. Participants will be asked to complete a detailed self-administered 
questionnaire assessing the acceptability of the study product and the 
applicator.
Women with vaginal discharge or vaginitis symptoms during the Follow-Up Visit 11 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 Treatment Guidelines.72
Women who develop symptomatic BV confirmed by Nugent 7-10 on Gram stain at least 4 
weeks after the last Metronidazole treatment will be retreated with Metronidazole.
This practice follows CDC treatment guidelines and FDA recommendations. The 7-
day course of Metronidazole will begin as soon as possible. Women diagnosed with 
asymptomatic BV during the follow-up visit will not be retreated with Metronidazole.
If test results and clinical screening suggest a UTI, the woman will be managed as 
clinically indicated. 
Participants who test HIV-positive after randomization, will discontinue study product, but 
continue follow-up and attend all remaining study visits to monitor for adverse events.  

Page 50 of 124
HIV-specific care, including the provision of antiretroviral treatment and ongoing 
management will be provided by the FRESH Study.
7.6
Check-In Visits 12 –18
Coinciding with the regular twice weekly visits of the FRESH study, brief Check-
Visits will be conducted.
a.
Check-In Visit 12 (Day 39)
b.
Check-In Visit 13 (Day 43)
c.
Check-In Visit 14 (Day 46)
d.
Check-In Visit 15 (Day 50)
e.
Check-In Visit 16 (Day 53)
f.
Check-In Visit 17 (Day 57)
g.
Check-In Visit 18 (Day 60)
The following short assessments will be performed at these Check-In Visits 12 – 18:
1.
Staff will review 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 will be reminded not to use tampons or any other vaginal products 
throughout the study.
3.
Participants will be encouraged to use the provided non-spermicidal condoms if they 
engage in vaginal intercourse throughout the study.
4.
Participants will be counselled to try to abstain from sexual intercourse for 12 hours 
after each study product application and for 12 hours before those study visits that 
include a gynaecological exam.
5.
An appointment for the next Check-In will be confirmed or rescheduled if necessary.
6.
At Check-In Visit 18: The appointment for the Final Visit 19 (Monday or Tuesday) 
will be confirmed. Depending on the time of the enrolment 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 she 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 
Final Study Visit 19, Day 64 (Allowable window: Days 57 - 71)
The following procedures and assessments will be performed at the Final Visit 19, 
Day 64:
1.
Participants will return on Day 64 (Monday or Tuesday). Staff will review symptoms, 
concomitant medications and any medical problems since the last visit, which will be 

Page 51 of 124
recorded on the appropriate CRF.
2.
Medical, gynaecological and sexual history to include assessment of STI  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 Gram stain (Nugent scoring system)
e. Two Vaginal swabs for complete mucosal sampling including 
identification of vaginal bacteria, lactobacilli species, cytokines and HIV 
target cells as well as multiomic (e.g. proteomics, metabolomics, etc.) 
testing
f.  Vaginal swab for prostate specific antigen testing as a proxy for recent 
exposure to semen
g.  Vaginal swab for STI testing if indicated by symptoms
h.  A cervicovaginal lavage sample
i.  Vaginal swabs for L. crispatus identification with qPCR
j.   Vaginal swab for prostate specific antigen testing as a proxy for recent 
exposure to semen
5.
Dipstick on clean catch urine; if abnormal, urinalysis (UA) will be performed.
6.
Rapid 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 at the Final Visit 19 will be referred 
for standard treatment.
If the test results and clinical screening 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 STI Treatment Guidelines. 72 The 
participant should be treated in case of positive findings.
Women who develop symptomatic BV confirmed by Nugent Score 7- 10 on Gram stain at 
least 4 weeks after the last Metronidazole treatment will be retreated with Metronidazole. 
This practice follows CDC treatment guidelines and FDA recommendations. The 7-day 
course of Metronidazole will begin as soon as possible. Women diagnosed with 

Page 52 of 124
asymptomatic BV during the follow-up visit will not be retreated with Metronidazole.
If test results and clinical screening suggest a UTI, the woman will be managed as 
clinically indicated. 
Participants who test HIV-positive after randomization, will discontinue study product, but 
continue follow-up and attend all remaining study visits to monitor for adverse events.  HIV-
specific care, including the provision of antiretroviral treatment and ongoing management 
will be provided by the FRESH Study.
7.8 
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 5.3.3.1, 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 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, gynaecological and sexual history to include assessment of STI 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 Gram stain (Nugent scoring system)
e. Two Vaginal swabs for complete mucosal sampling including 
identification of vaginal bacteria, lactobacilli species, cytokines and HIV 
target cells as well as multiomic (e.g. proteomics, metabolomics, etc.) 
testing
f. Vaginal swab for prostate specific antigen testing as a proxy for recent 
exposure to semen
g. Vaginal swab for STI testing if indicated by symptoms
h. A cervicovaginal lavage sample
i. Vaginal swabs for L. crispatus identification with qPCR
j. Vaginal swab for prostate specific antigen testing as a proxy for recent 
exposure to semen
5.
Dipstick on clean catch urine; if abnormal, urinalysis (UA) will be performed.

Page 53 of 124
6.
Rapid 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.
Administer acceptability questionnaire
9.
If participants remain in follow up, they will receive non-spermicidal lubricated 
condoms for their male sexual partners. Participants will be encouraged to use 
condoms if they engage in vaginal intercourse throughout the study.
10. 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 STI 
Treatment Guidelines.
7.9 
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 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, gynaecological and sexual history to include assessment of STI 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 Gram stain (Nugent scoring system)
e. Two Vaginal swabs for complete mucosal sampling including 
identification of vaginal bacteria, lactobacilli species, cytokines and HIV 
target cells as well as multiomic (e.g. proteomics, metabolomics, etc.) 
testing
f. Vaginal swab for prostate specific antigen testing as a proxy for recent 
exposure to semen
g. Vaginal swab for STI testing if indicated by symptoms
h. Cervical (or vaginal) swabs for nucleic acid amplification of N. gonorrhoeae, 
and C. trachomatis.
i. A cervico-vaginal lavage sample
j. Vaginal swabs for L. crispatus identification with qPCR

Page 54 of 124
5.
Dipstick on clean catch urine; if abnormal, urinalysis (UA) will be performed.
6.
Rapid 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.
An additional unscheduled visit as deemed necessary by the site investigator 
to ensure short-term surveillance will be planned.
9.
Participants will be reminded not to use tampons or any other vaginal 
products throughout the study.
10. Participants will be counselled to try to abstain from sexual intercourse for 
12 hours after each study product application and 12 hours before the 
remaining study visits.
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 throughout the study.
12. An appointment for the next regular follow-up visit will be scheduled. Depending 
on the time of the enrolment 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 at the unscheduled visit will be referred for 
standard treatment and continue to receive study product.
If the test results at the unscheduled 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 STI Treatment Guidelines. 72 The participant should be treated 
in case of positive findings and continue to use study product.
Women who develop symptomatic BV confirmed by Nugent 7-10 on Gram stain at least 4 weeks 
after the last Metronidazole treatment will be retreated with Metronidazole. This practice follows 
CDC treatment guidelines and FDA recommendations. The 7-day course of Metronidazole will 
begin as soon as possible.
Women diagnosed with asymptomatic BV during the follow-up visit will not be retreated with 
Metronidazole.
If test results and clinical screening suggest a UTI, the woman will be managed as 
clinically indicated. 
Participants who test HIV-positive after randomization, will discontinue study product, but 
continue follow-up and attend all remaining study visits to monitor for adverse events.  HIV-
specific care, including the provision of antiretroviral treatment and ongoing management will be 

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provided by the FRESH Study.
8.0 
STUDY PROCEDURES/EVALUATIONS
8.1 
Clinical Evaluations
The following assessments and procedures will be performed:

Sociodemographic and participant contact information

Medical, gynaecological 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 the 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 urinalysis (UA), if abnormal.

HIV testing will be conducted using standardized algorithms.*

Cervical (or vaginal) swabs will be tested for N. gonorrhoeae, T. 
vaginalis, Mycoplasma genitalium and C. trachomatis by nucleic acid 
amplification.

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 16S rRNA gene/shotgun sequencing, 
which will be performed by a central laboratory at the Ragon Institute of 
MGH, MIT and Harvard

Cervicovaginal lavage (CVL) specimens will be analyzed for cytokines 
and chemokines using a luminex array

Cervical cytobrush samples will be used to assess presence of HIV target 
cells by flow cytometry.

Vaginal specimens will be analyzed using multiomic (e.g. 
proteomics, metabolomics, etc.) testing.

Vaginal samples will be used for culturing of live bacterial isolates for 
quenching and functional analysis

CVL will also be used for in vitro anti-HIV activity assays

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8.2.3.   Specimen Preparation, Handling, and Shipping

Instructions for Specimen Preparation, Handling, and Storage will be 
described in further detail in the MOP.

Many of the collected samples will be analyzed in laboratories in Durban and at 
UKZN. 

But some of your collected vaginal swabs will be shipped to a laboratory located 
in Boston, USA, headed by Dr. Douglas Kwon of the Ragon Institute at MGH. 

Mucosal sampling swabs, and cytobrush cells will all be initially processed and 
stored at UKZN. Further analysis will be performed at both UKZN and in the U.S. 
at the Ragon Institute of MGH, MIT and Harvard. All work performed in the U.S. 
will be done in close collaboration with South African LACTIN-V investigators.

Instructions for specimen shipment will be described in further detail 
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 the Final Visit 19 (Day 64).
9.2 
Methods and Timing for Assessing, Recording, and Analyzing Safety Parameters
9.2.1    Adverse Events
ICH (International Conference on Harmonisation) E6 73 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 adequate resolution.

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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, the 
following guidelines will be used to quantify intensity.
Mild (Grade 1): Events require minimal or no treatment and do not 
interfere with the participant’s daily activities.
Moderate (Grade 2): Events result in a low level of inconvenience or 
concern with the therapeutic measures. Moderate events may cause 
some interference with functioning.
Severe (Grade 3): Events interrupt a participant’s usual daily activity 
and may require systemic drug therapy or other treatment. Severe 
events are usually incapacitating.
Life-threatening (Grade 4): Life-threatening consequences; urgent 
intervention indicated.
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*

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
Inpatient hospitalization or prolongation of existing hospitalization

A persistent or significant incapacity or substantial disruption of the ability 
to conduct normal life functions

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 CRF

Followed through resolution by a study physician

Reviewed and evaluated by the study chairs, relevant IRBs, 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 gynaecological 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 2.1 July 2017.
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 following 
address:
BIOMEDICAL RESEARCH ETHICS COMMITTEE (BREC)
University of KwaZulu-Natal 
(UKZN) Research Office, Westville 
Campus Govan Mbeki Building
Private Bag X 54001
Durban 4000
KZN, SOUTH AFRICA
Tel: 27 31 2604769
Email: BREC@ukzn.ac.za
Any AE that meets a protocol-defined serious criterion must also be submitted within 
7 days of site awareness) on an SAE form to the following address:
Chief Executive Officer
South African Health Products Regulatory 
Authority Clinical Trials Unit
Private Bag X828 
Pretoria
ctcsaes@sahpra.org.za
Other supporting documentation of the event may be requested by the study sponsor 
or the DSMB and should be provided as soon as possible.
The medical monitor and clinical protocol manager will be notified of the SAE by the 
site. The medical monitor will review and assess the SAE for regulatory reporting 
and potential impact on study subject safety and protocol conduct.
At any time during 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 
IRB at UKZN, UCSF and the Ragon Institute of MGH, MIT and Harvard.
9.3.2 Regulatory Reporting
Following notification from the site principal investigator or appropriate sub-
investigator, the study sponsor, will report any suspected adverse reaction that is 
both serious and unexpected. UCSF 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. UCSF will notify SAHPRA in a 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. UCSF will also notify SAHPRA 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 a safety report will be submitted as 

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soon as the information is available. Upon request from SAHPRA, UCSF will submit 
to SAHPRA 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
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 enrolment 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)  Two or more participants experience a treatment-related severe (Grade 3) or 
life-threatening (Grade 4) systemic adverse event.
4)  An overall pattern of symptomatic, clinical, or laboratory events that the 
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.
9.6 
Safety Oversight (DSMB)
Safety oversight will be under the direction of a DSMB, consisting of 3 voting members. The 
DSMB will meet once - prior to first enrollment, once - after half of the 60 participants 
complete the Follow-Up Study Visit 11(Day 36), and then, finally – once, after study 
conclusion and database lock, to assess safety and efficacy data in each arm of the study. 

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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 an 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 advise UKZN, UCSF and the Ragon 
Institute at MGH of its findings.

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10.0 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. 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 the sponsor and may be made 
more frequently as directed by the sponsor. Monitoring visits will include, but are not limited 
to, review of regulatory files, accountability records, CRFs, 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 sponsor-
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 2 randomized double-blind placebo-controlled trial to assess the impact of 
the live biotherapeutic product LACTIN-V containing Lactobacillus crispatus CTV-05 on the 
non-lactobacillus dominant microbiome of young women in South Africa at high risk of HIV 
acquisition.
The study plans to enrol and randomize 60 sexually experienced women age 18 to 23 
years, who are using a reliable method of long- acting injectable birth control or are of non-
childbearing potential (permanently sterile). After enrolment, women will start a standard 7 -
day course of oral Metronidazole tablets. After completing the 7-day course of 
Metronidazole, subjects will be randomized to receive either placebo or LACTIN-V in a 1:2 
ratio. The participants will receive protocol treatment for four weeks and will have four weeks 
of additional off treatment follow-up time.
11.2 Study Objectives and Outcome Measures
As described in section 3.2 and 3.3, the primary study objectives are to compare LACTIN-V 
with placebo following a 7-day treatment course with Metronidazole with respect to safety 
and impact on the vaginal microbiome, specifically lactobacillus growth and decrease in pro-
inflammatory cytokines and HIV target cells.
In Objective 1, the outcomes of interest will be:
(1) a decrease in genital tract inflammation from baseline (the FRESH Study Visit before 
enrollment) to Day 36 Follow-Up Visit, as defined by a 1 Log10 decrease in the 
concentration of cytokines that have been associated with an increased risk for HIV 
infection.17 , and
(2) the change in the concentration of cytokines at the Final Visit on Day 64 (4 weeks after 
dosing phase completed) compared to baseline, number of endocervical CD4+ HIV target 
cells at Day 36 Follow-Up and Day 64 Final Visits compared to baseline, and in vitro anti- 
HIV activity of cervicovaginal lavage at Day 36 Follow-Up and Day 64 Final Visits. We will 
compare each outcome by study arm.
In Objective 2, the outcomes of interest will be:
(1) the presence of Lactobacillus-dominant vaginal microbial cervicotypes at the Day 36 
Follow-Up Visit, and following the post-dosing phase at the Day 64 Final Visit in the LACTIN-
V arm; and
(2) the comparison of L. crispatus vs. L. iners prevalence between treatment groups, 
quantity of vaginal L. crispatus, presence of the specific CTV-05 L. crispatus strain, 
persistence of colonization after stopping therapy, effect of sex and/or vaginal hygiene 
practices on colonization by lactobacilli, and stability of vaginal microbial communities over 
time in the treatment vs. placebo arms.
In Objective 3, the outcomes of interest will be:
(1) the proportion of treatment related adverse events study arm, in particular Grade 3  
AEs; and
(2) the proportion of participants finding the product acceptable and are willing to use it

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should it become commercially available, as measured in a standardized acceptability 
questionnaire.
11.3 Sample Size Considerations
The study will accrue a total of 60 randomized subjects (n=20 for the placebo arm A and 
n=40 for the LACTIN-V arm B). The accrual for this study is expected to be completed within 
75 weeks (18 months) with projected accrual rate of 3 subjects per month. Each subject will 
be followed up for 64 days.
The primary endpoint upon which the sample size calculation was based is the proportion 
of subjects with a 1 Log10 decrease in at least 3 of 9 proinflammatory cytokines in CVL 
specimens on the Day 36 Visit, i.e. at the completion of the LACTIN-V/Placebo dosing 
phase. The proportion of women with decreased inflammation will be compared between 
the two study arms. This endpoint is adapted from the CAPRISA 004 study which 
demonstrated that women with the highest levels of at least 3 of 9 proinflammatory 
cytokines in CVL specimens had an increased risk of HIV acquisition.25 Our adaptation of 
the CAPRISA 004 analysis is that we will define “decreased inflammation” as a 1 Log10 
decrease in the concentration of at least 3 of the same 9 proinflammatory cytokines. Based 
on our prior data,2, 42 we assume that no more than 10% of placebo-treated women will 
achieve a decrease in 3 of the 9 proinflammatory genital tract cytokines. Moreover, we 
hypothesize that at least half of the participants in the treatment arm will achieve a 
decrease 1 log10 in 3 of the 9 proinflammatory genital tract cytokines. With the targeted 
sample size of 60 randomized women (1/3 in placebo arm & 2/3 in the LACTIN-V arm; 
there will be more than 88% power to detect a 40% absolute difference (10% vs. 50%) in 
the proportion of women with decreased inflammation between the two treatment arms. 
This power calculation was based on simulation study using 10,000 Monte Carlo samples 
and two-sided Fisher's exact test with type 1 error rate of 5%.
11.4 Safety Analysis
This study will be monitored for safety and to determine if any of the safety halting rules 
described in detail in Section 9.5 are met (one or more treatment-related SAE, two or more 
treatment-related vaginal ulceration, two or more treatment-related severe Grade 3 
systemic adverse events). Thus, all patients will be evaluated for toxicity. The DSMB will 
review interim analyses comparing product-related AEs between the two treatment arms 
will be performed after half of the 60 participants complete the Follow-Up Study Visit 11, 
and then annually. Reports of these analyses will be sent to the Principal Investigator or 
Senior Investigators at the participating institutions.
The table below gives the probability of observing at least one incidence of AE together 
with the corresponding true AE rate for a total of 60 participants.
True AE rate:
0.5%
1%
2%
5%
P [AE>1]:
0.26
0.45
0.70
0.95
For example, the probability of observing at least one incidence of AE with true rate of 5% 
is 0.95.

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11.5.   Statistical Analysis Plan
The primary analyses in Objective 1 is to compare the levels of i) pro-inflammatory genital 
tract cytokines levels & proportion of subjects with a significant decrease (1 log10) in 
cytokines levels, ii) HIV target cells (i.e., CD4+/CCR5+/HLA-DR+/CD38+ T cells) and iii) 
anti-HIV effect of CVL, as assessed by HIV p24 levels, between the two treatment arms. 
Graphical and descriptive measures (such as frequency, percent mean, median, standard 
deviation and IQR) will be used to summarize data. Spearman rank correlation will be used 
to examine associations among the aforementioned outcomes. Statistical tests (such as the 
two sample T and Wilcoxon rank sum tests) will be used to compare levels of cytokines, HIV 
p24 levels and HIV target cells between the two treatment groups. 
For within group comparison, statistical tests (such as paired T and Wilcoxon signed rank 
tests) will be used. Longitudinal data analyses using nonlinear mixed models or generalized 
estimating equations will be performed to examine and compare the overtime changes in 
cytokines levels and HIV target cells. Fisher’s exact test will be used to compare the 
proportion of subjects with a significant decrease (1 log10) in cytokines levels. 
Data classification and dimension reduction techniques (e.g., principal component analysis, 
and cluster analysis) will be used to group a set of cytokines or HIV target cells to 
uncorrelated summary variables or to identify study subjects with similar cytokine or HIV 
target cell profiles. Adjustment will be made for multiple comparisons using less 
conservative multiple testing correction procedures (such as the Holm’s and Benjamini-
Hochberg methods) where appropriate.  
The primary analysis in Objective 2 is to compare the presence and abundance of 
Lactobacillus spp. (including L. crispatus CTV-05) between the two study groups. As in 
Objective 1, graphical and descriptive measures will be used to summarize data. Fisher’s 
exact test will be used to compare presence of specific strains of vaginal lactobacilli and 
cervicotypes (CT).1 Empirical Bayes method will be used for identification of microbes that 
show differential abundance between study arms. Empirical Bayes method is more efficient 
due to its ability of pooling information across microbes. 
Sparse clustering, where clustering and feature selection are integrated, will be used to 
identify study subjects with similar microbial profiles.  Sparse clustering has a number of 
advantages. If the underlying groups differ only in terms of some of the features, then it 
might result in more accurate identification of these groups than standard clustering. It also 
yields interpretable results, since one can determine precisely which features are 
responsible for the observed differences between the groups or clusters. Similarly, Sparse 
Principal Component analysis will be used to group a set of highly correlated microbial reads 
to uncorrelated summary variables. As in Objective 1, adjustment for multiple testing will be 
made using less conservative multiple testing correction methods (e.g., Benjamini-
Hochberg).
Solicited AEs will be analyzed by taking the most severe response over the Day 64 follow-
up period. The analyses of AEs and SAEs is mainly descriptive. Descriptive measures 
(frequency and percent) will be used to summarize the proportion of participants with 
product-related AEs (Grade 0, Grade 1, Grade 2, and Grade 3) in each treatment arm. 
Confidence intervals for AEs rates will be estimated using methods for exact binomial 
confidence intervals. Fisher’s exact test will be used to compare rates of AEs between the 

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two treatment arms. Multivariate analyses using logistic regression models will be used to 
compare AEs rates between the two arms while adjusting for the effect of other covariates.
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.

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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 
UKZN BREC, its designees, and appropriate regulatory agencies such as SAHPRA 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 CRFs and be provided by the UCSF study team in collaboration with the 
site and DF Net Data Management.

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13.0 QUALITY CONTROL AND QUALITY ASSURANCE
The data management company DF Net Research, Inc. 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 site is responsible for conducting routine quality control (QC) and quality 
assurance (QA) activities to internally monitor study progress and protocol compliance. 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 the trial-related site, 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.
The study coordinator will approach individual FRESH study participants about joining the 
parallel LACTIN-V study. The FRESH cohort has included sub-studies before (additional 
blood draws, high-frequency genital mucosal sampling), thus we anticipate that the overall 
idea will be acceptable and not stigmatizing to women enrolled in the FRESH cohort.
Probiotics for gut health are relatively common over-the-counter products in South Africa. 
Thus, while less information is available about using ‘probiotic-like’ products in the vagina, 
we do not anticipate significant challenges with recruitment of FRESH participants into the 
LACTIN-V study.74
The consent form 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. The consent form will 
be IRB-approved (at UKZN BREC, UCSF CHR and Ragon Institute IRB) 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 available in English and 
isiZulu 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. An Assessment of Understanding form, available in English and isiZulu, 
will be completed to ensure that study participants retained the most important aspects of 
the provided information.
A copy of the informed consent document will be given to the participants for their records. 

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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 enrol 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.
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
Children under the age of 18 are not eligible for this study, which requires 
participants to be sexually experienced.
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.

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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 CRFs 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 CRF 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 CRFs.
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.
DF Net Research Inc. 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, provided by DF Net Research Inc. 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.

Page 73 of 124
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 the 
sponsor. 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 the 
sponsor.
.
All deviations from the protocol must be addressed in study subject data collection forms. A 
completed copy of the 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

Page 74 of 124
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 
sponsor 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 as well as the South 
African National Clinical Trials Registry. Other biomedical journals are considering adopting 
similar policies. It is the responsibility of the sponsor to register this trial in an acceptable registry. 
Any clinical trial starting enrolment after 01 July 2005 must be registered on or before patient 
enrolment. For trials that began enrolment 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 (e.g., Phase 1 trials), would be exempt from 
this policy.
Any presentation, abstract, or manuscript will be made available by the Investigator to the sponsor, 
and Osel Inc. for review prior to submission.

Page 75 of 124
17.0 SPONSOR INDEMNIFICATION FOR SITES AND INVESTIGATORS
In consideration of the sites,  the Aurum Institute - Pharmacy and Females Rising Through 
Education, Support and Health,  participation in the study, we shall indemnify and hold harmless the 
Aurum Institute Pharmacy and Females Rising Through Education, Support and Health and its 
employees from any legal liability for costs or damages for death or personal injury which may 
result from the administration of LACTIN-V (Lactobacillus crispatus CTV-05) pursuant to the said 
study.  This indemnity does not apply to the extent that such death or personal injury arises out of 
any negligent act, default or omission of the Aurum Pharmacy and Females Rising Through 
Education, Support and Health participation in the study, we shall indemnify and hold harmless the 
Aurum Institute or its employees.  Furthermore, this indemnity is subject to the condition that the 
study is carried out in accordance with the Protocol approved by us in writing, that University of 
California, San Francisco (UCSF) is notified immediately on receipt of any claim, that University of 
California, San Francisco (UCSF shall have full control of the management and defence of any 
such claim and that no offer to compromise or settle any claim is made without the written 
agreement of University of California, San Francisco (UCSF).

Page 76 of 124
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48. 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.
49. Cohen CR, Lingappa JR, Baeten JM, et al. Bacterial vaginosis associated with increased risk of 
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54. Balkus JE, Richardson BA, Mandaliya K, Kiarie J, Jaoko W, Ndinya-Achola JO, et al. Establishing 
and sustaining a healthy vaginal environment: analysis of data from a randomized trial of periodic 
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an antiretroviral microbicide, for the prevention of HIV infection in women. Science. 
2010;329(5996):1168-1174.
56. 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.
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assessing colonization efficiency, safety, and acceptability of Lactobacillus crispatus CTV- 05 in 
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rates of bacterial vaginosis over the course of 12 months after oral metronidazole therapy and 
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67. Balkus JE, Manhart LE, Lee J, Anzala O, Kimani J, Schwebke J, et al. Periodic Presumptive 
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of oral periodic presumptive treatment for vaginal infections on the incidence of bacterial vaginosis 
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17(1):7 doi: 10.1186/s12905-017-0362-6. PMID: 28103868

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19.0 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 2.1 – July 2017
Appendix D
Coordination between FRESH and LACTIN-V studies

Page 82 of 124
Appendix A Schedule of Events
Study 
Treatment
Study 
Follow-Up
Evaluation
         Enrolment
             Visit 1
Day 1
Randomization Visit 3
(Day 8)
Check-In and Dosing 
Visits 4 - 10
Follow-Up Visit 11
Day 36
Check-In Visits 12 - 
18
Final Study Visit 19 
Day 64
Unscheduled Visit
Study Product 
Discontinuation
Early Termination 
Visit
Visit window (Study Days)
33- 43
57-71
Signed consent form
X
Assessment of eligibility criteria
X
X
Demographics
X
Randomization
X
Detailed medical, gynaecological and sexual history
X
Dispense Metronidazole
X
(X)
(X)
Dispense LACTIN-V/placebo and applicators
X
X
Dispense condoms
X
X
X
X
X
X
X
Brief medical, gynaecological and sexual history
X
X
X
X
X
X
Review of concomitant medications
X
X
X
X
X
X
X
Study intervention
X
X
Complete
X
Symptom-directed
X
X
X
X
X
X
Vital signs
X
X
X
X
X
X
X
Physical 
Examination
Pelvic examination
X
X
X
X
X
X
Review symptoms, AEs, menses, sexual activity
X
X
X
X
X
X
X
Counsel to abstain from sexual intercourse
X
X
X
X
X

Page 83 of 124
Study 
Treatment
Study 
Follow-Up
Evaluation
   Enrolment
   Visit 1
 Day 1
Randomization Visit 
3 (Day 8)
Check-In and Dosing 
Visits 4 - 10
Follow-Up Visit 11
Day 36
Check-In Visits 12 - 
18
Final Study Visit 19 
Day 64
Unscheduled Visit
Study Product 
Discontinuation
Early Termination 
Visit
Reminder not to use vaginal products
X
X
X
X
X
Assessment of adverse events
X
X
X
X
X
X
X
Clean catch urine dipstick
X
X
X
X
X
X
X
Urinalysis
(X)
(X)
(X)
(X)
(X)
(X)
(X)
Rapid urine βhCG pregnancy test
X
X
X
X
X
X
X
Clinical
Labor
Vaginal swab for N. gonorrhoeae, C. 
trachomatis, T. vaginalis and M. genitalium
(X)
(X)
(X)
(X)
(X)
(X)
Vaginal swab for pH
X
X
X
X
X
X
PSA test for sperm exposure as POCT
X
X
X
X
X
X
Vaginal swab for Gram stain
X
X
X
X
X
X
Vaginal swab for cytokines, HIV Target 
cells, vaginal bacteria, lactobacilli species
X
X
X
X
X
X
Vaginal swab for qPCR (L. crispatus
identification)
X
X
X
X
X
X
Cervicovaginal Lavage
X
X
X
X
X
X
Research
 Laboratory
Future Use vaginal swabs
X
X
X
X
X
X
Acceptability questionnaire
X
X
X
X
(X) if indicated

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 84 of 123
Version 1.0
APPENDIX B
INDIVIDUAL SIGNS/SYMPTOMS
PARAMETER
GRADE 0 
NORMAL
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
GENERAL
Odor
No complaint
Mild-moderate 
unpleasant odor
Severe unpleasant 
odor
NA
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
Disabling pain 
causing inability to 
perform basic self- 
care functions OR 
hospitalization 
(other than 
emergency room 
visit) indicated
Tenderness* 1
None
Mild tenderness
Moderate 
tenderness
Severe tenderness
NA
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
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
NA
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.

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 85 of 123
Version 1.0
INDIVIDUAL SIGNS/SYMPTOMS
PARAMETER
GRADE 0
GRADE 1
GRADE 2
GRADE 3
NORMAL
MILD
MODERATE
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
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
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
NA
Vulvar erythema
None
Erythema covering
< 50% of vulvar 
surface
Erythema covering
≥ 50% of vulvar 
surface
NA
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
NA
Vulvar rash
None
Rash covering
< 50% of vulvar 
surface
Rash covering
≥ 50% of vulvar 
surface
Severe epithelial 
disruption with 
hospitalization 
indicated
NA
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
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
NA
Vaginal erythema
None
Erythema covering
< 50% of vaginal 
surface
Erythema covering
≥ 50% of vaginal 
surface
NA
NA

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 86 of 123
Version 1.0
INDIVIDUAL SIGNS/SYMPTOMS
PARAMETER
GRADE 0
GRADE 1
GRADE 2
GRADE 3
NORMAL
MILD
MODERATE
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
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
NA
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
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
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, 
hospitalization 
indicated
Lacerations 
extending into the 
peritoneal cavity, 
bladder, or rectum
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
NA
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
Visible cervical 
cancer
GENITOURINARY SIGNS/SYMPTOMS – CERVIX
Cervical edema and 
friability
None
Edema without 
friability
Friable cervix
NA
NA

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 87 of 123
Version 1.0
INDIVIDUAL SIGNS/SYMPTOMS
PARAMETER
GRADE 0
GRADE 1
GRADE 2
GRADE 3
NORMAL
MILD
MODERATE
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Cervical erythema
None
Erythema covering
< 50% of cervix
Erythema covering
≥ 50% of cervix
NA
NA
Cervical discharge
White or clear 
discharge
Small amount of 
purulent discharge 
at os
Purulent discharge 
extending onto 
cervix or vagina
NA
NA
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
NA
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
Uterine mass that 
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 
and/or surgery 
indicated
NA
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 (see 
footnote #1)
NA
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 
and/or surgery 
indicated
NA
Adnexal mass based on 
ultrasound
None
Simple cyst, 
asymptomatic
Simple cyst, 
symptomatic
Mass suspicious 
for malignancy
Malignant mass

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 88 of 123
Version 1.0
INDIVIDUAL SIGNS/SYMPTOMS
PARAMETER
GRADE 0
GRADE 1
GRADE 2
GRADE 3
NORMAL
MILD
MODERATE
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
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 
indicated
Malignancy
GENITOURINARY SIGNS/SYMPTOMS – URINARY TRACT
Urinary frequency
None
Up to 2 times 
participant’s 
normal frequency
> 2 times 
participant’s 
normal frequency
NA
NA
Dysuria
None
Superficial only
Deep ± superficial
Inability to void 
due to pain
NA
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 or 
intervention 
indicated to obtain 
hemostasis 
(endoscopy, 
interventional 
radiology, or 
operative)
Profuse hemorrhage 
with shock or 
orthostatic dizziness

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 89 of 123
Version 1.0
COMPOSITE SIGNS/SYMPTOMS
(Use instead of individual categories if 2 or more signs/symptoms are present)
PARAMETER
GRADE 0 
NORMAL
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
GRADE 1 
MILD
(Use if all signs/ 
symptoms would 
individually be 
Grade 0 or 1)
GRADE 3 
SEVERE
(Use if one or more 
signs/symptoms 
would individually 
be Grade 3)
GRADE 2 
MODERATE
(Use if one or more 
signs/symptoms 
would individually 
be Grade 2 and all 
others Grade 0 or 1)
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
NA
Cervicitis (combinations 
of dyspareunia, 
erythema,
edema, tenderness, and 
discharge)
None
Mild signs/ 
symptoms
Moderate signs/ 
symptoms
Severe signs/ 
symptoms
NA
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
Tubo-ovarian 
abscess or surgery 
required for 
resolution
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
NA
Cervicitis (combinations 
of dyspareunia, 
erythema,
edema, tenderness, and 
discharge)
None
Mild signs/ 
symptoms
Moderate signs/ 
symptoms
Severe signs/ 
symptoms
NA
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
Tubo-ovarian 
abscess or surgery 
required for 
resolution

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 90 of 123
Version 1.0
INFECTIONS AND DYSPLASIA
PARAMETER
GRADE 0 
NORMAL
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
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
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
NA
Trichomonas
Negative
NA
Positive wet mount, 
culture, PCR or 
other licensed test, 
excluding pap 
smear, showing T. 
vaginalis, 
regardless of 
symptoms
NA
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
NA

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 91 of 123
Version 1.0
INFECTIONS AND DYSPLASIA
PARAMETER
GRADE 0
GRADE 1
GRADE 2
GRADE 3
NORMAL
MILD
MODERATE
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
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
Tubo-ovarian 
abscess or surgery 
required for 
resolution
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
Tubo-ovarian 
abscess or surgery 
required for 
resolution 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
Sepsis (septicemia) 
due to urinary tract 
infection

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 92 of 123
Version 1.0
INFECTIONS AND DYSPLASIA
PARAMETER
GRADE 0
GRADE 1
GRADE 2
GRADE 3
NORMAL
MILD
MODERATE
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
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 
the non- treponemal 
test after previous 
treatment 
regardless of 
symptoms or non- 
oral lesions positive 
by darkfield exam 
for treponemes
Criteria for Grade 2 
Syphilis in the 
presence of 
neurologic 
symptoms or a 
positive CSF VDRL 
or FTA-ABS
NA
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 
indicated
NA
Intraepithelial Neoplasia 
by biopsy
(VIN, CIN, VAIN)
None
Intraepithelial 
Neoplasia 1 (IN1)
Intraepithelial 
Neoplasia 2 (IN2)
Carcinoma in situ 
(CIS)
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
NA

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 
Grading Table and the main DAIDS AE Grading Table, use the grading scheme in this table.
November 2007
Page 93 of 123
Version 1.0
UTERINE BLEEDING AND PREGNANCY COMPLICATIONS
PARAMETER
GRADE 0
GRADE 1
GRADE 2
GRADE 3
NORMAL
MILD
MODERATE
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
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
Life threatening 
hemorrhage with or 
without shock
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
Life threatening 
hemorrhage with or 
without shock
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
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
Life threatening 
hemorrhage with or 
without shock
2 If both Menorrhagia and Metrorrhagia are present, a single adverse event should be reported as “Menometrorrhagia” and graded per the Menorrhagia grading 
scale.

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
Page 94 of 124
UTERINE BLEEDING AND PREGNANCY COMPLICATIONS
PARAMETER
GRADE 0
GRADE 1
GRADE 2
GRADE 3
NORMAL
MILD
MODERATE
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
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
Spontaneous 
abortion with 
profuse bleeding 
and/or shock
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
Ruptured TOA 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 1-2 
units of packed 
cells, but no other 
blood products 
indicated
Hemorrhage with 
shock or 
coagulopathy, for 
which transfusion of 
> 2 units 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
Severe infection 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
Criteria for Grade 3 
plus either fetal 
demise or maternal 
symptoms of shock

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
Page 95 of 124
UTERINE BLEEDING AND PREGNANCY COMPLICATIONS
PARAMETER
GRADE 1
GRADE 2
GRADE 3
MILD
MODERATE
SEVERE
GRADE 0
NORMAL
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Episiotomy infectionNone
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
Fever with signs of 
wound infection and 
shock or necrotizing 
fasciitis
Second/third 
trimester 
bleeding
None
Bleeding less 
than menses
Bleeding like 
menses or greater, 
but not requiring 
intervention
Bleeding requiring 
delivery or other 
intervention, e.g., 
transfusion
Bleeding with fetal 
demise or 
coagulopathy
Preterm 
rupture of 
membranes
None
NA
Preterm rupture with 
hospitalization but 
not resulting in 
delivery at less than 
37 weeks’ gestation
Delivery at 33-36 
weeks’ gestation 
or 1501-2500
grams birth weight
Delivery < 33 weeks’ 
gestation or ≤ 1500 
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 33-36 
weeks’ gestation 
or 1501-2500
grams birth weight
Delivery < 33 weeks’ 
gestation or
≤ 1500 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
NA

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
Page 96 of 124
APPENDIX C
DIVISION OF AIDS TABLE FOR 
GRADING THE SEVERITY OF ADULT 
AND PEDIATRIC ADVERSE EVENTS
VERSION 2.1, JULY 2017
The Division of AIDS (DAIDS) oversees more than 300 clinical trials domestically and 
internationally, which evaluate the safety and efficacy of therapeutic products, vaccines, and 
other preventive modalities. Adverse event (AE) data collected during these clinical trials 
form the basis for subsequent safety and efficacy analyses of pharmaceutical products and 
medical devices. Incorrect and inconsistent AE severity grading can lead to inaccurate data 
analyses and interpretation, which in turn can impact the safety and well-being of clinical 
trial participants and future patients using pharmaceutical products.
Over the years, DAIDS scientific knowledge and experience have expanded, 
necessitating revisions of the DAIDS grading table which serves as a guide for 
assessing the severity of AEs (including clinical and laboratory abnormalities) in 
participants enrolled in DAIDS-sponsored and -supported clinical trials. The Division of 
AIDS (DAIDS) Table for Grading the Severity of Adult and Pediatric Adverse Events, 
Corrected Version 2.1 (July 2017) updates and replaces version 2.1 (March 2017).
DAIDS is grateful to the DAIDS Grading Table Working Group, numerous government and 
non-government affiliated medical subject matter experts and reviewers who were 
instrumental in the revision of the DAIDS grading table.
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY
LIFE-THREATENING
Clinical adverse 
event NOT 
identified 
elsewhere in the 
grading table
Mild symptoms 
causing no or 
minimal 
interference with 
usual social & 
functional 
activities with 
intervention not 
indicated
Moderate symptoms 
causing greater than 
minimal interference 
with usual social & 
functional activities 
with intervention 
indicated
Severe symptoms 
causing inability to 
perform usual social 
& functional 
activities with 
intervention or 
hospitalization 
indicated
Potentially life-threatening 
symptoms causing 
inability to perform basic 
self-care functions with 
intervention indicated to 
prevent permanent 
impairment, persistent 
disability, or death

Major Clinical Conditions
Cardiovascular
Page 97 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Arrhythmia
(by ECG or 
physical 
examination)
Specify type, 
if applicable
No symptoms 
AND No 
intervention 
indicated
No symptoms 
AND Non-urgent 
intervention 
indicated
Non-life-threatening 
symptoms AND 
Non-urgent
intervention indicated
Life-threatening 
arrhythmia OR Urgent 
intervention indicated
Blood Pressure 
Abnormalities 1
Hypertension 
(with the lowest 
reading taken after 
repeat testing 
during a visit)
≥ 18 years of age
140 to < 160 
mmHg systolic
OR
90 to < 100 
mmHg diastolic
≥ 160 to < 
180 
mmHg 
systolic OR
≥ 100 to < 110 
mmHg 
diastolic
≥ 180 mmHg systolic 
OR
≥ 110 mmHg 
diastolic
Life-threatening 
consequences in a 
participant not 
previously diagnosed 
with hypertension (e.g., 
malignant 
hypertension) OR 
Hospitalization 
indicated
< 18 years of age
> 120/80 mmHg
≥ 95th to < 99th 
percentile + 5 
mmHg adjusted for 
age, height, and 
gender (systolic 
and/or diastolic)
≥ 99th percentile
+ 5 mmHg adjusted 
for age, height, and 
gender (systolic 
and/or diastolic)
Life-threatening 
consequences in a 
participant not 
previously diagnosed 
with hypertension (e.g., 
malignant 
hypertension) OR 
Hospitalization 
indicated
Hypotension
No symptoms
Symptoms 
corrected with oral 
fluid replacement
Symptoms AND IV 
fluids indicated
Shock requiring use of 
vasopressors or 
mechanical assistance 
to maintain blood 
pressure
Cardiac Ischemia or 
Infarction
Report only one
NA
NA
New symptoms with 
ischemia (stable 
angina) OR New 
testing consistent 
with ischemia
Unstable angina OR 
Acute myocardial 
infarction
Heart Failure
No symptoms 
AND Laboratory 
or cardiac 
imaging 
abnormalities
Symptoms with 
mild to moderate 
activity or exertion
Symptoms at rest or 
with minimal activity 
or exertion (e.g., 
hypoxemia) OR 
Intervention 
indicated (e.g., 
oxygen)
Life-threatening 
consequences OR 
Urgent intervention 
indicated (e.g., 
vasoactive 
medications, ventricular 
assist device, heart 
transplant)
1 Blood pressure norms for children < 18 years of age can be found in: Expert Panel on Integrated Guidelines for 
Cardiovascular Health and Risk Reduction in Children and Adolescents. Pediatrics 2011;128;S213; originally 
published online November 14, 2011; DOI: 10.1542/peds.2009-2107C.

Cardiovascular
Page 98 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Hemorrhage
(with significant acute 
blood loss)
NA
Symptoms AND 
No transfusion 
indicated
Symptoms AND 
Transfusion of  2 
units packed 
RBCs indicated
Life-threatening 
hypotension OR 
Transfusion of > 2 units 
packed RBCs (for 
children, packed RBCs
> 10 cc/kg) indicated
Prolonged PR 
Interval or AV Block
Report only one
> 16 years of age
PR interval 0.21 to
< 0.25 seconds
PR interval ≥ 0.25 
seconds OR Type 
I 2nd degree AV 
block
Type II 2nd degree 
AV block OR 
Ventricular pause ≥
3.0 seconds
Complete AV block
≤ 16 years of age
1st degree AV 
block (PR interval
> normal for age 
and rate)
Type I 2nd degree 
AV block
Type II 2nd degree 
AV block OR 
Ventricular pause ≥
3.0 seconds
Complete AV block
Prolonged 
QTc Interval2
0.45 to 0.47 
seconds
> 0.47 to 0.50
seconds
> 0.50 seconds OR
 0.06 seconds 
above baseline
Life-threatening 
consequences (e.g., 
Torsade de pointes, 
other associated 
serious ventricular 
dysrhythmia)
Thrombosis 
or Embolism
Report only one
NA
Symptoms AND 
No intervention 
indicated
Symptoms AND 
Intervention 
indicated
Life-threatening 
embolic event (e.g., 
pulmonary embolism, 
thrombus)
2 As per Bazett’s formula.

Dermatologic
Page 99 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Alopecia (scalp only)
Detectable by 
study participant, 
caregiver, or 
physician AND 
Causing no or 
minimal 
interference with 
usual social & 
functional 
activities
Obvious on visual 
inspection AND 
Causing greater 
than minimal 
interference with 
usual social & 
functional activities
NA
NA
Bruising
Localized to 
one area
Localized to 
more than one 
area
Generalized
NA
Cellulitis
NA
Non-parenteral 
treatment indicated 
(e.g., oral 
antibiotics, 
antifungals, 
antivirals)
IV treatment 
indicated (e.g., IV 
antibiotics, 
antifungals, 
antivirals)
Life-threatening 
consequences (e.g., 
sepsis, tissue 
necrosis)
Hyperpigmentation
Slight or localized 
causing no or 
minimal 
interference with 
usual social & 
functional 
activities
Marked or 
generalized 
causing greater 
than minimal 
interference with 
usual social & 
functional activities
NA
NA
Hypopigmentation
Slight or localized 
causing no or 
minimal 
interference with 
usual social & 
functional 
activities
Marked or 
generalized 
causing greater 
than minimal 
interference with 
usual social & 
functional activities
NA
NA
Petechiae
Localized to 
one area
Localized to 
more than one 
area
Generalized
NA
Pruritus 3
(without skin lesions)
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
NA

Dermatologic
Page 100 of 124
Rash
Specify type, 
if applicable
Localized rash
Diffuse rash 
OR Target 
lesions
Diffuse rash AND 
Vesicles or limited 
number of bullae or 
superficial 
ulcerations of 
mucous membrane 
limited to one site
Extensive or 
generalized bullous 
lesions OR Ulceration 
of mucous membrane 
involving two or more 
distinct mucosal sites 
OR Stevens-Johnson 
syndrome OR Toxic 
epidermal necrolysis

Endocrine and Metabolic
Page 101 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Diabetes Mellitus
Controlled 
without 
medication
Controlled with 
medication OR 
Modification of 
current medication 
regimen
Uncontrolled despite 
treatment 
modification OR 
Hospitalization for 
immediate glucose 
control indicated
Life-threatening 
consequences (e.g., 
ketoacidosis, 
hyperosmolar non- 
ketotic coma, end 
organ failure)
Gynecomastia
Detectable by 
study participant, 
caregiver, or 
physician AND 
Causing no or 
minimal 
interference with 
usual social & 
functional 
activities
Obvious on visual 
inspection AND 
Causing pain with 
greater than 
minimal 
interference with 
usual social & 
functional activities
Disfiguring changes 
AND Symptoms 
requiring intervention 
or causing inability to 
perform usual social 
& functional activities
NA
Hyperthyroidism
No symptoms 
AND Abnormal 
laboratory value
Symptoms 
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
Life-threatening 
consequences (e.g., 
thyroid storm)
Hypothyroidism
No symptoms 
AND Abnormal 
laboratory value
Symptoms 
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
Life-threatening 
consequences (e.g., 
myxedema coma)
Lipoatrophy4
Detectable by 
study participant, 
caregiver, or 
physician AND 
Causing no or 
minimal 
interference with 
usual social & 
functional 
activities
Obvious on visual 
inspection AND 
Causing greater 
than minimal 
interference with 
usual social & 
functional activities
Disfiguring changes
NA
4 Definition: A disorder characterized by fat loss in the face, extremities, and buttocks.

Endocrine and Metabolic
Page 102 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Lipohypertrophy5
Detectable by 
study participant, 
caregiver, or 
physician AND 
Causing no or 
minimal 
interference with 
usual social & 
functional 
activities
Obvious on visual 
inspection AND 
Causing greater 
than minimal 
interference with 
usual social & 
functional activities
Disfiguring changes
NA
5 Definition: A disorder characterized by abnormal fat accumulation on the back of the neck, breasts, and abdomen.

Gastrointestinal
Page 103 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
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
Life-threatening 
consequences OR 
Aggressive intervention 
indicated (e.g., tube 
feeding, total 
parenteral nutrition)
Ascites
No symptoms
Symptoms AND 
Intervention 
indicated (e.g., 
diuretics, 
therapeutic 
paracentesis)
Symptoms recur 
or persist despite 
intervention
Life-threatening 
consequences
Bloating or Distension
Report only one
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
NA
Cholecystitis
NA
Symptoms AND 
Medical 
intervention 
indicated
Radiologic, 
endoscopic, or 
operative 
intervention 
indicated
Life-threatening 
consequences (e.g., 
sepsis, perforation)
Constipation
NA
Persistent 
constipation 
requiring regular 
use of dietary 
modifications, 
laxatives, or 
enemas
Obstipation with 
manual 
evacuation 
indicated
Life-threatening 
consequences (e.g., 
obstruction)
Diarrhea
≥ 1 year of age
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 to 6 
stools over 
baseline per 24-
hour period
Increase of ≥ 7 
stools per 24-hour 
period OR IV fluid 
replacement 
indicated
Life-threatening 
consequences (e.g., 
hypotensive shock)
< 1 year of age
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
Life-threatening 
consequences (e.g., 
liquid stools resulting 
in severe dehydration, 
hypotensive shock)
Dysphagia or 
Odynophagia
Report only one 
and specify 
location
Symptoms but 
able to eat usual 
diet
Symptoms causing 
altered dietary 
intake with no 
intervention 
indicated
Symptoms causing 
severely altered 
dietary intake with 
intervention 
indicated
Life-threatening 
reduction in oral 
intake

Gastrointestinal
Page 104 of 124
Gastrointestinal 
Bleeding
Not requiring 
intervention 
other than iron 
supplement
Endoscopi
c 
interventio
n indicated
Transfusion 
indicated
Life-threatening 
consequences (e.g., 
hypotensive shock)

Gastrointestinal
Page 105 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Mucositis or 
Stomatitis
Report only one 
and specify 
location
Mucosal erythema
Patchy 
pseudomembranes 
or ulcerations
Confluent 
pseudomembranes 
or ulcerations OR 
Mucosal bleeding 
with minor trauma
Life-threatening 
consequences (e.g., 
aspiration, choking) 
OR Tissue necrosis 
OR Diffuse 
spontaneous mucosal 
bleeding
Nausea
Transient (< 24 
hours) or 
intermittent AND 
No or minimal 
interference with 
oral intake
Persistent nausea 
resulting in 
decreased oral 
intake for 24 to 48 
hours
Persistent nausea 
resulting in 
minimal oral 
intake for > 48 
hours OR 
Rehydration 
indicated (e.g., IV 
fluids)
Life-threatening 
consequences (e.g., 
hypotensive shock)
Pancreatitis
NA
Symptoms with 
hospitalization 
not indicated
Symptoms 
with 
hospitalization 
indicated
Life-threatening 
consequences 
(e.g., circulatory 
failure, 
hemorrhage, 
sepsis)
Perforation
(colon or rectum)
NA
NA
Interventio
n indicated
Life-threatening 
consequences
Proctitis
Rectal discomfort 
with 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
Life-threatening 
consequences (e.g., 
perforation)
Rectal Discharge
Visible discharge
Discharge 
requiring the use 
of pads
NA
NA
Vomiting
Transient or 
intermittent AND 
No or minimal 
interference with 
oral intake
Frequent 
episodes with 
no or mild 
dehydration
Persistent vomiting 
resulting in 
orthostatic 
hypotension OR 
Aggressive 
rehydration 
indicated (e.g., IV 
fluids)
Life-threatening 
consequences (e.g., 
hypotensive shock)

Musculoskeletal
Page 106 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Arthralgia
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
Disabling joint pain 
causing inability to 
perform basic self-care 
functions
Arthritis
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
Disabling joint 
stiffness or swelling 
causing inability to 
perform basic self-
care functions
Myalgia (generalized)
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
Disabling muscle pain 
causing inability to 
perform basic self-care 
functions
Osteonecrosis
NA
No symptoms 
but with 
radiographic 
findings AND 
No operative 
intervention 
indicated
Bone pain with 
radiographic findings 
OR Operative 
intervention indicated
Disabling bone pain 
with radiographic 
findings causing 
inability to perform 
basic self-care 
functions
Osteopenia6
≥ 30 years of age
BMD t-score
-2.5 to -1
NA
NA
NA
< 30 years of age
BMD z-score
-2 to -1
NA
NA
NA
Osteoporosis6
≥ 30 years of age
NA
BMD t-score < -2.5 Pathologic fracture 
(e.g., compression 
fracture causing loss 
of vertebral height)
Pathologic fracture 
causing life-
threatening 
consequences
< 30 years of age
NA
BMD z-score < -2
Pathologic fracture 
(e.g., compression 
fracture causing loss 
of vertebral height)
Pathologic fracture 
causing life-
threatening 
consequences
6 BMD t and z scores can be found in: Kanis JA on behalf of the World Health Organization Scientific Group (2007). 
Assessment of osteoporosis at the primary health-care level. Technical Report. World Health Organization 
Collaborating Centre for
Metabolic Bone Diseases, University of Sheffield, UK. 2007: Printed by the University of Sheffield.

Neurologic
Page 107 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Acute CNS Ischemia
NA
NA
Transient ischemic 
attack
Cerebral vascular 
accident (e.g., stroke 
with neurological 
deficit)
Altered Mental Status 
(for Dementia, see 
Cognitive, Behavioral, 
or Attentional 
Disturbance below)
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
Delirium OR 
Obtundation OR 
Coma
Ataxia
Symptoms causing 
no or minimal 
interference with 
usual social & 
functional activities 
OR No symptoms 
with ataxia detected 
on examination
Symptoms causing 
greater than minimal 
interference with 
usual social & 
functional activities
Symptoms causing 
inability to perform 
usual social & 
functional activities
Disabling symptoms 
causing inability to 
perform basic self-care 
functions
Cognitive, 
Behavioral, or 
Attentional 
Disturbance (includes 
dementia and attention 
deficit disorder)
Specify type, if 
applicable
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 indicated
Disability causing 
inability to perform 
usual social & 
functional activities 
OR Specialized 
resources on a full- 
time basis indicated
Disability causing 
inability to perform 
basic self-care 
functions OR 
Institutionalization 
indicated
Developmental Delay
< 18 years of age 
Specify type, if 
applicable
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
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
Symptoms causing 
inability to perform 
basic self-care 
functions OR 
Hospitalization 
indicated OR 
Headache with 
significant impairment 
of alertness or other 
neurologic function

Neurologic
Page 108 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Neuromuscular 
Weakness 
(includes 
myopathy and 
neuropathy)
Specify type, if 
applicable
Minimal muscle 
weakness causing 
no or minimal 
interference with 
usual social & 
functional activities 
OR No symptoms 
with decreased 
strength on 
examination
Muscle weakness 
causing greater than 
minimal interference 
with usual social & 
functional activities
Muscle weakness 
causing inability to 
perform usual social 
& functional 
activities
Disabling muscle 
weakness causing 
inability to perform 
basic self-care 
functions OR 
Respiratory muscle 
weakness impairing 
ventilation
Neurosensory 
Alteration (includes 
paresthesia and 
painful neuropathy)
Specify type, if 
applicable
Minimal paresthesia 
causing no or 
minimal 
interference with 
usual social & 
functional activities 
OR No symptoms 
with sensory 
alteration on 
examination
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
Disabling sensory 
alteration or 
paresthesia causing 
inability to perform 
basic self-care 
functions
Seizures
New Onset Seizure
≥ 18 years of age
NA
NA
1 to 3 seizures
Prolonged and 
repetitive seizures 
(e.g., status 
epilepticus) OR Difficult 
to control (e.g., 
refractory epilepsy)
< 18 years of age 
(includes new or 
pre- existing febrile 
seizures)
Seizure lasting < 5 
minutes with < 24 
hours postictal 
state
Seizure lasting 5 to < 
20 minutes with
< 24 hours postictal 
state
Seizure lasting ≥ 20 
minutes OR > 24 
hours postictal state
Prolonged and 
repetitive seizures 
(e.g., status 
epilepticus) OR Difficult 
to control (e.g., 
refractory epilepsy)
Pre-existing Seizure NA
Increased 
frequency from 
previous level of 
control without 
change in seizure 
character
Change in seizure 
character either in 
duration or quality 
(e.g., severity or 
focality)
Prolonged and 
repetitive seizures 
(e.g., status 
epilepticus) OR Difficult 
to control (e.g., 
refractory epilepsy)
Syncope
Near syncope 
without loss of 
consciousness 
(e.g., pre-syncope)
Loss of 
consciousness 
with no 
intervention 
indicated
Loss of 
consciousness AND 
Hospitalization or 
intervention required
NA

Pregnancy, Puerperium, and Perinatal
Page 109 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Stillbirth (report using 
mother’s participant ID)
Report only one
NA
NA
Fetal death 
occurring at ≥ 20 
weeks gestation
NA
Preterm Birth (report 
using mother’s 
participant ID)
Live birth at 34 to
< 37 weeks 
gestational age
Live birth at 28 to
< 34 weeks 
gestational age
Live birth at 24 to
< 28 weeks 
gestational age
Live birth at < 24 
weeks gestational age
Spontaneous 
Abortion or 
Miscarriage7 (report 
using mother’s 
participant ID)
Report only one
Chemical 
pregnanc
y
Uncomplicated 
spontaneous 
abortion or 
miscarriage
Complicated 
spontaneous 
abortion or 
miscarriage
NA
7 Definition: A pregnancy loss occurring at < 20 weeks gestational age.

Psychiatric
Page 110 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Insomnia
Mild difficulty 
falling asleep, 
staying asleep, or 
waking up early 
causing no or 
minimal 
interference with 
usual social & 
functional 
activities
Moderate difficulty 
falling asleep, 
staying asleep, or 
waking up early 
causing more than 
minimal 
interference with 
usual social & 
functional activities
Severe difficulty 
falling asleep, 
staying asleep, or 
waking up early 
causing inability to 
perform usual 
social & functional 
activities requiring 
intervention or 
hospitalization
NA
Psychiatric 
Disorders (includes 
anxiety, depression, 
mania, and 
psychosis)
Specify disorder
Symptoms with 
intervention not 
indicated OR 
Behavior causing 
no or minimal 
interference with 
usual social & 
functional 
activities
Symptoms with 
intervention 
indicated OR 
Behavior causing 
greater than 
minimal 
interference with 
usual social & 
functional activities
Symptoms with 
hospitalization 
indicated OR 
Behavior causing 
inability to perform 
usual social & 
functional activities
Threatens harm to 
self or others OR 
Acute psychosis OR 
Behavior causing 
inability to perform 
basic self-care 
functions
Suicidal Ideation or 
Attempt
Report only one
Preoccupied 
with thoughts of 
death AND No 
wish 
to 
kill 
oneself
Preoccupied 
with thoughts of 
death AND 
Wish to kill 
oneself with no 
specific plan or 
intent
Thoughts of killing 
oneself with partial 
or complete plans 
but no attempt to 
do so OR 
Hospitalization 
indicated
Suicide attempted

Respiratory
Page 111 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Acute Bronchospasm
Forced expiratory 
volume in 1 
second or peak 
flow reduced to
≥ 70 to < 80% OR
Mild symptoms 
with intervention 
not indicated
Forced expiratory 
volume in 1 
second or peak 
flow 50 to
< 70% OR 
Symptoms with 
intervention 
indicated OR 
Symptoms causing 
greater than 
minimal 
interference with 
usual social & 
functional activities
Forced expiratory 
volume in 1 
second or peak 
flow 25 to
< 50% OR
Symptoms causing 
inability to perform 
usual social & 
functional activities
Forced expiratory 
volume in 1 second 
or peak flow < 25% 
OR Life-threatening 
respiratory or 
hemodynamic 
compromise OR 
Intubation
Dyspnea or 
Respiratory Distress
Report only one
Dyspnea on 
exertion with no 
or minimal 
interference with 
usual social & 
functional 
activities OR 
Wheezing OR 
Minimal increase 
in respiratory rate 
for age
Dyspnea on 
exertion causing 
greater than 
minimal 
interference with 
usual social & 
functional activities 
OR Nasal flaring 
OR Intercostal 
retractions OR 
Pulse oximetry 90 
to < 95%
Dyspnea at rest 
causing inability to 
perform usual 
social & functional 
activities OR 
Pulse oximetry < 
90%
Respiratory failure with 
ventilator support 
indicated (e.g., CPAP, 
BPAP, intubation)

Sensory
Page 112 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Hearing Loss
≥ 12 years of age
NA
Hearing aid or 
intervention 
not indicated
Hearing aid or 
intervention indicated
Profound bilateral 
hearing loss (> 80 dB 
at 2 kHz and above) 
OR Non-serviceable 
hearing (i.e., >50 dB 
audiogram and <50% 
speech discrimination)
< 12 years of age 
(based on a 1, 2, 3, 
4,
6 and 8 
kHz 
audiogram
)
> 20 dB 
hearing loss at 
≤ 4 kHz
> 20 dB hearing 
loss at > 4 kHz
> 20 dB hearing loss 
at ≥ 3 kHz in one ear 
with additional 
speech language 
related services 
indicated (where 
available) OR 
Hearing loss 
sufficient to indicate 
therapeutic 
intervention, 
including hearing 
aids
Audiologic indication 
for cochlear implant 
and additional speech- 
language related 
services indicated 
(where available)
Tinnitus
Symptoms 
causing no or 
minimal 
interference with 
usual social & 
functional 
activities with 
intervention not 
indicated
Symptoms 
causing greater 
than minimal 
interference with 
usual social & 
functional activities 
with intervention 
indicated
Symptoms causing 
inability to perform 
usual social & 
functional activities
NA
Uveitis
No symptoms 
AND Detectable 
on examination
Anterior uveitis 
with symptoms OR 
Medical 
intervention 
indicated
Posterior or pan- 
uveitis OR Operative 
intervention indicated
Disabling visual loss in 
affected eye(s)
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
Disabling vertigo 
causing inability to 
perform basic self-
care functions
Visual Changes
(assessed 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
Disabling visual loss in 
affected eye(s)

Systemic
Page 113 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Acute 
Allergic 
Reaction
Localized urticaria 
(wheals) with no 
medical 
intervention 
indicated
Localized urticaria 
with intervention 
indicated OR Mild 
angioedema with 
no intervention 
indicated
Generalized urticaria 
OR Angioedema with 
intervention indicated 
OR Symptoms of 
mild bronchospasm
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
NA
Cytokine 
Release 
Syndrome8
Mild signs and 
symptoms AND 
Therapy (i.e., 
antibody 
infusion) 
interruption not 
indicated
Therapy (i.e., 
antibody infusion) 
interruption 
indicated AND 
Responds 
promptly to 
symptomatic 
treatment OR 
Prophylactic 
medications 
indicated for ≤ 24 
hours
Prolonged severe 
signs and 
symptoms OR 
Recurrence of 
symptoms following 
initial improvement
Life-threatening 
consequences 
(e.g., requiring 
pressor or 
ventilator support)
Fatigue or Malaise
Report only one
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
Incapacitating 
symptoms of fatigue or 
malaise causing inability 
to perform basic self-
care functions
Fever (non-axillary 
temperatures only)
38.0 to < 38.6°C 
or 100.4 to < 
101.5°F
≥ 38.6 to < 39.3°C
or ≥ 101.5 to
< 102.7°F
≥ 39.3 to < 40.0°C or
≥ 102.7 to < 104.0°F
≥ 40.0°C or ≥ 104.0°F
Pain9 (not associated 
with study agent 
injections and not 
specified elsewhere)
Specify location
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
Disabling pain causing 
inability to perform basic 
self-care functions OR 
Hospitalization indicated
8 Definition: A disorder characterized by nausea, headache, tachycardia, hypotension, rash, and/or shortness of breath.
9 For pain associated with injections or infusions, see the Site Reactions to Injections and Infusions section (page 23).

Systemic
Page 114 of 124
Serum Sickness10
Mild signs 
and 
symptoms
Moderate signs 
and symptoms 
AND Intervention 
indicated (e.g., 
antihistamines)
Severe signs and 
symptoms AND 
Higher level 
intervention indicated 
(e.g., steroids or IV 
fluids)
Life-threatening 
consequences 
(e.g., requiring 
pressor or 
ventilator support)
Underweight11
> 5 to 19 years 
of age
WHO BMI z-score
< -1 to -2
WHO BMI z-score
< -2 to -3
WHO BMI z-score
< -3
WHO BMI z-score
< -3 with life-threatening 
consequences
2 to 5 years of age WHO Weight-for- 
height z-score
< -1 to -2
WHO Weight-for- 
height z-score
< -2 to -3
WHO Weight-for- 
height z-score < -3
WHO Weight-for-height 
z-score < -3 with life- 
threatening 
consequences
< 2 years of age
WHO Weight-for- 
length z-score
< -1 to -2
WHO Weight-for- 
length z-score
< -2 to -3
WHO Weight-for- 
length z-score < -3
WHO Weight-for-length 
z-score < -3 with life- 
threatening 
consequences
Unintentional 
Weight Loss 
(excludes 
postpartum weight 
loss)
NA
5 to < 9% loss in 
body weight from 
baseline
≥ 9 to < 20% loss in 
body weight from 
baseline
 20% loss in body 
weight from baseline OR 
Aggressive intervention 
indicated (e.g., tube 
feeding, total parenteral 
nutrition)
10 Definition: A disorder characterized by fever, arthralgia, myalgia, skin eruptions, lymphadenopathy, marked 
discomfort, and/or dyspnea.
11 WHO reference tables may be accessed by clicking the desired age range or by accessing the following URLs: 
http://www.who.int/growthref/who2007_bmi_for_age/en/ for participants > 5 to 19 years of age and 
http://www.who.int/childgrowth/standards/chart_catalogue/en/ for those ≤ 5 years of age.

Urinary
Page 115 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Urinary Tract 
Obstruction
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
Obstruction 
causing life-
threatening 
consequences

Page 116 of 124
Site Reactions to Injections and Infusions
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Injection Site Pain or 
Tenderness
Report only one
Pain or 
tenderness 
causing no or 
minimal limitation 
of use of limb
Pain or tenderness 
causing greater than 
minimal limitation of 
use of limb
Pain or tenderness 
causing inability to 
perform usual social 
& functional 
activities
Pain or tenderness 
causing inability to 
perform basic self-
care function OR 
Hospitalization 
indicated
Injection Site 
Erythema or Redness 
12
Report only one
> 15 years of age
2.5 to < 5 cm in 
diameter OR 6.25 to
< 25 cm2 surface 
area AND 
Symptoms causing 
no or minimal 
interference with 
usual social & 
functional activities
≥ 5 to < 10 cm in 
diameter OR ≥ 25 to
< 100 cm2 surface 
area OR 
Symptoms 
causing greater 
than minimal 
interference with 
usual social & 
functional activities
≥ 10 cm in diameter 
OR ≥ 100 cm2 
surface area OR 
Ulceration OR 
Secondary infection 
OR Phlebitis OR 
Sterile abscess OR 
Drainage OR 
Symptoms causing 
inability to perform 
usual social & 
functional activities
Potentially life- 
threatening 
consequences 
(e.g., abscess, 
exfoliative 
dermatitis, 
necrosis involving 
dermis or deeper 
tissue)
≤ 15 years of age
 2.5 cm in 
diameter
> 2.5 cm in 
diameter with < 
50% surface area 
of the extremity 
segment involved 
(e.g., upper arm or 
thigh)
 50% surface area 
of the extremity 
segment involved 
(e.g., upper arm or 
thigh) OR Ulceration 
OR Secondary 
infection OR 
Phlebitis OR Sterile 
abscess OR 
Drainage
Potentially life- 
threatening 
consequences 
(e.g., abscess, 
exfoliative 
dermatitis, 
necrosis involving 
dermis or deeper 
tissue)
Injection Site 
Induration or 
Swelling
Report only one
> 15 years of age
Same as for 
Injection Site 
Erythema or 
Redness, > 15 
years of age
Same as for 
Injection Site 
Erythema or 
Redness, > 15 
years of age
Same as for 
Injection Site 
Erythema or 
Redness, > 15 
years of age
Same as for 
Injection Site 
Erythema or 
Redness, > 15 years 
of age
 15 years of age
Same as for 
Injection Site 
Erythema or 
Redness, ≤ 15 
years of age
Same as for 
Injection Site 
Erythema or 
Redness, ≤ 15 
years of age
Same as for 
Injection Site 
Erythema or 
Redness, ≤ 15 
years of age
Same as for 
Injection Site 
Erythema or 
Redness, ≤ 15 
years of age
Injection Site Pruritus
Itching localized 
to the injection 
site that is 
relieved 
spontaneously or 
in < 48 hours of 
treatment
Itching beyond the 
injection site that 
is not generalized 
OR Itching 
localized to the 
injection site 
requiring ≥ 48 
hours treatment
Generalized itching 
causing inability to 
perform usual social 
& functional 
activities
NA
12 Injection Site Erythema or Redness should be evaluated and graded using the greatest single diameter or measured 
surface area.

Laboratory Values*
Page 117 of 124
Chemistries
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Acidosis
NA
pH  7.3 to < LLN
pH < 7.3 without life- 
threatening 
consequences
pH < 7.3 with life- 
threatening 
consequences
Albumin, 
Low
(g/dL; g/L)
3.0 to < LLN
30  to < LLN
≥ 2.0 to < 3.0
≥ 20  to < 30
< 2.0
< 20
NA
Alkaline 
Phosphatase, High
1.25 to < 2.5 
x ULN
2.5 to < 5.0 x ULN
5.0 to < 10.0 x ULN
≥ 10.0 x ULN
Alkalosis
NA
pH > ULN to  7.5
pH > 7.5 without life- 
threatening 
consequences
pH > 7.5 with life- 
threatening 
consequences
ALT or SGPT, High
Report only one
1.25 to < 2.5 
x ULN
2.5 to < 5.0 x ULN
5.0 to < 10.0 x ULN
≥ 10.0 x ULN
Amylase (Pancreatic) 
or Amylase (Total), 
High
Report only one
1.1 to < 1.5 x ULN
1.5 to < 3.0 x ULN
3.0 to < 5.0 x ULN
≥ 5.0 x ULN
AST or SGOT, High
Report only one
1.25 to < 2.5 
x ULN
2.5 to < 5.0 x ULN
5.0 to < 10.0 x ULN
≥ 10.0 x ULN
Bicarbonate, Low
(mEq/L; mmol/L)
16.0 to < LLN
16.0 to < LLN
11.0  to < 16.0
11.0  to < 16.0
8.0  to < 11.0
8.0  to < 11.0
< 8.0
< 8.0
Bilirubin
Direct 
Bilirubin13, High
> 28 days of age
NA
NA
> ULN with other 
signs and 
symptoms of 
hepatotoxicity.
> ULN with life- 
threatening 
consequences (e.g., 
signs and symptoms 
of liver failure)
≤ 28 days of age
ULN to ≤ 1 mg/dL
> 1 to ≤ 1.5 mg/dL
> 1.5 to ≤ 2 mg/dL
> 2 mg/dL
Total Bilirubin, 
High
> 28 days of age
1.1 to < 1.6 x ULN
1.6 to < 2.6 x ULN
2.6 to < 5.0 x ULN
≥ 5.0 x ULN
≤ 28 days of age
See Appendix A. 
Total Bilirubin for 
Term and Preterm 
Neonates
See Appendix A. 
Total Bilirubin for 
Term and Preterm 
Neonates
See Appendix A. 
Total Bilirubin for 
Term and Preterm 
Neonates
See 
Appendix 
A. 
Total 
Bilirubin 
for 
Term and Preterm 
Neonates
*Reminder: An asymptomatic abnormal laboratory finding without an accompanying AE should not be reported to 
DAIDS in an expedited time frame unless it meets protocol-specific reporting requirements.
13 Direct bilirubin > 1.5 mg/dL in a participant < 28 days of age should be graded as grade 2, if < 10% of the total 
bilirubin.

Chemistries
Page 118 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Calcium, High
(mg/dL; mmol/L)
≥ 7 days of age
10.6 to < 11.5
2.65 to < 2.88
11.5  to < 12.5
2.88  to < 3.13
12.5 to < 13.5
3.13 to < 3.38
≥ 13.5
≥  3.38
< 7 days of age
11.5  to < 12.4
2.88  to < 3.10
12.4  to < 12.9
3.10  to < 3.23
12.9  to < 13.5
3.23  to < 3.38
≥ 13.5
≥  3.38
Calcium (Ionized), 
High
(mg/dL; mmol/L)
> ULN to < 6.0
> ULN to < 1.5
6.0 to < 6.4
1.5 to < 1.6
6.4 to < 7.2
1.6 to < 1.8
≥ 7.2
≥ 1.8
Calcium, Low
(mg/dL; mmol/L)
≥ 7 days of age
7.8 to < 8.4
1.95 to < 2.10
7.0 to < 7.8
1.75 to < 1.95
6.1 to < 7.0
1.53 to < 1.75
< 6.1
< 1.53
< 7 days of age
6.5 to < 7.5
1.63 to < 1.88
6.0 to < 6.5
1.50 to < 1.63
5.50 to < 6.0
1.38 to < 1.50
< 5.50
< 1.38
Calcium (Ionized), Low
(mg/dL; mmol/L)
< LLN  to 4.0
< LLN  to 1.0
3.6 to < 4.0
0.9 to < 1.0
3.2 to < 3.6
0.8 to < 0.9
< 3.2
< 0.8
Cardiac Troponin I, 
High
NA
NA
NA
Levels consistent 
with myocardial 
infarction or unstable 
angina as defined by 
the local laboratory
Creatine Kinase, High 3 to < 6 x ULN
6 to < 10x ULN
10 to < 20 x ULN
≥ 20 x ULN
Creatinine, High
*Report only one
1.1 to 1.3 x ULN
> 1.3 to 1.8 x ULN
OR Increase to 1.3 to
< 1.5 x participant’s 
baseline
> 1.8 to < 3.5
x ULN OR Increase 
to 1.5 to < 2.0 x 
participant’s 
baseline
≥ 3.5 x ULN OR
Increase of ≥ 2.0 x 
participant’s 
baseline
Creatinine Clearance 
14
or eGFR, Low
*Report only one
NA
< 90 to 60 ml/min or 
ml/min/1.73 m2
OR
10 to < 30% 
decrease from 
participant’s baseline
< 60 to 30 ml/min or 
ml/min/1.73 m2
OR
30 to < 50%
decrease from 
participant’s 
baseline
< 30 ml/min or 
ml/min/1.73 
m2 OR
≥ 50% decrease from 
participant’s baseline 
or dialysis needed
Glucose
(mg/dL; mmol/L)
Fasting, High
110 to 125
6.11 to < 6.95
> 125 to 250
6.95 to < 13.89
> 250 to 500
13.89 to < 27.75
≥ 500
≥ 27.75
Nonfasting, High
116 to 160
6.44 to < 8.89
> 160 to 250
8.89 to < 13.89
> 250 to 500
13.89 to < 27.75
≥ 500
≥ 27.75
14 Use the applicable formula (i.e., Cockcroft-Gault in mL/min or Schwartz, MDRD, CKD-Epi in mL/min/1.73m2). Sites 
should choose the method defined in their study and when not specified, use the method most relevant to the study 
population.    
*Reminder: Choose the method that selects for the higher grade.

Chemistries
Page 119 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Glucose, Low
(mg/dL; mmol/L)
≥ 1 month of age
55 to 64
3.05 to <3.55
40 to < 55
2.22 to < 3.05
30 to < 40
1.67 to < 2.22
< 30
< 1.67
< 1 month of age
50 to 54
2.78 to < 3.00
40 to < 50
2.22 to < 2.78
30 to < 40
1.67 to < 2.22
< 30
< 1.67
Lactate, High
ULN to < 2.0
x ULN without 
acidosis
 2.0 x ULN without 
acidosis
Increased lactate with 
pH < 7.3 without life- 
threatening 
consequences
Increased lactate 
with pH < 7.3 with 
life- threatening 
consequences
Lipase, High
1.1 to < 1.5 x ULN
1.5 to < 3.0 x ULN
3.0 to < 5.0 x ULN
≥ 5.0 x ULN
Lipid Disorders
(mg/dL; mmol/L)
Cholesterol, 
Fasting, High
≥ 18 years of age
200 to < 240
5.18 to < 6.19
240 to < 300
6.19 to < 7.77
≥ 300
≥ 7.77
NA
< 18 years of age
170 to < 200
4.40 to < 5.15
200 to < 300
5.15 to < 7.77
≥ 300
≥ 7.77
NA
LDL, Fasting, High
≥ 18 years of age
130 to < 160
3.37 to < 4.12
160 to < 190
4.12 to < 4.90
 190
 4.90
NA
> 2 to < 18 years 
of age
110 to < 130
2.85 to < 3.34
130 to < 190
3.34 to < 4.90
≥ 190
≥ 4.90
NA
Triglycerides, 
Fasting, High
150 to 300
1.71 to 3.42
>300  to 500
>3.42 to 5.7
>500 to < 1,000
>5.7 to 11.4
> 1,000
> 11.4
Magnesium15, 
Low
(mEq/L; mmol/L)
1.2 to < 1.4
0.60 to < 0.70
0.9 to < 1.2
0.45 to < 0.60
0.6 to < 0.9
0.30 to < 0.45
< 0.6
< 0.30
Phosphate, Low
(mg/dL; mmol/L)
> 14 years of age
2.0 to < LLN
0.65 to < LLN
1.4 to < 2.0
0.45 to < 0.65
1.0 to < 1.4
0.32 to < 0.45
< 1.0
< 0.32
1 to 14 years of age
3.0 to < 3.5
0.97 to < 1.13
2.5 to < 3.0
0.81 to < 0.97
1.5 to < 2.5
0.48 to < 0.81
< 1.5
< 0.48
< 1 year of age
3.5 to < 4.5
1.13 to < 1.45
2.5 to < 3.5
0.81 to < 1.13
1.5 to < 2.5
0.48 to < 0.81
< 1.5
< 0.48
Potassium, High
(mEq/L; mmol/L)
5.6  to < 6.0
5.6  to < 6.0
6.0  to < 6.5
6.0  to < 6.5
6.5  to < 7.0
6.5  to < 7.0
≥ 7.0
≥ 7.0
Potassium, Low
(mEq/L; mmol/L)
3.0  to < 3.4
3.0  to < 3.4
2.5  to < 3.0
2.5  to < 3.0
2.0  to < 2.5
2.0  to < 2.5
< 2.0
< 2.0
15 To convert a magnesium value from mg/dL to mmol/L, laboratories should multiply by 0.4114.

Chemistries
Page 120 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Sodium, High
(mEq/L; mmol/L)
146  to < 150
146  to < 150
150  to < 154
150  to < 154
154  to < 160
154  to < 160
 160
 160
Sodium, Low
(mEq/L; mmol/L)
130  to < 135
130  to < 135
125  to < 130
125  to < 130
121  to < 125
121  to < 125
 120
 120
Uric Acid, High
(mg/dL; mmol/L)
7.5 to < 10.0
0.45 to < 0.59
10.0  to < 12.0
0.59  to < 0.71
12.0  to < 15.0
0.71  to < 0.89
≥ 15.0
≥ 0.89

Hematology
Page 121 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Absolute CD4+ Count,
Low
(cell/mm3; cells/L)
> 5 years of 
age (not HIV 
infected)
300 to < 400
300 to < 400
200 to < 300
200 to < 300
100 to < 200
100 to < 200
< 100
< 100
Absolute Lymphocyte 
Count, Low
(cell/mm3; cells/L)
> 5 years of age 
(not HIV infected)
600 to < 650
0.600 x 109 to
< 0.650 x 109
500 to < 600
0.500 x 109 to
< 0.600 x 109
350 to < 500
0.350 x 109 to
< 0.500 x 109
< 350
< 0.350 x 109
Absolute Neutrophil 
Count (ANC), Low
(cells/mm3; cells/L)
> 7 days of age
800 to 1,000
0.800 x 109 to 
1.000
x 109
600 to 799
0.600 x 109 to 0.799
x 109
400 to 599
0.400 x 109 to 0.599
x 109
< 400
< 0.400 x 109
2 to 7 days of age
1,250 to 1,500
1.250 x 109 to 
1.500
x 109
1,000 to 1,249
1.000 x 109 to 1.249
x 109
750 to 999
0.750 x 109 to 0.999
x 109
< 750
< 0.750 x 109
≤ 1 day of age
4,000 to 5,000
4.000 x 109 to
5.000 x 109
3,000 to 3,999
3.000 x 109 to 3.999
x 109
1,500 to 2,999
1.500 x 109 to 2.999
x 109
< 1,500
< 1.500 x 109
Fibrinogen, Decreased
(mg/dL; g/L)
100 to < 200
1.00 to < 2.00
OR
0.75 to < 
1.00 x LLN
75 to < 100
0.75 to < 1.00
OR
≥ 0.50 to < 
0.75 x LLN
50 to < 75
0.50 to < 0.75
OR
0.25 to < 
0.50 x LLN
< 50
< 0.50
OR
< 0.25 x LLN
OR Associated with 
gross bleeding
Hemoglobin16, Low
(g/dL; mmol/L) 17
≥ 13 years of 
age (male only)
10.0 to 10.9
6.19 to 6.76
9.0 to < 10.0
5.57 to < 6.19
7.0 to < 9.0
4.34 to < 5.57
< 7.0
< 4.34
≥ 13 years of 
age (female 
only)
9.5 to 10.4
5.88 to 6.48
8.5 to < 9.5
5.25 to < 5.88
6.5 to < 8.5
4.03 to < 5.25
< 6.5
< 4.03
16 Male and female sex are defined as sex at birth. For transgender participants ≥13 years of age who have been on 
hormone therapy for more than 6 consecutive months, grade hemoglobin based on the gender with which they 
identify (i.e., a transgender female should be graded using the female sex at birth hemoglobin laboratory values).
17 The most commonly used conversion factor to convert g/dL to mmol/L is 0.6206. For grading hemoglobin results 
obtained by an analytic method with a conversion factor other than 0.6206, the result must be converted to g/dL using 
appropriate conversion factor for the particular laboratory.

Hematology
Page 122 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
57 days of age to < 
13 years of age
(male and female)
9.5 to 10.4
5.88 to 6.48
8.5 to < 9.5
5.25 to < 5.88
6.5 to < 8.5
4.03 to < 5.25
< 6.5
< 4.03
36 to 56 days of 
age (male and 
female)
8.5 to 9.6
5.26 to 5.99
7.0 to < 8.5
4.32 to < 5.26
6.0 to < 7.0
3.72 to < 4.32
< 6.0
< 3.72
22 to 35 days of 
age (male and 
female)
9.5 to 11.0
5.88 to 6.86
8.0 to < 9.5
4.94 to < 5.88
6.7 to < 8.0
4.15 to < 4.94
< 6.7
< 4.15
8 to ≤ 21 days of 
age (male and 
female)
11.0 to 13.0
6.81 to 8.10
9.0 to < 11.0
5.57 to < 6.81
8.0 to < 9.0
4.96 to < 5.57
< 8.0
< 4.96
≤ 7 days of age 
(male and female)
13.0 to 14.0
8.05 to 8.72
10.0 to < 13.0
6.19 to < 8.05
9.0 to < 10.0
5.59 to < 6.19
< 9.0
< 5.59
INR, High
(not on 
anticoagulation 
therapy)
1.1 to < 1.5 x ULN
1.5 to < 2.0 x ULN
2.0 to < 3.0 x ULN
≥ 3.0 x ULN
Methemoglobin
(% hemoglobin)
5.0 to < 10.0%
10.0 to < 15.0%
15.0 to < 20.0%
≥ 20.0%
PTT, High
(not on 
anticoagulation 
therapy)
1.1 to < 
1.66 x ULN
1.66 to < 
2.33 x ULN
2.33 to < 
3.00 x ULN
≥ 3.00 x ULN
Platelets, Decreased
(cells/mm3; cells/L)
100,000 to
< 125,000
100.000 x 109 to
< 125.000 x 109
50,000 to
< 100,000
50.000 x 109  to
< 100.000 x 109
25,000 to
< 50,000
25.000 x 109 to
< 50.000 x 109
< 25,000
< 25.000 x 109
PT, High
(not on 
anticoagulation 
therapy
1.1 to < 
1.25 x ULN
1.25 to < 
1.50 x ULN
1.50 to < 
3.00 x ULN
≥ 3.00 x ULN
WBC, 
Decreased
(cells/mm3; 
cells/L)
> 7 days of age
2,000 to 2,499
2.000 x 109 to 
2.499
x 109
1,500 to 1,999
1.500 x 109 to 1.999
x 109
1,000 to 1,499
1.000 x 109 to 1.499
x 109
< 1,000
< 1.000 x 109
≤ 7 days of age
5,500 to 6,999
5.500 x 109 to 
6.999
x 109
4,000 to 5,499
4.000 x 109 to 5.499
x 109
2,500 to 3,999
2.500 x 109 to 3.999
x 109
< 2,500
< 2.500 x 109

Urinalysis
Page 123 of 124
PARAMETER
GRADE 1 
MILD
GRADE 2 
MODERATE
GRADE 3 
SEVERE
GRADE 4 
POTENTIALLY 
LIFE- 
THREATENING
Glycosuria 
(random collection 
tested by dipstick)
Trace to 1+ or
≤ 250 mg
2+ or ˃ 250 to
≤ 500 mg
> 2+ or > 500 mg
NA
Hematuria (not to 
be reported based 
on dipstick findings 
or on blood believed 
to be of menstrual 
origin)
6 to < 10 RBCs per 
high power field
≥ 10 RBCs per high 
power field
Gross, with or 
without clots OR 
With RBC casts OR 
Intervention 
indicated
Life-threatening 
consequences
Proteinuria 
(random collection 
tested by dipstick)
1+
2+
3+ or higher
NA

Page 124 of 124
Appendix D
Coordination between FRESH and LACTIN-V studies