Clinical trial NCT02531295
Conditions: HIV Human Immunodeficiency Virus
Sponsor: University of California, San Francisco
Start date: 2019-05-15; Completion date: 2020-03-19
Enrollment: 5 participants; Allocation: NON_RANDOMIZED; Intervention model: SINGLE_GROUP

Brief summary:
The purpose of this study is to determine the safety and bioactivity of an herbal supplement called "kansui," which contains several active ingredients such as ingenols that may have a role in helping clear HIV from the body. Kansui has been used in traditional Chinese medicine for centuries to treat various ailments such as for eliminating excess fluid in the abdomen or lungs, loosening phlegm from the chest, and relieving constipation. Based on preliminary in vitro data from our group, kansui extract powder is a potent activator of HIV transpcription in latently infected Jurkat cells. The investigators' hypothesis is that kansui extract powder prepared as tea will be safe and well-tolerated, elicit an in vivo immunologic response, and at the doses administered, increase HIV transcription in latently-infected cells among HIV-infected patients on suppressive antiretroviral therapy.

Detailed description:
Millions HIV-infected individuals are now receiving life-saving antiretroviral therapy (ART). However, mortality remains high, particularly in resource-limited countries. Chronic HIV-infected individuals demonstrate evidence of persistent immune activation despite ART, which is an independent predictor of mortality in this setting. Given the current absence of an effective HIV vaccine, finding a cure for HIV will have a large impact on the long-term health of treated HIV-infected individuals. The key challenge of HIV eradication strategies is the persistence of a small pool of resting memory CD4+ T cells that harbor latent replication-competent HIV, untouched by current ART. One potential strategy to eliminate this reservoir in a "shock and kill" approach in which latency reactivating agents (LRAs) are used to "shock" the virus out of these cells in order for the host immune response, ART, and/or additional immunomodulatory agents to then kill the virus-expressing cells. The goal of the current study is to evaluate the safety and in vivo biological response to an herbal supplement used in traditional Chinese medicine ("kansui)" that has potent in vitro latency reactivating capabilities. Kansui is an inexpensive, readily available herbal supplement prescribed for thousands of years in traditional Chinese medicine and contains active compounds such as ingenols that have been shown to reverse latency in an animal model. A semi-synthetic form of ingenol has been shown to potently reactivate latent simian immunodeficiency virus (SIV) in rhesus macaques and is currently undergoing early drug development. Though kansui has been studied extensively in traditional Chinese medicine, this herbal supplement has never been evaluated for biologic activity in HIV disease using Western scientific research methods. This pilot clinical trial will generate preliminary results regarding the safety and in vivo biologic activity of kansui. Promising results from this study may allow future larger studies which can evaluate the efficacy of this non-pharmacologic agent in the treatment of HIV disease.

Arms: arm 1: Study participants will be given 1 g of Euphorbia kansui extract powder prepared as tea for a total of 1 daily dose. arm 2: Study participants will be given 1 g of Euphorbia kansui extract powder prepared as tea for a total of 2 consecutive daily doses. arm 3: Study participants will be given 1 g of Euphorbia kansui extract powder prepared as tea for a total of 3 consecutive daily doses.
Interventions: intervention 1: Euphorbia kansui extract powder prepared as tea
Intervention descriptions: intervention 1: 1 g of Euphorbia kansui extract powder, measured and reconstituted in 4 fluid ounces of boiled water allowed to cool and administered as tea, taken by mouth daily

Protocol documents:
Prot_SAP_000.pdf: 
 
 
 
 
 
 
 
Immunologic Response to Euphorbia Kansui Extract Powder Prepared as Tea 
in HIV-Infected Antiretroviral Therapy (ART)-Suppressed Individuals 
 
NCT02531295 
 
Date: October 8, 2018 


Protocol: KANSUI 
 
 
 
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Clinical Research Protocol 
IMMUNOLOGIC RESPONSE TO EUPHORBIA KANSUI EXTRACT POWDER 
PREPARED AS TEA IN HIV-INFECTED ANTIRETROVIRAL THERAPY (ART)-
SUPPRESSED INDIVIDUALS: A DOSE ESCALATION STUDY 
 
Protocol Number: 
Kansui.04 
Version Date: 
October 8, 2018 
Investigational Product: 
Euphorbia kansui extract powder prepared as tea  
IND Number: 
127153 
Development Phase: 
Phase 1 
Sponsor: 
Sulggi Lee, MD PhD 
Assistant Professor, Department of Medicine, Division of 
HIV/AIDS  
University of California, San Francisco 
995 Potrero Avenue, Building 80, Box 0874 
San Francisco, CA 94110 
Funding Organization: 
1. amfAR HIV Cure Institute 
2. Salary support from K23 grant (K23GM112526) 
3. Departmental Funds   
Principal Investigator: 
UCSF (Coordinating Center): 
Name: Sulggi Lee, MD PhD  
Telephone: (415) 735-5127  
Fax: (415) 476-6953  
 
E-mail: sulggi.lee@ucsf.edu  
Participating Site(s) and 
Local PI(s): 
University of Utah: 
Name: Adam M. Spivak, MD 
Telephone: (801) 587-1964 
Fax: (801) 585-3377 
E-mail: adam.spivak@hsc.utah.edu 
Medical Monitor: 
Name: Adam M. Spivak, MD 
Office Phone: (801) 587-1964  
 
Mobile Phone: (443) 854-1582 
Fax: (801) 585-3377 
E-mail: adam.spivak@hsc.utah.edu 
Participating Sites: 
Coordinating Center – UCSF 
Participating Site – University of Utah 
 


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Approval: 
 
 
 
 
 
Sulggi Lee, M.D., Ph.D. 
Assistant Professor of Medicine, UCSF  
 
Date 
This confidential information about an investigational product is provided for the exclusive use of 
investigators of this product and is subject to recall at any time.  The information in this document 
may not be disclosed unless federal or state law or regulations require such disclosure.  Subject to the 
foregoing, this information may be disclosed only to those persons involved in the study who have a 
need to know, with the obligation not to further disseminate this information. 
 
Immunologic response to Euphorbia kansui extract powder prepared as 
tea in HIV-infected antiretroviral therapy (ART)-suppressed 
individuals: a dose escalation study  
 
Principal Investigator 
UCSF: 
Sulggi Lee, MD PhD 
Assistant Professor of Medicine, Division of HIV/AIDS 
University of California 
San Francisco, CA 
Participating Site(s) 
and Local PI(s): 
 
 
University of Utah: 
Adam M. Spivak, MD 
Assistant Professor of Medicine, Divisions of Infectious 
Diseases 
University of Utah 
Salt Lake City, UT 
 


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PROTOCOL AGREEMENT 
 
I have read the protocol specified below. In my formal capacity as Investigator, my duties 
include ensuring the safety of the study participants enrolled under my supervision and 
providing complete and timely information, as outlined in the protocol.  It is understood 
that all information pertaining to the study will be held strictly confidential and that this 
confidentiality requirement applies to all study staff at this site. Furthermore, on behalf of 
the study staff and myself, I agree to maintain the procedures required to carry out the 
study in accordance with accepted GCP principles and to abide by the terms of this 
protocol. 
 
Protocol Number:  Kansui.04 
Protocol Title:  Immunologic response to Euphorbia kansui extract powder prepared as 
tea in HIV-infected antiretroviral therapy (ART)-suppressed individuals: a dose 
escalation study 
Protocol Date:  10/08/2018 
 
 
 
 
Principal Investigator Signature  
 
Date 
Sulggi Lee, M.D., Ph.D. 
Assistant Professor of Medicine, Division of HIV/AIDS 
University of California, San Francisco 
995 Potrero Avenue, Building 80, Box 0874 
San Francisco, CA 94110 
Print Name and Title 
 
Local Site Principal Investigator Signature 
 
Date 
Adam Spivak, M.D. 
Assistant Professor of Medicine, Division of Infectious 
Diseases  
University of Utah School of Medicine 
30 N 1900 E 
Infectious Diseases, 4B319 
Salt Lake City, UT 84132 
 
 
Print Name and Title 
 
 
 


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TABLE OF CONTENTS 
 
1
BACKGROUND 
13
1.1
Overview of Non-Clinical Studies ..................................................................................... 14
1.2
Overview of Clinical Studies .............................................................................................. 16
2
STUDY RATIONALE 
17
2.1
Risk / Benefit Assessment .................................................................................................. 18
3
STUDY OBJECTIVES 
19
3.1
Primary Objective ............................................................................................................... 19
3.2
Secondary Objectives ......................................................................................................... 19
4
STUDY DESIGN 
20
4.1
Study Overview .................................................................................................................. 20
5
CRITERIA FOR EVALUATION 
21
5.1
Primary Efficacy Endpoint ................................................................................................. 21
5.2
Safety Evaluations .............................................................................................................. 21
5.3
Other Evaluations (include only if applicable) ................................................................... 21
6
PARTICIPANT SELECTION 
21
6.1
Study Population ................................................................................................................ 21
6.2
Inclusion Criteria ................................................................................................................ 22
6.3
Exclusion Criteria ............................................................................................................... 22
7
CONCURRENT MEDICATIONS 
23
7.1
Allowed Medications and Treatments ................................................................................ 23
8
STUDY TREATMENTS 
24
8.1
Method of Assigning Participants to Treatment Groups .................................................... 24
8.2
Blinding .............................................................................................................................. 24
8.3
Formulation of Test and Control Products ......................................................................... 25
8.4
Supply of Study Drug at the Site ........................................................................................ 26
8.5 
Storage of Study Drug at the Site ....................................................................................... 27 
8.6
Study Drug Accountability ................................................................................................. 28
8.7
Measures of Treatment Compliance ................................................................................... 28
9
STUDY PROCEDURES AND GUIDELINES 
29
9.1 
Evaluations by Visit............................................................................................................ 32
9.2
Clinical Assessments .......................................................................................................... 35
9.3
Clinical Laboratory Measurements..................................................................................... 36
9.4
Pharmacokinetic Measurements ......................................................................................... 36
9.5
Research Laboratory Measurements................................................................................... 36 
9.6
Optional Tissue Banking .................................................................................................... 37
10 ADVERSE EXPERIENCE REPORTING AND DOCUMENTATION 
38
10.1 Adverse Events .................................................................................................................. 38
10.2 Serious Adverse Experiences (SAE) .................................................................................. 39
10.3 Monitoring ......................................................................................................................... 40


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10.4 Criteria for Discontinuation ............................................................................................... 41
11 DISCONTINUATION AND REPLACEMENT OF PARTICIPANTS 
42
11.1 Early Discontinuation of Study Drug ................................................................................. 42
11.2 Withdrawal of Participants from the Study ........................................................................ 43
11.3 Replacement of Participants ............................................................................................... 43
12 PROTOCOL VIOLATIONS 
43
13 DATA SAFETY MONITORING 
44
14 STATISTICAL METHODS AND CONSIDERATIONS 
45
14.1 Data Sets Analyzed ............................................................................................................ 45
14.2 Demographic and Baseline Characteristics ........................................................................ 45
14.3 Analysis of Primary Endpoint ............................................................................................ 45
14.4 Analysis of Secondary Endpoints ...................................................................................... 45
14.5 Sample Size ........................................................................................................................ 46
15 DATA COLLECTION, RETENTION AND MONITORING 
46
15.1 Data Collection Instruments ............................................................................................... 46
15.2 Data Management Procedures ............................................................................................ 46
15.3 Data Quality Control and Reporting .................................................................................. 47
15.4 Archival of Data ................................................................................................................. 47
15.5 Availability and Retention of Investigational Records ...................................................... 48
15.6 Participant Confidentiality ................................................................................................. 48
16 ADMINISTRATIVE, ETHICAL, REGULATORY CONSIDERATIONS 
49
16.1 Protocol Amendments ........................................................................................................ 49
16.2 Institutional Review Boards and Independent Ethics Committees .................................... 49
16.3 Informed Consent Form ..................................................................................................... 50
16.4 Publications ........................................................................................................................ 50
16.5 Investigator Responsibilities .............................................................................................. 50
17  REFERENCES                                                                                                                            52    


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LIST OF ABBREVIATIONS 
 
AE 
Adverse event 
AIDS 
Acquired Immunodeficiency Syndrome 
ART 
Antiretroviral therapy 
CA-US RNA 
Cell-associated unspliced HIV-1 RNA 
CBC 
Complete blood count 
CD38 
Cluster of differentiation 38 
CD69 
Cluster of differentiation 69 
CFR 
Code of Federal Regulations 
CHEM-7 
Basic metabolic panel (chemistry-7) 
CRF 
Case report form 
DMC 
Data Monitoring Committee 
FDA 
Food and Drug Administration 
GCRC 
General Clinical Research Center 
GMP 
Good Manufacturing Practice 
HIPAA 
Health Insurance Portability and Accountability Act of 1996 
HIV 
Human Immunodeficiency Virus 
HLA-DR 
Human Leukocyte Antigen-DR 
HPLC 
High performance liquid chromatography 
ICF 
Informed consent form 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
LFT 
Liver function test 
MS 
Mass spectrometry 
PBMC 
Peripheral blood mononuclear cells 
PI 
Principal Investigator 
PID 
Participant identification 
PD 
Pharmacodynamics 
PK 
Pharmacokinetics 
SAE 
Serious adverse experience 
SFGH 
San Francisco General Hospital 
SMC 
Safety Monitoring Committee 
SOP 
Standard Operating Procedures 
TCM 
Traditional Chinese medicine 
TSH 
Thyroid stimulating hormone 
UCSF 
University of California, San Francisco 


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PROTOCOL SYNOPSIS 
TITLE 
Immunologic response to Euphorbia kansui powder prepared as tea in 
HIV-infected antiretroviral therapy (ART)-suppressed individuals: a 
dose escalation study 
SPONSOR 
Investigator Initiated Study (Dr. Sulggi Lee) 
FUNDING 
ORGANIZATION 
1. amfAR HIV Cure Institute 
2. Salary support from K23 grant (K23GM112526) 
3. Departmental Funds 
NUMBER OF SITES 
2 (1 coordinating site, UCSF, and 1 enrollment site, University of  
Utah) 
RATIONALE 
The key challenge of HIV eradication strategies is persistence of a 
small pool of resting memory CD4+ T cells that harbor latent 
replication-competent HIV. One potential strategy to eliminate this 
reservoir is “shock and kill” in which agents designed to reverse 
latency (latency reactivating agents, or LRAs) are combined with 
agents aimed at eliminating these virus-expressing cells. The goal of 
the current proposal is to evaluate the in vivo biological response to an 
herbal supplement used in traditional Chinese medicine (“kansui)” 
that has potent in vitro latency reactivating capabilities. 
STUDY DESIGN 
This is a phase I open label dose escalation study with a randomized, 
double-blinded, placebo-controlled crossover cohort. 
PRIMARY 
OBJECTIVE 
1. To determine the safety and tolerability of a single or 3 
consecutive daily 1g doses of Euphorbia kansui extract 
powder, measured and prepared as tea, in HIV+ ART-
suppressed individuals. 
2. To determine the immunologic effect of a single or 3 
consecutive daily 1g doses of Euphorbia kansui extract 
powder, measured and prepared as tea, in HIV+ ART-
suppressed individuals. 
SECONDARY 
OBJECTIVES 
3. To determine the effect of a single or 3 consecutive daily 1g 
doses of Euphorbia kansui extract powder, measured and 
prepared as tea, on latent HIV in HIV-infected ART-
suppressed individuals. 
NUMBER OF 
PARTICIPANTS 
N=8 total (The first N=2 participants will receive 1 dose for a total of 
1 g; the final N=6 participants will receive 3 consecutive daily doses 
for a total of 3 g of Euphorbia kansui extract powder prepared as tea 
during the study period).  Following enrollment of the first 2 
participants, an interim analysis will be conducted to review all study 
data to determine if additional participants are needed to accomplish 
the study purpose, and if so, if enrollment should continue at the same 


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or a higher dose (i.e., next cohort). 
PARTICIPANT 
SELECTION 
CRITERIA 
Inclusion Criteria: 
1. Confirmed HIV-1 infection in adults aged 18 years or older. 
2. Continuous therapy with a DHHS recommended/alternative 
combination ART for least 36 months (at least 3 agents) at 
study entry with no regimen changes in the preceding 24 
weeks. 
3. Maintenance of undetectable plasma HIV-1 RNA (<40 
copies/ml) for at least 36 months. Episodes of single HIV 
plasma RNA 50-500 copies.ml will not exclude participation if 
subsequent HIV plasma RNA is <40 copies/ml. 
4. Two CD4+ T cell counts >350 cells/Pl in the six months prior 
to screening. 
Exclusion Criteria: 
1. Pre-ART viral load <2000 copies/ml (HIV controllers) 
2. Based on prior history and/or virologic testing, no alternative 
ART regimens are available in the event that the current ART 
regimen is compromised as a result of this study. 
3. Recent hospitalization in the last 90 days. 
4. Recent infection in the last 90 days requiring systemic 
antibiotics. 
5. Recent vaccination within the last 8 weeks prior to study scree 
or any study blood draw. 
6. Any known prior (lasting >6 months) or current history of 
liver-related diseases including but not limited to: 
a. Hepatic cirrhosis of decompensated chronic liver 
diseases 
b. Clinically active hepatitis B or C infection as 
evidenced by clinical jaundice or Grade 2 or higher 
liver function test abnormalities  
c. Any hepatic impairment, regardless of the graded liver 
function test abnormalities. 
7. Any known prior (lasting >6 months) or current history of 
gastrointestinal diseases including but not limited to: 
a. History of diarrheal illness requiring the use of anti-
motility agents including inflammatory bowel disease, 
chronic diarrhea not otherwise specified. 
b. History of gastrointestinal bleeding with hemoglobin 
below 12.5 g/dL. 
c. History of gastric or duodenal ulcers 
d. Inflammatory gastrointestinal disease such as Crohn’s 


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disease or ulcerative colitis 
8. Any significant renal disease (eGFR < 90 ml/min) or acute 
nephritis. 
9. Screening hemoglobin below 12.5 g/dL. 
10. Screening TSH consistent with hypothyroidism. 
11. Significant myocardial disease (current myocarditis or reduced 
left ventricular ejection fraction below the lower limit of 
normal) or diagnosed coronary artery disease. 
12. Significant respiratory disease requiring oxygen. 
13. Diabetes or current hypothyroidism. 
14. Participants of reproductive potential or breastfeeding. Women 
of childbearing potential must have a negative serum 
pregnancy test at screening. All participants of childbearing 
potential must agree to use a double-barrier method of 
contraception throughout the study period and up to 90 days 
after the last dose of kansui. 
15. Exposure to any immunomodulatory drug (including 
maraviroc) in the16 weeks prior to study.  
16. Prior or current use of experiment agents used with the intent 
to perturb the HIV-1 viral reservoir. 
17. History of seizures, psychosis, abnormal 
electroencephalogram or brain damage with significant 
persisting neurological deficit 
18. Positive test for tuberculosis by either skin test (PPD) or blood 
interferon-gamma release assay (QuantiFERON). 
19. Significant substance use, which in the opinion of the 
investigator(s), is likely to interfere with the conduct of the 
study. 
TEST PRODUCT, 
DOSE, AND ROUTE 
OF 
ADMINISTRATION 
1 g of Euphorbia kansui extract powder, measured and reconstituted 
in 4 fluid ounces of boiled water allowed to cool and administered as 
tea, taken by mouth daily as either a single or 3 consecutive daily 
doses. 
CONTROL 
PRODUCT, DOSE 
AND ROUTE OF 
ADMINISTRATION 
Cohort 1: no placebo. 
Cohort 2: a placebo treatment arm will be assigned to patients in a 
randomized crossover design. The placebo will be decaffeinated black 
loose leaf tea which produces a tea that is similar in appearance, 
consistency, and (bitter) taste to kansui extract powder, without any 
known immune modulating properties or drug-drug interactions (e.g., 
changes in pH balance that might affect drug absorption) with HIV 
antiretroviral therapy.  


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DURATION OF 
PARTICIPANT 
PARTICIPATION 
AND DURATION OF 
STUDY 
Cohort 1: Participants will be on study for up to 45 days. 
Screening:  up to 14 days 
Treatment:  1 day (participants to be admitted to the hospital 
during the day; no overnight stay) 
Follow-up: 31 days after treatment dose day 
 
Cohort 2: Participants will be randomized to either of two treatment 
arms, kansui or placebo, using a crossover design with a 56-day 
washout period in between treatment arms. Participants will be on 
study for up to 146 days. 
Screening (for each arm):  up to 14 days prior to treatment arm. 
Treatment (for each arm):  3 days (participants to be admitted to 
the hospital each day; no overnight stays) 
Follow-up (for each arm): 31 days after the initial dose for that 
treatment arm. 
 
The total duration of the study is expected to be 1 year. 
CONCOMMITANT 
MEDICATIONS 
Allowed:  
1. In the absence of drug-drug interaction information 
regarding kansui, participants may use their usual 
medications, as long as they are medically necessary and 
can be monitored safely during the study period.  
Prohibited: 
1. As stated in the exclusionary criteria above, participants 
may not have exposure to any immunomodulatory drug 
(including maraviroc) in the 16 weeks prior to study or 
during study period. 
2. Also as stated in the exclusionary criteria, participants may 
not have prior or current use of experimental agents used 
with the intent to perturb the HIV-1 viral reservoir. 
3. Participants may not be allowed to take anti-motility agents 
during the study period in order to accurately assess adverse 
events related to diarrhea. 
4. Participants will not initiate new medications that may also 
cause 
diarrhea, 
including 
proton 
pump 
inhibitors, 
antibiotics, antidepressants, colchicine, digitalis, etc., during 
the study period.  
In addition to the above medications, per traditional Chinese medicine 
practices, participants should also not ingest ice-cold food or 
beverages, spicy foods, or seafood in the two days prior to, during, 
and up to two days after kansui treatment.  


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EFFICACY 
EVALUATIONS 
x CD4+ and CD8+ T cell activation (expression of CD69, CD38, 
and HLA-DR). 
x 
Latent HIV reservoir quantification (cell-associated HIV RNA and 
plasma HIV RNA levels). 
PRIMARY ENDPOINT 
x 
Safety and tolerability of 1 g of Euphorbia kansui extract powder, 
prepared as tea, given as a single or 3 consecutive daily doses; no 
Grade 2 or greater clinical or laboratory adverse effects 
SECONDARY 
ENDPOINTS 
x 
Immunologic effect on CD4+ and CD8+ T cell activation (CD69, 
CD38, and HLA-DR expression on CD4+ and CD8+ T cells 
measured by flow cytometry). 
x 
Virologic effect on latent HIV Reservoir (cell-associated HIV 
RNA and plasma HIV RNA measured by rtPCR). 
OTHER 
EVALUATIONS 
With colleagues from the University of Utah Department of 
Pharmacology and Toxicology, the study team has begun developing 
an assay to measure levels of ingenol in participant plasma samples. 
Based on the bioassays performed in Matija Peterlin’s lab at UCSF, 
the abundance of ingenol in Euphorbia kansui extract powder is 
estimated to be approximately 1:100. We will be storing plasma 
samples collected from this study in order to measure plasma ingenol 
levels post-dosing with kansui as part of later pharmacokinetic/ 
pharmacodynamics analyses. 
SAFETY 
EVALUATIONS 
Incidence of adverse events 
Interim analysis following completion of Cohort 1 
PLANNED INTERIM 
ANALYSES  
During the study, safety will be monitored by a Safety Monitoring 
Committee (SMC), which will be led by an HIV specialist.  The SMC 
will review all study procedures before the initiation of the study.  
They will have the full and final authority to stop the study for any 
safety concern at any point. Given the unknown safety profile of 
Euphorbia kansui, the first participant in each dosing level will 
complete 5 days of study prior to any further participants commencing 
the study. The decision to proceed with further drug administration 
will be taken by the Principal Investigators, taking into consideration 
clinical and laboratory adverse events. The decision to proceed with 
the next dosing level will be taken by the SMC. Specifically, dosing 
will be stopped and the SMC will be notified if one Grade 4 or two 
Grade 3 drug related adverse events or laboratory abnormalities are 
reported, if a participant develops virologic failure (defined as any 
HIV-1 RNA levels >200 copies/mL or a single HIV-1 RNA level 
>1000 copies/mL), becomes pregnant or initiates breastfeeding, or is 
required to initiate one of the prohibited concomitant medications 
listed in section 7.1. If stopping/pausing criteria are not met, the 
remainder of the dosing cohort will be enrolled/dosed the subsequent 
week. The study will proceed to the next dosing level provided the 


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stopping/pausing criteria are not met. A University of Utah 
Department of Medicine faculty member who is not otherwise 
involved in the study and who will not communicate with the study 
investigators regarding any aspect of the SMC reports will prepare the 
monitoring reports. The SMC will review accrual, adverse events 
summaries, CD4+ T-cell counts and HIV RNA levels/suppression 
over time, off-study rates and completeness of follow-up, by dose 
cohort. 
STATISTICS 
Primary Analysis Plan 
Dr. Lee has expertise in epidemiology and biostatistics. She will be 
performing the data analysis for the study. Paired analyses using 
Wilcoxon signed rank tests will be performed to evaluate whether 
there is a statistically significant change in markers of immune 
activation (CD69, CD38, and/or HLA-DR) on CD4+ and CD8+ T 
cells after a 1 or 3 doses of Euphorbia kansui extract powder prepared 
as tea. Multivariate analyses will then be performed to evaluate the 
association between kansui and measures of immune activation at 
post-dosing, using linear mixed effects models, which account for 
within-participant correlation of observations and allows for greater 
stability in the estimate of the outcome measures within individuals.  
Similarly, for measures of the HIV reservoir, we will perform 
negative binomial mixed effects regression (a method to analyze over-
dispersed count data) to compare the size of the latent HIV reservoir 
before and after kansui administration.  
Rationale for Number 
of Participants 
A total of 8 participants (2 from dosing cohort 1 and 6 from dosing 
cohort 2) will contribute to the analysis, with 8 or 25 timepoint 
measures, respectively. The within-individual variability will be 
reduced by use of the within-individual control measures, as well as 
the repeated measurements post-dosing.  
 
The primary outcome of the study will be an increase in the % T cell 
activation (CD38+ HLA-DR+) of CD8+ and CD4+ T cells. Based on 
our recent experience performing a phase 1 trial of canakinumab (an 
interleukin-1 beta inhibitor) to reduce inflammation in chronic HIV-
infected ART-suppressed individuals,1 we estimate that we will have 
80% power to detect a within-individual increase of 2.7 points in the 
% CD8+ T cell activation (standard deviation [SD] at 31 days of 
1.6%). We will also assess virologic changes as secondary outcomes 
in the study. Based on data from our recent HIV latency phase 2b trial 
of disulfiram,2 we estimate that we will have 80% power to detect 0.6-
0.7 log increases in cell-associated unspliced (CA-US) HIV RNA 
(SD=0.4 and 0.5 for Day 4 and Day 31, respectively), and a 0.6-0.5 
log increases in ultra-sensitive plasma HIV RNA (SD=0.4 and 0.3 for 
Day 4 and Day 31, respectively). 
 


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1 
BACKGROUND 
The key challenge of HIV eradication strategies is persistence of a small pool of resting 
memory CD4+ T cells that harbor latent replication-competent HIV, untouched by 
current antiretroviral therapy (ART).3 One potential strategy to eliminate this reservoir is 
a “shock and kill” approach in which agents designed to reverse latency (latency 
reactivating agents, LRAs) are use to “shock” the virus out of these cells in order for the 
host immune response, ART, and/or additional immunomodulatory agents can then 
eliminate virus-expressing cells.4-7 The goal of the current proposal is to evaluate the in 
vivo biological response to an herbal supplement used in traditional Chinese medicine 
(“kansui)” that has potent in vitro latency reactivating capabilities.  
Kansui has been prescribed in Chinese medicine for thousands of years as a cathartic 
agent. It is typically given as a single dose of 0.5 -1.5 grams, and is used to treat intestinal 
obstruction, nodular skin lesions, water retention, and epilepsy.8,9 Kansui extract is made 
from the Euphorbia root and is thought to contain several potentially biologically active 
components, including a large number of ingenols, which are known to activate and/or 
interrupt a number of cellular pathways, including some known to be involved in the 
maintenance of HIV latency.10-12 Recently, a semi-synthetic version of ingenol from 
Euphorbia tirucalli has been developed as Ingenol B (Ing B).13 Ing B demonstrates the 
potent ability to reactivate latent HIV in ex vivo and non-human primate models.11,12,14 
Ing B was shown to induce significant immune activation (upregulation of CD38, HLA-
DR, CD69 expression on CD4+ T cells) and reactivate virus in both untreated and ART-
suppressed SIVmac251-infected rhesus macaques without hypercytokinemia.14,15 These 
effects were observed as early as three days in untreated monkeys15 to approximately 30 
days post-Ing B in ART-suppressed monkeys.14 The ability to induce T cell activation 
and viral reactivation were even more pronounced when Ing B was administered 
concomitantly with another LRA called suberanilohydroxamic acid (SAHA).14 
Kansui contains ingenols that induce immune activation and reactivate latent HIV-1 
Several compounds have already been tested to reactivate latent HIV, including histone 
deacetylase inhibitors such as suberoylanilide hdroxamic acid (SAHA)16 and protein 
kinase C (PKC) agonists such as prostratin17 and bryostatin.18 More recently, a new semi-
synthetic ingenol ester that acts as a PKC agonist, 3-caproyl-ingenol (Ingenol B, or Ing B, 
patent-pending), has been tested in both J-Lat cell lines and in primary resting CD4+ T 
cells.11-13 Ing B induced high levels of viral reactivation beyond those induced by SAHA, 
TNF-a, phorbol 12-myristate 13-acetate (PMA), or hexamethylene bisacetamide 
(HMBA) with minimal cellular toxicity.12 In addition, Ing B was found to act 
synergistically with a BET bromodomain inhibitor (JQ1) or HMBA in vitro. Ing B 
promotes PKC activation and NF-kB nuclear translocation, and also upregulation of P-
TEFb (which plays a critical role in HIV-1 transcriptional elongation). Therefore, 
ingenols may have multiple functions in promoting latent HIV reactivation.12 
Administration of Ing B has also been shown to increase the circulating viral load in 
untreated SIVmac251-infected monkeys as well as to reactivate virus from resting CD4+ 
T cells in ART-treated SIVDeltaB670+SIV17E-Fr-infected monkeys.15 Among untreated 
rhesus macaques, Ing B induces immune activation, upregulating CD38, HLA-DR, and 


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CD69 expression on CD4+ T cells.15 In all instances, no significant toxicity was 
observed.  
1.1 
Overview of Pre-Clinical Studies 
1.1.a. Kansui is a potent activator of in vitro HIV-1 transcription  
Based on in vitro bioassays performed in Matija Peterlin’s lab, Euphorbia kansui extract 
powder is a potent activator of HIV transcription in latently infected Jurkat cells.19 From 
these experiments, 1 ȝM of Ing B was estimated to possess equivalent bioactivity as 10 
ȝL/mL of Euphorbia kansui extract, suggesting a ratio of up to but not greater than 1:100 
of Ing B to kansui. Since there are up to 12 different ingenols that could differ in their 
potency in the Euphorbia kansui powder, this range could smaller. Importantly, 
Euphorbia kansui reactivated virus in patient peripheral blood mononuclear cell (PMBC) 
samples from HIV-infected ART-suppressed individuals (Figure 1), and a combination 
of Euphorbia kansui and vorinostat (a histone deacetylase inhibitor and also a latent 
reactivating agent) or JQ1 (a bromodomain inhibitor and latent reactivating agent) 
resulted in synergistic reactivation of latent HIV at suboptimal concentrations. Taken 
together, these results demonstrated that Euphorbia kansui functioned as a potent PKC 
agonist to reactivate latent HIV, which may be later used in combination with another 
HIV latent reactivating agent (LRA). In addition, Dr. Peterlin’s lab tested the stability and 
potency of the kansui powder over time (stored at room temperature) and has not 
observed any loss of biological activity (latency reversal). These results have been 
internally validated in the lab of our clinical trial study collaborator, Dr. Adam Spivak, at 
the University of Utah. In a separate study published by another group, the researchers 
 
Figure 1. Euphorbia kansui reactivates HIV in a model of HIV latency using resting human CD4+ T cells. (a) Human primary CD4+ T 
cells were activated and expanded with CD3/CD28 beads and 30 U IL-2/ml for 7 days. Cells were infected with VSV-G-pseudotyped 
HIV-1 NL4.3 HSA R+E- for 24 hours. Infectious virus was removed and cells were maintained over 12 days with decreasing 
concentrations of IL-2 to establish latency. Uninfected cells were maintained in the same conditions, for uninfected controls and to 
determine T cell reactivation. At 12 days post infection, cells were stimulated for 24 hours with DMSO, PMA (2 ȝg/ml) and PHA (10 
ng/ml), IngDB (50 ng/ml) or Euphorbia kansui (5, 50, and 500 ȝg/ml) (***p<0.001). (b) CD69 expression was measured by flow 
cytometry. (c) HSA expression was measured by flow cytometry. Data are representative of infections using cells from three healthy 
donors. Error bars represent standard error of the mean (*p<0.05, **p<0.01). (Cary et. al, PLoS ONE, 2016). 


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identified an ingenol derivative (EK-16A) from Euphorbia kansui. They determined that 
this derivative of kansui, EK-16A, was 200-fold more potent than prostratin (a strong 
protein kinase C agonist) in reactivating HIV-1 from latently infected cell lines and 
primary HIV+ patient cells.20 They also found that EK-16A exhibited synergy with other 
LRAs in reactivating latent HIV-1. 
1.1.b. Non-human primate study 
In collaboration with Dr. Dennis Hartigan-O’Connor (University of California, Davis), 
we have completed a non-human primate study to evaluate the safety of Euphorbia 
kansui prepared as tea, given at increasing dose and frequency to three juvenile 
SIVmac251-infected rhesus macaques compared to two controls (Figure 2). The rhesus 
macaques studied were part of 
an NIH-funded study (R01-
AI118451, 
PI:Hartigan-
O’Connor). 
Three 
juvenile 
male rhesus macaques (RM) 
were infected with SIVmac251 
by intravenous administration. 
Two juvenile male RMs were 
included as “control” animals 
to receive early ART but no 
other kansui therapy. After 7 
days post-infection, the three 
RM in the treated group began 
a treatment regimen of once 
daily subcutaneous injections 
of tenofovir (TFV, Gilead) 20 
mg/kg subcutaneously daily; 
emtricitabine (FTC, Gilead) 50 
mg/kg subcutaneously daily; 
dolutegravir (DTG, ViiV) 3.25 mg/kg subcutaneously daily for a period of 12 weeks. The 
three animals assigned to receive kansui were administered kansui at an initial safety 
dose of 5 mg/kg Euphorbia kansui powder prepare as tea was given via oral gavage, a 
dose equivalent to 1/4 the dose administered in traditional Chinese medicine (~0.25 g, or 
5 mg/kg/day = 20 mg x 1 in a typical 4 kg juvenile RM). The animals were then followed 
for a 2-week washout period. Once safety goals were achieved with this initial dosing, the 
same treated animals then received kansui at 20 mg/kg/day = 80 mg x 1 and followed for 
another 2 week period. Next, after safety goals were achieved at this second dosing, the 
same three RM received kansui at 200 mg/kg/day = 800 mg x 2 consecutive days and 
followed for 2 weeks. Finally, after safety goals were achieved at this third dosing, the 
same three RM received kansui at 200 mg/kg/day = 800 mg x 3 consecutive days and 
followed for 3 weeks. At the end of this fourth dose 2-week washout period, the animals 
were followed for an additional 2-week follow-up period before undergoing necropsy.  
Given that the animals demonstrated tolerability to an initial safety dose of 5 mg/kg 
kansui, treatment doses of 20 mg/kg kansui were administered at increased frequency in 
2-week washout period intervals. Even at the highest frequency, 20 mg/kg kansui given 
NHP Kansui Dose Frequency Escalation 
N=3 Kansui Treatment, 2=Controls 
SIVmac251  
infec<on 
Necropsy 
CONTROLS (N=2) 
+ Kansui  
5 mg/kg x 1 
ART start 
+ Kansui  
20 mg/kg x 1 
+ Kansui  
20 mg/kg x 2 
+ Kansui  
20 mg/kg x 3 
 
 
 
 
 
 
 
4/1           4/18                                                8/2                    8/16                          8/30                             9/13                           9/27       
KANSUI TREATED (N=3) 
SIVmac251  
infec<on 
ART start 
Necropsy 
 
 
 
 
 
 
 
 
Figure 2. Study design of the non-human primate study. Kansui-treated 
rhesus macaques received doses as shown above with 2-week 
washout periods. Control monkeys did not receive placebo but were 
started on antiretroviral therapy (ART) and followed over the time as the 
kansui-treated animals.


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for 3 consecutive days, no adverse clinical events (i.e., the expected and anecdotally 
reported events such as diarrhea). This initial work demonstrates that Euphorbia kansui 
extract powder, administered at weight-based dosing equivalent to that given in 
traditional Chinese medicine (20 mg/kg) for up to 3 days was well tolerated in rhesus 
macaques.  
In addition, we observed evidence for low levels of biologic efficacy in this small study 
such as increased natural killer cell expansion (measured as CD3-CD8+ cells) and 
increased activation markers on CD11b++CD11c- monocytes (Figure 3). Most 
strikingly, we observed a decrease in the size of the viral reservoir (SIV DNA) with 
evidence of increased SIV transcription (RNA) in two of the three kansui-treated 
monkeys (measured as cell-associated SIV DNA and RNA, respectively, from PBMCs). 
We are currently proceeding with performing the virologic assays on the necropsy tissues 
and performing additional immunophenotyping assays. 
1.2 
Overview of Clinical Studies 
Kansui is well tolerated at doses prescribed in traditional Chinese medicine 
Kansui is made by grinding up the root of Euphorbia plants into powdered form and is 
known to have a bitter taste.21 Per traditional Chinese medicine practices, kansui is 
efficacious and well tolerated at doses ranging from 1 gram to 8 grams for adults, given 
as a single dose, above which mild diarrhea has been reported.8,9 Mice studies suggest 
that at extremely high doses of 1.2 grams/kg given orally as a single dose (approximately 
Kansui 
Control 
Kansui 
Control 
Kansui 
Control 
SIV RNA per cell 
SIV DNA per cell 
Control 
Kansui 
Control 
Kansui 
A.  
 
 
 
 
 
 
 B. 
C.  
 
 
 
 
 
 
  
Figure 3. Kansui-treated animals demonstrated increased natural killer (NK) cell expansion (A) and increased activation markers on 
CD11b++CD11c- monocytes by percent expression and mean fluorescence intensity (B). Two of the three kansui-treated monkeys 


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84 grams for a 70 kg human) Euphorbia kansui extract can induce severe diarrhea with 
abdominal distension and evidence of acute inflammatory intestinal injury.22 But these 
abnormalities were not observed at the lower doses studied (0.3 and 0.6 grams/kg, 
equivalent to 21 and 42 grams, respectively, for a 70 kg human), only slight changes in 
intestinal relaxation, secretion, and motility. Other potential side effects shown in mice 
include mild perturbations in glycolysis and amino acid and lipid metabolism.23 
Ingenols are one of many diterpenoid forms isolated from the sap of plants of the genus 
Euphorbia.13 The root of Euphorbia, processed into powdered or liquid form, has long 
been used in traditional Chinese medicine to treat medical conditions such as edema, 
pleural effusion, urinary retention, and cancer.8,9,24-26 Euphorbia kansui is one of the most 
commonly used Euphorbia in traditional Chinese medicine, which is prescribed as an 
herbal supplement known as “kan sui.”27,28 Various chemical constituents have been 
identified in Euphorbia plants, including sesquiterpenoids, diterpenoids (which includes 
ingenanes), triterpenoids, and phenol derivatives.21 The constituents thought to play a role 
in latent HIV reactivation include ingenols,10-12 but euphols29,30 and other chemical 
constituents31 may also be biologically active. Recently, ingenol mebutate, has been 
FDA-approved for the topical treatment of actinic keratosis.24 
 
2 
STUDY RATIONALE 
Millions HIV-infected individuals are now receiving life-saving antiretroviral therapy.32  
However, mortality remains high, particularly in resource-limited countries.33 Moreover, 
chronic HIV-infected individuals demonstrate persistent immune activation despite ART-
mediated viral suppression, which is an independent predictor of mortality in this 
setting.34  Given the current absence of an effective HIV vaccine, finding a cure for HIV 
will likely have a large impact on the long-term health of ART-treated HIV-infected 
individuals, in particular for those living in resource-limited settings.  
Kansui is an inexpensive, readily available herbal supplement prescribed for thousands of 
years in traditional Chinese medicine8,9 and contains active compounds such as ingenols 
that have been shown to reverse latency in an animal model. A semi-synthetic form of 
ingenol has been shown to potently reactivate latent SIV in rhesus macaques and is 
currently undergoing early drug development.11-13 A human clinical trial testing a non-
pharmacologic agent to treat HIV disease will be challenging unless we can demonstrate 
evidence of both safety and in vivo biologic activity. Though kansui has been studied 
extensively in traditional Chinese medicine, the herbal supplement has never been 
evaluated for biologic activity using Western scientific research methods.  
Per discussions with the Department of Herbal Medicine at the American College of 
Traditional Chinese Medicine in San Francisco, kansui administration leads to clinical 
elimination of feces within two hours after administration of a single 1 gram dose of 
Euphorbia kansui extract powder, measured by weight, boiled with water, and prepared 
as a tea, suggesting rapid absorption and bioavailability. In mice, Euphorbia kansui 
extract potentiates time of fecal excretion but not overall quantity of fecal mass.22 This 
pilot study will provide key preliminary data to test the safety of low doses of Euphorbia 
kansui extract powder (1 gram daily for a single or 3 consecutive doses) prepared as tea 


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and confirm in vivo human biologic activity of kansui. This study will provide important 
preliminary data for future studies to perform a larger, more comprehensive clinical and 
pharmacokinetic/pharmacodynamics (PK/PD) study of kansui. 
2.1 
Risk / Benefit Assessment 
The most significant potential benefit of this study is to contribute to the study of an 
inexpensive, non-pharmacologic agent for the possible use in future HIV cure strategies. 
The study will generate key preliminary data for investigating an agent that may have 
similar potency to a semi-synthetic compound currently undergoing early drug 
development. The collaborations formed as part of this study will provide a foundation 
for future larger studies evaluating similar botanicals for the use in HIV cure trials. The 
benefits of this short-term treatment with Euphorbia kansui extract powder prepared as 
tea (up to 3 days of dosing) outweigh the potential risks outlined below. 
 
Kansui-related risks  
Kansui is known to induce (and is used for the purpose of causing) a mild diarrhea as a 
means of eliminating excess water from the body in traditional Chinese medicine.8,9 
Participants will be advised to read labels and check ingredients of foods to be sure to 
avoid products that may also induce diarrhea. Per traditional Chinese medical literature, 
common adverse events may include gastrointestinal irritability and headache, usually 
occurring within 30 minutes to 2 hours after ingestion.8,9 At very high doses (between 9 
to 15 grams of kansui extract powder), kansui can cause dehydration with subsequent 
light-headedness, hypotension, and tachycardia. These high doses of kansui may also 
cause diarrhea with mucus and blood, pupillary dilation, convulsions, and 
unconsciousness. Participants for this study will be monitored closely for 8 hours after 
each dose of kansui and will be instructed to report any diarrhea with mucus or blood 
immediately to the study staff.  
 
Virologic risk 
Given that the purpose of studying kansui in this study is to evaluate whether it can 
reactivate HIV from latently infected cells, there is a risk that taking kansui for up to 3 
days could lead to transient loss of viral suppression and subsequent development of 
resistance to the participant’s current antiretroviral therapy. However, given the short 
duration of kansui administration and the predicted small increases in plasma viremia as a 
result of kansui, we believe that these risks will be low. Nonetheless, as per protocol with 
other currently studied latent reversing agents (LRAs), we will perform frequent plasma 
HIV RNA monitoring (screening, every dosing day, each 24-hour follow-up, and days 31 
and 132) and even more frequent monitoring of the research-based reservoir 
measurements of cell-associated HIV DNA and RNA (see section 9.1 below). In 
addition, we will only enroll participants for whom alternative ART regimens are 
available in the event that their previously effective regimens are compromised. Finally 
kansui treatment will be discontinued if the participant has any two consecutive plasma 
HIV RNA levels levels >200 copies/mL, or any single plasma HIV RNA level >1000 
copies/mL. These values would be above the levels predicted to be seen with HIV 
reactivation with most current latent reactivating agents and are safety stopping criteria 
currently used for other HIV latent reactivating agent trials, e.g., the AIDS Clinical Trials 


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Group (ACTG 5336) trial, evaluating the role of Sirolimus on immune activation and the 
latent reservoir in chronic HIV-infected, ART-suppressed individuals. 
  
Reproductive risks 
Given the unknown reproductive risks associated with kansui as tested scientifically, and 
its use in traditional Chinese medicine as an abortifacient,8 women of childbearing 
potential must have a negative serum pregnancy test in the medical workup for study 
entry and excluded from participation if pregnant. All participants must agree to use two 
forms of contraception throughout the study period and up to 90 days after the last dose 
of kansui (to account for the male sperm cycle). Women (or female partners of male 
study participants) must not breastfeed during the study period and up to 90 days after the 
last dose of kansui.  
 
Confidentiality 
As with any study collecting personal information in research records, this information 
could lead to loss of confidentiality. In particular, any study that collects genetic data 
poses the potential risk of loss of confidentiality that might be relevant to the study 
participant, relatives of the participant, and/or people with similar genetic background as 
the participant. Given that this particular study will not perform whole genome 
sequencing (DNA) data, but rather select RNA sequencing information, the risk of this 
occurring in this current study is minimal. However, in order to safeguard against this 
potential risk, genetic information pertaining to the study will not placed in the 
participant’s medical record. All samples will be labeled with de-identified codes, and the 
informed consent includes language to inform the participant of these risks, per NHGRI 
guidelines (http://www.genome.gov/10000921#update). 
 
Potential discomforts 
Potential discomforts of taking kansui include the bitter taste of the extract powder. 
Participants will be offered room temperature beverages or snack to alleviate discomfort 
due to the bitter taste. In addition, the requirement that participants avoid ice-cold 
beverages and ice-cold foods, may cause discomfort. The dietary restrictions will be for 
48 hours prior to the first dose of kansui, during the days of kansui dosing, and up to 48 
hours after the last dose of kansui. 
 
3 
STUDY OBJECTIVES 
3.1 
Primary Objective 
The primary objective is to assess the safety and tolerability of up to 3 consecutive daily 
doses of 1 g Euphorbia kansui extract powder prepared as tea in HIV-infected ART-
suppressed participants. 
3.2 
Secondary Objectives 
The secondary objective is to determine whether 1 g of Euphorbia kansui extract powder 
prepared as tea, administered up to 3 consecutive daily doses, induces a biologic effect, 


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measured as immune activation (expression of CD69, CD38, and/or HLA-DR) in CD4+ 
and CD8+ T cells. 
A third objective is to determine whether 1 g of Euphorbia kansui extract powder 
prepared as tea, administered up to 3 consecutive daily doses, reactivates latent HIV, 
measured as cell-associated HIV RNA and plasma HIV RNA levels.  
 
4 
STUDY DESIGN 
4.1 
Study Overview 
Prior trials evaluating latent reactivating agents have demonstrated that a “priming” 
period appears to yield greater latency reversal.5,7 Therefore, we will perform this multi-
center, phase I clinical study of kansui in eight HIV-infected ART-suppressed 
participants as a dose escalation trial with a double-blinded, randomized, placebo-
controlled crossover cohort.  The first two participants will complete a kansui-only 
treatment phase in which they will be given a single, open label 1g dose of Euphorbia 
kansui extract powder prepared as tea. The second group of six participants will complete 
the study twice (once on a decaffeinated black tea placebo treatment arm and once with 
the kansui treatment arm) in a randomized, double-blinded, placebo-controlled crossover 
design. Which treatment arm occurs first will be randomly assigned and will include a 
56-day washout period between the two phases. A second screening visit will occur 
immediately following the washout period on Day 88.  The second screening visit will 
occur 14-days prior to starting the second treatment assignment on Day 102; the second 
treatment phase will therefore begin on Day 88 and end on Day 101 (See Study Events 
Table). As indicated by the dose-escalation design of the study, participants in the kansui 
treatment phase for group 2 will receive 3 consecutive daily 1g doses of Euphorbia 
kansui extract powder served as tea.  
We propose using a crossover double-blinded design due to our experience in performing 
in vivo studies of latent HIV reactivation.  We have previously demonstrated statistically 
significant inter-individual differences in baseline values of the virologic and 
immunologic outcomes proposed in our study.2 For these reasons, we have applied a 
similar crossover study design in another recent study which allowed the ability to detect 
even small differences in HIV RNA levels after intervention.35 Therefore, due to the 
small detectable changes that most HIV latent reactivating agents (LRAs) produce at the 
doses tested in these trials2,5,36,37 and the possibility of small detected changes from our 
trial of kansui, a within-subject control component to the study will allow us the greatest 
ability to accurately detect treatment-related differences in our study outcome measures.38 
Subjects will initiate dosing on separate days. All safety data from each cohort (through 
week two of observation) will be collated and presented to an SMC before we escalate to 
the next dose level, as described below. We hypothesize that 1 g of kansui powdered, 
measured and prepared as tea, given as a single or 3 consecutive daily doses will be safe 
and well tolerated. We also hypothesize that kansui given as a single or 3 consecutive 
daily doses may induce T cell activation (CD69, CD38, and/or HLA-DR expression on 
CD4+ and CD8+ T cells) and latent HIV reactivation (cell-associated HIV RNA and 
plasma HIV RNA).  


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Participants will be screened for eligibility. Individuals meeting inclusion criteria without 
meeting exclusion criteria will be enrolled in the study in sequential dosing cohorts as 
below. The following treatment regimens will be used: 
x Cohort 1: Kansui Phase of (1 g) x 1 dose (the first N = 2 participants) 
x Cohort 2: Kansui Phase of (1 g) x 3 consecutive daily doses that is either preceded 
or followed by a Placebo Phase (the final N = 6 participants) 
Study participants will be followed for 31 days following each treatment phase. There 
will also be a 56-day washout period in between the two treatment phases. The total 
duration of the study is expected to be up to 45 days for Cohort 1 and up to 146 days for 
Cohort 2 (See Study Events Table). 
 
5 
CRITERIA FOR EVALUATION 
5.1 
Primary Efficacy Endpoint 
There is not a primary efficacy endpoint aim for this phase I safety and tolerability 
feasibility study, though we will be reporting changes in measures of T cell activation 
and latent HIV.  
5.2 
Safety Evaluations 
Incidence and nature of adverse events 
5.3 
Other Evaluations (include only if applicable) 
PBMCs will be collected and stored for future gene expression analyses. Plasma samples 
will be stored for future PK analyses 
 
6 
PARTICIPANT SELECTION 
6.1 
Study Population 
We will perform a dose-escalation, proof-of-concept study of Euphorbia kansui extract 
powder prepared as tea in chronically HIV-infected individuals with long-term ART 
suppression. A total of 8 ART-suppressed patients will be recruited from the University 
of Utah for participation in this trial.  The University of Utah Principle Investigator will 
oversee the recruitment of potential participants who meet inclusion criteria. Dr. Spivak 
will identify and recruit potential participants through his own clinic panel in Clinic 1A 
and through a cohort of patients already participating in an ongoing study at the 
University of Utah entitled, “Analysis of Latent HIV-1 Infection in Peripheral Blood 
Lymphocytes of Aviremic HIV-1 Infected Patients and Explorations of Therapeutic 
Misconception.”      
Participants will include HIV-positive adults  18 years old with long-term virologic 
suppression on stable ART, with a plasma HIV RNA below the assay limit of detection, 
CD4+ cell count >350 cells/mm3, and adequate organ function (per criteria listed below).   


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6.2 
Inclusion Criteria 
1. Confirmed HIV-1 infection in adults aged 18 years or older. 
2. Continuous therapy with a DHHS recommended/alternative combination ART for 
least 36 months (at least 3 agents) at study entry with no regimen changes in the 
preceding 24 weeks. 
3. Maintenance of undetectable plasma HIV-1 RNA (<40 copies/ml) for at least 36 
months. Episodes of single HIV plasma RNA 50-500 copies/ml will not exclude 
participation if subsequent HIV plasma RNA is <40 copies/ml. 
4. Two CD4+ T cell counts >350 cells/ȝl in the six months prior to screening. 
5. Written informed consent obtained from participant and ability for participant to 
comply with the requirements of the study. 
6.3 
Exclusion Criteria 
1. Pre-ART viral load <2000 copies/ml (HIV controllers). 
2. Based on prior history and/or virologic testing, no alternative ART regimens are 
available in the event that the current ART regimen is compromised as a result of 
this study. 
3. Recent hospitalization in the last 90 days. 
4. Recent infection in the last 90 days requiring systemic antibiotics. 
5. Recent vaccination within the last 8 weeks prior to study scree or any study blood 
draw. 
6. Any known prior (lasting >6 months) or current history of liver-related diseases 
including but not limited to: 
a. Hepatic cirrhosis of decompensated chronic liver diseases 
b. Clinically active hepatitis B or C infection as evidenced by clinical 
jaundice or Grade 2 or higher liver function test abnormalities  
c. Any hepatic impairment, regardless of the graded liver function test 
abnormalities. 
7. Any known prior (lasting >6 months) or current history of gastrointestinal diseases 
including but not limited to: 
a. History of diarrheal illness requiring the use of anti-motility agents 
including inflammatory bowel disease, chronic diarrhea not otherwise 
specified. 
b. History of gastrointestinal bleeding with hemoglobin below 12.5 g/dL. 
c. History of gastric or duodenal ulcers 
d. Inflammatory gastrointestinal disease such as Crohn’s disease or 
ulcerative colitis 
8. Any significant renal disease (eGFR < 90 ml/min) or acute nephritis. 
9. Screening hemoglobin below 12.5 g/dL. 


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10. Screening TSH consistent with hypothyroidism. 
11. Significant myocardial disease (current myocarditis or reduced left ventricular 
ejection fraction below the lower limit of normal) or diagnosed coronary artery 
disease. 
12. Significant respiratory disease requiring oxygen. 
13. Diabetes or current hypothyroidism. 
14. Participants of reproductive potential or breastfeeding. Women of childbearing 
potential must have a negative serum pregnancy test at screening. All participants of 
childbearing potential must agree to use a double-barrier method of contraception 
throughout the study period and up to 90 days after the last dose of kansui. 
15. Exposure to any immunomodulatory drug (including maraviroc) in the16 weeks 
prior to study.  
16. Prior or current use of experiment agents used with the intent to perturb the HIV-1 
viral reservoir. 
17. History of seizures, psychosis, abnormal electroencephalogram or brain damage with 
significant persisting neurological deficit 
18. Positive test for tuberculosis by either skin test (PPD) or blood interferon-gamma 
release assay (QuantiFERON). 
19. Significant substance use, which in the opinion of the investigator(s), is likely to 
interfere with the conduct of the study 
20. Anticipated conflict or inability to attend and complete all protocol-scheduled study 
visits and assessments, especially for participants in Cohort 2 where treatment phases 
are separated by a 56-day washout 
 
7 
CONCURRENT MEDICATIONS 
Participants may continue to take their usual medications, as long as they are medically 
necessary and can be monitored during the study period.  
7.1 
Allowed Medications and Treatments 
Participants may not have exposure to any immunomodulatory drug (including 
maraviroc) in the 16 weeks prior to study or during study period and may not currently be 
taking experimental latent HIV reversing agents.  
In the absence of drug-drug interaction information with kansui, only concomitant 
medications that are medically necessary will be continued with appropriate monitoring. 
In addition, the following medications are prohibited during the study and administration 
will be considered a protocol violation. 
x 
Participants may not be take anti-motility agents during the study period. This is to 
allow accurate assessment of diarrhea-related adverse events. 


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x 
Participants may not initiate new medications that may cause diarrhea during the 31-
day study period. These may include but are not limited to: 
o Proton pump inhibitors 
o Antibiotics 
o Antidepressants 
o Colchicine 
o Digitalis 
In addition to the above medications, per traditional Chinese medicine practices, 
participants should also not ingest ice-cold food or beverages, spicy foods, or seafood in 
the two days prior to, during, and up to two days after kansui treatment.  
 
8 
STUDY TREATMENTS 
8.1 
Method of Assigning Participants to Treatment Groups 
Cohort 1: NA 
Cohort 2: Participants will be randomized to either kansui versus placebo treatment first 
using a random number generator. Whichever treatment the participant receives first, 
they will receive the other treatment (placebo or kansui) for their second treatment staring 
at Day 102 (See Study Events Table in Section 9 below).  
8.2 
Blinding 
Cohort 1: NA 
Cohort 2: The order in which participants in Cohort 2 complete the two treatment phases 
(i.e., kansui and placebo) will be unknown to both the participants and the PI/study team.  
Both the kansui and placebo will be prepared and delivered to the Center for Clinical & 
Translational Science (CCTS) in identical, HDPE vials (described later in section 8.3.3). 
Upon arrival at the CCTS, the HDPE vial will be received by a CCTS study nurse.  At the 
appropriate time, the CCTS study nurse will prepare the tea (either kansui or placebo) in 
the med room of the CCTS, out of sight of the study participant, study coordinator, and 
study site PI to maintain double blinding.  Following preparation the study nurse will 
administer the tea (kansui/placebo) to the participant following protocol section 8.4.3.  
The University of Utah Investigational Drug Services (“UU IDS”) will randomize each 
participant in Cohort 2 according to the methods described in Protocol section 8.1.  In the 
event that participant experiences an adverse event that requires the identity of the study 
drug be revealed, the PI will be able to contact UU IDS to break the blind.  In the event 
that a participant blind is broken, the study PIs will determine the impact upon the un-
blinded subject’s continued participation in the study and if a replacement subject is 
needed on a case-by-case basis. 


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8.3 
Formulation of Test and Control Products 
8.3.1 
Formulation of Test Product 
For the current pilot study, we will use the same standardized batch of Euphorbia kansui 
extract powder studied in Dr. Matija Peterlin’s laboratory at UCSF to perform the 
preliminary experiments described above. The Euphorbia kansui extract powder was 
purchased from Baoji F.S. Biological Development Company, and is Good 
Manufacturing Practice (GMP)-certified. The Euphorbia kansui root powder will be 
provided by the study investigator at UCSF and shipped in bulk to the University of Utah 
Health Investigational Drug Service (UUH IDS) Pharmacy.  The Euphorbia kansui root 
extract powder is stored at the UUH IDS Pharmacy in a re-sealable plastic bag at room 
temperature, away from moisture and light exposure.  Since the test product is in powder 
form, UUH IDS will prepare individual 1 g doses of Euphorbia kansui extract powder 
provided by the Department of Herbal Medicine at the American College of Traditional 
Chinese Medicine at UCSF. The details regarding these procedures can be found in the 
Standard Operating Protocol (SOP), Euphorbia kansui Extract Tea Preparation Guidance, 
for kansui preparation and administration. The University of Utah Health Investigational 
Drug Service Pharmacy is located at the Huntsman Cancer Hospital, 1950 Circle of 
Hope, Suite 2110 in Salt Lake City, UT  84112. 
8.3.2 
Formulation of Control Product 
Placebo tea will be prepared using Twinings English Breakfast 100% pure black 
decaffenated tea. One packet of tea will be prepared and administered as for kansui tea 
(see section 8.4.3). Briefly, four ounces of boiled water will be cooled to 170-185° F and 
added to the tea bag in a cup. The tea will be stirred for approximately 30 seconds using a 
wooden stirring stick and allowed to cool for at least 5 minutes, reaching a temperature of 
less than or equal to 100° F, before administration. The placebo will be prepared in a 
separate room such that study participants will not observe differences in tea preparation 
and packaging. 
8.3.3 
Packaging and Labeling 
The University of Utah Health Investigational Drug Service (UUH IDS) Pharmacy will 
prepare individual 1 g doses Euphorbia kansui extract powder or placebo using a 
Ohaus® Pharmacy Scale w/ Internal Calibration. As kansui (the root of Euphorbia 
kansui) is a Chinese herb with known safety issues, all laboratory and clinical personnel 
who handle kansui extract powder must use proper personal protection equipment 
(specifically - facemask, labcoat, and gloves) to prevent potential allergic reactions (e.g., 
contact dermatitis). Preparations will be packaged in white HDPE (high density 
polyethylene plastic) vials with screw caps and a tight, leakproof inner seal. Each study 
preparation bottle will be labeled with the required FDA warning statement, the protocol 
number, study participant number, a visit number, and directions for patient use.  
 


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Hunstman Cancer Hospital IDS 
1950 Cirlce of Hope  Salt Lake City  UT 84112  801-585-0272 
 
RX: xxxxx-x 
 
 
 
Presriber name 
Date 
 
 
Subject ID: xxxxxxx 
 
Protocol#: Kansui 
Subject full name:   
Mix 1 gram of powder in 4 ounces of warm water and ingest by mouth as directed. Euphorbia 
kansui extract powder or placebo. 
Qty: 1 gram 
Rt: oral  
Do not use after: “expiration date” 
 
Refills: 0 
Caution: Drug limited by Federal (United States) Law to investigational use only 
 
8.4 
Supply of Study Drug at the Site 
8.4.1 
Dosage/Dosage Regimen 
One gram of Euphorbia kansui extract powder or placebo, reconstituted in 4 fluid ounces 
of warm water as tea, will be taken orally once daily for up to 3 days total. Participants 
enrolled in cohort 1will be administered 1 g of Euphorbia kansui extract powder prepared 
as tea for a total of 1 day and participants in cohort 2 will be administered 1 g of 
Euphorbia kansui extract powder prepared as tea or placebo for 3 consecutive days 
during the study period.  
8.4.2 
Dispensing 
All handling of the trial products, storage, reconstitution, individual dose preparation, and 
drug accountability will be done by the study investigators, delegated pharmacy staff, or 
delegated member of the study team.  
8.4.3 
Administration Instructions  
Study Investigators will instruct study staff on how to prepare the Euphorbia kansui 
extract powder as a tea, per traditional Chinese medicine practice as outlined in the 
Euphorbia kansui Extract Tea Preparation Guidance SOP.  
Study staff will dispense and observe study participant take 1 vial (1 g) of Euphorbia kansui 
extract powder in 4 mL of water prepared as follows: 
a. One gram of Euphorbia kansui extract from the labeled vial will be place into a 6-ounce 
Styrofoam or paper cup.  
c. Four ounces of boiled water cooled to 170-185° F will be added to the powder in cup. 
Research staff will measure the water temperature using a designated thermometer for 
tea use only. 
d. The tea will be stirred for approximately 30 seconds using a wooden stirring stick.  


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e. The tea will be allowed to cool for at least 5 minutes, reaching a temperature of less than 
or equal to 100° F, before administration. 
f. All contents in the cup will be checked to ensure that the powder and water have been 
stirred appropriately and fully consumed.  Research staff will record the time of dose 
(Time 0) on the treatment flowsheet.   
g. Specific restrictions will be followed: no ice-cold beverages below <40°F) but graham 
crackers and room temperature juice will be allowed after the kansui dose (up to three 
servings of each), but other food & beverages will be restricted until AFTER 2+hr post-
dose draw. 
Study staff will then observe administration and side effects of participants on the day(s) 
of kansui treatment.  
Study staff will similarly dispense and observe study participant take 1 packet of 100% pure 
decaffeinated black tea in 4 mL of water prepared as follows: 
a. One packet of Twinings English breakfast 100% pure black decaffeinated tea from the 
labeled vial will be place into a 6-ounce Styrofoam or paper cup.  
c. Four ounces of boiled water cooled to 170-185° F will be added to the tea in cup. 
Research staff will measure the water temperature using a designated thermometer for 
tea use only. 
d. The tea will be stirred for approximately 30 seconds using a wooden stirring stick.  
e. The tea will be allowed to cool for at least 5 minutes, reaching a temperature of less than 
or equal to 100° F, before administration. 
f. All contents in the cup will be checked to ensure that the tea and water have been stirred 
appropriately and fully consumed.  Research staff will record the time of dose (Time 0) 
on the treatment flowsheet.   
g. Specific restrictions will be followed: no ice-cold beverages below <40°F) but graham 
crackers and room temperature juice will be allowed after the kansui dose (up to three 
servings of each), but other food & beverages will be restricted until AFTER 2+hr post-
dose draw. 
Study staff will then observe administration and side effects of participants on the day(s) 
of placebo administration as above for kansui treatment. 
8.5 
Supply of Study Drug at the Site 
UUH IDS will package the study drug in HDPE vials and arrange for courier delivery 
directly from the UUH IDS Pharmacy to the University of Utah Center for Clinical and 
Translational Science (CCTS) located 421 Wakara Way, Suite 360 in Salt Lake City, UT 
84108. 


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8.5.1 
Storage 
Euphorbia kansui extract powder storage will be in a cool, dry place, away from strong 
light, heat, or moisture. The shelf life is 2 years when properly stored with its original 
packaging. For this study, the vials of pre-measured 1 g doses of Euphorbia kansui 
extract powder will be stored in a locked cabinet in the UUH IDS Pharmacy. Entrance to 
the pharmacy is secure by electronic badge access, limited to IDS pharmacy personnel 
and managers. Temperature is controlled by air conditioning and monitored between 15-
25 °C. A fully automated temperature monitoring system provides continuous 
temperature monitoring, recording, and notification. Temperature monitoring hardware 
accurately measure temperature and continually sends information to a web-based 
software system, which is accessible by IDS pharmacy personnel. Temperature records 
can be produced by authorized users for investigational refrigerator, freezer, or ambient 
temperature sensor through the temperature monitoring software system.  If the 
temperature begins to go out of range, then the temperature monitoring software system 
will send a message to the on-call IDS pharmacist, who will respond within 15-30 
minutes and take appropriate action to preserve the quality of the investigational product.  
 
The UUH IDS will dispense study drug to the CCTS and maintain the distribution 
records.  The CCTS Clinical Services Center (CSC) bionutritionist will administer study 
drug to participants and maintain the administration records. 
8.6 
Study Drug Accountability 
An accurate and current accounting of the dispensing of study drug for each participant 
will be maintained on an ongoing basis by the study investigators. The number of study 
drug dispensed will be recorded on the Investigational Drug Accountability Record. The 
study investigators and CSC bionutrtionist will verify these documents throughout the 
course of the study. 
8.7 
Measures of Treatment Compliance 
Study participants will be monitored in the CCTS for directly observed therapy on the 
day(s) when Euphorbia kansui extract powder prepared as tea or placebo is administered. 
They will be receiving clinical and laboratory assessments on those days for up to 6 hours 
post-treatment.


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9 
STUDY PROCEDURES AND GUIDELINES 
Prior to conducting any study-related activities, written informed consent and the Health Insurance Portability and Accountability Act 
(HIPAA) authorization must be signed and dated by the participant.  
Eligible participants will receive a single dose for either a single or 3 consecutive days (Cohort 1: day 1; Cohort 2: days 1, 2, 3). Extensive 
sampling will occur before, during, and after the last dose.  A full schedule of events for each cohort is provided below: 
Study Events Table Cohort 1 
Parameter 
Day -14a 
Day -7a 
Day 1 
Day 1 
Day 1 
Day 1 
Day 2 
Day 31 
Early Withdrawal 
Visit (if applicable) 
Screen 
Baseline 
0 hrsb 
0.5 hrsb 
2 hrsb 
4 hrsb 
24-hr post-dose 
Follow-up 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
Questionnaires 
X 
X 
X 
 
 
 
X 
X 
X 
Demographics 
X 
 
 
 
 
 
 
 
 
Medical history, medications, AE 
X 
X 
X 
 
 
 
X 
X 
X 
Vital signs 
X 
 
X 
 
X 
X 
X 
X 
X 
Physical exam (either Complete / Targeted)c 
X 
 
X 
 
 
 
X 
X 
X 
Study kansui administration 
 
 
X 
 
 
 
 
 
 
Complete blood count w/diff 
X 
 
X 
X 
X 
X 
X 
X 
X 
Comprehensive Metabolic Panel 
X 
 
X 
 
 
 
X 
X 
X 
Quantiferon test (QFT) 
X 
 
 
 
 
 
 
 
X 
Pregnancy test (female participants) 
X 
 
 
 
 
 
 
X 
X 
Thyroid-stimulating hormone (TSH) 
X 
 
 
 
 
 
 
 
 
Hep B Ag 
X 
 
 
 
 
 
 
 
 
HCV Ab 
X 
 
 
 
 
 
 
 
 
CD4+/CD8+ T cell counts 
X 
X 
X 
 
 
 
X 
X 
X 
HIV RNA: standard assay  
X 
X 
X 
 
 
 
X 
X 
X 
Immune activation (CD69, CD38, HLA-DR) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
HIV reservoir measures 
X 
X 
X 
X 
X 
X 
X 
X 
X 
PBMC and plasma cryopreservation for 
future studies (PK, transcriptome analyses) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
a Days -14, -7, 4 and 31 represent the time from receiving the first dose of Euphorbia kansui extract powder prepared as tea on the Day 1 Visit.  
b Hours 0, 0.5, 2, and 4 represent time from receiving Euphorbia kansui extract powder prepared as tea dose on that dosing day.  
c The complete physical exam must occur at Screening.  In the event of an Early Withdrawal Visit a complete physical exam is to be performed. A targeted physical exam is to be completed for all other time points. 


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Cohort 2. Participants in cohort 2 will be randomly assigned to either kansui or placebo first. The study will include a 56-day washout period 
between the two treatments (kansui and placebo). On study Day 88 a “second screening” visit for the second treatment assignment will occur; the 
second treatment phase will begin on study Day 102 and end on Day 132. 
Study Events Table Cohort 2 (Treatment Phase 1) 
Parameter 
Day -14a 
Day -7a 
Day 1 
Day 1 
Day 1 
Day 1 
Day 2 
Day 3 
Day 3 
Day 3 
Day 3 
Day 4 
Day 31 
Day 32-87 
Tx #1 
Screening 
Baseline 
Tx #1 
0 hrsb 
0.5 hrsb 
2 hrsb 
4 hrsb 
0 hrsb 
0 hrsb 
0.5 hrsb 
2 hrsb 
4 hrsb 
24-hr post-
dose follow-up 
 
56-Day 
Washout 
Period 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
No Study Procedures During Washout 
Questionnaires 
X 
X 
X 
 
 
 
X 
X 
 
 
 
X 
X 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history, medications, AE 
X 
X 
X 
 
 
 
X 
X 
 
 
 
X 
X 
Vital signs 
X 
 
X 
 
X 
X 
X 
X 
 
X 
X 
X 
X 
Physical exam (either Complete / 
Targeted)c 
X 
 
X 
 
 
 
X 
X 
 
 
 
X 
X 
Study kansui administration 
 
 
X 
 
 
 
X 
X 
 
 
 
 
 
Complete blood count w/diff 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Comprehensive Metabolic Panel 
X 
 
X 
 
 
 
X 
X 
 
 
 
X 
X 
Quantiferon test (QFT) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy test (female 
participants) 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
TSH 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Hep B Ag 
X 
 
 
 
 
 
 
 
 
 
 
 
 
HCV Ab 
X 
 
 
 
 
 
 
 
 
 
 
 
 
CD4+/CD8+ T cell counts 
X 
X 
X 
 
 
 
X 
X 
 
 
 
X 
X 
HIV RNA: standard assay  
X 
X 
X 
 
 
 
X 
X 
 
 
 
X 
X 
Immune activation (CD69, CD38, 
HLA-DR) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
HIV reservoir measures 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
PBMC and plasma 
cryopreservation for future 
studies (PK, transcriptome 
analyses) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
a Days -14, -7, 4, 31, 88, 102-105, and 132 represent the time from receiving the first dose of treatment on the Day 1 Visit.  
b Hours 0, 0.5, 2, and 4 represent time from receiving treatment (kansui or placebo) on that dosing day.  
c The complete physical exam must occur at screening visits (Day -14 and Day 88).  In the event of an Early Withdrawal Visit a complete physical exam is to be performed. A targeted physical exam is 
to be completed for all other time points. 


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Study Events Table Cohort 2 (Treatment Phase 2) 
Parameter 
Day 88 
Day 102 
Day 102 
Day 102 
Day 102 
Day 103 
Day 104 
Day 104 
Day 104 
Day 104 
Day 105 
Day 132 
Early 
Withdrawal 
Visit (if 
applicable) 
Tx #2 
Screening 
Tx #1 
0 hrsa 
0.5 hrsa 
2 hrsa 
4 hrsa 
0 hrsa 
0 hrsa 
0.5 hrsa 
2 hrsa 
4 hrsa 
24-hr post-dose 
follow-up 
 
Informed consent 
 
 
 
 
 
 
 
 
 
 
 
 
 
Questionnaires 
X 
X 
 
 
 
X 
X 
 
 
 
X 
X 
X 
Demographics 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history, 
medications, AE 
X 
X 
 
 
 
X 
X 
 
 
 
X 
X 
X 
Vital signs 
X 
X 
 
X 
X 
X 
X 
 
X 
X 
X 
X 
X 
Physical exam (either 
Complete / Targeted)c 
X 
X 
 
 
 
X 
X 
 
 
 
X 
X 
X 
Study kansui administration 
 
X 
 
 
 
X 
X 
 
 
 
 
 
 
Complete blood count 
w/diff 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Comprehensive Metabolic 
Panel 
X 
X 
 
 
 
X 
X 
 
 
 
X 
X 
X 
Quantiferon test (QFT) 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
Pregnancy test (female 
participants) 
X 
 
 
 
 
 
 
 
 
 
 
X 
X 
TSH 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hep B Ag 
 
 
 
 
 
 
 
 
 
 
 
 
 
HCV Ab 
 
 
 
 
 
 
 
 
 
 
 
 
 
CD4+/CD8+ T cell counts 
X 
X 
 
 
 
X 
X 
 
 
 
X 
X 
X 
HIV RNA: standard assay  
X 
X 
 
 
 
X 
X 
 
 
 
X 
X 
X 
Immune activation (CD69, 
CD38, HLA-DR) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
HIV reservoir measures 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
PBMC and plasma 
cryopreservation for future 
studies (PK, transcriptome 
analyses) 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
a Hours 0, 0.5, 2, and 4 represent time from receiving treatment (kansui or placebo) on that dosing day.  
 


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9.1 
Evaluations by Visit 
A full schedule of events by visit is show above. 
9.1.1 
Screening Procedures 
1. Participants will be consented by the study investigator, or properly trained and 
delegated coordinator, before any procedures take place. Eligibility will be 
confirmed and medical history and concurrent medications ascertained. 
2. A complete physical exam and vital signs, including blood pressure, pulse, 
temperature, respiratory rate, and weight will be performed. 
3. A detailed interview regarding past and current medical history, medications, 
substance abuse will be obtained. 
4. Participants will complete the Baseline Questionnaires, which includes questions 
regarding general and HIV-specific medical history, previous and current 
medications or therapies, medication adherence, previous and intercurrent 
illnesses/conditions, hospitalizations, and minor lifestyle questions.   
5. The full screening blood tests will be obtained: 
a. Complete blood count (hemoglobin, hematocrit, red blood cell count, 
white blood cell count, white blood cell differential, and platelet count) 
b. Comprehensive metabolic panel (serum sodium, potassium, chloride, 
bicarbonate, random glucose, blood urea nitrogen, creatinine) 
c. Liver 
enzymes 
(aspartate 
aminotransferase 
[AST], 
alanine 
aminotransferase [ALT], alkaline phosphatase, total bilirubin, direct 
bilirubin) 
d. Thyroid panel (thyroid stimulating hormone [TSH]) (Please note that for 
Cohort 2: TSH collected at the Screening Visit for Treatment Phase 1 but 
NOT collected for Treatment Phase 2) 
e. Hepatitis B surface antigen and Hepatitis C antibody (Please note that for 
Cohort 2: Hep B and HCV Ag is collected at the Screening Visit for 
Treatment Phase 1 but NOT collected for Treatment Phase 2) 
f. Quantiferon (QFT) 
g. Plasma E-hCG (females only) 
h. CD4+ and CD8+ T cell counts and plasma HIV RNA by clinical assay 
6. Blood will also be collected for: 
a. Immunophenotyping (CD69, CD38, HLA-DR expression on CD4+ and 
CD8+ T cells) 
b. Latent HIV reservoir quantification (cell-associated HIV RNA, plasma 
HIV RNA). Given the potential for diurnal effect on the measures of HIV 
in resting cells, the first blood draw on this day will occur between 7:30 to 
9:30 am. 
c. Transcriptome analysis (RNA-seq) 


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9.1.2 
Baseline Procedures 
1. For eligible participants, a baseline visit will occur within 2 weeks of the 
screening visit and prior to day 1. 
2. Concomitant medications and adverse events will be reviewed. 
3. Baseline questionnaire will be re-administered. 
4. Blood will be collected for: 
a. CD4+ and CD8+ T cell counts and plasma HIV RNA by clinical assay 
b. Latent HIV reservoir quantification (cell-associated HIV RNA, plasma 
HIV RNA. Given the potential for diurnal effect on the measures of HIV 
in resting cells, the first blood draw on this day will occur between 7:30 to 
9:30 am. 
c. PMBC (transcriptomics analyses) and plasma (PK analyses) storage 
9.1.3 
Dosing Day Procedures 
1. For eligible participants, Day 1 will occur within 2 weeks of the screening visit. 
The 0.5, 2, and 4 hour visits noted below will occur within 30 minute windows. 
Participants will be free to leave the clinic in between the 0, 0.5, 2, and 4 hour 
visits. 
2. 0 hours (prior to study drug administration that day) 
a. History including concomitant medications and adverse event record 
b. Follow-up questionnaires will be administered 
c. Targeted physical examination & vital signs 
d. Full blood examination (CBC, CMP) 
e. HIV RNA: standard assay 
f. Immune activation (CD69, CD38, HLA-DR expression on CD4+ and 
CD8+ T cells) 
g. HIV reservoir: Given the potential for diurnal effect on the measures of 
HIV in resting cells, the first blood draw on this day will occur between 
7:30 to 9:30 am. 
i. Plasma HIV RNA (single copy assay) 
ii. Cell associated HIV RNA (unspliced RNA) in CD4+ T-cells.  
h. PBMC and plasma storage as below 
3. 0.5 hours (after study drug administration that day) 
a. CBC with differential 
b. Immune activation 
c. PBMC and plasma cryopreservation 
4. 2 hours (after study drug administration that day) 


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a. Vital signs 
b. CBC with differential 
c. Immune activation 
d. PBMC and plasma cryopreservation 
5. 4 hours (after study drug administration that day) 
a. Vital signs 
b. CBC with differential 
c. Immune activation 
d. PBMC and plasma cryopreservation 
9.1.4 
Post-Dosing Days Procedures 
1. No dosing will occur at the 24-hour follow-up visit following the last dosing day, 
nor on Day 31.   
2. A history including concomitant medications, adverse event record and 
assessment of adherence antiretroviral therapy.  
3. A physical assessment will occur as needed.  
4. Vital signs will be obtained. 
5. Follow-up Questionnaire will be re-administered. 
6. Full blood examination including CBC, CHEM-7, and LFTs will be performed.  
7. Samples will be collected for immunophenotyping (CD69, CD38, HLA-DR 
expression on CD4+ and CD8+ T cells), and for quantification of the latent HIV 
reservoir (plasma HIV RNA, cell associated HIV RNA in CD4+ T-cells). PBMCs 
and plasmas will be collected for future transcriptomics and PK analyses, 
respectively. 
9.1.5 
Early Withdrawal Visit 
1. Record any Adverse Experiences and/or Review participant diary for adverse 
experiences and exclusionary medication use. 
2. Record changes to concomitant medications. 
3. Follow-up Questionnaire will be re-administered. 
4. Perform complete physical examination, including recording of vital signs. 
5. Collect blood for clinical laboratory tests (CBC, CHEM-7, LFTs) 
6. Collect samples for immunophenotyping (CD69, CD38, HLA-DR expression on 
CD4+ and CD8+ T cells), and for quantification of the latent HIV reservoir 
(plasma HIV RNA, cell associated HIV RNA in CD4+ T-cells. 
7. PBMCs and plasmas will be collected for future transcriptomics and PK analyses, 
respectively. 


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9.2 
Clinical Assessments 
9.2.1 
Concomitant Medications 
All concomitant medication and concurrent therapies will be documented at Screening/ 
Baseline, Study Treatment Day(s), at the 24-hour post dosing follow-up visits on Day 2 
(for Cohort 1) and Days 4 and 105 (for Cohort 2), and Day 31 and 132. Dose, route, unit 
frequency of administration, and indication for administration and dates of medication 
will be captured. 
9.2.2 Demographics  
Demographic information (date of birth, gender, race) will be recorded at Screening. 
9.2.3 Medical History  
Relevant medical history, including history of current disease, other pertinent medical 
history, and information regarding underlying diseases will be recorded at Screening. 
Updated medical history including medication reconciliation and medication adverse 
effects will be recorded at Baseline, Study Treatment Day(s), at the 24-hour post dosing 
follow-up visits on Day 2 (for Cohort 1) and Days 4 and 105 (for Cohort 2), and Day 31 
and 132. 
9.2.4 
Physical Examination 
A complete physical examination will be performed by a study physician at Screening. 
Targeted physical examination will be performed on Study Treatment Day(s), at the 24-
hour post dosing follow-up visits on Day 2 (for Cohort 1) and Days 4 and 105 (for Cohort 
2), and Day 31 and 132.   
9.2.5 
Vital Signs 
Body temperature, blood pressure, pulse and respirations will be performed after resting 
for 5 minutes at Baseline/Screening, Study Treatment Day(s), at the 24-hour post dosing 
follow-up visits on Day 2 (for Cohort 1) and Days 4 and 105 (for Cohort 2), and Day 31 
and 132. 
9.2.6 
Questionnaires 
Study questionnaires were developed in collaboration between UCSF and UCLA 
investigators for use in clinical trials evaluating the safety and efficacy of HIV cures.  
The questionnaires consist of a detailed interview, including medical history, current and 
previous medications/therapies, medication adherence, previous and intercurrent 
illnesses/conditions, hospitalizations, lifestyle, side effects, adverse events, etc.  There is 
a baseline and follow-up version, both of which are completed electronically through the 
REDCap web application.  The baseline/screening questionnaires require approximately 
45-60 minutes to complete and the follow-up questionnaires require approximately 15-30 
minutes. 


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9.2.7 
Adverse Events 
Information regarding occurrence of adverse events will be captured throughout the 
study. Duration (start and stop dates and times), severity/grade, outcome, treatment and 
relation to study drug will be recorded on the case report form (CRF). Criteria for 
participant management, dose interruptions, modifications, and discontinuation of 
treatment will be mandated only for toxicities attributable to kansui. 
9.3 
Clinical Laboratory Measurements 
9.3.1 
Basic Laboratory Measures 
Blood will be obtained and sent to the San Francisco General Hospital clinical laboratory 
for complete blood count (hemoglobin, hematocrit, red blood cell count, white blood cell 
count, white blood cell differential, and platelet count), blood chemistry profile (serum 
sodium, potassium, chloride, bicarbonate, random glucose, blood urea nitrogen, 
creatinine), 
and 
liver 
enzymes 
(aspartate 
aminotransferase 
[AST], 
alanine 
aminotransferase [ALT], alkaline phosphatase, total bilirubin, direct bilirubin). At 
screening, additional laboratory measures will include Hepatitis B surface antigen and 
Hepatitis C antibody, thyroid panel (thyroid stimulating hormone [TSH]), quantiferon 
(QFT), and plasma E-hCG (females only).  
9.4 
Pharmacokinetic Measurements 
Blood for determination of serum concentrations of ingenol (the component in kansui 
powder that has been shown to reactivate latent HIV in vitro and in animal models) will 
be collected at 0.5, 2, 4, and 24 hours after each dose of kansui, with the exception of the 
Day 2 and Day 103 visits for Cohort 2, which will be collected at 24 hours post-dose. For 
example, for cohort 1, blood will be collected for PK measurement on day 1 (hours 0.5, 
2, 6) and day 2 (hour 0). For cohort 2, blood will be collected for PK measurement on 
days 1 and 102 (hours 0.5 2, 4), days 2 and 103 (hours 0), and days 3 and 104 (hours 0, 
0.5, 2, 4). Serum concentrations of ingenol will also be collected at the 24-hour post 
dosing follow-up visits on Day 2 (for Cohort 1) and Days 4 and 105 (for Cohort 2), and 
Day 31 and 132 for all dosing cohorts. 
9.5 
Research Laboratory Measurements  
9.5.1 
HIV Clinical Laboratory Assay Measures 
Blood will be obtained and sent to San Francisco General Hospital clinical laboratory for 
real-time determination of CD4+ and CD8+ T cell counts and plasma HIV RNA (viral 
load). 
9.5.2 
HIV Immunologic and Virologic Research Assay Measures 
Blood will also be collected before, during, and after dosing to measure parameters of 
immune activation (CD69, CD38, and HLA-DR expression on CD4+ and CD8+ T cells) 
and to quantify the latent HIV reservoir (cell-associated HIV RNA [unspliced RNA] and 
plasma HIV RNA [single copy assay]). Given the potential for diurnal effect on the 
measures of HIV in resting cells, the blood draw for the 0-hour (zero hour) time point 


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(prior to first dose of kansui) will occur between 7:30 to 9:30 am on the screening, 
baseline, and treatment day(s). 
9.5.3 
Transcriptome Analyses 
We will measure the host and viral transcriptome pre- and post-dosing by performing 
RNA sequencing (RNA-seq) on isolated CD4+ T-cells and applying validated 
bioinformatic pipelines for gene expression analysis. Transcriptomic profiling of 
longitudinal samples will enable characterization of the effects of kansui (which contains 
ingenols) on host gene expression. In addition, consideration of the gene expression data 
within the context of the aforementioned virologic measurements will allow us to identify 
specific host transcriptomic correlates of viral reactivation. We hypothesize that the 
expression of particular genes (NFkB pathway components, cell-cycle regulators, cell-
intrinsic immune factors) will be associated with the degree of viral reactivation.  
9.6 
Optional Tissue Banking  
We are interested in collecting plasma and peripheral blood mononuclear cells taken from 
peripheral whole blood to be used in future studies on HIV eradication, including 
immunologic studies to evaluate markers of inflammation and viral transcription.  
Provided samples will be shipped from the University of Utah to be stored and 
maintained as part of the UCSF SCOPE Cohort at the UCSF AIDS Specimen Bank 
(ASB), which specializes in biospecimen storage and processing.  Specimens will be 
stored in Oyster Point at 612 Forbes Boulevard in South San Francisco, CA. 
Specimens stored for future use will not contain any identifiable information.  Samples 
will be coded with a 4-digit PID code and include the collection date and specimen type 
(i.e., PBMC, plasma, serum, etc.). This code will be kept confidential and only the 
Principle Investigators will have access to the key linking specimens to study 
participants.  The Principle Investigator will not give participant names or other 
identifying information to researchers who want to use specimens stored in the tissue 
bank, but will only provide non-identifying information, like age and disease history. 
Future studies may be performed by scientists based at the University of Utah, the 
University of California, San Francisco and/or by scientists based at other institutions, 
such as other universities, the NIH and commercial laboratories.  The types of studies 
which may be performed using tissue bank specimens include:  
x tests for infections that are common in HIV-infected patients, such as 
cytomegalovirus or human herpesvirus 8  
x genetic testing 
x new tests to measure the amount of “latent” HIV reservoir.   
Genetic information (genotype data) and medical record data (phenotype data) may be 
shared broadly in a coded form for future genetic research or analysis. Non-identifiable 
medical information (diagnoses, blood pressure, age if less than 85) may be provided to 
other scientists or companies not at the University of Utah or UCSF, including a public 
government health research database.  Research results from studies conducted from the 


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tissue bank will not be returned to participants, included in patient medical records, or 
provided to their local study doctors. 
Researchers that wish to obtain tissue samples from the bank are required to complete a 
SCOPE sample request form, which is reviewed and approved by the SCOPE study PI, 
Dr. Steve Deeks, MD, and the primary study coordinator, Becky Hoh.  Dr. Deeks is a 
Professor of Medicine in Residence at the University of California, San Francisco 
(UCSF) and a faculty member in the Division of HIV, Infectious Diseases and Global 
Medicine at Zuckerberg San Francisco General Hospital. Dr. Deeks has been engaged in 
HIV research and clinical care since 1993. 
Specimens will be kept until they are used up or destroyed.   
Providing the specimen for use in future research is optional for participants.  Should a 
participant choose to withdraw their sample from the tissue bank they can have their 
blood sample removed by contacting the Principle Investigator using contact information 
contained in the consent and authorization form. 
 
10 ADVERSE EXPERIENCE REPORTING AND DOCUMENTATION 
10.1 Adverse Events 
An adverse event (AE) is any untoward medical occurrence in a clinical investigation of a 
patient administered a pharmaceutical product and that does not necessarily have a causal 
relationship with the treatment.  An AE is therefore any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom or disease temporally associated 
with the administration of an investigational product, whether or not related to that 
investigational product.  An unexpected AE is one of a type not identified in nature, 
severity, or frequency in the current Investigator’s Brochure or of greater severity or 
frequency than expected based on the information in the Investigator’s Brochure. 
The Investigator will probe, via discussion with the participant, for the occurrence of AEs 
during each participant visit and record the information in the site’s source documents.  
Adverse events will be recorded in the patient CRF.  Adverse events will be described by 
duration (start and stop dates and times), severity, outcome, treatment and relation to 
study drug, or if unrelated, the cause. 
AE Severity 
The National Cancer Institute’s Common Terminology Criteria for Adverse Events 
(CTCAE) Version 3.0 should be used to assess and grade AE severity, including 
laboratory abnormalities judged to be clinically significant. The modified criteria can be 
found in the study manual.  If the experience is not covered in the modified criteria, the 
guidelines shown in Table 1 below should be used to grade severity.  It should be pointed 
out that the term “severe” is a measure of intensity and that a severe AE is not necessarily 
serious. 


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Table 1.  AE Severity Grading 
Severity (Toxicity Grade) 
Description 
Mild (1) 
Transient or mild discomfort; no limitation in activity; no medical 
intervention or therapy required. The participant may be aware of the 
sign or symptom but tolerates it reasonably well. 
Moderate (2) 
Mild to moderate limitation in activity, no or minimal medical 
intervention/therapy required. 
Severe (3) 
Marked limitation in activity, medical intervention/therapy required, 
hospitalizations possible. 
Life-threatening (4) 
The participant is at risk of death due to the adverse experience as it 
occurred. This does not refer to an experience that hypothetically 
might have caused death if it were more severe. 
 
AE Relationship to Study Drug 
The relationship of an AE to the study drug should be assessed using the following the 
guidelines in Table 2. 
Table 2.  AE Relationship to Study Drug 
Relationship 
to Drug 
Comment 
Definitely 
Previously known toxicity of agent; or an event that follows a reasonable temporal 
sequence from administration of the drug; that follows a known or expected response 
pattern to the suspected drug; that is confirmed by stopping or reducing the dosage of 
the drug; and that is not explained by any other reasonable hypothesis. 
Probably 
An event that follows a reasonable temporal sequence from administration of the 
drug; that follows a known or expected response pattern to the suspected drug; that is 
confirmed by stopping or reducing the dosage of the drug; and that is unlikely to be 
explained by the known characteristics of the participant’s clinical state or by other 
interventions. 
Possibly 
An event that follows a reasonable temporal sequence from administration of the 
drug; that follows a known or expected response pattern to that suspected drug; but 
that could readily have been produced by a number of other factors. 
Unrelated 
An event that can be determined with certainty to have no relationship to the study 
drug. 
10.2 Serious Adverse Experiences (SAE) 
An SAE is defined as any AE occurring at any dose that results in any of the following 
outcomes: 
x 
death 
x 
a life-threatening adverse experience 
x 
inpatient hospitalization or prolongation of existing hospitalization 
x 
a persistent or significant disability/incapacity 


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x 
a congenital anomaly/birth defect  
Other important medical events may also be considered an SAE when, based on 
appropriate medical judgment, they jeopardize the participant or require intervention to 
prevent one of the outcomes listed.  
10.2.1 Serious Adverse Experience Reporting 
The study site will document all SAEs that occur (whether or not related to study drug) 
per the University of Utah IRB Guidelines.  The collection period for all SAEs will begin 
after informed consent is obtained and end after procedures for the final study visit have 
been completed. 
In accordance with the standard operating procedures and policies of the local 
Institutional Review Board (IRB), the site investigator will report SAEs to the IRB.   
 
10.3 Monitoring 
During the study, safety will be monitored by a Safety Monitoring Committee (SMC), 
which will be led by a qualified University of Utah faculty member in the Department of 
Medicine with expertise in HIV clinical research (see Section 13 below).  The SMC will 
review all study procedures before the initiation of the study.  They will have the full and 
final authority to stop the study for any safety concern at any point. The Principal 
Investigator at the University of Utah will be the primary medical monitor responsible for 
study adverse event monitoring and will report adverse events and unanticipated 
problems to the University of Utah IRB and the SMC. All participants will be followed 
for possible adverse events and unanticipated problems throughout the study period.  
Participants will be monitored in an outpatient clinic during the first 4-6 hours post-dose 
on dosing days. At each visit, participants will be assessed for any new symptoms, and a 
study coordinator will obtain vital signs. The study will require 48-hour reporting of all 
laboratory values, signs/symptoms, and serious adverse events (SAEs). The study will 
have intensive Phase I safety monitoring, which will include regular and frequent team 
review (every week for the first 2 months of the study; then every two weeks thereafter) 
of all reported events. In addition, for any Grade 3 or 4 events, sites will be instructed to 
contact the study team by email. 
x Grade 1 or 2 Toxicity: Participants who develop a Grade 1 or 2 AE or toxicity 
may continue study treatment. If a participant chooses to discontinue study 
treatment, the site should notify the kansui protocol core team as noted above, and 
encourage the participant to complete any remaining study visits. 
x Grade 3 or 4 Toxicity: Participants experiencing Grade 3 or 4 AEs requiring 
permanent discontinuation of study treatment should be followed closely for 
resolution of the AE to Grade  2 and the protocol core team must be notified. 
Participants discontinuing study treatment should be encouraged to complete any 
remaining study visits. 
 


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Dr. Adam Spivak will be contacted directly to report medical concerns or questions 
regarding safety. 
Phone: (443) 854-1582 
10.4 Criteria for Discontinuation 
Safety will be monitored by the dedicated SMC, led by a qualified HIV specialist in the 
University of Utah Department of Medicine (see Section 13 below). The SMC will have 
full and final authority to stop the study at any point for safety concerns. Given the 
unknown safety profile of Euphorbia kansui, the first participant in each dosing level will 
complete 5 days of study prior to any further participants commencing the study. The 
decision to proceed with further drug administration will be taken by the Principal 
Investigator, taking into consideration clinical and laboratory adverse events. The 
decision to proceed with the next dosing level will be taken by the SMC. Specifically, 
dosing will be paused and the SMC will be consulted if one Grade 4 or two Grade 3 drug 
related adverse events or laboratory abnormalities are reported.  
In addition, since there is currently insufficient data demonstrating the effect of kansui on 
antiretroviral therapy or other concomitant medications (and vice versa), we will evaluate 
serum HIV-1 RNA levels using standard clinical assays within each dosing cohort prior 
to dose escalation. HIV RNA measures will be collected on the initial dosing day(s) (Day 
1 for Cohort 1, Days 1-3 and 102-104 for Cohort 2), at the 24-hour post dosing follow-up 
visits on Day 2 (for Cohort 1) and Days 4 and 105 (for Cohort 2), and on Day 31 and 132. 
This is to safeguard against the potential risk of virologic failure and/or the development 
of resistance due to sub-therapeutic antiretroviral therapy drug levels in study 
participants. 
Specifically, safety discontinuation criteria will include: 
1. Any serious adverse event assessed as at least possibly related to study treatment: 
a. Any Grade 4 drug-related adverse event or laboratory abnormality 
b. Two Grade 3 drug-related adverse event or laboratory abnormality 
2. Virologic failure (defined as any two consecutive HIV-1 RNA levels >200 
copies/mL or a single HIV-1 RNA level >1000 copies/mL). These values would 
be above the levels predicted to be seen with HIV reactivation with most current 
latent reactivating agents and are safety stopping criteria currently used for other 
HIV latent reactivating agent trials, e.g., the AIDS Clinical Trials Group (ACTG 
5336) trial, evaluating the role of Sirolimus on immune activation and the latent 
reservoir in chronic HIV-infected, ART-suppressed individuals. 
3. Pregnancy or breastfeeding 
4. Requirement for prohibited concomitant medications (see section 7.1) 
5. Clinical reasons believed life threatening by the physician, even if not addressed 
in the toxicity section of the protocol 
The specific adverse events that will be solicited include: diarrhea, gastrointestinal 
irritability, gastrointestinal bleeding, headache, and symptoms of dehydration (light-


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headedness, tachycardia). For the most likely expected reported adverse event, diarrhea, 
we will strictly adhere to established toxicity grading used by the National Cancer Institute 
for chemotherapy-induced diarrhea.39,40 
Grade Description 
1  
Increase of fewer than four stools per day over baseline  
2  
Increase of four to six stools per day over baseline 
3  
Increase of seven or more stools per day over baseline; incontinence; 
hospitalization indicated 
4  
Life-threatening consequences; urgent intervention indicated 
5 
Death 
* Based on information from National Cancer Institute, 2010. 
 
If stopping/pausing criteria are not met, the remainder of the dosing cohort will be 
enrolled/dosed the subsequent week. The study will proceed to the next dosing level 
provided the stopping/pausing criteria are not met. A University of Utah Department of 
Medicine faculty member who is not otherwise involved in the study and who will not 
communicate with the study investigators regarding any aspect of the SMC reports will 
prepare the monitoring reports. The SMC will review accrual, adverse events summaries, 
CD4+ T-cell counts and HIV RNA levels/suppression over time, off-study rates and 
completeness of follow-up, by dose cohort. 
 
11 DISCONTINUATION AND REPLACEMENT OF PARTICIPANTS 
11.1 Early Discontinuation of Study Drug  
A participant may be discontinued from study treatment at any time if the participant or 
the investigator feels that it is not in the participant’s best interest to continue.  The 
following is a list of possible reasons for study treatment discontinuation:  
x Participant withdrawal of consent  
x Participant is not compliant with study procedures 
x Adverse event that in the opinion of the investigator would be in the best interest 
of the participant to discontinue study treatment 
x Protocol violation requiring discontinuation of study treatment 
x Lost to follow-up 
x Sponsor request for early termination of study 
x Positive pregnancy test or breastfeeding (females) 


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If a participant is withdrawn from treatment due to an adverse event, the participant will 
be followed and treated by the Investigator until the abnormal parameter or symptom has 
resolved or stabilized.   
All participants who discontinue study treatment should come in for an early 
discontinuation visit as soon as possible and then should be encouraged to complete all 
remaining scheduled visits and procedures. 
All participants are free to withdraw from participation at any time, for any reason, 
specified or unspecified, and without prejudice. 
Reasonable attempts will be made by the investigator to provide a reason for participant 
withdrawals.  The reason for the participant’s withdrawal from the study will be specified 
in the participant’s source documents (refer to early termination procedures). 
11.2 Withdrawal of Participants from the Study 
A participant may be withdrawn from the study at any time if the participant, the 
investigator, or the Sponsor feels that it is not in the participant’s best interest to 
continue.   
11.3 Replacement of Participants 
Participants who withdraw from the study treatment before last day of study drug dosing 
(i.e., Day 1 for Cohort 1, Day 104 for Cohort 2) will be replaced by another enrolled 
participant to maintain total study numbers.  
The CRF will document the reason for the withdrawal and date of withdrawal. Date of 
withdrawal will be documented as the date of last study drug treatment, not the date that 
the decision to withdraw treatment was made. 
Participants will be followed after withdrawal from the study for 3 calendar days after 
cessation of treatment. All adverse events during that period will be reported. 
 
12 PROTOCOL VIOLATIONS 
A protocol violation occurs when the participant or the study investigator fails to adhere 
to significant protocol requirements affecting the inclusion, exclusion, participant safety 
and primary endpoint criteria.  Protocol violations for this study include, but are not 
limited to, the following: 
x Failure to meet inclusion/exclusion criteria 
x Use of a prohibited concomitant medication 
Failure to comply with Good Clinical Practice (GCP) guidelines will also result in a 
protocol violation. The Principal Investigator will determine if a protocol violation will 
result in withdrawal of a participant. 
When a protocol violation occurs, it will be discussed with the investigator and a Protocol 
Violation Form detailing the violation will be generated. A copy of the form will be filed 
in the site’s regulatory binder and in the Sponsor’s files. 


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13 DATA SAFETY MONITORING  
The study will require 48-hour reporting by sites of all laboratory values, signs/ 
symptoms, and SAEs. The study will have intensive Phase I safety monitoring, which 
will include regular and frequent team review (every week for the first 2 months of the 
study; then every two weeks thereafter) of all reported events. In addition, for any Grade 
3 or 4 events, sites will be instructed to contact the study team by email. 
Safety monitoring will include team review of adverse events (including all reported 
signs/symptoms, laboratory abnormalities, diagnoses, and SAEs) and team assessment as 
to the possible relationship of adverse events to the study treatment. The review will also 
include assessment any participants with an unconfirmed CD4+ T cell or HIV RNA 
measurement indicating a potential safety endpoint. Regular team monitoring will also 
assess early study discontinuations and visit/sample completeness. In addition, study 
accrual and baseline characteristics of study participants will be reviewed periodically 
during accrual. After a dose cohort has completed accrual and sufficient follow-up time is 
available, the team will evaluate whether to dose-escalate and open the next dose cohort 
to accrual, as described below. 
Safety Monitoring Committee (SMC). We have established an independent Safety 
Monitoring Committee (SMC) for this study. As safety concerns for kansui pertain 
primarily to gastrointestinal symptoms (expected to be mild) and perhaps control of HIV 
infection, these areas are represented on the SMC by well-recognized experts: Dr. 
Andrew Pavia (Professor of Medicine, University of Utah, expert in epidemiology, 
infectious disease, HIV, and clinical research), Dr. Ma Somsouk (Assistant Professor of 
Medicine, UCSF, expert in clinical gastroenterology), Rick Hecht (Professor of 
Medicine, UCSF, and an expert in complementary medicine) and Annie Luetkemeyer 
(Associate Professor of Medicine, UCSF, and expert on HIV management and clinical 
trials). 
The committee will be co-chaired by Dr. Pavia at the University of Utah and Dr. Hecht at 
UCSF, who both have experience in the regulatory aspects of clinical trials and will 
independently deliberate using study data. 
The SMC will meet after completion of each dose cohort to review safety data. The 
meeting will occur no earlier that two weeks after the last dose. The decision to move to 
the next dose cohort will be made by the SMC, after consultation with the study 
investigators.  
A study data coordinator will produce administrative reports regularly describing study 
progress including the following: (1) accrual, (2) demographics, (3) study subject status, 
(4) laboratory data, and (5) number and type of serious AEs. Reviews will be 
communicated to the University of Utah and UCSF Committee on Human Research 
(CHR), study sponsor, and/or federal agencies, as appropriate. The SMC will have access 
to treatment assignment. The study will be discontinued if the SMC determines that it is 
in the best interest of the subjects. 
Grade 1 or 2 AEs will not result in any change to the study plans. If there is evidence for 
a Grade 3 AE that is not caused by the study drug, the study will continue as planned. On 


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the other hand, Grade 3 AEs thought to be possibly caused by the intervention and any 
Grade 4 AEs will result in a hold on any future enrollments until a decision to proceed or 
to stop the study is made by the SMC 
 
14 STATISTICAL METHODS AND CONSIDERATIONS 
14.1 Data Sets Analyzed 
Dr. Lee will be performing the data analysis for the study. Paired analyses using 
Wilcoxon signed rank tests will be performed to evaluate whether there is a statistically 
significant change in markers of immune activation (CD69, CD38, and/or HLA-DR) on 
CD4+ and CD8+ T cells after a 1, 2, or 3 doses of Euphorbia kansui extract powder 
prepared as tea compared to baseline (reference will be the average of the three baseline 
measures). Multivariate analyses will then be performed to evaluate the association 
between kansui and measures of immune activation at post-dosing, using linear mixed 
effects models, which account for within-participant correlation of observations and 
allows for greater stability in the estimate of the outcome measures within individuals.  
Similarly, for measures of the HIV reservoir, we will perform linear mixed effects 
regression to compare CA-US RNA levels before and after kansui and use negative 
binomial mixed effects regression (a method to analyze over-dispersed count data) to 
compare plasma HIV RNA levels before and after kansui administration (reference will 
be the average of three baseline measures). 
14.2 Demographic and Baseline Characteristics 
The following demographic variables at screening will be summarized by dose level: 
race, gender, age, height and weight.   
14.3 Analysis of Primary Endpoint 
The safety and tolerability data will be summarized by dosing cohort. Adverse events will 
be tabulated by dosing cohort and will include the number of participants for whom the 
event occurred, the rate of occurrence, and the severity and relationship to study drug. 
We may be underpowered to perform Fisher’s exact tests to compare crude rates of 
adverse events between dosing cohorts or to perform adequate Cochran-Armitage trend 
tests for dose-toxicity. 
14.4 Analysis of Secondary Endpoints 
We will perform Wilcoxon rank sum tests to compare levels of immune activation 
(CD69, CD38, and/or HLA-DR expression on CD4+ and CD8+ T cells) between dosing 
cohorts and Wilcoxon signed rank tests to compare measures within individuals. We will 
perform linear mixed effects modeling to compare the effect of Euphorbia kansui extract 
powder prepared as tea on immune activation over time and account for repeated 
measures within individuals, compared to pre-treatment (using the average of three 
baseline measures). Similarly, we will perform linear mixed effects regression modeling 
to assess changes in CA-US RNA levels and use negative binomial mixed effects 


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modeling to changes in plasma HIV RNA levels, before and after kansui administration 
(the reference will be the average of three baseline measures). 
14.5 Sample Size 
A total of 8 participants (2 in dosing cohort 1 and 6 in dosing cohort 2) will contribute to 
the analysis, with 8 or 25 timepoint measures, respectively. The within-individual 
variability will be reduced by repeated measurements post-dose. Based on existing data 
from our study population regarding the percent CD38+HLA-DR+ CD4+ T cells 
(standard deviation of 4.9%) in our study population and a paired, one sample, repeated 
measures analysis, we will have greater than 80% power to detect a 2.7% change in 
CD4+ T cell activation levels post-dose. Similarly, we will have greater than 80% power 
to detect a 17% change in cell-associated HIV-1 RNA and a 0.37% change in plasma 
HIV-1 RNA. 
 
15 DATA COLLECTION, RETENTION AND MONITORING 
15.1 Data Collection Instruments 
The Investigator will prepare and maintain adequate and accurate source documents 
designed to record all observations and other pertinent data for each participant treated 
with the study drug.   
Case report forms (CRFs) will be provided for each participant. Study personnel will 
enter data from source documents corresponding to a participant’s visit into the protocol-
specific paper CRF when the information corresponding to that visit is available.  
Participants will not be identified by name in the study database or on any study 
documents to be collected by the study investigators, but will be identified by a four-digit 
patient identification number (PID). If a correction is made on a CRF, the study staff 
member will line through the incorrect data, write in the correct data and initial and date 
the change. 
The Principal Investigator is responsible for all information collected on participants 
enrolled in this study.  All data collected during the course of this study must be reviewed 
and verified for completeness and accuracy by the Principal Investigator.  A copy of the 
CRF will remain at the study site at the completion of the study. 
15.2 Data Management Procedures 
All data for our proposed study will be managed by the UCSF Data Coordinating Center, 
which is housed in the Department of Epidemiology and Biostatistics. This center 
currently serves 25 multicenter cohort and randomized trials throughout the world. Data 
management for this study will be directed by Dr. Jeffrey Martin, who has worked on 
similar studies for the past five years.  
The UCSF Department of Epidemiology and Biostatistics complies with federal, state, 
University, and campus electronic information security requirements through a 
combination of physical, technical, procedural, and management controls. At the 
procedural level, all Coordinating Center (CC) personnel sign a confidentiality agreement 


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and undergo security awareness training for HIPAA and the handling of sensitive data. 
All employees of the University of California, San Francisco were required to obtain 
Security Awareness Training and implement appropriate security measures. New 
employees who use computers must take this training. Remote users of the data also 
receive training from the Data Management Group prior to gaining access to data 
systems. 
15.3 Data Quality Control and Reporting 
After data have been entered into the study database, a system of computerized data 
validation checks will be implemented and applied to the database on a regular basis. 
Query reports (Data Clarification Requests) pertaining to data omissions and 
discrepancies will be forwarded to the Investigators and study monitors for resolution.  
The study database will be updated in accordance with the resolved queries.  All changes 
to the study database will be documented. 
15.4 Archival of Data 
The database is safeguarded against unauthorized access by established security 
procedures; appropriate backup copies of the database and related software files will be 
maintained.  Databases are backed up by the database administrator in conjunction with 
any updates or changes to the database.   
The network at UCSF CC is privately maintained, hardware firewalled and none of the 
workstations or database servers can be directly addressed from outside the Local Area 
Network. Website communications are encrypted using an SSL certificate. Network OS 
is Windows Active Directory. Remote access is via SSL-VPN. A network administrator 
and server administrators support the network and servers and the Data Systems Services 
Group (developers/database administrators) support the database and web applications. 
The support team is paged 24/7 when servers or critical data center equipment 
experiences issues. 
All study data is housed at the UCSF CC in a secure server room. The building is locked 
outside of normal business hours. All system servers are located in a limited access suite 
fitted with an Access Control System. Within the locked suite is a locked server room 
fitted with an additional secure door. Only critical Information Systems staff possesses 
the access code required to enter the room. All who enter the system server room must 
sign a server room access log in accordance with UCSF CC IT Security SOPs. 
Study database access is controlled via two-factor password security. Development 
workstation access is controlled via Microsoft logon. Once a workstation is accessible, 
access to the study data on the SQL server via any development application requires 
appropriate 
logon-specific 
permission 
assigned 
in 
SQL 
Security 
Manager. 
Communication between study servers and client machines on the UCSF network are 
encrypted using an SSL certificate.  All servers are protected from viruses by McAfee 
VirusScan. This software automatically checks for virus signature file updates from a 
McAfee FTP site once an hour, and if necessary directly updates itself. All anti-virus 
software is monitored and network personnel notified in the event that the software stops 
functioning on a given server. 


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All study data are stored on SQL servers managed by the UCSF Coordinating Center. All 
servers are housed in a secure server room. 
Web site access: The study web sites are protected by two hardware-based firewalls to 
shape incoming and outgoing traffic. Access to the study management web site is 
restricted to approved personnel only. Approved personnel gain access to the system 
using a multi-layered authentication scheme.   A log of all personnel with level of access 
is kept and updated regularly. Once a clinic site user accesses the system they are only 
permitted to view data received from their site, with the exception of official aggregate 
reports. Users are not permitted to view or alter another clinic's data. 
Data transmission from web server to client: The UCSF CC currently utilizes Secure 
Socket Layer (SSL) protocol which protects all data transmission sent over the Internet 
between the CC IIS Web Server and every client machine which accesses our study web 
sites. 
System Backup 
Back-ups: All department workstations and servers are automatically backed-up every 
night. Back-up systems are monitored daily. 
Failover Site: As part of the nightly database maintenance procedures, all SQL databases 
are backed up to a "failover" site at our co-location facility.  This site has copies of the 
study databases as well as all associated systems required to carry on a study in the event 
of a disaster at the primary location. 
Off-site Storage: Network back-ups are written to tape and sent to an off-site vendor 
every two weeks, with tapes being rotated every two months. 
Recovery/File Restores: If important files or data from the network are accidentally 
deleted, the IT staff can locate the items and restore data within an hour in most cases. 
15.5 Availability and Retention of Investigational Records 
The Investigator must make study data accessible to the monitor, IRB, and Regulatory 
Agency (e.g., FDA) inspectors upon request.  A file for each participant must be 
maintained that includes the signed Informed Consent, HIPAA Authorization and copies 
of all source documentation related to that participant.  The Investigator must ensure the 
reliability and availability of source documents from which the information on the CRF 
was derived. 
All study documents (patient files, signed informed consent forms, copies of CRFs, Study 
File Notebook, etc.) must be kept secured for a period of two years following marketing 
of the investigational product or for two years after centers have been notified that the 
IND has been discontinued.   
15.6 Participant Confidentiality 
In order to maintain participant confidentiality, only a site number, participant number 
and participant initials will identify all study participants on CRFs and other 
documentation submitted to the Sponsor.   
 


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16 ADMINISTRATIVE, ETHICAL, REGULATORY CONSIDERATIONS 
The study will be conducted according to the Declaration of Helsinki, Protection of 
Human Volunteers (21 CFR 50), Institutional Review Boards (21 CFR 56), and 
Obligations of Clinical Investigators (21 CFR 312). 
To maintain confidentiality, all laboratory specimens, evaluation forms, reports and other 
records will be identified by a coded number and initials only.  All study records will be 
kept in a locked file cabinet and code sheets linking a patient’s name to a patient 
identification number will be stored separately in another locked file cabinet.  Clinical 
information will not be released without written permission of the participant, except as 
necessary for monitoring by the FDA.  The Investigator must also comply with all 
applicable privacy regulations (e.g., Health Insurance Portability and Accountability Act 
of 1996, EU Data Protection Directive 95/46/EC). 
16.1 Protocol Amendments 
Any amendment to the protocol will be written by the study investigators.  Protocol 
amendments cannot be implemented without prior written IRB approval except as 
necessary to eliminate immediate safety hazards to patients.  A protocol amendment 
intended to eliminate an apparent immediate hazard to patients may be implemented 
immediately, provided the IRBs are notified within five working days. 
16.2 Institutional Review Boards and Independent Ethics Committees 
The protocol and consent form will be reviewed and approved by the IRB of the 
participating center prior to study initiation.  Serious adverse experiences regardless of 
causality will be reported to the IRB in accordance with the standard operating 
procedures and policies of the IRB, and the Investigator will keep the IRB informed as to 
the progress of the study.  The Investigator will obtain assurance of IRB compliance with 
regulations. 
Any documents that the IRB may need to fulfill its responsibilities (such as protocol, 
protocol amendments, Investigator’s Brochure, consent forms, information concerning 
patient recruitment, payment or compensation procedures, or other pertinent information) 
will be submitted to the IRB.  The IRB written unconditional approval of the study 
protocol and the informed consent form will be in the possession of the Investigator 
before the study is initiated.  The IRB unconditional approval statement will be 
transmitted by the Investigator prior to the shipment of study supplies to the site.  This 
approval must refer to the study by exact protocol title and number and should identify 
the documents reviewed and the date of review. 
Protocol and/or informed consent modifications or changes may not be initiated without 
prior written IRB approval except when necessary to eliminate immediate hazards to the 
patients or when the change(s) involves only logistical or administrative aspects of the 
study.  Such modifications will be submitted to the IRB and written verification that the 
modification was submitted and subsequently approved should be obtained.   
The IRB must be informed of revisions to other documents originally submitted for 
review; serious and/or unexpected adverse experiences occurring during the study in 
accordance with the standard operating procedures and policies of the IRB; new 


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information that may affect adversely the safety of the patients of the conduct of the 
study; an annual update and/or request for re-approval; and when the study has been 
completed. 
16.3 Informed Consent Form  
Informed consent will be obtained in accordance with the Declaration of Helsinki, ICH 
GCP, US Code of Federal Regulations for Protection of Human Participants (21 CFR 
50.25[a,b], CFR 50.27, and CFR Part 56, Subpart A), the Health Insurance Portability 
and Accountability Act (HIPAA, if applicable), and local regulations. 
The Investigator will prepare the informed consent form and HIPAA authorization and 
provide the documents to the Sponsor or designee for approval prior to submission to the 
IRB.  The consent form generated by the Investigator must be acceptable to the Sponsor 
and be approved by the IRB.  The written consent document will embody the elements of 
informed consent as described in the International Conference on Harmonisation and will 
also comply with local regulations. The Investigator will send an IRB-approved copy of 
the Informed Consent Form to the Sponsor (or designee) for the study file. 
A properly executed, written, informed consent will be obtained from each participant 
prior to entering the participant into the trial.  Information should be given in both oral 
and written form and participants must be given ample opportunity to inquire about 
details of the study. A copy of the signed consent form will be given to the participant, 
and the original will be maintained with the participant’s records. 
16.4 Publications  
The publication or presentation of any study results shall comply with all applicable 
privacy laws, including, but not limited to, the Health Insurance Portability and 
Accountability Act of 1996.  
16.5 Investigator Responsibilities 
By signing the Agreement of Investigator form, the Investigator agrees to: 
1. Conduct the study in accordance with the protocol and only make changes after 
notifying the Sponsor (or designee), except when to protect the safety, rights or 
welfare of participants. 
2. Personally conduct or supervise the study (or investigation). 
3. Ensure that the requirements relating to obtaining informed consent and IRB review 
and approval meet federal guidelines, as stated in § 21 CFR, parts 50 and 56. 
4. Report to the Sponsor or designee any AEs that occur in the course of the study, in 
accordance with §21 CFR 312.64. 
5. Ensure that all associates, colleagues and employees assisting in the conduct of the 
study are informed about their obligations in meeting the above commitments. 
6. Maintain adequate and accurate records in accordance with §21 CFR 312.62 and to 
make those records available for inspection with the Sponsor (or designee). 


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7. Ensure that an IRB that complies with the requirements of §21 CFR part 56 will be 
responsible for initial and continuing review and approval of the clinical study. 
8. Promptly report to the IRB and the Sponsor (or designee) all changes in the research 
activity and all unanticipated problems involving risks to participants or others (to 
include amendments and IND safety reports). 
9. Seek IRB approval before any changes are made in the research study, except when 
necessary to eliminate hazards to the patients/participants. 
10. Comply with all other requirements regarding the obligations of clinical investigators 
and all other pertinent requirements listed in § 21 CFR part 312. 
 
 


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