Clinical trial NCT03308786
Conditions: HIV Infection
Sponsor: Case Western Reserve University
Start date: 2019-04-01; Completion date: 2020-08-20
Enrollment: 9 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
The purpose of this pilot study is to examine the effects of eight 4-day cycles of subcutaneous recombinant interleukin-2 (rIL-2) given every 8 weeks on levels of replication-competent HIV in CD4 cells and on the size of HIV viral reservoir in up to 20 participants with chronically suppressed HIV infection (viral load \<50 copies/mL).

Detailed description:
Interleukin-2 (IL-2) has been extensively studied in HIV infected individuals with no demonstrated clinical benefit as far as improving survival or decreasing risk of progression to AIDS. The results of the two landmark, international, multicenter, phase III, randomized trials of IL-2 in HIV infected participants (SILCAAT and ESPRIT) have been recently published. These trials, which started more than a decade ago, enrolled over 5800 participants who were randomized to anti-retroviral therapy (ART) +/- IL-2 and showed no benefit to IL-2 treatment in survival or progression to AIDS. Many individuals with HIV infection can lead normal lives on ART but replication-competent virus remains within resting CD4+ cells, referred to as the "HIV reservoir". There is a renewed interest in strategies to decrease or eliminate the viral reservoir in an attempt to provide a sterilizing or a functional "cure" for HIV that would allow the discontinuation of ART, which currently must be taken life-long. These therapies have long-term metabolic and cardiovascular toxicities as well as substantial cost. More recent data suggest that IL-2 administration may decrease the size of the HIV reservoir, getting ART-treated participants closer to levels of HIV persistence that may ultimately allow for sterilizing or functional cure.

The purpose of this pilot study is to examine the effects of eight 4-day cycles of subcutaneous recombinant interleukin-2 (rIL-2) given every 8 weeks on levels of replication-competent HIV in CD4 cells and on the size of HIV viral reservoir in up to 20 participants with chronically suppressed HIV infection (viral load \<50 copies/mL).

Arms: arm 1: Subcutaneous recombinant interleukin-2 (rIL2), 5 MIU twice daily for four consecutive days(cycle) every 8 weeks for 8 cycles, in addition to combination antiretroviral therapy.
Interventions: intervention 1: Recombinant Interleukin-2
Intervention descriptions: intervention 1: Subcutaneous recombinant interleukin-2 (rIL2), 5 MIU twice daily for four consecutive days(cycle) every 8 weeks for 8 cycles

Protocol documents:
Prot_SAP_000.pdf: 
 
i 
 
AIDS 400 
 
HIV Reservoir Reduction with Interleukin-2 
 
Funded by: 
Gilead Sciences 
 
 
 
IND Holder and Sponsor: Benigno Rodriguez, MD 
Study Phase: II 
This protocol will be performed under the following IND#: 137291 
 
 
 
Protocol Co-Chairs:  
 
Benigno Rodriguez, MD 
 
 
 
 
 
Michael M. Lederman, MD 
 
 
Study Coordinator:  
 
Jane Baum, RN 
 
 
 
 
 
 
Version 2.3 
December 17th, 2019 
 
 


 
ii 
TABLE OF CONTENTS 
 
Contents 
TABLE OF CONTENTS .................................................................................................. ii 
SITES PARTICIPATING IN THE STUDY ......................................................................... vi 
PROTOCOL TEAM ROSTER ........................................................................................ vii 
STUDY MANAGEMENT .............................................................................................. ix 
CLINICAL MANAGEMENT .......................................................................................... ix 
SYNOPSIS 1 
Introduction ........................................................................................................................... 1 
Purpose .................................................................................................................................. 1 
Design 1 
Power and Sample Size Considerations .................................................................................. 1 
Inclusion Criteria ..................................................................................................................... 2 
Exclusion Criteria .................................................................................................................... 2 
Study Treatment .................................................................................................................... 3 
Safety Monitoring ................................................................................................................... 4 
Study endpoints and outcome measures ............................................................................... 4 
Primary Objective .................................................................................................................... 4 
Secondary Objectives ............................................................................................................. 4 
A. INTRODUCTION ....................................................................................................... 5 
A.1. BACKGROUND ................................................................................................................ 5 
A.2. INTERLEUKIN-2 AND THE HIV RESERVOIR ........................................................................ 5 
A.3. SUBCUTANEOUS rIL-2 ..................................................................................................... 7 
A.4. CLINICAL EXPERIENCE WITH SUBCUTANEOUS rIL-2 IN HIV INFECTION .......................... 7 
A.5. PHARMACOLOGIC AND SAFETY PROFILE OF THE STUDY AGENT ................................... 8 
B. HYPOTHESES AND STUDY OBJECTIVES ..................................................................11 
B.1. STUDY ENDPOINTS AND OUTCOME MEASURES ............................................................ 11 
B.2. PRIMARY OBJECTIVE ...................................................................................................... 11 
B.3. SECONDARY OBJECTIVES ............................................................................................... 11 
C. 
METHODS .........................................................................................................12 


 
iii 
C.1. STUDY DESIGN .............................................................................................................. 12 
C.2. STATISTICAL CONSIDERATIONS..................................................................................... 12 
C.2.1. Analytic Plan .......................................................................................................... 12 
C.2.2. Power and Sample Size Considerations.................................................................. 13 
C.3. INCLUSION CRITERIA ..................................................................................................... 13 
C.4. EXCLUSION CRITERIA ..................................................................................................... 14 
C.5. STUDY TREATMENT PLAN .............................................................................................. 15 
C.5.1. Study Medication (rIL-2) ........................................................................................ 15 
C.5.2. Guidelines for Dosage Modification ...................................................................... 16 
C.6. CONCOMITANT MEDICATIONS ..................................................................................... 17 
D. CLINICAL AND LABORATORY EVALUATIONS ..........................................................18 
D.1. SCHEDULE OF EVENTS ................................................................................................... 18 
D.2. TIMING AND CONTENT OF EVALUATIONS ..................................................................... 18 
D.2.1. Screening Visit ...................................................................................................... 18 
D.2.2. Leukapheresis Visit ................................................................................................ 18 
D.2.3. rIL-2 Initial Treatment Visit – Cycle 1, Day 0 ......................................................... 19 
D.2.4. rIL-2 Treatment Cycle 1, Day 7 .............................................................................. 19 
D.2.5. rIL-2 Treatment Cycles 4 and 8, Day 0 ................................................................... 20 
D.2.6. rIL-2 Treatment Cycles 4 and 8, Day 7 ................................................................... 20 
D.2.7. rIL-2 Treatment Cycles 2 and 3, Day 0 ................................................................... 20 
D.2.8. rIL-2 Treatment Cycles 5, 6, and 7, Day 0 .............................................................. 21 
D.2.9. rIL-2 Treatment cycles 1-8, Days 2 and 4 ............................................................... 21 
D.2.10. End of Study Visit (or Premature Discontinuation Visit) ....................................... 21 
D.2.11. Immunogenicity follow-up ................................................................................... 22 
D.2.12. Management of off-window visits ....................................................................... 22 
D.2.13. Holding rIL-2 cycles .............................................................................................. 22 
D.3. INSTRUCTIONS FOR EVALUATIONS ................................................................................ 22 
D.3.1. Documentation of HIV ........................................................................................... 22 
D.3.2. Medical History ..................................................................................................... 23 
D.3.3. Medication History ................................................................................................ 23 
D.3.4. Clinical Assessments .............................................................................................. 23 
D.3.5. Laboratory Evaluations .......................................................................................... 24 
D.4. SPECIMEN COLLECTION, HANDLING, AND PROCESSING ............................................... 25 
D.4.1. General Specimen Management Guidance ........................................................... 25 
D.4.2. Storage of Specimens for Future Use .................................................................... 25 
E. CLINICAL MANAGEMENT ISSUES ...........................................................................27 
E.1. MANAGEMENT OF SPECIFIC ADVERSE EVENTS .............................................................. 27 
E.1.1. Serious Infections .................................................................................................. 27 
E.1.2. Acute Hypersensitivity Reactions ........................................................................... 28 
E.1.3. Neutropenia ........................................................................................................... 28 
E.1.4. Thrombocytopenia ................................................................................................ 28 


 
iv 
E.1.5. AST and ALT Abnormalities .................................................................................... 29 
E.1.6. Thyroid Test Abnormalities .................................................................................... 29 
E.1.7. Renal Dysfunction .................................................................................................. 29 
E.1.8. Malignant Conditions ............................................................................................. 30 
E.1.9. Viral Reactivation ................................................................................................... 30 
E.1.10. Thrombotic Disease ............................................................................................. 30 
E.2. MANAGEMENT OF ADVERSE EVENTS ACCORDING TO SEVERITY ................................... 30 
E.2.1. Grade 1 or 2 AEs .................................................................................................... 30 
E.2.2. Grade 3 or 4 AEs .................................................................................................... 30 
E.3. PREGNANCY ................................................................................................................... 31 
E.4. REPORTING OF ADVERSE REACTIONS TO THE RESPONSIBLE IRBs .................................. 31 
E.5. SOCIAL HARMS REPORTING ........................................................................................... 31 
F. CRITERIA FOR DISCONTINUATION .........................................................................32 
F.1. PERMANENT TREATMENT DISCONTINUATION .............................................................. 32 
F.2. PREMATURE STUDY DISCONTINUATION ........................................................................ 33 
F.3. TEMPORARY TREATMENT DISCONTINUATION ............................................................... 33 
G. SAFETY MONITORING ...........................................................................................34 
H. DATA COLLECTION AND MONITORING AND ADVERSE EVENT REPORTING ...........35 
H.1. RECORDS TO BE KEPT .................................................................................................... 35 
H.2. STUDY COORDINATION ................................................................................................. 35 
H.3. ADVERSE EVENT REPORTING ......................................................................................... 35 
H.3.1. Definitions ............................................................................................................. 35 
H.3.2. Expedited Adverse Event Reporting ...................................................................... 37 
H.3.3. Reporting to the University Hospitals of Cleveland Medical Center (UHCMC) 
Institutional Review Board (IRB) .......................................................................... 37 
H.3.4. Expedited Reporting to the Food and Drug Administration ................................... 37 
H.3.5. Reporting Requirements for this Study .................................................................. 38 
H.3.6. Grading Severity of Events ..................................................................................... 38 
H.3.7. Relationship to Study Agent .................................................................................. 38 
H.3.8. Expedited AE Reporting Period .............................................................................. 39 
H.3.9. Reporting Procedures ............................................................................................ 39 
I. HUMAN SUBJECTS ..................................................................................................40 
I.1. IRB Review and Informed Consent .................................................................................. 40 
I.2. Subject Confidentiality .................................................................................................... 40 
I.3. Study Discontinuation..................................................................................................... 40 
I.4. Human Subjects Involvement, Characteristics, and Design ............................................. 41 
I.5. Sources of Materials ....................................................................................................... 41 
I.6. Potential Risks and Risk Mitigation Strategies ................................................................. 41 
I.6.1. Risks of rIL-2 ........................................................................................................... 41 


 
v 
I.7. Adequacy of Protection against Risks ............................................................................. 45 
I.7.1. Recruitment and Informed Consent ...................................................................... 45 
I.7.2. Protections against Specific Study-related Risks .................................................... 46 
I.8. Potential Benefits of the Proposed Research to Human Subjects and Others ................. 46 
I.9. Importance of the Knowledge to Be Gained ................................................................... 46 
I.10. Data and Safety Monitoring Plan .................................................................................. 46 
I.11. ClinicalTrials.gov Requirements .................................................................................... 46 
I.12. Inclusion of Women and Minorities .............................................................................. 46 
I.13. Inclusion of Children ..................................................................................................... 46 
J. PUBLICATION OF RESEARCH FINDINGS ..................................................................47 
K. BIOHAZARD CONTAINMENT ..................................................................................48 
L. 
REFERENCES .....................................................................................................49 
 
 
 
 
 
 
 
 
 
 


 
vi 
SITES PARTICIPATING IN THE STUDY 
 
 
This is a single-site study that will open at the Case Western Reserve University/University Hospitals 
Cleveland Medical Center Clinical Research Site only. 
 
 
 


 
vii 
PROTOCOL TEAM ROSTER 
 
 
Co-Chairs 
 
Benigno Rodriguez, MD 
2061 Cornell Road, Suite 401 
Cleveland, OH 44106 
Phone: (216) 844-2057 
Fax: (216) 844-5523 
E-Mail: rodriguez.benigno@clevelandactu.org  
 
 
Michael M. Lederman, MD 
2061 Cornell Road, Suite 401 
Cleveland, OH 44106 
Phone: (216) 844-8786 
Fax: (216) 844-5523 
E-Mail: MXL6@case.edu 
 
 
Study Coordinator 
 
Jane Baum, RN BSN 
2061 Cornell Road, Suite 301C 
Cleveland, OH 44106 
Phone: (216) 844-2546 
Fax: (216) 844-5523 
E-Mail: baum.jane@clevelandactu.org  
 
 
Data Manager 
 
Patrick James 
Case Western Reserve University 
2061 Cornell Road, Suite 307 
Cleveland, OH 44106 
Phone: 216-844-3605 
E-Mail: james.patrick@clevelandactu.org 
 
Research Nurses 
 
Julie Pasternak, RN, BSN, MBA 
2061 Cornell Road, Suite 301D 
Cleveland, OH 44106 
Phone: (216) 844-2738 
Fax: (216) 844-5523 
E-Mail: pasternak.julie@clevelandactu.org  
 
 
Kelly Matatics 
2061 Cornell Road, Suite 301C 
Cleveland, OH 44106 
Phone: (216) 844-1392 
Fax: (216) 844-5523 
E-Mail: Matatics.kelly@clevelandactu.org  
 
 
Nurse Practitioner 
 
Ann Conrad, CNP 
2061 Cornell Road, Suite 301A 
Cleveland, OH 44106  
Phone: (216) 844-3962 
Fax: (216) 844-5523 
E-Mail: Conrad.ann@clevelandactu.org 
 
 
 
 
Pharmacist 
 
Michael Banchy, RPh 
11100 Euclid Ave #122, Suite B-52 
Cleveland, OH 44106 
Phone: (216) 844-8018 
Fax: (216) 844-1445 
E-Mail: Michael.banchy@uhhospitals.org 
 
 
 
 
 
 


 
viii 
Laboratory Coordinator 
 
Daniela Moisi 
2109 Adelbert Road, Suite 1048B 
Cleveland, OH 44106 
Phone: (216) 368-4853 
Fax: (216) 368-5415 
E-Mail: Moisi.Daniela@clevelandactu.org 
Regulatory Coordinator 
 
Cheryl Smith 
2061 Cornell Road, Suite 303 
Cleveland, OH 44106 
Phone: (216) 844-8052 
Fax: (216) 844-5523 
E-Mail: smith.cheryl@clevelandactu.org  
 
Statistician 
 
Curtis Tatsuoka, PhD 
Departments of Neurology and Epidemiology and 
Biostatistics 
Case Western Reserve University 
2103 Cornell Road, Suite 6206 
Cleveland, OH 44106 
Phone: (216) 368-6724 
Fax: (216) 368-4835 
E- Mail: cmt66@case.edu 
 
 
Unit Administrator 
 
Mary Wenzel 
2061 Cornell Road, Suite 401 
Cleveland, OH 44106 
Phone: (216) 844-2342 
Fax: (216) 844-5523 
E-Mail: wenzel.mary@clevelandactu.org  
 
 
 
 
 
 


 
ix 
STUDY MANAGEMENT 
 
 
All questions concerning this protocol should be sent to wenzel.mary@clevelandactu.org. Ms. 
Wenzel will direct the communications to the most appropriate team member. A response should 
generally be received within 24 hours (Monday-Friday). 
 
 
CLINICAL MANAGEMENT  
 
 
For questions concerning entry criteria, toxicity management, concomitant medications, and co-
enrollment, 
contact 
the 
protocol 
co-chairs. 
Send 
an 
e-mail 
message 
to 
rodriguez.benigno@clevelandactu.org AND MXL6@case.edu. One of the co-chairs will address 
them. 
 
 
 


 
1 
SYNOPSIS 
 
 
Introduction 
 
Interleukin-2 (IL-2) has been extensively studied in HIV infected individuals with no demonstrated clinical 
benefit as far as improving survival or decreasing risk of progression to AIDS. The results of the two 
landmark, international, multicenter, phase III, randomized trials of IL-2 in HIV infected participants 
(SILCAAT and ESPRIT) have been recently published. These trials, which started more than a decade ago, 
enrolled over 5800 participants who were randomized to anti-retroviral therapy (ART) +/- IL-2 and showed 
no benefit to IL-2 treatment in survival or progression to AIDS. Many individuals with HIV infection can lead 
normal lives on ART but replication-competent virus remains within resting CD4+ cells, referred to as the 
“HIV reservoir”. There is a renewed interest in strategies to decrease or eliminate the viral reservoir in an 
attempt to provide a sterilizing or a functional “cure” for HIV that would allow the discontinuation of ART, 
which currently must be taken life-long. These therapies have long-term metabolic and cardiovascular 
toxicities as well as substantial cost. More recent data suggest that IL-2 administration may decrease the 
size of the HIV reservoir, getting ART-treated participants closer to levels of HIV persistence that may 
ultimately allow for sterilizing or functional cure.  
 
Purpose 
 
The purpose of this pilot study is to examine the effects of eight 4-day cycles of subcutaneous recombinant 
interleukin-2 (rIL-2) given every 8 weeks on levels of replication-competent HIV in CD4 cells and on the size 
of HIV viral reservoir in up to 20 participants with chronically suppressed HIV infection (viral load <50 
copies/mL).  
 
Design 
 
Pilot open label trial of rIL-2 administration.  
 
Power and Sample Size Considerations 
 
We base our sample size calculations on the primary analysis using a mixed effect model to estimate the 
effect of rIL-2 administration on the magnitude of the inducible reservoir by QVOA. In the Chun experiment 
(see below), the difference between the IL-2 and the HAART-only group was 0.64 IUPM, and the variance 
in the IL-2 group was 0.41. In a 200-simulation run, we estimate that a total sample size of 16 participants 
will provide an 80% power (95% CI, 0.74-0.84) to detect a difference from baseline to post-IL-2 
administration as large as that seen in the Chun paper. Of note, these estimates are likely conservative, 
since the variation observed in repeated measurements with the optimized version of the QVOA assay that 
will be used in this study may be lower (variance around 0.11) than that of the assay used in the original 
Chun report (1). 
 
 
 
                     
1 Accelevir, data on file 


 
2 
Inclusion Criteria 
 
Participants may enroll in the study if they meet the following criteria: 
 
1. Written informed consent signed and dated by study participant. 
2. Male or female, at least 18 years of age and not older than 65 years of age. 
3. HIV-1 infection, documented by and FDA-approved ELISA, EIA, or rapid antibody detection method, 
and confirmed by a second approved antibody-based test or by a positive approved HIV RNA 
detection assay. 
4. CD4+ T cell count ≥ 350 cells/mm3.  
5. HIV-1 RNA < 50 copies/mL obtained within 60 days prior to study entry performed with an FDA-
approved HIV-1 RNA assay. 
6. Adequate venous access and no other contraindications for leukapheresis. 
7. Absolute neutrophil count (ANC) > 1500/mm3. 
8. Hemoglobin level >10 g/dL. 
9. Platelet count >100,000/mm3. 
10. Serum creatinine <1.5 mg/dL 
11. AST and ALT <2.5 times the upper limit of normal 
12. TSH, T3, and T4 levels within the normal range of the processing laboratory.  
13. Anti-thyrosine peroxidase (TPO) within the normal range of the processing laboratory.  
14. Willing to comply with study-mandated evaluations; including not changing antiretroviral regimen 
(unless medically indicated) during the study period. 
15. All participants must have received HAART, and had viral loads below the limit of 
quantification of the assay for at least 1 year. Participants who had intermittent isolated 
episodes of detectable low-level viremia < 500 copies RNA/mL flanked by viral loads below the limit 
of quantification of the assay will remain eligible. 
16. On a stable combination antiretroviral regimen (no changes to treatment within 4 weeks of 
enrollment) including at least 3 medications and willing to continue on current antiretroviral 
therapy for the duration of the study, unless otherwise medically indicated.  
 
Exclusion Criteria 
 
1. Childbearing potential for female participants. For the purposes of this study, a woman is 
considered to be of childbearing potential if she is postmenarchial, has not had a documented 
surgical sterilization procedure, has an intact uterus and at least 1 ovary, and has had a 
spontaneous menstrual period in the last 2 years.  
2. Acute or chronic hepatitis C infection, defined as a positive plasma HCV RNA using any FDA-
approved qualitative or quantitative test in a participant with a positive HCV antibody (HCV RNA 
testing is not required in participants with a negative HCV antibody). Participants who have 
completed a course of a direct-acting antiviral agent for hepatitis C and have a confirmed plasma 
HCV RNA level below the limit of detection of the assay 12 weeks or longer after completion of 
therapy will be eligible. 
3. Acute or chronic hepatitis B infection, defined as a positive HBV surface antigen or a positive HBV 
DNA.  
4. History of advanced chronic liver disease, including cirrhosis, advanced liver fibrosis, severe portal 
hypertension, or manifestations or hepatic failure. 
5. History of malignant disease that is not considered to be surgically or medically eradicated or that 
has required any form of therapy in the past 5 years.  


 
3 
6. Current diagnosis of congestive heart failure of any severity, uncontrolled angina or uncontrolled 
arrhythmias.   
7. History of chronic lung disease that has required pharmacologic treatment, oxygen 
supplementation, medical monitoring, or hospitalization in the previous year, or that is expected to 
cause persistent or recurrent pulmonary symptoms or impairment. Examples of the latter include 
but are not limited to chronic bronchitis, emphysema, and pulmonary fibrosis. 
8. History or any features on physical examination indicative of a bleeding diathesis. 
9. History or current diagnosis of thromboembolic disease, including deep vein thrombosis and 
pulmonary embolism, or family history of the same.  
10. History of hypersensitivity to radiological contrast media or anticipated need for exposure to 
radiological contrast media during the study period. 
11. Use of chronic corticosteroids, hydroxyurea, or immune-modulating agents (e.g., interleukin-2, 
interferon-alpha or gamma, granulocyte colony stimulating factors, etc.) within 30 days prior to 
enrollment.  
 
NOTE: Use of inhaled or topical steroids is not exclusionary.  
12. Breast-feeding.  
13. Use of aspirin, warfarin or any other antithrombotic or antiplatelet agent during the 2-week period 
prior to leukapheresis.  
14.  History of autoimmune disorders, including but not limited to Crohn’s disease, scleroderma, 
thyroiditis, inflammatory arthritis, myasthenia gravis, glomerulonephritis, systemic lupus 
erythematous, and vasculitis.  
15. Type 1 diabetes mellitus.  
16. History of thyroid disease that has required antithyroid or thyroid hormone replacement therapy at 
any time in the past.  
17.  Current continued use, or anticipated continued medical indication for nephrotoxic agents, 
including but not limited to aminoglycosides and other potentially nephrotoxic antimicrobials, 
indomethacin, high scheduled doses of other NSAIDs, and lithium salts.   
NOTE: Low doses or limited duration of these agents (i.e., ≤14 days) is not exclusionary. 
18.  Current continued use, or anticipated continued medical indication for hepatotoxic agents, 
including but not limited to amiodarone, methotrexate, and anticonvulsants and antimicrobials with 
elevated hepatotoxic potential.   
NOTE: Low doses or limited duration of these agents (i.e., ≤14 days) is not exclusionary. 
19. Active drug or alcohol use or dependence that, in the opinion of the investigator, would  interfere 
with adherence to study requirements.  
20. Serious illness requiring systemic treatment and/or hospitalization within 30 days prior to study 
 entry that in the judgement of the investigator may compromise study participation or pose 
additional risks to the participant.  
21. Any other condition that, in the opinion of the clinical investigator or sponsor, might compromise 
any aspect of this trial.  
 
Study Treatment 
 
All 20 participants will receive subcutaneous rIL-2 therapy in addition to combination antiretroviral therapy. 
Any combination of three FDA-approved antriretrovirals may be used.  
Recombinant IL-2 at a dose of 5 MIU twice daily will be given subcutaneously for 4 consecutive days every 
8 weeks for eight cycles.  
 


 
4 
Blood will be drawn for CD4 cell counts, for viral load, for routine safety monitoring and for HIV reservoir 
assays as detailed in section D.3.5 of the protocol. 
 
Safety Monitoring 
 
rIL-2 has been given safely to HIV infected persons. Study participants will be monitored by phone contact 
for safety and tolerance by study staff on days 2 and 4 of each IL-2 cycle. Before each rIL-2 cycle and on day 
7 of several of the IL-2 cycles and whenever else indicated clinically, safety laboratories will be obtained on 
all study participants. Nursing staff and physicians are available 24 hours per day, 7 days per week to deal 
with emergent toxicities.  
 
Study endpoints and outcome measures 
 
The primary endpoint of the study is the change in the level of replication-competent virus from baseline 
to the end of rIL-2 treatment, as measured by the Quantitative Viral Outgrowth Assay (QVOA).  
 
Primary Objective 
 
The primary objective will be to compare levels of replication competent HIV in circulating CD4 T cells 
before and after up to 8 cycles of IL-2 administration. The frequency of CD4 T cells containing replication-
competent virus in leukapheresis samples obtained at baseline and at the end of IL-2 treatment will be 
enumerated using several state of the art methods. The primary readout for this objective will be 
measurement of replication-competent virus by Quantitative Viral Outgrowth Assay (QVOA) performed by 
Robert Siliciano’s group at Accelevir.  
 
Secondary Objectives 
 
1) To examine the relationships between levels of replication competent HIV as identified by QVOA and 
other measures of HIV persistence:  
a) the intact proviral DNA assay (Siliciano),  
b) the Envelope Detection by Induced Transcription-based Sequencing (EDITS, Karn) performed on 
the same pre-trial and post-trial leukapheresis samples. 
2) To explore the effects of IL-2 administration on induction of HIV expression in vivo as measured by the 
EDITS assay and plasma HIV levels. 
3) To examine the effects of IL-2 administration on natural killer cell phenotype and function and on the 
ability of NK cells to limit HIV propagation in vitro.  


 
5 
A. INTRODUCTION 
 
A.1. BACKGROUND 
 
Highly active anti-retroviral therapy (HAART) has been successful in controlling viral replication and 
decreasing levels of virus in plasma to levels below limits of detection as determined by commercially 
available assays in most human immunodeficiency virus (HIV)-infected individuals (1-3). Even in 
individuals who have been treated for considerable periods of time and whose plasma virus levels 
remain below detectable, replication-competent HIV can be invariably isolated from latently infected, 
resting CD4+ T cells (4-6). This observation, and the common experience of viral rebound among HIV-
infected individuals in whom HAART has been discontinued (7), as well as the fact that this pool of 
latently infected cells is long-lived and does not decay substantially over time (4, 5), have led to the 
recognition that these cells constitute a principal impediment to the “cure” of HIV infection (4-6, 8-
10). 
 
A variety of cytokines, including interleukin (IL)-2, tumor necrosis factor (TNF)-α IL-15 and IL-6 can 
induce in vitro the expression of HIV from latently infected, resting CD4+ T cells obtained from HIV 
infected individuals (11). Thus, it has been proposed that latent HIV might be deliberately ‘purged’ by 
treating infected individuals simultaneously with HAART and agents that activate cells to express HIV 
(8-10, 12). After being activated, these latently infected cells may die from cytopathic effects and/or 
immune effector mechanisms, whereas HAART would prevent new rounds of infection mediated by 
the replication competent viruses expressed by activation from latency (8-10, 12). 
 
Many novel strategies are being explored in an effort to completely eradicate HIV infection. The 
majority will likely fail and, for the reasons outlined above, even those that reliably decrease the size 
of the HIV reservoir may be insufficient to cure HIV. We still do not have a sense that there exists a 
level of reservoir reduction — without complete elimination — that would suffice to result in durable 
control of HIV as defined by the sustained absence of viremia after discontinuation of antiretroviral 
therapy. In this regard, the limits of our ability to monitor virus persistence make it impossible to know 
if every infectious virus has been eliminated from the one person who has been cured. In that patient, 
replacement of the entire immune cell pool with cells resistant to HIV likely rendered the emergence 
from latency of any residual infectious virus incapable of amplification. There is reason to suspect that 
administration of interleukin-2 may have significant impact on the size of the HIV reservoir.  
 
 A.2. INTERLEUKIN-2 AND THE HIV RESERVOIR  
 
Exogenous administration of interleukin-2 has been explored as a strategy to purge HIV from latently 
infected CD4+ T cells and thus reduce the viral reservoir (13-15). The rationale for this approach was 
the observation that in a pooled analysis of three of the phase II randomized studies of rIL-2 (16) the 
mean decrease from baseline plasma HIV RNA was significantly greater in patients randomized to 
receive rIL-2 plus ART versus ART alone, and that in vitro IL-2 can be used to activate latent integrated 
virus (13). Chun et al reported a cross sectional analysis of reservoir size among 26 ART treated 
participants who had been treated with ART alone or ART plus an average of 10 cycles of interleukin-
2 (IL-2). IL-2 had been administered with an eye to increasing circulating CD4+ T cells as was the 


 
6 
rationale for this therapy at that time. Fourteen of these 
participants received ART plus IL-2 and 12 received ART alone. 
At the time of “reservoir” analysis all participants were 
receiving combination ART and had plasma HIV levels <50 
copies/mL. Shown in Figure 1 from this publication (13), eight 
of 14 ART plus IL-2-treated participants had a frequency of CD4 
T cells in peripheral blood that contained replication-
competent HIV (as detected by cocultivation assay) at or 
below the lower limit of detection (0.03/106 IUPM) while only 
one of 12 participants who had received ART alone had 
replication competent virus levels that low. Two participants 
in the ART plus IL-2 group also had an examination of lymph 
node CD4+ T cells and monocyte/macrophages (4-5 x 107 cells) and virus could not be found by 
cocultivation assay. Encouraged by these findings, Chun et al discontinued antiviral therapy in these 
two participants. Despite undetectable virus levels in plasma and the inability to find replication 
competent virus in blood and lymph nodes, viremia recurred in both, indicating that cure was not 
achieved (17) and providing early indication, more recently confirmed by other groups (18) that our 
assays for detection of replication competent virus in blood and tissue are not now (nor likely ever to 
be) sufficiently sensitive to exclude levels of virus in the body that are capable of rebound. 
Nonetheless, an effect on reservoir size as detected by these assays is a useful finding from which to 
proceed in a step-wise fashion to the ultimate objective of complete reservoir eradication. A 
demonstrable effect on this reservoir is a valuable addition to ultimate goal of HIV eradication. As 
these published studies have never been replicated, our goal is to confirm these important 
observations in a prospective study specifically designed to evaluate the effects of IL-2 infusion on 
indices of HIV persistence. As noted above, interleukin-2 has been studied intensively for its ability to 
increase circulating CD4 T cells in vivo and was examined in two large clinical trials (ESPRIT and 
SILCAAT) to see if this CD4 T cell increase conferred clinical benefit. These controlled studies, enrolling 
nearly 6,000 patients, could show no clinical benefit of IL-2 administration (19). We are proposing to 
examine the effects of IL-2 administration to ascertain if this strategy can decrease the size of the 
reservoir of replication competent HIV. To our knowledge, there have been no studies attempting to 
reproduce the Chun work and we propose that a carefully designed trial is an important priority for 
HIV eradication research because the effect on the HIV reservoir as reported by Chun is substantial 
and because cycles of IL-2 infusion have manageable toxicity, have been given safely to thousands of 
HIV infected persons, can be administered in an outpatient setting, and thus are readily scalable.  
 
There is growing recognition that natural killer (NK) cells play an important role in the course of HIV 
disease as genetic studies have linked polymorphisms in surface receptors expressed by NK cells - killer 
cell immunoglobulin-like receptors (Kirs) and HLA antigens to which they can bind - to differential 
outcomes of HIV disease in natural history studies (20, 21). In early studies, we demonstrated 
significant impairment in NK cell function in HIV infected persons (22) and later, we and others have 
shown that this could be improved in vitro by exposure to interleukin-2 (23, 24). More to the point, 
clinical trials of IL-2 administration in vivo have found that IL-2 administration increases NK cell activity 
[but decreases the cytolytic activity of HIV-specific CD8 T cells (25)]. Thus, we propose that in vivo 
administration of IL-2 will both activate HIV expression from latency among memory CD4 T cells and 
concurrently will activate NK cells. NK cells are recognized to limit HIV replication in vitro and this may 
be mediated by direct cytolytic activity as well as by the elaboration of type 1 and type 2 interferons 
and beta chemokines (CCL3, CCL4, CCL5) that by different mechanisms can block HIV spread in tissues. 
 


 
7 
The hypothesis being tested in this pilot trial is that intervention with intermittent IL-2 therapy in 
combination with antiretroviral therapy among patients with controlled HIV infection on a stable 
HAART regimen will reduce the reservoir of replication competent HIV in blood.  
 
A.3. SUBCUTANEOUS rIL-2 
 
Interleukin-2 (IL-2) is a T-cell growth factor and is integral to the function of the immune system. 
Recombinant interleukin-2 (rIL-2), with the trade name Proleukin®, is a potent immunomodulator 
currently licensed for the treatment of metastatic renal cell carcinoma and metastatic melanoma. 
Originally described as T-cell growth factor, this natural protein exerts potent in vitro effects on cells 
derived from patients with HIV. Critically, IL-2 induces proliferation of T-lymphocytes and B-
lymphocytes, enhances cytolytic activity against a variety of target cells, increases production of 
gamma-interferon, increases secretion of gamma-globulins and importantly for this trial, increases 
natural killer cell function (26). Initial clinical studies coupled with laboratory evaluations identified a 
regimen for optimal induction of CD4+ T-lymphocyte proliferation (27). Intermittent administration of 
rIL-2 to patients with HIV infection based upon a regimen delivered for five days every 8 weeks has 
now been examined in multiple trials (as detailed below). 
 
A.4. CLINICAL EXPERIENCE WITH SUBCUTANEOUS rIL-2 IN HIV INFECTION 
  
Phase I studies of exogenous IL-2 in HIV infection were initiated as early as 1983, before the availability 
of HAART. These initial trials were conducted with the native protein purified from T-cell cultures. 
They have demonstrated that the intermittent administration of rIL-2 either as a continuous 
intravenous infusion or subcutaneously (usually given twice daily for 5 consecutive days) with HAART 
result in substantial and significantly higher CD4+ T-cell increases than those achieved with either dual 
nucleoside reverse transcriptase inhibitor therapy or more potent HAART alone (28). To summarize: 
 
 
rIL-2 plus ART produces significant CD4+ T-cell expansion compared with ART alone; it is 
noteworthy that many of these phase II studies preceded the use of fully virologically suppressive 
HAART (29). 
 
Subcutaneous polyethylene glycol (PEG)-modified IL-2 appears to be less biologically active than 
continuous infusion intravenous IL-2 (CIVIL-2) (30). 
 
Subcutaneous rIL-2 is better tolerated than CIVIL-2; the magnitude of the CD4+ T-cell count 
response was proportional to the baseline CD4+ T-cell count (31). 
 
5 days of CIVIL-2 are superior to 3-day cycles with respect to CD4+ T-cell expansion (32) but cycle 
duration longer than 5 days or every 4 week versus every 8 week cycles using CIVIL-2 (30) or 
subcutaneous rIL-2 were associated with increased adverse effects without additional CD4+ T-cell 
expansion. 
 
Subcutaneous rIL-2 7.5 million international units (MIU) induces significantly higher CD4+ T-cell 
increases than 1.5 MIU, although 4.5 MIU doses are biologically active (33-36). 
 
CD4+ T-cell count increases can be sustained for up to 5 years without adverse effects on steady 
state HIV-1 plasma RNA levels and often with reduced dosing cycle frequency (31, 37-40). 
 
In summary, these phase II studies demonstrated that the cyclical administration of subcutaneous 
rIL-2 (4.5–7.5 MIU per dose) twice daily for 5 consecutive days every 8 weeks with a background of 
ART resulted in large increases in CD4+ T-cell count, minimal changes in plasma HIV viral load and 
no significant changes in CD8+ T-cell count (41). 
 


 
8 
These early studies set the stage for two large prospective randomized controlled trials: the 
Subcutaneous Recombinant, Human Interleukin-2 in HIV-Infected Patients with Low CD4+ Counts 
under Active Antiretroviral Therapy (SILCAAT) study and the Evaluation of Subcutaneous Proleukin in 
a Randomized International Trial (ESPRIT) study (42). In each, patients infected with HIV who had CD4+ 
cell counts of either 50 to 299 per cubic millimeter (SILCAAT) or 300 or more per cubic millimeter 
(ESPRIT) were randomly assigned to receive rIL-2 plus ART or ART alone. The rIL-2 regimen consisted 
of cycles of 5 consecutive days each, administered at 8-week intervals. The SILCAAT study involved six 
cycles and a dose of 4.5 million IU of rIL-2 twice daily; ESPRIT involved three cycles and a dose of 7.5 
million IU twice daily. Additional cycles were recommended to maintain the CD4+ cell count above 
predefined target levels. The primary endpoint of both studies was opportunistic disease or death 
from any cause. In the SILCAAT study, 1695 patients (849 receiving rIL-2plus ART and 846 receiving 
ART alone) who had a median CD4+ cell count of 202 cells per cubic millimeter were enrolled; in 
ESPRIT, 4111 patients (2071 receiving rIL-2 plus ART and 2040 receiving ART alone) who had a median 
CD4+ cell count of 457 cells per cubic millimeter were enrolled. Over a median follow-up period of 7 
to 8 years, the CD4+ cell count was higher in the rIL-2 group than in the group receiving ART therapy 
alone — by 53 and 159 cells per cubic millimeter, on average, in the SILCAAT and ESPRIT studies, 
respectively. Hazard ratios for opportunistic disease or death from any cause with rIL-2 plus 
antiretroviral therapy (vs. antiretroviral therapy alone) were 0.91 (95% confidence interval [CI], 0.70 
to 1.18; P=0.47) in the SILCAAT study and 0.94 (95% CI, 0.75 to 1.16; P=0.55) in ESPRIT. The hazard 
ratios for death from any cause and for grade 4 clinical events were 1.06 (P=0.73) and 1.10 (P=0.35), 
respectively, in the SILCAAT study and 0.90 (P=0.42) and 1.23 (P=0.003), respectively, in ESPRIT (42). 
Thus, to date, there is no evidence that the administration of IL-2 confers clinical benefit to persons 
with ART-treated HIV infection. 
 
A.5. PHARMACOLOGIC AND SAFETY PROFILE OF THE STUDY AGENT 
 
Interleukin-2 (IL-2) in its natural form is a 15-Kdalton immunoregulatory protein. Natural IL-2 is 
hydrophobic and stable at 70°C for 15 minutes at a pH of 2 to 10 in 0.1 percent sodium dodecyl 
sulphate (SDS) and 6M urea (43, 44). It is produced in vivo by T-lymphocytes following antigen 
activation and is central to the appropriate responsiveness of the immune system challenged by 
invading pathogens. Its synthesis and release by CD4+ T-lymphocytes, in particular, are of critical 
importance to the orchestrated events that follow detection of foreign antigen and lead to clearance 
of pathogen and resolution of disease. Exposure to IL-2 results in the proliferation and maturation of 
both T- and B-lymphocytes (45). After proliferation, immune system cells retain their antigen 
specificity. In vitro, exogenous IL-2 can restore the natural killer (NK) activity and the cytolytic activity 
of lymphocytes from patients with AIDS, directed toward CMV-infected target cells (26) as well as 
against tumor targets. 
 
Recombinant DNA technology has made the production of rIL-2 in large quantities possible. 
Messenger RNA from the human Jurkat cell line was used to create a double-stranded cDNA that was 
cloned into pBR322 plasmids; a clone containing the IL-2 gene was identified; the gene was inserted 
into a region of the plasmid that has a convenient restriction site; the appropriate promoter and 
ribosome binding site was inserted in front of the IL-2 gene, and the resulting expression clone 
encoded a modified recombinant IL-2 (rIL-2). Unlike native IL-2, this modified rIL-2 has no N-terminal 
alanine and has serine substituted for cysteine at amino acid position 125, resulting in a more 
homogenous IL-2 product (46). The molecule is not glycosylated because it is derived from Escherichia 
coli. 
 


 
9 
The most prominent side effects of SC rIL-2 occur 2-6 hours following dosing and may be associated 
with peak plasma levels of rIL-2; most toxicities resolve within 5 days of completion of the treatment 
cycle, reflecting the short half-life of the agent. At doses used in recent SC rIL-2 HIV trials, toxicities 
seen have included fever, fatigue, myalgias, and other constitutional symptoms that were dose-
dependent and similar to those seen with CIVIL-2 (46). In addition, most patients experienced a local 
rash characterized by erythema, tenderness, and occasional nodularity at the site of injection. 
 
A syndrome of acute cholecystitis with right upper quadrant pain and nausea and vomiting in HIV-
infected patients receiving rIL-2 was described by Powell and coworkers (47). By ultrasound, the 
gallbladder was noted to be thickened and no calculi were observed. Symptoms resolved with 
cessation of rIL-2 therapy, and surgery was not required. 
 
Thyroid function abnormalities have been reported in participants receiving IL-2 treatment for 
malignancies (48-54) and for HIV (19, 33, 37, 42, 55). The reported frequency of thyroid abnormalities 
among persons receiving IL-2 has varied from 2.5 to 47%, but early reports included participants who 
received much larger doses than those planned in this study, administered intravenously, and often 
in combination with other immunomodulatory therapies such as lymphokine-activated killer (LAK) 
cells (48, 49) or interferon alfa . Among HIV-infected participants receiving subcutaneous rIL-2, the 
frequency of thyroid dysfunction in small studies has been reported to be between 2.5 and 11.7% (33, 
37, 56). The two largest trials of rIL-2 among HIV-infected participants (42), however, did not 
specifically report the frequency of thyroid dysfunction, but senior investigators in those teams 
estimate the frequency to be between 10 and 15% (Lane HC, Levy Y, Kovacs J, Sereti I, verbal 
communications).  
 
The progression of thyroid dysfunction during rIL-2 treatment is variable, but it is thought to involve 
an initial period of thyroid stimulation akin to autoimmune thyroiditis, which is usually undetected, 
followed by variable degrees of hypothyroidism (50, 55, 57). The mechanisms of these effects on the 
thyroid are incompletely understood. It has been proposed that IL-2-mediated induction of 
proinflammatory cytokine production may trigger the initial autoimmune thyroiditis (48, 50, 51). This 
notion is supported by the finding of increased lymphocyte infiltration of the thyroid, with features 
suggestive of autoimmune thyroiditis, during rIL-2 treatment (58, 59). In this model, the initial 
thyroiditis may result from enhancement of class II expression and presentation of autoantigens by 
thyrocytes due to increased local release of proinflammatory cytokines by thyroid-infiltrating 
mononuclear cells (48, 51). The clinical course of rIL-2-induced thyroid dysfunction has not been 
comprehensively described, but at least in some cases, there is spontaneous resolution of the thyroid 
abnormalities. In a closely monitored study of a single cycle of rIL-2 administered to 20 euthyroid HIV-
infected participants, there was a rapid concomitant rise in TSH, T3, T4, and free T4 within the first 
three days of treatment, with return of all indices to baseline after approximately 14 days (55).  The 
need for thyroid hormone replacement for rIL-2-induced hypothyroidism has been variable and 
inconsistently reported. In 3 out of 7 participants who developed hypothyroidism in a trial of rIL-2 
given with LAK cells for malignant diseases, thyroid function tests returned to normal while these 
participants were not receiving thyroid replacement, but the authors indicate that they could not 
ascertain the course of thyroid dysfunction for other participants (49). In a similar study of cancer 
patients, thyroid function tests returned to the normal range in the absence of thyroid replacement 
therapy approximately 6 months after treatment among 4 of the 7 participants with rIL-2-induced 
hypothyroidism. The remaining 3 participants received levothyroxine and also had normal thyroid 
tests 6 months after rIL-2 treatment, but it is unclear if thyroid replacement had been discontinued 
by that time (48). In a study including 49 HIV-infected participants randomized to either low (1.5 MIU 


 
10 
SC BID) or high (7.5 MIU SC BID) dose rIL-2, 2 of the 5 participants who developed hypothyroidism did 
not receive thyroid replacement therapy, but the duration of thyroid replacement and the follow-up 
results of thyroid function tests were not reported (33).   
 
Risk factors for thyroid dysfunction during rIL-2 treatment include female sex, pre-existing thyroid 
dysfunction, large cumulative doses of rIL-2, and importantly, the presence of anti-thyroid antibodies 
(49, 50, 57). The association of IL-2 thyroid dysfunction with the presence of anti-thyroid antibodies 
has not been accurately quantified, but it has been observed in multiple reported studies (48, 49, 52). 
In one study including 34 cancer patients, antithyroid antibodies were present in none of the 27 
participants who remained euthyroid during treatment, but were present in 5 out of the 7 (71%) 
participants who developed hypothyroidism (49, 52). Therefore, in this study, participants will be 
screened for the presence of anti-thyroid antibodies (in addition to routine thyroid function testing) 
both at study entry and before each rIL-2 cycle. Participants who have abnormal thyroid function tests 
or elevated levels of antithyroid antibodies at screening will be excluded. Participants who develop 
abnormal thyroid function tests or antithyroid antibodies at any time during study participation will 
be required to discontinue study treatment permanently.  
 
Patients may experience mental status changes when taking rIL-2, including irritability, insomnia, 
confusion, or depression. Mental status changes due solely to rIL-2 are generally reversible when drug 
administration is discontinued. However, alterations in mental status may continue for several days 
before recovery begins. 
 
In ESPRIT, there was an excess of grade 4 clinical events in the rIL-2 recipients; the same excess was 
not seen in SILCAAT. Abrams and colleagues (42) have suggested this is via an impact on procoagulant 
pathways. In ESPRIT, patients with the highest CD4+ T-cell counts in the rIL-2 arm had the greatest 
relative risk of clinical events, including death. Perhaps, therefore, receipt of rIL-2 primes the patient 
for a proinflammatory state subsequently associated with more clinical events, and this is amplified in 
patients with the greatest CD4+ T-cell response to rIL-2, i.e. the ESPRIT cohort, which had higher 
baseline CD4+ T-cell counts than in SILCAAT. However, it is still important to remember that while rIL-
2 receipt in ESPRIT was associated with more embolic events, overall there was no excess of 
opportunistic diseases, death or cardiovascular disease and non-AIDS cancers compared with the ART-
only arm.  
 
There is a theoretical risk of emergence of antibodies against IL-2 with exogenous administration, as 
is the case with other biological products. This appears to be uncommon with rIL-2, however, as 
neutralizing antibodies were not detected among 77 metastatic renal cell carcinoma patients and 50 
metastatic melanoma patients treated with rIL-2. Only 1 out of 106 patients treated with IV rIL-2 for 
various other indications developed neutralizing antibodies, without associated clinical 
manifestations. Low titers of non-neutralizing antibodies have been observed in 66 to 74% of patients 
treated with rIL-2. (Proleukin® Product Monograph, Novartis Pharmaceuticals, revision dated 
September 16, 2014). Therefore, the probability of emergence of biologically significant anti-IL-2 
antibodies in this small study is thought to be extremely low. Nonetheless, immunogenicity testing 
will be conducted at several points during the study, and participants who have persistent neutralizing 
antibodies at the end of study visit will be followed until resolution or 12 months after the end of 
study, whichever is first.  
 
 


 
11 
B. HYPOTHESES AND STUDY OBJECTIVES 
 
 
The purpose of this pilot study is to observe the effects of up to eight 8-weekly cycles of subcutaneous 
recombinant interleukin-2 (SC rIL-2) on levels of replication-competent HIV in blood CD4 T cells in 20 
participants with chronically suppressed HIV infection (viral load <50 copies/mL) who are stable on the  
same ART regimen for at least one year and have a CD4 T cell count ≥350 cells/mm3. We hypothesize that 
IL-2 administration will result in a reduction of the replication-competent reservoir, as measured by the 
QVOA assay, compared to the baseline values in this population.  
 
B.1. STUDY ENDPOINTS AND OUTCOME MEASURES 
 
The primary endpoint of the study is the change in the level of replication-competent virus from 
baseline to the end of rIL-2 treatment, as measured by the Quantitative Viral Outgrowth Assay (QVOA).  
 
B.2. PRIMARY OBJECTIVE 
 
The primary objective will be to compare levels of replication competent HIV in circulating CD4 T cells 
before and after up to 8 cycles of rIL-2 administration. The frequency of CD4 T cells containing 
replication-competent virus in leukapheresis samples obtained at baseline and at the end of rIL-2 
treatment will be enumerated using several state of the art methods. The primary readout for this 
objective will be measurement of replication-competent virus by Quantitative Viral Outgrowth Assay 
(QVOA) performed by Robert Siliciano’s group at Accelevir.  
 
B.3. SECONDARY OBJECTIVES 
 
1) To examine the relationships between levels of replication competent HIV as identified by QVOA 
and other measures of HIV persistence:  
a) the intact proviral DNA assay (Siliciano),  
b) the Envelope Detection by Induced Transcription-based Sequencing (EDITS, Karn) performed 
on the same pre-trial and post-trial leukapheresis samples. 
2) To explore the effects of rIL-2 administration on induction of HIV expression in vivo as measured 
by the EDITS assay and plasma HIV levels. 
3) To examine the effects of rIL-2 administration on natural killer cell phenotype and function and 
on the ability of NK cells to limit HIV propagation in vitro. 
 
 
 
 
 


 
12 
C. METHODS 
 
 
C.1. STUDY DESIGN 
 
This is an open label pilot study of 20 participants with chronically suppressed HIV infection (viral load 
<50 copies/mL), stable on an ART regimen for at least one year, who have a CD4 T cell count ≥350 
cells/mm3. All participants will receive rIL-2.  
 
All participants will receive rIL-2, 5 million units (MU) subcutaneously (SC) twice a day x 4 consecutive 
days, every 8 weeks, for 8 cycles in addition to ART.  
 
Ideally, rIL-2 doses should be 10 – 12 hours apart, but no closer than 6 hours, and no greater than 18 
hours apart.  
 
If at any point rIL-2 is discontinued, efforts will be made to maintain follow-up for all data collection 
as outlined in the schedule of events. 
  
C.2. STATISTICAL CONSIDERATIONS 
 
C.2.1. Analytic Plan 
 
The primary analysis will test whether the change in the size of the replication-competent 
reservoir, as measured by the modified QVOA assay, from baseline to two weeks after the last 
rIL-2 infusion is significantly different than is expected by random variation. In this intent-to-
treat analysis, all participants who received at least one dose of IL-2 will be included. 
Secondarily, we will perform an on-treatment analysis including only the subset of participants 
who received all eight planned IL-2 cycles. We will use mixed effects models to estimate the 
effect of IL-2 treatment on the replication-competent reservoir among all participants, 
controlling for possible confounding factors including at a minimum CD4 T cell count at baseline 
and at pre-ART nadir, duration of virologic suppression, type of antiretroviral regimen at study 
entry, historical peak plasma HIV RNA, and demographic factors.  
 
We will then fit the relevant models to address the following secondary objectives:  
 
a. Replicate the analyses above in the on-treatment population, i.e., those who received all 8 
planned IL-2 cycles.  
 
 
b. In the intent-to-treat population, add a term indicating the number of IL-2 cycles each 
participant received. This will account for variability of total dose, and the associated 
parameter and its interaction to time point will provide an estimation of the effect 
modification expected from repeated dosing. We will assess for non-linearity of any dose 
effect both graphically and formally, and fit higher-order terms as suggested by those 
analyses, to explore whether there is a threshold effect (i.e., whether the effect size changes 
drastically past a given number of doses), an analysis that was not reported in the original 
Chun paper. 
 
 


 
13 
c. Use each of the alternate readouts as the outcome to obtain estimates of the effect size on 
each of those assays, and then, fit a reverse regression model to estimate the effect of 
treatment on any of the readouts for which a treatment effect is demonstrated. While many 
approaches are available for this type of problem, reverse regression has the appealing 
feature for this small-size trial of not being as overly penalizing as more traditional 
approaches to the multiplicity problem, such as Bonferroni-like corrections (60). We will 
also use conventional nonparametric correlation analyses and the intraclass correlation 
coefficient derived from mixed effects models using each of the readouts to assess how the 
various readouts relate to one another.   
 
d. We will then fit models with time-updated total CD4 T cell count as a covariate. These 
models will allow us to establish how much of the variation in the change of the measured 
reservoir size is attributable to the expected CD4 T cell increase due to IL-2 administration. 
We do not believe that, if the magnitude of the effect is similar to the difference observed 
between the IL-2 alone and the HAART alone groups in the Chun paper, this can be 
explained simply by a dilutional effect, but this will be tested more formally in this phase of 
the analysis.  
 
 
C.2.2. Power and Sample Size Considerations 
 
We base our sample size calculations on the primary analysis using a mixed effect model to 
estimate the effect of IL-2 administration on the magnitude of the inducible reservoir by QVOA. 
In the Chun experiment, the difference between the IL-2 and the HAART-only group was 0.64 
IUPM, and the variance in the IL-2 group was 0.41. In a 200-simulation run, we estimate that a 
total sample size of 20 participants will provide an 80% power (95% CI, 0.74-0.84) to detect a 
difference from baseline to post-IL-2 administration as large as that seen in the Chun paper. Of 
note, these estimates are likely conservative, since the variation observed in repeated 
measurements with the optimized version of the QVOA assay that will be used in this study 
may be lower (variance around 0.11) than that of the assay used in the original Chun report(2). 
 
C.3. INCLUSION CRITERIA  
 
Participants may enroll in the study if they meet the following criteria: 
 
1. Written informed consent signed and dated by study participant. 
2. Male or female, at least 18 years of age and not older than 65 years of age. 
3. HIV-1 infection, documented by and FDA-approved ELISA, EIA, or rapid antibody detection method, 
and confirmed by a second approved antibody-based test or by a positive approved HIV RNA 
detection assay. 
4. CD4+ T cell count ≥ 350 cells/mm3.  
5. HIV-1 RNA < 50 copies/mL obtained within 60 days prior to study entry performed with an FDA-
approved HIV-1 RNA assay. 
6. Adequate venous access and no other contraindications for leukapheresis. 
7. Absolute neutrophil count (ANC) > 1500/mm3. 
8. Hemoglobin level >10 g/dL. 
9. Platelet count >100,000/mm3. 
                     
2 Accelevir, data on file 


 
14 
10. Serum creatinine <1.5 mg/dL 
11. AST and ALT <2.5 times the upper limit of normal 
12. TSH, T3, and T4 levels within the normal range of the processing laboratory.  
13. Anti-thyrosine peroxidase (TPO) antibodies within the normal range of the processing laboratory. 
14. Willing to comply with study-mandated evaluations; including not changing antiretroviral regimen 
(unless medically indicated) during the study period. 
15. All participants must have received HAART, and had viral loads below the limit of 
quantification of the assay for at least 1 year. Participants who had intermittent isolated 
episodes of detectable low-level viremia < 500 copies RNA/mL flanked by viral loads below the limit 
of quantification of the assay will remain eligible. 
16. On a stable combination antiretroviral regimen (no changes to treatment within 4 weeks of 
enrollment) including at least 3 medications and willing to continue on current antiretroviral 
therapy for the duration of the study, unless otherwise medically indicated.  
 
C.4. EXCLUSION CRITERIA 
 
1. Childbearing potential for female participants. For the purposes of this study, a woman is 
considered to be of childbearing potential if she is not postmenarchial, has not had a 
documented surgical sterilization procedure, has an intact uterus and at least 1 ovary, and has had 
a spontaneous menstrual period in the last 2 years. 
2. Acute or chronic hepatitis C infection, defined as a positive plasma HCV RNA using any FDA-
approved qualitative or quantitative test in a participant with a positive HCV antibody (HCV RNA 
testing is not required in participants with a negative HCV antibody). Participants who have 
completed a course of a direct-acting antiviral agent for hepatitis C and have a confirmed plasma 
HCV RNA level below the limit of detection of the assay 12 weeks or longer after completion of 
therapy will be eligible. 
3. Acute or chronic hepatitis B infection, defined as a positive HBV surface antigen or a positive HBV 
DNA.  
4. History of advanced chronic liver disease, including cirrhosis, advanced liver fibrosis, severe portal 
hypertension, or manifestations or hepatic failure. 
5. History of malignant disease that is not considered to be surgically or medically eradicated or that 
has required any form of therapy in the past 5 years.  
6. Current diagnosis of congestive heart failure of any severity, uncontrolled angina or uncontrolled 
arrhythmias.   
7. History of lung disease that has required pharmacologic treatment, oxygen supplementation, 
medical monitoring, or hospitalization in the previous year, or that is expected to cause persistent 
or recurrent pulmonary symptoms or impairment. Examples of the latter include but are not limited 
to chronic bronchitis, emphysema, and pulmonary fibrosis. 
8. History or any features on physical examination indicative of a bleeding diathesis. 
9. History or current diagnosis of thromboembolic disease, including deep vein thrombosis and 
pulmonary embolism, or family history of the same.  
10. History of hypersensitivity to radiological contrast media or anticipated need for exposure to 
radiological contrast media during the study period. 
11. Use of chronic corticosteroids, hydroxyurea, or immune-modulating agents (e.g., interleukin-2, 
interferon-alpha or gamma, granulocyte colony stimulating factors, etc.) within 30 days prior to 
enrollment.  
 
NOTE: Use of inhaled or topical steroids is not exclusionary.  
12. Breast-feeding.  


 
15 
13. Use of aspirin, warfarin or any other antithrombotic or antiplatelet agent during the 2-week period 
prior to leukapheresis.  
14.  History of autoimmune disorders, including but not limited to Crohn’s disease, scleroderma, 
thyroiditis, inflammatory arthritis, myasthenia gravis, glomerulonephritis, systemic lupus 
erythematous, and vasculitis.  
15. Type 1 diabetes mellitus.  
16. History of thyroid disease requiring that has required antithyroid or thyroid hormone replacement 
therapy at any time in the past.  
17.  Current continued use, or anticipated continued medical indication for nephrotoxic agents, 
including but not limited to aminoglycosides and other potentially nephrotoxic antimicrobials, 
indomethacin, high scheduled doses of other NSAIDs, and lithium salts.   
NOTE: Low doses or limited duration of these agents (i.e., ≤14 days) is not exclusionary. 
18.  Current continued use, or anticipated continued medical indication for hepatotoxic agents, 
including but not limited to amiodarone, methotrexate, and anticonvulsants and antimicrobials with 
elevated hepatotoxic potential.   
NOTE: Low doses or limited duration of these agents (i.e., ≤14 days) is not exclusionary. 
19. Active drug or alcohol use or dependence that, in the opinion of the investigator, would  interfere 
with adherence to study requirements.  
20. Serious illness requiring systemic treatment and/or hospitalization within 30 days prior to study 
 entry that in the judgement of the investigator may compromise study participation or pose 
additional risks to the participant.  
21. Any other condition that, in the opinion of the clinical investigator or sponsor, might compromise 
any aspect of this trial.  
 
C.5. STUDY TREATMENT PLAN 
 
C.5.1. Study Medication (rIL-2) 
 
Proleukin® (Prometheus Laboratories) is provided as a sterile, white to off-white, lyophilized 
cake in glass vials, each containing 22 MIU. 
 
C.5.1.1. Dosage and Cycle Guidelines 
 
Participants will receive rIL-2 at an initial dose of approximately 5 MIU twice daily for 
4 consecutive days every 8 weeks (8 cycles total). Each vial will be reconstituted 
according to the package insert instructions using 1.2 mL of diluent, and 4 doses will 
be obtained from each vial. Occasionally, the reconstituted volume that can be drawn 
from the vial may result in doses that are slightly smaller than 5 MIU each. These small 
deviations from the total intended dose are biologically inconsequential and do not 
constitute protocol deviations.     
 
C.5.1.2. Preparation of rIL-2 for Subcutaneous Administration 
 
The Investigational Pharmacy will reconstitute rIL-2 at the beginning of each cycle for 
each participant, and draw each individual dose into tuberculin syringes under sterile 
conditions. As was done in two previous large trials of rIL-2 in HIV-infected 
participants(19), all eight doses will be prepared, labeled, and delivered to the 
participant on day 0 of each cycle. This procedure may be modified in the course of 


 
16 
the study if deemed necessary by the Investigational Pharmacy, the investigators, or 
a regulatory authority, including the option to prepare a smaller number of doses in 
advance. In that case, pre-filled syringes may be shipped by fast courier to the 
participant’s residence.     
 
Participants will be taught to give themselves rIL-2 injections. This will require 
substantial clinician support in terms of both time spent instructing participants and 
in availability to answer participant questions and respond to participant concerns 
about injections and side effects. Refer to the Manual of Operating Procedures 
(MOPS) document for further details on initial and subsequent dose administration 
 
C.5.2. Guidelines for Dosage Modification 
 
Participants will be monitored closely for side effects of rIL-2. Participants who experience dose-
limiting side effects may have their rIL-2 temporarily interrupted or their dose reduced.  
 
The Manual of Operations (MOPs) includes a list of toxicities for which the investigator may 
choose to temporarily interrupt or dose-reduce rIL-2 (hereinafter, dose-limiting toxicities). An 
outline of criteria for certain specific potential adverse events are provided in section E.1. 
Briefly, the following guidelines apply:  
 
 
For toxicities during the 4-consecutive-day administration of rIL-2 that are considered 
dose-limiting, the remaining rIL-2 doses of that cycle of therapy will be interrupted until 
the dose-limiting toxicity is no longer consider dose-limiting.  
 
 
In some circumstances, a toxicity may be regarded as dose-limiting in the opinion of the 
investigator, even if it does not meet the above-mentioned criteria. In these instances, 
the clinical judgment of the investigator takes precedence. 
 
 
When rIL-2 treatment is reinitiated after interruption because of a dose-limiting toxicity, 
the dose will be reduced by up to 1.5 MIU per injection (3 MIU/day). If the reduced dose 
results in a dose-limiting toxicity during the same cycle, rIL-2 therapy will again be 
interrupted. Further dose reduction, if necessary, will be made in the same fashion.  
 
 
If a participant cannot tolerate an rIL-2 dose of 2 MIU twice a day then rIL-2 therapy will 
be permanently stopped.  
 
 
If, after a dose reduction, a participant completes a treatment cycle without significant 
toxicity, then escalation of the rIL-2 dose at the next cycle may occur by an increment 
of up to 1.5 MIU/dose (3 MIU/day). 
 
 
The total duration of a course of rIL-2 will not be extended for doses missed as a result 
of toxicity or any other reason. 
 
 
If a participant develops a toxicity that is subjectively intolerable, but which does not 
meet criteria for a dose-limiting toxicity, the dose of rIL-2 can be lowered after 
consultation with the protocol chairs (employing the above-described dose decrement 


 
17 
scheme) without actually interrupting the treatment phase of the cycle. 
 
 
Toxicities that result in a dose reduction or interruption will be recorded on the CRF.  
 
 
C.6. CONCOMITANT MEDICATIONS 
 
All participants should be on an HAART regimen for at least one year before enrollment, without 
changes in the 4 weeks prior to enrollment. Changes in HAART regimen after enrollment are to be 
undertaken at the discretion of the treating physician and as clinically indicated, but should otherwise 
be avoided.  
 
Symptomatic treatment for management of expected clinical manifestations associated with IL-2 
treatment is permitted according to the guidelines contained in the MOPS. 
 
Co-administration of cytotoxic agents with rIL-2 is prohibited, as is the administration of any 
medications that meet exclusion criteria.  
 
Recombinant IL-2 may affect central nervous system function. Thus, interactions could occur following 
concomitant administration of psychotropic drugs (e.g., narcotics, analgesics, antiemetics, sedatives, 
antidepressants and tranquilizers). The investigators will determine whether the clinically indicated 
use of any of the prohibited medications requires discontinuation of study treatment.  
 
Although systemic use of glucocorticoids has been shown to reduce IL-2-induced side effects, 
including fever, concomitant administration of these agents with rIL-2 may reduce the effectiveness 
of rIL-2; therefore, they will not be used for symptomatic management. If there is a clinical indication 
for use of systemic steroids after enrollment, however, this will be recorded in the concomitant 
medications log, but will not require discontinuation of study treatment.  
 
Beta-blockers and other antihypertensives may intensify the hypotension seen with rIL-2. Thus, 
participants receiving these medications will be enrolled only after careful review of the doses and 
combinations of antihypertensive medications they are receiving by the investigators.  
 
 
 


 
18 
D. CLINICAL AND LABORATORY EVALUATIONS 
 
 
D.1. SCHEDULE OF EVENTS 
 
  
Refer to the Manual of Operations (MOPS) for the schedule of events chart. 
 
D.2. TIMING AND CONTENT OF EVALUATIONS 
 
D.2.1. Screening Visit 
 
The screening visit will occur 8-16 weeks prior to start of rIL-2 treatment, and will include:  
 
 
History and complete physical examination that includes evaluation of adequate venous 
access for leukapheresis 
 
Height and weight measurements 
 
Concomitant medication review 
 
CBC and metabolic panel  
 
Pregnancy test  
 
Thyroid function tests and anti-Tpo antibodies 
 
CD4+ and CD8+ T cell count (both absolute and as percent of lymphocytes). 
 
Plasma HIV RNA level (using the locally available assay) and verification that plasma HIV RNA 
levels prior to screening meet the inclusion criteria. 
 
Hepatitis B and C testing 
 
Informed consent 
 
D.2.2. Leukapheresis Visit 
 
The pre-treatment leukapheresis visit will occur 4-8 weeks prior to start of rIL-2 treatment, and 
will include:  
 
 
Interval history and targeted physical examination 
 
Concomitant medication review. 
 
CBC and metabolic panel  
 
CD4+ and CD8+ T cell count (both absolute and as percent of lymphocytes) and 
documentation of all interim CD4+ counts (absolute and percents). 
 
Thyroid function tests and anti-Tpo antibodies. 
 
Participant will be instructed as to how IL-2 will be injected subcutaneously. Instructions for 
preparing rIL-2 for administration are given in the Manual of Operations, which includes the 
Investigator’s Brochure as an appendix. Participants receiving rIL-2 will be taught to give 
themselves injections. Participants will be given a dosing log for future use and will be 
encouraged to refer to it during their daily activities. Supporting materials for clinical staff 
and for participants on administering rIL-2 and managing expected side effects are included 
in the Manual of Operations. The Manual of Operations also includes contact information 
for questions concerning clinical management. No rIL-2 will be administered at this visit. 
 
A 4 liter leukapheresis will be performed at the Seidman Ambulatory Stem Cell Transplant 


 
19 
Unit at University Hospitals using AIDS protocol 328. 
 
Plasma will be frozen for single copy HIV RNA assay.  
 
Leukapheresis samples will be processed into PBMC that will be cryopreserved for assays 
of: 
o HIV reservoir by QVOA 
o HIV reservoir by EDITS 
o Total and intact proviral DNA assay (Accelavir) 
o Immune Cell Phenotype 
o NK cell phenotype 
 
D.2.3. rIL-2 Initial Treatment Visit – Cycle 1, Day 0 
 
The first IL-2 cycle will start 4-8 weeks after the leukapheresis visit and will include: 
 
 
Interval history and targeted physical examination, including weight. 
 
Concomitant medication review. 
 
Delivery of pre-filled cycle doses of rIL-2 and review of handling, storage, and administration 
procedures 
 
CBC and metabolic panel  
 
Thyroid function tests and anti-Tpo antibodies 
 
CD4+ and CD8+ T cell count (both absolute and as percent of lymphocytes)  
 
Plasma HIV RNA level by PCR (using the locally available assay)  
 
IL-2 immunogenicity 
 
PBMC will be cryopreserved for assays of immune cell phenotype and NK cell phenotype 
 
Plasma will be cryopreserved for single copy HIV RNA assay 
 
The participant will be instructed again as to how IL-2 will be injected subcutaneously. 
Instructions for preparing rIL-2 for administration are given in the Manual of Operations, 
which includes the Investigator’s Brochure as an appendix. Participants receiving rIL-2 will 
be taught to give themselves injections. Questions regarding the use of the dosing log will 
be resolved at this time. Supporting materials for clinical staff and for participants on 
administering rIL-2 and managing expected side effects are included in the Manual of 
Operations. The Manual of Operations also includes contact information for questions 
concerning clinical management.  
 
The participant will be observed as he/she administers the first dose of rIL-2 (approximately 
5 million units) subcutaneously, and this dose will be recorded, under the supervision of the 
research staff conducting the visit, on the dosing log.  
 
The participant will be observed for approximately 4 hours after the injection. During the 
administration period, vital signs will be monitored every hour.  
 
D.2.4. rIL-2 Treatment Cycle 1, Day 7 
 
Participant returns to clinic for: 
 
 
Interval history and complete physical examination. 
 
Concomitant medication review 
 
Tolerance and compliance with injection schedule 
 
CBC and metabolic panel  


 
20 
 
CD4+ and CD8+ T cell count (both absolute and as percent of lymphocytes)  
 
Plasma HIV RNA level by PCR (using locally available assay)  
 
IL-2 immunogenicity 
 
PBMC will be cryopreserved for HIV reservoir assay by EDITS 
 
PBMC will be cryopreserved for assays of immune cell phenotype and NK cell phenotype 
 
Plasma will be cryopreserved for single copy HIV RNA assay 
 
D.2.5. rIL-2 Treatment Cycles 4 and 8, Day 0  
 
NOTE: Each cycle should start 7-10 weeks after day 0 of the last treatment cycle. These visits will 
include:  
 
 
Interval history and targeted physical examination, including weight. 
 
Concomitant medication review. 
 
Delivery of pre-filled cycle doses of rIL-2 and review of handling, storage, and administration 
procedures 
 
CBC and metabolic panel  
 
Thyroid function tests and anti-Tpo antibodies 
 
CD4+ and CD8+ T cell count (both absolute and as percent of lymphocytes)  
 
Plasma HIV RNA level by PCR (using the locally available assay)  
 
PBMC will be cryopreserved for assays of immune cell phenotype and NK cell phenotype 
 
Plasma will be cryopreserved for single copy HIV RNA assay 
 
The participant will be observed as he/she administers the dose of rIL-2 (approximately 5 
million units) subcutaneously.  
 
 D.2.6. rIL-2 Treatment Cycles 4 and 8, Day 7 
 
Participant returns to clinic for: 
 
 
Interval history and complete physical examination. 
 
Concomitant medication review 
 
Tolerance and compliance with injection schedule 
 
CBC and metabolic panel  
 
CD4+ and CD8+ T cell count (both absolute and as percent of lymphocytes)  
 
Plasma HIV RNA level by PCR (using locally available assay)  
 
PBMC will be cryopreserved for assays of immune cell phenotype and NK cell phenotype 
 
Plasma will be cryopreserved for single copy HIV RNA assay 
 
D.2.7. rIL-2 Treatment Cycles 2 and 3, Day 0 
 
NOTE: Each treatment cycle should begin 7-10 weeks after start of last treatment cycle. These 
visits will include:  
 
 
Interval history and targeted physical examination, including weight. 
 
Concomitant medication review. 
 
Delivery of pre-filled cycle doses of rIL-2 and review of handling, storage, and administration 
procedures 


 
21 
 
CBC and metabolic panel  
 
Thyroid function tests and anti-Tpo antibodies 
 
CD4+ and CD8+ T cell count (both absolute and as percent of lymphocytes)  
 
Plasma HIV RNA level by PCR (using the locally available assay)  
 
IL-2 immunogenicity (cycle 2 only) 
 
D.2.8. rIL-2 Treatment Cycles 5, 6, and 7, Day 0 
 
NOTE: Each treatment cycle should begin 7-10 weeks after start of last treatment cycle. These 
visits will include:  
 
 
Interval history and targeted physical examination, including weight. 
 
Concomitant medication review. 
 
Delivery of pre-filled cycle doses of rIL-2 and review of handling, storage, and administration 
procedures 
 
CBC and metabolic panel  
 
Thyroid function tests and anti-Tpo antibodies 
 
CD4+ and CD8+ T cell count (both absolute and as percent of lymphocytes)  
 
Plasma HIV RNA level by PCR (using the locally available assay)  
 
D.2.9. rIL-2 Treatment cycles 1-8, Days 2 and 4 
 
Staff will contact the participant by phone to assess tolerance and compliance with injection 
schedule 
 
D.2.10. End of Study Visit (or Premature Discontinuation Visit) 
 
NOTE: The end of study visit should take place 8 weeks (+/- 2 weeks) after Day 0 of the last (8th) 
treatment cycle. In the case of premature discontinuation, the end of study visit should take 
place at least 6 weeks after day 0 of the last treatment cycle and may take place up to 10 weeks 
after day 0 of the last treatment cycle. 
 
These visits will include:  
 
 
Interval history and targeted physical examination. 
 
Immunogenicity testing 
 
CD4+ and CD8+ T cell count (both absolute and as percent of lymphocytes)  
 
Plasma HIV RNA level by PCR (using the locally available assay)  
 
IL-2 immunogenicity 
 
At this visit the participant will undergo a 4 Liter leukapheresis at the Seidman Ambulatory 
Stem Cell Transplant Unit at University Hospitals using AIDS protocol 328. 
 
Plasma will be cryopreserved for single copy HIV RNA assay 
 
Leukapheresis product PBMC will be cryopreserved for:  
o HIV reservoir assay by EDITS 
o HIV reservoir assay by QVOA  
o Total and intact proviral DNA assay (Accelavir) 
o Assays of immune cell phenotype and NK cell phenotype 


 
22 
 
If leukapheresis cannot be done after premature treatment discontinuation for any reason, a 
120 cc. blood draw will be obtained for preparation of PBMC and plasma. Based upon cell yield 
these samples will be used for:  
 
 
Plasma will be cryopreserved for single copy HIV RNA assay 
 
HIV reservoir assay by EDITS 
 
HIV reservoir assay by QVOA  
 
Total and intact proviral DNA assay (Accelavir) 
 
Assays of immune cell phenotype and NK cell phenotype 
 
D.2.11. Immunogenicity follow-up 
 
Participants who have detectable neutralizing antibodies at the end of study visit will be 
followed approximately every 90 days for repeat testing until 12 months after the end of study 
or until a negative result is obtained. During these visits, an interval medical history and 
targeted physical exam will be conducted. If clinically significant events have occurred, the 
participant will be referred for appropriate medical care.  
 
D.2.12. Management of off-window visits 
 
Every effort should be made to conduct each visit within its allocated window. If, however, a 
participant cannot conduct a scheduled visit within the scheduled window, the principal 
investigators will determine whether the visit can be conducted within a few days outside of 
the per-protocol window. If conducting the visit on the proposed off-window date would raise 
a safety concern or could compromise the integrity of the study, the visit will not be 
rescheduled and will be recorded as missed. In either case, the reasons for the off-window visit 
will be recorded in the source document and the protocol deviation CRF will be completed.  
 
D.2.13. Holding rIL-2 cycles 
 
The initiation of an rIL-2 cycle can be delayed or cancelled by the principal investigators, if 
deemed necessary for clinical or logistical reasons. When a cycle is delayed beyond the end of 
the scheduled window, the reasons for the delay or cancellation will be recorded in the source 
document and the protocol deviation CRF will be completed. If a cycle is cancelled, the 
corresponding day 2, 4, and 7 visits will also be cancelled.       
 
D.3. INSTRUCTIONS FOR EVALUATIONS 
 
All clinical and laboratory information required by this protocol is to be present in the source 
documents. Results of all approved laboratory tests performed as part of the study will be provided 
to the participants’ physicians, and any resulting clinical action will be taken by the participant and 
their physician without interference from the study personnel.  
 
D.3.1. Documentation of HIV 
 
For the purposes of this protocol, any combination of two positive results of the following tests 
is sufficient for documentation of HIV infection: a) FDA-approved HIV ELISA or EIA; b) FDA-


 
23 
approved HIV Western blot; c) FDA-approved HIV rapid test; d) p24 antigen immunoassay; e) 
FDA-approved nucleic acid test; f) detectable HIV RNA in plasma by an FDA-approved method.  
 
D.3.2. Medical History 
 
The medical history must include all diagnoses that were either established within 45 days prior 
to or ongoing at the time of enrollment. Any allergies to any study medications and their 
formulations must be documented. All elements of the medical history will be recorded on the 
source documents. 
 
D.3.3. Medication History 
 
A medication history must be present, including start and stop dates. The table below lists the 
medications that must be included in the history to be recorded in the source documents.  
 
Table 1. Medications to be recorded 
Medication Category 
Timeframe 
Antiretroviral medications 
Complete history 
Immune-based therapies 
Within 90 days prior to study entry 
Vaccines 
Within 30 days prior to study entry 
All other prescription and non-prescription 
medications 
Within 90 days prior to entry 
 
D.3.4. Clinical Assessments 
 
D.3.4.1. Complete Physical Exam  
 
A complete physical exam is to include at a minimum an examination of the skin, head, 
mouth, and neck; auscultation of the heart and lungs; abdominal exam; and examination 
of the lower extremities for edema. The complete physical exam will also include vital 
signs (temperature, heart rate, respiration rate, and blood pressure).  
 
D.3.4.2. Targeted Physical Exam 
 
A targeted physical exam is directed to the site or organ system involved in any 
previously identified or new signs or symptoms that the participant has experienced 
since the last visit. This exam also includes vital signs (temperature, heart rate, 
respiration rate, and blood pressure). 
 
D.3.4.3. Height 
 
Height without shoes in centimeters will be obtained at screening and recorded on the 
CRF at entry. 
 
D.3.4.4. Weight 
 
Weight without shoes in kilograms will be obtained at screening, leukapheresis visit, at 


 
24 
entry and at day 0 of each cycle. The weight obtained at entry and at day 0 of each cycle 
will be recorded on the CRF. 
 
D.3.4.5. Interval History 
 
At entry, all signs and symptoms, regardless of grade, that occurred within 45 days 
before entry will be recorded in the source documents. Post-entry, only grade ≥ 2 signs 
and symptoms, or those that led to a change in treatment, regardless of grade, will be 
recorded on the corresponding CRFs. 
 
D.3.4.6. Diagnoses 
 
After study entry, all new diagnoses established while on study will be recorded on the 
source document. Any gradable diagnoses that meet AE criteria will be recorded on the 
CRF, and relationship to study agent will be assessed. 
 
D.3.4.7. Concomitant Medications 
 
Concomitant prescription or over-the counter medications initiated or discontinued 
since the last visit will be recorded on the source documents. 
 
D.3.4.8. Study Treatment Modifications 
 
All study drug modifications, including actually administered doses preceding each of the 
scheduled in-person or phone assessments will be recorded. Any permanent 
discontinuation of treatment will be recorded on the CRF.  
 
D.3.4.9. Antiretroviral Medications 
 
All modifications to antiretroviral medications post-entry will be recorded on the CRF. If 
the modification includes discontinuation of antiretrovirals, the rules for treatment 
discontinuation (section F.3) must be followed. 
 
 
D.3.5. Laboratory Evaluations 
 
All clinical laboratory results will be stored as part of the source document. Only emerging (i.e. 
not present before or at the time of entry) laboratory values grade 2 or higher must be recorded 
on the CRF. 
 
D.3.5.1. Clinical Laboratory Tests  
 
All clinical labs will be processed in the CLIA-certified clinical laboratory of University 
Hospitals Cleveland Medical Center. Clinical laboratories include:  
  
 
CBC will include hemoglobin, hematocrit, white cell count with differential and 
platelet count. This test will be submitted and results obtained in real time. 
 
Metabolic panel will include at least glucose, BUN, creatinine, sodium, potassium, 
chloride, bicarbonate, total and direct bilirubin, AST, ALT, and alkaline phosphatase. 


 
25 
This test will be submitted and results obtained in real time. 
 
HIV-1 RNA testing will be done using an FDA-approved method with a lower limit of 
detection of 50 copies/mL or lower. This test will be submitted in real time, but the 
turnaround time is approximately 3 days. 
 
HBsAg with reflex HBV DNA, and HCV Ab with reflex HCV RNA will be performed 
using FDA-approved kits as needed to determine eligibility. These tests will be 
submitted in real time. Results will be obtained, however, prior to study entry.  
 
Thyroid function tests will include TSH, T4, and T3 serum levels. 
 
D.3.5.2. Research Evaluations 
 
Specimens for immunologic monitoring, virologic testing, and storage for deferred 
assays will be processed, stored, and distributed by Dr. Lederman’s laboratory as 
needed. Immunogenicity testing for antibodies against rIL-2 will be done in batched 
serum using standard methods for both binding and neutralizing activity. These methods 
will be validated in Dr. Lederman’s laboratory before testing of study-derived samples. 
Refer to the LPC for details on volumes, collections procedures, transport, and 
processing.  
 
D.4. SPECIMEN COLLECTION, HANDLING, AND PROCESSING 
 
D.4.1. General Specimen Management Guidance 
 
The study site will adhere to the standards of good clinical laboratory practice, DAIDS 
Laboratory Requirements and site standard operating procedures for proper collection, 
processing, labeling, transport, and storage of specimens at the local laboratories, as described 
in 
(http://www.niaid.nih.gov/LabsAndResources/resources/DAIDSClinRsrch/Documents/gclp.pd
f)  
 
Specimen collection, testing, and storage at the site laboratories will be documented per 
standard site practice. In cases where laboratory results are not available due to administrative 
or laboratory error, specimens intended may be re-drawn if within a window of the intended 
visit that the investigators determine is acceptable for the scientific goals of the study.  
 
D.4.2. Storage of Specimens for Future Use 
 
Study staff will store all specimens collected in this study on site at least through the end of the 
study. Specimens will not be labeled with any personal identifiers. Storage of all study samples 
will follow local standard operating procedure to ensure the anonymity and confidentiality of 
the trial research participants. Specimens remaining at the end of the study will be transferred 
to a designated bio-repository with appropriate participants’ permission and after all protocol-
required and quality assurance testing has been completed. If such permission is not obtained, 
those participant’s samples will be destroyed. 
 
Informed consent for storage of specimens for future studies will be obtained through an 
existing IRB-approved protocol that governs the existing bio-repository at UHCMC. This 
protocol exists under the oversight of the Case Western Reserve University Center for AIDS 


 
26 
Research (CFAR), and is one of the resources of the CFAR Clinical Services Core, which is 
directed by Dr. Lederman. The Clinical Services Core maintains a fully HIPAA-complaint 
repository management system, and the protocol provides for separate consents to use stored 
specimens for: a) use of de-identified data for research purposes; b) non-genetic studies; c) 
genetic studies; and d) authorization to contact participants for future studies. Participants can 
consent to any, all, or none of the four activities. The repository management system permits 
tracking and updating in real time, for each record in the database and for each specimen, 
whether a valid consent of any of the four types described above exists in the system.  


 
27 
E. CLINICAL MANAGEMENT ISSUES 
 
 
If at any time, a decision is made to discontinue study agent in all participants, the IND Sponsor (Dr. Benigno 
Rodriguez), after consultation with the protocol team, will inform the US Food and Drug Administration 
(FDA), the IRB, and the site investigators.  
 
E.1. MANAGEMENT OF SPECIFIC ADVERSE EVENTS 
 
The Guidelines for Dose Modification, (protocol section C.5.2), apply to all of the scenarios listed in this 
section. 
 
E.1.1. Serious Infections 
 
All subjects will be monitored for signs or symptoms of a serious or local infection at each visit. 
All subjects who develop a serious infection while on study will be referred for immediate 
medical care to a qualified healthcare professional. Participants who develop any of the 
following infectious events will be required to discontinue study treatment:  
 
 
Tuberculosis, pulmonary or extrapulmonary 
 
Non-tuberculous mycobacterial infection, disseminated or extrapulmonary 
 
Pneumocystis jirovecii pneumonia 
 
Coccidioidomycosis, disseminated or extrapulmonary 
 
Cryptococcosis, extrapulmonary 
 
Cryptosporidiosis or isosporiasis, chronic intestinal (greater than 1 month's duration) 
 
Cytomegalovirus disease (other than liver, spleen, or lymph nodes) and including retinitis 
with loss of vision 
 
Histoplasmosis, disseminated or extrapulmonary 
 
Kaposi's sarcoma 
 
Lymphoma, Burkitt's or immunoblastic, regardless of anatomical location 
 
Lymphoma, primary of brain 
 
Progressive multifocal leukoencephalopathy 
 
Toxoplasmosis of brain 
 
Herpes zoster reactivation involving more than one dermatome or visceral involvement 
including but not limited to viral pneumonia, encephalitis and hepatitis. 
 
Any serious infection that is considered life-threatening or requires inpatient treatment.  
Participants who experience other serious infections not listed above that do not require 
inpatient treatment and are not considered life-threatening will have study treatment 
temporarily stopped until the infection is controlled. These subjects may restart study drug 
once the infection is controlled. 
 
Other infections, including local infections, will also require referral to qualified medical 
treatment. The study principal investigator, in consultation with the SMC if necessary, will 
determine if an infection not listed above warrants permanent treatment discontinuation. 
 
 
 


 
28 
E.1.2. Acute Hypersensitivity Reactions 
 
To minimize the risk of a severe, immediate-type hypersensitivity reaction or capillary leak 
syndrome, the first dose of study agent will be administered in the Special Immunology Unit 
by personnel with experience administering rIL-2 to over 50 participants in the SILCAAT and 
ACTG 328 trials. Participants will be monitored for a minimum of 30 minutes following the first 
dose of study drug by personnel with life support training and access to adequate life support 
equipment and resuscitation medication. 
 
Development of a grade ≥3 hypersensitivity reaction, a grade 2 hypersensitivity reaction that 
includes manifestations of angioedema, or suspected or confirmed capillary leak syndrome will 
require permanent treatment discontinuation.  
 
E.1.3. Neutropenia 
 
Participants who develop neutropenia will be referred for treatment by a qualified healthcare 
professional. Volunteers with an ANC <2,000 cells/mm3 at screening will be excluded. 
 
 
Should the ANC decrease to ≥500 but ≤1,000 cells/mm3, the rIL-2 dose will be interrupted 
until the ANC is >1,000 cells/mm3 and then rIL-2 will be restarted at 3.5 million units twice 
daily. If the ANC then remains above 1,000 cells/mm3, this dose will be continued until the 
end of study.  
 
If the ANC drops to ≥500 but ≤1,000 cells/mm3 while on the reduced dose of 3.5 million 
units twice daily, rIL2 will be discontinued until the ANC reaches 1,000 cells/mm3, and then 
resumed at a dose of 2 million units twice daily. If the ANC then remains above 1,000 
cells/mm3, this dose will be continued until the end of study. If the ANC falls again to ≤1,000 
cells/mm3 while on the reduced 2 million unit twice daily dose, rIL2 will be permanently 
discontinued.  
 
Should the ANC decrease to <500 cells/mm3, rIL-2 will be permanently discontinued. 
 
E.1.4. Thrombocytopenia 
 
Participants who develop thrombocytopenia will be referred for treatment by a qualified 
healthcare professional. Volunteers with platelet counts <150,000/mm3 will be excluded.  
 
 
Should the platelet count decrease to ≥50,000 but ≤100,000/mm3 the rIL-2 dose will be 
interrupted until the platelet count is >100,000/mm3 and then rIL-2 will be restarted at 3.5 
million units twice daily. If the platelet count then remains above 100,000 /mm3, this dose 
will be continued until the end of study. 
 
 If the platelet count drops to ≥50,0000 but ≤100,000/mm3 while on the reduced dose of 
3.5 million units twice daily, rIL2 will be discontinued until the platelet count reaches 
100,000/mm3 and then resumed at a dose of 2 million units twice daily. If the platelet count 
then remains above 100,000 /mm3, this dose will be continued until the end of study. If 
the platelet count falls again to ≤100,000 /mm3 while on the reduced 2 million unit twice 
daily dose, rIL2 will be permanently discontinued. 
 
Should the platelet count decrease to <50,000/mm3, rIL-2 will be permanently 
discontinued. 


 
29 
E.1.5. AST and ALT Abnormalities 
 
Participants who develop AST or ALT elevations will be referred for treatment by a qualified 
healthcare professional. Volunteers with AST or ALT levels > 2.5x ULN at screening will be 
excluded. 
 
 
Volunteers with cirrhosis, severe liver disease, or active hepatitis B or C infection will be 
excluded from the study. 
 
Should AST or ALT values rise to > 3x ULN, rIL-2 will be interrupted. rIL-2 may be resumed 
at 3.5 million units twice daily when AST or ALT fall to < 2x ULN. If AST and ALT values then 
remain below 3x ULN, this dose will be continued to the end of study.  
 
If AST or ALT values rise again to >3x ULN while on the reduced dose of 3.5 million units 
twice daily, rIL-2 will be interrupted until AST and ALT fall to <2x ULN and then resumed at 
a dose of 2 million units twice daily. If AST and ALT values then remain below 3x ULN, this 
dose will be continued to the end of study. If AST or ALT levels rise again to >3x ULN while 
on the reduced 2 million unit twice daily dose, rIL2 will be permanently discontinued. 
 
If ALT values rise again to > 3x ULN while the patient is receiving 2 million units twice daily, 
rIL-2 will be discontinued permanently.  
 
Should AST or ALT values rise to >5x ULN, rIL2 will be permanently discontinued.  
 
 
E.1.6. Thyroid Test Abnormalities 
 
Participants who develop thyroid function test (TFT) abnormalities will be referred for treatment by a 
qualified healthcare professional. Volunteers with abnormal TFTs or levels of anti-thyroid antibodies 
(anti-Tpo) at screening will be excluded.  
 
 
If a participant develops a TSH level >3.98 mIU/L, rIL-2 will be permanently discontinued.  
 
If T3 or T4 levels are outside the normal reference range of the laboratory, rIL-2 will be 
permanently discontinued.  
 
If a participant develops anti-Tpo antibody levels that are above the normal reference range 
of the laboratory, rIL-2 will be permanently discontinued.   
 
If a participant develops clinical signs or symptoms of hypo- or hyperthryroidism, rIL-2 will be 
permanently discontinued.  
 
E.1.7. Renal Dysfunction 
 
Participants who develop evidence of renal dysfunction will be referred for treatment by a 
qualified healthcare professional. Volunteers with serum creatinine >1.5 mg/dL at screening will 
be excluded. 
 
 
Should serum creatinine increase to >2.0 mg/dL but ≤3 mg/dL, rIL-2 will be interrupted. rIL-
2 may be resumed at 3.5 million units twice daily when creatinine falls to <1.5 mg/dL. If 
creatinine remains ≤1.5 mg/dL on the reduced dose of 3.5 million units twice daily, this dose 
will be continued to the end of study.   
 
If serum creatinine rises again to >1.5 mg/dL while on the reduced dose of 3.5 million units 
twice daily, rIL-2 will be interrupted until it falls to <1.5 mg/dL and then resumed at a dose 
of 2 million units twice daily. If serum creatinine then remains below 1.5 mg/dl, this dose 


 
30 
will be continued to the end of study. If serum creatinine rises again to >1.5 mg/dL while on 
the reduced 2 million unit twice daily dose, rIL2 will be permanently discontinued. 
 
Should serum creatinine rise to >3 mg/dL, rIL-2 will be discontinued permanently 
 
E.1.8. Malignant Conditions 
 
All participants will be monitored for signs or symptoms of a malignant condition at each visit, 
and referred for treatment by a qualified healthcare provider if evidence of malignancy is found. 
Volunteers with a history of malignant disease that has not been fully resected and considered 
cured or in remission for at least 5 years will be excluded. Participants who develop a malignancy 
other than a basal cell skin carcinoma requiring no more than local excision during study will be 
required to discontinue study treatment permanently.  
 
E.1.9. Viral Reactivation 
 
Participants who develop pain, a skin rash, or other clinical manifestation deemed consistent 
with an episode of herpes zoster, will be immediately referred for evaluation by a qualified 
clinician, and will be required to discontinue study treatment until any pharmacologic treatment 
for varicella-zoster has been completed and the clinical manifestations have resolved in the 
judgment of the treating physician. Participants who develop recurrence of signs or symptoms 
or herpes zoster reactivation, and those who develop involvement of more than two 
dermatomes or have evidence of visceral involvement while on study will be required to 
discontinue study treatment permanently.  
 
Participants who develop a detectable HBV DNA at any time during the study will be required 
to discontinue study treatment permanently, and will be referred for specialized medical care a 
soon as the study team becomes aware of a positive HBV DNA result.  
 
E.1.10. Thrombotic Disease  
 
At each visit, signs and symptoms of venous thrombosis will be sought. Participants who develop 
deep vein thrombosis or pulmonary embolism will permanently discontinue rIL-2 
administration.  
 
E.2. MANAGEMENT OF ADVERSE EVENTS ACCORDING TO SEVERITY 
 
E.2.1. Grade 1 or 2 AEs 
 
Participants who develop a Grade 1 or 2 AE may continue study treatment.  
 
E.2.2. Grade 3 or 4 AEs 
 
If the investigators have compelling evidence that the grade 3 or 4 AE has NOT been caused by 
the study treatment, dosing may continue without modification. In all other cases, the guidelines 
for dose adjustment will be applied. Refer to sections E.1 and C.6.2 and to Manual of Operations 
for dosing modification guidelines.  
 
Participants experiencing Grade 3 or 4 AEs will be followed closely for resolution of the AE to 


 
31 
Grade ≤ 2. 
 
E.3. PREGNANCY  
 
Women of reproductive potential will be excluded from enrollment in the study. In the unlikely event 
that a participant does become pregnant while on study treatment (e.g., tubal ligation failure), study 
treatment will be permanently discontinued and the participant will be referred for immediate medical 
evaluation. Any such participants will be encouraged to remain in the study to be followed on study/off 
study treatment until study completion and will be followed by telephone contact thereafter to 
determine the pregnancy outcome. Pregnancy-related outcomes (health of the infant) and any 
pregnancy-related complications (e.g., fetal loss/abnormalities) will be reported on the CRF.  
 
 
NOTE: Pregnant participants will be considered on study until the outcome of the pregnancy has been 
obtained and reported on the CRF.  
 
E.4. REPORTING OF ADVERSE REACTIONS TO THE RESPONSIBLE IRBs 
 
The investigators will report adverse reactions to the responsible IRB in accordance with respective IRB 
policies and procedures. 
 
Follow-up information to a reported adverse event will be submitted to the IRB as soon as the relevant 
information is available. If the results of the investigator’s follow-up investigation show that an adverse 
event that was initially determined not to require reporting to the IRB does, in fact, meet the 
requirements for reporting, the investigator will report it as soon as possible in accordance with 
respective IRB policies and procedures. 
 
E.5. SOCIAL HARMS REPORTING 
 
Although the study site makes every effort to protect participant privacy and confidentiality, it is 
possible that participants' involvement in the study could become known to others, and that social 
harms may result (i.e., because participants could become known as HIV-infected). For example, 
participants could be treated unfairly or discriminated against, or could have problems being accepted 
by their families and/or communities. 
 
Social harms that are judged by the study chairs to be serious or unexpected will be reported to 
responsible site IRB at least annually or according to their individual requirements. In the event that a 
participant reports social harm, every effort will be made by study staff to provide appropriate care 
and counseling to the participant, and/or referral to appropriate resources for the safety of the 
participant as needed.  
 
 
 
 
 


 
32 
F. CRITERIA FOR DISCONTINUATION 
 
 
F.1. PERMANENT TREATMENT DISCONTINUATION 
 
 
Interruption of antiretroviral medications for ˃4 consecutive weeks 
 
Occurrence of any of the following opportunistic complications:  
 
o Tuberculosis, pulmonary or extrapulmonary 
o Non-tuberculous mycobacterial infection, disseminated or extrapulmonary 
o Pneumocystis jirovecii pneumonia 
o Coccidioidomycosis, disseminated or extrapulmonary 
o Cryptococcosis, extrapulmonary 
o Cryptosporidiosis or isosporiasis, chronic intestinal (greater than 1 month's duration) 
o Cytomegalovirus disease (other than liver, spleen, or lymph nodes) and including retinitis with 
loss of vision 
o Histoplasmosis, disseminated or extrapulmonary 
o Kaposi's sarcoma 
o Lymphoma, Burkitt's or immunoblastic, regardless of anatomical location 
o Lymphoma, primary of brain 
o Progressive multifocal leukoencephalopathy 
o Toxoplasmosis of brain 
 
 
Occurrence of herpes zoster reactivation involving more than two dermatomes or visceral 
involvement including but not limited to viral pneumonia, encephalitis and hepatitis. 
 
Occurrence of a serious infection that is considered life-threatening or requires inpatient 
treatment.  
 
Occurrence of an incident cancer other than a localized basal cell carcinoma of the skin that 
requires local excision only. 
 
Requirement for prohibited concomitant medications (see exclusion criteria and section C.6). 
 
Pregnancy or breastfeeding. 
 
Deep vein thrombosis or pulmonary embolism. 
 
Myocardial infarction or other acute coronary syndrome. 
 
Development of a grade ≥3 hypersensitivity reaction, OR a grade 2 hypersensitivity reaction that 
includes manifestations of angioedema, or suspected or confirmed capillary leak syndrome. 
 
Development of an ANC <500 cells/mm3. 
 
Development of a platelet count <50,000/mm3.  
 
Elevation of AST or ALT to >5x ULN.  
 
Serum TSH elevation to ≥3.99 mIU/L, abnormal serum T4 or T3 levels, abnormal levels of anti-Tpo 
antibodies, or symptomatic hypo- or hyperthyroidism. 
 
Completion of treatment as defined in the protocol. 
 
Request by participant or his/her healthcare providers to terminate treatment. 
 
Reasons believed to be clinically significant by the investigators, even if not addressed in the 
adverse event management section of the protocol. 
 
 


 
33 
F.2. PREMATURE STUDY DISCONTINUATION 
 
 
Failure by the participant to attend 3 consecutive visits. 
 
Request by participant or his/her healthcare providers to terminate participation in the study. 
 
Participant judged by the investigator to be at significant risk of failing to comply with the 
provisions of the protocol as to cause harm to self or seriously interfere with the validity of the 
study results. 
 
At the discretion of the institutional review board (IRB), Office for Human Research Protections 
(OHRP), FDA, NIAID or investigator.  
 
F.3. TEMPORARY TREATMENT DISCONTINUATION 
  
 
Criteria for withholding dose met (refer to section C.5.2 and to Manual of Operations).  
 
 
 
 
 
 


 
34 
G. SAFETY MONITORING 
 
 
All adverse events grade 2 or greater will be reviewed in real time by the study investigators, who will 
establish their relationship to study treatment (see below). The study investigators will also determine 
whether specific treatment for each adverse event is warranted, whether they meet criteria for study 
treatment discontinuation, and whether they constitute an emerging exclusionary criterion.  
 
In addition to the real-time review of adverse events, the study data manager and statistician will prepare 
a bi-yearly report of accrual, early study treatment and study discontinuations (and related reasons), 
baseline characteristics, longitudinal CD4 T cell count and plasma HIV RNA measurements, Grade ≥2 signs 
and symptoms, Grade ≥2 laboratory abnormalities and reported serious adverse events (SAEs). This report 
will be reviewed by the research team and the Safety Monitoring Committee (SMC) during regularly 
scheduled conference calls every 6 months. The investigators and SMC chair may jointly forgo an actual 
conference call if the reports have been reviewed and no additional discussion us deemed necessary.  
 
In addition to the regularly scheduled reviews, the SMC will perform expedited reviews of the safety data 
whenever any of the following happens:  
 
 
Two or more participants have experienced a grade 4 AE that is deemed possibly, probably, or 
definitely related to study treatment 
 
Any death occurs on study that is deemed possibly, probably, or definitely related to study treatment 
 
Whenever either of the two criteria immediately above occurs, enrollment into the study will be paused 
until the SMC review has taken place and a determination has been made that enrollment can resume.  
 
The SMC will be composed of an investigator affiliated with Case Western Reserve University in a 
department other than the Division of Infectious Diseases and HIV Medicine, an investigator not affiliated 
with Case Western Reserve University, and a biostatistician with no direct responsibilities managing trial-
derived data.  
 
 
 
 
 


 
35 
H. DATA COLLECTION AND MONITORING AND ADVERSE EVENT 
REPORTING 
 
 
H.1. RECORDS TO BE KEPT 
 
CRFs will be provided for each participant. Participants will not be identified by name on any CRFs. 
Participants will be identified by the participant identification number (PID). Source documents and 
data will be maintained in accordance with Requirements for Source Documentation in DAIDS Funded 
and/or 
Sponsored 
Clinical 
Trials 
(http://www.niaid.nih.gov/LabsAndResources/resources/DAIDSClinRsrch/Documents/sourcedocpoli
cy.pdf).  
 
Study personnel will maintain and securely store complete, accurate, and current study records 
throughout the study. Per US regulations, for each of the investigational products tested, the 
investigators will retain all study records on site for at least two years after the investigation is 
discontinued and the US FDA is notified.  
 
Study records will be maintained on site for the entire period of study implementation.  
 
H.2. STUDY COORDINATION 
 
Dr. Benigno Rodriguez will hold the IND for this study.  
 
Study implementation will follow the FDA approved protocol. All amendments will be signed off by 
the FDA prior to implementation, unless the change is required emergently to assure participant 
safety.  
 
Study implementation will also be guided by the MOPS instructions and operational guidance on 
conducting study visits, data and forms processing, specimen collection, processing, and shipping, AE 
assessment, management and reporting, dispensing study products, documenting product 
accountability, and other study operations. 
 
Close coordination among protocol team members is necessary to track study progress, respond to 
queries about proper study implementation, and address other issues in a timely manner. Rates of 
accrual, retention, follow-up, and AE incidence will be monitored closely by the team. 
 
H.3. ADVERSE EVENT REPORTING 
 
H.3.1. Definitions 
 
H.3.1.1. Adverse event (AE) 
 
An AE is any untoward medical occurrence in a participant who is being administered 
a study agent/intervention, but does not necessarily have a causal relationship with 
the study agent/intervention. An AE can therefore be any unfavorable and unintended 


 
36 
sign (including an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of the study agent/intervention, whether or not related to the 
study agent/intervention.  
 
Adverse events are graded according the Division of AIDS Table for Grading the 
Severity of Adult and Pediatric Adverse Events, Version 1.0, December 2004 
(Clarification, August 2009), which can be found on the DAIDS RSC Web Site: 
http://rsc.tech-res.com/safetyandpharmacovigilance/ 
 
H.3.1.2. Adverse Reaction 
 
An adverse reaction is defined as any adverse event caused by the use of a drug. 
Adverse reactions are a subset of all suspected adverse reactions for which there is 
reason to conclude that the drug caused the event.  
 
H.3.1.3. Suspected 
 
A suspected adverse reaction is defined as any adverse event for which there is a 
reasonable possibility that the drug caused the adverse event. For the purposes of IND 
safety reporting, “reasonable possibility” indicates that there is evidence to suggest a 
causal relationship between the drug and the adverse event. A suspected adverse 
reaction implies a lesser degree of certainty about causality than an adverse reaction.  
 
H.3.1.4. Unexpected 
 
An adverse event or suspected adverse reaction is considered unexpected if it is not 
listed in the package insert, or is not listed with the same characteristics or severity 
observed in the trial, or is not consistent with the risk information described elsewhere 
in the current protocol.  
 
Some adverse events are listed in the package insert as occurring with the same class 
of drugs, or as anticipated from the pharmacological properties of the drug, even 
though they have not been observed with the drug under investigation. Such events 
would be considered unexpected until they have been observed with the drug under 
investigation.  
 
H.3.1.5. Serious 
 
An adverse event or suspected adverse reaction is considered serious if, in the view of 
either the investigators or sponsor, it results in any of the following outcomes:  
 
 
Death  
 
Life-threatening adverse event  
 
Inpatient hospitalization or prolongation of existing hospitalization  
 
A persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life function  
 
Congenital anomaly/birth defect  
 


 
37 
Important medical events that may not result in death, are not life-threatening, and 
do not require hospitalization may be considered serious when, based upon 
appropriate medical judgment, they may jeopardize the patient or subject and may 
require medical or surgical intervention to prevent one of the outcomes listed in this 
definition. Examples of such medical events include allergic bronchospasm requiring 
intensive treatment in an emergency room or at home, blood dyscrasias or convulsions 
that do not result in inpatient hospitalization, or the development of drug dependency 
or drug abuse.  
 
H.3.1.6. Life-Threatening 
 
An adverse event or suspected adverse reaction is considered life-threatening if, in the 
view of the investigators, its occurrence places the patient or subject at immediate risk 
of death. It does not include an adverse event or suspected adverse reaction that, had 
it hypothetically occurred in a more severe form, might have caused death. 
 
H.3.2. Expedited Adverse Event Reporting  
 
If a death occurs during the treatment phase of the study or within 30 days after the last 
administration of the study drug(s) and it is determined to be related either to the study drug(s) 
or to a study procedure, the investigators or his/her designee must notify the SMC Chair (or 
qualified alternate) no later than 3 reporting days after the investigators become aware of the 
event. For the purposes of expedited reporting to the SMC the definition of a “reporting day” 
in Version 2.0 of the DAIDS EAE Manual will be used, i.e, a reporting day begins at 12:00 AM 
and ends at 11:59 PM local time, Monday through Friday, holidays falling from Monday 
through Friday included.  
 
 
H.3.3. Reporting to the University Hospitals of Cleveland Medical Center (UHCMC) Institutional Review 
Board (IRB) 
  
In compliance with the UHCMC IRB policy titled “Event Reporting – Unanticipated Problems, 
Adverse Events, and Protocol Deviations”, the Principal Investigators will report all non-fatal 
events meeting the UHCMC IRB definition of unanticipated problem involving risk to 
participants or others within 14 calendar days of awareness of the event. All fatal events will 
be reported to the IRB within 7 calendar days of awareness of the event. 
 
H.3.4. Expedited Reporting to the Food and Drug Administration  
 
This study is being conducted under an IND held by Dr. Benigno Rodriguez. Dr. Rodriguez and 
Dr. Lederman, study co-chairs, will be responsible for determining whether or not the 
suspected adverse reaction meets the criteria for expedited reporting in accordance with 
Federal Regulations (21CFR 312.32).  
 
The Investigators will report in an IND safety report any suspected adverse reaction (see 
section H.4.1.2) that is both serious (see section H.4.1.5) and unexpected (see section H.4.1.4). 
If the adverse event does not meet all three of the definitions (serious, unexpected adverse 
reaction), it will not be submitted as an expedited IND safety report.  
 


 
38 
The timeline for submitting an IND safety report to FDA is no later than 15 calendar days after 
the Investigator determines that the suspected adverse reaction qualifies for reporting (21 CFR 
312.32(c)(1)).  
 
Any unexpected fatal or life-threatening suspected adverse reaction will be reported to FDA 
no later than 7 calendar days after the Investigator’s initial receipt of the information (21 CFR 
312.32(c)(2)).  
 
Any relevant additional information that pertains to a previously submitted IND safety report 
will be submitted to FDA as a Follow-up IND Safety Report without delay, as soon as the 
information is available (21 CFR 312.32(d)(2)).  
 
H.3.5. Reporting Requirements for this Study 
 
The SAE Reporting Category, as defined in Version 2.0 of the DAIDS EAE Manual, will be used 
for this study. The study agent for which expedited reporting is required is rIL-2 (PROLEUKIN). 
In addition to the EAE reporting category identified above, other AEs that will be reported in 
an expedited manner are:  
 
 
 
All incident cancers 
 
All opportunistic infections listed in section C.4 
 
All recurrent serious infections 
 
H.3.6. Grading Severity of Events 
 
Adverse events are graded according the Division of AIDS Table for Grading the Severity of 
Adult and Pediatric Adverse Events, Version 1.0, December 2004 (Clarification, August 2009), 
which 
can 
be 
found 
on 
the 
DAIDS 
RSC 
Web 
Site: 
http://rsc.tech-
res.com/safetyandpharmacovigilance/ 
 
H.3.7. Relationship to Study Agent  
 
The Principal Investigators will determine if there is a reasonable possibility that rIL2 caused or 
contributed to the AE. The relationship assessment, based on clinical judgment, will rely on the 
following:  
 
 
A temporal relationship between the event and administration of rIL2 
 
A plausible biologic mechanism for rIL2 to cause the AE  
 
Another possible etiology for the AE,  
 
Previous report of similar AEs associated with rIL2  
 
Recurrence of the AE after re-challenge or resolution after de-challenge.  
 
The terms used to assess the relationship of an event to rIL2 are:  
 
 
Definitely related – The AE is clearly related to rIL2  
 
Probably related – The AE is likely related to rIL2 
 
Possibly related – The AE may be related to rIL2 


 
39 
 
Probably not related – The AE is not likely related to rIL2 
 
Not related – The AE is clearly NOT related to rIL2 
 
When an AE is assessed as “not related” to rIL2, an alternative etiology, diagnosis or explanation 
for the AE will be provided. If new information becomes available, the relationship to 
assessment of any AE will be reviewed and updated, as required.  
 
H.3.8. Expedited AE Reporting Period 
 
The protocol-defined EAE Reporting Period for this protocol is the entire study duration for an 
individual participant (from study enrollment until study completion or discontinuation of the 
participant from study participation for any reason). After the protocol-defined AE reporting 
period, unless otherwise noted, only SUSARs as defined in Version 2.0 of the DAIDS EAE Manual 
will be reported if the study staff become aware of the events on a passive basis (from publicly 
available information). 
 
H.3.9. Reporting Procedures 
  
All participants will be followed for possible adverse events throughout their involvement in 
the study, including issues with study conduct. At each study visit, research staff will elicit 
participant input as to discomforts or adverse experiences. All grade ≥2 AEs will be reported to 
the Principal Investigators on a daily basis. A complete blood count, metabolic panel as defined 
in D.3.5.1, CD4 T cell count, and plasma HIV-1 RNA level will be performed on most visits. The 
Principal Investigator will obtain these safety data in “real-time” (i.e., within 1-10 days of a 
study visit) when laboratory values become available. The Principal Investigators will review 
these data within that timeframe, assess degree of severity, and assess the relationship to 
study agent/intervention.  
 
The following adverse events will be reported: adverse events graded 3 and above, and any 
possibly, probably, or definitely related, unexpected, and serious adverse events. These AEs 
will be reported to the Safety Monitoring Committee (SMC), and FDA. Reporting to the UHCMC 
IRB will follow current UCHCMC IRB policy (see section H.4.3). 
 
For the purposes of expedited reporting to the SMC the definition of a “reporting day” in 
Version 2.0 of the DAIDS EAE Manual will be used. Reporting to the UHCMC IRB will follow 
current UHCMC IRB policy (see section H.3.3).  
 
If at any time, a decision is made to discontinue study agent in all participants, the IND Sponsor 
(Dr. Benigno Rodriguez), after consultation with the protocol team will inform the US Food and 
Drug Administration (FDA), the IRB, and the site investigators.  
 
The grading system for drug toxicities is located in the Division of AIDS (DAIDS) Table for Grading 
the Severity of Adult and Pediatric Adverse Events, Version 1.0, December 2004 (Clarification, 
August 2009), available at http://rsc.tech-res.com/safetyandpharmacovigilance.  
 
 


 
40 
I. HUMAN SUBJECTS 
 
 
I.1. IRB Review and Informed Consent 
 
This protocol and the informed consent document and any subsequent modifications will be reviewed 
and approved by the IRB of University Hospitals Cleveland Medical Center. A signed consent form will 
be obtained from the subjects. The consent form will describe the purpose of the study, the procedures 
to be followed, and the risks and benefits of participation. A copy of the consent form will be given to 
the subject, and this fact will be documented in the subject’s record. 
 
I.2. Subject Confidentiality 
 
All laboratory specimens, evaluation forms, reports, and other records that leave the site will be 
identified by coded number only to maintain subject confidentiality. All records will be kept locked. All 
computer entry and networking programs will be done with coded numbers only. Clinical information 
will not be released without written permission of the subject, except as necessary for monitoring by 
the IRB, NIAID, OHRP, FDA or designee.  
 
I.3. Study Discontinuation 
 
The study may be discontinued at any time by the IRB, the NIAID, the OHRP, the FDA, or other 
government agencies as part of their duties to ensure that research subjects are protected.  
 
The SMC will monitor the occurrence of all grade ≥2 signs, symptoms, diagnoses, or laboratory 
abnormalities.  
 
The SMC will review accrual, toxicity summaries, off-treatment and off-study rates, and reasons broken 
down by study arms. Meetings of the SMC are described above. The SMC will be asked to consider the 
following regarding safety events: the grade of the event, the time to resolution (if any), and the site 
clinician’s judgment of the relationship to treatment. The first interim safety review by the SMC is 
planned 3 months after the first subject enrolls and approximately every 3 months thereafter, but 
expedited reviews will occur whenever the threshold for temporary enrollment discontinuation is 
reached. Criteria for temporary enrollment discontinuation and expedited SMC review are:  
 
 
Three or more participants have experienced a grade 3 AE that is deemed possibly, probably, or 
definitely related to study treatment 
 
Two or more participants have experienced a grade 4 AE that is deemed possibly, probably, or 
definitely related to study treatment 
 
Any death occurs on study that is deemed possibly, probably, or definitely related to study 
treatment 
 
The SMC will review the events whenever any of the criteria above is met, and recommend, based on 
the results of the review, whether the study can proceed as planned, proceed with modifications, or 
be discontinued.  
 
 
 


 
41 
I.4. Human Subjects Involvement, Characteristics, and Design 
 
Up to 20 participants will be enrolled in the clinical trial. Potential participants will be recruited primarily 
from the Special Immunology Unit, the HIV clinic of University Hospitals Cleveland Medical Center, 
although recruitment from other area hospitals through direct outreach and targeted advertisement is 
also possible. Characteristics of the study population, inclusion/exclusion criteria, and planned study 
procedures are described in the clinical protocol. No vulnerable populations will be included in these 
studies.  
 
I.5. Sources of Materials  
 
Laboratory and clinical staff have received Good Clinical Practices (GCP) and Good Clinical Laboratory 
Practices (GCLP) training per their role in the study. Clinical monitoring and screening laboratories will 
be run in CLIA certified labs at University Hospitals Cleveland Medical Center. All specimens will be 
stored with coded identifiers only in restricted-access laboratories. The CWRU/UHC CFAR Patient Care 
and Research Database personnel and the study data manager will store, manage and retrieve all study-
related data, which will be stored on firewalled servers at UHCMC, in full compliance with relevant 
HIPPAA requirements. All study records will be stored and accessed using only a participant identifier 
(PID), and locator data linking identifiable information to the PID will be kept in a separate database in 
a different location to ensure the confidentiality of these data. Clinical information will not be released 
without written permission of the subject, except as necessary for monitoring by the IRB, the FDA, the 
NIAID, the OHRP or the subject’s designees. Information about the subject’s participation will not be 
shared with persons who are not directly involved with the research subjects or as identified in the 
HIPAA consent. 
 
I.6. Potential Risks and Risk Mitigation Strategies 
 
I.6.1. Risks of rIL-2  
 
 
Exposure to rIL-2 in this study will be much lower than exposure to rIL-2 when it is used for 
treatment of malignancy (0.6 million units/kg (42 million units for a 70 kg subject) by intravenous 
infusion every 8 hrs x 14 doses per cycle ) where the greatest toxicities have been observed. In 
the current study, exposure is minimized by dosing at 5 million units sq twice daily for 5 day cycles 
every 8 weeks. This starting dose is similar to the starting dose used in the SILCAAT study (4.5 
million units twice daily for 5 days every 8 weeks for six cycles) and lower than the starting dose 
for ESPRIT (7.5 million units sq twice daily for 5 days every 8 weeks for 3 cycles) In those studies, 
849 and 2071 patients respectively were randomized to receive IL-2 plus ART. We justify 
continuing rIL-2 administration for 8 cycles to achieve a similar exposure that was reported in the 
Chun study that provides rationale for an effect of IL-2 on diminishing HIV reservoir size.  
 
In ESPRIT, there was an excess of grade 4 clinical events in the rIL-2 recipients; the same excess 
was not seen in SILCAAT. Abrams and colleagues (42) have suggested this is via an impact on 
procoagulant pathways. In ESPRIT, patients with the highest CD4+ T-cell counts in the rIL-2 arm 
had the greatest relative risk of clinical events, including death. Perhaps, therefore, receipt of rIL-
2 primes the patient for a proinflammatory state subsequently associated with more clinical 
events, and this is amplified in patients with the greatest CD4+ T-cell response to rIL-2, i.e. the 
ESPRIT cohort, which had higher baseline CD4+ T-cell counts than in SILCAAT. However, it is still 
important to remember that while rIL-2 receipt in ESPRIT was associated with more embolic 


 
42 
events, overall there was no excess of opportunistic diseases, death or cardiovascular disease 
and non-AIDS cancers compared with the ART-only arm.    
 
I.6.1.1. Risk Mitigation Strategy for Serious Infections 
 
Although there was no increased risk of infections in the two large phase III clinical trials 
of IL-2 administration (SILCAAT and ESPRIT), to mitigate the risk of serious infections, 
individuals with any of the following conditions will be excluded from enrolling in this 
study: 
 
 
A screening CD4 T-cell count <350 cells/mm3 
 
An absolute neutrophil count <1500 cells/mm3 
 
An active local or systemic infection 
 
Use of immunosuppressive or immune modulating therapy 
 
Use of any investigational agent 
 
Actively co-infected with HBV or HCV  
 
If a serious infection develops, study drug will be held until the infection is adequately 
controlled. Study drug administration will be interrupted if the ANC is <1,000 cells/mm3.  
 
I.6.1.2. Risk Mitigation Strategy for Hypersensitivity Reactions 
 
To mitigate the risk of hypersensitivity reactions including anaphylaxis: 
 
 
Patients with a known allergy/sensitivity or any hypersensitivity to components of 
the study drug or its formulation will be excluded. 
 
The first dose of study agent will be administered in the Special Immunology Unit 
that has treated more than 50 patients with IL_2 on SILCAAT and ACTG 328 trials. 
Subjects will be monitored for a minimum of 30 minutes following the first dose of 
study drug by personnel with life support training and access to adequate life 
support equipment and resuscitation medication. 
 
A severe allergic reaction related to study treatment will be grounds for study 
treatment discontinuation. 
 
I.6.1.3. Risk Mitigation Strategy for Thromboembolic Disease 
 
In the ESPRIT trial but not among participants in the SILCAAT trial, there was an increased 
occurrence of vascular events (but not in cardiac disorders) that were seen among 40 of 
466 patients receiving IL-2 plus ART and 14 of 386 receiving ART alone. The most 
frequent vascular event was deep vein thrombosis seen in 10 IL-2 plus ART recipients 
and in 2 ART alone recipients. To mitigate risk for vascular events in this trial, persons 
with a history of venous thrombosis will be excluded from participation and at each visit, 
signs and symptoms of venous thrombosis will be sought. 
 
 
 
 


 
43 
I.6.1.4. Risk Mitigation Strategy for Laboratory Abnormalities 
 
I.6.1.4.1. Neutropenia 
 
The risk mitigation plan for neutropenia includes:  
 
 
Participants with an ANC <1500 cells/mm3 will not be permitted to enroll in 
the study; 
 
ANC will be measured at each clinic visit 
 
Should the ANC decrease to ≥500 but ≤1,000 cells/mm3, the rIL-2 dose will 
be interrupted until the ANC is >1,000 cells/mm3 and then rIL-2 will be 
restarted at 3.5 million units twice daily. If the ANC remains above 1,000 
cells/mm3, this dose will be continued until the end of the study.  
 
Should the ANC decrease ≥500 but ≤1,000 cells/mm3 while on the reduced 
dose of 3.5 million units twice daily, rIL2 will be discontinued until the ANC 
reaches 1,000 cells/mm3, and then resumed at a dose of 2 million units 
twice daily. If the ANC then remains above 1,000 cells/mm3, this dose will 
be continued until the end of study. If the ANC falls again to ≤1,000 
cells/mm3 while on the reduced 2 million unit twice daily dose, rIL2 will be 
permanently discontinued.  
 
Should the ANC decrease to <500 cells/mm3, rIL_2 will be discontinued. 
 
I.6.1.4.2. Thrombocytopenia 
 
The risk mitigation plan for thrombocytopenia includes:  
 
 
Participants with a platelet count <150,000/mm3 will not be enrolled in 
the study; 
 
Platelet counts will be measured at each clinic visit; 
 
Should the platelet count decrease to ≥50,000 but ≤100,000/mm3 the rIL-
2 dose will be interrupted until the platelet count is >100,000/mm3 and 
then IL-2 will be restarted at 3.5 million units twice daily. If the platelet 
count remains above 100,000 /mm3, this dose will continue until the end 
of the study. 
 
 Should the platelet count drop to ≥50,0000 but ≤100,000/mm3 while on 
the reduced dose of 3.5 million units twice daily, rIL2 will be discontinued 
until the platelet count reaches 100,000/mm3 and then rIL-2 will be 
restarted at 2 million units twice daily. If the platelet count remains above 
100,000/ mm3 , this dose will be continued until the end of the study. If 
the platelet count falls again to ≤100,000/mm3  while on the reduced 2 
million units twice daily, rIL2 will be permanently discontinued. 
 
Should the platelet count decrease to <50,000/mm3 ,rIL-2 will be 
discontinued. 
 
 
 
 


 
44 
I.6.1.4.3. AST and ALT Abnormalities 
 
The risk mitigation plan for AST or ALT abnormalities includes: 
 
 
Participants with an AST or ALT > 2.5x ULN will be excluded from the study. 
 
Patients with cirrhosis, severe liver disease or active or chronic hepatitis B 
or C infection will be excluded from the study. 
 
AST and ALT will be evaluated at each clinic visit. 
 
For AST or ALT values > 3x ULN, the rIL-2 will be discontinued. rIL-2 may be 
resumed at 3.5 million units twice daily when AST or ALT fall to < 2x ULN. If 
AST and ALT values then remain below 3X ULN, this dose will be continued 
until the end of the study. 
 
If AST or ALT values rise again to > 3X ULN while on the reduced dose of 3.5 
million units twice daily, rIL-2 will be discontinued until AST and ALT fall to 
<2X ULN and then resumed at a dose of 2 million units twice daily. If AST and 
ALT values then remain below 3X ULN, this dose will be continued until the 
end of the study.  
 
If ALT values rise again to > 3x ULN while the patient is receiving 2 million 
units twice daily, rIL-2 will be discontinued permanently. 
 
I.6.1.4.4. Thyroid Abnormalities 
 
The risk mitigation strategy for thyroid abnormalities includes: 
 
 
Volunteers with abnormal thyroid function tests or elevated levels of anti-
Tpo antibodies at screening will be excluded.  
 
Participants who develop symptomatic thyroid disease or abnormal T3 or 
T4 serum levels will be required to discontinue study treatment 
permanently.  
 
Participants who develop TSH levels ≥3.99 mIU/L will be required to 
discontinue study treatment permanently.  
 
Participants who develop elevated anti-Tpo antibodies will be required to 
discontinue study treatment permanently. 
 
I.6.1.4.5. Renal Dysfunction 
 
The risk mitigation strategy for renal function abnormalities includes:  
 
 
Participants with serum creatinine >1.5 mg/dL will be excluded from the 
study, and serum creatinine will be evaluated at each clinic visit. 
 
Should the serum creatinine increase to >2.0 mg/dL but ≤3 mg/dL, rIL-2 will 
be interrupted. rIL-2 may be resumed at 3.5 million units twice daily when 
creatinine falls to <1.5 mg/dL.  If the creatinine remains ≤1.5 mg/dL on the 
reduced dose of 3.5 million units twice daily, this dose will be continued until 
the end of the study. 
 
If serum creatinine rises again to > 1.5 mg/dL while on the reduced dose of 
3.5 million units twice daily, rIL-2 will be interrupted until creatinine falls to 


 
45 
< 1.5 mg/dL and then rIL2 may be resumed at 2 million units twice daily. If 
serum creatinine then remains below 1.5 mg/dL, this dose will be continued 
until the end of the study. If serum creatinine rises again to >1.5 mg/dL while 
on the reduced dose of 2 million units twice daily, rIL2 will be permanently 
discontinued. 
 
Should serum creatinine rise to > 3.0 mg/dL , rIL-2 will be discontinued 
permanently 
 
I.6.1.5. Risk Mitigation Strategy for Malignancies 
 
To minimize the risk or emergent or recurrent malignancies, subjects with a history of or 
active cancer will be excluded, and a review of interval diagnoses or medical events and 
a full or targeted physical exam will be performed at each visit. Additionally, concomitant 
immunosuppressive medications will be prohibited during the study.  
 
I.6.1.6. Risk Mitigation Strategy for Viral Reactivation 
 
The risk mitigation strategy for viral reactivation includes:  
 
 
Volunteers with evidence of active hepatitis B or C infection will not be enrolled in the 
study.  
 
Participants who develop herpes zoster will be required to discontinue treatment 
until completion of treatment and resolution of symptoms.  
 
Participants who develop a recurrence of herpes zoster or murtidermatomal 
involvement will be required to discontinue study treatment permanently.  
 
Participants who develop a detectable HBV DNA while on study will require 
permanent study discontinuation.  
 
I.6.1.7. Risk Mitigation Strategy for Blood Sample Collection and Intavenous Infusion  
 
The most common risks of blood sample collection are pain at the puncture site, bruising, 
and a feeling of lightheadedness. To minimize these risks, blood draws will be performed 
by trained personnel, and will be performed in a secure environment with access to first 
aid equipment, bandages, and trained healthcare professionals.  
 
I.7. Adequacy of Protection against Risks 
 
I.7.1. Recruitment and Informed Consent 
 
Before the initiation of any study procedures, subjects will be informed about the study and 
asked to sign an IRB approved informed consent/HIPAA document. Subjects will be consented in 
a private exam room. Subjects will be given time to read the consent, ask questions and consider 
the risks and/or benefits to participation in this research study prior to obtaining their signature. 
All subjects enrolled in the study will be given a copy of their signed and dated informed consent 
document. This consenting process will be done by trained research staff at the Case Clinical 
Trials Unit.  
 
 
 


 
46 
I.7.2. Protections against Specific Study-related Risks 
 
An extensive risk mitigation strategy has been implemented to address risks derived specifically 
from the study treatments and procedures. Details of the risk minimization strategy for each risk 
category are provided above. All study-related activities will be conducted in private areas to 
protect patient confidentiality.  
 
I.8. Potential Benefits of the Proposed Research to Human Subjects and Others  
 
Participants in this trial are not expected to derive a direct benefit from their participation. If this trial 
provides proof of concept for the notion that rIL-2 decreases the size of the persistent HIV reservoir in 
peripheral blood, the results could offer the starting point for the implementation of a therapeutic 
strategy to cure or induce ART-free remission of HIV infection and that could result in a tangible clinical 
benefit to persons living with HIV/AIDS, including those directly involved in the study.  
 
I.9. Importance of the Knowledge to Be Gained  
 
As there is great community and scientific interest in developing strategies to allow cure or remission 
of HIV infection, confirmation of a significant effect of rIL-2 administration on indices of HIV persistence 
will be important to both enhance understanding of mechanisms of persistence as well as to provide a 
therapeutic strategy that could contribute to HIV eradication or remission.  
 
I.10. Data and Safety Monitoring Plan 
 
The two PIs, Drs. Rodriguez and Lederman, both experienced HIV clinical trialists, will review all 
adverse events, determine their relationship to study procedures, and generate reports to the IRB as 
needed. The data manager will prepare data reports every four months, and inconsistencies in data 
elements will be resolved by review of primary sources, interview with research personnel, and 
general consensus among study team members. The protocol statistician will be responsible for 
preparing the overall data reports, and for alerting the team to trends in adverse event frequency or 
data discrepancies. Trial safety will be monitored by an SMC. 
 
I.11. ClinicalTrials.gov Requirements 
 
When regulatory approval is secured, this study will be registered with ClinicalTrials.gov. Results 
information (including adverse events) will be reported no later than 1 year after the primary 
completion date per Food and Drug Administration Amendments Act (FDAAA) requirements 
(http://grants.nih.gov/ClinicalTrials_fdaaa/steps.htm).  
 
I.12. Inclusion of Women and Minorities 
 
Both men and women will be included in the trial. Minorities, including Spanish-speaking persons, will 
be eligible to enroll in the trial, and a Spanish language consent will be available for them.  
 
I.13. Inclusion of Children 
 
Children ages 18 to 21 will be included in this study.  
 


 
47 
J. PUBLICATION OF RESEARCH FINDINGS 
 
Publication of the results of this trial will be decided by consensus of the study team.  
 
 
 
 
 
 


 
48 
K. BIOHAZARD CONTAINMENT 
 
As the transmission of HIV and other blood-borne pathogens can occur through contact with 
contaminated needles, blood, and blood products, appropriate blood and secretion precautions 
will be employed by all personnel in the drawing of blood and shipping and handling of all 
specimens for this study, as currently recommended by the Centers for Disease Control and 
Prevention and the National Institutes of Health. 
 
All dangerous goods materials, including diagnostic specimens and infectious substances, will be 
transported using packaging mandated by CFR 42 Part 72, as per the International Air Transport 
Association (IATA) Dangerous Goods Regulations.  
 
 
 
 
 
 


 
49 
L. 
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2001/08/02. doi: 10.1200/JCO.2001.19.15.3477. PubMed PMID: 11481353. 
54. Franzke A, Peest D, Probst-Kepper M, Buer J, Kirchner GI, Brabant G, Kirchner H, Ganser A, Atzpodien 
J. Autoimmunity resulting from cytokine treatment predicts long-term survival in patients with 
metastatic renal cell cancer. J Clin Oncol. 1999;17(2):529-33. Epub 1999/03/18. doi: 
10.1200/JCO.1999.17.2.529. PubMed PMID: 10080596. 
55. Witzke O, Winterhagen T, Saller B, Roggenbuck U, Lehr I, Philipp T, Mann K, Reinhardt W. Transient 
stimulatory effects on pituitary-thyroid axis in patients treated with interleukin-2. Thyroid. 
2001;11(7):665-70. Epub 2001/08/04. doi: 10.1089/105072501750362736. PubMed PMID: 
11484895. 
56. Abrams DI, Bebchuk JD, Denning ET, Davey RT, Fox L, Lane HC, Sampson J, Verheggen R, Zeh D, 
Markowitz NP, Terry Beirn Community Programs for Clinical Research on A. Randomized, open-label 
study of the impact of two doses of subcutaneous recombinant interleukin-2 on viral burden in 
patients with HIV-1 infection and CD4+ cell counts of > or = 300/mm3: CPCRA 059. J Acquir Immune 
Defic Syndr. 2002;29(3):221-31. Epub 2002/03/02. doi: 10.1097/00126334-200203010-00002. 
PubMed PMID: 11873071. 
57. Burch HB. Drug Effects on the Thyroid. The New England journal of medicine. 2019;381(8):749-61. 


 
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Epub 2019/08/23. doi: 10.1056/NEJMra1901214. PubMed PMID: 31433922. 
58. Kragel AH, Travis WD, Feinberg L, Pittaluga S, Striker LM, Roberts WC, Lotze MT, Yang JJ, Rosenberg 
SA. Pathologic findings associated with interleukin-2-based immunotherapy for cancer: a postmortem 
study of 19 patients. Hum Pathol. 1990;21(5):493-502. Epub 1990/05/01. doi: 10.1016/0046-
8177(90)90005-p. PubMed PMID: 2338330. 
59. Pichert G, Jost LM, Zobeli L, Odermatt B, Pedia G, Stahel RA. Thyroiditis after treatment with 
interleukin-2 and interferon alpha-2a. Br J Cancer. 1990;62(1):100-4. Epub 1990/07/01. doi: 
10.1038/bjc.1990.237. PubMed PMID: 2390468; PMCID: PMC1971759. 
60. Zhang Z. Reverse Regression: A Method for Joint Analysis of Multiple Endpoints in Randomized Clinical 
Trials. Statistica Sinica. 2014;24:1753-69. 
 

ICF_001.pdf: 
UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
1
INTRODUCTION
We invite you to take part in a research study at the Case Western Reserve University 
(CWRU)/University Hospitals Cleveland Medical Center (UHCMC) Clinical Trials Unit. You are 
being asked to take part in this research study because you are infected with the human 
immunodeficiency virus (HIV), the virus that causes AIDS. This study is supported by research 
funding provided by Gilead. 
The doctor in charge of this study at this site is: Dr. Benigno Rodriguez. Before you decide if you 
want to be a part of this study, we want you to know about the study. 
First, we want you to know that:
Taking part in this research is entirely voluntary.
You may choose not to take part, or you may withdraw from the study at any time. In 
either case, you will not lose any benefits to which you are otherwise entitled. 
You may receive no benefit from taking part. The research may give us knowledge that 
may help people in the future.
Second, some people have personal, religious or ethical beliefs that may limit the kinds of 
medical or research treatments they would want to receive (such as blood transfusions). If you 
have such beliefs, please discuss them with your research team before you agree to the 
study.
This is a consent form. It gives you information about this study. The study staff will talk with 
you about this information. You are free to ask questions about this study at any time. If you 
agree to take part in this study, you will be asked to sign this consent form. You will get a copy 
to keep.
You are invited to participate in a voluntary research trial that will examine the potential role of 
interleukin-2 (IL-2), a drug that is used to treat certain cancers, in decreasing the number of 
cells in your body that contain HIV. We call this the Latent Reservoir. 
WHY IS THIS STUDY BEING DONE?
IL-2 is a molecule that is naturally produced by a certain part of the body’s immune system, 
called T cells. In HIV infected patients, IL-2 treatment cycles can increase CD4 counts but these 
CD4 T cell increases do not seem to prevent complications from HIV. In an earlier study 
however, persons receiving a combination of HIV medicines plus cycles of IL-2 had lower 
numbers of cells in blood and lymph node that contained HIV than persons who received HIV 
medicines alone. In a few of these patients, the HIV medicines were stopped and HIV levels in 
blood became detectable telling us that these persons were not cured of infection. 
The purpose of this study is to find out if IL-2 will decrease the numbers of cells in the body that 
contain HIV capable of infecting new cells. We call these HIV viruses “replication competent”. It 
is important to do this study so that we can examine the levels of HIV in immune cells in each 
    
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UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
2
person both before and after IL-2 treatment and to learn how IL-2 might decrease levels of virus 
in the body. 
HOW THE STUDY WORKS
Entry into the study will only be permitted if you, in the opinion of the protocol team, have a good 
level of knowledge about the potential risks and benefits of participation. In addition, you must 
agree to comply with study requirements and clinic policies. You must also agree to allow extra 
research blood specimens to be collected and stored (frozen) for potential future use in studies 
related to HIV infection or the immune system. If you are actively engaging in substance abuse 
or you have a history of substance abuse that may interfere with protocol compliance or 
compromise your safety, you may also be excluded. You may also be excluded if you have a 
history of certain medical condition or if certain laboratory tests are outside of the normal range.   
If you are eligible to participate in the study, you will undergo a pre-treatment leukapheresis 
procedure approximately 4 to 8 weeks before your first dose of IL-2. The procedure called 
leukapheresis is explained below in this document. You will continue your antiretroviral therapy 
(HIV medicines) and receive eight cycles of IL-2, which is the drug that will be used in the study. 
The antiretroviral therapy during study will be based a continuation of your current therapy and 
the costs for this treatment will be your responsibility or the responsibility of your insurer as they 
are now. You can continue to receive your usual medical care through your usual provider while 
you are on the study. 
The medicine used in the study, called IL-2, is given by injection into the tissue under the skin 
using a syringe and needle. You will receive one of these injections twice a day for 4 days, and 
then again 8 weeks later for a total of eight periods of 4 days each. 
A healthcare professional will show you how to administer these injections yourself. At the 
beginning of the study, and several times later, you will be asked to give yourself the injections 
in the clinic under the supervision of a member of the research staff to make sure that you can 
do it safely, and to give you a chance to ask any questions you might have about the injection.
You will be instructed as to how to inject IL-2. The staff will observe you give yourself the first IL-
2 injection to make sure that you can do it safely, and to give you a chance to ask any questions 
you might have about the injection. Once you have given yourself the first dose, you will receive 
the remaining doses that you will need for the cycle already loaded into sterile syringes. The 
study staff will give you detailed instructions on how to store the medication, how to handle the 
pre-filled syringes, and how to administer each dose.  You will then leave the clinic and will 
inject IL-2 yourself twice a day for a total of 4 days (a total of 8 injections including the first 
injection in the clinic). These 8 injections make up the first cycle of IL-2 administration.
It is possible that the study investigators will decide to provide only some, but not all, of the 
doses needed to complete a cycle at the time of your visit to the clinic. If this happens, you may 
be asked to ensure that you are physically available at a stable address to receive the 
remaining doses for a cycle through a courier service. This means that your identity may 
become known to personnel working for the courier service. 
    
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UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
3
You will get a total of eight cycles of IL-2 during the study (one cycle every 8 weeks). The 
procedure will be the same for each cycle as described above for the first cycle, except you will 
not be asked to administer the first dose in the presence of study staff every time. Cycles are 
defined as 8 calendar weeks, including the 4-day period of IL-2 administration. The dose will be 
5 million units of IL-2 given as an injection under the skin (subcutaneously) twice a day, once in 
the morning and once at night. Each of the eight IL-2 cycles will last four days, and will not be 
extended if doses are missed. At the start of your first cycle of IL-2 treatment, you will be taught 
how to manage potential side effects. If you are unable to self-administer the IL-2, your doctor or 
nurse will talk to you about possibly returning to the clinic for injections. 
You will also be evaluated, by phone contact with the study staff, during each cycle (usually on 
days 2 and 4) for the presence of significant adverse effects, defined as those that, in the 
Principal Investigator’s opinion, may be related to the study drug and require a change in 
treatment. You may be asked to return to the clinic if a physical examination/assessment is 
needed to evaluate any symptoms you may be experiencing. 
If serious side effects develop during the injection period, the dose of IL-2 may need to be 
reduced, temporarily discontinued, or even stopped. 
Eight weeks after your last IL-2 treatment cycle or if you must end IL-2 treatments for any other 
reason, you will be asked to return to the Clinical Trials Unit for an interval history and if 
indicated a targeted physical examination. At this time, you will have another leukapheresis to 
collect immune cells and plasma to examine the effects of IL-2 treatment on immune function 
and on the HIV reservoir. 
WHAT DO I HAVE TO DO IF I AM IN THIS STUDY?
If you decide to take part in this research study, you will be asked to sign this consent form. 
Before signing it, ask your study nurse or doctor to explain anything that you do not fully 
understand. After you have signed the form, you will be asked some questions and will undergo 
some tests to see if it is safe for you to join the study. This will be done at the screening visit, 
which may take about 1.5 hours.
Screening visit
This visit will occur about 8 to 16 weeks prior to the start of the study treatment.

Your HIV infection will be confirmed. If there is no record available, you will have another 
HIV-1 test. 

You will have a physical exam, which includes a vein assessment for leukapheresis.

You will be asked about your health and medicines you have taken in the past or are 
taking now.

Approximately 2 tablespoons of blood will be drawn for routine tests of blood, kidney, 
thyroid, and liver function, a test for hepatitis B and hepatitis C, and for tests of immune 
function and HIV levels. 

If you have female reproductive organs, you will only be allowed to participate in the 
study if you cannot become pregnant (for example, because you have your womb or 
ovaries removed, you are past menopause, or had your tubes tied). Study personnel will 
    
        IRB NUMBER: STUDY20180025
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        IRB EXPIRATION DATE: 4/13/2021


UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
4
ask you about your medical history in order to determine this and a pregnancy test will 
be done at this visit. 
If you do not enroll into the study
If you decide not to take part in this study or if you do not meet the eligibility requirements, 
we will still use some of your information. As part of this screening visit, some demographic 
(for example, age, sex, race), clinical (for example, disease condition, diagnosis), and 
laboratory (for example, CD4+ T cell count, viral load) information is being collected from 
you to help the study team determine whether there are patterns or common reason why 
people do not join the study. This information may be held for an indefinite length of time. 
Information will be stored using code numbers without information that could identify you.
Please indicate with your initials below whether you agree to the use of some of your 
information if you decide not to take part in this study or if you do not meet the eligibility 
requirements.
            _________YES   __________NO
Pre-treatment leukapheresis visit (see also below)
If you are determined to be eligible to participate in the study, then this visit will occur 
approximately 4-8 weeks prior to the start of the study treatment and will include:

You may have a physical exam and will be asked about your health and medicines you 
have taken since the previous visit or are taking now.

Approximately 2 tablespoons of blood will be drawn for routine tests of blood, kidney, 
thyroid, and liver function and for tests of immune function.

The leukapheresis procedure will be done at this visit.

The leukapheresis samples obtained will be stored for detailed tests of HIV levels and 
for additional tests of immune function.

This visit will take approximately 4 hours.
Initial Treatment Visit (Cycle 1 Day 0)
This visit will occur about 4-8 weeks after the pre-treatment leukapheresis visit.

At this visit, you may have a physical exam and will be asked about your health and 
medicines you have taken since the previous visit or are taking now.

Approximately 6 tablespoons of blood will be drawn for routine tests of blood cell, kidney, 
thyroid, and liver function, for tests of immune function, and for detailed testing of virus 
levels. 

You will be instructed as to how to inject IL-2. You will be observed as you give yourself 
the first injection under the skin.

You will be given a dosing log along with instructions of how to complete while you were 
administering IL-2 injections. 

Information about managing expected side effects will be reviewed with you during this 
visit and will be given to you to take home for future reference.

You will be observed in the clinic for at least 4 hours after the injection.

This visit will take approximately 5 to 6 hours.
    
        IRB NUMBER: STUDY20180025
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        IRB EXPIRATION DATE: 4/13/2021


UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
5
Subsequent Treatment Cycles (Cycles 2,3,4,5,6,7,8 Day 0)

At these visits that occur about 8 weeks apart, you may have a physical exam and will 
be asked about your health and medicines you have taken since the previous visit or are 
taking now.

Approximately 6 tablespoons of blood will be drawn for routine tests of blood cell, kidney, 
thyroid, and liver function, for tests of immune function, and for testing of HIV levels. 
Detailed testing of HIV levels will be done at cycle 4 and 8.

You will be instructed as to how to inject IL-2. You will be observed as you give yourself 
the first injection of cycle 4 and 8 under the skin.

You will be given a dosing log along with instructions of how to complete while you were 
administering IL-2 injections. 

Information about managing expected side effects will be reviewed with you during this 
visit and will be given to you to take home for future reference.

This visit will take approximately 1 to 1.5 hours.
Day 2 and 4 after beginning each Treatment cycle
You will be contacted by a study nurse who will ask you how you are feeling and how you are 
tolerating the treatment. You may be asked to come to the clinic for physical exam and/or 
laboratory testing, if you are experiencing side effects that require additional evaluation or 
intervention. 
Day 7 after Treatment cycles 1,4 and 8:

At this visit, you may have a physical exam and will be asked about your health and 
medicines you have taken since the last visit or are taking now.

Approximately 6 tablespoons of blood will be drawn for routine tests of blood cell, kidney 
and liver function, for tests of immune function, and for detailed testing of virus levels. 

This visit will take approximately 1 hour.
Final study visit and unscheduled study visits
This visit will occur approximately 8 weeks after day 0 of treatment cycle 8. If you stop 
participating in the study prematurely, then you will be asked to come to clinic for this final study 
visit approximately 6-10 weeks after day 0 of the last treatment cycle. This visit will include a 
leukapheresis procedure.

You may have a physical exam and will be asked about your health and medicines you 
have taken since the previous visit or are taking now.

Approximately 8 tablespoons of blood will be drawn for routine tests of blood cell, kidney, 
thyroid, and liver function, for tests of immune function, and for detailed testing of HIV 
levels. 

The leukapheresis samples obtained will be stored for detailed tests of HIV levels and 
for additional tests of immune function.

This visit will take approximately 4 hours.
    
        IRB NUMBER: STUDY20180025
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        IRB EXPIRATION DATE: 4/13/2021


UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
6
You may be asked to return to clinic to have a repeat blood draw in order to confirm a laboratory 
results at a time that is not part of the original schedule. These unscheduled visits typically last 
30 minutes or less, and will involve only a few questions and a routine blood draw.
In the unlikely event that we detect through laboratory testing that your immune system has 
developed antibodies against the study drug, you may be asked to return to the clinic for a blood 
draw, a review of any medical issues you have had in the meantime, and a routine physical 
examination. If the lab tests show that the antibodies are still in your system, these visits may be 
required approximately every 3 months for up to a year. These visits typically last 30 minutes or 
less. 
Leukapheresis
Your participation in this study will involve the collection of white blood cells by a process call 
leukapheresis. During leukapheresis, blood is removed from either peripheral veins or a central 
venous catheter and passed through a blood cell separator (apheresis machine). For this study, 
veins are used. Blood is removed from a vein in one arm with passage of the blood through the 
cell separator, the cells are removed, and the remainder is returned to a vein in the other arm. 
This machine uses a centrifuge to separate the blood into its various components (red blood 
cells, white blood cells, cells that help the blood to clot, and plasma). The white blood cells will 
be collected in a sterile bag and the rest of the blood components will be given back to you 
through the veins in your arm. White blood cells are the cells which fight infection. During the 
collection you will receive an anticoagulant (a drug to prevent the clotting of blood) which will be 
ACDA (citrate) and/or heparin. The anticoagulant is added to keep your blood from clotting 
during this procedure. The procedure could take up to 4 hours. Your samples will be collected 
for this study and may be stored indefinitely and used in other research protocols.
You will come to the Special Immunology Unit and be taken to the Seidman Ambulatory Stem 
Cell Transplant Unit at University Hospitals Cleveland Medical Center. 
Four to eight weeks after the leukapheresis, you will return to the Clinical Trials Unit where you 
will undergo a brief history and, if indicated, a targeted physical examination. Blood will be taken 
for immune and viral studies. 
USE OF YOUR STORED SAMPLES 
During your participation in this study, blood will be collected by standard blood drawing 
techniques. In addition, blood components will be collected by leukapheresis. Some blood 
samples will be used for this research study. We will also store some of your blood samples. 
These samples will be kept and used in future research to learn more about HIV, the immune 
system and/or other medical conditions. 
Generally, the results from the research done with your stored samples will not be given to your 
private doctor and will not be put in your medical record. This is because the test results, unlike 
routine medical testing, may be experimental or preliminary. The relevance of these tests to 
your care may be unknown.
    
        IRB NUMBER: STUDY20180025
        IRB APPROVAL DATE: 4/14/2020
        IRB EFFECTIVE DATE: 4/14/2020
        IRB EXPIRATION DATE: 4/13/2021


UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
7
Your stored samples most of the time will be labeled with a code (such as a number) that only 
the study team can link to you or with an identifier such as your name. Any identifying 
information about you will be kept confidential to the extent permitted by law. 
FUTURE STUDIES
In the future, other investigators (at CWRU or elsewhere) may wish to study your stored 
samples for studies unrelated to the current protocol.  When the study team shares your 
materials, they may share it with no identifying information or with a code. Some information 
about you, such as your gender, age, health history, or ethnicity may also be shared with other 
investigators. 
Any future research using your samples in studies unrelated to the current protocol will be 
reviewed by the investigator’s Institutional Review Board (IRB), a special committee that 
oversees medical research studies to protect the rights and welfare of human subject 
volunteers.
Your stored materials will be used only for research and will not be sold. The research done with 
your materials may be used to develop new products in the future but you will not receive 
payment for such products.
HOW MANY PEOPLE WILL TAKE PART IN THIS STUDY?
About 20 people will take part in this study.
HOW LONG WILL I BE IN THIS STUDY?
You will be in this study for up to 80 weeks.
WHY WOULD THE DOCTOR TAKE ME OFF THIS STUDY EARLY?
The study doctor may need to take you off the study early without your permission if you miss 
study visits, if you have not been compliant with your antiretroviral treatment regimen or with 
your IL-2 treatments, or if you become pregnant. 
The study doctor may also need to take you off the study drug without your permission if you 
develop side effects that cannot be controlled, if it is determined that your participation in the 
study is no longer in your best interest, or upon instructions from the sponsors of the study or 
from the Food and Drug Administration, the Institutional Review Board, or any other regulatory 
agency involved in the oversight of this study. 
IL-2 treatment may temporarily increase levels of HIV in blood. This is possibly the way by 
which IL-2 can decrease the size of the reservoir. If the study staff sees that your viral load has 
gone up, you will be asked to repeat your blood test to see if your viral load has returned to 
levels below levels of detection. If your viral load remains elevated above 200 copies/mL on 
three consecutive measurements after any one cycle of IL-2 administration and you have been 
compliant with your antiretroviral treatment regimen, you may decide to discontinue participation 
in the study.
    
        IRB NUMBER: STUDY20180025
        IRB APPROVAL DATE: 4/14/2020
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        IRB EXPIRATION DATE: 4/13/2021


UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
8
If you must stop taking the study drug before the study is over, the study doctor may ask you 
to continue to be part of the study and return for some study visits and procedures.
If you must permanently stop taking IL-2 before your study participation is over, the study staff 
will discuss other options that may be of benefit to you. After you have completed study 
participation, the study will not be able to continue to provide you with IL-2 that you received 
on the study.
WHAT ARE THE RISKS AND/OR DISCOMFORTS RELATED TO THE STUDY?
Your participation in this study will require a minimum of thirty visits to the Clinical Trials Unit as 
indicated above. These visits will involve physical assessments and blood tests for research and 
safety monitoring and may be time consuming and inconvenient. The major risks of the study 
are primarily those associated with IL-2 therapy. 
Potential Risks associated with IL-2 therapy 
The IL-2 used in this study may have side effects, some of which are listed below. Please note 
that these lists may not include all the possible side effects that could be seen with IL-2. These 
lists include the more serious or common side effects with a known or possible relationship. If 
you have questions concerning additional side effects, please ask the Clinical Trials Unit staff. 
The most common side effects include:

Flu-like symptoms such as fever, chills, feeling tired

Nausea

Rash

Redness or hard lumps in the areas where IL-2 is injected; the lumps may take weeks to 
months to resolve.
Persons who receive IL-2 may develop abnormal function of the thyroid gland. This has happened 
to participants who are enrolled in this research study. 
Abnormal function of the thyroid gland can cause fatigue, changes in bowel habits, skin and hair 
changes, slow or fast heartbeat, irregular heart rhythm, swelling of the thyroid gland, intolerance 
to cold or heat, changes in sleep pattern, appetite changes, and changes in body weight and 
composition, including weight gain or weight loss. In some cases, thyroid abnormalities in persons 
who received IL-2 have been reversible, but it is not known how often that happens. Thyroid 
abnormalities can be treated with medications. If you develop thryroid abnormalities, it is possible 
that you will be required to take medication for life. 
Your thyroid function will be measured at the beginning of the study and at the beginning of each 
IL-2 cycle. At the same time, levels of antibodies against the thyroid in your blood will be 
measured. Antibodies are proteins made by the immune system that help defend against 
substances or particles that may be harmful, such as bacteria, but occasionally may be directed 
against a person’s own tissues. Persons who have antibodies against the thyroid appear to be 
more likely to develop thyroid abnormalities during IL-2 treatment. If any of these test results 
becomes abnormal at any time, you will be asked to discontinue the IL-2 treatment.   
    
        IRB NUMBER: STUDY20180025
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        IRB EXPIRATION DATE: 4/13/2021


UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
9
Other side effects include:

Vomiting, loose or watery stools, stomach pain, loss of appetite

Joint or muscle aches, sweats

Abnormal liver tests, which may mean liver damage

Skin peeling or itching

Sores in the mouth

Flushing

High blood sugar 

Anxiety, sleeping problems, change in mood, headache, dizziness

Abnormal kidney function 

Swelling, which is caused by leakage of fluid from the blood vessels into the surrounding 
tissues

Low blood pressure and fast heartbeat 

Decreases in the amount of certain elements in the blood (calcium, magnesium, phosphate, 
sodium) 

A decrease in the number of red blood cells, which may cause weakness, dizziness, and 
fatigue

A decrease in the number of platelets, which help the blood to clot

Shortness of breath, cough, wheezing and nasal/sinus stuffiness

Development of antibodies against IL-2

Inflammation of the gallbladder
The following side effects have occurred infrequently:

Severe allergic reactions, with breathing/swallowing difficulties and hives 

Serious heart problems, which may include angina (chest pain), abnormal heart rhythm, 
heart attacks or
decreased pumping ability 

Development or worsening of certain auto-immune/inflammatory diseases 

Serious neurological or psychiatric side effects (for example, delerium, mania, depression, 
attempted suicide, loss of consciousness, convulsions, memory loss, swelling of the brain, 
or nerve disorders, such as disease of the nerve supplying the eye) 

Damage to an area of the brain or to other organs, caused by low blood supply

Kidney failure (which may be fatal)

Worsening of viral hepatitis and liver failure

Blood clot formation in a vein or artery.

Pancreatitis, an inflammation of the pancreas.

Development or worsening of Kaposi’s sarcoma 

Significant bacterial infections

Death
Il-2 may lead to a temporary increase in the amount of HIV in your blood. With combination ARV 
medications, that is less likely to occur.
Sometimes, when people who have received IL-2 are given a certain type of dye for X-ray 
examinations, a reaction may occur that includes symptoms such as fever, chills, nausea, 
vomiting, itchiness rash, diarrhea, low blood pressure, swelling, and low urine output.
    
        IRB NUMBER: STUDY20180025
        IRB APPROVAL DATE: 4/14/2020
        IRB EFFECTIVE DATE: 4/14/2020
        IRB EXPIRATION DATE: 4/13/2021


UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
10
Risks associated with blood drawing 
Blood drawing from a vein may cause some discomfort, and occasionally some bleeding or 
bruising at the site. Rarely, people may faint while having blood drawn. Blood drawing will not 
exceed 450 milliliters (1 pint) over any 8-week period, which is within the safety guidelines for 
blood drawing practiced at the Clinical Trials Unit. 
Risks associated with Stored Specimens
The greatest risk is the unplanned release of information from your medical records. The 
chance that this information will be given to an unauthorized person without your permission is 
very small. Possible problems with the unplanned release of information include discrimination 
when applying for insurance and employment. Similar problems may occur if you disclose 
information yourself or agree to have your medical records released.
Risks associated with leukapheresis 
The potential risks of peripheral intravenous catheter placement for leukapheresis include:

Pain 

Anxiety 

Bruising, including a form of bruising called a hematoma

Light-headedness

Fainting 

Chills 

Very rarely, infection 
You may also have a greater chance of bleeding for a few hours after leukapheresis, since a 
blood thinner (heparin or citrate) is used in the leukapheresis machine, to which you will be 
connected through IV lines. Leukapheresis allows only immune cells to be removed from your 
blood, while re-circulating and giving back your red blood cells. Side effects are uncommon. 
In rare cases, if blood in the cell separator (apheresis machine) clots (thickens) or the centrifuge 
stops working, the leukapheresis may be stopped and a loss of up to one half (½) pint of blood 
could result. If this happens we will ask you not to donate blood for at least 2 months. In extreme 
cases, subjects may require a blood transfusion.
Potential risks involved in this type of blood donation process are usually minimal and may 
include:

A sour taste in the mouth, 

A lowering of your blood calcium levels, 

Tingling/numbness around the mouth and face

Nausea

Vomiting

Fainting

Blood loss

Low platelets

Anemia

Infection

Low potassium

Bleeding
    
        IRB NUMBER: STUDY20180025
        IRB APPROVAL DATE: 4/14/2020
        IRB EFFECTIVE DATE: 4/14/2020
        IRB EXPIRATION DATE: 4/13/2021


UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
11

Heparin induced clotting

Fluid overload
These are temporary effects and may be reversed by the addition of fluid during the leukapheresis 
process.
In extremely rare cases complications could include introduction of air into the blood stream, 
seizures, or death. The numbness/tingling, nausea, vomiting and seizures may be due to the 
anticoagulant ACD-A used in the procedure. Using the least possible amount of anticoagulant 
minimizes these effects. Bleeding may occur, especially after the procedure. The risk of infection 
that can occur from the needle insertion into the arm is minimized by the use of gloves and an 
aseptic cleaning procedure. The introduction of air into the blood stream is prevented by air 
detectors and alarms in the cell separator, which are monitored by a trained technologist or nurse. 
You should discuss these risks and side effects with the study doctor /study nurse. There also 
may be other risks and side effects that we cannot predict. Other procedures may be performed 
to make side effects less serious and uncomfortable. Many side effects go away shortly after the 
blood draw is stopped, but in some cases side effects can be serious or long lasting or permanent.
ARE THERE RISKS RELATED TO PREGNANCY?
IL-2 has not been studied adequately in pregnant women. Animal studies do not suggest that IL-
2 causes birth defects, but it is not known whether or not this is true in humans. Because it is 
not known whether IL-2 may be harmful during pregnancy, you will not be allowed to participate 
in the study if you are a woman who can become pregnant. 
ARE THERE BENEFITS TO TAKING PART IN THIS STUDY?
If IL-2 treatment decreases the size of the HIV reservoir, this might be of some benefit to you 
but such a benefit is uncertain. It is important to recognize that although there have been 
numerous studies evaluating the risks and benefits of IL-2, it remains an experimental 
medication in the treatment of HIV infection, and it is possible that taking this therapy could 
make things worse. In that situation, having taken no treatment would have been better than 
participating in this trial. 
Another possible benefit for you from this study is a more intensive immunologic and virologic 
monitoring of your HIV-1 infection than usually done in clinics. The clinical significance of 
some of these test results is still unknown, however. Additionally, what we learn from this 
study may help us to improve the treatment of other people who are infected with HIV. 
    
        IRB NUMBER: STUDY20180025
        IRB APPROVAL DATE: 4/14/2020
        IRB EFFECTIVE DATE: 4/14/2020
        IRB EXPIRATION DATE: 4/13/2021


UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
12
WHAT ARE ALTERNATIVES TO PARTICIPATION?
An alternative to participating in this study is simply to remain on your licensed antiretroviral 
combination treatment and continue to be followed by your private physician over time. 
WILL I RECEIVE ANY PAYMENT?
You will receive compensation for your time according to the type of study visit, as follows: 

You will receive $40 for the screening visit, if you live less than 15 miles away from the 
clinic. You will receive $50 for the screening visit, if you live 15 miles or more away from 
the clinic.

You will receive $60 for the visits on day 0 of cycles 1, 4, and 8 ($180 total for those 3 
visits), if you live less than 15 miles away from the clinic. You will receive $70 for the 
visits on day 0 of cycles 1, 4, and 8 ($210 total for those 3 visits), if you live 15 miles or 
more, away from the clinic.

You will receive $210 for each visit that includes a leukapheresis, if you live less than 15 
miles away from the clinic. There are two scheduled visits that include a leukapheresis: 
the initial leukapheresis visit (done before you start study treatment) and the final or 
premature discontinuation visit ($420 total for those 2 visits if leukapheresis is done at 
both of them). You will receive $220 for each leukapheresis visit ($440 total for those 2 
visits if leukapheresis is done at both of them), if you live 15 miles or more away from the 
clinic.

You will receive $40 for each of the other study visits, if you live less than 15 miles away 
from the clinic. You will receive $50 for each of the other study visits, if you live 15 miles 
or more away from the clinic (the total will vary because you may be required to return 
for unscheduled visits).
Your parking will be paid for each study visit. The mileage for the above determinations of 
compensation is the round-trip distance from your residence to the Foley Building, 2061 Cornell 
Road, Cleveland, Ohio. The mileage will be determined by an AIDS Clinical Trials Unit research 
nurse per Google Maps. If you travel by public transportation, you will be provided with 2 one-
trip bus passes.
To receive payment you must agree to complete a W-9 form, which requires you to provide an 
address and social security number to the accounting department. This payment to you may be 
considered taxable income by the IRS. Subjects will be issued a 1099-Misc form only if payment 
exceeds $600 in a fiscal year from all studies in which you are participating. If you are an 
employee of Case Western Reserve University, you will be asked to provide your employee ID 
number, and compensation provided to you will be reported to the Payroll Department. 
ARE THERE ANY COSTS FOR MY PARTICIPATION IN THE STUDY?
There will not be any direct cost to you for participating in the study. 
    
        IRB NUMBER: STUDY20180025
        IRB APPROVAL DATE: 4/14/2020
        IRB EFFECTIVE DATE: 4/14/2020
        IRB EXPIRATION DATE: 4/13/2021


UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
13
NEW FINDINGS
You will be told of any new information learned during the study that might cause you to 
change your mind about staying in the study. At the end of the study, you will be told when 
study results may be available and how to learn about them. 
WHAT IF I AM INJURED?
If injury occurs as a result of your involvement in this research, medical treatment is available 
from University Hospitals Cleveland Medical Center or another medical facility but you/your 
medical insurance will be responsible for the cost of this treatment. A research injury is an 
injury that happens as a result of taking part in this research study. If you are injured by a 
medical treatment or procedure that you would have received even if you weren’t in the study, 
that is not considered a “research injury”. There are no plans for payment of medical 
expenses or other payments, including lost wages, for any research related injury. To help 
avoid injury, it is very important to follow all study directions. 
WHAT ABOUT CONFIDENTIALITY?
You will be consented in a private exam room within the Special Immunology Unit at 
University Hospitals Cleveland Medical Center by Dr. Lederman or one of the research 
nurses. All laboratory specimens will be identified by coded number only to maintain your 
confidentiality. The study-required samples will be kept in a secure area in Dr. Lederman’s 
Immunology Assessment Laboratory (2109 Adelbert Road, BRB Room 1048B) and only the 
research team will have access to the samples. The samples and data are identified only by 
code numbers and only limited research staff has access to the list of participants. This 
access is password protected and can be monitored.
All records will be kept locked. All computer entry and networking programs will be done with 
coded numbers only. Information about your participation will not be shared with individuals who 
are not directly involved with the research participant or as identified in the privacy of protected 
health information section below.
If the study team decides at any time that some of the doses needed for each cycle will be 
shipped rather than delivered to you in person, your identity will be known to the shipping 
company. In that event, you may be required to show proof of identity and/or to sign your name 
in order to receive the shipment. 
Privacy of Protected Health Information
The Health Insurance Portability & Accountability Act (HIPAA) is a Federal law that helps to 
protect the privacy of your health information and to whom this information may be shared within 
and outside of University Hospitals. This Authorization form is specifically for a research study 
entitled “HIV Reservoir Reduction with Interleukin-2” and will tell you what health information 
(called Protected Health Information or PHI) will be collected for this research study, who will 
see your PHI and in what ways they can use the information. In order for the Principal 
Investigator, Dr. Benigno Rodriguez, and the research study staff to collect and use your PHI, 
you must sign this authorization form. You will receive a copy of this signed Authorization for 
your records. If you do not sign this form, you may not join this study. Your decision to allow the 
    
        IRB NUMBER: STUDY20180025
        IRB APPROVAL DATE: 4/14/2020
        IRB EFFECTIVE DATE: 4/14/2020
        IRB EXPIRATION DATE: 4/13/2021


UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
14
use and disclosure of your PHI is voluntary and will have no impact on your treatment at 
University Hospitals. By signing this form, you are allowing the researchers for this study to use 
and disclose your PHI in the manner described below. 
Generally the Principal Investigator and study staff at University Hospitals and Case Western 
Reserve University who are working on this research project will know that you are in a research 
study and will see and use your PHI. The researchers working on this study will collect the 
following PHI about you: Your name, your medical history, a list of your current medications, you 
will have a physical examination and you will be given IL-2. This PHI will be used to find out if 
IL-2 will decrease the number of cells in the body that contain HIV capable of infecting new 
cells. Your access to your PHI may be limited during the study to protect the study results. 
Your PHI may also be shared with the following groups/persons associated with this research 
study or involved in the review of research: Gilead Sciences, Inc. (the sponsor); other staff from 
the Principal Investigator’s medical practice group; University Hospitals, including the Clinical 
Research Center and the Law Department; Government representatives or Federal agencies, 
when required by law. 
Your permission to use and disclose your PHI does not expire. However, you have the right to 
change your mind at any time and revoke your authorization. If you revoke your authorization, 
the researchers will continue to use the information that they previously collected, but they will 
not collect any additional information. Also, if you revoke your authorization you may no longer 
be able to participate in the research study. To revoke your permission, you must do so in 
writing by sending a letter to:
Dr. Benigno Rodriguez
2061 Cornell Road, 4th Floor
Foley Building
Cleveland, OH 44106
If you have a complaint or concerns about the privacy of your health information, you may also 
write to the UH Privacy Officer, Management Service Center, 3605 Warrensville Center, MSC 
9105, Shaker Heights, OH 44122 or to the Federal Department of Health and Human Services 
(DHHS) at DHHS Regional Manager, Office of Civil Rights, US Department of Health and 
Human Services Government Center, JF Kennedy Federal Building, Room 1875, Boston, MA 
02203. Complaints should be sent within 180 days of finding out about the problem.  
The researchers and staff agree to protect your health information by using and disclosing it 
only as permitted by you in this Authorization and as directed by state and Federal law. 
University Hospitals is committed to protecting your confidentiality. Please understand that once 
your PHI has been disclosed to anyone outside of University Hospitals, there is a risk that your 
PHI may no longer be protected; however other Federal and State laws may provide continued 
protection of your information. 
U.S. NATIONAL INSTITUTES OF HEALTH (NIH) CLINICAL TRIAL DATABASE
A description of this clinical trial will be available on http:///www.clinicaltrials.gov, as required by 
U.S. Law.  This website will not include information that can identify you.  At most, the website 
    
        IRB NUMBER: STUDY20180025
        IRB APPROVAL DATE: 4/14/2020
        IRB EFFECTIVE DATE: 4/14/2020
        IRB EXPIRATION DATE: 4/13/2021


UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
15
will include a summary of the results.  You can search this website at any time to find out 
information about the trial and basic results.
WHAT DO I DO IF I HAVE QUESTIONS OR PROBLEMS?
If you have questions about this research study, please contact Dr. Benigno Rodriguez at 216-
844-2342 between the hours of 9am-5pm daily from Monday through Friday. After hours please 
call 216-207-7244, enter pager number 35333, and then enter the phone number where you 
can be reached. The research nurse on-call is available 24 hours a day, 7 days a week and will 
return your call. 
 
SUMMARY OF YOUR RIGHTS AS A PARTICIPANT IN A RESEARCH STUDY
Your participation in this research study is voluntary. Refusing to participate will not alter your 
usual health care or involve any penalty or loss of benefits to which you are otherwise entitled. If 
you decide to join the study, you may withdraw at any time and for any reason without penalty 
or loss of benefits. If information generated from this study is published or presented, your 
identity will not be revealed. In the event new information becomes available that may affect the 
risks or benefits associated with this study or your willingness to participate in it, you will be 
notified so that you can decide whether or not to continue participating. If you experience 
physical injury or illness as a result of participating in this research study, medical care is 
available at University Hospitals Cleveland Medical Center (UHCMC) or elsewhere; however, 
UHCMC has no plans to provide free care or compensation for lost wages.
DISCLOSURE OF YOUR STUDY RECORDS
Efforts will be made to keep the personal information in your research record private and 
confidential, but absolute confidentiality cannot be guaranteed. The University Hospitals 
Cleveland Medical Center Institutional Review Board may review your study records. If this 
study is regulated by the Food and Drug Administration (FDA), there is a possibility that the FDA 
might inspect your records. In addition, for treatment studies, the study sponsor and possibly 
foreign regulatory agencies may also review your records. If your records are reviewed your 
identity could become known.
CONTACT INFORMATION
________________________________________ has described to you what is going to be 
done, the risks, hazards, and benefits involved. The Principal Investigator, Dr. Benigno 
Rodriguez, can also be contacted at 216-844-2432. If you have any questions, concerns or 
complaints about the study in the future, you may also contact them later.
If the researchers cannot be reached, or if you would like to talk to someone other than the 
researcher(s) about; concerns regarding the study; research participant’s rights; research- 
related injury; or other human subject issues, please call the University Hospitals Cleveland 
Medical Center’s Research Subject Rights phone line at (216) 983-4979 or write to: President, 
Cleveland Medical Center, 11100 Euclid Avenue, Lakeside 1400, Cleveland, Ohio, 44106-7061.
    
        IRB NUMBER: STUDY20180025
        IRB APPROVAL DATE: 4/14/2020
        IRB EFFECTIVE DATE: 4/14/2020
        IRB EXPIRATION DATE: 4/13/2021


UNIVERSITY HOSPITALS CLEVELAND MEDICAL CENTER
CONSENT FOR INVESTIGATIONAL STUDIES
Title of Project: HIV Reservoir Reduction with Interleukin-2
Principal Investigator: Dr. Benigno Rodriguez
16
SIGNATURE
Signing below indicates that you have been informed about the research study in which you 
voluntarily agree to participate; that you have asked any questions about the study that you may 
have; and that the information given to you has permitted you to make a fully informed and free 
decision about your participation in the study. By signing this consent form, you do not waive 
any legal rights, and the investigator(s) or sponsor(s) are not relieved of any liability they may 
have. A copy of this consent form will be provided to you.
x
Signature of Participant                                                  Date                                Time
x
Printed Name of Participant
x
Signature of Witness                                                       Date                                Time
x
Printed Name of Witness 
x
Signature of person obtaining informed consent                Date                              Time
x
Printed name of person obtaining informed consent 
    
        IRB NUMBER: STUDY20180025
        IRB APPROVAL DATE: 4/14/2020
        IRB EFFECTIVE DATE: 4/14/2020
        IRB EXPIRATION DATE: 4/13/2021