Conditions: HIV Coinfection
Keywords: parasitic infection chronic immune activation HIV coinfection Malawi sCD14 sCD163 I-FABP intestinal damage
Allocation: NON_RANDOMIZED | Intervention model: PARALLEL
Enrollment: 120
Healthy volunteers: yes

Brief summary:
The overall goal of this study is to determine if periodic de-worming of persons living with HIV in intestinal parasite-endemic regions will lead to decreased morbidity and mortality associated with HIV by reducing immune activation and intestinal damage associated with these diseases. The hypothesis for this project is that intestinal parasitic infections contribute to a modifiable pro-inflammatory state in persons living with HIV (PLWH).

Aim 1: Determine the prevalence of intestinal parasitic infections in PLWH receiving care at an HIV-treatment center in Lilongwe, Malawi using a highly sensitive multi-parallel stool PCR test. Hypothesis: highly sensitive stool PCR testing will demonstrate that disease burden of parasitic infection in PLWH in Malawi is higher than historically reported based on stool microscopy.

Aim 2: Determine the impact of parasitic infection on intestinal damage and immune activation by measuring sCD14, sCD163, and intestinal fatty acid binding protein (I-FABP) in PLWH. Hypothesis: plasma biomarkers reflecting intestinal damage and immune activation are elevated in those with HIV and parasitic co-infection compared with parasite-negative participants with HIV.

Aim 3: Determine the impact of eradication of parasitic infection on intestinal damage and immune activation by measuring sCD14, sCD163, and intestinal fatty acid binding protein (I-FABP) in PLWH before and after treatment of parasitic co-infection. Hypothesis: plasma biomarkers reflecting intestinal damage and immune activation are elevated in those with HIV and parasitic co-infection, and these biomarkers decrease with anti-parasitic treatment.

Detailed description:
This is a prospective study in which participants will be enrolled in outpatient HIV clinics associated with Kamuzu Central Hospital in Lilongwe, Malawi, where there are over 25,000 patients in care with over 90% virally suppressed on ART.

Any subject meeting inclusion criteria and lacking exclusion criteria who is currently receiving care at the clinics affiliated with Kamuzu Central Hospital or Bwaila Hospital will be eligible to participate in this study. After informed consent is signed, a total of 10ml of blood, 20g stool sample, and 20mL urine sample will be collected. Each participant will be asked a series of questions. Clinical variables including age, sex, CD4+ T-cell count, and CD4% will be collected from the participant's medical chart.

Stool samples will be processed by stool microscopy in the local UNC Project Malawi laboratory, and the remaining sample will be stored at -80 degrees Celsius (C) until transported to the Laboratory of Parasitology National School of Tropical Medicine Baylor College of Medicine in Houston, Texas for detection of 9 different parasites and quantification of parasite burden by stool qPCR. Blood samples will be collected in EDTA-blood collection tubes and centrifuged. Plasma will be frozen at -80 degrees C at UNC Project Malawi until transport to the National School of Tropical Medicine Baylor College of Medicine for determination of levels of immune activation and gut mucosal impairment (sCD14, sCD163, and I-FABP). Urine samples will be evaluated by microscopy to look for Schistosoma haematobium at UNC Project Malawi laboratory.

Multi-parallel real-time quantitative PCR (qPCR) performed on stool will evaluate for 9 different parasites including Ascaris lumbricoides, Ancylostoma duodenale, Necator americanus, Schistosoma mansonii, Strongyloides stercoralis, Taenia solium, Trichuris trichiura, Entamoeba histolytica, and Giardia lamblia.

Participants that test positive for parasitic infection will be contacted and appropriate treatment administered according to the local standard of care. Albendazole single 400mg dose will be given for infection with Ascaris lumbricoides, Ancylostoma duodenale, Necator americanus, Trichuris trichiura. Albendazole 400mg daily for 5 days will be given for Strongyloides stercoralis. Praziquantel single dose 40mg/kg will be given for infection with Schistosoma mansoni and Schistosoma haematobium. Praziquantel single dose 10mg/kg will be given to treat intestinal infection with Taenia solium. Metronidazole 500mg two times a day x5 days for Giardia lamblia and 500mg three times a day x7 days for Entamoeba histolytica.

Follow up appointments will be performed 8-12 weeks after treatment and will include repeated blood and stool sample collection.

The study team anticipates enrollment of 120 patients in a period of 8-12 weeks. With an estimated intestinal parasite prevalence of 30%, the study team predicts 30 cases and 70 controls will be enrolled. Participants found to be positive at both the initial and follow up visit will be considered reinfected rather than treatment failure. These will be included in the analysis of prevalence, but the change in markers of immune activation will not be measured in this group since parasite clearance not established. Using Student's unpaired t-test to compare mean values of biomarkers between study groups, there will be 80% power to detect a difference of 0.434 x106 pg/ml, 0.56 mg/l, and 598 pg/ml between groups for biomarkers sCD14, sCD163, and I-FABP, respectively with effect sizes within the range of prior studies. Using paired t-tests to compare pre- and post-treatment biomarker levels, there will be 80% power to detect post-treatment changes of 0.317 x106/ml, 0.41 mg/l, and 435 pg/ml in sCD14, CD163, and I-FABP respectively.

Clinical variables including age, sex, and most recent CD4 count will be recorded. Clinical predictors of parasitic infection (eg CD4%) will be determined using multivariable logistical regression. Univariable linear regression will be used to determine associations between markers of immune activation (continuous outcome variable) and predictors including the clinical variables above as well as presence of multiple parasitic infections.

Arms:
arm 1: Participants will be evaluated for intestinal parasitic infection by stool microscopy or stool PCR. If positive by either of these, the participant will be treated for the detected parasitic infection. The biomarker levels of this parasite-positive group will be compared to the parasite-negative group. Additionally the parasite-positive pre-treatment biomarker levels will be compared to the parasite-positive post-treatment levels. arm 2: Participants will be evaluated for intestinal parasitic infection by stool microscopy or stool PCR. If negative by all of these tests on the initial sample collection, the participants will not receive treatment and will be in the "parasite-negative"/no intervention arm.

Interventions: intervention 1: Antiparasitic medication
Intervention descriptions: intervention 1: Participants in the "parasite-positive" group (based on positive result of either stool microscopy or stool PCR) will be administered antiparasitic treatment. Antiparasitic medication administered will be targeted to treat the parasite identified. See detailed description of protocol for medication, dose, and frequency that will be given for each parasitic infection identified.

Participants with negative stool microscopy and negative stool PCR will not be administered treatment, thus will serve as controls.

Protocol document:
Prot_SAP_001.pdf: 
 
 
Impact of parasitic infections on intestinal epithelial barrier and 
immune activation among persons living with HIV in Lilongwe, Malawi 
 
 
NCT number NCT05323396 
Document Date 02/15/2022 
 


NHSRC #21/08/2764 
 
Research Proposal v4   15 Feb 2022 
 
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Title:  Impact of parasitic infections on intestinal epithelial barrier and immune activation among persons living 
with HIV in Lilongwe, Malawi 
 
Abbreviated study name:  HAPI (HIV And Parasitic Infection) study 
 
Background:  
In sub-Saharan Africa (SSA), more than 22 million people are estimated to be co-infected with HIV and 
helminths1 and studies within SSA have reported 14-25% of persons living with HIV (PLWH) coinfected with 
pathogenic intestinal protozoa2,3.  A prior study from Lilongwe, Malawi published in 2007 reported a prevalence 
of 30% of PLWH coinfected with intestinal parasitic infection when including both helminths and pathogenic 
intestinal protozoa4. Although treatable, intestinal parasitic infections are underdiagnosed due to lack of testing 
and inadequate sensitivity of currently used techniques such as light microscopy. Furthermore, reinfection in 
endemic regions is common. Consequently, co-infection remains highly prevalent.  
CD4+ T cell recovery has been shown to be lower in patients from sub-Saharan Africa compared to Europeans 
early after starting cART after adjusting for age, sex, initial regimen, pre-ART CD4+ T-cell count, and HIV RNA5-
7. This is an indication that factors other than initial HIV disease state contribute to HIV disease progression in 
these resource-limited, parasitic-endemic settings. A study in Uganda- using the same stool PCR test that we 
will use in our proposed study- demonstrated significantly lower levels of CD4 cells in patients co-infected with 
hookworm, suggesting that intestinal parasitic infection could be contributing to the low CD4 count and delayed 
recovery in resource-limited settings8.  
Soluble CD14 is a marker of microbial translocation, released upon LPS stimulation9.  Both sCD14 and soluble 
CD163 (sCD163) are markers of macrophage and monocyte activation9-11. Intestinal fatty acid binding protein 
(I-FABP) is a marker of intestinal permeability and enterocyte turnover10.  Increased levels of each of these- 
soluble CD14 (sCD14), soluble CD163 (sCD163), and (I-FABP)- have been shown to predict morbidity and 
mortality in treated HIV infection, including cardiac disease and neurocognitive decline9-14.  Preliminary data 
from a study in Houston, Texas, showed increased levels of sCD14 in PLWH co-infected with Strongyloides 
stercoralis when compared to Strongyloides negative PLWH, and a correlation of Strongyloides IgG levels with 
sCD14 and sCD163 levels15.  
Characterizing the effects of intestinal parasitic infections on HIV disease will provide clarification as to whether 
periodic deworming would improve CD4+ T cell recovery and decrease inflammation in PLWH, and will 
highlight key pathways to explore for optimizing the health of PLWH worldwide. The impact on systemic 
inflammation and intestinal damage may have consequences for the long-term risk of serious non-AIDS 
events.  
Objectives: 
The overall goal of our research program is to determine if periodic deworming of persons living with HIV in 
intestinal parasite-endemic regions will lead to decreased morbidity and mortality associated with HIV by 
reducing immune activation and intestinal damage associated with these diseases.  Our hypothesis for this 
project is that intestinal parasitic infections contribute to a modifiable pro-inflammatory state in PLWH.   
 
Aim 1:  Determine the prevalence of intestinal parasitic infections in PLWH receiving care at an HIV-treatment 
center in Lilongwe, Malawi using a highly sensitive multi-parallel stool PCR test. Hypothesis: highly sensitive 
stool PCR testing will demonstrate that disease burden of parasitic infection in PLWH in Malawi is higher than 
historically reported based on light microscopy. 
 
Aim 2:  Determine the impact of parasitic infection and eradication on intestinal damage and immune activation 
by measuring sCD14, sCD163, and intestinal fatty acid binding protein (I-FABP) in PLWH before and after 
treatment of parasitic co-infection. Hypothesis: plasma biomarkers reflecting intestinal damage and immune 
activation are elevated in those with HIV and parasitic co-infection compared with parasite negative participants 
with HIV, and these biomarkers decrease with anti-parasitic treatment. 


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Research Proposal v4   15 Feb 2022 
 
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Few studies have evaluated the effect of eradication of intestinal parasitic infection on PLWH on suppressive 
ART15-16, and fewer have been prospective studies.  We will use a modern molecular diagnostic and quantitative 
technique, the multi-parallel real-time quantitative PCR (qPCR), which detects and quantifies the burden of 9 
common GI parasites including helminths and protozoa simultaneously, with more than 10 times higher 
sensitivity compared to traditional microscopy8.  This assay has been optimized at the US National Institutes of 
Health (NIH) and field tested in Ecuador, Colombia, Mozambique, Argentina, and Uganda8,17,18. Our test will be 
modified to include PCR for Schistosoma mansoni, given the high prevalence of intestinal schistosomiasis in 
Malawi. This improved sensitivity will overcome the deficiencies of microscopy that have plagued previous 
studies, resulting in under-diagnosis of parasitic infections and contamination of parasite-negative groups with 
undiagnosed parasite-infected persons. This approach will facilitate learning the prevalence of parasitic 
infections, maximize our ability to ensure a truly parasite-uninfected control group, and enable us to assess the 
impact not only of the presence of intestinal parasites but also the impact of intestinal parasite burden on HIV 
infection.  Comparison of sCD14, sCD163, and I-FABP levels in PLWH with and without parasitic infections, and 
repeated measurements after eradication will provide data on the impact of intestinal parasitic infections on 
systemic immune activation and intestinal permeability.  Outside of preliminary data from our study performed in 
Houston, Texas15, these markers of systemic immune activation and intestinal damage have not been explored 
in PLWH on ART with parasitic coinfection.    
 
In accordance with the SMART objectives, our goals are specific, measurable, achievable, relevant, and time-
bound.  The laboratory data obtained by qPCR, Strongyloides stercoralis IgG, sCD14, sCD163, and I-FABP are 
specific and easily measured.  The estimated patient enrollment is achievable in the outlined period of time 
based on the number of patients that regularly receive clinical care at the participating clinics.  Once the data 
are obtained, our research question is achievable with the power calculations outlined above.  The relevance of 
our research question is highlighted by the fact that intestinal parasitic infections may be a modifiable pro-
inflammatory state in PLWH contributing to increased morbidity and mortality of this vulnerable population.   
 
Literature Review: 
 
I. 
HIV and intestinal parasitic coinfection 
In sub-Saharan Africa, more than 22 million people are estimated to be co-infected with HIV and helminths1 
and regions of SSA have reported 14-25% of PLWH coinfected with pathogenic intestinal protozoa2,3.  One 
study from Ethiopia reported as many as 59.8% of PLWH coinfected with intestinal parasitic infections when 
including both helminths and protozoa19.  A prior study from Lilongwe, Malawi published in 2007 reported a 
prevalence of 30% of PLWH coinfected with intestinal parasitic infection4.   
 
Although treatable, intestinal parasitic infections are underdiagnosed due to lack of testing and inadequate  
sensitivity of currently used techniques such as light microscopy. Furthermore, reinfection in endemic 
regions is common.  Consequently, co-infection remains highly prevalent.   
 
II. 
Delayed CD+ T cell recovery in PLWH in intestinal parasite-endemic regions 
CD4+ T cell recovery has been shown to be lower in patients from sub-Saharan Africa compared to  
Europeans early after starting cART5-6. CD4+ T-cell counts after 3 years of ART were higher in people from 
North America (529 cells/mm3) compared to East Africa (437 cells/mm3), West Africa (494 cells/mm3), 
Southern Africa (515 cells/mm3), and Asia (503 cells/mm3) after adjusting for age, sex, initial regimen, pre-
ART CD4+ T-cell count, and HIV RNA20. In a study from East Africa, 63% of adults had CD4+ T-cell counts < 
500 cells/mm3 and 40% had CD4+ T-cells <350cells/mm3 after 5 years of ART5. Similarly, in a Ugandan 
cohort, 49.1% of adults had CD4+ T-cells ≤ 400 cells/mm3 after 5 years of ART6. Five years of ART increased 
CD4+ T-cell counts from a median of 114 cells/mm3 to 395 cells/mm3 in a consortium of participants from 
low-income countries in Africa, Latin America, and Asia21. This is an indication that factors other than initial 
HIV disease state contribute to HIV disease progression in (PLWH) in these resource-limited, parasitic-
endemic settings.   
 
III. 
Impact of parasitic infection on the immune system 


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Parasitic infections induce Th2 immune responses, characterized by high IgE titers and eosinophil 
recruitment22,23. Consequently, the Th1 response in someone with parasitic infection is often impaired24-26. 
One study showed that mice with chronic infection with the roundworm Trichinella spiralis and acute norovirus 
infection, the frequency and polyfunctionality of norovirus-specific CD4+ and CD8+ T-cells were decreased 
and virus burden increased compared to non-Trichinella infected mice27.  Mice with chronic infection with the 
hookworm Heligmosomoides polygyrus bakeri had impaired antigen-specific and polyfunctional responses 
to norovirus27. Similar results were observed with influenza virus in Trichinella spiralis infection26. These data 
indicate that parasitic infections impair virus-specific CD4+ and CD8+ T-cell responses and may facilitate virus 
replication. 
 
 
Intestinal parasitic infections induce immune activation as demonstrated by the following studies: Trichuris 
infection upregulates CCR5 expression on CD4+ T-cells28, and hookworm, Trichuris, and Ascaris induce 
HLA-DR expression on CD4+ and CD8+ T-cells28-30. Trichuris and Ascaris treatment downregulates CCR5 
expression on CD4+ T-cells and HLA-DR expression on CD8+ T-cells17. Hookworm also decreases CD3+ and 
CD4+ populations likely due to increased T-cell apoptosis and decreased T-cell proliferation29-32.  Among HIV-
uninfected South Africans, the frequency of HLA-DR+ CD8+ T-cells and expression of CCR5 on CD4+ T-cells 
decreased 3 months after albendazole and praziquantel treatment of hookworm and Trichuris infection28. In 
summary, intestinal parasitic infections seem to increase T-cell activation, increase CCR5 expression, induce 
T-cell apoptosis, and suppress T-cell proliferation.   
 
IV. 
Potential impact of parasitic infections on HIV  
Recurrent enteric parasitic infections cause impaired gut healing29,30 and increased microbial translocation30-
32, increased activation of macrophages33, and intestinal fibrosis34,35.  Parasitic infections increase CCR5+ 
CD4+ T-cell frequency, creating more HIV targets in HIV-infected persons16,26. Parasitic infections also 
increase CD8+ T-cell activation24. Malnutrition, weight loss, chronic diarrhea, and changed immune 
responses caused by the intestinal parasitic infections may further accelerate HIV/AIDS progression1,36-39. In 
a reciprocal manner, HIV infection may impair the immune system's ability to defend against parasitic 
infections40,41. 
 
 
Some studies have shown that patients living with HIV (PLWH) with parasitic coinfection have weakened 
CD4 recovery8,30,42,43 and/or higher HIV viral loads44,45 compared to those without parasitic coinfection, yet 
the data are inconsistent.  HIV-infected persons in Southern Ethiopia not taking ART who were treated for 
Ascaris lumbricoides had a significant increase in CD4+ T-cells from 469 to 551 cells/mm3 at 6 months, 
compared to a non-significant decrease in helminth-uninfected participants46.  Similar results were observed 
in a randomized, double-blind, placebo-controlled trial in ART-naive Kenyans treated for Ascaris 
lumbricoides47. A study in Uganda- using the same stool PCR test that we will use in our proposed study- 
demonstrated significantly lower levels of CD4 cells in patients co-infected with hookworm, suggesting that 
instestinal parasitic infections could be contributing to the low CD4 count and delayed recovery in resource-
limited settings8.  Higher HIV viral loads were observed in pregnant women with hookworm or Trichuris 
infections44.   Deworming of T. trichiura or hookworm in an observational study increased CD4+ T-cell counts 
and decreased the percentage of pregnant women on ART with detectable HIV viral load45.  
 
In contrast to the studies above, meta-analysis of randomized controlled trials of antiparasitic medications or 
placebo in HIV-infected people with unknown parasitic infection status showed no significant effect of one-
time or repeated deworming on viral load or CD4+ T-cell count in people not taking suppressive ART48.  A 
retrospective, observational study, empiric deworming did not increase CD4+ T-cell counts among Ugandans 
on ART except when restricted to women in the first year of ART49. A study published in 2007 conducted in 
outpatient clinics in the same setting as our study- Lilongwe, Malawi- found no improvement of HIV viral load 
after treatment of parasitic infection in PLWH4.    
 
Even with the studies above, there are gaps that remain in the question of the impact of intestinal parasitic 
infection on HIV.  Few of the studies are prospective, controlled trials involving treatment of intestinal parasitic 
infection.  Additionally, most of the studies above used low-sensitivity light microscopy to identify those with 
parasitic infection.  Given the low sensitivity of light microscopy, the cohort of patients identified as parasite-


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negative likely included a notable number of patients with unidentified parasitic infections.  Third, studies of 
parasitic infections in PLWH on suppressive ART are limited.   Our proposed study will help to address the 
gaps identified in this topic of PLWH and parasitic coinfection.    
 
V. 
Impact of chronic immune activation and intestinal damage on morbidity of PLWH 
In HIV infection, enterocyte loss, tight junction destruction, CD4+ T-cell depletion, decreased intestinal 
mucosal IgA, bacterial overgrowth, and dysbiosis result in increased translocation of pro-inflammatory 
bacterial products such as LPS9,50.  Non-human primate models have illustrated that this gut destruction and 
microbial translocation begins in the first week of infection51,52. Increased microbial translocation results in 
increased T-cell and monocyte activation, increased production and recruitment of HIV target CD4+ T-cells, 
and increased lymphatic tissue fibrosis50,52,53.  Early suppression of microbial translocation and inflammation 
in SIV infection reduces immune activation, decreases SIV replication, and preserves intestinal CD4+ T 
cells54. In sum, increased microbial translocation is a key driver of immune activation and inflammation in 
HIV infection. 
 
Soluble CD14 (sCD14) is a marker of microbial translocation, released upon LPS stimulation9.  Both sCD14 
and soluble CD163 (sCD163) are markers of macrophage and monocyte activation9-11. Intestinal fatty acid 
binding protein (I-FABP) is a marker of intestinal permeability and enterocyte turnover10.  Increased levels of 
each of these- soluble CD14 (sCD14), soluble CD163 (sCD163), and (I-FABP)- have been shown to predict 
morbidity and mortality in treated HIV infection, including cardiac disease and neurocognitive decline9-14.  One 
study analyzing 74 participants from the Strategies for Management of Antiretroviral Treatment (SMART) 
trial who died and 148 matched controls found that participants with the highest quartile of soluble CD14 
(sCD14) levels had a 6-fold increased risk of death compared to participants with the lowest quartile, even 
after adjusting for CD4+ T-cell count and other inflammatory markers9. 
 
HIV-uninfected South Indians with hookworm have higher LPS, sCD14, endotoxin core IgG, and I-FABP 
levels compared to hookworm-negative persons from the same village, and LPS and sCD14 levels 
decreased after documented parasite clearance with treatment55. Preliminary data from our pilot study in 
Houston, Texas, showed increased levels of sCD14 in PLWH co-infected with Strongyloides stercoralis when 
compared to Strongyloides negative PLWH, and a correlation of Strongyloides IgG levels with sCD14 and 
sCD163 levels15. 
 
As demonstrated in the literature referenced above, HIV infection and recurrent enteric parasitic infections 
have each been shown to be independent causes of intestinal damage, increased microbial translocation 
from the gut, and immune activation; all of which contribute to a pro-inflammatory state that may drive chronic 
diseases more prevalent in the HIV-positive population.  Characterizing the effects of intestinal parasitic 
infections on HIV disease will provide clarification as to whether periodic deworming would improve CD4+ T 
cell recovery and decrease inflammation in PLWH, and will highlight key pathways to explore in order to 
optimize the health of PLWH worldwide.  The impact of parasitic infection on systemic inflammation and 
intestinal damage may have consequences for the long-term risk of serious non-AIDS events.  
 
Methodology 
Research Design  
This is a prospective study in which participants will be enrolled in outpatient HIV clinics associated with 
Kamuzu Central Hospital in Lilongwe, Malawi, where there are over 25,000 patients in care with over 
90% virally suppressed on ART.  
 
Subjects and Methods 
Inclusion criteria include the following:  Age ≥ 18 years; HIV-1 infection; currently living in Malawi; on ART 
≥ 1 year with undetectable HIV RNA level at the last evaluation, and willingness to be treated with anti-
parasitic therapy if infection with intestinal parasite is identified.  Exclusion criteria include the following:  
Inflammatory bowel disease; gastrointestinal tract malignancy; major intestinal surgery during prior 2 
years; use of antibiotics other than prophylaxis with trimethoprim-sulfamethoxazole within 60 days of 
screening; use of antiparasitic medication (ex- albendazole, praziquantel) in the last year; coinfection with 


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Mycobacterium tuberculosis; pregnancy, breastfeeding mother, or planning pregnancy.  The last two are 
included in exclusion criteria because of the potential risk of teratogenicity with the antiparasitic 
medications used for treatment and because these can affect the markers of immune activation that we 
are measuring as a part of the study.   
Any subject meeting inclusion criteria and lacking exclusion criteria who is currently receiving care at the 
clinics affiliated with Kamuzu Central Hospital or Bwaila Hospital will be eligible to participate in this study.  
Subjects will be given time to ask questions, and if agreeable they will sign consent and then study 
procedures will be initiated. The investigator will keep the original consent form as part of the study 
records, and a copy will be provided to the subjects.  A pregnancy test will be performed on all women of 
childbearing years.   
After informed consent is signed, a total of 10ml of blood, 20g stool sample, and 20mL urine sample will 
be collected.  Subjects will be given an explanation about hygienic collection of stool samples. They will 
be given a clean, plastic, wide-mouthed, leak-proof container (of about 125 mL) with a snap-on lid. In 
addition, each subject will receive a pair of gloves and a small biohazard plastic bag. All subjects will be 
asked to put 5-25 g of stool in the container (which is approximately 1/5 of the volume content), close the 
lid and return the container to investigators in the biohazard bag. Each participant will be asked a series 
of questions (Participant information sheet attached).   
Clinical variables including age, sex, CD4+ T-cell count, and CD4% will be collected from the participant’s 
medical chart. 
Blood samples will be collected in EDTA-blood collection tubes and centrifuged, then serum will be 
frozen at -80 degrees at UNC Project Malawi until transport to Houston, Texas. Stool samples will be 
frozen at -80 degrees until transport to Houston, Texas.  Coded serum samples- without personal 
identifiers- will be sent to the laboratory of Dr. Rojelio Mejia at the National School of Tropical Medicine 
Baylor College of Medicine for determination of levels of immune activation and gut mucosal 
impairment (sCD14, sCD163, and I-FABP) and Strongyloides stercoralis IgG.  Stool samples will be 
processed by stool microscopy in the local UNC Project Malawi laboratory, then the remaining sample 
will be transported to Houston, Texas to be processed by qPCR for detection of 10 different parasites 
and quantification of parasite burden at the Laboratory of Parasitology National School of Tropical 
Medicine Baylor College of Medicine.  Urine samples will be brought to UNC Project Malawi for 
processing and evaluation by microscopy to look for Schistosoma haematobium.   
The COVID-19 precautions followed by the study team are as follows: all subjects will complete a 
clinical questionnaire before entry into the clinic.  Only those with low risk for current infection with 
SARS-CoV-2 will be approached for the study.   All clinical team members will be wearing gloves and a 
surgical mask at the time of participant enrollment.  All patients are required to wear a mask in the clinic 
and will be given gloves when they are given the stool sample collection kit.   
After enrollment is completed, the serum and stool samples will be shipped to Houston, Texas.  Stool 
samples will be processed by multi-parallel real-time quantitative PCR (qPCR) for detection of 9 
different parasites and quantification of parasite burden.  Parasites to be evaluated include Ascaris 
lumbricoides, Ancylostoma duodenale, Necator americanus, Schistosoma mansonii, Strongyloides 
stercoralis, Taenia solium, Trichuris trichiura, Entamoeba histolytica, and Giardia lamblia. Serum will be 
processed for Strongyloides stercoralis IgG, sCD14, sCD163, and I-FABP.   
Participants that test positive for parasitic infection will be contacted and appropriate treatment 
administered according to the local standard of care.  Albendazole single 400mg dose will be given for 
infection with Ascaris lumbricoides, Ancylostoma duodenale, Necator americanus, Trichuris trichiura.  
Albendazole 400mg daily for 5 days will be given for Strongyloides stercoralis.  Praziquantel single 
dose 40mg/kg will be given for infection with Schistosoma mansoni and Schistosoma haematobium.  
Praziquantel single dose 10mg/kg will be given to treat intestinal infection with Taenia solium.  


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Metronidazole 500mg two times a day x5 days for Giardia lamblia and 500mg three times a day x7 
days for Entamoeba histolytica.   
Female participants that test positive for parasitic infection will have a repeat pregnancy test before 
administration of antiparasitic medication.  If newly pregnant on repeat testing, the study team will be 
referred to her regular medical provider for evaluation, review of diagnostic tests performed by the 
study, and for potential treatment with antiparasitic medication.  Any participant found to be pregnant at 
this stage will not be included in the comparison of markers of immune activation or the follow up visit 
since pregnancy can affect these markers of chronic immune activation.  Follow up appointments for all 
non-pregnant participants will be performed 8-12 weeks after treatment and will include repeated blood 
and stool sample collection.  Pregnancy test will be repeated at the follow-up visit.  Any participant 
found to be pregnant at this stage will not be included in the comparison of markers of immune 
activation since pregnancy can affect these markers of chronic immune activation.  The decision for 
post-treatment period of 8-12 weeks was made based on prior studies of sCD1456 and other 
inflammatory markers57 that used a time frame of 12 weeks between intervention and repeat 
measurement.  A third study showed a decrease in sCD163 in the first eight weeks of treatment for 
HCV, but no change in either sCD14 or sCD163 from week 8 to week 24 following treatment for HCV58.   
We anticipate enrollment of 100 patients receiving care at the participating clinics during the recruitment 
period.  With an estimated intestinal parasite prevalence of 30%, we predict 30 cases and 70 controls 
will be enrolled.  This estimate is based on a study with similar patient population in the same region in 
2007 which reported 17.3% of participants infected with helminth infections and 12.8% with pathogenic 
protozoal infections4.  Our prevalence may be higher than this prior study given the increased 
sensitivity of our stool PCR test.  Participants found to be positive at both the initial and follow up visit 
will be considered reinfected rather than treatment failure.  These will be included in the analysis of 
prevalence, but the change in markers of immune activation will not be measured in this group since 
parasite clearance not established.  Using Student’s unpaired t-test to compare mean values of 
biomarkers between study groups, we will have 80% power to detect a difference of 0.434 x106 pg/ml, 
0.56 mg/l, and 598 pg/ml between groups for biomarkers sCD14, sCD163, and I-FABP, respectively 
with effect sizes within the range of prior studies9,14,59. Using paired t-tests to compare pre- and post-
treatment biomarker levels, we will have 80% power to detect post-treatment changes of 0.317 x106/ml, 
0.41 mg/l, and 435 pg/ml in sCD14, CD163, and I-FABP respectively60.  A sample size less than 100 
increases the chance of a type II error where a true difference in markers of chronic inflammation does 
not reach clinical significance.  A sample size of greater than 100 should not be necessary given the 
estimated findings in our patient population and the data presented by the studies cited above.  A 
sample size of 100 should be easily attainable in a reasonable amount of time (4-8 weeks) without the 
unnecessary use of additional resources. 
 
Clinical variables including age, sex, and most recent CD4 count will be recorded.  Clinical predictors of 
parasitic infection (eg CD4%) will be determined using multivariable logistical regression.  Univariable 
linear regression will be used to determine associations between markers of immune activation 
(continuous outcome variable) and predictors including the clinical variables above as well as presence 
of multiple parasitic infections.   
 
Study visits: 
- 
v0= Screening visit: includes explanation of study, inclusion/exclusion criteria, sign ICF 
- 
v1= Baseline visit: complete CRF; collection of blood, stool, and urine samples 
- 
v2= Treatment visit: only for those participants positive for parasitic infection 
- 
v3= Post-treatment/follow-up visit performed 8-12 weeks after administration of antiparasitic therapy 
to those participants found to be parasite-positive. Sample collection from controls (parasite-
negative participants) will be done in a similar time window.  
 
*screening and baseline visits can be done the same day 
**Participants positive for parasitic infection will complete v0, v1, v2, v3.  Participants negative for 


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Research Proposal v4   15 Feb 2022 
 
7 
parasitic infection will not have v2.  Full participation in the study for a parasite negative participant 
includes completion of v0, v1, v3.   
***Participants will be reimbursed for v1, v2, v3.   
 
Ethical Considerations 
In addition to the Malawi National Health Sciences Research Committee, we will submit for IRB approval 
from University of North Carolina School of Medicine, and the National School of Tropical Medicine at 
Baylor College of Medicine.  Participation in the study will be voluntary.  All study participants will be 
explained the study design and all questions answered before the participant provides written, informed 
consent.   
Neither the investigator, nor any research team member will coerce or unduly influence nor specifically 
target vulnerable subjects to participate in the study. Research subjects will be informed that participation 
is voluntary and that they are free to withdraw from the study for any reason at any time.  Subjects will 
be given time to ask questions, and if agreeable they will sign consent and then study procedures will be 
initiated. The investigator will keep the original consent form as part of the study records, and a copy will 
be provided to the subjects. A Chichewa translator will be present for the entirety of each interaction with 
each participant.   
The possibility of a breach in confidentiality will be minimized by limiting the number of people that will 
have access to the information, the use of coded data, and the stringent security measures that will be 
utilized.  Only Dr. Reimer-McAtee and members of the research team will have access to the patient 
clinical data.  The Participant Information Sheet with clinical information will only have the participant 
codes and deidentified clinical information.  The informed consent forms and the “link-log form” with 
patient names and patient codes will be kept in a locked cabinet at UNC Project Malawi.  Information 
entered into the electronic database will only include the participant identification number.  The patient 
names will not be included in the electronic database.  The database will not be saved on personal 
computers, rather will only be saved to a secure UNC server and will be password protected.   
Work Plan 
We plan to begin enrollment of participants starting January 2022.  We estimate that 2-3 months will be 
sufficient to recruit 100 participants.  After 100 participants are enrolled and samples collected, we will 
send samples to Houston, Texas.  We expect it will take 1-2 months to process all of the samples in the 
laboratory of Dr. Mejia.  Follow up visits will take place 2-3 months after participants with parasitic 
infections were treated.  Once follow up visits completed and samples obtained, the second shipment of 
samples will be sent to Houston, Texas.  We expect another 1-2 months for the processing of samples 
in the laboratory of Dr. Mejia.   Once all samples are processed, laboratory analysis can be performed.  
A manuscript will be prepared and submitted for publication.  An infectious diseases journal will be the 
target for publication of the manuscript.  The NHSRC will be provided a copy of the manuscript.  
Additionally, we plan to present our findings at both a local and an international academic conference. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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8 
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ICF_000.pdf: 
Informed Consent 
 
 
Impact of Parasitic Infections on Intestinal Epithelial Barrier and 
Immune Activation Among Persons Living With HIV in Lilongwe, 
Malawi 
 
 
 
NCT number NCT05323396 
Document Date 03/05/2022