Conditions: HIV Infections
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 31
Healthy volunteers: no

Brief summary:
This study evaluated the effects of tamoxifen exposure in combination with vorinostat on viral reactivation among HIV-1 infected post-menopausal women with virologic suppression on antiretroviral therapy (ART), when compared to vorinostat alone.

Detailed description:
The selective estrogen receptor modulator (SERM) tamoxifen may enhance the ability of the histone deacetylase inhibitor (HDACi) vorinostat to reverse HIV-1 latency. This study evaluated the safety of tamoxifen therapy combined with vorinostat and the effectiveness of this combination on latent virus reactivation in HIV-1 infected post-menopausal women with virologic suppression on antiretroviral therapy, when compared to vorinostat alone.

The study was conducted in two steps. During Step 1, the study enrolled women with HIV into two groups. Arm A received tamoxifen daily for 38 days, plus a single dose of vorinostat on Days 35 and 38. Arm B had a 38-day observation period with no tamoxifen, plus a single dose of vorinostat on Days 35 and 38. All participants continued to take ART drugs prescribed by their doctors. ART drugs were not be provided by the study.

Study visits during Step 1 occurred at Days 0, 28, 35, 38, 45, and 65. Study visits could include physical examinations, blood collection, electrocardiograms, and adherence assessments.

During Step 2, all participants were followed for 240 additional weeks for annual long-term safety follow-up. These visits were conducted by phone and collected information from participants on vital status and any new cancer diagnoses.

Step 1 and Step 2 have been completed and this results submission pertains to both.

Arms:
arm 1: From Day 0 to Day 38, participants will receive tamoxifen orally once a day. On Days 35 and 38, participants will receive a single dose of vorinostat orally. arm 2: Day 0 to Day 38 will be an observation period with no tamoxifen. On Days 35 and 38, participants will receive a single dose of vorinostat orally.

Interventions: intervention 1: Tamoxifen intervention 2: Vorinostat intervention 3: Antiretroviral drugs
Intervention descriptions: intervention 1: 20 mg orally intervention 2: 400 mg orally intervention 3: Participants will receive antiretroviral drugs provided by their own doctors. Antiretroviral drugs will not be provided by the study.

Protocol document:
Prot_001.pdf: 
 
 
 
 
 
A5366 
 
 
Selective Estrogen Receptor Modulators to Enhance the Efficacy of Viral 
Reactivation with Histone Deacetylase Inhibitors 
 
 
A Multicenter Trial of the AIDS Clinical Trials Group (ACTG) 
 
 
Sponsored by: 
National Institute of Allergy 
and Infectious Diseases 
 
Industry Support Provided by: 
Merck Research Labs 
 
 
 
IND #  
 
 
The ACTG CURE Transformative 
Science Group: 
 
 
 
 
 
Rajesh Gandhi, MD, Chair 
 
Protocol Co-Chairs:  
 
 
 
 
Rajesh Gandhi, MD 
 
 
 
 
 
 
 
 
Eileen Scully, MD, PhD 
 
Protocol Vice-Chair:  
 
 
 
 
Daniel R. Kuritzkes, MD 
 
DAIDS Clinical Representative: 
 
 
 
Catherine Godfrey, MD 
 
Clinical Trials Specialist: 
 
 
 
 
Lara Hosey, MA 
 
 
 
 
 
FINAL Version 1.0 
December 8, 2017 
 


A5366 
 
 
FINAL Version 1.0 
 
 
12/8/17 
 
A5366 
 
Selective Estrogen Receptor Modulators to Enhance the Efficacy of Viral Reactivation with 
Histone Deacetylase Inhibitors 
 
SIGNATURE PAGE 
 
I will conduct the study in accordance with the provisions of this protocol and all applicable 
protocol-related documents. I agree to conduct this study in compliance with United States (US) 
Health and Human Service regulations (45 CFR 46); applicable US Food and Drug 
Administration regulations; standards of the International Conference on Harmonization 
Guideline for Good Clinical Practice (E6); Institutional Review Board/Ethics Committee 
determinations; all applicable in-country, state, and local laws and regulations; and other 
applicable requirements (e.g., US National Institutes of Health, Division of AIDS) and 
institutional policies. 
 
 
 
 
Principal Investigator: _______________________________________________ 
Print/Type 
 
 
 
 
 
Signed: ___________________________________ Date: __________________ 
Name/Title 
 
 
 
 
 


 
 
A5366 
FINAL Version 1.0 
 
 
12/8/17 
 
 
TABLE OF CONTENTS 
Page 
 
SIGNATURE PAGE .................................................................................................................... 2 
SITES PARTICIPATING IN THE STUDY .................................................................................... 5 
PROTOCOL TEAM ROSTER ..................................................................................................... 6 
STUDY MANAGEMENT ............................................................................................................. 9 
GLOSSARY OF PROTOCOL-SPECIFIC TERMS ..................................................................... 12 
SCHEMA .................................................................................................................................. 13 
1.0 
HYPOTHESIS AND STUDY OBJECTIVES ................................................................... 15 
1.1 
Hypothesis ......................................................................................................... 15 
1.2 
Primary Objectives ............................................................................................. 15 
1.3. 
Secondary Objectives ........................................................................................ 15 
1.4. 
Exploratory Objectives ....................................................................................... 15 
2.0 
INTRODUCTION ........................................................................................................... 16 
2.1 
Background........................................................................................................ 16 
2.2 
Rationale ........................................................................................................... 17 
3.0 
STUDY DESIGN ........................................................................................................... 23 
4.0 
SELECTION AND ENROLLMENT OF PARTICIPANTS ................................................ 24 
4.1 
Inclusion Criteria ................................................................................................ 24 
4.2 
Exclusion Criteria ............................................................................................... 26 
4.3 
Study Enrollment Procedures............................................................................. 27 
4.4 
Co-enrollment Guidelines ................................................................................... 29 
5.0 
STUDY TREATMENT ................................................................................................... 29 
5.1 
Regimens........................................................................................................... 29 
5.2 
Administration .................................................................................................... 29 
5.3 
Study Product Formulation ................................................................................. 30 
5.4 
Pharmacy: Product Supply, Distribution, and Accountability .............................. 30 
5.5 
Concomitant Medications ................................................................................... 31 
6.0 
CLINICAL AND LABORATORY EVALUATIONS ........................................................... 32 
6.1 
Schedule of Evaluations (SOE) .......................................................................... 32 
6.2 
Timing of Evaluations ......................................................................................... 34 
6.3 
Instructions for Evaluations ................................................................................ 36 
7.0 
ADVERSE EVENTS AND STUDY MONITORING ......................................................... 42 
7.1 
Definition of Adverse Events .............................................................................. 42 
7.2 
Adverse Event Collection Requirements ............................................................ 42 
7.3 
Expedited Adverse Event (EAE) Reporting to DAIDS ........................................ 43 
7.4 
Study Monitoring ................................................................................................ 44 
8.0 
CLINICAL MANAGEMENT ISSUES .............................................................................. 45 
8.1 
Toxicity .............................................................................................................. 45 
8.2 
Specific Management of Toxicities Related to Study-Provided Drugs ................ 46 


A5366 
 
 
FINAL Version 1.0 
 
 
12/8/17 
 
CONTENTS (Cont’d)  
Page 
 
9.0 
CRITERIA FOR DISCONTINUATION ........................................................................... 48 
9.1 
Premature Study Treatment Discontinuation ...................................................... 48 
9.2 
Premature Study Discontinuation ....................................................................... 48 
10.0 
STATISTICAL CONSIDERATIONS ............................................................................... 48 
10.1 
General Design Issues ....................................................................................... 48 
10.2 
Outcome Measures ............................................................................................ 49 
10.3 
Randomization and Stratification ........................................................................ 49 
10.4 
Sample Size and Accrual ................................................................................... 50 
10.5 
Data and Safety Monitoring ................................................................................ 50 
10.6 
Analyses ............................................................................................................ 50 
11.0 
PHARMACOLOGY PLAN.............................................................................................. 52 
11.1 
Pharmacology Objectives .................................................................................. 52 
11.2 
Pharmacology Study Design .............................................................................. 52 
11.3 
Primary and Secondary Data, Modeling, and Data Analysis............................... 53 
11.4 
Anticipated Outcomes ........................................................................................ 53 
12.0 
DATA COLLECTION AND MONITORING ..................................................................... 53 
12.1 
Records to Be Kept ............................................................................................ 53 
12.2 
Role of Data Management ................................................................................. 53 
12.3 
Clinical Site Monitoring and Record Availability .................................................. 54 
13.0 
PARTICIPANTS ............................................................................................................ 54 
13.1 
Institutional Review Board (IRB) Review and Informed Consent ........................ 54 
13.2 
Participant Confidentiality ................................................................................... 54 
13.3 
Study Discontinuation ........................................................................................ 54 
14.0 
PUBLICATION OF RESEARCH FINDINGS .................................................................. 55 
15.0 
BIOHAZARD CONTAINMENT....................................................................................... 55 
16.0 
REFERENCES .............................................................................................................. 56 
APPENDIX I: SAMPLE INFORMED CONSENT ....................................................................... 60 
 
 


 
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SITES PARTICIPATING IN THE STUDY 
 
A5366 is a multicenter study open only at US AIDS Clinical Trials Group (ACTG) clinical 
research sites (CRSs). Refer to the protocol webpage on the ACTG member website for the list 
of eligible sites. 
 
  
 
 
 
 


 
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PROTOCOL TEAM ROSTER (Cont’d) 
12/8/17 
 
PROTOCOL TEAM ROSTER 
 
Co-Chairs 
Rajesh Gandhi, MD 
Massachusetts General Hospital (MGH) 
CRS 
Cox 5th Floor 
55 Fruit Street 
Boston, MA 02114 
Phone: 617-724-9690 
Fax: 617-726-7653 
E-mail: rgandhi@partners.org 
 
Eileen Scully, MD, PhD 
Johns Hopkins University School of 
Medicine 
Pre-Clinical Teaching Building, Suite 211 
725 N Wolfe Street 
Baltimore, MD 21205 
Phone: 203-906-6071 
E-mail: escully1@jhmi.edu 
 
Vice Chair 
Daniel Kuritzkes, MD 
Brigham and Women's Hospital 
Therapeutics (BWHT) CRS 
Section of Retroviral Therapeutics 
Harvard Medical School 
65 Landsdowne Street, Room 447 
Cambridge, MA 02139 
Phone: 617-768-8371 
Fax: 617-768-8738 
E-mail: dkuritzkes@partners.org 
 
DAIDS Clinical Representative  
Catherine Godfrey, MD 
HIV Research Branch 
TRP, DAIDS, NIAID, NIH 
Room 9E42 
5601 Fishers Lane 
Rockville, MD 20852 
Phone: 240-627-3074 
Fax: 301-432-9282 
E-mail: cgodfrey@niaid.nih.gov 
Clinical Trials Specialist 
Lara Hosey, MA 
ACTG Network Coordinating Center 
Social & Scientific Systems, Inc.  
8757 Georgia Avenue, 12th Floor 
Silver Spring, MD 20910 
Phone: 301-628-3395 
Fax: 301-628-3302 
E-mail: LHosey@s-3.com 
 
Statisticians 
Evgenia Aga, MS 
Statistical and Data Analysis Center 
Harvard TH Chan School of Public Health 
FXB Building, Room 504 
651 Huntington Avenue 
Boston, MA 02115 
Phone: 617-432-3029 
Fax: 617-432-3163 
E-mail: eaga@sdac.harvard.edu 
 
Ronald Bosch, PhD 
Statistical and Data Analysis Center 
Harvard TH Chan School of Public Health 
FXB Building, Room 603 
651 Huntington Avenue 
Boston, MA 02115-6017 
Phone: 617-432-3024 
Fax: 617-432-2843 
E-mail: ronbosch@sdac.harvard.edu 
 
Data Manager 
Apsara Nair, MSc 
Frontier Science & Technology Research 
Foundation, Inc.  
4033 Maple Road 
Amherst, NY 14226 
Phone: 716-834-0900 Ext. 7293 
Fax: 716-834-8432 
E-mail: nair@fstrf.org 


 
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12/8/17 
 
DAIDS Pharmacist 
Irene Rwakazina, PharmD 
Pharmaceutical Affairs Branch 
DAIDS, OCSO, PAB 
5601 Fishers Lane 
Room 9E14 
Rockville, MD 20892 
Phone: 301-761-7269 
E-mail: irene.rwakazina@nih.gov 
 
Immunologist 
Scott Sieg, PhD 
Case CRS 
Wood Building, Room W-119 
2109 Adelbert Road 
Cleveland, OH 44106-4984 
Phone: 216-368-1965 
Fax: 216-368-1969 
E-mail: sfs2@case.edu 
 
Virologist  
Athe Tsibris, MD 
Harvard University VSL 
65 Landsdowne Street, Room 422 
Cambridge, MA 02139 
Phone: 617-417-1162 
Fax: 617-768-8738 
E-mail: atsibris@partners.org 
 
Pharmacologists 
Qing Ma, PhD 
University of Rochester Adult HIV 
Therapeutic Strategies Network CRS 
Pharmacy Practice 
315 Kapoor Hall 
Buffalo, NY 14214 
Phone: 716-881-7500 
Fax: 716-849-6890 
E-mail: qingma@buffalo.edu 
 
Pharmacologists (Cont’d) 
Gene Morse, PharmD 
University of Rochester Adult HIV 
Therapeutic Strategies CRS 
Translational Pharmacology Research Core 
NYS Center of Excellence in Bioinformatics 
and Life Sciences 
701 Ellicott Street 
Buffalo, NY 14203 
Phone: 716-881-7464 
E-mail: emorse@buffalo.edu 
 
Investigators  
Nancie Archin, PhD 
Chapel Hill CRS 
120 Mason Farm Road, CB 7042 
Genetic Medicine Building, Room 2049H  
Chapel Hill, NC 27599-7042 
Phone: 919-962-0180 
E-mail: nancie_archin@med.unc.edu 
 
Nicolas Chomont, PhD 
Université de Montréal 
Centre de Recherche du CHUM 
900, rue St-Denis, Tour Viger, R09.430 
Montreal, Quebec H2X 0A9 
CANADA 
Phone: 1-514-890-8000 Ext. 31266 
E-mail: nicolas.chomont@umontreal.ca 
 
Elizabeth Connick, MD 
University of Arizona CRS 
1501 N. Campbell Ave 
P.O. Box 245039 
Tucson, AZ 85724 
Phone: 520-626-6887 
Fax: 520-626-5183 
E-mail: connicke@email.arizona.edu 
 


 
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PROTOCOL TEAM ROSTER (Cont’d) 
12/8/17 
 
Investigators (Cont’d) 
Steven Deeks, MD 
University of California, San Francisco 
HIV/AIDS CRS 
Building 80, Ward 84 
Box 0874 
995 Potrero Avenue 
San Francisco, CA 94110-2859 
Phone: 415-476-4082 Ext. 404 
Fax: 415-476-6953 
E-mail: steven.deeks@ucsf.edu 
 
Monica Gandhi, MD, MPH 
University of California, San Francisco 
HIV/AIDS CRS 
4th floor, Building 80, Room 423D 
995 Potrero Avenue 
San Francisco, CA 94110 
Phone: 415-476-4082 x 127 
Fax: 415-476-6953 
E-mail: monica.gandhi@ucsf.edu 
 
Jonathan Karn, PhD 
Case Western Reserve University 
Department of Molecular Biology & 
Microbiology 
10900 Euclid Avenue, LC 4960 
Cleveland, OH 44106 
Phone: 216-368-3915 
Fax: 216-368-3055 
E-mail: jxk153@case.edu 
 
Field Representative 
Erin Hoffman, BS 
Chapel Hill CRS 
130 Mason Farm Road 
Chapel Hill, NC 27599 
Phone: 919-843-0720 
Fax: 919-966-8928 
E-mail: erin_stephenson@med.unc.edu 
 
Laboratory Technologist 
Francoise Giguel, BA 
Massachusetts General Hospital 
Partners AIDS Research Center 
Division of Infectious Diseases 
65 Landsdowne Street 
Room 435 
Cambridge, MA 02139 
Phone: 617-768-8374 
Fax: 617-768-8299 
E-mail: fgiguel@mgh.harvard.edu 
 
Community Scientific Subcommittee (CSS) 
Representative 
Kate Borloglou, BS 
Ohio State University CRS 
5789 Redsand Road 
Hilliard, OH 43026 
Phone: 614-353-2944 
E-mail: borloglou@gmail.com 
 
Industry Representative 
Kathleen Squires, MD 
Merck Research Labs 
351 N. Sumneytown Pike, 
Mailstop UG3CD-28 
Upper Gwynned, PA 19454 
Phone: 267-305-6779 
E-mail: kathleen.squires@merck.com 
 
Laboratory Data Managers 
Andrew Bakatsias, BS 
Frontier Science & Technology Research 
Foundation, Inc.  
4033 Maple Road 
Amherst, NY 14226 
Phone: 716-834-0900 Ext. 7201 
E-mail: bakatsia@fstrf.org 
 
Alex Benns, BS 
Frontier Science & Technology Research  
Foundation, Inc.  
4033 Maple Road 
Amherst, NY 14226 
Phone: 716-898-7464  
E-mail: benns.alex@fstrf.org 


 
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STUDY MANAGEMENT 
 
 
All general questions concerning this protocol should be sent to actg.teamA5366@fstrf.org via 
e-mail. The appropriate team member will respond with a "cc" to actg.teamA5366@fstrf.org. A 
response should generally be received within 24 hours (Monday through Friday). 
 
Protocol E-mail Group 
Sites should contact the User Support Group at the Data Management Center (DMC) as soon 
as possible to have the relevant personnel at the site added to the actg.protA5366 e-mail group. 
Include the protocol number in the e-mail subject line.  
• 
Send an e-mail message to actg.user.support@fstrf.org.  
 
Clinical Management: 
For questions concerning entry criteria, toxicity management, concomitant medications, and co-
enrollment, contact the core protocol team.  
• 
Send an e-mail message to actg.corea5366@fstrf.org. Include the protocol number, patient 
identification number (PID), and a brief relevant history. 
 
Laboratory 
For questions specifically related to virologic laboratory tests, contact the Protocol Virologist:  
• 
Send an e-mail message to actg.teamA5366@fstrf.org (ATTENTION: Athe Tsibris). 
 
For questions specifically related to pharmacologic laboratory tests, contact the Protocol 
Pharmacologists: 
• 
Send an e-mail message to actg.teamA5366@fstrf.org (ATTENTION: Qing Ma and Gene 
Morse). 
 
For questions specifically related to immunologic laboratory tests, contact the Protocol 
Immunologist:  
• 
Send an e-mail message to actg.teamA5366@fstrf.org (ATTENTION: Scott Sieg). 
 
Data Management 
• 
For nonclinical questions about transfers, inclusion/exclusion criteria, electronic case report 
forms (eCRFs), randomization/registration, and other data management issues, contact the 
Data Manager. Completion guidelines for eCRFs and participant-completed CRFs can be 
downloaded from the FSTRF website at www.frontierscience.org. 
• 
For transfers, reference the Study Participant Transfer SOP 119, and contact Apsara Nair 
directly.  
• 
For other questions, send an e-mail message to actg.teamA5366@fstrf.org (ATTENTION: 
Apsara Nair).  
• 
Include the protocol number, PID, and a detailed question. 
 


 
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STUDY MANAGEMENT (Cont'd) 
12/8/17 
 
Randomization  
For randomization questions or problems and study identification number (SID) lists:  
• 
Send an e-mail message to rando.support@fstrf.org or call the DMC Randomization Desk at 
716-834-0900, extension 7301.  
 
DMC Portal & Medidata Rave Problems 
Contact DMC User Support 
• 
Send an e-mail message to actg.user.support@fstrf.org or call 716-834-0900 x7302. 
 
Protocol Document Questions 
For questions concerning the protocol document, contact the Clinical Trials Specialist.  
• 
Send an e-mail message to actg.teamA5366@fstrf.org (ATTENTION: Lara Hosey). 
 
Copies of the Protocol 
• 
To request a hard copy of the protocol, send an e-mail message to ACTGNCC@s-3.com 
(ATTENTION: Diane Delgado).  
• 
Electronic copies can be downloaded from the ACTG website at 
https://www.actgnetwork.org. 
 
Product Package Inserts and/or Investigator Brochures 
To request copies of product package inserts or investigator brochures, contact the DAIDS 
Regulatory Support Center (RSC) at RIC@tech-res.com or call 301-897-1708. 
 
Protocol Registration 
For protocol registration questions, send an e-mail message to Protocol@tech-res.com or call 
301-897-1707.  
 
Protocol Activation 
For questions related to protocol activation, contact the Clinical Trials Specialist or ACTG Site 
Coordination Group at actgsitecoordination@s-3.com.  
 
Study Product 
For questions or problems regarding study product, dose, supplies, records, and returns, call 
Irene Rwakazina, Protocol Pharmacist, at 301-761-7269.  
 
Study Drug Orders 
Call the Clinical Research Products Management Center (CRPMC) at 301-294-0741. 
 
Expedited Adverse Event (EAE) Reporting/Questions  
Contact DAIDS through the RSC Safety Office at DAIDSRSCSafetyOffice@tech-res.com or call 
1-800-537-9979 or 301-897-1709; or fax 1-800-275-7619 or 301-897-1710.  
 


 
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STUDY MANAGEMENT (Cont'd) 
12/8/17 
 
Telephone Calls 
Sites are responsible for documenting telephone calls made to A5366 team members.  
• 
Send an e-mail message to actg.teamA5366@fstrf.org. 
 
Protocol-Specific Web Page 
Additional information about management of the protocol can be found on the protocol-specific 
web page (PSWP). 


 
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GLOSSARY OF PROTOCOL-SPECIFIC TERMS 
 
 
CA-RNA 
cell associated HIV-1 RNA 
 
ESR-1  
estrogen receptor-1 
 
HDACi  
histone deacetylase inhibitor  
 
SERM  
selective estrogen receptor modulator 
 
shRNA  
small hairpin RNA  
 
TCR   
T cell receptor  
 


 
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SCHEMA 
 
A5366 
 
Selective Estrogen Receptor Modulators to Enhance the Efficacy of Viral Reactivation with 
Histone Deacetylase Inhibitors 
 
DESIGN 
Randomized, open-label, exploratory  study assessing the effects of 
tamoxifen exposure in combination with vorinostat compared to vorinostat 
alone on viral reactivation among HIV-1 infected post-menopausal 
women with virologic suppression on antiretroviral therapy (ART).  
 
DURATION 
65 days per participant 
 
SAMPLE SIZE 
30 participants (20 participants in Arm A, 10 participants in Arm B) 
 
POPULATION  
HIV-1-infected post-menopausal women (age 18-65) with virologic 
suppression on ART 
 
REGIMENS  
Arm A:  
Days 0-38: Tamoxifen 20 mg orally (PO) once a day (QD) 
Day 35: Vorinostat 400 mg PO x 1 
Day 38: Vorinostat 400 mg PO x 1 
Day 39-65: Observation 
 
Arm B:  
Days 0-38: Observation period (no tamoxifen) 
Day 35: Vorinostat 400 mg PO x 1 
Day 38: Vorinostat 400 mg PO x 1 
Day 39-65: Observation 
 
 
 


 
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SCHEMA (Cont’d) 
12/8/17 
 
Figure 1: Study Design 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Arm A 
Arm B 
Day 
0 
Day 
28 
Day 
35 
Day 
38 
Vorinostat 
400mg 
 
Tamoxifen  
Or Observation Period 
 
 
Observation 
Day 
65 
Screening 
  HDACi 
Vorinostat  
400mg 
 
Observation Period (No Tamoxifen) + Vorinostat 
Tamoxifen 20mg/day + Vorinostat 


 
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1.0 
HYPOTHESIS AND STUDY OBJECTIVES 
 
1.1 
Hypothesis 
 
Treatment with the selective estrogen receptor modulator (SERM) tamoxifen will 
enhance the ability of the histone deacetylase inhibitor (HDACi) vorinostat to reverse 
HIV-1 latency. In HIV-1-infected participants on antiretroviral therapy (ART), combination 
therapy with tamoxifen and vorinostat will lead to higher levels of HIV-1 cell-associated 
RNA than will vorinostat alone. 
 
1.2 
Primary Objectives 
 
1.2.1 Determine the safety and tolerability of combined therapy with the SERM 
tamoxifen and the HDACi vorinostat among HIV-infected post-menopausal 
women on ART. 
 
1.2.2 Evaluate the level of HIV-1 reactivation following treatment with vorinostat versus 
a combination of tamoxifen and vorinostat as measured by cell associated HIV-1 
RNA (CA-RNA) in CD4+ T cells (primary efficacy endpoint) among HIV-infected 
post-menopausal women on ART. 
 
1.3. 
Secondary Objectives 
 
1.3.1 Evaluate the impact of therapy with vorinostat versus a combination of tamoxifen 
and vorinostat on residual viremia, as measured by a single copy assay. 
 
1.3.2 Assess the impact of therapy with vorinostat versus a combination of tamoxifen 
and vorinostat on markers of HIV-1 persistence, as measured by total DNA 
levels. 
 
1.4. 
Exploratory Objectives 
 
1.4.1 Assess the impact of therapy with vorinostat versus a combination of tamoxifen 
and vorinostat on markers of HIV-1 persistence, including: 
1.4.1.1 Integrated HIV-1 DNA levels 
1.4.1.2 HIV p24 antigen expression by ultrasensitive assay 
1.4.1.3  Ex vivo HIV-1 RNA expression assays  
 
1.4.2 Measure levels of HIV-specific immunity and activation before and after therapy 
with vorinostat versus a combination of tamoxifen and vorinostat, including: 
1.4.2.1 HIV-1-specific immune responses 
1.4.2.2 T cell activation 
1.4.2.3 Expression of exhaustion markers on T cells 
 
1.4.3 Assess the effect of vorinostat on bulk levels of histone acetylation. 
 


 
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1.4.4 Assess pharmacokinetic interactions between vorinostat and tamoxifen. 
 
1.4.5 Assess pharmacodynamic interactions between vorinostat and tamoxifen, as 
measured by the relationship between drug levels and the degree of histone 
acetylation and HIV-1 expression. 
 
1.4.6 Assess innate cellular markers and soluble factors in relationship to treatment 
intervention arms or virologic outcome measures. 
 
2.0 
INTRODUCTION 
 
2.1 
Background 
 
A critical barrier to HIV-1 eradication is the maintenance of transcriptionally silent, 
replication competent proviruses in resting CD4+ T cells [1-3]. These proviruses, which 
cannot be detected by the immune system, comprise a reservoir with a very slow rate of 
decay [4,5] from which viremia can rebound when antiretroviral therapy is withdrawn. 
One pathway to eradication of HIV-1 requires activation of proviral transcription coupled 
with immune surveillance and elimination of residual cells harboring virus [6]. The 
potential of this approach has been highlighted by recent work delineating some of the 
mechanisms whereby HIV-1 establishes and maintains latency. 
 
Controls on HIV-1 transcription include cellular signaling machinery and epigenetic 
silencing modifications, with recent work highlighting several potential pathways for 
therapeutic interventions to release transcriptional control [7]. Clinical trials have tested 
candidate latency reversal agents, with demonstrated increases in measures of HIV-1 
RNA after treatment of study participants with the histone deacetylase inhibitors (HDACi) 
vorinostat [8,9], panobinostat [10], romidepsin [11,12], and the phosphatase and tensin 
homolog inhibitor, disulfiram [13]. However, despite the induction of HIV-1 RNA 
production, none of these agents has led to a statistically significant change in the size 
of the HIV reservoir. Further work is needed to optimize both latency reversal and 
subsequent immune clearance of the activated reservoir. 
 
Another feature of early results from HIV cure studies has been the substantial 
heterogeneity in the level of responses to reactivation agents. The sources of 
interindividual variability in response are likely multiple, but a clearer understanding of 
these factors will help target specific interventions to the populations most likely to 
benefit. One potential source of variation is the sex of the individual. Numerous studies 
have demonstrated substantial sex-based differences between men and women in terms 
of vaccine responses, autoimmunity, and the acquisition and progression of infectious 
diseases [14,15]. Women bear a significant burden of the global HIV epidemic, 
estimated at slightly more than half of worldwide infections, with a marked risk for young 
women to acquire HIV in sub-Saharan Africa (UNAIDS Global Factsheet, 2017). Despite 
this, women are underrepresented in clinical trials relevant to HIV cure [16]. As a  


 
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relevant cure strategy will need to have efficacy for both men and women, studies 
addressing key biological differences will be critical to either identify significant 
distinctions in cure strategies by sex or to rationally design cure studies to be inclusive of 
women. 
 
With this clinical trial, we seek to investigate a pathway to enhance viral reactivation in 
vivo in women, with potential implications for cure efforts in both men and women. 
 
2.2 
Rationale 
 
A5366 is designed primarily to evaluate the safety of 38 days of tamoxifen therapy 
followed by two doses of vorinostat with continued tamoxifen and the effectiveness of 
this combination on latent virus reactivation in women who are suppressed on ART in 
comparison to the effects of vorinostat alone. 
 
Rationale for study treatment regimen 
One notable barrier to efforts at eradication lies in the inefficiency of current methods of 
latency reversal. Even after maximal activation of T cells in vitro, a relatively small 
proportion of proviruses is transcribed, and notably a significant proportion of the 
noninduced proviruses retain intact genomes [17]. Agents investigated in clinical trials to 
date have significantly lower efficiency at HIV-1 induction in vivo compared to the 
maximal induction observed in vitro with T cell receptor stimulation, requiring further 
research into potential synergistic approaches to enhance reactivation with a 
combination of agents. In an unbiased, genome-wide small hairpin RNA (shRNA) 
screen, Karn et al identified the estrogen receptor-1 (ESR-1) as a cellular factor critical 
to HIV-1 latency reversal in the Jurkat cell model (Figure 2.2-1).  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 2.2-1. shRNA screen strategy that identified the ESR-1 as a critical cellular factor in latency 
reversal (left panel). Silencing of the ESR-1 with a shRNA activates transcription of HIV-1 as 
indicated by eGFP expression whereas a scrambled shRNA shows no activation. 
 


 
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These findings were validated in a primary cell model of HIV-1 latency [18], where Karn 
and colleagues demonstrated that exposure to estrogen (or stilbestrol, an estrogen 
agonist) decreased HIV-1 expression as assessed by Nef expression measured by flow 
cytometry. In contrast, treatment with an estrogen antagonist (Fulvestrant or gossypol) 
led to increased HIV-1 expression in combination with other activation stimuli (Figure 
2.2-2).  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Taken together, these data suggest that the estrogen receptor is a key cellular factor in 
modulating HIV-1 latency reversal, and, thereby, a potential therapeutic target. To probe 
the physiologic relevance of these observations, a cohort of HIV-infected women and 
men (matched on age, duration of viral supression, CD4 cell nadir and current CD4 cell 
count) with full viral suppression on ART was recruited for asessement of multiple 
metrics of HIV persistence. The women in this study had full viral suppression of at least 
a year, had active menstrual cycles, and were not on hormonal contraception or 
replacement. Leukapheresis samples from women in this cohort on fully suppressive 
ART were exposed in vitro to T cell receptor (TCR) stimulation, or latency reversal 
treatments, including IL-15 or vorinostat in combination with either estradiol or an  
Figure 2.2-2. Synergistic reactivation of HIV transcription in primary T-cells by ESR-1 
antagonists and vorinostat or IL-15. HIV transcription was assessed by flow 
cytometry using an antibody to HIV-Nef. β-estradiol and stilbestrol are able to potently 
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estrogen receptor antagonist, and HIV-1 RNA induction was subsequently assessed. 
Strikingly, estradiol potently inhibited activation of HIV-1 transcription, including TCR-
induced reactivation. Conversely, incubation with an estrogen receptor antagonist (ICI) 
enhanced the activity of vorinostat (Figure 2.2-3).  
 
The effect of combining TCR stimulation with estradiol ex vivo was significantly 
influenced by biologic sex; leukapheresis samples from men displayed a 43-fold higher 
induction of HIV RNA with exposure to TCR+estradiol compared to samples from 
women (p<0.01 by t-test). Conversely, the combination of vorinostat and the estrogen 
antagonist (ICI) had a larger induction effect among samples from women compared to 
men (fold effect 1.7, p<0.01). These ex vivo results are consistent with the cell line and 
primary cell in vitro models summarized above [14,15], suggesting an important role for 
hormonal modulation of HIV-1 activity with a likely  sensitivity to these hormonal 
pathways among female participants. 
 
 
These results have critical implications for eradication studies. First, they suggest that 
concurrent exposure to estrogen may limit the efficacy of latency reversal agents 
currently under study. Given the small size and exploratory nature of clinical trials of cure 
to date, the stark underrepresentation of women in trials relevant to cure [16], and 
variation of endogenous estrogen levels over the course of a menstrual cycle, these 
findings argue for boosting the inclusion of women in trials with careful investigation of 
their hormonal milieu. Further, these results suggest a novel biological pathway as a 
target for synergistic activation of HIV-1 transcription in combination with other latency 
reversal classes, such as HDACi. While in vitro and ex vivo studies offer significant 
support for the role of hormones in latency reversal, the complexity of the system in vivo 
Figure 2.2-3. Ex vivo induction of HIV-1 transcription in leukapheresis samples from ART-
treated women. TCR stimulated reactivation is abrogated in the presence of estradiol. 
Conversely, treatment with the estrogen antagonist ICI in combination with vorinostat 
enhanced the transcription to higher levels than seen with vorinostat alone. This effect is 
more pronounced in women than in men.  


 
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obligates further investigation. With these data, we propose to study the effects of in vivo 
combined exposure to selective estrogen receptor modulators and latency reversal 
agents via an exploratory clinical trial. 
 
Rationale for selection of study drugs 
SERMs are a well-characterized class of drugs with indications in the treatment of and 
chemoprophylaxis for breast cancer and postmenopausal osteoporosis. The effects of 
SERMs are tissue specific, and can include both agonist and antagonist activity, 
depending on the agent. These drugs have generally favorable safety profiles, with risks 
notable for venous thromboembolism, cerebrovascular events, and inducing 
menopausal symptoms [19]. Tamoxifen is a SERM with an extensive record of clinical 
use with favorable pharmacologic properties. Tamoxifen is taken orally, has a terminal 
half-life of 5 to 7 days, and reaches steady state concentrations after 4 weeks of dosing. 
In vitro testing directly supports the synergistic activity of tamoxifen in combination with 
vorinostat on transcription as shown in Figure 2.2-4, with this effect being more 
pronounced in females  (representative in the right panel) versus males  (left panel). 
Finally, the combination of the HDACi vorinostat with tamoxifen has already been tested 
among patients in a Phase II trial with refractory breast cancer and was well-tolerated 
[20]. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 2.2-4. Direct assessment of the synergy between tamoxifen and vorinostat 
confirms that in a female participant there is synergistic activation of transcription 
as measured by the EDITS assay described above. 
 
As above, multiple agents are currently under investigation for potential efficacy in 
latency reversal. Of those that have been used in clinical trials in the United States and 
internationally, vorinostat, panobinostat, and romidepsin have all shown some efficacy in 
induction of HIV RNA transcription. Panobinostat has the caveat of concerns about 
potential cardiac toxicity requiring more intensive monitoring during the period of 
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binding to estrogen receptors in vitro and showing reversible effects on testes and 
ovaries in mice [21]. To isolate the effects of tamoxifen-mediated estrogen blockade, we 
have opted to use vorinostat, with the safety of this combination already demonstrated in 
the context of breast cancer. 
 
Taken together, preliminary data suggest a role for estrogen in the control of HIV-1 
transcription in cell line models, primary cell latency models and in ex vivo models using 
leukapheresed patient samples. In vitro assays indicate that the combination of HDACi 
and SERMs enhances HIV transcription. Vorinostat and tamoxifen have demonstrated 
safety in combination in other clinical contexts. We therefore propose to evaluate the 
impact of this combination on HIV-1 transcription in vivo to hopefully define a novel 
pathway to enhance HIV-1 reactivation. 
 
Rationale for pharmacologic studies 
Tamoxifen is a SERM that is widely used for the treatment of estrogen receptor-α-
positive breast cancer. The formation of tamoxifen active metabolites, including N-
desmethyl-tamoxifen, 4-hydroxy-tamoxifen, and 4-hydroxy-N-desmethyltamoxifen 
(endoxifen), is predominantly catalyzed by CYP3A4/5 and CYP2D6 [22]. Thus, 
alterations of tamoxifen metabolism through a modulation of the CYP system may 
directly affect the efficacy and toxicity of tamoxifen. Inhibition of the CYP3A4 isoform 
with protease inhibitors, i.e., darunavir/ritonavir or cobicistat, would potentially decrease 
drug activity due to a significant decrease of active metabolite formation. The impact of 
CYP3A4 and -2D6 induction by efavirenz, however, is difficult to predict in that increased 
generation of active metabolites could result in both improved efficacy and/or worse 
adverse effects, whereas a reduction in tamoxifen efficacy might be also possible due to 
overall increased systemic clearance [23]. There are no data to confirm these theoretical 
drug interactions between tamoxifen and antiretrovirals. A significant reduction in 
tamoxifen (86%) and N-desmethyl-tamoxifen (38%) exposures by rifampicin has been 
reported in a randomized, placebo-controlled, crossover study, suggesting that the 
efficacy of tamoxifen could be compromised by concurrent use of CYP3A4 inducers [24]. 
Members of the non-nucleoside reverse transcriptase inhibitor class (NNRTIs), such as 
efavirenz and rifampin, are CYPP3A4 inducers. However, the clinical significance of 
interactions between tamoxifen and efavirenz remains unclear as efavirenz exhibits 
significantly weaker inductive effects (~3 fold) in comparison to that of rifampin (~6 fold) 
[25].  
 
The modulating effects of CYP system by tamoxifen have been reported with conflicting 
results from studies using in vitro cell systems and animal models where both induction 
and inhibition of CYP3A4 have been noted [26-28]. The current consensus is that 
tamoxifen exhibits mild CYP3A4 inductive effects based on findings from a case report 
and a clinical study with unexpected 38% lower letrozole concentrations following 6-
week combination therapy with tamoxifen [29,30]. There are no data currently available 
that document the effects of tamoxifen-mediated CYP3A4 induction on antiretrovirals. A 
recommendation on the use of alternative non-CYP3A4 dependent regimens was made 
based on the theoretical interaction that tamoxifen might decrease protease inhibitor and 
elvitegravir concentrations. This recommendation, however, does not consider the 
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combination with protease inhibitors and elvitegravir [31]. While a significant interaction 
between tamoxifen and darunavir/ritonavir or elvitegravir/cobicistat is unlikely, this 
requires confirmation by drug interaction studies. Tamoxifen is also an inhibitor of P-
glycoprotein (P-gp) and endoxifen is a substrate of P-gp [32]. No P-gp mediated 
tamoxifen drug interactions, however, have been reported to date.  
 
Vorinostat exhibits nonlinear pharmacokinetics in Phase I studies [33,34]. Cmax 
increased with dose between 100-400 mg, but not when the dose exceeded 400 mg. Its 
mean t1/2 ranged from ~2 hour (400 mg daily) to 4 hour (500 mg daily) and Cl/F 
decreased from 605 (100 mg BID) to 313 l/hour (400 mg daily). Meals containing high fat 
increase vorinostat exposure by 38% and significantly delay the absorption rate [35]. 
Vorinostat is primarily metabolized through glucuronidation mediated by UGTs including 
-1A1, -1A3, -1A7, -1A8, -1A9, -1A10, -2B7, and -2B17 [36] into inactive metabolites, O-
glucuronide and 4-anilino-4-oxobutanoic acid, whereas the cytochrome P450 system 
plays a negligible role in its metabolism [37], suggesting a low drug interaction potential 
between vorinostat and antiretrovirals. However, the inductive effects of vorinostat on 
multiple transporters including P-gp, breast cancer resistance protein, and multidrug 
resistance-associated proteins have been demonstrated in the in vitro studies, 
suggesting potential drug interactions with P-gp substrates and/or inhibitors [38,39].  
 
Rationale for selection of study participants 
This protocol focuses exclusively on women, seeking to specifically interrogate the role 
of the estrogen receptor pathway in HIV-1 latency reversal. Women represent 
approximately half of all individuals living with HIV-1 worldwide but are a minority of 
participants in clinical trials relevant to HIV-1 cure [16]. Clinical data suggests that there 
are relevant differences in virologic and immunologic measures between men and 
women and understanding how these differences may affect curative efforts is critical to 
ensure that an intervention will be likely to be efficacious in women as well as in men. 
For this initial trial, we have opted to include only postmenopausal women. The reasons 
for this are to maximize patient safety; due to concerns for potential genotoxicity of 
vorinostat, including only postmenopausal women eliminates concerns about future 
fertility. From the perspective of tamoxifen, the drug is less likely to induce menopausal 
symptoms in women who have already stopped menstruating and has a significant track 
record of use within this population. To verify the role of the estrogen receptor pathway 
in this population, we examined cryopreserved PBMCs from four postmenopausal 
women on fully suppressive ART followed as part of a longitudinal observational cohort 
(ACTG A5321). These samples were stimulated ex vivo and induction of HIV-1 RNA was 
measured using the EDITS (Envelope Detection by Induced Transcription-based 
Sequencing) assay, which measures inducible cell-associated HIV-1 RNA. The 
production of RNA is normalized to a calibration curve of known cell inputs with HIV RNA 
expression. These results demonstrated a strong susceptibility to estrogen-mediated 
repression of transcription as well as an increase in HIV-1 RNA production after a brief in 
vitro treatment with tamoxifen alone. In this set of samples, levels of HIV-1 RNA 
production induced by vorinostat were similar to levels induced by the combination of 
tamoxifen and vorinostat (Figure 2.2-5).  
 


 
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Taken together these data support continued susceptibility to estrogen and estrogen 
antagonism in the postmenopausal population, with an antagonist inducing a 
measurable increase in transcription as a single agent. Whether there will be synergy 
between tamoxifen and vorinostat in vivo will depend on the hormonal milieu and effects 
of steady state estrogen antagonism. These factors are not fully modeled in vitro where 
the system is stripped of estrogen and there is only a brief exposure to antagonists. The 
proposed study will allow interrogation of the estrogen receptor pathway in vivo while 
minimizing risks to participants and will yield data on cure interventions for a critically 
understudied segment of the HIV-1 infected population.  
 
3.0 
STUDY DESIGN 
 
This is a randomized, open-label, exploratory study among HIV-1-infected virologically 
suppressed postmenopausal women on ART to assess the effects of vorinostat versus 
tamoxifen and vorinostat on HIV-1 transcription. Participants (n=30) will be randomized 
2:1 to receive tamoxifen 20 mg daily for 38 days (Arm A) plus two doses of vorinostat 
400 mg (days 35 and 38) or to a 38-day observation period with no tamoxifen (Arm B) 
plus two doses of vorinostat 400 mg each (days 35 and 38).  
  
The lead-in phase will allow tamoxifen to reach steady-state plasma levels and provides 
the opportunity to assess the influence of this SERM on HIV-1 activity and immune 
function alone prior to administration of vorinostat. Following HDACi treatment, all 
interventions will be discontinued and observation will continue until day 65.  
0
10
20
30
40
50
Cell Equivalents (per million cells)
Unstim
Tamoxifen
1 µM
SAHA
500 nM
SAHA
+ TAM
Estradiol
300 pg/ml
+ ConA
ConA
10 µg/ml
Figure 2.2-5. Induction of HIV-1 RNA as measured by the EDITS assay in 
samples from four postmenopausal women. Results demonstrate estrogen 
mediated suppression of T cell activation induced (ConA) HIV transcription 
and an increase in HIV-1 RNA production after exposure to tamoxifen. 


 
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4.0 
SELECTION AND ENROLLMENT OF PARTICIPANTS 
 
4.1 
Inclusion Criteria 
 
4.1.1 HIV-1 infection, documented by any licensed rapid HIV test or HIV enzyme or 
chemiluminescence immunoassay (E/CIA) test kit at any time prior to study entry 
and confirmed by a licensed Western blot or a second antibody test by a method 
other than the initial rapid HIV and/or E/CIA, or by HIV-1 antigen, plasma HIV-1 
RNA viral load. 
 
NOTE: The term “licensed” refers to a US FDA-approved kit. WHO (World Health 
Organization) and CDC (Centers for Disease Control and Prevention) guidelines 
mandate that confirmation of the initial test result must use a test that is different 
from the one used for the initial assessment. A reactive initial rapid test should be 
confirmed by either another type of rapid assay or an E/CIA that is based on a 
different antigen preparation and/or different test principle (e.g., indirect versus 
competitive), or a Western blot or a plasma HIV-1 RNA viral load. 
 
4.1.2 Women between 18 and 65 years of age up until the 66th birthday at the time of 
study entry.  
 
4.1.3 Women who are postmenopausal at the time of study entry and have agreed not 
to participate in assisted reproductive technology in the future. Menopausal 
status will be verified by any one of the following: 
 
4.1.3.1 Age ≥40 years, amenorrhea ≥12 months, and FSH >40 mIU/mL with 
a negative serum or urine -HCG (urine test must have a sensitivity of 
≤25 mIU/mL) and no oral or injectable exogenous hormone use within 
12 months prior to study entry.  
 
4.1.3.2 Any woman ≥18 years of age is eligible for consideration if there is a 
documented history of surgical removal of both of the ovaries >6 months 
prior to study entry and no injectable or oral exogenous hormone 
therapy for a period of ≥12 months prior to study entry. 
 
4.1.4 CD4+ cell count >300 cells/uL obtained within 90 days prior to study entry at any 
US laboratory that has Clinical Laboratory Improvement Amendments (CLIA) 
certification or its equivalent. 
 
4.1.5 Continuous ART containing nucleoside or nucleotide reverse transcriptase 
inhibitors with a non-nucleoside reverse transcriptase inhibitor, a 
pharmacologically-boosted protease inhibitor, or an integrase inhibitor for at least 
2 years prior to enrollment with no known interruption in therapy for >7 days 
within 90 days prior to study entry. 
 


 
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NOTE: Other ART regimens may be acceptable. Sites must consult the core 
protocol team for a case-by-case basis review of ART regimens not specified 
above.  
 
NOTE: Regimens composed of three nucleoside reverse transcriptase inhibitors 
are not acceptable.  
 
NOTE: Regimen changes within the 2-year period are acceptable, but candidates 
must have been on a stable regimen for at least 30 days prior to study entry. 
 
4.1.6 At least one documented plasma HIV-1 RNA that is below the limit of detection of 
the FDA-approved assays (limit of detection: 75, 50, 40, or 20 copies/mL) 
between 13 and 24 months prior to the screening HIV-1 RNA in section 4.1.7. 
 
4.1.7 Plasma HIV-1 RNA level of <20 copies/mL obtained by the Roche TaqMan v2.0 
assay or <40 copies/mL obtained by the Abbott assay, within 90 days prior to 
study entry by any US laboratory that has CLIA certification or its equivalent. 
 
4.1.8 The following laboratory values obtained within 21 days prior to study entry by 
any US laboratory that has CLIA certification or its equivalent. 
 
• 
Absolute neutrophil count (ANC) ≥1500 neutrophils/mm3 
• 
Hemoglobin ≥11.0 g/dL 
• 
Platelet count ≥125,000 platelets/uL 
• 
Creatinine ≤1.3 x upper limit of normal (ULN) OR, if serum creatinine levels 
˃1.3 x ULN, calculated creatinine clearance (as estimated by the Cockcroft-
Gault equation) ≥50mL/min 
 
NOTE: A calculator for the Cockcroft-Gault equation is available on the DMC 
website at www.fstrf.org.  
 
• 
Aspartate aminotransferase (AST) (SGOT) ≤2 x ULN 
• 
Alanine aminotransferase (ALT) (SGPT) ≤2 x ULN 
• 
Alkaline phosphatase ≤2.5 x ULN 
• 
Total bilirubin <1.5 x ULN, OR if the total bilirubin is elevated, direct bilirubin 
will be measured and the potential participant is eligible if the direct bilirubin is 
<2 x ULN  
 
NOTE: For participants on atazanavir-based ART, if total bilirubin is >1.5 x 
ULN and there is no transaminase elevation, enrollment is acceptable if the 
indirect bilirubin (calculated value of total bilirubin minus direct bilirubin) is <3 
x ULN.  
 
4.1.9 No history of opportunistic infections within 90 days prior to study entry.  
 
4.1.10 Karnofsky performance score ≥70 within 90 days prior to study entry.  


 
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4.1.11 Weight ≥52.2 kg at time of screening. (This stipulation is because of the blood 
draw volumes involved with this trial.) 
 
4.1.12 Body Mass Index (BMI) ≤40 kg/m2 at time of screening. 
 
NOTE: A program for calculating BMI is available on the DMC website at 
www.fstrf.org.  
 
4.1.13 HCV antibody negative result within 90 days prior to study entry or, for study 
candidates who are HCV antibody positive (based on testing performed at any 
time prior to study entry), a negative HCV RNA result obtained within 90 days 
prior to study entry. 
 
4.1.14 Negative HBsAg result obtained within 90 days prior to study entry or a positive 
HBsAb result at any time prior to study entry.  
 
4.1.15 QTc interval ≤450 milliseconds within 90 days prior to study entry. 
 
NOTE: A program for calculating QTc by Fridericia’s correction is available on 
the DMC website at www.fstrf.org.  
 
4.1.16 Ability and willingness of potential participant to provide written informed consent. 
 
4.2 
Exclusion Criteria 
 
4.2.1 History of venous thromboembolism. 
 
4.2.2   History of stroke.  
 
4.2.3 Known history of hypercoagulable state including Factor V Leiden mutation, 
Protein C and S deficiency, or decompensated cirrhosis. 
 
4.2.4 Tobacco smoking or e-cigarette use within 90 days prior to study entry. 
 
NOTE: If recent cessation of smoking, must have been without cigarettes and e-
cigarettes for ≥90 days prior to study entry.  
 
4.2.5 History of any malignancy requiring systemic chemotherapy or systemic 
immunotherapy. 
 
4.2.6 History of endometrial or breast cancer or known genetic testing with BRCA 
positive results indicating an increased risk for breast and ovarian cancer.  
 
NOTE: If additional genetic testing for breast or ovarian cancer exists, study sites 
should contact the core protocol team for review.  
 
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4.2.8 History of myocardial infarction (MI) within 6 months prior to study entry, New 
York Heart Association (NYHA) class III or IV heart failure at any time prior to 
study entry, or personal or family history of prolonged QTc syndrome. 
 
4.2.9 Use of immunomodulators (e.g., interleukins, interferons, cyclosporine), HIV 
vaccine, or investigational therapy within 60 days prior to study entry.  
 
NOTE: Study candidates receiving stable physiologic glucocorticoid doses, 
defined as the equivalent of prednisone 10 mg/day or less, will not be excluded. 
Study candidates receiving inhaled or topical corticosteroids will not be excluded. 
 
4.2.10 Any systemic hormonal therapy defined as oral or injectable contraceptives, 
estrogen and combined estrogen-progesterone replacement therapy in the prior 
12 months, or a hormone containing IUD within 6 months prior to study entry.  
 
NOTE: Hormonal therapy also includes aromatase inhibitors and suppressors of 
ovarian function including gonadotropin releasing hormone (GnRH) agonists and 
luteinizing-hormone releasing hormone (LH-RH) agonists. Topical estrogen 
cream use in the prior 12 months is acceptable, but should not be used during 
the study period.  
 
4.2.11 Use of any study-prohibited medications that carry the risk of torsades de pointes 
within 60 days prior to study entry.  
 
NOTE: A list of prohibited medications is available on the protocol-specific web page 
(PSWP).  
 
4.2.12  Use of any study-prohibited medication in the HDACi class or use of any study-
prohibited medication with HDACi-like activity within 60 days prior to study entry.  
 
NOTE: A list of prohibited medications is available on the PSWP.  
 
4.2.13 Known allergy/sensitivity or any hypersensitivity to components of study drugs or 
their formulations. 
 
4.2.14 Active drug or alcohol use or dependence or psychiatric illness that, in the 
opinion of the site investigator, would interfere with adherence to study 
requirements. 
 
4.2.15 Acute or serious illness requiring systemic treatment, antibiotics, and/or 
hospitalization within 90 days prior to study entry. 
 
4.3 
Study Enrollment Procedures 
 
4.3.1 Prior to implementation of this protocol, and any subsequent full version 
amendments, each site must have the protocol and the protocol consent forms 
approved, as appropriate, by their local institutional review board (IRB)/ethics 


 
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committee (EC) and any other applicable regulatory entity (RE). Upon receiving 
final approval, sites will submit all required protocol registration documents to the 
DAIDS Protocol Registration Office (DAIDS PRO) at the Regulatory Support 
Center (RSC). The DAIDS PRO will review the submitted protocol registration 
packet to ensure that all of the required documents have been received. 
 
Site-specific informed consent forms (ICFs) WILL be reviewed and approved by 
the DAIDS PRO, and sites will receive an Initial Registration Notification from the 
DAIDS PRO that indicates successful completion of the protocol registration 
process. A copy of the Initial Registration Notification should be retained in the 
site's regulatory files. 
 
Upon receiving final IRB/EC and any other applicable RE approvals for an 
amendment, sites should implement the amendment immediately. Sites are 
required to submit an amendment registration packet to the DAIDS PRO at the 
RSC. The DAIDS PRO will review the submitted protocol registration packet to 
ensure that all required documents have been received. Site-specific ICF(s) 
WILL NOT be reviewed by the DAIDS PRO. Sites will receive an Amendment 
Registration Notification when the DAIDS PRO receives a complete registration 
packet. A copy of the Amendment Registration Notification should be retained in 
the site's regulatory files. 
 
For additional information on the protocol registration process and specific 
documents required for initial and amendment registrations, refer to the current 
version of the DAIDS Protocol Registration Manual.  
 
Once a candidate for study entry has been identified, details will be carefully 
discussed with the participant. The participant will be asked to read and sign the 
approved protocol consent form.  
 
For participants from whom a signed informed consent has been obtained, an 
ACTG Screening Checklist must be entered through the DMC Participant 
Enrollment System.  
 
4.3.2 Protocol Activation 
 
Prior to enrollment, sites must complete the Protocol Activation Checklist found 
on the ACTG Member website. This checklist must be approved prior to any 
screening evaluations.  
 
4.3.3 Randomization/Participant Registration 
 
For participants from whom informed consent has been obtained, but who are 
deemed ineligible or who do not enroll into the initial protocol step, an ACTG 
Screening Failure Results form must be completed and keyed into the database.  
Participants who meet the enrollment criteria will be registered to the study 
according to standard ACTG DMC procedures.  


 
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4.4 
Co-enrollment Guidelines  
 
• 
Sites are encouraged to co-enroll participants in A5128, “Plan for Obtaining Informed 
Consent to Use Stored Human Biological Materials (HBM) for Currently Unspecified 
Analyses.” Co-enrollment in A5128 does not require permission from the A5366 
protocol chairs. Due to blood volume restrictions, participants who elect to co-enroll 
in A5128 must defer A5128 blood draws until after all A5366 blood draws are 
completed. 
• 
Sites are encouraged to co-enroll participants in A5332, “Randomized Trial to 
Prevent Vascular Events in HIV (REPRIEVE).” Co-enrollment in A5332 does not 
require permission from the A5366 protocol chairs. A5332 participants are not 
permitted to enroll in A5366 until after they have completed their month 4 A5332 
study visit.  
• 
For specific questions and approval for co-enrollment in other studies, contact the 
core protocol team via e-mail as described in the Study Management section. 
 
5.0 
STUDY TREATMENT  
 
Study treatment is defined as vorinostat and tamoxifen, both of which are provided by the 
study.  
 
ART is required but will not be provided by the study. 
 
5.1 
Regimens 
 
At entry, participants will be randomized (2:1) in open-label fashion to Arm A or Arm B: 
 
 
5.2 
Administration 
 
Tamoxifen tablets should be swallowed whole, with water or another non-alcoholic drink. 
Tamoxifen can be taken with or without food. Tamoxifen should be taken consistently at 
approximately the same time of day, preferably in the morning. Participants in Arm A 
should complete all 38 days of tamoxifen. Sites should contact the core protocol team for 
guidance if participants have missed any doses of tamoxifen.  
 
Vorinostat will be administered by clinic staff on days 35 and 38 in both Arms A and B 
along with a snack provided by the clinic. Vorinostat dosing must occur between 8:00 
AM and 1:00 PM, local time. On day 35, all evaluations, including blood draws, must be 
done prior to administration of vorinostat. On day 38, the first blood draw for 
pharmacokinetic studies must be done prior to administration of vorinostat. 
 
Days 0-38 
Day 35 
Day 38 
Arm A 
Tamoxifen  
20 mg PO daily 
Vorinostat  
400 mg PO x 1 
Vorinostat  
400 mg PO x 1 
Arm B 
-------- 
Vorinostat  
400 mg PO x 1 
Vorinostat  
400 mg PO x 1 


 
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All vorinostat capsules (4 capsules) should be taken together as one dose on each day 
of administration. Vorinostat capsules should be swallowed whole, with water or another 
non-alcoholic drink. Vorinostat should be taken with food.  
 
5.3 
Study Product Formulation  
 
Vorinostat is available as 100 mg capsules. The capsules are white, opaque hard gelatin 
capsules. The product should be stored at room temperature between 20–25°C (68–
77°F), away from moisture and out of direct sunlight. Temperature excursions are 
permitted between 15–30°C (59–86°F). The capsules should not be opened or crushed. 
Caution should be exercised in handling vorinostat; the use of gloves is recommended. 
Direct contact of the powder in vorinostat capsules with the skin or mucous membranes 
should be avoided. If such contact occurs, wash thoroughly. The container should be 
kept tightly closed, retaining the silica gel desiccant in the bottle.  
 
Tamoxifen is available as 20 mg tablets. The product should be stored at room 
temperature between 20–25°C (68–77°F). Dispense in a well-closed, light-resistant 
container. 
 
5.4 
Pharmacy: Product Supply, Distribution, and Accountability 
 
5.4.1 Study Product Acquisition/Distribution 
 
Vorinostat and tamoxifen will be made available to sites through the NIAID 
Clinical Research Products Management Center (CRPMC). Upon successful 
completion of protocol registration procedures, the products may be obtained by 
the site pharmacist by following instructions provided in the manual Pharmacy 
Guidelines and Instructions for DAIDS Clinical Trials Networks.  
  
5.4.2 Study Product Accountability 
 
The site pharmacist is required to maintain complete records of all study products 
received from the NIAID CRPMC and subsequently dispensed. All study 
products must be stored in the pharmacy.  
 
5.4.3 Final Disposition of Study Product 
 
All unused study products remaining at US clinical research sites after the study 
is completed or terminated must be returned to the NIAID CRPMC (unless 
otherwise directed by the sponsor). Study products may also be returned to the 
CRPMC for other reasons, as requested by the sponsor. Site pharmacists will 
follow the relevant instructions for return of unused study products provided in 
the manual Pharmacy Guidelines and Instructions for DAIDS Clinical Trials 
Networks. 
  


 
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5.5 
Concomitant Medications 
 
Whenever a concomitant medication or study agent is initiated or a dose changed, 
investigators must review the concomitant medication’s and study agent’s most recent 
package insert, Investigator’s Brochure, or updated information from DAIDS to obtain the 
most current information on drug interactions, contraindications, and precautions. 
Additional drug information may be found on the ACTG Precautionary and Prohibited 
Medications Database located at http://tprc.pharm.buffalo.edu/home/di_search/. 
 
5.5.1 Required Medications 
 
Suppressive ART as specified in section 4.1.5. 
 
5.5.2 Prohibited Medications 
 
A list of prohibited medications is available on the PSWP.  
 
5.5.3 Precautionary Medications 
 
A list of precautionary medications is available on the PSWP.  


 
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6.0 
CLINICAL AND LABORATORY EVALUATIONS 
 
6.1 
Schedule of Evaluations (SOE) 
Evaluation 
Screen 
Pre-
Entry 
Entry 
Post-Entry Evaluations 
Confirmation of 
Virologic Failure  
Premature  
Study/Treatment 
Discontinuation  
Week 4 
Week 5 
Week 6 
Week 7 
Week 9 
Day 
28 
Day  
35 
Day  
38 
Day 
45 
Day 
65 
 
Hour 0 
Hour 0.5 
Hour 0 
Hour 0.5 
Hour 5.5 
 
 
Documentation of HIV-1 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
Medication History 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
Complete Physical Exam 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
Targeted Physical Exam 
 
X 
X 
X 
 
 
X 
 
X 
X 
X 
X 
X 
Clinical Assessments 
 
X 
X 
X 
X 
 
X 
 
 
X 
X 
X 
X 
ECG 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Hematology 
X 
X 
 
X 
 
 
 
 
 
X 
 
X 
X 
Liver Function Tests 
X 
X 
 
X 
 
 
 
 
 
X 
 
X 
X 
Blood Chemistries 
X 
X 
 
X 
 
 
 
 
 
X 
 
X 
X 
Calculated CrCl 
X 
X 
 
X 
 
 
 
 
 
X 
 
X 
X 
Pregnancy Test 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Hormone Testing (FSH) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Hepatitis Screen 
X 
 
 
 
 
 
 
 
 
 
 
 
 
CD4+/CD8+ Count 
X 
 
 
X 
 
 
 
 
 
X 
 
X 
X 


 
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Evaluation 
Screen 
Pre-
Entry 
Entry 
Post-Entry Evaluations 
Confirmation of 
Virologic Failure  
Premature  
Study/Treatment 
Discontinuation  
Week 4 
Week 5 
Week 6 
Week 7 
Week 9 
Day 
28 
Day  
35 
Day  
38 
Day 
45 
Day 
65 
 
Hour 0 
Hour 0.5 
Hour 0 
Hour 0.5 
Hour 5.5 
 
 
Plasma HIV-1 RNA  
(Real Time) 
X 
 
X 
 
X 
 
 
 
 
 
 
 
X 
Plasma HIV-1 RNA 
(Expedited) 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
Vorinostat Dose 
 
 
 
 
 
X 
 
X 
 
 
 
 
 
Stored Plasma for Hormone 
Testing 
(Estradiol and Progesterone) 
 
 
X 
X 
 
 
 
 
X 
X 
X 
X 
X 
Stored Plasma for HIV-1 
RNA Single Copy Assay 
 
X 
X 
X 
X 
 
 
 
X 
X 
X 
 
X 
Stored PBMCs for Histone 
Acetylation  
 
 
 
X 
 
 
 
 
X 
 
 
 
 
Stored Plasma & PBMCs for 
Immunology Assays 
 
 
X 
X 
 
 
 
 
 
X 
X 
X 
X 
Stored Plasma & PBMCs for 
Virology Assays 
 
X 
X 
X 
X 
 
 
 
X 
X 
X 
X 
X 
PK Samples: ARVs 
 
 
X 
 
X 
 
X 
 
 
 
X 
X 
X 
PK Samples: Tamoxifen 
(Arm A) 
 
 
 
 
X 
 
X 
 
 
 
X 
X 
X 
PK Samples: Vorinostat 
 
 
 
 
 
 
X 
 
X 
 
 
X 
X 
Adherence Assessment 
 
X 
X 
X 
X 
 
X 
 
 
X 
X 
X 
X 
Questionnaire 
 
 
X 
 
 
 
 
 
 
 
X 
 
 


 
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6.2 
Timing of Evaluations 
 
6.2.1 Screening and Pre-Entry Evaluations  
 
Screening and pre-entry evaluations must occur prior to the participant starting 
any study medications, treatments, or interventions. 
 
Screening 
Screening evaluations to determine eligibility must be completed between 90-50 
days prior to study entry unless otherwise specified. 
 
In addition to data being collected on participants who enroll into the study, 
demographic, clinical, and laboratory data on screening failures will be captured 
on a Screening Failure Results eCRF and entered into the ACTG database.  
 
Due to blood volume restrictions, candidates who fail screening must wait a 
minimum of 60 days before being rescreened. 
 
Pre-Entry  
Pre-entry evaluations must be completed between 21 and 14 days prior to entry 
and at least 29 days after screening evaluations have been completed. 
 
Pre-entry laboratory values must be obtained and reviewed prior to initiating 
tamoxifen. 
 
6.2.2 Entry Evaluations 
 
Entry evaluations must occur at least 14 days after pre-entry evaluations unless 
otherwise specified. Participants in Arm A must begin study treatment within 3 
days after randomization. 
 
6.2.3 Post-Entry Evaluations 
 
For Arm A, all post-entry evaluations occur in reference to the date on which the 
participant starts study treatment. For example, day 28 evaluations occur 28 
days after the date participant started study treatment. 
 
For Arm B, post-entry evaluations occur in reference to the date of study entry. 
 
On-Treatment Evaluations  
The day 28 visit must occur 28 days ±3 days after entry or initiation of tamoxifen, 
if the latter is delayed. 
 
The window for the day 35 visit is -3 and +2 days. 
 
The window for the day 38 visit is -2 and +3 days. 
 


 
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The day 35 visit cannot overlap with the day 38 visit. 
 
Post-Treatment Evaluations  
The day 45 and day 65 visits have a window of ±3 days for each visit. 
 
Study Completion Evaluations  
The day 65 evaluations will serve as the study completion evaluations unless a 
participant experiences an adverse event, in which case monitoring will be as 
described in section 8. 
 
Confirmation of Virologic Failure 
If the day 28 expedited HIV-1 RNA level is ≥200 copies/mL, the participant 
should be contacted immediately upon the site’s receipt of the HIV-1 RNA result 
and asked to return for a confirmatory visit for repeat expedited HIV-1 RNA as 
soon as possible, optimally within 72 hours of the site’s receipt of the original 
result. Tamoxifen should be continued during the time that confirmation is being 
obtained for participants in Arm A. Participants should not proceed to vorinostat 
dosing while awaiting HIV-1 RNA confirmation.  
 
PK samples for vorinostat will not be collected at this confirmatory visit unless the 
visit occurs between day 35 and 38. PK samples for ARVs and tamoxifen (Arm 
A) will be collected at this study visit. 
 
If the HIV-1 RNA is confirmed to be ≥200 copies/mL, the participant should not 
proceed to vorinostat dosing. These participants will have premature study 
treatment discontinuation evaluations performed as noted on the SOE and 
described below. These participants will remain on study, off study treatment and 
have all evaluations performed per the SOE.  
 
6.2.4 Discontinuation Evaluations 
 
Evaluations for Randomized Participants Who Do Not Start Study Treatment 
All eCRFs must be keyed for the period up to and including the entry visit. 
 
Premature Treatment Discontinuation Evaluations  
Participants who prematurely permanently discontinue study treatment will have 
premature study treatment discontinuation evaluations performed as noted on 
the SOE. These participants will remain on study, off study treatment and have 
all evaluations performed per the SOE.  
 
PK samples for vorinostat will not be collected at this visit unless the visit occurs 
between day 35 and 38. PK samples for ARVs and tamoxifen (Arm A) will be 
collected at this study visit. 
 
Site personnel should notify the core protocol team within 72 hours of any 
participant who prematurely discontinues study treatment. 
 


 
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Premature Study Discontinuation Evaluations  
Participants who prematurely discontinue from the study will have premature 
study discontinuation evaluations performed as noted on the SOE. 
 
Site personnel should notify the core protocol team within 72 hours of any 
participant who prematurely discontinues the study. 
 
6.3 
Instructions for Evaluations 
 
All clinical and laboratory information required by this protocol is to be present in the 
source documents. Sites must refer to the Source Document Guidelines on the DAIDS 
website for information about what must be included in the source document:  
https://www.niaid.nih.gov/sites/default/files/sourcedocappndx.pdf. 
 
All stated evaluations are to be recorded on an eCRF unless otherwise specified. Refer 
to section 7.0 for information on the DAIDS AE Grading Table and requirements for 
reporting AEs. 
 
6.3.1 Documentation of HIV-1 
 
Section 4.1.1 specifies assay requirements for HIV-1 documentation. HIV-1 
documentation is not recorded on an eCRF. 
 
6.3.2 Medical History 
 
The medical history must include all signs and symptoms regardless of grade 
within the past 30 days and all diagnoses identified by the ACTG criteria for 
clinical events and other diagnoses regardless of grade within the past 30 days. 
Diagnoses, signs & symptoms, and medical history must be recorded on eCRFs 
and keyed within two business days.  
 
In addition, the following diagnoses must be recorded regardless of when the 
diagnosis was made: 
• 
AIDS-defining conditions 
• 
Bone fractures (verbal history accepted) 
• 
Coronary heart disease 
• 
Cancer (exclusive of basal/squamous cell skin cancer) 
• 
Diabetes 
• 
Tuberculosis 
• 
Chronic Hepatitis C 
• 
Chronic Hepatitis B 
• 
Pregnancy 
• 
Document the pre-ART HIV-1 RNA level and nadir CD4 count, if available (if 
nadir CD4 count or pre-ART HIV-1 RNA documentation is not available, then 
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• 
Record the date of the first undetectable HIV-1 RNA level prior to sustained 
viral load suppression (may be estimated if exact date not available) 
• 
Record date(s) of any previous virologic failure on ART (if known) as 
determined by the investigator 
• 
If recent cessation of smoking, record date of cessation  
• 
Document any allergies to any medications and their formulations 
 
6.3.3 Medication History 
 
A medication history must be present, including start and stop dates.  
 
Table 6.3.3-1: Required Medication History 
 
 
*Includes: hormone-releasing IUDs (e.g., Mirena inserted in the last 5 years); 
oral, injectable, implanted, or patch contraceptives; vaginal ring, creams, or 
inserts; estrogen, progesterone, or testosterone therapy; leuprolide or other 
synthetic gonadotropin-releasing hormone; tamoxifen, raloxifene, aromatase 
inhibitors or any other androgen, estrogen, or progesterone analogue or 
antagonist therapy.  
 
6.3.4 Complete Physical Examination 
 
A complete physical examination must include, at a minimum, an examination of 
the skin, head, mouth, and neck; auscultation of the chest; cardiac examination; 
abdominal examination; examination of the lower extremities for edema; 
calculation of a Karnofsky performance score; signs and symptoms; diagnoses; 
height (cm); weight (kg); temperature; pulse; respiration rate; and blood pressure. 
 
6.3.5 Targeted Physical Examination 
 
A targeted physical examination must include, at a minimum, vital signs (height, 
weight, temperature, pulse, respiration rate, and blood pressure). The exam will 
be driven by any previously identified or new signs or symptoms and diagnoses 
that the participant has experienced since the last visit or at this visit. 
 
Medication Category 
Complete History or Timeframe 
Antiretroviral therapy 
Complete history 
Immune-based therapy 
Complete history 
Blinded study treatment 
Complete history 
HIV-1-related vaccines 
Complete history 
Prescription drugs  
Within 60 days prior to entry 
Sex-hormone medications or sex-
hormone analogues or antagonists* 
Last 12 months except as noted below 
Potassium and magnesium supplements 
Within 21 days prior to entry 


 
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Refer to section 7.2, Adverse Event Collection Requirements, for AE reporting 
requirements.  
 
6.3.6 Clinical Assessments 
 
Concomitant Medications 
Post-entry, record all new or discontinued medications, including potassium and 
magnesium supplements, since last visit. 
 
Antiretroviral Treatment Modifications 
Post entry, all modifications to the participant’s ARV regimen, including any ARV 
interruptions (there is no minimum number of days of interruption needed for 
report), dose modifications, formulation modifications, starts, and permanent 
discontinuations since the last study visit or at the study visit must be recorded 
on eCRFs and keyed within two business days.  
 
Study Treatment Modifications 
Post entry, record all study treatment modifications, including initial doses, 
participant-initiated and/or protocol-mandated modifications, and inadvertent and 
deliberate interruptions of more than one day since the last study visit. Record 
any permanent discontinuation of study treatment on eCRFs and key within two 
business days. 
 
6.3.7 ECG 
 
For the ECG done at screening, the QTc interval must be signed off by the site 
investigator prior to treatment with vorinostat and should ideally be taken from 
limb lead II. ECG results do not need to be recorded on an eCRF. 
 
NOTE: A program for calculating QTc by Fridericia’s correction is available on 
the DMC website at www.fstrf.org.  
 
6.3.8 Laboratory Evaluations 
 
At screening, pre-entry, and entry, all laboratory values and toxicities must be 
recorded on eCRFs and keyed at entry. For post-entry assessments, record all 
Grade ≥2 laboratory values and key within 2 business days. Refer to section 7.2 
for AE reporting requirements for abnormal laboratory findings. 
 
Hematology 
Hemoglobin, hematocrit, red blood cells [RBC], mean corpuscular volume [MCV], 
white blood cell count [WBC], differential WBC, absolute neutrophil count (ANC), 
and platelets.  
 
Liver Function Tests 
Total bilirubin, AST [SGOT], ALT [SGPT], alkaline phosphatase, and direct and 
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Blood Chemistries 
Electrolytes [sodium, potassium, chloride, phosphate, bicarbonate], magnesium, 
calcium, creatinine, and blood urea nitrogen (BUN). 
 
Blood potassium and magnesium values on day 28 must be within the site’s 
laboratory’s normal limits. If the potassium and/or magnesium value on day 28 is 
below the lab's limit of normal, the participant should be supplemented as 
medically indicated and retested as soon as possible. If the potassium or 
magnesium level is above the lab’s limit of normal, the participant should be 
encouraged to increase his or her oral hydration and should be then retested as 
soon as possible. The repeated potassium and/or magnesium values must be 
within range for the lab’s limit of normal for the administration of vorinostat to take 
place on days 35 and 38. If the potassium and magnesium levels are still out of 
range after retest, vorinostat should not be given and the site should consult with 
the core protocol team. 
 
Calculated Creatinine Clearance 
Calculated creatinine clearance estimated by the Cockcroft-Gault equation will be 
evaluated.  
 
NOTE: A calculator for the Cockcroft-Gault equation is available on the DMC 
website at www.fstrf.org.  
 
Pregnancy Test 
Serum or urine -HCG (urine test must have a sensitivity of ≤25 mIU/mL).  
 
Hormone Testing: Follicular Stimulating Hormone 
Levels of follicular stimulating hormone (FSH) will be measured as indicated on 
the SOE. Results will not be recorded on eCRFs. 
 
Hepatitis Screen 
HBsAg and HCV antibody testing will be done per the SOE. HCV RNA testing is 
required if HCV antibody positive. Results will not be recorded on eCRFs. 
 
6.3.9 CD4+/CD8+ 
 
Obtain absolute CD4+/CD8+ count and percentages at screening from a 
laboratory that possesses CLIA certification or equivalent.  
 
Post entry, absolute CD4+/CD8+ counts should be obtained again as per the 
SOE. 
 
For entry and post-entry evaluations, all laboratories must possess a CLIA 
certification or equivalent and must be certified for protocol testing by the DAIDS 
Immunology Quality Assurance (IQA) Program. 
 


 
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6.3.10 Plasma HIV-1 RNA (Real-Time)  
 
Screening HIV-1 RNA (real-time) by standard ultrasensitive assay must be 
obtained within 90 days prior to study entry. Eligibility will be determined based 
on the screening value. 
 
All post-screening HIV-1 RNA quantification assays will be performed using the 
Roche Taqman V2.0 assay. Samples will be sent real time per the SOE to the 
protocol-designated laboratory. 
 
6.3.11 Plasma HIV-1 RNA (Expedited) 
 
Samples for day 28 HIV-1 RNA quantification and confirmation of virologic failure 
must be processed and shipped overnight. See LPC for shipping instructions. 
 
6.3.12 Vorinostat Dosing 
 
If day 28 liver function tests are elevated (Grade ≥3), the site must consult with 
the core protocol team before dosing vorinostat on day 35.  
 
If tamoxifen is withheld/discontinued prior to day 35, vorinostat should not be 
administered on day 35 or day 38.  
 
On day 35, all evaluations, including blood draws, must be done prior to 
administration of vorinostat. Vorinostat dosing times on the SOE (hour 0.5) are 
provided as a guide to ensure that all required evaluations are completed prior to 
administration of vorinostat. 
 
On day 38, the first blood draw for pharmacokinetic studies must be done prior to 
administration of vorinostat. Vorinostat dosing times on the SOE (hour 0.5) are 
provided as a guide to ensure that all required evaluations are completed prior to 
administration of vorinostat.  
 
On day 38, the second blood draw must be done 5 hours after administration of 
vorinostat. 
 
Dehydration often occurs with administration of vorinostat. Participants should be 
instructed to drink at least 1 liter of water (32 ounces or 4 cups) on the days 
when vorinostat is administered.  
 
6.3.13 Stored Plasma for Hormone Testing: Estradiol and Progesterone 
 
Levels of estradiol and progesterone will be measured as indicated on the SOE. 
 


 
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6.3.14 Stored Plasma for HIV-1 RNA Single Copy Assay (SCA) 
 
HIV-1 RNA by SCA will be measured in plasma obtained per the SOE.  
 
6.3.15 Stored PBMCs for Histone Acetylation 
 
Histone acetylation assay will be performed in total CD4+ cells isolated from 
PBMCs.  
 
6.3.16 Stored Plasma & PBMCs for Immunology and Virology Assays 
 
Plasma and PBMCs will be obtained per the SOE for immunology and virology 
assays. Refer to the LPC for details of collection, processing, and shipping. 
 
Cell-Associated Total HIV-1 DNA and CA-RNA  
Cell-associated total HIV-1 RNA and HIV-1 DNA (total and integrated) will be 
measured in CD4+ T cells from PBMCs.  
 
CD4+ T Cells for Inducible HIV-1 RNA Expression (EDITS) 
Inducible HIV-1 expression will be measured from PBMCs.  
 
T Cell Phenotyping 
PBMCs will be collected for immunologic studies, T cell subset frequencies, and 
markers of T cell activation, proliferation, and exhaustion.  
 
HIV-Specific T Cell Responses 
PBMCs will be collected for studies of HIV-specific T cell responses. PBMCs will 
be used to assess CD4+ and CD8+ T cells responses to HIV antigen. 
 
CD4+ T Cells for Ultrasensitive p24 Antigen Quantification 
Intracellular HIV-1 p24 antigen levels will be measured from PBMCs.  
 
6.3.17 Pharmacokinetic Samples: ARVs, Tamoxifen (Arm A), and Vorinostat 
 
PK samples as outlined in section 11.0 will be collected at the time points 
indicated on the SOE. Specific blood volume requirements for these time points 
are as per the LPC. 
 
6.3.18 Adherence Assessment  
 
Adherence to tamoxifen and antiretroviral therapy will be assessed by self-report 
at the intervals indicated on the SOE. 
 
6.3.19 Questionnaire 
 
A questionnaire regarding study participation, HIV cure research, and prior 
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will not be recorded on an eCRF; it will be completed by the participant online. 
Links to the survey and instructions can be found on the PSWP. 
 
7.0 
ADVERSE EVENTS AND STUDY MONITORING 
 
7.1 
Definition of Adverse Events 
 
An adverse event (AE) is any unfavorable and unintended sign (including an abnormal 
laboratory finding), symptom, or diagnosis that occurs in a study participant during the 
conduct of the study REGARDLESS of the attribution (i.e., relationship of event to 
medical treatment/study product/device or procedure/intervention). This includes any 
occurrence that is new in onset or aggravated in severity or frequency from the baseline 
condition.  
 
7.2 
Adverse Event Collection Requirements 
 
All AEs must be reported on eCRFs and keyed within two business days if any of the 
following criteria have been met: 
• 
All grade ≥3 AEs 
• 
All AEs that led to a change in study treatment regardless of grade 
• 
All AEs meeting SAE definition or EAE reporting requirement 
 
NOTE: SAEs or events meeting EAE reporting requirements should also be entered into 
the DAIDS Adverse Experience Reporting System (DAERS), an Internet-based reporting 
system. 
 
All AEs that are reported must have their severity graded. To grade AEs, sites must refer 
to the Division of AIDS Table for Grading the Severity of Adult and Pediatric Adverse 
Events (DAIDS AE Grading Table), corrected Version 2.1, July 2017, which can be 
found on the DAIDS RSC website at http://rsc.tech-res.com/clinical-research-
sites/safety-reporting/daids-grading-tables. 
 
Serious Adverse Events (SAEs) 
An SAE is defined as any untoward medical occurrence that: 
 
 
• 
Results in death 
• 
Is life-threatening  
• 
Requires inpatient hospitalization or prolongation of existing hospitalization 
• 
Results in persistent or significant disability/incapacity  
• 
Is a congenital anomaly/birth defect 
• 
Is an important medical event that may not be immediately life-threatening or result 
in death or hospitalization but may jeopardize the patient or may require intervention 
to prevent one of the other outcomes listed in the definition above) 
 


 
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7.3 
Expedited Adverse Event (EAE) Reporting to DAIDS 
 
7.3.1 Expedited Reporting of Adverse Events to DAIDS 
 
Requirements, definitions and methods for expedited reporting of Adverse 
Events (AEs) are outlined in Version 2.0 of the DAIDS EAE Manual, which is 
available on the RSC website at http://rsc.tech-res.com/clinical-research-
sites/safety-reporting/manual. 
 
The DAIDS Adverse Experience Reporting System (DAERS), an internet-based 
reporting system, must be used for EAE reporting to DAIDS. In the event of 
system outages or technical difficulties, EAEs may be submitted using the DAIDS 
EAE Form. This form is available on the DAIDS RSC website at http://rsc.tech-
res.com/clinical-research-sites/safety-reporting/daids/paper-eae-reporting. 
 
For questions about DAERS, please contact NIAID CRMS Support at 
CRMSSupport@niaid.nih.gov. Please note that site queries may also be sent 
from within the DAERS application itself. 
 
For questions about expedited reporting, please contact the DAIDS RSC Safety 
Office at (DAIDSRSCSafetyOffice@tech-res.com). 
 
7.3.2 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 agents for which expedited reporting are required are tamoxifen 
and vorinostat.  
• 
In addition to the EAE Reporting Category identified above, other AEs that 
must be reported in an expedited manner are:  
o All thromboembolic events 
o All cardiac events requiring hospitalization 
o Grade ≥2 platelet count 
o Grade ≥2 hemoglobin 
o Vaginal bleeding events (see section 8.2) 
o Grade ≥2 nausea that is unresponsive to antiemetic therapy 
o Marked changes in glucose control defined as a change of ≥2 grades that 
is not attributable to changes in diabetes treatment regimen or adherence 
to diabetes treatment regimen 
o Any event requiring a change in study treatment 
o Any bone fractures 
o Any incident cancers 
o Fetal losses 
o Serious immune reconstitution inflammatory syndrome (IRIS) events 
 


 
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7.3.3 Grading Severity of Events 
 
The Division of AIDS Table for Grading the Severity of Adult and Pediatric 
Adverse Events (DAIDS AE Grading Table), corrected Version 2.1, July 2017, 
must be used and is available on the DAIDS RSC website at http://rsc.tech-
res.com/clinical-research-sites/safety-reporting/daids-grading-tables. 
 
7.3.4 Expedited AE Reporting Period 
 
• 
The expedited AE reporting period for this study is for the duration of the 
protocol.  
• 
After the protocol-defined AE reporting period, unless otherwise noted, only 
suspected, unexpected serious adverse reactions (SUSARs), as defined in 
Version 2.0 of the EAE Manual, will be reported to DAIDS if the study staff 
become aware of the events on a passive basis (from publicly available 
information). 
• 
Overdoses of vorinostat, should the study team be aware of them, do not 
require expedited reporting, but will be reported to Merck every three months 
by the Statistical and Data Analysis Center (SDAC)/DMC. Overdoses of 
vorinostat should be recorded on the CRF and keyed in the database in a 
timely manner.  
 
7.4 
Study Monitoring 
 
The core protocol team will monitor the conduct of the study via regular summaries 
pooled over treatment arms of accrual, baseline characteristics, data completeness, and 
specimen collection. The core protocol team will review individual participant-level safety 
data frequently to assess the relation of all reported AEs to study treatment; core team 
review of AEs will be unblinded to study treatment arm. In addition, the core team will 
regularly review by-arm summaries of premature study discontinuations and premature 
study treatment discontinuations (and reasons), AEs, any missed vorinostat doses, and 
any reported interruptions or changes in ART and HIV-1 RNA levels ≥200 copies/mL 
(see section 6.2.3). Any interruptions in tamoxifen will also be summarized and reviewed 
by the core team. 
 
The DAIDS clinical representative will review and assess EAE reports for potential 
impact on the study participant safety and protocol conduct as per DAIDS policies, 
guidance documents, and SOPs, as applicable.  
 
The study will undergo interim review at least annually by an independent ACTG-
appointed Study Monitoring Committee (SMC). The SMC will review accrual, baseline 
characteristics, conduct of the study (including premature study discontinuations, 
premature study treatment discontinuations and any reported interruptions or changes in 
ART), AEs by study treatment arm (including core protocol team assessment of 
relationship to study treatment), CD4+ T-cell counts and HIV-1 RNA levels/suppression 
over time by study treatment arm, and completeness of follow-up and sample 
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monitored. The first interim review by the SMC will occur approximately 6 months after 
the enrollment of the first study participant or, if earlier, after 10 participants have 
enrolled and initiated study treatment. Regarding review of study implementation in 
terms of accrual, if the study has not enrolled 50% of the target sample size within 12 
months after the first participant is enrolled (i.e., enrollment of n=15 within 12 months), 
this will trigger a review of the protocol by the team leadership along with SMC. This 
review will focus on barriers to enrollment and steps that the team and the ACTG can 
take to increase the pace of enrollment. Potential steps include changes to the protocol 
design, in particular the study eligibility criteria. If the study is not able to accrue the 
target population and sample size, consideration will be given to possible study 
termination for futility. This discussion will also include members of the Cure TSG 
leadership. An interim review may also be convened if a concern is identified by the 
DAIDS clinical representative, the study chairs, or study statisticians in consultation with 
the team. See also section 10.5 for statistical considerations related to interim 
monitoring. 
 
Detailed plans for study monitoring will be outlined in a Study Monitoring Plan developed 
by the Statistical and Data Management Center (SDMC) prior to enrollment of the first 
participant. 
 
8.0 
CLINICAL MANAGEMENT ISSUES 
 
8.1 
Toxicity  
 
 
Only toxicities related to study medications provided through the study will be considered 
in the toxicity management section.  
 
The general guidelines presented in section 8.1 apply to toxicities that are not 
specifically addressed in section 8.2. 
 
Grade 1 or 2 
Participants who develop Grade 1 or 2 AE or toxicity felt to be related to study drug may 
continue study treatment at the discretion of the site investigator with close follow-up. If a 
participant chooses to discontinue study treatment, the site should notify the core 
protocol team within 72 hours. Participants will have premature study treatment 
discontinuation evaluations performed as noted on the SOE. These participants will 
remain on study, off study treatment and have all evaluations performed per the SOE.  
 
Grade 1 or 2 symptoms including menopausal symptoms such as hot flashes, vaginal 
dryness, and flushing will not obligate study treatment discontinuation. Similarly, nausea, 
vomiting, and diarrhea responsive to supportive measures such as antiemetics will not 
obligate study treatment discontinuation.  
 
Grade 3  
• 
Participants who develop a Grade 3 AE or toxicity thought by the site investigator to 
be related to study drug should have study drug withheld and the site should consult 
with the core protocol team. The participant should be reevaluated weekly until the 


 
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AE returns to Grade ≤2, at which time study drug may be reintroduced at the 
discretion of the site investigator in consultation with the core protocol team.  
• 
If the same Grade 3 AE recurs within 4 weeks after reintroduction of tamoxifen, study 
drug must be permanently discontinued if the site investigator considers the AE 
related to study drug and the site should notify the core protocol team within 72 
hours. However, if the same Grade 3 AE recurs after 4 weeks, the management 
scheme outlined above may be repeated. 
• 
Participants experiencing Grade 3 AEs requiring permanent discontinuation of study 
drug should be followed weekly until resolution of the AE. Participants will have 
premature study treatment discontinuation evaluations performed as noted on the 
SOE. These participants will remain on study, off study treatment and have all 
evaluations performed per the SOE.  
  
Grade 4 
• 
Participants with Grade 4 asymptomatic laboratory abnormalities may continue study 
drug if the site investigator has compelling evidence that the toxicity is NOT related 
to study drug.  
• 
Participants who develop a Grade 4 symptomatic AE or toxicity will have study drug 
permanently discontinued and the site should notify the core protocol team within 72 
hours.  
• 
Participants experiencing Grade 4 AEs requiring permanent discontinuation of study 
drug should be followed weekly until resolution of the AE or return to baseline. 
Participants will have premature study treatment discontinuation evaluations 
performed as noted on the SOE. These participants will remain on study, off study 
treatment and have all evaluations performed per the SOE.  
 
8.2 
Specific Management of Toxicities Related to Study-Provided Drugs 
 
Virologic Failure 
If the day 28 real-time HIV-1 RNA level is ≥200 copies/mL, the participant should be 
contacted immediately upon the site’s receipt of the HIV-1 RNA result and asked to 
return for a confirmatory visit as soon as possible, optimally within 72 hours of the 
original result. Tamoxifen should be continued during the time that confirmation is being 
obtained for participants in Arm A. Participants should not proceed to vorinostat dosing 
while awaiting HIV-1 RNA confirmation.  
 
If the HIV-1 RNA is confirmed to be ≥200 copies/mL (virologic failure), the participant 
should not proceed to vorinostat dosing. The site should notify the core protocol team 
within 72 hours.  
 
Participants will have premature study treatment discontinuation evaluations performed 
as noted on the SOE. These participants will remain on study, off study treatment and 
have all evaluations performed per the SOE.  
 


 
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Vaginal Bleeding 
Participants should be instructed to report vaginal bleeding. If a participant develops 
vaginal bleeding, the site should consult with the core protocol team, which may 
recommend tamoxifen discontinuation, an endometrial ultrasound, a gynecological 
evaluation, deferral of subsequent vorinostat administration, and/or another course of 
action. 
 
Diarrhea/Nausea/Vomiting 
Participants are permitted to receive supportive care measures as considered 
appropriate by the site investigator including: 
• 
Diarrhea: Diarrhea should be treated promptly with appropriate supportive care per 
guidelines. Supportive care should begin at the first sign of poorly formed or loose 
stool, occurrence of more bowel movements than usual in one day, or unusually high 
volume of stool. Supportive care should be deferred, and evaluation per standard 
clinical guidelines pursued, if blood or mucus is present in the stool or if diarrhea is 
accompanied by fever. Participants should also be advised to drink at least 2 
liters/day of clear fluids to help prevent dehydration. 
• 
Nausea and Vomiting: Nausea and vomiting should be managed according to 
standard practice. 
  
Vorinostat Dose-Limiting Toxicity 
Non-hematologic dose-limiting toxicity is defined as any confirmed symptomatic Grade 
≥3, if related (definitely, probably, or possibly) to vorinostat therapy, with the specific 
exception of:  
• 
Grade 3 vomiting or diarrhea that lasts for less than 12 hours 
• 
Grade 3 elevation of liver function tests (LFTs), glucose, lipase, or creatinine without 
associated clinical symptoms, lasting for 7–14 days 
 
For any symptoms Grade ≥3 reported between the two scheduled vorinostat doses, the 
following modifications may be considered in consultation with the core protocol team: 
• 
Vorinostat dosing may be halted 
• 
Laboratory testing may be performed 
 
Any participant who does not complete the full vorinostat dosing schedule will have 
premature study treatment discontinuation evaluations performed as noted on the SOE. 
The site should notify the core protocol team within 72 hours. These participants will 
remain on study, off study treatment and have all evaluations performed per the SOE.  
 
Deep Vein Thrombosis 
Participants in the tamoxifen arm who develop signs or symptoms of deep vein 
thrombosis including local pain, swelling, erythema, or a palpable cord should be 
evaluated for intravascular clot with a venous ultrasound. If the presence of a deep vein 
thrombosis is confirmed, tamoxifen should be discontinued and vorinostat will not be 
administered. The site should notify the core protocol team within 72 hours. Clinical 
management should be as per standard of care with referral to primary care and/or 
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treatment discontinuation evaluations performed as noted on the SOE. These 
participants will remain on study, off study treatment and have all evaluations performed 
per the SOE.  
 
Malignancy 
All study treatment will be discontinued and the site should notify the core protocol team 
within 72 hours if a participant is diagnosed with any malignancy while on study, except 
for skin cancers not requiring systemic treatment. Carcinoma in situ (CIS) is not 
considered a malignancy for the purposes of this study. 
 
These participants will remain on study, off study treatment and have all evaluations 
performed per the SOE.  
 
9.0 
CRITERIA FOR DISCONTINUATION 
 
9.1 
Premature Study Treatment Discontinuation 
 
• 
Requirement for prohibited concomitant medications (see section 5.4) 
• 
Request by participant to terminate study treatment 
• 
Clinical reasons believed life threatening by the physician, even if not addressed in 
the toxicity section of the protocol 
• 
Confirmed viral load ≥200 copies/mL  
• 
Discontinuation of ART 
 
9.2 
Premature Study Discontinuation 
 
• 
Failure by the participant to attend two or more consecutive clinic visits 
• 
Request by the participant to withdraw 
• 
Request of the primary care provider if she or he thinks the study is no longer in the 
best interest of the participant 
• 
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 IRB/EC, FDA, NIAID, Office for Human Research Protections 
(OHRP), other government agencies as part of their duties, investigator, or industry 
supporter 
 
10.0 
STATISTICAL CONSIDERATIONS  
 
10.1 
General Design Issues 
 
A5366 is a randomized, open-label, exploratory study to evaluate whether tamoxifen 
enhances the viral reactivation effect of vorinostat, an HDACi that previously has been 
shown to reactivate latent HIV. Study participants will be post-menopausal women well 
suppressed on ART with CD4+ T cell counts >300 cells/mm3. Each participant will 
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obtained 5 hours after the second dose of vorinostat. Participants randomized to the 
tamoxifen arm (Arm A) will additionally receive daily tamoxifen for 38 days prior to and 
during receipt of vorinostat. Accrual of the targeted 30 participants is anticipated to take 
18 months.  
 
10.2 
Outcome Measures 
 
10.2.1 Primary Outcome Measures 
 
10.2.1.1 Safety 
 
Occurrence of a new Grade ≥3 adverse event that is considered 
definitely, probably, or possibly related to study treatment (as judged 
by the core protocol team) 
 
10.2.1.2 Efficacy 
 
Change in cell-associated HIV-1 RNA in resting CD4+ T cells from 
baseline to the day 38 post-vorinostat time point 
 
10.2.2 Secondary Outcome Measures  
 
10.2.2.1 Single copy HIV-1 RNA assay 
 
10.2.2.2 Total HIV-1 DNA levels 
 
10.2.3 Exploratory Outcome Measures 
 
10.2.3.1 Integrated HIV-1 DNA levels, HIV p24 antigen expression, and ex vivo 
HIV-1 RNA expression 
 
10.2.3.2 HIV-specific immunity and activation: HIV-1-specific immune 
responses, T-cell activation, T-cell exhaustion markers 
 
10.2.3.3 Histone H3 acetylation 
 
10.2.3.4 Pharmacokinetic parameters of vorinostat and tamoxifen 
 
10.2.3.5 Measures of innate cellular markers and soluble factors 
 
10.3 
Randomization and Stratification 
 
Participants will be randomized in a 2:1 ratio to Arm A (tamoxifen and vorinostat) vs. Arm 
B (vorinostat alone), using permuted blocks. The rationale for the 2:1 randomization is 
that it provides for a greater number of participants to evaluate the safety of the 
combination treatment than in a 1:1 design. 
 


 
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10.4 
Sample Size and Accrual 
 
Regarding the assessment of safety, the sample size of 20 participants in the tamoxifen 
plus vorinostat arm provides >90% probability of observing a treatment-related adverse 
event (10.2.1.1) that would occur in 11% or more of combination treated participants. 
 
The analysis of whether tamoxifen enhances the viral re-activation effect of vorinostat 
will be based on a 2-group t-test of the change from baseline in resting CD4 cell-
associated HIV-1 RNA (10.2.1.2). With the pilot nature of this study, the test will be 
based on a 1-sided alpha of 0.1. The standard deviation (SD) of the change in log10-
transformed cell-associated HIV RNA is assumed to 0.38, based on data from two 
longitudinal measurements in 18 virally suppressed individuals [40]. A similar SD was 
seen in the recent ACTG A5342 study: SD=0.40. Note that a smaller SD was observed 
in the single-dose vorinostat study (SD=0.28, n=8) [8], but this was based on assaying at 
each time point between18-72 million resting CD4 cells obtained by leukapheresis; this 
study will instead obtain cells from large-volume blood draws and thus a smaller number 
of analyzed cells than in Archin et al. (2012) is anticipated. 
 
With evaluable sample sizes of n=18 and n=9, respectively, in the two arms, the study 
will have 80% power to identify a 2.2-fold greater effect on HIV transcription as assessed 
by CA-RNA in the tamoxifen and vorinostat arm compared to vorinostat alone. To 
address the potential for early treatment or study discontinuation, or other analysis 
exclusions, an additional three participants will be enrolled. Hence, the study will enroll 
and randomize a total of 30 participants. 
  
(To obtain 80% power for a 2.5-fold effect size, n=14 and 7 evaluable are needed. 
With a 1-sided alpha=0.05 test and 2.5-fold effect size, n=18 and 9 are needed to 
achieve 80% power.) 
 
10.5 
Data and Safety Monitoring  
 
At SMC reviews, data will be considered as detailed in Section 7.4. There are no pre-
specified stopping guidelines.  
 
10.6 
Analyses 
 
10.6.1 Primary Analyses 
 
For the primary safety analysis, AEs attributed to study treatment based on core 
protocol team review will be summarized separately for the two treatment arms. 
All participants who have been exposed to the study treatment will be included in 
this analysis. The primary safety outcome (see 10.2.1.1) will be summarized 
separately by treatment arm, including a 1-sided 95% confidence interval using 
exact binomial methods. Tolerability will be assessed by summaries of early 
treatment discontinuations, including reasons, separately by treatment arm. 
 


 
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Because the aim of this pilot study is to assess biologic activity, the primary 
efficacy analysis will be as-treated, limited to participants who received the full 
study treatment. In addition, any participant who interrupts ART or has confirmed 
HIV-1 RNA level ≥200 copies/mL between the pre- and post-treatment time 
points will be excluded. The primary efficacy outcome (10.2.1.2) is the change 
from baseline (average of the pre-entry and entry time points) to the post-
vorinostat time point (5 hours following vorinostat dosing) of resting cell-
associated HIV-1 RNA. The change (and the average of the pre-treatment 
measurements) will be done on log10-transformed measurements; results below 
assay limits will be set to half the lower limit prior to statistical analysis. (Only a 
minority of results, estimated to be 10%, are anticipated to be below assay limit; 
Dr. Athe Tsibris, Brigham and Women’s Hospital, personal communication.) The 
primary analysis to assess whether tamoxifen enhances the effect of vorinostat 
will be based on a 2-group t-test. The level of the test for this pilot study will be at 
a 1-sided alpha=0.1.  
 
10.6.2 Secondary Analyses 
 
Secondary analyses of HIV-1 persistence measures, immunologic 
measurements and histone acetylation will be analyzed similarly to the primary 
efficacy outcome (see 10.6.1) but using 2-sided alpha of 0.05 for each 
comparison. It is anticipated that measures of HIV-1 persistence will be log-
transformed prior to analysis. Plots and descriptive data summaries will also be 
presented, by treatment arm, including 95% confidence intervals of changes from 
baseline to post-baseline time points. This will address, for example, the potential 
effects of tamoxifen alone on HIV-1 reservoir measures. Because it is anticipated 
that a substantial fraction of single copy HIV-1 RNA measurements will be below 
assay limit, changes will be evaluated using statistical methods for longitudinal 
censored data [41]. The proportion below assay limit, by arm, will also be 
summarized longitudinally.  
 
Correlations between measurements will also be examined, in particular 
correlations between changes in the cell-associated RNA and changes in the 
other virologic and immunologic measures. 
 
While measurements at pre-entry and entry will be averaged to assess treatment 
effects (see 10.6.1), supplemental descriptive analyses will summarize the 
biologic and measurement variability, and stability, of the virologic and 
immunologic measures while on stable suppressive ART (i.e., prior to treatment 
intervention).  
 
Section 11.0, Pharmacology Plan, provides details of the analyses of the PK-
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11.0 
PHARMACOLOGY PLAN 
 
A5366 is designed primarily to evaluate safety of a sequential combination of 38-day 
tamoxifen and vorinostat treatment and its effectiveness on latent virus reactivation in 
women who are suppressed on ART in comparison to that of vorinostat alone. 
 
Pharmacologic Considerations/Hypotheses: 
 
1. Tamoxifen pharmacologic effects are due to the parent drug plus the active 
metabolite. Drug interactions that influence the ratio of parent/metabolite may 
influence the receptor blockade that is thought to contribute to viral latency.  
2. Participants will be on suppressive ART regimens that may have either inductive or 
inhibitory effects on metabolic pathways, thus influencing the ratio of tamoxifen 
parent/metabolite. 
3. Vorinostat is a P-glycoprotein (P-gp) inducer and tamoxifen is an inhibitor. Therefore, 
a pharmacokinetic interaction between vorinostat and concurrent tamoxifen may 
occur at the membrane transporter level. 
 
11.1 
Pharmacology Objectives 
 
11.1.1. Investigate vorinostat plasma concentrations to compare pharmacokinetic 
parameters in participants with and without tamoxifen. 
 
11.1.2. Investigate tamoxifen plasma concentrations in relation to ART regimens that 
participants are receiving upon entry. 
 
11.1.3. Investigate pharmacodynamic associations between tamoxifen and vorinostat 
concentrations in a multivariate analysis. 
 
11.2 
Pharmacology Study Design 
 
11.2.1 
A single abbreviated plasma PK study of vorinostat on day 38 for all 
participants. This will include a pre-dose sample at time 0, and then a sampling 
at 5-hour post dosing. Dose information (date/time of the day 35 and day 38 
vorinostat doses) will be captured on an eCRF. 
 
11.2.2 
Repeated trough samples of tamoxifen (Arm A) on days 35, 38, and 65. Dose 
information (date/time of last 3 doses) will be captured on an eCRF. 
 
11.2.3 
Antiretroviral plasma concentrations on days 0, 35, 38, and 65. Dose 
information (date/time of last 3 doses) will be captured on an eCRF. 
 


 
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11.3 
Primary and Secondary Data, Modeling, and Data Analysis 
 
11.3.1 
Vorinostat. The intensive plasma samples will be required and used to calculate 
key pharmacokinetic parameters of vorinostat, including exposure, as indicated 
by area under the concentration curve (AUC) and clearance (Cl/F) due to its 
short half-life.  
 
11.3.2  Tamoxifen. Since tamoxifen exhibits a prolonged half-life (5-7 days), the trough 
concentrations of tamoxifen will adequately represent its exposure.  
 
11.3.3 
Pharmacodynamics. The vorinostat pharmacokinetic estimates and tamoxifen 
trough concentrations will then be used in analyses to correlate with the 
magnitude of HIV reactivation (10.2.1.2) and for comparison of exposure 
between participants with and without treatment-related adverse effects 
(10.2.1.1). 
 
11.3.4  Drug interactions. The potential drug interactions between tamoxifen and 
selective antiretroviral agents including elvitegravir, dolutegravir, raltegravir, and 
efavirenz, will be explored as well as the relationship between 
pharmacokinetics and changes in other biomarkers. 
 
11.4 
Anticipated Outcomes 
 
We anticipate that participants in A5366 will enter the study on a variety of ART 
regimens. These participants will receive the recommended doses of tamoxifen and 
vorinostat, as per protocol, but there will be a wide range of individual plasma exposures 
of these two agents based on interpatient variability. The proposed clinical 
pharmacology objectives will provide additional PK data and strengthen the multivariate 
analysis that will help identify specific covariates that are associated with the primary 
outcomes as well as provide a confirmation of vorinostat-driven HIV reactivation. The 
pharmacokinetic interactions between tamoxifen and selected antiretroviral agents will 
be explored to identify potentially significant ones for further investigation.  
 
12.0 
DATA COLLECTION AND MONITORING  
 
12.1 
Records to Be Kept 
 
Electronic case report form (eCRF) screens will be made available to sites for data entry. 
Participants must not be identified by name on any data submitted to the DMC. 
Participants will be identified by the patient identification number (PID) and study 
identification number (SID) provided by the ACTG DMC upon randomization. 
 
12.2 
Role of Data Management 
 
12.2.1 Instructions concerning entering study data on eCRFs will be provided by the 
ACTG DMC. Each CRS is responsible for keying study data in a timely fashion. 
 


 
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12.2.2 It is the responsibility of the ACTG DMC to assure the quality of computerized 
data for each ACTG study. This role extends from protocol development to 
generation of the final study databases. 
 
12.3 
Clinical Site Monitoring and Record Availability 
 
12.3.1 Site monitors under contract to the NIAID will visit participating clinical research 
sites to review the individual participant records, including consent forms, eCRFs, 
supporting data, laboratory specimen records, and medical records (physicians’ 
progress notes, nurses’ notes, individuals’ hospital charts), to ensure protection 
of study participants, compliance with the protocol, and accuracy and 
completeness of records. The monitors also will inspect sites’ regulatory files to 
ensure that regulatory requirements are being followed and sites’ pharmacies to 
review product storage and management. 
 
12.3.2 The site investigator will make study documents (e.g., consent forms, drug 
distribution forms, eCRFs) and pertinent hospital or clinic records readily 
available for inspection by the local IRB, the site monitors, FDA, NIAID, OHRP, 
other local, US, and international regulatory entities, and the industry supporter 
or its designee for confirmation of the study data.  
 
13.0 
PARTICIPANTS 
 
13.1 
Institutional Review Board (IRB) Review and Informed Consent 
 
This protocol and the informed consent document (Appendix I) and any subsequent 
modifications will be reviewed and approved by the IRB or EC responsible for oversight 
of the study. A signed consent form will be obtained from the participant. 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 participant 
and this fact will be documented in the participant’s record. 
 
13.2 
Participant Confidentiality 
 
All laboratory specimens, evaluation forms, reports, and other records that leave the site 
will be identified by coded number only to maintain participant 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 
participant, except as necessary for monitoring by the ACTG, IRB/EC, FDA, NIAID, 
OHRP, other local, US, and international regulatory entities as part of their duties, or the 
industry supporter or its designee.  
 
13.3 
Study Discontinuation 
 
The study may be discontinued at any time by the ACTG, IRB/EC, FDA, NIAID, OHRP, 
or other government agencies as part of their duties to ensure that research participants 
are protected, or by the industry supporter. 


 
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14.0 
PUBLICATION OF RESEARCH FINDINGS 
 
Publication of the results of this trial will be governed by ACTG policies.  
 
15.0 
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 CDC and the 
National Institutes of Health. 
 
All dangerous goods and materials, including diagnostic specimens and infectious 
substances, must be transported using packaging mandated by CFR 42 Part 72. Please 
refer to instructions detailed in the International Air Transport Association (IATA) 
Dangerous Goods Regulations.  
 
 


 
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16.0 
REFERENCES 
 
1. Finzi D, Hermankova M, Pierson T, et al. Identification of a reservoir for HIV-1 in 
patients on highly active antiretroviral therapy. Science 1997; 278(5341):1295-1300. 
 
2. Chun TW, Stuyver L, Mizell SB, et al. Presence of an inducible HIV-1 latent reservoir 
during highly active antiretroviral therapy. Proceedings of the National Academy of 
Sciences of the United States of America 1997; 94(24):13193-13197. 
 
3. Wong JK, Hezareh M, Gunthard HF, et al. Recovery of replication-competent HIV 
despite prolonged suppression of plasma viremia. Science 1997; 278(5341):1291-
1295. 
 
4. Strain MC, Gunthard HF, Havlir DV, et al. Heterogeneous clearance rates of long-
lived lymphocytes infected with HIV: intrinsic stability predicts lifelong persistence. 
Proceedings of the National Academy of Sciences of the United States of America 
2003; 100(8):4819-4824. 
 
5. Siliciano JD, Kajdas J, Finzi D, et al. Long-term follow-up studies confirm the stability 
of the latent reservoir for HIV-1 in resting CD4+ T cells. Nature Medicine 2003; 
9(6):727-728. 
 
6. Deeks SG. HIV: Shock and kill. Nature 2012; 487(7408):439-440. 
 
7. Mbonye U, Karn J. Transcriptional control of HIV latency: cellular signaling pathways, 
epigenetics, happenstance and the hope for a cure. Virology 2014; 454-455:328-
339. 
 
8. Archin NM, Liberty AL, Kashuba AD, et al. Administration of vorinostat disrupts HIV-1 
latency in patients on antiretroviral therapy. Nature 2012; 487(7408):482-485. 
 
9. Elliott JH, Wightman F, Solomon A, et al. Activation of HIV transcription with short-
course vorinostat in HIV-infected patients on suppressive antiretroviral therapy. PLoS 
Pathogens 2014; 10(10):e1004473. 
 
10. Rasmussen TA, Tolstrup M, Moller HJ, et al. Activation of latent human 
immunodeficiency virus by the histone deacetylase inhibitor panobinostat: a pilot 
study to assess effects on the central nervous system. Open Forum Infectious 
Diseases 2015; 2(1):ofv037. 
 
11. Wei DG, Chiang V, Fyne E, et al. Histone deacetylase inhibitor romidepsin induces 
HIV expression in CD4 T cells from patients on suppressive antiretroviral therapy at 
concentrations achieved by clinical dosing. PLoS Pathogens 2014; 10(4):e1004071. 
 
12. Sogaard OS, Graversen ME, Leth S, et al. The Depsipeptide Romidepsin Reverses 
HIV-1 Latency in Vivo. PLoS Pathogens 2015; 11(9):e1005142. 


 
57 
A5366 
FINAL Version 1.0 
 
 
12/8/17 
 
13. Spivak AM, Andrade A, Eisele E, et al. A pilot study assessing the safety and 
latency-reversing activity of disulfiram in HIV-1-infected adults on antiretroviral 
therapy. Clinical Infectious Diseases 2014; 58(6):883-890. 
 
14. Klein SL, Flanagan KL. Sex differences in immune responses. Nat Rev Immunol 
2016; 16(10):626-638. 
 
15. Markle JG, Fish EN. SeXX matters in immunity. Trends Immunol 2014; 35(3):97-104. 
 
16. Johnston RE, Heitzeg MM. Sex, age, race and intervention type in clinical studies of 
HIV cure: a systematic review. AIDS Research and Human Retroviruses 2015; 
31(1):85-97. 
 
17. Ho YC, Shan L, Hosmane NN, et al. Replication-competent noninduced proviruses in 
the latent reservoir increase barrier to HIV-1 cure. Cell 2013; 155(3):540-551. 
 
18. Das B, Dobrowolski C, Shahir AM, et al. Short chain fatty acids potently induce latent 
HIV-1 in T-cells by activating P-TEFb and multiple histone modifications. Virology 
2015; 474:65-81. 
 
19. Mirkin S, Pickar JH. Selective estrogen receptor modulators (SERMs): a review of 
clinical data. Maturitas 2015; 80(1):52-57. 
 
20. Munster PN, Thurn KT, Thomas S, et al. A phase II study of the histone deacetylase 
inhibitor vorinostat combined with tamoxifen for the treatment of patients with 
hormone therapy-resistant breast cancer. British Journal of Cancer 2011; 
104(12):1828-1835. 
 
21. http://www.accessdata.fda.gov/drugsatfda_docs/nda/2009/022393s000_PharmR_P1
.pdf. 
 
22. de Vries Schultink AH, Zwart W, Linn SC, Beijnen JH, Huitema AD. Effects of 
Pharmacogenetics on the Pharmacokinetics and Pharmacodynamics of Tamoxifen. 
Clin Pharmacokinet 2015; 54(8):797-810. 
 
23. Antoniou T, Tseng AL. Interactions between antiretrovirals and antineoplastic drug 
therapy. Clin Pharmacokinet 2005; 44(2):111-145. 
 
24. Binkhorst L, van Gelder T, Loos WJ, et al. Effects of CYP induction by rifampicin on 
tamoxifen exposure. Clin Pharmacol Ther 2012; 92(1):62-67. 
 
25. Hariparsad N, Nallani SC, Sane RS, Buckley DJ, Buckley AR, Desai PB. Induction of 
CYP3A4 by efavirenz in primary human hepatocytes: comparison with rifampin and 
phenobarbital. J Clin Pharmacol 2004; 44(11):1273-1281. 
 


 
58 
A5366 
FINAL Version 1.0 
 
 
12/8/17 
 
26. Cotreau MM, von Moltke LL, Harmatz JS, Greenblatt DJ. Molecular and 
pharmacokinetic evaluation of rat hepatic and gastrointestinal cytochrome p450 
induction by tamoxifen. Pharmacology 2001; 63(4):210-219. 
 
27. Desai PB, Nallani SC, Sane RS, et al. Induction of cytochrome P450 3A4 in primary 
human hepatocytes and activation of the human pregnane X receptor by tamoxifen 
and 4-hydroxytamoxifen. Drug Metab Dispos 2002; 30(5):608-612. 
 
28. Zhao XJ, Jones DR, Wang YH, Grimm SW, Hall SD. Reversible and irreversible 
inhibition of CYP3A enzymes by tamoxifen and metabolites. Xenobiotica 2002; 
32(10):863-878. 
 
29. Dowsett M, Pfister C, Johnston SR, et al. Impact of tamoxifen on the 
pharmacokinetics and endocrine effects of the aromatase inhibitor letrozole in 
postmenopausal women with breast cancer. Clin Cancer Res 1999; 5(9):2338-2343. 
 
30. Jefferson JW. Tamoxifen-associated reduction in tricyclic antidepressant levels in 
blood. J Clin Psychopharmacol 1995; 15(3):223-224. 
 
31. http://hivclinic.ca/main/drugs_interact_files/Chemo-int.pdf. 
 
32. Iusuf D, Teunissen SF, Wagenaar E, Rosing H, Beijnen JH, Schinkel AH. P-
glycoprotein (ABCB1) transports the primary active tamoxifen metabolites endoxifen 
and 4-hydroxytamoxifen and restricts their brain penetration. J Pharmacol Exp Ther 
2011; 337(3):710-717. 
 
33. Badros A, Burger AM, Philip S, et al. Phase I study of vorinostat in combination with 
bortezomib for relapsed and refractory multiple myeloma. Clin Cancer Res 2009; 
15(16):5250-5257. 
 
34. Ramalingam SS, Parise RA, Ramanathan RK, et al. Phase I and pharmacokinetic 
study of vorinostat, a histone deacetylase inhibitor, in combination with carboplatin 
and paclitaxel for advanced solid malignancies. Clin Cancer Res 2007; 13(12):3605-
3610. 
 
35. Rubin EH, Agrawal NG, Friedman EJ, et al. A study to determine the effects of food 
and multiple dosing on the pharmacokinetics of vorinostat given orally to patients 
with advanced cancer. Clin Cancer Res 2006; 12(23):7039-7045. 
 
36. Balliet RM, Chen G, Gallagher CJ, Dellinger RW, Sun D, Lazarus P. Characterization 
of UGTs active against SAHA and association between SAHA glucuronidation 
activity phenotype with UGT genotype. Cancer Res 2009; 69(7):2981-2989. 
 
37. Sandhu P, Andrews PA, Baker MP, et al. Disposition of vorinostat, a novel histone 
deacetylase inhibitor and anticancer agent, in preclinical species. Drug Metab Lett 
2007; 1(2):153-161. 


 
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38. Hauswald S, Duque-Afonso J, Wagner MM, et al. Histone deacetylase inhibitors 
induce a very broad, pleiotropic anticancer drug resistance phenotype in acute 
myeloid leukemia cells by modulation of multiple ABC transporter genes. Clin Cancer 
Res 2009; 15(11):3705-3715. 
 
39. Lautz TB, Jie C, Clark S, et al. The effect of vorinostat on the development of 
resistance to doxorubicin in neuroblastoma. PLoS One 2012; 7(7):e40816. 
 
40. Hong F, Aga E, Cillo AR, et al. Novel Assays for Measurement of Total Cell-
Associated HIV-1 DNA and RNA. J Clin Microbiol 2016; 54(4):902-911. 
 
41. Vaida F, Liu L. Fast implementation for normal mixed effects models with censored 
response. J Comput Graph Stat 2009; 18:797-817. 
 
 
 


 
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APPENDIX I: SAMPLE INFORMED CONSENT 
 
DIVISION OF AIDS 
AIDS CLINICAL TRIALS GROUP (ACTG) 
PROTOCOL A5366 
 
Selective Estrogen Receptor Modulators to Enhance the Efficacy of Viral Reactivation with 
Histone Deacetylase Inhibitors, FINAL Version 1.0, 12/8/17 
 
SHORT TITLE FOR THE STUDY: Effects of SERM and HDACi on HIV-1 Latency and RNA 
 
 
INTRODUCTION 
 
You are being asked to take part in this research study because you are a woman who is 
infected with HIV, the virus that causes AIDS, and you are currently taking antiretrovirals (ARVs) 
to treat your HIV infection. This study is sponsored by the National Institutes of Health (NIH). 
The doctor in charge of this study at this site is: (insert name of Principal Investigator). Before 
you decide if you want to be a part of this study, we want you to know about 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. 
 
 
WHY IS THIS STUDY BEING DONE? 
 
ARVs are effective for treating HIV, but it is impossible to completely eliminate HIV infection 
from the body because some virus “hides” in the cells of the immune system. These cells with 
“hidden” virus are called latent immune cells. If a person stops taking ARVs, the virus in these 
latent immune cells makes more copies of itself and levels of HIV virus in the blood increase. 
Some investigational medications (these are medications not approved by the US Food and 
Drug Administration [FDA]) have been shown to wake up these latent cells so that they can 
expel the virus that is hiding there, but these medications have only been partially effective and 
the results are not the same in all people. Early studies suggest that these medications may not 
work as well for women as they do for men due to women’s hormones.  
 
This study will look at a medication (vorinostat) that has been shown to wake up latent immune 
cells. Vorinostat will be given with an approved medication (tamoxifen) that blocks the hormone 
estrogen. Researchers will study whether these two medications given together are safe and 
tolerable. Researchers will also look at whether the two drugs work better together in waking up 
the latent virus in women than vorinostat given alone. Because Vorinostat is not an approved 
medication, taking it is considered experimental. 
 


 
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WHAT DO I HAVE TO DO IF I AM IN THIS STUDY? 
 
Screening 
If you would like to be in this study, after you have read and signed this consent form, you will 
come to the clinic for a screening visit to make sure you meet the requirements for joining the 
study. This will take about 1 hour. At this visit: 
• 
You will have a physical exam and answer questions about your medical history and any 
medications you are taking or have taken in the past. 
• 
You will have approximately 2 tablespoons of blood drawn. This blood will be used for the 
following tests: 
o For routine lab tests for safety and to see if you are infected with hepatitis B and/or C 
virus (infections of the liver). 
o To measure the amount of HIV in your blood and to measure your CD4+ cell count (cells 
that help fight infection).  
• 
You will be asked to give blood (1 teaspoon) or a urine sample for a pregnancy test. 
• 
If your HIV status is unknown or not documented, additional blood may be drawn to confirm 
your HIV status. You may have to sign a separate consent form for this test.  
• 
You will have an electrocardiogram to look at the electrical activity of your heart. 
 
Pre-Entry 
If the tests at screening show that you are eligible for the study, you will have one more study 
visit before you join the study. This visit will take about 1 hour. At this visit: 
• 
You will have a physical exam. 
• 
You will have approximately 5 tablespoons of blood drawn. This blood will be used for the 
following tests: 
o For routine lab tests for safety.  
o Some of the blood will be stored for future protocol-required testing. 
• 
You will answer questions about how well you take your antiretroviral (ARV) medications. 
 
If you enter the study 
At the study entry visit, you will be assigned to one of two treatment groups: 
 
Group A:  
Days 0-38: Tamoxifen 20 mg by mouth once a day 
Day 35: Vorinostat 400 mg PO (vorinostat will be given by study staff at the visit) 
Day 38: Vorinostat 400 mg PO (vorinostat will be given by study staff at the visit) 
 
 
Group B:  
Days 0-38: Observation period (no tamoxifen) 
Day 35: Vorinostat 400 mg PO (vorinostat will be given by study staff at the visit) 
Day 38: Vorinostat 400 mg PO (vorinostat will be given by study staff at the visit) 
 
Your assignment is random, like the flip of a coin. You will have a chance of being in each of the 
two groups, but you are more likely to be in Group A because more people will be assigned to 
that group. You will not be able to choose your group, but you and the study doctor, as well as 
the study staff, will know which group you are in.  


 
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Regardless of which group you are assigned to, you will continue to take your ARV medications. 
ARV medications will not be provided by the study.  
 
Entry 
After your screening and pre-entry visits, you will come in for an entry visit. This visit will take 
about 2 hours. At this visit: 
• 
You will have a physical exam and answer questions about your medical history and any 
medications you are taking or have taken in the past. 
• 
You will have approximately 7 tablespoons of blood drawn. This blood will be used for the 
following tests: 
o To test the level of hormones in your blood. You will be given the results of this test. 
o To measure the amount of HIV in your blood. You will be given the results of this test. 
o For pharmacokinetic testing (to see how the levels of the study drugs rise and fall in your 
blood over time). You will not receive the results of this testing.  
o Some of the blood will be stored for future protocol-required testing. You will not receive 
the results of this testing.  
• 
You will answer questions about how well you take your ARVs.  
• 
You will answer a questionnaire about why you chose to enroll in this study, your 
understanding of HIV cure research, and whether you have participated in clinical trials 
before. This questionnaire will take about 45 minutes to complete.  
 
Study Visits 
After your entry visit, you will come to the clinic at days 28, 35, 38, 45, and 65. These study 
visits will last about 1 hour, unless noted otherwise. At these visits: 
• 
You will have a physical exam and answer questions about any medications you are taking. 
• 
You will have approximately 1-10 tablespoons of blood drawn, depending on the study visit. 
This blood will be used for the following tests: 
o To test the level of hormones in your blood (days 28, 38, 45, and 65 only). You will be 
given the results of these tests. 
o For routine lab tests for safety (days 28 and 45 only). You will be given the results of 
these tests. 
o To measure the amount of HIV in your blood (days 28 and 35 only). You will be given 
the results of these tests. 
o To measure your CD4+ cell count (days 28 and 45 only). You will be given the results of 
these tests. 
o For pharmacokinetic testing (days 35, 38, and 65 only). On day 38 your two blood 
samples will be taken 5.5 hours apart, so this clinic visit might take longer than usual. 
You will not be given the results of these tests. 
o Some of the blood will be stored for future protocol-required testing. You will not be 
given the results of these tests. 
• 
You will be given your dose of vorinostat to take while you are at the clinic (days 35 and 38 
only). You will be given a snack at the clinic to take with your vorinostat dose.  
• 
You will answer questions about how well you take your ARVs and your tamoxifen (if you 
are in Group A).  


 
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• 
You will answer a questionnaire about why you chose to enroll in this study, your 
understanding of HIV cure research, and whether you have participated in clinical trials 
before (day 65 only). This questionnaire will take about 30 minutes to complete. 
 
Additional Visits 
• 
If your viral load shows that your anti-HIV drugs are not fighting your HIV infection well, you 
will come to the clinic for an additional visit. 
• 
If you have to stop taking the study drugs early or you have to stop the study early, you will 
come to the clinic for an additional visit. 
These visits will take about 1 hour. At these visits: 
• 
You will have a physical exam and answer questions about any medications you are taking. 
• 
You will have approximately 7 tablespoons of blood drawn. This blood will be used for the 
following tests:  
o For routine lab tests for safety. You will be given the results of these tests. 
o To test the level of hormones in your blood. You will be given the results of these tests. 
o To measure the amount of HIV in your blood and to measure your CD4+ cell count. You 
will be given the results of these tests. 
o For pharmacokinetic testing. You will not be given the results of these tests. 
o Some of the blood will be stored for future protocol-required testing. You will not be 
given the results of these tests. 
 
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, gender, race), clinical (for example, disease condition, diagnosis), and laboratory 
(for example, CD4 cell count, viral load) information is being collected from you so that ACTG 
researchers may help determine whether there are patterns or common reasons why people do 
not join a study. 
 
Other 
If you agree, some of your blood that is left over after all required study testing is done may be 
stored (with usual protections of your identity) and used for future ACTG-approved research that 
is separate from this study. Genetic testing will not be done on these blood samples. These 
samples may be stored for an indefinite period. Results of testing performed on these samples 
will not be given to you. You may withdraw your consent for research on stored specimens at 
any time and the specimens will be discarded. No matter what you decide, it will not affect your 
participation in this study. 
 
 
________ YES, I agree to have my leftover blood stored.  
 
 
 
________NO, I do not agree. 
 
 


 
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HOW MANY PEOPLE WILL TAKE PART IN THIS STUDY? 
 
About 30 women will take part in this study (20 in Group A and 10 in Group B). 
 
 
HOW LONG WILL I BE IN THIS STUDY? 
 
You will be in this study for about 65 days. 
 
 
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: 
• 
the study is stopped or cancelled  
• 
you are not able to attend the study visits as required by the study 
• 
you stop taking your ARV medications 
• 
the doctor believes the study is no longer in your best interest 
 
The study doctor may also need to take you off the study drugs without your permission if: 
• 
continuing the study drugs may be harmful to you 
• 
you need a treatment that you may not take while on the study 
• 
you are not able to take the study drugs as required by the study 
 
If you must stop taking the study drugs before the study is over, the study doctor will ask you to 
continue to be part of the study and return for some study visits and procedures. 
 
 
IF I HAVE TO PERMANENTLY STOP TAKING STUDY-PROVIDED DRUGS OR ONCE I 
LEAVE THE STUDY, HOW WOULD DRUGS BE PROVIDED? 
 
During the study 
If you must permanently stop taking study-provided drugs before your study participation is 
over, the study staff will discuss other options that may be of benefit to you. 
 
After the study 
After you have completed your study participation, the study will not be able to continue to 
provide you with drugs you received on the study. If continuing to take these or similar 
drugs/agents would be of benefit to you, the study staff will discuss how you may be able to 
obtain them. 
 
 
WHAT ARE THE RISKS OF THE STUDY? 
 
The drugs used in this study may have side effects, some of which are listed below. Please note 
that these lists do not include all the side effects seen with these drugs. These lists include the 
more serious or common side effects with a known or possible relationship. It is very important 


 
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that you tell your study doctor of any changes in your medical condition while taking part in the 
study. At any time during the study, if you believe you are experiencing any of these side 
effects, you have the right to ask questions on possible and /or known risks.  
 
Risks of Vorinostat 
Vorinostat comes as a capsule to take by mouth. It will be given to you with food. We will be 
with you when you take this medicine. Do not crush or open a vorinostat capsule. Swallow the 
pill whole. The medicine inside the capsule can be dangerous if it gets in your eyes, mouth, or 
nose, or on your skin. If contact occurs, wash your skin with soap and water or rinse your eyes 
thoroughly with plain water. 
 
The risks associated with vorinostat have a greater chance of occurring when vorinostat is taken 
every day over several weeks. In this study, you will receive two doses of 400 mg vorinostat. 
Your total dose will be 800 mg. In previous studies done with cancer patients who took a single 
high dose (800 mg) of vorinostat, the drug was generally well tolerated. No serious clinical or 
laboratory abnormalities were reported and no patient had to leave the study because of a bad 
side effect caused by vorinostat.  
 
The most common side effects seen with this one time dose: 
• 
Nausea (10%)  
• 
Fatigue (9%) 
 
The most serious side effects observed with multiple doses of vorinostat taken every day for 
many weeks are:   
• 
The development of blood clots in the legs (deep vein thrombosis) 
• 
The development of blood clots in the lungs or pulmonary emboli (4 out of 86 patients or 
4.7%) 
• 
Squamous cell carcinoma (3 out of 86 patients or 3.5%) 
 
Additional side effects were seen when people were given multiple doses of vorinostat every 
day for many weeks. These included: 
• 
Nausea, fatigue, and diarrhea (40-50%)  
• 
Loss of appetite 
• 
Dehydration 
• 
Vomiting 
• 
Low red blood cell counts or anemia (2 out of 86 patients or 2.3%) 
• 
Low platelet counts 
• 
Weight loss (10-20%)  
• 
Decreased kidney function 
• 
Altered taste  
• 
Increase in blood sugar  
• 
Constipation (10% or less)   
 
Although some of the serious side effects noted above occurred in a study population with 
cancers, we still need to let you know this information. We think you are unlikely to experience 
these side effects with the two doses of vorinostat that you will receive in this study. 


 
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We do not know if the following events are related to taking vorinostat but some single events 
occurring after taking vorinostat are: cholecystitis (gall bladder inflammation), death (of unknown 
cause), deep vein thrombosis (blood clot), enterococcal (bacterial) infection, exfoliative 
dermatitis (scaly skin), gastrointestinal hemorrhage (bleeding in the stomach or intestine), 
infection, lobar pneumonia, myocardial infarction (heart attack), ischemic stroke (stroke caused 
by a clot), pelvi-ureteric obstruction, sepsis (blood infection), spinal cord injury, streptococcal 
bacteremia (bacterial infection in the blood), fainting, T-cell lymphoma, thrombocytopenia (low 
platelet count), and ureteric obstruction (obstructions in the tubes that drain urine from the 
kidneys to the bladder). 
 
Vorinostat has the potential to be “genotoxic”, that is, it could cause damage to your genes that 
might increase your risk for developing cancer. 
 
Dehydration often occurs when you take this medicine. You will need to drink at least 1 liter of 
water (32 ounces or 4 cups) on the days that you are receiving the drug to keep from getting 
dehydrated.  
 
Risks of Tamoxifen 
Tamoxifen comes as a tablet that you should swallow whole, with water or another non-
alcoholic drink. You may take tamoxifen with or without food but you should take it at about the 
same time each day.  
 
Although study doctors think it is unlikely, tamoxifen may decrease some the levels of ARV 
medications in your blood. 
 
The following serious side effects have been associated with the use of tamoxifen. The side 
effects listed below are more common in people who have received longer courses of tamoxifen 
than will be given in this study. If you have any of the following signs or symptoms contact your 
health care provider right away.  
 
Changes in lining (endometrium) or body of your uterus (womb). These changes may be due to 
serious problems such as cancer of the uterus. If you have these changes, you may notice: 
• 
Vaginal bleeding or bloody discharge that could be a rusty or brown color 
• 
Pain or pressure in your pelvis (below your belly button) 
 
Blood clots. These can occur in your veins or lungs or can cause a stroke. These may be 
serious and can cause death. You may get clots up to 2-3 months after you stop taking 
tamoxifen. If you have a blood clot, you may notice:  
• 
Sudden chest pain 
• 
Shortness of breath  
• 
Coughing up blood  
• 
Pain, tenderness, or swelling in one or both of your legs  
 


 
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Stroke. If you are having a stroke, you may notice: 
• 
Sudden weakness, tingling, or numbness in your face, arm, or leg, especially on one side of 
your body 
• 
Sudden confusion, trouble speaking or understanding 
• 
Sudden trouble seeing in one or both eyes 
• 
Sudden trouble walking, dizziness, loss of balance or coordination 
• 
Sudden severe headache with no known cause 
 
Cataracts or increased chance of needing cataract surgery. If you are developing cataracts, you 
may notice slow blurring of your vision.  
 
Liver problems. If you are developing liver problems, you may notice:  
• Yellowing of the skin or whites of your eyes 
• Dark urine 
• Pain on the right side of your stomach 
• Loss of appetite, upset stomach, or vomiting  
• Pale colored stools 
• Itchy skin 
 
Additional side effects may include: 
• 
Difficulty urinating or a decrease in the amount of urine 
• 
Hot flashes 
• 
Noisy, rattling breathing 
• 
Redness of the face, neck, arms and, occasionally, upper chest 
• 
Skin changes 
• 
Swelling of the fingers, hands, feet, or lower legs 
• 
Troubled breathing at rest 
• 
Weight gain or loss 
• 
Bone pain 
• 
Stomach cramps 
• 
Feeling sad or difficulty concentrating 
 
Risks of Non-Study Medications 
There is a risk of serious and/or life-threatening side effects when non-study medications are 
taken with the study drugs. For your safety, you must tell the study doctor or nurse about all 
medications you are taking before you start the study and before starting any new medications 
while on the study. You must also tell the study doctor or nurse before enrolling in any other 
clinical trials while on this study. 
 
Risks of Drawing Blood  
Taking blood may cause some discomfort, bleeding, bruising, and/or swelling where the needle 
enters the body, lightheadedness, and in rare cases, fainting or infection.  
 


 
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Risks of Electrocardiogram 
You may experience mild irritation, slight redness, and itching on your skin where the electrodes 
from the electrocardiogram machine are placed. 
 
Risks of Social Harm 
It is possible that participating in this study will make it difficult for you to keep your HIV status 
secret from people close to you. This may lead to unwelcome discussions about or reactions to 
your HIV status. Please talk with the study staff if you are worried about this. 
 
Risks of Stored Samples  
There is a risk that your stored samples and/or health information may be misused. There are 
laws against this kind of misuse, but they may not fully protect you. The chance that this will 
happen is considered small because of the security taken with your samples and information.  
 
Risks to Future Study Participation 
If you participate in this study you may not be able to participate in future studies because you 
have taken tamoxifen and/or vorinostat.  
 
 
ARE THERE RISKS RELATED TO PREGNANCY? 
 
Vorinostat and tamoxifen are not safe for unborn babies. You can only participate in this study if 
you are postmenopausal (you no longer have a menstrual period) at the time of study entry and 
if you agree not to participate in assisted reproductive technology in the future.  
 
 
ARE THERE BENEFITS TO TAKING PART IN THIS STUDY? 
 
You will receive no benefit from being in this study. Information learned from this study may help 
others who have HIV. 
  
 
WHAT OTHER CHOICES DO I HAVE BESIDES THIS STUDY? 
 
Instead of being in this study you have the choice of: 
• 
treatment with prescription drugs available to you 
• 
treatment with experimental drugs, if you qualify  
• 
no treatment 
 
Please talk to your doctor about these and other choices available to you. Your doctor will 
explain the risks and benefits of these choices. 
 
 
WHAT ABOUT CONFIDENTIALITY? 
 
We will do everything we can to protect your privacy. In addition to the efforts of the study staff 
to help keep your personal information private, we have gotten a Certificate of Confidentiality 


 
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from the US Federal Government. This certificate means that researchers cannot be forced to 
tell people who are not connected with this study, such as the court system, about your 
participation. Any publication of this study will not use your name or identify you personally.  
 
People who may review your records include the US Food and Drug Administration, the ACTG, 
Office for Human Research Protections (OHRP) or other local, US, and international regulatory 
entities as part of their duties, (insert name of site) institutional review board (IRB) (a committee 
that protects the rights and safety of participants in research), US National Institutes of Health 
(NIH), study staff, study monitors, the drug company supporting this study, and their designees. 
Having a Certificate of Confidentiality does not prevent you from releasing information about 
yourself and your participation in the study. 
 
Even with the Certificate of Confidentiality, if the study staff learns of possible child abuse and/or 
neglect or a risk of harm to yourself or others, we will be required to tell the proper authorities. 
 
A description of this clinical trial will be available on www.ClinicalTrials.gov as required by US 
law. This web site will not include information that can identify you. At most, the web site will 
include a summary of the results. You can search this web site at any time.  
 
 
WHAT ARE THE COSTS TO ME? 
 
Taking part in this study may lead to added costs to you and your insurance company. In some 
cases, it is possible that your insurance company will not pay for these costs because you are 
taking part in a research study.  
 
 
WILL I RECEIVE ANY PAYMENT? 
 
[Insert site-specific information about payment] 
 
 
WHAT HAPPENS IF I AM INJURED? 
 
If you are injured as a result of being in this study, you will be given immediate treatment for 
your injuries. The cost for this treatment will be charged to you or your insurance company. 
There is no program for compensation either through this institution or the National Institutes of 
Health. You will not be giving up any of your legal rights by signing this consent form. 
 
 
WHAT ARE MY RIGHTS AS A RESEARCH PARTICIPANT? 
 
Taking part in this study is completely voluntary. You may choose not to take part in this study 
or leave this study at any time. Your decision will not have any impact on your participation in 
other studies conducted by NIH and will not result in any penalty or loss of benefits to which you 
are otherwise entitled.  
 


 
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We will tell you about new information from this or other studies that may affect your health, 
welfare, or willingness to stay in this study. If you want the results of the study, let the study staff 
know.  
 
 
WHAT DO I DO IF I HAVE QUESTIONS OR PROBLEMS? 
 
For questions about this study or a research-related injury, contact: 
 
• 
name of the investigator or other study staff 
• 
telephone number of above  
 
For questions about your rights as a research participant, contact: 
 
• 
name or title of person on the Institutional Review Board (IRB) or other organization 
appropriate for the site 
• 
telephone number of above 
 


 
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SIGNATURE PAGE 
 
If you have read this consent form (or had it explained to you), all your questions have been 
answered and you agree to take part in this study, please sign your name below. 
 
 
 
_______________________________         __________________________________ 
Participant’s Name (print) 
Participant’s Signature and Date 
 
 
______________________________ 
___________________________________ 
Study Staff Conducting 
Study Staff’s Signature and Date 
Consent Discussion (print)  
 
 
______________________________ 
___________________________________ 
Witness’s Name (print) 
Witness’s Signature and Date 
(As appropriate) 

SAP_000.pdf: 
A5366 Primary Statistical Analysis Plan Version 2.0 
September 10, 2019 
 
 
Page 1 of 14 
This is the Statistical Analysis Plan Version 2.0 for A5366 with names of authors, names of publication 
writing team members and analysis timeline redacted. 
 
A5366 
Primary Statistical Analysis Plan 
Version 2.0 
 
Selective Estrogen Receptor Modulators to Enhance the Efficacy 
of Viral Reactivation with Histone Deacetylase Inhibitors 
 
ClinicalTrials.gov Identifier: NCT03382834 
 
(Based on A5366 protocol version 1.0, CM #1 - #5 and LOA #1) 
 
 
September 10, 2019 
 
 
 
 
 


A5366 Primary Statistical Analysis Plan Version 2.0 
September 10, 2019 
 
 
Page 1 of 14 
 
Table of Contents 
TABLE OF CONTENTS ................................................................................................................... 2 
1 
INTRODUCTION ........................................................................................................................ 4 
1.1 
Purpose ............................................................................................................................ 4 
1.2 
Key Updates .................................................................................................................... 4 
2 
PROTOCOL OVERVIEW .......................................................................................................... 5 
2.1 
Study design.................................................................................................................... 5 
2.2 
Hypothesis ....................................................................................................................... 5 
2.3 
Study Objectives ............................................................................................................. 5 
2.4 
Outcome Measures ......................................................................................................... 6 
3 
DEFINITIONS ............................................................................................................................ 6 
3.1 
Time on Study ................................................................................................................. 6 
3.2 
Analysis Populations ...................................................................................................... 6 
4 
STATISTICAL METHODS ......................................................................................................... 7 
4.1 
Primary Analyses ............................................................................................................ 7 
4.2 
Secondary Analyses ....................................................................................................... 7 
5 
REPORT COMPONENTS ......................................................................................................... 9 
5.1 
Screening (if data available in SDTM) ........................................................................... 9 
5.2 
Accrual ............................................................................................................................. 9 
5.3 
Eligibility Violations (if data available in SDTM) .......................................................... 9 
5.4 
Baseline Characteristics ................................................................................................ 9 
5.5 
Study Status .................................................................................................................. 10 
5.6 
Treatment Status ........................................................................................................... 10 
5.7 
ART Status ..................................................................................................................... 10 
5.8 
Day 28 HIV-1 RNA level ................................................................................................ 10 
5.9 
Primary Analyses .......................................................................................................... 11 
5.9.1 
Safety: Adverse Events (AEs) ............................................................................. 11 
5.9.2 
Efficacy: Cell associated RNA ............................................................................. 11 
5.10 Secondary Analyses ..................................................................................................... 11 
5.10.1 
Cell associated HIV DNA .................................................................................... 11 
5.10.2 
SCA ..................................................................................................................... 11 
5.11 Exploratory Analyses ................................................................................................... 11 
5.11.1 
Integrated HIV-1 DNA levels, HIV p24 antigen expression, and ex vivo HIV-1 
RNA expression (EDITS) .............................................................................. 11 
5.11.2 
HIV-specific immunity and activation: HIV-1-specific immune responses, T-cell 
activation, T-cell exhaustion markers ........................................................... 11 
5.11.3 
Histone H3 acetylation ........................................................................................ 11 
5.11.4 
Pharmacokinetic parameters of vorinostat and tamoxifen .................................. 11 
5.11.5 
Measures of innate cellular markers and soluble factors .................................... 12 


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5.11.6 
Hormone levels (estradiol, estrone, progesterone) ............................................. 12 
6 
CORE MANUSCRIPT WRITING TEAM .................................................................................. 13 
7 
TIMETABLE FOR PRIMARY ANALYSIS AND MANUSCRIPT PREPARATION.................. 13 
 
 


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1 
Introduction 
1.1 
Purpose  
This Primary Statistical Analysis Plan (SAP) describes the primary and secondary outcome 
measures of A5366 that will be included in the primary manuscript addressing the major primary 
and secondary objectives of the study, as well as the primary and secondary outcome measures 
for which results will be posted on ClinicalTrials.gov. The Primary SAP also outlines the general 
statistical approaches that will be used in the analysis of the study. It has been developed to 
facilitate discussion of the statistical analysis components amongst the study team; and to 
provide agreement between the study team and statisticians regarding the statistical analyses to 
be performed and presented in the primary statistical analysis report. 
1.2 
Key Updates 
Version 1.0 of the A5366 Primary Statistical Analysis Plan is based on A5366 protocol version 
1.0, CM #1, CM #2 and LOA #1. 
Version 2.0 of the A5366 Primary Statistical Analysis Plan is based on A5366 protocol version 
1.0, CM #1, CM #2, CM #3, CM #4, CM #5 and LOA #1, and team discussions:  
• 
Updated efficacy population definition 
• 
Clarified analyses for secondary and exploratory outcomes  
• 
Updated to focus on Step 1 analyses  
 
 


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2 
Protocol Overview 
2.1 
Study design 
A5366 is a randomized, open-label, exploratory study of post-menopausal women with HIV and 
virologic suppression on antiretroviral therapy (ART) assessing the effects of tamoxifen exposure 
in combination with vorinostat compared to vorinostat treatment alone on viral reactivation.  
The study population is post-menopausal women (age 18-65) with HIV and virologic suppression 
on ART. The planned sample size is 30 participants, who will be randomized (2:1) to Arm A or 
Arm B to receive the following regimens: 
Arm A:  
 
Days 0-38: Tamoxifen 20 mg orally once daily 
 
Day 35: Vorinostat 400 mg orally once daily 
 
Day 38: Vorinostat 400 mg orally once daily 
 
Arm B:  
 
Days 0-38: Observation period (no tamoxifen) 
 
Day 35: Vorinostat 400 mg orally once daily 
 
Day 38: Vorinostat 400 mg orally once daily 
A5366 has 2 Steps: participants will be followed for 65 days in Step 1, and an additional 240 
weeks in Step 2 (long-term safety follow-up). The study primary efficacy outcome, however, is 
based on data collected during Step 1. 
2.2 
Hypothesis 
Treatment with the selective estrogen receptor modulator (SERM) tamoxifen will enhance the 
ability of the histone deacetylase inhibitor (HDACi) vorinostat to reverse HIV-1 latency. In 
participants with HIV on ART, combination therapy with tamoxifen and vorinostat will lead to 
higher levels of HIV-1 cell-associated RNA than will vorinostat alone. 
2.3 
Study Objectives 
The primary objectives of A5366 are the following: 
• 
Determine the safety and tolerability of combined therapy with the SERM tamoxifen and 
the HDACi vorinostat among HIV-infected post-menopausal women. 
• 
Determine the level of HIV-1 reactivation following treatment with vorinostat versus 
tamoxifen and vorinostat as measured by cell associated HIV-1 RNA (CA-RNA) in CD4+ 
T cells (primary efficacy endpoint). 
 
 


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The secondary objectives of A5366 are the following:  
• 
Evaluate the impact of therapy with vorinostat versus a combination of tamoxifen and 
vorinostat on residual viremia, as measured by a single copy assay. 
• 
Assess the impact of therapy with vorinostat versus a combination of tamoxifen and 
vorinostat on markers of HIV-1 persistence, as measured by total DNA levels. 
2.4 
Outcome Measures 
The primary outcome measures are: (protocol section 10.2.1) 
• 
Safety: Occurrence of a new Grade ≥3 adverse event that is considered definitely, 
probably, or possibly related to study treatment (as judged by the core protocol team) 
• 
Efficacy: Change in cell-associated HIV-1 RNA in CD4+ T cells from baseline to the day 
38 post-vorinostat time point 
The secondary outcome measures are: (see protocol section 10.2.2): 
• 
Single copy plasma HIV-1 RNA assay 
• 
Total HIV-1 DNA levels 
 
3 
Definitions 
3.1 
Time on Study 
“Day 0” is defined as the day of study randomization  
“Baseline” refers to parameters measured on or before randomization/on-study date. 
Days and weeks on Step 1 will be based on Step 1 registration day through “day 0”. Days and 
weeks on Step 2 will be based on Step 2 registration through end of study. 
3.2 
Analysis Populations 
“Study treatment” is defined as vorinostat and tamoxifen. 
“Safety population” is defined as the subset of participants who have been exposed to the study 
treatment.   
“Efficacy population” was originally defined as the subset of participants who have received the 
full study treatment, and do not have interruption of ART or confirmed HIV-1 RNA ≥ 200 
copies/mL between the pre-treatment and post-treatment (Day 38) time points. Based on plasma 
HIV-1 RNA testing by SCA, one participant had a pre-entry HIV-1 RNA level = 28,452 copies/mL 
and entry HIV-1 RNA level = 164 copies/mL (11,000 and 33 copies/mL, respectively, by Roche 
cobas 6800/8800); after team discussion it was decided that this participant would be excluded 


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from all efficacy analyses. In addition, a site erred and did not collect PBMCs/plasma at Day 38 
Hour 5 (post vorinostat) for one participant; because this is the timing of the primary efficacy 
outcome measure, after team discussion it was decided that this participant would also be 
excluded from all efficacy analyses.   
  
4 
Statistical Methods 
4.1 
Primary Analyses 
For the primary safety analysis, AEs attributed to study treatment based on core protocol team 
review will be summarized separately for the two treatment arms. All participants who have been 
exposed to the study treatment will be included in this analysis. The primary safety outcome (see 
protocol section 10.2.1.1) will be summarized separately by treatment arm, including a 1-sided 
95% confidence interval using exact binomial methods. Tolerability will be assessed by 
summaries of early treatment discontinuations, including reasons, separately by treatment arm. 
Because the aim of this pilot study is to assess biologic activity, the primary efficacy analysis will 
be as-treated, limited to participants who received the full study treatment; see efficacy population 
above. The primary efficacy outcome (see protocol section 10.2.1.2) is the change from baseline 
(average of the pre-entry and entry time points) to the post-vorinostat time point (5 hours 
following the second vorinostat dosing) of CD4+ T cell-associated HIV-1 RNA. The change (and 
the average of the pre-treatment measurements) will be done on log10-transformed 
measurements; results below assay limits will be set to half the lower limit prior to statistical 
analysis. (Only a minority of results, estimated to be 10%, are anticipated to be below assay limit; 
Dr. Athe Tsibris, Brigham and Women’s Hospital, personal communication.) The primary analysis 
to assess whether tamoxifen enhances the effect of vorinostat will be based on a 2-group t-test. 
The level of the test for this pilot study will be at a 1-sided alpha=0.1.  
4.2 
Secondary Analyses 
A supplemental analysis of the primary efficacy outcome will also be performed, in which results 
below assay limit will be addressed using censored-data longitudinal analysis methods (see 
Riddler at al, JID 2016). 
Secondary analyses of HIV-1 persistence measures, immunologic measurements and histone 
acetylation will be analyzed similarly to the primary efficacy outcome (see protocol section 10.6.1) 
but using 2-sided alpha of 0.05 for each comparison. It is anticipated that measures of HIV-1 
persistence will be log-transformed prior to analysis. Plots (including participant-specific 
longitudinal profiles) and descriptive data summaries will also be presented, by treatment arm, 
including 95% confidence intervals of changes from baseline to post-baseline time points. This 
will address, for example, the potential effects of tamoxifen alone on HIV-1 reservoir measures. 
Because a substantial fraction of single copy HIV-1 RNA measurements are below assay limit, 
changes will be evaluated using statistical methods for longitudinal censored data (Vaida F, Liu L. 
Fast implementation for normal mixed effects models with censored response. J Comput Graph 


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Stat 2009; 18:797-817). The proportion below assay limit, by arm, will also be summarized 
longitudinally.  
Correlations between measurements will also be examined, in particular correlations between 
changes in the cell-associated RNA and changes in the other virologic and immunologic 
measures.  
While measurements at pre-entry and entry will be averaged to assess treatment effects (see 
protocol section 10.6.1), supplemental descriptive analyses will summarize the biologic and 
measurement variability, and stability, of the virologic and immunologic measures while on stable 
suppressive ART (i.e., prior to treatment intervention). 
 


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5 
Report Components 
Analysis summaries will be presented for each arm and overall. 
For the final analysis, lists will be indexed by the alternate patient identifier (SUBJID variable), 
and visit week/date as needed. For interim analyses, the database patient identifier (USUBJID 
variable) will be used to facilitate cross-referencing with site communications. 
NOTE: Each table/list/figure in the reports will be annotated with the name and location of the 
program that created it, and the creation date. 
5.1 
Screening (if data available in SDTM) 
Table(s) summarizing: 
• 
Number (%) screened by month/year  
• 
Number (%) screened by site 
• 
Number of screen failure reasons  
5.2 
Accrual  
Table(s) summarizing: 
• 
Number (%) of participants enrolled by month/year  
• 
Number (%) of participants enrolled by site 
 
5.3 
Eligibility Violations (if data available in SDTM) 
• 
Table summarizing violations of eligibility criteria by site (if any). 
• 
List summarizing details of exclusions from analyses (if any). 
5.4 
Baseline Characteristics  
Table summarizing: 
• 
Sex 
• 
Age at entry date  
• 
Self-reported race/ethnicity 
• 
IV drug use  
• 
Entry ART regimen 
• 
Years since first ARV use 
• 
Entry HIV-1 RNA level 
• 
Screening CD4 cell count 
• 
Nadir CD4 cell count 
For categorical variables: showing number (%) by category. 


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For continuous variables: showing median, 25th and 75th percentiles, min, and max. 
Age will be summarized both as categorical (<50, 50-59, ≥60) and continuous. 
5.5 
Study Status  
Tables summarizing (Step 1): 
• 
Number of participants enrolled to the study 
• 
Number of participants on study 
• 
Number of participants off study 
o 
Reasons off study 
5.6 
Treatment Status 
• 
Tamoxifen status (for arm A participants only) 
o 
Number of participants on arm A without a tamoxifen treatment record (did not 
initiate) 
o 
Number of participants who completed tamoxifen per protocol 
o 
Number of participants who discontinued tamoxifen early  
 
Reasons for early tamoxifen discontinuation 
• 
Vorinostat status (for all participants)  
o 
Number of participants who received 2 doses of vorinostat 
o 
Number of participants who received <2 doses of vorinostat 
 
Reasons for receiving <2 doses of vorinostat 
5.7 
ART Status 
Table(s) summarizing: 
• 
ART discontinuations (if any) 
• 
ART interruptions (if any) 
• 
ART modifications (if any) 
5.8 
Day 28 HIV-1 RNA level 
Table(s) summarizing: 
• 
Number of participants with plasma HIV-1 RNA level ≥ 200 copies/mL at day 28 
o 
Number of participants who returned for a repeat HIV-1 RNA level 
 
Summary of the repeat HIV-1 RNA level 
o 
Number of participants who have not (yet) returned for a repeat HIV-1 RNA level 
 
Distribution of elapsed time from first HIV-1 RNA level ≥ 200 copies/mL 
result until data retrieval date 


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5.9 
Primary Analyses 
 
5.9.1 
Safety: Adverse Events (AEs) 
List of all AEs: participant ID, randomized Arm, age, days from study entry to onset day, AE 
description, AE grade, AE outcome, and safety core team attribution to study treatment.  
 
5.9.2 
Efficacy: Cell associated RNA    
Table of CA-RNA levels at each time point (baseline, Day 28, Day 35, Day 38, Day 45, Day 
65): median, 25th and 75th percentiles, min, max, N. 
Table of change from Baseline to Day 38: median, 25th and 75th percentiles, min, max, 
mean, N. 95% confidence interval separately by arm. P-value from 2 group t-test and point 
estimate (mean) and 95% confidence interval for the difference between arms in change 
from baseline to Day 38.  
Figure of CA-RNA levels over time: median, mean, 25th and 75th percentiles. 
5.10 
Secondary Analyses 
5.10.1 Cell associated HIV DNA 
5.10.2 SCA 
 
5.11 
Exploratory Analyses  
5.11.1 Integrated HIV-1 DNA levels, HIV p24 antigen expression, and ex vivo HIV-1 
RNA expression (EDITS) 
5.11.2 HIV-specific immunity and activation: HIV-1-specific immune responses, T-cell 
activation, T-cell exhaustion markers 
5.11.3 Histone H3 acetylation  
5.11.4 Pharmacokinetic parameters of vorinostat and tamoxifen  
Summaries of vorinostat levels at Day 38 (pre-dose and post-dose hour 5) will be presented 
overall and by Arm. The post-dose level will be compared between arms (t-test, 95% 
confidence interval on difference between Arms). Summaries of tamoxifen levels by week 
will be presented for Arm A only. The average of tamoxifen levels at Day 35 and Day 38 will 
be summarized and associated with study outcomes. Initial analyses will correlate vorinostat 
levels (Day 38 post-dose hour 5) with change in histone H3 antibody levels pre-vorinostat to 
post-vorinostat (Day 28 to Day 38 post-dose hour 5). Additional pharmacokinetic parameters 
will also be summarized and associated with study outcomes. The specifics of these 


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pharmacodynamics analyses will be developed by the study team after review of the 
pharmacokinetic data and the results of the primary and secondary study analyses.       
5.11.5 Measures of innate cellular markers and soluble factors  
5.11.6 Hormone levels (estradiol, estrone, progesterone) 
Due to skewed distributions of hormone levels, initial summaries will be on log-transformed 
hormone levels. Further analyses of hormone levels may be performed upon team review of 
these summaries.  
 


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6 
Core Manuscript Writing Team 
Protocol Co-chairs, Statisticians, Clinical Representatives and selected Investigators. 
7 
Timetable for Primary Analysis and Manuscript Preparation 
Note that the actual calendar dates will only be filled in in the final version of the SAP 
 
 
Information redacted